Food Categories, China, and the Biomedical Model

As a trained nutritionist, I was taught about food and nutrition mainly as a science, chemical interactions divorced from their larger cultural contexts. Western scientists have “fine-tuned” nutritional components into large categories (protein, carbohydrates, fat) and small categories (vitamins, minerals). I was taught that this form of categorization is science, it is biological, and these are the components that are compatible with life on this planet.

Nutrition has been medicalized in the West, but humans enjoy the taste of food as well, ensuring that food and nutrition have become part of consumer culture. Each time we sit down to a table, or put something in our mouth we do so in the context of this culture. There are good foods (vegetables, fruits, organics, whole) and bad foods (fast food, convenience food, GMO’s, pesticides). Western society also has a somewhat collective understanding of snack food and comfort food, healthy food and unhealthy food, food for babies and food the elderly. There are foods that men eat, and foods that women eat. This is food, but this is NOT food.

Biological necessities such as food and nutrition do not develop outside of the context of culture and human interaction. In fact, we can probably say that one of the roles of “culture” has been to modify these biological dispositions, and the most rudimentary ways we do this is through categorization. George Lakoff explained in Women, Fire and Dangerous Things “…the chain of inference–from conjunction to categorization to commonality–is the norm. The inference is based on the common idea of what it means to be in the same category: things are categorized together on the basis of what they have in common”. Creating and understanding categories helps us reaffirm our shared identity that is culture.

There are multiple and contradictory categories of food and nutrition globally. Because nutrition and food are inextricably linked both politically and economically to health, however, what foods are categorized and why, matters. Food and nutrition are packaged and marketed for things like taste and enjoyment. But food is also packaged and sold to promote health, oftentimes by corporations with the blessing of global health organizations. This is primarily done through our understanding of the biomedical model of nutrition. Worldwide, however, traditional categories of what foods are healthy and why do not always integrate well into this model.

Food Categorization in China
In the dominant Chinese medical paradigm, food and nutrition is used as an integral part of health and healing that is much different from this biomedical paradigm of the West. The categories of protein, carbohydrates and fat make sense to Chinese people, who understand the biological and chemical premise behind these concepts, but are much less important to their everyday understanding of the interaction between food and health.

When many Chinese people sit down to a meal, everything on the table is there for a reason not, in fact, having to do with taste. Thousands of years of collective history dictates what is on that table and why. This one is good for your skin; this one will help calm you down. This food is excellent for your digestion, but this one you can’t eat with that one or it will cause harm. You can NEVER eat that food in the summer. There are foods that increase your “qi” (energy), and ones that cause it to slow down. A menstruating woman should eat this, this and this, and not that, that or EVER that.

Because China is currently transitioning to a consumer-driven economy, this idea of nutrition as health in both a Western and Chinese sense is being sold to the masses. This article last year by the Wall Street Journal wrongly states that Chinese people are becoming “more health conscious”. What the article meant, I’m assuming, is they are becoming more aware of Western concepts of health and nutrition. In the “Western” concept, we add more to our diet and foods (vitamins, health foods, organics) in order to make ourselves more healthy. There is a belief that adding medicines, adding supplements, adding culturally and biologically defined nutrients to our everyday routine, we can make ourselves healthy, wipe out disease and increase wellness. This concept does not work in the dominant Chinese paradigm, however, as there is more a focus on balance and harmony. But because our idea of “adding more” has shaped the way we treat micronutrient deficiencies through food fortification globally, trying to integrate this in China is turning out to be problematic.

Food Fortification and Health
Food fortification is the process of adding nutrients to foods where they don’t naturally occur. The premise is by adding micronutrients that lack in the diet (for whatever reason) to foods that are widely eaten, we can decrease the incidence of these deficiencies. It has been very successful in many parts of the world, China included (see this blog post for more information). China implemented an iodine salt program a few years ago, and has essentially eliminated iodine deficiency from its populace. Outside of the iodized salt program, however, China has been unable to implement other nationwide food fortification programs for folic acid, iron, or vitamin A (among others).

To illustrate this point and its significance, I will use my current research area of complementary feeding in infants. Complementary feeding includes all foods other than breastmilk or its alternatives, and is strongly influenced by culture. Western concepts of complementary feeding, including those recommended by the American Pediatric Association, are based on our ideas of nutrition and medicine more than traditional beliefs. Here is a complementary feeding guide that I use on my own website and blog that shows what is appropriate and why. If you notice the very first food we recommend to give a child, it is iron-fortified infant cereal.

There are a variety of foods that babies need at around 6 months that breastmilk no longer provides, including iron, zinc, protein and extra calories. American companies saw this, and baby’s propensities towards allergies as a business opportunity and created iron-fortified cereal. While I won’t go into the small details of why they recommended iron-fortified cereal (or some of the problems associated with this), it has turned into a cultural norm in the U.S. to feed your baby iron-fortified cereal as the first food.

This has not worked in China for a number of reasons, but first and foremost is the way the dominant Chinese paradigm has categorized foods. There is no straight concept of “baby” food; this has been created by corporations in the Western world and has only been introduced to China recently. There is no difference between “baby foods” and “adult foods” intrinsically; in the U.S. and in other parts of the world, “baby foods” are in a jar and pureed and labeled by “baby food” brands. In China, “baby foods” are categorized by other things, including texture and traditional food ways.

For now, “baby food” has not gained popularity in China for a variety of reasons. But because of this, coupled with the dominant global model for preventing vitamin deficiencies being through fortification of baby foods, iron-deficiency anemia remains a problem in all areas of China. In other words, the way we have categorized foods has shaped how we prevent “disease”, but these categories do not exist in other parts of the world. The question nutritionists and physicians are grappling with in China, then, is how do we prevent iron deficiency if the dominant paradigms for prevention it (i.e. fortification and supplementation) aren’t widely accepted?

There is much value by scientific categories assigned by the dominant Western biomedical model of nutrition and food. More than a few researchers, Chinese and Western, however, are mystified at how to integrate these cultural systems created from categorization. It is not news that food is culturally relevant, and it is not news that public health campaigns need to be more localized to be successful. But the last 30 years has seen the integration of China, India, and other parts of the “non-western” world into the global market. This is not only affecting consumerism of food products globally, but also how food and nutrition interacts in global public health programs.

Lua Wilkinson (路依依) recently finished her graduate degree in medical anthropology at the University of Colorado Denver and is currently in China as part of the Fulbright U.S. Student Program. A registered dietitian, she has worked in clinical nutrition settings, public health and policy development, and health education projects. Her current research interests include nutrition and the role of social inequities, infant feeding among migrant women, and the worldwide impacts and causes of malnutrition. 

7 thoughts on “Food Categories, China, and the Biomedical Model

  1. Has there been any research that directly compares modern diets including fortified foods with traditional diets, e.g., those based on traditional Chinese thinking, in terms of health benefits? I ask because I find it hard to imagine how such a study could be constructed, given that what most people now eat is, at least here in Japan, a jumble of both types of diets. There is also the question of how to distinguish between benefits created by the the diet per se (conceived as a typical mix of foods chosen for either traditional or modern reasons) and the effects of things like portion size.

  2. John, take a look at Nutrition and Physical Degeneration by Weston A Price. He did a study like this in the early 20th century, comparing isolated communities that still followed traditional diets with nearby communities that had adopted Western diets. He was a dentist and used dental health as evidence of the effect of diet.

    He went around the world, and documented traditional diets from Switzerland, islands off of Scotland, Africa, Alaska and the South Pacific (I think I am forgetting a few).

    His findings, in both statistical form (# of cavities etc) and photographic are remarkable. Although there was tremendous variation in WHAT people ate, depending on what was available locally, the people on traditional diets all showed much better dental health — not just in decay (which might be explained by white flour and sugar alone), but in the broad facial structure that allows all the teeth to grow in completely with good spacing.

    Reading your article, Lua, I am surprised that you are addressing iron deficiency using fortification as a primary approach. What about eating iron rich foods?

  3. Thanks for pointing that out Elizabeth. One aspect of my fulbright project is exploring providing babies with meat as a complementary food vs iron-fortified cereal. Meat is a much better source of iron, zinc, and protein than it’s iron-fortified cereal counterpart, and it’s what I personally recommend to many mothers, fathers, and grandparents who ask what the first food they should feed their baby. I hope that this study, which includes multiple countries and is sponsored by international health organizations, can change the way we look at complementary feeding (and our collective recommendations along the way!)

    The main barrier that I’ve found to providing meat as a first food in rural areas has been poverty. If they live on a farm and have access to meat, there may be the issue of storage or electricity. They may not have a refrigerator for example. If they don’t raise livestock themselves, meat can be considered more expensive and they may not eat it. Other barriers to providing meat to infants and children include education, where some consider it inappropriate to give babies.

    Of course, there are many other iron-rich foods than meat that can be recommended as a first food over iron-fortified cereal. I have a feeling – and i could be completely wrong – that China will never use iron-fortified cereal as a primary approach to preventing iron-deficiency in babies.

    @John, keep your eyes open for this study when it is published — it will be a good comparison of the differences in traditional diets to ones including fortified foods (the cohort is randomized to meat group and iron-fortified cereal group), at least among infants.

  4. Elizabeth,

    Thanks for the pointer. But I still have questions. You note that the study you mention was conducted in the early twentieth century. We are now in the early twenty-first century, nearly a century and a lot of globalization later. I am wondering how you would now find comparable populations, one of which ate an exclusively traditional diet while the other ate an exclusively modern diet. I know that in the case of Japan, where I live, even the most remote villages are now online and accessible by modern transportation. The odds are overwhelming that wherever the villagers shop, they will be exposed to fast food, fortified food, and other modern innovations. Then, when I think of my former area specialty China, I try to imagine comparing the “traditional” diet of a peasant living in poverty in the loess country in Shanxi with the “traditional” diet deliberately adopted by a wealthy Shanghai believer in traditional Chinese medicine and the various modern diets of, say, elderly people who prefer the cuisine they grew up with and their children, who may happily consume a wide variety of regional Chinese cuisines, and their grandchildren who love KFC and are in the marketing target for Yum Brands (Pepsi, Taco Bell…).

    How do you design research in the face of this degree of variation?

  5. John, You couldn’t design a study like it today. That is one of the things that makes it so important.

    His tools were limited compared to 21st century science, but he did a pretty good job documenting one extremely visible, photograph-able, and quantifiable aspect of health. And when he visited a community, he talked to leadership, got them on board, and looked at EVERYONE in that community.

    Then he searched for common factors in the healthy traditional diets he studied, and investigated the properties of the types of foods they had in common. All had high-quality sources of protein in the diet; all had a lot of fat in the diet. Areas where dairy was available included unpasteurized dairy, including cream and butter (nutrients available in milk drop significantly with pasteurization).

    I have actually had dentists explain to me that our bodies “evolved” so that our jaws are smaller than those of our ancestors, so that our teeth are crowded and crooked, requiring orthodonture. But that kind of “evolution” took place over just a generation or two: Dr. Price’s investigation was prompted by the realization that the kids he was treating had problems their parents and grandparents never had.

    Lua, yes, poverty is a huge factor in dietary choices. It is true even in the U.S. Examination of any charity “food box” will reveal white rice, white bread, white-flour pasta, canned fruits and vegetables, peanut butter, and little or no meat, eggs, dairy or seafood, though a can of tuna or salmon is typical. Fortification can’t make up the difference, because not only are the elements we fortify limited compared to what is available in whole foods, but often also chemically different, and in different proportions.

  6. Hi Lua,

    I enjoyed reading your post and mostly, if there’s still interest in baby food in China, wanted to point you in the direction of the Zuo Yue Zi Bao Mu (or the post-natal confinement doulas). You’ve probably come across it already in your research on some level but, in case not, the practice of confinement has very much modernized in the past ten years in China; where in places in Shanghai, you can check yourself into a Roman palace spa for 30 days (where you are allowed to wash your hair and bathe) at the mercy of extreme pampering by doctors, nurses, massage therapists and doulas; who will even do nightly feeding sessions with your baby (your breast milk) so that you can get an adequate 8 hours of sleep. I bring this up because the meal portion of the program (something that can also be outsourced just at home if you’re less interested in the 5-star surroundings) is based on traditional Chinese medicine diets of replenishing the system post-delivery for 30-100 days. There may be some attention placed now on the “building blocks” of nutrition as created by the Western paradigm of food biology but much of it is related to replenishing diminished blood and qi in the body, balancing out your meals (usually 6-8 a day) to get adequate nutrition. In Chinese, there are two common sayings related to this type of fortified nutrition through eating just food: “shi bu” (food replenishment as opposed to “yao bu” or medicinal replenishment/cure) and “chi shenme, bu shenme” (what you eat heals what’s wrong–i.e. eating cartilage will help that knee injury). These are concepts that are still brought down to modern society and taught at the top TCM schools–and an area which I’d find fascinating to study from a biological perspective if there were one. There may also be a gap of knowledge around Food Synergy (or how the combinations of foods can benefit health), which is where I think much of the genius takes place. I’d wonder if this is where some of the best of East and West can collide?

    Looking forward to reading more,

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