Cultural Factors impacting the well-being of Asian Indian Children in the United States

The Lancet commission on Culture and Health emphasizes that Culture should not be neglected in health and health care provision [1] as cultural behaviors can impact health in many different ways [2]. Culture is a shared set of knowledge, experiences, and beliefs that are shaped over time for a specific group of people and it is important for a practitioner to have a general understanding and be better equipped to improve the care provided.

There are an estimated 5.2 million people of Asian Indian origin in the United States (US) which account for 21% of the total Asian population as reported in the 2023 Census [3]. Asian Indians began immigrating to the US as early as the turn of the 20th century and have seen a 174% growth in the last two decades. The Asian Indian population is diverse economically and linguistically, and includes highly educated young professionals as well as blue-collared service industry workers such as hotel staff, gas station workers, and taxi drivers.

As with other immigrant populations, the Asian Indian population is relatively young in age with growing families. The health concerns may have a genetic predisposition but can be impacted by the culture. Since research is limited in the United States on these topics, the summary of evidence is presented through segmentation in different phases of life starting from birth to adolescence based on anecdotal reports and research generated in other countries.

Asian Indian mothers, the largest subgroup of Asians, have been categorized as a low-risk group for adverse birth outcomes due to their favorable sociodemographic characteristics such as higher education levels, better prenatal care and low substance or tobacco use. However, this group has been described as a “paradox” due to higher rates of adverse birth outcomes despite a low-risk profile of sociodemographic characteristics [4]. Asian Indians living in the United States and Canada have been shown to experience high rates of low birth weight infants, small for gestational age births and a much higher incidence of gestational diabetes. It is unclear if the maternal diet during pregnancy plays a role in the birth weight of the infant as food choices and restrictions based on family and cultural traditions are common in the Asian Indians [5]. In a study evaluating the births of Asian Indian mothers in New Jersey, higher rates of certain medical risk factors during pregnancy including gestational diabetes, placenta previa, and cephalopelvic disproportion were seen [6] Higher rates of small for gestational age along with low birth weight were found in the same cohort. Even though low birth weight infants are associated with a higher incidence of suboptimal physical growth and lower cognition and neurodevelopmental delays typically, the long-term impact of such birth outcomes in Asian Indian children have not been studied [7].

As the baby ages through infancy and toddlerhood, anecdotal reports from pediatricians state that Asian Indian parents’ desire to have a “chubby baby” especially if the birth had resulted in a low birth weight infant. The parents revolve their lifestyle and their daily schedule around the feeding of the child which becomes their mainstay of the daily challenges. Parents often get consumed by the mission to try to feed their child and get extremely stressed if their child does not eat a specific meal amount. As a result, the parents resort to the use of media, reading of books, and other entertainment strategies to distract the child while they force the child to eat. Forcing the child to eat leads to a power struggle resulting in unnecessary friction between the child and the parent. Undue stress in the home environment subsequently then leads to poor eating habits [8].

“Williams et al. showed that most inner city non-South Asian infants from Leeds were still feeding from a bottle at the age of 2 years and that two-thirds of the milk feeds were sweetened. Many Asian Indian mothers reject the health professional’s advice to discontinue using a feeding bottle by 12 months because of a concern that this change might stop their infants from drinking milk and impact the weight of the child.” [9,10] At 15 months, 90% of the Asian Indian children and 75% of the White children were reported to be still using a bottle to some extent to ensure some nutrition. These cultural feeding patterns have also been reported as reasons for significantly higher levels of caries in the primary dentition among the Asian population as compared to the majority White population [9]. Negative feeding patterns need to be addressed with culturally appropriate education and strategies for the Asian Indian mother to ensure optimal health outcomes [11].

Asian Indian children are known to have higher risk factors that predispose them to the development of metabolic syndrome including excess body fat and thicker truncal obesity [12]. The prevalence of metabolic syndrome and the age when heart disease develops in children is currently unknown and studies describing prevalence and factors leading to obesity in Asian Indian children are limited. Studies of Asian Indians report a higher body fat content, particularly abdominal fat, compared to other ethnic groups for any given BMI increasing the risk of insulin resistance at a lower BMI [13].

The BEACHES study conducted in the UK reported a greater prevalence of obesity by the end of primary school in Asian Indian children as compared to the White population [14]. A study of 5-7 year old children of the East Berkshire Health System reported Asian Indian children to be 27% more overweight and 45% more obese as compared to whites [15]. At any given BMI in a study of 7th and 8th grade children in the New York City public schools, the fractional body fat content was found to be higher in Asian Indian children [16]. Physical activity measurements of counts per minute of registered time and number of steps in 9-10 year old British children of different origins in the CHASE study were reported less in children of Asian Indian origin as compared to those of European and African origin [17].

The growing body of literature on the developmental origin of chronic disease in adulthood suggests a life-course approach for tackling risk factors in early childhood. Obesity is one of those prominent risk factors with serious health implications across the lifespan as obese children and adolescents are more likely to be obese adults and at a much higher risk for developing cardiovascular diseases, diabetes, musculoskeletal disorders and cancers at a younger age [18]. Studies from high-income countries have demonstrated that obesity with poor diet and low physical activity levels, abnormal lipid profiles, impaired glucose tolerance and hypertension are various well-known risk factors for the development of the metabolic syndrome, a predictor of type 2 diabetes and heart disease in adults and are impacted by the eating patterns [19]. Food in the South Asian context is controlled by the caregiver who influences what the child eats and how that food should be given, impacting eating patterns [20]. Parents who are stressed and consumed by the weight of their child overlook the risk factors for development of the metabolic disorders and ignore such warnings.

The type of food a child eats also plays a strong role in the daily management of the atopic child [21]. The Ayurvedic beliefs around the temperature of the food, how it is cooked, and what a child can eat or not eat when they have such diseases often restrict the nutrition of the child. Most Asian Indian mothers who breastfeed in the first year of life focus on management of their diet to reduce its impact on the eczema of the child.

The incidence of Atopic Dermatitis has been steadily increasing over the last ten years and the prevalence in mixed race populations is higher than in the whites [22]. The incidence in North Indian children has been reported at 41% for mild and 55% for moderate atopic dermatitis [23]. There is speculation that there is an environmental component and a relationship to food which leads to fluctuation in the severity of this illness. In a study to understand how Asian Indians in the United States conceptualize and interpret the relationships between culture, food, and health, there was widespread agreement about ideal or positive foods that contribute to health [24]. Families of Asian Indians report less severe symptoms when they travel to their home country as opposed to being in the Western country as referenced in the Consensus Guidelines for the management of Atopic Dermatitis- an Asia Pacific perspective [25].

Many Asian Indian infants and children with atopic dermatitis develop asthma over time creating a fear around the illness as per the belief that asthma is a lifelong debilitating illness which can be fatal. Pediatricians report that the fear steers the parent away from acceptance of the diagnosis and appropriate management of the child. Limited reports on knowledge and attitudes about asthma in Asian Indian children reveal that 34.1% of the respondents believed asthma to be contagious, 48.2% of the parents hesitated in referring to their child’s illness as asthma, 88.2% stated that food items are important precipitating factors for acute attacks and 35.3% believed that asthma is a life long illness [26]. Once again the food and nutrition become restrictive for the child and the cultural beliefs surrounding the illness and misconceptions about the side effects of the corticosteroid medications often used to treat asthma lead to non-compliance with the appropriate treatment of the child [27].

It is well known that poor management of the disease leads to frequent exacerbations, more emergency room visits, and higher hospital admission rates. It is speculated that poor compliance with appropriate management may also be a reflection of a lesser use of asthma self-management plans by Asian patients. This, in turn, may be reflective of less patient education and self-management training being offered to these patients by their providers [28].

Having a successful career path for the child and excellence in academic achievement is the goal of most Asian Indian parents. The relationship of food with cognitive development leads to ensuring proper nutrition as the main thrust for the parent on a daily basis. Sanghvi states that Asian Indian parents engage in high levels of academic socialization at home [29]. In the Value of Education Survey Report of the HSBC Holdings, 91% of Indian parents reflected a desire to have their child complete at least an undergraduate degree and 88 % wanted a master’s or more. Conversations from pediatricians reveal that children who are delayed and not up to par with their colleagues are considered to be the Asian Indian parent’s worst fear equating to “Failed aspirations”.

Being diagnosed with any developmental disorder such as autism becomes a “death sentence” for the Asian Indian parent. The grief associated with the diagnosis that comes into play in this situation leads to poor management of the child. Optimal treatment and appropriate management strategies then become delayed as reported by the Early Intervention centers coordinating the care of these patients. In addition, once the diagnosis is accepted by the parents, many do not know how to navigate the system or learn about the available services for the child which leads to suboptimal care of the delayed child. Since most children with autism have difficulty with eating and food choices, the parent’s daily routine revolves around ensuring the child eats a balanced meal leading to multiple stressors.

The majority of children in Asian Indian families assimilate into mainstream society once they begin school. These children have to deal with the challenge of integrating two cultures, two languages, the cultural beliefs of their parents on how their daily routine should be managed for their well-being. The types of food, eating patterns, dressing style, family interactions, and various other aspects of the culture become constant sources of daily conflicts for the families.

It is well known that Asian Indian culture promotes the importance of the welfare of the family [30]. Adolescents want to be a part of the western culture whereas the family or parents coerce the child to participate in the Eastern family culture. The child wants to experience the difference and assimilate but the parent is usually resistant. A UK based study reports that Asian Indian students with integrated friendship choices from multiple cultures had lower levels of mental health problems as compared to white adolescents [31].

Zaidi et.al. state that the majority of Asian Indian youth have been involved in culturally deviant activities of varying degrees and outlines three main points where the cultures of the East and West diverge and where the adolescents are at a crossroads. The first being the foundation itself in which the Western culture is known as an individualistic culture that values independence and thinking of oneself as compared to the Eastern culture that promotes welfare of the family as the goal. The second difference becomes that of gender socialization where Eastern culture outlines the roles of each gender from early childhood and the importance of these roles, e.g. the importance of the male to be a successful breadwinner for the family. The third major difference is the acceptance of premarital dating and intimate relationships [32].

During this adolescent age of experimentation, the use of drugs and alcohol may be introduced leading to dangerous behavior. Binge drinking and alcohol-related problems were found to be significantly more in Asian American adolescents of Asian Indian descent as compared to other ethnic groups. Ethnic identity was significantly associated with alcohol-related problems where lower levels of ethnic identity were related to more negative consequences of alcohol use [33]. A stronger sense of ethnic identity is found to promote cultural traditions of stronger family values which become more important than the individual desires [34-38].

This summary of evidence has outlined the role of cultural concepts and food practices specific to the Asian Indian child during several stages of childhood. Asian Indians have various genetic predispositions, cultural beliefs and social factors that may impact the health of their child. As the family assimilates into the Western society these beliefs may interfere with their daily routine and may impact their outcome on various disease processes and their well-being. Little is known on how these factors can influence their management.

The current research based knowledge about Asian Indian children in the United States is very limited and is largely based on anecdotal experiences. Research efforts need to be escalated on the following:

1) Genetic and dietary factors that may predispose to adverse outcomes in Asian Indian births and their long term impact
2) Cultural practices that may affect the feeding practices in childhood leading to obesity and other metabolic conditions
3) Genetic factors that lead to early onset of abdominal and truncal obesity with increased risk of metabolic syndrome and development of diabetes
4) Health beliefs and cultural practices that may impact compliance with treatment and management of chronic diseases such as asthma
5) Advocacy efforts for acceptance of academic underachievement and guidance on access to services for special needs children.
6) Social beliefs that influence the construct of ethnic identity and impact the well-being of the adolescent

Parents need to be educated about the child and the struggles that they may face to assimilate into a new cultural environment. Providers need to be made aware of the health disparities and the cultural influences that may impact the management of the Asian Indian child.

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