Physiology & Behavior xxx (2014) xxx–xxx

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Physiology & Behavior

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Using a biocultural approach to examine migration/globalization, dietquality, and energy balance

David A. Himmelgreen ⁎, Allison Cantor, Sara Arias, Nancy Romero DazaDepartment of Anthropology, University of South Florida, 4202 E. Fowler Ave, SOC 107, Tampa, FL 33620, USA

H I G H L I G H T S

• Globalization/migration influence diet quality, energy balance, and dietary recommendations.• Globalization is linked with the nutrition transition, and the adoption of a more Western diet.• The impact of globalization/migration on dietary change varies across settings and populations.• New conceptual models are needed to examine transnational processes that shape diet.• Critical biocultural approaches can be used to examine globalization/migration and diet change.

⁎ Corresponding author at: Department of AnthropoloTampa, FL 33620, USA. Tel.: +1 813 974 2138.

E-mail addresses: dhimmelg@usf.edu (D.A. Himmelgr(A. Cantor), saraarias@mail.usf.edu (S. Arias).

0031-9384/$ – see front matter © 2014 Published by Elsehttp://dx.doi.org/10.1016/j.physbeh.2013.12.012

Please cite this article as: Himmelgreen DAbalance, Physiol Behav (2014), http://dx.doi

a b s t r a c t

a r t i c l e i n f o

Article history:Received 30 September 2013Accepted 17 December 2013Available online xxxx

Keywords:Bio-cultural synthesisMigration/globalizationDiet qualityEnergy balanceDietary acculturationNutrition transition

The aimof this paper is to examine the role and impact that globalization andmigration (e.g., intra-/intercontinental,urban/rural, and circular) have had on diet patterns, diet quality, and energy balance as reported on in the literatureduring the last 20 years. Published literature from the fields of anthropology, public health, nutrition, and otherdisciplines (e.g., economics) was collected and reviewed. In addition, case studies from the authors' own researchare presented in order to elaborate on key points and dietary trends identified in the literature. While this reviewis not intended to be comprehensive, the findings suggest that the effects of migration and globalization on dietquality and energy balance are neither lineal nor direct, and that the role of social and physical environments,culture, social organization, and technologymust be taken into account to better understand this relationship.More-over, concepts such as acculturation and the nutrition transition donot necessarily explain or adequately describe allof the global processes that shape diet quality and energy balance. Theories from nutritional anthropology andcritical bio-cultural medical anthropology are used to tease out some of these complex interrelationships.

© 2014 Published by Elsevier Inc.

1. Introduction

Bogotá, Colombia, like other metropolises throughout theworld, is acity of great contrasts. New buildings of glass and steel that spiral up tothe sky abound in the backdrop of the magnanimous Andes Mountains.The Transmilenio, a rapid transit bus system, shuttles 1.4 million“Bogotanos” along its 84 km (54 miles) of four-lane arteries throughoutthe expanding city, reducing travel time by nearly one-third. Cars andtaxies clog up the streets and avenues while street vendors sell freshproduce from horse-drawn carts. Malls, box stores, global fast foodchains, and mega-supermarkets are interspersed between bodegasand bakeries. On the one hand, sustained economic growth in

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Colombia even during the global recession [8] has resulted in increasingeconomic prosperity among a growingmiddle class. On the other hand,poverty and hunger are ever present in Colombia's capital wheremultitudes of homeless and working poor struggle to survive. Through-out the city homeless people comb through trash in search of food orscrap-metal or beg or steal to make it through another day. Middleclass and working poor families work harder and harder to make endsmeet as the cost of living rises rapidly [31].

Colombians from the countryside continue to stream into Bogotáeven as the 40 plus years of political instability and para-military anddrug-cartel related violence have subsided [31]. Weather related eventssuch as La Niña and climate change have resulted in increased floodingand mudslides, leaving thousands homeless [84]. About 1.5 millionColombians have been displaced and many of them are migratingfrom the rural areas to the big cities. In most cases, these internallydisplaced people (IDP) arrive in urban centers destitute, without landor money to survive. The Colombian government estimates the rate of

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Fig. 1. An ecological model of food and nutrition. Excerpt from Pelto et al. [63].

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food insecurity (i.e., lack of access to food of adequate quantity andqual-ity obtained through socially-acceptable means) to be about 50% forIDPs [93].

While this scenariomayplay out in differentways, depending on thecountry, city, political and economic conditions, culture(s), geography,and climate, the Bogotá case underscores' the fact that globalization,migration, and climate change are having a significant impact on thelives of millions of people throughout the world.

The aim of this paper is to examine the role and impact that global-ization and migration (e.g., internal/external, urban/rural, and circular)have had on diet patterns, diet quality, and energy balance as reportedon in the literature during the last 20 years. Published literature fromthe fields of anthropology, public health, nutrition, and other disciplines(e.g., economics) was collected and reviewed. In addition, case studiesfrom the authors' own research are presented in order elaborate onkey points and dietary trends identified in the literature. While thisreview is not intended to be comprehensive, the findings suggest thatthe effects of migration and globalization on diet quality and energybalance are neither lineal nor direct, and that the role of social andphysical environments, culture, social organization, and technologymust be taken into account to better understand this relationship.Moreover, concepts such as acculturation and the nutrition transitiondo not necessarily explain or describe all of the global processesthat shape diet quality and energy balance. Theories from nutritionalanthropology and critical bio-cultural medical anthropology are usedto tease out some of these complex interrelationships.

1.1. Ecological model for food and nutrition and critical bioculturalperspective

Kandel et al. state that “food by virtue of its pivotal place in thehuman experience is, at once, a bundle of energy and nutrients withinthe biological sphere, a commodity within the economic sphere, and asymbol within the social and religious spheres” ([43]:1). Nutritionalanthropology, with roots in medical and biological anthropology, is“explicit in its goal of [examining] the linkages between the biologicalsignificance of nutrients and the sociocultural and economic meaningof food” ([35]: 151). As Pelto et al. state, nutritional anthropologistsstudy the way in which food use patterns and nutritional status areinfluenced by the interaction of social and biological factors ([62]: 2).Another way to think about this is that culture and the social and phys-ical environment determine what foods are (and are not) consumed.These foods contain macro- and micro-nutrients, which, along withother factors such disease exposure, physical activity patterns, andmental health, influence nutritional status. In the end, through a chainof interactions, culture and environment shape biological functioning,which is reflected in human phenotypes and genotypes.

The influence of social class, race and ethnicity, and power andagency on biological functioning can be examined through the criticalbiological perspective, which borrows theory from biology and thesocial sciences (most notably from critical medical anthropology). Thisperspective incorporates the idea that biological functions becometransformed socially [49] through political economic processes (e.g.,global capitalism), and that social and economic inequalities andpoverty become embodied in human biology. This theoretical frame-work is particularly useful when looking at globalization and migrationin relationship to rising health disparities especially among those livingin extremepoverty, theworking poor, and even themiddle class. Hence,a critical bio-cultural perspective provides a useful framework forexamining the socio-cultural and political aspects of health [23,47].

In 1980, Jerome et al. proposed an ecological model for food andnutrition [41] which is still used today in nutritional anthropologyand other fields. More recent bio-cultural perspectives that addresssociocultural and biological dimensions of food and nutrition often bor-row from this model [35]. Fig. 1 shows the redrawn ecological model offood and nutrition [62] in which global forces have proximal and distal

Please cite this article as: Himmelgreen DA, et al, Using a biocultural apbalance, Physiol Behav (2014), http://dx.doi.org/10.1016/j.physbeh.2013.1

effects on the physical (e.g., climate, water resources, flora and fauna)and social environments (e.g. societal, regional and communityfood systems), social organization (e.g., institutional and individualrelationships), culture (idea systems such as knowledge and skills)and technology (e.g. industrial food system), as well as on the diet(e.g., food consumption patterns), and nutritional needs and status(e.g., diet quality, growth and development, immune function). Theinteractions among the domains are identified by the bidirectionalarrows, indicating the bio-cultural nature of the conceptual model.Since the macro- and micro-level forces that shape diet are complex inthe modern era and are interconnected with global capitalism andneoliberal economic policies, migration, and culture, the ecologicalmodel of food and nutrition and the critical bio-cultural perspectiveare ideal theoretical frameworks for examining changes in diet, dietquality, and energy balance among contemporary populations.

1.2. Definition of variables

Since themeaning of themain variables (as concepts andmeasures)examined here varies across disciplines, it is worthwhile to discussthembeforemoving onto the rest of the paper. These include: globaliza-tion, migration, diet quality, and energy balance.

1.2.1. GlobalizationGlobalization has been defined as a process of increasing inter-

connections and linkages, within societies and across geography,due to improved communication and expanded world trade [81].As a multidimensional phenomenon, globalization “can be brokendown into numerous complex interrelated processes that have adynamism of their own” ([88]: 2). For example, Appadurai [4] con-ceptualizes the process based on the relationships among fivedimensions of global cultural flow: ethnoscapes, mediascapes,technoscapes, financescapes, and ideoscapes, and the Globalizationand World Cities study Group and Network (GaWC) have identifiedfour spheres of transnational activities and transactions that consti-tute globalization processes: economic, cultural, political, and social[37,82]. The dynamic interactive processes of globalization can beexamined in the context of the distal and proximal domains of the

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ecological model of food and nutrition (see Section 1.1), and thecritical bio-cultural perspective can be used to examine both thepositive and negative effects of globalization processes such asthe development of infrastructure and increased job opportu-nities on the one hand, and rising inequalities and poverty on theother hand. Together, the ecological model and critical bio-culturalperspective are useful for linking globalization with diet and dietquality, energy balance, and biological functioning.

1.2.2. Migration“[Human] migration is the movement of people from one place in

the world to another for the purpose of taking up permanent orsemi(-)permanent residence, usually across a political boundary…People can either choose to move (“voluntary migration”) or beforced to move (“involuntary migration”)” ([57]: 1). One of themost prominent types of migration today is rural to urbanmigration,with millions of rural people from across the globe searchingout new opportunities (e.g., employment, education) in growingurban centers. Rural to urban migration occurs at different scales:inter-continental, intra-continental, and most notably interregional,or within a country migration. Other types of migration include stepmigration (shorter migrations from a person's place of origin), chainmigrations (migration of family or other social group where oneindividual or a few persons move first to a new location beforesending money to bring other members there), return or circular mi-gration (individuals go back and forth between their place of originand the new location), and seasonal migration (periodic migrationin response to labor, climatic, and other conditions) [57]. Sincemigrations often involve the crossing of political, economic, cultural,climatic, and food systems boundaries, they have significant implica-tions for food access and availability, diet patterns, diet quality, andenergy balance. For example, because Puerto Ricans have US citizen-ship, they routinely engage in circular migration between the U.S.main-land and the island. As a result, the Puerto Rican diet is shapedby two if not more cultural environments that have varying influencein diet depending onwhere individuals are located at any given time,their age, socioeconomic status, language use, and the strength oftheir Puerto Rican cultural identity [34].

1.2.3. Diet qualityThe concept of diet quality is relatively new and was developed to

assess both the nutritional value and the variety of the total diet,allowing for the examination of the association between foods (ratherthan just nutrients) and health status [92]. Normally, diet quality ismeasured using scoring tools such as the healthy eating index (HEI)and the healthy diet indicator [21]. In this paper, literature using scoringtools and indices as well as more qualitative data (e.g., ethnographic) todescribe diet quality were included in the review.

1.2.4. Energy balanceEnergy balance, which is used synonymously with macronu-

trient balance, is a measurement of the balance between calorie intakeand caloric expenditure in living organisms. In humans, intake isdetermined by measuring caloric (energy) consumption of foods andbeverages while expenditure is determined by measuring caloriesburned by the body through metabolic processes (e.g. basal metabo-lism, thermogenesis) and physical activity.

2. Methods

For the purpose of the literature review, globalization andmigrationwere considered independent variables while diet quality and energybalance were viewed as dependent variables (refer to the ecologicalmodel of food and nutrition in Section 1.1). Since the literature on thistopic cuts across disciplines, it is important to note that the review isnot comprehensive but rather focuses on published research in

Please cite this article as: Himmelgreen DA, et al, Using a biocultural apbalance, Physiol Behav (2014), http://dx.doi.org/10.1016/j.physbeh.2013.1

anthropology, public health, nutrition and other fields such economicsfrom 1994 to 2013. Searches were conducted using combinations ofthe following key terms: “globalization,” “migration,” and “trends,” onthe one hand, and “diet quality,” “diet,” “energy balance,” and “macro-nutrient energy change,” on the other.

Google scholar was used for the preliminary search. Additionalsearches included the following article databases: Anthropology Plus,AnthroSource, JSTOR Anthropology, Academic Search Premiere, Webof Science, PubMed, and Wiley Online Library. Papers were chosenbased on search criteria: 1) focus on contemporary human populations;2) active discussion of migration and/or globalization; and 3) inclusionof information about quality of the diet (i.e., healthy/not healthy,specific micro or macronutrients, and energy balance). Articles thatmet the search criteria were gathered for review and citations werestored using Endnote [84]. Only the articles that fulfilled the criteriaafter a complete reading were included in the literature review.

3. Results

A summary of the findings from the literature review is presentedfirst, followed by two case-studies (U.S. and Costa Rica). The ecologicalmodel of food and nutrition and the critical bio-cultural perspectivewill be used to elucidate complex interactions.

3.1. Summary of the reviewed literature

The search terms and the total number of papers included in theliterature review by type of literature are presented in Table 1. Asshown, most of the literature (8.9.9%) included in this review comefrom public health, nutrition, and anthropology.

3.2. Globalization and diet quality

The increased flow of goods, services, and capital, and the wideningof social networks through advanced communication technologies andimproved transportation systems facilitate the sharing of culturalideas and information [90]. Together these globalization processeshasten diet and lifestyle changes. Almost all of the studies reviewedon globalization and diet quality focus on Westernization or thenutrition transition [2,5,9,10,45,48,52,63,64,73,80]. The term “nutritiontransition” was first coined in the early 1990s by Popkin to describethe transition to a more Western diet, as a result of the increasedreliance on the global industrial food system and dietary delocalization(decreased food production at the local level and increased reliance onimported foods). The nutrition transition is characterized by “highintakes of refined carbohydrates, added sugars, fats, and animal-source foods” ([66]:6; [14,71]).

Although first documented in industrialized countries, the nutritiontransition is now found in low andmiddle income countries worldwide[6,9,10,33,48,63,64,73]. The nutrition transition has been associat-ed with poorer diet and resulting high rates of overweight, obesityand other chronic non-communicable diseases (e.g., cardiovascular dis-ease, metabolic syndrome) [65,68]. For example, in Costa Rica, whereinternational tourism has become a major economic engine, food im-ports rose more than 170% between 1992 and 2005 [86], while localfood production has significantly declined at the same time. The shifttowards the global industrialized food system is reflected in increasedintakes of palm and hydrogenated oils (high in saturated fat), energy-dense carbohydrates, and sweetened beverages (e.g., fruit drinks andsodas) among rural, suburban, and urban Costa Ricans [42,73]. Further,these diet changes are associated with increased coronary heart diseaserisk factors amongCosta Rican adolescents [56], high prevalence rates ofoverweight and obesity among school aged children in the CentralValley where most Costa Ricans live [59], and adult obesity prevalencerate of 23.7% in 2008, which was the 73rd highest in the world [7].Leatherman and Goodman [48] have coined the term “coca-

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Table 1Search terms and numbers of articles by discipline in the literature review.

Search terms Total number of articles included in literature review (N= 79)

• Migration AND dietary quality• Globalization AND dietary quality• Migration AND diet• Globalization AND diet

• Anthropology: 19 (38%)• Public health & nutrition literature: 26 (52%)• Other (Economics): 5 (10%)

• Migration AND energy balance• Migration AND macronutrient energy change• Globalization AND energy balance• Globalization AND macronutrient energy change• Trends AND macronutrient energy• Changing trends AND macronutrient nutrition

• Anthropology: 5 (17%)• Public health & nutrition: 21 (72%)• Other (e.g., Economics): 3 (10%)

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colonization” to refer to the availability and frequency of “calorie-densebut nutrient-poor snack foods” that are commonly consumed in CentralAmerica and Northern Mexico. Other studies show similar findings be-tween dietary changes and health problems in Latin America and else-where, particularly in places where tourism predominates and wherethere is diet delocalization [2,9,10,30,44,45,52–54,58,73,79,80].

In China, where the nutrition transition is currently underway,Dearth-Weasley et al. [10] found that urban children are adopting lesstraditional Chinese diets, and as they get older, they start influencingtheir mothers' diets. Specifically, the data show that mother–childdyads were opting for foods higher in saturated fat and lower in grains.This relationship was linked with maternal education and socioeco-nomic status, with higher education and income being associated witha decrease in dietary quality. The researchers explained this phenome-non using China's cultural history. “Given their past experiences duringthe Cultural Revolution, Chinese parents want to give their childreneverything they did not have as a child and are now able to providetheir children with diverse and plentiful foods” ([10]: 1709). Lateradoption of the Western diet has been attributed to affordability,accessibility, and availability of certain foods. This study and others[12,44,64,80] suggest that setting-specific historical and cultural pro-cesses have a strong influence on diet quality in countries experiencingthe nutrition transition.

In addition to these changes occurring in urban areas, globalizationand the nutrition transition are impacting diet patterns and diet qualityin remote areas. For example, Sheehy et al. [80] found thatwhile Inuit inNorthern Canada are still consuming traditional foods (e.g., caribou,muktuk, and Arctic char), other game foods are being displaced byWestern energy-dense and nutrition-poor foods including sugaredbeverages, potato chips, cookies and cakes, and pilot biscuits. The aban-donment of many traditional foods is attributed to the “lack of time forhunting due to increased involvement in the wage economy, high costof hunting equipment, ammunition and fuel, a decline in communalfood sharing net-works, concerns about food supply contamination byorganochlorines and heavy metals, and reduced animal populationsand changing migration patterns due to climate change” ([80]: 7). Theauthors also suggest that the lack of consumption of fresh fruits andvegetables, associated with positive aspects of Western diets, is due tothe very limited growing season in the Canadian tundra and the highcost of importing these foods. Other researchers [16,17,40,46,76] havedocumented how climate and lifestyle changes associated with globali-zation and the nutrition transition affect diet quality and food securitystatus among people living in remote areas.

Although many studies document the adverse effects of the nutri-tion transition, it should be noted that there are cases where the shifttowards a Western diet has led to dietary improvements, especiallyamong migrant populations residing in urban settings. Delisle [12], forinstance, found that African-origin participants living in Madrid, Mon-treal, and Benin added salads and low-fat food items to their dietwhile still maintaining a healthy traditional diet. This has also been doc-umented among other migrant populations [5,52,53,58] as well as

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native populations living in countries that have undergone or areexperiencing the nutrition transition [12,29,73,80].

3.2.1. Globalization, neoliberal trade policy, and diet qualityIt has been argued that, like other globalization processes, neoliberal

trade policies have played a significant role in the nutrition transition.Hawkes et al. [27] suggest that the global trend toward increasedconsumption of certain fats (saturated fats and trans-fatty acids) andthe concomitant decrease in the consumption of fruits, vegetables,pulses, and whole grains reflect agricultural policies that support tradeliberalization. The link between agricultural policies and the nutritiontransition is predicated on the fact that free trade policies, such as theNorth American Free Trade Policy (NAFTA) and the Central AmericanFree Trade Policy (CAFTA) have opened food markets thereby affectingfood availability, affordability, and acceptability. The authors cite theexample of the increased availability of chickenmore recently in severalcountries in the Western Hemisphere. Additionally, Seiden et al. [79]point to the influence that trade organizations (e.g.,World TradeOrgani-zation) have in encouraging the maintenance of open markets withouttaking into account the effects on diet. Seiden et al. state that “while themajority of pork has remained domestically produced [78], the in-creased availability of fat from poultry, mutton, and vegetable oilsources can be linked largely to the globalization of food productionand trade and changes in local legislation. Vegetable oils, in particular,have received attention in both academic and political literature inrecent years as their export to lower income countries continues torise” (2002: 291). Thow [85] also argues that trade liberalization islinked to the nutrition transition and addresses its implications fordomestic food production and public health nutrition by stating that:

Trade liberalisation influences the food environment through facili-tating trade in goods and services, of processed foods and animalproducts. The framework highlights the complex relationshipbetween trade policy and the nutrition transition, with both nega-tive and positive outcomes arising from different aspects of tradeliberalisation ([85] 2150).

For example, in a study on economic changes in rural Costa Rica,where tourism is replacing agriculture as the primary economic driver,Himmelgreen et al. [29] found that local residents described bothpositive and negative changes to their diets, with increased fruit andvegetable consumption but also an increased consumption of energy-dense processed foods and fast foods such as pizza and hot dogs.

3.2.2. Migration and diet qualityWhile themovement of human ancestors dates back several million

years, the magnitude and numbers of humans on the move today farout-pace any previous migrations [54,89]. Individuals and groupsmigrate for a variety of reasons, such as work and education, politicalunrest in their home country (making them refugees), to be with rela-tives, or in search of better living conditions. As people migrate (within

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or between countries) they enter different physical and social, cultural,and technological environments, which alter the fabric of their dailylives. Identifying and understanding the role that migration has ondietary patterns and diet quality is important in the context of healthand disease patterns in the modern era. Before summarizing thefindings from the literature, the concepts of acculturation and dietaryacculturation will be discussed and later critiqued.

Acculturation has been defined as a process that “occurs when a so-ciety undergoes drastic culture change under the influence of a moredominant culture and society with which it has come in contact”([36]:48). While the acculturation process may ultimately lead toassimilation, or almost total loss of cultural identity, it can also resultin adaptation to the dominant cultural milieu through new patterns ofthinking and behavior modification [25]. At the same time, it mayallow individuals to hold onto their values, customs, and communica-tion patterns [36] in order to maintain a sense of cultural identity.Although the less dominant society is often affected to a greater degreeby acculturation, changes in the cultural pattern are also experienced bythe more dominant society as specific customs and practices (e.g., foodconsumption) of the less dominant become embedded in the largercultural milieu. Therefore, the cultural influences are bi-directionaland can lead to varying degrees of cultural exchange and acculturationfor immigrant groups [34]. Dietary acculturation is used to describethe processwherebymigrants adopt the food habits and food consump-tion patterns of the larger society in which they find themselves. Thisprocess “is multidimensional, dynamic, and complex; in addition, itvaries considerably, depending on a variety of personal, cultural, andenvironmental attributes” ([77]:1105). Finally, it must be noted thatdietary acculturation does not necessarily begin with immigration to anew country. Instead, changes in dietary patterns are likely to occur inthe migrant's native country. This is particularly true in settings wherefood commoditization and food advertising (as globalization processes)have taken root, for instance, in urban settings [30].

There is a multitude of studies on migration, acculturation, and dietquality [9,18,45,51,52,58]. The findings from these studies are mixed. Inmany cases, whether or not an association exists between migrationand diet quality varies according to how acculturation is measured. Insome studies, variables such as age at migration, years of residence,and language use have been used as proxy measures of accultura-tion and nutritional status (including diet quality). For example,Himmelgreen et al. [34] found a statistically significant increasein body mass index (BMI) with the length of time in the U.S. amonglow-income Puerto Rican women in Hartford, Connecticut. They alsoobserved that the BMI increase was greater for women born in PuertoRico than for their U.S. born Puerto Rican counterparts who movedback and forth between the island and the mainland (cyclical migra-tion). Considering that Puerto Rico is a U.S. territory and that there is along history of cultural and economic exchange between the twonations, these findings highlight the role that globalization processeshave in influencing nutritional status. Similarly, changes in diet canbegin even before migrants leave their homeland. For example, in astudy among Hispanic immigrants living in Tampa, FL, Himmelgreenet al. [32] found that among Colombian participants, the preferencefor pizza and hamburgers was partially rooted in the fact that inColombia such foods are expensive and are reserved for occasionssuch as birthdays and other special celebrations. The availability andaffordability of such foods, perceived to be “high status,” increasedtheir consumption by adults and children alike.

In research conducted among Hmong refugees living in SaintPaul/Minneapolis, Minnesota, Franzen and Smith [18] found thatacculturation influenced diet quality and physical activity butthat the inclusion of rice (a traditional staple) in every meal was acultural mandate in order for Hmong to feel satiated. This relianceon rice was also attributed to the cultural belief that Americanfoods are considered snacks and not complete meals. While theHmong diets included American foods, they were skewed towards

Please cite this article as: Himmelgreen DA, et al, Using a biocultural apbalance, Physiol Behav (2014), http://dx.doi.org/10.1016/j.physbeh.2013.1

heavy rice consumption (and other traditional foods) to maintaincultural identity and to make meals complete.

However, the maintenance of traditional diets is not a given whenpeople migrate to new places. For instance, Colby et al. [9] comparedthe diets of Mexicans in the U.S. with those of their counterparts inMexico and found evidence of significant changes in the diet anddiet quality. While the Mexican diet traditionally consists of complexcarbohydrates, beta-carotene, fiber, calcium, animal and vegetableprotein, iron and major vitamins, the researchers found that this dietwas displaced in the U.S. due to high food costs, among other factors.The US sample reported higher consumption of fat, salt, meat, dairy,and sugar and a lower consumption of beans, fruits, and vegetablesthan their compatriots in Mexico. The latter group of foods happens tobe less expensive and more readily available in Mexico.

Studies outside of the U.S. also show mixed results. For example,Nicolau et al. [58] found no association between acculturation and dietquality among 1528 Surinamese Afro-Caribbean and South Asian immi-grants living in the Netherlands. In fact, the migrants maintained ahealthier diet when compared to their ethnic Dutch counterparts,consuming more fruits, vegetables, and fish, and less red meat. Somegender difference were noted however, with women using less saltand oil and consuming less fish, while men more frequently consumedredmeat. This suggests some acculturation effects.While not elaboratedon, the authors note that the Surinamese have a high risk for obesity,type 2 diabetes, hypertension, and cardiovascular disease (CVD),all diet-related diseases, and that Suriname is a former Dutch Colony.Like Puerto Rican example above, previous cultural contact and accul-turation might have had an influence on diet quality and disease riskover time.

In another example, Méjean et al. [53] found that Tunisian mi-grant men living in France had better health than non-migrants,which was partially explained by differences in dietary quality. Themigrants had a more varied diet, possibly due to the consumptionof nuts and beans, which are found in the traditional diet. The au-thors identified specific aspects of the diet that may impact overallhealth trends, such as high fiber intake and high intake of VitaminC. Méjean et al. [52]. also examined the association between accul-turation and diet quality in a follow-up study, which includedmeasures of length of time living in France. In this case, the re-searchers found a positive association between the number of yearsin France and increased carbohydrate consumption among the mi-grants. The inclusion of sugars and sweets explains the rise in carbo-hydrate consumption, which follows national dietary trends inFrance. Conversely, salt intake decreased the longer migrants wereliving in France, and this is explained by reduced meat consumption,reflecting a more traditional Tunisian diet.

Other research shows the opposite effect, with a decline in dietquality after migration. For example, in a study of Somalis refugeesliving in the United Kingdom (UK), McKewan et al. [51] found thatthey consumed fewer portions of fruit and vegetables when comparedto the UK population overall. This was attributed to the Somali culturalvalue in which red meat consumption is associated with affluence andfruit and vegetable consumption with poverty. Here the maintenanceof traditional views about diet and affluence has an adverse effect ondiet quality when certain foods such as red meat are more readilyavailable.

In another study on Somali refugees, Burns et al. [5] examined dietquality among Somali women living in Australia. Their results showedthat “Somaliwomen largelymaintained the structure of their traditionaldiet in Australia and that the addition of processed foods of the econom-ically developed world were made within the framework of the eatingpattern of their own culture” (2004: 223). For example, some energy-dense foods were adopted by these women including instant noodles,crisps, pizza and soft drinks. Moreover, while there was limitedconsumption of takeaway or restaurant foods, the women did reporteating these foods outside the home if theywereHalal (followed Islamic

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Fig. 3. Comparison of the carbohydrate recommendations of the individual countriesagainst the cereal per capita supply (kg/yr) as per Food and Agricultural Organization(FAO) food balance sheets of the same countries. In Kapur and Dunning [44].

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laws). These findings suggest that these refugees adopted someWestern foods and food habits but they largelymaintained a traditionaldiet.

Finally, in Germany, Kleiser et al. [45] looked at diet quality amongmigrant children and adolescents from Turkey and Russia. The resultsshow migrant specific diets that were of greater or lesser diet quality,depending on origin of the participants. For example, while the Turkishand Russian youth consumed high amounts of fruits, the Turkish youthconsumed higher amounts of soft drinks, white bread and rolls, friedpotatoes, and snack foods. Conversely, the Russian youth consumedhigher amounts of sausage and bacon. Although the Russian youthhad a lower healthy diet score than their Turkish counterparts, bothgroups of youth have adopted the least healthy aspects of the German(and Western) diet. Other studies also show that immigrant youthare more susceptible to dietary acculturation than migrant adults[9,18,45,51,52,58].

In conclusion, these migration studies suggest that while accultura-tion has an important role in shaping diet quality, the concept itselfdoes not always capture the complex interactions that lead to dietarychanges. In fact, in many cases, migrants hold on to aspects of thetraditional diet for a variety of reasons such as cultural identity butalso adopt Western foods because of convenience, cost, and otherfactors associated with lifestyle changes [5,26,51,54].

3.3. Globalization/migration and energy balance

As discussed in Section 3.2.1., globalization and neoliberal tradepolicies have had a major impact in terms of the nutrition transition.This has resulted in major shifts and imbalances in energy and macro-nutrient intake both within countries and across lower- and higher-income countries [54]. For example, during the early 1970s, dietaryrecommendations for carbohydrateswere b45% of the total daily intake.Since that time, the trend has been towards an increased daily intake ofcarbohydrates, ranging from 45% to 70%, depending on the country [44].These changes are attributed to the rise of the global industrial foodsystem, economic development, and food availability. Kapur and Dun-ning [44] provide evidence that recommendations for the three majormacronutrients (protein, fat, and carbohydrate) have changed morerecently and that they vary worldwide, according to gross domesticproduct (GDP) per capita and the Food and Agricultural Organization(FAO) food balance sheets. As shown in Fig. 2, nations with higherGDP per capita tend to recommend a lower ratio of carbohydrate toother macronutrients than do lower GDP per capital countries. Forexample, while health professionals in the Netherlands recommendthat 45% total daily energy intake comes from carbohydrates, this risesto 70% in Bangladesh. In addition, as Fig. 3 shows, health professionals

Fig. 2. Comparison of the carbohydrate recommendations of the individual countriesagainst the GDP PPP per capita in $ of the same countries. In Kapur and Dunning [44].

Please cite this article as: Himmelgreen DA, et al, Using a biocultural apbalance, Physiol Behav (2014), http://dx.doi.org/10.1016/j.physbeh.2013.1

in countrieswith higher supplies of cereals tend to recommend a higherdaily percentage of carbohydrate intake.

The authors also found that the availability of vegetable oil per capita(kg/yr) and GDP purchasing-power-parity (PPP) was associated withmacronutrient recommendations in different countries. Here, countrieswith a higher per capita supply of vegetable oil recommended higher fatintake than thosewith a lower supply. In another study of vegetable andanimal oils, the average Gross National Product (GNP) or cost, toconsume 20% of fat energy declined significantly from 1962 to 1990,making fat more affordable in lower income nations [70]. Finally, coun-tries with a higher per capita supply of meat tended to recommend ahigher daily percentage of meat than those with lower supplies.Although the prices of protein energy and animal foods have comedown (with some exceptions more recently), they are still too highfrom many people in lower income countries [11,44]. Overall, whenlooking at diet recommendations and macronutrient intake, the litera-ture shows increasing rates of fat consumption as countries progressthrough the nutrition transition and that the differences in intake likelyreflect different stages of the transition [14,54,67,70].

These findings highlight the fact that dietary recommendations andmacro-nutrient intake are influenced by globalization associated withneoliberal trade policies and economic development. The higher carbo-hydrate recommendations and intake in lower income countriesmaybedue to the cost of rice, wheat and maize, the three global food staples,which have remained relatively affordable (with some exceptions,most notably during the Great Recession that started in 2008) due toincreasing demand and increased yields [31,54]. Thismay also be attrib-uted in part to the high cost of protein-rich foods [11]. In the same vein,higher intakes of fat are associated with increased availability ofvegetable oil and reductions of the price of both vegetable and animaloils in wealthier countries.

Migration within and between countries in general, and rural-to-urban migration in particular, has been on steep rise since the secondhalf of the 20th Century. For example, Golpalan [24] shows that while15% of India's population was urban in the 1960s, it is estimated torise to 40% during the upcoming decades. With so many peoplemigrating to urban centers, stress is being put on the rural agriculturalsector as fewer people are available to work the fields, and agriculturalknowledge is being lost since it is mostly the young that move away[24,29]. Moreover, research shows that there is an association betweenrural-to-urban migration and the increased consumption of processed,fatty and carbohydrate-rich foods [14,44,54,75]. However, the degreeto which there is a shift in the energy balance depends on wheremigrants migrate to, their employment status in the new setting, andtheir cultural and religious food beliefs [22,61,72]. For example,many rural people that migrate to urban centers find employment in

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construction or manufacturing, where the hours are long and the pay ismodest [54]. Their ability to purchase healthier foods is constrained bylimited income and there is little time for food preparation and homecooked meals. In the end, the consumption of low cost carbohydratesand high fat foods increases [3,40,44,54].

Globalization and migration, especially rural-to-urban migration,appear to have a strong influence on diet recommendations andmacro-nutrient intake, which have resulted in shifts in energy balance in themodern era. Neoliberal trade policies, economic development, andclimatic conditions affect food availability and access within any givencountry. In turn, the ability of migrants throughout the world to con-sume a well-balanced diet is dependent upon many factors includingthe availability of resources in their new locales, employment, andculture.

4. Case studies

The following two case studies are intended to elaborate on severalkey points that were made in the literature review and to raise someissues that were not previously addressed.

4.1. Globalization, tourism, and dietary changes in rural Costa Rica

The nutrition transition is not only an urban phenomenon; it is alsotaking place in rural areas that have experienced rapid economicgrowth and a rise in household income [19,56]. One region of theworld where globalization and the nutrition transition are having animpact on diet quality and energy balance includes areas in Mexicoand several countries in Central America (e.g., Costa Rica, Panama, andBelize) where there has been a rapid rise in tourism.

As mentioned earlier, international tourism has had a major impacton the economy of Costa Rica. While agriculture and a growing high-technology sector are important economic drivers, tourism has becomethe main economic driver in Costa Rica, with more than two milliontourists visiting this small country (51,100 km2) of 4.7 million peopleannually. Political stability, an emphasis on education and universalhealth care, and economic development have contributed to high lifeexpectancy (78.06 y) and literacy rate (96.3%) [7,15]. Even thoughhousehold incomes have risen over the years, there is now evidence ofgrowing economic inequality since the start of the Great Recession in2008. For example, in 2012, the wealthiest 20% of Costa Ricans earnedover 18 times more than the poorest 20%, an increase of 1.3 timessince 2010. Further, 21.6% of Costa Rican households were living in pov-erty [83].

Since 2004, Himmelgreen et al. have been studying the effects of theeconomic shift (from an agricultural economy to a mixed economywhere tourism predominates and agriculture is on the wane) on foodsecurity status, nutritional status, food choices and preferences, andhealth among residents of the rural Monteverde Zone (MVZ). Home toseveral thousand Ticos (nationals) and expatriates, the MonteverdeCloud Reserve, and thousands of species of plants and animals, theMVZ is a magnet that attracts 250,000 visitors annually, the secondmost popular tourist destination in Costa Rica [39].

In a study conducted from 2004 to 2005, data were collected from148 households from two different MVZ towns. Most of the residentsof the first town, the tourist hub of the MVZ, are primarily involved intourism work, while the majority of residents of the second town en-gage in agricultural economy with some mixture of tourism. The aimof this study was to examine if employment and lifestyle were associat-ed with food security status, maternal and child nutritional status, anddietary intake. There was a very high rate of food insecurity, regardlessof residence or occupation,withmore than 70% of households reportingsome degree of food insecurity during the previous 12 months. In addi-tion, diet qualitywas shown to vary by food security statuswith the dietbecoming more unbalanced as food insecurity worsened. For example,the frequency of vegetable consumption among adult participants

Please cite this article as: Himmelgreen DA, et al, Using a biocultural apbalance, Physiol Behav (2014), http://dx.doi.org/10.1016/j.physbeh.2013.1

declined as food insecurity became more severe. The same trendswere found when examining the consumption of dairy, fruits, and ani-mal proteins. Desserts, which are considered luxury foods, were con-sumed less frequently in households with worsening food insecurity.Other findings show that household socioeconomic status,membershipin food cooperatives (which are in decline), and the use of condimentspredicted food security status and hence diet quality [30,33]. In conclu-sion, the high rate of food insecurity (regardless of residence or occupa-tion) and the association between the degree to which households arefood insecure and diet quality, suggest that the tentacles of tourismreach far and wide in this rural area with varying effects.

4.2. Pre- to post-migration dietary acculturation among Hispanic immi-grants in the US

It is becoming increasingly clear that dietary acculturation can anddoes take place prior to people migrating within or to a new country.In a mixed methods study with mostly undocumented immigrants,Himmelgreen et al. [32] looked at pre- to post-migration dietary andlifestyle changes among 18 Latino adults with a mean age of 37.06 y(SD = 11.88) living in the Tampa Bay, Florida. In addition to surveysthat sought information on country of origin, education level, fluencyin spoken and written English, and change in diet and lifestyle frompre- to post-migration, retrospective and prospective interviews weredone with 10 participants to examine daily life in their native countriesand since migrating to the U.S.

All of the participants had been in theU.S. for less than 2.5 years, twothirds were from Colombia, more than one half had education beyondhigh school, and over 70% reported being able to speak at least someEnglish. While this sample did not fit the prototypical profile of undoc-umented migrants, it reflected the profile of well-educated Colombiansand others that are leaving their native country because of safety issuesand in search of a better life. Inmost cases, post-migration food patternsand behaviors represented unhealthy changes including weight gain, alack of physical activity and corresponding increase in televisionwatching, and an increase in the consumption of fast food, processedfoods, soft drinks, and to a lesser extent artificial juices.

In the interviews all of the participants reported that although theirdiets had changed since migrating to the U.S., there were some similarfoods consumed back home including processed foods (e.g. chips),soft drinks, and fast foods (e.g., hot dogs, hamburgers, and pizza). Sixthemes emerged with regard to post-migration lifestyle changes:increased pace of life, reduced family interaction, more social isolationand less integration, lower socioeconomic status, increased sense ofphysical security, and reduced control over child eating patterns. All ofthese themes were related to food choices and dietary intake. Whatfollows are some examples of these themes and their impact on lifestyleand diet as discussed in the interviews.

In commenting about the pace of life, one participant stated: “Lifehere is faster, so I am always on the run.” Eighty percent of respondentsmade similar comments explicitly citing the effects of a faster pace of lifeon decreased time available for cooking, increased reliance on processedfoods and soda, and reduced physical activity and social interaction. Onewoman stated: “I don't make the soups anymore, just rice, always rice.It's quick, easy, and I rush off to work.” The inability to prepare soupsand other traditional dishes “from scratch,” was often cited, becomingalmost emblematic of post-migration change.

In addition, 60% of the respondents made reference to a decrease in“family time” (including time spent in communal meals), and in overallsocial support. Unlike the positive Hispanic ghetto effect, describedby Gordon-Larsen et al. ([94]:2030) as the retention of “traditionallifestyle patterns” among “low SES immigrants who speak their nativelanguage and live in neighborhoods with high immigrant density andavailability of traditional goods and services,” a majority reportedbeingmore socially isolated in the U.S. Given the centrality of food shar-ing and communal meals in social interactions among Colombians, this

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decrease in social networks and social support may indirectly affect thedietary patterns of immigrants.

Finally, 40% of respondents indicated that they have less control overtheir children's diet in the U.S., than when they were living in theirnative country. As one interviewee stated “[My child] is really pickyhere. He won't eat the same things he ate in Colombia. He used to eatfruits and veggies and here, nothing…My child has given me a lot ofproblems. I can't get him to eat the same things. I guess it's the tastethat's different.”

In spite of their limited numbers, this sub-sample provided insightinto the multiple conflicting and reinforcing themes associated withmigration, some of which were discussed in the literature review.Their narratives explored the interaction of these themes and the im-pact on lifestyle, diet quality, and diet intake.

5. Discussion and conclusion

The findings from the literature review and the case studies suggestthat the effects of globalization and migration on diet quality, energybalance, and even dietary recommendations reflect complex interac-tions that are neither lineal nor direct. Even though global forces tendto be uniform (e.g., neoliberal trade policies, dominance of the industrialfood system, global food marketing), their impact varies across theworld. Two concepts, acculturation and the nutrition transition havebeen used to explain the differences in diet quality, energy balance,and health disparities. Acculturation provides a mechanism for under-standing the role of migration on diet and health, while the nutritiontransition offers a description of dietary changes in the modern era.However, since globalization involves interacting spheres or environ-ments (economic, cultural, political, and social) [37,82], these conceptsdo not always explainwhy dietary variations exist. Therefore, other the-ories might be useful as heuristic devices for filling in the knowledgegap in efforts to understand the relationship between globalization/migration and diet quality and energy balance.

The Ecological Model of Food and Nutrition [41,62] provides a visualfor examining the distal and proximal effects of global forces (globaliza-tion) on different interacting environments (spheres): social, physical,social organization, technology, and ultimately diet, and nutritionalstatus and needs. This model is useful when considering environmentaldifferences in various settings and how they influence diet quality andenergy balance. For example, the availability and access of differentfoods are dependent upon climatic conditions, economic development,technology (related to food production and distribution), and socialorganization (food redistribution) and food beliefs (the what, where,when, and with whom to eat food). The Critical Biological Perspective[23,47] offers an approach to examine the effects of social class, raceand ethnicity, and gender on diet and ultimately biological function-ing. Since global capitalism is the predominant economic system inthe world today, understanding power relations and the control ofresources is critical when examining differential food availability andaccess within and between countries.

Based on the review of the literature, several themes emerged andare discussed below. Keeping in mind that the results from the studiesare not always consistent and at times contradictory, care must betaken in assuming that these are definitive statements about globaliza-tion/migration and diet quality and energy balance.

5.1. Main themes emerging from the literature review

• When discussed in the context of migration, acculturation does notnecessarily capture the complex processes associated with globaliza-tion and its effects on dietary changes. Although migrants adopt thefoods and food habits of their new country or city, they may alsohold onto their traditional diets to maintain cultural identity, amongother reasons. The degree to which diets change depend on a numberof factors related to the new social and physical environments, culture

Please cite this article as: Himmelgreen DA, et al, Using a biocultural apbalance, Physiol Behav (2014), http://dx.doi.org/10.1016/j.physbeh.2013.1

and religion, socioeconomic status, age, and gender among others.Many of the findings from the studies discussed here show varyingoutcomes (e.g., [9,18,58])

• In light of the lack of uniform definitions of acculturation and thedifficulty in measuring it, some researchers are proposing new con-ceptual models that use a transnational lens to focus on the similari-ties and differences between the native country and the new hostcountry in relation to diet and lifestyle (e.g., [32,50]). Other modelsare moving away from the notion of lineal assimilation toward recip-rocal acculturation and the influence of cultural beliefs, race and classsegregation, and gender and age on diet [1]. These two approachesprovide a more suitable approach to examine the dynamic relation-ship between the immigrants' native and host country experiencesand the nuanced changes that occur as a result of that interaction.

• The literature overwhelmingly links globalization with the nutri-tion transition, and the adoption of a more Western diet (e.g.,[10,30,48,80]). However, the rate and degree at which the nutritiontransition occurs vary depending on the local setting. Thus, differencesmay be evident even between regions of the same countrywith differ-ent local realities.

• There is a growing body of literature that suggests that the macro-level forces associated with global capitalism and neoliberal tradepolicies are shaping diet quality, energy balance, and dietary recom-mendations (e.g., [27,44,67,85]). For example, when compared totheir counterparts in wealthier countries, health professionals inlower income countries recommend that higher proportion oftotal daily energy intake come from carbohydrates which tend to bemore easily available and less expensive for the general population.

5.2. Critiques of concepts of the nutrition transition and acculturation

The concept of the nutrition transition has been critiqued for thenarrow perspective that it brings to the phenomena of globalization,westernization and dietary change. When Popkin [71] first describedthe stages of the nutrition transition, it was neatly in line with Omran's[60] work on the epidemiologic transition, moving from conditions offamine (and associated health problems) to conditions where degener-ative diseases became the norm. Popkin [71] described that a “diet highin total fat, cholesterol, sugar, and other refined carbohydrates and lowin polyunsaturated fatty acids and fiber accompanied by a sedentarylife-style is characteristic of many high-income societies” (1994: 287).Since the time Popkin first described this pattern, its application hasbeen widespread [20,28,65,69,74,87,91]. However, critics recognizethat applying a “one-size-fits-all” model does not work in understand-ing the complex interactions between local populations and globalizedmacro processes [2,13,64]. For instance, Dodd [13] explored the specificways in which changes in nutrition have occurred in Central America,and “deconstructed contemporary notions of nutritional transitionsand demonstrate their complex, dynamic and diachronic nature”(2011: 130). Piperata et al. [64] examine the way that wages andgovernment assistance alter local nutrition in the Amazon and concludethat, “these findings make important contributions to our understand-ing of the ‘nutrition transition,’ and demonstrate that the pattern andimpact of the transition are sensitive to local economic and culturalconditions” (2011: 468). In a study of Bedouin Arabs in SouthernIsrael, Abu-Saad et al. [2] found that previous studies using the nutritiontransition to explore pregnancy health and nutrition have been limited,perhaps by the nature of the model itself. Additionally, the researchersreported that, “these recommendations may thus not adequatelyaddress the needs of women who are experiencing overlapping nutri-tion transition stages, and the coexisting problems of inadequatenutrient intakes and an increasing risk of obesity” (2012: 8), highlight-ing the need for a more nuanced understanding of how the looseconcept of the “nutrition transition” can and should be applied withina local context.

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While acculturation is discussed in the literature and may be usefulfor explaining changes in dietary patterns over time, it has also beencritiqued more recently. Martinez [50], for example, argues that accul-turation is an outdated concept when applied to dietary changesamong Latinos in theU.S. Instead, the author suggests that transnationalglobalization (consisting of transnational processes) is better suited forunderstanding dietary changes. Abraído-Lanza et al. [1] argue that theexplanatory power of traditional acculturation studies is weak becausethey are based on linear association models, They further propose thata more encompassing public health perspective, which focuses onthe roles of cultural and structural forces, “may help identify mecha-nisms underlying links between acculturation and health (and dietarychanges” (1342). Finally, Hunt et al. [38] also critique the use of accul-turation because the concept lacks an “appropriate historical andsocio-economic context… (and) problems of unequal access to healthposed by more material barriers, such as insurance, transportation,education, and language, are pushed from the foreground, and ethnicculture is made culpable for health inequalities” (982).

5.3. Conclusion

The literature review presented in this paper points to the complexnature of diet-related behavior as influenced by a multiplicity of factorsof different nature (e.g., economic, social, cultural) and at differentlevels (from local conditions of specific settings to macro policies atthe transnational and global levels). While both the nutrition transitionand acculturation have merit when it comes to describing how dietarychanges come about, they need to be redefined and expanded in orderto capture the reality of the globalized world of the 21st. Century. Forexample, the measurement of acculturation is challenging because forthe most part it views change as linear and flowing in one direction,and fails to capture the multi-dimensional and bidirectional changesthat occur when individuals from different cultural, economic, and so-cial backgrounds interact. Similarly, the evidence is clear from the liter-ature that globalization is a complex set of processes that take place inmultiple environments (spheres) and its effects on diet quality and en-ergy balance are not always the same in each setting. The EcologicalModel of Food and Nutrition and the Critical Biocultural Perspectiveoffer a theoretical framework for enhancing our understanding of notonly dietary changes but also health disparities worldwide.

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