Food beliefs and practices among British ...

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Food beliefs and practices among British Bangladeshis with diabetes: Implications for health education a

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A. Mu'Min Chowdhury , Cecil Helman & Trisha Greenhalgh

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Department of Primary Core and Population Sciences , Royal Free and University College London Medical School , UK Published online: 09 Jun 2010.

To cite this article: A. Mu'Min Chowdhury , Cecil Helman & Trisha Greenhalgh (2000) Food beliefs and practices among British Bangladeshis with diabetes: Implications for health education, Anthropology & Medicine, 7:2, 209-226, DOI: 10.1080/713650589 To link to this article: http://dx.doi.org/10.1080/713650589

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Anthropology & Medicine, Vol. 7, No. 2, 2000

Food beliefs and practices among British Bangladeshis with diabetes: implications for health education (Accepted date: 14 April 2000)

A. MU’ MIN CHOWDHURY, CECIL HELMAN & TRISHA GREENHALGH Department of Primary Core and Population Sciences, Royal Free and University College London Medical School, UK

ABSTRACT In order successfully to promote `healthier’ food choices, health professionals must ® rst understand how people classify and select the foods they eat. We explored the food beliefs and classi® cation system of British Bangladeshis by means of qualitative interviews with 40 ® rst-generation adult immigrants with diabetes. Methods included audiotaped, unstructured narrative interview in which participants were invited to `tell the story’ of how diabetes affects them, pile sorting of food items, and participant observation of meals. We found considerable heterogeneity of individual food choices against a background of structural and economic factors (i.e. food choices were partly determined by affordability and availability), as well as cultural in¯ uences. Important themes included strong religious restrictions on particular food items (chie¯ y the Islamic prohibition of pork), and widely held ethnic customs based on the availability of foods in rural Bangladesh. Modi® cation of the diet on immigration did not generally incorporate many `Western’ foods but included increased quantities of `special menu’ Bangladeshi foods such as meat and traditional sweets. Foods were not classi® ed or selected according to Western notions of food values (protein, carbohydrate, etc.). Rather, within religious and ethnic patterns, further food choices were determined by two interrelated and intersecting binary classi® cation systems: `strong’ /`weak’ and `digestible’ /ìndigestible’ , which appear to replace the `hot’ /`cold’ classi® cation prevalent elsewhere in South Asia. Different methods of cooking (especially baking and grilling) were perceived to alter the nature of the food. A desire for dietary balance, and a strong perceived link with health, was apparent. These ® ndings have important implications for the design of health education messages. Dietary advice should re¯ ect religious restrictions, ethnic customs and the different cultural meaning of particular foods, while also acknowledging the ability of the individual to exercise choice within those broad limits.

Introduction Helping patients to change behaviour concerned with eating, drinking, exercise or taking medication is a common task in health promotion and medical smoking, Correspondence to: Dr Trisha Greenhalgh, Department of Primary Care and Population Sciences, Royal Free and University College London Medical School, Holborn Union Building, Whittington Campus, London N19 3UA, UK. Tel: 1 44 171 288 5731. Fax: 1 44 171 281 8004. E-mail [email protected] ISSN 1364-8470 (print) ISSN 1469-2910 (online)/00/020209-22 Ó

2000 Taylor & Francis Ltd


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care. In some chronic illnesses such as heart disease and diabetes, a change to a different pattern of food choices has profound implications for survival (de Lorgeril et al., 1994). But it is well recognized that such changes are dif® cult to make and sustain (Thorogood, 1996). Unlike nutritionists, human societies do not classify their foods in terms of vitamins, proteins, carbohydrates and so on, nor do they generally measure food consumption in terms of total calorie intake. Rather, societies invest a range of symbolic meanings to their foods and associate particular roles and interactions to the preparation, presentation and consumption of foods (Douglas, 1974; Helman, 1994). These meanings and roles, adapted and interpreted by the individual, the family, and the wider social network, play a decisive part in shaping the willingness and ability of a person to change his or her food choices. Previous studies have shown that retention of ethnic food behaviour is one of the most enduring aspects of a migrant culture (Helman, 1994; Jerome, 1969). The transformation of `raw’ into `cooked’ foods is one of the de® ning features of human societies, a key criterion of `culture’ as opposed to `nature’ (LeÂviStrauss, 1970), and virtually all societies classify edible items along a number of different dimensions (`food’ vs `non-food’ , sacred vs profane, `hot’ vs `cold’ , foods eaten by particular social or occupational groups, and so on) (Helman, 1994; Nichter, 1989; Pool, 1987; Robson, 1986). It is no wonder, then, that nutritionists and medical practitioners have written despairingly that their patients’ beliefs and practices relating to food are stubbornly resistant to change (Neil et al., 1995; Family Heart Study Group, 1994). In order successfully to promote `healthier’ food choices by the members of any cultural group, the initial focus of the exercise must be to understand how these people (both individually and as members of a wider group) classify and select the foods they eat and, equally importantly, the foods they choose not to eat. In this paper we report on the food beliefs and classi® cation system of British Bangladeshis. Because of our interest in diabetes and health promotion, we have emphasized the possible implications of our ® ndings for the self-management of diabetes in this ethnic group. Subjects and methods The ® eldwork for this paper is part of a wider qualitative study of the health beliefs and folk models of British Bangladeshi patients with Type 2 diabetes reported in detail elsewhere (Greenhalgh et al., 1998). In brief, we recruited 40 informants with diabetes, all immigrants from the Sylhet region of Bangladesh, from a primary care setting using practice diabetes registers or manual note search. Informants were aged between 24 and 78, with an equal gender mix. All were ® rst-generation migrants and lived in the inner city areas of Tower Hamlets, Newham or Islington in London. This group is not representative of Bangladeshi society as a whole; rather, it represents a small sector of that society de® ned by their peasant status and rural domicile back in Bangladesh and by high levels of socioeconomic deprivation, unemployment, overcrowding


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and ill health on immigration to the UK (Health Education Authority, 1994). We used a variety of qualitative methods to explore informants’ health beliefs and illness maps of diabetes as well as their speci® c beliefs and behaviours about food (Greenhalgh et al., 1998). All interviews were conducted in the informants’ homes by one of us (AMC). AMC is a male Bangladeshi social anthropologist who speaks Sylheti as a mother tongue and has lived and worked in inner London for over 10 years. He had previously studied kinship networks in rural Bangladesh. Informants were asked to describe their eating regimen and what they had eaten during the previous day. In addition, they were asked to sort particular food items into `permitted’ , `prohibited’ and `neither permitted nor prohibited’ , and again into `good for my health’ , `bad for my health’ and `neither good nor bad’ . Explanations were sought in the case of discrepancies between the two sources of information. As part of their norms of hospitality, informants frequently offered the researcher nasta (snacks) or bhath (main meal), which allowed further discussions about food choices, mode of cooking, use of ingredients, and so on. The classi® cation of particular food items was used as the basis for tape recorded individual interviews and focus group discussions in which the basic classi® catory schemas were explored in depth. Data were analysed with the aid of NUDISTÓ computer software for analysis of non-numerical unstructured data, and responses grouped under different themes. Our preliminary impressions were fed back to informants in a second round of interviews and focus groups to validate the constructs, as described in more detail elsewhere (Greenhalgh, et al., 1998). In the area of food beliefs, there was a high degree of consistency between individual responses and the content of group discussions.

Results This study illustrated a general principle of anthropology, namely, that within any cultural group there is considerable variation and idiosyncracy. The `cultural’ factors described here are not static or deterministic. Rather, it was evident from our research that they provide a background context within which the choices of the individual and those of particular subgroups (e.g. the sick, the rich, or the elderly) are exercised.

Themes arising from the research Primacy of religious prohibitions All informants observed the Muslim faith, though not all attended the Mosque regularly. The Islamic norms of avoiding pig products, wine and ànimal fat’ in manufactured foods and eating halal meat were strongly adhered to. Not a single informant admitted transgressing any of the above. Indulging in


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prohibited foods and drinks was de® ned categorically as amounting to an act of feeble faith, if not outright faithlessness. The demand for cultural adherence in this group was clearly very strong. The religious norms and practices observed by our informants are drawn from the Islamic edibility rules. Islam places no speci® c restriction on plant foods. But in respect of mobile, sensitive living creatures it is very discriminating, requiring that: only grazing animals which chew cud and have cloven hooves are edible; only feathered birds which do not prey and scavenge are edible; only ® sh with ® ns and with or without scales are edible; and insects and all creeping creatures are non-edible; Moreover, the permitted birds and animals are required to be slaughtered in a prescribed manner and the blood from their meat must be washed out before cooking. Blood is seen as strictly non-edible. These explicit rules provide for a permitted/prohibited (halal/haram) distinction which every Muslim is expected to maintain. Any food which does not fall into the permitted/prohibited categories is classed under an indeterminate category of `neither prohibited, nor permitted’ (makru) and is left to individual choice. In addition, intoxicant drugs and drinks, especially the wine and spirits, are prohibited since they are perceived to corrode responsible human conduct. These rules derive from the Judao-Islamic notion that there are three spheres of living world (land, air and water) and three respective appropriate modes of locomotion for each of the spheres (walking, ¯ ying and swimming). Furthermore, animate sources of food are held to reproduce behaviour in their human partakers. Thus, the nature of an animal species is thought to be expressed in its behaviour, and that animal essence can, it is thought, be passed on through consumption of its blood. Since humankind are the pinnacle of human creation (ashraful makhlukat) endowed with living in accordance with their human status rather than their animal passions, they must avoid succumbing to animal in¯ uence. Hence, Muslims are required to avoid all animals whose status is either suspect (because they do not have a speci® c sphere of living or they lack a sphere-speci® c mode of locomotion) or dangerous (scavengers and predators who themselves consume blood), as well as the blood of all edible birds and animals. This explains the implicit fear amongst Muslims of contamination by animal blood, and the practice of halal slaughtering in which the animal’ s throat is slit and the blood ritually drained out before the carcass is processed. Apart from laying down what can or cannot be eaten, Islam also requires all its adult followers to abstain from food and water from sunrise to sunset during the month of Ramadan. The traveler, the ill, the in® rm, the pregnant and lactating women are exempted.


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Ethnic dietary customs imported from Bangladesh If Islam has set the outer limits of Bangladeshi food choices, their speci® c dietary habits have been formed by their land. Bangladesh is a low delta land with tropical monsoon climate where rice and ® sh are the main gifts of nature. Rice, ® sh and vegetables are the main staples, while mustard oil, salt, onion, chili powder, turmeric and coriander are the common cooking ingredients. In the Sylhet area, where our informants came from, the custom is to have plain rather than pre-¯ uffed rice. Red lentil is the commonly used pulse but it is eaten mainly when the menu is short of ® sh and vegetable curry. Traditionally salads and desserts are not included in meals since these are rarely available. However, if available, milk, sugar or molasses and/or sweet fruits such as mangoes and jack fruits are eaten with rice after the main meal. Because of the hot and humid climate in Bangladesh, the custom is to buy fresh ® sh and vegetables daily and not to keep curries for more than 24 hours. In rural Bangladesh, families normally eat three rice meals a day, and freshly cooked rice is served with every meal. Faced with extreme poverty or occasional famine people may however substitute chapati for rice in one or more meals. While rice forms the substance of the meal (the expression for èating rice’ , vath khawa, is the same as that for `having a meal’ ), curries and side dishes are intended to make the eating of rice more tasty and enjoyable. Advice from health professionals to alter the form or content of the rice in meals appeared to meet particular resistance or resentment, as a previous study also showed (Kelleher & Islam, 1996). Although meat does not form part of the everyday menu, there is a strong liking for it and when entertaining guests or celebrating special occasions, the pan-Islamic tradition is followed of serving meat rather than ® sh as the main dish along with pilau rice, instead of plain rice. Meat dishes and pilau rice are normally cooked in ghee (clari® ed butter) with more exotic spices such as ginger, garlic, cinnamon, cardamom and sultanas. On special occasions various snacks and sweets (`nasta’ ) are also served, and when guests are present the morning rice meal may be replaced by a `breakfast’ centred on paratha or a loaf of bread. This exempli® es the general principle that the consumption of wheat-based foods is now part of Bangladeshi food choices, but is not part of their everyday food choices. The dominant mode of cooking is for everyday meals is boiling and shallow frying. In cooking the emphasis is on taste and ¯ avour rather than on visual presentation. Because of this there is a marked tendency to make liberal use of oil, ghee, and spices, especially when entertaining or celebrating. Their generous use is seen as a mark of af¯ uence and hospitality. In most families tea is drunk along with a small portion of puffed rice or biscuits as breakfast. Generally tea is prepared by boiling tea leaves, milk, sugar and water in a sauce pan and the strong and thick brew is served in cups. Some also drink tea at other times. While many men smoke either hukka (hubble bubble) or cigarettes, smoking is considered unbe® tting for a woman.


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We have not come across a single smoker in our women informants, in contrast with other researchers, who may have unwittingly accessed a more `Westernised’ sample (McKeigue et al., 1988). Unlike smoking, chewing paan [prepared betel leaf (paan) betel nut (gua, supari) and burnt lime paste (chun) with or without leaf tobacco (shada) or a sweetened preparation of leaf tobacco (zarda)] is common among men and women, especially older women (Health Education Authority, 1994). It is customary to offer guests, including casual visitors, paan, hukka or cigarettes, and tea and biscuits. Important guests are entertained with snacks and sweets and rich meals. This is part of the hospitality code and refusal to partake is considered indecorous and unfriendly, and in certain contexts even insulting. The use of spices plays a less central place in Bangladeshi food customs than the elsewhere in South Asia. The `spice islands’ are sited to the south of the Indian subcontinent. The extensive use of a wide range of spices, characteristic of south Indian and Sri Lankan cooking, does not extend to traditional Bangladeshi food. Rather, a small selection of spices (chie¯ y garam masala) is used to ¯ avour the meal, and different individuals and families may use more or less of this, rather like the typical white British family uses salt and pepper. Modi® cation of diet on immigration to UK: impact of availability and affordability Immigrant Bangladeshis have retained to a very high degree their traditional ethnic dietary habits. Any changes made by the British Bangladeshis in this study appeared to be in the form of elaboration of the traditional customs rather than adaptation to the host culture. There were a few exceptionsÐ for example, peas, baked beans, noodles and pizza were found in a minority of homes, especially where children had been exposed to them at school. Whether the new generation, when grown up, will make substantial changes in their food beliefs and behaviour, or adopt a few selected Western dishes as an adjunct to their parents’ food choices, remains to be seen. A major determinant of food choices in any society is the availability and affordability of preferred foods. For example, meat is relatively much cheaper and more widely available in the UK. British Bangladeshis appear to consume far more meat than their counterparts in Bangladesh. Likewise, we found that oil and spices were also used in increased quantities. Bread, milk, butter, biscuits, sweets, and fruits were all consumed more regularly and in greater quantities than in Bangladesh. In rural Bangladesh, the only fruit to be found all year round is banana. Two of the most popular fruits, mangoes and jack fruits, are only available seasonally. Grapes and apples do not grow in Bangladesh and can only be bought as imports in the cities. In Britain, all these fruits, and many other varieties, are readily available and our informants ate them almost daily. The same was true for fruit juice and other soft drinks. We detected little or no change in the style of cookingÐ for example, grilling and baking were almost never used.



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In spite of the discernible shift towards regular consumption of meat, especially chicken, the overall consumption of ® sh and vegetables was also high in our informants and their families. Fish and vegetables from Bangladesh are widely available in ethnic shops and our informants expressed a strong preference for them over local ® sh and vegetables. Apart from their habitual liking for Bangladeshi ® sh and vegetables, unfamiliarity with the taste of British food and how to cook it also stands in the way of the consumption of local ® sh and vegetables. We found only two examples of locally produced ® sh (sardines and mackerel) in the kitchens of our informants. In summary, we appear to be witnessing relatively little in the way of adoption of the dietary customs of the host community, but rather an incorporation into the Bangladeshi èveryday menu’ (traditionally rice, ® sh and vegetables cooked in modest amounts of oil) of the traditional Bangladeshi `special menu’ (meat cooked in ghee, as well as fried and sweet snacks). This lack of adoption of food choices of the host culture may be one mechanism for of expressing and maintaining Bangladeshi identity (Gardner, 1984). There is, however, a growing awareness of the association between eating large amounts of meat and fatty foods and the development of diabetes and heart attack. Many of our informants concurred with the medical advisability of avoiding fat, ghee and red meat, an issue we have discussed in more detail elsewhere in relation to diabetes education (Greenhalgh et al., 1998). Classi® cation of food: strength and digestibility dimensions It is generally believed that the Bangladeshis, in common with many other non-Western societies, adhere to a fundamental binary classi® cation of foods into `hot’ and `cold’ as described in relation to other groups in the Indian subcontinent (Pool, 1987; Nichter, 1989). We were surprised, therefore, when our ® eldwork demonstrated that the `hot’ /`cold’ classi® catory schema did not appear to be applied by the Bangladeshis to their foods and illnesses. We have previously reported the results of a `structured vignette’ study in which these informants were asked to comment on the story of a ® ctional Bangladeshi character with diabetes (e.g ª Do you think Mr Ali would describe diabetes as a `hot’ illness?º ). In this previous study, we detected a highly inconsistent classi® cation of particular foods, and the disease diabetes, into `hot’ /`cold’ categories by the 18 informants in this study, suggesting that if such a classi® cation exists at all, it is not exclusive or ® xed. We attempted to ® nd other ® eldwork in the literature which speci® cally addressed the question of whether a `hot’ /`cold’ food classi® cation exists amongst Bangladeshis, and we have been unable to identify any such work. We have demonstrated previously that the social organisation and kinship networks of Bangladeshis are fundamentally very different from those of most Indian and Pakistani groups (Chowdhury, 1986). We suspect that in the absence of speci® c ® eldwork, it may have been assumed that this schema applied more widely amongst south Asians than is actually the case.

FIG. 1. The semantic network of Bangladeshi food.


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We did, however, ® nd evidence of two other interrelated and intersecting binary systems of food classi® cation in our 40 Bangladeshi informants, along the two axes `strong’ /`weak’ and `digestible’ /ìndigestible’ (Fig. 1). We believe that these systems re¯ ect a different underlying classi® cation of food, based upon the implicit belief that all foods, in common with all living beings including humankind, have two aspects of being: a physical substance or `body’ (gator or sharir) and a life energy or `strength’ (shakti). Although a food’ s nourishing power is seen as lying hidden in the food’ s physical substance, they are viewed as separable. Indeed, the digestion of food is thought to be a mechanism by which the power of the food is extracted from its physical substance; the latter is then excreted as waste. The physical form of the food determines its digestibility, while the power determines the nourishing quality (khaidyya guun) and is absorbed into the body. When talking about the human body, our informants frequently likened it to a mechanical machine, and talked of food as `the body’ s fuel’ . Digestibility dimension. Different foods, and different physical forms, are perceived to have different degrees of digestibility, attributed to the ease or dif® culty with which the nourishing power can be separated. Our informants talked about various foods as being easy to digest (loghu pak) or hard to digest (guru pak) as if these were two absolute categories rather than being mere contrasting polar types. The perceived overall digestibility of a particular food appears to be determined by a combination of different elements, made up from the aspects of the physical substance of the food shown in Table 1. However, it is not a simple aggregating scale with all elements having equal weight. Rather, the differentials used are sometimes sub-classes or intermediate gradients of a more encompassing class or gradient and are accorded different weights in the light of their overall position in the semantic hierarchy. The belief that foods with solid form, tough texture and sour taste are hard to digest is apparently based on common experience as well as a lay explanation of the digestive process. The element of texture in Table 1 may appear as an

TABLE I. Mode of loghu pak/guru pak classi® cation. Digestibility category Feature of the food

Easy

Hard

Source Plant origin Form Texture Taste Flavour

Plant Above ground Liquid Soft Sweet Mild

Animal Below ground Solid Tough Sour Sweet


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independent constituent. But our ® eldwork suggests that in the Bangladeshi perspective it occupies a semantic space within the liquid/solid spread. The notion that foods that grow under the ground are indigestible is encountered throughout the South Asian subcontinent and in the Ayurvedic system of medicine (Nichter, 1989; Robson, 1986). Strong± weak dimension. In addition to the digestible± indigestible dimension, the nourishing power of foods is also perceived to vary along a second dimensionÐ from weak to strong. Whereas a food’ s physical form, and hence its digestibility, is readily visible, its nourishing power is perceived as ìnvisible’ or hidden within its physical substance. This nourishing power is deemed to be extracted by digestion, and the semantic network of the strong± weak dimension centres around the stages of the extraction of nourishing power which different types and forms of food seemingly represent. The classi® cation includes several elements: the level of extraction of the food from the earth, the age (maturity or ripeness) of the food, the degree of extraction (during processing) by humans, and the cooking methods and accompanying spices, all of which can alter the nourishing power of the food (Fig. 2). Since the earth is seen as the repository of all nourishment, the plant foods growing on soil are seen as the ® rst level of successful extraction of this nourishing power. Plants which grow below the ground are deemed to represent an incomplete extraction of the earth’ s nourishing power. Hence, they are seen as weak in strength and dif® cult to digest. Herbivorous animals are seen as the second level of extraction and carnivores as a higher, and therefore stronger, level producing dangerously strong (inedible and dangerous) food. The blood of animals, and the sap of plants, is seen as the carrier of the species’ nature. Carnivores are dangerous not only because of their excessive nourishing power, but also because of their predatory and heterogeneous nature (having consumed the blood of different species of animal). Nonetheless, blood and sap are viewed as the extracted `fuel’ of the organism and hence as the embodiment of power and strength. Thus, the visible consistency of blood or sap is taken as an element of the strength of the food. Thus red meat (beef and lamb) is seen as stronger than poultry, duck stronger than chicken and all birds and animals stronger than ® sh. Another element of this dimension is the perception (perhaps based on the human experience) that an organism’ s strength diminishes with aging. Hence, young animals and plants are seen as more nourishing than older ones. Similarly, it is felt that through their own digestion and extraction plants and animals grow and bear `fruits’ , which are seen as stronger than their respective `parent’ sources of food. Thus, the egg is stronger than the chicken, milk stronger than beef, and the fruit of a plant stronger than the ¯ ower or leaf. Other `fruits’ which may be viewed as extracted forms of organisms such as juice, vegetable oil and ghee are, in turn, more potent than their respective parent sources (fruit, nut and milk). Thickness/thinness of consistency and mild/strong ¯ avour help to distinguish further among sub-classes.

FIG. 2. Semantic network of Bangladeshi foods showing strong/weak differential. Arrows indicate the progress from `weak’ to `strong’ that is perceived to occur with harvesting, cooking, etc.


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Role of cooking in modifying edibility The extremes of both `strong’ and `dif® cult to digest’ foods are considered inedible. Within this perspective, the role of human intervention in modifying both the strength and the digestibility of foods was acknowledged by our informants, and had an important in¯ uence on the meaning attached to different cooking methods (Figs 2 and 3). As shown in Fig. 2, raw (kacha) foods are distinguished from ripe fruits and cooked foods. The word for cooking is pak. Ripe fruits are designated with the pre® x paka, signifying that they are a form of `cooked’ edibles. Since cooking per se is a human act, and therefore a cultural act, cooked foods, unlike ripe fruits, are cultural products. As such, Bangladeshi cooked foods, like the foods of all ethnic groups, have major cultural signi® cance within the community. The Bangladeshis take great pride in the `superiority’ of their cuisine and the presence of their ethnic restaurants all over the world. Pak, the word for `cooking’ or `cooked’ , also stands for `digestion’ (hence loghu pak/guru pak) as well as for `pure’ or `puri® cation’ . Cooking, it is perceived, completes the `killing’ of `live’ edibles and therefore removes their active characteristics, including the nature of their species (and hence their intrinsic threat to human nature), making edible what was previously inedible. Different modes of cooking are seen to modify edibility in different ways, altering either strength (for example through dilution by water, or through addition of `strong’ constituents such as ghee and spices) or digestibility (through the softening of texture through boiling/steaming or the compression of substance through baking). Cooking methods are varied to suit the different perceived needs of the partakers and the social function of the meal. Rice, the Bangladeshi staple, for example, is cooked in a variety of ways ranging from jau, a soggy and semi liquid preparation made through prolonged boiling, through to biryani, the strongly ¯ avoured and ghee fried dish prepared with meat. The jau, low in strength and easy to digest, is commonly served to the sick and taken at the end of the day-long fast during Ramadhan when the body is weak and needs quick replenishment. Conversely, the biryani, strong and hard to digest, is reserved for guests and special occasions. Note that a change in physical form brought about by cooking or processing may alter the perceived value of a particular food, such that, for example, white table sugar is seen as an entirely different entity from the dark, liquid form of molasses.

Food, health and illness The use of animal and plant products in medicine, either as well as, or instead of, for their perceived nutritional value, is well described in the anthropological literature (Helman, 1994). In keeping with their view of the human body as a machine, our informants generally perceived illness as arising from outside the body (e.g. via germs) or as a result of an imbalance in the food (fuel) taken into

FIG. 3. Classi® catory grid of Bangladeshi foods in sickness and health.


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the body, rather than to primary failure of the organs within the body (which are seen to succumb to wear and tear through aging, but not to intrinsic malfunction) (Greenhalgh et al., 1998). The notion of illness as extrinsic has undoubtedly been reinforced by the predominance of acute infectious illness in their cultural history. Irrespective of its speci® c cause, an illness is seen to affect the body’ s ability to process strong and dif® cult to digest foods. But the extent of this impairment is seen to vary with the nature and extent of the illness as well as with the age, general health and strength of the subject. An acutely ill individual, especially if old or debilitated, is perceived to need weak, easy to digest foods. In order to help restore balance within the body as it recovers from the acute phase of an illness, strong foods (but ones that are easy to digest) are chosen for convalescence. A similar range of foods is deemed appropriate for the growing child, and for pregnancy and lactation. This classi® cation is shown in Fig. 3. The classi® cation shown in Fig. 3 illustrates that Bangladeshi food choices are in¯ uenced by interacting schemas: the weak± strong and digestible± indigestible matrix, the perceived needs of the individual determined by their age and health status, and sociocultural factors such as hospitality rules for special occasions. Conclusion: implications for health education and health promotion It has been repeatedly demonstrated that lack of congruence in explanatory models of health and illness between patients and health professionals leads predictably to failure of educational interventions (Tuckett et al., 1985), and, conversely, that a health promotion intervention which builds on rather than challenges existing belief systems can potentially alter health behaviour considerably (Green & Kreuter, 1991). Both we (Greenhalgh et al., 1998) and others (Hagey, 1989) have discussed the importance of such explanatory models in relation to successful diabetes management. The classi® cation presented here, based upon detailed ® eldwork with 40 British Bangladeshi informants (Greenhalgh et al., 1998), has profound implications for the design and content of health education for Bangladeshis in general and for dietetic advice in particular. We suggest that the following speci® c principles should be borne in mind by individual health professionals when giving dietetic advice to British Bangladeshis. Furthermore, we propose that although the detail of any health education programme for a community must be predicated upon a detailed analysis of the particular needs and perspective of that community, the broad principles presented below could form the framework for training in ethnic awareness and cultural sensitivity for those offering dietetic advice to any ethnic group. Non-Western ethnic groups may have a strong belief in the healing potential of particular food choices Both our own ® eldwork reported here, and the work of others (Zimermann, 1987), has underlined the strong belief amongst certain non-Western groups that altering the combination of foods in the diet can sustain or restore health and


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strength. Patients from these communities are, in principle, highly motivated to improve their health by dietary modi® cation, and the potential for successful collaboration with health professionals is high. Religious injunctions have overriding signi® cance for the food choices of many cultural and ethnic groups Our ® eldwork demonstrated that religious requirements and restrictions on food choices were almost never breached, and took precedence over other classi® catory schemas. The ® rst task of the health professional in this area is to determine and respect these religious rules, including the requirement to fast at certain periods. However, it should be noted that èscape clauses’ may apply in speci® c situations and to certain categories of people, such as the ill and in® rm, for whom some restrictions can legitimately be broken. Foods of equivalent nutritional content should not be assumed to be interchangeable in the eyes of the patient Standard dietetic advice holds that, for example, a portion of boiled rice is nutritionally equivalent to one of potatoes, a carrot is equivalent to a piece of cauli¯ ower, a small portion of chicken is equivalent to an egg, and brown sugar is identical to white sugar or molasses. An understanding of the very different meanings and values which these different èxchanges’ hold for the Bangladeshi patient (as illustrated in Fig. 4) is essential if advice is to have any impact and if the problem of `non-compliance’ is to be understood. Furthermore, modes of cooking which have an equivalent impact on the nutritional content of the food (e.g. boiling, grilling and baking) may produce, in the eyes of the patient, very different meals. For our Bangladeshi informants, grilled and baked foods are viewed as particularly indigestible, and therefore as particularly unsuitable for those who are ill or convalescing. Ethnic customs in raw ingredients and cooking methods are retained to a high degree on migration Our ® eldwork demonstrated that there is little evidence amongst the Bangladeshis of àcculturation’ to a Western diet per se, but that traditional `special menu’ foods may become everyday dishes when they are affordable and plentiful. Given the enduring nature of food customs in any migrant culture, the standard diet of most British Bangladeshis is unlikely to transform to one based on hamburgers and ® sh and chips, but pilau and biryani dishes with fried meat are increasingly replacing meals based on boiled rice and vegetables. An awareness of the very different nutritional content of these different forms of Àsian food’ is essential. Encouragement to return to the traditional èveryday menu’ is likely to resonate with the Bangladeshis’ inherent belief in the concept of balance

FIG. 4. Classi® catory grid of Bangladeshi food using `carbohydrates’ as example. Foods of equivalent nutritional value in biomedical taxonomy are joined with straight lines; the length of the line indicates distance between these same items in the Bangladeshi semantic space.


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(Greenhalgh et al., 1998) (avoidance of excess) and to uphold their cultural and culinary traditions. Such an approach is likely to be more successful than suggesting Western-style substitutes in the menu or advising to grill or bake foods rather than fry them. Similarly, a reduction in animal fat consumption might be achieved through acknowledging the belief that red meat is both strong and indigestible, rather than by attempting to introduce concepts of fat content or calori® c values. Food classi® cations based on the traditional concept of balance may have positive implications for health education The traditional Ayurvedic notion of balance has many parallels with the biomedical notion of homeostasis that underpins the discipline of endocrinology. The desire to remain in balance, to avoid excesses in eating and excreting, is a notion that can and should be built upon by health professionals (Upadyay, 1998). Recommendations for healthy eating should not be constrained by ® xed ethnic stereotypes Our ® eldwork has demonstrated that food consumption patterns in this group, as in all other societies, are not determined solely by cultural factors. Rather, there is considerable scope for individual choice and variation within the broad cultural patternÐ for example, in the quantity of meat eaten when available and affordable. Health professionals should consciously avoid adherence to ® xed notions of Bangladeshi `beliefs’ and be prepared to negotiate different dietary solutions which acknowledge both cultural values or beliefs and the agency of the individual (Caplan, 1997). References CAPLAN, P. 1997. Food, Health and Identity. London: Routeledge. CHOWDHURY, A. M. 1986. Household kin and community in a Bangladesh village. PhD thesis, University of Exeter. DE LORGERIL, M., RENAUD, S., MAMELL, N., SALEN, P., MARTIN, J. L., MONJAUD, I., GUIDOLLET, J., TOBOUL, P. & DELAYE, J. 1994. Mediterranean alpha-linolenic acid-rich diet in secondary prevention of coronary heart disease. Lancet, 343, 1454± 1459. DOUGLAS, M. 1974. Food as an Art Form. London: Sage. FAMILY HEART STUDY GROUP. 1994. Randomised controlled trial evaluating cardiovascular screening and intervention in general practice: principal results of British Family Heart Study. British Medical Journal, 308, 313± 320. G ARDNER, K. 1984. I’ m Bengali, I’ m Asian and I’ m living here. In BALLARD, R. ed. Desh Pradesh. London: Hurst. G REEN, L. W. & KREUTER, M. W. 1991. Health Promotion Planning: An Educational and Environmental Approach, 2 edn. Palo Alto. G REENHALGH, T., HELMAN, C. & CHOWDHURY, A. M. 1998. Health beliefs and folk models of diabetes in British Bangladeshis: a qualitative study. British Medical Journal, 316, 978± 983.


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