Dietary Intake of Arab International Students in Northeast Ohio

DIETARY INTAKE OF ARAB INTERNATIONAL STUDENTS IN NORTHEAST OHIO

A thesis submitted to the Kent State University College and Graduate School of Education, Health, and Human Services in partial fulfillment of the requirements for the degree of Master of Science

Abdulaziz Kh. Alfarhan

August, 2011

Thesis written by

Abdulaziz Kh. Alfarhan

B.S., Oregon State University, 2007

M.S., Kent State University, 2011

Approved by

______, Director, Master’s Thesis Committee Karen Gordon

______, Member, Master’s Thesis Committee Natalie Caine-Bish

______, Member, Master’s Thesis Committee Nancy Burzminski

Accepted by

______, Director, School of Health Sciences Lynne Rowan

______, Dean, College and Graduate School of Daniel F. Mahony Education, Health, and Human Services

iii

ALFARHAN, ABDULAZIZ KH., M.S, August 2011 Health Sciences

DIETARY INTAKE OF ARAB INTERNATIONAL STUDENTS IN NORTH EAST OHIO (98 pp.)

Director of Thesis: Karen Lowry Gordon, Ph.D.

This descriptive study was conducted to provide a description of dietary intake of

Arab international college students along with dietary changes associated with relocation in Northeast Ohio in addition to evaluating the overall differences in food intake based on gender and marital status. A self administrated Food Frequency Questionnaire (FFQ) was completed by 95 Arab international college students.

The respondents reported noticeable changes in their food preferences and consumption of both traditional and westernized foods. The results revealed shift toward westernized and local foods along with a general unbalanced consumption from food groups for the majority of participants. However, the results showed few differences based on gender and marital status. Traditional food consumption decreased (p ≤ 0.05) whereas westernized food consumption increased (p ≤ 0.05).

Overall, the results suggested newly arriving Arab international college students might benefit from nutrition education relative to westernized food intake. .

ACKNOWLEDGEMENTS

Thanks to all the Arab international students who were willing to take their time and effort to participate in this study and to complete this survey for the betterment of future Arab college students abroad. Thanks to all individuals who helped distribute and collect the surveys at Kent State University and University of Akron. Thanks to my

Master’s Thesis Committee, Dr. Karen Gordon, Dr. Natalie Caine-Bish, and Dr. Nancy

Burzminski, for their assistance and support. I also would like to thank dean, Dr. Fatema

Al-Khandari, and Dr. Khawla Yaqoub at the College of Nursing in Kuwait, and Shoghig

Sahakyan and Sherif Salem at the Embassy of the State of Kuwait in Washington D.C for their continuous academic and scholarship support. Finally, a special thanks to my family and to the dear friend Jaber Almuhanna.

TABLE OF CONTENTS

Page

ACKNOWLEDGEMENTS ...... iv

LIST OF FIGURES ...... vii

LIST OF TABLES ...... viii

CHAPTER Page

I INTRODUCTION ...... 1

Problem Statement ...... 5 Purpose of the Study ...... 6 Hypothesis...... 6 Operational Definitions ...... 6

II REVIEW OF LITERATURE ...... 8

History and Background ...... 8 Culture and Food ...... 9 Socioeconomic Status of Arabian States in the Gulf Region ...... 10 History of Food Importation and Food Availability of Arab Countries in the Middle East ...... 11 Features of the Arabic Diet ...... 12 Specific Nutrients of the Diet in the Arabic Gulf Region ...... 14 Nutrition and Chronic Diseases ...... 17 Impact of Relocation on Life Style ...... 19 Barriers and Challenges for Adaptation ...... 20 Eating Habits and Behaviors ...... 22 American College Student’s Diet and Eating Pattern ...... 23

III METHODOLOGY ...... 26

Purpose ...... 26 Design ...... 26 Subjects ...... 26 Questionnaire ...... 27 Procedures ...... 28 Statistics ...... 28 v

IV RESULTS ...... 29

Subject Demographics ...... 29 Body Mass Index (BMI) ...... 30 Daily Eating of Traditional Food ...... 30 Eating Locations and Preference (Before/After) ...... 36 Eating Traditional Food at Home/Restaurant ...... 39 Eating Westernized Food at Home/Restaurant ...... 39 Methods of Food Intake – After Moving to the U.S...... 42 Intake from Traditional Food Groups and Cuisines ...... 44 Intake from Westernized Food Groups ...... 44 Average Daily Consumption of Dairy Products ...... 44 Average Daily Consumption from Bread ...... 48 Average Daily Consumption of Beverages...... 48 Average Daily Consumption of Fats...... 48 Average Daily Consumption of Snack Foods and Desserts ...... 52 Average Daily Consumption of Meats, Legumes, and Eggs ...... 52 Average Daily Consumption of Vegetables and Fruits ...... 52 Average Daily Consumption of Starches ...... 52

V DISCUSSION ...... 57

Daily Intake of Traditional and Westernized Food...... 58 Characteristics of Food Consumption after Moving to the U.S...... 59 Impact of Relocating on Food Choices and Intake ...... 65 Applications ...... 66 Limitations ...... 68 Future Research ...... 68 Conclusion ...... 70

APPENDICES ...... 72

APPENDIX A CONSENT FORM ...... 73

APPENDIX B FOOD FREQUENCY QUESTIONNAIRE ...... 76

APPENDIX C ADDITIONAL DATA ...... 82

REFERENCES ...... 93

LIST OF FIGURES

Figure Page

1 North African and Middle Eastern States of Arab League ...... 3

2 Traditional food consumption of Arab international students before/after moving to the U.S...... 32

3 Westernized food consumption by Arab international students before/after moving to the U.S...... 34

vii

LIST OF TABLES

1 Composition of Major Bread Types Consumed In Kuwait and Their Contribution to Daily Requirements ...... 17

2 Demographic Characteristics of Arab International Students ...... 31

3 BMI Mean and Standard Deviation of Arab International Students ...... 32

4 Percentages of Daily Eating of Traditional Food of Arab International Students ...... 33

5 Percentages of Daily Eating of Westernized Food of Arab International Students ...... 35

6 Eating Location by Arab International Students Before/After Moving to the U.S...... 37

7 Percentage of Eating Locations by Arab International Students ...... 38

8 Eating Traditional Food at Home/Restaurant by Arab International Students ...... 40

9 Eating Westernized Food at Home/Restaurant by Arab International Students ....41

10 Percentages Regard Methods of Intake Food by Arab International Students after Moving to the U.S...... 43

11 Percentages of Intake from Traditional Food Groups and Cuisines by Arab International Students ...... 45

12 Percentages of Intake from Westernized Food by Arab International Students ....46

13 Percentages of Daily Consumption of Dairy Products by Arab International Students ...... 47

14 Diary Fortification Use by Arab International Students ...... 49

15 Percentages of Dairy Fat Percentages Consumed by Arab International Students ...... 49

16 Percentages of Daily Consumption of Bread by Arab International Students...... 50

viii

LIST OF TABLES (Continued)

17 Percentages of Daily Consumption of Beverages by Arab International Students ...... 51

18 Percentages of Daily Consumption of Fats by Arab International Students ...... 51

19 Percentages of Daily Consumption of Snack Foods and Desserts by Arab International Students ...... 53

20 Percentages of Daily Consumption of Meats, Legumes, Eggs by Arab International Students ...... 54

21 Percentages of Daily Consumption of Vegetables and Fruits by Arab International Students ...... 55

22 Percentages of Daily Consumption of Starches by Arab International Students...56

23 Percentages of Weight Status of Arab International Students after Moving to the U.S...... 85

24 Percentages Diet Changes by Arab International Students after Moving to the U.S...... 86

25 Percentages of Eating Pattern of Arab International Students after Moving to the U.S...... 87

26 Percentages of Dieting of Arab International Students after Moving to the U.S. .89

27 Percentages of Supplemental Use of Arab International Students after Moving to the U.S...... 90

28 Percentages of Exercising of Arab International Students after Moving to the U.S...... 91

29 Percentages of Amount of Times of Cook and Eat out when Consuming Red Meat, Chicken and/or Sea Food Per Week of Arab International Students after Moving to the U.S...... 92

CHAPTER I

INTRODUCTION

In the United States, international students are distributed in more than 2,500

American institutions of higher education and represent over 186 nationalities (Mori,

2000). In the United States, international students are usually identified as foreign non-

U.S citizens. Foreign non-U.S citizens are defined as students who have lived most of their lives in their native countries; English is not the dominant language for most of these students back in their homes, but serves as a second language. According to the

Open Doors 2006 report, the number of international students enrolled in the U.S institutions of higher education was 564,799; in academic year 2008/2009, the number had increased to 671, 616 (Katz, 2008). International students represent different cultures and traditions around the world. For example, 57% of all international students are

Asians and they are considered as the fastest and the largest growing subgroup enrolled within the American system of higher education (Walker, 2000). The majority of the international students are coming from different parts of Asia such as India, China, Japan,

Korea, and Taiwan.

The majority of international students experience significant cultural transitions and challenges when they relocate to a new life during their academic life period. Earlier studies of international students suggested that even a short-term stay in a foreign country can result in a significant and often undesirable changes involving eating patterns.

(Papadaki, Scott, 2002). Relocating international students become independent from their

1 2 families and friends back home and lack their support which creates physical and mental stresses related to their new life adaptation. This often lead to undesirable changes in their eating patterns and dietary intake affecting their nutritional status and overall health and well-being (Papadaki, 2002). Coping and adjustment with a totally different environment, culture, and food choice is usually difficult when other barriers such as language, transportation, communication, and self skilled are presented. Hence, international students are often facing a cultural shock that may cause compulsive eating and drinking as a result of social isolation and depression (Winkelman, 1994). Cultural shock is a condition of anxiety and disorientation that can affect someone suddenly exposed to a new culture (Hamboyan, 1995). International students are usually exposed to dietary food habits and life style changes when they first come to the U.S. As a result, they also find a hard time in maintaining their traditional eating habits due to limited access or availability of their own traditional food and lack of food preparing and cooking skills (Papadaki, 2002).

Different cultures around the world are influenced by the westernized food, especially in the form of fast food. In western countries, the increasing prevalence of obesity has been linked to changing dietary habits and the increase in the consumption of foods that contain fats or refined sugars (Reeves, 2000). Westernized diet availability dominant international student’s food preferences and influences their eating pattern while they study abroad which may contribute to certain negative health issues such as obesity and diseases related to it (Scott, 2002). Consumption of fast foods such as beef burgers and fried chicken is high among the younger generation (Bourne, 1987). Since

3 fast food are usually available around the clock, accessible on campus, in their meal plans, and economically suitable, fast food are considered practical meals for college students in general who do not cook or do not have the time to prepare their food at home. They consume more ready to eat foods (Greaney, 2009).

Cultural and religious restrictions may also restrict dietary options among certain international students such as Arab international students. For example, certain types of food such as pork or pork derivates are restricted religiously. The Arab international students who come from the Middle East and North Africa are among other international students in the U.S. They are fewer in number compared with international students coming from Asia. In general “Arab” is a term that refers to persons who belong to the

22 North African and Middle Eastern member states of Arab League (Figure 1), speaking

Arabic language as their mother language (Amer, 2007).

Figure 1: North African and Middle Eastern States of Arab League

Like other ethnicities of international students, Arab international students eating preferences and food choices are usually influenced by the types of food available in their new living environment. However, their diet and food habits remain tied to their usual traditional food selections preferring to consume familiar foods available (Gilbert, 2008).

Back in their home countries, the prevalence of obesity, hypertension and type 2 diabetes among the Arab population is high (Reshaid, 1999). It is linked to the availability of a variety of different cuisines and foods which are imported from different countries around the world including American food (Sawarya, 1999). During the last two decades, Arab Gulf countries’ diet has changed and their citizens have become more sedentary while their consumption of fat, meat, sugar, rice, and wheat flour has increased.

This has resulted in a rise in obesity, diabetes, and cardiovascular disease prevalence

(Dehghan, 2005). This is practically due to changes in the socio-economic status including increased income of Arab Gulf Countries (Musaiger, 1994). During the past three decades, rapid changes with food habits have occurred in the Arabic diet. Most of the popular American and other westernized restaurants are available in Middle East’s

Gulf region. This is in addition to conventional food stores, foodservice and restaurant sectors that are abundant. People are increasingly eating outside their home. This change is characterized by a trend of consuming a Westernized diet that is rich in high energy dense foods, fat and sugars, and is low in complex carbohydrates. A pilot study conducted on female college students in Kuwait indicated that consumption of healthy fats, vegetables, and water consumption was low, while sweets and fatty foods consumption was high in their diet (Al-Khamees, 2009). In United Arab Emirates, a

5 study showed that there was a high proportion of meal skipping among female college students especially in the morning and afternoon. This study also showed that fruits and vegetables intakes were low in their daily food intakes and they consumed more

Westernized food in general (Musaiger, 1994).

Problem Statement

Arab international students in the U.S are experiencing transitions from their own cultures to a new different culture that has a unique impact on their physical, mental, psychological, and nutritional health status. Arab international students may be facing health and nutritional problems due to a change in their eating patterns, food choices, and lack of physical activity. Arab international students’ diet was previously described as high in fat, high in carbohydrates and sugar, and limited in fruit, vegetables and dairy products (Miladi, 1998). Due to changing in life style, food choices, and physical activity, Arab international students may experience unstable fluctuating body weights with an increased tendency toward weight abnormality (Yoh, 2008). There has been insufficient or unavailable evaluation of Arab international students’ diet to estimate the incorporation of nutrition guidelines into their current eating habits and behaviors effectively. Although there have been studies focusing on dietary habits of Arab college students in their home countries, there are limited or non sufficient number of studies done to examine, discuss, or to analyze the dietary intake of Arab international students in the U.S. Domestic students still have access to traditional cultural food and can maintain these preferences in their diet. However, Arab international students do not have the same access to traditional cultural foods when they study abroad. Married

6 students may be more likely to maintain their traditional food habits and food choices, which allows their eating pattern to become healthier (Cueto, 2008). As a result, maintaining a balanced diet maybe more difficult for single Arab international students than married Arab international students. Single international Arab students may lack certain cooking and time management skills; others may be forced to consume a westernized diet moving from their traditional food habits more so than married students.

Purpose of the Study

The purpose of the research study is to examine the dietary intake among male, female, single and married Arab international students. The secondary purpose of the study is to look at differences in food consumption patterns amongst these different groups.

Hypothesis

There will be a difference in food consumption between males and females Arab international students. There will be also a difference in food consumption between single and married Arab international students.

Operational Definitions

An Arab international student is an individual who is enrolled at North East Ohio universities, who is from the gulf region countries in the Middle East such as Saudi

Arabia, Kuwait, United Arab Emirates, Bahrain, Qatar, and Oman. These countries are members of the 22 North African and Middle Eastern member states of Arab League.

Food consumption defined as the process of food and/or beverages intake by mouth, including the intake of foods and beverages been provided in this study’s Food

Frequency Questionnaire (FFQ).

CHAPTER II

REVIEW OF LITERATURE

History and Background

International students are defined as a non-U.S citizen, who have lived most of their lives in their native countries, and English May be their second language.

International students have been coming to the U.S boarding schools since the mid-nineteenth century. “The number of international students has multiplied more than fifteen fold from 29,813 in 1950-51 to 453,787 in 1995-96” (Mori, 2000). They are representing over 186 nationalities, and they are located in more than 2,500 American institutions of higher education. According to the Institute of International Education annual statistical report, “In all, the 623,805 international students who studied here in

2007-8, an increase of 7 percent from a year earlier, contributed an estimated $15-billion to the U.S economy” (Mcmurtrie, 2008). The majority of international students coming to the United States are from India, China, the Republic Korea, Japan, and Taiwan.

Students from Saudi Arabia are representing the largest segment of Arab international students who come from the Gulf States of the Arabian Peninsula in the Middle East, including countries such as Kuwait, United Arab Emirates, Bahrain, Qatar, and Oman.

Unlike immigrants, most international students plan to return to their home countries and are in the United States temporarily. These students are abroad only to live in a foreign academic setting and to realize their educational objectives (Katz E., 2008).

8 9

Culture and Food

The influences of western societies increase conflicts with other cultures on such issues as the inclusion and the adaptation to a variety of factors including types of food, food sources and eating habits, religious restrictions toward certain types of food, and maintaining traditional cultural foods and its availability (Guo S., 2007). International students from different cultures considered their traditional food as part of their identity when they move to live in the U.S. Food can be used to create a common ground between different cultures from around the world. A variety of cuisines and food styles are usually available in the U.S, in particular on college campuses. Usually westernized foods are accepted and consumed regularly by international students in addition to other different cuisines available while they still maintaining eating their own favorite traditional food when they live abroad (Gilbert, 2008).

This helps in exchange cultural foods between students and encourages cultural interaction, facilitating international student’s adaptation of life in their new environments (Gilboy, 2009). Cultural and traditional foods reinforce religious and ethnic boundaries, playing an important role in connecting people to their identity (Mintz,

2002). Psychologically, traditional foods create feeling of home to many international students.

Culturally, gathering as groups during meal times is usually common and essential, and provides a sense of security and happiness (Miladi, 1998). Food plays an important role in social relations, unifying groups and families. Arab international students are more likely to eat in groups most of their meals. Arab international students

10 are used to live within extended and large group of family back in their homes. As students abroad they gathered at meal times as a social activity that helps provides them with cultural, ethnicity, and psychological support (Mintz, 2002). Religiously, food is also playing a major role in their eating behaviors. Islam emphasize on sharing food between people to help other poor people and to strengthen people’s care, kindness, brotherhood especially when food scarce. As Muslims, Pork and pork derivatives’ is forbidden by Islam and other meat must be halal, which refers to the manner in which the animal was slaughtered (Gilbert, 2008). Finding stores that provide select food such as halal meat is an important factor in food purchasing and food consumption. Although these foods are important for Arab diet, Arab international students are still can utilize nontraditional food products available local food stores.

Socioeconomic Status of Arabian States in the Gulf Region

Historically, Arab States in the gulf region were characterized as small a poor society that depend on limited life resources such as pearl collecting, and small farming.

Factors such as lack of arable land, rainfall and water scarcity were associated with limited agricultural ability for food production (Miladi, 1998). The advent of oil strengthened the economy and the Arabian Gulf countries became wealthy, characterized by a high growth per capita income and sufficient food supply. As a result, more urbanization and cities grew a rapid population increase, including imported labors such as Asian workers. This led to a dramatic increase in food consumption and food expenditure. Paid jobs in the oil industry attracted local laborers which led to a decline in the historically rooted crafts and trades. As a result, the societies shifted from

11 independent family based and locally controlled societies to large and interconnected societies that imported commodities and goods, including food (Musaiger, 1983).

Related to high income status of Arab Gulf States, markets become abundant by a variety of food suppliers that strongly influences food availability and average consumption.

Even with the change in society and access to new food sources, basic traditional foods supply continued to be available and provided by state governments. Basic traditional foods such as rice, wheat, fat, sugar, meat, chicken, powder milk, and legumes continued to be subsidized and regulated by governmental food policies for purchasing and pricing for local population consumption (Musaiger, 1994). The traditional diet of Arab countries is changing due to the influence of economic and social changes, which is affecting their food habits and energy consumptions. The high income per capita in the

Arab gulf countries led to an increased demand for convenience foods, fast food, and for eating meals outside homes (Miladi, 1998). For example, in Saudi Arabia within the years from 1969 to 1994, calories and protein intake have increased from 1879 kcal to

2395 kcal and from 48 g to 63.3 g respectively. For example, in Kuwait, the percentage of food expenditure rose from 27.5% to 37.5% during the period 1973 to 1978. Where is in Bahrain, the annual family expenditure on food was about 46% (Musaiger, 1983).

History of Food Importation and Food Availability of Arab Countries in the Middle East

Over the last three decades, the Arab countries in the Middle East, including the

States in Gulf region, have, in general, experienced higher demand for imported food and commodities. This is related to the increased availability and consumption of all food

12 groups. Sugar, fat, meat, wheat, and rice are mostly imported. In the last three decades, the average annual growth rate of food production in the Arab countries has increased by around 2.2 % compared to an increase of more than 5 % in food demand (Miladi, 1998).

Factors associated with the increased food importation were mostly related to limited agricultural resources, which was influenced by climate, soil, and land availability.

Therefore, inadequacy in food supply for local consumption led to the increase of imported food up to 90%. The Arabian Gulf countries possess a strong economic situation. A problem with food shortage or unavailability is scarce in these countries.

Besides food subsidizing, people of the Arabian Gulf countries have a high purchasing power (Musaiger, 1983). In Kuwait, more than ninety percent of foods consumed are imported from foreign countries such as Europe, Asia, and the United States (Sawaya,

Al-Awadhi, Saeed 1999). Simultaneously, an expansion of local industries that make bread, soft drinks, and dairy products helped maintained food availability year-round in all Arab countries in the Gulf region (Miladi, 1998). Also these countries do exchange products produced locally such as dairy products, and importing fruits and vegetables from other Arab countries.

Features of the Arabic Diet

In the Arabian Gulf countries, foods like dates, fresh vegetables, whole wheat bread, rice, and fish are the major constituents of diet as basic traditional food. In addition to sugar, oils, fats, meat and chicken that are regularly consumed by the people of these countries (Musaiger, 1994). Cereals are considered a vital component of the Arabic diet, contributing to most energy in the diet (Miladi, 1998). Carbohydrates in the form of rice

13 and wheat are considered to be the major constituents of the diet of Arabic countries in the Gulf region. Rice is usually consumed at lunch, while wheat in the form of bread is usually consumed as a major carbohydrates source for breakfast and dinner (Musaiger,

1983). The basic traditional diet became more diversified. Red meats especially lamb is more consumed than fish and poultry, while dairy products emerged as an essential element of the diet. Moreover, nuts, seeds, soft drinks, corn, potato chips, chocolate, and sweets became increasingly consumed between meals as snacks instead of fruits and vegetables.

In United Arab Emirates, traditional foods such as fish and dairy products including laban (diluted yogurt) are usually consumed by elderly people more than young people. Older men are more likely to consume healthier foods such as milk, fruits, vegetables, and rice compared to younger people who consume foods high in protein and fat such as eggs, chicken, and cheese. Milk consumption is higher among older women than younger women. In general, women’s intake of eggs, milk, cheese, vegetables, and bread is higher compared to men (Musaiger, 1994). In the United Arab Emirates, consumption of fruits and vegetables in both men and women is considered low, and the average daily calories intake was estimated by 4396 kcal per capita. In Bahrain, eggs, cheese, meat, and rice consumption is higher among men, where carbonated beverages and cheese is the most preferred food by women (Musaiger, 1998).

The Kuwaiti diet described as high in grains, vegetables, and fruits intakes.

Yoghurt, feta cheese, and whole and skim milk are the major dairy products consumed

(Sawaya, 1999). White rice is a major carbohydrate source in the traditional Kuwaiti diet

14 along with meat, poultry, and fish as major sources of protein. Fruits such as banana, apple, oranges and vegetables such as green salads are also considered essential part of the traditional Kuwaiti diet. Beans, eggs, and dairy products along with wheat bread are the usual components of breakfast meal. In Kuwait, Arabic and Iranian bread, white and semi-white flour respectively, are major cereal sources. Both are consumed with a daily average of 277g per capita. In year 2000, the estimated amount of wheat flour required for making bread was 294 tons (Eid, 1986). Calories from bread are contributed to 48% of the total average daily Kuwaiti diet of 3269 kcal (Musaiger, 1985). The Kuwaiti cuisine is the most dominant among other cuisines such as Indian, Chinese, Lebanese,

Persian and other Arab countries influences. The influence of fast food as a Western dietary source in the Arab Gulf countries is huge. Westernized cuisines and fast food popularity in Kuwait are occupying people’s food eating preferences, especially youths since they are form the majority of society equivalent to other cuisines mentioned. In

Kuwait Intake of fried chicken and hamburgers, cola and other carbonated beverages is high. Chocolates, candies, and desserts are part of almost every meal (Sawaya, 1999).

Recent food habits in most Arab countries are characterized by a high intake of saturated fat, cholesterol, sugar, refined wheat flour, soft drinks, and empty calorie foods. In the

Arab Gulf region people are consuming fast foods on a regular bases because it is cheap, tasty, and available around the clock (Miladi S, 1998).

Specific Nutrients of the Diet in the Arabic Gulf Region

Seventeen of the commonly consumed dishes in the Arabic gulf region were chemically tested in regard to their vitamins and minerals constituents. These chemical

15 tests indicated that most of these nutrient contents of food in the dishes such as thiamine, riboflavin, niacin, and ascorbic acid were low except for vitamin A which was relatively high (bourne,1987). Iron levels were low in all dishes. The average per capita for energy intake by Arab countries in the Gulf region has increased by 30%, there were also an increase of 45% in fat intake (Miladi, 1998). The energy content of the seventeen dishes ranged between 82 and 242 kcal per 100 grams edible portion, and the amount of protein varied between 3 and 8.1 grams per 100 grams. In Saudi Arabia, cereal and legumes dishes showed that their protein contents ranged from 2.6 to 7.5%, whereas fat content was ranging from 0.1 to 1.8%. The calories content ranged from 92 to 193 kcal per 100 grams edible portion. Essential amino acids such as tryptophan, lysine, methionine, and cystine were deficient (bourne, 1987). About 3.6% to 9.4% of protein, 0.7% to 14.7% of fat, 0.1% to 1.1% of fiber, and 82 to 236 kcal per 100 grams edible portion are the nutritional composition of dishes based on meat, fish, and eggs. Vitamins such as A, folacin, and ascorbic acid content are low in those dishes, and due to the use of table salt and spices such as cumin, coriander leaves and cloves sodium content in most dishes are high. A reasonable concentration of potassium, phosphorus, iron, copper, and some B- complex vitamins are found in these Saudi’s dishes. Dishes containing eggs such as meat paste (mutabak) and/ or omelets (shakshuka) contribute to high cholesterol levels of 96.7 mg/100 g, and 181 mg/100 g respectively. Based on the Recommended Daily

Allowances (RDA) guidelines, the composition of the commonly consumed dishes in the

Gulf region may provide an appropriate amount of protein and energy if consumed in sufficient amounts (bourne, 1987). In Kuwait, the Relative Nutrition Value (RNV) of the

16 cooked rice was 65% lower because of its lysine and methionine deficiency. This was because of their high meat contents. The RNV for all other dishes ranged between 63% and 102%. The Kuwaiti sweets appeared to be low in essential amino acids which may be improved if supplemented with milk. In Kuwait, a survey of 1,420 subjects consuming an average of 277 g/capita/day indicated that their daily bread consumption contribute to about 29% to 33% of daily nutrient requirements of iron, thiamin, energy, and about 40% to 50% of protein and niacin (Eid, 1986). Based on the food balance sheet, the estimated consumption per capita of cereals, 486 g would supply around 50% of energy and 43% of protein (Eid, 1986). Arabic bread (white flour, 78% extraction rate) and Iranian bread

(semi-white flour, a mixture of 78% and 98% extraction rate in a ratio 1:1), both represents 73% and 27% of total amount of bread made in Kuwait respectively. Both breads are the most common types of bread consumed in Kuwaiti diet in the form of flat white Arabic bread (54%), English or French bread (19%), and Iranian semi-white bread

(43%) (Eid, Bourisly, 1986). Bread supplies around 23 g of protein/capita/day, which is approximately 41% of daily protein requirements, and fifty percent of niacin, and about one-third of thiamine and iron daily nutrition requirements. In comparison between both the Arabic and the Iranian bread’s energy and nutrients contents, Arabic bread provides around 291 kcal compared to 271 kcal from Iranian bread per 100 g. This is due to the less nutrient content in white flour. Although the Iranian bread is less in calories, , the

Iranian bread (semi-white flour) contain higher nutrients protein (9.0 g), fiber (0.9 g), iron (1.8 mg), thiamine (0.2 mg), and niacin (5.7 mg) when compared to Arabic bread

(white flour) nutrient contents of protein (8.1 g), fiber (0.1 mg), iron (1.0 mg), thiamine

(0.12 mg), and niacin (2.5 mg) in a composition Per 100 g of fresh bread. As the chart below shows (1.1), when comparing total nutrients and energy contents of white bread semi-white bread with the Percentage Recommended Daily Allowances (RDA) for daily nutrients energy needs, the total of 791 kcal/capita/day would be only 29%, and only 41% of daily protein based on the % RDA daily nutrient requirements. 68 mg of calcium is equivalent to 8% RDA, 3.3 mg of iron is equivalent to 33% RDA, 0.4 mg of thiamin Is equivalent to 29% RDA, 0.3 mg of riboflavin is equivalent to 18% RDA, and 9.0 mg from niacin is equivalent to 50% RDA (Eid, Bourisly, 1986).

Table 1

Composition of Major Bread Types Consumed In Kuwait and Their Contribution to Daily Requirements

Bread Protein Fat Fiber Ash Energy Ca Fe B1 B2 Niacin Type (g) (Kcal) (mg)

Arabic* 8.1 0.4 0.1 1.5 291 24 1.0 0.12 0.09 2.5

Iranian* 9.0 0.6 0.9 2.3 271 27 1.8 0.2 0.13 5.7

Consumed ** 23.0 1.3 0.9 4.7 791 68 3.3 0.4 0.3 9.0

RDA (%) 41 - - - 29 8 33 29 18 50

*Composition per 100 g fresh bread, moisture = 26.4 Arabic Bread and 29.9 Iranian bread.

**nutrient content of bread consumed (203 g and 74 g of white and Iranian bread, respectively).

Nutrition and Chronic Diseases

Obesity in the Arab countries in Persian Gulf is a prevalent issue. Chronic diseases such as type 2 diabetes, cardiovascular diseases, hypertension and cancer are increasing and becoming a health crisis that alerts governments to take action (Dehghan,

2005). A study of health centers in Kuwait indicated that 47.5% of Kuwaiti population had diabetes. In Bahrain, at least 12% of pregnant women had a history of diabetes

(Mausaiger, 1985). Cardiovascular diseases cause 30% of annual deaths and now considered the top cause of death in the Gulf region. The prevalence of overweight and obesity among women in the gulf is up to seventy percent (Musaiger, 1994). Ischemic heart diseases and hypertension are linked to approximately 26% of total deaths in

Bahrain; where in Kuwait it contributed to 20% of total deaths. Obesity became life threatening problem among all age groups of Arab Countries mainly in developed Arab

Gulf countries (Al-Almaie, 2005). According to the American Public Health

Association, 75% of the Kuwaiti population is obese, and childhood obesity is rising. The same phenomenon is effecting the Saudi Arabia population. In Bahrain and Oman, nutritional surveys show that that prevalence of obesity among women is 40% and 17% respectively. The poor iron source in the typical Arabian Gulf diet is related to the prevalence of iron deficiency anemia among pregnant women (Musaiger, 1985).

Because of the similarity in culture, economy, and social changes as the rest of the region, nutrition related diseases are prevalent within vast Saudi population segments.

The Obesity epidemic in Kuwait resembles other countries epidemic such as the United

States, and the obesity epidemic is associated with tendency for higher blood pressure with age and the close association of essential hypertension with type 2 diabetes mellitus and. Most patients in Kuwait had mild to moderate hypertension, which is similar to that reported from the USA (El-Reshaid, 1999). The Changing dietary habits and increase in the consumption of foods that contain fats or refined sugars led to the increase prevalence

19 of obesity in western countries (Reeves, 2000). In the United States, the proportion of overweight has increased 15% over the last decade, and one-third of adults aged 20 or older are overweight. In addition, among youth overweight is 22%, and at least 300,000 deaths per year are contributed to inactivity and poor diet in the United States (Wint E.

2003).

Arab international students in the U.S may be involved in the same situation by the effects of high fat, high sugar diets as some American college students. Many college students have low intakes of fruits and vegetables and high intakes of food with excessive calories, saturated fats, and added sugars (Greaney M, 2009). Moving from a traditional eating pattern to a more westernized diet might have some undesirable effects on health since it characterized as a high in calories, saturated fat, sugar, and salt. Fast foods and ready-to-eat foods are popular because of their reliability, price, variety, and availability.

College students including single Arab international students who don’t cook at home may rely on these foods, which can cause them to become overweight and obese in the long term. In addition, lack of physical activity and nutrition education are other related factors that exacerbate overweight and obesity among many of the international students

(Yoh, 2008).

Impact of Relocation on Life Style

The Changing in international college student’s life style, including their eating patterns, is usually due to acculturation and integration into a new host country.

Modifications in their dietary intake and food consumptions are usually related to change in certain food items available. Some studies show that dietary habits are more likely to

20 change into mixed food or westernized diet than traditional diets (Gilbert, 2008). Other factors such as social setting, living arrangements, cost and financial resources are critical in maintaining certain eating pattern and life style (Papadaki, 2006). In regard to international students’ dietary changes, some studies show that married students are more likely to eat healthier than single students; the fruit and vegetables consumption was higher in married students. The study also shows that sugar consumption was less among single females than males (Cueto, 2008). International college students do not prioritize the participation in physical activity due to other challenges they face while residing in the U.S. Daily life activities are limited to school, home duties, and social networking with other similar ethnic groups (Yoh, 2008). Exercising is usually considered an optional activity to most of international students. In general, the international students may not have been as accustomed to the concept of dietary supplementation such as multivitamins and minerals as U.S students (McArthur, 1990).

Barriers and Challenges for Adaptation

International students are facing a new set of basic values and beliefs, and accommodating themselves to a variety of cultural differences and challenges usually associated with stress, depression, and disorientation. International students have always remained one of the quietest, invisible, and underserved groups on American campuses

(Andrade, 2006). Lack of participating in community activities especially on campus, and unfamiliarity with the U.S schools traditions increase their social isolation. This might affect their daily life performances, mental health, and nutrition status. Maintaining traditional food eating habits is another challenge international students are facing when

21 they relocate, which is often found to be difficult to keep, especially when traditional food sources are scares or unavailable. Other related factors that limit international students’ access to traditional food are lack of communication with people because of cultural differences and language limitations, lack of transportation which limits their mobility and, finally, the unfamiliarity with the surrounding environment, especially when they become new to the area. International students are usually forced to adapt with time to the new environmental including modifying and changing their food choices, eating patterns, and their overall daily life performances (Andrade, 2006).

The change in living arrangements cost and financial resources, as well as increased availability of convenience and fast foods are considered the most common reasons affecting food choices in young students’ population. There are common factors that most international students are encountering when they move to a new cultural setting which cause them to experience unstable life styles such as eating patterns, changes in physical and social activities, and food availability (Papadaki, 2007).

Language barrier is considered an obstacle for international students to seek adjustment and adaptation into their new relocated environment. Language barrier prevents them from interacting with their surrounding environment and communities which are necessary in guiding them for effective life adaptation. Limited community involvement caused by language barrier may restrict their community benefits and, most importantly, food choices. A dietary study indicated that ninety eight percent of female hostel college students in Saudi Arabia are consuming high fat high calories mainly fast food (AL-

Almaie, 2005). Single Arab international students may be used to consuming

Westernized foods including fast foods back in their homes, which might dominantly become part of their eating pattern while they are residing in the U.S. (Miladi S., 1998).

Eating Habits and Behaviors

International students’ food habits are continuously subjected to changed circumstances such as economics, geographic, and social. These alterations are reflected in their food habits and behaviors. Post migration dietary behaviors are characterized by adoption of non-traditional foods when international students become used to available food types within their community surroundings such as school. Arab international students may consume more westernized fast foods than traditional foods since Arabic cuisines and restaurant are usually not available in all American cities. Post migration dietary changes may be associated with the exclusion of certain traditional foods due to limited resources such as restaurants. Cooking at home will enable some international students to retain eating their traditional foods. Poor unbalanced diet among International students is more likely to be caused by unfamiliarity with American food marketing, and food preparation techniques (Martin, 1981). Poor cooking and food preparing skills among international students are more likely to be associated with poor health outcomes when they are relying primarily on fast and ready to eat foods as their daily nutrition resources. Unbalanced energy consumption because of these types of food they eat will contribute to their weight status, which is constantly fluctuating as a result of changes in daily activities, eating times, and school stress.

Eating at local restaurants that provide a variety of food choices such as sea food, beef, and vegetarian entrees may be common among single international students.

Married international students since they are more settled and self sufficient are less likely to eat far from home, consuming healthier foods (Perez-Cueto, 2008). Among international students, married students and single females were more likely than singles males to change their dietary habits to an increasing consumption of fruits and vegetables

(Perez-Cueto, 2008). Settlement and steadiness in food consumption usually occurs when students make their diets at home. Controlling meal time, portion size, food variety, quality, and value are more likely to be managed by married couples than single students.

Married couples who eat at home have a greater chance to incorporate their diets with a variety of healthy food especially fruit and vegetables. They also have the options of trying different food choices, which help them to become healthier with their eating pattern. Single students on the other hand may have limited opportunities in maintaining healthful eating habits especially when they prefer to eat outside their homes only at mealtimes which discourage fruit and vegetables consumptions (Perez-Cueto, 2008).

American College Student’s Diet and Eating Pattern

Unhealthful lifestyle increases the risk of developing serious health problems among many of college students (Brunt, 2008). Good dietary habits of college students decline when they leave their homes and start to live independently during college life, they may be exposure to health risks due to unhealthy dietary behaviors. College students eating behaviors and food choices are usually influenced by several factors including food availability, price, location, preparation skills, and culture. Students who live on campus and purchase meal plans are more likely to have a variety in their diets compared to students who live off campus (Brunt, 2008). Most of college students are consuming

24 diets that are lack in fruits, vegetables, and dairy products compared to the current dietary recommendations. They consume diets that are high fat, sodium, and sugar with limited variety, in addition to high snacking, high consumption of fat foods, high alcohol consumption, and meal skipping (Brunt, 2008). A sample study of 48 males and 52 females undergraduate students who are residing in public Minnesota University dorms, the study shows that 83% of them are on the university meal plan indicated that most of the students had higher quantities of items such salty snacks, cereal or granola bars, main dishes, and sweetened beverages. These items had an estimated 22,888 calories compared to a few items such as low calorie beverages, fruits, vegetables, dairy products, and 100% fruit or vegetable juices in their rooms (Nelson, 2009). The study concluded that despite the students being enrolled in full time service meal plan they are consuming extra amounts of foods that contributed to excess weight gain and unhealthier dietary behaviors in their rooms (Nelson, 2009).

Unhealthful eating behaviors such as skipping meals, frequent snacking on energy dense food, and involving in unhealthful weight loss and dieting methods are common practices by college students due to lack of nutritional knowledge and/or education (Ha,

Caine-Bish, 2009). College students’ dietary intakes appear to be high in saturated fat, simple sugar, cholesterol, and sodium. In addition, college students consume inadequate amounts of fiber, folate, iron, calcium, and vitamin A, C, E contents in their diet (Ha,

Caine-Bish, 2009). Previous studies had indicated that fruits and vegetables intake is below the current recommendation of nine servings or four and a half cups per day.

Compared to adults, college students have less awareness about the benefits of fruits and

25 vegetables consumption on their health outcome. A 15 weeks study conducted by a

Midwest University in a fifteen weeks basic nutrition class to investigate and assess the intake of fruits and vegetables among eighty participants of college undergrad students, indicated that the majority of participants consumption of vegetables, and fruits was low at the beginning of the study up to one cup or less per day, and by the end of the study, the intakes were improved to become more than a cup of fruits and vegetables per day.

The study confirmed that college students’ consumption of fruits and vegetables is below the recommended dietary intake (4.5 cups for women, 5 cups for men) (Ha, Caine-Bish,

2009). Several studies indicated that females are more health conscious than males; females possess more positive attitudes toward healthful eating especially fruits consumption (Ha, Caine-Bish, 2009).

CHAPTER III

METHODOLOGY

Purpose

The purpose of this study was to investigate the dietary intake of single and married Arab international students who reside in Northeast Ohio.

Design

This study design was a descriptive, quantitative analysis of the participants’ dietary intake who has been residing for more than six months in Northeast Ohio.

Participants completed a Food Frequency Questionnaire (FFQ). Independent variables were gender and marital status. Dependent variables were dietary intake including food groups (meat and beans, dairy, fruit, vegetables, fat and oil), of traditional and westernized food, and dietary consumption.

Subjects

Participants were recruited using a convenience sample of Arab international students including both single and married college students who attend universities in

Northeast Ohio. This population was selected based on ethnicity, and university enrollment, and period/tenure of residency.

Inclusion criteria included both graduate and undergraduate students at Kent State

University and University of Akron, all ages within college enrollment period and both

26 27 genders single and married. Exclusion criteria included non college enrolled and children less than 18 years old. Students who had been residing less than six months in the U.S and/or who did not belong to universities located in North East Ohio were not included in the texts and/or table descriptions.

Questionnaire

A self completed food frequency questionnaire (FFQ) of forty one questions incorporated with subtopic questions was utilized (Appendix B). The questionnaire language was English, using open ended questions in the form of standardized and fixed- alternative questions with sets of response alternatives. The FFQ was developed based on standards and examples from previous FFQ books in addition to modifying the questions to incorporate traditional foods into the food groups. Additional questions concerning dieting, supplementations, and exercise were also included in the FFQ. The design of the FFQ was developed by the researcher along with the staff at the Research

Bureau at Kent State University who specializes in survey designing and development.

The FFQ questions addressed demographic information, and comprehensive categories of food groups including traditional and westernized entrees, food choices and food consumption.

Demographic information collected including gender, age, level of education, marital status, self reported height (cm) and weight (kg), residential status and period.

Body Mass Index (BMI) was calculated by dividing weight (kg) by height (cm) squared to classify participants’ within BMI ranges based on World Health Organization (WHO)

28 classifications for BMI, with < 18.5 classified as underweight, 18.5-24.9 normal range,

25-29.9 pre-obese, 30-34.9 obese class 1, 35 – 39.9 obese class 2, and ≥ 40 obese class 3

(Must, 1999).

Procedures

The research was approved by the Kent State University Institutional Review

Board (IRB). The questionnaire was a self-administered, distributed to the study audience as hard copies by the researcher himself and also via a team assistants consisted of Arab college students. The study participants filled and returned the FFQ personally to both the researcher and to the team assistants. The collected FFQ’s were gathered and sent to the Research Bureau at Kent State University by the researcher for data entering.

Statistics

The data were entered as an SPSS file by the Research Bureau at Kent State

University. Descriptive statistics were converted to percentages. In the study, a repeated measures factorial (2 X 2), ANOVA was utilized to examine the changes in the consumption of traditional/westernized food as well as differences regarding eating locations and preferences before and after moving to the U.S within total participants in the study. A pre-post paired t-test and Pearson’s Chi-square test were also conducted to measure the differences between gender and marital status. Both the level of significance

(P <0.5) as well as the statistical package for the social sciences (SPSS) for windows

(version 6.0, 1993, SPSS Inc, Chicago, IL) for data analysis were used.

CHAPTER IV

RESULTS

This chapter reviews the results of the study associated with investigating the dietary intake among male, female, single and married Arab international students. The purpose of this study was to examine the effect of relocating to the U.S on the food consumption of Arab international students.

Subject Demographics

The study consisted of Arab international college students who completed a dietary Food Frequency Questionnaire (FFQ). Both undergraduate and graduate males, females singles, and married Arab international students attending universities in North

East Ohio were enrolled in the study (n=95). Among the 95 Arab international students that participated in the study, 66 were males; 37 were single and 29 were married. Total female respondents were 29, seven were single and 22 were married. The majority of participants (77) were from Saudi Arabia while 12 participants were from Kuwait; three were from Jordan, and one participant from each of Syria and United Arab Emirates.

Most of the respondents in the study were academically sponsored and had been residing in the U.S for more than one year. Most of them lived off campus. In regard to participants academic characteristics 68 participants attended Kent State University, 21 participants attended University of Akron, one participant at Case Western University as well at Riyadh University in Middle East. Thirty nine of respondents were graduate students, while undergraduate students were 37 participants’ in addition to 17

29 30 respondents who were students at the university’s English Language Institute program.

Results are presented in Table 2.

Body Mass Index (BMI)

In Table 3, the overall averages for weight and BMI for total participants indicated that the overall average weight and BMI in males was higher than in females.

The highest average weight (85.2kg) was among married males with a BMI of 29.3 which are considered pre-obesity compared to married females which had a normal BMI

(21.8) and an average weight of 62.1kg.

Daily Eating of Traditional Food

Figure 2 illustrates differences in traditional food consumption by participants in _ _ the study before (x=10.8 ±2.9), and after (x=8.33 ±2.9) moving to the U.S. indicating a significant decrease in traditional food consumption (p ≤ 0.001). There was no significant results in both interaction between time and gender (p=0.062), or intersection effect based on gender (p= 0.287).

Table 4 reflected the differences in traditional food intake among total participants before and after moving to the U.S. the majority of participants were consuming more traditional food before moving to the U.S. Moreover, married couple participant’s intake from traditional food almost remained the same after they moved to the U.S compared to both single males and females who declined their intake from traditional food after moving to the U.S.

Table 2

Demographic Characteristics of Arab International Students

n %

Total participants 95 100 %

Male 66 69.5 % Single 37 56 % Married 29 44 %

Female 29 30.5 % Single 7 24 % Married 22 76 %

Religion Muslim 95 100 %

Country of Origin

Jordan 3 3.2 % Kuwait 12 16.8 % Saudi Arabia 77 81 %

Syria 1 1.1 % United Arab Emirates 1 1.1 %

Where do you live On campus 10 10.5 % Off campus 84 88.4 % Unspecified 1 1.1 %

Total residential periods in the U.S More than a Year 94 99 % Less than six months 1 1 %

Academic Sponsorship Sponsored 81 85.3 % Unsponsored 10 10.5 % Unspecified 4 4.2 %

Academic level Graduate 39 41.1 % Undergraduate 37 38.9 % ELI 17 17.9 %

University Kent State University 68 71.6 % University of Akron 21 22.1 % Case Western Reserve 1 1.1 % Riyadh University 1 1.1 %

Table 3

BMI Mean and Standard Deviation of Arab International Students

Mean / Std. Deviation WHO Classification (n=88)

Male 28.5 ± 7.0 (pre-obesity) Single 27.7 ± 7.8 (pre-obesity) Married 29.4 ± 5.8 (pre-obesity)

Female 23.5 ± 3.4 (normal) Single 24.7 ± 3.8 (normal) Married 23.1 ± 3.3 (normal)

Married 26.8 ± 5.8 (pre-obesity)

BMI Criteria Range based on the World Health Organization (WHO) Classifications for Body Mass Index (BMI).

8 Standard Deviation Mean 6

0 Total Participants - Before * Total Participants - After

*Statistical significance was set at p ≤ 0.05 Figure 2: Traditional food consumption of Arab international students before/after moving to the U.S.

Table 4

Percentages of Daily Eating of Traditional Food of Arab International Students

n %

Before

Male 57 94 Single 30 81 Married 27 93

Female 26 90 Single 4 57 Married 22 100

Married 49 96

After

Male 37 56 Single 12 32 Married 25 86

Female 21 72 Single 3 43 Married 18 62

Married 43 84

Daily Eating of Westernized Food

Figure 3 illustrates differences westernized food consumption by total participants _ _ in the study before (x = 5.3 ±2.6) and after (x = 6.7 ±2.7) moving to the U.S indicating a significant decrease in traditional food consumption (p ≤ 0.001). In addition to a non significant results in interaction between time and gender (p = 0.328), in addition to the less significant results intersection between gender (p = 0.025).

5 Standard Deviation 4 Mean

0 Total Participants - Before Total Participants - After*

*Statistical significance was set at p ≤ 0.05

Figure 3: Westernized food consumption by Arab international students before/after moving to the U.S.

Table 5 illustrates the changes in the percentages of daily westernized food before and after moving to the U.S. Before moving to the U.S, percentages of daily consumption of westernized food were in general lower among all participants in the study. Married females daily westernized food consumption (7%) was the least compared to single females (28%), single males (30%).

After moving to the U.S, married couple’s intake from westernized food had almost doubled from 25% to 52% in addition to the noticeable increase in single males’ daily consumption from 30% to 62%. Daily westernized food consumption among single females remained the same (28%) after moving to the U.S.

Table 5

Percentages of Daily Eating of Westernized Food of Arab International Students

n % Before

Male 22 33 Single 11 30 Married 11 38

Female 4 14 Single 2 28 Married 2 7

Married 13 25

After

Male 38 57 Single 23 62 Married 15 52

Female 20 69 Single 2 28 Married 18 82

Married 33 65

Eating Location and Preference (Before/After)

In the FFQ “please select how often you do or did the following before and after moving to the U.S” regard to eating location and preferences by total participants. The statistical results indicated a significant increase in the consumption from _ local/westernized foods and restaurants after moving to the U.S (x= 2.17 ± 0.735) (p ≤ _ _ 0.001), eating out after (x=2.22 ± 0.750) (p ≤ 0.001), eating on campus after (x=1.15 _ ±1.051) (p ≤ 0.001), eating in public after (x=1.57 ±0.944) (p ≤ 0.001), in addition to _ eating alone (x= 1.47 ± 1.12) (p ≤ 0.001). However, less significant results were _ indicated in both eating at home (x=2.28 ± 0.917) (p ≤ 0.28), and in eating with friends _ (x=1.86 ± 0.885) (p ≤ 0.688) after moving to the U. Results are illustrated in Table 6.

The results in Table 7 illustrated changes in percentages regard eating preferences by participants before and after moving to the U.S. An increase from eating at local westernized restaurants occurred among all participants groups; single males from 24% to 95%) and single females from 0 to 43% compared to married couples from 6 to 20%.

There was also an increased in eating out and on campus by the majority of respondents in addition to the increased percentages of single males who ate in public places from 4% to 14%. Meanwhile, the majority of participants experienced a decline in eating with friends, while they became more frequent to eat alone. Moreover, percentages of eating at home were higher among married couples.

Table 6

Eating Location by Arab International Students Before/After Moving to the U.S

Eating pattern n Before After p-value *

Eat from a local/westernized 92 1.74±.768 2.17±.735 ≤.001* food and restaurants

Eat Out 88 1.76±.695 2.22±.750 ≤.001*

Eat at Home 89 2.51±.990 2.28±.917 ≤.028* Eat on Campus 79 0.70±.992 1.15±1.051 ≤.001* Eat with Friends 90 1.89±.771 1.86±.855 ≤.688 Eat Alone 86 0.97±.999 1.47±1.124 ≤.001* Eat in Public 88 1.33±.840 1.57±.944 ≤.001*

Paired t-test to compare significant changes regard eating preferences and location before/after moving to the U.S

*Statistical significance was set at p ≤ 0.05

Table 7

Percentage of Eating Locations by Arab International Students

Eat from Eat Out Eat at Eat on Eat with Eat Alone Eat in Local / Home Campus Friends Public Westernized restaurants n % n % n % n % n % n % n % Before Male 16 24 11 16 55 83 4 6 16 24 6 9 7 11 Single 13 35 9 24 36 97 4 11 13 62 5 14 4 11 Married 3 10 2 18 19 65 0 0 3 10 1 3 3 10

Female 0 0 2 7 18 27 1 3 3 10 1 3 3 10 Single 0 0 0 0 2 5 0 0 1 14 0 0 3 43 Married 0 0 2 9 16 55 1 4 2 7 1 4 0 0

Married 3 6 4 8 35 69 1 2 5 10 2 4 3 5

After

Male 43 65 29 44 31 47 8 12 20 30 18 27 15 23 Single 35 95 24 65 15 40 6 16 18 49 13 35 14 38 Married 8 28 5 17 16 55 2 7 2 7 5 17 1 3

Female 5 17 9 31 16 55 2 7 2 7 5 17 1 3 Single 3 43 4 57 1 14 1 14 1 14 3 42 2 29 Married 2 9 5 23 15 68 0 0 1 4 0 0 0 0

Married 10 20 10 20 31 61 2 4 3 6 5 10 1 2

Eating Traditional Food at Home/Restaurant

Decreases in the consumption of traditional food at home were observed in both married males from 27% to 24% and females from 27% to 14% along with both single males from 11% to 3% and females from 43% to 14% after moving to the U.S.

Eating traditional food at restaurant also decreased among both married males from 36% to 21% and females from36% to 23%. In addition, single males and daily traditional food consumption at restaurants decreased from 49% to 41% after moving to the U.S, where no changes had been observed in the percentages of daily consumption among single females after moving to the U.S.

Participants who consumed traditional food at both home and restaurant showed an increase in their daily traditional food consumption after moving to the U.S. Total female daily traditional food consumption was high compared to total male daily consumption. In addition, there was an increase of consumption among married couples after moving to the U.S which was the least high compared to total of both female and male participants. Results are presented in Table 8.

Eating Westernized Food at Home/Restaurant

The percentages in Table 9 showed that consumption of westernized food at home decreased among both single males from 54% to 30% and single females from 57% to

28% after moving to the U.S. However, eating westernized food at restaurants increased from 3% to 24% among single males and from 14% to 28% in single females after both had moved to the U.S.

Table 8

Eating Traditional Food at Home/Restaurant by Arab International Students

Home Restaurant Both

n % n % n % Before

Male 12 18 28 42 22 33 Single 4 11 18 49 12 32 Married 8 27 10 34 10 34

Female 9 31 20 69 10 34 Single 3 43 2 28 2 28 Married 6 27 8 36 8 36

Married 14 27 18 35 18 35

After

Male 8 12 21 32 30 45 Single 1 3 15 41 17 46 Married 7 24 6 21 13 45

Female 4 14 7 24 18 62 Single 1 14 2 28 4 57 Married 3 14 5 23 14 64

Married 10 20 11 22 27 53

Table 9

Eating Westernized Food at Home/Restaurant by Arab International Students

Home Restaurant Both

n % n % n %

Before

Male 36 54 3 5 27 41 Single 20 54 1 3 18 49 Married 16 55 2 7 9 31

Female 22 76 1 3 9 31 Single 4 57 1 14 0 0 Married 18 62 0 0 9 41

Married 34 66 2 4 18 35

After

Male 30 45 10 15 23 35 Single 11 30 9 24 18 49 Married 19 65 1 3 5 17

Female 14 48 3 10 11 38 Single 2 28 2 28 2 28 Married 12 41 1 5 9 41

Married 31 61 2 4 14 27

On the other hand, eating westernized food at home was the highest among married males; it also increased from 55% to 65% after moving to the U.S. while eating westernized food at restaurants decreased from 7% to 3% after moving to the U.S. For married females, their eating of westernized food at home after moving to the U.S had decreased from 62% to 41%, while increased at restaurant from 0% to 5%.

Other participants who chose both of eating westernized food at home and restaurant before and after moving to the U.S, married males had a decrease from 31% to

17%, while an increase from 0% to 28% occurred among single females daily westernized food consumption.

Methods of Food Intake - After Moving to the U.S

In regard to “I usually cook, buy and prepare, neither, and both” in the FFQ which was designed to investigate and to compare methods and skills used by respondents associated with their food consumption as well as whether if any changes and/or developments accrued before/after moving to the U.S. With cooking skill, 22% of single males had no changes with their cooking skills, while with married males there was an increase from 52% to 68% after moving to the U.S. In both single and married females, a decrease from 28% to 14% and from 59% to 41% in their cooking skills occurred after moving to the U.S.

There was an increase in food buy and preparation among both married males from 14% to 21% and single females from 0% to 14%, while married females showed constant results after moving to the U.S. However, single males showed a decrease from

57% to 24% in the same category.

In the category of both cook and buy & prepare, there was an increase percentages observed among single males (30% to 38%) and married males (27% to

34%), and also among married females (23% to 45%). Single females results did not changed.

The number of both single and married males who neither cooked nor bought and prepared had decreased from 38% to 8% and from 10% to 3%, respectively, after moving to the U.S. Detailed results are indicated in Table 10.

Table 10

Percentages Regard Methods of Intake Food by Arab International Students after Moving to the U.S

Cook Buy & Prepare Both Neither n % n % n % n %

Before

Male 23 35 8 12 19 29 17 26 Single 8 22 4 11 11 30 14 38 Married 15 52 4 14 8 27 3 10

Female 15 52 2 7 8 27 1 3 Single 2 28 0 0 3 43 0 0 Married 13 59 2 9 5 23 1 4

Married 28 55 6 12 13 25 4 8

After

Male 23 35 15 23 25 38 4 6 Single 8 22 9 24 11 30 3 8 Married 15 52 6 21 10 34 1 3

Female 10 34 3 10 13 45 0 0 Single 1 14 1 14 3 43 0 0 Married 9 41 2 9 10 45 0 0

Married 24 47 8 16 18 35 1 2

Intake from Traditional Food Groups & Cuisines

Table 11 illustrates changes in types of foods commonly been eaten by Arab international students before and after moving to the U.S. A consumption decline in traditional food groups such as Makboos, Falafel, and pastries (fatayer) was observed among vast majority of participants after moving to the U.S. Meanwhile, an increased consumption from cuisines was more seen among total males in addition to the consumption of Tabouli by single males. Total female participants showed general decline in most traditional food groups.

Intake from Westernized Food Groups

In regard to the intake from westernized food groups, the percentages in Table 12 showed that the majority of participants increased their consumption from foods such as chicken and beef burgers as well as sandwiches and subs, sea food, and cereals and milk after moving to the U.S. The percentages also indicated an increased intake from bagel and cream cheese by total males while total females consumed more from pizza, and cereal and milk. Percentages of intake from other westernized food groups such as taco and burrito, spaghetti, corn and beans almost did not changed, thus, were the least consumed the respondents.

Average Daily Consumption of Dairy Products

The daily consumption of dairy products indicated that participants were mostly consuming flavored milk and cheeses along with milk derivatives such as laban and labna. Percentages are showed in Table 13.

Table 11

Percentages of Intake from Traditional Food Groups and Cuisines by Arab International Students

Makboos/Kabsa/Maraq Flafel/Fule/Hummus Pasta/Macaroni Pastries Taboli Cuisine Laham/dajaj/kabab lentil/hares/jareesh béchamel/lasagna (fatayer) salads Indian/Iranian/Italian egg dishs Chinese/Mediterranean

n % n % n % n % n % n %

Before

Male 42 64 39 59 3 5 9 14 21 32 15 23 Single 25 67 24 65 1 3 4 11 11 30 10 27 Married 17 59 15 41 2 7 5 17 10 34 5 17

Female 16 55 9 31 5 17 3 10 9 31 7 24 Single 3 43 2 28 1 14 0 0 1 14 2 28 Married 13 59 7 32 4 18 3 14 8 36 5 23

Married 30 59 22 43 6 12 8 16 18 35 10 20

After

Male 8 12 17 26 5 7 1 2 14 21 28 42 Single 4 11 11 30 1 3 1 3 4 57 18 49 Married 4 14 6 21 4 14 0 0 10 34 10 34

Female 6 21 7 24 1 3 2 7 8 27 5 17 Single 1 14 0 0 0 0 0 0 1 14 1 14 Married 5 23 7 32 1 4 2 9 7 32 4 1

Married 9 18 13 25 5 10 2 4 17 33 14 27

Table 12

Percentages of Intake from Westernized Food by Arab International Students

Beef burger chicken burger fish/shrimp sandwiches spaghetti pizza taco beans bagel cereal cheese burger chicken fajita oyster/crab subs lasagna/ pasta burritos corn cream cheese with milk Steak/hotdog grilled chicken

n % n % n % n % n % n % n % n % n % n %

Before

Male 5 7 5 8 2 3 10 15 2 3 1 2 1 2 3 5 4 6 18 27 Single 3 8 3 8 2 5 6 16 2 5 1 3 1 3 2 5 3 8 13 35 Married 2 7 2 7 0 0 4 14 0 0 0 0 0 0 1 3 1 3 5 17

Female 2 7 2 7 1 3 2 7 0 0 1 3 0 0 1 3 0 0 5 17 Single 0 0 1 14 0 0 0 0 0 0 1 14 0 0 0 0 0 0 1 14 Married 2 9 1 5 1 5 2 9 0 0 0 0 0 0 1 4 0 0 4 18

Married 4 8 3 6 1 2 6 12 0 0 0 0 0 0 2 4 1 2 9 18

After

Male 24 36 8 12 4 6 15 23 5 7 2 3 4 6 2 3 8 12 18 27 Single 20 54 4 11 2 5 10 27 4 11 0 0 4 11 2 5 6 75 11 30 Married 4 14 4 14 2 7 5 17 1 3 2 7 0 0 0 0 2 25 7 24

Female 4 14 5 17 4 14 6 21 2 7 3 10 2 7 0 0 0 0 9 31 Single 2 28 2 28 3 43 3 43 2 28 1 14 0 0 0 0 0 0 3 43 Married 2 9 3 14 1 5 3 14 0 0 2 9 2 9 0 0 0 0 6 27

Married 6 12 7 14 3 6 8 16 1 2 4 8 2 4 0 0 2 4 13 25

Table 13

Percentages of Daily Consumption of Dairy Products by Arab International Students

Milk Soy milk Yogurt Milk derivatives Cheese Flavored milk ice cream laban/qaimer/labna cream cheese/ cheddar n % n % n % n % n %

Male 30 45 4 6 13 20 17 26 33 50 Single 16 43 3 8 8 23 9 24 20 54 Married 14 48 1 3 5 17 8 27 13 49

Female 12 41 0 0 6 21 12 41 12 41 Single 3 43 0 0 1 14 4 57 2 28 Married 9 41 0 0 5 23 8 36 10 45

Married 23 45 1 2 10 20 16 31 23 45

Table 14 showed percentages of consumption from fortified dairy products. The results indicated that about half of married couples and single females consumed fortified dairy product compared to total males less consumption.

Percentages in Table 15 showed that 39% in married couples, 38% in total females, and 44% in total males consumed regular (2% fat) dairy products. Intake from low fat (1%) dairy was seen in married couples (27%), and in both total females (21%), and males (23%). On the other hand, intake from skim (0% fat) dairy was the least by total participants, only few married couples (8%), total females (5%), and total males

(3%) had skimmed dairy.

Average Daily Consumption from Bread

Table 16 illustrated the average daily percentages of bread consumption, indicating that daily consumption of Arabic/Pita bread and toast was greater compared to other different types of bread by total participants in the study.

Average Daily Consumption of Beverages

Table 17 shows the results of daily beverages consumptions along with averages of daily water consumption. The percentages in the results indicated that the majority of participants consumed more from caffeinated beverages such as tea and coffee in addition to carbonated beverages and juices.

Average Daily Consumption of Fats

The results in Table 18 illustrate percentages and type of fat consumed by total participants. Unsaturated fat was mostly consumed by married couples and single females. Single males were the least consumers.

Table 14

Dairy Fortification Use by Arab International Students

Yes No Don’t Know n % n % n %

Male 26 39 8 12 31 47 Single 12 32 3 8 21 57 Married 14 48 5 17 10 34

Female 14 48 1 3 15 52 Single 3 43 0 0 3 43

Married 11 50 1 5 12 54

Married 25 49 6 12 22 43

Table 15

Percentages of Dairy Fat Percentages Consumed by Arab International Students

Skim Low fat 1% Regular 2% Whole fat 3% n % n % n % n %

Male 3 5 15 23 29 44 13 20 Single 2 5 6 16 17 46 8 22 Married 1 3 9 31 12 41 5 17

Female 4 14 6 21 11 38 6 21 Single 1 14 1 14 3 43 2 28 Married 3 14 5 23 8 36 4 18

Married 4 8 14 27 20 39 9 18

Table 16

Percentages of Daily Consumption of Bread by Arab International Students

Pita/Arabic bread Toast/bagel Waffle/biscuit Breakfast cereal Other grain Muffin Kasha/couscous/bulgar n % n % n % n % n %

Male 50 76 28 42 11 16 14 21 9 14 Single 29 78 20 54 8 22 6 16 4 11 Married 21 72 8 27 3 10 8 27 5 17

Female 14 48 15 52 5 17 6 21 3 10 Single 6 86 3 43 0 0 1 14 0 0 Married 8 36 13 59 5 23 5 23 3 14

Married 29 57 21 41 8 16 13 25 8 16

Table 17

Percentages of Daily Consumption of Beverages by Arab International Students

Carbonated Tea/Ice tea Green Tea Coffee Arabic coffee Starbucks Alcohol Juices Sport drinks Water Ice tea Turkish coffee Beer Avg cup n % n % n % n % n % n % n % n % n % n

Male 24 36 40 60 14 21 31 47 26 39 20 30 4 6 25 38 10 15 3.5 Single 18 48 25 67 8 22 20 54 19 51 15 40 4 11 16 43 7 19 3.4 Married 6 21 15 52 6 21 11 38 7 24 5 17 0 0 9 31 3 10 3.6

Female 10 34 15 52 13 45 8 27 7 24 6 21 1 3 16 55 5 17 3.6 Single 3 43 3 43 1 14 2 28 1 14 1 14 1 14 3 43 2 28 3.8 Married 7 32 12 54 12 54 6 27 6 27 5 23 0 0 13 59 3 59 3.4

Married 13 25 27 53 18 35 17 33 13 25 10 20 0 0 22 43 6 12 3.5

Table 18

Percentages of Daily Consumption of Fats by Arab International Students

Butter/lard/cream Olive/corn/canola oils Mayonnaise/mustard/ salad dressing n % n % n % Male 18 27 19 29 24 36 Single 9 24 8 22 16 43 Married 7 24 11 38 8 27

Female 6 21 16 55 10 34 Single 1 14 2 28 3 43 Married 5 23 14 64 7 32

Married 12 23 25 49 15 29

Average Daily Consumption of Snack Foods and Desserts

Table 19 showed that that majority of participants consumed sweets and added sugar foods. Total female participants consume more snack foods and desserts such as

Arabic desserts, jelly and pudding and cookies compared to total males who consumed more candy, brownies and cheesecake.

Average Daily Consumption of Meats, Legumes, and Eggs

The majority of participants consumed white meat compared to other meat groups provided in Table 20, especially by female participants. Egg consumption was more seen in single females.

Average Daily Consumption of Vegetables and Fruits

Table 21 indicated that consumption from raw fruits and vegetables’ including zucchini and broccoli was greater by married couples, in addition to married females’ noticeable consumptions from a variety of vegetables.

Average Daily Consumption of Starches

In regard to daily starches intake, white rice consumption was the most food item consumed by the majority participants, particularly total females, compared to other sources of starches provided in Table 22. Intake from potatoes such as mashed and baked was more often by married females where fried potatoes were more often consumed by both single males and females. The results also showed that intake from pastas and macaroni was more seen among total females in addition to brown rice consumption by married couples.

Table 19

Percentages of Daily Consumption of Snack Foods and Desserts by Arab International Students

Arabic desserts Jelly/pudding cake/brownies candy cookies popcorn Nuts Rahash/baqlawa peanut butter cheese cake pretzels seeds konafa jam/honey potato chips n % n % n % n % n % n % n %

Male 7 11 5 7 11 16 16 24 13 20 6 9 9 14 Single 4 11 4 11 6 16 10 34 6 16 3 8 7 19 Married 3 10 1 3 5 17 6 21 7 24 3 10 2 7

Female 7 24 5 17 4 14 7 24 7 24 6 2 5 17 Single 3 43 1 14 1 14 2 28 2 28 0 0 0 0 Married 4 18 4 18 3 14 5 23 5 23 6 27 5 23

Married 7 14 5 10 8 16 11 22 12 23 9 17 7 14

Table 20

Percentages of Daily Consumption of Meats, Legumes, Eggs by Arab International Students

Red meat White meat Sea food Pork Beans Eggs Steak/hamburgers chicken/turkey fish/shrimp ham/bacon peas/lentils Shellfish chickpeas n % n % n % n % n % n %

Male 7 10 21 32 5 7 1 2 4 6 12 18 Single 3 8 11 30 3 8 1 27 3 8 6 16 Married 4 14 10 34 2 7 0 0 1 3 6 21

Female 6 21 13 45 2 7 0 0 4 14 7 24 Single 3 43 3 43 0 0 0 0 0 0 3 43 Married 3 14 10 45 2 9 0 0 4 18 4 18

Married 7 14 20 39 4 8 0 0 5 10 10 20

Table 21

Percentages of Daily Consumption of Vegetables and Fruits by Arab International Students

Green vegetables Tomato/onion Zucchini/pumpkin Raw fruits Leafy vegetables cucumber/carrot eggplant/okra/peas bananas/apples/ oranges Lettuce/cabbage celery broccoli/beets grapes/barriers… n % n % n % n %

Male 20 30 24 36 7 11 22 33 Single 10 27 17 46 2 5 8 22 Married 10 34 7 24 5 17 14 48

Female 13 45 14 48 6 21 9 31 Single 2 28 1 14 0 0 0 0 Married 11 50 13 59 6 27 9 41

Married 21 41 30 59 11 22 23 45

Table 22

Percentages of Daily Consumption of Starches by Arab International Students

White rice Brown rice Pasta Mashed potato Fried potato Baked potato Potato chips macaroni/noodles n % n % n % n % n % n % n %

Male 23 35 9 14 3 5 2 3 7 11 2 3 8 12 Single 13 35 3 8 1 3 2 5 6 16 1 3 5 14 Married 10 34 6 21 2 7 0 0 1 3 1 3 3 10

Female 12 41 3 10 4 14 4 14 6 21 5 17 4 14 Single 3 43 0 0 1 14 0 0 2 28 0 0 0 0 Married 9 41 3 14 3 14 4 18 4 18 5 23 4 18

Married 19 37 9 18 5 10 4 8 5 10 6 12 7 14

CHAPTER V

DISCUSSION

This study investigated the dietary intake of Arab international college students residing in Northeast Ohio. Overall, there were noticeable variations per sub-group of the sample participants. The number of total male participants was considerably higher than the total number of females. Moreover, the ratio of single females out of total females was also smaller than that for males. Married couples constituted about one half of total number of surveyed participants. The majority of participants from Arab students were living off campus for more than a year and attending Kent State University. This contrasts with other research where the students primarily lived alone, shared a flat and/or lived in student residents (Papadaki, 2007). In this study, the average BMI of total participants indicated that pre-obesity were seen among married and single male participants respectively, making them more vulnerable to chronic diseases such as type 2 diabetes, cardiovascular diseases, hypertension and cancer. Obesity in the Arab countries in Persian Gulf is an increasing health issue (Dehghan, 2005). In contrast, normal average BMI values were observed among both married and single female participants.

Other research suggests reasons why Arab females were of normal BMI, females regardless of marital status, have shown healthier dietary intake pattern than males

(Perez Cueto, 2009), eating more fruits and vegetables, fiber rich products, and reduced salts than males (Wardle et al, 2004). Another reason why males overall BMI may have fallen in pre-obesity range, was their consumption habit from saturated fat, bread, and starch. However, regardless of the differences in BMI readings between males and 57 58 females, in general, college students in the U.S including Arab international college students are usually more vulnerable to the effects of unhealthy diets such as those associated with low intakes of fruits and vegetables and high intakes of food with excessive calories, saturated fats, and added sugars (Greaney M, 2009), which may eventually contribute to abnormal BMI status.

Daily Intake of Traditional and Westernized Food

While comparing the changes in dietary choice between traditional versus westernized food consumption after moving to the U.S, the results reflected a significant shift toward westernized food consumption which agrees with previous research which suggests that westernized foods, and to a lesser extent other available cuisines, are usually well accepted and consumed regularly by international students even while they seek to maintain eating their own favorite traditional food when living abroad (Gilbert,

2008). Before moving to the U.S, traditional food consumption was significantly higher among all participants, particularly in married couples, compared to the lower westernized food consumption amongst the total sampled participants. The changes in international college student’s life style, including their eating patterns, is due to acculturation and integration into a new host country where ninety nine percent of all participants in this study were residing in the U.S for more than one year. Modifications in their dietary intake and food consumptions may be related to change in certain food items available. Some studies show that dietary habits are more likely to change into mixed food or westernized diet than traditional diets (Gilbert, 2008). Subsequently, in

59 this study, westernized food consumption became significantly increased after moving to the U.S accompanied by a significant decrease in traditional food consumption. Both single males and married females consumed more westernized food than married males and single females. These findings indicate that Arab international college students adopted the consumption of alternative food and cuisines available in their newly inhabited living environment. Despite this shift, the overall reduction in traditional food consumption within married couples was less observed in comparison to single students.

This may also be associated with cooking and preparation skills, as some students may be poorly equipped to prepare their own meals (Brunt, Rhee, 2008), a consequence of having left the family home and taking on responsibility of food purchasing, and preparation for the first time (Scott, 2002). Scarcity of traditional food sources in the U.S is another challenge that international students face when they relocate. Moreover, limited time, and/or limited knowledge to shop and prepare food also affect their maintaining traditional food consumption (Greaney, Less, 2009)

Characteristics of Food Consumption after Moving to the U.S

The results of this study indicated a significant increase in food consumption from local Westernized restaurants among total participants after moving to the U.S, most evident in single males (95%). This was also associated with a significant increase in eating out by total respondents, compared to their less significant change in eating at home. Thus, there was a significant increase in eating on campus and in public after moving to the U.S among total respondents. Similarly, eating alone was significantly

60 increased after moving to the U.S. International students have always remained one of the quietest, invisible, and underserved groups in the new society they live in, this may be due to the lack of communication, and language limitation facing international students, including Arab international students, (Andrade, 2006).

These results also suggest variations regarding where each subgroup eats. When examining intake of traditional food at restaurants, married couples were the least in traditional food consumption compared to both single participants, especially males. As for consumption of westernized food at restaurants, married couples consumed even less compared to both single participants, especially females. As for eating at home, married couples were more likely to eat either types of food at home in comparison to both single participants. In addition, married couples tend to maintain the habit of eating at home after moving to the U.S. In line with other ethnic groups of strong cultural bonds, Arab international students are used to living within extended and large group of family back in their homes. After coming to the U.S., they gather at meal times as a social activity that helps provides them with cultural, ethnicity, and psychological support (Mintz,

2002). It is very common to hold gathering of food feasts in groups, which provides a sense of security and happiness (Miladi, 1998). Therefore, these results agreed with previous research that showed married international students are more settled and self sufficient as they would be less likely to eat outside their residence (Perez-Cueto, 2008).

Hence, they demonstrate a higher likelihood for maintaining traditional food consumption compared to both single males and females in the study.

In addition to moving to more westernized food intake by total participants, this study also investigated common types of food consumed from both traditional and westernized origins. Resulting outcomes in this study revealed several interrelated indicators in relation to facts from tangent similar studies (Gilbert, 2008). After moving to the U.S, consumption from traditional delicacies such as makboos, kabsa, flafel, fule, taboli, and pastries reduced by up to 46% in total participants. Further, the consumption from cuisines other than traditional and westernized increased 22% by single males, and

17% in married males. In addition there was increased consumption from westernized foods such as beef burger, cheeseburger, steak, and hotdog especially by both single males (29%) and females (28%), whereas married couples increased their percentages of consumption for those same food types by only 4%. Moreover, increased intake percentages of sandwiches and subs were observed in single males (11%), single females

(43%), and married couples (4%). This suggested that single participants eat more fast food than married couples would. Moreover, increased percentages of consumption from westernized and fast food by both single males and females participants in this study resembled other studies’ conclusions that single Arab international students may be used to consuming westernized foods including fast foods back in their home country, which might become part of their predominant eating pattern while they are residing in the U.S

(Miladi S, 1998).

One objective of this study was to investigate the average daily consumption equal to one cup or more per day from food groups such as dairy, meat (Including beans

62 and eggs), fruit, vegetables, and fat in addition to beverages. The results of the study indicated that both milk and flavored milk were the most consumed dairy products compared to other types of dairy products. Consumption of traditional milk derivatives such as laban and labna was higher among females and married couples. Cheese intake was more indicated among single males and married couples. The majority of participants were mostly consuming a regular (2% fat) dairy. One observation was the need to further encourage the total participants, especially singles, to select more from healthier dairy choices such as low fat and fortified dairy products for optimum health benefits in addition to weight control.

As indicated in previous studies, in the Arabic countries in the Gulf region, carbohydrates in the form of rice and wheat are considered to be the major constituents of the diet (Musaiger, 1983), in addition to cereals which contributed to most energy in diet

(Miladi, 1998). In this study, the average daily bread consumption showed that higher consumption of pita bread was observed in all males and single females. On the other hand, intake from toast and bagel was more evident among all females, and single males.

Breakfast cereal and grains intake was more likely seen among married couples and in the majority of respondents results showed similar intakes from bread. Moreover, enriched products such as cereals and grains were not the dominant bread choices amongst the majority of respondents. The important matter remains that enriched breakfast cereals and grains are healthier food choices since they are good sources for vitamins, minerals and fiber. However, the respondents were not making the healthiest

63 choices. The survey revealed that married couples’ selection from starches included white and brown rice, pasta, mashed and baked potato, whereas both single males and females consumed more white rice and fried potato, which may agree with previous research that married students are more likely to eat healthier than single students (Cueto, 2008). In order to help control the elevated blood cholesterol and other implications of such dietary behavior among all participants in the study, international students should be encouraged to their shift from excess calories intake to be replaced with more nutrient and fiber rich foods such as brown rice and pasta, and from chips and French fries to baked potatoes.

Percentages of average daily beverages consumption showed that the majority of single males consumed more caffeinated beverages such as tea, coffee including Arabic,

Turkish, and Starbucks than other participants reported. Single participants consumed more carbonated beverages compared to married couples. Beverages choices by married couples were primarily restricted to juices, tea and green tea. The majority of participants’ daily intake from water was estimated from three to four cups per day.

Alcohol consumption was the least reported amongst participant. Alcohol consumption is forbidden by Islam. As a result, carbonated along with caffeinated beverages were occupying most of daily beverages choices by the majority participants when comparing to other least reported items such as juices, and sport drinks. Thus, the healthier direction would involve restricting the intake from carbonated and caffeinated beverages which in turn would help avoid excess calorie levels as well as the loss of more fluids and essential nutrients due to diuretic effect. Meanwhile, an increased intake from healthier beverages

64 choices such as fortified juices, sport drinks, and most importantly encouraging water consumption to the average of two litters per day.

Intake of desserts was generally observed among all participants alike, with differences in the choice per type, single females dominated the intake of Arabic desserts.

Snack foods, including nuts and seeds, were mostly consumed by married females and single males. Thus, these types of snack foods in addition to soft drinks became increasingly consumed between meals in the Arab diet (Musaiger, 1983), in addition to the higher intake from excess calorie and added sugar foods by many college students

(Greaney M, 2009).

As previous research indicated red and white meat in addition to eggs were the mostly types of meat consumed by younger Arab people in the Gulf region (Musaiger,

1994). In this study, the percentages of average daily meat consumption indicated that the majority of respondents consumed white meat more than other meat groups. In addition, red meat consumption was greater by single females. Saturated fat was consumed almost equally amongst all participants, which consumption of unsaturated fat was greater among total females. Egg consumption was reported by all participants at similar percentages whereas beans, chickpeas, and lentil consumption was more seen with married females. Seafood was considered the least type of meat consumed by respondents. Since it is a forbidden type of meat by Islam, only one single male participant indicated the consumption of pork. In analyzing the dietary responses of all participants, a general intake of more saturated fat and cholesterol associated meat

65 sources such as red and white meat, in addition to eggs, was observed. Meanwhile, the respondents had a more limited intake from sources containing healthier fat such as fish, beans and chickpeas. This selection of more saturated fat and cholesterol in their diet may be associated with higher propensity for related cardiovascular diseases such as hypertension, as well as a probable contributor to other health risks such as obesity, diabetes mellitus, and cancer. Thus, in the Arabian Gulf area the prevalence of these chronic diseases which are related to dietary intake habits is high (Dehghan, 2005).

A previous study had indicated that married couples’ consumption from fruit and vegetables was higher than in both single females and males (Cueto, 2008). The percentages in the results of this study also indicated that married couples’ consumed more vegetables and fruits compared to both single male and female participants. This may be related to the advantages of eating at home by incorporating fruits and vegetables in the diet (Perez-Cueto, 2008). Thus, this study’s percentages agreed that married couples appear to spend more time of cooking and preparing food at home than eating out.

Impact of Relocating on Food Choices and Intake

Relocating usually affects international students’ food choices and eating habits

(Andrade, 2006), due to their unstable life styles such as eating patterns, changes in physical and social activities, and food availability (Papadaki, 2007). The results of this study showed that after moving to the U.S, most participants reported a reduction in their fruit intake. Simultaneously, males decreased their intake from vegetables. Most

66 respondents reported unchanged in their bread consumption after moving to the U.S. An increase in meat consumption was reported by single participants, while more percentages of married couples expressed a reduced intake after moving to the U.S. No change was observed with average daily beans consumption by most participants, although, half of married females reported a more conservative beans intake. Increased intakes were also indicated with fat and oil in single males and single females, while results of married couples showed no increase, married females reported a decrease in their intake of fat and oil. No change was observed in dairy consumption among all participants.

Applications

Findings of this study can be used to rectify the negativities associated with the impact of relocation on the diet of international Arab students as they reside in the U.S.

Notably, nutritional educators, dietitians, and university foodservice professionals that hold consultation and education roles can use this information to provide general nutrition courses involving food preparation and cooking classes which provide general nutrition education and dietary skills enhancement as an academic orientation within the freshman year for newly enrolled foreign college students. Foreign college students have been characterized as an invisible student population in U.S college campuses (Andrade,

2006). Thus, current orientation programs may not contain components specific to their specialized needs. Therefore, newly enrolled Arab international college students may need to be more alerted about programs and activities provided on-campus including

67 those involved nutrition education. Nutrition education is an important factor in guiding college students to become healthier with their eating habits. Moreover, nutrition education may be lacking or insufficient amongst many Arab international college students (Martin, 1981). This also may be related to the lack of sole nutritional courses in schools’ curriculums’ back in their home countries (Mausaiger, 1985). Consultant dietitians provide nutritional consultation involving weight maintenance and healthy direction that would help on-campus students improve their dietary behavior by providing the latest nutritional guidance and recommendations. Eventually, this would help control and even reduce the impact of relocation on the whole international student population. The dietitian’s role would shed most emphasis on periodic weight monitoring of relocating students, to help keep track of their overall weight status since it is one important index relating to eating patterns contributing to nutrition-related diseases, such as obesity and underweight. Factors such as poor eating and rapid weight gain are usually occurred during college life (Nelson, 2009). Another important role for the dietitian is to provide consultations elaborating the alternative healthy food choices to the targeted segment, in addition to developing brochures, handouts, as well as a list of reliable nutrition websites to help increase nutrition education and health awareness. This would eventually help relocating students to overcome this lack of traditional food sources, meanwhile, it facilitates finding healthier local food choices. They could encourage those college students to maintain diversified foods such as fruits and

68 vegetables in their refrigerators, as well as to prepare more of their food at home than eating out.

Limitations

There are limitations to this study related to ethnicity, location, and type of population in addition to ratio and proportion with regards to gender along with marital status. The main objective of the study was the dietary intake and did not address other related nutrition aspects such as dieting, supplemental use, and exercise. Therefore, other nutritional related issues such as diseases were not included in the study. The study investigated only Arab international students as college population ethnicity in the U.S, residing only in North East Ohio. When grouping by gender, the lower number of female participants, particularly single females, caused the results to be skewed. As a result, limited generalized outcome regard comparison between single males and females was provided from the study. Moreover, since this study was based on self-reported Food

Frequency Questionnaire (FFQ), it is subject for error and self bias. As a result, there were missing or/and incomplete information such as weight and height by some participants. This may be due to the length of the FFQ and also might be caused from a misunderstanding related to some vocabulary or/and questions associated with food and nutrition.

Future Research

Several research areas related to nutrition and well-being of Arab international students in the U.S as well as back in their homes need to be further studied. It is also

69 important to mention that during the past few years’ nutrition education and health awareness messages which are mostly geared by the private nutrition centers sector have been rapidly expanding within societies in the Arab countries, especially Arab countries in the Gulf region where obesity is becoming an epidemic issue. However, efforts and strategies provided by the governments regard unifying nutritional and educational guidelines including nutritional recommendations and standards toward people and their societies are still limited and/or inconsistent, since there is no specific nutrition policy in the Arab countries (Musaiger, 1985). In addition, many of the Arab countries governmental sectors such as hospitals and nutrition departments are usually characterized as patients oriented. For example, in Kuwait, the dietitians at the Food and

Nutrition Department provide nutrition education for hospitalized patients as well as via out-patient consultations (Musaiger, 1985); in other words, nutrition education through hospitals is more likely available for people with serious health conditions. Therefore, further steps toward developing and expanding a solid community nutrition education and standards in the societies of Arab countries are needed to help people to improve their overall health and well-being as well as preparing future Arab international students who are willing to live abroad. Research on the current nutrition education status in the

Arab countries would help guide this focus for an overall effective changes and improvements toward delivering nutrition knowledge and guidelines within societies.

Future emphasis on investigating diseases such as obesity and diabetes related to dietary intake among Arab international students would be considered an important issue. Also,

70 increasing the sample size of covered population of Arab International college students as to include more academic institutions in other regions in the U.S may allow further accuracies in having a larger data sample. Another potential research area is investigating the nutritional status and diseases involving children of Arab international students in the U.S will also help provide dietary information, therefore estimating future nutritional needs. Future directions of this study are to continue updating the findings of the study with future changes associated with dietary intake of Arab international students abroad. Research can also utilize the additional findings involving exercise, supplemental use, and dieting as separate individualized studies. This will help comprehend the overall study content to become more sufficient and reliable resource to be used.

Conclusion

The study results indicate that International Arab college students experience change in their dietary intake during their temporary residency in the U.S. Westernized foods sources increase and replace the more familiar traditional food. It is important to illustrate that usually health and nutrition consequences affecting people who live temporary abroad which is caused by changing the type of food consumed from traditional to westernized or vice versa does not necessarily mean that either one of these foods is unhealthy. However, the nutrient density and quantity of the foods consumed must be taken into consideration regardless of if it is a traditional or westernized food.

In general, females were relatively more healthy in their eating pattern than males were;

71 females’ dietary intake was more diversified in consuming more fruits and vegetables in their diet and less saturated fat. Similarly, female participant in this study showed a normal BMI range. These differences in food consumptions between males and females agreed with the predicted hypothesis as well. Married couples showed a better eating and lifestyle choice than singles. In general, married couples had relatively maintained more traditional food consumption than single Arab students. Furthermore, married couples ate more at home than at restaurants in comparison to singles. In addition, married couples consumed a better array from the necessary food groups such as starches, fortified low fat dairy, fruits and vegetables which also agreed with the hypothesis which predicted that there is going to be a difference between single and married couples in food consumption. Finally, both research hypotheses were accepted by the researcher as they were supported by the data. Overall, this study concluded that the surveyed Arab international college students experienced significant impact on their dietary intake as well as on food choices and eating pattern once relocating to the U.S.

APPENDICES

APPENDIX A

CONSENT FORM

Appendix A

Consent Form

74 75

APPENDIX B

FOOD FREQUENCY QUESTIONNAIRE

Appendix B

Food Frequency Questionnaire

77 78

APPENDIX C

ADDITIONAL DATA

Appendix C

Additional Data

Gender: * Marital Status: Crosstabulation Marital Status: Single Married Total Gender: Male Count 37 29 66 % within Gender: 56.1% 43.9% 100.0% % within Marital 84.1% 56.9% 69.5% Status: Female Count 7 22 29 % within Gender: 24.1% 75.9% 100.0% % within Marital 15.9% 43.1% 30.5% Status: Total Count 44 51 95 % within Gender: 46.3% 53.7% 100.0% % within Marital 100.0% 100.0% 100.0% Status:

83 84

Chi-Square Tests Asymp. Sig. (2- Exact Sig. Exact Sig. Value df sided) (2-sided) (1-sided) Pearson Chi-Square 8.257a 1 .004 Continuity Correctionb 7.023 1 .008 Likelihood Ratio 8.604 1 .003 Fisher's Exact Test .007 .004 Linear-by-Linear Association 8.170 1 .004 N of Valid Cases 95 a. 0 cells (.0%) have expected count less than 5. The minimum expected count is 13.43. b. Computed only for a 2x2 table

Weight Status after Moving to the U.S

Regard to weight status after moving to the U.S, single females and married couples reported a weight gain were more single males had weight loss. Table 23 shows changes in weight status occurred in total male, female, and married couples after moving to the U.S. Indicating that weight gain was more seen among both married males and single females.

Table 23

Percentages of Weight Status of Arab International Students after Moving to the U.S

Weight gain Weight loss No change in weight n % n % n %

Male 26 39 23 35 17 26 Single 12 32 20 54 6 16 Married 14 48 3 10 11 38

Female 13 45 7 24 7 24 Single 4 57 1 14 1 14 Married 9 41 6 27 6 27

Married 23 45 9 18 17 33

Diet Change after Moving to the U.S

Table 24 indicates that less than half of males, females, and married couples had reported a change in their diet. However, more than half of total participants indicated no change in their diet.

Table 24

Percentages Diet Change by Arab International Students after Moving to the U.S

A change in diet No change in diet n % n %

Male 27 41 34 51 Single 15 40 19 51 Married 12 41 15 52

Female 10 34 17 59 Single 2 28 4 57 Married 8 36 13 59

Married 20 39 28 55

Eating Pattern after Moving to the U.S

Percentages in Table 25 indicated a general change in eating pattern among all participants in the study.

Table 25

Percentages of Eating Pattern of Arab International Students after Moving to the U.S

A change in eating pattern No change in eating pattern n % n %

Male 45 68 21 32 Single 26 70 13 35 Married 19 65 8 27

Female 18 62 9 31 Single 4 57 2 28 Married 14 64 7 32

Married 33 65 15 29

Dieting & Supplements Intake

Table 26 shows that few participants have been dieting, where the vast majority of participants were not dieting. Hence, almost none of total female participants were involved in the types of diets listed in the table below, except for one single female participant. In addition to fewer single and married male participants were dieting.

Table 27 also indicated that there were fewer participants who used supplements compared to the majority of participants who were not using supplements. However, intakes from multivitamins, vitamin D, and fish oils were the most supplements used.

The percentages in Table 28 indicated that the majority of participants in the study were not involving in daily exercise practice, in addition to the increased percentages of total females and married couple who did not exercise regularly. Single male were more likely to exercise on a weekly and monthly bases in addition to their average time of exercising per week compared to total females and married males.

Percentages in Table 29 indicated that married couples eats at home more frequent than single males and females who prefer to eat out more frequent when all eating red meat, Chicken, and sea food.

Table 26

Percentages of Dieting of Arab International Students after Moving to the U.S

Atkins Weight Diabetic Dash High protein Other None watcher n % n % n % n % n % n % n %

Male 2 3 5 7 3 5 1 2 1 2 3 5 44 66 Single 2 5 2 5 0 0 1 3 0 0 0 0 30 81 Married 0 0 3 10 3 10 0 0 1 3 3 10 14 48

Female 0 0 1 3 0 0 0 0 0 0 3 10 25 86 Single 0 0 1 14 0 0 0 0 0 0 1 14 5 71 Married 0 0 0 0 0 0 0 0 0 0 2 9 20 91

Married 0 0 3 6 3 6 0 0 1 2 5 10 34 66

Table 27

Percentages of Supplemental Use of Arab International Students after Moving to the U.S

Multivitamins Fish oil Vitamin D Iron/folate Other None n % n % n % n % n % n %

Male 7 11 8 12 5 7 1 2 8 12 38 56 Single 3 8 3 8 1 3 1 3 3 8 27 73 Married 4 14 5 17 4 14 0 0 5 17 11 38

Female 3 10 2 7 2 7 0 0 3 10 25 86 Single 1 14 1 14 0 0 0 0 0 0 5 71 Married 2 9 1 5 2 9 0 0 3 14 20 69

Married 6 12 6 12 6 12 0 0 8 16 31 61

Table 28

Percentages of Exercising of Arab International Students after Moving to the U.S

Every day several times once or twice Couple times Don’t exercise Average a week a week a month regularly min/hrs/ n % n % n % n % n % wk

Male 4 6 17 26 10 15 15 23 19 29 6:35 Single 2 5 10 27 6 16 8 22 9 24 6:30 Married 2 7 7 24 4 14 7 24 10 34 5:33

Female 1 3 2 7 4 14 5 17 17 59 4:21 Single 0 0 0 0 1 14 1 14 5 71 4:20 Married 1 5 2 9 3 14 4 18 12 54 4:21

Married 3 6 9 18 7 14 11 22 22 43 5:17

Table 29

Percentages of Amount of Times of Cook and Eat Out when Consuming Red Meat, Chicken and/or Sea Food Per Week of Arab International Students after Moving to the U.S

Cook/prepare at home Eat out Average Times Average Times

Male 3.6 3.2 Single 3.3 4.4 Married 4.0 1.9

Female 2.8 2.9 Single 2.3 4.0 Married 4.6 1.7

Married 4.3 1.8

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