- Email: [email protected]
Exploratory Investigation of Obesity Risk and Prevention in Chinese Americans
RESEARCH BRIEF
Exploratory Investigation of Obesity Risk and Prevention in Chinese Americans Doreen Liou EdD, RD; Kathleen D. Bauer PhD, RD ABSTRACT Objective: To examine the beliefs and attitudes related to obesity risk and its prevention in Chinese Americans via in-depth, qualitative interviews using the guiding tenets of Health Belief Model, Theory of Planned Behavior, and social ecological models. Design: A qualitative study using tenets of the Health Belief Model, the Theory of Planned Behavior, and social ecological models. Setting: The New York City metropolitan area. Participants: Forty young Chinese American adults (24 females; 16 males) were interviewed. Main Outcome Measures: Obesity risk and prevention. Analysis: Common themes were identified, coded, and compared using NVivo computer software. Results: Poor dietary habits and sedentary lifestyles were seen as major weight gain contributors. Obesity was seen predominately as a non-Asian phenomenon, although 60% of the participants felt susceptible to obesity. Physical and social environmental factors were the overriding themes generated as to the causes of weight gain among young adult Chinese Americans. Physical factors included the powerful effect of media-generated advertisements and a plethora of inexpensive fast and convenience foods emphasizing large portion sizes of low nutrient density. The social environment encourages the consumption of large quantities of these foods. Traditional Chinese cuisine was seen as providing more healthful alternatives, but increasing acculturation to American lifestyle results in less traditional food consumption. Some traditional Chinese beliefs regarding the desirability of a slightly heavy physique can encourage overeating. Conclusion and Implications: Nutrition educators need to be public policy advocates for environments providing tasty, low cost, healthful foods. Young adult Chinese Americans seek knowledge and skills for making convenient healthful food selections in the midst of a culture that advocates and provides an abundance of unhealthful choices. Key Words: qualitative, Chinese Americans, obesity prevention, psychosocial theories (J Nutr Educ Behav. 2007;39:134-141)
INTRODUCTION The World Health Organization identifies obesity as a worldwide epidemic. Also on the increase are obesityrelated chronic diseases such as heart disease and diabetes, which raises concern about future mortality rates. Epidemiological studies provide evidence that these trends are occurring in all population groups in the United States, Department of Health and Nutrition Sciences, Montclair State University, Montclair, New Jersey Funds supporting this project came from Montclair State University Separately Budgeted Research Funds. Author for correspondence: Doreen Liou, Ed.D., R.D., Associate Professor, Department of Health and Nutrition Sciences, University Hall 4022, Montclair State University, Montclair, NJ 07043; Fax: (973) 655-7042; E-mail: lioud@mail. montclair.edu
©2007 SOCIETY FOR NUTRITION EDUCATION doi: 10.1016/j.jneb.2006.07.007
including the Chinese American community. Behavioral factors including high-fat, calorie-dense diets and sedentary lifestyles are ranked among the most salient contributors to obesity-related mortality.1,2 Popkin and Udry reported that Asian-American adolescents born in the United States were more than twice as likely to be obese as compared to first-generation residents of the United States.3 The percentage of low-income Asian children in California who are overweight more than doubled between 1994 and 2003, from 7% to 15%.4 Lauderdale and Rathouz found that the proportions of overweight and obese were lower among Asian-Americans than in white, black, and Mexican-Americans.5 However, US-born Asian-Americans were significantly more likely to be overweight or obese than those who were foreign-born. Among the foreign-born, the number of years of US residence is directly related to the risk of being overweight or obese. As
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the population shifts to a higher proportion of US-born Chinese Americans, the trend toward increased obesity rates is expected to continue.5 Social psychological theories have been used extensively to reveal key determinants of human dietary behavior, providing health professionals with a theoretical framework for targeting dietary interventions. However, theorybased research on obesity has rarely been conducted among ethnic minorities, including Chinese Americans.6 Because of tremendous growth in the Chinese American population on the East Coast,7 there is an immediate need among health professionals to understand the Chinese culture, with its specific beliefs, attitudes, and behaviors, as it relates to obesity risk. Thus, the purpose of this study was to explore the beliefs and attitudes pertaining to obesity risk and its prevention in Chinese Americans via in-depth, qualitative interviews using the guiding tenets of the Health Belief Model (HBM), the Theory of Planned Behavior (TPB), and social ecological models. The main objective of this project was to seek determinants of dietary behavior that will enable health professionals and nutrition educators to develop culturally sensitive programs and counseling sessions focused on chronic disease prevention.
DESCRIPTION OF QUALITATIVE STUDY During 2005, a purposive sample of 40 healthy individuals of Chinese American descent was recruited from the New York City metropolitan area to participate in qualitative research. Study participants were 16 male and 24 female U.S.-born Chinese Americans between the ages of 18 to 30 years, with a mean age of 22 years. Approximately 60% of the participants were full-time college students, and 40% were full-time employees. Several methods were employed to recruit volunteers. News releases were sent to newspapers serving heavily populated Chinese American communities; flyers were distributed to Chinese businesses and religious organizations, and Chinese community leaders were approached to announce the volunteer opportunity within their organizations. The goal was to obtain perceptions of a cross-section of this population group. Prior to starting the interviews, the study was described and participants were asked to complete a consent form. This study was approved by the university Institutional Review Board for Research Involving Human Subjects. On completion of the interview, participants received 20 dollars in compensation. A semistructured interview format was established in which 11 broad initial categories of questions were asked (Table 1). Constructs from major psychosocial theories guided development of these questions after a review of the literature (Table 2). The HBM posits that whether a person takes action depends largely on a rational estimate of the cost and benefit of engaging in a behavior. Four major constructs of the model include: (1) the perceived susceptibility of the individual to a condition; (2) the perceived
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severity of the condition if contracted; (3) the perceived benefits of taking action to prevent the condition; and (4) the perceived barriers to effective action. Additional constructs of the HBM include cues to action and self-efficacy, or confidence in the ability to perform a specific action.8 The TPB is an expectancy-value model incorporating behavioral, attitudinal, normative, and control beliefs that impact health behavior.9 Social ecological models of health behavior posit that behaviors are influenced by intrapersonal, social, cultural, and physical environmental variables. These models have been developed in an attempt to examine how physical and social environments directly affect health.10 All interview questions were pilot-tested with 20 individuals. The interviews lasted between 30 minutes to an hour and were tape-recorded and transcribed verbatim. The same 2 researchers conducted all interviews. Sampling continued until interviewing failed to provide fresh insight. Two researchers independently coded data to ensure agreement and consistency. Then transcripts were systematically coded using NUD*IST Vivo (NVivo, OSR International Pty. Ltd, Melbourne, Australia, 2000) software for qualitative research. Multiple investigators checked for consistency between codes and coding of text data. Data were methodically analyzed to identify recurrent patterns and themes based on the original interview questions. Cases of disagreement in interpretation were discussed to generate consensus among the researchers, and theoretical formulations were then derived.
FINDINGS Obesity was defined by the participants as being very overweight based on standard weight for height measures or based only on observation. The health consequences perceived by the subjects included cardiovascular problems, impairment of physical activity, and negative psychological effects owing to social stigma.
Perceived Susceptibility of Obesity Approximately 42% (17/40) of the respondents indicated that obesity was a major issue for Chinese Americans, and 52% (21/40) perceived the benefits of protective genetic factors and healthful traditional Chinese diets. Many respondents felt obesity was more prevalent in other ethnic groups. Perceived susceptibility to obesity was indicated in approximately 60% (24/40) of the respondents, who cited poor diet, genetic factors, and lack of exercise as risk factors. In contrast, other respondents cited self-consciousness, the desire for beauty attainment, and high metabolic rates as impediments for gaining weight. Fifty-four percent (21/40) of respondents stated they were satisfied with their current weight. Of the 38% who were not satisfied, 40% (6/15) of those felt they were too skinny, and 60% (8/15) claimed they were too heavy. Several participants felt they were
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Table 1. Social Psychological Constructs Related to Each Question
Question How would you define obesity? What are some health consequences of obesity? Do you think obesity is a health concern for Chinese Americans? Do you personally feel susceptible to obesity? What are the major causes of obesity in Chinese Americans? Are US-born or foreign-born individuals more prone to this condition? In your opinion, are genetic or environmental factors more powerful in resulting in a likelihood of developing obesity? What do you think is the best way to prevent obesity in Chinese Americans? What kind of diet would best prevent obesity among Chinese Americans? (Example: “high CHO, low fat” or “low CHO, high fat”) Besides preventing obesity in adopting this kind of diet, what are other benefits in adhering to this way of eating? What are some barriers that you face in eating healthfully? Are there social influences that impact the way that you eat? Who are these social influences in your life? What are some ways to increase your confidence in eating healthfully (self-efficacy)? Describe your overall satisfaction or dissatisfaction with your current body weight
HBM Construct
TPB Construct
Social Ecological Construct
Perceived severity Perceived susceptibility Perceived susceptibility Perceived susceptibility
Perceived behavioral control
Social and physical environment
Perceived behavioral control
Social and physical environment
Cues to action
Attitude Attitude
Perceived benefits Perceived barriers
Perceived behavioral control Subjective norm
Social and physical environment Social environment
Self-efficacy
burdened with the stereotype that Asians are supposed be thin.
Major Causes of Obesity in Chinese Americans Study respondents cited environmental factors as the major cause of obesity among Chinese Americans, including an abundance of readily available, unhealthful foods and powerful food advertisements and media influences (Table 3). Many participants believed that because many parents work, levels of stress and the consumption of fast food had increased. A trend toward eating mainstream American foods and away from traditional Chinese foods was indicated. Adaptation to American culture included the pressure among college students to consume high amounts of alcoholic beverages. A decline in physical activity was attributed to the popularity of computer-generated entertainment. Eighty-three percent (33/40) of the respondents felt US-born Chinese Americans were more prone to obe-
Attitude
sity than those who were foreign-born because of westernization of diets, especially the consumption of fast food. Fast-food restaurants were even described as a comforting symbol of home when spending time out of the United States. Fifty-five percent (22/40) of the respondents believed that social and physical environmental factors were more powerful, whereas 40% (16/40) of the respondents believed genetic factors had a dominating effect in the development of obesity.
Obesity Prevention The most common themes elicited for obesity prevention were adopting healthful diets and increasing exercise. Modifying dietary factors included decreasing portion sizes, eating breakfast, eating at home, and reducing fast food consumption. Providing a healthful environment, which encompassed role modeling of parents, positive media advertisements, and the provision of more healthful foods served in restaurants, was suggested. Increasing awareness
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Table 2. Themes Identified by Social Psychological Constructs
Health Belief Model Perceived susceptibility Perceived severity Perceived benefits (eating healthfully and physically active) Perceived barriers
Self-efficacy Cues to action Theory of Planned Behavior Attitude Subjective norm Perceived behavioral control Social Ecological Model Physical environment
Social environment
Sixty percent of the respondents felt susceptible to obesity Respondents identified numerous social, psychological and health consequences of obesity Health – decreased risk of illness and longer life Increased quality of life – emotional well being, improved social life, increased mobility Enhanced physical appearance Physical environment – plethora of fast and convenient food; mass media advertising; healthy foods not readily available and expensive Social environment – Lack of social support to eat healthfully Internal environment – Taste preferences for high fat and refined carbohydrates Increased awareness and education Attainment of initial dietary goals Peer support Mass media Generally positive attitudes toward healthful eating and physical activity U.S. social culture encourages unhealthful eating; traditional Chinese culture encourages healthful eating Respondents perceived obstacles in taking control. Frequently cited lack of availability of tasty, inexpensive, and healthful choices Abundance of fast food establishments emphasizing large portion sizes Powerful media-generated advertisements promoting convenient and highly processed food Parental influence to encourage healthful eating Negative peer influence
and education of obesity risk were perceived as beneficial in obesity prevention.
Benefits of Healthful Eating Enhanced health was the most common theme identified as an additional benefit of following a diet that would prevent obesity. Health benefits included improved nutritional health, normal organ function, an enhanced immune system, stronger bones, a decreased risk of illness, and a longer lifespan. Another theme generated was quality of life benefits, including emotional well-being, a fulfilling social life, more energy, and increased mobility. Healthful eating was also believed to result in a favorable physical appearance, including healthier skin and a toned body.
Barriers to Healthful Eating The most common theme related to barriers to healthful eating was the environment. Social environmental factors included celebrations, parties, and eating with friends. Physical environmental barriers included an abundance of generally unhealthy food and large food portions served in
restaurants. In general, the American society was viewed as one that emphasized unhealthful eating. In some cases, respondents felt that their relatives were following a traditional Chinese cultural norm by encouraging overeating. In addition, psychological factors such as stress, boredom, or reaction to deprivation were also identified as barriers.
Social Influence and Self-efficacy Eighty percent (32/40) of respondents indicated parents were a major influence impacting their food choices. The second category of responses identified friends as an important social influence. Other social influences included other relatives, media, track coach, and co-workers. Thirty-five percent (14/40) identified social impetus factors as a way to increase confidence in eating healthfully, including peer support, doctor’s advice, and parental pressure. Others said that knowledge of health and physical appearance benefits, and how to eat healthfully would increase self-efficacy. An additional theme was the identification of internal locus of control factors, including being in touch with one’s perception of health, realization of self-responsibility for weight, awareness of food choices, and cooking for oneself. Many
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Table 3. Representative Quote by Theme
Physical Environment Fast food: 70-80% of the time that I go out with my friends we eat at fast food places. Abundance: US-born are exposed to excess – oversized portions. Lack of healthful foods: We have so many more resources for unhealthy food. Social Environment Peers: When I go out they order french fries or something else unhealthy. I want to eat what my friends do because I enjoy those kinds of food so I feel pressured to eat unhealthy foods. My friends do not say let’s eat a salad together. If you are a guy, it is a wussy thing to do. It is kind of looked down upon if you are a guy – weak. Eat the steak, eat the greasy stuff, be a man. Mainstream American Culture Abundance: The main stress in America is getting more for your buck. . .over what you need. Stress: Sometimes school work interferes with eating healthy. I can’t concentrate on what to eat so I just eat what is convenient. Acculturation: When I go to Taiwan (usually every summer), I only want to eat fast food – McDonalds. It made me feel like home. Traditional Chinese Culture Healthful eating: See more fruits and vegetables in Chinese households. Encourages eating: My grandmother wants us to eat a lot. She thinks a healthy kid is one who eats a lot – traditional values – my uncle has the same values, they are happy to see the children eat. Cultural Interface When I shared an apartment with friends, I would not cook anything too ethnic because I would not be able to share the food with my roommates. They shared their food with me. Genetic Factors Even if genetically you are not prone to obesity, if you eat a lot of unhealthy food and do not exercise, you will override that tendency and gain weight. Behavioral Intention I like how I feel when I eat well and that will encourage me to eat better. Attitude Toward Behavior How I feel, I do not feel good when I eat unhealthy. Belief System: Perceived Threat I absolutely feel susceptible, especially for women and as one ages. Belief System: Perceived Benefits By cutting down on fats and sugars, a person would have more energy throughout the day. You would not just have a quick sugar high. Belief System: Perceived Barriers Cost: Chips are less expensive than a bag of apples. Time: Sometimes you just need to eat and go quickly, you don’t have time – part of the American culture is hurry up. Taste: Today I ate a lot of cookies, I like the taste. Convenience: I will eat fast food or chips. I select these foods because they are convenient. Fruits are not as easy to take. Self-Efficacy Doctor telling me to eat better would increase my confidence.
felt incentives, such as preparing for a special event, could have a powerful influence.
DISCUSSION A model was developed from major themes elicited on the perceptions and prevention of obesity in a sample group of young adult Chinese Americans (Figure). As this model indicates, social, cultural, environmental, and physiological factors may impact an individual’s intention to engage in
preventive health behaviors. An individual’s belief systems, attitudes, and self-efficacy may also affect behavioral intention and actual dietary behavior. The results of this study indicate that environmental factors were perceived to be the overriding influence on food behaviors and obesity risk. Obesity is caused by genetic predisposition; however, the substantial increases in obesity during the past 2 decades can be attributed to behavioral and social ecological factors.6 Participants of this study clearly identified environmental and social factors as the foundation for encouraging
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behaviors leading to obesity among Chinese Americans. Harrison and colleagues, who conducted focus groups with low-income Asians and Pacific Islanders, reported that parents expressed a sense of powerlessness over the influence of television, food advertising, and the school environment on their children.4 Many respondents complained about a lack of tasty, healthful, and low-cost food options in their work and school environments. Research provides strong evidence that availability of calorie-dense foods encourages overcon-
Mainstream American Culture
sumption of calories, which leads to obesity.11 An environment that supplies more healthful food choices has been associated with increased selection of these foods. Availability of more healthful food choices in supermarkets was found to be related to the increase of more healthful food choices in home settings.12 Participants felt their social environment had a major impact on their food-related behavior. The negative impact of peers on the social environment has been noted by other researchers’ reports on adolescents.13 The peer eating pat-
Traditional Chinese Culture
Social Environment Physical Environment (micro & macro levels)
Attitude Toward Behavior
Genetic Physiological Factors
Belief Systems Perceived Threat Perceived Benefits Perceived Barriers
Behavioral Intention
Behavior Figure. Chinese American model for obesity prevention.
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Self-Efficacy
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tern described by study participants has been found to be associated with obesity. Specifically, there is a positive correlation with soft drink consumption and an inverse association with high consumption of fruits and vegetables.14 Participants described home meals as more closely following traditional Chinese food patterns. Correspondingly, in a study by Harrison and colleagues, low-income Chinese groups in California described home-cooked meals as more healthful than restaurant-prepared food.4 Acculturation to American food behaviors was clearly evident among research participants. According to De Castro, culture has a marked influence on choice of foods consumed and meal patterns.15 Among research participants, degree of acculturation to the American lifestyle reflected a movement away from consuming traditional Chinese foods. Similarly, Nan and Cason found the degree of acculturation of Chinese Americans living in Pennsylvania was associated with decreased consumption of traditional Chinese food and increased consumption of fats, sweets, and soft drinks.16 Although home environments were seen as providing more healthful foods, some participants described family members who encouraged overconsumption of food. Traditionally, Chinese parents encouraged children to eat, and being slightly overweight has been associated with good health and high social status. As a result, individuals who have experienced marked weight gain may not perceive the condition as hazardous to their health.17 However, perceptions of participants regarding the social impact of body size varied. Some female individuals who did not possess a thin body type felt they were doubly stigmatized by an American ideal to be thin as well as by an expectation that Asians should be thin. Barriers to healthful eating were perceived as stemming from the social, physical, and internal environments. Taste has repeatedly been shown to be a major factor influencing food choices,18 and participants in this study clearly indicated that taste was a driving force for choosing fast and convenience foods. Cost of food was a major perceived barrier for this population group. Many of the participants were college students or just beginning a career, so they had financial concerns. In contrast, this was not the case for an older Chinese American population group who were economically secure.16 The Chinese American respondents perceived a number of ways to increase self-efficacy of healthful eating. These methods included social impetus or the possession of peer/parental support aimed at shifting the food choices from less nutrient-dense food to more healthful fare. An individual’s self-efficacy is affected by his or her previous success and attainment of diet-related goals and increased education of obesity risk and prevention. In addition, the successful attainment of past goals reflecting increment weight loss can propel individuals to continue their behavioral modification. In this study, respondents cited nutrition and health education as salient components of obesity risk reduction. Increasing awareness of the risks and health
consequences of obesity may be an effective deterrent for individuals to make poor dietary choices based on convenience or erroneous assumptions of fad diets.
LIMITATIONS There are a number of limitations to this qualitative study. First, the sample of respondents in the New York City metropolitan area was not large and random. Instead, a purposive sample of 40 participants was attained to meet research protocol for age, country of birth, and ethnic identity. Thus, the findings of this study cannot be generalized to the entire Chinese American population residing in this northeast location. Second, data analyses of transcribed interviews may be subject to investigator bias in interpretation. In order to minimize this bias, multiple coders were used to identify coding schemes in order to establish consistency. Third, this study did not use quantitative surveys to confirm the beliefs, attitudes, and behavioral outcomes of the respondents. Anthropometric data such as height and weight measurements were not collected. Body mass index (BMI) is used as the global standard for classification of body weight. In recent years, international experts have used a lower BMI scale for Asians, with cut-offs for overweight and obesity set as 23 kg/m2 and 25 kg/m2, respectively. This recommendation has resulted from findings that weight-related disorders were more common in some Asian ethnic groups at BMI levels above 23 kg/m2.19 Future studies can combine both qualitative and quantitative methods to generate a more comprehensive approach in understanding the beliefs and attitudes of obesity prevention among Chinese Americans.
IMPLICATIONS FOR RESEARCH AND PRACTICE Participants clearly indicated a strong need for physical and social environmental changes in order to decrease the risk of obesity. Nutrition educators targeting Chinese Americans need to be advocates for public policies that promote tasty, low-cost, healthful food choices. These changes require the collaboration of food industry and governmental, agricultural, and academic institutions, as advocated by Hill and Peters.2 Egger and Swinburn proposed an ecological approach to addressing the obesity issue, including actions such as the development of new food taxation policies and food laws and regulations.20 In order for positive attitudes toward obesity prevention to be formulated, health professionals need to acknowledge cultural perspectives and social stigmas of obesity inherent in this population group. Short-term outcomes such as enhanced physical appearance and energy levels may be more effective motivators than long-term goals of chronic disease prevention. Strategies aimed at modifying eating behaviors include making informed food choices at various eateries, establishing portion size control, and providing
Journal of Nutrition Education and Behavior ● Volume 39, Number 3, May/June 2007
ingredient substitutions in Chinese American dishes. Dietary modifications could include substituting low-fat for high-fat meat products or reducing the meat content of traditional Chinese dishes. Young Chinese American adults can be encouraged to prepare home-cooked meals with less added fat as an alternative to dining at fast-food establishments. Increased awareness of sound nutrition principles can be promoted through Web sites, and obesity prevention tips can be offered at university and worksite settings. Social support is crucial for these positive behaviors to be maintained. Nutrition education should also encompass the family members of these young adults, especially those responsible for food purchasing and preparation. Possible locations for community interventions include grocery stores, schools, churches, and cultural groups that serve predominately Chinese populations.
ACKNOWLEDGMENTS Funds supporting this project came from Montclair State University Separately Budgeted Research Funds. We would like to thank Shannon Kane for her assistance with data analysis.
REFERENCES 1. World Health Organization. Chronic Disease Information Sheet – Obesity and Overweight. Available at: http://www.who.int/ dietphysicalactivity/publications/facts/obesity/en/print.html. Accessed July 5, 2006. 2. Hill JO, Peters JC. Environmental contributions to obesity epidemic. Science. 1998;280:1371. 3. Popkin, BM, Udry JR. Adolescent obesity increases significantly in second and third generation U.S. immigrants: The national longitudinal study of adolescent health. J Nutr. 1998;128:701-706. 4. Harrison GG, Kagawa-Singer M, Foerster SB, et al. Seizing the moment: California’s opportunity to prevent nutrition-related health disparities in low-income Asian American populations. Cancer. 2005; 104:2962-2968. 5. Lauderdale DS, Rathouz PJ. Body mass index in a U.S. national sample of Asian Americans: Effects of nativity, years since immigration and socioeconomic status. Int J Obes. 2000;24:1188-1194.
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6. Baranowski T, Cullen KW, Nicklas T, Thompson D, Baranowski J. Are current health behavioral change models helpful in guiding prevention of weight gain efforts? Obes Res. 2003;11:23S-43S. 7. New York City Department of City Planning. The newest New Yorkers: 1995-1996. An update of immigration to New York City in the mid ‘90s. New York: Department of City Planning, City of New York; 1999. 8. Strecher VJ, Rosenstock IM. The health belief model. In: Glanz K, Lewis FM, Rimer BK, eds. Health Behavior and Health Education: Theory, Research, and Practice. 2nd ed. San Francisco, Calif: Jossey-Bass Publishers; 1997:41–59. 9. Ajzen I. The theory of planned behavior. Organ Behav Hum Decis Process. 1991;50:179-211. 10. MacIntyre S, Ellaway S. Ecological approaches: Rediscovering the role of the physical and social environment. In: Berkman LF, Kawachi I, eds. Social Epidemiology. London: Oxford University Press; 2000:332– 348. 11. Tordoff MG. Obesity by choice: The powerful influence of nutrient availability on nutrient intake. Am J Physiol Regul Integr Comp Physiol. 2002;282:R1536-R9. 12. Fisher BD, Strogatz DS. Community measures of low-fat milk consumption: Comparing store shelves with households. Am J Public Health. 1999;89:235-237. 13. Granner ML , Sargent RG, Calderon KS, Hussey JR, Evans AE, Watkins KW. Factors of fruit and vegetable intake by race, gender, and age among young adolescents. J Nutr Educ Behav. 2004;36:173180. 14. Epstein L, Gordy CC, Raynor HA, Beddome M, Kilanowski CK, Paluch R. Increasing fruit and vegetable intake and decreasing fat and sugar intake in families at risk for childhood obesity. Obes Res. 2001;9:171-178. 15. De Castro JM. Socio-cultural determinants of meal size and frequency. Brit J Nutr. 1997;77(1):S39-S55. 16. Nan LV, Cason KL. Dietary pattern change and acculturation of Chinese Americans in Pennsylvania. J Am Diet Assoc. 2004;104:771778. 17. Sobal J, Stunkard A. Socio-economic status and obesity: A review of the literature. Psychol Bull. 1989;105:260-275. 18. Ganchrow, JR. Ontogeny of human taste perception. In: Doty RL, ed. Handbook of Olfaction and Gustation. New York: Dekker; 1995:715729. 19. Appropriate body mass index for Asian populations and its implications for policy and intervention strategies. WHO expert consultation. Lancet. 2004;363:157-163. 20. Egger G, Swinburn B. An “ecological” approach to the obesity pandemic. Brit Med J. 1997;315:477-480.
Erratum The January/February issue of The Journal of Nutrition Education and Behavior carried a research brief entitled Food Spending Behaviors and Perceptions Are Associated With Fruit and Vegetable Intake Among Parents and Their Preadolescent Children (JNEB 2007;39: 26-30). The article
incorrectly stated, “Parents and children in households that cited cost as a frequent barrier to the purchase of fruits and vegetables were also heavier than those who did not find cost to be a significant barrier.” This statement should have been omitted from the article.
Exploratory Investigation of Obesity Risk and Prevention in Chinese Americans Doreen Liou EdD, RD; Kathleen D. Bauer PhD, RD ABSTRACT Objective: To examine the beliefs and attitudes related to obesity risk and its prevention in Chinese Americans via in-depth, qualitative interviews using the guiding tenets of Health Belief Model, Theory of Planned Behavior, and social ecological models. Design: A qualitative study using tenets of the Health Belief Model, the Theory of Planned Behavior, and social ecological models. Setting: The New York City metropolitan area. Participants: Forty young Chinese American adults (24 females; 16 males) were interviewed. Main Outcome Measures: Obesity risk and prevention. Analysis: Common themes were identified, coded, and compared using NVivo computer software. Results: Poor dietary habits and sedentary lifestyles were seen as major weight gain contributors. Obesity was seen predominately as a non-Asian phenomenon, although 60% of the participants felt susceptible to obesity. Physical and social environmental factors were the overriding themes generated as to the causes of weight gain among young adult Chinese Americans. Physical factors included the powerful effect of media-generated advertisements and a plethora of inexpensive fast and convenience foods emphasizing large portion sizes of low nutrient density. The social environment encourages the consumption of large quantities of these foods. Traditional Chinese cuisine was seen as providing more healthful alternatives, but increasing acculturation to American lifestyle results in less traditional food consumption. Some traditional Chinese beliefs regarding the desirability of a slightly heavy physique can encourage overeating. Conclusion and Implications: Nutrition educators need to be public policy advocates for environments providing tasty, low cost, healthful foods. Young adult Chinese Americans seek knowledge and skills for making convenient healthful food selections in the midst of a culture that advocates and provides an abundance of unhealthful choices. Key Words: qualitative, Chinese Americans, obesity prevention, psychosocial theories (J Nutr Educ Behav. 2007;39:134-141)
INTRODUCTION The World Health Organization identifies obesity as a worldwide epidemic. Also on the increase are obesityrelated chronic diseases such as heart disease and diabetes, which raises concern about future mortality rates. Epidemiological studies provide evidence that these trends are occurring in all population groups in the United States, Department of Health and Nutrition Sciences, Montclair State University, Montclair, New Jersey Funds supporting this project came from Montclair State University Separately Budgeted Research Funds. Author for correspondence: Doreen Liou, Ed.D., R.D., Associate Professor, Department of Health and Nutrition Sciences, University Hall 4022, Montclair State University, Montclair, NJ 07043; Fax: (973) 655-7042; E-mail: lioud@mail. montclair.edu
©2007 SOCIETY FOR NUTRITION EDUCATION doi: 10.1016/j.jneb.2006.07.007
including the Chinese American community. Behavioral factors including high-fat, calorie-dense diets and sedentary lifestyles are ranked among the most salient contributors to obesity-related mortality.1,2 Popkin and Udry reported that Asian-American adolescents born in the United States were more than twice as likely to be obese as compared to first-generation residents of the United States.3 The percentage of low-income Asian children in California who are overweight more than doubled between 1994 and 2003, from 7% to 15%.4 Lauderdale and Rathouz found that the proportions of overweight and obese were lower among Asian-Americans than in white, black, and Mexican-Americans.5 However, US-born Asian-Americans were significantly more likely to be overweight or obese than those who were foreign-born. Among the foreign-born, the number of years of US residence is directly related to the risk of being overweight or obese. As
Journal of Nutrition Education and Behavior ● Volume 39, Number 3, May/June 2007
the population shifts to a higher proportion of US-born Chinese Americans, the trend toward increased obesity rates is expected to continue.5 Social psychological theories have been used extensively to reveal key determinants of human dietary behavior, providing health professionals with a theoretical framework for targeting dietary interventions. However, theorybased research on obesity has rarely been conducted among ethnic minorities, including Chinese Americans.6 Because of tremendous growth in the Chinese American population on the East Coast,7 there is an immediate need among health professionals to understand the Chinese culture, with its specific beliefs, attitudes, and behaviors, as it relates to obesity risk. Thus, the purpose of this study was to explore the beliefs and attitudes pertaining to obesity risk and its prevention in Chinese Americans via in-depth, qualitative interviews using the guiding tenets of the Health Belief Model (HBM), the Theory of Planned Behavior (TPB), and social ecological models. The main objective of this project was to seek determinants of dietary behavior that will enable health professionals and nutrition educators to develop culturally sensitive programs and counseling sessions focused on chronic disease prevention.
DESCRIPTION OF QUALITATIVE STUDY During 2005, a purposive sample of 40 healthy individuals of Chinese American descent was recruited from the New York City metropolitan area to participate in qualitative research. Study participants were 16 male and 24 female U.S.-born Chinese Americans between the ages of 18 to 30 years, with a mean age of 22 years. Approximately 60% of the participants were full-time college students, and 40% were full-time employees. Several methods were employed to recruit volunteers. News releases were sent to newspapers serving heavily populated Chinese American communities; flyers were distributed to Chinese businesses and religious organizations, and Chinese community leaders were approached to announce the volunteer opportunity within their organizations. The goal was to obtain perceptions of a cross-section of this population group. Prior to starting the interviews, the study was described and participants were asked to complete a consent form. This study was approved by the university Institutional Review Board for Research Involving Human Subjects. On completion of the interview, participants received 20 dollars in compensation. A semistructured interview format was established in which 11 broad initial categories of questions were asked (Table 1). Constructs from major psychosocial theories guided development of these questions after a review of the literature (Table 2). The HBM posits that whether a person takes action depends largely on a rational estimate of the cost and benefit of engaging in a behavior. Four major constructs of the model include: (1) the perceived susceptibility of the individual to a condition; (2) the perceived
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severity of the condition if contracted; (3) the perceived benefits of taking action to prevent the condition; and (4) the perceived barriers to effective action. Additional constructs of the HBM include cues to action and self-efficacy, or confidence in the ability to perform a specific action.8 The TPB is an expectancy-value model incorporating behavioral, attitudinal, normative, and control beliefs that impact health behavior.9 Social ecological models of health behavior posit that behaviors are influenced by intrapersonal, social, cultural, and physical environmental variables. These models have been developed in an attempt to examine how physical and social environments directly affect health.10 All interview questions were pilot-tested with 20 individuals. The interviews lasted between 30 minutes to an hour and were tape-recorded and transcribed verbatim. The same 2 researchers conducted all interviews. Sampling continued until interviewing failed to provide fresh insight. Two researchers independently coded data to ensure agreement and consistency. Then transcripts were systematically coded using NUD*IST Vivo (NVivo, OSR International Pty. Ltd, Melbourne, Australia, 2000) software for qualitative research. Multiple investigators checked for consistency between codes and coding of text data. Data were methodically analyzed to identify recurrent patterns and themes based on the original interview questions. Cases of disagreement in interpretation were discussed to generate consensus among the researchers, and theoretical formulations were then derived.
FINDINGS Obesity was defined by the participants as being very overweight based on standard weight for height measures or based only on observation. The health consequences perceived by the subjects included cardiovascular problems, impairment of physical activity, and negative psychological effects owing to social stigma.
Perceived Susceptibility of Obesity Approximately 42% (17/40) of the respondents indicated that obesity was a major issue for Chinese Americans, and 52% (21/40) perceived the benefits of protective genetic factors and healthful traditional Chinese diets. Many respondents felt obesity was more prevalent in other ethnic groups. Perceived susceptibility to obesity was indicated in approximately 60% (24/40) of the respondents, who cited poor diet, genetic factors, and lack of exercise as risk factors. In contrast, other respondents cited self-consciousness, the desire for beauty attainment, and high metabolic rates as impediments for gaining weight. Fifty-four percent (21/40) of respondents stated they were satisfied with their current weight. Of the 38% who were not satisfied, 40% (6/15) of those felt they were too skinny, and 60% (8/15) claimed they were too heavy. Several participants felt they were
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Table 1. Social Psychological Constructs Related to Each Question
Question How would you define obesity? What are some health consequences of obesity? Do you think obesity is a health concern for Chinese Americans? Do you personally feel susceptible to obesity? What are the major causes of obesity in Chinese Americans? Are US-born or foreign-born individuals more prone to this condition? In your opinion, are genetic or environmental factors more powerful in resulting in a likelihood of developing obesity? What do you think is the best way to prevent obesity in Chinese Americans? What kind of diet would best prevent obesity among Chinese Americans? (Example: “high CHO, low fat” or “low CHO, high fat”) Besides preventing obesity in adopting this kind of diet, what are other benefits in adhering to this way of eating? What are some barriers that you face in eating healthfully? Are there social influences that impact the way that you eat? Who are these social influences in your life? What are some ways to increase your confidence in eating healthfully (self-efficacy)? Describe your overall satisfaction or dissatisfaction with your current body weight
HBM Construct
TPB Construct
Social Ecological Construct
Perceived severity Perceived susceptibility Perceived susceptibility Perceived susceptibility
Perceived behavioral control
Social and physical environment
Perceived behavioral control
Social and physical environment
Cues to action
Attitude Attitude
Perceived benefits Perceived barriers
Perceived behavioral control Subjective norm
Social and physical environment Social environment
Self-efficacy
burdened with the stereotype that Asians are supposed be thin.
Major Causes of Obesity in Chinese Americans Study respondents cited environmental factors as the major cause of obesity among Chinese Americans, including an abundance of readily available, unhealthful foods and powerful food advertisements and media influences (Table 3). Many participants believed that because many parents work, levels of stress and the consumption of fast food had increased. A trend toward eating mainstream American foods and away from traditional Chinese foods was indicated. Adaptation to American culture included the pressure among college students to consume high amounts of alcoholic beverages. A decline in physical activity was attributed to the popularity of computer-generated entertainment. Eighty-three percent (33/40) of the respondents felt US-born Chinese Americans were more prone to obe-
Attitude
sity than those who were foreign-born because of westernization of diets, especially the consumption of fast food. Fast-food restaurants were even described as a comforting symbol of home when spending time out of the United States. Fifty-five percent (22/40) of the respondents believed that social and physical environmental factors were more powerful, whereas 40% (16/40) of the respondents believed genetic factors had a dominating effect in the development of obesity.
Obesity Prevention The most common themes elicited for obesity prevention were adopting healthful diets and increasing exercise. Modifying dietary factors included decreasing portion sizes, eating breakfast, eating at home, and reducing fast food consumption. Providing a healthful environment, which encompassed role modeling of parents, positive media advertisements, and the provision of more healthful foods served in restaurants, was suggested. Increasing awareness
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Table 2. Themes Identified by Social Psychological Constructs
Health Belief Model Perceived susceptibility Perceived severity Perceived benefits (eating healthfully and physically active) Perceived barriers
Self-efficacy Cues to action Theory of Planned Behavior Attitude Subjective norm Perceived behavioral control Social Ecological Model Physical environment
Social environment
Sixty percent of the respondents felt susceptible to obesity Respondents identified numerous social, psychological and health consequences of obesity Health – decreased risk of illness and longer life Increased quality of life – emotional well being, improved social life, increased mobility Enhanced physical appearance Physical environment – plethora of fast and convenient food; mass media advertising; healthy foods not readily available and expensive Social environment – Lack of social support to eat healthfully Internal environment – Taste preferences for high fat and refined carbohydrates Increased awareness and education Attainment of initial dietary goals Peer support Mass media Generally positive attitudes toward healthful eating and physical activity U.S. social culture encourages unhealthful eating; traditional Chinese culture encourages healthful eating Respondents perceived obstacles in taking control. Frequently cited lack of availability of tasty, inexpensive, and healthful choices Abundance of fast food establishments emphasizing large portion sizes Powerful media-generated advertisements promoting convenient and highly processed food Parental influence to encourage healthful eating Negative peer influence
and education of obesity risk were perceived as beneficial in obesity prevention.
Benefits of Healthful Eating Enhanced health was the most common theme identified as an additional benefit of following a diet that would prevent obesity. Health benefits included improved nutritional health, normal organ function, an enhanced immune system, stronger bones, a decreased risk of illness, and a longer lifespan. Another theme generated was quality of life benefits, including emotional well-being, a fulfilling social life, more energy, and increased mobility. Healthful eating was also believed to result in a favorable physical appearance, including healthier skin and a toned body.
Barriers to Healthful Eating The most common theme related to barriers to healthful eating was the environment. Social environmental factors included celebrations, parties, and eating with friends. Physical environmental barriers included an abundance of generally unhealthy food and large food portions served in
restaurants. In general, the American society was viewed as one that emphasized unhealthful eating. In some cases, respondents felt that their relatives were following a traditional Chinese cultural norm by encouraging overeating. In addition, psychological factors such as stress, boredom, or reaction to deprivation were also identified as barriers.
Social Influence and Self-efficacy Eighty percent (32/40) of respondents indicated parents were a major influence impacting their food choices. The second category of responses identified friends as an important social influence. Other social influences included other relatives, media, track coach, and co-workers. Thirty-five percent (14/40) identified social impetus factors as a way to increase confidence in eating healthfully, including peer support, doctor’s advice, and parental pressure. Others said that knowledge of health and physical appearance benefits, and how to eat healthfully would increase self-efficacy. An additional theme was the identification of internal locus of control factors, including being in touch with one’s perception of health, realization of self-responsibility for weight, awareness of food choices, and cooking for oneself. Many
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Table 3. Representative Quote by Theme
Physical Environment Fast food: 70-80% of the time that I go out with my friends we eat at fast food places. Abundance: US-born are exposed to excess – oversized portions. Lack of healthful foods: We have so many more resources for unhealthy food. Social Environment Peers: When I go out they order french fries or something else unhealthy. I want to eat what my friends do because I enjoy those kinds of food so I feel pressured to eat unhealthy foods. My friends do not say let’s eat a salad together. If you are a guy, it is a wussy thing to do. It is kind of looked down upon if you are a guy – weak. Eat the steak, eat the greasy stuff, be a man. Mainstream American Culture Abundance: The main stress in America is getting more for your buck. . .over what you need. Stress: Sometimes school work interferes with eating healthy. I can’t concentrate on what to eat so I just eat what is convenient. Acculturation: When I go to Taiwan (usually every summer), I only want to eat fast food – McDonalds. It made me feel like home. Traditional Chinese Culture Healthful eating: See more fruits and vegetables in Chinese households. Encourages eating: My grandmother wants us to eat a lot. She thinks a healthy kid is one who eats a lot – traditional values – my uncle has the same values, they are happy to see the children eat. Cultural Interface When I shared an apartment with friends, I would not cook anything too ethnic because I would not be able to share the food with my roommates. They shared their food with me. Genetic Factors Even if genetically you are not prone to obesity, if you eat a lot of unhealthy food and do not exercise, you will override that tendency and gain weight. Behavioral Intention I like how I feel when I eat well and that will encourage me to eat better. Attitude Toward Behavior How I feel, I do not feel good when I eat unhealthy. Belief System: Perceived Threat I absolutely feel susceptible, especially for women and as one ages. Belief System: Perceived Benefits By cutting down on fats and sugars, a person would have more energy throughout the day. You would not just have a quick sugar high. Belief System: Perceived Barriers Cost: Chips are less expensive than a bag of apples. Time: Sometimes you just need to eat and go quickly, you don’t have time – part of the American culture is hurry up. Taste: Today I ate a lot of cookies, I like the taste. Convenience: I will eat fast food or chips. I select these foods because they are convenient. Fruits are not as easy to take. Self-Efficacy Doctor telling me to eat better would increase my confidence.
felt incentives, such as preparing for a special event, could have a powerful influence.
DISCUSSION A model was developed from major themes elicited on the perceptions and prevention of obesity in a sample group of young adult Chinese Americans (Figure). As this model indicates, social, cultural, environmental, and physiological factors may impact an individual’s intention to engage in
preventive health behaviors. An individual’s belief systems, attitudes, and self-efficacy may also affect behavioral intention and actual dietary behavior. The results of this study indicate that environmental factors were perceived to be the overriding influence on food behaviors and obesity risk. Obesity is caused by genetic predisposition; however, the substantial increases in obesity during the past 2 decades can be attributed to behavioral and social ecological factors.6 Participants of this study clearly identified environmental and social factors as the foundation for encouraging
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behaviors leading to obesity among Chinese Americans. Harrison and colleagues, who conducted focus groups with low-income Asians and Pacific Islanders, reported that parents expressed a sense of powerlessness over the influence of television, food advertising, and the school environment on their children.4 Many respondents complained about a lack of tasty, healthful, and low-cost food options in their work and school environments. Research provides strong evidence that availability of calorie-dense foods encourages overcon-
Mainstream American Culture
sumption of calories, which leads to obesity.11 An environment that supplies more healthful food choices has been associated with increased selection of these foods. Availability of more healthful food choices in supermarkets was found to be related to the increase of more healthful food choices in home settings.12 Participants felt their social environment had a major impact on their food-related behavior. The negative impact of peers on the social environment has been noted by other researchers’ reports on adolescents.13 The peer eating pat-
Traditional Chinese Culture
Social Environment Physical Environment (micro & macro levels)
Attitude Toward Behavior
Genetic Physiological Factors
Belief Systems Perceived Threat Perceived Benefits Perceived Barriers
Behavioral Intention
Behavior Figure. Chinese American model for obesity prevention.
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Self-Efficacy
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tern described by study participants has been found to be associated with obesity. Specifically, there is a positive correlation with soft drink consumption and an inverse association with high consumption of fruits and vegetables.14 Participants described home meals as more closely following traditional Chinese food patterns. Correspondingly, in a study by Harrison and colleagues, low-income Chinese groups in California described home-cooked meals as more healthful than restaurant-prepared food.4 Acculturation to American food behaviors was clearly evident among research participants. According to De Castro, culture has a marked influence on choice of foods consumed and meal patterns.15 Among research participants, degree of acculturation to the American lifestyle reflected a movement away from consuming traditional Chinese foods. Similarly, Nan and Cason found the degree of acculturation of Chinese Americans living in Pennsylvania was associated with decreased consumption of traditional Chinese food and increased consumption of fats, sweets, and soft drinks.16 Although home environments were seen as providing more healthful foods, some participants described family members who encouraged overconsumption of food. Traditionally, Chinese parents encouraged children to eat, and being slightly overweight has been associated with good health and high social status. As a result, individuals who have experienced marked weight gain may not perceive the condition as hazardous to their health.17 However, perceptions of participants regarding the social impact of body size varied. Some female individuals who did not possess a thin body type felt they were doubly stigmatized by an American ideal to be thin as well as by an expectation that Asians should be thin. Barriers to healthful eating were perceived as stemming from the social, physical, and internal environments. Taste has repeatedly been shown to be a major factor influencing food choices,18 and participants in this study clearly indicated that taste was a driving force for choosing fast and convenience foods. Cost of food was a major perceived barrier for this population group. Many of the participants were college students or just beginning a career, so they had financial concerns. In contrast, this was not the case for an older Chinese American population group who were economically secure.16 The Chinese American respondents perceived a number of ways to increase self-efficacy of healthful eating. These methods included social impetus or the possession of peer/parental support aimed at shifting the food choices from less nutrient-dense food to more healthful fare. An individual’s self-efficacy is affected by his or her previous success and attainment of diet-related goals and increased education of obesity risk and prevention. In addition, the successful attainment of past goals reflecting increment weight loss can propel individuals to continue their behavioral modification. In this study, respondents cited nutrition and health education as salient components of obesity risk reduction. Increasing awareness of the risks and health
consequences of obesity may be an effective deterrent for individuals to make poor dietary choices based on convenience or erroneous assumptions of fad diets.
LIMITATIONS There are a number of limitations to this qualitative study. First, the sample of respondents in the New York City metropolitan area was not large and random. Instead, a purposive sample of 40 participants was attained to meet research protocol for age, country of birth, and ethnic identity. Thus, the findings of this study cannot be generalized to the entire Chinese American population residing in this northeast location. Second, data analyses of transcribed interviews may be subject to investigator bias in interpretation. In order to minimize this bias, multiple coders were used to identify coding schemes in order to establish consistency. Third, this study did not use quantitative surveys to confirm the beliefs, attitudes, and behavioral outcomes of the respondents. Anthropometric data such as height and weight measurements were not collected. Body mass index (BMI) is used as the global standard for classification of body weight. In recent years, international experts have used a lower BMI scale for Asians, with cut-offs for overweight and obesity set as 23 kg/m2 and 25 kg/m2, respectively. This recommendation has resulted from findings that weight-related disorders were more common in some Asian ethnic groups at BMI levels above 23 kg/m2.19 Future studies can combine both qualitative and quantitative methods to generate a more comprehensive approach in understanding the beliefs and attitudes of obesity prevention among Chinese Americans.
IMPLICATIONS FOR RESEARCH AND PRACTICE Participants clearly indicated a strong need for physical and social environmental changes in order to decrease the risk of obesity. Nutrition educators targeting Chinese Americans need to be advocates for public policies that promote tasty, low-cost, healthful food choices. These changes require the collaboration of food industry and governmental, agricultural, and academic institutions, as advocated by Hill and Peters.2 Egger and Swinburn proposed an ecological approach to addressing the obesity issue, including actions such as the development of new food taxation policies and food laws and regulations.20 In order for positive attitudes toward obesity prevention to be formulated, health professionals need to acknowledge cultural perspectives and social stigmas of obesity inherent in this population group. Short-term outcomes such as enhanced physical appearance and energy levels may be more effective motivators than long-term goals of chronic disease prevention. Strategies aimed at modifying eating behaviors include making informed food choices at various eateries, establishing portion size control, and providing
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ingredient substitutions in Chinese American dishes. Dietary modifications could include substituting low-fat for high-fat meat products or reducing the meat content of traditional Chinese dishes. Young Chinese American adults can be encouraged to prepare home-cooked meals with less added fat as an alternative to dining at fast-food establishments. Increased awareness of sound nutrition principles can be promoted through Web sites, and obesity prevention tips can be offered at university and worksite settings. Social support is crucial for these positive behaviors to be maintained. Nutrition education should also encompass the family members of these young adults, especially those responsible for food purchasing and preparation. Possible locations for community interventions include grocery stores, schools, churches, and cultural groups that serve predominately Chinese populations.
ACKNOWLEDGMENTS Funds supporting this project came from Montclair State University Separately Budgeted Research Funds. We would like to thank Shannon Kane for her assistance with data analysis.
REFERENCES 1. World Health Organization. Chronic Disease Information Sheet – Obesity and Overweight. Available at: http://www.who.int/ dietphysicalactivity/publications/facts/obesity/en/print.html. Accessed July 5, 2006. 2. Hill JO, Peters JC. Environmental contributions to obesity epidemic. Science. 1998;280:1371. 3. Popkin, BM, Udry JR. Adolescent obesity increases significantly in second and third generation U.S. immigrants: The national longitudinal study of adolescent health. J Nutr. 1998;128:701-706. 4. Harrison GG, Kagawa-Singer M, Foerster SB, et al. Seizing the moment: California’s opportunity to prevent nutrition-related health disparities in low-income Asian American populations. Cancer. 2005; 104:2962-2968. 5. Lauderdale DS, Rathouz PJ. Body mass index in a U.S. national sample of Asian Americans: Effects of nativity, years since immigration and socioeconomic status. Int J Obes. 2000;24:1188-1194.
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6. Baranowski T, Cullen KW, Nicklas T, Thompson D, Baranowski J. Are current health behavioral change models helpful in guiding prevention of weight gain efforts? Obes Res. 2003;11:23S-43S. 7. New York City Department of City Planning. The newest New Yorkers: 1995-1996. An update of immigration to New York City in the mid ‘90s. New York: Department of City Planning, City of New York; 1999. 8. Strecher VJ, Rosenstock IM. The health belief model. In: Glanz K, Lewis FM, Rimer BK, eds. Health Behavior and Health Education: Theory, Research, and Practice. 2nd ed. San Francisco, Calif: Jossey-Bass Publishers; 1997:41–59. 9. Ajzen I. The theory of planned behavior. Organ Behav Hum Decis Process. 1991;50:179-211. 10. MacIntyre S, Ellaway S. Ecological approaches: Rediscovering the role of the physical and social environment. In: Berkman LF, Kawachi I, eds. Social Epidemiology. London: Oxford University Press; 2000:332– 348. 11. Tordoff MG. Obesity by choice: The powerful influence of nutrient availability on nutrient intake. Am J Physiol Regul Integr Comp Physiol. 2002;282:R1536-R9. 12. Fisher BD, Strogatz DS. Community measures of low-fat milk consumption: Comparing store shelves with households. Am J Public Health. 1999;89:235-237. 13. Granner ML , Sargent RG, Calderon KS, Hussey JR, Evans AE, Watkins KW. Factors of fruit and vegetable intake by race, gender, and age among young adolescents. J Nutr Educ Behav. 2004;36:173180. 14. Epstein L, Gordy CC, Raynor HA, Beddome M, Kilanowski CK, Paluch R. Increasing fruit and vegetable intake and decreasing fat and sugar intake in families at risk for childhood obesity. Obes Res. 2001;9:171-178. 15. De Castro JM. Socio-cultural determinants of meal size and frequency. Brit J Nutr. 1997;77(1):S39-S55. 16. Nan LV, Cason KL. Dietary pattern change and acculturation of Chinese Americans in Pennsylvania. J Am Diet Assoc. 2004;104:771778. 17. Sobal J, Stunkard A. Socio-economic status and obesity: A review of the literature. Psychol Bull. 1989;105:260-275. 18. Ganchrow, JR. Ontogeny of human taste perception. In: Doty RL, ed. Handbook of Olfaction and Gustation. New York: Dekker; 1995:715729. 19. Appropriate body mass index for Asian populations and its implications for policy and intervention strategies. WHO expert consultation. Lancet. 2004;363:157-163. 20. Egger G, Swinburn B. An “ecological” approach to the obesity pandemic. Brit Med J. 1997;315:477-480.
Erratum The January/February issue of The Journal of Nutrition Education and Behavior carried a research brief entitled Food Spending Behaviors and Perceptions Are Associated With Fruit and Vegetable Intake Among Parents and Their Preadolescent Children (JNEB 2007;39: 26-30). The article
incorrectly stated, “Parents and children in households that cited cost as a frequent barrier to the purchase of fruits and vegetables were also heavier than those who did not find cost to be a significant barrier.” This statement should have been omitted from the article.