This chapter will address the following American College of Graduate Medical Education competencies: patient care, medical knowledge, interpersonal and communication skills, and professionalism.

Patient Care: This chapter will help the pediatric health care provider understand effective strategies for working with children and families from different cultures, an essential component of family-centered, compassionate care.

Medical Knowledge: This chapter will help the pediatric health care provider be able to define culture and cultural competency and the relationship between cultural factors such as race or ethnicity, socioeconomic status, gender, and education and use this knowledge in the prevention and treatment of childhood obesity.

Interpersonal and Communication Skills: It is important to be able to communicate effectively with patients, family, and the public across a broad range of socioeconomic and cultural groups, and this chapter will highlight culturally competent communication skills that the pediatric health care professional can use in care delivery.

Professionalism: This chapter will help the pediatric health care provider deliver effective cultural care by helping foster sensitivity and responsiveness to diverse patient populations.

Culture can be simply defined as “a system of shared understandings that shapes and, in turn, is shaped by experience”¹ or more broadly as “(something that is) learned, shared, transmitted intergenerationally, and reflected in a group’s values, beliefs, norms, practices, patterns of communication, familial roles, and other social regularities.”² The key to an understanding of culture is that it is learned and thus, is dynamic and that it is formed and influenced by both individual and group experiences.

Culture can impact all aspects of health, including beliefs surrounding healing, wellness, illness, disease, and health care services. Culture may affect health-related communications and interventions in 2 ways.^3,4 The first has been termed the “surface structure” and describes the matching of materials and messages to cultural characteristics observed within the target group. An example of this would be the incorporation of music and verbiage familiar to and preferred by a specific culture into health-related communications. The second has been termed the “deep structure,” and refers to the incorporation of cultural, social, historical, environmental, and psychological forces that have been found to influence a health behavior of interest in a specific culture. An example in which deep structure is incorporated into health communications would include acknowledging (although not necessarily accepting) that a certain culture may have a belief that illness or disease is brought on by religious causes.

Cultural sensitivity is an awareness of cultural differences without assigning inherent values to those differences. Cultural competence goes beyond cultural sensitivity and describes an ability to understand and appreciate characteristics associated with different cultures, including values, norms, and traditions important for each and refers to the practice of incorporating cultural ideas and practices into health care messages and interventions. Through cultural competence, an effort is made to more fully understand external aspects that may contribute to or affect an individual’s health and view of health—these aspects can be markedly different across cultures and can greatly impact the care of each patient.⁵ Culturally effective pediatric health care can be defined as the delivery of care within the context of appropriate physician knowledge, understanding, and appreciation of all cultural distinctions leading to optimal health outcomes.⁶

Despite the expenditure of numerous resources, the rates of childhood obesity continue to be high and are increasing among certain cultures. One of the reasons programs and policies aimed at decreasing childhood obesity may have met limited success is because they largely ignore cultural influences and perceptions regarding the disease.⁴ Indeed, research has shown that broadly targeted antiobesity public health messages have little resonance with particular minority groups.⁷ Cultural competence or effectiveness is a critical tool for addressing several of the major health disparities, including those involving childhood obesity. This is especially important, considering the growing populations of a number of cultural groups within the United States. Different cultural influences contribute greatly to the development of childhood obesity, and these differences vary considerably across cultures. Thus, they should be taken into account when developing approaches and strategies for childhood obesity prevention and treatment. Care should be exercised, however, to avoid overgeneralizing this information to all members of these cultures; instead, it should be considered routine practice to view the individual child and family individually within the context of their culture.

Childhood obesity is most prevalent among children from minority racial and ethnic groups. National studies consistently report that Latino, African American, and Native American children have the highest rates of overweight and obesity in the country. This chapter will specifically focus on Latino, African American, and Native American or Alaskan Native cultures.

The Centers for Disease Control and Prevention (CDC) routinely tracks and reports overweight and obesity prevalence data for Latino, African American, and white children through the National Health and Nutrition Examination Survey (NHANES). NHANES is a cross-sectional survey that collects health information and conducts physical examinations on noninstitutionalized children aged 2 to 19 years residing in the United States.⁸ According to the most recently released survey from 2009 to 2010, the overall prevalence of overweight (body mass index [BMI] ≥ 85th percentile) and obesity (BMI ≥ 95th percentile) was 31.8% and 16.9%, respectively, for all youth aged 2 to 19 years.⁹ Hispanic and non-Hispanic black children had among the highest prevalence of overweight (39.1%) and obesity (21.2% and 24.3%). In contrast, the prevalence of both overweight (27.9%) and obesity (14.0%) was far lower among non-Hispanic white children.

Although NHANES provides nationally representative information, data for Native American children are not available and few national studies report overweight and obesity prevalence among American Indian children. According to the CDC Pediatric Nutrition Surveillance System (PedNSS), which monitors nutritional information on children from birth through 4 years enrolled in federally funded programs that serve low-income families, obesity rates for all racial and ethnic groups stabilized from 2003 to 2008 except for Native American or Alaska Native preschool children, who continued to show an increase in obesity prevalence (from 18% in 2003 to 21% in 2008).¹⁰ Emerging evidence, points to a plateauing effect among obesity in white children, causing the disparities in obesity rates to climb.⁹

While variation exists in rates of obesity across tribes, the prevalence of overweight and obesity is widespread in Native American youth, beginning early in life, and continues to increase among American Indian children. Tribal population–based studies indicate that American Indian school-aged children have the highest prevalence of childhood overweight and obesity in the United States, with estimates ranging from 39% to 47% for overweight, and 28% for children with obesity.^11,12 Native American preschool-aged children also have the highest rates of obesity. Measured data from the 2005 Early Childhood Longitudinal Study showed American Indian 4 year olds had an obesity prevalence of 31% compared to 22% for Hispanic, 21% for non-Hispanic black, and 16% for white children.¹³

While race and ethnicity have underlying genetic components predisposing to obesity, it is a complicated and ill-defined relationship. Perhaps more important are notable metabolic differences across races. For example, fat pattern distribution has been found to differ in different races, with African American children having less visceral and hepatic fat compared to whites and Hispanics.¹⁴ Additional differences in resting metabolic rates have also been proposed to account for some of the disparities between races.¹⁵ Insulin secretion and insulin response differences have been reported, with African American and Hispanic children showing lower insulin sensitivity compared with white children.¹⁶ The thrifty gene hypothesis posits that in populations that have experienced periods of both feast and famine, the survival of individuals with the so-called “thrifty alleles”—that is, those that promote the storage of fat and energy—was favored in natural selection.¹⁷ This hypothesis offers a potential explanation for the high prevalence of obesity in certain cultures.

The prevalence of childhood obesity has increased across all education and income levels over the past decade.¹⁸ In general, however, the literature points to an association between lower socioeconomic status and increased risk for childhood obesity. This link is not fully attributable to income level, though, and is likely also affected by educational opportunities and living environment.

Data from the NHANES (2005-2008) have shown that obesity is more prevalent among children and adolescents from low-income families compared to higher-income families.¹⁸ For both boys and girls, obesity prevalence decreases as income increases. This relationship, however, is not consistent across all racial and ethnic groups. Figure 17-1 shows obesity rates by income level for each racial group.

For both boys and girls, non-Hispanic whites are most affected by poverty level, with approximately 20% of children from lower-income families (130% below poverty) having obesity, compared to approximately 10% of children whose parents have higher incomes (350% above poverty). Among non-Hispanic black and Mexican American children and adolescents, there is no significant trend in prevalence by income level for either boys or girls. Even at the highest-income level, Hispanic boys and African American girls have high rates of obesity.

Regardless of race, obesity prevalence is increasing across all income levels. In the United States, the prevalence of obesity among boys at the highest income level (household income at or above 350% of the poverty level) increased from 6.5% in 1988 to 1994 to 11.9% in 2007 to 2008. Nearly 2-fold increases were also seen at middle-income (household income between 130% and 350% of the poverty level) level (from 10.1% to 17.4% between 1988 and 1994 and 2007 and 2008) and lowest-income (household income lower than 130% the poverty level) level (from approximately 12.5% to 21.1% between 1988 and 1994 and 2007 and 2008). Notably, the prevalence of obesity is highest among lower-income boys. Among girls, the prevalence of obesity in the United States in 2007 to 2008 increased compared to 1988 to 1994 at the highest- (12.0% vs 5.2%), middle- (15.8% vs approximately 10.3%), and lowest- (19.3% vs 11.9%) income levels. Again, the prevalence of obesity was highest among girls from lower-income families.

Children and adolescents from families in which the head of the household has a college degree are less likely to have obesity when compared with those from families where the head of the household has less education, although children of parents at all education levels showed an increase in obesity in 2005 to 2008 as compared with 1988 to 1994.¹⁸ For boys who lived in households headed by an individual with a college degree, the obesity prevalence rate was 11.8%, households headed by an individual with some college education (15.9%), with high school education (17.9%), or less than a high school education (21.1%). The same was true for girls, who showed an obesity rate of 8.3% from households headed by an individual who was a college graduate, compared with households headed by an individual with some college (14.8%), high school (19.8%), or less than a high school (20.4%) education.

Although prevailing data point to a decrease in the prevalence of childhood obesity with an increase in the education level of the head of the household, this relationship does not appear to be consistent across race and ethnic groups. For example, while non-Hispanic white boys and girls show a stepwise decrease in the prevalence of obesity with increasing education level, a similar relationship is not shared by Mexican American boys and girls. In these groups, the prevalence of obesity remains nearly the same regardless of education level.¹⁸

Studies also suggest living environment has an important impact on childhood obesity. For example, neighborhood safety can greatly affect the likelihood that children will be physically active outdoors. Various environmental factors such as neighborhood walkability, proximity to higher quality parks, and access to healthy foods have been associated with decreased rates of childhood obesity. In one study, children from neighborhoods which possessed these neighborhood attributes were 59% less likely to have obesity than children from neighborhoods without these characteristics.¹⁹ Neighborhood environment remained significantly associated with childhood obesity rates even when models were controlled for parent weight status, individual, and household demographic factors. The issue of environment is further complicated when considering that a disproportionate share of minority children live in high-crime neighborhoods and areas with poor access to parks and school fields.

A large study involving Native American children, for example, reported lack of facilities and physical activity programs on various tribal reservations.²⁰ In addition, safety concerns and limited transportation have been reported as environmental barriers, which result in decreased physical activity.^21,22

Culture influences beliefs about oneself and one’s social structure. Cultural views not only influence perceptions of oneself but also contribute to the understanding of health, disease, and treatment—including the issue of childhood obesity.

Parents and other family members play a critical role in modeling eating behaviors and decision making for the types and amounts of food eaten by their children. Among Latinos, the influence of the family unit plays a major role in child eating behaviors. The dynamics both within and surrounding the Latino family often lead them to engage in frequent family meals, which have been shown to decrease the risk for overweight and obesity in non-Hispanic white and non-Hispanic black boys. Among Latino families, the solution is not as simple as sitting down to a family meal, however. A higher frequency of family meals increased the risk for obesity among Hispanic boys in low-education households, although the same association was not apparent for Hispanic girls in similar households.²³ While the authors of this study offer potential explanations for this difference among race or ethnicity, including evidence pointing to a greater reliance on fast food for family meals among Hispanics, further research is needed to probe the reason behind this discrepancy.

When discussing the family meal as a potential intervention point for behavioral change in Hispanic families, consideration should be given to the possibility that the family unit is so strong that children will have multiple “family dinners”; for example, when schedules bring fathers home late. Is the father eating his dinner later than the rest of the family and are the children sitting with him for their “second” dinner, consisting of a bowl of cereal?

Another important point for considering the impact of the family unit is to determine if, within the culture, it is normal or typical for the grandparents to either live with or have a significant role in raising the child. In a multigenerational, genealogical, prospective cohort study of the US population, a statistically significant relationship was found between child weight status and grandparental obesity that was independent of parental obesity.²⁴ The influence of the grandparents can be greater than genetics alone—often grandparents serve as child care providers, and therefore, they may make many of the dietary decisions for the children. In families where the grandparents are influential to the family unit, dynamics, and/or eating habits, it is important to engage the grandparents as much as the parents to promote healthy lifestyle change.