Understanding of Dietary Intake and Factors That Influence Food Consumption Choices Among Chinese International Students in Northeast Ohio

UNDERSTANDING OF DIETARY INTAKE AND FACTORS THAT INFLUENCE FOOD CONSUMPTION CHOICES AMONG CHINESE INTERNATIONAL STUDENTS IN NORTHEAST OHIO

A thesis submitted to the Kent State University College Of Education, Health, and Human Services In partial fulfillment of the requirements For the degree of Master of Science

Xiaoyan Liu

August 2018

A thesis written by

Xiaoyan Liu

B.S. Indiana University of Pennsylvania, 2016

M.S. Kent State University, 2018

Approved by

______, Director, Master’s Thesis Committee Eun-Jeong (Angie) Ha

______, Member, Master’s Thesis Committee Karen Lowry Gordon

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

Accepted by

______, Interim Director, School of Health Sciences Ellen Glickman

______, Dean, College of Education, Health and Human James Hannon Services

Liu, Xiaoyan., M.S., August 2018 Nutrition

UNDERSTANDING OF DIETARY INTAKE AND FACTORS THAT INFLUENCE FOOD CONSUMPTION CHOICES AMONG CHINESE INTERNATIONAL STUDENTS IN NORTHEAST OHIO (107 pp)

Director of Thesis: Eun-Jeong (Angie) Ha, Ph.D.

In recent years, the largest international student population in the U.S. is Chinese, which accounted for 32.5% of the total number of international students. As a result of adapting to American culture while living away from their home countries, international students confront dietary changes. These dietary changes include irregular dietary patterns, reduced intake of fruits and vegetables, and increased unhealthy food consumption that may result in unfavorable health outcomes, such as obesity, cancer, and diabetes. The purpose of this study was to understand the current dietary intakes and the factors that influence food consumption choices among Chinese international college students in the United States. Inclusion criteria included part-time and full-time undergraduate and graduate Chinese international students in Midwest United States colleges. The findings from this study show that Chinese international students had irregular eating patterns, skipped meals, and ate at irregular times since they came to the

United States. Many students increased intakes in meat, fast food, low nutrient dense foods, soda, and coffee. The most important factors that influenced food choices among

Chinese international students were time, nutrition concerns, taste, food price, convenience, dietary habits, and food availability and access.

ACKNOWLEDGMENTS

I would like to thank Dr. Ha for her guidance, support, and knowledges as my thesis director. I have learned a lot form her. Also, I would like to thank my other committee members, Dr. Natalie and Dr. Gordon, for their suggestions to improve my study. Thank you to Han Zhang and Anthony Shreffler of the Research and Evaluation

Bureau for their help with data analysis. Moreover, thank you to Tara Rogers of Writing

Common for her extensive help with my grammar. Finally, thank you to my parents. My parents have provided tremendous support to me in past seven years.

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TABLE OF CONTENTS

ACKNOWLEDGMENTS……………………………………………….……………… iii

CHAPTER I. INTRODUCTION ………….……………………..………………………………… 1 Statement of the Problem ………………….…………………………………...... …. 2 Purpose Statement ………………………….………………………..………………. 3 Research Questions……………………………………………………..…………..... 3 Operational Definitions …………………….……………………..…………………. 3

II. REVIEW OF LITERATURE …………………………….………………………… 4 Dietary Guidelines ………..………………………………………………………….. 4 Dietary Guidelines for Americans 2015-2020 …………………………………….. 4 MyPlate …………………………………………………………………………..... 6 Dietary Reference Intakes ………………………………………………………..... 7 Dietary Guidelines for Chinese Residents 2016 …………………………………... 8 Dietary Patterns and Diseases …………………………………………………...... 10 Obesity …………………………………………………………………………… 10 Cancer …………………………………………………………………………..... 13 Cardiovascular Disease …………………………………………………………... 16 Osteoporosis ……………………………………………………………...…...... 18 Other Conditions …………………………………………………………………. 19 Dietary Patterns …………………………………………………………………….. 20 Dietary Consumption Patterns in the United States ………………………...…..... 20 Dietary Issues Related to Immigrants in the United States……………………….. 26 Dietary Consumption Patterns in China …………………………………………. 28 College Students ………………………………………………………………...... 32 Factors that Influence College Students’ Dietary Patterns ……………….…….... 33 International students …………………………………………………………...... 35 Dietary Patterns among International Students ….…………………………..…… 36

III. METHODOLOGY …………….…………..…………..…………………...…….. 41 Research Design ………………………………………………………………….… 41 Research Sample ……………………………………………………..…...... 41 Procedures …………………………………….…………….……………………… 41 Interview Survey ………………………….………………………………..………. 42 Part I: General Demographic ……………………………...……………………... 42 Part II: Dietary Intake Information …………………………………………...... 43 Part III: A Typical Day Food Recall ………………………………………...…… 43 Statistical Analysis …………………………………………………………….....… 43 iv

IV. JOURNAL ARTICLE ………………………………………………………..….. 44 Introduction ………………………………………………………………………… 44 Methodology ……………………………………………………………………….. 45 Research Sample ……….…………..…………………………………………..… 46 Procedures ………………...……………………………………………………… 46 Interview Survey …………...…………………………………………………….. 47 Statistical Analysis ………...………….……………………………………..…… 47 Results ………………………………………………………………………...……. 48 Demographics …………………………………………...………………….……. 48 Dietary Patterns and Weight Changes ………………………………………….... 51 Eating pattern ……...……………………………………………...……………. 51 Fruit, vegetable, and meat consumption …………………………...…………... 52 Consumption of low nutrient dense food and beverages …...…………...……... 53 Perception of American food environment ……………………………...……... 54 Cooking behavior change ………………………………………………...…..... 55 Weight change ………………………...……………………………………...... 55 Dietary Practice ……………….…………………………………...……………... 56 Access to traditional Chinese food and snacks ………………….…….....…….. 56 Staple foods ………………………………………………………...... ………… 58 Snacks ………………………………………………...……………...……...…. 58 Dining out ………………………………………………………….……….….. 59 Perception of current dietary pattern ……………………………...……………. 61 Dietary Intake Assessed by a Typical Day Food Recall …...………..…………… 61 Macronutrients ……...…………………………………………………...…...… 61 Vitamins ………………………………………………..………………………. 62 Minerals …………………………………………………...…...………………. 63 Food groups …………………………………………………...……………….. 64 Factors Influence Food Choice and Cooking Practice ………………………...…. 64 Food choices ………………………………………………………………..….. 64 Cooking practices ………………………………………………………..…...… 67 Discussion …………...……………………………………………………………... 70 Dietary and Weight Changes ……….………….….……………………………… 71 Dietary Analysis ……………………...……………………………………….….. 74 Factors that Influence Food Choices ………………………………..……………. 75 Factors that Influence Cooking Practices ….……...………………..…………….. 76 Limitations …………………………………………………………………………. 78 Implications ………………………………………………………………………… 78 Conclusion …….………………………...…………………………………………. 79

APPENDICES …………………………………………………………………………. 81 APPENDIX A. INTERVIEW SURVEY …..……………………..…………….…… 83

REFERENCES ………………………………………………………………………… 88 v

CHAPTER I

INTRODUCTION

A healthy dietary pattern is not only essential for promoting current health status, but is also associated with a reduced risk of chronic diseases and maintenance of overall health (U.S. Department of Health and Human Services, 2017). During the 2016-2017 academic year, 903,127 international students studied in the U.S. (IIE, 2017). In recent years, the largest international student population has been Chinese, which accounted for

32.5% of the total number of international students (IIE, 2017).

In the past few decades, China has become one of the most powerful economies in the world (Morrison, 2013). Due to the rapid growth of the economy, more and more middle-class Chinese families can afford to send their children to study abroad in order to grow academically and professionally, to be proficient in a foreign language, to learn about different cultures, and to improve future employment opportunities (Smith & Mitry,

2008; Yan, 2015;). As a result of adapting to American culture while living away from their home countries, international students confront multiple challenges including, but not limited to, academic pressures, language barriers, financial stresses, loneliness, homesickness, culture shocks, stereotyping, discrimination, misunderstandings, and dietary changes (Lin & Yi, 1997). The factors influencing the dietary changes that international students experience include time constraints, food price, food

1 2 availability, food accessibility, food storage, food preparation skills, and food environment factors (O’Sullivan & Amirabdollahian, 2016). Limitations of food availability and food accessibility are unique factors that affect dietary habits of international students (Alakaam, Castellanos, Bodzio, & Harrison, 2015).

Several studies indicated that international students and immigrants switched their dietary patterns to a typical Western diet the longer they had lived in America (Pan,

Dixon, Himburg, & Huffman, 1999; Rosenmoller, Gasevic, Seidell, & Lear, 2011).

These dietary changes include irregular dietary patterns, reduced intake of fruits and vegetables, increased unhealthy food consumption, and frequent dining out (O’Sullivan

& Amirabdollahian, 2016; Almohannna, Conforti, Eigel, & Barbeau, 2015) that may result in unfavorable health outcomes, such as obesity, cancer, cardiovascular diseases

(CVD), and diabetes (Gilbert & Khokhar, 2008; Papadaki & Scott, 2002; Alakaam et al.,

2015).

Statement of the Problem

The number of Chinese students studying in the U.S. has significantly grown, and currently 350,755 Chinese students are attending colleges in America (IIE, 2017).

Studying in countries with different cultures leads international students to handle dietary changes (Satia-Abouta, 2003). Evidence suggests that dietary acculturation influences food habits among Chinese students and most of them have poor food choices

(Almohannna et al., 2015). This is concerning because numerous studies showed that chronic disease risk in Chinese immigrants has increased compared to those living in

China, due to lifestyle changes after immigration (Rosenmoller, et al, 2011; Yu et al.,

1991). Early intervention may help Chinese students develop healthy eating behavior while they are adopting western foods, which may contribute to reducing their health risk later in life. Therefore, it is important to understand current dietary practices among

Chinese students and factors influencing their eating patterns. However, there are limited studies related to dietary consumption patterns of Chinese students in Northeast Ohio.

Purpose Statement

The purpose of this study is to understand the current dietary intakes and the factors that influence food consumption choices among Chinese international college students in Northeast Ohio.

Research Questions

1. What is the current dietary intake among Chinese international students in

Northeast Ohio?

2. What are the most important factors that influence the dietary behaviors of

Chinese international students enrolled at a Midwest University?

Operational definitions

Chinese international students—Undergraduate and graduate Chinese international students include those from mainland China, Taiwan, Hong Kong, and

Macau, ages 18 and above, that hold F-1 visas and are enrolled part-time or full-time in

Northeast Ohio colleges during the Spring 2018 semester.

Dietary intake—The daily eating practices of an individual, including specific foods, beverages, nutrients, and calories consumed.

CHAPTER II

LITERATURE REVIEW

Dietary Guidelines

Dietary components that individuals customarily eat and drink act “synergistically” in respect to health (U.S. Department of Health and Human Services, U.S. Department of

Agriculture, 2015). Almost every country has developed dietary recommendations in order to improve their residents’ nutrition status and health (Institute of Medicine, 2003).

Possessing a healthy dietary pattern can help individuals achieve and maintain a healthy body weight, supply adequate nutrients within calorie need, and prevent chronic diseases throughout the lifespan (Academy of Nutrition and Dietetics, 2013; HHS, USDA, 2015).

Individuals need to consume adequate amounts of certain foods that include essential nutrients, while limiting the intake of certain foods high in saturated fats, simple carbohydrates, and sodium as much as possible (Joint WHO/FAO Expert Consultation,

2003). Moreover, a healthy dietary pattern has been strongly associated with decreased risk of chronic diseases, and this evidence is sufficient to support dietary guidance (HHS,

USDA, 2015). Therefore, dietary guidelines have been developed to help individuals reach the nutritional goals (Joint WHO/FAO Expert Consultation, 1998).

Dietary Guidelines for Americans 2015-2020

The 2015-2020 Dietary Guidelines deliver recommendations for individuals to improve their dietary patterns (HHS, USDA, 2015). The purpose of these guidelines is to

4 5 encourage an individual to consume an overall healthy dietary pattern, including vegetables, fruits, grains dairy, protein foods, and oils, consumed within an appropriate calorie need and caution with limited amounts of saturated fats, added sugars, and sodium.

The Healthy U.S.-Style Dietary Pattern developed by the U.S. Department of Agriculture

(USDA), is based on foods that Americans prefer and typically consume, but in nutrient- dense forms and moderate amounts to exemplify the guidelines above (HHS, USDA,

2015).

The Healthy U.S.-Style Dietary Pattern recommends that healthy dietary patterns should include a variety of vegetables from all five vegetable subgroups: dark green, red and orange, legumes, starchy, and other (HHS, USDA, 2015). The daily recommended amount of vegetables at the 2,000-calorie level is 2 ½ cups. The fruits food group contains both whole fruits and 100% fruit juices. The daily recommended amount of fruits at the 2,000-calorie level is 2 cups. One cup of 100% fruit juice and one-half cup of dried fruit count as 1 cup of fruit. However, fruit juice and dried fruits can contribute extra calories, so at least half of the recommended amount of fruits should be whole fruits.

In the grain group, individuals should limit the consumption of refined grains and products made with refined grains. The daily recommended amount of grains at the

2,000-calorie level is 6 ounces. Importantly, at least half of the recommended amount of grains comes from whole grains. The dairy group includes milk, yogurt, cheese, and fortified soy beverages. The daily recommended amount of dairy is based on age; for individuals ages 8 and above, the recommended amount is 3 cups. The protein food group includes foods from both animal and plant sources, such as seafood, meat, poultry,

6 eggs, nuts, seeds, and soy products. The daily recommended amount of protein foods at the 2,000-calorie level is 5 ½ ounces per day (HHS, USDA, 2015).

Although oil is not a food group, oils are a part of a healthy dietary pattern, because they are a major source of essential fatty acids and vitamin E (HHS, USDA,

2015). The daily recommended amount of oils at the 2,000-calorie level is 27 grams, which about 5 teaspoons. In addition to the food groups, it is also necessary to consider other food components in food and beverage choices, such as added sugars, saturated fats, trans fats, cholesterol, and sodium. Healthy dietary patterns suggest that individuals should limit added sugars and saturated fats to less than 10 percent of calorie intake per day. Individuals should limit consumption of trans fats and cholesterol to as little as possible. The Healthy U.S.-Style Dietary Pattern recommends amounts of cholesterol from 100 to 300 mg, which is based on calorie levels, and individuals should limit sodium intake to less than 2,300 mg per day for ages 14 years and above (HHS, USDA,

2015).

MyPlate

MyPlate was developed from Dietary Guidelines for Americans, and was created to help people make better food choices and create a healthy eating style (USDA, 2017).

Four principles were given to build a healthy eating style: “All food and beverage choices matter, focus on variety, amount, and nutrition. Choose an eating style low in saturated fat, sodium, and added sugars. Make small changes to create a healthier eating style.

Support healthy eating for everyone” (USDA, 2017).

In MyPlate, the daily needs for oils and the five food groups (including fruits, vegetables, grains, protein food, and dairy) were given, and the daily needs of the five groups are varietal depending on age, sex, and level of physical activity (USDA, 2017).

MyPlate indicates that daily recommendations of fruit, vegetables, grains, and protein foods are given to individuals who have daily moderate physical activity. More importantly, MyPlate suggests that at least half of all the grains eaten should be whole grains. In the dairy group, 1 cup of milk or soy beverage, 1 ½ ounces of natural cheese, and 2 ounces of processed cheese counts for 1 cup of dairy in MyPlate’s dairy group

(USDA, 2017).

Dietary Reference Intakes

DRIs are a set of reference values including Recommended Dietary Allowance

(RDA), Adequate Intake (AI), and Tolerable Upper Intake Level (UL), and are used to plan and evaluate nutrient intakes of healthy individuals (National Institutes of Health,

2017). In 1941, RDA was published in the U.S. (Health Canada, 2010). In 1994, there were two major factors that contributed to the development of Dietary Reference Intakes

(DRIs). The first was that the endpoint of the reference values had been associated with the risk of chronic disease. Second was that the need for development of more nutrient- based reference values increased (Health Canada, 2010; Russell, 2008).

RDA refers to “average daily level of intake sufficient to meet the nutrient requirements of nearly all (97-98%) healthy people”. AI represents “established when evidence is insufficient to develop an RDA and is set at a level assumed to ensure nutritional adequacy”. UL indicates that “maximum daily intake unlikely to cause

8 adverse health effects” (NIH, 2017). Specifically, these reference values are varying and dependent on age and gender (NIH, 2017). According to DRIs, Acceptable

Macronutrient Distribution Ranges of fat for adults are 20-35% of energy. Further, 5-10% and 0.6-1.2% of fats need to come from linoleic acid and alpha-linolenic acid, respectively. 45-65% of energy come from carbohydrates, and protein contributes to 10-

35% of energy (NIH, 2017).

Dietary Guidelines for Chinese Residents 2016

Dietary Guidelines for Chinese Residents 2016 was developed by the Chinese

Nutrition Society, and it was revised from the 2007 Dietary Guidelines for Chinese

Residents (Food and Agriculture Organization of the United Nations, 2017). The guidelines are formed as the Chinese food pagoda (The Chinese Nutrition Society, 2016), and there are three parts of the guideline including the dietary guidelines for the general population, the dietary guidelines for specific populations, and the practice of balanced diet of Chinese residents above (S. Wang, Lay, Yu, & Shen, 2016). The objectives of these guidelines are to provide guidance for Chinese residents to make better food choices and create a balanced diet in order to decrease public nutrition problems and protect against diseases (Food Industry Asia, 2017).

More specifically, the main parts of the guidelines are the guidelines for the general population; there are six guidelines recommended for healthy people aged 2 years and older (FAO, 2017). First, “eat a variety of foods, with cereals as the staple”; a balanced diet pattern for the Chinese population features a variety of foods with cereals as the staple, and 250-400 grams of cereals and potatoes are recommended for daily

9 consumption (S. Wang et al., 2016). The guidelines also recommended that at least 12 types of food need to be consumed daily in order to have a diverse diet (Food Industry

Asia, 2017). Second, “balance eating and exercise to maintain a healthy body weight”; the guidelines suggested that at least 150 minutes of moderate intensive exercise and

6000 steps per day (S. Wang et al., 2016).

Third, “eat plenty of fruit, vegetables, and dairy and soy products”; 220-350 grams of fruit is suggested for daily, but this amount of fruit does not include fruit juice

((Food Industry Asia, 2017; S. Wang et al., 2016). The daily amounts of vegetables and milk suggested are 300-500 grams and 300 grams, respectively. Moreover, it is recommended that individuals consume bean products and nuts within an appropriate amount (S. Wang et al., 2016). Fourth, “consume fish, poultry, eggs, and lean meat in moderate amounts”; weekly recommended consumption amounts of fish, poultry, and meat are all 280-525 grams (Food Industry Asia, 2017). Weekly recommended consumption of eggs is 280-350 grams, with no more than 120-200 grams of daily consumption on average (S. Wang et al., 2016). Fifth, “limit intake of salt, oil, sugar and alcohol”; adults are suggested to consume 25-30 grams of cooking oil and less than 6 grams of salt per day (Food Industry Asia, 2017). Moreover, S. Wang et al (2016) summarized that no more than 50 grams of daily sugar should be consumed, and it is best to consume less than 25 grams per day. Additionally, the daily recommended amounts of alcohol are 25 grams and 15 grams for men and women, respectively. Sixth, “develop healthy eating habits and eliminate food waste”; frugality is one of the principles of

Chinese culture, so wasting food is against Chinese culture and is not encouraged. (Food

Industry Asia, 2017).

Dietary Patterns and Diseases

People are now anticipating a longer life. However, the incidence of non- communicable diseases, especially the prevalence of chronic diseases related to the diet, has increased and presents the largest public health burden since poor dietary and physical activity patterns have become more prevalent (HHS, USDA, 2015; Joint

WHO/FAO Expert Consultation, 2003). Approximately half of all American adults (117 millions) have one or more poor dietary patterns and/or physical inactivity that may lead to chronic diseases such as obesity, diabetes, cancer, and cardiovascular disease (CVD).

Evidence shows that healthy dietary patterns have been strongly associated with lower risk of CVD, type 2 diabetes, certain types of cancers, overweight and obesity (HHS,

USDA, 2015). The characteristic healthy dietary pattern in Western countries is rich in vegetables, fruits, legumes, whole grains, poultry, and fish (Berg et al., 2008; Lutsey,

Steffen, & Stevens, 2008; Sonnenberg et al., 2005).

Obesity

“Body mass index (BMI) is a person’s weight in kilograms divided by the square in meters” (National Center for Disease Prevention and Health Promotion, 2016). BMI is used to diagnose obesity; a BMI equal to 30 kg/m2 or larger for adults is defined as obese

(National Heart, Lung, and Blood Institute, 1998). For children and youth aged 2 to 19, obesity is defined as a BMI equal to or larger than the age-specific 95th percentile of the

2000 Centers for Disease Control and Prevention growth chart (Ogden, & Flegal, 2010).

Since 1999-2000, a significantly increasing frequency of obesity was found among

American adults and children and youth groups (Hales, Carroll, Fryar, & Ogden, 2017).

The continued increase in rates of obese populations over decades suggests that many individuals in the United States consume more calories than needed (HHS, USDA, 2015).

According to the National Health and Nutrition Examination Survey (NHNES) 2015-

2016, 39.8% of American adults are obese and 18.5% of American children and youth are obese. More specifically, adults aged 40 to 59 have a higher prevalence of obesity than adults aged 20 to 39 in the U.S. Both non-Hispanic Asian men and women have a lower obesity rate than other races and Hispanic-origin groups (Hales, Carroll, Fryar, &

Ogden, 2017). The prevalence rates of obesity among American adults and children and youth are 9.3% and 4% higher, compared to the goals of the Healthy People 2020 of 30.5% and 14.5% among adults and children and youth, respectively (Office of Disease

Prevention and Health Promotion, 2017). Obesity is associated with many health risks

(NHLBI, 1998), such as type 2 diabetes, hypertension, coronary artery disease, many types of cancer, and cognitive dysfunction (Mitchell, Catenacci, Holly, Wyatt, & Hill,

2011). In addition, children and youth who become obese are beginning to develop health risks of chronic diseases later in life (Freedman, Mei, Srinivasan, Berenson, &

Dietz, 2007). The prevalence rates of type 2 diabetes among obese children and youth are increasing (Fagot-Campagna, et al., 2000); a few decades ago, type 2 diabetes was commonly absent in this age population (Mitchell et. al. 2011). Similarly, studies showed that obese children and youth have a higher risk of CVD (Freedman, et al, 2007;

Freedman, Mei, Srinivasan, & Berenson, 1999).

Energy balance is the key of body weight management. Energy intake of food and energy expenditure of metabolism and physical activity are the two factors that influences the body’s state of energy balance (Hill, Wyatt, & Melanson, 2000; Peters,

Wyatt, Donahoo, & Hill, 2002). When energy intake is greater than energy expenditure, it is called positive energy balance, which results in weight gain. In contrast, negative energy balance is when energy expenditure exceeds energy intake, which results in weight loss. For individuals who want to maintain body weight, daily energy intake needs to equal energy expenditure (Mitchell, Catenacci, Wyatt, & Hill, 2011). In general, energy intake and energy expenditure is affected by genetic, epigenetic, and environmental factors (Bouchard, Perusse, Rice, & Rao, 2004). However, Mitchell,

Catenacci, Wyatt, and Hill (2011) stated that genes are not a major factor of gradual weight gain for individuals. A study reported that 90% of weight gain among adults is caused by an excess energy intake of 100 calories per day or less (Hill, Wyatt, Reed, &

Peters, 2003). Therefore, consuming an appropriate dietary pattern of foods and drinks within an appropriate calorie need is key to stay at a healthy weight (HHS, USDA, 2015).

Another study reported that low income individuals are susceptible to obesity, because inexpensive foods are usually rich in fats and sugars (Drewnowski, & Specter, 2004). In light of high calorie values, fast food also plays a significant role in modern diet, which includes lager amounts of sugar, white flour, trans fat, sodium and food additives while lacking in proteins, vitamins, essential minerals and fiber. Consistently consuming fast food contributes to excess energy, which may contribute to not only obesity, but also diabetes, CVD, cancer, hypertension and hyperlipidemia (Shridhar et al., 2015). In

13 addition, a body of evidence has shown that frequently skipping breakfast is a common unhealthy dietary behavior which may lead to unfavorable consequences (Uzhova et al.,

2017) such as obesity, diabetes, and unfavorable lipid profile (Mekary, Giovannucci,

Willett, Van Dam, & Hu, 2012; Shafiee et al., 2013; van der Heijden, Hu, Rimm, & van

Dam, 2007).

Environment also plays a significant role in weight gain, because of the human biological preferences for energy-dense foods and physical inactivity (Mitchell, Catenacci, Wyatt,

& Hill, 2011). People currently live in an obesogenic environment which promotes this consumption of energy-dense foods and a sedentary lifestyle (Richard, 2015). Our living environment facilitates increased energy intake and decreased energy expenditure, because sedentary lifestyles and large portions of food are abundant (Hill, Wyatt, &

Melanson, 2000; Mitchell, Catenacci, Wyatt, & Hill, 2011). Thus, cognitive effort is required for individuals to remain in control of eating patterns and physical activity and maintain a healthy body weight (Mitchell, Catenacci, Wyatt, & Hill, 2011).

Cancer

“Cancer is a generic term for a large group of diseases characterized by the growth of abnormal cells beyond their usual boundaries that can then invade adjoining parts of the body and/or spread to other organs” (World Health Organization, 2017).

Cancer is one of the leading causes of death worldwide, representing a major public health issue (Fitzmaurice, et al. 2013). In 2015, cancer was the second leading cause of death in the world, which caused over 8.7 million deaths, and 17.5 million cancer cases were diagnosed worldwide (Global Burden of Disease, 2015). In 2017, the American

Cancer Society predicted that approximately 1.6 million new cancer cases will be diagnosed and cancer will cause 600,000 deaths in 2017. The most common cancers among women are breast (25.2%), colorectal (9.2%), lung (8.8%), cervical (7.9%) and stomach cancers (4.8%); whereas lung (16.7%), prostate (15.0%), colorectal (10%), stomach (8.5%) and liver cancers (7.5%) are most common in men (Ferlay et al., 2014;

WHO, 2017).

Cancer is caused by changes in the genes; genetic changes in individuals may be inherited from families or caused by environmental exposure (American Cancer Society,

2016; National Cancer Institute, 2017). Approximately 5 to 10 percent of all cancers are affected by inherited genetic mutations, and TP53, which secretes a protein that inhibits the growth of cancers, is the most commonly mutated gene in all cancers (National

Cancer Institute, 2017). Although a cancer-predisposing mutation may appear in a family, the process by which one person develops cancer and another does not is still unclear

(National Cancer Institute, 2015; National Cancer Institute, 2017). Research has reported that the risk factors that influence whether an individual develops cancer include aging, alcohol and tobacco use, cancer-causing substances, chronic inflammation, diet, hormones, immunosuppression, infectious agents, obesity, radiation, and sunlight

(National Cancer Institute, 2015). Furthermore, higher intake of alcohol is one of most commonly unhealthy dietary consumption behaviors, and alcohol-related dietary patterns are high consumption of spirits and fortified wines, which also have been suggested to increase the risk of oral cavity, pharyngeal, esophageal, colorectal, liver, laryngeal, and breast cancers (Bagnardi, et al., 2015). High alcohol consumption may contribute to high

15 levels of estrogen which generate from reduced metabolic clearance (Shield,

Soerjomataram, & Rehm, 2017). These reactions may cause an increased risk of breast cancer (Shield et al., 2017). Thus, the key to cancer prevention is to reduce exposure to the cancer risk factors (WHO, 2017).

Research has shown that 30 to 50% of all cancers is preventable by reducing exposure to risk factors, which includes lifestyle changes and dietary modifications

(WHO, 2017; Grosso et al., 2017). Dietary change is an important approach to cancer prevention; a diet rich in fruits and vegetables has an independent benefit for cancer control (WHO, 2017). Unhealthy dietary patterns appeared in a trend of relation with higher risk of cancer. In general, unhealthy dietary patterns are related to a larger BMI and excess energy intake, which have potentially mediating effects of obesity in the risk of cancer (Grosso et al., 2017). Unhealthy dietary patterns can be composed of red and processed meats, sweet drinks, salty snacks, starchy foods, and refined grains (Abid,

Cross, & Sinha, 2014). Based on 87 studies, the World Cancer Research Fund and

American Institute for Cancer Research have reported that red and processed meats have been associated with colorectal cancer (WCRF/AICR, 2007). Research concluded that red and processed meats are high in salt, N-nitroso compounds, heterocyclic amines, and heme iron. These compounds, cooked in high temperatures, generate polycyclic aromatic hydrocarbons which have been associated with the carcinogenic effects of meat consumption (Abid et al., 2014). Moreover, healthy dietary patterns rich in fruit, vegetables, legumes, and whole grains have been found to reduce the risk of cancers, especially for colon, breast, and lung cancers (Grosso et al., 2017) because of the

16 substantial amount of antioxidants in these foods, which can counter chronic inflammation and inhibit multiple cancer-related biological pathways (Giacosa, et al.,

2013). High-fiber diets may also have benefits against colon cancer by improving fecal bulking, decreasing transit time and interaction of carcinogens with the colonic mucosa, and acting as a probiotic (Grosso, et al., 2013).

Cardiovascular Disease

CVD is a set of disorders of the heart and blood vessels which contains coronary heart disease, cerebrovascular disease, peripheral arterial disease, rheumatic heart disease, congenital heart disease, and deep vein thrombosis and pulmonary embolism (WHO,

2017). The World Health Organization (WHO) has reported that, in 2015, CVD contributed to 17.7 million deaths globally, which amounted to about 31% of all deaths.

More specifically, CVD is the number one cause of death worldwide; approximately 7.4 million and 6.7 million died from coronary heart disease and stroke in 2015, respectively

(WHO, 2017). Every year, 610,000 people die from CVD and, for both genders, CVD is the number one cause of death in the United States (National Center for Health Statistics,

2015).

The main cause of CVD is atherosclerosis, and atherosclerosis is caused by oxidative stress and inflammation of the arterial wall (Scott, 2004). High blood pressure, high cholesterol, and smoking are the three major risk factors of CVD, and 47% of

Americans are affected by at least one of those factors (Fryar, Chen, & X. Li, 2012).

Additionally, hypertension is a major risk factor of ischemic heart disease, cerebrovascular disease, and cardiac and renal failure (Chockalingam, Campbell, &

Fodor, 2006). The symptoms of CVD vary depending on its type, but the first sign of

CVD is chest discomfort or heart attack (National Center for Chronic Disease Prevention and Health Promotion, 2017).

The prevention of CVD can be achieved via eating a healthy diet, maintaining a healthy weight, being physically active, not smoking, and limiting alcohol intake

(National Center for Chronic Disease Prevention and Health Promotion, 2015). Evidence has shown that diets rich in vegetables, fruits, and fishes were associated to reduce the risk of CVD, while diets high in red and processed meats, refined grains, and fried foods were associated with increased risk of CVD (Wang, Deng, Qu, P. Yang, & Yang, 2014).

Diets rich in vegetables, fruits, fishes, nuts, low-fat dairy products, poultry, and low in fat and sugar are beneficial for reducing blood pressure (Appel et al., 1997). Moreover, A large prospective study has shown that a Mediterranean diet has benefits on inhibiting the production of oxidative stress by providing the necessary anti-oxidants (Trichopoulou,

Costacou, Bamia, & Trichopoulos, 2003). The risk of CVD can be decreased by as much as 30% by reducing low-density lipoproteins (LDL), which is the best treatment for atherosclerosis (Scott, 2004).

Unhealthy diet, physical inactivity, and harmful use of alcohol and/or tobacco are the major behavioral risk factors of heart disease and stroke which may result in high blood pressure, high blood glucose, high blood lipids, and overweight and obesity that facilitates the development of CVD (WHO, 2017). In addition, Uzhova, et. al. (2017) found that unhealthy eating behaviors like skipping breakfast have been associated with an increased risk of atherosclerosis, since breakfast consumption affects satiety, daily

18 energy intake, metabolic efficiency, and appetite regulation, which can all have effects on cardiovascular health.

Osteoporosis

“Osteoporosis is a disease characterized by low bone mass and structural deterioration of bone tissue, leading to bine fragility and an increased risk of fractures of the hip, spine, and wrist” (NIH, 2017). Today, over 200 million people suffer from osteoporosis in the world (International Osteoporosis Foundation, 2017). In the United

States and Europe, over 30% of postmenopausal women population have osteoporosis

(Cooper, Campion, & Melton, 1992). Due to no symptoms of bone loss so people may realize they have osteoporosis until they fall causes a fracture or collapse of vertebra

(NIH, 2017). Every year in the United States there are around 1.5 million incidences of osteoporotic fractures, fractures are very common in the elderly, especially hip fractures in postmenopausal women due to aging (Avenell, Mak, & O’connell, 2014; Moyer, 2013;

Weaver, 2015). According to the research, 50% postmenopausal women will have an osteoporotic fracture during their lifetime. Osteoporotic fractures can contribute to disability or even death, and survivors often have reduced mobility and may need special care (Avenell, Mak, & O’connell, 2014; Moyer, 2013).

The risk factors of osteoporotic can be divided into two groups: risk factors you cannot change and risk factors you can change. The irreversible risk factors are gender, age, bone size, ethnicity, and family history. The reversible risk factors include sex hormone, anorexia nervosa, calium and vitamin D intake, medication use, lifestyle, tobacco and alcohol use (NIH, 2017).

Calcium is the main building block of bone growth, and vitamin D promotes calcium absorption in the intestine and interacts with parathyroid hormone to retain the concentration of serum calcium to allow the normal mineralization of the bone (Avenell,

Mak, & O’connell, 2014; Moyer, 2013; Weaver, 2015). However, Older people usually lack exposure to sunlight and have a low consumption of vitamin D in their diet, so they often have low vitamin D levels (Moyer, 2013). Therefore, it may be beneficial to use vitamin D and calcium supplements to prevent osteoporotic fracture in elders.

Other Conditions

To prevent obesity, cancer, CVD, and other chronic diseases, healthy dietary patterns also have other benefits, such as improving fertility, promoting a healthy pregnancy and lowering the risk of depression (Molendijk, Molero, Sanchez-Pedreno,

Does, & Martinez-Gonzalez, 2017; Skerrett &Willett, 2010; HHS, USDA, 2015). The

Nurses’ Health Study found that avoiding trans fats, including more unsaturated vegetable oils in diet, eating more vegetable proteins, choosing whole grains and other sources of carbohydrates that have lower effects on blood sugar, and consuming low-fat or fat-free dairy products were associated with reduced risk of ovulatory infertility

(Chavarro, Rich-Edwards, Rosner, & Willett, 2007). Healthy dietary patterns also play a significant role throughout pregnancy which can optimize maternal health, decrease the risk of birth defects, promote fetal growth, and prevent chronic diseases in children

(Skerrett &Willett, 2010). Along with this, a study reported that healthy dietary patterns were associated with reduced risk of the onset of depression (Molendijk et al., 2017).

Dietary Patterns

Dietary pattern refers to “the combination of foods and beverages that constitute an individual’s complete dietary intake over time” (HHS, USDA, 2015).

Dietary Consumption Patterns in the United States

Nowadays, the Western diet or standard American diet (SAD) is characterized by excess energy intake from refined carbohydrates, fatty meats, and empty calories found in whole grains, fruits, and vegetables (Grotto & Zied, 2010). In addition, this dietary pattern also contains excess consumption of sodium, which has been associated with many chronic diseases such as overweight and obesity, type 2 diabetes, hypertension and

CVD (Moore, Diez Roux, & Nettleton, 2009; Tucker, 2010). According to USDA’s

Economic Research Service (ERS) (2010), the greatest change in SAD happened in the

1950s; the average daily caloric intake of individuals has changed from 1,900 kcal to

2,661 kcal between late 1950s and 2008, with a 761 kcal increase during 58 years. The greatest increase in daily caloric intake happened from 1970 to 2000.

The biggest increase in total calorie intake since the 1950s is contributed by grains, mostly refined grains, and added fats which increased by 9.5% and 9%, respectively (Grotto & Zied, 2010). Today, Americans’ consumption of total grains almost meets the recommended amounts for all age-sex groups. However, individuals over-consume refined grains, and average consumptions of whole grains are under the recommended amounts in all age-sex groups (HHS, USDA, 2015). From 2011 to 2012, only 1.6% American adults met the recommended daily consumption of whole grain foods (Rehm, Penalvo, Afshin, & Mozaffarian, 2016). However, Nutrition and You 2011

21 has shown that 48% of Americans have increased their whole grain food intake, while 7% of Americans decreased and 45 % of Americans stayed the same (American Dietetic

Association, 2011). Rehm, Penalvo, Afshin, and Mozaffarian (2016) found that the whole grain consumption of American adults is greatly composed of an increase in whole grain breads, pastas, and crackers from 1999 to 2012.

The ERS (2010) found that daily average consumption of fruits among Americans is 0.9 cups, which is under the recommended 2 cups. Specifically, approximately 33% of the consumption of fruit in the U. S. population comes from fruit juice, whereas 66% comes from whole fruits (HHS, USDA, 2015). As a result, the whole fruit consumption in the U.S. population is about 0.6 cups, which only meets 30% of the recommendation.

Kimmons, et. al. (2009) concluded that 8.6% and 12.3% of American men and women, respectively, meet recommended amounts of fruit intake, and 6.2% of adolescents meet the recommendation.

Nutrition and You 2011 has shown that 49% of Americans have increased their vegetable intake, while 6% of Americans decreased, and 45% of Americans stayed the same (American Dietetic Association, 2011). Although many individuals in the U.S. have increased their fruit intake, the baseline for fruit consumption is far under the recommendation. A study concluded that only 7.9% of American adults met the daily recommended amounts of vegetables from 2011 to 2012 (Rehm et al., 2016).

Comparatively, Kimmons, et. al. (2009) concluded that 18.6% and 5.8% of American adults and adolescents meet daily recommended amounts of vegetable intake, respectively. The difference of fruit intakes between these two studies results from the

22 fact that Rehm, et. al. (2016) used American Heart Association (AHA) 2020 Strategic

Impact Goals to assess American dietary intake. Moreover, 21% of all vegetable consumption comes from potatoes, which are starchy vegetables, and tomatoes are another common vegetable that American consumed, accounting for 18% of all vegetable consumption (HHS, USDA, 2015). One of the reasons of high consumption of potatoes and tomatoes is because large supply. Potatoes are the leading vegetable in the U.S. accounted for 15% of farm sales for vegetables, and U.S. is the second tomatoes producers in the world (ERS, 2016).

The most commonly consumed dairy products are fluid milk and cheese, which account for 51% and 45% of total dairy consumption, respectively. The other 4% of dairy consumption comes from yogurt and calcium fortified soy beverages, which compose 2.6% and 1.5% of total consumption, respectively (HHS, USDA, 2015). On average, American adults consume 53.1 kcal and 23.1 kcal from whole milk and low-fat milk per day, respectively, which is about a ½ cup daily consumption (Moshfegh,

Goldman, Ahuja, Rhodes, & LaComb, 2009). Comparatively, ERS (2010) reported that each day Americans consume 1.8 cups of milk or milk products, which amounts to about

60% of the daily recommendation; cheese contributed to 0.69 cups of the daily consumption, and American adults consume 0.03 cups of yogurt daily. Americans’ average consumptions of dairy are far under the recommendations (3 cups) for the

Healthy U.S.-Style Pattern. Furthermore, only most children ages 1 to 3 years’ average dairy consumption meets target amounts (2 cups); all other age groups’ average consumptions are far below recommended amounts (HHS, USDA, 2015). Nutrition and

You 2011 has shown that 17% of Americans have increased their dairy intake, while 22% of Americans decreased, and 61 % of Americans stayed the same (American Dietetic

Association, 2011). The trend of consumption of dairy among Americans continues to decrease.

Overall, Americans’ average consumptions of protein foods meet target the recommended amounts for all age-sex groups (HHS, USDA, 2015). Rehm, et. al. (2016) concluded that milk consumption of American adults decreased by 0.19 servings per day, while cheese and yogurt increased by 0.15 and 0.03 servings per day, respectively.

Specifically, average consumptions of protein foods subgroups are varied. For example, average consumptions of seafood are under recommended levels for all age-sex groups, average consumptions of nuts, seeds, and soy products are close to recommended levels, and average consumptions of meats, poultry, and eggs are high for teen boys and adult men (HHS, USDA, 2015). However, some studies have shown that Americans consume

5.5 ounces of meat and beans daily, which is about 16% more than the suggested amount

(Agricultural Research Service, 2010; HHS, USDA, 2005; USDA, 2010). Beef, chicken, pork, processed meats, and eggs are commonly consumed protein foods in the U.S., the most commonly consumed seafood are shrimp, tuna, and salmon, and the most common nut choices are peanuts, peanut butter, almonds, and mixed nuts (HHS, USDA, 2015).

Americans’ average consumptions of oils are slightly under the recommended levels for almost all age-sex groups (HHS, USDA, 2015). The ERS (2010) reported that

Americans’ average daily consumption of oils contained 71.6 grams of added fats and oils, 59.6 grams of vegetable fats and oils, 9.2 grams of animal fats, and 2.7 grams of

24 dairy fat. A study found that the major sources of oils in American diet are chips, salad dressing, nuts and seeds and their mixed dishes, chicken and chicken mixed dishes, and mayonnaise; and the largest sources of solid fats come from grain-based desserts, cheese, high fat meats, pizza, fried white potatoes, dairy desserts, and whole milk (Bachman,

Reedy, Subar & Krebs-Smith, 2008). The recommendation for a total daily fat intake suggested that most of fat consumption should come from monounsaturated and polyunsaturated fats (HHS, USDA, 2005). Americans’ average consumptions of saturated fats account for 11% of caloric intake, and only 29% of Americans consume saturated fats under the recommended 10 % of total calories. Overall, 35% of all saturated fats come from mixed dishes which include burgers, sandwiches, tacos, pizza; rice, pasta, grain dishes, meat, poultry, and seafood dishes. Moreover, snacks and sweets, protein foods, and dairy products are other major sources of saturated fats (HHS, USDA,

2015).

Added sugars contributed to more than 13% of caloric intake per day—3% more than the recommended less than 10% of total calories (HHS, USDA, 2015). Americans’ daily added sugars intake was 22.2 teaspoons, or about 355 kcal, per person from 2001 to

2004. By contrast, in 2005, the average daily intake of added sugars of Americans increased to 30 teaspoons, which about 120 grams or 477 kcal (Buzby, & Wells, 2008).

The HHS and USDA (2015) stated that beverages are a major source of added sugars in

American diets, which include soft drinks, fruit drinks, sweetened coffee and tea, energy drinks, alcoholic beverages, and flavored waters, and beverages account for 47% of all added sugars consumption in the U.S. Similarly, Popkin (2010) reported that American

25 adults consume 411.6 kcal per day from beverages, and 141.72 kcal come from soda and fruit drinks. Additionally, snacks and sweets are two other major sources of added sugars consumed by the U.S. population, which includes grain-based desserts such as cakes, pies, cookies, brownies, doughnuts, sweet rolls, and pastries; dairy desserts such as ice cream, other frozen desserts, and puddings; candies; sugars; jams; syrups; and sweet toppings.

These foods contributed to more than 75% of total consumption of all added sugars (HHS,

USDA, 2015).

According to the 2,300 mg UL of sodium, 89% of American adults’ average consumptions of sodium are higher than the recommended amount (HHS, USDA, 2015).

A study has shown that only 1.6% of American adults consumed under 2,300 mg of sodium per day from 2011 to 2012 (Rehm et al., 2016). The HHS and USDA (2015) concluded that about 3,440 mg per day is consumed for those ages 1 year and above;

American men have a slightly higher average intake of sodium than American women, which are 4,240 mg and 2,980 mg per day, respectively. Most sodium consumed among

Americans comes from salts added during commercial food processing and preparation; moreover, sodium can be found in almost all food categories, and mixed dishes account for about half of the sodium consumed in the U.S. (HHS, USDA, 2015).

The current dietary patterns indicated that many Americans do not follow the

Dietary Guidelines. Furthermore, most Americans consume enough amounts of most nutrients, but some nutrients are under the EAR or AI levels; these include potassium, dietary fiber, choline, magnesium, calcium, and vitamins A, D, E, and C (HHS, USDA,

2015). Unhealthy dietary patterns are the reasons attributed to low intake of these nutrients.

Dietary Issues Related to Immigrants in the United States

The United States is a diverse nation, 61.3% White, 13.3% Black, 17.8% Hispanic,

5.7% Asian, and 1.5% Native (US Census Bureau, 2017). The number of Chinese immigrants in the United States has increased by 50% since 1990 (US Census Bureau,

2000). In 2003, Chinese immigrants reached about 4.5 million, which accounts for 23.9% of the total Asian American population and the largest Asian population in the U.S. (US

Census Bureau, 2013). Thus, the health status of Chinese immigrants in the U.S. has become an important public health issue (Satia, 2010).

Immigrants undergoing dietary acculturation, which can be defined as “the extent to which immigrants adopt the dietary patterns of their host countries” (Satia-Abouta,

Patterson, Neuhouser, & Elder, 2002), experience critical effects on their diets (Satia et al., 2001; Varghese & Moore-Orr, 2002; Gray et al., 2005; Ayala et al., 2008; Kim et al.

2007). In the meantime, the Chinese population holds different dietary beliefs from

Western people and believe that the traditional Chinese diet is healthier than the typical western diet (Lu, Sylvestre, Melnychuk, & Li, 2008; Kwok, Mann, Wong, & Blum,

2009). Chinese believe in the Yin and Yang system of Traditional Chinese Medicine

(TCM), which has stark differences from the Western system (Harrison, et al., 2005; Lee,

& Shen, 2008; Manderson, 1987). In general, foods can be specified as cold and hot, and need to be consumed in balance to keep one healthy (Harrison, et al., 2005).

The dietary patterns of Chinese immigrants have changed along with living in a different culture country in order to adapt to American culture. With regard to dietary acculturation, several studies have shown that immigrants who have higher scores of dietary acculturations have the benefit of increased fruit and vegetable intake (Lv &

Cason, 2004; Park, Murphy, Sharma, & Kolonel, 2005; Satia-Abouta et al. 2002). A study has shown that traditional Asian diets are high in fruit and vegetables, which may protect from chronic diseases (Patil, Jayaprakasha, & Vikram, 2012). Comparatively, the typical Western diet is rich in red and processed meats, high-fat dairy products, refined grains, sugary drinks and desserts, and low intakes of fruits, vegetables, whole-grain foods, fish, and poultry (Barbaresko, Koch, Schulze, & Nothlings, 2013). Therefore, encouraging immigrants to maintain their traditional diets while adopting healthy eating patterns of the host country would be a useful public health approach (Satia, 2010).

However, it would not be easy for immigrants to maintain their traditional diets in many aspects because of food access and food availability. It is harder to maintain this diet for second-generation immigrants, because they were born and grew up in a different food culture environment. Several studies have proven this; Asian immigrants’ children preferred and consumed more Western foods than traditional foods (Cluskey et al., 2008;

Diep et al., 2015; Lv & Brown, 2010). Similarly, a group of researchers also reported that the longer the first-generation of Chinese immigrants had lived in the west, the less they associated Chinese diets with health. Additionally, those who lived in the west for the longest time consumed larger portion sizes, dined out more often, and used convenience foods more often (Lu, McGinn, Xu, & Sylvestre, 2017). These dietary

28 behavior changes toward a Western diet indicate dietary acculturation. Meanwhile, immigrants experience diet-related disparities, which refer to differences in dietary intake, behaviors, and patterns in different segments of the population, which lead to poorer diets and undesired health outcomes (Satia, 2009). Furthermore, the disease risk of Asian immigrants in the U.S. has increased. Asian Americans born in the U.S. had a higher risk of becoming obese compared to first-generation immigrants, with about the same prevalence of obesity as non-immigrant adolescents (Bates, Acevedo-Garcia, Alegria, &

Krieger, 2008). In addition, Chinese immigrants also have increased risk of CVD

(Lutsey et al., 2008), and obesity (L. Chen, Joun, & Lee, 2012) among their offspring due to dietary pattern changes (Demory-Luce, Morales, & Nicklas, 2005; Diep et al., 2015;

Lv & Brown, 2010). Thus, the problem of dietary change among Chinese immigrants need awareness, since is a critical public health issue.

Dietary Consumption Patterns in China

China is the second largest and most populous country in the world, which has 1.3 billion of people (Zhu et al., 2013). The traditional Chinese diet includes rice, wheat and wheat products, and vegetables with low animal-source foods, and it has been considered an extremely healthy diet (Zhang, Wang, et al., 2015). In general, people from northern

China eat wheat-based foods, whereas people from southern China eat rice-based foods

(Yuan et al., 2017), and staple foods of the traditional Chinese diet are grains and tubers, which compose the major energy source. Chinese cuisine includes frying, but most food is cooked by braising, streaming, and boiling, which gives a lower fat content (Kakde,

Bhopal, Bhardwaj, & Misra, 2016). These healthier cooking methods of traditional

Chinese diet are one of the factors that contribute to its status as a healthy diet. Leonetti, et. al. (2016) reported that, despite equal calories and percentage of nutrients, individuals that are overweight or obese with basic traditional Chinese diet had a greater decrease in

BMI, and the loss of lean body mass (LBM) was significantly lower after 6 weeks of treatment when compared to individuals with a standard Western diet. During weight loss, the loss of LBM was significantly lower in the basic traditional Chinese diet group compared to their counterparts. It indicated that the traditional Chinese diet preserves the

LBM and gives physiological support to obese patients during weight loss. The authors also found that more than 25% of participants of the basic traditional Chinese diet maintained their weight loss after five years of the treatment. The study gave an idea of the efficacy of traditional Chinese diet for maintaining a healthy body weight.

However, over the past decade, Chinese people have experienced significant shifts in their traditional dietary and disease patterns (Zhang, Wang, et. al., 2015). In the mid-1980s, fast food restaurants entered in China, such as Kentucky Fried Chicken

(KFC), Pizza Hut, and McDonald’s. Today there are over 4,800 KFCs and 1,300 Pizza

Huts, and McDonald’s opens 10 new restaurants every week in China (Y. Wang, L.

Wang, Xue, & Qu, 2016). The rapid growth of fast food restaurants in China has shaped a Chinese traditional dietary pattern mixed with an unhealthy Western diet. In addition, in 2004, snacking trended and kept growing; 12.3% and 4.1% of total energy came from snacking among children and adults, respectively (Wang, Zhai, Zhang, & Popkin, 2012).

In addition, cooking methods also were changed; frying increased and replaced steaming and boiling (Wang, Zhai, Du, & Popkin, 2008). It also has been found that there is a

30 significant increase in food diversity in China (Popkin, Lu, & Zhai, 2002). Thus, nowadays many in China are espoused in an abundant food environment, especially composed of empty calories.

Obviously, China is experiencing an extremely fast but undesired shift towards a stage of nutrition transition characterized by a high intake of oils, processed foods, animal products, and a low intake of whole-grain foods, legumes, and other healthy foods

(R. Zhang et al., 2015). Batis, et. al. (2014) reported that the mean total energy intake increase in Chinese residents was 64 kcal per day between 1991 and 2009. Since 1990,

China has entered the later stage of the transition, and, at the same time, chronic diseases started to increase (Du, Lu, Zhai, & Popkin, 2002). There are more than 40 million diabetes patients in China, while there are 200 to 300 million overweight, and 70 million obese people. Among Chinese adults, the prevalence of obesity increased from 7.1% to

11.9%, and the prevalence of hypertension increased from 18.8% to 25.5% between 2002 and 2012 (A. Zhang, Wu, & MacLennan, 2004). The prevalence of diabetes was 2.6% and 9.7% in 2002 and 2012, respectively (N. Zhang, Du, & Ma, 2017). The prevalence of these chronic diseases among Chinese people has increased over time. The problem of increasing prevalence of multiple chronic diseases in China could be due to rapid economic progress and lifestyle changes (Yuan et al., 2017).

Not only are there differences in cooking style and food diversity, but there are differences in intake, as well. Yuan, et. al. (2017) reported that the intake of dairy was low, based on the China Health and Nutrition Survey 2011. Additionally, inadequate dairy intake could be caused by the low supply of dairy products; only 3.5% of the

31 world’s total dairy production in China which was much lower than the average of other developing countries (Y. Wang, & Li, 2007). Moreover, lactose intolerance and lactase insufficiency among the Chinese population is another factor that influences insufficient consumption of dairy products. The prevalence of lactase intolerance is 12.2 %, 32.2%, and 29%, for children ages 3 to 5 years, 7 to 8 years, and 11 to 13 years, respectively

(Yang, et al., 2008). Among Chinese adolescents and adults, the prevalence of lactose malabsorption is 76.4% to 92.3%, respectively. Therefore, for individuals with lactose intolerance, yogurt and lactose-free dairy products are good foods to replace. The low supply of dairy products and high prevalence of lactose-related digestion problems of the

Chinese population contribute to the low intake of dairy in individuals.

In another study, R. Zhang, et. al. (2015), using NHANES 2009-2010 data, found that Chinese participants had lower intakes of fiber, carbohydrates, and proteins when compared to Americans. Also, it was found that fat and cholesterol intakes in Chinese participants were higher than American women, and similar to American men.

Specifically, the total energy from fat was between 33.2% and 41.0%, which was higher than both American females and males. Chinese participants also consumed 13.0% to

15.0% of their total energy from protein, which was lower than Americans’ consumption.

Yuan, et. al. (2017) also found that nearly 60% of the participants in the study did not consume whole grains and mixed beans, and the major consumption of total grains came from refined grains. In addition, the consumption of cooking oils and sodium were moderately and severely higher than recommended levels, respectively.

The current typical diet of the Chinese population was low in fiber, calcium, phosphorus, potassium, selenium, vitamin A, vitamin B1, vitamin B2, and vitamin C; the intakes of sodium, iron, copper, and vitamin E were higher among Chinese participants

(R. Zhang, et. al., 2015). Thus, the structure of the current Chinese diet has been changing away from the traditional diet toward high-fat, low in complex carbohydrate, low in fiber, and low in nutrient-dense foods intakes, but older generations tended to retain the traditional Chinese diets (Zhang, Wang, et al., 2015).

These facts suggested that the dietary intake of the Chinese population has been shifting toward that of Americans, which is generally considered an unhealthy diet (Ogce,

Ceber, Ekti, & Oran, 2008). This could be caused by low prices of animal-sourced foods and oils and income increases (Ng, Zhai, & Popkin, 2008; Popkin & Du, 2003), and cooking and eating behaviors are changing, which includes the decrease in the percentage of healthy food cooking methods, such as steaming, boiling, and baking. In addition, the increase in snacking, fried food consumption, dining away from home, and more available western food choices also are the reasons (Z. Chen, et al., 2006).

College Students

Better food choices and good nutrition are important for many long-term health outcomes (Deshpande, M. Basil, & D. Basil, 2009). Good food choices and nutrition also have independent effects against diseases such as cancer, CVD, and diabetes (Nicklas, et al., 2001). Taste is the first factor that influences people to choose a food (Glanz, Basil,

Maibach, Goldbery, & Snyder, 1998). A study has shown that people establish their food preferences when they are young (Birch, 1999). Thus, childhood, adolescence, and early

33 adulthood are critical periods to establish good eating habits. However, food decisions of children and adolescents are often made by parents (Nicklas et al., 2001). Furthermore, the transition from adolescence to young adulthood is a high-risk period due to poor quality of diet and weight gain (Gordon-Larsen, Adair, Nelson, & Popkin, 2004; Gordon-

Larsen, The, & Adair, 2010; McDade, et al., 2011). Therefore, college life is an important period for young adults who live away from home, become independent, and make their own food choices for the first time (Baker, 1991; Gordon-Larsen, et al., 2004;

Levitsky, Halbmaier, & Mrdjenovic, 2004; Marquis, 2005).

Factors that Influence College Students’ Dietary Patterns

Evidence indicates that the period during individuals’ transitions to college makes their dietary patterns poorer (Grace, 1997). Some studies have found that college students often have poor diets characterized by inadequate fruit and vegetable intake, overconsumption of high-fat and high-calorie foods (Brevard & Ricketts, 1996; Driskell,

Kim & Goebel, 2005; Racette, Deusinger, Strube, Highstein, & Deusinger, 2005), along with high intakes of added sugars (Hirshberg, Fernandes, Melanson, Dwiggins, &

Lofgren, 2011) and sodium (Burke, Reilly, Morrell, & Lofgren, 2009; Irazusta, et. al.,

2007), and low intake of whole grains (Ha & Caine-Bish, 2011; Rose, Hosig, Davy,

Serrano, & Davis, 2007) and fiber (Irazusta, et al., 2007). More specifically, college students consumed 11% more than the recommended 35% of total calories from fat, and

3% more than the recommended 10% calories from saturated fat (Irazusta, et. al., 2007).

Total sugar intake should be less than 10% of total caloric intake, but college students; intake is over 24% (Hirshberg, et. al., 2001; Kobayashi, et. al., 2001). The intake of

34 whole-grains by college students also did not meet the recommendation; they consumed just 10% of the recommended 3 ounces (Ha & Caine-Bish, 2011).

One study found that the dietary habits established in the first two years of college would carry into later college life (Driskell et al., 2005). Importantly, students’ residency affects their dietary patterns and diet-related health (Brevard & Rickets, 1996). The authors found that students living off-campus have higher intake of protein and high cholesterol and serum triglyceride levels. College dining environments play an important role in students’ dietary intake. “All you can eat”-style dining halls lead to larger portion sizes, excessive energy intake, and weight gain (Holm-Denoma, Joiner, Vohs, &

Heatherton, 2008). Furthermore, students now have more options of on-campus restaurants, cafes, and vending machines (Horacek et al., 2013; Levitsky & Youn, 2004).

Similarly, off-campus fast-food restaurants are also widespread, which encourages unhealthy eating behaviors (Horacek et al., 2013). In addition, gender also affects students’ food decisions (Racette et al., 2005). Female college students a have higher intake of fatty foods. Comparatively, another study has shown that female college students are more likely to avoid certain foods than males, because they worry more about weight and health issues (Mooney & Walbourn, 2001). In summary, there are many different factors that influence college students’ dietary intakes. Stress and lack of nutrition knowledge are additional factors that could cause unhealthy eating habits (Barr,

1984; Cartwright et al., 2003; Van den Reek & Keith, 1984). A study conducted by

Martinez, Harmon, Nigg, Bantum, and Strayhorn (2016) concluded that 45% of participants take a nutrition course and 25% taking a cooking lesson in order to eat

35 healthier. However, nutrition knowledge only has modest effects on students’ food choice and behaviors (Crites & Aikman, 2005); one of the reasons may be lack of awareness of dietary recommendations (Health Canada, 2007) and low coping self- efficacy among college students (Matthews, MScFN, & Dworatzek, 2015).

Therefore, the overall features of college students’ dietary intake are consuming excessive calories than needed, overconsuming high-fat and added sugar snacks; frequently skipping meals; low intake of fruits, vegetables, and low-fat dairy products; and practicing unhealthy weight-loss strategies (Ha, Caine-Bish, Holloman, & Lowry-

Gordon, 2009; Hendricks & Herbold, 1998; Levitsky, Halbmaier, & Mrdjenovic, 2004;

Nishida, Uauy, Kumanyika, & Shetty, 2004).

International Students

There were 903,127 enrolled international students out of 20,185,000 total U.S. college student enrollments during the 2016-2017 academic year in the United States (IIE,

2017). In 2017, Chinese students contributed to 32.5% of the total international student population (IIE, 2017). Furthermore, the total number of Chinese students in the U.S. rose from 54,466 to 328,547 from the 1999-2000 to the 2015-2016 academic years, a 503% increase. The continued increase in number of international students studying in the U.S. not only provides international perspectives to universities, but also contributes to a positive economic impact on the U.S. (IIE, 2016). According to the U.S. Department of

Commerce, international students contributed $35.8 billion to the U.S. economy in 2015

(Open Doors Report, 2016).

During the 2016-2017 academic year, 175,695 international students were approved for the Optional Practical Training (OPT) program that allows they work in the

U.S. after graduation (IIE, 2017; Pew Research Center, 2017). According to Pew

Research Center (2017), 68,000 Chinese international students were approved for OPT and found jobs between the years 2012 and 2015. Chinese students are the second largest population of foreign college graduates to stay in the U.S. for working.

Dietary Patterns among International Students

International students face multiple challenges in their host countries, such as learning a new language, adapting to a new culture and lifestyle, and coping with academic pressures that may cause anxiety, stress, sleeping disorders, confusion, and depression (Almohannna, Conforti, Eigel, & Barbeau, 2015). A different food culture is one of the changes that international students have to cope with when they are studying abroad, which may result in changes in their dietary habits. (Satia-Abouta, 2003). This dietary transition among international students is called dietary acculturation, which refers to a process of adapting to a new environment and adjusting to different dietary habits in another country (Satia, 2010). However, these dietary changes of international students in order to adapt to the U.S. culture were associated with unfavorable healthy outcomes, including weight gain, increased blood glucose levels, high blood pressure, diabetes, food neophobia, and mental problems (Alakaam, Castellanos, Bodzio, &

Harrison, 2015; Edwards, Hartwell, & Brown, 2010; Jabber, Brown, Hammad, Zhu, &

Herman, 2003; Mansell, Bennett, Northway, Mead, & Moseley, 2004; McDonald, &

Kennedy, 2005; Rondinelli et al., 2011; Roshania, Narayan, & Oza-Frank, 2008).

A study has shown that the factors that affect dietary changes of international students include food access and availability, individual preference, time, and campus environment (Alakaam et. al., 2015). The authors stated that the busy and unstable schedules of college students are also factors that lead students to consume more convenient and ready-to-eat food. Similarly, campus environment is another major factor that affects students’ dietary pattern changes, especially for students who have a meal plan. Students stated that buffet-style cafeterias on campus made them eat more, which resulted in weight gain (O’Sullivan & Amirabdollahian, 2016; Alakaam et. al., 2015). In addition, fruit and vegetable intake was decreased when international students began studying abroad (Kremmyda et. al., 2008; Perez-Cueto et. al., 2008; Sue, Reeves &

Henry, 2000), while fast foods and confectionery intakes increased (Cappellini & Yen,

2013; Kremmyda et al., 2008). The reasons for increased intake of fast foods are because fast foods are link international students and local dishes (Cappellini & Yen, 2013).

Additionally, the features of fast foods are that they are convenient, cheap, have large portion sizes, and decrease students’ cooking times (O’Sullivan & Amirabdollahian,

2016). Although most of the international students gained weight after coming to study in the U.S. (Kuo, Ebro, Leong, & Warde, 1996; Pan, Dixon, Himburg, & Huffman, 1999), perhaps due to high intake of fast food, it has also been shown that some students experienced weight loss because of irregular dietary patterns, decreased appetite caused by the unfamiliar taste of local food, or lack of cooking skills (O’Sullivan &

Amirabdollahian, 2016). However, the factors that affect dietary changes of international students are complicated. Alakaam, et. al. (2015) concluded that food access and food

38 availability are unique factors that influence international students’ dietary changes. The authors indicated that public transportation to traditional grocery stores is limited, especially for students who do not have a vehicle. In the same light, length of immigration, and economic and employment status also play important roles in food access (Winham, 2009). Food availability can be defined as the availability of quantities of food for individuals on a daily basis near where they live (Yusuf et al., 2001).

However, traditional grocery stores are usually located in major cities which may take two to three hours to reach, and some traditional foods are unavailable or difficult to find in the host countries (Alakaam et al., 2015; O’Sullivan & Amirabdollahian, 2016). These factors all make it difficult for international students to maintain their traditional diets.

Many international students resist changing their diets to a Western diet (Alakaam,

Castellanos, Bodzio, & Harrison, 2015) by preparing traditional meals at home for themselves in order to keep their traditional dietary patterns (Alakaam et al., 2015).

However, O’Sullivan and Amirabdollahian (2016) found that breakfast is a meal commonly skipped by international students. They also found that not only was breakfast skipped, but also any meal of the day could be skipped depending financial issues, busy schedules, personal mood, or lack of space and privacy to cook in a kitchen. Moreover, international students were more concerned about their academic performance, because

Asian international students have greater acculturative stress than European international students in the United States (Kegel, 2009). Therefore, their studies are considered as priority when compared to their diet. Therefore, Asian international students would intentionally skip meals or refuse to cook when they need extra time for school work

(O’Sullivan & Amirabdollahian, 2016). However, a study showed that academic performance is affected by poor nutrition, physical, mental, and emotional problems

(Ansari & Stock, 2010). English fluency was also negatively related to acculturative stress of international students in the United States, while English proficiency appears to be an important factor on homesickness among international students. Additionally, homesickness is the most frequently reported concern of international students in the

United States due to way from family, friends, and a home culture to pursuit degree abroad; 30% of total international students report frequent feelings of homesickness

(Kegel, 2009). Therefore, dietary patterns among international students are not only influence by external environments but also internal environments (psychological and language factors).

Banna, Gilliland, Keefe, and Zheng (2016) conducted a study to compare the perspectives of healthy eating between American and Chinese college students. They found that Chinese students concern more about the timing of meals and digestive health.

These emphases may be impacted by TCM. The Yin and Yang belief of TCM suggested that meals need to be eaten on time because it will help food digest better. Yang increases until noon and becomes weak at dusk. Therefore, it is better for people to eat a light meal at dinner (Jing, 1986). Another reason that digestive health was considered an important part of healthy eating is because of the high prevalence of functional gastrointestinal disorders among college students in China. Study has shown that digestive problems among college students in China are common, including irritable bowel syndrome, functional constipation, and functional dyspepsia (Dong et al., 2013).

There are also some controversial beliefs among college students in China, such as the beauty of thinness. Several studies indicated that many normal-weight Chinese female college students have a strong desire for weight loss, sometimes even to extremely thin and unhealthy weight levels (Madanat, S. Hawks, Campll, Fowler, J. Hawks, 2010; Tao,

2010). The reason for female students to pursue a thin body weight may be due to widespread Western beauty ideals that may led to fear of overeating and fat-phobia on body image (Peat et al., 2015).

CHAPTER III

METHODOLOGY

Research Design

This was a mixed methods study analyzing current dietary intakes and factors that influence the food choices of Chinese international students in Midwest colleges in the

United States.

Research Sample

A convenience sample of both undergraduate and graduate Chinese international students around the Cleveland area were used in this research. Participants were recruited based on current enrollment during the Spring 2018 semester. Inclusion criteria included part-time and full-time undergraduate and graduate Chinese international students in Midwest United States colleges.

Procedures

Participants were Chinese international students attending various colleges around the Cleveland area. Upon KSU’s Institutional Review Board (IRB) approval, an email invitation for in-person interviews was sent out to recruit a total of 454 Chinese international students currently enrolled in the Spring 2018 semester at KSU. Email addresses were obtained from Institutional Research of KSU. Also, the invitation for the survey was posted on China’s social media Wechat in the KSU Chinese students’ chat groups. In addition, face-to-face invitations were given at a local church to recruit 41 42 students who attend other universities in Northeast Ohio. The church administrator was contacted and was asked for permission before the students were invited to participate.

The students who were willing to participate in the study replied to the researcher in person, by email, by phone, or through Wechat. Then the researcher set up an interview time with the students. The interviews were conducted over two weeks with once-weekly email and Wechat reminders sent through the interview period. All interviews were face- to-face and were conducted in the study room of the library at KSU. A closed and quiet study room was chosen as the study setting to provide a comfortable environment for the participants. Participants who complete the interviews were given an option to receive a home-made cookie.

Interview Survey

The survey was included in Appendix A, consisting of three main parts, included general demographics, diet-related questions, and a typical 24-hour day food recall. All interviews were conducted in Chinese, a primary language of the researcher. The data was translated into English by the researcher after interviews were completed.

Part I: General Demographic

General Demographic included general demographic questions, such as age, gender, height, weight, hometown, major, class ranking, and residency. Part I was also include questions about the number of years they have been studying in America, English proficiency, and any weight changes after they came to study in America. There were 16 questions in this part.

Part II: Dietary Intake Information

Part II of the survey included questions about students’ eating and cooking behaviors. Participants in this section answered 19 questions related to their dietary intakes. In this section, participants also answered questions about the factors that influence their diet and barriers for cooking. There were questions that ask participants if they are satisfied with their eating pattern, if they want to change it, and if their diet has previously changed because they studied in the U.S.

Part III: A Typical Day Food Recall

This part of the survey assessed Chinese international students’ dietary intakes by using a typical day food recall. The students were asked all food and beverages they customarily consume within a normal day, including portion size and time of day. In order to help students to identify the portion size, portion size models were provided.

Statistical Analysis

Statistical Package for Social Sciences (SPSS, Version 24) was used to analyze results. Descriptive statistics (mean, standard deviation, frequency distribution, and/or percentages) were used for demographic data, included age, gender, class ranking, and major. Describe statistics also was used for students’ dietary intakes. Food Processor

Nutrition Analysis software of ESHA Research (2011, Version 10.8.0) was used to analyze participants’ nutrients and food groups intake. The factors that influence students’ dietary behaviors were categorized by the researcher.

CHAPTER IV

JOURNAL ARTICLE

Introduction

A healthy dietary pattern is not only essential for promoting current health status, but is also associated with a reduced risk of chronic diseases and maintenance of overall health (U.S. Department of Health and Human Services, 2017). International students accounted for 5.3% of 20.1 million college students enrolled during the 2016-2017 academic year in the U.S. (Institute of International Education, 2017). Furthermore,

903,127 international students studied in the U.S. during the 2016-2017 academic year

(IIE, 2017). In recent years, the largest international student population has been Chinese, which accounted for 32.5% of the total number of international students (IIE, 2017).

2008; Yan, 2015;). As a result of adapting to American culture while living away from their home countries, international students confront multiple challenges including, but not limited to, academic pressures, language barriers, financial stresses, loneliness, homesickness, culture shocks, stereotyping, discrimination, misunderstandings, and 44 45 dietary changes (Lin & Yi, 1997). The factors influencing the dietary changes that international students experience include time constraints, food price, food availability, food accessibility, food storage, food preparation skills, and food environment factors

(O’Sullivan & Amirabdollahian, 2016). Limitations of food availability and food accessibility are unique factors that affect dietary habits of international students

(Alakaam, Castellanos, Bodzio, & Harrison, 2015).

Several studies indicated that international students and immigrants switched their dietary patterns to a typical Western diet the longer they had lived in America (Pan,

Dixon, Himburg, & Huffman, 1999; Rosenmoller, Gasevic, Seidell, & Lear, 2011). These dietary changes include irregular dietary patterns, reduced intake of fruits and vegetables, increased unhealthy food consumption, and frequent dining out (O’Sullivan &

Amirabdollahian, 2016; Almohannna, Conforti, Eigel, & Barbeau, 2015) that may result in unfavorable health outcomes, such as obesity, cancer, cardiovascular diseases (CVD), and diabetes (Gilbert & Khokhar, 2008; Papadaki & Scott, 2002; Alakaam et al., 2015).

The purpose of this study is to understand the current dietary intakes and the factors that influence food consumption choices among Chinese international college students in Northeast Ohio.

Methodology

This was a mixed methods study analyzing current dietary intakes and factors that influence the food choices of Chinese international students in Midwest colleges in the

United States.

Research Sample

Procedures

Participants were Chinese international students attending various colleges around the Cleveland area. Upon KSU’s Institutional Review Board (IRB) approval, an email invitation for in-person interviews was sent out to recruit a total of 454 Chinese international students currently enrolled in the Spring 2018 semester at KSU. Email addresses were obtained from Institutional Research of KSU. Also, the invitation for the survey was posted on China’s social media Wechat in the KSU Chinese students’ chat groups. In addition, face-to-face invitations were given at a local church to recruit students who attend other universities in Northeast Ohio. The church administrator was contacted and was asked for permission before the students were invited to participate.

The students who were willing to participate in the study, they replied to the researcher in person, by email, by phone, and through Wechat. Then the researcher set up an interview time with the students. The interviews were conducted over two weeks with once-weekly email and Wechat reminders sent through the interview period. All interviews were face- to-face and were conducted in the study room of the library at KSU. A closed and quiet study room was chosen as the study setting to provide a comfortable environment for the

47 participants. Participants who complete the interviews were given an option to receive a home-made cookie.

Interview Survey

The survey was included in Appendix A, consisting of three main parts, included general demographics, diet-related questions, and a typical day food recall. General

Demographic included general demographic questions, such as age, gender, height, weight, hometown, major, class ranking, and residency. Part I was also include questions about the number of years they have been studying in America, English proficiency, and any weight changes after they came to study in America. There were 16 questions in this part. Part II of the survey included questions about students’ eating and cooking behaviors. Participants in this section answered 19 questions related to their dietary intakes. In this section, participants also answered questions about the factors that influence their diet and barriers for cooking. There were questions that ask participants if they are satisfied with their eating pattern, if they want to change it, and if their diet has previously changed because they studied in the U.S. This part of the survey assessed

Chinese international students’ dietary intakes by using a typical day food recall. The students were asked all food and beverages they customarily consume within a normal day, including portion size and time of day. In order to help students to identify the portion size, portion size models were provided.

Statistical Analysis

Statistical Package for Social Sciences (SPSS, Version 24) was used to analyze results. Descriptive statistics (mean, standard deviation, frequency distribution, and/or

48 percentages) were used for demographic data, included age, gender, class ranking, and major. Describe statistics also was used for students’ dietary intakes. Food Processor

Results

Out of 454 Chinese international students enrolled in the Spring 2018 semester at

KSU invited to participate in the study, a total of 33 KSU students and 3 students from other universities completed the face-to-face interview, equating to a 7.93% response rate.

Demographics

The demographic data of the participants is highlighted in Table 1. Participants ranged from 20 to 37 years old with a mean age of 25.03 ± 4.1 years (n=36).

Approximately, 41.7% (n=15) of the participants were females and 58.3% (n=21) of the participants were males. In addition, 47.2% of the participants were undergraduate students while the remaining 30.6% and 22.2% were masters and doctoral students, respectively. Table 1 and Table 2 show the general demographics and characteristics of the participants, respectively.

Table 1

General Characteristics of the International Chinese Students Enrolled in a Northeast Ohio University (n=36)

Characteristic n n (%)

Hometown East China 13 36.1

South China 5 13.9

Central China 2 5.6

North China 6 16.7

Northwest China 2 5.6

Southwest China 3 8.3

Northeast China 5 13.9

Total 36 100

Residency On campus 2 5.6

Off campus 34 94.4

Total 36 100

Do you have a car? Yes 19 52.8

No 17 47.2

Total 36 100

Table 2

Academic Characteristics of the International Chinese Students Enrolled in a Northeast Ohio University (n=36)

Characteristic n %

Class rank Freshman 2 5.6

Sophomore 7 19.4

Junior 2 5.6

Senior 6 16.7

Master 11 30.6

Doctoral 8 22.2

Total 36 100

College Engineering 5 13.9

Arts & Sciences 11 30.6

Business 8 22.2

Education, Health & Human 5 13.9 Services

Communication & Information 2 5.6

The Arts 4 11.1

Digital Sciences 1 2.8

Total 36 100

Dietary Patterns and Weight Changes

Chinese international students in the study reported that their food intake has changed since they came to the United States. They have changed intake of beverages, fruit, vegetables, meats, fast foods, as well as sugary desserts. This section also describes how the Chinese international students in the study expressed their opinion in food in the

United States. In addition, the majority of students reported that they have experienced weight changes since they came to study in the United States.

Eating pattern. About 52.8% (n=19) of students reported that their eating patterns became irregular since they started studying in the United States. They skipped more meals than before, mostly breakfast, and ate at irregular times more frequently than before. They stated that they had irregular eating pattern mostly due to their busy schedules. A female sophomore student who has stayed in the United States for 1 year and 6 months said:

“I had three meals a day in China. Now I have switched three meals to two meals a day and have adopted irregular meal times due to my class schedule.”

A male master student who study in the United States for 6 years and 7 months said:

“My eating pattern has become irregular since I came to United States due to my busy schedule.”

Another male master student who has stayed in the United States for 6 years and 6 months said:

“I often skip meals and only eat two meals a day. I eat more noodles than rice compared when I am in China because cooking noodles is more convenient.”

Fruit, vegetable, and meat consumption. There were 25% (n=9) of participants who stated their fruit intake has increased while 19.4% (n=7) of participants have decreased their fruit intake since they came to study in the United States. Specially, among nine students who answered that they increased fruit intake, five said that they intentionally ate more fruits because they concerned their health. In the meantime, two out of seven participants who reported that their fruit intake decreased stated they did not eat as much fruit as before due to limited variety of fruit. Along with this, 22.2% (n=8) of participants stated their vegetable intakes have increased while 8.3% (n=3) of participants claimed they have decreased their vegetable intakes. A half of students who reported increase in vegetable intake stated that health concern was the reason why they ate more vegetables than before they came to the United States. There were 25% (n=9) of participants increased their meat intake and only one participant said his meat intake has decreased because he is too lazy to cook meat and thinks cooking meat is complicated and time-consuming. A female sophomore student said:

“It is inconvenient for me go to grocery stores so I buy a lot of vegetables and fruits every time my friends give me a ride to the grocery store. Fruits and vegetables are

53 easy go bad. Then I eat fruit as snack every day and my intake of vegetables and fruit has increased compared to when I was in China.”

A senior student said:

“I ate a lot of fast foods and frozen foods when I just came to study in the United

States. Now, I pay more attention to health so I eat more fruit and vegetables. However, my meal portion sizes are bigger.”

A female music major master student who came to the United States six months said:

“I eat less fruit and more meat than before. I feel I need to eat meat every day to prevent me from having a lack of energy.”

Consumption of low nutrient dense food and beverages. There were 44.4%

(n=16) of participants that stated their intake of fast food has increased since they came to study in the United States. Furthermore, 11.1% (n=4) of participants have increased their chips and sugary desserts intakes such as cheese cakes, chocolates, cookies, and ice creams. There were 27.8% (n=10) of participants that reported increase in coffee intake while 36.1% (n=13) of participants that reported increased soda intake since they came to

United States. Six participants that reported they increased both in coffee and soda intake.

Moreover, there were eight out of thirteen participants who reported have increased soda intake also increased in fast food intakes because fast food combos always come with

54 soda. The increased consumption of milk and juice were 6.7% (n=6) and 11.1% (n=4) of participants, respectively. A male sophomore student said:

“I drink more coffee and soda, and eat more fast food than before. I drink soda with every meal.”

Another male sophomore student said:

“I did not drink any coffee in China but now, I drink a lot of coffee”

A male freshman student who has stayed in the United States for five years said:

“I eat a lot of fried foods and fast foods since I came to study in the U.S. and now

I drink soda every day.”

Perception of American food environment. There were 36.1% (n=13) of participants who suggested that the types of foods offered are limited in the United States compared to that of China. Five participants among these thirteen participants stated that the types of fruits and vegetables offered are limited. In addition, 11.1% (n=4) of participants mentioned that foods in the U.S. were too oily. A male freshman student said:

“I feel like foods are too oily here and it is not healthy so I remind myself to eat one or two fruits a week which I do not usually eat in China.”

A male doctoral student who has been studying in the U.S. for six and a half years said that:

“Food variety is limited in the U.S. and there are not many choices for me, especially vegetables.”

Cooking behavior change. There were 16.7% (n=6) of participants who mentioned that their cooking behaviors have changed. Five of them stated that they cooked more often than before, and one said that his cooking skill has improved. A male sophomore student said:

“I lived on campus at the first year. It was inconvenient to cook and go to grocery stores because I do not have a car. Now I have a car and live off campus which allows me to cook at home and go to grocery stores more often.”

Weight change. About 44.4% (n=16) of the participants reported they gained weight since they came to study in the United States while 27.8% (n=10) lost weight.

Only one participant in the study reported that he has not noticed any weight change since studying in the United States. Rest of nine students reported weight fluctuation about 13.9% (n=5) of participants experienced weight loss first, later they gained weight.

On the other hand, 11.1% (n=4) of the participants experienced weight gain first then they tried losing weight intentionally.

In addition, there were twelve participants who mentioned that they gained weight within the first year studying in the United States because of increased intake of fast foods, low nutrient dense foods and frequent dining out. Their weight gain ranged from

3.5 to 18kg (7.7 to 40lbs) with an average 7.6kg (16.7lbs). The mean BMI of the

56 participants was 22.5 ± 3.8 with more than half of the participants (66.7%, n=24) reporting a BMI in the normal range of 18 to 24.9. A male doctoral student said:

“I have lost 5.5 pounds in the first two month in the United States. However, I ended up gaining 17 pounds in the first year because I ate too much fast foods and drank too much soda.”

A nutrition major master student said:

“Every time I return to America after spending time at home, I lose weight because I am too lazy to cook for myself and I do not eat much foods.”

A female freshman student said:

“I drink and eat a lot of soda, juice, coffee, chips, and cookies. I have $1800 meal plan for one semester which lets me eat larger portions of food in the buffet style dining hall and increase fast foods intake at Kent State.”

Dietary Practice

This section described how the Chinese international students in this study experienced dietary practices at home or outside of the home and accessed traditional

Chinese foods and snacks. They also reported their food intake, food choice, and food preference. More importantly, participants indicated if they were satisfied with their current dietary patterns.

Access to traditional Chinese food and snacks. About 77.8% (n=28) of the

57 participants reported bringing traditional Chinese foods when they first came or returned to the United States after they went home over the breaks. There were 94.4% (n=34) of the participants who purchased traditional Chinese foods in the United States. Of this number, one of 34 participants reported the only foods she bought were Chinese snacks because of her limited cooking skills. Another individual of the 34 only purchased

Chinese frozen foods due to a lack of cooking skills. The remaining two of the total participants did not purchase any traditional Chinese foods since they lived on campus and never cooked in their dorms. Almost every participant bought Chinese vegetables that included napa, baby bok choy, daikon, tofu, enoki, bean sprouts, and dried mushroom; frozen foods such as dumplings, steam buns, fish balls, and wontons; and traditional Chinese noodles, seasonings and spices. Moreover, two students indicated that they cooked Chinese dishes using American ingredients. A male senior student said:

“I like Chinese foods more than American foods, so I usually eat rice and noodles at home. But I often eat sandwiches for breakfast because it is easy to make. I usually buy napa, baby bok chop, fish balls, traditional noodles, seasonings and spices from the

Chinese traditional grocery stores. I also use American foods to cook Chinese style dishes such as stir fried bacon with vegetables.”

A master student said:

“My husband is Italian. Our meals are mixed with Chinese and Italian dishes. I also go to Chinese grocery stores, and I usually buy napa, baby bok choy, bean sprouts, and traditional Chinese noodles. However, the types of food available is limited in the

U.S so we usually use American ingredients to cook Chinese and Italian dishes.”

Staple foods. The majority of staple foods participants usually eat at home were

Chinese foods. Students stated that they frequently consumed rice and traditional Chinese noodles at home due to their personal preference and dietary customs (75%, n=27).

Furthermore, about 11.1% (n=4) of the participants reported that they consumed more noodles than rice compared to when they were in China. Dumplings, wontons, and steam buns were minor Chinese staple foods that they consumed at home. American food items that students frequently ate included sandwiches, breads, pastas, pancakes and oatmeal.

Approximately, 16.7% (n=6) of the participants who reported they usually ate sandwiches as breakfast to save time. Steaks were another American food students often ate at home (22.2 %). It appeared that students changed their staple diet intake mostly due to time and convenience. A male doctoral student said:

“I usually eat noodles and rice at home because I used to eat them. And I eat more noodles than before and eat less rice compared to when I was back home. I also eat some American foods at home such as breads and steaks.”

A female master student said:

“I usually eat noodles at home because I do not like to eat rice. Sometimes I make pancakes as breakfast. I often eat sandwiches for breakfast because it is easy to make.”

Snacks. On the average, students consumed snacks 1.56 (SD±1.11) times per day.

Seventy five percent (n=27) of the participants ate fruits as snacks. Nuts, ice creams,

Asian cookies, American or Chinese brand chips, and traditional Chinese snacks such as dried fruits, dried shredded squid, and Sachima were also the most popular snacks that were consumed by the participants. In addition, about 13.9% (n=5) of the participants stated they did not eat any snacks daily. A female junior student said:

“I eat snacks one to two times every day and I usually eat fruits such as bananas, watermelons, and plums, Chinese brand crackers, Chinese rice crackers, and Chinese bear cookies.”

Dining out. The number of times participants dine out per week ranged from 0 to

14 with a mean of 4.4 ± 3.7 (n=36). Approximately, 80.6% (n=29) of the participants reported that they usually went to Chinese restaurants when they dined out because of their personal preference and they thought Chinese food was relatively healthier compared to American food. Fast food restaurants such as McDonald’s, Burger King, and Wendy’s were the secondary choice for the international students (30.6%, n=11).

Another place that students often visited was school dining services (19.4%, n=7) included Subway, Auntie Anne’s and Einstein Bros. The students who reported to eat at those fast food restaurants said that they went those places because it is convenient and save time. Students chose to dine out in the dining halls on campus because they were close, convenient, and time saving. Mexican food, American restaurants such as steak houses, and other Asian restaurants such as Japanese food, Korean food, Thai food, and

Vietnamese food were other minor restaurants that students would go to for dining out.

Some students thought that Subway and Chipotle are relatively healthy because their

60 meals are combined with meats and vegetables. In addition, two of the participants reported they usually do not eat outside of the home. A male master student said:

“Now, I do not eat outside of the home. When I did dine out before, I used go to

Chinese restaurants or eat on campus such as Subway and Fresco.”

Another male master student said:

“I dine out about seven to eight times per week. I usually go to Chinese restaurants or Subway because I like Chinese food, and I think Subway is healthy because every time I order whole wheat bread and add vegetables into my sub.

Sometimes, I also go to fast food restaurants such as Five-guys because it is delicious.”

A female sophomore student said:

“Every week I go out to eat about 14 times. I usually go to Chinese restaurants because I think Chinese food is healthy. I also frequently eat fast food because of limited time. I go to steak houses to treat myself if I have time.”

A female junior student said:

“I dine out about four times a week. I usually go to food stores on campus such as Subway, Auntie Anne’s or Kent-market because they are close. Sometimes I also go to Chinese restaurants because they taste good and the prices are not expensive.”

Perception of current dietary pattern. Almost half of the participants stated that they were satisfied with their current diet because they thought their diets were healthy, they were not picky eaters, or they had access to Chinese food (47.2%, n=17). To contrast, about 52.8% (n=19) of the participants reported they were not satisfied with their current diet. They believed they ate too much fast food, deep fried food and meats, lacked time to cook, their meal patterns were irregular, and there were not many food choices in the United States compared to in China. A male sophomore student said:

“I am not satisfied with my current diet because I do not have enough time to cook a good meal for myself. Also, food types are too limited in America.”

A male doctoral student said:

“I am satisfied with my current diet because I think I get enough nutrients from my diet. I do not spend too much time to prepare my meals so, I have enough time to study. I am satisfied with it.”

Dietary Intake Assessed by a Typical Day Food Recall

A typical day food recall for each participant in this study showed calorie, macronutrients, micronutrients, and MyPlate intakes among international Chinese students in Northeast Ohio.

Macronutrients. The average of daily calorie intake of the participants was

2088±611 Kcal with a range from 1109 to 3464 Kcal. In addition, half of the participants

(n=18, 50%) only consumed 51-75% of their recommended daily calories, and about 28% of the participants consumed recommended daily calories between 76-100%.

Furthermore, 17% of the participants consumed over the recommended daily calories.

This indicated that most students did not meet their recommended calorie needs. The mean of daily protein intake of the participants was 103±39 grams, carbohydrate was

291±90 grams, and fat was 59±27 grams. More specifically, almost every participant consumed more than recommended protein needs (n=35, 97.2%). About half of the participants (n=17, 47.2%) consumed under 75% of recommended carbohydrate needs, and 14% of the participants exceeded recommended amounts. Over half of the participants consumed under 75% of recommended fat intake (n=22, 61.1%). At the same time, a quarter of the participants consumed more than the recommended fat intake

(n=9, 25%). Moreover, only13.9% of the participants consumed more than recommended saturated fat amounts.

Vitamins. The average of vitamin A intake of the participants was 913±741mg.

About 39% of the participants’ vitamin A intakes were under 75% of the recommended amounts, and 41% of the participants exceeded recommended needs. The average of vitamin B1 intake of the participants was 1.3±0.6mg. Over half of the participants consumed vitamin B1 in amounts greater than recommended (n=22, 61.1%). The average of vitamin B2 and B3 intake of the participants were 1.8±0.9mg and 19.2±10mg, respectively. Also, 72% and 58% of the participants exceeded recommended amounts of vitamin B2 and vitamin B3, respectively. Over 80% of the participants consumed greater than recommended amounts of both vitamin B3 Niacin E Equiv (n=31, 86.1%) and vitamin B6 (n=29, 80.6%). The average of vitamin B3 Niacin E Equiv and B6 intake of

63 the participants were 29.8±15.9 mg and 2±0.9 mg, respectively. The average of vitamin

B12 intake of the participants was 3.5±2.4 mcg. Moreover, 67% of the participants consumed more than the recommended amounts of vitamin B12. Over half of the participants consumed less than 75% of the recommended amounts of Biotin (n=19,

52.8%). One-third of the participants consumed under 75% of the recommended amounts of vitamin C (n=11, 30.6%), and over half of the participants consumed greater than the daily recommendations (n=24, 66.7%). Over 90% of the students consumed less than 75% of recommended amounts of vitamin D (n=34, 94.4%). No students met the recommendation of daily vitamin E intake. Over half of the participants consumed under

75% of the recommended daily vitamin K intake (n=20, 55.6%).

Minerals. The average of calcium intake of the participants was 802±447mg.

Half of the participants consumed under 75% of the recommendation of daily calcium intake, and one-third of the participants exceeded the recommended amounts. The average of copper and iron intake of the participants were 1.05±0.5 mg and 14.9±5.04 mg, respectively. Further, 55.6% of the participants consumed more than the recommended amounts of both copper and iron. The average of selenium intake of the participants was

81±49 mcg. Over half of the participants consumed more than the recommended amounts of selenium (n=24, 66.7%). The average of zinc intake of the participants was

10.4±5.6 mg. One-third of the participants consumed less than 75% of the daily recommendations of zinc (n=13, 36.1%), whereas over half of the participants consumed more than the recommended amounts (n=19, 52.8%).

Food groups. According to MyPlate, 52.8% of the participants consumed less than recommended grain intake, and 44.4% of the participants consumed more than recommended grain intake. The average of grain intake of the participants was 9.4±4.9 oz. In vegetable group, 69.4% of the participants consumed less than recommended vegetable intake. The average of vegetable intake of the participants was 2.7±1.7 cups.

Also, 63.9% of the participants (n=25) consumed less than recommended fruit intake.

Surprisingly, 8 out of those 25 students did not consume any fruits. The average of fruit intake of the participants was 2.3±2.8 cups. In the meantime, 88.9% of the participants

(n=32) consumed less than recommended milk intake. More importantly, 17 out of those

32 students did not consume any milk products. The average of milk intake of the participants was 1±1.3 cups. Finally, 61.1% of the participants consumed more than recommended meat and bean intakes, and 38.9% of the participants consumed less than recommended meat and beans intake. The average of meat and beans intake of the participants was 9.2±5.3 oz.

Factors Influence Food Choice and Cooking Practice

This section described the factors influencing students’ food choices and the frequency of cooking. Figure 1 and Figure 2 show factors that influence the food choices and cooking practice among Chinese international students in the U.S. respectively.

Food choices. Price, time, taste, convenience, nutrition concerns, dietary habit, food availability, and cooking skills are the main factors influencing Chinese international students’ food choices. Over half of the participants (55.6%) reported that

65 time was the major reason affecting their food choices. Nutrition concerns and tastes were the second main reason influencing food choices among students (36.1%).

Convenience was another key factor that impacted participants’ food choices (30.6%).

Students indicated convenience was referred to if foods were easy to prepare or if the distance of access to food was close. About one third of students (30.6%) stated their dietary habits affected their food choices. It appeared that students were willing to stick to the diet that they customarily consumed in home country. Food availability and cooking skills also played important roles in students’ food choices. Some students

(27.8%) stated that variety of food items were limited in the U.S. and they did not have access to Chinese foods they wanted. There were 13.9% of the participants who reported that they were not good at cooking which limited their food choices. They tended to purchase the foods that they know how to prepare. A female master student said:

“The most important factors that influence my food choices are food availability and time. I only know how to cook some dishes so my cooking kills also limited my food choices.”

A male sophomore student said:

“The most important factors that influence my food choices are taste, time, distance, and calories.”

The average food budget among Chinese students was 416.7 dollars (SD=163.4) per month. Specifically, over half students (58.3%, n=21) had monthly food budget between 400 and 600 dollars. One third of the participants (33.3%, n=12) reported that their food budget ranged from 200 to 350 dollars per month. Even though most

66 participants reported that their monthly food budget was enough (88.9%), many students mentioned that food price affected their food choices (30.6%). About 22.2% (n=8) of participants suggested that the overall food price in America was cheaper than in China while 30.6% (n=11) of participants thought American food price was more expensive than China’s. There were 19.4% (n=7) of participants who reported that they were not familiarized with China’s food prices because they did not do grocery shopping back home. There were 55.6% (n=20) and 52.8% (n=19) of participants who suggested that the price of vegetable and fruit in America is more expensive than in China, respectively.

About 16.7% (n=6) of participants mentioned that dining out is expensive in the United

States compared to in China. In addition, 41.7% (n=15) of participants suggested that

American meat price is cheaper than China’s while 25.0% (n=9) of participants thought the prices of meat in two countries are about the same. More importantly, 63.9% (n=23) of participants suggested that food price would not affect their purchase because it is affordable and not necessary to save money on food. At the meantime, 36.1% (n=13) of participants said that the price of food did affect their purchases, because sometimes they chose cheaper substitutes. A male sophomore student said:

“Fruit and vegetables are more expensive in the U.S. but meat is cheaper. The price of food does affect me in purchasing. I buy more meat because is cheaper compared to fruit and vegetables.”

A female senior student said:

“The price of grocery food is okay but dining out is expensive in the United States.

Fruit also is a little bit expensive. The price of food sometimes does affect types of food

I purchase, for example, I will buy other fruit instead of strawberry if it is expensive.”

Factors that influence international Chinese students' food choices 25 20 20

15 13 13 11 11 11 10 10 5 5

Number of the participants

Figure 1. Factors that influence International Chinese students’ food choices

(N=36)

Cooking practices. The number of times participants cooked per week ranged from 0 to 21 with a mean of 6.8 ± 5.1 (n=36). Along with this, 50% of the participants

68 reported they cooked seven or greater times per week. In addition, 25% of the participants indicated that they cooked three or less meals per week. There were 29 participants who prepared meals for themselves, and two freshman participants who never cooked at home due to living on campus, which lacks the facility and space to cook.

The remaining five participants’ meals were prepared by their family, boyfriends, girlfriends, or roommates. A female junior student said:

“I cook about 11 times per week for myself.”

A male doctoral student said:

“My roommate usually prepares meals for me and I cook only 4 or 5 times a week for myself.”

When they were asked, what is the reason that make they cannot cook more often.

The majority of the participants reported they did not have time to cook meals for themselves (72.2%). Personal mood like laziness also played a role in cooking practice among students. One third students said that personal mood made them not willing to cook. Therefore, Laziness was the second big factor that prevented students from cooking (n=30.6%). Students also reported that academic stresses caused exhaustion so they were not able to cook as much as they wanted (13.9%). Some participants stated that preparing Chinese meals was time-consuming which made them difficult to cook

(11.1%). Furthermore, 8.3% of students mentioned that they did not want to wash dishes

69 which made them unwilling to cook more often, and they cooked one big meal and eat leftovers for a few days. A female doctoral student said:

“Time availability limited me to cook more often. Also, every time I prepare meals, I cook a lot. So, I can eat leftovers for one or two days.”

Cooking skills, food availability and food access also affected cooking practice among Chinese students. There were 16.5% of the participants who indicated they were not good at cooking which discourage them to cook. Some students said that the foods they wanted were not available in the U.S., which made them less motivated to cook

(8.3%). A male sophomore student said:

“It is time-consuming to cook. Food types are limited here, so sometimes I do not want to cook and I want to dine out. Also, I do not like to wash dishes. All of these reasons made me not want to cook.”

Factors that influence international Chinese students' cooking practices 30 26 25

15 11 10 6 5 4 5 3 3 3

Number of the participants

Figure 1. Factors that influence international Chinese students’ cooking practice

(N=36)

Discussion

The primary purpose of this descriptive study was to understand dietary intake and influential factors on food consumption choices among Chinese international students in the United States. Study results indicated that: 1) almost every student has experienced weight changes and dietary changes, including changes in intake of fruit,

71 vegetables, meat, fast food, soda and coffee and 2) there were many factors that influenced food choice and cooking practice among international Chinese students, such as food price, food availability, time, convenience, distance, dietary habit, cooking skill, laziness, and stress.

Dietary and Weight Changes

Irregularity in eating patterns was one of the most remarkable characteristics of dietary intake among international Chinese students. Students trended to skip meals, mostly breakfast; this result mirrors findings from a study that found that the most commonly skipped meal by international students was breakfast (Edwards, Hartwell, &

Brown, 2010). Students also skipped lunch and dinner; they reported that this behavior depended on their schedules or personal mood. Moreover, students reported that they more frequently ate at irregular times due to their busy schedules. However, past studies found that frequently skipping meals characterized college students’ dietary intake due to their work and school schedules (Halbmaier, & Mrdjenovic, 2004; Nishida, Uauy,

Kumanyika, & Shetty, 2004), and this behavior is not only found in international students.

Frequently skipped meals are a feature of college students’ eating habits maybe due to their busy schedules.

In this study, one quarter of the students increased fruit intake, while about 20% of the participants reported they decreased the intake of fruits. In the same way, more than 22% of students that increased their vegetable intakes and less than 10% of the participants decreased vegetable intake. These findings do not agree with past research on consumption of fruits and vegetables among international students, which found that

72 international national students decreased their fruit and vegetable intakes when they started to study abroad (Alakaam, Castellanos, Bodzio & Harrison, 2015; Hartwell &

Brown, 2010). This study clarifies that participants that increased fruit and vegetable intake cited health concerns as their rationale, while the limited types of vegetables and fruits students could obtain was a major reason that caused the participants that decreased their vegetable and fruit intakes to do so. The participants stated that they started to pay more attention to nutrition because they were getting older, and theirs was the critical age to become more concerned about nutrition and health.

One quarter of the participants claimed they consumed more meats in the U.S. compared to when they were in China. This result may be explained by the belief of over

40% of the participants that the meat prices in the U.S. are cheaper than those in China.

Furthermore, fast food and soda consumption increased after Chinese international students began studying in the United States. These findings were consistent with a previous study examined by Alakaam et al. (2015), Cappellini and Yen (2013), and

O’Sullivan and Amirabdollahian (2016). Fast food acted as a bridge between students and soda intake. This study has shown that students who increased intake of fast food also have increased soda intake because soda always comes with fast food combos; participants who had busy academic schedules increased their fast food intakes, mostly for convenience or to save time. In addition, more than half of the participants reported weight gain since they began studying in the United States, and most of the students in the study gained weight within the first year of their study in the United States. This finding could be a result of increased intake of fast food and low nutrient dense food, and

73 frequent dining out. This finding is accordant with past research by Pan, Dixon, Himburg, and Huffman (1999), which observed that Asian students changed their eating patterns toward a typical Western diet after living in the United States. However, high intakes of fast food and soda were also found in other college student populations (Halbmaier, &

Mrdjenovic, 2004; Nishida, Uauy, Kumanyika, & Shetty, 2004); therefore, it is a common feature of American college students’ dietary intakes.

It should be noted that high intake of meat, fast food, soda, and low nutrient dense food, along with being overweight, increases the risk of chronic diseases. Several studies have shown that chronic disease risk in Chinese immigrants has increased due to lifestyle changes after immigration (Rosenmoller, et al, 2011; Yu et al., 1991). Moreover, past research has reported that dietary changes may result in unfavorable health outcomes among Chinese immigrants; Chinese immigrants in the U.S. have higher risks of heart diseases and some cancers than those living in Asia (Campbell, Parpia, & Chen, 1998;

LeMarchand, Wilkens, Kolonel, Hankin, & Lyu, 1997). Specifically, the risk of colorectal cancer among Asian immigrants has increased significantly in the U.S.

(LeMarchand et al., 1997), and subsequent generations of Asian immigrants have a higher prevalence of obesity compared to first-generation immigrants (Bates, Acevedo-

Garcia, Alegria, & Krieger, 2008). In this study, many participants have experienced weight gained and switched their diets toward American diet after studying in the United

States. All of these are the risk factors of developing chronic diseases. Therefore, the improvement of international students’ diets is urgent and necessary.

Dietary Analysis

According to participants’ 24-hour food recall, 80.6% of the participants did not consume enough recommended calorie needs. This may be due to over one-third of the participants (38.9%, n=14) skipped meals, and half of them skipped breakfast.

Inadequate energy intake of the participants caused them to not meet their needs of other nutrients such as vitamin D, vitamin E, Biotin, and calcium. High protein intakes were found among the international Chinese students’ food recall, 97.2% of the participants consumed more than recommended protein needs. This may be linked to students reporting that they consumed more meat since they came to study in the U.S. because the price of meat is cheaper compared to in China. Moreover, 88.9% of the participants consumed less than recommended milk intakes. This finding could be a result of high prevalence of lactose intolerant and lactase insufficient among Chinese population. Yang, et. al. (2000) reported that among Chinese adolescents and adults, the prevalence of lactose malabsorption is 76.4% to 92.3%, respectively. In addition, 50% of the participants consumed under 75% of the recommendation of daily calcium intake.

Inadequate milk and calcium intake of the participants who are physical inactivity due to sedentary lifestyle. It may increase the risk of osteoporosis in the long run. Further, 44.4% of the participants (n=16) consumed less than the recommended amounts of iron.

Surprisingly, 15 out of those 16 participants are females. This finding could be a result of women of reproductive age have the highest probability of suffering iron deficiency due to their inadequate intake during stage of high iron demand (Abbaspour, Hurrell, &

Kelishadi, 2014).

Factors that Influence Food Choices

Overall, numerous factors influenced food choices among Chinese international students in the United States; major factors are time constraints, nutrition concerns, tastes, food prices, convenience, dietary habits, food availability, cooking skills, and food access.

These findings are consistent with past research studies which examined international students’ dietary intake in the UK and the U.S. (Alakaam, et al., 2015; O’Sullivan &

Amirabdollahian, 2016).

O’Sullivan and Amirabdollahian (2016) found that the major reasons for time restriction among international students are busy class schedules and assignments. The current study discovered that fast food restaurants were the second choice after Chinese restaurants by the participants when they were dining out. Moreover, time constraints may play an important role in leading students to choose the food that is most convenient to prepare and consume. This result can possibly explain that convenience and saving time are the reasons that students choose fast food restaurants. At the same time, health concerns act as underlying factors for food choices among the participants. Despite the awareness of nutrition concerns, students prioritize their study over their diet. Hartwell,

Edwards, and Brown (2011) found that international students stick to their dietary habits and food culture by preparing traditional food on their own. The same result occurred with the participants of this study; students brought traditional ingredients from China when they first came to the U.S. or every time they went back to China over the breaks.

They also trended to eat in Chinese restaurants when they dined out and frequently

76 purchased traditional Chinese food from Chinese grocery stores. It appears that students still stick to the diets that they consumed in China and are not willing to change their diets.

Furthermore, this study revealed that limitations in food availability and access are unique factors that influence Chinese students’ food choices in the U.S. This finding is in line with a past study examined by O’Sullivan and Amirabdollahian (2016). Many participants have repeatedly mentioned the limitations of food availability and food access of traditional Chinese foods, which limited their food choices and affected dietary practices and satisfaction of their current diets. In conclusion, time, nutrition concerns, taste, food prices, convenience, dietary habits, and food availability and access are the major factors that influence the participants’ food choices.

Factors that Influence Cooking Practices

Several factors that affected cooking practices among Chinese international students included time constraints, leftovers, laziness, academic stress, and time- consuming preparation of Chinese meals. Overall, students cook traditional Chinese meals at home and occasionally make some American dishes such as pasta and steaks.

Some students also shift towards American breakfasts due to time and convenience reasons. Students stated that American-style breakfast sandwiches were easy to prepare and did not require any cooking methods. This finding is consistent with past research that found international students decreased in cooking frequency and consumption of their traditional diets, and shifted toward an American diet by increasing consumption of fast food and frequently dining out (Almohanna et al., 2015).

Time constraints also acted as a major reason that affected the participants’ cooking frequency. It should be noted that in the present study, academic stress is one of the reasons that caused students to cook less on their own. Moreover, the participants living away from China and studying in the U.S. confront language barriers, which may worsen their academic stresses (Almohannna, Conforti, Eigel, & Barbeau, 2015). In addition, personal moods like laziness played an important role in cooking practice among students. Laziness has repeatedly been mentioned by students as a reason which made them unwilling to cook. As stated above, leftovers can have an important impact on students’ cooking frequency. This study found that most students prepare meals for themselves often by cooking a big meal, and therefore leftovers from the last meal decreased the frequency of cooking of students. Frequently eating the same foods can be healthy, but if these meals are not well balanced, this may lead to insufficient intake of certain nutrients due to limited exposure to a variety of foods. In addition, certain nutrients, like water-soluble vitamins, are lost when food is reheated several times.

This study discovered a unique factor that influence Chinese international students’ cooking practices; many students reported that preparation of traditional

Chinese meals is time-consuming, which obstructed them from cooking more frequently on their own. In this study, students cooked more noodles than rice for their staple diets.

They stated that cooking noodles was less time-consuming compared to rice, because they would need to cook at least one or more accompanying dishes to serve with rice.

Therefore, constraints, academic stresses, and laziness caused the participants cook fewer rice-based traditional Chinese meals for themselves at home. To the author’s knowledge,

78 there are currently no other research studies that have examined cooking behavior among international students in the U.S.; more study is needed in the future.

Limitations

As with any study, there are limitations that exist within this study. The first limitation was that all the themes in this study were coded, categorized, and analyzed by a researcher, which could affect the reliability of findings. Another limitation of this study was the validity and reliability of the questionnaire, which utilized questions that were developed by the researcher. Therefore, the validity and reliability studies on the questions have not been evaluated. The third limitation of this study was that the data was self-reported, and therefore the validity of the responses cannot be determined.

Finally, the participants and the researcher speak English as a second language. The interviews were conducted in Mandarin, and therefore analyzing and translating data limits the ability of the researcher to fully express the participants’ thoughts and opinions in English.

Implications

This study explores the current dietary intake and factors that influence the food choices among Chinese international students in the United States. In this current study, more than half of the participants were not satisfied with their current diet in the United

Sates. The present findings could have practical implications by informing universities to improve their food environments. A healthy food environment will not only beneficial for Chinese international students but also other students. Therefore, this research suggests that university dining services should offer a wider variety of healthy foods and

79 more dietary options for international students, such as Chinese or Asian vegetables for

Chinese or other Asian students. In this study, the most common Asian vegetables that the participants bought were napa, baby bok choy, daikon, tofu, enoki, bean sprouts, and dried mushrooms. A recent study found that international students increased frequency of fast food consumption, dining out, and skipping meals, and experienced weight gain which could potentially have an adverse impact on their health if continued long-term

(Almohanna et al., 2015). Additionally, the largest international student population is

Chinese in the U.S., but universities do not typically offer traditional Chinese food.

Therefore, this is extremely important both for freshmen who have a meal plan and must eat in the dining halls and for students who do not know how to cook or are not good at cooking. For these groups, there are fewer options for them to adhere to their traditional diets. In this study, nutritional concerns were a major factor that influence students’ food choices. Therefore, providing effective nutrition education, offering cooking classes, and familiarizing international students to American ingredients may be important and necessary. However, limited research has been conducted in cooking practices among

Chinese international students, highlighting the need for future research.

Conclusion

Although most research studies reported that fruit and vegetable intakes decreased while fast foods and sugary food intakes increased among international students as they studied abroad (Perez-Cueto et. al., 2008; Sue et. al., 2000; Cappellini & Yen, 2013;

Kremmyda et al., 2008). Moreover, dietary patterns among international students are influenced by external environments and internal environments such as psychological and

80 language factors (Kegel, 2009). The findings from this study show that Chinese international students had irregular eating patterns, skipped meals, and ate at irregular times since they came to the United States. More students increased their fruit and vegetable intakes than decreased them. Many students increased intakes in meat, fast food, low nutrient dense foods, soda, and coffee. More importantly, about 70% of the participants have experienced weight gain since they came to study in the United States.

The most important factors that influenced food choices among Chinese international students were time, nutrition concerns, taste, food price, convenience, dietary habits, and food availability and access. Time constraints, leftovers, laziness, academic stress, and time-consuming preparation of Chinese meals were the major factors that influenced the participants’ cooking practices.

APPENDICES

APPENDIX A

INTERVIEW SURVEY

Appendix A

Interview Survey

I. General demographics

1. What is your age? ______

2. What is your gender? ______

3. What is your height in centimeters? ______cm (_____ in)

4. What is your current weight in kilograms? ______kg (____ lb)

5. Where is your hometown (province and city)? ______

6. What is your major? ______

7. What is your class ranking?

 Freshman ___  Sophomore ___  Junior ___  Senior ___  Master ___  Doctoral ______ Other ___

8. How long have you been studying in the U.S? ______years

9. How would you describe your English proficiency?

 Below average ___  Slightly below average ___  About average ___  Slightly above average ___  Above average ___

83 84

10. Do you live on or off campus? ______

11. Do you have roommates? If you do have roommates,

 How many do you have? ______

 Are they Chinese, American, or other? ______

12. Have you noticed that your weight has changed since you came to study in

America? If yes, how did it change?

______

13. When you go to grocery stores, how do you get there?

 Driving own car ______ Getting a ride from a friend/roommate ______ Taking a bus ______ Walking ______

14. How often do you go back to China? ______

 Do you bring any traditional Chinese food items with you when

you return to the U.S.? ______

15. Do you currently take any dietary supplements? (If yes go to #16) ______

16. What kind of dietary supplement are you taking? ______

a. How often do you take it? ______

b. How much do you take each time? ______

c. Why do you take it? ______

II. Dietary Intake Questions

1. Are you on a meal plan at school? If yes, what type of meal plan are you on?

2. How much is your food budget every month? Is it enough to buy foods you want

to eat?

3. What do you think about the cost of food in the U.S. compared to China? Fruits,

vegetables, and meats (cheaper or more expensive)? Does it affect types of food

you purchase?

4. Have you changed your diet since leaving home to study in the United States? If

you have, how did you change your diet?

5. How many meals (breakfast, lunch, and dinner) do you have each day during

weekdays (Monday- Friday)?

6. How many meals (breakfast, lunch, and dinner) do you have each day during

weekends (Saturday and Sunday)?

7. How many times do you eat snacks each day?

8. Who usually prepares meals for you?

9. On average, how many times do you usually cook for yourself per week?

10. If you want to cook more often, what is the reason that makes you cannot cook

more often?

11. Do you usually eat meals with anybody?

12. What types of food do you usually eat for meals at home? Chinese or American?

Why?

13. What types of snack do you usually eat? Why do you choose them?

14. On average, how many times do you dine out per week?

15. What type of food do you usually eat when you dine out? Chinese or American or

other? Why?

16. Do you buy any traditional Chinese foods? What kinds? Why and why not?

17. What is (are) the most important factor(s) that influence your food choices?

18. Are you satisfied with your current diet? Why and why not?

19. Do you want to change your diet? Why and why not? If yes, how do you want to change your diet?

III: A Typical Day Food Recall

I will ask you about all foods and beverages you usually eat within a normal day,

including breakfast, lunch, dinner, and snacks. You will also be asked about any water

and beverages you consume at times other than meal and snack times. In order to help

you identify the portion size, portion size models will be provided.

Time Meal/Snack Food Item and Detail Cooking Portion Where Food is (time Method Size Prepared you (Cup, (Home/Dorm, usually tbsp) Packaged, eat) Restaurant)

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