CARDIOVASCULAR DISEASE is currently the leading cause of death, worldwide.1 In the United States, nearly 801 000 people die from heart disease each year.2 Thus, promoting cardiovascular health across the general population to prevent cardiovascular disease is both a global and national priority. The World Health Organization has established goals of decreasing cardiovascular disease incidence and mortality.3 Supporting these goals, the American Heart Association recommends a focus on lifestyle interventions, including dietary change, to improve cardiovascular health and reduce associated risk factors, such as hypertension, diabetes, high cholesterol, and obesity.1 , 2
Diet has been identified as a practical, economical, and effective means of preventing heart disease.1 , 2 However, multiple complex factors may impact individual dietary choices. Researchers have identified links between culture, diet, and cardiovascular health.4–7 For example, among Native Hawaiians and Pacific Islanders there has been a cultural shift away from traditional diets high in fruit and vegetable intake toward diets that are high in fat, sugar, carbohydrates, and processed meats.4 Researchers identified these changing dietary patterns as a factor contributing to an increased incidence of cardiovascular disease.4 Likewise, researchers have identified a relationship between Western cultural influences on diet and an increase in cardiovascular disease risk factors among Chinese older adults.6 Although these findings suggest cultural influences on diet, researchers who study dietary change for cardiovascular health promotion typically emphasize individual factors, such as what individuals eat, individual knowledge and education, and personal barriers.8 , 9
Within studies aimed at examining dietary habits and cardiovascular health, cultural influence is often implicit within the research findings rather than explicitly identified and discussed.10–12 Furthermore, the concept of dietary culture has not been defined by nurse scientists for theory development and application to nursing practice. Despite theoretical knowledge of the importance of culture to holistic practice, the cultural impact of diet on health is underrecognized.8 , 13–15 Zou14 and Rong et al13 identified the need to look beyond the individual to explore the complex factors contributing to dietary habits within a cultural context. Acknowledging and understanding the concept of dietary culture is critical to promoting dietary habits that improve cardiovascular health outcomes.
Statement of Significance
What is known or assumed to be true about this topic:
Diet is a practical and effective means to prevent and manage cardiovascular disease. Despite this knowledge, cardiovascular disease remains the leading cause of death, worldwide. Researchers commonly emphasize individual factors rather than cultural factors when examining impediments to heart-healthy diets. Theoretical knowledge supports the importance of culture to holistic nursing practice, yet the cultural impact of diet on health is underrecognized.
What this article adds:
The concept of dietary culture is undefined in the nursing literature. This article adds a definition of dietary culture and promotes an understanding of the relationship between diet, culture, and cardiovascular health. Dietary culture can be defined as patterned group eating behaviors that are unconsciously influenced and socially organized. The proposed definition provides a means for nurses to recognize and assess dietary culture. Furthermore, this analysis provides a building block for future exploration and development of the concept in nursing theory and research.
Nursing evolved from a social mandate to provide human services for the good of the community.16 , 17 Nurses have an ethical and scientific imperative to explore and reevaluate changing public health care needs from a theoretical perspective to guide research and practice. Thus, the purpose of this concept analysis is to define the concept of dietary culture to increase understanding of the relationship between diet, culture, and cardiovascular health. The results of this analysis may inform future nursing theory development and research that promotes culturally congruent, sustainable dietary habits that support cardiovascular health.
Concept analysis is a cognitive and linguistic exercise that assists in defining a concept.18 The aim of Walker and Avant's18 analysis process is to identify the structure and function of a concept, which aligns with the aim of this concept analysis. The process includes the following 8 steps: (1) select a concept, (2) determine the aims or purposes of the analysis, (3) identify as many uses of the concept as possible, (4) determine defining attributes, (5) identify a model case, (6) identify borderline, related, contrary, invented (as needed), and illegitimate cases, (7) identify antecedents and consequences, and (8) define empirical referents.18 Although numbered, the steps are not intended to be followed in a linear fashion but are to be explored and revisited as part of an iterative, cognitive exercise. The results of a concept analysis are limited because they are not absolute; while the analysis process provides meaning and structure to the concept, meaning may change with time, context, and paradigm.18
Dietary culture was selected to gain a clear understanding of the concept and how the concept may inform cardiovascular health promotion. The first step in analyzing the concept of interest was to identify dictionary definitions. Definitions of the base words “diet” and “culture” were obtained from 2 online dictionaries: Merriam-Webster and Dictionary.com. Defining base words was of particular importance because neither dictionary contained a definition for the compound word “dietary culture.”
Next, a search was conducted to identify uses of the concept across publications. The search began with using PubMed to identify MeSH terms for dietary culture and cardiovascular health. Suggested terms included the following: “diet,” “culture,” “cardiovascular,” “cardiovascular system,” and “health.” Searches were then conducted using OhioLINK through The University of Akron library, allowing for simultaneous searches of 152 electronic databases, including CINAHL, MEDLINE, Academic Search Complete, and Anthropology Plus. The goal was to identify as many uses of the concept as possible across a breadth of disciplines. To achieve this goal, the only selected limiter was English language.
The following terms and combinations were used to thoroughly search the available literature: “dietary culture”; “dietary culture” and “concept”; “diet” and “culture”; “diet” and “culture” and “cardiovascular health”; “diet” and “culture” and “cardiovascular system”; “diet” and “culture”; and “cardiovascular.” The search yielded 67 publications that were reviewed for the use of the concept. Publications were included in the analysis if the term “dietary culture” was used within the text of the article, such that some level of meaning or context could be derived. Publications were excluded if the term was used nonspecifically, or vaguely in the abstract. The final sample included 15 publications from which data were extracted and added to a matrix for analysis.
Definitions and use
Definitions of the base words of the concept were obtained from Merriam-Webster's online dictionary and Dictionary.com. Within the concept, the word “dietary” functions as an adjective to modify or describe the word “culture.” The adjective “dietary” means “of or relating to a diet or the rules of diet.”19 Thus, the definition of diet was used in the analysis for clarity. A representative sample of the various definitions for the base words “diet” and “culture” is included in the Table. The definitions are organized by their fit within the context of cardiovascular health. The contextual fit of the definitions was determined through an iterative process of returning to the definitions after identifying uses of the concept across the literature. The definitions of diet that were identified as having good contextual fit with cardiovascular health included the key components of regular or habitual consumption of food and drink or nourishment.19 , 20 One definition describes the consumption of food and drink as related to health effects.20 Overall, culture is defined as shared ideas, values, beliefs, knowledge, and social norms.19 , 20
Among the sample of publications that included the concept, dietary culture was commonly used in the context of indigenous food choices, preparation, and availability.21–25 Another common use was within a historical context, exploring food heritage.26–30 Tamang24 used the term in reference to how cultural groups eat food. For example, the cultural norm in India is to eat with one's fingers.24 Sato et al31 used the term “dietary culture” to discuss eating habits and how those habits vary across cultures. In one instance, the term was used in examining the biochemical effects of diets fed to quail.32
Although the term was not found in any nursing publications, 3 instances of its use were identified within the context of health. Gorelik et al33 identified dietary culture as a potential influence on the reduced dietary intake of certain nutrients among people with congestive heart failure. The researchers included the term within the conclusion, identifying “dietary culture” as a potential alternate explanation for lack of association between disease process and nutrient insufficiencies.33 Sproesser et al34 used the term “dietary culture” when exploring the association between life expectancy and traditional versus modern Japanese diets. The authors proposed that traditional Japanese diets play a role in increased life expectancy.34 Finally, Tan35 linked dietary culture to the acceptability and use of Chinese medicinal diets.
In summary, uses of the concept dietary culture encompassed multiple, complex factors. Common themes included the cultural connection to types of foods eaten, how they are eaten, cost considerations, production, traditions, patterns of eating, intangibility, social aspects, and the impact of culture and diet on health.19–36 Analyzing and integrating definitions and uses of dietary culture in the literature assisted in determining the defining attributes of the concept.
Defining attributes are the qualities or characteristics frequently associated with a concept.18 For this analysis, common attributes of dietary culture were identified using the dictionary definitions, uses of the term “dietary culture,” and through the process of developing cases. The defining attributes of dietary culture include the following: (a) patterned group eating behaviors, (b) unconscious influence, and (c) social organization. Thus, dietary culture can be defined as patterned group eating behaviors that are unconsciously influenced and socially organized.
Exploring the various uses of dietary culture provided significant insight into the defining attributes of the concept. Dietary culture does not refer to onetime or infrequent food choices but rather a pattern of group eating behaviors. Patterned behavior is evident in the definition of diet, which includes the words “habitual” and “regularly consumed.”19 , 20 Also, this attribute is either explicitly stated or implicitly expressed when authors and researchers use the term “dietary culture.”22–24 , 29 , 31 , 37 Unconscious influence is evident in the definitions of culture, as well as within the literature.22 , 23 , 28 Rath28 (p2) uses the word “intangible” when discussing the traditional dietary culture of Japan. One's own culture is often so deeply ingrained as to be imperceptible to the individual without intentional awareness.15 Finally, dietary culture is socially organized, generated from social construction and interaction around what, how, and when members of a particular culture eat.8 , 15 , 19 , 20 , 23 , 24 , 29 These defining attributes of dietary culture are exemplified and further clarified through the following cases.
The purpose of a model case is to provide a clear example of the concept.18 Thus, the following case depicts a scenario in which all defining attributes of dietary culture are evident.
Miriam is a Qatari woman who has undiagnosed hypertension and high cholesterol, two risk factors for cardiovascular disease. She is at home preparing dinner for her family, as she does every evening. The meals she makes are designed to please her family members, who prefer dishes containing meat, grains, oil, and salt. Vegetables are served in smaller quantities because they do not usually get eaten. Today, Miriam is preparing harees, a meal that she makes at least once a week because it is a family favorite. The traditional dish is composed of wheat, ground meat, ghee (clarified butter) and seasonings, such as salt, pepper, cinnamon, and cumin. Miriam prepares the dish using her grandmother's recipe, which has been handed down through multiple generations. She has fond, childhood memories of making harees with her grandmother during the month of Ramadan. When the meal is ready, the family gathers around the table to eat while talking about the events of the day.
This scenario exemplifies a patterned group eating behavior that is unconsciously influenced and socially organized. Patterned group eating behaviors are evident in the daily ritual of Miriam preparing the evening meal, the family sitting down to eat it together, and the weekly appearance of harees at the dinner table. The selection and preparation of an evening meal by Miriam, as well as the family eating the prepared meal together, are socially organized constructions. These elements of the scenario are also unconsciously influenced by cultural norms and traditions.7 If Miriam did not participate in this aspect of the dietary culture by refusing to prepare family meals or making foods that the family does not prefer, she would likely draw negative attention from the group.7 In this scenario, Miriam is unaware that she has risk factors for cardiovascular disease. The patterned group eating behavior of a diet high in oil, salt, and meat, while being low in vegetable intake, may be contributing to these risk factors, impacting Miriam's overall cardiovascular health.1 , 7
The borderline case includes some defining attributes of the concept but not all of them.18 The following borderline case includes patterned group eating behaviors and demonstrates social organization but does not include unconscious influence.
Oscar, a Canadian man who was recently diagnosed with cardiovascular disease, is attending a support group aimed at implementing heart-healthy eating. After learning about positive food choices and eating strategies, the meeting concludes with refreshments, as always. An array of snacks that support cardiovascular wellness is presented to the group. The recipes are easy to make, using fresh, local ingredients. Oscar thinks about how he can incorporate these and other heart-healthy foods into his daily meals as he eats the sample foods.
A patterned group eating behavior is evident in the provision of snacks or refreshments at every meeting of this support group. The group interaction, eating, and bonding with a common purpose demonstrate social organization. However, in this case, the choice of foods is more consciously influenced by the goal of promoting cardiovascular health. The people participating in the group have intentionally selected the foods served with a specific purpose in mind.
The related case presents an example of a concept that is similar to and connected with dietary culture but does not contain all of the defining characteristics.18 A closely related concept is “food culture.”
An American couple traveling for the first time in France stop at a local restaurant for dinner. They have heard that the restaurant is a favorite among locals and that it serves traditional French cuisine. The couple chooses foods they have never had before to experience local, French cuisine. They enjoy a meal of ratatouille and a soufflé for dessert.
The concept of food culture was identified during the literature search for this analysis. The word “food” is conceptually different from “diet” because while diet includes the concept of a pattern and its impact on health, food refers only to the substances being eaten.19 In the preliminary phase of selecting a concept, literature searches including food culture reflected this difference through a lack of association with patterned behavior and an emphasis on the type of food eaten.38 , 39 Dietary culture was selected for this analysis because of this difference.
The borderline case presents a subtle difference in emphasizing the type of food eaten, based on local availability and food preparation styles. This case demonstrates people deviating from a patterned eating behavior to eat food from a foreign culture. The attributes of unconscious influence and social organization are evident but less clear in this case. The couple's food choice is more about the desire to try something new while traveling than promoting a sense of togetherness or belonging to a group. The lack of a dietary pattern makes it difficult to link the food to cardiovascular health because pattern is an important component in cardiovascular disease risk.1
The purpose of a contrary case is to provide a clear example of a situation that has no defining attributes of the concept.18
A lone, lost, prehistoric man, roams across a barren plain for days. He is starving. He hunts the first animal he finds, then kills and eats the animal.
This contrary case demonstrates no defining attributes of the concept of dietary culture. The scenario exemplifies the act of eating strictly for survival. A social component is lacking in this scenario. The starving man intentionally acquired and ate the first available food source. The act of eating is strictly about survival in a crisis, with no evident pattern.
The term “dietary culture” can be used in a biochemical context, as identified during the literature search.32 This use provides a real example of an illegitimate case:
Farmers have encountered problems with multiple mycotoxicoses in poultry. A study was conducted to examine the effects of two commonly encountered mycotoxins on quail. A scientist fed 40, newly hatched quail a dietary culture material containing aflatoxin and T2 toxin.32
The illegitimate case uses the concept outside of the context of this analysis. None of the identified defining attributes of dietary culture are present within the context of the illegitimate case. This case adds a clear picture of what is not meant by dietary culture when exploring the concept as applied to cardiovascular health.
The development of cases was crucial in delineating the defining attributes of dietary culture. With that accomplished, the next step in the analysis was to identify antecedents and consequences.18 This step was particularly critical to the analysis of dietary culture because the social context of the concept was revealed.18
Antecedents are events or incidents that must take place for the concept to exist.18 Examining uses of the concept provided essential insight into the complex factors that result in the particular dietary habits and behaviors of a cultural group. The identified antecedents of dietary culture include necessity, practicality, availability, economic resources, and culinary traditions.
People eat food out of necessity to fulfill biological requirements for energy and nutrients needed for survival.15 The human need for food is a basic fact, which is reflected in the dictionary definitions of diet.19 Furthermore, human beings require social interaction to thrive.15 Food performs a universal function of uniting people through social connection and interaction, which leads to socially constructed dietary traditions.5 , 15
Practicality is a factor because access to and preparation of food for inclusion in the diet must be feasible.28 For example, the United States has experienced a cultural shift toward processed and convenience foods that can be prepared and eaten quickly and easily.40 , 41 During the 1960s, households more commonly prepared and cooked meals at home. However, the number of meals prepared by manufacturers has increased because of changing cultural factors, such as less formal eating among families, more individual meals, increases in disposable income, an increased value on leisure time, and changing gender roles.40 Convenience foods in the United States are highly accessible, relatively affordable, and meet cultural demands, which makes them practical.
Cultural group members eat the foods that are available to them either through geography or having the skills and abilities to access particular foods.8 , 22 , 28 Shifts in the food choices of people living in Central America demonstrate the connection of food availability to dietary culture. Central Americans historically have eaten a diet centered around maize but have begun to eat more wheat-containing products.21 This dietary shift may be due to environmental and commercial influences that impact food availability.21
Economics affects food choice, frequency, and preparation.5 , 15 Differences in economic resources stem from multiple individual, community, and geographic factors.15 People living in an economically disadvantaged culture may experience more limited access to food, both in quantity and variety. In contrast, those living within a culture with a high level of economic resources may be less limited in food choice and quantity.5 , 15 Thus, economics will impact cultural eating patterns and traditions. For example, economic factors may lead to eating the least expensive foods that provide a feeling of satiety or a dietary pattern of eating only 1 meal per day.
Social groups generate customs in all things, including diet. Culinary traditions are constructed on the basis of social interactions surrounding food, with complex influences such as religion, politics, and economics.15 Each cultural group establishes culinary traditions that range from simple to complex, healthy to unhealthy. Over time, culinary traditions become deeply rooted in a cultural group's identity.22 , 28 Culinary traditions evolve into a base of food preferences among particular cultural groups.15
Consequences occur as a result of the concept.18 In the case of dietary culture, the consequences inform our understanding of how the concept potentially impacts people. Thus, the consequences are useful in providing a deeper understanding of the cultural impact on diet, rather than viewing diet primarily within the context of the individual. The identified consequences of dietary culture include food choices, nourishment, government guidelines, health status, and belongingness, as depicted in the Figure. Each consequence of dietary culture can potentially impact the continuum of cardiovascular health in a positive or negative way, moving individuals toward or away from cardiovascular wellness.
Food choices and dietary culture are distinctly connected.8 , 22 For example, if the members of a cultural group do not have access to certain types of foods, individuals within that group will be unable to choose those foods. Likewise, people become accustomed to and develop a taste for foods commonly consumed within the cultural group.15 To promote cardiovascular health, the American Heart Association1 and the US Department of Health & Human Services42 recommend diets rich in vegetables, fruits, whole grains, low-fat or nonfat dairy, seafood, legumes, and nuts. Limiting intake of red and processed meats, sugar, and refined grains is also recommended.1 , 42 However, cultural norms may influence eating behaviors that negatively impact heart health. Researchers studying cardiovascular disease risk factors among Indian Australians illustrated this point as they described the cultural importance of sweets at the end of each meal.5
The dietary culture will positively or negatively impact nourishment, depending on the complex factors at play. Nourishment refers not only to the biological aspects of caloric and nutrient intake but also to the mind and spirit.15 Eating meals as part of a cultural group results in either a positive or negative nourishment of the body, mind, and spirit, depending on the dietary culture.7 For example, Qatari women described a cultural emphasis on eating rice and meats cooked with oil and salt, with vegetables being viewed as less desirable.7 Diets that are deficient in fruits and vegetables and high in salt are associated with an increased risk of cardiovascular disease.2 Participants also described feelings of well-being and social connection when eating traditional, good tasting, foods with family and friends.7
People with the power to make the government dietary guidelines typically have been raised and function within the dominant dietary culture. Furthermore, policy makers and constituents are likely to support dietary guidelines that are culturally acceptable. The process of creating the 2015-2020 Dietary Guidelines for Americans provides an example of how culture can impact policy. The dietary guidelines are updated every 5 years, with the initial phase of the revision process including public commentary and discussion.42 The US Department of Health & Human Services creates the guidelines through a process that involves reports of scientific evidence in conjunction with public and federal agency input.42 Multiple, complex factors are at play in creating the government guidelines, such as group and individual ideology and values, external influences and interests, and the personal experiences and intuition of committee members.43 Because the guidelines serve as the premiere source of dietary information for the nation, it is essential that the Dietary Guidelines for Americans advocate for diets that have demonstrated effectiveness in promoting cardiovascular health. However, bias may occur during the development of the guidelines due to cultural beliefs, traditions, and preferences.
Dietary patterns contribute either to a state of health or illness. Since culture is associated with dietary patterns, health status is a logical consequence of dietary culture. For example, people in the United States commonly consume diets that include high amounts of fat, sugar, sodium, and processed foods.41 This type of diet is associated with heart disease, as well as with increased cardiovascular disease risk factors, such as hypertension, type 2 diabetes mellitus, obesity, and hyperlipidemia.1 Thus, foods commonly consumed in the dominant US culture may negatively impact cardiovascular health.
Belongingness encompasses feelings of acceptance or rejection by a social group. When an individual does not ascribe to the dominant dietary culture, the person can feel isolated or rejected.44 For example, people who choose not to eat meat within a dominant meat-eating culture may face discrimination or ridicule that impacts feelings of belongingness.44–46 Food plays a critical role in promoting feelings of belongingness across cultures.15 The need for belonging may prevent people from making dietary choices that promote cardiovascular health if those choices result in feelings of isolation from the group.7
Empirical referents provide a means of measuring or recognizing the defining attributes of a concept.18 The defining attributes of dietary culture include (a) patterned group eating behaviors, (b) unconscious influence, and (c) social organization. Empirical referents of these attributes include food frequency, habit, sociability, and social norms. Food frequency is an empirical referent for patterned group eating behaviors. Data on food frequency among groups can be used to identify and measure the patterned eating behaviors within that group. The Harvard Food Frequency Questionnaire (FFQ) is an instrument that provides a means to measure food frequency among groups. Including FFQs as a data collection instrument provides researchers with a means of quantifying dietary patterns for a variety of purposes. For example, Ogilvie et al47 used the Harvard FFQ to examine the relationship between habitual dietary intake and peripheral artery disease. Habit is an empirical referent for unconscious influence. Referring to habit in terms of diet is evidence of unconscious influence when eating and making food choices. Habit, as related to dietary choice, can be identified by using The Eating Motivation Survey.36 Finally, sociability and social norms are empirical referents of the defining attribute of social organization. The Eating Motivation Survey can also be used to capture sociability and social norms, in terms of individual eating motivation. No instruments were located that integrated measurement of all the empirical referents of dietary culture. Further research on dietary culture is needed for instrument development to promote accurate measurement of the empirical referents.
The concept of dietary culture as related to cardiovascular health lends itself to a philosophical discussion of freewill versus determinism. A central tenet of freewill is that people have full autonomy over their actions. The person is considered the cause of action, with human choices being free from external, influencing factors.48 , 49 The philosophical assumption of freewill is essential to scientific study in nursing.48 Consider the numerous intervention studies aimed at improving diet. Without the assumption of freewill supporting the autonomy of the participants to make dietary choices, research findings may be inherently flawed. When researchers and practitioners exclusively focus on interventions aimed at the individual, the philosophical assumption is that the individual is in complete control of his or her own choices and behaviors. However, the results of this analysis indicate that diet is not strictly a matter of freewill. For example, a person cannot choose to eat foods that are completely unavailable. Likewise, one may experience a sense of social isolation when making dietary choices outside of the dominant culture, which may impact the individual's choice of foods. These examples demonstrate that external factors can impact a person's diet, which then may impact cardiovascular health.
In contrast to freewill, hard determinism encompasses the worldview that humans are not responsible for their behavior.49 Choices are predetermined and guided by external forces.49 This viewpoint is problematic because of the complete removal of individual choice from the discussion. Scientific exploration and intervention development are useless if everything is predetermined. In considering the philosophical assumptions of dietary culture, neither freewill nor hard determinism aligns completely with the complex interplay of factors that encompass the concept. Dietary culture impacts people's eating patterns through cultural norms, beliefs, and attitudes. Despite these external cultural forces, individuals hold some level of individual responsibility for the choices made among those available to him or her.
Freewill and determinism are often viewed as being incompatible and contradictory to one another. The philosophical perspective of soft determinism, or compatibilism, more fully encompasses the complexity of dietary culture within the context of individual choices and behaviors. Compatibilism acknowledges the external forces at play while conceding that individuals also have some level of freewill to make decisions.48 , 50 This philosophical perspective connects individual choices with external factors, such as culture, that impact diet and health.
The debate between freewill and determinism is of central importance to nursing research and practice. The holistic nature of nursing requires a unique understanding of how freewill and determinism interact within the nursing paradigm.48 Rather than debating which philosophical perspective is “right,” nurses are better served by embracing the inherent value and practicality of integrating both perspectives, exploring ways in which both paradigms inform nursing theory and practice. Recognizing individual choice and accountability while acknowledging the deterministic properties of dietary culture better equips nurses to help people effectively navigate the cultural landscape to make heart-healthy dietary choices.
Relevance and Implications for Practice
Considering the global threat of diet-related cardiovascular disease, understanding and defining the concept of dietary culture are of critical importance to nursing. As previously stated, dietary culture can be defined as patterned group eating behaviors that are unconsciously influenced and socially organized. The proposed defining attributes provide a means for nurses to recognize and assess dietary culture. From a philosophical perspective, identified antecedents, defining attributes, and consequences may inform nurses' understanding of how to help individuals assert freewill to work in harmony with external cultural influences to promote successful dietary changes that support cardiovascular health. The consequences identified through this concept analysis are useful to clarify potential connections between dietary culture and cardiovascular health. Overall, recognizing the relationship between diet, culture, and cardiovascular health may assist nurses to identify potential interventions aimed at reducing cultural conflict to increase heart-healthy diet compliance.15
The complex nature of dietary culture lends itself to an interdisciplinary approach. Nurses can collaborate with nutrition experts to identify nutritionally balanced eating behaviors that are congruent with the dietary culture while supporting positive heart health. Social workers can provide people with valuable support regarding physical and financial access to heart-healthy foods and promote family support for positive dietary choices.
Because of the significant health threat posed by cardiovascular disease, nurses need to advance theoretical and practical knowledge aimed at promoting cardiovascular health. This analysis aimed to define the concept of dietary culture to increase the understanding of the links between diet, culture, and cardiovascular health. The findings of this analysis suggest that dietary culture is defined by patterned group eating behaviors that are unconsciously influenced and socially organized. Expressing the concept in clear and measurable terms may allow opportunities for nurses and other health care professionals to collaborate in applying the concept to cardiovascular health promotion. The proposed definition of dietary culture provides a building block for future exploration and development of the concept in nursing theory, research, and practice. Suggestions for future research include the identification and analysis of related concepts to be used in theory construction and further theoretical and clinical validation of the proposed defining attributes.18
1. Benjamin EJ, Blaha MJ, Chiuve SE, et al Heart disease and stroke statistics—2017 update: a report from the American Heart Association. Circulation. 2017;135(10):e146–e603.
2. Writing Group Members; Mozaffarian D, Benjamin EJ, Go AS, et al Heart disease and stroke statistics—2016 update: a report from the American Heart Association. Circulation. 2016;133(4):e38–e360.
3. Mendis S, Puska P, Norrving B. Global Atlas on Cardiovascular Disease
Prevention and Control. Geneva, Switzerland: World Health Organization in collaboration with the World Heart Federation and World Stroke Organization; 2011.
4. Tung W-C, Barnes M. Heart diseases among Native Hawaiians and Pacific Islanders. Home Health Care Manag Pract. 2014;26(2):110–113.
5. Fernandez R, Rolley JX, Rajaratnam R, Everett B, Davidson PM. Reducing the risk of heart disease among Indian Australians: knowledge, attitudes, and beliefs regarding food practices—a focus group study. Food Nutr Res. 2015;59:1–7.
6. Sun J, Buys NJ, Hills AP. Dietary pattern and its association with the prevalence of obesity, hypertension and other cardiovascular risk factors among Chinese older adults. Int J Environ Res Public Health. 2014;11(4):3956–3971.
7. Donnelly TT, Al Suwaidi J, Al Enazi NR, et al Qatari women living with cardiovascular diseases—challenges and opportunities to engage in healthy lifestyles. Health Care Women Int. 2012;33(12):1114–1134.
8. Koenig CJ, Dutta MJ, Kandula N, Palaniappan L. “All of those things we don't eat”: a culture
-centered approach to dietary health meanings for Asian Indians living in the United States. Health Commun. 2012;27(8):818–828.
9. Casas Patino D, Rodriguez Torres A, Contreras Landgrave G, Casas Patiño I, Maya Martinez MdlA. Social representations of the diet
in patients with diabetes mellitus. Divers Equality Health Care. 2017;14(2):46–52.
10. Cole JA, Smith SM, Hart N, Cupples ME. Do practitioners and friends support patients with coronary heart disease in lifestyle change? A qualitative study. BMC Fam Pract. 2013;14(1):126–135.
11. Yehle KS, Chen AM, Plake KS, Yi JS, Mobley AR. A qualitative analysis of coronary heart disease patient views of dietary adherence and web-based and mobile-based nutrition tools. J Cardiopulm Rehabil Prev. 2012;32(4):203–209.
12. Doyle B, Fitzsimons D, McKeown P, McAloon T. Understanding dietary decision-making in patients attending a secondary prevention clinic following myocardial infarction. J Clin Nurs. 2012;21(1/2):32–41.
13. Rong X, Peng Y, Yu HP, Li D. Cultural factors influencing dietary and fluid restriction behaviour: perceptions of older Chinese patients with heart failure. J Clin Nurs. 2017;26(5–6):717–726.
14. Zou P. Diet
and blood pressure control in Chinese Canadians: cultural considerations. J Immigrant Minor Health. 2017;19(2):477–483.
15. Leininger M, McFarland M. Transcultural Nursing: Concepts, Theories, Research, & Practice. 3rd ed. New York, NY: McGraw-Hill; 2002.
16. Kim HS. The Essence of Nursing Practice: Philosophy and Perspective. New York, NY: Springer; 2015.
17. McCurry MK, Revell SMH, Roy SC. Knowledge for the good of the individual and society: linking philosophy, disciplinary goals, theory, and practice. Nurs Philos. 2010;11(1):42–52.
18. Walker L, Avant K. Strategies for Theory Construction in Nursing. Upper Saddle River, NJ: Pearson/Prentice Hall; 2011.
21. Salvador Peña A, Arie Crusius JB. Central America in transition: from maize to wheat. Challenges and opportunities. Nutrients. 2015;7(9):7163–7171.
22. Hui-Tun C. The rise of culinary tourism and its transformation of food cultures: the national cuisine of Taiwan. Copenhagen J Asian Stud. 2009;27(2):84–108.
23. Ren J, Chung J-E, Stoel L, Xu Y. Chinese dietary culture
influences consumers' intention to use imported soy-based dietary supplements: an application of the theory of planned behaviour. Int J Consumer Stud. 2011;35(6):661–669.
24. Tamang JP. Indian dietary culture
. J Ethnic Foods. 2016;3(4):243–245.
25. Hu FB, Satija A, Rimm EB, et al Diet
assessment methods in the nurses' health studies and contribution to evidence-based nutritional policies and guidelines. Am J Public Health. 2016;106(9):1567–1572.
26. Lewicka PB. Diet
. On the medical context of food consumption in the medieval Middle East. Hist Compass. 2014;12(7):607–617.
27. Clarence-Smith WG. The traditional dietary culture
of South East Asia: its formation and pedigree. J Asian Hist. 2005;39(2):188.
28. Rath EC. How intangible is Japan's traditional dietary culture
? Gastronomica. 2012;12(4):2–3.
29. Matsuyama A. The Traditional Dietary Culture
of Southeast Asia: Its Formation and Pedigree. Tomomatsu A, trans-ed. London; New York: Kegan Paul; New York: Distributed by Columbia University Press; 2003.
30. Chinese Dietary Culture
Library. Natl Central Libr Newsl. 2008;39(2):9.
31. Sato Y, Tsubota-Utsugi M, Chiba T, et al Personal behaviors including food consumption and mineral supplement use among Japanese adults: a secondary analysis from the National Health and Nutrition Survey, 2003-2010. Asia Pac J Clin Nutr. 2016;25(2):385–392.
32. Madheswaran R, Balachandran C, Murali Manohar B. Influence of dietary culture
material containing aflatoxin and T(2) toxin on certain serum biochemical constituents in Japanese quail. Mycopathologia. 2004;158(3):337–341.
33. Gorelik O, Almoznino-Sarafian D, Feder I, et al Dietary intake of various nutrients in older patients with congestive heart failure. Cardiology. 2003;99(4):177–181.
34. Sproesser G, Imada S, Furumitsu I, et al What constitutes traditional and modern eating? The case of Japan. Nutrients. 2018;10(2):pii–E118.
35. Tan MG. Chinese dietary culture
in Indonesian urban society. In: Wu DYH, Cheung SCH, eds. The Globalization of Chinese Food. Honolulu, HI: University of Hawaii Press; 2002:152–169.
36. Renner B, Sproesser G, Strohbach S, Schupp HT. Why we eat what we eat. The Eating Motivation Survey (TEMS). Appetite. 2012;59(1):117–128.
37. Lee KW, Cho MS. The traditional Korean dietary pattern is associated with decreased risk of metabolic syndrome: findings from the Korean National Health and Nutrition Examination Survey, 1998-2009. J Med Food. 2014;17(1):43–56.
38. Ezme AT. Muslim immigrants' food culture
and its effects on location preference. J Suleyman Demirel Univ Inst Soc Sci. 2017;29(4):735–759.
39. Sapkota S, Brien JE, Gwynn J, Flood V, Aslani P. Perceived impact of Nepalese food and food culture
in diabetes. Appetite. 2017;113:376–386.
40. Harris JM, Shiptsova R. Consumer demand for convenience foods: demographics and expenditures. J Food Distrib Res. 2007;38(3):22–36.
41. Grotto D, Zied E. The standard American diet
and its relationship to the health status of Americans. Nutr Clin Pract. 2010;25(6):603–612.
43. Hinshaw AS, Grady PA. Shaping Health Policy Through Nursing Research. New York, NY: Springer Publishing; 2011.
44. Greenebaum JB. Managing impressions: “face-saving” strategies of vegetarians and vegans. Humanity Soc. 2012;36(4):309–325.
45. MacInnis CC, Hodson G. It ain't easy eating greens: evidence of bias toward vegetarians and vegans from both source and target. Group Process Intergroup Relat. 2017;20(6):721–744.
46. Bresnahan M, Zhuang J, Zhu X. Why is the vegan line in the dining hall always the shortest? Understanding vegan stigma. Stigma Health. 2016;1(1):3–15.
47. Ogilvie RP, Lutsey PL, Heiss G, Folsom AR, Steffen LM. Dietary intake and peripheral arterial disease incidence in middle-aged adults: the Atherosclerosis Risk in Communities (ARIC) Study. Am J Clin Nutr. 2017;105(3):651–659.
48. Polifroni EC, Packard S. Psychological determinism and the evolving nursing paradigm. Nurs Sci Q. 1993;6(2):63–68.
49. Sappington AA. Recent psychological approaches to the free will versus determinism issue. Psychol Bulletin. 1990;108:19–29.
50. James W. The dilemma of determinism. The Will to Believe and Other Essays in Popular Philosophy. New York, NY: Longmans, Green and Co; 1896:145–183.