Breastfeeding, Bottle-feeding, and Introduction of Solid Foods
There is a great deal of cultural variability in terms of acceptable feeding practices and behaviors. Intergenerational factors contribute to patients' and families' eating and feeding practices. These cultural and generational contributing factors are pronounced during infancy and early childhood. It is during this period that decisions are made about breastfeeding or bottle-feeding, parental responses to crying cues in preverbal infants are formulated, and decisions are made regarding the introduction of solid foods. The timing and type of food that is introduced may be affected by the parents' and extended family's beliefs and cultural practices. Pediatricians should inquire about these issues and should try to elicit any dissonance between the parents' and extended family's food-related expectations.
Minorities share a disproportionate burden of overweight and obesity. Specifically, the prevalence of overweight and obesity is highest among Hispanic/Latinos, American Indians, and African Americans. While some data do suggest that the obesity epidemic has stabilized in some communities, the health disparity between minorities and non-minorities has persisted. The length of time that immigrant mothers have lived in the United States and their degree of acculturation may adversely affect the rate of childhood obesity. Specifically, as families live for longer periods in the United States and become more acclimated to the American lifestyle, these immigrant families tend to acquire a more sedentary lifestyle, consume less wholesome diets, and purchase more fast foods. In addition to encouraging exercise and low-fat diets, pediatricians should consider the added barriers to healthy lifestyles, such as the availability of affordable fruits and vegetables in minority or inner-city urban populations, the built environment (safe parks and "green spaces"), availability of junk food in school vending machines, and cultural food preparation practices. Pediatricians should also inquire about the preparation method (eg, baked, fried, deep-fried) of culture-specific or traditional foods.
Poor, minority, migrant, homeless, and other underserved populations are at risk for being food insecure (having a limited or uncertain supply of food) and the associated child health sequelae. Researchers have reported a relationship between food insecurity and overweight; developmental, behavioral, or academic problems; and other adverse health consequences.1 Immigrant families that lived in poverty in their country of origin may consider buying fast foods or purchasing food in abundance as a newly acquired privilege for themselves and their children. In some instances, the pendulum swings from food insecurity to more abundant but unhealthy foods. Pediatricians should screen all children (with or without weight loss or history of hunger) for the presence of food insecurity as a pediatric risk factor. Prompt referral to Women, Infants, and Children services; Supplemental Nutrition Assistance Program (formerly food stamp program); or other social services is recommended.
Body Image Perceptions
Parents' and patients' perception of body image and specifically what they consider normal or overweight body size is influenced by their culture. In Hispanic cultures, for example, parents often view overweight or obese babies and children favorably and consider them to be "healthy." Pediatricians should be aware that these perceptions or hunger-related past experiences exist and discuss healthy weight-to-height standards with parents.
1. Rose-Jacobs R, Black MM, Casey PH, et al. Household food insecurity: associations with at-risk infant and toddler development. Pediatrics. 2008;121:65–72
Chapter 3 Resources
Resource 3A: Book chapter: "Promoting Healthy Nutrition"
Hagan JF, Shaw JS, Duncan PM, eds. Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents. 4th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2017:167-192.
Bright Futures provides detailed information on well-child care for health care practitioners. This chapter specifically focuses on food and nutrition behaviors that are influenced by myriad environmental and cultural forces.
Resource 3B: "Influence of Race, Ethnicity, and Culture on Childhood Obesity: Implications for Prevention and Treatment: A Consensus Statement of Shaping America's Health and the Obesity Society"
Caprio S, Daniels SR, Drewnowski A, et al. Diabetes Care. 2008;31:2211–2221