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Factors associated with obesity in Chinese-American children.

Objective: A cross-sectional study design was utilized to examine factors associated with obesity in Chinese-American children.

Subjects: Chinese-American children (8 to 10 years old) and their mothers (N = 68) in California participated in the study.

Measurements: Mothers completed demographic information, the Family Assessment Device, Attitudes Toward Child Rearing Scale, and Suinn-Lew Asian Self-Identity Acculturation Scale. Children's body mass index was measured, and children completed a self-administered physical activity checklist, Food Frequency Questionnaire, and the Schoolagers' Coping Strategies Inventory.

Results: Results indicated three variables that predicted children's body mass index: older age, a more democratic parenting style, and poor communication ([R.sup.2]=.263, F=8.727, p = .0001). Children whose mothers had a low level of acculturation were also more likely to be overweight than were children whose mothers were highly acculturated.

Conclusion: This study revealed that children's ages, a democratic parenting style, and poor family communication contribute to increased body mass index in Chinese-American children. Other factors related to children's BMI and dietary intake include acculturation level of the mother and family affective responses. Future studies should examine the change in BMI over time and in different age groups and why parenting and family communication impact children's body weight.

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In 1998, the World Health Organization designated obesity as a global epidemic. The most recent ,data indicate that the prevalence of overweight among Chinese-American children aged 6-11 years is 31% (Tarantino, 2002). Chinese-American children born in the second and third generations have the most significant changes in the prevalence of obesity with an increase from 11.6% to 27.2% compared with first-generation children (Mei et al., 1998). Substantial evidence has indicated that several physical health problems, including cardiovascular diseases, sleep disorders, and type II diabetes, as well as psychosocial problems, such as low self-esteem and social withdrawal, are associated with childhood obesity (Barlow & Dietz, 1998; Young, Dean, Flett, & Wood-Steiman, 2000). Because of the difficulty in controlling obesity in adults and the many long-term adverse effects of childhood obesity, the prevention of childhood obesity has been recognized as a public health priority (Young et al., 2000).

Understanding factors associated with health-promoting behaviors in children can help health care providers and researchers to develop culturally appropriate and more efficient programs to promote health behavior and prevent obesity. Therefore, the purposes of this study were to (a) describe family functioning, parenting style and Chinese-American children's coping strategies, dietary intake, and levels of physical activity and inactivity; (b) examine the relationships between these factors and children's body mass index (BMI); and (c) investigate other factors related to children's BMI, including gender, age, maternal acculturation, and mothers' levels of education.

Method

Participants and procedures. This study examined data collected from a larger study titled "Factors Associated With Chinese Children's Health in Taiwan and in the U.S." A cross-sectional study design was used to examine factors associated with Chinese-American children's health and body composition. Upon approval from the University of California, San Francisco Committee on Human Research, children ages 8 to 10 years old (third through fifth graders), who self-identified as Chinese or of Chinese origin, and their mothers were invited to participate in this study. Standardized instruments were used to measure family functioning; parenting style; maternal acculturation level; and children's dietary behaviors, levels of physical activity, and coping strategies.

Participants (68 children and their mothers) were recruited through two Chinese language schools located in urban and suburban areas of Northern California. Most children were born in the U.S., and their parents had immigrated from Mainland China, Taiwan, Hong Kong, Malaysia, or Indonesia. Children's body mass and stature were measured privately during recess time in a classroom provided by the schools. Stature was measured three times using a portable standiometer (Seca 214 Road Rod, Vogel & Halke GmbH & Co., Hamburg). Body mass was measured three times using an electronic body mass scale (840 Bella Digina; Scale, Vogel & Halke GmbH & Co., Hamburg). The means of the three measurements of stature and body mass were used to compute children's BMIs.

Children also recorded their dietary intake and activity questionnaires on Sunday, Monday, and Thursday at home, with the researcher making phone calls on Sunday and Thursday to remind children to fill out the dietary intake, activity and coping questionnaires as well as to answer any questions. The mothers participating in the study completed the questionnaires (family demographic, Suinn-Lew Asian Self-Identity Acculturation Scale, Family Assessment Device, and Attitudes Toward Child-Rearing Scale) and returned them in a sealed envelope within two weeks of recruitment. All questionnaires that mothers filled out have a standardized Chinese version, except for the family demographic questionnaire. Children in this study filled out questionnaires in English.

Measures

Body mass index (BMI). This is an equation determined by body mass in kilograms divided by stature in meters squared (kg/[m.sup.2]). BMI has a well-established association with stature and age in children and adolescents (Must, Dallal, & Dietz, 1991). BMI has wide ranges of sensitivities, specificity, and misclassification. Sensitivity ranged from 29% to 88%, specificity ranged from 94% to 100%, predictive value ranged from 90% to 100%, and efficiency ranged from 85% to 100% (Freedman & Perry, 2000; Goran, 1998). In this study, children's body mass and stature were measured while the children were wearing lightweight clothes and no shoes. The 214 Road Rod portable stadiometer, which has an excellent gradation of 1/8 inch (0.1 cm), was used to measure stature. The 840 Bella Digital Scale was used to measure body mass; it has a gradation of 0.2 lbs (100 grams). The scales were calibrated based on the instructions provided by the manufacturers.

Family demographic information (FD). Mothers completed 31-item basic family demographic questionnaires. Included in the questionnaire are questions regarding parents' and children's ages and race/ethnicity, parents' and grandparents' countries of origin, parents' number of years living in the U.S., parents' occupation(s), families' incomes, parents' levels of education, and types of residence. The questionnaire is written at a third-grade reading level and takes approximately 5 minutes to complete by the parent. The Chinese FD was translated into Chinese by the first author and tested in a group of three bilingual Cantonese- and Mandarin-speaking parents to ensure that translation was adequate for this population.

Suinn-Lew Asian Self-Identity Acculturation Scale (SL-ASIA). The SL-ASIA scale is a 21-item multiple-choice questionnaire covering topics such as language (4 items), identity (4 items), friendships (4 items), behaviors (5 items), general and geographic background (3 items), and attitudes (1 item) (Suinn, Richard-Figueroa, Lews, & Vigil, 1987). Scores range from a low of 1.00, indicative of a low level of acculturation or strong Asian identity, to a high of 5.00, indicative of a high level of acculturation or a strong Western identity. Moderate validity has also been reported, and Cronbach's alpha for the SL-ASIA was found to be .79 to .91 for Chinese-Americans (Suinn, Richard-Figueroa, Lews, & Vigil, 1987). The Cronbach's alpha was found to be .80 in this study. Mothers in this study completed this questionnaire.

Family Assessment Device (FAD). The FAD is based on the McMaster Model derived from systems, roles, and communication theories, and it evolved from work with nonclinical families (Epstein, Bishop, & Levin, 1978). It has six subscales: problem solving, communication, roles, affective responsiveness, affective involvement, and behavior control. The FAD also includes a 12-item general functioning subscale that has been used as a global assessment of general health of the family. A 4-point Likert-type scale, with anchor points of strongly agree, agree, disagree, and strongly disagree, is utilized to evaluate a family member's perception of the family. The score in each item ranges from 1 to 4 with 1 reflecting healthy functioning and 4 reflecting unhealthy functioning. An average score for each subscale is used to measure family functioning in a specific domain, such as problem solving. A higher average score indicates poor family functioning. Several studies have reported concurrent validity of the FAD as ranging from 0.48 to 0.53, with reliabilities ranging from 0.69 to 0.86 (Kabakoff, Miller, Bishop, Epstein, & Keitner, 1990; Miller, Bishop, Epstein, & Keitner, 1995). The Cronbach's alpha was .73 for problem solving, .72 for communication, .70 for roles, .69 for affective responsiveness, .64 for affective involvement, .52 for behavior control, and .82 for general functioning in this study. Mothers in this study completed this questionnaire.

Attitudes Toward Child-Rearing Scale (ATCRS). The ATCRS includes two subscales: a 26-item authoritarian subscale and a 14-item democratic subscale. The 40-item scale is responded to on a 5-point Likert-type scale. A total score has been used to indicate a parenting style or attitude that is either democratic or authoritarian. A higher score indicates agreement with an authoritarian attitude. In Wang and Phinney's (1998) study on child rearing attitudes between immigrant Chinese mothers and Anglo-American mothers, the ATCRS was translated into Chinese and then translated back into English. The ATCRS has a moderate to good reliability, ranging from .77 to .90 for the democratic and authoritarian parenting subscales and has a one-week test-retest reliability of .91. Current study found a reliability of .75 for 40 items scale. Mothers completed ATCRS in this study.

Children Self-Administered Physical Activity Checklist (SAPAC). The modified SAPAC was used in the Cardiovascular Health in Children study (Sallis et al., 1995). Children were asked to recall activities that occurred the previous day before school, during school, and after school. In the original questionnaire, there are 25 activity-related questions and two questions related to TV/video viewing and video/computer game playing time. Three extra blank columns were added to capture activities that might be culturally relevant but were not listed in the original SAPAC. Children estimated the minutes they spent engaging in each activity during three time periods. They also reported whether the activity caused them to "breathe hard or feel tired none, some, or most of the time." SAPAC provides a moderate criterion validity (r= .57 - .75) and a moderate one-week test-retest reliability (r =.60) (Sallis et al., 1995). An estimated energy expenditure was computed based on the reported frequency and intensity. SAPAC provides a moderate criterion validity (r= .57 - .75) and a moderate 1-week test-retest reliability (r =.60) (Sallis et al., 1995).

Food Frequency Questionnaire (FFQ). This 50-item self-report tool is used to assess Chinese children's dietary behaviors and preference patterns, which include Taiwanese dietary foods identified from previous research that are high-fat and/or high-density and high sugar. The FFQ was used to assess children's high-fat and high-sugar dietary behaviors in a national children's health research study in Taiwan (Sheu & Edmundson-Drane, 2001). Children indicated daily whether they are the type of high-fat or high-sugar food listed for 3 days. A mean score was computed for the total food consumed in three days. The FFQ has a good internal consistency (r=.92) (Sheu & Edmundson-Drane, 2001). The Cronbach's alpha was found to be .88 for this study.

The Schoolagers' Coping Strategies Inventory (SCSi). This 26-item self-report instrument has been used in several Western studies. It measures the type, frequency, and effectiveness of the stress-coping strategies used by children ages 8 to 12 years old (Ryan-Wenger & Copeland, 1994). Each child identifies a stressor and then scores on a scale of zero to 3, where zero refers to never used it to three refers to most of the time, in each coping strategy for frequency of use and for degree of helpfulness (effectiveness). Total scores were used for the frequency scale score, effectiveness scale score, and total SCSI with high score referring to frequently used and more effective of coping strategy. Construct validity and adequate internal consistency (r=.79) and test-retest reliability (r -.73 - .82) have been reported (Ryan-Wenger & Copeland, 1994). The current study found the Cronbach's alpha was .84 for frequency subscale and .85 for effectiveness subscale.

Statistical Analysis

Chi square tests were performed for categorical data, and Pearson correlation coefficient was used to determine the relationship between variables and children's BMI. A two-way analysis of variance (age x gender) was performed to examine the main and interaction effect of variables. Stepwise multiple linear regressions were performed to examine factors that contributed to higher BMI among Chinese-American children. Children's ages and genders and mothers' levels of education were entered into the model as the first step to control for their effect on children's body mass, and then all variables from study constructs were entered at the second step. All statistical analyses were performed with SPSS 10 for Windows.

Results

Family Information and Demographic Characteristics. A sample of 68 children, 31 boys (45.6%) and 37 girls (54.4%), participated in the study. The mean age of these children was 8.99 years (SD=.82). The average age of the mothers was 42.09 (SD = 3.81), and their average number of years of education was 13.43 (SD= 4.16). Most mothers were married (95.6%). Twenty-eight percent of mothers were housewives (N=19), and 21% were employed in semiskilled occupations. Forty-five percent of the families had annual incomes greater than US $40,000. The average number of years since immigrating to the U.S. was 16.35 (SD=6.64).

BMI and overweight. The average stature was 1.35 meters (SD=.09), average body mass was 34.06kg (SD=9.62), and average BMI was 18.36 (SD=3.37). Twenty-three children (33.8%) were classified as overweight based on their BMIs, which were greater than the 85th percentile for age and gender norms. Two-way ANOVAS indicated that older children had higher BMIs than did younger children (F-4.83, p=.011).

Maternal level of acculturation. The mean SL-ASIA score was 2.02 (SD=.35). By mothers' report, 38 (55.9%) characterized themselves as being primarily of Asian identity, whereas 30 (44.1%) characterized themselves as being Western identity. Mothers who were highly acculturated (Western identity) had lived in the U.S. longer than those who were less acculturated (Asian Identity) (17.27 years and 14 years, respectively; t=-3.489, p=.001). Children whose mothers were less acculturated were more likely to be overweight than were children whose mothers were highly acculturated (chi-square=4.58, p=.032).

Family functioning and parenting styles. A significant correlation was found between communication within the family and children's BMIs (r=.275, p-.023). An interaction between children's age and gender was found in the behavior control subscale (F=5.36, p=.007). Families of nine year old children reported poorer behavior control than families of 8 and 10-year-old children.

The mean score was 2.37 in ATCRS. Highly acculturated mothers reported higher mean total scores (M-2.44, SD=.17) than did less acculturated mothers (M=2.32, SD-.27; t=2.107, p=.039). Highly acculturated mothers reported a more authoritarian parenting style than low acculturated mothers. A significant relationship was found between a more democratic parenting style and higher BMI in children (r=-.37, p=.002).

Children's coping. The mean score was 27.83 (SD-9.54) for coping frequency and 36.63 (SD=10.66) for coping effectiveness. An interaction between gender and age was found in both coping frequency (F=4.29, p=.018) and effectiveness (F=6.08, p=.004). Coping frequency scores and effectiveness scores decreased with age for girls. For boys, coping frequency and effectiveness decreased from eight years old to nine years old and then increased from nine years to 10 years. No relationship was found between children's coping strategies and their BMIs.

Dietary intake and physical activity. Children reported eating approximately seven high-fat and high-sugar items everyday. No interaction or correlation was found between children's dietary intakes and their BMIs. Significant correlations were found between a democratic parenting style and higher sugar intake in children (r=-.332, p=.006) and poor family affective response and higher fat intake in children (r=.27, p=.026). However, higher sugar intake and high-fat intake were not related to children's BMI.

Children spent on average 84 minutes engaging in moderate and vigorous activities, 469.60 metabolic equivalents (METs) and 120.6 minutes in sedentary activities per day. No significant interaction or correlations were found between children's levels of physical activity, sedentary activity, and their BMI.

Regression model. One of the purposes of the study was to assess the effect of factors contributed to children's BMI. Thus, children's ages and genders and mothers' levels of education were entered in the first step to control for their confounding effect followed by seven FAD subscales, ATCRS, SL-ASIA, two SCSI subscales, FFQ, physical activity time, and sedentary activity time as the second step. Multiple regressions indicated three variables that significantly contributed to the variance in children's BMIs: older age of children (1.5%), more democratic parenting style (17%), and poor communication within the family (9.7%). The model as a whole explained 26.3% of the variance in Chinese-American children's BMIs (R2=.263, F=8.727, p=.0001) (see Table 1).

Discussion

Results of this study suggest that older Chinese-American children in families with a democratic parenting style and poor communication are at risk for obesity. Parenting styles have been studied because of their essential and vital influence on various psychological and physical health outcomes (Lau & Klepper, 1989; Olvera-Ezzell, Power, & Cousins, 1990). Results suggest a relationship between democratic parenting style and children's BMIs; the more democratic parenting style is related to higher BMI in children. This is not consistent with other studies which suggest that democratic parenting is associated with better health in children (Hill & Franklin, 1998; Russell, Kopec-Schrader, Rey, & Beumont, 1992). However, Hill and Russell's studies focused on adolescents rather than elementary school age children.

There are possible explanations for the finding that a more democratic parenting style contributes to a higher BMI in Chinese-American children. First, several studies have shown that an authoritarian parenting style in Chinese families may not necessarily reflect the strict parenting that was measured in Western society and measures (Chao, 1994; Stewart et al., 1998; Wang & Phinney, 1998). Conversely, parents' involvement, care, supervision, and encouragement of academic achievement, all of which typically have been identified as components of an "authoritarian" parenting style in Western society, are, in fact, a reflection of caring and loving parenting in the Chinese culture (Chiu, 1987).

For Chinese, parental obedience and some aspects of strictness may be equal with parental concern, caring and involvement. For instance, the concept of "chiao shun" or "training" indicates parental roles in teaching and educating children in the appropriate or expected behaviors in Chinese culture (Chao, 1994). However, this type of parenting behavior can be viewed as rejecting and uninvolved parenting practices in Western society. Therefore, the concepts of "training" and "authoritarian" have very different cultural roots, and thus very divergent implications. In this study, a less authoritarian parenting style might, indeed, mirror less caring and loving parenting in the Chinese culture. Since ATCRS only measure two aspects of parenting styles (authoritarian and democratic), it might not capture other important aspects of parenting in Chinese (such as warmth and control). Stewart and associates (1998) found that parenting characteristics associated with "training" showed coherence, correlated with parental warmth, and predicted children's well-being. Additionally parental control and warmth were found to be important factors in relation to children's adaptation and well-being. Thus, studies examining Chinese parenting styles may need to consider these two concepts (control and warmth).

Lastly, children in this study were between 8 and 10 years old. They might need more appropriate and adequate guidance to help them establish healthy dietary and exercise habits. An authoritarian parenting style might provide more structure than a less-authoritarian parenting style since children in this age group might still need some type of structured supervision, such as being reminded to choose healthy foods and to exercise regularly. Although this study did not find dietary intake and physical activity levels as significant factors contributing to children's BMI, healthy dietary behavior and physical activity have been found to be related to better cardiovascular function (Lou, Ganley, & Flynn , 2002; Sanchez-Bayle & Soriano-Guillen, 2003). Thus, authoritarian parenting that facilitates healthy lifestyle might help protect against weight problems in Chinese-American children.

This study also revealed that poor communication between family members is related to higher BMI in children. In this study, communication refers to the degree to which the family members communicate with each other in a clear and direct way. The internal consistency was found to be.72 in the communication subscale. This study which examined the psychometric properties of FAD found that FAD has acceptable reliability and validity in a Chinese population (Chen et al., 2004).

This finding of the relationship between family communication and children's BMI is supported by other studies which have shown that poor family functioning is associated with higher BMI in Anglo children (Kinston, Loader, Miller, & Rein, 1988; Valtolina, & Ragazzon, 1995).

Chinese culture emphasizes collectivism rather than individualism. In collectivism, family interest is more important than one's own interest, and maintaining harmony is the goal of family (Chao, 1994). Since harmony is the foundation of Chinese culture, the preservation of peaceful relationships with family members determines effective communication. Family communication is an important aspect of family functioning and appears to play a critical role in predicting children's BMI and their health behaviors across cultures.

The regression analysis indicated that older children in families with more democratic parenting and poor communication are at risk for higher BMI. A different parenting style and family dynamic occur in families of children in different stages of development. Families of older children face the challenge of the children's transition from childhood to adolescence. During this transition, the parents use an increasingly democratic parenting style that involves children in decision making. More communication conflicts arise between the parents and children during this time period because of the children's desire to be independent and have more autonomy. This may create tensions in a predominant Chinese culture, with the emphasis on the family instead of on the individual, as is the case in Western culture. It is possible that older children whose parents use a democratic parenting style and have poor communication skills are at risk for obesity.

In addition to the three factors identified in the results of the regression analysis, mothers' level of acculturation appears to be related to children's BMI. Results suggest that children whose mothers had a low level of acculturation were more likely to be overweight than children whose mothers were highly acculturated. A highly acculturated mother might have more resources to health care and know more about problems related to oversight. Unexpectedly, results also found that higher acculturated mothers have more authoritarian parenting styles. Future study needs to examine the interaction between parenting styles, acculturation levels and children's BMI in a larger sample and diverse populations.

Studies have found conflicting relationships between acculturation and adult's body weight (Curb & Marcus, 1991; Davis & Katzman, 1999; Lee, Sobal, & Frongillo, 2000; Schultz, Soinder, & Josephson, 1994). Lee and associates found higher acculturation was associated with higher body weight in Korean men. Yet, lower acculturated Japanese men had lower body weight (Curb & Marcus, 1991) and no significant relationship was found between acculturation levels and adults' body weight in Chinese (Schultz et al., 1994).

Davis and Katzman (1999) assessed the relationships among acculturation, self-esteem, depression, and characteristics associated with eating disorders in Chinese college students in the U.S. Results indicated that for women, a higher level of acculturation was related to more eating disorders, a drive for thinness, body dissatisfaction, and fear of maturation. This finding is consistent with the results of Root's study (1990), suggesting that in an effort to assimilate, immigrants may overcorrect real or imagined deficits. For female immigrants, the challenge to be part of mainstream society and to meet the beauty standards, including being slim, tall, and blond, becomes a struggle (Lee, 1993; Lee, Leung, Lee, Yu, & Leung, 1996; Pawson, Martirell, & Mendoza, 1991). Perhaps it is not surprising that as one acculturates, the awareness of body weight and the drive for thinness increases (Lee et al., 1996). However, no studies have examined maternal acculturation and children's physical health.

Results of the current study indicate that Chinese-American children of highly acculturated mothers had lower BMI, possibly because of an enhanced awareness of obesity, health issues related to obesity, or desirability of thinness that is reinforced in mainstream Western society.

Interestingly, children's dietary behaviors and levels of physical activity did not correlate with or contribute to their BMIs. The instruments used in this study to measure physical activity and dietary behavior might not be sensitive enough to accurately measure these behaviors. The FFQ was developed and tested in a population of Taiwanese children. Because it does not ask about other types of common American foods, further work is needed to develop a comprehensive food assessment tool. A more sensitive and culturally appropriate measure is needed to capture dietary behavior and intake in this population. The SAPAC is a self-report measure of physical activity. Although children were instructed to record time and intensity of the activities they performed during the daytime, underestimation or overestimations of time and intensity could have occurred. The difficulty in obtaining a more accurate assessment of children's levels of physical activity has been noted in other studies (Sallis, 1993).

Because this is one of the first research reports examining familial factors, children's health behavior, and obesity in Chinese-American children, there are some limitations. Children's BMI only measures children's weight relatively to their height based on their age and gender. Studies have found that BMI is not an equivalent measure of percent body fat for each race-sex group and suggest that gender and racial differences in the relationship of BMI to body fatness may be present throughout life (Deurenberg, Weststrate, & Seidell, 1991: Gallagher et al., 1996). Therefore, these studies suggested that there are important factors to consider when using BMI as a measure of obesity in children, particularly when the objective is to make comparisons across race or gender. Other physiological measures, such as skin-fold thickness and percentage of body fat, may be included as a measure of children's body fat.

A future study with a larger sample size of underweight, normal weight and overweight children might help to further explain the degree to which family factors and children's health-related behaviors contribute to children's weight status. Since mothers were invited to participate in the study, perceptions of family functioning only reflect the mother's perspective. A future study should include the perspectives of other family members, especially if extended family members are involved in the child's daily life. Additionally, because the study used only self-report measures, errors in measurement might have occurred. Use of observation technique and physiological measures may enhance the reliability and validity of study results. A longitudinal study examining the change in BMI over time and in different age groups will provide more accurate information on factors predict changes of BMI in Chinese-American children.

In conclusion, this study revealed that children's ages, a democratic parenting style, and poor family communication contribute to higher BMI in Chinese-American children. Other factors related to children's BMI and dietary intake include acculturation level of the mother and family affective responses. Families with clear communication, appropriate affective responses, and structured parenting help to regulate a child's health behavior. Thus, improving family communication can help improve health and maintain healthy weight in children.
Table 1. Simultaneous Multiple Regression Summary Table

                          Dependent variable: BMI
                                  N = 68

Source           [R.sup.2]         beta        [sr.sup.2] *

Overall             .263
Age                                .232           .015
ATCRS                             -.386           .17
Communication                      .284           .097

Source               df             F              p

Overall            3, 62           8.727          .001
Age                3, 62           4.50           .038
ATCRS              3, 62          12.72           .001
Communication      3, 62           6.69           .012

* [sr.sup.2] = percentage of variance explained by the variable


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Jyu-Lin Chen, PhD, RN, is Assistant Professor, University of California, San Francisco Department of Family Health Care Nursing, San Francisco, CA.

Christine Kennedy, PhD, RN, PNP, is Associate Professor, University of California, San Francisco Department of Family Health Care Nursing, San Francisco, CA.

Acknowledgments: This study was made possible by funding to the first author from the University of California Pacific Rim Research Program and Sigma Theta Tau Alpha Eta chapter at USCF.
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Author:Chen, Jyu-Lin; Kennedy, Christine
Publication:Pediatric Nursing
Geographic Code:1USA
Date:Mar 1, 2005
Words:5668
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