By Zahra Sajad-Mohamed, RD, Reviewed by Harriet Smith, RD
The UK is becoming more ethnically diverse1; it is crucial that dietitians provide nutrition support information which reflects this diversity. According to the 2011 census, over 230,500 people in the UK identified themselves as Arabs. However, this figure is likely to underestimate the actual Middle Eastern (ME) population in the UK1. This is because some ME people identify themselves as ‘African’, ‘White Other’ or ‘Other’. The different countries that make up the Middle East include Egypt, Syria, Jordan, Algeria, Bahrain, Kuwait, Lebanon, Libya, Iran, Iraq and the United Arab Emirates2.
There is no data on the prevalence of malnutrition in the UK’s ME population. However, 5.4% are aged 60 years and above3. This figure is likely to be higher as the UK’s ageing population is increasing4. In the literature, it is well documented that the risk of malnutrition increases with age4. Therefore tailoring nutrition support information to meet the cultural needs of this ethnic group is essential. It will help to build rapport, increase patient compliance and in turn, help reduce the prevalence of malnutrition in ethnic minority groups.
Background to ME Diets
Due to dietary acculturation, the traditional ME diet has become more Westernised. This is particularly true amongst the younger generations. However, within the elderly generation, the ME diet has more or less remained the same5.
Generally speaking, a main meal consists of tagines and marags which include red meat (lamb and mutton are favoured meats), fish or poultry along with vegetables and/or legumes. Chickpeas, split peas, fava beans and lentils are common legumes in the ME. This is usually served with a staple and some salad. Rice, bread (i.e. pitta bread) and grains including burgher, freekeh and couscous are everyday staples in the ME diet. Traditional dishes such as falafel (chickpeas fried balls), dolma (stuffed grape leaves) and kibbeh (stuffed patties), kebabs and shawarma are also culturally distinctive dishes in the ME diet.
There is moderate dairy consumption in the form of white cheese (halloumi/akawi) and yoghurt. Labneh, which is strained yoghurt, is commonly consumed for breakfast and supper. Milk is used in hot drinks, haresa (porridge) or desserts such as mahalabia.
Olive oil is one of the most common types of fats used. It is used in salads such as tabbouleh (fresh herbs and bulgur) and fattoush (fried bread green salad), in tahini (sesame seed sauce) and many different dips including hummus and baba ghanoush (aubergine dip). Clarified butter (ghee) is mostly used for frying or pouring over rice dishes for scent and flavour.
Nutrition Support Challenges with the ME Population
With the rise in non-communicable diseases such as type 2 diabetes, hypertension and heart disease in the ME and the UK, people are becoming more health-conscious when making dietary choices5. This may present as a challenge when giving nutrition support information, as it may go against the typical healthy dietary recommendations.
Additionally, in an attempt to cure disease, some people may seek alternative medicine and herbal remedies or others may submit to what is seen as God’s will. These could become potential barriers for people seeking medical and nutritional support. The predominant religion amongst the ME population is Islam. There are religious obligations such as fasting from dawn until dusk every day during the month of Ramadan. Also, Muslims can only eat ‘halal meat’, while pork consumption is prohibited.
The most common language spoken is Arabic. Other languages include Persian or Farsi and Turkish. Patients with limited proficiency in English may not be able to communicate effectively or understand what is being advised by their healthcare professional. This can make the delivery of high-quality healthcare challenging, and a translator may be required6.
Nutrition Support - Food First ideas:
The following are commonly eaten with bread:
- Dibis-wa-tahini (date syrup mixed with tahini paste)
- Zeit wa za’atar (dried thyme mix mixed with olive oil)
- Ful medames ( fava beans dip)
- Makdous (oil-cured stuffed aubergines)
- Full fat labneh topped with with olive oil and olives
- Falafel and hummus
- Traditional dips
- Fried Kibbeh (a mixture of bulgur wheat, onions, and ground beef)
- Manaeesh (flatbread, 3 classic toppings: mince meat, zeit with za’atar and cheese)
- Arayes (meat filled pies)
- Dolma (stuffed vine leaves)
- Ka’ak (sesame bread)
- Medjool dates
- Mixed nuts
- Traditional desserts such as mahalabia, baklawa (filo pastry soaked in syrup), kunafa, maamoul (date filled cookies), layali lubnan (semolina pudding with pistachios)
- Add extra ghee, raisins and fried nuts over rice dishes.
- Fortify one pint of full fat milk with four tbsp of skimmed milk powder and add to milky recipes such as haressa (porridge), rice pudding, and milk based drinks or tea.
- Add Arabic style cream to desserts like mahalabia, rice pudding, layali lubnan and top with crushed nuts and extra sugar syrup.
- Fill dates with walnuts/almonds, pour tahini all over and sprinkle desiccated coconut.
- Add extra olive oil to fattoush/tabbouleh, soups and dips
Add extra pulses and lentils to soups, marags and tagines or plain rice.
- Date-based syrup drinks
- Yogurt drinks
- Fruit cocktail (made with Arabian clotted cream)
- Majoon milkshake (made with dates, banana, ice-cream, honey, milk, toasted nuts and seeds)
Where possible, encourage patients and carers to prepare and plan ahead. They may wish to use slow/pressure cookers and cook extra portions of marag and tagines which can be frozen. Traditional and ready-made foods can be shop bought from ME supermarkets, and many big brand supermarkets now stock a wide selection of ME products.
Statistics, O., 2020.Population Of England And Wales. [online] Ethnicity-facts-figures.service.gov.uk. Available at: <https://www.ethnicity-facts-figures.service.gov.uk/uk-population-by-ethnicity/national-and-regional-populations/population-of-england-and-wales/latest#by-ethnicity-over-time> [Accessed 12 October 2020].
Musaiger, A., 1993. Socio-Cultural and Economic Factors Affecting Food Consumption Patterns in the Arab Countries.Journal of the Royal Society of Health, 113(2), pp.68-74.
Ethnicity-facts-figures.service.gov.uk. 2020.Age Groups. [online] Available at: <https://www.ethnicity-facts-figures.service.gov.uk/uk-population-by-ethnicity/demographics/age-groups/latest#average-age-by-ethnicity> [Accessed 12 October 2020].
- Bapen.org.uk. 2020. [online] Available at: <https://www.bapen.org.uk/pdfs/economic-report-full.pdf> [Accessed 12 October 2020].
Musaiger, A., 2002. Diet and Prevention of Coronary Heart Disease in the Arab Middle East Countries.Medical Principles and Practice, 11(2), pp.9-16.
Al Shamsi, H., Almutairi, A., Al Mashrafi, S. and Al Kalbani, T., 2020. Implications of Language Barriers for Healthcare: A Systematic Review.Oman Medical Journal, 35(2), pp.e122-e122.