RESEARCH AND PROFESSIONAL BRIEFS

hildhood obesity, a risk factor for

C adult obesity, is an increasing global

concern (1-5). Studies show that both
genetic and environmental factors, includ-
ing familial and sociocultural factors, con-
tribute to childhood obesity (3,6-12). Atti-
tudes about food and eating are learned
and reinforced within the home (13).
In socializing children, parents instill a
sense of group membership, which is
used in learning cultural values and be-
haviors leading to self-definition (14).
The significance of food among cultural
groups is demonstrated by the offering of
food as a sign of hospitality and the belief
about certain food taboos (15,16). Per-
ception of “weight normalcy” or accept-
able body image may be influenced by
cultural beliefs and practices, varying by
socioeconomic status and dietary habits
of various ethnic groups (17,18).
We sought to identify sociocultural
perceptions, beliefs, attitudes, and be-
haviors related to child feeding and
weight normalcy. The Commonwealth of
the Northern Mariana Islands (CNMI), a
Prevention of childhood obesity: US jurisdiction comprised of 14 islands
located between the Philippines and the
Sociocultural and familial factors international date line, provided many of
the ideal conditions necessary to con-
duct such research, including high rates
MOZHDEH B. BRUSS, MPH, RD; JOSEPH MORRIS, PhD; of obesity and a stable multicultural pop-
LINDA DANNISON, PhD ulation with distinct caregiving percep-
tions and attitudes that may influence
child feeding and children’s weight sta-
tus (19,20). Food plays a major role in
family gatherings and socialization. Fam-
ily, especially maternal grandmothers,
ABSTRACT influence infant-feeding practices (20).
The purpose of this study was to ex-
This study examined sociocultural and familial factors related to the prevention of amine sociocultural and familial factors
childhood obesity. Primary caregivers of 6- to10-year-old children representing related to the prevention of childhood
several ethnic populations in Saipan participated in 4 focus groups (N⫽32). obesity. This study will aid in the design
Trained moderators used semi-structured interviews and qualitative methods were and development of culturally appropri-
used in data analysis. A central theme with several related factors emerged. The ate community- and family-based inter-
theme was a conflict expressed by the primary caregiver between sociocultural val- vention strategies in the prevention of
ues, family expectations, traditional dietary beliefs and attitudes, and knowledge childhood obesity.
about food and disease. These findings have important implications for designing
culturally sensitive interventions for prevention of childhood obesity. J Am Diet METHODS
Assoc. 2003;103:1042-1045.
Study Design and Population
In February 2002, 4 focus groups were
M. B. Bruss is assistant professor and L. Dannison is professor and chair, conducted in the CNMI (total partici-
Department of Family and Consumer Sciences, and J. Morris is a professor pants⫽32). Asian/Pacific Island partici-
and chair of Counselor Education and Counseling Psychology, all with the pants included mothers, fathers, and
College of Education, Western Michigan University, Kalamazoo. grandparents of children age 6 to10
Address correspondence to: Mozhdeh B. Bruss, MPH, RD, Assistant Profes- years from 4 public and private schools in
sor, 3018 Kohrman Hall, Department of Family and Consumer Sciences, Col- Saipan. Participants self-reported eth-
lege of Education, Western Michigan University, Kalamazoo, MI 49008. nicity and age of children in the house-
E-mail: brussm@wmich.edu hold. The Western Michigan University
Copyright © 2003 by the American Dietetic Association. Human Subject Review Board approved
0002-8223/03/10308-0012$35.00/0 the research proposal, and informed
doi: 10.1053/jada.2003.50192 consent of the participants was obtained.

1042 / August 2003 Volume 103 Number 8


Data Analysis
Qualitative methods were used to collect
and analyze the data. Three trained mod-
erators used a semi-structured interview
protocol in English (the common spoken
language). The questions investigated per-
ception, attitudes, and behaviors related to
physical activity, physical inactivity, food
preferences, weight normalcy, and care-
giving practices associated with childhood
obesity. Participants were invited to an-
swer open-ended questions related to
their personal experience, their children’s
experience, and behaviors that may influ-
ence child feeding and weight status re-
lated to 6- to 10-year-old children. Inter-
views were audiotaped and transcribed by
a Saipan-based transcription agency. Con-
tent of transcripts were verified for accu-
racy by the primary investigators. Data
analysis was conducted using methods
previously described by Bogden and Bik-
len, 1998 (21).
RESULTS
Among participants, the mother was typ-
ically identified as the primary caregiver.
A central theme with several related fac-
tors emerged from this study, with po-
tential impact on childhood obesity. The
theme was a conflict expressed by the
primary caregiver between sociocultural
values, family expectations, traditional
dietary beliefs and attitudes, and knowl-
edge of food and disease (Table 1).
Primary caregivers,
especially the mother,
seem to experience
inner dissonance when
child-feeding practices
conflict with deeply
rooted cultural values
related to food
Primary caregivers, especially the
mother, seem to experience inner disso-
nance when child-feeding practices con-
flict with deeply rooted cultural values
related to food. Food in Micronesia is
perceived as a demonstration of love,
generosity, and care. With the marked
presence of type 2 diabetes in this re-
gion, an increasing number of individuals
are aware of the role of diet and activity
in chronic diseases. As a result, some
parents recognize the need for child-
feeding interventions related to the pro-
RESEARCH AND PROFESSIONAL BRIEFS
tection of their children’s health and
well-being. Caregivers reported serious
consideration of dietary messages re-
lated to diabetes and the intense conflict
that it elicits in response to sociocultural
and familial beliefs regarding child feed-
ing. Specifically, mothers reported con-
flict between their cultural values that
associate food and love with their per-
ception that preventing diabetes re-
quires avoiding certain foods. Although
parents recognize their influence on
their children’s feeding practices, they
identified the challenges posed by the
community on their ability to promote
healthful eating habits for their children.
Regarding weight status, parents be-
lieve that individual characteristics influ-
enced by specific factors determine their
children’s weight. These include genetic
makeup, physiology and metabolism, ac-
tivity level, and dietary intake. However,
cultural differences were observed
among the different ethnic groups re-
garding attitudes about children’s weight
status. These differences were reported
as a source of conflict in multiethnic fam-
ilies. Among the Filipinos, for example,
overweight was less acceptable than
among the Micronesians, who perceive
thinness as resulting from illness and
therefore less desirable.
Intergenerational conflict related to
child feeding was observed between
mothers and grandmothers, beginning
soon after a child’s birth. Mothers identi-
fied the source of conflict as the substan-
tial influence of grandmothers’ advice
about child feeding, and the undermin-
ing of the mother’s role in child feeding.
It was noted that children believe that
grandparents and elderly aunts give
them what they want despite parental
disapproval. Parents also indicated that
grandmothers, when they perceive that
their grandchildren are thin, may con-
clude that the mothers are inadequately
feeding the children.
Both mothers and fathers reported in-
trafamily conflict related to child feed-
ing. Mothers identified fathers’ weight
status as a factor influencing child feed-
ing and a source of conflict in the family.
Fathers expressed the belief that while
children decide how much to eat, moth-
ers are responsible for child feeding, in-
cluding control of discretionary sweets.
Parental conflict with child feeding also
involved the children. Parents, who were
challenged with children’s finicky eating
behavior, reported deep concern and in-
effective child-feeding practices.
Journal of THE AMERICAN DIETETIC ASSOCIATION / 1043
The prevention of
obesity has a direct
benefit to individuals,
families, and society
In general, parents reported that they
try to avoid emotional conflicts related to
child feeding. In a cultural environment
in which feeding children to ensure an
acceptable body image is highly valued,
the process seems to elicit conflict and
intense emotional reaction in parents.
Caregivers believe that limiting food in-
take as an intervention for obese chil-
dren may have negative emotional impli-
cations. Parents find it easier to avoid
purchasing certain foods than to have
conflict at home.
DISCUSSION
The prevention of obesity has a direct
benefit to individuals, families, and soci-
ety. The cost of obesity in the United
States is $99.2 billion annually (22). The
increasing global concern for childhood
obesity, a risk factor for adult obesity,
may suggest an expected increase in
these figures (1). Childhood obesity is
especially pressing in US ethnic minority
populations (2,6), with the CNMI af-
fected significantly by this problem (19).
In a sample of CNMI school-aged chil-
dren, the prevalence of overweight and
obesity was 33%.
Familial and sociocultural factors have
been associated with childhood obesity
(12). Attitudes about food and eating are
learned and reinforced within the home
(13). Among some Pacific Islanders,
“Eating, the sharing of food, is a means
by which to establish physical commin-
gling, interdependence and oneness”
(15). Our findings suggest that family
members reinforce cultural values re-
lated to diet and weight status, resulting
in conflict for the primary caregiver.
In addition, limited awareness of dis-
ease and its relationship to diet was iden-
tified as a stress factor for primary care-
givers attempting appropriate child-
feeding practices. These factors seem to
create personal, intergenerational, and
intrafamily conflict, resulting in ineffec-
tive child-feeding practices. Conse-
quently, parents may struggle to find
strategies that can help them deal effec-
tively with these conflicts.
Different ethnic groups may have dif-
ferent perceptions of body image and
weight status. In a study of predomi-

Table 1
Sample primary caregiver responses (N⫽32)
Potential sources of
conflict
Sociocultural values
Family expectations
Traditional dietary beliefs
and attitudes
Knowledge of food and
disease
Table 2
Suggested strategies for professionals
Application
Cultural consideration
Intervention/counseling
strategies
Professional development
1044 / August 2003 Volume 103 Number 8
RESEARCH AND PROFESSIONAL BRIEFS
Sample responses
“When you think you really love your child, and your child says
‘Mom I want this,’ you want to hold the feeling of that child so
you go ahead and give it to them.”
“So my mom says, ‘your kids are very slim’. They’re tall and she
thinks that I’m not feeding them and I say ‘no I am feeding
them’.”
“When they are still babies, the doctor tells you, ‘you should give
them just this much food’ and then you go home. Your
grandparents tell you, ‘are you feeding that child?’ and you give
them more food.”
“My husband likes to tell me to give them [our children] whatever
food. I know it’s bad, and we always argue.”
“The culture on Saipan, the fat one is the healthy one. ‘Oh, good,
he is eating the right food.’ But when they are skinny, ‘oh, my
goodness, nobody is feeding that child’.”
“We have to teach them about diabetes . . . tell them that they have
to reduce food intake and sugar in their diet or they will become
diabetic. So we have to reduce all intakes, more exercise and
reduce sweets.”
Suggest strategies
Engage client in identifying individual beliefs, attitudes, and values
related to child feeding and weight status.
Recognize and be sensitive to potential conflicts resulting from
caregivers’ desire to maintain social harmony.
Encourage the client to share strategies commonly used to prevent
conflict.
Determine the emotional significance of client’s comment, such as in
this example, “I think that the kid needs to be encouraged more.
Give them more motivation to do more activities, and something
fun to do, because I know it is really hard to just cut their food.
They are going to feel bad.”
Recognize the power of the network surrounding and influencing the
primary caregiver and work holistically with the family and within
the community structure to enable change.
Conduct focus groups to identify acceptable strategies and to
negotiate on culturally appropriate behavior outcomes, as
reflected in a respondent’s comment, “We need to do this
[participate in such focus groups] more often. It’s nice to hear
what other parents think.”
Develop a step-by-step process of behavior change with the client,
while considering sociocultural and familial beliefs, attitudes and
values.
Use qualitative/quantitative methods to study different ethnic
groups’ beliefs, attitudes, and values related to food and weight
status.
nantly Hispanic parents, more than one
third did not believe that their obese chil-
dren were overweight. This belief, cou-
pled with certain feeding practices, may
put children at increased risk for obesity
(23,24). Cultural differences were also
observed among different ethnic groups
in relation to their attitudes about chil-
dren’s weight status. These differences
can be a source of conflict in multiethnic
families. Perception of “weight nor-
malcy” may be influenced by cultural be-
liefs and practices. Among Micronesians,
being overweight or obese is less stigma-
tized and a more acceptable social norm
(18). Our findings indicate an observed
difference between Pacific-Island and
Filipino participants.
Food taboos and religious use of food
are common among cultural groups in
the Pacific Islands (15,16). Our findings
indicate that caregivers may identify cer-
tain foods as food taboos because of their
health implications and encourage their
avoidance, which may become a source
of conflict. Family, especially maternal
grandmothers, influence infant-feeding
practices (20). Our results suggest that
mothers may face ostensible social pres-
sure to respond to intergenerational ad-
vice as it relates to child feeding. This
study suggests the need to further inves-
tigate the presence of such conflicts
among other ethnic groups in developing
culturally appropriate nutrition educa-
tion intervention strategies.
Although the results of this inquiry can-
not be generalized, the multiethnic compo-
sition of the focus groups strengthens its
potential for applicability.
APPLICATIONS
■ From an ethnographic perspective,
this study looked at value and belief sys-
tems of people as revealed in child-feed-
ing practices and weight normalcy. This
study examined child-feeding practices
within the social context of families influ-
enced by culture. The findings have im-
portant implications for dietitians in the
prevention of childhood obesity (Table
2).
■ Recognizing and being sensitive to po-
tential conflicts may result in more effec-
tive nutrition counseling. Dietitians who
gain the trust of their clients may be
more likely to recognize the presence of
such conflicts and negotiate culturally
acceptable behavior objectives. With the
increasing rates of childhood obesity
among ethnic minority populations, die-

titians need to develop a deeper under-
standing of sociocultural and familial in-
tricacies in these at-risk communities.
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