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(2)

A Quantitative and Qualitative Study of Lifestyle and Obesity

in Asian Adolescents in New Zealand

Shirin Foroughian

A thesis submitted in fulfillment of the requirements for the degree of Doctor of

Philosophy [Population Health], The University of Auckland, 2010.

(3)

ii

Abstract

Overweight and obesity in childhood is a major and growing public health concern with short and long term physical and psychological consequences. Historically obesity was seen as a non-Asian phenomenon, hence this research focused on looking at issues of overweight and obesity in twelve to eighteen year old Asians in New Zealand.

Particular emphasis was given to investigating the nutritional and exercise behaviours of young New Zealand Asians, in order to suggest a health promotion approach to empower and improve the health of young people.

The research was based on both quantitative (structured individual interviews and anthropometry measurements with 821 students) and qualitative approaches (semi- structured interviews with 12 focus groups comprising 46 students) of South Asian, East Asian and European ethnicity who lived and attended high schools in South Auckland.

The findings suggest that being overweight is a concern faced by Asian adolescents at the same level as European adolescents. The results show no significant difference in mean body mass index or mean waist to height ratio amongst the three ethnic groups;

and no difference in fat mass between South Asian and European adolescents when using same cut-off points for all ethnicities. Additionally, there are a number of other risk factors affecting the weight status of Asian adolescents including: missing breakfast or lunch; consumption of junk food such as chips, biscuits, chocolates and pies while at school or at home before dinner; purchasing food from school canteens or dairies;

discrimination of traditional foods at school; high consumption of sugary drinks, fried and fast foods; having access to more food and more variety than in their traditional cultures; lack of exercise and opportunities to be active; and hours spent watching television or playing computer or electronic games. There are also a number of factors that play a protective role for all adolescents in maintaining a healthy weight including:

having breakfast and lunch; bringing food from home; walking to school; and doing sports at school or being involved in an organised or team sport.

Empowering and culturally appropriate ‘educational and physical activity

interventions’ for young people and their families are recommended; but to deal with

the issue of obesity in Asian adolescents, family, school, community and government all

have to play a role.

(4)

iii

Dedication

To my loving and supportive parents

(5)

iv

Acknowledgements

I wish to express my sincere gratitude for the untiring support, encouragement, and guidance of my supervisor, Associate Professor Robert Scragg, I will forever be indebted to you. I would also like to express my special thanks to my second supervisor Professor David Thomas, for his continuous advice and expertise.

I would like to acknowledge my advisors Professor John Raeburn and Associate Professor Samson Tse who were a source of inspiration and encouragement for the study of this topic.

I would also like to acknowledge the New Zealand OPIC team (Dr Sarah Carne, Ofa Dewes, Gavin Faeamani, Dudley Gentles, Dr Maea Hohepa, Pratima Namasivayam, Faasisila Savila, Dr David Schaaf, Lois Shaw, John Sluyter, Dr Tasileta Teevale, Dr Jennifer Utter, and Jody Warbrick); Professor Boyd Swinburn, Associate Professor Roger Marshall, Professor Rod Jackson, and Associate Professor Peter Adams for creating a supportive environment.

I would like to offer my gratitude to the participating schools especially James Cook High School for generously giving their time to share their experiences, as well as the National Heart Foundation of New Zealand, Health Research Council of New Zealand, the Centre for Asian Health Research and Evaluation, and the University of Auckland Scholarships Office, without their support this study would not have been attempted.

I would like to acknowledge many colleagues and friends, who assisted me with various part of this study: Dr Glenn Laverack, Dr Janine Wiles, Tess Liew, Dr Amritha Sobrun-Maharaj, Dr Helen Mavoa, Dr Siniva Sinclair, Sue Kelly, Alistair Stewart, Dennis Hsu, and Dr Simon Thornley. I would also like to acknowledge Professor Sirus Naraqi for directing my path of study in Population Health.

I offer my deepest gratitude to my parents Roya and Parviz, their sacrificial

support enabled me to fulfil my dream of entering the Public Health domain in

path of service to the community; and my dear brother Shahin, for his help, wise

counsel and sense of humour.

(6)

v

Table of Contents

ABSTRACT II

DEDICATION III

ACKNOWLEDGEMENTS IV

LIST OF FIGURES IX

LIST OF TABLES X

GLOSSARY XI

CHAPTER 1. OVERVIEW 1

1.1. A

IMS OF

T

HESIS

2

1.2. N

EW

Z

EALAND

’

S

A

SIAN

C

OMMUNITY

4

1.3. T

HE

R

ESEARCHER

’

S

B

ACKGROUND

5

1.4. T

HIS

R

ESEARCH

5

1.5. T

HESIS

S

TRUCTURE

6

CHAPTER 2. BACKGROUND AND LITERATURE REVIEW 7

2.1. A

SIANS

’ B

ACKGROUNDS

8

2.2. C

HILDHOOD

O

VERWEIGHT

/O

BESITY

14

2.2.1 A

USTRALASIAN

S

TUDIES OF

C

HILDHOOD

O

BESITY

18

2.2.2 C

AUSES OF

C

HILDHOOD

O

BESITY

21

2.3. A

SIANS AND

W

EIGHT

R

ELATED

I

SSUES

24

2.3.1 S

TUDIES OF

A

SIAN

C

HILDREN LIVING IN

A

SIAN

C

OUNTRIES

26 2.3.2 S

TUDIES OF

A

SIAN

C

HILDREN LIVING IN

W

ESTERN

C

OUNTRIES

30 2.4. H

EALTH

P

ROMOTION

T

HEORIES

, M

ODELS AND

E

XAMPLES

42

CHAPTER 3. METHODOLOGY 51

3.1. T

HE

P

ROJECT AND

T

HE

T

HESIS

52

3.1.1 T

HE

OPIC P

ROJECT

52

3.1.2 T

HE

T

HESIS

53

3.2. Q

UANTITATIVE

M

ETHODOLOGY

54

3.2.1 P

RELIMINARIES

54

3.2.2 S

AMPLING

M

ETHOD

55

3.2.3 S

TUDY

P

OPULATION

55

3.2.4 D

ATA

C

OLLECTION

P

ROCEDURE

56

3.2.5 I

NTERVIEW

G

UIDELINE

56

3.2.6 I

NTERVIEW

P

ROCEDURE

60

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vi

3.2.7 D

ATA

A

NALYSIS

61

3.3. Q

UALITATIVE

M

ETHODOLOGY

64

3.3.1 P

RELIMINARIES

64

3.3.2 S

AMPLING

M

ETHOD

66

3.3.3 S

TUDY

P

OPULATION

68

3.3.4 D

ATA

C

OLLECTION

P

ROCEDURE

69

3.3.5 I

NTERVIEW

G

UIDELINE

69

3.3.6 I

NTERVIEW

P

ROCEDURE

73

3.3.7 D

ATA

A

NALYSIS

75

CHAPTER 4. QUANTITATIVE RESULTS 79

4.1. D

EMOGRAPHIC

V

ARIABLES

80

4.2. A

NTHROPOMETRY

82

4.3. N

UTRITION

86

4.3.1 F

OOD

P

ATTERNS

: B

REAKFAST

& S

CHOOL

M

EALS

86 4.3.2 F

OOD

P

ATTERNS

: A

FTER

S

CHOOL

M

EALS

88 4.3.3 F

OOD

P

ATTERNS

: F

RUIT

, V

EGETABLES

, S

UGARY

D

RINKS AND

T

AKEAWAYS

91

4.4. A

CTIVITY

P

ATTERNS

94

4.4.1 P

HYSICAL

A

CTIVITY

94

4.4.2 TV P

ATTERNS

97

4.4.3 G

AMES

P

ATTERNS

100

4.5. E

NVIRONMENT

102

4.5.1 F

AMILY

E

NVIRONMENT

102

4.5.2 S

CHOOL

E

NVIRONMENT

107

4.5.3 N

EIGHBOURHOOD

E

NVIRONMENT

110

4.6. K

NOWLEDGE

112

4.7. O

PINIONS OF

B

ODY

W

EIGHT AND

S

HAPE

114

4.8. S

UMMARY

118

CHAPTER 5. QUALITATIVE RESULTS 120

5.1. D

EMOGRAPHIC

V

ARIABLES

121

5.2. I

NTERVIEW

G

UIDELINE

122

5.3. F

OOD

P

ATTERNS

124

5.3.1 F

AVOURITE

F

OODS AND

D

RINKS

125

5.3.2 S

CHOOL

F

OOD

127

5.3.3 A

FTER

S

CHOOL

F

OOD

130

5.3.4 T

RADITIONAL

D

IET

133

5.4. A

CTIVITY

P

ATTERNS

135

5.4.1 L

EISURE

A

CTIVITIES

135

5.4.2 P

HYSICAL

A

CTIVITIES

137

5.4.3 C

ULTURAL

B

ARRIERS TO

P

HYSICAL

/R

ECREATIONAL

A

CTIVITIES

140

5.5. I

NFLUENCING

F

ACTORS

142

5.5.1 E

NVIRONMENTAL

I

NFLUENCES

142

5.5.2 F

AMILY

I

NFLUENCES

145

5.5.3 F

OOD AND

M

OOD

147

5.6. K

NOWLEDGE AND

E

XPERIENCE

149

5.6.1 K

NOWLEDGE OF

H

EALTHY

F

OOD

150

(8)

vii

5.6.2 S

OURCE OF

K

NOWLEDGE OF

H

EALTHY

F

OOD

151

5.6.3 K

NOWLEDGE OF

H

EART

H

EALTH

153

5.6.4 S

OURCE OF

K

NOWLEDGE OF

H

EART

H

EALTH

155 5.7. R

ECOMMENDATIONS FOR

P

REVENTION

P

ROGRAMMES

156

5.7.1 P

REVENTION

P

ROGRAMMES

157

5.7.2 P

ARTICIPATION IN

P

REVENTION

P

ROGRAMMES

162 5.8. S

UMMARY OF

M

AIN

T

HEMES AND

C

OMMON

T

HEMES

167 5.8.1 C

OMMON

T

HEME

1: R

ISK

F

ACTORS

174 5.8.2 C

OMMON

T

HEME

2: P

ROTECTIVE

F

ACTORS

174 5.8.3 C

OMMON

T

HEME

3: R

P

REVENTION

P

ROGRAMMES

175

CHAPTER 6. DISCUSSION 176

6.1. R

ESULTS

D

ISCUSSION

177

6.1.1 A

NTHROPOMETRIC

M

EASUREMENTS

177

6.1.2 F

OOD

P

ATTERNS

180

6.1.3 A

CTIVITY

P

ATTERNS

184

6.1.4 I

NFLUENCING

F

ACTORS

187

6.1.5 K

NOWLEDGE

189

6.1.6 O

PINIONS ABOUT

B

ODY

W

EIGHT

& S

HAPE

190 6.1.7 R

P

REVENTION

P

ROGRAMMES

191

6.2. S

UMMARY IN TERMS OF

C

OMMON

T

HEMES

192

6.2.1 O

VERWEIGHT

/O

BESITY IN

A

SIAN ADOLESCENTS

193

6.2.2 R

ISK

F

ACTORS

193

6.2.3 P

ROTECTIVE

F

ACTORS

193

6.2.4 R

P

REVENTION

P

ROGRAMMES

194

6.3. A H

EALTH

P

ROMOTION

A

PPROACH

194

6.3.1 G

ENERAL

F

RAMEWORK

195

6.3.2 D

EVELOPING A

H

EALTH

P

ROMOTION

A

PPROACH FOR

Y

OUNG

A

SIANS IN

N

EW

Z

EALAND

197

6.4. L

IMITATIONS OF THE

S

TUDY

204

6.4.1 S

TUDY

D

ESIGN

204

6.4.1.1. A

CROSS

-

SECTIONAL SURVEY

204

6.4.1.2. S

AMPLE SIZE

204

6.4.1.3. C

LUSTERED SAMPLING

204

6.4.2 V

ALIDITY OF THE STUDY

205

6.4.2.1. E

XTERNAL VALIDITY

205

6.4.2.2. I

NTERNAL VALIDITY

205

6.4.3 A

NALYSIS

206

6.5. R

ELATING

F

INDINGS TO

O

RIGINAL

O

BJECTIVES OF THIS

R

ESEARCH

207 6.5.1 O

BJECTIVE

O

NE

: T

O DETERMINE IF OVERWEIGHT

/

OBESITY IS A PROBLEM IN

N

EW

Z

EALAND

A

SIAN ADOLESCENTS

207

6.5.2 O

BJECTIVE

T

WO

: T

O IDENTIFY YOUNG

N

EW

Z

EALAND

A

SIAN

’

S NUTRITIONAL AND EXERCISE BEHAVIOURS AND TO UNDERSTAND THE FACTORS INFLUENCING THESE

BEHAVIOURS

207

6.5.3 O

BJECTIVE

T

HREE

: T

O INVESTIGATE YOUNG

N

EW

Z

EALAND

A

SIAN

’

S

UNDERSTANDING AND KNOWLEDGE OF HEART HEALTH

208

6.5.4 O

BJECTIVE

F

OUR

: T

O SUGGEST A HEALTH PROMOTION

/

COMMUNITY

DEVELOPMENT MODEL TO EMPOWER AND IMPROVE THE HEALTH OF YOUNG

N

EW

Z

EALAND

A

SIANS

209

(9)

viii

CHAPTER 7. CONCLUSION 211

7.1. T

HE

R

ESEARCH

212

7.2. F

UTURE

D

IRECTIONS

214

7.3. R

ESEARCH

O

UTPUTS OF

T

HESIS

215

APPENDICES 217 APPENDIX ONE: SEARCH HISTORY FOR ‘OBESITY IN ASIAN ADOLESCENTS’

218 APPENDIX TWO: PARTICIPANT INFORMATION SHEET FOR STUDENTS AGED

16 YEARS AND OLDER 219

APPENDIX THREE: CONSENT FORM FOR STUDENTS AGED 16 YEARS AND

OLDER 221

APPENDIX FOUR: PARTICIPANT INFORMATION SHEET FOR STUDENTS AGED

LESS THAN 16 YEARS 222

APPENDIX FIVE: PARTICIPANT INFORMATION SHEET FOR PARENTS OF

STUDENTS AGED LESS THAN 16 YEARS 224

APPENDIX SIX: CONSENT FORM FOR STUDENTS AGED LESS THAN 16 YEARS

AND PARENTS 226

APPENDIX SEVEN: OPIC BASELINE QUESTIONNAIRE 227 APPENDIX EIGHT: LIVING FOR LIFE QUESTIONNAIRE 236 APPENDIX NINE: CODING SYSTEM FOR 'OTHER' ETHNICITY 250

APPENDIX TEN: SAS CODES 251

APPENDIX ELEVEN: GUIDELINES FOR FOCUS GROUPS 254 APPENDIX TWELVE: PARTICIPANT INFORMATION SHEET FOR STUDENTS 256 APPENDIX THIRTEEN: CONSENT FORM FOR STUDENTS AGED 16 YEARS OR

ABOVE 258

APPENDIX FOURTEEN: CONSENT FORM FOR STUDENTS AGED LESS THAN 16

YEARS 259

APPENDIX FIFTEEN: PARTICIPANT INFORMATION SHEET FOR PARENTS OF

STUDENTS AGED LESS THAN 16 YEARS 260

APPENDIX SIXTEEN: CONSENT FORM FOR PARENTS OF STUDENTS AGED

LESS THAN 16 YEARS 262

APPENDIX SEVENTEEN: GATHERING OF DEMOGRAPHICS 263

REFERENCES 264

(10)

ix

List of Figures

F

IGURE

2.1. M

AP OF

A

SIA AND

A

USTRALASIA

(

FROM

G

OOGLE

E

ARTH

)

8

F

IGURE

2.2. M

AP OF

C

HINA

(

FROM THE

C

ULTURAL

P

ROFILES

P

ROJECT

)

10

F

IGURE

2.3. M

AP OF

I

NDIA

(

FROM THE

C

ULTURAL

P

ROFILES

P

ROJECT

)

12

F

IGURE

6.1. D

ETERMINANTS OF

W

EIGHT

S

TATUS IN

Y

OUNG

A

SIANS

208

F

IGURE

6.2. R

P

REVENTION

P

ROGRAMMES

210

(11)

x

List of Tables

T

ABLE

1.1. A

SIAN

P

OPULATION IN

N

EW

Z

EALAND

4

T

ABLE

2.1. C

HILDHOOD

O

VERWEIGHT AND

O

BESITY

P

ERCENTAGE IN

A

SIA

25

T

ABLE

2.2.

SUMMARY OF STUDIES OF OBESITY

R

ISK

F

ACTORS IN

A

SIAN CHILDREN

L

IVING IN

W

ESTERN

C

OUNTRIES

38

T

ABLE

3.1. S

UMMARY OF

L

IFESTYLE

I

NFORMATION

C

OLLECTED ON THE

PDA

57

T

ABLE

3.2. S

UMMARY OF QUESTIONS

C

OLLECTED ON THE

P

APER

Q

UESTIONNAIRE

58

T

ABLE

3.3. S

TRUCTURE OF

F

OCUS

G

ROUPS

67

T

ABLE

4.1. D

EMOGRAPHICS

– E

THNIC

C

OMPARISONS OF

P

ARTICIPANTS IN THE

OPIC S

TUDY

81

T

ABLE

4.2.1. M

EAN LEVELS OF ANTHROPOMETRY VARIABLES

,

FOR ETHNIC GROUPS

,

ADJUSTED FOR AGE AND GENDER

84

T

ABLE

4.2.2. W

EIGHT

S

TATUS BY

E

THNIC

G

ROUP

85

T

ABLE

4.3.1. B

REAKFAST AND

S

CHOOL

M

EALS

– B

Y

E

THNIC

G

ROUP

87

T

ABLE

4.3.2. A

FTER

S

CHOOL

M

EALS

– B

Y

E

THNIC

G

ROUP

90

T

ABLE

4.3.3. F

OOD

H

ABITS

– B

Y

E

THNIC

G

ROUP

92

T

ABLE

4.4.1. A

CTIVITY

P

ATTERNS

– B

Y

E

THNIC

G

ROUP

96

T

ABLE

4.4.2. TV P

ATTERNS

– B

Y

E

THNIC

G

ROUP

98

T

ABLE

4.4.3. G

AMES

P

ATTERNS

– B

Y

E

THNIC

G

ROUP

101

T

ABLE

4.5.1. F

AMILY

E

NVIRONMENT

– E

THNIC

G

ROUP

C

OMPARISON

105

T

ABLE

4.5.2. S

CHOOL

E

NVIRONMENT

– E

THNIC

G

ROUP

C

OMPARISON

108

T

ABLE

4.5.3. N

EIGHBOURHOOD

E

NVIRONMENT

– E

THNIC

G

ROUP

C

OMPARISON

111

T

ABLE

4.6. K

NOWLEDGE

– B

Y

E

THNIC

G

ROUP

114

T

ABLE

4.7. O

PINIONS OF

B

ODY

W

EIGHT AND

S

HAPE

– B

Y

E

THNIC

G

ROUP

117

T

ABLE

4.8. O

VERWEIGHT

/O

BESITY

P

ROTECTIVE AND

/

OR

R

ISK

F

ACTORS

– E

THNIC

G

ROUP

C

OMPARISON

119

T

ABLE

5.1. D

EMOGRAPHICS OF

F

OCUS

G

ROUPS

122

T

ABLE

5.2. S

TRUCTURE OF THE

I

NTERVIEW

G

UIDELINE

123

T

ABLE

5.3. T

HEMES ACROSS ALL

E

THNIC

G

ROUPS AND

E

THNIC

D

IFFERENCES

: F

OOD

P

ATTERNS

168

T

ABLE

5.4. T

E

THNIC

G

ROUPS AND

E

THNIC

D

IFFERENCES

: A

CTIVITY

P

ATTERNS

170

T

ABLE

5.5. T

E

THNIC

G

ROUPS AND

E

THNIC

D

IFFERENCES

: I

NFLUENCING

F

ACTORS

171

T

ABLE

5.6. T

E

THNIC

G

ROUPS AND

E

THNIC

D

IFFERENCES

: K

NOWLEDGE AND

E

XPERIENCE

172

T

ABLE

5.7. T

E

THNIC

G

ROUPS AND

E

THNIC

D

IFFERENCES

: R

P

REVENTION

P

ROGRAMMES

173

T

ABLE

6.1. T

HE

PEOPLE S

YSTEM

196

(12)

xi

Glossary

%BF P

ERCENTAGE

B

ODY

F

AT

A A

GE

(

Y

)

AQ

O

L A

SSESSMENT OF

Q

UALITY OF

L

IFE

BIA B

IOELECTRICAL

I

MPEDANCE

A

NALYSIS

BMI B

ODY

M

ASS

I

NDEX

CF C

ONSENT FORM

CMDHB C

OUNTIES

M

ANUKAU

D

ISTRICT

H

EALTH

B

OARD

CVD C

ARDIOVASCULAR

D

ISEASE

DBP D

IASTOLIC

B

LOOD

P

RESSURE

DOH

A

D D

EVELOPMENTAL

O

RIGINS OF

H

EALTH AND

D

ISEASE

DVD D

IGITAL

V

IDEO

D

ISC

E E

THNICITY

FOAD F

OETAL

O

RIGINS OF

A

DULT

D

ISEASE

FFM F

AT

F

REE

M

ASS

FM F

AT

M

ASS

H H

EIGHT

(

CM

)

HDLC H

IGH

D

ENSITY

L

IPOPROTEIN

C

HOLESTEROL

HEHA H

EALTHY

E

ATING

H

EALTHY

A

CTION

IOTF I

NTERNATIONAL

O

BESITY

T

ASK

F

ORCE

LBD L

ET

’

S

B

EAT

D

IABETES

LTSA L

AND

T

RANSPORT

S

AFETY

A

UTHORITY

MOH M

INISTRY OF

H

EALTH

NCNS N

ATIONAL

C

HILDREN

’

S

N

UTRITION

S

URVEY

NHMRC N

ATIONAL

H

EALTH AND

M

EDICAL

R

ESEARCH

C

OUNCIL

NZHS N

EW

Z

EALAND

H

EALTH

S

URVEY

OPIC O

BESITY

P

REVENTION

I

N

C

OMMUNITIES

P P-

VALUE

PA P

HYSICAL

A

CTIVITY

PDA P

ERSONAL

D

IGITAL

A

SSISTANT

P

EDS

Q

O

L P

AEDIATRIC

Q

UALITY OF

L

IFE

PEOPLE P

LANNING AND

E

VALUATION OF

P

EOPLE

-L

ED

E

NDEAVOURS

PIS P

ARTICIPANT INFORMATION SHEET

R R

ESISTANCE

SAS S

TATISTICAL

A

NALYSIS

S

YSTEM

SBP S

YSTOLIC

B

LOOD

P

RESSURE

SE S

TANDARD

E

RROR

SES S

OCIOECONOMIC

S

TATUS

SPARC S

PORT AND

R

ECREATION

N

EW

Z

EALAND

TBCA T

ANITA

B

ODY

C

OMPOSITION

A

NALYSER

TBW T

OTAL

B

ODY

W

ATER

TG T

RIGLYCERIDE

TV T

ELEVISION

W W

EIGHT

(

KG

)

WC W

AIST

C

IRCUMFERENCE

WHO W

ORLD

H

EALTH

O

RGANIZATION

WHR W

AIST TO

H

EIGHT

R

ATIO

Z I

MPEDANCE

(Ω)