Introduction to the Community
Bangladesh, located in South Asia, and is one of the most populated countries in the world. The official language is Bengali. Among the major challenges that Bangladesh faces, are high rates of poverty, malnutrition, corruption and low levels of health and education. However, the nation has made notable progress in many indicators of the Human Development Index: reduction in maternal and under-five mortality, total fertility, and immunization coverage. Women’s quality of life also improved, which englobes education, economic status and life expectancy (World Health Organization, 2015).
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In 1990, nutritional, neonatal, maternal, and communicable disorders accounted for 583/100,000 deaths. In 2010, these numbers dropped to 178/100,000, while the mortality rates from cardiovascular diseases rose. This health transition is mainly characterized by the double burden of disease, attributable to the emergence of noncommunicable diseases. Although the rates of underweight children reduced in the last decades, malnutrition is still prevalent with high rates among women. While the proportion of chronic energy deficiency among women decreased from over 50% to 25% in 16 years, the proportion of those overweight increased from 6% to 25%, mainly due to the fast urbanization, (Waid, Ali, Thilsted, & Gabrysch, 2018). The increase in sedentary lifestyles and consumption of high-calorie processed food resulted in increased obesity rates and a prevalence of diabetes estimated at 6.9% (Waid et al., 2018).
As Bangladesh only became independent from Pakistan in 1971, official records just account for Bangladeshi immigrants after that time. However, registers show immigrants from the Bengali region (now known as Bangladesh) arriving in the US since 1887 (Harrison, 1998). According to data from 2012, the Bangladeshi diaspora and their children (first and second generation) in the US is nearly 277,000 people. Overall, Bangladeshis represent a small share of the US immigrant population- only 0.5% in 2012, (Migration Policy institute, 2014). Its largest population is concentrated in New York State, especially the city. In New York City, according to data from the Census Bureau’s 2006-2008 and 2009-2011 American Community Survey, Bangladeshis were one of the fastest growing ethnic Asian populations. The population grew 42%, from 34,237 in 2008 to 48,677 in 2011, representing the fifth largest Asian group. Ninety-one percent of New York State’s Bangladeshi residents lived in the city. The greatest number of Bangladeshi New Yorkers (60%) lived in Queens, 19% in Brooklyn, 17% in the Bronx, 4% in Manhattan, and 0.4% in Staten Island (AAFCI, 2013).
Regarding education attainment, 22% of New York City’s Bangladeshi population did not have a high school diploma, which represents a similar level of education as the citywide population with 21%. On the other hand, 36.5% of Bangladeshis had a bachelor’s diploma or higher, once again close to 34% for the citywide population, (AAFCI, 2013). Sixty-one percent of the adults had English limitations. Also, they were one of the poorest ethnic Asian groups in the city, where almost one in three individuals lived below the poverty line, representing 28.8% of Bangladeshi adults. The per capita income of Bangladeshis was $13,504, which is much lower than the general population ($30,717) (AAFCI, 2013).
Few studies investigated the health status of Bangladeshi immigrants in America. Those available aggregate South Asian immigrants (Asian Indians, Pakistanis, Bangladeshis, and Sri Lankans) as a heterogeneous group, without distinguishing the data between the subgroups (Ghosh, 2003). Studies that focus on South Asian immigrants have shown significant health disparities when compared to the general population. Health problems include high rates of obesity, cardiovascular diseases, hypertension, and diabetes (Misra et al., 2010; Mohanty, Woolhandler, Himmelstein, & Bor, 2005). Studies that focused specifically on South Asian women that came to the US suggest a higher vulnerability among them regarding high risks of obesity (Misra et al., 2010), and high risks of cardiovascular disease (Patel, Rajpathak, & Karasz, 2012).
Introduction to Interviewee
The interviewee is Bangladeshi, 28 years old, male, middle class and Muslim. We first met during college in Upstate New York. His pseudonym in this paper will be Joy. He was born in New York City, while his parents were born in Bangladesh. When he was 3-months old, he and his family moved to Dhaka, Bangladesh. In 2009, he returned to New York to attend college and has lived here since then.
Review and Discussion of Findings
Description of Traditional Diet
Bengal is the region that originated the culinary style of Bangladesh. Bengal was later divided, and what before was its eastern region, is now known as Bangladesh. For this reason, Bangladeshi food is often called Bengali food. In the early sixteenth century, when the Portuguese first visited Bengal, they registered that staple foods included wheat, fruits, vegetables, milk and dairy products such as yogurt and clarified butter (ghee), and also a variety of rice that was higher in quality when compared to European rice, (Walker, 1997). Nowadays, these staple foods continue to be traditionally consumed in the country.
Dried fish is a very traditional food known as shutki. It is also an important source of income for many Bangladeshis (Walker, 1998). Shutki is commonly fermented or salted in order to be preserved as well. Along with rice, fish is the principal part of the country’s diet (Walker, 1998). There is an old proverb that says machee bhatee Bangali, which can be translated as “fish and rice make a Bengali”. Several factors affect fish consumption in the nation, including season, location, water level, and household income (Roos, Islam, & Thilsted, 2003). The livestock eaten include beef, chicken, lamb, and goat. Shrimp and other seafood are also well consumed.
Joy stated that a combination of spices that include ginger paste, garlic paste, coriander, cumin, turmeric, chili powder, and curry, combined with salt, pepper, and oil are the “foundation of Bengali food”. According to Bladholm (2016), the most common way of using such spices is frying them in oil or ghee until they release the aroma and become bittersweet. The mix is then used in the preparations, bringing a unique taste to the dishes.
To refresh the palate at the end of a spicy meal, Bangladeshis have hundreds of desserts that are famous for their milky sweetness. Desserts are also served with afternoon tea. Curiously, tea is not served with spices as it is in India. Instead, the tradition calls for English-style tea, served with milk. According to Waler (1997), the Bangladeshi passion for sweets goes back to the Middle Ages. Sugar cane crops have been grown in the country since ancient times. In Bengali, sugar is known as Chini, and the love for sweets among the population is so intense that in the old times, wealthy landowners were known for having lived their lives on diets based on sweets alone (Walker, 1997). Currently, there are sweet shops in every corner of the big cities. Joy also emphasized the abundance of sweets in his home country during our conversation:
For dessert, we have cakes, and thousands of desserts, like caramel pudding, rice pudding, Tusha Halwa (a little sweet made of dough, cinnamon, and cloves), Shandesh (cheese sweets with pistachios), and many more. I think we are the country that makes the most sweets. We have many stores with piles of sweets.
However, the famous sweets are not the only peculiarity of food tradition in Bangladesh. According to Joy, Bengali tradition requires a typical menu that is prepared especially for weddings:
In weddings, the food is very different. It is very rich and heavy. You have this big pot with Chicken Biryani (chicken with rice, potatoes, and many spices) and also Dhokar Dalna (fried lentil cake in a sauce made of curry, tomatoes, and coconut milk).”
Usual Eating Patterns
The diversity of ingredients and spices make Bangladesh culinary very distinct. Dishes are composed by a variety of flavors and fragrances: sweet, savory, bitter, nutty, pungent, spicy, sour and astringent, combined with different textures and colors. Joy quotes:
Every single food there is unique, we have food for different times of the day and for different occasions. For example, for breakfast, we have paratha (a deep-fried flatbread), fried eggs, and potatoes with spices and curry. We have it with tea or coffee. For lunch and dinner, we have rice, lentils, chicken, beef, and sabzi (mixed vegetables). We have thousands and thousands of food items that are served.
When asked how often he eats traditional food, Joy promptly answered: “We eat traditional food every day because it is our favorite.” According to him, when he first moved to the US, he lived alone in upstate New York, where he had to adapt the traditional recipes due to the lack of spices available in the grocery stores. This demonstrates that food accessibility challenged his food values, however, he kept preparing traditional food. Many times, the traditional food consumed daily is a form of affirmation of cultural identity and is used as a social marker (Anderson, 2014). Other times, food is used in an attempt to deal with the distance and homesickness of family members left in the country of origin (Vallianatos & Raine, 2008). By cooking, Joy began to perpetuate his ethnic identity, not only to maintain the Bangladeshi tradition but also to find meaning and comfort in a strange environment through his family foodways.
After moving to New York City, Joy was able to find all the ingredients for his home country’s traditional dishes. Even though he lived by himself, Joy kept cooking the food that he grew up eating in Bangladesh, evidencing the transnational practices of immigrants in an attempt to connect with home.
Dietary acculturation is described as an immigrant effect by which minority groups adopt food practices from the host country (Lesser, Gasevic, & Lear, 2014). There are several studies pointing that after voluntary migration, people experience poor health outcomes, which is also known as acculturation hypothesis (Franzini & Fernandez-Esquer, 2004). The social context of immigration and the new social network influence the changes in the food habits of immigrants. Joy’s dietary pattern modifications demonstrated some level of acculturation, as he mentioned:
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We eat traditionally with our right hands (no cutlery). For example, we have pastes called tabhoo that we mix with rice and eat. Now I only eat with my hands when my family is here.
Although Joy emphasized his daily intake of Bangladeshi food, during the interview, he was having a bagel with peanut butter and jelly. When asked about other kinds of food that he eats, he said: “My favorite foods are Thai and Japanese, and American food, of course.” Regarding foods from other cultures that he likes, he mentioned: “Italian food, like pasta and lasagna.” With that, it is possible to identify Joy’s adoption of some Western dietary habits. Also, through the way he characterized his present food consumption patterns, it was possible to observe a lack of his own perceptions of acculturation.
According to the acculturation hypothesis, the longer the immigrants stay in the Western host country, the more they add unhealthy dietary habits to their routine. However, Bangladesh and most developing countries are experiencing a substantial increase in the rates of chronic diseases, which are associated with the increase of obesity among Bangladeshis over the last decades (Biswas, Garnett, Pervin, & Rawal, 2017). This reality makes it difficult to affirm that acculturation related to migration is, in fact, responsible for health deterioration among minority groups. Globalization is converging all cultures towards a Western diet by spreading supermarkets and fast food chains all over the globe, known as westernization (Pingali, 2007) or nutrition transition (Popkin, 2009). For example, at the same time that South Asian immigrants are presenting high diabetes prevalence (Lee, Brancati, & Yeh, 2011; Lesser et al., 2014), the same trends are been observed in their home country (Jayawardena et al., 2012). Not only are immigrants changing their eating habits, but traditional local habits of many countries are also being modified.
Religion and Health
Because most of the population is Muslim, pork is not usually consumed in the country (Sengupta, 2014). When asked if there are foods that he cannot eat, Joy said: “Because of religion, I cannot eat pork.” Many times, religious identity also represents food identity, and when people move to a new nation, religion continues to play an important role in their personal identity. As a Muslim immigrant, Joy shifted from being part of the dominant group in Bangladesh to a minority community in the US.
Health disparities among religious immigrants, especially Muslims, have been observed and the factors influencing this trend include their interpretation that illnesses are mainly God’s will (Johnson et al., 1999; Padela, Killawi, Forman, DeMonner, & Heisler, 2012). This sometimes leads this population to believe that traditional medicine should not interfere in the treatment of the condition (Franklin et al., 2007). Also, they are careful when choosing medical treatment, as it must be appropriate according to the rules of the sacred texts (Inhorn & Serour, 2011), and many American medical procedures go against their beliefs (porcine-based medications, use of donor gametes, conflicts regarding organ transplantation, use of sedatives). Muslims also report discrimination from health care providers (Inhorn & Serour, 2011), which also affects their motivation to seek healthcare. All of these barriers confirm the need for the improvement of the healthcare system, and the need for practitioners to develop the cultural competence to facilitate the health access for the Muslim population, and other religious groups.
Gender roles and health
The migration does not only lead to changes in the dietary habits of immigrants, but it can also represent modifications in the division of household tasks in families (Vallianatos & Raine, 2008). In this way, moving to another country exerts pressure and offers challenges for men and women in relation to gender behaviors and roles, which can be rethought and transformed during this process. Before moving to the US, Joy’s mother taught him how to cook so he could prepare Bangladeshi food while living by himself. This demonstrates that the migratory process brought challenges to him and that he had to learn a new routine. Besides that, Joy recently got married, and when I asked him about how his wife and him divided the home tasks he said:
We do the groceries (him and his wife). When my mother is here, she does it. I cook because my wife does not know how to cook. When my mother is here, she cooks.
Men and women suffer the impacts of migration differently. In many cases, with the labor market opportunities in the developed countries, women’s position in society changes, and they undergo a process of empowerment when compared to the country of origin: they gain personal autonomy and financial independence, contribute to the maintenance of the household, deal with the control of household expenses and participate in family decision-making (Tienda & Booth, 1991). The mobility and access to social and economic resources of these women make changes in domestic positions. Thus, the migratory process changes the traditional patriarchal form of social organization for men and women.
Although changes in the gender roles of immigrants have been reported, inequalities are still present. In general, women’s work conditions are inferior to men’s. They engage more in part-time work and receive lower wages which result in lower socioeconomic status (SES). This is one of the factors that affect women’s health as they have fewer resources to access the healthcare system, which contribute to gender disparities among the same ethnicity (Read & Gorman, 2006). SES combined with ethnicity also influences health status. Among low-income Bangladeshi immigrant women in NYC, significant health disparities are experienced when compared to other ethnic groups, especially risk for cardiovascular disease development (Patel et al., 2012). Many other determinants are involved in gender disparities in the health of immigrants, including age, religion, education, sexual orientation, access to health services, and immigration status. All of these factors affect the health practices of immigrants and must be considered when assessing their health status.
Several elements influence the quality of life of immigrants, including living conditions, stress due to overworking, adaptation to the new society, homesickness, and discrimination, among others. Health is manifested in all aspects of life, thus it is essential to include this aspect in the process of integration of immigrants. However, immigrants are generally focused on work, and health is rarely thought of as central to their lives.
Despite the fact that the US has regulations that allow immigrants access to health services, considerable racial and ethnic disparities still persist (Ku & Matani, 2001). For this reason, there is a need to address these inequalities on the accessibility of healthcare, and the different barriers that condition immigrants to have poor health outcomes.
The fundamental aspect that must be considered when addressing immigrant health statuses is the fact that they are not a homogenous group, neither should they be stereotyped according to generalized ideas of determined groups (Setiloane, 2016). In fact, their heterogeneity is much deeper. It is manifested in language, race, ethnicity, socioeconomic levels, gender, sexual orientation, age, social habits, religion, cultural practices, legal status and the variety of life experiences and motives to migrate. These aspects are highly relevant from a health perspective, as they determine the types of resources needed to respond appropriately to each situation. Immigrants present different patterns of mortality, diseases, specific conditions and health status, and on the other hand, different patterns of use of health services.
With Bangladeshi immigrants for example, hardly ever are their health outcomes studied based on their population. Most of the time, they are included in studies that investigate immigrants from South Asia (Ghosh, 2003; Johnson et al., 1999; Lesser et al., 2014; Vallianatos & Raine, 2008). As mentioned above, the problem with generalizing and not distinguishing subgroups is that the immigrants from South Asian countries have unique characteristics that make them completely distinguished. These characteristics play an important role on social and health needs among these communities, and for this reason, it is very difficult to extract data from these studies that could be useful in the development of culturally adequate interventions targeting health promotion. Future studies on South Asian immigrants should provide detailed information regarding data obtained from each subgroup (Asian Indians, Pakistanis, Bangladeshis, and Sri Lankans). This would allow data to be used by researchers who aim to study immigrants from a specific country.
In the field of nutrition, for example, lifestyle as well as lifestyle changes resulting from migration, and acculturation are factors that influence the health status of immigrants. Furthermore, changes in the type of diet and exercise can lead to health problems such as obesity or an increased incidence of cardiovascular disease and diabetes. If dietitians and researchers do not utilize strategies and methodologies that culturally tailor to groups and communities to improve their adherence and health outcomes, the treatments or interventions will not be fully effective, if effective at all.
It is urgent and necessary to improve access to health care for all immigrants. Likewise, greater participation of people of different ethnic backgrounds in health services, such as community health workers, could contribute to preventing discrimination and improvement of accessibility among minority groups. Special attention should be given to culturally-tailored health education actions that are aimed at prevention, in order to change attitudes and risk behaviors, promoting healthy life habits.
Finally, there is an under-utilization of prevention and promotion in situations that may be related to the various factors that influence accessibility. One of these factors is the health care providers ignorance regarding the cultural aspects of immigrants, combined with the stereotyped representations and discrimination. These inadequate attitudes and behaviors result in a difficult relationship between patients and professionals. For this reason, it is necessary to implement training and education of healthcare providers in the area of cultural competence, giving them the importance of cultural aspects in the attitudes and behaviors of individuals in health or illness.
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