Disparities in Heart Disease Among Women

Heart disease is the leading cause of death in women in the United States, accounting for more deaths than stroke, lung cancer, and breast cancer.^[1,2] Cardiovascular diseases account for one third of all deaths in women worldwide.^[3] This third essay on “Nutrition, Culture, and Women’s Health” focuses on the influence of acculturation on dietary habits of women.

Within the United States, heart disease prevalence is highest among black women, followed by Mexican-American and Caucasian women.^[2] Data specifically detailing the prevalence of heart disease among Asian-American women is lacking, although heart disease is the leading cause of death among women of Asian/Pacific Island descent. Women of South Asian descent are at greater risk of heart disease than those of Japanese descent.

Internationally, coronary events among women occur most often in the United Kingdom and least often in Spain and China.^[3] Mortality attributed to heart disease, however, is highest for women in the Ukraine and lowest in women living in Japan.^[4] In developing countries, heart disease morbidity and mortality are steadily increasing, and this has been attributed to the adoption of a Western lifestyle.^[3,5] It has been predicted that within the next 10 to 20 years, developing countries will list heart disease as the most common cause of death.

Culture and Diet

The impact of diet on heart health is well established, with the American Heart Association recommending a heart-healthy diet focused on limiting foods high in saturated fats and cholesterol and emphasizing whole grains, fruits, and vegetables.^[6-8] However, a woman’s cultural beliefs, traditions, and ethnic preferences exert a strong influence on her diet.^[9] In addition, availability, cost, and convenience, as well as role responsibilities, time constraints, and dietary knowledge, influence food selection and preparation. For women immigrating to the United States, acculturation is a major influence on their diet.

Immigrants to the United States experience greater risks of chronic diseases, such as heart disease, than their counterparts in their countries of origin.^[10] One explanation for the increased risk is dietary change. As a result, “dietary acculturation”^[10] has received considerable attention in recent research examining ethnic groups’ dietary habits. Acculturation refers to the adoption of a majority culture’s attitudes, beliefs, values, and behavior. The process of acculturation is complex and nonlinear and is influenced by many factors. Satia-Abouta and colleagues^[10] propose a model for understanding the complexity of the acculturation process: Socioeconomic/demographic and cultural factors are influenced by the new culture that result in changes in knowledge, attitudes, beliefs, values, and preferences, which affect food purchasing and preparation. The result of these changes can be the adoption of some majority culture dietary practices and the maintenance of some traditional practices. For example, an immigrant may adopt a Western-style breakfast and continue eating a traditional evening meal or may replace portions of meals with Western foods. Some of the adopted practices may be healthful, such as reducing dietary saturated fats. Other adopted practices may not promote a healthy diet, such as increasing consumption of soft-drink beverages and fast food.

Results of a recent study showed that the measure used to define acculturation influenced the outcome.^[11]This study of 119 Hispanic women in the San Francisco Bay Area showed that language and birthplace combined were most discriminating in identifying dietary changes as compared with language preference alone or number of years living in the United States. The number of years of residence in the United States was not associated with changes in diet, and language alone identified fewer dietary changes than birthplace and language preference combined. The most highly acculturated Hispanic women — defined as born in the United States with English as the preferred language — consumed more convenience foods, salty snacks, and fatty foods than the less-acculturated women who were born outside the United States and preferred speaking Spanish. Less-acculturated women consumed more beans in their diet.

Another study using preferred language, birthplace, and ethnic self-identification as determinants of acculturation examined dietary habits of Hispanics and non-Hispanic whites from the Yakima Valley in central Washington.^[12] Most of the Hispanics in this region immigrated from Michoacan, Mexico, thus constituting a predominantly homogenous group. More than half of the sample was female. The results showed that of the 1689 interviews analyzed, Hispanics who were less acculturated ate more fruit and vegetables daily than the highly acculturated Hispanics. More highly acculturated Hispanics reported using more oil when cooking. However, the difference in total fat consumption between highly acculturated and low-acculturated Hispanics was not statistically significant. Interestingly, low-acculturated Hispanics used no added fat when eating potatoes and bread. All of the Hispanic subjects seldom chose low-fat items when eating in fast-food restaurants and consumed more fruits and vegetables than the non-Hispanic white subjects. The results of this study suggest that maintenance of traditional dietary practices of eating fruits and vegetables and eating potatoes and bread without adding margarine at the table is important and should be encouraged.

Heterogeneity within immigrant groups may lead to differences in acculturation levels and subsequent changes in diet. A study of Hispanic elders in Massachusetts illustrates the effect of diversity within an ethnic group.^[13] Subjects were 61 to 80 years old, and more than half were female. Of the 937 subjects interviewed, 436 were Puerto Rican, 128 Dominican, 147 other Hispanic, and 226 non-Hispanic whites. Results of this study showed that on the basis of language preference and familiarity, Puerto Ricans were more highly acculturated than Dominicans, although both were less acculturated than other Hispanic groups. Overall, the majority of these Hispanic subjects were not highly acculturated. Dietary differences were found between the groups: Dominicans ate more complex carbohydrates and less monounsaturated fats than the other 2 Hispanic groups. Puerto Rican and Dominican women reported lower total energy intake and lower saturated fat and higher polyunsaturated fat consumption than non-Hispanic white women. The more acculturated Hispanics residing in the United States for more than 20 years had diets similar to non-Hispanic white subjects who obtained most of their energy from sweet baked foods and breads. The main source of complex carbohydrates for all Hispanic groups was beans and plantains, with rice as the main contributor of total energy.

As is the case for Hispanic Americans, the adoption of Western dietary practices among Asian Americans varies with the country of origin. According to a recent study, first-generation Chinese immigrants from Mainland China increased their consumption of grain products, fruits, and meats to a greater degree than individuals from Taiwan, Hong Kong, and other locations.^[14] Consumption of dairy products and a wider variety of foods increased for all immigrant subjects. Other dietary changes noted among more acculturated subjects included consumption of more bagels, pizza, fats and sweets, and sodas than those less acculturated (based on length of residency). Sixty-four percent of study participants reported skipping breakfast after moving to the United States, although 44.1% said they believed their diet was more healthful in the United States. Availability and convenience were the most prevalent reasons cited for changes in eating patterns.

Korean immigrants may change their traditional eating habits more slowly than other Asian immigrants.^[15]Results of a study of predominantly South Korean immigrants showed overall low levels of acculturation; nevertheless, greater acculturation was associated with changes in diet.^[15] Those immigrants who viewed themselves as American, spoke English, used American media, and had American friends were considered more acculturated. Subjects who were more acculturated consumed more bread, cereal, spaghetti, pizza, green salads, sweets, and soft drinks than those who were less acculturated. Greater acculturation was associated with higher levels of fat as a percent of total energy, although the total amount of fat consumed was still lower than that found in the typical US diet. The less-acculturated Koreans consumed significantly less fat, more fiber, and more salt than the more highly acculturated Koreans.

Practice Implications

Although acculturation affects eating habits of all immigrants, there are important differences between and among immigrant groups.^[10] Some immigrants may adopt new dietary patterns more quickly than others. For example, Koreans may be slower to change their eating habits than other Asian immigrants,^[15] and Dominicans and Puerto Ricans may be more inclined to maintain traditional eating habits than other Hispanic groups.^[13] English proficiency and birthplace have a significant influence on the extent of dietary change, as do food availability and accessibility,^[10,12-14] and are important to assess when encouraging dietary changes to improve heart health. Because immigrants bring unique beliefs and strong family values with them to the United States, attention to health beliefs and household composition also can be important in identifying barriers to adopting heart-healthy eating habits.^[10]

Dietary acculturation can include healthy and unhealthy change.^[10] Some immigrants may maintain traditional consumption of fruits and vegetables and increase consumption of fast foods and sweets. The fusion of traditional eating habits with Western-style eating habits requires an individualized approach that assesses the dietary practices, language proficiency, level of nutrition knowledge, food availability and accessibility, and the individual’s level of affiliation with their ethnicity.