Culture, food, and defiance of medical advice in cardiovascular care

• Cardiovascular diseases are primarily lifestyle-associated illnesses stemming from unhealthy food choices and limited physical activity. This is further aided by our genetic predisposition toward clogging the arteries with fats¹.
• Culture determines our food habits and shapes our beliefs and value systems.
• Often what we love to eat and have learned to believe are at loggerheads with medical advice in cardiovascular care².
• Interventions that address cultural beliefs are important to curb the menace of culturally influenced non-adherence for better heart health^3,4.

Culture determines our dietary patterns including what we eat, when we eat, and how much we eat. It also influences our lifestyle practices like physical activity and attitude towards exercise, alcohol consumption, smoking, and other forms of drug abuse. Importantly, culture shapes our belief systems that affect our perception of health issues and trust in evidence-based treatments – a key deterrent to medication adherence for cardiovascular diseases.

Cardiovascular disease (CVD) is primarily a lifestyle-associated illness. A healthy heart asks for healthy food with dollops of physical activity, failure to do this result in vasculature blockage and disruption in blood supply to key organs. Poor lifestyle choices are partially born out of our cultural practices related to food habits, meal timings, and tendency to exercise. Our cultural beliefs also hugely influence our adherence to diet restrictions, recommended physical activities, and medication for CVD. This article describes the cultural influence on adherence to medical advice for CVD patients⁵.

Culture determines our dietary habits

Our dietary pattern is pivotal in the development and prevention of CVD It is also an established risk factor for adverse events in CVD patients^1,6. WHO recommends a higher intake of dietary fiber from whole grains, legumes, fruits, and vegetables with a lower intake of saturated/trans fat found in red meat and processed food. Mediterranean cuisine that conforms to the WHO recommendations is one of the most advised food for a healthy heart⁷. A prospective study in English men in their midlife revealed a lowering of CVD risk with better adherence to a healthier diet. However, our culture’s influence on food habits is sometimes in conflict with the suggested nutritional/international guidelines and is a major confounding variable for the CVD treatment success^2,4.

Observational studies indicate that people owing to their culturally shaped habits do not easily adopt suggestions for lifestyle changes. An Australian study highlighted the unwillingness of participants in adopting vegetarian food even though they acknowledged its superiority for cardiovascular health, primarily because of the culturally formed meat-eating habits and the pleasure derived from it⁸. Culture also impacts our food preparations and a cultural shift from rural to urban households has impacted the nutritional quotient of the food eaten. Food preparation from fresh seasonal ingredients is healthy and is a norm in rural cuisines; however, urban households rely on the unhealthier processed and frozen ingredients for the sake of reducing preparation time.

Additionally, globalization-led changes in dietary habits due to the availability of cheaper energy-dense high-salt food combined with the advent of creature comfort has brought tectonic shifts in the trend of cardiovascular disease incidence across the globe. Acculturation, defined as the cultural shift resulting from the interaction of two different cultures, due to either immigration or being born to parents belonging to different cultures also affects food habits. For example, diet adaptations in the Arab, Asian and Hispanic immigrants to the USA for highly processed food are extremely harmful to their heart’s health¹¹.

Cultural determinants of medication non-adherence in CVD

Culture influences our experiences, which in turn impart specific beliefs and value systems. It profoundly impacts the way patients define illnesses, report symptoms, cope with diseases, believe in its curability, and their attitude toward self-care, overall affecting medication adherence⁵. In line with other chronic diseases, adherence to cardiovascular medication is suboptimal with about 60% of patients self-reported to be non-adherent¹². The low adherence rate to cardiovascular medication is normally associated with the asymptomatic nature of the disease and a requirement for life-long medications. Nevertheless, research has acknowledged the role of cultural beliefs and practices as a significant variable in the limited adherence⁵. A few specific ethnocultural drivers for non-adherence to CVD medication are listed below.

• Cultural health beliefs: Several cultures like Latino, Middle-Eastern and Asian believe that illnesses are an outcome of imbalance in different elements of the body. These cultures categorize food and surroundings on their supposed effect on the human body as “hot/cold”, “dry/wet” or “yin/yang” and use it to restore the imbalance in elements. Such practices are often in contrast with the available medical advice⁴.
• Distrust in modern medical practices: Culturally influenced mistrust of modern medicine is a significant barrier to both initiation and persistence in adherence to CVD medication. A qualitative analysis of the ethnocultural drivers of non-adherence in South-Asian cardiac patients identified distrust of the western healthcare system as the major reason for non-adherence. Patients of South Asian and Chinese ethnicity were also more anxious about the long-term effect of the prescribed medicines¹³.
• Complementary and alternative medicines (CAM): Alternative medicines include using herbal products from Chinese or Ayurvedic medicine and following health practices like acupuncture, yoga, energy therapies, etc¹⁴. A Canadian study reported lower adherence to anti-hypertension medication among Chinese immigrants chiefly due to belief in traditional Chinese herbs and a perception of lower benefits of western medications^3,15.
• Language Barriers: As the majority of literature, clinical studies, and guidelines are in the English language, comprehensive communication between practitioner and the patient in other languages become a concern when imparting medication-related information. A discordance in understanding the patient’s language creates mistrust and increases the concern-beliefs causing non-adherence^3,15.
• Variation in social structure: The importance of family support for medication adherence is a well-known factor in adherence. In Asian cultures decision-making is often done in consultation with extended family where elders can be authoritative and influence adherence behavior. Patients of these ethnicities tend to avoid confrontations with the healthcare provider and their authority is not questioned even though they disagree with certain aspects of the therapy leading to suboptimal adherence behavior³.

Measures to curb culturally influenced non-adherence to CVD treatment

• Patient-centered communication: Delivering tailored, interactive and frequent information about the disease and the role of medication is of utmost importance. One-to-one discussion with a healthcare provider (nurse/pharmacist/counselor) describing the advantage of therapy, especially in the language spoken by the patient improves adherence significantly. A randomized trial with moderate-high risk CVD patients showed 20% enhanced adherence compared to the non-intervention group. Frequent visits to specialist care along with telephonic follow-up are associated with better adherence (from 40% to 58%)¹⁶.
• Cultural competence training: The sensitivity of healthcare practitioners toward patient culture could help in building trust and improve adherence to treatment. Awareness about unintended bias among healthcare practitioners using self-administered training materials can help reduce unconscious cultural bias³.
• Language concordant services: Providing language interpretation assistance for patients with language barriers and interventions for providers to sensitize them about the issue can help to reduce patient-provider miscommunication.
• Acceptance of CAM usage: Explicit communication between patient-provider about using CAM can help build an understanding of the patient’s attitude towards modern medications. Practitioners can use this information to inspire the necessity-belief for the conventional CVD treatment and discourage its premature termination³.

Conclusions

Globalization coupled with rising immigration will result in a significant population in several countries being foreign-born or children of first-generation immigrants. This has the potential to have conflicting beliefs towards healthcare recommendations of the host country¹¹. Poor understanding of the culturally influenced factors by healthcare providers creates the rift between medical advice and adherence. Succinctly pointed out by the author of Culturally Tailored Food and CVD Risk – “the naiveté of healthcare professionals about patient’s acceptance of medical advice for lifestyle modifications is a major hurdle in the translation of clinical trials to daily practice”. To make health guidelines adherable, it needs to be culturally tailored and relatable to different dietary practices⁴. Indeed, when people derive such joy and happiness from the food they have grown up eating, it is an uphill task to counsel them to do otherwise.

“When diet is wrong, medicine is of no use. When diet is correct, medicine is of no need.” –
Ayurvedic proverb