Cultural Influences on Dietary Choices of Mexican Americans with Type 2 Diabetes: A Qualitative Synthesis

Abstract

Diabetes care and education focuses on knowledge and self-management behaviors related to physical activity, healthy eating, taking medication, monitoring, reducing risk, and problem-solving. 1-3 Certified Diabetes Care and Education Specialists provide individualized nutrition counseling and other behavior change strategies. 4 Although nutrition counseling may be straightforward, such as recommending consistent carbohydrate intake at each meal, cultural foods and beliefs influence dietary choices and should be a consideration when counseling individuals of ethnically diverse backgrounds. In the United States, ethnically diverse populations are disproportionately affected by type 2 diabetes (T2DM). Among Mexican Americans, the rates of T2DM are much higher (24.6%) than the overall US population (14.6%). 5 Mexican Americans comprise 11.2% of the US population, and from 2010 to 2020, the Hispanic population grew by 23%, accounting for more than 50% of the population growth. 6,7 The rate of T2DM prevalence is tied to age, family history, sedentary lifestyle, history of gestational diabetes or prediabetes, and overweight status, which are factors strongly linked to diet quality. 8 Studies with Mexican Americans and Puerto Ricans suggest that including ethnic and cultural preferences can improve glycemic status and reduce the incidence of complications. 9-13 Some examples of ethnic and cultural adaptations include the use of traditional foods, such as tortillas, rice, beans, and different forms of chili peppers; providing health information in the preferred language; and including a paraprofessional with a high degree of cultural and community knowledge as part of the health care team. However, it is still unclear which and how cultural adaptations influence self-management behaviors relative to diet, a cornerstone for ameliorating T2DM complications. Resnicow and colleagues 14 describe a cultural sensitivity model for public health interventions that provides a comprehensive approach to understanding how cultural influences may impact behavioral interventions for disease prevention. 14 This approach distinguishes the types of cultural influences as either surface or deep structure. Surface-structure influences are those observable or "superficial" characteristics of a target population, such as using people, places, language, music, food, locations, and clothing familiar and preferred by the target population in audiovisual material. It also includes having ethnically matched staff who recruit participants and deliver and evaluate programs. 14 Deep-structure influences require an understanding of cultural, social, historical, environmental, and psychological forces influencing the health of a target population. This includes examining how perceptions of religion, family, society, economics, and the US government influence health behaviors. 14 Deep-structure influences in the literature are more prevalent in qualitative studies because the findings report stories, quotes, explanations, and examples to describe the phenomena being studied. Due to increasing evidence of enhanced outcomes when accounting for culture in health interventions, 15-17 the purpose of this article is to review qualitative studies to identify cultural factors important for health care professionals delivering nutrition education and counseling to Mexican Americans with T2DM. More specifically, this seeks to identify deep-structure cultural influences using a qualitative synthesis approach. 18-20 Syntheses of qualitative studies can amplify the barriers and facilitators of diabetes self-management voiced by study participants, thereby providing an opportunity to build evidence-based recommendations. 18 Methods Content analysis methodology guided this