Health Affairs, 23, no. 2 (2004): 215-219 doi: 10.1377/hlthaff.23.2.215 © 2004 by Project HOPE	New Online   Pay Cuts For Medicare Docs   Access To Care Woes   Public Coverage More Efficient   Empowering Consumers

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Narrative Matters

No Come Nada

PREFACE: "Cultural competence" is one of those buzz phrases that has become so commonplace in some circles as to become meaningless. It is anything but that. Within the health care delivery sector, being sensitive to patients’ cultural attitudes toward health and medicine can mean the difference between providing best care and substandard care. Growing numbers of medical training programs are attempting to teach physicians how to respond to patients of various races, ethnicities, and language groups different from their own. Empathy and compassion—staples of all good clinical care—cannot be taught overnight but are needed now more than ever. The two stories here illustrate that these qualities, even with innate cultural competence, do not guarantee an effective doctor-patient interchange, but that their absence can do great harm. California-based pediatrician Richard S. Garcia, raised like many of his patients by a Mexican mother, tells us that cultural competence is not always enough to produce healthy patient outcomes. Physician David Malebranche observes the cost to patients of cultural "incompetence," recounting what he learned as a black medical student watching a white medical team misread a "noncompliant" patient.

The child "doesn’t eat anything" is the literal translation of no come nada but is not what the Mexican mother of an obese toddler really means when she presents this complaint. Deciphering the code of Mexican culture in present-day California, I think the mother means that the child doesn’t eat as much as Mama would like him to—that he doesn’t eat as much as he did when he was a hungry, rapidly growing, normal infant.

I hear this chief medical complaint over and over again each day in the Los Angeles pediatric clinic where I treat mostly Hispanic children. It’s usually not the ostensible reason for the clinic visit, but it emerges as the parent’s most pressing concern. Each of these patients at morning clinic falls within the normal or higher range for weight; all are healthy. But the parents want me to stimulate their child’s hunger. They want me to provide them with proof that their alarm about their child’s "poor appetite" is valid.

The Clash Between Culture And Good Sense

Top The Clash Between Culture... Formidable Family Forces Ingrained Behavior Mountains Can Be Moved,... Editor's Notes

 
I disappoint them each time, all the more so because I’m Mexican American; I should not only understand but should agree with their anxieties. My own mother shared the same beliefs about infant nutrition—eat more, fat babies are healthy babies—so I am intimately familiar with the push for more food. My mother wanted me to eat more, and still does, even now that I am thirty-nine years old. She wonders why my daughter is so thin, why she "doesn’t eat," why my wife and I don’t force her to ingest food when she’s not hungry. Ditto for my baby son. To want infants and toddlers to eat more is a Mexican cultural certainty.

But I don’t agree with it. My chief complaint is that already obese toddlers are eating too much. So I explain to each set of parents that babies with a fever, an ear infection, a simple cold, or just about any illness are not typically as hungry as when they are well. They are sort of like us adults in that way. I counsel one mother about proper infant and toddler nutrition and encourage appropriate meals, snacks, and exercise, as my medical education and common sense dictate. In each exam room with a child who "doesn’t eat anything," I try various strategies to convince the parents that their child doesn’t need more food. By the end of a usual day, I don’t know what else to say that might sway them. And whether or not I am successful with one mother, another anxious parent awaits in the next exam room, and the next. And more will be in tomorrow.

Few of these parents seem to understand that an obese infant is likely to become an obese toddler/obese child/obese teenager/obese adult. A 2002 surgeon general’s report says that in that year there were almost twice as many overweight children and almost three times as many overweight adolescents as there were in 1980. More than 15 percent of six-to-nineteen-year-olds are at or above the ninety-fifth percentile for weight, according to the American Academy of Pediatrics. Five years ago the Centers for Disease Control and Prevention reported that nearly two-thirds of U.S. adults were overweight or obese; the problem has only grown since then. The girth of adulthood is nourished in infancy and prescribed by loving parents with good intentions. So I worry about what these parents’ attitudes will mean for the future health of my young patients and their generation.

What can a Mexican American pediatrician who disagrees with his culture’s beliefs about feeding children do to treat childhood obesity, to help contain this exploding health problem? How can I practice "good" medicine, which includes advocating proper feeding based on accepted U.S. medical practices, if my recommendations directly conflict with the culture of my patients? American medicine, so far, has failed to manage the widening problem of childhood obesity, and I wonder how I can make a difference. Even if my advice is accepted and acted upon by a few individual parents, I know I cannot reach all the parents who harbor this chief complaint in neighborhoods and kitchens across America. Solving the public health problem of childhood obesity is a much larger goal than we pediatricians alone can achieve in our exam rooms—no matter how sincere and culturally competent we may be.

Formidable Family Forces

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I believe that Hispanic parents don’t want their children to become adults with the diabetes, heart disease, and hypertension that is associated with obesity. But the view that overweight babies are healthier babies is culturally imbedded, reinforced by friends, grandparents, and history. These forces exercise far more influence over Hispanic parents than do pediatricians—even one of my background. The attitudes I encounter are solidly entrenched. Researchers writing in 2003 about Latina women’s body image, weight, and food choices in the Journal of Nutrition Education and Behavior confirm what I see daily: Mexican women prefer "a thin figure for themselves but a plumper figure for their children." So it’s nearly impossible for me to convince a mother that her child does not need more food. She leaves the clinic and goes home to a culture that disagrees with the young doctor.

Hispanics make up a growing portion of the U.S. population. In 2002 more than 13 percent of Americans were Hispanic and two-thirds of them came from Mexico, so obesity among Mexican-born families matters to the United States as a whole. But the problem doesn’t rest within the Mexican or Hispanic family alone, nor is it due entirely to that culture. Purely American culprits include fast food, oversize restaurant portions, and children’s increasing sedentary lifestyles as they watch more television, play more video games, and sit before computers more often than any previous generation of U.S. children.

Certainly, government efforts to promote more healthful school cafeteria meals and more physical exercise for elementary and middle schoolers are a start. And congressional moves to combat childhood obesity are on the upswing. Last August the Washington Post reported 140 anti-obesity bills proposed by state legislators in 2003, double the number in the previous year. State lawmakers are pushing bills to restrict soda and candy sales in schools and increase physical education levels, to require fast-food outlets to list the nutritional content of the foods they sell, and to tax high-fat foods and movie tickets and use the revenue to carry out nutrition and exercise programs. And just as physicians advocate disease prevention such as vaccines and advice on how to prevent childhood accidents, we also push healthy eating styles and regular exercise to prevent obesity-related problems. Still, America is now home to the least healthy, most obese adolescents ever. Americans have evolved to a time when we eat in full absence of hunger. And what we eat is not good for us.

In a talk two years ago at a meeting of the National Medical Association, an organization that represents primarily African American physicians, former Surgeon General David Satcher told the audience, "It’s not about beauty; it’s about health." He encouraged audience members to communicate this to their patients. He pushed more fruits, vegetables, and daily exercise. Dr. Satcher’s recommendations would certainly lead us toward a healthier state. But how can his message be delivered to the people like those in my clinic who need to hear it? And, once the message is heard, what will convince them that he is right?

Ingrained Behavior

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Laying out this argument as a medical warning to parents of toddlers can be interpreted as a personal affront. "I know how to feed my child," is the response I get when I inform parents that they might be over-feeding their child. Nor is the economic argument—the costs to families, employers, health insurance companies (and ultimately to healthy subscribers)—effective with my patients’ parents. According to a paper in Health Affairs (Web Exclusive, 14 May 2003), this country spends $93 billion a year in health care costs related to treating conditions resulting from obesity or overweight. But telling my families that won’t persuade them to feed their children less. Advice about health, diet, and exercise just isn’t received well by the people in a position to do something to relieve the health care costs of obesity. I saw a woman on strike outside a Los Angeles grocery store the other day. She walked off her job to get more health care benefits while holding a picket sign in one hand and a cigarette in the other.

The issue I face as a physician fighting childhood obesity is the same as that of the rhetorician who looks at communication as a triad: speaker, speech, audience. Is the speaker the individual pediatrician in the exam room? What is my speech? If I argue that a thinner physique is a better physique, that not having diabetes in the future is superior to having diabetes, that being more productive and contributing to the world’s economic machinery is better than eating butter, is the audience one family at a time? And what is the outcome? I can’t help suspecting that with this approach alone, the country will get fatter while I plug away in my exam room.

Instead, it seems to me that a larger cultural shift is needed, akin to the movement against drunk driving, whose success in decreasing alcohol-related fatalities has taken several decades to achieve. (The proportion of alcohol-related fatalities to all traffic fatalities fell from 60 percent in 1982 to 41 percent in 2003, according to data on the MADD Web site.) That drop is likely the result of public education, enforcement, and new cultural attitudes about driving while drunk. Antismoking campaigns in this country have also been effective in reducing smoking. Such campaigns are needed to combat childhood obesity. Pediatricians and family practitioners are not able to keep up with the onslaught of human weight when treating patients one at a time.

Mountains Can Be Moved, Slowly

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Change in cultural attitudes—both Mexican and American—toward feeding babies and toddlers and eating in general will be slow, if it occurs at all. But I have reason to hope. I have a thin daughter. My eight-month-old son is well within the normal weight curve for his age. And I have evidence in my own medical career that parents’ cultural beliefs about medicine can change. I finished medical school in 1991. In those days my greatest daily battle was convincing parents that their child didn’t need antibiotics for viral infections. Within the past year, while working at a clinic with affluent, white parents, I was confronted with a spectacular rhetorical problem: A mother who had been on the Internet, read parent magazines, and spoken with friends requested that I not prescribe antibiotics for her child because she feared he would develop resistance to them. I was at a rare and complete loss for words. I found myself fumbling to convince the mother to accept antibiotics for the bacterial infection I diagnosed. I assured her that I agreed with her concern about emerging antibiotic resistance but that this time antibiotics were warranted. The culture had changed in the other direction among this local group of parents.

The American problem of childhood obesity, which is so pronounced among my Hispanic patients, requires the full attention of private and public health care professionals and the agencies charged with education and health. It calls for a shift in the greater American culture itself.

Even yesterday, I saw a child and his parents in clinic. The Mexican American mother was concerned that this boy, in the ninety-seventh percentile for weight but with two older brothers far above that, was "too thin because he’s not like the other kids." I explained this essay to her and mentioned that I’d like to include her visit in my story. She smiled, agreed, and asked for a copy when it’s published. She and her husband promised to go home and tell the grandparents what I’d said about how to properly feed their children. I wished them luck. And I promised to do my part. I imagine the day when, after mass education and a shift in cultural attitudes about feeding babies, I try to convince a Mexican American mother that her child should eat a little more.

Editor's Notes

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Richard Garcia (rsgarcia{at}pol.net) is medical director of the pediatrics section of an emergency department in Burbank, California. He is working on a documentary on U.S. health disparities and an essay collection on race in American medicine.

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