The Influence of U.S. Chain Restaurant Food Consumption and Obesity in China and South Korea: an Ecological Perspective of Food

Health Communication

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Kevin B. Wright, Raphael Mazzone, Hyun Oh, Joshua Du, Anne-Bennett Smithson, Diane Ryan, David MacNeil, Xing Tong & Carol Stiller

To cite this article: Kevin B. Wright, Raphael Mazzone, Hyun Oh, Joshua Du, Anne-Bennett Smithson, Diane Ryan, David MacNeil, Xing Tong & Carol Stiller (2016) The Influence of U.S. Chain Restaurant Food Consumption and Obesity in China and South Korea: An Ecological Perspective of Food Consumption, Self-Efficacy in Weight Management, Willingness to Communicate About Weight/Diet, and Depression, Health Communication, 31:11, 1356-1366, DOI: 10.1080/10410236.2015.1072124

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Download by: [Liverpool John Moores University] Date: 14 November 2016, At: 04:19 HEALTH COMMUNICATION 2016, VOL. 31, NO. 11, 1356–1366 http://dx.doi.org/10.1080/10410236.2015.1072124

The Influence of U.S. Chain Restaurant Food Consumption and Obesity in China and South Korea: An Ecological Perspective of Food Consumption, Self-Efficacy in Weight Management, Willingness to Communicate About Weight/Diet, and Depression Kevin B. Wright, Raphael Mazzone, Hyun Oh, Joshua Du, Anne-Bennett Smithson, Diane Ryan, David MacNeil, Xing Tong and Carol Stiller Department of Communication George Mason University

ABSTRACT This study examined the impact of U.S. chain restaurant food consumption in China and South Korea from an ecological perspective. Specifically, it explored the relationships among several environmental and individual variables that have been found to affect obesity/weight management in previous research, including the prevalence/popularity of U.S. chain restaurants in these countries, frequency of U.S. chain restaurant food consumption, self-efficacy in weight management, willingness to communicate about weight/diet, self-perceptions of weight/obesity stigma, body mass index (BMI), and depression. The results indicated that willingness to communicate about weight/diet predicted increased self-efficacy in weight management. Higher BMI scores were found to predict increased weight/obesity stigma, and increased frequency of U.S. restaurant food consumption, weight/obesity stigma, and reduced self-efficacy in weight management were found to predict increased levels of depression. The theoretical and practical implications of the findings are discussed, along with limitations and directions for future research.

Industrial business expansions have not only led to a global cultural dietary practices (Arcan et al., 2013;Hicksonetal., economy, but also to cross-cultural immersion and cultural 2011). adaptation to new global influences that can affect indivi- One particular new market that has experienced a simul- duals at a variety of levels, including their health (Naor, taneous growth in U.S. chain restaurants and obesity in recent Linderman, & Schroeder, 2010). One particular manifesta- years is Asia, particularly China and South Korea (Ji & Cheng, tion of this phenomenon is the expansion of the U.S. chain 2008; Kim, Park, Kim, Kim, & Park, 2006; Reynolds et al., restaurant industry to numerous developed and developing 2007; Shi, Lien, Kumar, & Holmboe-Ottesen, 2005; Wang countries. According to Belk (1996), “With Ronald et al., 2007). In both countries, the preferred diets of people McDonald leading the way, multinational consumer goods have rapidly shifted in recent years from traditional meals corporations are now breaking down international barriers (often consisting of lower fat vegetables and fish) to calorie- that have withstood armies, missionaries, crusaders, and dense, high-fat food, especially food consumed at U.S. chain politicians of the past” (p. 25). restaurants like McDonald’s and Kentucky Fried Chicken For generations Americans have lived with the U.S. chain (DeVogli, Kouvonen, & Gimeno, 2014; Ji & Cheng, 2008; restaurant industry, and in recent years researchers have Kim et al., 2006; Reynolds et al., 2007). explored the negative health implications associated with a However, food consumption behaviors are highly com- diet overly reliant on the types of food that these restaurants plex and result from the interplay of multiple influences typicallyoffer(Dunn,Sharkey,&Horel,2012; Fleischhacker, across different contexts. An ecological approach to studying Evenson, Rodriguez, & Ammerman, 2011; Lee, 2012). Most food consumption/diet behaviors can be a helpful perspec- U.S. chain restaurants tend to serve large portions of calorie- tive for understanding this type of issue, since such dense and/or high-fat-content food, which has been linked approaches examine relationships among variables at multi- to numerous health problems, including heart disease, can- ple levels, including connections between individual psycho- cer, and type 2 diabetes. Despite thesenegativehealtheffects, logical and communication traits that may influence diet/ the availability and reach of the U.S. chain restaurant indus- weight control behaviors (such as weight self-efficacy or try are larger than ever, expanding to new markets interna- willingness to discuss diet/weight control), as well as envir- tionally and offering potential alternatives to traditional onmental factors, such as barriers to healthy lifestyle

CONTACT Kevin B. Wright, PhD [email protected] Department of Communications, George Mason University, Robinson Hall A, Room 307B, Fairfax, VA 22030, USA. © 2016 Taylor & Francis HEALTH COMMUNICATION 1357 practices and cultural influences on diet/exercise (Glanz, cost-prohibitive (James, 2008). This often leads to the Rimer, & Viswanath, 2008;Kingetal.,2011;Stokols,1996). increased consumption of unhealthy, calorie-dense foods, The purpose of this study was to examine the impact of U. such as what is available in chain restaurants, and often S. chain restaurant food consumption from an ecological considered an easier and more affordable option. perspective in China and South Korea. Specifically, it explores McDonald’s, Burger King, Pizza Hut, and Kentucky Fried the relationships among several environmental and individual Chicken (KFC) are among the most popular U.S. chain res- variables that have been found to affect obesity and weight taurants globally, including in countries such as China and management, including the prevalence and popularity of U.S. Korea (DeVogli et al., 2014). In addition, aggressive marketing chain restaurants in these countries, frequency of U.S. chain strategies associated with these chains often lead individuals, restaurant food consumption among consumers, self-efficacy especially children, to consume these unhealthy foods in large in weight management, willingness to communicate about quantities (Freedman, 2011; Green, Riley, & Hargrove, 2012). weight/diet, self-perceptions of weight/obesity stigma, body mass index (BMI), and depression. Toward that end, the Health risks of obesity following sections review literature on global obesity and This rapid increase of overweight and obese individuals glob- health risks, the influence of U.S. chain restaurants globally, ally has had many adverse effects, including serious long-term and theory and research regarding self-efficacy in weight health risks such as heart disease, stroke, hypertension, and management, willingness to communicate about health, orthopedic issues (Green et al., 2012; WHO, 2014). Moreover, weight/obesity stigma, and depression (and the relationships obese individuals have an increased risk of breast, ovary, and among these variables). This is followed by a report of a thyroid cancer, infertility, Type 2 diabetes, hypertension, survey of U.S. chain restaurant food consumption and these stroke, and coronary artery disease Janssen, Katzmarzyk, & variables among individuals living in China and South Korea. Ross, 2004; Kopelman, 2007) compared to people with a Finally, we discuss the theoretical and practical implications normal weight. When measuring body mass index across of the study findings, limitations of the study, and directions cultures, a BMI of 25 kg/m2 is typically deemed high risk, for future research. and there has been a sharp increase in high BMI levels globally in recent years (Zhang and Wang, 2012). Environmental influences on obesity As globalization has continued to expand, food consumption has changed throughout the world. U.S. chain restaurant Global obesity health risk food is becoming more popular, leading to higher risk of

The rise of global obesity Western health problems (Hawkes, 2005). Within the last decade, individuals in many countries, including China and The rise of obesity in China and South Korea parallels the South Korea, have seen an increase in prevalence of diabetes larger trend of increased obesity rates worldwide. Obesity has and complications associated with this disease (Yach, Stuckler, become a severe global health issue (in both undeveloped and & Brownell, 2006). The World Health Organization (WHO) developed countries) and it has increased steadily in recent has warned that the obesity epidemic and diabetes will likely years (World Health Organization [WHO], 2014). In 2014, continue to affect Asian countries, including China and South more than 1.9 billion adults, 18 years and older, were over- Korea, more, as new cases of such illnesses are projected to weight. Of these, more than 600 million were obese. Of adults grow to hundreds of millions in the next 20 years (Prentice, aged 18 years and over, 39% were overweight in 2014, and 2006). 13% were obese (WHO, 2014). The majority of the world’s population lives in countries where being overweight or obese kills more people than underweight. Even developed countries, such as China and South Korea, have seen a significant Global influence of U.S. chain restaurants increase in the average body weight that can be attributed to Children in countries outside of the United States can recog- Western-style (primarily U.S.) dietary practices (DeVogli nize the image of a fast food brand for McDonald’s or KFC as et al., 2014; Han, Powell, & Kim, 2013; Reynolds et al., 2007). easily as a child within the United States because it carries a common meaning, despite some local nuances. Food market- Causes of obesity ers are well versed in reaching children and youth, and they There appear to be many causes of the obesity epidemic, with recognize the importance of establishing brand loyalty on the most prevalent being lifestyle and environment, including future food purchasing behavior (Arredondo, Castaneda, the introduction of high-calorie/fat fast food into global mar- Elder, Slymen, & Dozier, 2009). Fast food is a multi-billion- kets via U.S. chain restaurants (James, 2008). Of course, other dollar industry with considerable influence on what and how factors have contributed to obesity worldwide, including peo- people eat. In the United States, fast food chains have grown ple becoming less physically active in many countries as from a $6 billion per year industry in 1970 into a corporate changes in the economies have altered the nature of work juggernaut with more than $170 billion in annual revenues from physical work to more technology-assisted work, today, mainly due to expansion into newer markets such as increased time in front of the computer, using transportation China and South Korea (Bernstein, 2011). China in particular instead of walking, and other factors. In urban settings around has been a lucrative market in recent years due to the growth the world, people often lack healthy food options, especially in of its economy. McDonald’s has 35,000 restaurants in 118 locations where healthier food options are difficult to find or countries and KFC has 18,875 restaurants in 118 countries, 1358 K. B. WRIGHT ET AL. and many of these restaurants are in China and South Korea of overweight individuals in China increased (Hawkes, 2005). (Bernstein, 2011). McDonald’s now has more than 1,600 restaurants in China (Ji & Cheng, 2008), and there are large numbers of other well- known U.S. restaurant chains in China, including KFC, Pizza Affluence, social status, and U.S. chain restaurant food Hut, and Burger King. consumption According to Hill et al. (2003), obesity doubled among There appears to be a link between rising affluence, food Chinese women and almost tripled among men from 1989 consumption patterns, and obesity on a global scale. As to 1997. Wang et al. (2007) showed that the rate of obesity countries acquire greater wealth, U.S. restaurant chains in China rose from 1992 to 2002 according to either the tend to appear as investors hope to capitalize on emerging WHO standard (from 14.6 to 21.8%) or the China domestic markets. These restaurant chains have become extremely standard (from 20.0 to 29.9%). One study found the pre- popular in many countries around the world, but they valence of obesity in China was 16.1% in men and 37.6% in have also led to a number of health problems. For example, women, with links to increased diseases such as stroke, Eric Schlosser, author of Fast Food Nation: The Dark Side of hypertension, type 2 diabetes, and coronary heart disease the All-American Meal, argues that the arrival of (Reynolds et al., 2007). The prevalence of childhood obesity McDonald’s in 1971 in Japan caused a major shift in in China reached 32.5% in males and 17.6% in females in Japanese eating habits. During the 1980s, as the sale of U. the northern urban area where this research was conducted. S. chain restaurant food in Japan doubled, the rate of Similarly, Wang et al. (2007) reported an increase in the obesity among children also doubled. Today about one- prevalence of hypertension and chronic disease related to third of all Japanese men in their thirties are currently diet and exercise changes in China. Ding and Malik (2008) overweight. Similarly, in recent years, in countries such as found that the change to a high-glycemic-index diet China and Korea, there has been increased reliance upon U. (including U.S. fast food chain consumption) has contrib- S. chain restaurants and there have been rapid increases in uted to increasing type 2 diabetes and cardiovascular risks the rates of obesity (Ji & Cheng, 2008;Kim,Ahn,&Nam, in China. Twelve percent of China’s adult population (114 2005; Popkin, Adair, & Ng, 2012). million) have weight-related diabetes, causing complications One key issue appearing to fuel the popularity of U.S. such as cardiovascular and kidney disease, which experts say restaurant chains is the high social status that is associated is a rising epidemic (Reynolds et al., 2007). with them. In many countries around the world, individuals Much of this change in obesity rates has been attributed to

perceive that having the means to eat at restaurants like dietary and lifestyle changes involving the influence of U.S. McDonald’s, Pizza Hut, KFC, and so on is a sign of prosperity fast food chains, as well as increases in television viewing and and higher social status (Park, 2004; Shi et al., 2005). In lack of exercise. Cheng (2003) and Ji and Cheng (2008) linked addition, in many countries, it is considered “hip” among Chinese youth obesity to U.S. chain restaurant food consump- younger people to consume food from U.S. restaurant chains tion. These researchers found that more than half of the (Park, 2004). In China, young people have been reported to students in their sample reported liking U.S. chain restaurant bring a significant other to chain restaurants such as KFC to food. In addition, researchers have found that eating at U.S. propose marriage or engage in other activities that many restaurant chains in China is associated with wealth and people in the United States would reserve for a more expen- higher social status (Shi et al., 2005; Zhou & Hui, 2003). sive restaurant. South Korea The prevalence of obesity in South Korea has risen, particu- Prevalence of U.S. food chains, obesity, and health larly in the younger population, where cardiovascular disease problems in China and South Korea is one of the leading causes of death (Kim et al., 2006). In As we have seen, the prevalence of U.S. restaurant chains in 1995, the Ministry of Health and Welfare began conducting China and South Korea appears to be largely due to the standardized national nutrition surveys at 3-year intervals. healthy economy within these countries and the desire of U. According to this data, the prevalence of obesity in adults S. fast food chain investors to capitalize on these lucrative and children increased rapidly from 1995 (13.9%) to 2001 Asian markets. These countries have simultaneously wit- (31%). Over the last 30 years, traditional Korean diets, based nessed an increase in obesity among their respective popula- largely on vegetables and fish, have slowly shifted from car- tions, as well as obesity-related health problems. This section bohydrates to fat. More young people are migrating from briefly explores literature related to U.S. restaurant chain food rural to urban areas, where U.S. restaurant chains are highly consumption and its link to health problems in China and prevalent (Kim et al., 2005; Kim, Moon, & Popkin, 2000). South Korea. Estimates of food-away-from-home consumption reached $60 billion in 2009, up from $48 billion in 2004—although this China figure does not differentiate between fast food and full service The emerging economy and the introduction of U.S. chain restaurants. Recent studies focusing on TV advertisement restaurant food have contributed to obesity problems in exposure have found an increase in fast food product adver- China (Hill, Wyatt, Reed, & Peters, 2003). After China tisements, especially among children (Han, Powell, & Kim, adopted an “open door” policy during the 1980s to embrace 2013). Studies have also found that South Koreans associate foreign economic investment and connections, the prevalence U.S. restaurant chains with greater affluence and social status HEALTH COMMUNICATION 1359

(Anholt, 2005; Park, 2004), and this helps to justify the Willingness to communicate about weight/diet increased costs of eating at U.S. fast food chains (i.e., Willingness to communicate about health issues has been McDonald’s) over eating at traditional Korean restaurants. identified as a communication trait in which people vary in their willingness to discuss their health concerns with health Individual variables influencing diet choices and care providers and members of their social network (Wright, obesity Frey, & Sopory, 2007). This concept has is related to larger theoretical work on willingness to communicate as a trait that In addition to larger global influences, researchers have iden- has been found to influence a variety of behaviors across a tified a number of individual-level variables that affect diet variety of cultures (McCroskey, 1992; McCroskey & choices and obesity. This section discusses theory and Richmond, 1990). Willingness to communicate about health research regarding several key individual-level variables that includes disclosing sensitive information about their lifestyle appear to play an important role in managing weight, as well behaviors that may put them at risk for disease. It has been as negative outcomes related to obesity, across cultures. found to be related to both information-seeking behaviors and patient assertiveness (Wright & Frey, 2008; Wright Self-efficacy in weight management et al., 2007), and it has been linked to a number of other behaviors, including seeking social support, provider–patient Several scholars have extended Bandura’s(1977)moregeneral interaction, health information seeking, and everyday conver- theory of self-efficacy into the more specific area of health- sations about health issues (Cline, 2003; Wright & Frey, 2008; related self-efficacy, or an individual’s belief in his or her ability Zolnierek & DiMatteo, 2009). Willingness to communicate to perform and succeed when confronting challenging situa- about health has also been studied within the context of tions. Health self-efficacy has been identified as an important specific health conditions, such as hypertension, HIV preven- individual-level barrier that has been linked to a variety of tion, organ donation, and sexual health (See Canzona, 2015; health behaviors (Bandura, 1990;O’Leary, 1985; Roach et al., Crowell, 2004; Morgan & Miller, 2002). 2003; Strecher, DeVellis, Becker, & Rosenstock, 1986). As far as Moreover, previous research suggests that willingness to the current study is concerned, health-related self-efficacy has discuss certain health issues, including weight and obesity, also been examined within the context of obesity and weight may vary due to cultural norms (Morgan, Miller, & control (specifically labeled “self-efficacy in weight manage- Arasaratnam, 2003; Naik, Kallen, Walder, & Street, 2008). ment”) in prior research (King et al., 2010; Linde et al., 2004; Yet prior research on willingness to communicate about

Wolff & Clark, 2001), and it has been found to be a strong health has not examined this concept within countries such predictor of dietary and weight control behavior (Roach et al., as China and South Korea, although it may influence an 2003). Self-efficacy in weight management has been conceptua- individual’s ability to obtain health information and social lized as a person’s perception that he or she has the ability to support for weight and obesity issues. Previous studies suggest control intake of high-calorie foods, resist eating such foods, that willingness to communicate about weight/diet issues may and/or maintain a healthy weight by engaging in exercise in be an important communication variable to assess, particu- addition to restricting food intake and calorie consumption larly in cases where the cultural norms regarding discussion of (Clark, Abrams, Niaura, Eaton, & Rossi, 1991). weight, diet, and obesity are relatively understudied, such as Numerous studies have identified self-efficacy in weight within China and South Korea. While previous work has not management (including one’s ability to resist fast food and focused on willingness to communicate about weight/diet eating at chain restaurants like McDonald’s) as an important issues specifically, it is likely that the predisposition willing- psychological variable that is related to obesity (French, Story, ness of communicate about weight/diet would follow patterns Neumark-Sztainer, Fulkerson, & Hannan, 2001; King et al., similar to those of other health issues. 2010; Roach et al., 2003; Wolff & Clark, 2001). Researchers have found that people with lower levels of self-efficacy in weight management are more likely to be overweight (Marcus Stigma associated with weight/obesity and depression et al., 1990; Musante, Costanzo, & Friedman, 1998; Wolff & Clark, 2001). Moreover, a number of studies have also linked The study of stigma and health issues has been of interest to low self-efficacy in weight management to increased depres- social scientists for decades, particularly in terms of how sion (Cargill, Clark, Pera, Niaura, & Abrams, 1999; Fairburn various stigmatized health conditions (including obesity) are et al., 1998; Linde et al., 2004; Musante et al., 1998). For the associated with outcomes such as increased stress and depres- purposes of the current study, this prior research suggests that sion (See Ablon, 1981; Link & Phelan, 2006; Puhl & Heuer, self-efficacy in weight management may be an important 2010). Health-related stigma appears to be a global phenom- individual-level variable to assess since it is important pre- enon that often leads to increased depression and discrimina- dictor of one’s ability to resist high calorie foods (such as U.S. tion against individuals living with stigmatized health restaurant chain food), and it is related to obesity and depres- conditions, including in Asian countries (Ustiin et al., 1999). sion. However, previous research has not examined self-effi- Negative attitudes toward overweight individuals appear to be cacy in weight management within the context of U.S. chain widespread, and obese people often suffer discrimination in restaurant food consumption or in countries such as China multiple aspects of their lives (Puhl & Brownell, 2001; Wott & and South Korea, or how it may be related to depression Carels, 2010). For example, in addition to experiencing nega- among people within these countries. tive physical health consequences, overweight and obese 1360 K. B. WRIGHT ET AL. people also face problems in their social relationships, includ- studies have not examined these variables together in a single ing encountering prejudice, discrimination, and poor treat- study or from an ecological or communication perspective. ment from others. Research indicates that experiences with Therefore, the current study posed the following hypotheses weight stigma have a significant negative psychological and research questions: impact, including increased depression and body dissatisfac- tion, as well as lower self-esteem (Wott & Carels, 2010). H1: Increased willingness to communicate about weight/diet Weight stigma appears to be quite common, and it has been will be predictive of increased self-efficacy in weight linked to psychological distress and depression in several management. studies (Puhl, Moss-Racusin, & Schwartz, 2007; Wott & Carels, 2010). Although health-related stigma has not been H2: Increased social status associated with eating at U.S. looked at specifically within the context of obesity among chain restaurants will be predictive of decreased self-efficacy Chinese and Korean citizens, prior research has identified in weight management. obesity as a stigmatized health condition among Asian Americans that has been linked to depression and discrimina- H3: Increased BMI will be predictive of increased self-per- tion (Gee, Spencer, Chen, & Takeuchi, 2007). In the current ceptions of weight/obesity stigma. study, the researchers were interested in depression as an important outcome variable since it can lead to other pro- H4: Controlling for exercise frequency, increased U.S. chain blems related to weight control. For example, depression restaurant food consumption, and self-perceptions of weight/ associated with weight stigma has also been linked to lower obesity stigma will be predictive of increased depression, self-efficacy in terms of engaging in exercise and weight con- while increases in self-efficacy in weight management will be trol (Schmalz, 2010; Seacat & Mickelson, 2009; Vartanian & predictive of decreased depression. Novak, 2011). In other words, individuals who feel stigmatized by others for being obese tend to feel that exercise will RQ1: Does the popularity of U.S. restaurant chains differ by not help them lose weight, and they tend to overeat or engage country? in binge eating more than individuals who do not feel stigmatized because of their weight (Vartanian & Novak, 2011). RQ2: Does the self-reported frequency of U.S. restaurant There is some evidence of global obesity and related stigma chain advertising differ by country? against obese people may be a growing issue. For example, RQ3: Scott et al. (2008) studied obesity and depression in 13 devel- What is the relationship between frequency of U.S. oped nations and found a significant relationship between restaurant chain food consumption and BMI? obesity and depressive or anxiety-related mental disorders (Scott et al., 2008). Specifically, individuals with a BMI of 35 + reported the highest rates of depression and other mental disorders. This study suggests that there may be a growing Methodology global trend toward low self-image and depression due to Survey procedures stigmatization related to obesity. However, prior research has not examined stigma and obesity stemming from U.S. The research team consisted of several communication scho- chain restaurant food consumption or its relationship to key lars who were natives of China and South Korea and who mental health outcomes such as depression, particularly in aided in the translation of the survey questionnaire and newer developing markets such as China and South Korea. recruitment of participants in these countries. The survey questionnaire was translated into two language versions: Mandarin and Korean. Participants were recruited through Rationale and hypotheses/research questions contacts at several major universities within each targeted This reviewed literature suggests that U.S. chain restaurants country (e.g., Shanghai University, Seoul University) who have influenced obesity and obesity-related illness globally helped to generate a snowball sample of participants by and specifically within China and South Korea. However, it using alumni association social media (e.g., Facebook and is unknown how several environmental variables (such as the Twitter) to disseminate the survey to graduates. Potential popularity of U.S. chain restaurants and the social status participants were linked to an online informed consent form associated with them) influence individual variables (such as and to the online survey questionnaire if they were willing to self-efficacy) or how perceptions of weight stigma, popularity participate in the study. of U.S. restaurant chains, and frequency of advertising may differ in China and Korea. Moreover, relatively little is known Participants about the influence of individual-level variables and their relationship to obesity/outcomes of obesity, such as the rela- The survey yielded 358 responses. However, only N = 286 tionships of self-efficacy, willingness to communicate about individuals sufficiently completed the survey questionnaire. weight/diet, weight-related stigma, BMI, and depression These respondents represented both people from China within the context of consuming U.S. chain restaurant food (213) and South Korea (73). Of the participants, 28% were within these countries. Although there is some evidence that male (81) and 72% were female (205). The mean age of suggests these relationships/differences may exist, previous participants was 28.10 years (SD = 7.34). In terms of HEALTH COMMUNICATION 1361 education, 270 individuals had attained a college degree or This measure asks participants to indicate their level of agree- higher (93%) and 16 participants had some college education ment/disagreement on a 5-point Likert-type scale and it con- (7%—these individuals were listed on the university alumni sists of 10 items, including “I am comfortable talking about association social media pages despite never actually complet- my weight/diet issues with a wide variety of people not count- ing their degree). The majority of people reported living in an ing physicians,” and “I only talk about weight/diet issues urban environment (79%), followed by suburban (10.5%), when I have to” (reverse-coded). The reliability coefficient small town (6.6%), and rural (3.5%). The average BMI of for this measure was Cronbach’s α = .88. participants was 22.63 (SD = 6.08). Participants reported that they received information Self-efficacy in weight management regarding U.S. restaurant chains from television advertise- Self-efficacy in weight management as it applies to U.S. chain ments (46.2%), followed by information from members of restaurant food was assessed using a modified version of their social network (24.8%%), billboard advertisements Clark, Abrams, Niaura, Eaton, and Rossi’s(1991) Self- (17.8%), and magazine advertisements (7.8%). With regard Efficacy in Weight Management Scale. This 20-item measure to self-reported frequency of number of U.S. restaurant food asks individuals to indicate their level of agreement/disagree- chain advertisements people saw in the media each week, 34 ment on a 5-point Likert-type scale. However, for the pur- individuals reported seeing no advertisements, 122 people poses of the current study, only 10 items (reflecting said they saw between 1 and 3 advertisements, and 130 availability and social pressure to consume fast food) were respondents mentioned seeing 3 or more advertisements. used. Items included statements such as “I can resist eating U. S. chain restaurant food even when I have to say ‘no’ to others” and “I can resist eating U.S. chain restaurant food Survey measures even when it is readily available.” The reliability coefficient for Frequency of U.S. chain restaurant food consumption this measure was Cronbach’s α = .77. Frequency of U.S. chain restaurant food consumption was measured as a single item that asked “How many times per week do Weight and obesity stigma you eat a meal at American chain restaurants?” The researchers Weight and obesity stigma was measured using 10 items provided participants with examples of American chain restau- representing the personalized stigma and negative self-image rants, such as McDonald’s, Burger King, Pizza Hut, and several dimensions of the HIV Stigma Scale (Berger, Ferrans, & other restaurants, to help individuals identify major U.S. restau- Lashley, 2001). However, these items were adapted to be

rant chains. Participants reported eating at American chain applicable to weight and obesity issues. Sample items from restaurants an average of 2.05 times a week (SD =.89). each of the three subscales include “I have lost friends due to being overweight” and “I feel I’m not as good as others Popularity of U.S. chain restaurants because of my weight.” Ratings were made on a 5-point Popularity of U.S. chain restaurants was assessed with a single 5- scale with the anchors strongly disagree (1) and strongly point Likert-type scale item (strongly agree to strongly disagree) agree (5). Items from the two subscales were combined to that stated “Eating at American chain restaurants is popular in form a single index representing the degree to which respon- my country.” The mean score on this variable was 3.73 (SD =.85). dents perceived their self-with-illness to be stigmatized. The reliability coefficient for this measure was Cronbach’s α = .89. Social status associated with eating at American chain restaurants Depression Social status associated with eating at U.S. chain restaurants Depression was evaluated with the Beck Depression Inventory was measured with a single 5-point Likert-type scale item (BDI; Beck, Steer, & Brown, 1996). Sample items included “I (strongly agree to strongly disagree) that stated “Eating at don’t feel like doing regular activities or things I used to do” American chain restaurants is associated with having higher and “I would say I am depressed.” Ratings were made on a 5- social status in my country.” The mean score on this variable point scale with the anchors never (1) and often (5). All 21 was 2.54 (SD = .99). items were combined to form a single index representing respondents’ level of depression during the previous month. Exercise frequency The reliability coefficient for this measure was Exercise frequency was included as a control variable. It was Cronbach’s α = .71. assessed with a single item that asked participants to indicate the number of times a week they engaged in moderate exer- Body mass index (BMI) cise (e.g., going to the gym, aerobics, running, walking, etc.) Body mass index (BMI) was calculated using the self-reported for more than 30 minutes. The respondents indicated that height and weight of participants (in centimeters and kilo- they engaged in moderate exercise an average of 2.62 times a grams, since the target countries use the metric system). The week (SD = .89). average BMI score for the sample was 22.63 (SD = 6.08).

Willingness to communicate about weight/diet Results Willingness to communicate about weight/diet was measured using a modified version of Wright, Frey, and Sopory’s(2007) The survey data were entered into SPSS 21 for statistical Willingness to Communicate about Health (WTCH) scale. analysis, and the researchers used regression analysis to 1362 K. B. WRIGHT ET AL.

TABLE 1. Descriptive statistics for study variables. Mean SD U.S. chain restaurant food consumption 2.05 .89 Popularity (American chain restaurants) 3.73 .85 Social status (American chain restaurants) 2.54 .99 Self-efficacy in weight management 34.82 7.64 Body mass index (BMI) 22.63 6.08 Depression 18.30 4.77 Exercise frequency 2.26 .65 Weight and obesity stigma 16.78 5.66 Willingness to communicate about health/diet 17.96 3.27 examine the relationships among the study variables. The SD = 1.01) reported eating at U.S. restaurant chains signifi- descriptive statistics for each variable appear in Table 1. cantly more than individuals in China (M = 1.78; SD = .67), Hypothesis 1 posited that increased willingness to commu- t = −8.185, p < .001). nicate about weight/diet would be predictive of increased self- Research question 2 asked whether the frequency of U.S. efficacy in weight management. A regression analysis revealed restaurant chain advertising differed by country. A chi- that willingness to communicate about weight/diet was a squared test revealed that China and South Korea differed significant predictor of self-efficacy in weight management, significantly in terms of the number of U.S. restaurant chain β = .19, t = 3.116, p < .01, supporting Hypothesis 1. advertisements that participants self-reported seeing in the Hypothesis 2 stated that higher social status associated with media each week, χ2(3) = 78.65, p < .001. Individuals from eating at U.S. restaurant chains would be predictive of China were more likely to report seeing only one advertise- decreased self-efficacy in weight management. A regression ment per week than participants from South Korea, and analysis revealed that increased social status associated with people from South Korea were more likely to report viewing eating at U.S. restaurant chains was predictive of decreased 3 or more advertisements per week compared to China. self-efficacy in weight management, β = −.15, t =−2.029, Research question 3 asked about the relationship between p < .05, supporting Hypothesis 2. frequency of U.S. restaurant chain restaurant food consump- Hypothesis 3 asserted that increased BMI would be pre- tion and BMI. A regression analysis indicated that frequency dictive of increased self-perceptions of weight/obesity stigma. of U.S. chain restaurant food consumptions was not a signifi- A regression analysis revealed that higher BMI scores were cant predictor of BMI, β = −.09, t = –1.585, p > .05. predictive of increases in self-perceptions of weight/obesity stigma, β = .17, t = 2.931, p < .01, supporting Hypothesis 3. Hypothesis 4 stated that controlling for exercise frequency, Discussion increases in U.S. restaurant chain food consumption and self- The purpose of this study was to examine the impact of U.S. perceptions of weight/obesity stigma would be predictive of chain restaurant food consumption in China and South Korea increased depression while increases in self-efficacy in weight from an ecological perspective. Specifically, it explored the management would be predictive of decreased depression. A relationships among several environmental and individual regression analysis revealed that increased frequency of U.S. variables that affect obesity and weight management, includ- fast food consumption and increases in self-perceptions ing the popularity of U.S. chain restaurants in these countries, weight/obesity stigma were predictive of higher levels of frequency of U.S. chain restaurant food consumption among depression, whereas higher self-efficacy in weight manage- consumers, self-efficacy in weight management, willingness to ment scores were predictive of lower levels of depression, communicate about weight/diet, self-perceptions of obesity supporting Hypothesis 4 (see Table 2). stigma, body mass index (BMI), and depression. This section Research question 1 asked whether the popularity of eating discusses the theoretical and practical implications of the at U.S. restaurant chains differed by country. A t-test indi- study findings, limitations, and directions for future research. cated that the popularity of U.S. restaurant chains did not The first hypothesis examined the role willingness to com- differ between China (M = 3.73; SD = .88) and South Korea municate about weight/diet as a predictor of increased self- − (M = 3.71; SD = .89), t = .784, p > .05. However, a follow-up efficacy in weight management. The results provide support t-test revealed that people in South Korea (M = 2.82; for the idea that willingness to discuss weight and diet issues

TABLE 2. Health behaviors/perceptions as predictors of depression. Depression Block 1: Control variable Β T ΔR2 .014* Exercise frequency −.111 −2.003 Block 2: Health behaviors/perceptions .17** Frequency U.S. chain restaurant consumption .19** 3.272 Self-efficacy in weight management −.14* −2.355 Weight/obesity stigma .32** 5.609 Note. Model summary: Depression, F(4, 259) = 14.97, p < .001, R2 = .18. *p ≤ .05; **p < .01. HEALTH COMMUNICATION 1363 with others increases a person’s self-efficacy in terms of his or study provided support for this hypothesis. Increased BMI her ability to manage diet/weight/obesity issues. This finding was predictive of stigma associated with weight/obesity across is consistent with previous theory and research that suggests a both of the targeted countries. Future research would benefit person’s willingness to communicate about various health from examining how perceptions of weight/obesity stigma issues is linked to positive health behaviors such as informa- may vary across cultures, as well as attempting to understand tion seeking, social support, and being more assertive and/or the cultural norms for ideal body weight within China and proactive in terms of interactions with health care providers South Korea. (Wright & Frey, 2008). However, the current findings extend The findings suggest that the frequency of U.S. restaurant this research by suggesting that willingness to communicate chain food consumption and weight/obesity stigma may be about weight/diet may increase an individual’s self-efficacy in problematic across both cultures in terms of predicting terms of managing weight. It makes conceptual sense that increases in depression levels (even when controlling for willingness to communicate about weight/diet would help a frequency of exercise). Moreover, decreased levels of self- person in the process of obtaining information about obesity/ efficacy in weight management were found to be predictive weight/diet, mobilizing social support for obesity and diet of increased depression levels. However, researchers should issues, and discussing these issues with health care providers, continue to study obesity cross-culturally, since frequency of which could enhance a person’s resources and skills in terms U.S. restaurant food consumption is likely to vary by country, of coping with obesity. However, future research would ben- the ways in which obesity is stigmatized likely varies by efit from examining individual and cultural barriers to com- culture, and individuals most likely differ in terms of their municating about weight and diet issues, as well as cultural levels of self-efficacy and how they cope with depression. differences in the process of how individuals seek information These results also have several implications for health inter- and mobilize support for weight management within China ventions. It appears that developing an intervention attempt- and Korea, as well as other countries. Moreover, future work ing to reduce U.S. restaurant food consumption and weight/ should focus on how individuals from Asian cultures such as obesity stigma while bolstering self-efficacy in weight manage- China and Korea understand the link between communicat- ment may have a positive influence of depression levels. Of ing about health issues with health care professionals, family course, future research is needed to further understand the members, and peers and how this relates to their ability to relationships between these variables, especially in terms of obtain information and support for managing diet and weight cultural variation. In addition, many people cope with depres- issues. sion by overeating, and future research is needed to determine

Given that eating at U.S. restaurant chains has been found whether people cope with depression across a variety of cul- to be associated with higher social status in many cultures, tures by eating at U.S. restaurant chains more frequently. including China and Korea (Shi et al., 2005; Zhou & Hui, It was interesting that the first research question revealed 2003), the researchers were interested in testing whether that China and South Korea did not differ in terms of parti- higher status associated with eating at such restaurants is cipant perceptions of the popularity of U.S. chain restaurants, predictive of reduced self-efficacy in weight management. despite the fact that people in South Korea reported seeing The results of the current study provide some limited support considerably more advertisements (three or more per week) for this hypothesis, and this suggests that despite people’s than China. These findings suggest that there are likely other perceived skills in terms of managing their weight, their self- cultural variables that influence the popularity of U.S. chain efficacy may be negatively influenced by social pressure to restaurant food aside from aggressive advertising, and these consume U.S. chain restaurant foods (due to the high social should be investigated in future research. status associated with eating at such restaurants). However, Finally, it was interesting that there was no relationship given the relatively low frequency of U.S. chain restaurant between frequency of U.S. chain restaurant food and BMI food consumption reported by participants from both China levels across China and South Korea. However, part of this and South Korea (slightly more than 2 times per week) com- may be explained by the fact that more than two-thirds of the pared to U.S. norms, the high level of education of the sample was female participants. On average, women tend to participants (in which one would assume that educated people have lower BMI levels than men and less variability than men. are more likely to be aware of the effects of both social status In addition, there may have been limited variability in the on behavior and negative health outcomes associated with data set due to the high number of individuals from China high-calorie, fatty foods), and the relatively small effect size and Korea. Future research should continue to examine the of the regression analysis, this finding should be interpreted relationship between U.S. chain restaurant food consumption, with some caution. Future research would benefit from exam- BMI, and health problems related to obesity using longitudi- ining how individuals manage their need for social approval nal data in an effort to find support for the notion that within these cultures (in terms of consuming U.S. restaurant consuming this type of food has negative health food) vis-à-vis their perceptions of the health risks associated consequences. with eating this type of food. The current study has a number of limitations that should Previous research suggests that obesity is associated with be discussed. First, the study relied on a cross-sectional con- negative stigma and discrimination globally (Puhl et al., 2007; venience sample of alumni from universities in the two tar- Scott et al., 2008). It follows that increased BMI would be geted countries, and this limits the ability to generalize the predictive of increased self-perceptions of weight/obesity findings. 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