Lan’s Story: Feeding My Children

A resource for health care professionals serving

Vietnamese communities in the US

“They [doctors] all say the same thing, do this or do that, but the reality is not like that,” Lan said.

“I don’t think they understand. So I don’t talk about it, I just say okay.”

Introduction Promoting healthy eating practices is a major focus of health care providers who work with families of young children, particularly in light of the growing prevalence of overweight children. For providers who work with Vietnamese families, this goal is often challenging. Vietnamese families may have culturally specific infant and child feeding practices that are unfamiliar to health care professionals and differ from traditionally accepted approaches. The aim of this case study is to introduce the feeding practices and social norms common among Vietnamese families with young children. The information comes from two primary sources: interviews with Vietnamese mothers, grandmothers, and babysitters; and discussions with staff from agencies that serve Vietnamese families with young children—WIC, Early Intervention, community-based civic organizations and health centers. Although the information gathered here came from one city, the information should be applicable to other Vietnamese communities in the United States.

Using the case studyThe main part of the case study is Lan’s story. It presents the experiences of a mother who had one child for whom feeding went well and a second child for whom feeding was difficult. Key phrases in Lan’s story are highlighted and link to more detailed information about feeding practices and questions that facilitate dialogue with families. The case study can be used along with its companion booklet, What We Eat to Help Us Grow: Vietnamese-American Food for Infants and Toddlers. Both booklets are available in an interactive format and for download at www.vietfamilyhealth.org.

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In the kitchen of Lan’s Dorchester apartment the smell of Vietnamese porridge is in the air. The porridge has been cooking for hours, since early morning when Lan started boiling a whole chicken to make the broth. Now, she removes the chicken, shreds the meat and adds the shredded meat, rice and carrots into the broth. After another few hours, she will skim off the fat and puree the soup in a blender to make it easier for An to eat. When it cools, she will feed it to her 18-month-old son, An.

The boiling porridge adds a good smell and cozy feeling to the kitchen. It is the food she fed her older son, Tho, for two years, the same food her mother fed her when she was a baby in Vietnam. She considers it healthier than American food, since it is fresh, has little fat and combines a variety of foods.

Tho is now four years old, and he is thriving, in the middle percentage for height and weight. When he was a toddler, he was easy going and readily ate the porridge Lan spoon fed him. He didn’t mind sitting still in a chair or on the floor, and he digested his food easily. He had no trouble swallowing the porridge, which she also made with beef or pork, even after she blended it less and added potatoes, pumpkin and other vegetables. Now, he eats rice in a bowl and broth with bits of chicken, pork, beef or fish and vegetables. She has less time to spoon feed him, so he usually feeds himself. But she tries to make some time to feed him, since he seems to eat more when she does. When he takes food from her, Lan feels like she is doing her job as a mother.

Lan’s Story: Feeding My Children

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Vietnamese Porridge — Rice SoupThis simple soup is a comfort food for Vietnamese families and is often the first food after breast milk or formula for babies. The simplest version of this porridge starts with a large cooking pot and a handful of rice. The cook fills the pot halfway with chicken broth, another meat base, or water. The soup is simmered for about half an hour or until the rice has disintegrated. To smooth it out even more for a baby, the soup is pureed in a blender.

Many mothers will add infant cereal to this recipe and blend that together with the rice. In addition, some mothers like to add vegetables, such as carrots and butternut squash. The more that mothers add to the soup, the more time-consuming the process becomes. Many mothers place a high value on freshness and on making this soup for their young children. One variation on this soup is to add pork bones into the rice and broth mixture. Other meat or bone substitutes used are beef or chicken. As the fat rises to the top of the pot, it is skimmed off until the fat and bone marrow are almost completely gone. The bones are removed before the rice soup is blended. Sometimes a pot of rice porridge is made on the weekend and served as the basis for meals throughout the week.

The broth component of rice porridge is believed to encompass all of the nutritional benefits of the solid ingredients. It is also believed to be “easier to digest” for “immature” toddler digestive systems. The fat that is skimmed and discarded is considered to be “too hot” based on the Eastern Traditional Medicine model of Yin/Yang. Foods that are classified as “too hot” for infants

and toddlers are believed to be difficult to digest. The inappropriate dietary inclusion of “hot” foods is cited as the cause for a number of ailments from rashes to vomiting, diarrhea, and abdominal pain.

Quote from a Mom:“When he was 7 or 8 months, I cooked vegetables and other ingredients then. Like carrots, broccoli, beans, or all different types of vegetables that I would simmer. I simmer it with meat and water, you just want the broth. You continue to cook it and then take it out and blend. You blend it in a blender and then add it to water. At that time, you add the baby cereal instead of adding rice.” — A Vietnamese mother living in Boston, MA

Consider:• Howdoesthenutritionalvalueofriceporridgecompare

to more commonly used baby foods? What nutrients are present/lacking?

• Howdoesstandardguidanceregardingintroductionofsolids and advancing an infant’s diet fit with Vietnamese practices around a baby’s first foods?

Questions to encourage healthy feeding and eating:• Whendoyouplantogiveyourbabyfoodotherthanyour

milk or formula? • Whatfoodswillyouintroduce?• Canyoutellmehowyoumakericesoup?Doyouuseany

vegetables or meat?• Whenwillyouknowthatyourbabyisreadyforother

foods or foods that have more texture?

Growth ChartsCliniciansreportthatexplainingtoparentsthattheirchild’sgrowth is normal is often challenging, regardless of the family’s ethnic or cultural background. Parental perceptions of their child’s weight often do not coincide with actual growth parameters. Parents may perceive that their children are too thin when their growth is appropriate or that their children look healthy when they are overweight. In countries where there has been a history of deprivation and limited access to food, as was the case in Vietnam, aligning parental perceptions of their child with appropriate weight guidelines may be more difficult. Key public health agencies, suchastheWorldFederationofPublicHealthAssociationsandtheCanadianPediatricSociety,recommendtheuseofgrowthchartsasateachingtoolforparents.However,studies have shown that without specific strategies to help parents understand the growth charts, they are meaningless and often incomprehensible.1 Beginning when the child is born and providing repeated, simple interpretations of a child’s progress on a growth chart may be a helpful, though unproven, approach. One strength of using the standard CDCgrowthchartsisthatitcomparesthechildtoU.S.childnorms, which are considered standards to emulate by many immigrant communities.

Consider:• AVietnamesemother’sparentingisoftenjudgedbyher

child’s growth; thus concerns about growth may be more important to her than otherwise “expected.”

• Thepasthistoryofafamilywithrespecttoaccess to food and child survival may underlie concerns about growth.Understandingwhetherfamilymembersspenttime in refugee camps, had limited access to food while in Vietnam, or have had experience with a child who died during infancy can give context to growth concerns.

• Parentsoftencomparegrowthamongsiblingsandrelatives as a gauge of successful childrearing.

Questions to encourage healthy feeding and eating:• Wouldyoubeinterestedtoseewhereyour

child’s growth fits relative to other children in the UnitedStates?

• IsthereanythingthatIcandotohelpexplainto you or other family members your child’s growth?

• IfthechildisunderweightoroverweightPROBE: Howdoyoufeelaboutyourchild’sgrowth?Doesthebaby’s father/mother-in-law feel the same way?

1Ben-JosephEP,DowsenSA,IzenbergN.,Publicunderstandingofgrowthcharts:Areviewoftheliterature.PatientEducationandCounseling.2007;65:288-295. 3

“If I feed him, then it is faster. He eats less messy and he tends to finish all his food,” Lan said. “If I didn’t feed him, he would still eat, but less and very slowly, and it’s not very neat either.”

When Lan works part-time at the nearby nail salon, Tho goes to pre-school a few mornings and her mother-in-law takes care of him and An the rest of the day. At preschool, Tho eats American food (see page 11), and since he tells her he likes the crackers, pretzels and cut-up fruits, she gives him these as snack at home. As a treat, she takes him to McDonald’s, whose French fries and chicken nuggets he loves. These he can pick up easily with his fingers and feed himself entirely. Lan doesn’t like the food at McDonald’s. But she doesn’t mind bringing Tho there sometimes, since she knows the foods are high in calories and very popular with American children. While Tho is solid, she sometimes wishes he was “rounder,” (see Body Image, page 11) since she thinks pudgy kids look more appealing and better cared for. She admires the way American kids look big and strong and healthy.

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Feeding Progression and Independence “Even though Lan’s son Tho is 4 years old, she still spoon feeds him occasionally.”

VietnameseviewsaboutfeedingprogressionandindependencedifferfromstandardnormsintheUnitedStates.Forexample,Vietnamese mothers interviewed for this project did not encourage self-feeding and tended to spoon feed their children until at least age 2. The chart below outlines different expectations around feeding progression and independence. We have presented informationfromrespected,commonlyusedsourcesofnutritionalguidance—theWomen,Infants,andChildrenSupplementalNutritionProgram(WIC)andBrightFuturesandthenfromtheperspectiveofVietnamesemothersandcaregivers.

Traditional Guidance for Developmental Milestones for Nutrition*

At about 6 months, start introducing the infant to soft foods—baby cereal, fruits, vegetables. Newfoodsshouldbeintroducedoneatatime.

At 9 months, introduce meats and offer foods that have more texture and lumps. Give the child opportunities to feed him/herself finger foods.

At 12 months, children generally eat family or table foods that have been chopped more finely or mashed. Encourage self feeding and allow the baby to reach for foods and discover what s/he likes through self-feeding.

Between 12 and 24 months, parents should begin feeding children 3 daily meals and two snacks. Childrencaneatfamilyfoodsbutshouldavoid“junk”.Child-sizeportionsareequalto1tablespoonoffoodfor each year of life.

Commonfeedingguidanceincludes:• Expectchildrentoeatlessandsometimesrefusetoeat.• Donotforcefeedchildren,butallowchildrento

determine how much to eat.• Parentsdecide,orcontrol,twothingsinthechild’s

eating:whatfoodtoserveandwhentoserveit.• Childrenalsodecidetwothingsabouteating:how

much to eat, and whether or not to eat.

Perspectives of Vietnamese Families with Young Children

At 6 months, infants are given Vietnamese porridge or rice soup. It is made with rice and sometimes other things, like vegetables and meat. Before serving the porridge, mothers skim the fat from the top of bowl and then blend the mixture together. In addition to rice and meats, mothers sometimes blend infant cereal into the mixture. The practice of introducing foods individually is not followed.

At 9 months old, children are still fed by their parent or caregiver. Their diet is primarily blended foods. Parents avoid solids because they believe their infants do not have enough teeth to chew solids and the texture may cause choking. Self-feeding is considered too messy and wasteful. Ground meats are a regular part of the baby’s diet, along with cooked vegetables, which are pureed in soups.

At 12 months, children continue to be spoon fed and to eat what parents provide. The children are not considered mature enough to make choices or to feed themselves. Wasting food and messiness is not acceptable.

Beginning around 24 months, new foods such as stir fries that includevegetables,meatandnoodlesareintroduced.Childrenmay begin to use a spoon after age 2, but are not expected to feed themselves independently until about 4 years of age.

Commonviewsaboutfeedingtoddlersinclude:• Agoodmothermakessureherchildeatsandtriesavariety

of tactics if the child is not interested.• Coaxing,bribing,puttingthechildinfrontoftheTV,followingthe

child around the home, and even feeding by bottle or syringe are accepted ways to get a child to eat.

• Parentssubstitutemilkifchildrendonoteatenoughotherfood.• Manyfamiliesmayfeedtheirchildrentwomealsperdaywith

many small snacks throughout the day.

*Sources:StoryM,HoltK,SofkaD,eds.2002.Bright Futures in Practice: Nutrition(2nded.).Arlington,VA:NationalCenterforEducationinMaternalandChildHealth. WICworksresourcesystem.UnitedStatesDepartmentofAgriculture.http://www.nal.usda.gov/wicworks/

Consider: • HowdoesLanallowbothThoandAnindependence

in feeding? • InwhatwaysdoesLancontroltheireating?• WhataresomewaysthatThoexertshis

independence?HowdoesAnshowhisindependence?• WhatvaluesdriveLan’sdecisionsaboutfeeding

control and independence? • Whatisthecommongroundbetweenthese

values and the developmental approach to feeding suggestedbyBrightFuturesandWIC?

Questions to encourage healthy feeding and eating:• Doesyourchildfeedherselfordoyouhelpher?Ifno,whendo

you think it would be the right time for her to feed herself?• Whatdoyoudotomakesurethatyourchildeatsenough?

(PROBE:Whathappensifthemethodsdonotwork—forcefeeding,bribes,substitutemilk)

• Howdoyou/otherfamilymembersfeelwhenyourchildmakesa mess or does not eat all the food you have prepared for her?

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“Vietnamese kids, they are so skinny. I feel so bad when I look at them,” Lan said. “If they are skinny, it seems like they have malnutrition. In America, kids are plump. They look so cute.”

She thinks American children are large partially because they drink a lot of milk, so she gives Tho milk at every meal and at snack time. She is grateful that milk is so affordable here, since in Vietnam it was expensive and not readily available. When Lan starting putting milk in a cup when Tho was around age 2, she was relieved that he drank it and didn’t request the bottle.

Tho is playing with his cars on the kitchen floor, and now An is ready to be fed. Lan starts to feel the anxiety that often nags at her when she feeds An. An is very different than Tho. Weighing just 20 pounds at 18 months, An is quite underweight, according to his doctor. An was at a good weight until around age six months, but his weight gain slowed greatly when Lan introduced the Vietnamese porridge. An didn’t like it very much, reluctantly opening his mouth. At the suggestion of her doctor, she tried American rice cereal, but An didn’t take to that well either, even when she mixed the rice cereal into the porridge. Lan hoped An would become a more eager eater, but he continues to be “lazy to eat” and

“bored” with the food she feeds him. Lan feels awful about this, especially when her mother-in-law points out how thin An is. Her mother-in-law encounters the same challenges when she feeds An, and thinks his reluctance reflects poorly on Lan. At times, she feels inadequate and a disappointment to her family.

“He doesn’t look as round as I would like and I feel badly, especially when my mother-in-law tells me An should be bigger,” Lan said.

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Valued Foods: Milk Vietnamese mothers interviewed as part of this project emphasizedtheimportanceofmilkintheirchildren’sdiets.In Vietnam, dairy products are not a common part of the traditional diets because of lack of access to refrigeration andexpense.VietnamesecommunitiesintheUnitedStatesenjoy the availability and relatively low price of milk. As a result, many Vietnamese mothers give children large volumes of milk. Milk is also seen as an alternative to food if children are picky eaters. Visit www.vietfamilyhealth.org to listen to one Vietnamese mother’s description of the importance ofmilkwithinherculture.BrightFuturesandWICguidelinesrecommend20–24oz.ofwholemilkperdaybeginningat 1 year and suggest transitioning to 1% milk by age 2. Excessive milk intake may actually suppress children’s appetites for solid foods or foods higher in iron content and contribute to iron deficiency in young children, a risk that Vietnamese parents may not understand.

Consider:• DairyisnothighlyconsumedintraditionalVietnamese

diets but is valued for its nutritional content.• Howdoesthefamilyviewmilkwithinthecontextofthe

child’s diet?• Frequentmilkintake,especiallyatnight,maycontribute

to early childhood caries.• Somechildrenhaveaccesstomilkallday,whichleadsto

decreased intake during mealtimes and a sense that the child is not eating adequately.

Questions to encourage healthy feeding and eating:• Howmuchmilkdoyouthinkyourchildneedsinorderto

be healthy and strong? • Howoften,andatwhattimesofday,doyouofferyour

childmilktodrink?Howmuchmilkdoesyourchilddrinkeach time?

Problem Eaters: “Lazy to eat,” “bored,” “picky eater,” and other ways parents express that they are concerned about their child’s eating

There are a number of terms that caregivers used to describe their children’s eating styles. Most common terms are loosely translated to “lazy to eat” and “picky eater.” The term

“bored with eating” is also used but less often.

“Lazy to eat” children typically are not easily engaged in the feeding process. They seem disinterested in eating and do not readily come when called to eat. At mealtimes they will eat “a few spoonfuls” of food even when there are a variety of different dishes on the table, and then refuse to eat any more. Parents attribute their children’s eating habits to a “low appetite;” and frequently request a prescription for a medication that will increase or amplify their appetite. Many of these children do not have set mealtimes and are not taught the concept that foods are eaten in a scheduled, socialcontext(i.e.afamilymeal).Theyarechasedaroundthe room being fed while they play or while they watch television. Feeding time often lasts for prolonged periods and becomes increasingly frustrating as parents make multiple attempts to get their child to eat. As an alternative toregularmeals,parentswillalsoallowtheir“lazytoeat”childrento“graze”ortoeatfrequentsmallamountsofsnacks such as chips. Often, children are constantly sipping excessive amounts of sugar-laden drinks such as juice, soda pop, or milk that they carry around when they play. This behaviorcanleadtodecreasedintakeatmeals.Childrenwhoarealwaysgrazingneverbecomehungry.

Parents who describe their children as “picky eaters” usually have older toddlers who refuse to eat foods that are harder in texture and require chewing. They have specific preferences for food types and textures and their food

choices may be very limited. These children have a history of a late introduction to harder textured foods. Extensive painfulearlychildhoodcaries(i.e.cavities),whicharevery common among young Vietnamese children, may also contribute to delayed introduction of these foods. Parents may introduce liquid dietary supplements such as Pediasure to compensate for underweight.

A “bored” eater is a child who eat foods when initially served but becomes disinterested or refuses to eat the food on other occasions, e.g., when the child becomes “bored” with the food. Parents feel that the child needs other tastes or textures to engage his/her in eating again.

Consider:• Parentsorcaregiversmayallowchildrenaccessto

milk before meals as a snack, which can decrease their appetite.

• SinceVietnameseparentsintroducefoodswithmoretexture later than the Bright Futures recommendations, there is a potential aversion to foods that require chewing when introduced at older ages.

• Dentalcariesmaycontributetoachild’sreluctanceto eat textured foods.

Questions to encourage healthy feeding and eating:• Canyouexplaintomewhatyourchilddoesthattells

youthatsheis“lazytoeat”?• PROBE:Mealtimeexperience,frequencyofjuiceandmilk

intake, and timing in relationship to meals.• Canyouexplaintomewhyyoufeelyourchildisa

“picky eater”? • PROBE:Whatkindsoffoodsdoesyourchildlike?

Doessheeatfoodswithlumpsorthatrequirechewing?• Whathaveyoutriedtohelpyourchildeatbetter?

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It’s lunch time, and Lan sits An on the couch and turns on cartoons. She holds the bowl, dips in the spoon and brings it to An’s mouth. It is slow going. Sometimes, An won’t open his mouth and other times he just holds the food inside, “pocketing it.” At times, he has spit it up and even vomited, although not today. That upsets Lan the most, since An isn’t getting the nutrition he needs, but also is wasting food and making a mess.

To get him to eat, Lan resorts to “sweet talking.” She tells him she loves him and offers bribes of chips, sweets and more television if he will eat. After half an hour, An gets up and starts to play, and Lan follows him around, trying to pop a bit of food in his mouth while he is distracted. Another half an hour passes, Tho wants her attention, and Lan puts away the bowl of food, which still is half full. She pours milk into a bottle and gives it to An, who drinks a little and then ignores it. Sometimes, when he won’t drink, she pours the milk into a children’s medicine syringe and squirts it into his mouth. Later, before An goes down for his nap in mid-afternoon, Lan pours the remaining porridge in a bottle, with the nipple opening widened. She holds him in her lap and puts the bottle in his mouth.

“I have to force him to eat, because he doesn’t like to do it. There is nothing else to it,” she said. “I’m sad, I’m tired. On days when I can feed him, I feel so happy inside.”

Lan is stumped and dismayed about An. The advice she has received from reading pamphlets and talking to her doctor and WIC provider hasn’t helped. They talk to her about the ways Americans feed their young children and about nutritious foods.

She appreciates their efforts, but their advice doesn’t make sense to her. The providers haven’t asked Lan about her feeding practices and beliefs, and she has said little about them. Lan wants to try to follow the recommendations, but they differ so much from what she believes are the right methods to get An to eat enough.

When Lan first introduced food other than formula, they told her to feed An rice cereal and to gradually add other foods, like jarred baby foods of fruit, then vegetables, then meat. Not only did An dislike the cereal, but Lan believed that the porridge was superior nutritionally because it combined a variety of fresh foods.

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The Feeding Relationship: When Feeding Does Not Go As Expected

Feeding is most fundamentally about relationships. Feeding should be developmentally appropriate and build upon a child’s skills. It is an interactive process that supports a sense of mutual trust and reciprocity between caregivers and the child. A positive feeding relationship is one that is enjoyable for both the child and the parent or caregiver. In traditional Vietnamese culture, feeding is considered a passive event in which the child sits obediently and accepts food when the spoon is raised to his/her mouth.

Concernsaboutinsufficientintakewerewidespreadamongthe mothers we interviewed. Mothers often described the child as“lazytoeat,”andexplainedavarietyofstrategiesusedto encourage their child to eat and ensure adequate intake. These feeding practices were also described by providers who worked with families. Some of these practices are common in all cultures; while others seem more pronounced among Vietnamesefamilies.Herearesomeofthemostcommonstrategiesmothersusetogetchildrentoeat:

• Forcefeedingwithaspoon• Forcefeedingwithasyringe• Substitutingmilkorsupplements,suchasPediasure,

when the child was perceived as not eating enough

In addition, many caregivers and mothers described behaviors that children exhibit when children are pushed to eat. These behaviors frustrated mothers and resulted in a feeding relationship that was not enjoyable for the mother or the child. One commonly reported behavior is “pocketing” food, which is when a child takes food and holds it within his cheeks. Just as parents develop strategies to coax their children to eat, children develop strategies to demonstrate their independence.

It is important that providers ask families about their feeding practices and the child’s response in a nonjudgmental manner. Itmayhelptostrategizewithparentsaboutalternativeapproaches that promote healthy eating and a mutually satisfying parent-child relationship. Examples may include diversifying food choices, allowing children choice in food eaten, or restructuring the family mealtimes. Thoa’s Story, available online at www.vietfamilyhealth.org, presents the conflicts a mother feels when the feeding relationship does not go as expected.

Consider:• Parents,caregivers,andevenyoungchildrenwillallhave

strategies in the feeding relationship, but their strategies may have different goals.

• Vietnameseparentsandcaregiversthinkthefeedingrelationship is based on authority.

• Parentalcontrolinthefeedingrelationshipisalsobasedon fears about the child’s nutrition and on concerns for thehousehold(likecleanliness)andnotwastingfood.

• Childreninchildcaremayexperienceadifferentmealtimestructure than in the home environment and may eat much better in childcare than when home with the family.

Questions to encourage healthy feeding and eating:• Pleasedescribehowyoufeedyourchild.Youmaywant

toprompt:where—e.g.,highchairorfloor;howlongittakes; spoonfed or self-feeding.

• Doyouenjoymealtimewithyourchild?Whyorwhynot?• Doyouthinkyourchildiseatingenough?• Whatstrategieshaveyoutriedtohelpyourchildeat?• Howdoesyourchildletyouknowthatshedoesnot

want to eat?

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Now, they tell her to allow An to feed himself, by giving him a spoon and bits of food he can pick up with his fingers and mash with his gums. They say she should serve richer, more caloric American foods like pasta with butter and cheese, peanut butter on bread, and meats with a higher fat content. If An doesn’t eat and just plays with the food, they say she should take it away and try later, even if An has only eaten little. They want An to eat in a chair, not while playing or watching TV. And they suggest An would eat more if he were allowed to eat independently, like American toddlers.

Lan thinks this advice might make sense for a three-year-old. But to her, An still is a baby. He is too young to feed himself and has an immature digestive system. Even if he could feed himself, she is convinced that he wouldn’t eat enough on his own, and he would make a wasteful mess of food she has spent a long time preparing. Since An has so few teeth, he could choke on thicker porridge with thicker bits of solid food. And she’s sure the fat will upset his digestive system. Lan can’t stand the thought that An could feel sick from the food or that he would be hungry. She views the sweet talking and promises of treats and television as rewards, rather than bribes.

“They all say the same thing, do this or do that, but the reality is not like that,” Lan said. “I don’t think they understand. So I don’t talk about it, I just say okay.”

Lan’s frustration is magnified by the way her mother-in-law compares An, and even, Tho, to their first cousin, Bao, a robust and chubby four-year-old who weighs 52 pounds. Han, Bao’s mother, used to prepare porridge and Vietnamese food, but now she usually feeds Bao American style food. Lan notices that Bao eats lots of snacks, juice and soda and large quantities of rice at meals. At times, Han has boasted that Bao is a good eater. Han disagrees with the doctor, who tells her Bao is too heavy. Since his flesh is firm and tight when she squeezes it, rather than loose and flabby, so he doesn’t seem fat to her.

Lan agrees—to her, Bao looks good, especially since boys, more than girls, should be round. Right now, she doesn’t think Han should worry about Bao. Lan expects Bao will slim down when he’s around eight or nine as he grows taller. If he doesn’t, then Lan thinks that Bao will be too heavy and that Han should follow

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American FoodsAmerican foods are often used to substitute or to supplement meals once children begin school. After trying American foods at school, many children request these foodsathome.CommonAmericanfoodsconsumedinVietnamese homes include hamburgers, hot dogs, chicken nuggets,spaghetti,potatochips,Doritos,frenchfriesandpizza.ManyfamilieswillsupplementmealswithAmerican foods because of their relatively low cost and easy availability, as well as child preference. For others, the convenience and shorter preparation time make it more appealing than a typical Vietnamese meal. Although less time-intensive in preparation, American meals often include higher calories or fat content and the emphasis on fresh fruits and vegetables common in a traditional Vietnamese diet is diminished. As many parents are unfamiliar with Americanfoods,providersshoulddiscussportionsize,aswell as the decreased nutritional values of fried and certain frozenfoodchoices.

Consider:• OneimportantthingtonoteisthatVietnamesefamilies

are less likely to integrate dairy products like cheese and yogurt into their children’s diets. These dairy products are often recommended by providers as good substitute sources of protein and calcium, but may not be easily adopted by Vietnamese parents.

• InmanyVietnamesefamilies,parentsofyoungchildrenare working long hours and may not have time to prepare traditional Vietnamese foods if they do not have the assistance of grandmother.

• FamiliesmaynotbefamiliarwiththenutritionalvalueofAmerican foods. The concept of reading food labels may be quite foreign.

Questions to encourage healthy feeding and eating:• WhatAmericanfoodsdoyouofferyourchild?• Howmanytimesaweekdoyouserveyourchild

American foods? • Doyoucookitathomeorbuyoreatitwhenout?• HowdoyouchoosewhichtypesofAmericanfoodsto

offer your child?• DoyouserveAmericanfoodsassnacksorfullmeals?

Body ImageVietnamese community members who were interviewed use the Vietnamese words “chắc ” and “ních” to describe the ideal body for infants. These terms translate to “tight” and “firm.” These characteristics are seen as desirable until a child reaches about the age of 4 or 5, the time when children enter school or childcare. Most parents believe that the slimming down process occurs naturally, without parental intervention. When it does not, parents find it difficult to implement strategies to achieve desired weight loss. Being overweight at older ages is not considered desirable, particularly for girls who are expected to be thin. There is more acceptance of “chubby” boys through elementary school.However,aschildrengetolder,beingoverweightforboth boys and girls is seen as detrimental to a child’s physical and intellectual well-being as described by Lan’s commentary about her sister-in-law’s son, Bao.

Many Vietnamese parents consider all American dishes as inherently “fattening” or “excessively nourishing.” Parents of children who are overweight often fault exposure to “American food” during school lunch and may express

feeling powerless to make changes because of this. Restrictingachild’sfoodportionorintakewasdifficultformany parents because resulting behaviors—tantrums, whining, demanding—are considered undesirable and may reflect negatively upon the mother’s parenting.

Consider:• Historically,chubbierchildrenreflectedhighersocial

standing and wealthier families. • Vietnameseparentsandgrandparentspreferchubby

children, for health and social acceptability.• Achild’shealthandappetiteoftenreflectaparent’slove,

devotion, and ability to provide for their family.

Questions to encourage healthy feeding and eating:• Howwouldyoudescribeyourchild’sappearance?• Wheredoyoulookonyourchild’sbodyforsignsof

appropriate weight?• Whatmakesyoubelievethatyourchildishealthy?

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the doctor’s feeding advice. At that age, the weight will be bad for him. She believes it will tire his brain and his body, and he will not think or move as well as he could. And she would be even more concerned if he were a girl, since it’s better for girls to look slender than boys.

Lan is discouraged about An, but she also is hopeful the situation will change. She knows other children who were “lazy to eat” like An and then became very “round’ like Bao. She hopes if she keeps trying to get An to eat the porridge by feeding and coaxing him, he will develop more of an appetite like his older brother. And she plans to buy and prepare foods with more fat and calories that Tho likes, hoping he will grow larger and reflect well on her as a mother. She’d love to hear her mother-in-law speak proudly of both An and Tho. Above all, she wants her children to be well fed and to look healthy. Then she thinks she will be free of her worry about feeding them.

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1353 Dorchester Avenue Dorchester, MA 02122617.288.3230 dorchesterhouse.org

To access interactive learning tools and downloads of materials for healthcare and service providers who work with Vietnamese families in the United States, visit our project website at www.vietfamilyhealth.org.

Developed by Dorchester House Multiservice Center with support from the Blue Cross Blue Shield of Massachusetts Foundation and Boston University School of Public Health, Department of Maternal and Child Health, MCHB Training Grant #T76MC00017