THE CULTURAL ADAPTATION OF THE USDA'S MYPLATE GUIDELINES FOR THE PUNJABI SIKH HERITAGE COMMUNITY OF GREATER SACRAMENTO PDF Free Download
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THE CULTURAL ADAPTATION OF THE USDA’S MYPLATE GUIDELINES FOR THE
PUNJABI SIKH HERITAGE COMMUNITY OF GREATER SACRAMENTO
A Thesis
Presented to the faculty of the Department of Nutrition, Food and Dietetics
California State University, Sacramento
Submitted in partial satisfaction of
the requirements for the degree of
MASTER OF SCIENCE
in
Nutrition and Food
by
Arjudeep Kaur
SPRING
2025
ii
© 2025
Arjudeep Kaur
ALL RIGHTS RESERVED
iii
THE CULTURAL ADAPTATION OF THE USDA’S MYPLATE GUIDELINES FOR THE
PUNJABI SIKH HERITAGE COMMUNITY OF GREATER SACRAMENTO
A Thesis
by
Arjudeep Kaur
Approved by:
, Committee Chair
Dr. Mical Shilts
, Second Reader
Dr. Jeannie Gazzaniga-Moloo
Date
iv
Student: Arjudeep Kaur
I certify that this student has met the requirements for format contained in the University format
manual, and this thesis is suitable for electronic submission to the library and credit is to be
awarded for the thesis.
, Graduate Coordinator
Dr. Mical Shilts Date
Department of Nutrition, Food and Dietetics
v
Abstract
of
THE CULTURAL ADAPTATION OF THE USDA’S MYPLATE GUIDELINES FOR THE
PUNJABI SIKH HERITAGE COMMUNITY OF GREATER SACRAMENTO
by
Arjudeep Kaur
Introduction: Punjabi Sikhs are disproportionally affected by chronic diseases in the United
States. Public health interventions such as MyPlate have failed to reach marginalized groups due
to cultural and linguistic barriers. Given the absence of a formal adaptation or translation of
MyPlate in Punjabi, this study aimed to develop a culturally adapted MyPlate visual tool for the
Punjabi Sikh community of Greater Sacramento area.
Methods: Employing a mixed methods research design, the study consisted of two phases
informed by the cultural adaptation process. In Phase 1, a quantitative survey was administered to
a convenience sample of 36 Punjabi Sikh adults from a local Sikh Temple to assess barriers to
adhering to the USDA MyPlate. Descriptive analyses of key variables informed the initial
adaptation of MyPlate in Phase 2, followed by two rounds of qualitative interviews with nine
Punjabi Sikh adults. Interview data was analyzed through an iterative process by continuously
revising the adaptation and then finalizing the tool.
Results: Survey results revealed that key barriers to MyPlate adherence were that 53% of
participants ate their meals in a plate & bowl combination and 64% of participants consumed
Punjabi food daily. Additionally, 42% preferred the Punjabi language for nutrition & health
vi
education and 67% recommended showcasing examples of cultural food sources for each food
group to make MyPlate easier to comprehend. Findings from Phase 1 informed the preliminary
adaptation design of the MyPlate visual. Feedback from interviews emphasized simplifying text,
integrating color coding to highlight the connection to the original MyPlate, and including an
animal-based protein in the visuals. This iterative process led to the development of the Healthy
Punjabi Plate, a five-page, double-sided visual tool featuring five digital photographs of
traditional Punjabi meals, bilingual text, and a list of culturally relevant foods for each food
group.
Conclusion: The Healthy Punjabi Plate addresses the dietary preferences and cultural needs of
the Punjabi Sikh community of Greater Sacramento area. Future research should evaluate this
tool’s effectiveness in promoting dietary change and consider it as a potential model for adapting
MyPlate for other racial and ethnic communities.
, Committee Chair
Dr. Mical Shilts
Date
vii
DEDICATION
This thesis is dedicated to the memory of my little brother, Inderdeep Singh, whose
unwavering strength and resilience helped shape the person I am today. He taught me that hope
can bring light to even the darkest moments in life. May this accomplishment stand as a tribute to
his legacy. I love you, Inder, and I carry you in my thoughts with every step I take.
viii
ACKNOWLEDGEMENTS
First, I would like to express immense gratitude to my advisor, Dr. Mical Shilts, for truly
being one of the kindest and most compassionate human beings I know. Her continuous support
and guidance have been a privilege throughout this program and research project. Thank you for
sharing your expertise with me.
I would also like to sincerely thank my committee member, Dr. Jeannie Gazzaniga-
Moloo, for her time and commitment in providing thoughtful insights, suggestions, and support.
A big thank you to Dr. Alberto Aguilera for recognizing the need for this research and laying a
foundation for its success.
A heartfelt thank you to my mother and father, who blessed me with the opportunity to
pursue higher education by making countless sacrifices. Thank you to my husband for his
unconditional love and support throughout this journey. I deeply appreciate all my beloved
siblings and family members who contributed their Punjabi language expertise to help complete
this project. Lastly, thank you to the Roseville Sikh Temple committee for generously sharing
their space and time so I could conduct this research.
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TABLE OF CONTENTS
Page
Dedication.................................................................................................................................vii
Acknowledgements................................................................................................................. viii
List of Tables ............................................................................................................................ xi
List of Figures .......................................................................................................................... xii
Chapter
1. INTRODUCTION ............................................................................................................... 1
Background ................................................................................................................... 1
Research Objective and Purpose ................................................................................. 5
Limitations .................................................................................................................... 8
Study Organization ....................................................................................................... 8
2. LITERATURE REVIEW ................................................................................................... 9
The Prevalence of Chronic Diseases in the United States ........................................... 9
The Role of Nutrition in Chronic Disease Prevention ............................................... 13
National Dietary Guidelines ....................................................................................... 14
Self-Determination Theory ......................................................................................... 25
Cultural Inclusivity in Nutrition Education ................................................................ 28
The Cultural Adaptation of MyPlate for the Punjabi Sikh Community .................... 37
Conclusion .................................................................................................................. 45
3. METHODS ........................................................................................................................ 47
Research Objectives ................................................................................................... 48
Stages of Cultural Adaptation of Evidence-Based Interventions ............................... 49
Theoretical Framework .............................................................................................. 51
x
Study Setting............................................................................................................... 52
Participant Recruitment .............................................................................................. 52
Ethical Considerations ................................................................................................ 53
Measurement Tools .................................................................................................... 54
Data Analysis .............................................................................................................. 60
Procedure .................................................................................................................... 62
4. RESULTS .......................................................................................................................... 67
Phase 1: Quantitative Survey Results ........................................................................ 67
Phase 2: Initial Design and Qualitative Interview Results ......................................... 73
The Final Adaptation .................................................................................................. 79
Conclusion .................................................................................................................. 80
5. DISCUSSION AND CONCLUSION ............................................................................... 82
Phase 1 ........................................................................................................................ 82
Phase 2 ........................................................................................................................ 84
Strengths and Limitations ........................................................................................... 88
Implications and Recommendations ........................................................................... 90
Conclusion .................................................................................................................. 92
Appendix A. Letter Requesting the Sikh Temple’s Permission........................................... 94
Appendix B. Informed Consent Form .............................................................................. 95
Appendix C. Phase 1: Survey Questionnaire ..................................................................... 96
Appendix D. Phase 2: Semi-Structured Interview Questions .............................................. 99
Appendix E. Healthy Punjabi Plate Visual Tool (English and Punjabi Version) ................ 100
References.............................................................................................................................. 120
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LIST OF TABLES
Tables Page
1. Stages Utilized in the Cultural Adaptation Process of the USDA MyPlate for the
Punjabi Sikh Community.............................................................................................. 50
2. Phase 2: Sample of Theory Based Qualitative Interview Questions Utilized to Acquire
Feedback from Punjabi Sikh Participants on the Initial Cultural Adaptation of
MyPlate ......................................................................................................................... 60
3. Phase 1: Demographic Characteristics of Punjabi Sikh Participants for the
Quantitative Survey: Age, Gender, Education Level (N=36) ................................... 68
4. Phase 1 Food Frequency Questionnaire Results: Percentage of Punjabi Sikh
Participants by Food Item (N=36) ......................................................................... 71
5. Phase 2, Round One Interviews: Participant Feedback on the Initial Design of the
Culturally Adapted MyPlate Visual Tool for the Punjabi Sikh Community (n=5) ..... 76
6. Phase 2, Round Two Interviews: Participant Feedback on the Initial Design of the
Culturally Adapted MyPlate Visual Tool for the Punjabi Sikh Community (n=4) ..... 78
xii
LIST OF FIGURES
Figures Page
1. MyPlate Visual Graphic ............................................................................................... 15
2. Visual Depiction of the Self-Determination Theory Constructs: Autonomy,
Competence, and Relatedness………………………………………………………...26
3. Arabic, Chinese, Hindi, and Spanish Translations of the MyPlate Visual ................... 30
4. Examples of Cultural and Linguistic Adaptations of Harvard’s Healthy Eating Plate
for Pakistani Women in Catalonia, Barcelona.............................................................. 34
5. Two-Phase Mixed-Methods Research Design to Culturally Adapt MyPlate for the
Punjabi Sikh Community Based on The Cultural Adaptation Process of
Evidence-Based Interventions ...................................................................................... 48
6. MyPlate Visual Graphic ............................................................................................... 56
7. An Example of a Cultural and Linguistic Adaptation of Harvard’s Healthy Eating
Plate for Pakistani Women in Catalonia ....................................................................... 57
8. Phase 1 Quantitative Survey: Perceived Barriers Reported to Making Healthy and
Balanced Meals by Punjabi Sikh Participants to (N=3)………………………………69
9. Phase 1 Quantitative Survey: Selected Modifications to Make MyPlate Easier to
Understand by Punjabi Sikh Participants (N=36)…………………………………….72
10. Phase 2: The Iterative Process of Developing a Culturally Adapted MyPlate Visual
Tool for the Punjabi Sikh Community of Greater Sacramento (N=9)………………..80
1
Chapter 1: Introduction
Background
Chronic disease has become the largest contributor to death and disability in the
United States (Center for Disease Control and Prevention [CDC], 2024c). In fact, six in
every 10 Americans or an estimated 129 million individuals have at least one major
chronic disease (CDC, 2024c). Many of the leading causes of death are from preventable
and treatable diseases like heart disease, diabetes, and cancer (Benavidez et al., 2024).
The number one cause of premature death among Americans is heart disease and has
been for several decades (CDC, 2024d). In 2022, approximately 702,880 people died due
to heart disease, accounting for one in every five deaths in the country (CDC, 2024d).
The prevalence of chronic disease does not only impact the quality of life for Americans
but also places a heavy burden on the economy. Of the nation's 4.5 trillion annual health
care expenditure, 90% is spent on chronic and mental health conditions (CDC, 2024e).
The United States (U.S.) healthcare costs have skyrocketed, and the economic burden of
heart disease is projected to increase in the years coming, making it one of the costliest
diseases (Kazi et al., 2024; Water & Graf, 2018). More importantly, the rate of disease is
significantly higher in marginalized communities, especially racial and ethnic groups
who are disproportionately affected by diabetes and other diseases (Clements et al.,
2020).
There are several risk factors that increase the risk of chronic disease such as
smoking, drinking, sedentary lifestyle, unhealthy diets, poor environments, and non-
medical social determinants of health (SDOH) (Benavidez et al., 2024; Hacker, 2024).
2
Although chronic disease is a complex multifactorial issue, making simple lifestyle
changes has been shown to be effective in improving health and preventing the risk for
disease (Benavidez et al., 2024; CDC, 2024b). For instance, healthy dietary change over a
prolonged period has been shown to play an integral role in significantly reducing the risk
of disease and death (Gropper, 2023; Neuhouser, 2019; Sotos-Prieto et al., 2017; Taylor
et al., 2024). Many national public health interventions and initiatives have aimed to
provide nutrition education for disease prevention and health promotion. For example,
the Dietary Guidelines for Americans (DGA) serve as a highly influential federal source
of evidence-based nutrition information to promote healthful eating and prevent chronic
disease (U.S. Department of Agriculture and U.S. Department of Health and Human
Services[USDA & HHS], 2020).To simplify the complex dietary recommendations from
the DGA, the visual icon MyPlate was launched in 2011 replacing the previous nutrition
icon MyPyramid (U.S. Department of Agriculture [USDA], n.d.)
Despite being the primary federal education tool to communicate the DGA for
over a decade, awareness of MyPlate still remains significantly low among the public
(Wambogo et al., 2022). Low awareness of MyPlate has been strongly associated with
poorer diet quality and lower Healthy Eating Index (HEI) scores, a measurement tool
used by the USDA to assess how well the nation's food choices align with the
recommendations of the DGA (Hoy et al., 2017; Shams-White et al., 2023). Data from
several national surveys since the implementation of MyPlate have consistently shown
low awareness and even lower awareness among marginalized sociodemographic
communities (Hoy et al., 2017; Kinderknecht et al., 2024; Wambogo et al., 2022). For
3
instance, according to the 2017 to March 2020 National Health and Nutrition
Examination Survey (NHANES) a total of only 25.3% of adults had heard of MyPlate,
while only 8.3% had tried utilizing it (Wambogo et al., 2022). Survey results showed
visible variability in knowledge of MyPlate across different racial and ethnic populations
compared to their White counterparts. With the lack awareness for national dietary
guidance and the increasing rates of chronic disease in racial and ethnic minorities, it is
clear that MyPlate has failed to reach the most vulnerable populations (CDC, 2024c).
Moreover, although MyPlate education is widely disseminated across several
federally funded programs who largely serve marginalized communities, lack of
adherence and awareness remain a constant issue (Chrisman & Diaz Rios, 2019; Wang et
al., 2021). It is evident there is substantial NHANES data supporting the link between
individuals that utilize or have awareness of the MyPlate tool have self-reported healthier
diets, however participants who have reported awareness or usage are mostly Non-
Hispanic Whites (Hoy et al., 2017; Kinderknecht et al., 2024; Wambogo et.al., 2022).
Research that rigorously evaluates MyPlate’s effectiveness in racial/ethnic communities
is still limited (Chrisman & Diaz Rios, 2019; Hoy et al., 2017; Schwartz & Vernarelli,
2019). Most studies in relation to MyPlate focus on associations rather than causation and
lack evaluation of MyPlate’s compatibility in diverse cultural groups and different food
customs (Chrisman & Diaz Rios, 2019). Statistical variability in awareness of MyPlate in
different sociodemographic subgroups signifies a greater need for inclusive research
assessing barriers to utilization in these populations. A few notable studies that recruited
diverse groups reported barriers such as cost, cultural irrelevancy, language barriers, lack
4
of awareness, perceived lower level of confidence, and less ease-of-use of MyPlate
compared to White populations (Garcia et al., 2022; Kim, 2013; McCarthy et al., 2023;
Mulik & Haynes-Maslow, 2017; Wambogo et al., 2022). These findings indicate the
potential ineffectiveness of MyPlate in racial/ethnic communities and further imply a
need for cultural adaptation of nutrition education material to achieve the initiative's
purpose (Wang et al., 2021).
On the other hand, while several enhancements have been implemented to make
MyPlate more inclusive such as providing translations in 21 languages and incorporating
images of cultural foods on the government website, there is still an absence of
comprehensive cultural adaptions of MyPlate for specific racial and ethnic groups
(USDA, n.d.). Designing culturally and linguistically adapted nutrition education
materials that represent cultural food preferences and traditional customs has shown to be
a successful strategy to increase adherence, increase comprehension, improve diet
quality, and result in greater satisfaction among diverse groups (Alsukait et al., 2021;
Benameur et al., 2023; Hammons et al., 2019; Mohamed-Bibi et al., 2022; Nur et al.,
2023; M. Shilts et al., 2012; M. K. Shilts et al., 2015). With nearly half of the United
States population having at least one major preventable chronic disease, it is imperative
for national nutrition interventions be equitable and culturally relevant to lower rates of
illness among impacted marginalized communities (Hacker, 2024; Wang et al., 2021).
Compared to White populations, racial and ethnic communities encounter higher rates of
death from heart disease and project lowers rates of adherence to national dietary
guidance (Javed et al., 2022; Wambogo et al., 2022). To bridge the gap between dietary
5
guidance and healthy equity it is important that national research be conducted with racial
and ethnic populations to eliminate potential barriers to utilizing dietary guidance and
prevent further chronic diseases from arising (Wang et al., 2021).
Research Objective & Purpose
Taking a step towards equitable research, in this project we selected a sub-
community from the rapidly growing Asian Indian population in the Greater Sacramento
area known as Punjabi-Sikhs (Rico et al., 2023). Unfortunately, Asian Indian immigrants
also have higher rates of heart disease compared to the general United States population
and other racial groups (Gidwani et al., 2021). According to the Sikh Coalition, it is
estimated that 500,000 Sikhs live in the U.S with the highest concentration in California,
and yet it is an ethnic minority that is still underrepresented and widely unknown.
Although, the MyPlate guidelines are offered in major languages, there is still a
deficiency of several vastly spoken languages such as Punjabi (USDA, n.d.). The 2019
United States Census Bureau survey on language use in America, recorded 322,446
individuals who spoke Punjabi at home (Dietrich & Hernandez, 2022). Punjabi culture is
rich with several historical traditions that influence dietary patterns, emphasizing the
importance for the community to receive personalized nutrition education for better
health (Hosking, 2006). Previous research in public health has aggerated several Asian
American subgroups into one homogeneous group, disregarding the heterogeneity of
various cultures, languages and ethnicities that originate from the Asian continent (Yom
& Lor, 2022). As mentioned earlier, health disparities are clearly evident in various Asian
6
subpopulations, hence the need to desegregate and individualize research for specific
subgroups is important to collect accurate data (Yom & Lor, 2022).
The purpose of this research study was to identify potential barriers to utilizing
MyPlate within the Punjabi Sikh heritage community of the Greater Sacramento area and
to develop a culturally adapted MyPlate tool that meets the community's needs. This
study employed a two-phase mixed-method research design, utilizing the first two stages
of the framework proposed by Barrera et al. (2013) for culturally adapting evidence-
based interventions. The first two stages include information gathering and preliminary
adaptation design, which involve conducting a community needs assessment, integrating
the outcomes of the assessment into the development of the initial adaptation, and
acquiring feedback on the design through an iterative process. Additionally, Barrera et al.
(2013) recommends informing the cultural adaptation process with a theoretical
framework to evaluate the efficacy of the intervention and potentially test theory.
Considering these insights by Barrera et al. (2013), this study utilized Self-Determination
Theory, which explains that a person’s basic psychological needs must be met to foster
motivation to engage in a behavior (Deci & Ryan, 1985; Ryan & Deci, 2000). These
needs include autonomy, competence, and relatedness. Following the first stage
(information gathering), in the cultural adaptation process, Phase 1 focused on
administering a theory-based quantitative survey that assessed barriers to MyPlate
adherence. Phase 2 followed Stage 2 (preliminary adaptation design), focusing on
identifying key barriers to MyPlate adherence, designing the initial adaptation of
7
MyPlate, and gaining qualitative feedback from the Punjabi Sikh community through
iterative, theory-based, semi-structured interviews.
Project Goal
To develop a culturally adapted MyPlate visual tool for the Punjabi Sikh heritage
community of Greater Sacramento area.
Objectives
• To assess Punjabi Sikhs barriers’ to utilizing the USDA's MyPlate through
quantitative data collection.
• To design a culturally adapted MyPlate tool incorporating the communities'
needs and food preferences.
• To field-test the culturally adapted material for acceptability, through
qualitative data collection with the target audience.
The Punjab Sikh heritage community is a significantly underrepresented
subgroup with limited research focusing on the development of culturally adapted
interventions. This research project aimed to contribute to the field of nutrition by
acknowledging and supporting a community that has been historically invisible under the
umbrella term of “Asian American.” This visual tool can serve as a model for future
research studies to reference when adapting nutrition education materials for other racial
and ethnic communities. Implementing personalized multifactorial changes for
communities serves as an essential step to enhance the nutrition field and practice cultural
inclusivity, humility, and equity to prevent chronic disease across diverse populations
(Wang et al., 2021).
8
Limitations
Results and tools developed from this research study are subject to several
limitations. This study recruited a small sample of participants from a specific ethnic
community, set within a selected geographical region, limiting its generalizability to
other racial /ethnic communities and demographic areas. Participants were between the
ages of 18-64 years, thus limiting application to younger audiences or older. The primary
researcher's previous knowledge of the selected target ethnic population may have
influenced researcher bias in the data's interpretations. The use of convenience sampling
to recruit participants from a local Sikh temple may have introduced biases due to a non-
random selection of the target population, potentially not acquiring a representative
sample. Lastly, the self-report method of quantitative data collection may have
introduced social desirability bias, influencing participants to potentially not answer
accurately.
Study Organization
Chapter 1 provides an overview of the study's research focus, purpose,
significance, and objectives. The following chapter will lay out a comprehensive
literature review of previous research related to the studies' focus. Chapter 3 will explain
the methodology used to conduct the research and the visual tool's development process.
Lastly, Chapter 4 will present the key findings and Chapter 5 will discuss further
implications for future research.
9
Chapter 2: Literature Review
This Literature Review aims to examine the impact of chronic disease prevalence
in the United States, emphasizing the role of nutrition in prevention and management. It
evaluates the effectiveness of the Dietary Guidelines for Americans and the MyPlate
visual, highlighting key statistics on the current low awareness and cultural challenges
encountered by racial and ethnic communities. Underscoring the need to culturally adapt
MyPlate to better serve diverse groups, particularly the Punjabi Sikh community. By
applying the Self-Determination Theory and cultural adaptation process this review
presents strategies to create effective culturally adapted nutrition interventions.
The Prevalence of Chronic Diseases in the United States
With nearly half the population being impacted, Americans are facing a heavy
burden of chronic diseases (Benavidez et al., 2024). According to the CDC, “chronic
diseases are defined broadly as conditions that last one year or more and require ongoing
medical attention or limit activities of daily living or both” (CDC, 2024c). Some of these
health conditions include heart disease, cancer, obesity, and diabetes. Six out of 10
Americans are living with at least one of these chronic conditions, while four in 10 have
two or more diseases (Buttorff et al., 2017). When examining the top ten leading causes
of death, 80% are from chronic diseases (Benavidez et al., 2024). The CDC reported in
2021 alone, a total 944,800 people died due to heart disease or stroke, which is equivalent
to one in every three deaths in the country (CDC, 2024d). Individuals living with chronic
conditions encounter various physical, social, financial, and mental health challenges that
can decrease the quality of life. In addition to individual hardships, the economic burden
10
of chronic disease has led to an enormous toll on the American healthcare system. This
section of the Literature Review is divided into two subsections for clarity. These two
sections will be discussed in further detail.
The Economic Burden of Disease
This subsection of the Literature Review will cover the economic burden of
chronic diseases in America. The U.S. spends an estimated 90% of the 4.9 trillion annual
healthcare expenditure on chronic illnesses and mental health conditions (CDC, 2024e).
Many alarming findings were reported in a 2020 Commonwealth Fund analysis, in which
the U.S. healthcare system was compared to 10 other high-income countries (Tikkanen &
Abrams, 2020). The results indicated the U.S. spends more money than any other high-
income country on healthcare, while having the lowest life expectancy across 11 nations.
Besides the highest spending rates, the U.S. also has the highest burden of chronic
diseases and instances of preventable deaths. Despite being the most expensive healthcare
system in the world, Americans are subjected to the worst outcomes with unhealthier and
shorter lives in relation to their peer nations. Unfortunately, these chronic diseases and
economic trends are projected to place further upward pressure on health care costs with
an aging and increasing population (Water & Graf, 2018). The prevalence of chronic
disease not only leads to direct costs for individuals, families, insurance companies, and
employers but also produces indirect costs such as work absences, lost wages, and
reduced economic productivity (Water & Graf, 2018). These findings clearly indicate a
tremendous economic impact from chronic diseases and address the need for national
level cost-effective interventions that target underlying factors (Hacker, 2024). The
11
literature review will move into the second subsection exploring factors that influence
chronic diseases and can be addressed when developing public health interventions.
Factors Influencing Chronic Disease
Healthcare costs are rising and the need to better understand factors influencing
chronic disease has become vital. In this subsection of the Literature Review, causes of
chronic diseases will be discussed. Surprisingly, 50% of the leading causes of mortality
in the U.S. are from preventable and treatable illnesses that root from four major risk
factors: physical inactivity, poor nutrition, tobacco use, and alcohol consumption
(Hacker, 2024). Consistent and steady lifestyle changes can help prevent and modify
many of these health conditions such as cancer, chronic respiratory diseases, type 2
diabetes, and cardiovascular disease (Hacker, 2024; Oster & Chaves, 2023). However,
when using a broader lens several environmental factors and social determinants of health
(SDOH) can also play a crucial role in exacerbating these conditions, especially for
marginalized communities (Hacker, 2024). SDOH can encompass a variety of non-
medical factors such as the conditions in which people are born, grow, work, live, and
age (CDC, 2024a). These factors can significantly impact disadvantaged communities
and hinder their opportunities to make healthy lifestyle changes (Hacker, 2024).
According to the Healthy People 2030 initiative launched by the Department of Health
and Human Services (HHS), there are five SDOH factors: economic stability, health care
and quality, education access and quality, neighborhood and built environment, and
social and community context (U.S. Department of Health and Human Services & Office
of Disease Prevention and Health Promotion [HHS & ODPHP], n.d.).
12
For instance, there is substantial research to support the idea that SDOH can
influence major risk factors such as poor nutrition. Several studies have reported
communities that are food insecure, lack accessibility to nutritious foods and have lower
nutrition literacy, encounter more difficulty engaging in healthy eating patterns (Hacker,
2024; Jiao, 2024; Vilar-Compte et al., 2021). Expanding on these findings, in a large-
scale study that used the SDOH framework to assess sociodemographic and geographic
variations by zip codes of chronic disease prevalence, found that regions with statistically
higher rates of disease consisted of marginalized racial and ethnic groups, smaller in
population, older residents, lower income, and socioeconomically disadvantaged
communities (Benavidez et al., 2024). Historically, researchers have used the individual
responsibility framework to identify behaviors that contribute to chronic diseases, while
disregarding the complex socio-environmental factors that interplay (Temmann et al.,
2021). Although poor nutrition has been viewed as an individual choice, it is significantly
influenced by several external factors such as inequitable nutrition education (HHS &
ODPHP, n.d.). It is evident that health disparities exist, and some groups are affected
more than others by chronic diseases. Therefore, it is important to consider the deep
interconnectedness of individual behaviors and the SDOH when developing public health
interventions to address chronic disease (Hacker, 2024). In the next section of this
Literature Review, a major underlying risk factor for chronic disease will be discussed
and the current federal interventions implemented.
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The Role of Nutrition in Chronic Disease Prevention
In this section of the Literature Review, we will cover nutrition's role in chronic
disease prevention. The CDC recommends an array of preventative measures to avoid
risk factors influencing chronic diseases (CDC, 2024b). However, one behavior that has
been significantly studied to prevent and manage chronic conditions across various
sociodemographic groups is higher diet quality (Gropper, 2023; Neuhouser, 2019; Sotos-
Prieto et al., 2017; Taylor et al., 2024). In fact, many illnesses like cardiovascular disease,
diabetes, cancer, and obesity have been linked to poor nutrition and referred to as diet-
related diseases (Gropper, 2023). According to Gropper, (2023) diet-related diseases are
health conditions caused by unhealthy eating patterns with the combination of other
lifestyle factors over a prolonged period.
Although healthy eating can have its own context among diverse groups, an
evidence-based healthful diet consists of a balance of whole fruits, vegetables, whole
grains, lean protein, low-fat dairy product, while limiting added sugars, saturated fats,
and sodium (U.S. Department of Agriculture and U.S. Department of Health and Human
Services [USDA & HHS], 2020). Unfortunately, most Americans are simply not eating
enough fruit and vegetables, while excessively consuming low-quality grains, and
exceeding recommended limits of added sugar, salt, and saturated fat intake (USDA &
HHS, 2020). The current national Healthy Eating Index (HEI) score is 58 out 100,
indicating most Americans do not eat according to the recommended national nutrition
guidelines (U.S. Department of Agriculture & Food and Nutrition Service [USDA &
FNS], 2023). Trends of unhealthy eating patterns among the U.S. population have
14
remained constant and are disproportionally prevalent in marginalized, low income, low
literacy, and underserved communities (McCullough et al., 2022). The federal
government has been providing dietary guidance on healthy eating for more than 100
years; however, more recently with the emerging advances in nutrition science the focus
has expanded to promoting health and preventing disease across the nation (USDA &
HHS, 2020). The current federal source that uses extensive scientific evidence to provide
advice on what to eat and drink at all stages of life, is known as the Dietary Guidelines
for Americans (DGA) (USDA & HHS, 2020). The next section of this Literature Review
will provide an overview of the DGA.
National Dietary Guidelines
As mentioned in the last subsection, this part of the Literature Review will focus
on the DGA. Acknowledging the need for a clear set of guidelines to help Americans
make informed choices about their nutrition intake, rising chronic disease rates and years
of evolving nutrition research led to the first publication of the DGA in 1980 (U.S.
Department of Agriculture & U.S. Department of Health and Human Services [USDA &
HHS, 1980). Prior to the first publication of the DGA, the federal government focused on
providing information on food groups in a healthy diet to ensure people received enough
minerals and vitamins to prevent certain diseases from deficiencies (USDA & HHS,
1980). However, after years of investigation in nutritional science, it became evident that
dietary patterns can play a significant role in promoting health and preventing chronic
diseases (USDA & HHS, 2020). Therefore, since the 1980’s the USDA and the HHS
department have collaboratively issued the DGA. Which serve as a highly influential
15
federal source of evidence-based nutrition information and guidance on healthy dietary
practices to promote health and prevent disease (USDA & HHS, 2020). The DGA is
renewed every five years and developed through a comprehensive two-step process
incorporating scientists, health professionals, policy makers and the general public
(USDA & HHS, 2020). Since the implementation of the DGA there have been several
complementary tools released to visually represent the recommendations such as
MyPyramid and MyPlate (UDSA, n.d.). MyPlate was developed in 2011 replacing
MyPyramid to provide a clearer, simpler, easy to understand visual tool that relayed the
complex nutrition information from the DGA for the public (UDSA, n.d.) (Figure 1).
Figure 1
MyPlate Visual Graphic
Note. From, MyPlate Graphics, by U.S. Department of Agriculture and Department of
Health and Human Services, n.d. MyPlate ( https://www.myplate.gov/)
16
As shown in Figure 1, the MyPlate visual depicts a colorful plate sectioned into
five food groups (grains, protein, vegetables, fruit, and dairy) that are recommended by
the DGA to build balanced meals (USDA & HHS, 2020). Each food group is portioned
according to a nutritionally adequate amount, for instance fruits and vegetables are
emphasized to make up half of the plate, while grains and protein should make up one
fourth each, and dairy accounts for one cup apart from the plate. In efforts to expand the
reach of the MyPlate initiative an interactive government website was created to help
individuals personalize and customize their plates to meet their own needs (USDA, n.d.).
In addition, federally funded community food and nutrition programs at the state and
local level, schools, health care providers, and many other organizations have adopted
MyPlate as a foundation to educate their members on healthy eating (Wang et al., 2021).
MyPlate has been the national nutrition icon for over a decade and despite its expansion
on adaptability to personal preferences, cultural customs, and budget considerations its
public awareness and usage remains staggeringly low (Wambogo et al., 2022). To further
explain this section of the Literature Review it has been divided into three sub-sections.
MyPlate Awareness and Usage
This subsection will explore literature that has assessed the public's awareness and
utilization of MyPlate. Although MyPlate has been widely used for over a decade across
the nation to provide education on healthy eating habits, there is limited awareness of the
tool. According to the 2017 to 2020 National Health and Nutrition Examination Survey
(NHANES) report, from a sample of n=9,232 only 25.3% adults were aware of MyPlate
and 8.3% had tried to follow the visual (Wambogo et al., 2022). Survey results were
17
stratified by sociodemographic characteristics including gender, age, race/ethnicity,
marital status, income, place of birth, language spoken at home, and education level. The
results clearly indicated a higher prevalence of MyPlate awareness in younger age adults,
women, non-Hispanic Whites, American born, English speaking, higher income, and
higher education level individuals. Participants who reported both being aware of
MyPlate and utilizing it, were more likely to rate their diet qualities higher and vice versa
(Wambogo et al., 2022). These findings highlighted the significantly lower awareness
and usage of MyPlate in low income, low literacy, marginalized racial and ethnic groups.
Further implying the need to conduct research in disadvantaged communities to assess
potential barriers to MyPlate awareness and utilization. Supporting these results,
Kinderknecht et al. (2024) observed similar findings when analyzing three NHANES data
sets from 2013 to 2018. The data had a total sample size of n=17,023 and the survey
results indicated the rate of awareness remained consistently low and even lower among
marginalized racial and ethnic communities throughout all three data sets. Although the
percentage of awareness increased from 19.5% to 24.6% in 2013 to 2018, it was not
remarkable considering the number of years since the implementation of MyPlate.
Moreover, a study that utilized even older NHANES data from 2007 to 2012 with
a sample size of n=13,022 found results that are reflective of recent survey data, such as
general low awareness and lower awareness of national dietary guidance among
marginalized populations (Hoy et al., 2017). In addition, this study observed higher diet
quality scores among participants who were aware and tried to utilize nutritional
guidance similar to the results from the Wambogo et al. (2022) study. From this
18
collection of studies, it can be concluded that before and after the launch of MyPlate,
awareness of national dietary guidance has remained low and even lower across different
sociodemographic subgroups. These findings emphasize the need to conduct further
research on effective strategies to disseminate MyPlate education equitably across
marginalized communities. MyPlate was launched with an initiative to help the public
make healthy dietary choices; however, after more than a decade it has failed to reach
many vulnerable groups. While MyPlate's public awareness and adherence is limited, it
does not imply that it has not been effective. There is evidence to suggest its potential
effectiveness in promoting healthy eating patterns, increasing nutrition knowledge,
positively impacting glycemic & lipid profiles, reducing waist circumference, and
lowering blood pressure (Blondin & LoGiudice, 2018; Brown et al., 2014; McCarthy et
al., 2023; Ogbonnia, 2021; Schroeter et al., 2021; Zakerkish et al., 2022). In the following
subsection, we will review a few notable studies that researched the effects of MyPlate
usage.
Behavioral Effects of MyPlate. As mentioned in the previous section, MyPlate's
reach and usage has been limited over the years, yet its ability to produce positive
behavioral and physiological changes has been successfully assessed in many small
intervention studies. For instance, Brown et al. (2014) conducted a pilot study with a
sample of 150 college students, evaluating the acceptance and effectiveness of receiving
repeated text messages in relation to the MyPlate icon. Results indicated the participants
in the intervention group had a statistically significant (p < .05) increase in fruit
consumption and upward trend in vegetable intake compared to the control group.
19
Moreover, a statistically significant increase in MyPlate’s knowledge scores was
observed in the intervention group from 20.7% to 52.8% compared to the control group.
Although this study had significant findings in relation to MyPlate’s effectiveness, there
were many limitations to consider like demographics, duration, and the validity of self-
reported assessments. The study was conducted with a group of college students ranging
between the ages of 18-24 years and 90% of the sample population was White, limiting
the generalizability to older, low literacy, and racial/ethnic groups. Some other limitations
were the uncertainty of whether participants read the texts content, and the method of
collecting behavior change data by self-reported assessments which can potentially lead
to reporter bias and limited external/internal validity of results.
Similarly, another pilot study was conducted by Schroeter et al. (2021) with 57
college students; however, in this study they incentivized participating in a health
program focused on MyPlate. Learning from the drawbacks of electronic nutrition
education in the previous study, Schroeter et al. (2021) administered the intervention in-
person. Participants were randomly assigned into two groups, one education intervention
and one control group that received no education (non-Edu). Aligning with the findings
from the previous study, results indicated an increase in nutrition knowledge by 13% in
Edu and 15% in Edu +, while the non-Edu remained stagnant with only a 2% change. In
addition, an increase in whole grains, vegetable, and fruit consumption was observed
when comparing baseline survey data to post survey results. Moreover, HEI scores in the
intervention groups increased by an average of 15% while the non-Edu group was only
8%. Data collected in this study further strengthens the effectiveness of MyPlate
20
education in enhancing diet quality, however like the study by Brown et al. (2014), there
are still several limitations to consider. The sample size was small, consisting of college
students ages 18-24 years, and results were from self-reports, and racial demographics
were not disclosed, which may not be accurate for generalizing results nationwide. While
the nutrition education was in-person and more interactive in comparison to electronic
methods, the intervention length was short and not sufficient to determine long term
effects of MyPlate education. Despite these limitations, these studies provide a
foundational understanding of the potential effectiveness of MyPlate in influencing
behavioral change; however, there is a need for further research with more representative
samples. Having explored studies that have assessed behavioral effects of MyPlate
education, the following subsection will review the literature that has studied the physical
effects of MyPlate education.
Physiological Effects of MyPlate Education. Although there is a small number
of studies evaluating the effectiveness of MyPlate, there are a few notable studies that
have assessed positive physiological changes in association with MyPlate education,
specifically in underserved communities. For instance, McCarthy et al. (2023) conducted
a randomized controlled trial study comparing the effectiveness of the nation's top two
approaches for acquiring healthy body fat composition: calorie counting and MyPlate
guidelines. Researchers recruited 261 adult primary care patients who were medically
overweight, low income, mostly Latine and from a federally qualified health center.
Anthropometrics, psychosocial, and lifestyle behaviors were measured at baseline, 6
months, and 12 months after enrollment, along with food frequency and satiation
21
assessments. Results indicated a significant reduction in waist circumference
measurements from baseline to 12-months in both experiment groups. In addition,
satiation/satiety scores also increased in both groups from baseline to 12-month follow-
ups. Blood pressures measures were not significant, however the MyPlate intervention
participants showed a slight reduction in systolic blood pressure readings at six months.
After performing a comparative analysis, researchers concluded that both intervention
approaches resulted in improving satiety/satiation and decreasing waist circumference.
However, when results were stratified by moderating variables such as acculturation
which is influenced by whether participants were U.S. born or foreign, the individuals
with highest acculturation scores significantly reduced their waist circumference
compared to less acculturated participants. This data potentially suggests that Latine
individuals that have culturally assimilated to the western diets, benefit more from federal
weight reduction approaches compared to individuals who are less assimilated, further
implying the need to conduct research diverse groups for equitable guidance. A key
strength in this study was the 6-month duration of the intervention including a 12-month
follow-up, which strengthens the sustainability of behavior change.
Furthermore, a study conducted by Ogbonnia, (2021) found MyPlate education
was effective in increasing nutrition knowledge and reducing A1c levels in African
American adults with type 2 diabetes. Forty participants were recruited from a wellness
center where they were receiving diabetes treatment. Participants received nutrition
education material from MyPlate and the CDC. Post-intervention results indicated an
increase in nutrition knowledge and a decrease in A1c levels from an average of 9.53
22
(SD.2.18) to 8.53 (SD =1.84). Although the intervention was short, the researcher
attempted to take long term sustainability measures such as meal planning, posting
informational MyPlate content in the facility, and encouraging the wellness center staff to
incorporate MyPlate teachings in treatment plans for all diagnosed diabetic patients.
Despite some limitations in this study, the findings are important, considering that
Africans Americans are disproportionally affected by Type 2 diabetes (McLaurin, 2024).
In conclusion, a small but influential set of studies have researched the behavioral and
physiological effects of MyPlate education while yielding robust and consistent findings
supporting the use MyPlate to promote health. However, many of the studies did lack
representation, potentially preventing the findings from being generalizable to diverse
groups. Now that we have discussed the benefits of MyPlate education, in the next
subsection we will explore data collected on potential barriers influencing the low
awareness and adherence of MyPlate especially in marginalized racial/ethnic groups.
Barriers To Adherence. In the previous subsection, evidence to support the
utilization of MyPlate education to promote healthy eating and potentially manage
chronic conditions was revealed. However, we previously learned that public’s awareness
and adherence of MyPlate remains significantly low, and these trends are highly
prevalent in marginalized communities. As mentioned in the conclusion of the McCarthy
et al. (2023) study, Latine individuals that reduced their waist circumference were also
the most acculturated indicating potential barriers for non-acculturated participants.
Surprisingly, only a limited number of studies have been conducted to identify the
potential barriers to utilizing MyPlate in marginalized racial and ethnic groups. However,
23
the limited studies have yielded important key findings. For example, a study conducted
by Garcia et al. (2022), assessed significant cultural barriers to adhering to MyPlate
guidelines among Asian Americans. Participants were recruited from Los Angeles
counties USDA Supplemental Nutrition Assistance Program Education (SNAP-Ed)
program. Both qualitative and quantitative data was collected from participants (n=349)
who comprised of several Asian subgroups (Cambodian, Filipino, Chinese, Japanese,
Vietnamese, and Korean). After performing an analysis of responses to both methods of
data collection, researchers identified similar themes in barriers to following MyPlate
recommendations. A total of 86.8 % of Asian American adults reported a customary
practice of consuming meals in family style along with using plates and bowls to serve
food verses one plate. In addition, 73.4% of survey participants stated that they rarely or
never or sometimes using MyPlate guidelines considering their food customs did not
align with the visual presented. Several other barriers were assessed in the surveys and
interviews such as not relating to MyPlate's depiction of dairy, whole grains, and fruit
servings. The main barrier to not following dairy recommendations among Asian
subgroups was lactose intolerance and 30.7% of participants reported having a preference
of refined grains (white rice) over MyPlate's whole grain recommendations. Many Asian
subgroups reported contrasting cultural traditions when consuming fruits and vegetables.
Participants reported not prioritizing fruits and vegetables, portioning them differently
and typically not eating them alongside meals. Overall, many significant cultural barriers
were assessed among several Asian subgroups in this study, underscoring the need to
revise or culturally adapt the MyPlate visual to better serve these communities.
24
Moreover, a study conducted by Kim (2013) at California State University, Long
Beach analyzed the usability of MyPlate as a healthy eating tool among a group of
diverse college students (N=302) (Hispanics/Latinos, Blacks, Asians/Pacific Islanders
and Whites). The questionnaire assessed demographics, perceived ease of use and
confidence with MyPlate guidelines. The data analysis indicated a statistically
significantly higher level of confidence and ease of use among White participants
compared to other racial and ethnic groups. Some limitations to consider in this study
include the use of college students ranging from 18-19 years, limiting the application to
older ethnic populations. This study was conducted prior to Garcia et al. (2022), however
even data from over a decade ago indicated racial and ethnic groups encountered more
difficulty adhering to MyPlate guidelines compared to their White counterparts.
Moreover, other researched barriers to utilizing MyPlate among marginalized
communities have simply been low awareness, language barriers, and cost (Mulik &
Haynes-Maslow, 2017; Wambogo et al., 2022). Findings in these studies imply many
diverse groups find difficulty adhering to MyPlate, thus it is imperative for researchers to
conduct further studies to develop inclusive and equitable interventions. In the next
section we will discuss techniques to ensure MyPlate is effective by applying the Self
Determination Theory to gain further insight into constructs such as culture influencing
low awareness and adherence.
25
Self-Determination Theory
Many studies with theory-driven interventions have shown to be more effective in
relaying nutrition information and increasing healthy eating patterns (Contento & Koch,
2020; Lo Dato et al., 2024). Lo Dato et al. (2024) emphasizes how theoretical
frameworks can help provide a comprehensive understanding of constructs that influence
behaviors and guide the development of interventions that promote sustainable behavior
change through targeting the most relevant factors such as culture. Considering the
effectiveness of theoretical frameworks in many studies, the Self-Determination Theory
(SDT) was used to explain the studies that have assessed low awareness and usage of
MyPlate among marginalized racial and ethnic communities (Deci & Ryan, 1985; Ryan
& Deci, 2000). The SDT emphasizes motivation as a key component in behavior change
and explains that humans have three basic psychological needs that drive the quality of
motivation (intrinsic and extrinsic) needed for sustainable behavior change: autonomy,
competence, and relatedness (Ng et al., 2012). As shown in Figure 2, the fulfillment of
these needs fosters self-motivation to engage in behavior change (Ryan & Deci, 2000).
26
Figure 2
Visual Depiction of the Self-Determination Theory Constructs: Autonomy, Competence,
and Relatedness
Note. From "Self-Determination Theory and the Facilitation of Intrinsic Motivation,
Social Development, and Well-Being," by R. M. Ryan and E. L. Deci, 2000, American
Psychologist, 55(1), 68-78. https://doi.org/10.1037/0003-066X.55.1.68
According to Patrick & Williams (2012), the theoretical construct autonomy,
“reflects the need to feel choiceful and volitional, as the originator of one's actions,” in
other words a sense of control over one's actions or decisions (p.3). For instance, the
Garcia et al. (2022) study found that Asian participants had trouble adhering to MyPlate
because it did not align with their cultural food preferences. This highlights that the
MyPlate tool potentially lacks representation of cultural foods and limits the autonomy
and control of Asian Americans over their food choices, thus decreasing their motivation
for adherence. In addition, the second construct in SDT is competence, which involves,
27
“the need to feel capable of achieving desired outcomes, conceptually similar to self-
efficacy,” in other words a sense of mastery to be effective in the behavior change
(Patrick & Williams, 2012, p.3). Competence can play a significant role in adherence to
MyPlate and individuals who do not feel capable or competent are less likely to engage
with MyPlate.
For example, in the study by Kim (2013) results indicated racial and ethnic
minority groups had lower perceived ease of use and confidence levels in utilizing
MyPlate compared to Whites. Confidence and ease of use are highly associated with
competence and low levels correspond with less motivation to adhere to behavior change.
Moreover, the third construct in SDT is relatedness which, “reflects the need to feel close
to and understood by important others,” and this is especially important for ethnic groups
whose cultural traditions and food customs are a crucial part of their identities (Patrick &
Williams, 2012, p.3). Cultural disconnect and lack of relatedness to MyPlate has created
difficulty in adherence for racial and ethnic groups such as Asian Americans. This was
observed in the Garcia et al. (2022) study when Asian subgroups expressed consuming
their meals in family style because it was a cultural tradition, however it conflicted with
MyPlate’s visual representing individual plate recommendations. The inclusion of
cultural traditions and food customs on the MyPlate tool are a crucial step for deeper
connections with the Asian American population, as their cultures are an integral part of
their identity. Furthermore, other barriers that have been assessed to adherence across
several racial and ethnic groups are low awareness, and language barriers, which are
clearly related to all three constructs of SDT (Wambogo et al., 2022). Low awareness of
28
MyPlate can potentially hinder an individual's feeling of competence, limit autonomy to
make informed decisions, and create a sense of disconnect from social networks that
promote healthy eating. Likewise, the lack of culturally appropriate language options, can
play a similar role in decreasing motivation by affecting someone's confidence levels, the
ability to understand and connect to presented material or the environment (Alamer &
Almulhim, 2021). Having applied the SDT framework to identify influencing factors of
low awareness and underutilization of MyPlate in racial and ethnic communities, has
brought attention to cultural barriers that impact the autonomy, competence, relatedness,
and motivation of diverse groups to adherence. Therefore, it can be concluded that the
need to culturally adapt nutrition education materials like MyPlate for racial and ethnic
groups is imperative to increase adherence. The next section of Literature Review will
explain the process of cultural adaptation.
Cultural Inclusivity in Nutrition Education
Cultural irrelevancy is a significant factor influencing many barriers to MyPlate
utilization in racial and ethnic groups and ultimately contributing to the lack of awareness
and adherence within these communities (Garcia et al., 2022; Kim, 2013; McCarthy et
al., 2023; Mulik & Haynes-Maslow, 2017). Cultural irrelevancy correlates with the DGA
being significantly influenced by Eurocentric dietary patterns, excluding the
representation of cultural food norms, practices, and traditions from different racial and
ethnic groups (Burt, 2021). Over the years, researchers have acknowledged the impact of
SDOH, and how culture plays a pivotal role in shaping dietary practices (Benavidez et
al., 2024; Jayasinghe et al., 2025). With these findings, efforts to make MyPlate
29
culturally inclusive and equitable for marginalized groups has been executed by offering
diverse language options, encouraging customizability, and displaying cultural food
photography on the interactive website (USDA, n.d.)
However, despite informing educators that, “MyPlate works best when it is
customized for the individual consumer to include eating style, food likes and dislikes,
cultural foodways, and family favorites,” there is no availability of formal culturally and
linguistically adapted MyPlate visuals that account for all the cultural aspects of specific
ethnic subgroups (USDA, n.d.). While there is considerable amount of evidence that
indicates that the most effective strategy to overcome cultural barriers for socially
disadvantaged people in adherence to health interventions, is by developing deeply
structured culturally adapted interventions (Barrera et al., 2013; Lee et al., 2024; Mattei
et al., 2024; H. Singh et al., 2024). As shown in Figure 3, the different language options
of MyPlate only provide surface level messaging for specific communities and fail to
integrate cultural, social, historical, environmental, and psychosocial factors that
influence behaviors in marginalized groups (Mattei et al., 2024). In the next subsection of
the Literature Review, deeply structured verses surface level cultural adaptation will be
discussed in depth.
30
Figure 3
Arabic, Chinese, Hindi, and Spanish Translations of the MyPlate Visual
Note. This figure depicts a sample of translated MyPlate’s provided from, MyPlate in
Multiple Languages, U.S. Department of Agriculture and Department of Health and
Human Services, n.d. MyPlate ( https://www.myplate.gov/)
Deep Versus Surface Level Structured Cultural Adaptation
According to Bernal et al. (2009), cultural adaptation is defined as, “the
systematic modification of an evidence-based treatment or intervention protocol to
consider language, culture, and context in such a way that it is compatible with the
client’s cultural patterns, meanings, and values” (p. 362). Furthermore, Barrera et al.
(2013) explains the cultural adaptation process to be comprehensive, collaborative,
iterative and in consensus with various literature involving five stages: information
31
gathering, preliminary adaptation design, preliminary adaptation tests, adaptation
refinement, and cultural adaptation trial. Barrera et al. (2013) also suggests having the
adaptation process be informed by a theoretical framework to measure improvement in
constructs and its effectiveness in comparison to baseline measures from the original
intervention. Evidence from a systematic review conducted by Singh et al. (2024),
concluded that health interventions that were culturally sensitive and provided tailored
education materials resulted in being most effective for marginalized communities to
promote behavior change.
Moreover, Resnicow et al. (1999) developed a model for cultural sensitivity in
public health interventions and introduced two dimensions of cultural adaptation: surface-
level adaptation and deep-structured adaptation. Surface level refers to adapting
intervention material to observable superficial changes as shown previously in Figure 3,
such as language, food, appearance, and location of the target population, whereas deep-
structured adaptation requires a comprehensive lens to understand the target population
and incorporates many SODH. Resnicow et al. (1999) further explains when developing
culturally sensitive material it is important to understand that surface level and deep
structured adaptations are not independent, but rather interconnected and on a spectrum
influencing each other. Using both dimensions to culturally adapt interventions has been
shown to be feasible and valuable (Mattei et al., 2024). While cultural adaptation is ideal
and more effective in influencing behavior change among racial and ethnic minorities
groups, researchers have expressed there are potential challenges.
32
Issues and Challenges of Cultural Adaptation
When culturally adapting evidence-based interventions like MyPlate, risks of
limiting effectiveness can become present. Castro et al. (2010) provides an overview of
the critical issues that emerge when developing culturally adapted evidence-based
interventions. For instance, Castro et al. (2010) emphasizes that culture is a complex
concept and when interventions are adapted for specific cultural groups, the competence
of the researcher is imperative for developing deep structured adaptations. To encapsulate
all the components of a cultural group's needs and preferences, the complexities of
culture must be understood by the investigator.
Moreover, another controversy in relation to cultural adaptations is the fidelity-
adaptation dilemma, in other words ethical and practical challenges to ensuring the
original elements of the evidence-based intervention are intact versus also incorporating
the subcultural group's needs (F. Castro et al., 2004; F. G. Castro et al., 2010). However,
Castro et al. (2010) provides strategies to navigate through this dilemma by identifying
specific sources of intervention-consumer mismatch and understanding the difference
between surface level versus deep structured adaptations. Despite the issues and
challenges that are present in the cultural adaption process, many studies have
successfully designed culturally adapted nutrition education interventions that have been
effective in increasing adherence, and comprehension, and improving diet quality,
resulting in greater satisfaction among marginalized racial and ethnic groups (Alsukait et
al., 2021; Benameur et al., 2023; Hammons et al., 2019; Mohamed-Bibi et al., 2022; Nur
et al., 2023; M. Shilts et al., 2012; M. K. Shilts et al., 2015).
33
Successful Cultural Adaptation of Health Education Interventions
In the previous subsection of the Literature Review we learned that the
complexities of developing cultural adaptations of evidence-based interventions can be
difficult, potentially making it more challenging for researchers to implement valuable
interventions. However, many researchers have overcome these challenges by
successfully developing effective culturally adapted education materials for underserved,
marginalized, racial and ethnic minorities. Many studies that have developed
interventions for specific racial and ethnic groups have resulted in high satisfaction levels
among participants. For example, a randomized controlled conducted in Catalonia,
Barcelona found that Pakistani women who were introduced to culturally and
linguistically adapted nutrition education material expressed great appreciation for
relevant visuals, cultural and linguistic adequacy, and ease of comprehension (Mohamed-
Bibi et al., 2022). In this study researchers developed a series of culturally and
linguistically adapted materials for existing tools such as the Harvard Health Eating Plate,
while also generating new nutrition education materials such as infographics debunking
common nutrition misconceptions and booklets with healthy Pakistani recipes (Harvard
T.H. Chan School of Public Health, 2011). Figure 4 depicts a sample of education
material that was created where images of traditional Pakistani meals plated according to
the Harvard Healthy Eating Plate were generated for participants.
34
Figure 4
Examples of Cultural and Linguistic Adaptations of Harvard’s Healthy Eating Plate for
Pakistani Women in Catalonia, Barcelona
Note. This image is from "Design of Culturally and Linguistically Tailored Nutrition
Education Materials to Promote Healthy Eating Habits among Pakistani Women
Participating in the PakCat Program in Catalonia," by S. Mohamed-Bibi, C. Vaqué-
Crusellas, and N. Alonso-Pedrol, 2022, Nutrients, 14(24),
5239. https://doi.org/10.3390/nu14245239.
Similarly, a study conducted by Alsukait et al. (2021) among African American
women found high satisfaction levels for a culturally adapted cardiovascular prevention
program. Researchers culturally adapted a community-based program called Strong
Women-Healthy Hearts for African American women in different faith centers using the
deep structure framework. After participants completed the 12-week program, they
expressed great appreciation for being able to build social relationships and feel a sense
of connectedness with the program's content. Culturally relevant nutrition and physical
35
activity education were also incorporated in this program and post-intervention
measurements for diet quality indicated slight improvements in vegetable intake.
Moreover, changes in dietary quality have also been observed in several other studies
(Hammons et al., 2019; Nur et al., 2023).
For instance, a randomized controlled trial implementing a culturally adapted six-
week workshop that consisted of nutrition education based on the DGA and MyPlate
measured significant improvements in diet quality of Hispanic mothers compared to the
control group (Hammons et al., 2019). Similar findings were also present in a study by
Nur et al. (2023) where Somali refugees received education from a culturally adapted
nutrition-related Utah State intervention program known as Create Better Health.
Participants engaged in 12 nutrition education lessons via Zoom and using the Expanded
Food and Nutrition Education Program (EFNEP) behavior assessment survey, post
intervention scores indicated a significant increase in diet quality. Moreover, some
researchers have developed culturally adapted nutrition interventions which have been
effective in influencing adherence to healthy eating and increasing nutrition knowledge.
For example, Benameur et al. (2023) introduced a culturally adapted
Mediterranean diet based on the concept of Southern soul food which is a diet consumed
by African Americans in the south. Participants were hospitalized patients who had
experienced an acute ischemic stroke and were diagnosed with at least one chronic
condition. The benefits of the Mediterranean diet have been extensively researched in
reducing the risk for cardiovascular disease, thus researchers chose to create an
intervention to promote adherence and nutrition knowledge for this diet for African
36
Americans with increased risk. Patients were provided culturally appropriate dietary
education and materials such as handouts, pamphlets, and recipe booklets according to
the Mediterranean Soul Food diet. Post-intervention results indicated a significant
increase in the participations adherence to and nutritional knowledge of the
Mediterranean diet (Benameur et al., 2023).
Similarly, when a group of parents participated in a 5-week intervention
incorporating a customized MyPlate curriculum called My Healthy Plate, they reported
adherence to the dietary education and efficacy in recalling the major themes from My
Healthy Plate during the interviews (Shilts et al., 2012). Although this intervention was
not culturally adapted for a specific racial or ethnic community, the researchers aimed to
translate the tool for low literacy and low-income audiences who participated in federal
assistance programs which predominantly consist of racial and ethnic marginalized
groups (M. K. Shilts et al., 2015). When developing this tool, M. K. Shilts et al. (2015)
included culturally appropriate messages on the education materials suggested by the
target audience. Education material consisted of handouts, worksheets, and visuals of
MyPlate-inspired meals commonly consumed by marginalized communities. Collectively
the evidence from these studies supports the results from the Singh et al. (2024) study
indicating that culturally adapted interventions are effective in promoting behavior
change. Researchers were effective in implementing culturally adapted interventions and
yielded high satisfaction levels, greater appreciation, increased diet quality, increased
nutrition knowledge, and improved adherence to adapted evidence-based interventions.
37
The Cultural Adaptation of MyPlate for the Punjabi Sikh Community
Building upon the previous subsection of this Literature Review, cultural
adaptation can be effective in influencing positive outcomes for racial and ethnic
communities. Further implying that MyPlate may be more effective if it is culturally
adapted for specific ethnic subgroups to increase awareness and utilization nationwide.
Currently, there are limited culturally relevant options provided by the federal
government that correspond with MyPlate education other than simple language
translations (USDA, n.d.). More importantly, MyPlate is only translated into 21
languages, while in the United Sates there are more than 350 languages spoken
nationwide (Dietrich & Hernandez, 2022). The Asian population is one of the fastest
growing groups in America, which explains why the majority of MyPlate language
options originate from the different subcontinents of Asia due to their widespread use
(Chinese, Korean, Vietnamese, Tagalog, Arabic, Hindi, Urdu, Thai, Pashto, Malay,
Indonesia) (Budiman & Ruiz, 2021; USDA, n.d.). However, in 2020 Asian Indians
became the nation's largest Asian alone group, with a 50% increase in population from
2010 to 2020 (Rico et al., 2023). Subgroups that originate from the Indian subcontinent
are incredibly diverse with numerous ethnic and linguistic identities which are also
widely represented in the United States (Budiman & Ruiz, 2021). For example, some
Indian ethnic identities and languages that are not represented in MyPlate education
include Punjabi, Gujarati, Bengali, Marathi, Telugu, Tamil and many more (USDA,
2020).
38
Historically, the Asian population has been studied as one homogeneous group,
masking health disparities among unique subgroups (Yom & Lor, 2022). When the Asian
population is aggregated the leading cause of death is cancer, whereas the desegregation
of subgroups highlights the heterogeneity of mortality factors (Yom & Lor, 2022). For
example, when Asian subgroups are studied individually, Asian Indians disproportionally
have higher rates of overweight/obesity, type 2 diabetes, metabolic syndrome, and
cardiovascular disease compared to the general US population and other groups
(Fernandez Perez et al., 2022; Gidwani et al., 2021; Hastings et al., 2015; Koirala et al.,
2021). In addition, the leading cause of death for Asian Indians is heart disease, while the
leading cause of death among Asian Americans is cancer (Fernandez Perez et al., 2022).
The heterogeneity of leading causes of death and disease highlight the importance of
considering ethnic differences of subgroups when developing nutrition education tools
such as MyPlate.
With a large Asian Indian population and the higher prevalence of diet-related
chronic conditions in this community, it is imperative that MyPlate be culturally adapted
for the diverse Indian population. The Asian Indian population makes up 20% of all
Asian Americans, and there are various distinct subgroups within the Asian Indian
population who are significantly underrepresented in nutrition research (Rico et al.,
2023). Considering the lack of formal translations of MyPlate in various Indian languages
and culturally tailored nutrition education interventions, the current study selected an
Asian Indian ethnic subgroup known as the Punjabi Sikhs, to develop a culturally adapted
MyPlate for (USDA, n.d.). In the next section of the Literature review, the cultural
39
background, health issues and current literature gaps for the Punjabi Sikh community will
be discussed.
The Punjabi Sikh Community
In the previous subsection we discussed the diversity of the Asian American
population, and the historical underrepresentation of several subgroups in research
assessing health disparities. This section of the Literature Review is divided into different
subsections, to further understand the Punjabi Sikh community.
Background. The Punjabi identity is not only cultural, but also linguistic and
geographical (Ranganath, n.d.). Punjabi people are an ethnic subgroup that originate from
the region of Punjab, which is in the northwestern part of India. While the region of
Punjab encompasses a variety of people with different religions like Islam, Hinduism,
and Jainism the majority follows Sikhism (Jakobsh, 2012). There are more than 25
million Sikhs in the world, and the greatest population lives in Punjab, India (Sikh
Coalition, n.d.). However, the Punjabi Sikh diaspora has established communities all
around the world with the largest concentration of communities being in North American
countries such as the United States and Canada (Sikh Coalition, n.d.). The first Asian
Indians to arrive in the United States were from Punjab and 90% were Sikhs (Ranganath,
n.d.). In search for work opportunities, economic growth, and farming land the first
record of Punjabi Sikhs arriving to the United States was documented in 1899 in San
Francisco, California (Lewis, 2017).
The peak immigration of Punjabi’s to United States happened in the early 1900’s
which led to them working in the lumber mills and railroad construction in Washington,
40
Oregon, and California (Lewis, 2017; Rajan et al., 2015). The expansion of railroad lines
increased agricultural activity in Northern California, resulting in many Punjabi Sikhs
shifting to farming and acquiring higher wages due to their previous agricultural expertise
(Gibson, 1988; Lewis, 2017). Punjabi Sikhs later sought permanent settlements in
Sacramento valley, San Joaquin Valley and in the Imperial Valley in California (Gibson,
1988). Punjabi Sikhs played a key role in the early growth of California’s agriculture by
contributing to the initiation of rice farming and growing large cash crops becoming
among the most successful farmers in California (Gibson, 1988). Today there is an
estimated 500,000 Punjabi-Sikhs that live in the United States and reside predominately
in California, New York, and New Jersey (Sikh Coalition, n.d.).
Despite the significant contributions to the society and their distinct appearance,
Punjabi Sikhs are underrepresented and unknown by the American population. Punjabi
Sikhs have resided in the United States for over 100 years, yet many Americans report
little to no awareness of them. A survey conducted by the National Sikh Campaign
reported findings that indicated 60% of Americans admitted to not being aware of who
Punjabi Sikhs were (National Sikh Campaign, 2015). Lack of awareness of the Punjabi
Sikh community has led underrepresentation in nutrition research and the limited
availability of culturally tailored educational interventions to promote health and prevent
disease (Sikh Coalition, n.d.).
The Sikh Religion. Sikhism is the fifth largest religion in the world with the most
followers being of Punjabi descent (Ranganath, n.d.; N.-G. K. Singh, 2011). Sikhism was
founded in 1469 by Guru Nanak Dev Ji in the Punjab region (N.-G. K. Singh, 2011). The
41
teachings of Guru Nanak Dev Ji and his successors are all written in Gurmukhi script
which is the standard written form of the Punjabi language (Ranganath, n.d.). According
to the Jakobsh (2012), Sikhism is a monotheistic religion believing one true creator with
three core principles:
• To remember the creator with every breath.
• To work hard and provide truthful selfless service to the broader community.
• To share your wealth, resources, and blessing with those in need.
A significant component of the Sikh religion is the concept of, “sarbat da bhala”
which translates to the collective well-being of all and fostering unity through strong
community (N.-G. K. Singh, 2011). Deeply rooted in the Sikh belief of collectivism,
equality, humility, and inclusion of all human beings. A Sikh tradition that reinforces,
“sarbat da bhala” is the practice of ‘langar” in other words communal kitchen (N.-G. K.
Singh, 2011). Sikhs have been serving free food in all their places of worships for over
500 years, ensuring all humans regardless of socioeconomic status, religion, or caste are
fed equally (Jakobsh, 2012). The historical merging of the Punjabi identity and Sikh
religion has created an immensely strong and resilient community of Punjabi Sikhs
worldwide, which is important to consider when culturally adapting relevant educational
materials.
The Language of Punjab. The official language of Punjab is in fact Punjabi
which is a modern Indo-Aryan language (Bhatia, 1993; P. Singh, 2019). Punjabi is also
one of the most spoken languages in the world (Sikh Coalition, n.d.). Although Punjabi is
written in multiple scripts, Gurmukhi was standardized and established by one of the Sikh
42
Gurus in Punjab during the 16th century (Jakobsh, 2012). According to the 2019 U.S.
Census Bureau a reported 322,446 speak Punjabi and the largest population of Punjabi
speakers is in California due to its dense population of Punjabi Sikhs, underscoring the
need to include Punjabi when translating nutrition education materials like MyPlate
(Dietrich & Hernandez, 2022; Gibson, 1988).
Punjabi Food and Diet. Hosking (2006) describes the Punjabi cuisine as
“simple, robust, and closely linked to land” (p. 394). The Punjabi diet is heavily
influenced by years of the regional farming and agricultural traditions in Punjab
(Mooney, 2011). Staple foods include whole wheat roti, lentils & legumes, seasonal
vegetables, and full fat dairy products such as milk, ghee, curd, and buttermilk (Hosking,
2006). In addition to these foods, an array of spices is used to enhance flavor and to help
with overall wellness in the Punjabi diet (Sandhu & Heinrich, 2005). Historical
agricultural traditions required Punjabi farmers to spend long hours in their fields, thus
needing high energy foods (Mooney, 2011). The calorically dense profiles of dairy
products and abundance became an integral part of the Punjabi identity (Hosking, 2006).
While westernization and globalization of foods have altered the diets of Punjabi Sikhs
around the world, many older generations have kept their cultural food patterns intact (G.
E. Chapman et al., 2011). However, over the years migration, transnational Punjab
communities, historical marginalization, dietary acculturation, sedentary lifestyles, and
less labor-intensive occupations, has contributed to the increase in chronic diseases
among Punjabi Sikhs (G. Chapman et al., 2006; G. E. Chapman et al., 2011; Chauhan,
43
2021, 2023; Fernandez Perez et al., 2022; Galdas et al., 2012; Gidwani et al., 2021; Kaur,
2014).
Health Issues. Despite the vast differences among Asian Americans, researchers
have aggregated Asians into one racial group, resulting in limited data being available on
health disparities among smaller subgroups like Punjabi-Sikhs (Yom & Lor, 2022). The
Punjabi-Sikh community is significantly underrepresented in research literature and
acquired health information is from broad studies with Asian Indians. While there is
limited recruitment of Punjabi Sikhs in studies, there is enough data overall supporting
the disproportionate risk of diabetes, heart disease, overweight/obesity in Asian Indians
and South Asians (Fernandez Perez et al., 2022; Hastings et al., 2015). However, the few
studies that have assessed health risks in the Punjabi community have observed a high
prevalence of type 2 diabetes, mental health challenges, hypertension, and heart disease.
These studies found these health issues to be significantly influenced by low health
literacy, cultural and language barriers, physical inactivity, acculturation, and migration-
related challenges (Chauhan, 2021; Galdas et al., 2012; Kaur, 2014; Mann, 2023;
Nadimpalli et al., 2016; Roberts et al., 2016). These studies have all further supported the
need for culturally appropriate interventions to target these health issues.
Health Interventions for Punjabi Sikhs. Furthermore, only a few notable
studies have successfully implemented effective culturally adapted health interventions
for the Punjabi Sikh community. For instance, a quasi-experimental study that culturally
adapted a Diabetes Prevention Program (DPP) that was pilot tested in the Sikh
community of New York City, found significant improvements in knowledge, glucose
44
levels, weight, and BMI among the treatment group post intervention (Islam et al., 2014).
The intervention demonstrated feasibility, acceptability, and efficacy in the Sikh
community. To further build upon these findings and test the efficacy of the culturally
adapted DPP, another quasi-experimental study was conducted by Lim et al. (2019),
however this time participants were randomly allocated to intervention groups upon site.
Aligning with the pilot study Islam et al. (2014) findings from this study further
strengthened the effectiveness of the culturally adapted DPP by resulting in positive and
significant changes in the treatment groups weight, BMI, physical activity, self-efficacy,
and barriers to heathy eating compared to the control group.
Similarly, a study conducted by Gill (2022), that also implemented a culturally
tailored diabetes prevention and management education intervention among a group of
older adult Punjabi Sikhs in northern California resulted in increased knowledge post
intervention. Participants also shared appreciation for the culturally relevant education
due to having barriers to understanding previously received diabetes education.
Moreover, a community based participatory research study that culturally tailored an oral
health program called Sikh American Families Oral Health Promotion Programs, found
statistically significant improvements in brushing/flossing behaviors, self-efficacy,
healthy eating, physical activity, and all participants expressed satisfaction with the
programs content. Although there are only a handful studies that have developed health
and nutrition interventions for the Punjabi Sikh community, findings have been important
in understanding the effectiveness of culturally adapted interventions. Evidence from
these studies suggests that culturally adapted interventions can be effective in promoting
45
behavior change and physiological measures in the Punjabi Sikh community. Considering
MyPlate awareness and usage is significantly low in racial and ethnic communities, it
further implies the need to culturally adapt the USDA MyPlate for the Punjabi Sikh
heritage community (Wambogo et al., 2022).
Conclusion
In conclusion, this literature review has examined the prevalence of chronic
diseases impacting the lives of millions of Americans and significantly imposing an
economic burden (Benavidez et al., 2024; Tikkanen & Abrams, 2020). A brief list of
behavioral risk factors and several social determinants of health have played an integral
role in exacerbating chronic conditions especially for marginalized communities (Hacker,
2024). Healthy dietary changes have been shown to be effective in preventing and
managing chronic diseases (Taylor et al., 2024). Although federal government resources
such as the Dietary Guidelines for Americans and tools like MyPlate can support dietary
change and promote positive biomarkers, they have failed to resonate with marginalized
racial and ethnic communities (Wambogo et al., 2022). Cultural and language barriers
have been reported by several diverse ethnic groups (Garcia et al., 2022). By applying the
Self-Determination Theory, it has given insight on ways to improve MyPlate adherence
among marginalized groups and has emphasized the need to use the cultural adaptation
process (Deci & Ryan, 1985; Ryan & Deci, 2000).
Considering the limited availability of culturally relevant MyPlate content and
underrepresentation of ethnic subgroups this study will focus on the Punjab Sikh
community. Asian Indian subgroups are at a higher risk for developing chronic diseases
46
such as diabetes and heart disease, thus it is imperative for the community to receive
personalized education material to prevent illness (Gidwani et al., 2021). As of now there
is no formal Punjabi translation or cultural adaptation of MyPlate provided by the federal
government. This study aims to develop a culturally adapted MyPlate visual tool for the
Punjabi Sikh Heritage community of Greater Sacramento area. The objectives of this
research are to assess Punjabi Sikhs barriers to utilizing the USDA's MyPlate through
quantitative data collection; to design a culturally adapted MyPlate visual tool
incorporating the communities' needs and food preferences; and to field test the culturally
adapted material for acceptability, through qualitative data collection with the target
audience. Addressing this gap is imperative for developing equitable interventions for all
Americans to promote health, prevent chronic disease, and increase economic stability.
47
Chapter 3: Methods
This study employed a mixed methods research design consisting of two phases: a
quantitative phase followed by a qualitative phase. The goal was to develop a culturally
adapted MyPlate visual tool for the Punjabi Sikh Heritage community of Greater
Sacramento area. As reviewed in the previous chapter, the Punjabi Sikh community is an
ethnic subgroup of Indian descent underrepresented in research and currently there is no
formal cultural or linguistic adaptation of the USDA MyPlate tool for this community
(Yom & Lor, 2022). Considering the Punjabi Sikh population is at a higher risk for diet-
related chronic diseases, this study was conducted to create a culturally relevant nutrition
tool to promote health and prevent chronic disease for this community (G. Chapman et
al., 2006; Chauhan, 2021, 2023; Fernandez Perez et al., 2022; Galdas et al., 2012;
Gidwani et al., 2021; Kaur, 2014).
The phases were informed by the proposed stages for the cultural adaptation
process of evidence-based interventions by Barrera et al. (2013). Data collection methods
were driven by the constructs of the Self-Determination Theory (SDT). Quantitative data
was collected through a theory-based survey assessing barriers to MyPlate utilization in
the Punjabi Sikh community. Then survey outcomes were analyzed to identify key
barriers to adherence and areas of modifications needed for MyPlate. The results from
Phase 1 informed the initial design of a culturally adapted MyPlate visual tool and
qualitative feedback was collected through iterative semi-structured interviews to refine
and finalize the tool. Figure 5 is a flowchart providing a visual representation of the study
design and steps taken in a sequential order to meet the studies goals and objectives.
48
Research Objectives
• To assess Punjabi Sikhs barriers to utilizing the USDA's MyPlate through
quantitative data collection.
• To design a culturally adapted MyPlate visual tool incorporating the communities'
needs and food preferences.
• To field test the culturally adapted material for acceptability, through qualitative
data collection with the target audience.
Figure 5
Two-Phase Mixed-Methods Research Design to Culturally Adapt MyPlate for the Punjabi Sikh
Community Based on The Cultural Adaptation Process of Evidence-Based Interventions
Note. The research design was based on the first two stages of the cultural adaptation process
from “Cultural Adaptations of Behavioral Health Interventions: A Progress Report,” by M.
Barrera, F. G. Castro, L. A. Strycker, & D. J. Toobert, 2013, Journal of Consulting and Clinical
Psychology, 81(2), 196–205. https://doi.org/10.1037/a0027085
49
Stages of Cultural Adaptation of Evidence-Based Interventions
According to a comprehensive report conducted by Barrera et al. (2013) the
cultural adaptation process of evidence-based interventions involves five stages, which
have been implemented in various influential sources of literature. These stages have
been identified as stage one: information gathering, stage two: preliminary adaptation
design, stage three: preliminary adaptation tests, stage four: adaptation refinement, and
stage five: cultural adaptation trials (Barrera et al., 2013). In this study, adaptation
activities presented by Barrera et al. (2013) from the first two initial stages of the cultural
adaption process were selected to develop a culturally adapted USDA MyPlate visual tool
for the Punjabi Sikh community. The implementation of the other stages will be
discussed in the last chapter while elaborating on future research directions. Table 1
displays the first two stages of the cultural adaptation process by Barrera et al. (2013),
and what actions were taken in the current study to ensure adherence to recommended
stages.
50
Table 1
Stages Utilized in the Cultural Adaptation Process of the USDA MyPlate for the Punjabi Sikh
Community
Stages
Possible Adaptation Activities
Recommended by
Action Taken in Current Study
Stage One
Information Gathering
Conduct quantitative surveys
to assess the needs and
intervention preferences of
potential subcultural group
participants.
Phase One: A theory-based
quantitative survey was
administered assessing perceived
barriers, awareness, competence,
comprehension, cultural food and
language preferences, and needs
in relation to the USDA MyPlate.
Stage Two
Preliminary Adaptation
Integrate the input of relevant
stakeholders (potential
participants, program
developers, agency staff) into
draft treatment adaptation.
Phase Two: Results from the
participant quantitative survey
(e.g., language and food
preferences) were integrated into
the drafted culturally adapted
MyPlate visual.
Translate and back-translate
materials from original
language into language
appropriate for subcultural
group.
Phase Two: Dietary messaging
on drafted material was translated
into Punjabi and reviewed by
native Punjabi speakers.
Conduct qualitative research
to gather opinions from
potential participants and
community experts on draft
materials and descriptions of
intervention activities.
Phase Two: Qualitative data was
collected from participants
through iterative semi-structured,
one-on-one interviews to gain
feedback on drafted materials.
The interview questions were
theory-based.
Note. Selected stages are from “Cultural Adaptations of Behavioral Health Interventions: A
Progress Report,” by M. Barrera, F. G. Castro, L. A. Strycker, & D. J. Toobert, 2013, Journal of
Consulting and Clinical Psychology, 81(2), 196–205. https://doi.org/10.1037/a0027085.
51
Theoretical Framework
There is substantial data supporting that theory-driven nutrition education and
interventions are more effective in influencing long term adherence to healthy eating
patterns (Contento & Koch, 2020; Lo Dato et al., 2024). To strengthen the adaptation
activities and gain a deeper understanding of motivating factors, the integration of a
behavior change theoretical framework was incorporated in both phases of this study. In
addition, Barrera et al. (2013) also advised utilizing a theoretical approach to address
factors that justify the need for cultural adaptation for a specific subgroup and to identify
elements that should be modified to meet those needs. In the previous chapter, the SDT
was introduced, and its constructs were used to explain the potential causes of barriers to
MyPlate usage in racial and ethnic communities (Deci & Ryan, 1985; Ryan & Deci,
2000).
The application of the SDT framework suggested that MyPlate’s lack of cultural
inclusivity is potentially hindering motivation for adherence due to lower autonomy,
competence, and relatedness in racial and ethnic groups. Accounting for these
conclusions, the current study used the SDT constructs in Phase 1 to develop questions
for the quantitative survey based on autonomy, competence, and relatedness to MyPlate,
which are discussed later in this chapter. As shown in Table 2, in Phase 2, the SDT
constructs were used to guide interview questions, gathering feedback for the preliminary
adaptation design of MyPlate. The development process of the assessment tools will be
discussed in further detail in the following sections.
52
Study Setting
The Punjabi Sikh population of the Greater Sacramento region was selected for
this study and this community tends to congregate weekly for spirituality, social support,
and langar (community meal) at local gurdwaras, also referred to as Sikh temples (Sikh
Coalition, n.d.). Considering Sikh temples are a central part of the Punjabi Sikh
community, and many members attend weekly congregates, research was conducted at
the American Sikh Foundation Sikh Temple, located in Roseville, California. Verbal
consent and permission was obtained from the Sikh Temple Committee. A formal
permission letter requesting to utilize the site to conduct this study was sent via email,
and a copy of this letter can be viewed in Appendix A. Data collection for Phase 1 and
Phase 2 was implemented at the same location.
Participant Recruitment
Convenience sampling was used to recruit participants during the weekly
congregational meetings at the Sikh Temple. In comparison to other sampling techniques
this method was adopted because it was culturally sensitive and respectful of the religious
setting. In the Sikh religion, places of worship are open for all individuals who seek
shelter, comfort, and food through the institution of langar (Sikh Coalition, n.d.).
Therefore, specific eligibility criteria were implemented to ensure the sample consisted of
only the intended target population of Punjabi Sikh immigrants. Moreover,
acknowledging that less acculturated Punjabi groups may encounter more difficulty in
adhering to interventions like MyPlate, the eligibility criteria allowed for the study to
clearly focus on the unique experiences of Punjabi Sikh immigrants, which may differ
53
from native-born individuals. The following eligibility criteria was used to prescreen
potential participants in both phases of the study.
Inclusion Criteria:
1. Ages 18-65.
2. Must be able speak and comprehend Punjabi or English.
3. Must be a Punjab-Sikh immigrant.
4. Consent to quantitative survey/qualitative interview.
Exclusion Criteria:
1. Individuals under 18 years of age.
2. Participants unable to speak either Punjabi or English language.
3. Non-Punjabi Sikh individuals.
4. Punjabi Sikhs who are native-born and raised in the United States.
Ethical Considerations
Prior to conducting research this study was reviewed and approved by the
California State University, Sacramento’s Institutional Review Board (IRB) under
approval number Cayuse-23-24-336. Signing consent forms is not a norm in the Punjabi
culture, and the research presented no more than minimal risk, thus verbal consent was
obtained during each phase. The consent process consisted of each participant receiving a
detailed verbal explanation of the study’s purpose, procedures, risks, and benefits with
the option of Punjabi or English translations. The informed consent was also printed and
displayed at the recruitment table for participants to read on their own. A copy of the
informed consent form can be viewed in Appendix B. The primary researcher ensured
54
each participant was aware of the voluntary nature of the study and their right to
withdraw at any point. To protect the participants privacy, all data was collected
anonymously, and no personally identifiable information was recorded other than basic
demographics: age, gender, residence, and education level.
Measurement Tools
Phase 1: Quantitative Survey
The first stage in the cultural adaptation process of evidence-based interventions
is information gathering and, the recommended action to complete this step is to
administer quantitative surveys and assess the needs of the selected cultural group
(Barrera et al., 2013). Following this stage, a needs assessment was conducted by
administering a quantitative survey to eligible Punjabi Sikhs at the Sikh Temple to further
understand barriers to adherence to the original MyPlate visual. The purpose of this
survey was to identify potential cultural barriers in the current MyPlate visual for the
Punjabi Sikh community, informing the design of the preliminary adaptation of MyPlate
in Phase 2. The survey questions were aligned with the core constructs of the SDT
framework, focusing on autonomy, competence, and relatedness (Deci & Ryan, 1985).
Survey Content. The survey consisted of 14 multiple choice questions and one
open-ended question. Many of the question were based on previously assessed barriers to
MyPlate adherence in studies among racial and ethnic groups, such as low awareness,
low comprehension, language barriers, perceived low confidence levels, and cultural
irrelevancy (Garcia et al., 2022; McCarthy et al., 2023; McCullough et al., 2022;
Wambogo et al., 2022). Some of the questions were adapted from a quantitative survey
55
that was previously utilized in a research study that assessed to MyPlate utilization in
low-income Asian Americans (Garcia et al., 2022). Permission to use the questions was
obtained from the corresponding author via email.
To understand the characteristics of the recruited sample, the first four questions
assessed demographics: age, gender, residence, and education level. Major variables
assessed in the survey included: perceived competence to make healthy meals, MyPlate
awareness and adherence, perceived barriers to healthy eating, meal-serving style, food
and language preferences, food frequency, MyPlate comprehension, and suggestions to
make MyPlate easier to comprehend. Each question was informed by the constructs of
the SDT, and many of the questions addressed more than one construct. The food
frequency questionnaire was based on commonly consumed foods in the Punjabi diet (G.
E. Chapman et al., 2011; Hosking, 2006, p.394).
For example, a question displaying the MyPlate icon shown in Figure 6 and
asking participants, “Do you make your meals as shown in the picture above?”, was used
to assess behavioral adherence to MyPlate. This question aligned with the SDT constructs
autonomy and competence. The response options, “Yes,” “No,” “Maybe, I am not sure,”
and “I do not understand the image,” allowed participants to express their ability to
follow the MyPlate visual and if they preferred to make meals in correlation with the
MyPlate visual. Competence was assessed by measuring the participants perceived ability
to use MyPlate and autonomy was measured by their choice to adhere to it. Similarly, the
question, “How do you normally eat your meals?” also addressed two constructs of the
SDT (Garcia et al., 2022). This question aligned with the construct’s autonomy and
56
relatedness. Response options included, “On a plate,” “In a bowl,” “Family style,” “In a
plate and bowl combination,” or “Other” (with a fill in option). This question was related
to autonomy by assessing the participants' preference or choice on how they eat their
meals, while also measuring relatedness, as in cultural and social norms (e.g., communal
eating) that influence their meal settings.
Figure 6
MyPlate Visual Graphic
Note. From, MyPlate Graphics, by U.S. Department of Agriculture and Department of
Health and Human Services, n.d. MyPlate ( https://www.myplate.gov/)
The survey also included a question where both the MyPlate visual (Figure 6) and
a culturally adapted healthy plate (Figure 7) for the Pakistani community from a
previously conducted study were shown simultaneously (Mohamed-Bibi et al., 2022).
Participants were asked, “The two pictures presented below (A & B) show you what a
healthy and balanced plate looks like. Which picture do you understand more? Please
select one.” The response options included, “Picture A (MyPlate),” “Picture B (Culturally
57
Adapted Healthy Plate),” “None of the above,” or “All of the above.” By asking the
participants which image they comprehended more, the question tapped into the
constructs of competence and relatedness. Displaying an image of a culturally relevant
plate, showing traditional foods, allowed participants to identify which visual they
connected to more. For more details, the full survey may be viewed in Appendix C.
Figure 7
An Example of a Cultural and Linguistic Adaptation of Harvard’s Healthy Eating
Plate for Pakistani Women in Catalonia
Note. This image is from "Design of Culturally and Linguistically Tailored
Nutrition Education Materials to Promote Healthy Eating Habits among Pakistani
Women Participating in the PakCat Program in Catalonia," by S. Mohamed-Bibi,
C. Vaqué-Crusellas, and N. Alonso-Pedrol, 2022, Nutrients, 14(24),
5239. https://doi.org/10.3390/nu14245239.
58
Survey Development. The survey was developed using Qualtrics, a user-friendly
online software program that is widely utilized in research to collect and analyze data
(Qualtrics, 2025). The survey was intended to be in a digital format using a barcode link
to distribute the survey questionnaire. However, the researcher also had printed surveys
for any participant who preferred a paper survey. In addition, participants had the option
to take the survey in Punjabi or English. To accommodate and ensure accessibility to the
target population with limited English proficiency, the survey was translated into Punjabi
by the researcher, who is a fluent native speaker of the language. To further verify
translation accuracy and appropriateness, it was reviewed by a Sikh Temple Committee
member, who was a fluent native Punjabi speaker. Lastly, the survey content was
reviewed by the research committee members. Prior to publishing the surveys, they were
pilot tested with two community members for clarity, comprehension, and relevancy.
Phase 2: Qualitative Semi-Structure Interviews
The second stage of the cultural adaptation process is preliminary adaptation
design in other words it is the drafting of a modified intervention integrating the cultural
needs of the subgroup recruited in stage one (Barrera et al., 2013). In addition, another
part of this stage is to gather qualitative feedback from the target population on the
drafted materials to ensure the adaptations aligns with the communities’ cultural norms,
values, and practices. Acknowledging this stage, semi-structured interviews were
conducted with eligible Punjabi Sikhs at the Sikh Temple to gain feedback on the initial
draft of a culturally adapted MyPlate visual tool. Barrera et al. (2013) explains the
cultural adaptation process to be collaborative and iterative, thus the purpose of
59
conducting interviews was to engage the Punjabi Sikh community in developing a useful
tool relevant to them. The interviews followed a semi-structured guide, and the questions
were based on the constructs of the SDT framework, exploring autonomy, competence,
and relatedness (Deci & Ryan, 1985; Ryan & Deci, 2000).
Interview Questions. The interview questions were a combination of open ended
and close ended questions. Participants were asked a total of nine questions, focusing on
language preference, visual appeal, linguistic clarity, linguistic appropriateness,
identifying missing elements, perceived confidence, cultural relevance, suggestions for
improvement, and ease of use. Many of the questions were structured around autonomy,
competence, and relatedness to the drafted materials. For example, one of the interview
questions was, “Does this visual tool represent your cultural values and traditions in a
way that feels authentic to you?” This question was based on the construct of relatedness
from the SDT. It measured whether the drafted visual material resonated with the
participant by creating a sense connection with their cultural identity and social norms. In
Table 2, more sample questions related to the constructs of SDT are presented. For a
complete list of interview questions please refer to Appendix D.
60
Table 2
Phase 2: Sample of Theory Based Qualitative Interview Questions Utilized to Acquire
Feedback from Punjabi Sikh Participants on the Initial Cultural Adaptation of MyPlate
Question
Sample Interview Questions
Theoretical Constructs of
Self-Determination
Theory
4
Does the food shown in the visual tool
reflect your personal preferences or
choices for meals?
Autonomy
5
On a scale from 1 to 5 (5 being very
confident vs 1 being not very
confident) how confident do you feel
using this tool to create balanced
meals?
Competence
6
Does this visual tool represent your
cultural values and traditions in a way
that feels authentic to you?
Relatedness
Note. This table presents a sample of questions from the interview that were based on the
Self Determination Theory (Ryan & Deci, 2000). Probing questions are not included in
the presented table. The theoretical constructs autonomy, competence, and relatedness are
aligned with corresponding questions.
Data Analysis
Phase 1: Quantitative Data Analysis
All quantitative data collected from the survey was analyzed using descriptive
statistics in the Microsoft Excel (Version 16.87) software program. The availability of
surveys in both English and Punjabi, resulted in collecting two separate datasets. Prior to
combining the datasets using Excel, the Punjabi language survey responses were coded in
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Qualtrics to ease merging with accuracy. For categorical variables (e.g., awareness of
MyPlate), frequencies and percentages were calculated to understand the distribution of
responses. The open-ended question responses were not included in the analysis but were
reviewed to guide the selection of meal combinations for Phase 2. Furthermore, charts
were generated using Excel’s Pivot Chart feature to provide visual representations of the
results. Results were further evaluated through the lens of the SDT framework, focusing
on factors influencing the participants autonomy, competence, and relatedness to
MyPlate. Findings from the quantitative survey were then used to further guide the next
stage in cultural adaptation process in Phase 2.
Phase 2: Qualitative Data Analysis
All qualitative data collected from the semi-structured interviews were analyzed
through an iterative process to identify areas of the culturally adapted MyPlate visual tool
that needed revisions. Modifications were implemented prior to conducting each set of
interviews, ensuring the next participants would review an updated version. Interview
responses and modification details were recorded in an Excel spreadsheet to maintain
documentation of all changes. This analysis technique was adopted from a study by Díaz
Rios et al. (2023), where researchers described the successful cross-cultural adaptation of
a self-assessment tool for food-related parenting practices with young children, for
Spanish speakers. Díaz Rios et al. (2023) utilized an iterative process to implement item
modifications to text and accompanying visuals, based on feedback from experts and the
target audience by conducting cognitive interviews. This process was also adopted in this
current study because it mirrored the cultural adaptation framework proposed by Barrera
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et al. (2013), emphasizing that adaptations are comprehensive, collaborative, and an
iterative process. The continuous integration of feedback from the target audience moved
the adaptation closer to being culturally appropriate. Additionally, this allowed the
participants to engage in the development process fostering a cultural connection to the
adapted tool.
Procedure
Before implementing the research study, approval from the California State
University Sacramento’s IRB was acquired on August 13th, 2024. Then a letter outlining
the study’s details and requesting approval for conducting research onsite was sent to a
local Sikh Temple. The Sikh Temple committee provided verbal consent in late August
2024 to proceed with the research and requested to review the content of the survey prior
to administration. Both the English survey and Punjabi survey were reviewed by a
committee member for appropriateness. Additionally, the accuracy of Punjabi
translations was verified by native Punjabi speaking committee members. Then the
surveys were pretested with a group of English-speaking and native Punjabi-speaking
community members for clarity and comprehension of questions.
Phase 1
From late August to November 2024, quantitative data was gathered in person
from a convenience sample of Punjabi Sikh adults who attended the weekly
congregational meeting at the American Sikh Foundation Sikh Temple, located in
Roseville. A table was strategically set up on Sundays from 11:00 AM to 1:00 PM, next
to the entrance of the langar hall (communal kitchen), a space designated for attendees to
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engage in a community meal and outreach activities. Although the tabling was intended
to occur every Sunday, data collection was not performed on some Sundays, due to
scheduling conflicts. Interested attendees approached the table and were prescreened with
eligibility criteria requirements. Eligible participants were given a full explanation of the
studies details and their right to withdraw at any time. The informed consent form was
also displayed on the table for potential participants to read on their own. Once
participants gave verbal informed consent, they were provided the option to take the
survey electronically on the researchers iPad or their personal device in their preferred
language (English or Punjabi). Barcodes linking to both survey questionnaires were
visibly displayed on the table. Participants that required assistance with reading or digital
navigations of the survey, were supported by the researcher, who verbally administered
the questions in their preferred language (English or Punjabi). Most participants
requested to take a picture of the survey barcode to complete in their own time. Each
survey took about 5 to15 minutes to complete. After enough participants completed the
survey, the barcode link was closed.
All quantitative data collected was securely stored in a Qualtrics account, which
has a unique login and passcode. Survey responses were recorded in two separate datasets
(English and Punjabi), thus identical variable coding was performed in Qualtrics. The
datasets were then exported from Qualtrics into Microsoft Excel to merge and conduct a
further analysis. The combined dataset underwent a cleaning, which consisted of
removing irrelevant information (e.g., location latitude), unanswered questions, and
addressing coding errors. Once all the data was cleaned, descriptive analyses was
64
conducted calculating percentages and frequencies of responses for each question. In
addition, charts were generated in Excel to analyze a visual representation of quantitative
data. An initial review of measurement variables such as perceived competence level for
healthy eating, MyPlate awareness & adherence, perceived barriers to healthy eating,
meal-serving style, preferred language, food frequency, food preferences, MyPlate
comprehension, and suggested enhancements for MyPlate was conducted and key
barriers were identified. Then data outcomes were further interpreted through the lens of
the SDT framework. All the findings were compiled to inform the next phase of the
study.
Phase 2
The second phase focused on the integration of outcomes from quantitative data
collected in Phase 1, to design a draft of the culturally adapted MyPlate visual tool for the
Punjabi Sikh community. Key findings influencing the constructs of the SDT framework
were incorporated in the preliminary design of the adapted visual tool. The first step in
the design development process consisted of identifying foods commonly consumed by
the Punjabi Sikh community from the quantitative data collected and from previous
literature. Once the foods were identified, digital photographs were taken of culturally
appropriate meals meeting the MyPlate recommendations. Tips from Chang et al. (2017)
were followed to create impactful and visually appealing colorful images of meals.
Strategies to implement effective photography included pre planning meal concepts,
lighting, composing, and styling (Chang et al., 2017). A series of photos were taken at a
local Indian restaurant, after obtaining verbal consent to use facility food, and kitchen
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equipment. Meals were made in the kitchen and then plated according to MyPlate’s
recommended portions sizes and food groups. The photographs were used to create an
initial draft of the culturally adapted MyPlate visual tool using Adobe Express. The
drafted tool incorporated visuals customizing MyPlate for the Punjabi Sikh community
with concrete images of real food. Clear and culturally appropriate nutritional messaging
accompanied each visual and additional information was provided on the reverse side,
highlighting culturally relevant sources for each food group (fruits, vegetable, grains,
protein, and dairy). Once the initial draft was designed, qualitative data collection was
implemented.
In March 2025, qualitative data was gathered through semi-structured one-on-one
interviews from a convenience sample of Punjabi Sikh adults who attended the weekly
congregational meeting at the same Sikh Temple. The sample recruitment process from
Phase 1 was implemented by prescreening interested participants. Eligible attendees who
provided informed verbal consent were offered the option to be interviewed in English or
Punjabi. Participants were asked a series of interview questions in relation to the
culturally adapted MyPlate visual tool. The visuals were displayed on a laptop screen for
attendees to observe and critique. The feedback was electronically recorded in a
Microsoft Excel spreadsheet. Following the iterative data analysis process, prior to the
second round of interviews, the culturally adapted visuals were modified according to
collected feedback in round one interviews. The second round of participants were asked
the same series of interview questions, however, were subjected to the adaptation design
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with updated modifications. Qualitative feedback acquired from round two facilitated the
final changes to the culturally adapted MyPlate visual tool.
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Chapter 4: Results
This study aimed to develop a culturally adapted MyPlate visual tool for the
Punjabi Sikh community of Greater Sacramento area. Research was conducted in two
phases: a quantitative phase assessing barriers to MyPlate adherence followed by a
qualitative phase to design and develop a finalized visual tool. In this chapter the results
are presented and organized by each phase. First, the results from the quantitative phase
will be presented, which includes conducting a descriptive analysis of key variables.
Then the findings from the qualitative phase will be shared, focusing on the iterative
feedback and the finalized version of the culturally adapted MyPlate visual.
Phase 1: Quantitative Survey Results
Participant Demographic Characteristics
A total of 36 Punjabi Sikh adult participants completed the quantitative survey.
All surveys were completed on the digital platform Qualtrics, and no participant
requested a paper survey. Twenty-one participants completed the survey in Punjabi and
15 participants completed the survey in English. The ages of the sample varied between
25 to 34 years (28%), followed by 45 to 54 years (25%), 35 to 44 years (22%), 55 to 64
years (22%), and a smaller proportion of 18-24 years. In relation to gender, the sample
size was predominantly made up of females (56%). In terms of education level, a
significant proportion of the sample were high school graduates or equivalent (31%) or
college undergraduates (25%) (Table 3).
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Table 3
Phase 1: Demographic Characteristics of Punjabi Sikh Participants for the Quantitative
Survey: Age, Gender, Education Level (N=36)
Demographics
n
Percentage %
Age
18 to 24
1
3
25 to 34
10
28
35 to 44
8
22
45 to 54
9
25
55 to 64
8
22
Gender
Female
20
56
Male
16
44
Education
Less than high school
3
8
High school or equivalent
11
31
Some college, no degree
7
19
Undergraduate degree
9
25
Postgraduate degree
6
17
Note. Percentages may not add up to 100% due to rounding.
Descriptive Statistics of Key Variables
This section will present the descriptive statistics of the key variables assessed in
the quantitative survey. The variables include perceived competence to make healthy
meals, MyPlate awareness & adherence, perceived barriers to healthy eating, meal-
serving styles, food preference and frequency, language preferences, MyPlate
comprehension and suggestions to make it easier to understand.
Participants were asked how sure they were about making healthy and balanced
meals. Overall, 53% of participants expressed being very sure and 30% reported being
somewhat sure. Moreover, 64% of participants reported being aware of the USDA
MyPlate, while 22% reported not being aware of the visual, and 14% were not sure.
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When participants were asked if they make their own meals according to the MyPlate
visual, 53% reported not following the visual, and 31% indicated following it, while a
few were not sure or did not understand the MyPlate visual. Figure 8 presents the
reported perceived barriers to making healthy and balanced meals. Time was the most
selected barrier by 44% of participants.
Figure 8
Phase 1 Quantitative Survey: Perceived Barriers Reported to Making Healthy and
Balanced Meals by Punjabi Sikh Participants to (N=36)
Note. Percentages indicate proportion of participants who selected each barrier.
Participants had the option to select more than one answer. Percentages have been
rounded up.
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Most participants reported eating their meals in a plate and bowl combination
(53%), while 25% indicated on a plate, and 22% reported in family-style. Furthermore,
64% of participants revealed eating Punjabi food on a daily basis, while 33% expressed
eating it several times a week. Many participants preferred Punjabi (42%) as their
primary language to acquire nutrition and health information, while 31% preferred both
(English & Punjabi), and 28% of participants reported English. Participants were asked to
choose the image they understood more, between the MyPlate graphic versus a plate with
a traditional balanced Pakistani meal, responses indicated 58% of participants understood
both the MyPlate and the culturally adapted visual, however 33% understood only the
culturally adapted visual versus 6% only understood the MyPlate.
Moreover, the responses to the food frequency questionnaire revealed that foods
consumed daily by a considerable proportion of participants consisted of tea (cha) (78%),
vegetables (sabji) (60%), roti (53%), milk (49%), fruits (44%), eggs (36%), and yogurt
(32%). Moreover, foods rated highest in the consumed several times a week category
included lentil & legumes (43%), nuts & seeds (29%) and fruit (28%). The foods that
were reported the most as never consumed were chicken (30%) and tofu/soybeans (19%).
Food frequency responses to all foods can be viewed in Table 4.
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Table 4
Phase 1 Food Frequency Questionnaire Results: Percentage of Punjabi Sikh Participants
by Food Item (N=36)
Food Item
Daily
(%)
Several
Times
Week
(%)
Once A
Week
(%)
Several
Times A
Month
(%)
Once A
Month
(%)
Rarely
(%)
Never
(%)
Beans
3
14
11
28
14
31
0
Cheese
9
11
11
34
17
14
3
Chicken
12
24
6
18
6
3
30
Eggs
36
22
8
6
14
6
8
Fruits
44
28
0
8
8
11
0
Lassi
17
22
0
11
0
36
14
Lentils
9
43
9
20
17
3
0
Milk
49
11
9
3
3
14
11
Nuts/Seeds
20
29
3
20
9
20
0
Paratha
6
6
6
22
17
39
6
Punjabi Snacks
11
9
14
11
20
31
3
Sweets/Desserts
8
8
8
14
17
39
6
Rice
0
19
8
11
22
33
6
Roti
53
39
0
0
3
6
0
Tea
78
8
3
0
0
6
6
Tofu/Soybeans
0
17
14
22
3
25
19
Vegetables
60
34
3
34
3
0
0
Yogurt
32
32
6
3
3
18
6
Note. Percentages represent the proportion of participants selecting each frequency
category for each food item. Percentages have been rounded.
Moreover, as shown in the Figure 9, when participants were asked to select what
changes can be made to MyPlate for it to be easier to understand, 67% selected examples
of culturally relevant foods sources for each food group, 50% reported that there should
be pictures of real Punjabi food, and 44% reported wanting to see pictures of real food in
recommended serving portions. The least selected suggestion for modifying MyPlate was
making words easy and simple to understand on the MyPlate visual, only 14% of
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participants selected this change. As shown in Figure 9, each modification was selected at
least once by participants.
Figure 9
Phase 1 Quantitative Survey: Selected Modifications to Make MyPlate Easier to
Understand by Punjabi Sikh Participants (N=36)
Note. Participants could select more than one option. Percentages represent how many
participants selected the suggested modification. Percentages have been rounded.
Descriptive Statistics by Survey Language. This section will present key
findings after stratifying results by survey language. A total of 21 participants completed
the survey in Punjabi, while 15 participants completed the survey in English. From the
respondents who completed the survey in Punjabi, 76% reported being very sure in their
perceived competence level for making healthy meals compared to the English group, in
which 20% of participants reported being very sure. Moreover, 75% of the Punjabi group
was aware of the USDA MyPlate, in contrast to 52% of participants in the English group
being aware. For adherence to MyPlate, 48% of participants in the Punjabi group
reported following the visual, while 20% reported following it in the English group. In
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the English group 80% of participants reported utilizing a plate & bowl combination to
eat their meals, and 33% of participants in the Punjabi group reported using a plate &
bowl combination. Punjabi food was consumed daily by 86% of participants in the
Punjab group, while only 33% of respondents in the English group reported eating
Punjabi food daily. For the language preference, the Punjabi group mostly preferred
Punjabi (71%) as their primary choice to acquire nutrition and health information, while
the English group mostly preferred English (53%) or both (47%) (English & Punjabi).
Phase 2: Initial Design & Qualitative Interview Results
The initial adaptation design of the MyPlate visual consisted of four double-sided
pages, each depicting four color photographs of traditional Punjabi meals in a plate &
bowl combination. Each image was accompanied with text boxes identifying the food
group and recommended portion size. For example, one of the text boxes read “Make
sure to fill ½ your plate fruits and vegetables.” Additionally, each page had a reverse side
listing culturally relevant sources for each food group. All the visuals were translated into
Punjabi. This initial adaptation was informed by Phase 1 results. Phase 1 findings
identified several barriers to MyPlate adherence for Punjabi Sikh participants, including
conflicting meal serving styles, time, taste, language & food preferences, and the lack of
cultural food representation.
Further stratification of results by survey language highlighted the need to
develop bilingual adaptations of MyPlate, considering Punjabi was preferred by the
Punjabi survey group, while English was preferred by the English survey group. The food
frequency questionnaire and food preference responses revealed that Punjabi food was a
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significant component of the target audience’s diet. As such, it was important to include
visual representation of Punjabi meals. In addition, many participants expressed a desire
to see real images of Punjabi food on the MyPlate visual, hence photographs were taken
of prepared foods plated according to the MyPlate recommendations. Furthermore, many
participants shared time and taste being major barriers to making healthy meals.
Considering this, the meals depicted in the visuals were time efficient and popular
traditional meals. Each depicted meal contained staple food items that were frequently
consumed and typically available in a Punjabi household (roti, rice, lentils, yogurt,
seasonal vegetables, fruits, etc.) (Hosking, 2006). Additionally, the foods were presented
in a plate and bowl combination to reflect meal serving style preferences shared by
several participants.
Participant Demographics
A total of nine Punjabi Sikh adults were interviewed in Phase 2. The ages ranged
between 25 to 65 years with the average age being 45.1 years (M=45.1, SD =13.7). The
sample consisted of 5 females (56%) and 4 males (44%). Five participants were recruited
for the first round of interviews and four were recruited for the second round.
Interview Results: Round 1. In this section, results from the first round of semi-
structured interviews will be presented. Results were analyzed through an iterative
process by incorporating feedback between each round to modify the culturally adapted
MyPlate tool. The interview questions focused on acquiring feedback on language
preference, visual appeal, linguistic clarity & appropriateness, identifying missing
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elements, perceived confidence with tool, cultural relevance, suggestions for
improvement, and ease of use.
In the first round of qualitative data collection, five participants were interviewed.
67% of the participants in round one preferred to review the preliminary adapted design
in Punjabi and 33% preferred English. Participants were asked to rate their confidence
level on a scale from 1 to 5 in using the adapted visual tool to make healthy meals and the
mean score was 3.67 (SD=0.71). The interviews concluded with a question asking the
participants which visual they understood and related to more, between the original
MyPlate visual versus the culturally adapted MyPlate visual. All the participants
responded they would select the culturally adapted MyPlate visual.
Participants provided feedback on visual appeal, linguistics clarity &
appropriateness, cultural relevance, and missing elements or suggestions for
improvement for the adapted tool and what modifications were made after round one. As
shown in Table 5, all participants in round one were satisfied with the visual appeal, and
cultural relevance of the adaptation design for both the English and Punjabi visuals. For
example, when Participant 5 was asked about the cultural relevance and authenticity of
the tool, they shared, “Yes, because this is food that I have ate since I was a kid and
Punjabi food is healthy.” Regarding the linguistics clarity and appropriateness,
Participant 2 stated, “I think the phrase, “make sure” should be removed, it sounds too
forceful and direct, maybe use something more subtle.” Moreover, Participant 1, 2, and 3
all identified that a serving of butter was missing on the visual with a paratha meal. For
instance, Participant 3 stated, “I think there should be butter on the picture with a paratha
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because you have to eat them together.” Another suggestion included a participant
requesting to see additional examples of culturally relevant protein sources.
Table 5
Phase 2, Round One Interviews: Participant Feedback on the Initial Design of the
Culturally Adapted MyPlate Visual Tool for the Punjabi Sikh Community (n=5)
Feedback Category
Participant Feedback
Participant Feedback
Modification
Punjabi Version
English Version
Visual Appeal
All participants
stated the culturally
adapted MyPlate in
Punjabi was visually
appealing.
All participants
stated the culturally
adapted MyPlate
visual in English
was visually
appealing.
No changes were
made.
Linguistic
Clarity/Appropriateness
All participants
stated the Punjabi
translations were
clear and
appropriate.
Participant 2 advised
changing the phrase,
“make sure” to
something less
forceful or direct.
The phrase
“make sure,” was
replaced with
food group
names instead.
Cultural Relevance
All participants
found the visual
culturally authentic
and relevant to their
own preferences.
All participants
found the visual
culturally authentic
and relevant to their
own preferences.
No changes were
made.
Missing
Elements/Suggestions
Participants 1 and 3
suggested adding a
serving of butter on
the visual with
paratha meal.
Participant 2
suggested adding a
serving of butter on
the visual with a
paratha meal.
Participant 2
requested to see
more culturally
relevant protein
sources.
A serving of
butter was added
to the suggested
visual.
Additional
sources of protein
were listed on the
reverse side of
visuals.
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Interview Results: Round 2. In the second round of qualitative data collection,
four participants were interviewed. Two of the participants selected the option to review
the Punjabi version of the culturally adapted tool, while the other two requested the
English version. Participants were asked to rate their perceived level of confidence on a
scale from 1 to 5 in using the adapted visual tool to make healthy meals and all
participants scored themselves a four on the scale. The interviews concluded with a
question asking participants which visual they understood and related to more, between
the original MyPlate visual versus the culturally adapted MyPlate visual. All the
participants responded they would select the culturally adapted MyPlate visual.
Moreover, Table 6 presents feedback from participants on visual appeal,
linguistics clarity and appropriateness, cultural relevance, and missing elements or
suggestions for the adapted tool and it also lists modifications that were made after round
two. As shown in Table 6 participants in round two all found the adapted design
culturally relevant and authentic. One participant provided feedback on the visuals appeal
by stating, “You can maybe emphasize the connection of this tool plate to MyPlate”
(participant 8). When asked about the linguistic clarity of the tool, some participants
suggested reducing the text on the visuals for it to be easier to comprehend, for example,
participant 9 stated, “I think the use of fractions can be reduced and you should use more
simpler phrases similar to the MyPlate visual, to quickly catch the eye.” For missing
elements most participants addressed that there were no visuals with animal-based
protein and suggested adding one.
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Table 6
Phase 2, Round Two Interviews: Participant Feedback on the Initial Design of the
Culturally Adapted MyPlate Visual Tool for the Punjabi Sikh Community (n=4)
Feedback Category
Participant
Feedback
Participant
Feedback
Modification
Punjabi Version
English Version
Visual Appeal
All participants
stated the
culturally adapted
MyPlate in
Punjabi was
visually appealing.
Participant 8
suggested
emphasizing the
connection of
the culturally
adapted MyPlate
to the original
visual.
Color coding was
added to adapted
visuals to mirror the
original MyPlate
visual colors.
Linguistic
Clarity/Appropriateness
All participants
stated the Punjabi
translations were
clear and
appropriate.
Participant 8
and 9 suggested
reducing the text
on the visuals
and using
simpler text like
MyPlate.
Messaging on all
visuals was
simplified to display
less text for easier
comprehension.
Cultural Relevance
All participants
found the visual
culturally
authentic and
relevant to their
own preferences.
All participants
found the visual
culturally
authentic and
relevant to their
own
preferences.
No changes were
made.
Missing
Elements/Suggestions
Participants 6
suggested
including an
animal-based
protein visual.
Participants 8
and 9 suggested
including an
animal-based
protein visual.
A sample meal
consisting of
animal-based
protein was added
to the tool.
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The Final Adaptation
The quantitative survey results and the iterative feedback from one-on-one
interviews led to the development of the Healthy Punjabi Plate. After continuously
incorporating modifications from Table 5 and Table 6, the final tool has five double-sided
pages, featuring five different color photographs of traditional Punjabi meals. Each page
has labeled food groups, which are color coded according to the original MyPlate
categories. The tool has bilingual translations in both English and Punjabi. Additionally,
all pages have a reverse side with culturally relevant food sources listed for grains,
vegetables, fruits, protein, and dairy. Figure 10 illustrates the iterative process involved in
the development of the final tool, starting with the original MyPlate visual, followed by
the initial adaptation and concluding with the final adaptation. To view the full Healthy
Punjabi Plate visual tool in both English and Punjabi please refer to the Appendix E.
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Figure 10
Phase 2: The Iterative Process of Developing a Culturally Adapted MyPlate Visual Tool
for the Punjabi Sikh Community of Greater Sacramento (N=9)
Note. This figure presents the front of all five visuals in the Healthy Punjabi Plate tool
and one of the reverse sides for reference.
Conclusion
In summary, key findings from the quantitative survey data included that 75% of
participants preferred eating their meals in a plate & bowl combination or family style.
Awareness of MyPlate was reported to be high (64%), while adherence was reported to
be low (31%). Many participants preferred to receive their nutrition and health
information in Punjabi (42%), while some preferred both (31%) (English & Punjabi).
Additionally, 64% of participants reported consuming Punjabi food on a daily basis. The
top five frequently consumed foods were tea (cha) (78%), vegetables (sabji) (60%), roti
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(53%), milk (49%), fruits (44%). Many participants suggested including culturally
relevant sources of the different food groups (67%), and 50% of participants reported
wanting to see images of real Punjabi food. Moreover, key findings from the qualitative
interviews involved feedback primarily regarding the linguistic clarity/appropriateness
and missing elements/suggestions for the adaptation design of MyPlate. Overall, all
participants shared the visual was culturally relevant & authentic, and they would prefer
utilizing it as a tool for healthy eating instead of the original MyPlate visual. The
implementation of simpler language, color coding, and the inclusion of an animal-based
protein image, led to the development of a finalized culturally adapted MyPlate visual
tool called the Healthy Punjabi Plate.
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Chapter 5: Discussion and Conclusion
Employing a two-phased mixed-methods design, this research study aimed to
develop a culturally adapted MyPlate visual tool for the Punjabi Sikh community of
Greater Sacramento area. Phase 1 identified barriers to MyPlate adherence through the
administration of a theory-based quantitative survey to 36 Punjabi Sikh adults. Then in
Phase 2 an initial design was drafted of the culturally adapted tool by incorporating the
community’s needs identified in Phase 1. Lastly, the initial design was field tested to gain
feedback and revise the tool by conducting qualitative interviews with 9 Punjabi Sikh
adults.
Phase 1
One of the key barriers identified in adhering to MyPlate in the quantitative phase
included the conflicting meal servings styles. The original MyPlate graphic depicts the
sole use of a plate, while 53% of Punjabi Sikh participants expressed using a plate and
bowl combination to consume their meals. Analyzing this barrier through the Self-
Determination Theory (SDT) framework, it can be interpreted by understanding that if an
individual’s sense of autonomy and relatedness is not met, it can potentially reduce
motivation to engage in the behavior (Ryan & Deci, 2000). In this case Punjabi Sikhs
may feel a lack of autonomy if they cannot plate their meals according to their choice.
Likewise, traditional Punjabi meals are served in separate dishes, thus MyPlate’s sole
plate representation may not reflect the cultural customs of the participants, hindering
their ability to relate to the visual. Another barrier identified was language preference,
42% of participants expressed obtaining their nutrition and health information in the
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Punjabi language, and 31% indicated both English and Punjabi. This barrier can be
explained through the SDT construct of competence, which posits that in order for one to
foster motivation to engage in a behavior they must feel capable or competent to do so
(Ryan & Deci, 2000).
Considering MyPlate is currently not available in Punjabi, it is potentially
preventing adherence among many Punjabi Sikhs with limited English proficiency. This
can be further explained with the fact that 58% of participants also completed the survey
in Punjabi. Moreover, 67% of participants shared wanting to see culturally relevant food
sources for each group to make MyPlate easier to understand and 50% of participants
also shared the desire to see real images of Punjabi food. These suggestions connect to
the SDT construct of relatedness, which explains that an individual needs to feel close to
and understood by significant others to engage in a behavior (Ryan & Deci, 2000).
Therefore, Punjabi Sikh participants may have felt a limited connection with the
traditional MyPlate due to the lack of cultural relevance and expressed the need to
include images of Punjabi foods to enhance the relatedness. This can be further explained
by the fact that 64% of participants also reported consuming Punjabi food daily. These
cultural barriers were also highlighted in the low adherence rate of MyPlate, with only
31% reporting following the MyPlate visual to make their own meals, despite their being
a reported high awareness (64%). These key barriers justified the need to culturally adapt
MyPlate for the Punjabi Sikh community and led to the initial adapted design in Phase 2.
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Transition to Phase 2
Moreover, the purpose of Phase 1 was to determine if the cultural adaptation of
MyPlate was needed and to identify what components might potentially be modified. As
anticipated, significant barriers were assessed in Phase 1 and provided insight to what
factors of MyPlate need to be altered. Considering the results from Phase 1, the initial
adaptation design included real images of Punjabi foods, accompanied with bilingual text
(Punjabi & English), and a list of culturally relevant sources for each food group on the
reverse side. To identify any shortcomings or problematic features of the preliminary
adaptation, qualitative data was collected through iterative semi-structured interviews in
Phase 2.
Phase 2
Furthermore, one of the key findings from the interviews in Phase 2, was that all
participants expressed the adaptation was culturally relevant and authentic to them.
Additionally, every participant selected the adapted MyPlate versus the original, when
asked which one was more useful or easier to relate to. Major revisions that were based
on the feedback from interviews included simplifying text, color coding the food group
labels to align with the MyPlate visual and adding an animal-based protein meal to the
tool. Some participants indicated the text on the visuals needed to be reduced, less
forceful, and simple. When viewing this feedback through the lens of the SDT, it directly
relates to the construct’s autonomy and competence (Ryan & Deci, 2000). For example,
one of the texts on the initial adaptation stated, “Make sure to fill ½ your plate with fruits
and vegetable,” which may have felt forceful and conflicted with the participants sense of
85
choice and control, thus the text was simplified to foster greater autonomy by only
labeling the food group name.
Moreover, the text heavy visual may have felt overwhelming or difficult to
understand affecting the ability to feel competent, hence the text was reduced to simple
phrases (grain, fruit, vegetables, protein, and dairy). Furthermore, another key revision
made to the visuals was the addition of an animal-based protein meal. Although, meat
consumption is not a significant component of the Punjabi diet, many participants
suggested adding a non-vegetarian option to be inclusive of the acculturated individuals
in America. The culmination of collected data resulted in the successful cultural adaption
of MyPlate for the Punjabi Sikh community. The final revisions resulted in the Healthy
Punjabi Plate, a five-page, double-sided visual tool with five color photographs of
traditional Punjabi meals in plates and bowls, accompanied by color coded bilingual text,
and a list of culturally relevant food sources on the reverse side of each page.
This study used a comprehensive and systematic process proposed by Barrera et
al. (2013) to culturally adapt MyPlate for the Punjabi Sikh community. This study
adopted the first two stages in the cultural adaptation process and informed each stage
with the Self Determination Theory. Phase 1 began with stage one (information
gathering), in which a community needs assessment was conducted through a theory-
based quantitative survey to identify cultural barriers in the original MyPlate visual. Then
in Phase 2, stage two (preliminary adaptation design) was conducted by integrating Phase
1 results into the development of the initial draft, translating text to the ethnic groups
preferred language, and then collecting qualitative feedback through theory-based semi-
86
structured interviews to refine the preliminary design. This systematic process was
effective in producing a culturally appropriate tool for the Punjabi Sikh community.
Iterative feedback, continuous collaboration, and engagement with community members
led to a well-received and acceptable product. All (N=9) participants expressed the tool
was culturally relevant & authentic, easy to understand, and visually appealing.
Previous studies that have utilized this framework to culturally adapt interventions
for racial and ethnic subgroups have produced similar findings (Guo et al., 2021; Kuhn et
al., 2020; Ramos & Alegría, 2014). For example, a study that culturally adapted an
evidence-based transition program for Spanish speaking Latino families with youth on
the autism spectrum, found that all participants were either very satisfied or satisfied with
the adapted intervention (Kuhn et al., 2020). Additionally, all Latino participants thought
the intervention was acceptable, accessible, and useful. Moreover, another study that used
the same framework to culturally adapt a United States based visual art training for
Chinese graduate students in nursing, found participants were highly satisfied with a
mean score of 4.5 on a 5-point Likert scale (Guo et al., 2021). All participants also said
they would recommend this intervention to other students in the field.
Furthermore, studies that have used different strategies to design culturally
adapted interventions have also observed high levels of satisfaction among their
participants. For example, in the study by Mohamed-Bibi et al. (2022), researchers used
the Transtheoretical Model to develop a culturally appropriate intervention for Pakistani
women. The participants expressed great appreciation for the culturally relevant nutrition
education that depicted traditional meals with their native language. Similarly, we
87
observed this when Punjabi Sikh participants were shown the adapted design, and all
participants were highly satisfied with the tool’s cultural relevance & authenticity, and
linguistic adequacy. Consistent with previous studies like Garcia et al. (2022) our
findings also reinforce the existing literature indicating racial and ethnic communities
encounter difficulty in adhering to MyPlate due to cultural barriers. For example, the
Garcia et al. (2022) study found that 86.8% of the Asian American participants reported
consuming their meals in family style, a bowl, or in a plate and bowl combination. These
trends were also observed in the current study with 75% of Punjabi Sikhs reporting eating
their meals in family style or a plate & bowl combination. These findings further suggest
that MyPlate’s depiction of a sole plate is not inclusive of diverse cultural customs and
continues to be a barrier for Asian Americans in adherence.
Additionally, 75% of participants in the Garcia et al. (2022) study reported rarely,
never, or sometimes using MyPlate to make their own meals, because it did not align
with their food customs. Similarly, in this study 70% of Punjabi Sikh participants
reported not following the MyPlate visual, not understanding it, or not being sure if they
adhered to it. Research assessing MyPlate usage has consistently shown low adherence
among Americans, especially in marginalized communities and these findings suggest
cultural barriers as a significant influencing factor. Furthermore, in the Wambogo et al.
(2022) study, researchers analyzed participants who only spoke English at home and
were born in the United States were more likely to be aware of MyPlate and utilize it.
Surprisingly, in the current study, awareness of MyPlate was high although all the
participants were Punjabi Sikh immigrants. A total 64% of Punjabi Sikh participants
88
reported awareness of MyPlate; however, only 31% of reported adherence to the MyPlate
visual. In addition, a significant proportion of participants (42%) selected Punjabi as their
only preferred language for communication. While awareness of MyPlate was high
among participants, the low adherence rate was similar to findings from previous studies
(Wambogo et al., 2022).
Strengths and Limitations
Although the findings and the developed tool from this study are important,
several limitations must be addressed. The first limitation was the use of convenience
sampling for both phases of the study limiting external validity. This resulted in small
samples sizes and not being representative of the whole Punjabi Sikh community in the
Greater Sacramento region. Additionally, data was collected only at a Sikh temple,
potentially excluding individuals who do not attend the weekly congregational meeting.
The target audience was specifically Punjabi Sikh immigrants, which limits
generalizability of the results to native born Punjabi Sikhs and other racial/ethnic
communities. Moreover, the researcher’s previous knowledge of the selected community
may have contributed to researcher bias in data interpretation. Data collected in Phase 1
was completed through self-reports, potentially creating space for error and social
desirability bias (Rosenman et al., 2011). Participants were notified of this study's
purpose, prior to engaging in it, thus potentially influencing their responses to be socially
acceptable.
Despite these limitations, this study also had its strengths. To our knowledge, this
study was the first to adapt the MyPlate visual for the Punjabi Sikh community of Greater
89
Sacramento area using a dynamic process. For instance, this study engaged in a
comprehensive data collection method by employing a two-phase mixed-methods
research design where both theory-based quantitative and qualitative data was collected.
The robust data collection process allowed for a deeper understanding of the community's
needs and fostered a collaborative environment yielding a meaningful and comprehensive
tool. An additional strength of this study was the bilingual process of data collection and
tool development. The survey tool was translated into Punjabi to increase accessibility to
participants with limited English proficiency and ensure accuracy in data collection. This
process was elevated from simple direct translations by rigorously evaluating cultural
nuances and appropriate text for non-equivalent translations. Studies have shown
translating assessment tools for ethnic groups can allow participants to fully comprehend
questions, which leads to more accurate and reliable responses (Czerwinski-Alley et al.,
2024). Considering a significant proportion of participants indicated Punjabi as their
preferred language, the Punjabi survey gave many participants the opportunity to engage
in the study and understand the assessment questions. Additionally, the Punjabi
translations were reviewed multiple times by several experts in the community, research
committee, and pilot tested with potential participants, which further increased the
validity of results. Similarly, all text translations on the Healthy Punjabi Plate visuals
underwent the same process, while preserving the original MyPlate visual messaging and
meaning.
90
Implications and Recommendations
Findings from this study add to existing literature suggesting that low adherence
of MyPlate among racial and ethnic communities is potentially due to cultural barriers.
Further implying the need to culturally adapt MyPlate for diverse groups to ensure
effective, accessible, and relevant dissemination of nutrition education. Considering
research evaluating MyPlate in marginalized groups is limited, the cultural and linguistic
barriers assessed in this study provided valuable insights into factors that can potentially
hinder the tools effectiveness. One of the key barriers assessed was that many of the
Punjab Sikh participants preferred to receive nutrition and health information in their
native language, specifically the participants who completed the survey in Punjabi,
emphasizing the need for more multilingual translations of MyPlate. Additionally, many
participants addressed the need to see cultural relevant images of real foods on MyPlate
for easier comprehension, suggesting MyPlate’s lack of visual representation of diverse
cultural eating patterns.
However, the successful cultural adaptation of MyPlate for the Punjabi Sikh
community in this study suggests modifying MyPlate is feasible. It also highlights the
importance of applying a comprehensive systematic process to develop a culturally
appropriate adaptation. By utilizing the cultural adaptation process in this study, it
provided a framework to adequately address what components of MyPlate needed
modifications and how to collect meaningful community feedback to inform the
adaptation. In addition, developing assessment tools based on an evidence-based
theoretical framework was helpful in providing interpretations for specific findings. It is
91
recommended that future research use a similar process when aiming to culturally adapt
MyPlate for other racial and ethnic groups. Moreover, the Healthy Punjabi Plate visual
tool developed in this study can be used to enhance the dissemination of MyPlate
education among Punjabi Sikhs in the Greater Sacramento area. It can be used to provide
nutrition education for community members to prevent or manage chronic conditions.
The tool has a culturally inclusive design with relevant foods and appropriate language
options to further explain how to build healthy meals. Healthcare providers, dietitians,
community health programs, and Sikh temples in the Greater Sacramento area can utilize
this tool to resonate with the Punjabi Sikh community at a deeper level.
Policy Recommendations
Considering racial and ethnic communities are disproportionately affected by
diet-related chronic diseases nationwide, it is imperative for national nutrition education
to be accessible for marginalized communities. The federal government must understand
the vital role culture plays in health outcomes among vulnerable groups. Researching the
complexities of culture and its interconnectedness with chronic diseases among diverse
groups is one step towards creating effective public health interventions. Policymakers
should advocate for more inclusive and equitable public health interventions by urging
policies that allocate funding for the research and development of these tools.
Future Research Directions
However, acknowledging the limitations in this study, there are opportunities to
build upon or improve these findings. The next stages in the Barrera et al. (2013) cultural
adaptation process includes preliminary adaptation tests, adaptation refinement, and
92
cultural adaptation trials. To further strengthen this tool and evaluate its appropriateness,
future research can refer to the next stage in the cultural adaptation process which
includes preliminary adaptation tests, by conducting pilot studies with the target audience
to identify areas for more improvement. Additionally, future research should also focus
on exploring the short-term and long-term impact of the Healthy Punjabi Plate
intervention on dietary behavior and chronic disease prevention with a larger and
representative sample size of the Punjabi Sikh community.
Conclusion
This study aimed to develop a culturally adapted MyPlate tool for the Punjabi
Sikh community in Greater Sacramento area, by using the first two stages of the cultural
adaptation process. This study employed a two-phased mixed-methods research study
informed by the Self-Determination Theory. In the first phase, a theory-based
quantitative survey assessed significant barriers such as meal serving styles, language
preferences, and the lack of culturally relevant foods on the original MyPlate visual.
These findings helped initiate the first version of the adapted MyPlate in Phase 2. Then
iterative feedback from the theory-based semi-structured interviews was used to
continuously revise the tool, eventually leading to the Healthy Punjabi Plate. The final
visual tool presents five double-sided pages, displaying five color photographs of
traditional Punjabi meals in a plate & bowl combination, accompanied with simple
bilingual text in English and Punjabi, and a reverse side listing culturally relevant food
sources for each group. This visual tool is a culturally relevant method to disseminate
MyPlate education to the underrepresented Punjabi Sikh community of Greater
93
Sacramento area in healthcare settings, community health programs, and places of Sikh
worship.
Limitations in this study highlight the opportunities to build upon these findings.
Further emphasizing that future research can focus on pilot testing the Healthy Punjabi
Plate with a larger, representative Punjabi Sikh sample to assess the tools effectiveness in
dietary behavior change and to identify potential areas for improvement. Moreover, the
findings from this study also signify the need to continue national research on MyPlate’s
effectiveness in other diverse communities that are at increased risk for chronic diseases.
In order to better serve marginalized groups, future studies can use the cultural adaptation
process and inform their research with a theoretical framework to identify the community
needs and barriers. To ensure health equity nationwide we must acknowledge the cultural
diversity in eating patterns and traditional customs and highlight the importance of
equitable and inclusive education to serve the entire population.
94
Appendix A
Letter Requesting the Sikh Temple’s Permission
95
Appendix B
Informed Consent Form
96
Appendix C
Phase 1: Survey Questionnaire
97
98
99
Appendix D
Phase 2: Semi-Structured Interview Questions
Inform Participants of Project Details
Ask Eligibility Criteria Questions
Ask For Verbal Consent
Demographics
• What is your age?
• What is your gender?
1. Do you prefer receiving nutrition information in English or the Punjabi
language?
2. Does this plate of food look appetizing/appealing/good enough to eat?
Yes_No _
a. If yes, why? (Food colors, they are familiar with the food, the plate color?)
b. If not, why not? (Food colors, they are familiar with the food, the plate
color?)
3. Do you find the language used in the Punjabi translation clear and easy to
understand? Are there any words or phrases that could be more familiar or
appropriate for your community?
4. Is there anything missing from the visual tool that would make it more
appealing for you to make balanced meals?
5. Does the food shown in the visual tool reflect your personal preferences or
choices for meals?
6. On a scale from 1 to 5 (5 being very confident vs 1 being not very confident)
how confident do you feel using this tool to create balanced meals?
7. Does this visual tool represent your cultural values and traditions in a way that
feels authentic to you? Yes_ No_
a. If yes, why? (cultural foods, plates & bowls, appropriate combinations,
language)
b. If not, why not?
8. Do you have any other suggestions for how this tool could be improved to
better serve you or your community to promote healthy eating?
9. Which visual tool do you find more useful or easier to relate to (Display
MyPlate vs. Healthy Punjabi Plate)? Why?
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Appendix E
Healthy Punjabi Plate Visual Tool (English and Punjabi Version)
101
102
103
104
105
106
107
108
109
110
(Punjabi Version)
111
112
113
114
115
116
117
118
119
120
References
Alamer, A., & Almulhim, F. (2021). The interrelation between language anxiety and self-
determined motivation; a mixed methods approach. Frontiers in Education, 6.
https://doi.org/10.3389/feduc.2021.618655
Alsukait, R. F., Folta, S. C., Chui, K., Seguin, R. A., Sinclair, C. G., & Hudson, L. B. (2021).
Healthy hearts for an abundant life: feasibility of a culturally adapted cardiovascular
disease prevention curriculum for African American women. Health Equity, 5(1), 398–
407. https://doi.org/10.1089/heq.2021.0005
Barrera, M., Castro, F. G., Strycker, L. A., & Toobert, D. J. (2013). Cultural adaptations of
behavioral health interventions: A progress report. Journal of Consulting and Clinical
Psychology, 81(2), 196–205. https://doi.org/10.1037/a0027085
Benavidez, G. A., Zahnd, W. E., Hung, P., & Eberth, J. M. (2024). Chronic disease prevalence in
the us: Sociodemographic and geographic variations by zip code tabulation area.
Preventing Chronic Disease, 21. https://doi.org/10.5888/pcd21.230267
Bernal, G., Jiménez-Chafey, M. I., & Domenech Rodríguez, M. M. (2009). Cultural adaptation of
treatments: a resource for considering culture in evidence-based practice. Professional
Psychology: Research and Practice, 40(4), 361–368. https://doi.org/10.1037/a0016401
Bhatia, T. (1993). Punjabi. Taylor & Francis Group.
http://ebookcentral.proquest.com/lib/csus/detail.action?docID=179031
Blondin, J. H., & LoGiudice, J. A. (2018). Pregnant women’s knowledge and awareness of
nutrition. Applied Nursing Research, 39, 167–174.
https://doi.org/10.1016/j.apnr.2017.11.020
121
Brown, O. N., O’Connor, L. E., & Savaiano, D. (2014). Mobile MyPlate: A pilot study using text
messaging to provide nutrition education and promote better dietary choices in college
students. Journal of American College Health, 62(5), 320–327.
https://doi.org/10.1080/07448481.2014.899233
Budiman, A., & Ruiz, N. G. (2021, April 9). Asian Americans are the fastest-growing racial or
ethnic group in the U.S. Pew Research Center. https://www.pewresearch.org/short-
reads/2021/04/09/asian-americans-are-the-fastest-growing-racial-or-ethnic-group-in-the-
u-s/
Burt, K. (2021). The whiteness of the Mediterranean diet: A historical analysis of the
Mediterranean diet’s rise to prominence through the lens of critical race theory. Journal
of Critical Dietetics, 5(2), 41–52. https://doi.org/10.32920/cd.v5i2.1329
Buttorff, C., Ruder, T., & Bauman, M. (2017). Multiple chronic conditions in the United States.
RAND Corporation. https://doi.org/10.7249/TL221
Castro, F. G., Barrera, M., & Holleran Steiker, L. K. (2010). Issues and challenges in the design
of culturally adapted evidence-based interventions. Annual Review of Clinical
Psychology, 6, 213–239. https://doi.org/10.1146/annurev-clinpsy-033109-132032
Center for Disease Control and Prevention. (2024a, January 17). Social determinants of health
(SDOH). https://www.cdc.gov/about/priorities/why-is-addressing-sdoh-important.html
Center for Disease Control and Prevention. (2024b, May 15). Preventing chronic diseases: what
you can do now. https://www.cdc.gov/chronic-disease/prevention/index.html
Center for Disease Control and Prevention. (2024c, October 4). About chronic diseases.
https://www.cdc.gov/chronic-disease/about/index.html
Center for Disease Control and Prevention. (2024d, October 24). Heart disease facts.
https://www.cdc.gov/heart-disease/data-research/facts-stats/index.html
122
Center for Disease Control and Prevention. (2024e, December 10). Fast facts: health and
economic costs of chronic conditions. https://www.cdc.gov/chronic-disease/data-
research/facts-stats/index.html
Chang, S., Ciampo, M., & Mitchell, H. (2017). Creating images with impact: Food photography
tips from MyPlate. Journal of the Academy of Nutrition and Dietetics, 117(8), 1171–
1173. https://doi.org/10.1016/j.jand.2017.06.003
Chapman, G. E., Ristovski-Slijepcevic, S., & Beagan, B. L. (2011). Meanings of food, eating and
health in Punjabi families living in Vancouver, Canada. Health Education Journal, 70(1),
102–112. https://doi.org/10.1177/0017896910373031
Chapman, G., Ristovski-Slijepcevic, S., Beagan, B., & Bassett, R. (2006). Food-related health
concerns of Punjabi British Columbians: Postcolonial perspectives on nutrition and health
education. Appetite, 47(3), 387. https://doi.org/10.1016/j.appet.2006.08.015
Chauhan, H. (2021). Health needs assessment of the Punjabi Sikh community in the San Joaquin
valley. https://escholarship.org/uc/item/5dr8f5wc
Chauhan, H. (2023). Importance of cultural tailoring: Identifying a type 2 diabetes prevention
intervention for the San Joaquin valley Punjabi population through qualitative
interviews. [UC Merced]. https://escholarship.org/uc/item/3vf0201r
Chrisman, M., & Diaz Rios, L. K. (2019). Evaluating MyPlate after 8 years: A perspective.
Journal of Nutrition Education and Behavior, 51(7), 899–903.
https://doi.org/10.1016/j.jneb.2019.02.006
Clements, J. M., West, B. T., Yaker, Z., Lauinger, B., McCullers, D., Haubert, J., Tahboub, M.
A., & Everett, G. J. (2020). Disparities in diabetes-related multiple chronic conditions
and mortality: The influence of race. Diabetes Research and Clinical Practice, 159,
107984. https://doi.org/10.1016/j.diabres.2019.107984
123
Contento, I. R., & Koch, P. A. (2020). Nutrition education: Linking research, theory, and
practice: linking research, theory, and practice. Jones & Bartlett Learning, LLC.
http://ebookcentral.proquest.com/lib/csus/detail.action?docID=6036862
Czerwinski-Alley, N. C., Chithiramohan, T., Subramaniam, H., Beishon, L., & Mukaetova-
Ladinska, E. B. (2024). The effect of translation and cultural adaptations on diagnostic
accuracy and test performance in dementia cognitive screening tools: A systematic
review. Journal of Alzheimer’s Disease Reports, 8(1), 659–675.
https://doi.org/10.3233/ADR-230198
Deci, E. L., & Ryan, R. M. (1985). Intrinsic motivation and self-determination in human
behavior. Springer US. https://doi.org/10.1007/978-1-4899-2271-7
Dietrich, S., & Hernandez, E. (2022). Language use in the United States: 2019. U.S. Census
Bureau. https://www.census.gov/content/dam/Census/library/publications/2022/acs/acs-
50.pdf
Fernandez Perez, C., Xi, K., Simha, A., Shah, N. S., Huang, R. J., Palaniappan, L., Chung, S., Au,
T., Sharp, N., Islas, N., & Srinivasan, M. (2022). Leading causes of death in Asian
Indians in the United States (2005–2017). PLoS ONE, 17(8), e0271375.
https://doi.org/10.1371/journal.pone.0271375
Galdas, P. M., Oliffe, J. L., Kang, H. B. K., & Kelly, M. T. (2012). Punjabi Sikh patients’
perceived barriers to engaging in physical exercise following myocardial infarction.
Public Health Nursing, 29(6), 534–541. https://doi.org/10.1111/j.1525-
1446.2012.01009.x
124
Garcia, V., Sklyar, L., Caldwell, J. I., Shah, D., Prudencio, J. M., & Kuo, T. (2022). MyPlate and
urban low-income Asian Americans in the United States: A study to improve nutrition
education. Journal of Public Health Policy, 43(4), 621–639.
https://doi.org/10.1057/s41271-022-00377-3
Gibson, M. A. (1988). Punjabi orchard farmers: An immigrant enclave in rural California. The
International Migration Review, 22(1), 28–50. https://doi.org/10.2307/2546395
Gidwani, S., Paul, D., Nalwa, G., Lin, B., Mahadevan, S. V., & Palaniappan, L. (2021). Indian
and Asian Indian immigrant health statistics. Stanford Medicine CARE,
1.https://asianhealth.stanford.edu/sites/g/files/sbiybj30391/files/media/file/india-data-
brief.pdf
Gill, M. K. (2022). Diabetes prevention and management education for Punjabi-Sikh older
adults (Doctoral project, University of San Francisco). Doctor of Nursing Practice (DNP)
Projects, 305. https://repository.usfca.edu/dnp/305
Gropper, S. S. (2023). The role of nutrition in chronic disease. Nutrients, 15(3), 664.
https://doi.org/10.3390/nu15030664
Guo, J., Zhong, Q., Tang, Y., Luo, J., Wang, H., Qin, X., Wang, X., & Wiley, J. A. (2021).
Cultural adaptation, the 3-month efficacy of visual art training on observational and
diagnostic skills among nursing students, and satisfaction among students and staff- a
mixed method study. BMC Nursing, 20(1), 122. https://doi.org/10.1186/s12912-021-
00646-8
Hacker, K. (2024). The burden of chronic disease. Mayo Clinic Proceedings: Innovations,
Quality & Outcomes, 8(1), 112–119. https://doi.org/10.1016/j.mayocpiqo.2023.08.005
125
Hammons, A. J., Hannon, B. A., Teran-Garcia, M., Barragan, M., Villegas, E., Wiley, A., &
Fiese, B. (2019). Effects of culturally tailored nutrition education on dietary quality of
Hispanic mothers: A randomized control trial. Journal of Nutrition Education and
Behavior, 51(10), 1168–1176. https://doi.org/10.1016/j.jneb.2019.06.017
Harvard T.H. Chan School of Public Health. (2011). Healthy eating plate—The nutrition source.
https://nutritionsource.hsph.harvard.edu/healthy-eating-plate/
Hastings, K. G., Jose, P. O., Kapphahn, K. I., Frank, A. T. H., Goldstein, B. A., Thompson, C. A.,
Eggleston, K., Cullen, M. R., & Palaniappan, L. P. (2015). Leading causes of death
among Asian American subgroups (2003–2011). PLoS ONE, 10(4), e0124341.
https://doi.org/10.1371/journal.pone.0124341
Hosking, R. (2006). Authenticity in the kitchen: Proceedings of the oxford symposium on food
and cookery 2005. Oxford Symposium.
Hoy, K., Goldman, J., & Moshfegh, A. (2017). Awareness of dietary guidance and diet quality of
adults by race/ethnicity, what we eat in America. Journal of Nutrition Education and
Behavior, 49(7), S39. https://doi.org/10.1016/j.jneb.2017.05.327
Islam, N. S., Zanowiak, J. M., Wyatt, L. C., Kavathe, R., Singh, H., Kwon, S. C., & Trinh-
Shevrin, C. (2014). Diabetes Prevention in the New York City Sikh Asian Indian
Community: A Pilot Study. International Journal of Environmental Research and Public
Health, 11(5), 5462–5486. https://doi.org/10.3390/ijerph110505462
Jakobsh, D. R. (2012). Sikhism. University of Hawai’i Press.
https://www.jstor.org/stable/j.ctt6wqh3q
126
Javed, Z., Haisum Maqsood, M., Yahya, T., Amin, Z., Acquah, I., Valero-Elizondo, J., Andrieni,
J., Dubey, P., Jackson, R. K., Daffin, M. A., Cainzos-Achirica, M., Hyder, A. A., &
Nasir, K. (2022). Race, racism, and cardiovascular health: Applying a social determinants
of health framework to racial/ethnic disparities in cardiovascular disease. Circulation:
Cardiovascular Quality and Outcomes, 15(1), e007917.
https://doi.org/10.1161/CIRCOUTCOMES.121.007917
Jayasinghe, S., Byrne, N. M., & Hills, A. P. (2025). Cultural influences on dietary choices.
Progress in Cardiovascular Diseases. https://doi.org/10.1016/j.pcad.2025.02.003
Jiao, L. (2024). Social determinants of health, diet, and health outcome. Nutrients, 16(21), 3642.
https://doi.org/10.3390/nu16213642
Kaur, R. (2014). Cultural factors and health issues faced by older Sikh immigrants in
Bakersfield (Master's thesis). California State University,
Bakersfield. https://scholarworks.calstate.edu/downloads/qv33s151t
Kazi, D. S., Elkind, M. S., Deutsch, A., Dowd, W. N., Heidenreich, P., Khavjou, O., Mark, D.,
Mussolino, M. E., Ovbiagele, B., Patel, S. S., Poudel, R., Weittenhiller, B., Powell-
Wiley, T. M., & Joynt Maddox, K. E. (2024). Forecasting the economic burden of
cardiovascular disease and stroke in the United States through 2050: A presidential
advisory from the American heart association. Circulation (New York, N.Y.), 150(4), e89-
. https://doi.org/10.1161/CIR.0000000000001258
Kim, J. E. (2013). Variations on the MyPlate initiative’s ease of use by ethnicity and
gender [Master’s thesis, California State University, Long Beach]. ProQuest
Dissertations & Theses Global. https://www.proquest.com/docview/1513579813
127
Kinderknecht, K. L., The, N. S., & Slining, M. M. (2024). Whose plate is it? Awareness of
MyPlate among us adults over time since implementation. Journal of the Academy of
Nutrition and Dietetics, 0(0). https://doi.org/10.1016/j.jand.2024.03.011
Koirala, B., Turkson-Ocran, R.-A., Baptiste, D., Koirala, B., Francis, L., Davidson, P.,
Himmelfarb, C. D., & Commodore-Mensah, Y. (2021). Heterogeneity of cardiovascular
disease risk factors among Asian immigrants: Insights from the 2010 to 2018 national
health interview survey. Journal of the American Heart Association, 10(13), e020408.
https://doi.org/10.1161/JAHA.120.020408
Kuhn, J. L., Vanegas, S. B., Salgado, R., Borjas, S. K., Magaña, S., & DaWalt, L. S. (2020). The
cultural adaptation of a transition program for Latino families of youth with autism
spectrum disorder. Family Process, 59(2), 477–491. https://doi.org/10.1111/famp.12439
Lee, J. D., Meadan, H., Sands, M. M., Terol, A. K., Martin, M. R., & Yoon, C. D. (2024). The
cultural adaptation checklist (CAC): Quality indicators for cultural adaptation of
intervention and practice. International Journal of Developmental Disabilities, 70(7),
1285–1296. https://doi.org/10.1080/20473869.2023.2176966
Lewis, J. R. (2017). American images of Punjabi immigrants in the early twentieth century. Sikh
Formations: Religion, Culture, Theory, 13(3), 181–192.
https://doi.org/10.1080/17448727.2016.1147173
Lim, S., Wyatt, L. C., Chauhan, H., Zanowiak, J. M., Kavathe, R., Singh, H., Kwon, S. C., Trinh-
Shevrin, C., & Islam, N. S. (2019). A culturally adapted diabetes prevention intervention
in the New York city Sikh Asian Indian community leads to improvements in health
behaviors and outcomes. Health Behavior Research, 2(1), 4.
https://doi.org/10.4148/2572-1836.1027
128
Lo Dato, E., Gostoli, S., & Tomba, E. (2024). Psychological theoretical frameworks of healthy
and sustainable food choices: A systematic review of the literature. Nutrients, 16(21),
3687. https://doi.org/10.3390/nu16213687
Mann, S. (2023). Perceptions and barriers to accessing diabetes services among the Punjabi
community in Fresno County, California [Master's project, California State University,
Fresno]. Scholar Works. https://scholarworks.calstate.edu/concern/projects/2227mx92s
Mattei, J., Caballero-González, A., Maafs-Rodríguez, A., Zhang, A., O’Neill, H. J., & Gago, C.
(2024). Lessons learned by adapting and implementing lucha: A deep-structure culturally
tailored healthy eating randomized pilot intervention for ethnic-diverse Latinos. Frontiers
in Public Health, 11, 1269390. https://doi.org/10.3389/fpubh.2023.1269390
McCarthy, W. J., Rico, M., Chandler, M., Herman, D. R., Chang, C., Belin, T. R., Love, S.,
Ramirez, E., & Gelberg, L. (2023). Randomized comparative effectiveness trial of 2
federally recommended strategies to reduce excess body fat in overweight, low-income
patients: Myplate.gov vs calorie counting. Annals of Family Medicine, 21(3), 213–219.
https://doi.org/10.1370/afm.2964
McCullough, M. L., Chantaprasopsuk, S., Islami, F., Rees-Punia, E., Um, C. Y., Wang, Y.,
Leach, C. R., Sullivan, K. R., & Patel, A. V. (2022). Association of socioeconomic and
geographic factors with diet quality in us adults. JAMA Network Open, 5(6), e2216406.
https://doi.org/10.1001/jamanetworkopen.2022.16406
McLaurin, N. (2024). Coping with discrimination among African Americans with type 2
diabetes: Factor structure and associations with diabetes control, mental distress, and
psychosocial resources. Preventing Chronic Disease, 21.
https://doi.org/10.5888/pcd21.230189
129
Mohamed-Bibi, S., Vaqué-Crusellas, C., & Alonso-Pedrol, N. (2022). Design of culturally and
linguistically tailored nutrition education materials to promote healthy eating habits
among Pakistani women participating in the PakCat program in Catalonia. Nutrients,
14(24), 5239. https://doi.org/10.3390/nu14245239
Mooney, N. (2011). Farming, family, and faith: Elements of Jat Sikh identity. In Rural nostalgias
and transnational dreams: Identity and modernity among Jat Sikhs (pp. 47–86).
University of Toronto Press. https://doi.org/10.3138/9781442694934-005
Mulik, K., & Haynes-Maslow, L. (2017). The affordability of MyPlate: An analysis of snap
benefits and the actual cost of eating according to the dietary guidelines. Journal of
Nutrition Education and Behavior, 49(8), 623-631.e1.
https://doi.org/10.1016/j.jneb.2017.06.005
Nadimpalli, S. B., Cleland, C. M., Hutchinson, M. K., Islam, N., Barnes, L. L., & Van Devanter,
N. (2016). The association between discrimination and the health of Sikh Asian Indians.
Health Psychology: Official Journal of the Division of Health Psychology, American
Psychological Association, 35(4), 351–355. https://doi.org/10.1037/hea0000268
National Sikh Campaign. (2015, January). Sikhism in the United States: What Americans know
and need to know. National Sikh
Campaign. https://d3n8a8pro7vhmx.cloudfront.net/sikhcampaign/pages/105/attachments/
original/1467171428/sikh-report-final.pdf
Neuhouser, M. L. (2019). The importance of healthy dietary patterns in chronic disease
prevention. Nutrition Research, 70, 3–6. https://doi.org/10.1016/j.nutres.2018.06.002
130
Ng, J. Y. Y., Ntoumanis, N., Thøgersen-Ntoumani, C., Deci, E. L., Ryan, R. M., Duda, J. L., &
Williams, G. C. (2012). Self-determination theory applied to health contexts: A meta-
analysis. Perspectives on Psychological Science, 7(4), 325–
340. https://doi.org/10.1177/1745691612447309
Nur, H., Atoloye, A. T., Wengreen, H., Savoie-Roskos, M. R., Archuleta, M., LeBlanc, H., Scott,
P., Wille, C., & Jewkes, M. (2023). Culturally adapted nutrition education for Somali
refugees improves nutrition-related behavior. Journal of Nutrition Education and
Behavior, 55(7, Supplement), 66–67. https://doi.org/10.1016/j.jneb.2023.05.147
Ogbonnia, I. V. (2021). Using MyPlate nutrition education to improve glycated hemoglobin (A1c)
levels in African American adults with type 2 diabetes (Doctoral dissertation). Brandman
University.
https://www.proquest.com/docview/2504534576/fulltextPDF?parentSessionId=%2FOaz
HL99c%2FRqAsWgTI8omifl0tXFQWPgATwagF6bTOk%3D&pq-
origsite=primo&accountid=10358&sourcetype=Dissertations%20&%20Theses
Oster, H., & Chaves, I. (2023). Effects of healthy lifestyles on chronic diseases: Diet, sleep and
exercise. Nutrients, 15(21), 4627. https://doi.org/10.3390/nu15214627
Patrick, H., & Williams, G. C. (2012). Self-determination theory: Its application to health
behavior and complementarity with motivational interviewing. International Journal of
Behavioral Nutrition and Physical Activity, 9, 18. https://doi.org/10.1186/1479-5868-9-
18
Qualtrics. (2025). Qualtrics Survey Software.
https://qualtricsxmnbldytlnn.pdx1.qualtrics.com/login
131
Rajan, S. I., Varghese, V. J., & Kumar Nanda, A. (Eds.). (2015). Migration, mobility and multiple
affiliations: Punjabis in a transnational world. Cambridge University Press.
https://doi.org/10.1017/CBO9781316337950
Ramos, Z., & Alegría, M. (2014). Cultural adaptation and health literacy refinement of a brief
depression intervention for Latinos in a low-resource setting. Cultural Diversity & Ethnic
Minority Psychology, 20(2), 293–301. https://doi.org/10.1037/a0035021
Ranganath, N. (n.d.). Punjab | Punjabi and Sikh diaspora digital archive. Retrieved February 28,
2025, from https://punjabidiaspora.ucdavis.edu/places/origins/punjab/
Resnicow, K., Baranowski, T., Ahluwalia, J. S., & Braithwaite, R. L. (1999). Cultural Sensitivity
in Public Health: Defined and Demystified. Ethnicity & Disease, 9(1), 10–21.
http://www.jstor.org/stable/45410142
Rico, B., Key Hahn, J., & Spence, C. (2023, September 21). Chinese, except Taiwanese, was the
largest Asian alone or in any combination group; Nepalese population grew fastest.
Census.Gov. https://www.census.gov/library/stories/2023/09/2020-census-dhc-a-asian-
population.html
Roberts, L. R., Mann, S. K., & Montgomery, S. B. (2016). Mental health and sociocultural
determinants in an Asian Indian community. Family & Community Health, 39(1), 31–39.
https://doi.org/10.1097/FCH.0000000000000087
Rosenman, R., Tennekoon, V., & Hill, L. G. (2011). Measuring bias in self-reported data.
International Journal of Behavioral & Healthcare Research, 2(4), 320–332.
https://doi.org/10.1504/IJBHR.2011.043414
Ryan, C. (2013). Language use in the United States: 2011 (Report No. ACS-22). U.S. Census
Bureau. https://www.census.gov/content/census/en/library/publications/2013/acs/acs-
22.html
132
Ryan, R. M., & Deci, E. L. (2000). Self-determination theory and the facilitation of intrinsic
motivation, social development, and well-being. American Psychologist, 55(1), 68–
78. https://doi.org/10.1037/0003-066X.55.1.68
Sandhu, D. S., & Heinrich, M. (2005). The use of health foods, spices and other botanicals in the
Sikh community in London. Phytotherapy Research: PTR, 19(7), 633–642.
https://doi.org/10.1002/ptr.1714
Schroeter, C., Corder, T., Brookes, B., & Reller, V. (2021). An incentive-based health program
using MyPlate: A pilot study analyzing college students’ dietary intake behavior. Journal
of American College Health, 69(3), 252–259.
https://doi.org/10.1080/07448481.2019.1661845
Schwartz, J. L., & Vernarelli, J. A. (2019). Assessing the public’s comprehension of dietary
guidelines: Use of MyPyramid or MyPlate is associated with healthier diets among us
adults. Journal of the Academy of Nutrition and Dietetics, 119(3), 482–489.
https://doi.org/10.1016/j.jand.2018.09.012
Shams-White, M. M., Pannucci, T. E., Lerman, J. L., Herrick, K. A., Zimmer, M., Mathieu, K.
M., Stoody, E. E., & Reedy, J. (2023). Healthy eating index-2020: Review and update
process to reflect the dietary guidelines for Americans, 2020-2025. Journal of the
Academy of Nutrition and Dietetics, 123(9), 1280–1288.
https://doi.org/10.1016/j.jand.2023.05.015
Shilts, M., Lamp, C., Johns, M., Schneider, C., & Townsend, M. (2012). My healthy plate and
preschool parents. Journal of Nutrition Education and Behavior, 44(4, Supplement),
S34–S35. https://doi.org/10.1016/j.jneb.2012.03.069
133
Shilts, M. K., Johns, M. C., Lamp, C., Schneider, C., & Townsend, M. S. (2015). A picture is
worth a thousand words: Customizing MyPlate for low-literate, low-income families in 4
steps. Journal of Nutrition Education and Behavior, 47(4), 394-396.e1.
https://doi.org/10.1016/j.jneb.2015.04.324
Sikh Coalition. (n.d.). About Sikhs. Sikh Coalition. https://www.sikhcoalition.org/about-sikhs/
Singh, H., Samkange-Zeeb, F., Kolschen, J., Herrmann, R., Hübner, W., Barnils, N. P., Brand, T.,
Zeeb, H., & Schüz, B. (2024). Interventions to promote health literacy among working-
age populations experiencing socioeconomic disadvantage: Systematic review. Frontiers
in Public Health, 12, Article 1332720. https://doi.org/10.3389/fpubh.2024.1332720
Singh, N.-G. K. (2011). Sikhism: An introduction. I. B. Tauris & Company, Limited.
http://ebookcentral.proquest.com/lib/csus/detail.action?docID=5245962
Singh, P. (2019). Panjabi. In A dictionary of Sikh studies. Oxford University Press.
https://www.oxfordreference.com/display/10.1093/acref/9780191831874.001.0001/acref-
9780191831874-e-255
Sotos-Prieto, M., Bhupathiraju, S. N., Mattei, J., Fung, T. T., Li, Y., Pan, A., Willett, W. C.,
Rimm, E. B., & Hu, F. B. (2017). Association of changes in diet quality with total and
cause-specific mortality. The New England Journal of Medicine, 377(2), 143–153.
https://doi.org/10.1056/NEJMoa1613502
Taylor, R. M., Haslam, R. L., Herbert, J., Whatnall, M. C., Trijsburg, L., de Vries, J. H. M.,
Josefsson, M. S., Koochek, A., Nowicka, P., Neuman, N., Clarke, E. D., Burrows, T. L.,
& Collins, C. E. (2024). Diet quality and cardiovascular outcomes: A systematic review
and meta-analysis of cohort studies. Nutrition & Dietetics, 81(1), 35–50.
https://doi.org/10.1111/1747-0080.12860
134
Temmann, L. J., Wiedicke, A., Schaller, S., Scherr, S., & Reifegerste, D. (2021). A systematic
review of responsibility frames and their effects in the health context. Journal of Health
Communication, 26(12), 828–838. https://doi.org/10.1080/10810730.2021.2020381
Tikkanen, R., & Abrams, M. K. (2020). U.S. Health care from a global perspective, 2019:
Higher spending, worse outcomes? The Commonwealth Fund.
https://www.commonwealthfund.org/publications/issue-briefs/2020/jan/us-health-care-
global-perspective-2019
U.S. Department of Agriculture. (n.d.). MyPlate. https://www.myplate.gov/
U.S. Department of Agriculture and U.S. Department of Health and Human Services. (2020,
December). Dietary Guidelines for Americans, 2020-2025. 9th Edition.
DietaryGuidelines.gov
U.S. Department of Agriculture and U.S. Department of Health and Human Services.
(2020). Dietary guidelines for Americans, 2020-2025 (9th
ed.). https://www.dietaryguidelines.gov/
U.S. Department of Agriculture & Food and Nutrition Service. (2023, September 14). Healthy
eating index (HEI). https://www.fns.usda.gov/cnpp/healthy-eating-index-hei
U.S. Department of Agriculture & U.S. Department of Health and Human Services. (1980).
Nutrition and your health: Dietary guidelines for Americans.
https://www.dietaryguidelines.gov/sites/default/files/2019-
05/1985%20Full%20DG%20Report.pdf
U.S. Department of Health and Human Services & Office of Disease Prevention and Health
Promotion. (n.d.). Social determinants of health—Healthy people 2030.
https://odphp.health.gov/healthypeople/priority-areas/social-determinants-health
135
Vilar-Compte, M., Burrola-Méndez, S., Lozano-Marrufo, A., Ferré-Eguiluz, I., Flores, D.,
Gaitán-Rossi, P., Teruel, G., & Pérez-Escamilla, R. (2021). Urban poverty and nutrition
challenges associated with accessibility to a healthy diet: A global systematic literature
review. International Journal for Equity in Health, 20(1), 40.
https://doi.org/10.1186/s12939-020-01330-0
Wambogo, E., Ansai, N., Wang, C.-Y., Terry, A., Fryar, C. D., Ahluwalia, N., & Ogden, C. L.
(2022). Awareness of the MyPlate plan: United States, 2017-March 2020. National
Health Statistics Reports, 178, 1–14.
Wang, V. H.-C., Foster, V., & Yi, S. S. (2021). Are recommended dietary patterns equitable?
Public Health Nutrition, 25(2), 464–470. https://doi.org/10.1017/S1368980021004158
Waters, H., & Graf, M. (2018, August). The costs of chronic disease in the U.S. Milken Institute.
https://milkeninstitute.org/content-hub/research-and-reports/reports/costs-chronic-
disease-us
Yom, S., & Lor, M. (2022). Advancing health disparities research: The need to include Asian
American subgroup populations. Journal of Racial and Ethnic Health Disparities, 9(6),
2248–2282. https://doi.org/10.1007/s40615-021-01164-8
Zakerkish, M., Shahmoradi, S., Haidari, F., Latifi, S. M., & Mohammadshahi, M. (2022). The
effect of nutrition education using MyPlate on lipid profiles, glycemic indices, and
inflammatory markers in diabetic patients. Clinical Nutrition Research, 11(3), 171–182.
https://doi.org/10.7762/cnr.2022.11.3.171
