back in the groove

After I was done with all the blissful relaxation of fall break, I was back in the groove of classes.

Something I’ve come to realize is that I value both having friends *in* my program and friends *not* in my program. My peers in my program are great, and we’re amazingly supportive of one another. It’s much less competitive than I’d feared. Nonetheless, however, I’m surrounded by perpetually anxious type A types and it can be a bit contagious.

So I see my other friends and hear about the psycho parents for whom they nanny!

I love Andrea because she has crappy health issues that keep her from being able to eat onions, peppers, tomatoes, or chocolate (agh!) but is still really cheerful and optimistic and cooks delicious things without those ingredients. This is her pasta dish.

Whole wheat pasta and chopped avocado:


A glug of fancy olive oil…

IMG_1075   Parmesan cheese…


And a bunch of lemon zest on top


Andrea is such a trooper. She’s had a crappy history with reflux and she’s managing it with a lot of grace despite the fact that she cannot eat onions, peppers, tomatoes, or chocolate (!!). This was a delicious delicious meal. (We rounded it out with salad and wine).


Also, when my fall break was up Steve’s crazy work deadline was up, meaning he could properly move into his new place in Raleigh and we could actually explore the neighborhood!

We ended up at the super cool The Station for dinner.


When I saw the menu, I knew I had NO CHOICE but to get the roasted beet LT.


It was extraordinary. While we ate we enjoyed the Halloween ambiance (yes this meal was eaten a good long while ago, when it was warm enough to eat outside- though actually I had coffee outside the day before yesterday and it was pleasant; bless you North Carolina- and when there were still Halloween directions around).


Then we went inside to enjoy some live music! There was a duo of really talented musicians who played some covers (Johnny Cash!) and some of their own stuff. Whilst enjoying the music I had this GREAT cocktail: muddled cranberries and jalapeno (!) with tequila and lime. The greatest margarita incarnation I’ve had in quite some time.


The inside was also pretty dang cool looking.


Problem, however: as we got up to leave, I grabbed my purse and leaned my hand on the counter for a moment… and felt AGONIZING PAIN in my right wrist! Horrified, I looked down and saw something thick and spiky sticking out of it. Loopy with pain, I did the first thing I could think of and ripped it out. I was confused and sore as we walked home, clutching my wrist in the opposite hand to lessen the sharp pain… and as we walked, we saw a black widow spider merrily spinning its web on the side of the sidewalk! Agh! We returned to Steve’s apartment and I started researching black widow bites in a frenzy, convinced spider poison was coursing through my veins. Steve was also horrified on my behalf. He took a minute to look in the jacket I’d been wearing (HIS jacket, which I’d borrowed) and I heard a muffled profanity from the other room, then water running. Steve came back with a terrified look and said, “I don’t know how this happened… there was a bee in the coat”. Yes, ONE WEEK after my previous unnerving encounter with a homicidal/suicidal bee, I’d been attacked yet again by a demon insect that’d been lurking inside Steve’s jacket, a jacket he’d worn all day with no problems!

I spent most of the weekend hopped up on Benadryl, convinced the world was out to get me. My wrist swelled up so I looked like I had a thick pink piece of ham wrapped around my hand and lower arm. Lovely.

Fortunately, to console me, the killer bee containing neighborhood also contains an incredible chocolate shop.


I particularly dug their historical hot chocolate recipes. The girl at the counter recommended the Italy, 1670 recipe and I thoroughly enjoyed the intense chocolatiness (these are drinking chocolates that don’t contain milk so you get a hardcore dark chocolate wham) and the natural, not fakey, citrus taste. I eagerly await trying every single one of these.


Saturday night we hit the club, whaa?! Steve wanted to warm his new apartment and blow off steam by checking out the Raleigh nightlife, so we had all our friends down. I am so not a clubber but we had fun- the best part was that we were waiting in line and our friend Laura went up to the front to ask about the wait. She told the bouncer, “I have kids and I just got a babysitter for the night and I really want to dance”, and he let us all in! It was great! Of course I am a special needs clubgoer and realized I’d forgotten my ID, and my youthful charm required that I go back to the car, drive home, drive back to the club, frantically hunt for parking, etc. So I did less dancing than others but Steve was still tickled that I’d come along, since the boy lives to dance. So it was nice.

Our friend Daniel (Steve’s former roommate, with whom he split a one bedroom apartment- DC rents, yo- and one slept in the bedroom and one in the dining room) came down for the weekend, so we took him to the fabulous Gugelhupf for brunch.

Their outdoor dining area is wonderful, but I was REALLY bee averse by this point and there were a few buzzing around. Steve and Daniel were kind enough to sit in the upper atrium with me (which was still really pretty).

I got a mushroom omelet, which came with fruit.


Steve naturally had been horribly jealous of my awesome beet sandwich earlier int he weekend, so he got Gugelhupf’s rendition. He said it wasn’t as good. I thought it was great. Throw goat cheese on anything and I”ll happily eat it.


Plus it came with Gugelhupf’s AWESOME German potato salad. It’s really tangy and flavorful and deliciously seasoned.


And then awesome Daniel bought me a seasonal ZOMBIE COOKIE! Gugelhupf’s bakery is the best.


So that’s the food business.

As for the school business- I wrote a paper, I got a good grade, and I’m really proud of it. But of course, that doesn’t mean you have to be interested. If and only if you’d like to learn a little more about southern food culture and history from a dietitian’s perspective, take a look!

Southern Food Culture: History and Implications for Providers in North Carolina


Frederick Opie, a history professor at Marist College, argues that the roots of Southern food are from three sources: Native Americans, Europeans, and Africans. Native Americans introduced corn as a staple and made meat-seasoned soups and barbecued venison, turkey, and fish (Cobb 2008). Native Americans also used complementary planting, crop rotation, nutritional enhancement, and renewable habits for plant gathering and hunting. Their diet was varied and nutritious. From the example of Native Americans, Southerners were more likely than colonists in other areas to enjoy vegetables and greens. Pigs were introduced in the 16th century and used in both Native American and colonial communities. Pigs were a primary meat source as well as a source for cooking grease, side meat, and flavoring (Green 2008). Pork was traditionally the most popular meat of the South; hogs were inexpensive to produce because they could eat scraps and forage in forests. Pork was also the source of the lard in biscuits, cornbread, and pie crust. Pork was often preserved by salting. There were large deposits of natural salt across the South; some economic development depended on saltworks (Smith 2006).

The slave trade also involved the movement of food crops; crops domesticated in Africa and crops from other continents that reached Africa before the migration to the Americas. African foods at the time were incredibly diverse. Sorghum was domesticated in the East African savanna. Watermelon and African rice were domesticated in the West African savanna. Yams, oil-producing palm trees, tamarind, okra, black eyed peas, and pigeon peas were domesticated in African rain forests (Hall 2007). Some African imports had implications on the Southern cooking style; such as rice, millet, and okra used as thickeners. Meanwhile, Europeans contributed to Southern cooking by by introducing meat pies and porridges, and vegetables that were often overcooked and mushy (Cobb 2008). Southerners combined native vegetables with Spanish-imported varieties like melons, peaches, and peppers; and African crops like sesame, okra, black eyed peas, and peanuts, as well as African spices (Green 2008). Slave import companies found that slaves fared better during their trip to America when they were provided with foods they were used to, like corn, yams, malagueta pepper, palm oil, and salt. In the colonial period, slaves in the lower South got smaller, lower protein rations than slaves around the Chesapeake. To have adequate nutrition, low country slaves often had to supplement their diets. They fished and hunted for animals like possum, raccoon, deer, rabbit, turtle, mullet, and catfish. They also had more varied gardens than Chesapeake slaves that included African-domesticated plants. Despite these efforts, slave children often suffered from protein calorie malnutrition, and high levels of infant mortality. Many slaves received insufficient vitamin C because vegetables were cooked for a long time in iron pots (Hall 2007).

After the end of slavery changed the agricultural system, pellagra (niacin deficiency) was rampant in the South, with higher prevalence than the rest of the country. By 1912, there were 30,000 cases and a mortality rate of 40% in South Carolina alone. A 1914 Surgeon General’s study found pellagra patients who continued to eat a corn-based diet did not recover from pellagra; but those who ate a varied diet including fresh meat, milk and vegetables did. Researchers experimented on each other, injecting blood from pellagra patients and rubbing patients’ nose and throat secretions onto their own faces. That it did not spread demonstrated pellagra was a disease of diet, not germs, as many thought (Kraut n.d.). Pellagra was indicative of a larger problem with Southern life. In the beginning of the 20th century, “High rates of tenancy and sharecropping, unhealthy work environments in textile mills, and relentless poverty made the South a virtual laboratory to examine illiteracy, public health issues, and substandard living conditions in rural America”(Ferris, 2012, p. 7). In 1914, the US Treasury department was in an ongoing effort to urge Southern farmers to diversity their crops. The public health service released a statement urging a varied diet to prevent pellagra, adding “… this fact suggests the advisability of farmers in the South cultivating beans and peas and raising dairy cattle instead of cotton, at a time when the market for the latter abroad has been all but destroyed by foreign wars” (“Avoid Pellagra”, 1914). Later, “North Carolina’s extension service and home demonstration agents traveled county to county to preach the gospel of vegetable gardens and diversified, small-scale agriculture in the 1920s and ‘30s…” (Ferris, 2012, p.7). In the early 1930s, commodity crops displaced healthier farm products. Sociologists noted, “First in the nation in its combined production of cotton and tobacco, no other area produces cash crops of such value; no area has increased its tenancy so rapidly, and in no area do livestock, milk, and home-grown vegetables play so little part in farming” (Ferris, 2012, p.28). With a change in the food system came a change in Southern institutions.

Social Support

Depression-era reformers had stereotypes of Southern classes: the moral and educated had an abundant diet; the illiterate and morally suspect were poor and unhealthy. Chapel Hill sociologist Margaret Jarman Hagood found that tenant farm women spent much of their day, from before light to after dark, preparing food for their large families, especially in the summer with extra chores of field work and canning. Most families ate meals of cabbage, sweet potatoes, and field peas (Ferris, 2012, p.14). A sociologist at UNC Chapel Hill, Rupert Vance, discussed the “cotton culture complex,” an ultimately destructive agricultural system that exhausted the soil and the people who farmed: southern laborers and small farmers. He asserted that the working poor in the South, black and white, had an inadequate diet based on salt fat pork, corn bread, and molasses. He also said that though the South had land that could grow a variety of crops, tradition caused its residents to limit their diet to staple foods (Ferris 2012).

Despite this trend, local food was, as it is today, a point of pride in the South. Women who lived in towns and cities, white and African American, did most of the family’s food shopping.  By the 1920s, there were many food choices, from home gardening to new national supermarket chains. Stores like Tennessee-based Piggly Wiggly continued to advertise their local poultry and produce. Some urban women would seek out specific grocers knowing they sold products from specific farm women. Rural women produced and sold eggs, chicken, butter, fruits and vegetables, and sold them to urban women. For rural women to use this system, and gain independent income, they needed time to produce and sell their goods, surplus food to sell, and good roads to transport food. As a result, African Americans were less likely to access this system. When they did, they sold wild foods, like blackberries or rabbits. Rural women also sold processed foods like sausage, cheese, canned goods, and baked goods (Sharpless 2012). Southern food was varied and healthy when it included local produce. An interview with Mrs. H, a woman now in her eighties who grew up in North Carolina, revealed healthy habits in her upbringing in the middle of the twentieth century. Mrs. H recalled daily family lunches with very little variation. They family would have turnip greens or green beans, tomatoes, onions, and lettuce served on a platter with oil and vinegar. With that, they would have corn on the cob or cornbread, and buttermilk or iced coffee to drink. Mrs. H always had a garden, both growing up and when she was raising her family. She grew okra, eggplant, tomatoes, onions, peppers, berries, and asparagus. She did not do much canning, preferring to eat everything fresh and simply prepared (Mrs. H, personal communication, October 2, 2014).

Not all Southerners ate so simply. During the Great Depression, WPA (Works Project Administration) funded writers created state guidebooks that included regional foods and restaurants. The Savannah and Charleston low country were referred to as the “Old South” and New Orleans Creole cuisine was described as new and fashionable. “Negro Restaurants” had their own section. Recipes discussed included “fish muddle” from eastern North Carolina, a Sunday morning breakfast of grilled salt roe herring and hot biscuits; coastal oyster roasts, honey and Libertwig apples from the mountains; peaches; Cherokee Indian acorn bread; and Moravian Christmas cookies. North Carolinians were said to love black walnuts, hickory nuts, wild grapes, and persimmon pudding. Another project, “America Eats”, discussed the stories behind traditional American foods like North Carolina oyster roasts and other iconic southern dishes. Most of the guidebooks’ contributors were conservative white southerners who were happy with the status quo of racial inequality (Ferris, 2012, pp.22-24).

Race was and is a complicated issue in Southern food culture after slavery. In the 1920s, sociologist John Dollard noted that of all the racial taboos in the South, “the commonest of these taboos are those against eating at a table with Negroes”, because breaking bread together seemed too great a symbol of social equality (Ferris, 2012, p. 26). Green argues that in the 1970s, terms like “soul food” became popular due to cultural movements of the 1960s. Plantation food, French/Creole and low country cuisine had already been popular, but in the 1970s more traditionally lower class cuisines like soul food and Cajun cooking rose in popularity and soul food was viewed as the best of traditional Southern cooking. Tensions still exist over who, black or white, contributed the most to traditional Southern cuisine and Native Americans remain absent despite their contributions (Green 2008). Latshaw argues that “… African American cookbook authors and scholars sometimes frame and define southern food in a slightly different way, interpreting it not as distinctively ‘southern’ per se, but as ‘soul food’ or ‘Black food,’ asserting that this cuisine symbolizes the persistent presence of an African worldview in their customs, beliefs and practices. In this sense, foods such as greens and grits are not necessarily connected to a communal southern identity, but to an enduring African American identity, serving as a reflection not only of the stamina, survival and inventiveness utilized to persevere through the experience of slavery, but also their cultural separateness, or at least difference, from white southerners” (Latshaw, 2009, p.109).

Cultural Food Practices

One exploration of these attitudes about southern food, which included aspects of race, was the Southern Focus Polls held by UNC from 1991 to 2001. In spring 1992, respondents across the South were asked what they thought about southern food. Responses were positive, with 62% saying “I love it” or an equally enthusiastic equivalent (Latshaw 2009). Enthusiasm about Southern food has spread across the country. The editor of Nation’s Restaurant News spoke at the 2008 Culinary R&D conference in Charlotte. He noted that Southern food is one of the most popular regional cuisines in the country. Frying is still more popular than grilling. In the country’s top chains, the top entrees branded “Southern” are fried chicken; biscuits, sausage, and gravy; chicken-fried steak, fried shrimp, and fried catfish. Sweet tea is also growing in popularity, selling well at McAlister’s Deli and Dunkin’ Donuts (Cobb 2008). The poll asked respondents in 1995 about how often they ate traditional southern dishes like okra, chitlins, fried tomatoes, sweet potato pie, catfish, and boiled peanuts. People with longer residency in the South and self-ascribed Southern identity were more likely to eat this food, particularly members of Protestant denominations (Southern food is frequently served at Southern church gatherings). Those with lower income and education were more likely to eat Southern food. African American Southerners were more likely to often or sometimes eat Southern food; white Southerners were more likely to seldom eat it. However, white and black Southerners ate more like each other than they did like non Southerners. An exception is for sweet potato pie and chitlins; those foods were much more likely to be consumed by African Americans (Latshaw 2009). For African Americans, attitudes about traditional Southern food are complicated. Nettles notes, “On the one hand, contemporary memories of soul food or black southern cuisine are linked to notions of family, love and community— to the idea that black people, struggling under the yoke of slavery and the post-slavery experiences of sharecropping, Jim Crow racism, migration north, and discrimination could at least rely on the comforts of the traditional foods that solidified their relationships with one another in the face of adversity” (Nettles 2007:108). Recent cookbooks have attempted to reconcile soul food with the health problems facing African Americans (including diabetes rates three times higher than forty years ago and the epidemic of obesity), with titles like Eating Soulfully and Healthfully with Diabetes (Nettles 2007).

The complications of race and cultural tradition in the South extend into infant feeding. NHANES after 1993 found an increasing proportion of mothers initiating breastfeeding; however, the increase was smaller for African Americans. In 2011, Street studied mothers in prenatal classes in hospitals across North Carolina to examine the relationship between race and infant feeding attitudes, comparing African American and white women. The study occurred in hospitals in Greensboro (which has a 37.4% African American patients), Gaston County (13.9% African American), and Charlotte (32.7% African American). Participants shared their perceptions of their cultural backgrounds’ influence on their infant feeding choices. African American participants were likelier to be younger, unmarried, receiving WIC and Medicaid, have a lower socioeconomic status, and be unemployed. There was no significant difference in feeding attitude score between white and African American participants. Only infant feeding attitude score significantly predicted the decision to breast feed; not income, education, or race. Study participants were asked, “The word culture means beliefs and traditions passed down by your family and friends. How has culture affected how you plan to feed your baby?” (Street 2011, 86). The most common responses about culture’s effect on breast feeding was that there was not cultural influence, there was family influence, there was a message breastfeeding is the best and healthiest method and, and the influence that the subject’s mother breastfed (Street 2011).

In the 1950s, Mrs. H. recalled giving her children “bottle milk”. She said at the time they did not have powder formula; she used a recipe from her pediatrician that included canned milk (Mrs. H, personal communication, October 2, 2014). Your Baby and Mine, a column that ran in newspapers across the country, noted, “One standard rule is to provide for the milk portion of the formula 1 ounce of evaporated or 2 ounces of fresh, pasteurized milk for each pound of baby’s weight… In addition to this there must be water to provide for the baby’s total fluid needs… and sugar to make the formula as nearly as possible like human milk…” (Eldred, 1943) Relying on cow’s milk to feed infants was dangerous in wartime. In December 1942, a pediatrician in Baltimore, urged the creation of a prescription system for evaporated milk. Mothers widely used evaporated milk for infant feeding, and some grocers had a self-imposed rationing system limiting customers to one can a day. This was inadequate and dangerous, particularly because bacteria formed in the cans shortly after they were opened (“Doctor Urges”, 1942). Sometimes infant formula was a way to get rid of excess produce. In 1948, researchers at the Virginia Tech dairy department announced that concentrated apple juice could reduce curdling and add a source of sugar to infant formula, creating a use for Virginia’s surplus apples (“Your Baby” 1948). A “You and Your Child” column published in 1964 discussed changes in recent years in feeding, noting, “Only one mother in five now fixes baby formula using the traditional evaporated milk mixed with carbohydrate modifiers, a mainstay of two-thirds of babies in 1952”. It continues, “Only one in 10 is breast-fed, still the safest, most convenient and least expensive method of nourishing an infant”  (Beck, 1964, p.A2).

Health Beliefs

Southern health beliefs are a reflection of history. Mrs. H now believes the way people cooked when she was growing up was not healthy. She says there was too much salt and too much grease. Now, when she is cooking beans, she does not cook them “all day” and does not cook vegetables “to death”. She also no longer cooks with fatback. She said, “If people want salt and things they can put it in, but you can’t take it out”. She uses other seasonings now like garlic, wine, and spices. She said that diet changed when people started moving around the country more. Additionally, “nutrition hopped in there and told us it wasn’t good for us”. On the other hand, some nutritious habits have been lost. Mrs. H’s children grew up eating food that was different than that she had grown up eating. They did not have a vegetable-based lunch as she did, but were more likely to have sandwiches or soup for lunch. (Mrs. H, personal communication, October 2, 2014).

The Southeastern US has been labeled the “Stroke Belt”, with significantly higher stroke mortality rates. There are also high rates of diabetes and cardiovascular disease, particularly for African Americans, particularly Southeast natives (Smith 2006). The 10.6% or higher prevalence of diabetes extends from the Mississippi River to the coastal Carolinas. They note, “The strong regional patterns of obesity and diabetes are believed to exist because of a convergence of social norms, community and environmental factors, socioeconomic status, and genetic risk factors” (Smith M, 2009, p.69). This likely has a lot to do with modern diet. Ms. B, a woman in her twenties raised in the South, described a shift in two generations. Her grandparents were subsistence farmers who grew most of their own food. They preserved and ate what they got off the land year round, only buying flour in bulk from the store. However, later in life her grandmother relied on government elderly assistance and began replacing her diet with canned foods from WalMart. Then most of Ms. B’s parents’ generation also changed their diet, from the vegetables they ate growing up to packaged foods like pizza. Coca Cola was the primary beverage for every meal except breakfast. Ms. B’s generation grow up with many of those packaged foods. Traditional southern foods did appear around the holidays, though they were often desserts like pecan pie and Divinity. Ms. B’s extended family also did not generally eat meals together. The farms near Ms. B’s home grew commodity crops like corn (Ms. B, personal communication, October 12, 2014).

Traditional health beliefs have been applied to these modern illnesses. The Southern (particularly Southern African American) model of health has a lot to do with blood. Someone’s health depends on whether their blood is high or low, or thick or thin, with balance being the goal. High blood sugar and high blood pressure both involve blood that is “high” (Smith et al 2006). New blood is always being formed, and blood leaves the body through menstruation (in women) and sweat (in men). Blood loss is weakening. Drinking sassafras tea helps thin blood. Red foods like beets, grape juice, and red meat help build up blood volume. “Low blood” means anemia. Traditional beliefs associate low blood with eating too many acidic foods like vinegar or pickles, which “bring down” the blood.  “High blood” is associated with hypertension. High blood comes from ingesting too many rich foods, especially red meat. You treat high blood with acidic foods, like vinegar, oranges, or pickle brine. If high blood goes untreated, blood will back up into the brain and cause a stroke. Diabetes is viewed as running in families and caused by eating too many starchy or greasy foods or worrying too much about family or work. People with diabetes should change their diet, use herbs, and reestablish harmony with loved ones. If these methods do not work, the patient will visit a doctor. Blue recommends that doctors tell diabetic patients that blood sugar is elevated. This explanation makes patients accept medications because they are thought of as “bittering” agents that lower the sugar content. Patients also eat foods at home they view as “bittering”, like herb tea, garlic, and lemon juice (Blue n.d.). Diabetes may simply be called “sugar” (Smith 2006).

Smith et al interviewed adults in the rural South about the cultural meanings of salt. Traditional foods containing salted pork were considered unhealthy and associated with low-income, rural, and African-American people. Subjects believed that foods they defined as “fresh” (like cabbage and collard greens but also cornbread, meat and fish) needed salt. “Fresh” was undesirable and meant bland. Some subjects acknowledged that food was healthier when it was eaten “fresh” and unsalted. However, most subjects believed a little salt was necessary due to sweating and the need to consume iodine. Many referred to the Bible passage that states, “Salt is good… have salt in yourselves and have peace with one another”. They did believe moderation was needed, because too much salt could have negative health effectives, particularly in the blood; many mentioned high blood pressure. However, the term “hypertension” was viewed as a state of mind caused by anxiety, not diet. Some participants blended characteristics of high blood pressure and diabetes into “high blood”, as described above. Pork was seen as unhealthy because it contributed to high blood. Many also believed that both sugar and salt could cause diabetes. Since participants believed that blood carried substances around the body, diabetes and high blood pressure were viewed as blood diseases. Because of the recognition of salt as a risk factor for disease, many minimized its effects by using salt in cooking but not adding it to food at the table. Many called salt added to already cooked food “raw salt”, and believed raw salt was more harmful than cooked salt because cooking the salt broke it down and took out impurities. Participants also tried boiling or soaking pieces of salty pork meat to remove some of its salt. Many men found it difficult to use less salt even with strong beliefs about its adverse effects, because they preferred its taste (Smith 2006)

Two special populations medical professionals may encounter are the Gullah people, who live on the sea islands off the coast of the South from North Carolina to Florida; and residents of the Appalachian mountains. Until the 1930s the Gullah’s islands were only accessible by boat. This led to a socially isolated population with a disproportionate number of African American slaves who traveled directly from Africa to the islands. These slaves had their own medical system, using plant and animal remedies from Africa, and herbal knowledge from local Indian tribes. Traditionally, these African Americans believe in natural and unnatural causes of illnesses. Natural illnesses exist in God’s world and are caused by an individual’s imbalance with the natural world, which can be affected by improper diet or lifestyle. People are more vulnerable to these illnesses when they are very young, very old, out of touch with God, or eating improper foods. Unnatural illnesses are the result of a curse or spell that has disrupted God’s plans. They are often gastrointestinal or behavioral. Patients may decide an illness is unnatural when a doctor has not made an immediate diagnosis or the treatment given by a doctor has not worked (Blue n.d.). In Slushing’s study of Appalachian women, health beliefs related primarily to health action and health state. Health action consists of health promoting behaviors, like getting out of bed, doing a day’s work, eating right, and serving others. Health state consisted of the absence of poor health. Health states were internally and externally controlled, and included things like enjoying life, believing in God, and not experiencing pain. Women who attended church more often were more likely to define health as an action, rather than a state. Women had an overall high score for self care activities (which included visiting health providers, eating a healthy diet and exercising, and avoiding tobacco, excessive alcohol, and drugs), except for breast self exams and a yearly Pap smear (Slushing 2004). If the interviews with Mrs. H, who is in her eighties, and Ms. B, who is in her twenties, are representative of trends in the Southern population, one way to approach improving health in the South is to rebuild agricultural connections. Ms. B.’s parents have returned to gardening, growing green beans, tomatoes, okra, banana peppers, and beets. Ms. B. says that the nutrition messages she grew up with were excessively simplistic, discussing calorie counting and not much about food substance (Ms. B, personal communication, October 12, 2014). However, vegetables that grow well in the South and were large proportions of recent generation’s diets may be culturally familiar to introduce to clients, and match the often-stated goal of eating fewer calories and losing weight. A study of rural residents in Appalachian Kentucky and Eastern North Carolina; both areas with high obesity rates and limited access to fruits and vegetables, found that most survey participants shopped at super centers or supermarkets, but 15% of the North Carolinians had visited a farmers’ market in the past year. Reported barriers to shopping at farmers’ markets included market days and hours, market location, and only visiting a market needing a specific item. Fruit and vegetable consumption was positively associated with shopping at farmers’ markets. Participants said that the best way to encourage more farmers’ market shopping was to have more vendors and more promotion of the market. The top reason given for not liking produce from the farmers’ market was not cost. Participants first ranked problems with spoilage, second the fact that the restaurants they frequented did not serve fruit, and third cost. In Pitt County, 17% of residents who received food stamp benefits used them at farmers’ markets (Jilcott Pitts 2014). Low income North Carolinians also said it would help them if they had access to affordable locally grown fruits and vegetables and knowledge about how to quickly and easily prepare them. Barriers to shopping at farmers’ markets included not being able to use food assistance program benefits or not knowing a farmer’s market in their area. This would be eased by having transportation and information about the markets’ hours (Leone 2012).

Farmer’s markets and CSAs (Community Supported Agriculture, in which customers pay an upfront fee to a farmer for a regular delivery of the farmer’s fresh produce that season) are increasingly popular in North Carolina. As of August 2012 North Carolina had 202 farmers markets, and the quantity of farmers markets grew across the Southeast (Western Farm Press 2012). More than a fourth of surveyed low income women living in rural Pitt County in Eastern North Carolina had shopped at a farmers’ market. Those women were more likely to consume five or more fruits and vegetables daily (Jilcott Pitts 2013). Jilcott Pitts also found increased proximity to a farmers’ market or product market was associated with lower BMI in youth (Jilcott 2011). Additionally, as of January 2010, there were approximately 60 CSA farms in North Carolina. Landis et al surveyed CSA members in the Triangle about their experience. CSA members tend to be white, middle-aged, married, economically secure, and highly educated. The top sources of information about CSAs for members were friends and the Internet. CSA members cited supporting local farms, healthier eating, and knowing where their food came from as major reasons to join a CSA. CSA members ate significantly more fruits and vegetables and in a greater variety than controls (Landis 2010). Practitioners can note that individual clients are receptive to from-the-farm shopping. The main barriers are finding convenient times to go and knowing how to cook the foods. This suggests dietitians can help their clients by knowing their local farmers’ markets and their hours, and teaching clients how to make easy recipes with farmers’ market foods. North Carolina woman in a weight loss intervention demonstrated that knowing one will be monitored for weight loss increases farmers market participation; and knowing the benefits of healthy food causes one to spend more money on groceries and feel more positively about their local store’s healthy food availability (Gustafson 2012). It may also help to connect more diverse clients to CSAs.

Data from the 2000 to 2005 South Carolina Pregnancy Risk Assessment Monitoring System (PRAMS) found that black women were less likely to initiate breastfeeding and breastfed their babies for a shorter duration than white women. Very obese white women were less likely than normal weight white women to initiate breastfeeding and more likely to discontinue breast feeding within the first six months. Among black women, pre pregnancy BMI was not associated with breastfeeding initiation or duration within the first six months (Liu 2010). This means practitioners should try to improve breastfeeding rates in African Americans as a group, regardless of size, but give special attention to very obese white women to encourage breastfeeding. Breast feeding helps a mother’s postpartum weight loss and decreases her infant’s likelihood of later childhood obesity.

Health beliefs about “balance” sometimes result in misinterpretations of diagnoses of diabetes or hypertension among southern clients. Practitioners should use the phrase “high blood sugar” and “high blood pressure” to improve clients’ understanding of their conditions and efforts to control them. Language about moderation, long a part of Southern health beliefs, can be harnessed to give advice about healthy eating. For example, a practitioner can say, “It is important to only eat moderate amounts of white food. That means eating less white food and more orange, yellow, red, and green vegetables.”

For African American clients, soul food is still a powerful symbol of shared history and a unique identity. Practitioners should be sensitive to that, and rather than disparaging traditional soul food, help clients come up with healthy versions of favorite foods. Traditional African ingredients that can be very healthy with good preparation methods, like greens, sweet potatoes and okra, are a particularly good choice for this technique.




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