Home Uncategorized Cultural Recipe Analysis

Uncategorized

Cultural Recipe Analysis

Assignment: Cultural analysis recipe and report. Three to five pages total of reported content. Reference page does not count toward this total. Format requirements are outlined in the course syllabus.

Find an “authentic” and “traditional” cultural recipe from a culture that is different then your own and different from the one covered in the Interview and Acculturation assignments.
Recipe must come from a cookbook (see “Important Information About References” below)
Prepare the recipe for yourself and a friend or family member.
Take a photo of the recipe to include in your report.
Evaluate the recipe (based on the provided sensory evaluation form). Evaluate the recipe for texture, flavor, color, appearance and overall acceptability. Be detailed and descriptive. Use a variety of sensory words.

Elements of Paper:

Introduction:

Clearly state your own cultural identity and the culture of the recipe you have chosen.
State why you choose this cultural recipe.
Describe your preparation methods of the recipe that you selected to prepare.
Evaluate the recipe for texture, flavor, color, appearance and overall acceptability (form provided below). Be detailed and descriptive. Use a variety of sensory words.
Make sure to include your completed sensory evaluation form (does not count towards page count)
Compare and contrast the information found in the preface of the cookbook or book and other source with the information provided in the textbook. Include a compare and contrast for the following:
Cooking/preparation methods.
Traditional flavor notes/principles.
Typical staple foods.
Meal/eating patterns or habits.
Discuss how your cultural perceptions may have affected your perception of the food you ate and reviewed.
Include a References page (detailed below).
Attach a picture of the final product at the END of your paper. Do not embed or include in the body of the text.

Important Information About References:

Before you begin your search for sources, make sure that you clearly understand and can define what are considered staple foods, flavor notes or principles, cooking/preparation methods, and eating/meal patterns. Refer to the chapter readings in your Introduction Modules (chapters 1-4).

At least 3 references should be used: 1) textbook, 2) ethnic cookbook or published book on chosen culture, 3) plus one other reference of choice.
Locate two resources that detail food and cooking practices of this culture.
One of these resources MUST be a COOKBOOK on a specific cultural cuisine or ethnic background OR a published book on a particular culture. The book or cookbook must detail staple foods(sometimes listed as pantry items), common flavor notes (seasonings & herbs traditional used), traditional cooking and preparation methods of the culture, and traditional eating/meal patterns.
The second resource can be from a website that also provides similar detail on the culture. It does not have to be in agreement with the book or cookbook, but it should provide additional insights or details about food in the chosen culture.

NFS 3173 Culture and Foods

Cultural Recipe Analysis

Value = 100 points

1. Find an “authentic” and “traditional” cultural recipe from a culture that is different then your own and different from the one covered in the Interview and Acculturation assignments.

a. Recipe must come from a cookbook (see “Important Information About References” below)

2. Prepare the recipe for yourself and a friend or family member.

3. Take a photo of the recipe to include in your report.

Evaluate the recipe (based on the provided sensory evaluation form). Evaluate the recipe for texture, flavor, color, appearance and overall acceptability. Be detailed and descriptive. Use a variety of sensory words.

Elements of Paper:

1. Introduction:

· Clearly state your own cultural identity and the culture of the recipe you have chosen.

· State why you choose this cultural recipe.

2. Describe your preparation methods of the recipe that you selected to prepare.

3. Evaluate the recipe for texture, flavor, color, appearance and overall acceptability (form provided below). Be detailed and descriptive. Use a variety of sensory words.

· Make sure to include your completed sensory evaluation form (does not count towards page count)

4. Compare and contrast the information found in the preface of the cookbook or book and other source with the information provided in the textbook. Include a compare and contrast for the following:

· Cooking/preparation methods.

· Traditional flavor notes/principles.

· Typical staple foods.

· Meal/eating patterns or habits.

5. Discuss how your cultural perceptions may have affected your perception of the food you ate and reviewed.

6. Include a References page (detailed below).

7. Attach a picture of the final product at the END of your paper. Do not embed or include in the body of the text.

Important Information About References:

· At least 3 references should be used: 1) textbook, 2) ethnic cookbook or published book on chosen culture, 3) plus one other reference of choice.

· Locate two resources that detail food and cooking practices of this culture.

· One of these resources MUST be a COOKBOOK on a specific cultural cuisine or ethnic background OR a published book on a particular culture. The book or cookbook must detail staple foods (sometimes listed as pantry items), common flavor notes (seasonings & herbs traditional used), traditional cooking and preparation methods of the culture, and traditional eating/meal patterns.

· The second resource can be from a website that also provides similar detail on the culture. It does not have to be in agreement with the book or cookbook, but it should provide additional insights or details about food in the chosen culture.

Trivia Fact About TWU: The Texas Woman’s University Library has the World’s largest Cookbook Collection — Hint: This would be a wonderful place to find a recipe in a cookbook to complete this assignment. Visiting this collection in our Library will enhance this learning experience and opportunity.

** Note: Reference page(s), sensory table and the picture at the end DO NOT count towards content page requirements above. Reference page, sensory table and picture are in addition to content pages.**

Grading:

The grading rubric has been provided so you know exactly what is expected of you. Please make sure you cover ALL the components that have been requested of you. Points will be deducted if you omit any areas, even if the paper is beautifully written.

The assignment MUST be submitted using the Turn-it-in link below. E-mailed assignments WILL NOT BE ACCEPETED OR GRADED.

**Just a reminder that plagiarized papers, whether intentional or not, will result in a zero. You can submit your papers multiple times through the turn-it-in site until the due date. By using the originality report provided, you can review your similarity score and make corrections and modification as needed. I recommend that you try and submit early and use this tool to double check your paper.**

Sensory Evaluation Form

Recipe Name:

Directions: Circle one rating in the light blue boxes for each of the different categories. Additional comments for each categories can be listed in the white boxes.

Category

Score

Appearance

Extremely Attractive

Moderately Attractive

Attractive/ Matches photo

Unappetizing

Unattractive

Taste /Flavor

Tasted Great

Flavorful

Acceptable

Off Flavor

Flavor did not appeal to me

Texture Rating

Wonderful Texture

Good Texture

Acceptable Texture

Off Texture

Inappropriate texture/flat/runny

Aroma/ Smell Rating

Wonderful Aroma

Appealing Aroma

Acceptable Aroma

Aroma is not appealing

Unappetizing Aroma

Overall Acceptability

Extremely Acceptable

Moderately Acceptable

Acceptable

Moderately Unacceptable

Unacceptable

Name:
Cultural Recipe Analysis Rubric (100 points total)

Criteria

100%

90%

80%

70%

60%

50%

0-points

100%

90%

80%

70%

60%

50%

0-points

Introduction (5%)
Clearly state own cultural Identity; Clearly state culture of chosen recipe; Clearly state why this recipe was chosen.

All information was provided in thorough detail. Thoughts and points very well organized.

n/a

Section addressed, but incorrect information provided and/or required information is missing.

Information is not provided.

Making of the Recipe (7.5%)
Provide a description of the preparation methods used for this recipe.

All information was provided in thorough detail. Thoughts and points very well organized.

All information was provided. Additional detail would have helped with organization and readability.

Basic information provided and/or minor parts missing. Organization fair.

Information missing and/or organization is poor making it difficult to read and understand.

Section addressed, but incorrect information provided; and/or organization poor making it difficult to read and understand.

Information is not provided.

Recipe Eval (12.5%)
Evaluated the recipe for texture, flavor, color, appearance, and overall acceptability. Include Sensory evaluation form

All information was provided in thorough detail. Thoughts and points well organized. Form is included

All information was provided in detail and correct.
Organization did not distract from readability. Form is included

All information was provided. Additional detail would have helped with organization and readability. OR form is not included

Basic information provided and/or minor parts missing. Organization fair.
OR form is not included

Information missing and/or organization is poor making it difficult to read and understand. Form is not included

Section addressed, but incorrect information provided; and/or organization poor making it difficult to read and understand. Form is not inlcuded

Information is not provided.

Flavor Notes (10%)
Discuss the common flavor notes of the culture you are reviewing.
Compare and contrast what the cookbook identifies as common flavors to what other sources identify as common flavors.

All information was provided in thorough detail. Thoughts and points well organized.

All information was provided in detail and correct.
Organization did not distract from readability.

All information was provided. Additional detail would have helped with organization and readability.

Basic information provided and/or minor parts missing. Organization fair.

Information missing and/or organization is poor making it difficult to read and understand.

Section addressed, but incorrect information provided; and/or organization poor making it difficult to read and understand

Information is not provided.

Meal Patterns (10%)
Discuss the meal patterns of the culture you are reviewing.
Compare and contrast what the cookbook identifies as common meal/eating patterns and habits, to what other sources identify as common practices.

All information was provided in thorough detail. Thoughts and points well organized.

All information was provided in detail and correct.
Organization did not distract from readability.

All information was provided. Additional detail would have helped with organization and readability.

Basic information provided and/or minor parts missing. Organization fair.

Information missing and/or organization is poor making it difficult to read and understand.

Section addressed, but incorrect information provided; and/or organization poor making it difficult to read and understand

Information is not provided.

Staple Foods (10%)
Discuss the staple foods of the culture you are reviewing.
Compare and contrast what the cookbook identifies as common staple foods of the culture/region, to what other sources identify as common staples.

All information was provided in thorough detail. Thoughts and points well organized.

All information was provided in detail and correct.
Organization did not distract from readability.

All information was provided. Additional detail would have helped with organization and readability.

Basic information provided and/or minor parts missing. Organization fair.

Information missing and/or organization is poor making it difficult to read and understand.

Section addressed, but incorrect information provided; and/or organization poor making it difficult to read and understand

Information is not provided.

Preparation Methods (10%)
Discuss the common preparation methods and/or cooking practices of the culture.
Compare and contrast what the cookbook identifies as common preparation methods, to what other sources identify as common methods.

All information was provided in thorough detail. Thoughts and points well organized.

All information was provided in detail and correct.
Organization did not distract from readability.

All information was provided. Additional detail would have helped with organization and readability.

Basic information provided and/or minor parts missing. Organization fair.

Information missing and/or organization is poor making it difficult to read and understand.

Section addressed, but incorrect information provided; and/or organization poor making it difficult to read and understand

Information is not provided.

Perceptions (10%)
Discuss how your cultural perceptions may have influenced your ideas of the food you prepared and reviewed.

All information was provided in thorough detail. Thoughts and points well organized.

All information was provided in detail and correct.
Organization did not distract from readability.

All information was provided. Additional detail would have helped with organization and readability.

Basic information provided and/or minor parts missing. Organization fair.

Information missing and/or organization is poor making it difficult to read and understand.

Section addressed, but incorrect information provided; and/or organization poor making it difficult to read and understand

Information is not provided.

References (7.5%)
Use at least 3-references: textbook, cookbook, +one other. Cite your sources correctly using APA.

All references types are used.
All in-text and reference page citations are completed correctly with APA format. All information is cited correctly.

One reference type is missing. OR
One in-text and/or one reference page citations are incorrect. APA format was used.

One reference type is missing AND/OR
Two or more incorrect in-text and/or reference page citations. APA format was used.

Two reference types are missing OR
Three or more incorrect in-text and/or reference page citations.
OR
APA Format was not used.

Two reference types are missing AND/OR
In-text citations incorrect and/or not used. Reference page citations incorrect.
OR
APA Format was not used.

Incorrect reference types.
Missing citations. Incorrect format. APA not used.

No citations references at all.

Format (5%)
The paper should be at least 3-pages in length using the appropriate font and format as outlined in the syllabus.

Paper is appropriate length, font, double spaced, and format.

Paper is of appropriate length, but incorrect format and/or font are used.

Paper is slightly short (>2- pages, <3-pages), format and/or font are correct. Paper is too short, and font and/or format are incorrect. Paper is <2 pages, correct font and format are used. Paper is <2 pages and incorrect font and/or format are used. Paper is <1-page. Spelling/Grammar(7.5%) Correct. Readability. No grammar and/or spelling errors. A few minor grammar and/or spelling errors that do not distract from reliability of the paper. Several minor grammar and/or spelling errors. Errors compromise readability of the paper. Few major errors and/ or several minor grammar and/or spelling errors. Do not distract from readability of the paper. Several major grammar and/or spelling errors. Distract from readability of the paper. Spelling and grammar errors compromise ability to understand content and readability of the paper. n/a Recipe Photo (5%) Provide a picture of the final product Picture was provided. n/a n/a n/a n/a n/a Picture was not provided.

5 REASONS
to buy your textbooks
and course materials at
SAVINGS:
Prices up to 75% off, daily coupons, and free shipping on orders over $25
CHOICE:
Multiple format options including textbook, eBook and eChapter rentals
CONVENIENCE:
Anytime, anywhere access of eBooks or eChapters via mobile devices
SERVICE:
Free eBook access while your text ships, and instant access to online homework products
STUDY TOOLS:
Study tools* for your text, plus writing, research, career and job search resources
*availability varies
1
2
3
4
5
Find your course materials and start saving at:
www.cengagebrain.com
Engaged with you.
www.cengage.com
Source Code: 14M-AA0107
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

Food
and
Culture
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

7e
Food and Culture
Australia • Brazil • Japan • Korea • Mexico • Singapore • Spain • United Kingdom • United States
Pamela Goyan Kittler, MS
Food, Culture, and Nutrition Consultant
Kathryn P. Sucher, ScD, RDN
Department of Nutrition and Food Science San Jose State University
Marcia Nahikian-Nelms, PhD, RDN, LD, CNSC
Medical Dietetics, College of Medicine, The Ohio State University
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

This is an electronic version of the print textbook. Due to electronic rights restrictions,
some third party content may be suppressed. Editorial review has deemed that any suppressed
content does not materially affect the overall learning experience. The publisher reserves the right
to remove content from this title at any time if subsequent rights restrictions require it. For
valuable information on pricing, previous editions, changes to current editions, and alternate
formats, please visit www.cengage.com/highered to search by ISBN, author, title, or keyword for
materials in your areas of interest.

Important notice: Media content referenced within the product description or the product
text may not be available in the eBook version.

© 2017, 2012 Cengage Learning
WCN: 01-100-101
Food and Culture, Seventh Edition
Pamela Goyan Kittler, Kathryn P. Sucher,
Marcia Nahikian-Nelms
Product Director: Dawn Giovanniello
Product Manager: Krista Mastroianni
Content Developer: Kellie Pettruzelli
Product Assistant: Victor Luu
Senior Content Project Manager:
Tanya Nigh
Art Director and Cover Designer:
Michael Cook
IP Analyst: Christine Myaskovsky
IP Project Manager: Farah Fard
Manufacturing Planner: Karen Hunt
Production Service and Compositor: SPi Global
Photo and Text Researcher: Lumina
Datamatics Ltd.
Text Designer: Lisa Buckley
Cover Image: Shutterstock/phototy;
Istock/AlfaOlga
Interior Design Images:
269965676 Shutterstock;
Getty 186839262;
Getty Images 183878381
For product information and technology assistance, contact us at
Cengage Learning Customer & Sales Support, 1-800-354-9706.
For permission to use material from this text or product,
submit all requests online at www.cengage.com/permissions.
Further permissions questions can be e-mailed to
permissionrequest@cengage.com.
Cengage Learning
20 Channel Center Street
Boston, MA 02210
USA
ALL RIGHTS RESERVED. No part of this work covered by the copyright
herein may be reproduced, transmitted, stored, or used in any form
or by any means graphic, electronic, or mechanical, including but not
limited to photocopying, recording, scanning, digitizing, taping, Web
distribution, information networks, or information storage and retrieval
systems, except as permitted under Section 107 or 108 of the 1976
United States Copyright Act, without the prior written permission of
the publisher.
Cengage Learning is a leading provider of customized learning solutions
with employees residing in nearly 40 different countries and sales in
more than 125 countries around the world. Find your local representa-
tive at www.cengage.com.
Cengage Learning products are represented in Canada
by Nelson Education, Ltd.
To learn more about Cengage Learning Solutions, visit www.cengage.com.
Purchase any of our products at your local college store or at our
preferred online store www.cengagebrain.com.
Library of Congress Control Number: 2015947527
ISBN-13: 978-1-305-62805-2
Printed in Canada
Print Number: 02 Print Year: 2016
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

v
What Is Health? 39
Cultural Definitions of Health 39
Health Maintenance 40
Disease, Illness, and Sickness 42
Cultural Definitions of Disease, Illness,
and Sickness 42
Healing Practices 46
Pluralistic Health Care Systems 50
Medical Pluralism 50
Biomedical Healing 50
3 Intercultural
Communication 56
The Intercultural Challenge 56
Intercultural Communication
Concepts 57
Verbal Communication 58
Nonverbal Communication 62
Role of Communication in Health
Care 64
Interaction between Provider
and Client 64
Responsibilities of the Health Care
Provider 66
Successful Intercultural
Communication 66
Intercultural Communication Skills 66
Intercultural Counseling 69
Intercultural Nutrition Assessment 71
Intercultural Nutrition Education 73
Culturally Relevant Program
Preparation 74
Implementation Strategies 76
Contents
Preface ix
1 Food and Culture 1
What Is Food? 1
The Omnivore’s Paradox 2
Self-Identity 2
Symbolic Use of Food 3
Cultural Identity 4
What Is Culture? 6
The Acculturation Process 6
Acculturation of Food Habits 6
Cultural Food Habits 7
Core and Complementary Foods Model 7
Flavor Principles 8
Meal Patterns and Meal Cycles 10
Developmental Perspective of Food
Culture 11
Individual Food Habits 12
Food Availability 12
Edible or Inedible? 13
Consumer Food Choice Model 13
Nutrition and Food Habits 18
The Need for Cultural Competency 18
Intercultural Nutrition Care 22
The American Paradox 23
2 Traditional Health Beliefs
and Practices 34
Worldview 34
Cultural Outlook 34
Biomedical Worldview 37
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

vi C O N T E N T S
4 Food and Religion 82
Western Religions 83
Judaism 83
Christianity 89
Islam 94
Eastern Religions 98
Hinduism 98
Buddhism 103
5 Native Americans 107
Cultural Perspective 107
History of Native Americans 107
Worldview 110
Traditional Food
Habits 112
Ingredients and Common Foods 112
Meal Composition and Cycle 120
Daily Patterns 120
Role of Food in Native American Culture
and Etiquette 121
Therapeutic Uses of Food 122
Contemporary Food Habits 123
Adaptation of Food Habits 123
Nutritional Status 126
6 Northern and
Southern
Europeans 139
Northern Europeans 139
Cultural Perspective 140
Traditional Food Habits 144
Contemporary Food Habits in the United
States 153
Southern Europeans 157
Cultural Perspective 157
Traditional Food Habits 160
Contemporary Food Habits in the United
States 169
7 Central Europeans, People
of the Former Soviet Union,
and Scandinavians 174
Central Europeans and the People
of the FSU 174
Cultural Perspective 175
Traditional Food Habits 183
Contemporary Food Habits in the United
States 192
Scandinavians 196
Cultural Perspective 196
Traditional Food Habits 199
Contemporary Food Habits in the United
States 203
8 Africans 208
Cultural Perspective 208
History of Africans in the United
States 210
Worldview 212
Religion 212
Traditional Food Habits 214
Ingredients and Common
Foods 214
Historical Influences 214
Meal Composition and Cycle 221
Daily Patterns 221
Role of Food in African American
Society and Etiquette 223
Therapeutic Uses of Food 223
Contemporary Food Habits in the
United States 224
Adaptations of Food
Habits 224
Ingredients and Common
Foods 224
Nutritional Status 225
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

C O N T E N T S vii
9 Mexicans and Central
Americans 237
Mexicans 237
Cultural Perspective 238
Traditional Food Habits 242
Contemporary Food Habits in the
United States 252
Central Americans 261
Cultural Perspective 261
Traditional Food Habits 264
Contemporary Food Habits in the
United States 268
10 Caribbean Islanders
and South Americans 278
Caribbean Islanders 278
Cultural Perspective 278
Traditional Food Habits 285
Contemporary Food Habits in the United
States 295
South Americans 301
Cultural Perspective 301
Traditional Food Habits 304
Contemporary Food Habits in the United
States 312
11 East Asians 319
Chinese 319
Cultural Perspective 320
Traditional Food Habits 325
Contemporary Food Habits in the United
States 335
Japanese 340
Cultural Perspective 340
Traditional Food Habits 343
Contemporary Food Habits in the United
States 348
Koreans 351
Cultural Perspective 352
Traditional Food Habits 354
Contemporary Food Habits in the
United States 359
12 Southeast Asians
and Pacific Islanders 370
Southeast Asians 370
Cultural Perspective 370
Traditional Food Habits 380
Contemporary Food Habits in the
United States 393
Native Hawaiians and Pacific
Islanders 399
Cultural Perspective 399
Traditional Food Habits 402
Contemporary Food Habits in the
United States 406
13 People of the Balkans
and the Middle East 416
Cultural Perspective 416
History of People of the Balkans and Middle
East in the United States 416
Current Demographics and Socioeconomic
Status 419
Worldview 420
Traditional Food Habits 425
Ingredients and Common Foods 426
Meal Composition and Cycle 434
Contemporary Food Habits in the
United States 441
Adaptations of Food Habits 441
Nutritional Status 442
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

14 South Asians 450
Cultural Perspective 450
History of Asian Indians and Pakistanis
in the United States 450
Worldview 453
Traditional Food Habits 456
Ingredients and Common Foods 457
Meal Composition and Cycle 464
Role of Food in Indian Society and
Etiquette 467
Therapeutic Uses of Food 468
Contemporary Food Habits in the United
States 470
Adaptations of Food Habits 470
Nutritional Status 472
15 Regional Americans 483
American Regional Food Habits 483
What Is Regional Fare? 483
Regional Divisions 485
The Northeast 485
Regional Profile 485
Traditional Fare 487
Health Concerns 494
The Midwest 495
Regional Profile 495
Traditional Fare 496
Health Concerns 503
The South 503
Regional Profile 503
Traditional Fare 505
Health Concerns 517
The West 517
Regional Profile 517
Traditional Fare 518
Health Concerns 530
Glossary of Ethnic Ingredients 533
Resources 545
Index 549
viii C O N T E N T S
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

ix
and nutrition-related health problems of
various ethnic and racial groups.
4. Possess specific knowledge of cultural
values, health beliefs, and nutrition
practices of particular groups served,
including culturally different clients.
This book offers information fundamental
to these competencies.
How the Book Is Organized
The first four chapters form an introduction
to the study of food and culture. Chapter 1
discusses methods for understanding food
habits within the context of culture, chang-
ing demographics, and the ways in which
ethnicity may affect nutrition and health sta-
tus. Chapter 2 focuses on the role of diet in
traditional health beliefs. Some intercultural
communication strategies are suggested in
Chapter 3, and Chapter 4 outlines the major
Eastern and Western religions and reviews
their dietary practices in detail.
Chapters 5 through 14 profile North
American ethnic groups and their cuisines.
We have chosen breadth over depth, discuss-
ing groups with significant populations in the
United States, as well as smaller, more recent
immigrant groups who have had an impact on
the health care system. Other groups with low
numbers of immigrants but notable influences
on American cooking are briefly mentioned.
Groups are considered in the approximate
order of their arrival in North America. Each
chapter begins with a history of the group in
the United States and current demographics.
Worldview (outlook on life) is then examined,
including religion, family structure, and tra-
ditional health practices. This background
information illuminates the cultural context
Preface
The population of the United States is The population of the United States is Tincreasingly heterogeneous, moving Tincreasingly heterogeneous, moving Ttoward a plurality of ethnic, religious, Ttoward a plurality of ethnic, religious, T
and regional groups. Each of these groups has
traditional food habits that differ—slightly
or significantly—from the so-called typical
American majority diet. Effective nutri-
tion counseling, education, and food service
require that these variations be acknowl-
edged and understood within the context of
culture. It is our goal to provide dietitians,
nutritionists, and food service profession-
als with the broad overview needed to avoid
ethnocentric assumptions and the nutrition
specifics helpful in working with each group
discussed. We have attempted to combine the
conceptual with the technical in a way that is
useful to other health professionals as well.
We would like to draw attention specifi-
cally to the area of nutrition counseling: “In
nutrition counseling, where many thera-
peutic interventions are on a personal level,
sensitivity to the strong influence of culture
on an individual’s food intake, attitudes, and
behaviors is especially imperative. . . . Multi-
cultural competence is not a luxury or a spe-
cialty but a requirement for every registered
dietitian” (Curry, 2000, pp. 1, 142). A model
(Harris-Davis & Haughton, 2000) recom-
mended for multicultural nutrition compe-
tencies specifically lists the following:
1. Understand food selection, preparation,
and storage with a cultural context.
2. Have knowledge of cultural eating pat-
terns and family traditions such as core
foods, traditional celebrations, and
fasting.
3. Familiarize self with relevant research and
latest findings regarding food practices
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

from which ethnic foods and food habits
emerge and evolve. The next section of each
chapter outlines the traditional diet, includ-
ing ingredients, some common dishes, meal
patterns, special occasions, the role of food in
the society, and therapeutic uses of food. The
final section explains the contemporary diet
of the group, such as adaptations made by the
group after arrival in the United States and
influences of the group on the American diet.
Reported nutritional status is reviewed, and
general counseling guidelines are provided.
One or more cultural food group tables are
found in each of the ethnic group chapters.
The emphasis is on ingredients common to the
populations of the region. Important variations
within regions and unique food habits are listed
in the “Comments” column of the table. Known
adaptations in the United States are also noted.
The tables are intended as references for the
reader; they do not replace either the chapter
content or an in-depth interview with a client.
Chapter 15 considers the regional Ameri-
can fare of the Northeast, the Midwest, the
South, and the West. Each section includes
an examination of the foods common in the
region and general nutritional status. Cana-
dian regional fare is also briefly considered.
This chapter brings the study of cultural
nutrition full circle, discussing the significant
influences of different ethnic and religious
groups on North American fare.
Chapter-Specific Changes
• Chapter 1. Food and Culture—Updated
population data.
• Chapter 2. Traditional Health Beliefs and
Practices—Updated data on the use of
complementary and alternative medicine
(CAM).
• Chapter 3. Intercultural
Communications—No changes.
• Chapter 4. Food and Religion—Updated
demographics data on religious affiliation
in the United States.
• Chapter 5. Native Americans—Updated
U.S. Census data on Native American
population and other demographics.
Updated information on current diets,
nutritional status, and medical disorders
related to diet and nutrition.
• Chapter 6. Northern and Southern
Europeans—Updated U.S. Census popula-
tion and other demographics on European
groups. Updated information on current
diets, nutritional status, and medical dis-
orders related to diet and nutrition.
• Chapter 7. Central Europeans, People
of the Former Soviet Union, and
Scandinavians—Updated U.S. Census
population and other demographics on
central and eastern European groups.
Updated information on current diets,
nutritional status, and medical disorders
related to diet and nutrition.
• Chapter 8. Africans—Updated
U.S. Census population and other
demographics on African Americans
and more recent immigrant groups from
Africa. Updated information on current
diets, nutritional status, and medical
disorders related to diet and nutrition.
• Chapter 9. Mexicans and Central
Americans—Updated U.S. Census
population and other demographics on
Mexicans and Central American groups.
Updated information on current diets,
nutritional status, and medical disorders
related to diet and nutrition.
• Chapter 10. Caribbean Islanders and
South Americans—Updated U.S. Census
population and other demographics on
Caribbean and South American groups.
Updated information on current diets,
nutritional status, and medical disorders
related to diet and nutrition.
• Chapter 11. East Asians—Updated U.S.
Census population and other demo-
graphics on East Asian groups. Updated
information on current diets, nutritional
status, and medical disorders related to
diet and nutrition.
• Chapter 12. Southeast Asians and Pacific
Islanders—Updated U.S. Census popula-
tion and other demographics on East
Asian groups. Updated information on
current diets, nutritional status, and medi-
cal disorders related to diet and nutrition.
x P R E F A C E
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

• Chapter 13. People of the Balkans and the
Middle East—Updated U.S. Census popu-
lation and other demographics on Balkan
and Middle Eastern groups. Updated
information on current diets, nutritional
status, and medical disorders related to
diet and nutrition.
• Chapter 14. South Asians—Updated U.S.
Census population and other demograph-
ics on South Asian groups. Updated
information on current diets, nutritional
status, and medical disorders related to
diet and nutrition.
• Chapter 15. Regional Americans—
Updated U.S. Census regional popula-
tion and other demographics. Updated
information on current diets, nutritional
status, and medical disorders related to
diet and nutrition.
Before You Begin
Food is so essential to ethnic, religious, and
regional identity that dietary descriptions
must be as objective as possible to prevent
inadvertent criticism of the underlying culture.
Yet as members of two Western ethnic and
religious groups, we recognize that our own
cultural assumptions are unavoidable and, in
fact, serve as a starting point for our work. One
would be lost without such a cultural footing.
Any instances of bias are unintentional.
Any definition of a group’s food habits
implies homogeneity in the described group. In
daily life, however, each member of a group has
a distinctive diet, combining traditional prac-
tices with new influences. We do not want to
stereotype the fare of any cultural group. Rather,
we strive to generalize common U.S. food and
culture trends as a basis for understanding the
personal preferences of individual clients.
We have tried to be sensitive to the desig-
nations used by each cultural group, though
sometimes there is no consensus among
members regarding the preferred name for
the group. Also, there may be some confusion
about dates in the book. Nearly all religious
traditions adhere to their own calendar of
events based on solar or lunar months. These
calendars frequently differ from the Grego-
rian calendar used throughout most of the
world in business and government. Religious
ceremonies often move around according
to Gregorian dates, yet usually they are cal-
culated to occur in the correct season each
year. Historical events in the text are listed
according to the Gregorian calendar, using the
abbreviations for before common era (BCE)
and common era (CE).
We believe this book will do more than
introduce the concepts of food and culture. It
should also encourage self-examination and
individual cultural identification by the reader.
We hope that it will help dietitians, nutrition-
ists, other health care providers, and food
service professionals work effectively with
members of different ethnic, religious, and
regional groups. If it sparks a gustatory interest
in the foods of the world, we will be personally
pleased. De gustibus non est disputatum!
Acknowledgments
We are forever indebted to the many research-
ers, especially from the fields of anthropology
and sociology, who did the seminal work on
food habits that provided the groundwork for
this book, and to the many nutrition profes-
sionals who have shared their expertise with
us over the years. We especially want to thank
the many colleagues who have graciously
given support and advice in the development
of the numerous editions: Carmen Boyd, MS,
LPC, RD, Missouri State University; Bonny
Burns-Whitmore, DrPH, RD, California State
Polytechnic University, Pomona; Arlene Grant-
Holcomb, RD, MAE, California State Poly-
technic University, San Luis Obispo; Carolyn
Hollingshead, PhD, RD, University of Utah;
Tawni Holmes, PhD, RD, University of Cen-
tral Oklahoma; Claire G. Kratz, MS, RD, LDN,
Montgomery County Community College;
Yvonne Moody, EdD, Chadron State College;
Sudha Raj, PhD, Syracuse University; Stacey A.
Roush, MS, Montgomery County Community
College; Dana Wassmer, MS, RD, Cosumnes
River College; and Donna M. Winham, DrPH,
Arizona State University. We are grateful for the
expertise of Gerald Nelms, PhD, as his develop-
ment of the discussion starters during the 6th
edition revision was an important contribution
to the pedagogy for this text.
P R E F A C E xi
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

1
What Is Food?
Food, as defined in the dictionary, is any sub-
stance that provides the nutrients necessary to
maintain life and growth when ingested. When
most animals feed, they repeatedly consume
those foods necessary for their well-being, and
they do so in a similar manner at each feeding.
Humans, however, do not feed. They eat.
Eating is distinguished from feeding by
the ways humans use food. Humans not only
gather or hunt food, but they also cultivate
plants and raise livestock. Agriculture means
that some foods are regularly available, alle-
viating hand-to-mouth sustenance. This
permits the development of specific customs
associated with foods that are the foundation
of the diet, such as wheat or rice. Humans
also cook, softening tough foods, including
raw grains and meats, and combine foods to
create new textures and taste sensations. This
greatly expands the number and variety of
edible substances available. What follows are
rules regarding what can be eaten with what
and creates the meal. Humans use utensils to
eat meals and institute complex rules, com-
monly called manners, about how meals are
consumed. And, significantly, humans share
food. Standards for who may dine with whom
in each eating situation are well defined.
The term f ood h abits (also called food cul-
ture or foodways) refers to the ways in which
humans use food, including everything from
how it is selected, obtained, and distributed
to who prepares it, serves it, and eats it.
The significance of this process is unique to
Food and Culture
What do Americans eat? Meat and potatoes, according to popular myth. There’s no denying that
per person in the United States, an average
of over half a pound of beef, pork, lamb, or
veal is eaten daily, and more than one hun-
dred pounds of potatoes (mostly as chips and
fries) are consumed annually. Yet the Ameri-
can diet is as diverse as its population, and we
should no longer describe the U.S. population
as white, Anglo-Saxon, and Protestant, or the
diet as consisting of mostly meat and potatoes.
U.S. Census and other demographic data
show that close to 40 percent of Americans are
not white, 13 percent are foreign born, 11 per-
cent have one parent who was foreign born,
and one in five people in the United States are
first or second generation. More than seventy-
five different ancestry groups were reported
in 2007.1,2 In that year the fastest and largest
growing ethnic groups in America were from
Latin America, but more recently Asians
became the fastest growing race or ethnic
group.3
Each American ethnic, religious, or regional
group has its own culturally based food hab-
its. Many of these customs have been modified
through contact with American culture and, in
turn, they have changed and shaped American
food habits. Today, a fast-food restaurant or
street stand is as likely to offer pizza, tacos,
egg rolls, or falafel as it is hamburgers. It is the
intricate interplay between food habits of the
past and the present, the old and the new, and
the traditional and the innovative that is the
hallmark of the American diet.
As suggested by their
names, not even ham-
burgers and French fries
are American in origin.
Chopped beef steaks
were introduced to the
United States from the
German city of Hamburg
in the late nineteenth
century. The American
term French-fried pota-
toes first appeared in
the 1860s and was prob-
ably coined to describe
the method used in
France for deep-frying
potato pieces until crisp.
Other foods considered
typically American also
have foreign origins, for
example, hot dogs, apple
pie, and ice cream.
Data from the 2006
Canadian census indicate
more than 200 differ-
ent ethnic origins were
documented. The most
common ethnic groups
noted included English,
French, Scottish, Irish,
German, Italian, Chinese,
North American Indian,
Ukrainian, and Dutch.
Newer groups include
individuals from Mont-
serrat in the Carribean
and African countries
such as Chad, Gabon,
Gambia, and Zambia.90
1CHA
P
T
E
R
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

2 F O O D A N D C U L T U R E
humankind. Why don’t people simply feed on
the diet of our primitive ancestors, surviving
on foraged fruits, vegetables, grains, and the
occasional insect or small mammal thrown
in for protein? Why do people choose to
spend their time, energy, money, and creativ-
ity on eating? The answers to these questions,
according to some researchers, can be found
in the basic biological and psychological con-
stitution of humans.
The Omnivore’s Paradox
Humans are omnivorous, meaning that they
can consume and digest a wide selection of
plants and animals found in their surround-
ings. The primary advantage to this is that
they can live in various climates and terrains.
Because no single food provides the nutrition
necessary for survival, humans must be able to
eat enough of a variety of items, yet cautious
enough not to ingest foods that are harmful
and, possibly, fatal. This dilemma, the need to
experiment combined with the need for cau-
tion, is known as the omnivore’s paradox.4,5
It results in two contradictory psychological
impulses regarding eating—an attraction to
new foods, but a preference for familiar foods.
The food habits developed by a community
provide the framework that reduces the anxi-
ety produced by these opposing desires. Rules
about which foods are edible, how they are
procured and cooked, how they should taste,
It is thought that children
are less likely than adults
to try new foods, in part
because they have not
yet learned cultural rules
regarding what is safe
and edible. A child who
is exposed repeatedly to
new items loses the fear
of new foods faster than
one who experiences a
limited diet.11
▲ Humans create complex
rules, commonly called
manners, about how food
is to be eaten.
To
m
M
cC
ar
th
y/
Ph
ot
oE
di
t
and when they should be consumed provide
guidelines for both testing new foods (based
on previous experience with similar plants
and animals or flavors and textures) and
maintaining food traditions through ritual
and repetition.
Self-Identity
The choice of which foods to ingest is fur-
ther complicated by another psychological
concept regarding eating—the incorpora-
tion of food. This means that consumption is
not just the conversion of food into nutrients
in the human body, but also includes gaining
the food’s physical properties as well—hence
the phrase “You are what you eat.” In most
cases this refers to the physical properties of
a food expressed through incorporation. For
example, some Asian Indians eat walnuts,
which look like miniature brains, to make
them smarter, and weight lifters may dine on
rare meat to build muscle. In other cases, the
character of the food is incorporated. Some
Native Americans believe that because milk is
a food for infants, it will weaken adults. The
French say a person who eats too many tur-
nips becomes gutless, and some Vietnamese
consume gelatinized tiger bones to improve
their strength.
It is a small step from incorporating the
traits associated with a specific food to mak-
ing assumptions about a total diet. The cor-
relation between what people eat, how others
perceive them, and how they characterize
themselves is striking. In one study research-
ers listed five typical diets: vegetarian (kale
quiche, brown rice, avocado, and bean sprout
sandwich), gourmet (oysters, caviar, French
roast coffee), health food (protein shake,
wheat germ, yogurt), and fast food (ham-
burger, fried chicken, pizza). It was found that
each category was associated with a certain
personality type. Vegetarians were consid-
ered to be pacifists and likely to drive foreign
cars. Gourmets were believed to be liberal and
sophisticated. Health food fans were described
as antinuclear activists and were also liberal.
Fast-food eaters were believed to be religious,
conservative, and fond of polyester cloth-
ing. These stereotypes were confirmed by
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

C H A P T E R 1 3
self-description and personality tests com-
pleted by people whose diets fell into the five
categories.6
Another study asked college students to
rate profiles of people based on their diets.
Those who ate “good” foods were judged to
be thinner, more fit, and more active than
people with the identical physical character-
istics and exercise habits who ate “bad” foods.
Furthermore, the people who ate “good” foods
were perceived by some students as being
more attractive, likable, practical, methodi-
cal, quiet, and analytical than people who
ate “bad” foods. The researchers attribute the
strong morality-food effect to several fac-
tors, including the concept of incorporation
and a prevailing Puritan ethic that espouses
self-discipline.7
Food choice is, in fact, influenced by self-
identity, a process whereby the food likes or
dislikes of someone else are accepted and
internalized as personal preferences. Research
suggests that children choose foods eaten by
admired adults (e.g., teachers), fictional char-
acters, peers, and especially older siblings.
Parents have little long-lasting influence.
Group approval or disapproval of a food can
also condition a person’s acceptance or rejec-
tion. This may explain why certain relatively
unpalatable items, such as chili peppers or
unsweetened coffee, are enjoyed if intro-
duced through socially mediated events, such
as family meals or workplace snack breaks.
Although the mechanism for the internaliza-
tion of food preference and self-identity is not
well understood, it is considered a significant
factor in the development of food habits.8,9
A study on the consumption of organic
vegetables, for example, found that those who
identified themselves as green (people who are
concerned with ecology and make consumer
decisions based on this concern) predicted an
intention to eat organic items independent of
other attitudes, such as perceived flavor and
health benefits.9
Food as self-identity is especially evident
in the experience of dining out. Researchers
suggest that restaurants often serve more than
food, satisfying both emotional and physi-
cal needs. A diner may consider the menu,
atmosphere, service, and cost or value when
selecting a restaurant; and most establish-
ments cater to a specific clientele. Some offer
quick, inexpensive meals and play equipment
to attract families. Business clubs feature a
conservative setting suitable for financial
transactions, and the candlelit ambiance of
a bistro is conducive to romance. The same
diner may choose the first in her role as a
mother, the second while at work, and the
last when meeting a date. In Japan, restaurants
serve as surrogate homes where company is
entertained, preserving the privacy of family
life. The host chooses and pays for the meal
ahead of time, all guests are provided the same
dishes, and the servers are expected to partake
in the conversation. Ethnic restaurants appeal
to those individuals seeking familiarity and
authenticity in the foods of their homeland
or those interested in novelty and culinary
adventure. Conversely, exposure to different
foods in restaurants is sometimes the first step
in adopting new food items at home.10
Symbolic Use of Food
The development of food habits clearly indi-
cates that for humans, food is more than just
nutrients. Humans use foods symbolically,
due to relationship, association, or conven-
tion. Bread is an excellent example—it is
called the staff of life; one breaks bread with
friends, and bread represents the body of
Christ in the Christian sacrament of com-
munion. White bread was traditionally eaten
by the upper classes, dark bread by the poor,
but whole wheat bread is consumed today by
people concerned more with health than sta-
tus. A person with money has “a lot of bread.”
In many cultures, bread is shared by couples
as part of the wedding ceremony or left for
the soul of the dead. Superstitions about bread
also demonstrate its importance beyond sus-
tenance. Greek soldiers took a piece from
home to ensure their safe, victorious return;
English midwives placed a loaf at the foot of
the mother’s bed to prevent the woman and
her baby from being stolen by evil spirits; and
sailors traditionally brought a bun to sea to
prevent shipwreck. It is the symbolic use of
a food that is valued most by people, not its
nutritional composition.
The inability to express
self-identity through
food habits can be devas-
tating. A study of persons
with permanent feeding
tubes living at home or
in nursing facilities found
they frequently avoided
meals with families and
friends. They missed
their favorite foods, but
more important, they
mourned the loss of their
self-identities reinforced
by these daily social
interactions.106
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

4 F O O D A N D C U L T U R E
Cultural Identity
An essential symbolic function of food is cul-
tural identity. What one eats defines who one
is, culturally speaking, and, conversely, who
one is not. In the Middle East, for example,
a person who eats pork is probably Roman
Catholic or Orthodox Christian, not Jewish
or Muslim (pork is prohibited in Judaism
and Islam). Ravioli served with roast turkey
suggest an Italian American family celebrat-
ing Thanksgiving, not a Mexican American
family, who would be more likely to dine on
tamales and turkey. The food habits of each
cultural group are often linked to religious
beliefs or ethnic behaviors. Eating is a daily
reaffirmation of cultural identity (Figure 1.1).
Foods that demonstrate affiliation with a
culture are usually introduced during child-
hood and are associated with security or
good memories. Such foods hold special
worth to a person, even if other diets have
been adopted due to changes in residence,
religious membership, health status, or daily
personal preference. They may be eaten dur-
ing ethnic holidays and for personal events,
such as birthdays or weddings, or during
times of stress. These items are sometimes
called comfort foods because they satisfy the
basic psychological need for food familiarity.
For example, in the United States one study
found comfort foods for women required
little preparation and tended to be snacks,
such as potato chips, ice cream, chocolate,
and cookies; men preferred foods served by
their mothers, such as soup, pizza or pasta,
steak, and mashed potatoes.11 Occasionally,
a person embraces a certain diet as an adult
to establish association with a group. A con-
vert to Judaism, for instance, may adhere to
the kosher dietary laws. African Americans
who live outside the South may occasionally
choose to eat soul food (typically southern
black cuisine, such as pork ribs and greens)
as an expression of ethnic solidarity.
Figure 1.1
An edible map—
food-related names of
cities and towns in the
United States. Food often
means more than simply
nutrients.
Source: From All Over the Map:
An Extraordinary Atlas of the United
States: Featuring Towns That Actually
Exist! by David Jouris, copyright Exist! by David Jouris, copyright Exist!
© 1994 by David Jouris. Used by
permission of Ten Speed Press, an
imprint of Crown Publishing Group, a
division of Random House, Inc.
Feeding
Hills
Beanville Cornish
Suncook
Commons
Bakersville
CranberryCranberryCranberryCranberryCranberryCranberryCranberry
IslesIsles
FeedingFeedingFeedingFeedingFeedingFeedingFeedingFeedingFeedingFeedingFeedingFeedingFeedingFeedingFeedingFeedingFeedingFeedingFeedingFeedingFeedingFeedingFeedingFeedingFeedingFeedingFeedingFeedingFeedingFeedingFeedingFeedingFeedingFeedingFeedingFeedingFeedingFeedingFeedingFeedingFeedingFeedingFeedingFeedingFeedingFeedingFeedingFeedingFeedingFeedingFeedingFeedingFeedingFeedingFeedingFeedingFeedingFeedingFeedingFeedingFeedingFeedingFeedingFeedingFeedingFeeding
HillsHillsHillsHillsHillsHillsHillsHillsHillsHillsHillsHillsHillsHillsHillsHillsHillsHillsHillsHillsHills
BeanvilleBeanvilleBeanvilleBeanvilleBeanvilleBeanvilleBeanvilleBeanvilleBeanvilleBeanvilleBeanvilleBeanvilleBeanvilleBeanvilleBeanvilleBeanvilleBeanvilleBeanvilleBeanvilleBeanvilleBeanvilleBeanvilleBeanvilleBeanvilleBeanvilleBeanvilleBeanvilleBeanvilleBeanvilleBeanvilleBeanvilleBeanvilleBeanvilleBeanvilleBeanvilleBeanvilleBeanvilleBeanvilleBeanvilleBeanvilleBeanvilleBeanvilleBeanvilleBeanvilleBeanvilleBeanvilleBeanvilleBeanville CornishCornishCornishCornishCornishCornishCornishCornishCornishCornishCornishCornishCornishCornishCornishCornishCornishCornishCornishCornishCornishCornishCornishCornishCornishCornishCornishCornishCornishCornishCornishCornishCornish
SuncookSuncookSuncookSuncookSuncookSuncookSuncookSuncookSuncookSuncookSuncookSuncookSuncookSuncookSuncookSuncookSuncookSuncookSuncookSuncookSuncookSuncookSuncookSuncookSuncookSuncookSuncookSuncookSuncookSuncookSuncookSuncookSuncookSuncookSuncookSuncookSuncookSuncookSuncook
CommonsCommonsCommonsCommonsCommonsCommonsCommonsCommonsCommonsCommonsCommonsCommonsCommonsCommonsCommonsCommonsCommonsCommonsCommonsCommonsCommonsCommonsCommonsCommonsCommonsCommonsCommonsCommons
BakersvilleBakersvilleBakersvilleBakersvilleBakersvilleBakersvilleBakersvilleBakersvilleBakersvilleBakersvilleBakersvilleBakersvilleBakersvilleBakersvilleBakersvilleBakersvilleBakersvilleBakersvilleBakersvilleBakersvilleBakersvilleBakersvilleBakersvilleBakersvilleBakersvilleBakersvilleBakersvilleBakersvilleBakersvilleBakersvilleBakersvilleBakersvilleBakersvilleBakersvilleBakersvilleBakersvilleBakersvilleBakersvilleBakersvilleBakersvilleBakersvilleBakersvilleBakersvilleBakersvilleBakersvilleBakersvilleBakersvilleBakersvilleBakersvilleBakersvilleBakersvilleBakersvilleBakersvilleBakersvilleBakersvilleBakersvilleBakersvilleBakersvilleBakersvilleBakersvilleBakersvilleBakersvilleBakersvilleBakersvilleBakersvilleBakersvilleBakersvilleBakersvilleBakersvilleBakersvilleBakersvilleBakersvilleBakersvilleBakersvilleBakersvilleBakersville
Muttonville
Clove
Oniontown
Grill
Cress
Chewsville
Custards
NectarineNectarineNectarineNectarineNectarineNectarineNectarineNectarineNectarineNectarineNectarineNectarineNectarineNectarineNectarineNectarineNectarineNectarineNectarineNectarineNectarineNectarineNectarineNectarineNectarineNectarineNectarineNectarineNectarineCeleryville
Kitchen
SandwichSandwich
AdlaiAdlaiAdlaiAdlaiAdlaiAdlaiAdlaiAdlaiAdlaiAdlai
MustardMustardMustardMustardMustardMustardMustardMustardMustardMustardMustardMustardMustardMustardMustardMustardMustardMustardMustardMustardMustardMustardMustardMustard
Kabob
Cookville
KabobKabobKabobKabobKabobKabobKabobKabobKabobKabobKabobKabobKabobKabobKabobKabobKabobKabobKabobKabobKabobKabobKabobKabobKabobKabobKabobKabobKabobKabobKabobKabobKabobKabobKabobKabobKabobKabobKabobKabobKabobKabobKabobKabobKabobKabobKabobKabobKabobKabobKabobKabobKabobKabobKabobKabobKabobKabobKabobKabobKabobKabobKabob
CookvilleCookvilleCookvilleCookvilleCookvilleCookvilleCookvilleCookvilleCookvilleCookvilleCookvilleCookvilleCookvilleCookvilleCookvilleCookvilleCookvilleCookvilleCookvilleCookvilleCookvilleCookvilleCookvilleCookvilleCookvilleCookvilleCookvilleCookvilleCookvilleCookvilleCookvilleCookvilleCookvilleCookvilleCookvilleCookvilleCookvilleCookvilleCookvilleCookvilleCookvilleCookvilleCookvilleCookvilleCookvilleCookvilleCookvilleCookvilleCookvilleCookvilleCookvilleCookvilleCookvilleCookvilleCookvilleCookville
CookstownCookstownCookstownCookstownCookstownCookstownCookstownCookstownCookstownCookstownCookstownCookstownCookstownCookstownCookstownCookstownCookstownCookstownCookstownCookstownCookstownCookstownCookstownCookstownCookstownCookstownCookstownCookstownCookstownCookstownCookstownCookstownCookstownCookstownCookstownCookstown
LeektownLeektownLeektownLeektownLeektownLeektownLeektownLeektownLeektownLeektownLeektownLeektownLeektown
BarleyBarleyBarleyBarleyBarleyBarleyBarleyBarleyBarleyBarleyBarleyBarleyBarleyBarleyBarleyBarleyBarleyBarleyBarleyBarleyBarleyBarleyBarleyBarleyBarleyBarleyBarleyBarleyBarleyBarleyBarleyBarleyBarleyBarleyBarleyBarleyBarleyBarleyBarleyBarleyBarleyBarleyBarleyBarleyBarleyBarleyBarleyBarleyBarleyBarleyBarleyBarleyBarleyBarleyBarleyBarleyBarleyBarleyBarley
Gloucester
GlaceGlace
SpiceSpiceSpiceSpiceSpiceSpiceSpiceSpiceSpiceSpiceSpiceSpiceSpiceSpiceSpiceSpiceSpiceSpiceSpiceSpiceSpice
PepperPepperPepperPepperPepperPepperPepperPepperPepperPepperPepperPepperPepperPepperPepperPepperPepperPepperPepperPepperPepperPepperPepperPepperPepperPepperPepperPepperPepperPepperPepperPepperPepperPepperPepperPepperPepperPepperPepperPepperPepperPepperPepperPepperPepperPepperPepperPepperPepperPepperPepperPepperPepperPepperPepperPepperPepperPepper
BaconBaconBaconBaconBaconBaconBaconBaconBaconBacon
Toast
Mayo
PeakPeak Oats
Veal
Rocket
Mint
Ice
DuffDuffDuffDuffDuffDuffDuffDuffDuff
LambLambLambLambLambLambLambLambLambLambLamb
Farina
BerryBerry
CrackerCrackerCrackerCrackerCrackerCrackerCrackerCrackerCrackerCrackerCrackerCrackerCrackerCrackerCrackerCrackerCrackerCrackerCrackerCrackerCrackerCrackerCrackerRabbitRabbit
Hash
Greens
BasilTaffy
Mace
Grape
Jam
Cooks
Cook
Blackberry
Frost
Kalo
CanningCanning
Buffalo
Yampa
Fruitland
FruitlandFruitland
Sugar
City
Rye
Sugarville
Honeyville
RosetteRosetteRosetteRosetteRosetteRosetteRosetteRosetteRosetteRosetteRosetteRosetteRosetteRosetteRosetteRosetteRosetteRosetteRosetteRosette
Shell
Currant
PanochePanochePanochePanochePanochePanochePanochePanochePanochePanochePanochePanochePanochePanochePanochePanochePanochePanochePanochePanochePanochePanochePanochePanochePanochePanochePanochePanochePanochePanochePanochePanochePanochePanochePanochePanochePanochePanochePanoche
Olive
Straw
Curry
Melba
Gervais
NonpareilNonpareil
Raisin
Jelly
Honeydew
Forks of SalmonForks of SalmonForks of SalmonForks of SalmonForks of SalmonForks of SalmonForks of SalmonForks of Salmon
Aromas
Tomales
Coquille
CoupevilleCoupevilleCoupevilleCoupevilleCoupevilleCoupevilleCoupevilleCoupevilleCoupevilleCoupevilleCoupevilleCoupevilleCoupevilleCoupevilleCoupevilleCoupevilleCoupevilleCoupevilleCoupevilleCoupevilleCoupevilleCoupevilleCoupevilleCoupevilleCoupevilleCoupevilleCoupevilleCoupevilleCoupevilleCoupevilleCoupevilleCoupevilleCoupevilleCoupevilleCoupevilleCoupevilleCoupevilleCoupevilleCoupevilleCoupevilleCoupevilleCoupevilleCoupevilleCoupevilleCoupeville
Sweet
Lime
Cook
ForksForksForksForksForksForksForksForksForksForksForksForksForksForksForksForksForksForksForksForksForksForksForksForksForksForksForksForksForksForksForksForksForksForksForksForksForks
Marengo
Dixie
Browning
Three Forks Wild RiceWild RiceWild RiceWild RiceWild RiceWild RiceWild RiceWild RiceWild RiceWild RiceWild RiceWild RiceWild Rice
Fried
Newburg
Bismarck
Baxter
Kensington
CorningCorningCorningCorningCorningCorningCorningCorningCorningCorningCorningCorningCorningCorningCorningCorning
Castana
WalnutWalnutWalnutWalnutWalnutWalnutWalnutWalnutWalnutWalnutWalnutWalnutWalnutWalnutWalnutWalnutWalnut
Surprise
Cook
Hominy
Greasy
Okra
Oatmeal
Comal
Apple
Noodle
Plum
Lollipop
Ginger
Crisp
Sugar LandSugar LandSugar LandSugar LandSugar LandSugar LandSugar LandSugar LandSugar LandSugar LandSugar LandSugar LandSugar LandSugar LandSugar LandSugar LandSugar LandSugar LandSugar LandSugar LandSugar LandSugar LandSugar LandSugar LandSugar LandSugar LandSugar LandSugar LandSugar LandSugar LandSugar LandSugar LandSugar LandSugar LandSugar LandSugar LandSugar LandSugar LandSugar LandSugar LandSugar LandSugar LandSugar LandSugar LandSugar LandSugar LandSugar LandSugar LandSugar LandSugar LandSugar LandSugar LandSugar LandSugar LandSugar LandSugar Land
Sandia
Platter
Apple
Platter
Apple
Corn
CookietownCookietownCookietownCookietownCookietownCookietownCookietownCookietownCookietownCookietownCookietownCookietownCookietownCookietownCookietownCookietownCookietownCookietownCookietownCookietownCookietownCookietownCookietownCookietownCookietownCookietownCookietownCookietownCookietownCookietownCookietownCookietownCookietownCookietownCookietown
Pumpkin Center
Littlefork
Plat
Sears
Cream
Rusk
Range
BlueberryBlueberry
GnawGnaw
Bone
Pimento
Napoleon
Herbs
Rice
Peck
Salty
Yum YumTomato
GumboGumbo
Cook StationCook Station
Peel
SageSage
Durian
DillDillDillDillDillDillDillDillDillDillDillDill
Eggville
Hero
Rosemary
SaucierSaucierSaucierSaucierSaucierSaucierSaucierSaucierSaucierSaucierSaucierSaucierSaucierSaucierSaucierSaucierSaucier
Baker
SupremeSupremeSupremeSupremeSupremeSupremeSupremeSupremeSupremeSupremeSupremeSupremeSupremeSupremeSupremeSupremeSupremeSupremeSupremeSupremeSupremeSupremeSupremeSupremeSupremeSupremeSupremeSupremeSupremeSupremeSupremeSupremeSupremeSupremeSupremeSupremeSupremeSupremeSupremeSupremeSupremeSupremeSupremeSupremeSupremeSupremeSupremeSupremeSupremeSupremeSupremeSupremeSupremeSupremeSupremeSupremeSupremeSupremeSupremeSupremeSupremeSupremeSupremeSupremeSupremeSupremeSupremeSupremeSupremeSupremeSupremeSupremeSupremeSupremeSupremeSupremeSupremeSupreme
MuscadineMuscadine
Almond
Service
Five
ForksFour
Forks
LinkLinkLinkLinkLinkLinkLinkLinkLinkLinkLinkLinkLinkLinkLink
CreoleCreoleCreoleCreoleCreoleCreoleCreoleCreoleCreoleCreoleCreole
Plateau
Bread Springs
Pinenut
Pie Town
Cherry
Dateland
Roll
Chili
SpudsTwo EggTwo EggTwo EggTwo EggTwo EggTwo EggTwo EggTwo EggTwo EggTwo EggTwo EggTwo EggTwo EggTwo EggTwo EggTwo EggTwo EggTwo EggTwo EggTwo EggTwo EggTwo EggTwo EggTwo EggTwo EggTwo EggTwo EggTwo EggTwo EggTwo EggTwo EggTwo EggTwo EggTwo EggTwo EggTwo EggTwo EggTwo EggTwo EggTwo EggTwo EggTwo EggTwo EggTwo EggTwo EggTwo EggTwo EggTwo EggTwo EggTwo EggTwo EggTwo EggTwo EggTwo EggTwo EggTwo EggTwo EggTwo EggTwo EggTwo EggTwo EggTwo EggTwo EggTwo EggTwo EggTwo EggTwo EggTwo EggTwo EggTwo Egg
CitronelleCitronelleCitronelleCitronelleCitronelleCitronelleCitronelleCitronelleCitronelleCitronelleCitronelleCitronelleCitronelleCitronelleCitronelleCitronelleCitronelleCitronelleCitronelleCitronelleCitronelleCitronelleCitronelleCitronelleCitronelle
Mango
Coconut
MangoMangoMangoMangoMangoMangoMangoMangoMangoMangoMangoMangoMangoMangoMangoMangoMangoMangoMangoMangoMangoMangoMangoMangoMangoMangoMangoMangoMangoMangoMangoMangoMangoMangoMangoMangoMangoMangoMangoMangoMangoMangoMangoMangoMangoMangoMangoMangoMangoMangoMangoMangoMangoMangoMangoMangoMangoMangoMangoMangoMangoMangoMangoMangoMangoMangoMangoMangoMangoMangoMango
CoconutCoconutCoconutCoconutCoconutCoconutCoconutCoconutCoconutCoconutCoconutCoconutCoconutCoconutCoconutCoconutCoconutCoconutCoconutCoconutCoconutCoconutCoconutCoconutCoconutCoconutCoconutCoconutCoconut CorkscrewCorkscrewCorkscrewCorkscrewCorkscrewCorkscrewCorkscrewCorkscrewCorkscrewCorkscrewCorkscrewCorkscrewCorkscrewCorkscrewCorkscrewCorkscrewCorkscrewCorkscrewCorkscrewCorkscrewCorkscrewCorkscrewCorkscrewCorkscrewCorkscrewCorkscrewCorkscrewCorkscrewCorkscrewCorkscrewCorkscrewCorkscrewCorkscrewCorkscrewCorkscrewCorkscrewCorkscrewCorkscrewCorkscrewCorkscrewCorkscrewCorkscrewCorkscrewCorkscrewCorkscrewCorkscrewCorkscrewCorkscrewCorkscrewCorkscrewCorkscrewCorkscrewCorkscrew
Picnic
TangreineTangerineTangerineTangerineTangerineTangerineTangerineTangerineTangerineTangreineTangerineTangreineTangreineTangerineTangreineTangreineTangerineTangreineTangreineTangerineTangreineTangreineTangerineTangreineTangreineTangerineTangreineTangreineTangerineTangreineTangreineTangerineTangreineTangreineTangerineTangreineTangreineTangerineTangreineTangreineTangerineTangreineTangerineTangerineTangerineTangerineTangerineTangerineTangerineTangerineTangerine
PersimmonPersimmonPersimmonPersimmonPersimmonPersimmonPersimmonPersimmonPersimmonPersimmonPersimmonPersimmonPersimmonPersimmonPersimmonPersimmonPersimmonPersimmonPersimmonPersimmonPersimmonPersimmonPersimmonPersimmonPersimmon
Bayleaf
ChewsvilleChewsvilleChewsvilleChewsvilleChewsvilleChewsvilleChewsvilleChewsvilleChewsvilleChewsvilleChewsvilleChewsvilleChewsvilleChewsvilleChewsvilleChewsvilleChewsvilleChewsvilleChewsvilleChewsvilleChewsvilleChewsvilleChewsvilleChewsvilleChewsvilleChewsvilleChewsvilleChewsvilleChewsvilleChewsvilleChewsvilleChewsvilleChewsvilleChewsvilleChewsvilleChewsvilleChewsvilleChewsvilleChewsvilleChewsvilleChewsvilleChewsvilleChewsvilleChewsvilleChewsvilleChewsvilleChewsvilleChewsvilleChewsvilleChewsvilleChewsvilleChewsvilleChewsvilleChewsvilleChewsvilleChewsvilleChewsvilleChewsvilleChewsvilleChewsvilleChewsvilleChewsville
ChantillyChantillyChantillyChantillyChantillyChantillyChantillyChantillyChantillyChantillyChantillyChantillyChantillyChantillyChantillyChantillyChantillyChantillyChantillyChantillyChantillyChantillyChantillyChantillyChantillyChantillyChantillyChantillyChantillyChantillyChantillyChantillyChantillyChantillyChantillyChantillyChantillyChantillyChantillyChantillyChantillyChantillyChantillyChantillyChantillyChantillyChantillyChantillyChantillyChantillyChantillyChantillyChantillyChantillyChantillyChantillyChantillyChantillyChantillyChantillyChantillyChantillyChantillyChantillyChantillyChantillyChantillyChantillyChantillyChantillyChantillyChantillyChantillyChantillyChantillyChantillyChantillyChantillyChantillyChantillyChantillyChantillyChantillyChantillyChantillyChantillyChantillyChantillyChantillyChantillyChantillyChantillyChantillyChantillyChantillyChantillyChantillyChantillyChantillyChantilly
ToppingToppingToppingToppingToppingTopping
Glace
Topping
Glace
Topping
Glace
Topping
Glace
ToppingToppingToppingToppingToppingToppingToppingToppingToppingToppingToppingToppingToppingToppingToppingToppingToppingToppingToppingToppingToppingTopping
BlanchBlanchBlanchBlanchBlanchBlanchBlanchBlanchBlanchBlanch
CharlotteCharlotte
FriesFriesFriesFriesFriesFriesFriesFriesFriesFriesFriesFriesFriesFriesFriesFriesFriesFriesFriesFriesFriesFriesFriesFriesFriesFriesFriesFriesFriesFries Chip
Orange
Strawberry
Lemons
Pancake
Cooks
Corning
Cream
Re
pr
in
te
d
w
ith
p
er
m
is
si
on
fr
om
A
ll
O
ve
r T
he
M
ap
b
y
D
av
id
J
ou
ris
. C
op
yr
ig
ht
1
99
4
by
D
av
id
J
ou
ris
, T
en
S
pe
ed
P
re
ss
, B
er
ke
le
y,
C
A
.
A
ll
O
ve
r T
he
M
ap
b
y
D
av
id
J
ou
ris
. C
op
yr
ig
ht
1
99
4
by
D
av
id
J
ou
ris
, T
en
S
pe
ed
P
re
ss
, B
er
ke
le
y,
C
A
.
A
ll
O
ve
r T
he
M
ap
b
y
w
w
w
.te
ns
pe
ed
.c
om
.
Maks Narodenko/
Shutterstock.com
Hurst Photo/
Shutterstock.com
Ti
m
U
R/

Sh
ut
te
rs
to
ck
.c
om
Ch
ris
tia
n
Ju
ng
/
Sh
ut
te
rs
to
ck
.c
om
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

C H A P T E R 1 5
The reverse is also true. One way to estab-
lish that a person is not a member of a certain
cultural group is through diet. Researchers
suggest that when one first eats the food of
another cultural group, a chain of reasoning
occurs, beginning with the recognition that
one is experiencing a new flavor and ending
with the assumption that this new flavor is an
authentic marker of other group members.12
Ethnic groups may be denigrated by using
food stereotyping, and such slurs are found
in nearly all cultures. In the United States,
Germans are sometimes called “krauts,”
Chinese “cookies” or “dim sums,” Italians
“spaghetti benders,” Mexicans “beaners,” Irish
“potatoheads,” Koreans “kimchi,” and poor
white southerners “crackers” (possibly from
“corncracker,” someone who cracks corn to
distill whiskey or from early immigrants to
Georgia who survived on biscuits).
Foods that come from other cultures may
also be distinguished as foreign to maintain
group separation. K af ir , a derogatory Ara-
bic term for “infidel,” was used to label some
items found in areas they colonized, includ-
ing the knobby kaffir lime of Malaysia, and
kaffir corn (millet) in Africa. Similarly, when
some non-Asian foods were introduced to
China, they were labeled barbarian or Wester
and named after items already familiar in the
diet. Thus, sweet potatoes were called barbar-
ian yams, and tomatoes became barbarian
eggplants.13 Less provocative place names
are used, too, though the origins of the food
are often incorrect, such as T ur k ey w h eat (the T ur k ey w h eat (the T ur k ey w h eat
Dutch term for native American corn, which
was thought to come from Turkey) and Irish
potatoes (which are indigenous to Peru but
were brought to the United States by immi-
grants from Ireland). The powerful symbolic
significance of food terms leads occasionally
to renaming foreign items in an attempt to
assert a new cultural identity. Turkish coffee
(it was the Ottomans of Turkey who popu-
larized this thick, dark brew from Africa and
spread it through their empire) became Greek
coffee in Greece after tensions between the
two nations escalated in the 1920s. Examples
in the United States include renaming sauer-
kraut liberty cabbage during World War I, and
more recently, calling French fries freedom
fries when France opposed the United States
in the invasion of Iraq.
The appropriate use of food and the
behaviors associated with eating, also known
as etiquette, are another expression of group
membership. In the United States, entirely dif-membership. In the United States, entirely dif-membership. In the United States, entirely dif
ferent manners are required during a business
lunch at an expensive restaurant, when eating
in the school cafeteria, when drinking with
friends at a bar, or when dining with a date.
Discomfort can occur if a person is unfamil-
iar with the rules, and if a person deliberately
breaks the rules, he or she may be ostracized
or shunned.
Another function of food symbolism is to
define status—a person’s position or ranking
within a particular cultural group. Food can
be used to signify economic social standing:
champagne, Kobe beef, and truffles suggest
wealth; trendy hip restaurants suggest upward
mobility; and beans or potatoes are tradition-
ally associated with the poor. Status foods are
characteristically used for social interaction.
In the United States, a wife may appreciate
a box of chocolates from her husband—but
not a bundle of broccoli. Wine is considered
an appropriate gift to a hostess—a gallon of
milk is not. In general, eating with someone
connotes social equality with that person.
Many societies regulate commensalism (who
can dine together) as a means of establishing
class relationships. Men may eat separately
from women and children, or servants may
eat in the kitchen, away from their employ-
ers. In India, the separate social castes did not
traditionally dine together, nor were people
of higher castes permitted to eat food pre-
pared by someone of a lower caste. This class
Children younger than
age two will eat anything
and everything. Children
between three and six
years of age begin to
reject culturally unac-
ceptable food items. By
age seven, children are
completely repulsed
by foods that their
culture categorizes as
repugnant.107
Typically, first-generation
immigrants remain
emotionally connected to
their ethnicity, surrounding
themselves with a reference
group of family and friends
who share their cultural
background.
▲
D
IZ
M
ue
nc
he
n
G
m
bH
, S
ue
dd
eu
ts
ch
e
Ze
itu
ng
P
ho
to
/A
la
m
y
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

6 F O O D A N D C U L T U R E
segregation was also seen in some U.S. restau-
rants that excluded blacks before civil rights
legislation of the 1960s.
What Is Culture?
Culture is broadly defined as the values,
beliefs, attitudes, and practices accepted by
members of a group or community. Culture
is learned, not inherited; it is passed from gen-
eration to generation through language and
socialization in a process called encultura-
tion.14 Yet culture is not rigid and does change
over time in response to group dynamics.15
Cultural membership is defined by ethnic-
ity. Unlike national origin (which may include
numerous ethnic groups), ethnicity is a social
identity associated with shared behavior pat-
terns, including food habits, dress, language,
family structure, and often religious affili-
ation.15 Members of the same ethnic group
usually have a common heritage through
locality or history and participate together
with other cultural groups in a larger social
system. As part of this greater community,
each ethnic group may have different status
or positions of power. Diversity within each
cultural group is also common due to racial,
regional, or economic divisions as well as dif-regional, or economic divisions as well as dif-regional, or economic divisions as well as dif
fering rates of acculturation to the majority
culture.16
The Acculturation Process
When people from one ethnicity move to an
area with different cultural norms, adapta-
tion to the new majority society begins. This
process is known as acculturation, and it takes
place along a continuum of behavior patterns
that can be very fluid, moving back and forth
between traditional practices and adopted
customs. It occurs at the micro level, reflect-
ing an individual’s change in attitudes, beliefs,
and behaviors, and at the macro level, result-
ing in group changes that may be physical,
economic, social, or political in nature.17,18,19
Typically, first-generation immigrants remain
emotionally connected to their culture of ori-
gin. They integrate into their new society by
adopting some majority culture values and
practices but generally surround themselves
with a reference group of family and friends
from their ethnic background. For example,
Asian Indians living in the United States who
consider themselves to be “mostly or very
Asian Indian” may encourage their children
to speak English and allow them to celebrate
American holidays, but usually do not permit
them to date non-Asian Indian peers.20
Other immigrants become bicultural,
which happens when the new majority cul-
ture is seen as complementing, rather than
competing with, an individual’s ethnicity.
The positive aspects of both societies are
embraced, and the individual develops the
skills needed to operate within either cul-
ture.21 Asian Indians who call themselves
Indo-Americans or Asian Indian Americans
fall into this category, eating equal amounts
of Indian and American foods, thinking and
reading equally in an Indian language and in
English. Assimilation occurs when people
from one cultural group shed their ethnic
identity and fully merge into the majority cul-
ture. Although some first-generation immi-
grants strive toward assimilation, due perhaps
to personal determination to survive in a for-
eign country or to take advantage of oppor-
tunities, most often assimilation takes place
in subsequent generations. Asian Indians who
identify themselves as being “mostly Ameri-
can” do not consider Asian Indian culture
superior to American culture, and they are
willing to let their children date non-Indians.
It is believed that ethnic pride is reawakened
in some immigrants if they become disillu-
sioned with life in America, particularly if
the disappointment is attributed to prejudice
from the majority society. A few immigrants
exist at the edges of the acculturation pro-
cess, either maintaining total ethnic identity
or rejecting both their culture of origin and
that of the majority culture.22
Acculturation of Food
Habits
Culturally based food habits are often the last
practices people change through accultura-
tion. Unlike speaking a foreign language or
wearing traditional clothing, eating is usu-
ally done in the privacy of the home, hidden
Ethnocentric is the term
applied to a person
who uses his or her own
values to evaluate the
behaviors of others. It
may be done uncon-
sciously or in the con-
scious belief that their
own habits are superior
to those of another
culture. Ethnorelativism
occurs when a person
assumes that all cultural
values have equal valid-
ity, resulting in moral
paralysis and an inability
to advocate for a belief.
Prejudice is hostility
directed toward persons
of different cultural
groups because they are
members of such groups;
it does not account for
individual differences.108
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

C H A P T E R 1 7
from observation by others. Adoption of
new food items does not generally develop
as a steady progression from traditional diet
to the diet of the majority culture. Instead,
research indicates that the consumption of
new items is often independent of traditional
food habits.17,18 The lack of available native
ingredients may force immediate accultura-
tion, or convenience or cost factors may speed
change. Samoans may be unable to find the
fresh coconut cream needed to prepare favor-
ite dishes, for instance, or an Iranian may
find the cost of saffron prohibitive. Some
immigrants, however, adapt the foods of the
new culture to the preparation of traditional
dishes.17 Tasty foods are easily accepted—
fast food, pastries, candies, and soft drinks;
conversely, unpopular traditional foods may
be the first to go. Mexican children living in
the United States quickly reject certain cuts
of meat, such as tripe, that their parents still
enjoy. It is the foods most associated with eth-
nic identity that are most resistant to accultur-
ation. Muslims will probably never eat pork,
regardless of where they live. People from sev-
eral Asian countries may insist on eating rice
with every meal, even if it is the only Asian
food on the table.
Cultural Food Habits
Food functions vary culturally, and each
group creates categories reflective of their
priorities. In the United States, food has been
typically classified by food group (protein,
dairy, cereal and grain, fruits and vegetables),
by percentage of important nutrients (as iden-
tified in Dietary Reference Intake [DRI] for
energy, protein, fat, carbohydrates, vitamins,
and minerals), or according to recommenda-
tions for health. American models, especially
the Dietary Guidelines for Americans 2010
and the new model, ChooseMyPlate, outline
current dietary recommendations to sup-
port health guidelines. These categories also
suggest that Americans value food more for
nutritional content and impact on health than
for any symbolic use. But only limited infor-
mation is provided about U.S. food habits;
although these schemes list what foods people
eat, they reveal nothing about how, when, or
why foods are consumed.
Culturally based categories are commonly
used by members of each culture. Examples
found in both developing and industrialized
societies include cultural superfoods, usu-
ally staples that have a dominant role in the
diet; prestige foods, often protein items or
expensive or rare foods; body image foods,
believed to influence health, beauty, and well-
being; sympathetic magic foods, whose traits,
through association of color or form, are
incorporated; and physiologic group foods,
reserved for, or forbidden to, groups with cer-
tain physiologic status, such as gender, age, or
health condition.23
Researchers have proposed numerous
models to understand the food habits of dif-models to understand the food habits of dif-models to understand the food habits of dif
ferent cultures. Some of these models are help-
ful in understanding the role of food within a
culture, including:
1. C or e and c ompl ementar y f oods model:
frequency of food consumption
2. F ood- f l av or pr inc ipl es: ways a culture
traditionally prepares and seasons its
foods
3. M eal patter ns and meal c y c l es: daily,
weekly, and yearly use of food
4. Dev el opmental per spec tiv e of f ood
c ul tur e: changes in food functions that
emerge during structural growth in a
culture
Core and Complementary
Foods Model
Foods selected by a culture can be grouped
according to how often they’re consumed.
Core foods are staples regularly included in a
person’s diet, usually on a daily basis.24 These
typically include complex carbohydrates,
such as rice, wheat, corn, yams, cassava, taro,
or plantains. Foods widely but less frequently
eaten are termed secondary foods. These
items, such as chicken or lettuce or apples,
are consumed once a week or more, but not
daily. Foods eaten only sporadically are called
peripheral foods. These foods are characteris-
tic of individual food preference, not cultural
group habit.
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

8 F O O D A N D C U L T U R E
A slightly different version of this model
suggests that in many cultures, the core food is
always served with fringe, or complementary,
items to improve palatability (Figure 1.2).25
Because most starchy staples are bland and
uniform in texture, these flavorful foods, eaten
in small quantities, encourage consumption of
the core food as the bulk of the diet. Legumes,
for example, are sometimes a complemen-
tary food and sometimes a secondary food.
It has been hypothesized that these core and
complementary food pairings often combine
to provide nutritionally adequate meals, espe-
cially when legumes are included. Another
example is in cultures where a grain is a core
food and additional sources of vitamins A
and C are required. Rice, breads and pastas,
and corn are frequently prepared with leafy
green vegetables, abundant herbs, or toma-
toes, which are high in these needed nutrients.
Chinese rice with pickled vegetables, Italian
noodles with tomato sauce, Mexican corn tor-
tillas with salsa, and Middle Eastern pilaf with
parsley and dried fruit are examples. When
the core diet is almost adequate nutritionally,
the addition of secondary foods—including
legumes (soybean products in China; beans or
lentils in Italy; red or pinto beans in Mexico;
and chickpeas, fava beans, and lentils in the
Middle East), small amounts of meats, poul-
try, fish, and cheeses or yogurt—can provide
the necessary balance.
Changes in food behaviors are believed
to happen most often with peripheral foods
and then core foods. A person who is will-
ing to omit foods that she or he rarely eats
is typically much more reluctant to change
those eaten daily and associated with her or
his cultural identity. Although little has been
reported on the significance of complemen-
tary foods in diet modification, presumably,
if complementary items were altered or omit-
ted, the core would no longer be palatable.
The complementary foods provide the flavor
familiarity associated with the core.
Flavor Principles
The significance of food flavor cannot be
overestimated. The ways foods are prepared
and seasoned is only second in importance
to the initial selection of ingredients. It is no
less than the transformation of feeding into
eating.
Foods demonstrate variability according
to location. Much is made, for example, of
wine ter r oir —the soil texture, natural miner-
als, drainage, source of water, sun exposure,
average temperature, and other environmen-
tal factors in which grapes are grown for wine
production. Each region and every vineyard
are distinctive, often producing appreciable
differences in the resulting product. Yet this
variation is insignificant when compared to
how foods in general are processed for con-
sumption. Every technique, from preparation
for cooking (e.g., washing, hulling or peeling,
chopping, pounding, squeezing, soaking,
leaching, and marinating) to cooking (e.g.,
baking, roasting, grilling, stewing, toasting,
steaming, boiling, and frying) and preserv-
ing (e.g., drying, curing, canning, pickling,
fermenting, and freezing), alters the original
flavor of the ingredient. Nevertheless, loca-
tion and manipulation practices alone do
not equal cuisine. For that, foods must be
seasoned.
Historians and scientists speculate there
are several reasons why herbs and spices have
assumed such an essential role in food habits.
Foremost is palatability. Salt, one of the most
widely used seasonings, prompts an innate
human taste response. It is enjoyed by most
people and physiologically craved by some.
Figure 1.2
The core and complemen-
tary foods model.
Complementary
Foods
Core
Foods
Secondary Foods
Peripheral Foods
©
C
en
ga
ge
L
ea
rn
in
g
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

C H A P T E R 1 9
Researchers also suggest that the burn of chili
peppers (and perhaps other spices) may trig-
ger the release of pleasurable endorphins.
Another recurrent theory on the popular-
ity of seasoning early on was to disguise the
taste of spoiled meats, though evidence for
this is limited. A more plausible assertion is
that spices were found effective in preserving
meats. A survey of recipes worldwide sug-
gested that the antimicrobial activity of spices
accounts for their widespread use, especially
in hot climates.26 Other researchers speculate
that eating chili peppers (and, by extension,
other hot seasonings such as mustard, horse-
radish, and wasabi) is a benign form of risk
taking that provides a safe thrill.27 Addition-
ally, the recurrent use of seasonings may pro-
vide the familiarity sought in the omnivore’s
dilemma.28
Theories aside, seasonings can be used
to classify cuisines culturally.28,29 Unique
seasoning combinations, termed f l av or
pr inc ipl es, typify the foods of ethnic groups
worldwide. They are so distinctive that few
people mistake their use. For example, a
dish flavored with soy sauce is Asian and not
European. These seasoning combinations are
often found in the complementary foods of
the core and complementary foods model,
providing the flavors associated with the
starchy carbohydrates that are the staples of
a culture. They usually include herbs, spices,
vegetables, and a fat or oil, although many
variations exist. A principle flavor combina-
tion in West Africa is tomatoes, onion, and
chili peppers that have been sauté in palm
oil. In the Pacific Islands, a flavor principle is
coconut milk or cream with a little lime juice
and salt. Yams taste like West African food
when topped with the tomato mixture and
like Pacific Islander food when served with
the coconut sauce. Some widely recognizable
flavor principles include:
• Asian Indian: garam masala (curry blend
of coriander, cumin, fenugreek, turmeric,
black pepper, cayenne, cloves, cardamom,
and chili peppers)
• Brazilian (Bahia): chili peppers, dried
shrimp, ginger root, and palm oil
• Chinese: soy sauce, rice wine, and ginger
root
• French: butter, cream, wine, boquet garni
(selected herbs, such as tarragon, thyme,
and bay leaf )
• German: sour cream, vinegar, dill,
mustard, and black pepper
• Greek: lemon, onions, garlic, oregano,
and olive oil
• Italian: tomato, garlic, basil, oregano, and
olive oil
• Japanese: soy sauce, sugar, and rice wine
vinegar
• Korean: soy sauce, garlic, ginger root,
black pepper, scallions, chili peppers, and
sesame seeds or oil
• Mexican: tomatoes, onions, chili peppers,
and cumin
• Puerto Rican: sofrito (seasoning sauce
of tomatoes, onions, garlic, bell peppers,
cilantro, capers, pimento, annatto seeds,
and lard)
• Russian: sour cream, onion, dill, and
parsley
• Scandinavian: sour cream, onion,
mustard, dill, and caraway
• Thai: fermented fish sauce, coconut milk,
chili peppers, garlic, ginger root, lemon
grass, and tamarind
It would be incorrect to assume that every
dish from each culture is flavored with its
characteristic seasoning combinations, or
that flavor principle seasonings are limited to
just those listed. It’s common to find regional
variations as well. In China, northern cuisine
often includes the flavor principle seasonings
enhanced with soybean paste, garlic, and ses-
ame oil. In the south, fermented black beans
are frequently added, although in the Szech-
wan region hot bean paste, chili peppers, or
Szechwan (fagara) pepper is more common.
In the specialty cuisine of the Hakka, the addi-
tion of red rice wine is distinctive. Further, in
any culture where the traditional seasoning
combinations are prepared at home, not pur-
chased, modifications to suit each family are
A few cuisines have
extremely limited sea-
sonings, including the
fare of the Inuits. Broadly
speaking, cuisines offer-
ing large portions of
meat and other protein
foods tend to be less
seasoned than those
with a higher proportion
of grains, fruits and veg-
etables, and legumes.
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

1 0 F O O D A N D C U L T U R E
customary.30 Flavor principles are therefore
more of a marker for each culture’s cuisine
rather than a rigid rule.
Meal Patterns and Meal
Cycles
People in every culture dine on at least one
meal each day, and meal patterns and meal
cycles reveal clues about complex social rela-
tions and the significance of certain events
in a society.31 The first step in decoding
these patterns and cycles is to determine
what types of food constitute a meal within
a culture.
In the United States, for instance, cocktails
and appetizers or coffee and dessert are not
considered meals. A meal should consist of a
main course and side dishes; typically a meat,
vegetable, and starch. In the western African
nation of Cameroon, a meal is a snack unless
cassava paste is served. In many Asian cul-
tures, a meal is not considered a meal unless
rice is included, no matter how much other
food is consumed. A one-pot dish is consid-
ered a meal if it contains all the elements of
a full meal. For example, American casserole
dishes often feature protein, vegetables, and a
starch, such as tuna casserole (tuna, peas, and
noodles). In England it could be shepherd’s
pie (ground beef, green beans, and tomato
sauce topped with mashed potatoes).
The elements that define a meal must also
be served in their proper order. In the United
States, appetizers come before soup or salad,
followed by the entrée and then by dessert. In
France, the salad is served after the entrée. All
foods are served simultaneously in Vietnam
so that each person may combine flavors and
textures according to taste. In addition to con-
sidering the proper serving order, foods must
also be appropriate for the meal or situation.
Some cultures do not distinguish which foods
can be served at different meals, but in the
United States eggs and bacon are considered
breakfast foods, while cheese and olives are
popular in the Middle East for the morning
meal. Soup is commonly served at breakfast
in Southeast Asia, but in the United States
soup is a lunch or dinner food, and in parts
of Europe fruit soup is sometimes served as
dessert. Cake and ice cream are appropriate
for a child’s birthday party in the United
States; wine and cheese are not.
Other aspects of the meal message include
who prepares the meal and what culturally spe-
cific preparation rules are used. In the United
States, ketchup goes with French fries; in Great
Britain, vinegar is sprinkled on chips (fried
potatoes). Orthodox Jews consume meat only if
it has been slaughtered by an approved butcher
in an approved manner and has been prepared
in a particular way. (See Chapter 4, “Food and
Religion,” for more information on Judaism.)
Who eats the meal is also important.
A meal is frequently used to define personal
relationships. Americans are comfortable
inviting friends for dinner, but they usually
invite acquaintances for just drinks and appe-
tizers. For a family dinner, people may include
only some of the elements that constitute a
meal, but serving a meal to guests requires that
all elements be included in their proper order.
The final element of what constitutes a
meal is portion size. In many cultures, one
meal a day is designated the main meal and
usually contains the largest portions. The
amount of food considered appropriate var-
ies, however. A traditional serving of beef in
China may be limited to one ounce added to a
dish of rice. In France, a three- or four-ounce
filet is more typical. In the United States, a six-
or even eight-ounce steak is not unusual, and
some restaurants specialize in twelve-ounce
or larger cuts of prime rib. American tradi-
tion is to clean one’s plate regardless of how
much is served, while in other cultures, such
as those in the Middle East, it is considered
polite to leave some food to demonstrate that
enough was provided by the host.
Just as individual meals have cultural dif-Just as individual meals have cultural dif-Just as individual meals have cultural dif
ferences, the number of meals and when they
are eaten also varies. In much of Europe a
large main meal is customarily consumed at
noontime, for example, while in most of the
United States today the main meal is eaten in
the evening. In poor societies only one meal
per day may be eaten, whereas in wealthy
cultures three or four meals are standard.
The meal cycle in most cultures also
includes feasting or fasting, and often both.
Feasting celebrates special events, occurring
in nearly every society where a surplus of food
can be accumulated. Religious holidays such as
The sprig of parsley
added to a plate of food
may have originated as
a way to safeguard the
meal from evil.
In many homes, few
meals are eaten as a
family. The term grazing
refers to grabbing
small amounts of food
throughout the day
to consume. There are
an estimated 7 million
vending machines in the
United States, with over
100 million customers
daily.
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

C H A P T E R 1 1 1
Christmas and Passover; secular holidays such
as Thanksgiving and the Vietnamese New
Year’s Day, known as Tet; and even personal
events such as births, marriages, and deaths
are observed with appropriate foods. In many
cultures, feasting means simply more of the
foods consumed daily and is considered a time
of plenty when even the poor have enough to
eat. Special dishes that include costly ingre-
dients or are time-consuming to prepare also
are characteristic of feasting. The elements of
a feast rarely differ from those of an every-
day meal. There may be more of an everyday
food or several main courses with additional
side dishes and a selection of desserts, but the
meal structure does not change. For example,
Thanksgiving typically includes turkey and
often another entrée such as ham or a casse-
role (meat); several vegetables; bread or rolls,
potatoes, sweet potatoes, and stuffing (starch);
as well as pumpkin, mincemeat, and pecan
pies or other dessert selections. Appetizers,
soups, and salads may also be included.
Fasting may be partial or total. Often it is
just the elimination of some items from the
diet, such as the Roman Catholic omission of
meat on Fridays during Lent or a Hindu per-
sonal fast day, when only foods cooked in milk
are eaten. Complete fasts are less common.
During the holy month of Ramadan, Muslims
are prohibited from taking food or drink from
dawn to sunset, but they may eat in the evening.
Yom Kippur, the day of atonement observed by
many Jews, is a total fast from sunset to sunset.
(See Chapter 4 for more details on fasting.)
Developmental Perspective
of Food Culture
Trends in food, eating, and nutrition also
reflect structural changes in society. The
developmental perspective of food culture
TA B L E 1.1 Developmental Perspective of Food Culture
Structural Change Food Culture Change
Globalization: Local to worldwide organizations Consumerization: Indigenous to mass-produced foods
Modernization: Muscle to fueled power Commoditization: Homemade to manufactured foods
Urbanization: Rural to urban residence Delocalization: Producers to consumers only
Migration: Original to new settings Acculturation: Traditional to adopted foods
SOURCE: Adapted from Sobal, J. 1999. Social change and foodways. In Proceedings of the Cultural and Historical Aspects of Food Symposium.
Corvallis: Oregon State University.
▲ Special dishes that
include costly ingredients
or are time-consuming to
prepare are characteristic of
feasting in many cultures.
(Table 1.1) suggests how changes may alter
how consumers obtain food, as well as types
of food and variety. Globalization is defined as
the integration of local, regional, and national
phenomena into an unrestricted worldwide
organization. The parallel change in cultural
food habits is c onsumer iz ation, the transition
of a society from producers of indigenous
foods to consumers of mass-produced foods.
Traditionally seasonal ingredients, such as
strawberries, become available anytime of
year from a worldwide network of grow-
ers and suppliers. Specialty products, such
as ham and other deli meats, which were at
one time prepared annually or only for festive
occasions, can now be purchased presliced,
precooked, and prepackaged for immediate
consumption.
The social dynamic of modernization
with new technologies results in socioeco-
nomic shifts, such as during the Industrial
Feasting functions to
redistribute food from
rich to poor, to demon-
strate status, to motivate
people toward a com-
mon goal (e.g., a political
fundraising dinner), to
mark the seasons and
life-cycle events, and to
symbolize devotion and
faith (e.g., Passover, Eid
al-Fitr, and communion).
Ro
be
rt
B
re
nn
er
/P
ho
to
Ed
it
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

1 2 F O O D A N D C U L T U R E
Revolution when muscle power was replaced
by fuel-generated engine power or during the
1990s with the rise of the information age.
Cultural beliefs, values, and behaviors are
modified in response to the structural changes
that take place. Food habits changed, with
foods becoming more processed and meals
pre-prepared instead of cooked at home. The
fresh milk from the cow in the barn becomes
the plastic gallon container of pasteurized
milk sold online over the Internet to a con-
sumer who has limited time.
Urbanization occurs when a large per-
centage of the population abandons the low
density of rural residence in favor of higher
density suburban and urban residence. Often,
income levels do not change in the move, but
families who previously survived on subsis-
tence farming become dependent on others
for food. Delocalization occurs when the
connections among growing, harvesting,
cooking, and eating food are lost, as meals
prepared by anonymous workers are pur-
chased from convenience markets and fast-
food restaurants.
Finally, migration of populations from
their original homes to new regions or
nations creates a significant shift from a
home-bound, culture-bound society to one
in which global travel is prevalent and immi-
gration common. Traditional food habits are
in flux during acculturation to the diet of
a new culture and as novel foods are intro-
duced they become accepted into the major-
ity cuisine. Often new traditions emerge
from the contact between diverse cultural
food habits.
The developmental perspective of food
culture assumes that cultures progress from
underdeveloped to developed through the
structural changes listed. Deliberate efforts to
reverse that trend can be seen in the renewed
popularity of farmers’ markets in the United
States and attacks on fast-food franchises in
Europe. Other evidence of resistance includes
the work of the Slow Food movement—mobi-
lizing against the negative effects of indus-
trialization—and the seed banks that have
opened throughout the nation to promote
genetic diversity and save indigenous plant
populations.32,33,34
Individual Food Habits
Each person lives within his or her culture,
unaware of the influences exerted by that
culture on food habits. Eating choices are
typically made according to what is obtain-
able, what is acceptable, and what is pre-
ferred: the diet is determined by availability
and by what each person considers edible or
inedible. Beyond that, factors that influence
an individual’s food selection are taste, cost,
convenience, self-expression, well-being, and
variety, which are explained in the consumer
food choice model, discussed later in the
chapter.
Food Availability
A person can select a diet only from foods that
are available. Local ecological considerations
such as weather, soil, and water conditions;
geographic features; indigenous vegetation;
the native animal population; and human
manipulation of these resources through culti-
vation of plants and domestication of livestock
determine the food supply at a fundamental
level. A society living in the cool climate of
northern Europe is not going to establish rice
as a core food, just as a society in the hot wet
regions of southern India is not going to rely
on oats or rye. Seasonal variations are a fac-
tor, as are unusual climactic events, such as
droughts, that disrupt the food supply.
The political, economic, and social man-
agement of food at the local level is typically
directed toward providing a reliable and
affordable source of nourishment. Advances
in food production, storage, and distribution
are examples. However, the development of
national and international food networks has
often been motivated by other needs, includ-
ing profit and power. The complexity of the
food supply system has been examined by
many disciplinary approaches. Historians
trace the introduction and replacement of
foods as they spread regionally and globally.
Economists describe the role of supply and
demand, the commodity market, price con-
trols, trade deficits, and farm subsidies (as
well as other entitlements) on access to food.
Psychologists investigate how individual
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

C H A P T E R 1 1 3
experience impacts diet; political scientists
detail how fear of biotechnology, bioterrorism,
and disease (such as the mad-cow or bovine
spongiform encephalopathy scare in Europe)
can alter acceptability. Sociologists document
how social structures and relations affect the
obtainment of food; legal experts debate the
ethics of food policies people who are poor,
incarcerated, and terminally ill. This is only a
small sampling of the factors influencing food
availability. However, except in regions where
serious food shortages are anticipated, avail-
ability issues are usually not at the forefront of
individual food choice.
Edible or Inedible?
This approach was one of the earliest food
habits models, describing the individual pro-
cess that establishes the available, appropriate,
and personal food habits. Each person’s choice
of what to eat is generally limited to the foods
found in this dietary domain.35
1. Inedible foods: These foods are poison-
ous or are not eaten because of strong
beliefs or taboos (or taboo foods,
from the Tongan word tabu, mean-
ing “marked as holy”). Foods defined
as inedible vary culturally. Examples
of frequently prohibited foods include
animals useful to the cultural group,
such as cattle in India; animals danger-
ous to catch; animals that have died of
unknown reasons or of disease; animals
that consume garbage or excrement; and
plants or animals that resemble a human
ailment (e.g., strawberries or beef dur-
ing pregnancy to protect the infant, as
described later).
2. Edible by animals, but not by me:
These foods are items such as rodents
in the United States or corn in France
(where it is used primarily as a feed
grain). Again, the foods in this
category vary widely by culture.
3. Edible by humans, but not by my kind:
These foods are recognized as accept-
able in some societies, but not in your
own culture. Some East Africans are
disgusted by eggs, for instance, which
are associated with excrement.36 Some
rural South Africans who consider
termites a delicacy are repulsed by
the idea of eating scorpions, a spe-
cialty enjoyed by some Chinese.37
Examples of foods unacceptable in the
United States but acceptable elsewhere
include giant snails (Africa), dog meat
(Asia), iguana (the Caribbean), horse
meat or blood sausage (Europe), and
bear paw (Mongolia).
4. Edible by humans, but not by me:
These foods include all those accepted
by a person’s cultural group but not
by the individual, due to factors such
as preference (e.g., tripe, liver, raw
oysters), expense, or health reasons
(a low-sodium or low-cholesterol
diet may eliminate many traditional
American foods). Other factors, such
as religious restrictions (as in kosher
law or halal practices) or ethical con-
siderations (vegetarianism), may also
influence food choices.
5. Edible by me: These are all foods
accepted as part of an individual’s
dietary domain.
There are always exceptions to the ways
in which foods are categorized. It is generally
assumed, for instance, that poisonous plants
and animals will always be avoided. In Japan,
however, fugu (blowfish or globefish) is con-
sidered a delicacy despite the deadly toxin
contained in the liver, intestines, testes, and
ovaries. These organs must be deftly removed
by a certified chef as the last step of cleaning
(if they are accidentally damaged, the poison
spreads rapidly through the flesh). Eating the
fish supposedly provides a tingle in the mouth
prized by the Japanese. Several people die
each year from fugu poisoning.
Consumer Food Choice
Model
An individual’s dietary likes and dislikes are
established before he or she sets foot in a res-
taurant, deli, or supermarket. The consumer
food choice model (Figure 1.3) explains the
factors that influence individual decisions.38
Among the most uni-
versal of food taboos is
cannibalism, although
anthropologists have
discovered numerous
examples of prehistoric
human consumption in
European and New World
excavations.
Insects, such as termites
and ants, provide 10
percent of the protein
consumed worldwide.
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

1 4 F O O D A N D C U L T U R E
Food selection is primarily motivated by
taste. Taste is defined broadly by the sensory
properties detectable in foods: color, aroma,
flavor, and texture. Humans anticipate a spe-
cific food will have certain sensory character-
istics; deviations can signal that the item is
poisonous or spoiled. Many of these expecta-
tions are developed through early exposure to
culturally acceptable and unacceptable foods.
For example, most core foods are pale white,
cream, or brown in color; however, some
West Africans prefer the bright orange of
sweet potatoes, and Pacific Islanders consider
lavender appropriate for the taro root prepa-
ration called poi. Should the core item be an
unanticipated color, such as green or blue, it
may be rejected. Similarly, each food has a
predictable smell. Aromas that are pleasur-
able may trigger salivation, while those con-
sidered disgusting, such as the odor of rotting
meat, can trigger an immediate gag reflex in
some people. Again, which odors are agree-
able and which are disagreeable are due, in
part, to which foods are culturally accepted:
Strong-smelling fermented meat products are
esteemed by some Inuit (muk tuk ) and some
rural Filipinos (itog). Strong-smelling cheese itog). Strong-smelling cheese itog
(controlled rotting of milk) appeals to many
Europeans, but even mild cheddar may evoke
distaste by many Asians and Latinos. Appro-
priate texture is likewise predictable. Ranging
from soft and smooth to tough and coarse,
each food has its expected consistency. New
textures may be disliked: Some Americans
object to gelatinous bits in liquid, as found
in tapioca pudding or bubble tea, yet these
foods are popular in China. Conversely, some
Asians find the thick, sticky consistency of
mashed potatoes unappetizing. Okra, which
has a mucilaginous texture, is well liked in
the U.S. South but is considered too slimy by
those living outside the South.
The human tongue has receptors for the
perception of sweet, sour, salty, and bitter. It
is hypothesized that food choice in all societ-
ies is driven, in part, by an inborn preference
for the taste of sugars and fats. These nutrients
are indicative of foods that are energy dense;
a predisposition for sweets and foods high in
fat ensures adequate calorie intake, an evolu-
tionary necessity for omnivores with a wide
selection of available foods. Sugars and fats are
especially pleasurable flavor elements, associ-
ated with palatability and satiety (including
the texture factor provided by fats, called
mouthfeel).
Preferences for sweets (especially when
combined with fats) are found during infancy
and childhood and peak in early adolescence.
One study found 45 percent of calories eaten
by young people came from discretionary
sugar and fat.39 This preference declines in
later years and may reduce their significance
in food choice.
The opposite is true for bitterness, which
is associated with toxic compounds found in
some foods and is strongly disliked by most
children. The ability to detect bitterness
decreases with age, however, and many adults
consume foods with otherwise unpleasant
sulfides and tannins, including broccoli and
coffee. There are some who remain especially
sensitive to certain bitter compounds, affect-
ing their other preferences as well; they tend
to dislike sweet foods and opt for bland over
spicy items. Sour alone is rarely well liked, but
is enjoyed when combined with other flavors,
especially sweet. It has been suggested that a
preference for the sweet—sour taste prompted
human ancestors to seek fruit, an excellent
source of vitamins and minerals.40,41,42
Unlike the tastes of sweet, bitter, and sour,
babies generally are indifferent to salt until
about four months of age. Similar to sugar,
children prefer higher concentrations of salt
Humans can detect
approximately 10,000
different odors, though
genetics may determine
which odors can be
detected. For example,
nearly 50 percent of peo-
ple cannot smell andro-
stenone (also called boar
pheromone), which is
found in bacon, truffles,
celery, parsnips, boar
saliva, and many human
secretions; however,
researchers have found
people can be taught to
perceive it through daily
sniffing.109
Figure 1.3
The consumer food choice
model.
Source: Adapted from A. Drewnowski,
Taste, Genetics, and Food Choice.
Copyright © 2002. Used by permis-
sion of Adam Drewnowski, PhD.
Adults
Food
Choice
Cost
Convenience
Self-
Expression
Taste
Variety
Well-Being
Health
Outcomes
Physiology/Metabolism
Children
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

C H A P T E R 1 1 5
than do adults. Their preference for salt is
shaped by the frequency of exposure to it after
birth, and perhaps perinatally.43
Finally, taste is influenced by flavor prin-
ciples, the characteristic combinations of core
and complementary foods, as well as tradi-
tional grouping of meal elements. These tradi-
tions are important in providing an expected
taste experience and satisfying a need for
familiarity in food habits.
Cost is often the second most important
influence on food choice, and income level is
the most significant sociodemographic fac-
tor in predicting selection. In cultures with
a limited food supply due to environmental
conditions or in societies where a large seg-
ment of the population is disadvantaged, food
price is more than taste, dictating nutritional
sufficiency and well-being. The wealthier the
society, the less disposable income is spent on
food, and, as income increases, food choices
change. Typically, the people of poorer cul-
tures survive on a diet dependent on grains or
tubers and limited amounts of protein, includ-
ing meat, poultry, fish, or dairy foods. Only
a small variety of fresh fruits or vegetables
may be available. People with ample income
consistently include more meats, sweets, and
fats in their diet (a trend seen in the global
popularity of American fast foods), plus a
wider assortment of fruits and vegetables.44,45
When nutritious food is available and afford-
able, the prestige of certain food items, such
as lobster or prime rib, is often linked to cost.
Protein foods are most associated with status,
although difficult-to-obtain items, such as
truffles, can also be pricey.
In the United States, affordability has been
found to limit the purchasing of healthy foods,
and in some cases even families with govern-
ment subsidies find it difficult to meet nutri-
tional needs.46 It is estimated that in 2013 over
14 percent of households were considered to
be food insecure.47
A subsistence farmer may have greater
access to fresh foods than a person with the
same limited income living in a city. In urban
areas, supermarkets with a cheaper selection
of foods often choose to locate outside low-
income neighborhoods, and residents may
have access only to higher-priced convenience
stores or small, independently run groceries
with a limited selection.46,48,49 Further, access
to healthful restaurant dining varies. Studies
suggest that predominantly African American
and low-income neighborhoods have more
fast-food restaurants per square mile than
white neighborhoods, with fewer healthy
options.50,51,52,53
Convenience is a major concern in food
purchases, particularly by members of urban-
ized societies. In some cultures, everyone’s
jobs are near home, and the whole family
joins in a leisurely midday lunch. In urban-
ized societies, people often work far from
home; therefore, lunch is eaten with fellow
employees. Instead of a large, home-cooked
meal, employees may eat a quick fast-food
meal. Furthermore, family structure can
necessitate convenience. In the United States,
the decreasing number of extended families
(with help available from elder members) and
increasing number of households with single
parents, along with couples who both work
outside the home and unassociated adults liv-
ing together all reduce the possibility that any
adult in the household has the time or energy
to prepare meals. Studies show that the greater
the number of hours a woman works outside
the home each day, the fewer the hours she
spends cooking. Only 40 percent of families
report cooking at least once a day, and in more
than one-quarter of all homes cooking is done
less than once a day.54 Recent research indi-
cates that a higher amount of family meals
is correlated with more positive health indi-
cators.55 Furthermore, the quality of dietary
intake improves when there is a reduction in
spending for food away from home.56 Conve-
nience generally spurs the increasing number
of takeout foods and meals purchased at res-
taurants. In 2014, restaurant industry share of
the U.S food dollar was 47 percent.
Self-expression, the way in which we indi-
cate who we are by behavior or activities,
is important for some individuals in food
selection, particularly as a marker of cultural
identity. Although the foods associated with
ethnicity, religious affiliation, or regional
association are predetermined through the
dietary domain, it is worth noting that every
time a person makes a food choice he or she
Though the physiologi-
cal response to disgust,
nose wrinkling, retrac-
tion of the lips, gaping,
gagging, and even nau-
sea seems instinctual, it
is actually a cognitively
sophisticated feeling
that does not develop in
children until between
the ages of four and
seven years old. Which
items are disgusting in
a culture is learned from
parents and peers.110
Some researchers con-
tend that there is a fifth
type of receptor on
the tongue for umami
(from the Japanese for
“yummy”). It is the taste
associated with meats,
mushrooms, cheese,
and the flavor-enhancer
monosodium glutamate
(MSG).
In addition to salt, other
flavor preferences may
be passed on perinatally.
A study of women who
ate garlic or a placebo
before amniocentesis
found the odor of garlic
in the amniotic fluid
evident from the garlic-
ingesting women.69
In 1901, the average
American family spent
nearly half (45 percent)
of their income on food.
A century later, that
figure had decreased to
just 13 percent of total
income.111
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

1 6 F O O D A N D C U L T U R E
may choose to follow or ignore convention.
Ethnic identity may be immediate, as in per-
sons who have recently arrived in the United
States; or it may be remote, a distant heritage
modified or lost over the generations through
acculturation. An individual who has just
immigrated to the United States from Japan,
for instance, is more likely to prefer traditional
Japanese cuisine than is a third- or fourth-
generation Japanese American.
Religious beliefs are similar to ethnic iden-
tity in that they may have a great impact on
individual food habits or an insignificant
influence depending on religious affiliation
and degree of adherence. Many Christian
denominations have no food restrictions,
but some, such as the Seventh-day Adven-
tists, have strict guidelines about what church
members may eat. Judaism requires that only
certain foods be consumed in certain combi-
nations, yet most Jews in the United States do
not follow these rules strictly (see Chapter 4).
A person may also choose foods associated
with a specific region. In the United States, the
food habits of New England differ from those
of the Midwest, the South, and the West, and
local specialties such as Pennsylvania Dutch,
Cajun, and Tex-Mex may influence the cook-
ing of all residents in those areas.
Self-identity can be another factor in food
selection, as discussed previously. An envi-
ronmentalist may be a vegetarian who pre-
fers organic, locally grown produce, while
Even when supermarkets
with a greater selection
of healthful foods are
available, less-accultur-
ated immigrants may feel
more comfortable shop-
ping at stores where their
language is spoken and
ethnic ingredients are
stocked.112
The status of food can
change over time. In the
early years of the United
States, lobster was so
plentiful it piled up on
beaches after storms, but
colonists considered it fit
only for Indians or starv-
ing settlers.
▲ Regional fare differs
throughout the United
States and can be consumed
for self-expression. The
southwestern foods shown
here represent one of many
distinct regional cuisines.
Ko
st
en
ko
M
ax
im
/S
hu
tt
er
st
oc
k.
co
m
a gourmet or foodie may patronize small
markets in ethnic neighborhoods through-
out a city searching for unusual ingredients.
Advertising has been directly related to self-
expression, especially self-identity. Research
indicates that in blind taste tests people often
have difficulty discriminating between differ-
ent brands of the same food item. Consumer
loyalty to a particular brand is believed more
related to the sensual and emotional appeal
of the name and packaging.57,58 For example,
similar-tasting flake cereals such as Wheaties
(which touts itself as the “breakfast of cham-
pions”), Special K, and Total target sports
enthusiasts, dieters, and health-conscious
individuals, respectively.
Advertising also promises food-provided
pleasure, appealing to the desire of consumers
to be seen as popular, fun-loving, and trendy.
Exploitation of sex to sell hamburgers and
beer is common, as are suggestions that eat-
ing a chocolate or drinking a soft drink will
add zest to living. A study of television food
ads targeting children found that 75 percent
were associated with “good times,” 43 percent
with being “cool and hip,” and 43 percent with
feelings of happiness.59,60,61 Such advertising
is a reflection of a larger trend: food as enter-
tainment, the vicarious enjoyment of eating
through reading about it or watching food-
related programs on television, also called
food porn.62 In the United States, nearly
150 food and wine magazines are published
monthly, almost 500 million food and wine
books are sold annually, and numerous net-
work cooking and dining shows air daily.
The impact of this media on food choice is
as yet unknown. Food entertainment may
popularize certain ingredients, such as kale
or mangoes, or cuisines, such as Spanish fare
or updated traditional American dishes like
spicy meatloaf and macaroni and cheese.
They may also set such a high standard of
preparation and presentation that some home
cooks feel inadequate, choosing to dine out or
select prepackaged items instead of making
meals from scratch.
Physical and spiritual well-being is another
food choice consideration for some individ-
uals. Physiological characteristics, includ-
ing age, gender, body image, and state of
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

C H A P T E R 1 1 7
health, often impact food habits. Preferences
and the ability to eat and digest foods vary
throughout the life cycle. Pregnant and lac-
tating women commonly eat differently than
other adults. In the United States, women are
urged to consume more food when they are
pregnant, especially dairy products. They
are also believed to crave unusual food com-
binations, such as pickles and ice cream. They
may avoid certain foods, such as strawber-
ries, because they are believed to cause red
birthmarks.
In some societies with subsistence econo-
mies, pregnant women may be allowed to eat
more meat than other family members; in
others, pregnant women avoid beef because it
is feared that the cow’s cloven hoof may cause
a cleft palate in the infant. Most cultures also
have rules regarding which foods are appro-
priate for infants; milk is generally considered
wholesome, and sometimes any liquid resem-
bling milk, such as nut milk, is also believed
to be nourishing.
Puberty is a time for special food rites in
many cultures. In the United States, adoles-
cents are particularly susceptible to advertis-
ing and peer pressure. They tend to eat quite
differently from children and adults, reject-
ing those foods typically served at home and
consuming more fast foods and soft drinks. A
rapid rate of growth at this time also affects
the amount of food that teenagers consume.
One survey found teenage boys down an aver-
age of five meals per day, and teenage girls eat
four meals.63,64
The opposite is true of older adults. As
metabolism slows, caloric needs decrease. In
addition, they may develop a reduced toler-
ance for fatty foods or highly spiced items.
Eating problems tend to increase as we age,
such as the inability to chew certain foods
or a disinterest in cooking and dining alone.
It is predicted that the shift toward an older
population in the next two decades will result
in a change in the types of foods purchased
(an increase in fruits, vegetables, fish, and
pork because older adults consume these
items more often than younger adults do)
and reductions in the total amount of food
consumed per capita (because older adults
eat smaller amounts of food).65
Gender has also been found to influence
eating habits. In some cultures women are
prohibited from eating specific foods or are
expected to serve the largest portions and best
pieces of food to the men. In other societies
food preference is related to gender. Some
people in the United States consider steak to
be a masculine food and salad to be a femi-
nine one; or that men drink beer and women
drink white wine. Research has shown that
gender differences affect how the brain pro-
cesses satiation responses to chocolate, sug-
gesting that men and women may vary in the
physiological regulation of food intake—per-
haps accounting for some food preferences.66
A person’s state of health also has an impact
on what is eaten. A chronic condition such as
lactose intolerance or a disease such as diabe-
tes or celiac disease requires an individual to
restrict or omit certain foods. An individual
who is sick may not be hungry or may find
it difficult to eat. Even minor illnesses may
result in dietary changes, such as drinking
ginger ale for an upset stomach or hot tea for
a cold. Those who are on weight-loss diets
may restrict foods to only a few items, such as
grapefruit or cabbage soup, or to a certain cat-
egory of foods, such as those low in fat or car-
bohydrates. Those who are exceptionally fit,
such as students or professional athletes, may
practice other food habits, including carbohy-
drate loading or consumption of high-protein
bars. In many cultures, specific foods are often
credited with health-promoting qualities, such
as ginseng in Asia or chicken soup in eastern
Europe. Corn in American Indian culture may
be selected to improve strength or stamina.
Well-being is not limited to physiological con-
ditions; spiritual health is equally dependent
on diet in some cultures where the body and
mind are considered one entity. A balance of
hot and cold or yin and yang foods may be
consumed to avoid physical or mental illness.
(See Chapter 2, “Traditional Health Beliefs
and Practices.”)
The final factor in consumer food choice
is variety. The omnivore’s paradox states that
humans are motivated psychologically to try
new foods. Further, the desire for new flavors
may also have a physiological basis. Sensory-
specific satiety (unrelated to actually ingesting
Meals and snacks pre-
pared at home are lower
in calories per eating
occasion, and lower in
total fat, saturated fat,
cholesterol, and salt
per calorie than foods
prepared away from
home. IHOP’s Breakfast
Country Chicken Fried
Steak & Eggs with Gravy
contains 1,570 kcalories,
close to one full day’s
requirement (from http://
www.calorieking.com).
Another aspect of food
as entertainment is
competitive eating as
a televised sport. Elite
eaters can make more
than $50,000 a year in
winnings, with records
such as forty-six dozen
oysters in ten minutes;
8.4 pounds of baked
beans in two minutes,
forty-seven seconds; and
11 pounds of cheesecake
in nine minutes.113
Old age is a cultural
concept; among some
American Indians and
Southeast Asians, indi-
viduals become elders in
their forties.114
Lactose intolerance, the
inability to digest the
milk sugar lactose, devel-
ops as a person matures.
It is believed that only
15 percent of the adult
population in the world
(those of northern
European heritage) can
drink milk without some
digestive discomfort.
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

1 8 F O O D A N D C U L T U R E
and digesting food) results when the pleasure
from a certain food flavor decreases after a
minute or two of consumption. Introduction
of a new food, or even the same food with
new added seasoning, arouses the enjoy-
ment in eating again, encouraging the search
for new flavor stimuli.67 In addition, hunger
increases the probability that a new food will
be liked.68,69 Marketers take advantage of the
innate human drive for diet diversity by con-
tinually reformulating and repackaging pro-
cessed food products to attract consumers.
Interest in the foods of other regions or cul-
tures is associated with the desire for new taste
experiences, and also with increased income
and educational attainment. Wealth permits
experimentation and education can increase
wealth. Nutritional knowledge, also affected
by educational attainment, includes the
health-promoting benefits of dietary diversity.
One study reported that college students
were more likely to try a new fruit, vegeta-
ble, or grain product if information on the
nutritional benefits were provided.70 Some
researchers have found that attitudes about
the healthfulness of certain foods is important
in food selection, and parents may purchase
foods they consider healthy for their children
even if they would not select those items for
themselves.71
The nutrition knowledge of the person
who plans meals in the home impacts food
selection for all household members.72 It has
been suggested, however, that food choices
are more often influenced by beliefs regarding
nutritional quality than the actual nutritional
value or health benefits.67,73,74,75 Whether
accurate or not, nutritional knowledge does
not always translate into knowledge-based
food choice; a poll found that six in every ten
consumers check nutrition labels frequently
for calories and fat content, but nearly half of
those who read the information still choose
items for taste even when they are aware that
the item is bad for them.76,77
The consumer food choice model’s influ-
ence on individual food habits are interre-
lated. The inborn preference for foods high
in sugar, fat, and salt can encourage the con-
sumption of items specifically formulated to
enhance those taste experiences. These foods
are often convenient, and items such as soft
drinks and sandwich meats may cost less
than fruit juice or fresh pork or beef (though
certainly some processed items are more
expensive than homemade equivalents).
Advertisers exploit the need for convenience
and the desire to try new foods. A person may
be aware of nutrition messages encouraging
a reduction in the amount of sugars and fats
in the diet, as seen in the Dietary Guidelines
for Americans, but this nutrition knowledge
is often overridden by the primary factor in
consumer food choice: taste.
Furthermore, influences on choice may
change for each person as she or he matures.
Food selection in infants (within the dietary
domain of available foods provided by par-
ents) is based almost exclusively on taste
factors, with a strong resistance to new
items. Children become more interested in
self-expression as they grow and become
sensitive to family and peer pressure. Young
adults continue to be concerned with taste
and self-expression, to which cost and conve-
nience are typically added, especially in fami-
lies with children. For middle-aged adults,
increased income may lessen cost issues; and
in older adults, health problems may become
a more significant factor in food choice than
even taste.
Nutrition and Food
Habits
The Need for Cultural
Competency
In recent years, the significance of cultur-
ally based food habits on health and diet has
been recognized, and the need for intercul-
tural competencies in the areas of nutrition
research, assessment, counseling, and educa-
tion has been cited.78 The Campinha-Bacote
model of competence outlines a process for
cultural competency in health care, involv-
ing steps from cultural awareness, cultural
knowledge, cultural skill, cultural encounter,
and cultural desire.79 Accurate data collec-
tion required for assessment and education is
dependent on respect for different values and
Research on sensory-
specific satiety suggests
people eat less food
when consuming a
monotonous meal, and
may overeat and gain
weight when abundant
variety is available.8
The Japanese say that for
every new food a person
tries, life is extended
seventy-five days.
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

C H A P T E R 1 1 9
a trusting relationship between respondent
and researcher; effective intercultural com-
munication is a function of understanding
and accepting a client’s perspective and life
experience. New standards of nutrition care
issued by professional accreditation organi-
zations reflect similar guidelines.80,81 Look-
ing toward the future, it has been proposed
that health care professionals should move
beyond the theoretical concepts to cultural
sensitivity and relevance to the practicalities
of cultural competency. Language skills, man-
agerial expertise, and leadership are needed to
guide diverse communities in healthy lifestyle
changes, to serve hard-to-reach populations,
and to effect change in the health care system.
Diversity in the U.S. Population
The growing need for cultural competency is
being driven by current demographic trends.
Since the 1970s, the United States has moved
increasingly toward a cultural plurality, where
no single ethnic group is a majority. In 1980,
only Hawaii and the District of Columbia
had plurality populations. Since that time,
California, New Mexico, and Texas have
joined the list. Pluralities also exist in sev-
eral metropolitan area populations, includ-
ing Chicago, Houston, Los Angeles, Miami,
New York City, and Philadelphia. Nationwide,
demographers estimate that non-Hispanic
whites will become less than 50 percent of the
total population by the year 2060.
This change can be seen in the difference
in projected ethnic group growth from 2014
to 2060 (see Figure 1.4). Gains for the Asian
population are expected at more than four
times the national average, and more than
three times the national average for the His-
panic population.
In actual numbers, Hispanics surpassed
African Americans as the largest U.S. minority
population in 2008, and now represent 17 per-
cent of the total population, whereas blacks
or African Americans make up approximately
13 percent. Asians are the third largest minor-
ity at 5 percent of the total U.S. population.
Smaller numbers of Pacific Islanders and
Native Americans are 1 percent, and mixed
races are 2 percent. Notably, many U.S. ethnic
populations have an average age significantly
“Respect for diverse
viewpoints and indi-
vidual differences” is an
Academy of Nutrition
and Dietetics value.
lower than that of the total population.
Predicted demographic changes are often seen
first among children and young adults.82
This profile of the general U.S. population
is notably different than that for health care
professionals, who are mostly white. Among
registered dietitians in 2013, 82 percent
reported being white, and the next the largest
minority was Asians at 5 percent.83 Research-
ers note that clients from minority popula-
tions prefer to receive health care in settings
with minority health care providers; that
minority health care providers are more likely
to work in underserved areas; and that people
from minority groups are more likely to par-
ticipate in research studies when the investi-
gator is from the same ethnic background.84
Diversity in the Canadian Population
The Canadian census is conducted differently
from the U.S. count. Canadians in 2006 were
asked to list their ethnicity in an open-ended
question, and multiple responses listing one
or more ethnicities were accepted. More than
200 different ethnicities were identified. This
has provided a broader picture of ancestry,
particularly because single responses and
multiple responses were reported separately.
For example, of the over 1.3 million Aborigi-
nals (including Native American Indians,
Més—people of mixed Aboriginal and non-
Aboriginal heritage—and Inuit), 565,040
listed this ethnicity as a single response and
Figure 1.4
Projected U.S. population by
percentage, 2010–2060.
Source: Census.gov 2014 national
population projections. n.d. Retrieved
from http://census.gov/population/
projections/data/national/2014/
summarytables.html (accessed
January 6, 2015).
White Black Asian
Native Am/PI Mixed Race
45%
2%
2060 Projected US Population
by Percentage
2%
29%
13%
9%
2014 Projected US Population by
Percentage
2%
62%
17%
13%
1%
5%
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

2 0 F O O D A N D C U L T U R E
800,020 listed it as part of a multiple response.
A separate question inquired if the census
respondent was a member of a visible minor-
ity, defined by the Employment Equity Act
as “persons, other than Aboriginal peoples,
who are non-Caucasian in race or non-white
in color.” The act specifically lists Chinese,
South Asians (i.e., Asian Indians, Pakistanis,
Sri Lankans), blacks, Arabs/West Asians, Fili-
pinos, Latin Americans, Japanese, Koreans,
and Pacific Islanders. Immigration growth
in Canada has dramatically exceeded overall
population growth in recent years: Immi-
grants in Canada represented more than
two-thirds of the population growth from
2001 to 2006—more than 19 percent of the
total population—and the nation is second
only to Australia (22 percent) in proportion
of foreign-born citizens. Of greater impor-
tance, Canadian immigration patterns have
shifted during the past three decades. Recent
immigrants include almost 60 percent from
Asia and 20 percent from the Caribbean. Chi-
nese, South Asian, and black groups are the
three largest minority populations, though the
fastest growing populations are Arabs/West
Asians and Koreans. Nearly all (94 percent)
recent immigrants to Canada have settled in
urban areas, particularly Toronto, Vancouver,
and Montreal. Other urban areas with dis-
proportionately large recent immigrant
populations include Calgary, Edmonton, and
Ottawa-Hull.85
Ethnicity and Health
Health is not enjoyed equally by all in the
United States. Disparities in mortality rates,
chronic disease incidence, and access to care
are prevalent among many U.S. ethnic groups
(Table 1.2). Poor health status in the United
States is also associated with poverty (see
Cultural Controversy—Does Hunger Cause
Obesity? later in this chapter), low educational
attainment, and immigrant status: Immi-
grant health has been found initially better
than similar U.S.-born populations in some
research, and is shown to decline with length
of stay.86,88
Acculturation to the majority culture is
believed to be a significant factor in health
independent of socioeconomic status. First
noted in heart disease rates, moderniza-
tion has also been linked to increased blood
cholesterol levels, increased blood pressure
levels, obesity, type 2 diabetes, and some
cancers.87,88,89,90,91,92 The stress of adapta-
tion to the pressures of a fast-paced society
is believed to be significant.91 Hereditary
predisposition to developing certain health
conditions most probably plays a significant
role. It is important to note, however, that
acculturation is difficult to define accurately
and is not an inherent risk factor in itself.93
Some changes in diet—such as a reduction in
pickled food intake associated with stomach
cancer or increased availability of fruits and
vegetables—can be beneficial. Better educa-
tional opportunities and health care services
can also promote health.
The effects of ethnicity and race on health
status is not well delineated, and research-
ers caution that the research results can be
misleading.94 The Human Genome project
determined that there is no genetic basis for
use of the term r ac e, and that 99.9 percent
of all humans have the same genes. Race is
simply a category used to describe groups of
individuals.95 Many studies do not explain
how participants are categorized. Individuals
may self-select differently than investigators,
and self-identity may change over time. Even
official classifications may vary and change.
In the United States, the Office of Manage-
ment and Budget is responsible for defining
the categories used in all government work,
including the Census. In 1997, the stan-
dards were revised to include five classifica-
tions for “race”: American Indian or Native
American, Asian, Black or African American,
Native Hawaiian or other Pacific Islander, and
White. Prior to the revision, there were only
four groupings because Asians were combined
with Pacific Islanders. Additionally, the two
categories for ethnicity were expanded in
1997 (ethnic members may be of any race):
Hispanic, and Not Hispanic. These changes
from earlier definitions can lead to difficul-
ties in interpreting data trends. Further, the
factor of ethnicity is not sufficiently separated
from socioeconomic status in many studies,
calling into question whether a stated find-
ing is due to ethnicity or whether it is due to
Acculturation is so
complex that it has
been difficult to develop
accurate assessments for
use in health care and
research. Neither U.S.
nativity nor number of
years in residence has
proved completely indic-
ative, and it has been
suggested that accultura-
tion is sometimes based
more on ethnic stereo-
typing than on cultural
differences.115,116
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

C H A P T E R 1 2 1
income, occupation, or educational status. For
example, evaluation of the incidence of type 2
diabetes in the Black Women’s Study indicates
a strong relationship between individual and
neighborhood socioeconomic status and type
2 diabetes even when controlling for factors
such as education and income.96
Nevertheless, ethnicity data suggesting
risks and disparities can be useful to health
care providers as long as the caveats above
are considered and care is taken to avoid ste-
reotyping a patient by group membership.
For example, Table 1.2 illustrates that not all
Asians or Hispanics have the same prevalence
for type 2 diabetes.
Ethnicity can be a significant factor in the
development of certain disease conditions, the
way they are experienced, and how they are
ultimately resolved. (See Chapter 2 for further
information.) The growth of ethnic groups in
the U.S. population since the mid-1980s, the
rapid movement toward cultural pluralism,
TA B L E 1. 2 Estimates of the Percentage of
Diagnosed
Adult Diabetes by Race/Ethnic Background
Non-Hispanic Whites 7.6%
Asian Americans 9.0%
Hispanics 12.8%
Non-Hispanic Blacks 13.2%
American Indians/Alaska Natives 15.9%
Among Asian Americans
Chinese
Filipinos
South Asians
Other Asian Americans
4.4%
11.3%
13.0%
8.8%
Among Hispanic Adults
Central and South Americans
Cubans
Mexican Americans
Puerto Ricans
8.5%
13.9%
13.9%
14.8%
SOURCE: Centers for Disease Control and Prevention. 2014. National diabetes sta-
tistics report: Estimates of diabetes and its burden in the United States, 2014. Atlanta,
GA: U.S. Department of Health and Human Services. Retrieved from http://www.cdc.
gov/diabetes/data/statistics/2014StatisticsReport.html (accessed January 27, 2015).
Does Hunger Cause Obesity?
One of the most perplexing problems in nutrition education and policy is
why socieconomic status is associated with
overweight and obesity in the United States.
Rates of overweight, defined as a body mass
index (BMI) over twenty-five but below
thirty, and obesity, defined as a BMI over
thirty, have doubled in Americans since the
late 1970s. Risk for overweight and obesity
is highest in the persons with the lowest
incomes and education levels regardless of
ethnic heritage, and the risk declines paral-
lel to socioeconomic improvement in most
studies. Additionally, overweight and obesity
rates are higher in all other ethnic groups
(except for Asians) than in whites. Because
poverty rates are also higher for all other
ethnic groups (in some cases more than three
times the rate for whites), it may be that
socioeconomic status contributes to some of
the disparity in the risk of overweight and
obesity between ethnic groups.117,118
Researchers suggest that food insecurity
in households that do not have enough to eat
sometimes or often, or do not have enough
of preferred foods to eat, may lead to over-
weight and obesity through overconsumption
of inexpensive, less nutritious foods high in
fats or sugar. First postulated by a physician
in 1995, it was observed that in the cycle of
food assistance, where monthly allocations
run out and food shortages occur episodi-
cally, a person may compensate by eating
larger portions of higher-calorie foods when
available.119 Further research has strength-
ened the hypothesis, finding that high-
energy density diets (those that include more
fast foods, snacks, and desserts than fruits,
vegetables, and lean protein) are cheaper,
more palatable, and more filling than health-
ier choices.118,120 As with obesity in adults,
obesity in children has been found to be asso-
ciated with lower household incomes, lower
education levels of parents, and consumption
of high-energy density foods; and family
meals, which improve quality of dietary
intake in adolescents (including reductions in
snacking), are significantly more frequent in
higher-income families.121,122 Biological fac-
tors, such as the taste preference for sweets
and fats; psychological factors, including
the comfort provided in such items; and an
obesigenic environment that promotes con-
sumption of energy-dense items in super-size
quantities may be other variables. Recent
studies, with larger samples sizes, did not
find statistically significant associations but
did show that food insecurity and being over-
weight go hand in hand, and that the preva-
lence of being overweight remains higher in
food-insecure children. Further, it is uncertain
whether hunger and food insecurity drive
being overweight and obese, or whether
being overweight or obese cause hunger and
food insecurity.123
C U L T U R A L C O N T R O V E R S Y
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

2 2 F O O D A N D C U L T U R E
and the undeniable connection between heri-
tage and health requires the need for cultural
competency among American health care
providers.
Intercultural Nutrition Care
The study of food habits has specific appli-
cations in determining nutritional status
and implementing dietary change. Even the
act of obtaining a twenty-four-hour dietary
intake record has cultural implications. (See
Chapter 3, “Intercultural Communication.”)
Questions such as what was eaten at break-
fast, lunch, and dinner not only ignore other
daily meal patterns but also make assump-
tions about what constitutes a meal. Snacks
and the consumption of food not considered
a meal may be overlooked. Common difficul-
ties in data collection, such as underreport-
ing or overreporting food intake, may also be
culturally related to the perceived status of an
item, for example, or portion size estimates
may be an unknown concept, complicated by
the practice of sharing food from other family
members’ plates. Terminology can be particu-
larly troublesome. Words in one culture may
have different meanings in another culture or
even among ethnic groups within a culture.
Stereotyping is another pitfall in cultur-
ally sensitive nutrition applications, resulting
from the overestimation of the association
between group membership and individual
behavior. Stereotyping occurs when a per-
son ascribes the collective traits associated
with a specific group to every member of
that group, discounting individual character-
istics. A health professional knowledgeable
about cultural food habits may inadvertently
make stereotypical assumptions about dietary
behavior if the individual preferences of the
client are neglected. Cultural competency in
nutrition implies not only familiarity with
the food habits of a particular culture, but
recognition of intraethnic variation within a
culture as well.
Researchers suggest that health care pro-
viders working in intercultural nutrition
become skilled in careful observation of cli-
ent groups, visiting homes, neighborhoods,
and markets to learn where food is purchased,
what food is available, and how it is stored,
prepared, served, and consumed. Participa-
tion in community activities, such as reading
local newspapers and attending neighbor-
hood meetings or events, is another way to
gather relevant information. Informant inter-
viewing reveals the most data about a group;
individual members of the group, group
leaders, and other health care professionals
serving the group are potential sources.97,98
Combining qualitative approaches such as in-
depth, open-ended interviews with clients and
quantitative measures through questionnaires
is one of the most culturally sensitive methods
of obtaining data about a group. Qualitative
information obtained through the interviews
should alert the researcher to nutrition issues
within the group and guide development
of assessment tools; the quantitative results
should confirm the data provided through the
interview in a larger sample. (See Chapter 3
for more information.)
Cultural perspective is particularly impor-
tant when evaluating the nutritional impact of
a person’s food habits. Ethnocentric assump-
tions about dietary practices should be
avoided. A food behavior that on first obser-
vation is judged detrimental may actually have
limited impact on a person’s physical health.
Sometimes other moderating food habits are
unrecognized. For instance, a dietitian may
be concerned that an Asian patient is getting
insufficient calcium because she eats few dairy
products. Undetected sources of calcium in
this case might be the daily use of fermented
fish sauces or broths rich in minerals made
from vinegar-soaked bones.
Likewise, a food habit that the investiga-
tor finds repugnant may have some redeem-
ing nutritional benefits. Examples include the
consumption of raw meat and organs by the
Inuits, which provides a source of vitamin C
that would have otherwise been lost during
cooking, and the use of mineral-rich ashes or
clay in certain breads and stews in Africa and
Latin America. In addition, physiological dif-Latin America. In addition, physiological dif-Latin America. In addition, physiological dif
ferences among populations can affect nutri-
tional needs. The majority of the research on
dietary requirements has been conducted on
Sometimes culturally
based food habits have
vital nutritional benefits.
One example is the use
of corn tortillas with
beans in Mexico. Neither
corn nor beans alone
supplies the essential
amino acids (chemical
building blocks of pro-
tein) needed to main-
tain optimum health.
Combined, they provide
complete protein.
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

C H A P T E R 1 2 3
young, white, middle-class American men.
Extrapolation of these findings to other popu-
lations should be done with caution.
Thus, diet should be carefully evaluated
within the context of culture. One effective
method is to classify food habits according to
nutritional impact: (1) food use with positive
health consequences that should be encour-
aged, (2) neutral food behaviors with neither
adverse nor beneficial effects on nutritional
status, (3) food habits unclassified due to
insufficient culturally specific information,
and (4) food behaviors with demonstrable
harmful effects on health that should be repat-
terned.99 When diet modification is necessary,
it should be attempted in partnership with
the client and respectful of culturally based
food habits. Adoption of dietary recommen-
dations is associated with an approach that
is compatible with the client’s traditional
health beliefs and practices. (See Chapter 2
for more information.) A study evaluating
women’s beliefs about weight gain during
pregnancy found that black women indicated
that a lower amount should be gained than
the recommendations and that prepregnancy
weight had no effect on how much should be
gained.100 Having this information could cer-
tainly impact the content and approach for
nutrition counseling given during pregnancy.
In another example, educators developed a
food guide for Caribbean Islanders living in
the United States that grouped cultural foods
into three categories: growth, protection, and
energy, reflecting client-group perceptions of
how food affects health.101
The American Paradox
Food habits are so intrinsic to culture that
food-related images are often use to describe
them. Melting pot suggests a blending of dif-them. Melting pot suggests a blending of dif-them. Melting pot suggests a blending of dif
ferent ethnic, religious, and regional groups
to produce a smooth, uniform identity; stew
implies a cooking of various populations to
achieve a bland sameness with only just a
touch of cultural integrity; and tossed salad
allows for maintenance of cultural identity,
randomly mixed and coated with a glistening
unity. A more accurate metaphor for the
American population is the omnivore’s para-
dox. The nation was founded by immigrants,
and most citizens today are proud of a heri-
tage that, to paraphrase the inscription on the
Statue of Liberty, accepts the tired, the poor,
and the huddled masses yearning to be free.
Yet many Americans are also suspicious of
cultural difference and comfortable with what
is familiar. The same can be said for food hab-
its in the United States.
The American paradox, in culinary terms,
is that although foods from throughout the
world are available, and often affordable, con-
sistency and conservatism are also needed.
At one end of the spectrum, people who are
exposed to new foods through travel and
those who crave new taste experiences have
driven the rapidly expanding market for
▼ Asian tofu is the main
ingredient in this vegetarian
adaptation of shepherd’s pie,
a traditional British entrée
popular in the United States.
Be
ck
y
Lu
ig
ar
t-
St
ay
ne
r/
Te
rr
a/
Co
rb
is
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

2 4 F O O D A N D C U L T U R E
Pre-17th century
• Regional American Indian cuisines develop.
1500s
• Columbian Exchange: New World foods from the Caribbean and
Central/South America (corn, potatoes, tomatoes, chili peppers,
peanuts, vanilla, chocolate, etc.) are brought to Europe, Africa,
Asia; Old World foods (wheat, rice, sugar, beef, pork, apples,
etc.) introduced to the Caribbean and Central/South America.
• Ponce de Leon discovers Florida and most likely brings tomatoes
to North America.
1620s
• British traditional midday meal introduced, with meat, fowl, or
fish as its centerpiece served with cornbread or biscuit. Steamed
or boiled pudding is the first course; dessert of fruit pie or cake
follows. It is eaten with a knife, spoon, and fingers.
• First Thanksgiving occurs in 1621 at Plymouth colony, a ten-day
celebration combining European and Native American hunting
and harvest feast traditions featuring fowl and venison.
• Dutch colonists at New Amsterdam (present-day Manhattan)
introduce coleslaw, doughnuts, cookies, and waffles.
1660s
• Yams, watermelon, okra, black-eyed peas, eggplant, and
sesame seeds brought with African slaves who also introduce
the New World foods peanuts and chili peppers to North
America.
1680s
• German Mennonites settle in Pennsylvania, creating
Pennsylvania Dutch fare and popularizing dishes such as
scrapple, apple butter, and funnel cakes.
• William Penn founds first brewhouse in Philadelphia, featuring
English-style ales.
*REFERENCES FOR TIMELINE
Davidson, A. 1999. T h e O x f or d c ompanion to f ood. New York: Oxford University Press.
Hess, K. 1992. Th e C ar ol ina r ic e k itc h en. Columbia: University of South Carolina Press.
Katz, S. H. (Ed.). 2003. E nc y c l opedia of f ood and c ul tur e. New York: Scribner’s.
Trager, J. 1995. Th e f ood c h r onol ogy . New York: Henry Holt.
Randolph, M. 1993. Th e V ir ginia h ousew if e, or , meth odic al c ook . A f ac simil e of an auth entic ear l y A mer ic an
c ook book . New York: Dover.
1770s
• Boston Tea Party occurs; coffee takes hold as a protest beverage.
• Thomas Jefferson experiments with crops found in Europe,
such as rice, broccoli, cauliflower, eggplant, savoy cabbage, and
olives.
1800s
• First shipment of bananas arrives in the United States.
• First recipe for tomato-based ketchup published in 1812, called
“love-apple or tomato catchup.”
1760s
• England takes control of Canada from France: French Canadians
migrate to New England (Franco-Americans) and Louisiana
(Cajuns), bringing fish stews, pork pates, boudin sausages,
French toast, and other specialties.
• An English plantation owner in New Smyrna, Florida imports
1,500 indentured servants from Italy, Greece, and Minorca to
work his indigo fields, who in turn bring eggplant, lemons, and
olives to the region.
1790s
• Pineapples introduced to what is now Hawaii by the Spanish.
• American Cookery by Amelia Simmons in 1796 is first
American cookbook; includes recipes for stuffed turkey, a
“tasty Indian pudding,” “pomkin” pudding (pie), “American
citron”(watermelon) preserves, and cornmeal johnnycakes or
hoecakes.
1820s
• First regional American cookbook published in 1824, The
Virginia Housewife, or Methodical Cook, by Mary Randall, with Virginia Housewife, or Methodical Cook, by Mary Randall, with Virginia Housewife, or Methodical Cook
recipes for southern specialties; also foreign dishes, such as ropa
vieja and “gaspacho”(Spain), polenta and vermicelli (Italy),
curry “after the East Indian manner,”and “gumbo—a West
Indian dish”(Caribbean).
CULTURAL FOODS IN THE UNITED STATES: A TIMELINE*
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

C H A P T E R 1 2 5
1690s
• Rice cultivation techniques introduced to Carolinas by Africans
are so successful that excess crops sold to British.
• Tomatoes popular in coastal southern cuisines, but elsewhere
considered poisonous.
• Jesuit and Franciscan priests plant grapes, oranges, lemons,
figs, and olives at California missions.
1700s
• Potatoes popularized by Irish immigrants in Boston.
1730s
• New England codfish industry trades salt cod for slaves in Africa,
who are brought to the Caribbean and traded for molasses,
which is brought back to the colonies for production of rum.
Estimated annual consumption of rum at the time: four gallons
per person.
1740s
• First written record of ice cream in the colonies (served with
strawberries and milk).
1750s
• The Ojibwa obtain complete control of wild rice stands in the
lakes of Minnesota after defeating the Santee (Dakota) at the
Battle of Kathio.
1830s
• Avocado introduced to Florida.
1840s
• Durgin-Park’s Market Dining Room opens in Boston, featuring New England specialties such
as chowders, fried cod tongues, and Indian pudding.
• Antoine’s restaurant is founded in New Orleans, offering French Creole cuisine.
• German immigrants in numerous states found commercial breweries, introducing the lager
that became American-style beer.
• First commercial pasta factory opened by Frenchman of Italian descent in Brooklyn.
• Macao and Woosung, the first recorded Chinese restaurant in United States, opens in
San Francisco.
1850s
• Sourdough bread and biscuits, the foundation of gold miner’s diet in California and the
Yukon, is baked commercially in San Francisco.
• Swiss immigrants introduce Emmentaler cheese, which becomes known in the United
States as “Swiss” cheese.
• American Indian chef George Crum creates potato chips after a diner in his restaurant
complains about his thick-sliced potatoes.
• Hazelnut trees introduced from the Mediterranean to Oregon—nearly the entire U.S.
hazelnut crop is now grown in the state.
• Artichokes, though previously introduced to Louisiana by the French, brought to California
by the Spanish, where they have been so successful nearly the entire U.S. commercial crop
comes from the state.
1860s
• Completion of the transcontinental railway shortens the trip between coasts from 120 days
to less than one week: California fruits, vegetables, and grains head east; and eastern
shellfish, especially oysters, go west.
• French, Hungarian, Italian, and German immigrants in California introduce European
varietal wine grapes and viticulture techniques.
• Confederate soldiers sometimes survived on boiled, raw (green) peanuts, earning those
from Georgia the nickname “goober grabbers.”
• Augustus Gutkind begins Goodman’s Matzohs in Philadelphia to supply the Passover
market.
• Cajun-style hot sauce called Tabasco first formulated by Edmund McIlhenny at Avery Island,
Louisiana.
Simmons, A. 1996. A mer ic an c ook er y , or th e ar t of dr essing v iands, f ish , poul tr y , and v egetabl es, and th e
best modes of mak ing puff- pastes, pies, tar ts, puddings, c ustar ds and pr eser v es, and al l k inds of c ak es
f r om th e imper ial pl umb to pl ain c ak e. A f ac simil e of th e sec ond edition. Bedford, MA: Applewood
Books.
Smith, A. F. 1994. Th e tomato in A mer ic a. Columbia: University of South Carolina Press.
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

2 6 F O O D A N D C U L T U R E
1870s
• Jewish Cookery,Jewish Cookery,Jewish Cookery first cookbook on the subject in the United States,
by Esther Levy published in Philadelphia.
• Chinese Pekin (“Peking”) ducks imported by New York farms.
• Acceptance of four-tined fork makes using a knife to eat
outmoded; American-style use (transferring the fork from right
hand to left when cutting foods) is established.
• Buffalo (a Plains Indian staple), which numbered 30 to 70 million,
are reduced to approximately 1,500 animals, in part due to
prestige of smoked buffalo tongue in urban areas.
• Navel oranges introduced to California from Brazil, by way of the
U.S. Department of Agriculture (USDA) in Washington, DC.
1950s
• Trader Vic’s restaurants in California popularize
Polynesian food, such as luau dishes and pupu
platters, as well as the mai tai cocktail, claimed
invented by the owner.
• USDA publishes Basic 4 Food Guide.
CULTURAL FOODS IN THE UNITED STATES: A TIMELINE* Continued
1880s
• Luchow’s restaurant opens in New York City, popularizing dishes
found in German American homes and local beer gardens,
such as smoked eel, bratwurst, weinerschnitzel, spatzle, and
German-style beers.
• Oscar F. Mayer, a German American butcher, opens sausage
shop in Chicago, later selling wieners to grocery stores
throughout the region.
• B. Manischewitz Co. begins production of kosher products in
Cincinnati.
• Italian immigrants from Naples introduce spaghetti made with
olive oil and tomato paste.
1890s
• Asian immigrants move into San Joaquin valley of California,
planting large tracts of land. By the 1940s, Japanese farmers
are growing two-thirds of all vegetables in the state, creating
shortages when they are interned during World War II.
• Chili powder, combining ground dried chili pepper bits with
other seasonings, such as cumin and oregano, is invented in
Texas—though attribution is uncertain. Chili stews of beef or
goat popular in the region.
1900s
• Chop suey, a Chinese American vegetable and meat dish that may have come originally from southern
China (tsap seui) is popular in “chow-chows”(Chinese restaurants) in California and New York.
• Foods prepared in the “French fashion”are popular, particularly among the upper classes who can
afford to employ cooks knowledgeable in their preparation and dine at expensive restaurants.
• Pistachio tree from Middle East introduced in California and Texas.
• Coca-Cola, combining extracts from African kola nuts, South American coca leaves, and fruit syrups,
goes on sale in Atlanta as a fountain drink.
• The Kellogg brothers at a Seventh-day Adventist spa create cereal flakes as a substitute for meat—a
year later they add malt sweetener to increase appeal.
• Loma Linda Foods begins production of health breads and cookies for patients at the Seventh-day
Adventist Loma Linda Hospital.
• Broccoli introduced to California by Italian immigrants.
• World’s Fair in St. Louis popularizes German hamburger sandwiches and frankfurters (later dubbed
hot dogs).
• First American pizzeria opened by Italian immigrant in New York City.
1960s
• Beef consumption reaches ninety-nine pounds per person in United States, surpassing pork consumption for the first time.
• Frieda’s Finest founded to market specialty produce using samples and recipes in supermarkets; popularizes items such as
Chinese gooseberries (renamed kiwifruit), Jerusalem artichokes (as sunchokes), radicchio, spaghetti squash, blood oranges,
cactus pears, and other items.
• Julia Child debuts her cooking show, The French Chef, on public television, demystifying gourmet cooking and promoting French The French Chef, on public television, demystifying gourmet cooking and promoting French The French Chef
cuisine.
• The first Taco Bell fast-food restaurant opens in Downey, California.
• Benihana of Tokyo opens teppanyaki-style restaurant in New York.
• Term soul food coined for traditional African American cuisine.soul food coined for traditional African American cuisine.soul food
• In Atlanta, Lester G. Maddox is ordered by the federal government to serve African Americans at his Pickrick Restaurant—he
closes the business instead.
• Catfish farming introduced in Arkansas, dramatically increasing production and popularizing the fish nationwide.
• Foods of the World cookbooks from Time-Life Books begin with publication of The Cooking of Provincial France by M. F. K.
Fisher—the series introduces international cuisine through twenty specialized volumes (African cooking to wines and spirits)
followed in the 1970s with seven volumes on regional American fare.
1970s
• Falafel stands and restaurants proliferate with increased immigration of Middle Easterners.
• Chez Panisse restaurant opens in Berkeley, California, emphasizing fresh, locally grown ingredients, leading to development of a new California
cuisine and promoting regional fare nationally.
• Nissin Foods USA founded in California to market instant noodle products popular in Japan, such as Top Ramen.
• Vietnamese refugees open small restaurants in California, Texas, and other locations, featuring traditional pho, sandwiches, and other items.
• Small numbers of immigrants arrive from Thailand, and many open restaurants, introducing fish sauces such as nuoc mam and noodle dishes,
including phad thai.
• Paul Prudhomme opens K-Paul Louisiana Kitchen in New Orleans, popularizing Cajun cooking nationwide, one of the first regional food trends.
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

C H A P T E R 1 2 7
1910s
• George Washington Carver extols the virtues of peanuts,
soybeans, and sweet potatoes; he popularizes peanut
butter, formerly considered a food for people who were
sick and aging adults.
• U.S. pasta production increases when imported supplies
from Italy are cut off during World War I.
• American cheese first processed in Chicago by J.L. Kraft &
Bros. (Canadian Mennonite immigrants) by melting bits
of cheddar with an emulsifier to produce a smooth, mild
cheeselike food.
• The fortune cookie created in California.
1920s
• La Choy Food Products founded to sell canned and jarred bean
sprouts.
• Polish baker Harry Lender opens first bagel plant outside New York,
and popularity begins to spread beyond eastern European enclaves.
• Aplets candy, based on the recipe for Turkish delight, invented by
two Armenian immigrants in Washington State.
• Marriott Corp. gets its start as a root beer, tamale, and chili con
carne stand in Washington, DC.
• The Russian Tea Room opens in New York, popularizing blinis, caviar,
tea in samovars, and other Russian specialties.
• Colombo Yogurt is founded by Armenian immigrants in
Massachusetts.
1930s
• Fritos corn chips first marketed in Texas based on a tortillas
fritas (fried tortilla strips) recipe purchased from a Mexican
restaurant owner.
• Spam is created, becoming a status food in Hawaii and the best-
selling canned meat worldwide.
• Goya Foods is founded in New York by Spanish immigrants
to import olives and olive oil, later tapping into the growing
Latino food market.
1940s
• Influx of Greek immigrants seeking asylum in areas such as New York, Detroit, and
Chicago popularize items such as souvlaki and gyros in family-run restaurants and
street stands.
• Ed Obrycki’s Olde Crab House in Baltimore converts from tavern to restaurant serving
Maryland specialties such as soft-shell crab and crab cakes.
• Domestic servants and some housewives take jobs to support the U.S. war effort during
World War II, leading to an increased consumption of convenience foods.
• The Gentleman’s Companion, Being an Exotic Cookery Book or, Around the World with
Knife, Fork and Spoon by Charles Baker, a two-volume set, published in 1946, describing
dishes and drinks from throughout Europe and Asia—a second two-volume set on the
foods and beverages of South America published in 1951.
• Balducci’s specialty food shop (founded as a vegetable stand in 1916 by an Italian
immigrant) opens in New York, offering an international assortment of foods from
Europe, Asia, and Latin America as well as regional specialties, such as rattlesnake and
Cajun andouille.
• The McDonald brothers offer franchises of their hamburger stand, founded in 1940 in
Pasadena, California.
2000s
• Americans consume an average of one tortilla per person each day—representing
30 percent of all bread sales, nearly equal to white bread.
• There are more Chinese restaurants in the United States than McDonald’s,
Wendy’s, and Burger King restaurants combined.
• $1 out of every $7 in grocery purchases is spent on ethnic items in 2005.
• Wine is neck-and-neck with beer as favorite U.S. alcoholic beverage.
1980s
• Ethiopian restaurants become popular in some cities where immigrants have
settled, introducing items such as injera and berbere.
• Yaohan supermarkets of Japan open in California catering to Asian population and
offering ingredients such as bean sprouts, daikon, seaweed, pickled plums, fresh
fish, and prepared items, including sushi.
• Korean immigrants, especially in Los Angeles, introduce Korean barbecue, kimchi,
and other specialties through restaurants and markets.
• Fresh fugu fish (which can be highly toxic) is imported for first time for use in
American Japanese restaurants under FDA supervision.
1990s
• Salsa becomes the favorite U.S. condiment when sales exceed those of ketchup.
• The term fusion food is used for combining the ingredients and preparation fusion food is used for combining the ingredients and preparation fusion food
techniques of two or more cultural cuisines, such as Thai chicken pizza.
• Chicken consumption per capita first tops beef consumption.
• USDA and Department of Health and Human Services (DHHS) release first version
of the Food Pyramid.
• The Food Network begins television broadcasting.
• Spanish tapas restaurants become trendy.
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

2 8 F O O D A N D C U L T U R E
imported fruits, vegetables, and meat prod-
ucts, cheeses, and condiments. The growth
in ethnic restaurants has far surpassed that
of the restaurant industry as a whole in
recent decades. A survey found that Italian,
Mexican, Japanese (sushi), Thai, Middle East-
ern, and Caribbean fare have grown most in
popularity in recent years, while interest in
French, German, Scandinavian, and soul food
has declined.102 One of the most recent devel-
opments is the success of fast-casual ethnic
restaurant chains, such as Chipotle, Curry
in a Hurry, L&L Hawaiian Barbecue, Mama
Fu’s, and Pho Hoa. Ninety-two percent of U.S
consumers have eaten some form of ethnic
food in the past three months (whether at
home or from a restaurant).103 At the other
end of the American continuum of cuisine,
some people find considerable satisfaction
in the uniformity of a meat-and-potatoes
diet. A national trends survey found “plain”
American food most well liked by respon-
dents (66 percent).104
In response to the ambivalence produced
by the American paradox, the rising interest
in new foods and the continued desire for
familiar flavors, ethnic fare is often adapted to
American tastes and standardized for national
consumption. Spicing is reduced, protein
elements (particularly meats and cheeses)
are increased, more desserts and sweets are
offered, and items considered distasteful to
the American majority are eliminated. In
considering the three most popular ethnic
cuisines in the United States, it is unlikely a
consumer will find roasted kid at an Italian
restaurant, 1,000-year-old eggs at a Chinese
takeout counter, or tripe soup at a Mexican
drive-up window. Many Americans are con-
vinced that spaghetti with meatballs, fortune
cookies, and nachos are authentic dishes, yet
they are all items created in the United States
for American preferences.105 Even cultural
foods prepared at home from cookbooks are
often modified for preparation in American
kitchens with American ingredients, los-
ing much of their original content and con-
text. Only in ethnic, religious, and regional
enclaves largely isolated from outside influ-
ences are traditional food habits maintained.
Otherwise, over time, even significant sym-
bolic practices can lose their meaning under
the pressure of acculturation. For example,
a study of Chinese Americans living in
California found that while many attempted
to balance their diet between hot and cold
foods, few understood the yin-yang principles
behind the practice.105
In many ways, U.S. cooking adapts to cur-
rent and emerging food trends. Hamburgers,
hot dogs, and fried chicken are clearly derived
from other cultural fare, yet they are changed
through the lens of the American paradox.
Cheese melted over burgers on a sesame seed
bun, chili con carne poured over frankfurters,
and cornmeal-crusted chicken served with
cream gravy and buttermilk biscuits are nearly
unrecognizable compared to their European
and African origins. And while the tamale pie
in Texas, ahi burger in Hawaii, tofu lasagna in
a vegetarian home, and avocado turkey crois-
sant sandwich in the university cafeteria are
not authentic ethnic fare, they are authentic
American foods. It is the unexpected and
exciting ways in which the familiar and the
new are combined that make the study of food
habits in the United States such a pleasurable
and appetizing challenge.
One example of a multi-
cultural culinary creation
is the California roll, the
addition of avocado to
traditional Japanese
crab sushi. It is called
“American sushi” in
Japan.
D I S C U S S I O N S T A R T E R S
Who Are You? And What Do You Eat?
● Write a short description of your cultural identity. What is your race? What is your
ethnicity? What about your parents and your grandparents? Where is your family
originally from? Think about your high school friends and classmates. What was
their race? Their ethnicity?
● Next, write a description of what you eat. What are your favorite foods? When
living at home, what foods did your family typically eat? If your parents cooked
meals, what would they typically cook?
Now, form groups of three to four and share your descriptions with each other. Imagine
that your instructor asks you to a “potluck,” a social gathering where everyone invited
is supposed to bring something for everyone else to eat. What do you want the other
members of your group to bring? What foods might they bring that you would like to try?
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

C H A P T E R 1 2 9
Review Questions
1. Define the terms f ood and f ood and f ood f ood h abits. How
does the omnivore’s paradox influence a per-
son’s food choices and food habits?
2. List four factors that may influence an indi-
vidual’s choice of foods. Pick one and explain
how this factor influences food choices.
3. Define the terms c ul tur e and ac c ul tur ation.
Describe an example of a change in food habits
that may reflect acculturation.
4. Describe the flavor principles, core foods, and
meal patterns of your family’s diet.
5. Which of the factors described by the con-
sumer food choice model currently influence
your food choices? Which factors do you think
will stay the same and which do you think will
change as you age?
References
1. Census.gov 2014 national population projec-
tions. n.d. Retrieved from http://www.census.gov/
population/projections/data/national/2014/
summarytables.htm (accessed January 4, 2015).
2. Grieco, E.M., Acosta, Y.D., de la Cruz, G.P,
Gambino, C., Gryn, T., Larsen, L.J., Trevelyan,
E.N., & Walters, N.P. 2012. The foreign-born
population in the United States: 2010. A mer ic an
C ommunity S ur v ey R epor ts. Washington, DC:
U.S. Department of Commerce Economics and
Statistics Administration. U.S. Census Bureau.
3. U.S. Census Bureau. 2013. Asians fastest-growing
race or ethnic group in 2012. Release Number:
CB13-112. Retrieved from http://www.census.
gov/newsroom/press-releases/2013/cb13-112.
html (accessed January 5, 2015).
4. Fischler, C. 1988. Food, self, and identity. S oc ial
S c ienc e I nf or mation, 2 7 , 275–292.2 7 , 275–292.2 7
5. Rozin, P. 1976. Selection of food by rats, humans,
and other animals. In J.S. Rosenblatt, R.A.
Hinde, E. Shaw, & C. Beer (Eds.), A dv anc es in th e
study of beh av ior . New York: Academic Press.
6. Sadella, E., & Burroughs, J. 1981, October. Profiles
in eating: Sexy vegetarians and other diet-based
stereotypes. P sy c h ol ogy T oday , 51–57.
7. Stein, R.I., & Nemeroff, C.J. 1995. Moral over-
tones of food: Judgments of others based on
what they eat. P er sonal ity and S oc ial P sy c h ol ogy
B ul l etin, 2 1 , 480–490.
8. Larson, N., & Story, M. 2009. A review of envi-
ronmental influences on food choices. A nnal s of
B eh av ior al M edic ine, 3 8 ( Suppl 1), S56–S73.
9. Rozin, P. 1996. The socio-cultural context of
eating and food choice. In H.L. Meiselman &
H.J.H. Macfie (Eds.), F ood c h oic e, ac c eptanc e
and c onsumption. London: Blackie Academic &
Professional.
10. Mccomber, D.R., & Postel, R.T. 1992. The role of
ethnic foods in the food and nutrition curricu-
lum. J our nal of H ome E c onomic s, 8 4 , 52–54, 59.
11. Wansink, B., Cheney, M.M., & Chan, N. 2003.
Exploring comfort food preferences across
age and gender. P h y siol ogy & B eh av ior , 7 9 ,
739–742.
12. Heldke, L. 2005. But is it authentic? Culinary
travel and the search for the “genuine article.”
In C. Korsmeyer (Ed.), T h e taste c ul tur e r eader .
New York: Berg.
13. Anderson, E.N. 2005. E v er y one eats: U nder stand-
ing f ood and c ul tur e. New York: New York Univer-
sity Press.
14. Helman, C. 2007. C ul tur e, h eal th and il l ness.
Oxford, England: Oxford University Press.
15. Andrews, M., Backstrand, J., B oyle, J.,
Campinha-Bacote, J., Davidhizar, R. E.,
Doutrich, D., Echevarria, M., et al. 2010. Theo-
retical basis for transcultural care. J our nal of
T r ansc ul tur al N ur sing, 2 1 (Suppl.), 53S–136S.
16. Harnack, L., Story, M., & Holy Rock, B. 1999. Diet
and physical activity patterns of Lakota Indian
adults. J our nal of th e A mer ic an Dietetic A ssoc ia-
tion, 9 9 , 829–835.
17. Satia-Abouta, J.A., Patterson, R.E., Neuhouser,
M.L., & Elder, J. 2002. Dietary acculturation:
Applications to nutrition research and dietetics.
J our nal of th e A mer ic an Dietetic A ssoc iation, 1 0 2 ,
1105–1118.
18. Franzen L., & Smith C. 2009. Acculturation and
environmental change impacts dietary habits
among adult Hmong. A ppetite. 5 2 ,173–183.
19. Mezzich, J.E., Caracci, G., Fabrega, H, & Kirmayer,
LJ. 2009. Cultural formulation guidelines. T r ans-
c ul tur al P sy c h iatr y , 4 6 , 383–405.
20. Sodowsky, G.R., & Carey, J.C. 1988. Relationships
between acculturation-related demographics and
cultural attitudes of an Asian-Indian immigrant
group. J our nal of M ul tic ul tur al C ounsel ing and
Dev el opment, 1 6 , 117–136.
21. Bookins, G.K. 1993. Culture, ethnicity, and
bicultural competence: Implications for children
with chronic illness and disability. P ediatr ic s, 9 1 ,
1056–1061.
22. Meleis, A.I., Lipson, J.G., & Paul, S.M. 1992.
Ethnicity and health among five Middle Eastern
ethnic groups. N ur sing R esear c h , 4 2 , 98–103.
23. Jelliffe, D.B. 1967. Parallel food classifications in
developing and industrialized countries. A mer i-
c an J our nal of C l inic al N utr ition, 2 0 , 279–281.
24. Passim, H., & Bennett, J.W. 1943. Social process
and dietary change. I n T h e P r obl em of C h anging
F ood H abits. Washington, DC: National Research
Council Bulletin.
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

3 0 F O O D A N D C U L T U R E
25. Mintz, S., & Schlettwein-Gsell, D. 2001. Food
patterns in agrarian societies: The “core-fringe-
legume hypothesis.” A dialogue. G astr onomic a. 1 ,
41–59.
26. Billings, J., & Sherman, P.W. 1998. Antimicrobial
functions of spices: Why some like it hot. Q uar –
ter l y R ev iew of B iol ogy , 7 3 , 3–49.
27. Rozin, P., & Schiller, P. 1980. The nature and
acquisition of a preference for chile peppers by
humans. M otiv ation and E motion 4 , 77–101.
28. Rozin, E., & Rozin, P. 2005. Culinary themes
and variations. In C. Korsmeyer (Ed.), T h e taste
c ul tur e r eader . New York: Berg.
29. Rozin, E. 2005. Flavor principles: Some applica-
tions. In C. Korsmeyer (Ed.), T h e taste c ul tur e
r eader . New York: Berg.
30. Fischler, C. 1988. Food, self, and identity. S oc ial
S c ienc e I nf or mation, 2 7 , 275–292.2 7 , 275–292.2 7
31. Douglas, M. 1972. Deciphering a meal. Daedal us,
1 0 1 , 61–81.
32. Sobal, J. 1999. Social change and foodways. In
P r oc eedings of th e C ul tur al and H istor ic al A spec ts
of F ood S y mposium. Corvallis: Oregon State
University.
33. Gaytan, M.S. 2004. Globalizing resistance: Slow
food and local imaginaries. F ood, C ul tur e &
S oc iety , 7 , 97–116.7 , 97–116.7
34. Waters, A. 2010. I n th e gr een k itc h en: T ec h niq ues
to l ear n by h ear t. New York: Clarkson-Potter.
35. Lowenberg, M.E. 1970. Socio-cultural basis of
food habits. F ood T ec h nol ogy , 2 4 , 27–32.
36. Schwabe, C.W. 1979. U nmentionabl e c uisine.
Charlottesville: University of Virginia Press.
37. Menzel, P., & D’Alusio, F. 1998. M an eating bugs:
T h e ar t and sc ienc e of eating insec ts. Berkeley, CA:
Ten Speed Press.
38. Drewnowski, A. 2002. Taste, genetics and food
choices. In H. Anderson, J. Blundell, & M. Chiva
(Eds.), F ood sel ec tion f r om genes to c ul tur e.
Levallois-Perret, France: Danone Institute.
39. Munoz, K.A., Krebs-Smith, S.M., Ballard-
Barbash, R., & Cleveland, L.E. 1997. Food intakes
of US children and adolescents compared with
recommendations. P ediatr ic s, 1 0 0 , 323–329.
40. Mccrory, M.A., Saltzman, E., Rolls, B.J., &
Roberts, S.B. 2006. A twin study of the effects of
energy density and palatability on energy intake
of individual foods. P h y siol ogy & B eh av ior , 8 7 ,
451–459.
41. Anderson, C.H. 1995. Sugars, sweetness and food
intake. A mer ic an J our nal of C l inic al N utr ition,
6 2 (Supp.), 195S–201S.
42. Anderson, E.N. 2005. E v er y one eats: U nder stand-
ing f ood and c ul tur e. New York: New York Univer-
sity Press.
43. Drewnowski, A., & Gomez-Carneros, C. 2000.
Bitter taste, phytonutrients and the consumer: A
review. A mer ic an J our nal of C l inic al N utr ition, 7 2 ,
1424–1435.
44. Crystal, S.R., & Bernstein, I.L. 1998. Infant salt
preference and mother’s morning sickness.
A ppetite, 3 0 , 297–307.
45. Delisle, H. 2010. Findings on dietary patterns in
different groups of African origin undergoing
nutrition transition. A ppl ied P h y siol ogy , N utr ition,
and M etabol ism, 3 5 , 224–228.
46. Liu, A, Berhane, Z, & Tseng, M. 2010. Improved
dietary variety and adequacy but lower dietary
moderation with acculturation in Chinese
women in the United States. J our nal of th e A mer i-
c an Dietetic A ssoc iation, 1 1 0 , 457–62.
47. Coleman-Jensen, A., Gregory, C., & Singh, A.
2014September. Household food security in the
United States in 2013. E c onomic R esear c h R epor t
N o. ERR-173. Retrieved from http://www.ers
.usda.gov/publications/err-economic-research-
report/err173.aspx (accessed January 28, 2015).
48. Jetter, K.M., & Cassady, D.L. 2005, March. The
availability and cost of healthier food items.
U niv er sity of C al if or nia A gr ic ul tur al I ssues C enter
A I C I ssues B r ief 2 9 .
49. Wilson, T.A., Adolph, A.L., & Butte, N.F. 2009.
Nutrient adequacy and diet quality in non-
overweight and overweight Hispanic children of
low socioeconomic status: The Viva la Familia
Study. J our nal of th e A mer ic an Dietetic A ssoc ia-
tion, 1 0 9 , 1012–1022.
50. Block, J.P., Scribner, R.A., & Desalvo, K.B. 2004.
Fast food, race/ethnicity and income: A geo-
graphic analysis. A mer ic an J our nal of P r ev entativ e
M edic ine, 2 7 , 211–217.2 7 , 211–217.2 7
51. Lewis, L.B., Sloan, D.C., Nascimento, L.M.,
Diamant, A.L., Guinyard, J.J., Yancey, A.K., &
Flynn, G.G. 2005. African Americans’ access to
healthy food options in south Los Angeles res-
taurants. A mer ic an J our nal of P ubl ic H eal th , 9 5 ,
668–673.
52. Moore, L.V., Diez Roux, A.V., Nettleton, J.A.,
Jacobs, D.R., & Franco, M. 2009. A mer ic an J our –
nal of E pidemiol ogy , 1 7 0 , 29–36.
53. Larson, N.I., Story, M.T., & Nelson, M.C. 2009.
Neighborhood environments: Disparities in
access to healthy foods in the US. A mer ic an J our –
nal of P r ev entiv e M edic ine, 3 6 , 74–81.
54. Energy Information Administration. 2002,
November 25. Cooking trends in the United States:
Are we really becoming a fast food country? U.S.
Department of Energy. Retrieved from http://eia
.doe.gov/emeu/recs/cooking-trends/cooking.html
55. Rollins, B.Y., Belue, R.Z., & Francis, L.A. 2010.
The beneficial effect of family meals on obesity
differs by race, sex, and household education: The
national survey of children’s health, 2003–2004.
J our nal of th e A mer ic an Dietetic A ssoc iation, 1 1 0 ,
1335–1339.
56. Beydoun, M.A., Powell, L.M., & Wang, Y. 2009.
Reduced away-from-home food expenditure and
better nutrition knowledge and belief can improve
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

C H A P T E R 1 3 1
quality of dietary intake among US adults. P ubl ic
H eal th N utr ition, 1 2 , 369–381.
57. National Restaurant Association. Facts at a glance.
n.d. Retrieved from http://www.restaurant.org/
News-Research/Research/Facts-at-a-Glance
(accessed January 25, 2015).
58. Lannon, J. 1986. How people choose food: The
role of advertising and packagings. In C. Ritson, L.
Gofton, & J. Mckenzie (Eds.), Th e f ood c onsumer .
New York: Wiley.
59. Folta, S.C., Goldberg, J.P., Economos, C.,
Bell, R., & Meltzer, R. 2006. Food advertising tar-
geted at school-age children: A content analysis.
J our nal of N utr ition E duc ation and B eh av ior , 3 8 ,
244–248.
60. Sykes, D. 2003. Food as pleasure: Other-
directedness in food ads. J our nal f or th e S tudy of
F ood and S oc iety , 6 , 49–56.
61. Henry, A.E., & Story, M. 2009. Food and beverage
brands that market to children and adolescents on
the Internet: A content analysis of branded web
sites. J our nal of N utr ition E duc ation and B eh av ior ,
4 1 , 353–359.
62. Duquesne, D. December 1, 2010. F ood por n:
L ov e it or h ate it? Huffington Post. Retrieved
from http://www.huffingtonpost.com/daphne-
duquesne/food-porn_b_790549.html#s196042
(accessed January 6, 2015).
63. Gardyn, R. 2003, March. Teen food fetishes: Aver-
age male teenager eats five times a day, female eats
four times a day. A mer ic an Demogr aph ic s, p. 2.
64. Contento, I.R., Williams, S.S., Michaela, J.L., &
Franklin, A.B. 2006. Understanding the food
choice process of adolescents in the context of
family and friends. J our nal of A dol esc ent H eal th ,
3 8 , 575–582.
65. Blisard, N., Lin, B.H., Cromartie, J., & Ballenger, N.
2002. America’s changing appetite: Food consump-
tion and spending to 2020. F ood R ev iew , 2 5 , 1–9.
66. Smeets, P.A., De Graaf, C., Stafleu, A., van Osch,
M.J., Nievelstein, R.A., & van Der Grond, J. 2006.
Effect of satiety on brain activation during choco-
late tasting in men and women. A mer ic an J our nal
of C l inic al N utr ition, 8 3 , 1297–1305.
67. Rozin, P. 1996. The socio-cultural context of
eating and food choice. In H.L. Meiselman, &
H.J.H. Macfie (Eds.), F ood c h oic e, ac c eptanc e
and c onsumption. London: Blackie Academic &
Professional.
68. Appleton, K.M., Gentry, R.C., & Shepherd, R.
2006. Evidence of a role for conditioning in the
development of liking for flavours in humans in
everyday life. P h y siol ogy & B eh av ior , 8 7 , 478–486.8 7 , 478–486.8 7
69. Birch, L.L. 1999. Development of food prefer-
ences. A nnual R ev iew of N utr ition, 1 9 , 41–62.
70. Martins, Y., Pelchat, M.L., & Pliner, P. 1997. “Try
it; it’s good for you”: Effects of taste and nutrition
information on willingness to try novel foods.
A ppetite, 2 8 , 89–102.
71. Sealy, Y.M. 2010. Parents’ perceptions of food
availability: implications for childhood obesity.
S oc ial W or k in H eal th C ar e, 4 9 , 565–580.
72. Variyan, J.N., & Golan, E. 2002. New information
is reshaping food choices. F ood R ev iew , 2 5 , 13–18.
73. Aikman, S.N., Min, K.E., & Graham, D. 2006.
Food attitudes, eating behavior, and the infor-
mation underlying food attitudes. A ppetite, 4 7 ,
111–114.
74. House, J., Su, J., & Levy-Milne, R. 2006. Defini-
tions of healthy eating among university stu-
dents. C anadian J our nal of Dietetic s P r ac tic e and
R esear c h , 6 7 , 14–18.6 7 , 14–18.6 7
75. Shepard, R., & Raats, M.M. 1996. Attitudes and
beliefs in food habits. In H.L. Meiselman, &
H.J.H. Macfie (Eds.), F ood c h oic e, ac c eptanc e
and c onsumption. London: Blackie Academic &
Professional.
76. Woolcott, D.M. 2002. Impact of information
and psychosocial factors on nutrition behavior
change. In H. Anderson, J. Blundell, & M. Chiva
(Eds.), F ood sel ec tion f r om genes to c ul tur e.
Levallois-Perret, France: Darone Institute.
77. Goody, C.M., & Drago, L. 2010. I ntr oduc tion:
Cultural competence and nutrition counseling.
In C ul tur al F ood P r ac tic es. Chicago: American
Dietetic Association.
78. Campinha-Bacote, J. 1999. A model and instru-
ment for addressing cultural competence in
health care. J our nal of N ur sing E duc ation, 3 8 ,
203–207.
79. Andrews, M.M., & Boyle, J.S. (Eds.). 2008.
T r ansc ul tur al c onc epts in nur sing c ar e (5th ed.).
Philadelphia, PA: Lippincott, Williams & Wilkins.
80. Skipper, A., Young, L.O., & Mitchell, B. 2008
accreditation standards for dietetic education.
J our nal of th e A mer ic an Dietetic A ssoc iation, 1 0 8 ,
1732–1735.
81. American Diabetes Association of Diabetes Edu-
cators. 2007. Cultural sensitivity and diabetes
education: Recommendations for diabetes edu-
cators. T h e Diabetes E duc ator , 3 3 , 41–44.
82. Census.gov 2014 national population projec-
tions. n.d. Retrieved from http://www.census.gov/
population/projections/data/national/2014/
summarytables.html (accessed December 6, 2010).
83. CDR registered dietitian demographics. Decem-
ber 1, 2013. Retrieved from http://www.cdrnet
. o r g / c e r t i f i c a t i o n s / r e g i s t e r e d – d i e t i t i a n s –
demographics (accessed January 26, 2015).
84. Pamies, R.J., Hill, G.C., Watkins, L., Mcnamee,
M.J., & Colburn, L. 2006. Diversity and the
health-care workforce. In D. Satcher & R.J. Pamies
(Eds,), M ul tic ul tur al medic ine and h eal th dispar i-
ties. New York: McGraw-Hill.
85. Statistics Canada. n.d. 2006 census analysis.
Retrieved from http://www12.statcan.gc.ca/
census-recensement/2006/as-sa/index-eng.cfm
(accessed December 6, 2010).
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

3 2 F O O D A N D C U L T U R E
86. Goel, M.S., Mccarthy, E.P., Phillips, R.S., &
Wee, C.C. 2004. Obesity among US immigrant
subgroups by duration of residence. J our nal of th e
A mer ic an M edic al A ssoc iation, 2 9 2 , 2860–2867.
87. Singh, G.K., & Siahpush, M. 2002. Ethnic-
immigrant differentials in health behaviors, mor-
bidity, and cause-specific mortality in the United
States: An analysis of two national data bases.
H uman B iol ogy , 7 4 , 83–109.
88. Delisle, H. 2010. Findings on dietary patterns in
different groups of African origin undergoing
nutrition transition. A ppl ied P h y siol ogy , N utr ition,
and M etabol ism, 3 5 , 224–228.
89. Liu, A., Berhane, Z., & Tseng, M. 2010. Improved
dietary variety and adequacy but lower dietary
moderation with acculturation in Chinese women
in the United States. J our nal of th e A mer ic an
Dietetic A ssoc iation, 1 1 0 , 457–462.
90. Perez-Escamilla, R. 2009. Dietary quality among
Latinos: Is acculturation making us sick? J our nal
of th e A mer ic an Dietetic A ssoc iation, 1 0 9 , 988–91.
91. Steffen, P.R., Smith, T.B., Larson, M., & Butler, L.
2006. Acculturation to Western society as a risk
factor for high blood pressure: A meta-analytic
review. P sy c h osomatic M edic ine, 6 8 , 386–397.
92. Yun, K., Hebrank, K., Graber, L.K., Sullivan,
M.C., Chen, I., & Grupta, J. 2012. High preva-
lence of chronic non-communicable conditions
among adult refugees: Implications for practice
and policy. J our nal of C ommunity H eal th , 3 7 (15),
1110–1118.
93. Palinkas, L.A., & Pickwell, S.M. 1995. Accultura-
tion as a risk factor for chronic disease among
Cambodian refugees in the United States. S oc ial
S c ienc e and M edic ine, 4 0 , 1643–1653.
94. Kaplan, J.B., & Bennett, T. 2003. Use of race and
ethnicity in biomedical publication. J our nal of th e
A mer ic an M edic al A ssoc iation, 2 8 9 , 2709–2716.
95. Hamilton, J. A. 2008, Fall. Revitalizing difference
in the Hap Map: Race and contemporary human
genetic variation research. J our nal of L aw and
M edic al E th ic s, 471–477.
96. Krishnan, S., Cozier, Y.C., Rosenberg, L., &
Palmer, J.R. 2010. Socioeconomic status and
incidence of type 2 diabetes: Results from the
Black Women’s Health Study. A mer ic an J our nal
of E pidemiol ogy , 1 7 1 , 564–570.
97. Stang, J., & Bayerl, C.T. 2010. Position of the
American Dietetic Association: Child and ado-
lescent nutrition assistance programs. J our nal of
th e A mer ic an Dietetic A ssoc iation, 1 1 0 , 791–799.
98. Nelms, M.N., & Habash, D. 2016. Nutrition
assessment: Foundation of the nutrition care
process. In M. Nelms, K. Sucher, & K. Lacey,
N utr ition th er apy and path oph y siol ogy (3rd ed.).
Belmont, CA: Cengage Learning.
99. Jelliffe, D.B., & Bennett, F.J. 1961. Cultural and
anthropological factors in infant and maternal
nutrition. P r oc eedings of th e F if th I nter national
C ongr ess of N utr ition, 2 0 , 185–188.
100. Groth, S.W., & Kearney, M.H. 2009. Diverse
women’s beliefs about weight gain in pregnancy.
J our nal of M idw if er y and W omen’ s H eal th , 5 4 ,
452–457.
101. Stowers, S.L. 1992. Development of a culturally
appropriate food guide for pregnant Caribbean
immigrants in the United States. J our nal of th e
A mer ic an Dietetic A ssoc iation, 9 2 , 331–336.
102. National Restaurant Association. August 24, 2000.
Non-traditional ethnic cuisines gain in popular-
ity. Retrieved from http://www.restaurant.org/
pressroom/pressrelease/?id=126
103. Ethnic foods—US. January 2014. Mintel Group
Ltd. Retrieved from http://store.mintel.com/
ethnic-foods-us-january-2014 (accessed January
27, 2015).
104. Sloan, A.E. (Ed.) 2005. Top 10 global food trends.
F ood T ec h nol ogy , 5 9 , 20–32.
105. Chau, P., Lee, H.S., Tseng, R., & Downes, N.J.
1990. Dietary habits, health beliefs, and food
practices of elderly Chinese women. J our nal of
th e A mer ic an Dietetic A ssoc iation, 9 0 , 579–580.
106. Walker, A. 2005. In the absence of food: A case
of rhythmic loss and spoiled identity for patients
with percutaneous endoscopic gastrostomy feed-
ing tubes. F ood, C ul tur e & S oc iety , 8 , 161–180.
107. Rozin, P., Fallon, A., & Augustoni-Ziskind, M.
1985. The child’s conception of food: The devel-
opment of contamination sensitivity to “disgust-
ing” substances. Dev el opmental P sy c h ol ogy , 2 1 ,
1075–1079.
108. Sutherland, L.L. 2002. Ethnocentrism in a plural-
istic society. J our nal of T r ansc ul tur al N ur sing, 1 3 ,
274–281.
109. Pause, B.M., Rogalski, K.P., Sojka, B., & Ferstl, R.
1999. Sensitivity to androstenone in female sub-
jects is associated with an altered brain response
to male body odor. P h y siol ogy & B eh av ior , 6 8 ,
129–137.
110. Rozin, P., Haidt, J., & McCauley, C.R. 1993.
Disgust. In M. Lewis & J.M. Haviland (Eds.),
H andbook of H uman E motions. New York:
Guilford.
111. U.S. Department of Labor/U.S. Department of
Labor Statistics. 2006. 100 years of U.S. consumer
spending. Retrieved from http://www.bls.gov/
opub/uscs/home.htm
112. Ayala, G.X., Mueller, K., Lopez-Madurga, E.,
Campbell, N.R., & Elder, J.P. 2005. Restaurant and
food shopping selections among Latino women
in Southern California. J our nal of th e A mer ic an
Dietetic A ssoc iation, 1 0 5 , 38–45.
113. Wilkins, J. 2005, August. This black widow has
quite a bite. S an Diego U nion- T r ibune, p. D3.
114. Yang, F. M., & Levkoff, S. E. (2005). Ageism and
minority populations: Strengths in the face of
challenge. G ener ations, 2 9 ( 3), 42–48.
115. Schwartz, S.J., Pantin, H., Sullivan, S., Prado, G., &
Szapocznik, J. 2006. Nativity and years in receiv-
ing culture as markers of acculturation in ethnic
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

C H A P T E R 1 3 3
enclaves. J our nal of C r oss C ul tur al P sy c h ol ogy , 3 7 , 3 7 , 3 7
345–353.
116. Hunt, L.M., Schneider, S., & Comer, B. 2004.
Should “acculturation” be a variable in health
research? A critical review of research on US His-
panics. S oc ial S c ienc e & M edic ine, 5 9 , 973–986.
117. Denavas-Walt, C., Proctor, B.D., & Lee, C.H.
2005. I nc ome, pov er ty , and h eal th insur anc e in th e
U nited S tates: 2 0 0 4 . U.S. Census Bureau. Wash-
ington, DC: U.S. Government Printing Office.
118. Drewnowski, A., & Spector, S.E. 2004. Poverty and
obesity: The role of energy density and energy costs.
A mer ic an J our nal of C l inic al N utr ition, 7 9 , 6–16.
119. Dietz, W.H. 1995. Does hunger cause obesity?
P ediatr ic s, 9 5 , 766–767.
120. Jetter, K.M., & Cassady, D.L. 2005, March. The
availability and cost of healthier food items.
U niv er sity of C al if or nia A gr ic ul tur al I ssues C enter
A I C I ssues B r ief 2 9 .
121. Kumanyika, S., & Grier, S. 2006. Targeting inter-
ventions for ethnic minority and low-income
populations. T h e F utur e of C h il dr en, 1 6 , 187–207.
122. Drewnowski, A. OBESITY, diets, and social
inequalities. 2009, May. N utr ition R ev iew s.
6 7 ( Suppl 1), S36–S39.
123. Eisenmann, J.C., Gundersen, C., Lohman, B.J.,
Garasky, S., & Stewart, S.D. 2011. Is food inse-
curity related to overweight and obesity in chil-
dren and adolescents? A summary of studies,
1995–2009. O besity R ev iew s, 1 2 (5), e73–e83.
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

3 4
Traditional Health
Beliefs and Practices2 CHA
P
T
E
R

$11 billion annually to nearly $40 billion.2
When biomedical care is sought, it is often
in conjunction with these other systems. The
term integr ativ e medic ine is used when there
is a combination of conventional and CAM
treatments that have demonstrated scientific
evidence of safety and effectiveness.1
Culture determines how a person defines
health, recognizes illness, and seeks treat-
ment. Traditional health beliefs and prac-
tices can be categorized in various ways:
through the etiology of illness (due to per-
sonal, natural, social, or supernatural causes)
or by the cures that are employed (the use of
therapeutic substances, physical forces, or
magico-religious interventions). There is no
consensus, however, on these classifications.
In this chapter, home remedies, popular
approaches such as folk and alternative tra-
ditions, and professional systems (including
U.S. biomedicine, traditional Chinese medi-
cine, and Asian Indian ayurvedic medicine)
are reviewed within the cultural context of
health and illness. Specific beliefs and prac-
tices are detailed in the following chapters on
each American ethnic group.
Worldview
Cultural Outlook
Each cultural group has a unique outlook on
life, based on a common understanding and
ranking of values. These standards typically
represent what is considered worthy in a life
well lived. They are a collective expression of
Health and illness in America are usually considered the specialty of mainstream biomedicine. B iomedi-
c ine is the term used to describe the conven-
tional system of health care in the United
States and other Western nations based on the
principles of the natural sciences, including
biology, physiology, and biochemistry. Fur-
thermore, health promotion is based on sci-
entific findings of researchers regarding diet,
exercise, and lifestyle issues such as smoking
cessation and stress management; disease is
treated according to the latest technologies. In
reality, health care is pluralistic in the United
States, as well as in most other cultures. Many
people in the United States never consult a
physician or allied health care provider when
physical or emotional symptoms occur, rely-
ing on home remedies and popular therapies
found readily on the Internet rather than
seeking professional help. Complementary
and alternative medicine (CAM) is popular
with many Americans. The National Cen-
ter for Complementary and Alternative
Medicine recently published data gathered
from the National Health Interview Survey
and estimates that approximately 38 percent
of all adults and approximately 12 percent of
all children used some form of CAM during
the year of 2007. This is a significant increase
since the last report in 2002. The top five CAM
therapies included natural products, deep
breathing, meditation, chiropractic and osteo-
pathic interventions, and massage.1 Consumer
spending on such practices and products has
more than tripled in the past decade, from
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

C H A P T E R 2 3 5
preferences and priorities—not absolutes—
and individuals within a society may hold a
spectrum of beliefs. However, expectations
about personal and public conduct, assump-
tions regarding social interaction, and assess-
ments of individual behavior are determined
by this cultural outlook, or worldview. This
perspective influences perceptions about
health and illness as well as the role of each
within the structure of a society.3,4,5 Majority
American values, which are shared by most
whites and to some degree by many other
ethnic groups in the United States, emphasize
individuality and control over fate (Table 2.1).
Personal accountability and self-help are
considered cultural cornerstones. One study
found that 82 percent of American consumers
believe they are directly responsible for their
own health.6 Most other cultures worldwide
believe that fate—including the will of God,
the actions of supernatural agents, or birth-
right (i.e., astrological alignment or cosmic
karma)—is a primary influence in health and
illness. Although most cultures have complex
practices regarding the maintenance of health,
the concept of preventative health care, such as
annual checkups, is unknown in some cultures
where fate dominates.
The significance of fate often coincides
with differences in perceptions of time. Many
Americans place great value on promptness
and schedules; they are also future oriented,
meaning they are willing to work toward long-
term goals or make sacrifices so that they or
their children will reap rewards in the future.
The majority members in the United States
TA B L E 2 .1 Comparison of Common Values
Majority American Culture Other Cultural Groups
Mastery over nature Harmony with nature
Personal control over the environment Fate
Doing—activity Being/becoming
Time dominates Personal interaction dominates
Human equality Hierarchy/rank/status
Individualism/privacy Group welfare
Youth Elders
Self-help Birthright inheritance
Competition Cooperation
Future orientation Past or present orientation
Informality Formality
Directness/openness/honesty Indirectness/ritual/“face”
Practicality/efficiency Idealism
Materialism Spiritualism/detachment
SOURCE: Adapted from E. Randall-David, Strategies for Working with Culturally Diverse Communities. Association for the Care of Children’s Health, 19 Mantua Rd.,
Mt. Royal, NY 08061. Copyright 1989.
▼
The concept of preventive
health care, such as annual
checkups provided by a
biomedical professional, is
unknown in some cultures
where fate is believed to
determine health.
M
ic
ha
el
N
ew
m
an
/P
ho
to
Ed
it
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

3 6 T R A D I T I O N A L H E A L T H B E L I E F S A N D P R A C T I C E S
are also monochronistic, with a preference for
concentrating on one issue or task at a time
in a sequential manner. Many other cultural
groups live in the present and are often poly-
chronistic, or comfortable doing many things
at once. A Mexican American who is talking
with his grandmother while fixing an appliance
and watching a baseball game on television is
unlikely to cut the visit short just because he
has a medical appointment. Immediate inter-
ests and responsibilities, including interper-
sonal relationships, are more important than
being on time. A few cultures, such as certain
Native American nations, are past oriented,
living according to historical direction.
Most majority Americans are very task ori-
ented and desire direct participation in their
health care; they feel best when they can do
something. Other cultures place a greater value
on being and feel comfortable with inactivity.
Self-worth is based more on personal relation-
ships than on accomplishments. The expecta-
tion is that the health care practitioner will
take responsibility for treatment. The whole
idea of the provider–client partnership may be
alien to Asians, who often expect to be fully
directed in their care. While many Americans
value patient autonomy and confidentiality,
other cultural groups, such as Middle Eastern-
ers, believe that the family should be involved
in all health care decisions—the welfare of the
group outweighs that of the individual.
Many cultures prefer indirect communi-
cation, which seems vague and noncommit-
tal to Americans, who consider honest, open
dialogue essential to effective communication
(see Table 2.2). In addition, Americans often
prefer informality, compared to many cul-
tures that expect a formal relationship with
everyone but intimate family members. In
cultures where identity with a group is more
significant than individuality, social status
and hierarchy are respected, which can have
an impact on the practitioner–client relation-
ship (see Chapter 3, “Intercultural Communi-
cation,” for more information).
Worldview is especially evident in serious,
life-and-death health care decisions. Southeast
Asians may appear indifferent to a terminally ill
family member and have little interest in pro-
longing life because of a faith in reincarnation.
Some African Americans distrust white Ameri-
can health care recommendations regarding
do-not-resuscitate orders in part because they
contradict the critical role of faith in African
American healing. An Orthodox Jewish patient
may believe that physicians are mandated to
preserve life and that any person who assists
death through denial of sustaining care is a
murderer; a non-Orthodox Jew may believe
that no one should endure uncontrollable
pain and thus dying should not be prolonged.
Middle Easterners traditionally demand that
everything be done to keep a person alive
because death is in God’s hands, and one must
never give up hope. Mexican American fam-
ily members might view death as part of God’s
plan for a relative; they might be against any-
thing that would quicken death, or they may
expect the practitioner to make the decision.7,8,9
Most health care situations are not cases of
life or death, and worldview affects many other,
less catastrophic aspects of health and illness as
well. It is useful to examine the biomedical
worldview and understand the perspective of
most U.S. health care providers before learning
about other traditional health beliefs and prac-
tices. Comparisons between biomedicine and
other medical systems can reveal areas of
potential disagreement or conflict regarding
Some majority
Americans find eating a
meal a disruption of daily
tasks; others adhere to
strict meal schedules. In
polychronistic (people-
oriented versus task-
oriented) societies, meals
are usually leisurely
events, a chance to enjoy
the blessings of food in
the company of family
and friends.
TA B L E 2 . 2 Direct and Indirect Communication
Direct Communication Indirect Communication
1 Openly confront issues or difficulties
2 Communicate concerns straight-forwardly
3 Engage in conflict when necessary
4 Express views or opinions in a frank manner
Example: Get right to the point during a
conversation.
1 Focus is not just on what is said but how it is said
2 Avoid difficult or contentious issues
3 Avoid conflict if possible
4 Express opinions and concerns diplomatically
5 Count on the listener to interpret the meaning
Example: Avoid saying no; say maybe or possibly,
even if you mean no.
SOURCE: Peterson, Brooks. 2004. Cultural intelligence: A guide to working with people from other cultures. Boston: Intercultural Press.
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

C H A P T E R 2 3 7
how and why illness occurs and the expecta-
tions for treatment before working with a client.
Compliance increases with clinical approaches
that concur with the client’s worldview.10,11
Biomedical Worldview
Biomedicine is a cultural subdivision of the
American majority worldview. It shares many
beliefs with the dominant outlook but differs
in a few notable areas.12,13 There are certainly
exceptions to the biomedical worldview within
certain specialties, and by some practitioners,
yet many of the underlying assumptions are
culture-specific. The tendency is for health
care providers to enforce their beliefs, prac-
tices, and values upon clients, sometimes
unknowingly because they are unaware of
cultural differences, but more often because
they believe their ideas are superior. This pro-
cess is called c ul tur al imposition, and it impacts
nearly all client care.14
Relationship to Nature
Biomedicine adheres to the concept of mas-
tery over nature. Practitioners are soldiers in
the war on cancer (or other conditions). They
fight infection, conquer disease, and kill pain.
Technology is considered omnipotent; its tools
are the arsenal used to battle pain and illness.
One factor in this approach is the attitude
that health can be measured numerically and
that there are standardized definitions of dis-
ease. Blood and urine analyses, X-rays, scans,
and other diagnostic tests are used to define
whether a patient is within normal physical or
biochemical ranges. Results falling within des-
ignated parameters mean the patient is func-
tioning normally; if the data are too high or
too low, the patient is in an abnormal state that
may indicate disease. Diagnosis occurs inde-
pendent of the idiosyncratic characteristics of
the individual, usually without consideration of
cultural factors such as ethnic background or
religious faith. Symptoms that cannot be linked
to a known medical problem are frequently
determined to be of psychosomatic origins.12
Personal Control or Fate?
The U.S. medical system leaves little room
for chance or divine intervention. Scientific
rationality dictates that there is a biomedi-
cal cause for every condition, even if it is as
yet undiscovered. Each individual inherits a
certain physiological constitution and has a
personal responsibility to make the choices
that prevent illness. Receiving immunizations
and getting regular checkups are biomedical
ways by which individuals can preserve their
health. Being obese, smoking cigarettes, con-
suming immoderate amounts of alcohol, and
failing to manage stress are biomedical exam-
ples of how individuals may endanger their
health.
When a person is ill, the biomedical
assumption is that he or she will reliably com-
ply with therapy, and that treatment, if under-
taken correctly by the patient, will alleviate
the condition. The onus of cure is dependent
on personal behavior. From the patient’s per-
spective, there is the presumption that health
care professionals will provide mistake-free
care. Malpractice suits filed when care was
less than perfect have led to extensive chart-
ing and record keeping in the U.S. biomedical
system.
State of Being
Consistent with the value placed on personal
control, biomedical patients are expected to
be active partners in their cure. Noncompli-
ance is disliked by biomedical practitioners.
Changes in lifestyle can help preserve health;
taking medications and completing therapeu-
tic regimens can relieve symptomatic pain
or cure disease. The biomedical emphasis is
on doing, not being. Other worldviews may
expect client nonparticipation and acceptance
of adverse conditions. Clients are the recipi-
ents of healing, not participants in healing.
Role of the Individual
Similar to the American majority worldview,
individuality is honored in U.S. biomedicine,
and client confidentiality is mandatory. Indi-
viduals are seen as a single, biological unit, not
as members of a family or a particular cultural
group. It is assumed that a person desires pri-
vacy, and clients are sometimes encouraged
by providers to keep medical matters quiet,
even if it means withholding information
from relatives. Typically, treatment is focused
solely on the client, in keeping with the beliefs
of personal responsibility and the provider–
patient partnership.
Some researchers have
noted that although
the biomedical com-
munity often calls clients
whose cultural back-
ground differs from the
majority “hard to reach,”
this term is equally
applicable to health
professionals who refuse
to provide culturally
appropriate care.70
The number of adults
over sixty-five years
in the United States is
expected to double by
the year 2050; figures
among some ethnic
groups, such as African
Americans, Asian Ameri-
cans, Native Americans
and Latinos, show even
greater growth.
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

3 8 T R A D I T I O N A L H E A L T H B E L I E F S A N D P R A C T I C E S
Human Equality
A fundamental premise in American biomed-
icine is that all patients deserve equal access
to care, although, practically speaking, cost,
location, and convenience prevents many
patients from receiving adequate health ser-
vices. This is a relatively unique perspective;
most other societies deliberately ration health
care through assessing physical status (e.g.,
a young person may receive services denied
to a terminally ill older person) or through
socioeconomic status (e.g., the wealthy can
purchase care; the poor are left to whatever
society offers).
The biomedical worldview on human
equality differs substantially from the main-
stream American outlook in one way, how-
ever. A hierarchy of biomedical professionals
is strictly observed in the United States, with
physicians having the highest status and allied
health professionals substantially less. Health
care workers outside the professional sys-
tem, such as clerical and custodial workers,
and those beyond the reach of biomedicine,
such as folk healers, are accorded even lower
standing. Deference to those of superior rank
is expected. The client is typically inferior to
biomedical professionals within this hierarchy.
Aging
Biomedicine supports the majority American
worldview in its value on youthfulness. Many
aspects of health care practice are dedicated
to postponing the aging process, from plastic
surgery to the technological prolongment of
life. The fear of aging is so pervasive in the
U.S. culture that it influences health care out-
side the conventional biomedical system as
well. Numerous alternative traditions promise
everlasting youth through the use of certain
products. The emphasis on youthfulness is in
direct conflict with other cultural worldviews
that honor the wisdom that comes with aging
and that hold high esteem for elders.
Perceptions of Time
Biomedicine is future oriented—that is, what
can be done today so that the client will be bet-
ter tomorrow. Often treatments are unpleas-
ant, invasive, and even painful at the moment
of their application, yet the hope is that they
will benefit the client in the future. Long-term
management of disease and illness-prevention
strategies such as diet are even more oriented
toward future benefits.
Although being on time for appointments
and taking medications when scheduled are
traits valued in clients, biomedical practi-
tioners are notorious for their disrespect of
clients’ time. Clients are frequently asked to
arrange nonemergency consultations weeks
or even months in advance and may be kept
waiting on the days of their appointments.
Degree of Formality/Degree
of Directness
The established biomedical hierarchy, as
well as the emphasis on timeliness, is often
reflected in the degree of informality observed
in dialogue between provider and patient. The
provider often addresses the client by his or
her first name, yet expects the patient to use
formal titles in return. The provider usually
spends limited time on small talk and attempts
to get quickly to the problem; the expectation
is the patient will also use a direct approach.
Extensive medical jargon without explanation
is often employed.
Biomedical practitioners value honest,
open communication with patients because
it enhances their ability to diagnose and
treat disease, and it assists in issues such as
informed consent. Other cultural world-
views, however, value indirect or intuitive
communication with health care practitio-
ners (see Chapter 3 for more information).
Some cultures also believe that the family,
not the patient, should be told about serious
conditions.15
Materialism or Spirituality?
Each disease, from the biomedical viewpoint,
has its own physiological characteristics: a
certain cause, specific symptoms, expected
test results, and a predictable response to
treatment. For many biomedical health care
providers, an illness isn’t real unless it is clini-
cally significant; emotional or social issues
are the domain of other specialists. Biomedi-
cine differs from most traditional health care
approaches in the recognition of the mind–
body duality. Nearly all other cultures consider
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

C H A P T E R 2 3 9
the mind and body as a unified whole. Soma-
tization refers to the expression of emotions
through bodily complaints. In biomedical cul-
ture, somatic symptoms are often interpreted
as a maladaptive emotional response, yet they
are the most common presentation of psycho-
logical distress in patients worldwide.16 In folk
medicine and some alternative traditions, the
emotional needs of the patient are addressed
through physical therapies. Spiritual interven-
tion is frequently sought concurrently.
What Is Health?
Cultural Definitions
of Health
Meaning of Health
The World Health Organization (WHO)
describes health as “a state of complete physi-
cal, mental, and social well-being, not merely
an absence of disease or infirmity.” Although
comprehensive from a biomedical perspec-
tive, this definition does not fit the worldview
of many cultural groups because it ignores the
natural, spiritual, and supernatural dimen-
sions of health.
Most Native Americans believe that health
is achieved through harmony with nature,
which includes the family, the community,
and the environment. Africans also empha-
size a balance with nature and believe that
malevolent environmental forces such as
those of nature, God, the living, or the dead
may disrupt a person’s energy and bring
illness. Many African Americans, Latinos,
Middle Easterners, and some southern
Europeans attribute health to living accord-
ing to God’s will. Gypsies maintain health
through avoiding contact with non-Gypsies,
who are considered inherently polluted. Most
Asians believe that health is dependent on
their relationship to the universe and that a
balance between polar elements, such as yin
and yang, must be maintained. Some South-
east Asians are concerned with pleasing their
ancestor spirits, who may cause accidents or
sickness when angry. Pacific Islanders believe
that fulfilling social obligations is essential to
health and that disharmony with family or
village members can result in illness. Asian
Indians consider mind, body, and soul to be
interconnected and believe that spirituality is
as important to health as a good diet or getting
proper rest (see individual chapters on each
ethnic group for more details).
Health in other cultures is less dependent
on symptoms than on the ability to accom-
plish daily responsibilities. Among Koreans,
there is a strong desire to avoid burdening
their children with their health problems.
Mexican men may ignore physical com-
plaints because it is considered weak and
unmanly to acknowledge pain. Even within a
single culture, socioeconomic differences may
contribute to the definition of health; daily
aches are tolerated when a weekly paycheck
is essential.12
Health Attributes
As health is defined culturally, so are the
characteristics associated with health. Physi-
cal attributes are commonly linked with
well-being, including skin color, weight main-
tenance, and hair sheen. Normal functioning
of the body, such as regular bowel movements,
routine menstruation, and a steady pulse is
expected, as is the use of arms, legs, hands,
and the senses. Undisturbed sleep and not
being tired also suggests good health.
Harmony within the context of marriage,
family, and community are sometimes consid-
ered signs of well-being. The specifics of
health characteristics vary culturally. Healthy
hair in the United States is advertised as clean,
shiny, and flake-free, but in many cultures oily
hair is the norm, and dandruff is not a signifi-
cant concern. Americans count on a single,
strong pulse of about seventy-two beats per
minute when resting, while in other medical
systems there is more than one pulse of
importance to health, and these pulses are a
primary diagnostic tool in illness. Pregnancy
is a medical condition in the United States
warranting regular exams by biomedical pro-
fessionals, whereas in many societies preg-
nancy is a normal aspect of a healthy woman’s
cycle, and prenatal care is uncommon. Gener-
ally speaking, Americans expect to be content
in their lives; many other cultures have no
such assumptions and do not link happiness
with well-being.
The separation between
physical and emotional
or psychological health is
so embedded in Ameri-
can culture that no Eng-
lish word exists to even
express the concept of
mind–body unity.
The word health comes
from the Anglo-Saxon
term hal, meaning
“wholeness.”
In ayurvedic medicine,
a distinction is made
between general health
and optimal health.
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

4 0 T R A D I T I O N A L H E A L T H B E L I E F S A N D P R A C T I C E S
Body Image
One area of significant cultural variation
regarding health is body image. Perceptions
of weight, health, and beauty differ world-
wide. In the United States, there is significant
societal pressure to be thin. Although there is
no scientific agreement on the definition of
ideal or even healthy weight for individuals,
being overweight is usually believed to be a
character flaw in the majority American cul-
ture. Even health care professionals report-
edly make moral judgments about obesity,
depicting overweight persons as weak-willed,
ugly, self-indulgent, and fair game for ridi-
cule.17,18,19 The health risks associated with
being overweight cause some providers to
presume ill health in their obese clients. Thin-
ness corresponds to the biomedical worldview
regarding mastery of nature, the idea that the
mind can control the appetite.20
Historically, thinness has been associated
with a poor diet and disease. In many cul-
tures today, including those of some Africans,
Caribbean Islanders, Filipinos, Mexicans,
Middle Easterners, American Indians, and
Pacific Islanders, being overweight is a protec-
tive factor that is indicative of health as well as
an attribute of beauty. Many overweight Afri-
can American women, for example, are less
concerned about weight issues and more satis-
fied with their bodies than overweight white
women.21,22 A larger ideal body image is the
norm for most black men and women regard-
less of age, education, or socioeconomic sta-
tus.23,24 Some black Caribbean Islanders and
Puerto Rican women also report a larger body
size as attractive to family and peers when
compared to Anglo, eastern European Amer-
ican, and Italian American women.25 Some
Hispanic women value a heavier profile for
themselves, and even if they opt for a slimmer
body personally, they may prefer plump chil-
dren.26,27 Researchers have found that some
young African American and Latina women
purposefully contest the majority culture
emphasis on thinness, focusing more on self-
acceptance and being caring and attentive.28
Researchers have found that attitudes about
weight sometimes change when an immi-
grant enters a culture with different attitudes
regarding health and beauty. More acculturated
Hispanic women and children were more likely
to choose a thinner figure as ideal than those
who were less acculturated, ideal body image
for Samoan women in Hawaii varied with
whether they identified with Western or non-
Western culture, and Puerto Ricans living on
the mainland United States expressed a desire
for thinness that is between that of their coun-
try of origin and that of the majority culture in
their new homeland.29,30 Among some Native
Americans, ideal body size has changed over
time. Elders are more likely than younger adults
to prefer a heavier profile, and children dem-
onstrate a desire for even thinner bodies.31,32,33
Some studies also suggest the pressure to be thin
may be impacting young persons more than
adults: the percentage of normal-weight teens
engaging in unhealthy weight control behaviors
did not vary by ethnicity in a national examina-
tion of high school students, and another study
found Asian, Hispanic, and American Indian
adolescent girls reported similar numbers of
weight-related concerns as white girls; how-
ever, African American girls had fewer weight
issues.34,35,36 Some Native American school-
children express a high level of body dissatis-
faction, and concerns about overweight were
high in a cohort of third-grade children, with
Latinas and African American girls reporting
the same or greater level of body dissatisfaction
than white and Asian girls.37,38
Health Maintenance
Health Habits
Just as with health attributes, there are some
broad areas of intercultural agreement on
health habits. Nearly all people identify a good
diet, sufficient rest, and cleanliness as neces-
sary to preserving health. It is in the defini-
tions of these terms that cultural variations
occur. For example, majority Americans typi-
cally identify three meals each day as a good
diet. Asians may indicate a balance of yin and
yang foods is a requirement. Middle Eastern-
ers may be concerned with sufficient quantity,
and Asian Indians may be concerned with reli-
gious purity of the food. To most Americans,
keeping clean means showering daily, while
some Filipinos bathe several times each day to
maintain a proper hot–cold balance.
In traditional Chinese
medicine, fifteen
separate pulses are
identified, each associ-
ated with an internal
organ and each with its
own characteristics.
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

C H A P T E R 2 4 1
In the United States the National Cen-
ter for Health Statistics describes the trends
for dietary intake. These include that during
2007–2008, the average energy intake for men
was 2,504 kcalories (kcal) and for women,
1,771 kcal. The average carbohydrate intake
of 47–50 percent total kcal is slightly reduced
from previous years, whereas protein intake
was slightly higher.39 Some cultural groups
would find these data irrelevant to health sta-
tus. Macronutrient intake may not be asso-
ciated with disease prevention, and dietary
supplement use may not be familiar. Physical
labor is often a factor in preserving health, but
recreational exercise is rare throughout much
of the world. Alcohol consumption is prohib-
ited by several religions. Preventive care is
unusual in many cultures.
Culturally specific health practices differ
particularly in those beliefs passed on within
families. A small survey of U.S. college stu-
dents from many backgrounds revealed nota-
ble variation in health habits beyond general
concepts regarding diet, sleep, physical activ-
ity, and cleanliness.40 Dressing warmly (eastern
European, French, French Canadian, Iranian,
Irish, Italian, Swedish) and avoiding going
outdoors with wet hair (eastern European,
Italian) were listed by some. Daily doses of cod
liver oil (British, French, French Canadian,
German, Norwegian, Polish, Swedish) or
molasses (African American, French, French
Canadian, German, Irish, Swedish) as a laxa-
tive were frequently reported maintenance
measures. Natural amulets were traditionally
worn in some families to prevent illness, such
as camphor bags (Austrian, Canadian, Irish)
or garlic cloves (Italian). Faith was important
to many of the students, expressed as bless-
ing of the throat (Irish, Swedish) and wear-
ing holy medals (Irish), as well as daily prayer
(Canadian, Ethiopian).
Health-Promoting Food Habits
Food habits are often identified as the most
important way in which a person can main-
tain health. Nearly all cultures classify certain
foods as necessary for strength, energy, and
mental acuity. Some also include items that
maintain the equilibrium within the body
and soul.
General dietary guidelines for health
usually include the concepts of balance and
moderation. In the United States, current
recommendations include a foundation of
complex carbohydrates in the form of whole
grains, vegetables, and fruits; supplemented
by smaller amounts of protein foods such
as meats, legumes, and dairy products; and
limited intakes of fats, sugar, salt, and alco-
hol. The Chinese system of yin–yang encour-
ages a balance of those foods classified as yin
(items that are typically raw, soothing, cooked
at low temperatures, white or light green in
color) with those classified as yang (mostly
high-kcalorie foods, cooked in high heat,
spicy, red-orange-yellow in color), avoiding
extremes in both. Some staple foods, such as
boiled rice, are believed to be perfectly bal-
anced and are therefore neutral. Although
which foods are considered yin or yang vary
regionally in China, the concept of keeping
the body in harmony through diet remains the
same, usually adjusted seasonally to compen-
sate for external changes in temperature and
for physiological conditions such as age and
gender (see Chapter 11, “East Asia”).
Aspects of the yin–yang diet theory are
found in many other Asian nations, and a
similar system of balance focused on the hot–
cold classification of foods is practiced in the
Middle East, parts of Latin America, the
Philippines, and India. Hot–cold concepts
developed out of ancient Greek humoral med-
icine that identified four characteristics in the
natural world (air-cold, earth-dry, fire-hot,
water-moist) associated with four body
humors: hot and moist (blood), cold and
moist (phlegm), hot and dry (yellow/green
bile), and cold and dry (black bile). Applied to
daily food habits, this system usually focuses
on only the hot and cold aspects of food
(defined by characteristics such as taste, prep-
aration method, or proximity to the sun) bal-
anced to account for personal constitution
and the weather. In Lebanon, it is believed that
the body must have time to adjust to a hot
food before a cold item can be eaten. In Mex-
ico, the categorization of hot and cold foods is
related to a congruous relationship with the
natural world. Asian Indians associate a hot–
cold balanced diet with spiritual harmony.
In ancient China,
nutritionists were ranked
highest among health
professionals.
The neutral category
of foods is usually
expanded by those
Asians who prefer
biomedicine and
believe that traditional
health systems are
unsophisticated.71
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

4 2 T R A D I T I O N A L H E A L T H B E L I E F S A N D P R A C T I C E S
Quantity of food is often associated with
health as well. Some African Americans, for
example, traditionally eat heavy meals, reserving
light foods for ill and recuperating family mem-
bers. In the Middle East ample food is necessary
for good health, and a poor appetite is some-
times regarded as an illness in itself. As dis-
cussed previously, being overweight is frequently
associated with well-being in some cultures.
In addition to balance and moderation,
specific foods are sometimes identified with
improved strength or vitality. In the United
States, milk is considered to build strong bones,
carrots are considered to improve eyesight, and
candy is considered to provide quick energy.
Chicken soup, a traditional tonic among
eastern European Jews, has become a well-
accepted cure-all. Navajos consider milk to be
a weak food, but meat and blue cornmeal are
strong foods. Asians call strengthening items
pu or bo foods, including protein-rich soups
with pork liver or oxtail in China, and bone
marrow or dog-meat soup in Korea. Puerto
Ricans drink eggnog or malt-type beverages
to improve vitality.
The sympathetic quality of a food, meaning
a characteristic that looks like a human body
part or organ, accounts for many health food
beliefs. The properties of a food entering the
mouth are incorporated into physical traits.
Some Italians drink red wine to improve their
blood, and American women sometimes eat
gelatin (which is made from animal skin,
bones, and other connective tissues) to grow
longer, stronger fingernails. Throughout Asia
and parts of the United States, ginseng, which
is a root that resembles a human figure, is
believed to increase strength and stamina.
Other foods are believed to prevent specific
illnesses. Americans, for instance, are urged
to eat cabbage-family (cruciferous) vegeta-
bles to reduce their risk of certain cancers.
Oatmeal (high in soluble fiber) and fish
(high in omega-3 fatty acids) have both been
promoted as preventing heart disease.
Some cultures believe that fresh foods pre-
pared at home are healthiest and, in the United
States, the popularity of locally grown items
and organic foods (those produced without
the use of chemical additives or pesticides)
has increased in recent years. Vegetarianism,
macrobiotics, customized diets that account
for an individual’s food sensitivities or aller-
gies, and very low-fat or low-carbohydrate
diets are a few of the other ways in which
health is promoted by some people through
food habits.
Disease, Illness,
and Sickness
Cultural Definitions of
Disease, Illness, and Sickness
When health is diminished, a person experi-
ences difficulties in daily living. Weakness,
pain and discomfort, emotional distress, or
physical debilitation may prevent an indi-
vidual from fulfilling responsibilities or
Ritualistic cannibalism,
especially when the
heart or liver of a brave
and worthy enemy was
consumed, is an extreme
example of the sympa-
thetic qualities of food.
▲ The health value
of specific foods varies
culturally. In the United
States, it is said that milk
builds strong bones. But
in certain Native American
cultures, milk is considered
a weak food. Some Latinos
believe milk is only good for
children.
M
itc
h
H
rd
lic
ka
/P
ho
to
di
sc
/G
et
ty
Im
ag
es
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

C H A P T E R 2 4 3
obligations to the family or society. Research-
ers call this experience illness, referring to a
person’s perceptions of and reactions to a
physical or psychological condition, under-
stood within the context of worldview. In bio-
medical culture, illness is caused by disease,
defined as abnormalities or malfunctioning
of body organs and systems. The term sic k –
ness is used for the entire disease–illness
process. When an individual becomes sick,
questions such as how did the illness occur,
how are the symptoms experienced, and
how is it cured arise—answered primarily
through cultural consensus on the meaning
of sickness.
Becoming Sick
During the onset of a sickness, physical or
behavioral complaints make a person aware
that a problem exists. The development may
be slow, and the symptoms may take time to
manifest into a disease condition. Or symp-
toms may occur suddenly, and it is quickly
obvious that illness is present.
Except in emergencies, an individual usu-
ally seeks confirmation of illness first from
family or friends. Symptoms are described
and a diagnosis is sought. A knowledgeable
relative is often the most trusted person in
determining whether a condition is cause
for concern and whether further care should
be pursued; in many cultures, a mother or
grandmother is the medical expert within a
family. This is a major step in social legiti-
mization of the sickness. If others agree
that the person is ill, then the individual
can adopt a new role within the family or
community—sick person. In this capacity,
the sick person is excused from many daily
obligations regarding work and family, as
well as social and religious duties. A reprieve
from personal responsibility for well-being
is also given, with care provided by relatives,
healers, or health professionals. The role
of sick person provides a socially accepted,
temporary respite from the physical and
psychological burdens of everyday life, with
the understanding that sickness is not a per-
manent condition and that recovery should
occur.12,40,41
Explanatory Models
When unexpected events happen, there is a
human need to explain the origins and causes
of seemingly random occurrences. Explana-
tory models consistent with a culture’s world-
view are used to account for why good or evil
happens to a person or a community and to
calm individual fears of being victimized. In
sickness, the explanatory model details the
cause of disease, the ways in which symp-
toms are perceived and expressed, the ways
in which the illness can be healed and pre-
vented from reoccurring, and why one person
develops a sickness whereas another remains
healthy.41,42,43
The etiology of sickness is of central con-
cern because the reason an illness occurs often
determines the patient’s outlook regarding
the progression and cure of the sickness. In
biomedical culture, three causes of disease
are identified: (1) immediate causes, such as
bacterial or viral infection, toxins, tumors, or
physical injury; (2) underlying causes, includ-
ing smoking, high cholesterol levels, glucose
intolerance, or nutritional deficiencies; and
(3) ultimate causes, such as hereditary pre-
disposition, environmental stresses, obesity,
or other factors.44 The causes of illness are
generally more complex. Four theories on the
etiology of sickness prevalent in most societies
have been described (Figure 2.1): those origi-
nating in the patient, those from the natural
world, those from the social world, and those
due to supernatural causes.12 It is important to
note that in no society do all persons subscribe
to any single cause, and there is considerable
variation in degree of belief, intraculturally as
well as interculturally. Additionally, believing
in a cause does not necessarily result in a prac-
tice associated with that cause.
Sickness Due to the Patient First are those that
develop within the individual patient, usually
attributable to a person’s constitution; that is,
an individual has a genetic (physical or psy-
chological) vulnerability to illness or disease.
Sickness may also be due to lifestyle choices.
A person in the United States may be blamed
for a heart attack if he has become overweight,
Macrobiotics is a
Japanese diet based on
brown rice, miso soup,
and vegetables that was
popularized in Europe
as promoting health in
the 1920s. Serious nutri-
tional deficiencies have
been identified in infants
and toddlers on this
restricted diet.72
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

4 4 T R A D I T I O N A L H E A L T H B E L I E F S A N D P R A C T I C E S
eats fatty foods, smokes tobacco, and never
exercises. A person who fails to wear a seat
belt and then is injured in an auto accident
may also be found at fault. Responsibility
for sickness falls primarily on the patient,
although in many other cultures when a
person’s actions are unfavorable to health, it
is outside forces that are thought to actually
cause an illness or accident in retaliation for
the offense.
Sickness Due to the Natural World Etiology
in the natural world includes environmental
elements such as the weather, allergens,
smoke, pollution, and toxins. Viruses, bacte-
ria, and parasites are natural biological agents
of sickness. Wind or bad air is of particular
concern in many cultural groups, includ-
ing some Arabs, Chinese, Italians, Filipinos,
and Mexicans, because it can enter the body
through pores, orifices, or wounds in the
body, causing illness. Humoral systems, which
associate various body humors with natural
elements (as described previously), connect
illness and disease with disharmony in the
environment. Astrology, which determines
an individual’s fate (including health status)
through planetary alignment at the time of
birth, is another natural world phenomenon.
Injuries due to natural forces, such as light-
ning or falling rocks, are sometimes catego-
rized with this group; however, many cultures
believe such accidents are actually the result of
supernatural injunction.
Sickness Due to the Social World Sickness
attributed to social causes occurs around
interpersonal conflict within a community. It
is common to blame an enemy for pain and
suffering. Inadvertent or purposeful malice is
the source of illness and disease in many cul-
tures. Among the most common causes is the
evil eye.
The evil eye is when an individual stares
at a person with envy, resulting in harm to
that person even if the gaze is unintentional.
It is widely believed in parts of Africa, Asia,
Europe, Greece and the Middle East, India,
Latin America, and some areas of the United
States. Children are believed to be vulner-
able to the evil eye, resulting in colic, crying,
hiccups, cramps, convulsions, and seizures.
Among adults, the evil eye can cause head-
aches, malaise, complications in pregnancy
and birth, impotence and sterility in men,
and insanity.45 Protections against the evil eye
include such practices as placing a red bag
filled with herbs on an infant’s crib in Gua-
temala; knotting black or red string around
children’s wrists in India; leaving children
unwashed (making them less admirable) in
Iran; wearing a charm in the form of a black
hand (mano negr o) in Puerto Rico; and paint-
ing a house white and blue to blend with the
sky, thus avoiding notice, in Greece. Eastern
European Jews wear a red ribbon; Sephardic
Jews wear a blue ribbon. In Scotland, a frag-
ment of the Bible is kept on the body, and in
Muslim areas of Southeast Asia a piece of the
Koran is worn.41
Conjury, invoking supernatural forces,
is another frequent social cause of sickness.
A person who is thought to have these pow-
ers can direct illness or injury toward an indi-
vidual, or sell the magic charms or substances
necessary for a normal person to inflict harm.
Conjury is practiced by witches (called br uj os
or br uj as in Spanish), sorcerers, root doctors,
herb doctors, voodoo or hoodoo doctors (see
Chapter 8, “Africans”), underworld men, and
conjure men, most of whom obtain their
powers from the devil or other evil spirit. For
example, a conjurer might sprinkle graveyard
dust under a person’s feet, causing him to
waste away, known as fading in rural African
Regarding the 1918
influenza epidemic, the
New York Post reported
that epidemics are
the punishment that
nature inflicts for the
violation of her laws and
ordinances.70,73
Figure 2.1
Client theories on the
etiology of sickness.
Source: From C.G. Helman, Culture,
Health, and Illness (2nd ed.).
© 2000 Hodder Arnold.
The Supernatural World
The Social World
The Natural World
The Patient
Other names for the evil
eye in the United States
include the bad eye, the
look, the narrow eye,
and the wounding eye.
Those who are victims
have been blinked, eye
bitten, forelooked, or
overlooked.
Fear of the evil eye is
mentioned in Talmudic
writings, the Bible, and
the Koran.
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

C H A P T E R 2 4 5
American tradition. A bundle of sticks placed
in the kitchen will cause illness in people who
consume food prepared there. A br uj o can
cause illness in Latinos through contagious
magic, using bits of a person’s hair or finger-
nails when casting a spell. Native American
conjury often uses animals or natural phe-
nomena (such as lightning) to attack a victim,
or causes natural objects to be inserted into
the body, resulting in pain. The bewitched
Native American may behave in inexplicable,
disruptive ways and may be abandoned by
the community if considered incurable and
unable to change undesirable conduct.41,47
There is often an overlap between sickness
attributed to the social world and that caused
by supernatural forces.
Sickness Due to the Supernatural World In
the supernatural realm, sickness is caused
by the actions of gods, spirits, or the ghosts
of ancestors. The will of God is a prominent
factor in illness and disease suffered by many
Jews, Christians, and Muslims. Sickness is
sometimes considered a punishment for the
violation of religious covenants, and other
times it is viewed as simply a part of God’s
unknowable plan for humanity. Even those
persons who do not follow a specific faith
may ascribe illness to fate, luck, or an act of
God. Some Africans, Asians, Latinos, Middle
Easterners, American Indians, and Pacific
Islanders believe that malevolent spirits can
attack a person, causing illness. For example,
among Cambodians, death can occur when
the nightmare spirit immobilizes a victim
through sitting on his or her chest and caus-
ing extreme fright.48 In other situations spirit
possession takes place. An evil spirit inhabits
the body of a victim who then exhibits aber-
rant behavior, such as incoherent speech or
extreme withdrawal. Many Southeast Asians
associate caretaker spirits with body organs
and life forces that may desert a person when
angered or frightened, leaving that individual
vulnerable to sickness. In addition, the ghosts
of ancestors usually protect their living rela-
tives from harm, but may inflict pain and ill-
ness when ignored or insulted.
One of the most common causes of sick-
ness in many cultures is soul loss, when the
soul detaches from a person’s body, usually
due to emotional distress or spirit possession.
The symptoms typically include general mal-
aise, listlessness, depression, a feeling of suf-aise, listlessness, depression, a feeling of suf-aise, listlessness, depression, a feeling of suf
focation, or weight loss. If left untreated, soul
loss can lead to more serious illness.
Folk Illnesses
Inasmuch as sickness is culturally sanctioned
and explained through culture-specific
models, it follows that each culture recog-
nizes different disorders. Certain symptoms,
complaints, and behavioral changes are asso-
ciated with specific conditions and are termed
folk illnesses or culture-bound syndromes.
Examples of such sicknesses are not uncom-
mon, such as cases of soul loss experienced
by some Asians, Latinos (who call it susto or
espanto), Native Americans, Pacific Islanders,
and Southeast Asians. Muso, experienced
by young Samoan women as mental illness,
and sudden unexpected nocturnal death
syndrome (SUNDS) suffered by Cambodi-
ans (see the previous section, “Sickness Due
to the Supernatural World”) are cases of folk
illness due to evil spirits. Strong emotions,
particularly fright or anger, cause many folk
conditions, such as stroke precipitated in bil is
or c ol er a in some Guatemalans, the cooling
of the blood and organs in c eeb among the
Hmong, or the stomach and chest pain of
h w aby ung in some Koreans. Psychological h w aby ung in some Koreans. Psychological h w aby ung
distress is often expressed through somatic
complaints in some cultures; for instance,
an Asian Indian may present symptoms of
extreme stress as burning on the soles of the
feet, or a depressed Asian Indian man may
experience dh at, the loss of semen.
Diet-related folk illnesses are common.
High blood and low blood among some African
Americans are examples. Depending on the
cultural group, imbalance in the digestive
system results in numbness of the extremities
(si z h i ma mu) in some Chinese; nausea and the
feeling of a wad of food stuck in the stomach
(empac h o) among Mexicans; and paralysis in
some Puerto Ricans (pasmosome Puerto Ricans (pasmosome Puerto Ricans ( ). The eating dis-
orders anorexia nervosa (a fear of being fat and
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

4 6 T R A D I T I O N A L H E A L T H B E L I E F S A N D P R A C T I C E S
failure to maintain body weight resulting in a
weight 15 percent or more below that recom-
mended) and bulimia nervosa (binge eating
followed by the use of self-induced vomiting,
laxatives, enemas, or medications to reduce
calorie intake, or the use of excessive exer-
cise or fasting) are sometimes described as a
culture-bound syndrome in the United States
and other Westernized nations, associated
with issues such as the drive to thinness, body
image, maturity, and control.49,50,51 In the case
of anorexia, it is usually the biomedical culture
that identifies the symptoms as a disease state.
Many anorectics do not consider themselves ill
or in need of medical intervention. Such differ-
ences in the definition of sickness account for
why some conditions, such as anorexia or other
folk illnesses, are difficult to cure with biomed-
ical approaches. Effective treatment of many
sicknesses depends on agreement between the
patient and the practitioner regarding how the
illness has occurred, the meaning of the symp-
toms, and how the sickness is healed.43
Healing Practices
Biomedical health professionals attempt to
diagnose and cure the structural and func-
tional abnormalities found in patients’ organs
or systems. In contrast, healing addresses the
experience of illness, alleviating the infirmi-
ties of the sick patient even when disease is
not evident. Healing responds to the per-
sonal, familial, and social issues surrounding
sickness.
Seeking Care
When sickness occurs, a person must make
choices regarding healing. Professional bio-
medical care, if available, is usually initi-
ated when the onset of symptoms is acute
or an injury is serious. Nearly all cultural
groups recognize the value of biomedicine in
emergencies.
Choice of care often depends on the
patient’s view of the illness in cases when the
sickness is not life threatening. In these situ-
ations, home remedies are generally the first
treatment applied.33,46 Therapies may be deter-
mined by the patient alone or in consultation
with family members, friends, or acquain-
tances. If the remedies are ineffective, if other
people encourage further care, or if the indi-
vidual experiences continued disruption of
work, social obligations, or personal relation-
ships, professional advice may be sought. The
type of healer chosen depends on factors such
as availability, cost, previous care experiences,
referrals by relatives or friends, and how the
patient perceives the problem. If the patient
suffers from a folk illness, a folk healer may
be sought immediately because biomedical
professionals are considered ignorant about
such conditions. Otherwise, biomedical care
may be undertaken, independently or simul-
taneously with other approaches. A study of
Taiwanese patients revealed that in acute ill-
ness, biomedical care was initially sought; but,
if treatment was ineffective, traditional Chi-
nese medical practitioners were employed;
if there was no progress in healing, another
traditional specialist would be tried; and if the
patient was still afflicted, sacred healers would
be sought. In chronic or recurrent sickness,
biomedical, traditional Chinese medicine, and
spiritual approaches would be attempted con-
currently.10 The use of multiple approaches is
particularly common when there are concerns
that a condition is culture specific.52,53,54,55
Research suggests that large numbers of
Americans obtain health care outside the
biomedical system for minor and major ill-
nesses.1,56,57 As many as one-third to one-half
of patients with intractable conditions (e.g.,
back pain, chronic renal failure, arthritis,
insomnia, headache, depression, gastrointesti-
nal problems), terminal illnesses such as can-
cer or acquired immune deficiency syndrome
(AIDS), and eating disorders seek unconven-
tional treatment. Nearly all do so without the
recommendation of their biomedical doctor,
integrating multiple therapies on their own.
Biomedicine is rejected by some people
because their experience with care has been
impersonal, costly, inconvenient, or inacces-
sible. Further, conventional treatments may
have been painful or harmful. Some clients
believe that biomedical professionals are hos-
tile or uninterested in ethnic health issues.44,58
Health care professionals may disregard the
patients’ explanations as to the cause of the
health problem or dismiss their complaints
as clinically insignificant. Folk healers and
▲ Body image is one area
where the viewpoint of the
client may vary from the
biomedical assumptions
of the health care provider.
Obesity in some cultures is
still considered desirable
because it indicates wealth
and having adequate
amounts of foods.
To
ny
F
re
em
an
/P
ho
to
Ed
it
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

C H A P T E R 2 4 7
other alternative practitioners can provide an
understanding of an illness within the context
of the patient’s worldview and can offer care
beyond the cure of disease, including sincere
sympathy and renewed hope.
Healing Therapies
There is no consensus concerning the classifi-
cation of what is called unconventional, alter-
native, or folk medical care. Home remedies
(e.g., herbal teas, megavitamins, relaxation
techniques), popular therapies (e.g., chiro-
practic, homeopathy, hypnosis, massage),
and professional practices (i.e., those that
require extensive academic training in con-
ventionally recognized medical systems, such
as biomedicine, traditional Chinese medicine,
and ayurvedic medicine) include a variety of
treatments that fall into three broad categories:
(1) administration of therapeutic substances,
(2) application of physical forces or devices,
and (3) magico-religious interventions.13,59
Most patients use unconventional therapies
without the supervision of a biomedical doc-
tor or any other kind of health care provider.
Popular and professional practitioners, when
consulted, may use one or several of these
treatments in healing a patient.
Administration of Therapeutic Substances
Biomedical medication and diet prescriptions
are two of the most common types of thera-
peutics in this category, which also includes
over-the-counter medications, health food
preparations, and prepackaged diet meals, as
The person most likely
to use complementary
and alternative medicine
in the United States is a
middle- to upper-class
white or Asian woman
who is well educated
in consumer health
issues and lives in an
urban area in one of the
Pacific states.5
Botanical Remedies
More than 80 percent of the world’s population uses herbal remedies
to treat illness and optimize health. Techni-
cally, an herbal medicine contains only leafy
plants that do not have a woody stem.76
A more comprehensive term is botanical, botanical, botanical
including all therapeutic parts of all plants,
from the root (e.g., ginseng), the bark
(e.g., willow), the sap (e.g., from aloe), the
gum (e.g., frankincense) or oil (e.g., from
nutmeg), the flowers (e.g., echinacea), the
seeds (e.g., gingko biloba), to the fruit (e.g.,
bilberries). Botanical remedies often use
the whole plant, which practitioners claim
is superior to using a single active extract
because other components in the plant may
work together synergistically in the prepara-
tion to enhance the therapeutic value and to
buffer any side effects. For this same reason,
plants are often combined in formulary
mixtures, particularly in traditional Chinese
medicine.
Most consumers select botanical rem-
edies instead of biomedicine because they
believe they are safer and more effective than
prescription drugs or they are treating chronic
conditions for which biomedicine has little to
offer in the way of relief. Some proponents
note that botanicals have been used for
centuries and that reported deaths each year
number in only the hundreds, while it is well
known and reported in the United States
that prescription medications can cause
adverse problems, especially among older
adults.77 The key word, however, is reported.
The Dietary Supplement Health and Educa-
tion Act (DSHEA) passed by Congress in 1994
defines dietary supplements as separate
from food and drugs and thus outside the
scope of federal monitoring. Manufactur-
ers are exempt from regulations requiring
that complaints, injuries, or deaths due to
consumption of their product be reported
to the Food and Drug Administration (FDA).
Though the FDA retains the right to protect
the public from harmful products, the burden
of proof is on the government to prove that a
particular botanical remedy is unsafe. Many
manufacturers have voluntarily adopted
good manufacturing processes, and the
American Herbal Products Association has
created a botanical safety rating system that
classifies herbs as (1) safe when consumed
appropriately; (2) restricted for certain uses;
(3) use only under the supervision of an
expert; and (4) insufficient data to make a
safety classification.
Unfortunately, the explosive, unregulated
growth of the industry has resulted in numer-
ous problems. Of particular concern is the inter-
action of botanicals when used with biomedical
therapies. For example, ginkgo biloba reduces
the effectiveness of some prescription drugs,
such as certain antacids and antianxiety medi-
cations, while potentiating others, including
anticoagulants, antidepressants, and antipsy-
chotics.77 Some botanicals can react adversely
with anesthesia, and others can interact with
radiation therapy.78,79 Further, natural products
can be adulterated with pesticides, heavy
metals (such as mercury), or prescription drugs
(such as warfarin or alprazolam).80
C U L T U R A L C O N T R O V E R S Y
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

4 8 T R A D I T I O N A L H E A L T H B E L I E F S A N D P R A C T I C E S
well as vitamins and mineral supplements.
In a 2007 survey, it was estimated that more
than 38 percent of all adult Americans used
complementary and alternative medicine,
including high doses of vitamins, during the
previous month.1 Home remedies and health
practitioners other than biomedical profes-
sionals often emphasize the use of botanical
medicine, which includes whole plants or
pieces (particularly herbs), and occasion-
ally animal parts, such as antlers or organs,
or certain powdered mineral elements. In
many cultures, healers specialize in the use
of herbal preparations; often they are elder
men or women with intimate knowledge of
the natural environment. Root doctors in
the American South, and the proprietors of
botá nic as (herbal pharmacies) found in some
Latino neighborhoods are a few examples. In
addition to folk healing, both traditional Chi-
nese medicine and ayurvedic medicine make
extensive use of botanical medicine (see the
chapters on each American ethnic group for
more details).
Homeopathy also prescribes therapeutic
substances, such as botanical medicine,
diluted venom, or bacterial solutions, and bio-
medical drugs. Originating in Germany,
homeopathy is based on the concept that
symptoms in illness are evidence that the
body is curing itself, and acceleration or exag-
geration of the symptoms speeds healing.
One primary tenant is that “like cures like.”
Naturopathic medicine also focuses on help-
ing the body heal itself, usually through non-
invasive natural treatments (including some
physical manipulations, as the following
section describes), although biomedical drugs
and surgery are used in certain cases. Nutri-
tional therapy, based on whole foods and
dietary supplements, is the foundation of
naturopathic health maintenance and
healing.
Application of Physical Forces or Devices
Manipulations of the body is based on the
premise that internal body function improves
with adjustments to its physical structure.
Chiropractic theory states that misalign-
ments of the spine interfere with the nervous
system, interrupting the natural intelligence
that regulates the body, resulting in disease
and disorder. Osteopathic medicine proposes
that blood and lymph flow, as well as nerve
function, improves through manipulation of
the musculoskeletal system, particularly the
correction of posture problems, mobilization
of bone joints, and spine alignment. Health
problems are treated through restoration of
mobility and improved flexibility.
Several Asian healing therapies can be
classified as the application of physical forces
or devices. Massage therapy, acupressure,
and pinching or scratching techniques are
used to release the vital energy flow through
the twelve meridians of the body identified
in traditional Chinese medicine, primarily
by relieving muscle tension so that oxygen
and nutrients can be delivered to organs
and wastes removed. Coining is a related
practice in which a coin or spoon is rubbed
across the skin instead of pressing or pinch-
ing specific points. Acupuncture is similar to
acupressure in that it attempts to restore the
balance of vital energy in the body along the
meridians, but it differs in that it stimulates
specific junctures through the insertion of
nine types of very fine needles. The needles
do not cause bleeding or pain. Acupuncture
is considered useful in correcting conditions
where too much heat (yang) is present in the
body. In conditions of too much cold (yin),
Medications using
digitalis, opiates, and
salicylates, common
today as biomedical
therapeutics, were first
used by folk healers.
▲ Ginseng, a root found in
both North America and Asia,
is one of the top ten common
herbal remedies used in the
nation. It reputedly promotes
health through increased
strength and vitality, and
may be taken specifically to
treat digestive upset, anxiety,
or sexual impotence.
M
itc
h
H
rd
lic
ka
/P
ho
to
di
sc
/G
et
ty
Im
ag
es
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

C H A P T E R 2 4 9
another technique is preferred, called moxi-
bustion, in which a small burning bundle of
herbs (e.g., wormwood) or a smoldering cig-
arette is touched to specific locations on the
meridians to restore the balance of energy. A
similar method is cupping—the placement of
a heated cup or a cup with a scrap of burning
paper in it over the meridian points.60
Application of electricity is used in vari-
ous electrotherapies, primarily to stimulate
muscle or bone healing, especially in sports
medicine. Biofeedback also uses small electric
pulses to teach a person how to consciously
monitor and control normally involuntary
body functions, such as skin temperature and
blood pressure, to alleviate health problems,
which include insomnia, gastrointestinal
conditions, and chronic pain. Hydrotherapy
involves the application of baths, showers,
whirlpools, saunas, steam rooms, and poul-
tices to relieve the discomforts of back pain,
muscle tension, arthritis, hypertension, cir-
rhosis of the liver, asthma, bronchitis, and
head colds. In addition to the hydrotherapeu-
tic qualities, the mineral content of the water
is considered stimulating.
Magico-Religious Interventions Spiritual heal-
ing practices are associated with nearly all reli-
gions. They typically fall into two divisions:
those actions taken by the individual, and
those taken on behalf of the individual by a
sacred healer.
In Western religious traditions, God has
power over life and death. Sickness repre-
sents a breach between humans and God.
Healing is interrelated with salvation because
both mend broken ties.22 Living according to
God’s will is necessary to prevent illness, and
prayer is the most common method of seek-
ing God’s help in healing. Roman Catholics,
for example, make appeals to the saints iden-
tified with certain afflictions—St. Teresa of
Avila for headaches, St. Peregrine for cancer,
St. John of God for heart disease, St. Joseph
for terminal illness, and St. Bruno for cases of
possession are just a few examples. Pilgrim-
ages to the shrines of these saints are made for
special petitions. In Eastern religions, health
is determined mostly by correct conduct in
this and past lives, as well as in the virtuous
behavior of ancestors. Religious offerings are
made regularly; for instance, Hindus choose
a personal deity to worship daily at a home
shrine. Improper actions leading to dishar-
mony within a person, family, community,
or the supernatural realm can cause sickness.
Healing occurs through restoration of bal-
ance, often including offerings to the deities
or spirits of the living and dead who have been
offended.
Individual healing practices developed
out of religious ritual include meditation, a
contemplative process of focused relaxation;
yoga, the control of breathing and use of sys-
tematic body poses to restrain the functions
of the mind and promote mind–body unity;
and visualization or guided imagery, induced
relaxation and targeted willing away of health
problems. Each concentrates the power of
mind on reducing health risks, such as stress,
high blood pressure, and decreased immune
response, or on alleviating specific medical
conditions. Hypnotherapy works in a similar
manner; although it is generally done with the
aid of a hypnotherapist, self-hypnosis can be
learned for personal use.
In many cases, the spiritual skills of the
individual are inadequate for the problem,
and the help of a sacred healer is sought.
These health practitioners generally work
through interventions with the supernatural
world, which may include prayers, blessings,
chanting or singing, charms, and conjuring,
as well as the use of therapeutic substances
(e.g., herbal remedies) and application of
physical cures (e.g., the laying on of hands).
Faith healers, most of whom get their heal-
ing gifts from God, are common among many
Christian groups. Some are affiliated with
certain denominations and rites, such as the
Cajun tr aiteur s of Louisiana, who specialize in
treating one or two ailments through prayers
and charms associated with Catholicism.61,62
Others, such as the sympathy healers of the
Pennsylvania Dutch who practice powwowing
(also known by the German name B r auc h e or
B r auc h er ei), are considered the direct instru-
ments of God.63
Persons with a spiritual calling are often
employed to treat illness. N eng among the N eng among the N eng
Kur (spa) therapy is
popular throughout
Europe, particularly in
Germany.
Naturopathic doctors
trained in the United
States attend a four-year
program including many
biomedical disciplines.
Doctors of chiropractic
(DC) are the third larg-
est category of health
care practitioners in the
United States, following
physicians and dentists.
Osteopaths are licensed
to prescribe medications
and perform surgery as
doctors of osteopathy
(DO) in all fifty states.
Eighty percent of
respondents in a study
on faith and healing
in the southeastern
United States said they
believe God acts through
physicians to cure
illness.74
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

5 0 T R A D I T I O N A L H E A L T H B E L I E F S A N D P R A C T I C E S
Hmong, Mexican c ur ander os (or c ur ander as),
practitioners of voodoo in the American
South, and espir itos or santer os (or santer as)
in the Caribbean may communicate with the
spirits or saints to heal their patients. Cer-
emonial invocation is the primary therapy,
although charms and spells to counteract
witchcraft and botanical preparations to ease
physical complaints are used as well.
Shamans, called medicine men among
many Native American groups, are sacred
healers with exceptional powers. They origi-
nated in Russia an estimated 20,000 years
ago and spread throughout the world to the
indigenous cultures of the Americas, South-
east Asia, Indonesia, Polynesia, and Australia.
Remote tribal groups found in Africa, India,
and Korea have similar healers. A shaman
is a composite priest, magician, and doctor;
the position is passed on from generation to
generation, or through a calling that could
include fainting spells or convulsive fits due
to attacks by spirits. Shamans typically com-
plete lengthy apprenticeships and are initiated
through a series of trials simulating death and
rebirth. In shamanic systems, sickness is due
to spiritual crisis, and healing emphasizes
strengthening of the soul through redirec-
tion of the life forces or, in cases of serious
illness, retrieval of the soul, which may have
been stolen by evil spirits. Shamanic practices
include visualization techniques to create har-
mony between the patient and the universe,
singing, chanting, predictions, dream analy-
sis, and séances. Shamans are often expert
herbalists.64,65
Pluralistic Health Care
Systems
The enduring popularity of traditional health
beliefs and practices is consistent with cultural
beliefs. Healing sickness, with or without the
services of an expert provider, takes place
according to a patient’s worldview. Humans
value what validates their beliefs and discount
anything that differs, regardless of statistical
data or scientific claims; they give dispro-
portionate authority to persons they like and
respect.
Medical Pluralism
M edic al pl ur al ism is the term for the consecu-
tive or concurrent use of multiple health care
systems.45 Although it is often assumed that
ethnic minorities, the poor, the less educated,
or recent immigrants are most likely to rely on
traditional folk medicine, studies report that
the use of healers in some groups increases
with education and income level. Further,
acculturation is not associated with a rise
in the use of biomedical services.44 Medical
pluralism is widespread in the United States.
Biomedical Healing
Clients using traditional health practices are
generally seeking to alleviate the difficulties
experienced in illness through understand-
able, flexible, and convenient treatment from
a warm and caring provider. The personal
relationship with the healer is as important as
the actual therapy (see Chapter 3).
Biomedical professionals often operate in
partnership, knowingly or not, with uncon-
ventional health care practitioners. A small
study of prostate cancer patients reported
that 37 percent used alternative therapies
in conjunction with radiation treatment.
A separate survey found that their physicians
believed only 4 percent of these patients used
any other health care practices.56 Researchers
A study of physician
beliefs about health
and religion found that
although 91 percent of
respondents said knowl-
edge of a client’s faith
practices is important
in care, only 32 percent
ask about religious
affiliation.75
When Navajos dream
frequently of death, it is
usually considered a sign
of serious illness.
Consultation with
a Native American
medicine man may take
hours to complete; some
healing ceremonies take
a week to perform and
may cost thousands
of dollars.81
▲ Acupuncture attempts to
restore the balance of vital
energy in the body through
inserting and manipulating
needles.
G
eo
rg
e
Sh
el
le
y/
Fl
irt
/A
la
m
y
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

C H A P T E R 2 5 1
suggest care is optimized when providers work
together rather than at cross purposes. Patients
are sometimes put in the confusing position of
choosing between biomedical and traditional
systems that contradict or reject each other.54
Studies suggest that some unconventional
therapies are effective, benefiting the patient
physiologically or psychologically, and should
be accepted as complementary to biomedical
approaches.66,67 Cooperative monitoring by a
biomedical professional can also detect those
few instances when a home remedy or popular
practice is harmful to the patient. Furthermore,
biomedical health care providers can adopt
certain healing strategies. Understanding the
patient’s perspective on illness and attend-
ing to differences in the patient–provider
relationship is one approach.10 Recommend-
ing alternate, experimental biomedical pro-
grams in cases of advanced chronic disease is
another.59 A more comprehensive methodol-
ogy is offered through transcultural nursing
theory, developed to provide culturally com-
patible care that is beneficial, satisfying, and
meaningful to clients.14 Transcultural nursing
theory identifies three modes of effective care:
(1) cultural care preservation and/or mainte-
nance, (2) cultural care accommodation and/
or negotiation, and (3) cultural care repattern-
ing or restructuring.
Cultural care preservation and/or mainte-
nance is used when a traditional health belief
or practice is known to be beneficial in its
effect and is encouraged by the provider. Cul-
tural care accommodation and/or negotiation
is accomplished between the provider and the
patient (or the patient’s family) when there is
an expectation for care that is outside biomed-
ical convention. Cultural care repatterning or
restructuring occurs when both provider and
patient agree that a habit is harmful to health,
and a cooperative plan is developed to intro-
duce a new and different lifestyle. Applied to
food habits, the culture care theory acknowl-
edges that some traditional beliefs and prac-
tices regarding diet have beneficial or neutral
consequences, some have unknown conse-
quences, and some may be deleterious to the
health of a client (see Chapter 1).
In addition to specific provider approaches,
the health care setting can also help promote
biomedical healing through services desired
by clients in a comfortable, welcoming
atmosphere. Some health care organiza-
tions are forming therapeutic alliances with
D I S C U S S I O N S T A R T E R S
What is Your “Worldview” of Health Care?
Culture determines how each of us defines health, recognizes illness, and considers
medical treatment of illness. Reflecting on how we view health and healthcare can
tell us a lot about our cultures. Answer each of the following questions. Don’t worry
about justifying your beliefs. All you want to do here is reflect on and write down your
beliefs. There are no right or wrong answers, as long as the answers honestly express
your beliefs.
● Which most determines a person’s health: The decisions and actions of the
person herself or himself? The decisions and actions of one’s family and others
with whom one has been brought up? The decisions and actions of the govern-
ment (whether national or local or both)? The will of God? The actions of some
other supernatural agency (please identify)? Astrological alignment of the stars
and planets? Karma? Fate? Something else?
● Who is most responsible for a person’s healthcare: The health care
practitioner? The person herself or himself (or, if a child, the parents or adult
caregivers)? Someone else?
● If you became seriously ill or injured and needed dramatic treatment,
such as surgery or radiation treatment, who would most influence your
decision(s) regarding that treatment: You alone? Your family? Your church,
synagogue, tabernacle, temple, mosque, or other religious congregation? Others?
● If a loved one is terminally ill—that is, dying from a disease or injury—
which of the following would be most important to you: Trying everything
possible to cure your loved one or at least, prolonging that loved one’s life? Doing
everything possible to relieve any pain that loved one might be enduring? Praying
with that loved one and sustaining her or his faith? Helping your loved one die
in a way that she or he wants, which could involve not employing life-sustaining not employing life-sustaining not
measures?
● Which of the following is the most important way you tell whether you
are healthy or not: By whether or not you have any symptoms of disease?
By whether or not you can accomplish daily tasks and meet daily responsibilities?
By how you look in the mirror and/or how others perceive how you look?
In small groups of three or four, compare answers for about ten minutes. Restrain any
impulse to criticize. Your task is to gather as much information as possible about each
person’s worldview relating to health care in the short time that you have. Remember,
there are no right or wrong answers. Different cultures exhibit different worldviews.
When members of your group have completed sharing answers with each other,
individually write a reflection on what you’ve learned and how you feel about it
(maximum one page).
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

5 2 T R A D I T I O N A L H E A L T H B E L I E F S A N D P R A C T I C E S
community folk healers or combining non-
Western practices with biomedicine in an inte-
grative approach. At a minimum, research on
traditional practices used by clients and infor-
mation about alternative community health
resources should be available to providers; staff
should be encouraged to keep up on current
trends through continuing education, diversity
training, and refresher workshops. Other use-
ful steps include increasing care accessibility by
taking education and services into client com-
munities when possible and providing flexible,
nontraditional hours for appointments. Clients
also feel more at ease with a staff representa-
tive of the community, so to some degree,
this preference should be accommodated.68,69
Successful biomedical healing is dependent on
the intercultural knowledge and sensitivity of
the health provider and setting. Care must be
undertaken in cooperation with the patient,
as well as the patient’s family and any concur-
rent traditional providers in use by the patient.
Healing should not be the sole domain of home
remedies, popular health care approaches, or
alternative medical systems. Medical plural-
ism offers the opportunity for biomedicine to
heal sickness through coordinated client care,
with understanding and appreciation for the
therapeutic value of traditional health beliefs
and practices.
Review Questions
1. If you become ill, how might your worldview
influence your expectations about your illness
and its treatment?
2. How does biomedicine in the United States
reflect the majority culture?
3. How does the U.S. biomedicine definition of
h eal th differ from that of the World Health
Organization: “a state of complete physical,
mental, and social well-being”?
4. Describe three ways that diet may be used to
promote or maintain health, using specific
examples of foods and practices.
5. What is meant by f ol k il l nesses or c ul tur e- bound
sy ndr omes? Using one example, explain how
effective treatment for the condition would
differ from the conventional biomedical
approach.
References
1. Barnes, P.M., Bloom, B., & Nahin, R. 2008,
December. C ompl ementar y and al ter nativ e
medic ine use among adul ts and c h il dr en: U nited
S tates, 2 0 0 7 . CDC National Health Statistics
Report #12.
2. Nahin, R.L., Barnes, P.M., Stussman, B.J., &
Bloom, B. 2009. C osts of c ompl ementar y and
al ter nativ e medic ine ( C A M ) and f r eq uenc y of v isits
to C A M pr ac titioner s: U nited S tates, 2 0 0 7 . CDC
National Health Statistics Report #18.
3. Kavanagh, K., Absalom, K., Beil, W., & Schliess-
mann, L. 1999. Connecting and becoming cultur-
ally competent: A Lakota example. A dv anc es in
N ur sing S c ienc e, 2 1 , 9–31.
4. Randall-David, E. 1989. S tr ategies f or w or k –
ing w ith c ul tur al l y div er se c ommunities and
c l ients. Bethesda, MD: Association for the Care
of Children’s Health.
5. Schilling, B., & Brannon, E. 1986. C r oss- c ul tur al
c ounsel ing: A guide f or nutr ition and h eal th
c ounsel or s. FNS #250. Alexandria, VA: U.S.
Department of Agriculture/U.S. Department of
Health and Human Services.
6. Yankelovich, Inc. 2006. Food for Life Study. In
T h e Y ank el ov ic h M O N I T O R . Chapel Hill, NC.
7. Blackhall, L.J., Murphy, S.T., Frank, G., Michel, V., &
Azen, S. 1995. Ethnicity and attitudes toward
patient autonomy. J our nal of th e A mer ic an M edi-
c al A ssoc iation, 2 7 4 , 820–825.
8. Klessig, J. 1992. The effects of values and culture
on life-support decisions. W ester n J our nal of
M edic ine, 1 5 7 , 316–322.M edic ine, 1 5 7 , 316–322.M edic ine, 1 5 7
9. Uche-riffin, Ndidi F. 1994. Perceptions of African
American women regarding health care. J our nal
of C ul tur al Div er sity , 1 , 32–35.
10. Kleinman, A. 1980. P atients and h eal er s in th e
c ontex t of c ul tur e. Berkeley: University of Cali-
fornia Press.
11. Kumanyika, S.K., & Morssink, C.B. 1997. Cultural
appropriateness of weight management programs.
In O v er w eigh t and w eigh t management: T h e
h eal th pr of essional ’ s guide to under standing and
pr ac tic e. Gaithersburg, MD: Aspen.
12. Helman, C.G. 2000. C ul tur e, h eal th and il l ness:
A n intr oduc tion f or h eal th pr of essional s (4th ed.).
London: Butterworth-Heinemann.
13. Spector, R.E. 2004. C ul tur al div er sity in h eal th and
il l ness (6th ed.). Upper Saddle River, NJ: Pearson.
14. Leininger, M.M. 1991. Becoming aware of types
of health practitioners and cultural imposition.
J our nal of T r ansc ul tur al N ur sing, 2 , 36.
15. Braun, U.K., Beyth, R.J., Ford, M.E., &
McCullough, L.B. 2008. Voices of African Ameri-
can, Caucasian and Hispanic surrogates on the
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

C H A P T E R 2 5 3
burdens of end-of-life decision making. J our nal
of G ener al I nter nal M edic ine, 2 3 , 267–274.
16. Ots, T. 1990. The angry liver, the anxious heart
and the melancholy spleen: The phenomenology
of perceptions in Chinese culture. C ul tur e, M edi-
c ine, and P sy c h iatr y , 1 4 , 21–58.
17. Cassell, J.A. 1995. Social anthropology and nutri-
tion. A different look at obesity in America.
J our nal of th e A mer ic an Dietetic A ssoc iation, 9 5 ,
424–427.
18. Ceballos, N., & Czyzewska, M. 2010. Body image
in Hispanic/Latino vs. European American ado-
lescents: Implications for treatment and pre-
vention of obesity in underserved populations.
J our nal of H eal th C ar e f or th e P oor and U nder –
ser v ed, 2 1 , 823–838.
19. Gracia-Arnaiz, M. 2010. Fat bodies and thin bod-
ies: Cultural, biomedical and market discourses
on obesity. A ppetite, 5 5 , 219–225.
20. DeGarine, I., & Pollack, N.J. 1995. S oc ial aspec ts
of obesity . Australia: Gordon & Breach.
21. Neumark-Sztainer, D., Croll, J., Story, M.,
Hannan, P.J., French, S.A., & Perry, C. 2002. Eth-
nic/racial differences in weight-related concerns
and behaviors among adolescent girls and boys:
Findings from Project EAT. J our nal of P sy c h oso-
matic R esear c h , 5 3 , 963–974.
22. York-Crowe, E.E., & Williamson, D.A. 2005.
Health and appearance concerns in young Cau-
casian and African-American women. E ating and
W eigh t Disor der s, 1 0 , e38–e44.
23. Greenberg, D.R., & LaPorte, D.J. 1996. Racial
differences in body type preferences of men for
women. I nter national J our nal of E ating Disor der s,
1 9 , 275–278.
24. Davis, D.S., Sbrocco, T., Odoms-Young, A., &
Smith, D.M. 2010. Attractiveness in African
American and Caucasian women: Is beauty in the
eyes of the observer? E ating B eh av ior s, 1 1 , 25–32.
25. Mossavar-Rahmani, Y., Pelto, G.H., Ferris, A.M., &
Allen, L.H. 1996. Determinants of body size
perceptions and dieting behavior in a multieth-
nic group of hospital staff women. J our nal of th e
A mer ic an Dietetic A ssoc iation, 9 6 , 252–256.
26. Contento, I.R., Basch, C., & Zybert, P. 2003. Body
image, weight and food choices of Latina women
and their young children. J our nal of N utr ition
E duc ation and B eh av ior , 3 5 , 236–248.
27. Crawford, P.B., Gosliner, W., Anderson, C.,
Strode, P., Becerra-Jones, Y., Samuels, S., . . .
Ritchie, L.D. 2004. Counseling Latina mothers of
preschool children about weight issues: Sugges-
tions for a new framework. J our nal of th e A mer i-
c an Dietetic A ssoc iation, 1 0 4 , 387.
28. Rubin, L.R., Fitts, M.L., & Becker, A.E. 2003.
“Whatever feels good in my soul”: Body ethics
and aesthetics among African American and
Latina women. C ul tur e, M edic ine and P sy c h iatr y ,
2 7 , 49–75.2 7 , 49–75.2 7
29. Olvera, N., Suminski, R., & Power, T.G. 2005.
Intergenerational perceptions of body image in
Hispanics: Role of BMI, gender, and accultura-
tion. O besity R esear c h , 1 3 , 1970–1979.
30. Wang, C.Y., Abbot, L., Goodbody, A.K., & Hui,
W.T. 2002. Ideal body image and health status in
low-income Pacific Islanders. J our nal of C ul tur al
Div er sity , 9 , 12–22.
31. Gittelsohn, J., Harris, S.B., Thorne-Lyman, A.L.,
Hanley, A.J., Barnie, A., & Zinman, B. 1996.
Body image concepts differ by age and sex in an
Ojibway-Cree community in Canada. J our nal of
N utr ition, 1 2 6 , 2990–3000.
32. Lynch, W.C., Heil, D.P., Wagner, E., & Havens,
M.D. 2007. Ethnic differences in BMI, weight
concerns, and eating behaviors: Comparison of
Native American, White, and Hispanic adoles-
cents. B ody I mage, 4 , 179–190.
33. Rinderknect, K., & Smith, C. 2002. Body-image
perceptions among urban Native American
youth. O besity R esear c h , 1 0 , 315–327.
34. Robinson, T.N., Chang, J.Y., Haydel, K.F., & Kil-
len, J.D. 2001. Overweight concerns and body
dissatisfaction among third-grade children: The
impacts of ethnicity and socioeconomic status.
J our nal of P ediatr ic s, 1 3 8 , 181–187.
35. Neumark-Sztainer, D., Croll, J., Story, M.,
Hannan, P.J., French, S.A., & Perry, C. 2002. Eth-
nic/racial differences in weight-related concerns
and behaviors among adolescent girls and boys:
Findings from Project EAT. J our nal of P sy c h oso-
matic R esear c h , 5 3 , 963–974.
36. Talamayan, K.S., Springer, A.E., Kelder, S.H.,
Gorospe, E.C., & Joye, K.A. 2006. Prevalence of
overweight misperception and weight control
behaviors among normal weight-adolescents in the
United States. S c ientif ic W or l d J our nal , 6 , 365–376.
37. Davis, S.M., & Lambert, L.C. 2000. Body image
and weight concerns among Southwestern Amer-
ican Indian preadolescent schoolchildren. E th nic –
ity and Disease, 1 0 , 184–194.
38. Xanthopoulos, M.S., Borradaile, K.E., Hayes, S.,
Sherman, S., Vander-Veur, S., Grundy, . . . Foster,
G.D. 2011. The impact of weight, sex, and race/
ethnicity on body dissatisfaction among urban
children. B ody I mage, 8 (4), 385–389.
39. Wright, J.D., & Wang, C.-Y. 2010. T r ends in
intak e of ener gy and mac r onutr ients in adul ts
f r om 1 9 9 9 –2 0 0 0 th r ough 2 0 0 7 –2 0 0 8 . NCHS Data
Brief, No 49. Hyattsville, MD: National Center for
Health Statistics.
40. Seo, D.C., Torabi, M.R., Jiang, N., Fernandez-
Rojas, X., & Park, B.H. 2009. Cross-cultural com-
parison of lack of regular physical activity among
college students: Universal versus transversal.
I nter national J our nal of B eh av ior al M edic ine, 1 6 ,
355–359.
41. Spector, R.E. 2004. C ul tur al div er sity in h eal th and
il l ness (6th ed.). Upper Saddle River, NJ: Pearson.
42. Kleinman, A., Eisenberg, L., & Good, B. (2006).
Culture, illness and care: Clinical lessons from
anthropologic and cross-cultural research.
F O C U S , 4 (1), 140–149.
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

5 4 T R A D I T I O N A L H E A L T H B E L I E F S A N D P R A C T I C E S
43. Kleinman, A., Eisenberg, L., & Good, B. 1978.
Culture, illness, and care: Clinical lessons from
anthropologic and cross-culture research. A nnal s
of I nter nal M edic ine, 8 8 , 251–258.
44. Douglas, M.K., & Pacquiao, D.F. (Eds.). 2010. Core
curriculum in transcultural nursing and health
care. J our nal of T r ansc ul tur al N ur sing, 2 1 (Suppl. 1).
45. Clark, M.M. 1983. Cultural context of medi-
cal practice. W ester n J our nal of M edic ine, 1 3 9 ,
806–810.
46. Hand, W.D. 1980. M agic al medic ine. Berkeley:
University of California Press.
47. Graham, J.S. 1976. The role of the curandero in
the Mexican American folk medicine system in
West Texas. In W.D. Hand (Ed.), A mer ic an f ol k
medic ine. Berkeley: University of California Press.
48. Adler, S.R. 1995. Refuge stress and folk belief:
Hmong sudden deaths. S oc ial S c ienc e and M edi-
c ine, 4 0 , 1623–1629.
49. Keel, P.K., & Klump, K.L. 2003. Are eating disor-
ders culture-bound syndromes? Implications for
conceptualizing care. P sy c h ol ogic al B ul l etin, 1 2 9 ,
747–769.
50. American Psychiatric Association. 2000. Prac-
tice guideline for the treatment of patients with
eating disorders. A mer ic an J our nal of P sy c h iatr y ,
1 5 7 (Suppl.), 1–39.
51. Garrett, L. 1994. T h e c oming pl ague: N ew l y emer g-T h e c oming pl ague: N ew l y emer g-T h e c oming pl ague: N ew l y emer g
ing diseases in a w or l d out of bal anc e. New York:
Farrar, Strauss & Giroux.
52. Kim, C., & Kwok, Y.S. 1998. Navajo use of native
healers. A r c h iv es of I nter nal M edic ine, 1 5 8 ,
2245–2249.
53. Ma, G. 1999. Between two worlds: The use of tra-
ditional and Western health services by Chinese
immigrants. J our nal of C ommunity H eal th , 2 4 ,
421–437.
54. Marbella, A.M., Harris, M.C., Diehr, S., Ignace,
G., & Ignace, G. 1998. Use of Native American
healers among Native American patients in an
urban Native American health center. A r c h iv es of
F amil y M edic ine, 7, 182–185.
55. Poss, J.E., Jezewski, M.A., & Stuart, A.G. 2003.
Home remedies for type 2 diabetes used by Mexi-
can Americans in El Paso, Texas. C l inic al N ur sing
R esear c h , 1 2 , 304–323.
56. Kao, G.D., & Devine, P. 2000. Use of comple-
mentary health practices by prostate carcinoma
patients undergoing radiation therapy. C anc er , 8 8 ,
615–619.
57. Rausch, S.M., Winegardner, F., Kruk, K.M., &
Phatak, V. 2011. Complementary and alternative
medicine: Use and disclosure in radiation oncol-
ogy community practice. S uppor t C ar e C anc er ,
1 9 (4), 521–529.
58. Hughes, C.K., & Higuchi, P. 2004. Ka Lokahi
Wahine: A culturally based training for health
professionals. P ac if ic H eal th Dial og, 1 1 , 166–169.
59. Murray, R.H., & Rubel, A.J. 1992. Physicians and
healers—Unwitting partners in health care. N ew
E ngl and J our nal of M edic ine, 3 2 6 , 61–64.
60. Mei, M.F. 2011 A systematic analysis of the theory
and practice of syndrome differentiation. C h inese
J our nal of I ntegr ativ e M edic ine, 1 7 , 803–810.J our nal of I ntegr ativ e M edic ine, 1 7 , 803–810.J our nal of I ntegr ativ e M edic ine, 1 7
61. Brandon, E. 1976. Folk medicine in French
Louisiana. In W.D. Hand (Ed.), A mer ic an f ol k
M edic ine. Berkeley: University of California Press.
62. Leistner, C.G., & Hirschfield, L. 2010. Cajun and
creole food practices. In C.M. Goody & L. Drago
(Eds.), C ul tur al f ood pr ac tic es (Introduction).
Chicago: American Dietetic Association.
63. Yoder, D. 1976. Hohman and Romanus: Origins
and diffusion of Pennsylvania German pow-
wow manual. In W.D. Hand (Ed.), A mer ic an f ol k
medic ine. Berkeley: University of California Press.
64. Balzer, M.M. 1987. Behind shamanism: Changing
voices of Siberian Khanty cosmology and politics.
S oc ial S c ienc e and M edic ine, 2 4 , 1085–1093.
65. Sheikh, A.A., Kunsendorf, R.G., & Sheikh, K.S. 1989.
Healing images: From ancient wisdom to modern
science. In A.A. Sheikh & K.S. Sheikh (Eds.), E aster n
and W ester n appr oac h es to h eal ing: A nc ient w isdom
and moder n k now l edge. New York: Wiley.
66. Oh, B., Butow, P., Mullan, B., Beale, P., Pavlakis,
N., Rosenthal, D., & Clarke S. 2010. The use and
perceived benefits resulting from the use of com-
plementary and alternative medicine by cancer
patients in Australia. A sia- P ac if ic J our nal of C l inic al
O nc ol ogy , 6, 342–349.
67. Lunny, C.A., & Fraser, S.N. 2010, July. The use of
complementary and alternative medicines among
a sample of Canadian menopausal-aged women.
J our nal of M idw if er y and W omen’ s H eal th , 5 5 (4),
335–343.
68. Kaptchuk, T.J., & Millar, F.G. 2005. Viewpoint:
What is the best and most ethical model for the
relationship between mainstream and alternative
medicine: Opposition, integration, or pluralism?
A c ademic M edic ine, 8 0 , 286–290.
69. Yehieli, M., & Grey, M.A. 2005. H eal th matter s: A
poc k et guide f or w or k ing w ith div er se c ul tur es and
under ser v ed popul ations. Yarmouth, ME: Intercul-
tural Press.
70. Kumanyika, S.K., & Morssink, C.B. 1997. Cul-
tural appropriateness of weight management
programs. In O v er w eigh t and w eigh t management:
T h e h eal th pr of essional ’ s guide to under standing
and pr ac tic e. Gaithersburg, MD: Aspen.
71. Anderson, E.N. 1987. Why is humoral medi-
cine so popular? S oc ial S c ienc e and M edic ine, 2 5 ,
331–337.
72. Dagnelie, P.C., & van Stavern, W.A. 1994. Mac-
robiotic nutrition and child health: Results of a
population-based, mixed longitudinal cohort
study in the Netherlands. A mer ic an J our nal of
C l inic al N utr ition, 5 9 (Suppl.), 1187S–1196S.
73. Garrett, L. 1994. T h e c oming pl ague: N ew l y emer g-T h e c oming pl ague: N ew l y emer g-T h e c oming pl ague: N ew l y emer g
ing diseases in a w or l d out of bal anc e. New York:
Farrar, Strauss & Giroux.
74. Chibnall, J.T., & Brooks, C.A. 2001. Religion in
the clinic: The role of physician beliefs. S outh er n
M edic al J our nal , 9 4 , 374–379.
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

C H A P T E R 2 5 5
75. Gurley, D., Novins, D.K., Jones, M.C., Beals, J.,
Shore, J.H., & Manson, S.M. 2001. Comparative
use of biomedical services and traditional healing
options by American Indian veterans. P sy c h iatr ic
S er v ic es, 5 2 , 68–74.
76. DeBusk, R.M. 1999. Herbal medicines: A primer.
O n th e C utting E dge: Diabetes C ar e and E duc a-
tion, 2 0 , 4–5.
77. Bressler, R. 2005. Interactions between Gingko
biloba and prescription medications. G er iatr ic s,
6 0 , 30–33.
78. King, A.R., Russett, F.S., Generali, J.A., & Grauer,
D.W. 2009. Evaluation and implications of natural
product use in preoperative patients: a retrospec-
tive review. B M C C ompl ementar y and A l ter nativ e
M edic ine, 9 , 38.
79. Sagar, S.M. 2010. Can the therapeutic gain of
radiotherapy be increased by concurrent admin-
istration of Asian botanicals? I ntegr ativ e C anc er
T h er apies, 9 , 5–13.
80. Colson, C.R., & De Broe, M.E. 2005. Kidney
injury from alternative medicines. A dv anc es in
C h r onic K idney Diseases, 1 2 , 261–275.
81. Mansfield, C.J. 2002. The doctor as God’s
mechanic? Beliefs in the southeastern United
States. S oc ial S c ienc e & M edic ine, 5 4 , 399–409.
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

5 6
3
Intercultural
CommunicationCH
A
P
T
E
R
status, health condition, religion, educational
background, group membership, sexual
orientation, or political affiliation.
Most people are comfortable convers-
ing with those who are culturally similar to
themselves. Communication is sometimes
described as an action chain,2 meaning that
one phrase or action leads to the next: in the
United States, a person who extends her hand
in greeting expects the other person to take
her hand and shake it, or when a person says
“thank you,” a “you’re welcome” should follow.
Communication comprises a whole series of
unwritten expectations regarding how a per-
son should respond, and such expectations are
largely cultural in origin. If a person under-
stands the communication action chain and
responds as expected, a successful relationship
can develop. When a person does not respond
as expected, communication can break down,
and the relationship can deteriorate.1
When meeting a person for the first time,
the only data that speakers usually have to
work with come from their own cultural
norms. They use these norms to predict how
that person will respond to their words and
what conversational approaches are appropri-
ate. They may also use social roles to determine
their communication behavior. Furthermore,
speakers modify their words and actions as
they get to know a person individually, observ-
ing personal cues about communication char-
acteristics that vary from cultural or social
customs.3 An employee, for example, may
make certain assumptions about a supervisor
based on ethnicity, gender, age, and especially
Whether a person is interacting with people from diverse cultural groups at work and in social set-
tings or traveling to another country for busi-
ness or pleasure, he or she needs intercultural
communication skills to successfully negoti-
ate daily life. Intercultural communication
is a specialty in itself. The field encompasses
language and the context in which words are
interpreted, including gestures, posture, spa-
tial relationships, concepts of time, the status
and hierarchy of persons, the role of the indi-
vidual within a group, and the setting. This
chapter presents a broad and limited overview
of intercultural communication concepts, as
well as information useful in nutrition coun-
seling with individuals or with groups in edu-
cational programs. Later chapters on each
American ethnic group provide more specific
details as reported by researchers and practi-
tioners familiar with cultural communication
characteristics.
The Intercultural
Challenge
Researchers have used an iceberg analogy (see
Figure 3.1) to describe how a person’s cultural
heritage can impact communication.1 Ethnic-
ity, age, and gender are the most visible per-
sonal characteristics affecting dialogue—the
so-called tip of the iceberg. Beneath the sur-
face, but equally influential, may be degree of
acculturation or assimilation, socioeconomic
“Observe the nature
of each country; diet;
customs; the age of the
patient; speech; man-
ners; fashion; even his
silence. . . . One has to
study all these signs
and analyze what they
portend.” Hippocratic
writings, fifth century BCE.
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

C H A P T E R 3 5 7
occupational status and then make adapta-
tions. An employee may start out calling his
boss “Mrs. Smith” as a sign of respect for her
position but use the more informal “Sue” when
she requests that he call her by her first name.
Interpersonal relationships between two
individuals are based mostly on personal
communication preferences; group interac-
tions commonly depend on cultural or social
norms. Misinterpretations at the cultural or
social levels of communication are more likely
to occur because they are more generalized.
As mentioned in Chapter 1, stereotyping
occurs if a person misjudges another individ-
ual’s degree of association with any particular
cultural or social group. Approximately one-
third of the people from any given group are
believed to actually behave in ways typified
by the group as a whole.3 Assumptions about
how a person of a different cultural heritage
should communicate can prompt certain
types of reactions based on norms in that per-
son’s culture: stereotyping can become a self-
fulfilling prophecy. For instance, Asians have a
reputation for being reserved in conversation
compared to the typical American approach.
A nutrition education provider teaching a
prenatal care program may respond to more
aggressive speakers during a group meeting,
failing to actively involve a Vietnamese Amer-
ican participant. The Vietnamese American
woman may feel the provider is disinterested
in her questions or comments, becoming even
less likely to offer input at the next meeting,
reinforcing the provider’s perception that all
Asians are quiet.
The challenge is to increase familiarity
with cultural communication behaviors, while
remaining aware of personal cues and mov-
ing toward an interpersonal relationship as
quickly as possible.
Intercultural
Communication
Concepts
Communication uses codes to represent
objects, ideas, or behaviors. Thoughts, emo-
tions, and attitudes are decoded into language
and nonverbal actions (e.g., gestures, posture,
eye contact) to send messages from one per-
son to another.
The two components of the message are
the content and the relationship between the
speaker and the receiver. Depending on the
situation, the content or the relationship may
assume greater prominence in interpretation
of meaning. Messages that violate cultural
expectations may be accurate in content but
have a negative impact on the relationship. If
the message consistently offends the receiver,
the relationship will deteriorate and the mes-
sage will be disregarded. For example, if a
health professional advises a Chinese client
to increase calcium intake through increased
milk consumption, this is an example of a
content message that does little to acknowl-
edge the role of milk in the Chinese diet. Is
the client lactose intolerant? Does the cli-
ent like milk? Does the client classify milk
as health promoting or as a cause of illness?
How does milk fit into the balance of the diet
according to the client? Unless the provider
gains an understanding of how the client
Figure 3.1
Iceberg model of
multicultural influences
on communication.
Source: Adapted with permission of
Sage, from Effective Communication
in Multicultural Health Care Settings,
G. L. Kreps & E. N. Kunimoto, 6.
Copyright © 1994. Permission
conveyed through Copyright
Clearance Center, Inc.
Va
d8
2/
Sh
ut
te
rs
to
ck
.c
om
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

5 8 I N T E R C U L T U R A L C O M M U N I C A T I O N
a group and perceptions of power, authority,
status, and time. In addition, context in com-
munication also encompasses the significance
of affective and physical expression (termed
low or high context) and level of tolerance for
uncertainty and ambiguity (called uncertainty
avoidance). Verbal communication occurs
within these cultural premises, often oper-
ating at an unconscious level in the speaker
(Figure 3.2).
Low- and High-Context Cultures
Conversational context can be defined as the
affective and physical cues a speaker uses to
indicate meaning, such as tone of voice, facial
expression, posture, and gestures.
In most Western cultures, messages usu-
ally concern ideas presented in a logical, lin-
ear sequence. The speaker tries to say what
is meant through precise wording, and the
content of the language is more objective than
personal along the continuum of personal
and object messages. This communication
style is termed low context because the actual
words are more important than who is receiv-
ing the message, how the words are said, or
the nonverbal actions that accompany them.
Communication in a low-context culture
is so dependent on words that the underly-
ing meaning is undecipherable if wording is
chosen poorly or deliberately to mislead the
recipient. Nearly every American has also
experienced the obtuse professional languages
of attorneys or scientists who fail to convey
their message in common, everyday English.
The Swiss, Germans, and Scandinavians are
examples of low-context cultures.2
In cultures with a high-context com-
munication style, most of the meaning of a
message is found in the context, not in the
words. In fact, the wording used may be
vague, circuitous, or incomplete. The content
of the language is more personal than objec-
tive, dependent on the relationship between
speaker and listener. Attitudes and feelings
are more prominent in the conversation than
thoughts. Communication in high-context
cultures is analogous to the expression “read-
ing between the lines.” Misunderstandings
easily occur if either participant is unfamiliar
with the meaning of the nonverbal signifiers
conceptualizes the situation, the content of
the message may be ignored because the cli-
ent assumes disinterest or even disrespect for
personal beliefs and expectations. Thus, the
provider–client relationship is weakened.
Messages that demonstrate respect for the
individuality of the receiver are called per-
sonal messages and these improve relation-
ships; those that are disrespectful are termed
object messages and these often degrade rela-
tionships. Communication occurs in a contin-
uum between personal and object messages.1
Verbal messages are most useful for com-
municating content, whereas nonverbal
messages usually convey information about
relationships. If the nonverbal message is
consistent with the verbal message, it can
build the relationship and help the receiver
correctly interpret the meaning intended by
the speaker. When the nonverbal message is
inconsistent with the verbal message, both the
relationship and the content are undermined.
Successful communication is dependent on
both verbal and nonverbal skills, each signifi-
cantly impacted by cultural considerations.
Verbal Communication
The abstract nature of language means it can
be correctly interpreted only within context.
The cultural aspects of context are so embed-
ded that a speaker often believes they are
inherent—that is, that other people must com-
municate according to the same expectations.
Context includes issues common to cultural
worldview, such as the role of the individual in
Figure 3.2
Cultural context is so
embedded in the individual
that many people believe
it is innate and assume all
other people share the same
background.
Source: ID: 38626, Published in
March 10, 1980.
©
Th
e N
ew
Yo
rk
er
Co
lle
ct
io
n
19
80
Pe
te
r S
te
in
er
fr
om
ca
rto
on
ba
nk
.co
m
.
Al
lR
ig
ht
sR
es
er
ve
d.
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

C H A P T E R 3 5 9
and indirect. In high-context cultures, direct
language is frequently used in intimate
relationships.
As an example of low- versus high-context
communication in different situations, con-
sider a researcher presenting current nutri-
tional data on spinach to a group of other
professionals. She will probably speak in a
relatively monotone voice and use scien-
tific jargon. She will present her points in a
sequential manner, support her thesis with
examples, and then restate her ideas in the
conclusion. She will probably stand erect and
limit the expressive use of her hands and face.
The message is almost entirely in the content
of the words she says. In contrast, this same
woman might behave very differently when
feeding her reluctant toddler spinach for
dinner. She might smile and make yummy
sounds as she offers him a spoonful or pre-
tends the spinach is a plane coming in for a
landing in his mouth. She might give him a
spoonful of meat or potato, then try the spin-
ach again. She might even dance around his
high chair a little or hum a few bars of the
old cartoon theme song about a sailor who
liked spinach. She doesn’t try to get him to eat
spinach by explaining its nutrient content, as
she did at her meeting. The message is non-
linear and not dependent on the content of
the words she uses. This is not to say that a
health care provider should burst out in song
when working with a client from a high-con-
text culture. But it does suggest that indirect,
being used, such as small eye movements or
sounds that are made when in agreement, or
disagreement, or when upset. For example,
many Americans tend to squirm a bit when
uncomfortable with a conversation, while
the Japanese will quickly suck in air. High-
context cultures are most prevalent among
homogeneous populations with a common
understanding of the affective and physical
expression used in sending the message (see
the following “Nonverbal Communication”
section). Asian, Middle Eastern, and Native
American cultures are very high context.
Latino societies are moderately high context.
American culture is thought to be toward the
low end, but more middle context than many
European societies.
In low-context cultures, communication is
usually explicit, straightforward, and unam-
biguous. The focus is on the speaker, who
uses words to send messages that are often
intended to persuade or convince the receiver.
In high-context cultures, indirect communi-
cation is preferred. Implicit language is used,
and many qualifiers are added; nonverbal cues
are significant to interpreting the message.
The locus of conversation is the receiver; the
speaker makes adjustments in consideration
of the listener’s feelings.3 Low-context lis-
teners are often impatient with high-context
speakers, wondering when the speaker will get
to the point of the conversation. Low-context
listeners also frequently miss the affective and
physical expression in the message.
Health care situations are often extremely
low context. The conversation is focused on
the provider who delivers a verbal message
to the client with little consideration for the
nonverbal message. The communication
is high on content and low on relationship.
Clients from high-context cultures are likely
to be dissatisfied, even offended, by such
impersonal, objective interactions. Commu-
nication problems may not be evident to a
low-context clinician until the client leaves
and never returns.
Interactions may range from low- to high-
context depending on the situation, regardless
of the overall cultural preference. In uncom-
fortable or embarrassing situations, a low-
context communicator may be very sensitive
▲ Only the person send-
ing the message knows the
meaning of the message: the
person receiving the message
must use what she knows
about cultural and social
norms, as well as what she
knows about the speaker
personally, to interpret the
message.
To
m
M
cC
ar
th
y/
Ph
ot
oE
di
t
One area of conflict
often found between
blacks and whites is
due to differences in
high- and low-context
communication. African
Americans tend to be
more high context than
white Americans, using
cognitive, affective, and
physical responses that
may appear disruptive
or overly emotional
to whites.90
One way to patronize
a person is to speak in
a low-context mode,
elaborating beyond
what is needed for
understanding.
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

6 0 I N T E R C U L T U R A L C O M M U N I C A T I O N
expressive approaches may be more effective
in some intercultural clinical, educational, or
counseling settings. Identification of a culture
as either low or high context provides a gen-
eral framework for communication but may
be affected by other situational factors.
Individuals and Groups
The relationship of the individual to the group
is determined in part by whether a culture is
low or high context. In low-context cultures,
the individual is typically separate from the
group, and self-realization is an important
goal. Self-esteem is dynamic, based on suc-
cessful mastery or control of a situation. In
high-context cultures, the individual is usually
defined by group association, and a person
desires oneness with the group, not individu-
ation. A mutual dependency exists and self-
esteem is based on how well a person can
adjust to a situation.3 Individualism is a promi-
nent characteristic in Australia, Canada, Great
Britain, New Zealand, the Netherlands, and
the United States. Collectivism is especially
valued in the nations of Denmark, Ghana,
Guatemala, Indonesia, Nigeria, Panama, Peru,
El Salvador, Sierra Leone, Taiwan, Thailand,
and Venezuela.
In societies emphasizing individuality,
a person must communicate to gain accep-
tance by the group, whether it is the family,
the workplace, or the community. Commu-
nication is used to establish the self within
an individual or group relationship. When
meeting someone new, the action chain in the
conversation is flexible, with few expectations.
The two people may focus on one or the other
speaker and often delve into personal prefer-
ences, such as favorite restaurants or sports
teams. When group identity is the focus of a
society, there is no need for a person to seek
acceptance from the group or to communicate
individuality. Silence is highly valued. Interac-
tions between strangers tend to be ritualized,
and if the action chain is broken, communica-
tion cannot continue. The expectation is that
each speaker will indicate group affiliation
and that such identity conveys all the infor-
mation needed to know that person.
The role of the individual within the group
can have an impact on health care delivery.
Within more group-oriented cultures, greater
participation is required of their members
in matters of health and illness, and it may
be expected that relatives will participate in
giving patient histories, overseeing physical
exams, or making decisions regarding treat-
ment.4 Middle Easterners expect to go to the
hospital with an ill family member to provide
care. Next of kin is determined along blood-
lines among Latinos, and care decisions are
often the responsibility of a grandmother or
mother instead of the spouse. Koreans prefer
the whole family make decisions regarding
treatment for a terminally ill patient. Some
American Indians are so strongly associated
with the group it is difficult for them to com-
municate individual needs.
Uncertainty Avoidance
Related to the role of the individual in a group
is tolerance for uncertainty and ambiguity.
Some groups exhibit great discomfort with
what is unknown and different; these are
defined as high uncertainty avoidance cul-
tures. Members of these cultures may become
anxious about behavior that deviates from the
norm; high uncertainty avoidance cultures
desire consensus. Argentina, Belgium, Chile,
Colombia, Costa Rica, Croatia, Egypt, France,
Greece, Guatemala, Israel, Japan, Korea,
Mexico, Panama, Peru, Portugal, Turkey,
Serbia, and Spain are stronger in uncertainty
avoidance than the United States, as are most
African and other Asian nations. They typi-
cally have a history of central rule and com-
plex laws that regulate individual action on
behalf of the group.3
Cultures with low or weaker uncer-
tainty avoidance include Canada, Denmark,
Great Britain, Hong Kong, India, Indonesia,
Jamaica, the Netherlands, the Philippines,
Sweden, and the United States. People from
these nations are usually curious about the
unknown and different. They are more infor-
mal, willing to accept dissent within a group,
and open to change.
It is important to distinguish the differ-
ences between risk avoidance and uncertainty
avoidance. A person from a high uncertainty
avoidance culture may be quite willing to
take familiar risks or even new risks in order
Even within low-context
cultures, intimate con-
versations are usually
highly contextual; words
and phrases may be
significantly shortened
or abbreviated—just a
look may be enough for
understanding.
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

C H A P T E R 3 6 1
to minimize the ambiguity of a situation. But
in general, risks that involve change and dif-in general, risks that involve change and dif-in general, risks that involve change and dif
ference are difficult for people with strong
uncertainty avoidance; this is especially a
concern when changes threaten acceptance
by the group. For example, researchers suggest
African American women may resist certain
preparations or seasonings if family members
object or if the foods might undermine eth-
nic identity. Furthermore, weight loss may be
avoided if being thin means the potential loss
of a peer group that values a larger figure.5
Working with family or peers in a group
setting to effect dietary change may be more
successful for persons with a low tolerance for
uncertainty, especially when the positive value
of change is accepted and group consumption
patterns are modified.
Power, Authority, and Status
The perception of power, or power distance,
can strongly influence communication pat-
terns. In low-context cultures, where individ-
uality is respected, power or status is usually
attributed to the role or job that a person ful-
fills. Power distance is small. People are seen
as equals, differentiated by their accomplish-
ments. It is common for an individual to ques-
tion directions or instructions; the belief is that
a person must understand why before a task
can be completed. A client may desire a full
explanation of a condition and expected out-
comes before undertaking a specific therapy.
In many high-context cultures, where group
identification is esteemed, superiors are seen
as fundamentally different from subordinates.
Authority is rarely questioned. For example, a
health care provider counseling an Ethiopian
patient with type 2 diabetes may believe that
a culturally sensitive approach is to ask him
about his perceptions of the disease. What does
he call it? How does he think it can be cured?
Unknown to the provider, the Ethiopian man
has a large power distance, and he assumes
that the provider is the expert. Why would she
ask such questions of him? Doesn’t she know
what she is doing? He expects her to provide
all the answers, with little participation from
him. He may even become uncooperative or
fail to return for a follow-up visit because he
questions her expertise.
Although there is usually some combina-
tion of both small and large power distance
tendencies in a culture, one tendency will pre-
dominate. Some countries with small power
distance include Austria, Canada, Denmark,
Germany, Great Britain, Ireland, Israel, the
Netherlands, New Zealand, Sweden, and the
United States. Those with larger power dis-
tance include most African, Asian, Latino, and
Middle Eastern cultures, including (but not
exclusively) Egypt, Ethiopia, Ghana, Guate-
mala, India, Malaysia, Nigeria, Panama, Saudi
Arabia, and Venezuela. Client empowerment,
particularly in setting goals and objectives,
may be resisted by people from groups who
come from cultures with a larger power dis-
tance; maximum personal responsibility may
be preferred by people from groups with a
smaller power distance.
Several cultures are gender oriented as
well. In masculine cultures, power is highly
valued. Some, such as Germany, Hong Kong,
and the United States, are considered mas-
culine due to their aggressive, task-oriented,
materialistic culture. Others, such as Italy,
Japan, Mexico, and the Philippines, are char-
acterized as masculine because sex roles are
strongly differentiated. Men are accorded
more authority in masculine societies. In more
feminine cultures, quality of life is important;
men and women share more equally in the
power structure. More feminine countries
can be task oriented and materialistic, such
as Denmark, the Netherlands, Norway, and
Sweden; but hard work and good citizenship
are seen as benefiting the whole society, not
a hierarchy of superiors within an organiza-
tion or nation. Workplace relationships and
an obligation to others are characteristically
emphasized. Nearly all other nations com-
bine masculine and feminine power qualities.
Strong gender orientation can cause conflict.
A health care team, for instance, may include
several experts, often both women and men.
An Italian American patient might show lit-
tle respect for the female members and may
ignore their directions unless restated by one
of the male practitioners, regardless of his
area of expertise. Even women from mascu-
line societies may find it difficult to accept
the authority of a female provider. Generally,
The Inuit conception of
time is governed by the
tides—one set of tasks
is done when the tide is
out, another when the
tide comes in.
The Arabs say, “Bukra
insha Allah,” which
means, “Tomorrow, if
God wills.”
To many Chinese, the
gift of a clock means the
same as saying, “I wish
you were dead.” Each
tick is perceived as a
reminder of mortality.
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

6 2 I N T E R C U L T U R A L C O M M U N I C A T I O N
masculine-oriented U.S. health care practitio-
ners can communicate more successfully with
most ethnic clients by using a less assertive,
less autocratic approach that includes com-
promise and consensus.
Time Perception
Being on time, sticking to a schedule, and not
taking too much of a person’s time are valued
concepts in the United States, but these values
are unimportant in societies where the idea of
time is less structured. Low-context cultures
tend to be monochronistic, meaning that they
are interested in completing one thing before
progressing to the next. Monochronistic soci-
eties are well suited to industrialized accom-
plishments. Polychronistic societies are often
found in high-context cultures. Many tasks
may be pursued simultaneously, but not to the
exclusion of personal relationships. Courtesy
and kindness are more important than dead-
lines in polychronistic groups.2 Exceptions
occur, however. The French have a relatively
low-context culture but are polychronistic;
the Japanese can become monochronistic
when conducting business transactions with
Americans.
People who are single-minded often find
working with those performing multiple tasks
frustrating. Monochronistic persons may see
polychronistic behaviors, such as interrupting
a face-to-face conversation for a phone call or
being late for an appointment, as rude or con-
temptuous. Yet no disrespect is intended, nor
is it believed that polychronistic persons are
less productive than monochronistic people.
In fact, multitasking, the ability to do many
things simultaneously, is valued in many orga-
nizations today.
Nonverbal Communication
High-context cultures place great emphasis
on nonverbal communication in the belief
that body language reveals more about what
a person is thinking and feeling than words
do. Yet customs about touching, gestures, eye
contact, and spatial relationships vary tre-
mendously among cultures, independent of
low- or high-context communication style. As
discussed previously, such nonverbal behavior
can reinforce the content of the verbal mes-
sage being sent, or it can contradict the words
and confuse the receiver. Successful intercul-
tural communication depends on consistent
verbal and nonverbal messages. During per-
sonal and group interactions, persons move
together in a synchronized manner. Barely
detectable motions, such as the tilt of the head
or the blink of an eye, are imitated when peo-
ple are in sync and communicating effectively.
The ways in which a person moves, however,
are usually cultural and often unconscious.
Although body language is closely linked to
ethnicity, most people believe that the way
they move through the world is universal.
Misinterpretations of nonverbal communi-
cation subtleties are common and often inad-
vertent. More than 7,000 different gestures
have been identified, and meaning is easily
misunderstood when awareness of differences
is limited.6
Touching
Touching includes handshakes, hugging, kiss-
ing, placing a hand on the arm or shoulder,
and even unintentional bumping. In China,
for example, touching between strangers, even
handshaking if one person is male and the
other female, is uncommon in public. Ortho-
dox Jewish men and women are prohibited
from touching unless they are relatives or are
married. To Latinos, touching is an expected
and necessary element of every relationship.
The abr az o, a hug with mutual back patting,
is a common greeting. Touching norms fre-
quently vary according to attributes such as
gender, age, or even physical condition. In the
United States, it is acceptable for an adult to
pat the head of a child, but questionable with
another adult. Women may kiss each other,
men and women may kiss, but men may not
publicly kiss other men. It is admirable to
take the arm of an elderly person crossing the
street but rude to do so for a healthy young
adult.7
Cultures in which touching is mostly
avoided include those of the United States,
Canada, Great Britain, Scandinavia, Germany,
the Balkans, Japan, and Korea. Those in which
touching is expected include the Middle East
and Greece, Latin America, Italy, Spain,
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

C H A P T E R 3 6 3
agreement and nod up and down to express
disagreement. Puerto Ricans may smile in
conjunction with other facial expressions to
mean “please,” “thank you,” “excuse me,” or
other phrases. The Vietnamese may smile
when displeased. In India, smiles are used
mostly between intimates; an Asian Indian
client may not know what to make of a health
care provider who smiles in a friendly fashion.
Good posture is an important sign of
respect in nearly all cultures. Slouching or
putting one’s feet up on the desk are generally
recognized as impolite. In many societies, the
feet are considered the lowest and dirtiest part
of the body, so it is rude to point the toe at a
person when one’s legs are crossed or to show
the soles of one’s shoes.
Eye Contact
The subtlest nonverbal movements involve
the eyes. Rules regarding eye contact are usu-
ally complex, varying according to issues such
as social status, gender, and distance apart.
Most Americans consider eye contact indica-
tive of honesty and openness, yet staring is
thought to be rude. To Germans, direct eye
contact is an indication of attentiveness. Afri-
can Americans may be uncomfortable with
prolonged eye contact, but may also find rapid
aversion insulting. In general, blacks tend to
look at a person’s eyes when speaking and look
away when listening. To Filipinos, direct eye
contact is an expression of sexual interest or
aggression. Among Native Americans, direct
Portugal, and Russia. Cultures that fall in
between are those of China, France, Ireland,
and India, as well as those in Africa, Southeast
Asia, and the Pacific Islands. Health care pro-
fessionals should take careful note of cultural
touching behaviors. Vigorous handshaking
is often considered aggressive behavior, and
a reassuring hand on the shoulder may be
insulting.6 Of special mention are attitudes
about the head. Many cultures consider the
head sacred, and an absent-minded pat or
playful cuff to the chin may be exceptionally
offensive. Conversely, persons from cultures
in which frequent touching is the norm may
be insulted if someone is reluctant to hug or
kiss, or they may be unaware of legal issues
regarding inappropriate touching in the
United States.
Gesture, Facial Expression, and Posture
Gestures include obvious movements such as
waving hello or goodbye or standing to indi-
cate respect when a person enters the room, as
well as more indirect motions such as handing
an item to a person or nodding the head in
acknowledgment. Facial expression includes
deliberate looks of attention or questioning
and unintentional wincing or grimacing. Even
smiling has specific cultural connotations.
Confusion occurs when movements have
significantly different meanings to different
people. Crossed arms are often interpreted
as a sign of hostility in the United States, yet
do not have similar negative associations
in the Middle East, where it is a common
stance while talking. The thumbs-up gesture
is obscene in Afghanistan, Australia, Nige-
ria, and many Middle Eastern nations. The
crooked-finger motion used in the United
States to beckon someone is considered lewd
in Japan; is used to call animals in Croatia,
Malaysia, Serbia, and Vietnam; and is used to
summon prostitutes in Australia and Indone-
sia. To many Southeast Asians, it is an insolent
or threatening gesture.7,8
Asians find it difficult to directly disagree
with a speaker and may tilt their chins quickly
upward to indicate “no” in what appears to
Americans to be an affirmative nod. Some
Asian Indians, Greeks, Turks, and Iranians
shake their heads back and forth to show
▼ Touching norms fre-
quently vary according to
attributes such as ethnicity,
gender, age, or physical
condition.
M
ic
ha
el
N
ew
m
an
/P
ho
to
Ed
it
Anthropologists speculate
that the handshake, the
hug, and the bow with
hands pressed together
all originated to demon-
strate that a person was
not carrying weapons.
In Japan, the small bow
used in greetings and
departures is a sign of
respect and humility.
The inferior person in
the relationship always
bows lower and longer
than the person in the
superior position.
Many Asians completely
avoid touching strangers,
even in transitory inter-
actions, such as returning
change after a purchase.
This can be offensive to
persons who consider
physical contact a sign
of acceptance, such as
African Americans and
Latinos.
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

6 4 I N T E R C U L T U R A L C O M M U N I C A T I O N
eye contact is considered rude, and averted
eyes do not necessarily reflect disinterest.
When Asians and Latinos avoid eye contact, it
is a sign of respect. Middle Easterners believe
that the minute motions of the eyes and pupils
are the most reliable indication of how a per-
son is reacting in any situation.7
Spatial Relationships
Each person defines his or her own space—
the surrounding area reserved for the indi-
vidual. Acute discomfort can occur when
another person stands or sits within the space
identified as inviolate. Middle Easterners pre-
fer to be no more than two feet from whom-
ever they are communicating with so that they
can observe their eyes. Latinos enjoy personal
closeness with friends and acquaintances.
African Americans are likely to be offended
if a person moves back or tries to increase the
distance between them. Intercultural com-
munication is most successful when spatial
preferences are flexible.
In addition to distance, the way a person
is positioned affects communication in some
cultures. It is considered rude in Samoan and
Tongan societies, for instance, to speak to a
person unless the parties are positioned at
equal levels, for example, both sitting or both
standing.
Role of Communication
in Health Care
Health care providers in the United States take
pride in their technical expertise and mastery
of knowledge. They spend years understand-
ing biochemical and physiological processes,
laboratory assessments, diagnostic data, and
therapeutic strategies; yet little of that time is
devoted to how valuable information is effec-
tively communicated to the client or members
of the health care team. Skills are needed for
successful communication with these and
other participants, such as extended family
members or traditional health practitioners,
despite possible differences in language, eth-
nicity, religious affiliation, gender, age, educa-
tional background, occupation, health beliefs,
or other cultural factors.
Words are the primary tool of the clinician
following diagnosis. Whereas the surgeon
depends on the scalpel, most other providers
rely on language to inform and guide patients
in the treatment and lifestyle changes neces-
sary to maintain or improve health.9 The sur-
geon has significant control within the surgical
setting; in most cases the patient is not even
conscious. In contrast, the clinician interacts
directly with a patient who has independent,
sometimes contradictory, ideas about health,
illness, and treatment. The provider can con-
trol only her or his side of the conversation;
if the words are ineffective, the client may
reject recommended medications or thera-
pies. Although the actions of the surgeon are
generally limited to the patient, the advice of
the health care provider often impacts not
only the patient, but also the patient’s family.
Dietary modifications in particular may have
long-term implications; if cultural food habits
are changed, the new ways of eating may be
passed on for generations.
Interaction between
Provider and Client
In the time-pressured and cost-constrained
setting of health care delivery, object messages
are more common than personal messages,
and content is considered more relevant than
the relationship. Typically, the health care
professional relies on the client to provide
accurate, detailed information about his or
her medical history and current symptoms so
that the appropriate diagnosis and treatment
can be determined. The client depends on the
practitioner to explain any medical condi-
tion in terms that are understandable and to
describe treatment strategies and expectations
clearly. This basic conversation is repeated
between providers and their clients daily; it is
the essence of clinical health care. In practice,
however, this common interaction between
provider and client greatly underestimates
the complexity of intercultural communica-
tion. Confidence and caring that is established
between health care providers and patients
can also contribute to the results of the overall
health outcome.10
Numerous barriers to the sharing and
understanding of knowledge can prevent
The one-finger salute is
considered an insult in
many cultures. This ges-
ture dates back to Roman
times, when it was called
digitus impudicus (the
“impudent finger”).
The Japanese demon-
strate attentiveness by
closing their eyes and
nodding.
Koreans say, “A man
who smiles a lot is not
a real man.”
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

C H A P T E R 3 6 5
Misunderstandings of meaning are
common.
The results of ineffective communication
in health care can be serious. Noncompliance
issues are among the most important for the
clinician.
Patients may reject recommendations
or fail to return for follow-up appoint-
ments because they are dissatisfied with
their relationship with their health care
provider.12,19,20 Patients with diabetes who
perceived discriminatory behavior from
their health provider due to race, age, socio-
economic status, or gender suffered more
symptoms and had higher levels of hemo-
globin A1C (a blood test for three-month
average sugar levels) than other patients.21
Conversely, patients who received treatment
by health professionals in accordance with
their desired care reported significantly bet-
ter dietary management of their diabetes in
another study.22 Patients often report better
outcomes with traditional healers than with
biomedical practitioners because there is
more time spent on explanation and under-
standing of the condition.23 Development
of the interpersonal relationship with the
practitioner is crucial to a patient’s under-
standing and accepting treatment strategies,
particularly if recommendations conflict
with cultural perceptions regarding health
and illness.24
successful communication in the health care
setting. For example, a client may be fearful
or in pain when seeking help, more focused
on immediate discomfort than on convers-
ing clearly with the provider. During times
of stress, a client is also more likely to use
her or his mother tongue than English if it
is a second language.11 The provider often
assumes the role of the expert, leaving little
room for participation of the client as the
authority on what he or she is experiencing
physically or emotionally.12,13 The provider
may rely on medical jargon because it is dif-may rely on medical jargon because it is dif-may rely on medical jargon because it is dif
ficult to interpret many terms without exten-
sive explanations or oversimplification.14,15
A provider may be most concerned with
the technical aspects of a health problem
and inadvertently ignore the interpersonal
aspects of the relationship with the patient or
may be too rushed to express care and com-
passion.1,16 Furthermore, cultural commu-
nication customs may interfere directly with
the trust and respect necessary for effective
health care.17
Researchers in effective communication
have identified five ways in which misun-
derstandings occur that are applicable to the
health care setting:3,18
1. A provider can never fully know a
client’s thoughts, attitudes, and emo-
tions, especially when the client is from
a different cultural background.
2. A provider must depend on verbal and
nonverbal signals from the client to
learn what the client believes about
health and illness, and these signals
may be ambiguous.
3. A provider uses his or her own cultural
understanding of communication to
interpret verbal and nonverbal signals
from the client, which may be inad-
equate for accurate deciphering of
meaning in another cultural context.
4. A provider’s state of mind at any given
time may bias interpretation of a
client’s behavior.
5. There is no correlation between what a
provider believes are correct interpreta-
tions of a client’s signals or behaviors
and the accuracy of the provider’s belief.
▲ The client depends on the
practitioner to explain any
medical condition in terms
that are understandable and
to describe treatment strate-
gies and expectations clearly.
A
le
xa
nd
er
R
at
hs
/S
hu
tt
er
st
oc
k.
co
m
Participatory research
on a Lakota Indian res-
ervation reported that
intercultural connections
were directly related
to the investment of
time and commitment
to establishing and
pursuing meaningful
dialogue.39
Health care providers
and consumers depend
on their abilities to com-
municate sensitively
and effectively with
one another to relieve
discomfort, save lives,
and promote health.
Ineffective communica-
tion in health care can,
and often does, result in
unnecessary pain, suffer-
ing, and death (p. 8).1
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

6 6 I N T E R C U L T U R A L C O M M U N I C A T I O N
Responsibilities of the
Health Care Provider
Although communication requires the active
participation of at least two persons, the
health care provider has certain responsibili-
ties in interactions with clients. The provider
often assumes the superordinate position in
the relationship because she is accorded that
status by the client or because the client is dis-
tracted by pain or discomfort. In that role, it
is the practitioner’s obligation to understand
what is said by the client and to provide the
client with the information needed to par-
ticipate in treatment. This may require that
the clinician be familiar with cultural norms,
listen carefully and seriously to the client
(observing personal cues), and take action
based on what is said by the client. Caring
and considered communication can empower
the client within the relationship and improve
treatment efficacy.1,7,25
It is believed intercultural communica-
tion awareness occurs in four stages. First is
unconscious incompetence, when a speaker
misunderstands communication behaviors
but doesn’t even know misinterpretation
has occurred. The second stage is conscious
incompetence, when a speaker is aware of
misunderstandings but makes no effort to
correct them. Third is conscious competence,
when a speaker considers his or her own
cultural communication characteristics and
makes modifications as needed to prevent
misinterpretations. The final stage is uncon-
scious competence, when a speaker is skilled
in intercultural communication practices and
no longer needs to think about them during
conversation.26
Successful Intercultural
Communication
Effective intercultural communication begins
when the speaker is mindful of his or her own
communication behaviors and is sensitive to
misinterpretations that may result from them.
Practitioner knowledge about a culture does
not necessarily facilitate effective care without
awareness of cultural differences and personal
biases.27,28,36 A willingness to listen carefully
to a client without assumptions or bias and to
recognize that the client is the expert when it
comes to information about his or her expe-
rience is requisite to successful health care
interactions.
The mnemonic CRASH has been sug-
gested as a useful way to remember the com-
ponents to cultural competency that underlie
effective care: C—consider Culture in all
patient–practitioner interactions; R—show
Respect and avoid gratuitous familiarity and
affection; A—Assess/Affirm intracultural dif-affection; A—Assess/Affirm intracultural dif-affection; A—Assess/Affirm intracultural dif
ferences due to language skills, acculturation,
and other factors, recognizing each individual
as an expert on his or her health beliefs and
practices; S—be Sensitive to issues that may
be offensive or interfere with trust in the rela-
tionship, and show Self-awareness regarding
personal biases that may cause miscommuni-
cation; and H—demonstrate Humility, apolo-
gizing quickly and accepting responsibility for
communication missteps.29 With CRASH in
mind, the health professional can begin mas-
tery of the communication skills needed to
promote understanding and acceptance from
clients of many cultural backgrounds.
Intercultural
Communication Skills
Reading about culturally based communica-
tion differences is an intellectual undertaking.
Actually applying intercultural communi-
cation concepts is much more challenging.
Successful face-to-face interactions require
understanding cultural communication
expectations and being familiar with the dis-
tinctive style of the other person. Often there
is contradictory information to assimilate.
The Japanese, for example, come from a cul-
ture that is male dominated, assertive, and
achievement oriented, yet also high in uncer-
tainty avoidance, emphasizing consensus and
ritualistic communication practices. Should
a precise or implied approach be used when
speaking with someone of Japanese heritage?
Clearly, much depends on the circumstances
surrounding the conversation and the particu-
lar people involved. Numerous books, articles,
and courses on health care communication are
available to supplement this brief overview.
Being involved with
decision making was
significantly associated
with adherence to medi-
cal advice for whites,
whereas being treated
with dignity improved
adherence for racial/
ethnic minorities in
one survey.91
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

C H A P T E R 3 6 7
Name Traditions
Determine how clients prefer to be addressed.
Americans are among the most informal
worldwide, frequently calling strangers and
acquaintances by their given names. Nearly
all other cultures expect a more respectful
approach. This can include the use of title
or prefixes (Mr., Mrs., Miss, Ms., Dr., Sir,
Madam, etc.), use of surname, and proper
pronunciation. Never use “Dear,” “Honey,”
“Sweetie,” “Fella,” “Son,” or other endearments
in place of proper names.
Name order is often different from the
United States pattern of title, given name,
middle name, and surname. In many Latin
American countries a married woman uses
her given name and her maiden surname,
followed by de (“of ”) and her husband’s fam-
ily surname. For instance, a married woman
named Ana would use her maiden name of
Lopez followed by de plus her husband’s fam-
ily surname of Perez. She would then use the
name Ana Lopez de Perez. Children typically
use their given name, their father’s surname,
and then their mother’s family surname. This
causes confusion because while most Latino
men prefer to be addressed by their father’s
family surname, it is often the name that
sequentially is placed on the “middle name”
line of forms. Persons reading the form often
assume the mother’s family surname is a
Latino’s last name.30
Middle Easterners use their title, given
name, and surname. They may also use bin
(for men) or bint (for women), meaning “of ” bint (for women), meaning “of ” bint
a place or “son/daughter of.” This is not to be
confused with the given name Ben (although it
is pronounced similarly). For example, Abdel
Al-Fakeeh bin Saud literally means Abdel son
of Saud. If the grandparent of a Middle East-
erner is well known, his or her last name may
be added to the name order, following the
surname, with another bin. The Vietnamese,
Hmong, and Cambodians place the surname
first, followed by the given name (although
many make the switch to the American name
order with acculturation). The Chinese and
Koreans use a similar system, including a
generation name following the family name
and before the given name (the generation
name is sometimes hyphenated with the given
name, or the two names are run together). For
example, a man whose name is Yung and has
a generation name of Tsing and a surname of
Wai would be referred to as Yung Tsingwai.
Married women in China and Korea do not
take their husband’s surname. In Japan, the
surname is followed by san, meaning “Mr.” or
“Ms.” Given names are only used among close
friends and intimates. Hindus in India do
not traditionally use surnames. A man goes
by his given name, preceded by the initial of
his father’s given name. A woman follows the
same pattern, using her father’s initial until
marriage, at which time she uses her given
name, followed by her husband’s given name.
Muslims in India use the Middle Eastern
order, and Christian Indians use the U.S. pat-
tern.31 There are numerous other name tra-
ditions and preferences of address. When in
doubt, it is best to ask.
Appropriate Language
Use unambiguous language when work-
ing with clients who are limited in English.
Choose common terms (not necessarily
simple words), avoiding those with multiple
meanings, such as “to address,” which may
mean to talk to someone, to give a speech, to
send an item, or to consider an issue. Vague
verbs, such as get, mak e, and do, may cause
confusion. Use specific verbs, such as pur –
c h ase, c ompl ete, or pr epar e, when directing
clients.
Slang and idioms may have no meaning
in another culture. Many new English speak-
ers interpret words literally. H ow ’ s it going?
makes no sense if one does not understand
the meaning of it in this context.it in this context.it 30 Sports
analogies, including sc or e and str ik e out, are
indecipherable if the game is unfamiliar.
Phrases that suggest a mental picture, such
as r un th at by me or easy as pie or dodge
a bul l et, are barriers to comprehension.32
Medical jargon is also likely to interfere with
communication.15 Some persons with lim-
ited English skills are embarrassed to admit
that they do not understand what is being
said or to ask that something be repeated.
When comprehension is critical, respectfully
request clients to repeat instructions in their
own words, or ask that they demonstrate
One researcher reports
that the use of cultural
food potlucks among
hospital staff members
has facilitated cultural
understanding among
employees of diverse
backgrounds.92
Studies suggest that the
provider–client relation-
ship improves when the
client is also trained in
communication skills.
A meeting with coaches
to guide clients in
formulating appropri-
ate questions and to
practice negotiation
techniques before an
appointment has been
successful in some health
care settings.41
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

6 8 I N T E R C U L T U R A L C O M M U N I C A T I O N
a skill so that misunderstandings can be
corrected.
Avoid asking questions that can be
answered with a simple yes or no. For exam-
ple, “Do you understand?” will often prompt
a positive response in practitioner–client
conversations, regardless of comprehension
level. It is better to ask leading questions—for
example, “What confuses you?” or “Tell me
what you don’t understand.”30 In some Asian
cultures it is impossible to say no to a request.
The Japanese, for instance, have developed
many ways to avoid a negative response, such
as answering maybe, countering or criticizing
the question, issuing an apology, remaining
silent, or leaving the room.33
The direct communication style of major-
ity Americans also assumes that each person
is saying what he or she means. This can cause
difficulties when conversing with persons for
whom negotiation is standard practice. For
example, a practitioner offers coffee or tea
to an Iranian client. She refuses, so he sits
down and begins the discussion. The client
is upset because she was being polite and had
expected the health care professional to ask
again, and then insist that she have something
to drink.
Typically, Americans not only believe what
is said initially; they also consider answers
absolute. In some cultures it is acceptable
to make a commitment, then decide later to
change the terms of the agreement or decline
altogether. People from these groups assume
that one cannot predict intervening events
or future needs. Further, there can be differ-
ences in what is accepted as “truth.” In the
United States, truth is considered objective,
supported by facts. In many other cultures,
truth is subjective, often based on emo-
tions.30,34 A Filipino American client may
report to the practitioner that she has not lost
any weight on her low-calorie diet this week.
But when she gets on the scale, she weighs
three pounds less. Asked about it, the client
explains she is frustrated because she gained
one-half a pound yesterday and does not feel
she is progressing. Understanding that the
definitions of truth vary culturally can help
explain some miscommunication.
Use of an Interpreter
Language can be the most difficult of all inter-
cultural communication barriers to overcome.
It is estimated that nearly 30 percent of immi-
grants living in the United States have poor
English skills.35 Many are recent immigrants,
and others view their stay in the United States
as temporary and therefore see no need to
learn English.10
According to Title VI of the Civil Rights
Act of 1964, all persons in the United States
are guaranteed equal access to health care
services regardless of national origin, which
has been interpreted to mean that there can
be no discrimination based on language.
Programs not offering access to persons with
limited English skills may lose federal fund-
ing, including Medicare and Medicaid reim-
bursements. However, the regulation is vague
and difficult to enforce. Compliance is mostly
complaint driven. Most medical institutions
have professional interpreters, and in areas
where interpreters are unavailable, telephone
interpretation services may be an alternative.
Unfortunately, it is common for health care
providers to resort to nonprofessional inter-
preters, such as the client’s family or friends,
to facilitate communication. The inadequa-
cies of such interpretations are numerous.
Patients may be reluctant or embarrassed to
discuss certain conditions in front of their
relatives, or family members may decide
that the information provided by the prac-
titioner isn’t really needed by the patient, so
they do not interpret accurately. Untrained
interpreters are often unfamiliar with medi-
cal terminology. One study indicated that
23 to 52 percent of phrases were misinter-
preted by nonprofessionals; for example,
l ax ativ e was the term used for “diarrhea,” and
sw el l ing was confused with “getting fat.” The sw el l ing was confused with “getting fat.” The sw el l ing
interpreter tended to ignore questions about
bodily functions altogether.34 Even totally
bilingual individuals may not be familiar with
all dialects; the terms used in one part of a
country may be very different from those used
in another region. Ethical issues arise when
children are used as interpreters. Children
may be frightened of medical procedures, and
dependence on a child for communication
A professional interpreter
reports that unintended
results due to limited
language skills can be
confusing, insulting, or
even comic. A friendly
physician meant to
ask one of his clients,
“Cuantos años tiene
usted?” (“How old are
you?”) He mispro-
nounced the word as
anos, however, saying,
“How many anuses do
you have?”11
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

C H A P T E R 3 6 9
can invert family dynamics, causing unneces-
sary intergenerational stress.
Issues regarding informed consent, patient
safety, and noncompliance occur when inter-
pretations are inadequate. Some health care
providers attempt to use their personal skills
in a foreign language, believing it is better to
try to communicate directly than to lose some
control through interpreters. Although con-
versing in the language of the client is often
greatly appreciated, it is important for the
provider not to over-estimate fluency. Obtain-
ing the services of a professional interpreter
is warranted in all but emergency situations
when a delay could be life threatening.10
When using an interpreter, the practitio-
ner should speak directly to the client, and
then watch the client rather than the inter-
preter during interpretation. If the nonverbal
response doesn’t fit the comment, confirma-
tion with the interpreter can ensure that the
meaning is clear. Sometimes an interpreter
may appear to answer for the patient; the
interpreter may be very familiar with the
patient’s history based on previous interpre-
tations for other health providers. Conversely,
it may take an interpreter considerably longer
to interpret a comment than it takes to say it
in English, in part because certain cultural
interpretations and explanations may be nec-
essary.37 The technique of back interpreta-
tion, meaning that instructions are repeated
back to the clinician, can prevent miscom-
munication and open the conversation to any
further questions by the client. Providers can
increase effective communication through an
interpreter by using a positive tone of voice
and avoiding a judgmental or condescend-
ing attitude. Short, direct phrases—avoiding
metaphors or colloquialisms—and repeating
important information more than once can
improve client understanding.
Intercultural Counseling
Practitioner attitude toward outcomes is per-
haps the most important element of success-
ful intercultural counseling. A health care
provider cannot be open minded if objectives
are completely preplanned. Participation in
a relaxed, give-and-take exchange can reveal
issues of primary concern to the client. An
invitation to share stories, for example, may
address concerns that cannot be expressed
directly. Mutual commitment to shared goals
can be developed by attentive listening to cli-
ent needs and learning about client expecta-
tions.25,38,39 This collaboration in defining and
achieving outcomes is the difference between
advocacy and manipulation. Effective inter-
cultural counseling is an ongoing process of
practice and refinement, requiring an open
attitude, cultural knowledge, and intercultural
communication skills.39,40
Pre-Counseling Preparation
Researchers have made many recommenda-
tions regarding effective intercultural com-
munication. The basic competencies needed
by practitioners include (1) information
transfer—the verbal and nonverbal ability
to convey object messages; (2) relationship
development and maintenance—the ability
to create rapport, establish trust, and dem-
onstrate empathy and respect; and (3) com-
pliance gaining—the ability to obtain client
cooperation (Table 3.1).41
Practically speaking, a health care provider
cannot be expected to become an expert in
intercultural communication or to fully
understand the communication modes best
suited to each of the many clients from dif-suited to each of the many clients from dif-suited to each of the many clients from dif
ferent cultural heritages. Most patients liv-
ing in the United States do not expect to be
treated as they would in their homeland. But
familiarity with intercultural communication
attitudes, knowledge, and skills can greatly
enhance health care efficacy.
The In-Depth Interview
The in-depth interview is essential in inter-
cultural counseling to determine many of the
iceberg issues that may affect communica-
tion and cooperation in health care, includ-
ing ethnicity, age, degree of acculturation or
bicultural adaptation, socioeconomic status,
health condition, religious affiliation, edu-
cational background, group membership,
sexual orientation, or political affiliation.
However, a client may believe that personal
questions about his background are invasive
Successful communica-
tion in the interpreter–
client relationship is
also dependent on
intercultural skills. It has
been suggested that
translators who build
rapport and trust are
more effective than those
who are emotionally
detached.75
A study on patient partic-
ipation in decision mak-
ing found that 96 percent
of clients want care
choices offered to them
and want their opinions
sought. However, 52 per-
cent preferred to leave
the final decision to their
physician. Well-educated
white women were most
likely to want shared
decision making; African
Americans and Hispanics
were least likely.93
Health care providers
note that age affects
intercultural commu-
nication because older
minority members are
often socially isolated
and may be unwilling to
communicate with health
care providers from a
different culture.94
Demographic data on
practitioners show a dis-
proportionate number of
whites (among dietitians,
81.8 percent are non-
Hispanic whites), sug-
gesting that intercultural
counseling will become
increasingly prevalent
until greater diversity in
the health care profes-
sions is achieved.95
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

7 0 I N T E R C U L T U R A L C O M M U N I C A T I O N
or unnecessary, especially if he comes from
a high-context culture. Direct inquiry may
even suggest to the client that the practitioner
is incompetent because she cannot determine
the problem through indirect methods.
One culturally sensitive approach is the
respondent-driven interview, in which simple,
open-ended questions by the provider initi-
ate conversation.12 The client can express her
understanding and experience in her own
words. The practitioner exerts little control
over the flow of the response, yet elicits data
through careful prompting.23,42 Useful ques-
tions to ask during the conversation include
these:
• What do you call your problem? What
name do you give it?
• What do you think caused it?
• Why did it start when it did?
• What does your sickness do to your
body? How does it work?
• Will you get better soon, or will it take a
long time?
• What do you fear about your sickness?
• What problems has your sickness caused
for you personally? For your family? At
work?
• What kind of treatment will work for
your sickness? What results do you expect
from treatment?
• What home remedies are common for
this sickness? Have you used these home
remedies?
Furthermore, information should be
requested about traditional healers:
• How would a healer treat your sickness?
Are you using that treatment?
For nutritional assessment within the con-
text of the client’s condition, questions about
food habits are appropriate:
• Can what you eat help cure your sickness
or make it worse?
• Do you eat certain foods to keep healthy?
To make you strong?
TA B L E 3.1 Checklist for Intercultural Nutrition Counseling
Attitudes Knowledge Skills
• I am open-minded and willing to be a
learner instead of the expert when it
comes to the client’s life experiences
and ways of knowing.
• I am sincerely interested in different
cultural perspectives on reality, and I
can respect cultural worldviews other
than my own.
• I can tolerate the ambiguities of
intercultural communication.
• I can accept that some interactions will
be uncomfortable or unfamiliar to me.
• I am patient; I attempt to understand
the ideas and feelings of the client.
• I understand that although some cultural
influences on communication are readily
apparent, others are hidden and require
development of a personal relationship
so that salient factors in communication
and compliance can be identified.
• I know that body language can provide
significant information about the
client’s concerns and feelings; the
relationship can improve or deteriorate
through nonverbal communication.
• I understand that modification of
culturally held beliefs and behaviors
can have significant, long-term effects
on the client and the client’s family.
Attempts to force change may result
in ineffective communication and
noncompliance by the client.
• I am familiar with cultural food habits of
my clients.
• I have learned about traditional health
beliefs and practices.
• I explain diet rationale in common
terms within the context of a client’s
worldview, including concepts
regarding the cause, prevention, and
treatment of illness; I set realistic goals
with the client.
• I emphasize the continuation of
positive cultural food habits and
recommend modification of only those
food habits that may be detrimental to
the client’s health. I avoid personal bias.
• I attempt to send nonverbal messages
consistent with my verbal messages.
• I engage in effective intercultural
communication with all participants
in the health care system to help
clients through illness and improve
health through supportive personal
relationships, through cooperation with
families, and through the gathering
and sharing of relevant data with other
health care professionals.
SOURCE: Adapted from Cassidy, C.M. 1994. Walk a mile in my shoes: Culturally sensitive food-habit research. Journal of the American Dietetic Association, 97, 1288–1292; Gudykunst, W.B., & Nishida, T. Journal of the American Dietetic Association, 97, 1288–1292; Gudykunst, W.B., & Nishida, T. Journal of the American Dietetic Association, 97
1994. Bridging Japanese/North American differences. Thousand Oaks, CA: Sage; Kavanagh, K.H., & Kennedy, P.H. 1992. Promoting cultural diversity: Strategies for health professionals. Newbury Park, CA: Sage;
Kreps, G.L., & Kunimoto, E.N. 1994. Effective communication in multicultural health care settings. Thousand Oaks, CA: Sage; Sanjur, D. 1995. Hispanic foodways, nutrition, and health. Boston: Allyn & Bacon.
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

C H A P T E R 3 7 1
• Do you avoid certain foods to prevent
sickness?
• Do you balance eating some foods with
other foods?
• Are there foods you will not eat? Why?
Learning about how a client understands
his illness, including expectations about how
the illness will progress, what the provider
should do, and what he has established as ther-
apeutic goals, allows the provider to compare
her own view of the illness and to resolve any
discrepancies that might interfere with care.
Demonstrating sincere interest in cultural
health beliefs through an open-ended con-
versation can elicit the information needed to
begin assessment and to determine the most
effective approaches for each individual.
Intercultural Nutrition
Assessment
Several difficulties in the collection and anal-
ysis of cultural health data have emerged in
recent years. Researchers have discovered that
standardized assessment tools can introduce
systematic bias into results or provide mis-
leading information when used with different
cultural populations.
Generalized approaches to the use of the
twenty-four-hour food recall, food frequency
forms, and nutrient databases can produce
large errors in assessment.12,43,44,45 Cultural
unfamiliarity with concepts, such as fiber;
terminology differences, such as using one
word for several foods or not having a name
for a certain category of food (e.g., there is no
American Indian word for “vegetables”), or
grouping foods by different categories (e.g., by
medicinal properties or status); lack of differ-
entiation between meals and snacks; checking
“phantom foods” (those not actually con-
sumed) when not enough traditional items are
available for selection; and translation mis-
takes (e.g., literal translations of food names,
use of a brand name for a generic item, or use
of the name for a traditional food for a similar
American item) are a few ways collected data
can be invalidated. Frequent consumption of
mixed dishes can result in omission of some
nutrient sources (as when rice is prepared
with dried peas or beans, yet reported as rice
by some Caribbean Islanders) and overesti-
mation or underestimation of intake due of
complications in portion-size estimates. Tre-
mendous variability in the amounts of food
eaten has been reported between individuals
and cultural groups.34 Nutritional variety may
be artificially reduced if the composition data
for a cultural food prepared in significantly
different ways among subgroups are used
without allowances for recipe modifications.
Using food composition data for similar foods
when specific listings on a cultural item are
unavailable can lead to intake miscalculations
if numerous substitutions are necessary.
Food lists derived from data on the U.S.
population as a whole may miss significant
dietary nutrient sources in subgroups. A study
comparing a generalized food frequency ques-
tionnaire with ethnic-specific tools developed
for African Americans, whites, and Mexican
Americans found improvement in assessing
total fat, vitamin A, and vitamin C intake
with the modified forms.46 Similar research
also reported a modest increase in nutrient
estimates for Hispanic, Chinese, and Japanese
respondents.47 A review of food frequency
questionnaires in minority populations, how-
ever, found that the number of published
examples was so few, and the methodologies
were so varied, that no conclusions regarding
how best to develop valid, reliable instruments
could be reported. Questions regarding how
extensive questionnaires should be (espe-
cially number of included foods), whether
food groupings need to be modified, and how
portion size should be standardized remain
unanswered.48
Other assessment tools may be question-
able in intercultural settings as well. A model
used to determine health attitudes among
whites was found unreliable when used with
Mexican Americans, even after operational
adjustments for cultural differences.49 Con-
tradictions were found, for example, between
self-administered and interviewer-directed
questionnaire responses; participants were
more likely to express disagreement about
an item when completed individually than
when asked about it by the interviewer. Cul-
tural attitudes regarding pleasing authorities
Research conducted
with African American
women found that an
interviewer-administered
food frequency question-
naire was more feasible,
and less burdensome
for staff and respon-
dents, than multiple
twenty-four-hour
dietary recalls.97
The USDA increased
the number of ethnic
and Native American/
Alaska Native foods in
the 2012 USDA National
Nutrient Database for
Composition of Foods.96
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

7 2 I N T E R C U L T U R A L C O M M U N I C A T I O N
The predictive value of waist-to-hip ratios
and body mass index (BMI) may vary in
some populations.57,58,59,60 Questions about
the standard BMI cutoff for over-weight and
obesity in Asians have been raised due to a
high risk for health problems at lower num-
bers.61 When percentage of body fat data were
used instead of BMI for calculating obesity in
African Americans and whites, the difference
in rates between women was cut in half (with
blacks still more at risk than whites), and the
gap for men was widened, with far more white
men identified as obese.62 Even physiologic
calculations, such as basal metabolic rate
equations, may differ culturally.63,64
The development of culturally specific
techniques and tools is a critical need in
nutritional assessment. For an individual cli-
ent, switching from a quantitative to a more
qualitative approach can establish trust and
cooperation in initial interviews. The twenty-
four-hour recall, for instance, can be con-
ducted in an open-ended manner, requesting
simply that all foods consumed the previous
day be remembered.12 This eliminates diffi-
culties with obtaining portion sizes or differ-
entiating meals. The dietitian does not need
to predetermine food items or categories. In
subsequent meetings more information, such
as frequency and amount of given items, can
be requested after an explanation on why the
information is needed.
When working with many clients of a
single cultural heritage, it may be useful to
prepare quantitative tools based on quali-
tative research. This approach is most suc-
cessful when done by an investigator already
familiar with the specific group’s food cul-
ture. A well-intentioned but culturally biased
open-ended question (for example, asking
a participant to list “any other foods eaten
weekly”) may not prompt the recall of foods
eaten seasonally, thus underestimating a par-
ticular nutrient. The burden of negotiating
two different cultural food systems should
be on the researcher, not the study partici-
pant.47,65 Detailed interviews with individuals
can provide information on appropriate lan-
guage, categories, concepts, and formatting of
the instruments helpful in culturally specific
nutritional assessment.
are believed to have influenced respondent
answers, calling into question the use of the
interview as a valid tool for gathering data
in this ethnic group. In another study on
low-literacy populations the opposite was
found; self-reported data on food frequency
questionnaires were found unreliable when
compared to comments made by respondents
during follow-up interviews.50,98
A review of acculturation scales and
indexes found that many were unsuited for
use in dietary interventions or nutrition edu-
cation programs.49 Single-item measures of
acculturation, including broad questions such
as “How long have you lived in the United
States?” and “What language do you speak at
home?” provide only introductory informa-
tion about a client and resulted in outcome
discrepancies in data collected on dietary
fat intake and acculturation in one study.51
Acculturation scales are more comprehensive
but also do not address questions regarding
food habit changes. In addition, acculturation
scales are typically validated on homogeneous
population samples, such as college students
or hospital patients, and may not be fully
applicable to a more diverse clientele. Food-
based assessments are more promising, but
they do not provide data on the psychological
or social aspects of acculturation and are usu-
ally limited to use with a single cultural group.
Furthermore, anthropometric measure-
ment tools are sometimes inappropriate
for certain populations. Height and weight
growth curves are particularly vulnerable to
misinterpretation due to cultural variation,
especially among Asian groups. Stature pre-
diction equations for whites were inaccurate
for Latinos52,53,54,55 and African Americans.56
Standardized height
and weight growth curves
have not been validated for
all ethnic groups and should
be applied cautiously with
cultural variation in mind. JH
er
sh
Ph
ot
o/
Sh
ut
te
rs
to
ck
.c
om▲

C H A P T E R 3 7 3
Monthly twenty-four-hour recalls of
small, representative samples are useful
in determining overall consumption pat-
terns, especially where seasonal variation
occurs.34 Focus groups have been found
effective in selecting food items to include
and quantification measures in the prepara-
tion of multicultural food frequency ques-
tionnaires.43,49 Guidance from the targeted
population is essential.49,65 Two questions
regarding the accuracy of data collection
are suggested: First, how do cultural per-
ceptions about food affect the way in which
clients report their intake? Second, how is
the report of intake affected by the client’s
relationship with the interviewer, the set-
ting, and the assessment tool? Answers to
these questions can suggest culturally sensi-
tive approaches and improve the validity of
collected data.13,29
Access to cultural foods composition data
and culturally specific anthropometric and
physiological measurements is more prob-
lematic. Requests for recipes can be used to
expand current databases, although this tech-
nique may be too time consuming to complete
with every client. Being mindful that data
analysis is often approximate and that stan-
dardized measurements may be questionable,
dietary modifications should be made care-
fully and cautiously with all clients from cul-
tural backgrounds other than the American
majority.
Intercultural Nutrition
Education
The biomedical paradigm emphasizes
behavioral change accomplished through
one-on-one work with an individual. How-
ever, many cultural groups prefer learning
about nutrition in settings with family mem-
bers or peers.66 For example, researchers
have found that while white adolescent girls
demonstrate poor outcomes when coun-
seled with their mothers, black adolescent
girls show significantly improved outcomes
when their mothers participate in weight-
loss sessions.67,68
Successful nutrition education strategies
for groups are as dependent on intercul-
tural communication skills as is nutrition
counseling with individuals. For example,
researchers have described how culture can
affect program outcomes in a group weight-
loss setting.69 Negative results are possible
at any phase of the process, from motiva-
tion and attendance to skill acquisition and
behavior change (see Figure 3.3). At each
point cultural influences may reinforce or
contradict the content and context of the
education messages conveyed by the health
care practitioner. When communication
conflict develops, an inexact period of time
exists when the client is willing to negotiate
toward resolution of the message. If dissat-
isfaction continues, a poor weight-loss out-
come results because the person (1) is never
motivated to sign up, (2) drops out of the
program before completion, (3) attends but
never learns skills, or (4) learns skills but
does not apply them in practice. Program
designers must do more than superficially
modify the program materials and the set-
ting to communicate effectively with a dif-ting to communicate effectively with a dif-ting to communicate effectively with a dif
ferent cultural group. Understanding the
cultural health beliefs, attitudes, and values
of a target audience; developing education
programs within the context of those per-
ceptions; and using culturally appropriate,
consistent verbal and nonverbal messages in
an accepted medium increase communica-
tion efficacy.
A comparison of food
composition tables in
nine European nations
exemplifies the difficulty
in obtaining accurate
nutrient data. Differences
in definitions, analysis
methods, and expres-
sion made it impossible
to compare local tables
with international data.66
Figure 3.3
Schematic illustration of
how cultural factors might
influence participation and
outcomes at various phases
of the program.
Cultural
Influence
Phase of
Process
Possible
Negative
Outcome
Tolerance for IneffectivenessNegotiation Space Negotiation Space
· Actual relevance
· Role models
· Cultural
acceptability
· Social
reinforcement
Behavior change;
weight change
Poor result
· Language
· Perceived
relevance
Learning
and skill
acquisition
Nonadherence
· Setting
· Interpersonal
component
Attendance
Drop out
· Body image
· Social
pressure
Motivation
Nonparticipation
©
C
en
ga
ge
L
ea
rn
in
g
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

7 4 I N T E R C U L T U R A L C O M M U N I C A T I O N
Culturally Relevant Program
Preparation
Although health education program models
typically advise a step-by-step process of plan-
ning and execution, the reality is that some
aspects of preparation and implementation
occur concurrently. A health educator may
begin planning with a general idea of goals for
a population group, but will probably modify
and refine objectives as more information
about the target audience is gathered. Ongo-
ing evaluation may suggest better message
formats or more suitable influence channels
as the effort proceeds. Effective programs are
often nonlinear, with each element in plan-
ning and implementation connected through
feedback and assessment into a continuous
improvement loop.
Targeting the Audience
Identification of the target audience in nutri-
tion education efforts is among the most
important steps in program planning. Learn-
ing about the cultural orientation of the group
is key; campaigns to change behaviors with-
out research are usually misdirected.70 What
appear to be significant needs to the health
educator may be considered unimportant or
too difficult to remedy by members of the tar-
get population.
Definitions of health differ widely among
cultures (see Chapter 2, “Traditional Health
Beliefs and Practices”). A common belief
is that illness is a matter of heredity, fate, or
punishment by God, or is due to supernatural
causes. In a study of health perceptions held
by hard-to-reach populations in the United
States, it was found that though individu-
als believed that lifestyle might impact acute
infection, there was almost no association
between diet or exercise and chronic dis-
ease; respondents had limited motivation to
improve health behaviors because they felt
they had little personal control over their
health.71 The role of the individual within the
group can also affect responsibility for health
maintenance; in some cultures, the extended
family is held accountable for the health of
each member.
Demographic information about the target
audience can guide program development.
Primary language should be identified, as well
as gender, average age, socioeconomic status,
educational attainment, religious affiliation,
and other iceberg factors in communication.
Assessment of acculturation or bicultural
adaptation is equally important. The more
culturally homogeneous the target popula-
tion, the more appropriate are the messages
that can be created.72,78 In many cases, the
larger, heterogeneous audience may be strati-
fied into smaller, segmented target groups that
share similar cultural beliefs and attitudes.
Involving members of the targeted audi-
ence in program planning is one of the best
ways to determine cultural orientation.73 Of
special note is the role of community leaders
or spokespersons in the process. Seeking the
respect, trust, and endorsement of influen-
tial persons within the target audience for a
particular nutrition education program can
open intercultural communication channels
otherwise limited to the formal interactions
reserved for strangers.39,74,75 The educa-
tor establishes a relationship with the group
through asking for permission to present the
health message to its members.
Setting Goals and Objectives
The next step in intercultural program plan-
ning is to define clear and realistic goals and
objectives within the cultural context of the
target audience. Even culturally sensitive edu-
cation messages do not necessarily translate
into sustained modification of food habits
without follow-up support, and overly ambi-
tious expectations are a common reason for
failure.76,77 Nevertheless, strategies emphasiz-
ing continuation of positive cultural dietary
patterns or portion control rather than elimi-
nation of certain foods are reportedly of inter-
est to African Americans, Asian Americans,
Latinos, and Native Americans, as well as
whites: One study found a barrier to eating
healthfully was that participants believed they
would have to give up their cultural heritage
and conform to the dominant culture.69,71,79
Programs coordinating objectives with cul-
tural beliefs about the role of food in health,
Content of the mes-
sage can be critical. For
example, one study on
the effects of public edu-
cation efforts to reduce
bulimic eating behaviors
revealed that some
women learned about
vomiting as a weight-
control method from the
campaign.99
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

C H A P T E R 3 7 5
such as balancing yin and yang foods in
Chinese meals, can reinforce dietary change.49
Consulting health care practitioners in the
targeted community can provide information
on local needs and concerns useful in defining
achievable goals and objectives.
Using Triangulation
An especially useful step in the program
design process is triangulation, a method of
confirming congruence between data col-
lected on the target audience and proposed
program goals and objectives (Figure 3.4).80
Triangulation means that information gath-
ered through one source or method is used
to confirm and extend information gathered
through other sources and methods. In addi-
tion to corroboration, triangulation can pro-
vide improved understanding of local issues
and perspectives.
In the triangulation pilot program, com-
munity nutritionists were interviewed to help
define the target population of young African
American women and for direction in pro-
gram development. Next, target group women
participated in focus groups and were asked
to discuss benefits and obstacles to healthy
eating. A final step surveyed community
resources on the availability of quality food
products. When researchers compared data
from the three qualitative studies, they found
that their target audience was confirmed as
appropriate, that the nutritionists had cor-
rectly identified the need for culturally rel-
evant skill-building messages, and that there
was a barrier to achieve program goals and
objectives due to the lack or excessive cost of
fresh and frozen foods. The triangulation pro-
cess provided concrete data on target popu-
lation needs and credible communication
channels, directing program planning toward
culturally relevant interventions and resource
development.
Developing the Message
It is believed that the more fundamental the
health message is in relation to a group’s sur-
vival, safety, or social needs, the more effec-
tive it will be interculturally.1 The message
must satisfy the individual’s need to gain
knowledge or offer a solution to a perceived
problem before it is worth the person’s time
to process the information.70 Messages should
be as direct and explicit as allowed within
cultural norms.81 Language relevant to the
group should be used in development of the
message, and translation of existing materials
should be avoided to prevent inappropriate
phrasing and terminology. Common words
used by the target audience are effective,
although it is important that they not be used
in an insincere or condescending way. Written
materials should be brief and prepared at the
reading level of the target population.
Marketing experts recognize many cul-
tural groups are high-context communica-
tors and have greater abilities than the white
American majority culture to send and receive
messages through nonverbal modes.75 Body
language must be culturally congruent with
the verbal message for successful communi-
cation to occur. The use of pictures, cartoons,
and photographic images can symbolically
enhance content meaning of a message in a
high-context culture, as well as aid target pop-
ulations with mixed English language skills or
reading abilities.
Educational messages are most effective
when they are more personal than objective;
the emotional dimension is as important
as the content. Many researchers recom-
mend the universally accepted format of
Figure 3.4
Triangulation.
Source: Based on Journal of the
American Dietetic Association,
Volume 99 (6), J. Goldberg et al,
‘Using 3 Data Sources and Methods
to Shape a Nutrition Campaign’,
pp. 717–722.
Community
Nutritionists:
Perspectives
Method:
Interviews
Community
Women:
Needs, preferences,
current activities
Method:
Focus group
discussions
Stores:
Available foods
and costs
Method:
Observation
©
T
he
A
m
er
ic
an
D
ie
te
tic
A
ss
oc
ia
tio
n.
The four barriers to
healthy eating identi-
fied by African American
women in the triangula-
tion focus groups were
taste, cost, time, and lack
of information such as
recipes, shopping tips,
and a chart comparing
healthful and unhealthful
choices.80
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

7 6 I N T E R C U L T U R A L C O M M U N I C A T I O N
storytelling to deliver the message.82,83 Actors
and other celebrities are especially suited
to recounting personal experiences about
health issues. Stories can transcend many
cultural boundaries; if a message is targeted
toward one cultural group yet applicable to
many audiences, a spokesperson identified
with the intended target group also may
have broader appeal when using a narrative
approach.
A pilot test of the message with targeted
audience members can improve success.
Focus groups can be especially useful in
assessing cultural appropriateness of educa-
tion materials and in identifying any resis-
tance triggers inadvertently included in the
message.70,71,84
Implementation Strategies
Dissemination of a nutrition education
message should include analysis of cultural
influence channels and media preferences,
development of an effective marketing mix,
and evaluation of the program. Whether a
person actually hears, sees, and understands
a message is dependent on frequency, timing,
and accessibility. Exciting, informative, cul-
turally appropriate messages fail if they never
reach the target audience.70,76
Influence Channels
Influence channels are the ways in which
message materials are transmitted to the
target audience. They include television,
video, computers, the Internet, radio, maga-
zines, newspapers, newsletters, direct mail,
and telephones. Each cultural group dem-
onstrates distinct media-use patterns and
is best approached through those influence
channels. Oral traditions are strong among
some populations, while written messages are
favored by others. It is estimated that many
African Americans (97 percent) listen to the
radio for more than thirty hours each week;
Latinos enjoy television programs focusing
on family and relationship issues, watching
on average fifteen hours of Spanish program-
ming and ten hours of English programming
each week.72,85 Asians watch about six hours
of native language television weekly. In a
study of Native Americans in California, a
majority of respondents reported that they
would prefer receiving nutrition information
through newsletters (69 percent) or video-
tapes (67 percent); approximately one-quarter
indicated they would like to receive a visit
from a health professional, and only 6 percent
selected a workshop with family and friends.79
Computer-based, interactive nutrition educa-
tion programs are now an established educa-
tional tool, particularly suitable for audiences
with low literacy or limited English language
skills, as was found in a study of rural Appa-
lachian women.86 The Internet has become a
useful technology, offering twenty-four-hour
access to health education materials and easy
access to group support through bulletin
boards and chat rooms, and individualized
therapy through e-mail.87,88,89
According to marketing experts, the most
effective presentation of a message requires a
combination of pictures, sounds, and words
in the broadcast and print media.72 The use
of multiple influence channels and frequent
repetitions of the message at times when the
target audience is listening or watching is also
important. Beyond the mass media, health
fairs, neighborhood clinics, farmers’ mar-
kets and grocery stores, traditional healers,
churches, schools, food banks or social ser-
vice centers, carnivals, and sporting events
are a few of the locations where culturally
relevant nutrition education materials can
be successfully distributed on a smaller scale.
Low-income, hard-to-reach whites, blacks,
and Latinos express interest in nonjudgmen-
tal small-group support meetings similar to
Alcoholics Anonymous and Tupperware-style
home meetings with food samples and cook-
ing demonstrations as settings for nutrition
education programs.71
Marketing Mix
The four Ps of the marketing mix are prod-
uct, price, placement, and promotion.1 They
refer to a well-developed message (product)
that advances program goals and objectives
Cultural icons incorpo-
rated into educational
messages should be
selected with care. For
example, the owl repre-
sents wisdom in some
American Indian cultures;
in others, the owl is a
symbol for death.82
Mass media cam-
paigns are believed
to influence a change
in health behavior
by about 10 percent
of the targeted audi-
ence, which can be a
significant number in
a large campaign.
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

C H A P T E R 3 7 7
4. What would be the culturally appropriate
verbal address for when you meet the follow-
ing individuals: an African American, a Latin
American, a Vietnamese, and an Asian?
References
1. Kreps, G.L., & Kunimoto, E.N. 1994. E f f ec tiv e
c ommunic ation in mul tic ul tur al h eal th c ar e set-
tings. Thousand Oaks, CA: Sage.
2. Hall, E.T. 1977. B ey ond c ul tur e. Garden City, NY:
Anchor/Doubleday.
3. Gudykunst, W.B. 2003. B r idging dif f er enc es: E f f ec –
tiv e inter gr oup c ommunic ation (4th ed.). Thou-
sand Oaks, CA: Sage.
4. Gostin, L.O. 1995. Informed consent, cultural
sensitivity, and respect for persons. J our nal of th e
A mer ic an M edic al A ssoc iation, 2 7 4 , 844–845.
at minimal economic or psychological cost to
target audience members (price) and presents
this message in a method congruent with tar-
get audience media preferences (placement) in
such a way that the target audience members
are encouraged to become more involved in
the program, either through phone numbers
for further information or through attendance
at group meetings (promotion). Attention to
all four areas of the marketing mix ensures
that the health care message is fully accessible
to the target audience.
Evaluation
Process evaluation keeps track of progress
throughout the program, especially the iden-
tification of larger community conditions
that may be presenting barriers to dissemina-
tion of the message. Summative evaluation is
used to assess program results after comple-
tion of the effort. Evaluation data are useful
in refining intercultural nutrition education
strategies both during implementation and
in future programs. Publication of culturally
sensitive nutrition education program results
greatly benefits other health professionals
and their clients through shared knowledge
about intercultural communication tech-
niques and tools.
Review Questions
1. Why is communication with another person
or group described as an action chain? Give an
example of an action chain that might occur
when you meet (1) a friend, (2) your new boss,
and (3) a young child.
2. Why is it important to become familiar with
other cultures’ communication behaviors?
Give three examples of nonverbal communi-
cation behaviors.
3. What is meant by low or high context and
uncertainty avoidance in describing verbal
communications? Name one culture that is low
context and one culture that is high context.
How may an individual’s relationship to the
group differ between high- and low-context
cultures? How does uncertainty avoidance dif-cultures? How does uncertainty avoidance dif-cultures? How does uncertainty avoidance dif
fer from risk avoidance? Give an example.
D I S C U S S I O N S T A R T E R S
How Does Dr. Petrocelli Improve His
Patient Relations?
Consider this situation: Dr. Petrocelli is a neighborhood doctor in a large U.S. city. His
office has been in this urban neighborhood for forty years. Originally, the neighbor-
hood was ethnically fairly homogeneous: primarily European American and African
American. Over the last decade, however, more people of various different ethnicities
(Asian, Hispanic, and Middle Eastern), mostly immigrants to the United States, have
moved into the neighborhood and are seeking health care. Dr. Petrocelli recognizes that
sometimes communications with his newer patients are strained, and he worries that he
is not fully understanding them and they are not fully understanding him. He’s consider-
ing several different options along with their drawbacks:
● Hire an interpreter. Drawback: To pay this person’s salary, he will need to increase
the fees for his patients.
● Continue to rely on patients’ relatives or friends to translate for him. Drawback: He
will continue to worry if the translations are accurate.
● Start holding an in-depth interview with each of his new patients to get to know
them better. Drawback: These interviews will take a lot of time and could mean
that either he will have to extend his hours—and pay his staff overtime—or set
a moratorium on taking any new patients until he has completed the interviews.
He worries that such a moratorium could mean that some people living in the
neighborhood might not receive adequate healthcare.
First individually and then in small groups, brainstorm which of these options might be
the best—or perhaps better yet, brainstorm a solution to Dr. Petrocelli’s problem that
combines options or offers a completely different option.
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

7 8 I N T E R C U L T U R A L C O M M U N I C A T I O N
5. Kumanyika, S.K., & Morssink, C.B. 1997. Cultural
appropriateness of weight management pro-
grams. In S. Dalton (Ed.), O v er w eigh t and w eigh t
management: T h e h eal th pr of essional ’ s guide to
under standing and pr ac tic e. Gaithersburg, MD:
Aspen.
6. Axtell, R.E. 1991. G estur es: T h e do’ s and taboos
of body l anguage ar ound th e w or l d. New York:
Wiley.
7. Eubanks, R.L, McFarland, M., Mixer, S.J., Munoz,
C., Pacquiao, D.F., & Wenger, A.F.Z. 2010. Cross
cultural communication. In M.K. Douglas & D.F.
Pacquiao (Eds.), Core curriculum in transcultural
nursing and health care. J our nal of T r ansc ul tur al
N ur sing, N ur sing, N ur sing 2 1 (Suppl.1).
8. Dresser, N. 2005. M ul tic ul tur al manner s: E ssential
r ul es of etiq uette f or th e 2 1 st c entur y . New York:
Wiley.
9. Tumulty, P. 1970. What is a clinician and what
does he do? N ew E ngl and J our nal of M edic ine,
283, 20–24.
10. Woloshin, S., Bickell, N.A., Schwartz, L.M.,
Gany, F., & Welch, H.G. 1995. Language barriers
in medicine in the United States. J our nal of th e
A mer ic an M edic al A ssoc iation, 2 7 3 , 724–728.
11. Haffner, L. 1992. Translation is not enough: Inter-
preting in a medical setting. W ester n J our nal of
M edic ine, 1 5 7 , 255–259.1 5 7 , 255–259.1 5 7
12. Brookins, G.K. 1993. Culture, ethnicity, and
bicultural competence: Implications for children
with chronic illness and disability. P ediatr ic s, 9 1 ,
1056–1062.
13. Cassidy, C.M. 1994. Walk a mile in my shoes:
Culturally sensitive food-habit research. A mer i-
c an J our nal of C l inic al N utr ition, 5 9 (Suppl.),
190S–197S.
14. Kreps, G.L. 1990. Communication and health
education. In E.B. Ray & L. Donohew (Eds.),
C ommunic ation and h eal th . Hillsdale, NJ:
Erlbaum.
15. Sevinc, A., Buyukberber, S., & Camci, C. 2005.
Medical jargon: Obstacle to effective communi-
cation between physicians and patients. M edic al
P r inc ipl es and P r ac tic e, 1 4 , 292.
16. Cricco-Lizza, R. 2006. Black non-Hispanic
mother’s perceptions about the promotion of
infant-feeding methods by nurses and physicians.
J our nal of O bstetr ic s and G y nec ol ogy , 3 5 , 173–180.
17. Fong, A.K.H. 1991. Educating clients: Success-
ful communication creates change. J our nal of th e
A mer ic an Dietetic A ssoc iation, 9 1 , 289–290.
18. Beck, A. 1988. L ov e is nev er enough . New York:
Harper & Row.
19. Lynch, J. 1990. Organ donation & approach-
ing the African American family. C ontempor ar y
Dial y sis & N eph r ol ogy , 1 1 , 21–22.
20. Uche-Griffin, Ndidi, F. 1994. Perceptions of
African American women regarding health care.
J our nal of C ul tur al Div er sity , 1 , 32–35.
21. Piette, J.D., Bibbins-Domingo, K., & Schillinger,
D. 2006. Health care discrimination, processes of
care, and diabetes patients’ health status. P atient
E duc ation and C ounsel ing, E duc ation and C ounsel ing, E duc ation and C ounsel ing 6 0 , 41–48.
22. Anderson, C.H. 1995. Sugars, sweetness and food
intake. A mer ic an J our nal of C l inic al N utr ition,
62(Suppl.), 195S–201S.
23. Kleinman, A., Eisenberg, L., & Good, B. 1978.
Culture, illness, and care: Clinical lessons from
anthropologic and cross-culture research. A nnal s
of I nter nal M edic ine, 8 8 , 251–258.
24. MacGregor, K., Handley, M., Wong, S., Sharifi, C.,
Gjeltema, K., Schillinger, D., & Bodenheimer, T.
2006. Behavior-change action plans in primary
care: A feasibility study of clinicians. J our nal of th e
A mer ic an B oar d of F amil y M edic ine, 1 9 , 215–223.
25. Street, R.L., Jr., Gordon, H.S., Ward, M.M.,
Krupat, E., & Kravitz, R.L. 2005. Patient participa-
tion in medical consultations: Why some patients
are more involved than others. M edic al C ar e, 4 3 ,
960–969.
26. Howell, W. 1982. T h e emph atic c ommunic ator .
Belmont, CA: Wadsworth.
27. Purnell, L.D., & Paulanka, B.J. 2003. T r ansc ul tur al
h eal th c ar e: A c ul tur al l y c ompetent appr oac h (2nd
ed.). Philadelphia: F.A. Davis.
28. Reimann, J.O., Talavera, G.A., Nunez, S.M., &
Velasquez, R.J. 2004. Cultural competence among
physicians treating Mexican Americans who have
diabetes: A structural model. S oc ial S c ienc e &
M edic ine, 5 9 , 2195–2205.
29. Rust, G., Kondwani, K., Martinez, R., Dansie, R.,
Wong, W., Fry-Johnson, Y., . . . Strothers, H. 2006.
A CRASH-course in cultural competence. E th nic –
ity & Disease, 1 6 , S3–29, S3–36.
30. Dresser, N. 2005. M ul tic ul tur al manner s: E ssential
r ul es of etiq uette f or th e 2 1 st c entur y . New York:
Wiley.
31. Morrison, T., Conaway, W.A., & Borden, G.A.
1994. K iss, bow , or sh ak e h ands: H ow to do busi-
ness in six ty c ountr ies. Holbrook, MA: Adams.
32. Harris, P.R., & Moran, R.T. 1987. M anaging c ul –
tur al diff er enc es (2nd ed.). Houston, TX: Gulf.
33. Usunier, J.C. 1993. I nter national mar k eting.
New York: Prentice Hall.
34. Hankin, J.H., & Wilkins, L.R. 1994. Development
and validation of dietary assessment methods for
culturally diverse populations. A mer ic an J our nal
of C l inic al N utr ition, 5 9 (Suppl.), 198S–200S.
35. Camarota, S.A. August 2012. I mmigr ants in th e
U nited S tates, 2 0 1 0 : A pr of il e of A mer ic a’ s f or eign-
bor n popul ation. Washington, DC: Center for
Immigration Studies, Table 18. Retrieved from
http://cis.org/2012-profile-of-americas-foreign-
born-population (accessed February 4, 2015).
36. Ebden, P., Bhatt, A., Carey, O.J., & Harrison, B.
1988. T h e bil ingual c onsul tation. L anc et, 13, 347.
37. Muecke, M.A. 1983. In search of healers—
Southeast Asian refugees in the American health
care system. W ester n J our nal of M edic ine, 1 3 9 ,
835–840.
38. Street, R.L., Jr., Gordon, H.S., Ward, M.M.,
Krupat, E., & Kravitz, R.L. 2005. Patient
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

C H A P T E R 3 7 9
participation in medical consultations: Why some
patients are more involved than others. M edic al
C ar e, 4 3 , 960–969.
39. Kavanagh, K., Absalom, K., Beil, W., &
Schliessmann, L. 1999. Connecting and becom-
ing culturally competent: A Lakota example.
A dv anc es in N ur sing S c ienc e, 2 1 , 9–31.
40. Nunez, A., & Robertson, C. 2006. Cultural
competency. In D. Satcher & R.J. Pamies (Eds.),
M ul tic ul tur al medic ine and h eal th dispar ities.
New York: McGraw-Hill.
41. Ruben, B.D. 1990. The health caregiver–patient
relationship: Pathology, etiology, treatment. In
E.B. Ray & L. Donohew (Eds.), C ommunic ation
and h eal th . Hillsdale, NJ: Erlbaum.
42. Anderson, C.H. 1995. Sugars, sweetness and food
intake. A mer ic an J our nal of C l inic al N utr ition,
6 2 (Suppl.), 195S–201S.
43. Forsythe, H.E., & Gage, B. 1994. Use of a multicul-
tural food-frequency questionnaire with pregnant
and lactating women. A mer ic an J our nal of C l ini-
c al N utr ition, 5 9 (Suppl.), 203S–206S.
44. Loria, C., Arroyo, D., & Briefel, R. 1994. Cultural
biases influencing dietary interviews with
Mexican Americans: The Hanes experience.
A mer ic an J our nal of C l inic al N utr ition, 5 9 (Suppl.),
290S.
45. Teufel, N.I. 1997. Development of culturally
competent food-frequency questionnaires.
A mer ic an J our nal of C l inic al N utr ition, 6 5 (Suppl.),
1173S–1178S.
46. Borrud, L.G., McPherson, R.S., Nichaman, M.Z.,
Pillow, P.C., & Newell, G.R. 1989. Development
of a food frequency instrument: Ethnic differ-
ences in food sources. N utr ition and C anc er , 1 2 ,
201–211.
47. Block, G., Mandel, R., & Gold, E. 2004. On food
frequency questionnaires: The contribution of
open-ended questions and questions about ethnic
foods. E pidemiol ogy , 1 5 , 216–221.
48. Coates, R.J., Clark, W.S., Eley, J.W., Greenberg,
R.S., Huguley, C.M., & Brown, R.L. 1990. Race,
nutritional status, and survival from breast can-
cer. J our nal of th e N ational C anc er I nstitute, 8 2 ,
1684–1692.
49. Satia-Abouta, J.A., Patterson, R.E., Neuhouser,
M.L., & Elder, J. 2002. Dietary acculturation:
Applications to nutrition research and dietetics.
J our nal of th e A mer ic an Dietetic A ssoc iation, 1 0 2 ,
1105–1118.
50. Bettin, K.J. 1994. A food frequency questionnaire
design for a low literacy population. A mer ic an
J our nal of C l inic al N utr ition, 5 9 (Suppl.), 289S.
51. Norman, S., Castro, C., Albright, C., & King, A.
2004. Comparing acculturation models in evalu-
ating dietary habits among low-income Hispanic
women. E th nic ity & Disease, 1 4 , 399–404.
52. Netland, P.A., & Brownstein, H. 1985. Anthropo-
metric measurements for Asian and Caucasian
elderly. J our nal of th e A mer ic an Dietetic A ssoc ia-
tion, 8 5 , 221–223.
53. Freimer, N., Echenberg, D., & Kretchmer, N.
1983. Cultural variation—Nutritional and clini-
cal implications. W ester n J our nal of M edic ine, 1 3 9 ,
928–933.
54. Gardner, W.E. 1994. Mortality. In N.W.S. Zane,
D.T. Takeuchi, & K.N.J. Young (Eds.), C onf r onting
c r itic al h eal th issues of A sian and P ac if ic I sl ander
A mer ic ans. Thousand Oaks, CA: Sage.
55. Chumlea, W.C., Shumei, S.G., Wholihan, K.,
Cockram, D., Kuczmarski, R.J., & Johnson, C.L.
1998. Stature prediction equations for elderly
non-Hispanic white, non-Hispanic black, and
Mexican-American persons developed from
NHANES III data. J our nal of th e A mer ic an
Dietetic A ssoc iation, 9 8 , 137–142.
56. Hoerr, S.L., Nelson, R.A., & Lohman, T.R. 1992.
Discrepancies among predictors of desirable
weight for black and white obese adolescent girls.
J our nal of th e A mer ic an Dietetic A ssoc iation, 9 2 ,
450–453.
57. Slattery, M.L., Ferucci, E.D., Murtaugh, M.A.,
Edwards, S., Ma, K.N., Etzel, R.A., . . . Lanier, A.P.
2010. Associations among body mass index, waist
circumference, and health indicators in American
Indian and Alaska Native adults. A mer ic an J our –
nal of H eal th P r omotion, 2 4 , 246–254.
58. Yatsuya, H., Folsom, A.R., Yamagishi, K.,
North, K.E., Brancati, F.L., & Stevens, J. 2010.
Atherosclerosis Risk in Communities Study
Investigators. Race- and sex-specific associations
of obesity measures with ischemic stroke inci-
dence in the Atherosclerosis Risk in Communi-
ties (ARIC) study. S tr ok e, 4 1 , 417–425.
59. Huxley, R., Mendis, S., Zheleznyakov, E.,
Reddy, S., & Chan, J. 2010. Body mass index, waist
circumference and waist:hip ratio as predictors of
cardiovascular risk—A review of the literature.
E ur opean J our nal of C l inic al N utr ition, 6 4 , 16–22.
60. Lusky, A., Lubin, F., Barell, V., Kaplan, G., Lay-
ani, V., & Wiener, M. 2000. Body mass index in
17-year-old Israeli males of different ethnic back-
grounds: National or ethnic-specific references?
I nter national J our nal of O besity and R el ated M eta-
bol ic Disor der s, 2 4 , 88–92.
61. McNeely, M.J., & Boyko, E.J. 2004. Type 2 diabe-
tes prevalence in Asian Americans: Results of a
national health study. Diabetes C ar e, 2 7 , 66–69.2 7 , 66–69.2 7
62. Crawley, J., & Burkhauser, R.V. 2006. Beyond
BMI: The value of more accurate measures of
fatness and obesity in social science research.
Working Paper No. 12291. N B E R B ul l etin on
A ging and H eal th , J une. Cambridge, MA: National
Bureau of Economic Research.
63. Case, K.O., Brahler, C.J., & Heiss, C. 1997. Resting
energy expenditures in Asian women measured
by indirect calorimetry are lower than expen-
ditures calculated from prediction equations.
J our nal of th e A mer ic an Dietetic A ssoc iation, 9 7 , 9 7 , 9 7
1288–1292.
64. Liu, H.Y., Lu, Y.F., & Chen, W.J. 1995. Predictive
equations for basal metabolic rate in Chinese
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

8 0 I N T E R C U L T U R A L C O M M U N I C A T I O N
adults: A cross-validation study. J our nal of th e
A mer ic an Dietetic A ssoc iation, 9 5 , 1403–1408.
65. Teufel, N.I. 1997. Development of culturally
competent food-frequency questionnaires.
A mer ic an J our nal of C l inic al N utr ition, 6 5 (Suppl.),
1173S–1178S.
66. Deharveng, G., Charrondiere, U.R., Slimani, N.,
Southgate, D.A.T., & Riboli, E. 1999. Comparison
of nutrients in the food composition tables avail-
able in the nine European countries participating
in EPIC. E ur opean J our nal of C l inic al N utr ition,
5 3 , 60–79.
67. Brownell, K.D., Kelman, J.H., & Stunkard, A.J.
1983. Treatment of obese children with and with-
out their mothers: Changes in weight and blood
pressure. P ediatr ic s, 7 1 , 515–523.
68. Kumanyika, S.K., & Morssink, C.B. 1997. Cultural
appropriateness of weight management programs.
In S. Dobson (Ed.), O v er w eigh t and w eigh t man-
agement: T h e h eal th pr of essional ’ s guide to under –
standing and pr ac tic e. Gaithersburg, MD: Aspen.
69. Kreuter, M.W., Sugg-Skinner, C., Holt, C.L.,
Clark, E.M., Haire-Joshu, D., Fu, Q., . . . Bucholtz,
D. 2005. Cultural tailoring for mammography
and fruit and vegetable intake among low-income
African-American women in urban public health
centers. P r ev entiv e M edic ine, 4 1 , 53–62.
70. Brown, J.D., & Einsiedel, E.F. 1990. Public health
campaigns: Mass media strategies. In E.B. Ray &
L. Donohew (Eds.), C ommunic ation and h eal th .
Hillsdale, NJ: Erlbaum.
71. White, S.L., & Maloney, S.K. 1990. Promoting
healthy diets and active lives to hard-to-reach
groups: Market research study. P ubl ic H eal th
R epor ts, 1 0 5 , 224–231.
72. Rabin, S. 1994. How to sell across cultures. A mer i-
c an Demogr aph ic s, 1 6 , 56–57.
73. Williams, J.H., Auslander, W.F., de Groot, M.,
Robinson, A.D., Housto, C., & Haire-Joshu, D.
2006. Cultural relevancy of a diabetes prevention
nutrition program for African American women.
H eal th P r omotion and P r ac tic e, 7 , 56–67.7 , 56–67.7
74. Massaro, E., & Claiborne, N. 2001. Effective strat-
egies for reaching high-risk minorities with dia-
betes. Th e Diabetes E duc ator , 2 7 , 820–826, 828.2 7 , 820–826, 828.2 7
75. Preloran, H.M., Browner, C.H., & Leiber, E. 2005.
Impact of interpreter’s approach on Latina’s use of
amniocentesis. H eal th E duc ation & B eh av ior , 3 2 ,
599–612.
76. Donohew, L. 1990. Public health campaigns:
Individual message strategies and a model. In
E.B. Ray & L. Donohew (Eds.), C ommunic ation
and h eal th . Hillsdale, NJ: Erlbaum.
77. Elshaw, E.B., Young, E.A., Saunders, M.J.,
McGurn, W.C., & Lopez, L.C. 1994. Utilizing a
24-hour dietary recall and culturally specific
diabetes education in Mexican Americans with
diabetes. Diabetes E duc ator , 2 0 , 228–235.
78. Chew, T. 1983. Sodium values of Chinese condi-
ments and their use in sodium-restricted diets.
J our nal of th e A mer ic an Dietetic A ssoc iation, 8 2 ,
397–401.
79. James, D.C. 2004. Factors influencing food
choices, dietary intake, and nutrition-related atti-
tudes among African-Americans: Application of a
culturally sensitive model. E th nic ity & H eal th , 9 ,
349–367.
80. Goldberg, J., Rudd, R.E., & Deitz, W. 1999. Using
3 data sources and methods to shape a nutrition
campaign. J our nal of th e A mer ic an Dietetic A sso-
c iation, 9 9 , 717–722.
81. Randall-David, E. 1989. S tr ategies f or w or k ing
w ith c ul tur al l y div er se c ommunities and c l ients.
Bethesda, MD: Association for the Care of Chil-
dren’s Health.
82. Hodge, F.S., Paqua, A., Marquez, C.A., & Geishirt-
Cantrell, B. 2002. Utilizing traditional storytelling
to promote wellness, in American Indian com-
munities. J our nal of T r ansc ul tur al N ur sing, 1 3 ,
6–11.
83. Esquivel, G.B., & Keitel, M.A. 1990. Counseling
immigrant children in the schools. E l ementar y
S c h ool G uidanc e & C ounsel ing, S c h ool G uidanc e & C ounsel ing, S c h ool G uidanc e & C ounsel ing 2 4 , 213–221.
84. Kiefer, E.C., Willis, S.K., Odoms-Young, A.M.,
Guzman, J.R., Allen, A.J., Two Feathers, J., &
Loveluck, J. 2004. Reducing disparities in diabetes
among African-American and Latino residents of
Detroit: The essential role of community planning
focus groups. E th nic ity & Disease, 1 4 (Suppl. 1),
S27–S37.
85. Mogelonsky, M. 1998, April. Watching in tongues.
A mer ic an Demogr aph ic s, 4 8 .
86. Tessaro, I., Rye, S., Parker, L., Trangsrud, K.,
Mangone, C., McCrone, S., & Leslie, N. 2006.
Cookin’ up health: Developing a nutrition inter-
vention for a rural Appalachian population.
H eal th P r omotion and P r ac tic e, 7 , 252–257.7 , 252–257.7
87. Archer, W.R., Batan, M.C., Buchanan, L.R., Soler,
R.E., Ramsey, D.C., Kirchhofer, A., & Reyes, M.
2011. Promising practices for the prevention and
control of obesity in the worksite. A mer ic an J our –
nal of H eal th P r omotion, 2 5 , e12–e26.
88. Chou, H.K., Lin, I.C., Woung, L.C., & Tsai, M.T.
2010, November 23. Engagement in e-learning
opportunities: An empirical study on patient
education using expectation confirmation theory.
J our nal of M edic al S y stems [Epub ahead of print].
89. Kaufman, N. 2010. Internet and information
technology use in treatment of diabetes. I nter –
national J our nal of C l inic al P r ac tic e, 1 6 6 (Suppl.),
41–46. Review.
90. Gilbert, S.E., & Gay, G. 1989. Improving the
success in school of poor black children. In
B.J. Robinson Shade (Ed.), C ul tur e, sty l e, and th e
educ ativ e pr oc ess. Springfield, IL: Thomas.
91. Beach, M.V., Sugarman, J., Johnson, R.L.,
Arbelaez, J.J., Duggan, P.S., & Cooper, L.A. 2005.
Do patients treated with dignity report higher sat-
isfaction, adherence, and receipt of preventative
care? A nnal s of F amil y M edic ine, 3 , 331–338.
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

C H A P T E R 3 8 1
92. Burner, O.Y., Cunningham, P., & Hattar, H.S.
1990. Managing a multicultural nurse staff in a
multicultural environment. J our nal of N ur sing
A dministr ation, 2 0 , 30–34.
93. Levinson, W., Kao, A., Kuby, A., & Thisted, R.A.
2005. Not all patients want to participate in deci-
sion making. A national study of public prefer-
ences. J our nal of G ener al I nter nal M edic ine, 2 0 ,
531–535.
94. Wood, J.B. 1989. Communicating with older adults
in health care settings: Cultural and ethnic consid-
erations. E duc ational G er ontol ogy , 1 5 , 351–362.
95. Commission on Dietetic Registration. 2013. Reg-
istered dietitians demographics. Retrieved from
http://www.cdrnet.org/certifications/registered-
dietitians-demographics (accessed February 4,
2015).
96. U.S. Department of Agriculture, Agricultural
Research Service. 2012. U S DA N ational N utr i-
ent Database f or S tandar d R ef er enc e, R el ease
2 5 . Nutrient Data Laboratory. Retrieved from
http://www.ars.usda.gov/ba/bhnrc/ndl (accessed
February 4, 2015).
97. Yanek, L.R., Moy, T.F., & Becker, D.M. 2001.
Comparison of food frequency and dietary recall
methods in African-American women. J our –
nal of th e A mer ic an Dietetic A ssoc iation, 1 0 1 ,
1361–1364.
98. Jerome, N.W. 1997. Culture-specific strategies for
capturing local dietary intake patterns. A mer ic an
J our nal of C l inic al N utr ition, 6 5 , 1166S–1167S.
99. Swartz, L. 1987. Illness negotiation: The case of
eating disorders. S oc ial S c ienc e and M edic ine, 2 4 ,
613–618.
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

8 2
4 Food and Religion
The function of religion is to explain the The function of religion is to explain the Tinexplicable, thus providing humans Tinexplicable, thus providing humans Twith a sense of comfort in a chaotic Twith a sense of comfort in a chaotic T
world. Food, because it sustains life, is an
important part of religious symbols, rites, and
customs, those acts of daily life intended to
bring about an orderly relationship with the
spiritual or supernatural realm.
In the Western world, Judaism, Christian-
ity, and Islam are the most prevalent religions,
whereas Hinduism and Buddhism are com-
mon in the East. The Western religions, origi-
nating in the Middle East, are equated with
the worship of a single God and the belief that
that God is omnipotent and omniscient. It is
for God to command and for humankind to
obey. This life is a time of testing and a prepa-
ration for life everlasting, when humans will
be held accountable to God for their actions
on earth.
The Eastern religions of Hinduism and
Buddhism developed in India. Unlike the
Western religions, they do not teach that
God is the lord and maker of the universe
who demands that humankind be righteous.
Rather, the principal goal of the Indian reli-
gions is deliverance, or liberation, of the
immortal human soul from the bondage of
the body. Moreover, nearly all Indian religions
teach that liberation, given the right disposi-
tion and training, can be experienced in the
present life.
This chapter discusses the beliefs and food
practices of the world’s major religions. Other
religions of importance to specific cultures are
introduced in the following chapters on each
ethnic group. As with any description of food
habits, it is important to remember that reli-
gious dietary practices vary enormously, even
among members of the same faith. Many reli-
gious food practices were codified hundreds
or thousands of years ago for a specific locale
and, consequently, have been reinterpreted
over time and to meet the needs of expanding
populations.
As a result, most religions have areas of
questionable guidelines. For example, fish
without scales are banned under kosher food
laws. Are sturgeon, which are born with scales
but lose them as they mature, considered fit to
eat for Jews? Orthodox Jews say no, whereas
many Conservative and Reform Jews say yes:
smoked sturgeon can be found at almost any
Jewish deli. Hindus, who avoid fish with “ugly
forms,” identify those fish that are undesirable
according to local tradition. In addition, reli-
gious food practices are often adapted to per-
sonal needs. Catholics, encouraged to make
a sacrifice during Lent, traditionally gave up
meat but today may choose to give up pastries
or candy instead. Buddhists may adopt a veg-
etarian diet only during the period when as
an elder they become a monk or nun. Because
religious food prescriptions are usually writ-
ten in some form, it is tempting to see them
as being black-and-white. Yet they are among
the most variable of culturally based food
habits. (See Table 4.1.)
C
H
A
P
T
E
R
A study on religious
affiliation in 2008 found
the percentage of self-
identified Christians in
the United States had
declined in the past
decade, whereas the
percentage that adhere
to non-Christian religions
remained relatively
constant. The biggest
gain was seen in those
who practice no religion,
nearly doubling from 8 to
15 percent. Younger per-
sons, men, Asians, and
those living in the West
were most likely to say
they have a secular out-
look (see Figure 4.1).2
U.S. law now prohibits
the census from includ-
ing mandatory ques-
tions regarding religion.
Independent national
survey data often differ
from religious group
records regarding
membership.
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

C H A P T E R 4 8 3
The cornerstone of the Jewish religion is
the Hebrew Bible, particularly the first five
books of the Bible, the Pentateuch, also known
as the books of Moses, or the Torah. It con-
sists of Genesis, Exodus, Leviticus, Numbers,
and Deuteronomy. The Torah chronicles the
beginnings of Judaism and contains the basic
laws that express the will of God to the Jews.
The Torah not only sets down the Ten Com-
mandments, but also describes the right way
to prepare food, give to charity, and conduct
one’s life in all ways. The interpretation of
the Torah and commentary on it are found
Western Religions
Judaism
The Jewish religion, estimated to be 4,000
years old, started when Abraham received
God’s earliest covenant with the Jews. Juda-
ism was originally a nation as well as a reli-
gion. However, after the destruction of its
capital, Jerusalem, and its main sanctuary, the
Temple of Solomon, by the Romans in 70 ce,
it had no homeland until the birth of Israel
in 1948.
During the Diaspora (the dispersion of
Jews outside the homeland of Israel), Jews
scattered and settled all over the ancient world.
Two sects of Judaism eventually developed:
the Ashkenazi, who prospered in Germany,
northern France, and the eastern European
countries; and the Sephardim (called M isr ah i
in Israel), originally from Spain, who now
inhabit most southern European and Middle
Eastern countries. Hasidic Jews are observant
Ashkenazi Jews who believe salvation is to
be found in joyous communion with God as
well as in the Bible. Hasidic men are evident in
larger U.S. cities by their dress, which includes
long black coats and black or fur-trimmed
hats (worn on Saturdays and holidays only),
and by their long beards with side curls.
Figure 4.1
Self-described
religious affiliation in
the United States by
percentage—2014.
Source: America’s Changing Religious
Landscape. Pew Research Center:
Religion and Public Life, May 12,
2015. Available: http://www
.pewforum.org/2015/05/12/
americas-changing-religious-
landscape/.
Hindu, 0.7%
Buddhist, 0.7%
Muslim, 0.4%
Jewish, 1.9%
No Religion, 22.8%
Catholic, 23.9%
Protestant, 51.3%
In the 2011 Canadian
census, 38.7 percent of
the population was iden-
tified as Roman Catholic,
and another 30 percent
was listed as Protestant.
It is estimated that there
are 1,053,945 Muslims
(3.2 percent of the popu-
lation), 550,700 Eastern
Orthodox Christians,
329,500 Jews, 366,800
Buddhists, 498,000
Hindus, and 455,000
Sikhs. Sixteen percent of
the population adheres
to no religion.
ADV BUD EOX HIN JEW MOR MUS RCABUD EOX HIN JEW MOR MUS RCA
Beef A X
Pork X A A XA X X
All meat A A R A R R R
Eggs/dairy O O R O RO O R O R
Fish A A R R R R
Shellfish X A O R XX A O R X
Alcohol X A X X
Coffee/tea X X AX A
Meat and dairy at the same meal X
Leavened foods R
Ritual slaughter of meats 1 1
Moderation 1 1 1 11 1
NOTE: ADV, Seventh-Day Adventist; BUD, Buddhist; EOX, Eastern Orthodox; HIN, Hindu; JEW, Jewish; MOR, Mormon; MUS, Muslim; RCA, Roman Catholic. X,
prohibited or strongly discouraged; A, avoided by most devout; R, some restrictions regarding types of foods or when foods are eaten observed by some adherents;
O, permitted, but may be avoided at some observances; 1, practiced.
TA B L E 4 .1 Common Religious Food Practices
©
C
en
ga
ge
L
ea
rn
in
g
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

8 4 F O O D A N D R E L I G I O N
in the Talmud. The basic tenet of Judaism is
that there is only one God, and his will must
be obeyed. Jews do not believe in original
sin (that humans are born sinful) but rather
that all people can choose to act in a right or
wrong way. Sin is attributed to human weak-
ness. Humans can achieve, unaided, their own
redemption by asking for God’s absolution (if
they have sinned against God) or by asking
forgiveness of the person they sinned against.
The existence of the hereafter is recognized,
but the main concern in Judaism is with this
life and adherence to the laws of the Torah.
Many Jews belong to or attend a synagogue
(temple), which is led by a rabbi, who is a
scholar, teacher, and spiritual leader. In the
United States, congregations are usually clas-
sified as Orthodox, Conservative, or Reform,
although American Jews represent a spectrum
of beliefs and practices. The main division
among the three groups is their position on
the Jewish laws. Orthodox Jews believe that all
Jewish laws, as the direct commandments of
God, must be observed in all details. Reform
Jews do not believe that the ritual laws are
permanently binding but that the moral law is
valid. They believe that the laws are still being
interpreted and that some laws may be irrel-
evant or out of date, and they observe only
certain religious practices. Conservative Jews
hold the middle ground between Orthodox
and Reform beliefs.1
Immigration to the United States
In the early nineteenth century, Jews, primar-
ily from Germany, sought economic oppor-
tunities in the New World. By 1860, there
were approximately 280,000 Jews living in
the United States. Peak Jewish immigration
occurred around the turn of the century
(1880–1920); vast numbers of Jews moved
from eastern Europe because of poverty and
pogroms (organized massacres practiced by
the Russians against the Jews before World
War II).
During the Great Depression, Jews con-
tinued to immigrate into the United States,
primarily to escape from Nazi Germany.
Their numbers were few, however, because of
restrictions in the immigration quota system.
Today Jews continue to come to the United
States, especially from Russia. Some come
from Israel as well. The Jewish population
in the United States was 6.34 million adults
and children in 2014, according to data com-
piled from local federations; close to half of
U.S Jews live in the northeastern region of the
nation.2 Large populations are found in New
York, California, and Florida. Most Jews in
the United States are Ashkenazi: 10 percent
identify themselves as Orthodox, 34 percent
as Conservative, 29 percent as Reform, and
the rest are not affiliated with a specific
congregation.
Kashrut, the Jewish Dietary Laws
Some people in the United States believe that
Jewish food consists of dill pickles, bagels and
lox (smoked salmon), and chicken soup. In
actuality, the foods Jews eat reflect the regions
where their families originated. Because most
Jews in the United States are Ashkenazi, their
diet includes the foods of Germany and east-
ern Europe. Sephardic Jews tend to eat foods
similar to those of southern Europe and the
Middle Eastern countries, whereas Jews from
India prefer curries and other South Asian
foods. All Orthodox and many Conserva-
tive Jews follow the dietary laws, kashrut, that
were set down in the Torah and explained in
the Talmud.
K osh er or K osh er or K osh er k ash er means “fit” and is a popuk ash er means “fit” and is a popuk ash er –
lar term for Jewish dietary laws and permitted
food items. G l att kosher means that the strictG l att kosher means that the strictG l att –
est kosher standards are used in obtaining and
preparing the food. Kashrut is one of the pil-
lars of Jewish religious life and is concerned
with the fitness of food. Many health-related
explanations have been postulated about the
origins of the Jewish dietary restrictions; how-
ever, it is spiritual health, not physical health
or any other factor, that is the sole reason for
their observance. Jews who keep kosher are
expressing their sense of obligation to God,
to their fellow Jews, and to themselves. The
dietary laws governing the use of animal foods
can be classified into the following categories:
1. Which animals are permitted for
food and which are not: Any mammal
that has a completely cloven foot and
also chews the cud may be eaten, and
its milk may be drunk. Examples of
Since 2003, sales of
kosher foods have
increased by 68 percent.
More than 50 percent of
kosher food is purchased
by non-Jews, including
Muslims, Seventh-Day
Adventists, vegetarians,
and those with food
allergies, in part due
to their reputation for
safety and purity.26,40
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

C H A P T E R 4 8 5
permitted, or clean, animals are cattle,
deer, goats, oxen, and sheep. Unclean
animals include swine, carnivorous ani-
mals, and rabbits. Clean birds must have
a crop, gizzard, and an extra talon, as
do chickens, ducks, geese, and turkeys.
Their eggs are also considered clean. All
birds of prey and their eggs are unclean
and cannot be eaten. Among fish, every-
thing that has fins and scales is permit-
ted; everything else is unclean. Examples
of unclean fish are catfish, eels, rays,
sharks, and all shellfish. As discussed
previously, Orthodox rabbis consider
sturgeon a prohibited food; Conserva-
tive authorities list it as kosher. Caviar,
which comes from sturgeon, is similarly
disputed.3 All reptiles, amphibians, and
invertebrates are also unclean.
2. Method of slaughtering animals: The
meat of permitted animals can be eaten
only if the life of the animal is taken by
a special process known as sh eh itah .
If an animal dies a natural death or is
killed by any other method, it may not
be eaten. The sh oh et (person who kills sh oh et (person who kills sh oh et
the animal) must be a Jew trained and
licensed to perform the killing, which
is done by slitting the neck with a sharp
knife, cutting the jugular vein and tra-
chea at the same time. This method,
which is quick and painless, also causes
most of the blood to be drained from
the carcass.4
3. Examination of the slaughtered animal:
After the animal is slaughtered, it is
examined by the shohet for any blem-
ishes in the meat or the organs that
would render the animal tr ef ah , mean-
ing unfit for consumption. Disease in
any part of the animal makes the whole
animal unfit to eat.
4. Forbidden parts of a permitted animal:
Two parts of the animal body are
prohibited. Blood from any animal is
strictly forbidden; even an egg with a
small bloodspot in the yolk must be
discarded. H el eb (fat that is not inter-
mingled with the flesh, forms a separate
solid layer that may be encrusted with
skin or membrane, and can easily be
peeled off ) is also proscribed. The pro-
hibition against heleb applies only to
four-footed animals.
5. The preparation of the meat: For
meat to be kosher, the heleb, blood,
blood vessels, and sciatic nerve must
be removed. Much of this work is now
done by the Jewish butcher, although
some Jewish homemakers still choose
to remove the blood. This is known as
koshering, or kashering, the meat. It
is accomplished in five steps: First, the
meat is soaked (within seventy-two
hours after slaughter) in tepid water
for thirty minutes; second, it is drained
on a slanted, perforated surface so that
the blood can drain easily; third, the
meat is covered with kosher salt for at
least one hour; fourth, the salt is rinsed
from the meat; and finally, the meat is
rinsed repeatedly to make sure all blood
and salt are removed.5 The liver cannot
be made kosher in the ordinary way
because it contains too much blood.
Instead, its surface must be cut across
or pierced several times, then it must be
rinsed in water, and finally it must be
broiled or grilled on an open flame until
it turns a grayish-white color.
6. The law of meat and milk: Meat
(f l eisc h ig(f l eisc h ig( ) and dairy (f l eisc h ig) and dairy (f l eisc h ig mil c h ig) products mil c h ig) products mil c h ig
may not be eaten together. It is gener-
ally accepted that after eating meat a
person must wait six hours before eating
any dairy products, although the period
between is a matter of custom, not law.4
Only one hour is necessary if dairy
products are consumed first. Many Jews
are lactose intolerant and do not drink
milk. However, other dairy items such as
cheese, sour cream, and yogurt are often
included in the diet (kosher cheese must
be made with rennet obtained from a
calf killed according to the Jewish laws
of slaughtering). Separate sets of dishes,
pots, and utensils for preparing and eat-
ing meat and dairy products are usually
maintained. Separate linens and wash-
ing implements are often employed.
Eggs, fruits, vegetables, and grains are
Most gelatin is obtained
from processed pig tis-
sues. Kosher, gelatin-like
products are available.
In 2002, the first kosher
food in outer space was
served to astronaut Ilan
Ramon on the space
shuttle Columbia.
Tevilah is the ritual puri-
fication of metal or glass
pots, dishes, and utensils
through immersion in
the running water of a
river or ocean. Chinese
porcelain and ceramic
items are exempt.
Because it is not known
how much salt remains
on the meat after rins-
ing, Orthodox Jews with
hypertension are often
advised to restrict their
meat consumption.
The prohibition of the
sciatic nerve is based
on the biblical story of
Jacob’s nighttime fight
with a mysterious being
who touched him on the
thigh, causing him to
limp. Because the nerve
is difficult to remove, the
entire hindquarter of the
animal is usually avoided.
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

8 6 F O O D A N D R E L I G I O N
pareve, neither meat nor dairy, and can
be eaten with both. Olives are consid-
ered dairy foods, prohibited with meat,
if they are prepared using lactic acid.
7. Products of forbidden animals: The
only exception to the rule that products
of unclean animals are also unclean
is honey. Although bees are not fit for
consumption, honey is kosher because
it is believed that it does not contain any
parts from the insect.
8. Examination for insects and worms:
Because small insects and worms can
hide on fruits, vegetables, and grains,
these foods must be carefully washed
twice and examined before being eaten.
Kosher-certified prepackaged pro-
duce is available from some suppliers.
A processed food product (including
therapeutic dietary formulas) is consid-
ered kosher only if a reliable rabbinical
authority’s name or insignia appears on
the package. The most common insignia
is a K , permitted by the U.S. Food and K , permitted by the U.S. Food and K
Drug Administration (FDA), indicating
rabbinical supervision by the processing
company. Other registered symbols
include those found in Figure 4.2.
Religious Holidays
The Sabbath The Jewish Sabbath, the day of
rest, is observed from shortly before sundown
on Friday until after nightfall on Saturday.
Traditionally, the Sabbath is a day devoted
to prayer and rest, and no work is allowed.
All cooked meals must be prepared before
sundown on Friday because no fires can be
kindled on the Sabbath. Challah, a braided
bread, is commonly served with the Friday
night meal. In most Ashkenazi homes the
meal would traditionally contain fish or
chicken or cholent, a bean and potato dish
that can be prepared Friday afternoon and
left simmering until the evening meal on
Saturday. Kugel, a pudding, often made with
noodles, is a typical side dish.
Rosh Hashanah The Jewish religious year
begins with the New Year, or Rosh Hasha-
nah, which means “head of the year.” Rosh
Hashanah is also the beginning of a ten-day
period of penitence that ends with the Day
Figure 4.2
Examples of kosher food
symbols.
The Union of Orthodox Jewish Congregations
New York, New York
Orthodox Rabbinical Council of S. Florida
(Vaad Harabonim De Darom Florida)
Miami Beach, Florida
Vaad Horabonim of Massachusetts
Boston, Massachusetts
Vaad Hakashrus of the Orthodox Jewish
Council of Baltimore
Baltimore, Maryland
Vaad Hakashrus of Denver
Denver, Colorado
Vaad Harabonim of Greater Seattle
Seattle, Washington
Atlanta Kashruth Commission
Atlanta, Georgia
Kashruth Council Orthodox Division
Toronto Jewish Congress
Willowdale, Ontario, Canada
Montreal Vaad Hair
Montreal, Canada
Vancouver Kashruth
British Columbia, Canada
O.K. (Organized Kashrut) Laboratories
Brooklyn, New York
Kosher Supervision Service
Teaneck, New Jersey
Asian-American Kashrus Services
San Rafael, California
The Heart “K” Kehila Kosher
Los Angeles, California
Chicago Rabbinical Council
Chicago, Illinois
Orthodox Vaad of Philadelphia
Philadelphia, Pennsylvania
Vaad Harabonim of Greater Detroit and Merkaz
Southfield, Michigan
Vaad Hakahrus of Dallas, Inc.
Dallas, Texas
©
C
en
ga
ge
L
ea
rn
in
g
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

C H A P T E R 4 8 7
of Atonement, Yom Kippur. Rosh Hashanah
occurs in September or October; as with all
Jewish holidays, the actual date varies from
year to year because the Jewish calendar is
based on lunar months counted according to
biblical custom and does not coincide with
the secular calendar. For this holiday, the chal-
lah is baked in a round shape that symbolizes
life without end and a year of uninterrupted
health and happiness. In some communities,
the challah is formed like a bird representing
God’s protection. Apples are dipped in honey,
and a special prayer is said for a sweet and
pleasant year. Some families traditionally con-
sume the head of a fish or of a sheep, with the
wish that God’s will for them is to be at the
head, not the tail, of any undertakings in
the upcoming year. Foods with Hebrew names
similar to other words may also be eaten, such
as beets (similar to r emov e and used to pray
that enemies be removed). On the second
night a new fruit, one that hasn’t been con-
sumed for a long period of time, is enjoyed
with a prayer for a year of plenty. Often, the
fruit is a pomegranate, which reputedly con-
tains 613 seeds, the same as the number of
commandments listed in the Torah. No sour
or bitter foods are served on this holiday, and
special sweets and delicacies, such as honey
cakes, are usually prepared.
Yom Kippur, the Day of Atonement Yom Kip-
pur falls ten days after Rosh Hashanah and is
the holiest day of the year. On this day, every
Jew atones for sins committed against God
and resolves to improve and once again fol-
low all the Jewish laws. Yom Kippur is a com-
plete fast day (no food or water; medications
are allowed) from sunset to sunset. Everyone
fasts, except boys under thirteen years old,
girls under twelve years old, persons who are
very ill, and women in childbirth. The meal
before Yom Kippur is usually bland to prevent
thirst during the fast. The meal that breaks the
fast is typically light, including dairy foods or
fish, fruits, and vegetables.
Sukkot, Feast of Tabernacles Sukkot is a fes-
tival of thanksgiving. It occurs in Septem-
ber or October and lasts one week. On the
last day, Simchat Torah, the reading of the
Torah (a portion is read every day of the year)
is completed for the year and started again.
This festival is very joyous, with much singing
and dancing. Orthodox families build a sukkah
(hut) in their yards and hang fruit and flowers
from the rafters, which are spaced far enough
apart so that the sky and stars are visible. Meals
are eaten in the sukkah during Sukkot.
Hanukkah, the Festival of Lights Hanukkah is
celebrated for eight days, usually during the
month of December, to commemorate the
recapture of the Temple in Jerusalem in 169 ce.
Families celebrate Hanukkah by lighting one
extra candle on the menorah (candelabra)
each night so that on the last night all eight
candles are lit. Traditionally, potato pancakes,
called latkes, are eaten during Hanukkah.
Other foods cooked in oil, such as doughnuts,
are sometimes eaten as well.
Purim Purim, a joyous celebration that takes
place in February or March, commemorates
the rescue of the Persian Jews from the villain-
ous Haman by Queen Esther. It is a mitzvah
(good deed) to eat an abundant meal in honor
of the deliverance. The feast should include
ample amounts of meat and alcoholic bever-
ages. Customarily, people dress in disguise for
the day to hide from Haman, to add surprise
to gift giving, or to hide from God in order
to overindulge in anonymity. A food closely
associated with Purim is h amantasc h en (liter-
ally, “Haman’s pockets,” but usually interpreted
to mean Haman’s ears clipped in the humilia-
tion of defeat). A hamantasch is a triangular-
shaped pastry filled with sweetened poppy
seeds or fruit jams made from prunes or apri-
cots. Another pastry associated with Purim is
kreplach (a triangular or heart-shaped savory
pastry stuffed with seasoned meat or cheese
and then boiled like ravioli). Purim challah
(a sweet bread with raisins) and fish cooked
for the holiday in vinegar, raisins, and spices
are often served. Seeds, beans, and cereals are
offered in remembrance of the restricted diet
eaten by the pious Queen Esther.
Passover Passover, called P esac h in Hebrew, is
the eight-day festival of spring and of freedom.
It occurs in March or April and celebrates the
In poor Ashkenazi
homes, gefilte (filled)
fish became popular on
the Sabbath. Similar to
the concept of meatloaf,
it is made by extending
the fish through pulver-
izing it with eggs, bread,
onion, sugar, salt, and
pepper, then stewing
the balls or patties with
more onions.
Two breads, or one
bread with a smaller one
braided on top, are usu-
ally served on Fridays,
the beginning of the
Sabbath, symbolic of the
double portion of manna
(nourishment) provided
by God to help sustain
the Israelites when they
wandered in the desert
for forty years after their
exodus from Egypt.
Ashkenazi Jews tradi-
tionally avoided pepper
during Passover because
it was sometimes mixed
with bread crumbs or
flour by spice traders.
In some Sephardic
homes, matzah is layered
with vegetables and
cheese or meat for the
Passover meal.
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

8 8 F O O D A N D R E L I G I O N
anniversary of the Jewish exodus from Egypt.
The Passover seder, a ceremony carried out at
home, includes readings from the seder book,
the Haggadah, recounting the story of the exo-
dus, of the Jews’ redemption from slavery, and
of the God-given right of all humankind to
life and liberty. A festive meal is a part of the
seder; in the United States and Canada, the
menu usually includes chicken soup, matzo
balls, and meat or chicken. When Moses
led the Jews out of Egypt, they left in such
haste that there was no time for their bread
to rise. Today, matz ah , a white-flour cracker,
is the descendant of the unleavened bread or
bread of affliction. During the eight days of
Passover, no food that is subject to a leaven-
ing process or that has come in contact with
leavened foods can be eaten. The forbidden
foods are wheat, barley, rye, and oats. Wheat
flour can be eaten only in the form of mat-
zah or matzah meal, which is used to make
matzo balls. In addition, beans, peas, lentils,
maize, millet, and mustard are also avoided.
No leavening agents, malt liquors, or beers can
be used.
Because milk and meat cannot be mixed at
any time, observant Jewish families have two
sets of special dishes, utensils, and pots used
only for Passover. The entire house, especially
the kitchen, must be cleaned and any foods
subject to leavening removed before Passover.
It is customary for Orthodox Jews to sell their
leavened products and flours to a non-Jew
before Passover. It is very important that all
processed foods, including wine, be prepared
for Passover use and be marked “Kosher for
Passover.”
The seder table is set with the best silver-
ware and china and must include candles,
kosher wine, the Haggadah, three pieces of
matzot (the plural of matz ah ) covered sepa-
rately in the folds of a napkin or special Pass-
over cover, and a seder plate. The following
items go on the seder plate:
1. Z’roah. Z’roah is a roasted shank bone,
symbolic of the ancient paschal lamb in
Egypt, which was eaten roasted.
2. Beitzah. Beitzah is a roasted egg, repre-
senting the required offering brought to
the temple at festivals. Although the egg
itself was not sacrificed, it is used in the
seder as a symbol of mourning. In this
case, it is for the loss of the Temple in
Jerusalem.
3. Marror. Marror are bitter herbs, usu-
ally horseradish (although not an herb),
symbolic of the Jews’ bitter suffering
under slavery. The marror is usually
eaten between two small pieces of
matzot.
4. Haroset. Haroset is a mixture of
chopped apple, nuts, cinnamon, and
wine. Its appearance is a reminder of
the mortar used by the Jews to build the
palaces and pyramids of Egypt during
centuries of slavery. The haroset is also
eaten on a small piece of matzah.
5. Karpas. A green vegetable, such as
lettuce or parsley, is placed to the left of
the haroset, symbolic of the meager diet
of the Jews in bondage. It is dipped into
salt water in remembrance of the tears
shed during this time. It also symbolizes
springtime, the season of Passover.
6. A special cup, usually beautifully deco-
rated, is set on the seder table for Elijah,
the prophet who strove to restore purity
of divine worship and labored for social
justice. (Elijah is also believed to be a
messenger of God, whose task it will be
to announce the coming of the Messiah
and the consequent peace and divine
kingdom of righteousness on earth.)
▼ Typical seder meal.
iS
to
ck
ph
ot
o.
co
m
/J
od
i J
ac
ob
so
n
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

C H A P T E R 4 8 9
Shavout, Season of the Giving of the Torah
The two-day festival of Shavout occurs seven
weeks after the second day of Passover and
commemorates the revelation of the Torah to
Moses on Mount Sinai. Traditional Ashkenazi
foods associated with the holiday include blin-
tzes (extremely thin pancakes rolled with a
meat or cheese filling, then topped with sour
cream), kreplach, and knishes (dough filled
with a potato, meat, cheese, or fruit mixture,
then baked).
Fast Days
There are several Jewish fast days in addi-
tion to Yom Kippur (see Table 4.2). On Yom
Kippur and on Tisha b’Av, the fast lasts from
sunset to sunset and no food or water can be
consumed. All other fast days are observed
from sunrise to sunset. Most Jews usually
fast on Yom Kippur, but other fast days are
observed only by Orthodox Jews. Extremely
pious Jews may add personal fast days on
Mondays and Thursdays.6 All fasts can be
broken if it is dangerous to a person’s health;
those who are pregnant or nursing are exempt
from fasting.
Additional information about Jewish
dietary laws and customs associated with
Jewish holidays can usually be obtained
from the rabbi at a local synagogue. The
Union of Orthodox Jewish Congregations of
America also publishes a directory of kosher
products.
Nutrition Status
Although Judism is a religion but in many
ways Jewish people are also considered an eth-
nic group. Few studies have been conducted
to determine the nutritional status of Jews but
certain physiological conditions and medical
disorders have been reported to have a higher
incidence in Jews. It is estimated that 60 per-
cent to 80 percent of Ashkenazi Jewish people
are lactose intolerant.7 Research has identi-
fied a genetic predisposition to inflammatory
bowel disease in Ashkenazi Jews (two to eight
times more common).8
Christianity
Throughout the world, more people follow
Christianity than any other single religion.
The three dominant Christian branches are
Roman Catholicism, Eastern Orthodox Chris-
tianity, and Protestantism. Christianity is
founded on recorded events surrounding the
life of Jesus—believed to be the Son of God
and the Messiah—chronicled in the New Tes-
tament of the Bible. The central convictions of
the Christian faith are found in the Apostles’
Creed and the Nicene Creed. These creeds
explain that people are saved through God’s
grace, through the life and death of Jesus, and
through his resurrection as Christ.
For most Christians, the sacraments mark
the key stages of worship and sustain the indi-
vidual worshiper. A sacrament is an outward
act derived from something Jesus did or said,
The Torah prohibits the
drinking of wine made
by non-Jews because it
might have been pro-
duced for the worship
of idols. Some Orthodox
Jews extend the prohibi-
tion to any grape prod-
uct, such as grape juice
or grape jelly.
Cottage cheese is asso-
ciated with Shavout
because the Israelites
were late in returning
home after receiving the
Ten Commandments and
the milk had curdled.
Many dishes served dur-
ing the holiday contain
cheese fillings.
Tzom Day after Rosh Hashanah In memory of Gedaliah, who ruled after the First
Temple was destroyed
Yom Kippur 10 days after Rosh Hashanah Day of Atonement
Tenth of Tevet
Seventeenth of Tamuz
December
July
Commemorate an assortment of national
calamities listed in the Talmud
Ta’anit Ester Eve of Purim In grateful memory of Queen Esther, who fasted
when seeking divine guidance
Ta’anit Bechorim Eve of Passover Gratitude to God for having spared only the
firstborn of Israel; usually only firstborn son fasts
Tisha b’Av August Commemorates the destruction of the First and
Second Temples in Jerusalem
TA B L E 4 . 2 Jewish Fast Days

©
C
en
ga
ge
L
ea
rn
in
g
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

9 0 F O O D A N D R E L I G I O N
through which an individual receives God’s
grace. The sacraments observed, and the
way they are observed, vary among Chris-
tian groups. The seven sacraments of Roman
Catholicism, for example, are baptism (enter-
ing Christ’s church), confirmation (the soul
receiving the Holy Ghost), Eucharist (partak-
ing of the sacred presence by sharing bread
and wine), marriage (union of a man and
woman through the bond of love), unction
(healing of the mind, spirit, and body), rec-
onciliation (penance and confession), and
ordination of the clergy.
Roman Catholicism
The largest number of persons adhering to
one Christian faith in the United States are
Roman Catholics (approximately 66 million
in 2014).2,9 The head of the worldwide church
is the pope, considered infallible when defin-
ing faith and morals. The seven sacraments
are conferred on the faithful.10
Although some Roman Catholics immi-
grated to the United States during the colo-
nial period, substantial numbers came from
Germany, Poland, Italy, and Ireland in the
1800s and from Mexico and the Caribbean
in the twentieth and twenty-first centuries.
There are small groups of French Catholics
in New England (primarily in Maine) and
in Louisiana. In addition, most Filipinos and
some Vietnamese people living in the United
States are Catholics.
Feast Days Most Americans are familiar with
Christmas (the birth of Christ) and Easter (the
resurrection of Christ after the crucifixion).
Other Christian feast days celebrated in the
United States are New Year’s Day, the Annun-
ciation (March 25), Palm Sunday (the Sunday
before Easter), the Ascension (forty days after
Easter), Pentecost Sunday (fifty days after
Easter), the Assumption (August 15), All
Saints’ Day (November 1), and the Immacu-
late Conception (December 8).
Holiday fare depends on the family’s coun-
try of origin. For example, the French tradi-
tionally serve bû c h e de N oë l (a rich cake in
the shape of a Yule log) on Christmas for des-
sert, while the Italians may serve panettone,
a fruited sweet bread (see individual chapters
on each ethnic group for specific foods associ-
ated with holidays).
Fast Days Fasting permits only one full meal
per day at midday. It does not prohibit the tak-
ing of some food in the morning or evening;
however, local custom as to the quantity and
quality of this supplementary nourishment
varies. Abstinence forbids the use of meat,
but not of eggs, dairy products, or condi-
ments made of animal fat, and is practiced on
certain days and in conjunction with fasting.
Only Catholics older than the age of fourteen
and younger than the age of sixty are required
to observe the dietary laws.11
The fast days in the United States are all the
days of Lent, the Fridays of Advent, and the
Ember Days (the days that begin each season),
but only the most devout fast and abstain on
all of these dates. More common is fasting and
abstaining only on Ash Wednesday and Good
Friday. Before 1966, when the U.S. Catholic
Conference abolished most dietary restric-
tions, abstinence from meat was observed on
every Friday that did not fall on a feast day.
Abstinence is now encouraged on the Fridays
of Lent in remembrance of Christ’s sacrificial
death.
Some older Catholics and those from other
nations may observe the pre-1966 dietary
laws. In addition, Catholics are required to
avoid all food and liquids, except water, for
one hour before receiving communion.
Eastern Orthodox Christianity
The Eastern Orthodox Church is as old as
the Roman Catholic branch of Christianity,
although not as prevalent in the United States.
In the year 300 ce, there were two centers of
Christianity, one in Rome and the other in
Constantinople (now Istanbul, Turkey). Dif-Constantinople (now Istanbul, Turkey). Dif-Constantinople (now Istanbul, Turkey). Dif
ferences arose over theological interpreta-
tions of the Bible and the governing of the
church, and in 1054 the fellowship between
the Latin and Byzantine churches was finally
broken. Some of the differences between the
two churches concerned the interpretation
of the Trinity (the Father, the Son, and the
Holy Ghost), the use of unleavened bread for
the communion, the celibacy of the clergy,
and the position of the pope. In the Eastern
St. Valentine’s Day tradi-
tions may date back to
Lupercalia, a Roman festi-
val held in mid-February,
at which a young man
would draw the name of
a young woman out of a
box to be his sweetheart
for a day.
The commemoration of
the Last Supper is called
Corpus Christi, when
Jesus instructed his
disciples that bread was
his body and wine his
blood. In Spain and many
Latin American countries,
Corpus Christi is cel-
ebrated by parading the
bread (called the “Host”)
through streets covered
with flowers.
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

C H A P T E R 4 9 1
services on Easter Sunday. Easter eggs in the
Eastern Orthodox religion range from the
highly ornate (eastern Europe and Russia) to
the solid reddish brown used by the Arme-
nians and red by the Greeks.
Fast Days In the Eastern Orthodox religion
there are numerous fast days (see Table 4.4).
Further, those receiving Holy Communion on
Sunday abstain from food and drink before
the service. Fasting is considered an opportu-
nity to prove that the soul can rule the body.
On fast days, no meat or animal products
(milk, eggs, butter, and cheese) are consumed.
Fish is also avoided, but shellfish is generally
allowed. Older or more devout Greek Ortho-
dox followers do not use olive oil on fast days,
but will eat olives.
Protestantism
The sixteenth-century religious movement
known as the Reformation established the
Protestant churches by questioning the prac-
tices of the Roman Catholic Church and
eventually breaking away from its teach-
ings. The man primarily responsible for the
Reformation was Martin Luther, a German
Augustinian monk who taught theology.14
He started the movement when, in 1517, he
nailed a document containing ninety-five
protests against certain Catholic practices on
the door of the castle church in Wittenberg,
Orthodox Church, leavened bread, called
phosphoron, is used for Communion, the
clergy are allowed to marry before entering
the priesthood, and the authority of the pope
of Rome is not recognized.
The Orthodox Church consists of four-
teen self-governing churches, five of which—
Constantinople, Alexandria (the Egyptian
Coptic Church), Antioch, Jerusalem, and
Cyprus—date back to the time of the
Byzantine Empire. Six other churches repre-
sent the nations where the majority of peo-
ple are Orthodox (Russia, Rumania, Serbia,
Bulgaria, Greece, and the former Soviet state
of Georgia). Three other churches exist inde-
pendently in countries where only a minority
practice the religion (Poland, Albania, and the
Sinai Monastery). Additionally, there are four
churches considered autonomous, but not
yet self-governing: Czech Republic/Slovakia,
Finland, China, and Japan.12 The Orthodox
Church in America was constituted in 1970.13
The beliefs of the Orthodox churches are sim-
ilar; only the language of the service differs.
The first Eastern Orthodox Church in
America was started by Russians on the
West Coast in the late 1700s. It is estimated
that nearly 3 million persons in the United
States are members of the Eastern Orthodox
religion, with the largest following (1.5 mil-
lion) being Greek.2 Most Eastern Orthodox
churches in the United States recognize the
patriarch of Constantinople as their spiri-
tual leader.
Feast Days All the feast days are listed in
Table 4.3. Easter is the most important holi-
day in the Eastern Orthodox religion and is
celebrated on the first Sunday after the full
moon after March 21, but not before the Jew-
ish Passover. Lent is preceded by a pre-Lenten
period lasting ten weeks before Easter or three
weeks before Lent. On the third Sunday before
Lent (Meat Fare Sunday), all the meat in the
house is eaten. On the Sunday before Lent
(Cheese Fare Sunday), all the cheese, eggs, and
butter in the house are eaten. On the next day,
Clean Monday, the Lenten fast begins. Fish is
allowed on Palm Sunday and on the Annun-
ciation Day of the Virgin Mary. The Lenten
fast is traditionally broken after the midnight
▲ Italian American
Catholics often serve panet-
tone, a sweet bread with
dried fruits, on feast days,
especially Christmas.
Br
az
ilP
ho
to
s/
Sh
ut
te
rs
to
ck
.c
om
Lent is the forty days
before Easter; the word
originally meant “spring.”
The last day before Lent
is a traditional festival of
exuberant feasting and
drinking in many regions
where Lenten fasting
is observed. In France
and in Louisiana, it is
known as Mardi Gras; in
Britain, Shrove Tuesday;
in Germany, Fastnacht;
and throughout the
Caribbean and in Brazil,
Carnival.
The Ethiopian Church is
an Orthodox denomi-
nation similar to the
Egyptian Coptic Church.
Timkat (Feast of the
Epiphany) is the most
significant Christian holi-
day of the year, celebrat-
ing the baptism of Jesus.
Beer brewing, bread
baking, and eating roast
lamb are traditional.
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

9 2 F O O D A N D R E L I G I O N
Germany. A decade later, several countries
and German principalities organized the
Protestant Lutheran Church based on Martin
Luther’s teachings.
Luther placed great emphasis on the
individual’s direct responsibility to God. He
believed that every person can reach God
through direct prayer without the interces-
sion of a priest or saint; thus, every believer
is, in effect, a minister. Although everyone is
prone to sin and inherently wicked, a person
can be saved by faith in Christ, who by his
death on the cross atoned for the sins of all
people. Consequently, to Luther, faith was all-
important and good works alone could not
negate evil deeds. Luther’s theology removed
the priest’s mystical function, encourag-
ing everyone to read the Bible and interpret
the scriptures. The beliefs taught by Martin
Luther established the foundation of most
Protestant faiths.
Other reformers who followed Luther are
associated with specific denominations. In
the mid-sixth century, John Calvin devel-
oped the ideas that led to the formation of the
Presbyterian, Congregationalist, and Baptist
The red Easter egg
symbolizes the tomb of
Christ (the egg) and is
a sign of mourning (the
red color). The breaking
of the eggs on Easter
represents the opening
of the tomb and belief in
the resurrection.
Koljivo, boiled whole-
wheat kernels mixed
with nuts, dried fruit, and
sugar, must be offered
before the church altar
three, nine, and forty
days after the death of
a family member. After
the koljivo is blessed by
the priest, it is distributed
to the friends of the
deceased. The boiled
wheat represents ever-
lasting life, and the fruit
represents sweetness
and plenty.
Feast Day Date
Christmas Dec. 25 or Jan. 7
Theophany Jan. 6 or Jan. 19
Presentation of Our Lord into the Temple Feb. 2 or Feb. 15
Annunciation Mar. 25 or Apr. 7
Easter First Sunday after the full moon after Mar. 21
Ascension 40 days after Easter
Pentecost (Trinity) Sunday 50 days after Easter
Transfiguration Aug. 6 or Aug. 19
Dormition of the Holy Theotokos Aug. 15 or Aug. 28
Nativity of the Holy Theotokos Sept. 8 or Sept. 21
Presentation of the Holy Theotokos Nov. 21 or Dec. 4
NOTE: Dates depend on whether the Julian or Gregorian calendar is followed.
TA B L E 4 . 3 Eastern Orthodox Feast Days
©
C
en
ga
ge
L
ea
rn
in
g
Fast Days
Every Wednesday and Friday except during fast-free weeks:
Week following Christmas until Eve of Theophany (12 days after Christmas)
Bright Week, week following Easter
Trinity Week, week following Trinity Sunday
Eve of Theophany (Jan. 6 or 18)
Beheading of John the Baptist (Aug. 29 or Sept. 27)
The Elevation of the Holy Cross (Sept. 14 or 27)
Fast Periods
Nativity Fast (Advent): Nov. 15 or 28 to Dec. 24 or Jan. 6
Great Lent and Holy Week: 7 weeks before Easter
Fast of the Apostles: May 23 or June 5 to June 16 or 29
Fast of the Dormition of the Holy Theotokos: Aug. 1 or 14 to Aug. 15 or 28
NOTE: Dates depend on whether the Julian or Gregorian calendar is followed.
TA B L E 4 . 4 Eastern Orthodox Fast Days and Periods
©
C
en
ga
ge
L
ea
rn
in
g
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

C H A P T E R 4 9 3
churches; John Wesley founded the Method-
ist movement in the eighteenth century. Other
denominations in the United States include
Episcopalians (related to the English Angli-
can Church started under King Henry VIII);
Seventh-day Adventists; Jehovah’s Witnesses;
Disciples of Christ; Church of Jesus Christ
of Latter-Day Saints (Mormons); Church of
Christ, Scientist (Christian Scientists); and
Friends (Quakers).
The most significant food ordinance in
Protestant churches is the Eucharist, also
called Communion, or the Lord’s Supper.
However, other than a liquid and a conse-
crated breadlike morsel being offered, there
is little consistency in celebration of this ordi-
nance. It can signify an encounter with the
living presence of God, a remembrance of the
Passover seder attended by Jesus, a continuity
of tradition through community, or an indi-
vidual spiritual experience. Though wine is
traditional, many churches switched to grape
juice during Prohibition and continue this
temperance practice. Some churches offer the
wine or juice in a single cup that is shared,
while others provide small, individually filled
cups. Many liturgical churches, such as the
Lutheran Church, offer wafers similar to
Catholic practice. Others, such as Method-
ists, often use a bread pellet. Some organize
their members to bake bread (of any type),
and many denominations simply cut up white
bread of some sort.15 The primary holidays of
the Protestant calendar are Christmas and
Easter. The role of food is important in these
celebrations; however, the choice of items
served is even more varied than Communion
practices, determined by family ethnicity and
preference rather than religious rite. Fasting is
also uncommon in most Protestant denomi-
nations. Some churches or individuals may
use occasional fasting, however, to facilitate
prayer and worship. Only a few of the Prot-
estant denominations, such as the Mormons
and the Seventh-Day Adventists, have dietary
practices integral to their faith.
Mormons The Church of Jesus Christ of
Latter-Day Saints is a religion that emerged
in the United States during the early 1800s.
Its founder, Joseph Smith Jr., had a vision of
the Angel Moroni, who told him of golden
plates hidden in a hill and the means by which
to decipher them. The resulting Book of
Mormon was published in 1829, and in 1830
a new religious faith was born.
The Book of Mormon details the story of
two bands of Israelites who settled in America
and from whom certain Native Americans
and Pacific Islanders are descended.16 Christ
visited them after his resurrection, and they
thus preserved Christianity in its pure form.
The tribes did not survive, but the last mem-
ber, Moroni, hid the nation’s sacred writings,
compiled by his father, Mormon.
The Mormons believe that God reveals
himself and his will through his apostles and
prophets. The Mormon Church is organized
along biblical lines. Members of the priest-
hood are graded upward in six degrees (dea-
cons, teachers, priests, elders, seventies, and
high priests). From the priesthood are cho-
sen, by the church at large, a council of twelve
apostles, which constitutes a group of ruling
elders; from these, by seniority, a church presi-
dent rules with life tenure. There is no paid
clergy. Sunday services are held by groups of
Mormons, and selected church members give
the sermon.17
To escape local persecution, Brigham
Young led the people of the Mormon Church
to Utah in 1847. Today, Utah is more than 60
percent Mormon, and many western states
have significant numbers of church mem-
bers. In North America, the estimated total
number of adherents was 5 million in 2014.2
The main branch of the church is headquar-
tered in Salt Lake City, but a smaller branch,
the Reorganized Church of Jesus Christ of
Latter-Day Saints, is centered in Indepen-
dence, Missouri. All Mormons believe that
Independence will be the capital of the world
when Christ returns.
Joseph Smith, through a revelation, pre-
scribed the Mormon laws of health, dealing
particularly with dietary matters.16 These laws
prohibit the use of tobacco, strong drink, and
hot drinks. Strong drink is defined as alco-
holic beverages; hot drinks mean tea and cof-holic beverages; hot drinks mean tea and cof-holic beverages; hot drinks mean tea and cof
fee. Many Mormons do not use any product
that contains caffeine. Followers are advised
to eat meat sparingly, and to base their diets
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

9 4 F O O D A N D R E L I G I O N
on grains, especially wheat. In addition, all
Mormons are required to store a year’s sup-
ply of food and clothing for each person in
the family. Many also fast one day per month
(donating to the poor the money that would
have been spent on food).
Seventh-Day Adventists In the early 1800s,
many people believed that the Second Com-
ing of Christ was imminent. In the United
States, William Miller predicted that Christ
would return in 1843 or 1844. When both
years passed and the prediction did not mate-
rialize, many of his followers became disil-
lusioned. However, one group continued to
believe that the prediction was not wrong
but that the date was actually the beginning
of the world’s end preceding the coming of
Christ. They became known as the Seventh-
Day Adventists and were officially organized
in 1863.18
The spiritual guide for the new church
was Ellen G. Harmon, who later became
Mrs. James White. Her inspirations were the
result of more than 2,000 prophetic visions
and dreams she reportedly had during her
life. Mrs. White claimed to be not a prophet
but a conduit that relayed God’s desires and
admonitions to humankind.
There were over a million Seventh-Day
Adventists in the United States in 2010 and
18 million worldwide.2 Besides the main belief
in Christ’s advent, or Second Coming, the
Seventh-Day Adventists practice the principles
of Protestantism. They believe that the advent
will be preceded by a monstrous war, pesti-
lence, and plague, resulting in the destruction
of Satan and all wicked people; the earth will
be purified by holocaust. Although the hour of
Christ’s return is not known, they believe that
dedication to his work will hasten it.
The church adheres strictly to the teach-
ings of the Bible. The Sabbath is observed
from sundown on Friday to sundown on Sat-
urday and is wholly dedicated to the Lord.
Food must be prepared on Friday and dishes
washed on Sunday. Church members dress
simply, avoid ostentation, and wear only func-
tional jewelry. The church’s headquarters are
in Tacoma Park, Maryland, near Washington,
DC, where they were moved after a series of
fires ravaged the previous center in Battle
Creek, Michigan.
Each congregation is led by a pastor
(more a teacher than a minister), and all the
churches are under the leadership of the presi-
dent of the general conference of Seventh-Day
Adventists. Adventists follow the apostle Paul’s
teaching that the human body is the temple
of the Holy Spirit. Many of Mrs. White’s writ-
ings concern health and diet and have been
compiled into such books as T h e M inistr y of
H eal ing, C ounsel s on H eal th , and C ounsel s on
Diet and F oods.19,20,21
Adventists believe that sickness is a result
of the violation of the laws of health. One can
preserve health by eating the right kinds of
foods in moderation and by getting enough
rest and exercise. Overeating is discouraged.
Vegetarianism is widely practiced because
the Bible states that the diet in Eden did
not include flesh foods. Most Adventists are
lacto-ovo vegetarians (eating milk products
and eggs, but not meat). Some do consume
meat, although they avoid pork and shellfish.
Mrs. White advocated the use of nuts and
beans instead of meat, substituting vegetable
oil for animal fat, and using whole grains in
breads. Like the Mormons, the Adventists do
not consume tea, coffee, or alcohol and do
not use tobacco products. Water is considered
the best liquid and should be consumed only
before and after the meal, not during the meal.
Meals are not highly seasoned, and hot spices
such as mustard, chili powder, and black
pepper are avoided. Eating between meals
is discouraged so that food can be properly
digested. Mrs. White recommended that five
or six hours elapse between meals.
Islam
Islam is the second-largest religious group in
the world. Although not widely practiced in
the United States, Islam is the dominant reli-
gion in the Middle East, northern Africa, Pak-
istan, Indonesia, and Malaysia. Large numbers
of people also follow the religion in parts of
sub-Saharan Africa, India, Russia, the former
Soviet Union, and Southeast Asia.
Loma Linda Foods began
as a bakery in 1906
providing whole-wheat
bread and cookies to
the Adventist patients
and staff of Loma Linda
University Medical Center
in Southern California.
The American breakfast
cereal industry is the
result of the dietary and
health practices of the
Seventh-Day Adventists.
In 1886, Dr. John Kellogg
became director of the
Adventists’ sanitarium in
Battle Creek, Michigan,
and in his efforts to find a
tasty substitute for meat,
he invented Corn Flakes.
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

C H A P T E R 4 9 5
Islam, which means “submission” (to the
will of God), is not only a religion but also
a way of life.22 One who adheres to Islam is
called a Muslim, “he who submits.” Islam’s
founder, Mohammed, was neither a savior nor
a messiah but rather a prophet through whom
God delivered his messages. He was born in
570 ce in Mecca, Saudi Arabia, a city located
along the spice trade route. Early in his life,
Mohammed acquired a respect for Jewish and
Christian monotheism. Later, the archangel
Gabriel appeared to him in many visions.
These revelations continued for a decade or
more, and the archangel told Mohammed that
he was a prophet of Allah, the one true God.
Mohammed’s teachings met with hostility
in Mecca, and in 622 he fled to Yathrib. The
year of the flight (hegira) is the first year in
the Muslim calendar. At Yathrib, later named
Medina, Mohammed became a religious
and political leader. Eight years after fleeing
Mecca, he returned triumphant and declared
Mecca a holy place to Allah.
The most sacred writings of Islam are found
in the Qur’an (sometimes spelled K or an or
Q ur an), believed to contain the words spoken
by Allah through Mohammed. It includes many
legends and traditions that parallel those of the
Old and New Testaments, as well as Arabian
folk tales. The Qur’an also contains the basic
laws of Islam, and its analysis and interpretation
by religious scholars have provided the guide-
lines by which Muslims lead their daily lives.
Muslims believe that the one true God,
Allah, is basically the God of Judaism and
Christianity but that his word was incom-
pletely expressed in the Old and New Testa-
ments and was only fulfilled in the Qur’an.
Similarly, they believe that Mohammed was
the last prophet, superseding Christ, who is
considered by Muslims a prophet and not
the Son of God. The primary doctrines of
Islam are monotheism and the concept of the
last judgment—the day of final resurrection
when all will be deemed worthy of either the
delights of heaven or the terrors of hell.
Mohammed did not institute an organized
priesthood or sacraments but instead advo-
cated the following ritualistic observances,
known as the Five Pillars of Islam:
1. Faith, shown by the proclamation of the
unity of God, and belief in that unity, as
expressed in the creed, “There is no God
but Allah; Mohammed is the Messenger
of Allah.”
2. Prayer, sal at, performed five times daily
(at dawn, noon, mid-afternoon, sunset,
and nightfall), facing Mecca, wherever
one may be; and on Fridays, the day of
public prayer, in the mosque (a building
used for public worship). On Fridays,
sermons are delivered in the mosque
after the noon prayer.
3. Almsgiving, z ak at, as an offering to the
poor and an act of piety. In some Islamic
countries, Muslims are expected to give
2.5 percent of their net savings or assets
in money or goods. The money is used
to help the poor or to support the reli-
gious organization in countries where
Islam is not the dominant religion. In
addition, zakat is given to the needy on
certain feast and fast days (see the next
section on dietary practices for more
details).
4. Fasting, to fulfill a religious obligation,
to earn the pleasure of Allah, to wipe
out previous sins, and to appreciate the
hunger of the poor and the needy.
5. Pilgrimage to Mecca, h adj , once in
a lifetime if means are available. No
non-Muslim can enter Mecca. Pilgrims
must wear seamless white garments; go
without head covering or shoes; practice
sexual continence; abstain from shav-
ing or having their hair cut; and avoid
harming any living thing, animal, or
vegetable.
There are no priests in Islam; every Muslim
can communicate directly with God, so a
mediator is not needed. The successors of
the prophet Mohammed and the leaders of
the Islamic community were the caliphes (or
k al if ah ). No caliphes exist today. A mufti, like
a lawyer, gives legal advice based on the sacred
laws of the Qur’an. An imam is the person
appointed to lead prayer in the mosque and
deliver the Friday sermon.
If one is unable to attend
a mosque, the prayers
are said on a prayer rug
facing Mecca.
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

9 6 F O O D A N D R E L I G I O N
God; they follow the Qur’an and traditional
Muslim rituals in their temple services. The
movement was originally known as the
Nation of Islam and its adherents identified as
Black Muslims. A split in the Nation of Islam
resulted in one faction of Black Muslims
becoming an orthodox Islamic religion called
the World Community of Al-Islam in the
West. It is accepted as a branch of Islam. The
other Black Muslim faction has continued as
the Nation of Islam under the leadership of
Louis Farrakhan.
Halal, Islamic Dietary Laws
In Islam, eating is considered to be a matter of
worship. Muslims are expected to eat for sur-
vival and good health; self-indulgence is not
permitted. Muslims are advised against eating
more than two-thirds of their capacity, and
sharing food is recommended. Food is never
to be thrown away, wasted, or treated with
contempt. The hands and mouth are washed
before and after meals. If eating utensils are
not used, only the right hand is used for eat-
ing, as the left hand is considered unclean.
Permitted or lawful foods are called
halal. Allah alone has the right to determine
what may be eaten, and what is permitted is
sufficient—what is not permitted is unneces-
sary.26 Unless specifically prohibited, all food
is edible. Unlawful or prohibited (haram)
foods listed in the Qur’an include:
1. All swine, four-footed animals that
catch their prey with their mouths,
birds of prey that seize their prey with
their talons, and any by-products of
these animals, such as pork gelatin or
enzymes used in cheese making. If the
source of any by-product is in question,
it is avoided.
2. Improperly slaughtered animals (includ-
ing carrion). An animal must be killed
in a manner similar to that described
in the Jewish laws, by slitting the front
of the throat; cutting the jugular vein,
carotid artery, and windpipe; and allow-
ing the blood to drain completely. In
addition, the person who kills the ani-
mal must repeat at the instant of slaugh-
ter, “In the name of God, God is great.”
The following prominent sects in Islam
have their origin in conflicting theories on
the office of caliph (caliphate): (1) Sunni,
who form the largest number of Muslims and
hold that the caliphate is an elected office that
must be occupied by a member of the tribe of
Koreish, the tribe of Mohammed. (2) Shi’ia,
the second-largest group, who believe that
the caliphate was a God-given office held
rightfully by Ali, Mohammed’s son-in-law,
and his descendants. The Shiites (followers
of Shi’ia Islam) are found primarily in Iran,
Iraq, Yemen, and India. (3) The Khawarij,
who believe that the office of caliph is open to
any believer whom the faithful consider fit for
it. Followers of this sect are found primarily
in eastern Arabia and North Africa. (4) The
Sufis, ascetic mystics who seek a close union
with God now, rather than in the hereafter.
Only 3 percent of present-day Muslims are
Sufis, and many remain outside mainstream
Islam.23,24
It is estimated that nearly 2.9 million Mus-
lims live in the United States; many came
from the Middle East.2 Most are Sunnis, with
only a small percentage of Shiites, though
there is some crossover in worship and reli-
gious celebrations.25 In addition, some Afri-
can Americans believe Allah is the one true
The Kaaba, in Mecca, is
the holiest shrine of Islam
and contains the Black
Stone given to Abraham
and Ishmael by the arch-
angel Gabriel. During
the hadj, each pilgrim
touches the stone and
circles the shrine.
No one claiming title to
the office of caliphate
has been recognized by
all Muslim sects since
its abolition by the
Turkish government in
1924 following the fall
of the Ottoman Empire.
The role of the caliph-
ate in modern Islam is
uncertain.
The status of fish varies
by sect. Most Muslims
consider anything from
the sea halal; however,
some, such as Shiites, eat
only fish with scales.26
Islamic laws consider
eating to be a matter of
worship, and Muslims are
encouraged to share meals.
N
ig
el
B
ly
th
e/
Ce
ph
as
P
ic
tu
re
L
ib
ra
ry
/A
la
m
y
▲

C H A P T E R 4 9 7
A Muslim can eat or drink prohibited food
under certain conditions, such as when the
food is taken by mistake, when it is forced by
others, or there is fear of dying by hunger or
disease. The term for a food that is question-
ably halal or haram is mash booh , and when in
doubt, a Muslim is encouraged to avoid the
item. Foods that combine halal items with
haram items, such as baked goods made with
lard or pizza with bacon, ham, or pork sau-
sage topping, are also prohibited.28 Muslims
vary in their observance of the halal diet,
however, with the strictest adherence found
among the most orthodox believers.29 Foods
in compliance with Islamic dietary laws are
sometimes marked with symbols registered
with the Islamic Food and Nutrition Council
of America (IFNCA) (Figure 4.3), signifying
the food is fit for consumption by Muslims
anywhere in the world.30
Fish and seafood are exempt from this
requirement.
Some Muslims believe that a Jew or a
Christian can slaughter an animal to
be consumed by Muslims as long as it
is done properly. Others will eat only
kosher meat, while some abstain from
meat altogether unless they know it is
properly slaughtered by a Muslim or can
arrange to kill the animal themselves.
Meat of animals slaughtered by people
other than Muslims, Jews, or Christians
is prohibited. Meat from an animal
that was slaughtered when any name
besides God’s was mentioned is also
prohibited.27
3. Blood and blood products.
4. Alcoholic beverages and intoxicating
drugs, unless medically necessary. Even
foods that have fermented accidentally
are avoided. The drinking of stimulants,
such as coffee and tea, is discouraged, as
is smoking; however, these prohibitions
are practiced only by the most devout
Muslims.
Figure 4.3
Examples of halal food
symbols.
© Cengage Learning
CERTIFIED
HALAL
ISLAMIC FOOD AND NUTRITION
COUNCIL OF AMERICA
MM
My name is Hafsabibi Mojy and I was a student at San Jose State Univer-
sity. I work as a dietitian in a local medical
center. Although I immigrated from India to
the United States in 1994, I am an observant
Muslim, especially when it comes to Islamic
food laws. I will shop at special stores in
order to buy halal meats, which for me
include beef, goat, chicken, veal, and turkey
and are more expensive than meat from the
supermarket. Most Americans I have met do
not know what halal means, and they often
think I am a vegetarian, probably because
I come from India. It is common for me to
call myself a “meat-eating vegetarian” as
I only eat meat at home or places where
halal is available, but otherwise I call myself
vegetarian when I am at places where halal
food is not available.
I do fast from sunrise to sunset during
Ramadan. It is not hard, but it takes a few
days in the beginning to get back to the
rhythm of fasting. To me, personally, I get
thirsty more than hungry. My favorite Islamic
holiday is Eid Al-Adha or Feast of Sacrifice.
It is the most important feast of the Muslim
calendar and lasts for three days. It concludes
the Pilgrimmage to Mecca. The feast reenacts
prophet Ibrahim’s obedience to God by sac-
rificing a cow or ram. The family eats about
a third of the meal and donates the rest to
the poor. My favorite foods include all Indian
meat curry dishes, Biryani (spicy rice pilaf
with meat or chicken), and kabobs.
Health care that includes dietary
modifications may interfere with Islamic
food laws. Say, for example, a patient is on
a clear liquid diet at a hospital . . . there will
be very few choices left to give to a Muslim
patient as Jell-O will be excluded (Jell-O,
considered a clear liquid because it is liquid
at body temperature, contains gelatin which
is usually derived from animals and hence
will be a non-halal item). Some “vegetarian”
dishes contain a chicken-broth base and
hence will be considered non-halal. Even a
vegetarian burger can have wine in it and
will be considered non-halal as all alcohol
products are also prohibited under Islamic
food laws.
N E W A M E R I C A N P E R S P E C T I V E S
Islam
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

9 8 F O O D A N D R E L I G I O N
Feast Days
The following are the feast days in the Islamic
religion:
1. Eid al-Fitr, the Feast of Fast Breaking—
the end of Ramadan is celebrated by a
feast and the giving of alms.
2. Eid al-Azha, the Festival of Sacrifice—
the commemoration of Abraham’s will-
ingness to sacrifice his son, Ishmael, for
God. It is customary to sacrifice a sheep
and distribute its meat to friends, rela-
tives, and the needy.
3. Shab-i-Barat, the night in the middle
of Shaban—originally a fast day, this
is now a feast day celebrated mostly in
non-Arab nations, often marked with
fireworks. It is believed that God deter-
mines the actions of every person for
the next year on this night.
4. Nau-Roz, New Year’s Day—primarily
celebrated by the Iranians, it is the first
day after the sun crosses the vernal
equinox.
5. Maulud n’Nabi—the birthday of
Mohammed.
Feasting also occurs at birth, after the con-
summation of marriage, at Bismillah (when a
child first starts reading the Qur’anic alpha-
bet), after circumcision of boys, at the harvest,
and at death.
Fast Days
On fast days, Muslims abstain from food,
drink, smoking, and coitus from dawn to sun-
set. Food can be eaten before the sun comes
up and again after it sets. Fasting is required
of Muslims during Ramadan, the ninth month
of the Islamic calendar. It is believed that dur-
ing Ramadan, “the gates of Heaven are open,
the gates of Hell closed, and the devil put in
chains.” At sunset, the fast is usually broken by
taking a liquid, typically water, along with an
odd number of dates.
All Muslims past the age of puberty (fif-All Muslims past the age of puberty (fif-All Muslims past the age of puberty (fif
teen years old) fast during Ramadan. A num-
ber of groups are exempt from fasting, but
most must make up the days before the next
Ramadan. They include sick individuals with
a recoverable illness; people who are traveling;
women during pregnancy, lactation, or men-
struation; elders who are physically unable to
fast; people who are mentally disabled; and
those engaged in hard labor. During Rama-
dan, it is customary to invite guests to break
the fast and dine in the evening; special foods
are eaten, especially sweets. Food is often
given to neighbors, relatives, and needy indi-
viduals or families.
Muslims are also encouraged to fast six
days during Shawwal, the month follow-
ing Ramadan; the tenth day of the month of
Muhurram; and the ninth day of Zul Hijjah,
but not during the pilgrimage to Mecca.
A Muslim may fast voluntarily, preferably on
Mondays and Thursdays. Muslims are not
allowed to fast on two festival days: Eid al-Fitr
and Eid al-Azha; or on the days of sacrificial
slaughter: Tashriq—the twelfth, thirteenth,
and fourteenth days of Dhu-al-Hijjah. It is
also undesirable for Muslims to fast exces-
sively (because Allah provides food and drink
to consume) or to fast on Fridays.
Eastern Religions
Hinduism
Hinduism is considered the world’s oldest
religion, and, like Judaism, it is the basis of
other religions such as Buddhism. Although
Hinduism was once popular throughout
much of Asia, most Hindus now live in India,
its birthplace. The common Hindu scriptures
are the Vedas, the Epics, and the Bhagavata
Purana. The Vedas form the supreme author-
ity for Hinduism. There are four Vedas: the
Rigveda, the Samaveda, the Yajurveda, and
the Aatharvaveda.
The goal of Hinduism is not to make
humans perfect beings or life a heaven on
earth but rather to make humans one with the
Universal Spirit or Supreme Being. When this
state is achieved, there is no cause and effect,
no time and space, no good and evil; all duali-
ties are merged into oneness. This goal can-
not be reached by being a good person, but
it can be obtained by transforming human
consciousness or liberation, mok sh a, into a
new realm of divine consciousness that sees
individual parts of the universe as deriving
Some devout Muslims
also avoid land animals
without external ears,
such as snakes and
lizards.
The month of Ramadan
can fall during any part
of the year. The Muslim
calendar is lunar but
does not have a leap
month; thus, the months
occur at different times
each solar year.
Women who wish to
undertake voluntary fasts
must seek permission
from their husbands.
In 2006, a French
humanitarian group
was accused of racism
when it deliberately
served “identity soup”
made with pork parts
to Muslims in need in
the country.
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

C H A P T E R 4 9 9
their true significance from the central unity
of spirit. The transformation of human con-
sciousness into divine consciousness is not
achieved in one lifetime, and Hindus believe
that the present life is only one in a series
of lives, or reincarnations. Hindus believe
in the law of rebirth, which postulates that
every person passes through a series of lives
before obtaining liberation; the law of karma,
that one’s present life is the result of what one
thought or did in one’s past life. In each new
incarnation, an individual’s soul moves up or
down the spiritual ladder; the goal for all souls
is liberation.
Meat Prohibitions
Scientists have calculated that animal protein comprised over 50 percent of
the total daily calories consumed by pre-
historic peoples, a far higher amount than
what most Americans eat today.41 Further, it
is believed that only 1 percent of the world
population refuses to eat all types of meat,
poultry, and fish and that total vegans, who
avoid all animal products, equal only one-
tenth of 1 percent. Humans favor protein
foods. Nevertheless, many cultures impose
some restrictions on what meats may be
consumed, mostly in accordance with pre-
vailing religious dietary laws. The devout
of each faith see little reason to ask why a
particular food is prohibited. It is considered
presumptuous or sacrilegious for humans to
question the directives of God or church.
This has not deterred researchers from
speculating on the rationale of meat taboos.
Some have investigated the whole field of
taxonomy and how animals are classified as
different or unnatural, thus abominable due
to their physical characteristics. The Jew-
ish prohibition against pork, for example,
seems to be because pigs do not chew their
cud, marking them as dissimilar from other
animals with cloven hooves.42 This theory
is supported by the omnivore’s paradox and
the psychological need for food familiarity.
Others have focused on the use of the term
unclean in relation to biblical and Qur’anic
pork prohibitions, claiming that pork con-
sumption is unhealthful. Many researchers
discard this theory because it is thought that
ancient populations could not have made
the association between eating pork and
the slow development of diseases, such as
trichinosis, not to mention that other animals
that carry fatal illnesses (e.g., spongiform
encephalitis or mad-cow disease) are not
avoided.
The socioecological theory for why
certain meats are avoided suggests that if
an animal is more valuable alive than dead
or, conversely, if it does not fit well into the
local ecology or economy, consumption will
be prohibited.43 Religious dietary codes often
reinforce preexisting food practices and prej-
udices. When reviewing the history of pork in
the Middle East, for example, archeological
records show it was part of the ancient diet.
But by 1900 BCE, pork had become unpopular
in Babylonia, Egypt, and Phoenicia, coin-
ciding with an expanding population and
deforestation of the region. Pigs compete
with humans for food sources. Additionally,
they do not thrive in hot, dry climates. Cows,
goats, and sheep, on the other hand, can
graze over large areas and survive on the
cellulose in plants unavailable to human
metabolism. And they need no protection
from the sun. The nomadic Hebrews were
unlikely to have herded pigs in their early
history, and by the time they settled there
was a broad aversion to pigs by many Middle
Easterners. The first followers of Mohammed
were also pastoral people, which may explain
why the only explicitly prohibited animal
flesh in Islam is pork.
The socioeconomic theory is useful in
examining other meat prohibitions. In India,
where beef is banned for Hindus, cattle are
the primary power source in rural farming
communities due to the expense of tractors.
Further, cattle provide dung that is dried to
produce a clean, slow-burning cooking fuel,
and cows provide milk for the dairy products
important in some vegetarian fare. Even dead
cows serve a purpose, providing the very poor
with scavenged meat to eat and skins to craft
leather products. The value of cattle in India
is reinforced by religious custom. Horsemeat
in Europe is a different example. Though
horse consumption was frequent in early
Europe, other cultures who used the animals
for travel and cavalry often banned it. Asian
nomads who roamed on horseback consumed
horse milk and blood but ate the flesh only in
emergencies. It was avoided by the Romans
and most Middle Easterners (prohibited for
Jews and by custom among Muslims). During
the eighth century, when European Christian
strongholds came under attack from Muslim
cavalry in the south and mounted nomads
from the west, Pope Gregory III recognized
the need for horses in the defense of the
church. He prohibited horsemeat as “unclean
and detestable.” However, horse consumption
was never entirely eliminated, especially dur-
ing times of hardship, and gradually religious
restrictions were eased. By the nineteenth
century, horsemeat had regained favor,
especially in France and Belgium, where it is a
specialty item today. Despite the initial need
for horsepower, the religious prohibition was
unsustainable over time because it contra-
dicted prevailing food traditions.
C U L T U R A L C O N T R O V E R S Y
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

1 0 0 F O O D A N D R E L I G I O N
There is one Supreme Being, Brahman,
and all the various gods worshiped by men are
partial manifestations of him. Hindus choose
the form of the Supreme Being that satisfies
their spirit and make it an object of love and
adoration. This aspect of worship makes Hin-
duism very tolerant of other gods and their
followers; many different religions have been
absorbed into Hinduism.
The three most important functions of
the Supreme Being are the creation, protec-
tion, and destruction of the world, and these
functions have become personified as three
great gods: Brahma, Vishnu, and Siva (the
Hindu triad or trinity). The Supreme Being as
Vishnu is the protector of the world. Vishnu
is also an avatara, meaning he can take on
human forms whenever the world is threat-
ened by evil. Rama and Krishna are regarded
as two such embodiments and are also objects
of worship.
Hindus believe that the world passes
through repeating cycles; the most common
version of the creation is connected to the
life of Vishnu. From Vishnu’s navel grows a
lotus, and from its unfolding petals is born the
god Brahma, who creates the world. Vishnu
governs the world until he sleeps; then Siva
destroys it, and the world is absorbed into
Vishnu’s body to be created once again.
The principles of Hinduism are purity,
self-control, detachment, truth, and nonvio-
lence. Purity is both a ceremonial goal and a
moral ideal. All rituals for purification and
the elaborate rules regarding food and drink
are meant to lead to purity of mind and spirit.
Self-control governs both the flesh and the
mind.
Hinduism does not teach its followers to
suppress the flesh completely but rather to
regulate its appetites and cravings. The high-
est aspect of self-control is detachment. Com-
plete liberation from this world and union
with the divine are not possible if one clings
to the good or evil of this existence. Pursuit
of truth is indispensable to the progress of
humans, and truth is always associated with
nonviolence, ahimsa. These principles are
considered the highest virtues. India’s great-
est exponent of this ideal was Mahatma
Gandhi, who taught that nonviolence must
be practiced not only by individuals, but also
by communities and nations.
One common belief of Hinduism is that
the world evolved in successive stages, begin-
ning with matter and going on through life,
consciousness, and intelligence to spiritual
bliss or perfection. Spirit first appears as life
in plants, then as consciousness in animals,
intelligence in humans, and finally bliss in
the supreme spirit. A good person is closer
to the supreme spirit than a bad person is,
and a person is closer than an animal. Truth,
beauty, love, and righteousness are of higher
importance than intellectual values (e.g., clar-
ity, cogency, subtlety, skill) or biological val-
ues (e.g., health, strength, vitality). Material
values (e.g., riches, possessions, pleasure) are
valued least.
The organization of society grows from the
principle of spiritual progression. The Hindu
lawgivers tried to construct an ideal society
in which people are ranked by their spiritual
progress and culture, not according to their
wealth or power. The social system reflects
this ideal, which is represented by four estates,
or castes, associated originally with certain
occupations. The four castes are the Brahmins
(teachers and priests), the Kshatriyas (sol-
diers), the Vaisyas (merchants and farmers),
and the Sundras (laborers). Existing outside
social recognition are the dal its, or untouch-
ables (e.g., butchers, leather workers), a group
of persons who do not fall into the other four
categories; although this designation was out-
lawed by the Indian government in 1950, it
is estimated that untouchables still constitute
almost 14.4 percent of the population.31
The four castes are represented as forming
parts of the Creator’s body: respectively, his
mouth, arms, thighs, and feet. The untouch-
ables were supposedly created from dark-
ness that Brahma discarded in the process
of creation. The castes also conform to the
law of spiritual progression, in that the most
spiritual caste occupies the top and the least
spiritual the bottom. The Hindus believe that
nature has three fundamental qualities: purity,
energy, and inertia. Those in whom purity
predominates form the first caste, energy
the second caste, and inertia the third and
fourth castes. Each caste should perform its
The Seven Social Sins
according to Gandhi are
politics without prin-
ciple; wealth without
work; pleasure without
conscience; knowledge
without character; com-
merce without morality;
science without human-
ity; and worship without
sacrifice.44
Ganesh got his elephant
head when he angered
his father, Siva, who
cut off his human
head. When his mother
pleaded with Siva to
replace his head, Siva
used the head of a
nearby elephant. Hindus
honor Ganesh through
offerings of the foods
he favored.
Yoga means “yoke,”
as in yoking together
or union.
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

C H A P T E R 4 1 0 1
own duties, follow its hereditary occupation,
and cooperate with the others for the com-
mon welfare. People’s good actions in this life
earn them promotion to a higher caste in the
next life.
There are thousands of subdivisions of the
four main castes. The subcastes often reflect a
trade or profession, but some scholars contend
that the latter was imposed on the former. In
reality, the subcaste is very important to daily
life, whereas what major caste one belongs to
makes little difference to non-Brahmins (see
Chapter 14, “South Asians”). The ideal life of
a Hindu is divided into four successive stages,
called asramas. The first stage is that of the
student and is devoted entirely to study and
discipline. The guru becomes an individual’s
spiritual parent. After this period of prepara-
tion, the student should settle down and serve
his or her marriage, community, and country.
When this active period of citizenship is over,
he or she should retire to a quiet place in the
country and meditate on the higher aspects of
the spirit (become a recluse). The recluse then
becomes a sannyasi, one who has renounced
all earthly possessions and ties. This stage
is the crown of human life. The goals of life
are dharma (righteousness), ar th a (worldly
prosperity), k ama (enjoyment), and mok sh a
(liberation). The ultimate aim of life is libera-
tion, but on their way to this final goal people
must satisfy the animal wants of their bodies,
as well as the economic and other demands
of their families and communities. However,
all should be done within the moral law of
dharma. Adherence to dharma reflects a
unique aspect of Hinduism, namely, that prac-
tice is more important than belief. There are
no creeds in Hinduism; it is the performance
of duties associated with one’s caste or social
position that make a person a Hindu.32
Common practices in Hinduism include
rituals and forms of mental discipline. All
Hindus are advised to choose a deity on
whose form, features, and qualities they can
concentrate their mind and whose image
they can worship every day with flowers and
incense. The deity is only a means of realiz-
ing the Supreme Being by means of ritualistic
worship. Externally, the deity is worshiped
as a king or honored guest. Internal worship
consists of prayer and meditation. Mental dis-
cipline is indicated by the word y oga. Along
with mental discipline, yoga has come to mean
a method of restraining the functions of the
mind and their physiological consequences.
Hindus can be divided into three broad
sects according to their view of the Supreme
Being. They are the Vaishnava, the Saiva, and
the Sakta, who maintain the supremacy of
Vishnu, Siva, and the Sakti (the female and
active aspects of Siva), respectively. Different
sects are popular in different regions of India.
Many Hindus do not worship one God exclu-
sively. Vishnu may be worshiped in one of his
full embodiments (Krishna or Rama) or par-
tial embodiments. In addition, there are hun-
dreds of lesser deities, much like saints. One is
Siva’s son, the elephant-headed Ganesh, who
is believed to bring good luck and remove
obstacles.
It is estimated that in 2014 there are nearly
2.2 million Hindus in the United States.2 This
number was based on the U.S. Census of
South Asian Indians, but it was adjusted by
the percentage of the Hindu population in
India.33 It was assumed that the percentage of
Hindus in the United States would be similar
to that found in India. A small percentage of
non–Indian Americans have become follow-
ers of the Hindu religion. The International
Society for Krishna Consciousness, founded
in 1966 by devotees of a sixteenth-century
Bengali ascetic, has the largest number of
converts.
Hindu Dietary Practices
In general, Hindus avoid foods believed to
hamper the development of the body or men-
tal abilities. Bad food habits will prevent one
from reaching mental purity and communion
with God. Dietary restrictions and attitudes
vary among the castes.
The Laws of Manu (dating from the fourth
century ce) state that “no sin is attached to
eating flesh or drinking wine, or gratify-
ing the sexual urge, for these are the natural
propensities of men; but abstinence from
these bears greater fruits.” Many Hindus are
vegetarians.34,35 They adhere to the concept of
ahimsa, avoiding inflicting pain on an animal
by not eating meat. Although the consumption
Some Hindu worshipers
break coconuts on the
temple grounds to sym-
bolize the spiritual expe-
rience. The hard shell
is a metaphor for the
human ego, and once it
is cracked open, the soft,
sweet meat representing
the inner self is open to
becoming one with the
Supreme Being.45
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

1 0 2 F O O D A N D R E L I G I O N
free from pollution; to become pure is to
remove pollution. Certain substances are con-
sidered both pure in themselves and purifying
in their application. These include the prod-
ucts of the living cow—milk products, dung,
and urine—and water from sources of special
sanctity, such as the Ganges River. Pure and
purifying substances also include materials
commonly employed in rituals, such as tur-
meric and sandalwood paste. All body prod-
ucts (e.g., feces, urine, saliva, menstrual flow,
and afterbirth) are polluting. Use of water is
the most common method of purification
because water easily absorbs pollution and
carries it away.
Feast Days
The Hindu calendar marks eighteen major
festivals every year. Additional important
feast days are those of marriages, births, and
deaths. Each region of India observes its own
special festivals; it has been said that there is
a celebration going on somewhere in India
every day of the year. All members of the
community eat generously on festive occa-
sions, and these may be the only days that
very poor people eat adequately. Feasting is
a way of sharing food among the population
because the wealthy are responsible for help-
ing the poor celebrate the holidays.
One of the gayest and most colorful of the
Hindu festivals is Holi, the spring equinox and
the celebration of one of Krishna’s triumphs.
According to legend, Krishna had an evil
uncle who sent an ogress named Holika to
burn down Krishna’s house. Instead, Krishna
escaped and Holika burned in the blaze. It is
traditional for Indians to throw colored water
or powder at passersby during this holiday.
The ten-day celebration of Dusshera in late
September or early October commemorates
the victory of Prince Rama (one of Vishnu’s
embodiments) over the army of the demon
Ravana. It is also a grateful tribute to the god-
dess Durga, who aided Rama. The first nine
days are spent in worshiping the deity, and the
tenth day is spent celebrating Rama’s victory.
Divali, celebrated throughout India in
November, marks the darkest night of the
year, when souls return to earth and must be
shown the way by the lights in the houses. For
of meat is allowed, the cow is considered
sacred and is not to be killed or eaten. If meat
is eaten, pork as well as beef is usually avoided.
Crabs, snails, crocodiles, numerous birds (e.g.,
crows, doves, domesticated fowl, ducks, fla-
mingos, parrots, vultures, and woodpeckers),
antelopes, camels, boars, bats, porpoises, and
fish with ugly forms ( ) should also
be rejected. In addition, the laws make many
other recommendations regarding foods that
should be avoided, including foods prepared
by certain groups of people (e.g., actors, art-
ists, carpenters, cobblers, doctors, eunuchs,
innkeepers, musicians, prostitutes, liars, spies,
and thieves); foods that have been contami-
nated by a person sneezing or through contact
with a human foot, clothing, animals, or birds;
milk from an animal that has recently given
birth; and water from the bottom of a boat.
No fish or meat should be eaten until it has
been sanctified by the repetition of mantras
offering it to the gods. Pious Hindus may also
abstain from alcoholic beverages. Garlic, tur-
nips, onions, leeks, mushrooms, and red-hued
foods, such as tomatoes and red lentils, may
be avoided. Despite such lengthy prohibitions,
Hindus exert considerable personal discretion
regarding taboo foods.36
Intertwined in Hindu food customs is the
concept of purity and pollution. Complex
rules regarding food and drink are meant to
lead to purity of mind and spirit. Pollution is
the opposite of purity and should be avoided
or ameliorated. To remain pure is to remain
Hindus are encouraged
to practice moderation—
they are advised not to
eat too early, not to eat
too late, and not to eat
too much.
According to legend,
Vishnu rested on a
1,000-headed cobra
between the creation
and destruction of the
world. During the festivi-
ties of Naga Panchami,
snakes are venerated at
Hindu temples, and milk
is offered to cobras to
prevent snakebite.
Students studying the
Vedas and other celibates
are usually vegetarians
and may restrict irritating
or exciting foods, such
as honey.
▼ The numerous religious
holidays and secular events
celebrated in India include
feasting, which serves to
distribute food throughout
the community.
U
ni
te
d
N
at
io
ns
/J
. I
sa
ac

C H A P T E R 4 1 0 3
many, Divali is also the beginning of the new
year, when everyone should buy new clothes,
settle old debts and quarrels, and wish every-
one else good fortune.
Fast Days
In India, fasting practices vary according to
one’s caste, family, age, sex, and degree of
orthodoxy. A devoutly religious person may
fast more often and more strictly than one
who is less religious. Fasting may mean eating
no food at all or abstaining from only specific
foods or meals. The fast days in the Hindu cal-
endar include the first day of the new and full
moon of each lunar month; the tenth and elev-
enth days of each month; the feast of Sivaratri;
the ninth day of the lunar month Cheitra; the
eighth day of Sravana; days of eclipses, equi-
noxes, solstices, and conjunctions of planets;
the anniversary of the death of one’s father or
mother; and Sundays.
Buddhism
Siddhartha Gautama, who later became
known as Buddha (the Enlightened One),
founded the Eastern religion of Buddhism
in India in the sixth century bce. Buddhism
flourished in India until 500 ce, when it
declined and gradually became absorbed into
Hinduism. Meanwhile, it had spread through-
out southeastern and central Asia. Buddhism
remains a vital religion in many Asian coun-
tries, where it has been adapted to local needs
and traditions.
Buddhism was a protestant revolt against
orthodox Hinduism, but it accepted certain
Hindu concepts, such as the idea that all liv-
ing beings go through countless cycles of
death and rebirth, the doctrine of karma,
spiritual liberation from the flesh, and that
the path to wisdom includes taming the
appetites and passions of the body. Bud-
dha disagreed with the Hindus about the
methods by which these objectives were to
be achieved. He advocated the Middle Way
between asceticism and self-indulgence,
stating that both extremes in life should be
avoided. He also disagreed with the Hindus
on caste distinctions, believing that all per-
sons were equal in spiritual potential.
The basic teachings of Buddha are found in
the Four Noble Truths and the Noble Eight-
fold Path.37 The Four Noble Truths are as
follows:
1. Duk k h a—The Noble Truth of Suffer-
ing: Suffering is part of living. Persons
suffer when they experience birth, old
age, sickness, and death. They also suf-
fer when they fail to obtain what they
want. At a deeper level, dukkha embod-
ies other concepts, such as imperfection,
emptiness, and impermanence.
2. S amuday a—The Noble Truth of the
Cause of Suffering: This is the arising of
dukkha. Suffering is caused by a person’s
cravings for life, which cause rebirth. It
is manifested by an attachment to plea-
sure, wealth, power, and even ideals and
beliefs.
3. N ir odh a—The Noble Truth of the
Cessation of Suffering: This is the
cessation of dukkha. A person no longer
suffers if all cravings are relinquished.
4. M agga—The Noble Truth to the Path
Leading to the Cessation of Suffer-
ing: This is the Eightfold Path. It is a
middle way between the search for
happiness through pursuit of pleasure
and the search for happiness through
self-mortification and asceticism. By
following this path (right view, right
thought, right speech, right action, right
livelihood, right effort, right mindful-
ness, and right concentration), craving
is extinguished and deliverance from
suffering ensues.
The third and fourth phases of the Eight-
fold Path (Figure 4.4), right speech and right
action, have been extended into a practical
code of conduct known as the Five Precepts.
These are (1) abstain from the taking of life,
(2) abstain from the taking of what is not
given, (3) abstain from all illegal sexual plea-
sures, (4) abstain from lying, and (5) abstain
from consumption of intoxicants because they
tend to cloud the mind.
The person who perfects Buddha’s teach-
ings achieves nirvana, a state of calm insight,
passionlessness, and wisdom. In addition, the
For Hindus, water is the
beverage of choice at
meals. Standing water
is easily defiled if it is
touched by a member
of a lower caste; flowing
water is so pure that even
an untouchable standing
in it does not pollute it.
In southern India the
rice harvest is celebrated
in the festival called
Pongal—new rice is
cooked in milk, and when
it begins to bubble, the
family shouts, “Pongal!”
(“It boils!”).
The Hindu calendar is
lunar; thus, its religious
holidays do not always
fall on the same day on
the Western calendar.
Every three to five years
the Hindu calendar adds
a thirteenth leap month
(a very auspicious period)
to reconcile the months
with the seasons.
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

1 0 4 F O O D A N D R E L I G I O N
Southeast Asia and their descendants. Based
on number of meditation centers, a majority
are believed to be Mahayana.39 A small num-
ber of non-Asians also have more recently
converted to Buddhism. Vajrayana Bud-
dhism, a Tibetan Mahayana sect also known
as Tantric Buddhism, and Zen Buddhism, a
Chinese sect that spread to Japan around the
year 1200, have gained followers, especially in
the West.
Dietary Practices
Buddhist dietary restrictions vary consid-
erably depending on the sect and country.
Buddhist doctrine forbids the taking of life;
therefore, many followers are lacto-ovo vege-
tarians (eating dairy products and eggs, but no
meat). Some eat fish, and others abstain only
from beef. Others believe that if they were not
personally responsible for killing the animal,
it is permissible to eat its flesh.
Feasts and Fasts
Buddhist festivals vary according to region.
From July to October, Buddhist monks are
directed to remain in retreat and meditate,
coinciding with the rainy season and the
sprouting of rice in the fields. The first day of
retreat is a time for worshipers to bring gifts
of food and articles of clothing to the monks;
the retreat ends with pr av ar ana, the end of
the rainy season, when worshipers once again
offer gifts to the monks, invite them to a meal,
and organize processions. On three separate
days (which vary according to the regional
calendar), Mahayana Buddhists commemo-
rate the birth of Buddha, his enlightenment,
and his death; Theravada Buddhists celebrate
Magha Puja, the Four Miracles Assembly, in
February or March when Buddha appointed
the first Buddhist brotherhood of monks at
a coincidental meeting of 1,250 disciples
at a shrine. In April or May they honor the
Buddha on a single holiday called Vesak. Bud-
dhist monks may fast twice a month, on the
days of the new and full moon. They also do
not eat any solid food after noon.
person is no longer subject to rebirth into
the sorrows of existence. Because the ideal
practice of Buddhism is impractical in the
turmoil of daily life, Buddhism has encour-
aged a monastic lifestyle. The ideal Buddhists
are monks, following a life of simplicity and
spending considerable time in meditation.
They own no personal property and obtain
food by begging. They are usually vegetarians
and are permitted to eat only before noon. The
monk confers a favor or merit (good karma)
on those who give him food.
There are numerous sects in Buddhism
and two great schools of doctrine: Theravada
(also known as Hinayana) Buddhism, which
is followed in India and Southeast Asia; and
Mahayana Buddhism, which is followed in
China, Japan, Korea, Tibet, and Mongolia.37,38
Theravada Buddhism is primarily a spiritual
philosophy and system of ethics. It places
little or no emphasis on deities, teaching that
the goal of the faithful is to achieve nirvana.
In Mahayana, a later form of Buddhism,
Buddha is eternal and cosmic, appearing
variously in many worlds to make known
his truth, called dharma. This has resulted in
a pantheon of Buddhas who are sometimes
deified and, for some sects, a hierarchy of
demons. Some sects promise the worshiper a
real paradise rather than the perfected spiri-
tual state of nirvana.
The number of Buddhists in the United
States was over 2.2 million in 20142 major-
ity are immigrants from Japan, China, and
In both Theravada and
Mahayana temples,
worshipers may offer
food at the altar, such
as apples, bananas,
grapes, oranges, pine-
apples, candy, rice, dried
mushrooms, and oil.
A Zen Buddhist monas-
tery, Tassajara, located
in central California is
famous for its vegetarian
restaurant and popular
cookbook. Macrobiotics
is not associated with
Zen Buddhism (see
Chapter 2 “Traditional
Health Beliefs and
Practices”).
Buddhist monks in Tibet
carve sculptures in but-
ter (as high as fifteen
feet) and parade them
during an evening in
March, lit by lanterns,
for Chogna Choeba, the
Butter Lamp Festival.
Afterward they are dis-
mantled and thrown in
the river, symbolic of the
impermanence of life.
Figure 4.4
The Buddhist Wheel of
Law—the spokes represent
the Eightfold Path.
©
C
en
ga
ge
L
ea
rn
in
g
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

C H A P T E R 4 1 0 5
Review Questions
1. What are the basic tenets of Western and
Eastern religions?
2. Pick two of the following religions and describe
the dietary laws for food preparation and con-
sumption, and any additional laws for holy
days: Judaism, Hinduism, and Islam.
3. List the Five Pillars of Faith in Islam and the
Four Noble Truths and Noble Eightfold Path
in Buddhism.
4. Describe and compare the roles of fasting in
Islam and Hinduism, using examples of fasting
practices in each faith.
References
1. Raphael, M.L. 2003. J udaism in A mer ic a. New
York: Columbia University Press.
2. America’s Changing Religious Landscape.
Pew Research Center: Religion and Pub-
lic Life, May 12, 2015. Available from:
h t t p : / / w w w. p e w f o r u m . o r g / 2 0 1 5 / 0 5 / 1 2 /
americas-changing-religious-landscape/.
3. Greenberg, B. 1989. H ow to r un a tr aditional
J ew ish h ouseh ol d. Northvale, NJ: Aronson.
4. Himelstein, S. 1990. T h e J ew ish pr imer . New York:
Facts on File.
5. Shwide-Slavin, C. 2010. J ew ish f ood pr ac tic es. In
C.M. Goody & L. Drago (Eds.), C ul tur al f ood
pr ac tic es. Diabetes C ar e and E duc ation Dietetic
P r ac tic e G r oup. Chicago: American Dietetic
Association.
6. Oxford University Press. 2002. T h e O x f or d
dic tionar y of th e J ew ish r el igion (R.J.Z.
Werblowsky & G. Weigoder, Eds.). New York:
Author.
7. Lloyd, M.L., & Olsen, W.A. 1995. Disaccharide
malabsorption. In W.S. Haubrich, F. Schaffner, &
J.E. Berk (Eds.), B oc k us gastr oenter ol ogy (5th ed.). B oc k us gastr oenter ol ogy (5th ed.). B oc k us gastr oenter ol ogy
Philadelphia, PA: Saunders, 1087–1100.
8. Shugart, Y.Y., Silverberg, M.S., Duerr, R.H.,
Taylor, K.D., Wang, M.H., Zarfas, K., . . . Brant SR.
2008, March. An SNP linkage scan identifies sig-
nificant Crohn’s disease loci on chromosomes
13q13.3 and, in Jewish families, on 1p35.2 and
3q29. G enes and I mmunity , 9 (2), 161–167.
9. National Council of Churches of Christ in the USA.
2012. Y ear book of A mer ic an and C anadian c h ur c h es
(E.W. Lindner, Ed.). Nashville: Abingdon Press.
D I S C U S S I O N S T A R T E R S
Does Your Religion Affect Your Eating Habits?
Explore your own religious and cultural dietary restrictions. Even if you are not religious, you can probably identify the major religions of your culture,
a religion or multiple religions of your parents, grandparents, or great grandparents. It’s probable that, unless you have made a conscious decision
to change your dietary habits from your childhood, you still adhere to at least some of the dietary practices of your family’s religion. Answer the
following:
● What foods and/or drinks are prohibited by your religion—or were prohibited by your family when growing up?
● Are there certain times during the year when your religion directs you—or your family directed you as a child—to avoid certain foods
and drinks or maybe even to fast (not eat at all)?
● Are there certain times during the year when your religion directs you—or when, as a child, your family directed you—to consume
particular kinds of foods or drinks?
● Do you observe certain feast days during the year, days when you are supposed to eat a lot?
After answering the questions, seek out others and compare your answers. Don’t ask only friends. Contact someone at a local mosque, synagogue,
temple, church, or other religious meeting place, and ask to interview someone about her or his religion. Be sure to explain that you are a student
studying food and religion. Another way of finding someone of a different culture and religion to interview is to look for local restaurants serving
foods of particular ethnic groups: Thai, Chinese, Vietnamese, Korean, Japanese, Mexican, Middle Eastern, Indian, Ethiopian, Cuban, Caribbean,
Greek, Italian, French, Cajun, African American, or another culture. Contact the owner or manager to request an interview, again making sure to
explain who you are and your reason for wanting to interview her or him. Because this person may be busy with work, she or he may not be able
to talk with you right away. When meeting with the person for the interview, show her or him these questions and your answers. Compare your
answers with those from your interviewee.
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

1 0 6 F O O D A N D R E L I G I O N
10. Eagan, J.F. 1995. R estor ation & r enew al : T h e
c h ur c h in th e th ir d mil l ennium. Kansas City, MO:
Sheed & Ward.
11. Clancy, P.M.J. 1967. F asting and abstinenc e.
In the new Catholic encyclopedia. New York:
McGraw-Hill.
12. Fairnbairn, D. 2002. E aster n or th odox y th r ough
W ester n ey es. Louisville, KY: Westminster John
Knox Press.
13. Smart, N. 1998. T h e w or l d’ s r el igions (2nd ed.).
New York: Cambridge University Press.
14. Kolb, R. 2004. Martin Luther. In H.J. Hillerbrand
(Ed.), T h e enc y c l opedia of P r otestantism. New
York: Rutledge.
15. Sack, D. 2000. W h itebr ead P r otestants: F ood
and r el igion in A mer ic an c ul tur e. New York:
St. Martin’s Press.
16. Newell, C. 2000. L atter day s: A guided tour
th r ough six bil l ion y ear s of M or monism. New York:
St. Martin’s Press.
17. Douglas, D. 2004. Mormonism. In H.J. Hiller-
brand (Ed.), T h e enc y c l opedia of P r otestantism.
New York: Rutledge.
18. Greenleaf, F. 2004. Seventh-day Adventists. In
H.J. Hillerbrand (Ed.), T h e enc y c l opedia of P r ot-
estantism. New York: Rutledge.
19. White, E.G.H. 1905. T h e ministr y of h eal –
ing. Hagerstown, MD: Review and Herald
Publishing.
20. White, E.G.H. 1923. C ounsel s on h eal th . Hager-
stown, MD: Review and Herald Publishing.
21. White, E.G.H. 1938. C ounsel s on diet and
f oods. Hagerstown, MD: Review and Herald
Publishing.
22. Frager, R. 2002. T h e w isdom of I sl am: A n intr oduc –
tion to th e l iv ing ex per ienc e of I sl amic bel ief and
pr ac tic e. Haupage, NY: Godsfield Press.
23. Denny, F.M., & Mamiya, L.H. 1996. Islam in the
Americas. In A.A. Nanji (Ed.), T h e M usl im al ma-
nac . New York: Gale Research.
24. Waines, D. 1995. A n intr oduc tion to I sl am. New
York: Cambridge University Press.
25. Pew Report. 2007. M usl im A mer ic ans: M iddl e
c l ass and mostl y mainstr eam. Retrieved from
http : / / p e w re s e arch . org / pub s / 4 8 3 / musl i m –
americans (accessed January 17, 2011).
26. Regenstein, J.M., Chaudry, M.M., & Regenstein,
C.E. 2003. The kosher and halal food laws. C om-
pr eh ensiv e R ev iew s in F ood S c ienc e and F ood
S af ety , 2 , 111–127.
27. Chaudry, M.M. 1992. Islamic food laws: Philo-
sophical basis and practical implications. F ood
T ec h nol ogy , 4 6 , 92–93, 104.
28. Kulkarni, K.D. 2010. Asian Indian and Paki-
stani food practices. In C.M. Goody & L. Drago
(Eds.), C ul tur al f ood pr ac tic es. Diabetes C ar e
and E duc ation Dietetic P r ac tic e G r oup. Chicago:
American Dietetic Association.
29. Eliasi, J.R., & Dwyer, J.T. 2002. Kosher and halal:
Religious observances affecting dietary intakes.
J our nal of th e A mer ic an Dietetic A ssoc iation, 1 0 2 ,
911–913.
30. Hussaini, M.M. 1993. I sl amic dietar y c onc epts
and pr ac tic es. Bedford Park, IL: Islamic Food and
Nutrition Council of America.
31. Censusindia.gov.in. n.d. C ensus of I ndia— I ndia at
a gl anc e: S c h edul ed c astes & sc h edul ed tr ibes pop-
ul ation. Retrieved from http://www.censusindia
.gov.in/Census_Data_2001/India_at_Glance/scst
.aspx (accessed January 10, 2010).
32. Flood, G. 1996. A n intr oduc tion to H induism. New
York: Cambridge University Press.
33. Hindu American Foundation. n.d. H indu
demogr aph ic s. Retrieved from http://www
.hafsite.org/resources/hinduism_101/hinduism_
demographics (accessed January 10, 2011).
34. Achaya, K.T. 1994. I ndian f ood: A h istor ic al c om-
panion. Delhi: Oxford University Press.
35. Pandit, B. 2005. T h e H indu mind: F undamental s
of H indu r el igion and ph il osoph y f or al l ages. Glen
Ellyn, IL: Dharma Publishing.
36. Kilara, A., & Iya, K.K. 1992. Food and dietary
practices of the Hindu. F ood T ec h nol ogy , 4 6 ,
94–102, 104.
37. Crosby, K. 2004. Theraveda. In R.E. Buswell (Ed.),
E nc y c l opedia of B uddh ism. New York: Macmillan
Reference.
38. Schopen, G. 2004. Mahayana. In R.E. Buswell
(Ed.), E nc y c l opedia of B uddh ism. New York:
Macmillan Reference.
39. Morreale, D. 1998. Everything has changed in
Buddhist America. In D. Morreale (Ed.), T h e
c ompl ete guide to B uddh ist A mer ic a. B oston:
S h ambh al a.
40. Barrow, K. 2010, April 13. More people choosing
Kosher for health. T h e N ew Y or k T imes.
41. Cordain, L., Miller, J.B., Eaton, S.B., Mann, N.,
Holt, S.H.A., & Speth, J.D. 2000. Plant-animal
subsistence ratios and macronutrient energy
estimations in worldwide hunter-gatherer diets.
J our nal of C l inic al N utr ition, 7 1 , 682–692.
42. Douglas, M. 1966. P ur ity and danger : A n anal y –
sis of c onc epts of pol l ution and taboo. New York:
Praeger.
43. Harris, M. 1998. G ood to eat: R iddl es of f ood and
c ul tur e. Long Grove, IL: Waveland Press.
44. Pandit, B. 2005. T h e H indu mind: F undamental s
of H indu r el igion and ph il osoph y f or al l ages. Glen
Ellyn, IL: Dharma Publishing.
45. Dresser, N. 2005. M ul tic ul tur al manner s: E ssential
r ul es of etiq uette f or th e 2 1 st c entur y . New York:
Wiley.
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

1 0 7
complete disappearance of many traditional
foods and food habits (Figure 5.1). This chap-
ter reviews both the past and present diet of
Native American ethnic groups.
Cultural Perspective
History of Native Americans
Settlement Patterns
It is hypothesized that the Native Ameri-
cans came to North America approximately
20,000 to 50,000 years ago across the Bering
Strait, which links Asia to Alaska, although
some evidence suggests earlier migrations
may have occurred. Archaeological research
provides little insight into the settlement pat-
terns and diversification of Native American
culture in the years before European contact
in the 1600s. Furthermore, the Native Ameri-
can languages were entirely verbal, so writ-
ten historical records are nonexistent. There
are, consequently, enormous gaps in what is
known of early Native American societies.
Observations of Native Americans by
white settlers have been well documented.
These commentaries identified three major
centers of American Indian culture during
the seventeenth century. In the Southeast the
sophisticated social organization of the Cher-
okees, Chickasaws, Choctaws, Creeks, and
Seminoles led the Europeans to call them the
“Five Civilized Tribes.” The Iroquois, in what
is now New York State, ruled a democratic
confederacy of five nations. Religion and the
Native Americans
The designation The designation T Native American, which includes the greatest number of ethnic Tincludes the greatest number of ethnic Tgroups of any minority population in Tgroups of any minority population in T
the United States, is a term for the indigenous
people of the Americas. It is used for both
American Indians and Alaska Natives, who
are comprised of American Indians, Inuit, and
Aleut. Each of the approximately 400 Ameri-
can Indian and Alaska Native nations has its
own distinct cultural heritage.
Over 5 million persons of Native American
heritage lived in the United States in 2009,
according to U.S. Census figures, represent-
ing 2 percent of the total population.1 The
vast majority of American Indians and Alaska
Natives today live west of the Mississippi
River. Roughly half live in rural areas, either
on government reservations or on nearby
farms. Native American ethnic identity varies
tremendously, from tenacious maintenance
of heritage to total adoption of the majority
culture.
Traditional Native American foods have
made significant contributions to today’s diet
in the United States. Corn, squash, beans,
cranberries, and maple syrup are just a few
of the items Native Americans introduced
to European settlers. Historians question
whether the original British colonists would
have survived their first years in America
without the supplies they obtained and the
cooking methods they learned from the Native
Americans. The diet of Native Americans has
changed dramatically from its origins, yet
recent renewed interest in American Indian
and Alaska Native culture has prevented the
5CHA
P
T
E
R
It has been suggested
that native Hawaiians
be included as Native
Americans; however,
the history and culture
of these peoples are
substantially different
from those of Native
Americans of the U.S.
mainland, Alaska, and
Canada, so they are
discussed in Chapter 12,
“Southeast Asians and
Pacific Islanders.” Native
American cultures of
Mexico, Central America,
and South America are
considered in Chapters 9,
“Mexicans and Central
Americans” and 10,
“Caribbean Islanders and
South Americans.”
The U.S. Census uses
the phrase “American
Indians and Alaska
Natives” (abbreviated
AI/AN), and notes that
approximately 15 per-
cent of this population
is also of Hispanic
ethnicity.130
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

1 0 8 N A T I V E A M E R I C A N S
arts flourished in Pueblo communities adja-
cent to the Rio Grande and Little Colorado
Rivers in the Southwest.
The introduction of horses, firearms, and
metal knives changed the lifestyles of many
nations, especially those that used the new
tools to exploit the resources of the Great
Plains. This initial interaction between white
settlers and Plains Indians resulted in the
development of the stereotype of the buffalo-
hunting horseman with feathered headdress
who came to represent all American Indian
ethnic groups. European diseases and the
massacre of whole nations reduced the num-
bers of both Native American individuals and
ethnic groups. In addition, many American
Indians were forced to migrate west to accom-
modate white expansion. The hardships of
involuntary relocation and the deaths caused
by illness and assault may have caused the
extinction of nearly one-quarter of all Native
American ethnic groups.
Native American lands dwindled as
white settlers moved westward. By the late
nineteenth century, the majority of Native
Americans lived on lands held in trust for
them by the U.S. government, called federal
reservations. Still others resided in state res-
ervation communities. Although they were
not required by law to live on reservations,
there were few other viable Native American
communities.
The Bureau of Indian Affairs (BIA) took
over the administration of the reservations
near the turn of the twentieth century. It
established a program of cultural assimilation
designed to bring the Native American resi-
dents into mainstream U.S. society. Before the
1930s, Native American children were sent
to off-reservation boarding schools where
white values were encouraged. Later, public
reservation schools attempted similar indoc-
trination. The BIA program usually failed to
force Native Americans to accept white val-
ues, however. The Native Americans changed
their dress, occupation, and social structure,
but they did not fully assimilate. In many
cases their religious beliefs were strength-
ened, and their involvement in crafts, music,
and dance was deepened to support their
ethnic identity.
Current Demographics
Many Native Americans left the reservations
for the employment opportunities available
during World War II. Some joined the armed
services, where they became fluent in English
and the ways of the majority society. Others
▲ Traditional Native
American foods: Some typical
foods include beans, berries,
corn, fish, jerky, maple syrup,
squash, and tomatoes.
M
ar
ily
n
A
ng
el
W
yn
n/
G
et
ty
Im
ag
es
Figure 5.1
Native food circle: Choices
for a healthy lifestyle.
Source: Great Lakes Inter-Tribal
Council, Inc., Lac du Flambeau.
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

C H A P T E R 5 1 0 9
took war-related industry jobs. In the 1950s
and 1960s, the BIA Employment Assistance
Program was a major factor in the continu-
ing out-migration of Native Americans from
the reservations to the cities. By 2000, two-
thirds of all American Indians and Alaska
Natives resided in the farms, towns, and urban
areas outside of reservations (Figure 5.2).
More recent statistics indicate that 60% live
in metropolitan areas.2,3 Among the states,
California has the highest number of resident
American Indians (fewer than 700, 000), fol-
lowed by Oklahoma and Arizona. In 2009,
the largest ethnic groups within the states of
Alaska, Montana, North Dakota, Oklahoma,
and South Dakota were Alaska natives and
Native Americans/American Indians.2
Large, urban Native American popula-
tions are found in Los Angeles, New York
City, Phoenix, Tulsa, Anchorage, Oklahoma
City, Albuquerque, and Tucson. The remain-
der of the American Indian and Alaska Native
population resides in rural areas, including
reservations where approximately 1.9 mil-
lion individuals reside. Many first-generation
urban Native Americans maintain close ties
with the reservation of their ethnic group and
travel often between the city and tribal land.
Members of the second generation living in
urban regions are more likely to think of the
city as their permanent home.
Socioeconomic Status
The socioeconomic status of Native Americans
declined drastically with the forced migra-
tions of the nineteenth century. Even those
Native American nations that were agricul-
turally self-sufficient suffered when relocated
to regions with poor growing conditions.
Further, there were few native occupations
that were valued in the job market outside the
reservations. BIA education efforts were gen-
erally unsuccessful, and most Native Ameri-
cans did not begin to find employment until
World War II and the development of the BIA
Employment Assistance Program. The Indian
Self-Determination and Education Act of 1975
was enacted to promote Native American
participation in government and education
but economic improvement continues to be
During the early nine-
teenth century, the
Cherokee had a written
language, a bilingual
newspaper, a school sys-
tem, a court system, and
a Cherokee Nation con-
stitution.131 They were a
prosperous tribe; many
owned black slaves.
Figure 5.2
Location of Native American
nations in the continental
United States.
Source: Adapted and reprinted by
permission of the publisher from
Harvard Encyclopedia of American
Ethnic Groups edited by Stephan
Thernstrom, Ann Orlov, and Oscar
Handlin, p. 61, Cambridge, Mass.;
The Belknap Press of Harvard
University Press, Copyright © 1980
by the President and Fellows of
Harvard College.
Indian Reservations in the Continental United States
Co
ur
te
sy
o
f N
at
io
na
l N
A
G
PR
A
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

1 1 0 N A T I V E A M E R I C A N S
slow. Approximately 26 percent of American
Indians and Alaska Natives work in man-
agement and professional occupations.3 The
Apache and Dakota have been active in ranch-
ing and are known for their expertise in the
rodeo circuit.4,6 In the Southwest, small-scale
agriculture and livestock grazing are still
important among some Hopi, Pueblo, and
Navajo peoples; and traditional crafts such
as weaving, pottery, and silversmithing are
significant.7,8,9 Some Alaska Natives combine
part-time paid employment with subsistence
living and often find jobs in the fishing and
forestry industries.10,11,12
The overall poverty rate for Native Ameri-
cans (nearly 26 percent) in 2012 was more
than double that of the general popula-
tion; however, significant tribal differences
are seen. The median family income for
American Indian and Alaska Natives in 2012
was $37,353. Most Alaska Natives have rates
somewhat higher than the U.S. average (15 to
23 percent), while poverty levels among the
Apache, Navajo, and Sioux approached or
exceeded three times the national rates (34 to
39 percent). In 2012, 82 percent of American
Indians and Alaska Natives over 25 years of
age have at least a high school diploma. Seven-
teen percent of American Indians and Alaska
Natives have at least a bachelor’s degree, and
6 percent have an advanced graduate degree.1
Native American Organizations
Few Native American neighborhoods develop
in urban areas. Native Americans who settle
in the cities usually arrive as individuals or
small family groups and typically do not live
near others of their nation. Sometimes long-
time city residents exhibit a sense of superior-
ity over recent arrivals from the reservations.
In general, the difficulties of adjusting to
urban white society stimulate many young
Native Americans to identify not only with
Native Americans of other nations but also
with people from other ethnic groups.
Activists for Native American rights often
come from the cities and are not always sup-
ported by Native Americans who live on tribal
lands. Native American organizations have
done much to maintain Indian identity. Most
areas with large Native American populations
have their own clubs and service associations.
Organizations to promote ethnic identity
have been founded by the Navajo, Pueblo,
Tlingit, Haida, and Pomo. Other groups such
as athletic clubs and dance groups serve the
social needs of the pan–Native American
community.
Worldview
Harmony best describes the Native American
approach to life. Each individual strives to
maintain a balance among spiritual, social,
and physical needs in a holistic approach.
Only what is necessary for life is taken from
the natural environment; the belief is that the
Earth should be cared for and treated with
respect. Generosity is esteemed and competi-
tiveness is discouraged, yet individual rights
are also highly regarded. Personal autonomy
is protected through the principle of noninter-
ference. Among the Navajo, for example, an
individual would never presume to speak for
another, even a close family member. For most
Native Americans, time is conceptualized as
being without beginning or end, and the cul-
ture is present oriented, meaning that the
needs of the moment are emphasized over the
possible rewards of the future.
Religion
Traditional Native American religions vary
from an uncomplicated belief in the power of
a self-declared evangelist to elaborate theo-
logical systems with organized hierarchies
of priests. Yet they all share one characteris-
tic: The religion permeates all aspects of life.
Rather than a separate set of beliefs practiced
at certain times in specific settings, religion is
an integral part of the Native American holis-
tic worldview. Religious concepts influence
both the physical and emotional well-being
of the individual.
Many Native American nations have
rejected all attempts at Christian conver-
sion, especially in the Southwest. The
Navajo, Arizona Hopi, Rio Grande Pueblo,
Potawatomi, Lakota, and Dakota have
retained most of their native religious val-
ues and rituals, such as sweat lodge purifica-
tion rites. Other religions unique to Native
Efforts to increase pros-
perity on reservations
include utilization of
natural resources and
establishment of gam-
bling operations, which
are legal on tribal lands.
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

C H A P T E R 5 1 1 1
Americans emerged after European con-
tact, such as the Drum Dance cult and the
Medicine Bundle religions, which combine
spiritual elements from several different
ethnic groups. A Paiute visionary, Wovoka,
founded the Ghost Dance religion in the late
1880s, which prophesied an end to white
domination through prayer, abstinence
from alcohol, and ritual dancing.13 In addi-
tion, religions mixing Christianity with tra-
ditional beliefs have been popular since the
late nineteenth century; the Native Ameri-
can Church has been especially successful.
Other groups claim Christian fellowship but
continue to practice native religions as well.
Finally, many Native Americans now adhere
to Roman Catholicism or some form of Prot-
estantism, especially in urban areas where
churches have been established to serve all
Native American congregations. In Alaska,
some Alaska Natives have become adherents
of Russian Eastern Orthodoxy.
Family
The primary social unit of Native Americans
is the extended family. Children are valued
highly, and there is great respect for elders.
All blood kin of all generations are consid-
ered equal; there is no differentiation between
close and distant relatives. Aunts and uncles
are often considered like grandparents, and
cousins are viewed as brothers or sisters. Even
other tribal members are sometimes accepted
as close kin. In many Native American societ-
ies an individual without relatives is consid-
ered poor.
Many Native American nations are matri-
lineal, meaning that lineage is inherited from
the mother. Traditionally, property was often
passed down through women in these tribes,
and decision making often rested with an
elder woman in the family.14,15 Today, even in
matrilineal systems, the men are the family
providers and heads of the household; women
are typically in charge of domestic matters.
Due to the respect for the individual within
most Native American groups, men and
women hold equal standing. Native American
children are expected to assist their parents in
running the home.
Traditional Health Beliefs and Practices
In Native American culture, health reflects
a person’s relationship to nature, broadly
defined as the family, the community, and the
environment. Every illness is due to an imbal-
ance with supernatural, spiritual, or social
implications. Treatment focuses on the cause
of the imbalance, not the symptoms, and is
holistic in approach. The sick individual is at
odds with the universe, and community and
family support is focused on restoring har-
mony, not curing the disease.16 As explained
by the Cherokee medicine man, Sequoyah,
“Indian medicine is a guide to health, rather
than a treatment. The choice of being well
instead of being ill is not taken away from an
Indian.”17 Traditional Native American medi-
cine is concerned with physical, mental, and
spiritual renewal through health maintenance,
prevention of illness, and restoration of health.
Many causes account for illness. Some
Navajo believe that witchcraft, through agents
such as animals, lightning, and whirlwinds;
transgressions committed at ceremonial occa-
sions; or evil spirits (especially ghosts) may
cause fainting, hysteria, or other conditions.
Witchcraft may also take the form of insidi-
ous objects, causing pain where the object is
inserted, as well as emaciation. Possession by
a spirit may dislodge the soul, resulting in a
feeling of suffocation (or possession may be a
sign of a gift for healing). Soul loss may also
cause mental disorders. Violation of a taboo,
▲ The primary social
unit of Native Americans
is the extended family,
which includes all close
and distant kin.
H
ill
S
tr
ee
t S
tu
di
os
/B
le
nd
Im
ag
es
/N
ew
sc
om
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

1 1 2 N A T I V E A M E R I C A N S
whether an actual breach by an individual
or contact with evil objects that have com-
mitted mythical breaches, results in general
seizures.18,19 Traditionally, these beliefs are
shared by many other Native Americans as
well. For example, some Iroquois believe in
a similar list of reasons for illness, adding
that unfulfilled dreams or desires may also
be a contributing factor,20 and some Inuit
believe sleep paralysis occurs when the soul
is attacked by malevolent spirits or through
witchcraft.21
Some Native Americans reject the concept
that poor nutrition, bodily malfunctions, or
an infection by a virus or bacteria can cause
sickness. An evil external source is often
identified instead. Some Dakota, for instance,
blame type 2 diabetes on disease-transmitting
foods provided by whites with the intention
of eliminating all Native Americans.22 An
outbreak of serious respiratory infections due
to the Hanta virus was explained by Navajo
healers as being due to rejection of traditional
ways and adoption of convenience foods.23
Some Native Americans attribute alcoholism
to soul loss and the cultural changes due to
domination by white society.15
Small bags of herbs (called “medicine
bundles” by certain Plains Indians), fetishes,
feathers, or symbols may be worn to protect
against malevolent forces. Fetishes are used
when an animal that has been harmed or
killed causes an ailment; a fetish in the form
of the animal is rubbed on the afflicted body
part with appropriate chants.
Traditional healers often specialize in their
practice. Navajo medicine men and women
usually exert a positive influence in preventing
disharmony through rituals such as the sweat
bath to promote peace. They also have nega-
tive powers, which can be used to counteract
witchcraft or evil acts by a person’s enemies.
Diagnosticians may be called on to identify
the cause of an illness through stargazing or
listening (if crying is heard, the patient will
die). Hand motions or trembling also may
be involved, sometimes including painting
with white-, blue-, yellow-, and black-colored
sand to produce a picture of magical healing
power. Other traditional Navajo practitioners
are singers, who cure with sacred chanting
ceremonies, and healers, who have specific
responsibility for care of the soul. Among the
Oneida, dreamers have the ability to see the
future and diagnose illness.24 In many Native
American groups, herbalists, often women,
assist in the treatment of illness through the
ceremonial collection and application of wild
plant remedies.25 (See “Therapeutic Uses of
Food” later in this chapter for examples.)
Among California Native Americans, ill-
ness was treated first with home remedies. If
that proved ineffective, non-sacred healers
such as herbalists or masseuses were con-
tacted. If the patient still did not improve,
a diviner would be consulted for a diagno-
sis. If spiritual or supernatural intervention
was needed, a shaman (medicine man) was
employed. Consultation with native healers
is often concurrent with seeking Westernized
health care.15,26,27
Traditional Food
Habits
The traditional food habits of Native Ameri-
cans were influenced primarily by geog-
raphy and climate. Each Native American
nation adopted a way of life that allowed it to
maximize indigenous resources. Many were
agriculturally based societies, others were pre-
dominantly hunters and gatherers, and some
survived mainly on fish. Most of each day was
spent procuring food.
Ingredients and Common
Foods
Indigenous Foods
Archaeological records and descriptions of
America by European settlers indicate that
Native Americans on the East Coast enjoyed
an abundance of food. Fruits, including blue-
berries, cranberries, currants, grapes, per-
simmons, plums, and strawberries, as well as
vegetables, such as beans, corn, and pumpkins,
are mentioned by the New England colonists.
They describe rivers so full of life that fish
could be caught with frying pans, sturgeon so
large they were called “Albany beef,” and lob-
ster so plentiful that they would pile up along
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

C H A P T E R 5 1 1 3
the shoreline after a storm. Game included
deer, moose, partridge, pigeon, rabbit, rac-
coon, squirrel, and turkey. Maple syrup was
used to sweeten foods. Farther south, Native
Americans cultivated groundnuts (Apios
americana, or Indian potatoes) and tomatoes,
and collected wild Jerusalem artichokes (a
starchy tuber related to the sunflower). Native
Americans of the Pacific Northwest collected
enough food, such as salmon and fruit, during
the summer to support them for the rest of the
year. Peoples of the plains hunted buffalo, and
those of the northeastern woodlands gathered
wild rice; nations of the Southwest cultivated
chile peppers and squash amid their corn (see
Table 5.1).
Native Americans not only introduced
whites to indigenous foods but also shared
their methods of cultivation and food prepa-
ration. Legend has it that the Pilgrims nearly
starved despite the plentiful food supply
because they were unfamiliar with the local
foods. One version of the tale is that Squanto,
the sole surviving member of the Pautuxet
(the other members had succumbed to small-
pox following contact with earlier European
explorers), saved the Pilgrims, who were
mostly merchants, by teaching them to grow
corn. He showed them the Native American
method of planting corn kernels in mounds
with a fish head for fertilizer and using the
corn stalks as supports for beans.
Foods Introduced from Europe
Foods introduced by the Europeans, espe-
cially the French Jesuits in the North and the
Spanish in the South, were well accepted by
Native Americans. Apples, apricots, carrots,
lentils, peaches, purslane, and turnips were
some of the more successful new foods. Settler
William Penn noted that he found peaches in
every large Native American farm he encoun-
tered barely one hundred years after they had
been introduced to the Iroquois. The Europe-
ans also brought rye and wheat. However, few
Native American nations replaced corn with
these new grains.
Livestock made a much greater impact
on Native American life than did the new
fruits and vegetables. Cattle, hogs, and sheep
reduced the Native Americans’ dependence
on game meats. The Creek and Cherokee of
the Southeast fed their cattle on corn and fat-
tened their suckling pigs and young lambs on
Fruits Berries (blackberries, blueberries, cranberries, gooseberries, huckleberries,
loganberries, raspberries, strawberries), cactus fruit (tuna), cherimoya,
cherries (acerola cherries, chokecherries, ground-cherries), grapes (e.g.,
Concord), guava, mamey, papaya, passion fruit (granadilla), pawpaw,
persimmon (American), pineapple, plums (American, beach), soursop
(guanabana), zapote (sapodilla)
Vegetables Avocado, bell peppers (sweet peppers, pimento), cactus (nopales, nopalitos),
chayote (christophine, chocho, huisquil, mirliton, vegetable pear),
pumpkins, squash, tomatillo, tomatoes
Tubers/roots Arrowroot, cassava (yuca, manioc, tapioca), groundnut, Indian breadroot,
Jerusalem artichoke, jicama, malanga (yautia), potatoes, sweet potatoes
Grains/cereals Amaranth, corn (maize), quinoa, wild rice
Nuts/seeds Brazil nuts, cashews, hickory nuts, pecans, pumpkin seeds (pepitas),
sunflower seeds, walnuts (black)
Legumes Beans (green beans, most dried beans), peanuts
Poultry Turkey
Seasonings/flavorings Allspice, chile peppers (e.g., hot and sweet ), chocolate (cocoa), maple syrup,
sassafras (filé powder), spicebush, vanilla
NOTE: Foods native to North, Central, or South America. Some items not indigenous to the United States (e.g., pineapple, potatoes) were popularized only after
acceptance in Europe and introduction by European settlers. Other foods (e.g., avocado, jicama, tomatillo) have become more common in the United States with
the growing Latino population.
TA B L E 5.1 Indigenous Foods of the Americas
©
C
en
ga
ge
L
ea
rn
in
g
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

1 1 4 N A T I V E A M E R I C A N S
apples and nuts. The Powhatan of Virginia fed
their hogs peanuts, then cured the meat over
hickory smoke. Lamb and mutton became sta-
ples in the Navajo diet after the introduction
of sheep by the Spanish. In addition, the Euro-
peans brought horses and firearms, which
made hunting easier, and metal knives and
iron pots, which simplified food preparation.
They also introduced the Native Americans to
distilled spirits.
Staples
The great diversity of Native American cul-
tures has resulted in a broad variety of cui-
sines. The cooking of one region was as
different from that of another as French food
is from German food today. Native American
cooking featured local ingredients and often
reflected the need to preserve foods for future
shortages. The only staple foods common
to many, though not all, Native American
nations were beans, corn, and squash. The
cultural food groups are listed in Table 5.2.
Regional Variations
Native American fare has been divided by
regions into five major types: northeastern,
southern, plains, southwestern, and Pacific
Northwest/Alaska Native. Although each area
encompasses many different Native American
nations, they share similarities in foods and
food habits.
Northeastern The northeastern region of
the United States was heavily wooded, with
numerous freshwater lakes and a long Atlantic
coastline. It provided the local Native Ameri-
cans, including the Iroquois and Powhatan,
with abundant indigenous fruits, vegetables,
fish, and game. Most nations also cultivated
crops such as beans, corn, and squash. Many
of the foods associated with the cooking of
New England have their origins in northeast-
ern Native American recipes. The clambake
was created when the Narragansett and the
Penobscot steamed their clams in beach pits
lined with hot rocks and seaweed. Dried beans
Group Comments Common Foods Adaptations in the United States
Protein Foods
Milk/milk products High incidence of lactose
intolerance among Native
Americans with a high
percentage of Native
American heritage.
No common milk products in
traditional diets.
Powdered milk and evaporated milk
are typical commodity products,
usually added to coffee, cereal,
and traditional baked goods;
ice cream is popular with some
groups.
Some reports have been made of
frequent milk consumption.
Meat/poultry/fish/
eggs/legumes
Meat is highly valued,
considered healthful.
Meats are mostly grilled or
stewed, preserved through
drying and smoking.
Beans are an important
protein source.
Meat: bear, buffalo (including jerky,
pemmican), deer, elk, moose, opossum,
otter, porcupine, rabbit, raccoon,
squirrel.
Poultry and small birds: duck, goose, lark,
pheasant, quail, seagull, wild turkey.
Fish, seafood, and marine mammals:
abalone, bass, catfish, clams, cod, crab,
eel, flounder, frogs, halibut, herring,
lobster, mussels, olechan, oysters,
perch, red snapper, salmon, seal, shad,
shrimp, smelts, sole, sturgeon, trout,
turtle, walrus, whale.
Eggs: bird, fish.
Legumes: many varieties of the common
bean (kidney, navy, pinto, etc.), tepary
beans.
Beef is well accepted; lamb and
pork are also popular.
Canned and cured meats (bacon,
luncheon meat) may be common
if income is limited.
Game is rarely eaten.
Meats remain a favorite food.
Chicken eggs are commonly eaten.
TA B L E 5. 2 Cultural Food Groups
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

C H A P T E R 5 1 1 5
Group Comments Common Foods Adaptations in the United States
Cereals/Grains Corn is primary grain; wild
rice is available in some
areas.
Cornmeal breads (baked, steamed),
hominy, gruels, corn tortillas, piki,
toasted corn; wild rice.
Wheat has widely replaced corn;
store-bought or commodity
breads and sugared cereals are
common.
Fruits/Vegetables Indigenous plants are major
source of calories in diet
of some Native American
nations.
Fruits and vegetables
are either gathered or
cultivated; fruit is a popular
snack food.
Fruit: blackberries, blueberries,
buffalo berries, cactus fruit (tuna),
chokeberries, cherries, crab apples,
cranberries, currants, elderberries,
grapes, groundcherries, huckleberries,
persimmons, plums, raspberries,
salal, salmonberries, strawberries
(beach and wild), thimbleberries, wild
rhubarb.
Vegetables: camass root, cacti
(nopales), chile peppers, fiddleheads,
groundnuts, Indian breadroot,
Jerusalem artichokes, lichen, moss,
mushrooms, nettles, onions, potatoes,
pumpkin, squash, squash blossoms,
sweet potatoes, tomatoes, wild greens
(cattail, clover, cow parsnip, creases,
dandelion, ferns, milkweed, pigweed,
pokeweed, saxifrage, sunflower leaves,
watercress, winter cress), wild turnips,
yuca (cassava).
Cakes, cookies, pastries are popular.
Apples became common after
European introduction.
Apples, bananas, oranges, peaches,
pineapple have been well
accepted; canned fruits are
popular.
Wild berries are still gathered in
rural areas.
Some traditional vegetables are
eaten when available.
Green peas, string beans,
instant potatoes are common
commodity items.
Intake of vegetables is low; variety
is limited.
Potato chips and corn chips often
are popular as snacks.
Additional Foods
Seasonings Chiles, garlic, hickory nut cream, onions,
peppermint, sage, salt, sassafras,
seaweed, spearmint, and other
indigenous herbs and spices.
Nuts/seeds Nuts and seeds are often
an important food source;
acorns are sometimes a
staple.
Acorn meal, black walnuts, buckeyes,
chestnuts, hazelnuts, hickory nuts,
mesquite tree beans, pecans, peanuts,
piñon nuts (pine nuts), pumpkin seeds,
squash seeds, sunflower seeds, seeds
of wild grasses.
Beverages Herbal teas are often
consumed for enjoyment,
therapeutic, or spiritual
value.
Teas of buffalo berries, mint, peyote,
rose hip, sassafras, spicebush, sumac
berries, yerba buena; honey and water.
Coffee, tea, soft drinks are common
beverages. Alcoholism is
prevalent.
Fats/oils Traditional diets vary in fat
content, from extremely
low in the mostly
vegetarian cooking of
California and Nevada
Indians to very high in the
primarily animal-based fare
of Native Alaskans.
Fats rendered from buffalo, caribou,
moose, and other land mammals; seal
and whale fat.
Butter, lard, margarine, vegetable
oils have replaced rendered fats
in most regions; seal and whale
fat are still consumed by the Inuit
and Aleut.
Sweeteners Consumption of sweets is
low in traditional diets.
Maple syrup, other tree saps, honey. Sugar is primary sweetener; candy,
cookies, jams, and jellies are
popular.
©
C
en
ga
ge
L
ea
rn
in
g
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

1 1 6 N A T I V E A M E R I C A N S
were simmered for days with maple syrup (the
precursor of Boston baked beans). The dish
that today is called succotash comes from
a stew common in the diet of most Native
Americans; it combined corn, beans, and
fish or game. In the Northeast it was usually
flavored with maple syrup. Clam chowder,
codfish balls, brown bread, corn pudding,
pumpkin pie, and the dessert known as Indian
pudding are all variations of northeastern
Native American recipes. In addition to clams,
the Native Americans of the region ate lobster,
oysters, mussels, eels, and many kinds of salt-
water and freshwater fish.
Game, such as deer and rabbit, was eaten
when available. Wild ducks, geese, and tur-
keys were roasted with stuffings featuring
crab apples, grapes, cranberries, or local
mushrooms. Corn, as the staple food, was
prepared in many ways, such as roasting the
young ears; cooking the kernels or meal in
soups, gruels, and breads; steaming it in pud-
dings; or preparing it as popcorn. Pumpkins
and squash were baked almost daily, and
beans were added to soups and stews. Local
green leafy vegetables were served fresh.
Sweets included cherries stewed with maple
syrup, cranberry pudding, crab apple sauce,
and hazelnut cakes.
Southern The great variety of foods found
in the northeastern region of the United
States was matched by the plentiful fauna and
lush flora of the South. Oysters, shrimp, and
blue crabs washed up on the warm Atlantic
beaches during tropical storms. The wood-
lands and swamplands teemed with fish, fowl,
and game, including bear, deer, raccoon, and
turtle, as well as ample fresh fruit, vegetables,
and nuts. The Native Americans of this region,
such as the Cherokee, Creek, and Seminole,
were accomplished farmers, growing crops of
beans, corn, and squash.
When Africans were first brought as slaves
to America, they were often housed at the
periphery of farms. Initially a great deal of
interaction took place between blacks and
local Native Americans, who taught them
how to hunt the native game without guns
and to use the indigenous plants. Some of the
Native American cooking techniques were
later introduced into white southern cuisine
by African American cooks, and many of
the flavors typical of modern southern cook-
ing come from traditional Native American
foods. Hominy (dried corn kernels with the
hulls removed) and grits (made of coarsely
ground hominy) were introduced to the set-
tlers by the Native Americans. The chicken
dish known as Brunswick stew is an adapta-
tion of a southern Native American recipe for
squirrel. The Native Americans also made
sophisticated use of native plants for season-
ing, and they thickened their soups and stews
with sassafras.
The staple foods of corn, beans, and squash
were supplemented with the indigenous
woodland fruits and vegetables. Blackber-
ries, gooseberries, huckleberries, raspberries,
strawberries, crab apples, grapes, groundcher-
ries, Jerusalem artichokes, leafy green vegeta-
bles, persimmons (pounded into a paste for
puddings and cakes), and plums were some of
the numerous edible native plants. Tomatoes
and watermelons were added after introduc-
tion by the Spanish into Florida. The Native
Americans of the South also used beechnuts,
A Native American hotel
chef, George Crum,
is attributed with the
invention of potato chips
in 1853. Today Americans
consume an average of
seventeen pounds of
potato chips per person
each year.
S A M P L E M E N U
A Traditional
Northeastern Indian Meal
Iroquois Soupa,b or Duck with Wild Ricea
Bannocksa,c
Indian Puddinga,b or Maple Popcorn Ballsa,c
Strawberry Juice
aCox, B., & Jacobs, M. 1991. Spirit of the harvest: North American Indian cooking.
New York: Stewart, Tabori & Chang.
bRecipeSource at http://www.recipesource.com/ethnic/americas/native/
cRecipe Goldmine at
http://www.recipegoldmine.com/regnativeam/nativeam.html
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

C H A P T E R 5 1 1 7
hazelnuts, hickory nuts, pecans, and black
walnuts in their cooking. The thick, cream-
like oil extracted from hickory nuts was used
to flavor corn puddings and gruels, and a tra-
ditional Cherokee specialty was kanuche, a
soup made from the nuts (often with the addi-
tion of corn, hominy, or rice), is still popular
today. Honey was the sweetener used most
frequently, and it was mixed with water for
a cooling drink. Teas were made from mint,
sassafras, or spicebush (Lindera benzoin), and
during the summer “lemonade” was made
from citrus-flavored sumac berries.
Plains The Native Americans who lived in
the area that is now the American Midwest
were mostly nomadic hunters, following the
great herds of bison across the flat plains for
sustenance. The land was rugged and gener-
ally unsuitable for agriculture. Those nations
that settled along the fertile Mississippi and
Missouri River valleys, however, developed
farm-based societies supported by crops of
beans, corn, and squash.
Bison meat was the staple food for most
plains nations such as the Arapaho, Cheyenne,
Crow, Dakota, and Pawnee. The more tender
cuts were roasted or broiled, while the tougher
ribs, joints, and other bones with marrow
were prepared in stews and soups. Pieces of
meat, water, and sometimes vegetables would
be placed in a hole in the ground lined with
cleaned buffalo skin. The stew would then be
stone boiled: rocks that had been heated in
the fire would be added to the broth until the
mixture was thoroughly cooked. All parts of
the bison were eaten, including the liver and
kidneys (which were consumed raw immedi-
ately after the animal was slaughtered), udder,
tongue, and hump. Extra meat was preserved
by cutting it into very thin strips and then
dehydrating it in the sun or over the fire. This
tough, dried meat would keep for several years
and was known as jerked buffalo or jerky. The
jerky would be pulverized and mixed with
water or corn gruel, or, in emergencies, eaten
dry. Most often it was shredded and mixed
with bison fat and berries, then formed into
cakes called pemmican.
When bison were unavailable, the plains
nations would hunt deer, rabbit, and game
birds. Fresh leafy green vegetables were con-
sumed in season, and root vegetables, such
as wild onions, prairie turnips (Psoralea
esculenta, also called breadroot, tipsin, and
timpsila), and Jerusalem artichokes, were
eaten throughout the year. Wild rice, a native
aquatic grass with an earthy, nutty flavor,
was collected in the northern parts of the
Midwest. It was served with bison, venison,
or duck and used as a stuffing for grouse, par-
tridge, and duck. Wild rice is believed to have
traditionally provided as much as 25 percent
of the total Ojibwa diet, and it was customar-
ily prepared with maple syrup.28 Blackberries,
shadberries (also called Juneberries or saska-
toon berries), cherries, crab apples, grapes,
persimmons, and plums were available in
some areas, but the most popular fruit was
the scarlet buffalo berry (Shepherdia canaden-
sis), so called because it was often served in
sauces for bison meat or dried for pemmican.
In addition, berries were traditionally boiled
with bison suet and/or blood to make a thick
pudding called wojapi.
Southwestern Some of the oldest Native
American settlements in North America
were located along the river valleys of the arid
Southwest. Despite the semidesert conditions,
many Native Americans such as the Hopi,
Pima, Pueblo, and Zuni lived in pueblo (Span-
ish for “town” or “village”) communities and
were mostly farmers, cultivating beans, chili
peppers, corn, and squash. Others, including
the Apache and Navajo, were originally rov-
ing hunters and gatherers. After the Spanish
introduced livestock, some of these nomadic
groups began to raise sheep. Mutton has since
become associated as a traditional staple food
of the region.
Until the arrival of livestock, the diet of the
region was predominantly plant based, pro-
viding a nourishing diet when supplemented
with small game such as rabbit and turkey.
Corn was the primary food, and at least five
different colors of corn were cultivated. Each
color symbolized one of the cardinal points for
the Zuni, and each had its own use in cook-
ing. White corn (East) was ground into a fine
meal and used in gruels and breads. Yellow
corn (North) was roasted and eaten in kernel
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

1 1 8 N A T I V E A M E R I C A N S
form or off the ear. The rarer red (South), blue
(West), and black (the nadir, the lowest point
beneath the observer) corn was used mostly
for special dishes, such as the lacy flat Hopi
bread made from blue cornmeal, known as
piki. Multicolored corn represented the zenith.
The Hopi also attached importance to the
color of corn and cultivated twenty different
varieties. In many areas, corn was prepared in
ways similar to those of the northern Mexican
Native Americans—tortillas (flat, griddle-
fried cornmeal bread), pozole (hominy), and
the tamale-like chukuviki (stuffed cornmeal
dough packets). Juniper ash (considered a
good source of calcium and iron) was often
added to cornmeal dishes for flavoring.29
Beans were the second most important
crop of the southwestern region. Many vari-
eties were grown, including the domesticated
indigenous tepary beans and pinto beans
from Mexico. Both squash and pumpkins
were commonly consumed, and squash blos-
soms were fried or added to soups and salads.
Squash and pumpkin seeds were also used to
flavor dishes, and chile peppers were used as
vegetables and to season stews. Cantaloupes
(also known as muskmelons) were also grown
after they were introduced by the Spanish.
When crops were insufficient, the south-
western Native Americans relied on wild
plants, and to add variety, tender amaranth
greens were eaten in summer. Piñon seeds
(also called pine nuts) flavored stews and
soups. Both the fruit (tunas) and the pads
(nopales) of the prickly pear cactus were
eaten, as were the pulp and fruit of other
succulents, such as yucca (the starchy fruit
known today as “Navajo bananas”). A unique
food popular with some Apache was the root
of the mescal plant, another desert succu-
lent. It would be baked for hours in a cov-
ered, stone-heated pit until it developed a
soft, sticky texture and a flavor similar to
molasses.5 The beans of the mesquite tree
were a staple in some desert regions; they
were ground into a flour and used in gruels,
breads, and sun-baked cakes.
Northwest Coast/Alaska Natives This culinary
region incorporates a diverse geographic area.
The climate of the Pacific Northwest coast is
S A M P L E M E N U
A Traditional
Southeastern Indian Meal
Cherokee Pepper Pot Soupa,b or Brunswick Stewa
Corn Ponea,b,
Huckleberry Honey Cakea,c or Grape Dumplingsa
Honey Water
aCox, B., & Jacobs, M. 1991. Spirit of the harvest: North American Indian cooking.
New York: Stewart, Tabori & Chang.
bRecipeSource at
http://www.recipesource.com/ethnic/americas/native/
cRecipe Goldmine at
http://www.recipegoldmine.com/regnativeam/nativeam.html
S A M P L E M E N U
A Traditional
Great Plains Indian Meal
Pemmicana,b,c
Stuffed Pumpkina or Buffalo/Bison Stewb
Broiled Jerusalem Artichokesa
Chokecherry Puddinga,b or Wojapi (pudding)Wojapi (pudding)Wojapi b
Peppermint Teab
aCox, B., & Jacobs, M. 1991. Spirit of the harvest: North American Indian cooking.
New York: Stewart, Tabori & Chang.
bNative Tech: Indigenous Foods and Traditional Recipes at
http://www.nativetech.org/recipes/index.php
cPemmican: Recipes, Stories and Stores at
http://w4.lns.cornell.edu/~seb/pemmican.html
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

C H A P T E R 5 1 1 9
temperate. The luxuriantly forested hills and
mountain slopes abound with edible plants
and game, and the sea supplies fish, shell-
fish, and marine mammals. Farther north,
in Alaska and Canada, the growing season
shortens to only a few summer months, and
temperatures in the winter regularly plunge
to minus fifty degrees Fahrenheit. Two-thirds
of Alaska is affected by permafrost, and the
vast stretches of tundra are inhospitable to
humans.
The Native American ethnic groups inhab-
iting this region include Indians as well as
the Inuit (Eskimos) and the Aleut, known as
Alaska Natives. Native American nations such
as the Tlingit and Kwakiutl inhabit the north-
west coastal area and some interior Alaskan
regions. The Aleut live on the thousand-mile-
long chain of volcanic islands that arch into the
Pacific from Alaska called the Aleutians. The
Inuit, including the Yupik and Inupiat, live in
the northern and western areas of Alaska, as
well as in Canada, Greenland, and Siberia.
The Native Americans of the Northwest
Coast had no need for agriculture. Food was
plentiful, and salmon was their staple. The fish
were caught annually in the summer as they
swam upstream to spawn. They were roasted
over the fire when fresh, and the eggs, known
today as red caviar, were a favorite treat when
dried in the sun into chewy strips. Extra fish
were smoked to preserve them for the winter.
In addition, cod, clams, crabs, halibut, her-
ring, shrimp, sole, smelt, sturgeon, and trout
were consumed. Ocean mammals such as
otter, seal, and whale were also hunted. Bear,
deer, elk, and mountain goats were eaten, as
were numerous wild fowl and game birds.
Despite the abundant fish and game, wild
plants made up more than half the diet of the
Northwest Coast Native Americans. More
than one hundred varieties of indigenous
fruits, vegetables, and even lichen were con-
sumed, including acorns, blackberries, blue-
berries, chokecherries (Prunus virginiana),
desert parsley, hazelnuts, huckleberries,
mint, raspberries, salal (Gaultheria shallon),
and strawberries. Camass roots (Camassia
quamash), a bulb related to the hyacinth,
were roasted or dried by many Indians of the
region. Fresh greens were also popular.
In contrast to the plenty of the Northwest
Coast, the diet of many Alaska Natives was
often marginal. The Inuit and Aleut were
usually seminomadic, traveling as necessary
to fish and hunt. Fish and sea mammals,
such as seal, walrus, and whale, were the sta-
ple foods. Arctic hare, caribou, ducks, geese,
mountain goats, moose, musk oxen (hunted
to extinction in Alaska by the 1870s), polar
bear, and mountain sheep were consumed
when available. Some items were boiled,
but many were eaten raw due to the lack
of wood or other fuel. The fat of animals
was especially valued as food. Muktuk (also
called muntak or onattak), still a commonly
consumed item, consists of chunks of meat
with the layer of fat and skin attached. Muk-
tuk is typically frozen before use. Walrus or
whale muktuk can also be preserved by roll-
ing it in herbs (with no salt) and fermenting
it in a pit for several months to make a treat
known as kopalchen. Akutok, a favored dish,
was a mixture of seal oil, berries, and cari-
bou fat. Even the stomachs of certain game
were examined for edible undigested foods,
S A M P L E M E N U
A Traditional
Southwestern Meal
Green Chili Stewa,b,c,d
Blue Corn Breadb,c,d or Frybreada,b,c,d
Pueblo Piñon/Feast Day Cookiesa,d or Navajo Peach Crispa,b
aCox, B., & Jacobs, M. 1991. Spirit of the harvest: North American Indian cooking.
New York: Stewart, Tabori & Chang.
bKeegan, M. 1996. Southwest Indian cookbook. Santa Fe, NM:
Clear Light Publishers.
cTraditional Native American Recipes from The Cooking Post at Traditional Native American Recipes from The Cooking Post at Traditional Native American Recipes from The Cooking Post
http://cookingpost.com/recipes.htm
dRecipe Goldmine at
http://www.recipegoldmine.com/regnativeam/nativeam.html
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

1 2 0 N A T I V E A M E R I C A N S
such as lichen in elk and clams in wal-
ruses. The limited selection of wild plants
included willow shrubs, seaweed, mosses,
lichen, a few blueberries, salmonberries,
and cranberries. Leaves from an aromatic
bush known as bog shrub (Ledum palustre)
were brewed to make tundra tea (also called
Hudson Bay tea), a beverage still popular
today.
Other Native American Cuisines Many tra-
ditional Native American diets do not fit
conveniently within the five major regional
cuisines. Among them was the fare of the
population found in what is now Nevada
and parts of California, called Digger Indi-
ans by the first whites to encounter them
because they subsisted mostly on dug-up
roots, such as Indian breadroot, supple-
mented by small game and insects. In central
California, numerous nations, such as the
Miwok and Pomo, had an acorn-based diet.
Acorns contain tannic acid, a bitter-tasting
substance that is toxic in large quantities.
To make the acorns edible, Native Ameri-
can women would first crack and remove
the hard hull, grind the meat into a meal,
add water to make a dough, and then leach
the tannic acid from the dough by repeat-
edly pouring hot water through it. Acorns
were sometimes leached in sandy-bottomed
streams as well.
In the rugged northern mountains and
plains lived nations such as the Blackfeet,
Crow, Shoshone, and Dakota, who were
nomadic hunters of game. Although many
may have hunted bison at one time, they
were limited to the local bear, deer, moose,
rabbits, wildfowl, and freshwater fish when
the expansion of other Native Americans
and whites into the Midwest pushed them
northward and westward. Wild plants added
variety to their diet. For example, the Nez
Percé baked camass roots in a covered pit
with heated rocks, which caramelized the
starch providing a sweet, onion-like flavor.
The cooked roots were made into gruel or
dough for bread.30
Meal Composition
and Cycle
Daily Patterns
Traditional meal patterns varied according to
ethnic group and locality. In the Northeast,
one large, hearty meal was consumed before
noon, and snacks, such as soup, were available
throughout the day. In some tribes, no specific
meal time was standard. The men were served
first, and stood or sat while they consumed
the meal in silence. Women and children
ate next.
▲ Inuit women preparing a
dead seal for butchering.
Be
tt
m
an
n/
CO
RB
IS
S A M P L E M E N U
A Northwest Coast Indian Meal
Barbecued Clamsa or Fresh Salmonc
Elk Stew with Acorn Dumplingsa,b
Steamed Fiddlehead Fernsa,b
Whipped Raspberry (Soup)a,b
aCox, B., & Jacobs, M. 1991. Spirit of the harvest: North American Indian cooking.
New York: Stewart, Tabori & Chang.
bAstray Recipes at http://www.astray.com/recipes/
cKwakuitl Recipes at http://www.hallman.org/indian/recipe.html
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

C H A P T E R 5 1 2 1
Serving two meals per day was more com-
mon in the Southwest. The women would rise
before dawn to prepare breakfast, eaten at sun-
rise. The afternoon was spent cooking the eve-
ning meal, which was eaten before sunset. Two
meals per day was also the pattern among the
Native Americans of the Pacific Northwest.
In regions with limited resources, meals
were often monotonous. The two daily meals
of the southwestern Native Americans, for
example, regularly consisted of cornmeal
gruel or bread and boiled dehydrated vegeta-
bles. No distinction was made between morn-
ing or evening menus. Other dishes such as
game, fresh vegetables, or fruit were included
when seasonally available. The single meal
of the northeastern Native Americans often
included roasted game; the Northwest Coast
Native Americans frequently included some
form of salmon twice a day, in addition to the
many local edible greens and roots.
Food was simply prepared. It was roasted
over the fire or in the ashes or cooked in soups
or stews. The northeastern and Northwest
Coast Native Americans steamed sea-food in
pits; southwestern Native Americans baked
cornmeal bread in adobe ovens called hornos.
(After the introduction of hogs, flat breads
were commonly fried in lard.) Seasonal items
were preserved by drying them in the sun or
smoking them over a fire; for meat, fish, and
oysters, special wood was often used to impart
a distinctive flavor. Other foods were ground
into a meal or pounded into a paste. In Alaska,
meats, greens, and berries were preserved in
fermented (aged) blubber. All nations liked
sweets, but they were limited to fruits and
dishes flavored with maple syrup, honey, or
other indigenous sweeteners.
Special Occasions
Many Native American religious ceremo-
nies were accompanied by feasts. Among the
northeastern Iroquois, seasonal celebrations
were held for the maple, planting, strawberry,
green corn, harvest, and New Year’s festivals.
The southern nations held an elaborate Green
Corn Festival in thanks for a plentiful summer
harvest. No one was allowed to eat any of the
new corn until the ceremony was complete.
Each home was thoroughly cleaned, the fires
were extinguished, and all old pieces of pot-
tery and clothing were replaced with newly
made items. The adult men bathed and purged
themselves with an emetic. When everything
and everyone were thoroughly clean in body
and spirit, a central fire was lit by rubbing two
sticks together, and each hearth fire was relit
with its flames. The feasting on new corn then
began. Amnesty was granted for all offenses
except murder, and the festival signified
the beginning of a new year for marriages,
divorces, and periods of mourning.
Role of Food in Native
American Culture and
Etiquette
Historically, many Native American nations,
especially in the inland regions, experienced
frequent food shortages. As a result, food is
valued as sacred, and, in the holistic world-
view of most Native American groups, food
is also considered a gift of the natural realm.
In some nations elaborate ceremonies accom-
panied cultivation of crops, and prayers were
offered for a successful hunt.
The men in many nations were tradition-
ally responsible for hunting or the care of live-
stock. The job of food gathering, preparation,
and storage usually belonged to the women, ▼ Baking bread in a south-
western outdoor oven.
Be
tt
m
an
n/
Co
rb
is
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

1 2 2 N A T I V E A M E R I C A N S
who also made the cooking utensils, such
as watertight baskets or clay pots.8,24 In pre-
dominantly horticultural societies, both men
and women were frequently involved in cul-
tivation of the crops. Among the nations of
the Northeast, the men ate first, followed by
women and children. In the Southwest, men
prepared the game they caught and served it
to the women.
Sharing food is an important aspect of
most Native American societies today. Food
is usually offered to guests, and in some tribes
it is considered rude for a guest to refuse food.
It is also impolite to eat in front of others with-
out sharing.31 Any extra food is often given
to members of the extended family. In some
nations of the Southwest, meals are prepared
and eaten communally. Each woman makes
a large amount of one dish and shares it with
the other families, who in turn share what
they have prepared. Many Native Americans
find the idea of selling food inconceivable; it
is suggested that this is one reason there are
few restaurants featuring Native American
specialties.
Therapeutic Uses of Food
The role of food in spiritual and physical
health is still important for many Native
Americans, and many food plants provide
medicine in some form. Corn is significant in
some healing ceremonies. Cornmeal may be
sprinkled around the bed of a patient to pro-
tect him or her against further illness. Corn
pollen may be used to ease heart palpitations,
and fine cornmeal is rubbed on children’s
rashes. Navajo women drink blue cornmeal
gruel to promote the production of milk after
childbirth, and Pueblo women use a mixture
of water and corn ear smut (Ustilago maydis a
kind of fungus) to relieve diarrhea and to cure
irregular menstruation. A similar drink was
given to Zuni women to speed childbirth and
to prevent postpartum hemorrhaging. Corn
silk tea was used as a diuretic and was pre-
scribed for bladder infections.32
Numerous other indigenous plants are
used by Native Americans for medicinal
purposes. For example, agave leaves (from
a succulent common in the Southwest) are
chewed as a general tonic, and the juice is
applied to fresh wounds. Another succu-
lent, yucca, was considered a good laxative
by the Hopi. Pumpkin pastes soothe burns.
Chile peppers are used in compresses for
arthritis and applied directly to warts. Infu-
sions are used for many remedies, such as
wild strawberries or elderberry flowers for
diarrhea and mint tea to ease colic, indi-
gestion, and nausea. The Ojibwa boiled
blackberry roots to prevent miscarriages
and sumac fruit and roots to stop bleeding.
Traditionally, maple sugar lozenges were
used for sore throats. Bitter purges and
emetics are administered because they are
distasteful and repugnant to any evil spirits
that might cause illness.33
Food restrictions are still common dur-
ing illness. Depending on the nation, many
Native Americans believe that cabbage, eggs,
fish, meat, milk, onions, or organ meats
should be eliminated from a patient’s diet.
Conversely, some foods may be considered
important to maintain strength during sick-
ness, such as meat among the Seminole in
Florida,34 and both meat and blue cornmeal
among the Navajo.35 The Navajo may avoid
sweets during pregnancy to prevent having a
weak infant.16 Some foods are prohibited after
childbirth, such as cod, halibut, huckleberries,
and spring salmon for Nootka women of the
Northwest Coast.
Native Americans found many plants had
psychotherapeutic properties. They were
used to relax and sedate patients, to stupefy
enemies, and to induce hypnotic trances dur-
ing religious ceremonies. The opiates in the
roots of California poppies dulled the pain of
toothache, for example. Lobelia was smoked
as an antispasmodic for asthma and bronchi-
tis. In the Southwest, knobs from the peyote
cactus were used to produce hallucinations,
sometimes in combination with other intoxi-
cants. Jimsonweed (Datura stramonium) was
traditionally used to keep boys in a semicon-
scious state for twenty days so that they could
forget their childhood during Algonquin
puberty rites.36 It is still used today by some
Native Americans for medicinal and ritual
purposes.
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

C H A P T E R 5 1 2 3
Contemporary Food
Habits
Native American ethnic identity is chang-
ing. Traditional beliefs and values are often
in direct conflict with those of the majority
society, and Native Americans’ self-concept
has undergone tremendous changes in the
process of acculturation. Three transitional
adaptations of members of the Ojibwa (also
called Chippewa) tribe, identified by three
different lifestyles, may serve as a model for
the adaptations made by members of other
Native American groups.37 The first stage of
adaptation is traditional; during this stage
parents and grandparents speak the Ojibwa
language at home, practice the Midewiwin
religion, and participate in Native American
cultural activities such as feasts and pow-
wows. The second stage is more acculturated.
English is the primary language, although
some Ojibwa also is spoken. Catholicism
is the preferred religion, and the family is
involved in activities of the majority soci-
ety. In the third Ojibwa lifestyle—the pan-
traditional stage—the family speaks either
English or Ojibwa exclusively; practices
a religion that is a combination of Native
American and Christian beliefs, such as the
Native American Church; and is actively
involved in activities of both traditional
Native American and white societies.
Adaptation of Food Habits
Food habits reflect changes in Native Ameri-
can ethnic identity. Many Native Americans
eat a diet that includes few traditional foods.
Others are consciously attempting to revive
the foods and dishes of their ancestors.
Ingredients and Common Foods
When Native Americans were uprooted from
their lands and their known food supplies,
many immediately became dependent on the
foods provided to the reservations. One study
evaluating the diets of Havasupai Indians liv-
ing on a reservation in Arizona found that
58 percent of the subjects ate only foods
purchased or acquired on the reservation
during the twenty-four-hour recall period.38
Commodity foods currently include items
such as canned and chopped meats, poultry,
fruit juices, peanut butter, eggs, evaporated
and powdered milk, dried beans, instant
potatoes, peas, and string beans. Research-
ers report that many of these foods, such as
kidney beans, noodles, and peanut butter,
are discarded by the Navajo; powdered milk
may also be rejected because it is disliked or
is considered a weak food suitable only for
infants or elderly people.19 On some reserva-
tions, large supermarkets provide a selection
of foods similar to that found throughout the
United States; however, on more remote res-
ervations and in many rural areas access to
markets is very limited.18,39,40 Other sources of
food include gardening (reportedly practiced
by between 43 and 91 percent of rural Native
Americans), fishing, hunting, gathering indig-
enous plants, and raising livestock. One study
of California Miwok, for instance, reports that
67 percent of respondents recall that their
grandparents harvested wild greens, nuts,
berries, and mushrooms, and that 47 percent
of respondents continue to supplement their
diet this way.41 A national Canadian survey
reported that 66 percent of aboriginal peoples
obtained some of their meat, poultry, and
fish through hunting and fishing; 10 percent
obtained most in this way; and 5 percent
obtained all this way.42 These supplementary
food sources are limited by seasonality and,
in some cases, by state and federal hunting
and fishing laws.39 Native Americans living in
urban areas have the same access to food as
other city dwellers.
Over the years, traditional foods were lost
and substitutions were made. For example,
beef is a commonly accepted substitute for
game among many Native American ethnic
groups. Fry bread is another example. It is a
flat bread made from wheat flour typically
fried in lard, and has been prepared in the
Southwest for about one hundred years and
in other regions for even less time. Though
made from ingredients introduced by the
Europeans, it is one of the items most often
identified as “traditional” among Indians
throughout the nation,43 and it is often served
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

1 2 4 N A T I V E A M E R I C A N S
at Native American festivals. It has been sug-
gested that the substitution of Western foods,
especially commodity items, in the prepara-
tion of traditional Indian dishes has adversely
affected the nutritional value of these foods.44
Traditional foods make up less than 25 per-
cent of the daily diet among the Hopi. Older
Hopi women lament the fact that younger
Hopi are no longer learning how to cook
these dishes.45 In a study of Cherokee women,
the degree of Native American heritage of the
woman in charge of the food supply in the
home directly affected the consumption of
traditional foods in that home.46 Corn and
corn products, such as hominy, were among
the most popular traditional foods; game
meat, hickory nuts, raspberries, and win-
ter squash were the least commonly served.
Among Cherokee teenagers, traditional items
such as fry bread, bean bread (corn bread with
pinto beans), and chestnut bread (made from
chestnuts and cornmeal) were well accepted.
Although more than 80 percent of the ado-
lescents were familiar with typical Cherokee
dishes, including native greens and game
meat (bear, deer, groundhog, rabbit, raccoon,
squirrel, and wild boar), these foods were
rarely eaten.47 Pima consume traditional
items, such as tepary beans and cactus stew,
mostly at community get-togethers.48 A small
sample of children from four different Native
American communities recorded that only
7 out of 1,308 items listed in food recalls for
the study were traditional.49 California Miwok
list mostly southwestern items such as beans,
rice, and tortillas as those they most associ-
ate with Native American foods and recall
numerous items eaten by their grandparents
but not consumed now, such as squirrel, rab-
bit, deer, acorn mush, and certain insects.
Access to wild game is limited due to hunt-
ing restrictions. Navajo women eat traditional
foods infrequently, with the exception of fry
bread, mutton, and tortillas. Blue cornmeal
mush (with ash), hominy, and sumac berry
pudding are a few of the native dishes con-
sumed occasionally.50 Dakota women of all
ages take pride in traditional foods but pre-
pare them only when it is convenient or for
special occasions. A study of Sencotan Indians
in British Columbia found that marine foods,
especially salmon, retain social and economic
importance within the community.51 Among
some Baffin Inuit, traditional foods (e.g., sea
and land mammals, fish) make up about one-
third of energy intake. Men were found to eat
more traditional items than women.52 A study
of Yupik Inuit found that younger respondents
(ages 14–19) ate significantly fewer traditional
foods than did the oldest respondents
(ages 40–81).53
Broader efforts to preserve traditional and
adapted Native American food traditions are
also underway. Notably, the group Renewing
America’s Food Traditions (RAFT), a coali-
tion of organizations dedicated to bring-
ing the foods of the past into the present,
have listed over 700 endangered food items
(see Table 5.3). Support of communities
attempting to recover and conserve food
traditions is their primary goal.54
Meal Composition and Cycle
Little has been reported regarding current
Native American meal patterns. It is assumed
that three meals per day has become the
norm, especially in families without income
constraints. Meals consumed by Native Amer-
icans vary considerably among regions. In
the text Cultural Food Practices, the diet for
Northern Plains Indians’ is described as one
centered around meats and starches with a
limited variety of fruits and vegetables. The
access to commodity food supplements also
influences food choices.18 The Navajo still use
traditional cooking methods but have also
adapted to using more fat and salt in food
preparation.18 Navajo women were found to
eat fry bread or tortillas, potatoes, eggs, sugar,
and coffee most frequently. Fried foods were
preferred for breakfast, and lunch and dinner
consisted of one boiled meal and one fried
or roasted meal. The Pima in Arizona prefer
eggs, bacon or sausage, and fried potatoes for
breakfast, while Southwest specialties, such as
tacos, tamales, and chili con carne, are com-
mon at other meals. A study comparing Indi-
ans in New England living on reservations to
those living in urban areas found baking and
boiling remain favored preparation meth-
ods by respondents living on reservations,
whereas urban residents were more likely to
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

C H A P T E R 5 1 2 5
fry items. Grilled meats and smoked fish were
also common ways of cooking.43
Special Occasions
Numerous traditional celebrations are main-
tained by Native American tribal groups.18
Among the largest is the five-day Navajo
Nation Fair held each Labor Day weekend;
the Pawnee Veteran’s Day Dance and Gather-
ing where ground meat with pecans and corn
with yellow squash are served; the Miccosukee
Arts Festival and the Seminole Fair in Miami,
where alligator meat is featured; the Iroquois
Midwinter Festival held in January to mark the
new year; the Upper Mattaponi Spring Festival
in Virginia over Memorial Day weekend; the
three-day Creek Nation Festival and Rodeo;
the Yukon International Storytelling Festival
at which wild game such as caribou and musk
ox are available; and the Apache Sunrise Cer-
emony which features gathered foods such as
amaranth leaves and the pulp and fruit from
the saguaro and prickly pear cacti. More local
festivities are also common. Pueblo Feast Days
are observed in honor of the Catholic patron
saint of each village with a soup of posole
(hominy) and beef or pork ribs. Northwest
Coast potlatches are common in the spring,
featuring herring roe, fish or venison stews,
euchalon, salmon, and other traditional foods.
In addition, there are all-Indian festivals that
draw attendees from throughout the country,
such as O’Odham Tash Indian Days in
Casa Grande, Arizona; the Red Earth Festival
in Oklahoma City; and the Gallup Intertribal
Indian Ceremonial in New Mexico. Native
Americans may also eat traditional foods on
special occasions such as birthdays, but for
holidays of the majority culture, other foods
are considered appropriate. For example, tur-
key with all the trimmings is served by the
Dakota for Thanksgiving and Christmas.55
Chapalote Corn Considered the original cultivated corn with small ears, coffee-colored kernels,
and a flinty flavor
Chiltepin Pepper Pea-sized, very hot wild chile pepper native to the Southwest considered the
ancestor of most varieties used today—drought, diminishing habitat, and
unscrupulous harvesting threatens this chile with extinction
Eulachon Smelt Pacific Northwest source of oil that has suffered serious declines in
population—further, traditional methods of processing are gradually being lost
Gulf Coast Sheep Introduced to the Southeast by the Spanish in the 1500s, this breed adapted
well to the humid conditions of the region, providing excellent meat and
wool—newer breeds are lessening their popularity
Java Chicken One of the first chicken breeds introduced to the United States, these birds now
number only about one hundred
Marshall Strawberry An heirloom fruit discovered in Massachusetts in 1890 but grown commercially
in the Pacific Northwest—very intense flavor
Native American
Sunflowers
Indigenous plants cultivated by the Native Americans for seeds and oil—
brought to Europe as an oil source—popularity of the oil led to growing a
single “improved” variety, and this one type is now susceptible to numerous rust
diseases—few sources of the original seeds remain
Pineywoods Cattle A foraging breed introduced by the Spanish to Florida, particularly suited to
conditions in the South, and popular with early Native American ranchers—
approximately 200 animals are left
Seminole Pumpkin A pear-shaped pumpkin grown on vines that use trees for support—found in
the Everglades but rarely cultivated today
White Abalone The deepest inhabitant of West Coast Abalone, it has neared extinction due
to the popularity of its sweet meat—now being bred in a recovery program
designed to save it
SOURCE: Nabhan, G.P., & Rood, A. 2004. Renewing America’s Food Traditions (RAFT): Bringing cultural and culinary mainstays of the past into the new millennium.
Flagstaff: Center for Sustainable Agriculture at Northern Arizona University.
TA B L E 5. 3 America’s Top Ten Endangered Foods
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

1 2 6 N A T I V E A M E R I C A N S
Nutritional Status
Nutritional Intake
Research on the nutritional status of Native
Americans is limited. Severe malnutrition
was documented in the 1950s and 1960s,
including numerous cases of kwashiorkor
and marasmus. Today, lower socioeconomic
status and higher unemployment contribute
to an inadequate diet for some Native Ameri-
cans. In general, however, recent changes in
morbidity and mortality figures suggest that
Native Americans have transitioned from the
conditions associated with underconsump-
tion, such as infectious diseases, to conditions
associated with overconsumption, including
obesity, type 2 diabetes, and cardiovascular
disease.56
Studies of current Alaska Native eat-
ing habits suggest that diets high in refined
carbohydrates (starchy and sugary foods)
and fat, and low in fruits and vegetables, are
common. The protein and nutrient of Alaska
Natives has declined during the past several
decades, as many foods obtained through
hunting and gathering were replaced by pro-
cessed, canned, and packaged items.57 The
estimated carbohydrate content of the Alaska
Native diet before contact with Westerners
was exceptionally low (3 to 5 percent of daily
calories) due to a dependence on sea mam-
mals and fish. Within only a few generations,
that figure had increased to 50 percent of total
calories, much of it from low-nutrient-density
foods.58,59 Research on Alaska Natives has also
shown low intakes of calcium, iron, phospho-
rus, magnesium, zinc, vitamins A, C, D, and
E, riboflavin, and folic acid, as well as fiber,
omega-6, and omega-3 fatty acids. Traditional
Alaska Native diets have been found lower in
fat and carbohydrates, and higher in protein,
phosphorus, potassium, iron, zinc, copper,
magnesium, manganese, selenium, and sev-
eral vitamins, including A, D, E, riboflavin,
and B6.
60,61,62,63
A similar transition occurred in the diets of
American Indians in other parts of the nation;
and today, refined carbohydrates are promi-
nent in the diet. Studies have identified white
breads, tortillas, potato chips, French fries,
and candy as the top contributors of energy
for many Native Americans.49,64,65,66,67 Of par-
ticular note is the consumption of sweetened
beverages, including soda and fruit-flavored
drinks, estimated to be 15 to 27 percent of
all carbohydrates consumed, and as much as
17 percent of daily calories.64,67,68,69,70,71 High-
fat foods, including fried foods and processed
meats and beef dishes, are another significant
source of energy.
A low intake of fruits and vegetables is
prevalent in the diets of both Native Ameri-
can adults and adolescents.64,65 Of Indians in
California, 60 percent said they had not eaten
any fruit the previous day, and 28 percent
reported they had not consumed any vege-
tables.72 Among the Lakota of South Dakota,
nearly 60 percent stated they ate fruit only two
to eight times a month; nearly half reported
eating vegetables (including potatoes) over
five times weekly.73 A study of Catawba
showed 47 percent ate less than one fruit daily,
and 87 percent consumed only one vegetable
or less.74 The vegetable most often consumed
in a study of Native American women in
Oklahoma was French fries; and only toma-
toes, tossed salad, green beans, potato salad,
and mashed potatoes were also mentioned in
the list of the top fifty-three items most often
eaten.69 Barriers to increased consumption of
fruit and vegetables included cost, availability,
and quality.
Native American nutrient intake has been
compared to that of the general population in
a few studies. It is notable that among both
children and adults, few differences are found.
One large study in three states reported that
median intakes of vitamins A and C and folate
were low for both American Indians and the
total population.75 A comparison of dietary
calcium intake among African American,
Native American, and white women in North
Carolina found that although whites ate sig-
nificantly more high-calcium foods than did
Native Americans, none of the respondents
were consuming recommended levels of the
mineral through their food.5,76 Other research-
ers who investigated rural Native American
and white children in Oklahoma suggest that
their diets are more influenced by factors such
as poverty and living in a rural area than by
cultural or structural issues related to race or
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

C H A P T E R 5 1 2 7
ethnicity.67 Nutrient deficiencies in Native
American adults and children may occur, but
with the exception of Alaska Natives, most
studies suggest dietary adequacy similar to
that of the total U.S. population.
Life expectancy has improved over recent
years, yet disparities are still found. The aver-
age life expectancy is approximately 4.2 years
less when compared to the U.S. popula-
tion. “American Indians and Alaska Natives
continue to die at higher rates than other
Americans from a variety of ailments, includ-
ing chronic liver disease and cirrhosis, diabe-
tes mellitus, unintentional injuries, assault/
homicide, intentional self-harm/suicide, and
chronic lower respiratory diseases.”77
Native American mothers are more likely
to be younger than the general population
and less likely to be married. Thirty percent of
American Indian and Alaska Native women
do not receive prenatal care during the first
trimester of pregnancy. American Indian
and Alaska Native infants die at a rate of
8.5 per every 1,000 live births, as compared
to 6.8 per 1,000 for the U.S. all races popu-
lation (2000–2008 rates).4,76 Postnatal
mortality rates are nearly 60 percent higher
for American Indians and Alaska Natives
compared to the total population; this is
mostly due to sudden infant death syndrome
(SIDS), congenital malformations, prematu-
rity, and injury.78 Breast-feeding has tradi-
tionally been considered the proper way to
feed infants among most Native Americans.
Among the Navajo in one study, elders
reported that breast-fed infants were better
able to hear traditional teachings and were
better disciplined. It also demonstrated that
the children are loved. Eighty-one percent of
subjects initiated breast-feeding. Most added
infant formula within the first week and used
this combined feeding practice for more than
five months.79 Other estimates of breast-
feeding show rates of 24 to 62 percent.80,81
Baby-bottle tooth decay, due most often to
extended use of a bottle with formula, milk,
juice, or soda, affects more than one-half of all
Native American and Alaska Native children.
Overweight and obesity are prevalent
among Native Americans. National data
suggest obesity rates of 37 percent among
American Indian adults in 2008, approxi-
mately 20 percent above the average for the
total population.4 In another survey, the
highest obesity rates were found in Native
Americans living in Alaska, and the lowest in
the Pacific Northwest.82 Though definitions of
overweight and obesity vary in other research,
the trends are consistent. Group-specific stud-
ies report 83 percent of Havasupai subjects
and 60 percent of Seminole were identified
as obese; 63 percent of Navajo women and
33 to 50 percent of Navajo men were over-
weight; and 61 percent of Indians residing in
Oklahoma were overweight or obese.83,84 In
some groups, such as the Inuit, overweight
was traditionally desirable as a visible dem-
onstration of wealth during times of priva-
tion.10 Among the Navajo, elder men and
women prefer a heavier body shape.85 Studies
of Native American school children and
adolescents show consistently higher weight-
for-height ratios than for white, black, or
Hispanic populations, while body mass index
(BMI) rates over the 85 percentile varied, up
to 50 percent for girls, and nearly 50 percent
for boys.79,86,87,88,89
Figures on obesity contradict some nutri-
tional intake data, which show the caloric
intake of many Native Americans to be nor-
mal or less than the recommended dietary
allowances. Metabolic differences in obese
Native Americans may be a factor,56,75,117 or
lower rates of energy expenditure through
exercise may contribute: American Indians
and Alaska Natives report lack of leisure-
time physical activity at higher rates than any
other U.S. ethnic group.82,83,84,85,86,87,88,89,90
However, a study of Hualapai women of
Arizona indicated that the daily caloric intake
of obese women was significantly higher than
for the non-obese women. Sweetened bever-
ages and alcoholic beverages accounted for
the differences. Researchers investigating
Zuni adolescents suggest that underreport-
ing of foods and/or alcohol may account for
low reported energy intakes.64,69,91,92 Diet-
ing behaviors among adult Native American
women mostly involve healthy approaches
such as eating more fruits and vegetables
and exercising more, according to one
study, although skipping meals, fasting, and
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

1 2 8 N A T I V E A M E R I C A N S
disordered eating such as self-induced vomit-
ing were also mentioned; 10 percent engaged
in binge eating. A national survey of Native
American youth revealed that over 40 per-
cent reported binge-eating behavior with
vomiting rates of 4 to 6 percent. Frequent
dieting was also common. All disordered eat-
ing occurred more frequently among over-
weight respondents.93,94
The incidence of type 2 diabetes mellitus,
especially among some Native Americans of
the Plains and Southwest, is estimated to
be between two and four times that of the
general population. More than 16 percent
of American Indians and Alaska Natives
are estimated to have diabetes, which is
the highest rate of any ethnic group in
the United States.4 The Pima Indians are
believed to have the highest rate of type 2
diabetes in the world, affecting 70 percent of
all adults over the age of forty-five. Rates of
the disease among children are also increas-
ing substantially, and it has been noted
that acanthosis nigricans (a patchy darken-
ing of the skin) is an independent marker
for insulin resistance in Native American
youngsters.95,96,97 The death rate from type
2 diabetes is more than three times as high
for Native Americans as for the total popu-
lation.98 Notably, diabetes was rare among
Native Americans fifty years ago.99
One theory for the high rates of type 2
diabetes among Native Americans is genetic
predisposition.100 However, a comparison
of type 2 diabetes among Pima Indians liv-
ing in Arizona and those living in Mexico
found rates in Arizona to be more than five
times those found in Mexico, suggesting that
genetic predisposition alone does not account
for high prevalence in the United States and
that a Westernized environment may be a
factor.101 Research has shown a significantly
lower plasma insulin level in Pima Indians
living in Mexico when compared to the U.S.
Pima population even before diabetes is diag-
nosed. The authors state: “This finding under-
scores the importance of lifestyle factors as
protecting factors against insulin resistance in
individuals with a high propensity to develop
diabetes.”102 Higher rates of diabetes are found
among Alaska Natives who have significant
increased intake of nonindigenous protein
(e.g., beef, chicken), carbohydrates (e.g., white
bread, potatoes or rice, soft drinks), and fat
(e.g., butter, shortening), combined with a
lower intake of native foods such as salmon,
caribou, berries, and seal oil; and higher rates
are found among Pima Indians who con-
sume an Anglo diet when compared to Pima
who consume a traditional diet.103,104 Some
researchers suggest the difference is due to
the dietary change from indigenous starches
to the refined flours and sugars of the adapted
diet. Traditional starches take longer to digest
and absorb, leading to lower blood sugar lev-
els and insulin responses that may be protec-
tive in the development of diabetes.105 Other
researchers suggest the increased intake of
fat in the modern Native American diet may
be responsible for the increase in type 2 dia-
betes.106 (See Cultural Controversy—Type
2 Diabetes, Thrifty Genes, and Changing
Theories.)
Associated with obesity and type 2 diabe-
tes is a dramatic increase in the prevalence of
heart disease among Native Americans dur-
ing the last twenty-five years; heart disease
is now the leading cause of death. Rates of
cardiovascular disease for Native Americans
have surpassed those of the total popula-
tion in many locations, and are often more
fatal. Additional risk factors include high
rates of cigarette smoking, alcohol consump-
tion, elevated blood lipid levels, obesity, and
hypertension.
Chronic kidney disease is also a concern,
particularly associated with type 2 diabetes,
with incidence up to twenty times higher than
in the general population. American Indians
and Alaska Natives die at higher rates than
other Americans from tuberculosis, with esti-
mates being up to 600 percent higher.2,3,4
The incidence of alcoholism among Native
Americans has decreased in recent years, but
it still remains a significant medical and social
problem. High unemployment rates and loss
of tribal integrity, ethnic identity, and self-
esteem are frequently cited as reasons for
substance abuse among both reservation and
urban Native Americans. The rate for alcohol-
related deaths is more than eight times that of
the general U.S. population.3,4
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

C H A P T E R 5 1 2 9
Counseling
A survey of Native American nurses identi-
fied attitudes, skills, and knowledge needed
to serve Native Americans successfully. They
listed being open-minded, avoiding ethnocen-
trism, and using intercultural communication
skills, especially the ability to listen carefully
and to provide respectful silence. Learning
about the Native American worldview, tra-
ditional health beliefs, differences between
nations, and the history of each group was
considered essential to effective interac-
tion.18,107 Of particular importance is recog-
nition of diversity within Native American
groups and understanding of local culture.
Access to biomedical health care may be
limited for some Native Americans because
of low income or inadequate transporta-
tion. Many are also limited to care through
the Indian Health Service (IHS), which has
a federal trust to provide health services to
all Native Americans who are members of
tribes recognized by the U.S. government.
It began operation under the BIA in 1924
and was placed under what is now called
the Department of Health and Human Ser-
vices in 1955.108,109 It has 612 IHS facilities
(46 hospitals; 494 health clinics) near or on
reservations, 80 percent tribally operated,
and 33 urban Indian programs. However,
the number of Native American health pro-
fessionals is limited, and intercultural care is
the norm rather than the exception in many
facilities.
Type 2 Diabetes, Thrifty Genes, and Changing Theories
Scientific theory sometimes takes on a life of its own, existing in the public
memory long past the time it has been
modified or disproved. Such is the case with
the thrifty gene hypothesis. In the 1960s
when researchers first proposed that certain
Native Americans might be predisposed to
developing diabetes mellitus (DM) due to a
feast-or-famine metabolism compromised
by a modern diet, type 1 DM had not yet
been fully differentiated from type 2 DM.
Four decades later, our understanding of the
disease has improved, revealing a complex-
ity that defies simple explanations.121
What is now known as type 1 DM results
from a complete lack of insulin in the body
and is not correlated to lifestyle. Type 2 DM is
more common; it is associated with normal
or reduced levels of insulin and the inability
to use insulin efficiently, and it is closely
correlated with obesity and limited physical
activity. Both types of diabetes result in high
levels of blood glucose that over time can
cause lifelong disability and death. Diagnosis
of type 2 DM has increased by more than
65 percent in the general adult population
over the past ten years. Long considered
a disease of middle age, type 2 DM was
rarely diagnosed in urban pediatric clinics as
recently as the early 1990s, but type 2 DM is
now increasing rapidly as a proportion of all
newly diagnosed cases of diabetes in chil-
dren.122 Among Native Americans, prevalence
rates vary from between 4 and 70 percent of
adults over the age of forty-five, depending
on group, with the lowest rates seen in Alaska
and the highest found in the Southwest. In a
few Native American groups a unique genetic
mutation has been identified as the cause,
as in the Oji-Cree of Canada, who have type
2 DM rates of 40 percent among adults.123
Yet attempts to find a universal thrifty
gene that predisposes other Native Americans
to the disease have been unsuccessful. It was
initially argued that a metabolism adapted to
a diet plentiful at times (feast periods) inter-
spersed with food shortages (famine periods)
could not cope with the constant abundance
of the modern diet, resulting in high insulin
responses and type 2 DM. The theory col-
lapsed when researchers were unable to find
a specific mechanism that causes an ethnic
predisposition to developing diabetes. Fur-
ther, it has been difficult to totally account
for high prevalence rates through differences
in diet and activity levels between diabetic
and non-diabetic members in certain Native
American groups.39,44,74,124,125,126
These data beg the question: Why do
some Native Americans develop type 2 DM
at rates many times above that of the white
U.S. population? Researchers propose that
the development of type 2 DM is much more
complex than previously thought, including
factors in three domains: political-economic
(such as ongoing stress, unavailability of
healthy foods, and barriers to health care
access), etiological (both genetic and non-
genetic), and cultural (including traditional
health beliefs, values regarding body image,
norms about exercise, etc.).127 Of particular
interest are theories regarding the roles of
historical trauma (similar to posttraumatic
stress syndrome)128 and prenatal adaptation
to malnutrition and gestational diabetes
in Native American mothers resulting in
increased rates of type 2 DM.129 Genes alone,
thrifty or not, cannot completely explain
what has become a problem of epidemic
proportions in much of the Native American
community.
C U L T U R A L C O N T R O V E R S Y
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

1 3 0 N A T I V E A M E R I C A N S
Some Native Americans hold beliefs that
cause them to avoid biomedical treatment in
general. For example, pregnancy is often con-
sidered a healthy state, and Native American
women may not seek prenatal care for this
reason. Some older Native Americans report
fear of non–Native American providers, and
others find biomedical physicians too negative
because of impersonal care. Disclosure of risks
may also be regarded as negative, in violation
of a positive approach to life.110 Some Native
Americans may be angry about their condi-
tion and may blame illnesses such as diabetes
on a Western conspiracy. Some are suspicious
of federal and state government and may be
hesitant to sign any forms.15
One social worker reports that her clients
at a dialysis center in Arizona are so accus-
tomed to friends and family members with
kidney failure that they fatalistically expect
a similar outcome for themselves and are
sometimes relieved when it finally happens.111
Research shows that many Native Americans
believe that renal failure, amputations, and
blindness are inevitable consequences of dia-
betes.98 Traditional attitudes about time may
cause delays in seeking care—the importance
of finishing a current project or commitment
I was born in Oljato, Utah, a rural Navajo reservation located 150 miles
northeast of Farmington, New Mexico. After graduating from high school,
I worked as a nurses’ aid in a small, fifteen-bed hospital near my home
in Utah. Later, I completed a bachelor’s degree in nutrition science at
the University of Utah and a dietetic internship and a master’s degree
in public health at the University of California, Berkeley. As a regis-
tered dietitian I have worked with the Navajo nation for approximately
twelve years.
Briefly, how would you describe the Navajo foods?
Traditionally, during the fifties, sixties, and early seventies, gardening
and sheepherding was our livelihood. We hauled all our water and used
wood-burning stoves for cooking. My parents told us of Navajo native foods
when they were young, some of which I have never seen. My mother told
me she spent many days grinding corn for the winter. One stew made by
parents was ad Alth ta’ nash besh, meaning boiled with several mixtures.
It had melon seeds, local wild green plants, and a variety of plant seeds,
and wild onions, and was thickened with corn meal. When I was young we
grew watermelon, cantaloupe, fresh corn, and summer and winter squash.
Other favorites included boiled mutton backbone in green chili stew, grilled
mutton ribs, liver and greater omentum (the fatty tissue that covers the
stomach) in an open-face sandwich with onions or green chili in a tortilla.
We may not have had as much mutton as we wanted, but we had plenty of
fruits and vegetables during the summer months.
Traditional food eaten today includes corn prepared many different ways
from fresh to dried or ground into meal in varying degrees of texture. One
recipe for fresh corn is called “Kneel down Bread” because it is prepared in a
sitting position. A one-fourth cup of the ground corn is placed in corn leaves,
wrapped and tied together. It is then placed in a large hole that is dug in the
ground and is cooked by building a fire on top. All parts of the sheep and
goat are used for food. This includes the head, intestine, organs, skin, hoofs,
and blood. Blood sausage and liver sausage are very popular. The stuffed
intestine is made by wrapping the greater omentum with the intestine. It is
then grilled on hot coals until crispy.
Most elderly like simple, unmixed foods. Older people dislike marinated
meats. They prefer the meats cooked plain. I would say Navajo native food is
fairly bland, although men like to eat with very hot chili and raw, fresh onions.
How much has Western food culture influenced
the current diet?
In the past three to four decades our diet has changed significantly. Our
level of physical activity also decreased at the same time. Popular foods now
include spam, canned meat, cold cuts, ramen noodles, chips, candy, sodas,
and flavored fruit drinks.
Are there any foods that would be difficult or easy to
modify in the diet?
Yes. Fried bread would be hard to modify. People enjoy the texture of bread
cooked in hot oil, which makes the recipe difficult to alter. Intestine wrapped
P R A C T I T I O N E R P E R S P E C T I V E S
Native American
LORRAINE WHITEHAIR, RD, MPH, RN, CDE • Worked at Indian Health Services for over ten years,
Tribal RD for a number of years, and currently works for CDC
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

C H A P T E R 5 1 3 1
may outweigh that of keeping an appointment
with a health provider.
In general, both verbal and nonverbal com-
munication with Native Americans must take
into account cultural traditions. Among the
Navajo, the patient should be asked directly for
his medical history, because even family mem-
bers may believe that they have no right to speak
for another. However, family members are often
consulted in making medical decisions.
It is estimated that more than one-half of
Native Americans speak their native language
in addition to English. Native American lan-
guages are primarily verbal, and some Native
Americans may experience difficulties with
written information or instructions. Further,
some English words, such as germ, may not
exist in Native American languages.23 It has
been reported, for example, that increasing
vegetables in the diet of some Native Ameri-
cans has met with resistance because the
closest equivalent Native American word for
vegetable is weeds.112 Many Native Americans
are comfortable with periods of silence in a
conversation, using the time to compose their
thoughts or to translate responses. A yes or
no response may be considered a complete
answer to a question, and a Native American
in greater omentum is the one that could be easy to modify. Replace the
intestinal fat with thick sliced vegetables like onions, carrots, cabbage, green
peppers, and celery. Ramen noodles, a non-traditional food, are easier to
modify as well—I suggest to my clients that they add a variety of vegetables
(frozen and fresh) and muscles from beef, chicken, or pork and decrease the
serving size, since the noodles contain fat. People seem to like it with fresh
ginger as well.
What advice would you give to new RDs working
with Native Americans?
Learn about the history of the people. Learn about the way of life then
and now. The Navajo people value family and community. There is a say-
ing which states, “Know who you are and where you came from.” That
is to know your clan system. Introductions are a very important part of
interaction with people on the Navajo reservation. As time consuming as
it may be, establishing good introductions helps establish trust, kinship,
and credibility. Making a good introduction about your family clan (family
background) is a cultural practice, and it is believed to help make busi-
ness meetings successful. For elderly clients you may address them as your
mother (Shi ma’ ) or your father (Shi yes ah’ ) even though they are not
related to you.
For the middle-aged and elderly population, living in harmony with the
surroundings is important. Parents and grandparents spend a great deal of
time talking about being respectful of kinship, elderly people, and nature,
including land and living creatures. We are to look toward living in harmony
with our surroundings. Illness is often thought of as a result of an interruption
of harmony.
We enjoy laughing. There is great pleasure in tastefully teasing when
appropriate. We have many jokes about life on the reservation, our first
boarding school experiences, interaction with people in towns, schools,
and medical clinics, and meeting with public health officials. We have many
animal stories that are funny, and they also teach. For example, I use this
story to help teach my clients about diabetes:
Two Birds
Two birds, Jay and Woody, lived near the Interstate 40 highway fifty miles
west of Albuquerque, New Mexico. Jay loves to pick up foods that are
left by humans who were traveling back on Interstate 40 highway from
Albuquerque, New Mexico. The most common foods that were left along
the highway were French fries, hamburgers, shakes, pies, cookies, ice
cream, fried chicken, biscuits, potato chips, fried bread, and candy bars.
Jay always invited Woody to help him eat the leftover foods that were
thrown near the highway. He would tell Woody about the “delicious” food
he had for the day. He would say, “You do not have to hunt for your food.
It is there along the road.” Woody told Jay the food he was eating was
not good for him. Woody faithfully hunted for his food supply. He worked
to store his food daily so that he would have enough for an emergency
during the winter months. Daily, Woody flew long distances to get his
food. Meanwhile, Jay had been steadily gaining weight. He also had dif-food. Meanwhile, Jay had been steadily gaining weight. He also had dif-food. Meanwhile, Jay had been steadily gaining weight. He also had dif
ficulty flying moderate distances. In the fall both birds wanted to visit
distant relatives near Albuquerque. Jay was not able to complete the trip
to Albuquerque. He experienced shortness of breath and exhaustion half
way to Albuquerque. Jay and Woody decided that Woody should go alone
to see their distant relatives. In early spring Jay became very ill after a
flu he had developed following a large snowstorm. He had frequency of
urination, tiredness, sores on his toes not healing, and blurred vision. His
doctor told him he had diabetes. Jay took the news very hard. He did not
want to change his diet. Woody begged Jay to eat more healthfully. In
the end Jay’s diet changed back to eating whole grains, nuts, and seeds
to help control his blood sugars. He also had to retrain his wings to fly
longer distances daily, which helped bring his good cholesterol (HDL)
in excellent ranges. His doctor was very happy to see Jay living more
healthfully.
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

1 3 2 N A T I V E A M E R I C A N S
may answer “I don’t know” if he or she thinks
that a question is inappropriate or does not
wish to discuss the topic. Stories or metaphors
may be used to make a point.15 Information
may be withheld until she feels she can trust
the provider. Saving face and avoiding con-
flict are crucial, and a Native American may
not ask questions during an interview because
that would suggest that the health care pro-
vider was not communicating clearly. Among
the Navajo, direct questioning by the provider
suggests that the practitioner is unknowledge-
able or incompetent. Open-ended questions
are preferred. The very concept of a dietary
interview may be interpreted by some Native
Americans as interference with their personal
autonomy. Emphasis on how personal health
promotes the welfare of the client’s family and
community can be effective.113
Nonverbal communication is very sophis-
ticated among some Native Americans. It has
been reported that some children may not be
taught to speak until other senses are devel-
oped.114 A Native American client may expect
the practitioner to intuit the problem through
nonverbal techniques rather than through an
interview.115 Although a smile and a hand-
shake are customary, a vigorous handshake
may be considered a sign of aggressiveness.
Native Americans often sit at a distance, and
direct eye contact may be considered rude—
the health professional should not interpret
averted eyes as evidence of disinterest. Quiet,
unhurried conversations are most conducive
to successful interaction.
Researchers note that one-on-one diet
education in a clinical setting is often inef-education in a clinical setting is often inef-education in a clinical setting is often inef
fective with Native Americans.39 Counseling
can be improved through recognition of the
strong oral tradition found in most Native
American groups. The preferred learning
style for many Native Americans is in an
interactive, informal, and cooperative set-
ting. Talking with clients, instead of to cli-
ents, can improve efficacy. For many Native
Americans, it is the relationship established
with the caregiver, not the content of the
conversation, which is important. The shar-
ing of personal stories, in particular, can
elicit information and address issues that are
uncomfortable for clients to address directly.
In group settings, talking circles can be effec-
tive because they facilitate communication
and demonstrate equality among all partici-
pants.79,113,116 In the text Cultural Food Prac-
tices, it is noted that visual learning is key so
the use of food models, pictures, or videos
may be successful as teaching tools.18 Devel-
oping a nutrition model that tells the story of
changes to traditional foodways and resulting
consequences, using culturally appropriate
narrative and imagery, has also been recom-
mended (Figure 5.1).117
A client may have misconceptions about
biomedicine. Because the Navajo health
system classifies illness by cause rather than
by symptom, clients may have difficulty
understanding the necessity for a physical
exam or medical history. There may also be
the expectation that medication can cure ill-
ness and that an injection is needed for every
disorder.19 Very low compliance rates among
some Native Americans on special diets have
been reported.122 A Native American may be
confused about recommendations for weight
loss because slimness is associated with
disease or witchcraft.
Native American clients may follow tra-
ditional health practices instead of, or in
D I S C U S S I O N S T A R T E R S
Who Are You? And What Do You Eat?
After reading about the different regional, traditional Native American diets, decide
which one you think would be the healthiest. Why? Then decide which one you think
would taste the best to you. Why? Once you’ve considered the traditional diets, reflect on
the differences between the traditional diet you see as the healthiest and the contempo-
rary diet of many Native Americans. Consider the following questions:
● What needs to be done to improve the diets of many Native Americans today?
● What are the major cultural obstacles in improving contemporary Native
American diets?
Imagine that you are a member of a research institution that has been asked to recom-
mend dietary policy for a contemporary Native American community. In a small group,
compose a list of your major recommendations for such a policy that the majority of
your group can agree to. Also provide advice to health care professionals serving that
community about how to implement those dietary changes.
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

C H A P T E R 5 1 3 3
conjunction with, biomedical therapies.18
In one rural Navajo community, 62 per-
cent of patients received care from “Native
healers,” defined as a consultation with a
“medicine man,” and 39 percent used such
ser vices more than once per year.118 A
study of Native American veterans found a
greater use of traditional therapies in areas
where biomedical facilities were less acces-
sible.20 Other research suggests that though
combining traditional and biomedical
approaches is common, up to 40 percent of
some American Indians use only traditional
healing.119 Some Indians believe a biomedi-
cal practitioner is needed to cure any “white
man’s disease,” and traditional healers, such
as herbalists and medicine men and women,
or shamans, will frequently decline to
treat conditions unfamiliar to them, refer-
ring patients to Westernized health care
instead.44,112,120 Compliance is most effec-
tive when traditional practices are accepted
and encouraged as an integral part of com-
plete care.
An in-depth interview is necessary to
determine not only ethnic identity but also
degree of acculturation. Traditional medical
beliefs and customs, if practiced, should be
acknowledged. Personal dietary preferences
are of special importance due to the variety of
Native American foods and food habits. Note
taking may be considered exceptionally rude,
so memory skills or a tape recorder may be
preferable during the interview.
Review Questions
1. In Native American culture, what is considered
the cause of illness? How may this influence
the treatment of a medical disorder such as
type 2 diabetes?
2. Pick two regional classifications of traditional
Native American cuisine. Describe the simi-
larities and differences between these two clas-
sifications in food and their preparation.
3. Describe three therapeutic uses of corn and
one therapeutic use of a non-corn item by
Native Americans.
4. What is Indian fry bread? Is it a traditional
food? Why or why not?
5. What factors may have increased the incidence
of type 2 diabetes among Native Americans?
References
1. U.S. Health and Human Services, Office of Minor-
ity Health. n.d. American Indian/Alaska Native
profile. Retrieved from http://minorityhealth.hhs
.gov/ (accessed February 1, 2015).
2. Public Information Office. 2010. Facts for features:
American Indian and Alaska Native Heritage
Month, November 2010. Washington, DC: U.S.
Census Bureau.
3. U.S. Health and Human Services, Office of Minor-
ity Health. n.d. American Indian/Alaska Native
profile. Retrieved from http://minorityhealth.hhs
.gov (accessed January 22, 2011).
4. Barnes, P.M., Adams, P.F., & Powell-Griner,
E. 2010. Health characteristics of the American
Indian or Alaska Native Adult Population: United
States, 2004–2008. Retrieved from http://www.
cdc.gov/nchs/data/nhsr/nhsr020 (accessed
January 20, 2011).
5. Birchfield, D.L. 2000. Apaches. In R.V. Das-
sanowsky & J. Lehman (Eds.), Gale encyclopedia
of multicultural America. Farmington Hills, MI:
Gale Group.
6. Birchfield, D.L. 2000. Sioux. In R.V. Das-
sanowsky & J. Lehman (Eds.), Gale encyclopedia
of multicultural America. Sioux. Farmington Hills,
MI: Gale Group.
7. Birchfield, D.L. 2000. Navajos. In R.V. Das-
sanowsky & J. Lehman (Eds.), Gale encyclopedia
of multicultural America. Farmington Hills, MI:
Gale Group.
8. Birchfield, D.L. 2000. Pueblos. In In R.V. Das-
sanowsky & J. Lehman (Eds.), Gale encyclopedia
of multicultural America. Farmington Hills, MI:
Gale Group.
9. French, E., & Hanes, R.C. 2000. Hopis. In
R.V. Dassanowsky & J. Lehman (Eds.), Gale ency-
clopedia of multicultural America. Farmington
Hills, MI: Gale Group.
10. Jones, J.S. 2000. Inuit. In R.V. Dassanowsky &
J. Lehman (Eds.), Gale encyclopedia of multi-
cultural America. Farmington Hills, MI: Gale
Group.
11. Benson, D.E. 2000. Tlingit. In R.V. Das-
sanowsky & J. Lehman (Eds.), Gale encyclopedia
of multicultural America. Farmington Hills, MI:
Gale Group.
12. Kawagley, O. 2000. Yupiat. In R.V. Das-
sanowsky & J. Lehman (Eds.), Gale encyclopedia
of multicultural America. Farmington Hills, MI:
Gale Group.
13. Hanes, R.C., & Hillstrom, L.C. 2000. Paiutes. In
R.V. Dassanowsky & J. Lehman (Eds.), Gale ency-
clopedia of multicultural America. Farmington
Hills, MI: Gale Group.
14. Birchfield, D.L. 2000. Choctaw. In R.V. Das-
sanowsky & J. Lehman (Eds.), Gale encyclopedia
of multicultural America. Farmington Hills, MI:
Gale Group.
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

1 3 4 N A T I V E A M E R I C A N S
15. Yehieli, M., & Grey, M.A. 2005. Health matters:
A pocket guide for working with diverse cultures
and underserved populations. Boston: Intercul-
tural Press.
16. Purnell, L.D., & Paulanka, B.J. 2003. Transcul-
tural health care: A culturally competent approach
(2nd ed.). Philadelphia: FA Davis.
17. Garrett, J.T. 1990. Indian health: Values, beliefs,
and practices. In M.S. Harper (Ed.), Minor-
ity aging: Essential curricula content for selected
health and allied health professions. Health
Resources and Services Administration, Depart-
ment of Health and Human Services, DHHS
Publication No. HRS (P-DV-90-4). Washington,
DC: U.S. Government Printing Office.
18. Brown, T.L., Zephier, E., & Johnson, M.L.
2010. American Indian food practices. In
C.M. Goody & L. Drago (Eds.), Cultural food
practices. Chicago: American Dietetic Associa-
tion/American Diabetes Association.
19. Kunitz, S.J., & Levy, J.E. 1981. Navajos. In
A. Harwood (Ed.), Ethnicity and medical care.
Cambridge, MA: Harvard University Press.
20. Wilson, C.S. 1985. Nutritionally beneficial cul-
tural practices. World Review of Nutrition and
Diet, 45, 68–96.
21. Castor, M.L., Smyser, M.S., Taualii, M.M., Park,
A.N., Lawson, S.A., & Forquera, R.A. 2006.
A nationwide population-based study identify-
ing health disparities between American Indians/
Alaska Natives and the general populations liv-
ing in select urban counties. American Journal of
Public Health, 96, 1478–1484.
22. Lang, G.C. 1985. Diabetes and health care in a
Sioux community. Human Organization, 44,
251–260.
23. Plawecki, H.M., Sanchez, T.R., & Plawecki, J.A.
1994. Cultural aspects of caring for Navajo Indian
clients. Journal of Holistic Nursing, Journal of Holistic Nursing, Journal of Holistic Nursing 12, 291–306.
24. Heisey, A.W., & Hanes, R.C. 2000. Oneidas. In
R.V. Dassanowsky & J. Lehman (Eds.), Gale ency-
clopedia of multicultural America. Farmington
Hills, MI: Gale Group.
25. Hillstrom, L.C., & Hanes, R.C. 2000. Nez Perce.
In R.V. Dassanowsky & J. Lehman (Eds.), Gale
encyclopedia of multicultural America. Farming-
ton Hills, MI: Gale Group.
26. Kim, C., & Kwok, Y.S. 1998. Navajo use of native
healers. Archives of Internal Medicine, 158,
2245–2249.
27. Sanchez, T.R., Plawecki, J.A., & Plawecki, H.M.
1996. The delivery of culturally sensitive health
care to Native Americans. Journal of Holistic
Nursing, Nursing, Nursing 14, 295–307.
28. Roy, L. 2000. Ojibwa. In R.V. Dassanowsky &
J. Lehman (Eds.), Gale encyclopedia of multicul-
tural America. Farmington Hills, MI: Gale Group.
29. Christensen, N.K., Sorenson, A.W., Hendricks,
D.G., & Munger, R. 1998. Juniper ash as a source
of calcium in the Navajo diet. Journal of the
American Dietetic Association, 98, 333–334.
30. Gunderson, M. 2003. The food journal of Lewis
& Clark: Recipes for an expedition. Yankton, SD:
History Cooks Publishing.
31. Woolf, N., Conti, K.M., Johnson, C., Martinez,
V., McCloud, J., & Zephier, E.M. 1999. Northern
Plains Indian food practices, customs, and holi-
days. Chicago: American Dietetic Association/
American Diabetes Association.
32. Kavasch, E.B., & Baar, K. 1999. American Indian
healing arts. New York: Bantam.
33. Vogel, V.J. 1981. American Indian medi-
cine. In G. Henderson & M. Primeaux (Eds.),
Transcultural health care. Menlo Park, CA:
Addison-Wesley.
34. Joos, S.K. 1980. Diet, obesity, and diabetes mel-
litus among the Florida Seminole Indians. Florida
Science, 43, 148–152.
35. Schilling, B., & Brannon, E. 1986. Cross-cultural
counseling: A guide for nutrition and health coun-
selors. FNS #250. Alexandria, VA: U.S. Depart-
ment of Agriculture/U.S. Department of Health
and Human Services.
36. Emboden, W.A. 1976. Plant hypnotics among
North American Indians. In W.D. Hand (Ed.),
American folk medicine. Los Angeles: University
of California Press.
37. Primeaux, M., & Henderson, G. 1981. Ameri-
can Indian patient care. In G. Henderson &
M. Primeaux (Eds.), Transcultural health care.
Menlo Park, CA: Addison-Wesley.
38. Vaughan, L.A., Benyshek, D.C., & Martin, J.F.
1997. Food acquisition habits, nutrient intakes,
and anthropometric data of Havasupai adults.
Journal of the American Dietetic Association, 97, 97, 97
1275–1282.
39. Wiedman, D. 2005. American Indian diets and
nutritional research: Implications of the Strong
Heart Dietary Study, Phase II, for cardiovascu-
lar disease and diabetes. Journal of the American
Dietetic Association, 105, 1874–1880.
40. O’Connell, M., Buchwald, D., & Duncan, G.
2011. Food access and cost in American Indian
communities in Washington State. Journal
of the American Dietetic Association, 111(9),
1375–1379.
41. Ikeda, J., Dugan, S., Feldman, N., & Mitchell, R.
1993. Native Americans in California surveyed on
diets, nutrition needs. California Agriculture, 47, 47, 47
8–10.
42. Wein, E.E. 1995. Evaluating food use by Canadian
Aboriginal peoples. Canadian Journal of Physi-
ological Pharmacology, 73, 759–764.
43. Di Noia, J., Schinke, S.P., & Contento, I.R.
2005. Dietary patterns of reservation and non-
reservation Native American youths. Ethnicity &
Disease, 15, 705–712.
44. Williams, D.E., Knowler, W.C., Smith, C.J.,
Hanson, R.L., Roumain, J., Saremi, A., . . . Nelson,
R.G. 2001. The effect of Indian or Anglo dietary
preference on the incidence of diabetes in Pima
Indians. Diabetes Care, 24, 811–816.
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

C H A P T E R 5 1 3 5
45. Kuhnlein, H.V., Calloway, D.H., & Harland, B.F.
1979. Composition of traditional Hopi foods.
Journal of the American Dietetic Association, 75,
37–41.
46. Story, M., Bass, M.A., & Wakefield, L.M. 1986.
Food preferences of Cherokee teenagers in
Cherokee, North Carolina. Ecology of Food and
Nutrition, 19, 51–59.
47. Story, M., Snyder, P., Anliker, J., Cunningham-
Sabo, L., Weber, J.L., Kim, R., . . . Stone, E.J. 2002.
Nutrient content of school meals in elementary
schools on American Indian reservations. Jour-
nal of the American Dietetic Association, 102,
253–256.
48. Smith, C.J., Nelson, R .G., Hardy, S.A.,
Manahan, E.M., Bennett, P.H., & Knowler, W.C.
1996. Survey of the diet of Pima Indians using
quantitative food frequency assessment and
24-hour recall. Journal of the American Dietetic
Association, 96, 778–784.
49. Lyttle, L.A., Dixon, L.B., Cunningham-Sabo, L.,
Evans, M., Gittelsohn, J., Hurley, J., . . . Story, M.
2002. Dietary intakes of Native American chil-
dren: Findings from the Pathways Feasibility
Study. Journal of the American Dietetic Associa-
tion, 102, 555–558.
50. Heck, K.E., Schoendorf, K.C., & Parker, J. 1999.
Are very low birthweight births among Ameri-
can Indians and Alaska Natives underregis-
tered? International Journal of Epidemiology, 28,
1096–1101.
51. Mos, L., Jack, J., Cullon, D., Montour, L.,
Alleyne, C., & Ross, P.S. 2004. The importance of
marine foods to a near-urban first nation commu-
nity in coastal British Columbia, Canada: Toward
a risk-benefit assessment. Journal of Toxicology
and Environmental Health, 67, 791–808.67, 791–808.67
52. Kuhnlein, H.V. 1995. Benefits and risks of tra-
ditional food for indigenous peoples: Focus on
dietary intakes of Arctic men. Canadian Journal
of Physiological Pharmacology, 73, 765–771.
53. B ersamin, A., Luick, B.R., Ruppert, E.,
Stern, J.S., & Zidenberg-Cherr, S. 2006. Diet qual-
ity among Yup’ik Eskimos living in rural commu-
nities is low: The Center for Alaska Native Health
Research Pilot Study. Journal of the American
Dietetic Association, 106, 1055–1063.
54. Nabhan, G.P., & Rood, A. 2004. Renewing
America’s Food Traditions (RAFT): Bringing cul-
tural and culinary mainstays of the past into the
new millennium. Flagstaff: Center for Sustainable
Agriculture at Northern Arizona University.
55. Bass, M.A., & Wakefield, L.M. 1974. Nutrient
intake and food patterns of Indians on Stand-
ing Rock Reservation. Journal of the American
Dietetic Association, 64, 36–41.
56. Compher, C. 2006. The nutrition transition in
American Indians. Journal of Transcultural Nurs-
ing, ing, ing 17, 217–223.17, 217–223.17
57. Jackson, M.Y. 1986. Nutrition in Ameri-
can Indian health: Past, present, and future.
Journal of the American Dietetic Association, 86,
1561–1565.
58. Murphy, N.J., Schraer, C.D., Thiele, M.C., Bulkow,
L.R., Doty, B.J., & Lanier, A.P. 1995. Dietary
change and obesity associated with glucose intol-
erance in Alaska Natives. Journal of the American
Dietetic Association, 95, 676–682.
59. Risica, P.M., Nobmann, E.D., Caulfield, L.E.,
Schraer, C., & Ebbesson, S.O. 2005. Springtime
macronutrient intake of Alaska Natives of the
Bering Straits region: The Alaska Siberia Project.
International Journal of Circumpolar Health, 64,
222–233.
60. Kuhnlein, H.V., Receveur, O., Soueida, R., &
Egeland, G.M. 2004. Arctic indigenous peoples
experience the nutrition transition with changing
dietary patterns and obesity. Journal of Nutrition,
134, 1447–1453.
61. Kuhnlein, H.V., Soueida, R., & Receveur, O. 1996.
Dietary nutrient profiles of Canadian Baffin
Island Inuit differ by source, season, and age.
Journal of the American Dietetic Association, 96,
155–162.
62. Nakano, T., Fediuk, K., Kassi, N., & Kuhnlein,
H.V. 2005. Dietary nutrients and anthropometry
of Dene/Metis and Yukon children. International
Journal of Circumpolar Health, 64, 147–156.
63. Nobmann, E.D., & Lanier, A.P. 2001. Dietary
intake among Alaska Native women resident
of Anchorage, Alaska. International Journal of
Circumpolar Health, 60, 123–137.
64. Cole, S.M., Teufel-Shone, N.I., Ritenbaugh,
C.K., Yzenbaard, R.A., & Cockerham, D.L. 2001.
Dietary intake and food patterns of Zuni adoles-
cents. Journal of the American Dietetic Associa-
tion, 101, 802–806.
65. deVera, N. 2003. Perspectives on healing foot
ulcers by Yaquis with diabetes. Journal of Trans-
cultural Nursing, cultural Nursing, cultural Nursing 14, 39–47.
66. Story, M., Snyder, P., Anliker, J., Cunningham-
Sabo, L., Weber, J.L., Kim, R., . . . Stone, E.J. 2002.
Nutrient content of school meals in elementary
schools on American Indian reservations. Jour-
nal of the American Dietetic Association, 102,
253–256.
67. Stroehla, B.C., Malcoe, L.H., & Velie, E.M. 2005.
Dietary sources of nutrients among rural Native
American and white children. Journal of the
American Dietetic Association, 105, 1908–1916.
68. Bersamin, A., Luick, B.R., Ruppert, E., Stern,
J.S., & Zidenberg-Cherr, S. 2006. Diet quality
among Yup’ik Eskimos living in rural communi-
ties is low: The Center for Alaska Native Health
Research Pilot Study. Journal of the American
Dietetic Association, 106, 1055–1063.
69. Teufel, N.I., & Dufour, D.L. 1990. Patterns of food
use and nutrient intake of obese and non-obese
Hualapai Indian women in Arizona. Journal of the
American Dietetic Association, 90, 1229–1235.
70. Taylor, C.A., Keim, K.S., & Gilmore, A.C. 2005.
Impact of core and secondary foods on nutritional
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

1 3 6 N A T I V E A M E R I C A N S
composition of diets in Native-American women.
Journal of the American Dietetics Association, 105,
413–419.
71. Wharton, C.M., & Hampl, J.S. 2004. Beverage
consumption and risk of obesity among Native
Americans in Arizona. Nutrition Reviews, 62,
153–159.
72. Ikeda, J.P., Murphy, S., Mitchell, A., Flynn, N.,
Mason, I.J., Lizer, A., & Lamp, C. 1998. Dietary
quality of Native American women in rural
California. Journal of the American Dietetic Asso-
ciation, 98, 812–813.
73. Harnack, L., Story, M., & Holy Rock, B. 1999. Diet
and physical activity patterns of Lakota Indian
adults. Journal of the American Dietetic Associa-
tion, 99, 829–835.
74. Costacou, T., Levin, S., & Mayer-David, E. 2000.
Dietary patterns among members of the Catawba
Indian nation. Journal of the American Dietetic
Association, 100, 83–835.
75. Stang, J., Zephier, E.M., Story, M., Himes, J.H.,
Yeh, J.L., Welty, T., & Howard, B.V. 2005. Dietary
intakes of nutrients thought to modify cardiovas-
cular risk from three groups of American Indians:
The Strong Heart Dietary Study, Phase II. Jour-
nal of the American Dietetics Association, 105,
1895–1903.
76. Bell, R.A., Quandt, S.A., Spangler, J.G., & Case, D.
2002. Dietary calcium intake and supplement use
among older African American, white, and Native
American women in a rural southeastern com-
munity. Journal of the American Dietetic Associa-
tion, 102, 844–847
77. Indian Health Service. Facts on Indian health
disparities. 2007–2009. Retrieved from http://
kff.org/disparities-policy/issue-brief/health-
coverage-and-care-for-american-indians-and-
alaska-natives/ (accessed February 9, 2015).
78. U.S. Department of Health and Human Services,
Health Resources and Services Administration,
Maternal and Child Health Bureau. 2013. Child
Health USA 2013. Rockville, MD: U.S. Depart-
ment of Health and Human Services. Retrieved
from http://mchb.hrsa.gov/chusa13/perinatal-
health-status-indicators/p/infant-mortality.html
(accessed February 7, 2015).
79. Wright, A.L., Clark, C., & Bauer, M. 1993.
Maternal employment and infant feeding prac-
tices among the Navajo. Medical Anthropology
Quarterly, 7, 260–280.7, 260–280.7
80. Story, M., Strauss, K., Zephier, E., & Broussard, B.
1998. Nutritional concerns in American Indian
and Alaska Native children: Transitions and
future directions. Journal of the American Dietetic
Association, 98, 170–176.
81. Houghton, M.D., & Graybeal, T.E. 2001. Breast-
feeding practices of Native American mothers
participating in WIC. Journal of the American
Dietetic Association, 101, 245–247.
82. Denny, C.H., Holtzman, D., & Cobb, N. 2003.
Surveillance for health behaviors of American
Indians and Alaska Natives. Findings from the
Behavioral Risk Factor Surveillance System,
1997–2000. Morbidity and Mortality Weekly
Report, CDC Surveillance Summaries, 52, 1–13.
83. Bursac, Z., & Campbell, J.E. 2003. From risky
behaviors to chronic outcomes: Current status
and Healthy People 2010 goals for American
Indians in Oklahoma. Journal of the Oklahoma
Medical Association, 96, 569–573.
84. Vaughan, L.A., Benyshek, D.C., & Martin, J.F.
1997. Food acquisition habits, nutrient intakes,
and anthropometric data of Havasupai adults.
Journal of the American Dietetic Association, 97, 97, 97
1275–1282.
85. White, S.L., & Maloney, S.K. 1990. Promoting
healthy diets and active lives to hard-to-reach
groups: Market research study. Public Health
Reports, 105, 224–231.
86. Bernard, L., Lavallee, C., Gray-Donald, K., &
Delisle, H. 1995. Overweight in Cree schoolchil-
dren and adolescents associated with diet, low
physical activity, and high television viewing.
Journal of the American Dietetic Association, 95,
800–802.
87. C aballero, B., Himes, J.H., L ohman, T.,
Davis, S.M., Stevens, J., Evans, M., . . . Pablo, J.
Pathways Study Research Group. 2003. Body
composition and overweight prevalence in 1704
school children from 7 American Indian commu-
nities. American Journal of Clinical Nutrition, 78,
308–312.
88. Jackson, M.Y. 1993. Height, weight and body mass
index of American Indian schoolchildren 1990–
1991. Journal of the American Dietetic Association,
93, 1136–1140.
89. Zephier, E., Himes, J.H., & Story, M. 1999. Preva-
lence of overweight and obesity in American
Indian school children and adolescents in the
Aberdeen area: A population study. International
Journal of Obesity and Related Metabolic Disor-
ders, 23(Suppl. 2), S28–S30.
90. Liao, Y., Tucker, P., Okoro, C.A., Giles, W.H.,
Mokdad, A.H., Harris, V.B., Division of Adult
and Community Health, National Center for
Chronic Disease Prevention and Health Promo-
tion, Centers for Disease Control and Preven-
tion (CDC). 2004. REACH 2010 surveillance for
health status in minority communities—United
States, 2001–2002. Morbidity and Mortality
Weekly Report, CDC Surveillance Summaries,
27, 1–36.
91. Wiedman, D. 2005. American Indian diets and
nutritional research: Implications of the Strong
Heart Dietary Study, Phase II, for cardiovascu-
lar disease and diabetes. Journal of the American
Dietetic Association, 105, 1874–1880.
92. Marshall, T., Kramer, K., McMahon, B., Starr, D.,
Phipps K., Warren, J., . . . Drake D. 2014. Post-
partum nutrient intakes and beverage patterns
of American Indian women. The Open Access
Journal of Science and Technology, 2, 1–6.
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209

C H A P T E R 5 1 3 7
93. Neumark-Sztainer, D., Story, M., Resnick, M.D., &
Blum, R.W. 1997. Psychosocial concerns and
weight control behaviors among overweight and
nonoverweight Native American adolescents.
Journal of the American Dietetic Association, 97, 97, 97
598–604.
94. Sherwood, N.E., Harnack, L., & Story, M.
2000. Weight-loss practices, nutrition beliefs,
and weight-loss program preferences of urban
American Indian women. Journal of the Ameri-
can Dietetic Association, 100, 442–446.
95. Copeland, K., Pankratz, K., Cathey, V., Immo-
hotichey, P., Maddox, J., Felton, B., . . . Blackett,
P. 2006. Acanthosis Nigricans, insulin resistance
(HOMA) and dyslipidemia among Native Amer-
ican children. Journal of the Oklahoma Medical
Association, 99, 19–24.
96. F a g o t – C a m p a g n a , A . , Pe t t i t t , D. J. ,
Englegau, M.M., Burrow, N.R., Geiss, L.S., Val-
dez, R. . . Narayan, K.M. 2000. Type 2 diabetes
among North American children and adoles-
cents: An epidemiological review and a public
health perspective. Journal of Pediatrics, 136,
664–672.
97. Acton, K.J., Burrows, N.R., Wang, J., & Geiss,
L.S. 2006. Diagnosed diabetes among Ameri-
can Indians and Alaska Natives ages <35 years: United States, 1994–2004. Morbidity and Mortal- ity Weekly Report, 55, 1201–1203. 98. Warne, D. 2006. Research and educational approaches to reducing health disparities among American Indians and Alaska Natives. Journal of Transcultural Nursing, Transcultural Nursing, Transcultural Nursing 17, 266–271.17, 266–271.17 99. Parker, J.G. 1994. The lived experience of Native Americans with diabetes within a transcultural nursing experience. Journal of Transcultural Nursing, Nursing, Nursing 6, 5–11. 100. Baier, L.J., & Hanson, R.L. 2004. Genetic studies of the etiology of type 2 diabetes in Pima Indi- ans: Hunting for pieces to a complicated puzzle. Diabetes, 53, 1181–1186. 101. Schulz, L.O., Bennett, P.H., Ravussin, E., Kidd, J.R., Kidd, K.K., Esparza, J., & Valencia, M.E. 2006. Effects of traditional and western environ- ments on prevalence of type 2 diabetes in Pima Indians in Mexico and the U.S. Diabetes Care, 29, 1866–1872. 102. Esparza-Romero, J., Valencia, M.E., Martinez, M.E., Ravussin, E., Schulz, L.O., & Bennett, P.H. 2010, November. Differences in insulin resis- tance in Mexican and U.S. Pima Indians with normal glucose tolerance. Journal of Clinical Endocrinology and Metabolism, 95(11), E358– 362. Epub July 28, 2010. 103. Murphy, N.J., Schraer, C.D., Thiele, M.C., Bulkow, L.R., Doty, B.J., & Lanier, A.P. 1995. Dietary change and obesity associated with glu- cose intolerance in Alaska Natives. Journal of the American Dietetic Association, 95, 676–682. 104. Williams, D.E., Knowler, W.C., Smith, C.J., Han- son, R.L., Roumain, J., Saremi, A., . . . Nelson, R.G. 2001. The effect of Indian or Anglo dietary preference on the incidence of diabetes in Pima Indians. Diabetes Care, 24, 811–816. 105. Brand, J.C., Snow, B.J., Nabham, G.P., & Traswell, A.S. 1990. Plasma glucose and insulin responses to traditional Pima Indian meals. American Jour- nal of Clinical Nutrition, 51, 416–420. 106. Gittelsohn, J., Wolever, T.M., Harris, S.B., Har- ris-Giraldo, R., Hanley, A.J., & Zinman, B. 1998. Specific patterns of food consumption and prep- aration are associated with diabetes and obesity in a Native Canadian community. Journal of Nutrition, 128, 541–547. 107. Weaver, H.N. 1999. Transcultural nursing with Native Americans: Critical knowledge, skills, and attitudes. Transcultural Nursing, Transcultural Nursing, Transcultural Nursing 10, 197–202. 108. Artiga, S., Arguello, R., & Duckett, P. 2013. Health coverage and care for Amer ican Indians and Alaska Natives. Kaiser Family Foundation. Retrieved from http://kff.org/ report-section/health-coverage-and-care-for- american-indians-and-alaska-natives-issue- brief/ (accessed February 3, 2015). 109. Indian Health Ser vices. 2015. Factsheets. Retrieved from http://www.ihs.gov/newsroom/ factsheets/ (accessed February 3, 2015). 110. Carrese, J.A., & Rhodes, L.A. 2000. Bridging cul- tural differences in medical practice: The case of discussing negative information with Navajo patients. Journal of General Internal Medicine, 15, 92–96. 111. Juarez, C.A.B. 1990. Professional practice at a Native American community. Contemporary Dialysis and Nephrology, 11, 23–28. 112. Jackson, M.Y., & Broussard, B.A. 1987. Cultural challenges in nutrition education among Ameri- can Indians. Diabetes Educator, 13, 47–50. 113. Hodge, F.S., Paqua, A., Marquez, C.A., & Geishirt-Cantrell, B. 2002. Utilizing traditional storytelling to promote wellness, in American Indian communities. Journal of Transcultural Nursing, Nursing, Nursing 13, 6–11. 114. Wilson, C.S. 1985. Nutritionally beneficial cul- tural practices. World Review of Nutrition and Diet, 45, 68–96. 115. Galanti, G.A. 2004. Caring for patients from dif-Caring for patients from dif-Caring for patients from dif ferent cultures (3rd ed.). Philadelphia: University of Pennsylvania Press. 116. Kavanagh, K., Absalom, K., Beil, W., & Schliess- mann, L. 1999. Connecting and becoming cul- turally competent: A Lakota example. Advances in Nursing Science, 21, 9–31 117. Conti, K.M. 2006. Diabetes prevention in Indian country: Developing nutrition models to tell the story of food-system change. Journal of Transcul- tural Nursing, tural Nursing, tural Nursing 17, 234–245.17, 234–245.17 118. Gurley, D., Novins, D.K., Jones, M.C., Beals, J., Shore, J.H., & Manson, S.M. 2001. Comparative use of biomedical services and traditional heal- ing options by American Indian veterans. Psychi- atric Services, 52, 68–74. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 1 3 8 N A T I V E A M E R I C A N S 119. Novins, D.K., Beals, J., Moore, L.A., Spicer, P., Manson, S.M., & AISUPERPFP Team. 2004. Use of biomedical services and traditional heal- ing options among American Indians: Sociode- mographic correlates, spirituality, and ethnic identity. Medical Care, 42, 670–679. 120. Conley, R.J. 2000. Cherokees. In R.V. Das- sanowsky & J. Lehman (Eds.), Gale encyclopedia of multicultural America, Farmington Hills, MI: Gale Group. 121. Neel, J.V. 1999. The “thrifty genotype” in 1998. Nutrition Reviews, 57, S2–S9.57, S2–S9.57 122. Kaufman, F.R. 2002. Type 2 diabetes mellitus in children and youth: A new epidemic. Jour- nal of Pediatric Endocrinology and Metabolism, 15(Suppl.), 737–744. 123. Hegele, R.A. 2001. Genes and environment in type 2 diabetes and atherosclerosis in Aborigi- nal Canadians. Current Atherosclerosis Reports, 3, 216–221. 124. Edwards, K.A., Pryor, S., Campbell, J., Jacobsen, S., & Booton-Hiser, D. 2000. Calorie use and obe- sity among diabetic and non-diabetic Mvskoke Indians. Journal of Cultural Diversity, 7, 36–40.7, 36–40.7 125. Swinburn, B.A., Boyce, V.L., Bergman, R.N., Howard, B.V., & Bogardus, C. 1991. Deteriora- tion in carbohydrate metabolism and lipopro- tein changes induced by modern, high fat diet in Pima Indians and Caucasians. Journal of Clinical Endocrinology and Metabolism, 73, 156–165. 126. Weyer, C., Vozarova, B., Ravussin, E., & Tataranni, P.A. 2001. Changes in energy metab- olism in response to 48 h of overfeeding and fasting in Caucasians and Pima Indians. Inter- national Journal of Obesity Related Metabolic Disorders, 25, 593–600. 127. Smith-Morris, C.M. 2004. Reducing diabetes in Indian country: Lessons from the three domains influencing Pima diabetes. Human Organization, 63, 34–46. 128. Benyshek, D.C. 2005. Type 2 diabetes and fetal origins: The promise of prevention programs focusing on prenatal health in high prevalence Native American communities. Human Organi- zation, 64, 192–200. 129. Brave Heart, M.Y.H. 1999. Gender differences in the historical trauma response among the Lakota. In Priscilla A. Day & Hilary N. Weaver (Eds.), Health and the American Indian. New York: Haworth Press. 130. Ogunwole, S.U. 2006. We the people: American Indians and Alaska Natives in the United States. Washington DC: U.S. Census Bureau. 131. Terry, R.D., & Bass, M.A. 1984. Food practices in an eastern Cherokee township. Ecology of Food and Nutrition, 14, 63–70. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 1 3 9 Although quite northern, the climate is tem- perate due to the warming influence of the Gulf Stream, and the lowlands are suitable for growing crops. Just across the English Channel is France, regarded for centuries as the center of Western culture politically, as well as in the arts and sciences. Its capital, Paris, is one of the world’s most beautiful and famed cities. France con- tains some of the best farmland in Europe, and three-fifths of its land is under cultiva- tion. It is especially well known for premium wine production. In 1607, people from Great Britain began immigrating to what has become the United States. They brought with them British trade practices and the English language, literature, law, and religion. By the time the United States gained independence from Britain, the British and their descendants constituted one-half of the American popu- lation. They produced a culture that remains unmistakably British-flavored, even today. The French came to the United States later and in smaller numbers, yet they have made significant regional contributions. Belgium, situated northeast of France, shares many French food habits but has had very little influence on the American diet due to the relatively low number of immigrants to the United States. The traditional foods of northern Europe and their influence on American cuisine are examined in the next section. Northern and Southern Europeans Some of the largest American ethnic groups come from northern and south-ern Europe (see the map in Figure 6.1). Immigrants from these regions began arriving in what is now the United States in the sixteenth century and are still coming, significantly influ- encing American majority culture. Many foods and food habits we consider to be American were introduced by these settlers. The northern European idea of a meal, consisting of a large serving of meat, poultry, or fish with smaller side dishes of starch and vegetable, was quickly adopted and expanded in the United States to include even bigger portions of protein foods. Adaptations of some southern European spe- cialties have become commonplace Ameri- can fare. Each ethnic group from northern and southern Europe has brought a unique cuisine that was combined with indigenous ingredients—blended with the cooking of Native Americans, other Europeans, and Afri- cans; and flavored with the foods of Latinos, Asians, and Middle Easterners—to form the foundation of the typical American diet. This chapter discusses the traditional foods and food habits of Great Britain, Ireland, France, Italy, Spain, and Portugal and examines their con- tributions to the cooking of the United States. Northern Europeans Great Britain includes the countries of England, Scotland, Wales, and Northern Ireland. Ireland is now a sovereign country. 6CHA P T E R Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 1 4 0 N O R T H E R N A N D S O U T H E R N E U R O P E A N S Cultural Perspective History of Northern Europeans in the United States Immigration Patterns Great Britain The British who immigrated in the seventeenth century settled primar- ily in New England, Virginia, and Maryland. Although many originally came to avoid reli- gious persecution, such as the Puritans in New England and the Catholics in Maryland, most later immigrants earned their passage to America by signing on as indentured servants. By the eighteenth century, British immigra- tion had slowed. After independence, British immigration to the United States further declined due to American hostility and dis- approval by the British government. However, reported arrivals of British in the nineteenth century increased substantially. Early in the century, most immigrants were families from rural areas of southern and western England and Wales. In the latter half of the century, the majority of immigrants were from large English towns; many were seasonal unskilled workers who repeatedly returned to Britain. Figure 6.1 Northern and southern Europe. BrusselsBrusselsBrusselsBrusselsBrusselsBrusselsBrusselsBrusselsBrusselsBrussels The Hague Paris MadridL is bo n London DublinDublin FRANCE SPAIN P O R T U G A L UNITED KINGDOM KINGDOM KINGDOM KINGDOM KINGDOM KINGDOM IRELAND NORTHERN IRELAND SCOTLAND ENGLAND North Sea Atlantic Ocean Mediterranean Sea Tyrrhenianhenianrrhenianrr Sea Bay of Biscay Bay of Biscay Bay of Adriatic Sea Rome Rome ITALY Adriatic Sea WALES BELGIUM © 2 01 7 Ce ng ag e Le ar ni ng Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 6 1 4 1 It is said there have been Scots in America as long as there have been Europeans on the continent. More than one hundred towns and cities in the United States bear Scottish names, and it has been estimated that 1.5 million Scots immigrated to America. Although the majority of Scots came during the eighteenth and nineteenth centuries, 400,000 immigrated between 1921 and 1931, when Scotland suf-Scotland suf-Scotland suf fered a severe economic depression. The Scottish settled over most of the United States and were often professionals or skilled laborers. Although British immigration did not decline in the early twentieth century, the United States was no longer the country of first choice for those leaving Great Britain. During the Great Depression in the 1930s, more Brit- ish people returned to Britain than came to America. After World War II, an increase in immigration was attributable to British war brides returning to the United States with their American husbands. Since the 1970s, British immigration has been constant at about 10,000 to 20,000 persons per year. Ireland The first Irish people to immigrate in substantial numbers to the United States were the descendants of Scottish Presbyteri- ans who had settled in Northern Ireland in the seventeenth century. Large-scale immigration began in the eighteenth century, and by 1775 there were an estimated 250,000 Scotch Irish living in the American colonies. Most of the immigration was the result of an economic depression brought on by a textile slump in Ireland. Initially, the Scotch Irish settled in Penn- sylvania. Before long the direction of Scotch Irish immigration was westward to the fron- tier, first up the Delaware River and then beyond the Susquehanna into the rich farm- lands of the Cumberland Valley. The Scotch Irish played an important role in the settle- ment of the trans-Allegheny region and even- tually clustered around the site of Pittsburgh and in other areas of southwestern Pennsyl- vania. They also settled in the frontier regions of western Maryland, the Shenandoah Valley of Virginia, and the backcountry of Georgia. Irish Catholics started to arrive in the United States by 1820, and their immigration reached an apex between 1840 and 1860, when approximately 2 million people arrived. The impetus to leave Ireland was not only religious persecution but also repeated crop failures. The potato blight that destroyed their principal crop in 1845 resulted in death by starvation of 1 million Irish people. The Irish Catholics were the first great ethnic minority in American cities, and their early history set the pattern for later minority immigrant groups. They settled in the north- eastern cities and were at the bottom of the socioeconomic ladder. The Scotch Irish, who were often of relatively high economic stand- ing and Protestant, found it fairly easy to move into mainstream American society; however, the Irish Catholics were often stereotyped as drunkards, brawlers, and incompetents. The Irish achieved success with painful slowness. For many, their first entry into the American mainstream came by way of city politics. France Immigration directly from France has been the smallest, yet most constant, of that from any European country, but the return rate has been high. Most of the estimated 1 million persons who have immigrated to the United States from France have been middle- class and skilled and have come for economic opportunity. A smaller number came because of reli- gious persecution. More than 12,000 Hugue- nots (French Protestants) settled in the American colonies in the eighteenth century. They were considered to be excellent skilled workers. Generally, French people who settled in the United States were eager to assimilate and able to do so because they were economi- cally successful. Few pockets of French culture remain in the United States, with the exception of southern Louisiana, originally a French hold- ing, and northern New England. However, the Frenchness of these areas is probably due more to the influence of French Canadian immigration than to direct French immigra- tion. French Canadians are the descendants of explorers and settlers who came from France, primarily Normandy and Brittany, during the seventeenth century. They established New France in what is today known as Canada. When the English gained control of Canada, Canadian census data from 2001 reported 5.9 million of English ancestry (almost 20 percent of the total population), 4.6 million of French heritage (over 15 percent of the total population), 4.1 million of Scottish heritage (almost 14 percent of the total population), and 3.8 million of Irish background (about 12 percent of the total population). The Scots have been stereotyped as thrifty. “Scotch” tape was so named with the hope it would suggest an economical product.1 Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 1 4 2 N O R T H E R N A N D S O U T H E R N E U R O P E A N S many French Canadians moved to the United States; in some instances they were deported from Canada. Most settled in northern New England, especially Maine, and their descen- dants are known as Franco-Americans. Others from Acadia (Nova Scotia, New Brunswick, Prince Edward Island, and part of Maine) relocated, often not by choice, to central and southern Louisiana; their descendants are known as Cajuns. Current Demographics and Socioeconomic Status British and Irish The British assimilated into American mainstream society easily. Distinct groups from specific regions of Great Britain can still be found, however. For example, Cornish immigrants of the nineteenth cen- tury were often miners, and their descendants are still living in certain old mining regions, such as Grass Valley, California; Butte City, Montana; and the areas around Lake Superior. The Welsh who immigrated in the nineteenth century were miners and mill workers. They settled in the mid-Atlantic and midwestern states, especially Ohio and Pennsylvania; many were Baptist, Calvinist, or Method- ist. Remnants of Welsh communities in the United States still celebrate St. David’s Day (the feast day of the patron saint of Wales) and the annual festival of the National Gymanfa Ganu Association (an assembly that sings Welsh folk songs).2 It is estimated that there were nearly 25.3 million Americans of English or British ancestry in 2013. Close to 5 million Irish Catholics have immigrated to the United States, and in 2012 there were approximately 34.7 million Ameri- cans who claimed Irish descent.3 Although they started out on a lower economic rung than other older immigrant groups, they are now scattered throughout the occupational structure. In the 1950s, the Irish were overrepresented as clergymen, firefighters, and police officers. Today, there are disproportionately more in law, medicine, and the sciences; and Irish Catholics are more likely than other whites to attend college and to pursue advanced gradu- ate degrees.3 Although Irish Catholics have to some extent assimilated into mainstream American society, they still remain an identi- fiable ethnic group. Persons identifying themselves as of Scot- tish and Scotch Irish heritage totaled over 8.3 million in the 2013 census estimate.4 They are well assimilated, though pockets of Scotch-Irish populations can still be found in certain Appalachian communities. French Over 8 million Americans listed French as their ancestry in the 2013 U.S. Census estimate. An estimated fewer than 25 percent of French Americans are descended from immigrants who came to the United States directly from France.4 More than 2.1 million people of French- Canadian descent live in the United States as of 2005, many of whom make their home in the Northeast.4 The French Canadians who settled in the New England states worked in factories that processed textiles, lumber, and bricks. Since 1950 there has been an increase in the percentage of Franco-Americans hold- ing white-collar jobs, but they still lag behind other ethnic groups economically. Compared to the French who immigrated directly from France and assimilated rapidly into American culture, the descendants of French Canadians have clung to their heritage, including lan- guage, customs, and religious affiliation. In Louisiana, more than 12 percent of the population has French ancestry, with smaller populations located along sections of the Gulf Coast, and one small colony remaining in northeastern Maine.5 The Cajuns settled in rural and inaccessible areas of southern ▼ Traditional foods of northern Europe. Some typical foods include apples, bacon, beef, cheese, cream, French bread, oatmeal, salt cod, and tripe. Ki ch ig in /S hu tt er st oc k. co m The Welsh honor the patron saint of Wales, St. David, by wearing a leek stalk on the lapel. St. David identified his followers by plac- ing a leek in the brim of their caps. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 6 1 4 3 Louisiana, the bayous, and along the Missis- sippi River. Primarily farmers, fishermen, and herders, they were self-sufficient and kept to themselves. Today they are still rural, but their occupations reflect local economic conditions. Worldview Religion British Nearly all early British immigrants to America were Protestant. Although many came to escape persecution by the Church of England, others maintained this faith and established congregations throughout the American colonies. The Church of England in the United States became the Episcopal Church during the late eighteenth century. British ethnicity was often expressed through religious affiliation, particularly with the Episcopal, Methodist, Baptist, and Quaker faiths. Many immigrants established distinc- tively English congregations, but within a gen- eration most became indistinguishable from other American churches. Today, Americans of British descent participate in most U.S. faiths. Irish Religion is a cornerstone of Irish Catho- lic society, and in the United States it is cen- tered on the parish. Over time, the Catholic Church in America came to be dominated by the Irish, often to the resentment of other Catholic immigrants. The church spared no effort to aid its members; it established schools, hospitals, and orphanages across the United States. The church helped to bridge the cultural gap for many Irish immigrants through advice, job placement, savings clubs, and temperance societies. Today, religion plays a less important role in Irish Catho- lic life, although the role of the Irish in the church is still significant. French Among French Americans, Franco- Americans, and Acadians, the Catholic Church provided the nucleus of the commu- nity, gave it stability, and helped preserve the language and traditions of the people. The church today still plays a central role. Family British The immigrant English family formed the model for the typical American family. It included a father, a mother, and their children. This family group sometimes resided near other relatives, but more often established solitary households. The father was in charge of the public and business aspects of the fam- ily, while the mother controlled the domes- tic and social responsibilities. Traditionally, the oldest children in the home were well educated and were sent to private schools, if affordable. Such an education was considered an investment in the future, and children were expected to continue the family business and to maintain the family’s social position. Due to the similarities between the British fam- ily and the emerging American family, new immigrants from England assimilated quickly. It was very common for British immigrants to marry non-English spouses. Irish Many of the characteristics of the Irish family in the nineteenth century persisted into the twentieth century. Irish Catholics tended to marry at a late age, have large families, and divorce rarely. Today, however, most first- and second-generation Irish Catholics are likely to marry outside their group and, with increas- ing frequency, outside Catholicism. Tradition- ally, the father was the breadwinner in the Irish Catholic family, but the mother’s posi- tion was a strong one. Daughters were often as well educated as sons. The Irish people’s relatively egalitarian attitudes toward sex roles may be responsible for the high concentration of Irish American women in professional jobs and white-collar work. French The Franco-Americans in New England maintained many French traditions through their continued contact with French relatives in Quebec. They had little desire to acculturate. During the 1930s, due to the Great Depression and new laws restricting reentry into the United States, the bond to Canada weakened, which diminished new French Canadian immigration. Today the descendants of the French Canadians speak French infrequently and often marry outsid- ers. Family ties are still strong, but, as with the Cajuns, family size has decreased. Franco- American women have traditionally had higher status and more authority than their counterparts in France. Until the twentieth century, Cajuns lived in rural areas in extended family households New England Puritans and English Quakers were among the first in the United States to promote free public education. Historically, Mac before a family name meant “son of,” whereas O signified “descended from.” A “pub,” or public house, is a bar that serves beer, wine, hard liquor, and light meals. The British pub is often the place where friends and family meet to socialize. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 1 4 4 N O R T H E R N A N D S O U T H E R N E U R O P E A N S with as many as ten or twelve children per couple. The whole family worked as a unit, and decisions that affected the group were made jointly by all the adults. Until 1945, many Cajuns were illiterate and spoke only Cajun French. The use of Cajun French was prohibited by the public schools in 1921; as a result, many younger Cajuns today do not speak or understand French. The average family size today is smaller, and there is more marriage outside the community, but Cajuns still retain strong ties to their families. Traditional Health Beliefs and Practices Many of what are characterized as American major- ity cultural beliefs regarding health originated in northern Europe. For example, when stu- dents were surveyed on family home rem- edies,6 those of British, Irish, and French descent shared similar health maintenance practices such as a good diet, plentiful sleep, and daily exercise. Fresh air, cleanliness, and keeping warm and dry were also commonly mentioned. The Irish traditionally wear pro- tective religious medallions. Among the British and the Irish there is the more generalized belief that good health is dependent on proper attitude (which includes religious faith) and a rigorous, regular life- style. Many northern Europeans associate a moderate diet with maintaining bowel regu- larity, and laxative use is common. Stomach ailments may be explained as due to food that is too spicy, spoiled, or incompatible (causing an allergic reaction). The traditional French lifestyle, which features leisurely meals and little structured exercise, presents a paradox to researchers. Although the French consume more total saturated fat and cholesterol than Americans, their death rate from heart disease is less than one-half of that in the United States. Scientists speculate that some other protective factor in the French diet or lifestyle may account for this discrepancy, such as the higher intake of wine or more frequent walking. Genetic fac- tors do not appear to be a cause. Studies com- paring the French with Americans of French ancestry have not been reported. The French Canadians who settled in Louisiana brought numerous traditional rem- edies. Today, Americans of French descent in Louisiana, including the Cajuns and urban dwellers of all socioeconomic groups, often use home remedies and consult folk healers. Salves of whiskey and camphor or sheep’s tallow and turpentine are considered benefi- cial for colds. Tobacco smoke is blown into the ears to cure earaches. A string of garlic is tied around the neck of a baby with worms. Red flannel pouches filled with camphor or asa- fetida are worn to prevent illness. It should be noted that some Americans of French descent living in the region may also consult practi- tioners of voodoo for health problems (see Chapter 8 for more details). Traditional Food Habits The influence of France on the food habits of Great Britain and Ireland and vice versa has led to many similarities in the cuisines of these countries, although the ingredients of southern French cooking differ in that they are more like those of Mediterranean coun- tries. The influence of these northern Euro- pean cuisines on American foods and food habits has been extensive. Ingredients and Common Foods Staples and Regional Variations Great Britain and Ireland Animal products are of key importance in Great Britain and Ireland. Some form of meat, poultry, or fish is present at most meals, in addition to eggs and cheese. In Britain and Ireland, lamb is a commonly eaten meat, as is roast beef, which is often made for Sunday dinner with York- shire pudding (a popover cooked in meat drippings). Pork is often served as sausages (bangers) and bacon. Various game birds are also eaten. The cultural food groups list (Table 6.1) includes a more complete detailing of ingredients. The British and Irish diets also contain a variety of seafood. A well-known fast-food item is fish and chips. The fish is battered and deep-fried, served with fried potatoes, and seasoned with salt and malt vinegar. Salt-dried fish, including ling, cod, and pollack, was traditionally served with a white sauce and potatoes for meatless days by Irish Catholics.7 Preserved fish is also found as an appetizer or at breakfast. Examples are smoked Scottish salmon and kippers, which are a salted and smoked fish. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 6 1 4 5 Group Comments Common Foods Adaptations in the United States Protein Foods Milk/milk products The English and Irish drink milk as a beverage. Cheese is eaten daily. Cheese (cow’s, sheep’s, and goat’s milk), cream, milk, sour cream, yogurt Meat/poultry/ fish/ eggs/ legumes Meat, poultry, or fish is usually the centerpiece of the meal. Meats are generally roasted or broiled in Great Britain; also prepared as stews or in pies. Smoked, salted, or dried fish is popular in England. Meat: beef (roasts; variety cuts such as brains, kidneys, liver, sweetbreads, tongue, and tripe), horsemeat, lamb, oxtail, pork, rabbit, snails, veal, venison Poultry and small birds: chicken, duck, goose, partridge, pheasant, pigeon, quail, thrush, turkeyFish and shellfish: anchovies, bass, clams, cod, crab, crawfish, haddock, herring, lobster, mackerel, mullet, mussels, oysters, perch, pike, pompano, salmon, sardines, scallops, shad, shrimp, skate, sole, sturgeon, trout, whiting Eggs: poultry and fish Legumes: kidney beans, lentils, lima beans, split peas The Irish consume more animal protein. Cereals/Grains Wheat bread usually accompanies the meal. In Britain and Ireland oatmeal or porridge is common for breakfast. Barley, hops, oats, rice, rye, wheat Corn and corn products are consumed more. Fruits/Vegetables Potatoes are frequently eaten in Ireland.Arrowroot starch is used as thickener, and tapioca (from cassava tubers) is eaten. Fruits: apples, apricots, cherries, currants, gooseberries, grapes (many varieties), lemons, melons, oranges, peaches, pears, plums, prunes, raisins, raspberries, rhubarb, strawberries Vegetables: artichokes, asparagus, beets, brussels sprouts, cabbage, carrots, cauliflower, celery, celery root, cucumbers, eggplant, fennel, green beans, green peppers, kale, lettuce (many varieties), leeks, mushrooms (including chanterelles, cèpes), olives, onions, parsnips, peas, potatoes, radishes, salsify, scallions, sorrel, spinach, tomatoes, turnips, truffles, watercress Native and transplanted fruits and vegetables, such as bananas, blueberries, okra, and squash, were added to the diet. Additional Foods Seasonings British and Irish dishes emphasize naturalness of foods with mild seasoning, served with flavorful condiments or sauces used to taste. French dishes are often prepared with complementary sauces or gravies that enhance food flavor. Angelica (licorice-flavored plant), bay leaf, capers, chile peppers, chives, chocolate, chutney, cinnamon, cloves, coffee, cognac, fennel seeds, garlic, ginger, horseradish, juniper berries, mace, malt vinegar, marjoram, mint, mustard, nutmeg, oregano, paprika, parsley, pepper (black, white, green, and pink), rosemary, saffron, sage, shallots, sweet basil, Tabasco sauce (and other hot sauces), tarragon, thyme, vanilla, Worcestershire sauce Cajun and Creole cooking are highly spiced. Stews are thickened with filé powder (sassafras). Nuts/seeds Nuts especially popular; used primarily in desserts. Nuts: almonds (sweet and bitter), chestnuts, filberts (hazelnuts), pecans, walnuts (including black) Seeds: sesame Beverages Alcoholic beverages consumed as part of the meal. Beer (ale, stout, bitters), black and herbal tea (mint, anise, chamomile, etc.), cider, coffee, gin, hot chocolate, liqueurs, port, sherry, whiskey, wine (red, white, champagne, and fruit/vegetable) TA B L E 6 .1 Cultural Food Groups: Northern European (Continued ) Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 1 4 6 N O R T H E R N A N D S O U T H E R N E U R O P E A N S Dairy products and eggs also play an important role in the diet of the British and Irish. Eggs are traditionally served for break- fast, and cheese is the key ingredient in the traditional ploughman’s lunch served in pubs. It consists of a piece of cheddar cheese, bread, pickled onions, and a pint of beer. Other cheeses produced in England are the slightly nutty Cheshire and Stilton, a blue cheese. In Ireland, a market for hand crafted farmhouse cheeses has developed over the past decade. They include both fresh, soft cheeses and aged types (often flavored with herbs or other sea- sonings), from cow’s or goat’s milk. One cheese that has gained international acclaim is Cashel blue, which is produced in Tipperary, Ireland. Devonshire, England, is known for its rich cream products, such as double cream (which has twice as much butter fat as ordinary Group Comments Common Foods Adaptations in the United States Fats/oils Butter used extensively in cooking of northern and central France; olive oil more common in southern regions of the country. Butter, goose fat, lard, margarine, olive oil, vegetable oil, salt pork Sweeteners Honey, sugar Molasses and maple syrup are used as sweeteners. Irish Americans use more sugar than members of other groups. TA B L E 6 .1 Cultural Food Groups: Northern European (C on t in u e d ) cream) and clotted cream, a slightly fer- mented, thickened cream. It is often spread on scones, biscuits made with baking powder. Though not the main focus of the meal, breads are not overlooked. In Ireland, soda bread, a bread made with baking soda instead of yeast, was traditionally prepared every day to accompany the meal and remains popular today. Another version was made of cornmeal. Wheat flour is commonly used for baking, and oatmeal is eaten as a porridge for breakfast in Scotland or used in making bread and biscuits throughout Britain and Ireland. Biscuits, or biskcake, in England can refer to bread, cake, cookies, crackers, or what are known in the United States as biscuits. Scottish shortbread is an example of a sweet, buttery biscuit. Fruits and vegetables are limited to those that grow best in cool climates. Potatoes, brought to Ireland from the New World in the seventeenth century, are the mainstay of the Irish diet and are found in British fare as well. Potatoes are found in stews or pies, such as stobhach Gaelach, an Irish stew of lamb’s neck, and shepherd’s or cottage pie, a meat pie made of leftover ground meat and onions and topped with mashed potatoes. Mashed potatoes are often just referred to as mash, as in bangers and mash (sausages and mashed potatoes). Some side dishes made of potatoes are boxty, a type of potato pancake or dumpling; bubble and squeak, a dish made of leftover cabbage and potatoes chopped and fried together; and colcannon, mashed and seasoned boiled white vegetables with onions or leeks. Berries are popular in puddings, pies, ▼ Fish and chips are classic pub food in England and Ireland, typically served with malt vinegar. m ar go ui lla t p ho to /S hu tt er st oc k. co m © C en ga ge L ea rn in g Oatcakes, called bannocks, were tradition- ally eaten to celebrate the pagan Celtic holiday of Beltane on May 1. One section was burnt or covered with ash; the unlucky person who received the marked portion was sacrificed (in more recent times the victim would leap through a small bonfire three times instead). Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 6 1 4 7 and jams. Kitchen gardens are still found in many areas, providing tomatoes, cucumbers, watercress, and other items. Farmers’ markets, featuring fresh local produce, are increasingly popular. One unusual vegetable of the region is sea- weed. Laver is a purple seaweed (called nori in Japan) that is a specialty in Wales and parts of northern coastal England. It is customar- ily boiled into a gelatinous paste, then mixed with oatmeal and formed into patties that are fried. Known as laverbread, these cakes are traditionally served at breakfast with bacon. Dulse, a red algae eaten in Ireland, can be con- sumed fresh, but is usually dried, then chewed like beef jerky for a snack, or flaked and added to soups or warm milk. The most common beverages consumed by adults in Ireland and England are tea, beer, and whiskey. Tea, which has become synony- mous with a meal or break in the afternoon, was introduced to England in 1662 by the wife of Charles II. Drunk with most meals and as a refreshment, strong black tea is preferred, served with milk and sugar. Frequently con- sumed alcoholic beverages include beer and whiskey. The British and the Irish do not drink the bottom-fermented style of beer common in the United States. Instead, in Britain the pubs usually serve bitters, an amber-colored, top-fermented beer, strongly flavored with hops, while in Ireland, a favor- ite is stout, a dark, rich beer that can provide substantial calories to the diet. Both beers are served at cellar temperature and are naturally carbonated. Whiskey is made in both Ireland and Scot- land, but the Irish are usually credited with its invention and name. In Ireland, it is dis- tilled from mashed, fermented barley. Scotch, or Scotch whisky (spelled without an e), is distilled from a blend of malted whiskey (in which the barley germinated before fermen- tation) and unmalted whiskey. Scotch is tra- ditionally a much stronger, smokier-tasting beverage than Irish whiskey. Other alcoholic drinks popular in Britain are gin, Port (a brandy-fortified wine made in Portugal), and Sherry (a fortified wine from Spain). A less common beverage but still popular in some regions is mead, a type of honey wine made from the fermentation of honey and water. The Welsh prefer a stronger, highly spiced variety called metheglyn. France The cooking of France has tradition- ally been divided into classic French cuisine (haute or grande cuisine) and provincial or regional cooking.8 Classic French cooking is elegant and formal, mostly prepared in restaurants using the best ingredients from throughout the country. Provincial cuisine is simpler fare made at home or local cafes fea- turing fresh local ingredients. Broadly speak- ing, butter and cream enriches many dishes in the northeastern and central regions of the country, while lard, duck fat, and goose fat flavor foods in the northwest and south cen- tral areas.9 In the southeast, olive oil is promi- nent. Seafood and lamb are specialties of the north, while pork is common in the regions bordering Belgium and Germany. Beef and veal are favorites in the central areas, and in the southernmost regions near Spain, fish is a specialty. Cold weather fruits and vegetables are featured in northern dishes, while temper- ate, Mediterranean produce is the mainstay in southern areas. In the north, foods are subtly seasoned. In the south, garlic flavors many dishes. S A M P L E M E N U An Irish Pub Supper Steak/Beef and Guinness Piea,b,c Brown Breada,b,c Apple Crumblea,b,c Stout aJohnson, M.M. 2006. The Irish pub cookbook. San Francisco: Chronicle Books. bRecipes from the Irish Kitchen at http://www.littleshamrocks.com/Irish-Food- Recipes.html cIrish Recipes and Baking at http://www.irelandseye.com/aarticles/culture/recipes/index.shtm Colcannon was customarily served for the harvest dinner and on Halloween in Ireland. For Halloween, coins were wrapped and buried in the dish so the children could find them as they ate. The term honeymoon originated with the European custom of newlyweds drinking mead for the first lunar month following their wedding. Tomatoes were intro- duced to Europe in 1523 from the New World. Reaction was mixed; some people thought they were poisonous, while others believed they brought luck. Tomato-shaped pin cushions developed from the latter superstition. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 1 4 8 N O R T H E R N A N D S O U T H E R N E U R O P E A N S The ancestors of most French Americans are from two of France’s northern provinces, Brittany and Normandy. Brittany, known as Bretagne, is located in the northwest; its shores are washed by the English Channel and the Bay of Biscay. Seafood, simply pre- pared, is common, and delicate Belon oysters are shipped throughout France. Mutton and vegetables from the region are said to have a naturally salty taste because of the salt spray. Apples are the prevalent fruit, and cider is widely exported. Located along the English Channel and east of Brittany is Normandy, also known for its seafood and apples. Calvados, an apple brandy, is thought to be the mother of apple- jack, an alcoholic apple drink used to clear the palate during meals in Louisiana. Another alcoholic drink produced in the region is Bénédictine, named after the Roman Catho- lic monks who still make it at the monastery in Fecamp. Normandy is also renowned for its rich dairy products; its butter is consid- ered one of the best in France. Camembert, a semisoft cheese with a mild flavor, and Pont-l’Évêque, a hearty aromatic cheese, are produced in the area. Dishes from Normandy are often prepared with rich cream sauces. Crêpes, very thin, unleavened pancakes, origi- nated in this region; they are typically served topped with sweet or savory sauces or rolled with meat, poultry, fish or seafood, cheese, or fruit fillings. Champagne, bordered by the English Channel and Belgium, has a cuisine influenced by the Germanic cultures. Beer is popular, as are sausages, such as andouille and andouil- lette, large and small intestinal casings stuffed with pork or lamb stomach. Charcuterie, cold meat dishes such as sausages, pâtés, and ter- rines, which often are sold in specialty stores, are especially good from this region. Pâté is a spread of finely ground, cooked, seasoned meats. A terrine is commonly made with left- over meats cut into small pieces, mixed with spices and a jelling substance, then baked in a loaf pan. Throughout the world, Cham- pagne is probably best known for its natu- rally carbonated wines. Only sparkling wines produced in this region can be legally called champagne in France. The province that borders Germany, Alsace-Lorraine, has been alternately ruled by France and Germany. One of its princi- pal cities is Strasbourg. Many German foods are favored in the region, such as goose, sausages, and sauerkraut. Goose fat is often used for cooking, and one of the specialties of the area is pâté de fois gras, pâté made from the enlarged livers of force-fed geese. Another famous dish is quiche Lorraine, pie pastry baked with a filling of cream, beaten eggs, and bacon. Alsace-Lorraine is a wine- producing area; its wines are similar to the German Rhine wines but are usually not as sweet. Distilled liquors produced in the region are kirsch, a cherry brandy, and the brandy eau de vie de framboise, made from raspberries. Located south of Normandy and Brittany in the west-central part of France is Touraine, the province that includes the fertile Loire val- ley. Along the river one can see the beautiful chateaux or palaces built by the French nobil- ity. Known as the “garden of France,” Touraine produces some of the finest fruits and veg- etables in the country. A dry white wine produced in the area is Vouvray. In the north- central region is the area surrounding the city of Paris called the Ile-de-France, the home of classic French cuisine. Some of the finest beef and veal, as well as a variety of fruits and vege- tables, are produced in this fertile region. Brie, semisoft and mild flavored, is the best-known ▲ Tea time in Great Britain has become an afternoon meal, with small sandwiches, scones (on the second rack of the silver tray), and an assortment of cookies and pastries. M ag da na tk a/ Sh ut te rs to ck .c om Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 6 1 4 9 cheese of the area. Dishes of the Ile-de-France include lobster à l’américaine, lobster pre- pared with tomatoes, shallots, herbs, white wine, and brandy; potage St. Germain, pea soup; filet de bœuf béarnaise, filet of beef with a béarnaise sauce; and tarte tatin, an upside- down apple and caramel tart. Located southeast of Paris is Burgundy, one of the foremost wine-producing regions of France. Burgundy’s robust dishes start to take on the flavor of southern France; they contain garlic and are often prepared with olive oil. Dijon, a principal city, is also the name of the mustards of the region, prepared with white wine and herbs. Dishes of the area are escargot, or snails (raised on grape vines) cooked in a garlic butter and served in the shell; coq au vin, rooster or chicken cooked in wine; and bœuf bourguignon, a hearty red wine beef stew. In Burgundy, the red wines are primarily made from the pinot noir grape and the white wines from the chardonnay grape. The great wines of the area are usu- ally named after the villages in which they are produced; for example, Gevrey-Chambertin, Vosne-Romanée, and Volnay. Cassis, a black currant liquor, is also produced in the region, and brandy from Cognac is a specialty. To the east, along the border with Switzerland, is the mountainous Franche-Comte region, known for its exceptionally tender and flavorful Bresse chicken. The other major wine-producing region of France is Bordeaux, which is also the name of its principal city. Famous for its hearty dishes, the term à la bordelaise can mean (1) prepared in a seasoned sauce containing red or white wine, marrow, tomatoes, butter, and shallots; (2) use of mirepoix, a finely minced mixture of carrots, onions, and celery seasoned with bay leaves and thyme; (3) accompanied by cèpes, large fleshy mushrooms; or (4) accom- panied by an artichoke and potato garnish. A red Bordeaux wine is full-bodied and made primarily from the cabernet sauvignon grape. (In Great Britain, Bordeaux is called claret.) Among the wines produced are St. Julien, Margaux, Graves, St. Emilion, Pomerol, and Sauternes, a sweet white dessert wine. In the south of France is Languedoc, famous for cassoulet, a complex dish containing duck or goose, pork or mutton, sausage, and white beans, among other ingredients. Provence, located on the Mediterranean Sea, is a favor- ite vacation spot because of its warm Riviera beaches. Provence is also known for the large old port city of Marseilles, its perfumes from the city of Grasse, and the international film festival in Cannes. The cooking of Provence is similar to that of Italy and Spain. Staple ingredients are tomatoes, garlic, and olive oil; à la Provençal means that a dish contains these three items. Other common food items are seafood from the Mediterranean, artichokes, eggplant, and zucchini. Popular dishes from the region are bouillabaisse, the famed fish stew made with tomatoes, garlic, olive oil, and several types of seafood, seasoned with saffron, and usually served with rouille, a hot red pepper sauce; ratatouille, tomatoes, eggplant, and zucchini cooked in olive oil; salade Niçoise, a salad originating in Nice, containing tuna, toma- toes, olives, lettuce, other raw vegetables, and sometimes hard-boiled eggs; and pan bagna, a French bread sandwich slathered with olive oil and containing a variety of ingredients, Belgians are renowned for their beers. One specialty ale is lambic, a fruity brew distinctive for its use of unmalted (raw) wheat and open- tank fermentation with wild yeast. Fresh cream in France, called fleurette, is often added to sauces or whipped for dessert. Also popular is crème fraîche, cream that is fermented until it is thickened and slightly tangy. The first eating chocolate was introduced by the British in 1847. Euro- peans now consume twenty to twenty-five pounds of chocolate per person each year—twice the amount eaten by U.S. citizens. S A M P L E M E N U A French Lunch P â t é a,b* and Baguette Q uich e (Seafood, Onion, or Lorraine)a,b Green Salad Selection of Cheeses (e.g., Br ie , P on t- l’ E v ê q u e ) Fresh Fruit or T ar t e au x P omme s (Apple Tart)a,b Wine aChild, J., Bertholle, L., & Beck, S. 2001. Mastering the art of French cooking (Vol. I). New York: Knopf. bFrench Food and Cook at http://www.frenchfoodandcook.comFrench Food and Cook at http://www.frenchfoodandcook.comFrench Food and Cook *Can be purchased at a specialty cheese shop or delicatessen. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 1 5 0 N O R T H E R N A N D S O U T H E R N E U R O P E A N S such as anchovies, tomatoes, green peppers, onions, olives, hard-boiled eggs, and capers. One unique specialty item in the region asso- ciated with haute cuisine is black truffles. This costly, pungent underground fungus flavors or garnishes many classic French dishes. Cooking Styles Although the ingredients used in the countries on the opposite sides of the English Channel are not substantially differ- ent, their cooking styles vary greatly. British and Irish food is described as simple and hearty fare that developed out of rural, sea- sonal traditions.10 French cuisine is admired for its fresh ingredients, attention to detail, and technical proficiency—and it is imitated around the world. Great Britain and Ireland Both the British and the Irish take pride in the naturalness of their dishes and their ability to cook foods so the flavors are enhanced rather than obscured. In recent years, the eating local movement (see Chapter 15 for more details) and government programs promoting regional specialties have led to a renewed interest in traditional fare.11 Meat is usually roasted or broiled, depend- ing on the cut, and lightly seasoned with herbs and spices. Strong-flavored condiments such as Worcestershire sauce (flavored with anchovies, vinegar, soy, garlic, and assorted spices) on roast beef or mint jelly on lamb are often served. Chutneys, highly spiced fruit or vegetable pickles originally from India, are also popular. Leftover meat is finely chopped, then served in a stew, pie, or pudding. Offal, parts of the animal often discarded, such as lamb’s brains, pig’s tail, and calf ’s heart, have become trendy items in England, appreci- ated for both their traditional heritage and the ecological or ethical value of using the whole animal. While most Americans think of pies and puddings as being sweet desserts, in Britain and Ireland this is not necessarily the case. A pie is a baked pastry consisting of a mixture of meats, game, fish, and vegetables, or fruit, covered with or enclosed in a crust. A Cornish pasty is an individual pillow-shaped pie filled with meat, onions, potatoes, and sometimes fruit. Another well-known British dish is steak and kidney pie. Pudding is a steamed, boiled, or baked dish that may be based on anything from custards and fruits to meat and vegetables. An example of a sweet pudding is plum pud- ding, which is served traditionally at Christ- mas. It is a steamed dish of suet, dried and candied fruit, and other ingredients. Trifle is a layered dessert made from custard, pound cake, raspberry jam, whipped cream, sherry, and almonds. France Classic French cuisine implies a care- fully planned meal that balances the texture, color, and flavor of the dishes, similar to the harmony found in musical compositions or paintings.12 The soul of French cooking is its sauces, often painstakingly prepared from stocks simmered for hours to bring out the flavor. A white stock is made from fish, chicken, or veal; and a brown stock is made from beef or veal.13 Sauces are subtly flavored with natu- ral ingredients, such as vegetables, wine, and herbs. They must never overwhelm the food, but rather complement it. The five basic sauces are espagnole (or brown sauce), made with brown stock, mirepoix, and roux (thickening agent made from flour cooked in butter or fat drippings); velouté, made with white stock, roux, onions, and spices; bécha- mel (or cream sauce), made with white stock, milk, and roux; tomato, made with white stock, tomatoes, onions, carrots, garlic, and roux; and, hollandaise, which combines egg yolks and drawn butter (béarnaise is similar, flavored with tarragon). Examples of classic cold sauces are mayonnaise and vinaigrette, a mixture of vinegar and oil. Some common rules in preparing French dishes are (1) never mix sweet and sour fla- vors in the same dish; (2) never serve sweet sauces over fish; (3) do not undercook or overcook food; (4) with the exception of salad and fruit, do not serve uncooked food; (5) always use the freshest, best-tasting ingredients; and (6) wine is an integral part of the meal and must complement the food. French breads and pastries are particularly noteworthy. Breads are typically made with white flour, shaped into long loaves (e.g., thin baguettes), rounds, braids, or rings, Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 6 1 5 1 then baked in a wood-fired oven. Sweeter breads, such as eggy brioche or buttery, flaky croissants, are between breads and pastries. Specialty doughs, such as cream puff pas- try, multilayered puff pastry, and the clas- sic sponge cake génoise, are used to create the numerous desserts of France, such as cakes, petits fours (small, bite-size pastries), and tarts. Chocolate, fresh fruits, and pastry cream thickened with egg yolks enrich these pastries. In recent years, classic French cuisine has merged with a rediscovery of regional fare to create what is known as nouvelle cuisine (new cuisine).12 The practice of nouvelle cui- sine has popularized French cooking world- wide and influenced the development of local specialties with an emphasis on fresh ingredients. An appreciation for the cooking of other nations, especially those of Asia, has occurred in France, and many dishes now use foreign seasonings or use exotic techniques and presentations. Meal Composition and Cycle Daily Pattern Great Britain and Ireland In Britain, four meals are traditionally served each day— breakfast, lunch, tea, and an evening meal (dinner). In the nineteenth and early twenti- eth centuries, breakfast was a very substantial meal, consisting of oatmeal; bacon, ham, or sausage; eggs (prepared several ways); bread fried in bacon grease; toast with jam or mar- malade; grilled tomatoes or mushrooms; and possibly smoked fish or deviled kidneys. All this was washed down with tea. Today, in Scotland, oatmeal is usually eaten for break- fast, while in England, packaged breakfast cereals are often eaten during the week, and the more extensive breakfast is reserved for weekends and special occasions. Lunch was originally a hearty meal and still is on Sundays, but during the week it is squeezed in between work hours. It may include a meat pie, fish and chips, or a light meal at the pub with a pint of bitters or stout. Both Sunday lunch and the weekday dinner are much like a U.S. dinner. The meals con- sist of meat or fish, vegetable, and starch. The starch is often potatoes or rice, and bread also accompanies the meal. Dessert (often called “pudding”) follows the main course. In the late afternoon in Britain and Ireland, most people take a break and have a pot of tea and a light snack. In some areas a high tea is served. This can be a substantial meal that includes potted meat, fish, shrimp, ham salad, salmon cakes, fruits, and a selection of cakes and pastries. High tea is associated with working-class or rural families who have maintained the custom of a large lunch, with high tea serving as dinner. It is thought that the upper British classes add the term high to tea as a dinner when it is served occasionally in place of dinner as a novelty or to children as an informal substitute for dinner. Whether snack or meal, the British often just call it tea. France The French eat only three meals a day—breakfast, lunch, and dinner. Second helpings are uncommon, and there is very little snacking between meals. Breakfast, in contrast to the British meal, is very light, consisting of a croissant or French bread with butter and jam, and strong coffee with hot milk or hot chocolate. The French breakfast is what is known in the United States as a con- tinental breakfast. Lunch is traditionally the largest meal of the day and, in some regions of France, businesses close at midday for two hours so people can return home to eat. The ▲ French breads are consumed at every meal, and include baguettes, braids, rings, and sweeter versions such as brioche (with little topknots). G re g D al e/ G et ty Im ag es Potted is an English term for fish, meat, poultry, or game pounded with lard or butter into a coarse or smooth pâté, then preserved in jars or pots. Deviled describes a dish prepared with a spicy hot sauce or seasoning. In the small town of Palmiers, the city council has banned any ready- made or mass-produced food (e.g., frozen pizza) from the local school cafeteria to “ensure our kids stay healthy, teach them the taste of proper French food, and help keep our small farmers in business.”15 Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 1 5 2 N O R T H E R N A N D S O U T H E R N E U R O P E A N S meal usually starts with an appetizer (hors d’oeuvre) such as pâté. The main course is a meat, fish, or egg dish accompanied by a veg- etable and bread. If salad is eaten, it is served after the main course. Dessert at home is usu- ally cheese and fruit. In a restaurant, ice cream (more like a fruit sherbet or sorbet), cakes, custards, and pastries are served in addition to fruit and cheese. Wine is served with the meal and coffee after the meal. Dinner is similar, but traditionally a lighter meal with a starter course of soup or appetizer, then a main dish, followed by a cheese course. However, meal patterns are changing in France. The popu- larity of fast foods and shorter lunch periods is resulting in a more American pattern of smaller lunch followed by larger dinner. Etiquette The fork is not passed from the right hand to the left hand when cutting food in England and Ireland. Instead the fork remains in the left hand, and the knife in the right. The two are often used together to scoop food onto the fork. All dishes are passed to the left. When not eating, the hands should be placed in one’s lap. In Ireland, a small plate to the left of the setting is used for placing potato peelings.14 France is similar to Great Britain in the use of the fork and knife. For example, lettuce in a salad should not be cut, but folded into a small, easy-to-eat packet. The French also pass dishes to the left. They do not usually use bread plates but place their portions of bread directly on the table. In contrast to England and Ireland, it is considered impolite to put your hands on your lap. The wrists should be rested on the table with the hands in view. Chocolates are appropriate gifts to bring to a dinner. In England, a bottle of champagne is appreciated, while in Ireland a bottle of wine to serve with the meal is also common. In France, a dessert-style wine or after-dinner liqueur is the best beverage to give. Special Occasions Christmas and Easter are the most important Christian holidays celebrated in England, Ireland, and France. Ireland and France are predominantly Catho- lic countries and tend to observe all the holy days of obligation and patron saints’ days. France commemorates the beginning of the French Revolution on July 14, Bastille Day. Great Britain and Ireland The British cel- ebrate Christmas by serving hot punch or mulled wine; roast beef, goose, turkey, or ham; plum pudding and mincemeat (or just “mince”) pies; and, afterward, port with nuts and dried fruit. The plum pudding is tradi- tionally splashed with brandy and then flamed before being served. Mincemeat pies were originally prepared with seasoned, ground meats, suet, and fruit, but today they are usu- ally made with only dried and candied fruit, nuts, and spices. Boxing Day, the day after Christmas, is when friends and relatives visit one another. Foods served at Easter include hot cross buns and Shrewsbury simnel. In ancient times, the cross on the buns is believed to have symbolized both sun and fire; the four quarters represented the seasons. Today the cross represents Christ and the resurrection. Shrewsbury simnel is a rich spice cake topped with twelve decorative balls of marzipan originally representing the astrological signs. (It is also served on Mother’s Day.) Another holiday celebrated throughout Great Britain is New Year’s Day on January 1. The Scottish traditionally eat haggis on New Year’s Eve. Haggis is a sheep’s stom- ach stuffed with a pudding made of sheep’s innards and oatmeal. After it is served, adult diners drench their portions with Scotch whisky before eating. It is also the traditional entrée (served with “neeps,” mashed turnips, and “tatties,” mashed potatoes) on Burns’s Night, commemorating the national poet Robert Burns (January 25). St. Patrick’s Day began as a religious commemoration for the patron saint of Ireland. The Irish American custom of eating a corned beef and cabbage meal on March 17 is now as popular in Ireland as it is in the United States.16 France In France, the main Christmas meal is served after mass on the night of Decem- ber 24. Two traditional dishes are a boudin noir and boudin blanc, also known as black pudding and white pudding (dark blood sau- sage or a light-colored one made from veal, chicken, or pork with milk) and a goose In Britain, a piece of mincemeat pie is eaten at midnight on New Year’s Eve while making a wish for the upcoming year. Robert Burns once wrote that haggis was the “great chieftain o’ the puddin’ race.” Nevertheless, Scottish government officials rec- ommended in 2006 that haggis be served to chil- dren no more than once a week due to its high fat and sodium content. The members of the French Foreign Legion are nicknamed “boudin,” because the red blanket roll they wear across their chests resembles a black pudding. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 6 1 5 3 or turkey with chestnuts. In Provence, the Christmas Eve meal is meatless, usually cod, but the highlight is that it is followed by thir- teen desserts. On Shrove Tuesday (Mardi Gras), the French feast on pancakes, fritters, waffles, and various biscuits and cakes. During Lent, no eggs, fat, or meat are eaten. Dishes served dur- ing Lent often contain cod or herring. Cod is also the traditional dish served on Good Fri- day; in some regions, lentils are eaten to wash away one’s sins. Easter marks the return of the normal diet, and eggs are often served hard- boiled (also colored), in omelets, or in breads and pastries. French toast (croûtes dorée) is a traditional Easter dish. Also common are pies filled with minced meats. Therapeutic Uses of Food Most northern Europeans share a belief that a good diet is essential to maintaining health. Traditional home remedies for minor illnesses include chicken soup, tea with honey or lemon or whiskey, hot milk, or hot whiskey with cloves. Practices less common today are taking sulfur with molasses as a laxative and regular use of cod liver oil. Some Irish Americans may use senna (Cassia actifolia) weekly to cleanse their bowels.18 Home remedies popular with Americans of French descent include infusions made from magnolia leaves, elderberry flowers, sassafras, or citronella, which are prescribed for colds. Sore throats are treated by gargling herbal teas or hot water with dissolved honey, salt, and baking soda. Sassafras tea is used to cleanse the blood, and garlic is ingested for worms. Contemporary Food Habits in the United States Adaptations of Food Habits Ingredients and Common Foods British and Irish Many U.S. dishes have their origins in Great Britain. The Puritans, adapt- ing Native American fare, made a pudding with cornmeal, milk, molasses, and spices. Today, this is called Indian pudding. Pump- kin pie is just a custard pie to which the Native American squash, pumpkin, is added. Apple pie has been so well accepted that we say, “American as apple pie,” despite its English heritage. Syllabub, a milk and wine punch drunk in the American South at Christmas- time, is also an English recipe. French French cooking has had less influ- ence on everyday American cooking (except for French fries), but there are probably few large cities that don’t have a French restaurant. French Americans adapted their cuisine to the available ingredients and other ethnic cooking styles. The best example of this is found in Louisiana, where Creole and Cajun cooking developed. Creole cooking is to Cajun cooking what French grande cuisine is to provincial cooking. Some dishes may sound typically French, such as the fish stew known as bouillabaisse, but this is made with fish from the Gulf of Mexico, not from the Medi- terranean. Even the coffee is slightly different, flavored with the bitter chicory root. Ingredients for Cajun cooking reflect the environment of Louisiana: Bayou Cajun foods are from lake and swamp areas, whereas prai- rie Cajun dishes are found in inland areas. Fish and shellfish abound, notably crawfish, crabs, oysters, pompano, redfish, and shrimp, to name just a few. Shellfish is commonly eaten raw on the half shell (oysters) or boiled in a spicy mixture. Gumbo and jambalaya are often made with seafood. Gumbo is a thick, spicy soup made with a variety of seafood, meat, and vegetables. It is thickened with either okra or filé powder and then ladled over rice. Jambalaya, also a highly seasoned ▲ St. Patrick’s Day in Savannah, Georgia. Ro be rt B re nn er /P ho to Ed it Gumbo is the African Bantu word for “okra.” The name for the popu- lar Cajun music style, zydeco, is derived from the French term for “green bean,” haricot (pronounced “ar-ee-ko”) because it is snappy, like a bean. Crawfish are also known as crayfish (especially in New Orleans), crawdads, crawdaddy crab (in the Great Lakes area), clawfish, and mudbugs, among others. They are small crustaceans that look like miniature lob- sters, found in the fresh waters of Louisiana, Lake Michigan, California, and the Pacific Northwest. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 1 5 4 N O R T H E R N A N D S O U T H E R N E U R O P E A N S stew made with a combination of seafood, meats, and vegetables, was brought to New Orleans by the Spanish. Originally made only with ham (jambon), it was later modified. The base for these stews and gravies is roux; how- ever, the Cajun roux is unique in that the flour and fat (usually vegetable oil) are cooked very slowly until the mixture turns brown and has a nutlike aroma and taste. Other key ingredients in Cajun cooking are rice (which has been grown in Louisiana since the early 1700s), red beans, tomatoes, chayote squash, eggplant, spicy hot sauce, and a vari- ety of pork products. One of the better-known hot sauces, Tabasco, is produced in the bayous of southern Louisiana from fermented chile peppers, vinegar, and spices. Tasso, a seasoned smoked pork product, is also used to flavor dishes. A deep-fried rice fritter, calas, is the Louisiana version of a doughnut. Other rice dishes are red beans and rice and dirty rice. Dirty rice derives its name from the fact that its ingredients, bits of chicken gizzards and liver, give the rice a brown appearance. Cajun boudin sausages are a specialty. Boudin blanc is made with pork and rice; boudin rouge has pork blood added to it. Cochon de lait, a suck- ling pig roasted over a wood fire, is prepared at Cajun festivals in central Louisiana. Fricot is a popular soup made with potatoes and sau- sage or shredded meat. Cracklings, known as gratons, are bite-size bits of fried pork skin (often with meat attached) popular in some regions. Pecan pralines are a famous New Orleans candy. Pecans are native to Louisiana; pralines are large, flat patties made from brown sugar, water or cream, and butter. Another confec- tion eaten often with coffee is beignets, round or square puffed French doughnuts dusted with powdered sugar. French toast, or pain perdu, is another French specialty that was transported to New Orleans and is now famil- iar to most Americans. The cuisine of French Americans in New England tends to be traditionally French, but it is influenced by common New England foods and food habits. Franco-Americans use more herbs and spices than other New Englanders and take time to prepare the best-tasting food. Traditional French dishes are pork pâté, called creton by the Franco-Americans, and the tra- ditional Yule log cake (bûche de Noël) served at Christmas. Franco-American cuisine offers numerous soups and stews. One of the most elaborate of the stews, which is also called a pie, is cipate, known as cipaille, si-pallie, six- pates, and sea pie in some areas. A typical recipe calls for chicken, pork, veal, and beef, plus four or five kinds of vegetables layered in a heavy kettle, covered with pie crust. It is slowly cooked after chicken stock has been added through vents in the crust. Maple syrup is commonly used. One unique breakfast dish is eggs poached in the syrup. Maple syrup is also served over bread dumplings or just plain bread. Franco- Americans appreciate wine and distilled spirits. One unusual combination of both is caribou, a mixture of white whiskey (a distilled, colorless liquor) and red wine, which is drunk on festive occasions. (See also Chapter 15.) Meal Composition and Cycle British and Irish American food habits have been greatly influenced by British and Irish immigrants. Meal patterns and composition are very similar to those in Great Britain. The typical meal of a meat, poultry, or fish main dish served with vegetable and starch side dishes, and often bread, continues to this day. Though English Americans also consumed a hearty breakfast that often included ham or bacon and eggs, in more recent years, time ▼ La boucherie: French-speaking Cajuns in Louisiana maintain the hog-butchering traditions of their past. Before the days of refrigeration, everyone in the community helped prepare the meat and lard. Partici- pants went home with fresh pork cuts and spicy sausages called boudin. La boucherie continues today at many Cajun festivals. Ed w in R em sb er g/ A la m y Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 6 1 5 5 constraints and health concerns have changed this pattern on weekdays; weekend breakfast sometimes reverts to the more British-style meal. Festive meals also reflect the British and Irish influence. A traditional Christmas din- ner includes roast turkey or ham, stuffing, and mashed vegetables. For dessert, a pie is customary, often mincemeat. Two holidays Americans think of as being typically Ameri- can, Thanksgiving and Halloween, are actu- ally of British and Irish origin. Thanksgiving combined the tradition of an old British har- vest festival with the Pilgrims’ celebration of surviving in their new environment. In Great Britain and Ireland, Halloween, or All Hallow’s Eve, is believed to have originated in ancient times. Ghosts and witches were thought likely to wander abroad on Hallow- een night. French Americans of French descent have adopted the U.S. meal cycle with the main meal in the evening. In Louisiana, the best- known celebration is Mardi Gras, culmi- nating on Shrove Tuesday, just before the beginning of Lent. In New Orleans there are parades, masquerading, and general revelry; the festival reaches its climax at a grand ball before midnight. After this day and night of rich eating and grand merriment, the forty days of fasting and penitence of Lent begin. In the Cajun countryside, Mardi Gras is cel- ebrated with “run”: Men on horseback ride from farmhouse to farmhouse collecting chickens and sausages to add to a commu- nity gumbo. Participants enjoy beer, boudin, and faire le maque (“make like a monkey,” or clowning around) at each stop. During the rest of the year, Cajuns sponsor many local festivals, such as the crawfish, rice, and yam festivals. Franco-Americans, like their French ancestors, serve meat pies on religious holi- days. The special pie for Easter has sliced hard-boiled eggs laid down on the bottom crust and then a layer of cooked meat topped with well-seasoned pork and beef meatballs. For Christmas, tourtière, a pie made with simmered seasoned pork, is eaten cold after midnight Mass. Nutritional Status The influence of the British and French on American cuisine is undoubtedly one rea- son the U.S. diet is high in cholesterol and fat, and low in fiber and complex carbohy- drates. Current research in Europe suggests continuing similarities. A survey of dietary habits found that consumption of potatoes, animal protein, processed foods, margarine and butter, and sweets is relatively high in the United Kingdom.19 In France, consumption of added animal fats and oils is high.20 The esti- mated prevalence of overweight and obesity in France in adults is 40 percent and 10 per- cent, respectively, and in the United Kingdom is 66 percent and 25 percent, respectively.21 Although few studies have been conducted on the nutritional status of Americans who are of French, Irish, and British descent, it is assumed that they have the same nutritional advantages and disadvantages as the general U.S. population. Nutritional Intake Ver y little has been reported on the diets of northern Europeans living in the United States. A study to deter- mine differences in mortality from coronary heart disease examined Irish brothers—one group in Ireland, one group living in the United States (Boston)—and a third control group of first-generation Irish Americans in Boston.22 Although there was no signifi- cantly different relative risk for death from heart disease among the three groups, it was found that their diets varied significantly. The Boston brothers and the first-generation Irish Americans had a higher intake (as a percent- age of caloric intake) of animal protein, total fat (more vegetable and less animal), sugar, fiber, and cholesterol, and a lower intake of starch. The Irish brothers had a higher caloric intake than the Boston brothers and the first- generation Irish Americans, yet their relative weight was significantly lower. It is commonly assumed that a high rate of alcoholism prevails among Irish Americans; however, little has been reported confirm- ing or refuting this belief. One comparative study found that Irish American men had higher rates of excessive drinking, and more Cornish pasties are still popular in parts of the country where immigrants from Corn- wall came to work in the mines, such as the Upper Peninsula in Michigan, where May 24 was declared Pasty Day in 1968. A study in France found that consumption of mineral water provided up to 25 percent of total daily intake of calcium and 6 to 7 per- cent of magnesium in participants.17 Some Cajuns think that being thin means a person is puny or unattractive.28 Cajuns may believe that milk and fish should not be consumed at the same meal. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 1 5 6 N O R T H E R N A N D S O U T H E R N E U R O P E A N S physical, psychological, sexual, and/or occu- pational problems with alcohol misuse than did Puerto Rican men.23 Prevalence for hereditary hemochroma- tosis, which may be treated with a low-iron diet (and avoidance of alcohol and foods or supplements high in vitamin C), are higher in northern Europeans (estimated to be 0.54 percent in whites).24 Though it is hypoth- esized that the gene for the disease is Celtic in origin,25 a study of French Canadians also noted a high prevalence rate.26 (It should be noted that hemochromatosis is often unde- tected in these populations, and may not show overt clinical symptoms until middle or late adulthood.) A study on the causes of inherited chylomicronemia indicates that the frequency of lipoprotein lipase deficiency is very high among French Canadians.27 Franco- Americans may also have high rates of this genetic defect, leading to elevated triglycer- ides and the necessity of a very low-fat diet. Counseling Studies of people in France suggest that the French are likely to under- take many activities at once, change plans frequently, ignore schedules, and commu- nicate indirectly with enthusiastic body language. 29 Direct, intense eye contact is important. Among the English and Irish, less eye contact between strangers or acquain- tances is common. The English are low con- text in their communication style, yet prefer understatement and somewhat indirect dis- cussion compared to Americans. The Irish are high context, direct, and often effusive. The French are very low context and can be exceptionally direct.14 Most northern Europeans use a quick, light handshake when greeting one another. It is important to note, however, that most Americans of British, Irish, or French descent are completely acculturated. Americans of British and Irish descent are often stoic in the face of illness and reserved in the communication of their symptoms. Some Irish believe that the best way to stay healthy is to avoid doctors unless very ill. The British, Irish, and French all tend to be more formal than Americans and politeness is expected. Socioeconomic status and religious practice are likely to have greater impact on foods J O H N C A S E Y , R e tire dC A S E Y , R e tire dC A S E Y Icame to the U.S. in 1956 from Ireland when I was twenty-six years old. I first lived in New York City where plenty of other Irish live. When I left Ireland, it wasn’t as well-off as it is now, and food was not plentiful, and it was mostly grown locally. You raised pigs and killed two a year, and that provided the bacon for the rest of a year. The foods we ate every day were bread, butter, milk, and eggs. My dad owned a food shop, so we had a bit more of other foods. When I came to America, I was over- whelmed by the amount of food available and all the different types. I had never had juice with breakfast, didn’t know what a grapefruit was—thought it was a very big lemon. Other foods that I tried for the first time were watermelon, turkey, hamburgers, corn on the cob, and French fries. I like all of them except the watermelon. In Ireland the main meal of the day was lunch, and what we usually had was all boiled together, like a New England boiled dinner but without as much meat and usually no meat. On sick days we got toast and tea. But the bread was only toasted on one side. When I first got toast here, it was toasted on both sides, and I wasn’t sure if you buttered both sides as well. The three biggest holidays in Ireland are Christmas, Easter, and St. Patrick’s Day. Christmas was the biggest feast day—bacon, eggs, and sausage for breakfast and for the main meal we had goose with dressing and mashed potatoes, plus custard for dessert. For Easter we often had mutton, and the children—if it was affordable— got chocolate Easter eggs, just like here. St. Patrick’s Day wasn’t as much fun because it fell during Lent, and the pubs were closed. I eat a lot of different foods now, more than I did when I was younger, and I like Chinese and German food, but I miss Irish bacon. My grandchildren are still trying to get me to order different flavors of ice cream, but I will only eat vanilla. When I first came to America, Ireland didn’t have enough food, and Americans ate too much. Today, both the Irish and Americans eat too much. N E W A M E R I C A N P E R S P E C T I V E S Irish Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 6 1 5 7 and food habits than country of origin. The in-depth personal interview should reveal any notable ethnically based preferences. Southern Europeans Southern European countries lie along the Mediterranean Sea and include Italy, south- ern France, Spain, and Portugal. Italy, shaped like a boot, sticks out into the Mediterranean and includes the island of Sicily, which lies off the boot toe. Italy is separated from the rest of Europe by the Alps, which form its northern border. Spain, located to the west of France (the Pyrenees Mountains form a natural bor- der between the two countries), occupies the majority of the Iberian Peninsula. Portu- gal sits on the western end of the peninsula and includes the Azore and Madeira Islands located in the Atlantic Ocean (the Cape Verde Islands were formerly a Portuguese territory, but they gained independence in 1975). Most of southern Europe enjoys a warm Mediter- ranean climate except in the cooler mountain- ous regions. Immigration to the United States from southern Europe has been considerable, pri- marily from the poorer regions of southern Italy. Many Americans, even those of non- European descent, enjoy Italian cuisine in some form. The foods of Spain and Portugal are similar to those of Italy and France due to the shared climate and history of Greek and Roman influence in the region, but their preparations differ. The following section reviews the traditional diets of Italy, Spain, and Portugal. The influence of these cuisines on U.S. fare is also discussed. Cultural Perspective History of Southern Europeans in the United States Immigration Patterns The majority of immi- grants from southern Europe were Italians, who swelled the population of U.S. cities on the Eastern Seaboard during the late nine- teenth and early twentieth centuries. Next in number were the Portuguese, primarily from the Azore Islands. Smaller numbers of Span- ish immigrants have been reported. Italians According to immigration records, more than 5 million Italians have settled in the United States. The majority came from the poorer southern Italian provinces and from Sicily between 1880 and 1920. Although earlier immigrants from northern Italy settled on the West Coast of the United States during the gold rush, most of these later immigrants settled in the large industrial cities on the East Coast. Many Italians who arrived faced dis- crimination and hostility, and, in response, formed concentrated communities within urban centers, often called Little Italies.30 Several cities still boast Italian neighborhoods such as the North End in Boston and North Beach in San Francisco. Many Italians came to the United States for economic reasons; more than one-half of the immigrants, mostly men, returned to their homeland after accumulating sufficient money. Peasants in their native land, Italians in the United States often became laborers in skilled or semiskilled professions, especially the building trades and the clothing indus- try. Immigration from Italy fell sharply after World War I; however, more than 1.6 million Italians have immigrated since World War II.31 According to the 2013 census estimates, over 17.3 million Americans claim Italian descent.5 Spaniards More than one-quarter of a million people from Spain have immigrated to the United States since 1820. However, ▼ Traditional foods of southern Europe. Some typical foods include almonds, artichokes, basil, cheese, eggplant, garlic, chickpeas, olive oil, olives, onions, pasta, prosciutto, salt cod, sweet bread, and tomatoes. Ig or D ut in a/ Sh ut te rs to ck .c om Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 1 5 8 N O R T H E R N A N D S O U T H E R N E U R O P E A N S the majority of the Spanish-speaking popu- lation in the United States comes from the U.S. acquisition of Spanish territories and the immigration of people from Latin American countries (see Chapters 9 and 10 for more detail). The earliest Spanish settlers arrived dur- ing colonial times, establishing populations in what is now Florida, New Mexico, Califor- nia, Arizona, Texas, and Louisiana. A major- ity were from the poorest regions of southern Spain and the Canary Islands.32 Half of all other Spanish immigrants to the United States came later in the nineteenth and early twen- tieth centuries, due to depressed economic conditions in Spain. In 1939, after the fall of the second Spanish republic, a small number of refugees immigrated for political reasons. Additional Spanish immigrants were from the Basque region, located in northeastern Spain on the border with France (there are also French Basques). The Basques are thought to be one of the oldest surviving ethnic groups in Europe; they lived in their homeland before the invasion of the Indo-Europeans around 2000 bce. Their language, Euskera, is not known to be related to any other living lan- guage. Though the earliest Basque immigrants to the United States were fishermen and whal- ers who probably arrived before Columbus, most came in the mid-nineteenth century, arriving first in California for the gold rush, then spreading north and east throughout the West. Many emigrated from South America, where they had first settled, and were listed as Chileans (the umbrella term used for all South Americans at the time). An accurate estimate of their numbers is impossible.33 Portuguese Over 1.4 million Portuguese Americans live in the United States.5 Begin- ning in the early nineteenth century, two waves of Portuguese immigrants arrived in the United States. Early immigrants were pri- marily from the Azore Islands and Cape Verde Islands, and they often located in the whaling ports of New England and Hawaii. They were followed in the 1870s by immigrants hoping to escape poverty. They arrived with little edu- cation and few skills, but were willing to do farm labor in California and Hawaii, and work in the service trades of northeastern cities. After World War II, a small number of Portuguese from Macao, a Portuguese settle- ment on the coast of China near Hong Kong, settled in California. They were well educated and many held professional jobs. A much more significant number of Portuguese, more than 150,000, entered the United States after 1958, again mostly from the Azore Islands, following a series of volcanic eruptions that devastated the region. Since 1965 over 210,000 Portuguese have immigrated to the United States. Current Demographics and Socioeconomic Status Italians In the United States in 2010 there were over 17 million Americans of Italian descent, most of whom live in or around major cities.5 Economic conditions improved during the 1980s in Italy, and immigration from the nation slowed significantly. Economically, Italian Americans shared in the general prosperity after World War II, and today most are employed in white- collar jobs or as skilled laborers. Four gen- erations of Italians living in the United States have been identified. Elderly people living in urban Italian neighborhoods are one group; those who are middle-aged and living in either urban or suburban settings are the second group; the well-educated younger Italian Americans of subsequent generations live mostly in suburban areas are the third group; and the very recent immigrants from Italy are the fourth.34 These groupings can be expected to change as each grouping ages and with increased assimilation: only 20 percent of Italian Americans born after 1940 married other Italian Americans. Spaniards People who report Spanish, Span- iard, or Spanish American heritage were over 1.1 million in the 2005 U.S. Census esti- mates and are now grouped with Hispanics in the U.S. Census. Seven percent were born in Spain. Most are well integrated into their communities, although larger populations are found in New York and Tampa, Florida. A distinctive group of Isleños, descendants of Canary Island immigrants, is found in south- ern Louisiana. The Basques settled mostly in the rural regions of California, Nevada, Idaho, Among the Basques, it is said that the devil once came to the region to learn their language, Euskera, so that he could entrap the inhabit- ants. He gave up after seven years when he was able to master only two words: bai and ez (“yes” and “no”). There are approximately 1.5 million Canadians of Italian ancestry, accord- ing to the 2011 Census figures. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 6 1 5 9 Montana, Wyoming, Colorado, New Mexico, and Arizona and became ranchers. Some Basque immigrants, however, were drawn to the mining jobs of West Virginia and the rub- ber and steel plants of Ohio, Illinois, Michigan, and Pennsylvania.33 Though the 2008 Census estimates report 58,000 Basque Americans, it is thought that this number may underrep- resent the total population, which may be as high as 100,000. Today most Basque descen- dants are involved in some aspect of animal husbandry or small business; few have entered other professions. Newer Basque communi- ties now exist in Connecticut and Florida because jai alai (a Basque sport) facilities were established there. Portuguese As of 2010 over 1.3 million Amer- icans were of Portuguese descent.5 In 2000, 50,000 claimed Cape Verdean ancestry, and 4,000 reported Azore Islands heritage. (Immi- grants from the Cape Verde and Azore Islands and those from Madeira may not feel Portu- guese. Instead, they identify with their island or city of origin.) Initially, the Portuguese Americans on the West Coast were farmers and ranchers, but eventually their descen- dants moved into professional, technical, and administrative positions.35 On the East Coast, the descendants of the Portuguese who settled in the whaling ports now make up a signifi- cant part of the fishing industry, though only 3 percent of all Portuguese Americans work in this occupation. The percentage of Portu- guese families living in poverty is half that of the U.S. average. Worldview Religion Italians In Italy, the Roman Catholic Church was a part of everyday life. Immigrants to the United States, however, found the church to be more remote and puritanical, as well as staffed by the Irish. The church responded by establishing national parishes (parishes geared toward one ethnic group with a priest from that group) that helped immigrants adjust to the United States. Some religious festivals, part of daily spiritual life in Italy, were transferred to the United States and are still celebrated today, such as the Feast of San Gennaro in New York’s Little Italy. Spaniards Most Spaniards are Roman Catholic. The Jesuit Order was founded in Basque country and has significantly influ- enced Basque devotion. Basque Americans are involved in their parishes, and there is the expectation that religion is part of daily life and sacrifice. Portuguese The Roman Catholic Church also helped the Portuguese ease into the main- stream of U.S. life. Local churches and special parishes often sponsor traditional religious fiestas that include Portuguese foods, dances, and colorful costumes. Family Italians The social structure of rural villages in southern Italy was based on the family, whose interests and needs molded each indi- vidual’s attitudes toward the state, church, and school. The family was self-reliant and dis- trusted outsiders. Each member was expected to uphold family honor and fulfill familial responsibilities. The father was head of the household; he maintained his authority with strict discipline. The mother, although subor- dinate, controlled the day-to-day activities in the home and was often responsible for the family budget. Once in the United States, the children broke free of parental control due to economic necessity. Although sons had always been allowed some independence, daughters soon gained freedom, as well, because they were expected to work outside the home like their brothers. Education eventually also changed the family. Early immigrants repeat- edly denied their children schooling, sending them to work instead. However, by 1920, edu- cation was considered an important stepping- stone for Italian Americans. Spaniards In the traditional Spanish fam- ily, the father spent much of his time work- ing and socializing outside the home, while the mother devoted her life to her children. Typically, one daughter would choose not to marry and would care for her parents as they aged. In the United States, Spanish Ameri- can families are usually limited to immediate members, although the obligation to parents remains stronger than for most Americans. An elder may live part of the year with one child, then part of the year with another child. Boise, Idaho, is consid- ered the Basque capital of the United States. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 1 6 0 N O R T H E R N A N D S O U T H E R N E U R O P E A N S Independent living and retirement homes are also common. The Basque family was cus- tomarily an extended one. Basques in Spain are prohibited from marrying non-Basques, but in the United States many Basques marry other nationalities. Basques accept all mem- bers who marry into their families. Spanish women hold unique status among southern Europeans. Class distinctions are more important than gender when it comes to educational and professional attainment. The Basque women are historically recognized for their equality. Since ancient times, their duties have been as valued as those of men, and jobs are often not gender-specific. Portuguese Like the Italians, the Portuguese have close family solidarity and have had some success in maintaining the traditional family structure. Grown sons and daughters often live in close proximity to their par- ents, and family members try to care for the sick at home. Family structure is threatened, however, when women must work or genera- tional values change. Men tend to dominate the family, and, as a result, some Portuguese American women marry outside the group. Traditional Health Beliefs and Practices Tradi- tional Italian health beliefs include concepts common in the American majority culture as well as concerns associated with folk medi- cine. Fresh air is believed necessary to health, and some older Italian Americans maintain that the heavy air of the United States is con- sidered unhealthy compared to the light air of Italy. Well-being is defined as the ability to pursue normal, daily activities. There is the expectation that health declines with age. Some Italian Americans believe that ill- ness is due to contamination (through an unclean or sick person) or heredity (blood). Older immigrants may also think that sick- ness occurs because of drafts (surgery may be avoided so that organs will not be exposed to air), the suppression of emotions (i.e., anxiety, fear, grief ), or supernatural causes. Some Italians believe that a minor illness can be attributed to the evil eye and that seri- ous conditions result from being cursed by a malicious person or God.6,35,37 Saints may be implored for protection, good luck charms worn, or, more traditionally, the practices of a maghi (witch) used to avoid illness. Although many Italians do not profess a belief that God punishes sin with a curse, there is often a fatal- istic approach to terminal illness as being the result of God’s will. Italian Americans, espe- cially those of older generations, sometimes believe that problems in pregnancy are due to diet. Unsatisfied cravings are reputed to cause deformities, and if a woman does not eat a food she smells, she may suffer a miscarriage. Little has been reported regarding Spanish and Portuguese health practices. Traditional Food Habits Although the foods of the southern European countries are similar, as detailed in the cul- tural food groups list in Table 6.2, there are notable differences in preparation and presen- tation. Many Americans think of Italian cook- ing as consisting of pizza and spaghetti. In reality, these dishes are only a small part of the regional cuisine of southern Italy, the original homeland of most Italian Americans. Spanish food is mistakenly equated with the hot and spicy cuisine of Mexico. Although Mexico was a colony of Spain, the foods and food habits of the two countries differ substantially. Portugal and Spain have very similar cuisines, but most of the Portuguese immigrants to the United States are from the Azore Islands and the island of Madeira. Their diet was less varied than that of the mainland Portuguese. Ingredients and Common Foods Foreign Influence The Phoenicians and Greeks, who settled along the Mediterra- nean coast in ancient times, are believed to have brought the olive tree and chickpeas (garbanzo beans) to the region. In addition, fish stew, known as bouillabaisse in France and zuppa di pesce alla marinara in Italy, may be of Greek origin. The Muslims brought egg- plants, lemons, oranges, sugarcane, rice, and a variety of sweetmeats and spices. Marzipan, a sweetened almond paste used extensively in Italian desserts, and rice flavored with saf-in Italian desserts, and rice flavored with saf-in Italian desserts, and rice flavored with saf fron, as in the northern Italian dish risotto alla Milanese, are both believed to have Muslim origins. In Spain the Muslim influence is also The market for pro- cessed spaghetti sauce in the United States is more than $500 million annually. A tortilla in Spain is an egg omelet, not the cornmeal flatbread eaten by the Mexicans. It is believed that the Spanish called the Mexican bread by that name because of its similar shape. An Italian proverb states that after age forty, a person can “expect a new pain every morning.” Some Italians believe that wine mixed with milk in the stomach causes too much acid, so milk is avoided at meals and consumed mostly with snacks. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 6 1 6 1 © C en ga ge L ea rn in g Group Comments Common Foods Adaptations in the United States Protein Foods Milk/milk products Most adults do not drink milk but do eat cheese. Dairy products are often used in desserts. Many adults suffer from lactose intolerance. Cheese (cow, sheep, buffalo, goat), milk It is assumed that second- and third- generation southern Europeans drink more milk into their adulthood than their ancestors did. Meat/poultry/ fish/eggs/ legumes Dried salt cod is eaten frequently. Small fish, such as sardines, are eaten whole, providing substantial dietary calcium. Meat: beef, goat, lamb, pork, veal (and most variety cuts Poultry: chicken, duck, goose, pigeon, turkey, woodcock Fish: anchovies, bream, cod, haddock, halibut, herring, mullet, salmon, sardines, trout, tuna, turbot, whiting, octopus, squid Shellfish: barnacles, clams, conch, crab, lobster, mussels, scallops, shrimp Eggs: chicken Legumes: chickpeas, fava and kidney beans, lentils, lupine seeds, white beans More meat and less fish are eaten than in Europe. Cereals/Grains Bread, pasta, or grain products usually accompany the meal. Cornmeal, rice, wheat (bread, farina, a variety of pastas) Fruits/Vegetables Fruit is often eaten as dessert. Fresh fruits and vegetables are preferred. Fruit: apples, apricots, bananas, cherries, citron, dates, figs, grapefruit, grapes, lemons, medlars, peaches, pears, pineapples, plums (prunes), pomegranates, quinces, oranges, raisins, Seville oranges, tangerines Vegetables: arugala, artichokes, asparagus, broccoli, cabbage, cardoon, cauliflower, celery, chicory, cucumber, eggplant, endive, escarole, fennel, green beans, lettuce, kale, kohlrabi, mushrooms, mustard greens, olives, parsnips, peas, peppers (green and red), pimentos, potatoes, radicchio, swiss chard, tomatoes, turnips, zucchini First- and second- generation southern Europeans generally eat only fresh fruits and vegetables. Fruit and vegetable consumption tends to reflect general American food habits by the third generation. Additional Foods Seasonings Dishes using similar ingredients in Italy, Spain, and Portugal often differentiated by distinctive use of herbs and spices. Seasoning in Azore Islands and Cape Verde Islands is usually very mild. Basil, bay leaf, black pepper, capers, cayenne pepper, chocolate, chervil, cinnamon, cloves, coriander, cumin, dill, fennel, garlic, leeks, lemon juice, marjoram, mint, mustard, nutmeg, onion, oregano, parsley (Italian and curley leaf ), rosemary, saffron, sage, tarragon, thyme, vinegar Nuts/seeds Nuts commonly used in desserts and added to some entrees and side dishes. Almonds, hazelnuts, pignolis (pine nuts), walnuts, lupine seeds Beverages Coffee, chocolate, liqueurs, port, Madeira, sherry, flavored sodas (e.g., orzata), tea, wine Fats/oils Olive oil flavors numerous dishes; used for deep-frying in Spain. Butter, lard, olive oil, vegetable oil Use of olive oil has decreased. Sweeteners Honey, sugar TA B L E 6 . 2 Cultural Food Groups: Southern European Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 1 6 2 N O R T H E R N A N D S O U T H E R N E U R O P E A N S seen in saffron-seasoned rice and in the use of ground nuts in sauces, candies, and other desserts. It was the food of the New World colonies, however, that shaped much of Italian, Spanish, and Portuguese cuisine. Chocolate, vanilla, tomatoes, avocados, chile peppers, pineapple, white and sweet potatoes, corn, many variet- ies of squash, and turkey were brought back from the Americas. The tomato is of particu- lar importance to the character of southern European cooking. Asian ingredients have had a significant impact on the fare of Portu- gal and, to a lesser degree, the dishes of Spain and Italy. From India and the Far East came coconuts, bananas, mangoes, sweet oranges, and numerous spices, such as pepper, nutmeg, cinnamon, and cloves. Staples Italy Although the cooking styles and ingre- dients vary from region to region in Italy, some general statements can be made about ingredients. Pasta is the quintessential dish throughout the nation. It is prepared fresh, from dough made with the addition of eggs, or dried, from a dough made without eggs. It is traditionally served three ways: with sauce (asciutta), in soup (en brodo), or baked (al forno). There are literally hun- dreds of pasta shapes, such as thin, round strips that include spaghetti (from the Italian word for “string”) and capelli d’angelo (angel hair); flat strips such as linguini and fettucini (ribbon); tubular forms, such as macaroni, penne, and the larger manicotti; and sheets such as lasagna and pappardelle. There are additional forms, such as spirals (e.g., fusilli, rotelle), shells (conchiglie), little ears (orechiette), bowties (farfalle), and small barley- or rice-shaped orzo. The most com- mon pasta in Italy is tagliatelle, a medium- width flat noodle.9 In the north, fresh pastas are more com- mon, and stuffed versions made with bits of meat, cheese, and vegetables, such as ravioli, are especially popular. Pasta in the north is also frequently topped with rich cream sauces. In the agriculturally poorer south, the pasta is generally dried, and it is usually served unfilled with a tomato-based sauce. Other broad differences are that northern fare uses more butter, dairy products, rice, and meat than the south, which is notable for the use of olive oil, more fish, and more beans and vegetables, such as artichokes, eggplants, bell peppers, and tomatoes. Garlic is found throughout the nation, though it is more pop- ular in the north. Other seasonings common to all of Italy are parsley, basil, and oregano. Anise, cinnamon, nutmeg, mace, and cloves are also used in many dishes. Spain The rugged terrain in Spain is suitable for raising small animals and crops, such as grapes and olives. Spain is the largest pro- ducer of olives in the world. Entrées usually feature eggs, lamb, pork, poultry, or dried and salted fish (especially cod, called bacalao). Eggs are consumed day and night. They are enjoyed fried in olive oil, often topped with migas (fried bread crumbs combined with garlic, bacon, and ham). Tortilla española (potato omelet) is perhaps the national dish, eaten as appetizers, entrées, snacks, and as a filling for bocadillos (sandwiches). Sausages, such as the paprika- and garlic-flavored cho- rizo and the blood sausage called morilla, are common. Serrano (meaning “from the moun- tains”) ham is a salty, dry-cured meat served in paper-thin slices that has gained worldwide acclaim. Seafood is popular in coastal regions. Meats are often combined with vegetables in savory stews. Each region has its own recipe for paella, which typically includes saffron- seasoned rice topped with chicken, mussels, shrimp, sausage, tomatoes, and peas. Cocido, a stew of chickpeas, vegetables (e.g., cab- bage, carrots, potatoes), and meats (e.g., beef, chicken, pork, meatballs, sausages), also var- ies from area to area, but is always served in three courses. The strained broth with added noodles is eaten first, followed by a plate of the boiled vegetables, and concluded with a plate of cooked meats. Crusty bread is served with the meal. Garlic and tomatoes flavor many Spanish dishes, for example, gazpacho, a refreshing pureed vegetable soup that is usually served cold, and zarzuela (meaning “operetta”), a fresh seafood stew. Olive oil is also a common ingredient used in almost all cooking, even “Cods’ tongues” are a specialty enjoyed by all southern Europeans. Though they are an especially succulent strip of meat from inside the fish’s mouth, they are not actually tongues. Olive oil is labeled according to method of processing and the percentage of acidity, from extra virgin to virgin (or pure) olive oil. In the United States, only the oils derived from the first press of the olives can be called virgin or extra virgin depending on its acidity (extra virgin is lower); a blend of olive oil, produced by refining, which does not alter its fat structure, and virgin olive oils developed to reduce acidity and must be labeled “pure.” The Italians eat more rice than any other Europe- ans. Thomas Jefferson supposedly smuggled rice out of Italy to the United States, where his first attempts to cultivate it were unsuccessful. Espresso, which may mean “made expressly for you,” is made from finely ground dark roast coffee through which water is forced by steam pressure. Cappuccino is espresso topped with frothy steamed milk. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 6 1 6 3 deep-frying pastries, such as the ridged, cylin- drical doughnuts known as churros. Sauces accompany many dishes. Alioli is made from garlic pulverized with olive oil, salt, and a little lemon juice. It is served with grilled or boiled meats and fish. Another popular sauce, called romescu, is sometimes mixed with alioli to taste by each diner at the table. It combines pureed almonds, garlic, paprika, and tomatoes with vinegar and olive oil. Fruit, particularly oranges, is popular for dessert, sometimes served in custard. One favorite is membillo, a quince paste served with slices of a salty sheep’s-milk cheese known as Manchego. Spain’s best-known dessert is flan, a sweet milk-and-egg custard topped with caramel. Wine usually accompanies the meal. Sangria, made with red or white wine and fresh fruit juices, is served chilled in the summer. Spain is probably most famous in the United States for its Sherries, which are wines fortified with added brandy. Sherries can be dry or sweet and are categorized by the length of time they are aged. They are often described as having a nutty flavor. Portugal Portuguese fare shares some simi- larities in ingredients with Spanish cuisine, but a more generous addition of herbs and spices, including cilantro, mint, and cumin, distinguishes the cooking. Fish dominates the diet of the Portuguese; they are said to have as many recipes for bacalhau (dried salt cod) as there are days in the year.39 Sardines are often grilled or cooked in a tomato and vegetable sauce. Lamprey is a popular food in north- ern Portugal, where it is often prepared with curry-like seasonings. Shellfish, such as clams, are often combined with pork or other meats in stewed dishes. Chouriço, similar to the Spanish pork sausage, chorizo, and linguiça, a pork and garlic sausage, are often eaten at breakfast. Other typical dishes are cacoila, a stew made from pig hearts and liver, then served with beans or potatoes; isca de figado, beef liver seasoned with vinegar, pepper, and garlic, then fried in olive oil or lard; and assada no espeto, meat roasted on a spit. A common soup is caldo verde, or green broth, made from kale or cabbage and potatoes. A unique dry soup of bread moistened with oil or vinegar and topped with anything from meat, chicken, or shellfish and vegetables is called açordu. Fava beans, chickpeas, and lupine seeds (tre- mocos) are added to some dishes. Rice and fried potatoes are so popular they are often served together. Crusty country breads and, in the north, a cornmeal bread called broa also accompany the meal. Portuguese sweet The name gazpacho may have come from the vinegar-and-water drink called posca, report- edly offered to Christ on the cross. Alcohol consumption among the Basques in Spain is high, especially for men.41 ▼ m ar go ui lla t p ho to /S hu tt er st oc k. co m Pasta comes in dozens of forms in Italy, including thin strings, flat ribbons, tubes, spirals, sheets, and shapes that resemble wheels, bowties, little ears, hats, rice, and other items. It is found fresh or dried. S A M P L E M E N U An Italian Lunch Cr os tin ia,b,c S pagh e tti c on C oz z e (Spaghetti with Mussels)a,c Chicken S altimb oc ab,c Sauteed Spinach Bis c otti and and Bis c otti E s pr e s s ob,c aHazin, M. 2004. Marcella says . . . New York: HarperCollins. bCasella, C. 2005. True Tuscan. New York: HarperCollins. cMario Batali at http://www.mariobatali.com/ Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 1 6 4 N O R T H E R N A N D S O U T H E R N E U R O P E A N S Venice, located on the east coast and known for its romantic canals (although the city actually consists of 120 mud islands), has a cuisine centered on seafood. Its best-known dish is scampi, made from large shrimp sea- soned with oil, garlic, parsley, and lemon juice. Inland is Verona, famous for its delicate white wines, such as Soave. Turin, the capital of the western province of Piedmont, is known for its grissini, the slender breadsticks popular throughout Italy, and bagna cauda (meaning “hot bath”), a dip for raw vegetables consisting of anchovies and garlic blended into a paste with olive oil or butter. A summer favorite is vitello tonnato, braised veal served cold with a spicy tuna sauce. Located on the northwest coast of Italy, Genoa is known for its burrida, a fish stew containing octopus and squid, and pesto, an herb, cheese, and nut paste (usually made with basil), which has become popular in the United States. Moving westward, the city of Bologna is the center of a rich gastronomic region known as Emilia-Romagna. Pasta favorites of the area include lasagne verdi al forno, spinach- flavored lasagna noodles baked in a ragu (a meat sauce typically made with four differ- ent meats and red wine), and a white sauce, flavored with cheese; and tortellini, egg pasta stuffed with bits of meat, cheese, and eggs, served in soup or a rich cream sauce. It is tra- ditionally served on Christmas Eve. A similar stuffed pasta is cappelleti, named for its shape, a little hat. Cured meats are a specialty of the region, including salami and sopresseta (simi- lar to salami but rougher textured); mortadella, a pork sausage (similar to American bologna); pancetta (a salt-cured bacon); prosciutto, a raw, smoked ham (served thinly sliced, often as an appetizer with melon or fresh figs); and culatello (a milder and creamier ham than prosciutto). Parmesan cheese, a sharply fla- vored cow’s milk cheese with a finely grained texture, also comes from the area, as does aceto balsamico di Modena (or di Reggio Emilia), a vinegar made from the white Trebbiano wine grapes. When labeled tradiziolone, it means the vinegar has been twice fermented and aged in wood casks for at least twelve years, which intensifies and sweetens the flavor, and thick- ens it into a syrupy consistency. Those labeled breads, pan doce, and doughnuts, malassa- das, are also specialties. Desserts often feature fruit, such as bananas, grapes, and figs, as well as eggs and almonds. Puddings, custards, and sponge cakes are popular. Regional Variations Italy Some of the regional specialties in the northern area of Lombardy, around Milan, are risotto, a creamy rice dish cooked in but- ter and chicken stock, flavored with Parmesan cheese and saffron; polenta, cornmeal mush (thought to have been made originally from semolina wheat), often served with cheese or sauce; and panettone, a type of fruitcake. Veal is very popular, served in the stew known as osso buco and in veal piccata (chops that are pounded very thin, then breaded and pan- fried, topped with lemon juice, capers, and minced parsley). The cheeses of the region include Gorgonzola, a tangy, blue-veined cheese made from sheep’s milk, and Bel paese, a soft, mild-flavored cheese. The area is also known for its aperitifs, such as bittersweet Vermouth. Linguiça comes from the Portuguese word meaning “tongue,” a reference to the shape of the sausage. Sweets were a traditional source of income for Portuguese convents, and the names of many pastries reflect this past, including papas- de-anjo (angel puffs) and gargantas de friera (nun’s wattles).39 Italian folklore has it that basil can develop its full flavor only if the gar- dener curses daily at it. Forks were originally two-pronged—the three-pronged fork was created in Italy for eating pasta. ▲ Olives and olive oil are found in numerous southern European dishes. Spain is the primary producer of olives worldwide. Cu rio so /S hu tt er st oc k. co m Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 6 1 6 5 condimento are imitations of vinegar blends and reduced aging. Florence, the capital of Tuscany, has a long history of culinary expertise. In 1533, Catherine de’ Medici (the Medici family ruled Florence) married into the royal family of France. She is often credited with introduc- ing Italian fare—at the time the most sophisti- cated cuisine in Europe—to France. Florence is renowned for its green noodles (colored by bits of spinach) served with butter and grated Parmesan cheese, called fettucini Alfredo. The term alla Fiorentina refers to a dish garnished with or containing finely chopped spinach. Whole grilled fish and wild game dishes are popular. Rosemary flavors many dishes of the region. Tuscany is also famous for its full- bodied red wine, Chianti, and its use of chest- nuts, which are featured in a cake eaten at Lent called castagnaccio alla Fiorentina. Rome, the capital of Italy, has its own regional cooking and is probably best known for fettucine Alfredo, long, flat egg noodles mixed with butter, cream, and grated cheese. Another dish is saltimbocca (meaning “jumps in the mouth”)—thin slices of veal rolled with ham and cooked in butter and Marsala wine. Gnocchi, which are dumplings, are eaten throughout Italy, but in Rome they are made out of semolina and baked in the oven. Fried artichokes are popular at Easter time, as is roast baby lamb or kid. Pecorino romano is the hard sheep’s milk cheese of Rome, similar to Parmesan but with a sharper flavor. The capital of Campania in southern Italy is Naples, considered the culinary capital of the south. Pasta is the staple food, and a favor- ite way of serving it is simply with olive oil and garlic, or mixed with beans, in the soup pasta e fagiole. Pizza is native to Naples and is said to date back to the sixteenth century, per- haps originating with toppings for the savory flatbread known as foccacia. Another form of pizza is calzone, which is pizza dough folded over a filling of cheese, ham, or salami, then baked or fried. The area’s best-known cheeses are Mozzarella, an elastic white cheese origi- nally made from buffalo milk; Provolone, a firm smoked cheese; and Ricotta, a soft, white, unsalted cheese made from sheep’s milk and often used in desserts. Sicily and other regions of southern Italy use kid and lamb as their principal meats. It is sometimes prepared alla cacciatore (hunter’s style), with tomatoes, olives, garlic, wine, or vinegar (and sometimes anchovies)—a method also used with wild boar, venison, and chicken. Along the coast, fresh fish, such as tuna and sar- dines, are used extensively; baccala, dried salt cod, is often served on fast days. The North African influence shows up in Sicily in the use of couscous, called cuscus in Italy, which is commonly served with fish stews. South- ern Italy’s cuisine is probably best known for its desserts. Many examples can be found in Italian American bakeries and espresso bars: cannoli, crisp, deep-fried tubular pastry shells filled with sweetened ricotta cheese, shaved bittersweet chocolate, and citron; cassata, a cake composed of sponge cake layers with a ricotta filling and a chocolate- or almond- flavored sugar frosting; gelato, fruit or nut (e.g., black currant or pistachio) ice cream; and granita, intensely flavored ices. Spumoni is chocolate and vanilla ice cream with a layer of rum-flavored whipped cream contain- ing nuts and fruits. Another popular sweet is zeppole, a deep-fried doughnut covered with powdered sugar. The sweet white wine S A M P L E M E N U Spanish Tapas Cr oque tas a,b Spanish Potato T or tilla (omelet)a,b E mpan ad as a,b G ambas (grilled shrimp)a,b Fried Almonds, Pieces of Cheese, Sausage Bites Sherry, Beer, or S an gr iaa,b aVon Bremzen, A. 2005. The new Spanish table. New York: Workman. bTapas Bonitas at http://www.tapasbonitas.com/food/Tapas_Recipes.php Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 1 6 6 N O R T H E R N A N D S O U T H E R N E U R O P E A N S fortified with grape spirits, Marsala, is also a specialty in the region. It develops a deep- tawny color when aged. Spain The cooking of Spain can be divided broadly by preparation methods. In the north, stewing is most common. In the cen- tral regions, roasting is favored. Although deep-fried foods are found in every region of the nation, they are especially popular in the southern regions.40 Most Spanish dishes prepared in the United States reflect the cooking of Spain’s southern region, with its seafood, abundant fruits and vegetables, and Muslim influence. Fried fish, arroz negro (rice blackened with squid ink), and salmorejo (a fresh tomato soup thick- ened with bread crumbs and garnished with Serrano ham and hard-boiled egg) are popu- lar dishes. Central Spain has a more limited diet; roast suckling pig and baby roast lamb are favorites. Garlic soup starts many meals. In the northwest, fish is common, and often fills empanadas (small pastry turnovers). Octopus flavored with paprika is a specialty. In the Basque provinces lamb is the primary meat, and charcoal-grilled lamb is a specialty. Seafood, such as bacalao al pil-pil (dried salt cod cooked in olive oil and garlic), bacalao a la vizcaina (dried salt cod cooked in a sauce of onions, garlic, pimento, and tomatoes), and angulas (tiny eel spawn cooked with olive oil, garlic, and red peppers), is a favorite in some Basque areas. Other popular dishes include garlic soup, babarrun gorida (red beans with chorizo), and pipperrada vasca (eggs with peppers). Simple rice puddings or fruit com- potes are typical desserts. Portugal Though Portuguese cuisine var- ies from north to south, from hearty soups and stews to a more refined, lighter style of entrée, the largest regional differences occur between the mainland and the islands. The foods of the Madeiras, the Azores, and the Cape Verde Islands include tropical ingre- dients imported from both Africa and the Americas. In Madeira, which attracts many tourists from throughout Europe, avocados, cherimoya, guava, mango, and papaya are featured in its dishes. Corn is common, as is couscous. Honey cakes and puddings reflect the influence of other European nations. In the Azores and Cape Verde Islands, fare var- ies significantly from island to island and even city to city. Bananas, corn, cherimoya, passion fruit, pineapples, and yams are prominent. Açorda d’azedo is one specialty—a mixture of cornbread, vinegar, onions, garlic, saffron, and a little lard boiled together and eaten for breakfast. Beef is the preferred meat, and sea- food, such as cockles, limpets, crab, lobster, and octopus, is eaten in many areas. Little fat or oil is added to dishes; and spicing is mild, often limited to onion, garlic, salt, and pep- per. Tea is the preferred beverage. Portugal is famous for its rich sweet wines: Port (from the northern region) and Madeira (from the islands), which are fortified with grape spir- its at the start of fermentation. They can be consumed young, or aged for forty or more years, becoming drier, nuttier, and smoother in flavor. They are popular with dessert or as after-dinner drinks. Meal Composition and Cycle Daily Patterns Italy A traditional Italian breakfast tends to be light, including coffee with milk (caffe latte), tea, or a chocolate drink, accompanied by bread and jam. Lunch is the main meal of the day and may be followed by a nap. It The art of making ice cream is credited to the Chinese, who brought it to India; from there it spread to the Persians and Arabs. The Muslims brought it to Italy, and it was a Sicilian, Francisco Procopio, who intro- duced ice cream to Paris in the 1660s. The British discovered it soon after and later brought ice cream to America. During the nineteenth century, Madeira wine was sent to other Euro- pean nations in the holds of ships where it became very hot. Instead of ruining the wine, it aged it more quickly—Madeira that had circumnavigated the globe twice became popular in England. Today, it is heated during aging to simulate voyage conditions. ▲ Co le G ro up /S to ck by te /G et ty Im ag es Fish and shellfish are a favorite in Italy, Spain, and Portugal. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 6 1 6 7 usually starts with an appetizer course of antipasti, such as ham, sausages, pickled veg- etables, and olives; or crostini, crispy slices of bread with various toppings, such as tomatoes or cheese. Next is minestra (wet course), usu- ally soup, or asciutta (dry course) of pasta, risotto, or gnocchi. The main course is fish, meat, or poultry, roasted, grilled, pan-fried, or stewed. It is served with a starchy or green vegetable, followed by a salad. Bread is served with the meal, often with olive oil and bal- samic vinegar for dipping. Dessert often con- sists of fruit and cheese; pastries or biscotti (crunchy twice-baked cookie slices) and ice creams are served on special occasions. Dinner is served at about 7:30 p.m. and is a lighter version of lunch. Wine usually accom- panies lunch and dinner. Coffee or espresso is enjoyed after dinner, either at home or in a coffeehouse. Marsala may be served with cheese before the meal for a light appetizer course, or after dinner. It is also often used in the preparation of desserts. One such sweet, now prepared all over Europe, is zabaglione, a wine custard. Spain By U.S. standards, the Spanish appear to eat all the time. The traditional pattern, four meals plus several snacks, is spread across the day. A light breakfast (desayuno) of coffee or chocolate, bread, or churros is eaten about 8:00 a.m., followed by a midmorning break- fast around 11:00 a.m. of grilled sausages, fried squid, bread with tomato, or an omelet. A light snack, tapas, is consumed around 1:00 p.m. as a prelude to a three-course lunch (comida) at around 2:00 p.m., consisting of soup or salad, fish or meat, and dessert, which is often followed by fruit and cheese. Many businesses close for several hours in the after- noon to accommodate lunch and a nap. Tea and pastries (merienda) are eaten between 5:00 and 6:00 p.m. and more tapas are enjoyed at 8:00 or 9:00 p.m. Finally supper, including three light courses such as soup or omelets and fruit, is consumed between 10:00 p.m. and midnight. Tapas are usually served in bars and cafés and are accompanied by Sherry or wine; the variety of tapas is tremendous; it is not unusual for more than twenty kinds to be offered on a menu. They are differentiated from appetizers in Spain in that they are strictly finger foods, such as olives, almonds, croquetas (fried croquettes with fish, ham, cheese, etc.), stuffed mushrooms, shrimp, sausage bits, pieces of cheese, and other small bites. The evening meal may be skipped if a substantial number of tapas are eaten at night. The main meal of the day is lunch, which is generally eaten at home and consists of three hefty courses. Portugal Portuguese meal patterns are simi- lar to those of Spain, often starting out with the day around 8:00 a.m. with espresso coffee and a roll with marmalade, or pastel de nata, a cinnamon-flavored custard tart in puff pas- try. A morning coffee break, including coffee served with hot milk, is followed by lunch in the early afternoon. This is traditionally the largest meal of the day, and even in urban areas often includes several courses. Unlike the Spanish pattern, the evening meal in Portugal is usually eaten earlier. As in Spain, red wine usually accompanies the meal. Etiquette Italy, Spain, and Portugal share many etiquette rules. The fork remains in the left hand, and the knife remains in the right hand. The knife can be used to help scoop food onto the fork. Bread is not served with butter and should be placed on the edge of the main plate, or next to it on the table. Manners regarding the consumption of pasta include using your fork to twirl the pasta against the ▲ Traditional Italian lunches are large, often ending with fruit and cheese. On special occasions, pastries, such as twice-baked cookies called biscotti, or ice cream are served with coffee or espresso. Tr ib un e Co nt en t A ge nc y LL C/ M cC la tc hy -T rib un e/ A la m y Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 1 6 8 N O R T H E R N A N D S O U T H E R N E U R O P E A N S edge of the plate or bowl (never use a spoon to help with this), and never slurping. Bread may be used daintily to soak up extra sauce, but should not be used to mop the plate. When not eating, the hands should be kept above the table with the wrists resting on the edge.14 When in someone’s home, or at a hosted meal, never start eating until the host has said buòn appetito (in Italy), buen apetito (in Spain), or bom appetite (in Portugal). In Italy, when invited to someone’s home, it is consid- ered rude to discuss any serious topic before a meal is shared. Chocolates are considered a good hostess gift when invited for dinner in all three nations. In Italy, wine is appreciated if enough is brought for all guests; wine should be avoided as a gift in Spain and Portugal, where hosts have likely chosen favorites to accompany the meal. Special Occasions Italy Italy celebrates few national holidays, probably because of its divided history. Most festas are local and honor a patron saint. Other significant religious holidays are usually observed by families at home, although some cities, such as Venice, have a public pre-Lenten carnival. In some areas of the United States where southern Italians predominate, St. Joseph, the patron saint of Sicily, is honored during Lent. Breads in the shape of a cross blessed by the parish priest, pasta with sardines, and other meatless dishes are featured. Among Italian Ameri- cans, it is traditional to serve seven seafood dishes on Christmas Eve. During the Easter holidays, Italian American bakeries sell an Easter bread with hard-boiled eggs still in their shells braided into it. Special desserts may accompany the holiday meal, such as panettone, amaretti (almond macaroons), and torrone (nougats) at Christmastime and cassata at Easter. Colored, sugar-coated Jordan almonds, which the Italians call con- fetti (meaning “little candies”), are served at weddings. Spain The most elaborate of Spanish festi- vals is Holy Week, the week between Palm Sunday and Easter. It is a time of Catholic processions; confections and liqueurs such as coffee, chocolate, and anisette (licorice flavored) are served. Holiday sweets include tortas de aceite, which are cakes made with olive oil, sesame seeds, and anise; cortados rellenos de cidra, or small rectangular tarts filled with pureed sweetened squash; torteras, or large round cakes made with cinnamon and squash and decorated with powdered sugar; and yemas de San Leandro, which is a sweet made by pouring egg yolks through tiny holes into boiling syrup. It is often served with marzipan. Special dishes are also prepared for Christ- mas and Easter. The Basques eat roasted chestnuts and pastel de Navidad, or individ- ual walnut and raisin pies, at Christmas; an orange-flavored doughnut, called causerras, is featured on Easter. At New Year’s, it is custom- ary for the Spanish (and the Portuguese) to eat twelve grapes or raisins at the twelve strokes of midnight to bring luck for each month of the coming year. Portugal Christmas Eve typically features two meals in Portugal: dinner and a post– midnight Mass buffet in the early hours of Christmas morning. Dinner often includes a casserole of bacalhau and potatoes, as well as meringue cookies known as suspiros (sighs). The buffet offers mostly finger foods, such as fried cod puffs and sausages. In the United States, the Holy Ghost (Spirit) Festival is the most popular and col- orful social and religious event in the Portu- guese community. It is not widely celebrated in Portugal and probably came to the United States with immigrants from the Azores. Although the origins of the event are obscure, it is believed to date back to Isabel (Eliza- beth) of Aragon, wife of Portugal’s poet-king Dom Diniz (1326). One story is that the fes- tival derives its character from the belief that because Isabel was particularly devoted to the Holy Ghost, she wanted to give an example of charity in the annual distribution of food to the poor. The week long festival is usually scheduled sometime after Easter and before the end of July. It is held at the local church or Hall of the Holy Ghost (also called an IDES Hall). The main event of the festival takes place on the last day, Sunday, with a procession to the Legend has it that zabaglione was created to increase male vigor by a Franciscan monk who tired of hearing the confessional complaints from women about their husbands. The word tapas means “lids,” and the first tapas were pieces of bread used to cover wine glasses to keep out flies. In the 1600s, the Spanish were the first to add sugar to the bitter choco- late beverage native to Mexico. Its popularity spread quickly through Europe, even though certain clerics tried to ban it due to its associa- tion with the “heathen” Aztecs. Although the Spanish are fond of chocolate, it is used mostly as a beverage and is rarely added to pastries or confections. In the Portuguese town Amarante, the Festa de São Gonçalo is held the first weekend in June. Dating back to pagan times, it is traditional for unmarried men and women to exchange phallus-shaped cakes as tokens of their affection for each other. In rural areas of Portugal, people traditionally col- lect medicinal plants for home remedies on Quinta-Feira da Espiga (Ear of Wheat Thursday or Ascension Day), the fortieth day after Easter. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 6 1 6 9 church and the crowning of a queen after the service. The donated food (originally distrib- uted to persons in need on Sunday afternoon but now often served at a free community banquet) is blessed by the priest. The most traditional foods at the feast are a Holy Ghost soup of meat, bread, and potatoes, and a sweet bread called massa sovoda. The bread is sometimes shaped like little doves, called pombas. Also celebrated in the United States is the Feast of the Most Blessed Sacrament, which was started in New Bedford, Massachu- setts, by four Madeirans in gratitude for their salvation from a shipwreck en route to the United States in 1915. It attracts over 150,000 visitors on the first weekend in August for music, dancing, and traditional foods such as linguiça, bacalhau, fava beans, assada no espeto, and cacoila. The Festa de Sennor da Pedra is held later in the month. This Azore Islands tradition includes a parade and similar traditional foods. Other festivities not men- tioned here are associated with the Madeiran cult of Our Lady of the Mount (a shrine on the island of Madeira). Therapeutic Uses of Food Little has been reported on the therapeutic uses of food by Americans of southern Euro- pean descent. Some Italians, particularly older immigrants, categorize foods as being heavy or light, wet or dry, and acid or nonacid.35,37 Heavy foods, such as fried items and red meats, are considered difficult to digest; light foods, including gelatin, custards, and soups, are regarded as easy to digest and appropri- ate for people who are ill. Wet and dry refers to how foods are prepared (with or without ample broth or fluid), as well as to their inher- ent qualities. For example, leafy greens such as escarole, spinach, and cabbage are consid- ered wet. A wet meal is served once a week by some Italian Americans to “cleanse out the system.” Wet meals, especially soups, are considered necessary when a person is sick because illness is associated with dryness in the body. Citrus fruits, raw tomatoes, and peaches are thought to be acidic foods that may cause skin ailments and are avoided if such conditions exist. Other Italian beliefs about foods are that liver, red wine, and leafy vegetables are good for the blood and that too many dairy prod- ucts make the urine hard (kidney stones). A clove of garlic may be eaten each day to prevent respiratory infections, and a raw egg or dandelion greens may be consumed for strength and vitality.36 Both balsamic vinegar and olive oil, which are served with bread at meals, are believed to be health-promoting foods in Italy. Contemporary Food Habits in the United States Adaptations of Food Habits It is generally assumed that second- and third- generation Americans of southern European descent have adopted the majority American diet and meal patterns, preserving some tra- ditional dishes for special occasions. These assimilated Americans consume more milk and meat but less fish, fresh produce, and legumes than their ancestors. Olive oil is still used often, although not exclusively; pasta remains popular with Italians. Nutritional Status Nutritional Intake Little research has been conducted on the nutritional intake of south- ern European Americans. It can be assumed that they suffer from dietary deficiencies and excesses similar to those of the majority of Americans. A study of elderly Portuguese immigrants in Cambridge, Massachusetts, found that dinner was the main meal of the day, and the subjects had moderate intake of breads and grains and low intake of fruits, vegetables, and dairy products. Although dairy intake was low, many of the subjects ate sardines, a rich source of calcium. The sub- jects reported low consumption of sweets and alcohol, although the researcher stated that the Americanized Portuguese diet tends to be high in sugar and fat.42 One study comparing body weights of American and Italian women with polycystic ovary syndrome found that though the BMIs for the American women were significantly higher, the total calorie intake and dietary constituents were similar, The Spanish American Isleños of Louisiana mari- nate shrimp in vinegar with olives and onions, make almond-honey nougat, and use ample olive oil (instead of the butter and lard favored in nearby Cajun cooking). Descendants of southern Europeans may have a higher incidence of lactose intolerance than other European groups. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 1 7 0 N O R T H E R N A N D S O U T H E R N E U R O P E A N S suggesting unknown genetic or lifestyle com- ponents may play a role.44 According to a survey of European dietary habits, a majority of the population in Italy consumes more plant products than protein, and approximately equal amounts of both are consumed in Spain.19 In addition, meat con- sumption is highest in the northern regions of these nations, and lowest in the southern areas.20 In general, the Mediterranean diet, which is typified in southern Italy and Spain, has been characterized as health promoting due to a high intake of complex carbohydrates, a high intake of protective phytochemicals, and a low intake of fat with a higher propor- tion of monounsaturated fats from olive oil as compared to saturated animal fats.45,46 The greater emphasis on grains, legumes, veg- etables, and fruits; lower intakes of meat and dairy foods; and promotion of wine in mod- eration differentiate the Mediterranean diet from that recommended by U.S. health offi- cials.47 However, a study by the Italian Asso- ciation for Cancer Research has found that cancer rates increased as food habits changed in Italy; pasta consumption has fallen, and meat intake has quadrupled since 1950; changes toward a more Westernized diet are found in Spain and Portugal as well.43,48 Rates of overweight and obesity in Italian women are 45 percent, but are over 66 percent in men. In Spain, rates exceed 82 percent for men and 61 percent in women; in Portugal, overweight and obesity in women approach 64 percent, and in men, 71 percent.21 Counseling The conversational style of southern Europeans is animated, warm, and expressive. Feelings are more important than objective facts in a discussion. Shaking hands with everyone in the room in greeting and leaving is appropriate; some men include pats on the back, and women may quickly embrace or kiss on the cheeks. Eye contact among elders tends to be frequent and quick, whereas younger people may prefer steady eye contact. Touching is very common, especially between members of the same sex. It has been noted that Italian American clients are open, willing to detail symptoms with their health care professional, and expressive with chronic pain—although some women may demon- strate high levels of modesty and may resist discussing personal topics.6,36 Italian Ameri- cans may seek medical advice from family and friends before consulting a health profes- sional. They express preference for providers who are warm and empathetic (simpatico) and disdain those who are perceived as arrogant and unapproachable (superbo). Recent Italian immigrants or those who are older adults may be very concerned about the qualities of their blood or may have many gastrointestinal complaints. There may be confusion regarding hypertension, which is considered high or too much blood, and ane- mia or low blood pressure, which is associated with low blood.37 Dietary requirements should be carefully detailed for some Italian Americans. Restric- tions recommended for clients with diabetes may be ignored if daily social activities (i.e., coffee and pastries with friends) must be modified. Language difficulties may occur among elders or new immigrants. Information regarding the counseling of Spanish Americans or Portuguese Americans is limited. The people of Spain and Portugal are traditionally high-context communica- tors and very polychromic (multi tasking), though many urban residents have more Western monochronic viewpoints. A quick handshake is the customary greeting, and clients from southern Europe will typi- cally sit and stand closer to each other than many Americans prefer. Direct eye contact is important.14 A high rate of illiteracy has been reported in the Portuguese American popula- tion (40 percent of surveyed elders; 15 percent of recent immigrants). This should be taken into consideration when preparing educa- tional materials. An in-depth interview can be used to assess the client’s degree of accul- turation and traditional health practices, if any. Personal food preferences should be determined. Recently, research has related the traditional food habits of the Mediterranean diet pattern to a lower inci- dence of coronary heart disease, various types of cancer, and other diseases. It appears that the traditional diet of southern Europe is pro- tective against several chronic diseases.38 Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 6 1 7 1 Review Questions 1. Summarize the immigration patterns of north- ern and southern Europeans. 2. Describe the American majority cultural beliefs regarding health, and the origins of these beliefs. 3. Describe the traditional food habits of Eng- land, Ireland, and Italy. List five of your favorite foods. Do any of these foods have their roots in Europe? Describe your typical meal cycle and meal composition. Are these similar to those of Europe? 4. What is the difference between Cajun and Creole cooking? What are the origins of both styles of cooking? 5. Compare and contrast the immigrant experi- ences of the Irish and Italians. 6. How did the New World foods (tomatoes, pota- toes, corn, etc.) influence European foodways? 7. Why is the Mediterranean diet considered healthy? References 1. Hess, M.A. Scottish and Scotch Irish Americans. In R.V. Dassanowsky & J. Lehman (Eds.), Gale encyclopedia of multicultural America. Farming- ton Hills, MI: Gale Group. 2. U.S. Census Bureau, Newsroom Archive. 2013. Facts for features: Thanksgiving Day: Nov. 28, 2013. Retrieved from http://www.census.gov/ newsroom/releases/pdf/cb13ff-24_thanksgiving (accessed February 12, 2015). 3. U.S. Census Bureau, Newsroom Archive. 2012. Facts for features: Irish-American Heritage Month (March) and St. Patrick's Day (March 17): 2012. Retrieved from http://www.census.gov/ newsroom/releases/archives/facts_for_features_ special_editions/cb12-ff03.html (accessed February 12, 2015). 4. U.S. Census Bureau, American FactFinder. n.d. Retrieved from http://factfinder.census .gov/faces/tableservices/jsf/pages/productview .xhtml?src5bkmk (accessed February 12, 2015). 5. Brittingham, A., & de la Cruz, G.P. June 2004. Ancestry: 2000. Census 2000 Brief. Retrieved Census 2000 Brief. Retrieved Census 2000 Brief from http://www.census.gov/prod/2004pubs/ c2kbr-35 (accessed February 11, 2015). 6. Spector, R.E. 2004. Cultural diversity in health and illness (6th ed.). Upper Saddle River, NJ: Pearson Education. 7. Sexton, R. 2005. Ireland: Simplicity and integra- tion continuity and change. In D. Goldstein & K. Merkle (Eds.), Culinary cultures of Europe. Strasbourg, France: Council of Europe Publishing. 8. Fisher, M.F.K. 1968. The cooking of provincial France. New York: Time-Life. 9. Zibart, E. 2001. The ethnic food lovers companion: Understanding the cuisines of the world. Birming- ham: Menasha Ridge Press 10. Bailey, A. 1969. The cooking of the British Isles. New York: Time-Life. 11. French, H.H., & VisitBritain. 2005. United King- dom: A flavorful adventure. In D. Goldstein & K. Merkle (Eds.), Culinary cultures of Europe. Strasbourg, France: Council of Europe Publishing. 12. Poulain, J.P. 2005. French gastronomy, French gastonomies. In D. Goldstein & K. Merkle (Eds.), Culinary cultures of Europe. Strasbourg, France: Council of Europe Publishing. D I S C U S S I O N S T A R T E R S Let’s Open a Pub! Americans often have an inaccurate view of British and Irish pubs. Many of us tend to identify these pubs with our American bars, but in fact, pubs are much more like American “bar and grills,” “sports taverns,” and restaurants that serve beer and wine. Most British and Irish pubs serve hot lunches and dinners as well as alcoholic beverages. Traditional British pub fare includes fish and chips (what Americans call French fries), shepherd’s pie or cottage pie (beef or mutton, mashed potatoes, maybe green peas, and a potato crust on top or cooked in a pie crust), steak or steak and kidney pie, bangers and mash (sausages and mashed potatoes), Yorkshire pudding (a batter such as a pancake batter, covered with beef gravy), Quaker pudding (a grayish spiced pudding), Cornish pastry, and mince pies. The name pub is short for public house, and historically, these pubs functioned as local meeting places and served to strengthen cultural ties within the community. Imagine that you plan to open an “authentic” British and Irish pub in your college community. In a small group, decide what your food menu should include. Remember that you will need to balance your effort to be authentic with your need to attract college students and serve students who eat only vegetarian meals. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 1 7 2 N O R T H E R N A N D S O U T H E R N E U R O P E A N S 13. Claiborne, C., & Franey, P. 1970. Classic French cooking. New York: Time-Life. 14. Foster, D. 2000. The global etiquette guide to Europe. New York: Wiley. 15. Henley, J. 2000, January 16. French town decrees local fare for students. San Jose Mercury News, p. 5AA. 16. Zibart, E. 2001. The ethnic food lovers companion: Understanding the cuisines of the world. Birming- ham: Menasha Ridge Press. 17. Galan, P., Arnaud, M.J., Czernichow, S., Delabroise, A.M., Preziosi, P., Bertrais, S., . . . Hercberg, S. 2002. Contribution of mineral waters to the dietary calcium and magnesium intake in a French adult population. Journal of the American Dietetic Association, 102, 1658–1662. 18. Wilson, S.A. 2003. People of Irish heritage. In L.D. Purnell & B.J. Paulanka (Eds.), Transcultural health care (2nd ed.), Philadelphia: F.A. Davis. 19. Slimani, N., Fahey, M., Welch, A.A., Wirfalt, E., Stripp, C., Bergstrom, E., . . . Riboli, E. 2002. Diversity of dietary patterns observed in the European Prospective Investigation into Can- cer and Nutrition (EPIC) project. Public Health Nutrition, 5, 1311–1328. 20. Linseisen, J., Bergstrom, E., Gafa, L., Gonzalez, C.A., Thiebaut, A., Trichopoulou, A., . . . Slimani, N. 2002. Consumption of added fats and oils in the European Prospective Investigation into Can- cer and Nutrition (EPIC) centres across 10 Euro- pean countries as assessed by 24-hour recalls. Public Health Nutrition, 5, 1227–1242; Inter- national Obesity Task Force. 2010. Overweight and obesity among adults in the European Union. Retrieved from http://www.iaso.org/site_media/- uploads/AdultEU27March2010notonwebyetup- datev2 (accessed February 11, 2015). 21. Sassi, F. 2010. Obesity and the economics of pre- vention—fit not fat. Organisation for Economic Co-operation and Development (OECD). Retrieved from http://www.keepeek.com/ Digital-Asset-Management/oecd/social-issues- migration-health/obesity-and-the-economics-of- prevention_9789264084865-en#page1 (accessed February 11, 2015). 22. Kushi, L.H., Lew, R.A., Stare, E.J., Curtis, R.E., Lozy, M., Bourke, G., . . . Kevaney, J. 1985. Diet and 20-year mortality from coronary heart dis- ease: The Ireland-Boston diet-heart study. New England Journal of Medicine, 312, 811–818. 23. Johnson, P.B. 1997. Alcohol-use-related prob- lems in Puerto Rican and Irish-American males. Substance Use and Misuse, 32, 169–179. 24. Phatak, P.D., Sham, R.L., Raubertas, R.F., Dunni- gan, K., O’Leary, M.T., Braggins, C., & Cappuccio, J.D. 1998. Prevalence of hereditary hemochroma- tosis in 16031 primary care patients. Annals of Internal Medicine, 129, 954–961. 25. Ryan, E., O’Keane, C., & Crowe, J. 1998. Hemo- chromatosis in Ireland and HFE. Blood Cells, Molecules, and Diseases, 24, 428–432. 26. Girouard, J., Giguere, Y., Delage, R., & Fousseau, F. 2002. Prevalence of HFE gene C282Y and H63D mutations in a French-Canadian popula- tion of neonates and in referred patients. Human Molecular Genetics, 11, 185–189. 27. Ma, Y., Murthy, V., Roderer, G., Monsalve, M.V., Clarke, L.A., Normand, T., . . . Hayden, M.R. 1991. A mutation in the human lipoprotein lipase gene as the most common cause of familial chylo- micronemia in French Canadians. New England Journal of Medicine, 324, 1761–1766. 28. Leistner, C.G. 1996. Cajun and Creole food prac- tices, customs, and holidays. Chicago: Ameri- can Dietetic Association/American Diabetes Association. 29. Hall, E.T., & Hall, M.R. 1990. Understanding cul- tural differences: Germans, French, and Ameri- cans. Yarmouth, ME: Intercultural Press. 30. Pozzetta, G. 2000. Italian Americans. In R.V. Dassanowsky & J. Lehman (Eds.), Gale ency- clopedia of multicultural America. Farmington Hills, MI: Gale Group. 31. Cavaioli, F. 2008. Patterns of Italian immigration to the United States. The Catholic Social Science Review, 13, 213-229. 32. Colahan, C. 2000. Spanish Americans. In R.V. Dassanowsky & J. Lehman (Eds.), Gale ency- clopedia of multicultural America. Farmington Hills, MI: Gale Group. 33. Shostak, E. 2000. Basque Americans. In R.V. Dassanowsky & J. Lehman (Eds.), Gale ency- clopedia of multicultural America. Farmington Hills, MI: Gale Group. 34. Harwood, A. 1981. Ethnicity and medical care. Cambridge, MA: Harvard University Press. 35. Norden, E.E. 2000. Portuguese Americans. In R.V. Dassanowsky & J. Lehman (Eds.), Gale ency- clopedia of multicultural America. Farmington Hills, MI: Gale Group. 36. Hillman, S.M. 2003. People of Italian heritage. In L.D. Purnell & B.J. Paulanka (Eds.), Transcultural health care (2nd ed.). Philadelphia: F.A. Davis. 37. Ragucci, A.T. 1981. Italian Americans. In A. Harwood (Ed.), Ethnicity and medical care. Cambridge, MA: Harvard University Press. 38. de Lorgeril, M., & Salen, P. 2008, December. The Mediterranean diet: Rationale and evidence for its benefit. Current Atherosclerosis Reports, 10(6), 518–522. 39. Pessoa e Costa, A. 2005. Portugal: A dialogue of cultures. In D. Goldstein & K. Merkle (Eds.), Culinary cultures of Europe. Strasbourg, France: Council of Europe Publishing. 40. Valverde Villena, D. 2005. Spain: Agape and con- viviality at the table. In D. Goldstein & K. Merkle Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 6 1 7 3 (Eds.), Culinary cultures of Europe. Strasbourg, France: Council of Europe Publishing. 41. Aranceta, J., Perez, C., Gondra, J., Gonzalez de Gai-deano, L., & Saenz de Buruaga, J. 1993. Fat and alcohol intake in the Basque country. Euro- pean Journal of Clinical Nutrition, 47, S66–S70.47, S66–S70.47 42. Poe, D.M. 1986. Profile of Portuguese elderly nutrition participants: Demographic characteris- tics, nutrition knowledge and practices. Master’s thesis, MGH Institute of Health Professions, Boston, MA. 43. Fernandez San Juan, P.M. 2006. Dietary habits and nutritional status of school aged children in Spain. Nutritión Hospilataria, 21, 374–378. 44. Carmina, E., Legro, R.S., Stamets, K., Lowell, J., & Lobo, R.A. 2003. Differences in body weight between American and Italian women with poly- cystic ovary syndrome: Influence of the diet. Human Reproduction, 18, 2289–2293. 45. Ferro-Luzzi, A., & Branca, F. 1995. Mediterranean diet, Italian-style: Proto-type of a healthy diet. American Journal of Clinical Nutrition, 61(Suppl.), 1338S-1354S. 46. Visioli, F., Bogani, P., Grande, S., Detopoulou, V., Manios, Y., & Galli, C. 2006. Local food and car- dioprotection: The role of phytochemicals. Forum of Nutrition, 59, 116–129. 47. Willet, W.C., Sacks, F., Trichopoulou, A., Drescher, G., Ferro-Luzzi, A, Helsing, E., & Trichopoulos, D. 1995. Mediterranean diet pyramid: A cultural model for healthy eating. American Journal of Clinical Nutrition, 61(Suppl.), 1402S–1406S. 48. Marquez-Vidal, P., Ravasco, P., Dias, C.M., & Camilo, M.E. 2006. Trends of food intake in Portugal, 1987–1999: Results from the National Health Surveys. European Journal of Clinical Nutrition, 60, 1414–1422. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 1 7 4 7 Central Europeans, People of the Former Soviet Union, and ScandinaviansCH A P T E R Germany, Austria, Hungary, Romania, the Czech Republic, Slovakia, and Poland, as well as Switzerland and Liechtenstein. Most of the countries share common borders; Austria, Hungary, the Czech Republic, Romania, and Slovakia are situated south of Germany and Poland. Switzerland, an isolated nation, is surrounded by Germany, Austria, France, Italy, and Liechtenstein. The climate of cen- tral Europe is harsher and colder than that of southern Europe, but much of the land is fertile. The FSU includes the Commonwealth of Independent States or CIS (the Russian Federation, Armenia, Azerbaijan, Belarus, Georgia, Kazakstan, Kyrgyzstan, Republic of Moldavia, Tajikistan, Turkmenistan, Ukraine, and Uzbekistan) and the Baltic states (Estonia, Latvia, and Lithuania), extending east to the border with China and the Pacific Ocean. Its vast geography includes the Arctic and parts of the Middle East. Except in the southern republics, the harsh winters of the region affect agricultural capacity. The large number of immigrants from central Europe and parts of the FSU made significant contributions to the literature, music, and cuisine of the United States. Many central European foods have become standard American fare. Imagine a baseball game without hot dogs and beer or a picnic without potato salad. This section explores these and other food customs of central Europe and the FSU and their impact on the American diet. The European settlers from central The European settlers from central TEurope, the former Soviet Union (FSU), TEurope, the former Soviet Union (FSU), Tand Scandinavia were some of the earliTand Scandinavia were some of the earliT - est and largest groups to come to the United States. Though many arrived as early as the 1600s and most had come before the begin- ning of the twentieth century, the upheavals of two world wars and the collapse of the Soviet Union have led to continuous immigration from these regions during the last century (see the map in Figure 7.1). The influence of immigrants from cen- tral Europe, the FSU (especially Russia), and Scandinavia on American majority culture, especially in the area of cuisine, is substantial. Bread baking, dairy farming, meat process- ing, and beer brewing are just a few of the skills these groups brought with them. Their expertise permitted the expansion of food production and distribution that encour- aged nationwide acceptance of their ethnic specialties, leading to the creation of a typical American cuisine. This chapter focuses on the traditional and adapted foods and food habits of Germans, Poles, and other central Euro- pean groups; Russians and other FSU popu- lations; and Danes, Swedes, and Norwegians. Central Europeans and the People of the FSU Central Europe stretches from the North and Baltic Seas, south to the Alps, and east to the Baltic states. It includes the nations of Eastern Europe is the term sometimes used to define the region that is also called “European Russia” (the western half of the country; east of the Ural Mountains is known as Siberia or “Asian Russia”). Before the breakup of the USSR, eastern Europe was sometimes used to describe those countries under Soviet control (e.g., Czechoslovakia, Hungary, East Germany). Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 7 1 7 5 Cultural Perspective History of Central Europeans and Russians in the United States Immigration Patterns Ge rmans For almost three centuries, Germans have been one of the most signifi- cant elements in the U.S. population. Accord- ing to U.S. 2010 Census figures, one in every six Americans is of German descent, making this the largest ethnic group in the nation.1 Germans are also one of the least visible of any American group. The earliest German settlement in the American colonies was Germantown, Penn- sylvania, founded in 1681. By 1709 large-scale immigration began, primarily from the Palati- nate region of southwestern Germany. Many of the immigrants, who were mostly of Amish, Mennonite, or other religious minority faiths Figure 7.1 Central Europe, Scandinavia, former Soviet Union. GERMANYGERMANYGERMANYGERMANYGERMANY Black Sea C a sp ia n S e a C a sp ia n S e a C a sp ia n S e a C a sp ia n S e a C a sp ia n S e a AUSTRIAAUSTRIAAUSTRIAAUSTRIAAUSTRIAAUSTRIAAUSTRIAAUSTRIAAUSTRIAAUSTRIAAUSTRIA POLAND HUNGARYHUNGARYHUNGARYHUNGARYHUNGARY CZECH CZECH CZECH CZECH CZECH CZECH CZECH CZECH CZECH CZECH CZECH CZECH CZECH CZECH CZECH CZECH CZECH CZECH CZECH REPUBLICREPUBLICREPUBLICREPUBLICREPUBLICREPUBLIC SWITZERLANDSWITZERLANDSWITZERLANDSWITZERLANDSWITZERLANDSWITZERLANDSWITZERLANDSWITZERLANDSWITZERLAND LIECHTENSTEINLIECHTENSTEINLIECHTENSTEINLIECHTENSTEINLIECHTENSTEINLIECHTENSTEINLIECHTENSTEINLIECHTENSTEINLIECHTENSTEIN ESTONIA LATIVIA LITHUANIA BELARUSBELARUSBELARUSBELARUSBELARUSBELARUSBELARUS UKRAINE RUSSIAN FEDERATION KAZAKSTANMOLDOVAMOLDOVAMOLDOVAMOLDOVAMOLDOVAMOLDOVAMOLDOVAMOLDOVAMOLDOVAMOLDOVAMOLDOVAMOLDOVAMOLDOVAMOLDOVA UZBEKISTANTURKMENISTAN TURKMENISTAN TURKMENISTAN TURKMENISTAN TAJIKISTAN KYRGYZSTAN AZERBAIJAN ARMENIA GEORGIAGEORGIAGEORGIAGEORGIA SLOVAKIASLOVAKIA ROMANIAROMANIAROMANIAROMANIAROMANIAROMANIAROMANIAROMANIAROMANIAROMANIAROMANIAROMANIAROMANIA © C en ga ge L ea rn in g Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 1 7 6 C E N T R A L E U R O P E A N S , P E O P L E O F T H E F O R M E R S O V I E T U N I O N , A N D S C A N D I N A V I A N S of second- and third-generation Germans living in urban areas. Cities with consider- able German populations included Cleve- land, New York, Toledo, Detroit, Chicago, Milwaukee, and St. Louis. German Russians, however, tended to settle in rural areas, espe- cially in Colorado. During the 1930s, many of the German immigrants were Jewish refugees. After World War II, displaced persons of German descent and East German refugees made up the siz- able German immigrant group who settled in the United States. Poles Poles have arrived in the United States continuously since 1608. The largest wave of immigration occurred between 1860 and 1914, mostly for economic reasons. The early phase was dominated by Poles (approx- imately 500,000) from German-ruled areas of Poland (Pomerania and Poznan) and by Poles who worked in western Germany. German Poles often became part of the German or Czech communities or estab- lished farming settlements in the Southwest and Midwest. The number of Polish immigrants from Germany began to decline after 1890, but the slack was taken up by the arrival of more than 2 million Poles from areas under Russian and Austrian rule. The German Poles left their homeland to become permanent settlers, but the Russian and Austrian Poles came as tem- porary workers. Although 30 percent returned to Poland, many eventually moved back to the United States permanently. The Austrian and Russian Poles tended to settle in the rapidly developing cities of the Mid-Atlantic and mid- western states, especially Chicago, Buffalo, and Cleveland. Polish emigration after World War I was usually not for economic reasons. Most (more than 250,000) left because of political dissat- isfaction: government instability and dicta- torship in the 1920s and 1930s, the German invasion and occupation from 1939 to 1945, and the pro-Soviet communist government after 1945. Many settled in urban areas in which there were substantial existing Polish populations. More recently, small numbers of younger Poles have taken advantage of the seeking freedom from discrimination, settled in Pennsylvania. The majority were farmers who steadily pushed westward searching for new lands for their expanding families. Those in Pennsylvania, Ohio, and Indiana became known as the “Pennsylvania Dutch.” Immi- gration dropped off after 1775, but an eco- nomic crisis in Europe once again prompted numerous Germans to come to the United States. Approximately 5 million Germans immigrated to the United States between 1820 and 1900. Like the earlier settlers, most were farmers who arrived with their families, although by the end of the century there were increasing numbers of young, single people who were agricultural laborers and servants. Many of these settled in the Mississippi, Ohio, and Missouri River valleys, the Great Lakes area, or the Midwest. Most Germans avoided the southern United States, but there are sizable German settlements in Texas and New Orleans. A third significant phase of immigration began after the turn of the twentieth century, when approximately 1.5 million Germans arrived. Many were unmarried indus- trial workers seeking higher pay, and oth- ers were the descendants of Germans who had settled in ethnically isolated colonies in Russia as early as the sixteenth century. Discrimination and the revolution of 1917 led to their departure. Most of these third- phase immigrants joined growing numbers ▼ Traditional foods of central Europe and the FSU. Some typical foods include beets, cabbage, ham, herring, kasha, potatoes, rye bread, sausages, and sour cream. yo rk 01 0/ A la m y Small numbers of Schwenk-felders from southern Germany, members of a pacifist religious sect similar to Quakers, settled in Pennsylvania in the mid- 1700s. They introduced crocus flowers, source of the spice saffron. The word Dutch is a corruption of Deutsch, meaning “German,” and has nothing to do with the Netherlands. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 7 1 7 7 freedom resulting from post-communist rule to come to the United States. Other Central Europeans Nearly 4 million Austrians, Hungarians, Czechs, Slovaks, and Swiss have come to the United States, primar- ily during the late nineteenth and early twen- tieth centuries, for economic and political reasons. Austrian immigration patterns are not entirely known because Austrians and Hun- garians were classified as a single group in U.S. statistics until 1910. More than 2 million Austrians are believed to have come to the United States searching for economic oppor- tunities in the decade following 1900. Most were unskilled, and many were fathers who left families in Austria with the hopes of making their fortune. Many Austrians never found the advancement they were seeking, and approxi- mately 35 percent returned home. A second, smaller wave of immigration occurred in the 1930s, when 29,000 well-educated, urban Austrian Jews fled Hitler’s arrival. The first group of Hungarians arriving in the United States was several thousand politi- cal refugees following the revolution of 1848. Most were men—well educated, wealthy, and often titled. Later Hungarian immigrants who arrived at the turn of the century were often poor, young, single men who found job opportunities in the expanding industrial workplace. Many worked in the coal mines of eastern Ohio, West Virginia, northern Illinois, and Indiana. Cities that developed large Hun- garian populations were primarily located in the Northeast and Midwest. More than 50,000 additional Hungarians entered the United States as refugees after World War II and the 1956 uprising against the communist govern- ment. They first settled in the industrial towns populated by earlier Hungarian immigrants, but many, mostly professionals, soon moved to other cities that offered better jobs. Czech immigrants initially tended to be farmers or skilled agricultural workers who settled in the states of Nebraska, Wiscon- sin, Texas, Iowa, and Minnesota, often near the Germans. Later Czech immigrants were skilled laborers; they settled in the urban areas of New York, Cleveland, and especially Chicago. The majority of the Slovak immigrants were young male agricultural workers who arrived before World War II. Those who decided to remain in the United States later sent for their wives and families. The major- ity settled in the industrial Northeast and Midwest; they labored in coal mines, steel mills, and oil refineries. Immigrants from Switzerland came to the United States for economic opportunities. The majority arrived prior to World War I, seeking jobs as artisans or professionals in the urban areas of New York, Philadelphia, Chicago, Cincinnati, St. Louis, San Francisco, and Los Angeles. Another group without national boundar- ies found throughout central Europe (as well as in northern and southern Europe) is the Gypsies, also known as Roma. Gypsy immi- grants to the United States are not counted in U.S. Census figures. There are an estimated 100,000 to 1,000,000 Gypsies in America, from a variety of Gypsy groups and speak- ing different dialects.2 Though they origi- nate from numerous European countries, the majority living in the United States are believed to have come from central Europe. Russians and People of the FSU Russian immi- grants originally came to Alaska and the West Coast, rather than to the eastern states. Most of their settlements were forts or outposts used to protect their fur trade and to shelter missionaries. When Russia sold Alaska to the United States in 1867, half of the settlers returned home and many of the others moved to California. Subsequent immigration was primarily to the East Coast, although some Russians (Molokans, followers of a religion that had rejected the Russian Eastern Ortho- dox Church) immigrated to the West Coast in the early twentieth century. Russians, mainly impoverished peasants seeking a better life, began to arrive in large numbers during the 1880s. Over 1.5 million were Jews seeking freedom from persecu- tion as well as economic opportunity. A sec- ond wave of immigrants came after the 1917 revolution, when more than 2 million people fled the country; 30,000 settled in the United States. After World War II, only small num- bers of Soviet refugees, primarily Jews, were The Gypsies are an insu- lar ethnic group found throughout the world. When they first arrived in Europe in the 1300s from India, they were mistaken for Egyptians. Their name derives from this error. Those from eastern and southeastern Europe are the Rom, and some Gypsies prefer the name Roma. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 1 7 8 C E N T R A L E U R O P E A N S , P E O P L E O F T H E F O R M E R S O V I E T U N I O N , A N D S C A N D I N A V I A N S allowed to emigrate. Following the breakup of the Soviet Union, nearly 200,000 Russians settled in the United States between 1990 and 1993. The settlement patterns of Russians are similar to those of other immigrants from central Europe. For the later wave of immi- grants, the port of entry was New York City. Many remained in New York, and others settled in nearby industrial areas that offered employment in the mines and factories. The largest populations of immigrants from the FSU are from Ukraine, Lithuania, and Armenia. Lengthy Russian domination of the region hinders estimates of the total numbers in the United States because some settlers were listed as Russians in immigra- tion figures. It is believed that the first signifi- cant number of Lithuanians, approximately 300,000, arrived in the United States follow- ing the abolition of serfdom in 1861.3 Nearly 30,000 refugees fleeing Soviet control came following World War II. The largest influx of Ukrainian immigrants occurred in the 1870s, when almost 350,000 men were recruited to work the Pennsylvania mines as strikebreak- ers. A majority settled in that state, though smaller numbers found factory work in Ohio, New York, and Michigan. Later immigrants, including 80,000 Ukrainians displaced by World War II, favored the urban centers of the Northeast. Significant Armenian immigration began in 1890, when immigrants came for economic opportunity. A second wave of Armenians from Turkey who were seeking escape from persecution arrived following the two world wars. More than 60,000 Armenian refugees have come since the 1980s, settling primarily in Los Angeles, with smaller numbers joining the older American communities in Boston, New York, Detroit, Chicago, and the agricul- tural region of Fresno, California. Current Demographics and Socioeconomic Status Germans There are more than 47 million Americans of German heritage in the nation today, according to 2010 Census estimates.1 Wisconsin-Minnesota-North Dakota-South Dakota-Nebraska-Iowa is considered the German belt; however, only the Pennsylvania Dutch, the rural-dwelling Germans from Russia who settled in the Midwest, and a few concentrated communities in Texas retain some aspects of their cultural heritage.4 Germans differ little from the national norms demographically, although they are slightly higher in economic achievement and are generally conservative in attitudinal rat- ings. The high degree of German accultura- tion is attributed to their large numbers, their occupations, and the time of their arrival in the United States. Furthermore, entry of the United States into World War I created a storm of anti-German feeling in America. German- composed music was banned, German-named foods were renamed, and German books were burned. As a result, German Americans rap- idly assimilated, abandoning the customs still common in other ethnic groups, such as ethnic associations and use of their oral and written language. Poles Polish Americans form one of the larg- est ethnic groups in the United States today. In 2011, it was estimated that there were over 9 million Americans of Polish descent;5 many still live in the urban areas of the Northeast and upper Midwest where their ancestors originally settled. Economically, the third- generation Polish American has moved upward, and the majority of Polish Americans live at a solidly middle-class level. Poles have been active in the formation and leadership of U.S. labor unions. More recent immigrants usually possess higher occupational skills and educational backgrounds than earlier immigrants.8 Other Central Europeans There is contin- ued confusion over Austrian ethnicity, dat- ing back to changing national boundaries and names. It is believed that although only 772,000 Americans identify themselves as being of Austrian descent in the 2010 U.S. Census figures,1 as many as 4 million U.S. citizens may actually be of Austrian ances- try.6 Though early immigrants settled mostly in the Northeast, the largest populations of Austrian Americans are now found in New York, California, Pennsylvania, Florida, and New Jersey. At the turn of the century, Austrians were involved in clothing and Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 7 1 7 9 tailoring, mining, and the food industry, including bakeries, meatpacking operations, and restaurants. Today, Austrians are found in a diverse range of occupations. In the 2010 U.S. Census figures, 1.5 million Hungarian Americans were estimated to be in the United States.1 Most settled originally in the Northeast, but younger generations have migrated to California and Texas, while many Hungarian retirees have moved to Florida.7 Economically, the Hungarians differ little from other central European immigrants. Most live in urban areas and work mostly in white-collar occupations. First- and second- generation Hungarian Americans encouraged their children to become engineers, a science that was respected by the Hungarian aristoc- racy at the turn of the century. Nearly 1.5 million Americans of Czech descent were identified in the 2011 U.S. Census estimates. Most Czechs now live in cities or rural nonfarm areas5 and are accul- turated. Cities and states with large Czech populations are California, Chicago, Iowa, Minnesota, Nebraska, New York City, Texas, and Wisconsin. Occupationally, only a small number of Czech Americans are still farmers; a majority of Czechs now hold sales, machin- ist, or white-collar jobs. Many Czechs have been successful in industry, founding busi- nesses that produce cigars, beer, and watches. There are over 730,000 Americans of Slovak descent, according to the 2011 U.S. Census figures.5 Actual numbers may exceed 2 million when those originally misidenti- fied as Czechoslovakian or Hungarian are included.9 The first two generations of Slovaks grew up in tightly knit communities anchored by work, church, family, and social activities. The third and fourth generations have sought higher education, work in white-collar jobs, and live in the suburbs; median family income is far above the national average. Cultural ties are still strong among the later generations of Slovaks. There were less than 1 million citizens who declared Swiss ancestry in the 2010 U.S. Census estimates.5 Most Swiss were multi- lingual and often multicultural when they arrived, assimilating quickly into U.S. culture. The few Swiss who come to the United States today work mostly in the U.S. branches of Swiss companies.10 After arrival in the United States, Gypsies (Romas) retained their tradition of roving; their exact numbers are unknown, and they are a very mobile population, often living in trailer parks. Many renovate apartments and houses to accommodate large social gather- ings, then pass the homes on to other Gypsy Americans when they move. It is estimated that approximately 1 million Gypsies live in the United States. The cities with the largest concentrations of Gypsies are Los Angeles, San Francisco, New York, Chicago, Boston, Atlanta, Dallas, Houston, Seattle, and Port- land. Traditionally tinkers and traders, Gyp- sies have been very successful at independent trades, such as house painting and asphalt paving, and service work such as body- fender repair and dry cleaning. Gypsies have also entered the car dealership profession in large numbers. Women are a strong presence in the mystical arts, including fortunetell- ing. The Gypsies divide the urban regions of the United States to minimize competition between Gypsy-owned businesses. Russians and People of the FSU In 2010, approximately 3 million Russian Americans were living in the United States.1 They have mostly moved out of the inner-city settlements to the suburbs, especially in the Northeast. Figures from the 2011 Census reported close to 1 million Americans of Ukrainian descent, 660,000 of Lithuanian heritage, and 464,000 of Armenian ancestry. In the past decade, one- third of FSU immigrants are from Russia, one-third are from Ukraine, and the remain- ing third are from all other FSU nations. These recent immigrants have settled in urban areas, including New York, Chicago, Los Angeles, Boston, Detroit, and San Francisco. Today, 40 percent of Ukrainians are found in Pennsylvania, and 60 percent of Armenians are living in California.11 Since World War II, the relations between the Russian American community and Amer- ican society have largely been dependent on the political relations between the United States and Russia. During the 1950s, anti- Soviet and anticommunist sentiments in the Based on 2011 Census data, it is estimated that there are over 3 million Canadians of German descent and over 1 mil- lion of Polish ancestry. In addition, more than 1 million Canadians list their heritage as Ukrai- nian, and over 500,000 report Russian origins.64 Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 1 8 0 C E N T R A L E U R O P E A N S , P E O P L E O F T H E F O R M E R S O V I E T U N I O N , A N D S C A N D I N A V I A N S United States caused many Russian Ameri- cans to assume a low profile that hastened their acculturation. Since the bulk of Ukrai- nian and Lithuanian immigration occurred several generations past, most of these popu- lations are assimilated. Armenians, who are typically well educated and English speaking on arrival, have also found it easy to adapt to U.S. society. Immigrants recently arriving from Rus- sia and the FSU have come from relatively advanced educational and professional back- grounds. Estimates are nearly half of Russian immigrants have a university degree. Most have professional experience, many as engi- neers, economists, scientists, or physicians. Worldview Religion Germans The majority of German immi- grants were Lutheran; a minority were Jewish or Roman Catholic. Today the Pennsylvania Dutch and the rural Germans from Russia faithfully maintain their religious heritage. Both groups are primarily Protestant, mostly Lutheran or Mennonite. Menno- nites are a religious group derived from the Anabaptist movement, which advocated baptism and church membership for adult believers only. They are noted for their simple lifestyle and rejection of oaths, public office, and military service. The Amish, a strict sect of the Mennonites, follow the Bible literally. They till the soil and shun worldly vanities such as electricity and automobiles. Their life centers on Gelassenheit, meaning submis- sion to a higher authority through reserved and humble behavior, and placing the needs of others before the needs of the individual. Poles Most Polish immigrants were devout Catholics; they quickly established parish churches in the United States. The Catholic Church is still a vital part of the Polish Ameri- can community, although Polish Americans have been found to marry outside the church more than other Catholics. Central Europeans Austrians are mostly Roman Catholic and have been actively involved in promoting Catholicism in America. In 1829 the Leopoldine Stiftung was founded in Austria to collect money throughout Europe to introduce religion to the U.S. frontier, resulting in more than 400 Catholic churches established in the East, the Midwest, and in what was known as “Indian country.” There are also small numbers of Austrian Jews. The majority of Hungarians are Catholic, although in the United States, nearly 25 percent are Protestant. In Europe most Czechs were Roman Catholics, but one-half to two-thirds of nineteenth-century Czech immigrants from rural areas left the church and were consid- ered free thinkers who believed in a strong separation of church and state. Subsequent generations now belong to a variety of faiths. Religion is still an important factor in the lives of Slovaks. Most are Roman Catholics who attend services regularly. First- and second-generation Slovaks usually send their children to parochial schools supported by the ethnic parish. Traditional spirituality for the Gypsies (Romas) is derived from Asian Indian reli- gions, such as Hinduism and Zoroastrianism (see Chapter 2 regarding Eastern religions, and Chapter 14 for more information on Asian Indian faiths). While traditions and customs vary by tribe and to a certain degree by the host culture, Gypsies are thought to be united in their worldview, called romaniya. Many believe in God, the devil, ghosts, and predestination. Most of all they adhere to the concept that persons and things are either pure or polluted. Gypsy culture is structured to preserve purity and to avoid contami- nation through contact with non-Gypsies. Some Gypsy Americans are Christians, often members of fundamentalist congregations, and several churches have specifically com- bined Gypsy spiritual concepts with Christian practices. Russians and People of the FSU Except for the Soviet Jews, the primary organization of the Russian American community today is the Russian Orthodox Church. Religion has always played a central role in the Russian community, and the Orthodox Church has tried to preserve the culture. However, the largest branch of the Eastern church, officially Seventy-three percent of the population in Switzerland speaks Swiss German, 20 percent speaks Swiss French, and 5 percent speaks Swiss Italian; in addition, most Swiss speak one or two other languages. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 7 1 8 1 known as the Orthodox Church in America (formerly the Russian Orthodox Church out- side Russia), now includes people from other central European and FSU countries, and the Russian traditions have been deemphasized. Among Ukrainian Americans, more belong to the Roman Catholic Church than to the Eastern Orthodox faith. Lithuanians are also predominantly Roman Catholic; however, there are small numbers of Protestants, Jews, and Eastern Orthodox followers. Most Arme- nians are members of the Armenian Apostolic Church (an Eastern Orthodox faith noted for allowing its members to make decisions on issues such as birth control and homosexu- ality without religious influence), although some Americans of Armenian descent are Protestants or members of the Armenian Rite of the Roman Catholic Church. Family Germans The traditional German family was based on an agricultural system that valued large families in which every member worked in the fields to support the household. Even when German immigrants moved to urban areas, family members were expected to help out in the family business. Most German fam- ilies today are assumed to have adopted the smaller American nuclear configuration. The exception may be among the Pennsylvania Dutch, particularly the Amish, who continue to have large families of seven to ten children. It is not unusual for an Amish person to know as many as seventy-five first cousins or for a grandparent to have thirty-five grandchil- dren.12 Many Amish families are finding it difficult to maintain traditional values due to growing contact with the majority culture through suburban sprawl. Poles Traditionally the Polish American family was patriarchal, and the father exerted strong control over the children, especially the daughters. The mother took care of the home, and, if the children worked, it was near the home or the father’s workplace. Since the 1920s, the overwhelming majority of Polish American families have been solely supported by the father’s income; wives and children have rarely worked. Other Central Europeans Tight nuclear fami- lies typify traditional Austrian households. Although the father is in charge of family finances, it is the mother who rules home life. Assimilation in the United States has led to a deterioration of the nuclear family, including an increased divorce rate. Traditional Czech and Hungarian families were male dominated and included many relatives. In the United States, participation in church activities, fra- ternal societies, and political organizations often served to replace the extended family for both men and women. The role of women has become less circumscribed; children are typically encouraged to pursue higher edu- cation and professional careers. Family ties are strong among the Slovaks. Parents are respected; they are frequently visited and cared for in their old age. Weddings are still a major event, although they are not celebrated for several days, as they once were. Gypsies customarily maintain extended families, although in the United States more nuclear families have been established. When traveling was common, multifamily groups (smaller than tribes) would temporarily band together. Affiliation with this group, called a k umpania, often continues today. The father is in charge of all public matters, but women may make most of the family income and manage all money matters. Women also retain some power through their ability to commu- nicate with the supernatural world. Usually Gypsies do not date, and arranged marriages are still common. Russians Traditionally, Russians lived in very large family groups with women legally dependent on their husbands. This structure changed, however, with the education and employment opportunities offered to women during the communist rule of the Soviet Union. Most women worked, and families became smaller. Even when employed full time, however, women remained respon- sible for all household chores. In the United States, Russian family structure has shrunk even further. Russian couples have sig- nificantly fewer children than the national average for American families. Education is emphasized, especially if it can be obtained Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 1 8 2 C E N T R A L E U R O P E A N S , P E O P L E O F T H E F O R M E R S O V I E T U N I O N , A N D S C A N D I N A V I A N S Traditional Health Beliefs and Practices German biomedicine makes extensive use of botanical remedies, though continued use is not documented in German Americans. A study of German Americans elders in Texas showed that many believe illness is caused by infection or stress-related conditions.14 Some Germans believe sickness is an expected con- sequence of strenuous labor. Health is main- tained by dressing properly, avoiding drafts, breathing fresh air, exercising, doing hard work, and taking cod liver oil. A few respon- dents mentioned the importance of religious practices and that suffering from illness is a blessing from God. Numerous home remedies are common (see “Therapeutic Uses of Foods” section for more information). The Pennsylvania Dutch traditionally believed a hearty diet high in meats, dairy products, and grain foods was important for maintaining good health. Many use home remedies, homeopathic preparations, and healers to treat illness. Sympathy healing is especially well developed. This traditional folk practice uses charms, spells, and blessings to cure the symptoms of disease. It is called either “powwowing” (though not related to Native American beliefs and practices) or by its German name, B r auc h e or B r auc h er ei. There is a strong religious foundation to the practice, and the healer acts as God’s instru- ment, requesting God’s direct assistance in treatment. Powwow compendiums still in use today offer everything from household tips to cures for warts, burns, toothache, and the common cold. The Amish in particular subscribe to sympathy healing, the laying on of hands to diagnose illness, and reflexology (foot massage thought to benefit other areas of the body, such as the head, neck, stomach, and back), as well as the use of herbal home cures, especially teas.15,16,17,18 Polish American elders in Texas have reported that a shortage of medical supplies in Poland led to the widespread use of faith heal- ers.14 Although such healing practices are not documented in the United States, many Pol- ish Americans are deeply religious and believe that faith in God and the wearing of religious medals will help prevent illness. Other health- maintenance beliefs include avoidance of sick at a Russian-language school. Many first- generation immigrants attempted to maintain ethnic identity by restricting their children to spouses from their immediate group, but mar- riage to non-Russians is now the norm. Since many of the Ukrainian and Lithu- anian immigrants in the nineteenth century were men, most were forced to intermarry with other ethnic groups. The men dominated the household, the women ran the home, and the extended family was the norm. Ukrainian and Lithuanian families have since moved toward a more typically American composi- tion with just two working parents and chil- dren. In many ways, Armenian homes are also similar to the average U.S. household. Both parents usually work, and education is a high priority. Nearly 70 percent of second- generation Armenian Americans obtain a col- lege degree. It has been noted, however, that most Armenian children retain respect for elders after acculturation, which is uncom- mon in other cultures, and tight-knit families have allowed many Armenians to pass on traditional customs.13 ▼ Eastern Orthodox priest blesses combine harvesters and the drivers during celebrations marking the start of the harvest. Va si ly F ed os en ko /R eu te rs The Amish and Men- nonites are referred to as the “Plain People.” The more liberal and worldly members of the Lutheran and Reformed Churches are called the “Gay Dutch,” “Fancy Dutch,” or “Church People.” In 301 CE, Armenia became the first nation to adopt Christianity as its state religion. Symptoms of colic in Amish infants are attributed to a condition known as livergrown, which can be cured only with sympathy healing. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 7 1 8 3 people, a healthy diet, sleep, keeping warm, exercise, a loving home, and avoidance of gossip. Gypsies have unique health beliefs.19 Health is maintained through mar imé , a sys- tem of purity and pollution that may be related to Asian Indian beliefs (see Chapter 14). The separation of clean from unclean dictates much of Gypsy life. The body is an example of this dichotomy. The upper body is pure, as are all its secretions, such as saliva. The lower half is impure and shameful. Care is taken to avoid contamination through contact of the upper body by the lower body (only the left hand is used for personal care). Menstrual blood is especially impure. Purity is also maintained by avoiding public places that non-Gypsies (who are considered unclean) frequent and by not touching contaminated surfaces, as well as by the use of disposable utensils, cups, and towels when in impure locations (e.g., hospitals). Gypsies divide illnesses into those that are due to contact with non-Gypsies, and those that are Gypsy conditions caused by spirits, ghosts, the devil, or breaking cultural rules. Home remedies and Gypsy healers (usually older women versed in medicinal lore) are considered best for Gypsy illnesses. Non- Gypsy conditions are suitable for treatment by non-Gypsy physicians, though a non-Gypsy folk healer such as a c ur ander o may be con- sulted as well. Natural cures and alternative medicine are used extensively in Russia and the nations of the FSU, and they are often integrated with a biomedical therapy.17 For example, cupping is used for respiratory illnesses. Saunas, mas- sage, steam baths, and balneotherapy (bath- ing in mineral springs) are often prescribed in conjunction with biomedical approaches; mud baths may be used for hypertension, and sul- furated hydrogen baths for cardiac ailments. In addition, homeopathic preparations and herbal remedies are popular.17,20,21,22 Magic and the occult may be used to cure illnesses due to supernatural causes. Psychics and z nak ar k i (elder women who whisper charms and sprinkle water with magic powers) may be employed for chronic conditions that bio- medicine cannot ameliorate. In the Siberian region of Russia, sickness was traditionally attributed to spiritual crisis, soul loss, evil spirits, breach of taboos, or curses. Treatments used by shamans (magico-religious healers) included realigning life forces or retrieving the soul through visualization techniques, singing, chanting, prognostication, dream analysis, and séances.23,24 Russians who do not believe in any occult practices may blame illness on other factors outside their control, including social conflict, political problems, war, poor medical care, and starvation.25 Traditional Food Habits Ingredients and Common Foods: Staples and Regional Variations The regional variations in central European and FSU cuisine are minor. The exceptions are the foods of the southern CIS nations, such as Armenia. (See “Exploring Global Cuisine—Armenia” on page 188.) The tem- perate climate of the region and proximity to the Arabs, Turks, and Greeks have resulted in a cuisine similar to Middle Eastern fare (see Chapter 13). Ingredients in traditional central European and FSU dishes were dic- tated by what could be grown in the cold, often damp climate. Common ingredients are potatoes, beans, cabbage and members of the cabbage family, beets, eggs, dairy products, pork, beef, fish and seafood from the Baltic Sea, freshwater fish from local lakes and rivers, apples, rye, wheat, and barley (see Table 7.1 for the cultural food groups). Foods were often dried, pickled, or fermented for preser- vation—for example, cucumber pickles, sour cream, and sauerkraut. Bread is a staple item, and there are more than one hundred varieties of bread. Because the climate in central Europe and FSU makes wheat harder to grow, bread is often made with rye and other grains; thus it is darker in color than bread made from wheat flour. Common types are whole wheat, cracked wheat, white, black, rye, pumpernickel, caraway, egg, and potato. Cornmeal breads are found in more southern nations such as Romania. Soft pretzels are a favorite in Germany and in Switzerland; they are some- times sliced to make sandwiches. Noodles and dumplings abound and are often served Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 1 8 4 C E N T R A L E U R O P E A N S , P E O P L E O F T H E F O R M E R S O V I E T U N I O N , A N D S C A N D I N A V I A N S Group Comments Common Foods Adaptations in the United States Protein Foods Milk/milk products Dairy items, fresh or fermented, are frequently consumed. Whipped cream is popular in some areas; sour cream popular in other regions. Milk (cow’s, sheep’s) fresh and fermented (buttermilk, sour cream, yogurt), cheese, cream Milk products are still frequently consumed or increased. Meat/poultry/ fish/eggs/ legumes Meats are often extended by grinding and stewing. Russians tend to eat their meat very well done. Meat: beef, boar, hare, lamb, pork (bacon, ham, pig’s feet, head cheese), sausage, variety meats, veal, venison Fish: carp, flounder, frog, haddock, halibut, herring, mackerel, perch, pike, salmon, sardines, shad, shark, smelts, sturgeon, trout Shellfish: crab, crawfish, eel, lobster, oysters, scallops, shrimp, turtle Poultry and small birds: chicken, Cornish hen, duck, goose, grouse, partridge, pheasant, quail, squab, turkey Eggs: hens, fish (caviar) Legumes: kidney beans, lentils, navy beans, split peas (green and yellow) Consumption of meat and poultry has increased; use of variety meats has decreased. Sausages and other processed meats are often eaten. Cereals/Grains Bread or rolls are commonly served at all meals. Dumplings and kasha are also common. Numerous cakes, cookies, and pastries are popular. Rye flour is commonly used. Barley, buckwheat, corn, millet, oats, potato starch, rice, rye, wheat More white bread, less rye and pumpernickel breads are eaten. Breakfast cereals well accepted. Fruits/Vegetables Potatoes are used extensively, as are all the cold-weather vegetables. Cabbage is fermented to make sauerkraut. Fruits and vegetables are often preserved by canning, drying, or pickling. Fruit is often added to meat dishes. Fruits: apples, apricots, blackberries, blueberries, sour cherries, sweet cherries, cranberries, currants, dates, gooseberries, grapefruit, grapes, lemons, lingonberries, melons, oranges, peaches, pears, plums, prunes, quinces, raisins, raspberries, rhubarb, strawberries Vegetables: asparagus, beets, broccoli, brussels sprouts, cabbage (red and green), carrots, cauliflower, celery, celery root, chard, cucumbers, eggplant, endive, green beans, kohlrabi, leeks, lettuce, mushrooms (domestic and wild), olives, onions, parsnips, peas, green peppers, potatoes, radishes, sorrel, spinach, tomatoes, turnips Tropical fruits may be eaten. Greater variety of vegetables consumed; salads popular. Additional Foods Seasonings Central Europeans tend to season their dishes with sour- tasting flavors, such as sour cream and vinegar. Allspice, anise, basil, bay leaves, borage, capers, caraway, cardamom, chervil, chives, cinnamon, cloves, curry powder, dill, garlic, ginger, horseradish, juniper, lemon, lovage, mace, marjoram, mint, mustard, paprika, parsley, pepper (black and white), poppy seeds, rosemary, rose water, saffron, sage, savory (summer and winter), tarragon, thyme, vanilla, vinegar, woodruff Saffron is a popular spice in Pennsylvania Dutch fare. Nuts/seeds Poppy seeds are often used in pastries; caraway seeds flavor cabbage and bread. Nuts: almonds (sweet and bitter), chestnuts, filberts, pecans, walnuts Seeds: poppy seeds, sunflower seeds TA B L E 7.1 Cultural Food Groups: Central European and Russian/FSU Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 7 1 8 5 as side dishes. Boiled dumplings (called kned- liky in Czech, Knödel in German, and kletski in Russian) can be made with flour or pota- toes and with or without yeast. Spätzle are tiny dumplings common in southern Germany. They are made by forcing the dough through a large spoon with small holes into the hot water. Stuffed dumplings, filled with meat, liver, bacon, potatoes, or fruit, are called Maultaschen (German), pierogi (Polish), pelmeni (Russian), or varenyky (Ukrainian). Related to the filled dumpling is stuffed pastry dough, which is baked or fried. It is custom- arily filled with meat or cabbage. Small indi- vidual pastries are called pirozhki in Russian, and a large oval pie is known as a pirog (also called a kulebi). One elaborate version, kule- biaka, usually includes a whole fish, such as salmon, with mushroom and rice filling. In Lithuania, lamb-stuffed pockets served with sour cream are called kulduny. A specialty product of Russia is buck-wheat (an Asian grain), which has a very distinctive, nutty fla- vor, especially when it is toasted. The groats (hulled and crushed grains) are prepared in ways similar to rice, especially as side dishes and stuffings.26 Buckwheat meal is used to make baked goods. Next to bread, meat is the most important element of the diet. Pork is the most popu- lar. Schnitzel is a meat cutlet, often lightly breaded and then fried. Ham is served fresh or cured. Poland is famous for its smoked ham, and in Germany, Westphalian ham is lightly smoked, cured, and cut into paper-thin slices. Beef is also common. In Germany, Sauerbra- ten, a marinated beef roast, is the national dish. It is also rolled around various fillings, such as bacon, onions, and pickles, to make Rouladen. Veal is especially popular in Lith- uania. Poultry is well liked. Germans often eat roast goose stuffed with onions, apples, and herbs on holidays. In Russia, chicken is stewed on special occasions, and breaded chicken cutlets called kotlety are common. A famous Russian dish is chicken Kiev— breaded, fried chicken breasts filled with her- bed butter. Game meats are a favorite in many areas, especially deer, wild boar, and rabbit. A well-known German dish is Hasenpfeffer— hare cooked in red wine with black pepper. In Poland, bigos (“hunter’s stew”), made of venison, hare, and vegetables (some form of cabbage is always added), is traditional. Geese and duck are widely eaten, also. In the past, meat was often scarce and expensive; thus many traditional recipes stretched it as far as possible. Dishes com- mon throughout the region consist of sea- soned ground meat mixed with a binder such as bread crumbs, milk, or eggs, then formed into patties and fried. In Germany, ground beef (and sometimes pork or veal) is served raw on toast as steak tartare. Ground meat is also used to stuff vegetables (such as stuffed cabbage) or pastry, or is cooked as meatballs, such as Königsberger Klopse topped with capers and a white sauce. Cut-up meat is often served in soups, stews, or one-pot dishes. In Germany a slowly simmered one-pot dish Legend has it that it was the Mongols who showed the central Europeans how to broil meat, make yogurt and other fermented dairy products, and preserve cabbage in brine. Gypsy women are tradi- tionally prohibited from touching food, water, or utensils intended for other family members during their period or following childbirth. The Poles say “A doctor’s mistakes are covered in earth.” Group Comments Common Foods Adaptations in the United States Beverages Central Europeans drink coffee; Russians drink tea. Many varieties of beer are produced. Hungarians and Austrians tend to drink more wine than other central European people. Beer, hot chocolate, coffee, syrups and juices, fruit brandies, herbal teas, milk, tea, kvass, vodka, wine Fats/oils Butter, bacon, chicken fat, flaxseed oil, goose fat, lard, olive oil, salt pork, suet, vegetable oil Soft drinks common. Sweeteners Honey, sugar (white and brown), molasses Commercial salad dressings, nondairy creamers added to diet. © C en ga ge L ea rn in g Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 1 8 6 C E N T R A L E U R O P E A N S , P E O P L E O F T H E F O R M E R S O V I E T U N I O N , A N D S C A N D I N A V I A N S of meat, vegetables, potatoes, or dumplings is called Eintopf. Hungary is known for its gulyás, a paprika-spiced stew known as gou- lash in the United States. Sweet Hungarian paprika is ground, dried, red chile peppers to which sugar has been added. As chile peppers are a New World food, it is thought that the Hungarians used black pepper to season their food before the discovery of the Americas. Ground meats are also made into sau- sages. In Germany there are four basic cat- egories of sausage (Wurst). Rohwurst, similar to American-style liverwurst, is cured and smoked by the butcher and can be eaten as is. Examples include Teewurst, a raw, spiced pork sausage that is spreadable like pâté, and Mettwurst, a mild, sliceable pork sausage. Bruhwurst (the frankfurter or Wienerwurst is one type) is smoked and scalded by the butcher; it may be eaten as is or heated by simmering. Knockwurst, which is like a cold cut, may be smoked and is fully cooked by the butcher. Leberwurst (liverwurst), Blutwurst (blood sausage), and Süize (head cheese) are examples. Bratwurst, similar to sausage links, is sold raw by the butcher and must be pan- fried or grilled before eating. The Polish are famous for kielbasa, a garlic-flavored pork sausage. In Austria, some sausages are called Wieners. Two popular sausages with both the Czechs and Slovaks are jaternice, made from pork, and jelita, a blood sausage, which can be boiled or fried. Freshwater and saltwater fish and sea- food are often eaten fresh, smoked, or cured. Trout, carp, and eel are popular throughout much of the region. In Germany herring is commonly pickled and eaten as a snack or at the main meal, sometimes as Rollmops, wrapped around a bit of pickle or onion. In Russia, smoked salmon and sturgeon are con- sidered delicacies, as is caviar, which is roe from sturgeon. Caviar is classified according to its quality and source. Beluga, the choic- est caviar, is taken from the largest fish and has the largest eggs; its color varies from black to gray. Sevruga and osetra, taken from smaller sturgeon, have smaller eggs and are sometimes a lighter color. Sterlet, or imperial caviar, is from a rare sturgeon with golden roe. The finest caviar is sieved by hand to remove membranes and is lightly salted. Less choice roes are more heavily salted and pressed into bricks. Though some fish is consumed in Poland, it is not a popular food, and is in some cases associated with shortages endured during Soviet rule.27 Dairy products are eaten daily. Cheeses may be served at any meal, from the fresh, sweet varieties, such as Lithuanian farmer’s cheese, to the strongly flavored aged types like German Limburger. Fresh milk is drunk; butter is the preferred cooking fat. Buttermilk (a thick type called kefir is popular in south- ern areas of the FSU), sour cream, and fresh cream are also common ingredients in sauces, soups, stews, and baked products. In Austria and Germany, whipped cream is part of the daily diet, served with coffee or pastries.28 Traditionally, cold-weather fruits and veg- etables added variety to the diet. Red and green cabbage is ubiquitous—found fried, boiled, fermented as sauerkraut, and added to stuffings, soups, and stews. Potatoes are equally popular. They are most often boiled, or roasted and sliced. One German specialty found in the northern area of the country is called Himmel und Erde (“heaven and earth”), a boiled dish of potatoes and sliced apples topped with fried bacon and onions. Other root crops such as beets and kohlrabi accom- pany many meals. Cucumbers are frequently pickled or served dressed with vinegar for a salad. Onions and mushrooms flavor numer- ous dishes. Wild mushrooms are so popular in Poland that they are often used as a meat substitute on religious fast days.27 Temperate vegetables, including tomatoes and eggplant, are found in the more southern nations of the FSU, and are now widely available throughout the region. Cauliflower and tomatoes are the favorite vegetables in Germany today.29 Com- mon fruits include apples, cherries, plums, and berries, though imported bananas are a favorite in Russia.30 In much of central Europe, sweets are enjoyed daily. They are eaten at coffee-houses in the morning or afternoon, or bought at the local bakery and served as dessert. There are numerous types, such as cheesecakes, cof-numerous types, such as cheesecakes, cof-numerous types, such as cheesecakes, cof fee cakes, doughnuts, and nut- or fruit-filled individual pastries. Apple, cherry, raspberry, Frankfurter means a sau- sage from the German city of Frankfurt; Weiner means one from Vienna. In the United States the term hot dog became popular in the late 1800s because of the sausage’s resemblance to a dachs- hund; stories about a cartoonist inventing the nickname are myth. After diners eat smoked eel on pumpernickel bread in some res- taurants of northern Germany, the server pours inexpensive Schnapps over their hands to rid them of a fishy odor. The national dish of Switzerland is cheese fondue (chunks of bread dipped into melted cheese). The Swiss are known for their zesty cheeses with holes, such as Emmenthal (the original Swiss cheese) and Gruyère. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 7 1 8 7 chocolate, almond, and poppy seed are favor- ite flavors. Austria is reputed to be the home of apple strudel, made from paper-thin sheets of dough rolled around cinnamon-spiced apple pieces.31 It is also known for Sacher- torte, a chocolate sponge cake with apricot or cream filling. Germany is famous for Schwar- zwälder Kirschtorte (Black Forest cake), a rich chocolate cake layered with cherries, whipped cream, and Kirsch (cherry liqueur). “Branch” cake, galęziak, which looks simi- lar to a gnarled log, is a popular pastry from Lithuania that is also found in Poland, where is it is known as sękacz or “pyramid” cake. Dobosch torte, a multilayered sponge cake with chocolate filling and caramel topping, is a favorite in Hungary. Though fresh fruits are eaten infrequently, cooked fruits, such as the berry pudding called kisel in Russia, are com- mon desserts throughout the region. In central Europe, the most common hot beverage is coffee. In Russia, strong tea diluted with hot water from a samovar is consumed instead. A samovar is a brass urn, which may be very ornate, heated by charcoal inserted in a vertical tube running through the urn’s center. Although southwestern Germany, Austria, and Hungary produce excellent white wine, the most popular alco- holic drink in the region is beer. The Czechs are known for pilsner beer, which is bitter tasting but light in color and body. German beers can be sweet, bitter, weak, or strong and are typically bottom-fermented (meaning the yeast sinks during brewing). Lager, a bottom- fermented beer that is aged for about six weeks, is the most common type. Bock beer is the strongest flavored, has a higher than aver- age alcohol content, and is sometimes called “liquid bread.” Märzenbier, a beer midway between a pilsner and a bock beer, is served at Oktoberfest (see section titled “Special Occasions”) in Munich. Weissbier is a light, top-fermented beer brewed from wheat, and often mixed with a lemon or raspberry fruit syrup for a refreshing summer beverage. In Russia and other FSU nations, a sour beer fer- mented from rye bread or beets, called kvass, is popular. It is slightly sweet and fizzy and sometimes flavored with black currant leaves, caraway, mint, or lemon. Mead, a beerlike product fermented from honey, is a Polish specialty. Schnapps, a fruit brandy made from fermented fruit, such as cherries, is popular in Germany. Vodka, which is commonly drunk in Poland and Russia, is a distilled spirit made from potatoes. It is served ice cold and often flavored with seasonings, such as lemon or black pepper. In Poland, the vodka goldwas- ser contains flakes of pure gold. Meal Composition and Cycle Daily Patterns Central Europe In the past, people of this region ate five or six large meals a day, if they could afford it. The poor, and usually the people who worked the land, had fewer meals, which were often meatless. Today, modern work schedules have changed the meal pattern, resulting in three meals with snacks each day. In Germany and the countries of central Europe, the first meal of the day is breakfast, which consists of bread served with butter and jam. Sometimes breakfast is accompanied by soft-boiled eggs, cheese, and ham. In Poland, tea served in glasses is the traditional bever- age. Traditionally, tea was sucked through a sugar cube held between the teeth. At mid- morning many people have their second breakfast, which may include coffee, tea, or hot chocolate, and pastries, bread, and fruit, or a small sandwich. Lunch is the main meal of the day. In the past, people ate lunch at home, but today they are more likely to go to a cafeteria or restaurant. A proper lunch begins with soup, followed by a fish course, and then one or two meat dishes served with vegetables, and perhaps stewed fruit. Dessert is the final course, usually served with whipped cream. A quicker and lighter lunch may consist of only a stew or a one-pot meal. A break is taken at midafternoon, if time permits. It typically includes coffee or tea and cake or cookies. The evening meal tends to be light, usually including salads and an assort- ment of pickled or smoked fish, cheese, ham, and sausages eaten with a selection of breads. In Germany this meal is called Abendbrot, meaning “evening bread.” However, Western- ization and shorter lunch hours mean that nearly a third of Germans now eat smaller Green vegetables as a group are called wloszczyzna in Polish, meaning “Italian com- modities,” since so many were originally imported from the southern nation.65 Sachertorte was the subject of a famous Viennese court battle regarding who had the rights to claim the origi- nal recipe—it was known as the “Sweet Seven Years War” due to the length of the case.66 Sharing food is essential to Gypsy culture. The harshest punishment that can be imposed on an individual is to be banned from communal meals. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 1 8 8 C E N T R A L E U R O P E A N S , P E O P L E O F T H E F O R M E R S O V I E T U N I O N , A N D S C A N D I N A V I A N S late afternoon. Meals are typically social occasions, featuring the dishes common in their adopted homeland; stews, fried foods, and unleavened breads are especially popular. Russia and the FSU In czarist times, the aris- tocracy ate four complete meals per day; dinner was the largest. The majority of the population never ate as lavishly or as often. The meal that peasants ate after a long day’s work is still the basis of a typical diet in pres- ent-day Russia, as well as in some parts of the FSU, including Ukraine. Three hearty meals a day are common, with the largest meal con- sumed at lunch. Snacking is rare. The staples are bread; soup made from beets (borscht, which is of Ukrainian origin), cabbage (shchi), or fish (ukha); and kasha (cooked porridge made from barley, buckwheat, or millet).31 In Lithuania, soup is often replaced by salads. Tea, kvass, vodka, or beer usually accompanies meals. Legend is that following the flood, Noah’s Ark first found land in Armenia and that the nation was founded by his descendants. One of the first countries to adopt Christianity, Armenia has been ruled by a succession of conquerors, from Rome to Russia, and today is surrounded by Muslim nations. Its fare reflects this unique past. Bread is so important there that the Armenian word for it is also used colloquially for meal or food in general.69 Lamb is a staple, though chicken and beef are also popular. Pork is rarely consumed, dating back to pre-Christian biblical pro- hibitions. Freshwater fish such as trout and sturgeon (including its roe, caviar) are well liked. Yogurt, known as mahdzoon, is consumed daily in soups, salad dress- ings, and beverages, as are cheeses such as feta and mozzarella-like string cheese, which are often flavored with spices or herbs. Numerous fruits and vegetables are cultivated, used fresh, dried, and pickled. Apricots, grapes, lemons, persimmons, pomegranates, quince, bell peppers, cabbage, cucumbers, eggplants, okra, squash, and tomatoes are examples. Olives and olive oil are common; however, lamb fat is often preferred for cooking. Dishes are seasoned with onions, garlic, lemon juice, sesame seeds, allspice, basil, cumin, fenugreek, rosemary, and mint. Honey flavors most desserts.70 Armenian cuisine has been significantly influenced by neighboring Greeks, Turks, Persians, Syrians, and other Arabs. Shared dishes include the chickpea puree called hummus, tabouli bulgur salad, grilled kebabs, kufta (meatballs), meat turnovers known as boereg, meat- or grain-stuffed vegetables called dolma, and paklava (baklava). Many dishes have a distinctly Armenian twist. Pilaf, also called plov, is pre- ferred with bulgur and vermicelli instead of rice in many areas. Lahjuman, an Armenian pizza made with lamb, vegetables, and feta cheese, is a favorite, as is keshkeg, a lamb or chicken stew that includes whole hulled wheat kernels called zezads. Dinner begins with a selection of mezze (appetizers) served with the anise-flavored aperitif raki. Soups follow, made with yogurt, eggs, and lemon, or tomatoes, often with added lentils, meatballs, or even fruit. Salads are also served regularly, often with the main course of kebabs, stew, or cas- serole. Every meal includes bread, such as pita, lavash, or choereg—Armenian yeast rolls. Dessert is usually fruit, with pastries on special occasions. Traditional beverages include coffee, tea, and tahn—yogurt thinned with water and flavored with mint. Armenians are world-acclaimed vintners. Wine and brandy made from grapes, rai- sins, apricots, or other fruits are frequently consumed. E X P L O R I N G G L O B A L C U I S I N E Armenia ▼ Many German foods have been adopted in the United States, including lager-style beer, pork or veal sausages, and pretzels. Ei si ng /P ho to di sc /G et ty Im ag es lunches with a larger meal than Abendbrot in the evening.29 Gypsies customarily eat two meals each day, first thing in the morning and in the Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 7 1 8 9 dumplings with a knife is an insult to the cook or host because it suggests that these items are tough. When not eating, keep your hands above the table with the wrists resting on the edge. Pass all dishes to the left. Wine and vodka may be poured in tumblers instead of glasses specific for each beverage, and will usually be refilled as soon as they are emptied. Vodka is traditionally consumed in one shot. Special Occasions The majority of central European holidays have a religious signifi- cance, although some traditions date back to pre-Christian times. The two major holi- days in the region are Christmas and Easter. Many of the familiar symbols and activities associated with these holidays, such as the Christmas tree and the Easter egg hunt, were brought to the United States by central Euro- pean immigrants. Germany Germany is a land of popular festi- vals. Nearly all are accompanied by food and drink. Probably the best-known celebration is Munich’s Oktoberfest, which lasts for sixteen One part of the traditional czarist eve- ning meal, z ak usk i (meaning “small bites”), is still part of dinner in Russia today. This traditional array of appetizers starts the meal, and may range from two simple dishes, such as pickled herring and cucumbers in sour cream, to an entire table spread with count- less hors d’oeuvres. An assortment of zakuski usually includes a variety of small, open- faced sandwiches topped with cold, smoked fish; anchovies or sardines; cold tongue and pickles; and ham, sausages, or salami. Caviar, the most elegant of zakuski, is served with an accompanying plate of chopped, hard- boiled eggs and finely minced onions. Other zakuski include marinated or pickled veg- etables, hot meat dishes, and eggs served a variety of ways. Etiquette Central Europeans tend to be more formal than most Americans. In Germany guests are generally not invited for dinner but may be asked for dessert and wine later in the evening. If you are invited for a meal at a home or restaurant, the invitation may indicate “c.t.” (cum tempore), meaning you can arrive up to fifteen minutes late, or “s.t.” (sine tempore) meaning to be exactly on time. Do not begin the meal before the host says “Guten Appetit.” In Poland people do not begin a meal until everyone is served and the host says “smac- znego.” In the Czech Republic and Slovakia the host says “dobrochot”; in Hungary it is “jo atvadyat.” In Russia, wait for the host to say “pree yat na vah appeteetah.” The word for “hospitality” in Russia is k h l ebosol ’ stv o, mean- ing “bread” and “salt.” Bread is traditionally served with butter and a small bowl of salt for dipping to welcome diners.32 Appropriate hostess gifts are good qual- ity dessert wines, candies, or pastries. Do not bring vodka in regions where it is commonly served, because it suggests your host does not have enough on hand. In the Czech Republic, Slovakia, and Hungary, Jack Daniels whiskey is particularly appreciated.32 The continental European style of eating with the fork in the left hand and the knife in the right is common throughout the region. Do not switch utensils when eating. In Ger- many, knives are only used when absolutely necessary. Cutting potatoes, pancakes, or S A M P L E M E N U German Abendbrot A Selection of Sausages, Sliced Ham, and Cheeses (We s tph alian Ham, T e e wur s t , etc.)* T e e wur s t , etc.)* T e e wur s t Herring (Salad) in Cream Saucea,a,c,* Pumpernickel Bread, Small Rolls Potato Salad,a,b,c Beet Salad,a,b,c Pickles M oh n k uch e n (Poppyseed Cake)a,b Beer or White Wine aHeberle, M.O. 1996. German cooking: The complete guide to preparing classic and modern German cuisine, adapted for the American kitchen. New York: HP Books. bGerman Recipes at http://www.myrecipes.com/german-recipes/ cGerman Recipes at http://www.food.com/recipes/german *Can be purchased at German-style delicatessens. Fast foods, including U.S. hamburger fran- chises, are very popular throughout the region. In Germany, street stands offering bratwurst and currywurst (sausage with curry seasoning) and French fries are common. Döner kebabs, Turkish- style lamb in pita bread, are another favorite in Germany and in Russia. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 1 9 0 C E N T R A L E U R O P E A N S , P E O P L E O F T H E F O R M E R S O V I E T U N I O N , A N D S C A N D I N A V I A N S traditional Christmas sweets. Other desserts prepared during the season are spice cakes and cookies (Pfeffernüsse and Lebkuchen), fruit cakes (Stollen), cakes in the shape of a Christmas tree (Baumkuchen), and ginger- bread houses. On Easter Sunday, the Easter bunny hides colored eggs in the house and garden for the children to find. Ham and pureed peas are typically served for Easter dinner. Candy Easter eggs and rabbits are also part of the festivities. Poland Christmas and Easter are the two most important holidays in Poland, a pre- dominantly Catholic country. On Easter, the festive table may feature a roast suckling pig, hams, coils of sausages, and roast veal. Always included are painted hard-boiled eggs, grated horseradish, and a Paschal lamb sculptured from butter or white sugar. Before the feast- ing begins, one of the eggs is shelled, divided, and reverently eaten. The crowning glory of the meal is the babka, a rich yeast cake. All the foods are blessed by the priest before being served. On Christmas Eve, traditionally a fast day, a meal of soup, fish, noodle dishes, and pastries is served when the first star of the evening is seen.27 One popular soup, barszcz Wigilijny, a cousin to Russian borscht, is made with mushrooms as well as beets. Carp is usu- ally the fish served on Christmas Eve. A rich Christmas cake, makowiec, is shaped like a jelly roll and filled with black poppy seeds, honey, raisins, and almonds. Jelly doughnuts, or paczki, are eaten on New Year’s Eve, while on New Year’s Day bigos, a hearty stew con- taining meats, cabbage, and other vegetables plus dried fruit, is washed down with plenty of vodka. Austria, Hungary, the Czech Republic, and Slovakia At Christmastime, the Czechs eat carp four different ways: breaded and fried, baked with dried prunes, cold in aspic, and in a fish soup. The Christmas Eve meal might also include pearl barley soup with mushrooms, as well as fruits and decorated cookies. Christmas dinner features giblet soup with noodles, roast goose with dump- lings and sauerkraut, braided sweet bread (vanocka or houska), fruits and nuts, and days from late September through early Octo- ber. Founded in 1810 to commemorate the marriage of Prince Ludwig of Bavaria, it is now an annual festival with polka bands and prodigious sausage-eating and beer-drinking. Advent and Christmas are the holi- est seasons in German-speaking countries. The Christmas tree, a remnant of pagan winter solstice rites, is lit on Christmas Eve when the presents, brought not by Santa Claus but by the Christ Child, are opened. The Christmas tree is not taken down until Epiphany, January 6. A large festive dinner is served on Christmas Day, and it is custom- ary for families to visit one another. Foods served during the Christmas season include carp on Christmas Eve and roast hare or goose accompanied by apples and nuts on Christmas Day. Brightly colored marzipan candies in the shape of fruits and animals are Marzipan, a paste of ground almonds and sugar, is commonly used in desserts and candies throughout central Europe. In the Polish Easter meal, the dairy products, meats, and pastries symbolize the fertility and renewal of spring- time, while the horserad- ish is a reminder of the bitterness and disap- pointments in life. ▼ Russian appetizers, called zakuski, often feature blini topped with sour cream, smoked salmon or caviar, and chives. Lo tt ie D av ie s/ D ig ita l V is io n/ G et ty Im ag es Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 7 1 9 1 In addition to Christmas and Easter, the Austrians celebrate Fasching (a holiday also known in southern Germany). Originating as a pagan ceremony to drive out the evil spirits of winter in which a procession would parade down the main street of a town ring- ing cowbells, it developed into a multiday carnival associated with Lent. In Vienna, over 300 sumptuous balls are held during the event, including those hosted by the cof-the event, including those hosted by the cof-the event, including those hosted by the cof fee brewers and the confectioners of the city. Doughnuts, fritters, and other sweets are typical festival food. Russia and the FSU Before the 1917 revolu- tion, Russians celebrated a full calendar of religious holidays, including 250 fast days.26 Fish was significant on days when it was allowed, but at other fast meals, mushrooms were so common as entrees that they became known as forest meat.30 Today, the observant still does not eat any animal products during fasts (see Chapter 4 for the fast days in the Eastern Orthodox Church). The most significant holiday is Easter, which replaced a pre-Christian festival that marked the end of the bleak winter season. The Butter Festival (maslenitas) precedes the forty days of Lent. One food eaten during this period is blini, raised buckwheat pancakes. Blini can be served with various toppings such coffee. Kolaches, round yeast buns filled with poppy seeds, dried fruit, or cottage cheese, are served at the Christmas meal and on most festive occasions. For Easter, a baked ham or roasted kid is served with mazanec (vanocka dough with raisins and almonds shaped into a round loaf ). The Slovaks break the Advent fast on Christmas Eve by eating oplatky, or small, wafer-like Communion breads spread with honey. The meal may contain wild mush- room soup, cabbage and potato dumplings, stuffed cabbage (holubjy), and mashed potato dumplings covered with butter and cheese (halusky). A favorite dessert is babalky, pieces of bread that are sliced, scalded, and drained and then rolled in ground poppy seeds, sugar, or honey. Mulled wine usually accompanies this meal, as do assorted poppy seed and nut pastries and a variety of fruits. For Easter, the Slovaks prepare paska, a dessert in the form of a pyramid containing cheese, cream, but- ter, eggs, sugar, and candied fruits, decorated with a cross. The meal, blessed by the priest on Holy Saturday, includes ham, sausage (klobása), roast duck or goose, horseradish, an Easter cheese called syrek, and an imitation cheese ball made from eggs (hrudka). In Hungary, the most important religious holiday is Easter. Starting before Lent, pan- cakes are traditionally eaten on Shrove Tues- day; sour eggs and herring salad are served on Ash Wednesday. During Easter week, new spring vegetables are enjoyed, as well as painted Easter eggs. The Good Friday meal may include a wine-flavored soup, stuffed eggs, and baked fish. The biggest and most important meal of the year is the feast of Easter Eve, which consists of a rich chicken soup served with dumplings or noodles, fol- lowed by roasted meat (ham, pork, or lamb), then several pickled vegetables, stuffed cab- bage rolls, and finally a selection of cakes and pastries served with coffee. The Christmas Eve meal, which is meatless, usually features fish and potatoes. The Christmas Day meal often includes roast turkey, chicken, or goose accompanied by roast potatoes and stuffed cabbage, followed by desserts of brandied fruits or fruit compote and poppy seed and nut cakes. One customary Christ- mas Eve dish in Poland is karp po zydowsku, chilled slices of carp in a sweet-and-sour aspic with raisins and almonds. It is of Jewish origin, dat- ing to when Poland was a haven for Jews in the fourteenth century. Vanocka, a Christmas bread popular in the Czech Republic. ▼ Vi kt or 1/ Sh ut te rs to ck .c om Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 1 9 2 C E N T R A L E U R O P E A N S , P E O P L E O F T H E F O R M E R S O V I E T U N I O N , A N D S C A N D I N A V I A N S mistrusted as not being fresh. Many Gypsies believe that non-Gypsies carry disease, and they may insist on using disposable plates and utensils anytime they must eat in a public place. Insufficient intake of lucky foods, such as salt, pepper, vinegar, and garlic, can predis- pose a person to poor health. Home remedies, such as tea with crushed strawberries, asafet- ida (called “devil’s dung”), and ghost vomit (Fuligo septica), are common.19,35 Russians and people of the FSU ascribe health benefits to many different foods. Butter is considered good for eyesight, dill for dys- pepsia, and honey for flatulence.23 Respira- tory infections may be treated with gogomul, a mixture of egg yolk, sugar, milk, and baking soda.20 Teas made from raspberry, chamomile, eucalyptus, and cornsilk are used for numer- ous complaints. Some alcoholic beverages are of particular therapeutic repute. Kvass, the slightly fermented beverage made from bread, is believed to be good for digestion and to cure hangovers. Balsam, flavored vodka, is traditionally used to cure everything from the common cold to alcoholism. More recently, vodka distilled with medicinal herbs, such as ginseng or schizandra berries, has become a favorite supplement consumed as a shot or added to tea or coffee. Full, hearty meals are considered important in maintaining health.36 Contemporary Food Habits in the United States Adaptations of Food Habits Ingredients and Common Foods The central European and Russian diet is not significantly different from U.S. fare. Immigrants made few changes in the types of foods they ate after they came to the United States. What did change did change did was the quantity of certain foods. Most cen- tral European immigrants were not wealthy in their native lands, and their diets had included meager amounts of meat. After immigrating to the United States, they increased the quan- tity of meat they ate considerably. The people of eastern Pennsylvania, where there is a large concentration of German Americans, still eat many traditional German dishes adapted to accommodate available ingredients. Common foods include scrapple as butter, jam, sour cream, smoked salmon, or caviar. Butter is the traditional topping because it cannot be eaten during Lent. Tra- ditional foods served on Easter after midnight Mass are pascha, similar to the Slovak paska but decorated with the letters X B (“Christ is risen”); kulich, a cake made from a very rich, sweet yeast dough baked in a tall, cylindrical mold; and red or hand-decorated hard-boiled eggs. On Pentecost (Trinity) Sunday (fifty days after Easter), kulich left over from Easter is eaten. Twelve different dishes, representing the twelve apostles, are traditionally served dur- ing the Russian and Ukrainian Christmas Eve meal. One of the dishes is kutia, or sochivo, a porridge of wheat grains combined with honey, poppy seeds, and stewed dried fruit consumed when the first stars of Christ- mas Eve appear. A festive meal is served on Christmas Day. On New Year’s Day children receive gifts, and spicy ginger cakes are eaten. A pretzel-shaped sweet bread, krendel, is eaten on wedding anniversaries and name days (saint’s days are celebrated as birthdays in the Eastern Orthodox faith). Therapeutic Uses of Foods A study of German American elders found that they sometimes use home remedies to treat minor illnesses. Chicken soup is used for diarrhea, vomiting, or sore throat. Tea is taken for an upset stom- ach, and milk with honey is commonly used for a cough.14 Traditionally, the Pennsylvania Dutch believe cold drinks are unhealthy and that eating meat three times a day is the cor- nerstone of a good diet. Herbal teas are con- sumed for a variety of complaints.18,33,36 Polish American elders reportedly believe that sauerkraut is good for colic, as are tea and soda water. Chamomile tea is used for cramps, tea with dried raspberries and wine for colds, cooked garlic for high blood pressure, and warm beverages (milk, tea, or lemonade) for coughs. Tea with honey and alcoholic spirits may be used to help sweat out an illness.14,34 Gypsies have unique health beliefs, many involving food. For example, Gypsies tra- ditionally think that fresh food is the most nourishing and that leftovers are unwhole- some. Canned and frozen items may be The term pascha comes from the Hebrew word for Passover, “Pesach.” Most Christmas food traditions in Russia did not survive the Soviet- ruled period when reli- gious ceremonies were discouraged.30 Ukrainians set a place at the table for the spirits of dead ancestors at Christmas. Malzbier is a German beer (1 percent alcohol) that is considered appro- priate for young children and nursing mothers. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 7 1 9 3 sausages may be eaten. Some traditional foods and ingredients may not be available in areas without large central European or Russian populations. Little dietary acculturation was found in a study of recent immigrants from Russia and other FSU countries.36 An increased quantity of familiar foods, particularly soured milk, sour cream, kefir, homemade cheeses, cold cuts, and eggs, and a greater variety of fruits (including citrus, bananas, mangoes, pine- apples, kiwis, and fruit juices) and vegetables (especially broccoli, cauliflower, spinach, red cabbage, and mixed salads) are consumed in the United States, but are incorporated into traditional dishes and meal patterns. Break- fast cereals are well accepted, and traditional grains such as barley, buckwheat, and millet are consumed less often. Favorite American items include soft drinks, ice cream, yogurt, commercial salad dressings, nondairy cream, and whipping cream. Coffee is consumed more often and soups less often, especially at dinner. Snacking on fruit, milk, bread, pastries, sandwiches, and candy is becoming more common. (also called ponhaus), a pork and cornmeal sausage flavored with herbs and cooked in a loaf pan, served for breakfast with syrup; sticky buns, little sweet rolls thought to be descended from German cinnamon rolls known as Schnecken; schnitz un knepp (apples and dumplings), a one-pot dish made from boiled ham, dried apple slices, and brown sugar, topped with a dumpling dough; boova shenkel, beef stew with potato dump- lings; hinkel welschkarn suup, a rich chicken soup brimming with tender kernels of corn; apple butter, a rich fruit spread, very much like a jam; schmierkaes, a German cottage cheese; funnel cake, a type of doughnut; shoofly pie, a molasses pie thought to be descended from a German crumb cake called Streuselkuchen; fastnachts, doughnuts originally prepared and eaten on Shrove Tuesday to use up the fat that could not be eaten during Lent; and sweets and sours, sweet-and-sour relishes, such as coleslaw, crabapple jelly, pepper relish, apple butter, and bread-and-butter pickles, served with lunch and dinner. Saffron crocuses were cultivated in parts of Pennsylvania, and the seasoning was used to color many dishes dark yellow, from soups to a traditional wedding cake known as Schwenkfelder. Much of German cooking has been incor- porated into U.S. cuisine. Many foods still have German names, although they are so com- mon in the United States that their source is unrecognized (e.g., sauerkraut, pretzels, pick- les). Other foods contributed by the Germans are hamburgers, frankfurters, braunschweiger (liver sausage), thuringer (summer sausage), liverwurst, jelly doughnuts, and pumpernickel bread. Beer production, especially in Milwau- kee, was dominated by the Germans for more than one hundred years. German immigrants created a lager-style beer that is milder, lighter, and less bitter than typical German beer; it can now be described as American-style beer (see also Chapter 15). Meal Composition and Cycle Third- and fourth-generation central European, Russian, and FSU Americans tend to consume three meals a day (with snacks), and meal com- position is similar to that of a typical Ameri- can meal, although more dairy products and S A M P L E M E N U A Russian Dinner P ir oz h k i (Baked Turnovers)P ir oz h k i (Baked Turnovers)P ir oz h k i a,b S h ch i (Cabbage Soup)S h ch i (Cabbage Soup)S h ch i a,b K otle t y (Chicken Cutlets)K otle t y (Chicken Cutlets)K otle t y a,b K as h a with Mushrooms (Buckwheat Groats)a,b Fruit Compote Vodka and Beer aVisson, L. 2004. The Russian heritage cookbook. Woodstock, NY: The Overlook Press. bRussian Cuisine at http://www.ruscuisine.com/ Ghost vomit (Fuligo septica) is a myxomycete or slime mold. The thin, yellow, creeping mass is found on rotting wood and other decaying material, where it eats bacteria. Some Russian American mothers fear that cold milk may cause illness in their child and leave milk at room temperature for hours to warm it.36 “Sauerkraut Yankees” was a derogatory nickname for the Pennsylvania Dutch during the Civil War. On average, Americans drink over 28 gallons of beer per person annually.67 Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 1 9 4 C E N T R A L E U R O P E A N S , P E O P L E O F T H E F O R M E R S O V I E T U N I O N , A N D S C A N D I N A V I A N S Many central European and Russian Amer- ican families serve traditional foods at special occasions. On October 11, Polish Ameri- cans celebrate Pulaski Day, a national day of remembrance that features a large parade in traditional apparel down the streets of New York City. The Austrians and Czechs typically observe St. Nicholas Day (December 6), when apples and nuts are put in the stockings of well-behaved children, and coal is given to the naughty ones. Hungarian Americans observe three unique holidays in the United States with a combination of patriotic and religious activities. The first is March 15, commemo- rating the revolution of 1848; the second is August 20, St. Stephen’s Day; and the third is the attempted revolt known as the Revolution of 1956 on October 23. Among the Amish, many national holidays, such as the Fourth of July and Halloween, are not observed. A second day of celebration is added to Christmas, Easter, and Pentecost: the first day is reserved for sacred ceremonies, the second day for social and recreational activi- ties. Most Amish celebrate all holidays quietly with family. Nutritional Status Nutritional Intake Ver y little has been reported on the nutritional intake of accul- turated central European or Russian Ameri- cans. Recent European-wide studies show the diets of central Europeans are among the highest in animal products, potatoes, sweets, and refined or processed items in Europe.37 Consumption of fats and oils of animal ori- gin was highest in Germany: the mean daily intake for added fats and oils was 66 grams for men living in Potsdam.38 Rates of over- weight and obesity are 50 percent for German women and nearly 66 percent for German men. Slightly lower rates are found in the Czech Republic, Slovakia, and Hungary. Polish men scored higher than Germans, but Polish women scored lower.39 Recent immi- grants from Russia and other FSU nations were found to consume a diet high in satu- rated fats, sodium, and sugar.36 In 2010, the World Health Association ranked Russia ninth in the world for death from cardio- vascular disease. Russian Americans may be at risk of developing cardiovascular disease and other conditions associated with high- fat items (particularly red meats, processed meats, and dairy products) popular both in their traditional cultures and in U.S. fare. Recent immigrants from Russian and FSU nations may suffer some nutritional deficien- cies due to inadequate consumption of fruits and vegetables. Low intakes of riboflavin and vitamin C are reported.37 In the Chuvash Republic of Russia, significant dietary sele- nium deficiency and moderate iron and manganese deficiencies have been reported.40 High rates of diabetes, hypertension, hyperlip- idemia, and cardiovascular disease are found in Russian-speaking immigrants. Tuberculosis and HIV incidence has been increasing dra- matically in Russia in recent years and is thus a concern for new immigrants. Nearly 80 per- cent of immigrants from Russia are thought to be from the regions most affected by the Chernobyl nuclear power accident of 1979. Increases in leukemia and thyroid cancer in this population have been noted.41 A study of recent immigrant Russian mothers found strong support for breast- feeding. All but one of ninety participants breast-fed their infants exclusively or par- tially for an average of twenty-eight to thirty weeks, regardless of whether the babies had been born in Russia or the United States.42 This contrasts with health reports from Rus- sia, where breast-feeding is discouraged, and infant nutrition has been compromised by inadequate supplies of formula. High rates of iron-deficiency anemia (affecting 25 to 50 percent of children) and endemic goiter have been reported.43 Older Russian women use a variety of complementary and alterna- tive medicine (CAM).44 Since the Chernobyl nuclear power accident, some Russians may resist having X-rays taken because they fear radiation exposure.20 Heavy alcohol use has been reported in Russia, certain FSU nations, and Poland.45,46,47 Some researchers are concerned that immi- grants from these countries may continue similar drinking patterns; however, data are limited.17,34 Low rates of alcoholism have been reported among Russian-speaking immigrants.46 In the 1800s, fried oysters with a glass of Schnapps was a popular Pennsylvania Dutch breakfast for men. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 7 1 9 5 and respectful and expect to be treated in a similar manner. Modesty is important to the Amish, and wearing conservative clothing when counseling clients is appropriate. Mod- ern health technology is not in conflict with traditional Amish religious precepts; however, it may be avoided unless absolutely neces- sary, such as during a medical emergency.17 Photos are not allowed, though X-rays and other scans are accepted if their necessity is explained. Educational materials should not include pictures of the Amish, nor illustra- tions representing human faces. A survey of physicians with experience treating the Amish noted more problems with digestive disorders, obesity, and chronic bed-wetting than with non-Amish clients.33 The doctors’ opinion was that the Amish eat a diet higher in fat and salt than the non-Amish, which may contrib- ute to these problems; however, the Amish showed fewer symptoms of heart disease and alcoholism than non-Amish patients. Condi- tions regarding maternal and child health are common, and hereditary diseases, including phenylketonuria and other metabolic disor- ders, are more prevalent among the Amish than the U.S. population as a whole.17 In working with Gypsy American clients, health care providers should be aware that English is usually a second language and that illiteracy is common. However, Gypsies are often very adaptive and may use many forms of communication, depending on the situ- ation. Gypsies believe that the measure of a A small study of Gypsies in Boston found high rates of hypertension, type 2 diabetes, and vascular disease, affecting between 80 and 100 percent of the population over age fifty. Approximately 85 percent were obese. Chronic renal insufficiency was also a prob- lem.48,49 In Europe, researchers have found high rates of dyslipidemia, obesity, and insu- lin resistance, suggesting a predisposition for metabolic syndrome (for more infor- mation on this topic, see Chapter 14).50,51 Genetic problems due to high rates of con- sanguinity—being descended from the same ancestor as another person—show Gypsies worldwide at risk for several metabolic con- ditions, including phenylketonuria, galacto- kinase deficiency, citrullinaemia, Wilson’s disease, and metachromatic leukodystrophy. Rates of both infant mortality and unfavor- able birth outcomes are high; overall life expectancy is low.52 Counseling Communication difficulties may occur with recent or older central European or Russian immigrants. Language barriers may necessitate the use of a competent translator. Good manners and formality are expected in German conversations. Education is respected, and the use of titles is important.32 Honesty and directness are appreciated. Germans are monochronistic and prefer to deal with one topic at a time. Direct eye contact is a sign of attentiveness and trust. A handshake is used in greeting, but there is little other touching between acquaintances. Poles tend to speak more quietly than Americans and feel uncom- fortable with loud behavior. Discussions about politics are avoided. Direct eye contact and a handshake during a greeting and when leav- ing are appropriate. German Americans, as well as other cen- tral European Americans, emphasize self- reliance and may avoid health care. Polish Americans may be reluctant to express pain and often deny symptoms of illness.34 Compli- ance problems develop if medication is seen as a last resort, taken only until symptoms disappear. Many Amish still speak a German dia- lect, so an interpreter may be necessary to provide care. The Amish are often reserved ▲ Pennsylvania Dutch funnel cake is an unusual “doughnut” made by pouring the batter through a funnel or from a pitcher into the hot oil in a swirled pattern. Br en t H of ac ke r/ Sh ut te rs to ck .c om High rates of gastric cancer in Lithuania are believed to be due in part to a high consump- tion of salted and cured meats and fish.68 Eggs are sometimes used raw in uncooked dishes by Russian and FSU Americans, putting them at risk for Salmo- nella poisoning. Gypsies may reject injections for fear that something impure from the outside will contaminate the pure inner body. Health care providers working with Russians report that some immi- grants believe potatoes cause type 2 diabetes. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 1 9 6 C E N T R A L E U R O P E A N S , P E O P L E O F T H E F O R M E R S O V I E T U N I O N , A N D S C A N D I N A V I A N S man’s worth is in his girth—weight gain is associated with health, weight loss with ill- ness.2 Gypsies will often not seek treatment until an emergency develops. Numerous fam- ily members will come with a client to pro- vide support, often bringing food, because most Gypsies consider food prepared by non- Gypsies impure.19 Russians expect formality between acquaintances, and first names are saved for close friends and relatives. Some Russians may initially respond to any question that requires an affirmative or negative answer with a no; in most cases, however, communication is direct, and may be loud or expressive.17 Direct eye contact is the norm. A quick three kisses on the cheeks or a handshake is used in greeting, and touching becomes more prominent with familiarity. Russians may consider it impolite to sit with the legs splayed or with an ankle resting on the knee. Preventive screenings or prophylactic therapies are uncommon in the FSU, and clients may not understand the need for the procedures.20 They may not be compliant with medication or lifestyle modi- fications. Counseling and mental health issues were avoided by elderly Russian immigrants in one study, perhaps due to the social and economic stigma associated with psychologi- cal disorders in Russia.24 These Russian clients expected extensive help with personal prob- lems and information on social services from their primary provider. An increased percep- tion of pain and somatic symptoms are com- mon; many Russian Americans do not believe U.S. physicians understand their ailments or treatments.21 Culture-specific illnesses, such as “avitaminosis” or “dysbacteriosis,” are unfamiliar diagnoses in the United States.23 Medical care in Russia mainly provides drug therapy regimes mixed with alternative ther- apies, thus Russians may expect medications in order to believe they are being helped, and they may believe care is incomplete if it does not include alternative treatments. Injec- tions are preferred over oral medications. One study found that patients frequently self-medicate with drugs obtained from the FSU and often cut the dosage of prescriptions obtained in the United States because they are considered “too strong.”20 Russian clients are often very assertive in their requests because aggressive behavior was necessary to receive attention in the Russian health care system. However, some Russian-speaking immigrants may be reluctant to discuss any infectious dis- eases for fear of being ostracized within their community. Many Americans of central European and Russian decent are highly acculturated. An in-depth interview can determine any com- munication preferences or traditional health practices. Scandinavians The Scandinavian countries include Sweden, Norway, Denmark, Finland, and Iceland. With the exception of Denmark and the island of Iceland, they are located north of the Baltic and North Seas and share common borders with each other and Russia. Most of the population in Scandinavia is concentrated in the warmer southern regions; the harsher northern areas extend above the Arctic Cir- cle. Norway’s weather is more moderate than that of Finland and Sweden because its long western coastline is washed in the temperate North Atlantic Drift. Denmark juts into the North Sea to the north of Germany, and its capital, Copenhagen, is directly opposite from Sweden. Numerous Scandinavians have made their homes in the United States. This section reviews the traditional foods of Scandinavia and the Swedish, Norwegian, and Danish contributions to the U.S. diet. Cultural Perspective History of Scandinavians in the United States Legend is that the Norsemen (ancient Scan- dinavians), renowned seafarers and explorers, first discovered North America and colonized as far west as Minnesota in the thirteenth and fourteenth centuries. The documented pres- ence of Scandinavians in the United States dates back to the seventeenth century. Jonas Bronck, a Dane, arrived in 1629 and bought a large tract of land from the Native Americans that later became known as the Bronx in New York City. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 7 1 9 7 Immigration Patterns The majority of Scan- dinavians arrived in the United States in the 1800s, led by the Norwegians and the Swedes. During the nineteenth century, no other country except Ireland contributed as large a proportion of its population to the settlement of North America as Norway. During the 1900s, an additional 363,000 Norwegians, more than 1,250,000 Swedes, 363,000 Danes, and 300,000 Finns entered the United States. The peak years of Scandinavian immigra- tion to the United States were between 1820 and 1930. The population of all the Scandi- navian countries had grown substantially, resulting in economies that could not absorb the unemployed and landless agrarian work- ers. In Sweden, the problem was magnified by a severe famine in the late 1860s. For the Norwegians there was the additional lure of freedom that the United States offered, and the chance for emancipation for the peasant class. Scandinavian immigrants typically set- tled in homogeneous communities. Norwegians and Swedes often moved to the homestead states of the Midwest, espe- cially Illinois, Minnesota, Michigan, Iowa, and Wisconsin. One-fifth of all Swedish immi- grants settled in Minnesota. Pockets of Finns and Danes also settled in this region, but they were fewer in number. Many Norwegians and Swedes later moved to the Northwest, work- ing in the lumber and fishing industries. The shipping industry attracted some Norwegians to New York City, where they still live in an ethnic enclave in Brooklyn. Although Swedes and Norwegians are often associated with the rural communities of the Midwest, by 1890 one-third of all Swedes lived in cities, and many Norwegians were seeking opportunity in the urban areas. Chicago and Minneapolis still have large Scandinavian populations. C L A R A S C H M I D T Iemigrated from the Moldova Republic (formerly Moldavia in the former Soviet Union), first to Israel in 1988, and then to the United States to be near my son. I was an English professor in the Soviet Union and Israel. My family was originally from Romania. In the Soviet Union, we had enough food but not in abundance. Food was very important to us because of previous short- ages, and as a result we were forced to finish everything we were served. Food was never thrown away. In the morning we might have tea with a bread sandwich of butter and jam and/or possibly an egg. Snacks were not typi- cal, but it might be a sandwich or fruit. It was something you brought with you if you went out, since you couldn’t purchase them. Dinner was at lunch time (1:00–3:00 p.m.) and was the biggest meal of the day. We ate at home, and the meal was served when my father came home. The meal included soup (veg- etable, chicken, or beet/cabbage), salad of several types of vegetables, meat, or fish with potatoes/rice, and fruit for dessert. We drank soft drinks with the meal. Supper was from 6:00 to 8:00 p.m. and could include sausage, vegetables, bread, and maybe leftovers, dairy (yogurt, cottage cheese), or cottage cheese pancakes with sour cream. My diet changed the most after I immi- grated to Israel. We ate less soup, less fat, and more fresh fruit and vegetables year round. We ate much less meat and of course no pork. In Israel I learned to love avocados and hummus (chickpea dip), and I still eat them here. In the United States, we started to eat the American way. Dinner, now the main meal, was closer to 5:00 or 6:00 p.m. It might include chicken soup with vegetables, lamb, cooked fish (not fried), and vegetables. One thing I love here is barbequed lamb ribs. Breakfast has changed to cereal/oatmeal, yogurt, and fruit. Lunch is now a sandwich or salad. I have switched from tea to coffee, and it is something I can’t do without. Other things I couldn’t change in my diet would be limiting fruit, vegetables, and dairy products. For spe- cial occasions I still prepare family recipes, like Georgian chicken with walnuts, chicken necks stuffed with chopped liver, and a three-layer sour cream cake with honey and nuts. My impression of American eating is that some Americans count every calorie they eat, but the food they eat is not tasty, and that most Americans eat a lot of very tasty but unhealthy food. Fast foods taste good, but the amount of fat is awful—seems like it is all meat and fried food. I prefer plain food, but made at home. N E W A M E R I C A N P E R S P E C T I V E S Russian Few Icelanders have made their home in the United States; the 2011 U.S. Census indi- cates approximately 44,000 Americans claim Icelandic descent. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 1 9 8 C E N T R A L E U R O P E A N S , P E O P L E O F T H E F O R M E R S O V I E T U N I O N , A N D S C A N D I N A V I A N S The Danes, in an effort to preserve their ethnicity, developed twenty-four rural com- munities between 1886 and 1935, in which, for a set number of years, land could be sold only to Danes. The best known of these com- munities are Tyler, Minnesota; Danevang, Texas; Askov, Minnesota; Dagmar, Missouri; and Solvang, California. Today, most Danes live in cities, primarily on the East or West Coasts. The largest concentrations of Danes are in the Los Angeles area and in Chicago. Following World War I, U.S. immigra- tion from Finland dropped significantly as Finns chose other countries for emigration. As the Finnish population stagnated, eth- nic identity became very difficult to main- tain. Second- and third-generation Finns are highly acculturated. Current Demographics and Socioeconomic Status According to the 2010 U.S. Census, there are approximately 1.4 million Danes, 4.1 million Swedes, 4.5 million Norwegians, and 650,000 Finns and their descendants now living in the United States.1 Most Scan- dinavians assimilated rapidly into U.S. soci- ety, rising from blue-collar to white-collar jobs within a few generations. A majority of Scandinavian immigrants were literate in their own language and often produced local newspapers, periodicals, and books. Education was valued as a way to improve economic standing. The Danes opened folk schools designed to foster a love of learning in their communities, as well as two liberal arts schools. Norwegians and Swedes established many colleges. The Finns founded summer schools where traditional Finnish culture and religion were taught. Women often had educational opportunities in these schools that were unavailable to them in Scandinavia. Today, many Norwegians and Swedes have continued farming in the Midwest or have taken jobs in the construction industry. However, nearly one-third of Norwegians are employed in management or specialty professions, while many Swedish Americans have moved into engineering, architecture, and education.53,54 Danes entered a variety of occupations, but they were most prominent in raising livestock and dairying. Urban Danes today are not associated with specific occu- pations.55 Finnish American men have been active in fields such as natural resources man- agement, mining engineering, and geology, while women have been attracted to nursing and home economics.56 Worldview Religion The majority of Scandinavians who immigrated to the United States were Lutheran, though each nationality had its own branch of the church, and within each branch numerous sects were represented. Factional- ism was common until many of the Scandi- navian and German Lutheran churches joined together to create the Evangelical Lutheran Church in America (ELCA) in 1987. Those Scandinavians who are not Lutheran often belong to other Protestant churches, including Methodist, Mormon, Seventh-Day Adventist, Baptist, Quaker, and Unitarian. Family The nuclear Scandinavian family was at the center of rural life. Families were typically large, and the father was head of the household. Kinship ties were strong: families were expected to pay the way for relatives remaining in Scandinavia to come to the United States, where they would be given a room, board, and help in finding employ- ment. The power of the father diminished and family size decreased as the Scandinavian Americans became more integrated in main- stream society. Among the Finns, it has been noted that when both parents work, they may choose to have only one child.56 Traditional Health Beliefs and Practices Infor- mation on traditional Scandinavian health beliefs and practices is very limited. Fish was considered necessary for good health. In Nor- way, cough and cold confectionaries (such as lozenges and pastilles) are very popular over- the-counter remedies. A current Norwegian study also found that 56 percent of cancer patients use herbs and dietary supplements primarily to boost immune function.57 The Finns believe in natural health care, prac- ticing massage, cupping, and bloodletting. Further, the sauna (a traditional steambath) is reputed to have therapeutic qualities. It is The Scandinavians introduced the cast- iron stove to the United States in the early 1800s. Cooking was previously done in fireplaces and brick ovens. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 7 1 9 9 used by Finns when ill and even by midwives during childbirth. It is considered a remedy for colds, respiratory or circulatory problems, and muscular aches and pains.56 One health practice in Sweden that has been widely adopted in the United States is Swedish massage, also known as therapeutic massage. It is a deep muscle technique that uses five main strokes to provide relaxation, increase circulation, and promote healing. Traditional Food Habits Scandinavian fare is simple and hearty, featur- ing the abundant foods of the sea and making the best use of the limited foods produced on land. Scandinavian cooking often reflects the preservation methods of previous centuries. Fish was traditionally dried, smoked, or pick- led, and milk was often fermented or allowed to sour before being consumed. Scandina- vians still prepare a large variety of preserved foods and prefer their food salty. The basics of the Scandinavian diet are given in the cultural food groups list (Table 7.2). Ingredients and Common Foods: Staples and Regional Variations The traditional cooking of Scandinavia is hearty. Spices were expensive in the past, and most dishes feature the natural flavors of ingredients with subtle seasoning. Black pep- per, onions, and dill are used in many recipes, and juniper berries add interest in others. Caraway, cloves, nutmeg, and cardamom fla- vor many baked goods. Scandinavians are probably best known for their use of fish and shellfish, such as cod, herring, mackerel, pike, salmon, sardines, shrimp, and trout. It is so common that in restaurants the lunch special is often listed simply as dagensratt (“fish of the day”).26 In Norway the fish-processing industry is believed to date back to the ninth century, and today, Scandinavian dried salt cod is exported all over the world. Popular fish dishes include salmon marinated in dill, called gravlax; smoked salmon, known as lox; and the many varieties of pickled herring. Fish sticks and fish baked with cheese and breadcrumbs are common homestyle dishes. Cream and butter are used in many dishes, especially in Denmark, which has a slightly warmer climate than the other Scandinavian nations. White sauce made with milk and minced parsley tops many Danish dishes, such as roast bacon, eel, and herring, as well as boiled and cured meats.58 One Swedish spe- cialty is known as Jansson’s frestelse (“temp- tation”) and includes anchovies and grated potatoes baked in a cream and onion sauce. Considerable quantities of fermented dairy products are used throughout the region, such as sour cream, cheese, buttermilk, and yogurt- like products, including filmjok (Sweden) and skyr (Iceland). Sour cream in particular is added to soups, sauces, and dressings for salads and potatoes. In Norway, it is tradi- tional to prepare an oatmeal porridge known as rømmegrøt with sour cream, and the dish is still found at many festive occasions. Fish, such as fried trout or herring, is also cus- tomarily served with a sour cream sauce and boiled potatoes. Denmark is renowned for its cheeses, such as semifirm, mellow, nutty- tasting Tybo (usually encased in red wax); firm and bland Danbo; semisoft, slightly acidic Havarti; rich, soft Crèma Dania; and Danish blue cheese. Jarlsberg, a Swiss-style cheese, is a well-known Norwegian product, but brunost, a sweet, brown cheese made from cow’s milk mixed with goat’s milk and served in thin slices on brown bread, is most popu- lar in the nation.59 Cheese is eaten daily for breakfast, on sandwiches, and as snacks. Though fish is popular in many parts of Scandinavia, the more inland areas feature many meat dishes. In the southern regions pork is particularly common. Roast loin stuffed with prunes and apples is a favorite in Denmark, which is also noteworthy for its smoked ham and bacon. Though beef is available, veal is more commonly consumed. Mutton and lamb are used in roasts and stews, such as the Norwegian fårikål (lamb with cab- bage), and are also dried or salt-cured, then thinly sliced and used like ham. In the more northern areas reindeer is raised and is a popular meat. Other game meats such as elk, venison, and hare are hunted in the fall and considered a delicacy. Poultry is not especially well liked; however, pickled goose and stuffed In Scandinavia they say “Danes live to eat, Norwegians eat to live, and Swedes live to drink.” Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 2 0 0 C E N T R A L E U R O P E A N S , P E O P L E O F T H E F O R M E R S O V I E T U N I O N , A N D S C A N D I N A V I A N S Group Comments Common Foods Adaptations in the United States Protein Foods Milk/milk products Dairy products, often fermented, are used extensively. Buttermilk, milk, cream (cow, goat, reindeer); cheese, sour cream, yogurt Meat/poultry/fish/ eggs/legumes Fish is a major source of protein, often preserved by drying, pickling, fermenting, or smoking. Meat: beef, goat, lamb, hare, pork (bacon, ham, sausage), reindeer, veal, venison Fish and shellfish: anchovies, bass, carp, cod, crab, crawfish, eel, flounder, grayling, haddock, halibut, herring, lobster, mackerel, mussels, oysters, perch, pike, plaice, roche, salmon (fresh, smoked, pickled), sardines, shrimp, sprat, trout, turbot, whitefish Poultry and small birds: chicken, duck, goose, grouse, partridge, pheasant, quail, turkey Eggs: chicken, goose, fish Legumes: lima beans, split peas (green and yellow) More meat and less fish are consumed. Cereals/Grains Wheat is used less than other grains. Rye is used frequently in breads. Barley, oats, rice, rye, wheat More wheat used, fewer other grains. Fruits/Vegetables Fruits with cheese are frequently served for dessert. Preserved fruits and pickled vegetables are common. Tapioca (from cassava) is eaten. Fruits: apples, apricots, blueberries, cherries, cloudberries, currants, lingonberries, oranges, pears, plums, prunes, raisins, raspberries, rhubarb, strawberries Vegetables: asparagus, beets, cabbage (red and green), carrots, cauliflower, celery, celery root, cucumber, green beans, green peppers, nettles, kohlrabi, leeks, mushrooms (many varieties), onions, parsnips, peas, potatoes, radishes, spinach, tomatoes, yellow and white turnips A greater variety of fruits and vegetables are obtainable in the United States than in Scandinavia but may not be eaten. Additional Foods Seasonings Savory herbs and spices preferred. Cardamom is especially associated with Scandinavian sweets. Allspice, bay leaf, capers, cardamom, chervil, cinnamon, cloves, curry powder, dill, garlic, ginger, horseradish, lemon juice, lemon and orange peel, mace, marjoram, mustard, mustard seed, nutmeg, paprika, parsley, pepper (black, cayenne, white), rose hips, saffron, salt, tarragon, thyme, vanilla, vinegar Nuts/seeds Marzipan (sweetened almond paste) is used in many sweets. Almonds, chestnuts, walnuts Beverages Coffee, hot chocolate, milk, tea, ale, aquavit, beer, vodka, wine, liqueurs Fats/oils Butter is often used. Butter, lard, margarine, salt pork Sweeteners Sugar (white and brown), honey, molasses TA B L E 7. 2 Cultural Food Groups: Scandinavian © C en ga ge L ea rn in g Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 7 2 0 1 fresh goose are eaten, as are certain game birds, such as grouse. Historically, meat was in limited supply, so it was stretched by chopping it and com- bining it with other ingredients, resulting in many traditional dishes. Scandinavians eat many vegetables, such as onions and cabbage, stuffed with ground pork, veal, or beef. The Swedes are known for their meatballs served in cream gravy or brown sauce, and the Danes for frikadeller, which are patties of ground pork and veal, breadcrumbs, and onion fried in butter. The Norwegians prepare kjøttkaker, minced beef cakes seasoned with a bit of gin- ger that are panfried, then boiled, and served with brown gravy. Beef hash made with beets and onions is another example. Sausages are also very common. Cold-weather vegetables, including pota- toes, cabbage, kale, brussels sprouts, car- rots, celery root, cucumber, beets, turnips, onions, and leeks are widely available. Ruta- bagas, sometimes called “Nordic oranges” or “swedes,” are a customary side dish.63 Yellow and green split pea soups with pieces of ham or pork are a winter specialty throughout Scandinavia, sometimes served with pan- cakes. Wild mushrooms are a specialty in some areas of Finland and Norway. Though vegetables were traditionally served cooked, fresh salads have become popular in recent years. Apples, cherries, prunes, and several varieties of berries (particularly lingonber- ries) are typical fruits, often stewed or made into preserves that are sometimes served with meat. Bread is a staple food item and is often pre- pared from rye flour, although wheat, barley, and oats are also used. Scandinavian breads may or may not be leavened, vary in size and shape, and may be white, brown, or almost black in color. Some are crisp, such as Norwe- gian flatbrød Swedish knäckebröd are similar to hardtack or crackers. A thin, round bread called lefse (also known as lompe in Norway) is made with a potato and wheat flour dough, then cooked on an ungreased griddle. It may be used to wrap a sausage, or be eaten with butter and sugar or jam and folded like a handkerchief. In Sweden a recent innovation is Tunnbrød, a very thin, wheat tortilla-like bread that is sold as fast food, rolled around fillings such as mashed potatoes, sausages, or shrimp salad and condiments such as pickles, mustard, and ketchup. Dumplings are a favor- ite in Norway, often made from potatoes. Desserts, whether they are served after a meal or at a coffee break, are rich but not overly sweet. Most are made with butter and also contain cream or sweetened cheese and the spice cardamom. Aebleskivers are spheri- cal Danish pancake puffs, sometimes stuffed with fruit preserves. During Advent, they are filled with whole almonds. Another popu- lar dessert is pancakes or crêpes served with preserved berries or jam. The Scandinavians use almonds, almond paste, or marzipan in desserts as often as Americans use chocolate. One regional dessert specialty is kransekake, a stack of progressively smaller frosted almond pastry rings. The Danes are best known for their pastries or, as they call them, Wienerbrød (“Vienna bread”). The pastries were brought to Denmark by Viennese bakers a century ago when the Danish bakers went on strike. When the strike was over, the Danes improved the buttery yeast dough by adding jam and other fillings. A Finnish specialty is pulla, a braided sweet bread popular at breakfast. Milk is well liked as a beverage in Scandi- navia. Other common drinks are coffee, tea, beer, wine, and aquavit. A q uav it, which means “water of life,” is liquor made from the distil- lation of potatoes or grain. It may be flavored with an herb such as caraway and is served ice cold in a Y-shaped glass. It is downed like a shot and often followed by a beer chaser. Meal Composition and Cycle Daily Patterns The Scandinavians eat three meals a day, plus a coffee break midmorn- ing, late in the afternoon, or after the evening meal. Breakfast is usually a light meal consist- ing of bread or oatmeal porridge, cold cereal, eggs, small pastries, cheese, fruit, potatoes, or herring. Sour cream or yogurt-like fermented milk may be served to eat with cereal. Fruit soups may be served in the winter. Milk and coffee or tea accompany the meal. Traditionally, lunch in Denmark is smør- rebrød, which means “buttered bread,” an open-faced sandwich eaten with a knife and The cooking of Finland mixes Swedish and Russian elements, such as smörgåsbords, pirozh- kis (meat turnovers), and blini (thin buckwheat pancakes). Vodka is pre- ferred over aquavit. Whey, a by-product of cheese making, was traditionally mixed with water to make a refresh- ing beverage in Norway, northern Sweden, and Iceland. When Scandinavians toast, they say “skoal,” which probably derives from the word for skull. Ancient Norsemen used the empty craniums of their enemies as drinking vessels. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 2 0 2 C E N T R A L E U R O P E A N S , P E O P L E O F T H E F O R M E R S O V I E T U N I O N , A N D S C A N D I N A V I A N S If lunch is light sandwiches, dinner is complete, often including an appetizer, soup, entrée, vegetables, and dessert. Potatoes are usually served with the evening meal. If a hot meal is eaten at lunch, a more informal supper with convenience foods is preferred. Italian items are especially popular. For example, the three most common dishes served in Swed- ish homes today are boiled Falun sausage (a Swedish specialty made of beef, veal, and pork), spaghetti with meat sauce, and pizza.61 Milk, beer, or wine accompanies the meal. Coffee or wine may be served with dessert. If a dessert wine is served, coffee will follow the end of the meal. Etiquette As with many other Europeans, the fork remains in the left hand, and the knife remains in the right one. Despite the prevalence of sandwiches in Scandinavian menus, only bread is eaten with the hands at the table; sandwiches are consumed using the fork and knife. Pass dishes to the left. When not eating, keep your hands above the table with the wrists resting on the edge. In Finland, it is important to wait for the host to initiate eating. In Norway, a male guest of honor is expected to thank the hosts on behalf of all guests. Wine is expen- sive throughout Scandinavia, so it is always appreciated as a hostess gift.32 Special Occasions Social occasions are usually marked with food in Scandinavia. In Sweden, conferences and meetings always offer milk and coffee with sweets, such as cinnamon buns, open-faced sandwiches, or fruit. Sand- wich cakes, which are layers of bread with fill- ings such as pâté, ham, and sliced sausages, garnished with mayonnaise, shrimp, and herbs, are served midafternoon whenever a crowd gathers for an event. December is the darkest month of the year in Scandinavia, and Christmas celebra- tions are a welcome diversion. The Christmas season lasts from Advent (four weeks before Christmas) until January 13, Saint Canute’s Day. In Sweden, on the morning of Decem- ber 13, St. Lucia’s Day, the eldest daughter in the home, wearing a long white dress and a crown of lingonberry greens studded with fork. Buttered bread is topped with anything from smoked salmon to sliced boiled potatoes with bacon, small sausages, and tomato slices. Smørrebrød may also be served as a late after- noon or bed-time snack. Today, Danes are as likely to pick up a quick sandwich made with a bagel or Italian bread as they are to eat smørrebrød. A buffet meal in Sweden is the smörgås- bord (bread and butter table), a large variety of hot and cold dishes arrayed on a table and traditionally served with aquavit. Ritual dic- tates the order in which foods are eaten at a smörgåsbord.60 The Swedes start with her- ring, followed by other fish dishes, such as smoked salmon and fried fins. Next are the meats and salads (pâtés and cold cuts), and the final course before dessert is comprised of hot dishes, such as Swedish meatballs and mushroom omelets. Today, the smörgåsbord is rarely served except at special occasions. More typically, Swedes consume a hot lunch that might include pea soup, brisket or hash, and mashed rutabaga at the school or work cafeteria.61 ▲ Danish smørrebrød: Danish Fontina and Havarti cheeses, ham, salami, and smoked salmon are a few of the toppings typical of the open-faced sandwiches known in Denmark as smørrebrød. Ay ni a Br en na n/ Sh ut te rs to ck .c om Veal Oscar, veal topped with a béarnaise sauce, white asparagus, and lobster or crab, is named after Swedish King Oscar II (1872–1907), a renowned gourmet. Eating lutefisk has become a symbol of ethnic identity in some Scandinavian American communities. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 7 2 0 3 fish accompanied by boiled new potatoes and wild strawberries are eaten; in Norway, røm- megrøt is served; and in Finland, new pota- toes with dill and smoked salmon are typical festive fare. Contemporary Food Habits in the United States Adaptations of Food Habits Scandinavians assimilated quickly into American society, yet their diet did not change significantly because many of their food habits are similar to the diet of the American major- ity, including three meals per day containing ample dairy products and animal protein. Many Scandinavian foods have been adopted by all Americans (see Chapter 15 for more information). Nutritional Status Nutritional Intake Very little has been pub- lished on the nutritional status of Americans of Scandinavian descent. In Scandinavia, lit candles, serves her parents saffron yeast buns and coffee in bed. However, the climax of the season is on Christmas Eve, when the biggest, richest, and most lavish meal of the year is eaten. In Norway, traditional foods eaten on Christmas Eve begin with rice porridge sprinkled with sugar and cinnamon. Buried in the dish is one blanched almond; the per- son who receives it will have good fortune in the coming year. Lutefisk, a dried salt cod soaked in lye, then boiled, is customary in the north. In the east, pork ribs and sausages with cabbage are served; in the west, a dried lamb rib specialty with mashed rutabaga is favored, while in the south, cod or halibut served with a white sauce and green peas is preferred. Boiled potatoes are a common side dish at all the meals. A selection of cookies and cakes complete the meal. Women tra- ditionally demonstrated their proficiency in the kitchen by offering at least seven types of sweets, a custom still followed in many homes today.59 In Sweden, a Christmas smorgasbord with twenty or thirty dishes featuring ham, her- ring, and other traditional fare is served. In Denmark, roast duck, goose, or pork is served with brown gravy. Typical side dishes are red cabbage and caramelized potatoes. Rice pud- ding with whipped cream and hot cherry sauce is also traditional. In Finland, the meal starts with pickled herring and salmon, then continues with ham, and vegetable casse- roles of potatoes, carrots, or turnips. Prunes are usually featured in one dessert, followed by cookies and pies. In recent years, other European Christmas specialties such as Stol- len, panettone, and bûche de Noël have also become popular.62 Dozens of cookies and cakes are prepared for the Christmas season. The cookies are often flavored with ginger and cloves; the Christmas tree may be hung with gingerbread figures. Deep-fried, brandy-flavored dough, known as klejner, klener, or klenätter, is also popular. The traditional holiday beverage is glögg, a hot alcoholic punch. Midsummer’s Day (June 24) is a popu- lar secular Scandinavian holiday. It features maypoles, bonfires, and feasting. In Sweden, St. Urho’s Day (March 16) was invented by Finnish Americans as a spoof on St. Patrick’s Day. It commemorates the saints driving out the grasshoppers from Finland. Midsummer’s Day is still observed by many Scandinavian Americans. In some areas of the United States, it has become Svenskarnas Dag (Swede’s Day), celebrating Swedish culture and solidarity. ▼ Crawfish are a specialty in Scandinavia, where they are boiled and seasoned with dill, then served chilled at summer festivals with aquavit, vodka, or beer. Su sa nn a Bl av ar g/ G et ty Im ag es Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 2 0 4 C E N T R A L E U R O P E A N S , P E O P L E O F T H E F O R M E R S O V I E T U N I O N , A N D S C A N D I N A V I A N S D I S C U S S I O N S T A R T E R S Which Cuisines Dominate in U.S. Restaurants? Whenever Americans go out to eat at an ethnic-based restaurant, they typically end up at an Italian, Asian, or Mexican institution. French restaurants also tend to carry a certain cache with Americans. German and other central European and Scandinavian restaurants are less common, however, and are typically concentrated in areas of the country with a tradition of central European or Scandinavian immigration. Fast-food Italian, Asian, and Mexican restaurants are also widespread in the United States, while there are few fast-food Scandinavian, German, or Russian restaurants. Individually and then in small groups, brainstorm why ethnic cuisines are distributed in this way. What possible reasons could explain why central European and Scandinavian restaurants are not more widespread, even though immigration from these countries has been as large historically as that from Italy, China, and Mexico? alcoholism, depression, and lactose intoler- ance.56 Because both their traditional diet and the well-accepted typical U.S. diet are high in cholesterol and saturated fat, Scan- dinavian Americans may be at increased risk of developing cardiovascular disease and other conditions associated with the Westernized diet. Counseling Scandinavians are often low- context communicators and highly analyti- cal. Emotions are controlled; superficiality and personal inquiries are avoided. Swedes and Finns are comfortable with silence dur- ing a conversation. As a rule, Danes are a lit- tle more informal than other Scandinavians or northern Europeans and may use first names. Danes and Swedes make and maintain direct eye contact, whereas Norwegians and Finns make direct eye contact intermittently. A brief, firm handshake is used in greetings. Other touching is infrequent, reserved for friends and relatives. Scandinavians are likely to avoid discus- sion of illness until necessary. Some may consider sickness indicative of either physi- cal or moral weakness. An in-depth interview should be used to establish any traditional health beliefs of clients, as well as dietary patterns. S A M P L E M E N U A Swedish Lunch Yellow Split Pea Soupa,b Swedish Meatballsa,b New Potatoes with Dilla,b P e ppar k ak or (Gingersnaps)P e ppar k ak or (Gingersnaps)P e ppar k ak or a,b Milk or Beer aHenderson, H. 2005. The Swedish table. Minneapolis: University of Minnesota Press. bScandinavian Cooking at http://scandinaviancooking.com estimated prevalence of over weight and obesity in Finland is nearly 40 percent for women and almost 60 percent for men. Figures are somewhat lower in Denmark, Norway, and Sweden.39,63 Finns purport- edly have high rates of heart disease, stroke, Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 7 2 0 5 Review Questions 1. Briefly describe the traditional health prac- tices and beliefs of the Russians, Germans, and Scandinavians. 2. What were the common staples of central Europeans, Scandinavians, and people of the former Soviet Union (FSU)? What were their methods of preservation? 3. List two well-known prepared foods associated with Germany, Poland, FSU, one Scandinavian country, and one other central European coun- try. Describe three sausages that can be found in Germany or Poland. List four U.S. foods that are thought to be descended from eastern European countries. 4. What is zakuski in a Russian meal? What foods may be included? What is a smorgasbord in Scandinavian countries? What foods might be included? 5. Describe a traditional Christmas or Easter dessert for three countries in central Europe, FSU, and one Scandinavian country. 6. Describe the religion, worldview, and food and health beliefs attributed to Gypsies. References 1. U.S. Census Bureau. n.d. P eopl e r epor ting anc estr y . 2010 American Community Survey. Retrieved from http://factfinder.census.gov/faces/tableservices/ jsf/pages/productview.xhtml?pid5ACS_10_1YR_ B04006&prodType5table (accessed February 15, 2015). 2. Heimlich, E. 2000. Gypsy Americans. In R.V. Das- sanowsky & J. Lehman (Eds.), G al e enc y c l opedia of mul tic ul tur al A mer ic a. Farmington Hills, MI: Gale Group. 3. Granquist, M.A. 2000. Lithuanian Americans. In R.V. Dassanowsky & J. Lehman (Eds.), G al e enc y - c l opedia of mul tic ul tur al A mer ic a. Farmington Hills, MI: Gale Group 4. Rippley, L.V.J. 2000. German Americans. In R.V. Dassanowsky & J. Lehman (Eds.), G al e enc y - c l opedia of mul tic ul tur al A mer ic a. Farmington Hills, MI: Gale Group. Selected 5. U.S. Census Bureau. n.d. P opul ation pr of il e in th e U nited S tates. 2011 American Community Survey. Retrieved from http://factfinder.census .gov/faces/tableservices/jsf/pages/productview .xhtml?src5CF (accessed February 15, 2015). 6. Jones, S. 2000. Austrian Americans. In R.V. Das- sanowsky & J. Lehman (Eds.), G al e enc y c l opedia of mul tic ul tur al A mer ic a. Farmington Hills, MI: Gale Group. 7. Vardy, S.B., & Szendry, T. 2000. Hungarian Amer- icans. In R.V. Dassanowsky & J. Lehman (Eds.), G al e enc y c l opedia of mul tic ul tur al A mer ic a. Farm- ington Hills, MI: Gale Group. 8. Jones, S. 2000. Polish Americans. In R.V. Das- sanowsky & J. Lehman (Eds.), G al e enc y c l opedia of mul tic ul tur al A mer ic a. Farmington Hills, MI: Gale Group. 9. Alexander, J.G. 2000. Slovak Americans. In R.V. Dassanowsky & J. Lehman (Eds.), G al e enc y - c l opedia of mul tic ul tur al A mer ic a. Farmington Hills, MI: Gale Group. 10. Schelbert, L. 2000. Swiss Americans. In R.V. Das- sanowsky & J. Lehman (Eds.), G al e enc y c l opedia of mul tic ul tur al A mer ic a. Farmington Hills, MI: Gale Group. 11. Magocsi, P.R. 2000. Russian Americans. In R.V. Dassanowsky & J. Lehman (Eds.), G al e enc y c l o- pedia of mul tic ul tur al A mer ic a. F ar mington H il l s, M I : G al e G r oup. 12. Kraybill, D.B. 2000. Amish. In R.V. Dassanowsky & J. Lehman (Eds.), G al e enc y c l opedia of mul ti- c ul tur al A mer ic a. Farmington Hills, MI: Gale Group. 13. Takooshian, H. 2000. Armenian Americans. In R.V. Dassanowsky & J. Lehman (Eds.), G al e enc y - c l opedia of mul tic ul tur al A mer ic a. Farmington Hills, MI: Gale Group. 14. Spector, R.E. 2004. C ul tur al div er sity in h eal th and il l ness (6th ed.). Upper Saddle River, NJ: Pearson Education. 15. Hirschfelder, G., & Schonberger, G.U. 2005. Germany: Sauerkraut, beer and so much more. In D. Goldstein & K. Merkle (Eds.), C ul inar y c ul tur es of E ur ope. Strasbourg, France: Council of Europe Publishing. 16. Offner, J. 1998. Pow-wowing: The Pennsylvania Dutch way to heal. J our nal of H ol istic M edic ine, 1 6 , 479–486. 17. Yehieli, M., & Grey, M.A. 2005. H eal th matter s: A poc k et guide f or w or k ing w ith div er se c ul tur es and under standing popul ations. Yarmouth, ME: Intercultural Press. 18. Yoder, D. 1976. Hohman and Romanus: Origins and diffusion of Pennsylvania German powwow manual. In W.D. Hand (Ed.), A mer ic an f ol k medic ine. Berkeley: University of California Press. 19. Sutherland, A. 1992. Gypsies and health care. W ester n J our nal of M edic ine, 1 5 7 , 276–280.1 5 7 , 276–280.1 5 7 20. Lipson, J.G., Weinstein, H.M., Gladstone, E.A., & Sarnoff, R.H. 2003. Bosnian and Soviet refugees’ experiences with health care. W ester n J our nal of N ur sing R esear c h , 2 5 , 854–871 21. Smith, L. 1996. New Russian immigrants: Health problems, practices, and values. J our nal of th e A mer ic an Dietetic A ssoc iation, 3 , 68–73. 22. B a l z e r, M . M . 1 9 8 7 . B eh i nd shaman is m : Changing voices of Siberian Khanty cosmol- ogy and politics. S oc ial S c ienc e and M edic ine, 2 4 , 1085–1093. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 2 0 6 C E N T R A L E U R O P E A N S , P E O P L E O F T H E F O R M E R S O V I E T U N I O N , A N D S C A N D I N A V I A N S 23. Grabbe, L. 2000. Understanding patients from the former Soviet Union. F amil y M edic ine, 3 2 , 201–206. 24. Brod, M., & Heurtin-Roberts, S. 1992. Older Russian émigrés and medical care. W ester n J our - nal of M edic ine, 1 5 7 , 333–336. 1 5 7 , 333–336. 1 5 7 25. Brod, M., & Heurtin-Roberts, S. 1992. Older Russian émigrés and medical care. W ester n J our - nal of M edic ine, 1 5 7 , 333–336.1 5 7 , 333–336.1 5 7 26. Zibart, E. 2001. T h e eth nic f ood l ov er ’ s c ompanion: U nder standing th e c uisines of th e w or l d. 27. Krzysztofel, K. 2005. Poland: Cuisine, culture and a variety on the Wisla River. In D. Goldstein & K. Merkle (Eds.), C ul inar y c ul tur es of E ur ope. Strasb ourg, France: C ouncil of Europ e Publishing. 28. Hazelton, N.S. 1969. T h e c ook ing of G er many . New York: Time-Life Books. 29. Hirschfelder, G., & Schonberger, G.U. 2005. Germany: Sauerkraut, beer and so much more. In D. Goldstein & K. Merkle (Eds.), C ul inar y c ul tur es of E ur ope. Strasbourg, France: Council of Europe Publishing. 30. Grigorieva, G. 2005. Russian Federation: Redis- covering classics, enjoying diversity. In D. Gold- stein & K. Merkle (Eds.), C ul inar y c ul tur es of E ur ope. Strasbourg, France: Council of Europe Publishing. 31. Papashvily, H., & Papashvily, G. 1969. R ussian c ook ing. New York: Time-Life. 32. Foster, D. 2000. T h e gl obal etiq uette guide to E ur ope. New York: Wiley. 33. Hostetler, J.A. 1976. Folk medicine and sympathy healing among the Amish. In W.D. Hand (Ed.), A mer ic an f ol k medic ine. Berkeley: University of California Press. 34. From, M.A. 2003. People of Polish heritage. In L.D. Purnell & B.J. Paulanka (Eds.), T r ansc ul tur al h eal th c ar e (2nd ed.). Philadelphia: FA Davis. 35. Hancock, I. 1991. Romani foodways: Gypsy culi- nary culture. Th e W or l d and I , 666–677.Th e W or l d and I , 666–677.Th e W or l d and I 36. Romero-Gwynn, E., Nicholson,Y., Gwynn, D., Kors, N., Agron, P., Flemming, J., . . . Screeniva- san, L. 1997. Dietary practices of refugees from the former Soviet Union. N utr ition T oday , 3 2 , 153–156. 37. Slimani, N., Fahey, M., Welch, A.A., Wirfalt, E., Stripp, C., Bergstrom, E., . . . Riboli, E. 2002. Diversity of dietary patterns observed in the European Prospective Investigation into Can- cer and Nutrition (EPIC) project. P ubl ic H eal th N utr ition, 5 , 1311–1328. 38. Linseisen, J., Bergstrom, E., Gafa, L., Gonzalez, C.A., Thiebaut, A., Trichopoulou, A., . . . Slimani,N. 2002. Consumption of added fats and oils in the European Prospective Investigation into Cancer and Nutrition (EPIC) centres across 10 European countries as assessed by 24-hour recalls. P ubl ic H eal th N utr ition, 5 , 1227–1242. 39. International Obesity Task Force. 2010. O v er - w eigh t and obesity among adul ts in th e E ur opean U nion. Retrieved from http://www.iaso.org/site_ media/uploads/-AdultEU27March2010notonwe- byetupdatev2 (accessed January 20, 2011). 40. Rabotaev, E.F., & Khokhlova,E.A. 2009, January– February. Topical problems of micronutrients deficiency in the Chuvash Republic. G igiena i sanitar ia, no. 1, 36–38. 41. Ackerman, L.K. 1997. Health problems of refu- gees. J our nal of th e A mer ic an B oar d of F amil y P r ac tic e, 1 0 , 337–348. 42. Knapp, R.B., & Houghton, M.D. 1999. Breast- feeding practices of WIC participants from the former USSR. J our nal of th e A mer ic an Dietetic A ssoc iation, 9 9 , 1269–1271. 43. Engs, R.C., Slawinska, J.B., & Hanson, D.J. 1991. The drinking patterns of American and Polish university students: A cross-sectional study. Dr ug and A l c oh ol Dependenc e, 2 7 , 167–175.2 7 , 167–175.2 7 44. Van Son, C.R., & Stasyuk, O. 2014. Older immi- grants from the former Soviet Union and their use of complementary and alternative medicine. G er iatr ic N ur sing, G er iatr ic N ur sing, G er iatr ic N ur sing 3 5 (2 Suppl.), S45–S48. 45. Grogan, L. 2006s. Alcoholism, tobacco, and drug use in the countries of central and eastern Europe and the former Soviet Union. S ubstanc e U se and M isuse, 4 1 , 567–571. 46. Shpilko, I. 2006. Russian-American health care: Bridging the communication gap between physi- cians and patients. P atient E duc ation and C oun- sel ing, sel ing, sel ing 6 4 , 331–341. 47. Webb, C.P., Bromet, E.J., Bluzman, S., Tintle, N.L., Schwartz, J.E., Kostyuchenko,S., & Havenaar, J.M. 2005. Epidemiology of heavy alcohol use in Ukraine: Findings from the world mental health survey. A l c oh ol and A l c oh ol ism, 4 0 , 327–335. 48. Thomas, J.D. 1985. Gypsies and American medical care. A nnal s of I nter nal M edic ine, 1 0 2 , 842–845. 49. Thomas, J.D. 1987. Disease, lifestyle, and consan- guinity in 58 American Gypsies. T h e L anc et, 2 , 377–379. 50. Krajcovicova-Kudlackova, M., Blazicek, P., Spustova, V., & Ginter, E. 2002. Insulin levels in Gipsy minority. B r atisl av sk é l ek á r sk e l isty , 1 0 5 , 256–259. 51. Krajcovicova-Kudlackova, M., Blazicek, P., Spustova, V., Valachovicova, M., & Ginter, E. 2004. Cardiovascular risk factors in young Gypsy populations. B r atil av sk é l ek á r sk e l isty , 1 0 5 , 256–259. 52. Sepkowitz, K.A. 2006. Health of the world’s Roma population. T h e L anc et, 3 6 7 , 1707–1708.3 6 7 , 1707–1708.3 6 7 53. Granquist, M.A. 2000. Swedish Americans. In R.V. Dassanowsky & J. Lehman (Eds.), G al e enc y - c l opedia of mul tic ul tur al A mer ic a. Farmington Hills, MI: Gale Group. 54. Lovoll, O.S. 2000. Norwegian Americans. In R.V. Dassanowsky & J. Lehman (Eds.), G al e enc y - c l opedia of mul tic ul tur al A mer ic a. Farmington Hills, MI: Gale Group. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 7 2 0 7 55. Nielsen, J.M., & Petersen, P.L. 2000. Danish Americans. In R.V. Dassanowsky & J. Lehman (Eds.), G al e enc y c l opedia of mul tic ul tur al A mer - ic a. Farmington Hills, MI: Gale Group. 56. Wargelin, M. 2000. Finnish Americans. In R.V. Dassanowsky & J. Lehman (Eds.), G al e enc y - c l opedia of mul tic ul tur al A mer ic a. Farmington Hills, MI: Gale Group. 57. Johansen, R., & Toverud, E.L. 2006. Norwegian cancer patients and the health food market— What is used and why? T idssk r if t f or den N or sk e L aegef or ening, L aegef or ening, L aegef or ening 1 2 6 , 773–775. 58. Boyhus, E.M. 2005. Denmark: Nation-building and cuisine. In D. Goldstein & K. Merkle (Eds.), C ul inar y c ul tur es of E ur ope. Strasbourg, France: Council of Europe Publishing. 59. Notaker, H. 2005. Norway: Between innovation and tradition. In D. Goldstein & K. Merkle (Eds.), C ul inar y c ul tur es of E ur ope. Strasbourg, France: Council of Europe Publishing. 60. Brown, D. 1968. T h e c ook ing of S c andinav ia. New York: Time-Life. 61. Tellstrom, R. 2005. Sweden: From crispbread to ciabatta. In D. Goldstein & K. Merkle (Eds.), C ul inar y c ul tur es of E ur ope. Strasbourg, France: Council of Europe Publishing. 62. Makela, J. 2005. Finland: Continuity and change. In D. Goldstein & K. Merkle (Eds.), C ul inar y c ul - tur es of E ur ope. Strasbourg, France: Council of Europe Publishing. 63. Meyer, H.E., & Tverdal, A. 2005. Development of body weight in the Norwegian population. P r ostagl andins, L euk otr ienes, and E ssential F atty A c ids, 7 3 , 3–7. 64. Statistics Canada. n.d. 2011 National Household Survey. Statistics Canada Catalogue no. 99-010- X2011028. Retrieved from http://www12.statcan .gc.ca/nhs-enm/2011/dp-pd/dt-td/Rp-eng.cfm? TABID=1&LANG=E&APATH=3&DETAIL=0 &DIM=0&FL=A&FREE=0&GC=0&GK=0&GR P=1&PID=105396&PRID=0&PTYPE=105277& S=0&SHOWALL=0&SUB=0&Temporal=2013& THEME=95&VID=0&VNAMEE=&VNAMEF= (accessed February 17, 2015). 65. Field, M., & Field, F. 1970. A q uintet of c uisines. New York: Time-Life. 66. Wechsberg, J. 1974. T h e c ook ing of V ienna’ s empir e. New York: Time-Life. 67. Beer Institute. n.d. Beer statistics. Retrieved from http://www.beerinstitute.org/br/beer-statistics/ latest-statistics (accessed January 20, 2015). 68. Strumylaite, L., Zickeute, J., Dudzevicius, J., & Dregval, L. 2006. Salt-preserved foods and risk of gastric cancer. M edic ina ( K aunas, L ith uania) , 4 2 , 164–170. 69. Wechsberg, J. 1974. T h e c ook ing of V ienna’ s empir e. New York: Time-Life. 70. Haik Poghosyan, S. 2005. Armenia: Insights into traditional food culture. In D. Goldstein & K. Merkle (Eds.), C ul inar y c ul tur es of E ur ope. Strasbourg, France: Council of Europe Publishing. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 2 0 8 C H A P T E R Africans African Americans are one of the largest cultural groups in the United States, including nearly 45 million people in 2013, more than 12 percent of the total American population.1 The majority are blacks who came originally from West Africa, although some arrived from the Caribbean, Central America, and, more recently, from the famine- and strife-stricken East African nations. A small number of Americans of African heritage are white, primarily immi- grants from the nation of South Africa. Most African Americans are the only U.S. citizens whose ancestors came by force, not choice. Their long history in America has been characterized by persecution and segre- gation. At the same time, blacks have contrib- uted greatly to the development of American culture. The languages, music, arts, and cui- sine of Africa have mingled with European and Native American influences since the beginnings of the nation to create a unique American cultural mix. African Americans live with this difficult dichotomy. They are in many ways a part of the majority culture because of their early arrival, their large population, and their role in the development of the country. Much of their native African heritage has been assimi- lated, and their cultural identity results more from their residence in the United States than from their countries of origin. Yet they are often more alienated than other ethnic groups from white American society. This chapter discusses sub-Saharan African cui- sines (North African fare is more similar to that of the Middle East; see Chapter 13) and their contributions to U.S. foods and food habits. The historical influence of West African, black slaves, and southern cuisines on current African American cuisine is examined. Cultural Perspective Africa is the second largest continent in the world and has a population estimated in 2013 at more than 1 billion people. It straddles the equator, and much of its climate is tropical, yet rainfall varies tremendously (see Figure 8.1). Rain forests, grassland savannas, high moun- tain forests, and temperate zones are found in the far south and along the Mediterranean. In the north, the Sahara, the largest desert in the world, stretches from the Atlantic to the Red Sea, separating the Arabic northern African nations (Morocco, Algeria, Tunisia, Libya, and Egypt) from the sub-Saharan west- ern, eastern, and southern regions. Numerous ethnic groups have evolved in Africa, and it is estimated that between 800 and 1,700 distinct languages are spoken. Cultural identity is strong. The long history of conflict and con- quest on the continent has never completely eliminated tribal affinity; most destabiliza- tion in individual nations today arises over ethnic issues. 8 The terms African American, black, and black American are used interchangeably in research literature. African American is usu- ally the preferred term because it emphasizes cultural heritage. How- ever, black or black American is used by many African Americans who feel these terms more accurately reflect their current identity. Some recent immigrants from Africa resent the use of African American by persons who have lived in the United States for generations. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 8 2 0 9 Figure 8.1 Sub-Saharan Africa. Republic of CongoRepublic of CongoRepublic of CongoRepublic of CongoRepublic of CongoRepublic of Congo Nouakchott Bamako Ouaga-Ouaga-Ouaga-Ouaga-Ouaga-Ouaga-dougoudougoudougoudougoudougoudougoudougou Ouaga-dougou Ouaga- Abidjan Monrovia Freetown Bissau Accra Abuja Bangui N'Djamena Addis Ababa Khartoum Lusaka Lilongwe Cape Town Harare Gaborone Windhoek M ap ut o M ap ut o Yaounde Kisangani Luanda K am pa la K am pa la K am pa la K am pa la K am pa la K am pa la K am pa la Nairobi Djibouti MogadishuMogadishuMogadishu Kigali Bujumbura Dar es Salaam Libreville Bra zza vill e Niamey Porto- Novo ConakryConakryConakryConakryConakryConakry Dakar BanjulBanjulBanjulBanjulBanjulBanjulBanjulBanjulBanjulBanjulBanjulBanjulBanjulBanjulBanjulBanjulBanjulBanjulBanjulBanjul El Aaiún AsmeraAsmeraAsmera MALI BU RK IN A BU RK IN A FA SOBU RK IN A FA SOBU RK IN A GABON NIGERIA CENTRAL AFRICAN REPUBLIC NIGER CHAD Democratic ANGOLA ZAMBIA BOTSWANA SOUTH AFRICA NAMIBIA ZIMBABWE M O ZA M BI Q U E RWANDARWANDARW BURUNDI SUDAN ETHIOPIA KENYA SOMALIA TANZANIA C A M ER O O N C O N G O MAURITANIA SEN EG AL Dakar SEN EG AL Dakar W E ST E R N SA H A R A LIBERIA SIERRA LEONE G A M B IA TOGO B E N IN GUINEA U G A N D A U G A N D A U G A N D A GUINEA-GUINEA-GUINEA-GUINEA- BISSAU COTE D'IVOIRE G H A N A DJIBOUTI ERITREA LESOTHO SWAZILAND MALAWMALAWMAL I Atlantic Ocean Atlantic Ocean Mediterranean Sea Indian Ocean © C en ga ge L ea rn in g Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 2 1 0 A F R I C A N S History of Africans in the United States The arrival of black indentured servants taken forcefully from West Africa preceded the arrival of the M ay f l ow er in America. In 1619, M ay f l ow er in America. In 1619, M ay f l ow er Dutch traders sold twenty West Africans to colonists in Jamestown, an early English set- tlement. More than 425,000 slaves were sub- sequently imported legally, ancestors of the majority of black Americans residing in the United States today. Enslavement The institution of slavery was well established before the first blacks were brought to North America. European slave traders negotiated with African slave suppliers for their human cargo; which West Africans became slaves and which sold slaves depended on inter- tribal conditions. The European traders kept some records of tribal affiliation, but none of place of origin. It is believed that more than one-half of the slaves in the United States came from the coastal areas of what are now Angola and Nigeria. Others came from the regions that are today Senegal, Gambia, Sierra Leone, Liberia, Togo, Ghana, Benin, Gabon, and the Democratic Republic of Congo (formerly Zaire). These political identities are relatively recent, however, and the slaves identified with their tribal groups, such as Ashanti, Bambara, Fulani, Ibo, Malinke, or Yoruba, rather than with a specific country or Africa as a whole. The tribal villages of West Africa were pre- dominantly horticultural. Individuals viewed their existence in relation to the physical and social needs of the group. The extended family and religion were the foundations of tribal culture. It was especially difficult for individuals to be separated from their tribe because identity was so closely associated with the group. It is perhaps for this reason that enslaved individuals held on tenaciously to their African traditions. African language, ornamentation (e.g., scarification and teeth filing), and other customs were very threat- ening to slave owners. New slaves, usually in small groups from eight to thirty, were often housed at the perimeter of plantations until they became acclimated. They learned English in two or three years through contact with Native Americans or white indentured ser- vants. When they became sufficiently accul- turated, they would be allowed to work in positions closer to the main plantation house. This initial period of separation allowed slaves to maintain many cultural values despite exposure to slaves from other tribal groups, indentured servants of different eth- nic groups, and the majority culture of the white owners. At the same time, frontier farm- ing was sufficiently difficult that slave own- ers were quite willing to learn from the slaves’ agricultural expertise; therefore, intercultural communication was inevitable. Instead of becoming totally acculturated to the ways of the owners, slaves developed a black Creole, native-born culture during the early slave period, combining both white and West African influences. After the end of slave importation in 1807, the black Creole population swelled. By law, slavery was a lifelong condition, and the children of female slaves were slaves as well. Although most slaves worked on farms and on cotton, tobacco, sugar, rice, and hemp planta- tions, many others worked in mines and on the railroads. A large number of slaves were found in the cities doing manual labor and service jobs. It was during this period of rapid growth in the African American population that separate racial group identities began to form in the United States. Emancipation The movement to free the slaves began with the American Revolution. Many of the north- ern states banned slavery from the beginning of independence. By the 1830s, there were 300,000 free persons of color living in urban areas outside the South. Tension between states that supported slavery (the Confed- eracy) and those that opposed it (the Union) was one factor that led to the Civil War (called the War between the States in the South) in 1861. In 1862, President Abraham Lincoln signed the Emancipation Proclamation. Union vic- tory over the Confederacy in 1865 and the subsequent ratification of the Thirteenth Slaves working in kitchens built outside plantation living quarters (due to fire danger) were asked to whistle as they brought food to the main house to prevent them from sampling along the way. The word Creole has numerous definitions, mostly describing Africans and Europeans who moved to the U.S. South and Latin America during the colonial period. Creole Negro (typically translated “black Creole”) was the term used for Africans who developed their own American culture influenced by the British, Spanish, and French settlers in the region. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 8 2 1 1 Amendment gave all blacks living in the United States their freedom. Some left the South immediately, searching for relatives and a better life. However, most remained in the South because they lacked the skills needed to begin an independent life; for instance, fewer than 2 percent of former slaves were liter- ate. After emancipation, former slave owners continued to exploit African American labor through tenant farming and sharecropping. Under this system, black farmers were perpet- ually in debt to white landowners. Slowly, as competition for skilled farm labor increased, working conditions for black Americans in the South improved. Literacy rates and politi- cal representation increased. At the same time, racial persecution by white suprema- cists, such as members of the Ku Klux Klan, became more frequent. At the turn of the twentieth century, depressed conditions in the South and industrial job opportunities in the northern states prompted more than 750,000 African Americans to settle in the Northeast and Mid- west. Most were young men, and the major- ity moved to large metropolitan areas, such as New York, Boston, Detroit, Chicago, and Philadelphia. The influx of southern blacks was resented by both whites and the small numbers of middle-class blacks who had been well accepted in the northern cities. Laws that established racial segregation were enacted for the first time in the early 1900s, resulting in inner-city African American ghettos. Because of poor economic conditions throughout the country, there was a pause in African American migration north during the Great Depression. The flow increased in the 1940s, and in the following thirty years more than 4 million African Americans left the South to settle in other regions of the country. This migration resulted in more than a change in regional demographics. It meant a change from a slow-paced rural life- style to a fast-paced, high-pressured, urban industrial existence. In the 1960s, the movement against the injustices of “separate but equal” laws (which permitted segregation as long as comparable facilities, such as schools, were provided for African Americans) gained momentum under the leadership of blacks such as Martin Luther King Jr. Violent riots in city ghettos under- scored the need for social reform. Civil rights activism resulted in the repeal of many overtly racist practices and passage of compensatory laws and regulations meant to reverse past discrimination, as typified by federal affirma- tive action requirements. Current Demographics Today, slightly more than one-half of African Americans live in the U.S. South (55 per- cent), most in suburban areas. Since 1988, more blacks have been moving to the South than to the northern states, reversing the demographic trend northward established in 1900. The remaining African American population is found predominantly in north- eastern and midwestern urban areas.2 The most recent Census data indicate that most African Americans live in geographic areas that are predominantly African American or Hispanic.3 As of 2010, approximately 1.6 million immigrants to the United States were of African descent. About 29 percent of African immigrants in the United States are from West Africa, including the countries Nigeria and Ghana. Approximately 17 percent are from East Africa, including the countries Kenya, Ethiopia, and Somalia.4 In addition, small populations from Eritrea (27,000) and Sudan (83,000) have arrived in recent years, many of whom are refugees seeking escape from ethnic and civil conflicts in the region.4 Less than 1 percent of the black population is of Caribbean or Central American descent. Socioeconomic Status African Americans continue to suffer from the discriminatory practices that began with their enslavement, yet it is estimated that 70 percent are making steady economic progress. The black middle class is growing, and the economic gap between blacks and whites is narrowing as blacks increasingly enter fields such as business, health care, and law. Nevertheless, according to 2013 Census data, the poverty rate for African Americans was close to twice the rate for non-Hispanic white families nationally.5,6 According to 2013 Census data, high school graduation Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 2 1 2 A F R I C A N S rates were close to 84 percent but below the national average of 86 percent.5 The African American unemployment rate is more than double that of whites, and median income is substantially lower. In 2013, nearly one in every four black households (27.2 percent) lived below the poverty line, which is double the national average of 14.5 percent.6 Many African Americans believe they are not completely accepted in U.S. society. Blacks isolated in urban ghettos frequently experience alienation. Frustration, hopelessness, and hos- tility often result. At the same time, discrimi- nation has promoted ethnic identity among African Americans, due in part to a shared history of persecution. Although Americans of African descent are geographically, politi- cally, and socioeconomically diverse, there is a strong feeling of ethnic unity. Socioeconomic status for recent immi- grants from Africa varies greatly. Nigerians often come to the United States for educa- tional opportunities, and 61 percent have advanced college degrees.4 Over 41 percent of foreign-born Africans have obtained college degrees. Worldview Religion Spirituality was integral to African tribal soci- ety, and indigenous religious affiliations were maintained by most slaves, despite attempts to convert blacks to Christianity. Although the first black church, a Baptist congregation, was founded in the 1770s in South Carolina, it was only after U.S. religious groups became involved in the antislavery movement that the black Creole community responded with large numbers of conversions. Religion is as essential to African Ameri- can culture today as it was to African society. For many black Americans, the church rep- resents a sanctuary from the trials of daily life. It is a place to meet with other African Americans, to share fellowship and hope. More than 75 percent of African Americans belong to a church. The largest denomina- tion is the National Baptist Convention of the U.S.A. Others with large African American followings include the Methodist Episcopal churches and Pentecostal denominations, such as the Church of God in Christ. A small percentage of African Americans who are Muslim are members of either the World Community of All Islam or the Nation of Islam (see Chapter 4 for more information about this religion). Recent immigrants from Africa adhere to a variety of faiths. Those who immigrated from northern Africa or the northeast coast are more likely to be Muslim while those from sub-Saharan are more Christian, primarily Protestant.7 Many Ethiopians and Eritreans follow an Eastern Orthodox faith that is simi- lar to, but separate from, the Egyptian Coptic Church. In addition, it is believed that nearly one-half of the African population partici- pates in traditional tribal religions or combine elements of several faiths. Family The importance of the extended family to African Americans has been maintained since tribal times. It was kinship that defined the form of African societies. During the early slave period, the proportion of men to women was two to one, and the family structure included many unrelated members. As the black Creole population increased, nuclear families were established but were often disrupted by the sale or loan of a parent. The extended family provided for dislocated parents and children. In 2012, 50 percent of African American families were headed by single women (com- pared to 19 percent of white families).8 The family network often includes grandparents, aunts, uncles, sisters, brothers, deacons or preachers, and friends. Such extended kin- ship still supports and protects individuals, especially children, from the problems of a discriminatory society. The extended family has been found to be equally valued by both wealthy and poor African Americans. Traditional Health Beliefs and Practices Africans view life as energy rather than mat- ter. A person lives transitionally on earth, interacting with all environmental forces, from those of the gods and nature to those Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 8 2 1 3 exerted by the living and dead. Life events can be influenced by these forces, and a person can, in turn, influence these forces toward good or evil. Health is maintained through harmony. Disharmony and illness occur when some- one (living or dead), the gods, or nature is intentionally malevolent. As described by one African expert: Even if it is explained to a patient that he has malaria because a mosquito carry- ing malaria parasites has stung him, he will still want to know why that mosquito stung him and not another person. The only answer which people find satisfac- tory to that question is that someone has “caused” (or “sent”) the mosquito to sting a particular individual, by means of magical manipulations (p. 169).10 One example of how a person may become ill is the evil eye, whereby one person causes illness and misfortune by sending negative energy through an evil gaze.9 A traditional African healer must first diagnose the illness, determine the supernatural cause of the ill- ness, then dislodge the evil and take measures to prevent reoccurrence. The healer often uses herbs and other natural prescriptions to treat the symptoms and may depend on the spirits of the ancestors to transmit medical knowl- edge. Bleeding, massage, dietary restrictions, chants, and charms may complete the cure. The health beliefs and practices of some African Americans reflect traditional African concepts as well as those encountered through early contact with both Native Americans and whites. It is often difficult to determine the origins of a specific practice, and it is also likely that both blacks and whites adhere to similar beliefs. Some Americans of African heritage maintain health by eating three meals each day, including a hot breakfast. Laxatives may be used regularly, and cod liver oil may be taken to prevent colds. Vicks® VapoRub® may also be ingested for colds. A copper or silver bracelet is sometimes worn for protection; if it is removed, harm will occur. If the skin dark- ens around the bracelet, illness is impending and precautions, such as more rest and a better diet, should be undertaken.11,12,13 One study of black men found that they defined health as more than simply lack of ill- ness. The ability to support their family, ful- fill social obligations, and maintain emotional and spiritual well-being was also important. Self-empowerment was one method used to combat the difficulties of racism and poverty thought to undermine good health.14 Prayer for health is common, practiced by a sig- nificant amount of this population.15 Some African Americans believe that illness is a punishment from God, and many feel that God acts through physicians to heal patients.10 Stress is frequently cited as the cause for poor health. It is considered by some blacks to be the source of hypertension; likewise, “worria- tion” results in diabetes.14,16,21,23 Others, espe- cially in the rural South, believe that illness is due to evil spirits or witchcraft. A person may be “hexed,” “fixed,” “mojoed,” or “rooted” by someone with supernatural skills. Healers and conjurers are needed to “fix” or “trick” the evil. The resulting illness can be cured by herbal treatments, incantations, or magi- cal transference. For example, a toad is placed on the head of someone with a headache, and when the toad later dies, the headache will disappear.11,16 Best known of traditional healers are the practitioners of voodoo, also called hoo-doo. This combination of African and Catholic beliefs is thought to have originated in the Caribbean (see Chapter 10); where it is still practiced in the South, it was also likely influ- enced by European witchcraft.17 The men and women practitioners can use voodoo magic for good or evil. They cure unnatural illnesses (those of supernatural cause) through casting spells, the use of magic powders and gris-gris, bags worn around the neck with powders, animal bones or teeth, stones, and/or herbs. Other healers include traditional herbalists or root doctors, and spiritual, sympathy, or faith healers who derive their powers from God. A patient may choose to use one or all such healers to treat an illness, and the specialty of one may overlap into another.18 A root doctor, for example, may apply home remedies or may use charms like a conjurer to remove (or even send) evil. In most cases, healers of all kinds use a holistic approach and spend a great deal Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 2 1 4 A F R I C A N S changed significantly due to the introduction of New World foods such as cassava (M anih ot esc ul enta, a tuber that is also called manioc), corn, chiles, peanuts, pumpkins, and tomatoes during the fifteenth and sixteenth centuries. The slaves brought a diet based on these new foods and native West African foods, such as watermelon, black-eyed peas, okra, sesame, and taro. Adaptations and substitutions were made based on available foods. Black cooks added their West African preparation meth- ods to British, French, Spanish, and Native American techniques to produce American southern cuisine, emphasizing fried, boiled, and roasted dishes using pork, pork fat, corn, sweet potatoes, and local green leafy veg- etables. The cuisines of other African regions have had little impact at this point on the typical U.S. diet, although recent immigrants may continue to prepare and consume tradi- tional fare. African Fare West African Knowledge of West African food habits before the nineteenth century is incomplete. It is mostly based on the records of North African, European, and U.S. trad- ers, many of whom considered the local cui- sine unhealthy. Most West Africans during the slave era lived in preliterate, horticultur- ally based tribal groups. There was a heavy dependence on locally grown foods, although some items, such as salt and fish (usually salt cured), could be traded at the daily markets held throughout each region. Historically, staple foods varied in each locality. Corn, millet, and rice were used in the coastal areas and Sierra Leone. Yams were popular in Nigeria. Cassava (often roasted and ground into a flour known as gari) and plantains formed the dietary foundation of the more southern regions, including the Congo and Angola. The arid savanna region of West Africa bordering the Sahara Desert was too dry for cultivation, so most tribes were pasto- ral, herding camels, sheep, goats, and cattle. In the north, these animals were eaten; in other regions, local fish and game were consumed. Insects such as termites and locusts were con- sumed in many regions of Africa and are still considered a treat in some areas. Chickens of time on a patient, providing a feeling of spiritual as well as physical well-being. Few African Americans today believe in African witchcraft or employ root doctors. However, the influence of traditional heal- ing practices is still found in the idea that ill health is due to bad luck or fate, in the fre- quent use of home remedies, and in a prefer- ence for natural therapies by some blacks,9,19,20 as in the popularity of garlic pills found in one study.14 Traditional Food Habits What are traditional African American foods: foods of Africans in the seventeenth and eigh- teenth centuries, foods of the slaves, or foods of the black South since emancipation? Afri- can American cuisine today often includes elements from each of these diets. Ingredients and Common Foods Historical Influences African American foods offer a unique glimpse into the development of a cuisine. Even before West Africans were brought to the United States, their food habits had ▲ Traditional African American foods. Some typical foods of the southern black diet include bacon, black- eyed peas, chayote squash, corn, greens, ham hocks, hot sauce, okra, peanuts, watermelon, and sweet potatoes. W ar re n Pr ic e Ph ot og ra ph y/ Sh ut te rs to ck .c om Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 8 2 1 5 were also raised, though in many tribes the eggs were frequently traded, not eaten, and the chicken itself was served mostly as a spe- cial dish for guests. Chicken remains a presti- gious meat in many regions today. There were many similarities in cuisine throughout West Africa. Most foods were boiled or fried, and then small chunks were dipped in a sauce and eaten by hand. Starchy vegetables including yams, plantains, cas- sava, sweet potatoes, and potatoes were often boiled, then pounded into a paste (called fufu). Each diner formed the dough into bite- size scoops that were used like spoons to eat stew. Palm oil was the predominant fat used in cooking, giving many dishes a red hue. Peanut oil, shea oil (from the nuts of the Afri- can shea tree), and occasionally coconut oil were used in some regions. The addition of tomatoes, hot chile peppers, and onions as seasoning was so common that these items were simply referred to as “the ingredients.” Most dishes were preferred spicy, thick, and sticky (mucilaginous). Legumes were popular throughout West Africa. Peanuts were especially valued and were eaten raw, boiled, roasted, or ground into meal, flour, or paste. Cow peas ( V igna ungul c ul ata, neither a standard pea nor a bean—black-eyed peas are one type of cow pea) were eaten as a substitute for meat, often combined with a staple starch such as corn, yams, or rice. Bambara groundnuts, similar to peanuts, were also common. Nuts and seeds were frequently used to flavor and thicken sauces. Mango seeds (called agobono, og bono, or apon), cashews, egusi (watermelon seeds, usually dried and ground), kola nuts, and sesame seeds were popular. Many varieties of tropical and subtropical fruits and vegetables were available to West Africans, but only a few were widely eaten. Ackee apples, baobab (both the pulp and seeds from the fruit of the baobab tree), guava, lemon, papaya (also called pawpaw), pineap- ple, and watermelon were the most common fruits. Many dishes included coconut milk. In addition to starchy staple roots and the flavor- ing ingredients of onions, chile peppers, and tomatoes, the most popular vegetables were eggplant, okra, pumpkin, and the leaves from plants such as cassava, sweet potato, and taro (also called callaloo or cocoyam). West African cuisine today remains very similar to that of the past. Fish is favored, and little meat is consumed. A mostly vegetarian fare has developed based on regional staples such as beans, yams, and cassava. Gari foto is a popular Nigerian specialty often eaten for breakfast; it combines gari (cassava meal) with scrambled eggs, onions, chiles, and tomatoes and is sometimes served with beans. Stews featuring root vegetables, okra, or peanuts and flavored with small amounts of fish, chicken, or beef are common. Curries are popular in Nigeria, often served with dozens of condi- ments and garnishes, such as coconut, raisins, chopped dates, peanuts, dried shrimp, and diced fruits. Pili-pili, a sauce of chile peppers, tomatoes, onion, garlic, and horseradish, is usually offered at the table so that each diner may spice dishes to taste. Deep-fried fish, fried plantain chips, and balls made from steamed rice, black-eyed peas, yams, or peanuts are snack foods avail- able at street stalls in urban areas. The favorite West African sweet is kanya, a peanut candy. Chin-chins, sweet fried pastries topped with sugar and flavoring such as cinnamon or orange zest, are also popular. Bananas are commonly baked and flavored with sugar, honey, or coconut for dessert. Sweetened dough balls prepared from millet or wheat flour are a specialty in many areas; in Ghana they are called togbei (“sheep balls”) and are brightly colored with food dye before being deep fried. They are served for special occa- sions such as birthdays and weddings. Ethiopian, Eritrean, Somali, and Sudanese Mountainous plains and lowland valleys cover much of Ethiopia, Eritrea, and Somalia, and the climate is mostly arid. Though Ethiopia is landlocked, Eritrea and Somalia have lengthy coastal access along the horn of Africa. Mil- let (including a variety unique to the region called teff ), sorghum, and plantains are the staple foods produced, and coffee is the lead- ing export crop. Other foods common to the region include barley, wheat, corn, cab- bage, collards, onions, kale, and potatoes, as well as peanuts and other legumes. Enset, a Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 2 1 6 A F R I C A N S on religious dietary practices). More signifi- cant has been the Ethiopian Eastern Orthodox religion, which has facilitated the develop- ment of vegetarian fare due to the restricted intake of animal proteins. Examples include yataklete kilkil, a garlic- and ginger-flavored casserole, and yemiser selatta, a lentil salad. A mixture of ground legumes called mitin shiro is added to most vegetarian stews. Wat, meaning stew, is the national dish of Ethio- pia. Typically thick and spicy, wat may include legumes, meats, poultry, or fish. Milder ver- sions are known as alechas, and most stews can be prepared either way.21 Doro wat is one popular example, featuring chicken and whole hard-boiled eggs. Yemiser wat is made with red lentils, sega wat with beef, and yebeg wat with lamb. Wat is served with rice or the tradi- tional Ethiopian flat bread called injera. Injera is prepared with a spongy, fermented dough made from teff cooked in a very large circular loaf on a griddle. (Sometimes wat is prepared with added pieces of injera in the stew, known as fitfit.) Another variation of this flat bread, known as kocho, is made with enset. Ethiopian foods are frequently flavored with a hot spice mixture known as berbere, which includes allspice, cardamom, cayenne, cinnamon, cloves, coriander, cumin, fenu- greek, ginger, nutmeg, and black pepper. Niter kebbeh, clarified butter with onions, garlic, ginger, and other spices, is added to many dishes, including kitfo, a raw ground beef spe- cialty. Salted and sweet cheeses are common. Honey (sometimes consumed with the bee grubs) is especially popular as a sweetener and is used in savory dishes such as alechas, and desserts such as baklava, a drier version of the Greek pastry.22 It is also fermented to make tej, a meadlike beverage. Tella, home-brewed millet or corn beer, is commonly consumed, as is coffee, especially espresso (introduced by the Italians). Eritrean and Somali food is very similar to Ethiopian, with the exception of more fre- quent use of seafood. For example, a typical meal includes a spicy stew, often with beef, lamb, kid, or fish, eaten with injera-like breads, known in Somalia as anjeero. The Eritreans often consume their bread with shuro, a thick paste made from chickpeas, onions, tomatoes, plantain-like plant, is a staple in the high mountainous regions of Ethiopia. Some chicken, fish, mutton, goat, and beef are available. Historically, Ethiopian cuisine had minimal outside influences, though a large number of Muslims now living in the nation have intro- duced certain halal dietary practices in some regions (see Chapter 4 for more information ▲ Market scene in Ghana, West Africa. iS to ck ph ot o. co m /s an je ri S A M P L E M E N U A West African Meal Spicy Fried Plantainsa,b Groundnut Chop/Stew over Ricea,b Ginger Beera,b or Green Tea with Mint Tropical Fruit Salada,b aJackson, E.A. 1999. South of the Sahara: Traditional cooking from the lands of West Africa. Hollis, NH: Fantail. bThe Congo Cookbook at http://www.congocookbook.comThe Congo Cookbook at http://www.congocookbook.comThe Congo Cookbook Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 8 2 1 7 doughy cornmeal porridge. Ugali is also found in Tanzania. Mashed beans, lentils, corn, plantains, and potatoes are also popu- lar. Coconut milk, chili peppers, and curry spice blends flavor many dishes. In Uganda, which is inland and less influenced by foreign cuisines, peanuts are a staple food used in everything from stews—such as beef, tomato, and onion stew with peanut butter sauce— to desserts. Plantains are the core food of Tanzania. They are used in soups (with or without beef ), stews, fritters, custards, and even wine. Coconut milk is a frequent fla- voring, as is curry powder. Throughout the region, dishes made with taro greens or other leafy vegetables and side dishes of local grains and produce, such as eggplant and papaya, round out the cuisine. South African South Africa has a very tem- perate climate favorable to many fruits and vegetables uncommon in the rest of the con- tinent, such as cucumbers, carrots, apricots, tangerines, grapefruit, quinces, and grapes. The cuisine has been strongly influenced by the European settlers of the region, including and a touch of berbere, similar to Ethiopian mitin shiro. In addition, though many Eritre- ans belong to the Coptic Eastern Orthodox faith and adhere to the proscriptions on meat, nearly all Somalis are Muslim and follow halal dietary practices. Camel milk is consumed in some areas, and in Somalia, sweetened tea is consumed frequently. In Eritrea, coffee is pre- ferred, and a bitter, fermented barley bever- age called sowa is served at most meals. On special occasions a wine similar to tej, called mez, is popular. Former Italian occupation of the region introduced numerous dishes. Favorites include spaghetti, lasagna, pasta, seafood, and frittata, a scrambled egg dish made with green pep- pers and onions.21 In some parts of Ethiopia and Eritrea and throughout Somalia, Asian Indian–influenced items, such as curried dishes, unleavened breads such as roti and chapati, and vegetable- or meat-stuffed fritters known as sambosa are also common.22 The Sudan, which bridges the desert regions of North Africa and the tropical for- ests of West and East Africa, has a cuisine reflecting both Middle Eastern and African influences. For example, fava beans or a salad of cucumber and yogurt might be served at the same meal as an okra stew and kisra, the Sudanese staple bread similar to injera. East African The climate and topography of Kenya, Tanzania, and Uganda are well suited to farming and ranching. Cassava, corn, mil- let, sorghum, peanuts, and plantains combine to form the foundation of the diet. Crops grown for export include coffee, tea, cashews, and cloves. Cattle are raised in the northern plateaus of Kenya; they are considered a gift of the gods (especially among the Maasai tribe), and they indicate wealth. The abundant game animals are also often sacred, although spe- cific taboos vary from region to region. Eating fish and seafood is common along the coast. The cuisines of East Africa are predomi- nantly vegetarian, influenced in part by Arab, Asian Indian, and British fare. Breads are common at every meal, including chapa- tis, kitumbua, a rice fritter, and mandazi, slightly sweetened doughnut-like bread. In Kenya, the national dish is ugali, a very thick, S A M P L E M E N U An Ethiopian Dinner Kitfoa,b,c Doro Wata,b Bamia Alich’ab or V e ge table Alechac Injeraa,c Fruit juice, Tejc , or E th iopian Coffee aHafner, D. 2002. A taste of Africa: Traditional and modern African cooking. Berkeley, CA: Ten Speed Press. bHarris, J.B. 1998. The Africa cookbook: Tastes of a continent. New York: Simon & Schuster. cEthiopian Recipes at http://ethiopianrecipes.net/ Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 2 1 8 A F R I C A N S The Slave Diet When West Africans were forcefully taken from their tribes, they were not immediately separated from their accustomed foods. Con- ditions on the slave ships were appalling, but most slave traders did provide a traditional diet for the tribal members on board. The basic staples of each region, plus dried salt cod (which was familiar to most West Africans), were fed to the slaves in minimal quantities. Chile peppers and the native West African malagueta peppercorns were used for season- ing because they were believed to prevent dys- entery. It wasn’t until the Africans were sold in the United States that significant changes in their cuisine occurred. The diet of the field workers was largely dependent on whatever foods the slave owners provided. Salt pork and corn were the most common items. Sometimes rice (instead of corn), salted fish, and molasses were included. Greens, legumes, milk, and sweet potatoes were occasionally added. The foods provided, as well as their amount, were usually contingent on local availability and agricultural surplus. Hunger was common among the slaves. Some slave owners allowed or required their slaves to maintain garden plots or to plant needed vegetables around the periphery of the cotton or tobacco fields. Okra and cow peas from Africa were favored, as well as American cabbage, collard and mustard greens, sweet potatoes, and turnips. Herbs were collected from the surrounding woodlands, and small animals such as opossums, rabbits, raccoons, squirrels, and an occasional wild pig were trapped for supplementary meat. Children would often catch catfish and other freshwa- ter fish. During the hog-slaughtering season in the fall, variety pork cuts, such as chitterlings (intestines, pronounced c h itl ins), maw (stom- ach lining), tail, and hocks, would some- times be given to slaves. Some slaves were encouraged to raise hogs and chickens. The eggs and the primary pork cuts were usually sold to raise cash for the purchase of luxury foods. Chickens, a prestigious food in West Africa, continued to be reserved for special occasions. the Dutch, British, and French. Muslim slaves imported from Malaysia and India have also had a significant impact on South African fare. Mutton, beef, pork, fish, and seafood are popular. South African meat specialties include sosaties, or skewered, curried mutton; bredie, a mutton stew that may include onions, chiles, tomatoes, potatoes, or pumpkin; frikkadels, braised meat patties; bobotie, a meatloaf fla- vored with curry and topped with a custard mixture when baked; and biltong, meat strips dried and preserved over smoke. Grape- stuffed chicken or suckling pig is sometimes served for special occasions. Spicy fruit or vegetable relishes called chutney (for more information see Chapter 14); atjar, or unripe fruit or vegetables preserved in fish or veg- etable oil with spices like tumeric and dried chiles; and fresh grated fruit or vegetable sal- ads flavored with lemon juice or vinegar and chiles accompany the dishes. Sweets are very common. Dried fruits, fruit leathers called planked fruit, and fruit pre- serves or jams are popular. Many pastries are available, too, such as tarts made with raisins, sweet potatoes, coconut, or custard. Cookies are a favorite. Koeksister are braided crullers that are deep fried and dipped in a cinnamon syrup, and soetkoekies are spice cookies fla- vored with the sweet wine Madeira. ▼ Many traditional south- ern foods, such as fried chicken, corn bread, spicy stews, bean dishes, and simmered greens, reflect West African influences. Bo nn ie K am in /P ho to Ed it Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 8 2 1 9 West African cooking methods were adapted to slave conditions. Boiling and fry- ing remained the most popular ways to pre- pare not only meats but also vegetables and legumes. Bean stews maintained popularity as main dishes. Corn was substituted for most West African regional staple starches and was prepared in many forms, primarily as corn- meal pudding, cornmeal breads known as pone or spoon bread, grits (coarsely ground cornmeal), and hominy (hulled, dried corn kernels with the bran and germ removed). Pork fat (lard) replaced palm oil in cooking and was used to fry or flavor everything from breads to greens. Hot pepper sauces were used instead of fresh chiles for seasoning. No substitutions were available for many of the nuts and seeds used in West African recipes, although peanuts and sesame seeds remained popular. Food for the slave field workers had to be portable. One-dish vegetable stews were com- mon, as were fried cakes, such as hush puppies (perhaps named because they were used to quiet whining dogs), and the cornmeal cakes baked in the fire on the back of a hoe, called hoecakes. Meals prepared at home after a full day of labor were usually simple. The slaves who cooked in the homes of slave owners had a much more ample and varied diet. They popularized fried chicken and fried fish. They introduced sticky vege- table-based stews (thickened with okra or the herb sassafras, which when ground is called filé powder), such as the southern specialty gumbo z’herbes, nearly identical to a recipe from the Congo. Green leafy vegetables (sim- ply called greens) became a separate dish instead of being added to stews, but they were still cooked for hours and flavored with meat. Ingredients familiar to West Africans, such as nuts, beans, and squash, were used for pie fillings. Foods after the Abolition of Slavery The food traditions of African Americans did not change significantly after emancipation, and they differed little from those of white farmers of similar socioeconomic status. One exception was that pork variety cuts and salt pork remained the primary meats for blacks, while whites switched to beef during the post– Civil War period. African American Southern Staples The traditional South African American cui- sine that evolved from West African, slave, and postabolition fare emphasizes texture before flavor; the West African preference for sticky foods continues. Pork, pork prod- ucts, corn, and greens still form the founda- tion of the diet. The cultural food groups list (Table 8.1) includes other common south- ern black foods. (For information about the food habits of blacks from the Caribbean, see Chapter 10; for more information on foods of the South, see Chapter 15) Pork variety cuts of all types are used. Pig’s feet (or knuckles) are eaten roasted or pickled; pig’s ears are slowly cooked in water seasoned with herbs and vinegar and then served with gravy. Bits of pork skin (with meat or fat attached) are fried to make cracklings. Chitterlings also are usually fried, sometimes boiled. Sausages and head cheese (a seasoned loaf of meat from the pig’s head) make use of smaller pork pieces. Barbecued pork is also common. A whole pig (or just the ribs) is slowly roasted over the fire. Each family has its own recipe for spicy sauce, and each has its opinion about whether the pork should be basted in the sauce or the sauce should be ladled over the cooked meat. Other meats, such as poultry, are also popular. Occasionally, the small game that was prevalent during the slave period, such as opossum and raccoon, is eaten. More often the meal includes local fish and shellfish, such as catfish, crab, or crawfish. Frog legs and tur- tle are popular in some areas. Meats, poultry, and fish are often combined in thick stews and soups, such as gumbos (still made sticky with okra or filé powder) that are eaten with rice. They may also be coated with cornmeal and deep-fried in lard, as in southern-fried chicken and catfish. The vegetables most characteristic of South African American cuisine are the many vari- eties of greens. Food was scarce during the Civil War, and most southerners were forced to experiment with indigenous vegetation, in addition to cultivated greens such as chard, Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 2 2 0 A F R I C A N S TA B L E 8 .1 Cultural Food Groups: African American (Southern United States) Group Comments Common Foods Adaptations in the United States Protein Foods Milk/milk products Dairy products are uncommon in diet (incidence of lactose intolerance estimated at 60–95 percent of the population). Milk is widely disliked in some studies; well accepted in others. Few cheese or fermented dairy products are eaten. Milk (consumed mostly in desserts, such as puddings and ice cream), some buttermilk; cheese Blacks in urban areas may drink milk more often than rural blacks. Meat/poultry/fish/ eggs/legumes Pork is most popular, especially variety cuts; fish, small game, poultry also common; veal and lamb are infrequently eaten. Bean dishes are popular. Frying, boiling are most common preparation methods; stewed dishes preferred thick and sticky. Protein intake is high. Meat: beef, pork (including chitterlings, ham hocks, sausages, variety cuts) Poultry: chicken, turkey Fish and shellfish: catfish, crab, crawfish, perch, red snapper, salmon, sardines, shrimp, tuna Small game: frogs, opossum, raccoon, squirrel, turtle Eggs: chicken Legumes: black-eyed peas, kidney beans, peanuts (and peanut butter), pinto beans, red beans Pork remains primary protein source; prepackaged sausages and lunch meats are popular. Small game is rarely consumed. Variety cuts are considered to be “soul food” and eaten regardless of socioeconomic status or region. Frying is still popular, but more often at evening meal; boiling and baking are second most common preparation methods. Cereals/Grains Corn is primary grain product; wheat flour is used in many baked goods. Rice is used in stew-type dishes Biscuits; corn (corn breads, grits, hominy); pasta; rice Store-bought breads often replace biscuits (toasted at breakfast, used for sandwiches at lunch). Fruits/Vegetables Green leafy vegetables are most popular, cooked with ham, salt pork, or bacon, lemon and hot sauce; broth is also eaten. Intake of fresh fruits and vegetables is low. Fruits: apples, bananas, berries, peaches, watermelon Vegetables: beets, broccoli, cabbage, corn, greens (chard, collard, kale, mustard, pokeweed, turnip, etc.), green peas, okra, potatoes, spinach, squash, sweet potatoes, tomatoes, yams Fruits are eaten according to availability and preference; intake remains low. Green leafy vegetables (“greens”) are popular in all regions; other vegetables are eaten according to availability and preference; intake remains low. Additional Foods Seasonings Dishes are frequently seasoned with hot-pepper sauces. Onions and green pepper are common flavoring ingredients. Filé (sassafras powder), garlic, green peppers, hot-pepper sauce, ham hocks, salt pork or bacon (added to vegetables and stews), lemon juice, onions, salt, pepper Nuts/seeds Nuts often used in ways similar to traditional West African dishes, such as nut- or seed-based desserts. Peanuts, pecans, sesame seeds, walnuts Beverages Coffee, fruit drinks, fruit juice, fruit wine, soft drinks, tea Fats/oils Butter, lard, meat drippings, vegetable shortening Sweeteners Honey, molasses, sugar Cookies (and candy) are preferred snacks © C en ga ge L ea rn in g Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 8 2 2 1 The West African tradition of frequent snacking continued through the slave period and after emancipation. Meals were often irregular, perhaps due to the variable hours of agricultural labor. The traditional southern- style meal pattern was adopted as economic conditions for both blacks and whites improved. Breakfast was typically large and leisurely, always including boiled grits and homemade biscuits. In addition, eggs, ham or bacon, and even fried sweet potatoes would be served. Coffee and tea were more common beverages than milk or juice. Lunch, called dinner, was the main meal of the day. It was eaten at midafternoon and featured a boiled entrée, such as legumes or greens with ham, or another stew-type dish. Additional vegetables or a salad may have been served, as well as potatoes and bread or biscuits. Dessert was mandatory and was usu- ally a baked item, not simply fruit. In some homes a full supper of meat, vegetables, and potatoes was served in the evening. Poorer agricultural families often ate only two of these hearty meals a day. Today, few South African Americans, or whites, continue this tradi- tional meal pattern in full. The southern-style collard greens, kale, mustard greens, spin- ach, and turnip greens. Dockweed, dande- lion greens, lamb’s quarter, marsh marigold leaves, milkweed, pigweed, pokeweed, and purslane were added as acceptable vegetables. Traditionally, the greens are cooked in water flavored with salt pork, fatback, bacon, or ham, plus hot chile peppers (or hot-pepper sauce) and lemon. As the water evaporates, the flavors intensify, resulting in a broth called “pot likker.” Both the greens and the liquid are served; hot sauce is offered for those who prefer a spicier dish. Other common vegeta- bles include black-eyed peas, okra, peas, and tomatoes. Onions and green peppers are fre- quently used for flavoring. Corn and corn products are as popular in southern black cuisine today as they were during the slave period. Corn bread and fried hominy are served sliced with butter. Wheat flour biscuits are also served with butter or, in some regions, gravy. Dumplings are some- times added to stews and greens. Squash is eaten as a vegetable (sometimes stuffed) and as a dessert pie sweetened with molasses. Sweet potatoes are also used both ways. Other common desserts include bread pie (bread pudding), crumb cake, chocolate or caramel cake, fruit cobblers, puddings, and shortcake, as well as sesame seed cookies and candies. Meal Composition and Cycle Daily Patterns Historically, two meals a day were typical in West Africa, one late in the morning and one in the evening. Snacking was common; in poorer tribes, snacks would replace the morn- ing meal and only dinner would be served. Food was eaten family style or, more formally, the men were served first, then the boys, then the girls, and last the women. Sometimes men gathered together for a meal without women. Mealtimes often were solemn; people concen- trated on the attributes of the food, and con- versation was minimal. S A M P L E M E N U A Traditional Black Southern Supper Fried Chickena,b with Biscuitsa,b Macaroni and Cheesea,b Collard Greensa,b Sweet Potato Piea,b or Pound Cakea,b Fruit Juice or Iced Tea aTillery, C.Q. 1996. The African American heritage cookbook. New York: Citadel Press. bThe Chitterling Site at http://www.chitterlings.com Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 2 2 2 A F R I C A N S It was a time to eat and share favorite foods with friends and relatives, a time to extend hospitality to neighbors. Many South African Americans still enjoy a large Sunday dinner, usually prepared by the mother of the house, who begins cooking in the early morning. The menu would probably include fried chicken, spareribs, chitterlings, pig’s feet (or ears or tail), black-eyed peas or okra, corn, corn bread, greens, potato salad, rice, and sweet potato pie. Homemade fruit wines, such as strawberry wine, might also be offered. Other holiday meals, especially Christmas, feature menus similar to the Sunday meal, but with added dishes and even greater amounts of food. Turkey with cornbread stuffing and baked ham are often the entrees; other veg- etable dishes, such as corn pudding, sweet peas, and salads, are typical accompaniments. A profusion of baked goods, including yeast rolls, fruit cakes and cobblers, custard or cream pies, and chocolate, caramel, and coco- nut cake, round out the meal. Some blacks eat symbolic foods on New Year’s Eve, such as fish for motivation, greens for money, black-eyed peas for good luck, and rice for prosperity.6 Southern black cuisine is particularly well suited to buffet meals and parties. A pan of gumbo, a pot of beans, or a side of barbecued ribs can be stretched to feed many people on festive occasions. Informal parties to celebrate a birthday, or just the fact that it’s Saturday night, are still common. Traditional southern food is also served at Juneteenth celebrations held in many African American communi- ties to commemorate the emancipation of the slaves. The African American holiday of Kwanzaa has gained popularity in recent years. Created in Southern California in 1966, Kwanzaa rec- ognizes the African diaspora and celebrates the unity of all people of African heritage. It begins on December 26 and runs through New Year’s Day. Each day, a new candle is lit to symbolize one of seven principles: unity, self- determination, collective work and respon- sibility, cooperative economics, purpose, creativity, and faith. The holiday culminates with a feast featuring dishes from throughout breakfast might be served just on weekends or holidays, for example. As in the rest of the country, a light lunch has replaced the large dinner on most days, and supper has become the main meal. Meal traditions vary for recent Afri- can immigrants to the United States today. Throughout West Africa, three meals a day are typical, though in some areas, only two meals are consumed during periods of priva- tion, such as just before the harvest.24 Ethio- pians, Eritreans, and Somalis usually eat one or two meals a day, snacking in between. In Eritrea and Somalia, fool, which is a puree made from chickpeas in Eritrea, and pinto beans in Somalia, is a popular breakfast item. Food is typically offered on a communal plate, and individuals use bread to scoop up what is desired. Meals are often joyous and noisy. Three meals each day are common in East Africa, and in Kenya many people also stop for British-style tea in the afternoon. However, in many areas meals are limited to two daily when food is in short supply. Traditionally, men were served first, followed by women, and then children dined. In South Africa, a Westernized pattern of three meals, with din- ner the largest, is usually followed. Special Occasions Sunday dinner had become a large family meal during the slave period, and it continued to be the main meal of the week after emancipation. ▼ Kwanzaa, the African American holiday celebrated from December 26 through January 1 each year, culmi- nates with a feast featuring dishes from throughout Africa, the Caribbean, the U.S. South, and other regions where Africans now live. M er rit t V in ce nt /P ho to Ed it Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 8 2 2 3 Africa, the Caribbean, the U.S. South, and any other region where Africans were transported. Recent African immigrants may celebrate many religious holidays, especially those associated with the Eastern Orthodox and Islamic faiths. In Nigeria, child-naming cer- emonies are particularly important celebra- tions.10 A grandmother performs the ritual, offering symbolic foods to the infant, includ- ing water (purity), oil (power and health), alcohol (wealth and prosperity), honey (happiness), kola nuts (good fortune), and salt (intelligence and wisdom). Following the tast- ing, the name is whispered to the child, then announced aloud to the attendees. The family and guests then enjoy a meal together. Many Nigerian Americans continue the custom in the United States. Role of Food in African American Society and Etiquette In the American South, food has tradition- ally been a catalyst for social interaction, and southern hospitality is renowned. For some blacks, eating is an intimate or a spiritual expe- rience that is shared with others.6,26,27,29 Food is lovingly prepared for family and friends, and food is considered an important factor in the cohesiveness of African American society. In Africa today, sharing food is still an important social activity, often accompa- nied by loud conversation and gaiety. Food is offered to anyone who is in the home, and in some nations, such as Nigeria, it is com- mon for extended family members to drop by unannounced for a meal.28 In many urban areas, Western styles of dining are practiced. However, in rural regions meals are often served communally and consumed with the hands. Only the right hand may be used for eating, and the left hand should not touch anything on the table. Although it is usually a sign of respect or affection to feed a bite of food directly into another person’s mouth, it is considered exceptionally rude to pass food from one person’s hand to another person’s hand.25 In Uganda diners stay seated until all people have finished eating, and sticking one’s legs out or leaning on an elbow is not acceptable.26 In Eritrea, an invitation to coffee means a visit of over an hour, with a mini- mum of three cups consumed in a ritual that includes the burning of incense.27 Therapeutic Uses of Food Many African Americans maintain health by eating three hearty meals each day, including a hot breakfast. Numerous other beliefs about food and health are noted among small num- bers of African Americans living in the rural South. Some of these dietary concepts were brought to other regions of the country during the great migrations and may be found among black elders. The conditions known as “high blood” and “low blood” are one example. High blood (often confused with high blood pressure and high blood sugar levels) is most prevalent and thought to be caused by excess blood migrating to one part of the body, typi- cally the head. High blood is caused by eating excessive amounts of rich foods, sweet foods, or red-colored foods (beets, carrots, grape juice, red wine, and red meat, especially pork). Low blood, associated with anemia, is believed to be caused by eating too many astringent and acidic foods (vinegar, lemon juice, garlic, and pickled foods) and not enough red meat. Other blood complaints include “thin blood” that cannot nourish the body, causing a per- son to feel chilly; “bad blood,” due to heredi- tary, natural, or supernatural contamination; “unclean blood” when impurities collect over the winter months and the blood carries more heat; and “clots,” when the blood thickens and settles in one area, associated with menstrua- tion or stomach and leg cramps.28,30 Tea made from the yellowroot shrub (X an- th or h iz a simpl ic issima) is thought to cure stomachache and fever and used to treat dia- betes. Some blacks also believe peppermint candies are helpful in diabetes. Sassafras tea or hot lemon-flavored water with honey is con- sidered good for colds, and raw onion helps break a fever. Turpentine sweetened with sugar reputedly cures intestinal worms when consumed orally, while a mixture of figs and honey will eliminate ringworm. Goat’s milk with cabbage juice is used to cure a stomach infection. In some areas, eggs and milk may Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 2 2 4 A F R I C A N S be withheld from sick children to aid in their recovery.13,31,32 Pica, the practice of eating nonnutritive substances such as clay, chalk, and laundry starch, is one of the most perplexing of all food habits practiced by African Americans, whites, and other ethnic groups. Studies have determined that pica is most often prac- ticed by black women during pregnancy and the postpartum period, and that rates are unchanged since the 1970s (information on pica among other ethnic groups or age groups in the United States is limited). It is common in the South, where anywhere from 16 to 57 percent of pregnant African American women admit to pica. But pica is also found in other areas of the country where large populations of African Americans reside. In rural regions the substance ingested is usually clay. In urban areas, laundry starch is often the first choice, though instances of women who ate large amounts of milk of magnesia, coffee grounds, plaster, ice, and paraffin have also been reported. Many causes for pica have been postulated—a nutritional need for min- erals, hunger or nausea, a desire for special treatment, and cultural tradition are the most common hypotheses. One study found pica was more common among women with lim- ited social support. Another theory suggests it may be related to obsessive-compulsive disorder (OCD). Reasons for pica reported by women include flavor, anxiety relief, tex- ture, and the belief that clay prevents birth- marks or that starch makes the skin of the baby lighter and helps the baby slip out during delivery.18,32,33 Recent immigrants from Africa may hold traditional beliefs about maintaining health through a balance of proper diet, exercise, good relations with family and community, emotional well-being, and spirituality.9 Poor diet is identified as a tangible cause of some conditions, and overweight is often valued as a sign of health. Meat consumption may be associated with longevity. Many people in Africa have limited access to biomedical care and make extensive use of botanical home remedies. In Nigeria, for example, unripe plantains and dried soursop (a tropical fruit) are two treatments used for diabetes.35 Contemporary Food Habits in the United States Most researchers have noted that the food habits of African Americans today usually reflect their current socioeconomic status, geographic location, and work schedule more than their African or southern heritage. Even in the South, many traditional foods and meal patterns have changed due to the pressures of a fast-paced society. Nevertheless, the same foods consumed by blacks and by whites are likely to have different meanings within each cultural context, and blacks often report that their food habits are uniquely African American.3 Adaptations of Food Habits Ingredients and Common Foods Food preferences do not vary greatly between blacks and whites in similar socio-economic groups living in the same region of the United States. Comparisons do show that African Americans choose items such as pork (espe- cially chops, bacon, and sausage), poultry, fresh fish and seafood, sugar, and noncar- bonated fruit drinks far more often than the general population. African American households also purchase fewer fruits and vegetables, fewer dairy products, less cereal and baked goods, fewer snack foods (such as potato chips), and less coffee than do any other households, however.36 Fast foods are popular, and one study determined that there are nearly 60 percent more fast-food restau- rants in predominantly black neighborhoods than in mainly white neighborhoods.37 The popularity of soul f ood—a term coined in the 1960s for traditional southern black cuisine—is notable. It is associated with fresh meats and vegetables made from scratch and thoroughly cooked. Items are preferred well spiced.28 Many African Americans have Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 8 2 2 5 adopted this cuisine as a symbol of ethnic solidarity, regardless of region or social class. Today soul food serves as an emblem of iden- tity and a recognition of black history for many African Americans. Meal Composition and Cycle While the common foods that African Ameri- cans eat reflect geographic location and socio- economic status, meal composition and cycle have changed more in response to work hab- its than to other lifestyle considerations. The traditional southern meal pattern of the large breakfast with fried foods, followed by the large dinner with boiled foods and a hearty supper, has given way to the pressures of industrial job schedules. One seminal study showed that southern breakfast habits were maintained for only eighteen months after migration to the North and then were replaced with a meal typically consisting of sausage and biscuits or toast.37 Research indicates that some African Americans no longer identify certain foods or preparation methods, such as okra and yams, and one-pot meals, as African in ori- gin.26 Many of the items known to be tradi- tional fare are not eaten often, including pig’s feet and chitterlings (some of these foods are also associated with the poor, and respon- dents may be reluctant to admit eating such items). The exception was greens, which were identified most often as a traditional African American food.38 African Americans throughout the coun- try now eat lighter breakfasts and consume sandwiches at a noontime lunch. Dinner is served after work, and it has become the big- gest meal of the day. Snacking throughout the day is still typical among most African Ameri- cans. In many households meal schedules are irregular, and family members eat when con- venient. It is not unusual for snacks to replace a full meal. Frying is still one of the most popular methods of preparing food. An increase in consumption of fried dinner items suggests that the customary method of making break- fast foods has been transferred to evening foods (which were traditionally boiled) when time constraints prevent a large morning meal.37 Boiling and baking are second to fry- ing in popularity.43 African Americans use convenience foods and fast foods as income permits. Research is limited on the food habits of more recent African immigrants. It has been noted that among Somalis, cheese, sodas, and sweetened fruit drinks are very popular. Reci- pes are being adapted to available ingredients. For example, wheat flour or pancake mix is now used to make anjeero.42 A study of Suda- nese Americans found that foods typically consumed at breakfast and lunch included fava or lentil beans made with feta cheese, vegetables, and sesame oil; eggs, fried liver, meat and vegetables stews, bread, salad, fresh fruit, yogurt, custard, Jell-O, and highly sweet- ened tea. Frying, stewing, sautéing in sesame oil (which was called “boiling”), fermenting, and grilling were the most common methods of preparation. Baking and steaming were extremely rare.43 Nutritional Status The nutritional status of African Americans is difficult to fully characterize because a limited number of studies have addressed this popu- lation, and conflicting data exist. In general, however, research has shown that African Americans’ nutritional intake is similar to that of the general population and varies more by socioeconomic status than by ethnicity. Nutritional Intake A larger percentage of African Americans have poor diets compared to the total popu- lation, with low intakes of dairy products, vegetables, whole fruit, and total grains.44,45,46 African Americans have also been reported to have diets high in fat—similar to that of the typical U.S. diet—associated with high meat intake, the popularity of frying, and fast food consumption.28,39,40,41,46,48,49,50,51 The percent- age of calories from animal proteins for blacks is often greater than for whites, due in part to a high intake of fatty meats, such as bacon and sausage.52 In a one year-long study, 90 percent of midlife African American women reported they intended to reduce their fat consump- tion, yet 77 percent consumed over 30 percent Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 2 2 6 A F R I C A N S of their daily calories as fat, and 61 percent consumed more than 10 percent of their total calories as saturated fat.31 High intake of cho- lesterol has been found in some studies.53 Approximately 60 to 95 percent of adult Americans of African descent are lactose intolerant. Some studies show that milk is widely disliked and avoided; others indicate milk is consumed as often by blacks as it is by whites. One trial found that lactose diges- tion in African American adolescent girls improved on a dairy-rich diet.54 The neces- sity of consuming dairy products is debatable, and research on older women reported that dietary calcium intake was similar between blacks and whites; however, grain products, such as fortified cereals, were the primary source of the nutrient for the African Ameri- can respondents.55,59 Even as income increases, fresh produce is sometimes ignored in favor of increased expenditure on meat and other protein foods. However, it is noteworthy that many dietary comparisons use food frequency data without defined portion sizes. A study of rural blacks found that when portion size was explained, participants ate on average larger portions of fruits and most vegetables than standard defi- nitions, increasing their daily intake of fruits and vegetables by a significant two-thirds serving.56 Further, national surveys suggest that prevalence of low fruit and vegetable intake among blacks is only slightly higher than among whites and may be more typical of the general American food pattern than of ethnic variation, except among some lower- income groups with limited access to fresh produce.56,60 Nutrient intake deficiencies may be found among some African Americans living at or near poverty levels in the United States, especially among older study subjects. Rural African American elders consumed fewer servings of meats, fruits, and vegetables, and fats, oils, sweets, and snacks than whites in one survey.58 The most frequent insufficien- cies are of calories, iron, and calcium.20,47,55,61 Deficiencies in vitamins D, E, B6 , B12, folate, potassium, copper, selenium, and zinc have also been reported.58,62,63,65 Insufficient intakes are often similar to, or only marginally lower than, those of whites living in the same location, however.55,68 Although significant dietary differences have been reported in some studies, a review of the literature on black elders’ low nutrient intake compared to white elders questioned the significance of reported deficiencies: study samples were small, and actual anthropometric, clinical, and biochemical data confirming differences were sparse.57 In deficiencies typical of the stan- dard American diet, it is noteworthy that use of vitamin and mineral supplements, which sometimes provides sufficiency in whites, is lower in the black population.55,64,65,66 On average, black men live 4.4 years less than white men in the United States, and black women live 4.1 years less than white women. However, the gap in life expectancy is far greater for certain subpopulations. African American men living in high-risk inner-city neighborhoods are likely to die twenty-one years earlier than Asian American women in general.67 Morbidity and mortality rates for black mothers and their infants are also dispro- portionately high. Maternal deaths are over three times higher for African Americans than for whites, and infant deaths are more than two times higher.69,70 Dietary factors, a large number of teenage pregnancies, and inadequate prenatal care may contribute to a higher incidence of low-birth-weight infants (12.4 percent, over double the rate for whites)69,70 African American mothers are also 50 percent more likely than non-Hispanic white mothers to have preterm births, and the rate for sudden infant death syndrome mortal- ity is twice that of non-Hispanic whites.71 Over 58 percent of African American mothers breast-feed their infants, which is a higher rate than white mothers, but only 27.5 percent continue to breast-feed past six months postpartum, which was less than white mothers. African Americans reported concerns about breast milk quality—if their diet wasn’t healthy or if they become sick, the illness would be passed to the infant. In addition, they also indicated that they are reluctant to breast-feed in public.68,72,73 Some blacks differ somewhat from whites in regard to which solid foods they feed their infants Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 8 2 2 7 and how soon after birth these are introduced. One-third of low-income mothers offered non-milk liquids or solids to their infants at seven to ten days, 77 percent did so by sixteen weeks, and 93 percent by sixteen weeks.74 Overweight is a common problem for adult Americans of African descent. African American women have the highest rates for overweight and obesity in the United States— about four out of five women. In 2011, all African Americans were 1.5 times more likely to be obese than non-Hispanic whites.2 Adolescents and children are also at risk, espe- cially girls, who are 80 percent more likely to be obese compared to non-Hispanic white girls.2 Fat patterning has also been shown to differ between African Americans and whites. African Americans may have more upper- body and deep-fat depositions than whites.76 Excess weight gain may be attributed to many factors, including difference in body- size ideal, preference in body shape by mem- bers of the opposite gender,77,78,79 and a more permissive attitude regarding obesity.80,81 Though some research suggests income and education levels are inversely associated with the risk for obesity, especially among chil- dren,75,81,82 one large study of adolescents found that the prevalence of overweight remained elevated or even increased with socioeconomic status among African Ameri- can girls.83 An environment that promotes high intake of fast foods and limits access to healthy items may be another factor.75,84,85,86,87 A sedentary lifestyle is also more prevalent among African Americans and is not asso- ciated with income, education, occupation, marital status, poverty levels, or other indica- tors of social class.34,79,87 Data from one study found families living in low-income areas and those with higher percentages of minority residents were significantly less likely to have access to recreational facilities.83 In addition, a desire to consume traditional African Ameri- can foods and to care for others through cook- ing, as well as a lack of family support were barriers to weight loss cited in studies.83,84 Some researchers have suggested that stan- dard anthropometric measures may be inap- propriate for African Americans. One study found that when body mass index (BMI) values were compared to body fatness, black women had lower body fatness than did white women with identical BMI numbers.88 A similar evaluation reported that when the percentage of body fat is used to measure obesity instead of BMI, rates for African American women drop dramatically, and rates for white men exceed those for black men.89 BMI does not account for differences in fat-free mass, such as muscle and bone, which accounts for the discrepancy between measures. Weight-for-height growth charts as indicators of percentage of body fat and the use of waist-to-hip ratios in defining heart disease risk have also been found misleading in some studies.90,91 However, a study of over- weight and obesity in children did not find significant differences in rates when using national standards for assessment compared to African American specific standards, and cautioned that ethnicity-specific standards may be confounded by differences in socio- economic status.92 Studies propose that African American women do not necessarily equate being over- weight with being unattractive and that they are less preoccupied with dieting than are white women.93,94 Research on disordered eating in African Americans has been lim- ited and contradictory. Some studies suggest black women have lower rates of dieting and are protected from eating disorders due to a collective acceptance of larger body size.95,96,97 Other researchers suggest low rates are due to an assumption that disordered eating does not affect blacks (hence African American girls are often excluded from studies) and that pressures to conform to societal norms regarding weight are eroding any possible preexisting cultural buffers, especially among children and adolescents.98,99,100,101 Concurrent with obesity is a dispropor- tionately high rate of type 2 diabetes mellitus among African Americans—twice the rate of diabetes and twice the number of incidents of complications compared to whites.102 There is a genetic predisposition for type 2 diabe- tes mellitus, but also a significant relation- ship with lifestyle factors such as obesity, sedentary lifestyle, and westernized dietary habits.103,104,105,106 Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 2 2 8 A F R I C A N S Hypertension is a significant health prob- lem for African Americans. In 2011, the prev- alence of high blood pressure was 1.4 times more likely when compared to whites.102,107 Hypertension has been found to be a potent risk factor for coronary heart disease (CHD) in blacks, especially women (whereas having diabetes was not predictive for CHD). Afri- can American adults are twice as likely to have a stroke than their white adult counter- parts. Further, men are 60 percent more likely to die from a stroke than their white adult counterparts.103 Rates of iron-deficiency anemia among African Americans are higher than for whites at every age, regardless of sex or income level. This incidence remains excessive even after adjustments for differences in hemoglobin distributions are made using reference stan- dards appropriate for blacks.108 Pica may result in anemia among pregnant women and newborns. Hookworm can also be a cause in the rural South. Other blood disorders resulting in anemias prevalent in African Americans include alpha-thalassemia, sickle- cell disease, and glucose-6-phosphate dehy- drogenase deficiency. Researchers have also suggested that undiagnosed celiac disease in blacks may underlie some cases of iron-defi- ciency anemia.109,110 Little has been reported on the nutritional adequacy of the traditional diet of recent Africans. Studies in Israel of Ethiopian immi- grants found deficiencies in vitamin D (result- ing in rickets in children), iodine (due in part to food goitrogens), and calcium. Vitamin A deficiency has led to xerophthalmia and blindness in many regions. Consumption of foods made from enset, a banana leaf plant, common in many parts of Ethiopia, is associ- ated with esophageal cancer.111,112,113 Among Sudanese immigrants in the United States, blindness due to trachoma is also common. High rates of extreme malnutrition, malaria, typhoid, hepatitis B, HIV infection, dengue fever, tuberculosis, syphilis, dental problems, diabetes, and parasitic infection have also been reported.114 Dietary changes of Ethiopians in Israel are marked. A survey of teens found that within eighteen months of arrival, only 30 percent maintained a traditional diet, 60 percent con- sumed a mixed diet, and 15 percent ate only Israeli foods.115,116 More than half of daily calories came from snacks and fast foods, especially sweets and soft drinks. Most milk products were disliked, with the exception of hot chocolate, a favorite with the youth. Fat intake increased, while fruit and vegetable intake decreased. Though obesity is unusual, glucose intolerance is common, and the prevalence rate of type 2 diabetes increased from 0.4 percent to between 5 and 8 percent within a few years. Over 20 percent of men also developed hypertension after immigra- tion.116 In Australia, immigrants from Ghana experienced similar changes in diet and health status. Fat intake accounted for 33 to 35 per- cent of total calories, and overweight was observed in 71 percent of men and 66 percent of women. High rates of diabetes, hyperten- sion, and dyslipidemia were reported.117 In Nigeria, some women believe that edema during pregnancy is an indication that the infant is male, and treatment may not be sought for the condition.118 Studies of Ethio- pian women in the United States found that most breast-fed their infants on average four months, and breast-feeding is acceptable in public. Going back to work and reduction in mother’s milk were the primary reasons given for cessation.119,120 Somali immigrants often associate fatness with health and may over- feed their children.121 The Somali Bantus are in particularly poor health due to acute or chronic malnutrition when living in African refugee camps prior to arrival in the United States. Most have little knowledge of Ameri- can foods. The prevalence of low-birth-weight infants is high, and weaning often occurs before six months due to subsequent preg- nancy. Diarrheal diseases and infections are common. Posttraumatic stress syndrome is also frequently found.122 Counseling Access to health care for African Americans has improved since 2009. Eight-five percent of blacks were covered by health insurance dur- ing all or part of 2013. Nationally, 86.6 percent of all races were covered by health insur- ance.123 Cost, including time off from work, Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 8 2 2 9 is often an issue. Self-reliance is highly valued and may lead to delay in seeking care or mini- mization of symptoms. Furthermore, an atti- tude that fate determines wellness may restrict medical visits. When a doctor’s care is sought, it is usually for treatment of symptoms (often after home remedies have been tried) rather than for prevention of illness and health main- tenance.124 Many blacks are present-oriented, and flexible scheduling and on-time policies may be helpful.125 Some African American clients feel patron- ized by nonblack providers and may choose to suffer at home rather than submit to humili- ation. Others may be suspicious or hostile when working with nonblack health care pro- fessionals. Such attitudes are rarely directed specifically at the health care worker; instead, they are an adaptation to what is perceived as a prejudicial society.124,125 Some African Americans may not consider themselves active participants in their interaction with providers and may not communicate needs or questions. This is sometimes done to test the competency of the provider, who is expected to diagnose without help from the client.126 It may also be a reflection of the belief that their health care is out of their control, up to luck or destiny.9 African American conversational style is fully engaged and very expressive.9 Interjec- tions of agreement or disagreement are fre- quent. Words are often spoken rhythmically and passionately. Response time is very quick. When counseling African Americans, it is helpful to be direct yet respectful. Eye con- tact is made while speaking, but prolonged eye contact is considered rude.30 African Americans may avert their eyes while listen- ing; however, some blacks may interpret rapid eye aversion as an insult. Attentive listening is more important than eye contact to many blacks. A firm handshake and smile are the expected greeting; hugging and kissing may also be included. Touching is common, and reluctance to touch may be interpreted as per- sonal rejection. Nonnutritive food intake during preg- nancy may be missed unless information about pica is solicited during the interview. Most women who eat clay, laundry starch, or other nonfood items will willingly list the items consumed when asked directly about the habit. The nutritional effects of pica are uncertain. Possible problems include exces- sive weight gain (from laundry starch), aggra- vated hypertension (from the sodium in clay), iron-deficiency anemia, and hyperkalemia.75 Furthermore, over-the-counter remedies for the gas and constipation that can accompany pica may be harmful during pregnancy.127 Traditional health practices, such as using diet to cure high and low blood, may com- plicate some nutrition counseling. Pregnancy is sometimes considered to be a high blood state, and pregnant women will avoid red meats. Patients who confuse hypertension with high blood may eat astringent foods, which are often high in sodium, to balance the condition. Home remedies for diabetes, such as peppermint candies or yellowroot bush tea, should also be investigated. A client is unlikely to mention any use of other healers.128 It may be useful to directly inquire whether a rural African American believes an illness is due to outside forces or witchcraft and what addi- tional treatment is being sought. Counseling recommendations should be action- or task-oriented. Several studies of African Americans have suggested family- oriented programs and group classes may be more successful than individual counsel- ing, and use of community resources, such as churches, can provide additional support for nutritional change.85,129 Culturally relevant education may include elements of spiritual- ity, ethnic pride, group planning, and the use of peer counselors.130,131,132,133 Diets that limit traditional African American foods are often resisted by clients, due to preference, expense, family desires, and ethnic identity.85,134 One study found that blacks felt socially isolated when restricted to nontraditional foods.135 Researchers have suggested that because many African Americans take pride in the adaptations made in their cuisine due to his- torical circumstances, the potential for dietary improvement associated with environmental change is high.26 Little information is available regarding counseling recent immigrants from Africa. Recommendations for Ethiopians include Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 2 3 0 A F R I C A N S Review Questions 1. Describe the cuisine that West African slaves brought to America and one American food recipe that has its origins in Africa. What tra- ditional food might be served on Juneteenth? 2. Compare similarities and differences in West and East African traditional cuisines. What countries have influenced East African cuisine? 3. Name the presented symbolic foods used in the Nigerian child-naming ceremonies, and explain what they symbolize. 4. Describe three therapeutic uses of food among African Americans. What is pica, and why is it practiced? 5. For African Americans, how might diet affect the incidence and treatment of hypertension and type 2 diabetes mellitus? use of an interpreter from the client’s com- munity; a warm, personable communica- tion style; a positive outlook; and disclosure of poor prognosis or terminal illness to the patient’s family (preferably not the wife or mother) or friend, who will then inform the patient.136,137 Ethiopians and Somali Bantus may view illness as a punishment from God or angry spirits, and they may employ herbal remedies or prefer spiritual healing.119,121 Injections may be requested by Ethiopians instead of oral prescriptions, and Sudanese may stop taking medications as soon as symptoms subside, saving them for a later recurrence of illness in themselves or among family members or friends.114 It has been noted that Eritreans have faith in certain botanical cures, and if they are unobtain- able in the United States, they may return to Africa for treatment.119 An in-depth interview is especially impor- tant with African American clients. Variability in diet related to region, socioeconomic con- ditions, and degree of ethnic identity should be considered. Information regarding coun- try of origin may be significant: Clients from the Caribbean or Central America are more likely to identify with the foods and food hab- its of Latinos than with those of blacks in the United States. Religious affiliation may also be important, such as among Americans of African descent who are members of Islam or an Eastern Orthodox faith. References 1. U.S. Census Bureau, Newsroom. 2015. F ac ts f or f eatur es: B l ac k ( A f r ic an- A mer ic an) h istor y month : F ebr uar y 2 0 1 5 . Retrieved from http://www .census.gov/newsroom/facts-for-features/2015/ cb15-ff01.html. (accessed February 20, 2015). 2. U.S. Department of Health and Human Services, Office of Minority Health. 2014. P r of il e: B l ac k / A f r ic an A mer ic ans. Retrieved from http://minority- health.hhs.gov/omh/browse.aspx?lvl53&lvlid561 (accessed February 20, 2015). 3. U.S. Census Bureau. 2011. A mer ic an C ommunity S ur v ey f iv e y ear estimates. Retrieved from http:// www.census.gov/acs (accessed January 25, 2011). 4. Gambino, C.P., Trevelyan, E.N., & Fitzwater, J.T. 2014. T h e f or eign- bor n popul ation f r om A f r ic a: 2 0 0 8 – 2 0 1 2 . Washington, DC: U.S. Department of Commerce, Economics and Statistics Admin- istration, U.S. Census Bureau. D I S C U S S I O N S T A R T E R S Health Risks of African Americans As this chapter makes clear, African Americans today often suffer from obesity, diabetes, hypertension, infant and maternal morbidity and mortality, and depression in greater numbers than other American races. Make a list of all the possible reasons for this phe- nomenon. Don’t limit yourself to just one or two, and look back at the diet and culture of the geographical area from which the ancestors of most modern African Americans came. In a small group, share your lists of reasons and come up with one group list. Again, your task is to list all the possible reasons that you can. After making this group list, individually take a blank sheet of paper and cluster the items on that list. That is, look the listed items and identify reasons that you see as possi- bly being somehow linked. On the blank sheet of paper, rewrite the reasons on the group list but locate them as best you can near to other reasons that you as somehow related. Circle each reason and draw lines between the ones that you believe are connected. Finally, imagine that you have been hired by a local health department in an area of the country with a large African American population to write a brief (one-page) resource handout for local health professionals on the reasons why many of their African American clients may have the above health problems. As you plan this short paper, consider whether—or not—it might have made a difference had most African slaves come from East Africa. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 8 2 3 1 5. U.S. Census Bureau, Newsroom. 2015. F ac ts f or f eatur es: B l ac k ( A f r ic an- A mer ic an) h istor y month : F ebr uar y 2 0 1 5 . Retrieved from http://www .census.gov/newsroom/facts-for-features/2015/ cb15-ff01.html 6. U.S. Department of Health and Human Services, Office of Minority Health. n.d. A f r ic an A mer ic an pr of il e. Retrieved from http://minorityhealth.hhs. gov/templates/browse.aspx?lvl52&lvlID551 (accessed January 25, 2011). 7. Pew Research Center. 2013. T h e r el igious af f il ia- tion of U . S . immigr ants: M aj or ity C h r istian, r is- ing sh ar e of oth er f aith s. Retrieved from http:// www.pewforum.org/2013/05/17/the-religious- affiliation-of-us-immigrants/ (accessed February 18, 2015). 8. U.S. Census Bureau. n.d. Population: House- holds, families, group quarter, Table 69: Children under 18 years old by presence of parents. T h e 2 0 1 2 S tatistic al A bstr ac t. Retrieved from http:// www.census.gov/compendia/statab/cats/popula- tion/households_families_group_quarters.html (accessed February 18, 2015). 9. Yehieli, M., & Grey, M.A. 2005. H eal th matter s: A poc k et guide f or w or k ing w ith div er se c ul tur es and under ser v ed popul ations. Boston: Intercultural Press. 10. Mbiti, J.S. 1970. A f r ic an r el igions and ph il osoph y . Garden City, NY: Double-day Anchor. 11. Jackson, B. 1976. The other kind of doctor: Con- jure and magic in black American folk medicine. In W.D. Hand (Ed.), A mer ic an f ol k medic ine. Berkeley: University of California Press. 12. Spector, R.E., 2004. C ul tur al div er sity in h eal th and il l ness (6th ed.). Upper Saddle River, NJ: Pearson Education. 13. Ravenell, J.E., Johnson, W.E., Jr., & Whitaker, E.E. 2006. African-American men’s perceptions of health: A focus group study. J our nal of th e N ational M edic al A ssoc iation, 9 8 , 544–550. 14. Hsiao, A.F., Wong, M.D., Goldstein, M.S., Yu, H.J., Anderson, R.M., Brown, E.R., . . . Wenger, N.S. 2006. Variation in complementary and alternative medicine (CAM) use across racial/ethnic groups and the development of ethnic-specific measures of CAM use. J our nal of A l ter nativ e and C ompl e- mentar y M edic ine, 12, 281–280. 15. Chester, D.N., Himburg, S.P., & Weatherspoon L.J. 2006. Spirituality of African-American women: Correlations to health promoting behav- iors. J our nal of th e N ational B l ac k N ur ses A ssoc ia- tion, 1 7 , 1–8.1 7 , 1–8.1 7 16. Lecca, P.J., Quervalu, I., Nunes, J.V., & Gonza- les, H.F. 1998. C ul tur al c ompetenc y in h eal th , soc ial , and h uman ser v ic es. New York: Garland Publishing. 17. Brandon, E. 1976. Folk medicine in French Loui- siana. In W.D. Hand (Ed.), A mer ic an f ol k medi- c ine. Berkeley: University of California Press. 18. Glanville, C.L. 2003. People of African American heritage. In L.D. Purnell & B.J. Paulanka (Eds.), T r ansc ul tur al h eal th c ar e (2nd ed.). Philadelphia: FA Davis. 19. Boyd, E.L., Taylor, S.D., Shimp, L.A., & Semier, C.R. 2000. An assessment of home remedy use by African Americans. J our nal of th e N ational M edi- c al A ssoc iation, 9 2 , 341–353. 20. Geller, S.E., & Derman, R. 2001. Knowledge, beliefs, and risk factors for osteoporosis among African-American and Hispanic-American women. J our nal of th e N ational M edic al A ssoc ia- tion, 9 3 , 13–21. 21. Zibart, E. 2001. T h e eth nic f ood l ov er s c ompanion: U nder standing th e c uisines of th e w or l d. Birming- ham: Menasha Ridge Press. 22. Kobel, P.S. 2000. Ethiopian Americans. In R.V. Dassanowsky & J. Lehman (Eds.), G al e enc y - c l opedia of mul tic ul tur al A mer ic a. Farmington Hills, MI: Gale Group. 23. Heymann, T.D., Bhupulan, A., Zureikat, N.E., Bomanji, J., Drinkwater, C., Giles, P., & Murray- Lyon, I.M. 1995. Khat chewing delays gastric emptying of a semi-solid meal. A l imentar y P h ar - mac ol ogic al T h er apy , 9 , 81–83. 24. Foster, D. 2002. The global etiquette guide to Africa and the Middle East. New York: Wiley. 25. Miller, O. 2000. Ugandan Americans. In R.V. Dassanowsky & J. Lehman (Eds.), G al e enc y c l o- pedia of mul tic ul tur al A mer ic a. Farmington Hills, MI: Gale Group. 26. Airhihenbuwa, C.O., & Kumanyika, S. 1996. Cultural aspects of African American eating pat- terns. E th nic ity & H eal th , 1 , 245–261. 27. Rudolph, L.C. 2000. Kenyan Americans. In R.V. Dassanowsky & J. Lehman (Eds.), G al e enc y - c l opedia of mul tic ul tur al A mer ic a. Farmington Hills, MI: Gale Group. 28. Weatherspoon, L., Chester, D., & Kidd, T. 2010. African American food practices. In C.M. Goody & L. Drago (Eds.), C ul tur al f ood pr ac tic e. Chicago: American Dietetic Association. 29. Sarkodie-Mensah, K. 2000. Nigerian Americans. In R.V. Dassanowsky & J. Lehman (Eds.), G al e enc y c l opedia of mul tic ul tur al A mer ic a. Farming- ton Hills, MI: Gale Group. 30. Jackson, J.J. 1981. Urban black Americans. In A. Harwood (Ed.), E th nic ity and medic al c ar e. Cambridge, MA: Harvard University Press. 31. Smith, S.L., Quandt, S.A., Arcur y, T.A., Wetmore, L.K., Bell, R.A., & Vitolins, M.Z. 2005. Aging and eating in the rural, southern United States: Beliefs about salt and its effect on health. S oc ial S c ienc e & M edic ine, 6 2 , 189–198. 32. Hunter, J.M. 1973. Geophagy in Africa and the United States. G eogr aph ic al R ev iew , 6 3 , 170–195. 33. Edwards, C.H., Johnson, A.A., Knight, E.M., Oyemade, U.J., Cole, O.J., Jones, S., . . . Westney, Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 2 3 2 A F R I C A N S L.S. 1994. Pica in an urban environment. J our nal of N utr ition, 1 2 4 , 954S–962S. 34. Rose, D., & Bodor, J.N. 2006. Household food insecurity and overweight status in young school children: Results from the Early Childhood Lon- gitudinal Study. P ediatr ic s, 1 1 7 , 464–473.1 1 7 , 464–473.1 1 7 35. Nwosu, M.O. 1998. Aspects of ethnobotanical medicine in southeast Nigeria. J our nal of A l ter - nativ e and C ompl ementar y M edic ine, 4 , 305–310. 36. Tucker, K.L., Maras, J., Champagne, C., Connell, C., Goolsby, S., Weber, J., . . . Bogle, M.L. 2005. A regional food-frequency question- naire for the US Mississippi Delta. P ubl ic H eal th N utr ition, 8 , 87–96 37. Jerome, N.W. 1969. Northern urbanization and food consumption of southern born Negroes. A mer ic an J our nal of C l inic al N utr ition, 2 2 , 1667–1669. 38. Byars, D. 1996. Traditional African American foods and African Americans. A gr ic ul tur e and H uman V al ues, 1 3 , 74–78. 39. National Center for Health Statistics. 2005. H eal th , U nited S tates, 2 0 0 5 w ith C h ar tbook on T r ends in th e H eal th of A mer ic ans. Hyattsville, MD: Author. 40. Block, J.P., Scribner, R.A., & DeSalvo, K.B. 2004. Fast food, race/ethnicity, and income: A geo- graphic analysis. A mer ic an J our nal of P r ev entiv e M edic ine, 2 7 , 211–217.2 7 , 211–217.2 7 41. Wheeler, M., & Haider, S.Q. 1979. Buying and food preparation patterns of ghetto blacks and Hispanics in Brooklyn. J our nal of th e A mer ic an Dietetic A ssoc iation, 7 5 , 560–563. 42. Haq, A.S. 2003. Report on Somali diet: Common dietary beliefs and practices of Somali participants in WIC nutrition education groups. EthnoMed, University of Washington Harborview Medical Center. Retrieved from http://ethnomed.org/ clin_topics/nutrition/somali_diet_report.html 43. Elmubarak, E., Bromfield, E., & Bovell-Benjamin, A.C. 2004. Focused interviews with Sudanese Americans: Perceptions about diet, nutrition, and cancer. P r ev entiv e M edic ine, 4 0 , 502–509. 44. Basiotis, P.P., Carlson, A., Gerrior, S.A., Juan, W.Y., & Lino, M. 2002. T h e H eal th y E ating I ndex : 1 9 9 9 – 2 0 0 0 . Washington, DC: U.S. Department of Agriculture, Center for Nutrition Policy and Promotion, CNPP–12. 45. Kirkpatrick, S., Dodd, K.W., Reedy, J., & Krebs- Smith, S.M. 2012. Income and race/ethnicity are associated with adherence to food-based dietary guidance among US adults and children. J our nal of th e A c ademy of N utr ition and Dietetic s, 1 1 2 (5), 624–635 46. Furomoto-Dawson, A.A., Pandey, D., Elliott, W.J., DeLeon, C.F., Al-Hani, A.J., Hollenberg S., . . . Black, H.R. 2003. Hypertension in women: The Women Take Heart project. J our nal of C l inic al H y per tension, 5 , 38–46. 47. Daroszewski, E.B. 2004. Dietary fat consump- tion, readiness to change, and ethnocultural association in midlife African American women. J our nal of C ommunity H eal th N ur sing, J our nal of C ommunity H eal th N ur sing, J our nal of C ommunity H eal th N ur sing 2 1 , 63–75. 48. Bowman, S.A., Gortmaker, S.L., Ebbeling, C.B., Pereira, M.A., & Ludwig, D.S. 2004. Effects of fast-food consumption on energy intake and diet quality among children in a national household survey. P ediatr ic s, 1 1 3 , 112–118. 49. Gans, K.M., Burkholder, G.J., Risica, P.M., & Lasater, T.M. 2003. Baseline fat-related dietary behaviors of white, Hispanic and black partici- pants in a cholesterol screening and education project in New England. J our nal of th e A mer ic an Dietetic A ssoc iation, 1 0 3 , 699–706. 50. Satia, J.A., Galanko, J.A., & Siega-Riz, A.M. 2004. Eating at fast-food restaurants is associated with dietary intake, demographic, psychosocial and behavioral factors among African Americans in North Carolina. P ubl ic H eal th N utr ition, 7 , 1089–1096. 51. Newby, P.K., Noel, S.E., Grant, R., Judd, S., Shikany, J.M., & Ard, J. 2011. Race and region are associated with nutrient intakes among black and white men in the United States. J our nal of N utr i- tion, 1 4 1 (2), 296–303. 52. Steyen, K., Fourie, J., Lombard, C., Katzenellbo- gen, J., Bourne, L., & Jooste, P. 1996. Hypertension in the black community of the Cape Peninsula, South Africa. E ast A f r ic an M edic al J our nal , 7 3 , 758–763. 53. Daroszewski, E.B. 2004. Dietary fat consumption, readiness to change, and ethnocultural associa- tion in midlife African American women. J our nal of C ommunity H eal th N ur sing, of C ommunity H eal th N ur sing, of C ommunity H eal th N ur sing 2 1 , 63–75. 54. Pribila, B.A., Hertzler, S.R., Martin, B.R., Weaver, C.M., & Savaiano, D.A. 2000. Improved lac- tose digestion and intolerance among African- American adolescent girls fed a dairy-rich diet. J our nal of th e A mer ic an Dietetic A ssoc iation, 1 0 0 , 524–528. 55. Mojtahedi, M.C., Plawecki, K.L., Chapman- Novakofski, K.M., McAuley, E., & Evans, E.M. 2006. Older black women differ in calcium intake source compared to age- and socioeco- nomic status-matched white women. J our - nal of th e A mer ic an Dietetic A ssoc iation, 1 0 6 , 1102–1107. 56. Campbell, M.K., Polhamus, B., McClelleand, J.W., Bennett, K., Kalsbeek, W., Coole, D., . . . Demark-Wahnefried, W. 1996. Assessing fruit and vegetable consumption in a 5 a day study targeting rural blacks: The issue of portion size. J our nal of th e A mer ic an Dietetic A ssoc iation, 9 6 , 1040–1042. 57. Fahm, E.G., & Senborn, C. 1998, Spring. Nutri- tional status of black elders: A review of the litera- ture. J our nal of th e F amil y and C onsumer S c ienc es, 23–27. 58. Diaz, V.A., Mainous, A.G., Koopman, R.J., & Geesey, M.E. 2005. Are ethnic differences in insulin sensitivity explained by variation in car- bohydrate in-take? Diabetol ogia 4 8 , 1264–1268. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 8 2 3 3 59. Baker, E.A., Schootman, M., Barnidge, E., & Kelly, C. 2006. The role of race and poverty in access to foods that enable individuals to adhere to dietary guidelines. P r ev enting C h r onic Disease, 3 , A76. 60. Zenk, S.N., Schulz, A.J., Hollis-Neely, T., Camp- bell, R.T., Holmes, N., Watkins, G., . . . Odoms- Young, A. 2005. Fruit and vegetable intake in African Americans income and store character- istics. A mer ic an J our nal of P r ev entiv e M edic ine, 2 9 , 1–9. 61. Vitolins, M.Z., Quandt, S.A., Bell, R.A., Arcury, T.A., & Case, L.D. 1992. Quality of diets con- sumed by older rural adults. J our nal of R ur al H eal th , 1 8 , 49–56. 62. Newby, P.K., Noel, S.E., Grant, R., Judd, S., Shikany, J.M., & Ard J. 2011. Race and region are associated with nutrient intakes among black and white men in the United States. J our nal of N utr i- tion, 1 4 1 (2), 296–303. 63. Maitland, T.E., Gomez-Marin, O., Weddle, D.O., & Fleming, L.E. 2006. Associations of nationality and race with nutritional status during perimeno- pause: Implications for public health practice. E th nic ity & Disease, 1 6 , 201–206. 64. Arab, L., Carriquiry, A., Steck-Scott, S., & Gaudet, M.M. 2003. Ethnic differences in the nutrient intake adequacy of premenopausal US women: Results from the Third National Health Exami- nation Survey. J our nal of th e A mer ic an Dietetic A ssoc iation, 1 0 3 , 1008–1014. 65. Ervin, R.B., & Kennedy-Stephenson, J. 2002. Mineral intakes of elderly adult supplement and non-supplement users in the Third National Health and Nutrition Examination Survey. J our - nal of N utr ition, 1 3 2 , 3422–3427. 66. Lewis, L.B., Sloane, D.C., Nascimento, L.M., Diamant, A.L., Guinyard, J.J., Yancey, A.K., & Flynn, G. 2005. African Americans’ access to healthy food options in south Los Angeles res- taurants. A mer ic an J our nal of P ubl ic H eal th , 9 5 , 668–673. 67. Lewis, S.M., Mayhugh, M.A., Freni, S.C., Thorn, B., Cardoso, S., Buffington, C., . . . Feuers, R.J. 2003. Assessment of antioxidant nutrient intake of a population of southern US African Ameri- can and Caucasian women of various ages when compared to dietary reference intakes. J our nal of N utr ition, H eal th & A ging, N utr ition, H eal th & A ging, N utr ition, H eal th & A ging 7 , 121–128.7 , 121–128.7 68. Cricco-Lizza, R. 2004. Infant-feeding beliefs and experiences of Black women enrolled in WIC in the New York metropolitan area. Q ual ity H eal th R esear c h , 1 4 , 1197–1210. 69. Arias, E. 2014. United States life tables, 2010. N ational V ital S tatistic s R epor ts, 6 3 (7). Hyattsville, MD: National Center for Health Statistics. 70. Martin, J.A., Hamilton, B.E., Sutton, P.D., Ven- tura, S.J., Mathews, T.J., Kirmeyer, S., Osterman, M.J.K. 2010. Births: Final data for 2007. N ational V ital S tatistic s R epor ts, 5 8 (20). Hyattsville, MD: National Center for Health Statistics. Retrieved from http://www.cdc.gov/nchs/fastats/birth- weight.htm (accessed February 19, 2015). 71. Martin, J.A., Hamilton, B.E., Sutton, P.D., Ven- tura, S.J., Mathews, T.J., Kirmeyer, S., Osterman, M.J.K. 2010. Births: Final data for 2007. N ational V ital S tatistic s R epor ts, 5 8 (20). Hyattsville, MD: National Center for Health Statistics. Retrieved from http://www.cdc.gov/nchs/fastats/birth- weight.htm (accessed February 19, 2015). 72. England, L., Brenner, R., Bhaskar, B., Simons- Morton, B., Das, A., Revenis, M., . . . Clemens, J. 2003. Breastfeeding practices in a cohort of inner- city women: The role of contraindications. B M C P ubl ic H eal th , 2 0 , 28. 73. Reeves, E.A., & Woods-Giscombé, C.L. 2014. Infant-feeding practices among African Ameri- can women: Social-ecological analysis and impli- cations for practice. J our nal of T r ansc ul tur al N ur sing. Published online printed May 8, 2014. doi: 10.1177/1043659614526244 74. Bronner, Y.L., Gross, S.M., Caulfield, L., Bentley, M.E., Kessler, L., Jensen, J., . . . Paige, D.M. 1999. Early introduction of solid foods among urban African-American participants in WIC. J our nal of th e A mer ic an Dietetic A ssoc iation, 9 9 , 457–461. 75. Kumanyika, S., & Grier, S. 2006. Targeting interventions for ethnic minority and low- income populations. T h e F utur e of C h il dr en, 1 6 , 187–207. 76. Zillikens, M.C., & Conway, J.M. 1990. Anthro- pometry in blacks: Applicability of generalized skinfold equations and differences in fat pattern- ing between blacks and whites. A mer ic an J our nal of C l inic al N utr ition, 5 2 , 45–51. 77. Kelly, N.R, Bulik, C.M., & Mazzeo, S.E. 2011. An exploration of body dissatisfaction and per- ceptions of black and white girls enrolled in an intervention for overweight children. B ody I mage, 8 (4), 379–384. 78. Becker, D.M., Yanek, L.R., Koffman, D.M., & Bronner, Y.C. 1999. Body image preferences among urban African-Americans and whites from low-income communities. E th nic ity & Disease, 9 , 377–386. 79. Sanchez-Johnsen, L.A., Fitzgibbon, M.L., Martinovich, Z., Stolley, M.R., Dyer, A.R., & Van Horn, L. 2004. Ethnic differences in cor- relates of obesity between Latin-American and black women. O besity R esear c h , 1 2 , 652–660. 80. Blixen, C.E., Singh, A., & Thacker, H. 2006. Values and beliefs about obesity and weight reduction among African American and Caucasian women. J our nal of T r ansc ul tur al N ur sing, J our nal of T r ansc ul tur al N ur sing, J our nal of T r ansc ul tur al N ur sing 1 7 , 290–297.1 7 , 290–297.1 7 81. Eckstein, K.C., Mikhail, L.M., Ariza, A.J., Thomson, J.S., Millard, S.C., & Binns, H.J. 2006. Parents’ perceptions of their child’s weight and health. P ediatr ic s, 1 1 7 , 681–690.1 1 7 , 681–690.1 1 7 82. Rose, D., & Bodor, J.N. 2006. Household food insecurity and overweight status in young school children: Results from the Early Childhood Longitudinal Study. P ediatr ic s, 1 1 7 , 464–473.1 1 7 , 464–473.1 1 7 Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 2 3 4 A F R I C A N S 83. Gordon-Larsen, P., Adair, L.S., & Popkin, B.M. 2003. The relationship of ethnicity, socioeco- nomic factors, and overweight in US adolescents. O besity R esear c h , 1 1 , 121–129. 84. Lewis, L.B., Sloane, D.C., Nascimento, L.M., Diamant, A.L., Guinyard, J.J., Yancey, A.K., & Flynn, G. 2005. African Americans’ access to healthy food options in south Los Angeles res- taurants. A mer ic an J our nal of P ubl ic H eal th , 9 5 , 668–673. 85. James, D.C.S. 2004. Factors influencing food choices, dietary intake, and nutrition-related atti- tudes among African Americans: Application of a culturally sensitive model. E th nic ity & H eal th , 9 , 349–367. 86. Zenk, S.N., Schulz, A.J., Hollis-Neely, T., Camp- bell, R.T., Holmes, N., Watkins, G., . . . Odoms- Young, A. 2005. Fruit and vegetable intake in African Americans income and store character- istics. A mer ic an J our nal of P r ev entiv e M edic ine, 2 9 , 1–9. 87. Crespo, C.J., Smit, E., Andersen, R.E., Carter- Pokras, O., & Ainsworth, B.E. 2000. Race/eth- nicity, social class and their relation to physical inactivity during leisure time: Results from the Third National Health and Nutrition Examina- tion Survey, 1988–1994. A mer ic an J our nal of P r e- v entiv e M edic ine, 1 8 , 46–53. 88. Evans, E.M., Rowe, D.A., Racette, S.B., Ross, K.M., & McAuley, E. 2006. Is the current BMI obesity classification appropriate for black and white post menopausal women? I nter national J our nal of O besity , 3 0 , 837–843. 89. Cawley, J., & Burkhauser, R.V. 2006. B ey ond B M I : T h e v al ue of mor e ac c ur ate measur es of f atness and obesity in soc ial sc ienc e r esear c h . National Bureau of Economic Research (NBER). Retrieved from http://papers.nber.org/papers/w12291 90. Croft, J.B., Keenan, N.L., Sheridan, D.P., Wheeler, F.C., & Speers, M.A. 1995. Waist-to-hip ratio in a biracial population: Measurement, implications, and cautions for cardiovascular disease. J our nal of th e A mer ic an Dietetic A ssoc iation, 9 5 , 60–64. 91. Hoerr, S.L., Nelson, R.A., & Lohman, T.R. 1992. Discrepancies among predictors of desirable weight for black and white obese adolescent girls. J our nal of th e A mer ic an Dietetic A ssoc iation, 9 2 , 450–453. 92. Dwyer, J.T., Stone, E.J., Minhua, Y., Webber, L.S., Must, A., Feldman, H.A., . . . Parcel, G.S. 2000. Prevalence of marked overweight and obesity in a multiethnic pediatric population: Findings from the Child and Adolescent Trial for Cardiovascular Health (CATCH) study. J our nal of th e A mer ic an Dietetic A ssoc iation, 1 0 0 , 1149–1156. 93. Kumanyika, S., Wilson, J.F., & Guilford- Davenport, M. 1993. Weight-related attitudes and behaviors of black women. J our nal of th e A mer i- c an Dietetic A ssoc iation, 9 3 , 416–422. 94. Stevens, J., Kumanyika, S.K., & Keill, J.E. 1994. Attitudes towards body size and dieting: Dif-Attitudes towards body size and dieting: Dif-Attitudes towards body size and dieting: Dif ferences between elderly black and white women. A mer ic an J our nal of P ubl ic H eal th , 8 4 , 1322–1325. 95. Neumark-Sztainer, D., Croll, J., Story, M., Hannan, P.J., French, S.A., & Perry, C. 2002. Ethnic/racial differences in weight-related con- cerns and behaviors among adolescent girls and boys: Findings from Project EAT. J our nal of P sy c h osomatic R esear c h , 5 3 , 963–974. 96. Rhea, D.J. 1999. Eating disorder behaviors of ethnically diverse urban female adolescent ath- letes and non-athletes. J our nal of A dol esc enc e, 2 2 , 379–388. 97. White, M.A., Kohlmaier, J.R., Varnado-Sullivan, P., & Williamson, D.A. 2003. Racial/ethnic dif-P., & Williamson, D.A. 2003. Racial/ethnic dif-P., & Williamson, D.A. 2003. Racial/ethnic dif ferences in weight concerns: Protective and risk factors for the development of eating disorders and obesity among adolescent females. E ating and W eigh t Disor der s, 8 , 20–25. 98. Mitchell, K.S., & Mazzeo, S.E. 2004. Binge eating and psychological distress in ethnically diverse undergraduate men and women. E ating B eh av - ior s, 5 , 157–169. 99. Perez, M., & Joiner, T.E. 2003. Body image dis- satisfaction and disordered eating in black and white women. I nter national J our nal of E ating Disor der s, 3 3 , 342–350. 100. Robinson, T.N., Chang, J.Y., Haydel, K.F., & Killen, J.D. 2001. Overweight concerns and body image dissatisfaction among third-grade children: The impacts of ethnicity and socio- economic status. J our nal of P ediatr ic s, 1 3 8 , 181–187. 101. Williamson, L. 1998. Eating disorders and the cultural forces behind the drive for thinness: Are African American women really protected? S oc ial W or k and H eal th C ar e, 2 8 , 61–73. 102. U.S. Census Bureau. 2012. Adults with hyper- tension whose blood pressure is under control, United States, 1999–2010, Table T2_2_1_2-1. 2 0 1 2 N ational H eal th c ar e Dispar ities R epor t. Retrieved from http://www.ahrq.gov/research/ findings/nhqrdr/nhqrdr12/index.html (accessed February 21, 2015). 103. Centers for Disease Control and Prevention. 2012. Age-adjusted percentages of selected cir- culatory diseases among adults aged 18 and over, by selected characteristics: United States, 2011, Table 2. S ummar y H eal th S tatistic s f or U . S . A dul ts: 2 0 1 2 . Retrieved from http://www. cdc.gov/nchs/data/series/sr_10/sr10_256 (accessed February 21, 2015). 104. Shai, I., Jiang, R., Manson, J.E., Stampfer, M.J., Willett, W.C., Colditz, G.A., & Hu, F.B. 2006. Ethnicity, obesity, and risk of type 2 diabetes in women: A 20-year follow-up study. Diabetes C ar e, 2 9 , 1585–1590. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 8 2 3 5 105. Diaz, V.A., Mainous, A.G., Koopman, R.J., & Geesey, M.E. 2005. Are ethnic differences in insulin sensitivity explained by variation in car- bohydrate intake? Diabetol ogia, 4 8 , 1264–1268. 106. Banini, A.E., Allen, J.C., Allen, H.G., Boyd, L.C., & Lartey, A. 2003. Fatty acids, diet, and body indices of type II diabetic American whites and blacks and Ghanaians. N utr ition, 1 9 , 722–726. 107. National Center for Health Statistics. 2008. H eal th , U nited S tates, 2 0 0 8 . Hyattsville, MD: National Center for Health Statistics. Retrieved from http://www.cdc.gov/bloodpressure/facts. htm (accessed April 7, 2011). 108. Jones, D.W., Chambless, L.E., Folsom, A.R., Heiss, G., Hutchinson, R.G., Sharrett, A.R., . . . Taylor, H.A, Jr. 2002. Risk factors for coronary heart disease in African Americans, 1987– 1997. A r c h iv es of I nter nal M edic ine, 1 6 2 (22), 2565–2571. 109. Beutler, E., & West, C. 2005. Hematologic differ- ences between African-Americans and whites: The roles of iron deficiency and a-thalassemia on hemoglobin levels and mean corpuscular vol- ume. B l ood, 1 0 6 , 740–745. 110. Brar, P., Lee, A.R., Lewis, S.K., Bhagat, G., & Green, P.H. 2006. Celiac disease in African- Americans. Digestiv e Diseases and S c ienc es, 5 1 , 1012–1015. 111. Belachew, T., Nida, H., Getaneh, T., Woldemar- iam, D., & Getinet, W. 2005. Calcium deficiency and causation of rickets in Ethiopian children. E ast A f r ic an M edic al J our nal , 8 2 , 153–159. 112. Fogelman, Y., Rakover, Y., & Luboshitzky, R. 1995. High prevalence of vitamin D deficiency among Ethiopian women immigrants to Israel: Exacerbation during pregnancy and lactation. I sr ael i J our nal of M edic al S c ienc es, 3 1 , 221–224. 113. Mengesha, B., & Ergete, W. 2005. Staple Ethio- pian diet and cancer of the oesophagus. E ast A f r ic an M edic al J our nal , 8 2 , 353–356. 114. Ackerman, L.K. 1997. Health problems of refu- gees. J our nal of th e A mer ic an B oar d of F amil y P r ac tic e, 1 0 , 337–348. 115. Rasbridge, L.A. 2006. Sudanese. R ef ugee h eal th — I mmigr ant h eal th . Baylor University. Retrieved from http://www3.baylor.edu/~Charles_Kemp/ refugees.htm (accessed February 21, 2015). 116. Trostler, N. 1997. Health risks of immigration: The Yemenite and Ethiopian cases in Israel. B iomedic ine and P h ar mac oth er apy , 5 1 , 352–359. 117. Bursztyn, M., & Raz, I. 1993. Blood pressure, glucose, insulin and lipids of young Ethiopian recent immigrants to Israel and in those resident for 2 years. J our nal of H y per tension, 1 1 , 455–459. 118. Salah, A., Amanatidis, S., & Samman, S. 2002. Cross-sectional study of diet and risk factors for metabolic diseases in a Ghanaian population of Sydney, Australia. A sia P ac if ic J our nal of C l inic al N utr ition, 1 1 , 210–216. 119. Okafor, C.B. 2000. Folklore linked to pregnancy and birth in Nigeria. W ester n J our nal of N ur sing R esear c h , 2 2 , 189–202. 120. EthnoMed. 2006. E th iopian c ul tur al pr of il e. University of Washington, Harborview Medical Center. Retrieved from http://ethnomed.org/ ethnomed/cultures/ethiop/ethiop_cp.html 121. Meftuh, A.B., Tapsoba, L.P., & Lamounier, J.A. 1991. Breastfeeding practices in Ethiopian women in Southern California. I ndian J our nal of P ediatr ic s, 5 8 , 349–356. 122. Rasbridge, L.A. 2006. Sudanese. R ef ugee h eal th — I mmigr ant h eal th . Baylor University. Retrieved from http://www3.baylor.edu/~Charles_Kemp/ refugees.htm 123. Owens, C.W. 2004. Somali Bantu refugees. Eth- noMed, University of Washington Harborview Medical Center. Retrieved from http://eth- nomed.org/cultures/somali/somali_bantu.html 124. U.S. Census Bureau, Newsroom. F ac ts fo r fe a- tur es: B l ac k ( A f r ic an- A mer ic an) h istor y month : F ebr uar y 2 0 1 5 . Retrieved from http://www. census.gov/newsroom/facts-for-features/2015/ cb15-ff01.html (accessed February 21, 2015). 125. Giger, J.N., Davidhizar, R.E., & Turner, G. 1992. Black American folk medicine health care beliefs: Implications for nursing plans of care. T h e A B N F J our nal , 3 , 42–46. 126. Galanti, G.A. 2004. C ar ing f or patients f r om dif -C ar ing f or patients f r om dif -C ar ing f or patients f r om dif f er ent c ul tur es (3rd ed.). Philadelphia: University of Pennsylvania Press. 127. Jackson, B. 1976. The other kind of doctor: Con- jure and magic in black American folk medicine. In W.D. Hand (Ed.), A mer ic an f ol k medic ine. Berkeley: University of California Press. 128. Boyle, J.S., & MacKay, M.C. 1999. Pica: Sorting it out. J our nal of T r ansc ul tur al N ur sing, J our nal of T r ansc ul tur al N ur sing, J our nal of T r ansc ul tur al N ur sing 1 0 , 65–67. 129. Graham, R.E., Ahn, A.C., Davis, R.B., O’Connor, B.B., Eisenberg, D.M., & Phillips, R.S. 2005. Use of complementary and alternative medical ther- apies among racial and ethnic minority adults: Results from the 2002 National Health Interview Survey. J our nal of th e N ational M edic al A ssoc ia- tion, 9 7 , 535–545.9 7 , 535–545.9 7 130. Peregrin, T. 2006. Cooking with soul: A look into faith-based wellness programs. J our nal of th e A mer ic an Dietetic A ssoc iation, 1 0 6 , 1016–1020. 131. Fitzgibbon, M.L., Stolley, M.R., Ganschow, P., Schiffer, L., Wells, A., Simon, N., & Dyer, A. 2005. Results of a faith-based weight loss inter- vention for black women. J our nal of th e N ational M edic al A ssoc iation, 9 7 , 1393–1402.9 7 , 1393–1402.9 7 132. Kieffe, E.C., Willis, S.K., Odoms-Young, A.M., Guzman, J.R., Allen, A.J., Two Feathers, J., & Loveluck, J. 2004. Reducing disparities in dia- betes among African-American and Latino resi- dents of Detroit: The essential role of community planning focus groups. E th nic ity & Disease, 1 4 , S27–S37. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 2 3 6 A F R I C A N S 133. Kreuter, M.W., Sugg-Skinner, C., Holt, C.L., Clark, E.M., Haire-Joshu, D., Fu, Q., . . . Bucholtz, D. 2005. Cultural tailoring for mammography and fruit and vegetable intake among low- income African-American women in urban public health centers. P r ev entiv e M edic ine, 4 1 , 53–62. 134. Williams, J.H., Auslander, W.F., de Groot, M., Robinson, A.D., Houston, C., & Haire-Joshu, D. 2006. Cultural relevancy of a diabetes preven- tion nutrition program for African American women. H eal th P r omotion P r ac tic e, 7 , 56–67.7 , 56–67.7 135. Patel, C., & Nicol, A. 1997. Adaptation of African-American cultural and food preferences in end-stage renal disease clients. A dv anc es in R enal R epl ac ement T h er apy , 4 , 30–39. 136. Horowitz, C.R., Tuzzio, L., Rojas, M., Monteith, S.A., & Sisk, J.E. 2004. How do urban African Americans and Latinos view the influence of diet on hypertension? J our nal of H eal th C ar e f or th e P oor and U nder ser v ed, 1 5 , 631–644. 137. Beyene, Y. 1992. Medical disclosure and refugees: Telling bad news to Ethiopian patients. W ester n J our nal of M edic ine, 1 5 7 , 328–332.1 5 7 , 328–332.1 5 7 Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 2 3 7 Latinos from the Caribbean Islands and South America. Mexicans Estados Unidos Mexicanos, the United Mexican States, is the northernmost Latin American country. Though Mexico seems logically a part of Central America, it is geo- graphically a part of North America. It is more than one-fourth the size of the United States, with 756,065 square miles of territory. The varied geography includes a large central plateau surrounded by mountains except to the north. Coastal plains edge the country along the Gulf of Mexico and the Pacific. The separate Baja peninsula is found in the west, and the Yucatán peninsula juts out in the southeast. Snow-capped volcanoes, such as Orizaba, Popocatépetl, Ixtacchiuatl, and El Chichón, and frequent earthquakes also affect the landscape. The climate ranges from arid desert in the northern plains to tropical lowlands in the south. O ver 80 percent of Mexicans are mestizos—that is, of mixed Indian and Spanish ancestry, based on genomics, while European and indigenous ancestr y are approximately even. Spanish is the official language. Only 1.5 percent of Mexicans speak a single Indian language, mostly Nahuatl.1 Mexicans and Central Americans Hispanics are the largest non-European ethnic group in the United States, representing 17 percent of the total population. Yet they are not a single cultural group, coming from more than twenty-five Latin American nations with diverse ethnic populations. Though a majority share Spanish as a common language of origin, others speak English, French, Portuguese, or a native Indian dialect as their mother tongue. Immigrants from Mexico and the coun- tries of Central America bring a rich cul- tural history (see Figure 9.1). The Olmec culture, known for its sophisticated sculp- ture, existed in southeastern Mexico as early as 1200 bce. The great Aztec, Mayan, and Toltec civilizations thrived while Europe was in its Dark Ages. Their independent mas- tery of astronomy, architecture, agriculture, and art astonished later explorers. Spanish occupation of Mexico and Central America introduced new ideas and traditions, most notably Roman Catholicism; British, French, and Austrian intrusions also provided minor contributions. The foods of Mexico and Cen- tral America reflect the native Indian and European heritage of the region. This chap- ter examines Mexican cuisine and the food habits of Americans of Mexican descent. An overview of recent immigration from Central America and the traditional fare is also included. The following chapter reviews 9CHA P T E R The terms Latino and Latina describe men and women, respectively, who are originally from Mexico, the Caribbean, and Central and South America. It suggests culture of Latin heri- tage, not exclusively of Spanish background. For example, Haitians and Brazilians are both Latinos but speak French and Portuguese, respectively. Hispanic is preferred by some, though there is no clear definition of this term. It can mean “born in Latin America,” “ancestors born in Latin America,” “Spanish surnames,” or “Spanish speaking.” Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 2 3 8 M E X I C A N S A N D C E N T R A L A M E R I C A N S Cultural Perspective History of Mexicans in the United States Immigration Patterns Mexican immigration patterns have changed over the years since the Mexican-American War clearly defined the U.S.–Mexican border. Today, Mexicans living in America and their descendants can be clas- sified in the following groups: (1) Chicanos— those who are born in the United States (from the descendants of the wealthy Mexican landowners who controlled the area from California to Texas in the eighteenth and early nineteenth centuries to the children of the most recent arrivals), as well as those who immigrated from Mexico and became U.S. cit- izens; (2) Braceros—those who worked here legally but remained Mexican citizens; and (3) unauthorized migrants—those who enter the country illegally. It should be noted, how- ever, that use of identifiers may vary region- ally or by generation. For example, many who live in New Mexico prefer the terms Spanish American or Hispano, while in Texas, Tejano is popular. Mexicans lived in what is now the Ameri- can Southwest for hundreds of years before the United States declared its independence in 1776. Although they welcomed American settlers, they soon found themselves out- numbered, and their economic and political control of the region weakened. At the end of the Mexican-American War in 1848, the 75,000 Mexicans living in the ceded territories became U.S. citizens. Between 1900 and 1935, it is estimated that 10 percent of the Mexican population, approximately 1 million persons, emigrated north to the United States. Then, during the Great Depression, tens of thousands of unau- thorized migrants, plus those admitted legally under the 1917 contract labor laws, were repa- triated and sent back to Mexico. Gulf of MexicoNorthrthrt Pacific Ocean BELIZE EL SALVADORLVADORLV GUATEMALA HONDURAS UNITED STATESTATESTA NICARAGUA COSTA RICA PANAMA MEXICO Mexico City CUBA Figure 9.1 Mexico and Central America. © C en ga ge L ea rn in g Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 9 2 3 9 After the Great Depression, the need for cheap labor increased. The Bracero program was created to meet this need. Thousands of Mexicans were offered jobs in agriculture and on the railroads. Following World War II, the continued need for farm workers encouraged additional immigration, resulting in a total of over 4.5 million contracts (some individu- als obtained multiple contracts over several years) issued to Mexican nationals between 1942 and 1964. In the past thirty-five years, Mexicans have been the largest single group of legal immigrants to the United States.2 Current Demographics More than half of the growth in the total population of the United States between 2000 and 2010 was due to the increase in the Hispanic population, with Mexican Americans accounting for 75 per- cent of the increase in the Hispanic commu- nity. Population estimates from 2009 show Mexican Americans in the United States (of whom over 11.5 million were born in Mexico) accounting for 59 percent of the Latino popu- lation.3 The majority of Mexican Americans live in California, Texas, and Arizona. How- ever, the settlement pattern for new immi- grants has changed since the 1990s, becoming more nationwide as evidenced by Illinois having over one and a half million Mexican American residents.4 Eighty percent of the immigrants from Mexico settle in U.S. cities such as San Diego, Los Angeles, San Antonio, and Chicago—and more recently, Dallas, Houston, Las Vegas, Minneapolis, New York City, and Phoenix.5 Many recent immigrants, legal and unauthorized, settle in the urban Latino neighborhoods called barrios. Research on unauthorized Mexican immi- grants suggests that approximately 8 million were living in the United States in 2009.6 Economic pressures in Mexico have increased the number of Mexican immigrants entering the United States each year. Many are attempt- ing to escape the life-threatening poverty affecting many of the populace. Socioeconomic Status Mexican Americans occupy three main socioeconomic classes. There are the migrant farmworkers, who maintain a culturally isolated community; the residents of the urban barrios, who also are segregated from much of American society; and a growing number of accultur- ated middle-class Chicanos. Unauthorized migrants tend to move in with family mem- bers who already reside in the United States. Usually, this is in a predominantly Latino neighborhood where they can live incon- spicuously among the residents while becom- ing familiar with the American social and economic systems. Specific data on Mexican Americans are limited because they are often grouped with data for all Hispanics. Despite a rapidly growing Mexican American middle to upper class, many Amer- icans of Mexican descent have low median incomes and more than 25 percent of fami- lies fall below the poverty level. This is due in part to a disproportionate number of Mexican Americans employed in unskilled or semi- skilled labor. Although some work in agricul- tural jobs, more than 27 percent are employed in manufacturing or service occupations. Approximately 20 percent hold professional or managerial positions. The skill level is ris- ing with increasing education. Eighty percent of Mexican Americans graduate from high school, compared to 60 percent for adults who were born in Mexico.6 Worldview Mexican Americans and unauthorized migrants frequently live in culturally homo- geneous communities. Many proudly main- tain their ethnic identity, speaking Spanish and enjoying Mexican music and food. The concept of la raza (meaning “the people”) was first promoted in the 1960s as a pride and solidarity movement for all persons of Latin American heritage. When exposed to the mainstream American society, however, immigrants from Mexico can be highly adaptive. Some Chicanos are completely assimilated. They may speak no Spanish and consider them- selves white or simply American. Others are successfully bicultural. Cross-cultural mar- riages are becoming more common, especially in the northern regions of the United States. Religion Approximately 61 percent of Ameri- cans of Mexican descent are Roman Catholics, The terms Chicano and Chicana, for men and women, respectively, came from the Aztec word for Mexicans, Meshicano. Some immigrants from Mexico seeking migrant agricultural jobs are Mexican Indians (mostly Mixtecos from Oaxaca), who speak neither English nor Spanish. The 2011 Canadian Census listed more than 381,280 residents of Latin heritage, which repre- sents 5 percent of the Canadian population. When a girl turns fifteen years old, her family hosts a quinceañera, an elaborate coming-out party with music, feast- ing, and dancing. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 2 4 0 M E X I C A N S A N D C E N T R A L A M E R I C A N S which is less than the percentage found in Mexico (81 percent). Traditional religious cer- emonies, such as baptism, communion, con- firmation, marriage, and the novenas (nine days of prayer for the deceased), are important family events (see Chapter 4). A strong faith in the will of God influences how many immigrants from Mexico perceive their world. Many believe they have no direct control over their own fate. Nearly all Mexican Americans who are not Catholic practice Protestant faiths. Evangelical churches are particularly popular in urban areas. The Mexican American Family The most important social unit in this community is the family. In contrast to American majority soci- ety, the well-being of the family comes before the needs of the individual. The father (or eldest male relative) is typi- cally the head of the household. He is the primary decision maker and wage earner. Machismo, roughly translated as “manhood,” is the word for the pride and self-worth a man feels when fulfilling his obligations and duties to his family and community. In traditional Mexican culture the wife is a homemaker, the person who provides all child care and holds the family together. Women are expected to be subservient to their husbands. In America, however, this role is changing. One-half of Mexican American women work outside the home, are responsible for household manage- ment, and are likely to be involved in family decisions. Men rarely increase involvement in chores as women increase their hours of employment. Some women find that their new roles are occasionally in conflict with their self-concept as mother and caregiver. Children are cherished in the Mexican American family. Families are typically large among new immigrants and first-generation families, but research suggests lower rates of marriage and improvements in educational attainment and socioeconomic status for women of subsequent generations result in the birth of fewer children and smaller fami- lies.8 Children are taught to share and to work together; sibling rivalry is minimal. When pos- sible, an extended family is the preferred living arrangement for many Mexican Americans. Grandparents are honored and are often involved in child care. Because of space limita- tions in the United States, however, many elders live in separate apartments. During periods of hardship, other relatives such as aunts, uncles, and godparents willingly accept the care of children. Girls were traditionally raised differ- ently from boys and were kept at home to learn household skills; they were carefully chaper- oned in public. Although such strict supervi- sion diminished with successive generations born in the United States, family expectations may limit the educational and professional attainments of some young women. Traditional Health Beliefs and Practices Tradi- tional health care in Mexico includes elements of Indian supernatural rituals combined with European folk medicine introduced from Spain. Beliefs and practices are closely inter- related with the culture, resulting in a health system widely shared throughout Latin America. Most Mexican Americans are famil- iar with the conditions specific to the culture, and many use the traditional cures. Health is a gift from God, and illness is almost always due to outside forces (unless one is being punished by God for one’s sins). An individual must endure illness as inevi- table. Prayer is appropriate for all illness, and beseeching the saints for intervention through the lighting of candles on behalf of a sick per- son is common. Pilgrimages may be made to religious shrines, especially those devoted to the Virgin Mary or St. Francis. Health care is traditionally sought from a hierarchy of healers.8,9 Treatment is first discussed with señoras or abuelas—mothers, grandmothers, wives, or older female neigh- bors who are the health experts in each family. Home remedies, especially teas and over-the- counter remedies such as Pepto Bismol, Alka Seltzer, and Vicks Vapo-Rub, are nearly always tried first before outside help is sought.8 Laxatives and enemas are common. If a cure is not found, a yerbero (herbalist), sobador (massage therapist or occupational therapist), or a patera (midwife who also specializes in the care of small children) may be consulted. Traditional herbal remedies, homeopathic cures, and amulets are available at pharmacies Aztec medicine was a highly developed system featuring an elite group of certified practitioners with access to a zoo and a herbarium for research. It was abolished during the Spanish conquest. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 9 2 4 1 called botánicas.10 Therapeutic items may also be sold at religious fiestas. When an ailment is unresponsive to these cures, the services of a healer known as a curandero (or curandera if the healer is female) are sought. Curanderos are esteemed members of each community who see patients without an appointment and customarily do not charge for their services, though they may accept gratuities.11,12 Their healing pow- ers may be God-given at birth, learned, or received through a calling.13 Curanderos are sought for a broad range of complaints, such as marital problems, infertility, alcoholism, and business failure, as well as for specific ill- nesses, including diabetes and cancer. They are important in diagnosing the underlying causes of a condition, which may be natural or supernatural in nature. Thus, diabetes in a cli- ent may be due to lifestyle and diet, amenable to biomedicine, or it may be due to evil spirits or witchcraft, in which case biomedicine is ineffective.11 Curanderos specialize in somatic ailments and are essential to curing illnesses due to supernatural causes. In regions where witchcraft is practiced, a curandero can coun- teract the hexes or spells of a brujo (a person who works on behalf of the devil). Faith is crucial to the success of a curandero. Prayer is his or her primary treatment; the lighting of candles or the use of wood or metal effi- gies formed in the shape of the afflicted body part (called milagros or exvoto) may also be used. Cleansing rituals are applied in certain conditions. Illness is believed to be due to (1) exces- sive emotion, (2) dislocation of organs, (3) magic, (4) an imbalance in hot or cold, or (5) an Anglo disease, such as pneumonia and appendicitis.13 Treatment is based on the cause of the disorder. Susto is an ailment considered due to excessive emotion—such as smoldering anger or shame—usually associated with a specific event. The response may be physical, physi- ological, or psychological, and symptoms include anxiety, depression or sadness, lack of appetite, paleness, shaking, headaches, bad dreams and too much sleep, and ennui.10,14,15 A type of susto known as espanto, which occurs when an individual is so frightened by a ghost that the soul leaves the body, is the most typical form of the disorder. Susto is considered a serious condition, associ- ated with other illnesses such as epilepsy and infectious diseases. Mild susto is sometimes treated at home with sugar or sugar water. More serious susto, particularly when the soul is involved, must be cured by a curandero and may require lengthy treatment. Susto is also believed to be a cause of nervios, a condition affecting primarily adult women (nervios may also cause susto). Symptoms include crying attacks, sleep problems, headache, trembling, sadness or hopelessness, ill-temper, lack of appetite, stomachache, feeling of choking, chills, itching, and general body ache. Nervios responds best to sedatives (provided by a bio- medical physician), prayer, or massage. Unlike susto, nervios cannot be cured by a traditional healer. Nervios is often a chronic condition in response to poor diet, alcoholism, drug use, or other underlying health behaviors. Some Mexicans believe that nervios can cause dia- betes if not cured. Feeling too much rage and suffering from revenge fantasies can result in bilis, a condi- tion where excess bile is thought to spill into the blood, causing symptoms such as loss of appetite, vomiting, headaches, nightmares, and inability to urinate. Envidia is another ailment taking the form of various illnesses (some terminal) caused by the emotion of envy among one’s friends and neighbors. A person’s success may be tempered by the misfortune of envidia. A problem caused by the displacement of organs in infants is caida de la mollera, or fallen fontanel. It occurs from a fall, yanking the nipple out of a baby’s mouth too quickly, or holding a baby vertically when it is too young. The fontanel appears depressed, and the palate is believed to drop, preventing the infant from feeding. The inability to suckle and a change in stools are symptoms, and serious weight loss may occur. Tight caps on the infant can help prevent the condition, and the application of salt poultices or olive oil (followed by a dip in water accompanied by prayers) may be used to treat it. The baby may be held upside down and shaken gently, the hair pulled, the fontanel sucked, or the palate Studies report that susto is associated with an increased risk for other illnesses and a higher mortality rate.158 Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 2 4 2 M E X I C A N S A N D C E N T R A L A M E R I C A N S pressed up with a finger or thumb to reposi- tion the fontanel. Mal de ojo (evil eye) is a condition with supernatural origins. Children are consid- ered especially vulnerable to the ailment, which has flulike symptoms, including fever and headache. It is caused when one per- son, usually inadvertently, casts a strong, admiring look on another person. Irrational behavior and mental disabilities are often attributed to mal de ojo. This condition can result in death, so prompt diagnosis and cure are imperative. A curandero is required for treatment. A cleansing ritual is performed that includes sweeping over the ill individual with an egg, then breaking the egg into a sau- cer. The egg is read to see whether the cure has been effective. It may be read immedi- ately or left under the bed overnight before examination. Prayers, herb teas, and sweep- ing with herb bundles may also be part of the treatment. Mal aire (bad air or wind) may cause headaches and colds,10 and mal puesto (witchcraft) accounts for certain other disor- ders, such as swelling, trembling, or paralytic twitching. Empacho, a digestive ailment character- ized by nausea, gas, and weakness, is widely known throughout Latin America. Empacho is sometimes classified as an illness due to eating too many hot or cold foods, or a hot–cold imbalance in the stomach due One researcher has shown that some Mexican dishes reflect Islamic culinary traditions (which arrived via Spain), such as aromatic nut-thickened sauces, fruit pastes, and sugar figurines (see Chapters 6 and 13).159 The scientific name for the cacao tree is Theobroma, meaning “food of the gods.” Chile (with an e) comes from the Nahuatl word chilli. Foods like the pow- ders, sauces, and stews made with chile peppers are conventionally called chili (with an i). to emotional upset (see the “Therapeutic Uses of Food” section in this chapter). The direct cause is believed to be a ball or wad of food adhered to the stomach. Herb teas are administered at home, and if they are inef-administered at home, and if they are inef-administered at home, and if they are inef fective, a curandero is employed. Treatment consists of prayer, pinching the spine, and stomach massage to restore a proper hot– cold balance. Traditional Food Habits Mexicans are very proud of their culinary heritage, which is a unique blend of native and European foods prepared with Indian (mostly Aztec) and Spanish cooking tech- niques. There are even some French and Viennese influences from the Maximilian reign. The resulting cuisine is both spicy and sophisticated. Ingredients and Common Foods Many people associate the cooking of Mexico with chile peppers. Although chile peppers are used frequently, not all Mexican dishes are hot and spicy. Other New World foods such as beans, cocoa (from the Aztec word for “bitter”), corn, and tomatoes add equally important flavors to the cuisine. These indig- enous ingredients were the basis of Indian fare throughout Mexico before the arrival of the Spanish. Aztec Foods The Aztec Empire had an esti- mated population of 25 million people at its peak in the fifteenth century. About one- quarter of the population was an elite class of nobles supported by the remaining 75 percent of the Indian slave populace. The capital city of Tenochtitlán was surrounded by lakes on which were built chinampas, rich agricultural fields of mud scooped from the lake bottoms. These drought-resistant fields are believed to have produced enough food to feed 180,000 people annually. The monarchy stored surplus crops to protect against famine. The Aztecs were also known for their animal husbandry and game protection laws. Documents from early Spanish expedi- tions recorded in glowing terms the enormous variety of foods enjoyed by the Aztec nobil- ity.16 More than 1,000 dishes are described. ▼ Traditional Latin American foods. Some typical foods include achiote, avocado, bacalao, black beans, cassava (yucca), chile peppers, cilantro, corn tortillas, jícama, papaya, plantains, pinto beans, pork, tomatillos, and tomatoes. Ra gn ar S ch m uc k/ fS to p/ Co rb is Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 9 2 4 3 Montezuma II reportedly ate up to thirty dif-Montezuma II reportedly ate up to thirty dif-Montezuma II reportedly ate up to thirty dif ferent items per meal, each kept warm on a pottery brazier. These items included roast turkey, quail, and duck; fish, crab, lobster, frog, turtle, newt, and insect dishes garnished with red, green, or yellow chiles; squash blossoms; and sauces of chiles, tomatoes, squash seeds, or green plums.17 Chocolatl, a hot, unsweet- ened chocolate drink made from native cacao beans, was the most popular beverage. Corn was the staple grain. Legumes, fruits, and vegetables were plentiful; turkeys and dogs were domesticated for meat; and some game was available, including deer, peccary, and rabbits. The notable deficiency of the Aztec diet was a consistent source of fat or oil, and the average Indian ate a mostly vegetarian diet of corn and beans.16 Spanish Contributions The Spanish arrived in Mexico with cinnamon, garlic, onions, rice, sugarcane, wheat, and, most impor- tantly, hogs, which added a reliable source of domesticated protein and lard to the native diet. These additions combined with indigenous ingredients produce the classic flavors and foods of Mexican cuisine, such as corn tortillas with pork filling; tomato, chile, and onion sauces or salsas; rice and beans; and panfried boiled beans, known as frijoles refritos, or, as they are incorrectly called in English, refried beans. The Spanish also introduced the distillation of alcohol to native Mexican fermented beverages; tequila and mescal were the result. Staples The cuisine of Mexico is very diverse, and many inaccessible regions have retained their native diets. Others have held on to tra- ditional foods and food habits despite Aztec or Spanish domination. The diets of still other areas differ because of the availability of local fruits, vegetables, or meats. The majority of poor Mexicans have little variety in their diet; some subsist almost entirely on corn, beans, and squash. This divergence makes it difficult to typify Mexican foods in general (Table 9.1). Nevertheless, some foods are found, in vary- ing forms, throughout Mexico. Tortillas are the flat bread of Mexico. Traditionally they are made by hand. Corn kernels are heated in lime solution until the skins break and separate. The treated ker- nels, called nixtamal, are then pulverized on a stone slab (metate). The resulting flour, masa harina, is combined with water to make the tortilla dough. Small balls of the dough are patted into round, flat circles, about six to eight inches across. The tortillas are cooked on a griddle (often with a little lard) until soft or crisp, depending on the recipe. Beans are ubiquitous in Mexican meals. They are served in some form at nearly every lunch and dinner and are frequently found at breakfast, too. They are often the filling in stuffed foods and are common in side dishes, such as simmered frijoles de olla (“out of the pot”) and frijoles refritos. One-dish meals are typical, almost always served with warm tortillas. Hearty soups or stews called caldos are favorite family din- ner entrées. Casseroles known as sopas-secas, using stale tortilla pieces, rice, or macaroni, are eaten as main dishes. Stale tortillas can also be broken up and softened in a sauce to make chilaquiles, which are served as a side dish or light entrée. They can also be soaked in milk overnight, and then pureed to make a thick dough. This dough is used to prepare gordos, which are fat-fried cakes, or bolitos, which are added to soup and are similar to dumplings. Meats are normally prepared over high heat. They are typically grilled, as in carne ▼ Handmade tortillas, made from masa harina (a type of cornmeal) or wheat flour, are the staple bread of Mexico. In this pho- tograph, taken in a tortilla factory, the lime-soaked corn kernels are pulverized on a stone metate. Below, a tortilla is patted into a flat circle by hand. iS to ck ph ot o. co m /R ob er t I ng el ha rt Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 2 4 4 M E X I C A N S A N D C E N T R A L A M E R I C A N S Group Comments Common Foods Adaptations in the United States Protein Foods Milk/milk products Few dairy products are used (incidence of lactose intolerance estimated at two-thirds of the population). Dairy products are used more in northern Mexico than in other regions. Milk (cow, goat), evaporated milk, café con lèche, hot chocolate; atole; cheese Aged cheese is used in place of fresh cheese; more milk (usually whole) is consumed; ice cream is popular. Meat/poultry/fish/ eggs/legumes Vegetable protein is the primary source for majority of rural and urban poor. Pork, goat, poultry are common meats. Beef is preferred in northern areas and seafood in coastal regions. Meat is usually tough, prepared by marinating, chopping, grinding (sausages are popular), or slicing thinly. It is cooked by grilling, frying, stewing, or steaming, and is usually mixed with vegetables and cereals. Meats: beef, goat, pork (including chicharrónes and variety cuts) Poultry: chicken, turkey Fish and seafood: camarónes (shrimp), huachinango (red snapper), other firm- fleshed fish Eggs: chicken Legumes: black beans, chickpeas (garbanzo beans), kidney beans, pinto beans Traditional entrées remain popular. Fewer variety cuts are used. Protein intake may decline in second- generation Mexican Americans. Beans are eaten less frequently. Cereals/Grains Corn and rice products are used throughout the country; wheat products are more common in the north. Principal bread is tortilla; European-style breads and rolls are also popular. Corn (masa harina, pozole, tortillas); wheat (breads, rolls, pan dulce, pasta); rice Wheat tortillas are used more than corn tortillas; convenience breads are used. Increased consumption of baked sweets, such as doughnuts, cake, and cookies, is noted. Increased consumption has occurred of sugared breakfast cereals. Fruits/Vegetables Vegetables are usually served as part of a dish, not separately. Semitropical and tropical fruits are popular in most regions (limited availability in north). Fruits: bananas, carambola, casimiroa, cherimoya, coconut, custard apple, granadilla (passion fruit), guanábana, guava, lemons, limes, mamey, mangoes, mamey, mangoes, mamey melon, oranges, papaya, pineapple, strawberries, sugarcane, sweet sop, tuna (cactus fruit), zapote Vegetables: avocados, cactus (nopales or nopalitos), calabaza criolla (green pumpkin), chile peppers, corn, jícama, lettuce, onions, peas, plantains, potatoes, squashes (chayote, pumpkin, summer, etc.), squash blossoms, sweet potatoes, tomatillos, tomatoes, yams, yuca (cassava) Fruit remains popular as dessert and snack item; apples and grapes are accepted after familiarization. Additional Foods Seasonings Food is often heavily spiced; 92 varieties of chiles are used. Regional sauces are typical. Anise, achiote (annatto), chiles, cilantro (coriander leaves), cinnamon, cocoa, cumin, epazote, garlic, hoja santa, mace, onions, vanilla Use of spices depends on availability. TA B L E 9.1 Cultural Food Groups: Mexican Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 9 2 4 5 asada (beef strips), or fried, as in chicharrónes (fried pork rind). Slow, moist cooking (stew- ing, braising, etc.) may also be used. These techniques help tenderize the tough cuts that are generally available, as does marinating, another common preparation method. Nearly all parts of the animal are used, including the variety cuts and organs. Sausage, such as spicy pork or beef chorizo, is especially popular. Mexico is famous for its stuffed foods, such as tacos, flautas, enchiladas, tamales, quesadil- las, and burritos. These are found throughout the country, with regional variations. Tacos are the Mexican equivalent of sandwiches. Torti- llas, either soft or crisply fried, are filled with anything from just salsa to meat, vegetables, and sauce. Flautas (“flutes”) are a variation on the taco, with tortillas tightly rolled around the filling, then fried until crispy. They may be served with a red or green chile sauce or guacamole. Enchiladas are tortillas softened in lard or sauce and then filled with meat, poultry, seafood, cheese, or egg mixtures. The tortilla rolls are then baked covered with sauce. Tamales are one of the oldest Mexican foods, dating back at least to the Aztec period. Dough made with either masa harina or left- over pozole (hominy) is placed in corn husks (in the north) or young leaves of avocados or bananas (in the south). The leaves are folded and then baked in hot ashes or steamed over boiling water. The tamale may be plain, filled Corn is believed to have been domesticated from extinct wild varieties in southern Mexico some- where between 8000 and 7000 BCE. It spread south into Central America and north into what is now the United States. with a meat or vegetable mixture, or sweet- ened for a dessert (tamales dulce). After cooking, the husk or leaf is unfolded, reveal- ing the aromatic tamale. Quesadillas are tor- tillas filled with a little cheese, leftover meat, sausage, or vegetable, then folded in half and heated or crisply fried. Burritos are popular in northern Mexico. They are similar to tacos, but large, thin, wheat flour tortillas—instead of corn tortillas—are folded around a filling such as beans with salsa. Vegetables are usually part of the main dish or served as a substantial garnish. Potatoes, greens, tomatoes, and onions are most com- mon. Chile peppers are used extensively in seasonings and sauces, and are stuffed, as in chiles relleños and the Independence Day dish chiles en nogada, garnished with the colors of the Mexican flag—white sauce, green cilantro, and red pomegranate seeds. Sugarcane grows well in Mexico, and sweets of all kinds are popular. Dried fruits and vegetables, candied fruits and vegetables, and sugared fruit or nut pastes are eaten alone and used in more complex desserts. The Spanish make many desserts with eggs, and some of these recipes have been adopted in Mexico. Flan, a sweetened egg custard topped with caramelized sugar, is the most common. Huevos reales is another popular dessert, made with egg yolks, sugar, sherry, cinna- mon, pine nuts, and raisins. Dulce de leche is Group Comments Common Foods Adaptations in the United States Nuts/seeds Seeds are often used in flavoring. Piñons (pine nuts), pepitas (pumpkin seeds), sesame seeds Beverages Atole, beer, coffee (café con lèche), hot chocolate, soft drinks, pulque, mescal, tequila, whiskey, wine Noted are increased consumption of fruit juices, Kool-aid, soft drinks, and beverages with caffeine; and decrease in use of hard spirits. Fats/oils Traditional diet is relatively low in fat. Butter, manteca (lard) Fat intake increases, including use of mayonnaise and salad dressings. Sweeteners Spanish-influenced pastries, candies, and custards and puddings are popular. Sugar, panocha (raw brown cane sugar) © C en ga ge L ea rn in g Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 2 4 6 M E X I C A N S A N D C E N T R A L A M E R I C A N S Epazote, a pungent herb with minty over- tones, is added to many dishes, especially those with beans, because it is thought to reduce flatulence. Menudo is a tripe and hominy soup believed to have curative prop- erties, particularly for hangovers. It is a popular weekend breakfast dish. made by boiling condensed milk down until the sugars caramelize and it thickens. It is used as a spread or hardened to make candy. A similar, distinctive, Mexican specialty is cajeta, made like dulce de leche but using goat’s milk flavored with cinnamon. It is eaten by itself as a pudding or used to top fresh fruit or ice cream. The most common beverage in Mexico is coffee, which is grown in the south. Soft drinks and fresh fruit blended with water and sugar, called aguas naturales, are also favored. Adults drink milk infrequently, except in sweetened, flavored beverages such as hot chocolate with cinnamon, or café con leche (coffee with milk). The most popular alco- holic beverage in Mexico is beer. The Mexi- can wine industry is also developing rapidly, in part due to a 1982 ban on the import of foreign wine. Men may drink alcoholic bev- erages at occasions when they gather socially. In addition to tequila and mescal, whiskey is typically served at these times. Regional Variations Mexican Plains The northern and central regions of Mexico, nearly half the nation, consist of mostly arid plains and high moun- tain valleys. The Indians who originally inhabited the area were called Chichimecs (“sons of the dog”) by the Aztecs because of their seminomadic lifestyle. Their diet probably consisted of corn, beans, squash, greens, cactus fruit (tuna), and young cac- tus leaves (nopales). They also hunted small game and ate domesticated poultry, such as turkey. When the Mexican Indians mixed with the Indians of the American Southwest, they adopted piñons (also called pine nuts or pignolis), pumpkin, and plums. Some special- ties of the region, such as hominy-based stews known as pozoles and salads made with sliced, cooked nopales, reflect this history. Due to the limited variety of foods available, traditional preparations emphasize the natural flavors of the ingredients; and sauces, when used, fea- ture simple seasoning. The Spanish introduced longhorn cattle to the northern plains, as well as dairy cows and wheat. It is the only area in Mexico where beef is frequently consumed, often served as steaks or in stews. Another favorite way to prepare beef is to air-dry it in thin slices called cecinas, which are similar to American chipped beef but more assertive in flavor. Cecinas can be used in stews or soups; they can be fried or used as fillings for other foods. In Chihuahua, beef is shredded and then fried to make a snack known as móchomos. Goat and sheep are also raised. Spit-roasted kid, cabrito al pastor, is served in the Monterrey area, and birria—kid or lamb stewed in a sauce fla- vored with roasted chiles and vinegar—is a specialty in Guadalajara. This area is also known for barbacoa, a method of pit-roasting meats that are first wrapped in maguey leaves (see below). Cow cheeks (or more tradition- ally, the whole head) and kid are commonly prepared this way in the more northern sec- tions, while in the more central regions lamb is preferred.18 In the Baja peninsula and along the Gulf of California and Gulf of Mexico coasts, fish is important in the diet. Huachinango, red snapper, is a specialty, cooked in orange sauce, used as a filling in tacos, or served chilled, marinated in vinegar with onions and chiles. Shark is found on the eastern coast, shredded A large variety of chile peppers are used in Mexican cuisine, providing complexity of flavor, heat (very mild to incendiary), and color (yellow, orange, red, green, brown, and black). ▲ N at io na l G eo gr ap hi c Im ag e Co lle ct io n/ A la m y Placement of a worm from the maguey plant in a bottle of mescal or tequila— supposedly a signature of authenticity—was actually begun as a marketing gimmick. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 9 2 4 7 and layered between tortillas and beans in the dish from Campeche known as pan de cazón.19 Shrimp and clams are other favorites. In the more inland areas, fish from freshwater lakes are available, such as pescado blanco, a small whitefish that is popularly served fried or added to soups. Cheese (see Table 9.2) is more common in the north than in other parts of Mexico, and one specialty is queso flameado (called queso fundido in the Guadalajara area), which is a fondue-like dish sometimes topped with cho- rizo crumbles and served with fresh tortillas and salsa. Wheat products are more popular as well, particularly wheat tortillas. A very popular dessert of northern Mexico is buñuelos, which may be made at home or purchased at street stands. Circles of sweet pastry dough are fried until they slightly puff. They are eaten fresh, sprinkled with sugar and cinnamon, or broken up and added to hot cinnamon-laced syrup. Café con leche is a common accompaniment to buñuelos. The sap of the maguey cactus (century plant) is credited with being a reliable substi- tute for fresh water in the arid countryside; it is called aguamiel or “honey water.” Tequila is probably the best-known beverage of the region, made from the distillation of fer- mented aguamiel, known as pulque. Pulque is the sour, mildly alcoholic beverage that was drunk throughout Mexico before the arrival of the Spaniards. The Spaniards, lacking grain, tried their distillation methods on pulque, producing mescal, a harsh brew. Tequila is the more refined, twice-distilled version of mescal. It is produced in the central-western state of Jalisco around the towns of Tequila Fresh: Unripened cheeses that do not melt, but soften when heated. Often used in stuffed foods and as a garnish on top of dishes. Queso blanco Crumbly cow’s milk cheese similar to a soft, dry, fresh mozzarella. Sometimes made by using lemon juice to coagulate the milk, providing a distinctive flavor. Sold commercially in blocks. Queso fresca A fine-grained, creamy farmer’s cheese or pot cheese. Sometimes called queso metate when formed in a traditional stone grinder. Often made daily in homes; sold commercially in small rounds. Queso panela A salty, semisoft white cheese formed in small baskets that leave an imprint. Is often served cubed or sliced with chorizo sausage or guava paste. Ranchero seco Drier version of queso fresco with much stronger flavor (similar to Romano); curds are broken apart and remolded during processing. Used grated over foods. Requesón Milky, ricotta-like cheese good for fillings, spreads, and desserts. Soft: Smooth, aged cheeses that melt well when heated, often used for baked dishes. Queso añejo Aged queso fresco that is firm and salty, similar to feta. Queso asadero Buttery, mild cheese that tastes like Provolone but with the slightly stringy texture of aged Mozzarella; used in queso flameado. Queso Chihuahua Mild, cheddar-like yellow cheese formed in large wheels, introduced by Mennonites in the farming communities of Chihuahua. Queso Oaxaca Tangy string cheese from the city of Oaxaca. Sold in balls. Firm: Semihard or hard aged cheeses, often eaten thinly sliced or added for flavoring to dishes. Queso añejo enchilada Strong, salty cheese made from longer-aged añejo, coated with spicy ground chiles. Queso Cotija Sharp goat’s milk cheese that is crumbled over beans or salads, sometimes called “Mexican Parmesan.” From the Michoacan city of Cotija. Queso Manchego Spanish-style, full-bodied, hard cheese that is served shaved with fruit or eaten with snacks, beer, or other drinks. TA B L E 9. 2 Traditional Mexican Cheeses © C en ga ge L ea rn in g Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 2 4 8 M E X I C A N S A N D C E N T R A L A M E R I C A N S and Tepatitlan from the maguey subspecies Agave tequiliana. Tropical Mexico The southern coastal areas of eastern Mexico include hot lowlands and tropical forests. Seafood and freshwater fish are prominent in the cuisine. Red snapper with a Spanish-influenced sauce of tomatoes, garlic, onions, olives, capers, and chiles, called Huachinango a la Veracruzana (“from Vera- cruz”), is a specialty. Arroz a la Tumbada, rice cooked and seasoned with tomatoes and gar- lic, topped with fresh fish, shrimp, octopus, crabs, and clams, is another favorite. It is often served in individual clay pots. Tamales and tostadas stuffed with shrimp are also popular. One unusual food enjoyed in some areas is black iguana.20 Tomatoes, green tomato-like tomatil- los, chayote squash, onions, jícama (a sweet, crispy root), bananas and starchy plantains, carambola (star fruit), cherimoya (custard apple), guanábana (soursop), guava, mamey (a type of plum), mango, pineapple, yucca (a tuber also called cassava or manioc), and zapote (the fruit of the sapodilla tree) are just a small sampling of the produce available in this area. Avocados are also cultivated. They vary in size from two to eight inches across, in skin color from light green to black, and in flavor from bland to bitter. Their succulent, smooth flesh is added to soups, stews, and sal- ads. They are most popular in guacamole— mashed avocado with onions, tomatoes, chile peppers or ground chiles, and cilan- tro, the pungent leaf of the coriander plant. Guacamole is used as a side dish, a topping, or a filling for tortillas. More than ninety varieties of chile peppers are found in the region, varying enormously in degree of hotness (see Figure 9.2). In gen- eral, the smaller the chile the hotter it is, and each variety develops more heat as it ripens. The heat also intensifies when it is dried. Some of the more common varieties include ancho (dried, red-ripened poblano chiles), chilaca (thin, ribbed, dark green chiles which are often cut into very thin strips after roast- ing), chipotle (dried, smoked jalapeño chiles), de arbol (long, very thin, curved green or red chile used fresh and dried), guajillo (long, thin, dark red chile used primarily dried), habañero (lantern-shaped, yellow, orange, or dark red, added fresh to sauces but removed before serving, or roasted and chopped into dishes), pasilla (dried chilaca chiles), jalapeño (short, three-inch chiles with smooth green or red skin and blunt end, used fresh in salsas and sauces, or sliced and pickled), mulato (dried chile with very dark brown, wrinkled skin, and sweet overtones, often used to make moles—see below), pequin (tiny, oval chiles used whole in stews, added pureed in sauces, soups, salsas, or pickled as a table condiment), poblano (large, heart-shaped, black-green chiles that are often stuffed), and serrano (small, two-inch dark green or red, torpedo- shaped chiles that are often chopped to add zest to salsa and cooked dishes or sliced and pickled, known as escabeche). Yucatán The cuisine of the Yucatán penin- sula reflects its unique history. It was isolated from the rest of the country by dense, moun- tainous jungles until modern times. Many of the residents are descendants of the Mayans, the early Indian dynasty of the region. Some regional favorites date from this time. For example, one popular preparation method is to steam foods wrapped in banana leaves, called píbil. Traditionally, food was cooked this way in an outdoor pit, but today it is pre- pared more often in a covered pot. Salbutes, small corn tortillas (some made with black bean paste so that they are black in color), are often fried until they puff, then layered with lettuce or cabbage, tomato, onion, bell pepper, and píbil-cooked meats. In some versions the black beans are stuffed inside the pocket of the puffed tortilla, in which case the treat is known as panucho. Citrus fruits flavor some dishes of the region. For example, in the recipe for chicken píbil, the poultry is marinated in sour orange juice, garlic, and cumin before steaming. A popular sliced pork dish, poc chuc, also uses sour orange juice to tenderize the meat before grilling. Bitter lime juice is featured in a spe- cialty of the area called sopa de lima, a chicken and vegetable soup made with bits of fried tortillas. Lime juice is also found in frijoles con puerco, a traditional dish of black beans Avocado comes from the Nahuatl word for the fruit, ahuactl, meaning “testicle,” which avocados resemble while hanging from the tree. The chemical heat of chiles comes from the alkaloid capsaicin, found mostly in the fleshy ribs and seeds inside the fruit. One theory as to why eating chiles is pleasur- able is that capsaicin may cause the body to release pain-killing endorphins in reaction to the irrita- tion, creating a comfort- able, gratified feeling. Achiote is called annatto in the United States. Made from the seeds of a tropical tree, achiote is sometimes used to color cheddar-style cheeses, ice creams, margarine, and some baked goods. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 9 2 4 9 with pork served weekly in most homes of the region. Some foods are pickled in citrus juice, including vegetables such as onions, and other items, including fish and oysters. Achiote is the other hallmark seasoning of the region, a bright red, nutty-flavored seed mixed with sour orange juice and mild spices to make a flavorful paste called recado colorado, used to coat foods before cooking. Shrimp are a local specialty; the long coast- line of the Yucatán along the Gulf of Mexico provides ample seafood. Grouper with recado baked in banana leaves is one example, and fish soups are also common. Eggs are promi- nent, served with tortillas, black beans, cheese, tomato sauce, and fried plantains, or wrapped in tortillas and served with a pumpkin seed sauce. Sauces of the region are often thickened with toasted squash seeds. Southern Mexico The foods of southern Mexico are similar to those of the Yucatán in that they are more tropical and more Indian- influenced than the foods of other regions. Cacao trees are cultivated in this area, and chocolate flavors both savory and sweet dishes. In particular, the renowned sauces of the region, moles (probably from the Aztec word for “sauce with chiles,” molli), some- times include unsweetened chocolate. Chiles, tomatoes, nuts, raisins, sesame seeds, avocado leaves, and seasonings are other typical ingre- dients. The complex, spicy sauces are the base for thick stews with added pork, beef, poul- try, or game, though some recipes call for the mole to be poured over the top of the meat. In Oaxaca mole manchamanteles (meaning “stew that stains the tablecloth”) is a deep-red sauce with yams, pineapple, plantains, and chicken or pork. Mole negro, another Oaxacan specialty, includes dark-roasted chiles, black- ened tortillas, and chicken. The best-known mole in Puebla is poblano de guajolote, a rich brown sauce served with turkey. Other variations include mole amarillo (an orange- colored sauce) and mole coloradito (a brick- red version also known as mole roja). Mole verde is yet another example, popular along the coast, made with green chiles and tomatil- los. Hoja santa (Piper sanctum), an herb with a peppery, anise flavor, seasons the sauce—the large leaves of the herb are also used to wrap steamed and grilled foods in the region. Poultry, goat, and pork are the most popu- lar meats of the region. One favorite is pork cut into thin strips and coated with ground chiles to make cecina enchilada (a version of the northern recipe above). It is frequently served as a topping on crunchy, platter-sized baked tortillas called tlayuda, which also include layers of black beans (more popular in the south than pintos), cabbage, salsa, tes- ajo (thinly sliced beef ), asiento (bits of pork skin fried in lard), chorizo, and cheese. Game, such as venison and quail, are eaten in some areas. One delicacy of the region is chapu- lines, a grasshopper found in the cornfields. They are panfried with chiles, garlic, salt, and lemon juice and traditionally served with beer or mescal.21 Figure 9.2 Scoville Scale of Hotness for Selected Chile Peppers: Scoville units, defined as the amount of sugar water needed to dilute chile pungency to the point it no longer burns the mouth, is one measure of chile hotness. It is a subjective scale, and hotness may vary within each variety due to seed lineage, soil, and climate, as well as taster individuality. High pressure liquid chromotography (HPLC) is another measure, but does not account for differences in capsaicin release properties, which also affect chile heat. PuPure Capsaicin Habañero Scotch Bonnet Scotch Bonnet Tepin (wild) Pequin Cayenne Ají De Arbol Serrano Chipolte Jalapeño Guajillo New Mexico Anahei Pasilla Mulato Ancho Chilaca Poblano Pimento Sweet Bell 15,000,000-16,000,000 150,000-577,000 150,000- 325,000 80,000-240,000 70,000-100,000 30,000-50,000 30,000-50,000 15,000-30,000 8,000-22,000 5,000-8,000 2,500-8,000 2,500-5,000 500-2,500 500-2,500 1,000-2,000 1,000-2,000 1,000-2,000 1,000-2,000 1,000-2,000 0 0 © C en ga ge L ea rn in g Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 2 5 0 M E X I C A N S A N D C E N T R A L A M E R I C A N S Hot chocolate, coffee, atole (a warm bev- erage of thin cornmeal and milk gruel) and horchata, a sweetened rice-based drink, are favorite beverages. Ice creams, including those made with fresh vanilla bean, and fruit ices are popular, as is chocolate flan. Meal Composition and Cycle Daily Patterns In families where income is not limited, the preferred meal pattern is four to five daily meals: desayuno (breakfast), almuerzo (coffee break), comida or almuerzo (lunch), merienda (late afternoon snack), and cena (dinner). Most meals are eaten at home and served family-style. If there are too many people to sit at the table, each one is served individually from the stove. Desayuno is a quick, early breakfast, which features pan dulce (sweet bread, pastry, or cake) or fresh fruit, served with café con lèche. Late morning is when almuerzo (similar to brunch) is eaten, often including tortillas, eggs, meat, beans left over from the previous night, bolillos (wheat rolls), pan dulce, and fruit. Coffee and hot chocolate are the pre- ferred beverages. Comida is traditionally the largest meal of the day, traditionally eaten in the early afternoon. A complete comida includes sev- eral courses, individually served. Custom- arily this would include a soup, a sopa-seca (including items that would be considered side dishes in the United States, such as sea- soned rice), a main course, beans, salad, and dessert. Today, the courses may be combined or, often, fewer are served. For example, soup, a sopa-seca, or a vegetable dish may precede the entrée. When possible, an afternoon rest period (siesta) follows this meal. Merienda is a light meal of sweet rolls, cake, or cookies eaten around 6:00 p.m. Coffee, hot chocolate, or atole accompanies the sweets. Cena, a light supper (often leftovers), follows between 8:00 and 10:00 p.m. This meal may be skipped entirely or expanded into a substantial feast on holidays or other formal occasions. Recently, many Mexicans have adopted the American habit of eating a light lunch (sometimes called almuerzo) and a heavy supper, eliminating merienda altogether. Snacking is frequent in urban Mexico; munching occurs from morning to midnight. Antojitos, or “little whims,” include foods made with masa, such as tostadas (called chalupas in northern Mexico), fried tortillas topped with shredded lettuce, cheese, or meat. These may be eaten as a snack or served for a light supper. Nearly every block offers street- side food vendors, providing everything from fresh fruits to grilled meats. Pastelerías offer coffee, chocolates, and pastries. In addition, many neighborhoods feature an open-air market that also sells ready-to-eat foods. Can- tinas are popular gathering places. Originally males-only drinking establishments, many now welcome women and families. Botanas, roughly translated as “cocktail foods,” are small plates of items that go well with alco- holic beverages (especially beer), such as cheese, sausages, fritters, tortillas with beans or salsa, and sometimes Anglicized Mexican dishes such as guacamole with tortilla chips, or other non-Mexican items, such as hum- mus. The term is often used for appetizers of any kind. Special Occasions Sundays, family celebra- tions (such as weddings, baptisms, and quince- añeras), and holidays are typically times when more difficult preparations are served. For example, homemade tamales or moles are labor intensive and may require numerous ingredients, so these foods are often reserved for special occasions.7 Turkey, arroz con leche (rice pudding), and pastel de tres leches, a rich sponge cake lightly soaked in three types of milk (whole or cream, condensed milk, and evaporated milk) and then topped with whipped cream, are other festive foods eaten throughout the year. Many foods are associated with specific holidays. For example, Día de los Santos Reyes (also called Día de los Reyes Magos, or Three Kings Day) on January 6 is customarily cel- ebrated with rosca de reyes, a raisin-studded, ring-shaped loaf of bread. Baked inside the bread is a figurine of the infant Jesus, and the person who receives it is obligated to give a party on Candelaria Day (February 2). Candelaria Day includes a mass, followed by Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 9 2 5 1 games and sweets such as tamales dulce and pink-tinted atole.22 During Lent, capirotada is a traditional dessert. Many families have their own recipe for this holiday bread pudding, often made with honey or brown sugar, cinnamon, nuts, raisins, and cheese. Another holiday food is bread decorated with a skull and crossbones (pan de muerto) eaten on Días de los Muertos (Days of the Dead, November 1 and 2) as part of a large feast honoring the deceased (the first day for children, the second for adults—additional days, for deaths due to certain causes, such as accidents, are identi- fied in some regions). Sugar paste is used to mold skulls and skeletons of the dead, known as alfeñique (a word of Arab origin), which are colorfully decorated with icing. Altars for the dead are set up in homes with a bowl of water to quench the thirst of the spirit, his or her favorite foods, pan de muerto, sugar skulls, fruit pastes, and dulce de calabaza (pumpkin cooked with brown sugar). Coffee, chocolate, atole, soft drinks, and preferred alcoholic beverages are offered as well.23 After the departed soul has absorbed the essence of the meal through the aromas, the family eats the remaining food. Christmas festivities, called posadas, fre- quently feature piñatas, or brightly deco- rated papier-mâché animals and figures that are filled with sweets. Blindfolded children take turns swinging a large stick at the hang- ing piñata until it breaks and candies fly everywhere. In some regions buñuelos are a Christmastime treat, drenched in syrup and served in pottery bowls that, when empty, are smashed on the street for good luck. On Christmas Eve a salad of fruits, nuts, and beets is served. Role of Food and Etiquette in Mexican Society In family-centered Mexican society, food- related activities facilitate interactions between family members and help delineate family roles. Meal planning is usually the wife’s responsibility. Depending on economic status, food is prepared by the wife or by ser- vants supervised by her, because Mexican foods can be laborious to prepare.17 The final dishes are greatly appreciated by all who par- take in the meal, and it is considered an insult not to eat everything that is served. In rural areas, food sharing is an important social activity, reflecting the Indian worldview. To reject offered food or drink is a severe breach of social conduct. Even refusal of an invita- tion to dine may be considered rude, though not attending an agreed upon event is often completely acceptable.26 No guest should begin eating at a Mexican meal until the host says “¡Buen provecho!,”24 which translates to “Enjoy your meal!” Mexicans share many dining rules with Europeans. The fork remains in the left hand and the knife in the right one. No switching is done when cutting food. When not eat- ing, the hands should remain above the table, with the wrists resting on the edge. Dishes are passed to the left. Portions are usually large, and it is all right to leave some food on your plate. Leaving the table for any reason before others are finished with the meal is impolite. S A M P L E M E N U A Traditional Oaxacan Comida Ch ilaquile s (Tortilla Casserole)a,b Chicken or Pork C olor ad it o (M ole R ojo)a,b,c Simmered Black Beansa,b and Rice Fresh Tropical Fruit or Fruit Ice/Sherbeta,b Fruit Juice or Beer aMartinez, Z. 1997. The food and life of Oaxaca: Traditional recipes from Mexico’s heart. New York: Macmillan. bOaxaca’s Tourist Guide (Cultural Attractions): Recipes at http://www.oaxaca-travel.com/guide/index.php?lang5us chttp://allrecipes.com/Recipe/Mexican-Mole-Sauce/ Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 2 5 2 M E X I C A N S A N D C E N T R A L A M E R I C A N S Therapeutic Uses of Food Some Mexican Indians and rural poor prac- tice a hot–cold system of diet and health. It is believed to have derived from the Arab system of humoral medicine brought to Mexico by the Spanish, combined with the native Indian worldview. Although it has parallels with other classification systems, such as the Asian prac- tice of yin–yang (see Chapter 11 for details), the Mexican system is applied only to foods and to the prevention and treatment of illness. It does not encompass moral or social beliefs. The Mexican hot–cold theory is based on the concept that the world’s resources are limited and must remain in balance. People must stay in harmony with the environment. Hot has the connotation of strength; cold, of weakness. When the theory is applied to foods, items can be classified according to proximity to the sun, method of preparation, or how the food is thought to affect the body. Meals balanced between hot and cold foods are considered to be health promoting. Unbal- anced meals may cause illness. Thus a typical comida in a rural village would consist of rice (hot), soup (made with hot and cold ingredi- ents), and beans (cold). Although the hot–cold classification of foods does vary, items generally considered hot are alcohol, aromatic beverages, beef, chiles, corn husks, oils, onions, pork, radishes, and tamales. Cold foods include citrus fruits, dairy products, most fresh vegetables, goat, and tropical fruits. Some foods, such as beans, corn products, rice products, sugary foods, and wheat products, can be classified as either hot or cold depending on how they are prepared. Illnesses are also believed to be hot or cold and are usually treated with a diet rich in foods of the opposite classification. Examples of hot conditions include pregnancy, hyper- tension, diabetes, indigestion, susto, bilis, and mal de ojo.and mal de ojo.and 9 In particular, many Mexi- can women increase their intake of cooling fruits, such as melons, mangoes, and bananas, and avoid hot, spicy foods and chiles during pregnancy. Some also believe that very cold foods, including cucumbers, tomatoes, and watermelon, can create a sudden imbalance. Examples of cold conditions are pneumonia, colic, and empacho. Sour foods are thought by some to thin the blood and are avoided by menstruating women because they are thought to increase blood flow; acidic foods may also be avoided because they are said to cause menstrual cramps (menstruation is con- sidered a hot condition by some, and a cold condition by others). Though the hot–cold system of food clas- sification is practiced by small numbers of Mexicans, one study reported that Latinos are more likely than non-Latinos to con- sider certain foods herbal medicines, and other research suggests home remedies are common.25,26,27 For example, chamomile is believed by many to cure colic, menstrual cramps, anxiety, insomnia, and itching eyes. Mint and anise tea are also prepared for nau- sea, gas, diarrhea, and colic. Garlic is chewed for yeast infections in the mouth, toothache pain, and stomach disorders; boiled peanut broth is used to cure diarrhea; boiled corn silk is taken for kidney pain; honey and water are given to infants for colic; oregano is used for fever, dry cough, asthma, and amenorrhea; and papaya is thought to help cure digestive ailments, asthma, tuberculosis, and intestinal parasites.9,13 Of particular interest are remedies for hypertension and diabetes. Hypertension may be treated with garlic, passion flower, or linden flowers. The leaves of the sapodilla tree, known as zapote blanco, which act as a strong sedative, are also used in a tea to lower blood pressure.9,26 For diabetes, several botanical remedies are used. Sage tea is common, as are infusions made from tronadora root (trumpet flower) and prodigiosa leaves and flowers (brickle- bush). Preparations made with Indian plan- tains (matarique), papayas, bitter gourds, aloe vera juice, and prickly pear cactus (both the tuna and nopales) are also popular.26,28 Several of these remedies have been shown to have potent diuretic or hypoglycemic properties. Contemporary Food Habits in the United States The foods of Mexico have significantly influenced cooking in regions of the United States bordering the nation. Four separate regional variations have been identified (see Early researchers were perplexed by the absence of the niacin- deficiency disease, pel- lagra, in Mexicans who consumed a corn-based diet. Pellagra was com- mon in the southern United States, where corn was also a staple. It was found that when the corn kernels were prepared for masa harina, the alkaline lime solution used to soften them released the niacin that was bound to a protein.160 Some Mexicans avoid cold air and drafts after eating chiles (which are classified as hot) to avoid causing a sudden imbal- ance in their bodies. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 9 2 5 3 Chapter 15 on regional U.S. foods for more information).29 The first region is Texas, where Mexican food has often been modi- fied into completely American dishes, such as tamale pie and nachos. Other foods retain slightly more of their Mexican heritage, such as chili con carne, which was developed just after the Mexican-American War in the 1850s. It probably began as a chile colorado (red chile stew), but was tamed by reducing the spicing and diluting the traditional meat dish with beans. Barbecued chile-spiced meat kebobs called anacuchos and capriotada with whiskey sauce known as “drunken pudding” are other examples of Tex-Mex creativity. The most commonly used chiles in Tex-Mex cooking are anchos and jalapeños, though pequins are also popular in some dishes, and a favorite season- ing is cumin. Beef is commonly ground rather than shredded for stuffed dishes.30 The Mexi- can restaurant staple in the United States— known as a combo plate, featuring a selection of enchiladas, tacos, and other stuffed items served with rice and beans all at one time—is also thought to be a Texas invention.29 The second region is New Mexico, where a single chile pepper developed for the region, known as the New Mexico chile, dominates seasoning. It is mildly pungent, used green in chile verde and red in chile colorado. Unlike the complex sauces of southern Mexico that include numerous types of ground chiles and different seasonings, these northern-Mexico- influenced sauces are often made simply with ground red chile pepper, water, garlic, oreg- ano, and salt to taste. Pork replaces beef, kid, and lamb in many dishes. The third region is Sonora, encompassing both the Mexican state and southern Arizona. As in New Mex- ico, milder chiles are preferred (in this case, Anaheims), and in some recipes the season- ing is so tepid that “chile” has been dropped from the name, resulting in “carne verde,” for example.29 Beef is the favored meat, and a tra- ditional dried beef jerky, machaca, is still used, shredded, for stuffed foods. Large, finely tex- tured wheat tortillas are a specialty, and this region may be the original home of burritos and their deep-fried version, chimichangas. The fourth and final region is along the California border, where the fluid movement of people back and forth between the nations has resulted in fare that cannot be claimed by either nation as its own, nor as a cuisine unique to the area.31 Numerous American fast-food franchises are established in Mex- ico, and on the U.S. side taco shops and Latino grocery stores offer Mexican dishes. However, most businesses provide a mix of products, even the franchise restaurants. For example, Mexicans can purchase hamburgers and fries with jalapeños on the side, and diners in the United States can order “American burritos” filled with refried beans, carne asada, and French fries. The market for Latino foods through- out the United States has grown dramati- cally since the 1980s, when the fare of Texas, New Mexico, and Arizona gained national recognition. It was expected to be a $10 billion a year industry in 2014.32 In the 1990s sales of salsa surpassed those of ketchup for the first time, and salsa has continued to dominate the condiment market. Tortillas and tortilla chips are also selling well. At the same time that Americanized Mexican foods, such as tacos in S A M P L E M E N U A Border Dinner Fresh Red Salsaa,b and Tortilla Chips Ch imich an gas a,b,c A r r oz a la Mexicana (Red Rice)a,b Refried Beans Almond Puddinga,b aTausend, M. 1997. Cocina de la familia: More than 200 authentic recipes from Mexican-American home kitchens. New York: Simon & Schuster. bSouthwestern Recipes at http://www.recipegoldmine.com/sw/sw.html cChimichanga History and Recipe at http://whatscookingamerica.net/History/Chimichanga.htm In the late nineteenth and early twentieth century, chile con carne stands were common in San Antonio, offer- ing a spicier version of the Texas stew made by Latina women in the community, who were known as the “Chile Queens.” They were shut down in the 1930s due to supposed health concerns.29 Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 2 5 4 M E X I C A N S A N D C E N T R A L A M E R I C A N S hard shells and fajitas, are spreading through- out the country, an appreciation of authentic regional Mexican fare is also increasing. Adaptations of Food Habits Ingredients and Common Foods Many Mexi- cans in the United States eat a diet similar to that of their homeland. Recent immigrants, those who live near the U.S.–Mexican bor- der, and migrant workers are most likely to continue traditional food habits. In a compre- hensive review of published research on the effect of acculturation on the diet of Latinos in the United States, no relationship between acculturation and dietary fat intake or per- centage of energy from fat was evident. How- ever, the source of the fat differed depending on acculturation. Less acculturated fat sources were from consumption of whole milk and fat added during food preparation, whereas among the more acculturated Latinos, fat sources were fast food, snacks, and added fats. In addition, the less acculturated individuals consumed more fruit, rice, and beans and fewer sugar and sugar-sweetened beverages than the more acculturated Latinos.33 Chicanos and Mexicans who are well estab- lished in the United States often become quite acculturated. An early marketing study noted that Mexican immigrants living in the south- western United States are more likely to eat a diet with a high intake of red meats, white bread, sugared cereals, caffeine-containing beverages, and soft drinks than their socio- economic counterparts in Mexico or white neighbors. This suggests that, rather than adopting a diet that falls somewhere between the food habits of Mexico and those of the United States, the Mexican immigrants in the survey accepted the stereotypical American consumption patterns of the 1950s through 1970s.34 In the intervening years, other studies have offered confirmation of these data. Stud- ies on Latinos in Southern California (who would be predominantly Mexican American) and Mexican Americans living in Washington have found higher intakes of fast foods, con- venience items, salty snacks, chocolate, and added fat at the table with bread and pota- toes, combined with lower intakes of beans, peas, fruits, and vegetables associated with acculturation.35,36,37,38 A more comprehensive study has detailed these changes. In a large sample of Mexican Americans, it was found that the greatest dietary changes occurred between the first generation born in Mexico and the sec- ond generation born in the United States— changes between the second generation and third generation were less significant. The exception was consumption of corn tortillas, which decreased 69 percent between the first and second generations, with an additional 30 percent drop observed between the second and third generations.39,40 Conversely, intakes of some items remained relatively constant between generations, particularly those of beef, green vegetables other than salad, and some fruits (bananas, apples, oranges and orange or grapefruit juice, and cantaloupe). Specific changes seen between the Mexican-born subjects and the first genera- tion of U.S.-born subjects included reduced consumption of legumes, most vegetables, rice, and pasta, and increased consumption of breads, cereals, margarine, mayonnaise, but- ter, potato chips, and French fries.39,40 Intake of eggs and of American-style cheese also increases with these subjects. Whole milk, which is preferred among Mexican-born sub- jects, is replaced with low-fat or nonfat milk by U.S.-born subjects. Soda intake is high in all generations, although the U.S.-born sub- jects prefer diet sodas. Coffee is popular in all groups. Alcohol intake in general increases, with beer consumption among males espe- cially popular (increasing 51 percent).41 A preference for sweet or carbonated bev- erages usually increases in the United States. Soft drinks, Kool-Aid, and juices are popular with meals and as snacks. More acculturated Mexican Americans buy many prepared and convenience foods. Baked goods are usually purchased, including tortillas (often wheat tortillas are chosen over corn), breads, pan dulce, and even special desserts like flan. Extra income is usually spent on meats, espe- cially more expensive cuts such as steaks and pork chops, and processed meats, such as hot dogs and bologna.31,39,42 Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 9 2 5 5 Meal Composition and Cycle Daily Patterns Few current data on the meal patterns of Mexican migrant farmworkers have been reported, but older data indicate that traditional foods are preferred for most meals. These include eggs, beans or meat, and tortillas or pan dulce for breakfast; a large lunch of beans, tortillas, and meat, or a soup or stew; and a lighter dinner of tortillas, beans or meat, and rice or potatoes. As in Mexico, vegetables tend to be served as part of a soup or stew. Fruit remains a typical snack and dessert, especially familiar varieties such as bananas, oranges, mangoes, guava, pineapple, strawberries, and melon.43,44 Chicanos more often adopt the Ameri- can meal pattern of small breakfast, small lunch, and large dinner; and meal-skipping may occur. As tortilla consumption declines, breads and breakfast cereals have become popular with all family members, and sand- wiches are a common lunch item. Meats and cheese become more prevalent at meals, beans are eaten less frequently, and vegetables are served as side dishes. Snacking has been found to increase, especially in the evenings, and is associated with education. College graduates are more likely to snack daily than are those who attended only elementary or high school.22,45,46,47 Soda, Kool-Aid, juice, beer, and coffee are consumed with meals or snacks throughout the day. Milk is considered a superfood for children, but adults, especially men, may consider it to be a juvenile drink. Milk is often flavored with chocolate, eggs, and bananas in a drink called licuado; mixed with coffee; or mixed with cornmeal to make atole. Some adults reject milk completely, saying that they are allergic to it (it is esti- mated that 50 percent of Latinos are lactose intolerant).48 Changes in preparation methods may also occur. Recent immigrants may not know how to use the baking and broiling apparatus on an oven and may continue to fry and grill foods outdoors. Newer immigrants sometimes avoid canned and frozen foods because they do not know how to prepare them. Soup is prepared at home three times more often by Hispanics than by non-Hispanics, according to one marketing survey, but this rate drops significantly with acculturation.49 General spending patterns, however, suggest that cooking at home is still common: Hispanics spend more than double the average for flour and 166 percent more on dried beans.42 Single women, those with larger families to feed, and those who identify more with their Mexican heritage have been found more likely to shop at small ethnic groceries or convenience stores that often have fewer healthy food options and may charge more for items such as low-fat milk compared to whole milk.35,50,51 Hispanics frequent restaurants more than any other ethnic group in the United States. Among Mexican Americans’ favorite types of establishments (in order of popularity) are fast food, pizza, Mexican fast food, Chinese, coffee shops, and full-service Mexican.52 One study of Latina women in the Los Angeles area found that younger, employed women with lower incomes who had lived more years in the United States preferred fast-food res- taurants, stating that distance, price, and a child-friendly environment were deciding factors in choice of establishment.35 In 2010 it was reported that over 13 percent of Hispanic children eat at a fast-food or sit-down restau- rant three or more times a week.53 Special Occasions The Mexican custom of reserving foods requiring extensive prepa- ration, such as tamales and enchiladas, for Sunday and holiday meals is continued in the United States.6 Even if such dishes are served only occasionally at family celebrations, Mexi- can Americans reconnect with their heritage through the preparation and consumption of these traditional items.29 In one study that included holiday practices of migrant work- ers,43 no main dish preferences were found for Easter, and tamales were favored for Christ- mas. Turkey with mashed potatoes was the most popular Thanksgiving entrée, indicating that this American holiday was adopted along with its traditional foods. In addition to religious holidays, two secular celebrations are significant in the Mexican American community. The first is Mexican Independence Day on September 16, Though consumption decreases with accul- turation, it is estimated that Mexican Americans eat more beans than any other group in the United States—thirty- four pounds per person annually, compared to six pounds per person each year for whites.30 In Mexico, the prevalence of malnutrition resulting in stunting of children varies between 10 and 35 percent depending on region.168 Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 2 5 6 M E X I C A N S A N D C E N T R A L A M E R I C A N S commemorating the war of liberation from Spain. Observations emphasize ethnic unity, such as mariachis and traditional clothing. Foods the color of the Mexican flag, such as white rice, green avocado, and red or green chile peppers, are eaten. Cinco de Mayo (May 5), the second secular holiday celebrated, is more widely recognized by all ethnic groups throughout the United States even though the meaning of the event (remembrance of a his- toric victory over France) is often forgotten amid the parades, piñatas, and Aztec dancing that typify the day. More recently, Mexica Aztec New Year’s Day has emerged as a celebration in some Mexican American communities. It welcomes the beginning of the Aztec solar year, com- prised of eighteen periods of twenty days each, plus several separate days of reflection. Four signs—“rabbit,” “reed,” “flint,” and “house”— are used to designate each year, along with a number between one and thirteen, result- ing in a fifty-two-year cycle. Each new cycle begins with an elaborate New Fire Ceremony that involves fasting and sacrifice. The annual event emphasizes indigenous Indian identity, as opposed to the Latino or Hispanic ethnicity that incorporates aspects of European culture, such as use of the Spanish language. Some Catholic Latinos disapprove of the holiday.54 Nutritional Status Nutritional Intake It can be difficult to deter- mine health statistics on Chicanos, Braceros, and unauthorized migrants because they are often grouped with whites or other Lati- nos in collected data. Information from research on Latinos can be used cautiously, since Mexicans comprise a majority of the total Latino population. Nevertheless, some nutritional problems have been identified in both new and acculturated immigrants from Mexico through studies of Spanish-surnamed patients, especially those residing in Texas, the Southwest, and California. Life expectancy for Mexican Americans is similar to that of whites in the United States despite disadvantages such as higher rates of poverty, lower levels of educational achievement, and reduced access to health care. Overall mortality rates as well as cause-specific mortality rates are lower for Mexican Americans compared to whites when controlled for gender, age, nativity, marital sta- tus, socioeconomic status, and demographic variables. (One notable exception is mortal- ity among younger Mexican Americans, aged eighteen to forty-four, who have elevated mortality risks, mostly due to external causes of death.)55,56,57 Researchers propose several reasons for the lower-than-expected mortality rates in Mexican Americans. Some report that nativity outside the United States is a factor, accounting for health-promoting lifestyle dif-accounting for health-promoting lifestyle dif-accounting for health-promoting lifestyle dif ferences.58 Another theory is that older immi- grants return home to Mexico before they die and are therefore not listed in vital statistics figures, resulting in a mortality advantage due to what has been dubbed “salmon-bias” effect.59,60 Similar trends are seen in infant mortal- ity statistics. The birthrate among Hispanic women is nearly twice that of white women, and the birthrate among women aged fif-and the birthrate among women aged fif-and the birthrate among women aged fif teen to eighteen is more than three times as high. Nearly 25 percent of Mexican American women receive no prenatal care during the first trimester of pregnancy.61,62 Despite these risk factors, rates for low-birth-weight infants and infant mortality are lower for Mexican Americans than for the total population (see Cultural Controversy: Breaking the Mold). In a multisite study of Mexican mothers, it was found that over 95 percent breast-fed their infants in the first week of life.63 Over 80 percent of Mexican American women in a national survey breast-fed, and by six months, 23 percent were still breast-feeding.64,65 In Mexico breast-fed babies are often given other fluids, including formula, water, and sweetened herbal teas to reduce colic or cure diarrhea,63 a practice that may continue in the United States. Babies are usually weaned from the breast to the bottle. Long-term use of the bottle or sleeping with one at night, with milk or sweetened liquids (e.g., Kool-Aid, fruit juice, tea), is sometimes a problem, resulting in iron-deficiency anemia and tooth decay among toddlers (baby-bottle tooth decay).66,68 In 2002, Mexican Americans had the highest component scores on the USDA Healthy Eating Index (HEI) of all ethnic Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 9 2 5 7 groups in the United States, indicating good compliance with the Food Guide Pyramid recommendations, especially dietary vari- ety and high fruit consumption, but also a high intake of sodium. Respondents born in Mexico had slightly higher scores than U.S.-born respondents.69 Most studies agree with the HEI findings that dietary qual- ity may decline with acculturation. Fat and cholesterol intake increases, while intake of beta-carotene, vitamin C, and fiber decreases due primarily to increased consumption of high-fat snacks, fried foods, eggs, cheese, and milk and decreased consumption of legumes, fruits, and vegetables.36,37,70,71,72 Research- ers caution, however, that acculturation is difficult to measure, and different methods may result in different findings. A study of low-income Hispanic women in San Diego found that when acculturation was defined Breaking the Mold: The Mexican American Immigrant Experience One of the assumptions regarding assimilation is that life improves continually for immigrants the longer they reside in the United States. Yet recent stud- ies of the largest immigrant population contradict this model. Foreign-born Mexican Americans are found to be healthier overall, to eat slightly better diets, and to have lower rates of infant mortality than U.S.-born Mexican Americans with foreign- born parents and for U.S.-born Mexican Americans with U.S.-born parents—despite higher rates of poverty and less access to medical care.45,161,162,163,164 The scientific community expressed little interest about differences in immigrant health status associated with place of birth until researchers in the late 1980s discovered a startling trend. Poor, disadvantaged women who had immigrated from Mexico were giving birth to babies who were as healthy as those of white U.S. women with overall higher levels of income and education. Rates of premature births, low-birth-weight rates, and newborn death rates among the immigrant women were equal to or less than those for whites.98,165,166 The foreign-born women also demonstrated better birth outcomes and fewer maternal disorders than Mexican American women who were born in the United States.170,171 One study even sug- gests that internal migration also improves health, showing that Mexican American women born outside the U.S. community where they give birth have better pregnancy outcomes than women born in the commu- nity.167 A comprehensive review of statistics on adolescents was even more revealing. The longer a subject’s family had lived in the United States, the poorer the subject’s health and the more likely the subject was to engage in risky behaviors, even after control- ling for neighborhood, family, education, and income variables. Mexican Americans who were born in the United States with U.S. parents had significantly higher rates of health problems (including obesity, asthma, and missing school due to illness) compared to those who were born in Mexico. Health risk behaviors, determined by sexual experi- ence, delinquency, violent behavior, and use of controlled substances, were more than double in U.S.-born Mexican American ado- lescents with U.S. parents than in Mexican American youth born in Mexico.163 Suddenly, the assimilation model of health was in question. What accounts for such significant differences? Most hypotheses have addressed the disparities in birth out- comes, suggesting that selective migration occurs (only healthy women come to the United States), that deaths during pregnancy may be greater (thus skewing the data), or that infant deaths are underreported in the foreign-born Mexican American com- munity (which may include high numbers of unauthorized residents). Other theories emphasize the protective factors of the Mexican culture.168 Research suggests that pregnant, foreign-born Mexican American women behave in ways different from those who are born in the United States. Intake of nutrients, including protein, folate, vitamin C, iron, and zinc, is better; smoking and alcohol consumption rates are substantially lower.79,169,170 Other factors considered important to positive pregnancy outcomes, such as adequate weight gain and prenatal care, are less likely in foreign-born Mexican Americans. Researchers suggest these negatives may be compensated for by greater community, family, and spousal support, and less accumulative acculturation stress.78,154,164,170 Determining the reasons that place of birth is so significant will help researchers devise a new assimilation model and suggest approaches for improving the diet, pregnancy, and health outcomes for all Mexican Americans. C U L T U R A L C O N T R O V E R S Y Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 2 5 8 M E X I C A N S A N D C E N T R A L A M E R I C A N S as number of years in the United States, fat intake did not change. When defined as being born in the United States, greater consump- tion of convenience foods and chocolate was found. When preference for speaking English at home was considered, lower intake of beans and peas was noted. When acculturation was defined as being born in the United States and a preference for speaking English at home, a higher consumption of salty snacks, high-fat foods, lower fiber, and convenience items was reported.38,72,73,74 Initial research indicated total protein intake may have declined with the length of stay in the United States, but recent research indicates that protein intake has leveled off in the last decade.45,74,75 Low protein consump- tion, combined with low iron and vitamin C intake, sometimes results in low hemoglobin levels among young children and pregnant women.67,76 However, excessive rates of low iron intake or low blood iron status among Americans of Mexican descent have not been confirmed. Deficiencies of calcium and riboflavin are common, often due to low consumption of dairy products. Although the traditional Mexican diet includes good sources of vita- mins A and C, thiamin, niacin, B6, folate, phosphorus, zinc, and fiber, low intakes of these nutrients by Mexican Americans have been reported; inadequate income or lack of traditional ingredients may limit consump- tion of these nutrients.77,78,79,80 Nutritional inadequacies may contribute to other diseases. More tuberculosis cases were reported among Hispanics than any other racial/ethnic population in 2008, for five consecutive years.81 However, the rate has decreased over this period. In contrast to the problem of undernutrition is the preva- lence of being overweight or obese in adults of Mexican descent—36 percent of men, and 47 percent of women in 2012.82 Overweight in children (when defined as BMI $95 percen- tile) has also been reported as being higher than for whites, between 22.4 and 24.3 per- cent for girls and boys, respectively.45,82,83 Low socioeconomic status and less leisure-time physical activity are thought to be factors in high rates of overweight.82,84,85,86 Cultural ideal weight may be greater for some Mexi- cans than for Anglo-Americans, and tradi- tionally, Latina women believed it was normal to gain weight after marriage. Extra weight may indicate health and well-being, not only for adults but also for children, and some par- ents may not recognize that their children are overweight.87 However, research suggests that many Hispanic adults and children perceive themselves as being overweight and are dissat- isfied with their body image.88,89,90 Unhealthy dieting practices are prevalent in some Lati- nos, and it is believed that Hispanic girls are at high risk of developing eating disorders.91,92 Prevalence of type 2 diabetes in Hispanic Americans is 1.7 times that for whites; how- ever, Hispanics were 70 percent more likely than whites to be diagnosed.82 This high rate is not explained by the incidence of obesity, age, or education, but may be related to percent- age of Indian heritage.93,94 Research suggests that Hispanics have greater insulin resistance than African Americans and whites, and their lower sensitivity may be due to a higher intake of carbohydrates.95 Type 2 diabetes in His- panic adolescents is three times that of white youth.96 Complications from diabetes, includ- ing kidney failure and diabetic retinopathy, are also more prevalent.82,96 Death rates from diabetes are estimated to be over 50 percent higher for Hispanics than for whites, and this difference is even greater in the counties along the Mexican border.97 Further, diabetes mor- tality rates are higher for Mexican Americans than for any other Hispanic group.98 Hispanic Americans have very high rates of metabolic syndrome, a clustering of con- ditions related to type 2 diabetes and heart disease, including insulin resistance, hyper- tension, and dyslipdemia.99 Interestingly, Mexican Americans have similar rates of hypertension to that of whites, but data on dys- lipdemia show higher prevalence in Mexican Americans than in whites and African Ameri- cans.82,100,101 The incidence of cardiovascular disease in American Hispanics is lower than the incidence in whites, and they are less likely to have heart disease but are 30 percent more likely to have a stroke.82 Researchers have noted the heart-healthy elements of the traditional Mexican diet.77 Though studies A study on the preva- lence of iron overload disorders in Hispanics suggests the rate may be slightly higher than among whites. 172 Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 9 2 5 9 on cardiovascular mortality risk relative to whites are contradictory,102,103,104,105 and sub- population risk varies, cardiovascular dis- eases are the number one cause of death in Hispanic adults.56,57 A higher prevalence of gallbladder disease has been found in Mexi- can Americans, and a higher rate is found in those born in the United States, compared to those born in Mexico. Diet may be involved in some cases, but more recent research suggests a genetic vulnerability may be a more impor- tant factor.106,107 Knowledge of osteoporosis and risk- reducing behavior was low among Hispanic women in Chicago.108 Cavities are common among Americans of Mexican descent, as is gingivitis. Studies show that nearly one-third of all immigrants from Mexico never receive any dental care. Migrant workers and their children are especially at risk.109,110 Alcohol intake was found to increase by 47 percent between Mexican Americans who were born in Mexico and the first generation of Mexican Americans born in the United States.45 Mexican American men drink greater quantities of alcoholic beverages less often and have lower rates of dependency than non-Hispanic men, and Mexican American women have low alcohol consumption rates that increase with acculturation.111,112 Counseling Access to biomedical health care may be limited for unauthorized migrants of Mexican descent. Income may restrict doctor visits, and transportation to clinics may be unavailable. In addition, 43 percent of Mexi- can Americans report that they speak Span- ish at home and that they are not proficient in English.2 Spanish-speaking clients may be uncomfortable with interviews conducted in English. Those who believe God or fate deter- mines health may be unwilling to undertake preventive procedures.116 The communication style of Latinos is high context and nonconfrontational; a warm, dig- nified relationship is most effective and cru- cial in difficult health care situations. Words are chosen carefully, and silence may be used to defuse disagreement.24 Kindness and gra- ciousness are appreciated.116 Touching a cli- ent with a hand-shake is important, although men should wait for women to extend their hands first. Eye contact varies, and some Mexican Americans consider prolonged eye contact impolite. However, it is best to maintain eye contact initiated by a client, as looking away may be thought rude. Mexican Americans often sit and stand closer together than Anglos do. Most Latinos are present oriented and polychronic (able to do several things at once). Inflexible appointments can be problematic for some Latino clients, who may prefer walk-in clinics.13 Latinos may be uninterested in lengthy indirect discussion of a condition and prefer a direct, action- oriented approach. Attitudes may differ from American bio- medical beliefs. For instance, it is sometimes considered inappropriate for men to acknowl- edge illness.112 People who go on working despite bad health are respected. Modesty and privacy are highly valued; thus a woman may wish to be treated by a female caregiver and a man by a male caregiver. Studies suggest that anywhere from 20 to 81 percent of Mexican Americans use folk remedies,11,12,112 and Latinos in one sur- vey used the services offered at their local botánica interchangeably with those offered by their biomedical provider.53 Another study found that increased use of herbal remedies by Mexican American women corresponded with fewer visits to biomedical practitioners. This association may be related to lack of medical insurance, which was also found to be a factor in use of traditional medicines.13 Sixty-one percent of surveyed Hispanic elders in New Mexico reported drinking herbal teas to maintain health, alleviate stress, and cure minor ailments.2 The most commonly consumed infusions included peppermint (called both yerba buena and poleo), chamo- mile (manzanilla), lavender (alhucema), and osha (related to parsley). However, it is impor- tant not to assume adherence to certain folk beliefs, such as the hot–cold classification of foods and illness. Though prevalent among some people in Mexico, these traditional practices may be limited in the United States (even among healers), and younger, urban clients may be offended by use of such “back- ward” theories.11,112 Traditional healers, such A study was done of Tarahumara Indians in Mexico to observe the effects of a high-calorie, high-fat, low-fiber diet on a population that traditionally consumes a low-fat, high-fiber diet. After five weeks, blood cholesterol levels increased 31 percent, and triglyceride levels increased 18 percent; all subjects also gained weight.173 Licorice root, known as yerba dulce or orozús, may be used as a general tonic or for infections, coughs, ulcers, and menstruation problems. It can be toxic in large quantities or taken over long periods, and may potentiate the effects of hypotensive drugs.26 Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 2 6 0 M E X I C A N S A N D C E N T R A L A M E R I C A N S as curanderos, are consulted by anywhere from 4 to 21 percent of the Mexican American population.25,113,114,115,116 Those who con- sult curanderos often believe that healers are most effective for symptoms caused by folk ill- nesses. In one small sample, nearly 26 percent of Mexican American women had personally used the services of a curandero; however, even larger numbers (almost 39 percent) had seen a sabadores (manual therapists).112 However, it should be noted that use of tradi- tional healers does not prevent a client from also seeking biomedical care concurrently.117 Although traditional practices are most com- mon in poor, rural regions, most Mexican Americans are knowledgeable about folk conditions: Studies in Texas report that mal de ojo had been diagnosed and treated in 63 to 70 percent of Mexican American homes surveyed, susto was known in 37 to 62 per- cent, and empacho in 27 to 48 percent. Mal de ojo was known in 70 percent of homes, and caída de mollera in 34 percent.and caída de mollera in 34 percent.and 11,115,116 Another study showed 71 percent of homes had a family member who had suffered from nervios, and that 46 percent had experienced it personally.14 Mexican American women in southern California also demonstrated famil- iarity with these illnesses.112 Sometimes mul- tiple etiologies are integrated. For example, some Mexican Americans believe that diabe- tes, which is an Anglo disease, is caused by eating a diet high in fat and sugar, but also due to experiencing strong emotions or chronic susto.28,118 Most traditional health beliefs and prac- tices among Mexican Americans support the emotional well-being of a client and do not interfere with therapy. Many researchers have suggested that folk conditions provide an important release valve in Latino cultures, especially for men who are expected to endure pain. Disorders due to outside causes are not blamed on an individual, and the resulting irrational behavior or lethargy is excused.13 Several potentially harmful situations are noteworthy. Suboptimal medication use has been noted, especially in diabetes treatment where intake is inconsistent, and in situations where prescription drugs are mixed with home remedies.119,120 For example, diabetes and hypertension may be treated with botan- ical remedies in addition to prescribed oral medications, risking excessive hypoglycemic and hypotensive activity, respectively. Clients consult friends and neighbors about effective treatments and are unlikely to disclose home remedies to their physicians.121 Digestive complaints such as empacho are sometimes treated with toxic lead- or mercury-based medications, such as greta, azarcón, and asogue.122 The condition of caída de la mollera in infants has been associated by some health practitioners with severe diarrhea and dehy- dration, resulting in the depressed fontanel.122 Failure to thrive syndrome may also be a con- cern. Providers should be aware of these pos- sibilities when presented with this disorder. In some regions, a tea made from the psychoac- tive wormwood (the toxic ingredient formerly found in the alcoholic beverage absinthe) is used for diarrhea. Though not widely used, vibora de cascabel (dried rattlesnake powder) vibora de cascabel (dried rattlesnake powder) vibora de cascabel can be a source of salmonella and botulism. Finally, babies may be given home remedies made with honey, a known cause of infant botulism. In one study, Latinos were the eth- nic group least likely to discuss the use of alternative and complementary therapies with their biomedical care providers.123 Family participation in health care is com- mon, and members should be consulted in both making a diagnosis and prescribing treatment. They may have specific ideas about the cause of an illness and the best approach for a cure; their confidence and coopera- tion can help ensure client compliance. One study found that family involvement in seri- ous choices about issues such as life support is more important to Mexican Americans than patient autonomy.124 Dietary changes may affect family members and social inter- actions; thus, gaining family support has also been suggested to increase compliance.125,126 An older study of Mexican American families living on the Texas–Mexico border found that the husband traditionally exer- cised control of the food budget and food purchases.127 The wife did the actual meal planning, shopping, and preparation. Women identified strongly with their food-related tasks within the family structure. Because Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 9 2 6 1 their self-concept and status in the family and community are related to their abilities as a cook and homemaker, nutrition intervention and advice may be perceived as an accusa- tion of inadequacy. More recent research shows that Mexican American women who are more acculturated are likely to have a shared meal decision-making style. However, they face greater barriers to making healthy eating changes due to resistance from family members, and they are more likely to eat at fast-food restaurants, eat more saturated fat, and make fewer efforts to increase fiber intake than are women who maintain traditional meal preparation roles.127 Children are also an important influence on food habits in some households. Those raised in the United States may be the only English-speaking members of the family and may be responsible for translating in the mar- ket. These children have been found to prefer foods that they have seen advertised on tele- vision. The adoption of new foods is influ- enced by the presence of bilingual children in the family.44 Researchers studied newly immigrated Latinos in the San Francisco area and found that the importance of the family unit can be used to motivate changes in food habits.128,129 Adults unwilling to make changes that would benefit their own health may make those same changes to improve the well-being of their children. As with all clients, an in-depth interview is crucial in effective nutrition counseling. Experts in the health care of Latinos recom- mend that health professionals who work often with Latinos learn Spanish. Familiar- ity with Spanish medical terminology is the minimum proficiency needed for meaning- ful communication. Further, interventions should be tailored to account for differences in acculturation.35 Central Americans The seven nations of Belize, Guatemala, El Salvador, Honduras, Nicaragua, Costa Rica, and Panama make up Central America, an isthmus connecting North America to South America. The eastern coastal region edges the Caribbean Sea. An 800-mile chain of active volcanoes and mountains, beginning at the Mexican border in the north and continuing with only one break into central Panama in the south, forms the temperate backbone of the region. Central America is similar to the rest of Latin America in history of foreign intervention and heterogeneous culture. Cultural Perspective History of Central Americans in the United States Immigration Patterns Central American immigrants to the United States have arrived in two distinct waves. Early records are inex- act because separate statistics on Central Americans were not kept by the U.S. Census Bureau until the 1960s and were reported in the 2010 census and not listed in with the South American data. Until the early 1980s, immigrants to the United States were of two groups. The first were well-educated profes- sional men who arrived in search of employ- ment opportunities. The second were women, who often outnumbered the men two to one, coming in search of temporary domestic jobs. These Central American immigrants were largely urban residents and settled mostly in New York, Los Angeles, San Francisco, Miami, and Chicago, where they blended into existing Latino communities. The second major wave began in the late 1970s and early 1980s, with the exodus of refugees from the brutal civil wars in El Sal- vador, Guatemala, and Nicaragua. Millions of residents are estimated to have been displaced in these countries, about one-third of whom have emigrated. Many moved to Mexico, and a substantial number have continued on to the United States. They are known as the “foot people” because many have literally walked to the United States.130 Less is known about this group, except that they are often younger, poorer, and less educated than the previous immigrants from the region. Current Demographics and Socioeconomic Status Just under 8 percent of U.S. Hispanic are from six nations of Central America, a majority of whom arrived since 1980. Exact figures are unknown, however, because it is Queso fresco, tradition- ally made from raw milk, is responsible for more food-borne illness than any other cheese in the United States.175 Latinos listen to radio programming in greater numbers than do Anglos. An evaluation of a Spanish radio nutrition course found it improved both nutrition-related knowledge and selected practices in both rural and urban sample populations.174 Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 2 6 2 M E X I C A N S A N D C E N T R A L A M E R I C A N S believed that many Central Americans may enter the United States illegally at the bor- der with Mexico and are undistinguished from unauthorized Mexicans.82 The larg- est populations are the 1.65 million Salva- dorans, 1.04 million Guatemalans, 633,000 Hondurans, and 348,000 Nicaraguans.131 It is believed that there may be an equal number of unauthorized migrants from these countries living in the United States as well.132,133 Immi- gration from Costa Rica, Belize, and Panama is minimal at less than 1 percent of Hispanics. Nearly one in every four Central Ameri- cans is born in the United States. Central American immigrants, even those from the first wave, are slow to naturalize, and only 31 percent of Central Americans in the United States have obtained citizenship.135 Those who are not refugees often return to Central America for visits and maintain active con- tact with their homeland. Those who are have sought asylum, and those who are unauthor- ized migrants, cannot visit their homelands without fear of persecution or difficulties in returning to the United States. A third of Central Americans live in Los Angeles, New York, and Washington, DC, and live in neighborhoods where other Central Americans reside. Central Americans are a very heterogeneous population, however, and it is a mistake to assume similar settlement patterns for each group. Identity is some- times more related to race and class than to country of origin. The majority of immi- grants before the 1980s were white profession- als; more recent refugees are predominantly Ladino (mixed Spanish and Indian heritage) or Indian campesinos (peasants). Even among recent immigrants, differences in associations are found. Hispanic Guatemalans, for exam- ple, may assimilate into the broader Latino community, while Mayan Guatemalans, some of whom do not speak Spanish, often establish ethnic enclaves.136 According to U.S. Census data, 45 percent of Central Americans work in service and personal care occupations. Approximately 50 percent have graduated from high school. Central American immigrants are more likely to live in poverty (23 percent) than those born in the United States (15 percent) or foreign born overall (20 percent).135 Information on unauthorized residents is scanty. It is thought that they often face dif-scanty. It is thought that they often face dif-scanty. It is thought that they often face dif ficulties in obtaining employment and educa- tion opportunities.132 In addition, disposable family income may be impacted by money sent to support relatives still living in the homeland. Worldview The large numbers of recent immigrants from Central America suggest that ethnic identity is preserved by many new residents in the United States. For example, Salvadorans often establish highly insular neighborhoods within the larger Latino community, where an immi- grant can live and conduct business exclusively with other Salvadorans.132 Guatemalans are a more diverse population of immigrants, and it is the Mayan communities that are most likely to keep traditional beliefs and practices.136 In contrast, Nicaraguans are dispersed among other Latinos and are adapting more to the pan-Latino community rather than retaining their own heritage exclusively.134 One unique Central American immi- grant population in the United States is the Garifuna, who are black Caribs from the A Mayan chocolate container. ▲ M ex ica n Sc ho ol /B rid ge m an A rt Lib ra ry /G et ty Im ag es Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 9 2 6 3 eastern, coastal areas of Belize and Honduras. Traditionally, men traveled great distances for work, leaving the women to farm and raise children. Today, their way of life is threatened by coastal development for tourism and lack of government support. Garifuna men often come to the United States for employment, sending much of their earnings home in an effort to save their culture.137,138 Religion Most Central Americans are Roman Catholic. Some Guatemalans observe Catholic practices while adhering to Mayan religious beliefs; participation in native reli- gions declines in the United States because they are usually dependent on sacred loca- tions in Guatemala. Evangelical and fun- damentalist denominations, such as the Pentecostal Church, have attracted many Central Americans after they arrive in the United States. Small storefront congregations that involve active participation and those churches that offer traditional Central Amer- ican social activities in addition to worship have been especially successful. Family Central Americans highly value family and extended kinship. It has been noted that some apartment buildings in Latino neighbor- hoods are rented entirely to several families from the same village in Central America. The father is traditionally the undisputed head of the household and provider for the family. Many Costa Ricans define the term family as having both a father and mother in the home.139 However, some studies suggest this dominance is changing, and shared decision making between men and women is becom- ing more common.140,141 Children are often carefully controlled, especially daughters. The roles of the men and women often change even further in the United States, where women are sometimes more easily employed, and husbands must take on some domestic responsibilities. Family disintegra- tion has taken place in some refugee camps, where overcrowding and unemployment led to intergenerational conflict prior to immigra- tion to the United States.142 In other situations, family members were forced to immigrate separately. Some married outside the Cen- tral American community for immigration benefits; others found that when their fami- lies were reunited, children had become more independent.134 Traditional Health Beliefs and Practices A good diet,especially consumption of fruits and vegetables, fresh air, and regular hours are thought necessary to preserve health by many Central Americans.143 Exercise is con- sidered important by some Guatemalans and Panamanians, though the concept of struc- tured exercise is unfamiliar to some Central Americans.140,141,144 Salvadorans believe that being too thin can cause sickness, and Americans are considered at risk for ill health because they are so thin. Some Central Americans view health as a balance between the spiritual and social worlds. For most, health is a gift of God, and prayer is often used to restore harmony dur- ing illness.141,145 Some Nicaraguans believe in witchcraft, practiced by brujos or brujas who can assume the shapes of animals and have the power to cure illness. Guatemalans consider outside forces to be the cause of some illnesses, which include diseases sent by Satan to pun- ish unbelievers and sickness due to witchcraft. Traditional healers include curanderos and sabadores, as well as jeberos (herbalists) and espiritistas who treat witchcraft with prayer. Naturalist doctors (sometimes called naturo- paths) who work in association with natural- ist shops that provide botanical remedies may be used by some Guatemalans.146 Priests may also be sought to help with prayers for health. A balance of hot and cold is also neces- sary to health and can be disrupted by sud- den exposure to extremes in temperature or strong emotions. In addition to susto and mal de ojo, other folk conditions include bilis and cólera, which in extreme cases are associated with anger and general distress and precipitate stroke. In a survey of Hispanic immigrants (with a large sampling of Central Ameri- cans) regarding beliefs about hypertension, respondents reported that cólera and susto may lead to high blood pressure, as may liv- ing at too high an altitude or having too much blood.142,147 In the culturally diverse region of Nica- ragua’s east coast, more than 200 plants with Mayan creation myths describe how humans were improved over time. They were first made of mud, then wood, and finally perfected when their flesh was made from corn dough. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 2 6 4 M E X I C A N S A N D C E N T R A L A M E R I C A N S traditional medicinal uses have been identi- fied. One study reported rural ethnic groups in Nicaragua were found to use traditional healing practices more often than urban resi- dents of mixed heritage.148 Another survey, however, found that more than three-quarters of respondents in an urban barrio used herbal remedies.147 Guatemalans believe that strength is main- tained through the quantity and quality of a person’s blood. In urban regions of Guate- mala, researchers have noticed the emergence of new categories of food items, such as strong or health-promoting foods, perhaps due to the influence of modern health promotion concepts.142 Over-the-counter remedies, such as anal- gesics and cough suppressants, are commonly used by Guatemalan Americans, although they are considered weak by Guatemalan standards. Medications (including antibiotics) and herbs, such as chamomile, are sometimes brought to immigrant families by new arrivals from Guatemala. Traditional Food Habits Ingredients and Common Foods Central American cuisine offers many of the foods common throughout Latin America. The native Indian dishes remain prominent in the highland areas, Spanish influences are found in the lowland regions, and the cooking of the multicultural eastern coast shares many similarities with Caribbean Islander fare. The northern nations have foods similar to those of southern Mexico; the southern countries have been more greatly influenced by European and African cuisines. Staples Early Mayan records indicate that the foundation of their diet was corn and beans, supplemented with squash, tomatoes, chiles, tropical fruit, cocoa, and some game. Indian foods were particularly important in the development of Guatemalan cuisine but gradually become less significant in the south of Central America. Rice, introduced by the Spanish, has become a staple in most regions. (See the cultural food groups listed in Table 9.3.) Beans are eaten daily. Black beans are espe- cially popular in Guatemala, while red beans are common in other nations. Beans are served simmered with spices (called frijoles sancocha- das in El Salvador), pureed, or fried and are often paired with rice. In Nicaragua, red beans and rice fried with onions are called gallo pinto (“painted rooster”) due to the colors of the dish. Corn is eaten mostly as tortillas. Enchila- das in Central America are open-faced sand- wiches similar to Mexican tostadas. They typically feature meat covered with pickled vegetables such as cabbage, beets, and car- rots. They are known as mixtas in Guatemala, and here the tortilla is spread first with guaca- mole, then topped with a sausage and pickled cabbage. In El Salvador, a stuffed specialty is called pupusas. A thick tortilla is filled with chicharrónes, cheese, or black beans and then completed with another tortilla; the edges are sealed and the pupusa is then fried. They are traditionally served with pickled cabbage. Tamales are also common, often stuffed with poultry or pork. They are called nactamal in Nicaragua, where the dough is flavored with sour orange juice, and the filling includes meat, potatoes, rice, tomatoes, onions, sweet peppers, and mint. Black tamales are served on special occasions in Guatemala, stuffed with a mixture of chicken, chocolate, spices, prunes, and raisins. Empanadas, small turn- overs made with wheat flour dough and filled with a savory meat mixture, are popular. French bread, introduced from Mexico, is eaten regularly in the form of small rolls in Hon- duras and Guatemala. In El Salvador, French bread is used with native turkey and pickled vegetables to make sandwiches. Coconut bread is a specialty on the Caribbean seacoast. Rice is often fried before boiling, cooked with coconut milk, or, in Costa Rica, served as pancakes. Soups and stews are popular throughout Central America, often including fruit or fruit juices. Beef, plantains, and cassava in coconut milk, spicy beef stew, beef in sour orange juice, pork and white bean stew, chicken cooked in fruit wine; mondongo (Nicaraguan tripe In Guatemala, refried black beans (fríjoles vol- teados) are fondly called “Guatemalan caviar.” The Mayan word for corn, wah, also means “food.” Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 9 2 6 5 Group Comments Common Foods Adaptations in the United States Protein Foods Milk/milk products Milk is not widely consumed as a beverage, but evaporated milk and cream are popular in some regions. Milk (evaporated), cream; cheese (aged and fresh—crumbly farmer’s cheese type) Milk and hard cheese may be disliked by Guatemalans, but increased intake reported for Salvadorans. Meat/poultry/fish/ eggs/legumes Legumes are important in the cuisine and are often served with rice. All types of meat/poultry are eaten, but pork is popular throughout the region. Eggs are commonly served. Fish and shellfish are consumed in the coastal regions. Sea turtle eggs are popular. Meat: beef, iguana, lizards, pork (all parts, including knuckles, tripe, and skin), venison Poultry: chicken, duck, turkey Fish and shellfish: clams, conch, flounder, mackerel, mussels, sea snail, shark, shrimp, sole, tarpon, turtle Eggs: poultry, turtle Legumes: beans—black, chickpeas, fava, kidney, red, white Bean dishes remain popular. Cereals/Grains Rice and corn are the predominant grains of the region. Wheat flour breads are common. Corn (tamales, tortillas), rice, wheat (bread, rolls) Tortillas may be replaced by breads. Fruits/Vegetables Tropical fruits are abundant. Some temperate fruits such as grapes and apples are also available. Salads and pickled vegetables are popular. Fruits: apples, bananas, breadfruit, cherimoya, coconut, custard apple, grapes as well as raisins, guava, mameys, mangoes, nances, oranges (sweet and sour types), papaya, passion fruit, pejihaye, pineapples, prunes, sour-sop, sweetsop, tamarind, tangerines, zapote (sapodilla) Vegetables: asparagus, avocados, beets, cabbage, calabaza (green pumpkin), carrots, cauliflower, chayote, chile peppers, corn, cucumbers, eggplant, green beans, hearts of palm, leeks, lettuce, loroco flowers, onions, pacaya buds (palm flowers), peas, plantains, potatoes, pumpkin (ayote), spinach, sweet peppers, tomatillos, tomatoes, watercress, yams, yuca (cassava), yucca flowers (izote) Increased intake of potato chips has been reported. Increased consumption of vegetable salads. Additional Foods Seasonings Cilantro (fresh coriander) and epazote are important herbs. Sour orange juice gives a tang to some food; coconut milk flavors others. Achiote is used to color foods orange. Achiote (annatto), chile peppers, cilantro, cinnamon, cloves, cocoa, epazote, garlic, onions, mint, nutmeg, thyme, vanilla, Worcestershire sauce Nuts/seeds Palm tree nuts, pepitoria (toasted squash seeds) Beverages Hot chocolate and coffee, grown in the region, are favorite hot beverages. Refrescas, cold drinks, are made with tropical fruit flavors. Boj, chicha, and venado are locally made alcoholic beverages. Coffee, chocolate, tropical fruit drinks, alcoholic beverages (rum, beer, and fermented or distilled fruit, sugarcane, and grain drinks) Increased intake of soft drinks. TA B L E 9. 3 Cultural Food Groups: Central Americans (Continued ) Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 2 6 6 M E X I C A N S A N D C E N T R A L A M E R I C A N S soup), sopa de hombre (“a man’s soup”) made with seafood, and plantains in coconut milk are a few specialties. In Guatemala the stews of meat and poultry, such as pepián and jocon, are thickened with toasted squash seeds. Meat, poultry, and fish are frequently roasted as well. Fruits and vegetables are numerous. Although bananas, coconut, plantains, yucca (cassava), tomatoes, sweet peppers, cab- bage, chayote squash (known as huisquil in Guatemala), mangoes (considered an aphro- disiac in Guatemala), oranges, and avocado predominate, cauliflower, carrots, beets, rad- ishes, green beans, lettuce, spinach, pump- kin, breadfruit, passion fruit (granadilla), pineapples, mameys, and nances (similar to yellow cherries) are also common. Flowers from yucca, palms (pacaya buds), and loroco (Fernandia pandurata) are eaten as vegetables throughout the region.165 Starchy fruit from the peach palm (pejibaye) and spiny palm (coyoles) are especially popular in Costa Rica and Honduras. Onions and garlic flavor many dishes. Salads and pickled vegetables are common as appetizers, as side dishes, and on sandwiches. Coffee, grown throughout the region, is a popular drink, usually consumed heavily sweetened. Hot chocolate is another favorite, and fresh milk, if consumed, may be sweet- ened with added sugar. Refrescas, cold bever- ages, are made in tropical fruit flavors, such as mango and pineapple. Tiste, a Nicaraguan favorite, is made with roasted corn, cocoa powder, sugar, cold water, and cracked ice. Beer is widely available. Fermented bever- ages such as boj (from sugarcane) and chicha (a wine made from fruit or grain, fortified with rum) are consumed. Venado is a com- mon distilled drink made from sugarcane. Sweets, such as the praline-like candy called nogada, sweetened baked plantains, ices made with fruit syrups, custards, rice puddings, and cakes or fritters flavored with coconut or rum, are eaten as snacks and for dessert. Regional Variations Although many foods of Central America are similar, they are often fla- vored with local ingredients for a unique taste. Coconut milk flavors many dishes in Belize and Honduras; seafood specialties include conch and sea turtle. The foods of El Salvador are often fried and feature many indigenous flavors including corn, beans, tomatoes, chiles, and turkey. Achiote is common in mild seasoned Guatemalan fare. The juice of sour oranges is mixed with sweet peppers or mint in many Nicaraguan recipes. Costa Ricans prefer foods simmered with herbs and season- ings such as cilantro, thyme, oregano, onion, garlic, and pimento; rice is also frequently consumed. Panamanian fare is more inter- national in flavor; one specialty is sancocho, a stew of pork, beef, ham, sausage, tomato, potato, squash, and plantains. Meal Composition and Cycle Daily Patterns As in other Latin American regions, beans and corn are the cornerstones of the daily diet, eaten at every meal by the poor. Rice is also common. Queso blanco (a fresh cheese) or meat is added whenever resources permit. Dinner in wealthier areas usually includes soup, meat or poultry (sometimes fish), tortillas or bread, and substantial gar- nishes such as avocado salad, fried plantains, and pickled vegetables. Appetizers, such as slivers of broiled beef, bites of meat- or cheese- filled pastry, and soft-boiled turtle eggs, are eaten in some urban regions before dinner; dessert may also be served, typically including custards, ice creams, cakes, or fritters. Though iguana is eaten throughout Central America and parts of Mexico, South America, and the Caribbean, it is especially popular with Indians in Nicaragua. Chocolate was so prized in Mayan culture that cacao beans were used as currency. TA B L E 9. 2 Cultural Food Groups: Central Americans (C on t in u e d ) Group Comments Common Foods Adaptations in the United States Fats/oils Lard is the most commonly used fat. Butter, lard, vegetable oils, shortening Lard and shortening use may decrease; vegetable oils and mayonnaise may increase. Sweeteners Honey and sugar are used as sweeteners. Honey, sugar, sugar syrup Increased intake of candy is noted. © C en ga ge L ea rn in g Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 9 2 6 7 Special Occasions Celebrations in Central America are focused on Catholic religious days. Christmas, Easter, and Lent, saints’ days (including All Saints’ Day), and even Sundays may mean a change in fare. Spe- cial dishes include the cheese-flavored bat- ter bread called quesadilla that is served in El Salvador on Sundays; sopa de rosquillas, a soup made with ring-shaped corn dumplings traditionally eaten on the Fridays of Lent in Nicaragua; gallina rellena Navidena, a Nica- raguan Christmas dish of chicken stuffed with papaya, chayote squash, capers, raisins, olives, onions, and tomatoes; and plantains served in chocolate sauce during Semana Santa (the Holy Week before Easter) in Guatemala. Chicken in tomato sauce (guisado), chicken served with cornmeal porridge, or stews thickened with masa harina are Indian specialties eaten at ceremonial occasions. In some areas the stews are provided by the village headman to serve the community. In Guatemala All Saints’ Day is celebrated with a unique salad called fiambre. These enor- mous salads involve a family social event at which as many as fifty friends and relatives share the creation.149 They feature vegetables (e.g., green beans, peas, carrots, cauliflower, beets, radishes, cabbage) mixed with chicken, beef, pork, and sausages and then artfully garnished with salami, mortadella, cheese, asparagus, pacaya buds, and hard-boiled eggs. The dressing is either a vinaigrette or a sweet- and-sour sauce. Etiquette Dining customs in Central America are often similar to those of Mexico. For example, no guest should begin eating at a meal until the host says “¡Buen provecho!”23 Most Central Americans eat European-style, with the fork remaining in the left hand and the knife in the right one. However, certain more Ameri- canized groups, such as some Nicaraguans, may eat in the American fashion of using the fork in the right hand, switching to the left when cutting food. When not eating, the hands should remain above the table, with the wrists resting on the edge. Bread or torti- llas may be served (typically without butter) and should be placed on the side of the plate. ▲ Tropical fruit from Latin America. Pe te r C oo k/ Do rli ng K in de rsl ey /G et ty Im ag es It is acceptable to scoop up small bits of food with pieces of tortilla. Dishes are passed to the left. Diners are expected to clean their plates, so taking small portions is appro- priate. Asking for seconds is considered a compliment. S A M P L E M E N U A Guatemalan Dinner Chicken Jo c on a,b or Pollo en Pipian (Chicken in Tomato-Pumpkin Seed Sauce)b Rice F r ijole s V olt e ad os (Refried Black Beans)a,b Radish Salad,a,b Plátanos al Horno (Baked Sweet Plantains) or Coconut Candya Hot Chocolate or Coffee aMarks, C. 2004. False tongues and Sunday bread: A Guatemalan and Mayan cookbook. Takoma Park, MD: Takoma Books. bGuatemalan Cuisine & Recipes at http://www.whats4eats.com/central-america/guatemala-cuisine In Guatemala, eggs poached and served with a seasoned broth are used to treat hangovers. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 2 6 8 M E X I C A N S A N D C E N T R A L A M E R I C A N S Therapeutic Uses of Foods Some Central Americans follow the hot–cold theory of health and illness, and some also go by the need to balance wet–dry. Guatemalan Americans commonly believe that diarrhea is caused by hot weather and can be alleviated by consuming cold drinks, such as Kool-Aid or Gatorade.142 However, ice cubes may be avoided during hot weather. Panamanians may avoid cold foods when sick, but in one sample, none applied hot–cold principles to daily meals.141,142 Guatemalans also appeared not to balance hot and cold foods; however, it has been suggested that the practice is so enculturated that it is done without conscious effort.142 Fatty foods and highly spiced dishes may also be avoided by both Guatemalans and Panamanians when ill. Herbal remedies are popular through- out Central America, especially teas. Stud- ies of Guatemalans and Panamanians found that the teas were consumed to maintain health, and even more often, to cure minor illness.141,142 Examples include teas such as manzanilla (chamomile) for improving cir- culation, menstrual cramps, and flu or colds; banana leaf and hierbabuena (mint) for good digestion and regularity; and lemon for gen- eral health. Rosa de jamaica (hibiscus) was used for respiratory illness, diarrhea, and urinary tract infections, while papaya-leaf tea was considered good for gastritis and as a laxative. Lime, fig leaf, and grapefruit teas were consumed for anxiety and alleviation of stress. Notably, avocado, garlic, ginseng, and valleriana were mentioned as remedies for hypertension and diabetes among Pana- manians. Coca leaves, the source of cocaine, are also reported to be used medicinally in some areas.148 Contemporary Food Habits in the United States Adaptations of Food Habits There is scant information on the Central American diet in the United States. Low rates of assimilation among many Central American immigrants are assumed to result in preservation of traditional food hab- its. Most Central American ingredients are available in the Latino communities where they settle. One study found that more than half of Honduran women living in New Orleans continued to consume a diet very similar to what they ate in their homeland.150 Rice, beans, fruit juices, tortillas, cheese, bananas or plantains, beef, and eggs were the items eaten most often. Few new foods were added by a small number of women, and only kiwi fruit, plums, canned vegetables, and olive oil were used by more than 10 per- cent of the sample. Prepared items, especially hamburgers (eaten by 30 percent of respon- dents), fried chicken, pizza, and regional dishes, such as jambalaya and Cajun foods (13 percent for each dish), were other new items consumed by a few of the Honduran women. Some also reported baking more foods, frying less, and using more vegetable oil instead of lard or coconut oil in cook- ing. A meal was defined as having courses, including meat of some sort, and requiring the diner to sit down. Though the women reported skipping meals, this sometimes meant that they ate a sandwich for lunch, which was not considered a meal. Salvadoran refugees report that, in gen- eral, the quality of their diet has declined since arriving in the United States. They state that in El Salvador more foods were made at home from fresh ingredients; they believe that in the United States more pro- cessed items and junk foods are eaten, and some nutritious foods are too costly to con- sume.144 However, findings from another study of Salvadorans found that there were some beneficial dietary changes after immi- gration to the United States. Though intake of high-sugar and high-fat foods such as jams or jellies, soft drinks, ice cream, may- onnaise, and vegetable oil increased, con- sumption of lard, shortening, and fatty meats, including chicharrones and sausage, decreased. Bean dishes, such as frijoles san- cochados, remain popular, although other traditional items including pupusas, tama- les, and plantain empanadas were eaten significantly less often. Although milk, fruit juice, and fresh salad intake increased, some Salvadorans sampled consumed inad- equate servings of dairy products, fruits, Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 9 2 6 9 and vegetables.151 A recently published study found that fruit and vegetable intake among all subgroups of Hispanic subgroups in the California, including Central Ameri- cans, were higher when compared to non- Hispanic ethnic groups. Health workers in Florida report that Guatemalan refugees believe that if a food is tasty and does not cause stomach discomfort, it must be good to eat. High intake of candy, soft drinks, and potato chips has been noted. Milk, which is often not well tolerated, may be avoided. WIC (Supplemental Food Pro- gram for Women, Infants, and Children) nutritionists found that some food supple- ments, including milk and cheese, are disliked because of their taste or texture and are some- times discarded.142 Nutritional Status Nutritional Intake Limited data on the nutri- tional status of Central American immigrants have been published. Those who arrive after spending time in refugee camps may suffer high rates of malnutrition resulting in dis- eases such as beriberi, pellagra, scurvy, and vitamin A deficiency problems, especially in children younger than the age of five. Infec- tious diseases often follow; tuberculosis and parasites are common.144 Endemic infec- tions may cause problems as well. Chagas heart disease, resulting from infections with Trypanosoma cruzi (found in most of Cen- tral America), presents symptoms similar to other coronary artery conditions. U.S. outbreaks of cyclosporiasis due to contami- nated raspberries imported from Guatemala in 1996 and 1997 suggest another source of infection. Rates of sickle-cell anemia were found to be high (5.7 percent) among mostly Central American adolescents in Los Ange- les, and the disease appears to be associated with this population independent of African heritage.152 Infant mortality rates for Central Ameri- cans in the United States are below the aver- age for whites.153 Low-birth-weight infants were not found to be a problem among Central Americans in a Chicago study. Even those at significant personal or environmen- tal risk (i.e., living in low income, urban neighborhoods) showed no excessive low birth weight.1,154 Researchers report that Guatemalans consider breast-feeding healthy for infants but impractical. Breast-feeding often is used as supplementation to formula and solid foods for the first two to three years of a child’s life.142 A study of Salvadoran American youth aged six to eighteen years in Washington, DC, found a prevalence of overweight dou- ble that of the national average and 1.7 times higher than for Mexican American children in national surveys. Thirty-eight percent were overweight (BMI $95 percentile), and another 22 percent were at risk for overweight. Overweight in this sample was associated with elevated blood pressure, body fat percentage over 30 percent, and early puberty.155 An occupational hazard for many Central Americans employed as U.S. farm-workers is pesticide or herbicide poisoning. Exposure occurs when labor codes are unenforced or through worker mishandling of the danger- ous products. Counseling Access to biomedical health care can be especially difficult for Central Ameri- cans. Many are economically and linguistically isolated within their communities; others are unauthorized residents avoiding detection by authorities. Failure to utilize health care is also thought to be due to cost: a high percentage of young adults of Central and South American origins were uninsured in one study, with the highest rates (73 percent) among those who were not U.S. citizens.156 Most immigrants from Central America are present oriented, though many are also polychronic, viewing time more as a circle than a straight line.24 They typically view health from day to day, believing that they have no control over the future. The concept of scheduled appointments may be unfamil- iar, and there is little interest in arriving on time. Touching is used to communicate feel- ings. Men usually embrace close friends, and women are likely to hug all acquaintances. Salvadorans, Guatemalans, and Nicaraguans prefer a light handshake that is lingered over. Men should wait for a woman to extend her hand before shaking, however. Eye contact Lactose intolerance may be prevalent among Central Americans. Illness is a sign of weak- ness among some Guatemalans, and a person may be stig- matized because he or she is unable to fulfill responsibilities. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 2 7 0 M E X I C A N S A N D C E N T R A L A M E R I C A N S may be direct when speaking, but it is often downcast when listening politely. Salvadorans use their hands expressively, but it is consid- ered impolite to point with the fingers or the feet. Most Central Americans have a different sense of personal space than do Anglos and prefer to sit and stand closer than is comfort- able for many whites, but backing away may be seen as an insult. Central Americans are high-context com- municators, using a calm, measured voice and emotional restraint, except among family and friends. A respectful, yet warm and caring speaking style is most effective.24 Culturally based descriptions of symp- toms were found among Guatemalans in Florida.142 “Weak heart” referred to palpi- tations or dizziness; “weak stomach” meant indigestion; and “weak nervous system” was applied to headaches or insomnia. Taking blood samples was very anxiety provoking because of the Guatemalan belief in the need for strong, ample blood. Anemia was associ- ated with weak blood, to be cured by “eat- ing iron.” Guatemalans also identify susto and nervios as illnesses (see “Traditional Health Beliefs and Practices” in the previ- ous Mexican section) found more often in women than men. If not treated, these conditions are thought to cause diabetes.14 Guatemalans believe injections are the most effective treatment for illness—more potent than pills. However, one study found that some Guatemalans fear the “chemicals” used in biomedicine.146 Treatment is successful if symptoms are alleviated. A study of Salvadorans found that the most important source of emotional support came M A R G A R E T K . W A R D , M S , R D , L D / ND / ND Ihave worked with Hispanic clients, primarily Mexican Americans, since 1990 when I returned to the western states after living eight years in the Midwest. In my experience many of the clients/patients tend to cook without recipes. The less accul- turated client/patient tends to use many more “basic” or less processed foods. They may or may not have been influenced by American food practices to the extent that they use less lard (manteca) and more oil (though the vegetable oils chosen are not necessarily the “best/healthiest” choices). I would say it’s dependent upon the length of time the person has been in the United States and his or her level of acculturation. If he or she has been here awhile and is learn- ing English, the person tends to acquire more of the Western food culture. Also, the number and age of children can have an effect. Families with older, school-aged children tend to acculturate more because of the influences of school and interaction with “American” children. My advice to new health care profes- sionals working with this community is to acquire Spanish language skills as soon as possible. I began my learning in the clinic; then in desperation I took two semesters of Spanish in the community college to acquire the grammatical background that the clinic wasn’t providing. Facility in the language is critical to communication. I’m a teacher of nutrition; if I can’t communicate with my student, I’m not able to do my job very well. Having good Spanish skills made working with clients on modifying the diet much easier, and most Mexican foods can be modified to meet nutritional needs. Don’t be afraid to make mistakes with Spanish language speakers. I have found that my Hispanic patients have almost always been extremely forgiving of my hor- rible Spanish. They seem to appreciate any attempt that one makes to communicate with them in their language. The worst that will happen if you do make an error is that you’ll both laugh. I have several Spanish error stories. One took place in the Women, Infant and Children (WIC) clinic when a postpartum patient returned for a follow-up hemoglobin determination, which was low again the second time. We reviewed the foods to include in her diet to increase her hemoglobin, and I again encouraged her to continue her prenatal vitamin use. At the end of my spiel, I told her that if she took her vitamins and ate well that she would “sen- tarse bien.” Unfortunately, I told her that she would sit well, rather than feel well (which is sentirse bien). N E W A M E R I C A N P E R S P E C T I V E S Hispanic Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 9 2 7 1 from family and friends. Single immigrant men preferred living with other Salvadorans when possible144 posttraumatic stress disor- der is prevalent among refugees from El Sal- vador and other Central American nations; it is especially acute among those who are here illegally and suffer continuous anxiety regard- ing the possibility of deportation.157 Central Americans sometimes assimilate into other Latino communities. Cross-cultural exchanges of health beliefs and practices may occur in some areas, and practitioners should be aware of possible Mexican or Caribbean Islander concepts adopted by Central Americans. The in-depth interview is crucial in counseling Central Americans because so few data about food habits, health practices, and nutritional status are available. In addi- tion, information from family members or community experts may be needed. D I S C U S S I O N S T A R T E R S Comic Books as Nutrition Education In a story on helping migrant workers in the United States improve their diets, Evelyn Theiss, a medical writer for the Cleveland, Ohio, newspaper The Plain Dealer (http://www.cleveland.com/healthfit/index.ssf/2010/07/comic_book_helps_families_in_m.html) tells how Jill Kilanowski, an assistant Plain Dealer (http://www.cleveland.com/healthfit/index.ssf/2010/07/comic_book_helps_families_in_m.html) tells how Jill Kilanowski, an assistant Plain Dealer professor at Case Western Reserve University, developed a comic book for migrant worker mothers and their young children. Kilanowski explains, “The mothers told me they wanted reading materials with primary colors to use as a teaching tool for their small children, as well as a story line and pictures.” It turns out that comic books are very popular in Mexican and Mexican American cultures. The major focus of this comic book story is on limiting portion sizes, because Mexican American immigrants often suffer from obesity, diabetes, and hypertension. Imagine that you have been hired to write another comic book for Mexican American migrant workers on making some change to their dietary or health habits to improve their health. Because limiting portion sizes has been done, what other change might you focus on? Outline the story line, if you can. Consider a comic book for Central American immigrants. Would the same themes and story lines work for them? In small groups, share your themes and story lines, getting feedback from your group members, and then revise your ideas for your comic books. Review Questions 1. Compare and contrast the staple foods of Mexico’s different regions. 2. Describe the hot–cold system of diet and health practiced traditionally by Mexicans. 3. List two regional U.S. foods that are modifi- cations of Mexican recipes. First, describe the possible original dish, and then explain how it is modified. 4. Which countries make up Central America? Roughly, what are the demographics of immi- grants in the United States from Central America? 5. Compare the traditional health beliefs and practices of Mexicans and Central Americans. 6. Describe the food staples of Central America. 7. What are the most common health problems of Mexicans and Central Americans and their decendants living in the United States? How may acculturation to the American diet con- tribute to these problems? References 1. Silva-Zolezzi, I., Hidalgo-Miranda, A., Estrada- Gil, J., Fernandez-Lopez, J.C., Uribe-Figueroa, L., Contreras, A., . . . Jimenez-Sanchez, G. 2009, May 26. Analysis of genomic diversity in Mexi- can Mestizo populations to develop genomic medicine in Mexico. Proceedings of the National Academy of Sciences, 106(21), 861–916. 2. Ennis, S.R., Ríos-Vargas M., & Albert, N.G. 2011, May. The Hispanic population: 2010. 2010 Cen- sus Briefs. U.S. Census Bureau. Retrieved from http://www.census.gov/prod/cen2010/briefs/ c2010br-04 3. Passel, J., & Cohn, D’Vera. n.d. Mexican immi- grants: How many come? How many leave? R e t r i e ve d f rom http : / / p e w h isp an i c . org / reports/report.php?ReportID5112 (accessed February 11, 2011). 4. Mexican Americans. n.d. In Wikipedia. U.S. Cen- sus Bureau: Table QT-P10 Hispanic or Latino by Type: 2010. Retrieved from http://en.wikipedia. org/wiki/ (accessed February 26, 2015). Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 2 7 2 M E X I C A N S A N D C E N T R A L A M E R I C A N S 5. Durand, J., Massey, D.S., & Charvet, F. 2000. The changing geography of Mexican immigration to the United States: 1910–1996. Social Science Quarterly, 81, 1–15. 6. Brick, K., Challinor, A.E., & Rosenblum, M.R. 2011. Mexican and Central American immigrants in the United States. Washington, DC: Migration Policy Institute. 7. Religion in Latin America. Pew Research Center’s Religion and Public Life. Retrieved from http:// www.pewforum.org/2014/11/13/religion-in- latin-america/ (accessed April 15, 2015). 8. Hill, L.E., & Johnson, H.P. 2002. Understand- ing the future of Californians’ fertility: The role of immigrants. San Francisco: The Public Policy Institute of California. 9. Neff, N. 1998. Folk medicine in Hispanics in the southwestern United States. Retrieved from http:// www.rice.edu/projects/HispanicHealth/Courses/ mod7/mod7.html (accessed February 13, 2011). 10. Lopez, R.A. 2005. Use of alternative folk medicine by Mexican American women. Journal of Immi- grant Health, 7, 23–31.7, 23–31.7 11. Trotter, R.T., & Chavira, J.A. 1997. Curanderismo: Mexican American folk healing. Athens: Univer- sity of Georgia Press. 12. Mikhail, B.I. 1994. Hispanic mothers’ beliefs and practices regarding selected children’s health problems. Western Journal of Nursing Research, 16, 623–638. 13. Spector, R.E. 2004. Cultural diversity in health and illness (6th ed.). Upper Saddle River, NJ: Pearson Education. 14. Baer, R.D., Weller, S.C., De Alba Garcia, J.G., Glazer, M., Trotter, R., Pachter, L., & Klein, R.E. 2003. A cross-cultural approach to the study of the folk illness nervios. Culture, Medicine, and Psychiatry, 27, 315–337.27, 315–337.27 15. Zoucha, R., & Purnell, L.D. 2003. People of Mex- ican heritage. In L.D. Purnell & B.J. Paulanka (Eds.), Transcultural health care: A culturally competent approach (2nd ed.). Philadelphia: F.A. Davis. 16. Laudan, R. 1999. Chiles, chocolate, and race in New Spain: Glancing backward to Spain or look- ing forward to Mexico? Eighteenth Century Life, 23, 59–70. 17. Leonard, J.N. 1968. Latin American cooking. New York: Time-Life Books. 18. Peterson, J., & Peterson, D. 1998. Eat smart in Mexico: How to decipher the menu, know the market foods, and embark on a tasting adventure. Madison, WI: Gingko Press. 19. Kennedy, D. 1990. Mexican regional cooking. New York: HarperCollins. 20. Kennedy, D. 1998. My Mexico: A culinary odyssey with more than 300 recipes. New York: Clarkson Potter. 21. Menzel, P., & D’Aluisio, F. 1998. Man eating bugs: The art and science of eating insects. Berkeley, CA: Ten Speed Press. 22. Romero-Gwynn, E., & Gwynn, D. 1994. Food and dietary adaptation among Hispanics in the United States. In T. Weaver, N. Kanellos, & C. Esteva- Fabregat (Eds.), Handbook of Hispanic cultures in the United States: Anthropology. Houston, TX: Arte Publico Press. 23. Carmichael, E., & Sayer, C. 2005. Feasting with dead souls. In C. Korsmeyer (Ed.), The taste cul- ture reader. Gordonsville, VA: Berg Publishers. 24. Foster, D. 2002. The global etiquette guide to Mexico and Latin America. New York: Wiley. 25. Bharucha, D.X., Morling, B.A., & Niesenbaum, R.A. 2003. Use and definition of herbal medicines differ by ethnicity. Annals of Pharmacotherapy, 37, 1409–1413.37, 1409–1413.37 26. Davidow, J. 1999. Infusions of healing: A treasury of Mexican American herbal remedies. New York: Simon & Schuster. 27. Dole, E.J., Rhyne, R.I., Zeilmann, C.A., Skipper, B.J., McCabe, M.L., & Low Dog, T. 2000. The influence of ethnicity on use of herbal reme- dies in elderly Hispanic and non-Hispanic whites. Journal of the American Pharmaceutical Associa- tion, 40, 359–365. 28. Coronado, G.D., Thompson, B., Tejada, S., & Godina, R. 2004. Attitudes and beliefs among Mexican Americans about type 2 diabetes. Jour- nal of Health Care for the Poor and Underserved, 15, 576–588. 29. Pilcher, J.M. 2001. Tex-Mex, Cal-Mex, New Mex, or whose Mex? Notes on the historical geography of southwestern cuisine. Journal of the Southwest, 43, 659–680. 30. Heise, D. 2002. Hispanic American influence on the U.S. food industry. Washington, DC: USDA Agricultural Research Service. 31. Ryan, R.W. 2003. Is it border cuisine or merely a case of NAFTA indigestion? Journal for the Study of Food and Society, 6, 21–30. 32. Hispanic food and beverages in the U.S.: Market and consumer trends in Latino cuisine (5th ed.). July 2012. Rockville, MD: Packaged Facts. 33. Ayala, G.X., Baquero, B., & Klinger, S. 2008. A sys- tematic review of the relationship between accul- turation and diet among Latinos in the United States: Implications for future research. Journal of the American Dietetic, 108, 1330–1344. 34. Wallendorf, M., & Reilly, M.D. 1983. Ethnic migration, assimilation, and consumption. Jour- nal of Consumer Research, 10, 292–302. 35. Ayala, G.X., Mueller, K., Lopez-Madurga, E., Campbell, N.R., & Elder, J.P. 2005. Restaurant and food shopping selections among Latino women in Southern California. Journal of the American Dietetic Association, 105, 38–45. 36. Gregory-Mercado, K.Y., Staten, L.K., Ranger- Moore, J., Thomson, C.A., Will, J.C., Ford, E.S., . . . Marshall, J. 2006. Fruit and vegetable consump- tion of older Mexican-American women is asso- ciated with their acculturation level. Ethnicity & Disease, 16, 89–95. 37. Neuhouser, M.L., Thompson, B., Coronado, G.D., & Solomon, C.C. 2004. Higher fat intake and lower fruit and vegetables intakes are associ- ated with greater acculturation among Mexicans Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 9 2 7 3 living in Washington State. Journal of the Ameri- can Dietetic Association, 104, 51–57. 38. Norman, S., Castro, C., Albright, C., & King, A. 2004. Comparing acculturation models in evalu- ating dietary habits among low-income Hispanic women. Ethnicity & Health, 14, 399–404. 39. Monroe, K.R., Hankin, J.H., Malcolm, C.P., Henderson, B.E., Stram, D.O., Park, S., . . . Kolonel, L.N. 2003. Correlation of dietary intake and colorectal cancer incidence among Mexican- American migrants: The Multiethnic Cohort Study. Nutrition and Cancer, 45, 133–147. 40. Ayala, G.X., Baquero, B., & Klinger, S. 2008. A systematic review of the relationship between acculturation and diet among Latinos in the United States: implications for future research. Journal of the American Dietetic Association, 108, 1330–1344. 41. Barquera, S., Hernandez-Barrera, L., Tolentino, M.L., Espinosa J., Ng, S.W., Rivera, J.A., & Popkin, B.M. 2008. Energy intake from beverages is increasing among Mexican adolescents and adults. Journal of Nutrition, 138, 2454–2461. 42. New Strategist Publications. 2005. Who’s buying groceries (3rd ed.). Ithaca, NY: Author. 43. Bruhn, C.M., & Pangborn, R.M. 1971. Food hab- its of migrant workers in California. Journal of the American Dietetic Association, 59, 347–355. 44. Dewey, K.G., Strode, M.A., & Ruiz Fitch, Y. 1984. Dietary change among migrant and nonmigrant Mexican-American families in northern Califor- nia. Ecology of Food and Nutrition, 14, 11–24. 45. Dwyer, J.T., Stone, E.J., Minhua, Y., Webber, L.S., Must, A., Feldman, H.A., . . . Parcel,G.S. 2000. Prevalence of marked overweight and obesity in a multiethnic pediatric population: Findings from the Child and Adolescent Trial for Cardiovascular Health (CATCH) study. Journal of the American Dietetic Association, 100, 1149–1156. 46. Moreno, C., Alvarado, M., Balcazar, H., Lane, C., Newman, E., Ortiz, G., & Forrest, M. 1997. Heart disease education and prevention program targeting immigrant Latinos: Using focus group responses to develop effective interventions. Jour- nal of Community Health, 22, 435–450. 47. Romero-Gwynn, E., Gwynn, D., Grivetti, L., McDonald, R., Stanford, G., Turner, B., . . . William- son, E. 1993. Dietary acculturation among Latinos of Mexican descent. Nutrition Today, 28, 6–12. 48. Jackson, K.A., & Savaiano, D.A. 2001. Lactose maldigestion, calcium intake and osteoporosis in African, Asian, and Hispanic Americans. Journal of the American College of Nutrition, 20(Suppl. 2), 198S–207S. 49. NPD Group. 2005. At the table with Hispanic fami- lies across America. Port Washington, NY: Author. 50. Wechsler, H., B as ch, C.E., Zy b er t, P., Lantigua, R., & Shea, S. 1995. The availability of low-fat milk in an inner-city Latino community: Implications for nutrition education. American Journal of Public Health, 85, 1690–1692. 51. Lisabeth, L.D., Sánchez, B.N., Escobar, J., Hughes, R., Meurer, W.J., Zuniga, B., . . . Morgenstern, L.B. 2010, May. The food environment in an urban Mexican American community. Health Place, 16(3), 598–605. Epub February 2, 2010. 52. Elder, J., Sallis, J.F., Zive, M.M., Hoy, P., McKenzie, T.L., Nader, P.R., & Berry, C.C. 1999. Factors affecting selection of restaurants by Anglo- and Mexican-American families. Journal of the Ameri- can Dietetic Association, 99, 856–857. 53. Moag-Stahlberg, A. January 2011. The American Dietetic Association Foundation’s 2010 Retrieved from http://www.eatright.org/foundation/fnpa/ 54. Normand, V. 2005. Montezuma’s revenge. Metro, July 13–19. Retrieved from http://www.metro- active.com/papers/metro/07.13.05/aztecs-0528. html (accessed February 14, 2011). 55. MacDorman, M.F., & Mathews, T.J. 2011. Under- standing racial and ethnic disparities in U.S. infant mortality rates. NCHS data brief, no 74. Hyattsville, MD: National Center for Health Statistics. 56. National Center for Health Statistics. 2013. Deaths: Final data for 2010. National Vital Statis- tics Report, 61(4), Table 7. 57. Xu, J.Q., Kochanek, K.D., Murphy, S.L., & Tejada-Vera, B. 2010. Deaths: Final data for 2007. National Vital Statistics Reports, 58(19). Hyatts- ville, MD: National Center for Health Statistics. 58. Hummer, R.A., Rogers, R.G., Nam, C.B., & LeClere, F.B. 1999. Race/ethnicity, nativity, and U.S. adult mortality. Social Science Quarterly, 80, 1083–1118. 59. Markides, K.S., & Eschbach, K. 2005. Aging, migration, and mortality: Current status of research on the Hispanic paradox. Journals of Gerontology, Series B, Psychological Sciences and Social Sciences, 60, 68–75. 60. Palloni, A., & Arias, E. 2004. Paradox lost: Explaining the Hispanic adult mortality advan- tage. Demography, 41, 385–415. 61. National Center for Health Statistics. 2005. Health, United States, 2005 with chartbook on trends in the health of Americans. Hyattsville, MD: Author. 62. Mathews, T.J., & MacDorman, M.F. 2010. Infant mortality statistics from the 2006. National Vital Statistics Reports, 58(17). Hyattsville, MD: National Center for Health Statistics. 2010. 63. Mennella, J.A., Turnbull, B., Ziegler, P.J., & Martinez, H. 2005. Infant feeding practices and early flavor experiences in Mexican infants: An intracultural study. Journal of the American Dietetic Association, 105, 908–915. 64. McDowell, M.M., Chia-Yih Wang, C.-Y., & Kennedy-Stephenson, J. 2008, April. Breastfeed- ing in the United States: Findings from the National Health and Nutrition Examination Survey, 1999– 2006. NCHS Data Brief Number 5, April 2008. 65. Tolbert Kimbro, R., Lynch, S.M., & McLana- han, S. 2008. The influence of acculturation on breastfeeding initiation and duration for Mexican-Americans. Population Research and Policy Review, 27(2), 183–199. 66. Brotanek, J.M., Schroer, D., Valentyn, L., Tomany- Korman, S., & Flores, G. 2009, January–February. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 2 7 4 M E X I C A N S A N D C E N T R A L A M E R I C A N S Reasons for prolonged bottle-feeding and iron defi- ciency among Mexican-American toddlers: An eth- nographic study. Academic Pediatrics, 9(1), 17–25. 67. Brotanek, J.M., Halterman, J.S., Auinger, P., Flores, G., & Weitzman, M. 2005. Iron deficiency, prolonged bottle-feeding, and racial/ethnic dis- parities in young children. Archives of Pediatric and Adolescent Medicine, 159, 1038–1042. 68. Huntingdon, N.L., Kim, I.J., & Hughes, C.V. 2002. Caries-risk factors for Hispanic children affected by early childhood caries. Pediatric Dentistry, 24, 536–542. 69. Ervin, R.B. 2008. Healthy Eating Index scores among adults, 60 years of age and over, by sociodemographic and health characteristics: United States, 1999–2002. Advance data from vital and health statistics; no 395. Hyattsville, MD: National Center for Health Statistics. 70. Evans, A.E., Sawyer-Morse, M.K., & Betsinger, A. 2000. Fruit and vegetable consumption among Mexican-American college students. Jour- nal of the American Dietetic Association, 100, 1399–1402. 71. Liu, J.H., Chu, Y.H., Frongillo, E.A., & Probst, J.C. 2012. Generation and acculturation status are associated with dietary intake and body weight in Mexican American adolescents. Journal of Nutrition, 142(2), 298–305. 72. Matias, S.L., Stoecklin-Marois, M.T., Tancredi, D.J., & Schenker, M.B. 2013. Adherence to dietary recommendations is associated with acculturation among Latino farm workers. Journal of Nutrition, 143(9), 1451–1458. 73. Montez, J.K., & Eschbach, K. 2008, March. Coun- try of birth and language are uniquely associated with intakes of fat, fiber, and fruits and vegetables among Mexican-American women in the United States. Journal of the American Dietetic Associa- tion, 108(3), 473–480. 74. Guendelman, S., & Abrams, B. 1995. Dietary intake among Mexican-American women: Gen- erational differences and a comparison with white non-Hispanic women. American Journal of Public Health, 85, 20–25. 75. Wright, J.D., & Wang, C.-Y. 2010. Trends in intake of energy and macronutrients in adults from 1999–2000 through 2007–2008. NCHS data brief, no 49. Hyattsville, MD: National Center for Health Statistics. 76. Ramakrishnan, U., Frith-Terhune, A., Cogswell, M., & Kettel Khan, L. 2002. Dietary intake does not account for differences in low-iron stores among Mexican American and non-Hispanic white women: Third National Health and Nutri- tion Examination Survey, 1988–1994. Journal of Nutrition, 132, 996–1001. 77. Dixon, L.B., Sundquist, J., & Winkleby, M. 2000. Differences in energy, nutrient, and food intakes in a US sample of Mexican-American women and men: Findings from the Third National Health and Nutrition Examination Survey, 1988–1994. American Journal of Epidemiology, 152, 548–557. 78. Hampl, J.S., Taylor, C.A., & Johnston, C.S. 2004. Vitamin C deficiency and depletion in the United States: The Third National Health and Nutrition Examination Survey, 1988 to 1994. American Journal of Public Health, 94, 870–875. 79. Harley, K., Eskenazi, B., & Block, G. 2005. The asso- ciation of time in the US and diet during pregnancy in low-income women of Mexican descent. Paediat- ric and Perinatal Epidemiology, 19, 125–134. 80. Zive, M.M., Taras, H.L., Broyles, S.L., & Frank- Spohrer,G.C. 1995. Vitamin and mineral intakes of Anglo-American and Mexican-American preschoolers. Journal of the American Dietetic Association, 95, 329–335. 81. Trends in tuberculosis incidence—United States, 2008. 2009, March 20. Morbidity and Mortality Weekly Report, 58(10), 249–253. 82. U.S. Department of Health and Human Services, Office of Minority Health. n.d. Pro- file: Hispanic/Latino Americans. Retrieved from http://minorityhealth.hhs.gov/omh/browse. aspx?lvl53&lvlid564 (accessed February 25, 2015). 83. Freedman, D.S., Khan, L.K., Serdula, M.K., Ogden, C.L., & Dietz, W.H. 2006. Racial and eth- nic differences in secular trends for childhood BMI, weight, and height. Obesity (Silver Spring, MD), 14, 301–308. 84. Ayala, G.X., Elder, J.P., Campbell, N.R., Slymen, D.J., Roy, N., Engleberg, M., & Ganiats, T. 2004. Correlates of body mass index and waist-to-hip ratio among Mexican women in the United States: Implications for intervention development. Women’s Health Issues, 14, 155–164. 85. Crespo, C.J., Smit, E., Andersen, R.E., Carter-Pokras, O., & Ainsworth, B.E. 2000. Race/ethnicity, social class and their relation to physical inactivity during leisure time: Results from the Third National Health and Nutrition Examination Survey, 1988–1994. American Journal of Preventive Medicine, 18, 46–53. 86. Gordon-Larsen, P., Adair, L.S., & Popkin, B.M. 2003. The relationship of ethnicity, socioeco- nomic factors, and overweight in US adolescents. Obesity Research, 11, 121–129. 87. Eckstein, K.C., Mikhail, L.M., Ariza, A.J., Thomson, J.S., Millard, S.C., & Binns, H.J. 2006. Parents’ perceptions of their child’s weight and health. Pediatrics, 11, 681–690. 88. Robinson, T.N., Chang, J.Y., Haydel, K.F., & Killen, J.D. 2001. Overweight concerns and body image dissatisfaction among third-grade children: The impacts of ethnicity and socioeconomic status. Journal of Pediatrics, 138, 181–187. 89. Sanchez-Johnsen, L.A., Fitzgibbon, M.L., Martinovich, Z., Stolley, M.R., Dyer, A.R., & Van Horn, L. 2004. Ethnic differences in cor- relates of obesity between Latin-American and black women. Obesity Research, 12, 652–660. 90. Talamayan, K.S., Springer, A.E., Kelder, S.H., Gorospe, E.C., & Joye, K.A. 2006. Prevalence of overweight and weight control behaviors among normal weight adolescents in the United States. Scientific World Journal, 26, 365–373. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 9 2 7 5 91. Byrd, T.L., Balcazar, H., & Hummer, R.A. 2001. Acculturation and breast feeding intention and practice in Hispanic women on the US-Mexico border. Ethnicity & Disease, 11, 72–79. 92. Regan, P.C., & Cachelin, F.M. 2006. Binge eating and purging in a multi-ethnic community sam- ple. International Journal of Eating Disorders, 39, 523–526. 93. Burke, J.P., Williams, K., Gaskill, S.P., Hazuda, H.P., Haffner, S.M., & Stern, M.P. 1999. Rapid rise in the incidence of type 2 diabetes from 1987 to 1996: Results from the San Antonio Heart Study. Archives of Internal Medicine, 159, 1450–1456. 94. Grant, R.W., Moore, A.F., & Florez, J.C. 2009. Genetic architecture of type 2 diabetes: Recent progress and clinical implications. Diabetes Care, 32(6), 1107–1114. 95. Haffner, S.M., Hazuda, H.P., Mitchell, B.D., Patterson, J.K., & Stern, M.P. 1991. Increased incidence of type II diabetes mellitus in Mexican Americans. Diabetes Care, 14, 102–108. 96. Centers for Disease Control and Prevention. n.d. 2011 national diabetes fact sheet. Retrieved from http://www.cdc.gov/diabetes/pubs/-figuretext11. htm#fig4 (accessed February 15, 2011). 97. Centers for Disease Control and Prevention. 2006. Diabetes death rate for Hispanics com- pared to non-Hispanic whites—United States versus counties along the U.S.–Mexico bor- der, 2000–2002. Morbid Mortal Weekly Report, 55(32), 882. 98. Smith, C.A., & Barnett, E. 2005. Diabetes-related mortality among Mexican Americans, Puerto Ricans, and Cuban Americans in the United States. Revista Panamericana de Salud Pública, 18, 381–387. 99. Ervin, R.B. 2009. Prevalence of metabolic syn- drome among adults 20 years of age and over, by sex, age, race and ethnicity, and body mass index: United States, 2003–2006. National health sta- tistics reports, no. 13. Hyattsville, MD: National Center for Health Statistics. 100. Statistics. 2008. Health, United States, 2008. Hyattsville, MD: National Center for Health Statistics. 101. Statistical fact sheet—risk factors, 2010 update, high blood cholesterol and other lipids. 2010. Retrieved from http://www.americanheart.org/ downloadable/heart/1261004785748FS13CH10 (accessed February 15, 2011). 102. Hunt, K.J., Resendez, R.G., Williams, K., Haffner, S.M., Stern, M.P., & Hazuda, H.P. 2003. All-cause and cardiovascular mortality among Mexican-American and non-Hispanic white older participants in the San Antonio Heart Study— evidence against the “Hispanic paradox.” Ameri- can Journal of Epidemiology, 158, 1048–1057. 103. National Center for Health Statistics. 2005. Health, United States, 2005 with chartbook on trends in the health of Americans. Hyattsville, MD: Author. 104. Nguyen, H.T., & Stack, A.G. 2006. Ethnic dis- parities in cardiovascular risk factors and cor- onary disease prevalence among individuals with chronic kidney disease: Findings from the Third National Health and Nutrition Examina- tion Survey. Journal of the American Society of Nephrologists, 17, 1716–1723.17, 1716–1723.17 105. Pandey, D.K., Labarthe, D.R., Goff, D.C., Chan, W., & Nichaman, M.Z. 2001. Community-wide coronary heart disease mortality in Mexican Americans equals or exceeds that in non-Hispanic whites: The Corpus Christi Heart Project. Ameri- can Journal of Medicine, 110, 81–87. 106. Puppala, S., Dodd, G.D., Fowler, S., Arya, R., Schneider, J., Farook, V.S., . . . Duggirala, R. 2006. A genomewide search finds major susceptibil- ity loci for gallbladder disease on chromosome 1 in Mexican Americans. American Journal of Human Genetics, 78, 377–392. 107. Tseng, M., Deveillis, R.F., Maurer, K.R., Khare, M., Kohimeier, L., Everhart, J.E., & Sandler, R.S. 2000. Food intake patterns and gallbladder dis- ease in Mexican Americans. Public Health Nutri- tion, 3, 233–243. 108. Geller, S.E., & Derman, R. 2001. Knowledge, beliefs, and risk factors for osteoporosis among African-American and Hispanic women. Journal of the National Medical Association, 93, 13–21. 109. Lukes, S.M., & Simon, B. 2005. Dental decay in southern Illinois migrant and seasonal farm- workers: An analysis of clinical data. Journal of Rural Health, 21, 254–258. 110. Nurko, C., Aponte-Merced, L., Bradley, E.L., & Fox, L. 1998. Dental caries prevalence and den- tal health care of Mexican American workers’ children. ASDC Journal of Dentistry in Children, 65, 65–72. 111. Chartier, K. and Caetano, R. 2010. Ethnicity and health disparities in alcohol research. Alcohol Research & Health, 33 (1 and 2), 154. 112. Lopez, R. A. 2005. Use of alternative folk medi- cine by Mexican American women. Journal of Immigrant Health, 7, 23–31.7, 23–31.7 113. Sobralske, M.C. 2006. Health care seeking among Mexican American men. Journal of Transcultural Nursing, Nursing, Nursing 17, 129–138.17, 129–138.17 114. Hsiao, A.F., Wong, M.D., Goldstein, M.S., Yu, H.J., Andersen, R.M., Brown, E.R., . . . Wenger, N.S. 2006. Variations in complementary and alterna- tive medicine (CAM) use across racial/ethnic groups and the development of ethnic-specific measures of CAM use. Journal of Alternative and Complementary Medicine, 12, 281–290. 115. Risser, A.L., & Mazur, L.J. 1995. Use of folk remedies in a Hispanic population. Archives of Pediatric and Adolescent Medicine, 149, 978–981. 116. Tafur, M.M., Crowe, T.K., & Torres, E. 2009. A review of curanderismo and healing practices among Mexicans and Mexican Americans. Occu- pational Therapy International, 16(1), 82–88. 117. Yehieli, M., & Grey, M.A. 2005. Health matters: A pocket guide for working with diverse cultures Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 2 7 6 M E X I C A N S A N D C E N T R A L A M E R I C A N S and underserved populations. Boston: Intercul- tural Press. 118. Poss, J., & Jezewski, M.A. 2002. The role and meaning of susto in Mexican Americans’ explan- atory model of type 2 diabetes. Medical Anthro- pology Quarterly, 16, 360–377. 119. Espino, D.V., Bazaldua, O.V., Palmer, R.F., Mouton, C.P., Parchman, M.L., Miles, T.P., & Markides, K. 2006. Journals of Gerontology, Series A, Biological Sciences and Medical Sciences, 61, 170–175. 120. Kuo, Y.F., Raji, M.A., Markides, K.S., Ray, L.A., Espino, D.V., & Goodwin, J.S. 2003. Inconsistent use of diabetes complications, and mortality in older Mexican Americans over a 7-year period: Data from the Hispanic established popula- tion for the epidemiologic study of the elderly. Diabetes Care, 26, 3054–3060. 121. Poss, J., Jezewski, M.A., & Stuart, A.G. 2003. Home remedies for type 2 diabetes used by Mexican Americans in El Paso, Texas. Clinical Nursing Research, 12, 304–323. 122. Galanti, G.A. 2004. Caring for patients from dif-Caring for patients from dif-Caring for patients from dif ferent cultures (3rd ed.). Philadelphia: University of Pennsylvania Press. 123. Graham, R.E., Ahn, A.C., Davis, R.B., O’Conner, B.B., Eisenber, D.M., & Phillips, R.S. 2005. Use of complementary and alternative medical ther- apies among racial and ethnic minority adults: Results from the 2002 National Health Interview Survey. Journal of the National Medical Associa- tion, 97, 535–545.97, 535–545.97 124. Blackhall, L.J., Murphy, S.T., Frank, G., Michel, V., & Azen, S. 1995. Ethnicity and atti- tudes toward patient autonomy. Journal of the American Medical Association, 274, 820–825. 125. Horowitz, C.R., Tuzzio, L., Rojas, M., Monteith, S.A., & Sisk, J.E. 2004. How do urban African Americans and Latinos view the influence of diet on hypertension? Journal of Health Care for the Poor and Underserved, 15, 631–644. 126. Wen, L.K., Shepherd, M.D., & Parchman, M.L. 2004. Family support, diet, and exercise among older Mexican Americans with type 2 diabetes. Diabetes Education, 30, 980–993. 127. Algert, S.J., Brzezinski, E., & Ellison, T.H. 1998. Mexican American food practices, customs, and holidays: Ethnic and regional food practices. Chicago: American Dietetic Association/Ameri- can Diabetes Association. 128. Yetley, E.A., Yetley, M.J., & Aguirre, B. 1981. Family role structure and food related roles in Mexican-American families. Journal of Nutrition Education, 13(Suppl. 1), S96–S101. 129. Ikeda, J., & Gonzales, M.M. 1986. Food habits of Hispanics newly immigrated to the San Francisco Bay area (abstract). Oakland: California Dietetic Association Annual Meeting. 130. Melville, M.B. 1985. Salvadorans and Guatema- lans. In D.W. Haines (Ed.), Refugees in the United States. Westport, CT: Greenwood. 131. Ennis, S.R., Ríos-Vargas, M., & Albert, N.G. 2011. The Hispanic population. 2010 Census Briefs. 132. Mumford, J. 2000. Salvadoran Americans. In R.V. Dassanowsky & J. Lehman (Eds.), Gale encyclopedia of multicultural America. Farming- ton Hills, MI: Gale Group. 133. Brick, K., Challinor, A.E., & Rosenblum, M.R. 2011. Mexican and Central American Immigrants in the United States. Washington, DC; Migra- tion Policy Institute, http://www.census.gov/ prod/cen2010/briefs/c2010br-04 (accessed February 26, 2015). 134. Smagula, S. 2000. Nicaraguan Americans. In R.V. Dassanowsky & J. Lehman (Eds.), Gale encyclopedia of multicultural America. Farming- ton Hills, MI: Gale Group. 135. Central American immigrants in the United States. n.d. Migration Policy Institute. Retrieved from http://www.migrationinstitute.org (accessed February 26, 2015). 136. Hong, M. 2000. Guatemalan Americans. In R.V. Dassanowsky & J. Lehman (Eds.), Gale encyclopedia of multicultural America. Farming- ton Hills, MI: Gale Group. 137. U.S. Census, Immigration Statistics Staff. 2004. Foreign-born profiles (STP-159). Retrieved from http://w w w.census.gov/p opulation/w w w/- socdemo/foreign/STP-159-2000tl.html (accessed February 15, 2011). 138. Maxwell, W. 2000. Honduran Americans. In R.V. Dassanowsky & J. Lehman (Eds.), Gale encyclopedia of multicultural America. Farming- ton Hills, MI: Gale Group. 139. Chase, C.S. 2000. Costa Rican Americans. In R.V. Dassanowsky & J. Lehman (Eds.), Gale encyclopedia of multicultural America. Farming- ton Hills, MI: Gale Group. 140. Purnell, L. 1999. Panamanians’ practices for health promotion and the meaning of respect afforded them by health care providers. Journal of Transcultural Nursing, 10, 331–339.of Transcultural Nursing, 10, 331–339.of Transcultural Nursing 141. Purnell, L. 2001. Guatemalans’ practices for health promotion and the meaning of respect afforded them by health care providers. Journal of Transcultural Nursing, of Transcultural Nursing, of Transcultural Nursing 12, 40–47. 142. Miralles, M.A. 1989. A matter of life and death: Health-seeking behavior of Guatemalan refugees in south Florida. New York: AMS Press. 143. Leonard, J.N. 1968. Latin American cooking. New York: Time-Life Books. 144. Boyle, J.S. 1991, April–May. Transcultural nurs- ing care of Central American refugees. National Student Nurses Association, Inc./Imprint, 73–77. 145. Rutherford, M.S., & Roux, G.M. 2002. Health beliefs and practices in rural El Salvador: An ethnographic study. Journal of Cultural Diversity, 9, 3–11. 146. Zapata, J. 1999. The use of folk healing and heal- ers by six Latinos living in New England: A pre- liminary study. Journal of Transcultural Nursing, Journal of Transcultural Nursing, Journal of Transcultural Nursing 136–142. 147. Ailinger, R.L., Molloy, S., Zamora, L., & Benavides, C. 2004. Herbal remedies in a Nica- raguan barrio. Journal of Transcultural Nursing, Journal of Transcultural Nursing, Journal of Transcultural Nursing 15, 278–282. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 9 2 7 7 148. Barrett, B. 1995. Ethnomedical interactions: Health and identity on Nicaragua’s Atlantic coast. Social Science and Medicine, 40, 1611–1621. 149. Marks, C. 2004. False tongues and Sunday bread: A Guatemalan and Mayan cookbook. Takoma Park, MD: Takoma Books. 150. Edmonds, V.M. 2005. The nutritional patterns of recently immigrated Honduran women. Journal of Transcultural Nursing, of Transcultural Nursing, of Transcultural Nursing 16, 226–235. 151. Romieu, I., Hernandez-Avila, M., Rivera, J.A., Ruel, M.T., & Parra, S. 1997. Dietary studies in countries experiencing a health transition: Mexico and Central America. American Journal of Clinical Nutrition, 65, 1159S–1165S. 152. Hamdallah, M., & Bhatia, A.J. 1995. Prevalence of sickle-cell trait in USA adolescents of Central American origin. Lancet, 346, 707–708. 153. Mathews, T.J, & MacDorman, M.F. 2010. Infant mortality statistics from the 2006 period linked birth/infant death data set. National Vital Statis- tics Reports, 58(17). Hyattsville, MD: National Center for Health Statistics. 154. Prevalence of low birth weight among Hispanic infants with United States–born and foreign- born mothers: The effect of urban poverty. American Journal of Epidemiology, 139, 184–192. 155. Mirza, N.M., Kadow, K., Palmer, M., Solano, H., Rosche, C., & Yanovski, J.A. 2004. Prevalence of overweight among inner city Hispanic-Ameri- can children and adolescents. Obesity Research, 12, 1298–1310. 156. Callahan, S.T., Hickson, G.B., & Cooper, W.O. 2006. Health care access of Hispanic young adults in the United States. Journal of Adolescent Health, 39, 627–633. 157. Molesky, J. 1986. Pathology of Central America refugees. Migration World, 14, 19–23. 158. Bladholm, L. 2001. Latin & Caribbean grocery stores demystified. Los Angeles: Renaissance Books. 159. Laudan, R. 2004. The Mexican’s kitchen’s Islamic connection. Saudi Aramco World, 55, 32–39. 160. Looker, A.C., Loria, C.M., Carroll, M.D., McDowell, M.A., & Johnson, C.L. 1993. Calcium intakes of Mexican Americans, Cubans, Puerto Ricans, non-Hispanic whites, and non-Hispanic blacks in the United States. Journal of the Ameri- can Dietetic Association, 93, 1274–1279. 161. Romieu, I., Hernandez-Avila, M., Rivera, J.A., Ruel, M.T., & Parra, S. 1997. Dietary studies in countries experiencing a health transition: Mexico and Central America. American Journal of Clinical Nutrition, 65, 1159S–1165S. 162. Basiotis, P.P., Carlson, A., Gerrior, S.A., Juan, W.Y., & Lino, M. 2002. The Healthy Eating Index: 1999–2000. Washington, DC: U.S. Depart- ment of Agriculture, Center for Nutrition Policy and Promotion. CNPP–12. 163. Harris, K.M. 2000. The health status and risk behaviors of adolescents in immigrant families. In D.J. Hernandez (Ed.), Children of immigrants: Health adjustment and public assistance. Wash- ington, DC: National Research Council. 164. Landale, N.S., Oropesa, R.S., & Gorman, B.K. 1999. Immigration and infant health: Birth out- comes of immigrant and native-born women. In D.J. Hernandez (Ed.), Children of immigrants: Health, adjustment, and public assistance. Wash- ington, DC: National Academy Press. 165. Franzini, L., & Fernandez-Esquer, M.E. 2004. Socioeconomic, cultural, and personal influ- ences on health outcomes in low-income Mexican-origin individuals in Texas. Social Science & Medicine, 59, 1629–1646. 166. Gould, J.B., Madan, A., Qin, C., & Chavez, G. 2003. Perinatal outcomes in two dissimilar immigrant populations in the United States. Pediatrics, 111, e676–e682. 167. Wingate, M.S., & Alexander, G.R. 2006. The healthy migrant theory: Variations in pregnancy outcomes among US-born migrants. Social Science & Medicine, 62, 491–498. 168. Guendelman, S., Thornton, D., Gould, J., & Hosang, N. 2006. Mexican women in California: Differentials in maternal morbidity between for- eign and US-born populations. Paediatrics and Perinatal Epidemiology, 20, 471–481. 169. Acevedo, M.C. 2000. The role of acculturation in explaining ethnic differences in the prenatal health-risk behaviors, mental health, and par- enting beliefs of Mexican-American and Euro- pean American at risk women. Child Abuse and Neglect, 24, 111–127. 170. Page, R.L. 2004. Positive pregnancy outcomes in Mexican immigrants: What can we learn? Jour- nal of Obstetrical and Gynecological Nursing, nal of Obstetrical and Gynecological Nursing, nal of Obstetrical and Gynecological Nursing 33, 783–790. 171. Jenny, A.M., Schoendorf, K.C., & Parker, J.D. 2001. The association between community con- text and mortality among Mexican-American infants. Ethnicity & Disease, 11, 722–731. 172. Guendelman, S., Thornton, D., Gould, J., & Hosang, N. 2006. Mexican women in Califor- nia: Differentials in maternal morbidity between foreign and US-born populations. Paediatrics and Perinatal Epidemiology, 20, 471–481. 173. McMurray, M.P., Ceriqueira, M.T., Conner, S.L., & Conner, W.E. 1991. Changes in lipid and lipo- protein levels and body weight in Tarahumara Indians after consumption of an affluent diet. New England Journal of Medicine, 325, 1704–1708. 174. Wright, J., Romero-Gwynn, E., Cotter, A., Powell, C., Garrett, C., Grajales-Hall, M., . . . Williamson, E. 1996. Radio is effective in teach- ing nutrition to Latino families. California Agri- culture, 50, 14–18. 175. Centers for Disease Control and Prevention. 2013. Listeria and food. Retrieved from http:// www.CDC.gov/foodsafety/specific-foods/listeria- and-food.html (accessed February 27, 2015). Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 2 7 8 10 Caribbean Islanders and South AmericansCH A P T E R Cuba, and the smallest islands are barely more than exposed rocks. Most were claimed at one time by Spain, Britain, France, the Netherlands, Denmark, or the United States, but now include the independent nations of Antigua/Barbuda, the Bahamas, Barbados, Cuba, Dominica, Dominican Republic, Grenada, Haiti, Jamaica, St. Christopher/ Nevis, St. Lucia, St. Vincent/Grenadines, and Trinidad and Tobago, as well as the U.S. terri- tory of Puerto Rico. Many islands, such as the Virgin Islands (U.S.) and Martinique (France), are still under foreign control. The islands are uniformly scenic. The tropical warmth and torrential rains provide the ideal climate for a lush plant cover that includes numerous indigenous fruits and veg- etables. Later immigrants found the region suitable for imported crops. The Caribbean islands share a history of domination by foreign powers and political turmoil. Native Indians, Europeans, blacks from Africa, and Asians from China and India have inter- married over the centuries to produce an extremely diverse population. Cultural Perspective History of Caribbean Islanders in the United States Immigration Patterns It is estimated that the Hispanic population was 17 percent of the United States’ total population in 2010. For Hispanics from the Caribbean, residents from Puerto Rico constituted the largest group, fol- lowed by those from Cuba and the Dominican Latinos from the Caribbean islands and South America often seem more differ-ent from one another than similar. Their homelands vary from the tropics of the islands and northern Brazil to the highland plains of Argentina and the snow-topped mountains of Peru. Their ethnic backgrounds include native Indian, Spanish, Portuguese, French, British, Danish, Dutch, African, Asian Indian, Chinese, Italian, German, and Japanese. And though Roman Catholicism is practiced by a majority, many others follow Protestant faiths, Judaism, and numerous indigenous Afro- European religions including voodoo, santería, and candomblé. One commonality between Caribbean Islanders and South Americans is a variety of regional fares with few national cuisines. Dishes typically combine native ingredients with foods introduced from Europe, Africa, and Asia, with a broad preference for strong, spicy flavors. This chapter reviews Caribbean Islanders and their fare, focusing on Puerto Ricans, Cubans, and Dominicans. A sum- mary of South Americans is also presented (see Figure 10.1). Other Latinos are covered in Chapter 9. Caribbean Islanders More than 1,000 tropical islands in the Carib- bean stretch from Florida to Venezuela. They include the Bahamas, the Greater Antilles (Jamaica, Cuba, Hispaniola, and Puerto Rico), and the Lesser Antilles. The largest island is When Columbus landed in the Bahamas in 1492, he believed he had dis- covered a new route to Indonesia and called the native people “Indians.” The Caribbean islands later became known as the West Indies. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 1 0 2 7 9 Republic. In addition, there were small groups of immigrants from other Caribbean nations, most significantly from Jamaica and Haiti. Puerto Ricans Puerto Ricans differ from most other people who come to the United States in that they are technically not immigrants. They come to the mainland as U.S. citizens and are free to travel to and from Puerto Rico without restriction. Over half the population of Puerto Rico resides on the mainland of the United States, and the number of Puerto Ricans who live in New York City is almost double the number living in San Juan, the largest city in Puerto Rico. Small numbers of political exiles from Puerto Rico arrived in America in the 1800s, but most returned home when Puerto Rico Figure 10.1 Caribbean islands and South America. North Atlantic Ocean South Atlantic Ocean Caribbean Sea BOLIVIA COLOMBIA VENEZUELA PERU BRAZIL FRENCH GUIANA SURINAME GUYANA CHILECHILE ECUADORDOR PARAGURAGURAGUAY URUGUAY ARGENTINA Caracas Brasilia AsunciónAsunción Santiago Buenos Aires La Paz Bogotá QuitoQuitoQuito Lima Montevideo FALKLAND ISLANDS (UK) JAMAICA HAITI DOM. REP. PUERTO RICO VIRGIN ISLANDS ST. ST. ST KITTS AND NEVIS DOMINICA BARBADOS GRENADA TRINIDAD AND TOBAGO CUBA BAHAMAS Caracas © C en ga ge L ea rn in g Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 2 8 0 C A R I B B E A N I S L A N D E R S A N D S O U T H A M E R I C A N S differences between the two countries, most Cubans have not been subject to the usual immigration quotas. Immigration from Cuba slowed with the end of the airlifts. In 1980, another large group of 110,000 Cubans arrived in Florida in pri- vate boats (the Mariel boatlift) seeking asy- lum. Unlike earlier immigrants, these recent arrivals, called marielitos, were mostly poor, unskilled laborers. They were often single and black. Today, a trickle of exiles continue to come to the United States. Some arrive by boat and others go through legal immigration channels from a neutral third country. Dominicans Information on early immi- grants from the Dominican Republic is lim- ited because prior to 1990, Dominicans were counted within the broader Hispanic category in the U.S. Census data (in 1990 “Dominican” was a write-in category; in 2000 it became a check-off category).1 Four immigration groups have been identified.2 The first was during the Trujillo era (1930–1960), when political dissidents came to the United States to escape the regime of President Rafael L. Trujillo. The second group came during the post-Trujillo era (1961–1981), when improved social and economic conditions slowed emi- gration to a trickle. The third is the flotilla group (1982–1986); this comprises Domini- cans who left the country by boat, seeking escape from oppressive poverty, hoping for a new start in the United States. The fourth group includes those who have left since the early 1980s, many of whom are urban Domin- icans better educated than those they leave behind, seeking employment opportunity. Some Dominicans enter the U.S. mainland after making Puerto Rico their home. The numbers of unauthorized Dominicans, or those who return to the island, are unknown.3 Current Demographics Puerto Ricans The number of Puerto Ricans living on the U.S. mainland reached over 5 million in the 2010 Census estimates.3 Over 25 percent of Puerto Ricans make New York State their home, with most living in New York City.4 In the 1930s, Puerto Ricans began moving into East Harlem, which became became a U.S. possession. Others arrived when unemployment increased in the depressed agricultural economy of the island during the 1920s and 1930s. It was after World War II that the largest number of Puerto Ricans moved to the mainland. Unlike other immigrants, the Puerto Rican population in the United States is in continual flux. Many Puerto Ricans live alternately between the mainland and the island, depending on eco- nomic conditions. Cubans Cubans have immigrated to the United States since the early nineteenth cen- tury. In the early years, the majority were those who found economic conditions dis- advantageous or who were politically out of favor with the current government. The majority of Cubans came to the United States after Fidel Castro overthrew the dicta- torship of Fulgencio Batista in 1959. In the three years following the revolution, more than 150,000 Cubans arrived in America. Most of these were families from the upper socioeconomic group fleeing the restraints of communism. Commercial air travel between Cuba and the United States was suspended after the Cuban missile crisis in 1962. Airlifts of immigrants from 1965 to 1973 increased the total number of Cubans in the United States to nearly 700,000. Due to the political Terms of identity vary for Puerto Ricans, including Puerto Rican American, Borrinqueño or Boricua (used by those who prefer the native Taíno Indian name for the island), and Nuyorican (used by second-genera- tion Puerto Ricans living in New York City). Puerto Ricans living in Puerto Rico are not counted in the U.S. Census totals. ▼ Cuban cafeteria, Miami, Florida. D an ie l K or ze ni ew sk i/ Sh ut te rs to ck .c om Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 1 0 2 8 1 known both as El Barrio and as “Spanish Harlem.” The median age of Puerto Ricans is 27 years, compared to 37 years for the U.S. total population.5 Cubans In 2013, the U.S. Census estimated that the number of Americans of Cuban descent was under 2 million.6 Most Cubans live in urban areas, but the largest number live in the Miami area, which is sometimes called “Little Havana,” where the climate is similar to that of their homeland. Economically, Cuban Americans have a higher median income than non-Hispanic whites.7 Dominicans Approximately 1.8 million indi- viduals of Dominican descent are living in the United States.6 The majority live in the urban areas of New York, New Jersey, Massachu- setts, and Florida. It has been estimated that as many as 300,000 unauthorized migrants also reside in those regions.8 Other Caribbean Islanders Steady immigra- tion to the United States during the 1990s had increased numbers of other Caribbean Islanders in 2010 to over 965,000 Jamaicans and nearly 881,000 residents from Haiti.6 Jamaicans have settled in the cities of the Northeast and South. Socioeconomic Status Immigrants from the Caribbean vary in both economic and educational attainment. Among Latinos, Puerto Rican Americans have a high rate of unemployment, and Cuban Americans have the lowest. More than 28 percent of Puerto Ricans live in poverty, which is higher than the rate for both the general U.S. popula- tion (16 percent) and for Hispanics overall (26 percent). However, it should be noted that second-generation mainland Puerto Ricans living in regions outside New York may have a different socioeconomic profile, with signifi- cantly higher rates of college graduation and white-collar employment.9 Economically, U.S. Cubans have a higher median income than non-Hispanic whites in the United States.10 Dominicans have the same median earnings similar to other Hispanics, but less than the U.S. population.11 Educational rates for first-generation immigrants from the Caribbean are very similar to those of other Latinos. Figures from 2010 show that for adults, both Puerto Ricans and Cuban Americans graduate from high school at rates of 76 and 81 percent, respectively, which are somewhat below that of the general population. However, rates of high school attendance are lower for those who were born in Puerto Rico or Cuba. The percentage of Puerto Ricans and Cubans who have college degrees was 18 and 26 percent, while total number of Americans with degrees was 30 percent.12 Many factors influence socioeconomic differences among Latino groups from the Caribbean. Puerto Ricans living on the main- land are free to travel between the United States and their homeland, and the frequent changes in residence may hamper socioeco- nomic improvement. Many Puerto Ricans have chosen to reside in New York City, where as a new ethnic minority they took over the lower-income neighborhoods pre- viously occupied by African Americans. In general, lower education levels and job skills translate into unemployment and low-level employment. Furthermore, some Puerto Ricans, Domin- icans, Jamaicans, and Haitians face biases sim- ilar to that experienced by African Americans because many are of African heritage. Racial distinctions are not as significant in the Carib- bean islands, and more overt discrimination is a new challenge for some immigrants.13 In contrast, Cubans in the United States are mostly political refugees who emigrated out of necessity, not choice. There are a dispro- portionate number of Cubans in the United States from the upper socioeconomic levels, and although many lost all their material goods when they emigrated, they brought upper-class values, including the importance of educational and financial success. Instead of displacing any ethnic minority in Florida, they immigrated in such numbers that they immediately became the dominant ethnic group. This is not to say that there are no well- educated, wealthy Puerto Ricans living on the main-land or no poor Cuban Americans. However, circumstances surrounding their immigration have influenced the general socioeconomic status of both groups. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 2 8 2 C A R I B B E A N I S L A N D E R S A N D S O U T H A M E R I C A N S Worldview Ethnic identity is strongly maintained in the Puerto Rican, Cuban, and Dominican com- munities in the United States. Puerto Ricans on the mainland continue close ties with the island, frequently returning to visit fam- ily and friends. Cubans believe it is impor- tant to retain their heritage because they cannot return. Dominicans often consider their stay in the United States temporary and may resist acculturation to maintain their identity. In all three groups, Spanish may be spoken at home, but Caribbeans were more likely to use English at home (32 percent) than those from South America (15 percent), Central America (7 percent), or Mexico (3 percent).1,4,14 In contrast, Carib- bean Islanders who are unauthorized resi- dents, often try to blend into existing Latino communities or assimilate into mixed ethnic neighborhoods.15 Religion A majority of Caribbean Islanders are Roman Catholics. The role of the Catholic Church has been less important in the Carib- bean than in other regions of Latin America and is less significant to immigrants in the United States. For example, the number of Puerto Ricans living on the mainland who are Catholic has declined since the 1960s, approx- imating 70 percent today,13 and it is estimated that only 64 percent of Cuban Americans born in the United States are followers of the faith.1 However, higher percentages of Catho- lics may be found in other Caribbean Islander groups who have been in the United States for shorter periods of time. For instance, about 95 percent of Dominicans are adherents to Roman Catholicism.16 A number of other religions are prac- ticed in the islands, including Protestant- ism and Judaism. For example, a majority of Jamaicans, who at one time lived under Brit- ish rule, belong to Protestant congregations, such as the Church of God and Seventh-Day Adventists. Folk religions are found as well. The best known of these is voodoo, a unique combination of West African tribal ritu- als with Catholic beliefs and local customs. St. Patrick is associated with the African snake deity Damballah, for example, and St. Christopher is identified with Bacoso, the god responsible for infectious illness. Cer- tain rites, such as repeating the Hail Mary, making the sign of the cross, and baptism, are practiced in conjunction with ancestor wor- ship, drums, and African dancing. Worship is family based, and there is no central lead- ership or organization of activities. Typically ceremonies are conducted for annual events such as Christmas and the harvest and for funerals. Voodoo originated in Haiti, although very similar Afro-Catholic cults are found on the other islands. In Cuba and Puerto Rico, these are called santer í a. Many followers of voodoo or santería are also members of Christian faiths and do not believe there is any contra- diction in practicing both religions simultane- ously.17 Rastafari is another Afro-Caribbean faith indigenous to Jamaica. Rastas practice a natural, simple lifestyle typified by bare feet, loose clothing, dreadlocks, and sacramental use of marijuana. It is also considered a politi- cal movement due to Rastafari opposition to traditional government and support for repa- triation of blacks to Africa. Family The Puerto Rican family is based on the concept of c ompadr az go, which means co- parenting. Grandparents, aunts and uncles, cousins, and godparents are all considered part of the immediate family, responsible for the care of children.18 Men are the heads of households as well as being in charge of community matters. The oldest boys in the family are expected to help with supervi- sion of younger siblings, particularly daugh- ters. Women maintain the home. Men are expected to be aggressive; women are tradi- tionally reserved. As in most Latino cultures, age is respected and elders are honored. Younger children are taught to defer even to older children. Duty to family is extremely important.19 Traditional Cuban families are also patriar- chal and extend to include relatives. Godpar- ents are significant in child rearing. Children are deferential to elders and well chaperoned in public. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 1 0 2 8 3 determines life and death. Prayer, the lighting of candles to saints, and the laying on of hands are important ways of maintaining health and curing disease.21,22,23,24 Many Dominicans employ the pr omesa, a promise or obligation to be performed by a supplicant in exchange for maintenance or restoration of health.16 In addition, some believe that all individuals have a guardian angel who protects them from evil. Some also believe illness can be caused by evil spirits or the devil, particularly Domini- cans and Haitians. The conditions of empacho, susto, nervios, and mal de ojo are known by many Puerto Ricans, but not by all.21 Of special note is nervios, which takes several forms.25,26 Someone who has experienced trauma as a child may become a nervous person for life, ser ner v ioso, with crying bouts, headaches, stomach maladies, and a tendency toward violence in men. This condition can be tem- pered by use of herbal teas and talking with family members, religious advisers, or mental health professionals. P adec er de l os ner v ios is a mental illness associated with depression that develops in adults. It is treated with the help of psychologists or psychiatrists. A taq ues de ner v ios, also known as ataq ues, is a hysteri- cal reaction to stressful events. It may include acute breathing difficulties, frenzy, or the sudden onset of illness. Nervios is a problem Caribbean Islander families often change in the United States. Women, who work in greater numbers than men, and who may make a higher income, often gain greater authority within the home, and Caribbean Islander children gain greater autonomy in the United States. Economic pressures, American values of individualism and equal- ity, and intergenerational stress are often cited as responsible for nontraditional adaptations. Studies of early immigrants have shown that one-third of Dominicans, for example, lived in nuclear family groupings in the United States even though only 1 percent did so in the Dominican Republic. Dominican women in the United States also had fewer children than those on the island.18 Among the rural population of Haiti, common-law marriage is frequent, and it is acceptable for a man to maintain several different households as long as he supports each wife and their children. This pl ac aj system is believed to be a remnant of the polygamous societies found in parts of West Africa.20 Gender roles are inflexible, with men responsible for farming and providing for the family, and women in charge of the household budget, marketing, and child care. Haitians have maintained more traditional families than some other Caribbean groups living in the United States. Typically, men still head the family, though Haitian Ameri- can women often insist on a greater role in making decisions than is customary in Haiti. Haitian children are still expected to obey their parents, bring honor to their family, and to reside at home until marriage. Haitian Americans establish a close network with other Haitian immigrants and keep in touch with family and friends remaining in Haiti. Those who are unable to return for political reasons may sponsor voodoo ceremonies on their behalf.13 Traditional Health Beliefs and Practices Many Caribbean Islanders hold health beliefs simi- lar to those of other Latin American cul- tures. For example, Puerto Ricans, Cubans, Dominicans, and Haitians often believe that illness is a punishment from God, or that fate M ire ill e Va ut ie r/ A la m y ▲ Serious conditions, such as sickness due to supernatural causes, may require the cures associated with the healing practice of santería. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 2 8 4 C A R I B B E A N I S L A N D E R S A N D S O U T H A M E R I C A N S found more often in women than men, and it is associated with a weak character.27 In gen- eral, nervios is helped by prayer, massage, sed- atives, and herbal teas. Physicians and mental health specialists are also useful. Other folk conditions reported by Puerto Ricans include pasmo, a type of paralysis due to an imbalance of hot and cold, and f atiq ue, acute breathing difficulties. Pasmo is cured through folk rem- edies, whereas fatique responds to emergency care provided by a physician. Haitians are especially concerned with the flow of blood, considered essential in the balance of hot–cold categories. Many blood irregularities are recognized, classified as hot, cold, weak, thin, thick, dirty, and yellow.28 F ebl es occurs when there is insufficient blood or anemia due to poor diet. The condition is characterized by general weakness and is cured by eating items such as liver, red meat, pigeon meat, cow’s feet, or leafy green veg- etables. S ez isman is a disruption of normal blood flow, due to sudden emotional trauma or chronic ill-treatment by others. It can cause vision loss, headaches, high blood pressure, or stroke. It is treated with relaxation, cold com- presses, sipping cool water, or drinking cof-presses, sipping cool water, or drinking cof-presses, sipping cool water, or drinking cof fee mixed with rum.29 Haitian women may be encouraged to eat red fruits and vegetables (such as beets or pomegranates) to strengthen their blood.20 G az (gas) is another common condition G az (gas) is another common condition G az for some Haitians. Gas may settle between the ears, causing headache; in the stomach, caus- ing indigestion; or in other parts of the body, where it causes pain. Eating leftovers (espe- cially beans) is one cause of gaz.29 A nursing mother may undergo a thickening of her milk, which causes headaches or depression in the woman and impetigo in her baby. M ov e san is a more serious condition in which a nursing mother experiences fright or negative emo- tions, causing her milk to spoil, resulting in diarrhea and failure to thrive syndrome in her infant.2 Some Haitians believe mal dy ok (evil eye) can also cause illness. The traditional healing practices common in the Caribbean are more closely related to African beliefs than the Arab Spanish humoral system used in hot–cold applica- tions. Mild conditions are treated through an informal system of older women (mothers, grandmothers, or neighbors) who are knowl- edgeable about the use of teas, herbs, amu- lets, and charms.30 A study of Dominican healers found that the women learned their skills from relatives or through spiritual guidance.31 When at home in the Domini- can Republic, they treated only clients they knew personally from within their com- munities. In the United States, the healers expanded their practice to include strangers and clients of all ethnicities. They typically accepted a wide variety of physical and psy- chological cases. When possible, the healers preferred to consult with the entire family in order to gain full support for recommended treatment. More serious conditions, such as those due to supernatural causes, particularly witchcraft, require the cures associated with voodoo and santería. Voodoo priests ( h ougans or bok or s) or priestesses (mambos) or spiritualist heal- ers, known as espir itos and santer os, intervene with the saints on behalf of a bewitched per- son (practices related to those of the American South; see Chapter 8). Santeros specialize in soul possession and mental disorders. Dreams may play an important role in health care because they are a connection with the super- natural world. Ancestors provide instructions to an individual regarding health behaviors through dreams. B r uj os (witches) and curen- deros (healers) (see Chapter 9) may also be sought for medical care.22 Dominicans often believe the best way to treat illness is to use a traditional healer who will consult with Catholic saints about which home remedies are appropriate for the symp- toms.16 This allows Dominicans to address the spiritual and emotional aspects of physi- cal problems as well as seek symptom relief. Many Haitians recognize two types of illness. The first is natural illness, due to a poor diet, blood conditions, bone displacement, or cold drafts and other environmental factors. These can be cured by home remedies or visits to biomedical practitioners. The second is super- natural illness, due to angry spirits. These can only be treated by a voodoo manger mor t (feast for the dead) ceremony.29 Cubans often consider santería a link to their past and may Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 1 0 2 8 5 use a biomedical provider for relief of physical symptoms but employ a santero to help them restore balance or counteract the circum- stances that led to their illnesses.24 Good hygiene, especially daily bathing, is done to promote health among Puerto Ricans. Some Puerto Ricans, Dominicans, and other Caribbean Islanders practice a modified ver- sion of the hot–cold classification system in their diet, and some use it for categorizing illness (see the “Therapeutic Uses of Food” section in this chapter).23,31 Dominican heal- ers may consider junk food, red meat, lack of exercise, emotional distress, contact with negative people, and environmental stresses as some contributing factors in health prob- lems.31 Haitians consider eating well, clean- liness, and regular sleep essential to health. Laxatives or enemas may be used to refresh the bowel, remove impurities, and prevent acne in children.29 Most Caribbean Islanders use herbal teas, and over-the-counter medications are often used to relieve symptoms—Dominicans may also take baths with herbs or flowers. Many Americans of Caribbean island heritage are also likely to use home remedies or visit a bontá nic as (herbal pharmacy) or a bodega (small market) to purchase cures (including antibiotics obtained without prescription) as a first step in treating symptoms.24,32 One study notes that some Dominicans refer to home remedies of all types as z umos, a word that, strictly translated, means “juices.”33 Traditional Food Habits Ingredients and Common Foods Caribbean food habits are remarkably simi- lar for an area influenced by so many other cultures. The indigenous Indians, the Spanish, French, British, Dutch, Danes, Africans, Asian Indians, and Chinese have all had an impact on the cuisine. The basic diet is similar through- out the region, with regional variations found on each island. In recent years, tourism has helped spread specialties from one nation to another in order to meet visitor expectations about what dishes are available, and the global economy has furthered the development of a pan-Caribbean cuisine.34,35,36 Indigenous Foods Columbus likened the West Indies to paradise on earth. The islands are naturally laden with fresh fruits and veg- etables originally from Central or South America, including the staple cassava (two varieties of tuber, bitter and sweet, also known as manioc and yuca; tapioca is a starch prod- uct of manioc), acerola (Barbados cherry, a small, sour fruit with exceptionally high vitamin C content), avocados, bananas and plantains, some varieties of beans, calabaza (a type of pumpkin), cashew apples (fruit of the cashew nut), cocoa, coconuts, corn, guavas, malanga (a mild yam-like tuber sometimes called cocoyam, yautia, tannier, or tannia), mammee apples (a small green fruit with flesh reminiscent of apricots), papayas (sometimes called pawpaws), pineapple, sapodilla or nas- eberry (a small fruit with aromatic flesh that has a gritty texture similar to pears), soursop (a fruit with a cotton-like consistency), sev- eral types of squash (including chayote, called chocho or christophene in the islands), sweet potatoes, and tomatoes. Fish and small birds are also plentiful. As in other Latin American areas, chile peppers grow profusely in the West Indies. Extremely hot varieties are favored, including Scotch bonnet and bird peppers (also called tepins—see Chapter 9, for more information on chiles). The native cuisine makes frequent use of these for flavoring, especially in pepper sauces, such as coui, a mixture of cassava juice and chiles. Other native seasoning includes allspice, recao (E r y ngium f oetidum, a pungent herb also known as culantro, long cilantro, or shandon beni), and annatto (achiote). Because of the abundance of fresh fruits and vegetables year-round, traditionally there was little need for preparation or preserva- tion of foods. Consequently, cooking tech- niques were underdeveloped in the native populations. Cassava was baked most often in a kind of bread, made from pressed, dried, grated cassava that was fried in a flat loaf. Fish and game were either covered with mud and baked in a pit or grilled over an open fire. Foreign Influence The Europeans who set- tled in the Caribbean were impressed with the abundant supply of native fruits and Cassava contains hydro- cyanic acid, which is toxic in large amounts. The acid must be leached out and the tuber cooked before it can be eaten safely. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 2 8 6 C A R I B B E A N I S L A N D E R S A N D S O U T H A M E R I C A N S all countries are prepared similarly, flavored with lard and salt. Onions, sweet peppers, and tomatoes or coconut milk are added in some variations. Other popular legumes include pigeon peas, popularly known as gungo (originally from Africa, often cooked with rice, also), lentils (from India), chickpeas (also known as garbanzo beans, introduced from Europe), and bodi beans (another variety of cowpea eaten as a green bean, also called Chi- nese long beans). Examples of other foods common throughout the West Indies are found in the cultural food groups list (Table 10.1). They include native Indian foods such as cassava bread, chile sauces, and pepper pot (a meat stew made with the boiled juice of the cassava, called cassarep). Tamales and pasteles are steamed cornmeal, cassava, or plantain dough packets with savory (such as meat, seafood, or cheese) or sweet (including coconut or guava) fillings. European-influenced items popular in many Caribbean countries include escabeche (fried, marinated fish, seafood, or poultry), asapao (a thick rice soup with chicken, pork, or seafood, often garnished with Parmesan cheese in Puerto Rico and slices of avocado or fried plantains in the Dominican Republic), morcillas (a type of blood sausage), flaky pas- try turnovers with meat, poultry, seafood, or fruit fillings, and fried corn cakes (known as surrulitos in Puerto Rico). Foods from Africa found throughout the region include callaloo (a dish of taro or malanga greens cooked with okra), dried salt cod fritters (called bacalaitas in Puerto Rico, these cakes have a different name on nearly every island, from ar c at de mar ue to “stamp and go”), foofoo (okra and plantain), and coocoo (cornmeal-okra bread). Dishes from India and Asia are also common on many islands, although they are better known in the areas where cheap labor was most needed: the islands dominated by the French, British, and Dutch (few Asians immi- grated to Puerto Rico, Cuba, or the Domini- can Republic). Curried dishes, called kerry on the Dutch-influenced islands and colombo on the French-influenced islands, and varia- tions of pilaf are considered Caribbean foods. Chinese cuisine is also popular and Chinese- owned restaurants are omnipresent. vegetables. Yet they longed for the accustomed tastes of home. The Spanish brought cattle, goats, hogs, and sheep to the islands, in addi- tion to introducing rice. Plants introduced for trade by the Europeans included breadfruit, coffee, limes, mangoes, oranges (both sweet and sour varieties), and spices such as gin- ger, nutmeg, and mace. The African slaves brought in to work the sugarcane fields cul- tivated akee (a mild, apple-sized fruit), yams, okra, and taro (also called eddo or dasheen; both the roots and the leaves are eaten). The demand for Asian ingredients by later immi- grants resulted in the introduction of soybean products, Asian greens, lentils, and tamarind to the Caribbean. Staples Legumes are eaten throughout the Caribbean, most often in the dish “rice and peas.” Rice with red (kidney) beans is popu- lar in Puerto Rico and is also found in the Dominican Republic and Jamaica (where the dish is nicknamed “coat of arms”). In Cuba, black beans with rice are preferred, called Moros y Cristianos (“Moors and Christians,” a reference to Spanish history). In Haiti, black- eyed peas (a type of cowpea from Africa) are combined with the rice. The legumes in Nearly all parts of the akee fruit contain hypo- glycins, which can cause fatal hypoglycemia. Most akee products are banned in the United States. S A M P L E M E N U A Puerto Rican Lunch E s c ab e ch e (E s c ovit ch e d Fish)E s c ovit ch e d Fish)E s c ovit ch e d a,b S ur r ulit os c or Caribbean Johnnycakea A r r oz c on P ollo (Peppery Chicken and Rice)a,b,c Habich ue las G uis ad o (Stewed Beans)a,c P lán tan os e n Alimbar (Candied Plantains/Baked Bananas) (Candied Plantains/Baked Bananas)P lán tan os e n Alimbar a,c Fruit Juice, Beer, and Coffee with Milk aDeMers, J. 1997. Caribbean cooking. New York: HP Books. bCocina Criollo at http://www.ricanrecipes.com c.The Boricua Kitchen at http://www.elboricua.com/recipes.html Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 1 0 2 8 7 Group Comments Common Foods Adaptations in the United States Protein Foods Milk/milk products Few dairy products are used; incidence of lactose intolerance is assumed to be high. Infants are given whole, evaporated, or condensed milk. Cow’s milk (fresh, condensed, evaporated), café con leche, café latte; aged cheeses More milk and cheese are consumed. Meat/poultry/fish/ eggs/legumes Traditional diet is high in vegetable protein, especially rice and legumes; red and kidney beans are used by Puerto Ricans, black beans by Cubans. Pork and beef are used more in Spanish-influenced countries. Dried salt cod is preferred over fresh fish; some seafood specialties. Eggs are a common protein source, especially among the poor. Entrées are often fried in lard or olive oil. Meats: beef, pork (including intestines, organs, variety cuts), goat Poultry: chicken, turkey Fish and shellfish: bacalao (dried salt cod), barracuda, bonito, butterfish, crab, dolphin fish (dorado), flying fish, gar, grouper, grunts, land crabs, mackerel, mullets, ostiones (tree oysters), porgie, salmon, snapper, tarpon, turtle, tuna Eggs: chicken Legumes: black beans, black-eyed peas, chick-peas (garbanzo beans), kidney beans, lima beans, peas, red beans, soybeans More beef and poultry are eaten as income increases, though pork intake may decline. Less fresh fish is consumed. Traditional entrées remain popular. Cereals/Grains Breads of other countries are well accepted. Fried breads are popular. Cassava bread; cornmeal (fried breads, surrulitos, puddings); oatmeal; rice (short-grain); wheat (Asian Indian breads, European breads, pasta) Short-grain rice is still preferred. More wheat breads are eaten. Fruits/Vegetables Starchy fruits and vegetables are eaten daily; leafy vegetables are consumed infrequently. Great diversity of tropical fruits is available, eaten mostly as snacks or dessert. Lime juice is used to “cook” (a marinating method called escabeche or ceviche) meats and fish. Fruits: acerola cherries, akee, avocados, bananas and plantains, breadfruit, caimito (star apple), cashew apple, cherimoya, citron, coconut, cocoplum, custard apple, gooseberries, granadilla (passion fruit), grapefruit, guava, guanábana (soursop), jackfruit, kumquats, lemons, limes, mamey, mamey, mamey mangoes, oranges, papayas, pineapple, pomegranates, raisins, sapodilla, sugarcane, sweetsop, tamarind Vegetables: arracacha, arrowroot, black- eyed peas, broccoli, cabbage, calabaza (green pumpkin), callaloo (malanga or taro leaves), cassava (yucaor taro leaves), cassava (yucaor taro leaves), cassava ( , manioc), chiles, corn, cucumbers, eggplant, green beans, lettuce, malan-gas, okra, onions, palm hearts, peppers, potatoes, radishes, spinach, squashes (chayote, summer, and winter), sweet potatoes, taro (eddo, dasheen), tomatoes, yams Temperate fruits are substituted for tropical fruits when latter are unavailable. More fresh fruit is eaten. Starchy fruits and vegetables are still frequently consumed. Low intake of leafy vegetables is often continued. Additional Foods Seasonings Aromatic, piquant sauces are often used to flavor foods. Very hot chiles popular in some regions. Anise, annatto, bay leaf, chiles, chives, cilantro (coriander leaves), cinnamon, coui (chiles mixed with cassava juice), coui (chiles mixed with cassava juice), coui garlic, mace, nutmeg, onions, parsley, pimento (allspice), recao (culantro), scallions, thyme TA B L E 10.1 Cultural Food Groups: Caribbean Islands (Continued ) Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 2 8 8 C A R I B B E A N I S L A N D E R S A N D S O U T H A M E R I C A N S distillation into rum, rum was shipped to Africa and exchanged for slaves, and slaves were shipped to the West Indies to work in the sugarcane fields. Juices made from tropical fruits such as lime, otaheite apple (also called ambarella, originally from Polynesia), pineapple, roselle (also known as “Jamaican sorrel,” brought from Africa), soursop, and tamarind are com- mon. Ginger often spices the juice mixtures, and coconut milk or condensed milk may also be added. Regional Variations Despite the similarities in foods throughout the Caribbean, some regional differences are notable. Same- named dishes prepared on one island may not taste the same on another island due to variations in ingredients and seasoning. For example, butter is the preferred cooking fat in French-influenced countries, whereas lard is more popular in Spanish-influenced nations. Coconut oil is common in Jamaica. In British-influenced countries, dishes often include scallions, parsley or cilantro, and thyme. On French-influenced islands roux (flour blended with butter or oil, then cooked until browned) is used to thicken stews and sauces, and sauce chien (“dog sauce”) is a popular fresh condiment served with pork, chicken, and seafood, made with olive oil and lime juice seasoned with ginger, gar- lic, scallions, parsley, chiles, allspice, and thyme. A similar preparation known as sauce The most popular beverage in the Carib- bean is coffee. It is often mixed with milk and is consumed at meals, as a snack, and even as dessert, flavored with orange rind, cin- namon, whipped cream, coconut cream, or rum. Some of the most expensive coffee in the world is produced in the Blue Mountains of Jamaica, where the cool, moderately rainy climate is ideal for coffee cultivation. Most of the rich beans are exported to England and Italy, although small amounts can be found in the United States. The most important beverage in the Carib- bean, at least historically, is the spirit distilled from fermented molasses—rum. This alco- holic drink is believed to have originated on the island of Barbados in the early 1600s as a by-product of sugarcane processing. Molasses is the liquid that remains after the syrup from the sugarcane has been crystallized to make sugar. It is fermented, naturally or with the addition of yeast, and then distilled to make a clear, high-proof alcoholic beverage. Rum can be bottled immediately or aged in oak casks from a few months to twenty-five years. Caramel is added to achieve the desired color. Nearly every island produces its own variety of rum. The molasses produced in the West Indies was crucial to the development of the region during the seventeenth and eighteenth centu- ries. The Caribbean islands were one corner of the infamous slave triangle, formed when molasses was shipped to New England for Group Comments Common Foods Adaptations in the United States Beverages Teas of all sorts are common and are often thought to have therapeutic value. Rum is especially popular and is often added for flavoring to foods and beverages. Beer, coffee (café con leche), teas, soft drinks, milk, rum, Irish moss (seaweed extract), sorrel Fruit juice and soft drink consumption may increase. Fats/oils Butter in French-influenced countries; coconut oil; ghee (Asian Indian clarified butter); lard in Spanish-influenced countries; olive oil Sweeteners Sugarcane products, such as raw and unrefined sugar and molasses TA B L E 10.1 Cultural Food Groups: Caribbean Islands (C on t in u e d ) © C en ga ge L ea rn in g Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 1 0 2 8 9 ti-malice is found in Haiti. Spanish-influenced islands use more piquant seasonings with less heat, including a greater use of tomatoes, onions, annatto, and sweet bell peppers. Each island is also known for its special- ties. In addition to rice and red beans, Puerto Rican fare is notable for its use of distinctive flavorings, such as alcaparrado, a pickle mix of capers, olives, and pimento, and recaito, an aromatic blend of recao, onions, garlic, and bell peppers. Sofrito, an all-purpose sauce that is the foundation for many Puerto Rican dishes, combines alcaparrado and recaito with tomatoes. All ingredients are then fried in lard colored with annatto seed until a thick paste is formed. Some foods are seasoned with adobo, a mixture of lemon, garlic, salt, pepper, and other spices. Ajilimojili sauce is a puree of bell peppers, garlic, olive oil, and lemon juice. Sazón, a commercial spice blend that is pri- marily monosodium glutamate (MSG, used to enhance flavors), is a popular seasoning as well.19,35 Starchy foods have a central role in Puerto Rican cuisine, traditionally consumed at nearly every meal as a side dish or in soups and stews. They are known as viandas and include bland-tasting, white or creamy colored roots, tubers, and fruits that must be cooked, such as cassava, malanga, potatoes, sweet potatoes (white or yellow are preferred), yams, celery root, breadfruit (and breadfruit seeds), under- ripe bananas, and plantains.19,35 One espe- cially popular preparation is mofongo, fried and mashed plantains flavored with either pork cracklings or bacon. Calabaza and car- rots are considered vegetables because their starch content is lower and they are a signifi- cant source of vitamins; ripe bananas are con- sidered a fruit that is eaten raw. Pork is a favorite meat in Puerto Rico, especially roast pork adobo. It is also used frequently for added flavor in the form of salt pork, ham, cracklings, or bacon. Beef and goat are also consumed. One very popular stew is sancocho, which includes beef short ribs, cal- abaza, malanga, yams, and corn. Chicken is very popular, frequently prepared with rice as arroz con pollo, which is usually served with stewed beans (known as habichuelas guisada), or in asopao. Land crabs and ostiones, a type of oyster that grows on the roots of mangrove trees,37 are eaten, as is some seafood, includ- ing shrimp, lobster, and conch, often prepared as soups or stews. Fresh fish is not consumed frequently (though a few dishes, such as esca- beche, are popular), but dried salt cod, called bacalao, is used in many dishes. It is soaked and drained before use to remove some of the salt and then added to numerous dishes including serenata, a mixture of cod and potatoes. Variety meats are featured in sev- eral national dishes, such as mondongo (tripe soup), lengua relleno (stuffed tongue), rinones guisados (calf kidneys), and sesos empanados (calf brains).34 Fritturas, or finger foods, are also a spe- cialty, consumed as snacks or appetizers or added to meals. They include simple fritters (e.g., banana, squash, or bacalaitos); alcapur- rias (starchy vegetable dough stuffed with spicy beef, pork rind, poultry, or sea-food and then fried); piñones (plantain strips wrapped around sausage, poultry, or sea-food fillings and fried); pastilillos (fried meat or cheese turnovers); and cuchifritos (deep-fried chit- terlings or variety meats). Empanadillas, small baked turnovers typically filled with ham, beef, lobster, conch, or cheese, are also a favorite. Sweets including cakes, pastries, puddings, and cookies are popular for des- serts and snacks. One specialty is tembleque, ▲ A typical Cuban meal often includes meat or fish, savory picadillo (right), black beans and rice, bread, and flan (a Spanish style custard) for dessert (not shown). Ro xa na G on za le z/ Sh ut te rs to ck .c om Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 2 9 0 C A R I B B E A N I S L A N D E R S A N D S O U T H A M E R I C A N S the Puerto Rican version of Spanish-style flan. Flans are also flavored with chocolate, coco- nut, pineapple, pumpkin, or rum. Candied ripe plantains and baked bananas are a com- mon fruit-based sweet in Puerto Rico, also found throughout the Caribbean. Nearly 70 percent of food in Puerto Rico is imported from the mainland. Ameri- can dishes are common, especially among younger diners. Pizza, canned spaghetti, hot dogs, canned soups, and cold cereals have become favorites.19 Cuba is noted for the prominent use of black beans in its cuisine. In addition to black beans and rice, spicy black bean soup is very popular. As in Puerto Rico, viandas are stan- dard fare, especially in the more rural eastern sections of the island where Indian heritage is prominent. Examples include foofoo (cassava balls) and tostones (plantain slices that have been pressed to make them larger and thin- ner, then fried in olive oil). Meats and viandas are often served with mojito, a sauce of olive oil, juice from limes or sour oranges, onions, and garlic. The western parts of the island are more urban and cosmopolitan, especially around Havana, where Spanish and Asian culinary influences are evident. Picadillo is a type of beef hash flavored with the traditional Spanish ingredients featured in alcaparrado (the same mix of olives, raisins, and capers used in Puerto Rico), as well as Caribbean tomatoes and chile peppers. Picadillo is served with fried plantains or boiled rice, or topped with fried eggs. Other Spanish- influenced beef dishes are ropa vieja (“old clothes”), spicy beef strips cooked until they begin to shred, and brazo gitano, a cassava dough pastry filled with corned beef. Roast pork is popular, and eggs are often prepared as Spanish-style potato omelets. In addition, the rice and beans are usually served separately in this region. Asian ingredients are less promi- nent, but notable. Chicharrónes de pollo is prepared with small pieces of chicken mari- nated in lime juice and soy sauce, breaded, and then fried in lard. Another example is arroz salteado, a fried rice dish made with eggs, shrimp, and vegetables cooked in olive oil and seasoned with soy sauce. Fish are eaten in western coastal areas, and one specialty is grilled or stewed crocodile.34,35 Fruit pastes, such as those made from guava, are typical desserts, sometimes served with a slice of salty cheese. Spanish-style egg desserts are also found, especially custards, flans, and pud- dings. Turrones, a nougat candy made with peanuts, is a Cuban favorite. Stews are a specialty in the Dominican Republic. Examples include pollo guisado (chicken with bell peppers, tomatoes, onions, and olives, seasoned with oregano), mon- dongo (similar to the Puerto Rican tripe soup), and stews made with fish or sea-food, such as shrimp, conch, or herring. Best known is the Dominican version of sancocho, made with several kinds of meats (including pork, chicken, beef, and Spanish-style longaniza pork sausage), plus numerous starchy veg- etables cooked in sour orange juice. On spe- cial occasions additional types of meats (e.g., goat, ham) are added to make sancocho pri- eto. Stews are often served with rice and red beans, and cassava bread. Locrio is another Dominican favorite—a rice dish that has its origins in Spanish paella (see Chapter 6 for more information), but differs in that only a single item, such as chicken, shrimp, or sardines, distinguishes each version. Other common dishes include chicharrónes de pollo (prepared like the Cuban recipe), rice with chicken and pigeon peas, and mangu (mashed plantains topped with olive oil-fried onions). Salads are espe- cially popular in the Dominican Republic. A few feature lettuce and tomatoes, but, more often, cooked vegetables such as okra, potatoes, chayote squash, or cabbage are cooled and dressed with oil and vinegar. Avocado and hearts of palm (a specialty of the island) are featured in other versions. Habichuelas con dulce is a unique Domini- can dish served as a side dish or as a dessert, combining red beans, coconut milk, evapo- rated milk, whole milk, sugar, and butter.18 Desserts include fruit compotes, Spanish- style flan, plantains or guavas with caramel sauce, coconut biscuits, or sweet potato or squash puddings. Jamaica specialties include akee and salt cod, curried goat, bammies, a type of cassava Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 1 0 2 9 1 Asian Indian may serve typically Asian Indian meals adapted to Caribbean ingredients, such as a curried dish garnished with coconut, fried plantains, and pineapple. Most menus, however, consist of a multicultural mix, such as European blood sausage and accra, West African-style fritters made from the meal of soybeans or black-eyed peas. More meats and foreign dishes are consumed by wealthy Caribbean Islanders and some reportedly visit the United States weekly to shop for grocer- ies.16,34 American fast foods have become popular throughout the region with rich and poor alike. Daily Patterns Meal patterns vary somewhat throughout the region. Three meals each day, with lunch the largest meal, is typical in most regions. In Haiti, however, two meals a day is not uncommon. In Puerto Rico, the traditionally large lunch and smaller dinner are gradually chang- ing to a dining schedule similar to that on the mainland, especially in urban areas. Toast and coffee are a common breakfast, though eggs bread, mackerel rundown, cooked in coconut milk with vegetables, and jerked foods (see the Exploring Global Cuisine box for more infor- mation). Haiti is known for its banana-stuffed chicken dish called poulet rôti à la créole and barbecued goat with chile peppers (kabrit boukannen ak bon piman). Griot is another popular dish made with pork that is first marinated in seasoned sour orange juice, then boiled, and then fried. Patties, a curried meat turnover, are a Haitian specialty now served throughout the Caribbean. Common Hai- tian side dishes include cornmeal mush and diri a djon djon (also called riz noir, or black rice, this is rice cooked in a broth made by boiling dried mushrooms native to the island called djon djon—the mushrooms themselves are not consumed). Curaçao is famous for its orange-flavored liqueur of the same name, and, in Dominica, crapaud, or “mountain chicken,” a large, tasty frog, is considered a delicacy. In Barbados, many more unusual seafood dishes are popular, including those made with flying fish, green turtles, and sea urchins. Meal Composition and Cycle The most typical aspect of a Caribbean meal is its emphasis on starchy vegetables with some meat, poultry, or fish served with rice and beans. Breads of all sorts are now com- mon in many areas. Meats are frequently fried or grilled. Sometimes before meat is added to mixed dishes it is cooked first with sugar to caramelize it (a technique thought to have been brought by Africans).34,35 Soups and stews are also popular. Soups are sometimes served in two courses—the strained broth first, followed by the cooked meats and veg- etables. Leafy vegetables are sometimes ingre- dients in soups, stews, and stuffed foods, and only served uncooked as part of the lettuce and tomato salads found in many regions, including Puerto Rico, Cuba, and the Domini- can Republic. Fruits are eaten infrequently in many areas but are found fresh in some des- serts and as snacks. Ethnic heritage and social class determine which dishes are served.34 A poor native Indian may eat mostly cassava, tomatoes, and chiles with a bit of salted fish at every meal. An S A M P L E M E N U A Caribbean Sampler Patties (Haiti, Jamaica)a,b Fritters-Black-Eyed Pea, Salt-Cod, or Conch (Pan-Island)a,b,c Callaloo Soup (Pan-Island)a,b P ue r c o As ad o (Cuban Pork Roast)a,b,c M an gú (Dominican Republic)a,d Black Cake/Rum Cake (Pan-Island) aDeMers, J. 1997. Caribbean cooking. New York: HP Books. bCaribbean Recipes at http://www.recipezaar.com/recipes/caribbean cCuban Recipes at http://www.recipehound.com/Recipes/cuba.html dAunt Clara’s Kitchen Dominican Cooking at http://www.dominicancooking.com/dominican-recipes/ Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 2 9 2 C A R I B B E A N I S L A N D E R S A N D S O U T H A M E R I C A N S are popular as well, often served as a Spanish- style omelet. Lunch and dinner menus may be similar, starting with soup (such as black bean soup or chicken with rice soup), fol- lowed by a stew served with rice and beans, fried plantains, and chayote squash. Quick lunches, such as fast food fare, may replace the full meal. Dessert is usually eaten daily, following whichever meal is largest, lunch or dinner. Bread puddings with rum sauce are favored. Soda, fruit juice, beer, or rum accom- pany the meal. Restaurants are widely avail- able in the cities, serving traditional Puerto Rican cuisine, as well as international fare, such as Spanish, Italian, and Japanese. Snack- ing is prevalent, particularly on fried items, such as bacalaitos, surrulitos, and cuchifritos. Toast and coffee is a customary breakfast in Cuba, often followed by a midmorning coffee break with pastries or cakes. Lunch and dinner menus are similar, with meat, poultry, or fish (if available) served with fried plantains, rice and black beans, and often cassava. Custards and puddings (bread or rice) are typical des- serts. Coffee is served after the meal. Lunch is typically the largest meal of the day, even in urban areas, and dinner is often leisurely, and may include beer, rum, or wine. Snacking on fruit, fruit juices, batidas (fruit juice blended with milk and ice), or ice cream is frequent. In the Dominican Republic, breakfast may be just bread and coffee, but more often it is larger, including eggs, cheese, and salami or longaniza sausage (scrambled together, or each fried separately), fried or mashed plantains, and espresso or hot chocolate. Lunch is usually the biggest meal of the day. Traditionally served between noon and 2:00 p.m., it is known as La Bandera Domini- cana (“the Dominican flag”), a plate with rice and beans, a meat or chicken dish, and salad—incorporating colors similar to those found on the national banner.16 Plantains or other starchy vegetables may also accompany lunch. Dessert always follows, and espresso or sweetened coffee with milk ends the meal. The nearly half million Americans of Jamaican ancestry have had significant TJamaican ancestry have had significant T impact on U.S. pop culture. Calypso, reggae, the Rastafari religion, and dreadlocks Rastafari religion, and dreadlocks Rastafari are among the many cultural additions. In cuisine, two regional specialties have piqued American interest: jerk and i-tal. Jerk is believed to be related to the dried meat called jerky. Legend is that the technique was created by escaped African slaves known as Maroons (from the Spanish word for “untamed”—cimarron) who spiced and smoked wild pig meat to preserve it. Today, the word jerk is used to identify jerk is used to identify jerk the wet spice mixture used as a barbecue seasoning. It includes allspice, black pepper, cinnamon, ginger, nutmeg, thyme, scal- lions, and extremely hot Scotch bonnet chile peppers—some recipes also call for garlic, onions, ground coriander, bay leaves, brown sugar, or other seasonings. The spices are moistened with a little oil, lime juice, or soy sauce to make a paste. Traditionally, the meat is rubbed with the jerk blend and marinated for several hours. It is then grilled in a pit over Jamaican pimento (allspice) wood, covered with banana leaves, typically one to four hours, depending on the meat. Though pork and chicken are found at every street jerk stand in Jamaica, more recently the cooking technique has been applied to turkey, fish, seafood, and even vegetables. Jerk pork is used to make jerk sausage in some parts of Jamaica. For a complete meal, rice and peas, cassava bread, or cornsticks accompany the meat.116 I-tal, meaning “vital,” is the Rasta way of I-tal, meaning “vital,” is the Rasta way of I-tal life. Applied to food it emphasizes simple, unprocessed vegetarian fare. Fruit, veg- etables, and grains are permitted, while pork, red meat, salt, and artificial additives are prohibited. Some Rastas will eat chicken or fish (but shun bottom feeders such as shrimp and lobster, scaleless fish such as shark, and any fish more than twelve inches long). In general, milk, coffee, soft drinks, and alcohol are not consumed. I-tal foods are ideally eaten raw or cooked over a fire (microwave ovens are avoided by many Rastas), prepared and served using pots, dishes, and utensils made from natural products, such as wood or earthenware. A woman is not allowed to pre- pare food for others when she is menstruat- ing. Typical i-tal dishes include rice and peas, cassava bread, baked yams, vegetable stews, cornmeal porridge, sautéed plantains, and freshly squeezed juices. Thyme, cinnamon, allspice, coconut, and reputedly marijuana are used to flavor foods.117,118 E X P L O R I N G G L O B A L C U I S I N E Specialty Cooking of Jamaica Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 1 0 2 9 3 American meal patterns are influencing many Dominicans, and abbreviated lunches are becoming more common, including only a main dish, dessert, and coffee. When lunch is the main meal of the day, dinner is light, con- sisting of scrambled eggs or soup, and fried plantains or cassava bread. But when lunch is light, dinner is more substantial, similar to the traditional lunch. Jamaicans often include fish at breakfast, including sardines, mackerel, herring, or salt cod. Other common items are eggs, fried plan- tains, cornmeal porridge, and bammies. On the weekends, liver with bananas is a breakfast specialty. Lunches and dinners are similar to those of other Caribbean Islanders, including soups, rice, and peas with added beef, chicken, or curried goat, pork stews, fish dishes, and tossed salad or sweet potatoes on the side.35,38 Special Occasions The early European domi- nance in the West Indies resulted in an emphasis on Christian holidays. Christmas is important, especially in the Spanish- influenced islands that are predominantly Catholic. In Puerto Rico pasteles are pre- pared to celebrate Christmas. Similar to Mexican tamales, pasteles are a savory meat mixture surrounded by cornmeal or mashed plantains, wrapped in plantain leaves, and steamed. Carolers traditionally stop at houses late at night to request hot pasteles from the occupants. Christmas Eve, or N oc h e B uena, includes Mass and a feast with lechón asado (spit-roasted pig), morcillas, rice with pigeon peas, coquito (rum and coconut milk), and special desserts such as rice pudding and coconut custard. In the Dominican Republic a whole-roasted pig is also customary, served with rice and peas, and a salad. Cubans asso- ciate pasteles (large turnovers) or pastelitos (smaller turnovers) with the holidays as well, but make them with a dough that is similar to French puff-pastry, stuffed with spicy meat or cheese fillings, or sweet fillings, such as guava, mango, or coconut.35 Other holidays reflect the multicultural history of the islands. C ar niv al is celebrated C ar niv al is celebrated C ar niv al in some Caribbean countries such as Trinidad and Tobago and is similar to Mardi Gras in the United States. The pre-Lenten festivities feature parades of dancing celebrants; many are elaborately costumed as traditional European or African figures. Food booths that line the parade route provide a day-and-night supply of carnival treats. Fried Asian Indian fritters are particularly popular. Examples of nonreligious events include the day-long birthday open house on Curaçao for friends, relatives, and acquaintances. Thanks- giving is observed in Puerto Rico. Turkey, stuffed with a Spanish-style meat filling, is the main course. Rum cake (also known as black cake) is a fruitcake specialty of the Caribbean, especially in Jamaica, where it is served at weddings, Christmas, and other special occa- sions. Dominican cake, a citrus-flavored cake with a cooked pineapple filling, topped with a caramelized sugar meringue, is popular in that nation for all holidays and events. Traditionally, Sunday meals emphasize fresh meats when available, especially beef or pork roasts. In the Dominican Republic lunch on Sunday is very large and may last into the early evening. On many islands Sundays are also times when picnics are enjoyed, called dí a del c ampo (“field day”) in Spanish-speaking nations. One dish often served is carne fiam- bre, a selection of cold cuts served with pick- les, olives, and green salad.34,39 Etiquette In Puerto Rico forks and knives are held European style—the fork in the left hand and the knife in the right hand with no switching hands for cutting food. This pat- tern is also the norm in Cuba, though in the Dominican Republic both European-style and American-style use of utensils is accepted. In these nations, dishes are passed to the left, and when not eating, hands should be kept visible, with the wrists resting on the edge of the table. In Puerto Rico it is impolite to start eating until a host says “ B on appetite!” whereas in Cuba and the Dominican Republic it is rude to eat before the host says “¡ B uen pr ov ec h o!”39 Food may be in short supply in some parts of the Caribbean, and respectful behavior is expected when eating. For example, in Cuba vegetables and fruits should not be consumed with the hands. In Puerto Rico, food should not be wasted, and one should not take more than one can eat. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 2 9 4 C A R I B B E A N I S L A N D E R S A N D S O U T H A M E R I C A N S Therapeutic Uses of Food Some Caribbean Islanders adhere to a hot–cold classification system of diet and health simi- lar to that found in Mexico (see Chapter 9). In addition to the categories of hot and cold, Puerto Ricans add cool. Imbalances in hot and cold—for example, sitting in the shade of a tree after being out in the sun—can cause illness even years after the imbalance has occurred.40 Haitians believe that women are warmer than men and that a person cools as he or she ages.28 Among Caribbean Islanders, it is mostly Puerto Ricans, Dominicans, and Haitians who follow dietary and disease hot– cold classifications, and only small numbers are strict adherents.35 The hot–cold theory of foods practiced in the Caribbean sometimes includes not only the category of cool foods, but also those con- sidered heavy or light. A balance of hot–cold elements is attempted at meals, and heavy foods, such as starches, are consumed during the day, whereas light foods, such as soup, are eaten in the evening. Although the specific classification of items varies from person to person, one guideline for Puerto Ricans indi- cates bananas, coconuts, and most vegetables are cold; chiles, garlic, chocolate, coffee, evap- orated milk and infant formula, and alcoholic beverages are hot.41 Cool foods include fruit, chicken, bacalao, whole milk, honey, onions, peas, and wheat. Excessive intake of cool or cold foods can make a cold condition, such as a cough, develop into a chronic illness, such as asthma. Pregnancy, defined as a hot condition by most Puerto Ricans, is a time when a hot–cold balance is practiced carefully, and hot foods are avoided. When infants suffer from hot ailments, including diarrhea or rash, infant formula may be replaced with whole milk, or cooling ingredients such as barley water, man- nitol, or magnesium carbonate may be added to the formula. High-calorie tonics (eggnogs and malts are popular types) are taken by some Puerto Ricans to stimulate the appetite and provide strength or energy. These are con- sidered especially appropriate for pale chil- dren and for pregnant or postpartum women. Research with Dominican Americans sug- gests the use of hot–cold classifications for numerous conditions. Examples cited are excessive cold causing asthma and fibroids, whereas perimenopausal hot flashes are a hot problem.31,33 Home remedies given to children for asthma include warming foods, such as oils (whale, cod liver, almond, and castor), honey or royal jelly (bee-larva food), onion, garlic, oregano, lemon, and aloe vera juice. Beets combined with molasses are used by traditional Dominican healers to treat fibroids (and may be used by some Carib- bean Islanders to lower blood pressure or treat arthritis and ulcers).38,42 Research on Dominican mothers suggests that nutritional practices during lactation may sometimes include avoidance of certain protein foods and increased intake of fluids such as malt beer, milk, orange juice, chocolate milk, and noodle soup.43 Formula may be withheld from sick infants and tea provided instead. Haitians apply the hot–cold theory, includ- ing the heavy-light categories, to a broader number of conditions impacting health. A person’s life cycle, a woman’s reproductive cycle, the climate, and the time of day are cat- egorized, and they must be balanced to main- tain health.20 For example, heavy foods should be eaten in the morning and light foods in the evening. Environmental forces (such as wind, or seeing a lightning strike) and social interac- tions can disrupt equilibrium and result in ill- ness. Women and their newborn infants may spend the first month after birth in seclusion to avoid excessive chilling. Therapeutic use of food is not limited to balancing hot–cold conditions. Some Haitians believe that certain illnesses in infants can be caused if a nursing mother’s milk is too thick or too thin. Further, if a woman is frightened while breast-feeding, her milk goes to her head, causing a headache in her and diarrhea in the baby. Gaz, another condition, causes pain in the shoulders, back, legs, or appendix, and headaches, stomachaches, or anemia. Foods such as corn or a tea made from garlic, cloves, and mint are home remedies for gaz.13 Other Caribbean Islanders, including Cubans, do not generally subscribe to the hot–cold theory but often use food-based home remedies.24,38 One study of Hispanics in the Miami area reported 75 percent had Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 1 0 2 9 5 used herbal cures during the previous twelve months. Cubans reportedly use grapefruit and garlic for hypertension, chayote to calm nerves, and beets to treat anemia and flu. Star anise tea is consumed to relieve intestinal pain and flatulence in adults and colic in infants. Other teas used for stomach aches include those made with aloe vera or spearmint. Teas with cinnamon, sour orange, or honey and lemon are used for colds and coughs. Cinnamon tea is also believed useful for men- strual cramps. Gastrointestinal parasites are treated with pumpkin seed tea. Linden leaf, also popular, is used for anxiety.24,38 Some non-Hispanic Caribbean Islanders believe cassava helps prevent heart disease and cancer. Plantains are also used to decrease the risk of heart disease, as well as for treating hypertension, ulcers, and constipation. Teas are used for many ailments, including lemon- grass tea for fever, and ginger tea for indiges- tion and flatulence (ginger may also be added to rum for diabetes). Cerasse tea, made from Asian bitter melon (which has hypotensive properties), may be consumed to lower blood sugar levels, and wild sage (ma B bz ou) tea is also used to treat diabetes.35,38,44 Contemporary Food Habits in the United States Adaptations of Food Habits Traditional food habits are easily maintained in the self-sustaining immigrant communities of Spanish Harlem in New York City and Little Havana in Miami. Ingredients for Caribbean cuisine are readily available through Puerto Rican and Cuban American markets. Cubans, for example, may consider drinking strong coffee a way to maintain their ethnic identity; by comparison, Americans drink weak coffee. Changes do occur, however, as immigrants settle into culturally mixed communities and children grow up as Americans. Few current data on Caribbean Islander food habits in the United States are available. One older study compared the diet of three groups of women from Puerto Rico: (1) those living in New York (forward migrants), (2) those who had lived on the mainland but later returned to the island (return migrants), and (3) those who never lived on the main- land (nonmigrants). It was found that nonmi- grants and return migrants ate more starchy vegetables, sugar, and sweetened foods than did forward migrants. Forward migrants ate a greater variety of foods, including more beef, eggs, bread, fresh fruit, and leafy green veg- etables. Puerto Rican women who had lived on the mainland quickly reverted to their tra- ditional food habits when they returned to the island.45 Recent research on Afro-Caribbean immi- grants (mostly Jamaicans) in Great Britain found that traditional items such as fish (boiled, baked, or fried), chicken (fried, roast, or curried), homemade soups, rice and peas, plain rice, and boiled potatoes were consumed by respondents several times each week. How- ever, some foods, including patties, salt cod fritters, akee and salt cod, callaloo, breadfruit, and cassava were consumed infrequently. Few Western foods were popular: 83 percent ate hamburgers less than once a month, and similar numbers reported rarely eating pizza, pasta, butter, and margarine.46 Ingredients and Common Foods Research on the food habits of Caribbean immigrants in the United States is limited. It is thought that rice, beans, starchy vegetables, sofrito, and bacalao remain the basis of the daily diet of many Puerto Ricans who live on the mainland. Poultry is used when possible, and egg intake decreases. Because of Cuban Americans’ greater discretionary income, their diet usu- ally includes additional foods, such as more pork and beef. Recent poorer immigrants from Cuba, including the marielitos, are more restricted in what foods they purchase, how- ever, and may follow a diet that is closer to the subsistence-level Puerto Rican regimen. According to marketing studies, Caribbean Islanders accept some American foods, espe- cially convenience items, and purchase fro- zen and dehydrated products when they can afford to do so. The proportion of meat in the diet often increases on the mainland, as does the consumption of milk (and other dairy foods) and soft drinks.35,47,48 Intake of leafy vegetables continues to be low. Local fruits often replace the tropical fruits of Puerto Rico. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 2 9 6 C A R I B B E A N I S L A N D E R S A N D S O U T H A M E R I C A N S Data regarding Dominicans in the United States indicate that only small changes have occurred in consumption patterns. Protein and fat intake has increased slightly, mostly due to eating more meat, while carbohydrate intake has decreased. Dominican women reported that their diet was more varied and abundant than in their homeland.44,48 A study of Hispanics over the age of fifty- five in Massachusetts, including Dominicans, Puerto Ricans, and other Latino groups, made dietary comparisons among less-acculturated Hispanics, more-acculturated Hispanics, and non-Hispanic whites. It was found that rice was the major contributor of energy for both groups of Hispanics, compared to bread for non-Hispanic whites. But Hispanics who had lived in the United States for at least twenty years had macronutrient profiles closer to non-Hispanic whites than to less-acculturated Hispanics, with a lower consumption of complex carbohydrates and an increased consumption of simple sugars.49 Meal Composition and Cycle The meals of Puerto Ricans residing on the mainland are similar to those of people on the island, with a few changes. A light breakfast of bread and coffee may be followed by a light lunch of rice and beans or a starchy vegetable, with or without bacalao. Often this traditional midday meal becomes a sandwich and soft drink, however. A late dinner consists of rice, beans, starchy vegetable, meat if available, or soup. Salad is included in some homes. Many researchers have reported an increase in the amount of snacking between meals, mostly on high-calorie foods with little nutritional value.35,48 Dominicans have started eating lighter lunches.48 Interviews with Haitians living in New York City suggest that some traditional dietary practices are discontinued; for exam- ple, the main meal is eaten in the evening instead of at noon. Although some Haitians adhere to hot–cold classifications of food, they may differ from those used in Haiti.28 One older study reported that many low- income Latina women living in New York did not plan menus far in advance and that this hampered their ability to add variety to their diets.49 It was found that food shopping serves as a social occasion for many of the women and is one of the few opportunities they have to get out of the house; thus they may go to the grocery store more often than is really nec- essary. The investigators reported that nearly half of the women questioned preferred to fry main dishes. Boiling was the second choice, baking third. Broiling food was a distant fourth choice. The researchers noted that in many low-income households the oven or broiler element may not work, restricting food preparation methods to frying and boiling. Special Occasions It is assumed that many Caribbean Islander holiday food traditions are retained after immigration to the United States. Several events have been added to the annual calendar, however, often featuring tra- ditional foods and music of the region. One of the largest is the West Indian Carnival that has been held annually for over sixty-five years in New York City. The carnival celebrates the cultures of the Caribbean, featuring an enormous parade, music competitions, and street vendors selling items such as curried goat and Jamaican jerk barbecue. In June, cit- ies with large Puerto Rican populations often host Puerto Rican Day parades. The Domini- can Day Parade is held every August in New York City. Major reggae music festivals with ample Caribbean food are held throughout the United States on February 6—reggae art- ist Bob Marley’s birthday. Nutritional Status Nutritional Intake There is limited informa- tion on the nutritional status of Caribbean American immigrants to the United States. The few studies available suggest several health trends in these immigrants that have important nutritional implications. Health disparities for Hispanics compared to the gen- eral population have been reported, including lower rates of preventive care (such as inocu- lations and screenings) health care insurance coverage, and higher rates of risk factors.50 Differences among Puerto Ricans have been reported between those living on the main- land and those living in Puerto Rico, with those living on the mainland experiencing In Haiti protein foods are served first to the father in the household; leftovers go to the wife and children. This pattern is believed to continue in Haitian American homes. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 1 0 2 9 7 more physical illness and having less access to health care.52 Low socioeconomic and educa- tion levels are often associated with some dis- parities.51,53,54,55 One study showed that some chronic health conditions, such as disabil- ity and diabetes, are more prevalent among Puerto Rican elders than in white elders living in the same neighborhoods.56 Mortality data suggest that although Puerto Rican and Cuban men have lower overall rates compared to whites, younger men die in disproportionately higher num- bers (often due to preventable causes). Among Puerto Ricans, those who are born in Puerto Rico have lower mortality rates than those born on the mainland.57 Nearly 10 percent of Puerto Rican infants born on the mainland are of low birth weight, and over 13 percent are born preterm. These factors contribute to a high infant mortal- ity rate. Nationally, infant mortality rates for Puerto Ricans living on the mainland are 40 percent higher than for whites, and one earlier study of Puerto Ricans in New York reported an infant mortality rate 40 percent higher than that of the total population. Risk factors including poverty, young maternal age, low educational attainment, and inadequate prenatal care are positively correlated with these figures.58 The numbers for low birth weight, preterm delivery, and infant mortality are even higher in Puerto Rico; however, one study found recent arrivals from the island had lower infant mortality rates than Puerto Ricans who had lived for an extended period on the mainland.59 High rates (8.2 percent) of low-birth-weight infants have also been reported in the Haitian American community, associated with hypertension and preeclamp- sia.60 In contrast, the infant mortality rate of Cuban American babies is below the national average. Recent data on breast-feeding practices are limited. One anecdotal report on Puerto Rican women states that breast-feeding is common.19 However, earlier studies found breast-feeding infrequent among Puerto Rican, Cuban, and Haitian women in the United States, and in another study, over- weight Hispanic women in New York were found to be less likely to initiate and more likely to discontinue breast-feeding than lower-weight women. This finding is sig- nificant when obesity rates in this popula- tion are considered (see below).61 Those few who started breast-feeding often switched to bottle feeding after two to four weeks. Whole milk, condensed milk, and evaporated milk were frequently fed to infants, as were juices. Solid food typically was introduced at a young age. When the traditional Caribbean diet is limited because of low income, it inevitably results in low intake of many vitamins and minerals. The emphasis on carbohydrates and vegetable protein, with a low consump- tion of leafy vegetables and often fruit, pro- vides inadequate intake of calories, vitamins A and C, iron, and calcium. An older study indicated that the only foods consumed by at least one-half of recent Cuban immigrants were eggs, rice, bread, legumes, lard and oils, sugar, and crackers.62 Newer studies of His- panics in New York and Boston suggest higher rates of fruit and vegetable intake, but still below national and state norms.63 Deficien- cies of B1, B12, folate, and sulfur amino acids have been reported.64 One study of Puerto Rican and Dominican elders found that the high prevalence of B12 deficiency was due to insufficient intake, and that supplementation or frequent consumption of fortified cereals reduced the risk of insufficiency.65 Low iron intake among African Caribbean Islanders has been reported in Great Britain.66,67 Several studies suggest rates of overweight and obesity are higher than national or state averages for many U.S. Hispanic popula- tions. Data from 2008 indicate that Hispanics have a 21 percent higher rate than whites for overweight and obesity.68 Among Hispanic elementary school students in New York City, who are assumed to be primarily of Puerto Rican and Dominican heritage, 31 percent were obese (BMI $95 percentile) compared to 20 percent of students overall,69 and His- panic preschool children enrolled in Women, Infants, and Children (WIC) programs in New York City were twice as likely as black children to be overweight.70 In a study of U.S. Hispanics published in 2012, Puerto Rican participants had the highest prevalence of Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 2 9 8 C A R I B B E A N I S L A N D E R S A N D S O U T H A M E R I C A N S obesity in men and women (31 percent and 51 percent).71 Research on Puerto Rican and Dominican elders found that obesity (as mea- sured by BMI and central waist circumference) was associated with a traditional diet based on rice and beans and poultry and oil, and that this diet was more prevalent among less acculturated subjects.72 In contrast, studies of Puerto Rican women in Connecticut report factors associated with acculturation resulted in an approximately 54 percent increase in obesity.73,74 Calorie and fat intake is reportedly high in many Caribbean Islander groups.55,75 Further, larger portion size has been noted in some research on Caribbean Islanders.55,76 Low levels of physical activity and cultural norms regarding weight and health may be significant factors of being overweight among Caribbean Islanders.63 Puerto Ricans, Cubans, and Haitians often associate well-being with being gor dita, or a little fat. This is particu- larly true for children, even when a thinner body ideal is desired by mothers.77 Thinness is thought by some Caribbean Islanders to be indicative of poor health due to emotional or psychological conditions.28,29 Research has established a genetic contri- bution to the development of the clustering of health characteristics (including obesity/waist circumference, insulin resistance, hyperten- sion, and dyslipidemia) known as metabolic syndrome in Caribbean Hispanic families.78 The prevalence of hypercholesterolemia was 52 percent among men, and ranged from 48 percent (Dominican and Puerto Rican men) to 55 percent (Central American men). In women, the prevalence of hypercholesterol- emia was 37 percent and ranged from 31 per- cent (South American women) to 41 percent (Puerto Rican women). Overall, 25 percent of men had hypertension; hypertension preva- lence was highest among Dominican men. Hypertension prevalence overall among women was 24 percent. The prevalence of hypertension ranged from 16 percent (South American women) to 29 percent (Puerto Rican women). Overall, 17 percent of men and women had diabetes; prevalence ranged from 10 percent in South American men and women to 19 percent in Mexican men and women and Puerto Rican women.79,80 Persons with metabolic syndrome are at increased risk for type 2 diabetes and car- diovascular disease. Health statistics in 2011 estimated that 12.1 percent of Hispanics had diagnosed diabetes.81 Studies indicate that the prevalence of type 2 diabetes mellitus is two to three times higher among Puerto Ricans and Dominicans than among whites; Cuban Americans develop the condition at rates slightly higher than whites.82,83 African Caribbean women also developed impaired glucose metabolism at rates nearly double those for white women after gestational dia- betes in one study (50 percent and 28 per- cent, respectively).84 A more recent study, the Hispanic Community Health Study/ Study of Latinos (HCHS/SOL), determined the prevalence of diabetes and rates of aware- ness and control among adults from diverse Hispanic or Latino backgrounds in the U.S. Hispanic Community. The rate of type 2 dia- betes among the participants in the study was 10.2 percent in South Americans and 13.4 percent in Cubans to 17.7 percent in Central Americans, 18.0 percent in Dominicans and Puerto Ricans, and 18.3 percent in Mexicans, and prevalence increased in with length of residence in the United States.80,85 The prevalence of hypertension is slightly lower in Hispanics than whites.85 Rates of mortality due to hypertension, heart disease, and stroke, however, vary between groups. Puerto Ricans have the highest rates of all Latinos, approximately 13 percent above whites. Higher rates of diabetes, which is a risk factor for high blood pressure, may be one reason for the discrepancy. In compari- son, Cuban Americans have the lowest rates, 39 percent below those of whites. Deaths from hypertension are higher for men than for women in all Hispanics.90 It has been noted that a high prevalence of hypertension and cerebrovascular atherosclerosis, as well as high rates of noncompliance regarding medications, is a contributing factor in strokes among black Caribbean Islanders in Miami.86 Although Hispanics experience cardiovas- cular disease at rates lower than the national average, there is some evidence that it may be higher than average among some subpopula- tions, such as in Hispanic women living in Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 1 0 2 9 9 New York City. Heart disease is still the lead- ing cause of death among Hispanics.63 Rates of renal failure due to diabetes among Hispan- ics are approximately 1.7 times higher than in whites. Death rates associated with diabetes are also 1.5 times higher in Hispanics.84 Chronic liver disease and cirrhosis are ranked as the sixth leading cause of death among Hispanics.87 Dental health is problem- atic for Hispanics. Data indicate that Hispanic preschool children have a high rate of dental caries. Hispanic adults have a larger propor- tion of untreated caries than whites.88 Counseling Counseling Americans of Carib- bean descent is similar to counseling other Latino clients and patients (see Chapter 9). Language problems may make interviews dif-Language problems may make interviews dif-Language problems may make interviews dif ficult, health beliefs may differ from those of the provider, and access to medical care may be limited. The idea that God or fate deter- mines the outcome of illness may also inter- fere with seeking health care. For example, Puerto Ricans perceive diabetes as a chronic condition and believe that complications of the disease are unavoidable.25 One study found Puerto Ricans in New York engaged in preventive behaviors, such as getting vaccina- tions or cholesterol testing, at rates below state averages.52 Illness may be viewed as a sign of personal weakness among Haitians, revealed only to family members for as long as possible. In addition, some Haitians may believe that supernatural illness worsens if biomedical treatment is used, and they may delay seeking care until very ill.29,89 Caribbean Islanders use an expressive conversational style. Respect and politeness are practiced, but it is not considered rude to interrupt a speaker. Periods of silence are uncommon.39 Shaking hands in greeting and in leaving is customary, firmly between men, and less vigorously with women. Touching is very common, especially between members of the same sex, who may hug freely. Even if touching within a group is not direct, passing items (such as a piece of paper) from practitio- ner to client (or to every client in a classroom situation) increases the personal connection.19 Direct eye contact is expected throughout the Caribbean, with some variations. Looking away suggests disrespect or dishonesty among Cubans; Dominicans maintain eye contact depending on the situation, and men are more likely to look directly at one another than are women; Haitians may avert their eyes from authority figures. Puerto Ricans are open about physical and emotional complaints, although they may hesitate to ask questions because this might be interpreted as disrespectful. Adequate time and consideration of symptoms are necessary for both diagnosis and the client–provider relationship. High degrees of modesty are found in both women and men, who may prefer health providers of the same gender. In contrast, Haitians may expect a quick physical examination (with a stethoscope) and a fast, accurate diagnosis. Lack of a prescription to address a complaint may be seen as incompe- tence. Haitians may also assume that men are physicians and women are nurses.29 Puerto Ricans and Cubans are typically present oriented, and may have a relativis- tic view of time. Flexible appointments and relaxed attitudes regarding timeliness can help facilitate interactions with these Carib- bean Islanders. It has been suggested that time limitations should be explained at the outset of the appointment so clients know what to expect.24,25,39 A few traditional Puerto Rican hot–cold practices may be problematic. Pregnant women may avoid iron supplements, which are classified as hot. Infant formula diluted with mannitol or magnesium carbonate to cool it (see the “Therapeutic Uses of Food” sec- tion) may cause diarrhea in infants. A mother may cool a hot medication, such as vitamins or aspirin, by providing a cool beverage with it, possibly fruit juice or milk of magnesia.41 Puerto Ricans also may interpret high blood pressure as being too much blood or thick blood; conversely, low blood pressure means weak blood or anemia. Hypertension may be treated with herbal teas.91 Some Puerto Ricans believe that ulcers lead to cancer. A study of Long Island Cuban Americans showed that 20 percent acknowledged some degree of belief in santería. Some Dominicans believe that biomedicine is not responsive to their spiritual and emotional needs and that Lactose intolerance is thought to be a problem among many Caribbean Islanders, although esti- mated incidence has not been reported. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 3 0 0 C A R I B B E A N I S L A N D E R S A N D S O U T H A M E R I C A N S effects.31,32 In addition, sharing prescription medications with family members or friends is common among Americans of Cuban, Dominican, and Haitian heritage.24,29,33 Some Haitians reportedly have difficulty with dietary compliance.28 Research on a diverse group of Latinos in New York reported that physicians were the primary source of health care information, followed by television. Educational programs with Puerto Ricans may be more successful if a respected member of the community is enlisted in support of the project, and women often respond better if men in the family approve of their participation.19 Caribbean Islanders are high-context communicators, and the relationship and process are as impor- tant as the results.39 A Caribbean Islander client may be of African, Asian, European, or Indian descent; however, the island of origin is equally impor- tant in determining ethnic identity and diet. A black from Puerto Rico, for example, is more likely to eat Latino foods than African dishes or soul food. Early researchers working with low-income Latinas and black women in New York recommended that significant attention be placed on the client’s socioeconomic sta- tus, a suggestion still valid today.95 Nutrition therapy for a poor Puerto Rican immigrant is likely to require a different approach than that for a wealthy Cuban immigrant within traditional healers provide the treatments needed to address all aspects of illness.16 Esti- mates of espirito and santero use vary consid- erably, from 1 to 23 percent.24,25 Many people who use traditional folk-healing practices and practitioners may be unwilling to admit to these folk practices or use them only in time of stress.92 Biomedical prescriptions may also present difficulties. Many medications available only by prescription in the United States are read- ily available over the counter or through the black market in Latin American countries. Overuse, inappropriate use, and addiction can occur. For example, one study found that New York Latinos did not understand that antibi- otics are useful only for certain infectious conditions, and they were obtained without prescription to treat pain. A study regarding Metamizole (dypyrone), a toxic nonsteroidal anti-inflammatory drug banned in the United States, found that 28 percent of Hispanics surveyed in Miami had purchased it in their homelands, and 13 percent had used it in the previous year.93,94 Another study found that medications for chronic conditions were used by Dominicans only during a medical crisis. As soon as symptoms subsided, the prescrip- tion therapies were replaced with home reme- dies. Dominicans often express concern about taking “chemicals” and worry that biomedical prescriptions cause addiction and serious side P A U L A V E L A Z Q U E Z Iwas born and raised in Puerto Rico and came to the United States when I was thirteen years old. In Puerto Rico I grew up on a farm, and my diet included rice and beans and products that we grew, such as fresh green bananas, sweet potatoes, and plantains. When my parents went to town to shop, that was when we ate meat and bread. Once a year we had pork for Christmas and turkey for Thanksgiving because these animals were raised by my parents for the holidays. My sister still owns the farm, and I try to get back for visits. Here in the United States I live with my aunt and uncle, and their diet is high in meat, vegetables, and “healthy” foods. They are in their eighties and still very healthy. The food that made the biggest impression on me when I came to the United States was mashed potatoes. I had never seen or eaten mashed potatoes, and it took me awhile before I would even try them. The second thing was having meat every day—that was really a treat. However, my favorite foods are bread and then the vegetables. I like all kinds of seafood. I will eat seafood rather than meat. Meat I could give up but not bread and vegetables. N E W A M E R I C A N P E R S P E C T I V E S Puerto Rican Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 1 0 3 0 1 the context of the basic Caribbean cuisine. An in-depth interview should be conducted with each client of Caribbean descent to establish country of origin and ethnic identity. The cli- ent’s degree of acculturation, socioeconomic status, use of traditional heath practices, and personal food preferences also should be determined. South Americans South America is a vast land that features the rugged ridge of the Andes Mountains stretch- ing from north to south. Highland plains, tropical rain forests, temperate valleys, and desert dunes extend from where the moun- tain peaks slope toward the coastal edges of the continent. Extremes in terrain and climate limit agriculture in many areas. The conti- nent contains twelve independent nations: Argentina, Brazil, Bolivia, Chile, Colombia, Ecuador, Guyana, Paraguay, Peru, Suriname, Uruguay, and Venezuela. In addition, France retains control of the territory called French Guyana, and Great Britain claims the Falkland Islands. Numerous native Indian groups popu- lated the continent prior to settlement by the Europeans. Although the Spanish were the first to arrive, significant numbers of Por- tuguese, Italians, and Germans also settled in South America. Forced labor from West Africa introduced blacks to the continent, followed by Asian Indian workers after slav- ery was outlawed. Indian and mixed Indian European populations live in the tropical highlands; Creoles (descendants of the Euro- peans) have concentrated in the southern, temperate regions of the continent; and parts of northeastern Brazil are populated primar- ily by blacks and mulatto black Europeans. In more recent times, Japanese immigration to South America has become notable. Cultural Perspective History of South Americans in the United States Immigration Patterns The first documented South Americans in the United States were Chileans who came to California to participate in the gold rush. It is believed that several thou- sand worked in the mines. Approximately half returned to Chile, and those who remained quickly intermarried and were absorbed into the general population. Prior to the 1960s, all South American immigrants were counted as Other Hispanics in the U.S. Census. Specific figures regarding the individual nations before this time are uncertain but are thought to be minimal. Most South American immigration has occurred in the past twenty years during periods of land reform, economic hardship, or political repression. Jobs and educational opportunities are the primary attractions for the majority of immigrants, although sig- nificant numbers of political exiles are from Argentina and Chile. Current Demographics Over 2.7 million Americans of South American descent are living in the United States.96 There are approx- imately 1 million Americans of Colombian ancestry; 663,000 from Ecuador; 594,000 from Peru; 223,000 from Guyana; 326,500 from Brazil; 249,000 from Argentina; 140,000 from Chile; 249,000 from Venezuela; and 104,500 from Bolivia. Most South Americans settle in the North- east, especially New York and New Jersey. In New York City, Colombians, Ecuadorans, and Peruvians have established ethnic enclaves in Queens, and “Little Brazils” are found in both Queens and Manhattan. Miami and Los Angeles also host large South American populations from most nations. In addition, Brazilians are found in Pennsylvania and Washington, DC; Chileans have settled in Texas; Colombians have clustered in Stam- ford, Connecticut, the urban areas of Illinois, and California; and Peruvian neighborhoods have developed in Houston, Chicago, and Washington, DC. Most South American immigrants are proud of their heritage and differentiate them- selves from Americans of Mexican, Caribbean, or Central American background. Brazilians in particular resent being mistaken as Hispan- ics who speak Spanish (Portuguese is their official language). Some South Americans suffer from discrimination directed toward Mexican Americans or Latinos in general. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 3 0 2 C A R I B B E A N I S L A N D E R S A N D S O U T H A M E R I C A N S Others, who are mostly of European heri- tage, are not recognized as Latinos but may continue the prejudices between some South Americans. Second- and third-generation South Americans often leave homogeneous neighborhoods and relocate into mixed communities. Socioeconomic Status Few data are available on the socioeconomic status of Americans of South American descent who have lived in the United States for extended periods. Most data are related to foreign-born immi- grants who have come in the past twenty-five years. Regardless of arrival date, a majority of immigrants from South America come to the United States in search of employment opportunities. Many are well-educated pro- fessionals; however, they sometimes find that their credentials are not accepted after arrival, forcing them to accept positions in the sales, service, trade, and labor fields, such as res- taurant work, construction, child care, or tex- tile and garment industry jobs. It is believed that many second- and third-generation Americans of South American ancestry obtain advanced education and work in professional occupations. Foreign-born Colombians arrive in the United States with overall education levels slightly lower than the U.S. average, though some are professionals with college degrees who hope to find employment commensurate with their skills.97 Most Ecuadorans are better educated than other Hispanic Americans, but still less than the total U.S. population.98 Peruvians have higher levels of educa- tion than the U.S. population and Argen- tineans have highest levels of education in the Hispanic population overall.99,100 Of the Brazilian population in the United States aged twenty-five and older, 20 percent have a high school diploma and 22 percent have a bach- elor’s degree, which is higher than the U.S. population.101 Worldview Religion South Americans are mostly Roman Catholic, a legacy of the European conquest. In most nations approximately 64 to 89 per- cent of the population are members of the Catholic Church. In some regions, Christian religion is often blended with other belief sys- tems. In Peru, Incan gods may be included in Catholic rites, for example, and in Venezuela the Cult of Maria Lionza mixes indigenous, Catholic, and African practices. Religious syncretism is greatest in Brazil. Spiritism, which was imported from France originally, combines Christian precepts with scientific principles. Popular with the upper middle class of the country, adherents communicate with the dead through spiritual mediums. Umbanda is very common in rural areas and among the urban poor, combining several Afro-Brazilian faiths with spiritism and the idea of Christian charity. Candomblé is prob- ably the best known of the mixed religions, and is an Afro-Brazilian faith founded by blacks in the Bahia region and is now prac- ticed nationwide by followers of all ethnici- ties.102 African-derived beliefs dealing with earthly matters such as health and wealth are combined with Catholic cosmology. Yoruba deities called or ix á or or ish a are venerated with rites of worship that include animal sacrifice, feasting, and dancing. Over twenty orixás are recognized in Brazil and most are correlated with a Catholic entity: Oxalá, god of creation, with Jesus Christ; Exú, the mes- senger god, with the devil; Ogun, god of war and iron-craft, with St. Anthony or St. George; Oxoosi, god of affluence, with St. Sebastian; Omolu, god of plagues and illness, with St. Lazarus; and Oxum, the fertility goddess (also called the goddess of vanity), with the Virgin Mary. Each orixá is associated with certain personality traits, day of the week, color, plants, animals, foods, and drinks; and each person has an orixá owner of his or her head who influences individual temperament and behavior. Protestant missionaries were active in South America starting in the twentieth cen- tury and were especially successful in Hon- duras and Uruguay where Catholics are no less than 50 percent of the population.103 In Brazil, the Baptist, Pentecostal, Seventh-Day Adventist, and Universalist denominations are most popular. Chilean Protestants are usually members of the Pentecostal or Seventh-Day Adventist churches, though those of German ancestry often follow the Lutheran or Baptist faiths. Small numbers of Jews and Buddhists Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 1 0 3 0 3 are also found in South America, in total less than 1 percent of the population together. Most South Americans who emigrate to the United States are Roman Catholic and very involved with their local parish. A major- ity of Guyanese Americans belong to an Episcopal church headed by a Guyanese priest and often also send their children to church- run schools with Guyanese teachers. In addi- tion, some Guyanese Americans frequent “Unity Centers,” which function as commu- nity centers and promote spirituality but are not affiliated with any organized religion.104 Family Family life is important in all South American societies. In Argentina, Span- ish and Italian traditions have shaped fam- ily structure. The extended family usually gathers together at least once a week and on holidays as well. Grandparents are involved in most family decisions, and children often stay at home until marriage. In Brazil, extended family members typically live close to one another, and daily visits are common. Rela- tives mentor children through rites of passage such as confirmation, graduation, the start of a career, and marriage. The father is the head of the household in Chilean homes, but the mother makes all decisions regarding the family. In Colombia the father holds all authority, and children are taught to obey their parents. Ecuadoran fam- ilies follow two models: Spanish-influenced families are ruled by the father, who has few responsibilities to the home other than finan- cial support; in Indian-influenced families, the father and mother share more power and household responsibilities. In Peru, extended families typically include godparents, who sponsor baptisms and provide both social and economic assistance. Families are pre- dominantly patriarchal, though more so in the Spanish-speaking upper and middle classes than in poor, rural Indian homes. In contrast to most of South America, the Venezuelan family has changed rapidly in the past decades due to increased national prosperity. Much of the population has relocated to urban centers. Many families have declined in size, and the extended family is less common. In many areas of South America, it is unac- ceptable for women to work outside the home. Even those with a profession traditionally stay at home after marriage. Among some Indian groups, however, women contribute to the well-being of the family through farmwork, and in the urban areas of Venezuela many women have outside jobs but remain respon- sible for household chores. In Chile, women are usually involved in local social and politi- cal issues. Most South Americans prefer to immi- grate as family groups, although financial pressures often demand that a single family member become established in the United States before the rest of the family follows. Individual immigrants commonly move to neighborhoods where relatives, godparents, or friends have settled. They depend on these contacts for housing and support. This sys- tem of mutual assistance is maintained after the immediate family arrives, bringing more relatives into the extended family. Colombians and Ecuadorans often broaden their relation- ships beyond national boundaries to form strong bonds with other Latinos. Many families suffer from the stresses of American informality and freedom. Men lose some authority over wives and children, and women find it difficult to adjust to working outside the home. Furthermore, many upper- and middle-class women, who had paid help with the housework in South America, must learn to balance a job with responsibility for running a home. Traditional Health Beliefs and Practices There are few data available on how Americans of South American heritage maintain health or how they approach illness. Brazilians often attribute bad health to liver problems or an imbalance between hot and cold, such as drinking a glass of cold water on a hot day or taking a cool shower after eating a hot meal. Many South Americans self-diagnose or seek health advice from their mothers or friends. They then visit a pharmacist where they can purchase many medications, such as antibiot- ics, by the pill. Most Brazilians associate faith with health. Catholics may believe in fate and seek inter- vention from patron saints when ill. Spirit- ists employ homeopathy, exorcism, past-lives therapy, acupuncture, yoga therapy, and Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 3 0 4 C A R I B B E A N I S L A N D E R S A N D S O U T H A M E R I C A N S chromotherapy to cure sickness.104 Followers of candomblé believe that health is maintained by achieving balance between the earthly and spiritual spheres. The pai- de- santo or baba- l or ix á (high priest) or the mä e- de- santo or ial or ix á (high priestess) may be hired to read the oracle of a personal orixá, for example, so that an individual can improve his or her rela- tionship with the deity.102 Harmonious rela- tions with one’s orixá can maximize ax é (vital ax é (vital ax é force). Spiritual equilibrium is maintained by observing the preferences and prohibitions of one’s orixá, including certain food and beverages, colors, therapeutic herbs, beaded necklaces, and other limitations. The priest or priestess also serves as the local c ur endier o, diagnosing physical and spiritual problems, prescribing healing herbal baths or botanicals, and manipulating occult forces. In Ecuador, either a healer, called a c ur ander o, or a witch doctor, called a br uj o, treats many illnesses in small villages. In Peru, urban residents typi- cally obtain biomedical health care, but in rural regions home remedies and ritual magic are often preferred.105 Herbal teas are a favorite remedy through- out most of South America, where street stands and small markets called y er beter í as sell medicinal botanicals for home use.106 Numerous plants, many unfamiliar in the United States, are used therapeutically.44 Soursop leaves are used to treat diabetes, and the seeds of the guaraná are thought to relieve fatigue and help with weight loss. Retained urine is treated with avocado leaves, and papaya leaves are considered useful in getting rid of intestinal worms. Rue is taken for uterine pain and as an abortive, and black nightshade is used for coughs. P au d’ ar c o, the bark of a tree native to Brazil, is widely used to treat rheumatism, diabetes, venereal diseases, yeast infections, enlarged prostate, and several cancers. Traditional Food Habits Ingredients and Common Foods Staples The cooking of South America is sim- ilar to that of other Latin American regions in that it combines some native ingredients and preparation techniques with the foods of colonial Europeans. The diet is largely corn based and spiced with chile pepper (see Table 10.2).Tomatoes are common, and in tropical areas cassava (called y uc a) is a popular tuber. Pumpkins, bananas, and plan- tains are consumed often. Beef, rice, onions, and olive oil, introduced by the Spanish and the Portuguese, are eaten regularly. Tropical fruits, such as those found in the Caribbean (see above), are plentiful in many regions. However, South American fare also features a number of ingredients used infrequently in the dishes of other Latin American areas. Potatoes, which were first cultivated by the Incas on mountain terraces, are particularly important in the highlands of Peru and Ecua- dor. Sweet potatoes (the orange-fleshed root vegetable usually called yams in the United States) are also native to the region. A white r oot similar to a mild carrot, known as r oot similar to a mild carrot, known as r oot apio or ar r ac ac h a, is found in Colombia, Peru, and Venezuela; oca (a tuber similar to the potato in appearance but with leaves like clover) and y ac ó n (an elongated tuber that has the taste and texture of a sweet turnip) are com- monly eaten raw and cooked in Bolivia, Brazil, Colombia, Ecuador, and Peru; and the tuber known as ah ipa (called jicama in the United States and Mexico) is native to the Amazon River basin. Beans, a foundation food in many Latin American regions, are common in most South American countries yet not eaten at every meal. Other legumes and nuts, such as peanuts and cashews, are used often in dishes. Indigenous meats, including llama, deer, rab- bit, wild pig, capybara, tapir, and cuy (guinea pigs who are raised for consumption), are con- sumed in some areas. Fish, such as anchovies and tuna, and shellfish, particularly shrimp, crab, spiny lobster, oysters, clams, giant sea urchins (evisos), and giant abalone (locos), are significant foods in the extensive coastal regions. Iguana is consumed occasionally, and alligator is a specialty in some areas. A favorite way to prepare meats in South America is grilling. Traditionally, sides of beef, whole lambs, hogs, and kids (young goats) are hung over smoldering wood to slowly cook for hours in a method called asado. Today, a grill is used more often. Steaks and marinated Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 1 0 3 0 5 Group Comments Common Foods Adaptations in the United States Protein Foods Milk/milk products Milk is not usually consumed as a beverage but used in fruit-based drinks and added to coffee. Many milk-based desserts are enjoyed. Cow’s, goat’s milk; evaporated milk; fresh and aged cheeses Available cheeses are sometimes substituted for unavailable traditional cheeses. Meat/poultry/fish/ eggs/legumes Beef is a foundation of the diet in parts of Argentina, Brazil, Paraguay, and Uruguay. Some game meats are consumed. Fish and seafood are significant in coastal regions, popular as ceviche in Ecuador and Peru. Beans are commonly consumed. Meat: alligator, armadillo, beef (including variety cuts), capybara, frog, goat, guinea pig (cuy), iguana, llama, mutton, pork, cuy), iguana, llama, mutton, pork, cuy rabbit, tapir Poultry: chicken, duck, turkey Fish and shellfish: abalone, bass, catfish, cod (including dried salt cod), crab, eel, haddock, lobster, oysters, scallops, shrimp, squid, trout, tuna Eggs: chicken, quail, turtle Legumes: beans (black, cranberry, kidney), black-eyed peas Less acceptable meats such as guinea pig may no longer be eaten. Cereals/Grains Cuzcuz, made from cornmeal, is prepared in parts of Brazil; arepa, cornmeal bread, is staple in some areas. Pasta is popular in Argentina, Paraguay, and Uruguay. Rice and corn puddings are a favorite. Amaranth, corn, rice, quinoa, wheat Fruits/Vegetables Tropical and temperate fruits are plentiful and popular, added to savory and sweet dishes. Fruit compotes and fruit pastes are enjoyed. Potatoes are a staple in the Andes. Cassava flour and meal are common in many areas; tapioca is used in desserts. Fruits: Abiu, acerola, apples, banana/ plantains, cashew apple (cajú), caimito, casimiroa, cherimoya, custard apple, feijoa, guava, grapes, jackfruit, jabitocaba, lemons, limes, lulo (naranjillo), mammea, mango, melon, olives, oranges (sweet and sour), palm fruits, papaya, passion fruit, peaches, pineapple, pitango, quince, raisins, roseapple, sapote, soursop, sweetsop, strawberries, sugarcane Vegetables: abipa (jicama), arracacha (apio), avocado, calabaza (green pumpkin), cassava (mandioca; yuca), green peppers, hearts of palm, kale, okra, oca, onions, roselle, squash (chayote, winter), sweet potatoes, tomatoes, yacón, yams Additional Foods Seasonings Toasted cassava meal, farinha, is sprinkled over foods in Brazil. Spicy hot foods are preferred in many areas; salsas are common. Achiote, allspice, chiles (aji, malgueta, pimento), cilantro, cinnamon, citrus juices (lemon, lime, and sour orange), garlic, ginger root, oregano, paprika, parsley, scallions, thyme, vinegar Nuts/seeds Coconut and coconut milk are added to numerous dishes. Peanut sauces flavored with chiles are common in the Andes. Brazil nuts, cashews, coconut, peanuts, pumpkin seeds TA B L E 10. 2 Cultural Food Groups: South Americans (Continued ) Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 3 0 6 C A R I B B E A N I S L A N D E R S A N D S O U T H A M E R I C A N S with indigenous ingredients such as mashed potatoes, cassava, or corn. The turnovers are usually baked, but sometimes they are fried. Fillings are as many as there are cooks. Chopped meat, olives, raisins, and onions are popular. In Chile, the turnovers may be filled with abalone, and in Brazil, where they are known as empadinhas, a spicy shrimp mixture is traditional. In Bolivia, where they are called salteñas, the turnovers are filled with cheese. Tamale-like steamed packets of dough-wrapped fillings are also popular throughout South America. In Peru, chapa- nas are made with cassava dough, while in Ecuador bollos are formed around cooked chicken meat with plantain dough. In Brazil, a freshly grated corn kernel dough is mixed with coconut and cassava (and no filling) to prepare pamonhas. Ground cornmeal dough flavored with annatto and tomatoes is pre- ferred for Venezuelan hallacas. A favorite in Argentina, Bolivia, Brazil, Chile, and Ecua- dor are humitas, which feature fresh kernel or ground cornmeal dough wrapped around a variety of savory or sweet meat, fish, or vegetable fillings. Regional Variations National differences exist, although there are few clearly distinc- tive divisions in South American fare. Several countries share similar dishes, and only a few nations have well-developed regional cuisines. Peru and Ecuador The cooking of Peru and Ecuador is divided into the highland fare of the Andes and the lowland dishes of the coastal regions. The cuisine of the mountain kebobs (which often include organ meats) are favorites. Another, even older cooking tradi- tion is to steam foods in a pit oven. In Peru, this method is called a pac h amanc a and typi- cally includes a young pig or goat with guinea pigs, chickens, tamales, potatoes, and corn tucked around layers of hot stones and aro- matic leaves and herbs.107 In Chile, a curanto is closer to an elaborate coastal clambake, including shellfish, suckling pig, sausages, potato patties, peas, and beans layered with seaweed. Stuffed foods are also common, including pastry turnovers filled with savory meat, fish, or cheese fillings. They are called empanadas in Argentina, which specializes in a turnover with a flaky, Spanish-style dough enriched ▼ A market in Pisaq, Peru. Yo sh io T om ii/ Su pe rS to ck Group Comments Common Foods Adaptations in the United States Beverages Coffee is often served concentrated, then diluted with evaporated milk or water. Maté is more popular than coffee or tea in parts of Argentina, Brazil, and Paraguay. Batidas (tropical fruit juices, sometimes made with alcoholic beverages), coffee, guaraná, soft drinks, sugarcane juice, tea, yerba maté and alcoholic beverages: yerba maté and alcoholic beverages: yerba maté beer, cachaça (sugarcane brandy), pisco (grape brandy), chicha (distilled corn liquor), wine Fats/oils Dendê oil flavors and colors many dishes in the Bahia region of Brazil. Dendê (palm) oil, olive oil, butter Vegetable or peanut oil is substituted for dendê oil. Sweeteners Sugarcane, brown sugar, honey TA B L E 10. 2 Cultural Food Groups: South Americans (C on t in u e d ) © C en ga ge L ea rn in g Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 1 0 3 0 7 cinnamon popular along the coastal regions of Ecuador.108 Pisco, a grape brandy that orig- inated in Peru, is a national favorite, often mixed with orange juice to make the refresh- ing drink called yugeno. Argentina, Chile, Boliv ia, Urug uay, and Paraguay Hearty, ample fare with an empha- sis on beef exemplifies the cooking of these southern nations. Argentina is a major beef- producing region, and its people eat more beef per capita than in any other country worldwide. The temperate weather permits the cultivation of numerous fruits and veg- etables, notably strawberries, grapes, and Jerusalem artichokes (known as topinambur in Chile). The cooking of Argentina, Chile, Paraguay, and Uruguay has been influenced more by their immigrant populations than by the numerous small Indian groups native to the area. The Spanish introduced cattle, and the Italians brought pasta. Smaller numbers of Germans, Hungarians, and other central Europeans have added their foods as well. The national dish of Argentina is matam- br e, which means “to kill hunger.” A special cut of flank steak is seasoned with herbs, then traditionally rolled pinwheel fashion around a filling of spinach, whole hard-boiled eggs, areas is among the most unique in South America, preserving many ingredients and dishes of the Inca Indians. Potatoes are eaten at nearly every meal and often for snacks. Over one hundred varieties are cultivated. Ocopa, boiled potatoes topped with cheese sauce and chile peppers or peanuts, is a typi- cal dish in Peru. In Ecuador fried potato and cheese patties, called llapingachos, and potato cheese soup served with slices of avocado, known as locro, are common. Traditionally, the tubers are preserved by freezing in the cold night air and then drying in the hot day- time sun. Papa seca are boiled first and then dried until the potatoes are rocklike chunks that must be rehydrated before consumption; chuño are not cooked before drying and are often ground into a fine potato starch. Corn is also grown in the mountains. Some variet- ies have kernels the size of small strawberries that when prepared as hominy are known as mote and are a popular snack item. Bananas and plantains are cooked as savory chips and made into flour for breads and pastries. The foods of Peru and Ecuador are pre- ferred picante and feature abundant use of chile peppers in both the highlands and along the coast. Salsa de ají, a combination of fresh chopped chile, onion, and salt, is served as a condiment at most meals. Orange- or yel- low-hued dishes are favored; along the coast, annatto colors foods, and in the Peruvian highlands an herb known as palillo is used. Charqui, dried strips of llama meat, is a spe- cialty of the Andes. Anticuchos, chunks of beef heart marinated in vinegar with chiles and cilantro, then skewered and grilled, are a spicy Peruvian favorite also from the Andes. Rabbit dishes are also popular in the region. Along the coast, seafood dominates the diet. The region is famous for its ceviches (also spelled c ebic h e), a method of preparing fresh fish, shrimp, scallops, or crab by marinating small raw chunks in citrus juice. The acidity of the juice cooks the fish and turns it opaque. At many beaches, cevicherias offer the dish as a snack or light meal with beer. Chopped onion, tomato, avocado, and cilantro are often added. In Peru, ceviche is typically garnished with sliced sweet potato. Chucula is a thick plantain and milk beverage flavored with S A M P L E M E N U An Ecuadoran Dinner C e bich e d e P e s c ad o (Fish C e vich e )a,b L oc r o (Potato Soup)a,c Humitas (Fresh Corn Tamales)a,b Ch ucula (Plantain and Milk)a or Juice aKijac, M.B. 2003. The South American table. Boston: Harvard Common Press. bEcuadoran Recipes at http://thelatinkitchen.com/ slide/galapagos-island-high-end-cuisine cEcuadoran Cuisine & Recipes at http://www.whats4eats.com/4rec_ecuad.html Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 3 0 8 C A R I B B E A N I S L A N D E R S A N D S O U T H A M E R I C A N S and whole or sliced carrots, and then tied with a string and poached in broth or baked. Matambre can be served as a main course, but it is often chilled first and offered as a cold appetizer. Grilled steaks are particularly pop- ular in Argentina and surrounding nations. In Paraguay, steaks are typically served with sopa Paraguay, a cornmeal and cheese bread. In Uruguay, beef is eaten nearly as often as in Argentina, although mutton and lamb are also common. Robust soups and stews are everyday fare. In Bolivia, beef stew is made with carrots, onions, hominy, and chuño. The stews of Argentina often pair meat with fruits as well as vegetables, such as carbonada criolla (beef cooked with squash, corn, and peaches) or carbonada en zapallo (veal stew cooked in a pumpkin). In Paraguay, soups reveal European inspiration, such as bori-bori, beef with corn- meal and cheese dumplings, and so’ o-yosopy, beef soup with bell peppers, tomatoes, and vermicelli or rice, topped with Parmesan cheese. Fish soups and stews are popular in Chile, which has an extensive coastline and plentiful seafood. A specialty is clam or aba- lone chowder with beans (chupe de loco) and congrio (an elongated, firm-fleshed fish that looks a little like an eel) cooked with potatoes, onions, garlic, and white wine. National favorites include pasta (e.g., spa- ghetti, ravioli, and lasagna), which is served in many homes on Sundays in Argentina. It is considered lucky to eat it on the twenty-ninth of every month as well. In Chile, beans are especially popular, and seafood is eaten regu- larly. Wines from the temperate midlands of the country are considered some of the best on the continent. Pisco is consumed in both Bolivia and Chile, where it is mixed with lemon juice, sugar, and egg whites to make a pisco sour. In Bolivia, legs from the giant frogs found in the Andean Lake Titicaca are a specialty, and chicha, a distilled corn liquor, is popular. Although coffee is consumed through- out the area, another caffeinated beverage is equally popular in some regions. Called maté, it is an infusion made from the leaves of a plant ( I l ex par aguar iensis) in the holly fam- ily native to Paraguay. Served hot or chilled, maté is consumed nearly every afternoon with small snacks in Paraguay and in parts of Argentina. The dried, powdered leaves are called yerba and are traditionally mixed in a gourd with boiling water. A special metal straw is inserted to drink the brew. Colombia and Venezuela The fare found in Colombia and Venezuela is colonial Spanish in character, cooked with olive oil, cream, or cheese and flavored with ground cumin, annatto, parsley, cilantro and chopped onions, tomatoes, and garlic. Yet native tastes are still evident. Guascas, or huascas (Galinsoga par- vilora Lineo), an herb native to Colombia, provides a flavor similar to boiled peanuts in soups and stews. Hot chile pepper sauces are served on the side of most dishes. Tropi- cal fruits and vegetables, including avocados, bananas and plantains, naranjillo (a small, orange fruit related to tomatoes used for its tart juice), pineapple, and coconut milk or cream are other common regional ingredients. In Colombia, Bogatá chicken stew (made with chicken, two types of potatoes, and cream) and sancocho (a boiled dinner tra- ditionally made with beef brisket or other roast, and ample starchy vegetables such as potatoes, sweet potatoes, plantains, or cas- sava) are typical Spanish-influenced dishes. Examples in Venezuela include ropa vieja (“old clothes”), shredded flank steak served in a sauce made with tomatoes, onions, and olive oil; and pabellón caraqueño, flank steak served on rice with black beans, topped with fried eggs, and garnished with fried plantain chips. Dishes with more indigenous flavors include arepa, the staple cornmeal bread of Venezuela that is formed into one-inch-thick patties and cooked on a griddle (it is some- times stuffed with meat or cheese before it is fried), cachapas, tender cornmeal crepes, and mashed black beans, known as caviar criollo or “native caviar.” Tropical fruits, such as gua- vas and pineapple, are often sweetened and dried to make favorite snacks of fruit leathers and fruit pastes. Guyana Guyana has a cuisine widely influ- enced by its proximity to the Caribbean, as well as by the many immigrants from throughout the world who have called Latin Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 1 0 3 0 9 America home. For example, one national favorite is pepper pot, a stew made with a variety of meats and onions and flavored with the Caribbean cassava-based sauce cassareep (see Chapter 9). Other common dishes simi- lar to those in the Caribbean include salt-fish cakes, blood pudding, coocoo (cornmeal and okra bread), cookup rice (rice with black-eyed peas or split peas), bammies, and ginger beer. Caribbean desserts are common, such as the dense fruitcake known as black cake, and kon- kee, a tamale made from sweetened cornmeal, coconut milk, and raisins wrapped in banana leaves, then boiled. African influence is found in foofoo, a pounded plantain paste like African fufu, and stews made with fish or meat, plantains, onions, and okra (see Chapter 8). Dumplings, called metamgee, are made from starchy vegetables and are often added to stews. Asian foods include Indian curries, roti (flat bread), the use of dal (a type of legume; see Chapter 14), and Chinese noodle dishes. One national specialty is Portuguese garlic pork, which is marinated in vinegar, then fried. The country is famous for Demerara sugar, a very rich, brown-colored, and crum- bly raw cane sugar named for a region in Guyana. It is the source of Demerara rum, a Guyanese specialty. Brazil The cooking of Brazil is very different from that of other South American countries due to Portuguese and African influences. The Portuguese arrived in the sixteenth cen- tury, looking for land on which to cultivate sugarcane. They contributed dried salt cod and linguiça to the diet, stews known as cozidos made with many different meats and vegetables (known as cocido in Portugal), and a variety of exceptionally sweet desserts based on sugar and egg yolks, such as cara- mel custards and corn (canjica) or rice (pirão de arroz) puddings flavored with coconut. African slaves put to work on the sugar plan- tations brought foods unknown in nearby countries, such as dendê oil (a type of palm oil) and okra. Spicy dishes were preferred. In West Africa, malagueta peppercorn, a small, hot grain, was used to season foods; in Brazil, Africans adopted a very small, mouth-searing chile pepper indigenous to the area and also called it malagueta. It is typically minced and added to dendê oil, often with dried shrimp and grated ginger root, to make a hot sauce. Although Indian, Portuguese, and African tastes and textures have influenced cooking throughout Brazil, nowhere are they more prominent than in the state of Bahia. Known as Afro-Brazilian fare, or cozinha baiana, this cuisine is famous for fritters made from dried shrimp, dried salt cod, yams, black-eyed peas, mashed beans, peanuts, and ripe plantains fried in dendê oil. Vatapá, another specialty, is a paste made with smoked dried shrimp, peanuts, cashews, coconut milk, and malagu- eta chiles. It is used as a filling for black-bean fritters called aracanjá and sometimes served with rice as an entree. The national dish of Brazil is feijoda com- pleta, which originated in Rio. Black beans cooked with smoked meats and sausages are served with rice, sliced oranges, boiled greens, and a hot sauce mixed with lemon or lime juice. Toasted cassava meal, called farinha, is sprinkled over the top like Parmesan cheese. Farinha is served with most dishes and is often S A M P L E M E N U A Brazilian Celebration F e ijoad a C om ple t a (Black Beans with Meats)a,b,c F ar of a (Toasted Manioc Meal)a,b,c Braised Collard Greensa,b,c Brazilian Ricea,b Coconut Bread Puddinga or T or t e d e Ban an a (Banana Pie)b C apir in h as ,a,b,c Beer or Juice aKijac, M.B. 2003. The South American table. Boston: Harvard Common Press. bMaria’s Cookbook at http://www.maria-brazil.orgMaria’s Cookbook at http://www.maria-brazil.orgMaria’s Cookbook cCook Brazil at http://cookingbrasil.com/Cook Brazil at http://cookingbrasil.com/Cook Brazil Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 3 1 0 C A R I B B E A N I S L A N D E R S A N D S O U T H A M E R I C A N S mixed with butter and other ingredients, such as bits of meat, pumpkin, plantains, or coco- nut milk to create crunchy side dishes called farofa. Rice or cornmeal porridge, called pirão, is another type of side dish. Middle Eastern- ers who immigrated to the southeastern areas of Brazil brought the concept of couscous to the country and adapted the dish to native ingredients. Cuzcuz paulista is prepared with cornmeal in a cuzcuzeiro, which looks like a colander on legs that is inserted over a pot of boiling water to steam. The basket of the cuz- cuzeiro is first lined with seafood or poultry and vegetables, which flavors the cornmeal as it cooks and looks decorative when the cuzcuz cake is inverted. In the far south, the cuisine has been influenced by the foods of Argentina. Grilled meats are a favorite in Brazil, especially in the south, home of the frontiersmen known as gauchos, who herded cattle on the grassland plains. Sides of beef were traditionally staked at the edges of a bonfire for slow cooking in a method called c h ur r asc o. The popularity of the outdoor barbecue led to c h ur r asc ar ia r odiz io, restaurants located in cities through- out the nation that specialize in spit-roasted beef, pork, lamb, and sausages brought to the table on large skewers and carved to taste. Specialties include picanha (rump roast) and beef heart. Assorted side dishes such as salads, potatoes, condiments, and desserts round out the meal. Brazilians in the South also drink maté, which they call chimmarão. Coffee, rum, and beer are common beverages in Brazil, but several other drinks are also popu- lar. Guaraná is a delicious, stimulating car- bonated soft drink made from the seeds of the native guaraná fruit, which contain caffeine. Cachaça (called aguardiente in other South American nations) is an alcoholic beverage, often compared to brandy, distilled from sug- arcane. It is used to make batidas, a refreshing punch with fruit juice, or caipirinhas, mixed with a little lime juice, sugar and mint, then consumed over ice. Meal Composition and Cycle Daily Pattern Three meals a day are tradi- tional among middle-class and affluent South Americans, with an afternoon snack often added. The poor, especially those in rural areas, are often limited to an early breakfast with a large dinner around 6:00 p.m.106 For those who can afford more than two meals daily, breakfast is typically light, often bread or a roll with jam and a cup of coffee, served black or with milk. A more complete meal features fresh fruit or pastries and occa- sionally ham or cheese. Lunch is usually the main meal, consumed in a leisurely manner with family or friends. Appetizers such as fritters, humitas, or empanadas may start the meal, followed by a meat or seafood stew or a grilled meat dish. Side dishes may include rice, beans, farofa, fried potatoes, and greens such as kale. Salads, typically featuring cooked vegetables, are popular in some areas, includ- ing Brazil, and are served with the meal. Des- sert, most often flan or another sweet custard or pudding, is usually served. In Argentina, the time spent relaxing and socializing after lunch is called l a sombr emes and sometimes includes a nap. Dinner is traditionally lighter, sometimes just cold cuts, a seafood salad, or a serving of soup or stew, and usually eaten around 9:00 each evening, often continuing past midnight. Beer, wine, fruit juice, and soft drinks are beverages commonly consumed at meals. An afternoon break is typical in much of South America: coffee is typically consumed in Argentina, Colombia, Ecuador, and Brazil; tea is served in the late afternoon in Chile and Uruguay; and maté is popular in parts of Argentina, Paraguay, Uruguay, and Brazil. Snacks eaten with the beverage are often fruit, cachapas or arepa, sandwiches, or a pastry. Street vendors offering coffee, fruit juice, and snacks throughout the day are common in urban areas. Unlike wealthier South Ameri- cans, the poor often skip lunch and eat a large dinner. The meal may consist of soup or a serving of stew with a side dish of potatoes, plantains, cassava, corn, or rice and beans, depending on the region. Special Occasions Catholic traditions have influenced many South American holidays. A rich Christmas Eve dinner is traditional in most nations, often with a roast, such as lechón (suckling pig) in Brazil and cuy or Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 1 0 3 1 1 lechón in Ecuador. Italian specialties includ- ing torrone and panettone are Christmas items in Argentina, where Epiphany is another significant religious holiday (see Chapter 6). Easter is important in many homes, and Carnival (C ar nav al ) festivities featuring danc- ing, parties, and traditional fare are popu- lar in Brazil, Ecuador, Peru, and Uruguay. Americans from these countries sometimes celebrate with parties during the three days before Lent. During the time of Lent, animals associated with water habits, such as alligators, armadillos, capybaras, iguanas, and turtles, were traditionally classified as fish; thus the Catholic Church permitted their consumption on meatless days.106 These game meats are still considered Lent specialties in some regions. St. John’s Day is a favorite in Brazil, featur- ing foods made with corn and pumpkin, and it is also celebrated by the citizens of Otavalo, Ecuador with all-night feasting and danc- ing. In Peru, All Soul’s Day on November 2 includes gifts of food and family picnics at the gravesites of deceased kin. Also signifi- cant for many Americans of South American descent are the independence days observed in various nations. Brazilian Americans com- memorate their independence on September 7 with day-long festivities in Boston, New York, and Newark, New Jersey. Americans from Chile sponsor traditional food and craft booths for fairs to celebrate their Indepen- dence on September 18. Colombian Ameri- cans consume tamales, empanadas, arepas, and other specialties on their independence day, July 20. In Ecuador, the pr imer gr ito (“first cry” of independence) is held on August 10 and is officially marked as Ecuador Day in New York City. Independence Day in Peru is July 28. The Day of Tradition is popular in the Argentinian American community, with customary foods, folk music, and equestrian displays by men dressed as gauchos. Etiquette Traditionally, women prepared meals and served them to men, who con- sumed their food first. Women would eat after the men finished. This custom is continued in many rural, and even some urban, homes in South America today, especially among fami- lies of Indian ancestry.106 European-style dining is common in most of South America. The fork is kept in the left hand, and the knife in the right, with no switching for cutting food. Bread is often served without butter and placed on the side of the plate. It is the only food that should be eaten with the hands. All other items, includ- ing fruit, require cutlery. Salads, however, should not be cut. Instead the lettuce should be folded into bite-size packets with the fork. In Brazil, even sandwiches are eaten with a knife and fork. All items are passed to the left. The hands should remain above the table when a person is not eating, with wrists rest- ing on the table edge. In Colombia, it is impo- lite to start a meal until the host says “¡ B uen pr ov ec h o!” In Bolivia, it is an insult to pour wine with your left hand or to hold the bottle at the base when pouring, which is interpreted to mean you dislike the person for whom the glass is intended.39 Therapeutic Uses of Foods Candomblé orixás are associated with certain foods, and fol- lowers honor their deity by eating those items. Examples include white corn, white beans, rice, porridge, yams, and water with Oxalá; rice, black beans, black-eyed peas, and roasted corn with Omolu; black beans with Ogun; farofa made with dendê oil, black beans, honey, steak with onions, and chachaça with Exú; tapioca, pudding, cooked corn, and a ginger-flavored drink called aluá with Oxoosi; and pudding, banana, ximxim (chicken stew), and champagne with Oxum. A hot–cold system of medicine, most likely introduced by European immigrants, has also been adapted by candomblé healers, treat- ing hot conditions associated with hot orixás with cool prescriptions associated with cool orixás. Classification is inconsistent, however, and cold conditions are rarely treated with hot remedies.102 Some South Americans may adhere to more general hot–cold classifications not asso- ciated with candomblé.112 Foods that are hot in temperature, or irritating to the stomach, may be avoided during fevers, for example. Conditions such as menstruation, pregnancy, and lactation also require specific foods. In addition, some people believe that certain Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 3 1 2 C A R I B B E A N I S L A N D E R S A N D S O U T H A M E R I C A N S foods should be eaten at specific times of day, such as fruit, which is considered wholesome in the morning but harmful in the evening. Some South Americans avoid combinations of some foods, such as eating acidic fruits at the same time as drinking milk. Contemporary Food Habits in the United States Adaptations of Food Habits Very little has been reported on the adapted food habits of South Americans living in the United States. Many continue cooking their favorites from home, although recipes are often adapted to accommodate U.S. ingredi- ents or to improve acceptability (e.g., cuy is not often prepared). Substitutions for unavail- able ingredients, such as feta cheese for fresh farmer’s cheese or peanut oil for dênde oil, are common. Sometimes the fact that certain cus- tomary ingredients are unobtainable makes other dishes that can be prepared traditionally more popular in the United States than these dishes are in their countries of origin. For instance, llapingachos is probably eaten more often by Peruvian Americans than by Peruvi- ans.109 Among Chileans, many find it difficult to adapt to typical American schedules with a work day that begins earlier than in Chile (dif-work day that begins earlier than in Chile (dif-work day that begins earlier than in Chile (dif ficult after a late dinner) and has a short lunch period precluding a leisurely meal. Nutritional Status Nutritional Intake There are minimal data on the nutritional status of Americans of South American descent. Parasitic infection, iron- deficiency anemia, and protein-calorie mal- nutrition are common in many rural areas of South America and in some crowded urban neighborhoods as well. Chronic Chagas dis- ease involving the esophagus and colon is endemic in some regions and may be a risk factor in cardiovascular disease. Studies in South America reveal trends that may be applicable to the population in the United States, particularly recent immigrants. Overweight and obesity is prevalent in some regions, with reported rates for BMI $25 in 48 percent of one Colombian adult sam- ple, 64 percent in Chilean, 55 percent in Ecuadoran, and 52 percent in Brazilian stud- ies. Reports on obesity show rates of BMI .30 in 19 percent of a study of Brazilians, 30 per- cent in Argentinans, and 30 percent of Chil- eans. The prevalence for high blood pressure in South American Countries ranges from 23 to 46 percent.110 Among Brazilians, traditional diets low in calorie density and high in fiber were associated with lower BMI, whereas more Westernized diets with foods high in added fats (especially butter, margarine, and fried snacks) and sugars (particularly soft drinks) were associated with a higher BMI.111 Type 2 diabetes rates are in the 6 to 12 per- cent range in South American countries.110 A study in Ecuador reported 41 percent of postmenopausal women had metabolic syn- drome.112 Research in Venezuela estimated that one-third of the adult population in the region had metabolic syndrome associ- ated with dyslipidemia. Among men, rates varied widely by ethnicity and were highest in those of mixed heritage (37 percent), fol- lowed by whites and blacks. The lowest rates (17 percent) were found in the Native Indian group.113,114 Counseling In many South American coun- tries, universal health care is available. How- ever, preventive health practices may or may not be provided, and care may not be sought except in emergency situations. Unauthorized South Americans living in the United States illegally typically have no medical insurance and may avoid contact with any government agency. South Americans tend toward formality in their interactions with others. Conversa- tions are often reserved, with little emotional expression. However, Venezuelans are note- worthy for their directness, and Brazilians are typically restrained with strangers but very animated with family and friends.39 Most South Americans prefer to sit and stand closer than is usual in the United States. Direct eye contact is common throughout South America, except in Colombia, where eye con- tact may be avoided with authority figures or elders, or in embarrassing situations as a sign of subordination. Most South Americans are Chileans commonly use both their paternal and maternal surnames. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 1 0 3 1 3 present oriented and polychronic, which may result in relaxed attitudes toward appointment and treatment schedules. Generally speaking, immediate interventions are valued more than either preventive or long-term care. In Argen- tina, a patient is often protected from a nega- tive prognosis. When counseling Argentinians, the eldest of the group will be introduced first. Maintaining eye contact is a sign of interest and will help build trust. With Venezuelans punctuality is valued and respected. Use only their first name if you are given per- mission. Family is important to Peruvians and be can be used in conversation to build a relationship. Peruvians consider it rude to use your index finger to point at an object or person. Dominicans expect direct eye contact and may interrupt you while you’re talking.115 The role of traditional health beliefs and practices is largely undocumented, though it D I S C U S S I O N S T A R T E R S Understanding Cultural Differences This chapter covers many cultures. Some share traits; others do not. Cultural differences can be subtle. It’s easy to stereotype people from unfamiliar cultures, but doing so can cause poor outcomes for U.S. health care professionals trying to counsel immigrant patients. Below are examples of two matrixes, intended to help us differentiate among immigrants from various Caribbean island and South American cultures. Your task is to create two tables using the following models, each with two rows: Caribbean islands and South America. The first table lists health issues, and the second lists cultural issues for the two groups. Place a plus sign in the squares where the features are present for the immigrants in each row. In the first matrix, identify which of the immigrant groups have been generally recognized as suffering from which diseases. This is an example of how you can organize your information: Counseling patients from different cultures is complicated not only by the fact that immigrants from different cultures may tend to suffer from different diseases, but also by the fact that different cultures tend to behave differently. In the second matrix, identify which problematic features are associated with which immigrant groups. In small groups, share your completed matrixes. Within your group, come to a consensus on your identifications and discuss the implications this infor- mation might have for training health professionals. Are there categories shared by several immigrant groups? Do the matrixes suggest some general guidelines for addressing the dietary needs of immigrants from the Caribbean islands and South America? Obesity Hypertension DiabetesHypertension Diabetes Liver Disease Parasitic Disease List the country in this column Language Problems FatalismLanguage Problems Fatalism1 Modest Reserved Behavior Direct Eye Contact List the country in this column 1By fatalism, we mean the idea that God or fate determines a person’s health. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 3 1 4 C A R I B B E A N I S L A N D E R S A N D S O U T H A M E R I C A N S Review Questions 1. Choose one Caribbean country and summa- rize the worldview of its immigrants living in the United States. Include an example of the use of the hot–cold system for cause or treat- ment of an illness. Describe the types of tradi- tional healers used in this region. 2. Select one indigenous food found in the Caribbean. Describe its taste and use in recipes from the region. Next, select a foreign food that was brought to the region and still commonly consumed—provide a recipe. Which foods are now the staples of the diet? Describe a holiday meal in one Caribbean country plus the spe- cialties of the island. 3. What health problems have become common for people from the Caribbean living in the United States? If you were a nutritionist, how would you modify the diet in the treatment of these disorders? References 1. Buffington, S.T. 2000. Dominican Americans. In R.V. Dassanowsky & J. Lehman (Eds.), G al e enc y - c l opedia of mul tic ul tur al A mer ic a. Farmington Hills, MI: Gale Group. 2. Torres-Saillant, S., & Hernandez, R. 1998. T h e Dominic an A mer ic ans. Westport, CT: Greenwood Press. 3. P uer to R ic ans in th e U nited S tates. n.d. Retrieved from http://en.wikipedia.org/wiki/Puerto_ Ricans_in_the_United_States (accessed March 1, 2015). 4. U.S. Census Bureau. n.d. Selected characteristics of the foreign-born population by region of birth. 2 0 0 9 – 2 0 1 3 A mer ic an C ommunity S ur v ey 5 - Y ear E stimates. Table S0506. Retrieved from http:// factfinder.census.gov/faces/tableser vices/jsf/ pages/productview.xhtml?pid5ACS_13_5YR_ S0506&prodType5table (accessed March 1, 2015). 5. Motel, S., & Patten, E. June 27, 2012. H ispan- ic s of P uer to R ic an or igin in th e U nited S tates, 2 0 1 0 statistic al pr of il e. Retrieved from http:// www.pewhispanic.org/2012/06/27/hispanics- of-puerto-rican-origin-in-the-united-states- 2010/#fn-14572-3 (accessed March 1, 2015). 6. U.S. Census Bureau. n.d. Selected population pro- file in the U.S. 2 0 1 3 A mer ic an C ommunity S ur v ey 1 - Y ear E stimates. Table S0201. Retrieved from http://factfinder.census.gov/faces/tableservices/ jsf/pages/productview.xhtml?pid5ACS_13_1YR_ S0201&prodType5table (accessed March 1, 2015). 7. Tafoya, S. December 6, 2004. S h ades of bel ong-S h ades of bel ong-S h ades of bel ong ing. Pew Hispanic Center. Retrieved from http:// pewhispanic.org/files/reports/35 (accessed March 1, 2015). 8. Hoefer, M., Rytina, N., & Baker, B.C. 2009. E sti- mates of th e unauth or iz ed immigr ant popul a- tion r esiding in th e U nited S tates: J anuar y 2 0 0 9 . Office of Immigration Statistics, Policy Direc- torate, U.S. Department of Homeland Security. Retrieved from http://www.dhs.gov/xlibrary/ assets/statistics/publications/ois_ill_pe_2009 9. Brown, A., & Patten, E. June 19, 2013. H ispanic s of P uer to R ic an or igin in th e U nited S tates, 2 0 1 1 . Pew Research Center, Hispanic Trends. Retrieved from http://www.pewhispanic.org/2013/06/19/ hispanics-of-puerto-rican-origin-in-the-united- states-2011/ (accessed March 3, 2015). 10. Monger, R. 2010. U . S . l egal per manent r esidents: 2 0 0 9 . Office of Immigration Statistics, Policy Directorate, U.S. Department of Homeland Secu- rity. Retrieved from http://www.dhs.gov/xlibrary/ assets/-statistics/publications/lpr_fr_2009 11. Motel, S., & Patten, E. June 27, 2012. H ispanic s of Dominic an or igin in th e U nited S tates, 2 0 1 0 , statistic al pr of il e. Retrieved from http://www .pewhispanic.org/2012/06/27/hispanics-of- dominican-origin-in-the-united-states-2010/ (accessed March 3, 2015). 12. Lewis Mumford Center for Comparative Urban and Regional Research. 2001. T h e new L atinos: W h o th ey ar e, w h er e th ey ar e. Albany, NY: Author. is assumed that as in other Latin American nations, only small numbers of people adhere completely to any single folk system. Homeo- pathic remedies and over-the-counter antibi- otics sent from family members still in South America may be obtained, and faith healers may be sought by some immigrants.36 One study of women with type 2 diabetes living in southeastern Brazil reported that many found dietary restrictions burdensome. Some were concerned with loss of autonomy, and others mentioned cravings for sweets. Some felt sadness when following the diet. Many mentioned that they had no symptoms of diabetes, and therefore believed dietary restrictions were unnecessary. Compliance was poor in this group. An in-depth client interview should be used to determine South American country of origin, preferred language, and length of stay in the United States. Client’s socioeconomic status, degree of acculturation, and use of traditional health practices will be significant factors in care.36 Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 1 0 3 1 5 13. Unaeze, F.E., & Perrin, R.E. 2000. Haitian Ameri- cans. In R.V. Dassanowsky & J. Lehman (Eds.), G al e enc y c l opedia of mul tic ul tur al A mer ic a. Farm- ington Hills, MI: Gale Group. 14. U.S. Census Bureau, Immigration Statistics Staff. 2010. F or eign- bor n pr of il es (ACS-19). American Community Survey Reports 2013. Retrieved from http://www.census.gov/acs/www/ 15. Murrell, N.S. 2000. Jamaican Americans. In R.V. Dassanowsky & J. Lehman (Eds.), G al e enc y - c l opedia of mul tic ul tur al A mer ic a. Farmington Hills, MI: Gale Group. 16. Lopez-De Fede, A., & Haeussler-Fiore, D. 2002. A n intr oduc tion to th e c ul tur e of th e Dominic an R epubl ic f or r eh abil itation ser v ic e pr ov ider s. C I R - R I E M onogr aph S er ies, J. Stone (Ed.), Buffalo, NY: Center for International Rehabilitation Research Information & Exchange (CIRRIE). 17. Edmonds, E., & Gonzalez, M. C ar ibbean r el igious h istor y : A n intr oduc tion. 2 0 1 0 . New York Univer- sity Press. Retrieved from http://muse.jhu.edu/ books/9780814722848 (accessed March 4, 2015). 18. Guilamo-Ramos, V., Dittus, P., Jaccard, J., Johans- son, M., Bouris, A., & Acosta, N. 2007, January. Parenting practices among Dominican and Puerto Rican mothers. J our nal of S oc ial W or k , 5 2 (1), 17–30. 19. Dahl, M. 2004. Working with Puerto Rican clients. H eal th C ar e F ood & N utr ition F oc us, 2 1 , 10–12. 20. Miller, N.L. 2000. Haitian ethnomedical systems and biomedical practitioners: Directions for clinicians. J our nal of T r ansc ul tur al N ur sing, J our nal of T r ansc ul tur al N ur sing, J our nal of T r ansc ul tur al N ur sing 1 1 , 204–211. 21. Freidenberg, J., Mulvihill, M., & Caraballo, L.R. 1993. From ethnology to survey: Some method- ological issues in research on health seeking in east Harlem. H uman O r ganiz ation, 5 2 , 151–161. 22. Anderson, N.L.R., Andrews, M., Bent, K.N., Douglas, M.K., Elhammoumi, C.V., Keenan, C., . . . Mattson, S. 2010. Culturally based health and illness beliefs and practices across the life span. In M.K. Douglas & D.F. Pacquiao (Eds.), Core cur- riculum in transcultural nursing and health care. J our nal of T r ansc ul tur al N ur sing, J our nal of T r ansc ul tur al N ur sing, J our nal of T r ansc ul tur al N ur sing 2 1 (Suppl 1). 23. Juarbe, T.C. 2003. People of Puerto Rican heri- tage. In L.D. Purnell & B.J. Paulanka (Eds.), T r ansc ul tur al h eal th c ar e (2nd ed.). Philadelphia: F.A. Davis. 24. Purnell, L.D. 2003. People of Cuban heritage. In L.D. Purnell & B.J. Paulanka (Eds.), T r ansc ul tur al h eal th c ar e (2nd ed.). Philadelphia: F.A. Davis. 25. Caban, A., & Walker, E.A. 2006. A systematic review of research on culturally relevant issues for Hispanics with diabetes. Diabetes E duc ator , 3 2 , 584–600. 26. Guarnaccia, P.J., Lewis-Fernandez, R., & Marano, M.R. 2003. Toward a Puerto Rican popular nosol- ogy: Nervios and ataque de nervios. C ul tur e, M edic ine and P sy c h iar ty , 2 7 , 339–366.2 7 , 339–366.2 7 27. Baer, R.D., Weller, S.C., Garcia, de Alba, Garcia, J., Glazier, M., Trotter, R., . . . Klein, R.E. 2003. A cross-cultural approach to the study of the folk illness. N er v ios C ul tur e, M edic ine and P sy c h iatr y , 2 7 , 315–337.2 7 , 315–337.2 7 28. Laguerre, M.S. 1981. Haitian Americans. In A. Harwood (Ed.), E th nic ity and medic al c ar e. Cambridge, MA: Harvard University Press. 29. Colin, J.M., & Paperwalla, G. 2003. People of Haitian heritage. In L.D. Purnell & B.J. Paulanka (Eds.), T r ansc ul tur al h eal th c ar e (2nd ed.). Phila- delphia: F.A. Davis. 30. Zapata, J., & Shippee-Rice, R. 1999. The use of folk healing and healers by six Latinos living in New England: A preliminary study. J our nal of T r ansc ul tur al N ur sing, T r ansc ul tur al N ur sing, T r ansc ul tur al N ur sing 1 0 , 136–142. 31. Reiff, M., O’Conner, B., Kronenberg, F., Balick, M., & Lohr, P. 2003. Ethnomedicine in the urban environment: Dominican healers in New York City. H uman O r ganiz ation, 6 2 , 12–26. 32. Larson, E.L., Dilone, J., Garcia, M., & Smolowitz, J. 2006. Factors which influence Latino commu- nity members to self-prescribe antibiotics. N ur s- ing R esear c h , 5 5 , 94–102. 33. Bearison, D.J., Minian, N., & Granowetter, L. 2002. Medical management of asthma and folk medicine in a Hispanic community. J our nal of P ediatr ic P sy c h ol ogy , 2 7 , 385–392.2 7 , 385–392.2 7 34. Houston, L.M. 2005. F ood c ul tur e in th e C ar ib- bean. Westport, CN: Greenwood Press. 35. Drago, L. 2010. Caribbean Hispanic food prac- tices. In C.M. Goody & L. Drago (Eds.), C ul tur al f ood pr ac tic es (Introduction). Chicago: American Dietetic Association. 36. Pereira, R.F., & Kurtz C. 2010. South American food practices. In C.M. Goody & L. Drago (Eds.), C ul tur al f ood pr ac tic es (Introduction). Chicago: American Dietetic Association. 37. Wolf, L. 1970. The cooking of the Caribbean Islands. New York: Time-Life Books. 38. Drago, L. 2005. Are you Caribbean savvy? Ethni- cally correct nutrition counseling tips. N ew sf l ash : Diabetes C ar e and E duc ation, 2 6 , 4–9. 39. Foster, D. 2002. T h e gl obal etiq uette guide to M ex ic o and L atin A mer ic a. New York: Wiley. 40. Spector, R.E. 2004. C ul tur al div er sity in h eal th and il l ness (6th ed.). Upper Saddle River, NJ: Pearson Education. 41. Harwood, A. 1981. E th nic ity and medic al c ar e. Cambridge, MA: Harvard University Press. 42. Fugh-Berman, A., Balick, M.J., Kronenberg, F., Oroski, A.L., O’Conner, B., Reiff, M., . . . Lee, R. 2004. Treatment of fibroids: The use of beets (B eta v ul gar is) and molasses (S ac c h ar um of f ic ina- r um) as an herbal therapy by Dominican healers in New York City. J our nal of E th noph ar mac ol ogy , 9 2 , 337–339. 43. Sanjur, D. 1995. H ispanic f oodw ay s, nutr ition, and h eal th . Boston: Allyn & Bacon. 44. Ortiz, B.I., & Clauson, K.A. 2006. Use of herbs and herbal products by Hispanics in south Florida. J our nal of th e A mer ic an P h ar mac eutic al A ssoc iation, 4 6 , 161–167. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 3 1 6 C A R I B B E A N I S L A N D E R S A N D S O U T H A M E R I C A N S 45. Immink, M.D.C., Sanjur, D., & Burgos, M. 1983. Nutritional consequences of U.S. migration pat- terns among Puerto Rican women. E c ol ogy of F ood and N utr ition, 1 3 , 139–148. 46. Sharma, S., Cade, J., Landman, J., & Cruickshank, J.K. 2002. Assessing the diet of the British African-Caribbean population: Frequency of consumption of foods and food portion sizes. I nter national J our nal of F ood S c ienc es and N utr i- tion, 5 3 , 439–444. 47. Chávez, N., Sha, L., Persky, V., Langenberg, P., & Pestano-Binghay, E. 1994. Effect of length of stay on food group intake in Mexican and Puerto Rican women. J our nal of N utr ition E duc ation, 2 6 , 79–86. 48. Sanjur, D. 1995. H ispanic f oodw ay s, nutr ition, and h eal th . Boston: Allyn & Bacon. 49. Bermudez, O.I., Falcon, L.M., & Tucker K.L. 2000. Intake and food sources of macronutrients among older Hispanic adults: Association with ethnic- ity, acculturation, and length of residence in the United States. J our nal of th e A mer ic an Dietetic A ssoc iation, 1 0 0 , 665–673. 50. Centers for Disease Control and Prevention. 2011. F ac t sh eet: C DC h eal th dispar ities and ineq ual i- ties r epor t— U S 2 0 1 1 . Retrieved from http://www .cdc.gov/minorityhealth/reports/CHDIR11/ FactSheet (accessed March 5, 2015). 51. Hajat, A., Lucas, J.B., & Kington, R. 2000. Health outcomes among Hispanic subgroups: Data from the National Health Interview Survey, 1992–1995. A dv anc e Data, 2 5 , 1–14. 52. Hosler, A.S., & Melnik, T.A. 2005. Population- based assessment of diabetes care and self- management among Puerto Rican adults in New York City. Diabetes E duc ator , 3 1 , 418–426. 53. Centers for Disease Control and Prevention. n.d. E l iminate dispar ities in diabetes. Retrieved from http://www.cdc.gov/omhd/AMH/factsheets/dia- betes.htm (accessed March 5, 2011). 54. U.S. Department of Health and Human Services, Office of Minority Health. n.d. H ispanic - L atino pr of il e. Retrieved from http://minorityhealth. hhs.gov/templates/browse.aspx?lvl52&lvlid554 (accessed March 5, 2011). 55. Borrell, L.N., Dallo, F.J., & White, K. 2006. Edu- cation and diabetes in a racially and ethnically diverse population. A mer ic an J our nal of P ubl ic H eal th , 9 6 , 1637–1642. 56. Tucker, K.L. 2005. Stress and nutrition in rela- tion to excess development of chronic disease in Puerto Rican adults living in the northeast- ern USA. J our nal of M edic al I nv estigation, 5 2 , 252–258. 57. Hummer, R.A., Rogers, R.G., Amir, S.H., Forbes, D., & Frisbie, W.P. 2000. Adult mortality dif-D., & Frisbie, W.P. 2000. Adult mortality dif-D., & Frisbie, W.P. 2000. Adult mortality dif ferentials among Hispanic subgroups and non- Hispanic whites. S oc ial S c ienc e Q uar ter l y , 8 1 , 459–476. 58. Centers for Disease Control and Prevention. 2013. Infant mortality statistics from the 2009 period linked birth/infant death data set. N ational V ital S tatistic s R epor ts, Table A. Retrieved from http:// www.cdc.gov/nchs/data/nvsr/nvsr61/nvsr61_08 (accessed March 5, 2011). 59. Landale, N.S., Gorman, B.K., & Oropesa, R.S. 2006. Selective migration and infant mortality among Puerto Ricans. M ater nal and C h il d H eal th J our nal , 1 0 , 351–360. 60. Odel, C.D., Kotelchuck, M., Chetty, V.K., Fowler, J., Stubblefield, P.G., Orejuela, M., & Jack, B.W. 2006. Maternal hypertension as a risk factor for low birth-weight infants: Comparison of Haitian and African American women. M ater nal and C h il d H eal th J our nal , 1 0 , 39–46. 61. Kugyelka, J.G., Rasmussen, K.M., & Frongillo, E.A. 2004. Maternal obesity is negatively associ- ated with breastfeeding success among Hispanic but not black women. J our nal of N utr ition, 1 3 4 , 1746–1753. 62. Gordon, A.M. 1982. Nutritional status of Cuban refugees: A field study on the health and nutri- tion of refugees processed at Opa-Locka, Florida. A mer ic an J our nal of C l inic al N utr ition, 3 5 , 582–590. 63. Liao, Y., Tucker, P., Okoro, C.A., Giles, W.H., Mokdad, A.H., & Harris, V.B. 2004. REACH 2010 surveillance for health status in minor- ity communities—United States, 2001–2002. M or bidity and M or tal ity W eek l y R epor t, 5 3 , 1–36. 64. Ackerman, L.K. 1997. Health problems of refugees. J our nal of th e A mer ic an B oar d of F amil y P r ac tic e, 1 0 , 337–348. 65. Kwan, L.L., Bermudez, O.I., & Tucker, K.L. 2002. Low vitamin B12 intake and status are more preva- lent in Hispanic older adults of Caribbean origin than in neighborhood-matched non-Hispanic whites. J our nal of N utr ition, 1 3 2 , 2059–2064. 66. Vyas, A., Greenhalgh, A., Cade, J., Sanghera, B., Riste, L., Sharma, S., & Cruickshank, K. 2003. Nutrient intake of an adult Pakistani, European and African-Caribbean community in inner city Britain. J our nal of H uman N utr ition and Dietetic s, 1 6 , 327–337. 67. Shoham, J., & Duffield, A. 2009. Proceedings of the World Food Programme/United Nations High Commissioner for Refugees Consultation on the management of moderate malnutrition in children 5 years of age. F ood and N utr ition B ul l etin, 3 9 (3 Suppl.), 464–474. 68. Centers for Disease Control and Prevention. 2012. S ummar y h eal th statistic s f or U . S . adul ts: 2 0 1 1 , Table 31. Retrieved from http://www.cdc.gov/ nchs/data/series/sr_10/sr10_256 (accessed March 4, 2015). 69. Thorpe, L.E., List, D.G., Marx, T., May, L., Helgerson, S.D., & Frieden, T.R. 2004. Child- hood obesity in New York City elementary school students. A mer ic an J our nal of P ubl ic H eal th , 9 4 , 1496–1500. 70. Nelson, J.A., Carpenter, K., & Chiasson, M.A. 2006. Diet, activity, and overweight among Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 1 0 3 1 7 preschool-age children enrolled in Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). P r ev enting C h r onic Disease, 3 , A49. 71. Daviglus, M.L., Talavera, G.A., Avilés-Santa, M., Allison, M., Cai, J., Criqui, M.H., . . . Stamler, J. 2012. Prevalence of major cardiovascular risk fac- tors and cardiovascular diseases among Hispanic/ Latino individuals of diverse backgrounds in the United States. J our nal of th e A mer ic an M edic al A ssoc iation, 3 0 8 (17), 1775–1784. doi:10.1001/ jama.2012.14517 72. Lin, H., Bermudez, O.I., & Tucker, K.L. 2003. Dietary patterns of Hispanic elders are associ- ated acculturation and obesity. J our nal of N utr i- tion, 1 3 3 , 3651–3657. 73. Fitzgerald, N., Himmelgreen, D., Damio, G., Segura-Perez, S., Peng, Y.K., & Perez-Escamilla, R. 2006. Acculturation, socioeconomic status, obe- sity and lifestyle factors among low-income Puerto Rican women in Connecticut, U.S., 1998–1999. P an A mer ic an J our nal of H eal th , 1 9 , 306–313. 74. Himmelgreen, D.A., Perez-Escamilla, R., Martinez, D., Bretnall, A., Eells, B., Peng, Y., & Bermudez, A. 2004. The longer you stay, the big- ger you get: Length of time and language use in the U.S. are associated with obesity in Puerto Rican women. A mer ic an J our nal of P h y sic al A nth r opol ogy , 1 2 5 , 90–96. 75. Gans, K.M., Burkholder, G.J., Upegui, D.I., Risica, P.M., Lasater, T.M., & Fortunet, R. 2002. Com- parison of baseline fat-related eating behaviors of Puerto Rican, Dominican, Colombian, and Guatemalan participants who joined a cholesterol education project. J our nal of N utr ition E duc ation and B eh av ior , 3 4 , 202–210. 76. Sharma, S., Cade, J., Landman, J., & Cruickshank, J.K. 2002. Assessing the diet of the British African-Caribbean population: Frequency of consumption of foods and food portion sizes. I nter national J our nal of F ood S c ienc es and N utr i- tion, 5 3 , 439–444. 77. Contento, I.R., Basch, C., & Zybert, P. 2003. Body image, weight, and food choices of Latina women and their young children. J our nal of N utr ition E duc ation, 3 5 , 236–248. 78. Lin, H.F., Boden-Albala, B., Juo, S.H., Park, N., Rundek, T., & Sacco, R.L. 2005. Heritabilities of the metabolic syndrome and its components in the Northern Manhattan Family Study. Diabeto- l ogia, 4 8 , 2006–2012. 79. Daviglus, M.L., Talavera, G.A., Avilés-Santa, M., Allison, M., Cai, J., Criqui, M.H., . . . Stamler, J. 2012. Prevalence of major cardiovascular risk fac- tors and cardiovascular diseases among Hispanic/ Latino individuals of diverse backgrounds in the United States. J our nal of th e A mer ic an M edic al A ssoc iation, 3 0 8 (17), 1775–1784. doi:10.1001/ jama.2012.14517 80. Daviglus, M.L., Talavera, G.A., Avilés-Santa, M., Allison, M., Cai, J., Criqui, M.H., . . . Stamler, J. 2012. Prevalence of major cardiovascular risk fac- tors and cardiovascular diseases among Hispanic/ Latino individuals of diverse backgrounds in the United States. J our nal of th e A mer ic an M edic al A ssoc iation, 3 0 8 (17), 1775–1784. doi:10.1001/ jama.2012.14517 81. Centers for Disease Control and Prevention. 2012. S ummar y h eal th statistic s f or U . S . adul ts: 2 0 1 1 , Table 8. Retrieved from http://www.cdc.gov/nchs/ data/series/sr_10/sr10_256 (accessed March 5, 2015). 82. Cleghorn, G.D., Nguyen, M., Roberts, B., Duran, G., Tellez, T., & Alecon, M. 2004. Practice-based interventions to improve health care for Latinos with diabetes. E th nic ity & Disease, 1 4 , S117–S121. 83. Ho, G.Y., Qian, H., Kim, M.Y., Melnik, T.A., Tucker, K.L., Jimenez-Velazquez, I.Z., . . . Rohan, T.E. 2006. Health disparities between island and mainland Puerto Ricans. P an A mer ic an J our nal of P ubl ic H eal th , 1 9 , 331–339. 84. Kousta, E., Efstathiadou, Z., Lawrence, N.J., Jeffs, J.A., Godsland, I.H., Barrett, S.C., . . . Johnston, D.G. 2006. The impact of ethnicity on glucose regulation and the metabolic syndrome follow- ing gestational diabetes. Diabetol ogia, 4 9 , 36–40. 85. Schneiderman, N., Llabre, M., Cowie, C.C., Barn- hart, J., Carnethon, M., Gallo, L.C., . . . Avilés- Santa, M.L. 2014. Prevalence of diabetes among Hispanics/Latinos from diverse backgrounds: The Hispanic Community Health Study/Study of Latinos (HCHS/SOL). Diabetes C ar e, 3 7 , 2233–2239. 86. Koch, S., Pabon, D., Rabinstein, A.A., Chirinos, J., Romano, J.G., & Forteza, A. 2005. Stroke etiology among Haitians in Miami. N eur oepidemiol ogy , 2 5 , 192–195. 87. Centers for Disease Control and Prevention. 2012. Death s: F inal data f or 2 0 0 9 , Table 16 and Table 17. Retrieved from http://www.cdc.gov/ nchs/data/nvsr/nvsr60/nvsr60_03 (accessed March 5, 2011). 88. U.S. Department of Health and Human Services, Office of Minority Health. n.d. R ac ial and eth nic spec if ic or al h eal th data 2 0 1 0 . Retrieved from http://minorityhealth.hhs.gov/templates/browse .aspx?lvl53&lvlid5209 (accessed March 5, 2011). 89. Saint-Jean, G., & Crandall, L.A. 2005. Sources and barriers to health care for Haitian immigrants in Miami-Dade County, Florida. J our nal of H eal th C ar e f or th e P oor and U nder ser v ed, 1 6 , 29–41. 90. U.S. Department of Health and Human Services, Office of Minority Health. n.d. H ispanic - L atino pr of il e. Retrieved from http://minorityhealth. hhs.gov/templates/browse.aspx?lvl52&lvlid554 (accessed March 5, 2011). 91. Vergara, C., Martin, A.M., Wang, R., & Horow- itz, S. 2004. Awareness about factors that affect management of hypertension in Puerto Rican patients. C onnec tic ut M edic ine, 6 8 , 269–276. 92. Pasquali, E.A. 1994. Santeria. J our nal of H ol istic N ur sing, N ur sing, N ur sing 1 2 , 380–390 Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 3 1 8 C A R I B B E A N I S L A N D E R S A N D S O U T H A M E R I C A N S 93. Garcia, S., Canoniero, M., Lopez, G., & Soriano, A.O. 2006. Metamizole use among Hispanics in Miami: Report of a survey conducted in a pri- mary care setting. S outh er n M edic al J our nal , 9 9 , 924–926. 94. Larson, E.L., Dilone, J., Garcia, M., & Smolowitz, J. 2006. Factors which influence Latino commu- nity members to self-prescribe antibiotics. N ur s- ing R esear c h , 5 5 , 94–102. 95. Haider, S.Q., & Wheeler, M. 1979. Nutritive intake of black and Hispanic mothers in a Brook- lyn ghetto. J our nal of th e A mer ic an Dietetic A sso- c iation, 7 5 , 670–673. 96. U.S. Census Bureau. n.d. Selected characteristics of the foreign-born population by region of birth. 2 0 0 9 – 2 0 1 3 A mer ic an C ommunity S ur v ey 5 - Y ear E stimates Table S0506. Retrieved from http:// factfinder.census.gov/faces/tableservices/jsf/ pages/productview.xhtml?pid=ACS_13_5YR_ S0506&prodType=table (accessed March 5, 2015). 97. Motel, S., & Patten, E. June 27, 2012. H ispanic s of C ol ombian or igin in th e U nited S tates, 2 0 1 0 , statistic al pr of il e. Retrieved from http://www. pewhispanic.org/2012/06/27/hispanics-of- colombian-origin-in-the-united-states-2010/ (accessed March 5, 2015). 98. Brown. A., & Patten, E. June 19, 2011. H ispan- ic s of E c uador ian or igin in th e U nited S tates, 2 0 1 1 . Retrieved from http://www.pewhispanic .org/2013/06/19/hispanics-of-ecuadorian- origin-in-the-united-states-2011/ (accessed March 5, 2015). 99. Brown. A., & Patten, E. June 19, 2011. H is- panic s of P er uv ian or igin in th e U nited S tates, 2 0 1 1 . Retrieved from http://www.pewhispanic .org/2013/06/19/hispanics-of-peruvian-origin- in-the-united-states-2011/ (accessed March 5, 2015). 100. Brown. A., & Patten, E. June 19, 2011. H ispan- ic s of A r gentinean or igin in th e U nited S tates, 2 0 1 1 . Retrieved from http://www.pewhispanic .org/2013/06/19/hispanics-of-argentinean- origin-in-the-united-states-2011/ (accessed March 5, 2015). 101. U.S. Census Bureau. n.d. Selected population pro- file in the U.S. 2 0 1 2 A mer ic an C ommunity S ur v ey 1 - Y ear E stimates, Table S0201. Retrieved from http://factfinder.census.gov/faces/tableservices/ jsf/pages/productview.xhtml?pid5ACS_12_1YR_ S0201&prodType5table (accessed March 5, 2011). 102. Voeks, R.A. 1997. S ac r ed l eav es of C andombl é : A f r ic an magic , medic ine, and r el igion in B r az il . Austin: University of Texas Press. 103. R el igion in L atin A mer ic a: W idespr ead c h ange in a h istor ic al l y C ath ol ic r egion. November 13, 2014. Pew Research Center. Retrieved from http:// www.pewforum.org/2014/11/13/religion-in- latin-america/ (accessed March 5, 2015). 104. Jefferson, A.W. 2000. Brazilian Americans. In R.V. Dassanowsky & J. Lehman (Eds.), G al e enc y c l opedia of mul tic ul tur al A mer ic a. Farming- ton Hills, MI: Gale Group. 105. Packel, J. 2000. Peruvian Americans. In R.V. Dassanowsky & J. Lehman (Eds.), G al e enc y c l opedia of mul tic ul tur al A mer ic a. Farming- ton Hills, MI: Gale Group. 106. Lovera, J.R. 2005. F ood c ul tur e in S outh A mer ic a. Westport, CN: Greenwood Press. 107. Leonard, J.N. 1968. L atin A mer ic an c ook ing. New York: Time-Life Books. 108. Kijac, M.B. 2003. T h e S outh A mer ic an tabl e. Boston: Harvard Common Press. 109. Novas, H., & Silva, R. 1997. L atin A mer ic an c ook - ing in th e U . S . A . New York: Knopf. 110. Gattini, C., & Ruiz, P. 2012. H eal th in S outh A mer ic a. Washington, DC: Pan American Health Organization/World Health Organization. 111. Sichieri, R. 2002. Dietary patterns and their asso- ciations with obesity in the Brazilian city of Rio de Janeiro. O besity R esear c h , 1 0 , 42–48. 112. Hidalgo, L.A., Chedraui, P.A., Morocho, N., Alvarado, M., Chavez, D., & Huc, A. 2006. The metabolic syndrome among menopausal women in Ecuador. G y nec ol ogic al E ndoc r inol ogy , 2 2 , 447–454. 113. Aballay, L.R., Eynard, A.R., Díaz Mdel, P., Navarro, A., & Muñoz, S.E. 2013. Overweight and obesity: A review of their relationship to metabolic syndrome, cardiovascular disease, and cancer in South America. N utr ition R ev iew s, 7 1 (3), 168–179. 114. Florez, H., Silva, E., Fernandez, V., Ryder, E., Sulbaran, T., Campos, G., . . . Goldberg, R. 2005. Prevalence and risk factors associated with meta- bolic syndrome and dyslipdemia in white, black, Amerindian and mixed Hispanics in Zulia State, Venezuela. Diabetes R esear c h and C l inic al P r ac - tic e, 6 9 , 63–77. 115. Bowling Green State University. n.d. H ow to c on- duc t business in L atin A mer ic a. Retrieved from https://blogs.bgsu.edu/latinamericabusiness/ category/caribbean/ (accessed February 28, 2015). 116. Lalbachan, P. 1994. T h e c ompl ete C ar ibbean c ook - book . Futland, VT: Tuttle. 117. Murrell, N.S. 2000. Jamaican Americans. In R.V. Dassanowsky & J. Lehman (Eds.), G al e enc y c l opedia of mul tic ul tur al A mer ic a. Farming- ton Hills, MI: Gale Group. 118. Walsh, R., & McCarthy, J. 1995. T r av el ing J amaic a w ith k nif e, f or k & spoon. Freedom, CA: Crossing. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 3 1 9 Korea. Southeast Asians are discussed in Chapter 12 and South Asians are considered in Chapter 14. Chinese Chinese civilization is more than 4,000 years old and has made numerous significant con- tributions in agriculture, the arts, religion and philosophy, and warfare. Silk and embroi- dered brocade cloth, intricate jade sculpture, Chinese porcelain and lacquerware, book printing, Confucianism, Taoism, and gun- powder are just a few examples. The name China, meaning “middle kingdom,” or center of the world, is probably derived from a ruling dynasty of the third century bce. China’s landscape is dominated by the valleys of two great rivers, the Huang (Yellow) River in the north and the Chang Jiang (Yangtze) in the south. The climate is monsoonal, with most of China’s rainfall occurring in the spring and summer months. The northern plain through which the Huang River flows is agriculturally very fer- tile. The area is cold, and sometimes the severe winter results in a growing season of only four to six months. In the south the Chang Jiang River starts in Tibet, traverses the southern provinces, and eventually empties into the China Sea near the city of Shanghai. South of the mouth of the Chang Jiang delta is a rug- ged and mountainous coastline off which are located the islands of Hong Kong and Taiwan. Marco Polo, the famous European traveler who went to China in the late thirteenth century, is said to have brought Chinese noodles to Italy. The Italians, however, were undoubtedly making pasta long before the times of Marco Polo— noodles are thought to have been developed independently in each region. East Asians Asia is one of the world’s largest conti-nents, stretching from the Ural Moun-tains and Suez Canal in the east and the Arctic Circle in the north, to the tropical peninsulas of India and Southeast Asia. It encompasses almost one-third of the world landmass and nearly two-thirds of the global population. Asia is divided into the regions of East Asia, Southeast Asia, and South Asia. Though the continent has historically included parts of Russia and several nations of the for- mer Soviet Union (sometimes known as Cen- tral Asia) and the Middle East (sometimes called West Asia, or Asia Minor), the people of these countries are culturally distinct from the rest of Asia and are covered in Chapters 7 and 13, respectively. East Asia is defined as China (the Peo- ple’s Republic of China), Taiwan (Republic of China), Japan, the Democratic People’s Republic of Korea (North Korea), the Repub- lic of Korea (South Korea), and the Mon- golian People’s Republic (see Figure 11.1). Immigrants from these nations, particularly China and Japan, have been coming to the United States since the 1800s. Many settled on the West Coast, where the majority of their descendants still live. In recent years, large numbers from throughout the region have arrived in the United States; many are refugees from political oppression, whereas others seek education and employment opportunities. This chapter introduces the peoples and cuisines of China, Japan, and 11CHA P T E R Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 3 2 0 E A S T A S I A N S The southern provinces are warmer and wet- ter and have a longer growing season (six to nine months) than in the north. The population of China is estimated to exceed 1.36 billion people, more than four and a half times as large as the population of the United States. The Chinese have a hetero- geneous society with numerous ethnic and racial groups. The Chinese language is equally diverse, with many dialects, some of which are incomprehensible to people of other Chinese regions. Cultural Perspective History of Chinese in the United States Immigration Patterns The first major surge in Chinese immigration to the United States occurred in the early 1850s when the Chinese joined in the gold rush to California; many Chinese still refer to America as the “Land of the Golden Mountain.” As mining became less lucrative, the Chinese opened their own busi- nesses, such as laundries and restaurants, but also found employment in other occupations. Figure 11.1 China, Japan, and Korea. PAPUA NEW GUINEA SRI LANKA CHINA INDIA THAILAND MALAYSIA PHILIPPINES Hong Kong TAIWAN JAPAN MONGOLIA South China Sea Bay of Bengal Philippine Sea Sea of Japan Pacific Ocean East China Sea BRUNEI SINGAPORESINGAPORE MYANMAR NEPALLLLLL BHUTAN BANGLADESH VIETNAM LAOS SOUTH KOREA NORTH KOREA Beijing Tokyo SeoulSeoul PyongyangPyongyangPyongyangPyongyang Bangkok Manila CAMBODIA INDONESIAAAA © C en ga ge L ea rn in g Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 11 3 2 1 The Central Pacific Railroad, which joined the Union Pacific as the first cross-country line, was built primarily by 10,000 Chinese workers. By 1870, there were 63,000 Chinese, mostly male, in the United States, nearly all on the West Coast. Another 120,000 Chinese are esti- mated to have entered the United States during the following decade. Racial discrimination against Asians increased as their numbers swelled. By 1880 Chinese immigration slowed to a trickle due to exclusion laws directed against Asians. The Chinese also immigrated to Hawaii, and when the islands were annexed by the United States in 1898, approximately 25,000 Chinese were living there. Most early Chinese immigrants were from the southeastern Guangdong province of China, formerly referred to as Canton. Most were young men with no intention of stay- ing—they came to make their fortune and then return to China and their families. Many married before coming to the United States, and more than half returned to China. By the 1920s the Chinese population in the United States had dropped to 1870 levels. In each city where the Chinese settled, they usually lived within a small geographic area known as “Chinatown.” Large Chinatowns evolved in San Francisco, New York, Boston, Chicago, Philadelphia, Los Angeles, and Oakland, California. These neighborhoods offered protection against a sometimes hostile social and economic environment; assimila- tion was not an option. Conditions were often crowded and unusual in the predominance of men, but were tolerated with the expectation of eventual return to China. It was not until 1943 that Chinese could become naturalized U.S. citizens. Current Demographics and Socioeconomic Status When the exclusion laws were repealed in 1943, people from many Asian countries once again entered the United States. Chinese immigrants who have arrived since World War II are usually not from Guangdong. They are urban dwellers from other regions and are gen- erally better educated than earlier immigrants. Political instability in the People’s Republic of China has led to a recent exodus of Chinese. Following the pro-democracy uprising in Tiananmen Square in 1989, U.S. immigration laws were changed with the Chinese Student Protection Act of 1992. More than 41,000 Chi- nese residents were granted visas and are eli- gible for citizenship under the provision. Furthermore, the return of Hong Kong to mainland China and the uncertainty of Tai- wan’s future have led to increased immigra- tion from these islands. In 2013, the U.S. Census estimated that 4.5 million Chinese (including Taiwanese) are living in the United States, representing nearly a quarter of all Asians in the nation.1 Within the Chinese American population, close to 3 million individuals were not born in the United States, and 14.5 percent of those born outside the United States have come here since 2010. More than half reside in Califor- nia and New York.1 Large numbers of Chinese Americans also reside in the cities of Houston, Boston, Chicago, Seattle, and Philadelphia, and parts of Hawaii. As of 2010, it is estimated that there are over 230,000 Taiwanese living in the United States.2 Sizable populations are found in Cali- fornia, New York, and Texas. Four types of Chinese American house- holds have been identified.3 First are the sojourners, mostly men born in the early twentieth century, who came to the United States with the intent of returning after accu- mulating some wealth. Political changes in China have stranded this group in urban Chinatowns throughout America. The sec- ond type are sojourners who were successful in bringing their wives to the United States. These elderly first-generation couples still live in Chinatown neighborhoods, although their children have often moved from the area. The third type of household is established by new immigrant families. Often one member will arrive to establish residency, and then family members will follow. These immigrants usu- ally settle with other Asians, often in China- towns, where the parents speak Chinese and children learn English in school. Although many families include two wage earners or combine the incomes of extended members, they may remain poor due to low salaries, large families, and supporting relatives in the homeland. Chinese American households of The first Chinese restaurants in the United States opened in San Francisco in 1849. Over 40,000 Chinese restaurants are in operation today.190 The number of Chinese American women in the United States did not equal men until the 1970s. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 3 2 2 E A S T A S I A N S the fourth type include acculturated subur- ban families. These families include both new immigrants who are white-collar profession- als and those Americans of Chinese descent who have lived in the United States for several generations. Both parents may be college edu- cated, often with specialization in engineering and the sciences. Chinese Americans value education, and there are disproportionately large numbers of them (over 50 percent according to 2010 Census figures) holding college and graduate degrees.4 Fewer than 18 percent of foreign- born Chinese in the United States do not have a high school diploma.4 High levels of educational attainment often translate into well-compensated professional employment. Americans of Chinese descent are so well known for their successful transition in the United States that a stereotype has developed, obscuring what is in reality a divided popula- tion.5 Though many Chinese Americans are in the upper and middle classes, immigrants who came before the 1950s were often poorly educated, and many found work in sweat- shops. Even those who had college degrees were sometimes unable to find jobs suitable to their skills due to discrimination. Worldview Religion Most Americans of Chinese descent are not affiliated with a specific church. Reli- gious practices are often eclectic, a combi- nation of ancestor worship, Confucianism, Taoism, and Buddhism. Many early Chinese immigrants were not formally schooled in any religion; instead, beliefs and practices were passed orally from generation to generation. Spirituality is integrated into family and com- munity life. Daily living includes avoiding any actions that might offend the gods, nature, or ancestors. Early Religion The ancient faith of China was probably a mixture of ancestor worship and respect for the forces of nature and the heav- enly bodies. The supreme power was either Tien (heaven) or Shang Ti (the Supreme Ruler or the Ruler Above). One gained favor with the spirits by the correct performance of cer- emonies. These beliefs and practices were later incorporated into subsequent Chinese religions. Ceremonies for the dead are a prominent Chinese religious practice. The dead are sup- posed to depend on the living for the condi- tions of their existence after death. In turn, the dead can influence the lives of the living. Confucianism Confucius was a sage, one of many who gave order to Chinese society by defining the ways in which people should live and work together. Confucianism incorpo- rated the ceremonies of earlier religions, with the following cornerstones: 1. Fatherly love and filial piety in the son (i.e., children are expected to obey their parents and adults are expected to take care of their children) 2. Tolerance in the eldest brother and humility in the younger 3. Proper behavior by the husband and submission by the wife 4. Respect for one’s elders and compassion in adults 5. Allegiance to rulers and benevolence by leaders Inherent in these relationships is the ideal of social reciprocity, which means that one should treat others as one would like to be treated. To enhance harmony in the family and in society as a whole, one must exercise self-restraint. An individual must never lose face—meaning a person’s favorable name and position in society—because that would defame the whole family. Many of these values influence Chinese behavior today. Taoism The Taoist, like the Confucianist, believes that heaven and humanity function in unison and can achieve harmony, but under Taoism people are subordinate to nature’s way. There is a fundamental duality within the universe of interacting, opposite principles or forces—the yang (masculine, positive, yang (masculine, positive, yang bright, steadfast, warm, hard, and dry; some- times referred to as shen) and the yin (femi- nine, negative, dark, cold, wet, mysterious, and secret; also called kwei) (Figure 11.2). Everything in nature contains both yin and yang, and a balanced unity between them is Early immigrants and their descendants, as well as many current immigrants from Hong Kong, speak Cantonese, a dialect that typically is difficult to understand by Chinese immigrants who speak Mandarin. 2011 Census data report 1.49 million Canadians of Chinese heritage. Confucius also developed protocols for cooking and eating that were practiced in China until the nineteenth century.17 Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 11 3 2 3 necessary for harmony. This balance occurs when Tao, the way of nature, is allowed to take its course unimpeded by human willfulness. Taoism advocates a simple life, communion with nature, and the avoidance of extremes. Buddhism Buddhism grew during the T’ang Dynasty but then suffered a slow decline. The Mahayana sect dominated in China, blending with traditional Chinese beliefs and resulting in a unique Chinese form of Bud- dhism. Ten schools of Buddhism flourished in China at one time, but only four were left by the twentieth century. The two dominant schools in China are Ch’an (Zen Buddhism in Japan) and Pure Land (see Chapter 2 for more information). Chinese American Spirituality Both Catholic and Protestant churches were established in the early Chinatown neighborhoods, usually organized by the Chinese dialect spoken in the area. Few first-generation Chinese Americans joined Christian religions, but converts were found in subsequent generations. Others maintain aspects of Buddhism, Taoism, or spirit and ancestor worship in their daily lives, keeping small altars at home in which to offer respect and perform the rites that will pre- serve good relations with the gods and bring good fortune. Only a minority of Taiwanese belong to Protestant faiths in their homeland; however, Baptist, Presbyterian, and several smaller evangelical churches have found Taiwanese followers in the United States. Services are conducted in Mandarin or Taiwanese dialects, and the church serves as a social network for the immigrant community. Buddhism has also gained adherents in recent years.6 Family Confucian teachings about correct relationships are still important for many Chinese American families, even if they have become Christians. Chinese American fami- lies are usually patriarchal. Women are tradi- tionally taught to be unassuming and yielding. They live by the formula of “thrice obeying”: Young girls are submissive to their fathers, wives are subordinate to their husbands, and mothers obey their sons. Children are expected to be quiet, acquiescent, and defer- ential to their elders. Harmony in the family is the ideal, so chil- dren are taught not to fight or cry. Showing emotion is discouraged. Chinese parents may be very strict, and children are commanded to honor the family. Many of these ideas conflict with American ideals of equal rights and free- dom of speech and may lead to intergenera- tional conflict in the Chinese American home. Traditional Health Beliefs and Practices Chinese medicine includes a complex hum- oral system of professional practice by physicians, known as Traditional Chinese Medicine (TCM), as well as correlated folk remedies used by laypersons at home. Health beliefs and practices have developed over generations, incorporating Confucian, Tao- ist, and Buddhist concepts regarding the interdependencies of humans and nature and the need for balance and moderation in life (Figure 11.3). Professional TCM follows texts prepared between approximately 2500 bce and the third century bce, outlining the dynamic equilibrium of forces necessary for health. These include the five elements, or five evolv- ing phases, of fire, earth, metal, water, and wood, each of which may become unbalanced, much as fire consumes wood or wood (as a tree) absorbs the earth. These elements cor- respond with five organs: the heart, spleen, lungs, kidneys, and gallbladder, respectively. Associations with secretions (perspiration, saliva, mucous, spit, and tears); the seasons (summer, late summer, autumn, winter, and spring); colors (red, yellow, white, blue, and green); tastes (bitter, sweet, pungent, salty, and sour); and directions (south, center, west, north, and east); as well as times of day, odors, sounds, and emotions may also occur.7,8,9 This system was further elaborated some- where between the third and sixth centuries by the adoption of Buddhist principles of hot and cold humoral medicine, which were congruent with the Taoist system of yin and yang.10,11 The concept of harmony was refined to include a balance of these opposites; illness develops when disequilibrium occurs. Organs such as the liver, heart, spleen, kidneys, and lungs are yin, as is the outside and the front of the body. The gallbladder, stomach, intes- tines, and bladder are yang, as well as the body Most Chinese believe in feng shui, the way in which a home should be situated and its furnish- ings arranged to promote optimal flow of energy and personal well-being. Chinese physicians were traditionally paid for their services when the client was healthy. Payment stopped if the client became ill. Jade charms are worn to keep children safe, and to bestow health, fertility, long life, power, and wisdom on adults. Figure 11.2 Yin–yang symbol. This symbol represents the fundamental duality of the universe and the balance between the forces of yang (light) and yin (dark). Each force has a little of the other in it (indicated by the dot of the opposite color). © C en ga ge L ea rn in g Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 3 2 4 E A S T A S I A N S surface and the back. Outside forces, such as the seasons, are also defined as yin (winter/ spring) and yang (summer/fall) and illnesses associated with these times may fall into cor- responding categories. Symptoms of disease usually reflect an imbalance between yin and yang. When there is an excess of yang, acne, rashes, conjunc- tivitis, hemorrhoids, constipation, diarrhea, coughing, sore throat, ear infections, fever, or hypertension may occur. Anemia, colds, flu, frequent urination, nausea, shortness of breath, weakness, and weight loss suggest that an excess of yin is the problem. Also associ- ated with yin and yang is the condition of the blood. Weak blood (yin) may develop dur- ing growth or pregnancy, postpartum, and in old age. Treatment includes yang therapies, particularly the intake of herbs and certain foods. The vital force of life is qi and is equated with energy, air, and breath. Qi flows along twelve defined meridians in the body, and some conditions are related to the disruption of qi or to excessive qi. Other types of energy that must be balanced for health include jing, jing, jing sexual or primordial energy, and sheng, spirisheng, spirisheng - tual energy or the essence of consciousness.7,11 Other lesser forces that may influence health include wind (including natural drafts and those resulting from fans, air condition- ers, exposure, or a symptom that rhymes with the Chinese word for wind); poison, which is somewhat related to the Western concept of allergies; and fright, a condition in children that includes listlessness, anorexia, low fever, and crying. Fright is believed to occur when the soul becomes scattered and is mostly lim- ited to Chinese from Taiwan and Hong Kong.3 ▼ Botanical remedies are ▼ Botanical remedies are ▼ usually combined in formu- lary mixtures in traditional Chinese medicine. A fr ic a St ud io /S hu tt er st oc k. co m A major difference between Chinese medi- cine and U.S. biomedicine is the idea that the body and mind are unified, governed by the heart. There is no English word to describe the concept. Emotions are often somaticized, meaning that feelings are related to specific conditions. More than 500 symptoms corre- sponding to emotions have been identified, each characteristic of one or more organs. For example, tou yun (or tou hun) is vertigo, the most common complaint made by Chinese patients worldwide. Dizziness or a confused state of mind indicates significant imbal- ance and serious illness. It is a nonspecific condition thought to originate from anger or anxiety manifested in liver, heart, or kidney dysfunction (if the patient is a young man, too much sexual intercourse or masturba- tion may be believed to be the cause). Liver disorders develop from suppressed hostil- ity. Anger is discouraged in Chinese culture and may accumulate in the liver, causing it to expand and attack other organs. This diag- nosis is common for many gastrointestinal complaints. Generalized stomachaches are believed to be due to eating bitterness in life, often including an inadequate diet when one is young. Anxiety, nervousness, or the stron- ger emotion of fear results in heart palpita- tions.12 Most Chinese prefer this integrated approach to health.13 Many Chinese maintain health through a properly balanced diet, moderation in activi- ties and sleep, and avoidance of sudden imbal- ance caused by forces such as wind. Qi must flow freely and blood must be strengthened through nourishment. For instance, if an indi- vidual is imprudent and celebrates too much by eating excessive yang foods (see the section “Therapeutic Uses of Food”), indigestion or a hangover may occur. Eating yin foods, which are often bland, is the remedy.10 One study of Chinese Americans found that almost all the participants had used TCM in the previ- ous year.13 When home cures are ineffective, advice from a TCM physician may be sought. Diagnosis is made through taking an exten- sive history, and examination of the client, particularly palpitation of pulses and evalu- ation of the tongue. Through this process a medical pattern is detected, in contrast to Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 11 3 2 5 determining a specific disease or condition based on symptoms or laboratory testing. It is the medical pattern that determines the appropriate intervention, not the illness. Treatment for nearly all illness involves the restoration of harmony. Therapy may empha- size dietary and lifestyle changes, or attempt to balance the organs so that emotional bal- ance results. Nearly every visit to the doc- tor results in a botanical remedy, and most medicinal herbs are only available through prescription. For instance, ginseng may be used to fortify qi, and antelope horn can help cool too much yang in the liver.11 Formulary mixtures of five to ten substances are com- mon. Most TCM remedies are prepared as decoctions, taken in a single dose. The client owns the prescription and can reuse it when symptoms occur or share it with family and friends. Acupuncture is another traditional Chinese treatment. It involves the use of nine types of exceptionally thin metal needles inserted at various points on the body where the qi meridians surface. Meridians are considered yin or yang and correspond with specific organs. The needles are placed to facilitate a balanced flow of qi, restoring harmony to the afflicted organ, mostly for symptoms of excess yang. Acupuncture may be performed by a TCM physician or by a specialist. Another, less common, therapy is moxibustion. Small bundles of dried wormwood are heated and carefully applied to certain meridians, usu- ally to balance a yin condition. Moxibustion is particularly used during labor and delivery. Massage or therapeutic exercise is another tra- ditional therapy, found more often in China and rarely in the United States. National board certification for TCM practitioners, which requires three to four years of full-time, postgraduate study at an accredited educational institution, is required in most states. Word-of-mouth recommen- dations are common within the Chinese community. TCM practitioners may use first aid on injuries or broken bones, prescribe herbs, perform acupuncture or moxibustion, or they may diagnose the condition and pro- vide a recommended course of therapy by a specialist in one of these practices. Asians Figure 11.3 Traditional Chinese Medicine (TCM) is a humoral system that incorporates Confucian, Taoist, and Bud- dhist concepts regarding the interdependencies of humans and nature and the need for balance and mod- eration in life. Source: New Yorker Cartoon Bank, www.cartoonbank.com; image ID 121130, originally published in The New Yorker on July 25, 2005. concerned with humoral conditions use TCM (often concurrently with biomedical therapies), and in recent years these practi- tioners have attracted a growing multiethnic clientele. Traditional Food Habits The Chinese eat a wide variety of foods and avoid very few. This may have developed out of necessity, as China has long been plagued with recurrent famine caused by too much or too little rainfall. Chinese cuisine largely reflects the food habits and preferences of the Han people, the largest ethnic group in China, but not to the exclusion of other eth- nic groups’ cuisines. For example, Beijing has a large Muslim population whose restaurants serve lamb, kid, horse meat, and donkey, but no pork. Foreigners have also introduced ingredients that have been incorporated into local cuisines. Some foods now common in China, but not indigenous, are water- melon, tomatoes, bananas, peanuts, and chile peppers. Ingredients and Common Foods Staples Traditional Chinese foods are listed in Table 11.1. In China, numerous fruits, vegetables, and protein items are consumed but few dairy products, whether fresh or fer- mented, are eaten. Grains are the foundation of the diet. Th e N ew Y or ke r C ol le ct io n 20 05 , A le x G re go ry fr om c ar to on ba nk .c om Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 3 2 6 E A S T A S I A N S Group Comments Common Foods Adaptations in the United States Protein Foods Milk/milk products Dairy products are not routinely used in China. Many Chinese are lactose intolerant. Traditional alternative sources of calcium are tofu, calcium-fortified soy milk, small bones in fish and poultry, and dishes in which bones have been dissolved. Cow’s milk, buffalo milk Many Chinese consume dairy products, especially milk and ice cream, some cheese. Some alternative sources of calcium may no longer be used. Meat/poultry/ fish/eggs/ legumes Mostly protein-rich foods are eaten. Beef and pork are usually cut into bite-size pieces before cooking. Fish is preferred fresh and is often prepared whole and divided into portions at the table. Preservation by salting and drying is common. Shrimp and legumes are made into pastes. Meat: beef and lamb (brains, heart, kidneys, liver, tongue, tripe, oxtails); pork (bacon, ham, roasts, pig’s feet, sausage, ears); game meats (e.g., bear, moose) Poultry: chicken, duck, quail, rice birds, squab Fish: bluegill, carp, catfish, cod, dace, fish tripe, herring, king fish, mandarin fish, minnow, mullet, perch, red snapper, river bass, salmon, sea bass, sea bream, sea perch, shad, sole, sturgeon, tuna Eggs: chicken, duck, quail, fresh and preserved Shellfish and other seafood: abalone, clams, conch, crab, jellyfish, lobster, mussels, oysters, periwinkles, prawns, sea cucumbers (sea slugs), shark’s fin, shrimp, squid, turtle, wawa fish (salamander) Legumes: broad beans, cowpeas, horse beans, mung beans, red beans, red kidney beans, split peas, soybeans, white beans, bean paste More meat and poultry are consumed, though some traditional protein sources are still popular Cereals/Grains Wheat is the staple grain in the north, long-grain rice in the south. Fan (cereal or grain) is the primary item of the meal; ts’ai (vegetables and meat or seafood) makes it tastier. Rice is washed before cooking. Buckwheat, corn, millet, rice, sorghum, wheat Chinese Americans eat less fan and more ts’ai. The primary staple remains rice, but more wheat bread is eaten. Fruits/Vegetables Many non-Asian fruits and vegetables are popular. Potatoes, however, are not well accepted. Vegetables are usually cut into bite- size pieces before cooking. Slightly unripe fruit is often served as a dessert. Fruits: apples, bananas, custard apples, coconut, dates, dragon eyes (longan), figs, grapes, kumquats, lily seed, lime, litchi, mango, muskmelon, oranges, papaya, passion fruit, peaches, persimmons, pineapples, plums (fresh and preserved), pomegranates, pomelos, tangerines, watermelon More temperate fruits are consumed. Both fresh fruits and vegetables preferred; seasonal variation dictates the type of produce used. Many vegetables are pickled or preserved. Fruits are often dried or preserved. Vegetables: amaranth, asparagus, bamboo shoots, banana squash, bean sprouts, bitter melon, cassava (tapioca), cauliflower, celery, cabbage (bok choy and napa), chile peppers, Chinese broccoli (gai lan), Chinese long beans, More raw vegetables and salads are eaten. Data on overall consumption trends are contradictory. TA B L E 11.1 Cultural Food Groups: Chinese Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 11 3 2 7 Group Comments Common Foods Adaptations in the United States Chinese mustard (gai choy), gai choy), gai choy chrysanthemum greens, cucumbers, eggplant, flat beans, fuzzy melon, garlic, ginger root, green peppers, kohlrabi, leeks, lettuce, lily blossoms, lily root, lotus root and stems, luffa, dried and fresh mushrooms (black, button, cloud ear, wood ear, enoki, straw, oyster, monkey’s head), mustard root, okra, olives, onions (yellow, scallions, shallots), parsnip, peas, potato, pumpkin, seaweed (agar), snow peas, spinach, taro, tea melon, tomatoes, turnips, water chestnuts, watercress, wax beans, water convolvus, winter melon, yams, yam beans Additional Foods Seasonings Complex, sophisticated seasoning combinations common. Various tastes appreciated, such as the moldy flavor of lily flower buds. Spice and herb preferences distinguish regional cuisines. Anise, bird’s nest, chile sauce, Chinese parsley (cilantro), cinnamon, cloves, cumin, curry powder, five-spice powder (anise, star anise, clove, cinnamon or cassia, Sichuan pepper), fennel, fish sauce, garlic, ginger, golden needles (lily flowers), green onions, hot mustard, mace, monosodium glutamate (MSG), mustard seed, nutmeg, oyster sauce, parsley, pastes (hoisin, sweet flour, brown bean, Sichuan hot beans, sesame seed, shrimp), pepper (black, chile, red, and Sichuan), red dates, sesame seeds (black and white), soy sauce (light and dark), star anise, tangerine skin, turmeric, vinegar Many Chinese restaurants use MSG, but it is not usually used in the home. Nuts/seeds Nuts and seeds are popular snacks and may be colored or flavored. Almonds, apricot kernels, areca nuts, cashews, chestnuts, ginkgo nuts, peanuts, walnuts; sesame seeds, watermelon seeds Beverages In northern China the beverage accompanying the meal often is soup. In the south, it is tea. Alcoholic drinks, usually called wines, are rarely made from grapes. They are either beers or distilled spirits made from starches or fruit. Beer, distilled alcoholic spirits, soup broth, tea Fats/oils Traditionally lard was used if affordable. In recent years, soy, peanut, or corn oil is more common. Bacon fat, butter, lard, corn oil, peanut oil, sesame oil, soybean oil, suet Fat intake increases with consumption of fast foods and snacks Sweeteners Sugar not used in large quantities; many desserts made with bean pastes. Honey, maltose syrup, table sugar (brown and white) Sugar consumption has increased due to increased intake of soft drinks, candy, cakes, and pastries. © C en ga ge L ea rn in g Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 3 2 8 E A S T A S I A N S Rice is essential in the cuisine of southern China, believed to have been introduced to the region from India in the first century bce. It is so common that people in southern China greet each other by asking, “Have you had rice today?” There are approximately 2,500 differ- ent forms of rice, but the Chinese prefer a polished, white, long-grain variety that is not sticky and remains firm after cooking. Short, sticky, glutinous rice is used occasionally, mainly in sweet dishes. Although it is usually steamed, rice can also be made into a por- ridge called congee, eaten for breakfast or as a late-night snack, with vegetables, meat, or fish added for flavor. Congee is also fed to people who are ill. Rice flour is used to make rice sticks, which can be boiled or fried in hot oil. Wheat is also common throughout China, although it is used more often in the north than the south. It is popular as noodles, thin wrappers, dumplings, pancakes, and steamed bread. Noodles are popular in soups, or pan- fried, then topped with meats and vegetables that have been stir-fried separately. Thin, square wheat-flour wrappers are used to make steamed or fried egg rolls with a meat, vegetable, or mixed filling and wontons (in which the wrapper is folded over the filling), served either fried or in soup. Spring rolls, similar to egg rolls, are made with very thin, The custom of throw- ing rice at newlyweds is believed to come from China, where rice is a symbol of fertility. Congee may be eaten at any meal in Hong Kong, where a family version topped with lobster is popular. In Taiwan, con- gee is also consumed throughout the day. One variety served in Chinese American restaurants is “sizzling rice soup.” ▼ Traditional foods of China. Some typical foods include bitter melon, bok choy, Chinese eggplant, ginger root, long beans, lotus root, mushrooms, oyster sauce, pork, long-grain rice, shrimp, soy sauce, and water chestnuts. M ar tin J ac ob s/ G et ty Im ag es round, wheat-flour wrappers. Dumplings can be small steamed bundles made with wontons filled with bits of shrimp, crab, and vegetables (called sui mai) or more substantial, breadlike versions, filled with spiced pork, minced beef, or sweetened bean paste, then baked, steamed, or panfried. Buckwheat is grown in the north and commonly made into noodles. The Chinese eat a variety of animal pro- tein foods. Pork, mutton, chicken, and duck are common in many regions (see “Regional Variations” below). Fish and seafood of all kinds are specialties. Eggs are frequently con- sumed. They are sometimes cooked as thin omelets in which to wrap foods or to add to mixed dishes. However, eggs are most often prepared cooked, then salted and brined, and are particularly popular in southern China.14 Thousand-year-old eggs (also called hundred- year-old, century, and pine flower eggs) are duck or chicken eggs cured for three months in a lime, ash, and salt mixture. The whites become black and gelatinous; the yolks turn greenish. In Taiwan a similar specialty called iron eggs is common. Chicken, pigeon, or quail eggs are cooked repeatedly in soy sauce, tea, or other flavored liquids until they shrink and become very chewy. They are eaten for breakfast and snacks.15 More unusual items include snakes, frogs, turtles, sea cucumbers (also known as sea slugs, shell-less echino- derms related to starfish and sea urchins), and seahorses. The Chinese also raise many kinds of insects for consumption, such as scorpions, which are prepared fried or in soups.16 In China soybeans are known as the poor man’s cow, as they are made into products resembling milk and cheese. Soybeans are transformed into an amazing array of food products that are indispensable in Chinese cooking (see Table 11.2). Other beans are also popular, made into pastes, flour, or even thin, transparent noodles known in the United States as cellophane noodles or bean threads. Chinese cuisine makes extensive use of vegetables. Many are those known in other regions of the world such as asparagus, broc- coli, cabbage, cauliflower, eggplant, green beans, mushrooms, onions, peas, potatoes, radish, and squash. Chinese varieties may differ, however. For instance, leafy bok choy Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 11 3 2 9 and wrinkled napa cabbage are preferred over European types; long beans, small purple egg- plant, gai lan (Chinese broccoli, also called Chinese kale), gai choi (Chinese mustard), and the large white icicle radish are featured in many dishes. One popular squash variety is called a winter melon (when immature it is called fuzzy melon); it is pale green and mild in flavor. Mushrooms of all types, including black mushrooms (a Japanese native also called shiitake), the tiny enoki, grayish oyster mushrooms, straw mushrooms, and dried kinds such as cloud (or wood) ears flavor numerous dishes. Lily buds, snow peas (pea pods), bamboo shoots, chrysanthemum greens, water chestnuts, bitter melon, water convolvulus, and lotus root are other, more distinctively Asian, vegetables found in Chi- nese cuisine. The Chinese eat fresh fruit infrequently, occasionally for a snack or for dessert, and it is preferred slightly unripe or even salted. Chinese dates (jujubes), persimmons, pome- granates, and tangerines are favorites. A few fruits are typically preserved in syrups, such as pungent kumquats, yellow-orange loquats, longans (dragon eyes), and litchis, a tropical fruit with creamy, jelly-like flesh. Traditionally people cooked with lard if they could afford it. In recent years, soy, peanut, or corn oil is more common. Until recently sugar was not used in large quanti- ties; many desserts were made with sweetened bean pastes. Hot soup or tea is the usual beverage accompanying a meal. Tea, used in China for more than 2,000 years, was first cultivated in the Chang Jiang valley and later introduced to western Europe in the seventeenth century. There are three general types of tea: green, black (red), and oolong (black dragon). Green tea is the dried, tender leaves of the tea plant. It brews a yellow, slightly astringent drink. Black tea is toasted, fermented black-colored leaves; it makes a reddish drink. Black tea is commonly drunk in Europe and America. Oolong tea is made from partially fermented leaves and is a Taiwanese specialty. Some teas Bird’s nest soup is often served at special occa- sions. It is made from the cleansed nests of swifts from the South China Sea. The flavor is bland, but the dish is very expensive and is reputed to be an aphrodisiac. TA B L E 11. 2 Common Chinese Soy Bean Products Soy sauce Cooked soybeans that are first fermented and then processed into sauce. The southern Chinese prefer light-colored soy sauce in some dishes over the darker, more opaque kind used in Japanese and some regional Chinese cooking. Soy milk Prepared with soaked soybeans that are first pureed, then filtered, and then boiled to produce a white, milk-like drink. Doufu (tofu) Made by boiling soy milk and then adding gypsum, which causes it to curdle. The excess liquid is pressed from the bean curd, producing a soft or firm, bland, custard-like product. Doufu can be purchased fresh, frozen, smoked, dried, sweetened, or in sheets to make wrapped dishes. Fuyu (sufu) Sometimes called Chinese cheese—bean curd is fermented in brine and 100- proof liquor. The aroma is tangy but the flavor is mild, except when chile peppers are added to the process. Black bean sauce Cooked fermented soybeans preserved with salt and ginger. Black beans are usually added as a flavoring in dishes. Brown bean sauce Similar to black bean sauce, but made with yellow soy beans. Sweet bean sauce Similar to soy sauce but with reduced spicing and added sugar. It is common in northern Chinese cooking. Hoisin sauce Thick, brownish-red sweet-and-sour sauce that combines fermented soybeans, flour, sugar, water, spices, and garlic with chiles—often used in southern Chinese cuisine. Oyster sauce Thick brown sauce prepared from oysters, soybeans, and brine that is also used in southern Chinese fare. Chile bean paste Very hot, thick paste made from brown bean sauce spiced with mashed chile peppers and vinegar. A favorite in Sichuan cuisine. © C en ga ge L ea rn in g Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 3 3 0 E A S T A S I A N S in China are flavored with fruits or flow- ers, such as black tea with litchis, or orange blossoms, or oolong with jasmine. Other infusions of fruits or flowers are called tea, including longan and chrysanthemum. Pearl tea, or bubble tea, made with chewy, pea-size balls of tapioca that are sucked up through large straws, was also created in Taiwan and has become popular with Chinese youth worldwide. Chinese alcoholic drinks are often called wines, but they are not usually made from grapes.17 They are typically distilled alco- hols made from grains or from fruit, such as plums. A few examples are bamboo leaf-green (95 proof ), fen (made from rice, 130 proof ), hua diao (yellow rice wine), mou tai (made from sorghum, 110 proof ), and red rice wine. Beer is also very popular. Most Chinese food is cooked, and very little raw food, except fruit, is eaten. Cooked foods may be eaten cold. Common cooking methods maximize the limited fuel available and include stir-frying, steaming, deep-fat fry- ing, simmering, and roasting. In stir-frying, foods are cut into uniform, bite-size pieces and quickly cooked in a wok (a hemispheri- cal shell of iron or steel) in which oil has been heated. The wok is placed over a gas burner or in a metal ring placed over an electric burner. Food can also be steamed in the wok. Bam- boo containers, perforated on the bottom, are stacked in a wok containing boiling water and fitted with a domed cover. Roasted food is usually bought from a commercial shop, not prepared in the home. The Chinese usually strive to obtain the freshest ingredients for their meals, and in most American Chinatowns it is common to find markets that sell live animals and fish. However, because of seasonal availability and geographic distances, many Chinese foods are preserved by drying or pickling. Regional Variations China is usually divided into five culinary regions characterized by flavor or into two areas (northern and south- ern) based on climate and the availability of foodstuffs. In recent years, however, regional differences have diminished due to increased global influences, particularly television.18 Northern This area includes the Shandong and Honan regions of Chinese cooking. The Shandong area (Beijing is sometimes included in this area, sometimes considered a third division of northern cooking) is famous for Peking duck and mu shu pork, both of which are eaten wrapped in Mandarin wheat pan- cakes topped with hoisin sauce. Honan, south of Beijing, is known for its sweet-and-sour freshwater fish, made from whole carp caught in the Huang River. Much of the north is bor- dered by Mongolia, whose people eat mainly mutton. Grilling or barbecuing is a common way of preparing meat in this area. One specialty is the Mongolian hot pot, featuring sliced meats and vegetables cooked at the table in a pot of broth simmering over a charcoal brazier. The food is eaten first, and the broth is consumed as a beverage afterward. (See also Exploring Global Cuisine—Mongolian Fare.) Northern China has a cool climate, limiting the amount and type of food produced. Tra- ditionally, foods were often preserved, result- ing in a preference for salty flavors. In general, its staples are millet, sorghum, and soybeans. Winter vegetables such as cabbage, turnips, and onions are common. A delicacy from this area is braised bear paw. Hot, clear soup is the beverage that usually accompanies a meal. Southern Southern China is divided into three culinary areas: Sichuan-Hunan, Yunnan, and Cantonese (with Fukien and Hakka regional specialties). Sichuan-Hunan (some English translations still use the term Szechuan or Szechwan), which is an inland region, features fare distinguished by the use of chiles, garlic, and the Sichuan pepper fagara. Typical dishes include hot and sour soup, camphor and tea- smoked duck, and an oily walnut paste and sugar dessert that may be related to the nut halvah of the Middle East. Yunnan cooking is distinctive in its use of dairy products, such as yogurt, fried milk curd, and cheese. Dishes are often hot and spicy, and some of the best ham and head cheese in China are found in this area. Cantonese cooking is probably the most familiar to Americans, because the majority of Chinese restaurants in the United States serve In some regions, two lon- gans or litchis are placed under the pillows of newlyweds because their names sound like the words “to have children quickly.”18 In China, a marriage is consummated when the new in-laws officially accept a cup of tea from the bride. If the groom dies before the wedding, the bride-to-be is said to have “spilled her tea.” Unlike northern or south- ern Chinese cooking, Taiwanese fare makes ample use of herbs such as basil and pars- ley. Vodka is a popular alcoholic beverage; the most popular brand is named for the infamous Mongolian ruler, Ghengis Khan.10 Dumplings shaped like animals, such as birds or frogs, are specialties in Xian. A dim sum ban- quet may feature several dozen varieties. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 11 3 3 1 Cantonese-style food. It is characterized by stir-fried dishes, seafood (fresh and dried or salted), delicate thickened sauces, and the use of vegetable oil instead of lard. The Cantonese are known for dim sum (“small bites,” such as sui mai, pork ribs, meatballs, and other tid- bits) served with tea. The staple foods of the south are rice and soybeans. As in the north, a variety of vegetables from the cabbage family are used, as well as garlic, melon, onions, peas, green beans, squashes, and a range of rootlike crops, such as taro, water chestnuts, and lotus root. Southern cooking uses mushrooms of many types to enhance the flavor of the foods and takes advantage of an abundance of fruits and nuts. Fish, both fresh and saltwater, are popular. Also important are poultry and eggs. Pork is the preferred meat. Tea is the beverage served with meals. Along the coast, Fukien provincial fare includes numerous seafood dishes and clear broths. Paper-wrapped foods and egg rolls are thought to have originated there. In the city of Shanghai, chefs specialize in new food cre- ations and elaborate garnishes. Red foods are also a specialty due to the use of red wine paste (a sediment remaining after the fermentation of rice wine) on pork, on poultry, in soups, and even in dumpling dough.19 A southern regional specialty is Hakka cuisine, sometimes called the soul food of southern China. The Hakkas fled to the south in the fourth century bce when the Mongols invaded the north. They remained an insular ethnic group, preserving their traditional lan- guage, dress, and foods. Their fare is hearty and robust, featuring dishes made with red rice wine and pungent seasonings, cooked for a lengthy time, often in clay pots. Salt-baked chicken, greens simmered with pork fat, and meat-stuffed doufu are examples. Meal Composition and Cycle Daily Patterns The Chinese customarily eat three meals per day, plus numerous snacks. Breakfast often includes the hot rice or millet porridge, congee, which in southern China may be seasoned with small amounts of meat or fish. In northern China hot steamed bread, deep-fried crullers, dumplings, or noodles are served for breakfast. In Taiwan both south- ern- and northern-style breakfasts are popu- lar. In urban areas lunch is a smaller version of dinner, including soup, a rice or wheat dish, The Mongolians once ruled an empire that stretched from China to Europe. Tthat stretched from China to Europe. T In more recent times, it has been colonized by Russia and China. Today, it is an inde- pendent nation reestablishing its cultural identity through shared language, customs, and cuisine. Historically, Mongolians consumed red foods (meat) and white foods (dairy), and this tradition continues today with the addition of some grain products. Meats, especially mut- ton, goat, and beef, are favorites (camel meat is eaten when available, though it is banned in some areas). Meat is enjoyed barbecued on a grill or over charcoal in a specially designed hot pot that sits on the table. It is also added to soups, stuffed into pancakes, and served on sesame seed buns.191 Dairy foods are numerous, prepared from cow, sheep, goat, or camel’s milk. There are three types of butter (liquid, yellow, and white), a type of milk doufu, sour milk (simi- lar to yogurt), milk leather (made from the film skimmed off boiled milk and air-dried), and fresh cheese. Milk is added to tea, called Mongolian tea, sometimes with a little salt or fried millet.192 Cheese is mixed with sugar and flour and then baked, to make a dessert known as milk pie. Kumys, a wine distilled from fermented milk (traditionally mare’s milk), is a Mongolian specialty and consumed at many occasions. Millet is the staple grain in Mongolia. It is cooked like a porridge or roasted until it pops like popcorn. Flour is made from millet, buck- wheat, or wheat and cooked as fried pancakes or steamed flat breads. Tea is consumed at every meal and with snacks. Three meals a day are typical, consumed with the fingers. Special occasions include Lunar New Years and the Naadam festival, a three-day event featuring wrestling, archery, and horse races. E X P L O R I N G G L O B A L C U I S I N E Mongolian Fare Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 3 3 2 E A S T A S I A N S vegetables, and fish or meat. Sliced fruit may be offered at the end of the meal. Although the Chinese are receptive to all types of food, the composition of a meal is governed by specific rules—a balance between yin and yang foods and the proper amounts of fan and cai. Fan includes all foods made from grains, such as steamed rice, noodles, porridge, pancakes, or dumplings, which are served in a separate bowl to each diner. Cai includes cooked meats and vegeta- bles, which are shared from bowls set in the center of the table. Fan is the primary item in a meal; cai helps people eat the grain only by making the meal tastier. A meal is not com- plete unless it contains fan, but it does not have to contain cai. At a banquet the opposite is true. An elaborate meal must contain cai, but the fan is usually an afterthought and may not be eaten. Street stalls and tea houses provide snacks and small meals when away from home. Although restaurants were traditionally uncommon in rural areas, today they are found throughout the nation. The Chinese all-you-can-eat buffet, which originated in the United States, is now found in some regions. Other American restaurant ideas that have made their way to China include fast-food franchises and food courts.14 Etiquette The traditional eating utensils are chopsticks and a porcelain spoon used for soup. Teacups are always made out of porcelain, as are rice bowls. Few foods are eaten with the fingers, though that is chang- ing somewhat in China today, where it is sometimes acceptable to pick up wrapped or stuffed items, such as dumplings.20 All courses of a meal are traditionally served at once. Each place setting includes a bowl of rice or noodles, and each diner then takes what is desired from the communal serving plates. At the meal all diners should take equal amounts of the cai dishes, and younger din- ers wait to eat until their elders have started; it is rude to reject food. It is also considered bad manners to eat rice or noodles with the bowl resting on the table; instead, it should be raised to the mouth. It is rude to pick at your food or to lick your chopsticks. Laying your chopsticks across the top of the rice bowl or dropping them brings bad luck. It is also improper to stick chopsticks straight up in a rice bowl because in some areas this sym- bolizes an offering to the dead. Any bones or other debris should be placed on the small plate at each place setting, or on the table next to the rice bowl. Proper Chinese behavior at the table was first outlined over 4,000 years ago, and many practices remain unchanged.14 Rules include not making noises while eating (except when consuming soup, when slurping facilitates cooling the soup and expresses pleasure), not grabbing food, not eating quickly, not putting food back on the communal plate after tast- ing it, and not picking one’s teeth. Beverages, such as tea, should be served to others at the table before pouring for one’s self, and the cups should not be filled to the brim. Both hands are used to offer a cup of tea, and the cup should be taken with both hands as well. Wine and other alcoholic drinks should not be consumed alone, and when the toast gam- bei (“bottoms up”) is made, everyone at the table drains his or her glass. Chopsticks were likely invented as an extension of the fingers. They are made from bamboo, ivory, or plastic. Chopsticks are used in most countries that have been influenced by China, including Japan (where the chopsticks are shorter and have rounded rather than squared sides and more pointed tips) and Korea (where the chop- sticks are typically made of metal, the same length as the Japanese type, but flatter). Chopsticks are found frequently in Viet- nam (the Chinese type), though forks, spoons, and fingers are also commonly used. Other Southeast Asian cultures use chop- sticks only occasionally, mostly for rice or noodles. S A M P L E M E N U Cantonese Dim Sum S pr in g R olls a,b or F r ie d W on t on s a,b Har gau (S h r imp D umplin gs ) a,b Sui mai (P or k D umplin gs ) a,b Ch ar s iu bao (S t e ame d BBQ Bun s ) a,b E g g C us tar d T ar tle ts a,b Jas min e T e a or Ch r y s an th e m um T e a aSimonds, N. 1994. Classic Chinese cuisine. Boston: Houghton Mifflin. bAbout: Chinese Cuisine at http://chinesefood.about.com/od/diningout/p/dim_sum.htm Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 11 3 3 3 Though strict rules regarding dining behavior are observed in China, it is not uncommon to play games at the table during a meal.14 This is especially true at banquets, with guests joining and leaving the game as they please. Multiple conversations may take place at once, and interruptions are frequent. It is considered polite to compliment the host throughout the meal on the deliciousness of the food and on his or her good taste and wisdom.21 Special Occasions Traditionally, the Chinese week did not include a day of rest. Conse- quently, there were numerous feasts to break up the continuous workdays. Chinese festival days do not fall on the same day each year because their calendar is lunar. Celebrations are traditionally yang occasions because heat symbolizes activity, noise, and excitement in China.10 Yang foods, such as meats, fried dishes, and alcoholic beverages, are featured at festive banquets (see the “Therapeutic Uses of Food” section). Most Chinese homes are small and unsuited to entertaining, so spe- cial meals with guests are generally held at restaurants.14 The most important festival is New Year’s, which can fall anytime from the end of Janu- ary to the end of February. Traditionally the New Year was a time to settle old debts and to honor ancestors, parents, and elders. The New Year holiday season begins on the eve- ning of the twenty-third day of the last lunar month of the year. At that time the Kitchen God, whose picture hangs in the kitchen and who sees and hears everything in the house, flies upward to make his annual report on the family to the Jade Emperor. To ensure that his report will be good, the family smears his lips with honey or sweet rice before they burn his picture. A new picture of the Kitchen God is placed in the kitchen on New Year’s Eve. Food preparation must be completed on New Year’s Eve, as knives cannot be used on the first day of the year because they might “cut” luck. Deep-fried dumplings, made from glutinous rice and filled with sweetmeats, and steamed turnip and rice flour puddings, are usually included in the New Year’s Day meal. During the New Year festivities, only good omens are permitted and unlucky-sounding words are not uttered. Foods that sound like lucky words, such as tangerine (good fortune), fish (surplus), chicken (good fortune), chest- nuts (profit), and doufu (fu (fu ( means “riches”), are eaten. Friends and relatives visit each other during the first ten days of the new year, and good wishes, presents, and food are exchanged. Children receive money in small red envelopes. Traditionally the Feast of Lan- terns, the fifteenth day of the first month, ends the New Year’s season and is marked by the dragon dancing in the streets and exploding firecrackers to scare away evil spirits. Ch’ing Ming, the chief spring festival, falls Ch’ing Ming, the chief spring festival, falls Ch’ing Ming 106 days after the winter solstice. Families The Chinese-controlled province of Tibet has a unique fare due to the isolation provided by its locale in the Himalayan Mountains. The foundation of the diet is zampa, a toasted flour produced from bar- ley or buckwheat. It is traditionally mixed with the butter obtained from yak, cow, or sheep milk (called “crispy oil”), sugar, milk or cream, and sometimes tea to make flat- tened balls consumed with tea or soup. The zampa can also be used to make momos, a Tibetan dumpling filled with meat. Yak and mutton are common, but most Tibetans who are Buddhist do not eat pork, poultry, or fish.25 Dairy products are also prevalent. Butter-tea, made by churning crispy oil, milk, and salt with brewed tea, is consumed throughout the day. Sour milk, milk solids preserved from the crispy oil process, and the milk film skimmed from boiled milk and then dried are all consumed. Cabbage, radishes, onions, garlic, leeks, and potatoes are available. Wine, made from barley or buckwheat, is served at special occasions. E X P L O R I N G G L O B A L C U I S I N E Tibetan Fare Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 3 3 4 E A S T A S I A N S customarily go to the cemetery and tend the graves of their relatives. Food is symbolically fed to the dead and then later eaten by the family. Sweets and alcoholic beverages are popular offerings. Duan wu, the Dragon Boat Festival, is held on the fifteenth day of the fifth month to commemorate the drowning death of a famous third-century bce poet. A boat race and special dumplings are traditional. The Moon Festival occurs at the end of Sep- tember on a full moon (the fifteenth day of the eighth lunar month). Because the moon is a yin symbol, this festival was traditionally for women, but today it also symbolizes the togetherness of the family. It is sometimes called the harvest festival or moon’s birthday. Large round cakes filled with spices, nuts, fruit, or red bean paste, called moon cakes, are typically eaten during this event. Therapeutic Uses of Food Most Chinese believe eating the proper bal- ance of yin and yang foods is necessary to assure physical and emotional harmony and to strengthen the body against disease (see Chapter 1). Extra care should be taken with children’s diets because they are more suscep- tible to imbalance. Hot foods generally include those high in calories, cooked in oil, and irritating to the mouth and those that are red, orange, or yel- low in color. Examples include most meats, eggs, chile peppers, tomatoes, eggplant, per- simmons, pomegranates, onions, leeks, garlic, ginger, and alcoholic beverages. Cold foods are often low in calories, raw or boiled/steamed, soothing, and green or white in color. Many vegetables and fruits are considered cold items, as are some legumes. Pork, duck, crab, clams, shrimp, snake meat, and honey also are classified as cold in some regions. Staples, such as boiled rice and noodles, and other commonly eaten foods, such as soy sauce and red or black tea, are typically placed in a third, neutral category.10,14,22 Some food preparations can make foods hotter or colder by the infusion or removal of heat. Foods classified as yin or yang vary from region to region. Acculturated Chinese Americans may be uncertain about some categorizations and thus identify many foods as neutral. Typically, hot foods are eaten in the win- ter by menstruating women and for fatigue. Pregnancy is considered a cold condition, and birth is a dangerously cooling expe- rience. Postpartum women often remain indoors and eat hot foods, such as chicken fried in sesame oil and pig’s feet simmered in vinegar, for four to six weeks after delivery.23 This period is known as tso yueh-tzu, “doing the month.” In addition to eating warming items, raw and cooling foods are avoided, as is contact with cold air, wind, and water (bathing in hot water with ginger in it is per- mitted after a few days). Other conditions caused by too much yin and that respond to eating more yang foods include colds, flu, nausea, anemia, frequent urination, shortness of breath, weakness, and unexplained weight loss. It is also believed that as a person grows older, the body cools off and more hot foods should be eaten. Conditions due to excessive yang that improve with an increase in yin food intake include constipation, diarrhea, hemorrhoids, coughing, sore throat, fever, skin problems, conjunctivitis, earaches, and hypertension. Cool foods are consumed in the summer, for dry lips, and to relieve irritability. In addition to yin and yang, some foods are believed to affect the blood or promote wound healing and are labeled pu, or bo, meaning “strengthening.” This classification is separate from the concept of yin and yang but often used in conjunction with it; most strengthening foods are also categorized as hot. The yin condition of weak blood (most associated with pregnancy, postpartum, and surgery) is treated with specific hot items such as protein-rich soups made with chicken, pork liver, eggs, pig’s feet, or oxtail. Other health- promoting foods identified by Chinese Amer- icans include royal jelly (made from honey), bee pollen, lin chih (edible fungus), rattlesnake meat, dog meat, roasted beetles, barley juice, garlic, dong gwai (angelica, a celery-like herb), fruit juice, and milk. However, it is believed that too many of certain yang items can cause the blood to thin, and these foods are avoided for conditions such as hypertension.9,10,22,24 Ginseng is one of the better known health-promoting Chinese foods. It is made The New Year’s dragon dance and firecrackers are thought to inhibit the yin element and promote the yang forces. Red, the color of yang, is used throughout the New Year’s season. Eating crab and persim- mons together is one food taboo maintained by some Chinese Ameri- cans elders because these foods represent extreme hot and extreme cold and are considered to be poisonous if mixed. In 1718, a Jesuit mission- ary in Quebec discovered an American species of ginseng that is nearly identical to the Chinese variety. Growing demand in China led many Ameri- cans, including Daniel Boone, to hunt the root for export. According to the Chi- nese, a child is one year old at birth and becomes two years old after the New Year. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 11 3 3 5 from an herb (genus Panax) found in Asia and the Americas. The root is boiled until only a sediment remains, then powdered for use in teas and broths. Ginseng reput- edly cures cancer, rheumatism, diabetes, sexual dysfunctions, and complaints asso- ciated with aging. It is most often used as a restorative tonic. Taro root is also thought to have therapeutic properties, such as improving eyesight, curing vaginal dis- charge, reducing weakness, and promoting multiple births; it will also bring good luck if eaten on the fourth day of the first lunar month.25 Bitter orange is used to alleviate bloating and constipation. Guava, which has some hypoglycemic properties, is used for diabetes.26 Other popular remedies include deer antlers, rhinoceros horns, and pulverized sea horses.27 The concept “like cures like” (sympathy healing) is seen in many food cures for specific illnesses.28 Walnuts (which resemble brains) are eaten as a remedy for headaches in Hong Kong and to increase intelligence in China.14 Red jujubes may be consumed for strengthen- ing blood, soups made with bones are used for treating broken bones, and male genital organs from sea otters, deer, or other ani- mals are eaten to cure impotence. Chinese foods and herbs, such as such as “bird nest” and “glucose drink”29 are also used in the infant weaning diet. The weaning diet is considered the semisolid food that is added to a child’s diet of formula or breast milk to increase appetite, balance the yin and yang system, restore qi, or treat diarrhea.30 Based on some traditional beliefs, orange skin is believed to enhance the taste and flavor of the soups and contributes to the ying–yang balance. Pork bone is believed to add calcium into the soup and is needed for growth. Moreover, some Chinese believes that alligator meats will benefit the respira- tory system.31 Some food taboos have been noted during pregnancy. Soy sauce may be avoided to pre- vent dark skin, and iron supplements may not be taken because they are thought to harden the baby’s bones and make birth difficult. Shellfish may also be shunned for the same reason.32 Contemporary Food Habits in the United States Adaptations of Food Habits Generally speaking, changes in the eating habits of Chinese Americans correlate with increased length of stay in the United States, particularly in subsequent generations. Din- ner often remains the most traditionally Chinese meal, whereas breakfast, lunch, and snacks tend to become more Americanized. Younger persons are also more likely than their elders to accept U.S. fare.33 Ingredients and Common Foods Most Amer- icans of Chinese descent regularly consume several Chinese foods, such as rice, pork, sea- food, soup broth, soybean products, cooked vegetables, tea, and fruit.34,35 One preliminary study suggests that the majority (88 percent) of foreign-born immigrants prefer Chinese fare at home, although younger respondents (aged twenty to thirty-four) expressed prefer- ence for American foods.24 Meat and poultry intake increases, while some traditional pro- tein items like pig’s liver and bone marrow soup often remain popular. Greater consump- tion of protein foods, in addition to increased intake of fast foods, soft drinks, candy, and pastries, results in higher fat and sugar intake among more acculturated Chinese Americans. The impact of acculturation on fruit and vegetable intake is less clear. Traditional fruits and vegetables may be replaced by more commonly available American items, such as potatoes, lettuce, apples, peaches, and watermelon.24,36 Some studies have found that greater fruit and vegetable intake is associ- ated with acculturation, education level, and income.37,38 Among families, however, data indicate that pressure to maintain a tradi- tional diet by elders living at home results in a higher intake of fruits and vegetables among all members.39 Even though milk is not a familiar item in the typical Chinese diet, several studies suggest that milk is consumed by nearly half to three-quarters of Chinese Americans in the United States.24,38,40 Cheese, yogurt, and ice cream have also been found to be well accepted.41 Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 3 3 6 E A S T A S I A N S One study found that dietary variety increased after immigration to the United States, and another noted that U.S.-born Chi- nese women have a more varied diet than Chinese American women who were foreign born.37,42 Respondents ate more breads, cere- als, dairy foods, meats, vegetables, and ethnic items, such as Italian and Mexican foods. In another study acculturation was significantly associated with improved dietary variety but with lower dietary moderation.43 Meal Composition Skipping meals and increased snacking have been reported in Asian students and in Chinese American and Chinese Canadian women.36,37,44 Surveys of Chinese in North America suggest that tra- ditional foods are the choice of older, less acculturated adults, and their preferences sometimes influence household meals.35,39,45 Lunches and dinners may consist mainly of Chinese-style foods, while breakfasts are more variable. Many Chinese Americans attempt to balance hot and cold items in their diets. Other studies suggest that the use of yin and yang in the diet may diminish over time and that Chinese Americans may prac- tice some aspects of it but without knowl- edge as to why certain food combinations are preferred.8,9,14,43,45 Stir-frying, simmering, and steaming remain the favored cooking methods.24,46 In one study, more acculturated respondents found cooking Chinese meals was inconvenient.39 Americans of Chinese descent usually celebrate the major Chinese holidays of New Year’s and the Moon Festival with traditional foods. Chinese American Christians some- times combine the spring festival of Ch’ing Ming with Easter festivities. In addition, some Ming with Easter festivities. In addition, some Ming Chinese Americans recognize the founding of the People’s Republic of China (mainland China) on October 1 (on the solar calendar) or the establishment of the Republic of China (Taiwan) on October 10 with cultural perfor- mances and banquets. Nutritional Status Nutritional Intake The traditional Chinese diet is low in fat and dairy products and high in complex carbohydrates and sodium. As length of stay and the number of genera- tions living in the United States increase, the diet becomes more like the majority Ameri- can diet—higher in fat, protein, sugar, and cholesterol, and lower in complex carbohy- drates. Research on women in the United States and Canada reported even less accultur- ated respondents consumed milk, ate cheese, ate fast foods, and snacked regularly,38 and another study of women including foreign- born Chinese Americans, U.S.-born Chinese Americans, and white Americans revealed that all three groups consumed more than recommended levels of fat in their diets, sug- gesting that some changes in food consump- tion may occur very quickly.40 The U.S.-born cohort also demonstrated high levels of nutri- tion knowledge, and their diet contained a higher concentration of nutrients than either the foreign-born Chinese Americans or the white Americans.42,43 Some Americans of Chinese descent con- tinue to avoid fresh dairy products because of lactose intolerance, which may be found in as many as 75 percent of Asians. Low calcium intake has been reported in some samples.40,47 Alternative calcium sources are bean curd, soy milk—if fortified with calcium—and soups or condiments made with vinegar in which bones have been partially dissolved. However, as noted previously, many Chinese Americans do consume milk, cheese, and yogurt, as well as leafy green vegetables, and calcium defi- ciency should not be presumed. Low vitamin A and C intake has been observed in some Americans of Chinese descent, but iron intake is satisfactory, perhaps due in part to the use of iron-containing cooking tools, such as woks.46 Obesity and overweight are found to be low among Chinese Americans.48,49,50,51 In one national survey Chinese were found to have very low median body mass indexes (BMIs) when compared to the general U.S. population. However, median BMI and pro- portion obese went up significantly for U.S.- born subjects when compared to foreign-born subjects and with acculturation.48,52 Some Chinese Americans feel pressured to overeat due to traditional Chinese eating behavior.53 In a study of Chinese American children, A study of Asian college students found fast foods and sweet and salty snacks very popular. Intake of fats, sweets, dairy products, and fruit increased, while intake of meats and vegetables decreased.44 Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 11 3 3 7 33 percent were reported overweight (BMI $85th percentile); however, the mother’s degree of acculturation was found inversely associated with risk.54,55 Concerns that overweight and obesity may become problematic in this popula- tion as demographics change over time are as yet unconfirmed. Research on anthro- pometric measures indicates that BMI and waste circumferences underestimate obesity in Chinese Americans.56,57 Chinese heritage was found to modify waist circumference measurements and metabolic risk factors.58 Calculated energy requirements may differ as well. Predictive equations for basal metabolic rate (BMR) and for resting energy expendi- ture (REE) are found to overestimate BMR and REE in adult Chinese Americans. There is concern in some Asian nations about the increasing incidence of eating disorders in young women.59,60,61 The percentage of type 2 diabetes in U.S Asians is 20 percent higher than in whites, but the percentage of overweight or obese was lower than all other Asians and non- Hispanic whites, although Asians are more likely than whites to develop the condition at a lower BMI.49,62,63,64,85 Further, data suggest that weight gain associated with incidence of type 2 diabetes was particularly detrimental in Asians—each 5-kilogram gain increased risk by 84 percent, nearly double the increase found in any other ethnic group in the study. Data on diabetes specific to Chinese Americans are sparse, but these pan-Asian studies suggest type 2 diabetes may become a significant health issue if overweight and obesity rates grow. It is generally assumed that many Chinese eat a diet high in sodium, which may contrib- ute to high blood pressure. Hypertension rates among Chinese Americans are lower than for whites, but 19 percent of adult Chinese Americans have hypertension.65 One study found Chinese subjects are 30 percent more likely than whites to have high blood pressure when adjusted for age, BMI, prevalence of dia- betes, and smoking.66 Asians are 20 percent more likely to suffer a stroke than whites.65 Another study found that when compared to whites, Chinese Americans who suffered from stroke had higher risk profiles, including his- tory of hypertension, history of diabetes, and higher levels of blood lipids and glucose.67,68 Hypertension is considered a yang condition and is often treated by the consumption of yin foods.69 Asian American adults are less likely than white adults to have heart disease and they are less likely to die from heart disease.65 How- ever, cardiovascular disease rates in China increased 60 percent between 1993 and 2003, paralleling increased rates of overweight and obesity, diabetes, and hypertension.70,87 Preva- lence in the United States may also increase with these changes in first-generation immi- grants, as well as with possible changes in sub- sequent generations. Cancer risk is higher in Asians than non- Hispanic whites for stomach, liver, and intra- hepatic bile duct and prostate cancer.71,72 Liver cancer is the result of contracting the hepatitis B virus, and Asians are 5.5 times more likely to develop chronic hepatitis B, as compared to whites.73 Risk of liver cancer should decrease with inoculation of the vaccine now available to prevent hepatitis B infection. The number of colorectal and breast cancer incidences has increased with length of stay in the United States, but is still less than for non-Hispanic white population.72,74 Inadequate preventive screenings and dietary changes, including lower intake of protective foods (e.g., soybean products) and higher intake of saturated fats, are thought to be factors for these increased cancer risks.54,75,76,77 Infant mortality rates for Asians are lower than for non-Hispanic whites, and Chinese were the least likely among Asians to have low- birth-weight children.78,79 Breast-feeding is reportedly common in China, and 65 percent of Chinese women in Australia breast-fed their infants in one study.27,80,81 Asians accounted for 28 percent of reported tuberculosis cases in the United States in 2010, while Asians born outside the United States represented 44 percent of the tuberculosis cases in foreign-born per- sons.82 Also noted are higher rates of certain inherited conditions, including thalassemia and glucose-6-phosphate dehydrogenase deficiency.84 Asian American women have the highest life expectancy (85.8 years) of any other ethnic group in the United States. Life expectancy varies among Asian subgroups: Filipino (81.5 years), Japanese (84.5 years), and Chinese women (86.1 years).202 A study of accultura- tion and diet in Chinese American women found that Chinese-language newspapers and friends were primary sources of nutrition information.36 Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 3 3 8 E A S T A S I A N S Counseling Americans of Chinese descent accept personal responsibility for their health; keeping healthy is considered an obligation to family and society. However, biomedical health care is underutilized. Language barriers are thought to be one issue. Over half of Chinese Americans speak English at home, and nearly 50 percent report that they speak English less than “very well.”1 Low income, long work hours, and inconvenient locations are other reasons believed to limit access. Lack of health care insurance is another factor, which may be due to expense, or because purchasing insur- ance is sometimes seen as inviting death.12,83,88 Mistrust of biomedicine, especially its possible side effects, is also found.12,86 The concept of preventive checkups is unfamiliar to many Chinese Americans.89,90 Perhaps because Chinese Americans fre- quently believe that hospitals are where a person goes to die, hospitalization rates of Chinese Americans are lower than for any other ethnic group in America. Blood tests, thought to permanently diminish the blood supply, are of particular concern to some Chi- nese clients, who may avoid all biomedical health care for this reason. Some Chinese Americans favor biomedi- cal providers of Chinese heritage, citing common language, mutual sympathy, and flexible appointments (many Chinese are polychronic).12 Effective treatment is the primary concern for most clients, however. Preferred communication style is formal and includes unrushed dialogue (focusing on time is considered offensive), detailed explanation of the origins and symptoms of any condition in understandable terms, simple treatment, and a positive outlook. Chinese patients con- sider it important to maintain hope. When possible, terminal illness should be discussed first with family members to determine how and when a client is informed. Medical confi- dentiality is not widely practiced.2 The Chinese have a quiet conversational approach, especially with strangers and acquaintances. Some speakers may pause during conversation as a sign of thoughtful- ness. Interruptions should always be avoided. Many Chinese avoid confrontation and may initially say yes to questions that require a positive or negative response. Asking ques- tions can be interpreted as disrespect, a sign that the person speaking is being unclear. Surprise or discomfort may be expressed by quickly and noisily sucking in air.91 If a person is offended, he or she may become very direct and even loud in expressing anger. Conversa- tions between friends or family members are often animated.21 Eye contact is made briefly during introductions, but indirect eye contact is standard. Direct eye contact may be inter- preted as confrontational. Elder or less acculturated Americans of Chinese descent may show deference to authority by means of acceptance and sub- mission. In the hospital setting, patients are often silent rather than voicing complaints; providers should not necessarily accept this as compliance but should actively seek infor- mation about patient satisfaction. Emotional displays are considered immature, but most Chinese patients are willing to discuss feelings in conjunction with somatic symptoms (see the section “Traditional Health Beliefs and Practices”).83 The traditional Chinese greeting is a nod or a slight bow from the waist while holding palms together near the chest, often with- out a smile. Traditionally, surnames come first, followed by given names, and women do not customarily take their husband’s last name when married, so surnames may differ within the same family. Use of any titles dem- onstrates respect. Touching between strang- ers and acquaintances is uncommon.87 Even handshaking may be inappropriate (wait for the extended hand, especially with women), except for Westernized Chinese Americans and people from Hong Kong. Hugging, kiss- ing, and back patting should be avoided. Good posture is expected, and slouching or putting one’s feet on a desk is considered rude. Personal space is typically farther apart than in Western cultures.21 Chinese American women may be very modest, especially regarding touching. Tradi- tionally, Chinese women were never touched by male health care providers (today, more than 90 percent of obstetricians and gyne- cologists in China are women). Symptoms would be discussed by pointing to an alabaster Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 11 3 3 9 figurine.44 If a male must do an examination, a formal, polite attitude, explanations of all procedures, and avoidance of tension-reliev- ing jokes or comments will help the client feel more at ease.2 Furthermore, within the family, sons receive more concern and attention over minor symptoms than daughters. Women, consequently, may believe that their com- plaints do not warrant care. Researchers are unsure how many Chinese Americans use Traditional Chinese Medi- cine.92,93,94 The majority are believed to first self-diagnose and self-prescribe at home before seeking outside care, although the reasons why certain foods or medications are consumed for an illness (particularly the complementary use of yin and yang) are often lost through acculturation.8,45 Biomedicine is completely accepted by many Chinese Amer- icans; one unpublished study found that 88 percent of foreign-born Chinese American subjects preferred biomedical care for the treatment of illness.24 Others consider bio- medicine best in the treatment of acute symp- toms, and TCM best for chronic conditions.12 For example, a client with type 2 diabetes may consult a biomedical physician regard- ing symptoms but, when he or she finds that no immediate cure is offered, may seek a TCM doctor to restore balance to the body and treat the actual cause of the disease.95 Practitioners of TCM are often con- sulted concurrently with biomedical care in an effort to maximize the chances of a cure. Few conflicts in therapies have been identi- fied, although the active agents in most herbal medicines remain unidentified in biomedical terms. It is possible that a formulary prepara- tion might be additive with a prescribed medi- cation, producing excessive response, such as taking guava juice with hypoglycemics. Con- versely, a TCM product taken for a different condition might counteract a drug therapy. For example, bitter orange peel (which contains synephrine, a chemical similar to stimulant ephedrine) may be taken for constipation, thus reducing the effectiveness of a client’s hypoten- sive prescription. Providers should encourage traditional practices if desired by a client, but ask for information regarding herbal medi- cines consumed. A prescription from a TCM In Asia, family members stay at the hospital to provide feeding, bathing, and general care for the patient. In 2004 the U.S. Food and Drug Administration banned the Chinese herb ma huang (ephedra), a methamphetamine-like stimulant with serious side effects such as heart attack, stroke, seizures, and psychosis. In a subse- quent lawsuit, a court rul- ing partially overturned the ban, permitting small amounts to be included in diet preparations. doctor remains in possession of the client, who may reuse it if symptoms reoccur or who may share it with family and friends. Some pre- scriptions are passed along from generation to generation; others are obtained directly from China. Occasionally, a client may present mul- tiple burn marks from moxibustion, and the client’s use of this treatment should be deter- mined before presumption of abuse. A Chinese client expects that the provider will perform few tests and ask a limited num- ber of questions during an examination. Rec- ommendations on diet, relaxation, and sleep are desired as an integral part of treatment. Long-term therapy intended to cure a disease is preferred over short-term surgical solutions or invasive treatment, even at the expense of pain or discomfort from symptoms. Most Chinese clients are resolved to die at home (many actually return to China), and their wishes should be accommodated. Few compliance problems have been noted. One difficulty that sometimes arises is the issue of lengthy or continuous medica- tion. Many Chinese are accustomed to single- dose Chinese remedies and may discontinue a prescription if directions are not thoroughly explained. Many researchers have remarked on the difficulty of eliminating high-salt items (e.g., soy sauce) from Chinese fare and rec- ommend reduction as a goal in cases where a low-sodium diet is required.96 Dairy products may be accepted when clients become familiar with the foods.40 One study of nursing home residents found a significant dislike of West- ern foods among Chinese elders.97 An in-depth interview should tactfully be conducted to identify which traditional practices, if any, are followed by a client. Even ▲ Traditionally, Chinese women were never touched by their male health care providers. Symptoms would be discussed by pointing to an alabaster figurine, like the one shown. SS PL /W el lc om e Tr us t/ Th e Im ag e W or ks Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 3 4 0 E A S T A S I A N S when concepts such as yin and yang are con- sidered primitive or rustic by some Chinese Americans, they may still adhere to certain food combinations learned at home without knowing why. Birthplace and acculturation may significantly impact dietary intake of Chinese Americans, and individual prefer- ences should be determined. Japanese The multi-island nation of Japan is off the coast of East Asia and has approximately the same latitude and range of climate as the East Coast of the United States. The capital of Japan is Tokyo, located on the island of Hon- shu. Today, Japan is a prosperous country of over 127 million people that has overcome the limitations of a mountainous geography, a rugged coastline, and few mineral resources. Perhaps Japan’s greatest natural resource is the sea, which provides one of the richest fishing grounds in the world. Cultural Perspective History of Japanese in the United States Immigration Patterns Significant Japanese immigration to the United States occurred after 1890 during the Meiji era. The immi- grants were mostly young men with four to six years of education from the rural southern provinces of Japan. Most came for economic opportunities and many eventually returned to Japan. They settled primarily in Hawaii and on the West Coast of the United States and often worked in agriculture, on the railroads, and in canneries. Like the Chinese before them, Japanese immigrants opened small businesses, such as hotels and restaurants. In contrast to the Chinese, many Japanese became farmers, ran plant nurseries, and were employed as gardeners. The Japanese pros- pered within their ethnic communities. Most Japanese women came to the United States as picture brides: Their marriages were arranged by professional matchmakers, and they were married by proxy in Japan. They did not usu- ally meet their husbands until they disem- barked from the ship in the United States. Among Japanese Americans, first-generation immigrants born in Japan are called Issei, second-generation Japanese Americans born in the United States are known as Nisei, and the third and fourth generations are known as Sansei and Yonsei, respectively. Discrimination against the Japanese was commonplace. The Issei were classified as aliens who were ineligible to become natural- ized U.S. citizens, and in 1913 land owner- ship became illegal in California. Although Japanese bought land in the names of their children, who were Americans by birth, the amount of land owned and leased by Japanese was reduced by half in the 1920s. In 1907 the Japanese government had informally agreed to limit the number of emigrants, and in 1924 the Japanese Exclusion Act halted Japanese immigration completely. World War II heightened the prejudice against the Japanese on the West Coast. After Japan attacked Pearl Harbor, all West Coast Japanese, even if they were U.S. citizens, were evacuated to war relocation camps, and many remained there for the duration of the war. Most lost or sold their businesses as a result of internment. Nevertheless, many Nisei volun- teered for combat duty and fought in Europe. Current Demographics and Socioeconomic Status After the war, most Japanese Ameri- cans resettled on the West Coast, and the most discriminatory laws were repealed or ruled unconstitutional. The successful postwar recovery of Japan resulted in reduced emigra- tion to the United States, usually far below the quota allotted under current immigration laws. According to 2010 U.S. Census esti- mates, 1.3 million Japanese Americans live in the United States, a majority of whom reside in California or Hawaii.98 Many West Coast cities have a section of town called “Little Tokyo” or “Japantown,” and a small number of older Japanese still live in these homogeneous neighborhoods. Most Japantowns contain Japanese American–owned restaurants, mar- kets, and other small businesses, as well as Chinese churches or Buddhist temples. More than 95 percent of Japanese Americans live in culturally mixed urban and suburban areas. Americans of Japanese descent are unique for a nonwhite ethnic group in the high rate of citizenship, degree of assimilation, Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 11 3 4 1 and economic mobility they have experienced.1 Over 95 percent of all Japanese Americans have graduated from high school, and of the third-generation Sansei, many of whom were born in the relocation camps, 46 percent have attended college and most hold professional jobs. In 2010, median family income was $65,390, and only 8 percent of adults lived in poverty. Some Japanese Americans have noted that few Asians are found in top private- and public-sector positions, however, and believe that they suffer from the stereotype of being too unassertive for upper management.98 Worldview Religion Early Japanese immigrants usually joined a Buddhist temple (Pure Land sect) or a Christian church after arriving in America. The church frequently provided employment and an opportunity to learn English. Today, it is thought that there are more Japanese Americans who belong to Protestant faiths than who follow Buddhism.1 Shintoism, the indigenous religion of Japan, does not have a formal organization, but its beliefs are a fundamental part of Japanese culture. The Shinto view is that humans are inherently good. Evil is caused by pollution or filthiness—physical as well as spiritual; goodness is associated with purity. Evil can be removed through ritual purification. Shinto deities, called kami, represent any form of existence (human, animal, plant, or geologic) that evokes a sense of awe. Kami are wor- shiped at their shrines as ritual expression of veneration and thankfulness. Prayers are also said for divine favors and blessings, as well as for avoidance of misfortunes and accidents. Family Until World War II the structure of the Japanese American family had its roots in Japan and was similar to that of the Chinese due to the strong influence of Confucianism. In addition, the rigid pattern of conduct that evolved in Japan during the sixteenth century resulted in the following practices among the Issei and their descendants: 1. Koko. Filial piety defines the relation- ship between parents and children, between siblings, and between individu- als and their community and rulers. (See the Chinese religion section on Confu- cianism in the first part of this chapter for further explanation.) One outcome is that the Issei expect their children to care for them in their old age. 2. Gaman. Most Japanese believe it is vir- tuous to suppress emotions. The prac- tice of self-control is paramount. 3. Haji. Individuals should not bring shame on themselves, their families, or their communities. This Japanese cultural concept exerts strong social control. 4. Enryo. There is no equivalent word in English, but many Japanese believe it is important to be polite and to show respect, deference, self-effacement, humility, and hesitation. Thus, some older or less acculturated Americans of Japanese descent are neither aggressive nor assertive. Japanese clan or village affiliation has tra- ditionally been much weaker than in China, and Japanese immigrants arrived in the United States prepared to raise nuclear fami- lies similar to those in white America. Even when picture brides were trapped in unhappy More than 110,000 residents of Japanese ancestry were living in Canada in 2011. Heikegani crabs are believed to be reincarnations of drowned warriors due to the facelike markings on their shells. Japanese physicians were polled to discover why they began prescribing traditional herbal remedies; a majority said they were influenced by pharmaceutical company salespeople and advertising. ▲ Japantown, San Francisco. Ke vi n Fl em in g/ En cy cl op ed ia /C or bi s Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 3 4 2 E A S T A S I A N S marriages, they persevered on behalf of their children. Most Issei women worked along- side their husbands to support the family financially. The internment of Japanese Americans during World War II brought further changes in family structure and accelerated accultura- tion into mainstream society after the war. In the camps very low wages were paid and the pay was the same for everyone; thus the father could no longer be the primary wage earner. The camps were run democratically, but posi- tions of authority could be held only by Amer- ican citizens, so the younger generation held these more prestigious jobs. The camps also allowed the Japanese to work in a wider range of fields than those available to them on the outside. After their internment, the Nisei no longer had to follow the few occupations of their parents, and many chose to follow dif-their parents, and many chose to follow dif-their parents, and many chose to follow dif ferent paths. Sansei couples generally form dual-career households. Nearly 50 percent marry outside their ethnic group. The societal problems prevalent in majority American homes, such as spousal abuse, have surfaced among Japa- nese Americans as well,99 and it is not known if the family values that have thrust Ameri- cans of Japanese descent into educational and financial success will continue in the fully assimilated fourth-generation of Yonsei. Traditional Health Beliefs and Practices Early Japanese health beliefs involved Shinto con- cepts of purity and pollution. Health was maintained through cleanliness and avoidance of contaminating substances such as blood, skin infections, and corpses.100 Botanical rem- edies were used, particularly purgatives, in the prevention and treatment of disease. When Buddhism was introduced in the sixth century, the concept of harmony was applied within the context of Japanese culture to mean a person’s relationship with nature, family, and society. Imbalance resulting from poor diet, insufficient sleep, lack of exercise, or conflict with family or society disrupts the proper flow of energy within the body, leading to illness. Chinese practices such as acupunc- ture, moxibustion, and massage were accepted as ways to restore the energy flow along the meridians of the body (see the section “Traditional Health Beliefs and Practices”). The application of yin and yang in health and diet was limited in Japan. The more complex herbal medications of China were brought to Japan as kanpo. However, the numerous plants, animals, and minerals necessary for kanpo were not widely available on the islands, so its use was confined to the elite, urban aristocracy until recent times. Practitioners of the profession were called kanpo-i and underwent rigorous training. Kanpo-i approached each case individually, reviewing symptoms carefully and in detail before determining the best combination of therapies and medications for the specific patient. Diagnosis was an art that recognized that symptoms may present differently in every consultation.101 Western biomedicine was introduced to Japan in the sixteenth century with the arrival of the Portuguese. It was widely embraced; Japanese kanpo-i were required to retrain if they wished to continue working as doctors. The majority of Japanese Americans migrated to the United States dur- ing the time when kanpo was rarely prac- ticed, and they were often unfamiliar with its therapies. Since 1960 Japan has been in the middle of a kanpo boom and is now approved reim- bursement under the Japanese health insur- ance policy.102 Concerns about the side effects of biomedical therapeutics and a growing interest in holistic and herbal healing have prompted the resurgence. Kanpo-i take a generalized approach, using natural medications with broad effects to stimulate the immune system. Some herbs also have known bacteriostatic action or anti- inflammatory properties. Small doses of the medications are taken for lengthy periods of time to promote gradual improvement. Physi- cians trained in biomedicine are also prescrib- ing kanpo for many clients (though without the extensive education of kanpo-i); mass pro- duction of herbal medications by pharmaceu- tical companies began in the 1970s. Stress-induced illness is of particular concern in Japan. Work-related fatigue and symptoms of anxiety and depression have Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 11 3 4 3 risen dramatically in the past decade.103 An estimated 10,000 men die annually from karoshi (literally “death from overwork,” but referring to suicide). The healing industry in Japan is an estimated $30 billion-a-year business.104 Stress-reducing therapies, called iyashi, include herbs, teas, and ten-minute massage parlors. One aquarium provides overnight accommodations in its tank rooms, where visitors can sleep to relaxing music in the company of swaying jellyfish. Spas offer specialized soaking alternatives, such as bath- ing in coffee, green tea, red wine, or sake, to rejuvenate and energize clients. Researchers report such activities result in reduced lev- els of stress hormones as measured in saliva tests.105 Napping on the job and at school has also gained some acceptance follow- ing studies on how short rests can improve productivity.106,107 Traditional Food Habits Japanese ingredients, as well as cooking and eating utensils, are very similar to those of the Chinese, due to China’s strong influence on Japan. Yet Japanese food preparation and pre- sentation are unique. The Japanese reverence for harmony within the body and community and with nature has resulted in a cuisine offer- ing numerous preparation methods for a lim- ited number of foods. Each item is to be seen, tasted, and relished. The Japanese also place an emphasis on the appearance of the meal so that the visual appeal reflects balance among the foods and the environment. For example, a summer meal may be served on glass dishes so that the meal looks cooler, while a Septem- ber meal may include the autumn colors of reds and golds. Ingredients and Common Foods Japan’s mountainous terrain and limited ara- ble land have contributed historically to a less- than-abundant food supply. Even today much of Japan’s food supply is imported. Staples and Regional Variations The basic foods of the Japanese diet are found in the cul- tural food groups list (Table 11.3). Several key ingredients were adopted from China, includ- ing rice, soybeans, and tea. Rice or gohan (the word for “cooked rice,” and also for “meal”) is the main staple eaten with almost every meal. In contrast to the Chinese, the Japanese prefer a short-grain rice that contains more starch and is stickier after cooking. Rice mixed with rice vinegar, called su, is used in sushi, one of the most popular Japa- nese specialties in both Japan and abroad. Sushi rice is formed with fish and seafood to make decorative, bite-size mounds served with soy sauce for dipping. Types of sushi include Nigirisushi, which features rice topped with items such as sliced raw fish or squid (called sashimi), cooked octopus, crab or shrimp, omelet strips, or roe of salmon (ikura), sea urchin (uni), or flying fish (tobi- kko), sometimes wrapped in a strip of seaweed; Makisushi, a roll of sushi rice, often including cucumber (kappamaki), tuna, mushrooms, or other fillings, then wrapped in a sheet of seaweed and sliced into individual pieces; and Chirashisushi, with the topping ingredients lit- erally scattered over a large mound of rice and eaten with chopsticks. Rice is also made into noodles, although those made from wheat (known as udon, somen, and ramen) or buckwheat (soba) are more commonly consumed. Other noodles made from less familiar starches, such as kudzu, are also eaten. Soybean products are an important com- ponent of Japanese cuisine. Tofu (bean curd), soy sauce (shoyu), and fermented bean paste Sea urchin roe, called uni, is thought to enhance male sexual potency in Japan, where wholesalers pay up to $100 per pound for it. California imposed strict urchin harvesting laws to prevent extinction along the coast. ▲ Traditional foods of Japan. Some typical foods include daikon, dried sardines, Japanese egg- plant, Japanese pickles, nori (seaweed), red beans, nori (seaweed), red beans, nori ( shiitake mushrooms, short- grain rice, shrimp, soy sauce, and wheat noodles. M IX A /G et ty Im ag es Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 3 4 4 E A S T A S I A N S Group Comments Common Foods Adaptations in the United States Protein Foods Milk/milk products Japanese cooking does not utilize significant amounts of dairy products. Many Japanese are lactose intolerant. Soybean products, seaweed, and small bony fish are alternative calcium sources. Milk, butter, ice cream First-generation Japanese Americans drink little milk and eat few dairy products. Subsequent generations eat more dairy foods. Meat/poultry/ fish/eggs/ legumes Soybean products and a wide variety of fish and shellfish (fresh, frozen, dried, smoked) are the primary protein sources in the Japanese diet. Fish and shellfish often eaten raw. Chicken is used more often than beef; price is the limiting factor in meat consumption. Meat: beef, deer, lamb, pork, rabbit, veal Poultry: capon, chicken, duck, goose, partridge, pheasant, quail, thrush, turkey Fish: blowfish, bonito, bream, carp, cod, cuttlefish, eel, flounder, herring, mackerel, porgy, octopus, red snapper, salmon, sardines, shark, sillago, snipefish, squid, swordfish, trout, tuna, turbot, yellowtail, whale Shellfish: abalone, ayu, clams, crab, earshell, lobster, mussels, oysters, sea urchin roe (uni), scallops, shrimp, snails Legumes: adzuki, black beans, lima beans, red beans, soybeans Dried fish and fish cakes are available in the United States, but some varieties of fresh fish are not. Japanese Americans eat more poultry and meat than fish. Cereals/Grains Short-grain rice is the primary staple of the diet and is eaten with every meal. Wheat is often eaten in the form of noodles, such as ramen, somen, and udon. Wheat, rice, buckwheat, millet Rice is still an important staple in the diet and usually eaten at dinner. Fruits/Vegetables Fresh fruits and vegetables are the most desirable; usually eaten only in season. Many fruits and vegetables are preserved, dried, or pickled. Fruits: apples, apricots, bananas, cherries, dates, figs, grapes, grapefruits (yuzufigs, grapes, grapefruits (yuzufigs, grapes, grapefruits ( ), kumquats, lemons, limes, loquats, melons, oranges, peaches, pears, pear apples, persimmons, plums (fresh and pickled), pineapples, strawberries, mikan (tangerine) Vegetables: artichokes, asparagus, bamboo shoots, beans, bean sprouts, broccoli, brussels sprouts, beets, burdock root (gobo), cabbage (several varieties), carrots, chickweed, chrysanthemum greens, eggplant (long, slender variety), ferns, ginger, ginger sprouts and flowers (myoga), and pickled ginger (beni shoga), green onions, green peppers, gourd (kanpyo, dried gourd shavings), kudzu, leeks, lettuce, lotus root, mizuna, mushrooms (shiitake, matsutake, nameko), okra, onions, peas, potatoes, pumpkins, radishes, rhubarb, seaweed, snow peas, shiso, sorrel, spinach, squash (including kabocha), sweet potatoes, taro, tomatoes, turnips, watercress, yams Fewer fruits and vegetables are eaten; freshness is less critical. Additional Foods Seasonings Sugar, shoyu, and vinegar are a basic seasoning mixture. Shoyu and mirin can vary in strength; amounts used will vary according to taste. Alum, anise, bean paste (miso), caraway, chives, dashi, fish paste, garlic, ginger, mint, mirin, MSG, mustard, red pepper, sake, seaweed, sesame seeds, shiso, shoyu, sugar, thyme, vinegar (rice), wasabi (green, horseradish-like condiment) TA B L E 11. 3 Cultural Food Groups: Japanese Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 11 3 4 5 (miso) are just a few. Miso comes in numerous varieties. Those made with the addition of rice are most popular; however, miso mixed with barley is found in western regions, and plain miso with just soybeans and salt is favored in a few central areas.108 Red miso (akamiso) is very salty and is used most often. White miso (shi- romiso) is sweeter, often used in cooked salads. Specialty misos, with added vegetables such as kombu or daikon, or seasoned with shiso, are also available. Sugar, shoyu, and vinegar are a basic seasoning mixture for foods. Teriyaki sauce (“shining broil”) made from soy sauce and mirin, a sweet rice wine, is another com- mon flavoring for foods. Shoyu and mirin can vary in strength, and the amounts used depend on personal taste. In addition to soy beans, small, red adzuki beans are significant in Japa- nese cuisine, most often made into sweetened red bean paste and a popular red bean jelly dessert (similar to gelatin) called yo-kan. Green tea is served with most meals. Tea was originally used in a devotional ceremony in Zen Buddhism. The ritual was raised to a fine art by Japanese tea masters, and as a result, they also set the standards for behavior in Japanese society. Today, the tea ceremony and the accompanying food (kaiseki ryori) remain a cultural ideal that reflects the search for harmony with nature and within one’s self. The meal features six small courses balanc- ing the tastes of sweet, sour, pungent, bitter, and salty. The tea used for the ceremony is not the common leaf tea usually used for meals, but rather a blend of ground, dry tea or a tea powder. Hot water is added to the tea, and the mixture is whipped together using a hand- made whisk, resulting in a frothy green drink. Diners demonstrate their sophistication and sensitivity through deliberate eating of each course after expressions of appreciation for the presentation. Soybean products and a wide variety of fish and shellfish (fresh, dried, or smoked) are the primary protein sources. Fresh fish and shellfish are often eaten raw. Beef, pork, and poultry are also popular but very expensive. One specialty is Kobe (or Tajima) beef, from a Japanese breed of cattle that is fed beer as an appetite stimulant and regularly massaged to relieve stress. It often costs more than $100 per pound. Pork is a favorite as cutlets. Chicken, which is often served as teriyaki sauce– glazed skewers, may also be very thinly sliced and served raw like sashimi.109 Only small amounts of meat, poultry, or fish are added to the vegetables in traditional Japanese recipes. Japanese fare does not use many dairy foods. Fresh fruits and vegetables are the most desirable and are eaten only when in sea- son. As in China, many Asian and European varieties are consumed (see the subsection “Staples” in the Chinese part of the chapter). A few favorites include herbs and greens such as chrysanthemum greens, mizuna (pot- herb), and shiso (perillaherb), and shiso (perillaherb), and shiso ( , a member of the When a family moves to a new home, they give soba noodles to the neighbors on either side and across the street as a gesture of friendship. kaiseki ryori meals have recently become trendy in both Japan and the United States, costing up to $100 per person at restaurants featuring the ceremonial menu. Group Comments Common Foods Adaptations in the United States Nuts/seeds Chestnut, gingko nuts, peanuts, walnuts; poppy (black and white), sesame seeds Beverages Green tea is the preferred beverage with meals; coffee or black tea is drunk with Western-style foods. Sake or beer is often served with dinner. Carbonated beverages, beer, coffee, gin, tea (black and green), sake, scotch Japanese Americans drink less tea and more milk, coffee, and carbonated beverages. Fats/oils The traditional Japanese diet is low in fat and cholesterol. Butter, cottonseed oil, olive oil, peanut oil, sesame seed oil, vegetable oil Japanese Americans consume more fats and oils because of increased use of Western foods and cooking methods. Sweeteners Honey, sugar Increased use of sugar; sweet desserts are noted. © C en ga ge L ea rn in g Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 3 4 6 E A S T A S I A N S mint family—the red variety is used to color pickled foods); many tubers, including gobo (burdock root, which is shaved and leached in water to remove bitterness), sweet pota- toes, a small variety of taro, and yams; and others such as daikon (a white radish similar to the Chinese radish, but longer, up to twelve inches in length), edamame (young soybean pods boiled in saltwater, then popped open for a snack, often with beer), kabocha (winter squash), shiitake mushrooms, and the winter tangerine known as mikan. Pickled vegetables are available year round and are eaten exten- sively. Fresh fruit is a traditional dessert. The Japanese use large amounts of seaweed and algae in their cooking for seasoning, as a wrapping, or in salads and soups. There are many types. Nori is a paper-thin sheet of algae that is rolled around sushi. Kombu is an essential ingredient in dashi, or soup stock made from dried bonito fish and seaweed. Misoshiru is a popular soup made with dashi and miso (either red or white miso can be used). Wakame and hijiki are used primarily in soups and salads. Aonoriko is powdered green seaweed used as a seasoning agent. Japanese dishes are classified by the way the food is prepared (see Table 11.4). Tempura is an Tempura is an Tempura example of an agemono dish. Adapted from a dish introduced in the sixteenth century by the Catholic Portuguese for religious fast days, it consists of shrimp and sliced vegetables—such as eggplant, carrots, sweet potato, lotus root, and green beans—lightly battered and deep- fried. Katsu is another agemono dish of deep-fried breaded pork cutlets or fish filets. Sukiyaki is a simmered beef dish usually pre- pared at the table. The name means “broiled on the blade of the plow” and probably dates back to ancient times.110 The current version of sukiyaki is mislabeled, however, because it is a nimono-style, not a yakimono-style food. Shabu shabu, a nabemono dish of small pieces of beef and vegetables cooked in broth at the table, is similar to a Mongolian hot pot (see “Chinese Regional Specialties” above). After the meat and vegetables are cooked and eaten, the broth is ladled into bowls and con- sumed. Teriyaki is one type of grilled yakimono dish, as is yakitori (grilled, marinated chicken skewers). Teppanyaki is a Japanese term for stovetop grilling. The style familiar to U.S. din- ers was invented to take advantage of the tour- ist trade. Beef, chicken, shrimp, and vegetables are cooked on a hot grill in the center of a large table, then served with ponzu, a soy sauce and citrus juice mixture. Chawanmushi, a savory egg custard in which meats and vegetables are cooked, is a typical steamed mushimono dish. Seafood, fish, fruits, and vegetables that are pickled in a mixture of miso, soy sauce, vinegar, and the residue from sake production are known as tsukemono, and they are served at nearly every meal. Suimono Clear soups, such as dashi or dashi or dashi misoshiru Yakimono Broiled or grilled food (often marinated), such as teriyaki or teriyaki or teriyaki yakitori Nimono Foods (usually a single item) simmered in seasoned water or broth, such as fish in sake- flavored broth, served hot or at room temperature Mushimono Steamed foods, such as chawanmushi Agemono Deep-fried foods, such as deep-fried tofu or katsu, usually served with a dipping sauce Aemono Fresh or cooked mixed foods tossed with thick sauces, such as salad with miso dressing Sunomono Mixed salads with vinegared dressing, such as crab and cucumber with rice vinegar and soy sauce dipping sauce Chameshi Rice cooked with other ingredients, such as chicken, fish, vegetables (especially mushrooms)—one specialty is rice with red adzuki beans, served for celebrations Men rui Noodle dishes, served hot or cold (plain or topped with fish or vegetables) with dipping sauce, or in a broth with items such as meats, seafood, tofu, and vegetables Nabemono Foods that are cooked at the table and one-pot dishes (usually a type of nimono dish), usually hearty combinations, such as sukiyaki and sukiyaki and sukiyaki shabu shabu TA B L E 11. 4 Selected Japanese Cooking Styles © C en ga ge L ea rn in g Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 11 3 4 7 Japanese foods are usually cut into small pieces if the item is not naturally easy to eat with chopsticks, and dishes are frequently modified for children, as it is believed that adult recipes are too spicy for them. Cooking style varies from region to region in Japan. Kyoto is known for its vegetarian specialties, Osaka and Tokyo are known for their seafood, and Nagasaki’s cooking has been greatly influ- enced by the Chinese. Meal Composition and Cycle Daily Pattern Traditionally the Japanese eat three meals a day, plus a snack called oyatsu. Simple meals, such as breakfast and lunch, are often ichiju—issei, meaning “soup with one side.” For example, breakfast usually starts with a salty sour plum (umeboshi), followed by rice garnished with nori, soup, and pickled vegetables. A side dish such as an egg or fried fish is served with the rice. A nabemono can replace the side dish, which often happens at lunchtime. The meal is typically simple and often consists only of rice topped with left- overs from the previous night. Sometimes hot tea or dashi is added to the rice mixture. A bowl of noodles cooked or served with meats, poultry, or fish and vegetables is a popu- lar alternative to leftovers. One such dish is oyakodon, which means “parent and child on rice,” a mixture of boiled chicken and scram- bled eggs on a bed of rice. Dinner is usually ichiju sansei, meaning “soup and three sides,” including rice, soup, and tsukemono, and three dishes: a raw or vinegared fish, a simmered dish, and a grilled or fried dish.108 Pink pickled ginger (beni shoga) garnishes many meals, and soy sauce is usually available. The pungent, green, horse- radish-like condiment called wasabi may also be offered, and it is mixed in small individual bowls with soy sauce to taste. The Japanese tend not to serve meals by courses. Instead, all the dishes are presented at the same time in individual portions, each food in its own bowl or plate. The soup, how- ever, is sometimes served last or near the end of the meal, and tsukemono may be placed on a communal plate for diners to add accord- ing to their personal preference. Traditionally, desserts were not common in Japan; meals usually ended with fruit. A small grill in Japan is called a hibachi, meaning “fire bowl.” Sansai ryori is a style of cooking with fresh wild herbs and vegetables such as goosefoot, mug- wort, nettles, ferns, and bracken. It is considered the essence of spring. Kombu sounds like the word for “happiness,” and it is often presented as a hostess gift by guests. Myoga ginger is prized in Japan for its tender shoots in the spring and its flower buds in the fall. The Japanese use 21 billion sets of dispos- able wood chopsticks in restaurants annually. In addition, the Japanese often eat a boxed meal called bento. A pleasing assortment of at least ten items is packaged attractively for con- sumption at school, picnics, or even between acts at the theater. Some restaurants specialize in bento meals. Snacks include several kinds of sweets, rice crackers, or fruit. Traditional Japanese confec- tions include mochi gashi (rice cakes with sweet mochi gashi (rice cakes with sweet mochi gashi red bean paste), manju (dumplings), and yo- kan. Green tea is served after all meals except when Western-style food is eaten; then coffee or black tea is served. Beer or sake (rice wine, usu- ally served warm) may be served with dinner. Eating out is common. Numerous small restaurants specialize in certain preparations, such as sushi, yakitori, or noodle dishes. Res- taurant windows often display their menu items with plastic replicas of their dishes. Etiquette The Japanese, like the Chinese, eat with chopsticks and follow many of the same customs regarding their use (see the “Etiquette” subsection in the Chinese part of the chap- ter); the rice bowl is not held as closely to the mouth, however. Soups are consumed directly from the bowl; the only dish eaten with a spoon is chawanmushi. Slurping soups and noodles is permitted and may be seen as a sign of appre- ciation. Tea should always be silently sipped.21 Traditionally the Japanese eat their meals at low tables, in a kneeling position with the heels tucked under the buttocks. In less for- mal situations men may sit cross-legged and women with their legs tucked to the side. ▼ The o sonae mochi is traditional in Japanese Bud- dhist homes at New Year’s, symbolizing prosperity and happiness in the future. G ar y Co nn er /P ho to Ed it Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 3 4 8 E A S T A S I A N S Shoes are removed first. Dishes on the left are picked up with the right hand, and dishes to the right are lifted with the left hand. It is impolite to serve sake, beer, or tea to oneself. Each diner is obliged to fill his or her neigh- bor’s glass whenever it is half-empty. Guests are usually entertained at restau- rants, where the host chooses the menu in advance. The meal may include frequent toasts, particularly kampai (“bottoms up”). Games may be played at the table after the meal. Karaoke singing is common, and guests are expected to good-naturedly participate.21 Special Occasions In Japan there are numer- ous festivals associated with the harvesting of specific crops or with local Shinto shrines or Buddhist temples. The most important and largest celebration in Japan is the New Year celebration. The Japanese share many holi- day traditions with the Chinese. Homes are cleaned thoroughly, and all debts are settled before the New Year; food is also prepared ahead so that no knives or cooking will inter- fere with the seven-day event. The Japanese celebrate New Year’s Day on January 1. The New Year’s foods consist of ten to twenty meticulously prepared dishes served in a spe- cial set of nesting boxes. Each dish symbolizes a specific value, such as happiness, prosperity, wealth, long life, wisdom, and diligence. For example, fish eggs represent fertility, mashed sweet potatoes and chestnuts protect against bad spirits, and black beans represent a will- ingness to keep healthy through hard work and sweat. An important New Year’s food is mochi, a rice cake made by pounding hot, steamed rice into a sticky dough. Traditionally a Bud- dhist o sonae mochi is set up in many homes. A large rice cake represents the foundation of the older generation and is placed on the bottom, and a smaller rice cake symbolizing the younger generation is placed atop it, fol- lowed by a tangerine indicating generations to come. The o sonae mochi is as meaningful to the Japanese as a Christmas tree is to Ameri- cans, preserving good fortune and happiness for future generations. Another special food is ozoni, a soup cooked with mochi, vegetables, fish cakes, and chicken or eggs. A special rice wine called otoso is consumed to preserve health in the coming year. Japanese Bud- dhist temples usually hold an Obon festival in the second or third week of July to appreci- ate the living, honor the dead, and comfort the bereaved. Food and dancing are a tradi- tional part of the holiday. Certain birthdays are considered either hazardous or auspicious in Japanese culture. When a man turns forty- two or a woman becomes thirty-three, spe- cial festivities are held to prevent misfortune. Age sixty-one marks the beginning of second childhood, and a person dons a red cap for this honor. At age seventy-seven a person puts on a long red overcoat, and at the most pro- pitious birthday of all, age eighty-eight, the celebrant may begin wearing both the hat and the coat. Therapeutic Uses of Food Although the use of yin and yang is not as prevalent among the Japanese as it is among the Chinese, there are many beliefs about the harmful or beneficial effects of specific foods and food combinations. Traditionally certain food pairs, such as eel and pickled plums, watermelon and crab, or cherries and milk, are thought to cause illness. Pickled plums and hot tea, which are cus- tomarily eaten for breakfast, are believed to prevent constipation. Both pickled plums and rice porridge, called okayu, are thought to be easily digested and well tolerated during recovery from sickness. Contemporary Food Habits in the United States Adaptations of Food Habits Little recent information on the food habits of Japanese Americans has been reported, but available data suggest the adoption of a West- ernized diet continues with each subsequent generation in the United States. It is thought that when acculturated Japanese Americans eat a typical American diet, they may eat more rice and use more soy sauce than non-Asians. Traditional foods are still prepared for special occasions. A Westernized diet is increasingly followed even in Japan. Bread and butter are becoming staples, and consumption of meat, milk, and eggs is increasing. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 11 3 4 9 A detailed study of Nisei and Sansei (mothers of Japanese immigrants and their daughters) reported several trends in dietary acculturation.111,112 Compared to the predom- inantly Japanese diet consumed by the Issei who immigrated to the United States, Nisei women in the study continued to eat rice daily but added other starches, such as breads and cereals. Traditional protein sources, including seafood, tofu, and eggs, were often replaced with more meats and dairy items. Condi- ments such as soy sauce and miso were con- sumed less often, while butter and margarine intake increased substantially. When com- pared to their mothers, the Sansei daughters consumed less rice and more pasta, ate less dried fish and more cheese, consumed fewer traditional preserved or pickled foods and more fresh fruits and vegetables (particularly potatoes), and used less butter and margarine. The Sansei women also ate fewer Japanese- style sweets and more salty snacks. Green tea consumption declined with the Sansei daugh- ters, and soft drink consumption increased. Notably, meal consumption became more irregular with the Sansei, and eating out and use of takeout foods were significantly more common. Nutritional Status Nutritional Intake The traditional Japanese diet is high in carbohydrates and very low in fat and cholesterol. Most cooking fats are polyunsaturated, and butter is rarely used. Japanese Americans, however, consume a more typically American diet, and this change may contribute to increased incidence of several diseases. The leading cause of death for Japanese Americans is cancer and heart disease, but it is still lower than death rates for other Americans.113 According to classic epidemiological studies, mainland Japanese Americans have a higher risk of developing colorectal cancer and heart disease than the Japanese in Hawaii, and those in Hawaii have a higher risk than the Japanese in Japan.114,115 More detailed evaluation has shown Japa- nese Americans have more rapid athero- sclerosis progression than do Japanese men and women.116 It has been postulated that the increase is caused by diet because it is Historically, rice was often in short supply in Japan, so eating the round rice cakes, mochi, at New Year’s represented wealth and prosperity. correlated to a higher intake of cholesterol and animal fat and a lower intake of dietary fiber and a lower intake of fish oil (omega-3 fatty acids).117 Other cancers, such as those of the breast and prostate, have also increased in Japanese Americans as their stay in the United States lengthens. Changes in diet have also been implicated in the high rates of type 2 diabetes found among Japanese American men.118,119,120 Among Nisei men in one study, the rates for diabetes were twice that for similarly aged white men living in the same region of the United States and four times that for simi- larly aged men in Japan.121 Data showed that the Japanese American men were consum- ing carbohydrate, protein, and fat propor- tions similar to the overall American diet, but with fewer total calories. (A third of Japanese Americans are overweight and obesity has been found to be higher in U.S.-born Japanese Americans than in foreign-born Japanese Americans, total rates are low.)122 However, insulin resistance and metabolic syndrome was greater in the Japanese American men when compared to Japanese subjects, and increased intra- abdominal fat deposits were found.123,124 S A M P L E M E N U A Japanese Family Dinner Misoshiru (M is o S oup) a,b Sashimia,b Tempuraa or Y e llo w t ail T e r iy ak ib P ick le d C ucumb e r a,bP ick le d C ucumb e r a,bP ick le d C ucumb e r S t e ame d R ic e , P ick le d G in ge r , Wasabi , an d S oy S au c e S ak e (R ic e W in e ) or G r e e n T e a aFukushima, S. 2001. Japanese home cooking. Boston: Periplus. bYasuko-san’s Home Cooking at http://www.nsknet.or.jp/~tomi-yasu/index_e.html Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 3 5 0 E A S T A S I A N S Among women, intra-abdominal fat increased with menopause.118 Intra-abdom- inal fat deposition was found predictive of type 2 diabetes in Japanese Americans inde- pendent of total adiposity, family history, and other risk factors.125,126,127 A genetic predispo- sition for diabetes combined with increased fat consumption, especially animal fats, may account for the disproportionately high rates. Earlier studies suggest Japanese American elders may have a low intake of calcium because of limited consumption of dairy prod- ucts.47 The Japanese have a high incidence of lactose intolerance. Although seaweed, tofu, and small bony fish contain calcium, they may not be eaten in adequate amounts to provide sufficient intake. Prevalence of osteoporosis may be higher than among whites (see Cultural Controversy—Dairy Foods, BMD, and Osteoporosis). Calorie consumption and meat intake have also been found to decline with age in Japanese Americans. The traditional Japanese diet tends to be high in salt from soy sauce, dashi, miso, monosodium glutamate (MSG), dried pre- served fish, and pickled vegetables. Rates of conditions sometimes linked to high-sodium diets, such as hypertension, stroke, and stom- ach cancer, are extremely high in Japan but have been dropping as the Japanese adopt Western fare.128 Infant mortality rates for Japanese Americans are lower than those for the general popula- tion.78 However, a study comparing pregnancy outcomes in Japanese Americans noted that U.S.-born mothers are significantly more likely to have low-birth-weight infants than are foreign-born mothers.129,130 A comparison of Asian (Chinese, Japa- nese, and Korean) alcohol consumption habits found that Americans of Japanese heritage had the most permissive attitude toward drinking, particularly among women. Japanese Ameri- can men had high rates of heavy drinking (nearly 30 percent) and the fewest abstain- ers (16 percent). Japanese American women showed similar trends, with the highest rates of heavy drinking (almost 12 percent) and the lowest number of abstainers (27 percent). Although the number of women engaged in chronic heavy drinking is lower than for white American women, the rates for men were comparable. Friends who drink and social occasions where drinking was expected were significant influences on consumption among men.131 These studies confirms previous work indicating that alcohol consumption may be more frequent than previously assumed among Japanese Americans, although behav- ior problems related to drinking have not been widely reported.120,132,133 Counseling Japanese American values such as placing the family before the individual, pre- serving harmony with society, and respect- ing and caring for elders may have a positive impact on health.99 Illness may be regarded as both a symptom of an unbalanced life as well as an impediment to fulfilling personal obligations. Japanese Americans were found less accepting of pain behaviors than whites in one study.134 Formality and politeness are essential con- versational elements in Japan. Addressing Jap- anese elders or Japanese American Issei, and some Nisei, by their first names is insulting. Sansei and Yonsei are often more informal.100 Emotional displays are avoided, especially of anger. The Japanese are nonconfrontational and may be reluctant to say no even when the answer to a question is negative. Waving a hand in front of the face with the palm out- ward indicates “I’m unsure” or “I don’t know.” Conversational style is typically indirect, and frequent pauses, up to several minutes, are common. It is usually best to remain silent during such pauses. Direct eye contact is dis- respectful—glancing around or downcast eyes are expected. Smiling can indicate pleasure but is also used to hide displeasure. Sucking in air through the teeth can also be a sign of discomfort or anger. The Japanese are a nontouching culture, and they often stand or sit farther apart than do most Americans. Their commu- nication style is extremely high context, and the slightest gesture may have meaning (see Chapter 3 for more details). Broad hand or body gestures may be misconstrued. Though touching between strangers or acquaintances is infrequent, most Japanese Americans are comfortable with a light A small percentage of Asians lack the ability to metabolize alcohol well. This inherited condition causes immediate skin flushing (reddening) and may even result in heart palpitations when alcohol is consumed. This reaction may contribute to the number of abstain- ers in the population. Korea is called Choson by Koreans, meaning “Land of Morning Calm.” Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 11 3 5 1 handshake. The traditional greeting is a bow from the waist with palms against thighs. The lower the bow and the longer it is held, the more respect is shown for the status of the other person.21 Slouching and putting one’s feet on a desk are signs of disinterest. Japanese Americans often believe that the health care provider is a knowledge- able authority figure who will meet their needs without assistance. Most Americans of Japanese descent expect to be directed in their health care, yet are insulted if they are ordered to do anything that they feel requires only an explanation. Criticism of a client’s health habits can lead to embarrassment and loss of effective communication. Concrete, structured approaches based on information gathered through an unhurried, in-depth interview that determines degree of accul- turation and personal preferences are most effective. Koreans The mountainous peninsula that forms Korea is suspended geographically and culturally between China and Japan. Korea has his- torically been caught in the middle of both Chinese and Japanese expansionism yet has maintained a homogeneous population with an independent, distinctive character. Lit- tle land is arable, and the climate fluctuates between cold, snowy winters and hot, mon- soonal summers that limit agriculture signifi- cantly. The peninsula is currently divided into two nations. The Democratic People’s Repub- lic of Korea (North Korea), with the capital city of Pyongyang, has a communist govern- ment. The Republic of Korea (South Korea) is a democracy supported by the United States. Seoul is the country’s capital. Both nations desire the reunification of Korea through political and military domination of the other. There were approxi- mately 169,000 Canadi- ans of Korean ancestry in the 2011 Census. The status of Koreans in the United States during World War II was unique. Many remained technically Japanese citizens and as such were declared enemy aliens (although none were interred). Yet many Koreans had been involved for years in anti-Japanese activities. They wore “I am Korean” buttons to distinguish themselves from Japanese residents. Dairy Foods, BMD, and Osteoporosis Osteoporosis, which means “porous bone,” affects 10 million women and 2 million men in the United States. Another 16 million have low bone mineral density (BMD), which may put them at risk of developing the disease. Osteoporosis is characterized by reduced height, a stooped spinal deformity, and over 1.5 million bone fractures annually, most often of the spine, the hip, and the wrist. The causes of osteoporosis are not completely understood. Contributing factors include ethnicity, family history, low calcium intake, insuf-family history, low calcium intake, insuf-family history, low calcium intake, insuf ficient weight-bearing exercise, smoking, high alcohol consumption, and low levels of estrogen in women and testosterone in men.192,193 White women have long been considered at highest risk for osteoporosis. In particular, thin white women have been thought most vulnerable because higher body mass is related to better BMD. Asian women have a lower incidence of hip fracture than white women, but the prevalence of vertebral fractures among Asians seems to be as high as that in white individuals. Protective factors that lower the risk for fracture in Asians may be diminishing, however. Hip fracture rates are rising dramatically in Japan, Hong Kong, and among the Chinese in Singapore.194,195, 196,197 Dietary recommendations regarding osteoporosis have traditionally emphasized a high intake of calcium-rich foods. Dairy foods are considered good sources because in addition to calcium they also contain vitamin D, which enhances absorption of the mineral. Although many Asians do not eat dairy foods, it has been thought that they obtained adequate calcium from eating small fish with bones (e.g., sardines), mineral-rich fish sauces, and ample dark green leafy vegetables. Some scientists also suggest that soybean intake may be protective, slowing bone mineral loss after menopause.198,199,201 Yet, if prevalence for low BMD and osteopo- rosis among Asians is higher than previously calculated, and if fractures are increasing, do nondairy foods provide adequate calcium intake? Or, if the intake of traditional calcium- rich foods declines with acculturation in the United States (and Westernization world- wide), are dairy foods needed to provide the calcium no longer being consumed?200 More research on the bioavailability of calcium in different foods and the role of diet in the development of BMD, osteoporosis, and fractures is needed to determine whether dairy food recommendations are sensible for all Americans or simply ethnocentric. C U L T U R A L C O N T R O V E R S Y Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 3 5 2 E A S T A S I A N S Cultural Perspective History of Koreans in the United States Immigration Patterns Early Korean immi- gration to the United States was severely restricted by the isolationist policies of Korea. A small number of Koreans arrived before 1900, most of whom were Protestants seek- ing to escape discrimination and further their education in America. Between 1903 and 1905 Christian mis- sionaries recruited more than 7,000 Korean men, women, and children to work in Hawaiian sugarcane fields. In 1905, when Korea was under Japanese rule, overseas emigration of Koreans was barred, and in 1907 the United States entered a gentlemen’s agreement with Japan limiting both Japanese and Korean immigration. During the next seventeen years, only picture brides and oppressed political activists were permitted entry. In 1924 the Japanese Exclusion Act was applied to Koreans as well, preventing all immigration. Most early Korean immi- grants worked as field hands or in domestic service; many first- and second-generation Koreans living in urban areas were barred from professional jobs and established small businesses such as vegetable stands and restaurants.135 Between 1959 and 1971, nearly all Korean immigrants were the wives and children of U.S. soldiers who fought in the Korean War. Following relaxation of U.S. immigration laws in 1965, the numbers of Korean immigrants increased, including many college-educated, middle-class professionals and their families. Current Demographics The Korean immi- grant population has increased dramatically in recent years. According to 2008 Census estimates, over 1.7 million Koreans are living in the United States, over half of whom have arrived since 1980. More than 78 percent of Koreans in America were born in Korea, and 67 percent of those have become citizens.4 Large numbers of immigrants to the United States relocated first from North Korea to South Korea, seeking greater freedom. Kore- ans coming to America hope to find economic opportunity and to avoid any North Korean– South Korean conflict that may arise in the future. Large numbers of Koreans have settled in California, particularly Los Angeles and the New York metropolitan area. Socioeconomic Status Families working together toward the success of a small busi- ness and the purchase of a home are common. Contributing factors include high achieve- ment in education and professionalism; quick mastery of English; over 50 percent of individ- uals have college degrees; and large numbers work in management and professional posi- tions. Family median incomes were slightly above the U.S. average, and poverty rates were 15 percent.1,4 Worldview Religion In South Korea, Buddhism and Con- fucianism are the majority religions. Approx- imately 28.4 percent of South Koreans are Christian, and smaller numbers adhere to sha- manism (belief in natural and ancestral spir- its) and the national Korean religion Chundo Kyo, formerly known as Tonghak (a mixture of Confucian, Taoist, and Buddhist concepts).136 In North Korea, all religious beliefs other than the national ideology of Marxism and self- reliance are suppressed. The first Korean immigrants at the turn of the century were Christians attracted to the United States as a religious homeland. Today, 71 percent identify themselves as Christian, and there are 4,000 Korean Christian churches in the United States. Only 6 percent of Korean Americans identify themselves as Buddhists.137 Family Hundreds of years of Confucianism in Korea have significantly influenced family structure regardless of current religious affili- ation. Family is highly valued, and loyalty to one’s immediate and extended family is more important than individual wants or needs. Generational ties are more important than those of marriage, and parents are especially close to children. Korean Americans often invite family members in Korea to join them in the United States, and extended families are not uncommon. In Korea, a male is always the head of the family; if a father is unable to fulfill that role, the eldest son (even if still a child) takes on that responsibility. Birth sequence orders The economic success of South Korea has lured thousands of second- generation Korean Amer- icans to immigrate there, where they have taken positions in marketing, public relations, and the entertainment industry. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 11 3 5 3 life’s events within the family, and older male children are traditionally awarded privileges, such as advanced education, that younger children and daughters are denied. The role of women is to take care of the house and care for children. Parenting tends to be authoritative, and any child over the age of five years exhibiting inappropriate behav- ior brings disrespect on the entire family.139 Elders are esteemed and cared for in Korea. The two major birthday celebrations in Korean culture occur at age one and when an individual reaches age sixty, meaning that the person has survived a full five repeats of the twelve-year cycle of life and attained old age. The opinions of elders are respected, and after age sixty a person is allowed to relax and enjoy life. Many changes occur in the Korean fam- ily after immigration to the United States. For example, the marriage bond often becomes more important than obligations to one’s par- ents. Few elders maintain traditional arrange- ments of living with an eldest son’s family. Some live with unmarried children or with married daughters, or live alone.138 Male dom- inance has declined with increased participa- tion of women in the workplace, yet most married women assume total responsibility for home and their job and often are not paid for their work if employed in a family-owned business. Traditional Health Beliefs and Practices Traditional Korean concepts related health to happiness, to the ability to live life fully, to function without impairment, and to not be a burden on one’s children.138 A good appetite is a significant indicator of health. The Korean system of health and illness is closely related to Chinese precepts (see the section “Traditional Health Beliefs and Practices” in the Chinese part of the chapter). The proper balance of um (yin) and yang must occur to maintain health, influ- enced by the relationships of the five evolu- tive elements (fire, water, wood, metal, and earth) and ki (vital energy). Too much or too little of these forces results in illness. For example, cold, damp, heat, or wind can enter a body through the pores and then interfere with ki and weaken yang. Symptoms of the imbalance include indigestion, arthritis, and asthma. Other disruptive causes such as phys- ical exhaustion, eating too much or too little food, and spiritual intervention (by ancestors or supernatural deities) may also result in disease.140 MICHAEL HAN, Foodservice Management I am a Korean American born in South Korea, and my parents moved to the United States in 1979 when I was eight months old. Members of my father’s family came over first and then we followed. We pretty much ate Korean meals at home. Most meals consisted of short-grain (sticky) rice, kimchi, with a soup/stew. The soup contains meat (including Spam) and vegetables. My father really likes meat, so we probably had more than other Korean families, and really unusual is that he added butter as well. Now he adds olive oil instead because his cholesterol is too high. Once in a while we would have Korean barbecue, but that was for special occasions or as a treat. Dessert was mostly fruit. When I was young I wanted to eat more American food. For a while my mom would make pancakes for breakfast on the weekend, and when she stopped, I was really upset. Now I eat American food for breakfast and lunch but not dinner, and I usually have rice once a day. My aunt has taken over making kimchi for the family, but I don’t live that close to her, so I only get it once in a while. When I do have it—I eat it all the time, so my supply lasts only a week. In general, it would be hard to get Koreans in the United States to modify the amount and type of rice they eat, and I don’t think they would ever give up pickled, spicy vegetables like kimchi. N E W A M E R I C A N P E R S P E C T I V E S Korean Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 3 5 4 E A S T A S I A N S Both digestion and circulation are promi- nent in the maintenance of health, because energy is absorbed into the body through the stomach when food is mixed with air or one of the forces, and the blood distrib- utes this vital energy. Good-quality food is restorative, but too much food can block ki, resulting in cold hands and feet, cold sweats, or even fainting.138 A few Koreans attribute diabetes to eating too much rich food, such as meat, sugar, or honey, and getting too lit- tle exercise. Blood conditions that interfere with the distribution of vital energy include a lack of blood; a drying or hardening of the blood (typical in old age, causing indigestion, neuralgia, and body aches); and bad blood, caused by a sudden fright, which can result in chronic pain. Korean-specific folk illnesses often include somatic complaints that are an expression of psychological distress.141 Excessive emotions such as joy, sadness, depression, worry, anger, fright, and fear are believed to result in certain physical conditions. Hwabyung, attributed most often to anger, victimization, or stress, is associated with poor appetite, indigestion, stomach pain, chest pain, shortness of breath, weight gain, and high blood pressure among other symptoms. A study of middle-aged Korean women found that nearly 5 percent suffered from hwabyung, with rates higher in women of lower socioeconomic status, those who lived in rural areas, those who were sepa- rated or divorced, and those who smoked or drank alcohol.142,143 Han, which causes a pain- ful lump in the throat, occurs when a person suffers disappointments and regrets, such as guilt over the neglect of one’s children, par- ents, or spouse. Shinggyongshaeyak, resulting from stress (especially from oversensitivity and lack of happy interactions with fam- ily and friends), can cause insomnia, weight loss, and nervous collapse. Traditional cures include use of a shaman or spiritual mediator (mansin or mudang) to determine whether the mudang) to determine whether the mudang cause of an illness is due to disharmony with one’s ancestors or natural and supernatural forces.140 Sacred therapeutic rituals to rectify such spiritual disruptions are conducted with the patient, the family, and sometimes the community. Hanyak is the traditional approach to natu- ral cures in Korea. It is typically practiced by a hanui. When a client visits a hanui, he or she obtains a medical history, observes how the patient looks, listens to the quality of the voice, and takes the patient’s pulse. More than twenty-four pulse conditions are defined, from floating to sunken, and smooth, vacant, or accelerated.144 Hanyak medications are classi- fied according to their plant, animal, or min- eral source, and mixed in ways to balance um (yin), yang, and ki. Other physical therapies to restore harmony and vital energy, such as acu- puncture, moxibustion, cupping, and sweating (see Chapter 2), may also be applied. In the United States, the hanui may use some bio- medical procedures in conjunction with tradi- tional practices. It has been reported that some hanui take blood pressures and body tempera- tures. Some even offer the convenience of tak- ing hanyak prescriptions in pill form so that bitter-tasting broths or teas are avoided.144 Many professional Korean health practices have been popularized and may be used as home remedies. In the United States, where access to traditional healers may be limited in some regions, the mother or grandmother in the home often takes responsibility for administering these cures.145 Some Koreans believe that a person’s fate is determined by the forces of um and yang at the moment of birth. Christian Koreans may believe strongly in faith healing and in fate as determined by God. However, it does not appear to influ- ence their desire for health care or practicing health-promoting lifestyles.146 Traditional Food Habits Ingredients and Common Foods Korean cuisine is neither Chinese nor Japa- nese, although it has been influenced by both styles of cooking. It is a distinctly hearty Asian fare that is highly seasoned and instanta- neously recognizable as Korean by its flavors and colors. Sweet, sour, bitter, hot, and salty tastes are combined in all meals, and foods are often seasoned before and after cooking. Five colors—white, red, black, green, and yel- low—are also important considerations in the preparation and presentation of dishes. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 11 3 5 5 Staples Korean cooking is based on grains flavored with spicy vegetable and meat, poul- try, or fish side dishes. Korean staples are listed in Table 11.5. Rice is the foundation of the Korean diet. Rice cooking is an important skill in Korea; the rice must be neither under- done nor overcooked and mushy. Short-grain varieties are usually preferred, both a regular and glutinous (sticky) type, the latter most often in sweets. Long-grain rice, called Viet- namese rice in Korea, is available but not com- mon. Millet and barley are used, most often as extenders for rice. Noodles are also an important staple and are made from wheat, buckwheat, mung beans, and from the starch of sweet potatoes and the kudzu plant (a pervasive vine).147 The buckwheat variety is often used in cold dishes. Fritters, dumplings, and pancakes flavored with scallions, chile pepper, and sometimes fish or meat placed directly in the batter before cooking are other popular grain dishes.148 Vegetables are served at every meal. Chi- nese cabbage (both bok choy and napa), Euro- pean cabbage, and a long white radish (similar but not identical to the Japanese daikon rad- ish) are eaten most often. Eggplant, cucum- bers, perilla (a mint-family green also called shiso), chrysanthemum greens, bean sprouts, sweet potatoes, and winter melon are also very popular. Vegetables are added to soups and braised dishes and are often served individu- ally as hot or cold side dishes. Pickled, fer- mented vegetables are included at every meal, usually in the form of kimchi, which comes in many types, based on seasonal availability of produce. A common version of kimchi is made with shredded Chinese cabbage and white radish, heavily seasoned with garlic, onions, and chile peppers, then fermented. Cucumber, eggplant, turnip, and even fruits or fish are sometimes added. Some recipes are mild, but most are very hot. Seaweed is eaten as a vegetable, including kelp and laver (called kim). Kim is brushed with sesame oil, salted, and toasted to make a condiment. The seaweed called wakame in Japan is used in Korean soups.149 Fruits are eaten mostly fresh. Crisp, juicy Asian pears (known as apple pears in the United States) are very popular; apples, cherries, jujubes (red dates), plums, melons, grapes, tangerines, and persimmons are also common. Fish and shellfish are eaten throughout Korea. Fresh fish dishes are preferred near the coast or in river regions, but dried or salted fish is more common in the inland areas. Saewujeot, a Korean fermented fish sauce, is made from tiny shrimplike crusta- ceans. Saewujeot flavors many dishes. Beef and beef variety cuts are especially popular in Korea.109 Cubes, thin slices, or small ribs of marinated beef are barbecued or grilled at the table over a small charcoal brazier or gas grill. Bulgogi, grilled strips of beef flavored with garlic, onions, soy sauce, and sesame oil, is best known. Another Korean specialty is the fire pot (sinsullo), similar to the Mongo- lian hot pot, featuring beef or liver, cooked egg strips, sliced vegetables (e.g., mushrooms, car- rots, bamboo shoots, onions), and nuts that are cooked in a seasoned broth heated over charcoal. After the morsels of food have been eaten, the broth is served as a soup. Chicken and poultry are not especially popular in Korea. Soybean products, however, are com- mon, including soy sauce and soy paste. Bean curd, made from soybeans (tobu) or mung beans (cheong-po), is a favorite. Mung beans, adzuki beans, and other legumes are steamed and added to many savory and sweet dishes. Nuts, such as pine nuts, chestnuts, and pea- nuts, and toasted, crushed sesame seeds are frequent additions as ingredients or garnish. Seasonings are the soul of Korean cooking. Garlic, ginger root, black pepper, chile pep- pers, scallions, and toasted sesame in the form of oil or crushed seeds flavor nearly all dishes. Ginseng is added to some soups.149 Prepared condiments, such as soy sauce, toenjang (fertoenjang (fertoenjang - mented soy bean paste), fish sauce (saewu- jeot), and hot mustard are also frequently added to foods. Kochujang, a fermented jamKochujang, a fermented jamKochujang - like chile paste, is prepared by each family on March 3 and then traditionally stored for use throughout the year in black pottery crocks. Marinades and dipping sauces are common. Soup or a thin barley water is used as a bev- erage. Herbal teas are very popular; ginseng tea flavored with cinnamon is a favorite. Ginger, cinnamon, or citron can also be used separately To make an accurate diagnosis, a hanui must determine a client’s character through questions such as “Do you like meats or vegetables?,” “What season is your favorite?,” “Do you worry much?,” or “Are you stubborn?”144 The preparation of kimchi every autumn is a special family event. In the past a family’s wealth was demonstrated by the ingredients in their kimchi, with rare veg- etables and fruits used by the most affluent. Koreans consume over 2 tons annually. South Korea is the largest consumer of Spam out- side the United States. It is believed that a Por- tuguese Catholic priest introduced chile pep- pers into Korea in the sixteenth century. They were quickly adopted and have become ubiq- uitous in the cuisine. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 3 5 6 E A S T A S I A N S TA B L E 11. 5 Cultural Food Groups: Koreans Group Comments Common Foods Adaptations in the United States Protein Foods Milk/milk products Milk and milk products are generally not consumed or used in cooking. Milk, yogurt, and cheese product consumption increases. Meat/poultry/ fish/eggs/ legumes Beef and beef variety cuts are especially popular. Barbecuing is a popular method for cooking meat. Fish and shellfish, either fresh, dried, or salted, are eaten throughout Korea. Soybean products are added to many dishes. Meat: beef, variety meats (heart, kidney, liver), oxtail, pork Fish and shellfish: abalone, clams, codfish, crab, cuttlefish, jellyfish, lobster, mackerel, mullet, octopus, oysters, perch, scallops, sea cucumber, shad, shrimp, squid, whiting Poultry and small birds: chicken, pheasant Eggs: hen Legumes: adzuki, lima beans, mung beans, red beans, soybeans Beef, pork, and poultry consumption rises. Fish is eaten frequently. Many still consume tofu several times a week. Younger Korean Americans may consume more pork products. Cereals/Grains Rice is the most important component of the Korean diet. Noodles made from wheat, mung bean, or buckwheat flours are an important staple. Barley, buckwheat, millet, rice (short- grain glutinous), wheat Rice consumption declines, but it is still eaten every day. Breads, cereals, and pasta popular with well-acculturated Korean Americans. Fruits/Vegetables A wide variety of fruits are consumed. Vegetables are often pickled and are eaten at every meal. Fruits: apples, Asian pears, cherries, dates (jujubes, red date), grapes, melons, oranges, pears, persimmons, plums, pumpkin, tangerines Vegetables: bamboo shoots, bean sprouts, beets, cabbage (Chinese, European), celery, chives, chrysanthemum leaves, cucumber, eggplant, fern, green beans, green onion, green pepper, leaf lettuce, leeks, lotus root, mushrooms, onion, peas, perilla (shiso), potato, seaweed (kim), spinach, sweet potato, turnips, water chestnut, watercress, white radish Increased intake of fruits and vegetables is noted. The majority eat kimchi daily.kimchi daily.kimchi Additional Foods Seasonings Sweet, sour, bitter, hot, and salty tastes are combined in all meals. Dishes are often seasoned during and after cooking. Chile peppers (kochujang—fermented chile paste), Chinese parsley (cilantro), chrysanthemum greens, cinnamon, garlic, ginger root, green onions, MSG, hot mustard, red pepper sauce, pine nuts, rice wine, saewujeot (fermented saewujeot (fermented saewujeot fish sauce), sesame seed oil, sesame seeds, soy sauce, sugar, vinegar, sea salt Nuts/seeds Chestnuts, gingko nuts, hazelnuts, peanuts, pine nuts, pistachios, sesame seeds, walnuts Beverages Herbal teas are popular, as well as rice tea. They are commonly served after the meal. Soup or barley water is used as a beverage with the meal. Barley water, beer, coffee, fruit drinks, green tea, honey water, jasmine tea, magnolia flower drink, rice tea, rice water, rice wine, soju (sweet potato vodka), spiced teas (ginseng, cinnamon, ginger), wines made from other ingredients Hot barley water is still the preferred beverage and is served after the meal. Increased consumption of soft drinks. Fats/oils Animal fat is rarely used. Sesame oil, vegetable oils Sweeteners Sweets are made for snacks and special occasions. Honey, sugar Cookies and other sweets popular with Korean American youth. © C en ga ge L ea rn in g Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 11 3 5 7 to make a spice tea. A common drink is rice tea, made by pouring warm water over toasted, ground rice or by simmering water in the pot in which rice was cooked. On special occasions, wine might be served. Wines are made from rice and other grains; some include various flower blossoms or ginseng as flavorings. Beer is also well liked. Milk and other dairy products are generally not consumed or used in cooking. Meal Composition and Cycle Daily Patterns Three small meals, with fre- quent snacking throughout the day, are typical in Korea. Breakfast was traditionally the main meal in Korea, but today is more likely to be something light, caught on the run. Soup is almost always served at break- fast, along with rice (usually as gruel). Eggs, meat or fish, or vegetables may top the meal. Kimchi and dipping sauces are the usual accompaniments. Lunch is typically noodles served with broth of beef, chicken, or fish and garnished with shellfish, meat, or vegetables. Supper is more similar to breakfast, but with steamed rice. In many modern homes, it has become the main meal of the day. Snacks are widely available from street vendors, including grilled and steamed tidbits of all types. Sweets, such as rice cookies and cakes, or dried fruit (espe- cially persimmons) are also popular snacks. Rice is considered the main dish of each meal. Everything else is served as an accom- paniment to the rice and is called panch’an. For dinner, at least one meat or fish dish is included, if affordable, and two or three veg- etables are usually served. Kimchi is always offered. Soup is very popular and is served at most meals. Individual bowls of rice and soup are served to each diner, and panch’an dishes are served on trays in the center of the table for communal eating. Wine may be served before the meal with appetizers such as batter-fried vegetables, seasoned tobu, pickled seafood, meatballs, or steamed dumplings. Dessert is seldom eaten, although fresh fruit sometimes concludes the meal. Hot barley water or rice tea is served with the meal. Drinking is a social ritual, practiced mostly by men. Distilled beverages like soju, a sweet potato vodka, are consumed with snacks like spicy squid or chile peppers stuffed with beef. A special category of foods, called anju, are considered an alternative to a full meal. Analogous to tapas in Spain (see Chapter 6), they are small dishes especially well suited to eating while socializing and drink- ing.109 Examples include scallion-flavored pancakes usually accompanied by Korean rice wine, mukhuli, Japanese-style sashimi, quail eggs, bits of pork, raw crab in chile paste, or dumplings. These items are often served as appetizers in Korean American restaurants. Etiquette Chopsticks and soup spoons are the only eating utensils used in Korea. In the past, seating was around a low, rectangular table on the floor, and young women were assigned the awkward corner seats (today most tables are set with chairs). Traditionally, elders are served first, and children are served last at the meal. It is considered polite to fill the soy sauce dish of the people one is sitting beside. Food is always passed with the right hand, and a communal beverage may be passed for all to share. Special Occasions Korean cooking was histor- ically divided into everyday fare and cuisine for royalty. The traditions of palace cooking and food presentation, including the use of numerous ingredients in elaborate dishes, are At Korean weddings, sweetened dates rolled in sesame seeds are tossed at the bride by her in-laws to ensure health, prosperity, and numer- ous children. Dog meat soup is eaten by some men to enhance their strength and physi- cal prowess. Boyak is often given as a gift, particularly to one’s parents, to promote long life. ▲ Korean street vendors shredding daikon for the preparation of the spicy vegetable pickle kimchi. M ic ha el F re em an /E nc yc lo pe di a/ Co rb is Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 3 5 8 E A S T A S I A N S seen today in meals for special occasions. At a meal celebrating a birthday or holiday, or one shared with guests, more dishes are served and both wine and dessert are offered. For special occasions, Koreans offer a thick drink of persimmons or dates, nuts, and spices, or a beverage made with molasses and magnolia served with small, edible flowers floating on top. Both Koreans and Korean Americans cel- ebrate several holidays throughout the year. The first is New Year’s, called Sol, a three-day event at which traditional dress is worn and the elders in the family are honored. Festivi- ties include feasts, games, and flying kites. On the first full moon, in a tradition reflecting ancient religious rites, torches are lighted, and firecrackers are set off to frighten evil spirits away. Shampoo Day (Yadu Nal) on June 15 is when families bathe in streams to ward off fevers. Thanksgiving (Chusok) is a fall harvest festival; duk, steamed rice cakes filled with chestnuts, dates, red beans, or other items, are associated with the holiday. A special ceremony is observed on a child’s first birthday. He or she is dressed in tradi- tional clothing and placed among stacks of rice cakes, cookies, and fruit. Family and friends offer the child objects symbolizing various professions, such as a pen for writ- ing or a coin for finance, and the first one accepted is thought to predict his or her future career.135 Therapeutic Uses of Food Many Koreans follow the um and yang food classification system. Little has been reported about specific foods, although Koreans are believed to adhere to categorizations simi- lar to other Asians: um (cold) foods include mung beans, winter melon, cucumber, and most other vegetables and fruits; meats (e.g., beef, mutton, goat, dog), chile peppers, gar- lic, and ginger are considered yang (hot) foods. Preparation of healthy, tasty food is an important way that Korean women show affection for family and friends.138,148 Good appetite is considered a sign of good health. Foods that are believed to be health promot- ing include bean paste soup, beef turnip soup, rice with grains and beans, broiled seaweed, kimchi, and ginseng tea. Ginseng products are often used to promote health and stamina and to alleviate tiredness. One very popular tonic, called boyak, combines ginseng and deer horn or bear gallbladder.144 More than one-half of Korean American respondents in one survey reported using ginseng, with older women more likely to use such products than men or younger women.150 Other home remedies commonly used include ginger tea, yoojacha (hot cit- rus beverage), bean sprout soup, and lemon with honey in hot water. Restorative herbal medicines, vitamin supplements, meat soups, bone marrow soup, and samgyetang (game- hen soup) also were mentioned by subjects as useful when feeling weak. A study of pregnant Korean American women suggests that certain foods, such as seaweed soup, beef, and rice, are thought to build strength during this difficult time.151 Food taboos during pregnancy often involve the concept of “like causes like.” For instance, eating blemished fruit may result in a baby with skin problems. Other such items men- tioned are chicken, duck, rabbit, goat, crab, sparrow, pork, twin chestnuts, and spicy foods. Although most food avoidance was attributed to personal preference and availability, many of the women acknowledged familiarity with the traditional beliefs. Korean women tradi- tionally consumed seaweed soup, miyuk kook, three times a day for seven weeks after the birth of a child to restore their strength. ▲ Korean Americans cel- ebrate Sol, or the New Year, on the first full moon. G ar y Co nn er /P ho to Ed it Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 11 3 5 9 Contemporary Food Habits in the United States Adaptations of Food Habits Ingredients and Common Foods A survey of Korean Americans in the San Francisco area showed that many traditional Korean food habits continue after immigration to the United States. Nearly all respondents ate rice at one meal every day, and two-thirds ate kimchi daily. Beef and beef variety cuts were consumed regularly, and fish was eaten at least once a week. Sesame oil/seeds and vegetable oils were used more often than butter or may- onnaise. Soy sauce, soybean paste, kochujang, and garlic were the most popular condiments. More than 40 percent of Korean Americans surveyed consumed tobu several times a week. Pork and pork products were not commonly eaten, although younger respondents reported more frequent use of these foods than older subjects. Length of stay in the United States had little impact on diet.152 Among Korean American adults in Chicago, only one-third reported increased intake of beef, dairy prod- ucts, bread, coffee, and soda (combined with decreased consumption of fish and rice), and a majority continued to follow Korean dietary patterns.153 A national study of mostly first-genera- tion Korean Americans found similar trends. Regular consumption continued of some tra- ditional dishes and ingredients, such as rice, kimchi, garlic, scallions, Korean soup, sesame oil, Korean stew, soybean paste, and kochu- jang. Frequently consumed American foods included oranges, low-fat milk, bagels, toma- toes, and bread. Regularly eaten foods com- mon to both cultures included onions, coffee, apples, eggs, beef, carrots, lettuce, fish, and tea. The researchers found that most respondents had access to Korean items, but as participa- tion in American social life increased, accep- tance of American foods increased. Persons who had someone familiar with Korean fare to cook for them were more likely to continue eating traditional dishes than were those who cooked for themselves.154 In contrast, one study of Korean Ameri- cans, in New York found that while less acculturated adults consumed a relatively traditional Korean diet, well-acculturated adults consumed significantly more bread, cereals, spaghetti, ham, green salad, corn, chocolate, candies, and diet soft drinks.155 Another study reported that well-acculturated Korean American mothers were less likely to prepare Korean dishes at home and were more likely to dine out.156 Research on Korean, Korean American, and American adolescents found that Korean American teens adopted a diet in-between that of traditional Korean and American food patterns, eating less rice and kimchi, but more cookies and other sweets and soft drinks.157 Although milk and dairy products are not consumed in Korea, these foods are often well accepted in the United States. One study indicated that more than one-half of the subjects reported drinking milk or eat- ing yogurt or cheese one or more times each week.152 Another study of pregnant Korean American women reported a similar finding that 56 percent of respondents drank milk daily.151 Korean American adolescent boys were found to consume milk at 22 percent of meals, and teen girls drank it at 17 percent of meals.157 S A M P L E M E N U Dinner in Korea S oy b e an S pr out S oup a,b Bulgogi (K or e an B ar b e cue Be e f ) a,b S e as on e d Tobu S e as on e d Tobu S e as on e d ( B e an C u r d ) , a C h r y s an t h e m u m L e af S al ad aC h r y s an t h e m u m L e af S al ad aC h r y s an t h e m u m L e af S al ad S e as on e d E g gplan t a S t e ame d R ic e , Kimchi A pple P e ar Bar le y W at e r or G in s e n g T e a aKwak, J. 1998. Dok Suni: Recipes from my mother’s Korean kitchen. New York: St. Martin’s Press. bKorean Recipes at http://koreanrecipes.org/ Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 3 6 0 E A S T A S I A N S It should be noted that many changes in the traditional diet have been observed in Korea. A study of adolescents found only 30 percent consumed a diet dependent on rice and kimchi, while 70 percent ate a modified diet with added bread, noodles, cookies, pizza, and hamburgers.158 Recent immigrants from Korea may prefer a more Westernized diet than earlier immigrants, even when length of stay is shorter. Korean American Cuisine Koreans have blended their traditional flavoring and cook- ing techniques to American foods. One of the better-known dishes is the Korean taco, a Mexican corn tortilla with Korean style fill- ings, such as bulgogi (grilled beef ) and kim- chi. It started in a food truck in Los Angeles and rapidly spread across the country, espe- cially in metropolitan areas. Other examples of Korean fusion dishes are kimchi que- sadillas, short rib sliders, and Korean fried chicken. Meal Composition and Cycle Little has been reported regarding Korean American meal composition and cycle. It is assumed that because Korean meal and snacking patterns are similar to those in the United States, three meals a day remain common. One study found American foods were most popular at breakfast and lunch, but traditional Korean dishes were favored for dinner.159 Elderly Korean Americans are more likely to con- sume a Korean meal pattern for most of their meals.160 Survey data suggest that hot barley water served after meals is still the preferred beverage of Korean Americans.152 Accul- turation and/or length stay has been found to increase the frequency of eating out for Korean Americans.161,162 Korean Americans observe traditional Korean holidays (see “Special Occasions” in this section) as well as other events, such as Buddha’s birthday (April 8), Korean Memo- rial Day (June 6), South Korean Constitution Day (July 17), and Korean National Founda- tion Day (October 3). Fathers are honored on June 15. In addition, Christian Americans of Korean descent celebrate the major religious holidays. Nutritional Status Nutritional Intake Few health studies focusing on Korean Americans have been published. Most research on Asian Americans combines heterogeneous Asian and sometimes Pacific Islander populations. One study found that Korean Americans maintained a relatively traditional diet and that even with the addi- tion of some American foods, 60 percent of calories came from carbohydrates and only 16 percent from fat.153 Higher intakes of vita- mins A and C, beta-carotene, niacin, and fiber are associated with a more traditional diet. High sodium intake is also common when Korean foods are preferred.153,155,157,163 Korean Americans who adopt more American foods are reported to consume more calories and have higher intakes of total fat, saturated fat, cholesterol, B1, vitamin E, folate, iron, and zinc. Calcium, which is often deficient in the Korean diet, is increased with the use of dairy products. A survey of Korean Americans con- ducted in a midwestern city found that those with the worst eating habits were younger, not married, less educated, and more acculturated to mainstream American culture.164 Self-reported health behaviors and medical disorders indicate that 22 percent of Korean Americans smoke cigarettes, less than 10 percent drink moderately or heavily, 40 percent are physically inactive, and 30 percent overweight or obese. Their reported medical disorders were: 4.4 percent heart disease and 17 percent hypertension, 4 percent type 2 diabetes, 11 percent ulcers, cancer was less than 2 percent, and hepatitis B was 6 percent.65,158,159,172,173 Age-adjusted mortality rates for Korean Americans are lower than for the general population, although infant mortality rates are somewhat higher than those for whi tes.76,77,165,166 The more common causes of death among Koreans is stomach cancer; higher incidence of stomach, liver, and esoph- ageal cancers have been found among Korean Americans as compared to whites.73,167,168,169 However, self-reported incidence of digestive diseases decreased with increase length of res- idence in the United States but increased with more servings of rice or rice dishes.169 The rate Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 11 3 6 1 of hepatitis B (responsible for most liver can- cer) is very high in Korean Americans. Self-reported health behaviors and medi- cal disorders showed that 22 percent of Kore- ans smoke cigarettes, less than 10 percent drink moderately or heavily, 40 percent were physically inactive and 30 percent overweight or obese. Reported medical disorders were heart disease (4.4 percent), hypertension (17 percent), type 2 diabetes (4 percent), ulcers (11 percent), cancer (less than 2 percent), and hepatitis B (6 percent).65,171,172,173,184,186 Other research also reported high blood pressure rates in Korean Americans, but were not consistent in being higher or lower than the U.S. average.170,175,176,177,178 In Korea, hyper- tension affects 42 percent of the population.174 No correlation with diet (including alcohol, spicy food, or salt intake) was noted.179 Korean Americans diagnosed with high blood pres- sure are less likely to take hypertension medi- cations or to follow their physician’s advice on losing weight or lowering sodium intake.177,180 Incidence of death from heart disease also has been found to be very low. Information on obesity in Korean Ameri- cans is limited. One study found that 46 per- cent of Korean Americans living in California were overweight or obese.181 More recently, a literature review determined that first-gener- ation, foreign-born Koreans had significantly higher five-year increases in BMI, which was not associated with length of U.S. residence that is normally seen in other foreign-born Americans.182 Koreans have higher alcohol consump- tion rates compared to other Asian groups.183 However, for 77 percent of Korean Americans, drinking occurred at social occasions.132 Counseling Korean American clients are similar to many Asians in that language bar- riers may interfere with counseling. Proficient translators and cultural interpreters are often crucial to effective communication. Cultural attitudes may also interfere with health care. A client may be ashamed of needing help and fear being a burden to other family mem- bers during illness. Many Korean Americans avoid screening exams.139,185 The stresses of acculturation may be especially severe in the Korean American community due to the large number of recent immigrants. Koreans use a quiet, nonassertive approach to conversation. Emotional expression over pleasant topics may be animated, but dur- ing confrontation, emotional displays are avoided.21 Loud talking or laughing is con- sidered impolite (although some Koreans may laugh excessively when embarrassed). A mea- sured, indirect approach to topics is appreci- ated. Koreans may be hesitant to say no or to disagree with a statement. Instead, tipping the head back and sucking air through the teeth are often used to signal dissension. Direct eye contact is expected, and it is used to demon- strate attentiveness and sincerity. Koreans use few hand gestures when talking. Touching is uncommon, except for a light, introductory handshake between men. Hugging, kissing, and back patting should be avoided, as should crossing one’s legs or putting feet on the fur- niture. Rising whenever an elder enters the room and touching the palm of the left hand to the elbow of the right arm when shaking hands or passing an item to an elder is con- sidered respectful.91,187 The family is responsible for all its members and is usually involved in health care. In one study it was found that most Korean Americans believed a patient should not be told of a ter- minal illness, and the family should make any life support decisions, although younger, bet- ter educated, and wealthier Korean Americans were more open to patient autonomy.186,188,189 It also is helpful to determine who is head of the household (often the father, eldest son, or other male member). Some Koreans find biomedi- cal health systems very unsatisfactory. They become frustrated when a physician relies on lab tests to determine illness, especially if they are told there is no reason for a specific com- plaint, or conversely, that some problem exists even though they have no symptoms. They also may disagree with the cause of a complaint; some somatic symptoms may result from emotional distress, yet mental illness is highly stigmatized. Furthermore, they may expect physical treatments (e.g., acupuncture or cup- ping) from the provider and are likely to want a As with other Asians who use moxibustion or cupping, it is important for health care providers to determine the cause of burns and bruises on clients before assuming abuse has occurred. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 3 6 2 E A S T A S I A N S permanent cure.138 Inconvenient hours and the need for an appointment may also discourage the use of biomedical health care. In the United States, clients often administer home remedies and consult shamans or hanui before (or while) they seek advice from biomedi- cal health care providers.176 There is concern regarding the safety of some traditional products and overmedication due to herbal remedies used simultaneously with prescriptive medications.140 For example, clamshell powder (haigefen) may cause stomach and muscle pain or fatigue from lead toxicity.139 Korean Americans must some- times choose between treatments when tradi- tional and biomedical health practitioners work at cross purposes; professionals of both systems have been known to advise clients against using the services of the other.141,189 Religious affiliation varies in Korean Ameri- can clients and may have a significant impact on health and nutritional care. One study found that the influence of messages from religious leaders and congregants that discouraged excessive eat- ing or encouraged exercise was associated with fewer overweight or obese in Korean American congregants.190 An in-depth interview should be used to ascertain religious beliefs, degree of acculturation, traditional health practices used, and personal dietary preferences. Review Questions 1. List the countries for each region of Asia: East Asia, Southeast Asia, and South Asia. 2. Visit a Chinese restaurant or just look at the menu. Can you tell which region of China the recipes represent? How? Why do so many Chinese restaurants in the United States cook Cantonese style (Guangdong)? 3. What are the basic tenets of Confucianism, Taoism, and Buddhism? How might these reli- gions influence Asian food culture? 4. Describe what is meant by Traditional Chinese Medicines, Kanpo, and Hanyak. How might these be integrated into the Chinese, Japanese, and Korean meaning of a balanced diet and life? 5. What are the staples of the Asian diet? Describe some common foods derived from soybeans. What are different types of tea from Asia— describe how they differ, including their tastes. 6. How did the Chinese influence the cuisine and worldview of the Koreans and the Japanese? Provide two example of their influence, one each in Korea and Japan. References 1. U.S. Census Bureau. n.d. Selected population pro- file in the U.S. 2013 American Community Survey 1-Year Estimates, Table S0201. 2. U.S. Census Bureau. 2011. Asian alone or in combination with one or more other races, and with one or more Asian categories for selected groups. 3. Gould-Martin, K., & Ngin, C. 1981. Chinese Americans. In A. Harwood (Ed.), Ethnicity and medical care. Cambridge, MA: Harvard University Press. 4. Demographics of Asian Americans. April 4, 2013. Pew Research Center. Retrieved from http://www. pewsocialtrends.org/2013/04/04/asian-groups- in-the-u-s/ (accessed March 12, 2015). 5. Wang, L.L.C. 2000. Chinese Americans. In R.V. Dassanowsky & J. Lehman (Eds.), Gale encyclo- pedia of multicultural America. Farmington Hills, MI: Gale Group. 6. Jones, J. S. 2000. Taiwanese Americans. In R.V. Dassanowsky & J. Lehman (Eds.), Gale encyclo- pedia of multicultural America. Farmington Hills, MI: Gale Group. D I S C U S S I O N S T A R T E R S Examining the Diet of Asian Americans In small groups of three or four, compare and contrast the diet and culture of Chinese Americans, Japanese Americans, and Korean Americans, with each group focusing on a different aspect of the diet and culture of these groups: Within your group, try to come to a consensus on what findings to report to the rest of the class. Before breaking up, assign a number to each group member: A1, A2, A3, A4; B1, B2, and so forth. Form new groups with all the 1’s in a group; all the 2’s in another group; all the 3’s another group; and so on. In your new group, report the findings of your previous group, and, as a group, discuss the relationship of traditional attitudes toward diet and health and changes in diet and health due to immigration to the United States. Group A: The food habits and the typical eating etiquette and meal composition of these three immigrant groups Group B: Issues involved in counseling these immigrant groups on diet and health Group C: Attitudes within each immigrant group toward diet, health, and medical treatment, notably attitudes toward traditional home culture medical treatment and U.S. biomedicine Group D: Amount of obesity, diabetes, hypertension, and other diseases within each immigrant group Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 11 3 6 3 7. Flaws, B., & Sionneau, P. 2001. The treatment of modern Western medical diseases with Chinese medicine: A textbook and clinical manual. Boul- der, CO: Blue Poppy Press. 8. Goldberg, B. 2002. Alternative medicine: The definitive guide (2nd ed.). Berkeley, CA: Celestial Arts. 9. Ludman, E.K., Newman, J.M., & Lynn, L.L. 1989. Blood-building foods in contemporary Chinese populations. Journal of the American Dietetic Association, 89, 1122–1124. 10. Anderson, E.N. 1987. Why is humoral medi- cine so popular? Social Science and Medicine, 25, 331–337. 11. Molony, D. 1998. The American Association of Oriental Medicine’s complete guide to Chinese herbal medicine. New York: Berkley. 12. Ots, T. 1990. The angry liver, the anxious heart and the melancholy spleen: The phenomenology of perceptions in Chinese culture. Culture, Medi- cine, and Psychiatry, 14, 21–58. 13. Wu, A.P.W., Burke, A., & LeBaron, A. 2007. Use of traditional medicine by immigrant Chinese patients. Family Medicine, 39(3), 195–200. 14. Newman, J.M. 2004. Food culture in China. West- port, CN: Greenwood Press. 15. Newman, J.M. 2006. Iron eggs: Taiwanese snacks. Flavor & Fortune, 13(1), 5. 16. Menzel, P., & D’Alusio, F. 1998. Man eating bugs: The art and science of eating insects. Berkeley, CA: Ten Speed Press. 17. Hahn, E. 1968. The cooking of China. New York: Time-Life Books, Inc. 18. Newman, J.M. 1998. China: Transformations of its cuisine, a prelude to understanding its people. Journal for the Study of Food and Society, 2, 5–6. 19. Newman, J.M. 1999. Fujian, the province and its foods. Flavor & Fortune, 6(2), 13, 20. 20. Newman, J.M. 2005. Wraps, Chinese style. Flavor & Fortune, 12(2), 24. 21. Foster, D. 2000. The global etiquette guide to Asia. New York: Wiley. 22. Ludman, E.K., & Newman, J.M. 1984. Yin and yang in the health-related practices of three Chinese groups. Journal of Nutrition Education, 16, 3–5. 23. Pillsbury, B.L.K. 1978. “Doing the month”: Con- finement and convalescence of Chinese women after childbirth. Social Science & Medicine, 12, 11–12. 24. Sun, H.P. 1996. Dietary habits, health beliefs, and food practices of Chinese Americans living in the San Francisco Bay Area. Unpublished master’s thesis, California State University, San Jose. 25. Newman, J.M. 1998. Chinese ingredients: Both usual and unusual. In J.M. Powers (Ed.), Cathay to Canada: Chinese cuisine in transition. Willowdale, Canada: Ontario Historical Society. 26. Cheng, J.T., & Yang, R.S. 1983. Hypoglycemic effect of guava juice in mice and human subjects. American Journal of Clinical Nutrition, 11, 74–76. 27. Spector, R.E. 2004. Cultural diversity in health and illness (6th ed.). Upper Saddle River, NJ: Pearson Education. 28. Koo, L.C. 1984. The use of food to treat and pre- vent disease in Chinese culture. Social Science and Medicine, 18, 757–766. 29. Sit, C., David, L., & Yeung, L. (2001). The growth and feeding patterns of 9 to 12 month old Chi- nese Canadian infants. Nutrition Research, 21, 505–516. 30. Liu, S., Sucher, K., & McProud, L. 2005, August. Use of Chinese herbs for Chinese infant feed- ing in the San Francisco Bay Area. Journal of the American Dietetic Association, 105(8, Suppl.), 23. 31. Yun, W. (1996). A growing kid. Hong Kong, China: Sun Ya. 32. Campbell, T., & Chang, B. 1981. Health care of the Chinese in America. In G. Henderson & M. Primeaux (Eds.), Transcultural health care. Menlo Park, CA: Addison-Wesley. 33. Lv, N., & Brown, J.L. 2010, March–April. Chinese American family food systems: Impact of West- ern influences. Journal of Nutrition Education and Behavior, 42(2), 106–114. 34. Chau, P., & Lee, H.S. 1987. Dietary habits, health beliefs, and related food practices of female Chinese elderly. Master’s project, California State Univer- sity, San Jose. 35. Tseng, M., & Hernandez, T. 2005. Comparison of intakes of US Chinese women based on food frequency and 24-hour recall data. Journal of the American Dietetic Association, 105, 1145–1148. 36. Satia, J.A., Patterson, R.E., Taylor, V. M., Cheney, C.L., Thornton, S., Chitnarong, K., & Kristal, A.R. 2000. Use of qualitative methods to study diet, acculturation, and health in Chinese American women. Journal of the American Dietetic Associa- tion, 100, 934–940. 37. Lv, N., & Cason, K.L. 2004. Dietary pattern change and acculturation of Chinese Americans in Pennsylvania. Journal of the American Dietetic Association, 104, 771–778. 38. Satia, J.A., Patterson, R.E., Kristal, A.R., Hisiop, T.G., Yasui, Y., & Taylor, V.M. 2001. Development of scales to measure dietary acculturation among Chinese Americans and Chinese-Canadians. Journal of the American Dietetic Association, 101, 548–553. 39. Satia-Abouta, J., Patterson, R.E., Kristal, A.R., Teh, C., & Tu, S.P. 2002. Psychosocial predic- tors of diet and acculturation in Chinese Ameri- can and Chinese Canadian women. Ethnicity & Health, 7, 21–39.7, 21–39.7 40. Schultz, J.D., Spindler, A.A., & Josephson, R.V. 1994. Diet and acculturation in Chinese women. Journal of Nutrition Education, 26, 266–272. 41. Ishii, S., Cauley, J.A., Greendale, G.A., Danielson, M.E., Safae iNili, N., Karlamangl, A. 2012, April. Ethnic differences in composite indices of femo- ral neck strength. Osteoporosis International, 23(4), 1381–1390. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 3 6 4 E A S T A S I A N S 42. Spindler, A.A., & Schultz, J.D. 1996. Comparison of dietary variety and ethnic food consumption among Chinese, Chinese American, and white women. Journal of Agriculture and Human Values, 131, 64–73. 43. Liu, A., Berhane, Z., & Tseng, M. 2010, March. Improved dietary variety and adequacy but lower dietary moderation with acculturation in Chinese women in the United States. Journal of the Ameri- can Dietetic Association, 110(3), 457–462. 44. Pan, Y.L., Dixon, Z., Himburg, S., & Huffman, F. 1999. Asian students change their eating patterns after living in the United States. Journal of the American Dietetic Association, 99, 54–57. 45. Chau, P., Lee, H.S., Tseng, R., & Downes, N.J. 1990. Dietary habits, health beliefs, and food practices of elderly Chinese women. Journal of the American Dietetic Association, 90, 579–580. 46. Zhou, Y.D., & Britten, H.C. 1994. Increased iron content of some Chinese foods due to cooking in steel woks. Journal of the American Dietetic Asso- ciation, 94, 1153–1154. 47. Kim, K.K., Yu, E.S., Liu, W.T., Kim, J., & Kohrs, M.B. 1993. Nutritional status of Chinese-, Korean-, and Japanese American elderly. Jour- nal of the American Dietetic Association, 93, 1416–1422. 48. Lauderdale, D.S., & Rathouz, P.J. 2002. Body mass index in a US national sample of Asian Ameri- cans: Effects of nativity, years since immigration and socioeconomic status. International Journal of Obesity, 24, 1188–1194. 49. McNeely, M.J., & Boyko, E.J. 2004. Type 2 diabetes prevalence in Asian Americans. Diabetes Care, 27, 27, 27 66–69. 50. Popkin, B.M., & Udry, J.R. 1998. Adolescent obe- sity increases significantly in second and third generation U.S. immigrants: The National Lon- gitudinal Study of Adolescent Health. Journal of Nutrition, 128, 701–706. 51. Barnes P.M., Adams P.F., & Powell-Griner, E. 2008. Health characteristics of the Asian adult population: United States, 2004–2006. Advance data from vital and health statistics; no 394. Hyattsville, MD: National Center for Health Statistics. 52. Yeh, M.C., Fahs, M., Shelley, D., Yerneni, R., Parikh, N.S., & Burton, D. 2009. Body weight and length of residence in the US among Chinese Americans. Journal of Immigrant and Minority Health, 11(5), 422–427. 53. Liou, D., & Bauer, K. 2010, September. Obesity perceptions among Chinese Americans: The interface of traditional Chinese and American val- ues food, culture and society. International Journal of Multidisciplinary Research, 13(3), 351–369. 54. Chen, M.S. 2005. Cancer health disparities among Asian Americans. Cancer, 104, 2895–2902. 55. Chen, J.L. 2009. Household income, maternal acculturation, maternal education level and health behaviors of Chinese American children and mothers. Journal of Immigrant and Minority Health, 11(3), 198–204. 56. Xu, C., Yang, X., Zu, S., Han, S., Zhang, Z., & Zhu, G. 2008. Association between serum lipids, blood pressure, and simple anthropometric measures in an adult Chinese population. Archives of Medical Research, 39(6), 610–617. 57. Lutsey, P.L., Pereira, M.A., Bertoni, A.G., Kandula, N.R., & and Jacobs, D.R. 2010. Interactions between race/ethnicity and anthropometry in risk of incident diabetes: The multi-ethnic study of atherosclerosis. American Journal of Epidemiol- ogy, 172(2), 197–204. 58. Lear, S.A., Chen, M.M., Frohlich, J.J., & Birmingham, C.L. 2002. The relationship between waist circumference and metabolic risk factors: Cohorts of European and Chinese descent. Metabolism, 51, 1427–1432. 59. Case, K.O., Brahler, C.J., & Heiss, C. 1997. Resting energy expenditures in Asian women measured by indirect calorimetry are lower than expenditures calculated from prediction equations. Journal of the American Dietetic Association, 97, 1288–1292.97, 1288–1292.97 60. Liu, H.Y., Lu, Y.F., & Chen, W.J. 1995. Predictive equations for basal metabolic rate in Chinese adults: A cross-validation study. Journal of the American Dietetic Association, 95, 1403–1408. 61. Wouters-Adriaens, M.P., & Westerterp, K.R. 2008, October. Low resting energy expenditure in Asians can be attributed to body composition. Obesity, 16(10), 2212–2216. 62. Wong, W., Tang, N.L.S., Lau, T.K., & Wong, T.W. 2000. A new recommendation for maternal weight gain in Chinese women. Journal of the American Dietetic Association, 100, 791–796. 63. Centers for Disease Control and Prevention. 2012. Summary health statistics for U.S. adults: 2011, Table 8. Retrieved from http://www. cdc.gov/nchs/data/series/sr_10/sr10_256 (accessed March 12, 2015). 64. Centers for Disease Control and Prevention. 2008. Health characteristics of the Asian adult population: United States, 2004–2006, Table 2. Retrieved from http://www.cdc.gov/nchs/data/ ad/ad394 (accessed March 12, 2015). 65. Shai, I., Jiang, R., Manson, J.E., Stampfer, M.J., Willett, W.C., Colditz, G.A., & Hu, F.B. 2006. Ethnicity, obesity, and risk of type 2 diabetes in women: A 20-year follow-up study. Diabetes Care, 29, 1585–1590. 66. Barnes P.M., Adams P.F., & Powell-Griner, E. 2008. Health characteristics of the Asian adult pop- ulation: United States, 2004–2006. Advance data from vital and health statistics; no 394. Hyatts- ville, MD: National Center for Health Statistics. 67. Kramer, H., Han, C., Post, W., Goff, D., Diez-Roux, A., Cooper, R., . . . Shea, S. 2004. Racial/ethnic differences in hypertension treat- ment and control in the multi-ethnic study of atherosclerosis (MESA). American Journal of Hypertension, 17, 963–970.17, 963–970.17 Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 11 3 6 5 68. Fang, J., Foo, S.H., Jeng, J.S., Yip, P.K., & Alderman, M.H. 2004. Clinical characteristics of stroke among Chinese in New York City. Ethnicity & Disease, 14, 378–383. 69. Palaniappan, L.P., Wong, E.C., Shin, J., Fortmann, S.P., & Lauderdale, D.S. 2010, August 3. Asian Americans have greater prevalence of metabolic syndrome despite lower body mass index. Inter- national Journal of Obesity. 70. Newman, J.M. 2000. Chinese meals. In H.L. Meiselman (Ed.), Dimensions of the meal: The science, culture, business, and art of eating. Gaith- ersburg, MD: Aspen. 71. Wang, Y., Mi, J., Shan, X.Y., Wang, Q.J., & Ge, K.Y. 2007. Is China facing an obesity epidemic and the consequences? The trends in obesity and chronic disease in China. International Journal of Obesity, 31, 177–188. 72. National Cancer Institute. 2013. Seer cancer sta- tistics review, 1975–2010, Tables 2.15 through 24.15. Retrieved from http://seer.cancer.gov/ csr/2010sections.html (accessed March 12, 2015). 73. Gomez, S.L., Clarke, C.A., Shema, S.J., Chang, E.T., Keegan, T.H.M., & Glaser, S.L. 2010, May. Disparities in breast cancer survival among Asian women by ethnicity and immigrant status: A pop- ulation-based study. American Journal of Public Health, 100(5), 861–869. 74. Centers for Disease Control and Prevention. 2012. Healthy people 2010 database, Table 14-03a. Retrieved from http://wonder.cdc.gov/scripts/ data2010 (accessed March 12, 2015). 75. Miller, B.A., Chu, K.C., Hankey, B.F., & Ries, L.A.G. 2008. Cancer incidence and mortality pat- terns among specific Asian and Pacific Islander populations in the US. Cancer Causes Control 19(3), 227–256. 76. Jenkins, C.N.H., & Kagawa-Singer, M. 1994. Cancer. In N.W.S. Zane, D.T. Takeuchi, & K.N.J. Young (Eds.), Confronting critical health issues of Asian and Pacific Islander Americans. Thousand Oaks, CA: Sage. 77. Wong, S.T., Gildengorin, G., Nguyen, T., & Mock, J. 2005. Disparities in colorectal cancer screening rates among Asian Americans and non-Latino whites. Cancer, 104, 2940–2947. 78. Wang, S.S., Carreon, J.D., Gomez, S.L., & Devesa, S.S. 2010, February 15. Cervical cancer incidence among 6 Asian ethnic groups in the United States, 1996 through 2004. Cancer, 116(4), 949–956. 79. Centers for Disease Control and Prevention. 2013. Infant mortality statistics from the 2009 period linked birth/infant death data set. National Vital Statistics Reports, Table A. Retrieved from http:// www.cdc.gov/nchs/data/nvsr/nvsr61/nvsr61_08. pdf (accessed March 12, 2015). 80. Child Trends Databank. 2015. Low and very low birthweight infants. Retrieved from http://www. childtrends.org/?indicators5low-and-very-low- birthweight-infants (accessed March 12, 2015). 81. Xu, F., Qiu, L., Binns, C.W., & Liu, X. 2009. Breast- feeding in China: A review. International Breast- feeding Journal, 4, 6. 82. Diong, S., Johnson, M., & Langdon, R. 2000. Breastfeeding and Chinese mothers living in Australia. Breastfeeding Review, 8, 17–23. 83. Centers for Disease Control and Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention. 2012. Epidemiologic pro- file 2010: Asians and Native Hawaiians and other Pacific Islanders. Retrieved from http://www.cdc. gov/nchhstp/Publications/docs/Asian_NHPI_ Epi_Profile2010-20120813_01 (accessed March 12, 2015). 84. Wang, Y. 2003. People of Chinese heritage. In L.D. Purnell & B.J. Paulanka (Eds.), Transcultural health care (2nd ed.). Philadelphia: F.A. Davis. 85. Chen, K.T., Chen, C.J., Gregg, E.W., Williamson, D.F., & Yarayan, K.M. 1999. High prevalence of impaired fasting glucose and type 2 diabetes mel- litus in Penghu Islets, Taiwan: Evidence of a rap- idly emerging epidemic? Diabetes Research and Clinical Practice, 44, 59–69. 86. Gao, M., Ikeda, K., Hattori, H., Miura, A., Nara, Y., & Yamori, Y. 1999. Cardiovascular risk factors emerging in Chinese populations undergoing urbanization. Hypertension Research, 22, 209–215. 87. Ma, G., Li, Y., Wu, Y., Zhai, F., Cui, Z., Hu, X., . . . Wang. Y. 2005. The prevalence of body overweight and obesity and its changes among Chinese people during 1992 to 2002. China Journal of Preventive Medicine, 39, 311–315. 88. Yehieli, M., & Grey, M.A. 2005. Health matters: A pocket guide for working with diverse cultures and underserved populations. Boston: Intercultural Press. 89. Ma, G.X. 2000. Barriers to the use of health ser- vices by Chinese Americans. Journal of Allied Health, 29, 64–70. 90. Choe, J.H., Tu, S.P., Lim, J.M., Burke, N.J., Acorda, E., & Taylor, V.M. 2006. “Heat in their intestine”: Colorectal cancer prevention beliefs among older Chinese Americans. Ethnicity & Disease, 16, 248–254.16, 248–254.16 91. Liang, W., Yuan, E., Mandelblatt, J.S., & Pasick, R.J. 2004. How do older Chinese women view health and cancer screening? Results from focus groups and implications for interventions. Ethnic- ity & Disease, 9, 283–304. 92. Axtell, R.E. 1991. Gestures: The do’s and taboos of body language around the world. New York: Wiley. 93. Muse, E.A. 2007. Cultural competency and Chinese medicine: Immigrant Chinese beliefs of utilization and plurality in health seeking behaviors and health care coverage. International Journal of Transdisciplinary Research, 2(1). 94. Wang, J., & Matthews, J.T. 2010. Chronic disease self-management: Views among older adults of Chinese descent. Geriatric Nursing, Geriatric Nursing, Geriatric Nursing 31, 86–94. 95. Wade, C., Chao, M.T., & Kronenberg, F. 2007. Medical pluralism of Chinese women living in the United States. Journal of Immigrant and Minority Health, 9(4), 255–267. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 3 6 6 E A S T A S I A N S 96. Chesla, C.A., Chun, K.M., & Kwan, C.M.L. 2009, October. Cultural and family challenges to managing type 2 diabetes in immigrant Chinese Americans. Diabetes Care, 32(10). 97. Chew, T. 1983. Sodium values of Chinese condi- ments and their use in sodium-restricted diets. Journal of the American Dietetic Association, 82, 397–401. 98. Chan, J., & Kyser-Jones, J. 2005. The experience of dying for Chinese nursing home residents: Cultural considerations. Journal of Gerontologi- cal Nursing, cal Nursing, cal Nursing 31, 26–32. 99. Hoeffe, E.M., Rastogi, S., Kim, M.O., & Shahid, H. 2012. The Asian population: 2010. U.S. Census Bureau. Retrieved from http://www.census.gov/ prod/cen2010/briefs/c2010br-11 (accessed March 12, 2015). 100. Easton, S.E., & Ellington, L. 2000. Japanese Americans. In R.V. Dassanowsky & J. Lehman (Eds.), Gale encyclopedia of multicultural Amer- ica. Farmington Hills, MI: Gale Group. 101. Hashizume, S., & Takano, J. 1983. Nursing care of Japanese American patients. In M.S. Orque, B. Bloch, & L.S.A. Monrroy (Eds.), Ethnic nursing care: A multicultural approach. St. Louis: Mosby. 102. Lock, M. 1990. Rationalization of Japanese herbal medication: The hegemony of orchestrated plu- ralism. Human Organization, 49, 41–47. 103. World Health Organization. 2001. Legal status of traditional medicine and complementary/alterna- tive medicine: A worldwide review, pp. 155–159. Retrieved from http://apps.who.int/medicinedocs/ pdf/h2943e/h2943e (accessed April 18, 2015). 104. Pollack, R., & Kuo, I. 2004. Advances in the treat- ment of anxiety disorders—Transcultural issues. Retrieved from http://www.medscape.com/ viewarticle/47156 105. Faiola, A. 2006, June 6. Sleeping with the fish for inner peace. San Jose Mercury News, p. 9A. 106. Toda, M., Morimoto, K., Nagasawa, S., & Kitamura, K. 2006. Change in salivary physio- logical stress markers by spa bathing. Biomedical Research, 27, 11–14.27, 11–14.27 107. Faiola, A. 2006, June 21. Nation of workaholics sleeps on the job. Washington Post, p. A01. 108. Takeyama, H., Kubo, T., & Itani, T. 2005. The nighttime nap strategies for improving night shift work in workplace. Industrial Health, 43, 24–29. 109. Hosking, R. 1996. A dictionary of Japanese food: Ingredients and culture. Rutland, VT: Tuttle. 110. Zibart, E. 2001. The ethnic food lover’s compan- ion: Understanding the cuisines of the world. Bir- mingham, AL: Menasha Ridge Press. 111. Steinberg, R. 1969. The cooking of Japan. New York: Time-Life Books, Inc. 112. Kudo, Y., Falciglia, G.A., & Couch, S.C. 2000. Evolution of meal patterns and food choices of Jap- anese American females born in the United States. European Journal of Clinical Nutrition, 54, 665–670. 113. Pierce, B.L., Austin, M.A., Crane, P.K., Ret- zlaff, B.M., Fish, B., Hutter, C.M., . . . Fujimoto, W.Y. 2007. Measuring dietary acculturation in Japanese Americans with the use of confirmatory factor analysis of food-frequency data. American Journal of Clinical Nutrition, 86(2), 496–503. 114. CDC Faststats. n.d. Health of Asian or Pacific Islander population. Deaths: Final data for 2013, Table 12. Retrieved from http://www.cdc.gov/nchs/ fastats/asian-health.htm (accessed March 12, 2015). 115. Marmot, M.G., & Syme, S.L. 1976. Accultura- tion and coronary heart disease in Japanese Americans. American Journal of Epidemiology, 104, 225–247. 116. Wenkam, N.S., & Wolff, R.J. 1970. A half cen- tury of changing food habits among Japanese in Hawaii. Journal of the American Dietetic Associa- tion, 57, 29–32.57, 29–32.57 117. Watanabe, H., Yamane, K., Fujikawa, R., Okubo, M., Egusa, G., & Kohno, N. 2003. Westernization of lifestyle markedly increases carotid intimam- edia wall thickness (IMT) in Japanese people. Atherosclerosis, 166, 67–72. 118. Sekikawa, A., Curb J.D., Ueshima H., El-Saed A., Kadowaki T., Abbott R.D., . . . ERA JUMP 77 (Electron-Beam Tomography, Risk Factor Assessment Among Japanese and U.S. Men in the Post-World War II Birth Cohort) Study Group. 2008. Marine-derived n-3 fatty acids and athero- sclerosis in Japanese, Japanese-American, and white men—a cross-sectional study. Journal of the American College of Cardiology, 52, 417–424. 119. Fujimoto, W.Y., Bergstrom, R.W., Newell-Morris, L., & Leonetti, D.L. 1989. Nature and nurture in the etiology of type 2 diabetes mellitus in Japa- nese Americans. Diabetes/Metabolism Reviews, 5, 607–625. 120. Nakanishi, S., Okubo, M., Yoneda, M., Jitsuiki, K., Yamane, K., & Kohno, N. 2004. A comparison between Japanese Americans living in Hawaii and Los Angeles and native Japanese: The impact of lifestyle Westernization on diabetes mellitus. Biomedicine & Pharmacotherapy, 58, 571–577. 121. Pierce, B.L., Austin, M.A., Crane, P.K., Retzlaff, B.M., Fish, B., Hutter, C.M., . . . Fujimoto, W.Y. 2007. Measuring dietary acculturation in Japa- nese Americans with the use of confirmatory factor analysis of food-frequency data. American Journal of Clinical Nutrition, 86, 496–503. 122. Tsunehara, C.H., Leonetti, D.L., & Fujimoto, W.Y. 1990. Diet of second generation Japanese American men with and without noninsulin- dependent diabetes. American Journal of Clinical Nutrition, 52, 731–738. 123. U.S. Department of Health and Human Services. n.d. Obesity and Asian Americans. Retrieved from http://minorityhealth.hhs.gov/omh/ browse.aspx?lvl54&lvlid555; and Centers for Disease Control and Prevention. 2008. Health characteristics of the Asian adult population: United States, 2004–2006, Table 2. Retrieved from http://www.cdc.gov/nchs/data/ad/ad394. pdf (accessed March 12, 2015). Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 11 3 6 7 124. Bergstrom, R.W., Newell-Morris, L.L., Leonetti, D.L., Shuman, W.P., Wahl, P.W., & Fujimoto, W.Y. 1990. Association of elevated fasting C-peptide level and increased intra-abdominal fat distribu- tion with development of NIDDM in Japanese American men. Diabetes, 39, 104–111. 125. Yoneda, M., Yamane, K., Jitsuiki, K., Nakani- shi, S., Kamei, N., Watanabe, H., & Kohno, N. 2008. Prevalence of metabolic syndrome com- pared between native Japanese and Japanese Americans. Diabetes Research and Clinical Prac- tice, 79(3), 518–522. 126. Pribila, B.A., Hertzler, S.R., Martin, B.R., Weaver, C.M., & Savaiano, D.A. 2000. Improved lactose digestion and intolerance among African- American adolescent girls fed a dairy-rich diet. Journal of the American Dietetic Association, 100, 524–528. 127. Lee, C.G., Fujimoto, W.Y., Brunzell, J.D., Kahn, S.E., McNeely, M.J., Leonetti, D.L., & Boyko, E.J. 2010. Intra-abdominal fat accumulation is greatest at younger ages in Japanese American adults. Diabetes Research and Clinical Practice, 89, 58–64. 128. Morimoto, Y., Maskarinec, G., Conroy, S.M., Lim, U., Shepherd, J., & Novotny, R. 2012. Asian ethnicity is associated with a higher trunk/ peripheral fat ratio in women and adolescent girls. Journal of Epidemiology, 22(2), 130–135. 129. Ikeda, N., Inoue, M., Iso, H., Ikeda, S., Satoh, T., Noda, M., . . . Shibuya, K. 2012. Adult mor- tality attributable to preventable risk factors for non-communicable diseases and injuries in Japan: a comparative risk assessment. PLOS Medicine, 9(1), e1001160. doi: 10.1371/journal. pmed.1001160. Epub January 24, 2012. 130. Alexander, G.R., Mor, J.M., Kogan, M.D., Leland, N.L., & Kieffer, E. 1996. Pregnancy outcomes of US born and foreign-born Japanese Americans. American Journal of Public Health, 86, 820–824. 131. Qin, C., & Gould, J.B. 2010. Maternal nativity sta- tus and birth outcomes in Asian immigrants. Jour-Jour-Jour nal of Immigrant and Minority Health, 12, 798–805. 132. Chi, I., Lubben, J.E., & Kitano, H.H.L. 1989. Differences in drinking behavior among three Asian-American groups. Journal of Studies in Alcohol, 50, 15–23. 133. Zane, N.W.S., & Kim, J.H. 1994. Substance use and abuse. In N.W.S. Zane, D.T. Takeuchi, & K.N.J. Young (Eds.), Confronting critical health issues of Asian and Pacific Islander Americans. Thousand Oaks, CA: Sage. 134. Becerra, M.B., Herring, P., Hopp Marshak, H., & Banta, J.E. 2013. Association between acculturation and binge drinking among Asian-Americans: Results from the California Health Interview Survey. Journal of Addiction. doi: 10.1155/2013/248196. Epub December 11, 2013. 135. Hobara, M. 2005. Beliefs about appropriate pain behavior: Cross-cultural and sex differences between Japanese and Euro-Americans. Euro- pean Journal of Pain, 9, 389–393. 136. Nash, A. 2000. Korean Americans. In R.V. Das- sanowsky & J. Lehman (Eds.), Gale encyclopedia of multicultural America. Farmington Hills, MI: Gale Group. 137. Hackett, C., & Grim, B.J. 2012. The global reli- gious landscape. Pew Research Center, Religion & Public Life. Retrieved from http://www.pewfo- rum.org/2012/12/18/global-religious-landscape- exec/ (accessed March 12, 2015). 138. Asian Americans: A mosaic of faith. July 19, 2012. Pew Research Center, Religion & Public Life. Retrieved from http://www.pewforum.org/2012/07/19/asian- americans-a-mosaic-of-faiths-religious-affiliation/ (accessed March 12, 2015). 139. Pang, K.Y.C. 1991. Korean elderly women in America: Everyday life, health, and illness. New York: AMS Press. 140. Purnell, L.D., & Kim, S. 2003. People of Korean heritage. In Transcultural health care (2nd ed.). L.D. Purnell & B.J. Paulanka (Eds.), Philadelphia: F.A. Davis. 141. Chin, S.Y. 1992. This, that, and the other: Man- aging illness in a first-generation Korean Amer- ican family. Western Journal of Medicine, 157, 305–309. 142. Pang, K.Y.C. 1994. Understanding depression among elderly Korean immigrants through their folk illnesses. Medical Anthropology Quarterly, 8, 209–216. 143. Park, Y.J., Kim, H.S., Kang, H.C., & Kim, J.W. 2001. A survey of hwa-byung in middle-age Korean women. Journal of Transcultural Nurs- ing, ing, ing 12, 115–112. 144. Park, Y.J., Kim, H.S., Schwartz-Barcott, D., & Kim, J.W. 2002. The conceptual structure of hwa- byung in middle-aged Korean women. Health Care for Women International, 23, 389–397. 145. Pang, K.Y.C. 1989. The practice of traditional Korean medicine in Washington, DC. Social Science and Medicine, 28, 875–884. 146. Kim, M., Han, H.R., Kim, K.B., & Duong, D.N. 2002, April. The use of traditional and Western medicine among Korean American elderly. Jour-Jour-Jour nal of Community Health, 27(2), 109–120. 147. Heiniger, L.E., Sherman, K.A., Shaw, L.K., & Costa, D. 2015. Fatalism and health promoting behaviors in Chinese and Korean immigrants and Caucasians. Journal of Immigrant and Minority Health, 17(1), 165–171. 148. Shin-Hepinstall, H.S. 2001. Growing up in a Korean kitchen. Berkeley, CA: Ten Speed Press. 149. Marks, C., & Kim, M. 1993. The Korean kitchen. San Francisco: Chronicle. 150. Kwak, J. 1998. Dok Suni: Recipes from my moth- er’s Korean kitchen. New York: St. Martin’s Press. 151. Yom, M.S., Gordon, B.H.J., & Sucher, K.P. 1995. Korean dietary habits and health beliefs in the San Francisco Bay Area. Journal of the American Dietetic Association, 95(Suppl.), A–98. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 3 6 8 E A S T A S I A N S 152. Ludman, E.K., Kang, K.J., & Lynn, L.L. 1992. Food beliefs and diets of pregnant Korean Amer- ican women. Journal of the American Dietetic Association, 92, 1519–1520. 153. Gordon, B.H.J., Kang, M.S.Y., Cho, P., & Sucher, K.P. 2000. Dietary habits and health beliefs of Korean Americans in the San Francisco Bay Area. Journal of the American Dietetic Associa- tion, 100, 1198–1201. 154. Kim, K.K., Yu, E.S., Chen, E.H., Cross, N., Kim, J., & Brintnall, R.A. 2000. National health status of Korean Americans: Implications for cancer risk. Oncology Nursing Forum, 27, 1573–1583.27, 1573–1583.27 155. Lee, S.K., Sobel, J., & Frongillo, E.A. 1999. Accul- turation, food consumption, and diet-related factors in Korean Americans. Journal of Nutri- tion Education, 31, 321–330. 156. Kim, J., & Chan, M.M. 2004. Acculturation and dietary habits of Korean Americans. British Jour- nal of Nutrition, 91, 469–478. 157. Park, S.Y., Paik, N.Y., Skinner, J.D., Ok, S.W., & Spindler, A.A. 2003. Mothers’ acculturation and eating behaviors of Korean American families in California. Journal of Nutrition Education, 35, 142–147. 158. Park, S.Y., Paik, N.Y., Skinner, J.D., Spindler, A.A., & Park, H.R. 2004. Nutrient intake of Korean American, Korean, and American ado- lescents. Journal of the American Dietetic Asso- ciation, 104, 242–245. 159. Song, Y., Joung, H., Engelhart, K., Yoo, S.Y., & Paik, H.Y. 2005. Traditional v. modified dietary patterns and their influence on adolescents’ nutritional profile. British Journal of Nutrition, 93, 943–949. 160. Lee, S.K., Sobel, J., & Frongillo, E.A. 1999. Acculturation and dietary practices among Korean Americans. Journal of the American Dietetic Association, 99, 1084–1089. 161. Lee, Y.H., Lee, J., Kim, M.T., & Han, H.R. 2009. In-depth assessment of the nutritional status of Korean American elderly. Geriatric Nursing, Geriatric Nursing, Geriatric Nursing 30(5), 304–311. 162. Soo-Kyung Lee, S.K. 2008, Winter. Accultura- tion, meal frequency, eating-out, and body weight in Korean Americans. Nutrition Research and Practice, 2(4), 269–274. 163. Rajagopal, L., Zheng, T., Kang, J., & Lee, J.Y. 2009. Influence of acculturation on dining-out behavior of Koreans living in the United States— an exploratory study. Journal of Foodservice, 20(6), 321–329. 164. Park, S.Y., Murphy, S.P., Sharma, S., & Kolonel, L.N. 2005. Dietary intakes and health-related behaviours of Korean American women born in the USA and Korea: The Multieth- nic Cohort Study. Public Health Nutrition, 8, 904–911. 165. Shin, C.N., & Lach, H. 2011, December 15. Nutritional issues of Korean Americans. Clinical Nursing Research, 20, 162–180. 166. Lauderdale, D.S., & Kestenbaum, B. 2002. Mor- tality rates of elderly Asian American popula- tions based on Medicare and Social Security data. Demography, 39, 529–540. 167. Baker, L.C., Afendulis, C.C., Chandra, A., McConville, S., Phibbs, C.S., & Fuentes-Afflick, E. 2007. Differences in neonatal mortality among whites and Asian American subgroups: Evidence from California. Archives of Pediatrics and Ado- lescent Medicine, 161(1), 69–76. 168. Kim, K.E. 2003. Gastric cancer in Korean Americans. Korean and Korean American Stud- ies Bulletin, 13, 84-90. 169. McCracken, M., Olsen, M., Chen, M.S. Jr., Jemal, A., Thun, M., Cok-kinides, V., … Ward, E. 2007, November–December. Cancer incidence, mor- tality, and associated risk factors among Asian Americans of Chinese, Filipino, Vietnamese, Korean, and Japanese ethnicities. CA: A Cancer Journal for Clinicians, 57(6), 380. 170. Yang, E.J., Chung, H.K., Kim, W.Y., Bianchi, L., & Song, W.O. 2007, June. Chronic diseases and dietary changes in relation to Korean Americans’ length of residence in the United States. Journal of the American Dietetic Association, 107(6), 942–50. 171. Cho, J., & Juon, H.S. 2006. Assessing overweight and obesity risk among Korean Americans in California using World Health Organization body mass index criteria for Asians. Preventing Chronic Disease, 3(3), A79. 172. Lee, S.K. 2008, Winter. Acculturation, meal fre- quency, eating-out, and body weight in Korean Americans. Nutritional Research and Practice, 2(4), 269–274. 173. Crews, D.E. 1994. Obesity and diabetes. In N.W.S. Zane, D.T. Takeuchi, & K.N.J. Young (Eds.), Confronting critical health issues of Asian and Pacific Islander Americans. Thousand Oaks, CA: Sage. 174. Choi, J., Wilbur, J., & Kim, M.J. 2011. Patterns of leisure time and non-leisure time physical activ- ity of Korean immigrant women. Health Care for Women International, 32(2), 140–153. 175. Lee, J.H., Yang, D.H., Park, H.S., Cho, Y., Jun, J.E., Park, W.H., … Chae, S.C. 2011. Incidence of hypertension in Korea: 5-year follow-up study. Journal of Korean Medical Science, 26(10), 1286–1292. 176. Cross, N.A., Kim, K.K., Yu, E.S.H., Chen, E.H., & Kim, J. 2002. Assessment of the diet quality of middle-aged and older adult Korean Ameri- cans living in Chicago. Journal of the American Dietetic Association, 102, 552–554. 177. Kim, M., Han, H.R., Kim, K.B., & Duong, D.N. 2002. The use of traditional and Western medi- cine among Korean American elderly. Journal of Community Health, 27, 109–120.27, 109–120.27 178. Kim, M.T., Kim, K.B., Juon, H.S., & Hill, M.N. 2000. Prevalence and factors associated with high blood pressure in Korean Americans. Eth- nicity & Disease, 10, 364–374. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 11 3 6 9 179. Yang, E.J., Chung, H.K., Kim, W.Y., Bianchi, L., & Song, W.O. 2007, June. Chronic diseases and dietary changes in relation to Korean Americans’ length of residence in the United States. Journal of the American Dietetic Association, 107(6), 942–950. 107(6), 942–950. 180. Tamir, A., & Cachola, S. 1994. Hypertension and other cardiovascular risk factors. In N.W.S. Zane, D.T. Takeuchi, and K.N.J. Young (Eds.), Con- fronting critical health issues of Asian and Pacific Islander Americans. Thousand Oaks, CA: Sage. 181. Kim, M.J., Ahn, Y.H., Chon, C., Bowen, P., & Khan, S. 2005. Health disparities in lifestyle choices among hypertensive Korean Americans. Biological Research for Nursing, Biological Research for Nursing, Biological Research for Nursing 7, 67–74. 7, 67–74. 7 182. Cho, J., & Juon. H.S. 2006. Assessing overweight and obesity risk among Korean Americans in California using World Health Organization body mass index criteria for Asians. Preventing Chronic Disease, 3(3), A79. 183. Nam, S. 2013. Obesity and Asian Americans in the United States: Systematic literature review. Osong Public Health and Research, 4(4), 187–193. 184. Cook, W.K., Mulia, N., & Karriker-Jaffe, K. 2012, May–June. Ethnic drinking cultures and alcohol use among Asian American adults: Findings from a national survey. Alcohol and Alcoholism, 47(3), 340–348. 185. Hill, L., Hofstetter, C.R., Hovell, M., Lee, J., Irvin, V., & Zakarian, J. 2006. Korean’s use of medical services in Seoul, Korea and California. Journal of Immigration and Minority Health, 8, 273–280. 186. Sohn, L. 2004. The health and health status of older Korean Americans at the 100-year anni- versary of Korean immigrants. Journal of Cross Cultural Gerontology, 19, 203–219. 187. Morrison, T., Conaway, W.A., & Borden, G.A. 1994. Kiss, bow, or shake hands: How to do busi- ness in sixty countries. Holbrook, MA: Adams. 188. Blackhall, L.J., Murphy, S.T., Frank, G., Michel, V., & Azen, S. 1995. Ethnicity and attitudes toward patient autonomy. Journal of the American Medi- cal Association, 274, 820–825. 189. Kang, J.H., Han, H.R., Kim, K.B., & Kim, M.T. 2006. Barriers to care and control of high blood pressure in Korean American elderly. Ethnicity & Disease, 16, 145–151. 190. Ayers, J.W., Hofstetter, C.R., Irvin,V.L., Song, Y., Park. H.R., Paik, H. Y., & Hovel M.F. 2010. Can religion help prevent obesity? Religious mes- sages and the prevalence of being overweight or obese among Korean women in California. Journal for the Scientific Study of Religion, 49(3), 536–549. 191. Newman, J.M. 2006. Chinese restaurants begin- ning. Flavor & Fortune, 13(2), 17–18. 192. Newman, J.M. 2000b. Mongolians and their cui- sine. Flavor & Fortune, 7(1), 9–10, 24. 193. Ang, C. 2000. Tibetan food and beverages. Flavor & Fortune, 6(3), 21. 194. NIH Osteoporosis and Related Bone Diseases National Resource Center. January 2012. Osteo- porosis overview. Retrieved from http://www. niams.nih.gov/Health_Info/Bone/Osteoporosis/ overview.asp 195. Koh, L.K., Saw, S.M., Lee, J.J., Leong, K.H., & Lee, J. 2001. Hip fracture incidence rates in Sin- gapore 1991–1999. Osteoporosis International, 12, 311–318. 196. Lau, E.M. 1996. The epidemiology of hip fracture in Asia: An update. Osteoporosis International, 6(Suppl. 3), 19–23. 197. Orimo, H., Hashimoto, T., Sakata, K., Yoshimura, N., Suzuki, T., & Hosoi, T. 2000. Trends in the incidence of hip fracture in Japan, 1987–1997: The third nationwide survey. Journal of Bone Mineral Metabolism, 18, 126–131. 198. Dhanwal, D.K., Cooper, C., & Dennison, E.M. 2010. Geographic variation in osteoporotic hip fracture incidence: The growing importance of Asian influences in coming decades. Journal of Osteoporosis, 2(6), 1–5. 199. Harrison, E., Adjei, A., Ameho, C., Yamamoto, S., & Kono, S. 1998. The effect of soybean protein on bone loss in a rat model of postmenopausal osteoporosis. Journal of Nutritional Science and Vitaminology, 44, 257–268. 200. Messina, M., & Messina, V. 2000. Soyfoods, soy- bean isoflavones, and bone health: A brief over- view. Journal of Renal Nutrition, 10, 63–68. 201. McTiernan, A., Wactawski-Wende, J., Wu, L., Rodabough, R.J., Watts, N.B., Tylavsky, F., . . . Jackson, R. 2009, June. Low-fat, increased fruit, vegetable, and grain dietary pattern, fractures, and bone mineral density: The Women’s Health Initiative Dietary Modification Trial. American Journal of Clinical Nutrition, 89(6), 1864–1876. 202. U.S. Department of Health and Human Services, Office of Minority Health. n.d. Pro Asian Amer- icans. Retrieved from http://minorityhealth. hhs.gov/omh/browse.aspx?lvl53&lvlid563 (accessed March 12, 2015). Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 3 7 0 The Philippines Substantial immigration from the Philippines to the United States started in 1898 after the country became a U.S. territory. Approximately 113,000 young male Filipinos traveled to the Hawaiian Islands between 1909 and 1930 to work in the sugarcane fields. Many of these immigrants later moved to the U.S. mainland. These early immigrants were considered U.S. nationals and carried U.S. passports, yet they were not allowed to become citizens or own land. Most were uneducated peasant laborers from the island of Illocos. Because they were not permitted to bring their wives or families, social and politi- cal clubs replaced the family as the primary social structure. In 1924 the immigration of Filipinos slowed as a result of Asian exclusion laws (see Chapter 11, for more information). After World War II, it became legal for Filipinos to become U.S. citizens, and the number of immigrants increased. Significant numbers of Filipinos arrived in the United States after 1965 when the U.S. immigration laws were changed, and by 1980 more than 350,000 had emigrated to mostly urban areas. Two-thirds of the Filipinos who arrived after World War II qualified for entrance as professional or tech- nical workers. Yet discrimination against Asians often forced Filipinos into low- paying jobs. “Little Manilas” formed in many California cities, and similar homogeneous neighborhoods were found in Chicago, New York City, and Washington, DC, where some Filipinos opened small service businesses to meet the needs of their community. Southeast Asians and Pacific Islanders Southeast Asians and Pacific Islanders live in similar tropical regions and may share some common ancestors, yet their cultures have diverged markedly over the centuries. The countries of Southeast Asia have developed under hundreds of years of Chinese domination. Spanish expansionism in the Philippines and French occupation in Vietnam were also significant. In contrast, Asian and European contact in the Pacific Islands was limited until the eighteenth cen- tury, and subsequent foreign influence almost completely overwhelmed the traditional indigenous societies. This section discusses the cultures and cuisines of the Southeast Asians who have immigrated in substantial numbers to the United States—Filipinos, Vietnamese, Cambodians, and Laotians—as well as those Pacific Islander groups with significant American populations—Native Hawaiians, Samoans, Guamanians, and Tongans. Southeast Asians Cultural Perspective History of Southeast Asians in the United States Immigration Patterns Most Filipinos immi- grate to the United States for educational and economic opportunities. In contrast, the majority of mainland Southeast Asians who have come to the United States have arrived since the 1970s as refugees from the political conflicts of the region. 12 CHA P T E R The only Filipinos allowed to apply for U.S. citizen- ship prior to 1946 were those who had enlisted in the U.S. Navy, Naval Auxiliary, or Marine Corps during World War II; had served at least three years; and had an honor- able discharge. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 1 2 3 7 1 Figure 12.1 Southeast Asia and the Pacific Islands. Vietnam Vietnamese immigration to the United States is characterized by three dis- tinct waves. The first occurred when South Vietnam fell to the North in 1975, and 60,000 Vietnamese left the country with the assistance of the United States. Another 70,000 managed to flee on their own. Most of these refugees had been employed by the United States or were members of the upper classes. They immigrated in intact family AUSTRALIA PHILIPPINES M A L A Y S I AM A L A Y S I AM A L A Y S I AM A L A Y S I AM A L A Y S I AM A L A Y S I AM A L A Y S I AM A L A Y S I AM A L A Y S I AM A L A Y S I AM A L A Y S I AM A L A Y S I AM A L A Y S I A I N D O N E S I A CAMBODIA LAOS THAILAND NEW GUINEANEW GUINEANEW GUINEANEW GUINEA VIETNAM NEW CALEDONIA S O L O M O N I S L A N D S M I C R O N E S I A M E L A N E S I A South China Sea Indian Ocean © C en ga ge L ea rn in g Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 3 7 2 S O U T H E A S T A S I A N S A N D P A C I F I C I S L A N D E R S Figure 12.1 Southeast Asia and the Pacific Islands (continued). groups and were able to bring their property with them. From 1975 to 1977 another wave of Vietnamese left for political or economic reasons, often escaping by sea. Many of these boat people left their families and what little money they had to find freedom. The third phase of immigration started in 1978, when increasing numbers of ethnic Chinese living in Vietnam fled the country, again by boat. This wave of immigration was accelerated by NEW CALEDONIA VANUATU FIGI NEW ZEALAND Hawaiian Islands P O L Y N E S I A M I C R O N E S I A South PacifiSouth PacifiSouth Paci c Oceanfic Oceanfi © C en ga ge L ea rn in g Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 1 2 3 7 3 the Chinese invasion of northern Vietnam in 1979. This second group of boat people left with no financial resources, and many lost family members escaping in unseaworthy vessels that were easy prey for pirates. After being rescued, the boat people often lived for several months, even years, in refugee camps in various Southeast Asian countries before coming to the United States. In addition, the United States and Vietnam developed the Orderly Departure Program (ODP) in 1979 to bring imprisoned former South Vietnamese soldiers and the approximately 8,000 Amera- sians, children of U.S. fathers and Vietnamese mothers, to the United States. Cambodia and Laos Cambodian and Lao- tian immigration to the United States did not begin until the United States granted asylum to the residents of the refugee camps along the border with Thailand in 1976 to 1979. Inter- national concern about the large numbers of refugees and the conditions in the camps prompted accelerated admittance of Southeast Asian immigrants worldwide. Many of the refugees were members of tribal populations who lived in the isolated mountainous regions of Southeast Asia, including the Hmong and Mien (ethnic Chinese populations who migrated south to escape persecution in the eighteenth century). Current Demographics and Socioeconomic Status Filipino The Filipino American population has more than doubled since 1980. Over 3.6 million Filipinos live in the United States, according to 2013 Census estimates. Almost half reside in California, with significant pop- ulations of more than 30,000 Filipinos found also in Hawaii, Florida, Illinois, New York, New Jersey, Texas, and Washington.1 It should be noted that Filipino Americans are a very heterogeneous group who come from differ- ent cultural groups within the Philippines and often speak a variety of native languages.1,2 Over 50 percent of Filipino Americans are foreign born; citizenship rates are higher than in other Asian groups. Educational attainment is also high. Nearly 46 percent of Filipino Americans hold college degrees.2 Family median incomes are 50 percent above the national average, combined with poverty rates approximately half that of the general U.S. population, both due to higher earnings and, sometimes, to pooled income of several adults living in each household.4 Some Filipinos find that their education or professional experience is not recognized in the United States, forcing them to accept blue- collar jobs when they first arrive. Over time, many professionals do obtain licensing or accreditation and work as physicians, nurses, or lawyers. Nearly 40 percent are employed in professional or management careers.2 Others are employed in the sales and service indus- tries, or in construction, and this group is economically better off than previous immi- grants, many of whom are now poor, elderly single men. Vietnamese More than 700,000 Vietnamese have entered the United States since 1975, and the total Vietnamese population, including those born in America, was estimated at over 1.9 million in 2013 by the U.S. Census, indi- cating it has more than doubled since 1990, with roughly 60 percent foreign born.2,3 Some were initially sponsored by American agen- cies or organizations, which provided food, clothing, and shelter in cities throughout the United States until the Vietnamese could become self-supporting. Many Vietnamese Americans have since relocated to the western and Gulf states, probably because the climate is similar to that of Vietnam. Vietnamese Americans live primarily in urban areas. Many are young and live in large households with grandparents and other relatives. The first wave of Vietnamese immi- grants was well educated, could speak English, and had held white-collar jobs in Vietnam. Many of them had to accept blue-collar jobs initially and had difficulties supporting their extended families. The boat people were even less prepared for life in the United States because they often had no English language skills, were illiterate, had less job training, and did not have support from an extended family. Language acquisition has been important in the Vietnamese community,5 and many immigrants have made the decision to assim- ilate as quickly as possible. However, over 80 percent do not speak English at home. Edu- cation is highly valued, and a child’s academic There were over 662,600 Canadians of Filipino heritage in the 2011 Canadian Census. During the 1920s and 1930s, Filipinos were often barred from restau- rants, swimming pools (and other recreational facilities), and movie theaters because of their dark skin and heavy accents. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 3 7 4 S O U T H E A S T A S I A N S A N D P A C I F I C I S L A N D E R S achievement is considered a reflection on the whole family. High school dropout rates are very low among Vietnamese Americans, and 23 percent over the age of twenty-five had a college degree.5 Vietnamese have high rates of employment, and more than 50 percent have professional or service-related employment. Those who obtain college degrees often pre- fer technical professions, such as engineering. Median family income is slightly higher than the U.S. average, and their poverty rate is at the national average of 15 percent.5 Cambodian The 2013 U.S. Census identified approximately 323,000 Americans of Cambo- dian descent. Approximately 79 percent are foreign born, and 71 percent are American cit- izens.1 Nearly half of Cambodian Americans reside in California, with the greatest popu- lations found in Long Beach and Stockton. Another large Cambodian community has developed in Lowell, Massachusetts. Texas, Pennsylvania, Virginia, New York, Minnesota, and Illinois also have significant numbers of immigrants. Adjustment to America has been slower for Cambodians, most of whom came from rural regions where they worked as farmers. They have a high unemployment rate, and those who work have found employment in professional and service jobs, manufacturing, transportation, and manual labor. Median family income is slightly above the national average, but 19 percent of Cambodians live below the poverty level. Low levels of educa- tion have limited economic success for many Cambodian Americans. Thirty-eight percent of adult men and women have less than a high school education and only 15 percent have a college degree.1,2,6 Laotian Over 261,000 nontribal Laotians live in the United States, according to 2013 U.S. Census figures.2 Refugee resettlement ser- vices dispersed the Hmong, irrespective of family clan associations, in 53 American cit- ies. Secondary migration of Hmong Ameri- cans has reunited clan groups, mostly in the suburban and rural communities primarily in the southern and western states. Most Lao- tians have settled in the California cities with larger populations in the San Francisco Bay Area and Sacramento. Outside of California, Seattle, Dallas, Fort Worth, and Minneapo- lis–Saint Paul also have significant number of Laotians.1,2 Poor fluency in English and low education levels have hindered economic achievement for Laotian Americans. Only 70 percent of adults have a high school degree and 15 per- cent have a bachelor’s degree or higher.2 Many Laotians hold lower-paying jobs in transpor- tation and as machine operators, fabricators, and laborers, yet it is estimated that only 14 percent live in poverty. However, their median income is over $55,000, which is higher than the national median.2 More than 81 percent of American Hmong over twenty-five years old have a high school degree, and over 13 percent have a college degree. Median family income has improved in the last ten years, but it is still below the national average ($47,200, compared to $51,200), and the poverty rate (25 percent) is more than the national average (15 percent) in the United States for the same time period.6 Worldview Religion Many Southeast Asians hold beliefs dating back to the ancient religions prevalent before the introduction of Buddhism, Catholi- cism, and Islam. Most believe in spirits and ghosts, especially of ancestors, who have the ability to act as guardians against misfortune or cause harm and suffering. Ideas about spirit intervention have often been incorporated into Eastern and Western religious practices or survive as significant superstitions. Filipino The majority of Americans of Filipino descent are Roman Catholics, although it is estimated that as many as 5.5 percent are Mus- lim. Religion significantly affects the world- view of Filipinos, especially elders. Many hold that those who lead a good life on earth will be rewarded with life after death. Human misfor- tunes come from violating the will of God. One should accept one’s fate because supernatural forces control the world. Time and providence will ultimately solve all problems. Vietnamese Forty-three percent of Vietnam- ese Americans are Buddhists, and 30 percent are Roman Catholic. Small numbers of In 2011 the Canadian Census reported over 230,000 residents of Southeast Asian heritage, 221,000 of whom were Vietnamese. There are five major tribes among the Hmong—the White Hmong, the Black Hmong, the Blue Hmong, the Red Hmong, and the Flowery Hmong—named according to legend by the colors of clothing they were forced to wear by the ancient Chinese for identification pur- poses. Most Hmong refu- gees in the United States come from the White and Blue tribes. The U.S. Census reported that in 2013, 179,925 Thais were living in the United States; most have settled in Los Angeles, New York, and Texas. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 1 2 3 7 5 Protestants also are found. Those who are Buddhists follow the Mahayana sect, influ- enced particularly by the Chinese school of Ch’an Buddhism (Zen Buddhism in Japan) called Tien in Vietnam. Buddhists believe that their present life reflects their past lives and also predetermines their and their descen- dants’ future lives. They consider themselves as part of a greater force in the universe (see Chapter 4 for more information about Buddhism). Cambodian The predominant religion in Cambodia is Theravada Buddhism, which places greater emphasis on a person’s efforts to reach spiritual perfection than does the Mahayana sect, which employs the help of deities. Merit through good deeds, the par- ticipation in religious ritual, and the support of monks and temples is critical to one’s prog- ress through reincarnation. Although some Cambodian Americans have converted to Christian faiths, most still practice Buddhism, often in temples established in apartments or homes. Laotian Almost all Laotians are also Thera- vada Buddhists. Making merit for Laotians includes the expectation that every man will devote some time in his life to living as a practicing monk, either before marriage or in his old age. In the United States, men find it difficult to fulfill their obligation to the faith. Women may become nuns for periods in their lives as well, especially if widowed. Most Lao- tians in the United States worship at Buddhist temples alongside Cambodians or Thais who share their religious practices. About half the Hmong population in the United States is now Christian as a result of French and American missionary work in Laos and conversions after arrival. Baptists, Presbyterians, Mormons, Jehovah’s Wit- nesses, and members of the Church of Christ have actively recruited the Hmong. The other half of Hmong Americans practice animism, shamanism, and ancestor worship (Ua Dab). They believe that the world is divided into two spheres—that which is visible, contain- ing humans, nature, and material objects, and that which is invisible, containing spirits. The shaman acts as an intermediary between the two; some spirits, such as those of ancestors, are available to those who aren’t shamans. Women are generally responsible for making contact with these more accessible spirits. It has been suggested that many Hmong became Protestants because they believed it was necessary to gain entry to the United States or in deference to their church sponsors. Some try to combine ancestor worship with their new faiths so as not to offend the spir- its.7 Small numbers of other Hmong belong to a modern Hmong religion called Chao Fa (“Lord of the Sky”), started by a prophet in the 1960s who encouraged the Hmong to break with both Laotian and Western ways. Family Southeast Asians share a high esteem for the family, respect for elders, and interde- pendence among family members. Behavior that would bring shame to the family’s honor is avoided, as is direct expression of conflict. Social acceptance and smooth interpersonal relationships are emphasized. Filipino The Filipino family is highly struc- tured. At the center is the extended family, containing all paternal and maternal relatives. Kinship is extended to friends, neighbors, and fellow workers through the system of compa- drazgo. Lifelong relationships are initiated through shared Roman Catholic rituals, par- ticularly the selection of godparents and bap- tism of new babies. Community obligations created through this system include shared food, labor, and financial resources. The first Filipino immigrants were single men hoping to make their fortune and return to the Philippines. They developed surrogate family systems of fellow workers who lived together, with the eldest man serving as patri- arch. More recent immigrants have come as whole families and have been able to maintain much of their social organization. Filipino children are adored by the fam- ily and are typically indulged until the age of six. At that time, socialization through negative feedback (e.g., shame) begins. Chil- dren are taught to be obedient and respect- ful, to contain their emotions and avoid all conflict, and to be quiet and shy. Politeness is emphasized.10,11 People must avoid sham- ing themselves or their families; discord is Hmong ancestors are fed at every festive occasion with a little pork and rice placed in the center of the feast table. In Thailand, miniature Thai temples are built and posted on pedestals next to a home to shelter the family ancestors. Such spirit houses are believed to prevent the ghosts from moving in with the family and causing trouble. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 3 7 6 S O U T H E A S T A S I A N S A N D P A C I F I C I S L A N D E R S minimized by the use of euphemisms and by sending go-betweens in sensitive situations. The prestige of a family may be measured by how well children adhere to traditional values. Though Filipino parents often support their children in advanced education and profes- sional careers, women may be discouraged from attending schools where they would be beyond family supervision.11 Vietnamese The extended Vietnamese fam- ily has been modified in the United States to adapt to American norms. Close relatives are encouraged to move into homes next door or in the same neighborhood. Family values are in transition. The father is traditionally the undisputed head of the household, but patriarchy is diminishing as women attain higher levels of education and professional achievement. American-style dating has become common. Although most Vietnamese marry within their ethnic group, women are more likely than men to wed non- Vietnamese mates. Divorce is uncommon.12 The level of intergenerational conflict is reportedly high.12 Children are often the first to learn English and acculturate more easily than their parents, causing value conflicts and loss of respect for elders. The role of elders is also changing. Old age is valued in Southeast Asia, but in the United States older relatives are often physically isolated from their peers and even younger family members and may be linguisti- cally isolated within the larger community. ▼ The traditional Vietnamese extended family home is less common in the United States, but relatives often live near each other. A Cambodian proverb states “If you don’t take your wife’s advice, you’ll have no rice the next year.” When Cambodians wed, a Buddhist monk cuts a lock of hair from both the bride and groom to mix together symbolically in a bowl. Cambodian Large extended families are com- mon in Cambodia; children are considered treasures. Cambodians are notable in that their traditional kinship system was bilateral, emphasizing both the paternal and maternal lines. The family was primarily a matriar- chy until the 1930s, when French influence strengthened the authority of the father. Today, men are responsible for providing for their families, while women make all deci- sions regarding the family budget. It has been difficult for Cambodian Ameri- cans to retain their traditional family struc- ture in the United States. A large percentage of Cambodian homes are headed by single women, due most likely to the large numbers of men killed in recent years during conflicts in Cambodia. Furthermore, Cambodian American women are permitted formal edu- cation, and their financial contributions are needed to help support the whole family. Dif-needed to help support the whole family. Dif-needed to help support the whole family. Dif ferences between immigrants who have lived most of their lives in Cambodia and the chil- dren of these immigrants raised in the United States (with no memory of Cambodia) can be enormous in terms of language, acculturation, and values.7 Laotian Most families are agriculturally based in Laos. Extended members live and work together in the fields to support the whole family. In Laos men represent the fam- ily in village affairs, and women run the home. Great significance is given to the site of the family’s house; it is believed that as long as the site exists, the family will exist. Extended families are still important to Laotian Americans due to dependency on relatives for social and economic support. Although nuclear families have become the norm, extended members tend to live nearby each other. Women have attained nearly equal status with men in the United States, and it is not unusual for Laotian men to share respon- sibility for household chores.8 Hmong American families are among the youngest and largest in the United States: Less than half of all Hmong are under the age of eighteen. Typical family size is about 6 members; the Asian average is 3.7, and the white American average is less than 2.13 These Mi ch ae l N ew m an /P ho to Ed it Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 1 2 3 7 7 large families are usually nuclear, reflecting numbers of children rather than relatives. Extended family members are often located nearby, and families frequently congregate with other families from the same tradi- tional clan from Laos, sometimes pooling resources.9 Men remain the heads of households in the United States. Women are traditionally held in high regard in their roles as mothers, yet it has been noted that fathers are assuming a much larger role in child care in the United States.14 Children are the heart of the home, and much of family life revolves around them. At age five, however, children are expected to behave as adults. As in some other Southeast Asian groups, a generation gap has developed between recently arrived immigrants and their West- ernized children. Some Hmong customs have come in direct conflict with U.S. laws. Polygyny, marriage to more than one wife, is unusual but not illegal in Laos The practice that has received the most press in the United States, however, is the kidnapping of young women and enforced marriage. Tradition- ally, girls married between the ages of four- teen and eighteen after a bridal price (paid by the groom) was agreed to by both families. If no agreement was reached, the couple could elope, and a mediator would help settle the differences. If the bride was unwilling, the groom could kidnap the girl, and the mar- riage would be recognized after some pay- ment to the bride’s family was arranged. Men who have attempted this in the United States have been charged with abduction and sexual assault, often by the young women involved. Many Americans of Hmong descent believe that it is best to wait until a woman is in her late teens or early twenties to wed; arranged marriages are still common. Traditional Health Beliefs and Practices South- east Asian health concepts typically combine facets of multiple belief systems. Indigenous ideas about the origins of illness center on the supernatural world, particularly the inter- vention of malevolent spirits or the ghosts of angry ancestors. Chinese medical practices involving yin and yang or the five evolutive elements (see Chapter 11) are considerations in some areas of mainland Southeast Asia, while the Mexican hot–cold theory is more prevalent in the Philippines (see Chapter 9). Religious precepts regarding rewards for making merit, or performing good deeds, and punishment for violating God’s will are also involved in health maintenance. In the most general terms, keeping healthy requires per- sonal harmony with the supernatural world, nature, society, and family fulfilled through one’s obligations to one’s ancestors, one’s reli- gion, and one’s kin and community. Illness is usually defined by its cause, not its symptoms. Most Filipinos adhere to the concept of bahala na, meaning that life is controlled by the will of God and by supernatural forces. If a person behaves properly, shows consideration of others and sensitivity in relationships, ful- fills debts and obligations, shows gratitude, and avoids shame, he or she is rewarded with health in this life and eternal life after death.10 Many Filipinos believe that illness is a punish- ment for transgressions against God. Religious medals are worn for protection from evil. Spanish control of the islands administered through Mexico led to the adoption of some aspects of humoral medicine in the Philip- pines, including not only the hot–cold theory, but also the condition commonly known as wind or air (mal aire in Mexico; see the sec- tion titled “Traditional Health Beliefs and Practices” in Chapter 9). Supernatural illnesses in the Philippines are most often due to the unhappy ghosts of one’s ancestors, although witchcraft, or the powers of animal spirits, may also be involved. Usog or Usog or Usog tuyaw occurs when a person transmits tuyaw occurs when a person transmits tuyaw illness through the power of the evil eye or the use of hands, fingers, words, or even physi- cal proximity.15 Undesirable traits or condi- tions can be transferred magically through contact with a person or object. A pregnant woman will try to gaze upon beautiful objects or people and avoid looking at a person with a deformity to prevent a similar occurrence in her fetus. Some believe if a pregnant woman craves dark-skinned fruit, her infant will have a dark complexion.11,18 Some Filipino Ameri- cans who believe in supernatural causes of disease do not think that these forces apply in Hmong marriages are traditionally formalized at a two-day feast featuring a roasted pig. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 3 7 8 S O U T H E A S T A S I A N S A N D P A C I F I C I S L A N D E R S the United States, because ghosts and spirits cannot cross the ocean, nor can they sur- vive in the noisy cities where many Filipinos now live. In the Philippines health is maintained through the balance (timbering) of natural and supernatural elements.10,15,16,18 A person is thought to be predisposed to certain illnesses, and the timing of external events contributes to the development of disease. Unbalanced conditions, such as working too much, over- eating, excessive drinking, inadequate diet or sleep, unhygienic conditions, infections, acci- dents, emotional stress (especially fright or anxiety), or loss of self-esteem, may increase a person’s vulnerability, as do factors such as the season and the weather. Three practices are used to produce bal- ance: heating, protection, and flushing. It is widely believed that a warm body is needed to prevent illness. Heating means that a per- son balances hot and cold—whether through exposure to the elements or through eating the right proportions of foods classified as hot or cold—so that warmth is maintained and overheating is avoided. For example, cold or cooling foods, such as orange juice, are not consumed first thing in the morning. Bathing, often twice per day, is also used to maintain warmth in the body. Any imbalance, whether too hot or too cold, is believed to cause illness by reducing blood flow, causing loss of appe- tite, and lowering of the body’s ability to fight off sickness. For example, a nursing mother who becomes overheated by too much sun or from exposure to a hot kitchen may find that her milk has become rancid, producing colic or diarrhea in the baby.19 Specifics on the application of hot and cold classifications and treatment vary tremendously from person to person. Protection safeguards the body from natu- ral and supernatural forces. For instance, a layer of fat is needed to protect the body from external cooling. Wind is of special con- cern. It may cause disease directly through drafts or be absorbed through the pores or any wounds. Wind that is too cold or too hot affects the blood, causing increased or decreased circulation, resulting in a general malaise and increased susceptibility to illness. A postpartum woman avoids bathing for nine to forty days after birth of the baby to pre- vent wind from entering her vagina; a new- born’s umbilicus is bound to keep wind from entering that opening; and coconut oil may be rubbed into the skin to block the pores. Whooping cough and mental illnesses are two of the more serious conditions that can be caused by wind. Balance is also important in other areas as well. Any rapid change is avoided, such as going from the activity of heavy exercise to the inactivity of showering (thus a short rest period is needed in between). Emotional restraint is maintained when possible, because strong emotion may cause certain symptoms of illness.16 For instance, some Filipinos feel that excessive anger or envy is a hot condi- tion and great fright or joy is a cold condition. Somaticized complaints are common.11,20 Flushing is used to cleanse the body of impurities or evil forces through perspiration, flatulence, vomiting, or menstrual blood.19 Vinegar mixed with water, salt, and chile pep- pers is one example of a flushing treatment, taken to stimulate sweating. Several types of traditional healers are common in the Philippines: midwives, mas- seurs, curers (who diagnoses through evalua- tion of the pulse), arbularyos (herbalists), and shamans, who cure supernaturally caused ill- ness through use of folk remedies. In urban regions, where belief in ghosts and spirits is not as prevalent, faith healers are gaining in popularity. Faith healers do not diagnose illness but cure it through prayer, anointing with oil, and the laying on of hands, which transmits a sacred healing energy to the patient.11,15,18 For the Vietnamese, health is related to personal destiny. How one behaved in past lives and the number of good deeds per- formed by one’s ancestors determine one’s experiences in this life. Current behavior, such as pleasing good spirits and avoiding evil spirits, can also impact health. Similar to the Filipinos, pregnant Vietnamese women may avoid funerals or ugly objects or leaving their homes at the times malevolent spirits are active (noon and 5:00 p.m.). The use of divination, through fortune-telling, astrology, Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 1 2 3 7 9 or physiognomy (the shape of the body, espe- cially the head, as it correlates to the mind), is popular for predicting how a person might expect his or her life to proceed and what interventions might be needed to prevent certain negative experiences.21,22 Traditionally, the Vietnamese believe that the human body is sustained by three sepa- rate souls: one that encompasses the life force, one that represents intelligence, and one that embodies emotions. In addition, nine vital spirits provide assistance to the souls. Soul loss can be an important and life-threatening reason for illness. Typically, strong feelings, especially fright, can cause the soul to leave the body.23 The Chinese medical system is commonly used by ethnic Chinese Vietnamese and by some other Vietnamese as well. Maintaining a balance of yin and yang, especially through diet and the treatment of disease, is a primary consideration in health. Like the Filipinos, wind (or air) is sometimes seen as a cause of illness. Some Hmong are also concerned with hot, cold, and wind as well. Hmong women are reportedly thought to be in a cold condi- tion immediately following birth (having lost hot blood) and must avoid cold drinks, cold drafts and wind, and sexual intercourse to reestablish balance.24 Cambodians, Laotians, and Hmong are also concerned with spiritual intervention in health. Laotians identify thirty-two spir- its that oversee the thirty-two organs of the body.8 The Hmong recognize the world of the invisible, where the spirit of every animal, tree, and rock resides, amid the souls of the living, ancestor spirits, caretaker spirits, and evil spirits. Ancestor spirits require special consideration because if they become angry, they may leave their progenies or fail to pro- tect them from evil. The Laotians have elabo- rate rituals called baci, mostly performed at all special occasions by older men who have been monks, that bind the spirits to their possessor. Among the Hmong, the loss of one’s soul, usually due to strong emotional distress, is the single most important cause of illness. It generally results in malaise and weight loss, leading to more serious disease. Related to soul loss is the condition called ceeb, or fright illness. Ceeb typically occurs in children (although it can happen to adults as well) if they are in an accident, chased by a dog, startled by a noise, or plunged into cold water. The soul becomes disconnected; the blood cools down and slows, resulting in a chilling effect that begins in the extremities and can progress to the vital organs.25 Unique to Southeast Asians in the United States is the unexplained condition known as sudden unexpected nocturnal death syn- drome (SUNDS), when a seemingly healthy person dies in his or her sleep. It is especially prevalent among Cambodians, Laotians, and Hmong, although it may occur in other immigrants from the mainland as well. It was a leading cause of death among Hmong men aged twenty-five to forty who were the earliest immigrants to the United States.17 Although biomedical hypotheses have been proposed to account for the fatal syndrome, such as heart irregularities or sleep apnea, none has been proven. It is now believed the phenomenon known as sleep paralysis is involved.26,27 Some researchers believe that death is caused within the cultural context of the nightmare experi- ence. Specifically, the nightmare spirit, dab tsog, enters the room at night and the victim tsog, enters the room at night and the victim tsog “wakes” to the sensation of the spirit sitting on his or her chest; he or she is unable to move and is terrified. Although many immigrants report having experienced nightmares in Southeast Asia, the attack by the spirit does not usually result in death. Cultural disrup- tions are believed to have intensified the epi- sodes. Guilt and depression create increased vulnerability to fatal nightmare experiences. Posttraumatic stress disorder, panic attacks, exposure to chemical warfare agents, or blood electrolyte imbalances may be other risk factors.23,27 Traditional healers are typically special- ized practitioners among mainland Southeast Asians. They may provide services for broken bones, skin infections, or objects stuck in the throat. Hmong herbalists (kws tshuaj) treat natural disorders, such as menstrual problems, impotence, infertility, stomach disorders, and diarrhea, with teas and poultices.24 Hmong shamans treat patients for spiritual disorders at great personal risk due to interaction with In parts of Southeast Asia, opium is traditionally grown in home herb gardens for use as a pain killer.14 Among the ethnic Chinese-Vietnamese immigrants, many are Traditional Chinese Medicine practitioners. Laotians often wear copper or silver bracelets or colored strings around their wrists, necks, and ankles to keep their souls from leaving. White string is used by families; red or black strings are tied on by shamans during ritual ceremonies. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 3 8 0 S O U T H E A S T A S I A N S A N D P A C I F I C I S L A N D E R S the spirit world.28 They heal conditions such as mental illness, hypertension, diabetes, breathing difficulties, and fainting. In many cases, they often deal with lost souls. Magic healers are not spiritually chosen for their pro- fession but may interface with the spirit world to treat injuries and stones (such as those found in kidneys, or those placed in bodies by evil spirits). Monks may lead religious rituals. Among most Southeast Asians, minor illnesses may be treated by anyone with heal- ing experience, typically a grandmother or mother in the home. The family takes respon- sibility for the illness of an individual and will usually exhaust all remedies available within the house before seeking outside help.14 Botanical remedies are very popular with many mainland Southeast Asians living in the United States. Cambodians, Laotians, and Hmong sometimes maintain herb gardens for easy access to therapeutic ingredients. Some immigrants frequent Chinese herbalists or will buy imported products from Asia.29 Kws tshuaj (herbal medicine experts) sell tshuaj ntsuab (fresh herbs), tshuaj qhuav (dried roots tshuaj qhuav (dried roots tshuaj qhuav or bark), as well as other organic substances (e.g., rhinoceros bones/skin/dried blood, dried bear, and snake gall bladders, etc). Herbs and other substances are prepared as teas, broths, steam inhalants, or balms.14,30 Physical therapies may include massage; cupping (a heated cup or a cup with a small amount of burning paper is placed over a cer- tain spot on the body until the fire goes out, leaving a round red spot on the skin); moxi- bustion (burning a small bundle of herbs on the skin or using a lit cigarette); and coining (rubbing a coin or spoon dipped in tiger balm or eucalyptus ointment across the skin with pressure), scratching, or pinching affected areas. In most cases the therapy is used to release any bad wind or excess heat and to restore balance to the body.14,31 Religious rituals are also used to intervene on behalf of an ill person. Hmong soul call- ers perform the “Mandate of Life” ceremony to return a lost soul to its host body, and the Mien appeal to ancestor spirits to protect family members and assist in healing. These rituals sometimes include animal offerings. A butchered animal, typically a chicken, pig, or occasionally a cow, is purchased from a packinghouse prior to the ceremony; then it is cooked and consumed after the rite as part of a feast. Its soul is offered in exchange for the vic- tim’s missing soul.14,24 In Vietnam small shrines are sometimes constructed to appease ancestor spirits or the souls of premature infants who have died and still wander the earth. Offerings may also be made to the Goddess Quang Am for good health. Among Catholic Vietnamese and Filipinos, appeals are made to the Virgin Mary; group prayer has assumed significance for many Protestant Southeast Asians. It has been noted that Christian Hmong often avoid the use of shamans, soul callers, and other traditional practitioners, depend- ing on the clergy and the power of prayer to promote physical and spiritual healing. Herbs, however, may still be used at home.24,28 Traditional Food Habits The cuisines of Southeast Asia have many ingredients in common, but food preparation methods and meal patterns reflect the foreign cultures that have influenced each nation. For example, the Vietnamese often serve cream- filled French pastries for dessert, whereas Filipinos frequently have Spanish-style cus- tard flan. As in China and Japan, the staple foods are rice (primarily long grain), soybean products, and tea. A meal is not considered complete unless rice is included. Instead of soy sauce, however, Southeast Asians often season their food with strongly flavored fer- mented fish sauces and fish pastes. Ingredients and Common Foods: Staples and Regional Variations Filipino Filipino fare has blended Malaysian, Polynesian, Spanish, and Chinese influences into a distinctive cuisine. There are three prin- ciples in Filipino cooking: First, never cook any food by itself; second, fry with garlic in olive oil or lard; and third, foods should have a sour–cool–salty taste.32 For example, adobo, one of the most popular Filipino preparations, combines marinated chicken, pork, and some- times fish or shellfish, that is then fried with garlic in lard and then braised in soy sauce, vinegar, garlic, chile peppers, bay leaf, and Mien rituals involving ancestor spirits require a genealogical record of the family going back ten generations. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 1 2 3 8 1 peppercorn with whatever vegetables are on hand, such as plantains, potatoes, greens, or bamboo shoots.33 Filipinos traditionally used a clay pot for cooking but now use a large wok called a kawali, especially for frying. They tend to leave the food in longer than the Chi- nese do, to allow it to absorb more fat. The common foods of the Philippines are listed in Table 12.1. Rice is the foundation of the diet, and the long-grain variety accompanies the meal. It is typically steamed or fried (the preferred method of serving leftover rice). Garlic fried rice is a favorite, topped with bits of meat, sausages, and a fried egg. Vinegar, additional garlic, and a spicy vegetable/fruit pickle called atchara are added to taste. A common bread, pan de sal, is made from rice flour. Noodles are also used extensively. Pancit is a popular dish made with rice, wheat, or mung bean noodles mixed with cooked chicken, ham, shrimp, or pork in a soy and garlic-flavored sauce. Short-grain, glutinous rice is used for sweet desserts such as puto, a fluffy cake made from rice, sugar, and sometimes coconut milk. The amount of meat, poultry, or fish a family eats depends on economic status. Pork, chicken, and fish are popular, added as available to mixed dishes such as sinigang, a soup of fish or meat cooked in water with sour fruits, tomatoes, and vegetables; puchero, a beef, chicken, sweet potato, tomato, and garbanzo bean stew with an eggplant sauce; Group Comments Common Foods Adaptations in the United States Protein Foods Milk/milk products Filipinos make one of the few native cheeses in Asia, from carabao (water buffalo) milk. U.S. influence has resulted in the availability of many Western dairy products. Many Filipinos may be lactose intolerant. In desserts, coconut milk is frequently used in place of cow’s milk. Evaporated milk (cow, goat), white cheese (carabao) Consumption of milk and other dairy products has increased. Meat/poultry/ fish/eggs/ legumes Protein intake is often dependent on income. Meat: beef, carabao, goat, pork, monkey, variety meats (liver, kidney, stomach, tripe), rabbits Poultry and small birds: chicken, duck, pigeon, sparrow Consumption of fish has decreased; intake of meat, poultry, and eggs has increased. TA B L E 12 .1 Cultural Food Groups: Filipino ▼ Traditional foods of Southeast Asia and the Pacific Islands. Some typical foods include coconut, dried anchovies, dried mango, French bread, lemon grass, lime, nuoc mam, pineapple, pork, rice, rice paper, rice sticks, taro root, and water chestnuts. Kr is tia n Ca ba ni s/ A G E Fo to st oc k gulay, fried fish with vegetables; and lumpia, the Filipino version of egg rolls, stuffed with pork, chile peppers, and vegetables like hearts of palm. Other traditional dishes popular for special occasions include chicken relleno, a whole chicken stuffed with boiled eggs, pork, sausage, and spices; paella, a Spanish recipe for saffron-flavored rice typically topped with chicken, sausage, pork, seafood, tomatoes, and peas; and lechon, a whole roasted pig. Filipinos use all parts of the animal in their cooking; in addition to the pork meat, for example, the pig variety cuts might show up in various soups or mixed stews, such as dinuguan, consisting of diced pork, chicken, (Continued)Continued)Continued Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 3 8 2 S O U T H E A S T A S I A N S A N D P A C I F I C I S L A N D E R S Group Comments Common Foods Adaptations in the United States Fish and shellfish: anchovies, bonita, carp, catfish, crab, crawfish, cuttlefish, dilis, mackerel, milkfish, mussels, prawns, rock oyster, salt cod, salmon, sardines, sea bass, sea urchins, shrimp, sole, squid, swordfish, tilapia, tuna Eggs: chicken, fish Legumes: black beans, black-eyed peas, chickpeas, lentils, lima beans, mung beans, red beans, soybeans, white kidney beans, winged beans Cereals/Grains Rice is the main staple and is usually eaten at every meal. Corn, oatmeal, rice (long- and short-grain, flour, noodles), wheat flour (bread and noodles) Rice is not usually eaten at breakfast but is eaten at least once per day. Fruits/Vegetables Vegetables are often consumed in mixed stews, stir-fries, and soups. Braised vegetables may be consumed as entrée or side dish. Pickled fruits and vegetables are very popular. Fruits: apples, avocados, banana blossoms, bananas (100 varieties), breadfruit, calamansi (lime), citrus fruit, coconut, calamansi (lime), citrus fruit, coconut, calamansi durian, grapes, guava, jackfruit, Java plum, litchi, mangoes, melons, papaya, pears, persimmons (chicos), pineapples, plums, pomegranates, pomelo, rambutan, rhubarb, star fruit, strawberries, sugar cane, tamarind, watermelon Vegetables: amaranth, bamboo shoots, bean Vegetables: amaranth, bamboo shoots, bean Vegetables: sprouts, beets, bitter melon, burdock root, cabbage, carrots, cashew nut leaves, cassava, cauliflower, celery, Chinese celery, drumstick plant (sili leaves), eggplant, endive, garlic, green beans, green papaya, green peppers, hearts of palm, hyacinth bean, kamis, leaf fern, leeks, lettuce, long green beans, mushrooms, nettles, okra, onions, parsley, pigeon peas, potatoes, pumpkins, purslane, radish, safflower, snow peas, spinach, sponge gourd, squash blossoms, winter and summer squashes, sugar palm shoot, swamp cabbage, sweet potatoes, taro leaves and roots, tomatoes, turnips, water chestnuts, watercress, yams More green vegetables are consumed. More raw vegetables and salads are eaten. Additional Foods Seasonings Food is spicy, but the variety of spices used is limited. Regional cooking is differentiated in part by seasoning preferences. Atchuete (annatto), bagoong, baggong- alamang, chile peppers, garlic, lemon grass, patis, seaweed, soy sauce, turmeric, vinegar Nuts/seeds Betel nuts, cashews, kaong (palm seeds), peanuts, pili nuts Beverages Soy milk, cocoa, coconut juice, coffee with milk, tea Chocolate milk is substituted for soy milk. Soft drinks are popular. Fats/oils Traditional diet is considerably higher in fat than are other Asian cultures. Coconut oil, lard, vegetable oil Sweeteners Brown and white sugar, coconut, honey TA B L E 12 .1 Cultural Food Groups: Filipino (C on tin u e d ) © C en ga ge L ea rn in g Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 1 2 3 8 3 or entrails cooked in pig’s blood and seasoned with vinegar and hot green chile peppers or sausage such as garlicky longaniza. The skin is commonly fried to make sitsaron (similar to the Mexican chicharrónes or U.S. cracklings), which are eaten as snacks or pulverized to top noodle dishes. Due to the U.S. influence in the Philippines, many Western dairy products are available, but cow’s milk is used infrequently. Evapo- rated milk is a common ingredient in leche flan, a custard, and in halo-halo, a parfait- like dessert consisting of shaved ice, coconut milk, mung beans, purple yam pudding (ube), boiled palm seeds (kaong), corn kernels, pine- apple jelly, and other ingredients. Halo-halo can be bought premixed with just the shaved ice needed for completion. Rural Filipinos use carabao (water buffalo) milk to make one of the few native cheeses in Asia, kesong puti. Carabao milk is also popular in desserts, such as ice cream, flan, and pastille candies. A common seasoning, used instead of salt and found throughout Southeast Asia, is fermented fish paste or sauce. In the Philip- pines, the powerful paste is called bagoong and tastes somewhat like anchovies, although it can be made from a variety of fish. A similar paste made of shrimp is known as bagoong- alamang. Patis is a translucent amber fish sauce. To obtain the popular sour–cool taste, palm vinegar, or a paste made from either the cucumber-like vegetable called kamis or the pulp of the tamarind pod, may be used. Kini- law, a Filipino specialty, uses sour ingredients to marinate and pickle raw foods, including fruits and vegetables, but also meats, organs, and seafood. Bagoong, patis, lime (calamansi) wedges, and vinegar flavored with chilies are frequently placed on the table so that each diner may add saltiness or sourness to taste. A principal food in many Pacific Islands is the coconut, and it is widely used in Filipino cooking. In addition, copra (dried coconut kernels used for oil extraction) is an impor- tant export crop. It takes approximately one year for a coconut to mature, but if picked at six months, the soft, jellylike coconut meat can be eaten with a spoon and is a popular delicacy. The coconut plant provides several food products, including beverages, cooking ▼ Two traditional Filipino dishes—lumpia (similar to an egg roll) and pancit (noodles cooked with meat or shrimp in a soy- and garlic- flavored sauce). In Filipino culture, sticky, glutinous rice cakes symbolize the cohesiveness of the family. Among the more unusual Filipino special- ties is balut, eaten occa- sionally as snacks. These partially developed duck eggs are soft-boiled and sold warm by street vendors. Salt and a little vinegar are added to the embryonic birds before they are popped whole into the mouth. Durian is an acquired taste. Its odor, which has been likened to rot- ting onions mixed with gasoline, is so strong that some apartment build- ings in Asia ban the fruit. liquids, and even a vegetable. The sweet, clear liquid found in young coconuts is the juice or water. It is consumed fresh but is not used in cooking. Coconut cream, which is used for cooking along with coconut milk, is the first liquid extracted from grated, mature coconut meat. After the cream is removed, coconut milk is made by adding water to the meat and then squeezing the mixture. Coconut milk is used primarily in special dishes. Coconut palm blossom sap can be fermented to pro- duce a strong alcoholic drink called tuba, which, when distilled, is known as lambanog. Hearts of palm, sometimes called palmetto cabbage, is the firm, greenish inner core of the tree; it is used as a vegetable. Bananas, durian (a large, strong-smelling, sweet fruit with a creamy texture), jackfruit, mango, papaya, and pineapples are also popular. Regional cooking styles are divided into four regions: Luzon (the largest group of islands, also home to the nation’s capital, Manila), Bicolandia, the Viscayan Islands, and Mindanao.34 Luzon is made up of various eth- nic groups, and the cuisine has been strongly influenced by the Spanish. Ocean fish, such as prawns, milkfish (bangus), and halibut, as well as the ample use of anchovy sauce and shrimp paste, are preferred in the northern areas. Foods are typically boiled or steamed. Saluyot (“okra leaves”—not related to okra), a spinach-like green with a slippery texture when cooked, and drumstick plant leaves, called sili, are especially popular in the north. M ic ha el C oc ita /S hu tt er st oc k. co m Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 3 8 4 S O U T H E A S T A S I A N S A N D P A C I F I C I S L A N D E R S Rice is grown in the central region of Luzon, known for its freshwater fish and richly sauced dishes flavored with onions and garlic. One delicacy is rellenong manok, a deboned chicken stuffed with sausage, vegetables, and ground pork mixed with raisins and spices, topped with a tangy red sauce. Stir-frying is the most common cooking technique. Coconut products and tropical fruits predominate. Sweetened rice dishes such as suman, a snack made from rice (cassava or plantains can be used) steamed in banana leaves or corn husks, are a specialty. Bicolandia is an ethnically homogeneous region that came in contact with both Malay- sian and Polynesian cooking. Foods are spicy hot with chile peppers, balanced by copious use of coconut milk and cream. Taro leaves cooked in coconut milk with ginger and chiles are one example of the unique blend of foods found in this area. Viscayan Islands fare also reflects its heritage—abundant use of seafood (includ- ing a distinctive fermented shrimp paste called guinamos) and seaweed, as well as many des- sert specialties, such as candies and pastries developed due to the sugarcane plantations in the area. The Mindanao region was heavily In rural regions, raw pork is heavily salted and then stored in jars for many months until it ripens. Called itog, small amounts are added to other dishes to enhance their flavor. influenced by the Indonesians and Malaysians. The many ethnic groups living there are pre- dominantly Muslim, so little pork is consumed (see Chapter 4). Sauces made from peanuts and chiles are popular, as are curries and other spicy dishes, such as piarun (fish spiced with chiles) and tiola sapi (boiled beef curry). Vietnamese, Cambodian, and Laotian Ingre- dients are similar in all the mainland South- east Asian countries, but recipes and meal patterns vary. Indigenous fish and seafood, tropical fruits and vegetables, and glutinous rice were the foundation of the native diets. The Chinese introduced long-grain rice, soy products, stir-frying, hot pots, fried pastries, and chopsticks to areas they ruled. French regional occupation popularized such items as French bread, meat pâtés, asparagus, pota- toes, pastries, and strong coffee. Indian and Malaysian influence is seen in the curries and coconut milk–flavored dishes of eastern and southern Southeast Asia. The common foods of mainland Southeast Asians are listed in Table 12.2. Rice, both long and short grain, is the sta- ple of the diet. Rice products, such as noodles, paper, and flour, are used extensively. In Viet- nam, rice paper is used as egg roll or wonton wrappers. In the dish cha gio, the moistened paper is wrapped around a variety of meats, fish, vegetables, and herbs and then deep- fried. Often the rice paper is filled with meat, fresh herbs, and vegetables at the table. Dried rice noodles (sticks) are called pho, which is also the name of the popular noodle-based soup in Vietnam. In Laos, the sticky, gluti- nous short-grain rice is more prevalent than long-grain types (traditionally formed into small balls to use as scoops for other foods), and the very thin Chinese-style rice noodles are common. Wheat is used to make French bread, noodles, and some pastries. Fried noodles topped with meats and veg- etables are a favorite. Fish and shellfish are the predominant protein food on the mainland. Even landlocked Laos depends on freshwater varieties. Fish, shrimp, and squid are often preserved through salting and drying. Poultry is widely available, and pork or goat is eaten in wealthier areas. Beef is used occasionally. S A M P L E M E N U A Filipino Lunch L umpia (Egg Rolls)a,b,c S in igan g (Pork in Sour Broth)a,c Chicken A d ob oa,b,c Steamed Rice Pan s it C an t on (Sautéed Rice Noodles)a,c Halo - h alo (Shaved Ice Dessert)a,b or P u t o (Steamed Rice Cakes)a,b aGelle, G.G. 1997. Filipino cuisine: Recipes from the islands. Santa Fe: Red Crane Books. bFilipino Recipe at http://www.filipino-recipe.com/ cFilipino Recipes at http://www.filipinofoodrecipes.net/ Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 1 2 3 8 5 Religious prohibitions often influence which meats are consumed. Like other Asians, the people of mainland Southeast Asia do not use appreciable amounts of dairy products. However, soy milk is a common beverage. Soy products, particularly a chewier version of tofu (soybean curd) called tempeh, are common. Mainland Southeast Asians frequently consume vegetables, cooked in stir-fries and stews or uncooked in salads and pickles. Especially noteworthy are the many shred- ded vegetables and unripe fruits, such as cabbage, papaya, carrots, cucumber, rad- ishes, jicama, and bean sprouts topped with fish, poultry, meat, or peanuts and spicy hot Malaysia, which includes a western section contiguous with Thailand and an eastern section on the island of Borneo, extends south into the gap between Southeast Asia, the Philippines, and Australia (see Figure 12.1). At its tip is the independent city-nation of Singapore. Indonesia, comprised of over 10,000 islands (mostly uninhabited), arches eastward from Malaysia and includes Bali, Borneo (now known as Kalimantan), Java, New Guinea, and Sumatra. The region lies along the equator and contains a majority of the world’s tropical rainforests. The fertile land is conducive to the cultivation of the herbs and spices brought by Asian, Middle East- ern, and European traders, including chile peppers, cinnamon, cloves, cumin, ginger, nutmeg, and pepper. Parts of Indonesia are still known as the Spice Islands. The cuisines of Malaysia, Singapore, and Indonesia have been greatly influenced by the diversity of their populations: native Malays, Chinese, Asian Indians, Pakistanis, Arabs, Thais, Eurasians, Melaka Portuguese (Malaysian Portuguese), and Peranakan (southern Chinese and Malaysian or Indonesian—the women are called Nyonya and men are known as Baba).153 Further, the numerous religious practices of the region— Islam, Hinduism, Buddhism, Christianity, and Judaism—have played a role in the fare. Today, Malaysia and Indonesia are predominantly Muslim nations (with the exception of Bali, which is mostly Hindu), while Singapore is primarily Christian. Rice, both long-grain and glutinous, is the foundation of the diet. It is often steamed, but it is also popular fried, prepared as sticky rice balls, and especially as noodles. Noodles are typically stir-fried, added to soups, or topped with mixed vegetables, fish, or meat. They are eaten at nearly all meals, and often for snacks. One Indonesian favorite is nasi goring, Chinese fried rice topped with a European-introduced fried egg. Steamed rice in Malaysia is often served with both an Indian-influenced curried meat or fish and a Chinese stir-fried vegetable. Fish is very common (often fried) and eaten by all groups except some vegetarian Buddhists (who prefer tofu- or tempeh-based dishes). Beef and poultry are popular but costly in much of Malaysia and Indonesia, while pork is uncommon in majority Muslim areas. The exception is Singapore, a wealthier nation, which includes abundant meat and egg dishes in its fare. Temperate vegetables introduced from the Middle East and Europe, such as tomatoes, eggplants, and potatoes, are usually added to soups and rice dishes instead of being served separately. Salads are popular, however; an example is Indonesian gado gado, a mixture of cooked vegetables (including cabbage, green beans, and carrots) dressed with a peanut sauce. Tropical fruits are eaten at nearly every meal, fresh, pre- served, in baked goods and puddings, and deep-fried as fritters. Coconut flavors many foods, and season- ings are used liberally, including chiles, fresh coriander, ginger, lemongrass, pandanus leaf, pepper, and turmeric. Lemons, limes, unripe mangoes, tamarind, or vinegar is usually added for a sour taste. The most distinctive cooking in the region is Nyonya fare, found especially in Singapore, which combines Chinese preparations (often pork -based) with Malaysian seasonings, particularly coconut, turmeric, and lemongrass. All courses are served at once in Malaysian, Singaporean, and Indonesian meals, and the dishes are categorized by preparation technique, not ingredients. For example, sambals are fried dishes seasoned with chiles (or the name for just a chile dipping sauce); satays are delicate, grilled kebabs (of Middle Eastern origin) served with spicy dipping sauces; croquettes (from the Dutch influence) are fried rice, meat, vegetable; or fruit fritters; and sayur are soupy dishes with ample sauce for dipping rice balls. In most areas forks and spoons are used (knives are rarely available). The Chinese often use chopsticks, and Asian Indians frequently employ their right hand to scoop up food.153 One tradition is universal in the region: street vendors. Meals and snacks are usually available around the clock at food stalls and small eateries, and al fresco dining is a daily event. E X P L O R I N G G L O B A L C U I S I N E The Cooking of Malaysia, Singapore, and Indonesia Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 3 8 6 S O U T H E A S T A S I A N S A N D P A C I F I C I S L A N D E R S Group Comments Common Foods Adaptations in the United States Protein Foods Milk/milk products Most Southeast Asians do not drink milk and may be lactose intolerant. Sweetened condensed milk is used in coffee; whipping cream is used in pastries. Sweetened condensed milk, whipping cream It is expected that younger Southeast Asians will increase their use of dairy products. Ice cream is popular; milk and cheese are often disliked. Meat/poultry/fish/ eggs/legumes The traditional Southeast Asian diet is low in protein. Fish, poultry, and pork are common; most parts of the animal are used (brains, heart, lungs, spleen). Meat: beef, lamb, pork, goat, venison; variety meats of all types Poultry and small birds: chicken, duck, quail, pigeon, sparrow, doves Eggs: chicken, duck (both embryonic and unfertilized), fish Fish and shellfish: almost all varieties of freshwater and saltwater seafood, fresh and dried Legumes: chickpeas, lentils, mung beans (black Legumes: chickpeas, lentils, mung beans (black Legumes: and red), soybeans and soybean products (tempeh, tofu, soy milk), winged beans Meat, lamb, and eggs are eaten more; fish, shellfish, and duck are eaten less because of price. Cereals/Grains Rice is the staple grain and is usually eaten with every meal. French bread is commonly eaten. Rice (long- and short-grain, sticks, noodles), wheat (French bread, cakes, pastries) Intake of baked goods increases. Fruits/Vegetables Hearty garnishes of fresh vegetables are commonly added to dishes. The Vietnamese eat a considerable amount of fruit and vegetables, fresh and cooked. Fruit is often eaten for dessert or as a snack. Fruits: apples, bananas, cantaloupe, coconut, custard apple, dates, durian, figs, grapefruit, guava, jackfruit, jujube, lemon, lime, litchi, longans, mandarin orange, mango, orange, papaya, peach, pear, persimmon, pineapple, plum, pomegranates, pomelo, raisins, rambutan, roselle, sapodilla, star fruit, soursop, strawberries, tamarind, watermelon Vegetables: amaranth, arrowroot, artichokes, asparagus, bamboo shoots, banana leaves and flowers, betel leaves, beans (yard long and string), bitter melon, breadfruit, broccoli (Chinese and domestic), cabbage (domestic, Chinese, savoy, napa), calabash, carrot, cassava (tapioca), cauliflower, celery (domestic and Chinese), chayote squash, Chinese chard, Chinese radish (daikon), chrysanthemum, corn, cucumber, eggplant (domestic and Thai), leeks, lotus root, luffa, matrimony vine, mushrooms (many varieties), mustard (Chinese greens), okra (domestic, lady finger), peas, peppers, potato, pumpkin (flowers, leaves), spinach, squash, sweet potatoes (tubers, leaves), taro (root, stalk, leaf, shoots), tomatoes, turnips, water lily greens, water chestnuts, water convolvulus, was gourd, yams Use of fruits and vegetables is dependent on availability and price. It is expected that use of fruits and vegetables will decline. Fresh vegetables and herbs are sometimes grown in backyard gardens. TA B L E 12 . 2 Cultural Food Groups: Mainland Southeast Asian Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 1 2 3 8 7 dressing. One example is goi go, a Vietnam- ese specialty featuring cabbage and chicken. Greens and leaves are often used to wrap foods, such as collard greens for Cambo- dian steamed fish and la lot (betel leaves) used for Vietnamese spring rolls stuffed with minced beef. Further, fresh herbs and spices, including basil, coriander leaves, chile pep- pers, galangal (similar to young ginger root), garlic, ginger, kaffir lime leaves, lemon grass, and mint, are often added to foods as they are served, providing distinctive flavors and color to many dishes. Both Laotian laap, a spicy ground meat or fish dish (tradition- ally prepared uncooked), and Vietnamese grilled lemon grass beef, bo nuong xa, are served with a substantial garnish of basil, mint, and coriander leaves. Due to the strong influence of the French, the Vietnamese also frequently eat asparagus, green beans (hari- cots), and potatoes; though the French had less impact on the cuisine of surrounding nations, subsequent Vietnamese rule has popularized these vegetables in other regions as well. Tropical fruits are available, although in some areas bananas and plantains are the only fruit widely consumed. Banana leaves are used to wrap rice, vegetables, and meats for steaming in both Cambodia and Laos. Pineapple, papaya, limes, mangoes, and man- gosteens are common, as are soursop, star fruit, guavas, custard apples, durian, jackfruit, and tamarind (a pod with very tart pulp). Oranges, lemons, melon, and sugarcane are also popular. In Vietnam, foods are customarily sea- soned with a salty sauce made from fermented fish called nuoc mam. It can be transformed into a hot sauce, nuoc cham, with the addi- tion of chiles, vinegar, sugar, garlic, and citrus fruit juice. In Cambodia the fermented fish sauce is called tuk-trey; a stronger fish paste is also used, known as prahoc. The Laotian version of fish sauce is nam pa; pa dek is the fermented fish paste. In Vietnam, com, meaning “cooked rice,” is the same word used for “food.” Vietnamese Buddhists eat soybean products on the first, fifteenth, and last day of the lunar month, when meat is prohibited. Furr, a soup containing pork, noodles, garlic, and hemp (marijuana) leaves, is a Laotian specialty. “Without fish sauce or salt, life is nothing,” according to a Vietnamese saying. © C en ga ge L ea rn in g Group Comments Common Foods Adaptations in the United States Additional Foods Seasonings Fermented fish sauce, as well as soy sauce, is often used. Fresh herbs are very popular garnishes in Vietnamese dishes; typical Cambodian fare is delicately seasoned; Thai dishes are frequently very hot and spicy, with several types of curry and chile peppers especially popular. Allspice, alum, basil, black pepper, borax, cayenne pepper, chile pepper, chives, cinnamon, coconut milk, fresh coriander, curry powder, fennel, galanga, garlic, ginger, kaffir lime leaves, lemon grass, lemon juice, lily flowers, lotus seed, mint, MSG, nuoc mam (and other fermented fish sauces and pastes), paprika, saffron, star anise, tamarind juice, vinegar Nuts/seeds Almonds, betel nuts, cashews, chestnuts, macadamia nuts, peanuts, pili nuts, walnuts; locust seeds, lotus seeds, pumpkin seeds, sesame seeds, watermelon seeds Peanut butter is often disliked. Beverages Beverages are usually drunk after the meal or with snacks or desserts. Coffee, tea, sweetened soybean milk, a wide variety of fruit and bean drinks, hot water, hot soup, beer Carbonated drinks have increased in use. Fats/oils Bacon, butter, lard, margarine, peanut oil, vegetable oil The Vietnamese have increased their use of butter and margarine. Sweeteners Sweets are luxury foods. Cane sugar, candy The use of sweetened products has risen in the United States. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 3 8 8 S O U T H E A S T A S I A N S A N D P A C I F I C I S L A N D E R S Tea is the preferred beverage throughout mainland Southeast Asia. In Vietnam, it is served before and after meals but not during the meal. Tea is often blended with flowers such as rose petals, jasmine blossoms, chry- santhemums, and lotus blossoms (which are especially popular). Coffee is popular in French-influenced areas, usually served with large amounts of sweetened condensed milk added to it. Broth is traditionally consumed at meals, and in poorer, rural regions, such as where the Hmong live, it is the only bever- age besides water that is commonly available. In wealthier areas, men may drink beer, and women and children consume soft drinks during meals. Soybean drinks and fruit drinks are common; rice wine or whiskey is served on special occasions. Regional variations are prominent, espe- cially in Vietnam.35 The Chinese influence is stronger in the north than in other regions. Hot pots, stir-fried foods, and chao (rice gruel similar to congee) are especially popu- lar. Soups are a specialty, particularly pho bo ha noi, a delicate broth to which rice noodles, sliced beef, bean sprouts, herbs, and other Numerous small wild animals are consumed in Southeast Asia. In 2005 a new species of rodent, related to the porcu- pine, was discovered by scientists for sale in a Laos market. Called kha-nyou, it is roasted whole, then eaten by crunching up the small bones, and spitting out the larger ones.154 ▲ Shoppers choose from a wide selection of tropical fruits and vegetables in a Southeast Asian street market. M ea of ot o/ Sh ut te rs to ck .c om seasonings are added immediately before serving. Mein go is a chicken noodle soup served in a similar manner. Other favorites include stuffed tofu, bun cha (grilled pork over noodles), and snails (stir-fried, sim- mered in beer, or minced with garlic). The central region is known for sophisticated gastronomy. Presentation is emphasized and seasonal cooking reigns. Specialties include a sauce similar to nuoc mam made from shrimp called mam tom, shrimp pâté grilled on sugar cane, spicy pork sausages, sweet soups, ver- micelli soups, and both sweet and salty rice cakes. The climate of the South is tropical. Cooking is simpler and seasoning is stronger; curries and spicy Indonesian-style peanut sauces are favorites. Coconut milk and cara- mel flavor many dishes. Clay pot cooking is common. One specialty is tidbits of grilled meats, fresh vegetables, and fruits such as guava, mango, green papaya, pineapple, or starfruit wrapped in a lettuce leaf, according to personal preference, that can be dipped in salty or spicy sauces. Sweets are more popular in the south than in other areas. Khmer cooking of Cambodia features northern Indian, Malaysian, and Chinese elements. Although French cooking is much admired, it has never been integrated into the Khmer kitchen.36 Aromatic seasonings are preferred, particularly the paste known as kroeung, made fresh for each dish from pulverized herbs and spices such as galangal, garlic, kaffir lime leaves, lemon grass, shallots, and turmeric. A touch of spice is achieved with chile peppers, particularly in curried dishes, though it is usually moderated by the use of coconut milk. Sweet ingredients, such as ripe fruit or sugar, are often included as a contrast to the sour flavor provided by vinegar, lime juice, or tamarind. Salty fish sauce or soy sauce is always added, as are bitter herbs for bal- ance. Amok, fish in coconut milk steamed in a banana or collard leaf, is a national favorite as is num banh choc, a rice noodle and fish soup. In some areas, dishes featuring wild foods such as land crabs, snakes, and locusts are found. Laotians prefer glutinous rice over long- grain types. Added vegetables and fish make up the basic diet, with eggs, poultry, and beef included as affordable. In rural areas game Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 1 2 3 8 9 such as deer, squirrels, ducks, quail, lizards, frogs, snakes, and grasshoppers are common. Meats are frequently stewed or grilled, though a salty beef jerky prepared with nam pa is a specialty. Coconut cream or milk, nam pa and pa dek, lime juice, fresh coriander leaves, garlic, lemon grass, and mint are typical sea- sonings. Hot chile peppers add heat to most foods, though the extent of their use varies regionally. Spicy salads consisting of fresh veg- etables or shredded immature papaya topped with lime juice, palm sugar, and chile pepper dressing are popular. Chinese and French influence via Vietnam is seen in some areas where French bread, croissants, spring rolls, and a soup similar to pho are popular foods. Hmong fare traditionally differs from Lao- tian cooking and shares some similarities with Vietnamese cuisine. Long-grain rice is favored and stir-frying, steaming, and roasting are common preparation methods. Although rice and vegetables are the foundation of the diet, families sometimes raise chickens, ducks, pigeons, and pigs. These foods are supplemented with wild game and fish, crabs, and snails. Seasonings, however, are similar to Laotian, though the Hmong use soy sauce in addition to fish sauces. Hmong who were forced from the mountains to the lowlands during Southeast Asian conflicts have added many Laotian foods to their meals. Meal Composition and Cycle Daily Pattern Filipino The traditional meal pattern in the Philippines is three meals a day. Breakfast is garlic fried rice with eggs or broiled fish, sausage, or meat, plus coffee or hot chocolate; bread may be substituted for rice. Especially popular are sweet, cheesy rolls called ensay- mada. Lunch and dinner are similar in size and composition. Both are often large meals, characteristically including soup, rice, a crispy or chewy dish (such as fried fish), a salty dish (meat or poultry cooked in fish sauce or soy sauce), a sour dish (flavored predominantly with vinegar or tamarind), a noodle dish, and often, an adobo dish. Fresh fruit or des- sert concludes the meal. If the meal features mostly Spanish-style items, the courses are served consecutively. If the meal features more Filipino-style dishes, all courses are served together, including dessert.33 In addition to meals, two snacks, called meriendas, are consumed in the midmorning and late afternoon. Meriendas may be small or may consist of substantial amounts of food, such as fritters, pastries, fruits, ensaymadas, lumpia, or almost anything else except rice, which is served only at meals. Vietnamese and Other Mainland Southeast Asians Mainland Southeast Asians eat two or three meals a day with the number of meals and the amount of food consumed often based on income. Snacking is uncommon. Southeast Asians do not usually associate par- ticular foods with breakfast, lunch, or dinner. For example, soups are especially popular and are often consumed with every meal. In Vietnam, a traditional breakfast is large and may consist of soup with rice noodles topped with meat or poultry; a boiled egg with meat and pickled vegetables on French bread; chao with bits of leftover meat and vegetables; steamed rice cakes or Chinese-style crullers; or glutinous rice or boiled sweet potatoes with sugar, coconut, and chopped roasted peanuts. A strong cup of coffee may accompany the meal. Lunch and dinner typically include S A M P L E M E N U A Vietnamese Dinner Asparagus and Crabmeat Soupa,b Braised Bean Curda,b or Grilled Beef with Lemongrassa,b Stir-Fried Vegetables Steamed Rice Fruit Juice or Iced Coffee with Evaporated Milk aRouthier, N. 1999. The foods of Vietnam. New York: Stewart, Tabori & Chang. bVietnamese Recipes & Cuisines at http://www.vietnamese-recipes.com Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 3 9 0 S O U T H E A S T A S I A N S A N D P A C I F I C I S L A N D E R S rice, fish or meat, a vegetable dish, and a broth with vegetables or meat. Fresh vegetables and pickled garnishes are served with the meal. All items are served at once, and individual diners place whatever foods they wish over their por- tion of rice and flavor it as desired with nuoc mam and other condiments. French bread with meat or shrimp pâté may be substituted for a lunch or dinner meal. In late afternoon, tea or coffee may be enjoyed with a sweet cus- tard, pastry, candy, or piece of fruit. Cambodians also eat family style. Soups are often served for breakfast and accompany the main course at nearly every other meal. Steamed or fried rice or rice noodles are the centerpiece of lunch and dinner, accompa- nied by grilled or steamed freshwater fish and seafood, and less frequently poultry, pork, or beef. Fresh salads are common. Fruit is often eaten as dessert, though very sweet rice or corn dishes are also popular. Tea and coffee with condensed milk are usually consumed with the meal, and fruit juices, soft drinks, and beer may be available. In Laos gluti- nous rice, fish, poultry or meat, soup, and a cooked vegetable dish or fresh salads make up most meals. Chile pepper paste is the stan- dard condiment. Tea, coffee with condensed milk, and rice wine or rice whiskey round out the menu. Etiquette Filipinos generally dine at tables equipped with lazy Susan turntables so that dishes are accessible to everyone. Tradition- ally, no one starts eating until the eldest male at the table begins. Many Filipinos use a West- ern style of dining with forks, knives, and spoons. Others employ just forks and spoons. The spoon is used to hold the food down while the fork is used to pull bits away. The food is then pushed onto the spoon with the fork and eaten. Chopsticks may be used for Chinese dishes. In some rural areas, fingers are still more commonly used.33 In such cases, only the right hand is used for dining. Small mounds of rice are rolled between the index finger, middle finger, and thumb to form a ball that is dipped into a sauce, then pressed into a bit of meat or poultry and popped whole into the mouth. It is considered rude to take the last bits of food from the central platter.37 In Vietnam it is polite to wait for the eldest person to be served and then, after everyone else is served, to ask him or her if it is okay to eat. It is a breach of good manners to refuse any offer of food, yet when served, only small amounts of any single dish should be taken. If sufficient amounts remain, seconds will be offered.37 Throughout mainland Southeast Asia, an empty plate or cup indicates that the diner is still hungry or thirsty. Leaving a small amount of food or beverage signals satiety. Traditional dining in Vietnam is done on a low table with family gathered round, sitting cross-legged on mats. Both hands customarily rest on the table while dining, and conversa- tion is limited. In contrast, dinner is a time for socializing in Laos. The food is served on a low rattan tray, and women gather on one side, the men on the other side. Each diner eats from the dishes as desired. A variety of utensils are used to eat in Southeast Asia mainland nations. Chopsticks are used for most dishes in most of Vietnam, though spoons and fingers are considered appropriate for certain foods and in some areas. Rural Laotians often eat with their fin- gers, using balls of sticky rice to scoop up fish and meats and vegetables and sauce; however, spoons are used as needed. In urban areas forks are now common. Hmong typically employ forks and spoons, and Cambodians use spoons, chopsticks, or fingers dependent on the food. Special Occasions Filipino In the predominantly Catholic Phil- ippines, religious festivals and saints’ days are numerous (see Chapter 4). On all special occa- sions, it is customary to serve plenty of food buffet-style with a roasted pig (lechon) as the centerpiece. The Filipinos claim to have the longest Christmas season in the world, from the first Sunday of Advent in late November or early December to January 6. The midnight Mass celebrated on Christmas Eve is usually followed by the traditional media noche, a midnight supper of fiesta foods such as roast ham, sweet potatoes, banana flower salad, niaga—a dish made of boiled meat, onions, and vegetables whose name means “good life”—and hot chocolate. Other specialties Turo-turo are fast-food stands in the Philip- pines, specializing in rice bowls topped with foods according to the customer’s preference. Other hot items are also available. It is said that you can trace the penetration of Chinese rule in Vietnam by the areas in which chopsticks are common, compared to those where hands are still most frequently used to dine.32 Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 1 2 3 9 1 eaten during the Christmas season are puto bumbong, a rice flour delicacy cooked in a whistling bamboo kettle, and bibingka, a glu- tinous rice cake cooked in a clay pan topped with salted egg slices, kesong puti cheese, and a bit of coconut. A midnight Mass is also held on New Year’s Eve, but many Filipinos attend parties to cel- ebrate the holiday instead. Again, a midnight supper consisting of fiesta foods is traditional. There is also a superstition that eating seven grapes in succession as the clock strikes mid- night will bring good luck in the coming year. For birthdays, pancit is eaten to ensure a long life. There are numerous Filipino practices and customs associated with Easter, beginning with observances on Ash Wednesday. Late on Easter Eve, young children are awakened to partake of special meat dishes, such as adobo and dinuguan, in the belief that if they do not do so, they will become deaf. In May, fiestas honoring the Virgin Mary often include fam- ily feasts. Vietnamese and Other Mainland Southeast Asians Of all Vietnamese holidays, Tet, the New Year’s celebration, is the most important. Tet is observed at the end of the lunar year (end of January or beginning of February) just after the rice harvest. In Vietnam, the first Tet ritual is an observance at the family gravesites. Offerings of cake, chicken, tea, rice, and alco- hol, as well as money, are made at the graves, and then the family picnics on the offerings. The second ritual, held on the twenty-third day of the twelfth lunar month, is to celebrate the departure of the Spirit of the Hearth, Ong Tao. He is represented by three stones on which the cooking pots are placed and is hon- ored by a small altar. Like the Chinese Kitchen God, Ong Tao returns to the celestial realm each year and reports on the family’s behavior. After the family makes an offering to symbol- ize his departure, they share a feast including glutinous rice cakes and a very sweet soybean soup. One week later the family celebrates Ong Tao’s return to their hearth. The follow- ing day is the first day of Tet. Guests (espe- cially those with favorable names, such as Tho, meaning “longevity”) are entertained with tea, rice alcohol, red-dyed watermelon seeds, candied fruits, and vegetables. Special dishes prepared for the week-long celebration include banh chung, glutinous rice cakes filled with meat and beans and boiled in banana leaves, squid soup, stir-fried young seasonal vegetables, pork with lotus root, and sometimes a special shark fin soup. Many Vietnamese, including those in the United States, celebrate the Buddhist holiday called Trung Nguyen, or Wandering Souls Day. It occurs in the middle of the seventh lunar month and is celebrated with a large banquet prepared in honor of the lost souls of ancestors.12 Traditionally, the Vietnamese did not commemorate birthdays but rather honored their ancestors on the anniversary of their death with a special celebration and meal. In the United States, it is now more common to celebrate birthdays. The largest holiday of the year in Cam- bodia is also the New Year’s Day celebration, Chaul Chnam, which begins on April 13 and lasts for three days. Prayers and special foods like fried coconut and fried bananas rolled in coconut are offered to the New Year Angel, who descends with either blessings or ill will. The Water Festival, held in November after the seasonal rains have ended, features color- ful floats in local rivers. Most Laotian holidays are religious in ori- gin and are celebrated at local temples. Pha Vet, which occurs in the fourth lunar month, commemorates the life of Buddha. Boon Bang Fay, held in the sixth lunar month, also honors the Buddha with a fireworks display. Among the Hmong and other Laotians, the New Year’s celebration is a major event. It begins with the first crow of a rooster on the first day of the new moon in the twelfth lunar month, usually in December. The highlight of the festivities is the world renewal ritual, which involves an elder who chants while holding a live chicken. He circles a tree three times clockwise to remove the accumulated evil of the previous year and then circles the tree three more times counterclockwise to invoke good fortune in the upcoming year. The bad luck collects in the blood of the chicken, which is traditionally taken to a remote location and slaughtered. Customarily considered a good time to meet Hospitality is very impor- tant to the Filipinos, and food gifts to express love or appreciation are common. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 3 9 2 S O U T H E A S T A S I A N S A N D P A C I F I C I S L A N D E R S future wives and husbands, New Year’s was the one time each year when Hmong from differ- ent clans celebrated together. Therapeutic Uses of Food Filipino When the Spanish came to the Philippines, they introduced the Mexican hot– cold theory of health and diet (see Chapter 9). Foods are classified as being hot or cold based on their innate qualities or their effect on the body, not on their spiciness or temperature. Although the classification of certain foods varies regionally, avocados, alcoholic bever- ages, coconuts, nuts, legumes, spices, chile peppers, and fatty meats are generally con- sidered hot items; tropical fruits, vegetables, milk and dairy foods, eggs, fish, and lean or inexpensive meats are regarded as cold.20,38 A balance is attempted at meals between hot and cold elements. The reason Filipino dishes contain so many ingredients may be to ensure this balance. Some illnesses are characterized as hot or cold and are treated with foods of the opposite category. Diarrhea and fevers are hot; colds and chills are cold. Other food beliefs are based on sympathetic qualities (“like causes like”); for instance, pregnant women may avoid dark foods to prevent their babies’ skin from being too dark. Sometimes the meaning behind a therapeutic food use is more obscure; horseradish leaves and broth seasoned with ginger are believed to promote milk produc- tion in nursing mothers, and fish heads and onions are considered brain food by some Filipinos. Honey, as well as certain herbs such as thyme, marjoram, and chamomile, is used to treat diabetes. Licorice root is considered a general tonic, especially beneficial during times of stress. Some elderly Filipinos have adopted the Asian Indian practice of chew- ing areca nuts (also called betel nuts), which is believed to prevent tooth decay, although it leaves permanent stains. The Department of Health in the Philip- pines has approved several herbal remedies as safe and effective, including ampalaya (bitter melon, prepared as a side dish or as a juice) for diabetes, bawang (garlic) to lower blood bawang (garlic) to lower blood bawang cholesterol levels and reduce blood pressure, ulasaming bato (pepperomia, which is eaten as a salad or brewed into tea) for arthritis and gout, and sambong (an indigenous herb) as a sambong (an indigenous herb) as a sambong diuretic.39 Vietnamese and Other Mainland Southeast Asians Many Vietnamese follow the Chinese yin–yang theory of health and diet (see the section titled “Therapeutic Uses of Food” in Chapter 11). Yin is known as âm and yang is called duong. As in the hot–cold system, clas- sification is based on intrinsic characteristics rather than temperature or spiciness. Exam- ples of duong (hot) foods are red meat, unripe fruit, ginger, garlic, coffee, and alcoholic bev- erages. Âm (cold) items include noodles, bananas, oranges, gelatin, and ice cream.22,40 Some foods, such as rice, pork, eggs, chicken broth, teas, and sweets, are classified as neu- tral.41,42 Not only must a balance be main- tained within a meal, but extremes are also avoided during certain conditions, such as pregnancy. As with Filipinos and other Asians, illnesses are defined as âm and duong and are sometimes caused by eating too many âm or too many duong foods. During pregnancy, which is duong, hot foods are avoided, and equilibrium is restored by eating foods of the opposite type; during the postpartum period, which is âm, cold foods are avoided. Yin and yang concepts are less prevalent among Cam- bodians and Laotians, although some hot and cold beliefs exist regarding specific foods and certain conditions. The Chinese medical system details other influential elements in health, including the five flavors of sour, bitter, sweet, pungent, and salty; these tastes are harmonized in many Vietnamese dishes. Vietnamese believe that ingestion of specific organ meats will benefit the like internal organs. For example, con- sumption of liver will produce a stronger liver. Some Vietnamese believe that eating gelati- nous tiger bones (produced by prolonged cooking) will make them strong. Concur- rently, some foods may be injurious because they resemble certain disorders. Pregnant women may refuse to eat ginger because the multilobed root is thought to cause polydac- tyly (too many digits) in babies. A feast is held by the Hmong following the birth of a child. Included are two chickens representing the parents, a boiled egg signifying the child, and a small lit candle symbolic of the ancestor spirits whose blessing and protection are sought. Licorice root, which contains glycyrrhizin, can cause fluid retention and increase blood pressure if consumed in large amounts. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 1 2 3 9 3 The therapeutic value of some foods is unrelated to yin or yang or how they look. Some Vietnamese eat chile peppers to get rid of worms, or noodles with roasted rice paper and shrimp sauce for curing the flu. Cambodians may drink water with bitter melon for fevers. Vietnamese women may consume large amounts of salty foods during pregnancy,43 and mothers may avoid feeding chicken or duck to their babies to prevent them from becoming deaf or mute.44 Hmong women eat a diet of rice, chicken broth, black pepper, and herbs for a month after giving birth,45 and some clans have specific taboos against eating certain foods, such as heart.46 Contemporary Food Habits in the United States Adaptations of Food Habits Filipino Little current information on the food habits of Filipino Americans has been reported. Most are able to obtain traditional foodstuffs without much difficulty, although some of the familiar tropical fresh fruits and vegetables are not available. Research shows that most Filipinos still eat rice every day but not with every meal, and their diets tend to contain a greater variety of foods, especially more milk, green vegetables, meat, and sweets than they did in the Philippines.47,48,49,50 Meriendas are not eaten as often as in the Philippines. Filipinos born in the United States fre- quently consume a typically American diet. Breakfast consists of cereal, toast, eggs or meat, juice, and coffee; sandwiches, salads, and sodas are common at lunch; and dinner is usually a meat or fish dish served with rice or potatoes, followed by dessert. Traditional Filipino items may appear at some meals, such as eating longaniza sausage at breakfast or eat- ing halo-halo (sometimes topped with vanilla ice cream) for dessert.51 Vietnamese and Other Mainland Southeast Asians A study conducted in Washington, DC, found that 30 percent of the Vietnamese households surveyed had changed their eat- ing habits since coming to the United States.53 Although most continued to eat rice at least once a day, they ate more bread or instant noodles at lunch and more cereal at breakfast. Respondents also reported consuming more meat and poultry and less fish and shellfish than in Vietnam, mainly because of cost. Pork and pork products were still preferred to beef. They also reported consuming fewer bananas but more oranges, fruit juices, and soft drinks. More recent research indicates that Vietnamese Americans decreased their vegetable intake as their household income increased.52 More than 90 percent of Vietnamese Amer- ican adolescents in another study were found to prefer their native diet, although a major- ity listed items such as steak and ice cream as being among their favorite foods. Soft drinks and milk were well liked; cheese and peanut butter were strongly disliked. Only a small percentage of the teens snacked regularly.54 A more recent study on the same population reported that Vietnamese American high school students in Massachusetts consumed more fruits and vegetables than did other eth- nic groups, and fewer dairy products. Over 28 percent ate at least five fruits or vegetables each day; however, only 8.5 percent consumed the recommended number of dairy servings. Notably, fruit and vegetable consumption increased with degree of acculturation, but decreased with age.55 A sur vey of Cambodian and Hmong families indicated some similar trends. Although traditional items were preferred by the adults, both American and native foods were acceptable to the children. Most- liked items among the adults included steak, oranges, candy, and soft drinks, all of which are prestige foods in Cambodia and Laos.56 Least-liked items included cheese, chocolate milk, and milk.57 A detailed study of poor Hmong immigrants in California revealed that the majority of adults (52 percent) con- sumed two meals each day of rice, greens, and meats. Pork was the preferred meat, although chicken, turkey, fish, and eggs were also eaten. The adults were mostly unfamil- iar with baked products, such as bread or cookies, and most strongly disliked both milk and cheese. It was found that many Though overall con- sumption of fish by Vietnamese Americans is thought to be lower than in Vietnam, data show they have the highest intakes of recent Asian immigrants, particularly of shellfish.58 Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 3 9 4 S O U T H E A S T A S I A N S A N D P A C I F I C I S L A N D E R S Hmong grow their own vegetables and seasonings (especially varieties difficult to obtain from grocery stores) in backyard gardens. In a study limited to fish consump- tion, it was reported that Laotians and Mien were most likely to harvest fish and seafood locally, and that Mien (23 percent) and Hmong (90 percent) frequently consumed the entire fish, including head, bones, eggs, and organs.58 Food purchasing and preparation as well as meal patterns are also changing. South- east Asian American women report that men frequently help with shopping or cooking. Vietnamese, Cambodian, and Laotian ado- lescents often are involved in food purchases, and surveys indicate as many as 60 percent of girls and 35 percent of boys have total respon- sibility for fixing dinner each evening. South- east Asian women living in the United States are more likely to have a job or to attend adult education classes than in their homeland, relinquishing some household responsibili- ties to other family members. Further, many families report a significant decline in eating meals together.56,59,60 Some young Hmong women avoid eating gizzards because they are believed to toughen the placenta and make birth difficult. There are approximately sixteen times more Filipino Americans and ten times more Vietnamese Americans than there are Thai Americans in the United States. Yet Thai cooking is more familiar to the general pop- ulation than either Filipino or Vietnamese fare. Thai restaurants which are 16 percent of total U.S. market share in the restaurant industry have introduced the distinctive cuisine in many parts of the United States, even where few Thai Americans live, and dozens of cookbooks have further popular- ized the cuisine.152 The country of Thailand is located on the southern end of the archipelago that is Southeast Asia. The hot, monsoonal climate is ideal for rice cultivation. Long-grain rice is the foundation of the diet, though short- grain glutinous rice is used for snacks and desserts and is preferred in the regional Issan cuisine of the northeast (similar to Cambo- dian fare, also known for its culinary use of insects).155 Noodles made of rice, wheat, or mung beans are also common. Both tropi- cal and temperate fruits and vegetables are prominent in the cuisine. Seafood from the lengthy coast, especially shrimp, is popular. Dried herring-like fish (which are sometimes smoked as well) are often flaked into rice for added flavor. Beef, chicken, and pork are common. Duck is a favorite. Thai food differs from that of its South- east Asian neighbors because of its flavors. It is one of the hottest cuisines in the world, with lavish use of chile peppers. Several varieties of basil, fresh coriander leaves and root, galangal, garlic, ginger root, kaffir lime leaves, lemon grass, mint, and tamarind are typical seasonings. In addition, curried dishes are eaten daily. There are three types of curry sauces: yellow, which are smooth, mild, Indian-like sauces that include spices such as cardamom and turmeric; red, which are chunkier, hotter, and typically include ample fresh red chiles and coconut milk; and green, which are prepared with fresh green chiles whose heat is excruciating for all but the most experienced palates. Fermented fish products, such as nam pla (similar to the Vietnamese sauce called nuoc mam) and kapi (a paste made from fish or shrimp), are added to most dishes. Nam prik, a sauce that combines nam pla or kapi with other ingredients like garlic, peppers, shallots, lime juice, tamarind, palm sugar, and peanuts, complements dishes such as yam (fresh vegetables rolled up into a leafy package and dipped into the nam prik), salads (nam prik is the dressing), noodle dishes, dumplings, fried or grilled foods, and highly spiced raw pork called nam. Noodle dishes are usually eaten for breakfast and lunch. Phad Thai—stir-fried noodles cooked with bits of meat, seafood, and vegetables bound with eggs, then topped with peanuts and nam prik—is an example. Sweets such as coconut custards and fruit jellies are preferred snacks. Thai cooking began as a court cuisine, and this heritage is most obvious in the evening meal.32,156 Dinner often includes appetizers, such as deep-fried chicken wings stuffed with ground pork and shrimp or pas- tries shaped like delicate flowers. The main meal traditionally features steamed rice, soup, a curried dish, a fried dish, and a salad of raw vegetables and grilled poultry, beef, or seafood. Mee krob, a volcanic-looking mound of stir-fried noodles and meats or seafood cooked with sugar until caramelized, is a favorite addition. Various nam prik accom- pany the dishes. All dishes are served at the same time. Fingers and spoons are the usual implements, and forks are available for push- ing food into the spoon. The meal usually concludes with elaborately carved fruits. E X P L O R I N G G L O B A L C U I S I N E T h a i Fa r e Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 1 2 3 9 5 Nutritional Status Nutritional Intake Filipino Life expectancy rates for Filipino Americans are higher than for the general U.S. population.63 The traditional Filipino diet is higher in total fat, saturated fat, and cholesterol than most Asian diets, and urban Filipinos living in the United States tend to have an even higher intake of these dietary components.61,62 Median body mass indexes (BMIs) in men and women are close to those of whites in the United States, while rates of overweight and obesity are higher than in most other Asian groups.64 Filipino Americans have high rates of hypertension and serum cholesterol levels, equal to those of white Americans. Twenty-seven percent of Filipinos have reported being told that they had hypertension.64,65,66 Heart dis- ease is the leading cause of death in mor- tality statistics for Filipinos, and strokes are third. Filipinos develop type 2 diabetes mellitus (9 percent) more often than most other Asians.64,65 Filipina women are at an increased risk for developing gestational diabetes during pregnancy.67,68,69,73 Filipina women in the United States have been found to have larger waist circumferences and a higher percentage of visceral adipose tis- sue than white women despite lower rates of overweight and obesity, suggesting more research is needed on metabolic syndrome (which is also higher in Filipinas) in non- obese populations.70,71,72,74,75 Many are lactose intolerant and calcium intake may therefore be limited.11 Dried fish, fish sauce, and fish paste may provide cal- cium, but amounts vary depending on the source and quality of the product. Some Fili- pinos may be at risk for calcium deficiency, particularly newer immigrant women during pregnancy and postpartum.11 Infant mortality rates are slightly below those for the general population.76 When compared to other Asian groups, Filipino neonates are also at increased risk for death from infection, and postneonatal infants from respiratory distress syndrome.68 In addition, Filipino rates for hyper- uricemia (resulting in gouty arthritis) and Certain Filipino dishes are very high in purines, a concern for patients with gout; dinu-guan, for example, often includes pork liver, kidney, heart, and small intestine. glucose-6-phosphate dehydrogenase defi- ciency (causing anemia unrelated to iron intake) are also higher than for white Ameri- cans. It should also be noted that alpha thalassemia (hemoglobin H disease) is also prevalent and results in a hypochromic micro- cytic anemia, especially during an infection or when oxidant drugs are taken. Vietnamese and Othe r Mainland S outh- east Asians Food intake data suggest that the calcium intake of mainland Southeast Asians is low, although this observation does not account for fish sauces and other traditional foods that may contain sufficient calcium.77 An analysis of broth made with acidified bones reported that one table- spoon provided nearly as much calcium as one-half cup of milk.78 Vietnamese have been reported to have high rates of lactose intolerance. Very little health and nutrition research has investigated the children and grandchil- dren of Southeast Asian immigrants from spe- cific countries, but other studies have shown that diet and health risk factors are correlated to the adoption of American culture and lifestyle.59,77 As previously mentioned, Asian American women have the highest life expec- tancy (85.8 years) of any other ethnic group in the United States. The following health conditions are more common for these eth- nic groups: cancer, heart disease, stroke, unintentional injuries (accidents), and type 2 diabetes (at a lower BMI).78 Asian Ameri- cans also have a high prevalence for the fol- lowing conditions and risk factors: chronic ▲ Vietnamese restaurants, especially those featuring the noodle soups called pho, have become popular in many communities where Vietnamese immigrants have settled. Ro be rt F rie d/ A la m y Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 3 9 6 S O U T H E A S T A S I A N S A N D P A C I F I C I S L A N D E R S obstructive pulmonary disease, hepatitis B, HIV/AIDS, smoking, tuberculosis, and liver disease.64,77,79,80,81,83,84,85 Thalassemia, a genetic form of anemia, is more common in Southeast Asians and is not due to an iron deficiency.82 In a study of California Asian groups, Cambo- dian and Laotian women had adverse mater- nal risk profiles and higher death rates than whites for neonates, postnatal infants, and infants.69 Numerous studies have noted that the now older refugees from mainland Southeast Asia are at special risk for mental health prob- lems, due to the horrors of war, difficulties in escape, lengthy camp confinement, and the extreme cultural differences between their homeland and the United States. Posttrau- matic stress disorder is common. One study of the Hmong suggests, however, that levels of depression, anxiety, hostility, and other symp- toms of adjustment problems may gradually resolve with length of stay.92,95,96 Southeast Asians typically calculate age on a lunar calendar, often starting with being one year old at birth. Reported age may differ as much as two years from Western chronologi- cal age, which can distort the use of standard- ized growth curves. Some Vietnamese parents may claim, however, that their children are younger than they are to enroll them in lower school grades; this allows the children to catch up in their schooling. Counseling Filipino Americans of Filipino descent may accept illness as fate, tolerating symptoms until the severity forces them to seek care. Relatives, neighbors, and traditional healers may be consulted before obtaining biomedi- cal service. Language barriers may be signifi- cant. For example, some Filipino languages do not recognize gender, and there may be some confusion with pronouns. In 2010, over 22 percent of Filipinos reported they did not speak English well; nevertheless, the assump- tion that an interpreter is needed may offend those who have mastered the language.97 The communication style of many Fili- pino Americans is very high context, and expression is formal and polite.11 Confronta- tion is avoided, and all attempts to maintain harmony will be made, including the use of silent pauses and laughter to hide embarrass- ment.37 Raising one’s voice or losing emotional control is considered rude and immature. Positive expression, no matter the situation, is expected. Filipino elders should not be addressed by their first names, as this is disrespectful. Health care practitioners are often consid- ered to be authority figures, so responses to questions may be deferential; Filipinos will avoid voicing disagreement. Many Filipinos avoid situations in which self-esteem may be lost, and thus health care providers should be sensitive in discussing certain subjects, such as socioeconomic background. Modesty may make other topics uncomfortable to discuss as well, including sexuality (handled best by a provider of the same gender as the client) and “shameful” conditions such as tuberculosis or mental illness. Soft handshaking is the common greeting, although an eyebrow flash (quick lifting of the eyebrows) may be used between acquain- tances.86 Avoid any other touching, and keep hands exposed at the side of the body, not in pockets. Direct eye contact between peers of the same gender may occur, but in general quick contact and aversion is more common, particularly when addressing someone in a position of higher authority. Further, direct eye contact between men and women may be interpreted as an expression of sexual inter- est or aggression. Filipinos may expect quick results from their health providers and will switch to other healers if they feel that prog- ress is too slow.15 Unknown numbers of traditional heal- ers are used by some Filipino Americans. An older study in Los Angeles reported that most respondents, independent of education level, still adhered to many traditional beliefs about the cause of illness, including unbalanced conditions such as eating too much or eating the wrong combination of foods, working too hard, or being punished for one’s sins against God. Immigrants from rural regions were more familiar with traditional medical prac- tices than immigrants from urban areas, who were more likely to rely on over-the-counter therapeutics.15 The Mien in California have been found to be at high risk for trichinosis infection due to the use of raw pork in dishes such as laap. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 1 2 3 9 7 Due to the strong family orientation, rela- tives play a significant role in a Filipino client’s treatment and recovery. For most effective treatment, the provider should discuss diet modifications with family members as well as with the patient. Compliance may be moti- vated by desire to fulfill familial obligations and participate in social life.87 The in-depth interview should be used to determine the patient’s degree of acculturation, use of tra- ditional medical practices, and personal food habits. Vietnamese and Other Mainland Southeast Asians Cultural factors that are potential bar- riers to treatment are believing in the spiri- tual etiology of diseases, patriarchal values, modesty, and mistrust of the Western medi- cal system.60,85 Language barriers may also exist. Large numbers of Southeast Asians do not speak English well: Vietnamese (59 per- cent), Hmong (48 percent), Cambodians (53 percent), and Laotians (51 percent).97 In one study, Vietnamese Americans with lim- ited English proficiency considered quality translation services essential to care, express- ing a preference for professional, gender- concordant interpreters instead of the use of family members.89 Similar to Filipinos, some Southeast Asians believe that illness is in the hands of God, spir- its, or fate. For example, a study of college stu- dents found that over 38 percent of Hmong participants believe developing osteoporosis is due to chance or luck (though Vietnam- ese students were more likely to attribute the condition to diet).90 Furthermore, some Southeast Asian Americans may deny dis- comfort and pain until it becomes intolerable, or until all home remedies prove ineffective. Many Southeast Asians also philosophically regard quality of life to be more important than length of life, believing that personal illness or suffering will diminish in the next reincarnation. As a result, a client may be very ill before deciding to go to a clinic or hospital. Traditionally, prevention of disease occurs primarily through harmonious living; most Southeast Asians have little experience with medical checkups or treating a condition when no symptoms are present.24,91 Trust is a significant issue in Southeast Asian health care. Experiences with medical personnel in refugee camps have left many immigrants suspicious of biomedicine in general. Many Americans of Southeast Asian descent believe that Western practitioners do not understand their medical needs and are disrespectful of their traditional practices; many are fearful of invasive laboratory tests, especially the taking of blood because this may upset the body’s balance. Surgery may be avoided and even autopsies denied due to fears about the relationship between the body and soul. Privacy issues may also be of concern. For example, the need to completely undress or the use of hospital gowns, breast and pelvic exams, and discussions about family planning should be postponed until a client–provider relationship has been established, preferably between a provider of the same gender as the client.24 Southeast Asian clients desire a full description of their disorders and therapies, and interpreter fluent in a client’s dialect and culture may be essential to communication. For example, one study found that the con- cept of chronic illness did not exist in Hmong healing practices, and there were no words or explanations for conditions such as hyper- tension and diabetes. There was confusion among respondents between curing and con- trolling an illness.93 Differences in medical concepts and technologies require A very polite, unhurried, and reserved con- versational style is appreciated by most South- east Asians. Excited, informal, or frank speech may be considered rude.46 Many Hmong pre- fer an attitude of caring and respect, showing warmth through smiling and using a positive approach—negative statements and outcomes should be avoided.24,94 The Vietnamese place a high value on social harmony; both Con- fucian and Buddhist belief systems encour- age modesty. The clinician should be aware that, in general, Southeast Asian clients will be agreeable to avoid disharmony or to please the questioner. When angry or embarrassed, Southeast Asian Americans may laugh to mask their emotion. Proper posture and appearance are important. In addition, certain non-verbal forms of communication should Some Filipinos believe that fat is a protection against becoming too cold and losing vital energy; thus, being overweight is preferred to being too thin. Some Filipino elders prefer their food soft and warm and will reject beverages with ice.157 Traditional therapies such as coining or moxibustion may leave marks on the skin; abuse should not necessarily be presumed. Hmong may prefer unseasoned foods when hospitalized and may desire water that is boiled before drinking.46 Some Southeast Asians may not distinguish between fruit juices and fruit-flavored beverages in food recalls. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 3 9 8 S O U T H E A S T A S I A N S A N D P A C I F I C I S L A N D E R S be carefully observed. The head is considered sacred, and it is extremely offensive to pat or even touch the head of an adult or child with- out permission. The feet are the lowest part of the body, and thus it is impolite to point with the foot or show the bottoms of one’s shoes. It is also rude to snap one’s fingers or signal by using an upturned index finger, as this is how dogs are called. Respect is shown by giving a small bow of the head when greeting elders and by using both hands to present any item to the client. Numerous studies have noted that the now older refugees from mainland Southeast Asia are at special risk for mental health prob- lems, due to the horrors of war, difficulties in escape, lengthy camp confinement, and the extreme cultural differences between their homeland and the United States. Posttrau- matic stress disorder is common. One study of the Hmong suggests, however, that levels of depression, anxiety, hostility, and other symp- toms of adjustment problems may gradually resolve with length of stay.114 Adherence to traditional health beliefs varies, often accord- ing to whether new religious faiths have been adopted; Christian churches strongly discour- age ancestor and spirit worship.22 Some stud- ies suggest that the majority of immigrants continue certain practices, such as the use of botanical home remedies and coining (see the section “Traditional Health Beliefs and Prac- tices”), for many years after arrival although the costs and inconvenience of some tradi- tional cures, including difficulties in obtain- ing animals and herbs, the disintegration of clan ties, and the scarcity of shamans pres- ent barriers in some communities.17,27,33,95,115 Southeast Asians frequently develop a medical pluralism, accepting those theories and thera- peutics most congruent with their accultura- tion experiences. Adherence to traditional health beliefs and practices, such as hot and cold theories and the use of herbal remedies, is reportedly high among many Southeast Asians.24,31,88 It is not unusual for Southeast Asians to consult both biomedical practitioners and healers for relief Iwas born in Vietnam but came to the United States when I was about a year old. My parents left Vietnam in 1976. My grandparents got us and about thirty-five other people out on a boat. We first went to a refugee camp in Malaysia, and after a few months we were able to settle in Southern California. At home we ate a traditional diet, and I still do. Rice and noodles are staple foods. Breakfast is a French baguette with pâté and ham (there is a lot of pork in the diet). Lunch is soup or a bowl of rice with one entrée, usu- ally a leftover from dinner. There are always three things for dinner: (1) always soup, (2) a stewed meat entrée, and (3) vegetable stir- fry. Fruit is usually served for dessert. Snacks are commonly fruit or sticky rice. Western foods that I eat now are dairy products such as milk, cheese, and yogurt; cereal for breakfast; and more sweets for dessert. Viet- namese have always eaten a lot of sugar but not as desserts. I lost all my baby teeth due to cavities because I was given so much candy. In Vietnam, only children from wealthy fami- lies got candy, so it was a real treat here. When we first came over, our neighbors gave my parents cereal to try, and they liked it. At that time my parents hardly spoke or read English, and there were very few Viet- namese markets. Because the cereal box had pictures of cats and dogs on it, when they went to the grocery store they bought a box of something with pictures of cats or dogs on it, but it turned out to be pet food. They ate the whole box, but they did put sugar on it because it wasn’t sweet enough. This was not an uncommon problem when the Vietnamese first immigrated to the United States. A friend was enrolled in WIC (Women, Infants, and Children) while she was pregnant and had vouchers to buy WIC food at the market. She recognized the word cheese and she bought cream cheese and ate one package every day during her pregnancy. When counseling Vietnamese, it is important to remember that our meal is not complete unless it contains rice or noodles. Therefore you should not recommend eliminating these elements of the diet but rather just decrease their amount. N E W A M E R I C A N P E R S P E C T I V E S HAN LE, Student Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 1 2 3 9 9 of symptoms. The Vietnamese usually char- acterize U.S. biomedicine as yang (hot) and traditional Vietnamese medicine as yin (cold). Biomedicine is seen as fast-acting, temporary, and likely to have side effects. It is useful for emergency situations. Vietnamese medicine is considered slow-acting, gentle, without side effects, a permanent cure, or useful in preven- tion. Some immigrants believe it is important to counteract the yang impact of biomedical therapies with yin herbal remedies.23 Little is known about the active agents in Southeast Asian herbal remedies, and some may be of concern. High levels of lead have been found in paylooh, an orange powder ingested for rashes or fever. A case study found that the use of slang nut (the source of strychnine) was not toxic as applied in Cambodia, but is poisonous when used in the United States without the leaves it is traditionally wrapped in.24,98 Because the postpartum period is defined as yin (cold), women avoid exposure to cold and wind (see the section “Traditional Health Beliefs and Practices”). Clients may refuse to get out of bed soon after giving birth and refuse to take a shower or wash their hair. Âm foods, such as cold beverages and vegetables, may be refused even if prepared in a cultur- ally sensitive manner. Women may consume alcoholic beverages because they are duong, and alcohol is also thought to cleanse the reproductive system and promote milk pro- duction.40 Hmong women also consider the postpartum period a cold condition. An in-depth interview is critical to deter- mine the patient’s country of origin (a patient may be offended if grouped with all other Southeast Asians), length of time in the United States, and any immediate health problems. Degree of acculturation and personal food preferences should also be noted. Native Hawaiians and Pacific Islanders Native Hawaiians and Pacific Islanders (NHPIs) are the peoples inhabiting some of the 10,000 islands of Oceania. Polynesia, Micronesia, and Melanesia are the three areas that make up the Pacific region. Polynesia includes the major islands and island groups of Hawaii, American Samoa, Western Samoa, Tonga, Easter Island, and Tahiti and the Society Islands. The 2,000 small islands of Micronesia include Guam, Kiribati, Nauru, the Marshall and Northern Mariana Islands, Palau, and the Federated States of Microne- sia. Although the boundaries of Melanesia are not exact, it includes the nations of Fiji, Papua New Guinea, Vanuatu, the Solomon Islands, and the French dependency of New Caledonia. Although the area is geographically simi- lar, consisting of mostly small, tropical coral or volcanic islands, NHPI are a racially and culturally diverse population. European, American, and Japanese influences have been extensive. Today there are greater numbers of some NHPI groups living in the United States than in their native homelands. Cultural Perspective History of Native Hawaiians and Pacific Islanders in the United States Immigration Patterns Since the first settle- ment of the island Oceania, the migration of population groups has been very fluid among Polynesia, Micronesia, and Melanesia. As conditions on one island grew too crowded, colonization of surrounding islands occurred. That trend continues, with economic oppor- tunity the primary motivation for NHPI immigration to the United States and other nations. Hawaiians When British explorer James Cook first arrived in Hawaii, approximately 300,000 Native Hawaiians were living on the islands. European diseases introduced by the explorers and missionaries decimated the population, and by 1910 only a little more than 38,500 persons of Hawaiian ancestry remained. A high rate of intermarriage has resulted in a population with few Hawaiians of full native heritage. A large number of Hawai- ians have migrated to the mainland United States, but the census figures do not reflect such interstate relocations. Samoans In 1951 the Pago Pago naval base that employed many Samoans moved to Hawaii, and many Samoans followed. Increas- ing population pressures and a deteriorating Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 4 0 0 S O U T H E A S T A S I A N S A N D P A C I F I C I S L A N D E R S economy encouraged further immigration. Once in Hawaii, Samoans sometimes move to the mainland United States in search of broader job availability and for wider edu- cational opportunities for their children. A chain of immigration between Hawaii and the West Coast has been created, with Samoans established in the mainland helping extended family members settle nearby. Guamanians Following attainment of citizen- ship in 1950, many Guamanians enlisted in the U.S. armed forces seeking better employment. Some moved to Hawaii and the West Coast of the U.S. mainland. By the early 1970s, approxi- mately 12,000 Guamanians had immigrated, mostly Chamorros (native Micronesians). Major populations have settled in San Diego, Los Ange- les, San Francisco, the Seattle area, and Hawaii. Tongans The immigration of Tongans to the United States did not begin until population pressures in the 1960s decreased economic opportunities in Tonga. Under the strict hereditary social structure, only the eldest son in a family may inherit land, leaving younger men with little economic mobility. Unlike most other NHPIs, Tongans usually immi- grate directly to the U.S. mainland rather than settling first in Hawaii. Current Demographics and Socioeconomic Status Hawaiians More than 1.2 million U.S. citi- zens were self-identified as Native Hawaiians and Pacific Islander (NHPI) in the 2010 U.S. Census estimate. Over half a million are Native Hawaiians, and Samoans are the next largest group with under 200,000. More than half of NHPI peoples live in Hawaii and Califor- nia.97 Scant socioeconomic data are available, but reports indicate that some Hawaiians occupy the lowest economic strata in the state of Hawaii, along with other Pacific Islander immigrants, living mostly in rural and semiru- ral regions.99 Hawaiian heritage is less of a handicap on the mainland, where Hawaiians have a cultural advantage over other Pacific Islanders (through extensive exposure to U.S. society) and often enter the middle class. Overall, median family income is higher than the national average, and poverty rates are higher than the total U.S. figure. Over 90 per- cent have a high school degree and 19 percent have a college degree.97 Samoans Probably more Samoans are living outside Samoa than in American and Western Samoa combined. Over 184,000 Samoans total (alone and in combination with other eth- nicity) are U.S. residents. The largest groups are found in Honolulu, Los Angeles, the San Francisco Bay Area, and Salt Lake City.97 Though nearly one-third of Samoans in the United States work in office and sales jobs, and 18 percent hold management and professional positions, another 30 percent of Samoans in the United States are employed in unskilled or semiskilled labor such as assembly line jobs, construction, janitorial or maintenance jobs, or as security guards.99 Median family income is lower than the national average. Approxi- mately 17 percent of Samoans live in pov- erty. Over ninety percent of Samoan adults have a high school education and just under 15 percent have a college degree.97 Guamanians The 2010 U.S. Census statistics indicate over 63,000 Guamanians are residing in the United States. Many are Chamorros, although self-identification figures are unclear on the exact percentage. The Chamorros often become part of Pacific Islander communi- ties (with Samoan and Tongan immigrants). Large populations of Guamanians are found in Hawaii, California, Washington State, and Washington, DC.97 ▲ A rendering of the Resolution, the ship used by James Cook to explore Polynesia. Many Pacific Islander cultural traditions disappeared after European discovery of the islands in the eighteenth century. Be tt m an n/ Co rb is Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 1 2 4 0 1 Over one-quarter of Guamanians work in professional or management positions, and nearly one-third are employed in office and sales jobs.100 Their median family income is above the U.S. average.. Nearly 50 percent of Guamanian adults have attended college, though graduation rates are well below the national average. Additionally, 22 percent of adults have not graduated from high school.97 Tongans Over 27,000 Tongans live in the United States according to U.S. 2010 Census figures.97 Many are Mormons and are aided in their immigration by their church, and most move to communities of other NHPIs in San Francisco, Los Angeles, Dallas, Fort Worth, and Salt Lake City. In regard to educational attainment in the U.S. Tongan community, 81 percent of adults have graduated from high school. Median family income is higher than the national average.97 Worldview Religion Native Hawaiians and Pacific Island- ers follow a wide variety of religions, often according to which missionary groups were active in their homeland. Hawaiians practice mostly Protestantism, Buddhism, or Shinto- ism. Samoans are largely Methodist, Catholic, Mormon, and Anglican. Chomorros are pri- marily Catholic, and Tongans in the United States are mostly Mormon. Religion is often prominent in the lives of NHPIs, and minis- ters usually are held in high esteem. In Samoa, nightly readings from the Bible are common in most homes, and prayers are offered at every meal.101,102,103,104 Family Although most native religions were abandoned, many concepts central to Pacific Islander culture remained within the struc- ture of families. For example, on many islands social rank and power were established by birth order within the extended kinship sys- tem or clan, and even within families, younger siblings deferred to their older brothers and sisters. Elders were respected. The senior male in the group, whether in the village or in a family, managed all group matters. In Hawaii women and men were segregated under the kapu system, each with specific roles and responsibilities. Extended families were the foundation of society, and children were raised usually by grandparents, aunts and uncles, and even remote kin rather than by just the parents. Household composition was flexible, and all members were obligated to support the extended family, resulting in substantial redistribution of resources. Gen- erosity and sharing were highly valued. Any social transgressions committed by the indi- vidual were the responsibility of the whole family. In Samoa, if the violation was severe, the family could be disinherited from their land and stripped of any social title. Some of these same practices are contin- ued by NHPIs today. Unlike many immigrant groups, they typically maintain extended families in the United States. Responsibil- ity for child rearing is shared among family members (children may move freely between homes), and household chores are assigned according to age and gender. The oldest man (or occasionally the oldest woman) in the home assumes control, collecting everyone’s paycheck (or weekly contribution) and pro- viding for the household needs. The good of the whole family is considered before the benefit to the individual, and most NHPIs are guided by their desire to avoid bringing shame on their family. In Guam this interdependence is known as inafa’maolek and extends not only to family and community, but to national affil- iation as well.101,102,103,104 The stresses of acculturation in the United States usually occur due to moving from a society in which there is little anonymity (with individual behavior reflecting on the whole family or village) to a society in which NHPIs are often marginalized or even invisible if mis- identified as Asians or Filipinos. Most NHPIs maintain close contact with their homeland and fulfill their obligation to family by send- ing financial support. Trips back to the islands for political and social events are common. Traditional Health Beliefs and Practices Religion and medicine were closely linked in Pacific Islander culture, and the loss of many traditional health beliefs and practices occurred with the adoption of nonnative faiths. Although folk healers specializing in Nearly 40,000 Fijians live in the United States, according to 2013 U.S. Census data, primarily in California. Most are of Asian-Indian descent, were originally indentured laborers in Fiji, and follow the Islamic or Hindu faith. Though overall educational attainment is low, median family income approaches the national average, and poverty rates are significantly lower than the norm.158 In Samoa, a serious offense by an individual can be ameliorated by an ifoga (literally “a lowering”). The extended family positions themselves in front of the victim’s home and remains there until invited in and forgiven. They formally apologize through the presentation of gifts and cash. Certain fish in Hawaii were reserved for royalty, and women rarely consumed fish, although they were permitted to eat shellfish. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 4 0 2 S O U T H E A S T A S I A N S A N D P A C I F I C I S L A N D E R S herbs, massage, or religious and/or spiritual intervention work in Pacific Islander com- munities both in Hawaii and on the U.S. mainland, their current use is not well docu- mented. Traditional practitioners are iden- tified with a broad range of Eastern and Western religious affiliations and offer a wide spectrum of services. Their clientele are also extremely diverse, often crossing ethnic or religious lines to seek effective care.105 Many Native Hawaiians believe lokahi, harmony between individuals, nature, and the gods, is essential to good health. Hawai- ian healers typically practice massage (ho’olomilomi—used for conditions such as childbirth, asthma, congestion, bronchitis, inflammation, and rheumatism), herbal med- icine (la’au lapa’au), and/or conflict resolution (ho’ononpono, meaning “make things right”— used to remove emotional obstacles to heal- ing). Meditation, deep breathing, and Chinese Traditional Medicine may also be employed. Healing is initiated at the end of each session with spiritual blessings.106,107,108 It is reported that more than 300 Hawai- ian botanicals and animal- or mineral-based cures were available traditionally, with over fifty-eight remedies for respiratory prob- lems alone.101,110,111Today, only thirty plants are estimated to be used regularly. Examples include aloe vera for burns, hypertension, dia- betes, and cancer; plantain leaves to reduce blood sugar levels in diabetes; polokai (black nightshade) for asthma, coughs, and colds; and wild ginger for gastrointestinal prob- lems, ulcers, and asthma. Native Hawaiians also practice home remedies. For example, drinking seawater followed by freshwater is believed to be a general tonic. Samoans believe that health is maintained through a good diet, cleanliness, and harmony in interpersonal relationships. An individual is at high risk of illness if he or she does not fulfill family obligations or support village life. The concept of balance is essential: disruptions in interpersonal relationships, working too hard, sleeping too little, or eating the wrong foods can cause dislocation of the to’ala (the center of one’s being, located just beneath the navel) to another part of the body, where it induces pain, poor appetite, or other symptoms.112,113 Treatment typically requires the restoration of balance. A family may get together to openly air disputes so that harmony can be reestab- lished, or massage by an elder may be used to gently coax the to’ala back into position. A tra- ditional Samoan healer may be consulted to cure certain folk illnesses, particularly those due to supernatural causes, such as spirit pos- session by malevolent ghosts or the actions of ancestor spirits angered by a person’s conduct. One such condition is musu, a mental illness in young men and women typified by extreme withdrawal. Healers may be herbalists, mas- seuses, bone setters, midwives, taulasea (a general practitioner familiar with Samoan sicknesses), power healers (who provide spiritual interventions), or diviners (special- izing in the determination of why an illness has occurred). Massage, herbal remedies, and communication with the supernatural ele- ments are the usual therapies.102,113 Traditional Food Habits The cooking of the Pacific Islands developed without benefit of metal pots, pans, and uten- sils, and many foods were eaten raw. The indigenous cuisine was probably based on breadfruit, taro, cassava, yams, and perhaps pigs and poultry. Fruits were also widely avail- able, although those often associated with the Pacific region, such as coconuts and bananas, ▼ Taro root, staple of the Native Hawaiians and Pacific Islanders, is served boiled or pounded into a paste called poi. The leaves are also consumed. Is ab el le R oz en ba um /P ho to A lto A ge nc y RF C ol le ct io ns /G et ty Im ag es Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 1 2 4 0 3 were not introduced from Indonesia until approximately 1000 c.e. Other items, includ- ing sugar cane and pineapple, were brought by European plantation owners. Ingredients and Common Foods: Staples Starchy vegetables are the mainstay of the traditional Pacific Islander diet (Table 12.3). These include the root vegetable taro, which is a little denser and more glutinous than the white potato; breadfruit, with a fluffy, bread- like interior; cassava; and yams. These foods were often cooked and then pounded into a paste. In Hawaii, taro root paste eaten fresh, or partially fermented, is called poi (a word that originally referred to the pounding method). When food was scarce, the Native Hawaiians survived on the purplish-colored poi, some- times with a little seaweed or fish added to it. Although taro root is also a staple in Samoa, it is usually boiled but not pounded. Arrowroot is used to thicken puddings and other dishes. The Europeans introduced wheat, and bread is eaten in some areas; for instance, Portuguese sweet bread is known as Hawaiian bread in Hawaii. Asian settlers popularized both short- and long-grain rice, as well as noodles.151 More than forty varieties of seaweed are consumed. Cooked greens, including the leaves of the taro root, yam, ti plant, and sweet potatoes, are very popular. One specialty is to wrap foods in ti or taro leaves, then steam the packets for several hours. The musky flavor of the leaves permeates the entire dish, called laulau in Hawaii.32 Another specialty known as lu’au combines chopped taro leaves with chicken or octopus and coconut milk.114 Fish and seafood are abundant in the Pacific Islands, and in some regions they were eaten at every meal. Mullet is one of the most popular fishes, but many others, includ- ing mahimahi (“dolphin fish,” not related to the mammal), salmon, shark, tuna, and sardines are also consumed. A tremendous variety of shellfish is available, such as clams, crabs, lobster, scallops, shrimp, crawfish, and sea urchins, as well as many local species. Eel, octopus, squid, and sea cucumbers are also eaten. Although some fish and seafood was stewed or roasted, some was also eaten uncooked, marinated in lemon or lime juice, which turns the fish opaque much the same as cooking it. A popular Hawaiian specialty is lomi-lomi, made with marinated chunks of salmon, tomatoes, and onions, served with or without poi as an appetizer. A similar Samoan dish, called oka, is also made with chunks of raw fish marinated in a mixture of lemon juice and coconut cream. Pork is the most commonly eaten meat, especially for ceremonial occasions. Tradi- tionally it was cooked in a pit called an imu in Hawaii, a hima’a in Samoa, and an umu in Tonga. A fire was built over the stones lining the pit, and when the coals were hot, layers of banana leaves or palm fronds were added. The pig and other foods, such as breadfruit and yams, were placed on the leaves, then covered with more leaves and sealed with dirt. In some cases water was poured over the rocks just before the pit was closed, steaming the foods instead of baking them. The pit was left sealed for hours until the food was completely cooked. Chicken is widely available, as are eggs. Limited grazing land kept beef from becom- ing a frequently eaten item. Milk and other dairy products are also uncommon. Soybean products are used by Asian residents, and winged beans are a popular legume on some islands. Fruits and nuts are important ingredients in Pacific Islander cuisine. Bananas, candlenuts (kukui nuts), citrus fruits, coconuts, pineap- ples, guavas, litchis, jackfruit, mangoes, mel- ons, papayas, passion fruit, and vi (ambarella) are a few of the widely available varieties. Fruits are eaten fresh or added to dishes such as Samoan papaya and coconut cream soup (supo ’esi) and deep-fried dumplings filled with pineapple or bananas (pani keki). Coco- nuts provide juice for drinking, sap for fermen- tation, and milk or cream used in numerous stewed dishes (coconut milk can also be made into foods resembling cheese and buttermilk). Immature coconuts are considered a delicacy throughout the Pacific. Haupia, a traditional gelatin-like Hawaiian dessert, is made from coconut milk sweetened with sugar. Traditional Pacific Islander fare was not highly seasoned. The flavors of lime or lemon juice, coconut milk or cream, and salt pre- dominate, with occasional use of ginger, garlic, Hysterical behavior, especially by women, was called “ghost sickness” by the Tongans and attributed to possession by the spirit of a deceased female ancestor. Another traditional illness occurs in infants when the fontanel does not close (mavae ua). Traditionally, Samoan men obtained full-body tattoos, in part to help them empathize with the prolonged pain of childbirth suffered by Samoan women. Fish hooks are symbolic of good luck in Hawaii. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 4 0 4 S O U T H E A S T A S I A N S A N D P A C I F I C I S L A N D E R S © C en ga ge L ea rn in g Group Comments Common Foods Adaptations in the United States Protein Foods Milk/milk products Milk and other dairy products are uncommon. Many Pacific Islanders are lactose intolerant. Increased intake of milk has occurred. Meat/poultry/fish/ eggs/legumes Pork is the most commonly eaten meat. Soybean products are used by Asian residents. Winged beans are a popular legume on some islands. Meat: beef, pork Poultry and small birds: chicken, duck, squab, turkey Eggs: chicken, duck Fish and shellfish: ahi, clams, crabs, crawfish, eel, lobster, mahimahi, mullet, octopus, salmon, sardines, scallops, sea cucumber, sea urchin, shark, shrimp, swordfish, tuna, turtle, whale Legumes: beans (long, navy, soy, sword, winged), cowpeas, lentils, pigeon peas Dietary changes often occur before immigration. Many are dependent on imported foods such as canned meats and fish. Cereals/Grains Europeans introduced wheat bread, and Asians brought rice and noodles. Rice, wheat Increased intake of bread and rice is noted. Fruits/Vegetables Starchy vegetables are the mainstay of the diet. They were often cooked and pounded into a paste. More than 40 varieties of seaweed are eaten. Cooked greens are popular. Fruits are an important ingredient. Immature coconuts are considered a delicacy. Arrowroot is used to thicken puddings and other dishes. Fruits: acerola cherry, apples, apricot, avocado, banana, breadfruit, citrus fruits, coconut, guava, jackfruit, kumquat, litchis, loquat, mango, melons, papaya, passion fruit, peach, pear, pineapple, plum, prune, soursop, strawberry, tamarind Vegetables: arrowroot, bitter melon, burdock root, cabbage, carrot, cassava, cauliflower, daikon, eggplant, ferns, green beans, green pepper, horseradish, jute, kohlrabi, leeks, lettuce, lotus root, mustard greens, green onions, parsley, peas, seaweed, spinach, squashes, sweet potato, taro, ti plant, tomato, water ti plant, tomato, water ti chestnuts, yams The traditional starchy vegetables have decreased in use and may only be consumed at special occasions. Additional Foods Seasonings Food is not highly seasoned but often flavored with lime or lemon juice and coconut milk or cream. Curry powder, garlic, ginger, mint, paprika, pepper, salt, scallions or green onions, seaweed, soy sauce, tamarind Nuts/seeds Nuts are a core ingredient. Candlenuts (kukui), litchi, macadamia nuts, peanuts Beverages Coconuts provide juice for drinking and sap for fermentation. Cocoa, coconut drinks, coffee, fruit juice, kava (alcoholic beverage made from pepper plant), tea Increased consumption of sweetened fruit beverages and soft drinks has occurred. Fats/oils Coconut oil and lard are the preferred fats. Butter, coconut oil or cream, lard, vegetable oil and shortening, sesame oil Use of vegetable oils and mayonnaise has increased. Sweeteners Sugar TA B L E 12 . 3 Cultural Food Groups: Pacific Islanders Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 1 2 4 0 5 tamarind, and scallions or onions. Coconut oil and lard are the preferred fats, providing a dis- tinctive taste to many dishes. Foreign spices, such as Asian Indian curry blends, and sauces, such as soy sauce, have been incorporated into some dishes. Meal Composition and Cycle Daily Patterns Traditional meals included poi or boiled taro root, breadfruit, or green bananas; fish or pork; and greens or seaweed. In Samoa, Guam, and Tonga, most dishes are cooked in coconut milk or cream. Although the evening supper was generally the largest meal, little distinction was made between the foods served at the two or three daily meals. When food was pit-cooked, amounts suitable for two or three days at a time were prepared. Fresh fruit was eaten as snacks. Beverages made from coconut juice or sap were com- mon. The Asians introduced various teas, including those made from lemon grass and orange leaves. In Samoa a drink made from ground cacao beans mixed with water, called koko samoa, is traditional. Kava, a bland, mildly intoxicating beverage, remains a pop- ular drink in many regions. It is made from the chewed or ground root of the native pep- per plant, mixed with water in a stone bowl. It reputedly tastes a little like dirt or licorice. Etiquette Most NHPIs consider hospitality an honor, and outsiders are usually exempt from traditional manners. In Samoa, for example, it is considered rude to eat in front of someone without sharing. When eating a meal, respect should be shown for the food because it rep- resents the host’s generosity; this includes not talking during the meal.102 Most hosts will not eat until a guest is satisfied. As in many societ- ies, it is impolite to refuse food, although a guest is not obligated to eat every morsel served. At some Samoan celebrations, for example, a large box of food may be placed on the table for each guest. The diner samples items from the box until full, then brings the remaining food home to share with his or her extended family.116 Special Occasions Throughout the NHPI spe- cial events were commemorated with feasting, often including pit-roasted foods. In Hawaii weddings, childbirth, completion of a canoe or house, or a prolific harvest or abundant catch was celebrated with a luau, featuring a whole pig, poultry, fish, and vegetables cooked in the imu. In Samoa the feast is sometimes preceded by a kava ceremony, in which the beverage is distributed ritualistically to guests who are expected to drain the cup in one gulp. Traditionally kava was offered as a gesture of hospitality and for occasions such as the ordi- nation of a new chief. In Tonga, where umu- cooked food accompanies celebrations such as the commemoration of a royal birthday, special coconut frond stretchers are woven for transporting the massive amounts of food prepared for the occasion. Holidays celebrated in the NHPI are usu- ally those associated with religious affiliation. In addition, Hawaiians also honor Prince Kuhio on March 26 and the Kamehameha Dynasty on June 11. Samoans feast nearly every Sunday, and almost all denominations celebrate White Sunday on the third Sunday of October, venerating children. After a spe- cial service featuring religious recitations by children, a festive meal is served, and children are waited on by the adults in their extended family.102 Guamanians celebrate their Libera- tion Day on July 21 with parades, fireworks, and feasting.103 King Tuafa’ahau Tuopu IV’s birthday is a national holiday in Tonga.104 Role of Food Food holds particular importance within most Pacific Island cultures. Sharing food is a way of demonstrating generosity and Hawaii is a leader in aquaculture. As early as 1778, Captain Cook reported 360 fish farms on the island of Kauai, producing an estimated 2 million pounds of fish annually. The enzyme papain, extracted from papayas, is used in some meat ten- derizers. In Hawaii, papaya juice is applied to jellyfish stings to reduce the pain. Red salt, made from salt mixed with iron-rich earth, is a Hawaiian specialty, traditionally reserved for important feasts.114 When drinking kava, it is considered polite to drip a few drops onto the ground and say “manuia” as a blessing before quaffing. ▼ Pork was traditionally the most commonly eaten meat, particularly for ceremonial occasions. The pig and other foods were cooked in a stone- lined pit over coals. Po rt er fie ld - Ch ic ke rin g/ Sc ie nc e So ur ce Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 4 0 6 S O U T H E A S T A S I A N S A N D P A C I F I C I S L A N D E R S support for family and village. It is also a way of expressing prosperity or social standing. Many events are celebrated with feasting, and food is eaten to excess as part of the cer- emony in some regions. Traditionally, gender roles were defined by food interactions. Boys and girls were often raised similarly until the age of eight or nine, at which time they were separated for training in food procurement (farming and fishing) or food preparation (cooking and food storage). Throughout the NHPI, gifts of food are given often. Because the gifts are given without expectation of reci- procity, it is a serious affront to reject any item presented. Therapeutic Uses of Foods Numerous botanicals are used by Native Hawaiians as cures. Most notable is the pep- per plant (Piper methusticum—related to the betel vine), which is used to make kava or awa. It is sometimes used medicinally as an analge- sic or narcotic.116 In diluted form, it is used as a sedative and given to teething infants. Noni (Indian Mulberry) is consumed as a juice for anorexia, renal problems, urinary tract infec- tions, hypertension, diabetes, musculoskel- etal pain, to boost the immune system, and to prevent cancer.108 Turmeric is consumed as a blood cleanser, and breadfruit is made into a tea to treat high blood sugar and elevated blood pressure. Contemporary Food Habits in the United States Adaptations of Food Habits Ingredients and Common Foods In Hawaii, today’s population often eats fare that com- bines elements of Eastern and Western foods, typified by the plate lunch: rice heaped with one or two types of meat, poultry, or fish (such as teriyaki beef, spaghetti and meat sauce, fried mahi-mahi, pit-cooked pork, curry, or Spam) covered with gravy, served with a scoop of macaroni or potato salad, and eaten with chopsticks. Soy sauce is the most common condiment.114 Ethnic cuisines and typical American dishes are also widely con- sumed. Snacking is prevalent and may include noodles topped with meat (saimin), steamed pork rolls (manapua) or a large ball of glu- tinous rice with a bit of pickled daikon or teriyaki tuna tucked in the middle (musubi). Crack seed is especially popular, consisting of dried, salted, and sugared fruits (e.g., guava, sliced ginger, lemon peel, mango, plum) that provide a sweet-and-sour flavor experience. Some are also seasoned with spices, such as anise. The seed kernels (in whole preserved fruit) are traditionally cracked open with the teeth, adding extra flavor and giving the descriptive name to the treats.114 The dietary changes made by other Pacific Islanders often begin before immigration to the mainland United States. Most Pacific Islanders in their homelands are highly reli- ant on imported foods, particularly pro- cessed items such as canned meats and fish, cooking oil, mayonnaise, cookies, breakfast cereals, and soft drinks. One study of Samoa indicated that 80 percent of all foods found in one market were from the United States, New Zealand, or Australia.117 Consumption of native foods, such as taro and coconut, increases on Sundays.118 In Guam, a high intake of meats, fried foods, foods cooked in coconut milk, white rice, and sweetened bev- erages and a low intake of produce have been S A M P L E M E N U A Native Hawaiian Dinner L omi- L omi (Marinated Salmon) (Marinated Salmon)L omi- L omi a,b,c Chicken L u ’ au (Chicken with Taro/Spinach Leaves)a,c P oi (Fermented Taro Root)P oi (Fermented Taro Root)P oi a or Sweet Potatoesc Haup ia (Coconut Dessert)a,b,c or Guava Cakea,b,c Fruit Juice or Coffee aLaudan, R. 1996. The food of paradise: Exploring Hawaii’s culinary heritage. Honolulu: University of Hawai’i Press. bLocal Kine Recipes at http://www.hawaii.edu/recipes cLuau Foods and Recipes at http://alohaworld.com/ono/ Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 1 2 4 0 7 noted.119 Nutrient-rich native foods, such as fish, yams, papayas, and mangoes, were rarely consumed by Guamanian children in another study.119 Traditional starches, such as taro root and cassava, are often reserved for special- occasion feasts.120 Little has been reported on Pacific Islander food habits in the United States. A study com- paring the intakes of Western Samoans (living in a poorer, less Westernized culture) to those of American Samoans (living in a wealthier, more Westernized culture) found that the Western Samoans ate a diet higher in total fat due to a reliance on coconut cream compared to a diet higher in protein, cholesterol, and salt due to higher consumption of processed foods eaten by American Samoans.121 Older studies on Samoans who have moved to Hawaii show diets with greater vari- ety of foods; traditional foods contribute only minimally to daily intake, and items such as rice, bread, sugar, beef, canned fish, milk, soft drinks, and sweetened fruit beverages make up most of the diet.118 Available health statis- tics indicate that a diet substantially higher in fat and simple carbohydrates and lower in fruits, vegetables, and fiber has been adopted by many immigrants. Meal Composition and Cycle Three meals each day are common for most Pacific Islanders. Breakfast is most often cereal with coffee. More traditional meals may be eaten for lunch and dinner; a few Hawaiians still eat poi once or twice a day. Fruit appears more often as part of the meal rather than as a snack. It is believed that Sunday feasting among Samoans is still prevalent. Nutritional Status Nutritional Intake Serious nutritional defi- ciencies are uncommon in most Pacific Islander diets. A high calorie intake gener- ally guarantees nutritional sufficiency. How- ever, research in the last decade (2000–2007) indicated that 10 percent (6 to 27 percent) of NHPI elders reported food security issues as a result of inadequate income. California NHPI adults ate fast food meals 1.5 times a week, and teens were even higher at 2.4 times per week.122 A study of children in Guam found that three-quarters consumed fruits and vegeta- bles less than once daily, and Native Hawaiian and Pacific Islander adults consume approxi- mately one fruit or vegetable daily on aver- age.123,124 Rice, meat, powdered fruit drinks, milk, and fortified cereals were the primary sources of vitamins and minerals in the diets of Guamanian children in other research. Low intakes of calcium, vitamin E, and folate were identified.119 NHPIs have high rates of smoking, alco- hol consumption, and obesity. In 2011, they were almost four times more obese than the Asian American population and 30 percent more obese than non-Hispanic, and were twice as likely to be diagnosed with diabetes. Obesity may be caused by overeating (within the context of family and church activities) combined with inadequate physical exercise, and traditionally, being overweight was an aesthetic preference in the cultures. Hered- ity may also be a factor, and/or it may be due to the change in the types and amount of foods consumed plus lower levels of physical activity.103,125,126,127 Additionally, researchers have found that when Pacific Islanders are compared to whites with the same percentage of body fat, the Pacific Islanders have higher BMIs, suggesting greater nonfat density. Body mass index cutoffs for overweight and obesity that are standardized for whites may need to be modified.128 Many NHPIs value a larger body size. One study in Hawaii found that they believe whites and Europeans should be slim, but that NHPIs should be over-weight or obese.129 Though Samoans living in Westernized New Zealand identified a slim body as ideal, those who were above normal weight did not con- sider themselves to be obese and were positive about their body size and health.130 Research in Micronesia reported that many mothers of overweight children associate thinness with illness.131 Risk for type 2 diabetes mellitus is also high for the NHPI population.124,132,133 Prevalence estimates are the highest for Native Hawaiians (two to six times the 5 to 7 percent prevalence among whites) and from 9 to 16 percent for Samoans.109,134 It is postulated that Samoans Areca nuts are used throughout the Pacific Islands, and in Hawaii they are considered a stimulant. Guamanians are especially fond of chewing them. The practice is traditionally passed from grandparent to grandchild and is common at social occasions. Chomorrans chew them after meals.103 Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 4 0 8 S O U T H E A S T A S I A N S A N D P A C I F I C I S L A N D E R S may be especially susceptible to the kidney damage associated with hypertension because end-stage renal failure is a common cause of death in American Samoan diabetes patients. Leading causes of death among NHPIs are cancer, heart disease, unintentional injuries (accidents), stroke, and diabetes. In Hawaii, Native Hawaiians were 1.7 times more likely to die from heart disease compared to His- panic whites, three times more likely to be diagnosed with coronary heart disease as compared to non-Hispanic whites. and four times more likely than non-Hispanic white adults to die from a stroke.135,136,137 Interest- ingly NHPIs have a lower rate of hypertension compared to non–Hispanic whites.138 Native Hawaiians and Pacific Islanders are 30 percent more likely to be diagnosed with cancer, as compared to non-Hispanic whites. American Samoan women are twice as likely to be diagnosed with, and to die from, cervical cancer, as compared to non-Hispanic whites. American Samoan men are eight times more likely to develop liver cancer, and Native Hawaiian men are 2.4 times more likely to be diagnosed with the same disease, as compared to non-Hispanic whites. In Hawaii, Native Hawaiian men have the highest mortality rate (220) for all types of cancer, as compared to other ethnic groups in Hawaii, and Native Hawaiian women have the highest incidence rate (463.6) for all types of cancer, as compared to other ethnic groups in the state.139,140,141 In the U.S. territory of Guam, the incidence rate for liver cancer was 6.7 times higher in the Micronesian population, as compared to the national U.S. population (38.2 and 5.8, respec- tively), from 2003 to 2007.142 Infant mortality data suggest that Native Hawaiians have rates above the national aver- age.76 California data also report significantly higher rates of infant deaths among Samoans and Pacific Islanders, though for Native Hawai- ians and Guamanians, infant deaths were nearly half those of the total population despite higher rates of low-birth-weight neonates.143,144,145 Native Hawaiian mothers were twice as likely not to begin prenatal care until the third tri- mester of pregnancy.146 Native Hawaiians and Pacific Islanders are at increased risk for gestational diabetes, and 25 percent of births exceeded 4,000 grams (high birth weights are also reported in American Samoa).68 Counseling Concepts regarding the role of the individual in health care may be an issue for Pacific Islander American clients. Biomedi- cine presumes that better health depends on behavior changes made by a client. Pacific Islanders view the role of the individual as interdependent on the group and may not take responsibility for personal health.120 Family members may expect to be involved in the care of sick relatives, and decisions regard- ing treatment are often made through consul- tation with the entire family.147 Because health is defined as a harmonious balance of the physical, social, natural, and spiritual worlds, many Pacific Islanders prefer a comprehensive approach to care, which may involve religious rituals, including prayer. Samoan Americans generally seek care for symptomatic relief and are typically unin- terested in long-term approaches to disease prevention or management.113 Low compli- ance rates in the treatment of hypertension and diabetes in Pacific Islanders have been noted.124 A study on Native Hawaiian health needs found that cultural differences were a primary reason for underuse of services.148 Young adults defined health in terms of par- ticipating in their responsibilities, which include working and caring for their fami- lies.149 Further, some Pacific Islanders believe that illness is the will of God and may delay obtaining care until symptoms are advanced. Samoans expect exceptional politeness in interactions; showing irritation, anger, or other hostile emotion is considered rude and a sign of weakness.102 A reserved conversational style and the desire to maintain harmony may result in some Pacific Islanders enduring pain rather than expressing it.147 Judgmental or accusatory attitudes regarding lifestyle (espe- cially weight gain) may cause Pacific Islanders to avoid further counseling. When entering a room, Samoans walk around to greet each person with a smile and handshake. Eye contact is expected. Both Samo- ans and Tongans are concerned that all partici- pants in a conversation be at an equal level; for example, everyone should be sitting on mats or Research on Asian, mixed ethnicity, and white adolescent girls in Hawaii found that all groups could benefit from increased intake of fruits, vegetables, and calcium-rich foods.159 Many Pacific Islanders are lactose intolerant; it is estimated that 50 percent of Samoan adults do not tolerate milk.160 In Guam, an extremely high prevalence of both amyothrophic lateral sclerosis (called letigo) and Parkinsonism dementia (known as bodig) has been reported. Incidence has decreased significantly in recent years, however, suggesting environmental causes may be to blame.161 Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 1 2 4 0 9 in chairs. It is offensive to stand while speaking to someone who is sitting. When seated, legs should be crossed or kept close to the body; extended legs or pointing one’s feet at a person is considered poor manners.102 One study reported that weight-loss inter- ventions based on traditional Hawaiian foods were well accepted by Native Hawaiians, par- ticularly those who emphasized cultural val- ues and provided group support. However, most participants found it difficult to adhere to the diet long-term, citing difficulties in obtaining fresh produce and the pressures of an obesogenic environment.150 A study in Micronesia found significant cultural conflict in homes where mothers attempted to restrict the food intake of their overweight children. Food is associated with love, and grandpar- ents who perceive grandchildren as too thin often accuse mothers of inadequate care.131 An in-depth interview should be used to determine if a client has any traditional health beliefs or practices regarding a specific con- dition and if religious affiliation is a factor. Due to the paucity of research, coworkers or a client’s family members may provide signifi- cant information regarding particular Pacific Islander groups. Samoan women are traditionally treated to a rich coconut drink called vaisalo after childbirth. The large island continent of Australia and the two-island nation of New Tand the two-island nation of New T Zealand are thought to have been initially populated by peoples from Southeast Asia. Centuries later, Polynesians traveled to New Zealand, intermingling with the existing native peoples to become the Maoris. Despite a shared heritage, there are only a few similarities between the cooking of Southeast Asia and the Pacific Islands and the fare of Australia and New Zealand. British colonization of the countries in the eighteenth and nineteenth centuries over- whelmed the original inhabitants and their culinary traditions. Meat is the mainstay of the Austra- lian and New Zealand diets. Beef is most popular in Australia, especially steak, served with fried eggs or stuffed with oysters (carpetbagger steak). Lamb is favored in New Zealand (and also well liked in Australia), typically roasted and served with mint sauce or barbecued. Other meats and poultry are uncommon in both nations, though some wild game, particularly venison, boar, duck, and pheasant, is found in New Zealand. Fish and seafood, however, are eaten often, including shrimp, oysters, scallops, spiny lobster, and crawfish (called yabbies in Australia). Most meats and fish are simply prepared, by roasting, pan-frying, braising or poaching, and grilling. Traditionally, seasoning was very limited, but today, an international array of herbs and spices are used. For example, in New Zealand, Asian Indian lamb curries and Greek gyros are popular. Minced and ground meats appear in numerous dishes. In Australia, shepherd’s pie (ground lamb topped with mashed potatoes) and hamburgers topped with fried eggs and beet slices are common. Battered, fried sausages are a favorite snack in New Zealand. In both nations individual steak, sausage, bacon, and egg, or fish pies (consumed with tomato sauce or ketchup) are popular. Numerous fruits and vegetables are grown in the mild climate. Potatoes, beets, peas, carrots, and corn are typical accompani- ments to meals, though more exotic produce, such as eggplants, feijoas, kiwifruit (Chinese gooseberries), pineapple, and tamarillos are also available. Bread rounds out the meal. Sweets are eaten daily. Scones are common, as are biscuits (cookies) such as lamingtons (chocolate coconut) and ANZAC biscuits (oat- meal cookies provided to the Australian and New Zealand Army Corps during the world wars). Puddings and custards are especially popular. Both countries claim pavlova, a meringue and fruit dish topped with whipped cream, as a national dessert. Three meals each day are the norm. In Australia, an afternoon break for tea or beer is customary, and in New Zealand many people break for morning and afternoon tea. Australia is noteworthy for its beers and hearty wines, beverages that New Zealand is also successfully producing. The Aboriginal foods of Australia, called bush tucker, include kangaroo, wombat, emu, duck, fish, shrimp, snakes, and lizards, witchetty grubs, and wild plants such as yams, onions, wattle seeds, and quandong (a peach-like fruit). Most foods were prepared simply over a fire, in the ashes, or boiled. Foods introduced by Polynesians formed the foundation of the Maori diet in New Zealand, such as kumara (sweet potatoes), taro, and ti plants. Native greens and fruits were also available. Fish, seafood, birds, and sea mammals provided protein (there were no indigenous land mammals in the islands). The Polynesian influence is also seen in the use of the hangi, a pit-roasting method similar to imu used for ceremonial occasions. E X P L O R I N G G L O B A L C U I S I N E Australian and New Zealand Fare Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 4 1 0 S O U T H E A S T A S I A N S A N D P A C I F I C I S L A N D E R S Review Questions 1. Choose one typical Filipino dish and describe it. Explain how it conforms to the principles of Filipino cooking. Select one or two ingredients and discuss whether they are due to an influ- ence from another culture and why that might have happened. 2. Describe the traditional health and dietary beliefs for the prevention and treatment of disease in one Southeast Asian immigrant group. How does the concept of “balance” for maintenance of health fit within Southeast Asian health beliefs? 3. Pick one type of traditional healer used in Southeast Asian countries. Describe this type of healer’s practice and research whether he or she currently practices in the United States. 4. List the indigenous foods of the Pacific Islands. Pick two from your list, describe how they might be prepared today, and discuss whether they are considered to have any special dietary or health properties. 5. Processed meat products, such as Spam, are com- mon in the Filipino and Native Hawaiian and Pacific Islander diet. What is Spam, where does it come from, and how did it become prevalent in the NHPI diet? Include a recipe using Spam. References 1. Hoeffel, E.M., Rastog, S., Kim, M.O., & Shahid, H. March 2012. The Asian Population: 2010. 2010 Census Briefs. United States Census Bureau. Retrieved from http://www.census.gov/prod/ cen2010/briefs/c2010br-11 2. U.S. Census Bureau. n.d. Selected population pro- file in the U.S. 2013 American Community Survey 1 Year Estimates, Table S0201. Retrieved from http:// factfinder.census.gov/faces/tableser vices/jsf/ pages/productview.xhtml?pid5ACS_13_1YR_ S0201&prodType5table 3. Gryn, T., & Cambino, C. October 2012. The foreign born from Asia: 2011. American Community Survey Briefs. United States Census Bureau. Retrieved from http://www.census.gov/ prod/2012pubs/acsbr11-06 4. U.S. Department of Health and Human Services, Office of Minority Health. n.d. Profile: Native Hawaiians/Other Pacific Islanders. Retrieved from http://minorityhealth.hhs.gov/omh/browse. aspx?lvl54&lvlid588 5. Rkasnuam, H., & Batalova, J. August 25, 2014. Vietnamese immigrants in the U.S. Migration Policy Institute. Retrieved from http://www.migra- tionpolicy.org/print/14793#.VQ3T49FARFo 6. Pfeifer, M.E., & Thao, B.K. (Eds.). 2013. State of the Hmong American community. Washington, DC: Hmong National Development. 7. Bankston, C.L. 2000. Cambodian Americans. In R.V. Dassanowsky & J. Lehman (Eds.), Gale ency- clopedia of multicultural America, Farmington Hills, MI: Gale Group. 8. Bankston, C.L. 2000. Laotian Americans. In R.V. Dassanowsky & J. Lehman (Eds.), Gale encyclo- pedia of multicultural America, Farmington Hills, MI: Gale Group. D I S C U S S I O N S T A R T E R S Working with Differences in Diet and Culture In small groups of three or four, compare and contrast the diet and culture of Filipino, Vietnamese, Cambodian, and Laotian Americans, with each group focusing on a different aspect of the diet and culture of these groups: Within your group, try to come to a consensus on what findings to report to the rest of the class. Before breaking up, assign a number to each group member: A1, A2, A3, A4; B1, B2, and so forth. Form new groups with all the 1’s in a group, all the 2’s in another group, all the 3’s another group, and so on. In your new group, report the findings of your previous group, and, as a group, discuss the relationship of traditional attitudes toward diet and health and changes in diet and health due to immigration to the United States. Group A: The food habits and the typical eating etiquette and meal composition of these four immigrant groups Group B: Issues involved in counseling these immigrant groups on diet and health Group C: Attitudes within each immigrant group toward diet, health, and medical treatment, notably attitudes toward traditional home culture medical treatment and U.S. biomedicine Group D: Amount of obesity, diabetes, hypertension, and other diseases within each immigrant group Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 1 2 4 1 1 9. Bankston, C.L. 2000. Hmong Americans. In R.V. Dassanowsky & J. Lehman (Eds.), Gale encyclo- pedia of multicultural America, Farmington Hills, MI: Gale Group. 10. Anderson, J.N. 1983. Health and illness in Filipino immigrants. Western Journal of Medicine, 139, 811–819. 11. Pacquiao, D.F. 2003. People of Filipino heritage. In L.D. Purnell & B.J. Paulanka (Eds.), Trans- cultural health care (2nd ed.). Philadelphia: F.A. Davis. 12. Bankston, C. L. 2000. Vietnamese Americans. In R.V. Dassanowsky & J. Lehman (Eds.), Gale ency- clopedia of multicultural America, Farmington Hills, MI: Gale Group. 13. Pfeifer, M.E., & Thao, B.K. (Eds.). 2013. State of the Hmong American community. Washington, DC: Hmong National Development. 14. Nuttall, P., & Flores, F.C. 1997. Hmong healing practices used for common childhood illnesses. Pediatric Nursing, Pediatric Nursing, Pediatric Nursing 23, 247–214. 15. Montepio, S.N. 1986–1987. Folk medicine in the Filipino American experience. Amerasia Journal, 13, 151–162. 16. Becker, G. 2003. Cultural expressions of bodily awareness among chronically ill Filipino Americans. Annals of Family Medicine, 1, 113–118 17. Adler, S.R. 1995. Refuge stress and folk belief: Hmong sudden deaths. Social Science and Medicine, 40, 1623–1629. 18. Vance, A.R., & Davidhizar, R. 1999, December. Developing cultural sensitivity when your client is Filipino American. Journal of Practical Nursing, Journal of Practical Nursing, Journal of Practical Nursing 16–20. 19. Hart, D.V. 1981. Bisayan Filipino and Malayan folk medicine. In G. Henderson & M. Primeaux (Eds.), Transcultural health care. Menlo Park, CA: Addison-Wesley. 20. Orque, M.S. 1983. Nursing care of Filipino American patients. In M.S. Orque, B. Bloch, & L.S.A. Monrroy (Eds.), Ethnic nursing care: A multicultural approach. St. Louis: Mosby. 21. Nowack, T.T. 2003. People of Vietnamese heritage. In L.D. Purnell & B.J. Paulanka (Eds.), Transcultural health care (2nd ed.). Philadelphia: F.A. Davis. 22. Orque, M.S. 1983. Nursing care of South Vietnamese patients. In M.S. Orque, B. Bloch, & L.S.A. Monrroy (Eds.), Ethnic nursing care: A multicultural approach. St. Louis: Mosby. 23. Stephenson, P.H. 1995. Vietnamese refugees in Victoria, BC: An overview of immigrant and refugee health care in a medium-sized Canadian urban centre. Social Science and Medicine, 40, 1631–1642. 24. Her, C., & Culhane-Pera, K. 2004. Culturally responsive care for Hmong adults. Postgraduate Medicine, 116, 39–46. 25. Capps, L.L. 1994. Change and continuity in the medical culture of the Hmong in Kansas City. Medical Anthropology Quarterly, 8, 161–177. 26. Cheyne, J.A. 2001. The ominous numinous: Sensed presence and “other” hallucinations. Journal of Consciousness Studies, 8, 133–150. 27. Hinton, D.E., Pich, V., Chhean, D., & Pollack, M.H. 2005. “The ghost pushes you down”: Sleep paralysis-type panic attacks in a Khmer refugee population. Transcultural Psychiatry, 42, 46–77. 28. Plotnikoff, G.A., Numrich, C., Wu, C., Yang, D., & Xiong, P. 2002. Hmong shamanism: Animist spir- itual healing in Minnesota. Minnesota Medicine. Retrieved from http://mnmed.org/publications/ MNMed2002/June/Plotnikoff.html 29. Gilman, S.C., Justice, J., Saepharn, K., & Charles, G. 1992. Use of traditional and modern health services by Laotian refugees. Western Journal of Medicine, 157, 310–315.157, 310–315.157 30. Hoang, G.N., & Erickson, R.V. 1982. Guidelines for providing medical care to Southeast Asian refugees. Journal of the American Medical Asso- ciation, 248, 710–714. 31. Buchwald, D., Panwala, S., & Hooten, T.M. 1992. Use of traditional health practices by Southeast Asian refugees in a primary care clinic. Western Journal of Medicine, 156, 507–512. 32. Steinberg, R. 1970. Pacific and Southeast Asian cooking. New York: Time-Life Books. 33. Zibart, E. 2001. The ethnic food lover’s companion: Understanding the cuisines of the world. Birmingham, AL: Menasha Ridge Press. 34. Gelle, G.G. 1997. Filipino cuisine: Recipes from the islands. Santa Fe: Red Crane. 35. Routhier, N. 1999. The foods of Vietnam. New York: Stewart, Tabori & Chang. 36. O’Neill, M. 2001, July 23. Letter from Cambodia: Home for dinner. The New Yorker, 55–63. 37. Foster, D. 2000. The global etiquette guide to Asia. New York: Wiley. 38. Claudio, V.S. 1994. Filipino American food practices, customs, and holidays. Chicago: American Dietetic Association/American Diabetic Association. 39. Philippine Herbal Medicine. 2006. Retrieved from http://herbal-medicine.philsite.net/index.htm 40. Bodo, K., & Gibson, N. 1999. Childbirth customs in Vietnamese traditions. Canadian Family Physician, 45, 695–697. 41. Ahn, A.C., Ngo-Metzger, Q., Legedza, A.T.R., Massagli, M.P., Clarridge, B.R., & Phillips R.S. 2006. Complementary and alternative medical therapy use among Chinese and Vietnamese Americans: Prevalence, associated factors, and effects of patient–clinician communication. American Journal of Public Health, 96(2), 647–653. 42. Muecke, M.A. 1983b. In search of healers— Southeast Asian refugees in the American health care system. Western Journal of Medicine, 139, 835–840. 43. Nguyen, M.D. 1985. Culture shock: A review of Vietnamese culture and its concepts of health and disease. Western Journal of Medicine, 142, 409–412. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 4 1 2 S O U T H E A S T A S I A N S A N D P A C I F I C I S L A N D E R S 44. Vu, H.H. 1996. Cultural barriers between obstetrician-gynecologists and Vietnamese/ Chinese immigrant women. Texas Medicine, 92, 47–52. 45. Ikeda, J.P., Ceja, D.R., Glass, R.S., Harwood, J.O., Lucke, K.A., & Sutherlin, J.M. 1991. Food habits of the Hmong living in central California. Journal of Nutrition Education, 23, 168–175. 46. Rairdan, B., & Higgs, Z.R. 1992, March. When your patient is a Hmong refugee. American Jour- nal of Nursing, 52–55.nal of Nursing, 52–55.nal of Nursing 47. Lewis, J.S., & Glaspy, M.F. 1975. Food habits and nutrient intakes of Filipino women in Los Ange- les. Journal of the American Dietetic Association, 67, 122–125.67, 122–125.67 48. Dela Cruz, F.A. n.d. Food intake and dietary acculturative changes of first generation Filipino Americans. Western Institute of Nursing, 2010, meeting abstract. 49. Dela Cruz, F.A., Lao, B.T., & Heinlein, C. 2013. Level of acculturation, food intake, dietary changes, and health status of first-generation Filipino Americans in Southern California. Journal of the American Association of Nurse Practitioners, 25(11), 619–630. 50. Angosta, A.D., & Kirsten E. Speck. 2014. Assess- ment of heart disease knowledge and risk factors among first-generation Filipino Americans resid- ing in southern Nevada: A cross-sectional study. Clinical Nursing Studies, 2(2), 123. 51. Vargas, P.P. 2015. Acculturation, dietary pattern and health indicators among Filipino American immigrants in New Jersey (doctoral dissertation). immigrants in New Jersey (doctoral dissertation). immigrants in New Jersey The William Paterson University of New Jersey. 52. Dirige, O.V. 1995, February 28. Filipino-American diet and foods. Asian American Business Journal, 11–17. 53. Tran, T.V., Vatcher, R., Lee, H.N., Phan, P.T. & Nguyen, T.N. 2013. Household income and vegetable consumption among white, Chinese, Korean and Vietnamese Americans. International Journal of Social Science Studies, 1(2), 31–43. 54. Tong, A. 1986. Food habits of Vietnamese immi- grants. Family Economic Review, 2, 28–30. 55. Story, M., & Harris, L.J. 1988. Food prefer- ences, beliefs, and practices of Southeast Asian refugee adolescents. Journal of School Health, 58, 273–276. 56. Wiecha, J.M., Fink, A.K., Wiecha, J., & Hebert, J. 2001. Differences in dietary patterns of Vietnamese, white, African-American, and His- panic adolescents in Worcester, Mass. Journal of the American Dietetic Association, 101, 248–251. 57. Yang, R.C., & Mills, P.K. 2008, November. Dietary and lifestyle practices of Hmong in California. Journal of Health Care for the Poor and Underserved, 19(4), 1258–1269. 58. Story, M., & Harris, L.J. 1989. Food habits and dietary change of Southeast Asian refugee fami- lies living in the United States. Journal of the American Dietetic Association, 89, 800–803. 59. Sechena, R., Liao, S., Lorenzana, R., Nakano, C., Polissar, N., & Fenske, R. 2003. Asian American and Pacific Islander seafood consumption— a community-based study in King County, Washington. Journal of Exposure Analysis and Environmental Epidemiology, 13, 256–266. 60. Franzen, L., & C. Smith, C. 2009. Differences in stature, BMI, and dietary practices between US born and newly immigrated Hmong children. Social Science & Medicine, 69(3), 442–450. 61. Stang, J., Kong, A., Story, M., Eisenberg, M.E., & Neumark-Sztainer, D. 2007. Food and weight- related patterns and behaviors of Hmong adoles- cents. Journal of the American Dietetic Association, 107(6), 936–941. 62. Berg, J.A., Rodriguez, D., de Guzman, C.P., & Kading, V.M. 2001. Health status, health and risk behaviors of Filipino Americans. Journal of Multicultural Nursing, Multicultural Nursing, Multicultural Nursing 7, 29–36.7, 29–36.7 63. Stavig, G.R., Igra, A., & Leonard, A.R. 1988. Hypertension and related health issues among Asians and Pacific Islanders in California. Public Health Reports, 103, 28–37. 64. U.S. Department of Health and Human Services, Office of Minority Health. n.d. Profile: Asian Americans. Retrieved from http://minorityhealth. hhs.gov/omh/browse.aspx?lvl53&lvlid563 65. Barnes, P.M., Adams, P.F., & Powell-Griner, E. 2008. Health characteristics of the Asian adult population: United States, 2004–2006. Advance data from vital and health statistics; no 394. Hyattsville, MD: National Center for Health Statistics. 66. The Hawaii Health Data Warehouse, Data Source: State of Hawaii, Department of Health. n.d. Behavioral Risk Factor Surveillance System (BRFSS). Retrieved from: http://www.hhdw.org/ 67. Kim, G., Chiriboga, D.A., Jang, Y., Lee, S., Huang, C.H., & Parmelee P. 2010. Health status of older Asian Americans in California. Journal of the American Geriatrics Society, 58(10), 2003–2008. 68. Kieffer, E.C., Martin, J.A., & Herman, W.H. 1999. Impact of maternal nativity on the prevalence of diabetes during pregnancy among U.S. ethnic groups. Diabetes Care, 22, 729–735. 69. Rao, A.K., Cheng, Y.W., & Caughey, A.B. 2006. Perinatal complications among different Asian- American subgroups. American Journal of Obstet- rics and Gynecology, 194, e39–e41. 70. Cheng, Q., & Gould, J.B. 2006. The Asian birth outcome gap. Paediatric and Perinatal Epidemiology, 20, 279–289. 71. Lauderdale, D.S., & Rathouz, P.J. 2000. Body mass index in a US national sample of Asian Americans: The effects of nativity, years since immigration and socioeconomic status. International Journal of Obesity, 24, 1188–1194. 72. Araneta, M.R.G., Wingard, D.L., & Barrett-Conner, E. 2002. Type 2 diabetes and metabolic syndrome in Filipina American women: A high-risk non- obese population. Diabetes Care, 25, 494–499. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 1 2 4 1 3 73. Cuasay, L.C., Lee, E.S., Orlander, P.P., Steffen- Batey, L., & Harris, C.L. 2001. Prevalence and determinants of type 2 diabetes among Filipino- Americans in Houston, Texas metropolitan sta- tistical area. Diabetes Care, 24, 2054–2058. 74. Hedderson, M.M., Darbinian, J.A., & Ferrara, A. 2010, September. Disparities in the risk of ges- tational diabetes by race-ethnicity and country of birth. Paediatric and Perinatal Epidemiology, 24(5), 441–448. 75. Araneta, M.R.G., & Barrett-Conner, E. 2005. Ethnic differences in visceral adipose tissue and type 2 diabetes: Filipino, African-American, and white women. Obesity Research, 13, 1458–1465. 76. Palaniappan, L.P., Wong, E., Shin, J.J., Fortmann, S.P., & Lauderdale, D.S. 2009. Asian Americans have a greater prevalence of metabolic syndrome despite lower body mass index. Circulation, 119, e363 [Abstract]. 77. National Center for Health Statistics. 2005. Health, United States, 2005 with chartbook on trends in the health of Americans. Hyattsville, MD: Author. 78. Fu, H., & VanLandingham, M.J. 2012, October. Disentangling the effects of migration, selection and acculturation on weight and body fat dis- tribution: Results from a natural experiment involving Vietnamese Americans, returnees, and never-leavers. Journal of Immigrant and Minority Health, 14(5), 786–796. 79. McCracken, M., Olsen, M., Chen, M., Jemal, A., Thun, M., Cokkinides, V.,. . . Ward, E. 2007. Can- cer incidence, mortality, and associated risk fac- tors among Asian Americans of Chinese, Filipino, Vietnamese, Korean, and Japanese ethnicities. CA: A Cancer Journal for Clinicians, 57, 190–205.57, 190–205.57 80. U.S. Department of Health and Human Services, Office of Minority Health. n.d. Profile: Asian Americans. Retrieved from http://minorityhealth. hhs.gov/omh/browse.aspx?lvl53&lvlid563 81. Xiong, Z.B., & Smalkoski, K. 2013. Health dis- parities research in the Hmong American Com- munity: Implications for practices and policies. In M. E. Pfeifer & B. K. Thao (Eds.), State of the Hmong American community. Washington, DC: Hmong National Development. 82. Dawson-Hahn, E.E., Greenberg, S.L.M., Domachowske, J.B., & Olson, B.G. 2010, June. Eosinophilia and the seroprevalence of schisto- somiasis and strongyloidiasis in newly arrived pediatric refugees: An examination of Centers for Disease Control and Prevention screening guide- lines. Journal of Pediatrics, 156(6), 1016–1018. 83. Higgs, D.R., & Weatherall, D.J. 2009. The alpha thalassaemias. Cell and Molecular Life Sciences, 66, 1154–1162. 84. Her, C., & Mundt, M. 2005. Risk prevalence for type 2 diabetes mellitus in adult Hmong in Wisconsin: A pilot study. Wisconsin Medical Journal, 104, 70–77. 85. Mills, P.K., Yang, R.C., & Riordan, D. 2005. Cancer incidence in the Hmong in California, 1988–2000. Cancer, 104, 2969–2974. 86. Lee, H.Y., & Vang, S. 2010. Barriers to cancer screening in Hmong Americans: The influence of health care accessibility, culture and cancer literacy. Journal of Community Health, 35, 302–314. 87. Axtell, R.E. 1991. Gestures: The do’s and taboos of body language around the world. New York: Wiley. 88. Finucane, M.L., & McMullen, C.K. 2008, September–October. Making diabetes self- management education culturally relevant for Filipino Americans in Hawaii. The Diabetes Edu- cator, 34(5), 841–853. 89. Jenkins, C.N.H., Le, T., McPhee, S.J., Stewart, S., & Ha, N.T. 1996. Health care access and preven- tive care among Vietnamese immigrants: Do traditional beliefs and practices pose barriers? Social Science & Medicine, 43, 1049–1056. 90. Ngo-Metzger, Q., Massagli, M.P., Carridge, B.R., Manocchia, M., Davis, R.B., Iezzoni, L.I., & Phillips, R.S. 2003. Journal of General Internal Medicine, 18, 44–52. 91. Nguyen, D.N., & O’Connell, M.B. 2002. Asian and Asian-American college students’ aware- ness of osteoporosis. Pharmacotherapy, 22, 1047–1054. 92. Spring, M.A., Ross, P.J., Etkin, N.L., & Dein- hard, A.S. 1995. Sociocultural factors in the use of prenatal care by Hmong women, Min- neapolis. American Journal of Public Health, 85, 1015–1017. 93. Office of the Surgeon General (US), Center for Mental Health Services (US), National Institute of Mental Health (US). August 2001. Mental health: Culture, race, and ethnicity: A supple- ment to mental health. A Report of the Surgeon General. Rockville, MD: Substance Abuse and Mental Health Services Administration (US). 94. Helsel, D., Mochel, M., & Bauer, R. 2005. Chronic illness and Hmong shamans. Journal of Transcul- tural Nursing, tural Nursing, tural Nursing 16, 150–154. 95. Barrett, B., Shadick, K., Schilling, R., Spencer, L., Del Rosario, S., Moua, K., & Vang, M. 1998. Hmong/medicine interactions: Improving cross-cultural health care. Family Medicine, 30, 179–184. 96. Westermeyer, J., Neider, J., & Vang, T.F. 1984. Acculturation and mental health: A study of Hmong refugees at 1.5 and 3.5 years postmigration. Social Science and Medicine, 18, 87–93. 97. Gold, S.J. 1992. Mental health and illness in Vietnamese refugees. Western Journal of Medicine, 157, 290–294.157, 290–294.157 98. U.S. Census Bureau. n.d. 2006–2010 American Community Survey. Retrieved from http://www. census.gov/acs/www/ 99. Katz, J., Prescott, K., & Woolf, A.D. 1996. Strychnine poisoning from a Cambodian tradi- tional remedy. American Journal of Emergency Medicine, 14, 475–477. 100. Selected population profile in the United States Samoan. n.d. 2005 American Community Sur- vey, U.S. Census. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 4 1 4 S O U T H E A S T A S I A N S A N D P A C I F I C I S L A N D E R S 101. Selected population profile in the United States Guamanian or Chamorro alone. n.d. 2005 American Community Survey, U.S. Census. 102. Winters, E., & Swartz, M. 2000. Hawaiians. In R.V. Dassanowsky & J. Lehman (Eds.), Gale encyclo- pedia of multicultural America, Farmington Hills, MI: Gale Group. 103. Cox, P. 2000. Samoan Americans. In R.V. Dassanowsky & J. Lehman (Eds.), Gale encyclo- pedia of multicultural America, Farmington Hills, MI: Gale Group. 104. Spear, J.E. 2000. Guamanian Americans. In R.V. Dassanowsky & J. Lehman (Eds.), Gale encyclo- pedia of multicultural America, Farmington Hills, MI: Gale Group. 105. Swain, L. 2000. Pacific Islander Americans. In R.V. Dassanowsky & J. Lehman (Eds.), Gale encyclopedia of multicultural America, Farmington Hills, MI: Gale Group. 106. Cooper, A. 2000. Tongan Americans. In R.V. Dassanowsky & J. Lehman (Eds.), Gale encyclo- pedia of multicultural America, Farmington Hills, MI: Gale Group. 107. Snyder, P. 1984. Health service implications of folk healing among older Asian Americans and Hawai- ians in Honolulu. Gerontologist, 24, 471–476. 108. Chang, H.K. 2001. Hawaiian health practitioners in contemporary society. Pacific Health Dialog, Pacific Health Dialog, Pacific Health Dialog 8, 260–273. 109. Hilgenkamp, K., & Pescaia, C. 2003. Tradi- tional Hawaiian healing and western influence. Californian Journal of Health Promotion, 1, 34–39. 110. Judd, N. 1998. Laau lapaau: Herbal healing among contemporary Hawaiian healers. Pacific Health Dialog, Health Dialog, Health Dialog 5, 239–245. 111. Norton, S.A. 1998. Herbal medicines in Hawaii from tradition to convention. Hawaii Medical Journal, 57, 382–386.57, 382–386.57 112. Howard, A. 1986. Samoan coping behavior. In P.T. Baker, J.M. Hanna, & T.S. Baker (Eds.), The changing Samoans: Behavior and health in transition. New York: Oxford University Press. 113. Kinloch, P. 1985. Talking health but doing sickness: Studies in Samoan health. Wellington, New Zealand: Victoria University Press. 114. Janes, C.R. 1990. Migration, social change, and health: A Samoan community in California. Stanford: Stanford University Press. 115. Laudan, R. 1996. The food of paradise: Exploring Hawaii’s culinary heritage. Honolulu: University of Hawai’i Press. 116. Dresser, N. 2005. Multicultural manners. New York: Wiley. 117. Young, N.N., & Braun, K.L. 2010. La’au lapa’au and Western Medicine in Hawai’i: Experiences and perspectives of patients who use both. Journal of Health Services Research & Policy, 15, 54–61. 118. Shovic, A.C. 1994. Development of a Samoan nutrition exchange list using culturally accepted foods. Journal of the American Dietetic Association, 94, 541–543. 119. Hanna, J.M., Pelletier, D.L., & Brown, V.J. 1986. The diet and nutrition of contemporary Samoans. In P.T. Baker, J.M. Hanna, & T.S. Baker (Eds.), The changing Samoans: Behavior and health in transition. New York: Oxford University Press. 120. Pobocik, R.S., & Richer, J.J. 2002. Estimated intake and food sources of vitamin A, folate, vitamin C, vitamin E, calcium, iron, and zinc for Gaumanian children aged 9 to 12. Pacific Health Dialog, Dialog, Dialog 9, 193–202. 121. Fitzpatrick-Nietschmann, J. 1983. Pacific Islanders—migration and health. Western Journal of Medicine, 139, 848–853. 122. Galanis, D.J., McGarvey, S.T., Quested, C., Sio, B., & Afele-Fam’amuli, S. 1999. Dietary intake of modernizing Samoans: Implications for risk of cardiovascular disease. Journal of the American Dietetic Association, 99, 184–190. 123. Asian & Pacific Islander American Health Forum. 2012. Asian American, Native Hawaiian, & Pacific Islander maternal health disparities— San Francisco, CA. Retrieved from http://www. apiahf.org/si. . .sue%20Brief%20final 124. LeonGuerrero, R.T., & Workman, R.L. 2002. Physical activity and nutritional status of ado- lescents on Guam. Pacific Health Dialog, 9, 177–185. 125. Moy, K.L., Sallis, J.F., & David, K.J. 2010. Health indicators of Native Hawaiian and Pacific Islanders in the United States. Journal of Community Health, 35, 81–92. 126. Maskarinec, G., Takata, Y., Pagano, I., Carlin, L., Goodman, M.T., Le Marchand, L.,. . . Kolonel, L.N. 2006. Trends and dietary determinants of overweight and obesity in a multiethnic popula- tion. Obesity, 14, 717–726. 127. Centers for Disease Control and Prevention. 2004. Physical activity among Asians and Native Hawaiian or Other Pacific Islanders—50 states and the District of Columbia, 2001–2003. Morbidity and Mortality Weekly Report, 53, 756–760. 128. Mamphilly, C.M., Yore, M.M., Maddock, J.E., Nigg, C.R., Buchner, D., & Heath, G.W. 2005. Prevalence of physical activity levels by ethnicity among adults in Hawaii, BRFSS 2001. Hawaii Medical Journal, 64, 272–273. 129. Rush, E., Plank, L., Chandu, V., Laulu, M., Simmons, D., Swinburn, B., & Yajnik, C. 2004. Body size, body composition, and fat distribu- tion: A comparison of young New Zealand men of European, Pacific Island, and Asian Indian ethnicities. New Zealand Medical Journal, 117, U1203. 130. Mokuau, N., Hughes, C.K., & Tsark, J.U. 1995. Heart disease and associated risk factors among Hawaiians: Culturally responsive strategies. Health & Social Work, 20, 46–51. 131. Brewis, A.A., McGarvey, S.T., Jones, J., & Swinburn, B.A. 1998. Perceptions of body size in Pacific Islanders. International Journal of Obesity and Related Metabolic Disorders, 22, 185–189. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 1 2 4 1 5 132. Bruss, M.B., Morris, J., & Dannison, L. 2003. Prevention of childhood obesity: Sociocultural and familial factors. Journal of the American Dietetic Association, 103, 1042–1045. 133. McNeely, M.J., & Boyko, E.J. 2004. Type 2 diabetes prevalence in Asian Americans. Diabe- tes Care, 27, 66–69.27, 66–69.27 134. Centers for Disease Control and Prevention. 2012. Summary health statistics for U.S. Adults: 2011, Table 8. Retrieved from http://www.cdc. gov/nchs/data/series/sr_10/sr10_256 135. Grandinetti, A., Chang, H.K., Mau, M.K., Curb, J.D., Kinney, E.K., Sagum, R., & Arakaki, R.F. 1998. Prevalence of glucose intolerance among Native Hawaiians in two rural communities. Native Hawaiian Health Research (NHHR) project. Diabetes Care, 21, 549–554. 136. Centers for Disease Control and Prevention. 2011. Summary health statistics for U.S. Adults: 2010, Table 2. Retrieved from http://www.cdc. gov/nchs/data/series/sr_10/sr10_252 137. Centers for Disease Control and Prevention. 2012. Summary health statistics for U.S. Adults: 2011, Table 2. Retrieved from http://www.cdc. gov/nchs/data/series/sr_10/sr10_256 138. State of Hawaii. 2007. The burden of cardiovas- cular disease in Hawaii 2007, Figure 3. Retrieved cular disease in Hawaii 2007, Figure 3. Retrieved cular disease in Hawaii 2007 from http://hawaii.gov/health/statistics/brfss/ reports/CVDBurden_Rpt2007 139. Rush, E.C., Plank, L.D., Mitchelson, E., & Laulu, M.S. 2002. Central obesity and risk for type 2 diabetes in Maori, Pacific, and European young men in New Zealand. Food and Nutrition Bulletin, 23(3 Suppl.), 82–86. 140. Centers for Disease Control and Prevention. 2009. Summary health statistics for U.S. adults: 2008, Table 6. Retrieved from http://www.cdc .gov/nchs/data/series/sr_10/sr10_242 141. Rush, E.C., Plank, L.D., Mitchelson, E., & Laulu, M.S. 2002. Central obesity and risk for type 2 diabetes in Maori, Pacific, and European young men in New Zealand. Food and Nutrition Bul- letin, 23(3 Suppl.), 82–86. 142. Hawaii Department of Health. 2003. Hawaii can- cer facts & figures 2003–2004, Table 5. Retrieved from http://hawaii.gov/health/statistics/other- reports/cancer2003-04 143. Guam Department of Public Health and Social Services. 2009. Guam cancer facts and figures 2003– 2007, Table 10. Retrieved from http://dphss.guam.2007, Table 10. Retrieved from http://dphss.guam.2007 gov/docs/GUAMCANCERFinal10.14.09 144. California Department of Health Services. 2004. Sentinel health indicators for California’s multicul- tural populations 1999–2001. Author. 145. Centers for Disease Control and Prevention. 2013. Infant mortality statistics from the 2009 period linked birth/infant death data set. National Vital Statistics Reports. Retrieved from http://www.cdc. gov/nchs/data/nvsr/nvsr61/nvsr61_08 146. Centers for Disease Control and Preven- tion. 2007. Health United States, 2007, Table 7. Retrieved from http://www.cdc.gov/nchs/data/ hus/hus07 147. Rush, E.C., Plank, L.D., Mitchelson, E., & Laulu, M.S. 2002. Central obesity and risk for type 2 diabetes in Maori, Pacific, and European young men in New Zealand. Food and Nutrition Bulletin, 23(3 Suppl.), 82–86. 148. Yehieli, M., & Grey, M.A. 2005. Health matters: A pocket guide for working with diverse cultures and underserved populations. Boston: Intercultural Press. 149. Mayeno, L., & Hirota, S.M. 1994. Access to health care. In N.W.S. Zane, D.T. Takeuchi, & K.N.J. Young (Eds.), Confronting critical health issues of Asian and Pacific Islander Americans. Thousand Oaks, CA: Sage. 150. Boyd, J.K., & Braun, K.L. 2007. Supports for and barriers to healthy living for Native Hawaiian young adults enrolled in community colleges. Preventing Chronic Disease, 4(4), 1–12. Retrieved from http://www.cdc.gov/pcd/issues/2007/ oct/07_0012.htm (accessed March 14, 2011). 151. Fujita, R., Braun, K.L., & Hughes, C.K. 2004. The traditional Hawaiian diet: A review of the literature. Pacific Health Dialog, Pacific Health Dialog, Pacific Health Dialog 11, 250–259. 152. 2008 Restaurant Industry Pocket FactBook. National Restaurant Association. (2008). 2055 L St. NW, Suite 700, Washington, DC 20036. 153. Uhl, S. 2001, January–February. Exploring the culinary mysteries of Malaysia. Restaurants USA. Retrieved from http://www.restaurant.org/busi- ness/magarticle.cfm?ArticleID513 154. Owen, J. 2005. New rodent discovered at Asian food market. National Geographic News, May 16. Retrieved from http://news.nationalgeographic. com/news/2005/05/0516_050516_new_rodent.html 155. Gampell, J. 2006. Letter from Ubon: In northeast Thailand, a cuisine based on bugs. The New York Times, June 22. Retrieved from http://travel2. nytimes.com/2006/06/22/travel/22webletter.html 156. Sukalakamala, S., & Brittin, H.C. 2006. Food practices, changes, preferences, and accultura- tion of Thais in the United States. Journal of the American Dietetic Association, 106, 103–108. 157. Storz, D. 1998. Filipino culture. News and Views: The Newsletter of the San Jose Peninsula Dietetic Association, 29, 7. 158. U.S. Census. n.d. Fijian selected population pro- file in the United States 2011–2013. American Community Survey 3-Year Estimates. 159. Daida, Y., Novotny, R., Grove, J.S., Acharya, S., & Vogt, T.M. 2006. Ethnicity and nutrition of ado- lescent girls in Hawaii. Journal of the American Dietetic Association, 106, 221–226. 160. Seakins, J.M., Elliott, R.B., Quested, C.M., & Mataumua, A. 1987. Lactose malabsorption in Polynesian and white children in the southwest Pacific studied by breath hydrogen technique. British Medical Journal, 295, 876–878. 161. Steele, J.C. 2005. Parkinsonism-dementia complex of Guam. Movement Disorders, 12, S99–S107. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 4 1 6 The southeast European nations of the The southeast European nations of the TBalkan Peninsula and the countries of TBalkan Peninsula and the countries of Tthe Middle East are in close proximity Tthe Middle East are in close proximity T to central Europe, Africa, and Asia. The region has traditionally been a cultural crossroads of ideas, values, and material goods and is often considered the cradle of Western civilization. Many immigrants from the Balkans and the Middle East have come to the United States in search of economic opportunity and political stability. They frequently retain a strong eth- nic identity, exhibited in their strong religious faith and in their maintenance of traditional food culture. This chapter examines the cui- sine of the Balkans and the Middle East, its role in the U.S. diet, and the changes that have occurred in the United States. Cultural Perspective The Balkan nations include Greece, Albania, Bosnia-Herzegovina, Montenegro, Serbia (including the two autonomous provinces Kosovo and Vojvodina), the Republic of Macedonia, Croatia, Slovenia, Bulgaria, and Romania. Countries of the Middle East include Bahrain, Egypt, Iran, Iraq, Israel, Jordan, Kuwait, Lebanon, Oman, Saudi Arabia, Syria, Turkey, United Arab Emirates, and Yemen (see Figure 13.1). In addition, there are several notable groups who do not have a homeland in the region, including the Palestinians (an Arab ethnic group), the Kurds (an Indo-European ethnic group), and the Chaldeans and Assyr- ians (Semitic ethnic groups). Geographically, much of the Balkans is con- sidered temperate in climate and is suited to agriculture. In Greece, however, and in most of the Middle East, aridity limits cultivation. Even in the desert regions, distinct areas of arable land exist along the seacoasts and in some plains and valleys, such as the Fertile Crescent (a plain in Iraq fed by the Euphrates and Tigris Rivers) and the Nile River valley of Egypt. Greece dominated or greatly influenced its Balkan and Middle Eastern neighbors in ancient times, and, in turn, it was conquered and ruled by the Turkish Ottoman Empire for four centuries in the modern era. These hun- dreds of years of Greek and Turkish hegemony facilitated the spread of products, especially foods, throughout the region and stretched cultural influence to both the southern states of the former Soviet Union (see Chapter 7) and to North Africa. Despite such commonal- ities, however, populations within the nations of the Balkans and the Middle East are very diverse in religious affiliation. Judaism, Chris- tianity (particularly Eastern Orthodox), and Islam all have substantial numbers of follow- ers in the region. Faith is fundamental to daily life in both the Balkans and the Middle East. History of People of the Balkans and Middle East in the United States Balkans Immigration from Greece has occurred pri- marily in two waves. The first lasted from the late 1800s to the 1920s, when the restrictive People of the Balkans and the Middle East13 CHA P T E R An Arab is commonly defined as a person who speaks Arabic—the term does not refer to a particular religious belief. Iranians speak Farsi and call themselves Persians. The Turks, whose nation is geographically divided between Europe and Asia, speak modern Turkish, a language that is traced to the Altay region in the Eurasian steppes and now written with the Latin alphabet. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 1 3 4 1 7 Immigration Act of 1924 was imposed; the second wave started after World War II and has not yet ended. The early Greek immi- grants were mostly young men from rural agricultural areas who came to America pri- marily for economic opportunities. Many came to make their fortune and go back to their homeland—approximately 30 percent of early Greek immigrants returned to Greece. A bitter civil war from 1946 to 1949 and a military coup in 1967 resulted in numerous Greek refugees who sought asylum in the United States. While most settled in New York, Detroit, Chicago, and other cities of the Midwest, a large community developed in Tarpon Springs, Florida, supported by diving for sponges. Some Greeks were attracted to mining and railroad work in the West. During the 1850s and 1860s, numerous Croatian immigrants from the area of Dalma- tia arrived in the United States. Most migrated to the southern and western regions where they had a substantial impact on the oyster fisheries of Mississippi and the fig, apple, Until 1992, the nations of Serbia, Croatia, Slovenia, Bosnia-Herzegovina, Montenegro, and Macedonia were the states of a single country known as Yugoslavia. Figure 13.1 The Balkans and the Middle East. Mediterranean Sea IRAN BOSNIABOSNIABOSNIABOSNIABOSNIA AND HER-AND HER-AND HER-AND HER- ZEGOVINAZEGOVINAZEGOVINAZEGOVINA Caspian Sea GREECEGREECEGREECEGREECE REPUBLIC OF MACEDONIA MONTENEGROMONTENEGROMONTENEGROMONTENEGROMONTENEGRO S E R B IA CROATIACROATIACROATIACROATIACROATIACROATIACROATIACROATIACROATIACROATIACROATIA ALBANIAALBANIAALBANIAALBANIA BULGARIA ROMANIA EGYPT JORDAN ISRAEL LEBANON SYRIA IRAQ SAUDI ARABIA BAHRAIN OMAN YEMEN UNITED ARAB EMIRATES TURKEY HUNGARYHUNGARYHUNGARYHUNGARYHUNGARY KUWAIT SLOVENIASLOVENIA © C en ga ge L ea rn in g Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 4 1 8 P E O P L E O F T H E B A L K A N S A N D T H E M I D D L E E A S T grape, and plum horticulture of northern California. The many Serbs who immigrated to the United States in this period were unskilled laborers who obtained industrial jobs in the Northeast. Croatian and Serbian immigration increased following World War II, including professionals, such as engineers and physi- cians, seeking better job opportunities. The largest number of Slovenian immi- grants arrived between 1880 and World War I, though exact figures are not available because many were listed as Austrians. Most were farmers seeking economic opportunity. They settled initially in the rural Midwest, form- ing self-sustaining ethnic communities with Slovenian churches, schools, businesses, and social organizations. Middle East Statistics on immigration from the Middle East are inexact. Until 1900, all immigrants from the area were called “Egyptians.” Later arrivals were typically termed “Syrians” or “Turks from Asia.” More specific nationalities have been recognized since the 1930s, yet it has only been in recent years that Palestinian has been defined as an immigration category, and it is standard practice to combine Chal- deans with Assyrians. Early Arab immigrants arrived at the turn of the twentieth century seeking economic opportunity. Most were Christians from the area that is today Lebanon and Syria, although small numbers of Turkish Muslims also came during this period. Most settled in New Eng- land and the Midwest and were employed in the textile, shoe, and wire factories. The major influx of Middle Easterners began in the years following World War II. A high percentage of immigrants from Jordan, Egypt, Lebanon, Iraq, and Syria were Chris- tian Palestinians who initially fled Israel when it was declared a state. After first settling in refugee camps, many later immigrated to the United States when Israel won the 1967 war against neighboring Arab countries. Political unrest and Islamic revolution in Iran led to a large exodus of Persians beginning in 1976. Many were members of the wealthy Iranian elite; others were Jewish and Christian minor- ities, including Chaldeans and Assyrians. In addition, many Turks and Arabs who came to the United States for their college educa- tion elected to stay in the country to establish their careers. A similar situation is reported for Israelis, who immigrated in small but steady numbers to America for advanced education and professional, managerial, or technical jobs. ▼ A large Greek community ▼ A large Greek community ▼ developed in Tarpon Springs, Florida, based on diving for sponges. Va n Bu ch er /S ci en ce S ou rc e Though large numbers of Kurds have been displaced due to conflicts in the Middle East, most refugees—over 500,000—have gone to Europe. Much smaller numbers have come to the United States, particularly Nashville, Salt Lake City, and San Diego. Around the turn of the twentieth century, an elite group of Arab artists, writers, and poets settled in New York City. They called their literary circle the Pen League; the best-known member was Kahlil Gibran, author of The Prophet. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 1 3 4 1 9 Current Demographics and Socioeconomic Status People of the Balkans Nearly 1.27 million people claimed Greek ancestry in the 2013 U.S. Census estimates. New York City has the largest concentration of Greek Americans, followed by California, Illinois, Massachusetts, and Florida. In recent years, Greek Americans have moved progres- sively south and west in the United States. Early Greek immigrants preferred to live in urban areas. The Greeks sought economic independence by opening small businesses, especially in candy production and restau- rants. Greek Americans can be found in all occupations, particularly managerial, profes- sional, technical, and service jobs.1 Over 400,000 Croatian Americans and 189,000 Americans of Serbian descent lived in the United States in 2007.1 Most origi- nally settled in the mining regions of Penn- sylvania, Ohio, and other midwestern states; mining also attracted sizable populations to Colorado, Nevada, Arizona, and California.1,2 More than 160,000 Slovenian Americans were identified in the 2013 U.S. Census data.1 Although many Slovenian immigrants also became involved in mining, others moved to industrial urban areas in search of jobs. Forty percent live in Ohio; Cleveland has the largest Slovenian community in the nation. Other states with notable Slovenian popu- lations include Pennsylvania, Minnesota, Wisconsin, California, Colorado, Michigan, Florida, and New York. Many Croatians, Ser- bians, and Slovenians who first arrived in the United States were unskilled laborers in agri- culture or industry.3 Education was valued and second-generation immigrants obtained the training needed to secure white-collar employment. Over time, most Americans of Croatian, Serbian, and Slovenian descent have assimilated into the U.S. mainstream, working in all sectors of the economy. All have incomes at or over the U.S. average.1 Beginning in the early 1990s, nearly 200,000 Bosnian refugees seeking refuge from ethnic cleansing in that region were resettled in the United States. Many left their homeland suddenly, with little time to pack or prepare for life in a new country. Nearly all are Muslim, and most were not comfortable in the small number of Bosnian Serbian or Bos- nian Croatian communities already scattered throughout the United States. A majority have chosen to live in homogeneous Bos- nian Muslim neighborhoods in New York, St. Louis, Chicago, Salt Lake City, St. Petersburg, Florida, and Waynesboro, Pennsylvania.5 Sig- nificant populations are found in California as well.4 Though approximately half of Bosnian refugees arrived unskilled in any profession, today 68 percent of their young adults are attending institutions of higher education.1 Middle Easterners Demographic figures for Middle Easterners are more problematic. Some older immi- grants may deny their Arab ancestry due to a history of discrimination in the West, and more recent arrivals may refuse cooperation with government-sponsored surveys due to negative experiences in their homelands and fear of mistreatment following the September 11, 2001, attacks on the United States. Immi- gration figures suggest, however, that Arabs are one of the fastest-growing ethnic groups in the nation, increasing from approximately 200,000 in 1970 to over 1.6 million in 2007. This growth is even more dramatic if a poll on Arab ancestry is correct in estimating that the Arab population is actually closer to 3.5 million.5 In 2013, the Census estimated 491,000 self-declared Americans from Lebanon, 157,000 from Syria, 214,000 from Egypt of Palestinian heritage, 91,000 from Morocco, 10,000 from Jordan, and 98,000 from Iraq.1 A movement toward pan-Arab American- ism is seen in the number of U.S.-born Arabs who are selecting “Arab” or “Arabic” as their background instead of a national affiliation.7 Approximately 66,000 Arabs are now listed in this category, 25,000 in 2013.1 Two-thirds of Arabs have settled in California, New York, and Michigan. The largest concentration of Muslims, (including those from areas other than the Middle East) is in the Detroit met- ropolitan area.6,9 Most Arabs choose urban areas of residence, and ethnic neighborhoods have developed in cities with substantial Arab The 2011 Canadian census lists over 252,960 residents of Greek ancestry, 114,880 Croatians, and much smaller populations of Serbians and Slovenians. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 4 2 0 P E O P L E O F T H E B A L K A N S A N D T H E M I D D L E E A S T populations. These communities help pre- serve Arab culture within what is often viewed as an alien American society. Many Arabs suf-as an alien American society. Many Arabs suf-as an alien American society. Many Arabs suf fer discrimination and accept marginaliza- tion as a necessary part of living in the United States.7 Despite these experiences by some, foreign-born Arabs become U.S. citizens at rates 25 percent higher than the average for all foreign-born residents.8 Early Arab immigrants found it easy to assimilate into American society, in part because a majority of them were Christian.9 Many survived as peddlers and then later opened family businesses, usually dry goods or grocery stores. A tradition of entrepreneur- ship among Arabs continues today, and nearly one in five owns his or her own business. Even families that started with unskilled employ- ment or small businesses have made substan- tial economic progress through schooling. Nearly every Arab American group in the 2013 Census reported that 50 percent had a college degree or higher, and median family income was above the U.S average.1 Over 460,000 Americans of Iranian heri- tage were living in the United States accord- ing to 2013 Census figures.1 Nearly half reside in Southern California, and another large population is found in New York City. Many who immigrated following the 1979 Iranian revolution were among the well-educated elite who spoke English fluently and were skilled in the professions, such as engineer- ing, medicine, pharmacy, dentistry, and law. Others arrived in the United States with sub- stantial savings from their livelihood in Iran. This group has been economically successful in the United States. It is also reported that many Iranian immigrants are self-employed.9 Data on foreign-born Iranians show that over half hold college degrees, and median house- hold income far exceeds that of the average U.S. family.1 Turkish Americans numbered 194,000 in the census estimates of 2013.1 Immigration prior to 1965 was severely lim- ited by quotas, yet included a disproportion- ate number of engineers and physicians. Since that time, the numbers of Turkish immigrants have increased, most seeking educational and occupational opportunity. Homoge- neous neighborhoods, supported by Turkish American organizations, have been estab- lished in many cities, including New York City, Boston, Chicago, Detroit, Los Angeles, San Francisco, and Rochester, New York. Smaller populations are found in New England, the Midwest, and parts of the South, including Maryland, Virginia, Texas, and Georgia.10,15 Census statistics on foreign-born Turk- ish Americans indicate higher rates of high school and college graduation than the U.S. norm, and median household income above the U.S. family average.1 Turkish Americans are found in most employment sectors and are solidly middle class in socioeconomic status.1 Most Israelis today come to the United States for educational and professional oppor- tunities; most are of European heritage, typi- cally middle or upper class, and a significant number are single men and women.11 Some arrivals are also seeking security and escape from the political unrest in the region. Most possess the job skills that ensure an easy transition in the United States, and over half hold professional, managerial, or technical positions. They are prominent in the fields of medicine, technology, architecture, enter- tainment, and education. Approximately one-third are self-employed in the garment industry, electronic industry, or in small businesses catering to the Israeli community, including restaurants, nightclubs, and retail shops.12 Average earnings are believed to be higher than the U.S. norm. Worldview Religion Religion is often the defining factor in Bal- kan and Middle Eastern life. Though affilia- tion varies, strong devotion is common. Many congregations remain insular in the United States, serving the needs of a specific ethnic group, and there is little interest in proselytiz- ing to outsiders. People of the Balkans The ethnicity of Greek immigrants was affirmed mostly by religion; it was said that a person was not Greek by birth but through the active affiliation with the Greek Eastern Orthodox Church. The first Greek Orthodox Church in America was founded in New Orleans in 1864. Most McDonald’s and Walmart sell halal foods, such as Chicken McNuggets, at certain U.S. locations. Persia was the conventional European name for Iran, used until the early twentieth century; many Iranian immigrants prefer the designation Persian American. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 1 3 4 2 1 Greek Americans today still belong to the church, which continues to be the center of Greek community life. The word orthodox comes from the Greek for “correct” (orthos) and “worship” (doxa). A fundamental belief of the Greek Orthodox faith is that an indi- vidual attains complete identification with God through participation in the numerous religious services and activities sponsored by the church. Although the Greek Orthodox Church is conservative and traditionally resis- tant to change, some accommodations have been made in the United States; for instance, the service typically is conducted both in Greek and English, and modern organ music accompanies the liturgy (see Chapter 4 for more information about Greek Orthodoxy). Most Serbs also belong to the Eastern Orthodox faith, as members of the Serbian Orthodox Autonomous Church. A major- ity of Croatians and Slovenians are devout Roman Catholics, worshiping primarily in multiethnic congregations. A small number of Slovenians are Protestants known as Wind- ish. Windish churches have helped maintain Slovenian ethnic identity through services conducted in a Slovenian dialect. Small pop- ulations of Croatian Muslims are found in Cleveland and Chicago. Early Bosnian Croat immigrants were mostly members of the Catholic Church, and Bosnian Serb immigrants followed the East- ern Orthodox religion. An estimated sixty- eight Serbian Orthodox churches exist in the United States, serving both the worship and social needs of each community. The majority of recent Bosnian refugees are Sunni Muslims. Regardless of faith, many Bosnians are more secular than observant, attending services on major holidays only, or not at all. Intermar- riage between Bosnians of different religious beliefs is not uncommon.5,6 Middle Easterners Early Arab immigrants were primarily Christians belonging to the Eastern Orthodox (particularly the Egyptian Coptic Church) or the Latin rite Maronite, Melkite, or Chaldean churches. Although Christian Arabs are still a majority in Amer- ica, more recent immigrants follow Islam, and the number of Arab Muslims in the United States is growing rapidly. Most belong to the Sunni sect. Many Arab Muslims in the United States have made several adaptations to accommodate their religious practices to American society. Most significantly, the Fri- day Sabbath prayer has been moved to Sun- day, and many Muslims cannot fulfill their obligation to pray five times daily due to work or school limitations (see Chapter 4 for more information about Islam). Though the vast majority of Iranians in the United States are members of the Muslim Shiite sect, small numbers of Iranian religious minorities have come to the United States seeking freedom from persecution, including Jews, Catholics, Anglicans, Protestants, and members of the Baha’i faith (a Muslim off-members of the Baha’i faith (a Muslim off-members of the Baha’i faith (a Muslim off shoot that has renounced its ties to Islam and preaches gender equality, world brotherhood, and pacifism). Most Turkish Americans are Sunni Muslims, and many worship at Arab or Pakistani mosques.12 Presumably, most Israeli Americans are followers of Judaism. However, unlike other Middle Eastern groups, Israelis who immi- grate may be among the least orthodox of Jews in Israel. Many, upon arrival, choose to join Reform congregations or are unaffiliated with a synagogue. Family People of the Balkans The traditional Greek home is strongly patriarchal. The head of the household is the unquestioned authority, with responsibility for supporting the immediate family and elder parents. In addition, he is accountable for the family reputation within the community. The Greek term for this pride and obligation to family is philotomo, mean- ing “love of honor.” Each family member is expected to behave in ways that maintain fam- ily dignity and status. Obligation to family and community has lessened somewhat in the Greek American community. Extended families have become less common due to assimilation pressures and secondary migration to other areas of the country. Children are doted on, and parents often put their welfare first. Yet obedience and respect for elders are expected, and inter- generational conflict is less common among Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 4 2 2 P E O P L E O F T H E B A L K A N S A N D T H E M I D D L E E A S T Greek Americans than in many other immi- grant groups. Greek women had traditionally focused on family, home, and church. Even after coming to the United States, many Greek American women continued in this role. today they bal- ance their duty to family and community with personal interests in education or pursuing a career. Education is valued for Greek men and women. Croatian and Serbian families are also tra- ditionally patriarchal. Extended families are the norm, often including friends as well as relatives. Among Croatians, communal living may involve taking in boarders. Both Croa- tians and Serbians have become well accul- turated in the United States. The tradition of older generations caring for children has allowed many Croatian and Serbian women to take advantage of educational and career opportunities, and the authority of the father has lessened. Slovenian Americans are also assimilated. The extended family structure typical in Slovenia is rarely found among Slovenians in the United States, who prefer nuclear families. American women of Slove- nian descent are active in the home, church, and Slovenian schools and are increasingly involved in politics. B osni ans t radit iona l ly maint aine d extended family homes, but conflict in the region and migration to urban areas has resulted in more nuclear families living apart from relatives.5 In the United States the extended family structure is important to newer arrivals but difficult for some refu- gees who had no family members already established in the country. While strong fam- ily bonds support new immigrants, Bosnian women (who are not employed outside the home) and elders are often dependent on extended family and may become isolated within the larger community.6 Traditionally, Bosnian husbands and wives both work, but responsibility for the home remains with the woman. Bosnian children assimilate quickly to American culture, and some parents are frustrated by their inability to instill Bosnian cultural values and to maintain the Bosnian language within the home. Some refugees believe kinship ties and the integrity of the family are weakened with continuing expo- sure to American society.6 Middle Easterners Traditionally, Arab cul- tures center on a strong patriarchal family whose honor must be maintained. The fam- ily demands conformity and subordination of individual will and interest, but in return the members of the family are protected and can identify with the family’s status. Families often live with extended members in a single home or, for well-to-do Arabs, in a family compound. An exception is Egyptians, who traditionally live in nuclear family groups, often far from other relatives.13 The teachings of the Qur’an state that men and women are considered equal but with different roles and responsibilities. Children are valued in Arab families, and sacrifice for the good of the children is common. Men are obligated to provide economic security for children, while women are expected to socialize them, including the preservation of religious and cultural values. Due to the strict patriarchy, it is the role of women to provide the love and comfort in a home as well. The relationship between mothers and daughters is very intimate. There is also a strong bond between mothers and sons, especially the firstborn son.14 Marriage contracts in the Middle East are often arranged between children to establish political and business alliances through kin- ship. Also among Arabs there is a preference for marriage between cousins, with the excep- tion of Egyptians and some Arab Christians.9 Only after an engagement announcement is made are young men and women allowed to date, and then only when chaperoned. A fam- ily’s honor is related to the modesty and chas- tity of the women in the home: A woman is chaste before her wedding and faithful after. Actual or alleged violations of moral codes by a young woman are considered evidence that her mother has failed in her responsi- bilities; inappropriate sexual conduct also brings shame on her male relatives. Inter- ethnic marriages are strongly discouraged by both Muslims and Christians, especially for women. It is preferable to marry some- one of a different ethnic group and the same The tall white hats worn by professional chefs are thought to have originated with the tall black hats worn by Eastern Orthodox priests. Of the 90,000 Jews living in Iran in 1987, 55,000 have since left, including 35,000 who have immigrated to the United States. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 1 3 4 2 3 religious affiliation than to marry outside the religion. Most Iranians and Turks establish homes similar to those of Arabs, headed by the father or eldest sons, and centered on an extended family network for support. Tra- ditionally, Iranian families worked to place members in all significant sectors of the society (through marriage and employment) to ensure family status and security.11 Immi- gration to the United States often results in difficulties maintaining an extended fam- ily household for many Middle Easterners. Family ties remain strong among Arabs, Ira- nians, and Turks; however, nuclear families are the norm for most immigrants. It is still common for grandparents to live with their children and grandchildren, yet in some more acculturated families (such as in many Leba- nese homes) daughters are no longer solely responsible for the care of elders, a duty they now share with their brothers.15 The role of women of Middle Eastern heritage in the United States is changing for those who are engaged in American soci- ety, and the customarily strict separation of private and public spheres has blurred with increased numbers of women seeking college degrees and professional careers.11 For exam- ple, dating is becoming more accepted as seg- regation of the sexes cannot be maintained in most schools, nor in the U.S. workplace. Yet, more traditional Middle Eastern women are sometimes isolated in their home life. Some Iranian women, for instance, feel that their limited authority has decreased since arriv- ing in the United States, that they spend more time on household chores, and that they are less involved in family decisions and in mosque activities.11 More acculturated Arab women may also experience serious setbacks in acceptance of their Americanized conduct every time a large influx of new and conserva- tively minded Middle Eastern women settles in their area. Many second-and third-generation Mid- dle Easterners in the United States think that their parents are old-fashioned. Adop- tion of American practices, such as personal autonomy and self-determination, contradicts the Middle Eastern emphasis on doing what is best for the good of the family, increasing intergenerational conflict between parents and children. Acculturation also may result in the reduction of a father’s authority in some Middle Eastern homes, though filial respect is usually retained. Pressures for children to adhere to family expectations—from partici- pation in arranged marriages to denial of col- lege attendance—can be substantial, however, and not all children reject the values of their parents. Researchers note that among Iranian Americans, the stresses of living in the United States lead some children of immigrants to embrace their heritage.11 Although some Arab groups, such as Egyptians and Syrians, are especially well acculturated, and some subgroups within each population are fully integrated within the U.S. society, resistance to American culture can be strong among a small number of Middle Eastern immigrants. The attempt to retain ethnic identity takes many forms, and it cannot be assumed that assimilation is automatic, especially for new immigrants who may arrive with the intention of returning to their homeland when conflicts subside, or are fearful of discrimination in the United States. For example, some Arab immi- grants seek to insulate their families from the influences of American society by isolating them within homogeneous enclaves, and eth- nic identity is so important to most Turkish Americans that unlike most Arabs and Irani- ans (who have very high rates of citizenship), Turks who seek naturalization are often ostra- cized within their communities.9,12 A majority of Israelis live in nuclear fami- lies. After arrival in the United States, the nuclear family structure continues with sup- port from Jewish organizations and a network of Israeli American groups. Israeli American women are typically well educated and over half are employed, often in professional posi- tions. Israeli immigrants are often concerned that their cultural values will be lost if their children become acculturated, and that their children may become too competitive or too materialistic.14 Many Israeli parents, like American Jewish parents, strive to preserve ethnic identity by enrolling their children in religious training and Jewish summer camps, and by sending them to Israel to learn about their heritage. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 4 2 4 P E O P L E O F T H E B A L K A N S A N D T H E M I D D L E E A S T Traditional Health Beliefs and Practices People of the Balkans In many parts of the Balkans, physical fitness is thought essential to good health and is also considered neces- sary in the development of good character. Team sports, water activities, gymnastics, ski- ing, hiking, and bicycling are common forms of exercise.4,16,21 Among some Greeks, eating a good diet, relaxation, adequate sleep, and keeping a positive mental attitude are equally important to maintaining health.17,18 Traditionally, most health care was pro- vided by grandmothers or mothers at home. Many people kept an herbal pharmacy avail- able for preparation of therapeutic teas. In Greece, castor oil is taken to clean the bowels, quinine is used to relieve pain, chamomile tea is sipped to get rid of cramps, and a sore throat is treated with honey and lemon. Examples of Bosnian cures also include chamomile, as well as elder, rose hips, and mint.4,18,20 Cupping (see Chapter 2 for more information) in a manner similar to the Asian method, except that the skin is cut with a razor first to allow the blood out, is done by a few Greeks to treat colds and chest ailments. More severe conditions and serious injuries were treated by neighborhood experts, for instance, the midwives and bone- setters used in Croatia.2,20 Some people in the Balkans believe that the evil eye of one who envies a person can cause accidents or illness. Greeks may use ritual prayer or, the sign of the cross, or wear blue amulets with an eye in the center or garlic as a precaution against a jealous gaze. When receiving a compliment (a form of envy), it is also customary to spit two or three times to keep harm away.19,20 Middle Easterners Cleanliness, diet, and keep- ing warm and dry are all Middle Eastern fac- tors important to maintaining health. Some Middle Easterners believe that illness is due to wind or air in certain situations. Lebanese Muslims believe that following childbirth, a woman is especially susceptible to wind; showers and baths are avoided for ten days to prevent wind from entering the veins and causing sickness. An infant is vulnerable to wind through the umbilicus, so the baby’s stomach is wrapped at all times with a band called a zunaad.16 Traditional humoral medicine is impor- tant in the health practices of Iranians. Though traditional humoral theories iden- tify four bodily humors, in practice Iranians are concerned primarily with hot and cold. Each person is born with a physiological tem- perament dependent on the ratio of humors, which varies by gender, age, and race— women, for instance, are considered colder than men, and younger persons are hotter than older people—and can be influenced by diet, climate, geographic location and cer- tain conditions, such as childbirth.20 Sickness can be caused by consuming too many hot items or too many cold foods (see “Thera- peutic Uses of Food” section), but individual conditions and symptoms are not classified as being hot or cold. Iranians are also con- cerned with the amount of blood they have, which in turn is associated with numerous ailments, including thinness (due to lack of proper nourishment), weakness, irritability, lethargy, and headaches. Kam Kuhn—blood deficiency due to excessive bleeding from injuries, menstruation, or a poor diet that prevents the making of blood—is the source of these symptoms. Iranians use the term narahati for undif- for undif- for undif ferentiated feelings of physical and emo- tional discomfort. Most often it is expressed privately and in a nonverbal form through sullenness, anorexia, and, among women, bouts of crying. Expressions of anger are considered the public expressions of the con- dition and are usually discouraged because anger is a lack of control that can upset the social order and cause others to become narahat. Sorrow or grief is another public expression, but in contrast to anger, sadness is considered the poetic manifestation of fully experiencing the tragedy of the human condition. Naharati qalb (heart distress) is a folk condition typified by fluttering of the heart due to the strong expression of anger or sadness.21,22 A long-standing tradition of home health care exists among Middle Easterners. Folk remedies are common, such as rubbing ko’hl (a dark powder made mainly from the chemical element antimony and used mostly as a cosmetic) on the umbilical cord of an The Sufis, members of an ascetic and mystical Islamic sect, define health as an existential state of abstinence, patience, and self- examination, resulting in harmony with the universe. Zamzam water from the Mecca Valley is collected by Muslim pilgrims who complete the Hadj to be shared with family and friends at home—it is thought to have curative powers. Muslims often have serious concerns about raising their children in America. Permissive attitudes about dating and drinking and pressure to practice independent thought prompt some immigrants to send their children, especially their daughters, to the Middle East for schooling. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 1 3 4 2 5 infant to help it dry. Herbal therapies are especially prevalent, and it is believed that approximately 200 plant species are used in Arab traditional medicine today.22 Exam- ples include yarrow for diabetes and khella (a member of the parsley family) for kidney disorders. Palestinians use most traditional remedies as both food and medicine; for instance, caraway is used for digestive dis- orders and to increase milk flow in nursing mothers; mallow is used as a laxative; and olive oil to treat urinary tract infections, prostate conditions, and cancer.23 Other cures include snakeroot as a diuretic, laven- der for kidney stones, and rue as an analgesic and sedative. In Iran foxglove blossoms are used especially for nervous conditions, some digestive problems, to strengthen blood, relieve fear, and for pains of unknown etiol- ogy; arugula seeds are taken to clean dirty blood and for fever, constipation, and nau- sea; and mint tea with coriander seeds is used to promote sleep.22 In Turkey, nettle, oleander, and thyme are used therapeutically for cancer. Other commonly used herbal remedies include St. John’s wort, rosemary, sage, and hawthorne.24 Cupping (see Chapter 2) is used by some Middle Easterners to cure chronic leg pain, paralysis, headaches, and obesity. Another therapy that is sometimes applied is called wasm, or cauterization. A heated iron rod is used to place symbolic burn marks on the patient, for example, below the anus to treat diarrhea and under the ear lope to cure a toothache. The burns are then treated with special herbal poultices.25 Though supersti- tion is discouraged in Islam, many Arabs retain some beliefs in magic and supernatu- ral causes of illness. As in the Balkans, the evil eye is feared by some Arabs, who may place blue beads on infants to protect them, or wear amulets.16 In Iran, some believe the evil eye is the cause of cheshm-i-bad, the occurrence of a sudden or unexplained illness.22 Some Arabs attribute mental illness to possession by the devil, or by jinn (spirits who can be good or evil).26 Iranians often put their health into the hands of God. Tagdir, meaning “God’s will,” is thought to determine all aspects of life and, ultimately, death. Throughout the Middle East, illness is sometimes seen as a punish- ment from God. However, biomedical prac- tice is well established in the Middle East, and for the most part, Western therapies are con- sidered strong and effective.28 Traditional Food Habits The origins of most Balkan and Middle Eastern dishes may never be known because the geographic, political, and economic history of the region has resulted in simi- lar food cultures. Many ingredients in the Balkans and the Middle East, including wheat, olives, and dates, are indigenous. Sheep were first domesticated in the region over 10,000 years ago. Other foods, such as rice, chickpeas, and lemons, gained wide- spread acceptance after introduction. Yet most countries in the area claim one dish or another prepared by all ethnic groups to be their own invention. Culinary commonalities extend beyond the arbitrary designation of the Balkan and Middle Eastern nations. As previously mentioned, North Africa is sometimes con- sidered part of the Middle East and shares numerous dishes of the region. In addi- tion, the southern nations of the former Soviet Union, the southern regions of cen- tral Europe, and parts of South Asia exhibit influences as well. The most significant differences in Balkan and Middle Eastern foods are due to various religious dietary restrictions and proximity to other global cuisines. For example, the Chris- tian populations of Croatia, Serbia, and Slo- venia frequently consume pork, a favorite of neighboring central Europeans. Yet Christian Greeks, who have no pork prohibitions, eat it only occasionally, preferring lamb and goat, similar to adjacent Middle Easterners. Alco- holic beverages are banned for Muslims and are avoided in most Middle Eastern nations, though widely consumed in Turkey, perhaps due to historical associations with nearby Russia (beet soup is also popular). But despite these distinctions, foods are far more similar than different. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 4 2 6 P E O P L E O F T H E B A L K A N S A N D T H E M I D D L E E A S T Ingredients and Common Foods Staples The common ingredients used in Balkan and Middle Eastern cooking are listed in Table 13.1. Wheat, thought to have been cultivated first in this region, is consumed at every meal as bread. Leavened loaves are typical in Greece and the other Balkan nations, and leavened flat breads are more common in the Middle Eastern coun- tries. However, both loaves and flat breads are found throughout the region. Pita or pida, a thin, round Arabic bread with a hollow center (known as pocket bread in the United States), is a common type, as is lavash, a larger, crisp flatbread (also called cracker bread). Besides bread, wheat doughs are also used to make pies and turnovers prepared in a vari- ety of sizes and shapes. Bread dough, short crust, or paper-thin pastry sheets called filo or phyllo are all used. Savory pies may con- tain meat, cheese, eggs, or vegetables. Desserts are usually filled with nuts or dried fruits. An example of a fried meat or cheese-filled pas- try that can be served hot or cold is sanbusak. Traditionally half-moon shaped, it is popular in Syria, Lebanon, and Egypt. A similar turn- over is called burek in Slovenia and boereg in Bulgaria and Romania. Fatayeh is another specialty served as a snack, featuring bread At ancient Greek weddings the bride and groom were showered with wheat kernels. dough topped with cheese, meat, or spinach and baked like a pizza. Tiropetas are Greek flaky turnovers stuffed with cheese. In Serbia a cheese and egg pie called gibanjica is popular. A dessert made with filo dough, baklava or paklava, can be purchased at every bakery and café throughout the Balkans and Middle East. The sheets of dough are layered with a walnut, almond, or pistachio filling and then soaked in a syrup flavored with honey, brandy, rose water, or orange-blossom water. It is often cut into diamond shapes. Raw kernels of cracked whole wheat are used in a number of Balkan and Middle Eastern dishes. When the kernels are first steamed and then dried and crushed to dif-steamed and then dried and crushed to dif-steamed and then dried and crushed to dif ferent degrees of fineness, the cracked wheat is called burghul or burghul or burghul bulgur. Unripened dried but not cracked wheat kernels are known in Arabic markets as fireek. All varieties of wheat kernels are typically cooked as side dishes or made into tabouli, a popular salad contain- ing onions, parsley, mint, and various fresh vegetables. Another Arab specialty is kish’ka, made by blending bulgur with yogurt, dry- ing the mixture in the sun, then grinding it into a powder that can later be reconstituted with water to make a filling for pita or thinned enough for soup. In Serbia wheat kernels are cooked with sugar, dried fruits, and ground nuts to make koljivo. Dumplings filled with meat are called cmoki in Slovenia and are stuffed with fruit for dessert. In Turkey, cheese or meat dump- lings are known as manti. A few pasta dishes are found in the Balkans, such as the Greek pasta with baked lamb or goat and toma- toes called yiouvetsi and macaroni baked with cheese, ground meat, tomato sauce, and bechamel sauce called pastitsio. A dish similar to Italian pasta with beans is prepared. In the Middle East vermicelli is often added to rice, and noodles are found in a few dishes, such as Syrian chicken with macaroni. In addition to wheat, rice is also a staple item in Middle Eastern cuisine and found in some Balkan regions. The long-grain vari- ety is used to make pilaf or pilav, a dish that commonly accompanies meat or poultry. The rice is first sautéed in butter or oil in which chopped onions have been browned. It is then ▼ Traditional foods of the Balkans and the Middle East. Some foods include almonds, chickpeas (garbanzo beans), couscous, cracked wheat, dates, eggplant, feta cheese, figs, filo dough, garlic, lamb, lemon, olives, pita bread, and yogurt. En vi si on /E nc yc lo pe di a/ Co rb is Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 1 3 4 2 7 Group Comments Common Foods Adaptations in the United States Protein Foods Milk/milk products Most dairy products are consumed in fermented form (yogurt, cheese). Whole milk is used in desserts, especially puddings. Sour cream and whipped cream are common in northern Balkan nations. High incidence of lactose intolerance is reported. Cheese (goat’s, sheep’s, cow’s, and camel’s), milk (goat’s, sheep’s, camel’s, and cow’s), yogurt; buttermilk, cream More cow’s milk and less sheep’s, camel’s, and goat’s milk are drunk. Ice cream is popular. Feta is the most common Middle Eastern cheese available in the United States. Meat/poultry/ fish/eggs/ legumes Lamb is the most popular meat. Pork is eaten only by Christians, not by Muslims or Jews. Jews do not eat shellfish. In Egypt, fish is generally not eaten with dairy products. Legumes are commonly consumed. Meat: beef, kid, lamb, pork, rabbit, veal, many variety cuts Poultry: chicken, duck, pigeon, turkey Fish and shellfish: anchovies, bass, bream, clams, cod, crab, crawfish, eels, flounder, frog legs, halibut, lobster, mackerel, mullet, mussels, oysters, redfish, salmon, sardines, shrimp Eggs: poultry, fish Legumes: black beans, chickpeas (garbanzo Legumes: black beans, chickpeas (garbanzo Legumes: beans), fava (broad) beans, lentils, navy beans, red beans; peanuts Lamb is still very popular. More beef and fewer legumes are eaten. Cereals/Grains Some form of wheat or rice usually accompanies the meal in the Balkans and Middle East. Bread (wheat, barley, corn, millet), barley, buckwheat, corn, farina, millet, oatmeal, pasta, rice (long-grain and basmati), wheat (bulgur, couscous) Bread and grains are eaten at most meals. Pita bread is commonly available. Fruits/Vegetables Fruits are eaten for dessert or as snacks. Fresh fruit and vegetables are preferred, but if they are not available, fruits are served as jams and compotes and vegetables as pickles. Eggplant is very popular. Vegetables are consumed often; sometimes stuffed with rice or a meat mixture. Fruits: apples, apricots, avocado, barberries, bergamots, cherries, currants, dates, figs, grapes, lemons, limes, melons (most varieties), oranges, peaches, pears, plums, pomegranates, quinces, raisins, strawberries, tangerines Vegetables: artichokes, asparagus, beets, broccoli, brussels sprouts, cabbage, carrots, cauliflower, celeriac, celery, corn, cucumbers, eggplant, grape leaves, green beans, green peppers, greens, Jerusalem artichokes, leeks, lettuce, mushrooms, okra, olives, onions, peas, pimientos, potatoes, spinach, squashes, tomatoes, turnips, zucchini Fewer fruits and vegetables are consumed. Olives are still popular. Additional Foods Seasonings Numerous spices and herbs are used. Lemons are often used for flavoring. Ajowan, allspice, anise, basil, bay leaf, caraway seed, cardamom, cayenne, chervil, chives, chocolate, cinnamon, cloves, coriander, cumin, dill, fennel, fenugreek seeds, garlic, ginger, gum arabic and mastic, lavender, linden blossoms, mace, mahleh, marjoram, mint, mustard, nasturtium flowers, nutmeg, orange blossoms or water, oregano, paprika, parsley, pepper (red and black), rose petals and water, rosemary, saffron, sage, savory, sorrel, sumac, tamarind, tarragon, thyme, turmeric, verjuice, verbena, vinegar Nuts/seeds Ground nuts are often used to thicken soups and stews. Almonds, cashews, hazelnuts, peanuts, pine nuts, pistachios, walnuts; poppy, pumpkin, sunflower, sesame seeds TA B L E 13.1 Cultural Food Groups: Balkan and Middle Eastern (Continued)Continued)Continued Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 4 2 8 P E O P L E O F T H E B A L K A N S A N D T H E M I D D L E E A S T steamed in chicken or beef broth. Saffron or turmeric may be added to give the dish a deep yellow color. Polo is the Iranian version of pilaf, but a final step in its preparation produces rice with a crunchy brown crust known as the tah dig. A more fragrant variety of rice, basmati, is used in Iran for khoresh, rice topped with stewed meat, poultry, or legumes. Rice is frequently added to soups and stuffings for poultry and vegetables in both the Balkans and Middle East. A large variety of legumes are another important ingredient in both Balkan and Mid- dle Eastern cooking. Cooked, pureed chick- peas are the base for hummus, often served as an appetizer or as a dip. Ground chickpeas or fava beans are sometimes formed into small balls and then fried and served as a main course (ta’amia) or in pita bread with raw vegetables (falafel). A common breakfast food is foul, slowly simmered fava or black beans topped with chopped tomato, garlic, lemon juice, olive oil, and cilantro (fresh coriander leaves). Lentils are especially popular in the soups of some areas. Many vegetables are used, although egg- plant is the most popular in the Middle East, Greece, and southern Balkan regions. A common cooking method for Middle East- ern vegetables (the Greek term is yiachni; the Arabic word is yakhini) is to combine them with tomatoes or tomato paste and sautéed onions together with a small amount of water, then cook until the vegetables are soft and very little liquid remains. Vegetable salads (freshly sliced tomatoes or cucumbers are common) and cold, cooked vegetable salads are eaten. Vegetables are frequently stuffed with a meat or rice mixture. Moussaka or musaka is a Bal- kan specialty made with minced lamb, egg- plant, onions, and tomato sauce baked in a dish lined with eggplant slices. The Turks prefer imam bayildi (meaning “the priest fainted”), eggplant filled with tomatoes, onions, and gar- lic, stewed in olive oil and served cold.27 Grape or cabbage leaves are stuffed to make the spe- cialties known as dolma or sarma. Potatoes, particularly enjoyed in the northern Balkan nations, are also found in some Middle East- ern stews and side dishes. Vegetables are fre- quently enjoyed raw, mixed together in a salad, or preserved as pickles. Sauerkraut is eaten in Croatia, Serbia, and Slovenia. The olive tree contributes in many ways, particularly to Greek and Middle Eastern cooking. Olives prepared in the Middle In Bosnia-Herzegovina, Croatia, Serbia, and Slovenia, pida usually refers to filo dough, not pocket bread. TA B L E 13.1 Cultural Food Groups: Balkan and Middle Eastern (C on t in u e d ) Group Comments Common Foods Adaptations in the United States Beverages Coffee and tea are often flavored with cardamom or mint, respectively. Aperitifs are often anise flavored. Alcoholic beverages are prohibited for Muslims, but consumed in most of the Balkans, Turkey, and Israel. Coffee, date palm juice, fruit juices, tea and herbal infusions, yogurt drinks; beer, wine, brandy Fats/oils Olive oil is generally used in dishes that are to be eaten cold. For most deep-frying, corn or nut oil is used; olive oil is preferred for deep-frying fish. Clarified butter (samana) is also popular. Sheep’s tail fat is a delicacy. Butter, olive oil, sesame oil, various nut and vegetable oils, rendered lamb fat Olive oil is still popular. Sweeteners Coffee and tea are heavily sweetened. Dessert syrups are flavored with honey, rose water, or orange- flower water. Honey, sugar © C en ga ge L ea rn in g Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 1 3 4 2 9 Eastern way have a much stronger flavor than European or American olives; they often accompany the meal or are served as an appetizer (see Table 13.2). The olive is also a source of oil, which is frequently used in food preparation, although butter, clarified butter (samana), and most vegetable oils, as well as rendered lamb fat and margarine, are found in the Balkans and Middle East. Olive oil is gen- erally used in dishes that are to be eaten cold. For most deep-frying, corn or nut oil is used, but olive oil is preferred for deep-frying fish. Fruits are preferred fresh, eaten for dessert or as snacks. Apricots, cherries, figs, dates, grapes, melons, pomegranates, and quince are favor- ites. Pears, plums, and pumpkins are well liked in the more temperate climates of the northern Balkan nations. A distinctive characteristic of Middle Eastern fare is the addition of fruits to savory dishes; apricot sauce tops meatballs in Egypt and chicken in Syria. Fruits are also often served dried or as jams and compotes. Slatko is a Balkan specialty featuring fruits simmered in thick syrup. Fruit juices (especially lemon) and syrups flavor many foods. Fresh milk is not widely consumed in the Balkans or Middle East, though it is used in puddings and custards. Dairy products are usually fermented into yogurt or processed into cheese. Yogurt is eaten as a side dish and served plain (unsweetened) or mixed with cucumbers or other vegetables. It is diluted to make a refreshing drink. Cheese is usually made from goat’s, sheep’s, or (in the Middle East) camel’s milk. The most widely used cheese is feta, a salty, white, moist cheese that crumbles easily. Myzithra, a soft pot cheese, is a by-product of the feta process. Lebneh or labni is a fresh cheese made by draining the whey from salted yogurt overnight. Haloumi is a springy, semisoft cheese that is sometimes flavored with mint. It holds its shape when cooked, and pieces can be grilled quickly on both sides for a hot treat. Kaseri is a firm, white, aged cheese, mild in flavor and simi- lar to Italian provolone. Kashkaval is a hard, Kashkaval is a hard, Kashkaval tangy ewe’s milk cheese, sometimes called the cheddar of the Balkans. Almost all meats and seafood are eaten in the Balkans and Middle East, with the excep- tion of pork in Muslim countries and pork and shellfish among observant Jews in Israel. Lamb is the most widely used meat, though pork is very popular in the northern Balkan areas. Grilling, frying, grinding, and stewing are the common ways of preparing meat in the region. A popular dish is kabobs, mari- nated pieces of meat threaded onto skewers then grilled over a fire. Vegetables, such as onions or tomatoes, are sometimes added to the skewers. Souvlaki or shawarma is very thin slices of lamb (or chicken) layered onto a rotisserie with slices of fat (resulting in a single roast), grilled, then carved and served. In Greece, thin slices of souvlaki are folded into pita bread with tomatoes, cucumber, and yogurt to make the sandwich-like treat gyros. Meatballs, called kofta, are favorites, eaten as snacks or served with stewed vegetables. A whole roasted lamb or sheep is a festive dish prepared for parties, festivals, and family gatherings. Numerous spices and herbs are used in the Balkans and Middle Eastern seasoning as a result of a once-thriving spice trade with India, Africa, and Asia. Common spices and herbs are dill, garlic, mint, cardamom, cin- namon, oregano, parsley, and pepper. Sumac, ground red berries from a nontoxic variety of the plant, is sprinkled over salads to give a slightly astringent flavor; it is mixed with thyme to make the Arabic seasoning mix called za’atar. Other typical Middle Eastern spices include mahleb, made from the ground ▲ Assorted Egyptian pastries made with filo dough, couscous, and nuts. D av e Ba rt ru ff /E nc yc lo pe di a/ Co rb is The term yogurt is Turkish. In Syria and Lebanon the fermented milk product is called laban; in Egypt, laban zabadi; and in Iran, mast. Camel’s milk, unlike other commonly consumed animal milks, is high in vitamin C. Eggplant “caviar,” which is a cooked salad, and baba ganouj, an unusual smoked eggplant puree, are very popular appetizer dishes served throughout the Middle East. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 4 3 0 P E O P L E O F T H E B A L K A N S A N D T H E M I D D L E E A S T pits of a cherry-like fruit, and ajowan, small, black carom seeds with a thymelike flavor. The juice of unripe lemons, verjuice, is used to provide a sour taste to dishes. Ground nuts are often used to thicken soups and stews. Sesame seeds are crushed to make a thick sauce, tahini, which is used as an ingredient in Arabic cooking and in a sweet dessert paste known as halvah. Fruit juice is popular as a beverage through- out the Balkans and Middle East, and some- times fruit syrups or flower extracts are mixed with ice (or in the past, snow) to make the refreshing beverage known as sharbat in Arasharbat in Arasharbat - bic or şerbet in Turkish (origin of the şerbet in Turkish (origin of the şerbet English word “sherbet”). Coffee is a favorite (see “Is Coffee Beneficial for Health?” later in this chapter) across the entire region, consumed throughout the day at home and in cafés. It is frequently flavored with cardamom and copi- ous amounts of sugar. Traditionally, the drink is made in a long-handled metal briki, produc- ing a strong, very thick, and often sweet brew served in small cylindrical cups. It is called “Turkish coffee” in Turkey and “Serbian coffee” in Serbia. Tea is equally popular in many nations and is served sweetened and flavored with mint, or fruit such as dates or raisins. The Balkan countries are well known for their wines and distilled spirits. Civek is a rosé served throughout Slovenia, and a high-proof brandy made from plums called sljivovica is available in both Serbia and Slovenia. Best known in the United States are the Greek specialties retsina (white wine with a resinous flavor), ouzo and arak (anise-flavored aperi- tifs), and metaxia (orange-flavored brandy). Although observant Muslims do not drink alcohol, several Middle Eastern nations (e.g., Iraq, Israel, and Turkey) produce wines and spirits. Raki, a Turkish version of arak, is tra- ditionally consumed with appetizers. Regional Variations Balkan All Balkan nations combine both European and Middle Eastern elements in their cooking. The noteworthy division is between the more European-influenced fare TA B L E 13. 2 Glossary of Selected Olives Olives originated in the Middle East and spread throughout the Mediterranean. They are picked unripe (green, with dry, firm flesh and a bitter taste) or when fully ripened (black, oilier, soft textured, and milder in flavor). Raw olives are inedible and must be cured in salt (also called dry-cured) or in a brine, oil, wine, or lye solution before they can be consumed. Both the stage at which they are harvested and the type of curing process affect the flavor of the final product. Aleppo (Middle East) Small, dry-cured black olive (with wrinkled, chewy texture) named after a Syrian city Amphissa (Greek) Dark purple olives with nutty flavor Gaeta (Italy) Medium black olives, dry-cured (with wrinkled texture) or brine-cured (with smooth purplish flesh) Kalamata (Greece/Middle East) Large, deep-purple with crunchy texture—salt-cured, packed in vinegar (sometimes with preserved lemon in Morocco) Kura (Middle East) Large green olive with hard flesh cracked to allow penetration of brine, bitter flavored, also called Middle Eastern cracked green Manzanilla (Spain) Small to large green olive usually pitted and stuffed with other ingredients (e.g., pimento, garlic, almonds) Middle Eastern Green Small, brine-cured olives packed with olive oil, herbs, and often chile peppers Moroccan Dry-Cured Medium black, dry-cured with wrinkled flesh and bitter flavor, used mostly in cooking Nabali (Middle East)Nabali (Middle East)Nabali Dark green olive with soft texture, brine-cured, and often packed with lemon, garlic, and vinegar— grown in Israel (including the Palestinian territories) and Jordan; also called mushhan, baladi, or Roman olives Naphlion (Greece) Dark green, brine-cured, packed in olive oil Niçoise (France) Small, sour, salt-cured purplish black olives Picholine (France) Small, mild, salt-cured light green olives Sicilian (Italy) Very large, green olive, brine-cured, somewhat sour Thassos (Greece) Small, dry-cured black olives (with wrinkled texture), intense tart flavor © C en ga ge L ea rn in g Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 1 3 4 3 1 of Bosnia-Herzegovina, Croatia, Romania (see Exploring Global Cuisine: Romanian Fare), Serbia, Slovenia, and the other north- ern nations and the foods of the southern countries, including Albania (see Exploring Global Cuisine: Albanian Fare) and Greece, with a decidedly more Middle Eastern flavor (Greek cooking is considered in the discus- sion of Turkish fare in the following section). The use of pork and veal, the selection of fruits and vegetables, and the popularity of fresh dairy products are all characteristics of central European cooking in the northern Bal- kans. German-style sausages, pork roasts, and hams are frequently consumed. Veal is popu- lar for stew and is sometimes seasoned with paprika. One popular dish found in most of the Balkan countries is ćevapi (or ćevapčići), grilled elongated kebobs of spicy minced meat that are often eaten on somun (a thick pita bread) or lepinja (a small, flat roll). In Bosnia they are usually made with beef, or a beef and lamb mixture, served with chopped onions, cottage cheese, and an extra-rich sour cream called kajmak. Large, thin meat patties made from lamb and beef, known as pljeskavica, are con- sidered the national dish of Serbia but are also a favorite with Bosnians and Croatians. Middle Eastern–style grilled meats are also found in some areas, especially in Bosnia-Herzegovina. Potatoes, cabbage, and cucumbers are typical vegetables, and many families gather wild mushrooms. Ajyar, made with roasted red bell peppers and eggplant, seasoned with garlic and vinegar, is popular through- out the Balkans. It comes in many versions, from sweet to hot (flavored with chile pep- pers), and is served as a condiment with grilled meats, as a salad on a mezze plate (typically with a selection of sliced sausages or smoked meats, cheeses, hard-boiled eggs, and sliced tomatoes) or spread on bread. Veg- etables are sometimes stuffed with meat and rice mixtures similar to those in the Middle East, but with a Balkan flavor due to the use of bell peppers, onions, potatoes, or cabbage leaves. In Bosnia-Herzegovina these stuffed items are called sarma or dolma and may be served in the tureen in which they have been heated.5 Cooler-weather fruits such as apples, berries, peaches, pears, and plums are more M ar k D af fe y/ Lo ne ly P la ne t I m ag es /G et ty Im ag es ▼ Preparing Middle Eastern coffee. The coffee of the Balkans and the Middle East is made in a long-handled briki. It is preferred strong, thick, and sweet and is often flavoured with cardamom. common. They are found in desserts, such as sweet dumplings and strudels, and preserved as compotes. Fruit juices are favorites and an important industry in the region. Buttermilk is frequently consumed and fresh cheeses are well liked, often combined with herbs for mezze or mixed with eggs and honey or sugar for cheese-filled dessert pas- tries. Cream enriches soups, stews, casseroles, and sauces. Sour cream or whipped cream tops many dishes. A specialty dairy prod- uct found throughout the region is a heavy, crème fraiche–like product called smetana (in Slovenia), vrhnje (in Croatia), or pavlaka (in Bosnia-Herzegovina). In Croatia it is added to cottage cheese and seasoned with onions, gar- lic, radish or horseradish, and paprika, then eaten with cornbread. The definitive northern Balkan treat is a sweet yeast bread rolled with a rich walnut, butter, cream, and egg filling. It is widely known as potica and in some areas as povitica or kolachki. Some versions are more savory, flavored with tarragon—others are sweeter, with dried fruits. Variations include cream cheese, poppy seed, and pumpkin fillings. Whipped cream tops many sweet versions. In the Middle East coffee is consumed highly sweetened at happy occasions; it is drunk black and bitter at funerals. The Arabs were the first to mix gum arabic with sugar to produce chewing gum. The Greeks prefer to chew on the licorice-flavored resin mastic (source of the verb masticate). Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 4 3 2 P E O P L E O F T H E B A L K A N S A N D T H E M I D D L E E A S T Middle Eastern There are two schools of thought about the number of regional cooking areas in the Middle East. One identifies three culinary areas: Greek/Turkish, Iranian, and Arabic, and the other defines five divisions: Greek/Turkish, Arabic, Iranian, Israeli, and North African (see Exploring Global Cuisine: Moroccan Cooking). Certainly every region has some unique recipes and cooking methods, but the similarity in fare throughout the region is striking. The cooking of Greece and Turkey has evolved through an extensive exchange of ingredients and preparation techniques. Both cuisines feature more meat (especially grilled), fish and seafood, cheese, butter, and olive oil than in the fare of neighboring Middle Eastern countries. Both the Greeks and Turks prefer using flatware to fingers when eating. Similar distinguishing dishes include filo dough layered with spinach and Is Coffee Beneficial for Health? Despite the importance of wheat in the diet of Western nations, it can be argued that the most important Middle Eastern product consumed worldwide is coffee. Over 500 billion cups are consumed annually. Coffee is currently grown in over fifty countries and is second only to petroleum in global trade activity and value. The International Coffee Organization reports that exports increased 17 percent in 2006, and it is becoming increasingly common in tea-drinking nations such as Japan, China, and India. Coffee is indigenous to Ethiopia, but it was the Arabs who first brewed and popularized the beverage after it was introduced to the region sometime around the tenth century.87 It is said that a Sufi sheikh was first to note the ability of coffee to promote wakefulness, and it became widely used by worshippers to increase stamina and to produce a mystical euphoria.35 The Sufis called it qahwah (thought to be the origin of the term coffee), a word originally used for wine. By the early 1500s it had become a secular beverage consumed in Middle Eastern social settings, especially coffee houses, where men could drink and discuss the matters of the day. The coffeehouses attracted philosophers and poets, and in Istanbul they were known in jest as schools of knowledge.35 Some Islamic leaders became concerned that men were spending more time drinking coffee than attending mosque services, and that politically subversive activities were being planned in the coffeehouses. This led to their closure in some areas, but efforts to enforce a permanent ban among Muslims failed due to coffee’s broad popularity. During this period, coffee was successfully grown in the Arabian Peninsula nations, and the product was improved by dark-roasting the beans. The beverage spread with the expansion of the Turkish Ottoman Empire, especially in southern Europe, where the social tradition of coffeehouses was well accepted. The Middle East became the first major exporter of beans through the Yemenese port of Moccha. However, some sixteenth-century Catholics believed that coffee was the beverage of Satan, due to its association with infidels. Popular legend is that plans to prohibit coffee were foiled when Pope Clement VIII asked to taste the brew and immediately claimed it so good that Christians should make it their own. Historical controversies aside, the most significant issue regarding coffee in modern times has been its impact on health. Coffee contains numerous active ingredients, most notably caffeine and chlorogenic acid. Caffeine is an alkaloid that is classified with cocaine and amphetamines as a central nervous system stimulant. Chlorogenic acid is a phenolic compound that works as an antioxidant. Over the years, coffee has developed a bad reputation, related to studies on the development of ulcers, heart disease, cancer, and birth defects. Beginning in the 1980s, many health-conscious people began to cut consumption or switch to decaffeinated coffee. Recent research, however, is leading to redemption of the beverage. Coffee has been exonerated as a causative agent in many gastrointestinal disorders, in most cardiovascular conditions, and in almost all cancers.88,89,90,91 Even the association with birth defects has been disproved.92 Instead, research suggests that moderate consumption of three to four cups each day may actually offer health benefits, reducing the risk of metabolic syndrome,93 coronary heart disease,94,95 type 2 diabetes,96,97 several cancers,98,99,100 rheumatoid arthritis,101 and possibly Alzheimer’s disease.102 Studies on the effect of coffee on hypertension are contradictory.91,103 Coffee is still suspect in bladder cancer, spontaneous abortion, and impaired fetal growth, and may aggravate some gastrointestinal disorders.91,104 Researchers caution that coffee is not for everyone and that people with hypertension, children, elders, and pregnant women are most susceptible to adverse effects. C U L T U R A L C O N T R O V E R S Y Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 1 3 4 3 3 feta filling (spanakopita in Greece, ispanakli borek in Turkey); fish roe (caviar) dip made with olive oil and bread (taramasalata in Greece and tarama in Turkey); salads with fresh greens, tomato, cucumbers, olives, and lemon juice–olive oil vinaigrette (the Greek version adds feta cheese; the Turkish recipe includes more vegetables, such as green pep- pers); the lemony, egg-enriched sauce used to thicken soups and top meat and vegetable dishes (avgolemono in Greece, tebiye in Tur- key); yogurt cake; and anise-flavored alco- holic beverages. Yet many differences exist. Greeks prefer small pastries, such as the spe- cialty butter cookie, kourabiedes, for snacking and dessert, while the Turkish sweet tooth is more often satisfied with fruit compotes, rich custards, and candy, including lokum, also known as Turkish delight. More significantly, consumption due to religious affiliation var- ies. Feasting and fasting rules for the Eastern Orthodox of Greece and the Muslims of Tur- key differ tremendously (see Chapter 4). Arab fare, based originally on the cook- ing of nomadic tribes and later influenced by the foods of surrounding nations, features more grains, legumes, and vegetables than the Greek, Turkish, Israeli, or Iranian diet. In Syria and Lebanon, the national dish is kibbeh, a mixture of fine cracked wheat, grated onion, and ground lamb pounded into a paste. This mixture can be eaten raw or grilled, and with a great deal of dexterity it can be made into a hollow shell, then filled with a meat mixture, and deep-fried. In Jordan, a specialty is man- saf—flat breads layered with yogurt are placed on a communal platter and then topped with a mound of rice pilaf and shredded lamb or chicken. A broth mixed with whey or yogurt is poured over the top, then the dish is garnished with nuts. The national dish of Egypt is ful medames, cooked fava beans seasoned with oil, lemon, and garlic, sprinkled with parsley, and served with baladi, a whole-wheat type of pita bread. Many soups and stews include legumes, and some salads include grains, such as tabouli. Pieces of pita bread are added to many dishes as well. Tharid is a casserole of layered flatbread with meat stew found in many Arab nations. Fatout is a popular preparation in Yemen, combining toasted bread with honey, with scrambled eggs, or any other food; fattoush is a Lebanese favorite with greens, tomatoes, radishes, cucumbers, onions, and pieces of pita bread. Another feature of Arab cooking is the use of variety meats. Lamb, goat, and beef are costly; thus, all parts of the animal are used, with brains, chitterlings, heads, and feet considered deli- cacies. Pacha is an Iraqi soup of sheep heads, stomach, and trotters served with ample bread and pickled vegetables. Iran is the most eastern of Middle East- ern nations. It spans a region between the warm Persian Gulf and the cold Caspian Sea, encompassing several agricultural climates suited to a wide variety of fruits and vegeta- bles. Its dominance of the Middle East, parts of the Balkans, and areas of India during the Persian Empire dispersed indigenous prod- ucts such as spinach, pomegranates, and saf-ucts such as spinach, pomegranates, and saf-ucts such as spinach, pomegranates, and saf fron throughout the region. Later trade routes between China and Syria (the Silk Road) and between India and Africa crossed through Iran, introducing rice, tea, eggplants, citrus fruits, tamarind, and garam masala (the spice blend used in curried dishes) from these eastern cuisines. Though the cook- ing of Iran, usually called Persian cuisine, is very similar to other Middle Eastern foods, it is famous for its sophisticated rice dishes and its use of fruits for flavoring. The national dish is chelo kebab, which is thinly sliced pieces of marinated, charcoal-grilled lamb served over rice seasoned with butter, egg yolks, saf-over rice seasoned with butter, egg yolks, saf-over rice seasoned with butter, egg yolks, saf fron, and sumac. Soups and sauces are given a sweet and sour taste by combining different ripe and unripe fruits, such as oranges, bar- berries, cherries, dates, grapes, plums, pome- granates, quinces, and raisins with astringent seasonings, including lemon juice, vinegar, tamarind, and sumac. Israel probably has the most varied foods and food culture because its cuisine blends indigenous Middle Eastern cooking with that of the many Jewish immigrant groups who have settled in the area since nationhood. Hummus and pita bread may appear at the same meal as German schnitzel, Hungarian- style goulash, or Italian pasta.28 American immigrants introduced bagels; Russians brought kasha and borscht. Chocolate mousse One specialty of North African cooking is mirqaz (or merguez) sausage— which is also popular in France—made from lamb or other meats, seasoned with chiles, cinnamon, dried rose petals, and other spices, then typically sun-dried and packed in olive oil. Syrian food is often spicier than that of other Arab nations. They are known for their small baked lamb pies seasoned with cayenne called sfeehas. Tharid was reputedly Mohammed’s favorite dish. The Iranians call their breads nan and bake many of them, such as nan-e lavash and nan-e barbari, in a clay bread oven known as a tanoor. Both the name and oven were brought by the Persians to northern India, where naan flat-breads are baked in tandoor ovens. Israelis born in Israel are nicknamed sabra after the cactus of the same name because the fruit is tough and prickly on the outside but sweet inside. A U.S. native known as the prickly pear cactus was first exported to the Middle East in the nineteenth century. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 4 3 4 P E O P L E O F T H E B A L K A N S A N D T H E M I D D L E E A S T cake, linzertorte, and coconut macaroons are as popular as baklava. Furthermore, observant Israel’s citizens adhere to the kosher laws of the Jewish religion (see Chapter 4 for more information on Jewish dietary practices). Meal Composition and Cycle Daily Patterns The Balkans People in Balkan countries eat three meals a day. The main meal is at midday, and in the hotter climates a short nap follows. Dinner is lighter and is served in the cooler evening hours. Snacking is prevalent. In the northern regions a light breakfast of bread with preserves or honey and tea or coffee is most common. Lunch usually includes soup, a casserole of meats and veg- etables, or a fish dish, bread and cheese, and a fruit compote or pastry for dessert. Dinner is often leftovers or another soup or stew; sweet dumplings may also be served. Wine is the typical beverage for both lunch and dinner, though buttermilk, fruit juices, and soft drinks are consumed in some areas. In urban regions street vendors ply pastries and ice cream throughout the day. Late evening visits to cafés or coffee houses often include small kebabs, meatballs, vegetable salads and pickles, and other tidbits to accompany coffee, wine, or plum brandy. In Greece and the southern Balkan nations, the traditional breakfast typically consists of bread with cheese, olives, or jam plus coffee or tea. The main meal, eaten in early afternoon, usually begins with mezze or appetizers, such as hummus, baba ganouj, tiropetes, and dol- mas, often consumed with a small glass of ouzo: the actual selection of included items varies by the inclination of the homemaker and affordability. Next a meat stew, meatballs, kebabs, vegetables stuffed with chopped meat, or a bean dish is served with a salad of raw sea- sonal vegetables, yogurt or cheese, and fruit for dessert. Roasted or baked whole meats are served on weekends, accompanied by cooked vegetables, salad, and dessert. Late afternoon and early evening are times when neighbors and friends may drop by for some sweets and a cup of coffee or glass of ouzo. A light sup- per is served in the late evening. Throughout the day, mezze are widely available from street vendors and cafés for snacking. Middle East In most Arabic countries coffee or tea is often served first for breakfast around 7:00 or 8:00 a.m., followed by a light meal that might include bread, cheeses, beans, Romania is a nation poised between the West and the East. Some describe Romanian food as “pastoral” with Turkish and Hungarian overtones. However, there are also many Italian and central European influences. Beef, veal, mutton, lamb, pork, chicken, geese, and duck are popular. Freshwater fish such as pike and catfish are harvested from the Danube and other rivers. Cabbage, red and green peppers, leeks, tomatoes, onions, radishes, and let- tuce are common vegetables. Temperate fruits, particularly grapes, plums, and berries, are eaten. Other common foods include walnuts, filberts, olives, sour cream, and sheep and goat cheeses. The national bread is mamaliga, which is like the Italian polenta. It is sliced and spread with but- ter or topped with cheese, meats, or fruit for dessert. Another specialty is pastrama (from the Turkish meaning “to keep”), which is lamb, beef, pork, or goose cured (spic- ing varies, from garlic and black pepper to allspice, nutmeg, and hot red pepper) and then smoked. Ground meats are also popular, made into patties, stuffed into cab- bage leaves, or as sausages. One-dish meals such as stews and soups are eaten with whole-grain bread; one example is ciorba, a soup made with vegetables (e.g., peppers, onions, sauerkraut, tomatoes) and meat (usually ground) or fish and then flavored with sour ingredients (e.g., sauerkraut juice, pickle juice, or vinegar). Cake is a traditional dessert, but custards (including one similar to Italian zabaglione) and soufflés are also eaten. Romanian beverages include wine (red, white, sweet, dry) and tuica, a plum and wheat brandy. Most Romanians belong to the Eastern Orthodox Church and adhere to the numerous feasting and fasting days of the church calendar. E X P L O R I N G G L O B A L C U I S I N E Romanian Fare Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 1 3 4 3 5 eggs, olives, jam and bread, and plain yogurt. Lunch is the main meal of the day, eaten in the early afternoon. It is customarily bread, rice or bulgur, and a vegetable or legume casserole, a meat or poultry stew, or, where available, a fish or seafood dish. Fresh or cooked vegetable salad or onions and olives are common side dishes. Additional items, depending on region and affordability, may include a selection of mezze (such as hummus, tabouli, vegetables in yogurt, and bowls of nuts), a soup, and cheeses. Dessert is usually included, typically a piece of fresh fruit, a pastry, or a custard or pudding. Diluted yogurt drinks or water is served while eating, followed by sweetened tea or coffee. Dinner in the early evening is light, consisting of foods similar to those eaten at breakfast, soup, or leftovers from lunch. All the dishes in a meal are customarily served at once in Egypt, Iraq, and Yeman, and in courses in Jordan, Lebanon, and Syria.29 Turkish meals vary slightly from the Mid- dle Eastern pattern. Breakfast (often served a little later than in Arabic nations) varies regionally, but is often substantial, with leav- ened bread or simit (a chewy or crunchy ring-simit (a chewy or crunchy ring-simit shaped roll resembling a bagel in shape, but richer in flavor—also found in Greece where they are called koulouri), cheese, butter, toma- toes, olives, and jam served with sweetened tea. Eggs, soups or sausages are common additions in some areas. Lunch, eaten around noon, and dinner, served between 6:00 and 8:00 p.m., are also plentiful meals, especially dinner, which is the main meal of the day. It begins with a selection of mezze (mezeler in mezeler in mezeler Turkish) served with raki. Items may include lamb meatballs, dolma, stuffed mussels, fried squids, baba ganouj, hummus, and vegetable salads. These appetizers are followed by the olive oil course, featuring vegetables such as eggplant, tomatoes, or leeks stewed in olive oil. Kebabs, casseroles, or stews are the cen- terpiece of the meal, served with pilaf and bread. Fresh fruit such as melon, baklava, or rice pudding follows, and the sweets are consumed with coffee. In some regions, tripe soup with vinegar and garlic may be eaten Albania was not of interest to most Americans until the 1998 civil war in the Serbian province of Kosova focused attention on the plight of the Kosovar Albanians. Albanians, living in a country bordered by Greece, Macedonia, Serbia, and Montenegro, have often been involved in regional discord and shifting national boundaries.105 Years of foreign rule have left their mark on Albanian cuisine: pastitsio and feta cheese from Greece, versions of imam bayaldi and imam bayaldi and imam bayaldi halvah from Turkey, omelets and tomato sauces from Italy, boereg from Armenia, and borscht from borscht from borscht Russia. Other dishes including dolma, kofta, shish kebabs, moussaka, and baklava are popular throughout the region. In the poorest rural regions of Albania, farmers and shepherds are often limited to a diet of cornmeal bread, cheese, and yogurt, with added lamb or mutton when afford- able. In wealthier areas, three meals a day are typical with a mid-afternoon snack of thick Turkish-style coffee or tea consumed with pastries, nuts, or fresh fruit, called sille. A complete lunch or dinner begins with mezze (appetizers), such as salads, pickles, fish and seafood, omelets, spit-roasted lamb or entrails, and baked variety meats. Examples include liptao, a feta cheese salad garnished with bell pepper, deli meats, sardines, and hard-boiled egg; and soup- like tarator, yogurt flavored with garlic and olive oil and mixed with vegetables, such as cucumber. These are usually consumed with a glass of the distilled Turkish specialty, raki, or a beverage made from fermented raki, or a beverage made from fermented raki cabbage called orme. The meal follows with soups, meat, or cheese-stuffed vegetables or casseroles; pilaf-like dishes or pies filled with vegetables, cheese, and/or ground meats called byrek; and an assortment of vegetable side dishes and pickles. Dessert may include pastries but is typically a fruit compote. Few legumes are consumed, but nuts (especially walnuts) are added to numerous sweet and savory dishes. One of the most distinctive characteristics of Albanian fare is the differentiation made between vegetables and fruit. Only vegetables are pickled and served as side dishes, and fruits are only eaten fresh, as desserts or as preserves. There are no crossover items, such as a fruit pickle or a vegetable-sweetened filling for a pie. Vegetables and fruits are also prepared separately and not mixed together in dishes.106 E X P L O R I N G G L O B A L C U I S I N E Albanian Fare Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 4 3 6 P E O P L E O F T H E B A L K A N S A N D T H E M I D D L E E A S T after dinner, served with alcoholic beverages. Turkish meals are typically served in courses. In Iran, breakfast is usually a selection of flat breads served with feta or other cheeses, sweetened whipped cream, and jam. In some regions, offal soup or halim (a savory wheat porridge with meats and vegetables) is pre- ferred.30 Lunch and dinner are similar, usually with rice, a meat or poultry dish (roasted, or as kebabs or ground meat), often a vegetable salad, flat breads, some feta cheese or yogurt, and a selection of chopped herbs (such as mint, basil, and dill). A meat or vegetable stew is frequently substituted for the meat or poultry course, served over the rice. Fruit, especially melon or grapes, is a typical dessert, and tea or a yogurt drink accompanies the meal. Traditionally, the dishes are all served at one time and eaten communally. Weekday breakfasts in Israel are customar- ily light: coffee with some pita and olive oil and za’atar, European-style breads with jam or other spread, or a selection of cheeses, yogurt, and chopped vegetables and fruit. Sabbath breakfasts, however, are somewhat heartier. European Jews may choose coffee- cakes or pancakes, and Middle Eastern Jews may select bureks, kataif (a sweet, stuffed pan- cake), or sabikh (an Iraqi dish of pita bread topped with fried eggplant, hard-boiled egg, Morocco is one of five nations that make up the Maghreb, a region of North Africa differentiated from the Middle East by its substantial populations of nomadic Berbers, also including the countries of Algeria, Tunisia, Mauritania, and Libya. Although there are very few immigrants to the United States from the Maghreb, many Moroccan restaurants have opened, advertising an exotic dining experi- ence at low tables amid pillowed opulence, often with belly-dancing entertainment. The cooking of Morocco is predominantly Berber in origin, strongly influenced by neighboring Arabic fare and, to a much lesser degree, through interchange with sub-Saha- ran Africa and the southern European coun- tries of the Mediterranean. It is noteworthy for its exquisite seasonings. Spices, such as allspice, anise, cardamom, cayenne, cumin, cinnamon, cloves, mace, malagueta pep- per (see Chapter 8), nutmeg, turmeric, and saffron, are combined with herbs, including basil, fresh coriander, lavender, marjoram, mint, verbena, and za’atar. One mixture, ras el hanout, includes between ten and twenty-el hanout, includes between ten and twenty-el hanout five ingredients, depending on the chef and its intended purpose; medicinal herbs such as belladonna or reputed aphrodisiacs (such as the pulverized beetle known as “Spanish fly”) may also be added.107 Garlic, onions, lemons (some preserved through brining), almonds, and sweet peppers also flavor many dishes, and some are heated with the chile pepper and garlic paste condiment called harissa (from Tunisia, where foods are preferred very spicy). Rose water and orange-blossom water are also commonly used. Foods are also flavored by the preferred cooking fats of the region, zebeda (a sour fresh butter) and smen (a preserved clarified butter often seasoned with herbs; it is tradi- tionally stored for months underground until cheese like). Couscous is a staple eaten throughout the Mahgreb, where it is known by many names. It is made from a dough of hulled, crushed (not ground) grains of semolina wheat (other grains prepared the same way, such as barley and millet, are also called couscous) mixed with water and processed into very small pellets and dried. It is tra- ditionally cooked in a specialized steamer known as a couscousière. The word couscous is also used to describe the finished dish: the steamed grain topped with a mixture of lamb with chickpeas and vegetables, fish with fennel, dates with cinnamon (for dessert), or other popular versions. Moroccan stews, tagines, are slow-cooked in ceramic pots and feature any combination of meats, poultry, fish, organ meats, vegetables, and fruits. Mechoui is spit-roasted lamb or kid. The meat is first rubbed with cumin and garlic, and then cooked until it can be pulled off with the fingers. Bastilla or b’stila (from the Spanish word for pastry or pie, pastel) pastel) pastel is the quintessential Moroccan dish: sheets of warqa (a dough similar to filo, though thinner) enclose layers of ground almonds mixed with sugar and cinnamon alternating with pigeon or chicken meat. The layers are bound with a lemony egg sauce, and the pie is baked until golden. The crispy crust is often sprinkled with sugar and cinnamon before serving. Cooked or marinated vegetable salads usually start a meal, and fresh fruit and nuts add the finishing touch. All foods are eaten with the first three fingers of the right hand, and bread is used to sop up sauces. E X P L O R I N G G L O B A L C U I S I N E Moroccan Cooking Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 1 3 4 3 7 tahini, and a mango pickle). The traditional Israeli breakfast buffet associated with kib- butz life is offered at some restaurants, featur- ing a more typically Middle Eastern selection of flat breads, cheeses, vegetables, and olives, often with added eggs, baked goods, and other selections. The midday meal is the largest in most homes, beginning with hum- mus or tahini served with pita bread, then a salad—often cucumbers, tomatoes, and onions—followed by items appropriate to a meat or dairy meal (see Chapter 4 for more information on Kosher rules). The evening meal, typically eaten around 8:00 or 9:00 p.m., is usually light with cheeses, yogurt, salads, and eggs. Some families serve all the dishes of the meal at once, while others serve them in courses, often depending on heritage. Street stands offer falafel, kebabs, shawarma, and other snacks, and fast-food restaurants, espe- cially those serving hamburgers or pizza, are popular with many Israelis. Fruit juices, soft drinks, and beer are common meal beverages. Etiquette Throughout the Balkans and the Middle East, hospitality is a duty and a family’s status is measured by how guests are treated. Guests, even uninvited ones, are made to feel welcome and are automatically offered food and drink. In the Balkans it is likely to be fruit compotes, candies, and buttermilk, coffee, plum brandy, or, in Greece, ouzo or arak. In the Middle East it may be a few dates and water or an exten- sive choice of mezze served with coffee, tea, or raki. Even if food is initially refused, it will be offered again, and a guest must accept because refusal is considered an insult. Invited guests bring a gift, often candy or other sweets, which the host must open immediately and serve. Hospitality is even offered to clients in the office setting, and failure to make guests or clients comfortable may create extreme embarrassment for all parties.22 In the Middle East, a guest’s status is indi- cated by which pieces of food are offered, and the order in which the items are served. Status is based on sex, age, family, and social rank. For example, a dignitary or head of the family is served the best portion first. In Saudi Arabia and other nations of the Arabian peninsula, S A M P L E M E N U A Greek Mezze Olives and Cheeses (such as K as e r i or K as e r i or K as e r i M y z it h r a) T ar amos alata (Caviar Dip)a,b or Hummus (Chickpea Dip) T z atz ik i (Cucumber Yogurt Dip)T z atz ik i (Cucumber Yogurt Dip)T z atz ik i a,b Pita Bread S pan ak opita (Spinach and Cheese Triangles)a,b D olmas (Stuffed Grape Leaves)a,b with A v gole m on o (Egg and Lemon Sauce)a,b Ouzo or Wine aHarris, A. 2002. Modern Greek: 170 contemporary recipes from the Mediterranean. San Francisco: Chronicle Books. bbbEat Greek TonightEat Greek TonightEat Greek Tonight at http://www.greek-recipe.com at http://www.greek-recipe.com at http://www.greek-recipe.comEat Greek Tonight at http://www.greek-recipe.comEat Greek TonightEat Greek Tonight at http://www.greek-recipe.comEat Greek TonightEat Greek Tonight at http://www.greek-recipe.comEat Greek Tonight S A M P L E M E N U An Arab Sampler Baba G an ou s h a,b with Pita Bread K of t a (Kebabs) in Yogurt Saucea,b Tabouli (Bulgur Salad)a,b Olive and Orange Salada, Bak lav aa,b or Stuffed Datesa (or Apricots)b Arabic Coffee or Mint Tea aSalloum, H., & Peters, J. 2001. From the land of figs and olives. New York: Inter-link Books. bMiddle Eastern Recipes at http://middleeastkitchen.com/ Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 4 3 8 P E O P L E O F T H E B A L K A N S A N D T H E M I D D L E E A S T to end it.33 Three fingers of the right hand are used if forks or spoons are not offered. The left hand should not be used in any food-related manner (including passing food), and women should not touch any food that is to be eaten by a Muslim man who is not her immediate family member. Rice should be taken from the communal bowl and rolled into a small ball with the fingers before dipping it into stews or sauces. Licking the fingers after eating is expected, and appreciation is shown in some areas by making eating noises.32 It is rude to fill one’s own cup, and it is expected that a diner will refresh his or her neighbor’s cup as soon as it is half empty. It is also considered polite to continue eating until everyone else is finished because if one person stops the others feel compelled to stop, too. One should leave a little food on one’s plate to indicate satisfac- tion with the abundance of the meal. Most conversation takes place before and after the meal, and limited discussion of pleasant and joyful things takes place while dining. It is important to compliment the host and host- ess on their hospitality. Special Occasions In Balkan and Middle Eastern countries, food plays an important role in the celebration of religious occasions and in the observance of certain events such as weddings and births. In the Eastern Orthodox Church, there are numerous feast and fast days (see Chapter 4). The most important religious holiday for the Greeks is Easter. Immediately after midnight Mass on Holy Saturday, the family shares the first post-Lenten meal. It traditionally begins with red-dyed Easter eggs and continues with mayeritsa, a soup made of the lamb’s internal organs, sometimes flavored with avgolemono, a tart egg, and lemon. The Easter Sunday meal usually consists of roast lamb, rice pilaf, accompanying vegetables, cheese, yogurt, and a special Easter bread called lambrop- somo that is decorated with whole dyed eggs. Dessert usually includes sweet pastries made with filo dough and koulourakia, a traditional Greek sweet bread cookie, sometimes shaped into a hairpin twist or wreath or coiled in the shape of a snake (a creature that the pagan Greeks worshiped for its healing powers). “Spoon sweets” (seasonal fruits, vegetables, nuts, or rose petals preserved in a heavy, sweet syrup) are a Greek specialty specifically reserved for guests, offered by the spoonful on arrival as a sweet welcome. the honored seat at the table is in the middle of the table, whereas in Egypt, it is at the head of the table.31 In some areas, such as some parts of Yemen, it is customary for women to eat separately from men.31 Guests are tradi- tionally entertained in a separate room before the meal, at which time scented water is pro- vided so they may wash their hands. The din- ing table might be a large, round metal tray, resting on a low stool or platform, and the diners sit around it on cushions. Western- style dining is found occasionally, especially in Middle Eastern restaurants. In Iran, food is traditionally served on a rug. The meal is set out in several bowls placed on the table or rug and then shared by the diners. After the meal, the guests leave the table, wash their hands, and then have coffee or tea. Several rules of etiquette apply to eating in the Middle East. One should always wash one’s hands before eating. In Muslim regions the guests thank Allah before and after the meal. Other Middle Easterners may say “Sahain!” (“good appetite!”) to start the meal, “Sahain!” (“good appetite!”) to start the meal, “Sahain!” and “Daimah” (“may there always be plenty”) “Daimah” (“may there always be plenty”) “Daimah” S A M P L E M E N U A Persian Lunch Olives and Pistachios K h or e s h - e F e s e n jan (Chicken Stew with Walnuts and Pomegranate over Rice)a,b Cucumber, Tomato, and Onion Salada,b Feta Cheese and Lav as h Fresh fruit or Sholeh Zard (Saffron Pudding)a,b Tea aBatmanglij, N.K. 2000. New food of life: Ancient Persian and modern Iranian cooking and ceremonies. Washington, DC: Mage Publishers. bIranian/Persian Recipes at http://www.iranchamber.com/recipes/recipes.php Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 1 3 4 3 9 Easter is preceded by the pre-Lenten holiday of Apokreas, which is similar to Carnival or Mardi Gras and features costumed events and parties with ample merrymaking, food, and music. In addition to religious holidays, Greek Americans typically celebrate Greek Indepen- dence Day on March 25. It is commemorated with parades in traditional dress, folk dancing, songs, and poetry readings. The Easter meal in Croatia is typically lamb or ham and pogaca, an Easter bread with painted eggs on top that is similar to the Greek lambropsomo. Christmas Eve fea- tures a meal of cod, and a stuffed cabbage and sauerkraut dish is customary on Christmas. Among Serbians, the most auspicious day of the year is Krsna Slava, Patron Saint’s Day. This holiday dates back to the worship of protective spirits in pagan times; today each family honors its self-chosen patron saint with a sumptuous feast and dancing that may last for two to three days. The family customar- ily announces the annual open house with a small advertisement in the local newspaper. Krsni kolac is a ritual bread prepared for the occasion, decorated with the religious Serbian emblem “Samo sloga Srbina spašava” (“Only “Samo sloga Srbina spašava” (“Only “Samo sloga Srbina spašava” unity will save the Serbs”) as well as grapes, wheat, birds, flowers, barrels of wine, or other representations made in dough. Slovenians celebrate St. Nick’s Feast. Gifts are distributed to children by St. Nick, dressed as a bishop, who admonishes the youngsters to be good. The grape harvest and winemaking are tradi- tionally commemorated with numerous festi- vals and St. Martin’s Feast. There are also feasts and fasts connected with Islamic religious observances. Tradi- tional festive foods vary from country to country and may also vary seasonally since the Muslim calendar is lunar, and holidays fall at different times each year. Iftar is the Iftar is the Iftar meal that breaks the fast during Ramadan, the month in which Muslims fast from sunrise to sunset; it is common to dine with relatives and neighbors. The meal usually starts with a beverage, preferably water, followed by an odd number of dates and coffee or tea. A large meal, served after prayers, includes moist and hearty dishes. Regular items eaten during Ramadan include soups, fruit juices, cheeses, and fresh or dried fruit. Traditional sweets include kataif, which refers to a pancake or a shredded wheat dough dessert and, in Tur- key and Iran, rose-flavored rice puddings. In some Muslim homes, the post-fast meal is considered a feast with elaborate dishes that emphasizes the Muslim virtues of hospitality and community, while in other homes a more moderate meal is thought to be in keeping with the purposes of the fast.33 The dawn meal is usually light, and salty foods are avoided because water is not allowed during the fast. The holiday Eid al-Fitr follows the end of Eid al-Fitr follows the end of Eid al-Fitr Ramadan and is described as a cross between the feasting of Thanksgiving and the festivity of Christmas. Typically family, friends, and neigh- bors gather to celebrate; in areas with large Mus- lim populations, Eid al-Fitr may be held at the local fairgrounds with games, rides, and many food vendors. The other major holiday observed by Arab Muslims is Eid al-Adha, the Feast of Sacrifice held in conjunction with the annual pilgrimage (Hadj) to Mecca (see Chapter 4). In Turkey, Eid al-Fitr is known as Seker Bayram, meaning “sugar festival.” It is tradi- tional to exchange small gifts with friends, and for four days children are given sweet treats, such as lokums or chocolates. On the tenth day of the first lunar month of the Islamic calendar, Turks celebrate the martyr- dom of Mohammed’s grandson and the day Noah was able to leave the ark. They pre- pare asure, or Noah’s pudding, made from the ingredients remaining after the receding of the flood waters: fresh and dried fruits, nuts, and legumes. Kurban Bayram is a day of remembrance for when the prophet Abraham nearly sacrificed his son Ishmael. Families customarily sacrifice a sheep or a goat and distribute it to family, friends, and community charities. Another special occasion in Turkey is National Sovereignty and Children’s Day on April 23. It commemorates the establishment of the Grand National Assembly in 1923 and specifically honors all children. The following day has become Turkish American Day in the United States, featuring parades in traditional dress and other festivities. In Iran the most significant holiday of the year is Muharram, which commemorates the martyrdom of the grandson of Mohammed Yemen qat (the herb with amphetamine-like properties called khat in Ethiopia—see Chapter 8) is frequently chewed in social and business settings. In Greek Orthodox tradition, the egg represents life, and red is the color of the blood Christ shed. The breaking of the red-dyed egg symbolizes the resurrection. For New Year’s Day the Greeks prepare a sweet spicy bread called vasilopitta with a coin baked into it—the person who gets the piece with the money has good luck in the upcoming year (the Serbs have the same tradition for Christmas Day). Kahk is a sweet Egyptian bread made with ample butter and nuts that is served at all special occasions. Some non-Christian Arab Americans celebrate the birth of Jesus on Christmas; Jesus is considered a prophet in Islam. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 4 4 0 P E O P L E O F T H E B A L K A N S A N D T H E M I D D L E E A S T in the seventh century. It is a time of com- munal mourning and penitence for Shiites, and often features sholeh zard, a sweet rice pudding flavored with saffron. Another cel- ebration marking the spring equinox is Nau Roz, which features a meal, called haft-sinn, including a ceremonial table setting where the Qur’an, a mirror to reflect life, sweets, bread, cheese, and seven items starting with the letter s representing rebirth, good fortune, love, happiness, health, and other wishes for the new year are displayed. Foods and other goods starting with s may include serke (vine- gar), seeb (apple), sanjed (dried fruit or olives), sanjed (dried fruit or olives), sanjed sumagh (sumac), samanu (a sweet sprouted wheat kernel pudding), seer (garlic), sonbul seer (garlic), sonbul seer (hyacinth), sabzi (sprouted seeds), or sekeh (coins). Readings from the Qur’an are fol- lowed with a traditional meal of herbed rice (sabzu polo) and an herbed omelet (kukuye sabzi) served with fish. The number seven probably relates to the seven days of the week or the seven planets of the ancient solar sys- tem. On the thirteenth day of Nau Roz, it is customary to have a picnic. The traditional holidays of the Jewish cal- endar are observed in Israel (see Chapter 4 for Jewish food practices). The Shabbat, or Sabbath, occurs from sunset Friday to sun- set on Saturday evening. The Friday meal is served on a table set with white linen and includes the symbolic Kiddush cup of wine that is shared by all diners. In Ashkenazi homes a representative menu would include gefilte fish, a leavened, braided loaf of egg-rich challah bread, a roast chicken, a noodle pud- ding called kugel, and fruit or cake and tea for dessert. In Sephardic households a more Middle Eastern meal would be typical, such as pilaf, roast lamb, cooked eggplant or stuffed dolma, pita bread, and honey-soaked filo pas- tries with coffee for dessert. Jews from other regions have favorite Sabbath menus as well. For example, an Ethiopian family might serve chicken doro wat and caraway-flavored dabo bread. Because all work, including cooking, is prohibited on the Sabbath, the more obser- vant prepare food during the day on Friday or left cooking overnight, which can be con- sumed on Saturday. Stews that can simmer overnight on the stovetop are popular dishes for the midday meal following morning ser- vices, such as cholent, also known as hamim in Israel. Every family has its own version, though most include beans and potatoes. The Lebanese and Syrians use white beans, the Brazilians use black beans, and the Moroc- cans add rice. Most Ashkenazi recipes use beef brisket, and some Sephardic versions include sausages. In most homes whole eggs cooked in their shells are buried in the stew. Other religious holidays offer a similar vari- ety of food traditions based on nationality of origin. Israelis also observe the secular Yom Ha-Atzma’ut, Independence Day, on the fifth day of Iyar (a spring month in the Jewish lunar calendar). Celebrants view parades, hold bar- becues, and watch fireworks. Street vendors sell falafel, ears of corn, and numerous sweets, including candied fruits and nuts, sesame seed candy, and European cakes and tortes with whipped cream. Therapeutic Uses of Food Fresh foods are considered best, and canned or frozen foods are often avoided by Middle Easterners to preserve health. The amount of food eaten is of special concern in the diet. Ample meals are needed to prevent illness, and poor appetite is regarded as a disease in itself or as a generalized complaint signify- ing that one’s life is not as it should be. Food deprivation is believed to cause illness.22,34,35 Some Middle Easterners also believe that illness can be triggered by hot cold shifts in food, especially in people with weak or sus- ceptible constitutions. In Iran, eating too many hot foods may result in headaches, sweating, itching, and rashes. Excessive amounts of cold foods can cause dizziness, nausea, and vomiting.22,23 Foods and drinks of the opposite category can ameliorate these conditions. For example, citrus fruits or a sour lemonade called ablimu is used for headaches and acne. Nausea is treated with tea or a sweet similar to rock candy. Classi- fications can vary, but examples of hot foods include lamb, eggs, onions, garlic, carrots, bell peppers, apples, dates, quinces, chick- peas, wheat, almonds, walnuts, pistachios, honey, and tea. Cold foods can include beef, cucumbers, tomatoes, eggplant, grape leaves, In Greece and the Middle East, sugared almonds (Jordan almonds) are served at weddings to ensure sweetness in married life. The name of the Jewish Sabbath stew cholent may come from the French for “warm,” chaud, and “slow,” lent,30 or from cholent (or sholen) from the Hebrew she’lan, which means “that rested [overnight].”84 Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 1 3 4 4 1 grapes, lemons, sour cherries, apricots, mul- berries, pomegranates, rice, yogurt, coffee, and beer. The temperature (not spiciness) can cause a shift in the body from hot to cold and vice versa, and it is believed the digestive sys- tem must have time to adjust to one extreme before a food of the opposite temperature can be introduced. In addition, though ill- ness may be related to hot-cold imbalances, Iranians do not consider certain conditions as being hot or cold. Thus, a symptom such as coughing requires specific treatment unre- lated to classification: consuming cold turnips is considered beneficial, whereas cold pickles are deemed harmful.22 Some Middle Easterners also believe cer- tain combinations of incompatible foods are damaging to health. For example, Egyptians do not consume fish at the same time as dairy products. Other Middle Easterners avoid eat- ing sour foods with milk and legumes with cheese. Iranians believe consumption of melon with yogurt causes wind in the stom- ach and gastrointestinal disorders. Many special foods are associated with childbirth. Eggs cooked in garlic and chicken soup are frequently consumed by Lebanese women after childbirth. When a woman gives birth to a girl in Iran, coldness is neutralized with a diet high in hot foods to ensure a male child in the next pregnancy. Saffron custard garnished with nuts is thought to help Iranian women regain strength postpartum, while Palestinian women consume oats, coriander, or fennel. The division between food and medicine is somewhat blurred in the Middle East, especially in Arabic nations.25 Turnips are considered good for the kidneys and urinary tract, whereas cauliflower is beneficial for the respiratory system. Red onion bulbs and their leaves (which are added to salads) are con- sumed to help with diabetes and cancer. They are also eaten to ease liver disease, which is treated with asparagus and artichokes, too.24 Many foods have a multiplicity of therapeutic uses. Some Palestinians, for example, consider garlic to be good for colic, nausea, kidney infections, intestinal worms, ulcers, genito- urinary infections, prostate conditions, and tumors, and as an aphrodisiac.25 Contemporary Food Habits in the United States Adaptations of Food Habits There is scant information on the adaptation of Balkan or Middle Eastern diets in the United States. It is assumed that, as in other immi- grant groups, increasing length of stay is cor- related with Americanization of the diet, with traditional dishes prepared and eaten only for the main meal or for special occasions. It is less likely that religious dietary practices, such as adherence to halal or kosher law, change significantly after arrival in the United States. Ingredients and Common Foods Greek Americans still use olive oil extensively, although they use less of it than their immigrant relatives.41 Salads still accompany the meal, and fruit is often served for dessert. Vegetables are prepared in the traditional manner. Lamb is still very popular; for special occasions, roasted leg of lamb is substituted for the whole animal. Consumption of beef and pork has increased, whereas consumption of legumes has decreased. Cereal and grain consump- tion among Greek Americans remains high, and bread, rice, or cereal products are usu- ally included in every meal. Greek Americans consume more milk than their immigrant par- ents, and ice cream is very popular. ▼ Middle Eastern market. A le xe y St io p/ Sh ut te rs to ck .c om Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 4 4 2 P E O P L E O F T H E B A L K A N S A N D T H E M I D D L E E A S T One small study of first-generation Egyp- tians found that traditional wheat bread remained commonly consumed, though intake of legumes, especially fava beans, was somewhat lower than when the immigrants had lived in Egypt. Snacking and eating out had become much more prevalent, and soft drinks were more popular.36 Meal Composition and Cycle Greek Americans maintain traditional meal patterns, but the main meal of the day is now dinner.37 They prefer an American-type breakfast and lunch, but dinner is more tra- ditional. However, they have adapted Greek recipes to make them less time-consuming to prepare and to include fewer fats and spices. It is assumed that the meal pattern for most Americans of Croatian, Serbian, and Slove- nian heritage is much acculturated. After immigration to Canada and the United States, Arab Americans may have a substantial midday meal, but the main meal of the day has become dinner.38 Members of the extended family may dine together daily, with the women who stay at home cooking for employed female relatives.37 Nutritional Status Nutritional Intake Very little has been reported on the nutritional composition of the Balkan American or Middle Eastern American diet. However, research on the diets of nations bordering the Mediterra- nean (particularly Greece) often report that the traditional diet there, one that is low in satu- rated fats and high in monounsaturated fats and omega-3 fatty acids (due to a low intake of meats combined with high consumption of olive oil, fruits, and vegetables), lowers the risk of cardiovascular disease and cancer.38,39,40 Studies on the impact of the Mediterranean diet on the development of metabolic syndrome conditions (including obesity, hypertension, and type 2 diabetes) have been contradictory, but supports improvement in risk factors asso- ciated with heart disease.41,42,43,44,45 What is known is that the number of people consum- ing this traditional diet is declining with the Westernization of the region. Since the 1960s, the Greeks have been consuming significantly less olive oil and more alcohol.46 Rates of overweight and obesity in Greece are nearly 50 percent for women and almost 75 percent for men.47 A recent study in Lebanon found younger adults were eating fewer fruits, veg- etables, and legumes, while consuming more meat and sugar and drinking more soft drinks and alcoholic beverages, than older adults.48 Similar results were found among male college students in Saudi Arabia.49 Sparse data on Bosnian immigrants has shown that 8 percent of first-time patients seeking care at a refugee medical clinic were diagnosed with hypertension, and another 4 percent presented with type 2 diabetes. Thirty- six percent of those in a smaller surveyed subset desired care for chronic disease manage- ment. Providers report a need for diet and exer- cise counseling due to diets high in sugar, fat, and meat, and low in salads, fruits, and grains. Some refugees have stated they have little time for exercise beyond work-related physical activity. Dental problems were significant, and alcohol abuse may be seen in some refugees.6,18 Research suggests that Arab men living in the Arabian Peninsula region may be as susceptible to the clustering of risk factors in metabolic syndrome as are some other ethnic groups, such as Asian Indians (see Chapter 14 for more information). High prevalence of undiagnosed type 2 diabetes and hyperten- sion, and high rates of insulin resistance, low levels of high-density lipoprotein (HDL) cho- lesterol, and a tendency toward abdominal obesity were found. Coronary heart disease, diabetes, hypertension, and cancer are the primary health concerns in Arab countries.50 Studies of men and women in Turkey, where cardiovascular disease is the most common cause of death, have also reported strikingly low serum levels of HDL cholesterol unrelated to diet, obesity, or lifestyle.51,52,53 Worldwide, one of the greatest relative increases in type 2 diabetes is expected to occur in the eastern Mediterranean region.54 Limited research on Arabs living in the United States has reported similar health trends. One study of Arab American adults found that 29 percent of men and 37 percent of women were obese (body mass index [BMI] ≥30), with central obesity (as measured by waist-to-hip ratio) found in over 50 percent of both men and women. High blood pressures The demand for properly slaughtered (halal) meat among Muslims in the United States has led to increased numbers of Arab halal markets. Greek weddings in the United States offer a blend of Greek and American foods; for example, the wedding cake is served along with baklava. Life expectancy for adult Albanians is very high despite very low socioeconomic status, and some researchers hypothesize that this is due to a diet high in mono-unsaturated fats from olive oil and low intake of animal products due to privation.85 Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 1 3 4 4 3 were noted in about 20 percent of the adults.55 A more recent study reported higher rates of hypertension (37 percent), and 40 percent of Arab Americans had pre-hypertension.56 Rates of type 2 diabetes in Arab/Chaldean Americans in Michigan aged twenty to sev- enty-five years were found to be very high: over 15 percent for women and 20 percent for men, with rates of impaired fasting glucose and glucose intolerance above 32 percent in women, and almost 50 percent in men.57,58 When analyzed further, the data suggest that lack of acculturation was associated with diabetes risk, as was consumption of Arabic foods, being an older age at time of immigra- tion, unemployment, and reduced activity in Arab organizations.59 The age-adjusted prevalence of metabolic syndrome was found to be between 23 and 28 percent of Arab American adults in one study, and the most common component was low levels of HDL cholesterol.60 Low HDL cholesterol levels in Arab American women were accompanied by high triglyceride levels in another study.61 Data on cancer incidence in Arab/Chal- dean adults indicate that, when compared to the non-Arab white population, the men have disproportionately high rates of leukemia, mul- tiple myeloma, and liver, kidney, and urinary bladder cancers, while women have greater proportions of leukemia and thyroid and brain cancers.62 However, the leading causes of can- cer-related deaths in Arab Americans are lung, colorectal, and breast cancers.63,64 The effects of Ramadan fasting have been explored among Muslims. Although hunger increases in some fasters, there were no sig- nificant changes in body weight noted in one study.65 Increases in uric acid blood levels have been noted when weight loss occurs in non- obese men, however, which may be related to high rates of kidney stones and angina pecto- ris reported in some epidemiological surveys conducted during the month long fast.66,67 A majority of pregnant women go through Ramadan, and one study suggested that with certain precautions, such as excluding women with medical risk factors (including diabetes and history of preterm deliveries or renal stones), increased prenatal visits, avoiding strenuous exercise, staying cool, and con- sumption of extra fluids before dawn, fasting was safe for many of the women. It was also noted that immigrant Muslim women fasted on average more days than did women born in the United States.24 Individuals with type 2 diabetes who fasted during Ramadan were able to maintain normal blood sugar levels, but fasting is not recommend for those with type 1 diabetes.68 Cross-cultural research on breast-feeding reported that 82 percent of Iranian American mothers in the study exclusively breast-fed their infants. This high rate was attributed to a strong social network of support for the practice. In Turkey, mothers sometimes nurse their sons longer than daughters because breast milk is believed to increase strength.69,70 Though rates of celiac disease in the Middle East are estimated to be below those in north- ern Europeans (see Chapter 6), it is consid- ered the primary cause of chronic diarrhea in Iran and may contribute to iron deficiency, malnutrition, rickets, and short stature in children.71,72,73,74 Thalassemia syndromes may also be prevalent in Middle Easterners.75 Counseling Considerable discomfort has been noted between health care practitioners and their Middle Eastern American clients, much of it due to cultural differences. Most difficulties evolve from misunderstandings in the provider patient relationship.76 There are considerable similarities in culture between people of the Balkans and the Middle East, even among those immigrants who share Arabic as a language there can be notable differences in dialect, eth- nic background, and socioeconomic status.77 Religious affiliation and degree of orthodoxy are equally important. Language and commu- nication problems can cause significant health care access issues.78 Many refugees, especially elders who are homebound, have poor English skills, and lack of interpreter services is one barrier to health care services.7 Interactions are highly contextual through- out the Balkans and the Middle East, meaning that body language and general atmosphere are as important to communication as words, if not more so (see Chapter 3). People in the Middle East spend time getting to know one another before any business is discussed. Offering coffee or tea at the beginning of any Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 4 4 4 P E O P L E O F T H E B A L K A N S A N D T H E M I D D L E E A S T interaction helps to establish a warm and hospitable atmosphere with many Balkan or Middle Eastern clients.33,80 Direct eye contact is expected and neces- sary to interpret meaning, so Middle East- erners usually sit or stand quite close when conversing with intimates but may retain a larger distance with strangers.79 Greeks may smile when angry. Nodding one’s head up and down or back and forth can be very confusing. Traditionally, moving the chin up and down meant “no” and back and forth meant “yes” or “I don’t understand.” But many Greeks and Middle Easterners use the American protocol, so it is difficult to know whether the gesture is affirmative or negative. Touching between members of the same sex is frequent, including handshaking, pat- ting, shoulder slapping, hugging, and kissing. Contact between members of the opposite sex is prohibited in some Middle Eastern Mus- lim cultures and avoided in most. Extended eye contact between men and women can be considered a sexual overture (staring between members of the same sex is acceptable). The left hand is not used for any social purposes, nor to pass documents or administer medica- tions.33,80 In general, it is best to wait for Mid- dle Easterners to extend their hand in greeting before making any unwanted contact. Proper posture is a sign of respect, and crossing one’s legs, pointing with the foot, or showing the sole of the shoe is considered impolite. In Tur- key, one should stand when an elder enters a room. Good manners are important; if not an emergency situation, inquire first about over- all well-being of the patient and exchange pleasantries, such as a few minutes for gen- eral questions about the well-being of other family members or personal interests of the client.19,80,82 It is important to speak kindly, softly, and respectfully.22,81,82 Privacy is val- ued and clients may resist disclosure of per- sonal information to strangers, especially when it relates to familial disease conditions. Individual clients may be inexperienced with making independent decisions, thus options should be kept to a minimum to avoid over- whelming the client with too many choices.81 Family members, especially an elder male relative, may insist on participating in all conversations, even those that customar- ily take place in the office between only the practitioner and the patient. Because these family members may make the final deci- sions regarding care, their presence should be valued and their opinions fully solicited. However, if the client is a woman, she may ask to have her husband or father sign medi- cal forms, presenting liability issues regarding consent.81 There may be suspicion regarding questions about religious affiliation or socio- economic data. Fear of racial profiling may occur.79 Balkan and Middle Eastern Americans value biomedicine and have considerable respect for authority figures.80,81 When pro- viding information to the clients, verbal deliv- ery may be more receptively received than written information. They may be hesitant to ask questions when confused, however, or they may provide answers that are designed to please the provider. The health provider may have to assess and give advice about a medical or dietary problem without the client explain- ing his or her needs. If the provider does not repeat the offer to help, the client may believe that the provider is indifferent. Further, shame about certain conditions may cause noncom- pliance when a client is in public situations. Diabetes, for example, may be associated with male impotence and female infertility. Strate- gies for adhering to diet modifications without disclosure of the cause can increase efficacy.83 Culturally, Arab immigrants tend to view good health as a state of balance and poor health as a state of imbalance.82 Complaints by clients of Balkan or Middle Eastern heri- tage are frequently generalized or nonspecific, sometimes indicating anxiety or depression in a patient who does not distinguish culturally between physical and mental health. This may be particularly true with Bosnian refugees, who sometimes present with ill-defined symp- toms and may suffer from anxiety, depression, and post-traumatic stress disorder.6,81 Middle Eastern Americans may expect the health care provider to make decisions for them and be responsible for the consequences. They may also demand the services of the top expert or the department head because the expectation is that they will receive the best care from the most senior, most powerful Some researchers note that Muslim women who, for religious reasons, completely cover their bodies and heads with clothing when outdoors may be at risk for vitamin D deficiency.86 Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 1 3 4 4 5 person in the system. Female health care providers may face added difficulties in gaining the trust and respect of Balkan and Middle Eastern clients due to cultural norms regarding gender. Clients may believe that the more intrusive the medical procedure, the more effective the treatment.80 Among Irani- ans, the disclosure of bad news too quickly can cause a patient to become narahati.22 It is considered sacrilegious to presume death because only God can make that final deci- sion, and hope must always be maintained. Muslim clients usually feel most comfort- able with providers of the same gender.81,82 Less acculturated Greek Americans preferred seeing counselors (for psychological services) of the same ethnic background.83 Consistent care from a single provider is most success- ful and may eliminate many communication difficulties. Practitioners report that many Bosnian clients did not understand the importance of taking prescribed medications, and some did not follow instructions on how they should be taken or discontinued their use when side effects occurred.18 Though few studies have been conducted to assess the continuing use of traditional health practices in the United States, it is believed that Bosnians frequently take herbal cures and alcohol-based tinctures simultaneously with biomedical therapies.81 There are few data about the therapeutic ingredients in Balkan and Middle Eastern home remedies. Ko’hl, for example, used on the umbilical cords of newborns, is high in lead content and may present a danger, and the active ingredient in foxglove (used by some Iranians) is digitalis. Support for use of traditional remedies encourages clients to report their use, allowing the provider to pre- vent possible adverse interactions. The need to pray during a medical care visit is a problem for some Muslims. Provid- ers who have Muslim clients should consider setting up private areas with prayer rugs as a sign of respect. No talking can occur during prayers, and it is disrespectful to walk in front of someone who is praying.82 Practitioners who work with Balkan and Middle Eastern clients should recognize that a high-context relationship is often intensive and time-consuming.18 The in-depth inter- view should be used to determine country of origin, degree of acculturation, and religious faith. Information on traditional health care beliefs still being practiced should be elicited. Traditional healers in Saudi Arabia sometimes recommend drinking sheep bile to treat diabetes, a practice that can result in acute toxicity. Many pregnant Muslim American women in one study reported that they did not discuss Ramadan fasting with their prenatal care provider for fear of being treated disrespectfully or being told to stop outright.24 D I S C U S S I O N S T A R T E R S Diet and Culture of Balkan and Middle Eastern Americans In small groups of three to four, compare and contrast the diet and culture of Balkan Americans and Middle Eastern Americans, with each group focusing on a different aspect of the diet and culture of these groups: Given the scarcity of data in some cases, you may have to draw hypotheses about the diet, food habits, and so on of these groups from what we know about diet, food habits, and the like of nonimmigrants. Within your group, try to come to a consensus on what findings to report to the rest of the class. Before breaking up, assign a number to each group member: A1, A2, A3, A4; B1, B2, and so forth. Form new groups with all the 1’s in a group, all the 2’s in another group, all the 3’s another group, and so on. In your new group, report the findings of your previous group, and as a group, discuss the relationship of traditional attitudes toward diet and health and changes in diet and health due to immigration to the United States. Group A: The food habits and the typical eating etiquette and meal composition of these two immigrant groups Group B: Issues involved in counseling these immigrant groups on diet and health Group C: Attitudes within each immigrant group toward diet, health, and medical treatment, notably attitudes toward traditional home culture medical treatment and U.S. biomedicine Group D: Amount of obesity, diabetes, hypertension, and other diseases within each immigrant group Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 4 4 6 P E O P L E O F T H E B A L K A N S A N D T H E M I D D L E E A S T Review Questions 1. What food flavors and food ingredients are associated with the Balkan and Middle East- ern countries? Why might they be similar? Describe two recipes, one from the Balkans and one from the Middle East, that contain filo (phyllo) dough. 2. What is meant by the “evil eye”? How might you protect yourself from it? 3. What countries make up the Balkans and the Middle East? Pick either the Balkans or Mid- dle East and map the religions found in that region. Pick one religion, describe a recipe eaten for a holiday of that religion, and explain how the recipe reflects the ingredients of the region. 4. What are common health problems associated with peoples from the Balkans or the Middle East? Select one group and a health disor- der, and describe that group’s cultural beliefs regarding the cause and appropriate treatment of that disorder. 5. In several countries from these two regions, food and illness may be classified as “hot” or “cold.” What does this mean? Provide examples. References 1. Ifkovic, E. 2000. Croatian Americans. In R.V. Dassanowsky & J. Lehman (Eds.), Gale Encyclo- pedia of Multicultural America. Farmington Hills, MI: Gale Group. 2. Stevanovic, B. 2000. Serbian Americans. In R.V. Dassanowsky & J. Lehman (Eds.), Gale encyclopedia of multicultural America. Farmington Hills, MI: Gale Group. 3. Gobetz, E. 2000. Slovenian Americans. In R.V. Dassanowsky & J. Lehman (Eds.), Gale encyclo- pedia of multicultural America. Farmington Hills, MI: Gale Group. 4. Erwin, P., Leung, Y.Y., & Boban, D.I. 2001. Bosnian refugees in San Francisco: A community assessment. San Francisco: San Francisco Depart- ment of Public Health/International Institute of San Francisco. 5. Samhan, H. H. 2005. By the numbers. Arab American business magazine. Retrieved from http://www.allied--media.com/ArabAmerican/ Arab_demographics.htm 6. Arab American Institute. Retrieved from http:// www.aaiusa.org/pages/demographics/ (accessed April 20, 2015). 7. Abraham, N. 2000. Arab Americans. In R.V. Dassanowsky & J. Lehman (Eds.), Gale encyclo- pedia of multicultural America. Farmington Hills, MI: Gale Group. 8. Brittingham, A., & de la Cruz, G.P. 2005. We the people of Arab ancestry in the United States. Washington, DC: U.S.Census Bureau. 9. Gillis, M. 2000. Iranian Americans. In R.V. Das- sanowsky & J. Lehman (Eds.), Gale encyclopedia of multicultural America. Farmington Hills, MI: Gale Group. 10. Altschiller, D. 2000. Turkish Americans. In R.V. Dassanowsky & J. Lehman (Eds.), Gale encyclo- pedia of multicultural America. Farmington Hills, MI: Gale Group. 11. Gold, S.J. 2001. Gender, class, and network: Social structure and migration patterns among transna- tional Israelis. Global Networks, 1, 57–78. 12. Rudolph, L.C. 2000. Israeli Americans. In R.V. Dassanowsky & J. Lehman (Eds.), Gale encyclo- pedia of multicultural America. Farmington Hills, MI: Gale Group. 13. Mikhail, M. 2000. Egyptian Americans. In R.V. Dassanowsky & J. Lehman (Eds.), Gale encyclo- pedia of multicultural America. Farmington Hills, MI: Gale Group. 14. Luna, L. 1994. Care and cultural context of Lebanese Muslim immigrants: Using Leininger’s theory. Journal of Transcultural Nursing, Journal of Transcultural Nursing, Journal of Transcultural Nursing 5, 12–20. 15. Hajar, P., & Jones, J.S. 2000. Lebanese Americans. In R.V. Dassanowsky & J. Lehman (Eds.), Gale encyclopedia of multicultural America. Farming- ton Hills, MI: Gale Group. 16. Lipson, J.G., Weinstein, H.M., Gladstone, E.A., & Sarnoff, R.H. 2003. Bosnian and Soviet refugees’ experiences with health care. Western Journal of Nursing Research, 25, 854–871. 17. Papadopoulos, I. 2000. An exploration of health beliefs, lifestyle behaviors, and health needs of the London-based Greek-Cypriot community. Jour- nal of Transcultural Nursing, nal of Transcultural Nursing, nal of Transcultural Nursing 11, 182–190. 18. Rosenbaum, J.N. 1991. The health meanings and practices of older Greek-Canadian widows. Journal of Advanced Nursing, Journal of Advanced Nursing, Journal of Advanced Nursing 16, 1320–1327. 19. Jurgens, J. 2000. Greek Americans. In R.V. Dassanowsky & J. Lehman (Eds.), Gale encyclope- dia of multicultural America. Farmington Hills, MI: Gale Group. 20. Pliskin, K.L. 1992. Dysphoria and somatization in Iranian culture. Western Journal of Medicine, 157, 157, 157 295–300. 21. Hafizi, H., & Lipson, J.G. 2003. People of Iranian heritage. In L.D. Purnell & B.J. Paulanka (Eds.), Transcultural health care (2nd ed.). Philadelphia: F.A. Davis. 22. Saad, B., Azaizeh, H., & Said, O. 2005. Tradition and perspectives of Arab herbal medicine: A review. eCAM, 2, 475–479. 23. Abu-Rabia, A. 2005. Herbs as food and medicine source in Palestine. Asian Pacific Journal of Can- cer Prevention, 6, 404–407. 24. Ogur, R., Korkmaz, A., & Bakir, B. 2006. Herbal treatment usage frequency, types and preferences in Turkey. Middle East Journal of Family Medicine, 4, 38–44. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 1 3 4 4 7 25. Ghazanfar, S.A. 1995. Wasm: A traditional method of healing by cauterization. Journal of Ethnopharmacology, 47, 125–128.47, 125–128.47 26. Kulwicki, A.D. 2003. People of Arab heritage. In L.D. Purnell & B.J. Paulanka (Eds.), Transcultural health care (2nd ed.). Philadelphia: F.A. Davis. 27. Nickles, H.G. 1969. Middle Eastern cooking. New York: Time-Life Books. 28. Nathan, J. 2001. The foods of Israel today. New York: Knopf. 29. Zibart, E. 2001. The ethnic food lover’s companion: Understanding the cuisines of the world. Birming- ham, AL: Menasha Ridge Press. 30. Batmanglij, N.K. 2000. New food of life: Ancient Persian and modern Iranian cooking and ceremo- nies. Washington, DC: Mage. 31. Foster, D. 2002. The global etiquette guide to Africa and the Middle East. New York: Wiley. 32. Dresser, N. 2005. Multicultural manners: Essential rules of etiquette for the 21st century. New York: Wiley. 33. Seidal, K. 2001. Serving the guest: A Sufi cookbook and art gallery. Retrieved from http://www.super- luminal.com/cookbook/ (accessed April 20, 2015). 34. Meleis, A.I. 1981. The Arab American in the health care system. American Journal of Nursing, American Journal of Nursing, American Journal of Nursing 81, 1180–1183. 35. Packard, D.P., & McWilliams, M. 1993, May/June. Cultural foods heritage of Middle Eastern immi- grants. Nutrition Today, 6–12. 36. Maamoun, M., Sucher, K.P., & Hollenbeck, C. 2006. Food habits and acculturation among first generation Egyptians living in the San Francisco Bay Area (SFBA). Unpublished master’s thesis, San Jose State University. 37. Valassi, K. 1962. Food habits of Greek Ameri- cans. American Journal of Clinical Nutrition, 11, 240–248. 38. Estruch, R., Martinez-Gonzalez, M.A., Corelia, D., Salas-Salvado, J., Ruiz-Gutierrez, V., Covas, M.I., . . . Ros, E. 2006. Effects of Mediterranean- style diet on cardiovascular risk factors: A ran- domized trial. Annals of Internal Medicine, 145, 1–11. 39. Knoops, K.T., de Groot, L.C., Kromhout, D., Per- rin, A.E., Moreiras-Varela, O., Menotti, A., & van Staveren, W.A. 2004. Mediterranean diet, lifestyle factors, and 10-year mortality in elderly European men and women: The HALE project. Journal of the American Medical Association, 292, 1433–1439. 40. Sofi, F., Macchi, C., Abbate, R., Gensini, G.F., & Casini, A. 2013. Mediterranean diet and health. Biofactors, 39(4), 335–342. 41. Manios, Y., Detopoulou, V., Visioli, F., & Galli, C. 2006. Mediterranean diet as a nutrition edu- cation and dietary guide: Misconceptions and the neglected role of locally consumed foods and wild green plants. Forum of Nutrition, 59, 154–170. 42. Esposito, K., Marfelia, R., Ciotola, M., Di Palo, C., Giugliano, F., Giugliano, G., . . . Giugliano, D. 2004. Effect of Mediterranean-style diet on endothelial dysfunction and markers of vascular inflamma- tion in metabolic syndrome: A randomized trial. Journal of the American Medical Association, 292, 1490–1492. 43. Mi ch a l s e n , A . , L eh m an n , N . , Pit h an , C., Knoblauch, N.T., Moebus, S., Kannenberg, F., . . . Dobos, G.J. 2006. Mediterranean diet has no effect on markers of inflammation and meta- bolic risk factors in patients with coronary artery disease. European Journal of Clinical Nutrition, 60, 478–485. 44. Esposito, K., Di Palo, C., Maiorino, M.I., Petrizzo, M., Bellastella, G., Siniscalchi, I. & Giugliano, D. 2011. Long-term effect of Mediterranean-style diet and calorie restriction on biomarkers of lon- gevity and oxidative stress in overweight men. Cardiology Research and Practice, Article ID: 293916, 5 pages. doi:10.4061/2011/293916 45. Fung, T.T., Rexrode, K.M., Mantzoros, C.S., Man- son, J.E., Willett, W.C., & Hu, F.B. 2009. Medi- terranean diet and incidence and mortality of coronary heart disease and stroke in women. Circulation, 119, 1093–1100. 46. Kromhout, D., Keys, A., Aravanis, C., Buzina, R., Fidanza, F., Giampaoli, S., . . . Toshima, H. 1989. Food consumption patterns in the 1960s in seven countries. American Journal of Clinical Nutrition, 49, 889–894. 47. International Obesity Task Force. 2006. Over- weight and obesity among adults in the European Union. Retrieved from http://www.iotf.org/ media/europrev.htm 48. Nasreddine, L., Hwalla, N., Sibal, A., Hamze, M., & Parent-Massin, D. 2006. Food consumption patterns in an adult urban population in Beirut, Lebanon. Public Health Nutrition, 9, 194–203. 49. Al-Rethaiaa, A.S., Fahmy, A.E., & Al-Shwaiyat, N.M. 2010. Obesity and eating habits among col- lege students in Saudi Arabia: A cross sectional study. Nutrition Journal, 9(39). doi:10.1186/1475- 2891-9-39. Retrieved from http://www.nutritionj. com/content/9/1/39 (accessed April, 20, 2015). 50. Musaiger, A.O. 2002. Diet and prevention of coro- nary heart disease in the Arab Middle East coun- tries. Medical Principles and Practices, 11, 9–16 51. Mahley, R.W., Pepin, J., Palaoglu, K.E., Malloy, M.J., Kane, J.P., & Bersot, T.P. 2000. Low levels of high density lipoproteins in Turks, a popula- tion with elevated hepatic lipase. High density lipoprotein characterization and gender-specific effects of apolipoprotein e genotype. Journal of Lipid Research, 8, 1290–1301. 52. Robinson, T., & Raisler, J. 2005. “Each one is a doctor for herself ”: Ramadan fasting among pregnant Muslim women in the United States. Ethnicity & Disease, 15, S1-99–S1-103. 53. Ucar, B., Kilic, Z., Colak, O., Oner, S., & Kalyoncu, C. 2000. Coronary risk factors in Turkish school- children: Randomized cross-sectional study. Pediatrics International, 42, 259–267. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 4 4 8 P E O P L E O F T H E B A L K A N S A N D T H E M I D D L E E A S T 54. Regional strategy on nutrition 2010–2019 and Plan of Action. World Health Organization. Regional Office for the Eastern Mediterranean. Retrieved from http://www.emro.who.int/images/ stories/nutrition/publications/Regional-strategy- on-nutrition-and-plan-of-action (accessed on April 20, 2015). 55. Hammad, A., Herman, W.H., & Jaber, L.A. 2005. Cardiovascular risk factors in an Arab American population in southeastern Michigan. Ethnicity & Disease, 15, S1–S29. 56. Tailakh, A., Mentes, J.C., Morisky, D.E., Pike, N.A., Phillips, L.R., Evangelista, L.S. 2013. Prev- alence, awareness, treatment, and control of hypertension among Arab Americans. Journal of Cardiovascular Nursing, of Cardiovascular Nursing, of Cardiovascular Nursing 28(4), 330–337. doi: 10.1097/JCN.0b013e31825638ae 57. Jaber, L.A., Brown, M.B., Hammad, A., Nowak, S.N., Zhu, Q., Ghafoor, A., & Herman, W.H. 2003. Epidemiology of diabetes in Arab Americans. Diabetes Care, 26, 308–313. 58. Kridli, S.A., Herman, W.H., Brown, M.B., Fakhouri, H., & Jaber, L.A. 2006. The epide- miology of diabetes and its risk factors among Chaldean Americans. Ethnicity and Disease, 16(2), 351–356. 59. Jaber, L.A., Brown, M.B., Hammad, A., Zhu, Q., & Herman, W.H. 2003. Lack of acculturation is a risk factor for diabetes in Arab immigrants in the U.S. Diabetes Care, 26, 2010–2014. 60. Jaber, L.A., Brown, M.B., Hammad, A., Zhu, Q., & Herman, W.H. 2004. The prevalence of the meta- bolic syndrome among Arab Americans. Diabetes Care, 27, 234–238. 27, 234–238. 27 61. Hatahet, W., & Fungwe, T.V. 2005. Obesity and cardiovascular disease risk factors are ethnic- ity based: A study of women of different ethnic backgrounds in southeastern Michigan. Ethnicity & Disease, 15, S1-23–S1-25. 62. Schwartz, K.L., Kulwicki, A., Weiss, L.K., Fakhouri, H., Sakr, W., Kau, G., & Severson, R.K. 2004. Can- cer among Arab Americans in the metropolitan Detroit area. Ethnicity & Disease, 14, 141–146. 63. Darwish-Yassine, M., & Wing, D. 2005. Cancer epidemiology in Arab Americans and Arabs outside the Middle East. Ethnicity & Disease, 15, S1-5–S1-8. 64. Nasseri, K., Mills, P.K., & Allan, M. 2007. Can- cer incidence in the Middle Eastern population of California, 1988–2004. Asian Pacific Journal of Cancer Prevention, 8, 405–411. 65. Finch, G.M., Day, J.E., Razak, W.D.A., Welch, D.A., & Rogers, P.J. 1998. Appetite changes under free-living conditions during Ramadan fasting. Appetite, 31, 159–170. 66. Gumaa, K.A., Mustafa, K.Y., Mahmoud, N.A., & Gader, A.M. 1978. The effect of fasting in Rama- dan: Serum uric acid and lipid concentration. British Journal of Nutrition, 40, 573–581. 67. Nomani, M.Z.A., Hallak, M.H., & Siddiqui, I.P. 1990. Effects of Ramadan fasting on plasma uric acid and body weight in healthy men. Journal of the American Dietetic Association, 90, 1435–1436. 68. Azizi, F. 2010. Islamic fasting and health. Annals of Nutrition and Metabolism, 56, 273–282. doi: 10.1159/000295848 69. Geissler, E.M. 1998. Pocket guide to cultural assess- ment. St. Louis, MO: Mosby. 70. Ghaemi-Ahmadi, S. 1992. Attitudes toward breast-feeding and infant feeding among Iranian, Afghan, and Southeast-Asian immigrant women in the United States: Implications for health and nutrition education. Journal of the American Dietetic Association, 92, 354–355. 71. Ertekin, V., Selimoglu, M.A., Kardas, F., & Aktas, E. 2005. Prevalence of celiac disease in Turkish children. Journal of Clinical Gastroenterology, 39, 689–691. 72. Rawashdeh, M.O., Khalil, B., & Rawily, E. 1996. Celiac disease in Arabs. Journal of Pediatric Gastroenterology and Nutrition, 23, 415–418. 73. Shahbazkhani, B., Mohamadnejad, M., Malekza- deh, R., Akbari, M.R., Esfahani, M.M., Nasseri- Moghaddam, S., . . . Elahyfar, A. 2004. Coeliac disease is the most common cause of chronic diarrhoea in Iran. European Journal of Gastroen- terology & Hepatology, 16, 665–668. 74. Cataldo, F., & Montalto, G. 2007. Celiac disease in the developing countries: A new and challenging public health problem. World Journal of Gastroen- terology, 13, 2153–2159 75. Vichinsky, E.P., MacKlin, E.A., Waye, J.S., Lorey, F., & Olivieri, N.F. 2005. Changes in the epidemi- ology of thalassemia in North America: A new minority disease. Pediatrics, 116, 818–825. 76. Aboul-Enein, B.H., & Aboul-Enein, F.H. 2010. The cultural gap delivering health care services to Arab American populations in the United States. Journal of Cultural Diversity, 17, 20–23.17, 20–23.17 77. Jaber, L.A. 2003. Barriers and strategies for research in Arab Americans. Diabetes Care, 26, 514–515. 78. People of Arab heritage. 2014. In L.D. Purnell, Guide to culturally competent health care (pp. 101–117). to culturally competent health care (pp. 101–117). to culturally competent health care Philadelphia: F.A. Davis 79. Yehieli, M., & Grey, M.A. 2005. Health matters: A pocket guide for working with diverse cultures and underserved populations. Boston, MA: Inter- cultural Press. 80. Pennachio, D.L. 2005. Caring for your Muslim patients. Medical Economics, 82, 46–50. 81. Khoury, S. 2001. Translating medical nutrition ther- apy approaches of diabetes into the Middle Eastern culture. Diabetes Care & Education, 22, 30–32. 82. Abdulrahim, S., & Ajrouch, K. 2010. Social and cultural meanings of self-rated health: Arab immigrants in the United States. Qualitative Health Research, 20, 1229–1240. 83. Ponterotto, J.G., Rao, V., Zweig, J., Rieger, B.P., Schaefer, K., Michelakou, S., . . . Goldstein, H. 2001. The relationship of acculturation and gender to attitudes toward counseling in Italian and Greek American college students. Cultural Diversity & Ethnic Minority Psychology, 7, 362–375.7, 362–375.7 Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 1 3 4 4 9 84. Cholent. 2015. Wikipedia. Retrieved from http:// en.wikipedia.org/wiki/Cholent#Etymolog y. (accessed April 21, 2015). 85. Gjonca, A., & Bobak, M. 1997. Albanian para- dox, another example of protective effect of Mediterranean lifestyle? Lancet, 350, 1815–1817. 86. Alfawaz, H., Tamim, H., Alharbi, S., Aljaser, S., & Tamimi, W. 2014. Vitamin D status among patients visiting a tertiary care center in Riyadh, Saudi Arabia: a retrospective review of 3475 cases. BioMedCentral; Public Health, 14, 159. Retrieved from http://www.biomedcentral. com/1471-2458/14/159 (accessed April 21, 2015). 87. Davidson, A. 1999. The Oxford companion to food. New York: Oxford University Press. 88. Botelho, F., Lunet, N., & Barros, H. 2006. Coffee and gastric cancer: Systematic review and meta-analysis. Cadernos de Saúde Pública, 22, 889–900. 89. Higdon, J.V., & Frei, B. 2006. Coffee and health: A review of recent human research. Critical Reviews in Food Science and Nutrition, 46, 101–123.46, 101–123.46 90. Johnsen, R., Forde, O.H., Straume, B., & Burhol, P.G. 1994. Aetiology of peptic ulcer: A prospec- tive population study in Norway. Journal of Epi- demiology and Community Health, 48, 156–160. 91. Kaltenbach, T., Crockett, S., & Gerson, L.B. 2006. Are lifestyle measures effective in patients with gastroesophageal reflux disease? An evidence- based approach. Archives of Internal Medicine, 166, 965–971. 92. Browne, M.L. 2006. Maternal exposure to caf-Browne, M.L. 2006. Maternal exposure to caf-Browne, M.L. 2006. Maternal exposure to caf feine and risk of congenital anomalies: A sys- temic review. Epidemiology, 17, 324–331.17, 324–331.17 93. Hino, A., Adachi, H., Enomoto, M., Furuki, K., Shigetoh, Y., Ohtsuka, M., . . . Imaizumi, T. 2007. Habitual coffee but not green tea consumption is inversely associated with metabolic syndrome: An epidemiological study in a general Japanese population. Diabetes Research and Clinical Practice, 76, 383–389 94. Anderson, L.F., Jacobs, D.R., Jr., Carlsen, M.H., & Blomhoff, R. 2006. Consumption of coffee is associated with reduced risk of death attributed to inflammatory and cardiovascular diseases in the Iowa Women’s Health Study. American Jour- nal of Clinical Nutrition, 83, 1039–1046. 95. Lopez-Garcia, E., van Dam, R.M., Willett, W.C., Rimm, E.B., Manson, J.E., Stampfer, M.J., . . . Hu, F.B. 2006. Coffee consumption and coronary heart disease in men and women: A prospective cohort study. Circulation, 113, 2045–2053. 96. Salazar-Martinez, E., Willett, W.C., Ascherio, A., Manson, J.E., Leitzmann, M.F., Stampfer, M.J., & Hu, F.B. 2004. Coffee consumption and risk for type 2 diabetes. Annals of Internal Medicine, 140, 1–8. 97. Van Dam, R.M., Willett, W.C., Manson, J.E., & Hu, F.B. 2006. Coffee, caffeine, and risk of type 2 diabetes: A prospective cohort study in younger and middle-aged U.S. women. Diabetes Care, 29, 398–403 98. Baker, J.A., Beehler, G.P., Sawant, A.C., Jay- aprakash, V., McCann, S.E., & Moysich, K.B. 2006. Consumption of coffee, but not black tea, is associated with decreased risk of premeno- pausal breast cancer. Journal of Nutrition, 136, 166–171. 99. Dasanayake, A.P. 2005. Moderate coffee intake may reduce the risk of oral, pharyngeal, and esophageal cancer. Journal of Evidence-Based Dental Practice, 5, 31–32. 100. Gelatti, U., Covolo, L., Franceschini, M., Pirali, F., Tagger, A., Ribero, M.L., . . . Donato, F. 2005. Coffee consumption reduces the risk of hepato- cellular carcinoma independently of its aetiol- ogy: A case-control study. Journal of Hepatology, 42, 526–534. 101. Karlson, E.W., Mandi, L.A., Aweh, G.N., & Grod- stein, F. 2003. Coffee consumption and risk of rheumatoid arthritis. Arthritis and Rheumatism, 48, 3055–3060. 102. Arendash, G.W., Schleif, W., Rezai-Zadeh, H., Jackson, E.K., Zacharia, L.C., Cracchiolo, J.R., Tan, J. 2006. Caffeine protects Alzheimer’s mice against cognitive impairment and reduces brain beta-amyloid production. Neuroscience, 142, 941–952. 103. Winkelmayer, W.C., Stampfer, M.J., Willett, W.C., & Curhan, G.C. 2005. Habitual caffeine intake and the risk of hypertension in women. Journal of the American Medical Association, 294, 2330–2335 104. Cibickova, E., Cibicek, N., Zd’ansky, P., & Kohout, P. 2004. The impairment of gastroduodenal muco- sal barrier by coffee. Acta Medica, 47, 273–275.47, 273–275.47 105. Jurgens, J. 2000. Albanian Americans. In R.V. Dassanowsky & J. Lehman (Eds.), Gale encyclo- pedia of multicultural America. Farmington Hills, MI: Gale Group. 106. Hysa, K., & Hysa, R.J. 1998. The best of Alba- nian cooking: Favorite family recipes. New York: Hippocrene. 107. Wulfert, P. 1973. Couscous and other good food from Morocco. New York: Harper & Row. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 4 5 0 South Asia is the geographic region com-prising the nations of India, Pakistan, Bangladesh, Sri Lanka, Nepal, and Bhutan (see Figure 14.1). Immigrants from South Asia, mostly India and Pakistan, com- prise one of the fastest-growing populations in the United States. India is a culturally complex country with a population of more than 1.28 billion—over four times that of the United States. The sophisticated civilization began approximately 4,000 years ago and is the source of some of the most influential religions, art, architec- ture, and foods in the world. The South Asian subcontinent contains the fertile Indus and Ganges river basins, as well as parts of the Himalayan mountain range; it varies in cli- mate from extensive desert regions to jungle forests to the world’s largest mountain gla- ciers. The people of India are as diverse as its geography and climate. People from virtually every racial and religious group have migrated to or invaded India at some time in history, and each group has brought its own language and customs. As the different races and reli- gions intermingled, other cultures were cre- ated. One result is that there are currently fifteen separate languages recognized by the Indian government. Nearly 300 languages are actually spoken in India, and there are approximately 700 dialects. The Islamic Republic of Pakistan, located to the northwest of India, encompasses some of the most rugged territory in the world. The Himalayas stretch across the north, includ- ing the second-highest peak in the world, K2. The Hindukush range defines the northwest- ern region. From these mountains spills the Indus River, supplying the plains of the south before emptying into the Arabian Sea. Paki- stan received its independence from India in 1947 to provide a homeland for the Muslim minority of that nation. It was a bitter split. Two wars between the countries have been fought since independence, and tensions con- tinue over the province of Kashmir. Though Pakistan is an Islamic state, it is divided into four regions, each with its own cultural groups and languages: Punjab, Sindh, Baluch- istan, and the North-West Frontier Province (NWFP). Although India and Pakistan share a past, Asian Indians and Pakistanis each bring dis- tinctive contributions when they move to the United States, particularly in their traditional foods and food habits. This chapter examines the customary diets of India and Pakistan and the changes that occur when immigrants from these countries move to America. Cultural Perspective History of Asian Indians and Pakistanis in the United States Given the complexity of South Asian cul- ture, it is not surprising that the immigrants to the United States from India and Pakistan differ from other immigrant groups in sev- eral ways. Most significantly, the majority arriving in the United States are not escap- ing political or economic pressures in their South Asians 14 CHA P T E R Fewer than 55,000 Sri Lankans, Nepalese, and Bhutanese combined have immigrated to the United States. The 2013 Census reported that 163,000 Bangladeshis are estimated to live in the nation (over half of them in New York City), most of whom have arrived since 1990.1 Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 1 4 4 5 1 homelands. Since 1965, when the national quota system was temporarily dropped from U.S. immigration laws, the majority of South Asian immigrants have been from the upper socioeconomic classes. They were somewhat acculturated at the time of arrival, often fluent in English, and acquainted with many Ameri- can customs. Immigration Patterns Asian Indians The first immigrants to the United States from India were members of the Sikh religion, who arrived on the West Coast in the early twentieth century. Many were employed by the railroads, and oth- ers established large farms. They faced overt discrimination and persecution. Newspapers warned of the “Hindoo invasion”; anti–Asian Figure 14.1 India and Pakistan. Arabian Sea AFGHANISTAN PAKISTAN INDIA CHINA NEPAL BHUBHUTAN BANGLADESH SRI LANKA Bay of Bengal © C en ga ge L ea rn in g Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 4 5 2 S O U T H A S I A N S Indian feelings brought about the expulsion of Asian Indians from Washington logging communities and in 1907 sparked violent riots in California. Although such extreme bigotry lessened in time, the Asian Indian immigrant population remained small until after World War II. Relaxed immigration laws encouraged Asian Indians, especially well-educated urban professionals, to come to the United States in starting in the 1960s. Economic and social adjustment was a priority for this group, although many Asian Indian traditions con- tinue within the privacy of the home. These immigrants formed a self-reliant community and discouraged comparison or identification with other ethnic groups. Pakistanis Though Muslims from northern India certainly came to the United States prior to the founding of Pakistan, immigration from the nation technically began in 1947. However, prior to 1965, only 2,500 Pakistanis moved to the United States. Beginning in 1965, when certain immigration quotas were lifted, thousands have been arriving from Pakistan each year. Current Demographics and Socioeconomic Status Asian Indians According to U.S. Census esti- mates for 2013, the Asian Indian population has increased 800 percent during the previous 33 years, from 400,000 to an estimated 3.19 million. Over 71 percent of Indian Ameri- cans are foreign born, and most of them have arrived since 1970.1 Asian Indians have settled throughout the United States, but especially in the metropolitan areas of California, New York, and New Jersey, as well as in Illinois, Maryland, Massachusetts, Michigan, Ohio, Pennsylvania, and Texas. There are also sev- eral Asian Indian settlements in the agricul- tural regions of California.1 Some Asian Indians coming to the United States in recent years are exiles from regions where Indian immigration in the past has been substantial, such as East Africa, Fiji, and Guyana. These immigrants often feel unwel- come in Indian American communities, and form separate enclaves.2 The relative affluence of Americans of Asian Indian heritage is due mostly to a well-educated population: nearly 56 percent held a college or graduate degree in 2000.1 Many were employed in professional or white-collar occupations in India, such as college professors, engineers, physicians, and scientists, and most continue their careers in the United States. Nearly 69 percent of Indian Americans hold management or professional jobs.1 Newer immigrants have found success in small-business and franchise ownership involving many members of their extended family. Motel and hotel ownership is especially common, and it is estimated that over 50 percent of these businesses nationwide are run by Indian Americans.1 Median family income is 150 percent above the national norm, and family poverty rates are below average.3 Many Asian Indians come to the United States to complete their college or post- graduate education. They are often unmar- ried or have left their spouses and children in India. It is not uncommon for the families to join the student in America after he or she has become financially established. Pakistanis As of 2013, Census figures sug- gest the number of Pakistani Americans is less than 450,000, more than 50 percent of whom are foreign-born immigrants, and nearly all of whom have arrived since 1980.1 A majority have come from large cities and the largest population is in the New York City metropolitan area and Chicago.1 The immigrants who first arrived after 1965 were typically well-educated profession- als seeking employment in professions such as law, medicine, computer technology, and teaching. Many students obtaining advanced degrees also chose to stay in the United States. Over 56 percent of Pakistani Americans hold a college degree.1 However, Pakistanis are often grouped with Asian Indians and Arabs in data collection, so little is known specifi- cally regarding their socioeconomic status. It is believed that most Pakistani Americans are solidly middle class or upper middle class. Home ownership is valued and may be higher than average compared to other recent immi- grant groups. Family income for all Pakistani Americans is similar to the U.S. median.5 In the early 1900s it was not unusual for single Sikh men living in the United States to marry Mexican American women and start families. In the 2011 Canadian census, 1,567,400 individuals identified themselves as South Asian. Confusion over the term Indian (does it mean a Native American or an Asian Indian?) has made it difficult to find consen- sus on a designation for Asian Indians living in the United States. South Asian or Indian American have emerged as terms used by many Asian Indians. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 1 4 4 5 3 However, 15.9 percent of Pakistani families were living in poverty as of 2013.1 Worldview The Caste System in India The traditional Indian caste system, which influences the social structure of many Asian Indian groups, is the Hindu method of order- ing an individual’s role in society. A more encompassing term is j ati, which is the orga- nization of all aspects of Hindu life, including actions, places, things, and symbols, not just people. Caste categories are hereditary. There are four main castes associated with certain professions (although members are not neces- sarily employed in these jobs): the Brahmans (priests), Kshatriyas (soldiers), Vaisyas (mer- chants or farmers), and the Sudras (serfs). These castes are divided into more than 1,000 subcastes, usually according to occupation. Existing outside the caste system are individu- als considered so impure that they are called “untouchables.” Although the laws discrimi- nating against untouchables were repealed in 1949, this group of the desperately poor con- tinues to occupy the lowest stratum in Indian society. The caste system has permeated Indian society despite the fact that it is an exclusively Hindu classification. Americans of Asian Indian descent often continue to identify proudly with their caste. Most come from the upper castes of Brahmans and Kshatriyas. As with all cultural practices, it is important to remember that even within a group there is great diversity of individual beliefs and customs. Religion Asian Indians The influence of religion on Indian culture is ubiquitous. Every aspect of life and death is affected not only by individ- ual religious affiliation, but also by the Hindu ideology that pervades Indian society. Hinduism Nearly 85 percent of Indians are Hindus. Hinduism is an ancient faith, believed to have developed in India between 2000 and 1500 bce. from the Aryan hymns and prayers known as the Vedas mixed with elements from traditional Dravidian religion (see Chapter 4, for more information about Hinduism and other major Indian religions). The Hindu Society of India established community organizations to serve the reli- gious needs of early Asian Indian immigrants to the United States. Many Hindu temples now exist in regions where Asian Indians have settled, with services and religious ceremonies conducted by Brahman priests (who are often employed part-time in other occupations). However, temple attendance may be limited to significant religious events. Small shrines are often created in Asian Indian apartments or houses so that prayer and meditation may take place at home. Islam Today the Islamic religion in India is second only to Hinduism in number of fol- lowers; one in every nine Asian Indians is a Muslim. Islam was brought to India by traders from Persia, and it expanded with the Muslim invasions of the northern regions beginning about 1000. The Islamic Moghul Empire dominated the country for nearly 800 years. The influence of Islam is seen today mostly in northern India. Buddhism Buddhism developed as a prot- estant revolt against Hinduism. Its founder, known as Gautama Buddha, lived in India during the fifth century bce. Although it is a popular religion in other parts of Asia, Buddhism is followed by less than 1 percent of Asian Indians today. Jainism This branch of Hinduism devel- oped at about the time Buddhism emerged. The Jains believed that all living things have souls. Some wear masks to prevent breathing in insects and sweep a path in front of them to prevent stepping on any creatures. Ortho- dox Jains are strict vegetarians. Approximately 2 percent of Indians are Jains; in the United States, Jains have established their own tem- ples for worship. Sikhism The Sikh religion differs from Hin- duism in its belief in a single God. It is best known for its military fraternity, although most Sikhs in India are farmers. Male Sikhs wear a turban and follow the “five Ks”: uncut hair ( k es), a comb worn in the hair ( k anga), short pants ( k ac c h a), a steel bracelet worn on A reverence for all life, called ahimsa, is funda- mental to Asian Indian ideology. It is reflected in the religions native to India, as well as in the vegetarian diet that many Indians follow. The Moghul culture combined Persian and Indian influences, as seen in the architectural masterpiece of the period, the Taj Mahal. The untouchables were considered impure because of their contact with cattle carcasses and their consumption of beef. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 4 5 4 S O U T H A S I A N S the right wrist ( k ada), and use of a special saber ( k ir pan). Each has a spiritual mean- ing; for example, the short pants symbolize self-restraint; the bracelet, obedience; and the comb, purity of mind. In the United States many Sikhs continue these traditions, though some men forgo uncut hair to better fit into American society.4 Although Sikhs are only 2 percent of the population in India, it is reported that they make up nearly one-third of Asian Indians living in California. Christians It is estimated that Christians make up 2.3 percent of the Indian popula- tion. One form of Christianity emerged when the Syrians, who migrated to the Malabar Coast of southwest India in 345 ce, intermar- ried with native people. Syrian Christians do not observe Hindu dietary laws, but they do participate in the caste system. Their agricul- tural community is operated with farm labor- ers who can be described as serfs. Another Christian community developed at the former Portuguese colony of Goa, farther north on the southwest coast. Approximately half of cit- izens are Catholic, known as Goan Christians, and the city is dedicated to St. Catherine. Zoroastrianism More than 1,200 years ago the Parsis fled from religious persecution in Persia to northern India. The religion they brought is known as Zoroastrianism, an ancient faith that venerates Ahur Mazda, the wise god of fire. The sacred fires of Zoroastri- anism are tended in temples protected from the sun and from the eyes of unbelievers. The Parsis have adapted many of their practices to blend into Indian society but have maintained their faith through private schooling of their children. Parsis are considered the most West- ernized of all Asian Indians, and significant Parsi communities are found in New York and Los Angeles. Judaism Four small Jewish communities were established in India when Jews fled persecution in Greece, Palestine (under Roman domina- tion), Iraq, and Germany. The largest popula- tions are found in Bombay and Calcutta. Animism The oldest religions in India are those practiced by the small tribal populations that live in isolated regions of the Himalayas. They worship spirits associated with natural phenomena, a religious practice known as animism. In the past they have practiced such varied social customs as polyandry (having more than one husband) and head hunting. Pakistanis Nearly 98 percent of Pakistanis are Muslim (approximately three-quarters are Sunni and one-quarter are Shiite). Small numbers of Pakistanis are Hindus, Christians, Sikhs, and Zoroastrians. In the United States, families attend a local mosque at least once a week, and men often attend daily. Religious education for children is expected, often occurring on weekends, and may include instruction in Arabic (so that the Qur’an can be read in its original language). There are few strictly Pakistani congregations, and some fol- lowers may attend only on special holidays if there is no local mosque and they must travel long distances for services. Family Asian Indians The husband is the head of the household in the traditional Indian fam- ily. Traditionally the wife does not work out- side the home and is expected to perform all duties related to housekeeping and child care. She obtains help in these responsibili- ties from the extended family and, in some homes, from servants. If the wife does hold a job, she can depend on the help of relatives. Children are expected to show respect for their elders; parents may choose what career a child should pursue. Dating is uncommon in India, and many marriages are arranged by families based on similarities in caste, educa- tion, religion, and upbringing between pro- spective husbands and wives. In the United States most Indian Ameri- cans live in nuclear families, and strains in the traditional structure often occur. Asian Indian women are more likely to work in America than in their homeland, yet they lack the support system of an extended family. Elders may also find themselves cut off from their traditional role of advisers and may not have opportunities for involvement in certain religious activities that would fill their lives in India. Some Asian Indians, especially women raised in India, find it difficult to adjust to these changes. The kirpan has become a civil rights issue in some U.S. public schools, pitting religious freedom against provisions restricting weapons on campus. In India, marriage is con- sidered the beginning of a relationship from which love develops over time. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 1 4 4 5 5 Children who grow up in the United States usually insist on making their own career choices. Dating has become more acceptable, but some parents strongly discourage rela- tionships with persons of other ethnic or reli- gious backgrounds.4 Though most parents do not choose their child’s spouse, many Asian Indian children still defer to their parents’ opinions; young male students in the United States sometimes ask their families in India to find suitable wives for them. Elders are well respected in Indian cul- ture, and it is considered auspicious to have a senior at any social function.5 Older women are considered experts in family matters. Tra- ditionally, the oldest sons are expected to care for their parents, who in turn often help out with caring for children in the family. Some Indian Americans continue the practice of having elder parents in the home, and others (with parents who still live in India) host their mothers or fathers for months at a time. The family is seen as the way to preserve Indian values and beliefs while living in the United States. They consider themselves as bicultural—Indians at home but Americans at work.6 There is also strong interest in sponsoring the immigration of relatives to the United States. Most Asian Indians have found successful adjustment in the United States through educational and economic achieve- ment in American public life, while main- taining an emphasis on Asian Indian culture within the privacy of their home life. Pakistanis The traditional Pakistani home is strongly patriarchal. The husband is often the only wage earner in the family, and the wife is expected to stay inside the house to raise the children.7 She is allowed out to do essential chores such as shopping, but other activities require that she be accompanied by her husband. Faith is the centerpiece of fam- ily life for Muslims, and modesty for women is prized. Women are not allowed to have con- tact with unrelated men after puberty, and inappropriate touching could bring shame on the entire family and make a young girl unsuitable for marriage. In the United States most households include the immediate members, though close relatives such as grandparents or aunts and uncles may live in the home for extended periods. Some women prefer a traditional role. They may remain at home throughout the day and may never acquire English language skills. Oth- ers straddle a middle ground, working dur- ing the day, interacting with non-Pakistanis, and returning at night to don traditional garb and perform customary religious and family chores. Many young Pakistani Americans are not allowed to date, and marriages are still fre- quently arranged. In the more conservative homes, girls may be withdrawn from public schools in the seventh grade to prevent mix- ing with boys. If private segregated schools are unavailable or unacceptable, girls may be schooled at home or not at all. Other Pakistani teens are well integrated into American life and education, continuing on to college and often attaining advanced degrees. Traditional Health Beliefs and Practices Asian Indians Traditional medicine in India has a long and distinguished history. Sev- eral systems have developed over several thousand years, the most important of which is Ayurvedic medicine, which established the humoral concepts of the body that were later adopted in Greece and eventually evolved into biomedicine as it is practiced today. Ayurvedic medicine developed into its current form between 500 bce and 500 ce; it is based on Sanskrit texts and the writ- ings of practitioners. A y ur means “longevity” A y ur means “longevity” A y ur and v eda means “science or knowledge.” The purpose of the Ayurvedic system is to ensure a long and active life so that the wisdom of elders may be passed down to future genera- tions. Ayurvedic physicians, called vaidyas, are trained at government-supported schools that grant degrees based on an established curriculum. Their diagnosis focuses on who the person is that has the illness: their tastes, their work habits, their character, and their life history. Evaluation of the pulse, the face, the eyes, and the nails provides further data. A person’s constitution, including tempera- ment and preferences in food, is believed to be determined at birth. Deepak Chopra, an Indian-born physician, popularized Ayurvedic medicine in the United States through his best- selling books and videos. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 4 5 6 S O U T H A S I A N S Ayur vedic therapy uses diet, herbal remedies, and meditation to reestablish equi- librium between the sick person and the universe, including the social, natural, and spiritual worlds. Diet is considered most significant. Foods are classified as hot or cold depend- ing on their effect on the body and must be balanced for each condition (see the “Ther- apeutic Uses of Food” section later in this chapter). In addition, more than 700 plants and animal substances are listed in the Ayurvedic texts for prescriptive use. Because the mind, body, and soul are all considered to be interconnected parts of the whole system, meditation is used to address imbalance in the spirit of a person. Ayurvedic medicine has declined some- what in popularity in India as Westernized medicine has become more established and is frequently perceived as a paraprofessional practice. Folk beliefs about health and ill- ness are found in some regions. For example, Yunani or Unani-Tibb medicine is common in the northern areas of India. It is an Ara- bic system that has been modified by Indian practitioners known as hakim. It is a humoral system that identifies four humors—yellow bile, black bile, phlegm, and blood—and four qualities—heat, cold, moisture, and dryness. Health is sustained through balance of these humors and qualities. Illness is treated by complementary remedies; for example, dis- ease due to too much cold is cured with a hot therapy. Diet is an important therapeutic tool, and advanced conditions are often treated first with a fast, or limitation of intake, to allow the digestive system to rest.8 Siddha medicine, another humoral system, is developed within Tamil culture and is found mostly in southern India. Older practices, such as the use of sha- mans, bonesetters, and snakebite healers, are found in some rural regions. Home remedies such as herbal infusions and poultices are prevalent in India, often derived from Ayurvedic prescriptions or other traditional practices, but administered by home diagnosis. Many are known to have pharmacological activity, and several are con- traindicated in certain medical conditions or toxic in some preparations. Examples include aloe vera for obesity, liver problems, and both high and low blood sugar levels. Licorice root is used for indigestion and stomach aches, uri- nary tract problems, constipation, colds, and coughs. Black nightshade is considered help- ful in heart disease and liver problems. Diabe- tes is treated with numerous cures, including pellitory, neem, gudmar, and puncture vine.9 Recent surveys of more remote areas of the country have identified numerous previously unknown plants used by local inhabitants, many with demonstrated therapeutic proper- ties.10,11,12 Medications available only through prescription in the United States can be pur- chased over the counter in India. Widespread use of antibiotics and mixing of therapeutics have been reported.13 Pakistanis Little has been reported on the traditional health beliefs and practices of Pakistanis, though it has been noted that complementary care may be sought concur- rently with biomedicine.14 A recent study found 23 percent of a sample of young, well- educated residents of Karachi sought the help of healers, known as hakims.15 Similar to the same-named practitioners in India, hakims use Islami-Tibb, a humoral form of medi- cine adapted from traditional Arab systems and related to Indian Unani-Tibb. Therapeu- tic herbs or botanicals are used to maintain balance in the body and to cure a variety of ailments, such as common colds, coughs, cancer, leprosy, and reproductive disorders. Respondents who used such services reported that they believed hakims were reliable and inexpensive; those who did not visit hakims questioned their effectiveness and safety. Ayurvedic medicine is also available. Pro- phetic healing, prayer, and home remedies such as honey are often used to treat minor conditions or to seek protection from malign influence.15,16 Traditional Food Habits It is difficult to generalize about Indian cui- sine because of the diverse geography and het- erogeneous population of the country. Foods vary north to south, east to west, region to region, and among religious and caste groups. Meditation is the quiet consideration of religious teachings to understand faith and to achieve spiritual enlightenment. It is practiced by Hindus and Buddhists, and by some Christians and Muslims as well. Transcendental meditation (TM) is associ- ated with yoga and has no affiliation with any specific religion. Homeopathy is well accepted throughout India and Pakistan. Pakistani hakims sometimes use exotic preparations, such as those made from opium poppies or monitor lizard oil, in their treatment programs. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 1 4 4 5 7 The cooking of Pakistan is considered similar to aromatic northern Indian fare, though with Persian and Afghani influences, including a greater emphasis on meat dishes and a prefer- ence for onions, ginger, and garlic. Ingredients and Common Foods Staples India Few foods are eaten throughout all of India. Grains and legumes predominate in the frequently vegetarian cooking, with added vegetables and fruits. Dairy items often supplement the diet. The types of ingredients and preparation methods vary by locality and, often, according to religious practices. Rice is the grain most commonly con- sumed, and the average Indian eats half a pound of it each day. This amount, however, varies considerably by region, and it is most popular in the southern and eastern areas of the nation. Wherever it is consumed, long- grained rice is preferred. Wheat, used pri- marily in breads, is another staple. Legumes are consumed daily by nearly all Asian Indi- ans. Dal (or Dal (or Dal dh al ) is the Hindi term for dried beans, peas, and lentils, which come hulled, skinned, whole, and split (in some literature the English word pul se is used instead). Dal is also the name for the dish made when they are boiled and seasoned. They are also commonly added to rice or soups, prepared as seasoned purees, or ground into flour to make distinc- tive breads (see Table 14.1). Dairy foods are significant in most regions. Fermented milk products such as yogurt are found throughout most of the country, as is the cooking fat gh ee, which is pure, clarified butter (this butter, known as usl i gh ee, is too expensive for daily use in many homes, so vegetable shortening, also called ghee, is often used instead). Seasonings are distinc- tive. Masalas are mixtures of spices and herbs that can be either fresh and “wet” or dried and powdered. Coriander, cumin, fenugreek, turmeric, black and cayenne pepper, cloves, cardamom, cinnamon, and chile peppers are a common blend that is called curry in Western countries. Other typical spices and herbs include aj w ain (carom or loveage seeds), ▼ Traditional foods of India. Some foods typical of the traditional Indian diet include amchoor (mango powder), basmati rice, broccoli, coconut, cucumber, eggplant, ghee, herbs and spices (black pepper, cardamom, chiles, fresh coriander, cloves, coriander seeds, cumin, garlic, ginger root, mint, mustard seeds, nutmeg, tamarind, and turmeric), lentils, peas, plantains, and yogurt. amc h oor (unripe mango powder), asafetida amc h oor (unripe mango powder), asafetida amc h oor (a pungent powdered resin), coconut, fresh coriander, garlic, mint, saffron, and tamarind (the sour pulp of a bean pod).17 Beyond these generalities, the staples of the Indian diet are best classified by region. The greatest division in diet is seen between northern and southern India. Northern cuisine is characterized by the use of wheat, tea, a large number of eggs, garlic, dried or pickled fruits and vegetables, and use of dry masalas that are aromatic rather than hot. These foods are typical of a cooler climate, where wheat grows better than rice and where fruits, vegetables, herbs, and spices are available only seasonally. Boiling, stew- ing, and frying are the most common forms of cooking. In the south steaming is the pre- ferred method of food preparation. Rice, cof-ferred method of food preparation. Rice, cof-ferred method of food preparation. Rice, cof fee, fresh pickles (some known as chutney), pachadi (seasoned yogurt side dishes called raytas in northern India), “wet,” spicy-hot masalas, and fresh fruits, vegetables, herbs, and spices are fundamental to the cuisine. Again, these foods reflect the regional agri- cultural conditions. Many Asian Indians are vegetarians, and most use some milk products but avoid eggs (see Exploring Global Cuisine: Vegetarianism in India). Pork is eaten in some communities in the west, lamb and beef are eaten in many areas of the north, and fish and poultry are eaten in several coastal regions. The cultural food groups list is found in Table 14.2. J. Y. L ok e/ Sh ut te rs to ck .c om Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 4 5 8 S O U T H A S I A N S The ancient Indian diet featured a variety of meats, such as cows, bulls, buffalos, Tof meats, such as cows, bulls, buffalos, T horses, rams, goats, and pigs, in addition to wild game including deer, alligator, and tortoise. The vegetarian ethic entered India slowly, probably beginning with the bulls and barren cows used for sacrifice by the Aryans. Later, prohibitions were extended to the milk cow and the draft bull, as well as the village pig (a useful scavenger) and the village cock. Over time, a more general concern for animal life developed, though meat eating (especially in the upper classes) was difficult for many Indians to forgo. Buddhist and, later, Jain doctrines reinforced the concept of ahimsa, and vegetarianism became more widely practiced. It is often suggested that only in India, with its enormous variety of available fruits, vegetables, and grains, could such a broad acceptance of a vegetarian diet prevail.21 Yet the definition of vegetarianism in India is elusive. It is usually considered a symbol of piety in the Brahman castes and may be a necessity among the poor. Abstinence from meat and poultry is most common; however, nearly all Indian vegetarians consume milk products, and some eat eggs. Fish is problematic because it is an inexpensive food where available. Except in the state of Gujerat (where the influence of Jainism has been especially strong), a large percentage of people living in coastal regions eat fish, sometimes justifying it as fruit of the sea. Other Indians practice vegetarianism only on days of religious observance or as they age and become more devout. Some sources suggest that vegetarianism is most prevalent in southern India due to the Muslim influence found in the North. Indian census data show this is not the case. Overall, it is believed that 30 percent of Indians are strict vegetarians, abstaining from all meat, poultry, fish, and eggs but consuming milk, yogurt, and other dairy products. E X P L O R I N G G L O B A L C U I S I N E Vegetarianism in India English Hindi Common Preparations Black lentils (black gram) Urad dal Black skins with creamy insides—boiled, added to rice or vegetables, seasoned with mustard oil (Bengal); often ground for flatbreads (e.g., pappadams) or fermented and combined with rice flour to make flatbreads (e.g., idli, dosas). Black-eyed peas Lobhia Boiled, seasoned with onions, ginger, garlic (in the north), ginger, asafetida, mustard oil (in the west), or coconut (in the south). Chickpeas (Bengal gram) Channa dal Most commonly used dal in India—boiled, added to curries, chutneys, rice (pulao); pureed (sambar); roasted whole for snacks; ground into flour (besan) and added to curries, used for deep-fried fritters; made into thick, sweet puddings for dessert. Green peas Mutter dal Boiled, added to curries, rice (pulao) or pureed. Hyacinth beans Valor Boiled, often seasoned with coconut, ginger, and jaggery; sprouted in soups, salads. Lima beans Pavti Boiled, mixed with vegetables (especially potatoes, eggplant), added to curries; made into fritters or patties. Madras beans (horse gram) Kulith Assertive earthy flavor—boiled, added to curries; powdered for soup. Mung beans (green gram) Moong dal Brownish green—boiled with spices, added to rice (khichri), made into dumplings; sprouted for salads. Red lentils Masur dal Salmon colored—boiled, often mashed and added to meat for kebabs or curries (most common in the north). Yellow lentils (yellow split peas) Toor (Arhar) dal Pale yellow—boiled, often pureed with seasonings, or added to rice (khichri); mashed with other dals or rice to make pancakes (adai). TA B L E 14 .1 Selected South Asian Dals © C en ga ge L ea rn in g Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 1 4 4 5 9 Pakistan Pakistani fare combines the spices of India, such as cumin, turmeric, and chile peppers, with the more typically Arab flavors of cinnamon, cloves, and cardamom. It is dis- tinctive for its ample use of garlic, ginger, and onions in many savory and even some sweet dishes. Wheat is the staple of Pakistan, and flatbreads, similar to those in northern India, accompany every meal. Dal ia, the Pakistani version of Middle Eastern bulgur, is cooked with water or milk to make a porridge. Other commonly consumed grains include rice, usu- ally the nutty-flavored basmati rice cooked as pulao (cooked in a manner similar to Turkish pilau) and khichri (mildly spiced mixture of rice and legumes). Corn is popular in some areas, typically ground into meal and made into bread flavored with mustard greens and served with butter. Barley, sorghum, and mil- let are available but consumed less frequently. Legumes, especially chickpeas and lentils, are served daily, usually as one of several side dishes. One favorite is cholay, chickpeas or whole dried peas cooked with ginger, garlic, onions, tomatoes, chile peppers, cumin, and turmeric. Besan (chickpea flour) is used for breads and batters for fried foods. Dairy foods from cows and water buffaloes are another staple in the diet. Whole-milk yogurt (dah i) is used to prepare raytas (yogurt and vegetable side dishes) that are eaten with every meal. Lassi (the diluted yogurt bever- age found in India), paneer (Indian-style pot cheese), fresh milk, cream, and ice cream are other common dairy foods, consumed regu- larly or added to other dishes. Lamb, mutton, goat, beef, and chicken are Pakistani favorites. Pork is rarely eaten due to the Muslim majority, and nearly all meats are processed according to Islamic h al al guidelines (see Chapter 4). Meat or poultry is served at lunch and dinner if affordable. Beef stew, called nihari, is an example of pot roast- ing (dum), a popular preparation technique. Braising ( k or ma or q or ma) is also common, as is the Indian charcoal tandoor i style of cooking. B h una is a method of slowly frying wet seasonings (such as onions, ginger, and garlic), then adding dry spices to make a thick paste, then vegetables, and finally bits of meat to make a curried dish. Biryani rice is another specialty, a highly seasoned pilau (including saffron) with added meat. Yogurt or amc h oor is used to marinate both meats and poultry. Minced and ground meat dishes are especially popular, and meats are sometimes extended with ground legumes. Kabobs can be grilled or pan-fried patties; koftay are fried meat- balls (sometimes dipped in besan batter first) served with a curry sauce. G h ee is the pre- ferred cooking fat, although some Pakistanis must use less costly vegetable oils. Both tropical and temperate vegetables and fruits are available, though not consumed in large amounts. Apples, apricots, cabbage, car- rots, cauliflower, cucumbers, dates, grapes, guavas, mangos, onions, oranges, papayas, peas, plums, pomegranates, potatoes, pump- kin, spinach, tamarind, and watermelon are common. Vegetables are typically added to raytas, chutneys, curried dishes, and stews. Desserts are popular, especially ice cream and puddings made from rice, besan, carrots, bread, or vermicelli noodles. Cardamom, cloves, ginger, poppy seeds, aniseed, saffron, almonds, or pistachios flavor many sweets. One unique pudding dating from the Moghul period includes both ginger and garlic. Fried fritters are consumed, as are ladoos, balls made from sweetened besan and garnished with nuts. A Pakistani dessert specialty is ras malai, which may be best described as a rich cheesecake without a crust. Special-occasion desserts may be garnished with silver leaf. Tea is consumed throughout the day. It is usually heavily sweetened and boiled with milk, fla- vored with cinnamon or cardamom. Other popular beverages include lassi, sharbat (fruit juice), and sugarcane juice. Carbonated drinks are less common, and alcohol is prohibited for Muslims. Regional Variations Nor thern India The inf luences of the Moghul period are still found in the cooking of northern India, where Muslim influence was most prominent. The royal court fare of that time featured lavish meat and rice dishes flavored with expensive aromatic seasonings, nuts, dried fruits such as raisins, and yogurt or cream. Ample use of ghee and sugar was also characteristic. Many similarities The word curry is believed to be the English adaptation of a southern Indian term for “sauce,” kari. Curry powder is not a single spice but a complex blend of seasonings that varies according to the cook and the dish. The closest Indian equivalent is garam masala. In Bombay, it is legal for a vegetarian to refuse to sell his or her property to a nonvegetarian. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 4 6 0 S O U T H A S I A N S Group Comments Common Foods Adaptations in the United States Protein Foods Milk/milk products In general, milk is considered a beverage for children in India; consumed by some adults in Pakistan. Fermented dairy products are popular. Fresh cow’s, buffalo’s, ass’s milk; evaporated milk; cream used in Pakistan; fermented milk products (yogurt, lassi); fresh curds very popular; fresh cheese (paneer); milk-based desserts, such as kheer, khir, kulfi, barfi, and Pakistani puddings. Much cheese is consumed by Asian Indians; ice cream is popular with Asian Indians and Pakistanis. Meat/poultry/ fish/eggs/ legumes A sophisticated vegetarian cuisine exists in India; legumes are a primary protein source; meat and poultry are very popular in Pakistan. Hulled, split legumes, grains, and seeds, such as lentils, are known as dals. Legumes are typically prepared whole or pureed, or used as flour to prepare baked, steamed, or fried breads and pastries. Beef avoided by Hindus; pork prohibited for Muslims. Meats: beef, goat, mutton, pork Poultry: chicken, duck Fish and seafood: Bombay duck, carp, clams, crab, herring, lobster, mackerel, mullet, pomfret, sardines, shrimp, sole, turtle Eggs: chicken Legumes: beans (kidney, mung, etc.), chickpeas, lentils (many varieties and colors), peas (black-eyed, green) Consumption of legumes decreases; meat intake increases. Meat may be added to traditional Indian vegetarian dishes. Fast foods are popular. Cereals/Grains More than 1,000 varieties of Indian rice are cultivated. Basmati is preferred in Pakistan. Wheat used mostly in northern India and Pakistan; rice in southern India. Most breads (roti) are unleavened. Rice (steamed, boiled, fried, puffed), wheat, buckwheat, corn, millet, sorghum Use of American-style breads occurs in place of roti; breakfast cereals are popular Fruits/Vegetables More than 100 types of fruit and 200 types of vegetables are commonly used in India. Fruits and vegetables may be used in fresh or preserved pickles, called rayta (northern India/Pakistan), pachadi (southern), or chutney. Fruits often costly in Pakistan. Fruit: apples, apricots, avocados, bananas (several types), coconut, dates, figs, grapes, guava, jackfruit, limes, litchis, loquats, mangoes, melon, nongus, oranges, papaya, peaches, pears, persimmons (chicos), pineapple, plums, pomegranate, pomelos, raisins, starfruit, strawberries, sugarcane, tangerines, watermelon Vegetables: agathi flowers, amaranth, artichokes, bamboo shoots, banana flower, beets (leaves and root), bitter melon, Brussels sprouts, cabbage, carrots, cauliflower, collard greens (haak), corn, haak), corn, haak cucumbers, drumstick plant, eggplant, lettuce, lotus root, manioc (tapioca), mushrooms, mustard greens, okra, onions, pandanus, parsnips, plantain flowers, potatoes, pumpkin, radishes (four types, leaves and roots), rhubarb, sago palm, scallions, spinach, squash, sweet potatoes (leaves and roots), tomatoes, turnips, yams, water chestnuts, water convolvulus, water lilies Decreased variety of fruits and vegetables is available; decreased vegetable intake results for Asian Indians. More fruit juice is consumed by Asian Indians. Salad is well accepted by Asian Indians. Use of canned and frozen produce increases. TA B L E 14 . 2 Cultural Food Groups: South Asian Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 1 4 4 6 1 between the foods of this region, Pakistan, and modern-day Iran are still evident due to this shared history. Basmati rice is commonly served as a pilaf in northern India, and biriyani rice with seasoned chicken, lamb, or beef is popular. Meatballs (kofta) made with ground meats or with meat and dal mixtures are a specialty, as are skewered pieces of broiled or grilled meats (kabobs). Northern specialties include korma—a curried lamb dish with a nut and yogurt-thickened sauce—and masala chicken. Peanut and sesame oils are used in many prep- arations.8 The dishes of the north, particularly in Kashmir (which boarders Pakistan and has a significant Muslim population), are often seasoned with saffron.2,18 Bread, which is called ro ti in northern India, is eaten daily. Examples include whole- wheat flatbreads, such as chapatis, which are cooked on a griddle without oil until they puff up, and puris, which are deep-fried, usually in ghee. Paratha, a griddle-fried roti, is used as a wrapping for spiced vegetable fillings. A rich, leavened bread of the region, called sh eer mal , is flavored with rose water. Fresh cheese made from buffalo milk (similar to cottage cheese), called paneer , is added to many dishes, or skewered and grilled. Milk desserts are favored, such as carrot pudding (gajar halva) and rice pudding with cardamom (kheer). In northern and northwestern India a spe- cial cylindrical clay oven heated with charcoal and called a tandoor is used. Tandoori cook- ing is identified particularly with lamb and chicken dishes (the meat is often marinated in a spicy yogurt sauce before cooking), although the leavened bread known as naan is also typi- cally baked in a tandoor. This method of cook- ing is associated with the state of Punjab, and Group Comments Common Foods Adaptations in the United States Additional Foods Seasonings Aromatic (northern) and hot (southern) combinations of fresh or dried spices and herbs accentuate or complement food flavors. Pakistani fare similar to northern Indian but with ample use of ginger, garlic, and onions. Ajwain, amchoor, asafetida, bay leaf, amchoor, asafetida, bay leaf, amchoor cardamom (two types), chiles, cinnamon, cloves, coconut, fresh coriander, coriander seeds, cumin, dill, fennel, fenugreek, garlic, kewra, lemon, limes, mace, mint, mustard, nutmeg, pepper (black and red), poppy seeds, rose water, saffron, tamarind, turmeric Spice use depends on availability. Nuts/seeds Nuts and seeds of all types are popular; used to thicken korma sauces in India and garnish desserts in Pakistan. Almonds, betel nuts and leaves, cashews, peanuts, pistachios, sunflower seeds, walnuts Paan tray may be limited to betel nuts and spices. Beverages Tea is common in northern India/Pakistan, coffee in southern India. Coffeehouses are favored meeting places. Coffee, tea, water flavored with fruit syrups, sugarcane, spices, or herbs; alcoholic beverages such as fermented fruit syrups, rice wines, beer Increased consumption of soft drinks and coffee is noted for Asian Indians. Alcoholic beverages are widely accepted by Asian Indians (women may abstain); consumed by very few Pakistanis. Fats/oils Coconut oil, ghee (clarified butter), mustard oil, peanut oil, sesame seed oil, sunflower oil Purchased ghee is often made from vegetable oil instead of butter. Sweeteners Sugarcane, jaggery (unrefined palm sugar), jaggery (unrefined palm sugar), jaggery molasses Candy and sweets are enjoyed by Asian Indians but not overconsumed; cookies may replace flatbreads as snacks for Pakistanis. © C en ga ge L ea rn in g Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 4 6 2 S O U T H A S I A N S though few homes have tandoor ovens, it has been popularized throughout the nation (and with many visitors) by specialty restaurants. The northwestern region is characterized by the large percentage of Hindus and Jains and high numbers of vegetarians. In the state of Punjab, where the national capital Delhi is situated, many cooler weather vegetables associated more with temperate climates than tropical ones, such as cabbage, carrots, cau- liflower, potatoes, tomatoes, and turnips, are used. Onions and garlic, infrequently used in most of India, are common seasonings. Dairy products, including milk and buttermilk in addition to yogurt and paneer, are consumed more often in this area than in any other Indian region.9 In the state of Rajasthan, bar- ley, millet, and, later, corn were the primary grains grown in the region and are featured in many breads. Today, wheat is becoming much more prominent. Aromatic spices such as cumin and cardamom are found in many dishes, and red chiles add zing. A little farther south is the state of Gujarat, which special- izes in vegetarian dishes flavored with green chiles and ginger.8 Sweet-and-sour dishes are also featured, usually achieved by pair- ing sugar with a sour fruit indigenous to the region called kokum (related to mangosteen S A M P L E M E N U Pakistani Midday Meal Lamb K or ma ( Q or ma) a,b or Beef K of t aa S ambals : Imli (Tamarind) Chutney, (Tamarind) Chutney,S ambals : Imli a R ay ta (Yogurt Condiment),a C h ola y aC h ola y aC h ola y N aan * Tea *Store bought aDesi Cookbook at http://www.desicookbook.com/Desi Cookbook at http://www.desicookbook.com/Desi Cookbook bPakiRecipes at http://www.pakirecipes.com and tamarind). The combination is found in savory dishes as well as in desserts, and espe- cially in the drink k ok um sh ar bat. Coastal India The coastal region offers a num- ber of seafood specialties and fish prepared in a variety of ways, including fried, steamed, boiled, curried, and stuffed with herbs. For example, in the northeastern state of Bengal (which includes the city of Kolkata—formerly known as Calcutta), prawns are a specialty even in the more inland areas. Freshwater fish, mostly those from numerous rivers and estuaries, are consumed by most Bengalis every day. A favorite along the coast is bhapa, steamed packets of fish (or vegetables) sea- soned with mustard seed and spices, such as cumin, asafetida, and nigella (a small black seed with subtle bitterness called k al onj i in Hindi). A dessert version features sweetened yogurt. The inland dishes of Bengal are note- worthy for their use of poppy seeds. Mumbai (formerly known as Bombay), located on the west coast in the state of Maharashtra, boasts a dried, salted fish—which is thin, bony, and strongly flavored—known as Bombay duck. It is usually prepared fried. Other coastal foods eaten by the people of the Marathis region include numerous curried fish dishes as well as shrimp, crab, and lobster. In inland areas, Marathis are known for adding peanuts to their dishes, and for bhakris, a crispy, tradi- tional flatbread made from rice flour (sor- ghum flour is used in some rural areas) and cooked on an ungreased griddle. The tiny state of Goa, which is south of Mumbai, is home to many Christians. Fish is eaten daily, but pork is also popular. The most famous dish of the region is vindaloo, a hot-and-sour pork curry seasoned with coconut, vinegar, tomatoes, and ample chile peppers. Southern India The menus of the south fea- ture numerous steamed and fried rice dishes. A coarse red rice with a smoky flavor called rosematta is favored in some parts of south- eastern India, including the state of Tamil Nadu (home of the Tamils), and may be mixed with other grains.19 Rice is even served puffed, as in a snack called bhelpuri. Other grains, such as semolina wheat, are also popular cooked as a cereal known as uppama, which Samosas—angular, deep-fried turnovers with spicy potato, veg- etable, cheese or meat stuffings and served with chutney—are thought to be variations of Middle Eastern sanbusak.110 Green tea is made in a samovar in the Indian state of Kashmir, a method that may have been introduced to the region from Russia via central Asia.8 A comfort food in many parts of India is khichri, a combination of veg- etables sautéed with rice and dal in an ample amount of ghee. Khichri is usually served with kadhi, a curry made with yogurt and besan. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 1 4 4 6 3 may include vegetables. Dal s, particularly chickpeas and lentils, accompany nearly every meal in the form of a spiced purée known as sambar or as a thin, crisply fried roti called pappadams. Fermented black lentil flour mixed with rice flour is used at breakfast for steamed cakes called idli and for spicy, fried pancakes called dosas. A mixture of different dals (and sometimes rice) is cooked, seasoned with chile peppers, and mashed into a thick, unfermented puree that is fried for the savory pancakes known as adai, traditionally served with jaggery or coconut chutney. Fresh milk curds are also served for breakfast. Highly spiced vegetable curries, such as aviyal, include such southern ingredients as bananas, banana flowers, bittermelons, coco- nut, drumstick plant, green mango, and jack- fruit seeds, in addition to potatoes, cauliflower, and eggplant. Pandanus leaves, with a flavor reminiscent of mown hay, are used to season some dishes. Coconut milk is often used in cur- ries and sauces, and coconut oil is commonly used for frying.9 Refreshing yogurt-based pachadi and spicy, pickled fruits or vegetables, such as chutney, accompany the main course. In the state of Kerala (in the southwest), where there is the smallest percentage of vegetarians in the nation, fish or seafood is eaten often, as is chicken. Black pepper is a favorite sea- soning, often combined with coconut, green chiles, and karhi (curry leaves), an herb with a citrus-like, tangerine flavor). A large Muslim population prepares traditional biryanis and cooks lamb with garlic, anise, and ground chile peppers. In the large state of Andhra Pradesh, dishes are typically seasoned with tamarind (which is also used for beverages), gongura (the leaves of roselle, a type of hibiscus also used in African cooking), and red chile pep- pers. Andhran fare is reputedly the hottest in all of India. Throughout the South, deep-fried salty foods and sweets are favored snacks, such as the syrup-soaked, orange-colored pretzels called jalebis. Pakistan Pakistani fare consists of many regional variations. In Punjab, the royal cook- ing style of the Moghul period still influences a preference for elaborate, rich dishes. Tan- doori fare is popular, and the k ar ah i—a deep, A French Christian colony on the east coast of India at Pondicherry introduced baguettes, croissants, pâté, and French-style desserts into the regional fare. ▲ Samosas, spicy deep-fried turnovers. H ig hv ie w s/ Sh ut te rs to ck .c om cast-iron pot shaped something like a wok— is used to deep-fry foods. Fish is a common food in Sindh, which has a lengthy coastline, and is prepared as fritters, kabobs, steamed, or curried. Spit-roasted meats are a specialty in Baluchistan. Called sajji, the whole lamb or chicken is skewered on a small pole, then the poles are inserted into the dirt around a large fire. The poles are rotated by hand as the meat cooks, assuring even roasting. The North- West Frontier Province, which is populated by eight different tribes, has a simple cuisine that emphasizes rice, dal, and lamb. More locally, in the valley of Hunza, a distinctive fare devel- oped due in part to the limitations of its high altitude. Wheat predominates, traditionally baked as a flatbread (phitta) in hot ashes. M al tash , a strongly flavored aged butter, is prized, and k ur utz , a salty dry cheese, flavors soups. Wild thyme and turmeric are common seasonings. Apricots and apricot kernels are eaten as snacks, while oil extracted from the kernels is used in cooking.20 Religious Variations In addition to region, religious affiliation may greatly influence food habits, especially in India. Religious groups have varying dietary practices, yet their cooking is Indian in flavor. The relationship between food and spiritu- ality is very complex in Hinduism. Eating is an integral part of each person’s spiritual journey and defines one’s role within society (see the The English words pepper, sugar, and orange are all derived from Asian Indian terms for those foods. Balti cooking, from the Kashmir region (claimed by both Pakistan and India), uses a woklike karahi pan to stir-fry aromatic curries seasoned with fresh coriander, mint, and fenugreek served with flatbreads instead of rice. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 4 6 4 S O U T H A S I A N S sections “Special Occasions” and “Role of Food in Indian Society and Etiquette”). For example, each caste traditionally was associ- ated with different food habits.8 Brahmans were generally vegetarians. Kashatriyas con- sumed meat, and vaishyas consumed meat depending on their locale and whether it was available—farmers often had more access than merchants. Sudras ate meat, but typically only when it was provided for them as leftovers. Muslims avoid all pork and pork products but are not vegetarians. Orthodox Jains may eat only innocent foods that avoid injury to any life and are therefore strict vegetarians. In addition, there are twenty-two prohibited foods (e.g., fruit with small seeds or tender new greens) and thirty-two other items that may have the potential for life to exist, includ- ing root vegetables, because insects might be killed when the tubers are harvested and honey, because bees might be killed when it is gathered from the hive. They also refuse to eat Chai, a north Indian specialty, was created as a way of using lower-grade tea leaves by boiling them with spices, sugar, and milk.8 S A M P L E M E N U A Southern-Indian Vegetarian Dinner A viy al (Spicy South Indian Vegetable Curry)A viy al (Spicy South Indian Vegetable Curry)A viy al a,b S ambar (Seasoned Dal) (Seasoned Dal)S ambar a,b,c Steamed Rice Pineapple P ach ad ia,c P appad ams * (Spicy Fried Flatbread)P appad ams * (Spicy Fried Flatbread)P appad ams * Water (with the meal) Mango Las s ib,c or Ch aia,c (following the meal) *Store-purchased, fried before serving aKaimal, M. 2000. Kaimal, M. 2000. Savoring the spice coast of India: Fresh flavors from KeralaSavoring the spice coast of India: Fresh flavors from Kerala. New York: HarperCollins. bIndian and Pakistani Recipes at http://www.recipesource.com cSouth Indian Recipes at http://www.south-indian-recipes.com any foods made with eggs, or blood-colored foods such as tomatoes and watermelon. Water must be boiled (and re-boiled after six hours)—if boiled water is unavailable, dis- tilled water may be permitted.8,21 Sikh cuisine is noted for its use of wheat, corn, and sugar and the complete abstinence from alcohol and beef (pork is permitted). Sikhs are also prohibited from consuming halal meat. Some Sikhs are vegetarians and may avoid eggs. Many Sikh dishes are pre- pared in pure usli ghee, which gives them a richness not found in some other religious fare.8,22,23 The Syrian Christians are renowned for their beef (tenderized by mincing or mar- inating), duck, and wild boar dishes. Goan Christians are unique in Indian cooking for their use of pork. They make Western-style sausages and have such specialties as a vine- gar-basted hog’s head stuffed with vegetables and herbs.23 Most Jews in India keep kosher. The Parsis blend Indian and Persian elements in their cuisine, exemplified by dishes such as dhansak, an entrée combining lamb, tripe, lentils, and vegetables. Eggs, such as ekuri— spicy scrambled eggs—are especially popular. Dietary variations due to religious prac- tice are limited in Pakistan because of a large Muslim majority. The small number of Hindu, Christian, Sikh, and Zoroastrian Pakistanis are assumed to adapt their food habits in ways appropriate to their faith (see Chapter 4). Meal Composition and Cycle Daily Patterns Asian Indians Meal patterns in India, though not consistent across regions and classes, vary less than the foods served. Two full meals with substantial snacks are typical. Early risers enjoy a rich coffee or tea boiled with milk and sugar. Breakfast, usually eaten between 9:00 and 11:00 a.m., consists of rice or roti, a pickled fruit or vegetable, and a sambar or other dal dish, which may be left over from the previous evening. At 4:00 or 5:00 p.m., similar foods or snack items are eaten with coffee or tea. The main meal of the day follows between 7:00 and 9:00 p.m.23 Texture, color, and bal- ance of seasoning are all important factors in an Indian meal. A menu customarily includes Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 1 4 4 6 5 at least one rice dish; a curried vegetable, legume, or meat dish; a vegetable legume side dish; a baked or fried roti; a fruit or vegetable pickle; and a yogurt rayta or pachadi. Some- times a dessert is served, usually fruit. Water is the most common drink con- sumed with meals, though milk and butter- milk are also prevalent, especially in the north and west. Sugarcane juice, fruit juice, and sodas are popular in urban areas. Alcoholic beverages are not widely consumed, though rice beer, home-brewed rum made from molasses, toddy (a brandy-like drink made from palm sap), and melon wine are a few tra- ditional beverages still popular in some rural regions. Many Westernized Asian Indians, particularly men, drink beer or scotch. Courses are not presented sequentially in an Indian meal. They are placed on the table all at once, with savory dishes eaten at the same time as sweets. Typically, an individual serv- ing of rice or breads is served surrounded by a selection of other foods, such as curried dishes, dals, rayta, or pachadi, and pickled fruits or vegetables. Diners may combine tastes and textures according to personal preference. The meal concludes with the passing of the paan tray. Paan is a combination of betel (areca) nuts and spices, such as anise seed, cardamom, and fennel, wrapped in large, heart-shaped betel leaves secured with a clove. It is chewed to freshen the breath and to aid digestion. Snacking is very popular in India. In cities and small towns snacks are sold in numerous small shops and by street vendors. In villages they are prepared at home. A clear distinc- tion is made between meals and snacks. Many Indian languages have specific words to define each form of eating. In southern India the word tif f in is used to distinguish a snack from a meal. The coffee or tea drunk before break- fast or in the late afternoon is considered tiffin. A meal is not a meal unless the traditional sta- ple prepared in the traditional manner, such as boiled rice in southern India (or roti in north- ern India), is served. This means that no matter how substantial the snack—and some include more food than a meal—it is still called tiffin. Spicy snacks served with chutney often consist of batter-fried vegetables, pancakes with or without a filling, or fried seasoned ▼ Fast-food street vendor sells his food in Karachi, Pakistan. dough made from wheat or lentils. Savory saladlike mixtures of diced fruit and vegeta- bles (sometimes with added meat or shrimp) and flavored with amc h oor or tamarind, called amc h oor or tamarind, called amc h oor chaat, are popular. Snacks sweetened with sugarcane, molasses, or jaggery are usually milk-based, as are the saffron-spiced khir, the Indian ice cream called kulfi, and the candy barfi, although nuts, coconut, sesame seeds, or lentils are also used. Bengalis are noted for their sweetshops, which prepare numerous specialties, such as sandesh, a delicate curd candy, and singhara (a sweet version of the samosa filled with coconut and jaggery).18 A snack may also include a cooling beverage, such as the sweetened, diluted yogurt drink called l assi or the fruit juice known as sh ur but. Restaurants are becoming increasingly popular in India, and Western fast-food fran- chises are found in many regions. Chinese and Thai establishments are also common, particularly in urban areas. Pakistanis Breakfast, if consumed, is a light meal in Pakistan, consisting of fried flat- breads such as puris, a sweetened porridge, or a legume dish. Traditionally, however, only two meals a day are eaten. Lunch and dinner are large meals and if affordable, include a meat, poultry, or fish dish, and sambals: side dishes such as curries, cholay, raytas and other fresh vegetable or fruit saladlike mixtures, chutneys, and pickles selected for a balance of flavors and textures. Flatbreads and tea are served with the meal. St af fa n W id st ra nd /E nc yc lo pe di a/ Co rb is Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 4 6 6 S O U T H A S I A N S Dessert often follows, and paan may be chewed afterward. K h at, a plant with mild amphetamine-like properties, is often added to the betel-leaf roll (see Chapter 8). Snacking is common and hearty, including fried items such as meat, poultry, or fish fritters and pat- ties, stuffed pastries and flatbreads, kabobs, sandwiches, spicy saladlike mixtures, roast beef or chicken, and, in urban areas, Western fast food. Traditionally, meals were served on large trays and eaten with the hands while sitting on the floor. Many Pakistanis today have been influenced by European customs and consume their meals at tables using flatware and cutlery.24 Special Occasions Asian Indians Another aspect of Indian cul- ture affecting daily diet is the concept of feast- ing and fasting. As with other Indian food habits, feasting and fasting activities are com- plex and vary greatly from person to person and group to group. No occasion passes in India without some special food observance: regional holidays, community celebrations, and personal events such as births, weddings, funerals, and illness. A devout Hindu may feast or fast nearly every day of the year (see Chapter 4). Feasting Feasts serve as a method of food distribution throughout the community. They are generally observed by presenting large amounts of everyday foods and sweets of all kinds to the appropriate holy figure; all members of the community then eat the food. Feasts may be the only time that the poor get enough to eat. Some foods are associated with certain concepts. Rice and bananas both symbolize fertility, for example. Betel leaves represent auspiciousness; ghee, purity; salt, hospital- ity and pleasantness; mango, hospitality and auspiciousness; and betel nuts and coconuts, hospitality, sacredness, and auspiciousness. Most festivals are Hindu in origin, and although many are observed nationwide, each is celebrated differently according to the region. H ol i is a spectacular holiday in the north, featuring reenactments of Krishna’s life, fireworks, and colored powders tossed everywhere. Celebrants snack at bazaar booths. Dusseh r a is a ten-day holiday observed in both the north and the south. A special dish is prepared each day, and every day that dish is added to those prepared the previous days, culminating in an enormous feast on the last evening after a torchlight parade of ornamented elephants. Div al i, the festival of lights, is the New Year’s holiday celebrated everywhere with gifts of sweets. Another holiday, J anmash tami, commemorates the birth of Krishna. As a boy, Krishna and his friends would steal butter or curds hung high in earthen containers. This story is recreated during the celebration as young boys attempt to break elevated clay pots full of curds. Non-Hindu harvest festivals also feature feasts. They are dedicated to wheat in the North and rice in the South. At the three-day rice festival in Pongal, dishes made from the newly harvested rice are ceremonially fed to the local cows. The ten-day festival of Onam in Kerali culminates with a feast served by the local women, including thirty to forty dishes ranging from fiery curries to foods sweet- ened with a combination of molasses, milk, and sugar. Asian Indian Muslims may dine with friends on Eid al-Fitr at the end of Ramadan and Eid al-Azha (see Chapter 13). Christians celebrate Christmas and Easter in India. Fasting Fasting is also associated with special occasions in India. It accompanies both reli- gious and personal events. An orthodox Hindu may fast more days a week than not. However, the term f ast includes many differf ast includes many differf ast - ent food restrictions in India, from avoidance of a single food item to complete abstinence from all food. A person might adopt a com- pletely vegetarian diet for the day or eat foods believed to be spiritually purer, such as those cooked in milk (see the section “Purity and Pollution” in this chapter). Individuals rarely suffer from hunger because of fasting in India. In fact, more food may be consumed on fast days than on a nonfast day. Muslims in India also fast, notably during the month of Ramadan. No food or drink is consumed between sunrise and sunset (see Chapter 4 for more information). Sikhs may fast on the days of the full moon.22 It is illegal to bring betel leaves into the United States. There is a black market for paan obtained in Canada and other countries. Traditionally, six tastes (sweet, sour, salty, bitter, pungent, and astringent) and five textures (foods that need to be chewed, those that need no chewing, those that are licked, those that are sucked, and those that are drunk) were balanced in an Indian meal. McDonald’s restaurants in India do not serve beef hamburgers but offer instead selections such as paneer wraps and spicy potato burgers—all items are made with egg-free mayonnaise.111 The decorative red or yellow dot that Hindu Asian Indian women apply to their foreheads represents joy or prosperity. It is omitted during fast days. Sweets represent prosperity because they often include costly ingredients and may be decorated with silver or gold leaf. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 1 4 4 6 7 Pakistanis Most Pakistanis follow the Islamic calendar, fasting for the month of Ramadan and celebrating the feast days of Eid al-Fitr and Eid al-Azha (see Chapter 4). Several secular holidays are also observed, including Pakistan Day (March 23), Independence Day (August 14), and the birthday of the national founder, Jinnah (December 25). Special occa- sions are marked by dishes that use costly ingredients, such as silver leaf and nuts, and feature numerous sweets. Role of Food in Indian Society and Etiquette The importance of food in Indian culture goes far beyond mere sustenance. Sanskrit texts describe its importance: From earth sprang herbs, from herbs food, from food seed, from seed man. Man thus consists of the essence of food. . . . From food are all creatures produced, by food do they grow. . . . The self consists of food, of breath, of mind, of understanding, of bliss. (Achaya, 1994, p. 61) In a society that traditionally experienced frequent famines and chronic malnutrition, food is venerated. Complex traditions have developed around when, how, and why foods are prepared, served, and eaten. Purity and Pollution Many Hindu dietary customs are meant to lead to purity of mind and spirit. Pollution is the opposite of purity, and polluted foods should be avoided or ameliorated. To be pure is to be free of pollution. The Hindu classification system of j ati is used to evaluate the relative spiritual purity of all foods. Purity is determined by the ingre- dients, how they are prepared, who prepares them, and how they are served. Some foods, such as milk, are inherently pure. Raw foods that are naturally protected by a husk or a peel are less susceptible to pollution. P ak k a (meaning “cooked”) foods are those that are fried or fat-basted during preparation, prefer- ably in ghee. Pakka foods are relatively unre- stricted due to their high degree of purity and often include fried breads and many sweets. Pakka foods are considered appropriate for serving at temples and at community feasts because they are pure enough for anyone to consume.8 K ac c h a (meaning “undercooked”) foods are those that are boiled in water, baked, or roasted. Kaccha foods are more susceptible to pollution than pakka foods and must there- fore be treated carefully during serving and consumption. They include many of the foods that are central to the daily diet, such as rice and dal , and are typically only served within the home. Some foods, such as alcohol and meat, are j h uta, meaning that they are innately polluted. Jhuta foods are those that are by their very nature impure. All leftovers, unless completely untouched by the consumer or by other foods that have been eaten, are jhuta. Those foods that are identified as jhuta vary by religious sect. The term j h uta is also used for garbage and offal. Asian Indian Women and Food The role of women in food preparation is extremely important throughout Indian cul- ture. Feeding the family is an Indian woman’s primary household duty. She is responsible for overseeing the procurement, storage, preparation, and serving of all meals. Because arranged marriages are common, training in kitchen management is considered essen- tial for a Hindu woman in obtaining good marriage offers. It is generally believed that a woman cannot be completely substituted for in the kitchen, for she imparts a special sweetness to food. If the wife is unable to perform food- related duties, a daughter or daughter-in-law may substitute, and in multi-family homes, the mother-in-law assumes control of the kitchen. If servants help in meal preparation, it is still important for the woman of the house to serve the food directly from the c h ul a (stove) to the table. This often requires many trips. Etiquette Traditionally, only foods cooked and served by a member of an equal or superior caste could be consumed by any Hindu. The cus- toms were such that a Brahman would not eat food if the shadow from a member of another caste fell on it.8 Only members of the same caste ate together. Untouched leftovers can be Food served in brass dishes is less vulnerable to “pollution” than is food in clay dishes. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 4 6 8 S O U T H A S I A N S given to a member of a lower caste, such as servants, but polluted leftovers are eaten only by scavengers of the lowest caste. Today, Asian Indians adhere to these commensal rules to various degrees, however. An orthodox Hindu attempts to follow them at all times. A more modern Hindu might adhere to them only during holy services and holidays. Most Westernized Indians eat in restaurants and use convenience products in cooking, ignoring how and by whom the food was prepared. The consumption of jhuta foods also var- ies among Hindus. Historically, laborers and warriors were allowed to eat meat to help keep up their strength. Some Brahman sub- castes, though primarily vegetarian, permit consumption of impure foods that are plenti- ful in their region, such as fish in the coastal areas and lamb in the north. Other sects are so rigid that even inadvertent intake of pol- luted food results in spiritual disaster. Mem- bers of the International Society for Krishna Consciousness (see Chapter 4) believe that if they accidentally eat a prohibited animal food, they will lose human form in their next life and assume the form of an animal that is the prey of the animal they ate. Hospitality is highly valued in Hindu homes, where serving a guest is considered equivalent to serving God.8 Traditionally, the male head of the household was responsible for seeing that any guests, pregnant women, or elderly persons were well fed before he could sit down to eat. The order of serving today is more likely to be guests, oldest men, remain- ing male diners, children, and then women. In some situations men and women may be separated while eating.25 However, more Westernized Asian Indians are often relaxed about these customs, and in some homes each diner goes his or her own way at meals.8 Food is served in small individual bowls from serving trays called th al is. The thalis may be silver or brass, with matching bowls. Origi- nally, the thalis were simply banana leaves and the bowls were earthenware, and these are still used today in some rural areas or when dis- posable trays and bowls are desired. Only the right hand is used in dining, which may be done with spoons (the most common utensil), forks, and knives, or with just the fingers. When eating with the hand in the north, only the fingertips are used to delicately scoop up food with bits of bread, whereas in the south, the bread and food are dexterously rolled into the palm, then popped into the mouth.26 Food being served to oth- ers should never be directly touched with the hand, nor should a diner refill his or her glass, waiting instead for neighboring diners to do so, and carefully tending to their drinks whenever their glass is half empty. If alcohol is served, a guest is expected to make a toast to the health of the host (after the host toasts the guests). However, any verbal thanks for the meal are considered very rude, and only a quick nod with the head while holding the hands palm to palm and saying “namaste” (see “Counseling”) is appropriate.25 Therapeutic Uses of Food Asian Indians Ayurvedic medicine is based on the premise that each human is a microcosm of the uni- verse. As such, the body experiences the three inevitable laws of nature (also called universal tendencies) of creation (sattw a), maintenance (r aj us), and dissolution (tamas).9 The funda- mental elements of fire, water, and wind also have their counterparts in the humors of the body—bile (pittabody—bile (pittabody—bile ( ), phlegm ( k aph a), and wind (v ata). Pitta regulates metabolic activities and resulting heat. Kapha provides structure and support through bone and flesh, and vata represents movement of muscle and semen. Health is maintained through a careful bal- ance of humors and substances in the body according to each person’s internal constitu- tion and external experiences. When pitta is in balance, digestion is com- fortable and a person is content; balanced kapha produces physical and emotional stability, strength, and stamina; vitality and creativity are the results of balanced vata.27 Good digestion is critical because food is transformed into the body humors and sub- stances when it is cooked by the digestive agnis (“fires”), producing food juices and wastes. Food that is indigestible is harmful because it is believed to accumulate in the intestines and decompose, sending toxins A Hindu woman is traditionally considered impure during her menses and is prohibited from cooking or touching any food that is to be consumed by others. Many Brahmans were historically employed as cooks, because everyone could eat food prepared by this caste. Cow’s milk is thought to increase intelligence; buffalo’s milk is believed to strengthen the body. Garlic is found in many Ayurvedic remedies, and an old Indian proverb states: “Garlic is as good as ten mothers.” Curcumin, a chemical found in turmeric (used in many curry spice blends), has anti- inflammatory and immunomodulatory properties, and has been reported to be beneficial in arthritis, asthma, cardiovascular disease, diabetes, Alzheimer’s disease, and some cancers.112 Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 1 4 4 6 9 into the bloodstream; excessive waste or too little waste is an imbalance that causes illness.13 Foods are classified according to which humors they enhance or inhibit. For exam- ple, pomegranate increases vata and reduces pitta and kapha. Molasses does the opposite: it increases pitta and kapha and reduces vata. Some foods are also grouped according to their universal tendencies. Mung beans, for instance, are considered sattaw ic , chile pep- pers are r aj asic , and nutmeg is tamasic . Fur- thermore, the hot–cold classification system is used for foods, depending on how they affect the body. The specific identification of an item as hot or cold varies regionally; for example, lentils and peas are considered hot in western India, but cold in northern India. Generally wheat, spices, and seasonings (except mustard and sesame seeds), chicken, and oils are classi- fied as hot; rice, leafy vegetables, fruits (except mango, papaya, and jackfruit), dairy products, honey, sugar, pickles, and condiments are considered cold.21 The hot or cold nature of a food can be altered through the method of preparation. The use of hot spices or roasting may make a cold food hot; conversely, soaking a hot food in water or blending it with yogurt can change it into a cold food.13 Many foods are considered incompatible in Ayurvedic medicine, such as honey with ghee, rice with vinegar, and honeydew melon with yogurt, because of conflicting properties which over- whelm the agnis and diminish digestion. Although a balance of foods according to humoral effect, universal tendencies, and hot– cold is essential to health, the exact proportions of each change with age, gender, physical con- dition, and the weather. Traditionally, six sea- sons are recognized, each with certain dietary recommendations. During winter, when diges- tion is thought to be strongest, roasted or sour and salty dishes are preferred as well as sweets; in summer and during the monsoons, when digestion is thought to be weak, salty, sour, and fatty foods are avoided.21 The way foods are eaten is as important as which foods are consumed. To maximize digestion of foods, a person should eat in a quiet atmosphere, sip warm water throughout the meal, and sit for a short while after dining.27 ▲ Traditional Indian thali (individual silver serving tray), featuring a selection of roti (flat breads), fruit and vegetable pickles, such as chutneys, and yogurt-based pachadi or rayta. M uk es h Ku m ar /S hu tt er st oc k. co m Pregnancy is considered to be a normal and healthy condition; however, certain food taboos are sometimes followed. Women espe- cially avoid extremes in foods that are too hot or too cold. Lime juice with honey is a general tonic, believed to prevent excessive bleeding at birth, while cow’s milk (particularly with almonds and saffron) and rice porridge are thought to ensure proper development of the fetus. Fenugreek seeds in buttermilk are given for nausea, and butter or ghee is believed to make the body supple and ease delivery of the baby. Food taboos for infants and young chil- dren may also be practiced. A survey of Indian mothers found that many believed spicy foods and mangoes were too hot and caused diarrhea, bananas caused colds, and fried foods were considered difficult to digest and the source of coughs. A small percentage also reported that sweets and salty foods were avoided to prevent diabetes and hypertension, respectively.28 Numerous dietary remedies are listed for minor illness. Barley water is consumed for a fever; vomiting is treated with milk. Coconut water, buttermilk, anise seed oil, and pome- granate flowers are all considered helpful for diarrhea. A powder called ashtachooran (a mixture of asafetida, salt, ginger, pepper, cumin, and ajwain) is added to honey for indi- gestion. Ginger tea or garlic soup is used to treat colds. Gooseberries and hibiscus flower Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 4 7 0 S O U T H A S I A N S tea are considered general tonics.21,29 Bitter- melon and fenugreek seeds—used to treat diabetes—have been found to work clinically as hypoglycemic agents.30 It is widely believed that a highly spiced diet is necessary in the tropical Indian climate to stimulate the liver. One food habit that may result in ill health is the common practice of disguising otherwise undrinkable water with flavorful herbs and spices. Cholera, dysentery, and typhoid are endemic in many regions. Pakistanis Limited data suggest that a hot–cold system of classification is used by some Pakistanis. Items considered hot and therefore avoided during summer include beef and potatoes. Cold foods avoided during winter include chicken, fish, and fruit.31 Folk remedies are very common in Pakistan, for everything from colds and flu to asthma and jaundice.15 Eggs, curds, ginger, honey, and poppy seeds are just a few of the foods used therapeutically. For infant care Pakistanis may believe that colostrum is like stale milk and until the breast milk comes in the baby is given cow’s milk and a mixture of food called gh utti (honey, butter mixed with sugar and other liquids). In addition, some believe that certain foods should be restricted during children’s illness. Breast milk should not be given if the child has diarrhea, and the child has a fever milk and rice are withheld.32,33 Contemporary Food Habits in the United States Adaptations of Food Habits Asian Indians Americans of Asian Indian descent have usu- ally been exposed to American or European lifestyles in India and may be familiar with a Westernized diet before immigration to the United States. Yet even the most accultur- ated Indian Americans continue some tra- ditional food habits. Most accept American foods when eating out, but many prefer Asian Indian foods when at home.34,35 Ingredients and Common Foods Very little research has been conducted on the food habits of Asian Indians in the United States. Two study of Asian Indians college students in Pennsylvania suggested that acculturation takes place in two phases.36 Typically,35 the first lasts for two to three years, often while the immigrant is a student. Interaction with mainstream American society may be limited during this period. The recent immigrant pre- fers to associate with members of the same caste, regional, or linguistic group; experi- ence with American foods often includes only fast foods. Male Asian Indian students are often unable to cook and may rely heav- ily on purchased meals. Many Asian Indian immigrants will eat hamburgers because of their availability and low cost. Sometime dur- ing the next ten years, Asian Indians who stay in the United States longer than four years enter the second phase of acculturation. They are usually employed by American businesses and are raising families. They keep their social interactions with Americans separate from those with other Indian Americans. They might serve meat and alcohol to American guests, for example, and vegetarian dishes to Indian guests. Early research on Asian Indian immigrants reported some vegetarians become meat eat- ers when living in America. In one early study, one-third of those who were vegetarians in India became nonvegetarians in the United States.37 One survey on acculturation pat- terns revealed that nearly 75 percent of Indian Americans believe it is acceptable for nonveg- etarians to eat beef; 44 percent indicated that it is acceptable for vegetarians to eat beef.34 A recent study of software engineers living in northern California also found that accultura- tion resulted in increased acculturation and consumption of meat.38 As yet, the reasons vegetarians become nonvegetarians have not been stated con- clusively. It has been suggested that veg- etarianism may lose its social and cultural significance in the United States. Data regard- ing the influence of factors such as gender, income, region of origin in India, and length of stay in America have been contradictory. Variables that affect acculturation include Asian Indians who are practicing Muslims rarely begin eating pork in the United States. They may drive long distances to purchase halal or kosher meats to fulfill traditional Muslim dietary laws. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 1 4 4 7 1 gender (men tend to change their food hab- its more readily than women because women are the traditional food preparers in Indian society), age (children raised in the United States prefer American foods), marital status (single unmarried men are the most accultur- ated, married men with families in India next, and married men with families in the United States are least acculturated), caste (depend- ing on whether caste members used meat or alcohol in India), and region (Asian Indians from rural areas are often stricter vegetarians than those from the cities). A study of Asian Indians living in Cincinnati found several changes in the types of foods they ate.39 Foods that subjects used fre- quently in India but that were in only low to moderate use in the United States were ghee, yogurt, dal, roti, rice dishes, and tea. Foods that were in low to moderate use in India but in frequent use in the United States were fruit juice, canned or frozen vegetables, American bread, dry cereals, cheese and cheese dishes, and soft drinks. Coffee consumption also increased. A small study of Asian Indians living in New York City and Washington, DC, com- pared the diets of residents who lived in the United States for more than ten years to those who had lived in the United States for less than ten years. Few significant dif-for less than ten years. Few significant dif-for less than ten years. Few significant dif ferences were identified, though longtime residents reported a greater preference for traditional meals at dinner and on weekends than did more recent immigrants. Regard- less of length of residence, consumption of roots/tubers, vegetables oils, legumes, white bread, and tea remained about the same as in India. Ghee intake decreased for both groups; cheese, fruit juice, and whole-wheat bread intake increased. Cola beverages, low- fat milk, pizza, mayonnaise, and cookies were popular American items. Nontradi- tional foods that were never or rarely con- sumed included egg substitutes, nondairy creamer, nonfat milk, peanut butter, hot dogs, and hamburgers. The authors note that many American processed foods and baked goods are now available in India and that recent immigrants have incorporated these items into their diets before coming to the United States.40 Research that compared dietary intake of Asian Indian immigrants originally from different regions of India found some differences in food use. Those from the north were more likely to use fat spreads, such as butter or margarine, while those from the southern areas of India were more likely to eat starchy foods and fried chicken. Immigrants who came from western India ate significantly less fruit and eggs than those from the north and south.41 A majority of Americans of Asian Indian descent make an effort to obtain traditional food products. Many markets in the United States special- ize in Indian canned and packaged food products, including spices, and many stores provide mail orders. Fresh foods are more difficult to find. Some fruits and vegetables can be bought at Asian specialty markets, and Indian bakeries featuring sweets and tif-and Indian bakeries featuring sweets and tif-and Indian bakeries featuring sweets and tif fin items have opened in some areas. Even in an older study done in the Midwest, 100 percent of Indians interviewed reported that their traditional foods were available.39 Meal Composition and Cycle Asian Indian eating patterns may become more irregular in the United States, possibly because of the pressures of a faster-paced lifestyle. Breakfast is the meal most commonly omitted; snacking occurs between one and three times per day and may be more common in women than in men.42,43 Many Americans of Asian Indian descent eat American foods for breakfast and lunch. Traditional Indian evening meals are preferred if native foods and spices are avail- able. Yet dinners at home may also be influ- enced by U.S. food habits in that more meat, poultry, or fish may be eaten, and American breads may be served in place of roti. Recent research on Bengali Americans illustrates many of these changes. Dinner is now the main meal of the day, and breakfast is a little larger than is traditional, usually consisting of toast or cereal and milk, with tea.44 Lunch, unless brought from home, was typically pizza, a salad or a sandwich. Rice remains the core of the evening meal, and 60 percent of households reported serving it daily. Fish consumption, which is closely associated with Bengali ethnic identity, Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 4 7 2 S O U T H A S I A N S actually increases in American homes com- pared to those in India. Fish is served with rice and dal, seasoned with cumin, fennel, fenugreek, nigella seed, and mustard seed. The portion size of fish has doubled to about eight ounces, and this meal is eaten at approximately half of all dinners. Rice with other items, for example, roast chicken, is consumed at other main meals. Dishes are usually prepared Bengali-style by sautéing, stewing, or braising. Pakistanis Many Pakistani Americans are believed to consume at least one traditional meal each day, usually dinner, when the fam- ily can gather and discuss the day’s events.7 American-style convenience foods are popu- lar for breakfast and lunch; cereals, pizza, hamburgers, sandwiches, fried fish, and cook- ies replace the flatbreads, stews, and curries typically consumed for these meals. Research on Pakistani immigrants in Norway found that dinner had become the main meal of the day and that meals on weekends included more traditional foods than did meals during the week.45 Restaurant meals may be avoided by some Pakistani Americans if halal meats are unavailable.46 Nutritional Status Nutritional Intake Recent research on Asian Indians is notewor- thy for the dramatic health changes that have occurred among urban Indians in India and immigrants to Western nations, suggesting adverse effects of dietary differences and a sedentary lifestyle.47 In comparison, there are few data on Pakistani and other South Asian immigrants, especially those in the United States. Asian Indians Data on the nutritional status of Indian Americans suggest that in gen- eral, many meet recommended intakes for grains and vegetables but do not meet those for fruits, dairy products, or meats, poultry, and fish.4,48 Intake of dietary fat approxi- mates that of the U.S. population but is often higher than fat intake in India. Energy, car- bohydrate, and protein intakes may increase with length of stay.49 Figures on fiber intake are less conclusive. Although one study found older immigrants consumed ample amounts, others suggest fiber intake is low, even among vegetarians.49,50 Micronutrient intake is less studied. A study on older Gujarti Americans found that intakes of vitamins D and B6 were low and that intakes of calcium, magnesium, potassium, manganese, copper, zinc, and selenium were marginal. The research- ers questioned dietary sufficiency in this group given the possible reduced bioavail- ability of some micronutrients due to a rela- tively high intake of fiber, especially among vegetarians.49 Obesity rates in Indian Americans are lower than among African Americans and whites in the United States, and average body mass index (BMI) is less than that found in blacks, Mexican Americans, and whites.51,52 However, BMI tends to increase with urbanization and migration, and Asian Indians have a higher percentage of body fat in relation to BMI than other groups.53,54 In addition, Asian Indians have increased amounts of visceral fat, even in non-obese persons.55,56,57 Since a higher percentage of body fat, fat patterning, and abdominal adiposity are associated with increased rates of insulin resistance and dyslipidemia, this suggests that some Asian Indians who are not overweight by national standards are, nonetheless, metabolically obese.55,56,58,59 In 2002, the World Health Organization (WHO) recommended establishing new BMI standards for Asian populations: normal weight (18.5 to 23.0 kg/0 kg/0 k m2, ), a moderate-risk public health action point (23.0 kg/0 kg/0 k m )m )2m ), and a high-risk public health action point (27.5 kg/5 kg/5 k m )m )2m ). In 2009, India’s health ministry enacted even lower BMI ranges for overweight (23.0 to <25.0) and obesity (≥25.0).60,61 High rates of insulin resistance and dylipidemia, especially high triglyceride levels and low high-density lipoprotein (HDL) cholesterol levels, are associated with increased risk for type 2 diabetes and car- diovascular disease in Asian Indians.60,62,63 Data show that Asian Indians develop Chaat houses, specializing in the small, usually cold dishes of mixed fruits, vegetables, legumes, and meats topped with tangy dressing, are trendy gathering spots for Asian Indian Americans. Iron intake may be low among some Indian American vegetarians; however, substantial amounts of iron are obtained through the use of traditional iron cookware.113 Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 1 4 4 7 3 diabetes at an earlier age and at higher prevalence rates than whites and most other ethnic groups.64,65,66,67 Overall prevalence of diabetes in Indian Americans has been estimated to average 13 percent in adults,64 compared to 9.3 percent for the general U.S. population, and is higher than rates for other Asians, blacks, Hispanics, whites, and many Native American groups. Rates of cardio- vascular disease for Indian Americans are higher than for whites, and data show that it has earlier onset and higher mortality rates when compared to deaths from all other causes.68 Cardiovascular risk was found to increase in Asian Indian immigrants with length of stay in one study.69 Hypertension rates in Indian Americans are variable— slightly below the prevalence in whites in some studies and above the average in oth- ers.70,71,72,73 This clustering of conditions—a high waist-to-hip ratio indicative of abdomi- nal fat, insulin resistance or glucose intol- erance, high triglyceride levels, low HDL cholesterol levels, and hypertension—is considered the hallmark of metabolic syn- drome. It is especially associated with Asian Indians, and they may have the highest rates of all ethnic groups.74,75,76,77,78 Researchers are studying numerous other factors related to these issues in an attempt to fully under- stand the role of genetic predisposition and environmental influence (such as diet, inac- tivity, and stress) in the condition.79,80 It should be noted that a vegetarian diet does not necessarily provide protection from these health problems seen in many Asian Indians. Research outcomes that have studied South Asians’ dietary intake and its effect on health have been inconsistent. Veg- etarian diets can be higher in carbohydrates than higher-protein Western diets, but both diets may be hypercaloric, resulting in weight gain.81,82,83 The most prevalent cancers in Asian Indian men are of the lung and prostate. Colorectal cancers, leukemias, and liver can- cers are also common. Asian Indian women suffer from breast cancer most often, fol- lowed by lung and colorectal cancer. Women also have high rates of ovarian and uterine cancers, as well as cancers of the pancreas.84 Oral cancers are also common in South Asians, due in some subgroups to chewing of paan with betel nuts.85 Despite high socioeconomic status, few births to teen mothers, and good prena- tal care, Asian Indian women in one study were more likely to have adverse birth out- comes than blacks, Hispanics, and whites.86,87 These included high levels of low birth weight, mental retardation, and fetal mortal- ity. Other research comparing perinatal out- comes among Asians and Pacific Islanders reported Asian Indian/Pakistani women had the highest risk for preterm delivery, gestational diabetes, and low birth weight at term.85,88 Studies in Canada and Britain have found that South Asian women were more likely than whites to become insulin resistant during late pregnancy, and nearly half of all Asian Indian women who developed gesta- tional diabetes had metabolic syndrome fol- lowing birth.89,90,91 Scientists are uncertain as to why this paradox of poor birth outcomes in a population with few environmental risk factors exists. A study comparing neonatal feeding prac- tices of whites and Indian Americans in the United States and Asian Indians in India found that whites relied on health profession- als for advice, while Indian Americans sought information from family and friends during the first six months and from health profes- sionals thereafter.92 It is common practice in India to avoid breast-feeding colostrum to newborns due to various concerns such as causing indigestion or diarrhea, or that it is bad for the infant’s health. The research- ers report that all white, 76 percent of Indian American, and 32 percent of Indian moth- ers initiated breast-feeding within an hour of birth. Twenty-four percent of Indian American women and 68 percent of Indian mothers delayed breast-feeding for several days, in part to find an auspicious time to start based on astrological conditions.93 Foods such as ghee and fenugreek are believed to increase milk production.94 Prelacteal feeds were prepared for the infants during this period, including honey (which is thought by some Asian Indians to help rid the infant of meconium) and water with sugar, glucose, or jaggery and seasonings such as asafetida, Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 4 7 4 S O U T H A S I A N S cumin, and aniseed. Another study noted that the longer an Indian American woman has lived in the United States, the less likely she is to use traditional feeding practices.93 These same researchers found Asian Indian Ameri- can women breast-fed for shorter durations and introduced formula and solids earlier than did white women.95 Pakistanis Little has been reported on the consumption patterns of Pakistani Americans. Malnutrition has been noted in some regions of Pakistan where droughts limit the food supply, and some studies esti- mate stunting occurs in 40 to 50 percent of all Pakistani children, with stunting in female children three times more likely than in male children.96 Rural children have been found at potential risk for underconsumption of micronutrients even when ample food is available. Vitamin D and iron deficien- cies have been found in pregnant Pakistani women living in Norway, in part due to low intake of supplements; low levels of plasma vitamin D are also a concern in South Asian children living in England. Low bone min- eral density and a risk for early osteoporotic fractures in both men and women from South Asia have been noted.97 In contrast, overconsumption is more of a concern for Pakistanis living in urban areas and in Westernized nations. Children living in Pakistan cities were found to have a high intake of calories, sugar, total fats, and cho- lesterol.98 Overweight and obesity in adults is estimated at 25 percent in the nation, associ- ated with increased age, being female, urban residence, being literate, higher socioeco- nomic status, and higher intake of meat.99,100 Adults living in wealthier neighborhoods of Karachi reported higher rates of type 2 dia- betes and cardiovascular disease when com- pared to those living in impoverished Karachi households. 100 Of particular concern is a fat distribution pattern that favors abdominal fat, even at normal weight levels.101 Pakistanis in Britain had a higher aver- age BMI and higher intake of calories from fat than Europeans or Afro-Caribbean immi- grants in one study.102 When compared to other South Asians, Pakistani men were found to have higher rates of diabetes than Asian Indian men (22 and 15 percent, respectively). The prevalence of metabolic syndrome in adults aged twenty-five years and older from an urban population of Karachi, Pakistan, was over 35 percent.103 Counseling Asian Indians The majority of Indian Americans are very familiar with biomedi- cine, and health care access is considered good. English fluency is prevalent, and only 7 percent of Indian Americans report they speak English “less than well”—a small num- ber given the high percentage of first-genera- tion immigrants in the population. The largest dialects spoken in the United States are Hindi, Gujerati, and Bengali. Many Asian Indians whose native tongue is another dialect also speak Hindi.104 Traditional expectations regarding social interactions may present problems in the provider–client relationship.105 A client may not disagree with or correct a provider in situations where the client believes that the provider is superior in status, and compli- ance may be assumed because the client does not indicate otherwise. If the client does not feel that treatment is satisfactory, he or she will typically change providers rather than confront the problem. Conversely, if a cli- ent believes that she or he is an equal with the provider, the client may desire a social rather than professional relationship with the provider. The client may also feel entitled to special privileges, such as immediate access to the provider and longer appointments. Some Americans of Asian Indian descent may feel cheated if exhaustive testing procedures or invasive therapies are not provided for their condition.105 A polite, respectful, direct yet leisurely style of communication is preferred by most South Asians.5 Loudness is discouraged, whereas self-control and occasional periods of silence are valued. Small talk is significant, and rushing is considered rude. A direct “no” is considered impolite, so an evasive negative response is the norm. Feelings and faith may be more important than objective facts in making decisions.25 Asian Indians may have difficulty digesting fresh milk; estimates also indicate that 60 percent of adults in Pakistan are lactose intolerant.114 Conditions that may be of concern in some Asian Indians and Pakistanis include beta-thalassemia, which is a commonly inherited disorder, and a high prevalence of glu- cose-6-phosphate dehy- drogenase deficiency in some tribal groups from the North-West Frontier Province of Pakistan. Iodine deficiency and goiter are endemic in the Kashmir region. One Ayurvedic remedy for diabetes uses ginger and rock candy. Mental illness is highly stigmatized in India. Complaints of headache, leg tingling, or burn- ing on the soles of the feet may be related to psychological distress in recent immigrants. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 1 4 4 7 5 Though India is a relatively low-context culture,25 several nonverbal communication customs among Asian Indians are significant. Most Indian Hindu, Sikh, and Christian men and women avoid contact with the opposite sex in public, and contact between men and women in public is completely prohibited by Muslims. Direct eye contact between men and women who are not related may be interpreted by some less acculturated South Asians as suggestive.5 The traditional greet- ing is to nod with the head while holding the hands palm to palm beneath the chin and saying “namaste” (“I honor God within you”), but Westernized Indians will use a handshake (it is best to wait and follow the client’s lead). Some Asian Indians (especially those from South India) indicate agreement by head wobbling, which resembles the way Americans shake their heads back and forth to indicate the negative.25 Informal smiles are used between equals only—superiors do not generally smile at subordinates or vice versa. In both India and Pakistan the left hand is never used for any social purposes, including handshakes, giving an item to another person, or pointing. The head is considered the seat of the soul; patting or touching another person’s head should always be avoided. Conversely, the feet and shoe soles are considered the dirtiest parts of the body, and it is impolite to point with the foot or show the bottom of one’s shoe.25 All that said, it should be noted that most Indian Americans are highly acculturated and can converse in a style comfortable for Americans. Asian Indian women are often less vocal than men and may be very uncomfortable with a male health care provider. Men do not touch women in either informal or for- mal situations; physical exams of women are unusual. Female gynecologists and obstetri- cians may be preferred. Family members may accompany a patient, especially a woman, as a chaperone during an appointment. The chap- erone expects to participate in any discussion of the client and to oversee the exam (privacy among spouses and siblings is limited). Family members may also assume responsibility for all but the most technical care of a patient during hospitalization; it is their obligation to feed, bathe, and support a relative. If cost is an issue in obtaining health care, the male head of the household may receive priority over women, girls, or elders in a traditional Asian Indian home. Americans of Asian Indian descent may provide more information regarding their condition than the practitioner may feel is warranted. Ayurvedic medicine focuses on a person’s role within the cosmos, so details about what a client is eating, sleep patterns, and changes in the weather may be impor- tant to a client. Most clients expect lifestyle advice, particularly regarding diet, as part of their therapy.13,27 Some clients may expect a complete history and physical exam to be undertaken at each appointment, while oth- ers assume that the practitioner can diag- nose simply by taking a pulse and without prying into what may be perceived as per- sonal issues. The practitioner should pro- ceed cautiously with questioning until the client’s expectations have been determined. Indian Americans have strong opinions about the therapeutic value of medications. Injections are believed most potent, and in India a patient might receive between one and four shots each visit. Capsules are thought to be more effective than tab- lets, and colorful tablets more potent than white tablets. Furthermore, the medication becomes more effective through the skill of the provider; thus, it is imperative that the provider personally hand the prescription to the client. Little information has been reported regarding the use of Ayurvedic medicine or folk remedies by Asian Indians living in the United States. Research suggests that home remedies, Ayurvedic medicines, and homeopathic prescriptions are used fre- quently, most often for minor ailments or when biomedical therapies were ineffective. Traditional cures are often used concur- rently with biomedicine.106 Although most herbal preparations are compatible with biomedical therapies, some have potent therapeutic effects (see the earlier section “Traditional Health Beliefs and Practices”), Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 4 7 6 S O U T H A S I A N S thus it is important to ascertain which rem- edies are in use. Further, a study of herbal medicines purchased in South Asian grocery stores found that one in every five contained potentially harmful levels of lead, mercury, or arsenic.107 An in-depth interview should be used to establish the client’s religious affiliation and degree of adherence, length of residency in the United States, and degree of acculturation, as well as vegetarian or nonvegetarian preferences. Clients should also be asked about Ayurvedic practices, particularly those regarding diet and home remedies. Pakistanis There has been little reported spe- cifically on counseling Pakistani American clients. Most are familiar with biomedicine. Few data are available on health insurance coverage for Pakistanis. Though fewer than 10 percent of Pakistanis speak only English at home, another 90 percent reported speak- ing it well.104 The remaining 10 percent speak English less than “well,” which pres- ents potential language difficulties in some clinical situations. It should be noted that although Urdu is the official language of Pak- istan, only 8 percent of Pakistanis speak it as their native tongue. Nearly half of Pakistanis speak Punjabi, and the remainder are divided between six or seven other languages or dialects. In contrast to Asian Indians, Pakistanis tend to prefer indirect, restrained commu- nication and avoid confrontation. They are more high-context than Asian Indians, and meaning is interpreted through the specifics of the social situation and the use of sym- bolic language.25 In general, loud expression and body motions are avoided, and many gestures, including winking and whistling, are considered vulgar. Pakistan is essentially a nontouching culture, but hugs and other expressions of warmth are found between intimates of the same gender. A very soft shake of the right hand, then touching the heart, is known as the salaam and is the traditional greeting between men. Hand- shaking may be used with Westerners, though it tends to be an adaptation of the salaam and is light. Men and women do not use the salaam or shake hands in the American style unless the woman is west- ernized. Many Pakistanis maintain an expression of serious attention in interac- tions with acquaintances. Pakistanis are similar to Asian Indians regarding certain nonverbal communica- tion styles. No eye contact or only periph- eral glances may be preferred between men and women, for example. A Pakistani should never be touched on the head with- out requesting and receiving permission to do so, the foot should never be used to point, and the soles of shoes should not be shown when seated. Only the right hand should be used to touch people and pass objects, includ- ing papers and money. Slouching and leaning are inappropriate in most circumstances. Pakistanis may stand closer than is comfort- able for Americans, and it is considered rude to back away.25 Islamic rules regarding modesty may require women to seek care only from other women. Exposure of clients, even when men are examining men, should be limited.14 In Pakistan, families may be responsible for pro- viding food or medicine for ill members who are hospitalized. Pakistanis in Great Britain report that family care often includes prayer and massage.108 Women may be discouraged from decision making, which is traditionally the responsibility of a husband or older male relative. Many South Asians in Scotland (Pakistanis and Asian Indians) believe American medica- tions are superior to those from their home- land. A study on use of oral hypoglycemic agents found that some patients assumed they should take the medication only if they had symptoms, while others worried about long-term use or adverse effects if taken with other drugs or certain traditional foods.109 Clients sometimes reduce intake without supervision. An in-depth interview, including assess- ment of education level and acculturation status, is necessary to determine appropri- ate therapeutic approaches for Pakistani American clients. Accommodation of Muslim dietary laws and individual preferences in nutritional counseling is most effective. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 1 4 4 7 7 D I S C U S S I O N S T A R T E R S Comparing Native Diet and Culture to That of Immigrants in the United States In small groups of three to four, compare and contrast the diet and culture of Asian Indian and Pakistani immigrants to the United States with the diet and culture of immigrants to the United States from the Balkans and the Middle East (see Discussion Starter from Chapter 13) and from Vietnam, Cambodia, and Laos (see Discussion Starter from Chapter 12). Again, each group of students is to focus on a different aspect of the diet and culture of these groups: Within your group, decide on what findings to report to the rest of the class. Before breaking up, assign a number to each group member: A1, A2, A3, A4; B1, B2, and so on. Form new groups with all the 1’s in a group; all the 2’s in another group; all the 3’s another group; and so on. In your new group, report the findings of your previous group, and as a group, discuss the how traditional attitudes toward diet and health in these immigrant groups relate to the changes in diet and health due to immigration to the United States. Group A: The food habits and the typical eating etiquette and meal composition of these three immigrant groups Group B: Issues involved in counseling these immigrant groups on diet and health Group C: Attitudes within each immigrant group toward diet, health, and medical treatment, notably attitudes toward traditional home culture medical treatment and U.S. biomedicine Group D: Amount of obesity, diabetes, hypertension, and other diseases within each immigrant group I am from India and have been a practitioner in the United States for close to thirty years, and many of my clients are South Asians. I would describe the typical South Asian meal as containing a lot of variety on the plate— grains (rice and bread), beans (lentils), salad ingredients in the raytas, along with vegetables. The meal also contains several condiments, such as pappadams and pickled mangos—all these ingredients help balance the meal, which is important because many South Asians from India are vegetarians. For South Asians living in the United States, the typical fast foods that have crept into the diet tend to be those that can be vegetarian, such as pizza. Inexpensive convenience foods are bagels, pasta, and ramen noodles. Many South Asians will go out to eat in Mexican and most Asian restaurants. Preparation of South Asian food is labor intensive, and back home there are often servants to help in the kitchen. Here, especially for younger South Asian men who are not married, the ingredients may be hard to find, and they will have to prepare their own food. So it is not uncommon that they will go out to eat and, even though they are vegetarian, will sometimes even eat hamburgers. South Asians have a very high rate of type 2 diabetes and heart disease, so my advice to many of my clients is to eat smaller portions of rice and bread, increase their intake of vegetables and lentils, and be aware of the sodium content in food, especially pickles. I always ask about desserts and sweets in their diet since they are common in the diet. I never tell my clients to eliminate bread and rice in their diet because I know they won’t do it. Instead, I tell them how much they can eat. Same with fruit, but I tell them to eat whole fruit and not consume it as juice. P R A C T I T I O N E R P E R S P E C T I V E S Asian Indian Gita Patel, MS, RD, CDE, LD Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 4 7 8 S O U T H A S I A N S Review Questions 1. List the countries that comprise South Asia. List and briefly describe at least four religions practiced in this region. What are the simi- larities and differences in regard to religion between Pakistan and India? 2. Describe the vegetarian diet of Hindus. Which animal foods are allowed and which are not consumed? What are the staples of the diet? How would the Hindu diet differ from that of the Sikhs and Muslims? What would make a food pure or polluted? Are there regional dif-food pure or polluted? Are there regional dif-food pure or polluted? Are there regional dif ferences in staples used in India and Pakistan? Describe at least three types of bread con- sumed in India. 3. What are masalas, and when are they used in South Asian cooking? Describe regional varia- tions in South Asian cuisine. What is curry? 4. Briefly explain Ayurvedic medicine. How does food fit into the Ayurvedic system? 5. What is metabolic syndrome? How does it affect Asian Indians, and how may their diet contribute to its development? References 1. U.S. Census Bureau. 2013. American Community Survey 1 Year Estimates. S0201. Selected Popu- lation Profile in the U.S. Available from http:// factfinder.census.gov 2. Berger, J. 2004. Indian, twice-removed. N ew Y or k T imes, December 17. 3. Dhingra, P. 2012. L if e beh ind th e l obby : I ndian A mer ic an motel ow ner s and th e A mer ic an dr eam. Stanford, CA: Stanford University Press. 4. Pavri, T. 2000. Asian Indian Americans. In R.V. Dassanowsky & J. Lehman (Eds.), G al e E nc y c l o- pedia of M ul tic ul tur al A mer ic a. Farmington Hills, MI: Gale Group. 5. Yehieli, M., & Grey, M.A. 2005. H eal th matter s: A poc k et guide f or w or k ing w ith div er se c ul tur es and under ser v ed popul ations. Boston: Intercul- tural Press. 6. Arpana, G., Inman, Erin E. Howard, Robin L., & Beaumont, Jessica A. Walker. 2007. Cultural transmission: Influence of contextual factors in Asian Indian immigrant parents’ experi- ences. J our nal of C ounsel ing P sy c h ol ogy , 5 4 (1), 93–100. 7. Pavri, T. 2000. Pakistani Americans. In R.V. Das- sanowsky & J. Lehman (Eds.), G al e enc y c l opedia of mul tic ul tur al A mer ic a. Farmington Hills, MI: Gale Group. 8. Sen, C.T. 2004. F ood c ul tur e in I ndia. Westport, CT: Greenwood Press. 9. Tirtha, S.S. 1998. T h e A y ur v edic enc y c l opedia: N at- ur al sec r ets to h eal ing, pr ev ention and l ongev ity . New York: Ayurveda Holistic Center Press. 10. Chhetri, D.R., Parajuli, P., & Subba, G.C. 2005. Antidiabetic plants used by Sikkim and Darjeel- ing Himalayan tribes, India. J our nal of E th noph ar - mac ol ogy , 9 9 , 199–202. 11. Katewa, S.S., Chaudhary, B.L., & Jain, A. 2004. Folk medicines from tribal areas of Rajasthan, India. J our nal of E th noph ar mac ol ogy , 9 2 , 41–46. 12. Mahishi, P., Srinivasa, B.H., & Shivanna, M.B. 2005. Medicinal plant wealth of local commu- nities in some villages in Shimoga District of Karnataka, India. J our nal of E th noph ar mac ol ogy , 9 8 , 307–312. 13. Ramakrishna, J., & Weiss, M.G. 1992. Health, ill- ness, and immigration. East Indians in the United States. W ester n J our nal of M edic ine, 1 5 7 , 265–270.1 5 7 , 265–270.1 5 7 14. Geissler, E.M. 1998. P oc k et guide to c ul tur al assess- ment. St. Louis, MO: Mosby. 15. Qidwai, W., Alim, S.R., Dhanani, R.H., Jehangir, S., Nasrullah, A., & Raza, A. 2003. Use of folk remedies among patients in Karachi Pakistan. J our nal of A y ub M edic al C ol l ege, 1 5 , 31–33. 16. Shaikh, B.T., & Hatcher, J. 2005. Complementary and alternative medicine in Pakistan: Prospects and limitations. E v idenc e B ased C ompl ementar y and A l ter nativ e M edic ine, 2 , 139–142. 17. Bharadwaj, M. 2000. T h e I ndian spic e k itc h en. New York: Hippocrene Books. 18. Bladholm, L. 2000. T h e I ndian gr oc er y stor e demy stif ied. Los Angeles: Renaissance Books. 19. Zibart, E. 2001. T h e eth nic f ood l ov er ’ s c ompanion: U nder standing th e c uisines of th e w or l d. Birming- ham, AL: Menasha Ridge Press. 20. Flowerday, J. 2006. C ook ing in H unz a. Saudi Aramco World, May/June. Retrieved from http:// www.saudiaramcoworld.com/issue/200603/ cooking.in.hunza.htm (accessed April 23, 2015). 21. Achaya, K.T. 1994. I ndian f ood: A h istor ic al c om- panion. Delhi: Oxford University Press. 22. Kirkwood, N.A. 2005. T h e h ospital h andbook on mul tic ul tur al ism and r el igion. Harrisburg, PA: Morehouse. 23. Rau, S.R. 1969. T h e c ook ing of I ndia. New York: Time-Life Books. 24. Albyn, C.L., & Webb, L.S. 1993. T h e mul tic ul tur al c ook book f or students. Phoenix: Oryx Press. 25. Foster, D. 2000. T h e gl obal etiq uette guide to A sia. New York: Wiley. 26. Kaimal, M. 2000. S av or ing th e spic e c oast of I ndia: F r esh f l av or s f r om K er al a. New York: HarperCollins. 27. Larson-Presswalla, J. 1994. Insights into Eastern health care: Some transcultural nursing perspec- tives. J our nal of T r ansc ul tur al N ur sing, J our nal of T r ansc ul tur al N ur sing, J our nal of T r ansc ul tur al N ur sing 5 , 21–24. 28. Sivaramakrishnan, M., & Patel, V.L. 1993. Role of traditional knowledge in the explanation of childhood nutritional deficiency by Indian mothers. J our nal of N utr ition E duc ation, 2 5 , 212–129. 29. Khanna, G. 1986. H er bal r emedies: A h andbook of f ol k medic ine (4th ed.). New Delhi: Tarang Paperbacks. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 1 4 4 7 9 30. Jung, M., Park, M., Lee, H.C., Kang, Y.H., Kang, E.S., & Kim, S.K. 2006. Antidiabetic agents from medicinal plants. C ur r ent M edic inal C h emistr y , 1 3 , 1203–1218. 31. Galanti, G.A. 2004. C ar ing f or patients f r om dif f er -C ar ing f or patients f r om dif f er -C ar ing f or patients f r om dif f er ent c ul tur es (3rd ed.). Philadelphia: University of Pennsylvania Press. 32. Hirani, S.S.A. 2012. Malnutrition in young Pakistani children. J our nal of A y ub M edic al C ol l ege A bbottabad, 2 4 (2), 150–152. 33. Memon, Y., Sheikh, S., Memon, A., & Memon, N. 2006. Feeding beliefs and practices of mothers/ caregivers for their infants. J our nal of L iaq uat U niv er sity of M edic al and H eal th S c ienc es, 5 (1), 8–13. 34. Sodowsky, G.R., & Carey, J.C. 1988. Relationships between acculturation-related demographics and cultural attitudes of an Asian Indian immigrant group. J our nal of M ul tic ul tur al C ounsel ing and Dev el opment, 1 6 , 117–136. 35. Mahadevan, Meena, and Blair, Dorothy. 2009. Changes in food habits of South Indian Hindu Brahmin immigrants in State College, PA. E c ol ogy of F ood and N utr ition, 4 8 (5), 404–432. 36. Gupta, S.P. 1976. Changes in food habits of Asian Indians in the United States: A case study. S oc iol - ogy and S oc ial R esear c h , 6 0 , 87–99. 37. Karim, N., Bloch, D.S., Falciglia, G., & Murthy, L. 1986. Modifications of food consumption pat- terns reported by people from India, living in Cincinnati, Ohio. E c ol ogy of F ood and N utr ition, 1 9 , 11–18. 38. Shruti, Maheshwary, & Wagle, Ashwini. 2010. A c c ul tur ation, f ood h abits, and ph y sic al ac tiv ity in S outh A sian sof tw ar e engineer s l iv ing in th e U nited S tates, MS project, San Jose State University. 39. Karim, N., Bloch, D.S., Falciglia, G., & Murthy, L. 1986. Modifications of food consumption pat- terns reported by people from India, living in Cincinnati, Ohio. E c ol ogy of F ood and N utr ition, 1 9 , 11–18. 40. Raj, S., Gangnna, P., & Bowering, J. 1999. Dietary habits of Asian Indians in relation to the length of residence in the United States. J our nal of th e A mer ic an Dietetic A ssoc iation, 9 9 , 1106–1108. 41. Jonnalgadda, S.S., & Diwan, S. 2002. Regional variations in dietary intake and body mass index of first-generation Asian Indian immigrants in the United States. J our nal of th e A mer ic an Dietetic A ssoc iation, 1 0 2 , 1286–1289. 42. Raj, S., Gangnna, P., & Bowering, J. 1999. Dietary habits of Asian Indians in relation to the length of residence in the United States. J our nal of th e A mer ic an Dietetic A ssoc iation, 9 9 , 1106–1108. 43. Yagalla, M.V., Hoerr, S.L., Song, W.O., Enas, E., & Garg, A. 1996. Relationship of diet, abdominal obesity, and physical activity to plasma lipopro- tein levels in Asian Indian physicians residing in the United States. J our nal of th e A mer ic an Dietetic A ssoc iation, 9 6 , 257–261. 44. Ray, K. 2004. T h e migr ant’ s tabl e: M eal s and memor ies among B engal i A mer ic an h ouseh ol ds. Philadelphia: Temple University Press. 45. Mellin-Olsen, T., & Wandel, M. 2005. Changes in food habits among Pakistani immigrant women in Oslo, Norway. E th nic ity & H eal th , 1 0 , 311–339. 46. Balagopal, P., Ganganna, P., Karmally, W., Kulkarni, K., Raj, S., Ramasubramanian, N., & Siddiwui- Mufti, M. 2000. I ndian and P ak istani f ood pr ac tic es, c ustoms, and h ol iday s (2nd ed.). Ethnic and regional c ustoms, and h ol iday s (2nd ed.). Ethnic and regional c ustoms, and h ol iday s food practices. Chicago: American Dietetic Asso- ciation/American Diabetes Association. 47. Tang, J.W., Mason, M., Kushner, R.F., Tirodkar, M.A., Khurana, N., & Kandula, N.R. 2012. South Asian American perspectives on overweight, obesity, and the relationship between weight and health. P r ev enting C h r onic Disease, 9 . 110284. doi: http://dx.doi.org/10.5888/pcd9.110284. Retrieved f rom http://w w w.cdc.gov/p cd/ issues/2012/11_0284.htm 48. Jonnalgadda, S.S., Diwan, S., & Cohen, D.L. 2005. U.S. Food Guide Pyramid food group intake by Asian Indian immigrants in the U.S. J our nal of N utr ition, H eal th , and A ging, N utr ition, H eal th , and A ging, N utr ition, H eal th , and A ging 9 , 226–231. 49. Jonnalgadda, S.S., & Diwan, S. 2002. Nutrient intake of first generation Gujarati Asian Indian immigrants in the U.S. J our nal of th e A mer ic an C ol l ege of N utr ition, 2 1 , 372–380. 50. Jonnalgadda, S.S., & Diwan, S. 2002. Regional variations in dietary intake and body mass index of first-generation Asian Indian immigrants in the United States. J our nal of th e A mer ic an Dietetic A ssoc iation, 1 0 2 , 1286–1289. 51. Lauderdale, D.S., & Rathouz, P.J. 2000. Body mass index in a US national sample of Asian Americans: The effects of nativity, years since immigration and socioeconomic status. I nter national J our nal of O besity , 2 4 , 1188–1194 52. Chiu, M., Austin, P.C., Manuel, D.G., Shah, B.R., & Tu, J.V. 2011. Deriving ethnic-specific BMI cutoff points for assessing diabetes risk. Diabetes C ar e, 3 4 (8), 1741–1748. 53. Dudeja, V., Misra, A., Pandey, R.M., Devina, G., Kumar, G., & Vikram, N.K. 2001. BMI does not accurately predict overweight in Asian Indians in northern India. B r itish J our nal of N utr ition, 86, 105–112. 54. Lubree, H.G., Rege, S.S., Bhat, D.S., Raut, K.N., Panchnadikar, A., Joglekar, C.V., . . . Yudkin, J. 2002. Body fat and cardiovascular risk factors in Indian men in three geographical locations. F ood and N utr ition B ul l etin, 2 3 , 146–149. 55. Bajaj, M., & Banerji, M.A. 2004. Type 2 diabetes in South Asians: A pathophysio logic focus on the Asian Indian epidemic. C ur r ent Diabetes R epor t, 4 , 213–218. 56. Ivey, S.L., Mehta, K.M., Fyr, C., & Kanaya, A.M. 2006. Prevalence and correlations of cardiovascu- lar risk factors in South Asians: Population-based data from two California surveys. E th nic ity & Dis- ease, 1 6 , 886–893. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 4 8 0 S O U T H A S I A N S 57. Venkataranman, R., Nanda, N.C., Baweja, G., Parikh, N., & Bhatia, V. 2004. Prevalence of diabe- tes and related conditions in Asian Indians living in the United States. A mer ic an J our nal of C ar diol - ogy , 9 4 , 977–980. 58. Anand, S.S., Yusuf, S., Vuksan, V., Devanesan, S., Teo, K.K., Montague, P.A., . . . McQueen, M. 2000. Differences in risk factors, artherosclerosis, and cardiovascular disease between ethnic groups in Canada: The Study of Health Assessment and Risk in Ethnic Groups. L anc et, 3 5 6 , 279–284. 59. Raji, A., Seely, E.W., Arky, R.A., & Simonson, D.C. 2001. Body fat distribution and insulin resistance in health Asian Indians and Caucasians. J our nal of C l inic al E ndoc r inol ogy and M etabol ism, 8 6 , 5366–5371. 60. Expert Consultation WHO. 2004; Appropriate body-mass index for Asian populations and its implications for policy and intervention strate- gies. L anc et, 3 6 3 (9403), 157–163. 61. Misra, A, Chowbey, P, Makkar, BM, Vikram, NK, Wasir, JS, Chadha, D., . . . Concensus Group. 2009. Consensus statement for diagnosis of obe- sity, abdominal obesity and the metabolic syn- drome for Asian Indians and recommendations for physical activity, medical and surgical man- agement. J our nal of th e A ssoc iation P h y sic ians I ndia, 5 7 , 163–170.5 7 , 163–170.5 7 62. Gupta, M., Singh, N., & Verma, S. 2006. South Asians and cardiovascular risk: What clinicians should know. C ir c ul ation, 1 1 3 , e924–e929. 63. Palaniappan, L.P., Araneta, M.R., Assimes, T.L., Barrett-Connor, E.L., Carnethon, M.R., Criqui, M.H., . . . Wong, N.D. 2010. Call to action: Cardiovascular disease in Asian Americans: A science advisory from the American Heart Asso- ciation. C ir c ul ation, 1 2 2 (12), 1242–1252. 64. Centers for Disease Control and Prevention. 2014. N ational diabetes statistic s r epor t: E stimates of diabetes and its bur den in th e U nited S tates, 2014. Atlanta, GA: U.S. Department of Health and Human Services. 65. Enas, E.A., Mohan, V., Deepa, M., Farooq, S., Pazhoor, S., & Chennikkara, H. 2007. The meta- bolic syndrome and dyslipidemia among Asian Indians: A population with high rates of diabetes and premature coronary artery disease. J our nal of th e c ar diometabol ic sy ndr ome, 2 , 267–275. 66. Oza-Frank, R., Ali, M.K., Vaccarino, V., & Narayan, K.M. 2009, September. Asian Americans: Diabetes prevalence across U.S. and World Health Orga- nization weight classifications. Diabetes C ar e, 3 2 , 1644–1646. 67. Kanaya, A.M., Wassel, L., Mathur, D., Stewart, A., Herrington, D., Budoff, M.J., . . . Liu, K. 2010 Prevalence and correlates of diabetes in South Asian Indians in the United States: Findings from the metabolic syndrome and atherosclerosis in South Asians living in America study and the Multi-Ethnic Study of Atherosclerosis. M etabol ic S y ndr ome and R el ated Disor der s, 8 (2), 157–164. 68. Palaniappan, L., Wang, Y., & Fortmann, S.P. 2004. Coronary heart disease mortality for six ethnic groups in California, 1990–2000. A nnal s of E pidemiol ogy , 1 4 , 499–506. 69. Sunderam, B., Holley, D.C., Cornelissen, G., Naik, D., Hanumansetty, R., Singh, R.B., . . . Halberg, F. 2005. Circadian and circaseptan (about-weekly) aspects of immigrant Indians’ blood pressure and heart rate in California, USA. B iomedic al P h ar - mac oth er apy , 5 9 (Suppl. 1), S76–S85.5 9 (Suppl. 1), S76–S85.5 9 70. Agyemang, C., & Bhopal, R.S. 2002. Is the blood pressure of South Asian adults in the UK higher or lower than that in European white adults? A review of cross-sectional data. J our nal of H uman H y per tension, 1 6 , 739–751. 71. Mohanty, S.A., Woolhandler, S., Himmelstein, D.U., & Bor, D.M. 2005. Diabetes and cardiovas- cular disease among Asian Indians in the United States. J our nal of G ener al I nter nal M edic ine, 2 0 , 474–478. 72. Leenen, F.H., Dumais, J., McInnis, N.H., Turton, P., Stratychuk, L., Nemeth, K., . . . Fodor, G. 2008. Results of the Ontario survey on the prevalence and control of hypertension. C anadian M edic al A ssoc iation J our nal , 1 7 8 (11), 1441–1449. 73. Jose, P., Zhao, B., Chung, S., Fortmann, S., & Palaniappan, L. 2013. Variation in hypertension prevalence among Asian American subgroups: Results from PACS Pan Asian Cohort Study. C l in- ic al M edic ine & R esear c h , 1 1 (3), 136. doi:10.3121/ cmr.2013.1176.ps1–46 74. Merchant, A.T., Anand, S.S., Vuksan, V., Jacobs, R., Davis, B., Teo, K., & Yusuf, S. 2005. Protein intake is inversely associated with abdominal obesity in a multiethnic population. J our nal of N utr ition, 1 3 5 , 1196–1201. 75. Ramachandran, A., Snehalatha, C., Satyavani, K., Sivasankari, S., & Vijay, V. 2003. Metabolic syndrome in urban Asian Indian adults—a pop- ulation study using modified ATPIII criteria. Dia- betes R esear c h and C l inic al P r ac tic e, 6 0 , 199–204. 76. Dudeja, V., Misra, A., Pandey, R.M., Devina, G., Kumar, G., & Vikram, N.K. 2001. BMI does not accurately predict overweight in Asian Indians in northern India. B r itish J our nal of N utr ition, 86, 105–112. 77. Flowers, E., Molina, C., Mathur, A., Prasad, M., Abrams, L., Sathe, A., . . . Tarakhia, M.P. 2010. Prevalence of metabolic syndrome in South Asians residing in the United States. M etabol ic S y ndr ome and R el ated Disor der s, 8 (5), 417–423. 78. Shah, A., Hernandez, A., Mathur, D., Budoff, M.J., & Kanaya, A.M. 2012. Adipokines and body fat composition in South Asians: Results of the metabolic syndrome and atherosclerosis in South Asians Living in America (MASALA) study. I nter national J our nal of O besity , 3 6 (6), 810–816. 79. Brunner, J., Hemingway, H., Walker, B.R., Page, M., Clarke, P., Juneja, M., . . . Marmot, M.G. 2002. Adrenocortical, autonomic, and Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 1 4 4 8 1 inflammatory causes of the metabolic syndrome: Nested cases-control study. C ir c ul ation, 1 0 6 , 2659–2665. 80. Chandalia, M., Cabo-Chan, A.V., Devaraj, S., Jia- lal, I., Grundy, S.M., & Abate, N. 2003. Elevated plasma high-sensitivity C-reactive protein con- centrations in Asian Indians living in the United States. J our nal of C l inic al E ndoc r inol ogy and M etabol ism, 8 8 , 3773–3776. 81. Wang, E.T., de Koning, L., & Kanaya, A.M. 2010. Higher protein intake is associated with diabe- tes risk in South Asian Indians: The Metabolic Syndrome and Atherosclerosis in South Asians Living in America (MASALA) study. J our nal of th e A mer ic an C ol l ege of N utr ition, 2 9 (2), 130–135. 82. Garduno-Diaz, S.D., & Khokhar, S. 2013. South Asian dietary patterns and their association with risk factors for the metabolic syndrome. J our nal of H uman N utr ition & Dietetic s, 2 6 (2),144–155. 83. Gadgil, M.D., Anderson, C.A., Kandula, N.R., & Kanaya, A.M. 2014, February. Dietary patterns in Asian Indians in the United States: An analysis of the metabolic syndrome and atherosclerosis in South Asians Living in America study. J our nal of th e A c ademy of N utr ition and Dietetic s, 1 1 4 (2), 238–243. 84. Chu, K.C., & Chu, K.T. 2005. 1999–2001 cancer mortality rates for Asian and Pacific Islander eth- nic groups with comparisons to their 1988–1992 rates. C anc er , 1 0 4 , 2989–2998. 85. Ahluwalia, K.P. 2005. Assessing the oral cancer risk of South-Asian immigrants in New York City. C anc er , 1 0 4 , 2959–2961. 86. Gould, J.B., Madan, A., Qin, C., & Chavez, G. 2003. Perinatal outcomes in two dissimilar immi- grant populations in the United States: A dual epi- demiologic paradox. P ediatr ic s, 1 1 1 , e678–e682. 87. Alexander, G.R., Wingate, M.S., Mor, J., & Boulet, S. 2007. Birth outcomes of Asian Indian Americans. I nter national J our nal of G y naec ol ogy and O bstetr ic s, 9 7 (3), 215–220. 88. Rao, A.K., Daniels, K., El-Sayed, Y.Y., Moshesh, M.K., & Caughey, A.B. 2006. Perinatal outcomes among Asian American and Pacific Islander women. A mer ic an J our nal of O bstetr ic s and G y ne- c ol ogy , 1 9 5 , 834–838. 89. Kousta, E., Efstathiadou, Z., Lawrence, N.J., Jeffs, J.A., Godsland, I.F., Barrett, S.C., . . . Johnston, D.G. 2006. The impact of ethnicity on glucose regulation and the metabolic syndrome follow- ing gestational diabetes. Diabetol ogia, 4 9 , 36–40. 90. Retnakaran, R., Hanley, A.J., Connelly, P.W., Sermer, M., & Zinman, B. 2006. Ethnicity modi- fies the effect of obesity on insulin resistance in pregnancy: A comparison of Asian, South Asian, and Caucasian women. J our nal of C l inic al E ndoc r inol ogy and M etabol ism, 9 1 , 93–97. 91. Hedderson, M.M., Darbinian, J.A., & Ferrara A. 2010. Disparities in the risk of gestational diabetes by race-ethnicity and country of birth. P aediatr ic and P er inatal E pidemiol ogy , 2 (5), 441–448. 92. Kannan, S., Carruth, B.R., & Skinner, J. 2004. Neonatal feeding practices of Anglo American mothers and Asian Indian mothers living in the United States and India. J our nal of N utr ition E duc ation and B eh av ior , 3 6 , 315–319. 93. Kannan, S., Carruth, B.R., & Skinner, J. 1999. Cultural influences on infant feeding beliefs of mothers. J our nal of th e A mer ic an Dietetic A sso- c iation, 9 9 , 88–90. 94. Varma, S., Wagle, A., & Sucher, K. 2010. Dietar y beh av ior s and pr ac tic es of pr egnant and l ac tating S outh A sian w omen l iv ing in th e U nited S tates. San Jose State University, San Jose, CA. Master’s project. 95. Kannan, S., Carruth, B.R., & Skinner, J. 1999. Infant feeding practices of Anglo American and Asian Indian American mothers. J our nal of th e A mer ic an C ol l ege of N utr ition, 1 8 , 279–286. 96. Baig-Ansari, N., Rahbar, M.H., Bhutta, Z.A., & Badruddin, S.H. 2006. Child’s gender and house- hold food insecurity are associated with stunting among young Pakistani children residing in urban squatter settlements. F ood and N utr ition B ul l etin, 2 7 , 114–127.B ul l etin, 2 7 , 114–127.B ul l etin, 2 7 97. Nimitphong, H., & Holick, M.F. 2013. Vitamin D status and sun exposure in southeast Asia. Der mato- E ndoc r inol ogy , 5 (1), 34–37. 98. Hakeem, R., Thomas, J., & Badruddin, S.H. 1999. Rural-urban differences in food and nutri- ent intake of Pakistani children. J our nal of th e P ak istani M edic al A ssoc iation, 4 9 , 288–294. 99. Jafar, J.H., Chaturvedi, N., & Pappas, G. 2006. Prevalence of overweight and obesity and their association with hypertension and diabetes in an Indian-Asian population. C anadian M edic al A ssoc iation J our nal , 1 7 5 , 1071–1077. 100. Sherin, A. 2013. Obesity: How to prevent Paki- stani people from getting heavier? K h y ber M edi- c al U niv er sity J our nal , 5 (2), 59–60. 101. Bose, K. 1995. A comparative study of gener- alized obesity and anatomical distribution of subcutaneous fat in adult white and Pakistani migrant males in Peterborough. J our nal of th e R oy al S oc iety of H eal th , 1 1 5 , 90–95. 102. Vyas, A., Greenhaigh, A., Cade, J., Sanghera, B., Riste, L., Sharma, S., & Cruickshank, K. 2003. Nutrient intakes of an adult Pakistani, European and African-Caribbean community in inner city Britain. J our nal of H uman N utr ition and Dietetic s, 1 6 , 327–337. 103. Zafar Iqbal Hydrie, M., Samad Shera, A., Faw- wad, A., Basit, A., & Hussain, A. 2009. Preva- lence of metabolic syndrome in urban Pakistan (Karachi): Comparison of newly proposed International Diabetes Federation and Modified Adult Treatment Panel III criteria. M etabol ic S y ndr ome and R el ated Disor der s, 7 (2), 119–124. 104. U.S. Department of Health and Human Services, Office of Minority Health. Profile Asian Ameri- cans. Retrieved from: http://minorityhealth. hhs.gov/omh/browse.aspx?lvl=3&lvlid=63 (accessed April 24, 2015). Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 4 8 2 S O U T H A S I A N S 105. Periyakoil, V.J., & Dara, S. 2010. Health and health care of Asian Indian American older adults. In V.S. Periyakoil (Ed.). eCampus Geriatrics, Stanford, CA. Retrieved from http:// geriatriccs.stanford.edu/ethnomed/asian_india 106. R ao, D. 2006. Choice of medicine and hierarchy of resort to different health alter- natives among Asian Indian immigrants in a metropolitan city in the USA. E th nic ity & H eal th , 1 1 , 153–167. 107. Saper, R.B., Kales, S.N., Paquin, J., Burns, M.J., Eisenberg, D.M., Davis, R.B., & Phillips, R.S. 2004. Heavy metal content of ayurvedic herbal medicine products. J our nal of th e A mer ic an M edic al A ssoc iation, 2 9 2 , 2868–2873. 108. Cortis, J.D. 2000. Perceptions and experiences with nursing care: A study in Pakistani (Urdu) communities in the United Kingdom. J our nal of T r ansc ul tur al N ur sing, T r ansc ul tur al N ur sing, T r ansc ul tur al N ur sing 1 1 , 111–118. 109. Lawton, J., Ahmad, N., Hallowell, N., Hanna, L., & Douglas, M. 2005. Perceptions and expe- riences of taking oral hypoglycaemic agents among people of Pakistani and Indian origin: Qualitative study. B M J , 330, 1247.B M J , 330, 1247.B M J 110. Davidson, A. 1999. T h e O x f or d c ompanion to f ood. New York: Oxford University Press. 111. Rai, S. 2003. T astes of I ndia in U . S . w r apper s. N ew Y or k T imes, April 29. 112. Jagetia, G.C., & Aggarwal, B.B. 2007. “Spicing up” of the immune system by curcumin. J our nal of C l inic al I mmunol ogy , 27, 19–35. 113. Kollipara, U.K., & Brittin, H.C. 1996. Increased iron content of some Indian foods due to cook- ware. J our nal of th e A mer ic an Dietetic A ssoc ia- tion, 9 6 , 508–510. 114. Ahmed, M., & Flatz, G. 1984. Prevalence of pri- mary adult lactose malabsorption in Pakistan. H uman G enetic s, 3 4 , 69–75. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 4 8 3 associations with place and food suggest the importance placed on the superior quality of local items. Even today, with a global assort- ment available, there is a certain cachet to Maine lobsters, Vermont maple syrup, Geor- gia peaches, Florida oranges, Idaho potatoes, and Washington apples (see Figure 15.1). Ethnic and religious practices also affect the development of regional fare, particu- larly specialty foods. Jewish bagels in New York, German doughnuts called f astnac h ts in Pennsylvania, Cajun French–style sausages in Louisiana, West African–influenced hoppin’ John in South Carolina, southern Italian– flavored pizza in Chicago, Cornish pasties in Michigan, and Mexican-inspired chili con carne in Texas are just a few examples. Most regional cuisine is a blend of several ethnic elements, such as the British–Native American dishes of New England, the African–French– Spanish–British–Native American mélange that is southern fare, and the northern Ital- ian–Mexican–Asian mix found in California cuisine. Religious food habits are a factor in areas where large numbers of a specific faith have congregated. For instance, the majority of Mormons live in Utah, and Mormons typi- cally do not drink alcohol, tea, coffee, or other stimulating beverages. Alcohol purchases in Utah are more strictly controlled with more restrictions as to what and where they can be sold. Sweets are allowed, however, and are well integrated into family activities. A third fac- tor in regional foods is local history, which is often associated with certain dishes. A good example is the Kentucky stew called burgoo. Regional Americans In Boston, they eat beans. In Philadelphia, they eat cheesesteak. In Kansas City, they eat barbecue. And in Seattle, they drink café lattes. A person from Montana is no more likely to eat grits (ground hominy) than a person from Mississippi is likely to eat Rocky Mountain oysters (deep-fried beef testicles). Just as certain fare is associated with ethnicity and religious affiliation, local food preferences are central to American regional identity. This chapter profiles the Northeast, South, Midwest, and West regions and examines traditional fare, noting significant culinary variations and trends in U.S. regional food habits. American Regional Food Habits What Is Regional Fare? Regional fare has traditionally been home- style food prepared with local ingredients, dependent on agricultural conditions and seasonal availability. Most families made do with what they could grow, gather, or barter. Local foods are the most significant of several factors that influence the development of a particular regional cuisine. The spicy cooking of the Southwest with its emphasis on corn, beans, and chiles could not have been created in the upper Great Lakes area, which pro- duces wheat, fish, and dairy foods. Before the advent of food preservation and refrigerated shipping, local items were not only freshest and tastiest, but also most economical. Strong 15CHA P T E R Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 4 8 4 R E G I O N A L A M E R I C A N S Legend has it that the mixture of poultry and red meat with vegetables dates back to the Civil War when a chef for the Confederate cavalry at Lexington created the stew from native blackbirds, game, and greens. There is no single recipe for the dish, but today it typically includes chicken, pork, beef, or lamb; and cabbage, potatoes, tomatoes, lima beans, corn, and okra. It is seasoned with cayenne. Burgoo is traditionally served at picnics, political rallies, and sporting events, includ- ing Derby Day. Current trends can be an influence as well. Some dishes sweep through one region but never gain national accep- tance, such as caviar pie (layered hard-boiled eggs, scallions, caviar, and sour cream) in the Southeast, or loco moco (a bowl with rice topped with a ground beef patty, then an egg over easy, and gravy) in Hawaii. Other trends start out regionally and then catch on coun- trywide, such as the salsas of the Southwest. Economics contribute to the popularity of certain foods. One study found that some of the best markets for beer in the country are in the poorest areas. Wine is popular in upper-income regions,1 although more recently brewpubs are also popular. The number of brewpubs in the United States increased sevenfold from 1994 to 2012.2,5 Households with incomes below $20,000 a year spend about $1,400 per capita on food, buying more white bread, bacon, pork chops, luncheon meats, and eggs per person than the U.S. average. On the other end of the socioeconomic spectrum, households with incomes more than $100,000 annu- ally spend over $4,725 on food, with above- average purchases in almost every category, especially expensive cuts of beef, lamb, fresh fish and seafood, dairy products, biscuits/ rolls, fruits, prepared salads, nuts, and snack foods.3 Upscale consumers are more likely to be exposed to unique culinary ideas when dining out in trendy full-service restaurants and to be willing to pay for new or unusual food items. Figure 15.1 Foods associated with places. Source: de Wit, C. W. Food-place associations on American product labels. Geographical Review, 83, 323–330. Copyright 1992. Reprinted with permission by American Geographical Society. Rolls Bread Sugar THE SOUTH Hush puppies Hush puppy mix Taco sauce NEW ENGLAND ClamClamClamClam chowderchowderchowderchowder NEW YORK CITY Cheesecake Seltzer water Hot dog buns Flavored mustards Salad dressings Apple sauce Apple butter Cheddar cheese Maple syrup Key lime mangroveKey lime mangroveKey lime mangroveKey lime mangrove honey dressing honey dressing honey dressing honey dressing Mango dressingMango dressingMango dressingMango dressing Lime fruit juiceLime fruit juiceLime fruit juiceLime fruit juice cooler cooler cooler cooler BerBerBerBerry conserves conserves conserves conserves Organic fruitOrganic fruitOrganic fruitOrganic fruit sweetener Beer Berries1 Grapes Kadota figs Plums Cherries Berry juiceBerry juiceBerry juiceBerry juice Honey Cheddar cheeseCheddar cheeseCheddar cheeseCheddar cheese ProcessedProcessed potatoes5 Whole potatoesWhole potatoes KANSAS CITY Pork roast Sarsaparilla Cheese Wild rice Bread Chili mix Popcorn Cheese Corned beef brisket BBQ sauce Sirloin MILMILWAWAMILWAMILMILWAMIL UKEEUKEE Butter Margarine Sparkling mineral water Taco shells Chili spices Mexican foods Chili seasoning Hot sauce Salsa BBQ sauce BiscuitsBiscuitsBiscuitsBiscuits Spiced peanutsSpiced peanutsSpiced peanutsSpiced peanuts Grapefruit juiceGrapefruit juiceGrapefruit juiceGrapefruit juice Orange JuiceOrange JuiceOrange JuiceOrange Juice Okra picklesOkra picklesOkra picklesOkra pickles Bloody Mary mixBloody Mary mixBloody Mary mixBloody Mary mix Basmati rice Jalapeno slices Dried fruitsDried fruitsDried fruitsDried fruits2 Flavored mustardsFlavored mustardsFlavored mustardsFlavored mustardsFlavored mustardsFlavored mustards OlivesOlivesOlivesOlives CarrotsCarrotsCarrotsCarrots Misc. freshMisc. freshMisc. freshMisc. fresh vegetables vegetables vegetables vegetables Canned tomatoesCanned tomatoesCanned tomatoesCanned tomatoes Herb vinegarsHerb vinegarsHerb vinegarsHerb vinegars Vegetable oilsVegetable oilsVegetable oilsVegetable oils3 MarinatedMarinatedMarinatedMarinated vegetables vegetables vegetables vegetables Fruit jams4 Cheese Tomato juice Apple butter Organic apple sauces Carrot juice Catsup Burritos Peach juice CCCCCCCAPE CODAPE COD Cranberry juice BOSBOSBOSBOSTON BostonBostonBostonBostonBostonBostonBostonBoston cr cr cr cream pieeam pieeam pieeam pie Hot pepper sauce Sweet potatoesSweet potatoesSweet potatoesSweet potatoes Cream cheeseCream cheeseCream cheeseCream cheese Neufchâtel cheeseNeufchâtel cheeseNeufchâtel cheeseNeufchâtel cheese Sharp cheddarSharp cheddarSharp cheddarSharp cheddar Cheese Pickles Beer ChocolateChocolateChocolateChocolateChocolateChocolate Cocoa powderCocoa powder Choc. syrupChoc. syrup 1Gooseberries, boysenberries, blackberries, strawberries, blueberries, red raspberries. 2Apples, peaches, figs, prunes, raisins. 3 Walnut, olive, pecan. 4Black raspberry, strawberry, apricot, kiwi. 5Hash browns, tater tots, golden fries, potatoes O’Brien, crinkle cuts, homestyle potatoes, cottage fries, shoestrings, potatoes au gratin, scalloped potatoes, instamash potatoes. Cajun coatingCajun coatingCajun coatingCajun coatingCajun coatingCajun coatingCajun coating mixes Hot sauce Cajun seasoning Steak sauce Gumbo mix Crab & Shrimp boil mix *Listed in order from most to least frequent occurrence. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 1 5 4 8 5 This blending of physical, cultural, his- toric, current, and economic conditions in a region produces what researchers call a “taste of place,” from the French gout de ter r oir .4 Ele- mentally, the taste of place is the identification of certain ingredients or dishes with an area. At a deeper level, it is the emotional connec- tion between people and a local heritage, an appreciation for the regional characteristics that create flavors unlike those found any- where else in the nation, or the world. Regional Divisions The United States has been divided numer- ous ways. Sometimes regions are delineated by terrain, as in the Great Plains, or marked by major rivers or mountain ranges, as in the Mississippi River Valley or the Appalachians. Sometimes areas are defined by similarities in climate, as in the Sun Belt; by economic affili- ation, as in the Steel Belt and Silicon Valley; or by the characteristics of the population, as in Indian Lands and the Bible Belt. Histori- cal divisions, such as the Mason-Dixon Line, or political divisions, including state bound- aries, can also be used. Geographers suggest that traditional regions contain elements of all these variables, characterized as a syner- gistic relationship between a people and the land that develops over time and is specific to the locality. Such regional identity is dynamic, more of a process than a delineation, subject to changes in population, economy, ecology, and other factors.5,6 However, geographic considerations are used to set arbitrary regional divisions independent of cultural relationships. The U.S. Census Bureau and the U.S. Department of Commerce list four regions with nine subdivisions for data collec- tion purposes: Northeast, Midwest, South, and West. Although these categories group together states with distinctively different cuisines, such as Florida and Texas, or Alaska and Hawaii, most demographic and food consumption data are presented in this four- region format (see Figure 15.2). It is useful for detecting broad trends, as long as results are not overgeneralized to smaller popula- tions that may observe alternate regional boundaries. The Northeast Regional Profile The states of the U.S. Northeast include those of New England (Connecticut, Maine, Mas- sachusetts, New Hampshire, Rhode Island, and Vermont) and those of the Mid-Atlantic region (New Jersey, New York, and Penn- sylvania). The New England area features a rugged, irregular Atlantic coastline with many protected bays. Rolling hills and val- leys that gradually become densely forested mountains extend west. The region is noted for its spectacular autumn weather and col- orful fall foliage, followed by harsh winters. The Mid-Atlantic states are farther south and more temperate in climate. Sandy beaches and estuaries line the long coast. The ridges, river valleys, and fertile plateaus of the Adirondack, Appalachian, Blue, Catskill, and other moun- tain ranges crisscross much of the three states. Freshwater lakes dot the region and provide the northern boundary along Lake Ontario and Lake Erie. Despite differences in climate and geog- raphy, the entire Northeast shares a common early history of sophisticated Native American societies supplanted by European settlements. The colonial immigrants from England, Ger- many, the Netherlands, and France were followed by newcomers from Ireland, Italy, Portugal, Poland, and other central and east- ern European countries, particularly in the Mid-Atlantic states. African Americans from the South and more recent immigrants from the Caribbean, Central America, Africa, and Asia have added to the diversity of some parts of the Northeast (see each chapter on ethnic food habits for more immigration details and Table 15.1). Eighteen percent of the total U.S. popula- tion is found in the Northeast.7 Over eight million individuals (10 percent) living in the Northeast region are born in another coun- try.7 Over two-thirds of Puerto Ricans living on the mainland reside there, and more than one-third of all Asian Indians in the United States have settled in the region. Dispropor- tionately large populations of blacks and Lati- nos reside in New York and New Jersey. Yet the rest of the Northeast is still predominantly Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 4 8 6 R E G I O N A L A M E R I C A N S white, including large percentages of Italians, Ukrainians, Portuguese, French Canadians, Russians, Lithuanians, Slovaks, and Poles. Nearly half of all American Jews also live in the Northeast, primarily in New York, New Jersey, and Massachusetts. Compared to national figures, the North- east has a lower percentage (13 percent) of persons under the age of 15, and a higher proportion of persons over the age of 65. The Northeast region had a total population of 55.6 million in 2013. The median age was 38.6 years, with 16.2 percent of the population being under 18 years and 14.5 percent 65 years and older. Data from the 2009 American Fam- ily Survey also show that the Northeast has United States Northeast Region Estimate Estimate Total: 311,536,594 55,564,549 White alone 238,007,238 42,498,388 Black or African American alone 42,496,977 7,223,003 American Indian and Alaska Native alone 5,142,542 446,737 Asian alone 17,845,862 3,538,059 Native Hawaiian and Other Pacific Islander alone 1,177,092 62,544 Some other race alone 16,399,187 3,231,056 Hispanic or Latino (of any race) 51,786,591 7,199,979 SOURCE: U.S. Census Bureau, 2013 American Community Survey. TA B L E 15.1 Estimates of Ethnicity in the Northeast Region Figure 15-2 Regional divisions in the United States. West Midwest South Northeast DEDEDEDE MDMDMDMD OK NE SD NDMT KY ME PA MI MAMAMAMA RIRIRIRICTCTCTCTCTCTCT VA WV OH IN NC TN SC AL MS AR LA MO IA MN WI NJ GA VT NH TX FL CO NM UT AZ NV ID WY OR WA CA KS IL NY HI AK Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 1 5 4 8 7 the highest population density of all regions and the highest number of people living in metropolitan areas (nearly 90 percent). The average household income was $59,822 per year. An estimated 13 percent of the North- east population live in poverty. Fifteen percent of related children under 18 were below the poverty level.7 Traditional Fare The cooking of the Northeast features the abundance of the Atlantic, the plenty of native and introduced produce, and the freshwater wealth of the many rivers and lakes (see Table 15.2). In New England, sea- food—such as clams, lobster, scallops, and fish, especially cod—has been prominent. Indigenous game, including wild turkey and venison, supplemented the poultry, pork, and beef brought by early immigrants. The foun- dation of the diet was traditionally corn, and many dishes of the region reflect its impor- tance. Beans have also made a substantial contribution. Root vegetables (potatoes, onions, beets, turnips, rutabagas, carrots, etc.) quickly added to the vegetable selection. Wild berries, including blueberries, cranber- ries, gooseberries, and cloudberries (which look like bleached blackberries), grapes, and beach plums were the main fruits con- sumed until the apple orchards planted by immigrants became productive. Maple sugar sweetened many foods in New England. Even when molasses and cane sugar became widely available, maple syrup was preferred for many dishes. The warmer weather and fertile lands of the Mid-Atlantic states have provided more native foods than New England. The coastal waters offer clams, oysters, mussels, scal- lops, and crabs, while the estuaries shelter ducks, geese, and turtles. Passenger pigeons once darkened the skies with their massive numbers, and bison roamed the area around Lake Erie. Freshwater fish such as catfish, eels, pickerel, salmon, shad, smelt, trout, and whitefish were plentiful; at one time, shad, a flavorful relative of the herring, was the most numerous of all freshwater fish in the United States. Both the flesh and roe were commonly eaten. Introduced foods also flourished in the region. Cabbage, potatoes, yams, carrots, peas, apples, pears, cherries, peaches, and strawber- ries were easily grown. Tomatoes thrived in the hot summers. Although New Jersey is now one of the most industrialized states in the nation, it is still known as the Garden State due to the success of these early agricultural Figure 15-3 Estimates of obesity and diabetes mellitus in the United States, 2013, by state. Source: CDC, http://www.cdc.gov/ diabetes Age–adjusted Percentage of U.S. Adults Who Were Obese or Who Had Diagnosed Diabetes 2013 Obesity (BMI≥30 kg/m2) Diabetes <4.5%Missing data 4.5%–5.9% 6.0%–7.4% 7.5%–8.9% ≥9.0% 18.0%–21.9% <14.0%Missing Data 14.0%–17.9% 22.0%–25.9% ≥26.0% Shad migrate from the ocean up freshwater rivers to spawn in early summer. Shadberries (also known as juneberries) are a popular treat that ripen at the same time the fish arrive each year. Salmon served with fresh peas is a Fourth of July tradition for many New Englanders. Fudge was originally a maple sugar candy popular in New England in the 1800s. When cocoa became widely available, the chocolate version was developed. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 4 8 8 R E G I O N A L A M E R I C A N S efforts. Wheat, which was difficult to grow in New England, did well in the Mid-Atlantic. At one time, New York provided all the wheat consumed in the Northeast and much of the South. New England The cuisine of New England has been shaped predominantly by Native American prepa- ration techniques combined with British homestyle cooking. Roasting, boiling, and stewing are preferred. Dishes are often made with cream, and strong seasonings are avoided. People of the region take pride in simple fare. The immigrants of the early seventeenth century were mostly tradespeople, inexpe- rienced in farming and husbandry. History abounds with tales of how the first settlers were dependent on the skills and generosity TA B L E 15. 2 Northeastern Specialties Group Foods Preparations Protein Foods Milk/milk products Cream; cheddar and cream cheese Cream soups, sauces, puddings; ice cream Meats/poultry/fish/ eggs Native game, particularly venison and turkey Preserved meats, such as corned beef, pastrami, salt pork, ham, bacon, sausages Seafood prevalent, especially clams, lobster, oysters, scallops Salt and freshwater fish, such as salt cod and shad Numerous beans (e.g., cranberry, kidney, lima) New England boiled dinner; scrapple; red-flannel hash Fish stews, soups; clam chowder; clam bakes; oyster or lobster loafs Cod cakes; shad bakes; gefilte fish Baked beans; succotash Cereals/Grains Corn, wheat, rye Cornmeal porridges, puddings, and breads Dumplings Baked goods—savory and sweet pies, cakes, doughnuts, waffles, pretzels, bagels Fruits/Vegetables Apples, blueberries, cranberries, grapes Cabbage, fiddlehead fern fronds, potatoes Applesauce, apple butter; fruit puddings, pies Coleslaw; sauerkraut; ferns on toast; potatoes—mashed, fried, creamed, baked, scalloped, hashed, as croquettes, salad Additional Foods Seasonings Salt, pepper, onions, saffron Nuts/seeds Black walnuts, butternuts Beverages Apple cider, hard cider, applejack; ale, beer; rum, whiskey; wine New York State white, red, sparkling wines; sherry, port Fats/oils Lard, butter Sweeteners Maple sugar; molasses Maple sugar candies, maple syrup pie; chocolates © C en ga ge L ea rn in g Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 1 5 4 8 9 of local Indians in preventing starvation (see Chapter 5). Corn dishes were especially significant. Cornmeal porridge cooked into a mush like consistency was a Native American food called samp by the early colonists. It was often prepared with another cornerstone of the Indian diet, beans. New Englanders used cornmeal to make an adaptation of the tradi- tional English dish known as hasty pudding. The settlers would pour cornmeal porridge into a loaf pan to firm up overnight, then slice it and serve it topped with cream. This new dish, often flavored with maple syrup or molasses, was named Indian pudding. Steamed, baked, and boiled puddings were eaten daily in New England homes. They were known as grunts (steamed dough and berries), slumps (baked puddings), and flum- meries (a British molded oatmeal or custard pudding). As in England, a pudding could be savory or sweet and was generally served at the beginning of the meal. Breads were also a mainstay. Many were dense, baked with- out any leavening (reliable leavenings such as baking powder and baking soda were not available until the mid-1900s). Homegrown yeast from potatoes, hops, or the dregs of beer barrels was used in some recipes. Cornbread cooked in a skillet over the fire was most common. Rye, which grows well in cooler cli- mates, was often combined with cornmeal to make a popular bread called ryaninjun (from “Rye ‘n’ Indian”). Stewed pumpkin was some- times added for a moister loaf. Boston brown bread is a traditional recipe of the region—a steamed loaf made with whole-wheat and rye flours (sometimes with cornmeal as well) and flavored with molasses. Pork, cod, or beef flavored most main dishes. Long winters required that most meats and fish be preserved, and few recipes called for fresh cuts. Salt pork, bacon, smoked pork, dried salt cod, corned beef, and dried beef were common, usually braised or stewed with vegetables. The New England boiled dinner is typical. This one-pot meal is still popular throughout the region and usually includes corned beef brisket simmered for hours with potatoes, onions, carrots, turnips, and, tradi- tionally, beets. Cabbage is added toward the end of the cooking time. Seasoning is mild, often just a little black pepper. Leftovers are often chopped up the next day and heated in a skillet with a little cream and sometimes some bacon and more onions to make another New England specialty known as red-flannel hash, so called because the cooked beets would bleed into the other ingredients during fry- ing. A dried salt cod and potato version of the New England boiled dinner is prepared in Massachusetts, called Cape Cod turkey. Plym- outh succotash is another example. Although this Native American dish (see Chapter 5) is often associated with southern fare today, it was popular in the Northeast during colonial times. It combined corned beef, turkey or chicken, beans, corn, potatoes, and turnips. Other variations featured just vegetables or combinations of meats, poultry, and fish. Other popular dishes included dried beef rehydrated in boiling water and served with cream sauce over bread or potatoes (precur- sor to what is called chipped beef today), and fried salt pork topped with cream gravy. New England states without access to the coast were more dependent on meat, poultry, and dairy products. Today, New Hampshire is acknowledged for the quality of its butter, and Vermont is famous for its cheeses, such as cheddar and the similar but milder Colby. Beans were eaten regularly in early New England. Best known are baked beans fla- vored with molasses or maple syrup and salt pork, a recipe adapted from the Native Ameri- can dish. Traditionally the Puritans prepared a large pot of beans on Saturday morning, simmered them over the fire all day, and then ate them with Boston brown bread for dinner to start the Sabbath (observed from sundown to sundown). Leftovers were kept warm on the hearth for Sunday breakfast with codfish cakes and for Sunday lunch.8 Boston is still known as Bean Town due to its long associa- tion with baked beans. In Maine, a version of baked beans called bean pot is made with indigenous yellow-eye, cranberry, or kidney beans. Pies made with suet pastry were served at most meals. Savory kinds included an American version of the British steak and kidney pie, chicken pot pie (later topped with biscuits instead of pie crust), a ground The oldest continually operating cheese fac- tory in the United States was founded in 1822 in Healdville, Vermont. During the colonial period, dried salt cod was exchanged for fruit in the Mediterranean and for molasses in the Caribbean (the molasses was then used to make rum). Cod traders in Massachusetts became wealthy and were nicknamed the “codfish aristocracy.” The Maine bean pot is based on the Indian method of placing the ingredients in a pot that is then buried in a pit over embers, a so-called bean hole. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 4 9 0 R E G I O N A L A M E R I C A N S pork and onion pie seasoned with allspice called tourtière introduced by French Cana- dians in the region (served traditionally at Christmas or on New Year’s Day), clam pie, lobster and oyster pie, and a salt-cod pie cov- ered with mashed potatoes. Sweet pies were also popular, especially apple pies, made with fresh apple slices, dried rings, or even apple- sauce. Mincemeat, a traditional English treat combining savory and sweet ingredients, was featured at many meals because the filling of meat, dried fruits, nuts, and rum or other alcoholic preservative aged well, becoming tastier over time. Today, Vermont fried pies (fried applesauce turnovers flavored with cinnamon) and apple pie topped with sliced cheddar cheese are Vermont favorites, while in New Hampshire, apple pie is sometimes drenched in maple syrup. Blueberry pie is a specialty in Maine. No discussion of New England fare is complete without further detailing the use of fish and shellfish in coastal areas. In Mas- sachusetts, for example, cod helped sustain the earliest populations, and Cape Cod, the peninsula that curls out into the Atlantic, was so named in 1602 for an abundance of the fish. The Puritans used it in boiled and baked dishes, soups, stews, hash, and, most notably, codfish cakes. These cakes, which are also called codfish balls, are still a sign of regional affiliation for some residents of the Boston area. In Connecticut shad was enjoyed by the Native Americans of the region but disdained by the earliest Europeans in the area due to its multitude of tiny, difficult-to-remove bones. By the mid-eighteenth century Connecticut residents had changed their opinion of shad, especially the roe, which they fried quickly in butter. Traditionally, American Indians would plank the fish and slowly cook it at the edge of hot coals, a method still practiced today at shad bakes where the fillets are placed on an oak board with strips of bacon, then grilled or smoked. Lobster is a specialty, especially in Maine. The Indians of the area consumed the meat, used the discarded shells for fertilizer, and formed the claws into pipes. British settlers mostly added the meat to mixed fish dishes, and later colonialists added it to salads, sauces, soups, and fried cro- quettes. Commercial trapping began in the late 1800s with the advent of shipping by train and the development of the canning industry. The lobster supply diminished rapidly, increasing its prestige and popularity—today trapping regula- tions are strict. In addition to steamed or grilled lobster tail, a specialty in Maine and other coastal areas is lobster rolls, which take two forms (both served on toasted, fluffy white bread buns): plain meat drenched in butter, or meat mixed with mayonnaise, celery, onions, and lemon juice. Clams, oysters, and scallops are also New England favorites. The clambake, in which clams, corn, and other items such as onions, potatoes, or lobster are steamed in a pit on the beach, shares some similarities with American Indian seafood feasts, and was enjoyed as a way of connecting with what New Englanders in the early nineteenth century believed was their Puritan past.9 Clams are also featured in the cream-based soup known as clam chow- der. One version, the cream-based Boston clam chowder, is known nationally. It is typi- cally garnished with Boston crackers or oyster crackers, the slightly sweet, small, dry biscuits invented by Massachusetts sea captains for use on long journeys aboard ship. In Rhode Island tomato-based red clam chowder, a soup inac- curately attributed to Manhattan, is popular. Clams called steamers are just that—steamed and served with the broth and melted butter ▼ Lobster is a specialty of Maine, though it is also trapped in other New England coastal states. Ri ch ar d Sc hu ltz /C ra ve /C or bi s Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 1 5 4 9 1 (a bucket of steamers is often the first course of a lobster dinner). Oysters were typically prepared with cream and breadcrumbs in a dish called scalloped oysters, or served in oyster stew. In Rhode Island they were espe- cially popular among the nineteenth-century elite, who served them in pies (raw oysters in cream sauce topped with biscuit dough), as patties, creamed, curried, and, for New Year’s Eve, pickled, with eggnog to wash them down. Today they are commonly broiled with bacon or breaded and deep-fried. Bay, sea, and Digby scallops are prepared similarly to oysters. In Maine two less common shellfish specialties are found. The first is mussels (the state provides nearly two-thirds of those shell- fish consumed nationally), and the second is sea urchin roe (uni), served at local restau- rants and sushi bars, or exported to Japan.10 There are two fruits particularly associ- ated with the New England area. The first is cranberries, known as sassamanesh and ibimi (meaning bitter or sour) by some Native Americans, who ate them fresh with maple syrup, or dried and added to pemmican. It was the Dutch who introduced the term K r anbeer e, meaning “crane berry,” because the flower resembles the head of a crane. Cran- berries grow exceptionally well in the sandy peat bogs of eastern Massachusetts, where they were first cultivated in the early 1800s. They are used primarily in juices and sauces, though in recent years, dried cranberries have become popular as snacks or added to baked goods. The second fruit is wild or low-bush blueberries, which are used mostly in baked goods. Maine grows nearly 100 percent of this variety in the United States. New England desserts are mostly fruit based. In addition to the puddings and pies already discussed, pandowdies (baked fruit layered with bread), shortbreads (fruit pre- serves, biscuits, and cream), and roly-polys (fruit rolled up in biscuit dough, then baked) were other favorites. Pound cakes and fruit- cakes were enjoyed but were difficult to make before commercial leavening and reliable ovens were available. No sweet is as associated with New Eng- land, particularly Vermont, as is maple syrup. One New England des- sert popular throughout the nation is chocolate chip cookies, which were created by Ruth Wakefield in 1930 at the Toll House Inn in Whit- man, Massachusetts. Boston cream pie, a favorite in New England, is not a pie but a custard- filled white cake covered with chocolate icing. It probably derives from a popular colonial dessert called “pudding cake” that included cake, custard, and usually fruit or jam. S a m p l e M e n u A New England Supper New England Boiled Dinnera,b,c Boston Brown Breada,c Blueberry Pieb,c or Apple Pandowdy with Maple Syrupa aJamison, C.A., & Jamison, B. 1999. American home cooking. New York: Broadway Books. bOliver, S.L. 1995. Saltwater foodways. Mystic, CT: Mystic Seaport Museum. cNew England Recipes at http://www.newenglandrecipes.com The sweet sap of the sugar maple tree had long been used by Indians of the Northeast to cook beans and meats and to flavor other items (see Chapter 5). The syrup was an everyday sweetener in colonial kitchens throughout the region until cane sugar became more affordable. Maple syrup production peaked in the 1880s, and the sweet has since become a costly item. Vermont specialties include sugar-on-snow (hot syrup poured over fresh snow to make a chewy taffy eaten with pickles or doughnuts), maple syrup pie (with a filling of cream, eggs, and syrup), and maple-sugar candies. Tea and apple cider were consumed daily in colonial times. Hard cider, an alcoholic beverage caused by the fermentation of sug- ars in apple cider, was also favored. Many New Englanders would start their day with a pint of beer or ale made from barley, corn, pumpkins, persimmons, or spruce bark. Rum, as well as whiskey made from rye, was available. Wine from dandelions or gooseberries was a spe- cialty, and an American version of the Eng- lish drink called syllabub, containing apple cider, sherry or wine, and whipped cream, was served at special occasions. Today, apple cider remains a regional specialty, particularly in New Hampshire. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 4 9 2 R E G I O N A L A M E R I C A N S Mid-Atlantic Many of the influences on New England fare are seen in the foods of the Mid-Atlantic states as well. Native American fare was combined with immigrant preferences to produce a new regional cuisine. Unlike New England, where most of the colonists were from Eng- land, many settlers in New Jersey, New York, and Pennsylvania came from the Netherlands and Germany. They provided a distinctively different flavor to foods, including a greater use of pork (especially sausages) and dairy products, more baked goods, and stronger seasonings. Later immigrants from southern and eastern Europe contributed many special- ties. Further, the warmer climate and fertile farmlands offered a greater variety of ingre- dients to the cooks of New York, New Jersey, and Pennsylvania. The Dutch in the mid-1600s brought wheat to the New York area, which at the time was known as New Netherland. They also grew barley, buckwheat, and rye. Although these were preferred grains, the Dutch used what they called “turkey wheat” (corn) to make a boiled milk and cornmeal porridge known as Suppawn that was eaten daily at break- fast. This same porridge was topped with meats and vegetables for lunch, then baked to make the hearty dish called Hutspot, an American adaptation of a stew common in the Netherlands. Dairy cattle provided ample milk, butter, and cheese. The Dutch were among the first settlers wealthy enough to import sugar, brandy, chocolate, and numerous spices, including pepper, cloves, cinnamon, and saf-including pepper, cloves, cinnamon, and saf-including pepper, cloves, cinnamon, and saf fron. Many Dutch specialties of the region have made their way into American cooking, including pickled cabbage; Kool sla (from the Dutch word for “cabbage”), now known as coleslaw; and headcheese, a ball-shaped sausage made from the head and feet of the hog. Doughnuts, crullers, pancakes, and waf-hog. Doughnuts, crullers, pancakes, and waf-hog. Doughnuts, crullers, pancakes, and waf fles were also introduced by the Dutch. During the same period, German immi- grants arrived in the United States. Many were religious outcasts (mostly Mennonites, with smaller numbers of Amish, Schwenkfelders, and other sects) who made their home in the tolerant colony of Pennsylvania (see Chapter 7). They became known as the Pennsylvania Dutch, a corruption of the Ger- man word Deutsc h , which means “German.” Although some German religious communi- ties remained isolated (and are even to this day), many German immigrants gradually became integrated into the broader popula- tions of Pennsylvania and surrounding states. Likewise, many German foods of the region have become an indistinguishable part of U.S. cuisine. Pork was the foundation of the German diet, and immigrants brought ham, pork chops, pork schnitzel (pounded into thin slices), bacon, salt pork, pickled pig’s knuckles, souse (jellied pig’s feet loaf ), maw (stomach stuffed with meat and vegetables), and a German ver- sion of headcheese. Every part of the hog was used, and leftovers would be stretched with lima beans to make a Pennsylvania version of baked beans or with dried green beans and potatoes (B oh ne mit S c h ink en un’ G r umber r a). The best-known leftovers dish is scrapple, still popular throughout the state. Scrapple is a combination of ground pork or sausage, cornmeal porridge, and spices formed into a loaf, sliced into thick slabs when firm, and fried in butter. It is typically served with fried eggs, applesauce, and maple syrup. In addi- tion, smoked and fresh sausages were con- sumed daily. Chicken stews and soups, made substantial with homemade noodles or dump- lings, were also popular with the Pennsylva- nia Dutch. Beef was used in the braised roast known as sauerbraten and in the smoked, cured dried beef called Bündnerfleisch. Asparagus, green peas, sugar peas (called Mennonite pod peas), and rhubarb are a few of the vegetables favored by the Pennsylva- nia Dutch. Potatoes are eaten mashed, fried, creamed, baked, scalloped, hashed, as cro- quettes, as dumplings, in stews and soups, and as potato salad. Cabbage is also ubiqui- tous, mostly as sauerkraut and slaw. Apples are particularly popular—fresh, as apple- sauce, in pastries, as cider, and in preserves such as the thick, sweet spread known as apple butter. Many fruits and vegetables are pickled or preserved. Examples include spiced pears, pickled watermelon rind, sweet pickles, and corn relish. Dark rye breads, cornbreads, Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 1 5 4 9 3 yeast rolls, potato rolls, cinnamon rolls and sticky buns, Streuselkuchen (coffeecakes with a sugarcrumb topping), doughnuts (called Fastnachts), and buckwheat pancakes are just a few of the baked goods found in the region. The Pennsylvania Dutch also make numerous desserts, especially pies (see Chapter 7). Though generally considered a rural cuisine, Pennsylvania Dutch fare was well accepted in the early urban centers of the state, such as Pittsburgh, Allentown, Bethle- hem, and Reading. Even Philadelphia, which was founded by English Quakers, favored German foods. Scrapple has become so associated with the city that it is often called Philadelphia scrapple, despite its country beginnings. It is eaten for breakfast, often driz- zled with catsup, and is used to make deep- fried croquettes or to stuff vegetables like green peppers and cabbage for dinner. Leba- non bologna is a Pennsylvania Dutch smoked beef sausage that has become a state specialty. It is traditionally sliced, battered, or dipped in bread crumbs, fried, and served with sau- erkraut and mashed potatoes. Although the origins are lost to history, Philadelphia pep- per pot, a soup made with tripe, onions, pota- toes, and black peppercorns, is most likely a Pennsylvania Dutch recipe and is sometimes served with dumplings. Cheesesteak (grilled strips of beef topped with American cheese and grilled onions in a toasted Italian roll), the quintessential Philadelphia sandwich, was supposedly invented during the 1930s when a frankfurter pushcart vendor was acciden- tally sent beef instead of his standard order of hot dogs. The hearty fare of the Dutch and Germans combined with many traditional items also found in New England, such as puddings, savory pies, and seafood soups and stews, to produce Mid-Atlantic cuisine. Later immi- grants to the Mid-Atlantic region introduced foods that have become associated with certain cities and states. Notably, southern Italians in New York and New Jersey brought pizza, spaghetti with tomato–meat sauce, cal- zone, cannoli, gelato, and espresso. Eastern European Jews introduced pastrami, smoked salmon and whitefish, chopped liver, and other deli items. Particularly in New York, other eastern European, Russian, Greek, Chinese, Caribbean Island, and Middle East- ern cuisines became popular, due in part to numerous ethnic eateries (see chapters on each group for more information). New York is noteworthy for the influence of its restau- rant fare. Taverns, boarding houses, oyster houses, and coffeehouses served the needs of those eating out in the late eighteenth and early nineteenth centuries. The first Euro- pean-style bakery was opened in 1825, and delicatessens serving the Jewish community were established in the 1880s. Full-service continental-style restaurants became popular in the mid-1800s. By the turn of the century, New York City had become the gastronomic center of the nation. Many dishes created for elite diners are now American specialties, such as Waldorf salad (originally a mixture of apples and celery in mayonnaise served at the Waldorf-Astoria), vichyssoise (chilled leek and potato soup from the Ritz-Carlton), Lobster Newburg (lobster tail topped with a Madeira-flavored cream sauce), and the des- sert baked Alaska (from Delmonico’s). New Jersey, often called the garden basket of New York due to its numerous commercial Buffalo wings, deep-fried chicken wings drenched in spicy (often using Tabasco sauce) seasoned butter and served with celery and blue cheese dressing, evolved in Buffalo-area bars during the 1960s. No one has established the exact origins of the appetizer. The word cookie is derived from the Dutch word for a small cake, Koeckje. ▼ Bagels, introduced by Polish immigrants, were paired with an 1872 New York invention, cream cheese; the chewy doughnut-shaped roll was popularized nationwide during the 1990s. M ia F os te r/ Ph ot oE di t Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 4 9 4 R E G I O N A L A M E R I C A N S crops, is also known for its contributions in food technology. Scientific work on hybrid- ization has yielded new, improved varieties of peaches, tomatoes, and sweet potatoes. Food-processing techniques developed in New Jersey include condensed, canned soups (the Campbell Soup Company); inspected, bottled milk (the Borden Company); and the first application of pasteurization to milk at a small farm outside Princeton. Black tea, in convenient individually sized bags, was introduced in Hoboken in 1880 (the Thomas J. Lipton Company). In addition to the Dutch and Pennsylvania Dutch cookies, doughnuts, pies, pancakes, and waffles of the region, other sweets have gained nationwide acceptance, especially those from Pennsylvania. Philadelphia was one of the first cities to enjoy ice cream, per- haps as early as 1782. An ice cream parlor with frozen treats, cakes, syrups, and cordials was opened in 1800, and the following years saw the first wholesale distributor of ice cream and the first ice cream soda. The city gained a reputation for a high-quality product, and ice cream molded into flowers, fruits, animals, or holiday icons is still a specialty. Another confectionery contribution was affordable chocolate. Commercial production of choc- olate for beverages and bonbons began in Pennsylvania during the late 1700s, though it was so costly it was considered a luxury item. Milton Hershey of Derry Church was the first manufacturer of chocolate for the mass mar- ket beginning in 1905 when he reduced his expenses by making uniform bars instead of fancy novelties. Two years later, he introduced the chocolate candy, Hershey’s Kisses. Several beverages are associated with the Mid-Atlantic states. American beer, a heavy, top-fermented beverage similar to English ale, was first commercially produced during the late seventeenth century in Pennsylvania. Two hundred years later, a German immigrant to Philadelphia founded the first brewery that made a bottom fermented beverage. The new, lighter beer known as lager, or pilsner, soon became synonymous with beer in the United States (see Chapter 7). New York is the only major wine producer in the Northeast and is third nationally behind California and Wash- ington. Wine varieties include whites (Char- donnay, White Riesling, and Seyval-Villard varietals), reds (small amounts of Cabernet Sauvignon and Merlot), and sparkling wines as well as some fortified wines, such as sherry and port. New Jersey is the state where hard apple cider was first distilled to produce the apple brandy known as applejack, sometimes called New Jersey lightning. Health Concerns State-specific data suggest that people living in the New England states are often healthier than the U.S. average, while those in the Mid- Atlantic states are closer to national norms (see chapters on each ethnic group for popu- lation-specific data). As in all of the regions of the United States, obesity and rates of diabe- tes have consistently increased in the North- east and Mid-Atlantic states (see Table 15.3 and Figure 15.3). For the four regions of the United States, the Northeast ranks second lowest for the prevalence of cardiovascular disease (acute myocardial infarctions, coro- nary heart disease, strokes). In addition, they practice lifestyle activities that are healthier, such as lower prevalence of smoking and higher prevalence for physical activity).11 S a m p l e M e n u A Mid-Atlantic Brunch Philadelphia Scrapplea,c with Eggs Pecan Sticky Bunsb,c Toast with Apple Buttera,b,c Bagels and Cream Cheese aCunningham, M. 1996. Fannie Farmer cookbook: Anniversary. New York: Knopf. bJamison, C.A., & Jamison, B. 1999. American home cooking. New York: Broadway Books. cRecipe Source at http://www.recipesource.com Coffee milk, similar to chocolate milk but made with coffee syrup, is the official state beverage of Rhode Island. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 1 5 4 9 5 The Midwest Regional Profile The Midwest is known as the Great Plains region of the United States. The earliest American settlers and European immigrants in the area found a vast, flat terrain covered by tall prairie grasses. Oak-wooded hills and low mountain ridges ringed the territory. The rich soil irrigated by the extensive Mississippi and Missouri River systems proved ideal for wheat, corn, and numerous fruits. The region is still renowned for its agricultural CT ME MA NH NJ NYNH NJ NY PA RI VT Obesitya ↓↓ ↓ ↓↓ ↓↓ ↓↓ ↓↓ ↓ ↓↓ ↓↓↓↓ ↓ ↓↓ ↓↓ ↓↓ ↓↓ ↓ ↓↓ ↓↓↓↓ ↓ ↓↓ ↓↓ ↓↓ ↓↓ ↓ ↓↓ ↓↓↓↓ ↓ ↓↓ ↓↓ ↓↓ ↓↓ ↓ ↓↓ ↓↓↓↓ ↓ ↓↓ ↓↓ ↓↓ ↓↓ ↓ ↓↓ ↓↓↓↓ ↓ ↓↓ ↓↓ ↓↓ ↓↓ ↓ ↓↓ ↓↓↓↓ ↓ ↓↓ ↓↓ ↓↓ ↓↓ ↓ ↓↓ ↓↓↓↓ ↓ ↓↓ ↓↓ ↓↓ ↓↓ ↓ ↓↓ ↓↓↓↓ ↓ ↓↓ ↓↓ ↓↓ ↓↓ ↓ ↓↓ ↓↓ No Leisure-Time Exerciseb ↓ ↓↓ ↓ ↓↓ ↓↓↓ ↓↓ ↓ ↓↓ ↓↓↓ ↓↓ ↓ ↓↓ ↓↓↓ ↓↓ ↓ ↓↓ ↓↓↓ ↓↓ ↓ ↓↓ ↓↓ AVG AVG AVGAVG AVG AVGAVG AVG AVG ↓↓↓ Diabetesc ↓ ↓ ↓↓ ↓↓ ↓↓ ↓ ↓↓ ↓↓ ↓↓ ↓ ↓↓ ↓↓ ↓↓ ↓ ↓↓ ↓↓ ↓↓ ↓ ↓↓ ↓↓ ↓ AVG AVG AVGAVG AVG AVGAVG AVG AVG ↓↓↓ Hypertensiond ↓ ↓ ↓ ↓ ↓↓ ↓ ↓ ↓ ↓↓ ↓ ↓ ↓ ↓↓ ↓ ↓ ↓ ↓↓ ↓ ↓ ↓ ↓ AVG AVG AVGAVG AVG AVGAVG AVG AVG ↓ High Blood Cholesterole ↑↑ ↑↑ ↑ ↑↑ ↑↑ ↑↑ ↑↑ ↑ ↑↑↑ ↑↑ ↑ ↑↑ ↑↑ ↑↑ ↑↑ ↑ ↑↑↑ ↑↑ ↑ ↑↑ ↑↑ ↑↑ ↑↑ ↑ ↑↑↑ ↑↑ ↑ ↑↑ ↑↑ ↑↑ ↑↑ ↑ ↑↑↑ ↑↑ ↑ ↑↑ ↑↑ ↑↑ ↑↑ ↑ ↑↑↑ ↑↑ ↑ ↑↑ ↑↑ ↑↑ ↑↑ ↑ ↑↑↑ ↑↑ ↑ ↑↑ ↑↑ ↑↑ ↑↑ ↑ ↑↑↑ ↑↑ ↑ ↑↑ ↑↑ ↑↑ ↑↑ ↑ ↑↑↑ ↑↑ ↑ ↑↑ ↑↑ ↑↑ ↑↑ ↑ ↑ Don’t Consume 5 Fruits/Vegs.f ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓↓↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓↓↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓↓↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓↓↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓↓↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓↓↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓↓↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓↓↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓↓ Binge Drinkingg AVG AVGAVG AVG ↑ ↓ ↓↓ ↓ ↓↑ ↓ ↓↓ ↓ ↓↑ ↓ ↓↓ ↓ ↓↑ ↓ ↓↓ ↓ ↓↑ ↓ ↓↓ ↓ ↓ AVG AVGAVG AVG Low Birth Weighth AVG ↓ AVG ↓ AVG AVG AVG AVGAVG AVG AVG AVGAVG AVG AVG AVGAVG AVG AVG AVG ↓↓ Deaths from Heart Diseasei ↑↑ ↑ ↑ ↑ ↑↑↑ ↑↑↑ ↑↑↑ ↑↑ ↑↑↑ ↑ ↑ ↑ ↑↑↑ ↑↑↑ ↑↑↑ ↑↑ ↑↑↑ ↑ ↑ ↑ ↑↑↑ ↑↑↑ ↑↑↑ ↑↑ ↑↑↑ ↑ ↑ ↑ ↑↑↑ ↑↑↑ ↑↑↑ ↑↑ ↑↑↑ ↑ ↑ ↑ ↑↑↑ ↑↑↑ ↑↑↑ ↑↑ ↑↑↑ ↑ ↑ ↑ ↑↑↑ ↑↑↑ ↑↑↑ ↑↑ ↑↑↑ ↑ ↑ ↑ ↑↑↑ ↑↑↑ ↑↑↑ ↑↑ ↑↑↑ ↑ ↑ ↑ ↑↑↑ ↑↑↑ ↑↑↑ ↑↑ ↑↑↑ ↑ ↑ ↑ ↑↑↑ ↑↑↑ ↑↑↑ ↑↑ ↑ Deaths from Stroke j ↓ ↓ ↓↓ ↓ ↓ ↓↓↓↓ ↓ ↓↓ ↓ ↓ ↓↓↓↓ ↓ ↓↓ ↓ ↓ ↓↓↓↓ ↓ ↓↓ ↓ ↓ ↓↓↓↓ ↓ ↓↓ ↓ ↓ ↓↓↓↓ ↓ ↓↓ ↓ ↓ ↓↓↓ AVG ↓ ↓↓ ↓ Deaths from Cancerk ↑ ↑↑ ↑ AVG AVG AVGAVG AVG AVGAVG AVG AVG ↓ ↑↓ ↑ AVG AVGAVG AVG aU.S. prevalence 5 27.6 percent (overweight defined as body mass index [BMI] >30.0).
bU.S. prevalence 5 26.3 percent (persons who did no leisure-time physical activity in past month).
cU.S. prevalence 5 9.3 percent (self-reported data based on number of persons who were told they had condition by a health professional).
dU.S. prevalence 5 31.4 percent (self-reported data based on number of persons who were told they had condition by a health professional)
eU.S. prevalence 5 28.4 percent (self-reported data based on number of persons who were told they had condition by a health professional).
fU.S. prevalence 5 77.6 percent (adults who do not consume at least 5 fruits/vegetables per day).
gU.S. median 5 16.8 percent (>5 drinks/day on one occasion in the past month for men, >4 drinks on one occasion in the past month for women).
hU.S. prevalence 5 7.6 percent (live births of infants weighing <2,500 grams). iU.S. age-adjusted death rate per 100, 000 251000 2515000 251. jU.S. age-adjusted death rate per 100, 000 54.1000 54.5000 54. . kU.S. age-adjusted death rate per 100, 000 190000 1905000 190 AVG—similar to national average ↑—slightly above national average ↓—slightly below national average ↑↑—significantly above national average ↓↓—significantly below national average ↑↑↑—exceptionally above national average ↓↓↓—exceptionally below national average Sources: Centers for Disease Control and Prevention. 2014. National Diabetes Statistics Report: Estimates of diabetes and its burden in the United States, 2014. Atlanta, GA: U.S. Department of Health and Human Services; Division for Heart Disease and Stroke Prevention: Data Trends & Maps, U.S. Department of Health and Human Services, Centers for Disease Control and Prevention (CDC), National Center for Chronic Disease Prevention and Health Promotion. 2013. Retrieved from http://www.cdc.gov/dhdsp/; America’s Health Rankings®: A Call to Action for Individuals & Their Communities. 2014. United Health Foundation. Retrieved from http://www.unitedhealthfoundation.org TA B L E 15. 3 Northeast State-Specific Health Data Compared to National Averages, 2009–2014 productivity, which is why it is nicknamed “America’s breadbasket.” The Midwest encompasses twelve states with 21 percent of the total land area and just over 21 percent of the total U.S. population.7 It is divided into the east north central (ENC) region (Illinois, Indiana, Michigan, Ohio, and Wisconsin), and the west north central (WNC) region (Iowa, Kansas, Minnesota, Missouri, Nebraska, North Dakota, and South Dakota). The states of the ENC area are bounded by the Great Lakes, which temper the climate, Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 4 9 6 R E G I O N A L A M E R I C A N S ensuring milder weather than that experi- enced by other areas of the Midwest. Although the French were the first Europeans to explore the region, it was Americans from the North- east states, as well as Virginia and Delaware, who were the first pioneers. Later immigrants from Germany, Switzerland, Scandinavia, central Europe, and the Cornwall area of England were attracted by the fishing, dairy, mining, lumber, and meatpacking industries. The WNC states are geographically near the center of North America, exposed to long winters, short summers, and extreme tem- peratures. Most Americans who settled the territory were homesteaders, interested in the inexpensive land and farming opportunities. They came from New England and the Mid- Atlantic states, followed by new immigrants from Germany, Scandinavia, and central Europe, particularly Poland. As suggested by the history of immigration to the area, the Midwest has the largest per- centage of whites in the nation. Over half of all U.S. citizens of Czech and Norwegian ancestry live in the Midwest, as well as large numbers of people of Finnish, Croatian, Swedish, German, and Polish heritage. There are below-average numbers of blacks (approximately 6 percent of the total population) throughout the Midwest; the exceptions are in Ohio, Michigan, and Illi- nois, which have slightly above-average Afri- can American populations. Native Americans, Latinos, and Asians/Pacific Islanders are also underrepresented, although there is a large population of Latinos in Illinois, approach- ing the national average, and above-average numbers of Native Americans in the Dakotas. Overall, Illinois has the most diverse popula- tion in the Midwest; nearly one in every three residents is nonwhite (Table 15.4). One immigrant group that has made the Midwest home is Laotians, including Hmong, who have arrived since the 1970s (see Chapter 12 for immigration history and food habits). Over 44 percent of all Hmong counted in the 2013 U.S. Census live in Minnesota and Wisconsin.7 Other Southeast Asians have not tended to settle in the area, however. Addi- tional recent immigrant populations of note include Asian Indians in Illinois and Michi- gan, Koreans in Illinois, Middle Easterners in Michigan, and Russians in Illinois and Ohio. The Midwest has the lowest percentage of people living in metropolitan areas in the United States. Average household income is slightly above the national average, at $51,367 according to 2013 American Community Sur- vey data. Approximately 10 percent of indi- viduals living in the Midwest are considered to be living in poverty.7 Traditional Fare Midwestern fare is usually described as no- frills homestead and farm food, exemplifying what is called typical American cuisine (see Table 15.5). Prime meat or poultry is prepared United States Estimate Estimate Total: 311,536,594 67,148,157 White alone 238,007,238 56,326,045 Black or African American alone 42,496,977 7,641,724 American Indian and Alaska Native alone 5,142,542 897,699 Asian alone 17,845,862 2,127,328 Native Hawaiian and Other Pacific Islander alone 1,177,092 68,484 Some other race alone 16,986,453 1,709,122 Other races 16,399,187 172,334 Source: U.S. Census Bureau, 2013 American Community Survey. TA B L E 15. 4 Estimates of Ethnicity in the Midwest Region The number of farms in the United States has dropped from 5.7 million in 1900 to 2.2 million in 2012. During this period the average size of each remaining farm has more than tripled. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 1 5 4 9 7 simply, served with vegetables, potatoes, and fresh bread. Hearty breakfasts start the day, robust soups and stews replenish body and spirit, and homespun desserts round out the meal. The Midwest is a region of food traditions maintained over generations. Beef and pork are preferred meats, although better cuts are affordable today, and variety cuts may be consumed less often than in settlement days. Canning and freezing to preserve summer’s bounty is still a common activity. Bread is sometimes baked at home, and pies make use of seasonal fruits. Midwestern hospitality, which began with festive sorghum pulls, group apple peelings, and canning parties, is con- tinued through buffets, box socials, pitch-in or potluck suppers, strawberry socials, corn roasts, and fish boils popular throughout the region. East North Central The earliest American settlement in the East North Central (ENC) region was in Marietta, Ohio, in 1788. The people who came to the area from the original colonies were mostly farmers who survived in their new homes on hogs, corn, beans, squash and pumpkins, cab- bage, and potatoes. Corn was eaten at every meal as porridge or as baked or fried breads. Sun-dried or smoked meat strips called jerky were adopted from the Indians of the region, used first for game such as venison, then later for beef. Other wild meats, poultry, and fish, such as rabbit, squirrel, woodchuck, opos- sum, raccoon, skunks, duck, quail, sturgeon, and trout, were widely available. Even bear meat was consumed.12 Native fruits included persimmons, blueberries, bush cranberries, gooseberries, ground cherries, grapes, and many types of nuts. Later settlers brought wheat and oats, as well as apples, cher- ries, peaches, and berries. Fishing provided salmon, smelt, trout, and other freshwater fish; dairying, particularly cheese making, offered further food variety. Today, agricultural products are still signif-Today, agricultural products are still signif-Today, agricultural products are still signif icant in the region. In addition to wheat and corn, soybeans are a primary crop in Illinois and Ohio, grown for oil (used in products such as margarine, mayonnaise, salad dressing, and for industrial purposes), meat substitutes, and animal feed. Apples are a major crop in Michi- gan—local preparations include apple salad, apple meat loaf, and apple bread. The French introduced sour European cooking cherries to Michigan, where nearly all of these nationally used fruits are produced. One unusual Illinois specialty is horseradish. German immigrants brought the eastern European food to the state, and the pungent, gnarly root thrived. Illinois is the largest producer of horseradish in the United States. Dairying remains important in some regions as well. Wisconsin is the leading U.S. producer of milk, sweetened condensed milk, butter, and cheese. Dairying was sparked by the arrival of Swiss farmers to the state in the 1840s. They brought their expertise in breed- ing livestock and making cheese. Colby, a hard cheese similar to cheddar, is an original Wisconsin cheese that was created in 1885. Another variety developed in Wisconsin is brick, a semisoft cheese with holes and a fla- vor described as sweet, nutty, and spicy. Italian cheeses, including ricotta, mozzarella, provo- lone, Romano, and Parmesan, are specialties of northern Wisconsin, while blue cheese is made in the caves near Milwaukee. Contributions in food processing from ENC states have extended beyond regional importance to influence the development of American cuisine. Many of these changes took place in Illinois during the late 1800s and early 1900s. Historical accounts include The origins of meatloaf, the quintessential mid- western beef dish, are unknown. It may have come with German immi- grants who sometimes added rye bread as an extender, or sauerkraut for moisture, to ground meat dishes.10 Fish boils combining fish, potatoes, onions, and salt were begun by Scan- dinavians as an efficient way to feed the workers at lumber camps. Today, fish boils at the edge of Lake Michigan are annual tourist events in Wisconsin. ▼ Wisconsin is known for its dairy foods, especially cheeses such as Colby and brick. W ill S al te r/ Lo ne ly P la ne t I m ag es /G et ty Im ag es Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 4 9 8 R E G I O N A L A M E R I C A N S stories about Philip Armour, who made mil- lions in pork sales when he founded the Chi- cago meatpacking industry; Gustavus Swift, who made his fortune in hams and sausages; Oscar Mayer, a German immigrant who got his start in the hot dog business as a butcher in Chicago; Louis Rich, a Russian immigrant who became involved in poultry processing and founded a turkey luncheon meat empire; and James Lewis Kraft, a grocery clerk who came up with the idea that home-delivered, uniform pieces of cheese would be more popular than freshly cut wedges from a large wheel. He later introduced processed and pre- packaged cheeses, including Velveeta. Developments were not limited to Illinois. In Ohio, an Austrian immigrant, Charles Fleischmann, created the first standardized Group Foods Preparations Protein Foods Milk/milk products Milk, buttermilk, butter, cream, cheeses Cream gravy, fondue, rømmegrøt, skyr Meat/poultry/ fish/eggs/ legumes Native game, including buffalo, venison, beaver, raccoon, opossum, turkey, prairie chickens (grouse), pheasant Pork in all forms, especially salt pork, hams (country ham and Westphalian ham), and sausages (bratwurst, weinerwurst, kielbasa); beef Oysters shipped from the East Coast Freshwater fish, especially smelt, sturgeon, trout, and whitefish Dried beans Jerky, booyaw, Hasenpfeffer Ham with gravy, pork chops, barbecued pork, hot dogs, Bubbat Beef pot pie, stew, barbecued brisket, bierocks, pasties, Cincinnati chili Fish boils, fried trout or smelt Baked beans with salt pork or bacon Cereals/Grains Corn, wheat, rye, oats, wild rice Cornbreads, porridges; oatmeal; bannocks; rye breads, pumpernickel; biscuits, dumplings (including stuffed, such as pierogi and pierogi and pierogi verenikas) Baked goods, especially fresh fruit pies (apple, cherry, persimmon, rhubarb), iced cakes, strawberry shortcakes, strudel, kolaches, butter cookies, pancakes, aebelskivers, Danish pastries Fruits/Vegetables Apples, berries (blueberries, elderberries, strawberries), cherries, grapes, peaches, persimmons, rhubarb Cabbage, onions, peas, potatoes, rutabagas, turnips, wild mushrooms Applesauce; apple butter, fritters, bread, salad; fried apples, candied apples; fruit jams and jellies Sauerkraut, sauerkraut balls; coleslaw; potatoes—boiled, fried, baked, as dumplings, salad; onion pie Additional Foods Seasonings Salt, pepper; parsley, dill; cinnamon, Seasonings Salt, pepper; parsley, dill; cinnamon, ginger, nutmeg, saffron; molasses Most foods are preferred mildly spiced Nuts/seeds Almonds, black walnuts, hickory nuts, Nuts/seeds Almonds, black walnuts, hickory nuts, pecans; poppy seeds Nut pies, almond paste; nut candies; poppy seed cakes and pastries Beverages Apple juice, beer, wine, apple brandy Lager-style (American) beerBeverages Apple juice, beer, wine, apple brandy Lager-style (American) beerBeverages Apple juice, beer, wine, apple brandy Lager-style (American) beer Fats/oils Butter, lard Sweeteners Sugar, honey, molasses, sorghumSweeteners Sugar, honey, molasses, sorghum TA B L E 15. 5 Midwestern Specialties © C en ga ge L ea rn in g Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 1 5 4 9 9 yeast cakes for baking (he later formed a distillery that produced the first American gin). Michigan is probably best known for its role in the creation of the U.S. cereal indus- try. The city of Battle Creek was home to two health sanitariums during the late nineteenth century. The first was founded by Seventh- Day Adventist leader Ellen Harmon White, who advocated vegetarianism. Her medical director was Dr. John Kellogg, inventor of cornflakes (see Chapter 4). C. W. Post, a for- mer Kellogg patient, started his own health institute in Battle Creek. He created a coffee substitute, Postum (a blend of wheat berries, bran, and molasses), and a cereal based on his own recipe for digestive problems, called Grape-Nuts.13 Each group of pioneers in the region brought favorite dishes. Baked beans, meat pot pies with biscuit topping, and succotash were preferred by settlers from New England. In Ohio these settlers stuffed meats with breadcrumbs, a practice still popular in the state. The people from New York and Penn- sylvania favored sausages, sauerkraut, pick- les, and relishes when they moved westward. In Indiana, where the earliest pioneers came from the South, pork is especially popular, including roasts and chops, and sometime the whole roasted pig. Sausage patties and ham are common for breakfast, typically served with pancakes or biscuits, cream gravy, and fried apples. The southern influence is also seen in batter-fried chicken served with fried biscuits (made with a yeast dough that puffs up into spheres when dropped into hot oil, then slathered with butter while still warm). In areas where European immigrants con- gregated in numbers, regional ethnic fare developed. For example, the Michigan Dutch (actually from the Netherlands, not Ger- mans like the Pennsylvania Dutch) brought ham croquettes, pea soup, saucijzenbroodjes (now known in English as pigs-in-a-blanket), and double-salted licorice. In Ohio the fare of European immigrants was more broadly integrated into the regional cuisine: Germans popularized sausage, ham, potato, and cab- bage dishes, such as the unusual Ohio specialty called sauerkraut balls (deep-fried sauerkraut and ham fritters served with mustard sauce); Polish immigrants introduced pierogis (boiled dumplings traditionally stuffed with potatoes, cabbage, onion, and/or meat, or fruit), kiel- basa sausage, and strudel (flaky pastry rolls filled with sweetened fruit, nuts, poppy seeds, or cheese). Fish boils, pickled fish, and meat- balls are just a few of the items adopted from Scandinavian immigrants in Wisconsin. Some European foods are so well accepted that their ethnic associations have been forgotten. East- ern Europeans brought to Wisconsin their pork or veal sausages, which are now consid- ered state specialties—Sheboygan is the self- proclaimed “Bratwurst Capital of the World.” In other cases, European influence has been more limited, seen mostly in one or two dishes, such as Swiss cheese fondue in Indi- ana, and in Michigan, a dish with French roots known as booyaw or boolyaw (perhaps from the term bouil l on), a game stew featuring ven- ison or whatever else was available (includ- ing rabbit, woodchuck, squirrel, muskrat, or duck), salt pork, carrots, potatoes, and onions. Other dishes with ethnic origins have been adapted to midwestern tastes, losing much of their heritage along the way. For example, Ohio is probably best known nationally for Cincinnati chili. It is an all-beef version cre- ated by Greek and Macedonian immigrants in the 1920s, flavored with a balanced blend of sweet spices (e.g., cinnamon, allspice, cloves, and nutmeg) and hot spices (garlic, cumin, black pepper, and dried chiles). Some researchers note the similarities between the seasoning of Cincinnati chili and dishes such as pastitsio or moussaka (see Chapter 13).14 Chili parlors found throughout Ohio (and parts of nearby Kentucky) serve the mild chili “one-way” (just the meaty stew alone), “two- way” (over spaghetti), “three-way” (spaghetti, chili, grated-cheese topping), “four-way” (spaghetti, chili, cheese, and diced onions), or “five-way” (spaghetti, chili, cheese, onions, and kidney beans). The origins of some dishes reflect the suc- cession of immigration to an area. Cornish pasties are an example. Miners from Corn- wall arrived in Michigan’s Upper Peninsula to excavate iron and copper in the 1840s, bringing their traditional lunch specialty called pasties (see Chapter 6). This complete Wisconsin fare is sometimes called “white cooking.” Whitefish (from the Great Lakes) and white meat (pork, veal, or chicken) combined with white dairy products (such as farmer’s cheese, cottage cheese, cream cheese, fresh cream, or sour cream) are favored.30 Deep-dish Chicago-style pizza is baked in a skillet. It is an American adapta- tion of the pizza brought to the region by Italian immigrants from Naples. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 5 0 0 R E G I O N A L A M E R I C A N S meal-in-a-turnover often featured venison in the Michigan versions, with potatoes and turnips the common vegetable filling. Apples were the most popular fruit used for the des- sert end of the pastry. When immigrants from Finland came in the following years, they adopted the dish, which was similar to piiraat and kukko, Finnish pastries filled with meat or fish, rice, and vegetables. The ori- gins of the dish are claimed by many Finns in the region, though those of Cornish descent point out that the Finnish turnovers are not pasties because the filling is mixed instead of layered.15 Today’s pasty shops, often featuring untraditional fillings (e.g., pizza ingredients), are common throughout the Upper Peninsula (UP) and in cities where “UPers” (“Yoopers”) have settled, such as Detroit. Sweets, especially baked goods, hold a spe- cial place in the cooking of the ENC states. Traditional items such as hickory nut cookies and pies are found in many areas. In Indiana dessert favorites include steamed or baked persimmon pudding; pork cake, a moist des- sert made with sausage or salt pork, molas- ses, brown sugar, flour, dried fruits, and spices that is a Christmas tradition in some Indiana homes; and sweet cream pie, pastry filled with a heavily sweetened custard that is popular all year. In Michigan apple fritters, caramel-covered apples, candied apples, and Dutch apple kock (cake) are common. Elder- berry-flower fritters dipped in powdered sugar are also a specialty. In Wisconsin many popular desserts have retained their foreign names, including German kuchen (yeasted coffee cake, often with a fruit and cream fill- ing and crunchy, sugary streusel topping) and schaum torte (meringue topped with ice cream and/or whipped cream and fresh fruit); and Danish kringle (pretzel- or ring-shaped flaky pastry with fruit, nut, cheese, or butter- scotch filling). Beer is especially associated with the Midwest, particularly Wisconsin. The first breweries were located in the southwestern section of the state and produced the ales and stouts favored by English settlers. By the middle of the nineteenth century, however, ten breweries producing German-style lagers and pilsners had been founded in Milwaukee, including plants owned by Frederich Miller, Frederich Pabst, and Joseph Schlitz. At the beginning of the 1900s, there were over 300 breweries statewide, but Prohibition and con- solidation in recent years have reduced that number to eight. West North Central In the West North Central (WNC) states, the settlers of the mid-nineteenth century came to farm the fertile land of Iowa, Kan- sas, Minnesota, and Missouri. Harsh winters and a scarcity of provisions limited variety in many early pioneer homes. Homemakers of the period describe burying melons in sand, which with luck would stay fresh until Christ- mas. Other cooks would prepare up to a hun- dred fresh fruit pies at a time, covering the extras with snow for use throughout the win- ter months. Parched corn, herbs, bark, or root brews replaced coffee.15 Prestige foods were often unavailable, so ample, even excessive, amounts of common foods became symbolic of hospitality in the midwestern frontier. The more western areas of the WNC states, which are drier and less suitable for crops, provided limited opportunities for agriculture. The region attracted trappers, traders, and pros- pectors. Wild game, such as bear, buffalo, elk, deer, and small mammals, as well as turkeys, S a m p l e M e n u A Great Lakes Sampler Cheese P ie r ogi a,c Bratwurst or Kielbasa Apple Sauerkrautb,c Danish Kringleb,c or Sour Cherry Piea,c aFertig, J.M. 1999. Prairie home cooking. Boston: Harvard Common Press. bFussell, B. 1997. I hear America cooking. New York: Penguin Books. cCooks.com at http://www.cooks.com Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 1 5 5 0 1 prairie chickens (grouse), quail, doves, and frogs, was hunted; the meat or oil was often sold in settlement towns. These regional foods were first documented in an American cook- book in 1902.16 As in the ENC region, pioneers from New England and the Mid-Atlantic states contributed dishes eaten frequently in their eastern homes: Baked beans and pies of all sorts became as common as sausages and sauerkraut. One northeastern specialty that became surprisingly popular throughout the Midwest was oysters. By the mid-1800s the live shellfish were shipped regularly to the region packed in barrels filled with wet straw. One English visitor commented that the rich “consumed oysters and Champagne and the poor [ate] oysters and lager bier.”17 One 1859 recipe for small birds, such as magpies, sug- gested stuffing a breaded oyster into each bird before roasting over a hot fire.15 Irrigation improved crop production throughout the region, and today corn, wheat, soybeans, and sugar beets are widely cultivated. Barley, oats, sunflowers, rutabagas, and rye are other crops in some areas. Wild rice, called a grain but actually the triangular- shaped seed of an aquatic grass found in shal- low rivers and lakes, is a Minnesota specialty (see Chapter 5). Though Missouri is too hilly for grain crops, the terrain is well suited for nut trees. Eastern black walnuts are native to the area. The nuts are strongly flavored with a slightly bitter aftertaste and are the primary ingredient in black walnut pie. Pecans, too, are indigenous to the state. They are popular in pies, candies, cookies, and cakes. Further, beekeepers take advantage of the woodlands in the state to provide another specialty of the region—honey. Iowa is noteworthy for its commercial hog farms and is the number one producer of pork in the nation. Pork is also a favorite in Missouri due to the large number of south- erners who settled the state. Missouri is well known for its country hams, which are cured with salt, then smoked and hung to age in the cool winter months. The resulting meat is red, salty, and dry in texture. It is traditionally served with biscuits and red-eyed gravy made from ham drippings, coffee, and flour. Beef is more significant in Kansas, Nebraska, and the Dakotas. Before the intro- duction of cattle to the region, over 30 mil- lion bison roamed the Great Plains, providing sustenance, clothing, shelter, and fuel to the local Native Americans. American settlers and European immigrants also ate what they called hump-backed beef, at least until other meats became widely available. However, the huge bison herds interfered with expand- ing settlements, the railroads, and Texas cattlemen, who drove their longhorns through the prairie states to the slaughterhouses of the North and East. The bison were systematically eradicated, providing unimpeded access to the grazing lands of the plains. Today Kansas is famous for its corn-fed beef, and cattle are the most important agricultural commodity in the state. Steaks, beef stews, barbecued beef, and hamburgers are all Kansas favorites. In South Dakota, early settlers introduced long- horn cattle from Texas; they were soon joined by Scottish cattle, including Aberdeen, Angus, and Herefords. Immigrants from Scotland were soon exporting beef to their homeland. Cattle ranching is a major industry in the state, though sheep and hogs are also impor- tant commodities. South Dakota is one of the only states in the WNC that features lamb dish specialties. Despite a preference for pork or beef, poultry is well represented in WNC state fare. Chicken with dumplings or noodles, pan- fried chicken with cream gravy, and chicken or turkey pot pies (topped with pastry or bis- cuits) are classic midwestern dishes. Several notable religious communities were founded in WNC states. In Iowa the Amish who settled around Kalona grew all of their own food and butchered all of their own meat, traditions still practiced today. Cornbread with tomato juice gravy, stews or hashes with potatoes and peas, fried meats and eggs, and fresh fruit pies are com- mon dishes. A group of German Lutherans, known as True Inspirationists, settled in seven Iowa villages in 1859 to form what is known as the Amana Colonies. They lived communally, with everyone eating three enormous meals and two coffee breaks each day in a large dining hall. The weekly menu Dairying is common in several WNC states. Minnesota is one of the top butter and cheese producers in the nation, and Iowa is known for the development of American blue cheese, introduced in the 1920s by Maytag Dairy Farms. Pierogi are known as pelmeni by some Russians, varenyky by Ukrainians, and verenikas by German Russian Mennonites. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 5 0 2 R E G I O N A L A M E R I C A N S was set and included Mehlspeisen (literally “flour desserts,” such as simple puddings) on Tuesdays and boiled beef every Wednesday. The Colonies now serve German specialties to visiting tourists in several large restaurants. German Russian Mennonites (who had first migrated from Germany to southern Russia) came to Kansas in the 1870s. They brought German-style foods familiar in Pennsylvania Dutch areas, such as chicken noodle soup, pancakes, sausages, and buttermilk pie. They also introduced verenikas (their term for pierogis) served with cream gravy. Beef rolls stuffed with bacon, onions, and pickles similar to German Rouladen, and sausage-filled buns called Bubbat are other Kansas dishes brought by the German Russian Mennonites. European influence was seen in secular settlements as well. German Russian yeast dough turnovers (typically filled with beef, cabbage, and onions) are common through- out the Great Plains. They were derived from the Russian pirozhki. The turnovers are called bierocks in Kansas and the Midwest- ern regions east and south of that state, and they are known as runsas in Nebraska and the northern Midwest areas. In Minnesota, German immigrants brought hogs and dairy cattle and intro- duced their dark rye breads, including pum- pernickel. Specialties such as Hasenpfeffer (stewed rabbit), Spätzle (tiny dumplings), and Maultaschen (a sort of German ravioli filled with ground ham, eggs, onions, and some- times spinach) were other common German dishes. Preserved fish were a mainstay for the Scandinavians. Pickled fish, smoked fish, and salt-cured fish were popular, particularly the Norwegian dish known as lutefisk (see Chap- ter 7), served with butter and potatoes. Ham, bacon, Swedish meatballs, and Danish frik- adeller (fried, breaded ground beef and veal patties) were consumed. Dark breads and the thin Norwegian potato pancake called lefser are still common, as are butter cookies (espe- cially at Christmas) and Danish aebleskiv- ers, traditionally served with chokecherry or blueberry syrup or jam. The Scandinavian concept of the smörgåsbord was introduced to the nation in Minnesota (see Chapter 7). Several ethnic communities in Minnesota maintain their culinary heritage at holidays and festivals, including the German Catholic city New Ulm and the Danish town Askov. In Nebraska, the Swiss introduced plum tarts and a specialty called Thuna, bread- sticks topped with creamed greens thickened with flour. Czech settlers brought jaternice (pork sausage), jelita (blood sausage), and houska (a sweet, braided bread). Swed- ish yeasted waffles and Hungarian chicken paprika are other examples of European con- tributions in the state. In Missouri, the French introduced crêpes and brioche to the region. They also made hard cider from apples, wine from native grapes, and brandy from peaches. In North Dakota the Norwegians brought spekejøtt (smoked, dried lamb), rullepølse (cold, spicy rolled beef ), and søtsuppe (fruit soup) and baked goods, including the large pyramid of almond paste and meringue rings called kransekake. A large population of set- tlers from Iceland smoked mutton, made skyr (a sweet, cultured milk product similar to yogurt), fried kleinur (doughnuts), and baked vinarterta (a multilayered cardamom-flavored cake with fruit fillings) for dessert. The Scotch Irish introduced colcannon (mashed potatoes, onions, and cabbage), and the French Cana- dians came with croissants and cassoulet (see Chapter 6). A unique cuisine of the Midwest is found in the Ozark Mountains of Missouri. Contrary to immigration trends in urban areas, the peo- ple who came to the Ozarks gradually arrived from other states in small groups and were scattered throughout the region. They were known as backwoodsmen, and they subsisted on hunting, fishing, gathering, and cultivation of corn, beans, squash, and various tubers.18 Hogs were let loose to forage until butchering time in December or January. The people of the Ozarks were known for their stews made from opossum, raccoon, or squirrel. Sorghum was used to sweeten foods, ginger root was brewed for beer, and sassafras was steeped for tea. Today, the Ozarks are best known as a vacation and retirement destination. Popular desserts in the WNC states include fruit pies and frosted cakes. Czech kolaches are a specialty found throughout the region. These yeasted buns are baked The Danish community of Askov, Minnesota, has an annual festival commemorating the rutabaga. Although the tuber is commonly called a “Swede” or “ Swedish turnip,” Danes are believed to have introduced the rutabaga to the region. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 1 5 5 0 3 with an indentation on top that is filled with sweetened cheese, poppy seeds, or fruit (apple, apricot, cherry, and prune are traditional) and sprinkled with sugar or streusel before they are baked. The Scandinavian dessert kran- sekake is also found in many communities. Health Concerns Measures of health in the Midwest ranked second highest for coronary risk factors. This region has the highest smoking prevalence.12 For more indicators see Table 15.6. Significantly higher-than-average rates of heavy drinking are found in Michigan, Minnesota, Wisconsin, North Dakota, Nebraska, Illinois, and Iowa, with the highest rate in Wisconsin. The South Regional Profile Most southerners say the South is more an attitude than a location. This perhaps explains why there are so many definitions of the region, such as those states below the his- toric Mason-Dixon Line or those south of the culinary grits line (the divide between where grits are eaten and where they aren’t). While no one questions that Alabama, Arkansas, Florida, Georgia, Louisiana, Kentucky, Mary- land, Mississippi, the Carolinas, Tennessee, Virginia, and West Virginia are clearly part of the South, the borderline states of Delaware, Missouri, Oklahoma, and Texas can be argued for inclusion either way. Using the U.S. government definition, Missouri is consid- ered part of the Midwest, whereas Delaware, Oklahoma, and Texas are part of the South. The lands of the South are varied. They include the fertile coastal plains along the Atlantic and Gulf Coasts, the rolling hills leading up to the mountains (called the Pied- mont in most states), the rugged Appalachian and Ozark Mountain territories, the lowlands of the Mississippi Delta, and the high desert plains of the western reaches. The climate also ranges from the warm, moderate Atlan- tic states and the hot, humid Gulf Coast states to the hot, dry weather in parts of Texas and Oklahoma. The development of the South was in many ways independent from that of the northern United States. During colonial times, southern states were predominantly agricultural, grow- ing tobacco, wheat, corn, rice, and indigo (a blue dye). The plantation system that emerged in the coastal regions was characterized by commercial farms owned by aristocratic English or French immigrants and worked by African slaves. Each plantation was a self- sufficient, independent operation providing cash crops and food products for use by each household. It was a comfortable, leisurely life- style for the upper classes, enlivened by occa- sional visits to the cultural centers of Atlanta, Charleston, or New Orleans. For the lower classes, which included the slaves and the poor farmers of the inland hill and mountain regions, it was a hand-to-mouth existence. During the period when the northern areas of the nation became more urbanized and industrialized, the South remained rural and agricultural, adding cotton as a major crop. Differences of opinion regarding the role of the federal government in state issues, par- ticularly slavery, led to the Civil War in the mid-1800s. After losing the war, the South regrouped in the late nineteenth century. The S a m p l e M e n u A Hearty Plains Lunch Chicken Noodle Soupa,b Meatloafa,bMeatloafa,bMeatloaf Mashed Potatoes Pickled Cucumbers (Cucumbers in Vinegar)a Apricot Kolachesa aFertig, J.M. 1999. Prairie home cooking. Boston: Harvard Common Press. bStern, J., & Stern, M. 2001. Square meals: America’s favorite comfort food cBabi’s Czech Recipes from the Dumpling Newsletter Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 5 0 4 R E G I O N A L A M E R I C A N S IA IL IN KS MI MN MO NE ND OH SD WIIA IL IN KS MI MN MO NE ND OH SD WI Obesitya ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ No Leisure-Time Exerciseb ↑ AVG ↑ AVG ↓ ↓↓ ↑↓ ↓↓ ↑↓ ↓↓ ↑ AVG ↑ ↑ ↓ ↓↑ ↑ ↓ ↓↑ ↑ ↓ ↓↑ ↑ ↓ ↓ Diabetesc ↓ AVG ↑ ↓↑ ↓ AVG ↓↓↓ AVG ↓↓ ↓↓ ↑ ↓↓ ↓↓↓↓ ↓↓ ↑ ↓↓ ↓↓↓↓ ↓↓ ↑ ↓↓ ↓↓↓↓ ↓↓ ↑ ↓↓ ↓↓↓↓ ↓↓ ↑ ↓↓ ↓↓ Hypertensiond ↓ ↓↓ ↓ AVG ↓ ↓ ↓↓ ↓ ↓↓ ↓ ↓ AVG ↓↓ ↓↓↓↓ ↓↓ AVG ↓ ↓↓↓ ↓↓ High Blood Cholesterole ↑↑ ↑↑ ↑↑ ↑↑ ↑↑ ↑↑ ↑↑ ↑↑ ↑↑ ↑↑ ↑↑ ↑↑↑↑ ↑↑ ↑↑ ↑↑ ↑↑ ↑↑ ↑↑ ↑↑ ↑↑ ↑↑ ↑↑ ↑↑↑↑ ↑↑ ↑↑ ↑↑ ↑↑ ↑↑ ↑↑ ↑↑ ↑↑ ↑↑ ↑↑ ↑↑↑↑ ↑↑ ↑↑ ↑↑ ↑↑ ↑↑ ↑↑ ↑↑ ↑↑ ↑↑ ↑↑ ↑↑↑↑ ↑↑ ↑↑ ↑↑ ↑↑ ↑↑ ↑↑ ↑↑ ↑↑ ↑↑ ↑↑ ↑↑↑↑ ↑↑ ↑↑ ↑↑ ↑↑ ↑↑ ↑↑ ↑↑ ↑↑ ↑↑ ↑↑ ↑↑↑↑ ↑↑ ↑↑ ↑↑ ↑↑ ↑↑ ↑↑ ↑↑ ↑↑ ↑↑ ↑↑ ↑↑↑↑ ↑↑ ↑↑ ↑↑ ↑↑ ↑↑ ↑↑ ↑↑ ↑↑ ↑↑ ↑↑ ↑↑↑↑ ↑↑ ↑↑ ↑↑ ↑↑ ↑↑ ↑↑ ↑↑ ↑↑ ↑↑ ↑↑ ↑↑↑↑ ↑↑ ↑↑ ↑↑ ↑↑ ↑↑ ↑↑ ↑↑ ↑↑ ↑↑ ↑↑ ↑↑↑↑ ↑↑ ↑↑ ↑↑ ↑↑ ↑↑ ↑↑ ↑↑ ↑↑ ↑↑ ↑↑ ↑↑↑↑ ↑↑ ↑↑ ↑↑ ↑↑ ↑↑ ↑↑ ↑↑ ↑↑ ↑↑ ↑↑ ↑↑ Don’t Consume 5 Fruits/Vegs.f AVG AVG AVG AVG AVG AVG AVG AVG AVG AVGAVG AVG AVG AVG AVG AVG AVG AVG AVG AVGAVG AVG AVG AVG AVG AVG AVG AVG AVG AVGAVG AVG AVG AVG AVG AVG AVG AVG AVG AVGAVG AVG AVG AVG AVG AVG AVG AVG AVG AVGAVG AVG AVG AVG AVG AVG AVG AVG AVG AVGAVG AVG AVG AVG AVG AVG AVG AVG AVG AVGAVG AVG AVG AVG AVG AVG AVG AVG AVG AVGAVG AVG AVG AVG AVG AVG AVG AVG AVG AVGAVG AVG AVG AVG AVG AVG AVG AVG AVG AVG ↑ AVG Binge Drinkingg ↑↑ ↑↑ ↑↓ ↓ ↑ ↑↑↑↑ ↑↑ ↑↓ ↓ ↑ ↑↑↑↑ ↑↑ ↑↓ ↓ ↑ ↑↑↑↑ ↑↑ ↑↓ ↓ ↑ ↑↑↑↑ ↑↑ ↑↓ ↓ ↑ ↑↑↑↑ ↑↑ ↑↓ ↓ ↑ ↑↑ AVG ↑↑ ↑↑↑↑↑ ↑↑↑ AVG ↑ ↑↑↑↑ ↑↑↑ Low Birth Weighth ↓ AVG AVGAVG AVG ↓ AVG AVG ↓ ↓↓ ↑ ↓↓ ↓↓ ↓↓ ↑ ↓↓ ↓↓ ↓↓ ↑ ↓↓ ↓↓ ↓↓ ↑ ↓↓ ↓↓ ↓↓ ↑ ↓↓ ↓ Deaths from Heart Diseasei ↑↑ ↑↑ ↑↑↑ ↑↑ ↑↑↑ ↑↑↑ ↑↑↑ ↑↑ ↑ ↑↑↑ ↑ ↑↑↑ ↑↑ ↑↑↑ ↑↑ ↑↑↑ ↑↑↑ ↑↑↑ ↑↑ ↑ ↑↑↑ ↑ ↑↑↑ ↑↑ ↑↑↑ ↑↑ ↑↑↑ ↑↑↑ ↑↑↑ ↑↑ ↑ ↑↑↑ ↑ ↑↑↑ ↑↑ ↑↑↑ ↑↑ ↑↑↑ ↑↑↑ ↑↑↑ ↑↑ ↑ ↑↑↑ ↑ ↑↑↑ ↑↑ ↑↑↑ ↑↑ ↑↑↑ ↑↑↑ ↑↑↑ ↑↑ ↑ ↑↑↑ ↑ ↑↑↑ ↑↑ ↑↑↑ ↑↑ ↑↑↑ ↑↑↑ ↑↑↑ ↑↑ ↑ ↑↑↑ ↑ ↑↑↑ ↑↑ ↑↑↑ ↑↑ ↑↑↑ ↑↑↑ ↑↑↑ ↑↑ ↑ ↑↑↑ ↑ ↑↑↑ ↑↑ ↑↑↑ ↑↑ ↑↑↑ ↑↑↑ ↑↑↑ ↑↑ ↑ ↑↑↑ ↑ ↑↑↑ ↑↑ ↑↑↑ ↑↑ ↑↑↑ ↑↑↑ ↑↑↑ ↑↑ ↑ ↑↑↑ ↑ ↑↑↑ ↑↑ ↑↑↑ ↑↑ ↑↑↑ ↑↑↑ ↑↑↑ ↑↑ ↑ ↑↑↑ ↑ ↑↑↑ ↑↑ ↑↑↑ ↑↑ ↑↑↑ ↑↑↑ ↑↑↑ ↑↑ ↑ ↑↑↑ ↑ ↑↑↑ ↑↑ ↑↑↑ ↑↑ ↑↑↑ ↑↑↑ ↑↑↑ ↑↑ ↑ ↑↑↑ ↑ ↑ Deaths from Stroke j AVG AVGAVG AVG ↑ AVG AVG AVGAVG AVG AVGAVG AVG AVG ↑ AVG ↑ ↑ ↑↑ ↑ ↑↑ ↑ ↑ AVG Deaths from Cancerk AVG ↑ ↑↑ ↑ AVG ↑ AVG ↑ ↓ ↓↓ ↑ ↓↑ ↓ ↓↓ ↑ ↓↑ ↓ ↓↓ ↑ ↓↑ ↓ ↓↓ ↑ ↓↑ ↓ ↓↓ ↑ ↓ AVG aU.S. prevalence 5 27.6 percent (obesity defined as BMI >25.0).
bU.S. prevalence 5 25.8 percent (persons who did no leisure-time physical activity in past month).
cU.S. prevalence 5 6.6 percent (self-reported data based on number of persons who were told they had condition by a health professional).
dU.S. prevalence 5 25.7 percent (self-reported data based on number of persons who were told they had condition by a health professional).
eU.S. prevalence 5 30.4 percent (self-reported data based on number of persons who were told they had condition by a health professional).
fU.S. prevalence 5 77.6 percent (adults who do not consume at least 5 fruits/vegetables per day).
gU.S. prevalence 5 5.1 percent (>2 drinks/day in the past month for men, >1 drink per day in the past month for women).
hU.S. prevalence 5 7.3 percent (live births of infants weighing <2,500 grams). iU.S. age-adjusted death rate per 100, 000 245.8000 245.5000 245. . jU.S. age-adjusted death rate per 100, 000 57.9000 57.5000 57. . kU.S. age-adjusted death rate per 100, 000 194.4000 194.5000 194. . AVG—similar to national average ↑—slightly above national average ↓—slightly below national average ↑↑—significantly above national average ↓↓—significantly below national average ↑↑↑—exceptionally above national average ↓↓↓—exceptionally below national average SOURCES: Centers for Disease Control and Prevention. 2014. National Diabetes Statistics Report: Estimates of diabetes and its burden in the United States, 2014. Atlanta, GA: U.S. Department of Health and Human Services; Division for Heart Disease and Stroke Prevention: Data Trends & Maps, U.S. Department of Health and Human Services, Centers for Disease Control and Prevention (CDC), National Center for Chronic Disease Prevention and Health Promotion. 2013. Retrieved from http://www.cdc.gov/dhdsp/; America’s Health Rankings®: A Call to Action for Individuals & Their Communities. 2014. United Health Foundation. Retrieved from http://www.unitedhealthfoundation.org TA B L E 15. 6 Midwest State-Specific Health Data Compared to National Averages, 2009–2014 traditions and practices that give the South its character became more important than ever. The South continues to preserve its identity, in part, through its cuisine. Over one-third (37 percent) of Americans make their home in the South, the highest per- centage of the U.S. population in any region.12 It is divided into the South Atlantic states of Delaware, Florida, Georgia, Maryland, North Carolina, South Carolina, Virginia, West Vir- ginia, and the District of Columbia; the East South Central (ESC) states of Alabama, Ken- tucky, Mississippi, and Tennessee; and the West South Central (WSC) states of Arkansas, Louisiana, Oklahoma, and Texas. Overall, the South has below-average numbers of Asians and Pacific Islanders, Latinos, and Native Americans, but above-average numbers of African Americans: 20 percent of all U.S. blacks live in the South. However, the very size of the southern population means that signif-of the southern population means that signif-of the southern population means that signif icant numbers of most ethnic groups reside in the region. For example, 30 percent of all Native Americans and 57 percent of Hispanics live in the South; both Florida and Texas host above-average populations of Latinos. While only 22 percent of U.S. Asians are found in the South, larger numbers of some groups, such as Vietnamese, Pakistanis, and Asian Indians, reside there. In addition to African Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 1 5 5 0 5 Americans, groups with disproportionately large representation in the South include persons of British ancestry, Scotch Irish ances- try, Cuban ancestry, and Cajun ancestry (see Table 15.7). The population of the South is notable for its high numbers of Protestant Christians and low numbers of people without religious affiliation. Baptist and evangelical faiths are especially popular. Three-quarters of the population in the South live in metropolitan areas. Census data from 2013 show that aver- age household income in the South is near the national average in the South Atlantic— approximately $49,165. Poverty rates are at approximately 13 percent for all individuals.12 Traditional Fare The foods most associated with the South reflect both the bounty of the plantation and the scarcity of the slave diet. Corn dishes, pork, sweet potatoes, and greens began as the foundation of southern fare and remain char- acteristic components today (see Chapter 8). The southern lifestyle has fostered a cul- ture of graciousness and cordiality. The iso- lation of the plantations meant socialization was limited in frequency but lengthy in dura- tion. Hours of travel to nearby homes typically resulted in overnight visits or extended stays. Parties, balls, picnics, barbecues, and seafood feasts were all occasions for get-togethers. For the slaves, Sunday meals with extended kin were the primary way to maintain family connections. In the hills and mountains of the South, the difficulties of subsistence farming necessitated friendly relationships between neighbors. Poor families often survived through regular sharing of food. As a result of these conditions, the South has become syn- onymous with hospitality. The first European explorers in the South Atlantic states were the Spanish, who arrived in Florida in 1513 and founded St. Augustine in 1565. They were soon followed by the English, who started in Virginia and spread north and south along the Atlantic coastline during the seventeenth and eighteenth centuries into Delaware, Maryland, the Carolinas, Georgia, and eventually into Florida. The Native American population at the time numbered in the hun- dreds of thousands, including the members of the Powhatan, Cherokee, Chickasaw, Choctaw, Creek, and Seminole tribes (see Chapter 5). The white settlers discovered a region with plentiful fruits, nuts, game, fish, and seafood. Native strawberries, blackberries, blueberries, huckleberries, ground cherries, persimmons, muscadine grapes, beechnuts, hickory nuts, and pecans covered the land. Bream, catfish, perch, pike, and trout filled the rivers, while oysters, clams, and crab were abundant along the coast. In Florida pompano, red snapper, shrimp, spiny lobster, and conch were widely available. Diamondback terrapin, sea turtles, and alligators were found in many waterways; and bear, deer, opossum, rabbits, raccoons, squirrels, turkey, grouse, ducks, and quail United States South Region Estimate Estimate Total: 311,536,594 116,015,264 White alone 238,007,238 85,340,613 Black or African American alone 42,496,977 23,475,196 American Indian and Alaska Native alone 5,142,542 1,713,812 Asian alone 17,845,862 3,994,124 Native Hawaiian and Other Pacific Islander alone 1,177,092 167,976 Some other race alone 16,399,187 1/246,059 4,242,35246,059 4,242,352 SOURCE: U.S. Census Bureau, 2013 American Community Survey. TA B L E 15.7 Estimates of Ethnicity in the Southern Region Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 5 0 6 R E G I O N A L A M E R I C A N S were prevalent in woodland areas. Indians of the region grew corn, beans, pumpkin, squash, sweet potatoes, and sunflowers. Most of the first white settlers in the region were farmers who established plantations. They brought wheat, hogs, cattle, poultry, cabbage, potatoes, and fruit trees, including apples. Africans were imported as laborers. They introduced southern staples, such as peanuts, okra, watermelon, and sesame seeds, and taught the farmers of the lowland coastal areas how to successfully grow and harvest rice.19 It was these traditional foods of the Native Americans, the European settlers, and the African slaves that combined to create the foundation of southern fare (see Table 15.8). Group Foods Preparations Protein Foods Milk/milk products Buttermilk, milk Cream gravy Meat/poultry/fish/ eggs/legumes Native game, including buffalo, venison, raccoon, opossum, badger, squirrel, turkey, ducks, alligator, diamond back terrapin Pork in all forms, especially country-cured and Smithfield hams; beef, mutton, kid Chicken Crab (blue, stone), crawfish, conch, oysters, shrimp, spiny lobster; ocean fish, such as mullet, pompano, shad; freshwater fish, particularly catfish Chicken eggs Dried beans; peanuts Brunswick stew, squirrel stew, possum ‘n’ taters, turtle soup Ham on beaten biscuits, sliced ham and red- eye gravy; barbecued pork; souse (head cheese); chitterlings; Texas-style barbecued beef, chili con carne, son-of-a-bitch stew; cabrito Fried chicken with cream gravy, chicken and dumplings Crab, shrimp, or crawfish boils; crab cakes; she-crab soup; conch chowder; oyster stew; shrimp pilau; shrimp Creole; jambalaya; gumbo; étouffée; fish muddle; fried catfish Scrambled eggs and brains, scrambled eggs and ramps Baked beans, butter bean custard; peanut soup, peanut brittle Cereals/Grains Corn, rice, wheat, buckwheat Hominy, grits, corn pone, hush puppies, cornbread, spoon bread; rice pilaus; beaten biscuits; buttermilk or sour milk biscuits; buckwheat pancakes Fruits/Vegetables Apples, huckleberries, key limes, oranges, mayhaw, peaches, watermelon Wild greens (cochan, creases, dandelion, dock, lamb’s quarters, poke, sorrel, and ramp), domesticated greens (e.g., mustard, turnip), black-eyed peas, cabbage, okra, ramps, sweet potatoes Preserves and pickles; fried pies; key lime pie; ambrosia; peach pie Greens simmered with fat back or salt pork, consumed with pot likker; poke salad (sallet); fried ramps; hoppin’ John; coleslaw, fried okra, okra stews; sweet potato pie Additional Foods Seasonings Chile peppers (especially bird’s eye); filé; celery, garlic, onions, green peppers; bourbon, sherry, whiskey Pepper sherry, chile powder, hot sauce; High Holy mayonnaise; barbecue sauce Nuts/seeds Black walnuts, hickory nuts, pecans; sesame (benne) seeds Nut cakes, brittles, glazed pecans, pecan pie, pralines; sesame seed candies and cookies Beverages Buttermilk; bourbon, corn whiskey, Sherry, Tennessee whiskey Whiskey and bourbon are added to barbecue sauces, baked goods, candies Fats/oils Lard Sweeteners Sorghum syrup Used over pancakes, grits, cornbread, in coffee TA B L E 15. 8 Southern Specialties © C en ga ge L ea rn in g Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 1 5 5 0 7 South Atlantic Plantation hospitality was famous in the South Atlantic region. A description of a meal served to guests in Georgia from the early 1800s listed turtle soup, trout, ham with sweet potatoes, turkey with a cornmeal and walnut stuffing, rice, asparagus, and green beans, followed by orange sherbet to cleanse the diners’ palates before continuing with cold venison, cheese, corn fritters with syrup, and sweet potato pie.11 Traditional southern fare, such as Georgia squirrel stew, ham, hoecakes, okra with tomatoes, and biscuits served with preserves, was served at family meals as well. Hot breads are the cornerstone of every meal in the states of the South Atlantic, pri- marily cornbreads (see Table 15.9) or biscuits. In Virginia, spoon bread is a specialty; it is a cornbread enriched with eggs and milk then cooked until it forms a crust on the top but remains custardy underneath. In Delaware the biscuits are made with sour milk. Beaten bis- cuits prepared by hitting the dough repeatedly with a rolling pin to produce pockets of air for leavening, are a favorite in many areas. Country hams, ribs, fatback, cracklings, and chitterlings were traditionally produced from hogs, and remain important today. In Maryland, one recipe that is popular, particu- larly in the southern sections of the state, is stuffed ham. It calls for inserting greens (e.g., cabbage, kale, and/or watercress) flavored with onions, mustard seeds, and cayenne into deep slits of the ham. The ham is served cold and is often the centerpiece of the Easter meal. In Virginia, Smithfield ham is a specialty, adapted from the process used by the local Powhatan Indians to salt-cure and smoke venison. A Smithfield ham is similar to a country ham (see the section “West North Central”), but it is made with the shank end of the leg and with the bone in. It is first rubbed with salt, sugar, and pepper for curing, then smoked over hickory, and then hung to age. The meat differs from a country ham in that it is saltier, darker in color, and leaner. The flavor is very strong, and it is traditionally eaten in very thin slices on biscuits or fried with red-eye gravy (made with the ham drippings and coffee) and served with fried apples. Another Native American game dish adopted by the southern settlers, Brunswick stew, became a mainstay throughout the region. There are many varia- tions, but most contain chicken, ham or salt pork, corn, beans, potatoes, onions, tomatoes, and lots of black pepper. Chicken dredged in cornmeal or flour and fried in lard, traditionally served with cream gravy, is the quintessential dish of the region. Though popular throughout the entire South, poultry is especially associated with Delaware. The first broilers in the nation were marketed in the state during the 1920s when an excess of chicks prompted an enterprising egg producer to sell the birds when they reached about two pounds at sixteen weeks of age. This was far younger than most chickens were sold at the time and yielded a tender bird that could be roasted or broiled instead of stewed or fried. It was the beginning of a national industry, and today broiled chicken is the state dish of Delaware. Roasters are also popular in Maryland where other chicken specialties include pot pies and chicken seafood stews. Cornbread Made with white cornmeal, eggs, and water. No sugar is added. Baked in a pan, sliced into squares, served with butter, honey, or sorghum syrup. Cracklin’ bread Usually yellow cornmeal bread with added pork cracklings for flavor, traditionally cooked in a frying pan on the stove. Spoon bread Yellow cornmeal bread made with eggs and milk. Baked slowly in a pan until golden crest forms on top and center remains custard-like. Corn pone Yellow cornmeal and water (lard added if available) mixed into a stiff dough, formed into sticks (sometimes called “corn sticks”) or patties (sometimes called “hoecakes”) and cooked in a skillet. Hush puppies Yellow cornmeal and water dough, with added egg and buttermilk if available, Hush puppies Yellow cornmeal and water dough, with added egg and buttermilk if available, formed into balls and deep-fried. TA B L E 15. 9 Southern Corn Breads © C en ga ge L ea rn in g Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 5 0 8 R E G I O N A L A M E R I C A N S Seafood is especially important in the South Atlantic coastal areas. Maryland, for example, is famous for its shellfish. The state is indented by the largest estuary in the nation, Chesa- peake Bay, which teems with oysters, clams, scallops, and crabs. Oysters were so common that many settlers in the region ate them three times a day: raw, fried, baked, fricasseed, in seafood stews, in chowder, in oyster stuff-seafood stews, in chowder, in oyster stuff-seafood stews, in chowder, in oyster stuff ing for turkeys, and over steaks. Crabs were equally versatile. A regional specialty is blue crabs, a swimming crab so named because the underside of the large claws is blue. They are traditionally steamed over water flavored with vinegar and seasoned with salt, pepper, ground ginger, celery and mustard seeds, and paprika. Because they are small, half a dozen or more are served to each diner, with plenty of beer to wash them down. The meat is used to make one of Maryland’s most esteemed dishes, crab cakes. The crab is mixed with a little mayonnaise, cracker crumbs, and a spicy seasoning of cayenne, dry mustard, and hot sauce, and then formed into small patties and fried. They are served with lemon wedges and tartar sauce. Crab soup (with beef stock and bacon) and deviled crabs (baked in the shell and topped with bread crumbs) are other common preparations. Another noteworthy shellfish of the region is soft-shell crab—a blue crab that has shed its hard shell during a molt. The new papery shell is completely edible, but it begins to harden after only a day. Blue crabs are often kept in tanks until they shed their hard shells to time harvesting of the soft-shell crabs. The whole crab is served deep-fried or sautéed. The Florida waterways and coastline also offer a profusion of seafood. Red snapper, pompano (a very large, meaty fish), mullet, and tarpon are a few of the fish commonly available; shellfish includes shrimp (several varieties), spiny lobster (similar to those of New England, but without claws), conch (a large mollusk), and stone crabs (only the very large claw is eaten—the claw is removed when the crab is caught, and then the crab is thrown back in the water to grow a new one). Many of Florida’s specialties have developed out of this unique ocean larder. Red snapper fillets are baked with orange juice. Pompano is stuffed with shrimp, seasoned with Sherry, and baked, or prepared en papillote (with a nod to the French influence of the Gulf Coast states). Spiny lobster tails are stuffed with fish and grilled, while stone crab claws are traditionally boiled and served with garlic butter or mustard sauce. Rock shrimp, a hard- shelled, white shrimp that tastes like a cross between lobster and shrimp, has become a trendy restaurant item throughout the country. Conch fritters and conch chowder (made with onions and tomatoes, seasoned with Worcestershire sauce, oregano, and bay leaves) are popular. Elsewhere in the region, oyster roasts (sim- ilar to a New England clam bake) are favor- ites in South Carolina, served with hoppin’ John, biscuits, and small sandwiches, such as a crab omelet on slices of bread. Oyster suppers, informal feasts featuring oysters cooked over a fire in the moonlight, then served with melted butter, are popular in Georgia. Shrimp are common in the Caroli- nas, including shrimp pâté or butter-sautéed shrimp with grits for breakfast, and deep-fried shrimp and rice croquettes. In Delaware, one specialty called muddle (a stew of miscella- neous fish with potatoes and onions) capital- izes on coastal resources. A variation unique to South Carolina is pinebark stew, a muddle ▲ Fried chicken is the quintessential dish of the South. It is often served with cream gravy and biscuits. Be th D ix so n/ A la m y Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 1 5 5 0 9 flavored with bacon, named for the tiny roots of pine trees that seasoned it traditionally, or because it was cooked over a pine bark fire. Also common in the state are frogmore stew, a spicy seafood, sausage, and corn combination similar to gumbo, and she-crab soup simi- lar to that of Maryland but garnished with a spoonful of Sherry and a dollop of unsweet- ened whipped cream. Long-grain rice is common in many parts of the South Atlantic region. A variety of rice native to Madagascar was found suitable for the coastal plain climate of South Carolina, and thousands of acres of tidal lands were diked and flooded to support the crop. By 1700, it was well established, thanks in part to the skills of slaves from the rice-growing regions of Africa. It became known as “Carolina Gold” (due to its amber color when ripe). The rice was traditionally boiled instead of steamed to produce individual fluffy grains that did not stick together. French Hugue- nots who settled in South Carolina dur- ing the seventeenth century are thought to have introduced pilau (also spelled purlow, or pullow), which has become a specialty of the region. It is characterized by combin- ing a single additional ingredient with rice, which is first simmered in an aromatic broth (reserved from cooking the secondary ingre- dient) until dry, then mixed with the other food. Shrimp pilau and okra pilau are exam- ples. African-influenced hoppin’ John, made with black-eyed peas and rice, is also a pilau. Molded rice dishes that are baked until they form a golden crust are called rice pies or rice casseroles. Some include layers of meat or fish. One unusual rice dish found in Georgia is Country Captain Chicken, invented by a sea captain from Savannah who used Indian spices to liven up his routine fare aboard ship. It is a curried chicken that includes tomatoes and green peppers and is served over rice. In the Carolinas, rice breads, such as philpy (cooked rice added to cornbread), and des- serts, such as rice pudding, are also found. Certain crops historically associated with the South Atlantic states have been in the region so long they are occasionally mistaken as native foods. Some accounts state that Native Americans of the region cultivated melons. Melons are not native to the New World, although it is possible they were brought to Florida by the Spanish explorers of the sixteenth century, in which case the Indians may have been growing them for perhaps one hundred years by the time white settlers arrived from the North. Tomatoes are a food that the Spanish may have brought to the region from elsewhere in the Americas. They also introduced peaches to the Caro- linas, which at one time were so plentiful they were used as hog feed. Today South Carolina is the largest producer of peaches in the South, second only to California in the nation. Oranges, the foundation of the Florida citrus industry, were another early introduc- tion by the Spanish. Later, grapefruit were hybridized from pummelos that had been brought from the Caribbean, and other citrus fruits, such as tangerines, tangelos, and Per- sian (also known as Tahiti) limes, were intro- duced. Key limes—small, thin-skinned yellow limes with juicy, green flesh—were discovered in the Florida Keys. It is not known where the limes came from, but it is assumed that they drifted to the islands from the Caribbean. They are grown mostly in home gardens and are renowned for their tangy flavor. Today, 63 percent of the U.S. citrus crop is grown in Florida (nearly all the oranges are processed into juice). Florida is also known for other subtropical crops, such as avocados, guavas, kumquats, mangoes, papaya, and pineapples, as well as early-ripening crops, such as toma- toes and strawberries. Sugarcane is grown in the south of the state, and sabal palmetto palms grow like weeds, providing the deli- cacy known as hearts of palm. In Georgia, pecans, peanuts, and watermelon are com- monly cultivated. Vidalia onions, thought to be exceptionally sweet due to the mild Geor- gia weather and the low-sulfur soil around Vidalia in Toombs County, Georgia, are a specialty crop sold throughout the nation. Mayhaw jelly, made from the cranberry-like fruit of the native mayhaw tree, is a particu- lar favorite in Georgia and other states along the Gulf Coast. Other native fruits found in the South Atlantic are muscadine grapes and scuppernongs (the bronzy white version of Hoppin’ John is served on New Year’s Eve in South Carolina and other parts of the South because eating the rice and black- eyed peas is thought to bring good luck in the upcoming year. Unlike most states of the South Atlantic, neither corn nor rice grows well in the cool, damp climate of West Virginia. Buck- wheat, however, thrives. Buckwheat pancakes served with whole-hog sausage and applesauce are a specialty. Thomas Jefferson brought many French specialties to his home in Monticello, such as boeuf à la daube (jellied beef ) and crêpes. He also brought Italian foods, including pasta, to the United States. His daugh- ter, Mary Randolph, is credited with introducing macaroni and Parmesan cheese, which evolved into the American dish, macaroni with cheddar cheese. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 5 1 0 R E G I O N A L A M E R I C A N S muscadines), which are used to produce jams, jellies, pies, and wine. Immigrants from Europe have contrib- uted only limited ingredients and dishes to the foods of the South Atlantic. In Virginia, English settlers favored roasted beef dishes, mutton, and Yorkshire pudding. In Georgia, a French nuance can be seen in the popular- ity of dishes such as crab soufflé; common German-style dishes include sauerkraut and pepper pot soup; and the Scots brought scones and haggis (hog’s stomach stuffed with oatmeal—see Chapter 6). In South Carolina, a French influence was seen in many dishes, particularly elaborate desserts like Huguenot torte (a sponge cake with pecans and apples) and charlotte russe (a special cylindrical mold lined with ladyfingers, then filled with Bavarian cream and garnished with strawber- ries and whipped cream). In Florida, Greek immigrants who came to Tarpon Springs for sponge-fishing jobs at the beginning of the nineteenth century (see Chapter 13) intro- duced traditional dishes such as moussaka (stuffed eggplant), spanakopita (spinach- or cheese-filled phyllo dough pastries), and gyros (pita bread sandwiches). In West Virginia lasagna, fagiole (pasta with beans), minestra (vegetable soup), and cannoli are popular in the area around Clarksburg where more than half the population is of Italian descent.20 One notable ethnic group in North Caro- lina is the German Moravians, persecuted German Protestants who had immigrated to Pennsylvania originally but moved south in the early 1700s when they discovered that much of that land was already claimed. The Moravians established an insular German community near the Winston-Salem area, founding a wholesale produce business that sold local fruits and vegetables in markets extending to Philadelphia. They were best known for their baked goods, such as sugar cakes (a yeasted, potato bread dough covered with brown sugar and cinnamon before bak- ing) and citron tarts (tarts with lemon curd filling). Moravians commemorate special occasions, including November 17 (the found- ing of North Carolina), with Love Feasts fea- turing wine, creamy coffee, and cakes topped with a nut frosting. At Christmas, paper-thin ginger spice cookies and a sweet bread stud- ded with raisins and candied citron, sprinkled with sliced almonds, are specialties. In recent years a more significant culinary influence in Florida has been the contribu- tions of Cuban immigrants to the Miami area (see Chapter 9). Arroz con pollo is made with chicken and rice, flavored with the Cuban combination of tomatoes, olives, capers, rai- sins, and chile peppers. Black beans, tradition- ally prepared with rice and salt pork or ham, are common. So-called Cuban sandwiches, with roast pork, ham, sausage, cheese, and dill pickle filling mounded on Cuban bread, are fast-food favorites. Flan, a baked custard with caramel topping (sometimes flavored with orange), has become a popular dessert. Cuban cuisine is not the only spicy food found in the South. Many settlers, especially in South Carolina and Georgia, had lived first in Barbados and other Caribbean Islands. They brought a taste for tropical flavors and spicy seasonings. Fruit and vegetable pickles were common, for example, mango chutney from India, which was also made with other local fruits and called “Indian pickle.” Today, Jerusalem artichoke, okra, green tomato, squash, and watermelon rind pickles are still popular condiments in the region. In Geor- gia, very small (one-fourth to one-half inch) scorching-hot bird’s eye peppers (also known as tepin chiles) are sometimes crushed and placed at the bottom of a bowl before adding soup or stew. Pepper sherry, made by infusing incendiary Scotch Bonnet chiles in sherry, is a popular condiment added to dishes for zing in South Carolina. Desserts have always had a place on the South Atlantic table. Tea breads and cakes (such as Sally Lunn cake, best described as a sponge cake–like bread, which is popular throughout the region), fruitcakes, and pies are common. Peach pie is the consummate Georgia dessert, although recipes vary. Some are custard pies topped with sliced peaches, others are two-crust pies, and some are indi- vidual deep-fried pies. Pecan pie is popular as well. Key lime pie, a specialty from Florida now found throughout the South, tradition- ally includes a lime custard filling covered with a meringue topping but can also be made Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 1 5 5 1 1 as a chiffon pie (folding the meringue into the custard to lighten it and then topping the pie with whipped cream). Ambrosia, made with sliced oranges and grated coconut, is another Florida dessert common in other states of the region. Puddings and custards were an every- day treat in the early days of settlement, made with leftover cornmeal, rice, or bread; choco- late was a favorite but costly, so it was used only at special occasions. Today, bread pud- dings are still favorites. Candies, such as divin- ity with nuts and nut brittles, are specialties. The cooking of the more rural inland areas of the South Atlantic states differed from the more populated coastal areas. During the early 1800s, Scotch Irish immigrants search- ing for religious freedom began making their homes in the Blue Ridge, Cumberland, and Great Smoky mountains of the Appalachians. They also spread west to the Kentucky and Tennessee frontier. English and some Welsh settlers moved from the coastal South Atlan- tic states inland to the hilly Piedmont areas. Germans from Pennsylvania traveled south along the Shenandoah Valley into Virginia and North Carolina. Hogs ‘n’ hominy (pork and corn) kept the pioneers going until they established small farms. Frontier meals were robust. For example, the noon meal might consist of ham, bacon or sausage, chicken or grouse, game meat, dumplings or biscuits, cornbread or grits, gravy, sweet potatoes, and boiled greens served with coffee, milk, or corn whiskey. Traditionally every bit of the pig was con- sumed on Appalachian farms, including the snout, or rooter (which was roasted), the tail (which was added to stews), and the brains (which were usually boiled, mashed, and scrambled with eggs). Bacon and cabbage, and ham with cream gravy were typical entrees, while barbecued pork with spicy hot sauce on the side was prepared for special occasions. Most families kept a dairy cow and a breed- ing cow for a few calves each year. Fresh beef was preferred. When a cow was slaughtered, it would be shared with neighbors, who would later return the favor. Game supplemented the diet, especially squirrel, rabbit, raccoon, opossum, turtle, and frogs. Badger, considered by some a dish of last resort, was known as bombo in North Carolina hill country. Brunswick stew is a favorite. Wild greens were well loved by adults in the Appalachians, but not so popu- lar with children.21 Poke, creases (similar to watercress), dandelion, lamb’s quarters, dock, sorrel, and ramp (a particularly assertive wild onion) were added to soups, stews, potatoes, or eggs, or cooked as a side dish. Poke salad is representative: a cooked salad (from the Eng- lish tradition) in which the greens are par- boiled, then fried in bacon or fatback grease until tender. They are seasoned with salt, pep- per, and hot sauce or vinegar. Domesticated greens such as mustard and turnip greens were also common. Other than greens, green beans, hominy, sweet potatoes, potatoes, okra, and beets were the most frequently consumed vegeta- bles. Cornbread (sometimes with cracklings added), biscuits, dumplings, and/or grits were served at every meal. Pinto beans, called soup- beans, were common, served with cornbread crumbled on top or a dollop of pickled veg- etable relish (i.e., cabbage, bell peppers, green tomatoes, onions, chile peppers). Watermelon was a favorite fruit, eaten fresh or preserved as pickles or jam. Applesauce, apple pies, and fried apple slices were popular. Honey was the most common sweetener, even consumed ▼ Key lime pie, which has a lime custard filling and is traditionally covered with meringue, can also be made as a chiffon pie (folding the meringue into the custard to lighten it and then topping the pie with whipped cream). M ic ha el L am ot te /C ol e G ro up /P ho to di sc /G et ty Im ag es Coca-Cola was invented by an Atlanta pharmacist in 1886 as a headache remedy. “Dope” is a slang term for cola drinks in parts of the South. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 5 1 2 R E G I O N A L A M E R I C A N S alone as a dessert. Thick, caramel-colored sorghum syrup was also used, poured over cornbreads or used to sweeten coffee. Many of these foods are still favored in the Appalachians today, though research suggests changes in preparation techniques and the use of convenience food items are increasing as dependence on hunting and farming decreases.22 A survey of senior adult Appalachians found that they were interested in lower-fat diets and had switched to baking and broiling instead of frying. Shortening has replaced lard in many dishes. Many also use items such as cornbread mixes instead of pre- paring foods from scratch.22 However, even those who have relocated to other areas may maintain their heritage by regularly consum- ing fried chicken with gravy, soupbeans, skillet cornbread, biscuits and gravy, fried potatoes, green beans cooked in lard, and other foods typical of Appalachian fare.23 East South Central and West South Central The early fare of the East South Central and West South Central states was similar to that of the Atlantic states but with more significant French overtones. Immigrants from France settled in the Gulf Coast region during the seventeenth century, and at the end of the eighteenth century, French Acadians from Canada relocated to Louisiana (see Chapter 6). They were joined by white American and English settlers arriving from the North. Plan- tation life in the region was similar to that of the South Atlantic, except that it was more dependent on cotton than on tobacco. The tradition of the big southern breakfast and dinner may have originated in the region and was the norm for plantation owners and their city associates. Coffee and mint juleps were available for early risers. Late morning repasts included eggs, grits, biscuits, cornbreads or muffins, waffles, and several meats, such as ham, sausage, or fried chicken. A large dinner with soups, stews, and dishes similar to those at breakfast was consumed in the early after- noon; supper was a lighter version of dinner. Pork and corn remained key to the cook- ing of the ESC and WSC. The cornbread in this area is made from white cornmeal with- out the addition of sugar. The French added their recipes for soups, stews, fricassees, and baked goods to the southern mix, as well as their appreciation for good eating. The result- ing cuisine is found in some form through- out the Gulf Coast, from Mobile, Alabama to Beaumont, Texas. The French factor accounts for such adopted and adapted specialties as bouillabaisse (a French fish stew); fish cooked en papil l ote (in paper packets with a v el outé sauce); and sauc e mah onaise (homemade mayonnaise), particularly High Holy mayon- nais” (a fanciful, Anglicized term for aïoli) made with fresh garlic and served with shrimp or cucumbers. Creole cuisine, a blending of French, Spanish, African, English, and Native American cooking, is unique to New Orleans. It is a complex fare with many refined dishes; celery, tomatoes, bell peppers, onions, and garlic are the hallmark flavorings. Cajun fare, created by the French Acadi- ans, is mostly limited to the bayou country of Louisiana, though its gumbos, jambalayas, and é touf f é es have become popular throughout the region (see Chapter 6). While Oklahoma and Texas are both southern in attitude and enjoy many specialties of the South, such as grits, greens, Gulf Coast seafood, and Brunswick S a m p l e M e n u A Southeastern Luncheon Fried Oystersa,b,c Shrimp Pilaub,c Okra with Tomatoesa,c Biscuits or Cornbread Ambrosiaa aLewis, E., & Peacock, S. 2003. The gift of Southern cooking. New York: Knopf. bJamison, C.A., & Jamison, B. 1999. American home cooking. New York: Broadway Books. cSouthern U.S. Cuisine at http://www.southernfood.about.com Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 1 5 5 1 3 stews, their dishes are also influenced by Native American, central European, and Latino cook- ing. Beef is the dominant meat; barbecue is prevalent; and hot, spicy seasoning emboldens their dishes. The fare of the ESC states is more homoge- neous than that of the WSC region. Alabama, Kentucky, Mississippi, and Tennessee share many culinary traditions. The French influ- ence is limited to the coastal areas, where dishes feature seafood as the main ingredient. In Alabama, shrimp are especially prevalent, prepared fried, boiled in seasoned water, with rémoulade sauce, and stuffed into mir l eton (chayote squash), avocados, and other vege- tables. Plump, local oysters, called Bon Secour oysters, are plentiful and popular throughout the Gulf Coast. In Mississippi, rock shrimp and blue crabs are typically boiled, served with an assortment of seasonings, such as vin- egar, lemon juice, bird’s eye chiles, and cloves. Outdoor oyster bakes and fish muddle served with corn dumplings are other Mississippi coastal favorites. It is the inland foods of the ESC states that are most associated with the region, however. Sumptuous breakfasts are still common in some areas. In western Tennessee, for instance, the meal may feature eggs, tomatoes, potatoes, and cornmeal biscuits with sorghum syrup. During the winter, thick slices of Tennessee country ham with grits and red-eye gravy are often served with the meal; in the summer, fried chicken is more common. ESC dinners and suppers also include many traditional items. Fried chicken is found throughout the region. In Alabama chicken and dumplings, ham balls (fried fritters), and Brunswick stew (made with a whole hog’s head) are special- ties. In many areas biscuits and cornbreads such as sweet potato biscuits, crackling bread, hoecake bread (cornmeal and water cooked in a frying pan), and beaten biscuits are eaten daily. Tennessee pork sausages are a specialty, as is spiced beef (marinated in vinegar, brown sugar, and seasonings, then simmered and sliced thinly). In the eastern region of the state, barbecued ribs prepared with a tomato- whiskey sauce are a favorite. Hominy, greens, okra, green beans, black-eyed peas, peas, but- ter beans (similar to lima beans, but slightly smaller), rutabagas, and turnips are typical side dishes of the region. Many of these foods are cooked in lard or flavored with pork. In Kentucky, for example, green beans are sim- mered with bacon throughout the day to make a smoky, mushy stew. Game meats are prevalent in some areas. Squirrels and frogs are featured in certain dishes from Alabama. Early settlers in Ken- tucky depended on game. Bear meat was pop- ular because it could be smoked like pork and was fatty enough to provide bacon. Burgoo, a stew traditionally made with wild birds and game meats such as squirrel, is the signature dish of Kentucky. It is still made this way in some areas, though most current versions use chicken, pork, beef, or lamb; cabbage, pota- toes, tomatoes, lima beans, corn, okra, and cayenne—and some variations add filé pow- der, curry powder, or bourbon. In eastern Tennessee the diet was historically closer to Appalachian fare than the plantation style of the western half of the state. Deer, raccoon, opossum, squirrel, and wild turkey were pri- mary meats for the settlers of the area and are still consumed occasionally today. In Mississippi, catfish up to one hundred pounds can still be caught in the rivers and lakes of the state, but most are now farmed in ponds. Although the first catfish farms were started in Arkansas, Mississippi is the leading producer in the nation, with over 250 million pounds harvested annually. Traditionally, catfish is deep-fried in a cornmeal crust and served with hush puppies and coleslaw. Newer recipes include fried strips served with barbe- cue sauce or mustard, and catfish pâté.21 Sweets in the ESC states are favorites. In Alabama seasonal pies were popular, espe- cially dewberry (the first ripe fruit of the sum- mer season) and peach. Fried pies, a southern specialty, are thought to have originated in the state. Small circles of pie crust are filled with fruit (typically peaches or peach preserves in Alabama), then folded into a half-moon shape, crimped, deep-fried, and sprinkled with powdered sugar. Rich, chocolaty Mis- sissippi mud pie has become popular nation- wide, while butter bean custard pie is a local specialty of the region, made with mashed butter beans cooked as a sweet pudding Moon pies are a Chattanooga, Tennessee, confection that have become an obsession in the South. They are graham cracker sandwiches with a marshmallow filling covered in chocolate, vanilla, banana, or caramel icing. During the Great Depression, a moon pie and an RC Cola were called a “ working-class dessert” because both could be had for a dime. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 5 1 4 R E G I O N A L A M E R I C A N S flavored with cinnamon, cloves, and nutmeg. Banana pudding is another favorite. Pecans are native to Mississippi and added to breads, sugar glazed, orange glazed, and baked in the syrupy sweet pecan pie. Many farms in east- ern Tennessee had at least one apple tree, pro- viding fruit for apple butter and pies. Funnel cakes, undoubtedly introduced by German immigrants, are topped with sorghum syrup. Fried pies were also popular. Traditional beverages consumed in the ESC states include buttermilk and coffee, though iced tea and soda (most often called pop) are more popular now. Sassafras tea is common in eastern Tennessee. Perhaps the best-known food products of the region are alcoholic beverages. Bourbon was developed in Ken- tucky. Many of the early Scotch Irish settlers in the state discovered farming corn for corn whiskey was more profitable than farming it for cornmeal. It is thought that the first corn whiskey aged in oak barrels, creating the char- acteristic flavor of bourbon, was produced in Bourbon County, Kentucky, in the late eigh- teenth century. In 1860, a further refinement occurred when it was accidentally discovered that charred oak barrels added not only a touch of color, but also a favorable smoky taste. The favorite bourbon drink of Kentucky is the mint julep (bourbon sweetened with a touch of sugar or syrup and a hint of fresh mint), traditionally served in a silver cup. Bourbon also flavors stews, hams, pound cakes, fruit- cakes, and bourbon balls (a candy made with chocolate, crushed vanilla wafers, pecans, corn syrup, and bourbon). Whiskey is associated with Tennessee. In 1866 Jack Daniel purchased a corn whiskey still and added an extra refine- ment to the distillation process, using maple wood charcoal to filter the whiskey before aging it in charred oak barrels. This produced a flavor distinct from bourbon, and the liquor became known as Tennessee whiskey. The foods of the WSC states (Arkansas, Louisiana, Oklahoma, Texas) share some sim- ilarities due to geographic proximity but also vary due to historical influences. Arkansas exemplifies the region. It is at the crossroads of the South, the Southwest, and the Mid- west. The diverse terrain in the state includes the fertile alluvial plains of the Mississippi River in the southeast of the state, the dry pasturelands of the Southwest, the orchards and wheat fields of the Northwest, and the rocky hills and mountains of the Ozarks in the Northeast. Settlers were mostly of English or Scotch Irish heritage, and they brought the foods they prepared in their home states, such as cured hams, sausages, baking-soda biscuits, and molasses pies from the North, and fried chicken, buttermilk biscuits, sweet potatoes, and peach cobblers from the South. Barbecued beef and pinto beans are found in the areas of the state adjacent to Texas,23 and in the Ozarks the fare is similar to that found in the Missouri section of the mountains (see the previous section on the cooking of the Midwest), with pork, game meats (especially baked opossum and raccoon), corn, beans, and greens the foundation of the diet. Arkansas specialties include pork chops with cream gravy (sometimes made with bits of sausage in it) and pan-fried chicken that is then baked with a Creole sauce. Arkansas is also the leading producer of rice in the nation. Ducks, which are attracted to the rice paddies, are a specialty in the region, roasted over a fire, baked with bacon and basted with wine or port, and prepared as gumbo. Catfish have long been an Arkansas favorite, dredged in cornmeal and fried, or in catfish stew. Catfish is traditionally served with hush puppies (deep-fried cornmeal biscuits) and coleslaw. Fare in the other WSC states overlaps with that of Arkansas. The hilly north areas of Lou- isiana feature dishes with pork and cornmeal. The southern portions of Oklahoma are called Little Dixie, and a study of foods in the east- ern portion of the state found that pork, fried chicken, catfish, biscuits and cream gravy, cornbread, fried okra, and black-eyed peas were frequent items in local eateries. However, grits and buttermilk were rarely offered.24 In the affluent eastern region of Texas, southern- style dishes frequently feature costly ingredi- ents and tend to be richer (with extra butter, eggs, and cream) than versions from other southern states. Cornbreads, biscuits, hominy and grits, black-eyed peas, okra, sweet potato pie, bread pudding, and pralines are a few common items. Rice is an important crop, and southern-style rice dishes are popular. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 1 5 5 1 5 Other similarities in the WSC states are found. Cooking in parts of Oklahoma is simi- lar to food in southwestern Arkansas, as seen in the greater use of flour instead of cornmeal. Although the Oklahoma territory was not offi- cially opened up to settlement by whites until 1889, land-hungry homesteaders invaded the state before then (they were called Sooners). African Americans, many of whom had been held as slaves by the Indians, purchased land in the region after abolition. Most settlers established small family farms. The plains regions in the state are arid, and droughts occurred regularly. The fare in this region of Oklahoma derived more from scarcity than from ethnic and regional preferences of the settlers. Rabbit and turnip stew was flavored with flour-thickened gravy, while beef and wheat berries were the primary ingredients of Oklahoma Stew. Baking-soda biscuits were common, and black blizzard cake (a pound cake whose name refers to the frequent dust storms in the region) was a specialty. In the Northeast and panhandle areas of Texas, settlers also scraped out a living on small family farms, surviving on corn, beans, and native game and fish. When wheat proved a successful crop in the region, cornbreads were replaced with biscuits. In the western areas of the state, beef has always been pop- ular. It is served traditionally as stews and steaks. Chicken-fried steak was one specialty created to treat tough cuts—the steak is cut thinly, then pounded with a mallet, coated in flour, and fried. It is served with a ladleful of gravy made with coffee. Bread or tortillas and pinto beans often round out the meal. Today, Texas pasturelands are the leading producer of cattle, sheep, and lambs in the nation. It is the differences in the cuisines of the WSC states that are most noteworthy. Unlike Arkansas, Louisiana was colonized by the French, who established several fortified settlements along the Gulf Coast, includ- ing Nouvelle-Orléans (New Orleans) in the 1700s. African slaves were brought in to work the plantations, and thousands of French Aca- dians from Canada and French Creoles from Haiti seeking refuge arrived. Fish and seafood are more important than pork in the southern regions of Louisiana. The famous stews of the area, bouillabaisse, gumbo, and jambalaya, are examples of dishes made from coastal plenty. Shrimp is the pri- mary seafood industry in Louisiana, marketed throughout the nation fresh and frozen. It is commonly served boiled with lemon butter or with sauc e piq uante (tomatoes, green peppers, onions, bay, vinegar, and hot sauce) over rice, a dish often called shrimp Creole. Shrimp is also added to stews and to stuffings for veg- etables. Oysters are commonly served raw, on the half shell, and by the dozen in the many oyster bars of New Orleans. They are tradi- tionally slurped with a squeeze of lemon juice and a dash of hot sauce or a sauce mixed to taste by each diner with catsup, vinegar, and horseradish. Oysters, too, are added to soups and stews. Crawfish, which look like miniature lobsters, are found in the all the fresh water- ways of the state. They have become the ethnic emblem of Cajuns and the regional symbol of southern Louisiana. Over 100 mil- lion pounds are produced annually. Some are harvested from the wild, but most are culti- vated in approximately 300 crawfish farms. They are typically served at a crawfish boil, where they are cooked in water seasoned with cayenne, salt, and herbs. Potatoes or corn are often added for side dishes. The crawfish are placed in a gigantic mound in the center of the table, and each person takes and peels as many as desired. Only the meat in the tail and the claws is edible, along with the fat found in the head, which is extracted with a finger or sucked out appreciatively. Crawfish are also prepared fried, stuffed, as fritters, in soups and stews, in pies, and étouffée (meaning “smoth- ered”) in a spicy tomato sauce. Other regional specialties include rice dishes, such as the fried cakes called c al as, red beans and rice, and dirty rice (cooked with gizzards). Rice is also the foundation of dishes like gumbo and jambalaya. Baked goods and sweets are specialties, including French petits fours, crêpes, beignets (deep-fried squares similar to doughnuts), and pralines (pecan candies). Café au lait, a favorite beverage in New Orleans, is a dark-roasted coffee (some- times flavored with chicory root) prepared with equal amounts of hot milk. Café brûlot Chuck wagon fare was a cooking style all its own, dependent on the skills and whims of the cowboy chefs called “Cookie” or “Miss Sally.” Beans, cornbread, sourdough biscuits, and coffee were the staples, but some specialties were created on the trail, including “son-of- a-bitch stew” (known as “ son-of-a-gun stew” in more genteel circles) made with beef organs, including tongue, brain, liver, heart, and kidneys. The term Creole is often used to describe Europeans born outside Europe and is applied, for example, to the descendants of the original French and Spanish immigrants to New Orleans. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 5 1 6 R E G I O N A L A M E R I C A N S is a sweetened dessert coffee flavored with brandy and c ur aç ao (orange liqueur). Restaurant fare in New Orleans is renowned. Among the nationally recognized dishes created by local chefs are oysters Rock- efeller (baked on a bed of salt with a rich spinach sauce), oysters Bienville (baked with a béchamel sauce and green pepper, onions, pimento, and cheese), Bananas Foster (sliced bananas cooked in butter, brown sugar, rum, and banana liqueur served over vanilla ice cream—it started out as a breakfast specialty), and Ramos gin fizz (a shaken or blended cocktail with cream, gin, lemon juice, orange flower water, and egg whites). Street food is equally tasty in the city. Fried oysters, sliced tomatoes, and onions with tarter sauce on a French bread roll are especially popular. They are called peacemakers, from the nineteenth century, when men would bring one home as a surprise for dinner after a fight with their wives. Po’ boy (for “poor boy”) is another name for the sandwich, although a po’ boy may also refer to a sandwich with deli meats, sausages, and cheeses with or without gravy or toma- toes. A muffeletta sandwich is yet another ver- sion, usually including a chopped olive salad with the meats and cheeses on a whole round loaf of seeded Sicilian-style bread. Oklahoma started its U.S. history as Indian Territory, lands set aside in the 1820s for the Native American tribes that had been dis- possessed of their homes in the Gulf Coast areas. Five major Indian groups lived in the region: Cherokee, Chickasaw, Choctaw, Creek, and Seminole. They were primarily agrarian, growing corn, beans, and squash. They gathered indigenous foods (such as acorns, chestnuts, creases, grapes, Jerusalem artichokes, hickory nuts, persimmons, ramp, and sorghum) and hunted small game (see Chapter 5). Today, Native Americans make up approximately seven percent of the total population in the state, over eight times the national average. Traditional foods, such as a Cherokee soup made with hickory nut cream, called kanuche, and game dishes, are served mostly at ceremonial occasions. Fry bread and adapted dishes, such as scrambled eggs with spring onions, are more common but have not been accepted into the broader Okla- homa cuisine.25 Other ethnic fare is available in Oklahoma but not widely consumed. Some Italian American foods are consumed, such as spaghetti and meatballs, particularly around Krebs in the southeastern region of the state. Sauerkraut, potato soup, and dark breads are evidence of German Russian influence, and central European traditions are maintained at heritage festivals. A few Tex-Mex items such as chili con carne have become very popular. Ethnic cuisine is much more evident in Texas. The state is the size of New England, the Mid-Atlantic states, Ohio, and Indiana com- bined. It was occupied by Native Americans, claimed by the Spanish and French, ruled by Mexico, and existed as an independent nation before it became part of the United States in 1846. Germans, Czechs, and Poles emigrated from Europe to central Texas, attracted by land grants. Sausages, ham, sauerbraten, sau- erkraut, pumpernickel bread, potato salad, potato dumplings, bierocks (meat-filled pocket pastries), and strudel are popular in areas where the Germans and other central Europeans settled. The most distinctive Texan fare evolved in the south of the state, where Mexican and Spanish influence added their flavors to dishes. Some authentic Mexican foods, such as tortillas, tamales, chalupas, salsas, guacamole, and buñuelos (see Chapter 9) were accepted by white settlers in the region. However, most foods in the area are adapted dishes with Mexican overtones, often referred ▲ Crawfish is a specialty in southern Louisiana that has become popular in other areas of the South. L. F/ Sh ut te rs to ck .c om Sandwiches with deli meats and cheese on a French bread roll are found throughout the country. In addition to being called “po’ boys” in New Orleans, they are also known as “ bombers” (upstate New York), Cuban sandwiches (made with roast pork in Miami), “grinders” (New England), heros (New York City), “ hoagies” (Philadelphia), Italian meat sand- wiches (Chicago), and submarine sandwiches (from a World War II naval base in Connecticut). Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 1 5 5 1 7 to as “Tex-Mex cuisine.” Examples include tamale pie, nachos, and most tacos and enchiladas, which usually feature nontradi- tional fillings. One regional specialty is chili con carne, known in Texas as “a bowl of red,” which began as beans, progressed to beans with beef, and is now typically an all-beef stew flavored primarily with hot chili pow- der. Barbecue is also favored. Unlike barbecue in other regions of the country (e.g., Kansas City), there are two sauces involved in Texas barbecue. The first, called the mop, or sop, is used to marinate the meat before cooking and for basting the meat on the spit or grill. (The term mop for the sauce basted on barbecued meat may have come from the use of a clean mop to slap the sauce on whole carcasses.) The second sauce is served on the side with the cooked meat. Although barbecued beef is most associated with the state, barbecued goat kid (c abr ito) is almost as popular in the south- ern sections. The unifying element in most of these foods is that they are preferred hot and spicy. In addition to chili powder, chile peppers are used in many dishes. Numer- ous varieties are added, but worth mention is the tepín chile, the indigenous precursor to domesticated pequin chiles. They are among the hottest of all chiles (also called bird’s eye peppers, described previously). Chiles often flavor foods in Texas not normally associated with the spice, such as cornbread and jelly. In addition to chile peppers, other fresh fruits and vegetables are now prevalent in south- ern Texas due to irrigation. Cantaloupe, pink grapefruit, peaches, sugarcane, and tomatoes are a few examples of specialty crops. Health Concerns Health risk indicators in the South tend to be higher than in the rest of the nation (see chapters on each ethnic group for population-specific data).12 Florida and West Virginia have average or above-average rates in every health risk and mortality category— Alabama, Arkansas, Kentucky, Mississippi, and Oklahoma show a similar profile, with the exception of heavy drinking, which is below average. Rates of obesity are the highest in the nation with nine states having greater than 30 percent prevalence of obesity and diabetes.12 (See Figure 15.3.) Lack of leisure time exer- cise, diabetes, low birth weight, and mortality rates are of concern in many states. Only the percentage of heavy drinking is substantially lower in some areas. Nine of the southern states are ranked lowest in the nation (41–50) for health indicators.26 (See Table 15.10.) The West Regional Profile The western United States is the largest region in the nation, encompassing an enor- mous diversity of lands, from the icy tundra of Alaska to the tropical volcanic islands of Hawaii. The tallest mountains in the country, vast fertile valleys and coastal plains, stretches of scenic desert, and temperate rainforest add to the variety. It is the history of the open wil- derness that links this region. Indigenous peo- ples adapted their lifestyles to fit each climate and terrain. Pueblo Indians made their homes in the cliffs and cultivated corn, beans, chiles, and squash; the Inuits of Alaska lived in ice igloos and hunted sea mammals and fish for food; and the native Hawaiians enjoyed such fresh abundance that they cooked few dishes (see Chapters 5 and 12). The first whites in the West were explorers, trappers, miners, and traders—hardy individuals (mostly men) seeking their fortune. Emigrants came from every direction: the Spanish and Mexicans ▲ Barbecue is a traditional Tex-Mex method for preparing food. iS to ck ph ot o. co m /N oD er og Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 5 1 8 R E G I O N A L A M E R I C A N S from Mexico in the South, Russians from the North, Chinese and Japanese from the West, and the numerous pioneers of northern and southern European descent (mostly English, Scottish, Welsh, Danes, Swedes, Slavs, Italians, and Greeks) from the Midwest, looking for new farming, ranching, and fishing oppor- tunities. The West is the most diverse region not only in climate and terrain but also in population. The West is divided into the Mountain states of Arizona, Colorado, Idaho, Montana, Nevada, New Mexico, Utah, and Wyoming and the Pacific states of Alaska, California, Hawaii, Oregon, and Washington. Approxi- mately 23 percent of all Americans reside in the Western region,7 and, of these, over half live in California. Large numbers of many eth- nic groups reside in the West. Compared to total U.S. figures, five times as many Pacific Islanders and nearly twice the Asians, Latinos, and Native Americans make up approximately 23 percent of the western population. This includes disproportionate numbers of total Inuit, Japanese, Aleut, Filipinos, Salvadorans, Chinese, Vietnamese, Mexicans, American Indians, and Koreans. African Americans and whites fall below the U.S. average in the region. Among whites residing in western states, there are large numbers with Danish and Spanish ancestry and Yugoslavian heritage (including those from what are currently Croatia and Serbia). (See Table 15.11.) Furthermore, a few individual western states report notable ethnic population fig- ures. Asians and Pacific Islanders account for over half the population in Hawaii, for exam- ple. Latinos are a large percentage of both the New Mexico and California populations. Arizona and New Mexico host large numbers of American Indians; Alaska Natives, includ- ing Inuits and Aleuts, who make up 14 percent of the population in Alaska. Though only 40 percent of persons living in the West adhere to a Christian faith, the highest percentage of Christians in the nation reside in Utah (80 percent—nearly all are Mormons) and large numbers are also found in New Mexico (58 percent—many are Roman Catholics). Despite the vast open space of the region, over 86 percent of the population lives in met- ropolitan areas. Average household income according to American Community Survey data is approximately $57,198. Persons living in poverty is under the national average at 11 percent.7 Traditional Fare The West was largely unknown to whites before the nineteenth century. Adventurous trappers and traders made their way into the territory from the Great Plains, often surviv- ing on dried bison meat. Miners who followed the gold and silver strikes in the California Mother Lode, Pike’s Peak in Colorado, Mon- tana’s Grasshopper Creek, and the Alaska Klondike prepared their own meals, usually pork, beans, and hardtack (tough, dry, unleav- ened bread or biscuits) three times a day. Some were dependent on the way stations, hotels, and boarding houses that opened to support the rush.18 Neighborly hospitality, so common in the Midwest and South, disappeared in the name of profit; miners were charged the maxi- mum for supplies (e.g., eggs for 50 cents each, potatoes for $1 a pound, and a box of apples for $500), and a meal would cost about $3 in a local establishment. The farmers and ranchers who later made their way westward frequently consumed game with cornbreads and pota- toes to complete the meal. Sourdough breads and biscuits were common with settlers in S a m p l e M e n u A Gulf Coast Supper Deviled Craba,b Chicken and Sausage Gumboa,b,c Pecan Pralinesa,b,c or Mississippi Mud Piea,b aBarker, A. 2003. The best of Cajun and Creole cooking. New York: Gramercy Books. bClaiborne, C. 1987. Craig Claiborne’s sSouthern cooking. New York: Times Books. cThe Creole and Cajun Recipe page at http://www.gumbopages.com Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 5 1 9 AL AR DE FL GA KY LA M D M S NC OK SC TN TX VA W V O b es it ya ↑ ↑ ↑ ↑ ↓ ↓ ↑ ↑ ↑ ↑ ↓ ↓ ↑ ↑ ↑ ↑ ↓ ↓ ↑ ↑ ↑ ↑ ↓ ↓ ↓ G ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ A V G ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ A V G ↓ ↓ ↓ ↓ ↓ ↓ A V G N o L ei su re -T im e Ex er ci se b ↑ ↑ ↑ ↑ ↑ ↑ A V G A V G A V G A V G A V G A V G A V G A V G A V G ↑ ↑ ↑ ↓ ↑ ↑ ↑ ↑ ↑ ↑ ↓ ↑ ↑ ↑ ↑ ↑ ↑ ↓ ↑ ↑ ↑ ↑ ↑ ↑ ↓ ↑ ↑ ↑ A V G ↑ ↑ A V G ↑ ↑ ↑ ↑ ↑ ↑ A V G ↑ D ia b et es c ↑ ↑ ↑ ↑ ↑ ↑ A V G A V G A V G A V G A V G A V G A V G A V G A V G A V G A V G A V G A V G A V G A V G A V G ↑ ↑ A V G ↑ ↑ A V G ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ A V G ↑ ↑ H yp er te n si o n d ↑ ↑ ↑ ↓ ↓ ↑ ↑ ↑ ↓ ↓ ↑ ↑ ↑ ↓ ↓ ↑ ↑ ↑ ↓ ↓ A V G ↑ ↑ ↑ ↑ ↓ ↓ ↑ ↑ ↑ ↑ ↓ ↓ ↑ ↑ ↑ ↑ ↓ ↓ ↑ ↑ ↑ ↑ ↓ ↓ A V G ↑ A V G A V G A V G A V G A V G A V G A V G A V G A V G ↓ ↑ ↑ ↓ ↑ ↑ H ig h B lo o d C h o le st er o le ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↓ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↓ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↓ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↓ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↓ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↓ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↓ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↓ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↓ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↓ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↓ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↓ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↓ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↓ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↓ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↓ ↑ ↑ ↑ ↑ ↑ ↑ ↑ D o n’ t C o n su m e 5 Fr u it s/ Ve g s. f ↑ ↑ ↓ ↓ ↓ ↑ ↑ ↑ ↑ ↑ ↓ ↓ ↓ ↓ ↑ ↑ ↓ ↓ ↓ ↑ ↑ ↑ ↑ ↑ ↓ ↓ ↓ ↓ ↑ ↑ ↓ ↓ ↓ ↑ ↑ ↑ ↑ ↑ ↓ ↓ ↓ ↓ ↑ ↑ ↓ ↓ ↓ ↑ ↑ ↑ ↑ ↑ ↓ ↓ ↓ ↓ ↑ ↑ ↓ ↓ ↓ ↑ ↑ ↑ ↑ ↑ ↓ ↓ ↓ ↓ ↑ ↑ ↓ ↓ ↓ ↑ ↑ ↑ ↑ ↑ ↓ ↓ ↓ ↓ ↑ ↑ ↓ ↓ ↓ ↑ ↑ ↑ ↑ ↑ ↓ ↓ ↓ ↓ ↑ ↑ ↓ ↓ ↓ ↑ ↑ ↑ ↑ ↑ ↓ ↓ ↓ ↓ ↑ ↑ ↓ ↓ ↓ ↑ ↑ ↑ ↑ ↑ ↓ ↓ ↓ ↓ A V G ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ A V G A V G A V G A V G A V G A V G A V G A V G A V G ↑ ↑ ↑ Bi n g e D ri n ki n g g A V G ↓ ↓ ↓ A V G A V G A V G A V G ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ A V G ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ A V G A V G A V G A V G ↓ ↓ ↓ Lo w B ir th W ei g h th ↑ ↑ ↑ ↑ A V G ↓ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↓ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↓ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↓ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↓ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↓ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↓ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ A V G ↑ ↑ ↑ ↑ ↑ ↑ A V G A V G A V G A V G ↑ D ea th s fr o m H ea rt D is ea se i ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ D ea th s fr o m S tr o ke j ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↓ ↑ ↓ ↑ ↓ ↓ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↓ ↑ ↓ ↑ ↓ ↓ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↓ ↑ ↓ ↑ ↓ ↓ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↓ ↑ ↓ ↑ ↓ ↓ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↓ ↑ ↓ ↑ ↓ ↓ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↓ ↑ ↓ ↑ ↓ ↓ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↓ ↑ ↓ ↑ ↓ ↓ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↓ ↑ ↓ ↑ ↓ ↓ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↓ ↑ ↓ ↑ ↓ ↓ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↓ ↑ ↓ ↑ ↓ ↓ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↓ ↑ ↓ ↑ ↓ ↓ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↓ ↑ ↓ ↑ ↓ ↓ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↓ ↑ ↓ ↑ ↓ ↓ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↓ ↑ ↓ ↑ ↓ ↓ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ A V G ↑ ↑ D ea th s fr o m C an ce rk ↓ ↑ ↑ ↑ ↓ ↓ ↑ ↑ ↑ ↓ ↓ ↑ ↑ ↑ ↓ ↓ ↑ ↑ ↑ ↓ A V G ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ A V G ↑ ↑ ↑ A V G ↑ ↑ ↑ ↑ ↑ ↓ ↑ ↑ ↑ ↑ ↑ ↓ ↑ ↑ ↑ ↑ ↑ ↓ ↑ ↑ ↑ ↑ ↑ ↓ A V G ↑ ↑ ↑ a U .S . p re va len ce 5 5 8. 4 pe rce nt (o ve rw eig ht d ef in ed as B M I >
25
.0
).
b U
.S
. p
re
va
len
ce
5
2
5.
8
pe
rce
nt
(p
er
so
ns
w
ho
d
id
n
o
lei
su
re
-t
im
e p
hy
sic
al
ac
tiv
ity
in
p
as
t m
on
th
).
c U
.S
. p
re
va
len
ce
5
6
.6
p
er
ce
nt
(s
elf
-re
po
rte
d
da
ta
b
as
ed
o
n
nu
m
be
r o
f p
er
so
ns
w
ho
w
er
e t
ol
d
th
ey
h
ad
co
nd
iti
on
b
y a
h
ea
lth
p
ro
fe
ss
io
na
l).
d U
.S
. p
re
va
len
ce
5
2
5.
7
pe
rce
nt
(s
elf
-re
po
rte
d
da
ta
b
as
ed
o
n
nu
m
be
r o
f p
er
so
ns
w
ho
w
er
e t
ol
d
th
ey
h
ad
co
nd
iti
on
b
y a
h
ea
lth
p
ro
fe
ss
io
na
l).
e U
.S
. p
re
va
len
ce
5
3
0.
4
pe
rce
nt
(s
elf
-re
po
rte
d
da
ta
b
as
ed
o
n
nu
m
be
r o
f p
er
so
ns
w
ho
w
er
e t
ol
d
th
ey
h
ad
co
nd
iti
on
b
y a
h
ea
lth
p
ro
fe
ss
io
na
l).
f U
.S
. p
re
va
len
ce
5
7
7.
6
pe
rce
nt
(a
du
lts
w
ho
d
o
no
t c
on
su
m
e a
t l
ea
st
5
fru
its
/v
eg
et
ab
les
p
er
d
ay
).
g U
.S
. p
re
va
len
ce
5
5
.1
p
er
ce
nt
(>
2
dr
in
ks
/d
ay
in
th
e p
as
t m
on
th
fo
r m
en
, >
1
dr
in
k p
er
d
ay
in
th
e p
as
t m
on
th
fo
r w
om
en
).
h U
.S
. p
re
va
len
ce
5
7
.3
p
er
ce
nt
(l
ive
b
irt
hs
o
f i
nf
an
ts
w
eig
hi
ng
< 2, 50 0 gr am s) . i U .S . a ge -a dj us te d de at h ra te p er 10 0, 00 0 24 5. 8 00 0 24 5. 5 00 0 24 5. . j U .S . a ge -a dj us te d de at h ra te p er 10 0, 00 0 57 .9 00 0 57 . 5 00 0 57 . . k U .S . a ge -a dj us te d de at h ra te p er 10 0, 00 0 19 4. 4 00 0 19 4. 5 00 0 19 4. . AV G— sim ila r t o na tio na l a ve ra ge ↑ — sli gh tly ab ov e n at io na l a ve ra ge ↓ — sli gh tly b elo w n at io na l a ve ra ge ↑ ↑ — sig ni fic an tly ab ov e n at io na l a ve ra ge ↓ ↓ — sig ni fic an tly b elo w n at io na l a ve ra ge ↑ ↑ ↑ — ex ce pt io na lly ab ov e n at io na l a ve ra ge ↓ ↓ ↓ — ex ce pt io na lly b elo w n at io na l a ve ra ge So u rc es : C en te rs fo r D ise as e C on tro l a nd P re ve nt io n. 2 01 4. N at ion al D ia be te s S ta tis tic s R ep or t: Es tim at es of d ia be te s a nd it s b ur de n in th e U ni te d St at es , 2 01 4. A tla nt a, GA : U .S . D ep ar tm en t o f H ea lth an d Hu m an S er vic es ; D ivi sio n fo r H ea rt Di se as e a nd St ro ke P re ve nt io n: D at a Tre nd s & M ap s, U. S. D ep ar tm en t o f H ea lth an d Hu m an S er vic es , C en te rs fo r D ise as e C on tro l a nd P re ve nt io n (C DC ), Na tio na l C en te r f or C hr on ic Di se as e P re ve nt io n an d He alt h Pr om ot io n. 2 01 3. R et rie ve d fro m h ttp :// w w w. cd c.g ov /d hd sp /; Am er ica ’s He alt h Ra nk in gs ®: A Ca ll t o Ac tio n fo r I nd ivi du als & Th eir Co m m un iti es . 2 01 4. U ni te d He alt h Fo un da tio n. R et rie ve d fro m h ttp :// w w w. un ite dh ea lth fo un da tio n. or g T A B L E 1 5 .1 0 S o u th S ta te -S p e ci fi c H e al th D at a C o m p ar e d t o N at io n al A ve ra g e s, 2 0 0 9 –2 0 1 4 Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 5 2 0 R E G I O N A L A M E R I C A N S the Mountain states, California, and Alaska. Mashed potato or a milk and flour starter was left out to catch wild yeast and begin fermen- tation. Once going, the starter was kept indefi- nitely, replenished each time a little was used as leavening (see Table 15.12). The growth of towns and the success of irrigation increased the food supply. Expen- sive goods such as wines and chocolates became available, and eastern specialties, including Long Island duck and Smithfield ham, were offered at restaurants. Depending on the region, potatoes, corn, apples, wheat, and hops prospered; cattle, dairy cows, and sheep became plentiful. In Alaska and Hawaii, white settlers faced different challenges. With the arrival of experienced fishermen, more of the Pacific coast seafood was utilized. Salmon, crab, oysters, and clams were espe- cially popular. Immigrants from other countries came to the West in search of mining and railroad jobs, including the Chinese and Mexicans. Both of these groups enjoyed highly seasoned foods and promoted the use of chile peppers. Other groups, such as the Italians, Japanese, and some Greeks, became involved in fishing and introduced specialties such as seafood ciop- pino (a seafood stew using local fish and shell- fish) and teriyaki. Many immigrants opened restaurants and markets to serve the needs of the booming towns. German sausages, Italian cannoli, and Chinese stir-fried dishes were all available. Still other immigrants arrived looking for farmland; they planted the fer- tile Pacific coastal regions and the California Central Valley with temperate fruits and veg- etables such as apples, pears, dates, grapes, plums, prunes, cherries, artichokes, avocados, broccoli, brussels sprouts, lemons, grapefruit, and oranges. The Mountain States Cuisine in the Mountain states varies consid- erably between the North and South. Cooking in Idaho, Montana, Utah, and Wyoming was influenced by the American and European settlers and features the foods available in the cooler climates of the northern ranges and plains. Meats are a specialty. The fare in the southwestern states of Arizona and New Mexico is shaped by the limitations of the desert and the significant Native American, Spanish, and Mexican presence in the area. The foods of Colorado and Nevada are mostly northern states in their cooking, with some southern state influences. Bighorn sheep, deer, pronghorn antelope, elk, moose, javelina (wild pig), bear, and bison were prevalent in many parts of the North. Recreational hunting is popular in the region, and game meats are favorites. Venison with huckleberry sauce is a specialty in Idaho, and in Montana it is prepared roasted, or as chile con carne, or into meatballs in a spicy tomato sauce. Both venison and antelope are favorites in Wyoming. Tenderloin, sirloin, and T-bone steaks are cut; the ribs and sirloin tips make roasts (sometimes marinated and braised in wine, vinegar, and spices); the brisket, flank, and plate are used for stews or hamburgers; the hams are smoked; and miscellaneous meat United States West Region Estimate Estimate Total: 311,536,594 ***** 72,808,624***** 72,808,624 White alone 238,007,238 1/–45,816 53,842,192 Black or African American alone 42,496,977 1/–22,810 4,157,054 American Indian and Alaska Native alone 5,142,542 2,084,294 Asian alone 17,845,862 8,186,351 Native Hawaiian and Other Pacific Islander alone 1,177,092Native Hawaiian and Other Pacific Islander alone 1,177,092 878,088 Some other race alone 16,399,187 7,216,657 Source: U.S. Census Bureau, 2013 American Community Survey. TA B L E 15.11 Estimates of Ethnicity in the Western Region Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 1 5 5 2 1 is used to make Polish sausage or salami. In Nevada deer are ranched for consump- tion. Numerous game birds are found as well, including geese, ducks, pheasant, par- tridge, grouse, and wild turkeys. Pheasant roasted with apples or in a pie is a favorite in Wyoming. Fish, such as sockeye salmon, bass, and catfish, is available in thousands of fresh- water lakes and streams. Mountain trout is a regional specialty. Cattle and sheep ranching are the dominant agricultural activities of the Mountain states. TA B L E 15.12 Western Specialties Group Foods Preparations P r ot e in F ood s Milk/milk products Milk, cheese (Cheddars such as Cougar Gold, Monterey Jack, Tillamook); Basque sheep’s milk cheeses Meat/poultry/ fish/eggs/ legumes Native game, including buffalo, deer, elk, moose, antelope, mountain sheep, mountain goats, bear, javelina (wild pig), beaver, rabbit Beef, mutton and lamb, pork Clams (e.g., geoducks), crab (Dungeness, king, snow), oysters, shrimp, squid Salmon, tuna, halibut, mackerel, sardines, anchovies, mahi mahi, bonito, marlin, snapper; freshwater fish, particularly trout Chicken eggs Dried beans Game meat steaks, roasts, stews (such as chili con carne), hamburger, sausages; beaver tail Steaks; beef enchiladas, tamales, chimichangas, pirozhki; teriyaki; Indian tacos; pirozhki; teriyaki; Indian tacos; pirozhki; teriyaki; Pueblo pozole; lamb spit-roasted or roasted with chiles; chorizo; luau (pit- cooked) pork Clam chowder, Seattle clam hash; cioppino, steamed crab, crab cocktails, fried calamari; grilled or poached salmon, lobimuhenno’s (salmon chowder); sushi, sashimi, teriyaki; trout grilled with bacon Hangtown fry Chickpeas with lamb, chickpea pudding; Basque beans; lentil soup with lamb, lentil and sausage casserole, white beans cooked with pimento and cheese; split-pea soup C e r e als / G r ain s Wheat, corn Sourdough breads, biscuits, pancakes; sopapillas; fry bread; panocha; capriotada; whole-wheat Mormon bread; bara brith; malasadas; Hawaiian bread; tortillas (corn or wheat); piki; Asian noodle dishes (e.g., saimin) and dough-wrapped foods (egg/ spring rolls, lumpia, wonton); fortune cookies F r uits / V e ge table s Apples, apricots, wild and cultivated berries, cactus fruit, cherries, dates, figs, grapes, kiwifruit, lemons, oranges, peaches, pears, pineapple, plums, prunes, sugarcane Artichokes, avocados, asparagus, broccoli, breadfruit, cauliflower, chile peppers, eggplant, jicama, nopales, olives, onions, specialty lettuces (arugala, radicchio, rocket), tomatoes, tomatillos, potatoes, taro root, zucchini Fresh fruit desserts; fruit added to roasts or poultry stuffings; preserves, jellies, wines; cold fruit soups Fresh vegetable side dishes; mesclun salads; guacamole; Basque potatoes; squash patties; poi A d d ition al F ood s Seasonings Chile peppers (especially New Mexico/Anaheim, jalapeño/chipotle, serrano); cinnamon, cilantro, epazote, cumin, garlic, oregano, mint, safflowers (dried petals), yerba buena; chocolate; vanilla Fresh chiles, dried chile powders, smoked chiles, pickled chiles; salsas; red or green chile sauces; mole sauce; fresh, dried, powdered, roasted, pickled garlic Nuts/seeds Almonds, hazelnuts, macadamia nuts, pine nuts Nuts/seeds Almonds, hazelnuts, macadamia nuts, pine nuts (piñon seeds), pumpkin seeds Beverages Varietal wines; coffee; tea (chamomile, Brigham Beverages Varietal wines; coffee; tea (chamomile, Brigham Young); hot chocolate Coffee drinks (lattes, etc.); picón punch Fats/oils Olive oil Sweeteners Sugar from beets, caneSweeteners Sugar from beets, cane Sugarcane is eaten fresh in Hawaii © C en ga ge L ea rn in g Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 5 2 2 R E G I O N A L A M E R I C A N S Colorado is the leading producer in the nation of lamb, known as Rocky Mountain lamb. In addition, bison is raised and processed as a specialty meat in the region. Pork is farmed in Montana, and poultry, especially turkey and eggs, is produced in Utah. Forage is grown to support meat produc- tion in the region, though wheat, oats, barley, sugar beets, hops, lentils, beans, cherries, and apples are cash crops in some areas. Pota- toes are synonymous with Idaho. They are grown primarily in the volcanic soils of the Snake River plain, where 10 billion pounds are harvested annually, approximately one- third of national production. Sixty percent are frozen, dehydrated, or milled into flour. Peppermint and spearmint (grown for their oils used in flavorings) are specialty crops in the state. Native berries are a regional favorite, especially in Montana, including huckleber- ries, which are made into breads and pies, and sour-tasting chokecherries, which are used in pies, cakes, preserves, jellies, and wine. Settlers of the region often brought their favorite foods. For example, Wyoming attracted a diversity of immigrants, many of whom opened bakeries, confectionery stores, and restaurants. French croissants, Middle Eastern halvah (sesame seed candy), German schnitzel, and Chinese wonton soup were reportedly available in southeastern Wyo- ming as early as 1900.10 In Montana Scandi- navians who arrived from Minnesota to work in lumbering brought yellow split-pea soup, cold fruit soups, Swedish meatballs, and ham with cherry sauce. Borscht, cheese-filled pas- try shells (vatroushki), and cherry desserts were favored by the Russians. The Scots made oatmeal porridge and Mulligatawny stew with mutton, and central Europeans brought stuffed cabbage, dumplings filled with fruit or cheese, and pancakes rolled around cherries. In Idaho lobimuhenno’s (a salmon chowder) was brought by the Finns; and bara brith, a bread studded with currants, was favored by the Welsh. Many dishes in Idaho today fea- ture local ingredients with European nuances, such as split-pea soup, lentil soup with lamb, white beans cooked with pimento and cheese, and ham with apple casserole. Apple jelly is added to mayonnaise to make salad dressing. Prunes are used in preserves and desserts, such as prune-whip pie and prune pudding.10 In Colorado, chile peppers and other spices came with the Mexicans, and dishes such as chicken or turkey cooked in mole sauce (a rich blend of spices, nuts, and unsweetened chocolate) became popular throughout the state. One of the most notable ethnic groups in the northern Mountain states is the Basques, who settled in Idaho and Nevada, working first as shepherds and later as land-owning sheep ranchers. Initially only men came, later bringing their families. Women did most of the cooking, providing meals for the ranch- ers such as biscuits with sheep’s milk cheese and coffee for breakfast, and Basque beans (pinto beans with lamb or pork), lamb stews, or Spanish-style potato omelets for the main meal. They introduced sourdough bread and a pencil-thin version of the spicy Span- ish sausage chorizo. Sliced potatoes, onions, and bacon make up a casserole referred to as Basque potatoes, still a favorite in the region. Basques often established hotels, which served as meeting places for Basques doing business in the area and for new immigrants. The hotels became famous for their four- or five-course meals served family-style, and non-Basque visitors often came for the food. Chickpea and meat stews, spit-roasted lamb, and even traditional seafood dishes such as bacalao al pil-pil (dried salt cod cooked with garlic and olive oil) were offered when the ingredients were available. Red wine, chamomile tea, and picón punch (a beverage no longer common in Spain but still available where Basques live in the United States, made from bitter orange picón liqueur, brandy, grenadine, and soda water) were popular drinks. In Utah, another group that has main- tained many of their food traditions is the Roman Catholic Italians who originally came from Calabria for mining and railroad jobs in the late nineteenth century. They often grow Mediterranean vegetables and seasonings, such as eggplants, tomatoes, endive, fava beans, fennel, zucchini, garlic, parsley, and basil, in home gardens. Everyday fare includes bread sticks, pastas, minestras (see Chapter 6), salads, and fresh fruits for dessert. Specialties Basques from Nevada may have introduced sourdough bread to San Francisco, where it has become a signature item. Legend is that the famous Denver (or Western) sandwich, made with an omelet containing ham, onions, and green peppers between slices of bread, was invented by a Chinese chef making eggs foo yung with available ingredients.29 Colorado is the highest state in the nation, with an average elevation of nearly 6,800 feet. Pioneer cooks had difficulties making baked goods at high altitudes. Extensive experimentation found that leavening must be reduced and oven temperatures raised to produce satisfactory breads and cakes. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 1 5 5 2 3 such as goat meats and goat cheeses, vari- ety meats cooked up with eggs in a frittata or in a spicy stew, boiled chicken’s feet, and deep-fried squash patties made with chopped squash and squash blossoms are traditional favorites. Outdoor baking ovens used by the first settlers are still found in the region.27,28 Utah is also home to a large population of Mormons (nearly 80 percent of all residents in the state), who settled there in the early 1800s to escape the persecution suffered in Ohio, Illinois, Missouri, and other areas where the members of the Church of Jesus Christ of Latter-Day Saints had lived. Many were of northern European descent, particularly British and Scandinavians, and they brought a preference for hearty foods. Ham, pot roast, roast beef, stews, and fried chicken remain favorite entrees, often served with home- made whole-wheat bread or buttermilk bis- cuits. Spicing is usually mild. Hamburger bean goulash, a Utah specialty, is thought to be a denatured version of chili con carne.10 Milk gravy, made with browned flour, pork drip- pings, milk, and seasoned with black pepper, was served with so many foods that cowboys riding through the area dubbed it “Mormon dip.” Potatoes, red cabbage, green beans, and peas are still common side dishes. The Mor- mons are well known for their love of sweets, and desserts are prominent in the diet. Layer cakes, fruit pies, strawberry shortcake, fruit candies, chocolates, and ice cream are still commonly consumed. Sour cream raisin pie is a popular Utah dessert that recalls the sweet- ened milk custards and dried fruits of early pioneer days. Another notable favorite is pep- parkakor, a Scandinavian ginger cookie often Anglicized as “pepper cookies.” Mormons do not drink alcohol or stimulating beverages such as coffee or tea; lemonade and Brigham Young tea (sweetened hot water with milk) are traditional beverages. In the southwestern regions of the Moun- tain states, a warm climate conducive to agri- culture is combined with insufficient rain to grow most crops without irrigation. Some of the most scenic terrain in the nation, from the majestic Grand Canyon to the broad plains of the Sonoran Desert, is found in Arizona. New Mexico is a mix of high desert plateaus, portions of the Great Plains, and sections of the Rocky Mountains. Southwestern fare reflects the arid conditions and the prefer- ences of the people who settled the region, especially the Native Americans, the Spanish, and the Mexicans. Native Americans who lived in the region prior to European contact, particularly Pueblo peoples, cultivated small amounts of corn, ▼ Meat stews flavored with chile peppers are popular in New Mexico. st oc kc re at io ns /S hu tt er st oc k. co m S a m p l e M e n u A Southwestern Supper Posole/Pozolea,b,c Fresh Flour Tortillas Jicama Saladb or Nopalitos Salada Biscochitosa,b,c or Flanc aCox, B., & Jacobs, M. 1996. Spirit of the west: Cooking from ranch house to range. New York: Artisan. bFussell, B. 1997. I hear America cooking. New York: Penguin Books. cCocinas de New Mexico at http://www.visitalbuquerque.org/albuquerque/cuisine/recipes/ Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 5 2 4 R E G I O N A L A M E R I C A N S beans, chile peppers, squash, and pumpkins. Pine nuts (piñon seeds) were indigenous foods. Juicy fruits (called tunas, or Indian fig) and the young pads (nopales) of the saguro and prickly pear cactus were other native items. Small game, such as rabbit, provided meat in the diet. They prepared stews fla- vored with chiles and very thin, blue corn tortillas called piki. Other tribes, such as the Navajo and Apache, were initially hunters who roamed the region in search of big game and wild plants (see Chapter 5). When the Spanish arrived in the sixteenth century, they introduced many of the foods that became elemental in the cooking of the Indians in both the United States and Mexico, including wheat, hogs, sheep, and cattle, as well as chocolate and other items obtained through trade in the Americas. The Spanish explorers were followed by Mexican-born set- tlers who established small farms called haci- endas, ranchos, and estancias beginning in the late 1500s along the banks of the Rio Grande in New Mexico and in southern Arizona. Anglo-Americans (those who spoke English) followed, first to New Mexico and then into Arizona, adding to the population of Spanish Americans (mostly of Mexican and Native American ancestry who spoke Spanish) and Native Americans. The ethnic heritage of the region is evident in the many Native Ameri- can celebrations, adobe villages, and numer- ous examples of Spanish architecture that still exist. Nowhere is the blending of Native Ameri- can, Spanish American, and Anglo-American culture more evident than in southwestern fare. Wheat tortillas became a staple in parts of the American Southwest and in northern Mexico. Hearty beef or lamb stews replaced the mostly vegetarian versions, and fry bread, made with wheat flour and cooked in lard, became common. Popular dishes in Arizona and New Mexico with Native American and Spanish or Mexican roots include menudo (spicy tripe soup flavored with mint), pozole (hominy flavored with pork, chile peppers, and often epazote or oregano), chimichan- gas (wheat tortillas wrapped around a beef or chicken and vegetable filling, then deep-fried), green chili stew (beef, tomatoes, onions, and a variety of green chile peppers), chickpeas with lamb, and Indian tacos (fry bread folded and filled with meats, cheeses, vegetables, and salsa). Indian roasted lamb with red and green chile peppers, Spanish arroz con pollo (updated with chiles), and Mexican chilaquiles, enchiladas, tamales, quesadillas, and flautas are other common dishes in the region. Chile peppers, onions, garlic, oreg- ano, y er ba buena, epaz ote, safflower blossoms (dried and powdered, reminiscent of saffron), and abundant amounts of mint flavor savory dishes. Toasted pumpkin seeds or pine nuts from the native piñon tree were added to spice blends for sauces, providing a nutty flavor to roasted meats and poultry. Today almonds are used in the same way. Sweets depend on chocolate, vanilla, cin- namon, and other spices. Popular desserts include anise cookies called biscochitos (a Christmas specialty), the light, deep-fried wheat flour puffs called sopaipillas served with honey or cinnamon syrup, and flan. Puddings are also common, including panocha (similar to Indian pudding from the Northeast, but made with wheat kernels and flavored with cinnamon), and capriotada (bread pudding with pine nuts, raisins, and mild cheese, tra- ditionally served with a caramel sauce). Agriculture in Arizona has expanded with irrigation. Grapefruit, lemons, melons, and figs flourish in the region. Two vegetables popular in Mexico have found success in the state as well. Tomatillos, a relative of the ground cherry that looks a little like a green tomato in a papery husk, and jicama, a crispy tuber related to the morning glory, have both been transplanted from Mexico to Arizona. Tomatillos are added to salsa verde and other green sauces, and the sweet pea–flavored jicama frequently provides a crunch in local salads. New Mexico is the leading producer of chile peppers in the United States. There is no consensus on the common names for the hundreds of varieties, nor is there a single heat classification system. Mild New Mexican (also called Anaheim) chiles, medium hot ancho chile (the name for dried, ground poblano chiles), hotter jalapeños (sliced, pickled jalapeños are sprinkled on nachos; smoked jalapeños are called chipotles), and very hot Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 1 5 5 2 5 serrano chiles are the most popular in south- western cuisine. The Pacific States No region in the United States is as diverse as the Pacific states. Significant variations in climate, terrain, and settlement history have led to the development of very different cui- sines in the three coastal states of California, Oregon, and Washington and that of the two states separated from the continental nation: Alaska and Hawaii. The climate of the Pacific coast states ranges from cool and moist in the northern areas near the Canadian border to hot and dry in the southern deserts abutting Mexico. Parallel mountain ranges run north–south through the region, dividing the states into different agricultural zones. The foods of the Native Americans depended on their location. Those near the Pacific survived on clams, mus- sels, and fish, with local berries and greens. In inland areas of California, acorns were the foundation of the diet, leached of tannins and processed as a meal or flour. Western Oregon and Washington are endowed with a wealth of native foods, including deer, elk, antelope, rabbits, beaver, muskrats, ducks, geese, greens, wild mushrooms, and a multitude of berries. In the eastern sections of the states, however, high prairie-like plateaus and near-desert con- ditions exist (see Chapter 5). The first whites to settle in California were the Spanish in the eighteenth century. They built several presidios (forts), pueblos (small farms), and a series of missions (each one day apart in travel time), with the purpose of protecting their claim to the territory. The Spanish cultivated numerous crops, including wheat, olives, grapes, and oranges in the lands surrounding the missions, and planted native foods including corn, beans, and tomatoes as well. Cattle and hogs were raised. Many of the local Indians were forced into the mis- sions as laborers. When Mexico took control of the state in the early nineteenth century, much of the mission territory was redis- tributed as grants to resident families who founded wealthy rancheros producing mostly beef. Despite Spanish claims to the contrary, many other European powers sought access to California riches. Russia, in particular, established colonies in northern Califor- nia to support its fur trade along the Pacific coast and in Alaska. Trappers were the first whites to explore Oregon and Washington. Significant settlement from other states did not occur in the region until the discovery of gold in California during the 1840s and the opening of the Oregon Trail to pioneers from New England, the Midwest, and the South, who came to make their fortunes in the new frontier of the West. Regardless of ancestry, most early settlers adapted their cuisines to the local natural pantry. Coastal seafood was a mainstay for many settlers. In Oregon items familiar in Atlan- tic fare, particularly clams, were favored. Over two dozen varieties (e.g., butter, horse, Japanese littleneck, Manila, razor) live in the sands of the Pacific Northwest. Clam chowder, adapted with whatever local set- tlers could rustle up, including rice, toma- toes, and cabbage, was common.29 Geoduck (pronounced “gooey-duck”) clams are a large, bivalve native to Oregon and Washington with necks (siphons) that can stretch several feet. A geoduck may weigh up to fifteen pounds, although most are in the two- to three-pound range. The body is sliced and pounded into thin steaks (similar to abalone), and the neck is usually minced or ground for soups or stews. Washington also has an abundance of seafood. Beginning in the 1800s the five spe- cies of salmon in the region (king or chinook, sockeye, dog, humpback, and silver) were sent fresh to West Coast markets or pickled and shipped in barrels to Hawaii, South America, the East Coast, and Europe. Iced fish was also sent to Europe, where it was smoked, then returned to the United States. Washington still leads the nation in total salmon catch and products. Oysters are another specialty. The small native Olympia oyster is a favorite, but overharvesting has greatly reduced availabil- ity. Pacific oysters, which were imported from Japan in the early 1900s, are the species con- sumed most often on the West Coast, though European flat oysters are also harvested. Oys- ters are typically served on the half shell in the region, although bacon-wrapped broiled oysters, oyster fritters, barbecued oysters, Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 5 2 6 R E G I O N A L A M E R I C A N S oyster loaf, and oyster stew are common cook- ing preparations. Dungeness crab, named for the town of Dungeness on the Olympic Pen- insula, are caught during the winter months. In California, sardines were the leading catch during the early twentieth century. As their numbers diminished due to overfishing, other fish, such as tuna, salmon, halibut, mackerel, and anchovies, became the predominant catch. Dungeness crab, traditionally eaten steamed with melted butter and lemon or in crab cocktails, and squid, served deep-fried or over pasta, are popular. Abalone, a large, flat-shelled mollusk that clings to rocks off the California coast, is a specialty. The tough muscle must be pounded into a thin steak to tenderize it before cooking. It has a delicate, sweet flavor and is typically lightly floured and sautéed in butter. Many early settlers in the Pacific coastal states started small farms, which over the years have grown into a significant indus- try. California produces more than half the fruits and vegetables consumed nationally and accounts for nearly the entire U.S. pro- duction of avocados, artichokes, garlic (some of which are processed as granules and pow- der), walnuts, almonds, pistachios, apricots, nectarines, olives, dates, figs, pomegranates, prunes, and persimmons. It leads the nation in growing numerous other crops as well, such as lettuce, broccoli, grapes, lemons, strawber- ries, and melons. One hundred percent of U.S. raisins are produced in California. Specialty fruits, such as kiwifruit and f eij oa (a small, green, egg-shaped fruit native to Brazil that tastes a little like pineapple and eucalyptus with mint nuances), are now being grown. In Oregon, fruits such as pears (mostly Bartlett, with some Anjou, Bosc, Comice, Seckel, and Winter), apples, prunes, plums, cherries, and domestic berries, have proved very success- ful. An Oregon specialty is hazelnuts (also called filberts). The trees were introduced from France in the 1800s, and today nearly all hazelnuts consumed in the United States are grown in the state. Washington leads the nation in the production of both apples and cherries. Apples are especially associated with the state: Grown on the eastern slopes of the Cascade mountains, they require extensive hand labor to thin each cluster of blossoms to a single king blossom and to pick any fruit that appears after the initial crop sets. This process produces exceptionally large, well-formed apples. Nearly the entire crop is devoted to Red Delicious and Golden Delicious variet- ies, although several other types are grown in small amounts, such as Fuji, Gala, Granny Smith, and Winesap. Hops, Walla Walla onions (a cool weather sweet onion that is a different variety from the sweet onions grown in Georgia and Hawaii), mint, and spearmint are specialty crops. Dairying is significant in the Pacific states, with California first in milk production nationwide. Best known are the cheeses of the region, including several Cheddar styles such as Cougar Gold from Washington, Tillamook from Oregon, and Monterey Jack (a mild, white cheese) from California. More recently, French-style c h è v r e goat cheeses and other cheese varieties are being produced. The abundance of seafood, dairy products, and fruits and vegetables in the region has led to the creation of cuisines that emphasize what is fresh and local. In California, celebrity chefs, ▲ California produces more than half of the fruits and vegetables consumed in the nation and takes pride in a cuisine based on fresh, local ingredients. Pa ul B ar to n/ Co rb is Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 1 5 5 2 7 such as Wolfgang Puck and Alice Waters, have popularized dishes such as pasta with chan- terelles and grilled duck breasts, goat-cheese salad with arugula and radicchio, poached salmon with fresh basil and olive butters, and pears and figs poached in Zinfandel with Cassis cream (by Alice Waters, founder of the restaurant Chez Panisse in Berkeley)—all examples of the California approach to cook- ing. Other trendy items started in California include mesclun salads (made with a mixture of baby lettuces) and roasted garlic, which can be added to salads and stews or spread on bread like butter. Grilled fish, especially salmon and halibut, is a specialty in all three states. In Oregon, abundant use of fruit is seen in both savory and sweet dishes, such as fruit soups, poultry stuffed with prunes or apricots, and salads with fresh berries or dried fruit, as well as various fruit pies, soups, preserves, jams, and jellies. Few distinctively ethnic flavors are found in the cooking of Washington, and limited influence from the settlers of Oregon is seen in German items (schnitzels, sauerbraten, sage sausages, stuffed cabbage, sauerkraut, and strudels) and southern-style fried chicken served with biscuits and hominy. In contrast, thousands of Chinese, Italian, and Japanese immigrants came to California in the early twentieth century, lured by jobs in farming, ranching, fishing, fish processing, meatpack- ing, and the canning of fruits and vegetables. Agriculture continues to draw immigrants from Mexico and Central America looking for migrant farm work. Other recent immi- grants adding to the diversity of the state include Vietnamese, Cambodians, Laotians (particularly Hmong), Koreans, Asian Indi- ans, Ethiopians, Filipinos, and Samoans. Many California specialties are attributable to the ethnic preferences of the population. The Mexicans brought corn tortillas, refried beans, guacamole, and popular filled dishes like tacos and enchiladas. Italians introduced northern Italian favorites, such as polenta and pesto, as well as seafood dishes, such as the tomato-based fish stew made with local fish and Dungeness crab called cioppino, as well as fried calamari (squid). The Chinese offered authentic stir-fried dishes, wontons, egg rolls, and adapted dishes such as chop suey and for- tune cookies. The Japanese added sukiyaki, teriyaki, tempura, sushi, and other favorites to the mix. Armenians in the Central Valley brought flavorful lamb skewers, dolma (rice- and lamb-stuffed eggplant or grape leaves), and specialty desserts such as baklava. Newer immigrants have popularized hot Thai dishes, Vietnamese pho, Filipino lumpia, and Indian tandoori cooking and flat breads in the state (see the chapter specific to each ethnic group for more details). California, Oregon, and Washington are famous for their wines. The European set- tlers of the mid-nineteenth century first introduced the superior varietal grapes used in French and German wine making to Cali- fornia. Today there are many premier wine regions in the state, including Napa Valley, Sonoma, Santa Cruz, Monterey, San Luis Obispo, and Santa Barbara. The Central Val- ley accounts for most of the grapes cultivated for the bulk wine market. Successful varietals include Cabernet Sauvignon, Merlot, Syrah, and Zinfandel among red wines and Char- donnay and Sauvignon Blanc among whites. Sparkling wines, which may be made from red or white grapes, and dessert wines are also specialties of the state. Oregon wines have gained a reputation for quality, especially for cool weather varietals such as Pinot Gris (a white wine) and Pinot Noir (a red grape used in French-style burgundies). Washing- ton is best known for its white wines, such as Chenin Blanc, Gewürtztraminer, and White Riesling. In more recent years, fruit wines, such as those made from blackberries, cur- rants, cranberries, or peaches, have become common, especially in Oregon. The cooking of Alaska has been hampered in its development by the limited variety of foods. The climate and terrain are by no means uniform throughout the state, with warmer regions found along the coastal pan- handle extending south into Canada, around the Yukon River Delta, and the protected Matanuska Valley in the south-central region, but there is little land suited for agriculture. The Indians, Inuits, and Aleuts of the region lived primarily on seafood and game. Wild berries and roots were harvested in the short Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 5 2 8 R E G I O N A L A M E R I C A N S summer months (see Chapter 5). The first permanent white settlement in Alaska was on Kodiak Island. The Russians arrived in the 1700s to hunt fur seals. They brought kasha, a cooked buckwheat porridge, buckwheat blini, and soups of fish or cabbage. Pirogs, large filled pastries, were made with fish, game, or cabbage. On Easter, they prepared traditional dishes such as the rich fruitcake called kulich (see Chapter 7). A rush of prospectors search- ing for gold arrived in the Klondike area in the 1800s. Supplies were severely limited, and the new settlers lived on little more than flour, bacon, salt pork, lard, and a bit of coffee or tea. Most kept a sourdough culture going to make breads and biscuits. Sourdough specialties included poppy seed potato bread, rye bread with caraway seeds, and whole-wheat bread. Kelp was collected at the coast, and wild flow- ers were boiled to make syrup. Some miners hunted to supplement their diets, and game, such as deer, caribou, moose, Dall sheep, rabbits, and ptarmigan, was available. Game meats are still popular today, including steaks, roasts, and hamburgers made from moose meat, and caribou meat sausages and Swiss steaks. Sheep are now raised on the Aleutian Islands, providing lamb for the mainland. Cattle ranches are found on Kodiak Island and in the Delta and Matanuska. Reindeer herds were imported to Alaska in the late 1800s from Siberia and Scandinavia in the hopes they would become a profitable meat source. Many starved to death when the ranges were overgrazed, and others are thought to have become part of caribou herds. Today, some reindeer in the Seward Peninsula are raised for meat and for supplying antlers to Asia. More important are the dairy operations pro- viding fresh milk, butter, and cream. Potatoes are the most successful crop, but vegetables such as cabbage, cauliflower, and rhubarb also grow in the region. Many of the veg- etables attain gigantic proportions in the long daylight hours of summer; for example, cab- bages may reach seventy pounds, and rhubarb sometimes grows four feet tall. Seafood is the main commodity in Alaska, ranking first nationally in quantity and value of the yearly catch. Salmon, herring, and halibut are the most prevalent fish. Shrimp and crab, including Dungeness, Snow (also known as Tanner), and limited King crabs, are trapped during the winter months. Most are frozen or canned for export to the rest of the United States and Japan. In Hawaii, a mild tropical climate and abundant natural food resources greeted the earliest inhabitants. The volcanic islands are believed to have been first settled by Polyne- sians from the Marquesa Islands and Tahiti in the fifth century. The foundation of their diet was starchy vegetables such as taro root (tradi- tionally made into poi—boiled, pounded into a paste, and slightly fermented), breadfruit, plantains, cassava, and yams. Seafood and possibly pork and chicken were also eaten (see Chapter 12). British explorers discovered the islands in the late 1700s; the area became a major American port for whaling ships in the nineteenth century, and Japanese, Chinese, Korean, Filipino, and Asian Indian agricul- tural workers came to support the developing pineapple and sugarcane industries. Traditional native dishes and foods intro- duced to the islands by the many immigrants coalesced into Hawaiian fare. Unlike some areas of the nation, where various foreign contributions have melded into a single cuisine with occasional European, Latino, or Asian overtones, many dishes in Hawaii maintain their ethnic integrity. Foods from ▼ Salmon and other seafood are favorites in Alaska and the Pacific Northwest. Bu dd y M ay s/ Co rb is Coffee drinks such as lattes have become a specialty item associated with Seattle. The city is home to the Starbucks Corporation, which started the trend of U.S. coffee bars (modeled after Italian espresso bars) in 1984. There were over 12,000 Starbucks coffee bars nationwide in 2014. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 1 5 5 2 9 different cultures are commonly served at the same meal, however, representing the state’s diverse heritage. Popular Hawaiian foods include those with Japanese origins, such as teriyaki-grilled meats and fish, sashimi (raw, thinly sliced fish), and noodle dishes such as saimin, an island adaptation of ramen noo- dles, topped with pork and frequently eaten for lunch. The Chinese brought wok cook- ing, dim sum, long-grain rice, soybeans, bok choy, lotus root, kumquats, litchi, and ginger to the region. Scottish scones and shortbreads are available, and Portuguese sweet bread is so common it is often called Hawaiian bread. Another Portuguese specialty, malassadas (fried doughnuts without a hole), is especially popular, and local variations made with poi or macadamia nuts are novelty items. Fili- pino fish sauces and lumpia (Filipino-style egg rolls), Korean kimchi (hot cabbage relish) and spicy beef dishes, and Indian curries are other contributions. Historically, sugarcane was the most important crop in Hawaii, accounting for 20 percent of the raw sugar produced nationally. But soaring costs and environmental concerns AK AZ CA CO HI ID MT NV NM OR UT WA WY Obesitya ↓↓ ↓↓ ↓↓↓ ↓↓↓ ↓↓↓ ↓ ↓↓↓ ↓↓↓ ↓↓↓ ↓↓↓ ↓↓↓ ↓↓↓ ↓↓↓↓ ↓↓ ↓↓↓ ↓↓↓ ↓↓↓ ↓ ↓↓↓ ↓↓↓ ↓↓↓ ↓↓↓ ↓↓↓ ↓↓↓ ↓↓↓↓ ↓↓ ↓↓↓ ↓↓↓ ↓↓↓ ↓ ↓↓↓ ↓↓↓ ↓↓↓ ↓↓↓ ↓↓↓ ↓↓↓ ↓↓↓↓ ↓↓ ↓↓↓ ↓↓↓ ↓↓↓ ↓ ↓↓↓ ↓↓↓ ↓↓↓ ↓↓↓ ↓↓↓ ↓↓↓ ↓↓↓↓ ↓↓ ↓↓↓ ↓↓↓ ↓↓↓ ↓ ↓↓↓ ↓↓↓ ↓↓↓ ↓↓↓ ↓↓↓ ↓↓↓ ↓↓↓↓ ↓↓ ↓↓↓ ↓↓↓ ↓↓↓ ↓ ↓↓↓ ↓↓↓ ↓↓↓ ↓↓↓ ↓↓↓ ↓↓↓ ↓↓↓↓ ↓↓ ↓↓↓ ↓↓↓ ↓↓↓ ↓ ↓↓↓ ↓↓↓ ↓↓↓ ↓↓↓ ↓↓↓ ↓↓↓ ↓↓↓↓ ↓↓ ↓↓↓ ↓↓↓ ↓↓↓ ↓ ↓↓↓ ↓↓↓ ↓↓↓ ↓↓↓ ↓↓↓ ↓↓↓ ↓↓↓↓ ↓↓ ↓↓↓ ↓↓↓ ↓↓↓ ↓ ↓↓↓ ↓↓↓ ↓↓↓ ↓↓↓ ↓↓↓ ↓↓↓ ↓↓↓↓ ↓↓ ↓↓↓ ↓↓↓ ↓↓↓ ↓ ↓↓↓ ↓↓↓ ↓↓↓ ↓↓↓ ↓↓↓ ↓↓↓ ↓↓↓↓ ↓↓ ↓↓↓ ↓↓↓ ↓↓↓ ↓ ↓↓↓ ↓↓↓ ↓↓↓ ↓↓↓ ↓↓↓ ↓↓↓ ↓↓↓↓ ↓↓ ↓↓↓ ↓↓↓ ↓↓↓ ↓ ↓↓↓ ↓↓↓ ↓↓↓ ↓↓↓ ↓↓↓ ↓↓↓ ↓↓↓↓ ↓↓ ↓↓↓ ↓↓↓ ↓↓↓ ↓ ↓↓↓ ↓↓↓ ↓↓↓ ↓↓↓ ↓↓↓ ↓↓↓ ↓↓ No Leisure-Time Exerciseb ↓↓ AVG ↓↓ ↓↓↓ ↓ ↓ ↓↓ ↓ ↓ ↓↓↓ ↓↓↓ ↓↓↓ ↓↓↓ ↓↓↓ ↓ ↓ ↓↓ ↓ ↓ ↓↓↓ ↓↓↓ ↓↓↓ ↓↓↓ ↓↓↓ ↓ ↓ ↓↓ ↓ ↓ ↓↓↓ ↓↓↓ ↓↓↓ ↓↓↓ ↓↓↓ ↓ ↓ ↓↓ ↓ ↓ ↓↓↓ ↓↓↓ ↓↓↓ ↓↓↓ ↓↓↓ ↓ ↓ ↓↓ ↓ ↓ ↓↓↓ ↓↓↓ ↓↓↓ ↓↓↓ ↓↓↓ ↓ ↓ ↓↓ ↓ ↓ ↓↓↓ ↓↓↓ ↓↓↓ ↓↓↓ ↓↓↓ ↓ ↓ ↓↓ ↓ ↓ ↓↓↓ ↓↓↓ ↓↓↓ ↓↓↓ ↓↓↓ ↓ ↓ ↓↓ ↓ ↓ ↓↓↓ ↓↓↓ ↓↓↓ ↓↓↓ ↓↓↓ ↓ ↓ ↓↓ ↓ ↓ ↓↓↓ ↓↓↓ ↓↓↓ ↓↓↓ ↓↓↓ ↓ ↓ ↓↓ ↓ ↓ ↓↓↓ ↓↓↓ ↓↓↓ ↓↓↓ ↓↓↓ ↓ ↓ ↓↓ ↓ ↓ ↓↓↓ ↓↓↓ ↓↓↓ ↓ Diabetesc ↓↓↓ ↓↓↓↓↓ ↓↓ AVG ↓↓↓ ↓↓↓ ↓↓ ↓↓↓ ↓ ↓↓↓↓ ↓↓↓ ↓↓ ↓↓↓ ↓ ↓↓↓↓ ↓↓↓ ↓↓ ↓↓↓ ↓ ↓↓↓↓ ↓↓↓ ↓↓ ↓↓↓ ↓ ↓↓↓↓ ↓↓↓ ↓↓ ↓↓↓ ↓ ↓↓↓↓ ↓↓↓ ↓↓ ↓↓↓ ↓ ↓ AVG ↓↓ ↓↓ ↓↓↓↓ ↓↓ ↓↓↓↓ ↓↓ ↓↓ Hypertensiond ↓↓ ↓↓ ↓ ↓↓↓↓ ↓↓ ↓ ↓↓↓↓ ↓↓ ↓ ↓↓↓↓ ↓↓ ↓ ↓↓ AVG ↓↓↓ ↓↓↓ ↓↓↓↓ ↓↓↓ ↓↓↓↓ ↓↓↓ ↓ AVG ↓↓ ↓ ↓ ↓↓↓↓ ↓ ↓ ↓↓↓↓ ↓ ↓ ↓↓↓↓ ↓ ↓ ↓↓ High Blood Cholesterole ↑ ↑↑ ↑↑ ↑↑ ↑↑ ↑↑ ↑ ↑AVG ↑↑ ↑ ↑ ↑↑ ↑↑ ↑ ↑ ↑ ↑↑↑ ↑ ↑ ↑↑ ↑↑ ↑ ↑ ↑ ↑↑↑ ↑ ↑ ↑↑ ↑↑ ↑ ↑ ↑ ↑↑↑ ↑ ↑ ↑↑ ↑↑ ↑ ↑ ↑ ↑↑↑ ↑ ↑ ↑↑ ↑↑ ↑ ↑ ↑ ↑↑↑ ↑ ↑ ↑↑ ↑↑ ↑ ↑ ↑ ↑↑↑ ↑ ↑ ↑↑ ↑↑ ↑ ↑ ↑ ↑↑↑ ↑ ↑ ↑↑ ↑↑ ↑ ↑ ↑ ↑↑↑ ↑ ↑ ↑↑ ↑↑ ↑ ↑ ↑ ↑ Don’t Consume 5 Fruits/Vegs.f AVG AVGAVG AVG ↓ AVG AVG AVG AVG AVG AVGAVG AVG AVG AVG AVG AVGAVG AVG AVG AVG AVG AVGAVG AVG AVG AVG AVG AVGAVG AVG AVG AVG AVG AVGAVG AVG AVG AVG AVG AVG ↓ AVG AVG AVGAVG AVG AVGAVG AVG AVG Binge Drinkingg ↑↑ ↓ ↑↑↑ ↑↑↑ ↓ ↑↑↑ ↑↑↑ ↓ ↑↑↑ ↑↑↑ ↓ ↑↑↑ ↑ AVG ↓ ↑↑ ↓ ↓↓ ↑↑ ↓ ↓↓ ↑↑ ↓ ↓↓ ↑↑ ↓ ↓ AVG ↓↓↓ AVG AVGAVG AVG Low Birth Weighth ↓↓↓ ↓ ↓↓ ↓↓↓↓ ↓ ↓↓ ↓↓↓↓ ↓ ↓↓ ↓↓↓↓ ↓ ↓↓ ↓ AVG ↓↓↓ ↓↓↓↓↓ ↓↓ AVG AVGAVG AVG ↓↓↓ ↓ ↓↓↓ ↑↑↓↓↓ ↓ ↓↓↓ ↑↑↓↓↓ ↓ ↓↓↓ ↑↑↓↓↓ ↓ ↓↓↓ ↑↑ Deaths from Heart Diseasei AVG ↑ ↑↑↑ ↑↑ AVG ↓↓↓ AVG ↑ ↑ ↑↑ ↓ ↑↑ ↑ ↑↑ ↓ ↑↑ ↑ ↑↑ ↓ ↑↑ ↑ ↑↑ ↓ ↑↑ ↑ ↑↑ ↓ ↑ AVG ↓↓↓ ↑↓↓↓ ↑ Deaths from Stroke j ↓ ↓↓ ↓↓ ↓ ↓ ↑ ↑ ↓ ↓↓ ↓↓ ↓↓ ↓ ↓ ↑ ↑ ↓ ↓↓ ↓↓ ↓↓ ↓ ↓ ↑ ↑ ↓ ↓↓ ↓↓ ↓↓ ↓ ↓ ↑ ↑ ↓ ↓↓ ↓↓ ↓↓ ↓ ↓ ↑ ↑ ↓ ↓↓ ↓↓ ↓↓ ↓ ↓ ↑ ↑ ↓ ↓↓ ↓↓ ↓↓ ↓ ↓ ↑ ↑ ↓ ↓↓ ↓↓ ↓↓ ↓ ↓ ↑ ↑ ↓ ↓↓ ↓↓ ↓↓ ↓ ↓ ↑ ↑ ↓ ↓ AVG ↓ ↓ ↓↓↓ ↓ ↓↓↓ ↓ ↓↓ Deaths from Cancerk AVG ↓↓ ↓↓↓ ↓↓↓ ↓↓ ↓↓ ↓↓↓ ↓↓↓ ↓↓↓ ↓↓ ↓↓ ↓↓↓ ↓↓↓ ↓↓↓ ↓↓ ↓↓ ↓↓↓ ↓↓↓ ↓↓↓ ↓↓ ↓↓ ↓↓↓ ↓↓↓ ↓↓↓ ↓↓ ↓↓ ↓↓↓ ↓↓↓ ↓↓↓ ↓↓ ↓↓ ↓ AVG AVG AVGAVG AVG AVGAVG AVG AVG ↓↓↓ AVG ↓ aU.S. prevalence 5 58.4 percent (overweight defined as BMI >25.0).
bU.S. prevalence 5 25.8 percent (adults who did no leisure-time physical activity in past month).
cU.S. prevalence 5 6.6 percent (self-reported data based on number of adults who were told they had condition by a health professional).
dU.S. prevalence 5 25.7 percent (self-reported data based on number of adults who were told they had condition by a health professional).
eU.S. prevalence 5 30.4 percent (self-reported data based on number of adults who were told they had condition by a health professional).
fU.S. prevalence 5 77.6 percent (adults who do not consume at least 5 fruits/vegetables per day).
gU.S. prevalence 5 5.1 percent (>2 drinks/day in the past month for men, >1 drink per day in the past month for women).
hU.S. prevalence 5 7.3 percent (live births of infants weighing <2,500 grams). iU.S. age-adjusted death rate per 100,000 245.8000 245.5000 245. . jU.S. age-adjusted death rate per 100, 000 57.9000 57.5000 57. . kU.S. age-adjusted death rate per 100, 000 194.4000 194.5000 194. . AVG—similar to national average ↑—slightly above national average ↓—slightly below national average ↑↑—significantly above national average ↓↓—significantly below national average ↑↑↑—exceptionally above national average ↓↓↓—exceptionally below national average Sources: Centers for Disease Control and Prevention. 2014. National Diabetes Statistics Report: Estimates of diabetes and its burden in the United States, 2014. Atlanta, GA: U.S. Department of Health and Human Services; Division for Heart Disease and Stroke Prevention: Data Trends & Maps, U.S. Department of Health and Human Services, Centers for Disease Control and Prevention (CDC), National Center for Chronic Disease Prevention and Health Promotion. 2013. Retrieved from http://www.cdc.gov/dhdsp/; America’s Health Rankings®: A Call to Action for Individuals & Their Communities. 2014. United Health Foundation. Retrieved from http://www.unitedhealthfoundation.org TA B L E 15.13 Western State–Specific Health Data Compared to National Averages, 2009–2014 Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 5 3 0 R E G I O N A L A M E R I C A N S have put most sugarcane plantations out of business. Pineapples have also been a signifi- cant commodity, though pressures from Asia are reducing their profitability. Hawaii grows most of the world’s supply of macadamia nuts and also exports famous kona coffee, grown on the western slopes of the island of Hawaii. Cattle ranches are found on the islands of Maui, Hawaii, and the privately owned Nii- hau; most provide beef for local consumption. Seafood, another Hawaiian specialty, is also mostly fished for Hawaiian markets, although some tuna is canned and exported. In addi- tion to tuna, common food fish include mahi mahi (also called dorado), bonito, mackerel, and snapper. Health Concerns In general, people living in the West are health- ier than the national average (see chapters on each ethnic group for population-specific data).12,26 The western states have the low- est prevalence of cardiovascular diseases and higher rates of healthy lifestyle activities. (See Table 15.13.) Rates of obesity range from the lowest in Colorado at 20 percent to the highest among the western region in Idaho, Wyoming and Alaska.12 (See Figure 15.3). D I S C U S S I O N S T A R T E R S Examination of Ethnicity, Culture, Diet, and Health For Chapter 1, you described your cultural identity (your race and ethnicity) and the foods that you typically eat (what you like to eat, what foods are eaten in your home). Now, identify the regional area (Northeast, Midwest, South, or West) that your diet most reflects—and any more specific area(s) within that larger region (New England, Mid-Atlantic, East North Central, West North Central, South Atlantic, East South Central, West South Central, Mountain states, or Pacific states). Next, identify any even more specifically localized area and/or culture within that specific area that your diet seems to reflect. Are the region, area, and culture that your diet seems to reflect the same as the region, area, and culture that apply to you? Do other factors affect your diet, such as ethnicity? Look at the appropriate table of health concerns for the area that your diet reflects and think about your family members’ individual health histories, as well as your racial and ethnic background(s). Next, identify health concerns that you might need to address in the future. For example, if your diet is southern and, in particular, West Virginian, you would definitely identify high blood cholesterol, hypertension, and diabetes as possible future health concerns. On the other hand, if your diet is western and, in particular, Californian, but is also heavily influenced by a Greek heritage, you will want to analyze whether that Greek influence on your diet is strong enough that you should identify overweight and obesity as possible future health concerns, even though studies suggest that Californians generally are similar to the national average in those two categories. In small groups, share your findings. Together, brainstorm about what each person in your group could begin doing now to address possible future health concerns. Review Questions 1. List and describe three factors influencing regional cuisine. Pick one region and summa- rize its influences. 2. How did Native American foods/cooking methods influence regional U.S. cuisine? 3. Compare and contrast the preparation of beans, corn, and apples in different regions of the United States. 4. Describe one unique recipe associated with a particular region of the United States that you were not familiar with prior to reading this chapter. Would you try it? Why or why not? 5. Based on health statistics, which region of the country would you choose to live in to stay healthy? What dietary factors may be influ- encing these health statistics? If you wanted to eat “unhealthy” one day, which regional cuisine would you try? Why? 6. You have decided to eat local. What does this mean, and what foods would be available for you to purchase? List some of the arguments for eating local. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 C H A P T E R 1 5 5 3 1 References 1. Ferdman, Roberto A. 2014, July 29. Where the greatest beer, wine, and liquor drinkers live in the U.S. Th e W ash ington P ost. 2. U.S. brewery count by category. n.d. Statistics, Brewers Association. Retrieved from https://www. brewersassociation.org/ (accessed May 1, 2015). 3. New Strategist. 2005. W h o’ s buy ing gr oc er ies (3rd ed.). Ithaca, NY: Author. 4. Trubek, A.B. 2005. P l ac e matter s. In C. Korsmeyer (Ed.), Th e taste c ul tur e r eader . New York: Berg. 5. Pitzer, G.R. 2004. E nc y c l opedia of h uman geogr aph y . Westport, CN: Greenwood. 6. Lipard, L.R. 1997. Th e l ur e of th e l oc al : S enses of pl ac e in a mul tic enter ed soc iety . New York: New Press. 7. U.S Census. 2013. A mer ic an C ommunity S ur v ey , 2013. Retrieved from http://www.census.gov/acs/ www/ (accessed May 1, 2015). 8. Oliver, S.L. 1995. S al tw ater f oodw ay s. Mystic, CT: Mystic Seaport Museum. 9. Neustadt, K. 1992. C l ambak e: A h istor y and c el ebr ation of an A mer ic an tr adition. Amherst: University of Massachusetts Press. 10. Lee, H.G. 1992. T aste of th e states: A f ood h istor y of A mer ic a. Charlottesville, VA: Howell. 11. Division for Heart Disease and Stroke Prevention: Data Trends & Maps, U.S. Department of Health and Human Services, Centers for Disease Con- trol and Prevention (CDC), National Center for Chronic Disease Prevention and Health Promo- tion. 2013. Retrieved from http://www.cdc.gov/ dhdsp/ 12. Wilcox, E.W. 2002. B uc k ey e c ook er y and pr ac tic al h ousek eeping, 1877 (facsimile edition). pr ac tic al h ousek eeping, 1877 (facsimile edition). pr ac tic al h ousek eeping Bedford, MA: Applewood Books. (Original work published 1887) 13. Deutsch, R.M. 1962. Th e nuts among th e ber r ies. New York: Ballantine Books. 14. Lockwood, Y.R., & Lockwood, W.G. 1991. Pasties in Michigan’s Upper Peninsula. In S. Stern & J.A. Cicala (Eds.), C r eativ e eth nic ity : S y mbol s and str ategies of c ontempor ar y eth nic l if e. Logan: Utah State University Press. 15. Luchetti, C. 1993. H ome on th e r ange. New York: Villard. 16. Anderson, J. 1997. T h e A mer ic an c entur y c ook book . New York: Clarkson Potter. 17. Mandel, A. 1996. C el ebr ating th e midw ester n tabl e. New York: Doubleday. 18. Matson, M. 1994. F ood in M issour i. Columbia: University of Missouri Press 19. Hess, K. 1992. T h e C ar ol ina r ic e k itc h en. Columbia: University of South Carolina Press. 20. Carlson, B. 1997. F ood f estiv al s. Detroit: Visible Ink. 21. Page, L.G., & Wigginton, E. 1984. T h e f ox f ir e book of A ppal ac h ian c ook er y . New York: Dutton. 22. Smith, C. 2003. F ood and c ul tur e in A ppal ac h ian K entuc k y : A n eth nogr aph y . J our nal f or th e S tudy of F ood and S oc iety , 6 , 64–71. 23. Sohn, M.F. 2005. A ppal ac h ian h ome c ook ing: H istor y , c ul tur e, and r ec ipes. Lexington: University Press of Kentucky. 24. Milbauer, J.A. 1990. The geography of food in eastern Oklahoma: A small restaurant study. N or th A mer ic an C ul tur e, 6 , 37–52. 25. Milbauer, J.A. 1990. The geography of food in eastern Oklahoma: A small restaurant study. N or th A mer ic an C ul tur e, 6 , 37–52. 26. America’s health rankings. 2014. United Health Foundation. Retrieved from http://www.united- healthfoundation.org (accessed May 1, 2015). 27. Notarianni, P.F. 1994. Italians in Utah. In A.K. Powell (Ed.), U tah h istor y enc y c l opedia. Salt Lake City: University of Utah Press. 28. Raspa, R. 1984. Exotic foods among Italian- Americans in Mormon Utah: Food as nostalgic enactment of identity. In E th nic and r egional f ood- w ay s in th e U nited S tates. Knoxville: University of Tennessee Press. 29. Jones, E. 1981. A mer ic an f ood: T h e gastr onomic stor y (2nd ed.). New York: Vintage.stor y (2nd ed.). New York: Vintage.stor y 30. Fussell, B. 1997. I h ear A mer ic a c ook ing. New York: Penguin Books. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 St a r c h F o o d s Starchy foods form the foundation of nearly all diets. A. Rice and rice-like grains are eaten by millions worldwide and come in many varieties, including short-grain (far right), long-grain (in scoop), and wild rice (long, black grains in lower left mix). Rice products, such as noodles and papers, are also common. B. Wheat is popular in drier regions, typically eaten as bread, as pasta, and in cereal form, such as couscous (lower bag) and bulgar (upper bag). C. Corn is an important New World starch, traditionally prepared as flat breads (including these tortillas), as dumplings, in steamed packets, in stews, and as gruel. D. In tropical areas, fruit and root vegetables are significant sources of starch, including breadfruit (upper basket), cassava (lower basket), yams (lower left corner), taro root (left upper corner), lotus root (cut root with hollow spaces in center), sweet potatoes (ruby orange roots on right), and burdock root (long, pencil-thin roots). Potatoes are more important in cooler climates. E. Acorns are a starch consumed in some Native American, European, Middle Eastern, and Asian cultures. Ju pi te r I m ag es /c om st oc k. co m Be ck y Lu ig ar t- St ay ne r/ CO RB IS D an ny L eh m an /E nc yc lo pe di a/ Co rb is Ch am el eo ns Ey e/ Sh ut te rs to ck .c om A nd re w U na ng st /k ee ps ak e RF /C or bi s Si ed e Pr ei s/ St oc kb yt e/ G et ty Im ag es Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 P r o t e i n F o o d s Protein foods include a wide variety of meat prod- ucts, dairy foods, fish, and shellfish, as well as nu- merous legumes. A. Sausages are eaten in nearly every culture. They come in hundreds of types and make use of miscellaneous cuts and leftovers, such as blood (dark red links). Ch ris S ho rt en /C ol e G ro up /P ho to di sc /G et ty Im ag es B. Dairy products, including yogurt and cheese, are available in even more varieties. Yet many cultural groups consume only limited amounts of milk or other dairy foods. G on ch ar uk M ak si m /S hu tt er st oc k. co m C. Soy products, such as soy milk and bean curd (known as tofu or tobu) are especially significant in the diet of many Asians. na ito 8/ Sh ut te rs to ck .c om E. Legumes, such as beans, peas, and lentils, are eaten daily in many cultures. Co m st oc k/ G et ty Im ag es F. Nuts are an extra source of protein in some regions, including many European, Middle Eastern, Indian, and traditional Native American cuisines. S. M el tz er /P ho to Li nk /G et ty Im ag es D. It is estimated that nearly 30 percent of the population worldwide is dependent on fish, such as this dried salmon. Ed B en ne tt /A la sk a St oc k/ D es ig n Pi cs In c/ A la m y Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 A. Greens, such as this mizuna and bok choy, are especially common. KP G _M eg a/ Sh ut te rs to ck .c om D. Examples of vegetables grown on bushes or vines include egg- plants, which come in many shapes (from round to oblong, to long- thin) and colors (white, striped, green, orange, purple); chile peppers, which vary in heat from mild to mouth-searing; and numerous types of tomatoes.of tomatoes. to p, C LS D es ig n/ Sh ut te rs to ck .c om ; m id dl e, R F Im ag es ; b ot to m , S he be ko /S hu tt er st oc k. co m B. Root, tubers, and bulb vegetables, such as beets, carrtos (above), celeriac, gobo, Jerusalem artichokes, onion, radishes, turnips, and water chestnuts, are prevalent in many regions. M ic ha l M or av ec 9 8/ Sh ut te rs to ck .c om C. Mushrooms, fungi that are eaten as vegetables, are usually edible, but can be highly toxic. Types include shiitake (large, dark brown cap), oyster mush- rooms (yellow, funnel-shaped), lobster mushrooms (orange, knobby), and black cloud ears (dark, curly fungus). D an L am on t/ CO RB IS Ve g e t a b l e s Vegetables are featured in the cuisines of almost all cultures. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 Fruit is a favorite worldwide. A. Some regions have only a few fruit types avail- able, such as certain desert areas where prickly pear cactus fruit is a specialty. D ea n U hl in ge r/ CO RB IS B. Temperate regions have a broader selection of fruits, including apples, citrus fruits, berries, and more unusual fruit such as pomegranates. A nd re w U na ng st /C or bi s F. The fruits of palm trees, which include coconuts (above), dates, palmyra fruit, and pej ibay e, add variety in warmer re- gions worldwide. H an dm ad eP ic tu re s/ Sh ut te rs to ck .c om E. Durian, another tropical specialty, has a strong odor similar to rotting onions esteemed by its fans. Ke vi n R. M or ris /C O RB IS D. The variety of fruit in the tropics is extensive, includ- ing breadfruit (knobby, green), c asimir oa, (smooth, round, green), guavas, mangoes, papaya, and plantains. 16 7 M ic ha el M el fo rd /O ce an /C or bi s C. The seeds of some fruits are more important than the flesh, such as these cacao pods, which are the source of chocolate. Coffee, nutmeg, tamarind, and vanilla are the other examples. St ep he n B. G oo dw in /S hu tt er st oc k. co m Fr u i t s Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 5 3 3 Angelica root: Herb with a licorice-flavored root common in European dishes. Usually available candied. Used medici- nally in China. Annatto (achiote, atchuete): Seeds of the annatto tree used to color foods red or golden yellow. Used in Latin America, India, Spain, and the Philippines. In the United States annatto is added to some baked goods, Cheddar-style cheeses, ice creams, margarines, and butter for color. May be cooked whole in oil or lard to produce the right hue or used as a ground spice. Apio: See A r r ac ac h a. Apios: See G r oundnuts. Apon seeds (agonbono): Seeds of the wild mango commonly used in West Africa. Basis of the soup known as agonbono. Areca nuts: See B etel . Arracacha (apio; Peruvian carrot): Starchy white root of the carrot Arracacha (apio; Peruvian carrot): Starchy white root of the carrot Arracacha family with flavor similar to chestnuts and parsnips used in South America, especially Colombia, Peru, and Venezuela. Arrowroot (chee koo): Many varieties of a bland, mealy tuber found in Asia and the Caribbean. When made into a powder, it is used to thicken sauces and stews. Artichoke (carciofo): Globelike vegetable member of the thistle Artichoke (carciofo): Globelike vegetable member of the thistle Artichoke family, with multiple edible bracts (leaves) crowning the unde- veloped edible flower (the heart). The flavor is slightly sweet. Popular in Middle Eastern and southern European dishes. Arugula (rocket): Small member of the cabbage family native to the Mediterranean; the peppery leaves are popular in salads throughout Europe. Asafetida (devil’s dung): Dried resin with a pungent odor rem- iniscent of burnt rubber, which nonetheless imparts a deli- cate onion-like flavor. It is available as a lump or powder and is commonly used in Asian-Indian dishes. Asian pear (apple pear): Round, yellow fruit from Asia with the crispness of an apple and the flavor of a pear. Atemoya: Hybrid of the cherimoya and sweetsop. See C h er imoy a; S w eetsop. Aubergine: See E ggpl ant. Avocado (aguacate; alligator pear; coyo): Pear-shaped to round fruit with leathery skin (green to black) and light green, buttery flesh. Native to Central America. Numerous variet- ies; eaten mostly as a vegetable, though considered a fruit in some cuisines. Bacalao (bacalhau, baccala): Cod preserved by drying and salting, popular in northern and southern European Glossary of Ethnic Ingredients Abalone (paua): Large, flat mollusk with finely textured, sweet flesh in the broad muscular foot that holds it to rocks (must be pounded before use). It is common in the waters off Asia, California, Mexico, and New Zealand. Available fresh, frozen, canned, and dried. Abiu (caimito): Yellow egg-shaped or round fruit native to the Amazon; popular throughout Brazil and Peru. Translucent white flesh with caramel-like flavor. Acerola cherries (Barbados cherries): Exceptionally sour Caribbean berries resembling small, bright red cherries with orange flesh. Achiote: See A nnatto. Adzuki bean (aduki, azuki; red bean): Small, dark red bean used primarily in Japanese cooking, often as a sweetened paste. Ahipa: See J ic ama. Ajowan (ajwain; carom; omum or lovage seeds): Similar to celery seeds in appearance and to thyme in flavor. Used in Asian-Indian and Middle Eastern cooking. Ajwain: See A j ow an. Akee (ackee, ache; seso vegetal; pera roja): Red fruit with three segments containing large inedible seeds and flesh resem- bling scrambled eggs. Nearly all parts toxic, causing fatal hypoglycemia. Fresh, dried, frozen akee banned in United States; some canned types permitted. Alligator: Reptile native to rivers and swamps throughout the southern Gulf Coast region, from Florida to Texas. Mild white meat, with texture similar to veal. Tail and other parts eaten. Almond paste: Arab confection of ground almonds kneaded with sugar or cooked sugar syrup (some brands also con- tain egg white) used in many European and Middle Eastern desserts. Marzipan is a type of almond paste made with finely ground, blanched almonds. Amaranth (tampala; yien choy; Chinese spinach): Leafy, dark green vegetable similar to spinach; red and purple leaf vari- eties, also. The high-protein seeds can be ground into flour and used in baked products, or boiled and eaten as cereal. Popular throughout Asia and Latin America. Ambarella (hog or Jew plum; kadondong; otaheite or golden Ambarella (hog or Jew plum; kadondong; otaheite or golden Ambarella apple; vi-apple): Small, oval-shaped fruit with very strong flavor native to Polynesia but also found in Southeast Asia and Caribbean. Used unripe for preserves and ripe in desserts. Amchoor (amchur; khati powder): Dried, unripe mango slices or powder, with a sour, raisin-like flavor. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 5 3 4 G L O S S A R Y O F E T H N I C I N G R E D I E N T S cooking (especially Portuguese). Must be soaked, drained, and boiled before use. Bagoong: See F ish paste. Bagoong-alamang: See S h r imp paste. Bambara groundnut (Congo goober; kaffir pea): Legume very similar to peanuts, native to Africa. Bamboo shoot (juk suhn): Crisp, cream colored, conical shoot of the bamboo plant. Used fresh (stored in water) or avail- able canned in brine (whole or sliced). Banana flower (plantain flower): Native to Indonesia and Malaysia, bananas are now found in most tropical regions. Male inflorescence of the plant (female inflorescence that develops into fruit not eaten) is sheathed in inedible red- purple petals. Starchy interior must be boiled repeatedly to remove bitterness; used fresh in salads, cooked in curries, soups, or as side dish in palm oil or coconut milk. Bangus: See M il k f ish . Baobab (monkey bread, lalu powder): Slightly sweet seeds from the large fruit of the native African baobab tree. Used roasted or ground. Pulp of the fruit is also consumed. Basmati rice: See R ic e. Bean curd (cheong-po, tempeh, tofu, tobu): Custard-like, slightly rubbery white curd with a bland flavor made from soybean milk. Japanese bean curd (tofu) tends to be softer than Chinese, which is preferred for stir-fried dishes. A chewier version common in Southeast Asia is called tempeh. Cheong-po, a Korean bean curd, is made from mung beans. Beans: See specific bean type. Bean sprouts (nga choy): The young sprouts of mung beans or soybeans popular in Asian cooking (sprouts may also be grown from the tiny seeds of alfalfa or peas, also from legumes). The crisp 1- to 2-inch sprouts are eaten fresh or added to stir-fried dishes. Belgian endive: See C h ic or y . Berbere: Ethiopian spice mix (typically very hot) used to season many foods, usually including allspice, cardamom, cayenne, cinnamon, cloves, coriander, cumin, fenugreek, ginger, nutmeg, and black pepper. Bergamot orange: Pear-shaped orange with exceptionally tart flesh. Rind used to flavor dishes in the Mediterranean and North Africa; oil extracted from rind flavors Earl Grey tea. Betel (areca nuts; catechu): The heart-shaped leaves of the betel vine (related to black pepper) are used to wrap areca nuts (from the Areca palm; the nuts are usually called betel nuts because of their use with betel leaves) and spices for paan in India. Betel nuts and leaves are chewed together in many Southeast Asian countries and in India to promote digestion. May stain teeth red. Bindi: See O k r a. Bird’s nest: Swallows’ nests from the cliffs of the South China Sea made from predigested seaweed; added to Chinese soups or sweetened for dessert. Must be soaked before use. Bitter almond: An almond variety with an especially strong almond flavor, often used to make extracts, syrups, and liqueurs. Grown in the Mediterranean region, bitter almonds are used in European dishes. They contain prussic acid and are toxic when raw (they become edible when cooked) and are unavailable in the United States. Bitter melon (balsam pear; bitter gourd, foo gwa): Bumpy- skinned Asian fruit similar in shape to a cucumber; pale green when ripe. The flesh has melon-like seeds and an acrid taste due to high quinine content (flavor and odor become stronger the longer it ripens). Bitter orange: See S ev il l e or ange. Black bean (frijol negro; turtle bean): Small (less than 1.2 inches) black bean used extensively in Central American, South American, and Caribbean cooking. Black beans, fermented: Black soybeans salted and fermented to produce a piquant condiment. Used in Chinese cooking as a seasoning or combined with garlic, ginger, rice wine, and other ingredients to make black bean sauce. Black-eyed peas (cow peas; crowder peas): Small legume (technically neither a pea nor a bean), white with a black spot, native to Africa and southern Asia. Black mushrooms: See M ush r ooms. Blood orange: Old variety of orange with deep maroon- colored flesh, sometimes streaked with white. Intense sweet-tart flavor. Common in Spain and North Africa. Blowfish (bok; fugu; globefish; puffer): A popular Japanese specialty, blowfish contain a deadly neurotoxin in the liver and sex organs. Must be carefully prepared by expert; flesh has a slight tingle when eaten. Bok choy (Chinese chard; pak choi; white cabbage): Vegetable Bok choy (Chinese chard; pak choi; white cabbage): Vegetable Bok choy of the cabbage family with long, white leaf stalks and smooth, dark green leaves used in Chinese cooking. Boonchi: See L ong bean. Bottlegourd: See C al abash . Boxthorn: See M atr imony v ine. Breadfruit: Large, round, tropical fruit with warty green skin and starchy white flesh popular in nearly all tropical regions. It must be cooked. Unripe, green fruits are gener- ally prepared as a vegetable, boiled, fried, or even pickled. In South Pacific may be fermented to make poi-like starchy dish. Ripe, yellow-fleshed fruit usually sweetened and served as dessert. Available canned; frozen. Breadroot (Indian breadroot; prairie turnips; timpsil a; tipsin): Hairy perennial plant ( P sor al ea esc ul enta) with large brown root eaten by Native Americans of the Plains and adopted by European immigrants who knew it as pomme de pr air ie. Brinjal: See E ggpl ant. Buckwheat (kasha): Nutty-flavored cereal native to Russia (where it is called kasha), sold as whole seeds (groats) and ground seeds (grits if coarsely ground, flour if finely ground). It is common in Russian and eastern European cooking. Buffalo berry: Scarlet berry of the S h eper dia genus, so called because it was usually eaten with buffalo meat by Native Americans of the plains. Bulgur (bulghur, burghul): Nutty-flavored cracked grains of whole wheat that have been precooked with steam. Available in coarse, medium, and fine grades. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 G L O S S A R Y O F E T H N I C I N G R E D I E N T S 5 3 5 Burdock root (gobo): Long thin root with thin brown skin and crisp white flesh and an earthy, sweet flavor. Popular in Asian cooking. Cactus fruit (cactus pears, cholla, Indian figs, pitaya, sabra, strawberry pear, thang long): Succulent fruit of various cacti popular in numerous nations. Red prickly pear cactus fruit—cactus pears, cholla, Indian figs, sabra, tuna— common in Mexico, U.S. Southwest, Central America, Israel and some other Middle Eastern countries, Australia, South Africa, and Italy. Fruit of the organ pipe cactus sold in the United States as strawberry pear or pitaya. Fruit of saguaro cactus, nopales cactus, and apple cactus eaten in desert areas of Mexico and U.S. Southwest. Climbing epi- phytic cacti common in South America, Australia, Israel, and Vietnam; one variety called thang long red pitaya or dragon fruit. Cactus pads (nopales, nopalitos): Paddles of the prickly pear cactus or nopales cactus commonly eaten in Mexico and parts of the U.S. Southwest, fresh, cooked, or pickled. Available canned. Cactus pears: See C ac tus f r uit. Caimito: See S tar appl e. Cajú: See C ash ew appl e. Calabash (bottlegourd; calabaza; West Indian pumpkin): Gourd-like fruit of a tropical tree native to the New World. Calabaza: See C al abash ; C ush aw Calamansi (calamondin, Chinese or Panama orange, golden or scarlet lime, musk lime): Small sour lime native to China but widely distributed in Indonesia and the Philippines, also available in Southeast Asia, Malaysia, and India. Prized for its sour flavor in Filipino cooking. Callaloo (cocoyam): Edible leaves of root vegetables, especially amaranth, malanga, and taro. Callaloo is sometimes the name of a dish made from these leaves. Camass root: Sweet bulb of the camass lily common in the U.S. Pacific Northwest. Candlenut (kemini; kukui nut): Oily tropical nut sold only in roasted form (toxic when raw). Popular in Malaysia, Polynesia, and Southeast Asia. Càng cua: See P eper omia. Cannellini: See K idney bean. Capers: Small gray-green flower buds from a bush native to the Mediterranean; commonly pickled. Carambola: See S tar f r uit. Cardoon: Member of the artichoke family resembling a spiny celery plant, popular in Italian cooking. Cashew apple ( c aj ú ): The fleshy false fruit attached to the cashew nut. Native to Brazil, it is also eaten in the Caribbean and India. Casimiroa (white sapote, zapote blanco): Dark green to yellow fruit native to Central America; resembles an Asian pear. Soft, white flesh is eaten fresh or prepared as jellies, ices, milkshakes, and fruit leather. Cassarep: Caribbean sauce made from the juice of the bitter variety of cassava cooked with raw sugar. Cassava (cocoyam; fufu; manioc; yuca): Tropical Latin American tuber (now eaten in most tropical areas of the world) with rough brown skin and mild white flesh. Two types exist: bitter (poisonous unless leached and cooked) and sweet. Flour used in Africa (gari), the Caribbean, and Brazil (farinha). Cassava starch (fufu) is used to make the thickening agent tapioca. Leaves also consumed. Caviar (red caviar, ikura, tarama, tobikko): Fish roe from a variety of fish eaten worldwide, including sturgeon (techni- cally the only roe that is called caviar), salmon (red caviar, ikura in Japan), flying fish (tobikko), carp (tarama, most often made into a paste with lemon juice and other ingredi- ents, in Greece called taramasalata), herring, and mullet. Sturgeon caviar graded according to size and quality. Celeriac (celery root): Gnarled, bulbous root of one type of celery, with brown skin, tan flesh, and nutty flavor. Cèpes: See M ush r ooms. Chanterelles: See M ush r ooms. Chayote (christophine, chocho, huisquil, mirliton, vegetable pear): Thin-skinned, green (light or dark), pear-shaped gourd. Native to Mexico, it is now common in Central America, the Caribbean, the southern United States, and parts of Asia. Cheong-po: See B ean c ur d. Cherimoya (anona, custard apple, graviola): Large, dimpled, light green fruit native to South America. White, creamy, flesh has a flavor reminiscent of strawberries, cherries, and pineapple. See also C ustar d appl e. Chicharrónes (pork cracklings): Deep-fried pork skin, fried twice to produce puffy strips. Chickpeas (Bengal gram dal, chana dal, garbanzo bean): Pale yellow, spherical legume popular in Middle Eastern, Spanish, Portuguese, and Latin American cooking. Can be purchased canned or dried. Chico: See Z apote. Chicory (Belgian endive, witloof ): European chicory plant. Chicory (Belgian endive, witloof ): European chicory plant. Chicory Leaves used as salad green; bitter root roasted to prepare a coffee substitute. Often added to dark coffee in Creole cooking. Chile pepper: Although chile peppers, or chiles, are often called hot peppers, the fruits are not related to Asian pepper (such as black pepper) but are pods of capsicum plants, native to Central and South America. The alkaloid capsaicin, found mostly in the ribs of the pods, is what makes chile peppers hot. In general, the smaller the chile, the hotter it is. More than 100 varieties are available, from less than one-quarter inch in length to over eight inches long. Used fresh or dried. Common types include mild pods (see P epper s), slightly hot peppers such as Anaheim (also called C al if or nia or N ew M ex ic o c h il e) and Cayenne (used mostly dried and powdered as the spice cayenne); dark green, medium hot Jalapeño (often available canned— when smoked are known as Chipotle); spicy, rich green Poblano (used fresh, or ripened and dried, called Ancho); hot Serrano (small, bright green or red); and very hot Chile de Arbol, Japones, Péquin (tiny berrylike pepper, Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 5 3 6 G L O S S A R Y O F E T H N I C I N G R E D I E N T S meat valued for its smoky flavor; can be bitter. Used espe- cially in soups and stews. Copra: Dried coconut kernels used in the extraction of coco- nut oil. Coriander (cilantro, Chinese parsley, dhanyaka, yuen sai): Fresh leaves of the coriander plant with a distinctive “soapy” flavor, common in Asian, Middle Eastern, Indian, and Latin American cooking. Seeds used as spice; root used in Thai cooking. Corn smut (huitlacoche): Fungus ( U stil aginal es) that grows on corn ears. Prized in Chinese, Mexican, and Native American cooking. Couscous (cuscus, cuzcuz): Small granules of semolina flour used as a grain in African, Italian, Brazilian, and Middle Eastern dishes. Cow pea: See B l ac k - ey ed pea. Cracked wheat: Cracked raw kernels of whole wheat used in Middle Eastern cooking. Crawfish (crawdad, crayfish, mudbug): Small freshwater crus- tacean, 4 to 6 inches long, that looks and tastes something like lobster. Found in Europe and the United States (California, Louisiana, Michigan, and the Pacific Northwest). The names c r aw f ish and c r ay f ish are also applied to the langostino, a saltwater crustacean that lacks large front claws. Crème fraîche: Slightly thickened, slightly fermented cream popular in France. Culantro (bhandhani, ngo gai, recao, siny coriander): Herb (E r y ngium f oetidum) that is close relative of cilantro (see C or iander ); however, looks more like a dandelion with a pungent flavor reminiscent of crushed beetles. Used inter- changeably with cilantro in the Caribbean and Central America, especially associated with Puerto Rican sofrito. Seasons Thai curries, Malaysian rice dishes, Indian chut- neys and snacks; larger leaves used as a wrap for foods in Vietnam. Reportedly high in riboflavin, carotene, calcium, and iron. Curry leaves (kari): Herb with tangerine overtones used throughout India, Sri Lanka, and in parts of Malaysia. Fresh leaves are briefly fried in ghee, then added to dishes before other seasoning. Not usually a component of curry powder. Curry powder: The western version of the fresh Asian-Indian spice mixture (garam masala) used to flavor curried dishes. Up to twenty spices are ground, then roasted, usually including black pepper, cayenne, cinnamon, coriander, cumin, fenugreek, ginger, cardamom, and turmeric for color. Cushaw (calabaza, green pumpkin): Round or oblong winter Cushaw (calabaza, green pumpkin): Round or oblong winter Cushaw squash with yellow flesh and a flavor similar to pumpkin. Custard apple (anona roja, bullock’s heart, mamon): Green- skinned, irregular (heart-, spherical-, or ovoid-shaped) fruit about 3 to 6 inches in diameter, with granular, custardy flesh. Flavor sweet but considered inferior to related fruits such as cherimoya and sweetsop. See also C h er imoy a. Cuttlefish (inkfish): A mollusk similar to squid, but smaller. Available fresh or dried. exceptionally hot, also known as bird or bird’s eye peppers), Piri-piri (favored in West Africa for sauces and marinades; also name of dishes that include some form of the pepper) and Tabasco (small, red chiles, often used dried and for sauce of same name). Those with extreme heat include Habanero and Scotch Bonnet; similar varieties native to the Caribbean. Chile pepper sauce/paste (harissa, kochujang, pili-pili, Tabasco): Fiery condiments based on hot chile peppers. Sauce typically made from fermented chile peppers, vine- gar, and salt (Tabasco sauce is the best-known U.S. brand). Pastes often include other ingredients, such as garlic and oil (Chinese-style and North African harissa). Pili-pili used in West Africa made with the piri-piri chile (see C h il e pepper s) and other ingredients such as tomatoes, onions, or horse- radish. Korean kochujang includes soybeans and is fer- mented. Chili powder: Ground, dried chile peppers, often with added spices such as oregano, cumin, and salt. Chinese date (dae-chu; jujube): Small Asian fruit (not actually belonging to the date family) usually sold dried. Red dates are the most popular, but black and white are also available. Chinese parsley: See C or iander . Chitterlings (chitlins): Pork small intestines, prepared by boil- ing or frying. Chokecherry: Tart, reddish black cherry ( P r unus v ir giniana) native to the Americas. Cholla: See C ac tus f r uit. Chrysanthemum greens (chop suey greens, crowndaisy greens, sookgat): Spicy leaves of a variety of chrysanthe- mum (not the American garden flower), popular in Asian stir-fried dishes, especially in Korea. Cilantro: See C or iander . Citron: Yellow-green, apple-size citrus fruit. Valued primarily for its fragrant peel that is used raw to flavor Indonesian foods, and candied in European baked goods. Available crystallized and as preserves. Citronella: See L emon gr ass. Clotted cream (Cornish cream, Devonshire cream): Very thick cream made by allowing cream to separate from milk, then heating it and cooling it so that it ferments slightly. Finally, the cream is skimmed from the milk (although Cornish cream is skimmed before heating and cooling). Popular in southwest England, where it is spread on bread or used as a topping for desserts. Cloud (wood) ears: See M ush r ooms. Coconut cream: High-fat cream pressed from fresh grated coconut. Coconut milk: Liquid extracted with water from fresh grated coconut. Cocoplum: Bland plum with white flesh native to Central America, found in the Caribbean, Central America, and Florida. Eaten fresh or dried. Cocoyam: See C al l al oo; C assav a. Conch: Large, univalve mollusk found in waters off Florida and Caribbean (where it is sometimes called lambi). Chewy Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 G L O S S A R Y O F E T H N I C I N G R E D I E N T S 5 3 7 little like celery. Used as a root vegetable, especially in Italy (known as finnochio). Delicate licorice or anise flavor. Fenugreek (methi): Tan seeds of the fenugreek plant, with a Fenugreek (methi): Tan seeds of the fenugreek plant, with a Fenugreek flavor similar to artificial maple flavoring. Essential in the preparation of Asian-Indian spice mixtures. Leaves, called methi, also commonly eaten. Fiddlehead ferns: Young unfurled fronds a specialty dish of the U.S. Northeast and southeastern Canada. Roots were eaten by Native Americans. Filé powder: See S assaf r as. Fish paste (bagoong, kapi, pa dek, prahoc): Thick fermented paste made from fish, used as a condiment and seasoning in the Philippines and Southeast Asia. Fish sauce (nam pla, nam prik, nuoc mam, patis, tuk-trey): Thin, salty, brown sauce made from fish fermented for sev- eral days. Asian fish sauces vary in taste from mild to very strong, depending on the country and the grade of sauce. Filipino patis is the mildest; Vietnamese nuoc mam is among the most flavorful. Nuoc cham is a sauce made from nuoc mam by the addition of garlic and chile peppers. Five-spice powder: A pungent Chinese spice mixture of anise, cinnamon, cloves, fennel seeds, and Szechuan pepper. Fufu: See C assav a; Y am. Fugu: See B l ow f ish . Fuzzy melon (hairy melon, mo gwa): Asian squash similar to zucchini with peach fuzz-like skin covering. Called fuzzy. Gai choy: See M ustar d. Gai lan (Chinese broccoli, Chinese kale): Thick, broccoli-like stems and large, dark or blue-green leaves, with slightly bitter flavor. Used especially in stir-frying. Garbanzo bean: See C h ic k pea. Gari: See C assav a. Geoduck: Large (up to 15 pounds) clam native to U.S. Pacific Northwest, with neck or siphon as long as 3 feet. Neck used in soups, stews; body sliced for steaks. Ghee: Clarified butter (usl i gh ee) from cow’s or buffalo milk used in India. The term gh ee is also used for shortening made from palm or vegetable oil. Ginger root: Knobby brown-skinned rhizome with fibrous yellowwhite pulp and a tangy flavor. Used sliced or grated in Asian dishes. Immature root with milder flavor used in some preparations, particularly pickled ginger popular in Japanese cuisine and candied ginger. Dried, ground ginger provides ginger flavor without the bite of fresh. Ginkgo nut: Small pit of the fruit of the ginkgo tree (ancient species related to the pine tree), dried or preserved in brine, common in Japan. Ginseng: Aromatic forked root with bitter, yellowish flesh, used in some Asian dishes and beverages; best known for therapeutic uses. Glutinous rice: See R ic e. Granadilla: See P assion f r uit. Grape leaves: Large leaves of grape vines preserved in brine, common in Middle Eastern cooking. Graviola: See C h er imoy a. Gravlax: See S al mon, c ur ed. Daikon (icicle radish, white radish, mooli): Relatively mild white radish common in Asian cooking. The Japanese vari- ety is the largest, often 12 inches long, and is shaped like an icicle. The Chinese variety tends to be smaller. Dals: Indian term for hulled and split grains, legumes, or seeds. Many types are available, such as lentils and split peas. Dashi: Japanese stock made from kelp and dried fish (bonita). Dash i- no-m oto is the dried, powdered, instant mix. Dilis (daing): Small fish related to anchovies, dried and salted. Used in Filipino dishes. Dragon’s eyes: See L ongan. Drumstick plant (horseradish tree, malunggay, reseda, sili leaves): Small, deciduous tree native to India, now popular in India, Southeast Asia, the Philippines, and West Africa. Fern-like leaves (very spicy flavor), flowers, seeds (resem- bling bean pods but not a legume), and roots (indistin- guishable from horseradish) consumed. Duhat: See J ambol an. Durian: Football-size spiked fruit with a strong odor reminis- cent of gasoline or rotten onions and sweet, creamy flesh prized in Malaysia, Southeast Asia, and parts of China. Edamame: See S oy bean. Eddo: See T ar o. Eggplant (ai gwa, aubergine, brinjal, melananza, nasu): Large, pear-shape to round member of the nightshade family with smooth, thin skin (white or deep purple in color) and spongy, off-white flesh. Native to India, where it is called brinjal, it has a mildly bitter flavor. Especially popular in Mediterranean and Asian cuisine. Asian varieties known as Japanese (nasu) and Chinese (ai gwa) eggplant are widely available; the Thai type is small, round, and white with green stripes and is less common. Egusi: See W ater mel on seeds. Elderberries: Small shrubs up to 20 feet. Numerous species found throughout northern hemisphere. In the United States the small, dark purple berries used fresh and in pre- serves, pies, and wine. Blossoms fried as fritters. Enoki: See M ush r ooms. Epazote (Mexican tea; pigweed, wormseed): Pungent herb related to pigweed or goosefoot (and sometimes called by these names). Found in Mexico and parts of the United States. Often added to bean dishes to reduce gas. Farinha: See C assav a. Fava bean (broad bean, brown bean, horse bean, Windsor bean): Large, green, meaty bean sold fresh in the pod. Smaller white or tan fava beans are dried or canned and cannot be used interchangeably with the fresh beans. Common in Italian and Middle Eastern cooking. Feijoa (pineapple guava): Small (up to 3 inches), ovoid fruit with greenish skin and white flesh. Flavor is similar to strawberries and pineapple with minty overtones. Shrub native to central regions of South America, but now also found in California, Australia, and New Zealand. Fennel (finnochio, sweet anise): Light green plant with slightly bulbous end and stalks with feathery, dark green leaves, a Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 5 3 8 G L O S S A R Y O F E T H N I C I N G R E D I E N T S Hot pepper: See C h il e pepper . Huisquil: See C h ay ote. Icicle radish: See Daik on. Ikura: See C av iar . Imli: See T amar ind. Indian breadroot: See B r eadr oot. Indian fig: See C ac tus f r uit. Indian potato: See G r oundnuts. Irish moss (carrageen): Gelatinous seaweed extract added to milk or rum as a beverage in the Caribbean. Jaboticaba (guapuru, sabara): Brazilian shrub or small tree with 0.5- to 1.5-inch fruit clustered like grapes. Gelatinous pulp is mild and sweet. Jackfruit: Large (up to 100 pounds) fruit related to breadfruit and figs, native to India, now cultivated in Asia, Malaysia, and Southeast Asia. Two varieties are widely eaten, one with a crisp texture and bland flavor, the other softer and sweeter. Immature fruit is usually prepared like other starchy vegetables such as breadfruit and plantains, or pick- led. Sweeter types are popular as dessert. Available dried or canned. Jaggery: Unrefined sugar from the palmyra or sugar palm common in India. Jagua: See M amonc il l a. Jambolan (duhat, Indian blackberry, jaman, Java plum, rose apple, voi rung): Small sour fruit grown in India and Southeast Asia, especially the Philippines. Used primarily in preserves, juices, and sherbets. Jerusalem artichoke (sunchoke, sunroot): Small nubby- skinned tuber that is the root of a native American sun- flower. It is neither from Jerusalem nor related to the artichoke, though the flavor when cooked is similar. It is used raw and cooked. Jicama (ahipa, sa got, singkamas, yambean): Legume with medium to large tuber with light brown skin and crisp white flesh, indigenous to Brazil. Used raw in Latin American cuisine, it has a sweet, bland flavor, similar to peas or water chestnuts. Also found in Asia, where it is typ- ically stir-fried or added to other cooked dishes. Jujube: See C h inese date. Juneberries (saskatoons, serviceberries; shadbush): Red to deep purple berries on large bush native to the Great Plains region of the United States and Canada. White blooms in June associated with shad migratory run on East Coast; favorite of Native Americans. Juniper berry: Distinctively flavored dark blue berry of the juniper evergreen bush, native to Europe. Used to flavor gin. Kadondong: See A mbar el l a. Kaffir lime (ichang lime, makrut, wild lime): Aromatic citrus popular in Southeast Asia, especially in Thai cooking. Juice, rind, and leaves used to flavor curries, salad dressings, and sauces. Kamis: Sour, cucumber-like vegetable native to the Philippines. Used to achieve a sour, cool flavor in Filipino cooking. Greens: Any of numerous cultivated or wild leaves, such as chard, collard greens, creases, cochan (coneflower), dande- lion greens, dock, kale, milkweed, mustard greens, poke- weed, purslane, and spinach. Grits: Coarsely ground grain, especially hominy, which is typi- cally boiled into a thick porridge or fried as a side dish. Served often in the U.S. South. Ground-cherries (Cape gooseberries, poha, golden berries): Yellow fruit that looks similar to a tiny husked tomato, from a bush native to Peru or Chile. Now popular through- out Central and South America, Central and South Africa, and the South Pacific. Also available in Australia, China, India, Malaysia, and the Philippines. Groundnuts (apios, Indian potatoes): South American tuber A pios amer ic ana eaten by Native Americans, adopted by European settlers. Different from Africa groundnuts (refer- ring to either peanuts or Bambara groundnuts). Guanabana: See S our sop. Guapuru: See J abotic aba. Guarana (Brazilian cocoa): Shrub, P aul l inia c upana indige- nous to the Amazon. Dried leaves and seeds of the fruit are used to make a stimulating tea (containing caffeine) or mixed with cassava flour to form sun-dried sticks. Guava (araca de praia, cattley guava, waiwai): Small sweet fruit with an intense floral aroma, native to Brazil. Skin is yel- low-green or yellow, and the grainy flesh ranges from white or yellow to pink and red. Many varieties are available, including strawberry guava (also known as cattley guava, araca de praia, and waiwai) and pineapple guava. Guava is popular as jelly, juice, or paste. Guayo: See M amonc il l a. Guineps: See M amonc il l a. Headcheese: Loaf of seasoned meat made from the hog’s head and sometimes also feet and organs. Heart of palm (palmetto cabbage, palmito): White or light green interior of the palm tree, especially popular in the Philippines. Available canned. Hickory nuts: Tree indigenous to North America, in same family as pecans. Eaten fresh, roasted, or ground into meal or pressed for a cream-like fluid by Native Americans; used in confections in the U.S. South. Hog peanut: A high-protein underground fruit that grows on the root of the vine F al c ata c omosa in the central and southern United States. The peanut has a leathery shell that can be removed by boiling or soaking. The nut meat can be eaten raw or cooked. Hoisin sauce: Popular Chinese paste or sauce, reddish brown in color, with a spicy sweet flavor. It is made from fer- mented soybeans, rice, sugar, garlic, ginger, and other spices. Hominy (posole, pozole): Lime-soaked hulled corn kernels Hominy (posole, pozole): Lime-soaked hulled corn kernels Hominy (yellow or white) with the bran and germ removed. Traditionally prepared by some Native Americans with culinary ash, which increases potassium, calcium, iron, phosphorus, and other mineral values. Ground, commonly called grits (see G r its). Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 G L O S S A R Y O F E T H N I C I N G R E D I E N T S 5 3 9 North Carolina; meat from large claws and tail, premature eggs called c or al , and liver eaten. Spiny lobster ( P anul ir us ar gus and other species) looks similar to American lobster but is a different animal. Found in warm waters from North Carolina to Brazil; small claws, only tail meat eaten. Longan (dragon’s eyes): Fruit of an Asian Indian tree related to litchis. Used fresh, canned, or dried. Long bean (boonchi, dau gok, sitao, yardlong bean): Roundish Asian bean, 12 to 30 inches long. Similar in taste to string beans, long beans are softer, and chewier, less juicy, and less crunchy than string beans. Long-grain rice: See R ic e. Loquat (nispero): Slightly fuzzy yellow Asian fruit about 2 inches across, easily peeled, with tart peach-flavored flesh. Cultivated worldwide; available fresh, dried, and in syrup. Lotus root (lian, lin gau hasu, renkon, water lily root): Tubular vegetable (holes, as in Swiss cheese, run the length of the root, producing a flower-like pattern when the root is sliced) with brownish skin and crisp, sweet, white flesh. Becomes starchy when overcooked or canned. Lox: See S al mon, smok ed. Luffa (cee gwa, Chinese okra, loofa, padwal, silk melon): Long, thinskinned Asian vegetable, a member of the cucumber family, with spongy flesh. Immature luffas consumed fresh, stir-fried, and in curries; mature luffa becomes bitter. Also see S ponge gour d. Lulo: See N ar anj il l o. Lupine seeds (tremecos): Bitter seeds of a legume used pri- marily for fodder. Must be leached in water before eating. Macadamia nut: Round, creamy nut native to Australia, now grown in Africa, South America, and Hawaii. Mahi-mahi (dolphinfish, dorado): A saltwater finfish found in parts of the Pacific and the Gulf Coast (not the mammal also known as dolphin). Mahleb: Middle Eastern spice made from ground black cherry kernels, which impart a fruity flavor to foods. Makrut: See K af f ir l ime. Malagueta pepper (grains of paradise, guinea pepper): Small West African berries related to cardamom, with a hot, pep- pery flavor. In Brazil the term refers to a tiny Pequin chile pepper. Malanga (cocoyam, tannier, yautia): Caribbean tuber with creamcolored, yellow, or pinkish flesh, dark brown skin, and nutty flavor. Name also applied to other tubers (see T ar o). Mamey (sapote): Medium-size egg-shaped fruit with brown Mamey (sapote): Medium-size egg-shaped fruit with brown Mamey skin and soft flesh ranging in color from orange to yellow- ish to reddish. It has a flavor similar to pumpkin. See also M ammea. Mammea (mamey apple): South American fruit with reddish- brown skin and bright yellow flesh that tastes like peaches. Mamoncilla (guayo, guineps, jaguar, macao, Spanish lime): Small 1- to 2-inch green fruit found in the Caribbean and South America that grow in clusters like grapes but have thicker skin and distinctive sweet, citrusy flesh around a large seed. Kang kong: See W ater c onv ol v ul us. Kanpyo (kampyo): Ribbons of dried gourd used mostly for garnishing dishes in Japan. Kaong: See P al m nuts. Kapi: See F ish paste. Kasha: See B uc k w h eat. Kava: See P epper pl ant. Kemini: See C andl enut. Kewra: See P andanus. Key lime (dayap, nimbu, West Indian or Mexican lime): Small, tart lime indigenous to the Caribbean, popular in Florida Keys; also used in east and north Africa, India, and Malaysia. Known best as primary ingredient in key lime pie. Khati powder: See A mc h oor . Kidney bean (cannellini, red peas): Medium-size, kidney- shaped bean, light to dark red in color (a white variety is popular in Europe, especially Italy, where they are known as c annel l ini). The flavorful beans are common in Europe, Latin America, and the United States. Kochujang: See Ch il e pepper sauc e/ paste. Kohlrabi (tjin choi tow): Light green or purple bulbous vegeta- ble that grows above the soil and produces stems bearing leaves on the upper part. A member of the cabbage family, it can be eaten raw or cooked. Kola nut: Bitter nut of the African kola tree (extracts from this nut were used in the original recipe for Coca-Cola). Kudzu (ge gen, Japanese arrowroot): Japanese vine valued for its tuberous root (up to 450 pounds) that is dried and pow- dered for a starch used in sauces and soups and to coat foods before frying. Now found in much of Asia and U.S. Southeast where it is best known for its growth rate of up to 1 foot per day. May alleviate hangovers or induce sobriety. Kukui nut: See C andl enut. Kumquat (kin kan): Small, bright orange, oval fruit with a spicy citrus flavor common in China and Japan. Also avail- able in syrup and candied. Laverbread: Thick purée of laver (see S eaw eed) that is baked. Used in sauces and stuffings in Great Britain. Lemon grass (citronella root): Large, dull green, stiff grass with lemony flavor common in Southeast Asian dishes. Available fresh, dried, or powdered. Lily buds (golden needles, gum chum): The buds of lily flow- ers used both fresh and dehydrated in the cooking of China. Lingonberry (low-bush cranberry): Small wild variety of the Lingonberry (low-bush cranberry): Small wild variety of the Lingonberry cranberry found in Canada and northern Europe. Usually available as preserves. Litchi (lychee): Small Chinese fruit with translucent white flesh and a thin brown hull and single pit. The flavor is grape-like but less sweet. Available fresh and canned. Dried litchis, also called litchi nuts, have different flavor and tex- ture. Lobster: Ocean-dwelling crustacean valued for its sweet flesh. Two main species consumed in United States. American lobster ( H omar us amer ic anus) found from Labrador to Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 5 4 0 G L O S S A R Y O F E T H N I C I N G R E D I E N T S Popular mushrooms in Europe, available both fresh and dried, include c h anter el l es (a golden mushroom with an inverted cap), mor el s (a delicately flavored mushroom with a dark brown wrinkled cap), and por c ini or c è pes (large brown mushrooms with caps that are spongy underneath; also called bol etus). Musk lime: See C al amansi. Mustard (Chinese green mustard, gai choy, kyona, mizuna, potherb): Though best known for the condiment made from its seeds, greens of several varieties are popular in Asia, called gai choy in China (dark green-reddish leaves), mizuna (small yellowish, notched leaves) in Japan. Usually steamed, boiled, or stir-fried. Root also consumed. Nam pla: See F ish sauc e. Nam prik: See F ish sauc e. Nance: Small, yellow tropical fruit native to Central America and northern South America. Similar to cherries with a slightly tart flavor. Two varieties are available. Napa cabbage (celery cabbage, Chinese cabbage, Peking cab- bage, wong bok): Bland, crunchy vegetable with broad white or light green stalks with ruffled leaves around the edges. Several types are available, similar in taste. Naranjilla (lulo): Walnut-size, orange-skinned, green-fleshed fruit indigenous to the Americas, used mostly for its juice. Particularly popular in Central America. Naseberry: See Z apote. Nigella seed (“black cumin,” “black onion,” kalonji): Small, black seeds native to Europe, North Africa, and the Middle East. Sometimes used as a substitute for black pepper, the flavor of the seeds (which are related neither to cumin nor onions) is pungent, slightly bitter. Added to spice mixtures in India and the Middle East, sprinkled on savory breads and cakes in both regions, as well as in Eastern Europe. Nispero: See L oq uat. Nku: See S h ea nut. Nongus (palmyra): Fruit of the palmyra palm, grown in India, Indonesia, and Malaysia primarily as a source of sugar. See also J agger y . Nopales, Nopalitos: See C ac tus pads. Nuoc cham: See F ish sauc e. Nuoc mam: See F ish sauc e. Oca: Tuber of Andean plant ( O x al is tuber osa). Resembles a pink potato. Tastes lemony when fresh, sweet after storage. Used in South America, prepared like potatoes or eaten fresh. Okra (bindi, lady’s fingers): Small, green, torpedo-shaped pod with angular sides. A tropical African plant valued for its carbohydrates that are sticky and mucilaginous. Used as a vegetable and to thicken soups and stews. Olive: Fruit of a tree native to the Mediterranean. Green olives are preserved unripe. Large, soft Kalamata olives are a medium size, purplish Greek olive. Dark olives (such as Niçoise) are picked in autumn, often cured in salt, with a tannic flavor. Ripe, black olives are smooth-skinned and mild-flavored or wrinkled with a strong tannic flavor. Mango (mangoro, mangue): Fruit native to India, now found throughout Africa, Asia, Latin America, and parts of the South Pacific. Yellow to red when ripe, averaging 1 pound in weight. The flesh is pale and sour when the fruit is unripe, bright orange and very sweet when it is ripe. Used unripe for pickles and chutneys, ripe as a fresh fruit. Manioc: See C assav a. Marzipan: See A l mond paste. Masa: Dough used to make tortillas and tamales. Made fresh from dried corn kernels soaked in a lime solution, or from one of two flours available: masa harina (tortilla mix made from dehydrated fresh masa) or masa trigo (wheat flour tortilla mix). Mastic: Resin from the lentisk bush that has a slightly piney flavor, used to flavor Middle Eastern foods. Available in crystal form. Matai: See W ater c h estnut. Mate: Plant in holly family native to South America. Dried, powdered leaves, called y er ba, are brewed to make a stimu- lating tea (containing caffeine) that is popular in Argentina, Brazil, and Paraguay. Matrimony vine (boxthorn, wolfberry): Asian vine with culi- nary and medicinal uses; both leaves and fruit are used in China. Mayhaw: Type of hawthorn tree found in U.S. South. Its fruit looks like cranberries. Tart apple flavor. Used in preserves, syrups, and wines. Methi: See F enugr eek . Mikan: Japanese citrus related to tangerines and mandarin oranges. Eaten fresh, frozen, and canned in syrup. Milkfish (awa, bangus): Silvery, bony fish with oily flesh espe- cially popular in Filipino cooking. Millet: Cereal native to Africa, known for its high-protein, low-gluten content and ability to grow in arid areas. The variety common in Ethiopia is called teff .. Mirin: Sweet rice wine used in Japanese dishes. Miso: Fermented soybean-barley or soybean rice paste common in Japanese cooking. Light or white (shiro miso) is mild flavored; dark or red (aka miso) is strongly flavored. Also available sweetened and as powder. Mizuna: See M ustar d. Morels: See M ush r ooms. Mullet (ama ama): Finfish of two families that can be black, gray, or red. The flesh is a mix of dark, oily meat and light, nutty-tasting meat. The texture is firm but tender. Mung beans (green gram dal, mung dal): Yellow-fleshed bean with olive or tan skin used in cooking of China, India. See also B ean c ur d; B ean spr outs. Mushrooms: Fresh or dried fungi used to flavor dishes throughout the world. Common Asian types include enok i (tiny yellow mushrooms with roundish caps), oy ster mush - r ooms (large, delicately flavored gray-beige caps that grow on trees), sh iitak e (dark brown with wide flat caps, available dried as Chinese black mushrooms), str aw mush r ooms (creamy colored with bell-like caps), and c l oud ear s or w ood ear s (a large, flat fungus with ruffled edges, available dried). Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 G L O S S A R Y O F E T H N I C I N G R E D I E N T S 5 4 1 Pawpaw (Hoosier banana, Poor Man’s banana, tree melon): Pawpaw (Hoosier banana, Poor Man’s banana, tree melon): Pawpaw Light orange fruit that tastes like a cross between a banana and a melon. Native to the Americas, it is approximately 6 inches long. See also P apay a. Peanuts (groundnuts, goobers, monkey nuts): Legume native to South America, introduced to Africa by the Portuguese, then brought to the United States in the 17th century by black slaves. Eaten raw, roasted, or pulverized into peanut butter. Popular in Africa and the United States; used in some Chinese, Southeast Asian, and Asian- Indian dishes. Pejibaye (peach palm): Fruit of a Central American palm, especially popular in Costa Rica. Peperomia ( c à ng c ua) : Small plant with heart-shaped leaves P eper omia pel l uc ida found throughout Central and South America, Africa, and Southeast Asia. Used as a culinary herb in Vietnam, and as a medicinal herb in the Philippines, Polynesia, and parts of Latin America. Pepitas (cushaw seeds): Pumpkin or squash seeds, typically from cushaw, common in Latin-American cooking. May be hulled or unhulled, raw or roasted, salted or unsalted. Pepper plant ( P iper meth y stic um) : Leaves of the South Pacific plant used to produce the intoxicating beverage called k av a or aw a. Peppers: Misnamed pods of the capsicum plants native to South and Central America (not actually related to Asian pepper plants, which produce black pepper). Peppers are divided into sweet and hot types (see C h il e pepper ). Sweet peppers include bell peppers (green, red, yellow, and purple), pimentos, and peppers used to make paprika (see P apr ik a). Perilla (shiso; beefsteak plant; quen-neep): Aromatic herb with distinctive minty flavor; green or red. Available fresh or pickled. Used mostly as a seasoning or garnish in many Japanese and Korean dishes; sometimes served as a side dish or to wrap rice and other items. Pigeon pea: Small pea in a hairy pod (a member of the legume family, but not a true pea) common in the cooking of Africa, the Caribbean, and India. Yellow or tan when dried. Pignoli: See P ine nut. Pigweed: See A mar anth ; E paz ote. Pili nut: Almond-like nut of a tropical tree found in the Philippines eaten raw and toasted. Popular also in Chinese desserts. Pili-pili: See C h il e pepper sauc e/ paste. Pine nut (pignoli, piñon seed): Delicately flavored kernel from any of several species of pine tree. Pine nuts are found in Portugal (most expensive type), China (less costly, with a stronger taste), and the U.S. Southwest. Common in some Asian, European, Latin American, Middle Eastern, and Native American dishes. Pink bean (rosada): Small oval meaty bean that is a light tan- nish pink in color. Pinto bean: Mottled bean similar to kidney beans, especially popular in U.S. Southwest and Mexico. Olive oil: Extracted from the olive flesh, it is labeled according to percent acidity, from ex tr a v ir gin to v ir gin (or pur e). U.S. labeling laws restrict the use of the term virgin to only olive oil made from the first press; virgin olive oils mixed with refined olive oils to reduce acidity are labeled pur e. Ostiones: Oyster native to the Caribbean that grows on the roots of mangrove trees. Otaheite apple: See A mbar el l a. Oyster mushrooms: See M ush r ooms. Oyster sauce: Thick, brown Chinese sauce made with soy sauce, oysters, and cornstarch. Pacaya bud: The bitter flower stalk of the pacaya palm found in Central America. The edible stalk is about 10 inches long and is encased in a tough green skin, which must be removed before cooking. Pa dek: See F ish sauc e. Palillo: Peruvian herb, used dried and powdered to provide a yellowish- orange color to foods. Palmetto cabbage: See H ear t of pal m. Palm nuts (kaong): Seeds from palms; pounded into palm butter in West Africa. Also boiled and added to halo-halo mix in Philippines. Available canned, in syrup. Palm oil (aceite de palma, dende oil): Oil from the African palm, unique for its red-orange color, used extensively in West African and Brazilian Bahian cuisine. Crude oil con- tains high levels of carotenoids and tocopherols; refined oil deodorized and decolorized, significantly reducing nutri- tional value. Oil from the seed of the palm fruit high in sat- urated fats; should be labeled palm kernel oil, but often mislabeled as palm oil. Pandanus (flowers—kewra, screw pine; leaves—duan pandan, pandan, rampa, screw pine): Perfume essence of the male screwpine flower P andanus f asc ic ul ar is used primarily in north Indian cooking. Screw-pine leaves P andanus amar y l - l if ol ius reminiscent of mown hay, used to flavor the foods of Southeast Asia, Malaysia, South India, Bali, and New Guinea. Fresh withered leaves used in rice puddings and as wrappers for steaming foods in Thailand. Bright green screw-pine essence also available. Papaya (kapaya, pawpaw, tree melon): Thin-skinned green (underripe), yellow, or orange fruit with sweet flesh colored gold to light orange to pink; native to Central America, now found throughout the tropics. Mexican (large and round) and Hawaiian (smaller and pear shaped) varieties are commonly available. The shiny round black seeds are edible. Unripe papaya is used in pickles; the ripe fruit is eaten fresh. Paprika: Powdered red peppers especially popular in Hungarian cooking. Paprika is made from several types of pods related to bell and chile peppers. Paprika is usually designated sweet or hot. Spanish paprika, used in Spanish and Middle Eastern dishes, is more flavorful. Passion fruit (granadilla, lilikoi): Small oval fruit with very sweet, gelatinous pulp. Its berries are used dried; leaves brewed to make herbal tea. Patis: See F ish sauc e. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 5 4 2 G L O S S A R Y O F E T H N I C I N G R E D I E N T S Saewujeot: See S h r imp paste. Saffron: Dried stamens of the crocus flower. It has a delicate, slightly bitter flavor and bright red-orange color. Available as threads or powder. Sa got: See J ic ama. Salal: Thick-skinned black berries of a native American plant in the heath family. Used fresh and dried, good for pre- serves. Leaves used for tea. Salmon, cured: Salmon fillets cured in a mixture of salt, sugar, and dill weed, common in Sweden (where it is known as gravlax), Finland, and Norway. Salmon, smoked: Raw, tender salmon slices lightly smoked and cured in salt produced in Norway, Nova Scotia, and Scotland. Smoked salmon soaked in a brine solution is called l ox , a Jewish specialty. Salmon roe: See C av iar . Salt pork: White fat from the side of the hog, streaked with pork meat, cured in salt. Saluyot (jute, okra leaves, rau day): Leaves from Southeast Asian jute bush with slippery texture when cooked (not related to okra). Added to soups and stews in Filipino cooking. Samphire (beach asparagus, glasswort, sea pickle, pousse- pied): Several species of samphire thought to have origi- nated in Brazil, but now found worldwide, especially in Australia and the South Pacific. Yellow- and purple- skinned varieties are available. Passion fruit is often made into juice. Sapodilla: See Z apote. Sapote: See Z apote. Saskatoons: See J uneber r ies. Sassafras (filé powder): Native American herb used to thicken soups and stews. Screwpine: See P andanus. Sea cucumber (sea slug): Brown or black saltwater mollusk up to 1 foot in length. They lack a shell, but have a leathery skin and look something like smooth, dark cucumbers. Sold dried, they are rehydrated for Chinese dishes, becom- ing soft and jellylike, with a mild flavor. Sea urchin roe (uni): Small, delicate eggs of the spiny sea urchin, popular in Japan. Seaweed (kim): Many types of dried seaweed are used in Chinese, Korean, and Japanese dishes, including aonor ik o (powdered green seaweed), k ombu (kelp sheets), and nor i (tissue-thin sheets of dark green seaweed, also known as laver). Also popular in the Pacific Islands. See also I r ish moss; L av er br ead. Serviceberries: See J uneber r ies. Sesame seeds (benne seeds): Seeds of a plant native to Indonesia. Two types are available: tan colored (white when hulled) and black (slightly bitter). Untoasted sesame paste popular in the Middle East (tahini); toasted sesame paste and powdered seeds common in Asia, especially Korea. Widely grown for their oil. Light sesame oil is pressed from raw seeds, dark oil from toasted seeds; the dark oil has a strong taste and is used as a flavoring. Pitanga (Surinam cherry, Brazilian cherry): Small, bright red, ribbed fruit of shrub or small tree E ugenia unif l or a native to northeastern South America; found also in the Caribbean and Florida. Thin skin with orange flesh that melts in the mouth. Sweet with a slightly bitter bite. Pitaya, Pitahaya, Pitajaya: See C ac tus f r uit. Plantain: Starchy type of banana with a thick skin, which can be green, red, yellow, or black. There are many varieties, ranging in size from 3 to 10 inches. The pulp is used as a vegetable and must be cooked. It is similar in taste to squash. Flower also consumed (see B anana f l ow er ). Poha: See G r ound-c h er r ies. Poi: See T ar o. Porcini: See M ush r ooms. Posole, Pozole: See H ominy . Prahoc: See F ish paste. Prairie turnips: See B r eadr oot. Prickly pear: See C ac tus f r uit; C ac tus pads. Pulses: Term used especially in India for edible legume seeds, including peas, beans, lentils, and chickpeas. Quinoa: Cereal native to the Andes, typically prepared like rice. Also available as flour and flakes (hojuelas). Radicchio: Magenta-colored, slightly bitter member of the chicory family used throughout southern and northern Europe. Rambutan: Bristly, juicy, orange or bright red fruit used in Southeast Asian cooking; related to the litchi. Ramp: Strong-flavored indigenous American onion that tastes somewhat like a leek. Both leaves and bulbs are edible. Recao: See C ul antr o. Red bean: Small, dark red bean native to Mexico and the southwestern U.S. Red caviar: See C av iar . Red pea: See K idney bean. Rice: Grain native to India. More than 2,500 varieties are avail- able worldwide, including basmati rice (small grain with a flavor similar to popcorn, very popular in India and the Middle East); brown rice (unmilled rice with the bran layer intact; can be short-, medium-, or long-grain); glutinous rice (also called sw eet or sw eet or sw eet pear l r ic e; very short grain and very sticky when cooked); long-grain rice (white, polished grains that flake when cooked, common in China and Vietnam); and short-grain rice (slightly sticky when cooked, popular in Japan and Korea). Rice flour is used to prepare rice noodle, rice paper, and baked products. Roseapple (pomarrosa, kopo): Small, thin-skinned pink or red fruit native to Southeast Asia with somewhat spongy flesh that has slightly acidic flavor. Roselle (Florida cranberry; karkadeh; red sorrel; sorrel): Pods of a hibiscus plant relative, common in Africa, the Caribbean, Southeast Asia, Australia, and Florida. Used to make a tart tea popular in Egypt and Senegal and a rum- laced punch in the Caribbean. Also used for chutneys, pre- serves, and candies. Young leaves are eaten raw as salad or cooked as greens. Sabra: See C ac tus f r uit. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 G L O S S A R Y O F E T H N I C I N G R E D I E N T S 5 4 3 Sponge gourd (luffa): Immature vegetable consumed in Asia fresh and in soups; tough fibrous skin used for sponges (loofah), filters, and stuffing. Star anise: Eight-armed pods from a plant in the magnolia family, with an anise-like flavor. Native to China. Star apple (caimito): Purple, apple-size fruit with mild, gelati- nous, lavender-colored flesh native to the Caribbean. Seeds form a star around the center. Star fruit (carambola): Small, deeply ribbed, oval fruit with thin skin shaped like a star when sliced. Green and sour when unripe, yellow and slightly sweet (though still tart) when ripe. Unripe fruit is used in Indian and Chinese dishes. Ripe it is eaten fresh. Strawberry pear: See C ac tus f r uit. Straw mushrooms: See M ush r ooms. Sumac: Sour, red Middle Eastern spice made from the ground berries of a nontoxic variety of the sumac plant. Sunflowers: Native to the United States (genus H el ianth us); over 60 varieties. Seeds eaten by Native Americans raw, dried, and powdered (in breads). Unopened flower head can be cooked and eaten like an artichoke. Petals are dried and used like saffron in Southwest. Sweet peppers: See P epper s. Sweetsop (annona blanca, ata, sugar apple): Sweet, white- fleshed fruit related to the cherimoya, custard apple, and soursop. Szechwan pepper (fagara): Aromatic berries with a hot flavor popular in some Chinese and Japanese dishes. Tabasco sauce: See c h il e pepper sauc e/ paste. Tahini: See S esame seeds. Tamarind (imli, tamarindo): Tart pulp from the pod of the tamarind bean. Available in the pod, as a paste, in a brick, or as a liquid concentrate. Unripe pulp used extensively in flavoring numerous foods and beverages, especially Asian Indian and Latino dishes, as well as Worcestershire sauce and prepared salad dressings. Ripe pulp eaten fresh. Tampala: See A mar anth . Tannier (tannia): See T ar o; M al anga. Tapioca: See C assav a. Taramasalata: See C av iar . Taro (cocoyam, eddo, dasheen, tannier, malanga, yautia): Starchy underground vegetable similar to cassava with brown hairy skin and white to grayish flesh, common in the Caribbean and Polynesia. In Hawaii the boiled, pounded taro paste called poi is a staple in the traditional diet. The young shoots and large leaves are also eaten (see C al l al oo; M al anga). Tarpon: Large silver fish of the herring family found off the coasts of Mexico and Central America. Teff: See Teff: See Teff M il l et. Tempeh: See B ean c ur d. Tepary beans: Small, high-protein bean with wrinkled skin. Grows wild in the U.S. Southwest. Ti: Tropical plant popular in Polynesia (not related to tea). Ti leaves are used to wrap food packets, and the root is eaten and brewed for a beverage. Seville orange (bitter orange; naranja aria, sour orange): Orange with tough skin and dark flesh native to Mediterranean. Inedible raw; juice used in liqueurs (Grand Marnier, Cointreau, Curaçao) and in cooking of the Mediterranean, Caribbean, Central America, and Korea. Shadbush: See J uneber r ies. Shallot: Very small bulb covered with a reddish, papery skin, related to onions but with a milder, sweeter flavor. Shea nut (bambuk butter, nku): Nut from the African shea tree, grown for its thick oil, called shea nut butter or shea nut oil. Shiitake mushrooms: See M ush r ooms. Shiso: See P er il l a. Short-grain rice: See R ic e. Shoyu: See S oy sauc e. Shrimp paste: Strongly flavored fermented Asian sauce or paste made from small dried shrimp or similar crustaceans. Many types are available (bagoong-alamang is the Filipino variety; saewujeot is the Korean type). Singkamas: See J ic ama. Snail (escargot): Small, edible land snail (a common variety of garden snail, cleansed with a commercial feed), popular in France. Giant, baseball-sized snails popular in parts of Africa and the South Pacific. Snow pea (Chinese pea pod, ho lan dow, mange-tout, sugar pea): Flat, edible pod with small, immature peas. Sorghum (guinea corn, kaffir corn): Cereal common to tropi- cal regions of Africa with seeds produced on a stalk. In the Appalachians, Ozarks, and the U.S. South, sorghum is often processed to make sweet syrup. Sorrel (dock, sour grass, wild rhubarb): Small, sour green pop- ular in Europe and parts of United States. See also R osel l e. Sour orange: See S ev il l e or ange. Soursop (guanabana): Large (often 12 inches long) rough- skinned fruit with cottony, fluffy flesh that can be white, pink, or light orange. Native to northern South America or the Caribbean, now found in many parts of the Americas, Africa, India, China, Southeast Asia, Malaysia, and South Pacific. Often made into juice or conserves. Soybean: Small high-protein bean common in Asia. Many varieties of different colors, including black, green, red, and yellow, are available; immature beans in the pod (called edamame) popular in Japan. They are used fresh, dried, and sprouted, most often processed into sauces, condi- ments, and other products (see B ean c ur d; B ean spr out; H oisin sauc e; M iso; O y ster sauc e; S oy mil k , S oy sauc e). Soy milk: Soybeans that are boiled, pureed, then strained and boiled again to produce a white milk-like drink. Soy sauce (shoyu, tamari): Thin, salty, brown sauce made from fermented soybeans. Several types are available. Chinese and Korean soy sauces tend to be lighter in flavor than the stronger, darker Japanese shoyu. Very dark soy sauces, such as Chinese black soy sauce and Japanese tamari may be thickened with caramel or molasses. Spicebush: Shrub ( L inder a benz oin) with spicy-smelling bark and leaves; red berries. Used to make Native American teas. Spiny lobster: See L obster . Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 5 4 4 G L O S S A R Y O F E T H N I C I N G R E D I E N T S White bean: Three types of white bean are widely used: cannel- lini (see K idney bean); Great Northern beans, which are large, soft, and mild tasting; and the smaller, firmer navy beans. White radish: See Daik on. Wild rice: Seeds of a native American grass. Winged bean: Edible legume called the soybean of the tropics. All parts of the plant are consumed, including the shoots, leaves, flowers, pods and seeds, and tuberous root. The pods are large, from 12 to 24 inches long, and feature wing- like flanges. Winter melon (dong gwa, petha, wax melon/gourd): Round greenskinned member of the squash family with a waxy white coating and translucent white green or pink flesh. Similar in taste to zucchini, it is used cooked in Chinese dishes. Called fuzzy melon when immature, winter melon when mature. See also F uzzy mel on. Witloof: See Witloof: See Witloof C h ic or y . Wolfberry: See M atr imony v ine. Wong bok: See N apa c abbage. Worcestershire sauce: Sauce developed by the British firm of Lea and Perrins including anchovies, garlic, onions, molas- ses, sugar or corn sweetener, tamarind, and vinegar, among other ingredients. Yacón (yakon, leafcup): Sweet-tasting root, P ol y mnia sonc h if o- l ia, with brown skin and white flesh native to Andes. Eaten throughout South America; in some regions confusingly called j ic ama (See J ic ama). Yam (ñame; yampi; cush-cush; mapuey): Tuber with rough brown skin and starchy white flesh (not related to the orange sweet potato called y am in the United States). Numerous varieties; may grow quite large, up to 100 pounds. Found in all tropical regions. Yam paste called f uf u in West Africa. Yambean: See J ic ama. Yard-long bean: See L ong bean. Yautia: See M al anga; T ar o. Yerba buena: A variety of mint used in some Native American teas. Yuca: See C assav a. Yucca (Navajo banana): Spiky-leaved desert plant ( Y uc c a bac - c ata) with large, pulpy fruit that ripens in summer. Eaten fresh, boiled, baked, or dried into fruit leather. Zapote (chico, black sapote, naseberry, sapodilla): Drab- colored fruit of the sapodilla tree (which is the source of chicle used in chewing gum). It has granular, mildly sweet flesh, which can be yellow, red, or black. The zapote is a member of the persimmon family. Potato valued primarily for its sprouts and young leaves. Native to China; signifi- cant crop in Southeast Asia, Malaysia, and South India. Tilapia: Small freshwater fish with sweet, firm, white flesh. Timpsila: See B r eadr oot. Tipsin: See B r eadr oot. Tobikko: See C av iar . Tobu, Tofu: See B ean c ur d. Tomatillo (husk tomatoes, miltomate): Small, light green, tomato-like fruit surrounded by a green or tan papery husk, common in Mexico. The flesh is slightly tart and is eaten cooked, usually in sauces and condiments. Available fresh or canned. Tremecos: See L upine seeds. Truffle: Black (French) or white (Italian) fungus found under- ground. Truffles vary from the size of small marbles to as large as tennis balls and are distinctively flavored, similar to a wild mushroom. Available fresh or canned. Tuk-trey: See F ish paste. Tuna: See C ac tus f r uit. Turtle: Popular in Caribbean, Central America, and U.S. South. Diamondback terrapin ( M al ac l emy s ter r apin) is the primary ingredient in turtle soups of the Atlantic states. Green turtle ( C h el onia my das) is a sea turtle, commonly eaten as steaks or stews. Other turtles eaten occasionally (including eggs) are alligator snapping turtle, common snapping turtle, and loggerhead turtle. Ugli fruit: Citrus fruit that is a cross between a pommelo and a mandarin orange, with a very bumpy yellow-orange skin and a sweet orange-like flavor. Especially popular in Jamaica. Uni: See S ea ur c h in r oe. Usli ghee: See G h ee. Verjuice: Juice of unripe lemons used in Middle Eastern fare to give a tang to dishes. Voi rang: See J ambol an. Wasabi: Light green Japanese condiment from root of plant similar to horseradish with a powerful pungency. Available fresh or powdered; green-dyed horseradish often sold as wasabi. Water chestnut (matai): Aquatic, walnut-size tuber with fibrous brown peel and crunchy, sweet, ivory-colored flesh. Available fresh or canned. Water convolvulus (kang kong, ong choi, rau muong, water spinach) Plant related to sweet potato valued primarily for its sprouts and young leaves. Natives to China; significant crop in Southeast Asia, Malaysia, and South India. Watermelon seeds: Seeds often eaten in Africa (called egusi, toasted and ground or pounded into meal or paste for thickening soups and stews) and in Asia (toasted as a snack; sometimes flavored or dyed red). Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 5 4 5 management, medicine, nursing, psychol- ogy, and sociology publications are occa- sionally good resources as well. There are numerous books that have contributed to research on foods and food habits. Cookbooks and other popular lit- erature often include anecdotal informa- tion of interest. Online websites are an additional source of data. Some of the many resources available follow. Observation and participation in the community, at markets, at festivals and fairs, and at public religious events are also good ways to learn about a popu- lation. Community leaders, traditional healers, restaurateurs, and grocers can all contribute to cultural knowledge about foods and food habits. Accumulated expe- rience with a minority population can be an important adjunct to printed research. The authors encourage food profes- sionals to undertake and publish studies on cultural foods to expand the limited information on the topic. We also hope that all professionals share their diver- sity experiences through associations, journals, and online nutrition websites or list servers. Such research and commu- nication help us become more culturally competent and thus become more effec- tive health care providers and educators. General Bibliography Abala, K. (Ed.). 2003–present. F ood c ul tur e ar ound th e w or l d ser ies (14 vols.). Westport, CT: Greenwood Press. Academy of Nutrition and Dietetics/ American Diabetes Association. 1998–2000. E th nic and r egional f ood pr ac tic es: A ser ies (11 booklets). Chicago: Author. Anderson, E.N. 2005. E v er y body eats: U nder standing f ood and c ul tur e. New York: New York University Press. Avakian, A.V., & Haber, B. 2005. F r om B etty C r oc k er to f eminist f ood studies: C r itic al per spec tiv es on w omen and f ood. Amherst: University of Massachusetts Press. Beardsworth, A., & Keil, T. 1997. S oc iol - ogy on th e menu: A n inv itation to th e study of f ood and soc iety . New York: Routledge. Belasco, W. (Ed.) 2001. F ood nations: S el l ing taste in c onsumer soc ieties. New York: Routledge. Bell, D., & Valentine, G. 1997. C onsuming geogr aph ies: W e ar e w h er e w e eat. New York: Routledge. Bryant, C.A., Dewalt, K.M., Courtney, A., & Schwartz, J. 2003. T h e c ul tur al f east: A n intr oduc tion to f ood and soc iety (2nd ed.). Belmont, CA: soc iety (2nd ed.). Belmont, CA: soc iety Brooks/Cole. Caldwell, M., & Watson, J.L. 2005. T h e c ul tur al pol itic s of f ood and eating. Oxford: Blackwell. Carlson, B. 1997. F ood f estiv al s: E ating y our w ay f r om c oast to c oast. Detroit: Visible Ink. Civetello, L. 2003. C uisine and c ul tur e: A h istor y of f ood and peopl e. New York: Wiley. Counihan, C.M. (Ed.). 2002. F ood in th e U S A : A r eader . New York: Routledge. Counihan, C.M., & Van Esterik, P. (Eds.). 1997. F ood and c ul tur e: A r eader . New York: Routledge. Dalby, A. 2002. Danger ous tastes: T h e stor y of spic es. Berkeley: University of California Press. Dassanowsky, R.V., & Lehman, J. (Eds.). G al e enc y c l opedia of mul tic ul tur al In many ways a book like this poses more questions than it answers. Knowl- edge of cultural foods is neither balanced nor complete. Many interested readers are undoubtedly asking why there is so little research on adaptations of food habits in the United States or why there are such limited data available on certain cultural groups. As stated in the Preface, only the major American cultural groups are presented in this book. Although the authors reviewed many resources, the resulting text is undeniably inadequate in some areas. Thus, the most urgent question is: “Where to go from here?” Classes, semi- nars, association memberships, research, client interaction, and community involvement are all useful ways to learn more about cultural foods. In the nutri- tion field, many departments of dietet- ics, nutrition, and home economics offer courses in food and culture. Culinary schools often offer similar classes. Nutri- tion, dietetic, and food service organiza- tions occasionally sponsor seminars on general topics in food habits, as well as on culturally specific diets. Academic research on foods habits and nutrition is published in a limited number of journals. A mer ic an J our nal of C l inic al N utr ition, A mer ic an J our nal of P ubl ic H eal th , E th nic ity & Disease, E th - nic ity & H eal th , J our nal of th e A mer ic an Dietetic A ssoc iation, J our nal of N utr ition E duc ation & B eh av ior , J our nal of T r ans- c ul tur al N ur sing, and S oc ial S c ienc e and M edic ine are a few that frequently feature articles on diet and culture. Food ser- vice, hospitality, and restaurant journals sometimes address cultural food issues. Anthropology, folklore, history, home economics, human resources, geography, Resources Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 5 4 6 R E S O U R C E S MacClancy, J. 1992. C onsuming c ul tur e: W h y y ou eat w h at y ou eat. New York: Holt. McClelland, D.A. 1991. G ood as gol d— F oods A mer ic a gav e th e w or l d. Washington, DC: National Museum of History/Smithsonian Institution. McIntosh, W.A. 2002. S oc iol ogies of f ood and nutr ition. New York: Springer. Meiselman, H.L. (Ed.). 2000. Dimen- sions of th e meal: Th e sc ienc e, c ul tur e, business, and ar t of eating. Gaithersburg, MD: Aspen. Meiselman, H.L., & MacFie, H.J.H. 1996. F ood c h oic e, ac c eptanc e and c onsumption. Gaithersburg, MD: Aspen. Menzel, P., & D’Alusio, F. 1998. M an eating bugs: Th e ar t and sc ienc e of eating insec ts. Berkeley, CA: Ten Speed Press. Miller, W.I. 1997. Th e anatomy of disgust. Cambridge, MA: Harvard University Press. Mintz, S. 1997. T asting fo od, tasting f r eedom: E x c ur sions in eating, pow er , and th e past. Boston: Beacon Press. Montanari, M. 2006. F ood is c ul tur e. New York: Columbia University Press. Morgan, L. 1997. T h e eth nic mar k et guide: A n ingr edient enc y c l opedia f or c ook s, tr av el er s, and l ov er s of ex otic f ood. New York: Berkeley. Newman, J.M. 1993. M el ting pot: A n annotated bibl iogr aph y and guide to f ood and nutr ition inf or mation f or eth nic gr oups in A mer ic a (2nd ed.). New York: Garland. Pilcher, J.M. 2005. F ood in w or l d h istor y . New York: Routledge. Powers, J.M., & Stewart, A. (Eds.). 1995. O ur nor th er n bounty : A c el ebr a- tion of C anadian c uisine. Toronto: Random House of Canada. Purnell, L.D., & Paulanka, B.J. 2003. T r ansc ul tur al h eal th c ar e: A c ul tur - al l y c ompetent appr oac h (2nd ed.). Philadelphia: F.A. Davis. Rappoport, L. 2003. H ow w e eat: A ppe- tite, c ul tur e, and th e psy c h ol ogy of f ood. Toronto: ECW Press. Roberts, C. 1992. C ul tur al per spec tiv es on f ood and nutr ition. Beltsville, MD: National Agricultural Library. Rundle, A., Carvalho, M., & Robinson, M. 2002. C ul tur al c ompetenc e in h eal th c ar e. New York: Jossey-Bass. Satcher, D., & Pamies, R.J. 2005. M ul tic ul tur al medic ine and h eal th dispar ities. New York: McGraw-Hill Professional. Schivelbusch, W. 1992. T aste of par adise: A soc ial h istor y of spic es, stimu- l ants and intox ic ants. New York: Pantheon. Shepard, S. 2000. P ic k l ed, potted, and c anned: H ow th e ar t and sc ienc e of f ood pr eser v ing c h anged th e w or l d. New York: Simon & Schuster. Shortridge, B.G., & Shortridge, J.R. (Eds.). 1998. Th e taste of A mer ic an pl ac e. Lanham, MD: Rowman & Littlefield. Simoons, F.J. 1994. E at not th is f l esh : F ood av oidanc es f r om pr eh istor y to th e pr esent (2nd ed.). Madison: to th e pr esent (2nd ed.). Madison: to th e pr esent University of Wisconsin Press. Smith, A. (Ed.) 2004. O x f or d enc y c l o- pedia of f ood and dr ink in A mer ic a. New York: Oxford University Press. Sokolov, R. 1991. W h y w e eat w h at w e eat: H ow C ol umbus c h anged th e w ay th e w or l d eats. New York: Simon & Schuster. Spector, R.E. 2003. C ul tur al div er sity in h eal th and il l ness (6th ed.). New York: Prentice-Hall. Tannahill, R. 1995. F ood in h istor y . New York: Three Rivers Press. Trager, J. 1995. Th e f ood c h r onol ogy . New York: Holt. Van Wyk, B.E. 2005. F ood pl ants of th e w or l d: A n il l ustr ated guide. Portland: Timber Press. Vissar, M. 1991. Th e r itual s of dinner : Th e or igins, ev ol ution, ec c entr ic ities and meaning of tabl e manner s. New York: Grove Weidenfeld. Whit, W.C. 1995. F ood and soc iety : A soc iol ogic al appr oac h . Dix Hills, NY: General Hall. Wilson, D.S., & Gillespie, A.K. 1999. R ooted in A mer ic a: F oodl or e of popul ar f r uits and v egetabl es. Knoxville: University of Tennessee Press. Wood, R.C. 1995. Th e soc iol ogy of th e meal . Edinburgh: Edinburgh University Press. A mer ic a (3 vols.). Farmington Hills, MI: Gale Group. Davidson, A. 1999. Th e O x f or d c om- panion to f ood. Oxford: Oxford University Press. Farb, P., & Armelagos, G. 1980. C onsuming passions: Th e anth r opol- ogy of eating. New York: Washington Square Press. Fieldhouse, P. 1995. F ood and nutr i- tion: C ustoms and c ul tur e (2nd ed.). London: Chapman & Hall. Gabaccia, D.R. 2000. W e ar e w h at w e eat: E th nic f ood and th e mak ing of A mer ic ans. Cambridge, MA: Harvard University Press. Germov, J., & Williams, L. 1999. Th e soc ial appetite: A soc iol ogy of f ood and nutr ition. South Melbourne, Australia: Oxford University Press. Growther, G. 2013. E ating c ul tur e. North York: University of Toronto Press. Harris, M. 1998. G ood to eat: R iddl es of f ood and c ul tur e. Long Grove, IL: Waveland Press. Heiser, C.B. 1990. S eed to c iv il iz ation: T h e stor y of f ood. Cambridge, MA: Harvard University Press. Hess, J.L., & Hess, K. 2000. Th e taste of A mer ic a. Chicago: University of Illinois Press. Hopkins, J. 1999. S tr ange f oods: B ush meat, bats, and butter f l ies: A n epi- c ur ean adv entur e ar ound th e w or l d. North Clarendon, VT: Periplus. Inness, S.A. (Ed.). 2001. P il af , poz ol e, and pad th ai: A mer ic an w omen and eth nic f ood. Amherst: University of Massachusetts Press. Jacobs, J. 1995. T h e eaten w or d: Th e l an- guage of f ood, f ood in our l anguage. New York: Birch Lane. Katz, S., & Weaver, W.W. (Eds.). 2003. E nc y c l opedia of f ood and c ul tur e (3 vols.). New York: Thomson-Gale. Lee, H.G. 1992. T aste of th e states: A f ood h istor y of A mer ic a. Charlottesville, VA: Howell. Levenstein, H. 2003. P ar adox of pl enty : A soc ial h istor y of eating in mod- er n A mer ic a (Rev. ed.). Berkeley: University of California Press. Livingston, A.D., & Livingston, H. 1993. E dibl e pl ants and animal s: U nusual f oods f r om aar dv ar k to z amia. New York: Facts on File. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 R E S O U R C E S 5 4 7 W or l d F ood H abits B ibl iogr aph y : An outstanding listing of research in the field of food and culture. Search by region or topic (such as eating attitudes, festivals and feasting, and taboos). Religious B uddh ism and M edic al E th ic s (http:// www.changesurfer.com/Bud/ BudBioEth.html): An introduction to Buddhist perspective on abortion, death and dying, and euthanasia with numerous links. C ath ol ic E nc y c l opedia (http://newadvent. org/cathen): This comprehensive resource includes articles on feast- ing, abstinence, and fasting with detailed histories. I ndia Div ine (http://www.indiadivine. com): Comprehensive listing of articles on philosophy, mysticism, meditation, alternative health prac- tices, scriptures, and more. O r th odox C h r istian I nf or mation C enter (http://www.orthodoxinfo.com/): Provides extensive guidance on fasting. Click on “Church (Old) Calendar” within the text to get more information on the Orthodox calendar. S ev enth - Day A dv entist C h ur c h (http:// www.adventist.org): The official site of the faith; the church manual provides information on health and temperance under the standards for Christian living. Botanical/Alternative Health A M ini- C our se in M edic al B otany (http://A M ini- C our se in M edic al B otany (http://A M ini- C our se in M edic al B otany www.ars-grin.gov/duke/syllabus/): Excellent source of information on phytochemicals, ethnic plant uses, GRAS botanicals, and more, with a link to the search site to obtain data by plant name or active ingredient. H er bM ed (http://www.amfoundation.H er bM ed (http://www.amfoundation.H er bM ed org): Database maintained by the Alternative Medicine Foundation with information on evidence for activity, warnings, preparations, mixtures, and mechanisms of action. An enhanced version requires sub- scription, though daily use rates are available. C ul tur al and E th nic F ood and N utr ition E duc ation M ater ial s: A R esour c e L ist f or E duc ator s. 2013. Avail- able at: http://fnic.nal.usda.gov/ resource-lists-0 ( C ul tur al and E th nic ) H ol iday F ood and N utr ition R esour c es L ist. November 2012. http://www.nal.usda.gov/ fnic/pubs/holiday : annotated site run by the Food and Nutri- tion Information Center (FNIC) of the United States Department of Agriculture. E th noM ed (http://ethnomed.org/E th noM ed (http://ethnomed.org/E th noM ed ethnomed/): An ethnic medicine guide from the Harborview Medical Center, University of Washington. Provides somewhat inconsistent information on the groups profiled, but everything presented is reviewed by members of the target commu- nity for accuracy. I ndian H eal th S er v ic e (http://www.ihs. gov): Information about health pro- grams and resources for American Indians and Alaska Natives. M edl ineP l us (http://www.nlm.nih.gov/ medlineplus/): Government site is a great resource for quick updates on African American, Asian (includ- ing Pacific Islander), Hispanic, and Native American (including Alaska Native) health issues. Each listing (under Health Topics) includes latest news, prevention, research, diseases and conditions, organizations, sta- tistics, and information specific to seniors, teens, and women. M ul tic ul tur al H eal th C l ear ingh ouse (http://www.mckinley.illinois.edu/ multiculturalhealth/index.htm) An exceptional site run by the Univer- sity of Illinois with information on U.S. ethnic group health needs and links to other cultural health sites. N ational A l l ianc e f or H ispanic H eal th (http://www.hispanichealth.org): Health information of interest to Latinos. Catalog of resource materi- als offers several useful brochures. N ew M ex ic o S tate U niv er sity T r ansc ul - tur al and M ul tic ul tur al H eal th L ink s (http://nmsu.libguides.com/border- health): Listing of sites for numer- ous religious, ethnic, and special populations. Zibart, E. 2001. Th e eth nic f ood l ov er ’ s c ompanion. Birmingham, AL: Menasaha Ridge Press. PERIODICALS F l av or and F or tune: Dedic ated to th e A r t and S c ienc e of C h inese C uisine. Expert articles, reviews, and recipes on Chinese food and cooking. Pub- lished quarterly by the Institute for the Advancement of the Science and Art of Chinese Cuisine (PO Box 91, Kings Park, NY 11754; http://www .FlavorandFortune.com). F ood and F oodw ay s: E x pl or ations in th e H istor y and C ul tur e of H uman N our ish ment. Interdisciplinary research on the history and culture of human nourishment. Quarterly peer-reviewed journal (phone: 800-345-1420; fax: 215-625-8914; http://www.tandf.co.uk/journals/ titles/07409710.html). F ood, C ul tur e & S oc iety . A multidisci- plinary, international approach with an emphasis on the social aspects of food and food habits. Published by the Association for the Study of Food and Society (ASFS). Journal available with membership (http:// food-culture.org/). F ood H istor y N ew s. Food historians tackle subjects in America’s culinary past in this newsletter. Published quarterly by S.L. Oliver (19061 Main Road, Islesboro, ME 04848; http:// foodhistorynews.com). G astr onomic a: T h e J our nal of F ood and C ul tur e. This gorgeous quarterly offers provocative articles on every aspect of cultural foods, from his- tory, sociology, anthropology, and geography to literature, poetry, art, and film. (University of California Press–Journals Division, 2000 Center St. #303, Berkeley, CA 94704-1223; http://www.Gastronomica.org). Online Resources Ethnic A sian and P ac if ic I sl ander H eal th F or um (http://www.apiahf.org): Health fact sheets on Asian and Pacific Islander groups; links to other health sites. Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 5 4 8 R E S O U R C E S website that organizes information on cultural food studies. G er not K atz er ’ s S pic e P ages (http:// gernot-katzers-spice-pages.com/ engl/index.html?redirect=1): Well- maintained site is run by an Aus- trian chemist. Over 100 herbs and spices listed, indexed alphabetically, by region, and by part used in cook- ing; glossary of spice mixtures. Great links. I nter national F ood C omposition Dir ec - tor y (http://www.fao.org/infoods/tor y (http://www.fao.org/infoods/tor y infoods/tables-and-databases/ en/): Resources of the International Network of Food Data Systems (INFOODS) under the auspices of the Food and Agricultural Organiza- tion (FAO) of the United Nations, including listings for published and online food composition tables worldwide. R ec ipeS our c e. c om (http://www.recipe- source.com): This site has a search- able online archive of recipes that has cataloged over 70,000 recipes from throughout the world. Search by ethnic group or type of dish. Excellent selection, though recipes in ethnic categories are often not traditional. S al l y ’ s P l ac e (http://www.sallys-place. com): An overview of several inter- national cuisines can be found at this site. Recipes, restaurants, and ingredient sources are listed in some. Another useful page on this site lists professional food organiza- tions, including descriptions and addresses. and breaking food news, as well as tantalizing recipes. Information on some ethnic ingredients and cultural food events. F ood C omposition R esour c e L ist f or P r of essional s (http://riley.nal.usda. gov/nal_display/index.php?tax_ level=1&info_center=4&tax_sub ject=279): These food composi- tion resources are all available from the National Agricultural Library, including books, U.S. government publications, software databases, and journals. There is also a contact for assistance with specific requests and a bulletin board. I nter national F ood C omposition R esour c es (https://fnic.nal.usda.gov/ food-composition/international- food-composition-resources): USDA resource. F ood M useum (http://www.foodmu- seum.com): Described as a “one stop source for food exhibits, news/issues, resources, food history, answers to your food questions, book reviews and just plain fun.” Good for history information. F ood, N ation and C ul tur al I dentity (http://www.bl.uk/learning/citizen- ship/foodstories/Accessible/food nationidentity/foodnationidentity. html): A British website that explores the cultural diversity of food within the UK and be able to listen to actual stories of individuals about their experiences trying new foods. FOS T —FOS T —FOS T S oc ial and C ul tur al F ood S tudies (http://research.vub.ac.be/food- history/food-links/): Well-organized J iv a A y ur v edic (http://www.ayurvedic J iv a A y ur v edic (http://www.ayurvedic J iv a A y ur v edic .org/ayurveda/): A site that offers extensive information on beliefs and practices. Includes brief research reviews and an online consultation system. N ational C enter f or C ompl ementar y and A l ter nativ e M edic ine (http:// nccam.nih.gov): This center run by the National Institutes of Health conducts research and disseminates information on complementary and alternative medical practices. Its CAM on PubMed (http://www .nlm.nih.gov/nccam/camonpubmed. html) limits your search to the cita- tion index. T r opic al P l ant Database (http://wwwT r opic al P l ant Database (http://wwwT r opic al P l ant Database .rain-tree.com/plants.htm): Search by common or scientific name, condi- tion, plant properties, or recorded eth- nobotanical uses. A commercial site. Foods and Cooking C ul inar y H istor y T imel ine (http://www .foodtimeline.org/food1.html): This fun links site is set up chronologi- cally—from articles on prehistoric diet to the slow food movement with numerous ethnic and cultural topics. A companion site (http://www .foodtimeline.org) provides links on specific foods. E pic ur us (http://www.epicurus.com): Sponsored by a leading food and hospitality industry consultant, this site features a monthly e-zine with short, informative articles on foods, beverages, herbs, and spices; interviews with chefs and hoteliers; Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 5 4 9 Index demographics and socioeconomic status, 211–212 East African cuisine, 217 emancipation, 210–211 enslavement, 210 Ethiopian, Eritrean, Somali, and Sudanese cuisine, 215–217 family, 212 food after abolition of slavery, 219 historical influences, 214–221 history of, in United States, 210–212 ingredients and common foods, 214–221, 224–225 meal composition and cycle, 221–225 nutritional intake, 225–228 nutritional status, 225–230 religion, 212–214 role of food in African American society and etiquette, 223 slave diet, 218–219 South Africa, 217–218 special occasions, 222–223 therapeutic uses of food, 223–224 traditional food habits, 214–224 traditional health beliefs and practices, 212–214 West African cuisine, 214–215 worldview, 212–214 Afro-Brazilian fare, 309 Agave tequiliana, 248 Agemono, 346 Aging, 38 Agnis, 468 Agobono, 215 Ahimsa, 100–101, 453, 458 Ahipa, 304 Aioli, 512 Ajowan, 430 Ajwain, 457 Akamiso, 345 Alaska Natives, 107 demographics of, 109 diet of, 118–120 mortality rates of, 127 nutritional status of, 126–128 religion and, 111 socioeconomic status of, 109–110 Albanian fare, 435 Albanians. see Balkans, people of Alcohol use central Europeans and people of former Soviet Union, 194 East Asians, 350 Japanese Americans, 350 Koreans, 361 Midwestern Americans, 503 Northern Europeans, 155–156 people of Balkans and Middle Easterners, 442 Southern Americans, 517 Southern Europeans, 169 Western Americans, 530 Alcoholism Mexican-Americans, 259 Native Americans, 128 Russian-speaking immigrants, 194 AleutIndians, 107, 119 Alfeñique, 251 Alioli, 163 Almonds, 163, 190, 201 Almuerzo, 250 Âm, 392 Amchoor, 457, 459 American burritos, 253 Amish, 194–195 Ampalaya, 392 Anaheim chiles, 524 Ancho chiles, 248, 524 Angulas, 166 Animism, 454 Anjeero, 216 Anju, 357 Anorexia, 46 Anticuchos, 307 Aonoriko, 346 Apache Indians, 110, 117 Apio, 304 Apon, 215 Applejack, 148, 494 Apples ackee, 215 brandy, 148 butter, 492 cider, 491, 494 in Michigan, 497 strudel, 187 in Western America, 526 Applesauce, 492 Appropriate language, 67–68 Aquavit, 201 Arabs. see Middle Easterners Arak, 430, 437 Arapaho Indians, 117 Argentina. see South Americans Armenian Apostolic Church, 181 Armenians cuisine of, 188 demographics and socioeconomic status, 179 family, 182 immigration patterns, 178 religion, 181 A À la bordelaise, 149 À la Provençal, 149 Abalone, 525 Abendbrot, 187 Ablimu, 440 Abstinence Hinduism and, 101 Roman Catholicism and, 90 Acculturation of food habits, 6–7 health and, 20 process, 6 Aceto balsamico di Modena, 164 Achiote, 249 Ackee apples, 215 Açorda d’azedo, 166 Açordu, 163 Acorns, 119 Action chain, 56 Acupuncture/acupressure, 48, 325 Adaptations of food habits Africans, 224–230 Asian Indians, 470–472 Caribbean Islanders, 295–296 Central Americans, 268–269 central Europeans and people of former Soviet Union, 192–194 Chinese, 335–336 Japanese, 348–349 Koreans, 359–360 Native Americans, 123–125 Native Hawaiians and Pacific Islanders, 406–407 Northern Europeans, 153–155 Pakistanis, 472 people of Balkans, 441–442 Scandinavians, 203 South Americans, 312 Southeast Asians, 393–394 Southern Europeans, 169 Adobo, 289, 380, 389 Adolescents, food choice and, 17 Advertising, 16 Adzuki beans, 345, 355 Aebleskivers, 201 Africans adaptations of food habits, 224–230 African American southern staples, 219–221 contemporary food habits in United States, 224–230 counseling of, 228–230 cultural perspective, 208–212 daily patterns of meals, 221–223 Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 5 5 0 I N D E X Arracacha, 304 Arroz a la Tumbada, 248 Arroz con pollo, 510 Arroz negro, 166 Artha, 101 Asian Indians, 450–482 adaptations of food habits, 470–472 caste system in India, 453 contemporary food habits in United States, 470–476 counseling, 474–476 cultural perspective, 450–456 demographics and socioeconomic status, 452 etiquette, 467–468 family, 454–455 fasting, 103, 467 feasting, 102–103, 466 Hindu dietary practices, 101 history of, in United States, 450–453 immigration patterns, 451–452 ingredients and common foods, 457–464 meal composition and cycle, 464–465 nutritional intake, 472–474 nutritional status, 472–476 purity and pollution, 467 regional variations, 459–463 religion, 453–454 religious variations, 463–464 role of food in Indian society and etiquette, 467–468 self-identity and, 2 special occasions, 466 staples, 457–458 therapeutic uses of food, 468–470 traditional food habits, 456–470 traditional health beliefs and practices, 455–456 women and food, 467 worldview, 453–456 Asians. see Asian Indians; East Asians; Pakistanis; Southeast Asians Assada no espeto, 163 Assyrians. see Middle Easterners Ataques, 283 Ataques de nervios, 283 Australian fare, 409 Austrian Americans. see Austrians Austrians demographics and socioeconomic status, 178 immigration patterns, 176–177 religion, 180 Avgolemono, 438 Avocados, 248 Ayurvedic medicine, 48, 455–456, 468 Aztecs, 242–243 B Babalorixá, 304 Bacalao a la vizcaina, 166 Bacalao al pil-pil, 166 Bacalhau, 163, 168 Badger, 511 Bagels, 493 Bagoong, 383 Bagoong-alamang, 383 Baked beans, 489 Baklava, 216, 426 Balance, 378 Balkans, people of, 416–449 adaptations of food habits, 441–442 contemporary food habits in United States, 441–445 cultural perspective, 416–425 daily patterns of meals, 434 demographics and socioeconomic status, 419 family, 421–422 history of, in United States, 416–418 ingredients and common foods, 426–434 meal composition and cycle, 434–441 Middle East and, 416–449 nutritional intake, 442–443 nutritional status, 442–445 regional variations, 430–431 religion, 420–421 special occasions, 438–440 staples, 426–430 therapeutic uses of food, 440–441 traditional food habits, 425–441 traditional health beliefs and practices, 424 worldview, 420–421 Balsam vodka, 192 Balsamic vinegar. see Aceto balsamico di Modena Bananas, 215, 514 Bananas Foster, 516 Barbecue, 513, 517 Barley water, 355 Basmati rice, 461 Basques, 522 Bawang, 392 Beans adzuki, 345, 355 in Asian Indian diet, 457 baked, 489 Basque, 522 black, 264 bread, 124 cacao, 243 in Central American diet, 264 frijoles refritos, 243 mung, 355 pinto, 511 in South American cuisine, 304 as staple food for Aztecs, 243 as staple food for Mexicans, 243 as staple food of Native Americans, 114 Béchamel, 150 Beef assada no espeto, 163 in cuisine of Central Europe and former Soviet Union, 185 in food of New Mexico, 253 in food of Sonora, 253 heart, 310 Kobe, 345 in Midwestern American cuisine, 501 in Northeastern American cuisine, 492 in Pakistani cuisine, 459 in Portuguese cuisine, 166 in South American cuisine, 307, 310 in Southern American cuisine, 513, 517 Tajima, 345 in Tex-Mex food, 253 Beer, 147 American, 494, 500 bitters, 147 bock, 187 kvass, 187 lager, 187 Märzenbier, 187 pilsner, 187 stout, 147 Weissbier, 187 Bel paese, 164 Belize. see Central Americans Beluga caviar, 186 Bento, 347 Berbere, 216 Bhuna, 459 BIA. see Bureau of Indian Affairs Bigos, 190 Bilis, 252, 263 Biomedical healing, 50–51 Biomedicine aging and, 38 degree of formality/degree of directness and, 38 human equality and, 38 materialism/spirituality, 38 perception of time and, 38 personal control and, 37 relationship to nature and, 37 state of being and, 37 worldview, 37–39 Bird’s eye peppers, 510 Bison, 501 Bitter orange, 335 Bitters, 147 Black beans, 264 Black Forest cake. see Schwarzwälder Kirschtorte Black nightshade, 456 Black tea, 329 Blackfeet Indians, 120 Bock beer, 187 Body image, 40, 258 Bogatá chicken stew, 308 Bokors, 284 Bolivia. see South Americans Bombay duck, 462 Bon Secour oysters, 513 Bordeaux, 149 Bosnians. see Balkans, people of Boston brown bread, 489 Botanical remedies, 47, 260, 380 Botánicas, 48 Boudin blanc, 152 Boudin noir, 152 Bouillabaisse, 149, 160 Bourbon, 514 Brandy apple, 148 Cognac, 149 metaxia, 430 Pisco, 307 plum, 430 Schnapps, 187 Bratwurst, 186 Brauche, 182 Braucherei, 182 Brazil. see South Americans Breads in Balkan cuisine, 426 East African cuisine, 217 Ethiopian, 216–217 in Filipino diet, 381 French, 150, 264 Italian, 164 in Middle Eastern cuisine, 426 in Midwestern American cuisine, 501 Native Hawaiians and Pacific Islanders, 403 Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 I N D E X 5 5 1 Cambodians adaptations of food habits, 393–394 demographics and socioeconomic status, 374 family, 376 nutritional intake, 396 religion, 375 special occasions, 391 staples, 384–389 therapeutic uses of food, 392–393 traditional health beliefs and practices, 379–380 Camel milk, 217 Camembert, 148 Campinha-Bacote model of competence, 18 Candelaria Day, 250 Candies, 223 Candomblé, 302, 304, 311 Candomblé orixás, 311 Cannoli, 165 Cantonese, 330–331 Cape Cod turkey, 489 Carbonada criolla, 308 Carbonada en zapallo, 308 Cardiovascular disease Chinese Americans, 337 Mexican Americans, 258 Native Americans, 128 Scandinavians, 203–204 Caribbean Islanders, 278–301 adaptations of food habits, 295–296 contemporary food habits in United States, 295–301 counseling, 299–301 cultural perspective, 278–285 daily patterns of meals, 291–293 demographics and socioeconomic status, 280–281 etiquette, 293 family, 282–283 foreign influence, 285–286 history of, in United States, 278–281 indigenous foods, 285 ingredients and common foods, 285–291, 295–296 meal composition and cycle, 291–293 nutritional intake, 296–299 nutritional status, 296–301 regional variations, 288–291 special occasions, 293 staples, 286–288 traditional food habits, 285–295 traditional health beliefs and practices, 283–285 worldview, 282–285 Carolina Gold rice, 509 Carp, 190 Cassareep, 309 Cassava, 215, 217, 264, 295, 304 Cassis, 149 Castagnaccio alla Fiorentina, 165 Catfish, 513 Catholicism. see al so Roman Catholicism French, 143 Irish, 143 Cattle, 217 Causerras, 168 Caviar, 186, 189 Cecinas, 249 Celiac disease, 443 Cena, 250 Central Americans, 261–271 adaptations of food habits, 268–269 contemporary food habits in United States, 268–271 cultural perspective, 261–264 demographics and socioeconomic status, 261–262 etiquette, 267 family, 263 history of, in United States, 261–262 immigration patterns, 261 meal composition and cycle, 266–267 nutritional intake, 269 nutritional status, 269–271 regional variations, 266 religion, 263 special occasions, 267 staples, 264–266 therapeutic uses of food, 268 traditional food habits, 264–268 traditional health beliefs and practices, 263–264 worldview, 262–264 Central Europeans, 174–207 adaptations of food habits, 192–194 contemporary food habits in United States, 192–196 cultural perspective, 175–183 daily patterns of meals, 187–189 demographics and socioeconomic status, 178–180 etiquette, 189 family, 181–183 history of, in United States, 175–180 immigration patterns, 175–178 ingredients and common foods of, 183–187 meal composition and cycle, 187–192 nutritional status, 194–196 religion, 180–181 special occasions, 189–192 staples and regional variations, 183–187 therapeutic uses of food and, 192 traditional food habits, 183–192 traditional health beliefs and practices, 182–183 worldview, 180–183 Cerasse tea, 295 Cereal, 499 Cevapi, 431 Ceviches, 307 Chagas’ heart disease, 269 Chaldeans. see Middle Easterners Chamomile, 268 Champagne, 148 Chapanas, 306 Chapati, 217 Charcuterie, 148 Charqui, 307 Chawanmushi, 346–347 CHD. see Coronary heart disease Cheese Bel paese, 164 Brie, 149 brunost, 199 camel, 429 Camembert, 148 Colby, 497 Crèma Dania, 199 farmer’s, 186 goat, 429 Gorgonzola, 164 Havarti, 199 Jarlsberg, 199 in Northeastern American cuisine, 489, 492–493 Northern India, 461 Scandinavian, 201 in Southern American cuisine, 507, 511 as staple food in Central Europe and former Soviet Union, 185 as staple food in Great Britain, 146 symbolic use of, 3 Breast feeding African Americans, 226 Asian Indians, 473 Central Americans, 269 Central Europeans and people of former Soviet Union, 194 Mexican Americans, 255 Middle Easterners, 443 Bredie, 218 Brie, 149 Briki, 430 Brioche, 151 British. see al so Great Britain adaptations of food habits, 153 demographics and socioeconomic status, 142 family, 143 immigration patterns, 140–141 nutritional status, 155–156 religion, 143 traditional health beliefs and practices, 144 Bruhwurst, 186 Brujos, 284 Brunost, 199 Brunswick stew, 511 Bubble tea, 330 Buckwheat noodles, 343, 355 Buddhism, 103–105 Asian Indians and, 453 Chinese, 323 dietary practices, 104 feasts and fasts, 104 Japanese, 341, 342 Koreans, 352 Theravada, 375 Vietnamese, 375 Buffalo wings, 493 Bulgur, 426 Bündnerfleisch, 492 Buñuelos, 247 Bureau of Indian Affairs (BIA), 108–109, 129 Burek, 426 Burghul, 426 Burgoo, 513 Burgundy, 149 Burns’s Night, 152 Butter, 149, 463, 492 Butter Festival, 191 Buttermilk, 514 C Cacao beans, 243 Cachaça, 310 Caida de la mollera (fallen fontanel), 241, 260 Cajuns, 143–144, 153, 512 Calas, 515 Caldo verde, 163 Calvados, 148 CAM. see Complementary and alternative medicine Cambodia, 373 Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 5 5 2 I N D E X concepts, 57–64 direct v s. indirect, 36 effective, 66–73 iceberg model, 56–57 intercultural, 56–77 intercultural counseling, 69–71 intercultural nutrition assessment, 71–73 intercultural nutrition education, 73–77 intercultural skills, 66–69 nonverbal, 62–64 role in health care, 64–66 verbal, 57–60 Compadrazgo, 282 Complementary and alternative medicine (CAM), 34 Complementary foods, 7–8 Confucianism, 322, 341, 352 Congee, 328 Consumer food choice model, 13–18 Contemporary food habits in United States Africans, 224–230 Caribbean Islanders, 295–301 Central Americans, 268–271 Central Europeans and people of former Soviet Union, 192–196 Chinese, 335–340 Japanese, 348–351 Mexicans, 252–261 Native Americans, 123–133 Native Hawaiians and Pacific Islanders, 406–410 of northern Europeans, 153–157 of Scandinavians, 203–204 South Americans, 312–314 Southeast Asians, 393–399 of southern Europeans, 169–170 Convenience, 15 Cookie, 493 Core foods, 7–8 Corn African American southern staples, 218–219, 221 beer, 216 in Central American diet, 264 liquor, 308 in Northeastern American cuisine, 489 in Pakistani cuisine, 459 in South American cuisine, 307 in Spanish cuisine, 166 as staple food of Native Americans, 114 staple grain for Aztecs, 243 symbolic use of, 117 therapeutic uses of food and, 122 West African cuisine, 215 whiskey, 514 Corn ear smut, 122 Cornbread, 511–512 Cornish pasty, 150 Cornmeal breads, 183 cuzcuz paulista, 310 piki, 118 porridge, 489 therapeutic use of, 122 Coronary heart disease (CHD), 228. see al so Heart disease Cost, 15 Costa Rica. see Central Americans Counseling, 69–71 Africans, 228–230 Asian Indians, 474–476 Caribbean Islanders, 299–301 ingredients and common foods, 325–331, 335–336 meal composition and cycle, 331–334 northern, 330 nutritional intake, 336–337 nutritional status, 336–340 pickled, 264 regional variations, 330–331 religion, 322–323 southern, 330 special occasions, 333–334 staples, 325–330 therapeutic uses of food, 334–335 traditional food habits, 325–335 traditional health beliefs and practices, 323–325 traditional medicine, 323–325, 339 worldview, 322–325 Chinese medicine. S ee Traditional Chinese Medicine (TCM) Ch’ing Ming, 333–334 Chipotle chiles, 248 Chippewa Indians. see Ojibwa Indians Chirashisushi, 343 Chocolate, 152, 494 Choctaw Indians, 107 Chorizo, 162 Chouriço, 163 Christian Palestinians. see Middle Easterners Christianity, 89–94, 212, 454. see al so Eastern Orthodox Christianity; Protestantism; Roman Catholicism Christmas, 152–153, 168, 189–192, 202–203, 222, 251, 293, 390–391 Chucula, 307 Chundo Kyo, 352 Church of England, 143 Churrascaria rodizio, 310 Churrasco, 310 Chusok, 358 Chutney mango, 510 South African cuisine, 218 Cincinnati chili, 499 Cipaille. see Cipate Cipate, 154 Citrus fruits, 249, 509 Civek, 430 Clambake, 490 Clams, 490, 525 Clotted cream, 146 Coastal India, 462 Coca leaves, 268 Cochon de lait, 154 Cocido, 162 Coconut, 383–384 cream, 383 milk, 215, 217, 383–384, 463 in Native Hawaiians and Pacific Islanders diet, 403, 405 Cod, 490 Coffee, 187, 215, 266, 388 health and, 432 Cognac, 149 Coining, 48 Colby cheese, 497 Cólera, 263 Coleslaw, 492 Colombia. see South Americans Comida, 167, 250 Communication as action chain, 56 Cheese (C ontinued ) kurutz, 463 Limburger, 186 Manchego, 163 Mozzarella, 165 paneer, 461 Pecorino romano, 165 Pont-l’Évêque, 148 Provolone, 165 queso flameado, 247 Ricotta, 165 sheep, 429 as staple food in Great Britain, 144–146 Tybo, 199 Cheesesteak, 493 Chelo kebab, 433 Cheong-po, 355 Cherokee Indians, 107, 111, 113, 116, 124 Cherries, 497 Cheshm-i-bad, 425 Chestnut bread, 124 Cheyenne Indians, 117 Chianti, 165 Chicanos. see Mexicans Chicha, 308 Chichimecs, 246 Chickasaw Indians, 107 Chicken Bogatá chicken stew, 308 in cuisine of China, 328 gallina rellena Navidena, 267 in Japanese cuisine, 345 Kiev, 185 in Midwestern American cuisine, 501 in Native Hawaiians and Pacific Islanders diet, 403 in Northeastern American cuisine, 492 in Pakistani cuisine, 459 relleno, 381 in slave diet, 218 in Southern American cuisine, 507 in tomato sauce, 267 in West African cuisine, 215 Chickpeas, 428 Chilaca chiles, 248 Chile. see South Americans Chile colorado, 253 Chile peppers, 524 Chili Cincinnati, 499 con carne, 253 Chili peppers, 248, 307 Chimichangas, 253 Chin-chins, 215 Chinese, 319–340 adaptations of food habits, 335–336 coleslaw, 492 contemporary food habits in United States, 335–340 counseling, 338–340 in cuisine of Central Europe and former Soviet Union, 173 cultural perspective, 320–325 daily patterns of meals, 331–332 demographics and socioeconomic status, 321–322 etiquette, 332–333 family, 323 healing therapies, 48 history of, in United States, 320–322 immigration patterns, 320–321 Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 I N D E X 5 5 3 Spaniards, 158–159 Swiss, 179 Ukrainians, 179 Western Americans, 518 Desayuno, 167, 250 Desserts in cuisine of central Europe and FSU, 187 in cuisine of Germany, 190 in cuisine of Scandinavia, 201 in cuisine of Slovakia, 190 in Midwestern American cuisine, 500, 502 in Northeastern American cuisine, 491 in Pakistani cuisine, 459 in Southern American cuisine, 510 in Western American cuisine, 524 Dewberry pie, 513 Dhal, 457 Dharma, 101 Día de los Reyes Magos, 250 Día de los Santos Reyes, 250 Día del campo, 293 Diabetes mellitus, 128, 195 Africans, 224 Asian Indians, 456, 473 Asians, 337 Filipinos, 395 Gypsies, 195 herbal remedies, 268 Japanese Americans, 350 Mexican remedies for, 252 Middle Easterners, 442–443 Native Americans, 128 Native Hawaiians and Pacific Islanders, 407–408 Northeastern Americans, 494 Pakistanis, 474 soursop leaves as treatment for, 304 South Americans, 312 theories of, 129 type 2 ( S ee Type 2 diabetes mellitus) Días de los Muertos (Days of the Dead), 251 Dietary Guidelines for Americans 2010, 7 Dietary Supplement Health and Education Act (DSHEA) (1994), 47 Digger Indians, 120 Dim sum, 331 Direct communication, 36, 68 Dirty rice, 154 Disease, illness and sickness. see al so Alcoholism; Cardiovascular disease; Coronary heart disease; Diabetes mellitus; Heart disease becoming sick, 43 cultural definitions of, 42–46 etiology of, 43–44 folk illnesses, 45–46 healing practices, 46–50 kidney, 128 in Native Americans, 128 natural world, 44 patient, 43 social world, 44–45 supernatural world, 45 Diversity Canadian population, 19–20 U.S. population, 19 Dobosch torte, 187 Dominicans demographics and socioeconomic status, 281 family, 283 history of, in United States, 280 family, 181 immigration patterns, 176–177 religion, 180 D Dahi, 459 Daikon, 345 Daily patterns of meals Africans, 221–223 Caribbean Islanders, 291–293 Central Europeans and people of former Soviet Union, 187–189 Chinese, 331–332 Japanese, 347 Koreans, 357–358 Mexicans, 250, 255 Native Americans, 120–121 Native Hawaiians and Pacific Islanders, 405 Northern Europeans, 151–153 Scandinavians, 201–202 South Americans, 310 Southeast Asians, 389–390 Southern Europeans, 166–167 Dairy products. see Cheese; Milk Dakota Indians, 109–110, 112, 117, 120, 124–125 Dal in Asian Indian diet, 457–458, 463 in South American cuisine, 309 Danes. see Scandinavians Dashi, 346 Days of the Dead. see Días de los Muertos De arbol chiles, 248 Demerara sugar, 309 Demographics and socioeconomic status Africans, 211–212 Armenians, 179 Asian Indians, 452 Austrians, 178 British, 142 Central Americans, 261–262 Central Europeans and people of former Soviet Union, 178–180 Chinese, 321–322 Czechs, 179 French, 142–143 Germans, 178 Gypsies, 179 Hungarians, 179 Irish, 142 Italians, 158 Japanese, 340–341 Koreans, 352–333 Lithuanians, 179 Mexicans, 239 Middle Easterners, 419–420 Midwestern Americans, 496 Northeastern Americans, 485–487 Northern Europeans, 142–143 Pakistanis, 452–453 people of Balkans, 419 Poles, 178 Portuguese, 159 Russians and people of former Soviet Union, 179–180 Scandinavians, 198 Slovaks, 179 Southern Americans, 504–505 Southern Europeans, 158–159 Central Europeans and people of former Soviet Union, 195–196 in-depth interview, 69–71 Koreans, 361–362 Mexicans, 259–261 Middle Easterners, 443–445 Native Americans, 129–133 Native Hawaiians and Pacific Islanders, 408–409 northern Europeans, 156–157 Pakistanis, 476 people of Balkans, 443–445 preparation, 69 South Americans, 312–314 Southeast Asians, 396–399 southern Europeans, 170 Country Captain Chicken, 509 Couscous, 165–166 Cow peas, 215 Cozinha baiana, 309 Crabs, 508, 526 Crack seed, 406 Cracklings, 154 Cranberries, 491 CRASH, 66 Crawfish, 515 Cream clotted, 146 crème fraîche, 149 double, 146 fleurette, 149 Creek Indians, 107, 113, 116, 125 Crèma Dania, 199 Crème fraîche, 149 Creole cuisine, 512 Creton, 154 Croatians. see Balkans, people of Croissants, 151 Crow Indians, 117, 120 Cuban sandwiches, 510 Cubans demographics and socioeconomic status, 280 family, 282 history of, in United States, 280 Culatello, 164 Cultural competency diversity in Canadian population, 19–20 diversity in U.S. population, 199 ethnicity and health, 20–22 Cultural Food Practices (Goody and Drago), 124, 132 Cultural identity, food as, 4–6 Cultural imposition, 37 Culture acculturation of food habits, 6–7 acculturation process, 6 communication in low-and high-context, 58–60 definition of, 6 Cupping, 49, 380, 425 Curaçao, 516 Curanderos/curanderas, 241, 260, 263, 304 Curanto, 306 Curry in Asian Indian diet, 463 in South American cuisine, 309 in West African cuisine, 215 Cuzcuz paulista, 310 Czechs demographics and socioeconomic status, 179 Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 5 5 4 I N D E X demographics and socioeconomic status, 373 etiquette, 390 family, 375–376 meal composition and cycle, 389 nutritional intake, 395 religion, 374 special occasions, 390–392 staples, 380–384 therapeutic uses of food, 392 traditional health beliefs and practices, 377–378 Filo, 426 Finns. see Scandinavians Fireek, 426 Fish Buddhism and, 104 chips and, 144 in coastal Indian cuisine, 462 Eastern Orthodox Christianity and, 90–91 fermented paste of, 383 fermented sauce of, 355, 387 in German cuisine, 186 halal, 97 Hinduism and, 102 Kashrut/Kosher dietary laws and, 82, 84–86 in Korean cuisine, 355 in Native Hawaiians and Pacific Islanders diet, 403 in Northeastern American cuisine, 490 in Portuguese cuisine, 163 in Scandinavian cuisine, 199 in Southern American cuisine, 513–515 in West African cuisine, 215 in Western American cuisine, 525 Flan, 245, 510 Flank steak, 308 Flautas, 245 Flavor principles, 8–10 Fleurette, 149 Flummeries, 489 Flushing, 378 Folk illnesses, 45–46 Folk religions, 282 Food. see al so Hot-cold classifications of foods; Ingredients and common foods; Therapeutic uses of food availability, 12–13 cultural identity and, 4–6 culture and, 1–33 definition of, 1–2 edible/inedible, 13 indigenous, 112–113, 285–286 introduced from Europe, 113–114 religion and, 82–105 role in African American society, 223 role in Indian society, 467–468 role in Mexican society, 251 role in Native American culture, 121–122 as self-identity, 2–3 soul, 224 status, 5 symbolic use of, 3, 117 sympathetic quality of, 42 taste and, 14–15 women and, 467 Food and Drug Administration (FDA), 47 Food choice adolescents and, 17 advertising and, 16 convenience and, 15 Etiquette Asian Indians, 467–468 Caribbean Islanders, 293 Central Americans, 267 Central Europeans and people of former Soviet Union, 189 Chinese, 332–333 Japanese, 347–348 Koreans, 357 Native Americans, 121–122 Native Hawaiians and Pacific Islanders, 405 northern Europeans, 152 role of food in African American society and, 223 role of food in Mexican society and, 251 Scandinavians, 202 South Americans, 311 Southeast Asians, 390 southern Europeans, 167–168 Étouffées, 512, 515 Europeans. see Northern Europeans; Southern Europeans Evaluation, 77 Evangelical Lutheran Church in America, 198 Evaporated milk, 383 Evil eye. see Mal de ojo Eye contact, 63–64 F Facial expressions, 63 Faith healers, 182 Fallen fontanel. S ee Caida de la mollera (fallen fontanel) Family Africans, 212 Asian Indians, 454–455 Caribbean Islanders, 282–283 Central Americans, 263 central Europeans and people of former Soviet Union, 181–183 Chinese, 323 Japanese, 341–342 Koreans, 352–353 Mexicans, 240 Middle Easterners, 422–423 Native Americans, 111 Native Hawaiians and Pacific Islanders, 401 Northern Europeans, 143–144 Pakistanis, 455 people of Balkans, 421–422 Scandinavians, 198 South Americans, 303 Southeast Asians, 375–377 Southern Europeans, 159–160 Fasching, 191 Fasting, 10–11 Fatique, 284 Fatout, 433 FDA. see Food and Drug Administration Feasting, 102–103, 466 Febles, 284 Feijoa, 526 Feijoda completa, 309 Fen, 330 Feta, 429 Fettucine Alfredo, 165 Filé powder, 219 Filipinos adaptations of food habits, 392 counseling, 396–397 daily patterns of meals, 389 Doro wat, 216 Double cream, 146 Dried rattlesnake powder, 260 Dried rice noodles, 384 Dried salt cod, 309. see al so Bacalhau Drunken pudding, 253 DSHEA. see Dietary Supplement Health and Education Act Duan wu, 334 Duck, 328 Dukkha, 103 Dulse, 147 Dum, 459 Dumplings in Balkan cuisine, 426 in cuisine of Central Europe and former Soviet Union, 183, 185 in cuisine of China, 328 metamgee, 309 in Middle Eastern cuisine, 426 in Scandinavian cuisine, 201 in sopa de rosquillas, 267 Dungeness crab, 526 Duong, 392 Dussehra, 466 Dyslipdemia, 258 E East Africa, 217 East Asians, 319–369 Chinese, 319–340 Japanese, 340–351 Koreans, 351–362 Easter, 152–153, 168, 189–192, 391, 438–439 Eastern Orthodox Christianity, 90–91, 111, 181, 420, 421 Ecuador. see South Americans Edamame, 346 Edible foods, 13 Eggplant, 428 Eggs and childbirth, 441 in cuisine of China, 328 in Native Hawaiians and Pacific Islanders diet, 403 in Spanish cuisine, 162 Eid al-Adha, 439 Eid al-Azha, 98, 467 Eid al-Fitr, 98, 439, 466 Eintopf, 186 El Salvador. see Central Americans Electrotherapy, 49 Emancipation, of Africans, 210–211 Empacho, 242, 260, 283 Empadinhas, 306 Empanadas, 264, 306 En papillote, 512 Enchiladas, 245, 253, 255, 264 Enryo, 341 Enslavement, of Africans, 210 Epazote, 524 Eritrea, 215–217 Escargot, 149 Eskimos. see Inuit Indians Espagnole, 150 Espanto, 241 Espiritos, 284 Ethiopians, 215–217, 228 Ethnocentric, term, 6 Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 I N D E X 5 5 5 demographics and socioeconomic status, 400–401 family, 401 immigration patterns, 400 nutritional intake, 407–408 religion, 401 traditional food habits, 402–406 Guaraná, 310 Guascas, 308 Guatemala. see Central Americans Guava, 335 Gulyás, 186 Gumbo z’herbes, 219 Gumbos, 155, 512 Guyana. see South Americans Gypsies demographics and socioeconomic status, 179 family, 181 religion, 180 therapeutic uses of food, 192 traditional health beliefs and practices, 183 H Habañero chiles, 248 Haggis, 152 Haitians. see Caribbean Islanders Haji, 341 Hakka cuisine, 331 Halal dietary laws, 96–97, 216, 459 food symbols, 97 Hallacas, 306 Halo-halo, 383 Haloumi, 429 Han, 354 Hanui, 354 Hanukkah, 87 Hanyak, 354 Hard cider, 491 Hasenpfeffer, 185 Hasty pudding, 489 Havarti, 199 Havasupai Indians, 123, 127 Hawaiian bread, 403 Hawaiians contemporary food habits in United States, 406–410 demographics and socioeconomic status, 400 family, 401 immigration patterns, 399 nutritional intake, 407–408 religion, 401 traditional food habits, 402–406 traditional health beliefs and practices, 402 Western American cuisine and, 528 Hazelnuts, 526 Headcheese, 492 Healing therapies, 47–50. see al so Therapeutic uses of food; Traditional health beliefs and practices administration of therapeutic substances, 47–48 application of physical forces or devices, 48–49 Chinese, 48 magico-religious interventions, 49–50 French Americans, 143, 153–154 French bread, 150, 264 French Canadians, 143–144 Fricot, 154 Frijoles refritos, 243 Frikkadels, 218 Frittata, 217 Fritters, 309 Frog legs, 219 Fruits citrus, 249, 509 in Middle Eastern cuisine, 429 in Northeastern American cuisine, 491 in Spanish cuisine, 163 in Western American cuisine, 526 FSU. S ee Former Soviet Union (FSU), people of Fufu, 215 Ful medames, 433 G Gai lan, 328 Gallina rellena Navidena, 267 Gallo pinto, 264 Gaman, 341 Game meats, 249, 511, 513, 520 Gari foto, 215 Garlic, 162, 441 Gatorade, 268 Gaz, 284 Gelatin, 42 Gender, eating habits and, 17 Geoduck clams, 525 Germans demographics and socioeconomic status, 178 family, 181 immigration patterns, 175–176 religion, 180 therapeutic uses of food, 192 traditional health beliefs and practices, 182 Gestures, 63 Ghee, 457, 459 Gin, 147, 499 Ginseng, 334–335, 355, 357 Gnocchi, 165 Goat, 249, 459 Gohan, 343 Goi go, 387 Goldwasser, 187 Goose, 185 Goose fat, 148 Gorgonzola, 164 Great Britain. see al so British cooking styles, 150 ingredients and common foods of, 144–147 meal composition and cycle, 151, 154–155 special occasions, 152 staples and regional variations, 144–147 Great Plains Native Americans, diet of, 117 Greek Orthodox Church, 420–421 Greeks. see Balkans, people of Green tea, 329 Greens, 219 Grissini, 164 Grunts, 489 Guacamole, 248 Guajillo chiles, 248 Guamanians contemporary food habits in United States, 407–408 cost and, 15 ethnic identity and, 16 health and, 17 older adults and, 17 physical and spiritual well-being and, 16–17 self-expression and, 15–16 self-identity and, 16 taste and, 14–15 Food habits. see al so Adaptations of food habits; Contemporary food habits in United States; Traditional food habits acculturation of, 6–7 American paradox, 23–28 consumer food choice model, 13–18 core and complementary foods model, 7–8 cultural, 7–12 cultural competency, 18–22 definition of, 1 developmental perspective of food culture, 11–12 flavor principles, 8–10 food availability, 12–13 health-promoting, 41–42 individual, 12–18 influence from children, 261 meal patterns and meal cycles, 10–11 nutrition and, 18–23 taste and, 14–15 in United States, 24–27 yin-yang diet theory, 41 Food processing, 497 Former Soviet Union (FSU), people of, 174–207 adaptations of food habits, 192–194 contemporary food habits in United States, 192–196 cultural perspective, 175–183 demographics and socioeconomic status, 179–180 etiquette, 189 family, 181–182 history of, in United States, 175–180 ingredients and common foods of, 183–187 meal composition and cycle, 187–192 nutritional status, 194–196 religion, 180–181 staples and regional variations, 183–187 therapeutic uses of food and, 192 traditional food habits, 183–192 traditional health beliefs and practices, 182–183 worldview, 180–183 France. see al so French cooking styles, 150 etiquette, 152 ingredients and common foods of, 147–150 meal composition and cycle, 151–152, 155 special occasions, 152–153 staples and regional variations, 147–150 Franco-Americans. see French Americans Frankfurter, 186 French. see al so France adaptations of food habits, 153–154 demographics and socioeconomic status, 142–143 family, 143–144 immigration patterns, 141–142 nutritional status, 155–156 religion, 143 traditional health beliefs and practices, 144 Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 5 5 6 I N D E X people of Balkans, 426–434, 441–442 South Americans, 304–310 Southeast Asians, 380–389 Southern Europeans, 160–166 Injera, 216 Insects, 214, 328 Integrative medicine, 34 Interpreters, use of, 68–69 Inuit Indians, 14, 107, 112, 119, 124, 127 Inupiat Indians, 119 Iranians. see Middle Easterners Iraqis. see Middle Easterners Ireland. see al so Ireland; Irish cooking styles, 150 ingredients and common foods of, 144–147 special occasions, 152 Irish adaptations of food habits, 153 demographics and socioeconomic status, 142 family, 143 immigration patterns, 141 meal composition and cycle, 151, 154–155 nutritional status, 155–156 religion, 143 traditional health beliefs and practices, 144 Iroquois Indians, 107, 112–114, 121, 125 Isca de figado, 163 Islam, 94–98 Africans, 212 Asian Indians and, 453 fast days, 98 feast days, 98 halal dietary laws, 96–97 halal food symbols, 97 Islamic Food and Nutrition Council of America (IFNCA), 97 Israelis. see Middle Easterners Issei, 341 Italians. see al so Italy demographics and socioeconomic status, 158 family, 159 immigration patterns, 157 religion and, 159 traditional health beliefs and practices, 159 Italy. see al so Italians etiquette, 167 foreign influence, 160, 162 meal composition and cycle, 166–167 regional variations, 164–166 staples, 162 Iyar, 440 J Jainism, 453 Jalapeño chiles, 248, 524 Jamaicans. see Caribbean Islanders Jambalayas, 153, 512 Jansson’s frestelse, 199 Japanese, 340–351 adaptations of food habits, 348–349 contemporary food habits in United States, 348–351 counseling, 350–351 cultural perspective, 340–343 daily patterns of meals, 347 demographics and socioeconomic status, 340–341 etiquette, 347–348 Hot-cold classifications of foods in Ayurvedic medicine, 456 for Caribbean Islanders, 284, 294 for Central Americans, 263, 268 definition of, 41 for Mexicans, 252 Pakistanis, 469 for South Americans, 311 Hot cross buns, 152 Hougans, 284 Hua diao, 330 Huachinango, 246 Huachinango a la Veracruzana, 248 Huascas, 308 Human equality, 38 Humitas, 306 Hummus, 428 Hungarian Americans. see Hungarians Hungarians demographics and socioeconomic status, 179 family, 181 immigration patterns, 177 religion, 180 Hunger, 21 Hwabyung, 354 Hydrotherapy, 49 Hypertension African Americans, 228 Asian Indians, 473 Chinese Americans, 337 Filipinos, 395 Koreans, 361 Mexican Americans, 258 Mexicans, 254 I Ialorixá, 304 Ibimi, 491 Iceberg model, 56–57 Ichiju issei, 347 Ichiju sansei, 347 IFNCA. see Islamic Food and Nutrition Council of America Iftar, 439 IHS. see Indian Health Service Ikura, 343 Imam bayildi, 428 Imperial caviar, 186 Imu, 403 India. see Asian Indians Indian Health Service (IHS), 129 Indian pudding, 489 Indirect communication, 36 Inedible foods, 13 Influence channels, 76 Ingredients and common foods Africans, 214–221, 224–225 Asian Indians, 457–464, 470–471 Caribbean Islanders, 285–291, 295–296 central Europeans and people of former Soviet Union, 183–187 Chinese, 325–331, 335–336 Japanese, 343–347 Koreans, 354–357, 359–360 Mexicans, 242–250 Middle Easterners, 426–434, 441–442 Native Americans, 112–120 Native Hawaiians and Pacific Islanders, 403–405, 406–407 Northern Europeans, 144–151 Pakistanis, 457–464, 472 Health, 111–112. see al so Traditional health beliefs and practices attributes, 39 body image, 40 cultural definitions of, 39–40 disease, illness and sickness, 42–50 ethnicity and, 20–22 food choice and, 17 habits, 40–41 maintenance, 40–42 meaning of, 39 Health care biomedical healing, 50–51 interaction between provider and client, 64–65 medical pluralism, 50 responsibilities of provider, 66 role of communication in, 64–66 Health-promoting food habits, 40–42 Healthy Eating Index (HEI), 256 Heart disease. see al so Coronary heart disease black nightshade and, 456 Chinese Americans, 337 French paradox, 144 Irish Americans, 155 Native Americans, 128 Vietnamese, 395 Heating, 378 HEI. see Healthy Eating Index Hemochromatosis, 156 Herbal remedies, 259, 268 Herbalists, 263 Herring, 186 Hershey’s Kisses, 494 Hibiscus, 268 Hierbabuena, 268 High blood, 223 High-context cultures nonverbal communication and, 62 verbal communication and, 58–60 High Holy mayonnais, 512 High priest, 304 High priestess, 304 High tea, 151 Hijiki, 346 Hima’a, 403 Himmel und Erde, 186 Hinduism, 98–103 Asian Indians and, 453 dietary practices, 101–102 fast days, 103 feast days, 102–103 Gypsies and, 180 Hmong, 376–377, 379–380, 393, 396, 397–399 Hoisin sauce, 330 Hoja santa, 249 Holi, 466 Holidays. see Special occasions; spec if ic h ol iday s Hollandaise, 150 Holy Ghost Festival, 168 Holy Ghost soup, 169 Holy Week, 168 Homeopathy, 48 Honan, 330 Honduras. see Central Americans Honey, 216, 260 Hoodoo, 213 Hopi Indians, 110, 117, 122, 124 Horseradish, 497 Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 I N D E X 5 5 7 Laver, 147, 355 Laws of Manu, 101 Lebanese. see Middle Easterners Lebanon bologna, 493 Lebneh, 429 Lefse, 201 Legumes, 215, 428 Lentils, 428 Lepinja, 431 Limes, 248, 509 Lingonberries, 201 Lithuanians, 178 demographics and socioeconomic status, 179 family, 182 llapingachos, 307 religion, 181 Lobster, 490 Lokum, 433 Lomi-lomi, 403 Low blood, 223 Low-context cultures nonverbal communication and, 62 verbal communication and, 58–60 Lutheran, 198 M Madeira, 166 Mäe-de-santo, 304 Magga, 103 Magico-religious interventions, 49–50 Maguey cactus, 247 Mahayana Buddhism, 104 Mahleb, 429 Makisushi, 343 Mal de ojo (evil eye), 44, 242, 252, 260, 263, 283, 425 Malagueta, 309 Maltash, 463 Manchego, 163 Manger mort, 284 Mango seeds, 215 Mangoes, 266, 510 Manju, 347 Mansaf, 433 Mansin, 354 Manzanilla, 268 Maple syrup cherries stewed with, 116 dried beans and, 114, 116 French American use, 154 Native American use, 107, 113 in Northeastern American cuisine, 487, 491 wild rice and, 117 Mardi Gras, 153, 155 Marketing mix, 76–77 Marsala, 165 Märzenbier, 187 Marzipan, 160, 190, 201 Mashbooh, 97 Massa sovoda, 169 Massage, 380 Matambre, 307–308 Maté, 308 Materialism, 38 Matzah, 88 Maultaschen, 185 Maulud n’Nabi, 98 Mayans, 264 Mead, 187 Kokum sharbat, 462 Kombu, 345–346 Königsberger Klopse, 185 Kool-Aid, 268 Kool sla, 492 Koreans, 351–362 adaptations of food habits, 359–360 contemporary food habits in United States, 359–362 counseling, 361–362 cultural perspective, 352–354 demographics and socioeconomic status, 352 etiquette, 357 family, 352–353 history of, in United States, 352 immigration patterns, 352 ingredients and common foods, 354–357, 359–360 meal composition and cycle, 357–358 nutritional intake, 360–361 nutritional status, 360–362 religion, 352 special occasions, 357–358 staples, 355–357 therapeutic uses of food, 358 traditional food habits, 354–358 traditional health beliefs and practices, 353–354 worldview, 352–354 Korma, 459 Koroshi, 343 Kosher. see Kashrut/Kosher dietary laws Kranbeere, 491 Kransekake, 201 Krsna Slava, 439 Kudzu, 343 Kukuye sabzi, 440 Kurban Bayram, 439 Kurutz, 463 Kvass, 187, 192 Kwakiutl Indians, 119 Kwanzaa, 222 L Labni, 429 Lager, 187 Lakota Indians, 110, 126 Lamb in Greek American cuisine, 441 in Iranian cuisine, 433, 434 in Pakistani cuisine, 459 as staple food in Great Britain, 144 as staple food of Native Americans, 113–114 Lambropsomo, 438 Lamprey, 163 Laotians adaptations of food habits, 393–394 demographics and socioeconomic status, 374 family, 376–377 immigration patterns, 373 nutritional intake, 396 religion, 375 special occasions, 391 staples, 384–389 traditional health beliefs and practices, 379 Latinos. see Mexicans Lavash, 426 family, 341–342 history of, in United States, 340–341 immigration patterns, 340 ingredients and common foods, 343–347 meal composition and cycle, 347–348 nutritional intake, 349–350 nutritional status, 349–351 regional variations, 343–347 religion, 341 special occasions, 348 staples, 343–347 therapeutic uses of food, 348 traditional food habits, 343–348 traditional health beliefs and practices, 342–343 worldview, 341–343 Jarlsberg, 199 Jeberos, 263 Jicama, 304 Jing, 324 Jinn, 425 Judaism, 83–89 fast days, 89 holidays, 86–89 immigration to United States, 84 Kashrut/Kosher dietary laws, 84–86 nutritional status, 89 K Kabobs, 429 Kabocha, 346 Kajmak, 431 Kalonji, 462 Kam kuhn, 424 Kanpo, 342 Kanpo-i, 342 Kanya, 215 Kapha, 468 Kappamaki, 343 Karaoke, 348 Karma, 103 Kaseri, 429 Kashkaval, 429 Kashrut/Kosher dietary laws, 84–86 Katsu, 346 Kava, 406 Kawali, 381 Kelp, 355 Kenya, 217 Key lime pies, 511 Khat, 466 Khella, 425 Khichri, 459 Khoresh, 428 Ki, 353 Kibbeh, 433 Kiddush, 440 Kidney disease, 128 Kielbasa, 186 Kim, 355 Kimchi, 355 Kinilaw, 383 Kitchen God, 333 Knockwurst, 186 Kobe beef, 345 Kocho, 216 Kochujang, 355 Koeksister, 218 Kofta, 429 Ko’hl, 424, 445 Koko, 341 Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 5 5 8 I N D E X Moroccan cooking, 436. see al so Middle Easterners Mortadella, 164 Moussaka, 428 Mozzarella, 165 Mudang, 354 Muharram, 439 Muktuk, 119 Mulato chiles, 248 Mullet, 403 Mung beans, 355 Musaka, 428 Mushrooms, 329 Muslims. see Islam Mutton, 218, 329, 459 Myzithra, 429 N Nabemono, 346–347 Nactamal, 264 Naharati qalb, 424 Nam pa, 387, 389 Name traditions, 67 Narahati, 424 Native Americans adaptations of food habits, 123–125 body image and, 40 contemporary food habits, 123–133 counseling of, 129–133 cultural perspective, 97 current demographics of, 108–109 daily patterns of meals, 120–121 family, 111 Great Plains, diet of, 117 history of, 107–110 ingredients and common foods of, 112–120 meal composition and cycle, 120–121 Northeastern, diet of, 114–116 Northwest Coast/Alaska, diet of, 118–120 nutritional status, 126–133 organizations, 110 overweight and obesity among, 127 regional variations, 114–120 religion, 110–111 role of food in culture and etiquette, 121–122 self-identity and, 2 settlement patterns of, 107–108 socioeconomic status of, 109–110 Southern, diet of, 116 Southwestern, diet of, 117–118 special occasions, 121 therapeutic uses of food, 122 Western American cuisine and, 523–524 worldview, 110–112 Native Hawaiians and Pacific Islanders (NHPIs), 399–409 adaptations of food habits, 406–407 contemporary food habits in United States, 406–410 counseling, 408–409 cultural perspective, 399–402 demographics and socioeconomic status, 400–401 etiquette, 405 family, 401 history of, in United States, 399–402 immigration patterns, 399–400 ingredients and common foods, 403–405, 406–407 meal composition and cycle, 405–406, 407 nutritional status, 256–261 regional variations, 246–250 religion, 239–240 role of food and etiquette, 251 Spanish contributions, 243 special occasions, 250–251, 255–256 staples, 243–246 therapeutic uses of food, 252 traditional food habits, 242–252 traditional health beliefs and practices, 241–242 worldview, 239–242 Middle Easterners, 416–449 adaptations of food habits, 441–442 contemporary food habits in United States, 441–445 cultural perspective, 416–425 daily patterns of meals, 434–437 demographics and socioeconomic status, 419–420, 496 etiquette, 437–438 family, 422–423 health concerns, 503 history of, in United States, 418 ingredients and common foods, 426–434 meal composition and cycle, 434–441 Midsummer’s Day, 203 Midwestern Americans, 495–503 nutritional intake, 442–443 nutritional status, 442–445 people of Balkans and, 416–449 regional profile, 495–496 regional variations, 432–434 religion, 421 special occasions, 438–440 staples, 426–430 therapeutic uses of food, 440–441 traditional fare, 496–503 traditional food habits, 425–441 traditional health beliefs and practices, 424–425 worldview, 421 Milk African Americans, 226 in Balkan cuisine, 429 camel, 217 coconut, 217 consumption by Chinese Americans, 335 evaporated, 383 food habits, 42 Mexicans, 255 in Middle Eastern cuisine, 429 in Midwestern American cuisine, 497 in Scandinavian cuisine, 201 whole, 254 Millet, 215 Mincemeat pies, 152, 490 Mint, 268 Mint julep, 514 Mirin, 345 Mirleton, 513 Miso, 345–346 Misoshiru, 346 Mississippi mud pie, 513 Miwok Indians, 120, 124 Mixtas, 264 Mizuna, 345 Mochi gashi, 347 Moksha, 101 Moles, 248 Morilla, 162 Mormons, 93–94 Meals Africans, 221–225 Asian Indians, 471–472 Caribbean Islanders, 291–293, 296 Central Americans, 266–267 Central Europeans and people of former Soviet Union, 187–192 Chinese, 331–334 Japanese, 347–348 Koreans, 357–358, 360 Mexicans, 250–251, 255–256 Middle Easterners, 434–442 Native Americans, 114–121 Native Hawaiians and Pacific Islanders, 405, 407 northern Europeans, 151–153 Pakistanis, 472 patterns and cycles, 10–11 people of Balkans, 434–442 portion size of, 10 Scandinavians, 201–203 South Americans, 310–312 Southeast Asians, 389–392 southern Europeans, 166–169 Meat Buddhism and, 104 in cuisine of Central Europe and former Soviet Union, 185 Eastern Orthodox Christianity and, 90–91 halal, 97 Hinduism and, 101 indigenous, 304 Kashrut/Kosher dietary laws and, 84–86 in Mexican cuisine, 249–250 Mormons, 93 in Northeastern American cuisine, 489 prohibitions, 96, 99 Roman Catholicism and, 90 in Scandinavian cuisine, 199–201 Seventh-Day Adventists, 94 in Southern American cuisine, 511–513 Media noche, 390 Medical pluralism, 50 Medicine men/women. see Shamans Mediterranean diet, 442 Melons, 509 Membillo, 163 Merienda, 167, 250 Mescal, 243 Metabolic syndrome, 258, 312, 473–474 Metamgee, 309 Metaxia, 430 Metheglyn, 147 Mexican-Americans, 258 diabetes mellitus type 2 in, 258 immigrant experience of, 257 Mexicans, 237–261 Aztec food, 242–243 contemporary food habits in United States, 252–261 counseling, 259–261 cultural perspective, 238–242 daily patterns of meals, 250, 255 demographics and socioeconomic status, 239 family, 240 history of, in United States, 238–239 immigration patterns, 238–239 ingredients and common foods of, 242–250 meal composition and cycle, 250–251, 255–256 nutritional intake, 256–261 Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 I N D E X 5 5 9 Filipinos, 395 France, 145 Italy, 170 Japanese Americans, 349 Koreans, 361 Mexicans, 258 Middle Easterners, 442 Native Americans, 127 Native Hawaiians and Pacific Islanders, 407 Northeastern Americans, 494 people of Balkans, 442 Portugal, 170 Scandinavians, 204 South Americans, 312 Southern Americans, 517 Spain, 170 Western Americans, 530 Object messages, 58, 64, 69 Obsessive-compulsive disorder, 224 Ocopa, 307 Offal, 150 Og bono, 215 Ojibwa Indians, 122 Okra, 225 Oktoberfest, 187, 189 Old clothes, 308 Olive oil, 162, 428, 441 Olives, 162, 428 Omnivore’s paradox, 2, 17 Ong Tao, 391 Oolong tea, 329 Oplatky, 191 Oranges, 509 Orixá, 304 Orthodox, 421 Orthodox Church in America, 181 Osso buco, 164 Ouzo, 430, 437 Overweight. see Obesity/overweight Oyakodon, 347 Oyatsu, 347 Oysters, 491, 501, 508, 515–516, 525 Oysters Rockefeller, 516 P Pa dek, 387, 389 Paan, 465–466 Pacha, 433 Pachamanca, 306 Pacific Islanders. S ee Native Hawaiians and Pacific Islanders (NHPIs) Padecer de los nervios, 283 Pai-de-santo, 304 Painted rooster, 264 Paiute Indians, 111 Pakistanis, 450–482 adaptations of food habits, 472 contemporary food habits in United States, 470–476 counseling, 476 cultural perspective, 450–456 demographics and socioeconomic status, 452–453 family, 455 history of, in United States, 450–453 immigration patterns, 452 ingredients and common foods, 457–464 meal composition and cycle, 465–466 nutritional intake, 474 nutritional status, 474, 476 regional variations, 463 family, 143–144 history of, in United States, 140–143 immigration patterns, 140–142 ingredients and common foods of, 144–151 meal composition and cycle, 151–153 northern Europeans, 144 nutritional status, 155–157 religion, 143 therapeutic uses of food, 153 traditional food habits, 144–153 worldview, 143–144 Northern India, 459, 461–462 Northwest Coast/Alaska Native Americans, diet of, 118–120 Norwegian flatbrød, 201 Norwegians. see Scandinavians Nuoc mam, 387 Nutrition cultural competency, 18–22 food habits and, 18–23 intercultural, 22–23 intercultural assessment, 71–73 Nutrition education comic bopoks as, 271 developing message, 75–76 evaluation, 77 goals and objectives, 74–75 identification of target audience, 74 implementation strategies, 76–77 influence channels, 76 intercultural, 73–77 marketing mix, 76–77 program preparation, 74–76 triangulation, 75 Nutritional status Africans, 225–230 Asian Indians, 472–476 Central Americans, 269–271 Central Europeans and people of former Soviet Union, 194–196 Chinese, 336–34 Judaism, 89 Koreans, 360–362 Mexicans, 256–261 Middle Easterners, 442–445 Native Americans, 126–133 Native Hawaiians and Pacific Islanders, 407–409 northern Europeans, 155–157 Pakistanis, 474–476 people of Balkans, 442–445 Scandinavians, 203–204 South Americans, 312–314 Southeast Asians, 395–399 southern Europeans, 169–170 Nutritional therapy, 48 Nuts, 304 O O sonae mochi, 348 Oatmeal breakfast meal in Great Britain, 151 health benefits of, 42 Obesity/overweight rate, 21 African Americans, 227 Asian Indians, 472–473 Central Americans, 269 Central Europeans and people of former Soviet Union, 194 Chinese, 337 Chinese Americans, 336–337 nutritional intake, 407–408 nutritional status, 407–409 religion, 401 role of food, 405–406 special occasions, 405 staples, 403–405 therapeutic uses of food, 406 traditional food habits, 402–406 traditional health beliefs and practices, 401–402 worldview, 401–402 Naturopathic medicine, 48 Nau-Roz, 98, 440 Navajo bananas, 118 Navajo Indians contemporary food habits of, 124 counseling of, 131–132 diet of, 117–118 foods introduced from Europe and, 114 meal composition and cycle of, 124 nutritional status, 127 religion and, 110 socioeconomic status of, 110 therapeutic uses of food and, 122 traditional health beliefs and practices, 111–112 Nervios, 241, 260, 271, 283 New England boiled dinner, 489 New Mexico, 253 New Zealand fare, 409 Nez Perce Indians, 120 NHPIs. S ee Native Hawaiians and Pacific Islanders (NHPIs) Nicaragua. see Central Americans Nigella seeds, 462 Nigerians, 228 Nigirisushi, 343 Nimono, 346 Nirodha, 103 Nisei, 349 Noche Buena, 293 Nogada, 266 Nonverbal communication, 62–64 eye contact and, 63–64 gesture, facial expression, and posture, 63 among Native Americans, 131 spatial relationships and, 64 touching, 62–63 Noodles, 328 buckwheat, 343 in Filipino diet, 381 in Korean cuisine, 355 rice, 343 Vietnamese, 384 Nori, 346 Northeastern Americans, 485–495 demographics and socioeconomic status, 485–487 health concerns, 494–495 regional profile, 485–487 traditional fare, 487–494 Northeastern Native Americans, diet of, 114–116 Northern Chinese, 330–331 Northern Europeans, 139–171 adaptations of food habits, 153–155 contemporary food habits in United States, 153–157 counseling of, 156 cultural perspective, 140–144 demographics and socioeconomic status, 142–143 Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 5 6 0 I N D E X Prunes, 203 Puddings in Northeastern American cuisine, 489 plum, 150, 152 in Southern American cuisine, 511, 513–514 Pueblo Indians, 108, 110, 117, 122, 125, 523 Puerto Ricans demographics and socioeconomic status, 280–281 family, 282 history of, in United States, 279–280 Pulao, 459 Pulaski Day, 194 Pulla, 201 Pumpkin pie, 153 Purim, 87 Q Qi, 324 Qorma, 459 Quesadillas, 267 Queso flameado, 247 Queso fundido, 247 Quiche Lorraine, 148 Qur’an, 454 R RAFT. see Renewing America’s Food Traditions Rajus, 468 Raki, 430 Ramen, 343 Red beans, 264 Red chile stew. see Chile colorado Red-flannel hash, 489 Red jujubes, 335 Refrescas, 266 Regional Americans, 483–530 Midwestern, 495–503 Northeastern, 485–495 regional divisions, 485 regional food habits, 483–485 Southern, 503–505 Western, 517–530 Religion Africans, 212–214 Animism, 454 Asian Indians, 453–454 Buddhism, 103–105, 323, 341–342, 352 Caribbean Islanders, 282 Central Americans, 263 Central Europeans, 180 Chinese, 322–323 Christianity, 89–94, 212, 454 Chundo Kyo, 352 Confucianism, 322, 352 Eastern, 98–105 Eastern Orthodox Christianity, 90–91, 111, 181, 421 folk, 282 food and, 82–105 Germans, 180 Gypsies, 180 Hinduism, 98–103 Islam, 94–98 Jainism, 453 Judaism, 83–89 Mexicans, 239–240 Pisco, 308 Pita, 426 Pitta, 468 Plantains, 215, 217, 295 Pljeskavica, 431 Plum pudding, 150, 152 Plums, 502 Po’ boy, 516 Poblano chiles, 248, 524 Poles demographics and socioeconomic status, 178 family, 181 immigration patterns, 176–177 religion, 180 therapeutic uses of food, 179 traditional health beliefs and practices, 170 Polo, 428 Pombas, 169 Pomo Indians, 120 Pont-l’Évêque, 148 Ponzu, 346 Pork African American southern staples, 219 in cuisine of Central Europe and former Soviet Union, 185 in cuisine of central Europe and FSU, 185 in cuisine of China, 329 in Filipino diet, 381 in Japanese cuisine, 345 in Mexican cuisine, 249–250 in Midwestern American cuisine, 501 in Native Hawaiians and Pacific Islanders diet, 403 in Northeastern American cuisine, 492 in Pakistani cuisine, 459 pie, 154 prohibitions against, 96, 99 in Southern American cuisine, 506, 512 as staple food in Great Britain, 144 Port wine, 147, 166 Portugal. see al so Portuguese etiquette, 167 meal composition and cycle, 167 regional variations, 166 staples, 163–164 Portuguese. see al so Portugal demographics and socioeconomic status, 159 family, 160 immigration patterns, 158 religion and, 159 Portuguese garlic pork, 309 Portuguese sweet bread, 403 Posadas, 251 Postum, 499 Posture, 63 Potatoes in cuisine of Central Europe and former Soviet Union, 186 in South American cuisine, 304 as staple food in Ireland, 146 in Western American cuisine, 522 Potawatomi Indians, 110 Powhatan Indians, 114 Powwowing, 182 Prahoc, 387 Promesa, 283 Prosciutto, 164 Protection, 378 Protestantism, 91–94, 111, 282 Provolone, 165 Pakistanis (C ontinued ) religion, 454 religious variations, 463–464 special occasions, 467 staples, 459 therapeutic uses of food, 470 traditional health beliefs and practices, 456 worldview, 453–456 Paklava, 426 Palillo, 307 Palm oil, 215 Pamonhas, 306 Pan de sal, 381 Panama. see Central Americans Pancetta, 164 Pancit, 381 Paneer, 461 Papa seca, 307 Pappadams, 463 Paraguay. see South Americans Parmesan cheese, 164 Pasilla chiles, 248 Pasmo, 284 Passover, 87–88 Pasta, 162, 164–165, 308 Pau d’ arco, 304 Pawnee Indians, 117 Peach palm, 266 Peaches, 509–510 Peanuts, 215 Pearl tea, 330 Pears, 527 Pecan pralines, 154 Pecans, 514 Pelmeni, 185 Pennsylvania Dutch, 182 Peppermint candies, 223 Pequin chiles, 248 Perilla, 345 Personal control, 37 Personal messages, 58, 64 Peru. see South Americans Philippines, 370 Pho, 384 Phyllo, 426 Pica, 224, 228 Picanha, 310 Pida, 426 Pierogi, 185 Pies cipate, 154 Cornish pasty, 150 in cuisine of central Europe and FSU, 185 Franco-American, 155 in Northeastern American cuisine, 193, 489–490, 493 peach, 510 pork, 154 pumpkin, 153 in Southern American cuisine, 513 steak and kidney, 150 walnut and raisin, 168 Piki, 118 Pilaf, 426, 428 Pili-pili, 215 Pilsner beer, 187 Pima Indians, 117, 128 Piñatas, 251 Pine nuts, 118, 246 Piñon seeds. see Pine nuts Pinto beans, 511 Pirão, 310 Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 I N D E X 5 6 1 demographics and socioeconomic status, 198 etiquette, 202 family, 198 history of, in United States, 196–198 immigration patterns, 197–198 meal composition and cycle, 201–203 nutritional status, 203–204 religion and, 198 special occasions, 202–203 staples and regional variations, 199–201 traditional food habits, 199–203 traditional health beliefs and practices, 198–199 worldview, 198–199 Schnapps, 187 Schnitzel, 185 Schwarzwälder Kirschtorte, 187 Scotch whisky, 147 Scrapple, 492 Sea pie. see Cipate Seafood in Southern American cuisine, 508, 515 in Spanish cuisine, 162 in Western American cuisine, 525, 530 Seaweed aonoriko, 346 dulse, 147 hijiki, 346 kelp, 355 laver, 147, 355 nori, 346 wakame, 346, 355 Seeb, 440 Seer, 440 Sekeh, 440 Seker Bayram, 439 Self-expression, 15–16 Self-identity food as, 2–3 food selection and, 16 Seminole Indians, 107, 116, 122, 125 Sencotan Indians, 124 Serbet, 430 Serbs. see Balkans, people of Serke, 440 Serrano chiles, 248, 524 Serrano ham, 162 Seventh-Day Adventists, 94 Sezisman, 284 Shab-i-Barat, 98 Shabu shabu, 346 Shamans, 50, 112, 125, 354 Shandong, 330 Sharbat, 430 Shavout, 89 Shawarma, 429 Sheep balls, 215 Sheermal, 461 Shellfish Cajun dishes, 153 in Northeastern American cuisine, 490 Sheng, 324 Sherry, 147, 163 Shiitake, 329, 346 Shintoism, 341 Shiromiso, 345 Shiso, 345, 355 Shoofly pie, 193 Shoshone Indians, 120 Shoyo, 343, 345 Shrewsbury simnel, 152 Russians counseling of, 195–196 demographics and socioeconomic status, 179–180 family, 181–182 immigration patterns, 177–178 religion, 180–181 traditional health beliefs and practices, 182–183 worldview, 180–181 Ryaninjun, 489 Rye, 489 S Sabadores, 263 Sabbath, 86 Sabzi, 440 Sabzu polo, 440 Saewujeot, 355 Saffron custard, 441 Sage tea, 252 Salade Niçoise, 149 Salami, 164 Sally Lunn cake, 510 Salmon, 525 Salmorejo, 166 Salsa de ají, 307 Salteñas, 306 Saltimbocca, 165 Samana, 429 Samanu, 440 Samoans contemporary food habits in United States, 407–408 demographics and socioeconomic status, 400 family, 401 immigration patterns, 399–400 nutritional intake, 407–408 religion, 401 traditional food habits, 402–406 traditional health beliefs and practices, 402 Samovar, 187 Samudaya, 103 Sangria, 163 Sanjed, 440 Sansei, 342, 349 Santería, 282, 284 Santeros, 284 Sardines, 163, 526 Sashimi, 343, 345 Sassafras tea, 153, 223, 514 Sassamanesh, 491 Sattwa, 468 Sauce piquante, 515 Sauerbraten, 185, 492 Sauna, 198 Sausages in German cuisine, 186 in Portuguese cuisine, 163 in Spanish cuisine, 162 Scallops, 491 Scampi, 164 Scandinavians, 196–204 adaptations of food habits, 203 contemporary food habits in United States, 203–204 counseling of, 204 cultural perspective, 196–199 daily patterns of meals, 201–202 Middle Easterners, 421 Native Americans, 110–111 northern Europeans, 143 Pakistanis, 454 people of Balkans, 420–421 Poles, 180 Protestantism, 91–94, 111, 282 Roman Catholicism, 90, 111, 159, 180, 239–240, 282, 302–303 Russians and people of former Soviet Union, 180–181 Scandinavians, 198 Shintoism, 341 Sikhism, 453–454 South Americans, 302–303 Southeast Asians, 374–375 southern Europeans, 159 Taoism, 322–323 Tonghak, 352 traditional food habits, 112–122 Western, 83–98 Zoroastrianism, 180, 454 Remedies, botanical, 47, 260, 380 Renewing America’s Food Traditions (RAFT), 124 Retsina, 430 Rice in Asian Indian diet, 457 basmati, 461 in cuisine of southern China, 328 dried noodles, 384 as foundation of Filipino diet, 381 in Japanese diet, 343, 345 as key ingredient in Cajun cuisine, 154 in Korean cuisine, 355 Luzon, 383–384 noodles, 343 paper, 384 in Southern American cuisine, 509 as staple food in Middle Eastern cuisine, 426, 428 as staple food in Vietnam, 384 tea, 357 in West African cuisine, 215 Ricotta, 165 Rio Grande Pueblos, 110 Roe. see al so Caviar tarama, 433 taramasalata, 433 Rohwurst, 186 Roman Catholicism Caribbean Islanders, 282 Central Americans, 263 Central Europeans and people of former Soviet Union, 180 Filipinos, 374 Mexicans, 239–240 Native Americans and, 111 South Americans, 302–303 southern and, 159 Romanian fare, 434 Romescu sauce, 163 Rømmegrøt, 199 Root doctors, 213 Ropa vieja, 308 Rosa de jamaica, 268 Rosh Hashanah, 86–87 Roti, 217, 309, 461 Rouladen, 185 Rum, 309, 491 Russian Orthodox Church, 180 Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 5 6 2 I N D E X Spaniards demographics and socioeconomic status, 158–159 family, 159 immigration patterns, 157–158 religion and, 159 Spätzle, 185 Special occasions Africans, 222–223 Asian Indians, 466 Caribbean Islanders, 293 Central Americans, 267 central Europeans and people of former Soviet Union, 189–192 Chinese, 333–334 France, 152–153 Great Britain, 152 Ireland, 152 Italy, 168 Koreans, 357–358 Mexicans, 250–251, 255–256 Native Americans, 121 Pakistanis, 467 Portugal, 168–169 Scandinavians, 202–203 South Americans, 310–311 Southeast Asians, 390–392 Spain, 168 Spices in Asian Indian cuisine, 457 in Balkan cuisine, 429 in Middle Eastern cuisine, 429 in Pakistani cuisine, 459 Spiny palm, 266 Spirit of the Hearth, 391 Spiritualist healers, 284 Spirituality, 38 Spoon bread, 507 Spumoni, 165 Squash, 221 in cuisine of China, 329 as staple food of Native Americans, 114 St. Nicholas Day, 194 St. Patrick’s day, 152 Staples African American, 219–221 Asian Indians, 457–458 Caribbean Islanders, 286–288 Central Americans, 264–266 Central Europeans and people of former Soviet Union, 183–187 Chinese, 325–330 France, 147–150 Great Britain, 144–147 Italy, 162 Japanese, 343–347 Koreans, 355–357 Mexicans, 243–246 Middle Easterners, 426–430 Native Americans, 114 Native Hawaiians and Pacific Islanders, 403–405 Pakistanis, 459 people of Balkans, 426–430 Portugal, 163–164 Scandinavians, 199–201 South Americans, 304–306 Southeast Asians, 380–389 Southern Europeans, 162–164 Spain, 162–163 State of being, 37 Status, 5 traditional health beliefs and practices, 303–304 worldview, 302–304 South Asians. see Asian Indians; Pakistanis South Atlantic American cuisine, 507–512 Southeast Asians, 370–399 adaptations of food habits, 393–394 contemporary food habits in United States, 393–399 counseling, 396–399 cultural perspective, 370–380 daily patterns of meals, 389–390 demographics and socioeconomic status, 373–374 etiquette, 390 family, 375–377 history of, in United States, 370–374 immigration patterns, 370–373 ingredients and common foods, 380–389 meal composition and cycle, 389–392 nutritional intake, 395–396 nutritional status, 395–399 regional variations, 380–389 special occasions, 390–392 staples, 380–389 therapeutic uses of food, 392–393 traditional food habits, 380–393 traditional health beliefs and practices, 377–380 worldview, 374–380 Southern Americans, 503–517 demographics and socioeconomic status, 504–505 health concerns, 517 regional profile, 503–505 traditional fare, 505–517 Southern Chinese, 330 Southern Europeans, 139–171 adaptations of food habits, 169 contemporary food habits in United States, 169–170 counseling of, 170 cultural perspective, 157–160 demographics and socioeconomic status, 158–159 family, 159–160 history of, in United States, 157–159 immigration patterns, 157–158 ingredients and common foods of, 160–166 meal composition and cycle, 166–169 nutritional intake, 169–170 nutritional status, 169–170 regional variations, 164–166 religion, 159 staples, 162–164 traditional food habits, 160–169 traditional health beliefs and practices, 160 worldview, 159–160 Southern India, 462–463 Southern Native Americans, diet of, 116 Southwestern Native Americans, diet of, 117–118 Souvlaki, 429 Soy sauce, 343, 345 Soybeans, 328, 497 Spain. see al so Spaniards etiquette, 167 meal composition and cycle, 167 regional variations, 166 staples, 162–163 Shrimp fermented paste of, 383 scampi, 164 in Southern American cuisine, 509, 515 Shrove Tuesday, 153, 191 Shuro, 216 Si-pallie. see Cipate Sichuan-Hunan, 330 Sikhism, 453–454 Sitsaron, 383 Six-pates. see Cipate Sljivovica, 430 Slovaks demographics and socioeconomic status, 179 family, 181 immigration patterns, 177 religion, 180 Slovenians. see Balkans, people of Slumps, 489 Smithfield ham, 507 Snakeroot, 425 Soave, 164 Soda bread, 146 Sol, 358 Somalians, 215–217, 228 Somen, 343 Somun, 431 Sonora, 253 Sopa de rosquillas, 267 Sopresseta, 164 Sorghum, 215 Sosaties, 218 Soul food, 224 Soup açordu, 163 caldo verde, 163 canned, 494 chicken, 42 dashi, 346 Fricot, 154 Holy Ghost, 169 Iraqi, 433 in meal patterns and meal cycles, 10 misoshiru, 346 in South American cuisine, 308 Vietnamese, 388 zuppa di pesce alla marinara, 160 South Africa, 217–218 South Americans, 301–314 adaptations of food habits, 312 contemporary food habits in United States, 312–314 counseling, 312–314 cultural perspective, 301–304 daily patterns of meals, 310 demographics and socioeconomic status, 301–302 etiquette, 311 family, 303 history of, in United States, 301–302 immigration patterns, 301 ingredients and common foods, 304–310 meal composition and cycle, 310–312 nutritional intake, 312 nutritional status, 312–314 regional variations, 306–310 religion, 302–303 special occasions, 310–311 therapeutic uses of food, 311–312 traditional food habits, 304–312 Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 I N D E X 5 6 3 Central Europeans and people of former Soviet Union, 183–192 Chinese, 325–335 Japanese, 348–351 Mexicans, 242–252 Native Americans, 112–133 Native Hawaiians and Pacific Islanders, 402–406 northern Europeans, 144–153 Pakistanis, 459 Scandinavians, 199–203 South Americans, 304–312 Southeast Asians, 380–393 southern Europeans, 160–169 Traditional health beliefs and practices, 34–55. see al so Healing therapies Africans, 212–214 Asian Indians, 455–456 biomedical worldview, 37–39 Caribbean Islanders, 283–285 Central Americans, 263–264 Central Europeans and people of former Soviet Union, 182–183 Chinese, 323–325 cultural outlook, 34–37 health and, 39–42 Japanese, 342–343 Koreans, 353–354 Mexicans, 241–242 Middle Easterners, 424–425 Native Americans, 111–112 northern Europeans, 144 Pakistanis, 456 people of Balkans, 424 pluralistic health care systems, 50–52 Scandinavians, 198–199 Southeast Asians, 377–380 southern Europeans, 160 worldview, 34–39 Triangulation, 75 Trifle, 150 Tsukemono, 346 Tuk-trey, 387 Tunnbrød, 201 Turkey, 501 Turkish delight, 433 Turks. see Middle Easterners Turnovers, 426 Turtle, 219 Tybo, 199 Type 2 diabetes mellitus Asians, 337 Filipinos, 395 Gypsies, 195 Japanese Americans, 350 Mexican Americans, 258 Native Americans, 128 Native Hawaiians and Pacific Islanders, 407–408 prevalence of, 21 South Americans, 312 U Udon, 343 Ugali, 217 Uganda, 217 Ukrainians, 178 demographics and socioeconomic status, 179 family, 182 religion, 181 Tej, 216 Tella, 216 Tempura, 346 Teppanyaki, 346 Tequila, 243, 246 Teriyaki sauce, 345 Tet, 391 Tex-Mex cuisine, 253, 517 Thai fare, 394 Thanksgiving, 293 Tharid, 433 Therapeutic massage, 199 Therapeutic uses of food Africans, 223–224 Asian Indians, 468–470 Caribbean Islanders, 294–295 Central Americans, 268 Central Europeans and people of former Soviet Union, 192 Chinese, 334–335 Japanese, 348 Koreans, 358 Mexicans, 252 Middle Easterners, 440–441 Native Americans, 122 Native Hawaiians and Pacific Islanders, 46 Northern Europeans, 153 Pakistanis, 470 people of Balkans, 440–441 South Americans, 311–312 Southeast Asians, 392–393 Southern Europeans, 169 Theravada Buddhism, 104, 375 Three Kings Day, 250 Tiffin, 465 Tiropetas, 426 Tiste, 266 Tlingit Indians, 119 Tobikko, 343 Tobu, 355 Toenjang, 355 Tofu, 343 Togbei, 215 Tomatillos, 524 Tomato sauce, 150 Tomatoes in cuisine of Central Europe and former Soviet Union, 186 in South American cuisine, 304 in Southern American cuisine, 509 in southern European cuisine, 162 in Western American cuisine, 524 Tongans demographics and socioeconomic status, 401 family, 401 immigration patterns, 400 religion, 401 traditional food habits, 402–406 Tonghak, 352 Tortas de aceite, 168 Tortillas, 243, 253, 264 Tou yun, 324 Touching, 62–63 Traditional Chinese Medicine (TCM), 48, 323–325, 339, 392–393, 401–402 Traditional food habits Africans, 214–224 Asian Indians, 457–458 Caribbean Islanders, 285–295 Central Americans, 264–268 Steak and kidney pie, 150 Steamers, 490 Stereotyping, 5, 21, 22 Sterlet caviar, 186 Stews as national dish of Ethiopia, 216 in slave diet, 219 in South American cuisine, 308 Stobhach Gaelach, 146 Stout, 147 Sturgeon, 82 Su, 343 Succotash, 116, 489 Sudan, 215–217 Sudden unexpected nocturnal death syndrome (SUNDS), 45 Sugar, Demerara, 309 Sugarcane, 245, 309, 530 Sui mai, 331 Sukiyaki, 346 Sukkot, 87 Sumagh, 440 SUNDS. see Sudden unexpected nocturnal death syndrome Sushi, 343 Suspiros, 168 Susto, 241, 252, 263, 270, 283 Swedes. see Scandinavians Swedish knäckebröd, 201 Swedish massage, 199 Sweet potatoes, 304 Swiss demographics and socioeconomic status, 179 immigration patterns, 177 Symbolic use of food, 3 Syrians. see Middle Easterners T Tabasco, 154 Tabouli, 433 Tacos, 245 Tagdir, 425 Tajima beef, 346 Tamales, 245, 250–251, 255, 264, 268 Tamas, 468 Tandoor, 461–462 Tandoori, 459 Tanzania, 217 Taoism, 322–323 Tapas, 167, 168, 357 Tarama, 433 Taramasalata, 433 Taro root paste, 403 Taste, 14–15 TCM. see Traditional Chinese Medicine Tea, 147, 153 black, 494 cerasse, 295 in cuisine of Central Europe and former Soviet Union, 187 in cuisine of China, 329–330 green, 345 herbal, 268, 284, 355 high, 151 in Northeastern American cuisine, 491 rice, 355 sage, 252 sassafras, 223, 514 wild sage, 295 yellowroot shrub, 223 Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 5 6 4 I N D E X Worldview biomedical, 37–39 Caribbean Islanders, 282–285 Chinese, 322–325 comparison of common values, 35 cultural outlook, 34–37 Native Americans, 110–112 South Americans, 302–304 Y Yacón, 304 Yadu Nal, 358 Yakimono, 346 Yams in African American cuisine, 225 in West African cuisine, 215 Yataklete kilkil, 216 Yeast, 499 Yellowroot shrub, 223 Yemiser selatta, 216 Yemiser wat, 216 Yerba buena, 524 Yerbeterías, 304 Yin-yang acupuncture and, 325 diet theory, 41, 323–324, 334, 348 in Korean system of health and illness, 353 in Taoism, 323 Vietnamese and balance of, 378 Yo-kan, 345 Yogurt, 429, 457, 459 Yom Ha-Atzma’ut, 440 Yom Kippur, 87 Yorkshire pudding, 144 Yucca, 118. see al so Cassava Yugeno, 307 Yunnan, 330 Yupik Indians, 119, 124 Z Za’atar, 429, 436 Zabaglione, 167 Zakuski, 189 Zampa, 333 Zamzam water, 424 Zapote, 248 Zen Buddhism, 345 Zeppole, 165 Znakarki, 183 Zoroastrianism, 180, 454 Zunaad, 424 Zuni Indians, 117, 122, 127 Zuppa di pesce alla marinara, 160 Vodka, 187, 192 Voodoo, 213, 282, 284 Vouvray, 148 W Wakame, 346, 355 Walnuts, 335 Wasabi, 347 Wat, 216 Weissbier, 187 West Africa, 214–215 Western Americans, 517–530 demographics and socioeconomic status, 518 health concerns, 530 regional profile, 517–518 traditional fare, 518–530 Westphalian ham, 185 Wheat, 328, 426, 459 Whiskey, 147, 514 WHO. see World Health Organization Wienerbrød, 201 Wild mushrooms, 186, 201 Wild rice, 117 Wild sage tea, 295 Wine(s) Bordeaux, 149 Burgundy, 149 California, 494, 527 Central Europe, 187 Champagne, 148 Chianti, 165 Chinese, 330 Civek, 430 dandelion, 491 France, 148 German Rhine, 148 gooseberry, 491 Madeira, 166 Mexican, 246 mirin, 345 New York, 494 Oregon, 527 port, 147, 166 retsina, 430 rice, 357 Sangria, 163 sherry, 147 Soave, 164 South American, 308 Vouvray, 148 Washington, 527 Witchcraft, 213, 263 Worcestershire sauce, 150 World Health Organization (WHO), 39 Ulasaming bato, 392 Um, 353, 358 Umu, 403 Uni, 343 Uruguay. see South Americans V Varenyky, 185 Variety, 17–18 Vata, 468 Veal, 164, 185 Vegetables in Balkan cuisine, 428, 431 in Mexican cuisine, 245 in Middle Eastern cuisine, 428, 431 in Northeastern American cuisine, 492 in Pakistani cuisine, 459 Vegetarianism, 457, 458 Velouté, 150 Venado, 266 Venezuela. see South Americans Verbal communication, 58–62 individuals and groups, 60 in low-and high-context cultures, 58–60 power, authority, and status, 61–62 time perception, 62 uncertainty avoidance and, 60–61 Vermouth, 164 Vertigo, 324 Vibora de cascabel, 260 Vidalia onions, 509 Vienna bread, 201 Vietnam, 371–373 Vietnamese adaptations of food habits, 393–394 counseling, 397–399 daily patterns of meals, 389–390 demographics and socioeconomic status, 373–374 etiquette, 390 family, 376 meal composition and cycle, 389 nutritional intake, 395–396 religion, 375 special occasions, 391–392 staples, 384–389 therapeutic uses of food, 392–393 traditional Chinese medicine and, 392–393 traditional health beliefs and practices, 378–379 Vinegar aceto balsamico di Modena, 164 rice, 343 Vitello tonnato, 164 Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-209 Cover IFC Half Title Title Statement Copyright Contents Preface Ch 1: Food and Culture Ch 1: Introduction What Is Food? What Is Culture? Cultural Food Habits Individual Food Habits Nutrition and Food Habits The American Paradox Ch 1: Review Questions Ch 1: References Ch 2: Traditional Health Beliefs and Practices Ch 2: Introduction Worldview What Is Health? Disease, Illness,and Sickness Pluralistic Health Care Systems Ch 2: Review Questions Ch 2: References Ch 3: Intercultural Communication Ch 3: Introduction The Intercultural Challenge Intercultural Communication Concepts Role of Communication in Health Care Successful Intercultural Communication Intercultural Nutrition Education Ch 3: Review Questions Ch 3: References Ch 4: Food and Religion Ch 4: Introduction Western Religions Eastern Religions Ch 4: Review Questions Ch 4: References Ch 5: Native Americans Ch 5: Introduction Cultural Perspective Traditional Food Habits Contemporary Food Habits Ch 5: Review Questions Ch 5: References Ch 6: Northern and Southern Europeans Ch 6: Introduction Northern Europeans Southern Europeans Ch 6: Review Questions Ch 6: References Ch 7: Central Europeans, People of the Former Soviet Union, and Scandinavians Ch 7: Introduction Central Europeans and the People of the FSU Scandinavians Ch 7: Review Questions Ch 7: References Ch 8: Africans Ch 8: Inroducion Cultural Perspective Worldview Traditional Food Habits Ingredients and Common Foods Meal Composition and Cycle Meal Composition and Cycle Contemporary Food Habits in the United States Adaptations of Food Habits Ch 8: Review Questions Ch 8: References Ch 9: Mexicans and Central Americans Ch 9: Introduction Mexicans Ch 9: Review Questions Ch 9: References Ch 10: Caribbean Islanders and South Americans Ch 10: Introduction Caribbean Islanders South Americans Ch 10: Review Questions Ch 10: References Ch 11: East Asians Ch 11: Introduction Chinese Japanese Koreans Ch 11: Review Questions Ch 11: References Ch 12: Southeast Asians and Pacific Islanders Ch 12: Introduction Southeast Asians Native Hawaiians and Pacific Islanders Ch 12: Review Questions Ch 12: References Ch 13: People of the Balkans and the Middle East Ch 1: Introduction Cultural Perspective Traditional Food Habits Contemporary Food Habits in the United States Ch 13: Review Questions Ch 13: References Ch 14: South Asians Ch 14: Introduction Cultural Perspective Traditional Food Habits Contemporary Food Habits in the United States Ch 14: Review Questions Ch 14: References Ch 15: Regional Americans Ch 15: Introduction American Regional Food Habits The Northeast The Midwest The South The West Ch 15: Review Questions Ch 15: References Glossary of Ethnic Ingredients Resources Index 2016-11-10T14:43:09+0000 Preflight Ticket Signature

Turn in your highest-quality paper
Get a qualified writer to help you with

“ Cultural Recipe Analysis ”

Get high-quality paper

NEW! AI matching with writer

Hire a Writer

Client Reviews

4.9

Sitejabber

4.6

Trustpilot

4.8

Our Guarantees

100% Confidentiality

Information about customers is confidential and never disclosed to third parties.

Original Writing

We complete all papers from scratch. You can get a plagiarism report.

Timely Delivery

No missed deadlines – 97% of assignments are completed in time.

Money Back

If you're confident that a writer didn't follow your order details, ask for a refund.

New to Your Trusted Assignment Help Service? Sign up & Save

Calculate the price of your order

Type of paper needed:

Pages:

You will get a personal manager and a discount.

Academic level:

We'll send you the first draft for approval by at

Total price:

$0.00

Power up Your Academic Success with the
Team of Professionals. We’ve Got Your Back.

Power up Your Study Success with Experts We’ve Got Your Back.

Order Now Order Now