Infancy is a significant disease prevention and health promotion stage in life. Understanding and re-establishing healthy, traditionally based, complementary feeding behaviors for Native Hawaiians early in life could be one approach to prevent chronic diseases and obesity later in life. This article explores Hawaiian complementary feeding practices through in-depth interviews with kūpuna (elders) from across the state of Hawai‘i, examining their formative years, infant health, infant feeding, transgenerational knowledge, and opportunities and barriers related to traditional food consumption.
The Significance of Complementary Feeding
Complementary feeding refers to the stage during infancy when other foods and liquids are needed in addition to human milk (or formula) to meet nutritional requirements. Recommendations are to introduce a diversity of complementary foods that are rich in energy, protein, and micronutrients at 6 months of age. Infants develop the motor skill and gastrointestinal function to accommodate the introduction of other foods in addition to human milk or infant formula at ∼6 months. Global guidelines emphasize culturally based feeding practices with the use of indigenous-based first foods (e.g., basic local staple). Examining complementary feeding practices in Native Hawaiians is important because recent trend data from the Supplemental Program for Women, Infants, and Children (WIC) found that Native Hawaiian and/or Pacific Islander infants had the highest proportion (23.9%) of infants with weight-for-length >90% compared with the other race/ethnic groups participating in WIC. In addition, data from Hawai‘i WIC found Native Hawaiian children aged 2-4 y were significantly more likely to be ≥95th percentile for BMI compared with white children of the same age. Finally, data from the largest federally qualified community health center in Hawai‘i, of which a majority of patients were Native Hawaiian, found children who underwent rapid growth between 12 and 23 mo (48%) were at the highest risk of child obesity by age 4-5 y compared with those children who did not undergo rapid growth (19%). Complementary feeding practices, including the type and timing, are linked with growth and risk of obesity, chronic disease, and other health conditions later in life. There is evidence suggesting that high energy and protein intake in infants increases risk of a higher BMI in childhood. In infants, nationally representative data suggest that there is a low consumption of fruits and vegetables and that consumption of sugar-sweetened beverages increases with age. Complementary feeding practices that fail to align with recommendations put infants at greater risk of excess growth and obesity.
Traditional Hawaiian Diet: A Foundation for Health
The indigenous people of Hawai‘i are Native Hawaiians. The traditional foods of Native Hawaiians included kalo (taro), ‘uala (sweet potato), ʻulu (breadfruit), various greens and fruits, limu (seaweed), i‘a (fish), and moa (chicken), which are all nutrient-dense foods. Previous research demonstrated that a traditional Hawaiian diet resulted in weight loss and reduced serum cholesterol and blood pressure in adults.
The Waianae Diet
The Waianae Diet is based on the traditional Hawaiian diet, which is high in complex carbohydrates and fiber and low in fat. A study published in the American Journal of Clinical Nutrition in 1991 involves 19 Native Hawaiians, who had an average weight loss of 17 pounds after three weeks on the diet. Other benefits noted in the study include decreases in cholesterol and blood sugar after using Native Hawaiian foods and ancient Hawaiian cooking methods. The principle foods in the diet are taro, poi, sweet potatoes, yams, breadfruit, greens, seaweed, fruit, and small amounts of fish cooked using ancient cooking methods. Cooking includes steaming, though most foods are served raw. A major motivation for people who use this diet is the revival of Native Hawaiian culture.
Mana and Cultural Significance
Hawaiian foods reflect positive cultural and social qualities because it is believed that traditional foods carry mana (power), providing strength and health, and are an outcome of a reciprocal relationship between people and land. Complementary feeding practices shape children's long-term eating and health behaviors as well as convey cultural and familial beliefs, attitudes, and practices related to food. For Native Hawaiians, their intergenerational and cultural influences, household, environmental and social aspects of their community, spiritual beliefs, significant family events, and personal eating philosophy all contribute toward what and how they eat.
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The Impact of Colonization
Not unlike other indigenous communities, the effects of colonization have had significant impacts on the health of the Native Hawaiian community. After their arrival to the Hawaiian Islands, Europeans introduced various infectious diseases that decimated the Native Hawaiian population. Native Hawaiians now have the shortest life expectancy, and suffer disproportionately from chronic disease and obesity compared with other ethnic groups in Hawai‘i. Prevention is a recommended strategy for addressing obesity and noncommunicable disease, and starts with nutrition in the first 1000 days of life.
Kūpuna: The Keepers of Knowledge
Grandparents, or kūpuna (kupuna is singular and kūpuna is plural), play significant roles in the Native Hawaiian family unit. In Hawai‘i, older adults who live with a grandchild are more likely to be Native Hawaiian. Native Hawaiians honor their kūpuna, I ulu no ka lala i ke kumu (the branches grow because of the trunk), because their knowledge, traditions, and practices are passed on to their future through them. The Pilināhā (4 Connections) Framework outlines that for people to feel whole and healthy they need connection to place, community, past and future, and to their better self; engaging with kūpuna represents a way in which to establish that connection.
Methodology: Gathering Insights from Kūpuna
Potential kūpuna knowledgeable in Hawaiian complementary feeding practices for the in-depth interviews were recruited through key informants identified in 4 counties in Hawai‘i consisting of Honolulu County (the island of Oʻahu), the County of Hawaiʻi (the island of Hawaiʻi), Maui County (the islands of Maui, Molokaʻi, and Lānaʻi), and Kauaʻi County (the islands of Kauaʻi and Niʻihau) through the social and professional networks of the research team. Counties were chosen because they represent the various islands of Hawai‘i taking into account the smaller islands that are less populated. The research team was composed of 2 Native Hawaiian faculty members (Nutrition and Nursing/Public Health) at the University of Hawai‘i at Mānoa. The team also included 1 Native Hawaiian undergraduate student (Dietetics) and 2 Native Hawaiian graduate students (Hawaiian Studies and Nutrition). All research team members were lifelong residents of Hawai‘i. Kūpuna eligible for the in-depth interviews included those who were Native Hawaiian, had ≥1 grandchild, and resided in 1 of the 4 counties. The chain-referral-sampling method was then used to identify additional kūpuna. Interviews were conducted between March 2018 and September 2019. The interviews were stopped when the themes that were emerging were being repeated by the kupuna, thereby reaching saturation. Additionally, at that time, the referral chain had stopped and there were no additional referrals from those interviewed. An interview guide was developed using the social ecological model and informed by a literature review on complementary and Hawaiian feeding practices. General topics covered child formative years, infant health, infant feeding, transgenerational knowledge, and opportunities and barriers related to traditional food consumption. When we talk about feeding think about the first foods that you fed babies in addition to breastmilk or formula. What ways of feeding babies have remained among your children?
Interviews were arranged to be conducted location of the kupuna's choosing and included consent to participate prior to conducting the interview. Permission was granted by the kupuna to audio and/or video record the interview for subsequent review, editing, and analysis as well as to archive in the library at the University of Hawai‘i at Mānoa. The research team also provided a copies of the video and/or audio recordings to the kūpuna to share with their families. At the onset of the in-depth interview basic demographic information was collected including year of birth, sex, and number of children and grandchildren. Samples of various traditional Hawaiian foods were available at the interview to honor the kūpuna and stimulate discussion of traditional foods. At the end of the interview the kūpuna were compensated with a $20 gift card for their time.
Transcriptions were loaded into NVivo 12 Plus (QSR International) for coding, text retrieval, and content analysis. An initial set of a priori themes were developed based on previous literature and then emergent themes were identified through the analysis process. To ensure interrater reliability, 3 interview transcripts were selected at random and 3 members of the research team independently coded the transcripts based on an agreed code book using the a priori themes. Three rounds of independent coding were done, with discussion occurring after each round to update the codebook with emergent themes, until a mean Cohen κ of 0.79 was achieved, which is considered a moderate level of agreement. The remaining interviews were then independently coded by 2 researchers. One researcher independently coded all of the remaining interviews while 2 researchers divided the remaining in half and independently coded those interviews using the same codebook. The 3 researchers then examined the themes and merged similar ones into agreed higher-order themes, which became the final set of themes. The 3 researchers then agreed upon final themes and summarized the results. Validity was ensured using 2 strategies: use of a shared codebook that had operationalized definitions of themes, and through discussion and debate of main themes identified between the 3 researchers.
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Fourteen kūpuna participated in the study. Kūpuna were either raised in or currently resided in Honolulu, Kauaʻi, and Maui County. A majority of the kūpuna were female. One interview was conducted with a pair of kūpuna, 1 non-Native Hawaiian kupuna and 1 Native Hawaiian kupuna. The research team wanted to honor the kūpunas’ wishes and conducted the interview but did not include the non-Native Hawaiian kupuna in the analysis. Separate interviews were conducted with 1 father-daughter and 1 husband-wife pair. Overall findings of the interviews are presented thematically by childhood experiences, participant role as a parent in feeding their keiki (children), participant role as a grandparent in feeding their mo‘opuna (grandchildren), and reflections on the supports and barriers to promoting and consuming a traditional Hawaiian diet starting in infancy.
Childhood Experiences Shaping Food Preferences
Kūpuna shared rich narratives about their childhood experiences, which significantly shaped their food preferences and practices. For example, one kūpuna recounted, "Well, my mom did, and then she got, my mom and dad, and then they got divorced, I don't know what year it was, probably when I was in third grade. They got divorced then after that we kinda stayed. Then she remarried again so we stayed up in Kula, for a while then we came back down to Waiheʻe for a while. And then I stayed with my grandfather for a while ‘cause my stepfather and my mom didn't get along together so they kind of split up. So I stayed with my grandfather." Another kūpuna shared, "My grandmother had 18 children, she was a healer master of ho‘oponopono [to make right]. My grandfather was a conductor of the Royal Hawaiian Band. When he retired they moved to Moloka‘i with their 18 children, so her belief was that first child belongs to her. So out of all the families I grew up with 9 other boys. I was the youngest and the only girl. I was quite spoiled by my grandfather, who was very adamant about everyone learning to play an instrument. Our land quarter flowers, quarter la‘au [plants]. I grew up by the ocean in Kalama‘ula, so I was in that water all the time. So when we talk about food and being young." Another kupuna shared, "My grandmother came to get me 2 days after I was born. My father was in the military, my mother was pregnant as they were traveling back from Germany, landed at Fort Hamilton Kentucky, and I was born. So my grandmother came to get me and I grew up on the island of Moloka‘i. Staying with my grandpa was better than moving around. He got to teach us more than my parents did." Still another kupuna stated, "I grew up here, well, we moved here when I was 5 years old and I come from a family of nine. And there were these bowls always on the table, always there were bowls on the table. And 1 had poi, 1 had paʻakai, or sea salt. Poi was very available and the poi man came to the house in his truck. Yes, there was an abundance of poi when I was growing up. Would bring around poi on Fridays and we would run out with our order. My dad used to go diving, fishing, so we had ‘opihi [limpet], lobster, fish, turtle. Yeah. My dad used to hunt, too. I remember mom and dad would eat out of big bowl while we had our little [bowl] because that way we won't make the bowl messy."
These narratives highlight the importance of family, environment, and access to traditional foods in shaping childhood eating habits.
The Continued Importance of Poi
Poi, or steamed mashed taro root, was the most common traditional Hawaiian dietary staple of infancy. However, kūpuna shared that traditional dietary practices evolved to reflect contemporary dietary practices such as the mixing of poi with infant cereal or milk. Female family members were prominent influences on kūpuna complementary feeding practices. Complementary feeding practices have evolved over generations but aspects of traditional Hawaiian feeding practices have remained.
The Hawaiʻi Physical Activity and Nutrition (PAN) Plan 2030
The Hawaiʻi Physical Activity and Nutrition (PAN) Plan 2030 is a guide to increasing physical activity and healthy eating in the state, with the long-term goal of reducing overweight, obesity, and chronic disease among all Hawaiʻi residents. In Hawaiʻi, the majority of adults, adolescents, and children do not engage in regular physical activity or eat a nutritious diet. Insufficient physical activity combined with unhealthy eating can substantially increase the risk of health problems such as obesity, high blood pressure, heart disease, diabetes, cancer, and arthritis. The PAN Plan Tracker is funded by the Healthy Hawaiʻi Initiative with support from the Centers for Disease Control and Prevention.
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