Hindawi Publishing Corporation
Evidence-Based Complementary and Alternative Medicine
Volume 2013, Article ID 146214, 18 pages
http://dx.doi.org/10.1155/2013/146214

Review Article
Religiosity and Spirituality and the Intake of Fruit, Vegetable,
and Fat: A Systematic Review

Min-Min Tan, Carina K. Y. Chan, and Daniel D. Reidpath

Jeffrey Cheah School of Medicine and Health Sciences, Monash University, Sunway Campus, Jalan Lagoon Selatan,
46150 Bandar Sunway Selangor Darul Ehsan, Malaysia

Correspondence should be addressed to Min-Min Tan; minmin.tan@gmail.com

Received 29 May 2013; Accepted 2 September 2013

Academic Editor: Arndt Büssing

Copyright © 2013 Min-Min Tan et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Objectives. To systematically review articles investigating the relationship between religion and spirituality (R/S) and fruit, vegetable,
and fat intake. Methods. PubMed, CINAHL, and PsycInfo were searched for studies published in English prior to March 2013. The
studies were divided into two categories: denominational studies and degree of R/S studies. The degree of R/S studies was further
analyzed to (1) determine the categories of R/S measures and their relationship with fruit, vegetable, and fat intake, (2) evaluate the
quality of the R/S measures and the research design, and (3) determine the categories of reported relationship. Results. Thirty-nine
studies were identified. There were 14 denominational studies and 21 degree of R/S studies, and 4 studies were a combination of both.
Only 20% of the studies reported validity and 52% reported reliability of the R/S measures used. All studies were cross-sectional,
and only one attempted mediation analysis. Most studies showed a positive association with fruit and vegetable intake and a mixed
association with fat intake. Conclusion. The positive association between R/S and fruit and vegetable intake may be one possible link
between R/S and positive health outcome. However, the association with fat intake was mixed, and recommendations for future
research are made.

1. Introduction

Unhealthy diet is a major risk factor in the development of
noncommunicable diseases (NCD), which are responsible
for about 63% of deaths globally [1]. One of the main
characteristics of a healthy diet is the regular consumption
of a variety of fruit and vegetable, which is associated
with a lower risk of some cancers, coronary heart disease,
hypertension, and stroke [2, 3]. About 1.7 million deaths
worldwide are attributed to a low fruit and vegetable intake
[4]. In addition, about 14% of gastrointestinal cancers, 11%
of ischemic heart disease, and 9% of stroke worldwide are
also attributable to low fruit and vegetable intake [5]. Another
important dietary factor related to health is fat intake. A high
fat intake is associated with higher risk of coronary heart
disease, diabetes, and cancers, the common NCDs [6–8].

The World Health Organization recommends a daily in-
take of at least 400 g (5 servings) of fruit and nonstarchy
vegetable, and fat that is less than 30% of total dietary en-
ergy, of which less than 10% is from saturated fat and less

than 1% from transfat [9]. However, due to urbanization
and westernization, many countries that traditionally enjoyed
high fruit and vegetable and low dietary fat consumption are
moving towards a higher fat, lower fiber diet [10]. The global
burden of NCD is predicted to increase further because of this
global transition in lifestyles [10].

Research has shown that religion and spirituality (R/S)
has a positive association with health [11]. About 80% of the
studies looking at the relationship between R/S and health
examined mental health [12], showing a positive association
with wellbeing, self-esteem, and optimism [13–16]; lower
scores of depressive and suicidal symptoms [17, 18]; and lower
stress level [19–21]. Numerous studies have also reported
a positive association between R/S and physical health,
including an association with lower all-cause mortality and
lower rates of diet-related diseases such as hypertension,
cardiovascular diseases, and cancer [22–26].

The study of the relationship between R/S and health
remains relatively novel. Initially it was not well accepted
because it was thought that it is impossible (within a positivist

http://dx.doi.org/10.1155/2013/146214


2 Evidence-Based Complementary and Alternative Medicine

framework) to study R/S scientifically. However, starting in
the early 1990s, with the improvement of methodology, the
study of religion and health has been increasingly recognized
as a legitimate domain of scientific inquiry and is becoming
more established [27]. Between 2000 and 2010, at least 21,000
quantitative studies examining the relationship between R/S
and health have been published [28], covering a wide range
of health outcomes and behaviors.

In the research of R/S and health, one of the major issues
is defining religion and spirituality in a way that supports
their measurement. Historically the notions of religion and
spirituality have often been used interchangeably; however,
recently there has been a trend towards distinguishing the two
concepts [29]. Broadly, religion includes “beliefs, practices,
and rituals related to the Transcendent or the Divine” [30],
while spirituality is concerned with the “connection to that
which is sacred, the transcendent” and also “a search for the
transcendent and the discovery of the transcendent” [28].
Religion tends to convey a negative impression that it is
related to organized religion and theological rigidness, while
spirituality is viewed more positively and is associated with
personal experience of the transcendent. However, Koenig
recommends the use of spirituality in the context of religion,
that is, those who are spiritual are “deeply religious” [30].

The most commonly used R/S measure has been the
single-item measuring religious attendance because of its
“ease of use” [31]. In most of the studies that have used a
religious attendance measure, most have also found that it
is positively associated with better health outcomes [32]; for
example, it has been associated with lower mortality rates
[33, 34], better adoption of health behaviors [35, 36], more
life’s satisfaction [37], and a lower prevalence of hypertension
[24]. However, in many studies, R/S data were collected
as part of a larger study, and this can be a drawback [38,
39]. It is generally accepted that R/S is a multidimensional
construct [40], which means that a single-item measure such
as religious attendance will be insufficient to capture all
dimensions except possibly in the most general sense. This
also limits insights that can be gained about the relationship
between R/S and health. Recently, more specific scales have
been developed to measure different dimensions of R/S [40].

Religion is considered important to many people around
the world. One recent survey estimated that 51% of the
population in the world believe in god(s) [41]. Another survey
conducted in 143 countries found that the majority of people,
especially those from developing countries, reported that
religion was an important part of their lives [14].

One of the proposed mechanisms by which R/S benefits
health is through the adoption of religious practices that are
also health-promoting [42]. Many religions view the human
body as sacred and include specific prohibitions against
unhealthy behaviors, which are considered irreverent and
not only harmful physically but also spiritually. This view,
however, needs to be tempered by the fact that some religious
adherence may also result in poorer health outcomes, such as
extreme asceticism. Notwithstanding that, numerous studies
have shown that R/S is negatively associated with many
harmful behaviors such as smoking [43, 44], alcohol drinking
[45, 46], substance abuse [47, 48], and risky sexual activities

[49, 50] and positively associated with good health behaviors
such as the use of preventive health care services [51, 52],
physical activity [36], and seat belt use [53].

Certain health practices are endorsed and encouraged by
most religions, such as healthy eating. In fact, most religions
have specific dietary guidelines regarding what food to eat or
avoid. These guidelines fall into two categories. The first cate-
gory involves “a temporal abstinence from all or certain foods
(fasting)”—the majority of religions have fasting guidelines,
for example, Muslims fasting during Ramadan and oriental
orthodox Christians fasting before Holy Communion. The
second category relates to “stable and distinctive dietary
habits that differ from the general population”; for example,
Muslims consume halal meat and Jews consume kosher meat
[54]. The main purposes of these dietary guidelines are for
spiritual advancement.

R/S might encourage the consumption of fruit and
vegetable and discourage fat intake (especially animal fat)
because of specific doctrines of a particular religion. For
example, the teaching of Ahimsa (do no harm) in Mahayana
Buddhism and Hinduism encourages their adherents to be
vegetarians in order to cultivate compassion, since eating ani-
mals requires slaughtering. Nonvegetarian food is considered
impure and could hinder one’s spiritual development [55].
The Seventh-day Adventists are encouraged to be vegetarians,
as part of a religious duty to maintain a healthy body [56].
Even in religions that do not have specific dietary guidelines
or restrictions, the teaching that the body is sacred might
encourage the adoption of healthier behaviors, including a
healthier diet.

The long term dietary practices required by certain
religions could be a protective factor in preventing diet-
related diseases. For example, the Seventh-day Adventist
Church and the Church of Jesus Christ of the Latter-day
Saints both encourage their believers to consume more fruit
and vegetable and less fat. There is evidence from observa-
tional studies that Adventists, Mormons, and adherents of
religions with strict dietary guidelines have healthier diets,
better physical health, and longer lifespans than the general
population [57, 58].

Notwithstanding the importance of food in many reli-
gions, there is a surprising scarcity of research on the
relationship between R/S and diet. According to the first
edition of the Handbook of Religion and Health [59], the
most comprehensive review about R/S and health to date,
there were only seven studies on R/S and diet before 1990. The
second edition of this Handbook (2012) reviewed 21 studies
about R/S and diet between 2000 and 2012. Sixty-two percent
showed a positive association; that is, a higher measured R/S
is associated with a healthier diet.

A few other reviews also identified generally positive
associations between R/S and a healthier diet. Groen and
van der Heide [60], for instance, reviewed the role of dietary
cholesterol in the development of atherosclerosis and coro-
nary thrombosis among adherents of different religions. They
found that Jews and vegetarian Trappist monks have a lower
cholesterol level than the comparable groups. Shatenstein and
Ghadirian [61] reviewed the differences in health behaviors,
including dietary practices, among different religious groups.



Evidence-Based Complementary and Alternative Medicine 3

In another review, Sarri et al. [62] examined religious dietary
practices and physical health among Muslims, Seventh-
day Adventists, orthodox Christians, Jews, Buddhists, and
a few other religions. There was an inconsistent finding
about the influence of Ramadan fasting on physical health
among Muslims and an overall positive relationship between
religious dietary practices and health in other religions.

However, to date, there has been no review that examined
the relationship between R/S and specific dietary intake. The
past reviews have only examined R/S and diet in general.
Thus, the purpose our review was to address this gap and
systematically review the relationship between R/S and fruit,
vegetable and fat intake. We hypothesized that R/S was
positively associated with fruit and vegetable intake, and
negatively associated with fat intake.

2. Methods

2.1. Search Strategy. PubMed, CINAHL, and PsycInfo were
searched by using two categories of key terms: religious key
terms (religion, religiosity, religiousness, and spirituality) and
dietary key terms (diet, food, food habits, health behavior,
food preferences, eating, nutritional status, fruit, vegetable,
fibers, and fats). The Boolean operator “OR” was used to com-
bine key terms within each category, and “AND” to combine
both categories. In PubMed database, the “NOT” operator
was also used to eliminate studies related to clinical trials,
fasting, reviews, systematic reviews, case reports, editorial,
and comment. The full search strategy can be obtained from
the authors.

2.2. Inclusion Criteria. To be eligible for inclusion, a paper
had to fulfill the following criteria.

(1) The research analyzed the direct association between
at least one quantified R/S measure and at least
one quantified measure of fruit and vegetable or fat
intake. Thus, qualitative studies and case studies were
excluded.

(2) The paper was published in English and in a peer-
reviewed journal before 1 March 2013.

2.3. Exclusion Criteria. A paper was excluded if

(1) R/S and fruit, vegetable, and/or fat intake were
included but their relationship was not examined
directly (e.g., parents’ R/S and children’s intake)

(2) only overall health/dietary behavior was assessed but
not fruit, vegetable, and/or fat intake specifically

(3) R/S was included as part of the measure of another
variable (e.g., social support) but the direct relation-
ship between R/S and fruit, vegetable, and/or fat
intake was not assessed;

(4) the focus of the paper was fasting and/or eating
disorders;

(5) the paper examined only serum levels of nutrients
and not direct intake. Serum level or biomarkers of

nutrients might not be an accurate indicator of fruit,
vegetable, and fat intake since the nutrients could be
obtained from supplements;

(6) the paper examined fiber intake but did not specify its
dietary source as fruit and vegetable. Fiber could be
obtained from supplements and nonfruit or vegetable
food source such as grains.

The references and bibliographies of the papers were also
examined to identify other relevant articles. Previous reviews
of the relationship between diet (generally) and R/S were also
examined [28, 59, 61, 62], and in one case the review author
was contacted for his list of papers, which were not detailed
in the review itself.

3. Analysis

The frequency and types of fruit, vegetable, and fat intake
measures used were first examined. The measures were
categorized into dietary records, 24-hour dietary recall, food
frequency, brief dietary assessment methods, and dietary
history. A dietary record is a detailed record of all food and
drinks consumed over a period of time by a respondent; in
24-hour dietary recall, a respondent is asked about the food
and drinks he/she consumed during the past 24 hours; a
food frequency questionnaire is a list of commonly consumed
food that could be selected by respondents; brief dietary
assessments are used to estimate the intake of a nutrient or
a type of food but do not assess overall diet; dietary history
assesses dietary patterns over time [63].

The studies were divided into two categories: (1)denom-
inational studies that compared fruit, vegetable, and/or fat
intake between members of different religions, or denomi-
nations within the same religion, or between a religion with
the general population and (2) degree of R/S studies that
examined the degree of R/S and its association with fruit and
vegetable and/or fat intake. The two categories were analyzed
separately.

The analyses of degree of R/S studies were guided by Rew
and Wong [64] and Wong et al. [65]. First the categories of R/S
measures were analyzed. The classification scheme was based
on Wong et al. [65], which is a modification of Hackney and
Sanders [66]. There are six categories: institutional (social and
behavior aspects of R/S e.g., attendance and social support),
ideological (R/S beliefs e.g., importance of religion), personal
devotion (personal and internalized devotion, e.g., private
prayer), existential (measures that are spiritual but not reli-
gious, e.g., spiritual wellbeing), multidimensional (examined
more than one category of R/S), and generic (e.g., one-item
measure that asks about how religious are the respondents)
[65]. The relationships (positive (+), negative (−), mixed, or
none) between R/S measures and fruit, vegetable, and fat
intake were identified.

The quality of R/S measures was assessed by examining
whether their validity and reliability were reported. The
number of studies that used single-item measure was also
examined. Many R/S and health studies relied solely on the
use of single-item measure of religious attendance, which has
its limitations in health research [38]. The quality of research



4 Evidence-Based Complementary and Alternative Medicine

In
cl

ud
ed

El
ig

ib
ili

ty
Sc

re
en

in
g

Id
en

tifi
ca

tio
n

Qualitative studies
Did not assess direct 
relationship between R/S and 
intake of fruit/vegetable or fat
No specific dietary measures 
of fruit/vegetable or fat 
intakes
No R/S measures or R/S 
measures part of another 
variable

Records identified through 
database searching

Additional records identified 
through other sources

Records after duplicates removed

Records screened

Articles included in qualitative 
synthesis

(n = 4297) (n = 6)

(n = 3297)

(n = 3297)

(n = 137)

(n = 39)

(n = 3160)

Records excluded

eligibility
Full-text articles assessed for

2527 excluded based on titles
618 excluded based on abstracts
14 unreachable authors
1 unavailable

Full-text articles excluded
with reasons (n = 98)

∙

∙

∙

∙

Figure 1: Articles selection process.

design (control for covariates, utilization of longitudinal data,
and investigation of mediators) was assessed [64]. The studies
were also categorized based on their reported relationship
between R/S and fruit, vegetable, and fat intake.

4. Results

Out of the 3298 potentially relevant papers identified by the
database search strategy, 32 papers fulfilled the inclusion cri-
teria. An additional seven papers were obtained through cross
reference of included papers and previous reviews. Figure 1
shows the flowchart of article selection process. All of the
39 studies were cross-sectional. There are 14 denominational
studies that do not contain other R/S measures, 21 studies that
examined only degree of R/S, and four that included both
denominational differences and degree of R/S. See Table 1 for
the table of characteristics of the 39 studies.

The majority (77%) of the studies were conducted in
the United States. Five were conducted in other Western
countries (two in Australia (5.1%), and one each (2.6%) in
Scotland, Slovakia, and Canada), two in Israel (5.1%) one in
Japan (2.6%), and one in South Korea (2.6%). Four studies
included only female samples. Eleven studies were race-
specific; seven examined African Americans, two examined
non-Hispanic Whites, one examined Koreans, and one exam-
ined Japanese. Thirty-two of the studies (79.4%) included
samples that were predominantly Christians. Four studies
examined Jews and three examined Buddhists.

4.1. Assessment of Dietary Intake. Out of the 39 studies, 12
examined fruit, vegetable, and fat intake, 14 examined only

fruit and vegetable intake, and the other 13 only examined fat
intake.

Table 3 shows the categories of dietary assessments of
fruit, vegetable, and fat intake. Among the five categories
of dietary assessment methods, brief dietary assessments
were the most used, followed by food frequency. The most
used brief dietary assessment was the Fat- and Fiber-Related
Behavior Questionnaire [67], which was included in four
studies, followed by the National Institute’s 5-A-Day Survey
[68], which was included in three studies. Three studies used
more than one dietary assessment method, and two used
more than one brief dietary assessment.

4.2. Denominational Studies. A total of 18 studies were ana-
lyzed. Eight (44%) of them compared Seventh-Day Adven-
tists with the other denominations (Catholics, Methodists,
and Mormons) or non-Adventists, three compared fruit,
vegetable, and fat intake, three compared only fruit and
vegetable intake, and two compared only fat intake. Among
the six studies that compared fruit and vegetable intake, three
(50%) showed that Adventists consumed significantly more
fruit and vegetable than members of other denominations
and non-Adventists, one (16.7%) had positive but nonsignifi-
cant association, one was nonsignificant in vegetable intake
but significant in higher fruit intake, and one showed that
Adventists consumed less deep fried vegetable.

Five studies compared total fat intake between Adventists
and non-Adventists. Two (40%) showed that Adventists
consumed less fat. One showed that Adventists consumed less
fat when comparing total fat in grams, but similar amount
of fat as non-Adventists when comparing the percentage
of energy from fat. Another study showed that Adventist



Evidence-Based Complementary and Alternative Medicine 5

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3-
da
y
di
et
ar
y
re
co
rd
:n
on

si
gn

ifi
ca
nt
,

th
ou

gh
no

n-
A
dv
en
tis
ts
18
%
m
or
e
to
ta
lf
at

FF
Q

(i
)N

on
-A
dv
en
tis
ts
m
or
e
de
ep

fr
ie
d

ve
ge
ta
bl
e

(i
i)
N
on

-A
dv
en
tis
ts
m
or
e
an
im

al
fa
ta
nd

m
or
e
sa
tu
ra
te
d
fa
t

N
on

e



6 Evidence-Based Complementary and Alternative Medicine
(a
)
C
on

tin
ue
d.

N
o.

Fi
rs
ta
ut
ho

r
(p
ub

lic
at
io
n
ye
ar
)

Lo
ca
tio

n
𝑁

Po
pu

la
tio

n
Sa
m
pl
in
g

m
et
ho

d
D
en
om

in
at
io
ns

D
ie
ta
ry

m
ea
su
re
s

D
ie
ta
ry

as
se
ss
m
en
t

m
et
ho

ds
Fi
nd

in
g

C
on

tr
ol

va
ri
ab
le
s

F/
V

Fa
t

8
Fr
as
er

(1
98
7)

[7
9]

LA
&
O
ra
ng
e

C
ou

nt
ie
s,
U
SA

32
0

N
on

-H
is
pa
ni
c

W
hi
te
s,

35
–5
5
yr
s

R
an
do

m
(A

dv
en
tis
ts
)&

co
nv
en
ie
nc
e

(n
on

-A
dv
en
tis
t

ne
ig
hb

or
s)

A
dv
en
tis
ts

N
on

-A
dv
en
tis
ts

√
FF

Q
A
dv
en
tis
ts
—
le
ss
fa
t,
le
ss
sa
tu
ra
te
d
fa
t,

hi
gh

er
P
:S

ra
tio

;l
in
ol
ei
c
ac
id

no
ne

N
on

e

(b
)
D
en
om

in
at
io
na
ls
tu
di
es

(o
th
er

re
lig
io
ns
/d
en
om

in
at
io
ns
)

N
o.

Fi
rs
ta
ut
ho

r
(p
ub

lic
at
io
n
ye
ar
)

Lo
ca
tio

n
𝑁

Po
pu

la
tio

n
Sa
m
pl
in
g

m
et
ho

d
D
en
om

in
at
io
ns

D
ie
ta
ry

m
ea
su
re
s

D
ie
ta
ry

as
se
ss
m
en
t

m
et
ho

ds
Fi
nd

in
g

C
on

tr
ol

va
ri
ab
le
s

F/
V

Fa
t

9
Ep

st
ei
n
(1
95
6)

[8
0]

N
ew

Yo
rk
,

U
SA

41
5

G
ar
m
en
tw

or
ke
rs
,

>
40

yr
s

R
an
do

m
It
al
ia
n

Je
w
is
h

O
th
er
s

√
24
-h
rd

ie
ta
ry

re
ca
ll

It
al
ia
ns

an
d
Je
w
s—

no
di
ffe
re
nc
e
in

fa
ti
nt
ak
e

Je
w
sm

or
e
an
im

al
fa
ts

N
on

e

10
G
lic
k
(1
99
8)

[8
1]

Ya
te
s

C
ou

nt
ry
,N

Y,
U
SA

14
9

O
ld

or
de
r

M
en
no

ni
te
s

U
nc
le
ar

M
en
no

ni
te

U
SA

po
pu

la
tio

n
√

FF
Q

M
en
no

ni
te
sm

al
es

&
fe
m
al
es

m
or
e

fa
t&

ol
ei
c
ac
id

th
an

U
SA

sa
m
pl
e

M
en
no

ni
te
m
al
es
—
si
m
ila
r%

ca
lo
ri
es

fr
om

fa
tw

ith
U
SA

sa
m
pl
e

N
on

e

11
K
ita

(1
98
8)

[8
2]

Ky
ot
o,
Ja
pa
n

36
A
du

lts
,2
4–

35
yr
s

C
on

ve
ni
en
ce

Z
en

m
on

ks
U
ni
ve
rs
ity

st
ud

en
ts

√
24
-h
rd

ie
ta
ry

re
ca
ll

Z
en

m
on

ks
le
ss
fa
ti
nt
ak
e
&
hi
gh

er
P/
S
ra
tio

N
on

e

12
Le
e
(2
00
9)

[8
3]

G
ye
on

gb
uk

,
R
ep
ub

lic
of

K
or
ea

85
Fe
m
al
es
—
Bu

dd
hi
st

nu
ns

&
C
at
ho

lic
nu

ns
C
on

ve
ni
en
ce

Bu
dd

hi
st
s

C
at
ho

lic
s

√

Fa
ti
n
%
kc
al

To
ta
lf
at

Pl
an
tf
at

A
ni
m
al
fa
t

N
o
di
ffe
re
nc
es

in
fa
ti
n
%
kc
al
,t
ot
al

fa
t,
pl
an
tf
at

C
at
ho

lic
sm

or
e
an
im

al
fa
t

N
on

e

13
M
ul
le
n
(2
00
0)

[8
4]

W
es
to

f
Sc
ot
la
nd

,U
K

98
5

A
du

lts
,>

35
yr
s

St
ra
tifi

ed
ra
nd

om
C
at
ho

lic
s

N
on

-C
at
ho

lic
s

√
FF

Q
C
at
ho

lic
s—

pu
re

fr
ui
tj
ui
ce

C
at
ho

lic
m
al
es
—
le
ss
fr
ui
ta
nd

ve
ge
ta
bl
e

Se
x,

oc
cu
pa
tio

na
l

cl
as
s

14
Sh
at
en
st
ei
n

(1
99
3)

[8
5]

G
re
at
er

M
on

tr
ea
l,

C
an
ad
a

25
0

H
as
si
di
c
fa
m
ili
es

R
an
do

m

H
as
si
di
c

se
ct
s—

O
ut
re
m
on

t
H
as
si
di
m

&
Lu

ba
vi
tc
he
rH

as
si
di
m

√

Fo
od

fr
eq
ue
nc
y

&
fo
od

ha
bi
ts
lis
t

2-
da
y
fo
od

re
co
rd

Lu
ba
vi
tc
he
rH

as
si
di
m

m
or
e
co
ok
ed

fr
ui
t

N
on

e

(c
)
D
en
om

in
at
io
na
l+

de
gr
ee

of
R
/S

st
ud

ie
s

N
o.

Fi
rs
ta
ut
ho

r
(p
ub

lic
at
io
n
ye
ar
)

Lo
ca
tio

n
𝑁

Po
pu

la
tio

n
Sa
m
pl
in
g

m
et
ho

d
R
/S

m
ea
su
re
s

D
ie
ta
ry

m
ea
su
re
s

D
ie
ta
ry

as
se
ss
m
en
t

m
et
ho

ds
Fi
nd

in
g

C
on

tr
ol

va
ri
ab
le
s

F/
V

Fa
t

15
K
im

(2
00

4)
[8
6]

U
SA

54
6

A
du

lts
R
an
do

m

R
el
ig
io
us

de
no

m
in
at
io
n

R
el
ig
io
us

at
te
nd

an
ce

R
el
ig
io
us

ap
pl
ic
at
io
n

R
el
ig
io
us

co
m
m
itm

en
t

R
el
ig
io
us

id
en
tit
y

R
el
ig
io
us

co
pi
ng

R
el
ig
io
us

so
ci
al
su
pp

or
t

√

N
at
io
na
lC

an
ce
r

In
st
itu

te
’s
Q
ui
ck

Fo
od

Sc
an

C
on

se
rv
at
iv
e

Pr
ot
es
ta
nt
/o
th
er
s/
no

re
lig
io
n

w
om

en
m
or
e
fa
tt
ha
n

C
at
ho

lic
w
om

en
M
al
es
—
no

ne

A
ge
,r
ac
e,

ed
uc
at
io
n,

m
ar
ita

ls
ta
tu
s,

em
pl
oy
m
en
t



Evidence-Based Complementary and Alternative Medicine 7

(c
)
C
on

tin
ue
d.

N
o.

Fi
rs
ta
ut
ho

r
(p
ub

lic
at
io
n
ye
ar
)

Lo
ca
tio

n
𝑁

Po
pu

la
tio

n
Sa
m
pl
in
g

m
et
ho

d
R
/S

m
ea
su
re
s

D
ie
ta
ry

m
ea
su
re
s

D
ie
ta
ry

as
se
ss
m
en
t

m
et
ho

ds
Fi
nd

in
g

C
on

tr
ol

va
ri
ab
le
s

F/
V

Fa
t

16
K
im

(2
00
8)

[8
7]

Te
xa
s,
U
SA

42
4

N
on

-H
is
pa
ni
c

W
hi
te
s,

58
–1
00

yr
s

R
an
do

m

D
en
om

in
at
io
n

A
tte

nd
an
ce

R
el
ig
io
us

so
ci
al
su
pp

or
t

(%
ne
tw
or
k
in

ch
ur
ch

&
%

ne
tw
or
k
in

re
lig
io
n)

√
In
te
rv
ie
w
ab
ou

tf
at

re
du

ct
io
n
be
ha
vi
or

A
ll
R
/S

m
ea
su
re
s

no
ns
ig
ni
fic
an
tf
or

m
en

W
om

en
—
D
en
om

in
at
io
n

no
ns
ig
ni
fic
an
t;
m
or
e
%

ne
tw
or
k
in

ch
ur
ch
,l
es
sf
at

re
du

ct
io
n
be
ha
vi
or
;m

or
e
%

ne
tw
or
k
in

re
lig
io
n,

m
or
e
fa
t

re
du

ct
io
n
be
ha
vi
or

A
ge
,S
ES

,
ur
ba
n-
ru
ra
l

re
si
de
nc
e,

liv
in
g
w
ith

so
m
eo
ne
,

ch
ro
ni
c
ill
ne
ss
,

ph
ys
ic
al
ly

di
sa
bl
ed
,

he
al
th

&
di
sa
bi
lit
y,

ge
ne
ra
ls
oc
ia
l

su
pp

or
t

17
M
cI
nt
os
h
(1
98
4)

[8
8]

V
ir
gi
ni
a,

U
SA

37
1

El
de
rl
y

R
an
do

m

R
el
ig
io
us

pa
rt
ic
ip
at
io
n

R
el
ig
io
us

sa
lie
nc
e

R
el
ig
io
us

di
sa
gr
ee
m
en
t

R
el
ig
io
us

pr
ef
er
en
ce

√
24

hr
di
et
ar
y
re
ca
ll

+v
e
fo
rs
al
ie
nc
e
an
d
fa
ti
nt
ak
e

+v
e
fo
rd

is
ag
re
em

en
ta
nd

fa
t

in
ta
ke

M
or
e
lo
ca
lis
tic
,M

et
ho

di
st
s

m
or
e
fa
t,
Br
et
hr
en

le
ss
fa
t

Se
x,
in
co
m
e

18
Sc
hl
un

dt
(2
00

8)
[8
9]

N
as
hv
ill
e,

Te
nn

es
se
e,

U
SA

30
14

W
hi
te
&
A
fr
ic
an

A
m
er
ic
an
s,

>
18
yr
s

St
ra
tifi

ed
ra
nd

om

R
el
ig
io
us

de
no

m
in
at
io
n/
affi

lia
tio

n
R
el
ig
io
us

in
vo
lv
em

en
t

In
de
x
(r
el
ig
io
us

at
te
nd

an
ce
,r
el
ig
io
si
ty
,

pe
rc
ep
tio

n
of

re
lig
io
n
as

a
so
ur
ce

of
st
re
ng

th
an
d

co
m
fo
rt
)

√
√

Ea
tin

g
B
eh
av
io
rP

at
te
rn
s

Q
ue
st
io
nn

ai
re

Ea
tin

g
St
yl
es

Q
ue
st
io
nn

ai
re

(b
ot
h
A
da
pt
ed

fr
om

B
eh
av
io
ra
lR

is
k
Fa
ct
or

Su
rv
ei
lla
nc
e
Sy
st
em

)

D
en
om

in
at
io
n—

no
ns
ig
ni
fic
an
t

R
el
ig
io
us

in
vo
lv
em

en
ti
nd

ex
po

si
tiv

el
y
as
so
ci
at
ed

w
ith

he
al
th
y
ea
tin

g
be
ha
vi
or
sa

nd
hi
gh

-f
at
be
ha
vi
or
s

A
ge
,s
ex
,r
ac
e,

ed
uc
at
io
n,

in
co
m
e
&

em
pl
oy
m
en
t

(d
)
D
eg
re
e
of

R
/S

st
ud

ie
s

N
o.

Fi
rs
ta
ut
ho

r
(p
ub

lic
at
io
n
ye
ar
)

Lo
ca
tio

n
𝑁

Po
pu

la
tio

n
Sa
m
pl
in
g

m
et
ho

d
R
/S

m
ea
su
re
s

D
ie
ta
ry

m
ea
su
re
s

D
ie
ta
ry

as
se
ss
m
en
t

m
et
ho

ds
Fi
nd

in
g

C
on

tr
ol

va
ri
ab
le
s

F/
V

Fa
t

19
A
rr
ed
on

do
(2
00
5)

[9
0]

U
SA

21
1

W
om

en
,

18
–6

5
yr
s

R
an
do

m
C
hu

rc
h
at
te
nd

an
ce

√
√

Bl
oc
k
fa
t&

fib
er

sc
re
en
er

Fr
eq
ue
nt

ch
ur
ch
go
er
sm

or
e
fib

er
th
an

no
nc
hu

rc
hg
oe
rs

C
hu

rc
hg
oe
rs
(f
re
qu

en
t&

in
fr
eq
ue
nt
)m

or
e
fib

er
th
an

no
nc
hu

rc
hg
oe
rs

Ed
uc
at
io
n,

m
ar
ita

ls
ta
tu
s,

em
pl
oy
m
en
t,

ag
e



8 Evidence-Based Complementary and Alternative Medicine

(d
)
C
on

tin
ue
d.

N
o.

Fi
rs
ta
ut
ho

r
(p
ub

lic
at
io
n
ye
ar
)

Lo
ca
tio

n
𝑁

Po
pu

la
tio

n
Sa
m
pl
in
g

m
et
ho

d
R
/S

m
ea
su
re
s

D
ie
ta
ry

m
ea
su
re
s

D
ie
ta
ry

as
se
ss
m
en
t

m
et
ho

ds
Fi
nd

in
g

C
on

tr
ol

va
ri
ab
le
s

F/
V

Fa
t

20
Ba

ru
th

(2
01
1)
[9
1]

So
ut
h

C
ar
ol
in
a,

U
SA

11
36

A
fr
ic
an

A
m
er
ic
an
s,

>
18
yr
s

R
an
do

m

Pe
rc
ei
ve
d

en
vi
ro
nm

en
ta
lc
hu

rc
h

su
pp

or
t(
pe
rc
ei
ve
d

w
ri
tte

n
in
fo
rm

at
io
na
l,

pe
rc
ei
ve
d
sp
ok
en

in
fo
rm

at
io
na
l,

pe
rc
ei
ve
d
in
st
ru
m
en
ta
l,

to
ta
lp

er
ce
iv
ed

ch
ur
ch

su
pp

or
t)

√
√

N
at
io
na
lC

an
ce
r

In
st
itu

te
Fr
ui
t

an
d
Ve

ge
ta
bl
e

sc
re
en
er

Se
rv
in
gs

of
fr
ui
t

an
d
ve
ge
ta
bl
e

Fa
t-
an
d
Fi
be
r-

R
el
at
ed

B
eh
av
io
r

Q
ue
st
io
nn

ai
re

M
or
e
fr
ui
ta
nd

ve
ge
ta
bl
e

(i
)m

or
e
to
ta
lp

er
ce
iv
ed

ch
ur
ch

su
pp

or
t,
pe
rc
ei
ve
d
w
ri
tte

n
in
fo
rm

at
io
na
ls
up

po
rt
&

pe
rc
ei
ve
d
sp
ok
en

in
fo
rm

at
io
na
l

su
pp

or
t

M
or
e
lo
w
-f
at
be
ha
vi
or

(i
)m

or
e
to
ta
lp

er
ce
iv
ed

ch
ur
ch

su
pp

or
ta
nd

pe
rc
ei
ve
d
w
ri
tte

n
in
fo
rm

at
io
na
ls
up

po
rt

Se
x,
ye
ar
so

f
ed
uc
at
io
n,

he
al
th

ra
tin

g,
ag
e,
BM

I,
in
flu

en
ce

of
ch
ur
ch

21
B
en
ja
m
in
s(
20
12
)

[9
2]

U
SA

35
1

Je
w
is
h
st
ud

en
ts
,

5t
h–

8t
h
gr
ad
es

C
on

ve
ni
en
ce

R
el
ig
io
us

be
lie
fs
&

he
al
th

√

Yo
ut
h
R
is
k

B
eh
av
io
rS

ur
ve
y

(5
fr
ui
ta
nd

ve
ge
ta
bl
e
da
ily
)

N
on

si
gn

ifi
ca
nt

G
en
de
r,
w
ei
gh
t

st
at
us
,d
ie
tin

g,
pa
re
nt
al

in
vo
lv
em

en
t,

co
nfi

de
nc
e

22
D
eb
na
m

(2
01
2a
)

[9
3]

U
SA

23
70

A
fr
ic
an

A
m
er
ic
an
s,

>
21
yr
s

Pr
ob

ab
ili
ty
-

ba
se
d
bu

t
no

tr
ep
re
-

se
nt
at
iv
e

R
el
ig
io
n
so
ci
al
su
pp

or
t

(e
m
ot
io
na
ls
up

po
rt

re
ce
iv
ed
,e
m
ot
io
na
l

su
pp

or
tp

ro
vi
de
d,

an
tic

ip
at
ed

su
pp

or
t,

ne
ga
tiv

e
in
te
ra
ct
io
n)

√

N
at
io
na
lC

an
ce
r

In
st
itu

te
’s

Fi
ve
-A
-D

ay
Su
rv
ey

M
or
e
so
ci
al
su
pp

or
t,
m
or
e
fr
ui
t

an
d
ve
ge
ta
bl
e

(i
)a

dd
iti
ve

eff
ec
t:
em

ot
io
na
l

re
lig
io
us

su
pp

or
t

A
ge
,

ed
uc
at
io
n,

se
x,

se
lf-
ra
te
d

he
al
th

st
at
us

23
D
eb
na
m

(2
01
2b
)

[9
4]

U
SA

23
70

A
fr
ic
an

A
m
er
ic
an
s,

>
21
yr
s

R
an
do

m

Sp
ir
itu

al
H
ea
lth

Lo
cu
s

of
C
on

tr
ol
Sc
al
e
(a
ct
iv
e

sp
ir
itu

al
,p
as
si
ve

sp
ir
itu

al
)

√

N
at
io
na
lC

an
ce
r

In
st
itu

te
’s

5-
A
-D

ay
Su
rv
ey

O
ve
ra
ll:

+v
e
fo
ra

ct
iv
e
sp
ir
itu

al
an
d
da
ily

fr
ui
ts
er
vi
ng

s
−
ve

fo
rp

as
si
ve

sp
ir
itu

al
an
d

da
ily

ve
ge
ta
bl
e
se
rv
in
gs

M
al
es
:−

ve
fo
rp

as
si
ve

sp
ir
itu

al
an
d
da
ily

ve
ge
ta
bl
e
se
rv
in
gs
;

no
ns
ig
ni
fic
an
tf
or

fr
ui
t

Fe
m
al
es
:−

ve
fo
rp

as
si
ve

sp
ir
itu

al
an
d
da
ily

ve
ge
ta
bl
e
se
rv
in
gs
;

no
ne

fo
rf
ru
it

A
ge
,

ed
uc
at
io
n,

he
al
th

st
at
us



Evidence-Based Complementary and Alternative Medicine 9

(d
)
C
on

tin
ue
d.

N
o.

Fi
rs
ta
ut
ho

r
(p
ub

lic
at
io
n
ye
ar
)

Lo
ca
tio

n
𝑁

Po
pu

la
tio

n
Sa
m
pl
in
g

m
et
ho

d
R
/S

m
ea
su
re
s

D
ie
ta
ry

m
ea
su
re
s

D
ie
ta
ry

as
se
ss
m
en
t

m
et
ho

ds
Fi
nd

in
g

C
on

tr
ol

va
ri
ab
le
s

F/
V

Fa
t

24
Fi
fe
(2
01
1)
[9
5]

N
or
th
ea
st
,

U
SA

51
0

A
fr
ic
an

A
m
er
ic
an

un
iv
er
si
ty

st
ud

en
ts

C
on

ve
ni
en
ce

D
uk

e
U
ni
ve
rs
ity

R
el
ig
io
n
In
de
x

√

Yo
ut
h
R
is
k

B
eh
av
io
rS

ur
ve
y

(i
)A

te
no

fr
ui
t

du
ri
ng

th
e
pa
st
7

da
ys

(i
i)
A
te
no

sa
la
d

du
ri
ng

th
e
pa
st
7

da
ys

(i
ii)

D
ra
nk

no
10
0%

fr
ui
tj
ui
ce

du
ri
ng

th
e
pa
st
7

da
ys

C
hi
-s
qu

ar
e
te
st
:

(i
)n

on
si
gn

ifi
ca
nt
—
at
e
no

fr
ui
t

du
ri
ng

th
e
pa
st
7
da
ys
;a
te
no

sa
la
d
du

ri
ng

th
e
pa
st
7
da
ys

(i
i)
si
gn

ifi
ca
nt
—
dr
an
k
no

10
0%

fr
ui
tj
ui
ce

du
ri
ng

th
e
pa
st
7
da
ys

Lo
gi
st
ic
re
gr
es
si
on

:
(i
)u

ni
va
ri
at
e
&

m
ul
tiv

ar
ia
te
—
“i
nt
ri
ns
ic
on

ly
”

gr
ou

p
m
or
e
lik

el
y
to

dr
in
k
no

10
0%

fr
ui
tj
ui
ce

du
ri
ng

th
e
pa
st
7

da
ys

Ye
ar

in
sc
ho

ol
,

ge
nd

er

25
Fr
an
kl
in

(2
00
7)

[9
6]

U
SA

12
73

A
du

lts
,

18
–9

6
yr
s

St
ra
tifi

ed
ra
nd

om
R
el
ig
io
us

he
al
th

fa
ta
lis
m

qu
es
tio

nn
ai
re

√

Fa
t-
in
cr
ea
si
ng

be
ha
vi
or

Fa
t-
de
cr
ea
si
ng

be
ha
vi
or

H
ig
h
fa
ta
lis
m

+v
e
as
so
ci
at
ed

w
ith

bo
th

hi
gh

fa
t-
in
cr
ea
si
ng

be
ha
vi
or

&
hi
gh

fa
t-
de
cr
ea
si
ng

be
ha
vi
or

A
ge
,r
ac
e,

ge
nd

er
,

in
co
m
e,

ed
uc
at
io
n

26
Fr
ie
dl
an
de
r

(1
98
5)

[9
7]

Je
ru
sa
le
m
,

Is
ra
el

74
6

Je
w
is
h
ad
ul
ts

M
ul
tis
ta
ge

ra
nd

om

D
eg
re
e
of

re
lig
io
si
ty

(O
rt
ho

do
x,
tr
ad
iti
on

al
,

se
cu
la
r)

√
√

24
-h
rd

ie
ta
ry

re
ca
ll

+v
e
fo
rt
ot
al
fa
t,
sa
tu
ra
te
d
fa
t,

an
d
P
:S

ra
tio

in
m
al
es

N
on

si
gn

ifi
ca
nt

fo
rf
ru
it
an
d

ve
ge
ta
bl
e
in
ta
ke

A
ge
,r
eg
io
n
of

or
ig
in
,B

M
I,

so
ci
al
cl
as
s,

se
as
on

al
ity

27
H
ar
t(
20
04
)[
98
]

U
SA

23
75

A
du

lts
,>

35
yr
s

R
an
do

m
R
el
ig
io
us

or
ie
nt
at
io
n

(i
nt
ri
ns
ic
ve
rs
us

ex
tr
in
si
c)

√
√

Fa
t-
an
d
Fi
be
r-

R
el
at
ed

B
eh
av
io
r

Q
ue
st
io
nn

ai
re

N
on

si
gn

ifi
ca
nt

fo
rf
ru
it
an
d

ve
ge
ta
bl
e

M
or
e
ex
tr
in
si
c,
le
ss
fa
t

A
ge
,s
ex
,r
ac
e,

ed
uc
at
io
n,

m
ar
ita

ls
ta
tu
s,

ch
ur
ch

si
ze

28
H
ar
t(
20
06
)[
99
]

Se
at
tle
,U

SA
23
75

A
du

lts
,>

18
yr
s

R
an
do

m
C
oh

es
iv
en
es
so

f
re
lig
io
us

or
ga
ni
za
tio

n
m
em

be
rs

√

Fa
t-
an
d
Fi
be
r-

R
el
at
ed

B
eh
av
io
r

Q
ue
st
io
nn

ai
re

M
or
e
co
he
si
ve
ne
ss
,l
es
sf
at
,b
ut

no
ns
ig
ni
fic
an
ta
fte

rc
on

tr
ol
lin

g
fo
ra

ge
an
d
ra
ce

A
ge
,r
ac
e

29
H
ar
t(
20
07
)[
10
0]

W
as
hi
ng

to
n,

U
SA

15
20

A
du

lts
,>

18
yr
s

R
an
do

m

So
ci
al
en
vi
ro
nm

en
ta
l

(c
oh

es
io
n,

le
ad
er

su
pp

or
t,

or
de
r/
or
ga
ni
za
tio

n,
le
ad
er

co
nt
ro
l)

√
√

Fa
t-
an
d
Fi
be
r-

R
el
at
ed

B
eh
av
io
r

Q
ue
st
io
nn

ai
re

M
or
e
co
he
si
on

,m
or
e

or
de
r/
or
ga
ni
za
tio

n,
m
or
e
fr
ui
t

an
d
ve
ge
ta
bl
e

M
or
e
co
he
si
on

,
or
de
r/
or
ga
ni
za
tio

n,
lo
w
er

fa
t

A
ge
,r
ac
e,

ge
nd

er
,

ed
uc
at
io
n

m
ar
ita

ls
ta
tu
s,

si
ze

of
re
lig
io
us

or
ga
ni
za
tio

n



10 Evidence-Based Complementary and Alternative Medicine

(d
)
C
on

tin
ue
d.

N
o.

Fi
rs
ta
ut
ho

r
(p
ub

lic
at
io
n
ye
ar
)

Lo
ca
tio

n
𝑁

Po
pu

la
tio

n
Sa
m
pl
in
g

m
et
ho

d
R
/S

m
ea
su
re
s

D
ie
ta
ry

m
ea
su
re
s

D
ie
ta
ry

as
se
ss
m
en
t

m
et
ho

ds
Fi
nd

in
g

C
on

tr
ol

va
ri
ab
le
s

F/
V

Fa
t

30
H
ol
t(
20
05
)[
10
1]

M
is
so
ur
i,

U
SA

12
27

A
fr
ic
an

A
m
er
ic
an

w
om

en
,

18
–6

5
yr
s

C
on

ve
ni
en
ce

R
el
ig
io
si
ty
(b
el
ie
fs
&

be
ha
vi
or
)

(i
)4

ca
te
go
ri
es
:l
ow

re
lig
io
us

be
ha
vi
or

on
ly
,

be
lie
fo

nl
y,
hi
gh

re
lig
io
us

√

N
at
io
na
lC

an
ce
r

In
st
itu

te
’s

5-
a-
da
y
su
rv
ey

Fr
ui
t/
ve
ge
ta
bl
e
in
ta
ke

in
de
sc
en
di
ng

or
de
r:

H
ig
he
rr
el
ig
io
us
,b
eh
av
io
ro

nl
y,

be
lie
fo

nl
y,
lo
w
re
lig
io
us

Ed
uc
at
io
n,

in
co
m
e

ex
am

in
ed

as
po

te
nt
ia
l

co
va
ri
at
es

bu
t

no
ti
nc
lu
de
d

be
ca
us
e
th
ey

ar
e
no

t
as
so
ci
at
ed

w
ith

re
lig
io
us

or
ie
nt
at
io
n

31
Ly
tle

(2
00
3)

[1
02
]

M
in
ne
so
ta
,

U
SA

38
78

A
do

le
sc
en
ts

R
an
do

m
Sp
ir
itu

al
be
lie
fs
in

he
al
th

be
ha
vi
or
s

√

Fr
ui
ta
nd

ve
ge
ta
bl
e
fo
od

fr
eq
ue
nc
y
sc
al
e

(f
ro
m

B
eh
av
io
ra
l

R
is
k
Fa
ct
or

Su
rv
ei
lla
nc
e

Sy
st
em

)

H
ig
he
rs
pi
ri
tu
al
be
lie
f,
m
or
e

fr
ui
ta
nd

ve
ge
ta
bl
e

D
em

og
ra
ph

ic
&
ps
yc
ho

so
ci
al

va
ri
ab
le
s

32
O
bi
se
sa
n
(2
00

6)
[1
03
]

U
SA

14
,0
94

N
on

pr
eg
na
nt

ad
ul
ts
,>

20
yr
s

M
ul
tis
ta
ge

ra
nd

om
C
hu

rc
h
at
te
nd

an
ce

√

FF
Q

24
-h
rd

ie
ta
ry

re
ca
ll

N
on

si
gn

ifi
ca
nt

A
ge
,

so
ci
od

em
og
ra
-

ph
ic
va
ri
ab
le
s,

he
al
th

st
at
us

33
Pa
rk

(2
00

9)
[1
04
]

H
ar
tfo

rd
H
os
pi
ta
l,

U
SA

16
7

C
an
ce
r

su
rv
iv
or
s,

18
–5
5
yr
s

C
on

ve
ni
en
ce

R
el
ig
io
us

se
rv
ic
e

at
te
nd

an
ce

D
ai
ly
sp
ir
itu

al
ex
pe
ri
en
ce
s

R
el
ig
io
us

st
ru
gg
le

Sp
ir
itu

al
st
ra
in

sc
al
e

M
ed
ia
to
r:

Se
lf-
as
su
ra
nc
e

√

5
se
rv
in
gs

of
fr
ui
ta
nd

ve
ge
ta
bl
e
a
da
y

D
ai
ly
sp
ir
itu

al
ex
pe
ri
en
ce
s

po
si
tiv

el
y
re
la
te
d
to

da
ily

5
se
rv
in
gs

of
fr
ui
ta
nd

ve
ge
ta
bl
e

Se
lf-
as
su
ra
nc
e
no

tr
el
at
ed

to
5

se
rv
in
gs

of
fr
ui
ta
nd

ve
ge
ta
bl
e,

so
no

m
ed
ia
tio

n
te
st
co
nd

uc
te
d

N
o

34
Pi
te
l(
20
12
)[
10
5]

Sl
ov
ak
ia

36
74

A
do

le
sc
en
ts

St
ra
tifi

ed
ra
nd

om

R
el
ig
io
si
ty
(r
el
ig
io
us

at
te
nd

an
ce

&
se
lf-
ra
te
d

im
po

rt
an
ce

of
re
lig
io
us

fa
ith

)

√

N
o
re
gu

la
rf
ru
it

an
d
ve
ge
ta
bl
e

co
ns
um

pt
io
n

N
on

si
gn

ifi
ca
nt

A
ge
,p
ar
en
ta
l

di
vo
rc
e,

pa
re
nt
al

ed
uc
at
io
n,

fa
m
ily

affl
ue
nc
e,

de
gr
ee

of
ur
ba
ni
za
tio

n,
et
hn

ic
ity



Evidence-Based Complementary and Alternative Medicine 11

(d
)
C
on

tin
ue
d.

N
o.

Fi
rs
ta
ut
ho

r
(p
ub

lic
at
io
n
ye
ar
)

Lo
ca
tio

n
𝑁

Po
pu

la
tio

n
Sa
m
pl
in
g

m
et
ho

d
R
/S

m
ea
su
re
s

D
ie
ta
ry

m
ea
su
re
s

D
ie
ta
ry

as
se
ss
m
en
t

m
et
ho

ds
Fi
nd

in
g

C
on

tr
ol

va
ri
ab
le
s

F/
V

Fa
t

35
R
ee
ve
s(
20
12
)

[1
06
]

Ja
ck
so
n,

U
SA

23
78

A
fr
ic
an

A
m
er
ic
an
s

R
an
do

m

O
rg
an
iz
ed

re
lig
io
us

ac
tiv

ity
Pr
iv
at
e
pr
ay
er

D
ai
ly
sp
ir
itu

al
ex
pe
ri
en
ce
s

√
FF

Q
—
%
ca
lo
ri
es

fr
om

fa
t

N
on

si
gn

ifi
ca
nt

N
on

e

36
Sa
lm

oi
ra
go
-

Bl
ot
ch
er

(2
01
1)

[1
07
]

U
SA

71
,6
89

Po
st
m
en
op

au
sa
l

w
om

en
,

50
–7
9
yr
s

R
an
do

m
Se
rv
ic
e
at
te
nd

an
ce

√
FF

Q
—
sa
tu
ra
te
d

fa
ti
nt
ak
e

N
on

si
gn

ifi
ca
nt

A
ge
,r
ac
e,

m
ar
ita

ls
ta
tu
s,

ed
uc
at
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n,

he
al
th

in
su
ra
nc
e,

en
ro
llm

en
t

st
at
us
,p
hy
si
ca
l

fu
nc
tio

ni
ng

,
se
lf-
ra
te
d

he
al
th

37
Sh

m
ue
li
(2
00
7)

[1
08
]

Is
ra
el

30
56

Je
w
s,
>
18
yr
s

R
an
do

m
R
el
ig
io
si
ty
—
se
cu
la
r,

ob
se
rv
an
t,
re
lig
io
us

√
FF

Q
N
on

si
gn

ifi
ca
nt

A
ge
,g
en
de
r,

ed
uc
at
io
n,

m
ar
ita

ls
ta
tu
s,

et
hn

ic
or
ig
in
,

so
ci
oe
co
no

m
ic

st
at
us

38
U
nd

er
w
oo

d
(2
00

6)
[1
09
]

M
id
w
es
t,

U
SA

47
1

A
fr
ic
an

A
m
er
ic
an
s,

>
20

yr
s

C
on

ve
ni
en
ce

R
el
ig
io
us

in
te
ns
ity

/r
el
ig
io
us
ne
ss

Sp
ir
itu

al
in
te
ns
ity

/s
pi
ri
tu
al
ity

R
el
ig
io
us

pr
ac
tic

es

√
√

Pu
bl
ic
he
al
th

Se
rv
ic
e
he
al
th

St
yl
e
se
lf-
te
st

Ve
ry
/m

od
er
at
el
y
sp
ir
itu

al
,

ve
ry
/m

od
er
at
el
y
re
lig
io
us
,m

or
e

co
lla
bo

ra
tio

n—
le
ss
fr
ui
ta
nd

ve
ge
ta
bl
e,
m
or
e
fa
t

N
on

e

39
W
iis
t(
20
12
)[
11
0]

W
eb
-b
as
ed

81
1

Bu
dd

hi
st
s,

>
18
yr
s

C
on

ve
ni
en
ce

Bu
dd

hi
st
D
ev
ou

tn
es
s

In
de
x
(B
ud

dh
is
t

pr
ac
tic

es
&
be
lie
fs
)
√
√

FF
Q

N
on

si
gn

ifi
ca
nt

A
ge
,g
en
de
r,

in
co
m
e,

di
sa
bi
lit
y,

so
ci
al
su
pp

or
t

A
bb
re
vi
at
io
ns
:

F/
V
:f
ru
it/
ve
ge
ta
bl
e.

FF
Q
:f
oo

d
fr
eq
ue
nc
y
qu

es
tio

nn
ai
re
.

P
:S
:p
ol
yu
ns
at
ur
at
ed

fa
t:
sa
tu
ra
te
d
fa
t.



12 Evidence-Based Complementary and Alternative Medicine

females consumed more fat. One showed no significant
relationship. These five studies also examined the intake of
saturated fat, and all found that Adventists consumed less
saturated fat, even though their total fat intake was similar to
those of non-Adventists. Three of the studies also compared
the intake of unsaturated fat. Two found no significant
relationship, and one found that among Adventists, the
vegetarians consumed more unsaturated fat than Mormons,
but Adventist omnivores consumed less saturated fat than
the Mormons. Among the studies that compared unsaturated
fat intake, two also looked at the polyunsaturated fat and
saturated fat (P : S) ratio and found that Adventists had a
higher P : S ratio.

Two of the denominational studies examined Jews. One
compared the Jews with the general population in Italy and
found that there was no difference in fat intake between
the two groups. However, Jews consumed more animal fat
than the general population. Another study compared two
Jewish Hassidic sects and found that Lubavitcher Hassidim
consumed more cooked fruit.

There are two denominational studies that examined
fat intake in Buddhists. The study that compared Japanese
Zen Buddhist monks with the general population in Japan
found that Zen Monks consumed less total fat and saturated
fat, more unsaturated fat, and had a higher P : S ratio.
However, another study that compared Buddhist nuns with
Catholic nuns found no significant difference in total fat and
unsaturated fat intake, but Catholic nuns consumed more
animal fat.

One study compared Mennonites with the general US
population and found that the Mennonites have higher total
fat, saturated fat, and unsaturated fat intake. Another one
study compared Catholics with non-Catholics in Scotland
and found that Catholics consumed less pure fruit juice and
Catholic males consumed less fruit and vegetable.

Four studies were multidenominational. One examined
fruit, vegetable, and fat intake and found no significant
relationship. Three studies examined fat intake only. One
found no significant association. One study found that
religious denomination mediates fat intake. One showed that
among females, conservative protestant and those who have
no religious preferences consumed more fat than Catholics.

4.3. Degree of Religiosity Studies. A total of 25 studies were
analyzed. The R/S measures were categorized into the six
categories described in the previous section.

Table 4 shows the categories of R/S measures and their
association with fruit and vegetable intake. The most com-
monly used R/S measures are multidimensional (36.8%).
Among the 19 R/S measures, eight (42.1%) showed a positive
association with fruit and vegetable intake and another seven
(36.8%) showed no significant relationship. Among the seven
measures that showed no significant relationship, four of
them showed evidence of a positive trend in the relationship
between fruit and/or vegetable intake.

Table 5 shows the categories of R/S measures and their
association with total fat intake. The most commonly used
R/S measures are institutional (40.7%). Among the 27 R/S
measures, 15 (55.6%) showed no significant relationship

between R/S and total fat intake, while seven (25.9%) showed
a negative relationship. Among studies that show no signif-
icant relationship, five showed evidence of a positive trend,
and seven showed evidence of a negative trend.

In addition to total fat intake, three studies also examined
saturated fat intake. Two studies showed no significant
association. One examined the degree of orthodoxy among
Jews and found that more Orthodox Jews consumed less total
fat and saturated fat, more unsaturated fat, and have a higher
P : S ratio.

Only 20% (5 out of 25) of the papers reported the validity
of R/S measures, and 52% (13 out of 25) reported reliability
of at least one of the R/S measures. Of the 12 studies that
do not report reliability, three of them utilized a single-
item measure of attendance. The majority of the studies
(88%) controlled for covariates such as age, gender and
years of education. All the studies were cross-sectional. Only
one study investigated the mediator between R/S measures
and healthy behaviors. However, since the mediator (self-
assurance) was not associated with the intake of fruit and
vegetable in the study, no further mediation test was carried
out.

Table 6 shows the number of studies categorized based on
their reported relationship. Of the 17 studies that examined
the degree of R/S and fruit and vegetable intake, R/S reported
positive association with fruit and vegetable intake in about
half (52.9%) of the studies and no association in 35.3% of the
studies. As for fat intake, almost half (46.7%) of the studies
reported no association, and an equal number (20%) reported
positive and negative findings.

5. Discussion

About half of the denominational studies compared Adven-
tists and non-Adventists. Healthy eating is one of the major
teachings in the Adventist Church; other Christian denom-
inations (except the Church of Jesus Christ of the Latter-
day Saints) do not emphasize healthy eating as much as
the Adventist Church. Thus, it is not surprising to find that
Adventists generally consumed more fruit and vegetable and
less total fat and saturated fat than non-Adventists. Similarly
in studies that compared Buddhist monks and nuns with
non-Buddhists, because of the teaching of Ahimsa (do no
harm), Buddhists monks and nuns are vegans, and again it
is not surprising to find that they consumed less saturated fat
or animal fat. A weakness of denominational studies is the
assumption of homogeneity of dietary practices among the
members within a denomination. Denominational studies
only compared denominational differences as a whole and
omitted the individual variation of R/S of members within a
denomination. It is unknown whether this variation is associ-
ated with dietary intake. In addition, denominational studies
are “likely to be confounded with region and the effects
of socioeconomic status” [69], and almost all of the denomi-
national studies in this review did not control for covariates.

Four of the denominational studies included samples
from various Christian denominations. Three of the studies
found no significant relationship between religious denomi-
nation and dietary intake. The nonsignificant findings were



Evidence-Based Complementary and Alternative Medicine 13

Table 2

Categories of R/S measures Paper no. in
Table 1

Institutional

Attendance 15, 16, 19, 32,
33, 36

Organized religious activity 35
Perceived environmental church support 20
Religious social support 15, 16, 22
Cohesiveness of religious organization members 28
Social environment 29
Religious identity 15

Ideological
Religious beliefs and health 21
Religious application 15
Religious coping 15
Spiritual belief in health behaviors 31
Religious salience 17
Religious disagreement 17
Religious problem-solving 38
Religious struggle 33
Spiritual health locus of control 23
Religious health fatalism 25

Private devotion
Private prayer 35
Religious orientation (intrinsic versus extrinsic) 27

Spiritual
Daily spiritual experience 33, 35

Multidimensional
DUREL 24
Religiosity (beliefs and practices) 30
Religious participation 17
Religiosity (attendance and self-rated importance) 34
Religious involvement index 18
Jewish religiosity 26, 37
Religious commitment 15
Buddhist devoutness index 39

Generic
Religious intensity 38
Spiritual intensity 38

probably due to the fact that respondents from various
denominations interpreted questionnaire items related to R/S
differently.

Although a meta-analysis was not conducted due to
heterogeneity of R/S measures and dietary measures, the
present review on the relationship between degree of R/S
and fruit and vegetable intake points towards a positive
association; that is, a higher score of R/S is associated with
higher fruit and vegetable intake. About half of the Christian
studies showed a significant positive relationship with fruit
and vegetable. This is consistent with the previous review
that R/S is associated with a better diet [28]. The results of

the present review also suggest that the regular consumption
of fruit and vegetable may be one of the possible links
between R/S and positive health outcomes. Other possible
links include adoption of other health behaviors such as the
no smoking and drinking; better social integration and social
support from religious communities; higher self-esteem and
personal efficacy among the more religious; better coping
resources and behaviors; positive emotions from religious
practice; and healthy beliefs [42].

Six of the 17 studies reported no association between
degree of R/S and fruit and vegetable intake. All three studies
that included only Jewish samples showed no association.
This may arise because the dietary restrictions of Judaism
only revolve around meat and animal products and not on
fruit and vegetable. The consumption of fruit and vegetable is
neither restricted nor encouraged.

The findings for fat intake contradicted the previous
review. Almost half of the studies reported no association,
and an equal number reported positive and negative findings.
The contradiction might be due to the fact that the previous
review examined diet as a whole and not particularly fat
intake. There are other studies which showed that R/S was
positively associated with greater body weight [70] and
obesity [71], both of which might be related to high fat intake.
The proposed explanation of higher prevalence of obesity
among religious people could be that religious community
is more accepting towards obese people, rather than R/S
itself being the cause of obesity [71]. Kim et al. [70] found
that the positive relationship between R/S and greater body
weight disappeared after controlling for health behaviors,
particularly smoking. None of the degree of R/S studies in
this review controlled for health behaviors and it is unknown
whether similar attenuation effect was also found between
R/S and fat intake.

Most of the studies in this systematic review included
samples that were from the USA and Western countries
where Christianity is the predominant religion; only two
studies were conducted in Asia and one in Africa, even
though religion is considered important by most people on
these two continents [14]. None of the studies examined
Hinduism and Islam, the two major religions in the world
besides Christianity. Only three studies examined Buddhists;
however, they were Buddhists in the USA rather than in Asia,
even though there is a higher percentage of Buddhists in Asia.

The most frequently used dietary assessment methods
were brief dietary assessments. However, they are crude
estimates of dietary intake. For example, the Fat- and Fiber-
Related Behavior Questionnaire does not report dietary
intake per se but only an overall score of fruit and vegetable
and fat intake. Dietary records are considered the “gold
standard” of dietary assessment methods [68]. However,
only two studies in this review utilized dietary records. No
studies used dietary history, probably because they are cross-
sectional and assessing dietary history is time-consuming.

The present review also showed a diversity of R/S mea-
sures used. Even within a category (see Table 2), there was
variation. For example, the R/S measures coded as “insti-
tutional,” defined as “measures that focused on the social
and behavioral aspects of R/S” [65], included attendance and



14 Evidence-Based Complementary and Alternative Medicine

Table 3: Dietary assessments of fruit and vegetable and fat intake.

Dietary assessment methods Fruit and vegetable Fat
Total % Total %

Dietary records 0 0 2 7.4
24-hour dietary recall 2 6.9 6 22.2
Food frequency 8 27.6 9 33.3
Brief dietary assessments 19 65.5 10 37.0
Dietary history 0 0 0 0
Total 29 100.0 27 100.0

Table 4: Categories of R/S measures and fruit and vegetable intake.

Categories Relationships Total %
+ − Mixed None

Institutional 4 0 0 1 5 26.3
Ideological 1 1 1 1 4 21.1
Personal devotion 0 0 0 0 0 0.0
Existential 1 0 0 0 1 5.3
Multidimensional 2 0 1 4 7 36.8
Generic 0 0 1 1 2 10.5
Total 8 1 3 7 19 100
Mixed: when an R/S measure is positively associated with fruit intake
and negatively associated with vegetable intake or vice versa, or when a
R/S measure is positively/negatively associated with fruit intake and not
associated with vegetable intake or vice versa.

Table 5: Categories of R/S measures and total fat intake.

Categories Relationships Total %
+ − Mixed None

Institutional 2 0 1 8 11 40.7
Ideological 0 3 1 2 6 22.2
Personal devotion 1 0 0 1 2 7.4
Existential 0 0 0 1 1 3.7
Multidimensional 0 2 0 3 5 18.5
Generic 0 2 0 0 2 7.4
Total 3 7 2 15 27 100
Positive (+) relationship: a higher score of R/S measure is associated with
lower fat intake; negative relationship (−): a higher score of R/S measure is
associated with higher fat intake.
Mixed: when an R/S measure is both positively and negatively associated to
fat intake.

Table 6: Categories of studies.

Dietary intake Relationships Total
+ − Mixed 0

Fruit and vegetable 9 1 1 6 17
Fat 3∗ 3∗ 2 7 15
Notes:∗positive (+): a higher score of R/S measure is associated with lower fat
intake; negative (−): a higher score of R/S measure is associated with higher
fat intake.

religious social support, which are two different concepts that
warrant further categorization.

Because of the diversity of R/S measures and that
different R/S measures show different effects in different
populations, it was proposed that R/S should be treated
as a multidimensional construct [69]. However, less than a
third of the R/S measures included in the present review are
multidimensional.

Very little information was provided with regard to the
psychometric properties of the R/S measures. In this review,
only 20% of the papers reported validity and 52% reported
reliability of at least one R/S measure. However, only three
studies (out of 25) used single-item measures of religious
attendance. The overall quality of the degree of R/S studies
was mixed, most of the studies control for covariates, but
none of them used longitudinal data and only one attempted
mediation analysis. All the studies were cross-sectional; thus
the inference of causal relationship between R/S and fruit,
vegetable, and fat intake could not be established. In R/S
and health research, there are very few experimental studies,
and the wide use of cross-sectional data is another major
drawback, in addition to lack of clear definition of R/S [39].

There are several limitations in this review. Only peer-
reviewed studies that are published in English were included.
This could be the reason why most studies in this review
were from Western countries and included mostly Christian
samples. Second, unpublished studies were excluded and this
might lead to publication bias, since studies with significant
results are more likely to be published. Nonetheless, the
present review was the first that examined the relationship of
R/S with specific dietary intake.

The contradictory findings among the studies of degree of
R/S point to the need for more studies that control for health
behaviors, for example, smoking, and use more rigorous
dietary assessment method. In addition, more studies are
needed that include participants of other religions, especially
those of Eastern traditions and from non-Western countries.
There is also a need to use more rigorous R/S measures that
are validated, reliable, and multidimensional.

6. Conclusion

Overall, the denominational studies showed that religious
denomination is significantly related to fruit, vegetable, and
fat intake. Specifically, the Adventists consumed more fruit
and vegetable and less fat than non-Adventists. However, the
relationship between the degree of R/S and dietary intake is
mixed. The results of this review suggest that future research
on R/S and diet may help explain the possible mechanism
between religion and health. Methodology more sophisti-
cated than observational studies is required. Longitudinal
study methodologies (while still often observational) may
enhance our understanding of underlying mechanisms. As
religion is important for many people and affects their diet,
improved methodological quality of R/S and diet research
will surely shed more light on this area.

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