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.

Studies with Mexican Americans and Puerto Ricans suggest that including ethnic and cultural preferences can improve glycemic status and reduce the incidence of complications.

Resnicow and colleagues¹⁴ 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 systematic, exploratory review of qualitative peer-reviewed studies.^21-23 This approach allowed for the development of definitions that were applicable across studies from different disciplines (nursing, medicine, anthropology, health promotion, and diabetes).

Review by the Institutional Review Board was not required for this study because human subjects were not involved, per the US Department of Health and Human Services guidelines.²⁴

Data Selection

Criteria for selecting articles for inclusion were developed based on content analysis methodology for a consistent, systematic approach to sampling studies (Figure 1).²¹ The criteria included:

a qualitative study design of interviews, focus groups, or mixed methods;

published between 2000 and 2015;

at least 50% Mexican American participants in the study;

a combination of the following key terms:

diabetes and/or type 2 diabetes mellitus;

Hispanic, Latino, and/or Mexican American;

culture, cultural, culturally, culturally sensitive, and/or culturally competent;

barriers, facilitators, perspective, adapted, beliefs, and/or health beliefs;

nutrition, food, eating, and/or diet.

Figure 1

Flow Diagram of literature search and selection of studies

Studies were located using Web of Science (indexes social science journals), PubMed (indexes health and biomedical journals), ProQuest (indexes social science journals), and Cumulative Index to Nursing and Allied Health Literature (indexes nursing and allied health journals). All articles were available in English and were published in peer-reviewed journals.

From the initial search, 244 abstracts were examined by the primary author. Duplicate abstracts were excluded, and an ancestry search (a search of the bibliography) was conducted to find missed studies. When the ethnicity of study participants was unclear, the corresponding authors were contacted for confirmation. Finally, the studies were included if the primary author and a trained research assistant reached consensus that the study’s abstract reported on a concept(s) culturally relevant to diet for T2DM self-management. A total of 18 studies were included.

Cultural Influences Coding

The content analysis approach facilitated the “cultural influences” coding guide.^21,25 The primary author developed the coding guide by reviewing the 18 studies that met the inclusion criteria. The coding guide was created using an inductive approach to identify and develop the initial list of definitions and descriptions of the cultural influences relative to diet for T2DM self-management from the selected studies. Next, the primary author (and the primary coder) trained a secondary coder on material and concepts relative to nutrition recommendations for T2DM self-management,²⁶ cultural influences on T2DM self-management for Mexican Americans,^26-28 and using the coding guide. The coders met weekly for 10 weeks to discuss and clarify concepts and establish consensus on subcategories and definitions.

A number was assigned for the level of evidence of cultural influences identified in the results section of the studies: 0 indicated that the cultural influence was not present in the study, 1 indicated that the cultural influence was stated or paraphrased by the authors, and 2 indicated that a direct participant quote that represented the cultural influence from the original data was provided in the study. Interrater reliability was evaluated with Cohen’s kappa using STATA/IC 14.1.

Quality Appraisal

The adapted Critical Appraisal Skills Programme (CASP) qualitative checklist, which consists of 36 scored questions, was used to describe the quality of the article used in this study.²³ The items on the CASP qualitative checklist had a percentage agreement between 68.42% and 100% and an overall average agreement of 85.26% among the 2 coders. Each of the deep-structure cultural influences identified was grouped into categories of influences.

Results and Discussion

The 18 qualitative studies examined for this analysis revealed a variety of deep-structure cultural influences that play a role in diet-related behaviors of Mexican Americans in their efforts toward achieving glycemic targets (Table 1). Among the 18 studies, 7 were focus groups, 7 were in-depth interviews, 2 used both focus groups and in-depth interviews, and 1 was a secondary data analysis of qualitative data.^29-46 The average CASP score for all the articles was 17.16, ranging from 12.5 to 23 out of a score of 30; therefore, no studies were excluded from the analysis. At least one deep-structure cultural influence was coded in each study. The average percentage agreement for cultural influences in the analysis was 89%, and the average Cohen’s kappa was 0.79.²¹ Table 2 lists the food-related cultural influences related to the categories of family influences and beliefs about foods.

Table 1

Summary of Articles’ Research Methods and Frequency of Deep-Level Cultural Influences

Author and Date of Publication	Research Method	Participants	Percentage US Born	Years of T2DM Diagnosis	Number of Deep-Level Cultural Influences	CASP Checklist Score (range)
Alcozer, 2000²⁹	Secondary analysis of in-depth interviews	20 female 20 Mexican American	100	6 (14 mo to 20 y)	3	12.5 (12-13)
Benavides-Vaello and Brown, 2010³⁰	Individual interviews	9 female 9 Mexican American	NA	≥9 y	4	18 (17-19)
Clark et al, 2009³¹	Focus groups	15 female 5 male 20 Mexican/Mexican American	NA	≥1 y	4	21 (20-22)
Coronado et al, 2004³²	Focus groups	28 female 14 male 42 Mexican American	NA	NA	3	18.5 (18-19)
Hadwiger, 2005³³	Formal interviews	7 female 3 male 10 Mexican American	20	3.5 average (3 wk to 20 y)	1	23 (21-25)
Hansen and Cabassa, 2012⁴⁶	Focus groups	16 female 3 male 18 born in Mexico	0	NA	3	21.5 (21-25)
Heuer and Lausch, 2006³⁴	Interviews	6 female 6 male 12 Mexican American	NA	≥1 y	1	17 (16-18)
Hu et al, 2013³⁵	Focus groups	27 females 9 males 28 Mexican immigrants	22.2	NA	3	21 (19-23)
Hunt et al, 2000³⁶	In-depth interviews	21 female 22 male 43 Mexican American	NA	6 mo to <1 y: 3 1-5 y: 17 >6 y: 23	2	16 (15-17)
Jezewski and Poss, 2002³⁸	In-depth interviews and focus groups	19 female 6 male 25 Mexican American	16	14 average (1-45 y)	6	15.5 (15-16)
McCloskey and Flenniken, 2010⁴⁰	In-depth interviews	37 female 13 male >50% Mexican American*	NA	NA	3	14.5 (14-15)
McEwen and Murdaugh, 2014⁴¹	Focus groups	8 female 4 male 12 Mexican origin	NA	>1 y	4	17 (15-19)
Melancon, et al, 2009⁴²	Focus groups	9 female 9 male 18 Mexican American or Mexican native	NA	6.77 average (1-20 y)	5	14.5 (14-15)
Poss and Jezewski, 2002³⁹	In-depth interviews and focus groups	18 females 4 males 22 Mexican American	18.2	14 average (1-45 y)	3	16.5 (16-17)
Poss et al, 2003³⁷	Interviews	18 females 4 males 22 Mexican American	18.2	14 average (1-45 y)	2	15.5 (14-17)
Rustveld et al, 2009⁴³	Focus groups	34 males 27 Mexican origin	80	NA	3	16 (15-17)
Sawyer and Deines, 2013⁴⁴	Semistructured interviews	9 females 9 Mexican American or Mexican native	22.2	>1 y	6	17
Weiler and Crist, 2009⁴⁵	In-depth semistructured interviews	6 female 4 male >50% MexicanAmerican*	NA	10 average (1.5-40 y)	4	16

The author confirmed that more than 50% of participants in study were of Mexican-American heritage.

Abbreviations: CASP, Critical Appraisal Skills Programme; T2DM, type 2 diabetes.

Table 2

Frequency, Level of Evidence, and Interrater Reliability of Influences on Diet From 19 Studies

Influences by Categories	Average Code for Influences (N = 19)	Frequency of Influence Appearance (N = 19) n (%)	Frequency of Influence Appearance at Level 2 Evidence (N = 19) n (%)	Cohen’s Kappa Coefficient (% agreement)
Family influences
Influence of family involvement	1.05	11 (57.9)	9 (47.4)	0.97 (94.7)
Family turmoil	0.79	9 (47.4)	6 (31.6)	0.68 (79.0)
Influence of familismo	1.57	7 (36.8)	4 (21.1)	0.79 (89.5)
Beliefs about food
Beliefs or attitudes about foods in general	1.42	15 (78.9)	12 (63.2)	0.70 (84.2)
Beliefs or attitudes about Mexican/cultural foods	0.53	7 (36.8)	3 (15.8)	0.72 (84.2)
Beliefs or attitudes about nopal/cactus	0.32	5 (26.3)	1 (5.3)	0.87 (94.7)
Beliefs or attitudes about tea	0.32	5 (26.3)	2 (10.5)	0.74 (89.5)

Family Influences

The cultural influences related to family were the influences of familismo (7 studies), family involvement (11 studies), and family turmoil (7 studies). Table 3 provides quotes from each study demonstrating examples of the deep-structure cultural influences.

Table 3

Sample Quotes From Study Findings by Categories of Influences on Diet and Type 2 Diabetes

Author and Date of Publication	Quotes by Categories of Influences on Diet and T2DM “Author Descriptions” (coded as 1) Quotes From Participants in Studies (coded as 2)
Alcozer, 2000²⁹	Family influences My sister told me to cut down on sweets ‘cause I would get diabetes. [Influence of family involvement, 2] Beliefs about food We would go to the bakery and get our pan dulce [pastry] every Saturday morning, did that for years. Because of the sweet tooth, you get diabetes. [Beliefs or attitudes about foods general, 2]
Benavides-Vaello and Brown, 2010³⁰	Family influences I kept making them [flour tortillas] but I kept making less. They [family] would ask for more, but I would say, “That’s it, if you want more you can eat corn.” [Influence of family involvement, 2] Beliefs about food I eat sweets when I’m nervous. I just like calm down [when I eat sweets]. Not candy… I eat pies, cakes, pan dulce [Mexican pastry], you know. [Beliefs or attitudes about foods in general, 2]
Clark et al, 2009³¹	Family influences You can’t say no. We are a very big-hearted people, we worry about our family. We worry about our children. [Influence of familismo, 2] Beliefs about food My girlfriend will tell me if I’m eating sweetened stuff, “There you go, trying to kill yourself again.” [Beliefs or attitudes about foods in general, 2]
Coronado et al, 2004³²	Family influences From there, I began to feel poorly. I felt very hungry and had a lot of coraje. I would eat two full plates. My husband was an alcoholic and I was always alone and this gave me much coraje. Alone, I took care of my children, feeling my mouth really dry, and very hungry, and coraje. [Family turmoil, 2] Beliefs about food If I eat a lot, I eat candy, my children know that this is my poison and with this I can die. With this, I will die because I should not eat sweet bread nor corn tortillas. I am a big corn eater. [Beliefs or attitudes about foods in general, 2]
Hadwiger, 2005³³	Family influences Many times, we as women carry the heaviest burden. Men go to work, but we stay behind and take care of the household. [Influence of familismo, 2]
Hansen and Cabassa, 2012⁴⁶	Family influences I would get up with that depression, much sadness and I would cry… and my daughter said to me one day “Listen mom… how come all you do is cry?” She said, “You never cry.” A girl of eight years told me that. I started thinking… I have to look for help because this is making them feel bad and me also. [Influence of family involvement, 2]
Heuer and Lausch, 2006³⁴	Beliefs about food I could have taken better care of myself, not eat as much. I shouldn’t have eaten things like sweets. [Beliefs or attitudes about foods in general, 2]
Hu et al, 2013³⁵	Family Influences The food is a problem because my husband is not used to eating what I eat. He eats how I used to eat and it’s all junk food. He does not eat healthy foods. He eats other things, and it is difficult to make separate food for him, for my daughter, and me. He eats his own food, and my daughter eats her own food, and I eat healthy food. [Family turmoil, 2] Beliefs about food I was a coca cola addict. I drank a lot of sodas. It was 2 years ago that they told me I was killing myself by drinking all of the daily sodas. I finally stopped. Now, you can put a cold coca cola in front of me and I would refuse to drink it because I could feel myself dying when I drank sodas. My arms would become numb, my fingers would get swollen, and my cholesterol would rise. /Beliefs or attitudes about foods in general, 2]
Hunt et al, 2000³⁶	Beliefs about food Some people in our study reported having increased these dietary uses of nopal as an adjunct to their treatment for diabetes. [Beliefs or attitudes about nopal/cactus, 1]
Jezewski and Poss, 2002³⁸	Family influences Most of the people in the study could attribute a specific fright or emotional experience (accidents, witnessing deaths from motor vehicle accidents or drowning, or stress precipitated by the troubles of family members) as the contributing factor in developing diabetes. [Family turmoil, 1] Beliefs about food I always read the label on the food package, and if it says 8 grams of sugar, it is not too much because if it is below 8 grams, it is OK, but if it is more than 8 grams it is too much. [Beliefs or attitudes about foods in general, 2]
McCloskey and Flenniken, 2010⁴⁰	Family influences The food is a problem because my husband is not used to eating what I eat. He eats how I used to eat and it’s all junk food. He doesn’t not eat healthy foods…. He eats his own food, and my daughter eats her own food and I eat healthy food. [Influence of family involvement, 2] Beliefs about food See my parents ate sugar and they ate tamales and tacos and enchilada with lard! And my dad lived to be 82; my mom was 92. And they didn’t get diabetes ‘til later in life, and they were able to get away with it for so much longer. But it’s because, I think, all their foods weren’t chemicalized like ours are, contaminated with whatever. And so I think it was easier for them. And then junk foods, my parents never had… well, there weren’t any junk foods to buy. [Beliefs or attitudes about foods in general, 2] Because I was used to probably the worst of the worst. Potatoes and beans…. Hey, I’m Hispanic! Chili, tortillas, all that. A lot of that is out. Not completely, but in smaller quantities, portions, that it has been rough. [Beliefs or attitudes about Mexican/cultural foods, 2]
McEwen and Murdaugh, 2014⁴¹	Family influences I know I can have a little piece of the bread not the whole thing, we ask family to bring the veggies, it takes a while for them to get it… but some families are getting it they bring yogurt dips and veggies. That’s the hard part that we’re not all on the same page. [Influence of family involvement, 2] Beliefs about food We have tried to do things differently like using less oil and grease and we buy turkey for sandwiches. [Beliefs or attitudes about foods in general, 2]
Melancon et al, 2009⁴²	Family influences People who know they have diabetes do nothing to follow-up. Do it for [your] family if nothing else. I have 6 year-old girl and want to see her grow up. [Influence of familismo, 2] Beliefs about food I never go to the doctor after being diagnosed. I stopped going and treat myself with herbs, teas, and so on. [Beliefs or attitudes about tea, 2]
Poss and Jezewski, 2002³⁹	Beliefs about food And then the person starts to feel uneasy and nervous, and he eats more and more of the wrong type of foods. The only symptom I had was that I felt kind of sick and had no strength. [Beliefs or attitudes about foods in general, 2]
Poss et al, 2003³⁷	Beliefs about food When I started taking Glucotrol, I stopped drinking the herbal tea. I used to drink it, but I don’t anymore because I am afraid that my blood sugar may go down too much. /Beliefs or attitudes about tea, 2]
Rustveld et al, 2009⁴³	Family influences If there’s been a long time since you last went to visit your home country and your family is there, waiting for you with lots and lots of pork and all that… it’s really difficult to look at the pork and not eat it. And they’ll tell you: Come on, now that you live in the US you’re more used to hamburgers? You don’t want to share a meal with us? [Family turmoil, 2] Beliefs about food Like us Hispanics, it’s hard for us to eat foods that do not contain much fat or grease, because everything we grew up with was cooking that way. [Beliefs or attitudes about Mexican/cultural foods, 2]
Sawyer and Deines, 2013⁴⁴	Family influences Here, I didn’t cook them with any grease, I bought the kind that didn’t have lots of fat—[and I say] “No, no, I can’t eat that,” and he’ll say, “Come on, have some”… like on Saturdays and Sundays, he’ll cook for himself because he says that I make everything too low-fat. /Family turmoil, 2] Beliefs about food I buy nopales. And I put them in the Ostarizer with water and I drink the juice and it [blood sugar] goes down like that. Nopales are the best thing you can eat when your sugar is high. [Beliefs or attitudes about nopal/cactus, 2]
Weiler and Crist, 2009⁴⁵	Family influences There doesn’t go a day without somebody reminding me about, “Oh… I haven’t seen you take your medicine today,” or “I haven’t seen you take your shot, your insulin” uh… somebody is always reminding me or asking if I did, uh… because they are always looking out for each other. [Influence of family involvement, 2] Beliefs about food The most difficult part is… uh… the cooking… you know how Mexican people cook, and it doesn’t even come to mind what I should cook… and healthy. [Beliefs or attitudes about Mexican/cultural foods, 2]

Abbreviation: T2DM, type 2 diabetes.

Familismo was expressed as the importance of taking care of the family over oneself, and many of the quotes reflected on food or the needs of the youth in the family. Because family is an important value for many Hispanic/Latino ethnic groups, understanding familismo is central to making diet and health-related choices and can enhance the dietitian’s ability to help patients incorporate better choices toward achieving glycemic targets.^47,48 Several studies support the value of familismo as a motivating factor for self-management.^49-54 Understanding this cultural value may help health care providers build rapport and engage the family members by sharing knowledge and engaging them in a supportive role in the attainment of the patient’s goals.^47,55

Family members also got involved in their T2DM care by communicating their opinions on food preferences or social support. Inclusion of family in nutrition counseling sessions may also increase collective knowledge regarding the severity of the disease and aid in facilitating T2DM self-management behaviors.^56,57 Evidence supports family members’ role in supporting lifestyle behavior changes, including diet, physical activity, and simple daily tasks such as reminders to take diabetes medicine.^49-51,53,54

The cultural influences related to family were the influences of familismo (7 studies), family involvement (11 studies), and family turmoil (7 studies).

Family turmoil is an influence that harms mental or physical health—a type of disturbance, confusion, or uncertainty attributed to a family member or caused by a family member. Examples of family turmoil included teasing by family members regarding diet^31,35 and feeling social pressure to eat foods not congruent with diabetes care.^43,44 Diabetes educators and nutrition professionals can help patients overcome the challenge of eating different foods from their families. Nutrition professionals can also use their diet expertise to encourage a patient to include more cultural foods that the family enjoys, such as nopales, and set goals so that the family can explore and enjoy food together.

Beliefs About Foods

The cultural influences related to beliefs about foods were beliefs or attitudes about foods in general (15 studies), beliefs or attitudes about Mexican/cultural foods (7 studies), beliefs or attitudes about nopal/cactus (5 studies), and beliefs or attitudes about tea (5 studies). For the category of beliefs or attitudes about Mexican/cultural foods, participants reported reflections that associated Hispanic/ethnic cuisine as being detrimental to T2DM. Other studies show similar sentiments, specifically that tortillas and rice were “bad” for diabetes.^9,51,55 These beliefs or attitudes about Mexican/cultural foods may be due to a Eurocentric view on health. In focus groups with 21 Mexican American participants, participants reported that food preparation at home is healthier than dining out at a restaurant, especially for preventing T2DM.⁵⁸ To address the misconception that Mexican/cultural foods are detrimental to T2DM, nutrition counseling should be tailored to promote healthful food preparation methods rather than excluding cultural foods.^9,58-60

The current study provides examples of cultural foods that may benefit the diet: nopales because they are high in fiber and herbal teas to displace the consumption of sugar-sweetened beverages. Individuals with T2DM perceived nopal/cactus to have positive glycemic benefits, while those participants describing tea as a treatment were mixed. A cup of cooked nopales with no added fat contains 24 calories, 2 grams of protein, and 3 grams of fiber. Nopales are a good source of calcium, with 246 mg, or 24% of the daily reference intake for adults ages 19 to 50.^61,62 Regarding tea, the participants reported its use as either beneficial or ineffective but not detrimental. Chamomile tea or hibiscus flower (agua de Jamaica) are popular beverage choices among Mexican Americans.⁶³ Studies with Mexican Americans report examples of how nopales^50,52 and tea⁶⁴ are traditional cultural foods integrated into the diet. Knowledge and inclusive counseling of healthful traditional cultural food choices show attentiveness and respect for someone’s culture.

Clinical Application

Dietary behavior and patterns play an integral role in disease management for diabetes and should not be generalized. Cultural mores, beliefs, and values, especially as they relate to food choice behaviors, are unquestionably important for providing culturally sensitive, tailored, appropriate patient care for all patients. This study elucidates some key cultural considerations for practitioners involved in diabetes care with Mexican Americans.

Cultural mores, beliefs, and values, especially as they relate to food choice behaviors, are unquestionably important for providing culturally sensitive, tailored, appropriate patient care for all patients.

Family influences and beliefs about food were key aspects identified in this study that need to be explored to facilitate efficacious interventions in this target population. Therefore, health care professionals specifically working with Mexican American patients who have diabetes should leverage such knowledge to identify if and how they can utilize it to better understand and appropriately advise their patients to maximize cultural acceptance and efficacy of interventions. The lack of knowledge about how cultural beliefs and values impact diabetes self-management is a barrier that must be integrated into care to enhance the likelihood of success. It is, hence, important for practitioners to practice cultural humility and acknowledge when unfamiliar with a cultural belief, value, or food. This creates an opportunity to collaborate with patients and engage them in their care.

Regarding family influences, practitioners can explore factors associated with family and home dynamics that positively and potentially negatively influence food choices. They can further identify and explore how these factors can be ameliorated or expanded to facilitate diabetes self-management. A more in-depth exploration and understanding of diet beliefs and practices (specifically foods consumed or avoided and why) will allow practitioners to adjust nutrition guidance to be more inclusive of diet-related culture and traditions.

It should be noted that the inclusion criteria in the current study focused on a Hispanic subgroup, Mexican Americans, and this limits the broad application of findings to other Hispanic subgroups.⁶⁵ Another limitation is that studies published after 2015 were not included because the initial analysis was completed by the research team in 2015 and adding new studies would compromise the integrity of the content analysis methodology. Future studies should examine the clinical impact cultural influences have on diabetes outcomes.

Conclusion

The study findings help diabetes health professionals differentiate diet and culture-specific influences shared by Mexican Americans with T2DM. This work offers a way to circumspect the work that is done in disciplinary silos by showing that several disciplines share a common interest and need for studying phenomena such as cultural beliefs in diabetes self-management. The concepts of family influences and beliefs about foods are important considerations and serve as a tool for researchers and practitioners to develop stronger interventions for building evidence on culturally appropriate lifestyle interventions.

Footnotes

Acknowledgements

The authors would like to acknowledge Melissa Roberts, RDN, research assistant at Michigan State University, for her contributions to the development of the coding procedure. This study was completed as partial fulfillment of the requirements for the degree of doctor of philosophy in human nutrition at Michigan State University of the primary author.

Duality of Interest

The authors declare having no professional or financial association or interest in an entity, product, or service related to the content or development of this article.

Funding

The authors declare having received no specific grant from a funding agency in the public, commercial, or not-for-profit sectors related to the content or development of this article.

Julie Plasencia

Julie Plasencia, PhD, RDN, is with the University of Kentucky in Lexington, KY. Sharon Hoerr, PhD, RD, is with Michigan State University in East Lansing, MI. Hector Balcazar, PhD, is with Charles R. Drew University of Medicine and Science in Los Angeles, CA. Maria Lapinski, PhD, and Lorraine Weatherspoon, PhD, RD, are with Michigan State University in East Lansing, MI.

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