THE RELATIONSHIP BETWEEN ETHNICITY AND OBESITY IN ASIAN AND PACIFIC ISLANDER POPULATIONS:ALITERATURE REVIEW

The purpose of this literature review is to ex- James Davis, PhD; Jessica Busch, MA; plore the potential relationship between eth- nicity and obesity, and obesity-related risks, Zoe¨ Hammatt, Esq; Rachel Novotny, PhD; with a particular emphasis on disparities be- Rosanne Harrigan, EdD; Andrew Grandinetti, PhD; tween Asian and Pacific Islander populations. David Easa, MD We conducted a comprehensive search of available medical literature related to the rise of obesity in the United States, factors contrib- uting to obesity, evidence-based clinical guide- lines, and obesity and related risks as they oc- INTRODUCTION cently issued a ‘‘call to action,’’ advocat- cur in . In conducting this search, we ing a national effort to identify the root sought to illuminate obesity rates in Asians and This review seeks to explore the po- causes of obesity, and to outline effective Pacific Islanders in connection with various tential relationship between ethnicity and culturally appropriate interven- factors, such as diet and lifestyle, acculturation, tions.1 The Surgeon General noted that and body image, as they occur in diverse cul- and obesity, and obesity-related risks, tural contexts. We found that the rates of obe- with a particular emphasis on disparities causes of obesity may vary according to sity and related risks were highest in Native between Asian and Pacific Islander pop- race, ethnicity, gender, and socioeco- Hawaiians and Samoans. Based upon our re- ulations. After providing an overview on nomic status. Many obesity-related risk view of the literature, we conclude that further the rise of obesity in the United States, factors are over-represented in minority research is necessary to address the relation- populations, and research designed to ship between ethnicity and obesity risk factors this paper will review literature related in Asian and Pacific Islander populations. (Ethn to the disease’s contributing factors, ev- explore obesity and its related risks Dis. 2004;14:111–118) idence-based clinical guidelines, and could lead to interventions that would obesity as it occurs in Hawaii. We then significantly reduce the burden of dis- Key Words: Asians and Pacific Islanders, seek to illuminate obesity rates in Asians ease on minorities. Obesity, Related Risks, Ethnicity, Acculturation and Pacific Islanders, in connection with Innovative strategies to reduce obe- various factors, such as diet and lifestyle, sity prevalence rates, particularly among acculturation, and body image, as they minority populations who suffer a vast occur in diverse cultural contexts. range of health risks leading to dispari- We conclude that a relationship be- ties in health outcomes, are sorely need- tween ethnicity and obesity risk factors ed. In 2000, the US government spent does, in fact, exist. We believe that fur- an estimated $117 billion, nearly 10% ther research is necessary, particularly of the US healthcare expenditure for among Asian and Pacific Islander pop- that year, on obesity and weight prob- ulations, to better characterize the ex- lems.2 People with a body mass index tent of obesity-related variations be- (BMI) of 30 or greater are considered tween these ethnic groups. Such re- clinically obese; those with BMIs be- search will be vital to the development tween 25 and 29 are considered ‘‘over- and implementation of effective inter- weight.’’ Obesity is linked to numerous ventions designed to reduce obesity-re- health risks, including coronary artery lated disparities, and to improve clinical disease, hypertension, dyslipidemia, di- outcomes in at-risk racial and ethnic mi- abetes mellitus, stroke, gallbladder dis- norities. ease, osteoarthritis, sleep apnea, and re- From the John A. Burns School of Med- spiratory problems, as well as endome- icine (JD, JB, ZH, RH, DE), College of Trop- trial, breast, prostate, and colon can- ical Agriculture and Human Resources (RN), OBESITY IN THE UNITED cers.3,4 Studies also correlate obesity Pacific Biomedical Research Center (AG), University of Hawaii at Manoa, Honolulu, STATES with pregnancy complications, menstru- Hawaii. al irregularities, hirsutism, stress, incon- With a reduction in the prevalence tinence, and psychological disorders.4 Address correspondence and reprint re- of other diseases due to an increase in Among children, obesity heightens the quests to David Easa, MD; Kapiolani Med- smoking, obesity may soon become the risk of hyperlipidemia, hypertension, ical Center for Women and Children; Clin- 5,6 ical Research Center; 1319 Punahou St.; leading cause of preventable disease and and impaired glucose tolerance. Honolulu, HI 96826; 808-983-6233; 808- deaths in the United States. Conse- Chronic obesity requires greater car- 983-6240 (fax); [email protected] quently, the US Surgeon General re- diac expenditure to supply blood to pe-

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rates is occurring among men and wom- United States increased from 3300 calo- In 2000, the US government en, across ethnicities (non-Hispanic ries per day in 1970 to 3800 per day in Whites, non-Hispanic Blacks, and Mex- the late 1990s.22 In addition, fast food spent an estimated $117 ican ), and in all age groups, chains aggressively market foods that are billion, nearly 10% of the including children and adolescents. high in fat and calories, and low in nu- Comparing data from the 1988–1994 trients. Sixty percent of American adults US healthcare expenditure and 1999–2000 NHANES surveys, per- are not regularly active; 25% are consid- for that year, on obesity and centages of overweight children in- ered sedentary.1 Children and adolescents creased from 7.2% to 10.4%, respec- also succumb to pressure to consume weight problems.2 tively, among those aged 2 through 5 foods that lead to weight gain. Half the years, from 11.3% to 15.3%, respec- calories in children’s diets stem from add- tively, among 6- to 11-year-olds, and ed fat and sugar,23 frequently resulting in from 10.5% to 15.5%, respectively, energy intake that exceeds expenditure. among those aged 12 through 19 Most school vending machines sell high- ripheral tissues. As a result, risk for years.14 ly caloric soft drinks, along with snacks stroke and heart rate increase, and the The prevalence of overweight and with high fat and sugar content.24 The left ventricular mass becomes enlarged, obesity rates in racial and ethnic groups total and saturated fat content of school heightening the risk of electrical abnor- not adequately represented in the NHA- meals commonly exceeds recommended malities, heart failure, and sudden NES surveys are estimated from smaller, limits.25 For many children and adoles- death.7 In addition, obesity-associated less representative samples. For example, cents, lack of dietary supervision at home insulin resistance predisposes those who limited evidence suggests that it is less can increase the difficulty of maintaining exhibit it to diabetes.8 Indeed, mortality common for Asians to be overweight or a healthy weight.26 Moreover, many chil- rates increase sharply in people with obese.15 On the other hand, native pop- dren do not engage in regular physical BMIs greater than 30.9,10 ulations such as the Pima Indians and exercise, and, unfortunately, the preva- The third National Health and Nu- Pacific Islanders demonstrate high rates lence of physical education classes in trition Examination Survey (NHANES schools has declined from 42% in 1991 III), conducted from 1988–1994, ex- of obesity; in fact, in some settings, 16–19 to 25% in 1995.1 amined the rates of obesity among non- 40% to 70% are clinically obese. To Hispanic Whites, non-Hispanic Blacks, supplement the NHANES surveys, fur- Many overweight or obese persons and Mexican Americans, and reported ther studies are needed in disaggregated fail to recognize health risks related to that 50.7% of women, and 59.4% of Asian and Pacific Islander populations excess weight. In a recent US survey, men, were overweight or obese.11 These to determine obesity prevalence rates, to where two thirds of participants were percentages, which represent nearly 97 ascertain the presence of co-morbid overweight, and one-third were obese, million adults, reveal a significant rise in conditions, and to test the effectiveness 78% were not seriously concerned about 27 overweight and obesity rates over the of culturally appropriate interventions. their weight. Many physicians may also last three decades. Compared to a less under-recognize or under-treat obesity, than 1% increase between the 1971– Factors that Contribute to and minimal insurance reimbursement 1974 and 1976–1980 NHANES sur- Obesity for obesity treatments can compound the veys, overweight and obesity rates rose In 1998, more than half of Ameri- problem.21,28 A study of reimbursement by nearly 8% during the time between cans attempted to lose weight, spending for pediatric obesity reported that only the 1976–1980 and the 1988–1994 sur- over $33 billion on services and prod- 11% of treatments were reimbursed.29 veys.11–13 NHANES data from 1988– ucts.20 Despite their efforts, however, Patients and physicians often exhibit pes- 1994, and from 1999–2000, suggest a 95% of individuals tend to regain lost simistic attitudes about treatment out- continuation of this alarming trend; weight within 7 years.21 In spite of pub- comes, creating an additional barrier to overweight prevalence increased from lic and private expenditures, and exist- achieving a healthy weight.30,31 55.9% to 64.5%, respectively, and obe- ing treatment guidelines to promote ap- In addition to the above factors, ge- sity rates rose from 22.9% to 30.5%, propriate interventions, various factors netics may play a role in obesity and its respectively.13 During this same time pe- contribute to the steady rise in obesity related risks. Obesity is genetically com- riod, the percentage of the population rates in America, including dietary pat- plex. Multiple genes may be implicated, considered to be morbidly obese (BMI terns, lack of exercise, lack of awareness and contributing genes may interact ϭ 40) rose from 2.9% to 4.7%. of obesity and its related risks, and ge- with other genes and/or environmental According to the NHANES surveys, netic susceptibility. factors such as diet and physical activity. escalation of overweight and obesity The per capita caloric intake in the Variance in obesity rates between racial

112 Ethnicity & Disease, Volume 14, Winter 2004 OBESITY IN ASIANS AND PACIFIC ISLANDERS - Davis et al and ethnic groups may stem, in part, sence of systematic studies on obesity sity and related risk patterns in popu- from genetic susceptibility. Evidence treatments in diverse populations. lations who have immigrated to Hawaii suggests that genetics may account for Behavioral and nutritional therapies and adopted more ‘‘Western,’’ or ‘‘mod- 25% to 70% of variations in BMI.32,33 were reported to improve weight loss, ern,’’ behaviors. For example, the BMIs The hormone leptin is the most re- while pharmacological or surgical ap- of immigrants from South and East searched genetic factor in obesity. Lep- proaches may be more effective for some Asia, as well as from Polynesia, are gen- tin is secreted by adipocytes. Circulating patients. Medications approved in the erally higher than those of their coun- leptin levels correlate with the lipid con- United States either suppress appetite or terparts in their countries of origin. In tent of a non-fasting person.34,35 For decrease nutrient absorption,45 and addition, immigrants from East Asia, at some children, insufficient leptin levels short-term benefits of these have been lower BMIs, are exhibiting an increasing result in severe obesity, and treatment documented. In some cases, bariatric incidence of obesity-related diseases.15,48– with recombinant leptin can lead to dra- surgery, which enables the patient to ex- 50 These variances may be due, in large matic weight loss.36 Genes currently un- perience early satiation, can be effective part, to dietary changes that occur as der investigation include those that reg- on a long-term basis. In spite of evi- part of the acculturation process. In ulate appetite,37,38 determine the num- dence-based clinical guidelines and ef- more Westernized settings, where pro- ber of adipocytes available to store fat,39 fective available treatment, the rise in cessed foods high in sugar, fat, and cal- influence differences in resting energy obesity rates persists on a national scale. ories are more available, and more com- exposure,40 affect insulin resistance,41 monly integrated into daily diet, con- stimulate growth hormone release,42,43 Obesity in Hawaii sumption of such foods may lead to an and regulate energy expenditure Research efforts in Hawaii could increased risk of obesity and associated through protein uncoupling due to ox- provide exemplary models for national diseases. idative phosphorylation.44 Further in- efforts to assess the relationship between Fast food, in particular, is often in- vestigation of diet, lifestyle, genes, and ethnicity and obesity. Hawaii offers an tegrated into dietary patterns in modern other factors will be crucial to identify- ideal setting for obesity-related research, settings such as Hawaii, and fast food ing and evaluating the role of ethnicity particularly given the high rates of obe- chains even incorporate high caloric ver- in obesity. sity in Hawaii’s diverse population. sions of regional foods. For example, in More than 75% of Pacific Islanders (in- Hawaii, McDonald’s features Portuguese Evidence-Based Clinical cluding and Samoans) sausage, along with the regular burgers Guidelines in Hawaii are overweight or obese, com- and French fries. Convenience stores, The National Institutes of Health pared to 52% of Caucasians, 46% of such as 7-11, sell hot dogs and spam 47 (NIH) recently formed an expert panel Japanese, and 45% of Filipinos. Asians musubi (rice blocks topped with sliced that issued evidence-based guidelines for and Pacific Islanders are growing seg- spam and wrapped in seaweed), as well treating obesity.4 The NIH panel of- ments of the US population, increasing as pork and beef manapua (puffed fered treatment recommendations based from 1.5 million in 1970 to 3.7 million dough balls stuffed with meat). Zippy’s, 8 upon a review of more than 300 ran- in 1980, and to 7.3 million in 1990. a local fast food chain, offers meals such domized clinical trials, concluding that According to the 2000 US. Census, as spaghetti and meatballs, as well as lo- caloric consumption between 1,000 to Asians (alone, or in combination with cal dishes like ‘‘loco moco’’ (two scoops other races) number 11.9 million, while 1,200 kilocalories per day can lead to an of rice, a large burger, a fried egg, and Native Hawaiians and other Pacific Is- 8% average reduction of total body brown beef gravy). The availability of a landers number 800,000 (alone, or in weight over 3 to 12 months. Even short- variety of local and national fast food, combination with other races). These term weight loss of 5%–10% improves which is consumed by diverse ethnic significant findings illustrate the need glycemic control, blood pressure, and groups in Hawaii, is a likely contributor for further research in Asian and Pacific lipid profiles.45 Nevertheless, obesity to obesity-related risks. Islander populations. may best be viewed as a chronic disease, The adverse effects of Westerniza- requiring long-term treatment strategies, tion have been suggested by studies per- and the panel noted that social and cul- taining to Asian immigrants. Compared OBESITY AND tural factors should be taken into con- to those living in the country of origin, ‘‘WESTERNIZATION’’ IN sideration in the development of effec- ASIANS AND PACIFIC immigrants to the United States are at tive research and weight management ISLANDERS greater risk for coronary artery disease, programs. For example, attitudes toward diabetes, and breast and colon can- food and body mass vary across cul- One interesting phenomenon is the cers.51–54 Risk factors for, and incidence tures.46 The NIH panel noted the ab- acculturation process as it relates to obe- of, major chronic disease increase with

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Westernization. Mean levels of serum diastolic blood pressure, suggesting fur- Body Image Among Pacific cholesterol, serum triglyceride, and tri- ther obesity-related risks. Islanders glyceride are higher among Asians in the As illustrated by several studies Modernization has perhaps had less United States, and hypertension occurs among , increases in of an effect on body image than on diet more frequently.55 Risk factors, however, adiposity and BMI due to Westerniza- and lifestyle. In many traditional Poly- can vary by Asian ethnicity. Filipinos, tion may be associated with a higher risk nesian societies, even after Western con- for example, may be especially prone to of diabetes among Asians living in the tact, a very large body was a sign of hypertension.15 United States. The risk of diabetes in wealth, royalty, status, and prestige.68 As they become acculturated, Asian Japanese Americans is about twice that For example, many Hawaiian monarchs immigrants tend to be less physically ac- of Japanese living in Japan.50,59 Incident demonstrated their noble stature tive and consume more Westernized di- studies of non-insulin-dependent dia- through their robust physical image. Al- ets. A study of Japanese-American men betes mellitus show increased risks at though the idealization of a large body in Seattle, for instance, showed their BMIs of 25 to 29, below the clinical frame with abundant energy stores may mean intake of fat (32.4 g) to be twice obesity definition set forth by the Na- be shifting to a more modern context, that of men in Japan (16.7 g).8,56 A tional Heart, Lung, and Blood Institute. particularly in Hawaii, traditional cul- comparison of second and third gener- In addition, risks for Japanese Ameri- tural images often still influence body ation Japanese Americans in Los Angeles cans with impaired glucose tolerance in- self-image. This idealization may linger revealed that the third generation dined crease sharply at BMIs of 23 or higher.50 as a means of perpetuating Hawaiian out more often and consumed more Over one third of the Japanese partici- culture.69,70 A recent study found that takeout food and salty snacks, compared pants in one study had impaired glucose Pacific Islanders in Hawaii view body to the second generation.57 Another tolerance, likely due to a high preva- image differently, according to whether study demonstrated that Japanese living lence of insulin resistance.63,64 Asians they identify with a Western, or a non- in Hawaii ate more animal fat and sim- demonstrate a greater prevalence of in- Western, culture.71 Acceptance of larger ple carbohydrates, and fewer complex sulin resistance compared to non-His- body types also seems to persist among carbohydrates, compared to their coun- panic Whites, despite having lower av- Native Hawaiians when compared to terparts in Japan.58 Similarly, a compar- erage BMIs and waist-to-hip ratios.65 Whites and living in ison of Chinese in the United States and The above findings suggest that guide- rural Hawaii.72 China found that those living in the lines based upon studies conducted in Similarly, a study in Australia United States engaged in less physical other ethnic populations may not be showed that although overweight Sa- activity, got fewer calories from carbo- suitable for Asians. moan women were concerned about hydrates, and more calories from fat, As with Asian migrant populations, body fatness, they were less preoccupied and consumed more red meat and less there appears to be a connection be- by their concerns than their Australian fruit.49 tween Westernization and obesity in Pa- counterparts. Overweight Samoan wo- The negative health consequences of cific Islanders. For example, compari- men felt stronger and more fit and at- increased BMIs for Asians may be great- sons between traditional Western Samoa tractive than did Australian women of er than for Whites of European descent. and modern American Samoa demon- comparable weight.69 Another study in One Hawaii study reported that BMIs strate marked differences in dietary pat- New Zealand found that although the were higher among Japanese in Hawaii terns that are linked to increased cardio- ideal body type was slim, overweight Sa- than in Japan, even with similar total vascular disease prevalence.66 Increases moans did not view themselves as over- caloric intake.48 At a given BMI, Asians in cardiovascular disease rates in Samoa weight as often as their Western coun- may be more prone to central (visceral) appear to correlate with modernization terparts, and Samoan women did not adiposity, increasing their risk of obesi- of diet and lifestyle; high levels of social share strong negative views of obesity.70 ty-related diseases beyond that expected, support, parental ties, and knowledge of In spite of modern influences on tradi- based on their BMIs.59–61 Asians may Samoan culture are associated with low tional preferences for a large body size, also tend to accumulate subscapular fat blood pressure, while factors related to obesity rates tend to increase in Samoan more easily. For example, a study of modernization are associated with high- men along with modernity of residence young adult women in Hawaii reported er blood pressure levels.67 Specifically, or occupation.73 Ironically, as many that Asian women had greater subscap- the percentage of overweight Samoan modernized Pacific Islanders achieve the ular skin-fold thickness than Whites at women dramatically appears to increase prized large body, this ideal is being dis- similar BMIs, as well as a greater per- from 46%, for those living in Western carded in favor of more slender body centage of body fat.62 Subscapular skin- Samoa, to 80%, for those who have mi- images. Study of the tensions between fold thickness strongly correlated with grated to Hawaii. traditional and modern diet, lifestyle,

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abetes is about 20%, approximately 3 not appropriate for all ethnic groups, or While genetic factors may be times the national rate.76 Further, Native study populations. This is particularly Hawaiians die of diabetes at a rate of critical to obesity research in Hawaii, significant, diet and lifestyle 117 per 100,000, compared to the av- where most of the population represents also play a prominent role in erage rate of 53 per 100,000 for other an ethnic minority. Experts from Asia ethnic groups.77 Native Hawaiians may and the Pacific recently met to discuss the development of obesity be genetically susceptible to diabetes, as definitions of overweight and obesity in and its associated risks in well as to obesity; increased Hawaiian diverse populations, and concluded that blood quantum is associated with higher criteria for Asians and Pacific Islanders Native Hawaiians and fasting glucose levels.78 Interestingly, must reflect anthropometric trends in though, the risk of diabetes has not been order to accurately assess risks associated 83 Samoans. shown to diminish with a decreased per- with being overweight or obese. In ad- centage of Hawaiian ancestry. This find- dition to population-specific criteria for ing may be due to inaccurate ethnic self- determining overweight and obesity, reporting, or to mixed ancestry that in- Asian and Pacific Islander populations and body image, as these tensions man- cludes other ethnic groups with high di- may require population-specific dietary ifest in obesity and related risks, will be 8 abetes rates. and physical activity guidelines, all of an important component of studies de- which could be explored through stud- Among part-Hawaiian children, the signed to address the relationship be- ies implemented in Hawaii. prevalence of Type 1 diabetes is 2.5 tween ethnicity and obesity. times higher than in White children, Efforts to Address Obesity and ten times higher than in Japanese Obesity and Related Risks in Among Native Hawaiians children.79 Another consequence of Native Hawaiians and Samoans A few programs have already been childhood obesity for females is early Obesity and associated diseases oc- implemented in response to high rates menarche, which is associated with cur in alarming rates among Pacific Is- of obesity and associated diseases in Na- breast cancer later in life.80 Native Ha- landers. The mean BMI of Native Ha- tive Hawaiian populations, in particular. waiian girls report menarche at a signif- waiians is 31.0. Interestingly, BMI in- The Waianae Diet Program, for exam- icantly lower age than non-Hawaiians.81 creases in relation to percentage of Na- ple, is a community-based program that tive Hawaiian ancestry, suggesting a Cardiovascular risk factors also occur incorporates traditional Hawaiian diet genetic connection between ethnicity in high rates in Native Hawaiians. A and cultural teachings and has demon- and body weight.19,74 Samoans also study of Native Hawaiians living in an strated positive effects.84,85 Another ef- demonstrate high obesity rates. The isolated community (Molokai Island) fort, the Uli’eo Koa Program, consists of mean BMI for Samoans aged 25–54 reported that 14% of those aged 20–39 a pilot study to assess the effects of a years is 30–32 for males, and 32–36 for years, and 36% of those aged 40–59 traditional Hawaiian diet on moderately females.17 While genetic factors may be years, had either high blood pressure active, non-obese Native Hawaiian significant, diet and lifestyle also play a (systolic blood pressure greater than 140 adults, focusing particularly on wellness prominent role in the development of mm Hg,and/or diastolic pressure greater and physical fitness related to the diet.86 obesity and its associated risks in Native than 90 mm Hg), or were taking anti- An innovative approach, the Uli’eo Koa Hawaiians and Samoans. For example, hypertensive medications.74,82 Hyperten- Program seeks to reproduce the holistic a recent comparison of diet among sion, the presence of which was usually practices of ancient Hawaiian warriors, women of different ethnic groups dem- known to the participant, was frequent- including diet, traditional fighting arts, onstrated that Hawaiian women tended ly uncontrolled. In the Molokai Island and massage, and has combined them to follow a meat-based diet, which as- population, 8% of those aged 20–29 to create a culturally rich health educa- 87 sociated with higher BMI, while Japa- years, and 46% of those aged 50–59 tion program. Population-specific re- nese and Chinese women followed a years, experienced elevated serum cho- search will lend further support to pro- bean- or soy-based diet, which correlat- lesterol levels (6.2 mmol/L or greater).82 grams like these, which are designed to address the particular needs of Asian ed to lower BMI.75 The risk factors related to obesity that and Pacific Islander populations. Compared to other ethnic groups in occur in Native Hawaiians and other Hawaii, Native Hawaiians suffer dispro- Pacific Islanders contribute to significant portionately from obesity-related diseas- health disparities. ONCLUSION es, particularly diabetes and cardiovas- Research indicates that risk factors C cular disease. Among adult Hawaiians identified based on standard clinical cri- As demonstrated by the above stud- aged 30 and over, the prevalence of di- teria in limited study sets for obesity are ies, at least some correlation exists be-

Ethnicity & Disease, Volume 14, Winter 2004 115 OBESITY IN ASIANS AND PACIFIC ISLANDERS - Davis et al tween ethnicity and obesity, particularly 11. Flegal KM, Carroll MD, Kuczmarski RJ, 26. Wardle J, Sanderson S, Gutherie CA, Rap- in connection with genetic variance and Johnson CL. Overweight and obesity in the poport L, Plomin R. Parental feeding style United States: prevalence and trends, 1960– and the inter-generational transmission of lifestyle factors. Based upon our review 1994. Int J Obes Relat Metab Disord. 1998; obesity risk. Obes Res. 2002;10:453–462. of the scientific literature, we conclude 22:39–47. 27. Lee T, Oliver JE. Public opinion and the pol- that sufficient evidence exists to justify 12. Kuczmarski RJ, Flegal KM, Campbell SM, itics of America’s obesity epidemic. KSG Fac- further research among Native Hawai- Johnson CL. Increasing prevalence of over- ulty Research Working Series. May 2002. weight among US adults: the National Health 28. Grizzard T. Undertreatment of obesity. ians, Samoans, and other subpopula- and Nutrition Examination Surveys, 1960 to JAMA. 2002;288:2177. tions, including other Pacific Islanders, 1991. JAMA. 1994;272:205–211. 29. Tershakovec A, Watson MH, Wenner W Jr, Filipinos, and diverse Asian groups. 13. Flegal KM, Carroll MD, Ogden CL, Johnson Marx AL. Insurance reimbursement for the Such research will be vital to illuminat- CI. Prevalence and trends in obesity among treatment of obesity in children. Pediatrics. US adults, 1999–2000. JAMA. 2002;288: 1999;134:573–578. ing the extent of obesity-related dispar- 1723–1727. 30. Orleans CT, George LK, Houpt JL, Brodie ities between ethnic groups, and to de- 14. Ogden CL, Flegal KM, Carroll MD, Johnson KH. Health promotion in primary care: a veloping effective, culturally appropriate CI. Prevalence and trends in overweight survey of US family practitioners. 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Ide- Health Rep. 1996;111(suppl 2):59–61. al body image and health status in low-in- AUTHOR CONTRIBUTIONS 56. Lands WEM, Hamazaki T, Yamazaki K, et al. come Pacific Islanders. J Cult Divers. 2002;9: Design and concept of study: Davis, Busch, Changing dietary patterns. Am J Clin Nutr. 12–22. Harrigan, Grandinetti, Easa 1990;51:991–993. 72. Chang HK, Grandinetti A, Lan G, Rodriguez Acquisition of data: Davis, Busch, Harrigan, 57. Kudo Y, Falciglia GA, Couch SAC. Evolution BL, Melish JS, Curb JD. Cross-cultural com- Easa of meal patterns and food choices of Japanese- parisons of ideal body type among a multi- Data analysis and interpretation: Davis,

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Busch, Hammatt, Novotny, Harrigan, Statistical expertise: Davis, Harrigan, Gran- Administrative, technical, or material assis- Easa dinetti tance: Davis, Busch, Hammatt, Novotny, Manuscript draft: Davis, Busch, Hammatt, Acquisition of funding: Davis, Harrigan, Harrigan, Easa Novotny, Harrigan, Grandinetti, Easa Easa Supervision: Davis, Harrigan, Easa

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