Diet and acculturation in Chinese women

RESEARCH ARTICLE

Diet and Acculturation in Chinese Women JANICE D. SCHULTZ, AUDREY A. SPINDLER, AND RONALD V. JOSEPHSON

Nutritional Sciences, Department of Physical Education, San Diego State University, San Diego, California 92182-0171

ABSTRACT Information about acculturation of the increasing Asian-American population is limited. Three groups of women between 18 and 35 years of age were recruited to assess nutrition-related acculturation in Chinese-American (CA) women. BiophysIcal measurements, dietary intake, nutrition knowledge about cardiovascular risk factors, and eating attitudes were estimated In the test group of 18 US-born CA and In two control groups of 20 foreIgn-born Chinese (FBC) and 18 white Americans (W A). No group dIfferences existed for either percentages of body fat and lean body mass or for kilocalories from energy sources. Fat Intake, close to the national average of 34% of kilocalories, may reflect the affiuence of all groups. This findIng refutes the commonly held notion that Chinese consume low-fat diets. Of the three groups, CA women consumed the most nutrIent-dense dIets. The FBC scored significantly lower than the other groups on the nutrition knowledge test, missing questIOns about blood pressure, heart rate, and ingredient labels. NutritIOn knowledge about fat was low and not different among the groups. Sixty-seven percent of W A, 50% of CA, and 20% of FBC responded that nutritIOn Influenced their food chOIces. More nutrient-dense dIets, greater nutrition knowledge, and, to a lesser extent, improved attItudes about nutrition indIcate acculturation of US-born, CA women.

influences acculturation. 4 Generational changes in daily diets may reflect dynamic and complex shifts in food beliefs and attltudes, whether or not they are consciously determined,5 and generation-specific dietary information is seldom reported. Numerous sources 3,6,7,8 have emphasized that a better understanding of the practices and beliefs of minorIty ethnic groups in Western cultures is needed. Increasing numbers of Asian-Americans residing in the United States intensify a challenge for nutrition professionals because data about food habits, nutrition knowledge/attitudes, and physical traits of Asian-Americans are not only limited but also frequently confounded by bemg neither natIVIty or gender specific.!> Cardiovascular diseases (CVD) remain the leading cause of death for all ethnic groups in America, (, and Asians reportedly increase their fat and protein consumption upon migratIOn to the United States 7 ,8 which potentially increases their risk of CVD. The Chinese were selected as a subgroup for this study because of the Increasing size of the population,9 their long hIstory of US residency, and the existence of some published informatIOn about their food habits and nutrient intake. YUH has also noted that mortalIty from CVD was higher in US-born than in foreign-born Chinese (FBC). Since women have been under-represented in health studles in general,10-12 the study population was lImited to women only. The objectives of this small pilot study of ChineseAmerican (CA) women were to explore acculturation as related to (1) dietary intake and attitudes, (2) nutrItion knowledge about CVD risk factors, and (3) biophysical traits. Comparing data from CA women to those obtained from two control groups, FBC women and whIte-American (W A) women of unspecified European descent provides preliminary information about the role of acculturation on the measured variables.

UNE 26:266-272, 1994)

INTRODUCTION Acculturation is defined as cultural modifications through prolonged and continuous interaction of individuals from different sociocultural systems. Today, acculturation does not assume the end result is aSSImilation by a powerful, dominant culture. 1 Since food habits and beliefs about food vary among cultures, migrants between cultures may find themselves confronting long-held assumptions as they adjust to new environments.:> According to Sucher and Kittler,3 "cultural heritage may playa role in nutrient intake needs." Each generation of American residency strongly

METHODS Following approval by the San Diego State University's Committee on the Protection of Human Subjects, women between 18 and 35 years of age were recruited through announcements posted on the campus, invitational letters

ThIS research was supported by funds from the Zellmer Trust Fund, CalIforma DIetetIC ASSOCIation, and the San DIego DIStTlct Dletettc ASSOCIation. Address for correspondence Jamce D Schultz, MS., RD. 14651 Woodhue Lane, Poway, CA 92064-2977; Tel: 619-74H-8865 «:> 1994 SOCIETY FOR NUTRITION EDUCATION

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Journal of NutntlOn Education Volume 26 Number 6

to Asian community leaders, and an article in a Chinese community newspaper, The Jade Dragon. All subjects provided voluntary, written informed consent. The subjects completed a wntten questionnaire providing information about age, marital status, place of birth, and length of residency in the United States. 13 These data were used to classify subjects as CA, FBC, and WA. Each participant was subjectively rated on English language proficiency using a 3-point (A-B-C) scale. Respect for participant privacy and other potential barriers to recruitment and retention were considered in the study design. 14 For example, language translation assistance by a native Chinese speaker was available to participants as needed. A limitation inherent in any cross-cultural study is that compliance and accuracy are reduced when methods developed for the US majority are used on a minority ethnic group sample. 3

Biophysical measures. One investigator (first author) made all biophYSIcal measurements; therefore, no intennvestigator error exists. The mvestigator was tramed; measurements did not differ (±O.S%) upon replication or from those of the trainer (second author). HeIghts and weights were measured using a beam-balance standard scale (Health-O-Meter). Waist and hip measurements (cm) were taken using a fleXIble measuring tape and accordmg to standard procedures. IS To provide maXImal coverage and, therefore, privacy, yet mduce minimal error m absolute girth estimates, all subjects wore close-fitting, long SIlk underwear for waist and hip measurements. Body mass index (BMI; weight[kg]!ht[m 2]) and waist:hip ratios (WHR) were denved from the measurements. Subjects were instructed to maintain normal hydratlOn and to fast overnight before estimation of their body composition using bioelectrical impedance analysis (BIA). A computer program based on regression equatIons supplied by the manufacturer (RJL Systems, Detroit, MI) was used to derive body water, body fat, and lean body mass from the measured resistance and reactance values. 16 Several studies have addressed the absolute accuracy of body composition estimates using bioimpedance methodology; however, this technique was validated in white women against the hydrostatic technique. 17 .18 Bioimpedance methodology has not been validated in Asian subgroups. Although hydrostatic weighing has been considered the criterion measure, biOlmpedance was used in this study because it is safe, inexpensive, relatively rapid, and reqUlres less subject cooperation and investigator skill than other methods. Limited information from any methodology exists on body composition for any Asian subgroup. Therefore, BIA met the study's intent to examine relative differences among groups and did not deter subjects from participation. Dietary intake. The choice of method for collection of dietary data was based on four considerations to recruit and

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267

retain FBC subjects. Written records preserve a degree of privacy, allow a subjective measure of English literacy, permit reinforcement of oral instructions WIth written ones, and produce some limited measure of variety in selected foods. Observational and 24-hour recall methods do not meet one or more of those considerations. Also, the number of subjects m the study was too small to show differences among groups using 24-hour recalls. Food-frequency questionnaires specifically for Chinese groups were not developed at the time the study was initIated. While Basiotis et al. 19 showed that most nutrients required more than 4-day records to estimate true average intakes in groups of women, Gersovitz et al. 20 demonstrated that the number of usable food records deteriorated when records were kept more than 4 days. Subjects therefore kept 4-day written food records (3 weekdays and 1 weekend day) after they were instructed using food models and other tools for estimation of portion sizes. An interpreter who was a native of Taiwan and a graduate student majoring m nutrition was available at all instructional sessions. Food records were completed during March through July 1992, inclusively. As most fresh fruits and vegetables are available year round in the southern California county where the study was conducted, this does not introduce as extensive a bias as might eXIst elsewhere m the US. Completed food records were reviewed for errors or omissions and subjects were queried for clarificatlOn, if necessary. Nutrient content of diets was analyzed using the OhlO State University Nutrient Data Base. 21 Nutrient composition of foods not contained within the data base was added manually from Dietary Guidelinesfor People in Taiwan, ROCZ 2 and other standard food composition handbooks.

Nutrition knowledge and attitudes. Subjects completed an IS-item instrument to measure knowledge about fat, salt, and exercise factors associated with CVD risk. Subscales contained six questions on each of the factors. Vega et al,23 validated the instrument in southern California and reported on a sample that was 38% ASian (Asians were not subgrouped by place of birth), 36% whIte, 17% black, and 9% MeXIcan-American. To assess dIetary attitudes, four items were included on the demographic survey instrument. Subjects (1) described their eatmg as "healthy," "unhealthy," or "neutral;" (2) reported recent (i.e., within the last 6 months) eating habit changes as "no change," "some change," or "dramatic change;" (3) evaluated the mfluence of nutntion on their food choices as "very importantlinfluential daily," "important/ usually influential," "important/seldom influential," and "important/rarely influential;" and (4) rated their limIting of dietary fat, saturated fat, and cholesterol as "almost never," "sometimes," and "almost always." Statistical methods. Analysis of variance (ANOV A) followed by Tukey's post-hoc tests were used to determine

268

Schultz et al.lDIET AND ACCULTURATION IN CHINESE WOMEN

significant differences in parametric means among the three subject groups: FBC, CA, and WA. Bartlett's test for homogeneity of variance verified the applicability of the parametric ANOV A. All statistical tests were performed by the Systat program24 and an alpha of p :5 .05 was selected for significance. All tabular data are reported as means ± standard error of the mean (SEM).

RESULTS

Sample population characteristics. Ninety women participated in the study. As some members of each group failed to complete all parts of the study, data reported herein are only for complete cases including 20/32 FBC, 18125 US-born CA, and 18/30 WA subjects. Most (70% or 14120) of the foreign-born subjects had resided in the US 23 months or less. The remaining subjects were equally divided between those who were US residents from 2 years to 47 months and those who reported US residency of greater than 4 years (15% or 3120 each). Most (95%) of the immigrant Chinese were born in Taiwan, and the remainder were born in other Asian countries. All American-born Chinese received an "A" on the subjective English literacy rating; 20% and 80% of the FBC received "A" and "B" ratings, respectively. After enrollment and instruction about the study, the interpreter provided assistance with few (15% or 3120) subjects; specific questions about completing the food records were clarified for these subjects. Of the American-born Chinese, 61 % (11/18) were second-generation citizens, reporting that one or both of their parents immigrated, while 39% (7/18) were third-generation citizens, as they stated that their grandparents and either one or both parents were born in the US. The residences of the subjects in this study were not located in ethnically

Table 1.

identifiable enclaves but were geographically dispersed throughout the county.

Age and biophysical measurements. Age, anthropometric, and body composition data are summarized in Table 1. Although the majority of participants were college students (100% ofFBC, 66% ofCA, and 95% ofWA), the WA participants were significantly younger (22 years ± 1 year) than the FBC students (25 ± 1). The medians for age were 25, 23, and 21 years for the FBC, CA, and WA groups, respectively. The WA group was taller and heavier than both of the Chinese groups. Neither of these differences, however, was extensive enough to create a significant difference in BMI. Relative body composition (%) oflean body mass and body fat was similar among groups. Percentage of body water was higher and differed significantly (p < .039) between W A and CA. Greater mean hlP circumference in W A, rather than differences in mean waist girths, yielded a smaller waist:hip ratio in the W A than those in either group of Chinese women. Nutrient intake and eating habits. Although intakes of energy and sources of energy differed among groups (Table 2), mean percentages of kilocalones from carbohydrate (W A = 49%, CA = 50%, FBC = 50%), protein (W A = 14%, CA = 16%, FBC = 15%), and fat (WA = 34%, CA = 33%, FBC = 34%) did not differ among groups. Mean intakes of some regulatory nutrients are also summarized in Table 2. Of the three groups, CA women had the greatest dietary intakes of ascorbic acid, folacin, niacin, thiamin, calcium, and iron. The age range of subjects in this study spanned three age categories of the Recommended Dietary Allowances (RDA)25 for female Americans. However, the change in age category affects RDA values only for calcium and protem. Mean intakes of each group of women met or exceeded

Age and body composition characteristics of sample groups. Chinese

Chinese-American

White American

(n '" 20)

(n = 18)

(n = 18)

Significance of ANOVA

25 ± 18 159.8 ± 1.1"

22 ± 1" 166.1 ± 1.5",b

Weight (kg)

52.9 ± 1.5"

24 ± 1 160.1±1.lb 53.3 ± 1.9b

0.016

Height (cm)

59.9 ± 1.5",b

0.006

BMI (kg/m2)

20.67 ± 0.48 56.15±0.7S

20.69 ± 0.65

21.70 ± 0.49

58.28 ± 0.95" 76.06 ± 0.84 23.94 ± 0.84 93.13 ± 1 38b

55.17 ± 0.88" 74.39 ± 0.89 25.61 ± 0.89 98.14 ± 1.11 a ,b

69.29 ± 1.36 0.744 ± O.Olb

70,28 ± 1.07 0.716 ± 0.01 ",b

Age (yr)

Body water (%) Lean body mass (%) Body fat (%) Hip (cm) Waist (cm) Waist hip ratio

73.80 ± 0.71 26.20 ± 0.71 92.43 ± 0.99 a 69.63 ± 1.38 0.752 ± O.Ol a

a,bpaired symbols across rows show differences among means of at least p < .05 by Tukey's tests. NS = not significant.

0.001 NS

0.043 NS NS 0.002

NS

0.003

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Journal of Nutrition Education Volume 26 Number 6 Table 2.

269

Mean daily nutrient intakes by group.

Nutrient Energy (kcal) Carbohydrates (g) Protein (g) Fat (g) Calcium (mg) Iron (mg)

Chinese

Chinese-American

White American

(n = 20)

(n = 18)

(n = 18)

1,387 ± 81 a 17S ± 11'

1,801 ± 114a 223 ± 16a

Significance of ANOVA

1,632 ± 92

0.012

201 ± 11

0.030 0.013

S2 ± sa S2 ± 4 a

72 ± S·

S7 ±4

67 ± sa

61 ± 4

0.023

462 ± 38 a

720 ± 88 a

604 ± 43

0.012

10 ± 1

13 ± 2

11 ± 1

NS

Thiamin (mg)

1.2 ± 0.1

1.2 ± 0.1

1.0 ± 0.1

NS

Riboflavin (mg)

1.0 ± 0.1a

1.4±0.1a

1.3 ± 0.1

0.047

Niacin (mg) Vitamin C (mg) Folacin (mcg)

13 ± 1

17 ± 1

14 ± 1

NS

102 ± 19 131 ± 19a

127±21a 194 ± 21 a

6S ± sa

0.043

139 ± 10

0.030

a·bpalred symbols across rows show differences among means of at least p < .OS by Tukey's tests.

66% of the RDAs for each nutrient studied, except for calcium in all groups and for iron in the FBe. Percentages of the RDA were calculated for each individual subject (according to the appropriate age category) prior to computing the mean mtake of calcium for the subject groups. The mean percentages of the RDA for calcium achieved by the diets of the women were 49% for FBC, 71 % for CA, and 54% for W A. Mean intake of iron in the FBC met 63% of the RDA. When asked to describe their eating habits as "healthy," "neutral," or "unhealthy," 87% of all respondents stated "healthy" or "neutral" and 13% selected "unhealthy" as their response.

rise to significantly lower mean total scores than their US-born counterparts.

Attitudes toward nutrition. Responses to statements about attitude toward nutrition reflected a gradient across the three groups (Table 4). Eighty percent of FBC responded that nutrition did not influence food choices, while 67% ofWA reported that nutrition did influence their food chOlces. Responses of the CA women were divided equally mto "nutrition does/does not affect my food choices." White-American women also reported a greater likelihood to limit fat, saturated fat, and cholesterol in their diets than did both groups of Chmese women (Table 4).

Nutrition knowledge. Mean percentages of correct answers for the total questionnaire and knowledge subscales (salt, fat, and exercise) are reported in Table 3. All women demonstrated least knowledge on the "fat" questions, and there were no differences among groups. FBC women knew significantly less about "exercise" and "salt," glvmg

Table 3.

DISCUSSION BMI has been highly correlated with body fatness and a BMI greater than 27 (kg/m2) is generally accepted as indicative of obesity. BMI wlthin the range of 19 to 25 (kg/m 2) is

Nutrition knowledge: mean percentages of correct responses for entire test and for subscale by group.

Chinese Variable Total test (18 items)

(n = 20)

Chinese-American

(n

z

White American

18)

S2····b

(n = 18)

Significance 0.000

Subscale Dietary salt (6 items)

62 a ,b

79'

Dietary fat (6 Items)

40

43

NS

Exercise (6 items)

ssa.b

81 a

0.000

·Frequency reported as percentage. ··bpaired symbols across rows show differences among means of at least p :0; .OS by Tukey's tests.

0.001

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Schultz et al.lDIET AND ACCULTURATION IN CHINESE WOMEN

Table 4.

Self-reported descriptions of attitude and diet limits' in percentages by group.

Variable

Chinese

Chinese-American

White Ameflcan

(n = 20)

(n = 18)

(n = 18)

20 80

50

67

50

33

Attitude Nutrition is influential daily or usually. Nutntion is not usually or is rarely influential on food choices. Diet Limits' Almost never

30

17

11

Sometimes

60 10

66

39

17

50

Almost always '''1 limit the amount of fat, saturated fat, and cholesterol I eat."

normal for adults under 30 years of age. 26 The Chinese women in this study were shorter and lighter, but, unexpectedly, there were no significant differences in either BMI or percentage of body fat among groups. The slightly higher percentage of body water found in both groups of Chinese women supports similar findings by Jiang et al.,27 who compared the body composition of women from mainland Chma and North America. In contrast to those results,27 Chinese women in this study had neither a sigmficantly higher percentage of lean body mass nor a significantly lower percentage of body fat than the W A women. Most participants in this study came from affiuent Taiwan, which may be a factor affecting body composition. Vague 28 first reported an association between the prevalence of metabolic diseases and distribution of body fat; body fat was subsequently shown to be significantly correlated with WHR.29 The usefulness of WHR to Identify increased cardiovascular risk, even though the ratio increases with age, has been substantiated in white populations. 30 .31 Mean values for all subject groups herein fell within the range of normal values. However, these data do not differentiate whether or not the larger hip circumference in the white women occurs as a function of more adipose tissue and/ or of larger pelvic bones. Therefore, interpretation of these data appears premature; they are presented as the literature lacks such information. None of the three groups achieved mean caloric intakes suggested by the RDAs 25 for energy (i.e., 36-38 kcal/kg/day). Of the three groups, FBC women had the lowest daily intake (g) of carbohydrate. Consequently, the percentage of kilocalories from carbohydrate by FBC in this study sharply contrasts to recent dietary findings in mainland China, where 77% of kilocalories were from carbohydrate. 32 Protein intake of the FBC was similar to data reported from Taiwan and mainland China. 32 .33 All groups exceeded current recommendations for no more than 30% of total calories from fat. 11.25 In a recent study of 3000 Chinese from

northern California, the percentage of kilocalories from fat was estimated from 24-hour recalls at 29%, but 40% of the participants had intakes that exceeded 30% of calOries from fat. 34 While diets of mainland Chinese appear to remain low in fat, this stereotype may be erroneously applied to "Chinese" regardless of residence or relative affiuence . Based on the mean percentages of the RDA25 achieved for the nutrients under study, the nutrient intake of the subject groups was adequate, except for calcium in the FBC and W A groups and for iron in the FBC group. The fact that mean mtakes for energy, calcIUm, riboflavin, folacin, and vitamin C differed significantly among groups is important from an acculturation perspective. The energy intake of the Chinese American women reflects their greater food intake and accounts for most of the significant differences in nutrient intake that existed between the CA and FBC women. Low energy intake in the FBC group caused low intake for iron, riboflavin, niaclll, thiamin, and calcium. The differences in vitamm C and folacin intake among groups are a function of different proportional intakes of green vegetables (FBC and CA intakes> W A mtake) and fruits and legumes (CA and WA intakes > FBC intake). CA consumed two sources of folacm (green vegetables and legumes) and vitamin C (green vegetables and fruits) while FBC and W A typically had only one source of folacm and VItamin C. Interestingly, red beets, a folacm source, were consumed by four CA subjects, one W A, and not at all by FBC subjects. Low calcium intake 10 all groups and inadequate intake by the FBC and W A groups are of physiologic concern. Sources of calcium in the diets of CA subjects were dairy products and green vegetables. Cheeses were consumed by 78% of the CA, but 43% also drank fresh, fluid milk products. Similar to these findings, Ikeda et aP5 recently refuted the stereotypic assumption that Asians limit intake of dairy products because they are lactose intolerant. Most Asians studied35 were simply unfamiliar WIth dairy prod-

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Journal of Nutrition Education Volume 26 Number 6

ucts; after nutrition c:ducatlon intervention (which included some tasting of dairy products), subjects Increased their milk consumption. Our findings and those ofIkeda 35 suggest that Asians might benefit from education about the importance of calcium intake for bone health, dairy product food experiences, and information about lactase products. Despite training before keeping food records and followup queries, the real meaning of Western portion sizes, especially for the FBC women, may have been misunderstood. Newman 3" and Sanjur1 concur that Chinese parents commonly teach their children to leave the table when they are 70% satisfied. This feeling of satiety, rather than eating a defined quantity of food, may be highly variable among individuals. The need for preCisIOn in recording amounts of food consumed seemed especially difficult for the foreignborn participants in this study, perhaps because of their cultural focus on physiologic satiety rather than emphasis on eating certain quantities of food. Subjects were not queried, however, about factors that governed quantities of food consumed. Economic consideratIOns, under-reportIng (a problem common to many dietary studies), or other factors may be responsible for the limited quantity of food reportedly consumed, rather than the culturally taught attention to physiologic satiety. Results from the nutrition knowledge instrument21 Indicate that the questions most frequently missed by all subjects were about dietary fat (e.g., hydrogenation and saturated fat). Also, knowledge scale responses of CAs could be characterized as "more white American," based on correct responses to both exercise and salt subscales. Overall, knowledge about nutrition-related cardiovascular health In the FBC group was low. In addition to missing questions about hydrogenation and saturated fat, FBC subjects generally missed questions about heart rate, ingredient labels, and ways to reduce blood pressure. CA, though reporting some "Influence" of nutrition on food choices and "sometimes" limitIng fats and cholesterol, had the most nutrient-dense diets among the groups in this study. WA indicated that nutrition is influential and that they "almost always" try to limit their fat and cholesterol intake, but they had limited nutntion knowledge about dietary fat. Also, their dietary intake of fat was above the recommended maximum of 30% of kilocalories. Improving basic nutntion education messages for all groups about fat and dietary sodium and exercise for FBC would further the likelihood of achieving the Healthy People 2000 goals to reduce dietary fat and sodium intake. 37 When working with Asians, Wong38 has suggested the need for concrete rather than abstract educational messages, as well as recognition of the fact that for some Asians, avoidance of health-related messages may be perceived as a mechanism to stay healthy. These results confirm continued need for education that is age, residency-generation, and gender appropriate, and respectful to varying degrees of ethnic group identity.7

271

CONCLUSIONS Both the foreign-born and American-born Chinese women consumed an excess of 30% of kilocalories per day as fat, challenging the commonly held notion that persons of Chinese heritage consume diets low in fat. In contrast to published reports and general perceptions about the Chinese, body composition and the mean percentages of kilocalories from energy nutrients did not differ among these three groups of college-aged women. A contributIng factor may be that the Chinese women in this study, both foreign born and US born, have resided In relatively affiuent areas of Taiwan and/or the US and may not be typical of ChInese who live in areas that are geographically identifiable by ethnic group. Acculturation implies freedom to accept or reject aspects of either the "old" or "new" culture. The CA women in this study accepted some of the knowledge from the "new" culture about CVD risk factors such as dietary salt and exerCise, whIle most of their "attitude" responses were intermediate between those of the FBC and W A groups. When dietary intake data are viewed to reflect "behaviors," the "better" diets of the CA suggest that knowledge has a stronger bearing on behavior for them than "attitude" does. Little knowledge about CVD nsk factors and indifferent attitudes of the foreign-born group were clearly factors contributing to their lower nutnent intakes, but more knowledge and positive attitudes In W A women did not lead to meetIng recommended dietary goals In the context of this study. The differences between Chinese women In this study suggest that birthplace and length of US residency are important facts to be ascertained by nutntion professionals for planmng counseling or educational sessions. This small study indicates that first-generation ChInese immigrant women need information about CVD factors such as dietary fat, salt, and exercise. American-born women, either white or ChInese, need more understanding about dietary fat and CVD risk as well as improved food chOIces to meet recommended dietary goals.

ACKNOWLEDGMENTS This paper was developed from original research submitted as a thesis by Janice D. Schultz, R.D. in partial fulfillment of the requirements for the Master of Science degree. An abstract and poster from this thesis were previously presented at the 1993 Annual Meeting of the California Dietetic Association, Oakland, CA.

NOTES AND REFERENCES l. SpIndler LS. Cultural change and modermzatlOn. 1st ed. New York:

Holt, RInehart and WInston, 1977:31-3.

272

Schultz et al.lDIET AND ACCULTURATION IN CHINESE WOMEN

2. Tan SP, Wheeler E. Concepts relating to health and food held by Chmese women m London. Ecol Food Nutr 1983; 13:37-49. 3. Sucher KP, Kittler PG. Nutntion Isn't color bhnd. J Am DIet Assoc 1991; 91 :297-9 4. Cuellar I, Harns LC, Jasso R. An acculturatIOn scale for MexIcan Amencan normal and chmcal populations. Hisp J Behav SCI 1980; 2'199-217. 5. Hertzler AA, Wenkham N, Standal]. ClasslfYmg cultural food habItS and meamngs. J Am DIet Assoc 1982; 80:421-5. 6. KumanYlka S. DIet and chromc disease issues for mmonty populatIOns. J Nutr Educ 1990; 22:89-96. 7. SanJur D. Social and cultural perspectIves m nutntlOn. 1st ed. Englewood Chffs, NJ: PrentIce-Hall, 1982. 8. Yu PN. Heart dIsease m ASIans and PaCIfic-Islanders, Hlspamcs, and NatIve Amencans. CIrculatIOn 1991, 83 1475-7. 9. Wllkms]. It's offiCIal; county IS gettmg bIgger. San DIego Umon 1991; June 2' bl, b6.

22. DIetary gUIdelines for people in TaIwan, Repubhc ofChma (Vol. 2). TaIpeI, TaIwan. NatIOnal Health AdmlmstratlOn, Executive Yuan, 1991. 23. Vega W A, SalhsJF, Patterson T, Rupp J, Atkms C, Nader P. Assessmg knowledge of cardIOvascular health-related dIet and exerCIse behaVIOrs m Anglo-and MexIcan-Americans. Prev Med 1987; 16:696-709. 24. Systat computer program version 5.0, Evanston, IL, 1990. 25. National Research Council, Food and NutntlOn Board. Recommended dIetary allowances. 10th ed. Washington, DC: NatIOnal Academy of SCIences, 1989:283. 26. Zeman FJ, Ney DM. Apphcation of chmcal nutntlOn. 1st ed. Englewood Chffs, NJ: Prentice Hall, 1988:22 27.Jlang ZM, Yang NF, Chou C, et al. Body composition m Chmese subjects: companson WIth data from North Amenca. World J Surg 1991; 15:95-102. 28. Vague J. La dlfferenClatlon sexuelle humame: ses mCldeces en pathologle. Pans: Masson, 1953.

10. US Dept of Health and Human ServIces. Report of secretary's task

29 Ashwell M, Cole TJ, DIxon AK. ObeSIty· new mSlght mto the

force on black and mmonty health. Washmgton, DC: US Govern-

anthropometnc clasSIfication of dIstribution shown by computed to-

ment Pnntmg Office, 1987.

mography. Br MedJ 1985; 290:1692-4.

11. CommIttee on DIet and Health, Food and NutntlOn Board CommIs-

30. Wmg RR, Jeffery R W, Burton LR, Thorson C, Kuller LH, Folsom

SIOn on LIfe SCIences, NatIOnal Research CounCIl DIet and health:

AR Change m waIst-hIp ratIO with weIght loss and ItS assoCIatIOn

ImphcatlOns for reducmg chromc dIsease nsk. 1st ed. Washmgton,

with change m cardiovascular nsk factors. Am J Chn Nutr 1992, 55:

DC: US Government Pnntmg Office, 1987. 12. Worthmgton-Roberts B. DIrectIOns for research on women and nutntlOn. Am J Health Promo 1990; 5'63-9. 13. CopIes of questIOnnaIres are obtamable upon request from the correspondmg author. 14. Hooks PC, Tsong Y, Baranowski T, HenskeJC, Nader PR, LevmJS. RecrUItment strategIes for multlethmc famIly and commumty health research Fam Comm Health 1988; 11 (1):48-59 15. Lohman TG, Roche AF, Martorell R. Anthropometnc standardIzation reference manual. 1st ed. ChampaIgn, IL: Human Kmetlcs Books, 1988:177 16. RJL Systems BodyCompII, vemon 1 I. DetrOIt, MI: RJL Systems, 1988 17. Renvall MJ. Spmdler AA, NICholsJF, RamsdellJW. Body composI-

1086-92 31. Loos CA, Halals CM. WaIst: hlp ratIO versus body mass mdex-screenmg for nsk of cardIOvascular dIsease (abstract) Aust J Nutr DIet 1991 ;48.113-8. 32. Campbell TC. A study on the dIet, nutrItIOn and dIsease m the People's Repubhc of Chma, part I and part II. Con temp Nutr 1989; 14(5,6) 1-4. 33 Lee NY, Chu Y, ChangCP, ShlehJ, Kao M. DIetary survey m TaIwan area (abstract). J Chmese Nutr Soc 1991, 1639-60. 34 ASIan and PaCIfic Islander task force report on the year 2000 health promotIOn objectIves and recommendatIOns for CalIforma. Sacramento, CA: Cahforma Department of Health SerVICes, Health PromotIOn SectIOn, May 1992. 35 IkedaJP, MItchell RA, Brown G, Turner B, West E. IdentlfYmg and

tIOn of patients with AlzheImer's dIsease. J Am DIet Assoc 1993;

overcommg barners to mIlk and mIlk product consumption among

93.47-52.

Cahforma ASIan-Amencans. Poster presented at the Annual Meetmg

18. Kushner RF. BlOelectncaI Impedance analYSIS, a revIew of pnnClples and apphcatlons. J Am Coli Nutr 1992; 11: 199-209

of the Cahforma DIetetic AssocIatIOn, m San DIego, Cahforma, AprIl 29, 1994

19. BaslOtis PB, Welsh SO, Cromn FJ, Kelsay JL, Mertz W. Number of

36. Newman JM. Meltmg pot: an annotated blbhography and gUIde to

days of food mtake reqUIred to eStimate mdlvldual and group nutnent

food and nutntlOn mformatlon for ethmc groups m Amenca. 1st ed

mtakes with defined confidence. J Nutr 1987, 117: 1638-41.

New York. Garland Pubhshmg, 1986'65-7

20. Gersovltz M, MaddenJP, SmlClklas-Wnght H. Vahdlty of the 24-hr

37. US Department of Health and Human ServIces. Healthy people 2000'

dIetary recall and seven day record for group compansons. J Am DIet

objectives for the nation Washmgton, DC: US Government Printmg

Assoc 1978, 73'48-55 21. Umsoft Systems Associates, OhIO State Umvemty Data Base, verSIOn 4 0, 1991.

Office, 1990.154. 38. Wong H. The culture of poverty m Asian-PaCIfic Amencans. Presented to the NatIonal AdVISOry CommIttee on Cancer m the SocIOeconomICally DIsadvantaged, American Cancer SOCIety, February 24, 1988.