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James Davis, Phd; Jessica Busch, MA; Zoë Hammatt, Esq; Rachel Novotny, Phd; Rosanne Harrigan, Edd; Andrew Grandinetti, Phd;

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James Davis, Phd; Jessica Busch, MA; Zoë Hammatt, Esq; Rachel Novotny, Phd; Rosanne Harrigan, Edd; Andrew Grandinetti, Phd; 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, ZoeÈ Hammatt, Esq; Rachel Novotny, PhD; with a particular emphasis on disparities be- Rosanne Harrigan, EdD; Andrew Grandinetti, PhD; tween Asian and Paci®c 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 Hawaii. 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 Paci®c 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 Paci®c 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 Paci®c 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 signi®cantly reduce the burden of dis- Key Words: Asians and Paci®c Islanders, seek to illuminate obesity rates in Asians ease on minorities. Obesity, Related Risks, Ethnicity, Acculturation and Paci®c 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 Paci®c 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 Paci®c 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- Ethnicity & Disease, Volume 14, Winter 2004 111 OBESITY IN ASIANS AND PACIFIC ISLANDERS - Davis et al 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 Americans), 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 dif®culty 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- Paci®c 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 Paci®c 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 signi®cant 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.
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