Spotlight on the Southern Diet - Today's Dietitian Magazine

November/December 2021 Issue

Spotlight on the Southern Diet
By Constance Brown-Riggs, MSEd, RDN, CDCES, CDN
Today’s Dietitian
Vol. 23, No. 9, P. 44

Today’s Dietitian evaluates this eating pattern that has been blamed for causing CVD and other chronic illnesses and offers strategies for counseling clients for improved outcomes.

It’s common knowledge that a diet laden with added fats, fried foods, eggs, organ and processed meats, and sugar-sweetened beverages is considered unhealthful by the American Heart Association, Academy of Nutrition and Dietetics, and other organizations. And there’s an abundance of scientific evidence to support the association between obesity and chronic disease with such a diet.

For example, one of the latest research studies investigating the association between CVD and diet found that a “Southern diet” was linked with an increased risk of sudden cardiac death. This article provides an overview of the Southern diet, discusses the current evidence regarding health risks associated with it, and offers strategies RDs can use to improve outcomes in clients who eat Southern food.

What Is a Southern Diet?
Southern food and Southern cooking have long been popular topics for cookbooks, cooking shows, and magazines. At the same time, they’ve been criticized and demonized as unhealthful because people in the South have some of the highest rates of chronic disease in the United States. Headlines such as “Southern Diet May Raise Risk of Sudden Cardiac Death” appear in peer-reviewed journals and get sensationalized in the popular press as “What a Southern Diet Actually Is, and Three Ways It’s Killing You.”

Moreover, in scientific literature, the Southern diet typically is reduced to the stereotypical “high in added fats, fried foods, eggs, organ and processed meats, and sugar-sweetened beverages” definition. Deanna Pucciarelli, PhD, an associate professor at Ball State University in Muncie, Indiana, wrote in a 2020 article in Nutrition Today that “the unhealthy Southern diet moniker is widespread and propagated by both health professionals and academics, and often repeated propaganda has an unfortunate trajectory of morphing into ‘facts.’”1

The Southern diet is too complex and varied to be narrowed down to a few iconic foods. The food of the South reflects a unique blend of cultures and culinary traditions influenced by West African slaves, Native Americans, the Spanish, the Portuguese, and the French. The South is subdivided into three regions: South Atlantic, East South Central, and West South Central. And the way food is cultivated, prepared, and consumed reflects the social, economic, and political history of the region.1 Southern food may be best described as a living record of the people, places, and cultures contributing to the South.

Dietitians play a critical role in translating nutrition research and providing evidence-based education and support. This requires RDs to go beyond the stereotypical “Southern” food list and provide counseling that preserves Southerners’ cultural identity. “Food is more than macronutrients and micronutrients. Food is central to how people connect with land, heritage, loved ones, and self. That desire for connection to culturally familiar foods can be as big of an influence on food choice as other biological, economic, and physical determinants,” says Shamera Robinson, MPH, RDN, CDCES, cofounder of The Culture of Wellness, LLC, based in Washington, D.C.

The REGARDS Study
Year after year, southern states consistently rank among the worst in the United States for health and wellness.2 What’s causing residents in the South to experience higher rates of obesity, diabetes, heart disease, and stroke has been the subject of research over the last quarter-century.

One of the largest ongoing studies is the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study. For over a decade, this study has followed 30,239 Black and white participants recruited between 2003 and 2007 from the continental United States. The purpose of the study is to determine the causes for excess stroke mortality in the southeastern United States and among African Americans. As of January 2021, there have been more than 90 ancillary studies.3

In the most recent study, researchers identified trends toward an inverse association of the Mediterranean diet score and the risk of sudden cardiac death and a positive association of adherence to the “Southern” dietary pattern with the risk of sudden cardiac death. The “Southern” dietary pattern was characterized by added fats, fried foods, eggs, organ and processed meats, and sugar-sweetened beverages.4

The researchers examined data from more than 21,000 people aged 45 and older who were enrolled in the REGARDS study. Of the participants in this analysis, 56% were women, 33% were Black adults, and 56% lived in the southeastern United States, known as the Stroke Belt because of its higher stroke death rate. The Stroke Belt states included in the study were North Carolina, South Carolina, Georgia, Tennessee, Alabama, Mississippi, Arkansas, and Louisiana.4

Sudden cardiac death is caused by loss of heart function and is the largest cause of natural death in the United States, resulting in about 325,000 adult deaths each year. It’s responsible for one-half of all heart disease deaths occurring most frequently in adults in their mid-30s to mid-40s. Most of these deaths are caused by arrhythmias.5

In the REGARDS study, researchers assessed participants’ diets through a food frequency questionnaire completed at the beginning of the study. They asked subjects how often and in what quantities did they consume 110 different food items in the previous year.4

A Mediterranean diet score was calculated based on specific food groups considered beneficial or detrimental to health. They also categorized five dietary patterns. Along with the “Southern” dietary pattern, the analysis included a “sweets” dietary pattern, which featured foods with added sugars, such as desserts, chocolate, candy, and sweetened breakfast foods; a “convenience” eating pattern, which relied on easy-to-make foods such as mixed dishes, pasta dishes, or items likely ordered as takeout such as pizza, Mexican food, and Chinese food; a “plant-based” dietary pattern that was classified as being high in vegetables, fruits, fruit juices, cereal, beans, fish, poultry, and yogurt; and an “alcohol and salad” dietary pattern, which was highly reliant on beer, wine, and liquor along with green leafy vegetables, tomatoes, and salad dressing.4

After an average of nearly 10 years of follow-up every six months to check for CVD events, more than 400 sudden cardiac deaths had occurred among the 21,000 study participants. The researchers also found that subjects who ate a “Southern”-style diet most regularly had a 46% higher risk of sudden cardiac death than people who had the least adherence to this dietary pattern. Moreover, participants who most closely followed the traditional Mediterranean diet had a 26% lower risk of sudden cardiac death than those with the lowest adherence to this eating style.4

This research expands on earlier studies on the REGARDS cohort. In a 2018 analysis study, authors reported that adults aged 45 and older with heart disease who had an affinity for the “Southern diet” had a higher risk of death from any cause, while greater adherence to the Mediterranean diet was associated with a lower risk of death for any reason.6

In a 2015 study, the “Southern diet” was linked to a greater risk of coronary heart disease in the same population. The large population sample and regional diversity, including a significant number of Black participants, are considered strengths of the REGARDS research project. However, there were potential limitations of this study. Dietary intake was based on one-time, self-reported questionnaires; thus, it relied on participants’ memory. Self-reported diets can include inaccuracies, leading to bias that may reduce the strength of the associations observed.7

Reviewing the REGARDS cohort from the lens of what is or is not a Southern diet requires a closer look at the geographic location of the study cohort. Twenty-one percent was selected from the “buckle” of the stroke belt (ie, the coastal plain region of North Carolina, South Carolina, and Georgia, 35% from the stroke belt states (ie, the remainder of North Carolina, South Carolina, and Georgia, plus Alabama, Mississippi, Tennessee, Arkansas, and Louisiana), and the remaining 45% from the other 40 contiguous states.4

The REGARDS cohort isn’t a representative sample of all the regions of the South. The South Atlantic states and West South Central states aren’t represented in the cohort. As mentioned earlier, the South is subdivided into three regions, and the way food is cultivated, prepared, and consumed is specific to that region.1 In addition, in 2015, when the dietary patterns were developed and assigned names, the authors wrote, “Since this diet is similar to the culinary pattern observed in the Southeastern US, this pattern was named the ‘Southern’ pattern.”8

One could argue that a “Southeastern” pattern might have been a better description—although Southern food anywhere is more than the stereotypical list. The authors also acknowledged that a less healthful pattern categorized by excess sugars, fats, and processed foods often are identified as “Western.”8 The point is, these foods are unhealthful; they can be found everywhere and shouldn’t be used to demonize the Southern diet. “Dismissing roughly one-third of the American public of their cultural heritage by proclaiming the ‘Southern’ diet as unhealthy … disrespects a significant population of the country’s eating habits,” Pucciarelli wrote.1

For nutrition professionals, it’s important to think critically when evaluating research. RDs must go beyond a press release, abstract, or media hype. This requires reading research studies and evaluating the strength of the evidence. Are they observational studies or randomized controlled trials? Are the results generalizable to other populations? Do they really show cause and effect?

Notably, most of the existing evidence isn’t representative of the Southern diet. So rather than perceiving the Southern diet as an obstacle to overcome, Robinson suggests RDs use it as an opportunity to collaborate with clients to find culturally sensitive and sustainable solutions such as the Heart Healthy Lenoir Project.

Heart Healthy Lenoir Project
While research consistently has shown the efficacy of a Mediterranean-style eating pattern, when counseling clients, it’s important for RDs to refrain from promoting it without considering an individuals’ current style of eating. “When nutrition professionals promote one style of eating, like a Mediterranean eating pattern, it can easily send the message that people from other cultures must abandon their traditional food practices to be healthy,” Robinson says.

The Heart Healthy Lenoir Project is an example of a culturally inclusive lifestyle intervention designed to reduce CVD risk and disparities in CVD risk among Lenoir County, North Carolina, residents.9 “Our hope was to reduce health disparities related to high blood pressure,” says Alice Ammerman, DrPH, director of the Center for Health Promotion and Disease Prevention at the University of North Carolina at Chapel Hill.

Ammerman and colleagues developed a culturally tailored lifestyle intervention dietary pattern called “Med-South” because it was similar to the diet in the Prevención con Dieta Mediterránea (PREDIMED) study’s nut intervention arm. Both the dietary assessment and recommendations focus on foods Southerners commonly consume.9 Participants also were given a cookbook with Southern-style recipes such as hush puppies and barbecue (see recipes at the end of this article). “We used the principles of the Mediterranean diet to emphasize foods and recipes that were culturally acceptable to the Southeastern palate. This included greens, sweet potatoes, beans (pinto, etc), nuts, and oils, including full-fat salad dressings and mayonnaise given the high-quality vegetable oils included,” Ammerman says.

Nutrition professionals can register for free access to the Med-South Cookbook and full intervention materials at the University of North Carolina at Chapel Hill Center for Health Promotion and Disease Prevention website at hpdp.unc.edu/med-south-lifestyle-program.

Improve Outcomes and Respect Cultural Traditions
To improve outcomes and respect cultural traditions, dietitians can do the following during counseling sessions:

• Translate the science. The REGARDS study characterizes the Mediterranean diet by noting particular foods deemed healthful and that should be eaten more often. Robinson says, “Instead of suggesting someone follow a Mediterranean diet, find ways to incorporate those key elements using a person’s existing food preferences and practices.”

• Allow full-fat options. Foods such as peanuts and mayonnaise, which were previously discouraged, can be added back into a Mediterranean-style meal plan. Ammerman says, “Give back healthy foods like full-fat salad dressing. Encourage patients to roast their vegetables of all kinds (except leafy greens) and use that as a basis for their meals. And eat nuts for a snack—peanuts are just as good and less expensive.”

• Reframe the language. Every person deserves the opportunity to acquire health through foods that are familiar and culturally significant. “Remember to use words that value diverse foodways and be mindful of language that endorses the practices from one culture over another,” Robinson says. “An example would be asking your client to follow a Mediterranean diet to meet their health goals. That may imply that the person can be healthy only by rejecting their cultural foods. Instead, ask about their typical and traditional eating patterns and use your expertise to incorporate the core tenets.”

• Think critically. There’s more to food than its nutritional value. Food is connected to family, friends, land, and time. “For those in the Mediterranean region, the value of a Mediterranean eating pattern goes beyond nutritional benefit. It is a way of life that embraces local and familiar foods that have been shared at mealtimes from generation to generation. Southern food traditions can (and should) be honored and celebrated in that same way,” Robinson says.

Final Thoughts
Studies have shown that a “Southern diet” is associated with coronary heart disease, sudden cardiac death, and other chronic diseases, but the foodways of the South reflect a unique blend of cultures and culinary traditions from around the world.4,6,7 Demonizing the Southern diet will do little to improve the health outcomes of Southerners. Providing culturally tailored nutrition interventions such as the Heart Healthy Lenoir Med-South intervention likely will result in client acceptance and satisfaction.

— Constance Brown-Riggs, MSEd, RDN, CDCES, CDN, is a national speaker and author of the award-winning Living Well With Diabetes 14 Day Devotional and coauthor of Diabetes Guide to Enjoying Foods of the World. Learn more about her at ConstanceBrownRiggs.com.

References
1. Pucciarelli D. The Southern diet: a historical view on food consumption and how the region's foodways gets a bad rap. Nutr Today. 2020;55(4):157-162.

2. 2017 annual report. America’s Health Rankings website. https://www.americashealthrankings.org/learn/reports/2017-annual-report. Accessed August 20, 2021.

3. REGARDS study. The University of Alabama at Birmingham website. https://www.uab.edu/soph/regardsstudy/. Accessed August 14, 2021.

4. Shikany JM, Safford MM, Soroka O, et al. Mediterranean diet score, dietary patterns, and risk of sudden cardiac death in the REGARDS study. J Am Heart Assoc. 2021;10(13):e019158.

5. Sudden cardiac death (sudden cardiac arrest). Cleveland Clinic website. https://my.clevelandclinic.org/health/diseases/17522-sudden-cardiac-death-sudden-cardiac-arrest. Updated May 14, 2019. Accessed September 1, 2021.

6. Shikany JM, Safford MM, Bryan J, et al. Dietary patterns and Mediterranean diet score and hazard of recurrent coronary heart disease events and all-cause mortality in the REGARDS study. J Am Heart Assoc. 2018;7(14):e008078.

7. Shikany JM, Safford MM, Newby PK, Durant RW, Brown TM, Judd SE. Southern dietary pattern is associated with hazard of acute coronary heart disease in the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study. Circulation. 2015;132(9):804-814.

8. Judd SE, Letter AJ, Shikany JM, Roth DL, Newby PK. Dietary patterns derived using exploratory and confirmatory factor analysis are stable and generalizable across race, region, and gender subgroups in the REGARDS study. Front Nutr. 2015;1:29.

9. Embree GGR, Samuel-Hodge CD, Johnston LF, et al. Successful long-term weight loss among participants with diabetes receiving an intervention promoting an adapted Mediterranean-style dietary pattern: the Heart Healthy Lenoir Project. BMJ Open Diabetes Res Care. 2017;5(1):e000339.

[Recipes]

Heart-Healthy BBQ With Veggies & Rice

Serves 6

Ingredients
1 small onion, diced
2 cloves of garlic, minced
1 tsp of your favorite herb seasoning (thyme, oregano, Italian seasoning, etc)
Hot pepper or your favorite BBQ sauce, to taste*
3 T vegetable oil
1/2 large head of green cabbage (or add some red cabbage for color)
5 to 6 large leaves of collards, kale, or other dark green leafy vegetable
1 medium to large sweet potato
1 cup of shredded BBQ meat, cooked
3 cups cooked brown rice (takes longer than white so allow time)

Directions
1. In a large frying pan with a lid, sauté/steam onions, garlic, herbs, and hot pepper, in oil.

2. Chop cabbage and collards, kale, or other leafy green and add to the pan.

3. Peel and dice the sweet potato and add to the mix 5 minutes before done.

4. When the mix is tender but not mushy, mix with BBQ meat. Add BBQ sauce and serve over brown rice.

* Look for sauces with less than 6 g sugar and 300 mg sodium per serving.

Nutrient Analysis per serving (2 cups)
Calories: 310; Total fat: 11 g; Sat fat: 2 g; Cholesterol: 14 mg; Sodium: 190 mg; Total carbohydrate: 41 g; Dietary fiber: 5 g; Sugars: 9 g; Added sugars: 4 g; Protein: 13 g

— Source: ©2020 UNC-CH Center for Health Promotion and Disease Prevention, Alice S. Ammerman, DrPH, director of the Center for Health Promotion and Disease Prevention at the University of North Carolina at Chapel Hill

Heart-Healthy Hush Puppies

Serves 18

Ingredients
Oil for deep frying (corn, soybean, or peanut oil recommended; do not use lard or solid fat)
1 cup yellow cornmeal
1 cup yellow grits
1/2 cup white flour
1/2 cup whole wheat flour
3/4 tsp seasoned salt
1/2 tsp pepper
1 tsp baking powder
2/3 tsp baking soda
2 eggs
1 cup buttermilk
1/8 cup oil
1/3 cup nuts, finely chopped (pecans, almonds, walnuts, or any mixture)
A mixture of vegetables finely chopped—about 1 to 1 1/2 cups total (choose anything you like but include onions):
Red or green bell peppers
(or hot peppers)
Eggplant
Sweet potatoes
Zucchini or yellow squash
Okra
Cabbage

Directions
1. Begin heating the oil for deep frying (medium to high heat)—about 1 1/2 inches in depth.

2. Mix all dry ingredients in a bowl.

3. Mix all wet ingredients in a separate bowl.

4. Combine wet and dry ingredients.

5. Add chopped nuts and vegetables.

6. Add more buttermilk if needed for the consistency of cornbread (very thick pancake batter).

7. Drop batter into the heated oil using a small spoon. The oil should bubble vigorously around the dough. Turn the puppies with a slotted spoon to brown them on all sides. It should take only 2 to 3 minutes to cook.

8. Remove from oil and drain on a paper towel. Serve and enjoy.

Nutrient Analysis per serving (two large hush puppies)
Calories: 220; Total fat: 15 g; Sat fat: 2.5 g; Cholesterol: 21 mg; Sodium: 65 mg; Total carbohydrate: 19 g; Dietary fiber: 1 g; Sugars: 1 g; Protein: 3 g