Contextual background

The independent Pacific nation of Fiji comprises 57% indigenous Fijians (Fijians) and 38% Indo-Fijians.¹ Fiji has experienced a series of influences and socio-political changes, including: the arrival of indentured labourers from India (1897–1916; the gaining of independence (1971); and four coups. Since the 1960s, Fiji has been exposed to increasing international movement of people, ideas and goods, a rural–urban shift, greater access to cash, increasing consumption of high-energy imported foods^2–4 and changes in actual and ideal body size.^5,6 There is a high prevalence of obesity among Fijian adults; 42% of males⁷ and > 47% of females^7–9 have a BMI > 25 kg/m². The higher prevalence of obesity in young Fijian adults than Indo-Fijians⁷ suggests that the physical environment is not the only influence on body size, and that socio-cultural, historical and economic factors also come into play.

The socio-cultural environment influences body-size preferences, as well as eating and activity patterns.^21,32 This environment comprises structural characteristics and the dominant ethos, as well as culturally-shaped values, beliefs, attitudes and expectations.^31–33 The structure of a cultural group impacts on food-related practices in families, households and wider communities, thus impacting on the body size of group members.³² The hierarchical structure of a group is defined by the relative rank and status of individuals and/or families. Status is determined by a range of variables, including gender, seniority, life stage, education, employment and wealth. Body size, eating and activity patterns are often associated with the relative status of group members. For example, older Fijian men are given more prestigious and greater quantities of food than women and younger men.³⁴ A large body size characterizes social rank, status and power for sub-Saharan Africans.³⁵ In any group, high-status family members are likely to make key decisions about the nurturing of children and the acquisition, preparation and distribution of food. For example, grandmothers in intergenerational African American households often influence infant feeding practices.³⁶

The prevailing ethos or world-view within an ethnic group also influences body-size preferences and eating and activity patterns.³² A collective ethos is characterized by expectations of interdependence, awareness of others, a sense of duty and cooperation.^37–39 The family is the most fundamental social unit.³² There is often greater connectedness with extended family members and elders are more directly involved in child-rearing among Fijian families,^40,41 ethnic minority groups in the USA^21,42,43 and Africans⁴⁴ compared to white families.

Values, beliefs, attitudes and expected behaviors also impact on body size and eating and activity patterns.^21,32 While socio-cultural influences on body size are universal, their expressions differ among populations, classes and ethnic groups.²¹ For example, ideas about what constitutes a well-nurtured or healthy body are culturally shaped. The WHO’s definition of an optimal body mass index (18.5–25 kg/m²) does not necessarily concur with the views of all ethnic groups. Fijians,^6,32 African Americans²¹ and sub-Saharan Africans³⁵ prefer larger body sizes than Europeans, although emerging evidence suggests that Fijian preferences are shifting toward Western ideals.^5,45

Although attitudes may coexist among cultural groups sharing the same environment over time, the persistence of different body ideals is evident in data for African Americans vs US whites. Several qualitative studies report that African Americans tolerate large body sizes and view the meaning of large body size differently from health professionals.²¹ A study of low-income mothers of preschool children, the majority of whom were African American, indicated that having a larger body size than the growth charts was acceptable, providing children were healthy, active and had good self-esteem.⁴⁶ A study of 9–10-year-old white and African American girls reported that African American girls with a “normal” weight were more likely to receive maternal messages that they were underweight than white girls.⁴⁷ Similarly, African migrant adults may have maintained their preference for a large body size after migration to Australia, continuing to view a robust body as beautiful and as an expression of a family’s wealth.³⁵ However, it is not yet clear whether African migrants ’ body-size ideals will persist in Australia, given the increasing prevalence of obesity and awareness of obesity-related diseases.

Parents and/or primary caregivers have a major influence on their children’s eating and activity patterns via their ideals about a healthy body, knowledge about healthy eating and exercise, food available at home, structuring of family meals, shaping of opportunities for physical activity and modeling of acceptable behaviors and body sizes.⁴⁸ Eating and activity patterns that result in a large body size may be considered acceptable, or even desirable, to achieve a “healthy looking” child. A well-nurtured body may indicate high status and good health, as well as being associated with fertility in environments where people have been undernourished, for example, in some parts of Africa.⁴⁹ These associations between a robust body, social status and health are reflected in the post-migration eating patterns of African migrants in Australia, with reduced consumption of foods that are considered less desirable and seen as survival food for poor people, for example, vegetables and fruit.³⁵

Parents’ and children’s respective roles are culturally influenced and are likely to differ across ethnic groups. For example, many children in Western/white families have substantial control of what and how much they eat,⁵⁰ especially during adolescence.⁴⁸ This is not necessarily the case for children from all ethnic groups; many parents in Fijian⁵¹ and African⁴⁴ families have an authoritarian parenting style, with children having little control over their eating patterns. This has also been reported for African American families.²¹

The expression of socio-cultural factors varies within ethnic groups. For example, children experience the same exposures differently from their parents, who in turn have different perceptions from older generations. These intergenerational differences have major implications for body-size preferences, as well as ideas about how to attain the optimal body size. Studies with Fijians,⁵² African Americans⁴⁷ and African migrants in Australia^28,35 all report that adolescents preferred a leaner body than their parents. Thirty-one percent of Fijian adolescent females believed that that their parents wanted them to eat more than they thought was ideal. ⁵ In a US cohort study of pre-adolescent girls, African Americans were much more likely than white girls to report trying to gain weight.⁴⁷ Weight-gain strategies were associated with parents, especially in those with less education, telling girls that they were too thin.⁴⁷ African migrant parents reinforced traditional African body-size ideals using weight-gain strategies to achieve a culturally-desired body size, overfeeding their offspring and/or promoting energy-dense foods.⁵³ These strategies were often resisted by young African migrants.⁵³

There are also intergenerational differences between parents and older family members in terms of body-size preferences and body-change strategies. Fijian mothers reported that their mothers/mothers-in-law shaped their ideas about appropriate infant feeding and optimal body size.⁵⁴ Co-resident grandmothers often dominated feeding decisions in African American families, especially when they were key caregivers.²¹

Children from all three ethnic groups are exposed to a wide continuum of values and expectations from parents, older generations, siblings and peers. Children in ethnic minority groups are likely to experience a wider spectrum of body-size ideals and eating and activity practices compared to Fijians, the largest ethnic group in Fiji. African American and African migrant children are not only exposed to the different values, ideals and practices within their own group, but also those of other ethnic groups with whom they live while retaining a separate cultural identity. Both realities may be influential. When competing cultural perspectives are incongruent, the context, for example, the types and amounts of interactions with the mainstream groups, will determine which perspectives are most influential and the types of intrapersonal conflicts that arise from trying to be bicultural.³³

Cultural influences are also derived from various media sources and marketing strategies that interact with culturally-shaped preferences and practices—reflecting the larger culture in the case of ethnic minority groups—thus influencing body-size preferences and eating and activity patterns. For example, within three years of television exposure in Fiji, Fijian female adolescents⁵ and adults⁶ changed their body-size ideals; compared to a pre-television cohort. More adult females: were dissatisfied with their bodies; believed that body size could be changed; and made an effort to do so.⁶ Marketing practices also contribute to an obesogenic environment for African American children.^55,56 Studies examining the frequency and content of food advertisements in television markets with a high viewership of African American children have documented the higher than average occurrence of food advertisements, especially targeting high-calorie snack foods, soft drinks and candy, relative to advertisements in predominantly white markets.^21,57–59 The impact of the Australian media and marketing on African migrant children in Australia has yet to be studied.

While socio-cultural factors underpin body size, eating and activity patterns, the socio-cultural environment is shaped by historical,^21,32 physical and economic factors.^21,30,60 We now discuss interactions between the socio-cultural environment and historical and economic factors.

Historical events influence body-size ideals and strategies to achieve these ideals. The cultural acceptability of overeating may be conditioned by economic deprivation, with feasting occurring whenever food is available.⁶¹ The most valued foods may be associated with limited access and/or survival, for example, meat, fats, and sugars.²¹ These foods are often related to high social status and symbolize integration into the US mainstream society and/or upward social mobility.⁶² The status of such foods may persist for generations, even when they become cheap and abundant. The persistent preference for a large body size among African migrant adults in Australia may reflect previous experiences of hunger and deprivation, as well as experiences with tuberculosis and HIV/AIDS.³⁵

In terms of the economic environment, food cost and accessibility result in people with unstable or limited discretionary incomes relying on foods with high energy density^21,63 because they are the least expensive,⁶⁴ and more accessible. These two factors are directly related to the social and economic environments of the three ethnic groups considered here. For example, increased availability of high-energy imported foods in Fiji has been associated with a concomitant reduction in the consumption of traditional foods.^3,4 In the case of African Americans, there is a disproportionate prevalence of poverty and a high absolute or relative density of “fast food” outlets in black neighborhoods and impoverished areas.^65,66 African migrant children in Australia have probably been exposed to a greater range and availability of high-energy foods in Australia than in their countries of origin. Fijian, African American⁶⁷ and African migrant families often have high levels of economic stress and insecurity, including food insecurity.

Environmental contexts are in dynamic interaction with socio-cultural factors^21,32 and can either enhance cultural predispositions²¹ or limit or prevent the expression of cultural preferences.²¹ The ability of parents to provide healthy foods is influenced by food availability and access, other market-related variables and economic stress,^21,28 making it critical to consider the socio-cultural environment in a broader context, albeit through a socio-cultural lens.

Some programs designed to promote a healthy body size during childhood have incorporated socio-cultural components. We draw on examples of three such approaches: cultural-relevance, tailoring and cultural competence.

Culturally-relevant programs

The Pacific Obesity Prevention in Communities (OPIC) project aimed to reduce weight gain in adolescents via culturally-relevant programs where local communities set goals, determined action plans and implemented culturally-specific interventions, using the ANGELO framework.^30,68 Cultural relevance was determined via interviews that yielded adolescents ’ perspectives on socio-cultural factors that impacted on body size, eating and activity patterns, and consultations with adolescents and adults from target communities.^68,69 The Fiji team exchanged newly-acquired skills with community leaders and stake-holders who, in turn, advised on priorities and supported program implementation. Adolescent leaders were active in school health committees, completed health-promotion courses, and/or promoted and modeled healthy eating and activity patterns.

Culturally-tailored programs

“Tailoring” is a deliberate strategy that responds to important individual and subgroup variables when designing interventions.⁷⁰ A critical component of tailoring is identifying “focal points” for interventions, such as dinner time (setting) and parents of children in day care (population) relying on fast foods (behavior). Many elements of tailoring are related to cultural variables, for example, attitudes toward breastfeeding of African American teenage mothers enrolled in supplemental nutrition programs. Two examples of culturally-tailored programs that promote a healthy weight in young African American children are the Hip-Hop to Health Junior program for 3–5-year-old African American and Latino children in Head Start programs⁷¹ and the Memphis Girls Health Enrichment Multi-site Studies (GEMS) project for 8–10-year-old African American girls.⁷² The Hip-Hop to Health Junior program comprised “developmentally, culturally and linguistically appropriate diets and physical activity”.⁷¹ The GEMS project comprised a carefully tailored, family-based intervention that aimed to improve families ’ eating and activity patterns.⁷²

Culturally competent programs

Obesity initiatives in Australia that adopt “the one approach fits all” are more likely to increase inequalities because most ethnic minority groups experience language difficulties, live in high-rise estates, do not understand complex health messages, and experience social exclusion, discrimination and poverty.¹⁴ Together, these factors influence the eating and activity patterns of African migrants in Australia. These barriers can be overcome by working within a “cultural competence” framework, which extends beyond awareness of cultural differences to encompass behaviors, attitudes and policies that characterize an agency and support effective work in cross-cultural situations.⁷³ A system or agency is culturally competent when it: i) values diversity; ii) is capable of cultural self-assessment, iii) is conscious of the dynamics that occur when cultures interact, iv) institutionalizes cultural knowledge, and v) adapts services to reflect the diversity between and within cultures.⁷⁴

These three culturally-specific approaches (cultural relevance, cultural tailoring, cultural competence) have common threads: recognition that the socio-cultural environment shapes body-size preferences and associated behaviors; identification and integration of socio-cultural factors; consideration of socio-cultural factors in a broad context that includes historical, physical, economic and policy environments; engagement with experts and key community members during program design and implementation.

What is the evidence to suggest that these three approaches influence either intervention uptake or outcomes in terms of BMI? Data on the effectiveness of the Pacific OPIC project intervention in Fiji are not yet available. Programs that actively engage families have been more effective in reducing childhood obesity than programs that do not.⁷⁵ Data on programs designed for young African American children suggest that parents are key to developing an environment that successfully fosters healthy eating, activity and body image.^48,72 The culturally-tailored programs with African American children described earlier have produced encouraging results in their follow-up measures. Children in the intervention group of the Hip-Hop to Health Junior program had significantly smaller increases in BMI compared to the control group.⁷¹ Girls in the intervention group of the Girls Health Enrichment Multi-site Studies showed a significant decrease in excess weight gain, television viewing hours, and dinners eaten in front of television, compared to the control group.⁷⁶

In summary, socio-cultural factors shape body-size preferences and eating and activity patterns. Dominant world-views, values, attitudes and behaviors vary within and between ethnic groups. Within-group variations are often defined by intergenerational differences in body size preferences and ideas about how to attain these ideals. Intergenerational differences may be amplified with recent migration experiences, for example, with African migrants in Australia. The relatively high prevalence of childhood obesity for Fijians and African Americans, and potentially for Australian African migrants compared to other subgroups in their respective countries appears to be explained not only in terms of cultural differences, but also in interaction with economic disadvantage and physical and media environments that fail to support healthy behaviors. Emerging evidence from the USA suggests that the careful and timely integration of socio-cultural factors into culturally-tailored programs to promote healthy behaviors and body size are more effective in terms of both uptake and outcomes than those that do not address socio-cultural considerations. There is a need for more studies that measure the relative impact of socio-cultural factors on the effectiveness of programs to prevent obesity in children from different ethnic groups.

The three ethnic groups considered live in very different contexts; indigenous Fijians are the dominant ethnic group in their homeland, while both African Americans and African migrants in Australia are minority groups in their respective countries. However, the many common socio-cultural factors that appear to impact on the body size of children in these groups include: adults ’ acceptance of a larger body size than health professionals consider to be healthy; the generous provision of food to attain this ideal body size; and the family being the most fundamental influence on children’s eating and activity patterns. Importantly, there are common principles for integrating socio-cultural factors into effective interventions designed to reduce childhood obesity in these three ethnic groups and, indeed, in other ethnic groups.

What else can be done to ensure the effectiveness of programs that promote a healthy weight for children? Given the fundamental nature of socio-cultural influences and the available evidence for these three cultural groups, we recommend that programs to promote healthy eating, activity and body size during childhood should:

• integrate socio-cultural factors and culturally appropriate approaches into their design and implementation;
  
• evaluate the socio-cultural environment in interaction with historical factors and economic, policy and physical environments
  
• recognize that culturally specific factors are an asset rather than a deficit and use cultural structures and other socio-cultural factors to ensure cultural relevance
  
• actively engage key family and community members and local experts throughout design and implementation phases
  
• emphasize healthy eating and activities rather than weight per se in order to avoid an unhealthy body image and the uptake of unhealthy strategies to attain the thin ideal that is promoted by the media and other Western influences
  
• recognize that there may be less motivation to prevent weight gain in ethnic groups that value a robust body size, and explore culturally tailored strategies that provide relevant and sufficiently strong motivations for change in the targeted parenting behaviors
  
• Recognize that children are exposed to numerous competing influences, especially children from ethnic minority groups who experience strong influences from within their own group, as well as from larger ethnic groups.