Eating habits and reactions to dietaryadvice among two generations of

Caribbean people: a South Londonstudy, part 2

Penelope Scott*, Lynda Rajan

ABSTRACTThis article presents the ®ndings of a study into the dietary habits among two generations of Caribbean people inSouth London. Quantitative and qualitative methods were used to collect data from a sample of 80 people withdiabetes and 80 people without the disease on topics including food, the body, health and disease. The study's ®ndingssuggest that dietary information should take account of the role of traditional foods in people's diets and certain aspectsof their concepts of a `proper meal'. Other ®ndings include the probability that healthy eating campaigns/material arenot reaching this ethnic group; the low comprehension of nutritional terms used in health education material and theuse of other terms to classify foodstuffs among some members of the sample. The study also presented evidence ofacculturation in the food habits of the interviewees. Copyright # 2000 John Wiley & Sons, Ltd.

Practical Diabetes Int 2000: 17(7); 213±216

KEY WORDSCaribbeans; food habits; dietary advice

What interviewees considerto be a `proper meal':concepts of `balanced and`unbalanced' mealsInterviewees were asked to de®ne a`proper meal' by describing what fooditems they would like to see on theirplate. This hypothetical question wasintended to provide some indicationof the combination of food groupspeople are likely to have in their main

meal. The answers were analysed bycomparing them with the `platemodel' of dietary guidelines given topeople with diabetes at the SouthLondon Hospital. This advice issimilar to the healthy eating guidelinesissued by the Heath EducationAuthority, which stress the importanceof meals with a balance of proteins,carbohydrates and vegetables6.

Responses to this question werecategorised as either `balanced' or`unbalanced' depending on whetheror not the food groups and thenumber of food groups listed matchedthose suggested in the dietary guide-lines mentioned previously. No infor-mation on portion sizes was collected.A majority of the interviewees (49%)described a `proper meal' classi®ed as`unbalanced'; 39% gave a `balanced'description; 6% gave responses whichwere `unde®nable' Ð this group in-cluded people who listed soup andwho said that they would eat anything

or did not have a special preference. Atotal of 6% of interviewees said theycould not give an answer Ð for somethis was because there were a lot offoods they claimed they could noteat because of an existing healthcondition.

A breakdown of the de®nitions ofproper meals as `balanced' and `unba-lanced' by health status, sex and age/place of birth is as shown in Table 1.

Table 1 shows the percentagesgiving `unbalanced' concepts of a`proper meal' were highest amonginterviewees with diabetes. Thiswould seem to contradict the expecta-tion that they would be more likely togive `correct' answers as typical treat-ment for diabetes incorporates dietaryadvice which stresses the importanceof balanced meals. It may well be that,given the fairly strict dietary guidelinesthe diabetic sample must observe, thistrend in the answers re¯ects what theirpreferred or idealized choices are.

Penelope Scott, PhD, Social Researcher,

Lynda Rajan, BA(Hons), MSc, Social

Researcher, Social Science Research Unit,

Institute of Education, University of London,

18 Woburn Square, London WC1H 0NS, UK

*Correspondence to:

Penelope Scott, PhD, Social Researcher

Social Science Research Unit, Institute of

Education, University of London, 18 Woburn

Square, London WC1H 0NS, UK.

Received: 9 June 1998

Accepted in revised form: 6 May 1999

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Those with diabetes were also morelikely to give answers that were`unde®nable' (this group includedpeople who listed soup or who didnot have a speci®c choice) or to saythat did not know what answer togive; as noted previously, this wasusually quali®ed with concerns relat-ing to their health.

Men were less likely to offer de®ni-tions of proper meals that werebalanced and were more likely to saythat they could not answer the ques-tion. Interviewees in the older agegroup (55±75) were also less likely togive balanced descriptions and morelikely to give unde®nable answers ornot answer the question at all.

In what ways were thedescriptions of mealsunbalanced?Descriptions of meals were de®ned asunbalanced where there were `de®cits'and `surpluses' in the types andnumbers of food groups given(protein, carbohydrate, vegetables).Among the interviewees describing a`proper meal' the following de®citsand surpluses were recorded:

De®citsVegetables 14%Starch 6%Protein 2%

SurplusStarch 33%Starch and protein 3%Protein 7%

De®nitions of a proper meal were`unbalanced' mainly in terms of sur-

plus carbohydrate foods. Approxi-mately one in every three peopledescribed meals that consisted ofmore than one carbohydrate food.The percentage of people listing extrastarch food items is in real termshigher when the `starch' and `starchand protein' categories are consideredtogether. Surplus carbohydrate foodswere more likely to be listed indescriptions of `proper meals' bymembers of the non-diabetic sample.Men were more likely than women tolist more than one starch in theirde®nitions.

Concepts of healthy eatingInterviewees were asked to de®ne whatthey understood by the term `healthyeating'. Three different conceptualcategories of answers were recorded:

1. Answers focusing on the nutri-tional/health value of food and thetypes of food groups consumed. Morespeci®cally, these de®nitions usuallyincluded references to

$ no fat, no sugar, no sugar or fat,being low in carbohydrates andor fat (30%),

$ no salt (6%),$ having foods which provide pro-

teins, vitamins, ®bre (6%)

Cutting out all fats off meat,eating lots of vegetables, fruitsand doing exercises (39 year oldwoman with diabetes).

Having salads and fruits (75 yearold man).

2. Answers relating to the conceptsof balance (22%), eating regularly andin moderation (18%):

A mixed, balanced diet, substan-tial amount of starch foods, fruit,vegetables, ®sh and chicken (43year old man with diabetes). Noteating too much at one time (67year old man).

3. Answers focusing on the types offood consumed: this was usuallyde®ned as foods which are the

$ `right kind of food' ( 3%),$ not convenience foods (3%) and$ fresh foods and vegetables (20%).

Eating healthy foods like ®sh andchicken (42 year old woman withdiabetes).

Home made foods, fresh foods,lots of water (40 year oldwoman).

Interviewees with diabetes were morelikely to give de®nitions of healthyeating which included `low fat' and`no sugar' as well as mentions of `freshfruits and vegetables'. The answers ofinterviewees without diabetes werestatistically signi®cant and they weremore likely to mention `no salt' and`balance' and `regularity' in theirde®nitions.

Food classi®cationThe exploratory study suggested thatCaribbean people had culturally spe-ci®c terms to classify different foodsand they may have dif®culty under-standing the technical terms used todescribe food groups such as carbohy-drates, starch, ®bre, roughage andprotein. These ®ndings were furtherinvestigated in the survey and inter-viewees were asked whether theyunderstood and/or could give exam-ples of these terms. Generally, under-standing of these terms was not highand interviewees were unaware of theimportant function of each foodgroup in the diet. Age and place ofbirth were statistically signi®cant inanswers to this question: with theexception of `starch', these terms wereleast well understood by the 55s±75s

Table 1. De®nitions of a `proper meal'* by health status, gender, age.

Balanced%

Unbalanced%

Unde®nable%

DK%

With diabetes** 29 51 11 9No diabetes*** 50 46 1 3Female 46 45 6 3Male 33 53 6 9<45 born UK 41 53 6 ±<45 born WI 44 50 2 455+ born WI 36 46 9 9

*Proper meal de®ned as main meal of the day.

**People with diabetes.

***People without diabetes.

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while the 25s±45s, speci®cally thoseborn in the UK, were the bestinformed.

Interviewees understood and/orused terms such as `hard food' (76%)and `ground provisions' (45%) todescribe all Caribbean starches suchas yam, green bananas, sweet potato,cassava, cocoa, plantain, breadfruitand dumplings. The term `provisions'Ð understood by 44% Ð was used/understood in two different ways: (a)to refer to Caribbean starches such asyam, green bananas etc and (b)groceries or foods that are purchasedand stored such as ®sh, meat, chicken,fruit and vegetables. `Dry food' wasused by 64% of interviewees todescribe foods such as bread, biscuits,crackers, bun and bulla as well asmeals without gravy or meals without®sh, meat or chicken. `Fresh food' wasthe most widely recognised and usedterm (81%) and it embraced severaldifferent understandings of food: (a)freshly harvested foods or slaughteredmeats; (b) home cooked/ freshlycooked foods; (c) foods which arenot frozen or processed.

With the exception of `fresh food'and `hard food' all of the terms weremore commonly understood and usedby the older age groups. Apart from`fresh food' all of the terms were leastused or least well understood byinterviewees who were born in theUnited Kingdom. The terms `hardfood' and `provisions' were morecommon among Jamaican interview-ees and the term `ground provisions'was most frequently used and under-stood by interviewees from the otherislands.

Views on dietary adviceAmong the interviewees given advice,64% said it was helpful. However,34% or approximately one in everythree persons claimed the advice waseither not helpful or only partially so.Exactly half (50%) of those interview-ees given advice reported following it.The reasons for partial or non-coperation with advice generally fellinto two categories:

$ Problems with the advice/quality ofadvice

does not like foods or cookingmethods/foods are too `English',not usual foods eaten 33%portions too small/small portionswould cause weakness, fainting

27%foods boring and unappetising 7%prefers spicy foods 4%information too vague 2%suggested diet caused hypos 2%

$ Problems related to lifestyle andattitude

lazy/lacks discipline/resistantto learning new ways 13%dif®cult to give up certainfoods 11%already knew what to do/hadalready made changes to diet 11%too busy/ too time consumingto buy foods and prepare themin prescribed ways 9%does not take diabetesseriously 7%alters diet to suit own taste 4%did not want to lose anyweight 4%cannot read or write 2%diet expensive to follow 2%lack of family support 2%

Individuals with diabetes were askedfurther questions in the ethnographicinterviews about their views on thedietary advice they received. Theirresponses indicated the cultural inap-propriateness of the dietary advice:

Look, the things (dietary advice)are designed for white people,right? They're not designed for me(40 year old St Lucian male withdiabetes).

No, I did not get much dietaryadvice at the hospital, not that Icould take home and think well,now I know what I should beeating from what I should not beeating... the way she was asking methe questions like, yea, I'm Englishbut taking me on as an Englishperson eating English foods Ðthat's how she was dealing with

me. She would not deal with me asa Black person, knowing enoughabout my foods to really tell melook, look you have to cut down onrice `cos it's got too much starch, oryou have to not eat that or you nothave to eat this. She never give meno guidelines... the only advice thatI took from her was low fat butter,no ®zzy drinks Ð that's the onlything that was any good to me (33year old UK born Guyanese malewith diabetes).

There were also concerns about theuse of measured quantities in recom-mended diets. As noted7 elsewhere,the use of measured quantities is notcustomary in Caribbean cooking.Other problems related to themanner in which the information wasprovided and the un-responsiveness ofhealth professionals to problems thatwere encountered. Comments werealso made about the inadequacy ofthe portion sizes suggested, theexpense of following the special dietand the tendency for professionals notto specify what foods could be eaten.

DiscussionThe ®ndings of this study raise severalpoints health professionals could con-sider when providing dietary advice toCaribbean people. First, the studysuggests that some Caribbean peoplehave de®nitions of `proper meals'which are classi®ed as unbalancedwhen compared with the HealthEducation Authority guidelines onhealthy eating. These de®nitions wereunbalanced mainly in terms of atendency for people to list more thanone carbohydrate food as part of thesemeals. The study did not include datacollection on the actual portion sizesof these starches. However, from theexpressed concerns about the portionsizes in diabetic diets noted above andother data collected both in this studyand the exploratory project7 it isprobable that portion sizes are gener-ous. This is, therefore, an issue thatcould be addressed in health educationon healthy eating and weight controlaimed at the Caribbean community.

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Second, the de®nitions of healthyeating among interviewees without dia-betes were less likely to embrace theconcepts of eating more fresh fruit andvegetables and cutting down on fat andsugar consumption, which are all part ofhealthy eating messages. This point,when considered together with the®nding that only a minority of allinterviewees de®ned healthy eating interms of `balance', a concept used byhealth educators, perhaps suggests thathealth promotion messages abouthealthy eating are not reaching sectionsof the Caribbean community. Thiswould be consistent with the views ofother researchers that health promotioncampaigns are not reaching ethnicminority groups8. It also points to theclear need for the development of otherstrategies designed to get `healthy eating'and other health promotion messagesacross to this group.

Third, there was a generally lowunderstanding among the sample ofthe food classi®cation terms used inmuch of the literature and education onhealthy eating. This ®nding has implica-tions for the type of information/patienteducation provided to Caribbeanpeople. It also suggests that culturallybased food classi®cation terms, which aspreviously noted vary according to theisland interviewees are from, couldpossibly be included in healthy eatinginformation and patient education.However, the lower understanding ofthese terms among UK born Carib-beans, itself an important example of`cultural loss' among this group, further

highlights the heterogeneity of thiscommunity and the need to takeaccount of this when developing cultu-rally sensitive material.

Fourth, the study's ®ndings on per-ceptions of dietary advice con®rm theneed for health professionals to givedietary advice that acknowledges thetraditional foods and cooking methodsof this group; similar ®ndings wereprovided by another study conductedamong South Asians9. Given the crucialrole of dietary management in control-ling diabetes the importance of thispoint cannot be overemphasised.

Finally and on a more general level,the data presented here offer importantinsights into the acculturation process inthe dietary habits of this ethnic group.This process is re¯ected for example inthe consumption among some intervie-wees of typically British food items atChristmas and `roast' dinners at week-ends as well as the eating of snacks highin sugar and fats. Many studies havefocused on the acculturation of tradi-tional societies and the effects this has onnutritional status10; however, with someexceptions11,12 there has been less socialresearch, particularly in the UK, ondietary change and its consequencesamong ethnic minorities in an ethnicmajority culture. However, scholarsargue that although eating habits do notchange so quickly among immigrantgroups they are more likely to changerapidly among the young13 and it isusually `accessory foods' such as fats,sweets, fruits and drinks that are ®rst tobe assimilated into their diets14. Cer-

tainly the previously noted ®nding thatUK born Caribbeans were signi®cantlymore likely to eat snacks high in fats andsugars, i.e. `accessory foods', is consistentwith these views. The changing dietaryhabits observed in this study of twogenerations of Caribbean people warrantfurther investigation as these changes willultimately have an in¯uence on the typeof dietary advice they require.

References6. Health Education Authority. Nutrition in Min-

ority Ethnic Groups: Asians and Afro- Carib-beans in the United Kingdom. London: HEA,1991.

7. Scott PA. Culture, food, diet and diabetes: theWest Indian perspective. Practical Diabetes Int1997; 14(7): 207±208.

8. Howlett B, Ahmad W, Murray R. An explora-tion of white, Asian and Afro-Caribbean peoples'concepts of health and illness causation. NewCommunity 1992; 18(2): 281±292.

9. Samanta A, Campbell J, Spaulding D, Neogi S,Panja K, Burden A. Eating habits in Asiandiabetics. Diabet Med 1986; 3: 283±284.

10. Wirsing R. The health of traditional societies andthe effects of acculturation. Current Anthropol1985; 26(3): 303±315.

11. Freedman M, Grivetti L. Diet patterns of ®rst,second and third generation Greek Americanwomen. Ecol Food Nutr 1984; 14: 185±204.

12. Keane A, Willetts A. Concepts of Healthy Eating:an Anthropological Investigation in South EastLondon. London: Goldsmiths College, Universityof London, 1996.

13. Fieldhouse P. Food and Nutrition: Customs andCulture. London: Croom Helm, 1986.

14. Kocturk-Runefors T. A model for adaption to anew food pattern: the case of immigrants. In:Palatable Worlds Ð Sociocultural Food Studies,Furst E, Prattala R, Ekstrom M, Holm L,Kjaernes U (eds). Oslo: Solum, 1991; 185±191.

References1. World Health Organisation Expert Committee

on Diabetes Mellitus, Second Report. TechnicalReport Series 646, Geneva: WHO 1980.

2. World Health Organisation. Diabetes Mellitus:report of a WHO study group. TechnicalReport Series 727, Geneva: WHO 1985

3. Keen H, Jervell J. The St Vincent Declarationafter Istanbul: a new chapter. Diabetes Voice2000; 45: 68

3. Diabetes Care and Research in Europe: the StVincent Declaration. Diabetic Medicine 1990; 7: 360

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7. Diabetes Network International. Further infor-mation may be obtained from Ms HannaKazanowska, Chief Executive, 69 LutyensHouse, Churchill Gardens, London SW1V3AD UK. Tel **44 (0)20 7828 1516 E-mail:info@dni.org.uk Web: www.dni.org.uk

8. The Report of the Department of Health/BritishDiabetic Association St Vincent Joint Task Forcefor Diabetes, Department of Health/BritishDiabetic Association, London 1995

9. St Vincent and improving diabetes care. Spe-cialist U.K. workgroup reports. Diabetic Medi-cine 1996; 13 (Suppl 4).

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continued from p.212

Part 1 may be found in PracticalDiabetes International 2000; 17(6):183±186

This leader is based on an interviewbetween Professor Harry Keen andKate Start, Start Consulting.

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