Cross-cultural Medicine

Cultural Variation-Nutritional and Clinical Implications

NELSON FREIMER, MD, and DEAN ECHENBERG, MD, PhD, San Francisco, andNORMAN KRETCHMER, MD, PhD, Berkeley, California

Cultural variation may play an important role in human nutrition and must be consideredin either clinical or public health intervention particularly in areas with large immigrantpopulations. Acculturative and environmental change influence the food habits and healthof transitional groups. Nutritional assessment may be complicated by cultural variation.The relationship between ethnicity and nutrition may be of evolutionary significance. Foodbeliefs may have beneficial or detrimental effects on health status. The study of accultur-ating populations may elucidate the pathogenesis of nutrition-related chronic diseases.Appreciation of the interaction of culture and nutrition may be of benefit to physicians andnutritionists in clinical practice and to those concerned with the prevention of nutrition-related chronic diseases.

Cultural variation plays an important role in humannutrition and must be considered in either clinical

or public health intervention. A large body of literatureis now available concerned with the food beliefs andpractices of many different cultural groups. This litera-ture ranges from participant-observation studies in smallpreindustrial societies newly exposed to Western culturesto large epidemiological surveys in highly developedcountries. Because of the potentially confounding effectsof political, economic and individual variation, andbecause of the complexity of nutritional assessment, ithas been difficult to evaluate the interrelationship ofnutritional status and cultural influences. Many recentinvestigations have sought to elucidate the nutritionalimportance of culture by focusing on populations in theprocess of acculturation. The significance of studyingnutrition in transitional cultures has attained increasedimportance in the past decade, as the number of recentimmigrants to the United States is greater than at anytime in the past half century.' This influx has resultedin a drastic alteration in the demographic profile ofcommunities, particularly in California, with Asian andHispanic Americans representing the fastest growingsegments of that population.' Additionally, these im-migration patterns may be perceived as having shifted

large populations from marginally industrialized totechnologically advanced regions. Since these immi-grants are mostly young and will be characterized bya birthrate much higher than the American mean,' itis likely that we will encounter many of the maternaland child health problems associated with less developedcountries, including nutritional deficiencies, anemia,chronic infection and intestinal parasitism.2 Culturallydetermined beliefs and practices regarding food use andhealth must be considered in the promotion of any formof intervention.

The food practices of a transitional group are subjectto pressures for change which may be of two types;environmental and acculturative. There is evidence thatfood habits may be appropriate in a particular environ-ment yet may lead to nutritional deficiencies or diseaseunder different conditions. Or, food habits may bealtered in response to "demands" for acculturation; suchchanges may either improve or worsen the nutritionalquality of the diet and may be of importance in theepidemiology of several chronic diseases including den-tal caries, coronary artery disease, adult onset diabetesmellitus and hypertension. By studying the relationshipbetween changes in food habits and alteration in theprevalence of such diseases, it is possible to describe

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Refer to: Freimer N, Echenberg D, Kretchmer N: Cultural variation-Nutritional and clinical implications, In Cross-cultural medicine. West J Med1983 Dec; 139:928-933.

From the Department of Pediatrics, University of California, San Francisco (Dr Freimer); the Department of Nutritional Sciences, University ofCalifornia, Berkeley (Dr Kretchmer), and the Bay Area Human Nutrition Center, San Francisco General Hospital Medical Center (Dr Echenberg).

This study was supported in part by a grant from the San Francisco Foundation.Reprint reqtuests to Norman Kretchmer, MD, PhD, Department of Nutritional Sciences, 309 Morgan Hall, University of California, Berkeley, CA 94720.

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more clearly their natural history and to formulatetentative suggestions for their prevention.

In this paper we will discuss general patterns ofrelationships between cultural beliefs and practices andnutritional health. We will describe differences in foodhabits and their impact on nutritional assessment andstatus, note illustrative nutrition-related diseases andtheir association with particular food practices in situa-tions of environmental and cultural change, and exam-ine strategies for prevention and treatment of nutritionaldisease.

Nutritional AssessmentThe measurement of food intake and nutritional

assessment are complicated by cultural variation. Jer-ome and Pelto3 have highlighted the nutritional impor-tance of a number of culturally determined variablesincluding frequency of meals eaten away from home,form and content of occasional ceremonial meals andthe degree of regularity of consumption patterns. Be-cause of these factors the potential inaccuracies ofstandard clinical and research methods such as 24-hourdietary recalls or three-day food records becomes ob-vious. For instance, among low income urban blackfamilies in the United States, elaborate weekend mealsare very different from those of the rest of the weekand provide a substantial portion of total nutrients.4 Inaddition, cultural groups may have concepts of whatconstitutes a food that are very different from those ofnutritionists. For example, in Latin America, wildgreens are rarely listed in food records although theymay be an important source of vitamins.5 Anothersource of measurement error is the use of dietaryhandbooks, whose nutritional tables are largely basedon Western diets." Thus, among Vietnamese immigrantsto England it had been noted that, although calciumstores seemed adequate, the dietary intake of calciumwas very low with almost no consumption of dairyproducts. Biochemical studies have indicated significantcalcium supplies from dietary sources not usually con-sidered, including pork bones and shells.7

Nutritional assessment is sometimes affected byethnicity per se even when dietary intake does notappear to vary. Ethnicity may be associated with histor-ical isolation sufficient to have permitted biologic evolu-tionary changes resulting in unique nutritional needs.For instance, Young and Scrimshaw8'9 have notedmarked differences in urinary nitrogen excretion inhealthy Taiwanese and American college students fedsimilar protein-free diets. The Taiwanese conservedprotein whereas the Americans had urinary excretionof nitrogen.A number of studies have demonstrated an evolu-

tionary pattern linking long-term use of dairy productsby a group to the capability for digestion of lactose afterearly childhood, a feature that is unusual in non-pastoralpopulations derived from a non-pastoral background.This pattern is rather strikingly repeated through-out the world.10 A good deal of current interest isfocused on the effects of introducing simple carbohy-

drates into cultures that have not traditionally usedthem. Preliminary investigations have demonstrated thatEskimo groups, who satisfied their carbohydrate needsby gluconeogenesis of amino acids in association witha diet almost entirely based on meat and fish, have aveiy high prevalence of sucrose intoferance.10 It hasbeen suggested that the high prevalence of sucrasedeficiency may account for the high prevalence ofdiarrhea noted in Eskimo infants in rapidly acculturat-ing communities.1 2 Although the above relationshipsare not fully documented, they suggest the inappropri-ateness of applying universal standards of nutritionalneeds. The same difficulties are associated with func-tional measures of nutrition, particularly growth. Anumber of investigators have suggested that ethnicallyspecific standards for growth be used in recognition ofthe importance of biological variation between ethnicgroups.'3

Other investigators have highlighted the phenomenaof catch-up growth and secular change, by which cul-tural and socioeconomic changes may dramatically altergrowth patterns.'4"13 Conversely, rapid acculturationalchange and dietary transition may destabilize nutritionalstatus, as suggested by studies of Southeast Asian refu-gee children in the United States.2 In this population,it was found that hemoglobin levels were relativelynormal upon arrival in the United States and thendeclined for several weeks before returning to normal.A final and perhaps insurmountable difficulty may bedemonstrated in the many attempts to relate nutritionalstatus to intellectual performance. Here, the confound-ing effects of cultural variation are particularly impor-tant.

Food BeliefsOne of the most striking characteristics of food

beliefs, in most cultures, is the degree to which theyassociate with particular stages of the life cycle, notablypregnancy and the postpartum period for mother andinfant. The humoral concepts that dominate the tradi-tional medical systems of Latin America and Asia areamply shown in dietary prescriptions and prohibitionssurrounding childbirth and child rearing.'6 '7 Particularfoods are assigned opposing qualities such as hot andcold, tonic and nontonic. Foods in each category areconsidered hazardous or beneficial depending on thesetting. For instance, among Chinese families in SanFrancisco, infants are allowed only neutral foods, thusexcluding most fruits and vegetables.18 The nutritionalconsequences of such practices are controversial. Somehave suggested that humoral nutritional beliefs reflectfolk appreciation of health and disease.Among Puerto Rican women it has been observed

that those women who followed traditional food taboosconsumed more vitamin rich foods and fewer simplecarbohydrates and saturated fats than did women whoconsumed generally traditional diets without observingdietary restrictions.'9 On the other hand, nutritionalsurveys of Mexican-American primigravida womenfollowing humoral food beliefs have shown a number

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of nutritional deficiencies despite apparently adequateavailability of foods containing these nutrients.20 Inevaluating the benefits or liabilities of such traditionalpractices, there may be important nonnutritional con-siderations, particularly the role of food beliefs inmaintaining cultural identity. Matthews and Mandersonshowed that many of the Vietnamese women whom theystudied in Australia blamed a wide variety of subsequentminor ailments on their inability to follow certain tra-ditional food practices during the postpartum periodin the hospital.'7

While food taboos may be the most obvious manifes-tation of cultural determinants of nutritional practicesof pregnant women, more subtle beliefs may significantlyaffect the health of both mother and fetus, particularlywith regard to inadequate or excessive weight gainand to the use or nonuse of supplements. In less devel-oped countries and among a variety of disadvantagedgroups in Western countries, the most serious healthproblems of infants are likely to arise from the com-bined effect of malnutrition and infectious diseases,particularly diarrhea and respiratory tract infections.21'22Although there are a number of political and economicobstacles that may hinder attempts to break this cycle,it has become increasingly clear that socioculturalfactors may play an important part in the exacerbationof these diseases. Recent investigations have stronglysuggested the importance of immediate rehydration andfeeding in most childhood infections.22'23 In many cul-tures, however, there is a prohibition against feedingsick children their normal diet, and few public healthprograms have been successful in attempts to modifysuch traditional practices (D. Echenberg, MD, PhD,unpublished data).

Cultural and Biological InteractionThe study of groups in cultural and environmental

transition, particularly migrants, may illuminate theinteraction of cultural and biological influences on foodhabits and nutritional status. The recent epidemic ofrickets among the Indopakistani community in theUnited Kingdom provides an illustration of how suchinteractions may occur.

Rickets was a common childhood disease of the In-dustrial Revolution, with heavy smoke and dense hous-ing combining to block sunlight and thus interfere withthe critical step in the vitamin D pathway.24 With thediscovery of vitamin D early in this century, and thesubsequent fortification of staple foods in most devel-oped nations, rickets soon ceased to be a public healthproblem.24 Beginning in the 1960s many cases of ricketswere reported among new Indian immigrants in urbanareas of Britain. In some areas it was estimated that a5-year-old Indian child has a 4% to 5% likelihood ofhospital admission with rickets before age 16.25 Al-though the epidemiological picture is not quite complete,it now appears that the following scenario explains thisepidemic. It was soon determined that "Asian rickets"was associated with residence in the UK and that returnto the tropics resulted in increased vitamin D levels in

this population, thus suggesting the importance of de-creased exposure to irradiation in the pathogenesis ofthe disease. However, the absence of rickets amongWest Indian immigrant children suggests a culturallyspecific factor.26 It is significant that West Indians usemargarine fortified with vitamin D, while most Indianscontinue to use unfortified ghee, or clarified butter. Inaddition, the chapatti, a staple bread of the Indiancommunities, is known to have a high concentration ofphytate which may decrease calcium absorption in thesmall intestine.26 Vitamin D levels have had a strongnegative correlation with chapatti consumption in thispopulation.27

The "Asian rickets" epidemic may be viewed as athreshold phenomenon; alone, neither the low levelsof sunshine in the UK, nor a diet low in vitamin D andhigh in phytate in India, would have been sufficient toproduce the disease. Consequently, it is possible toassert that a dietary pattern well suited to the demandsof one environment may become maladaptive in anothersetting. Viewed in evolutionary terms, it is possible tosee such a situation as a source of selective pressurespromoting either biological or cultural change.

Just as environmental change may make cultural foodpractices maladaptive, so cultural changes may lead tonutritional deficiencies within an otherwise unchangingenvironment. The nutritional implications of such cul-tural changes are exemplified by the process of Sanskrit-ization in India, by which low caste forest tribes adoptthe rituals, dress and diet of higher caste groups in anattempt to increase their status. Golpades and co-work-ers28 have shown that this process of abandoning tradi-tional diets, including forest fruits and animal foods,has been associated with increasing incidence of vita-min A and C dificiencies, and with nutritional anemias.

Acculturational Dietary ChangeThe investigation of food habits and cultural change

has perhaps been most significant in providing a largeportion of the enormous literature devoted to the associ-ations between diet and the major chronic diseases ofdeveloped nations. A number of studies have promoteda general picture implicating the shift by acculturatingpopulations to long-term consumption of diets high insaturated fats and simple carbohydrates in the increasein prevalence of one or more of these pathologic en-tities. Such changes in prevalence have usually followeda consistent pattern with respect to broad changes with-in a culture.The investigation of acculturational dietary change

has figured prominently in the attempts to elucidate thepathogenesis of the chronic diseases that have preoccu-pied epidemiologists for the past two decades, such ascoronary artery disease and hypertension. The informa-tion gathered in these studies has had a strong impacton nutrition and health policy decisions in a number ofcountries, including the United States.21 Although thereis still a good deal of controversy regarding the role ofacculturative changes in pathogenic processes, thestrength of the evidence for the significance of cultural

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food ways can be shown through two illustrations: (1)dental caries and (2) obesity and non-insulin depen-dent diabetes mellitus.

Dental CariesDental caries provide a good illustration of the

relationship between acculturative change and healthfor three reasons. First, the role of diet in the develop-ment of dental caries is well documented. Recent re-views have confirmed the predominant pathogenic roleof sugar intake.30 Second, as the lag-time between ex-posure to cariogenic influences and the appearance ofclinical disease is short, it is possible to examine changesin incidence in relation to short-term cultural or envi-ronmental changes, such as water fluoridation. Finally,the emergence of unprecedented levels of dental cariesis one of the most evident public health consequencesof the spread of Western culture and dietary habits.

Eskimos of Alaska and Northern Canada provide aparticularly good illustration of this situation. Untilrecently, most Eskimos subsisted on an almost exclu-sively carnivorous diet with natural fluoride being pro-vided through the consumption of marine mammals.31Early nutritional surveys reported a virtual absence ofdental disease among Eskimos.32'33 As the subsistencepattern changed from one of hunting and gathering toone of low-wage manual labor, the traditional diet wasreplaced by imported staples, primarily sugar, cerealsand packaged foods purchased in trading posts. Cur-rently, many Eskimo communities have perhaps thehighest per capita sugar consumption in the world.There appears to be a strong relationship between thevelocity of acculturation and the extent and pattern ofdental caries.

Schaefer and his colleagues have investigated dentalcaries in two Eskimo villages.3' In Inuvik, in the rela-tively developed western Arctic, there is a high preva-lence of caries and missing teeth among middle-agedadults while the children of Inuvik, whose water is nowfluoridated and who have access to preventive andclinical dental service have relatively good teeth. Incontrast, in the Arctic Bay in the recently developedeastern Arctic, there is relatively little dental diseaseamong adults of the same generation, but the childrenthere, representing the first generation consuming anacculturated diet, have a high prevalence of dentaldisease.

Obesity and Non-insulin Dependent Diabetes MellitusAnother striking consequence of the spread of West-

ern culture has been massive weight gain in certainpopulations. Pacific Islanders and particular groups ofNative Americans have been especially prone to thedevelopment of obesity. Although there is some evi-dence of genetic susceptibility in these populations, ithas become progressively clear, through ethnographicand epidemiological studies, that a more important fac-tor is a cultural tendency to weight gain resulting fromincreased availability of certain low cost foods. Inves-tigations comparing migrants and nonmigrants or accul-

turated and nonacculturated members of the samepopulation have shown a strong association betweenobesity and the adoption of Western dietary habits andsedentary life-style.34'35 Dietary studies have describedincreased total caloric consumption, increased fat andprotein consumption and decreased consumption ofcomplex carbohydrates in a number of acculturatingPacific Island populations.36 Among Samoans there isa clear gradient of obesity between unacculturated pop-ulations in Western Samoa, moderately acculturatedpopulations in American Samoa and Hawaii, and highlyacculturated Samoan populations in California.37 Inthis last group, as many as 50% of adults may be at orabove the 95th percentile weight for age, by Americanstandards, despite height for age in the 25th to 50thpercentile range, making them among the most obesepopulations in the world.

It is difficult to establish the importance of "accul-turative obesity" in increasing risk factors for mostchronic diseases. It is becoming progressively clear,however, that obesity is highly correlated with anepidemic of non-insulin dependent diabetes mellitus inmany acculturating populations. Few cases of diabeteswere reported in non-Western populations until about40 years ago.'8 Within the past 40 years the epidemiol-ogy of non-insulin dependent diabetes has becomeclearer by intensive investigation of selected high-riskpopulations, notably Pacific Islanders and the Pima-Papago Indians of the southwestern United States.'3940

It has been postulated that the sudden emergence ofdiabetes in these populations represents the expressionof a "thrifty gene."40 In other words, in times of faminea genetic predisposition to diabetes mellitus would beadaptive in terms of enhanced ability to store nutrientsas adipose tissue and thus conserve energy resultingfrom excessive secretion of insulin. With "feasting"represented by conversion to Western food habits, pop-ulations with high frequencies of such a genotype wouldbe characterized by the disadvantageous appearance ofclinical diabetes. Although the "thrifty gene" theory issupported by the extreme variance of diabetes preva-lence in different ethnic populations, it is not clear whythose groups with exceptionally high prevalence, suchas the Pima-Papago, should have been subjected togreater selective pressures than other groups experienc-ing similar environmental conditions.

It has been noted that many groups with a rapidlyrising incidence of diabetes have undergone particularlyrapid cultural change. For instance, in Micronesia, therate of development and acculturation increased rapid-ly as a result of phosphate discoveries on the island ofNauru. Consequently, per capita ownership of cars andspeed boats became very high and the requirements forphysical activity dropped substantially.'6 Dietary sur-veys have indicated extremely high caloric intake andfrequenit consumption of highly refined carbohydratesand alcohol; the traditional meal pattern has been dis-placed by one of irregular snacking throughout the day.The diabetes prevalence in these people of about 40%is among the highest in the world and is substantially

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greater than in other Pacific Island populations withless westernized life-style.35

Patterns of PathogenicityDental caries and adult onset diabetes mellitus repre-

sent two different patterns of pathogenicity associatedwith acculturative dietary change; for dental cariesthere appears to be a direct relationship between theintroduction of large amounts of simple sugars into thediet and the appearance of disease. For diabetes thereis a more complex association between diet and diseasewith several possible mediators including morbid obe-sity and genetic predisposition. Most of the other chronicdiseases that have been linked with acculturation anddietary change exhibit equally individual epidemiolog-ical characteristics. For instance the increased preva-lence of coronary heart disease among Japanese inCalifornia, in comparison with those in Hawaii andJapan, may be associated not only with the adoption ofAmerican dietary habits but also with the deyelopmentof American social and work habits.41

Other diseases that have been extensively studied bynutritional epidemiologists and anthropologists includegastrointestinal tract malignancies,42 hypertension43 andgallbladder disease." The beneficial effects of dietarychange have been less popular subjects of investigationbut are exemplified, perhaps, by the phenomena ofcatch-up growth and secular change, mentioned earlier.

ConclusionFrom the examples discussed in this article, several

practical points may be considered in attempting toinclude recognition of the importance of cultural varia-tion in clinical and public health interventions.

In clinical settings, nutrition'ists could better evaluatedietary intake' if they had access to nutritional hand-books that include non-American foods and could con-duct more meaningful nutritional assessment and'coun-seling by taking into account the ethnic differences innutritional requirements and food habits. The evaluationof obese children or those suspected of failure to thrivewould be more straightforward if ethnically specifiedgrowth charts were available, particularly in areas withlarge immigrant communities. For instance, there wouldprobably be less concern about the growth of a Pilipinochild who' is'in the 3rd percentile for height-for-age byNational Center for Health' Statistics standards if itwere known that the child was in the 50th percentileaccording to Pilipino growth curves.45The greatest opportunities for using understanding of

cultural variation to improve nutritional status is prob-ably in the formulation of public policy and educationalprograms.

The recent decline of rickets among Asian childrenin Scotland and Northern England suggests the potentialeffectiveness of public health programs in improvingnutrition i'n high-risk populations.46 Programs in Scot-land have concentrated on providing vitamin D sup-plements, while those in England have focused on

incorporating vitamin D rich foods into the diet andincreasing the amount of time spent outdoors.46 In bothplaces, nutritional benefit was obtained without changein the traditional deficient diet. It is particularly impor-tant to consider the vulnerability of immigrant andacculturating groups to dominant cultural influencesthat may cause them to abandon nutritionally beneficialtraditional foods for the heavily advertised, though lessnutritious, foods of the new environment.The failure of health workers to recognize the accul-

turating power of Western dietary habits may havecontributed to the spread of Western diseases such asdiabetes, coronary heart disease and dental caries.Ironically, dietary beliefs closely linked to culturalidentity may be difficult to counter, even if they are

clearly nutritionally detrimental, as in the tendency ofmothers to underfeed a sick infant. The point is, there-fore, that we should not blindly encourage dietary habitssimply because they are traditional, but that we shouldrecognize the power of cultural influences in preventingor promoting nutritional health.

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