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Chapter 4. Social and cultural factors in nutrition

Social factors and cultural practices in most countries have a very great influence on what people eat, on how they prepare food, on their feeding practices and on the foods they prefer. Nonetheless, cultural food practices are very rarely the main, or even an important, cause of malnutrition. On the contrary, many practices are specifically designed to protect and promote health; providing women with rich, energy-dense foods during the first months following childbirth is an example. It is true, however, that some traditional food practices and taboos in some societies may contribute to nutritional deficiencies among particular groups of the population. Nutritionists need to have a knowledge of the food habits and practices of the communities in which they work so that they can help to reinforce the positive habits as well as strive to change any negative ones.

Food habits and their origins

All people have their likes and dislikes and their beliefs about food, and many people are conservative in their food habits. They tend to like what their mothers cooked for them when they were young, the foods that are served on festive occasions or those eaten with friends and family away from home during their childhood. The foods that adults ate without a second thought in childhood are seldom totally disagreeable to them in later life.

What one society regards as normal or even highly desirable, however, another society may consider revolting or totally inedible. Animal milk is commonly consumed and liked by many people in Asia, Africa, Europe and the Americas, but in China it is rarely taken. Lobsters, crabs and shrimps are considered delicacies and prized foods by many people in Europe and North America, but are revolting to many people in Africa and Asia, especially those who live far from the sea. The French eat horse meat; the English generally do not. Many people will delightedly consume the flesh of monkeys, snakes, dogs and rats or will eat certain insects, yet many others find these foods most unappealing. Religion may have an important role in forbidding the consumption of certain foods. For example, neither the Muslim nor the Jewish peoples consume pork, and Hindus do not eat beef and are frequently vegetarians.

Food habits differ most widely in regard to which foods of animal origin are liked, disliked, eaten or not eaten in a society. The foods in question comprise many of those that are rich in good-quality protein and that contain haem iron, both of which are important nutrients. People who do not consume these foods are deprived of the opportunity of obtaining these nutrients easily. On the other hand, those who overconsume animal flesh, some seafoods, eggs and other foods of animal origin will have undesirable amounts of saturated fat and cholesterol in the diet. Balanced consumption is the key.

Relatively few people or societies have strong negative feelings about consuming cereals, roots, legumes, vegetables or fruit. They may have strong preferences and likes, but most maize-eating people are also willing to eat rice, and most rice-eating people will eat wheat products.

It is often stated that food habits seldom or never change and are difficult to change. This is not true; in many countries the current staple foods are not the same as those eaten even a century ago. Food habits and customs do change, and they are influenced in many different ways. Maize and cassava are not indigenous to Africa, yet they are now major food staples in many African countries. Potatoes originated in the Americas and later became an important food in Ireland.

Food preferences are not made and abolished by whims and fancies, of course. More often the adjustments are generated by social and economic changes that take place throughout the community or society. The issue is often not what foods are eaten but rather how much of each food is eaten and how the consumption is distributed within the society or within the family.

The tendency of many wage-earners to spend almost all their wages within a few days of receiving them often results in a family diet of varying nutritive value. The family eats much better just after one payday than just before the next. Wages are often paid monthly, and there seems little doubt that a change to weekly payment of wages would improve the diet of wage-earners and their families.

The person who controls the family finances influences (intentionally or unintentionally) both the family diet and the food fed to children. In general, when mothers, rather than just fathers, have some control over finances, the family diet is likely to be better. When the mother has little control over family funds, dietary arrangements may become haphazard or even dangerous.

Nutrition education has been an important influence on food habits, and not always a positive one. Fortunately, the days are long gone when nutritionists promoted costly protein-rich foods to eople who couldn't possibly afford them. Unfortunately, the tendency to single out foods or nutrients either to promote or to prohibit has not yet gone, nor has the tendency to try to teach by creating fear and taking the enjoyment out of eating. However, change always comes slowly and old habits die hard; people who were taught in these old ways are still responsible for feeding themselves and their families, and they may find it hard to change again.

Nutritional advantages of traditional food habits

The traditional diets of most societies in developing countries are good. Usually only minor changes are needed to enable them to satisfy the nutrient requirements of all members of the family. Although the quantity of food eaten is a more common problem than the quality, this chapter focuses on types of food and eating habits.

Eating certain protein-rich foods such as insects, snakes, baboons, mongooses, dogs, cats, unusual seafoods and snails is definitely beneficial. Another habit that is good nutritionally is the consumption of animal blood. Some African tribes puncture the vein of a cow, draw off a calabash of blood, arrest the bleeding and consume the blood, usually after mixing it with milk. Blood is a rich food, and mixed with milk it is highly nutritious.

A custom frequently found among pastoral and other peoples is the drinking of soured or curdled milk, rather than fresh. The souring of milk has little effect on its nutritive value but often substantially reduces the number of pathogenic organisms present. In communities where milking is not hygienically performed and where the containers into which the milk goes are likely to be contaminated, it is safer to drink sour rather than fresh milk. Boiled milk would be safer still.

Many societies, for example in Indonesia and in parts of Africa, partly ferment foods before consumption. Fermentation may both improve the nutritional quality and reduce bacterial contamination of the food.

The traditional use of certain dark green leaves among rural peoples is another beneficial practice and should be encouraged. These leaves are rich sources of carotene, ascorbic acid, iron and calcium; they also contain useful quantities of protein. Non-cultivated or wild dark green leaves such as amaranth leaves as well as those from cultivated food crops such as pumpkin, sweet potato and cassava are much richer in vitamins than pale, leafy vegetables of European origin such as cabbage and lettuce. Well-meaning expatriate horticulturists in Africa have too often tried to get villagers to cultivate such European vegetables rather shall their traditional vegetables.

Many wild fruits are rich in vitamin C; an example is the pulp within the pod of the frequently consumed baobab.

Traditional grain preparation methods produce a more nutritious product than does elaborate machine milling.

Some communities sprout legume seeds prior to cooking, which enhances their nutritive value, as does the soaking of whole-grain cereals before their processing into local beers and some non-alcoholic beverages. These seeds and grains usually have a high vitamin B content. Finally, it cannot be stressed too strongly that the traditional method of infant feeding- from the breast - is nutritionally far superior to bottle-feeding (see Chapter 7).

Food taboos

A number of food habits and practices are poor from a nutritional point of view. Some practices result from traditional views about food that are liable to change under the influence of neighbouring peoples, travel, education, etc. Other food practices are governed by definite taboos.

A taboo may be followed by a whole national group or tribe, by part of a tribe or by certain groups in the society. Within the society, different food customs may be practiced only by women or children, or by pregnant women or female children. In certain cases traditional food customs are practiced by a particular age group, and in other instances a taboo may be linked with an occupation such as hunting. At other times or in other individuals a taboo may be imposed because of some particular event such as an illness or an initiation ceremony.

Although these matters border on the realm of anthropology, it is important for a nutritionist to be familiar with the food customs of people in order to be able to improve their nutritional status through nutrition education or other means. Moreover, it is evident that anthropology and sociology are important to the nutrition worker who is either investigating or trying to improve the nutritional status of any community.

Some customs and taboos have known origins, and many are logical, although the original reasons may no longer be known. The custom may have become part of the religion of the people involved. For example, the Jewish taboo against pork was probably introduced to eliminate the prevalent pork tapeworm, which was thought to be sapping the strength of the Jewish people. Even though 2 000 years later it is now possible to eat pork safely, Jews still do not eat pork. Muslims share this view about pork. In neither case is this a nutritionally damaging taboo.

Many taboos concern the consumption of protein-rich animal foods, often by those groups of the community most in need of protein. A common taboo in Africa against the consumption of eggs is rapidly disappearing. This taboo usually applies to females, who are said to become sterile if they eat eggs. The psychological connection between human fertility and the egg is obvious. In other places the custom applies to children, perhaps to discourage them from stealing the eggs of setting hens, which would endanger the survival of poultry. Other customs, again often affecting women and children, concern fish. These customs may amount to a full taboo, although people not used to fish often dislike it merely because they find its smell distasteful or its appearance "snake-like". Many cultures have strong views about the consumption of milk or milk products.

The customs that prohibit consumption of certain nutritionally valuable foods may not have an important overall nutritional impact, particularly if only one or two food items are affected. Some societies, however, forbid such a wide range of foods to women during pregnancy that it is difficult for them to obtain a balanced diet.

Many of the nutritionally undesirable taboos that existed a quarter of a century ago have weakened or disappeared as a result of education, mixing of people from different societies and travel. Of those that remain, some food habits may seem illogical and their origins obscure, but it is not advisable for outsiders to try to alter ancient food habits without looking very closely into their origins. Moreover, it makes no sense to attempt to alter a habit that does not negatively affect nutritional status.

Nutritionally bad habits, like all other habits, are best changed by the people who have them. In this regard, influential local people, with the welfare of their fellows at heart, may join nutritionists and become part of an important alliance pledged to eradicating malnutrition. A speech by the president or a cabinet minister, the sight of a respected tribe leader eating some forbidden food and coming to no harm or the return to the village of educated and enlightened local people will prove much more effective than the preaching or goading of an outsider.

Changing food habits

In some parts of the world the staple foods are changing or have changed. Maize, cassava and potatoes, now grown in large amounts in Africa, originated outside the continent. Since none of these foods were eaten in Africa a few hundred years ago, it is clear that the food habits of millions of people have changed. Vast numbers of people in Africa have abandoned yams and millet for maize and cassava, just as many in Europe abandoned oats, barley and rye for wheat and potatoes. Food habits are still changing rapidly. The difficulty, of course, lies in trying to guide and foster desirable changes and to slow down undesirable ones.

It is often difficult to fathom what factors have been most important in stimulating or influencing changes in food habits. The rapid increase in bread consumption in many African, Latin American and Asian countries where wheat is not the staple food is understandable. It is at least in part a labour-saving phenomenon; bread is one of the first "convenience" foods to have become available. Before leaving home to go to work one can eat some slices of bread instead of the traditional breakfast of porridge, which requires preparation time and is unpleasant cold. Bread can be carried in the pocket and eaten during a break in the working day, or when travelling.

In most of the world the traditional main staple food has remained constant, irrespective of urbanization, modernization or even westernization. Thus in much of Asia rice remains the preferred staple food in rural and urban areas. Some people in Africa, such as the Buganda in Uganda and the Wachagga in the United Republic of Tanzania, continue to have a preference for plantains as their staple food. Maize based products such as tortillas remain important in the diets of most Mexicans and many in Central America.

Changes in food habits are not just accidental, of course; they can be deliberately initiated. At community and family level, school-age children can be important agents for change. They are still forming their tastes and developing their preferences. If they are introduced to a new food they will often readily accept it and like it. School meals may usefully introduce new foods to children and thus influence food habits. This widening of food experience in childhood is extremely important. Children may influence the immediate family and later their own children to eat new, highly nutritious foods.

Harmful new habits

Not all change is desirable, of course, and not all new food habits are good. Chapter 7 describes in detail the harmful effects of the rapid spread of bottle-feeding using infant formula or animal milk in place of breastfeeding. This is an undesirable, relatively new food trend. Less attention has been given to the question of other baby foods that have been marketed and much promoted and advertised in developing countries. Locally available complementary or weaning foods, home-produced and traditionally fed, are often as or more nutritious than the manufactured baby foods, and then are always much cheaper. They are usually introduced gradually while breastfeeding continues well into the second year and beyond. Manufactured baby foods should only be promoted to those who are unable or unwilling to continue breastfeeding. They are safe and nutritionally adequate when prepared hygienically and in the right dilution. They are convenient for those who can afford to purchase them. However, such manufactured foods are expensive compared with local foods, and for most families in developing countries, other than the very affluent, they may be a waste of money. For families who already have too little money to spend on food and other essentials, these foods are a very expensive way of buying the nutrients that they are advertised to contain.

Another particularly misleading type of advertising relates to the glucose products said to provide "instant energy". Energy is present in large amounts in nearly all the cheapest foods. Similarly, drinks advertised as "rich in vitamin C" are usually unnecessary, since few children suffer from vitamin C deficiency. Vitamin C can be obtained just as well from fruits such as guavas, mangoes and citrus, or from a range of vegetables.

The so-called protein-rich weaning foods are also much advertised. These arc nutritionally good products, but they cost much more shall protein-rich foods available in the market such as beaus, groundnuts or dried fish, meat, eggs or milk. It usually costs much more to provide 100 g of protein from these commercially advertised products than, for example, from beans bought in the local market. The essential question is how a mother could best improve her child's diet if she had a little extra to spend. The answer would seldom be a manufactured baby food.

In some countries the staple food has remained unaltered, but the form in which it is preferred may have changed over the years. As described in Chapter 16, the rapid spread and popularity of highly milled rice in Asia had disastrous consequences and led to a high prevalence of beriberi, with much morbidity and many deaths. In many parts of the world highly milled cereals have replaced traditionally lightly milled and more nutritious wheat, rice and maize. In the United Kingdom and the Russian Federation, white bread has replaced brown or whole-grain breads, and in East Africa highly milled maize meal is often purchased and has replaced lightly milled maize flour. Urbanization, modernization and sophistication have often led to diets in which a greater percentage of energy intake comes from sugar and fats, and to increased consumption of salt. All Of these are generally undesirable changes from a nutritional standpoint.

Influencing change for the better

What can health workers or nutritionists in a community do about food habits, old and new? They can:

Chapter 38 describes the use of social marketing and other well-tested nutrition education techniques that can help achieve some of these objectives.

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