ORIGINAL RESEARCH

Level of acculturation, food intake, dietary changes, and health status of first-generation Filipino Americans in Southern California Felicitas A. dela Cruz, RN, DNSc, FAANP (Professor and Director)1 , Brigette T. Lao, RN, MA (Administrative Manager)2 , & Catherine Heinlein, RN, RD, EdD (Assistant Professor)3 1

Center for the Study of Health Disparities, School of Nursing, Azusa Pacific University, Azusa, California Medical Surgical/Definitive Observation Unit, Whittier Hospital Medical Center, Whittier, California 3 School of Nursing, Azusa Pacific University, Azusa, California 2

Keywords Filipino Americans; dietary intake and practices; dietary acculturation; anthropometric measurements; glycemic load; glycemic index. Correspondence Felicitas A. dela Cruz, RN, DNSc, FAANP, Center for the Study of Health Disparities, School of Nursing, Azusa Pacific University, 901 E. Alosta Avenue, Azusa, CA 91702. Tel: 626-815-5395 (work). Fax: 626-815-5090; E-mail: [email protected] Received: November 2011; accepted: August 2012 doi: 10.1111/1745-7599.12031

Abstract Purpose: This exploratory descriptive study investigates the acculturation level, food intake, dietary changes and practices, health status perceptions, and diet-related health indicators—body mass index (BMI), waist and hip circumferences, and waist-to-hip ratio—of first-generation Filipino Americans (FAs) in Southern California. Data sources: Healthy FA adults—20 women and 10 men—were interviewed. Acculturation level was obtained using A Short Acculturation Scale for Filipino Americans. A 24-h dietary recall elicited their food intake. Survey questions revealed dietary changes and practices, health status perceptions, and sociodemographic characteristics. Height, weight, waist and hip circumferences were measured. Conclusions: FAs consider themselves more Filipino than American, but their acculturation level reflects transitioning into biculturalism. FAs relinquish, maintain, and adapt elements of both Philippine and U.S. cultures in food intake, dietary changes, and practices. Although FAs perceive their health status as very good to excellent, many exceed the cut-off points for BMI, waist circumference, and waist-to-hip ratio. Implications for practice: This study underscores the importance of nurse practitioners and other healthcare givers conducting cultural dietary assessment as a basis for culturally appropriate dietary counseling. The inclusion of waist measurement to regularly monitor abdominal obesity—a predictor of cardiovascular disease and diabetes–is highly recommended.

The Filipino immigrant population in the United States has been increasing since the passage of the Immigration Act of 1965. Between 1970 and 2009, Filipino Americans (FAs) increased from 184,842 (Gibson & Jung, 2007) to 3.4 million (U.S. Census Bureau News, 2012), making FAs the second largest Asian group in the United States, behind Chinese Americans. In 2008, nearly half of foreign-born FAs resided in California, with more than one third residing in the Los Angeles-Long Beach-Santa Ana areas of Southern California (Terrazas & Batalova, 2010). Like other immigrants, FAs undergo acculturation during their sojourn in the United States. Acculturation

refers to the “process by which individuals adopt the attitudes, values, customs, beliefs, and behaviors of another culture” (Abraido-Lanza, Ambrister, Florez, & Aguirre, 2006, p. 1342). It is not, however, a linear process because it does not necessarily lead to a loss of a person’s ethnic identity (Beck, Froman, & Bernal, 2005). Hence, biculturalism (having two cultures) can ensue (Nguyen & Benet-Martinez, 2013), with immigrants being comfortable and proficient with both their own cultural heritage and the culture of the new country they have settled in (Schwartz & Unger, 2010). Immigrants can become bicultural—if they speak both the language of their original heritage and the host country, have friends from both

C 2013 The Author(s) Journal of the American Association of Nurse Practitioners 25 (2013) 619–630 

 C 2013 American Association of Nurse Practitioners

619

Level of acculturation, food intake, dietary changes, and health status

cultural backgrounds, and watch television programs, listen to radio programs, and read magazines from both cultural contexts (Schwartz & Unger, 2010). Changes associated with acculturation include dietary acculturation (Satia-Abouta, 2003)—the process “when members of a migrating group adopt the eating patterns/food choices of their new environment” (p. 74). Studies on acculturating ethnic groups have found that their dietary intake changes with time in the United States. For example, studies on Korean Americans (Yang, Chung, Kim, Bianchi, & Song, 2007), Thais (Sukalakamala & Brittin, 2006), and Mexican Americans (Montez & Eschbach, 2008) have all found that more acculturated immigrants and ethnic groups tend to adopt Westernized food, increasing their risks for dietaryrelated chronic illnesses. In spite of the steady increase in their numbers, FAs remain an invisible minority. Studies have shown that Filipino immigrants experience health disparities in two diet-related medical conditions: high blood pressure (Barnes, Adams, & Powell-Griner, 2008; California Health Interview Survey [CHIS], 2007) and diabetes (Araneta, Wingard, & Barrett-Connor, 2002; Office of Minority Health, 2011). Yet, a paucity of studies has examined FA dietary intake and the changes that occur as they acculturate to the United States. The purpose of this exploratory descriptive study was to investigate the (a) level of acculturation, (b) dietary intake, (c) changes in dietary intake since migrating to the United States, (d) dietary practices, and (e) health status perceptions and dietrelated health indicators—body mass index (BMI), waist and hip circumferences, and waist-to-hip ratio—of firstgeneration (Philippine-born) FAs. The study results will increase the sparse clinical knowledge about this ethnic group as well as inform the design of culturally appropriate nutritional counseling and intervention programs for first-generation FAs.

Methods Research design In this exploratory descriptive study, healthy FA adults—20 women and 10 men—were interviewed, and anthropometric measurements of height, weight, waist, and hip circumferences were taken. This study was part of a larger study that investigated the nutrient intake of healthy FAs. The university Institutional Review Board (IRB) approved the study. The study used the socioecological model for nutrition for its theoretical framework (Contento, 2007), which posits that personal, cultural, physiological, and environmental factors determine food intake, dietary changes, and practices. 620

F. A. dela Cruz et al.

Study settings The interviews and anthropometric measurements took place at a time and place mutually agreed upon by the interviewer and study participants. The majority of the participants chose their homes; only a few selected their work site.

Participants The participants met the following study criteria: (a) first-generation FA, and originally from one of the major islands of the Philippines—Luzon, Visayas, or Mindanao, (b) age 25 and older, (c) current residence in Southern California, (d) at least 5 years of residence in the United States, and (e) able to speak and understand English and Tagalog (the Philippine national language). Potential participants were excluded for prior medical conditions such as cancer, hypertension, and/or diabetes; or any health problem that required a definitive therapeutic diet; and for participation in a weight reduction program. Participants were recruited through personal contacts and from places frequented by FAs: beauty parlors, stores, and churches.

Data collection measures and procedures After training by a registered dietitian on how to carry out a 24-h dietary recall interview, a master’s prepared nurse who spoke fluent English and Tagalog and understood other Filipino dialects used in Luzon, Visayas, and Mindanao conducted the interviews. Participants signed a consent form after they were informed of the purpose of the study, their voluntary participation, confidentiality of responses, and the 1.5–2 h time for the study. Each participant received $30 as a token of appreciation. Data collection consisted of two parts: conducting an interview and obtaining anthropometric measurements. The interview covered the following topics: Twenty-four-hour dietary recall. The interviewer asked the participants to start with the last meal or snack that was eaten, and work backwards to recall all foods and beverages consumed during the last 24 h. Using a food recall kit (Gabel & Shuster, 2006), the interviewer asked the participants to estimate the amount and size of the foods eaten—using a cup, tablespoon, teaspoon, and ruler—and recorded the answers in a 24-h dietary recall form (Scott, Reed, Kubena, & McIntosh, 2007). This 24-h dietary recall has previously established significant correlations between observational and recall data, ranging from .46 to .92 (Scott et al., 2007). Dietary changes. Three questions adapted from The New Immigrant Survey (The NIS 2003–2, 2005) were used to examine similarities and differences in the

F. A. dela Cruz et al.

Level of acculturation, food intake, dietary changes, and health status

participants’ diet: (a) using a linear scale from 1 = the same to 10 = completely different, (b) what they eat now that was rarely eaten before coming to the United States, and (c) what they ate regularly before coming to the United States but rarely eat now. Dietary practices. Using questions adapted from a validated semiquantitative dietary history questionnaire for Chinese Americans (Lee, Lee, Ladenla, & Miike, 1994), the interviewer asked the participants about fat intake, specifically, the frequency (never, seldom, often, always, food not eaten, do not recall) of eating meat and trimming off the fat in the meat; eating chicken with the skin on it; using oil, butter, lard, bacon fat, or margarine in cooking meat, chicken, fish, and vegetables; and stir-frying vegetables, and about how beef was usually cooked (1 = rare; 2 = medium rare; 3 = medium; 4 = medium well; 5 = well done; 6 = variable; 7 = did not eat red meat). The study on Chinese Americans established significant correlations between nutrient intakes in the semiquantitative dietary history questionnaire and a typical day’s diet record, ranging from .21 to .66 (Lee et al., 1994). In addition, the interviewer asked the participants to identify the flavor enhancers used in preparing food as well as those used at the table. Traditional flavorings asked about included table salt, soy sauce, fish sauce, fermented fish, and other flavor enhancers high in sodium. Additionally, the interviewer asked the participants about their use of dietary supplements such as minerals and multivitamins.

Background information. The interviewer asked about and recorded the participants’ sociodemographic characteristics, including gender, marital status, age, age on arrival in the United States, years of U.S. residence, island of origin, dialects spoken, educational background, type of work and employment, family income, composition of household, religious preference, food preference, and self-identity. Health status perceptions. The interviewer asked and recorded how the participants perceived their health status—excellent, very good, good, fair, or poor (The NIS 2003–2, 2005). Anthropometric measures. After the interview, anthropometric measurements of height, weight, and waist and hip circumferences were obtained. The interviewer weighed the participants (without shoes and with light clothes on) using a self-calibrating battery operated electronic home weighing scale and measured their height with a metal tape measure, asking them to stand straight against a wall. In addition, using a nonelastic tailor’s tape measure, the interviewer measured in inches, the participants’ waist circumference—midway between the last palpable rib at the mid-axillary line and the top of the iliac crest (World Health Organization [WHO], 2011a), and the hip circumference—at the level of the symphysis pubis and the widest part over the buttocks (Dobbelsteyn, Joffres, MacLean, Flowerdew, & The Canadian Heart Health Research Group, 2001)—while they stood in a relaxed position.

A Short Acculturation Scale for Filipino Americans (ASASFA). The interviewer elicited the participant’s answers to this psychometrically validated measure (dela Cruz, Padilla, & Agustin, 2000; dela Cruz, Padilla, & Butts, 1998). The 12-item ASASFA includes three subscales of acculturation—language use and preference at work, at home, and with friends; language use and preference in media (TV and radio) programs; and preferred ethnicity of individuals in social relations. Participants respond to the first eight items, on language use and preference, using a Likert-type scale, ranging from 1 = only Philippine language(s), 2 = more Philippine language(s) than English, 3 = both Philippine language(s) and English equally, 4 = more English than Philippine language(s), and 5 = only English. For items 9–12, the subscale on ethnic relations, the response choices are 1 = all Filipinos, 2 = more Filipinos than Americans, 3 = about half and half, 4 = more Americans than Filipinos, and 5 = all Americans. The correlation between the ASASFA English and Tagalog language versions was .85, with an overall .85 Cronbach’s alpha. Principal components factor analysis yielded the three subscales of acculturation (dela Cruz et al., 1998, 2000).

Data analysis The types of food identified and portions consumed by the participants during the 24-h recall were content analyzed, sorted into food groups, and recorded in an Access database, as were the responses to the open-ended questions on dietary changes. This database was then imported into SPSS (version 16; SPSS, Chicago, IL) for analysis. In addition, data on the linear scale, dietary practices, fat intake questionnaire, ASASFA, background information, health perceptions, and anthropometric measurements were entered into SPSS. In this article, only the foods identified and eaten at meal times and snacks are reported. Frequency and percentages of all categorical data were computed, as well as means and standard deviations for continuous data. BMI was calculated by dividing weight in pounds by height in inches squared and multiplying by a conversion factor of 703 (Centers for Disease Control and Prevention [CDC], 2011). Waist-tohip ratio was obtained by dividing the waist measurement by the hip measurement.

621

Level of acculturation, food intake, dietary changes, and health status

F. A. dela Cruz et al.

Table 1 Demographic characteristics of participants (N = 30)

Table 1 (Continued)

Characteristic

Characteristic

Gender Female Male Marital status Married Single, widowed, divorced, separated Age in years as of last birthday 25–34 35–44 45–54 55–59 60–64 65–74 Median = 41.50 Mean = 44 (SD = 13.00) Age upon arrival in the United States 20 and below 21–40 >40 Mean = 28.6 (SD = 12.90) Years of residence in the United States 5–10 11–20 >20 Mean = 15.10 (SD = 7.92) Island of origin in the Philippines Luzon Visayas Mindanao Philippine dialects spokena Tagalog Bisaya,Cebuano, Ilonggo, Ilocano, Capampangan, Chavacano Highest educational attainment Elementary Some high school Completed high school Some college Completed college Some graduate school Employment Currently working Not working Type of work Management/professional and related occupations Sales and office Service Construction, extraction, and transportation Housewife Family income $5000–20,000 $21,000-$40,000 $41,000-$75,000 >$75,000

Frequency

Percentage

20 10

66.7 33.3

20 10

66.7 33.3

7 12 5 2 – 4

23.3 40.0 16.7 6.7 – 13.3

10 15 5

33.3 50.0 16.6

Percentage

17 5 8

56.7 16.7 26.6

27 2 1

90.00 6.7 3.3

1 15 14 –

3.3 50.0 46.7 –

14 10 4 2 –

46.7 33.3 13.3 6.7 –

a

11 13 6

36.6 43.3 20.0

20 5 5

66.6 16.66 16.66

29 15

96.7 50.0

2 1 4 10 11 2

6.7 3.3 13.3 33.3 36.7 6.7

20 10

66.6 33.3

5

25.0

5 8 1

25.0 40.0 5.0

1

5.0

7 4 8 11

23.3 13.3 26.6 36.6

In addition to Tagalog, many of the participants spoke several Philippine dialects.

Results Characteristics of participants

(Continued)

622

Household members Live with spouse Live with children under 18 Live with relatives Religious preference Roman Catholic Christian None mentioned Food preference Exclusively Filipino Food Mostly Filipino food, some American About equally Filipino and American Exclusively American food Self identity Very Filipino More Filipino than American Almost fifty-fifty More American than Filipino Very American

Frequency

Table 1 provides an overview of the participants’ background characteristics. Females and married participants comprised two thirds of the participants. The participants’ mean age was 44 years old (SD = 13). Most of them arrived in the United States at ages younger than 20 up to 40 years and have resided in the United States for an average of 15 years (SD = 7.92). The majority completed college, engaged in management/professional fields or sales and office work, and indicated a household income of >$75,000. With a few exceptions, the study participants showed similar sociodemographic characteristics when compared with FAs included in the 2010 Census (U.S. Census Bureau, 2012). For food preference, the participants almost equally preferred most Filipino food and some American, or both Filipino and American food. When asked about self-identity, nearly half identified themselves as totally Filipino, and a third as more Filipino than American.

Level of acculturation The overall mean on the acculturation scale was 2.85 (SD = 0.54), denoting that the participants were more Filipino than American but progressing toward biculturalism. The participants’ mean score on the subscale on language use and preference at home, work, and with friends was 2.67 (SD = 0.77), indicating a preference for Philippine language(s). In contrast, their mean score

F. A. dela Cruz et al.

Level of acculturation, food intake, dietary changes, and health status

(3.89, SD = 0.74) on the language use and preference in media (TV and radio programs) subscale showed that they prefer the English language over Philippine languages or dialects. Conversely, their mean score (2.29, SD = 0.50) on the preferred ethnicity of individuals in social relations subscale reveal that they favored Filipinos to Americans.

ear scale from 1 (the same) to 10 (completely different), the perceived dietary change registered a mean of 6 (SD = 0.50).

Dietary intake Table 2 shows the percentage of study participants eating common foods by food group at meal and snack times during a 24-h period. The table indicates that a sizeable majority ate three meals (breakfast, lunch, and supper) and nearly a half ate postbreakfast and postlunch snacks, and close to a quarter ate postsupper snacks. It also shows that there are common foods eaten at all these eating times—indicating that these foods are not particularly associated with any meal. In addition, the study demonstrates that participants consumed both traditional Filipino foods as well as American foods. The traditional Filipino foods eaten at all meals include: (a) steamed white rice as the main grain food, (b) processed meat (longaniza and chicharon), (c) beef, chicken, and pork, (c) fish or shrimp, (d) mixed dishes which are a combination of meat and poultry with vegetables, and (e) fresh fruits such as banana, papaya, cantaloupe, and mango. A glossary of the most common Filipino foods and dishes in this study is included in Table S1. At the same time, common American foods eaten at all meal times consist of: (a) bakery products such as bread, rolls, croissants, doughnuts, waffles, baguette, cookies, and crackers as grains; (b) processed meat (spam), (c) dairy products—milk, cheese, and yogurt; and (d) fresh fruits such as peaches, apples, and plums. Although Table 2 shows a negligible percentage of participants recalled consuming vegetables, legumes, and nuts, they consumed vegetables and legumes with mixed dishes—not as separate vegetable dishes. The participants acknowledged drinking a lot of water, coffee, and soda but rarely alcoholic drinks. Overall, the recalled 24-h dietary intake of FAs reveals that they drank plenty of beverages (water, coffee, and soda) and ate in order of frequency of consumption: (a) white rice and bakery products for grains; (b) beef, chicken, and pork for meat and poultry; (c) mixed dishes; (d) fresh fruits and juices; (e) dairy products; (f) seafood; and (g) desserts (see Figure 1).

Dietary changes Nearly two thirds of the participants perceived a change in the foods that they eat in the United States. On a lin-

Foods eaten a lot now but rarely eaten before coming to the United States. Nearly two thirds of the participants indicated that they now eat more beef, pork, and chicken, with nearly half of them specifying beef, beef steak, and hamburger. In contrast, nearly a fifth specified eating more seafood such as lobster, crab, shrimp, salmon, and tuna. In addition, more than half reported eating more fresh vegetables such as broccoli, lettuce, carrots, cucumbers, and salad greens. Other vegetables that they eat a lot in the United States in mixed dishes include celery, cauliflower, bean sprouts, tomatoes, green beans, okra, spinach, squash, bitter gourd, eggplant, and long beans. Also, close to half stated eating more fresh fruits such as bananas, grapes, pears, cherries, nectarines, apples, strawberries, mangoes, oranges, cantaloupes, melons, blueberries, and persimmons. Furthermore, nearly a fifth pointed out eating more commercially prepared cereals and bakery products; a sixth of the participants revealed drinking more milk and eating more dairy products (yogurt, cheese, and ice cream).

Foods regularly eaten in the Philippines but rarely eaten in the United States. The participants primarily cited native vegetables and fruits with limited availability or unavailable in Southern California. Additionally, the participants pinpointed that they rarely eat newly caught live fish and seafood. Similarly, they miss the native ways of food preparation liked kinilaw (newly caught, raw fish mixed with ginger and vinegar) and fish soup with malunggay leaves (leaves of the bean oil tree). They also miss eating dessert delicacies such as biko (sticky glutinous rice cooked in coconut and sugar), and suman malagkit (glutinous rice cooked in coconut milk and sugar, wrapped in ibus or buri leaves). Organ meat dishes prepared from freshly butchered cows, pigs, and goats were among the traditional viands that were missed. Finally, they missed native delicacies such as balut (fertilized duck embryo) and salted eggs.

Dietary practices Use of flavor enhancers. The study reveals that among the study participants flavor enhancers tend to be used in food preparation rather than at the table. More than half of the participants used ordinary salt in preparing food, followed by a third who used soy sauce, fermented fish sauce, and garlic salt. Although the majority of the participants stated that they rarely or never used flavor enhancers at the table while eating, a third of the participants used vinegar mixed with salt or fish sauce or 623

624

Grains and bakery products • White rice, steamed • Oatmeal • Ready-to-eat cereal, cereal bar • Bread, rolls, croissant, doughnut, waffle, baguette, cookies, crackers • Rice cake (puto) Meat and poultry • Eggs (fried/scrambled) • Processed meat (longaniza, chicharon, spam) • Beef, chicken, pork Seafood: fish or shrimps Mixed dishes (combination of meat and poultry with vegetables) • Pancit, chicken soup with bok choy, menudo, sauteed mung beans with shrimps and/or pork and amplaya (bitter gourd), beef stew, fish stew, chicken tinola, pinakbet, puso ng saging, arroz caldo, taco, spaghetti with turkey • Torta (ground beef with carrots and potatoes) ` Dairy products: milk, cheese, yogurt, ice cream, creme brulee Fresh fruits and juices • Banana, peaches, apple, papaya, plums, mango, cantaloupe, orange • Preserved fruits Legumes and nuts • Trail mix • Pistachio • Macadamia nuts, roasted Vegetables Beverages • Coffee (with sugar and creamer or without sugar and creamer) • Tea • Soda • Beer • Boost energy drink • Water Desserts • Maja blanca, Hopia, Yema • Mango ice cream, peaches in can, cassava cake • Chocolate bar, fruit salad, cake • M & M peanut candy

Food groups/common foods

53 – – 27 – – 6 45 30 30

– 3 17 – – – – – – – 20 – – 33 10 – – –

– 17 10 10 3 23

– 33 10 10 – – – – 50 3 – – – 36 – – – –

93

90 20 23 – 33

Lunch

Breakfast

Meal times

Table 2 Percentage of study participants eating common foods by food group at meal and snack times (N = 30)

– 17 6 –

7 17 13 – – 47

– – – –

10

30

– 20

43

– 10 37 20

–

50 – 3 23

100

Supper

– – – –

– – 3 – – 20

3 3 – 3

–

–

– –

–

– 3 – –

–

3 – – 30

40

Postbreakfast

Percentage of study participants eating

– – – –

13 – 10 – – 7

– – 3 3

–

10

3 3

–

– 3 7 –

3

– – 3 13

43

Postlunch

Snack times

– – – 3

13 – – 3 3 7

– – – –

–

–

– –

3

– – – –

3

3 – – 13

23

Postsupper

Level of acculturation, food intake, dietary changes, and health status F. A. dela Cruz et al.

F. A. dela Cruz et al.

Level of acculturation, food intake, dietary changes, and health status

the study participants exceeded the cut-off points for normal BMI as recommended by the National Heart, Lung, and Blood Institute [NHLBI]/National Institutes of Health [NIH], (2011) and the WHO (2011a). Of this percentage, 60% of the men were above the normal BMI: 30% were overweight (BMI ≥ 25 to 29.99) and 30% were obese (BMI > 30). Similarly, 40% of the women showed values above the normal BMI: 35% were overweight and 5% were obese. (Data on overweight and obese participants are not shown in Table 4.) At the same time, half of the men and slightly less than three-fourths of the women, respectively, exceeded the cut-off points for maximum waist circumference for Asians, as set by the International Diabetes Federation (IDF; Zimmet, Alberti, & Shaw, 2005), based on research that shows the existence of variation in the levels of obesity among population groups. Similarly, 70% of the men and 55% of the women, respectively, exceeded the waist-to-hip ratio cutoff points established by the WHO (2011b). Figure 1 Overall ranking of food groups consumed by study participants (N = 30) at all meals and snack times in a 24-h period.

soy sauce while eating; less than a fourth and a sixth used soy sauce alone and ketchup, respectively. Use of dietary supplements. Generally, a majority of the participants rarely or never took dietary supplements. Only a third took vitamin E while a fifth often or always used vitamin B6, B12, and calcium supplements. Fat intake. On the whole, the study showed that more than half to slightly less than two thirds of the study participants never and seldom ate meat, chicken, and fish cooked in oil, butter, lard, bacon fat, or margarine (Table 3). Similarly, over two thirds never and seldom added butter or margarine to the vegetables they ate; likewise, slightly over three-fourths never and seldom ate stir-fried vegetables. However, nearly half never and seldom trimmed the fat off the meat they ate; at the same time, nearly the same percentage cooked their meat medium rare and medium well, thereby retaining a high dietary fat content.

Health status: Perceptions and diet-related health indicators When participants were asked about their current health status, 17% rated their health status good, 63% very good, and 13% excellent. Table 4 displays the mean values of BMI, waist circumference, and waist-to-hip ratio and the percentage of study participants who exceeded recommended cut-off points for these healthrelated dietary indicators. The table shows that 46% of all

Discussion The study indicates that FAs consider themselves more Filipino than American, but their overall acculturation level reflects their transitioning into biculturalism. In addition, acculturating first-generation FAs give up, keep up, and pick up elements of both Philippine and U.S. cultures in their food intake, dietary changes, and practices. The study also shows that although FAs perceive their health status as good to excellent, health-related dietary indicators reveal that a significant percentage exceeded the recommended cut-off points for BMI, waist circumference, and waist-to-hip ratio.

Level of acculturation On the whole, the overall acculturation level of firstgeneration FAs alludes to their emerging biculturalism. These study results concur with previous studies on first-generation FAs’ level of acculturation (dela Cruz & Galang, 2008; Ea, Griffin, L’Eplattenier, & Fitzpatrick, 2008; Johnson-Kozlow et al., 2011; McAdam, Stotts, Padilla, & Puntillo, 2005). These studies have shown that levels of acculturation are associated with age at migration, length of stay, level of education, fluency with English, employment outside the home, and income.

Dietary intake, dietary changes, and practices This study reveals that the dietary intake of firstgeneration FAs who have been U.S. residents for 5 to >20 years has changed. Not only do they maintain their traditional foods but also incorporate American foods at each eating time, demonstrating an emerging 625

Level of acculturation, food intake, dietary changes, and health status

F. A. dela Cruz et al.

Table 3 Percentage of participants and frequency of dietary practice related to fat intakea (N = 30) Percentageb Dietary practice (a) When you ate meat, how often did you trim the fat off the meat? (b) When you ate meat, how often was it cooked in oil, butter, lard, bacon fat, or margarine? (c) When you ate chicken, how often did you eat it with the skin on it? (d) When you ate chicken, how often was it cooked in oil, butter, lard, bacon fat, or margarine? (e) When you ate fish, how often was it cooked in oil, butter, lard, bacon fat, or margarine? (f) When you ate vegetables, how often did you add butter/margarine to them? (g) When you ate vegetables, how often did you eat them stir fried? (h) When you ate beef, how was it usually cooked?

Never

Seldom (1/2 of the time)

Always

Food not eaten

Do not recall

3.3

40.0

20.0

36.7

–

–

–

60.0

23.3

16.7

–

–

16.7

43.3

20.0

20.0

–

–

6.7

56.7

30.0

6.7

–

–

6.7

56.7

30.0

6.7

–

–

36.7

33.3

23.3

6.7

–

–

6.7

73.3

16.7

3.3

–

–

Rare

Medium Rare 13.3

Medium Well 26.6

Well done 46.7

Variable

Did not eat red meat

3.3

10.0

– a b

Adapted from: Lee et al. (1994). Used with permission. Because of rounding of numbers, percentages may not add up to 100%.

Table 4 Mean values of BMI, waist circumference, waist-to-hip ratio and percentage of study participants exceeding recommend cut-off points (N = 30) Cut-off points Indicator

Mean value (SD)

BMI for both sexes • Men • Women Waist circumference • Men

25 (SD = 5) 26.42 (SD = 5.80) 24.69 (SD = 4.11)

• Women

Waist-to-hip ratio • Men • Women

a

Percentage of participants exceeding cut-off points

NHLBI/NIHa

WHOd

46 60 40

18.5–24.9 b

18.5–24.9e

g

>40 inches (>102 cm)

c

>37 inches (>94 cm)

>35 inchesc (>88 cm)

>31 inchesf (>80 cm)

36.25 inches (92.08 cm.) (SD = 4.52)

50

32.70 inches (83.06 cm.) (SD = 3.25)

70g

0.94 (SD = 0.09) 0.86 (SD = 0.05)

70

>0.90f

55

>0.85f

IDFg

f

For Asiansg >35 inches (>90 cm) For Asiansg >31 inches (>80 cm)

National Heart, Lung, and Blood Institute/National Institutes of Health. NHLBI/NIH (2011, June 25). c APT III. (2001). Third report of the expert panel of detection, evaluation, and treatment of high blood cholesterol in adults, Adult Treatment Panel (APT) III. National Heart, Lung, and Blood Institute. d World Health Organization. e WHO (2011a). f WHO (2011b). g International Diabetes Federation. (2005). The IDF consensus worldwide definition of the metabolic syndrome. Retrieved from http://www. idf.org/webdata/docs/MetSyndrome FINAL.pdf b

626

F. A. dela Cruz et al.

Level of acculturation, food intake, dietary changes, and health status

bicultural eating pattern (Satia-Abouta, Patterson, Neuhouser, & Elder, 2002). This bicultural eating pattern reflects dietary acculturation (Satia-Abouta, 2003). This dietary acculturation aligns with the findings of other studies on FAs (Johnson-Kozlow et al., 2011), Chinese Americans and Chinese Canadians (Satia et al., 2001), Korean Americans (Kim, Lee, Yang-Heui, Bowen, & Lee, 2007), Thais (Sukalakamala & Brittin, 2006), Hmong (Franzen & Smith, 2009), and Mexican Americans (Montez & Eschbach, 2008). In short, dietary acculturation resonates cross-culturally. The study participants cited a significant dietary change—they eat more beef (especially beef steak), pork, and chicken and dairy products. In addition, many indicated a preference for hamburgers from fast food restaurants. This increased meat intake along with a substantial number of study participants’ continued unhealthy related practices that increase their fat intake can escalate their risk for cardiovascular disease and diabetes (Nettleton, Polak, Tracey, Burke, & Jacobs, 2009). Meat and dairy products are expensive in the Philippines but are now within reach of most FAs in the United States—suggesting that this dietary change reflects their improved socioeconomic status. This dietary change underscores not only a sociodemographic determinant of food intake—the ability to purchase food—but also the social connotation of foods purchased and consumed. At the same time, the study participants indicated another important dietary change— they have increased their intake of fresh vegetables and fresh fruits as well as fish and shrimp. The increased consumption of fresh vegetables, fruits, fish, or shrimp can be explained by the availability of many Philippine foods in Southern California and the expansion of the participants’ vegetable intake to many of those commonly found in U.S. neighborhood groceries. These findings are consistent with Contento’s (2007) socioecological model which posits that the environment is a determinant of food intake. In the Philippines, the study participants’ diet generally consisted of rice, fish, and vegetables. The seas surrounding the Philippine islands provide newly caught live fish every day, and most families own small garden plots to grow fresh vegetables and fruits. Thus, fish, fresh vegetables, and fruits have been integral to the study participants’ diet before coming to the United States. A particular and important dietary change that the participants pinpointed in their vegetable intake is the eating of raw salad greens—an uncommon practice in the Philippines. In general, green leafy and other vegetables are cooked—not eaten raw—in the Philippines. Although the 24-h dietary recall does not show a lot of vegetable consumption, FAs generally eat vegetables in mixed dishes. In contrast to American eating practices,

FAs do not place all prepared foods on the plate at the same time but rather eat foods one at a time as a separate course. This practice may explain the minimal number of vegetables eaten as a separate food group in the 24-h recall. A sustained component of the traditional FA diet in the United States—hence a cultural determinant of food intake—is the consumption of white rice as the staple source of grain at all meals. To first-generation FAs, rice has been one of the earliest solid foods introduced in infancy; hence, it evokes symbolic meanings beyond the nourishment of the body. Rice symbolizes daily life in the Filipino culture—it has been embedded in music, in paintings, in the changes of the seasons, and in Filipino customs and practices, thus the central role of rice in the dietary intake of FAs. Nevertheless, steamed white rice has intermediate to high glycemic index (GI) as well as high glucose load (GL; Foster-Powell, Holt, & BrandMiller, 2002). At the same time, other foods with similar GI and GL that are now eaten at all meals in the United States include bakery products made from flour—bread, rolls, croissants, doughnuts, waffles, baguette, cookies, crackers (Foster-Powell et al., 2002). White rice and these bakery products are all processed foods. The GI is a measure of the speed at which food is digested and its effect on blood glucose and insulin levels (Beulens et al., 2007). High GI foods give a rapid increase in the blood sugar level that triggers an increase in insulin level. Similarly, GL is a measure that accounts for both the GI of food and its carbohydrate content. Studies have shown that sustained consumption of foods with high GI and high GL among women increase their overall risk of coronary heart disease (Beulens et al., 2007; Sieri et al., 2010) and stroke (Oh et al., 2005). A recent study by Sun et al. (2010) provides evidence that regular consumption of white rice in U.S. men and women is associated with an increased risk of type 2 diabetes. In sum, the dietary acculturation of FAs reflects both healthy and unhealthy elements. The increased intake of vegetables, fruits, and seafood (especially fish) reflects healthy eating, while the increased intake of meat, dairy, and bakery products reflects unhealthy eating.

Health status: Perceptions and diet-related health indicators A majority of the participants indicated that they have good to excellent health, a finding that concurs with recent studies on FAs (Berg, Rodriguez, de Guzman, & ´ & Sinay, 2008). Kading, 2001; Montano, Acosta-Deprez, However, their anthropometric measurements—BMI, waist circumference, and waist-to-hip ratio—suggest a trajectory of increasing weight and body fat. These 627

Level of acculturation, food intake, dietary changes, and health status

F. A. dela Cruz et al.

results confirm previous studies which demonstrated that immigrants who have lived in the United States for more than 10 years have shown increased BMI, and those who have lived for at least 15 years approximate that of U.S.born adults (Goel, McCarthy, Phillips, & Wee, 2004). This trend portends that they are at risk for cardiovascular conditions and metabolic disorders.

cut-off points for BMI, waist circumference, and waist-tohip ratio, suggesting risks for cardiovascular disease and diabetes. The results of this dietary study underscore the importance of nurse practitioners (NPs) and other professional healthcare givers conducting cultural dietary assessment when caring for FAs. This assessment—what they typically eat, how they prepare food, what dietary changes and practices they identify, and with whom they eat (Brown, 2003)—provides the information that can serve as the springboard for NPs to develop practical dietary counseling approaches that reinforce healthy dietary intake and practices from both the Philippine and U.S. cultures. NPs need to reinforce these healthy FA dietary intake and practices: drinking water regularly; regular mealtimes; increased intake of fish, fruits, and vegetables; use of boiling, steaming, roasting, and broiling in preparing foods; and balance of dietary intake (dela Cruz & Galang, 2008). Furthermore, NPs can advise FAs to use more of food enhancers such as garlic, ginger, onions, tomatoes, and other herbs and spices to limit the salt and fat used in preparing their favorite Philippine dishes. Further exploration of the actual rice intake of FAs over a longer period of time—beyond 24 h—is needed. NPs ought to address the intake of white rice among FAs by providing information about its high GI and GL and its adverse consequences. To help FAs keep track and limit their daily rice intake, NPs can recommend that they should put rice in a small bowl when they sit at the table to eat—instead of taking it from a general serving bowl— so they can actually observe the amount that they consume. Limiting their rice intake will be difficult initially, but NPs can draw upon the FA family value of taking care of one another by engaging a respected family member in this dietary change. Furthermore, NPs have to use available FA-tailored dietary information during their clinical encounters with FAs. An example that is readily available through the Internet from the U.S. Department of Health and Human Services, NHLBI/NIH, (2004) is Filipinos Take It to Heart: A How-to Guide for Bringing Heart Health to Your Community. Because studies have shown that immigrants increase their weight after 10 years of U.S. residence, NPs need to engage FAs during their early years in the United States in anticipatory dietary guidance and counseling— for them to maintain a healthy weight through healthy eating and adequate physical activity. Finally, NPs ought to include the measurement of waist circumference, in addition to height and weight, as part of the regular clinical data during the initial and followup visits of primary care patients. Measuring the waist circumference is a very inexpensive way to track and monitor abdominal obesity—a known critical predictor of

Limitations of the study This exploratory descriptive study has several limitations. First, the convenience sample and its small sample size can denote selection bias. Nonetheless, with a few exceptions, the overall convenience sample mirrors the 2010 U.S. Census sociodemographic characteristics of FAs. Second, the study participants could have forgotten some foods they have eaten during the 24-h recall, and the recalled day may not represent the regular dietary intake. An example is the discrepancy in vegetable intake. Also, they could have given socially desirable responses during the interview. However, the participants’ answers to the dietary recall and interview questions are supported by previous studies on FAs. And third, we did not collect data on the study participants’ physical activity levels. Hence, these limitations restrict the generalizability of the findings to the study participants. This study has several strengths because it adapted efforts to overcome cultural barriers in assessing FA dietary intake, changes, and practices. First, a trained FA who grew up in the Philippines and can fluently speak Tagalog—the Philippine national language—conducted the face-to-face interview with each study participant, providing a common cultural background that facilitated the 24-h dietary recall. Second, the study used a validated ethnic-specific acculturation measure instead of proxy measures. Finally, the interviewer actually measured the study participants’ height, weight, waist, and hip circumferences, providing definitive data that strengthens the validity of the study findings.

Conclusions, implications for practice, and further research The study indicates that the overall acculturation level of first-generation FAs is that they consider themselves more Filipino than American, but they are transitioning into biculturalism. As part of this transition, they experience dietary acculturation through the inclusion of elements of both Philippine and U.S. cultures in their food intake, dietary changes, and practices. This dietary acculturation, in turn, manifests in both healthy and unhealthy eating. In spite of their perception of good to excellent health status, many FAs exceed the recommended 628

F. A. dela Cruz et al.

Level of acculturation, food intake, dietary changes, and health status

cardiovascular disease and diabetes (Balkau et al., 2007; Janiszewski, Jannsen, & Ross, 2007). For further research, this study should be extended to a larger sample and to second-generation (U.S.-born) FAs, as well. In addition, future research needs to focus more broadly on the determinants of dietary intake, changes, and practices in both first- and second-generation FAs. This comparative research will increase the very limited dietary knowledge and information about FAs. This knowledge will help NPs and other professional healthcare givers develop culturally appropriate dietary education and counseling interventions tailored to each generation to promote healthy eating that in turn will reduce the risks for cardiovascular disease and diabetes for the burgeoning FA population in the United States.

Berg, J. A., Rodriguez, D. M., de Guzman, C. P., & Kading, V. M. (2001). Health status, health and risk behaviors of Filipino Americans. Journal of Multicultural Nursing and Health, 7(2), 29–36. Beulens, J. W., de Bruijne, L. M., Stolk, R. P., Peeters, P. H., Bots, M. L., Grobbee, D. E., & van der Schouw, Y. T. (2007). High dietary glycemic load and glycemic index increase risk of cardiovascular disease among middle-aged women: A population-based follow-up study. Journal of the American College of Cardiology, 50(1), 14–21. doi:10.1016/j.jacc.2007.02. 068 Brown, T. L. (2003). Meal-planning strategies: Ethnic populations. Diabetes Spectrum, 16(3), 190–192. doi:10.2337/diaspect.16.3.190 California Health Interview Survey (CHIS). (2007). Adult public use file. Release 1 [computer file]. Los Angeles, CA: UCLA Center for Health Policy Research, December 2008. Centers for Disease Control and Prevention (CDC). (2011, June). About BMI for adults. Retrieved from http://www.cdc.gov/healthyweight/assessing/ bmi/adult bmi/index.html Contento, I. R. (2007). Nutrition education: Linking research, theory, and practice. Sudbury, MA: Jones & Bartlett. dela Cruz, F. A., Padilla, G. V., & Butts, E. (1998). Validating a Short Acculturation Scale for Filipino Americans. Journal of the American Academy of Nurse Practitioners, 10(10), 453–460. doi: 10.1111/j.1745-7599.1998.tb00470.x dela Cruz, F. A., Padilla, G. V., & Agustin, E. O. (2000). Adapting a measure of acculturation for cross-cultural research. Journal of Transcultural Nursing, 11(3), 191–198. doi:10.1177/104365960001100305 dela Cruz, F. A., & Galang, C. B. (2008). The illness beliefs, perceptions, and practices of Filipino Americans with hypertension. Journal of the American Academy of Nurse Practitioners, 20(3), 118–127. doi:10.1111/j.1745-7599.2007.00301.x Dobbelsteyn, C. J., Joffres, M. R., MacLean, D. R., Flowerdew, G., & The Canadian Heart Health Surveys Research Group. (2001). A comparative evaluation of waist circumference, waist-to-hip ratio and body mass index as indicators of cardiovascular risk factors. The Canadian Heart Health Surveys. International Journal of Obesity, 25, 652–661. doi:10.1038/sj.ijo.0801582 Ea, E. E., Griffin, M. Q., L’Eplattenier, N., & Fitzpatrick, J. J. (2008). Job satisfaction and acculturation among Filipino Registered Nurses. Journal of Nursing Scholarship, 41(1), 46–51. doi:10.1111/j.1547-5069.2007. 00205.x Foster-Powell, K., Holt, S. H., & Brand-Miller, J. C. (2002). International table of glycemic index and glycemic load values: 2002. American Journal of Clinical Nutrition, 76(1), 5–56. Franzen, L., & Smith, C. (2009). Acculturation and environmental change impacts dietary habits among adult Hmong. Appetite, 52(1), 173–183. doi:10.1016/j.appet.2008.09.012 Gabel, C., & Shuster, E. (2006). Group 24 hour dietary recall protocols. College Station, TX: Texas A&M University. Gibson, C., & Jung, K. (2007). The foreign-born population of the United States: 1850–2000. NY: Nova Science Publishers. Goel, M. S., McCarthy, E. P., Phillips, R. S., & Wee, C. C. (2004). Obesity among US immigrant subgroups by duration of residence. JAMA, 292(23), 2860–2867. doi:10.1001/jama.292.23.2860 Janiszewski, P. M., Janssen, I., & Ross, R. (2007). Does waist circumference predict diabetes and cardiovascular disease beyond commonly evaluated cardiometabolic risk factors? Diabetes Care, 30(12), 3105–3109. doi:10.2337/dc07-0945 Johnson-Kozlow, M., Matt, G. E., Rock, C. L., dela Rosa, R., Conway, T. L., & Romero, R. A. (2011). Assessment of dietary intakes of FilipinoAmericans: Implications for food frequency questionnaire design. Journal of Nutrition Education and Behavior, 43(6), 505–510. doi:10.1016/j.jneb. 2010.09.001 Kim, M. J., Lee, S. J., Yang-Heui, A., Bowen, P., & Lee, H. (2007). Dietary acculturation and diet quality of hypertensive Korean Americans. Journal of Advanced Nursing, 58(5), 436–445. doi:10.1111/j.1365-2648.2007. 14258.x

Acknowledgments This study was supported in part by the Center for the Study of Health Disparities (CSHD) at the School of Nursing (SON), Azusa Pacific University (APU). The authors thank the 30 Filipino Americans who voluntarily participated in the study; Martha Ann Carey, RN, PhD, former Director of Research at the SON, APU for her ideas, reassuring presence, and encouragement during the early stage of our study; Annaliza Santos, BS, Administrative Assistant, for entering the data on the 24-h dietary recall and dietary changes into an Access database; and the CSHD student assistants: Angela Perez, MSN student, for assisting in preparing the data for analysis; and the undergraduate students—Tony Jien, Heather Scott, Ellen Husted—and MSN student, Supraja Komandur Elaiyavalli—for searching and retrieving the related literature.

References Abraido-Lanza, A. F., Ambrister, A. N., Florez, K. R., & Aguirre, A. N. (2006). Toward a theory-driven model of acculturation in public health research. American Journal of Public Health, 96(8), 1342–1346. doi:10.2105/AJPH.2005.064980 Araneta, M. R., Wingard, D. L., & Barrett-Connor, E. (2002). Type 2 diabetes and metabolic syndrome in Filipina-American women. Diabetes Care, 25(3), 494–499. doi:10.2337/diacare.25.3.494 ´ J.-P., Bassand, J.-P., Fox, K. A., Smith, S. Balkau, B., Deanfield, J. E., Despres, C., . . . Haffner, S. M. (2007). IDEA: A study of waist circumference, cardiovascular disease and diabetes in 168,000 primary care patients in 63 countries. Circulation, 116(17), 1942–1951. doi:10.1161/circulationaha.106.676379 Barnes, P. M., Adams, P. F., & Powell-Griner, E. (2008, January 22). Health characteristics of the Asian adult population: United States, 2004–2006. CDC: Advance Data from Vital and Health Statistics, 394, 1–22. Retrieved from http://www.cdc.gov/nchs/data/ad/ad394.pdf Beck, C. T., Froman, R. D., & Bernal, H. (2005). Acculturation level and postpartum depression in Hispanic mothers. MCN American Journal of Maternal Child Nursing, 30(5), 299–304.

629

Level of acculturation, food intake, dietary changes, and health status

F. A. dela Cruz et al.

Lee, M. L., Lee, F., Ladenla, S. W., & Miike, R. (1994). A semiquantitative dietary history questionnaire for Chinese Americans. Annals of Epidemiology, 4(3), 188–197. doi:10.1016/1047-2797(94)90096-5 McAdam, J. L., Stotts, N. A., Padilla, G., & Puntillo, K. (2005). Attitudes of critically ill Filipino patients and their families toward advance directives. American Journal of Critical Care, 14(1), 17–25. Montano, J. J., Acosta-Deprez, V., & Sinay, T. (2008). Assessing the health care needs of Filipino Americans in greater Long Beach. Public Administration & Management, 13(3), 156–190. Montez, J. K., & Eschbach, K. (2008). Country of birth and language are uniquely associated with intakes of fat, fiber, and fruits and vegetables among Mexican-American women in the United States. Journal of the American Dietetic Association, 108(3), 473–480. doi:10.1016/j.jada.2007.12.008 National Heart, Lung, Blood Institute/National Institutes of Health (NHLBI/NIH). (2011, June 25). Calculate your body mass index. Retrieved from http://www.nhlbisupport.com/bmi Nettleton, J. A., Polak, J. F., Tracy, R., Burke, G. L., & Jacobs, D. R., Jr. (2009). Dietary patterns and incident cardiovascular disease in the multi-ethnic study of atherosclerosis. American Journal of Clinical Nutrition, 90, 647–654. Nguyen, A-M. T. D., & Benet-Martinez, V. (2013). Biculturalism and adjustment: A meta-analysis. Journal of Cross-Cultural Psychology, 44(1), 122–159. doi: 10.1177/0022022111435097 Office of Minority Health. (2011, March 29). Asian American/Pacific Islander Profile. Retrieved from http://minorityhealth.hhs.gov/templates/ browse.aspx?lvl=2&lvlID=53 Oh, K., Hu, F. B., Cho, E., Rexrode, K. M., Stampfer, M. J., Manson, J. E., . . . Willett, W. C. (2005). Carbohydrate intake, glycemic index, glycemic load, and dietary fiber in relation to risk of stroke in women. American Journal of Epidemiology, 161(2), 161–169. doi:10.1093/aje/kwi026 Satia, J. A., Patterson, R. E., Kristal, A. R., Hislop, T. G., Yasui, Y., & Taylor, V. M. (2001). Development of scales to measure dietary acculturation among Chinese-Americans and Chinese-Canadians. Journal of the American Dietetic Association, 101(5), 548–553. doi:10.1016/s0002-8223(01)00137-7 Satia-Abouta, J. (2003). Dietary acculturation: Definition, process, assessment, and implications. International Journal of Human Ecology, 4(1), 71–86. Satia-Abouta, J., Patterson, R. E., Neuhouser, M. L., & Elder, J. (2002). Dietary acculturation: Applications to nutrition research and dietetics. Journal of the American Dietetic Association, 102(8), 1105–1118. doi:10.1016/s0002-8223(02)90247-6 Schwartz, S. J., & Unger, J. B. (2010). Biculturalism and context: What is biculturalism, and when is it adaptive? Human Development, 53, 26–32. doi:10.1159/000268137 Scott, A. R., Reed, D. B., Kubena, K. S., & McIntosh, W. A. (2007). Evaluation of a group administered 24-hour recall method for dietary assessment. Journal of Extension [Online], 45(1) Article 1RIB3. Retrieved from http://www.joe.org/joe/2007february/rb3p.shtml Sieri, S., Krogh, V., Berrino, F., Evangelista, A., Agnoli, C., Brighenti, F., . . . Panico, S. (2010). Dietary glycemic load and index and risk of coronary

heart disease in a large Italian cohort: The EPICOR Study. Archives of Internal Medicine, 170(7), 640–647. Sun, Q., Spiegelman, D., van Dam, R. M., Holmes, M. D., Malik, V. S., Willett, W. C., & Hu, F. B. (2010).White rice, brown rice, and risk of type 2 diabetes in US men and women. Archives of Internal Medicine, 170(11), 961–969. Sukalakamala, S., & Brittin, H. C. (2006). Food practices, changes, preferences and acculturation of Thais in the United States. Journal of the American Dietetic Association, 106(1), 103–108. doi:10.1016/j.jada.2005.09.050 Terrazas, A., & Batalova, J. (2010, April). US in focus: Filipino immigrants in the United States. Migration Information Source. Migration Policy Institute. Retrieved from http://www.migrationinformation.org/USFocus/ display.cfm?ID=777 The New Immigrant Survey (NIS). (2005). The New Immigrant Survey 2003–2: Section D-Health. Retrieved from http://nis.princeton.edu/nis 2003–2 questionaires.html U.S. Census Bureau. (2012). American FactFinder: Selected population profile in the United States 2010 American Community Survey 1 year estimates. Retrieved from http://www.census.gov/population/cen2000/stp-159/STP-159philippines.pdf U.S. Census Bureau News. (2012, March 21). 2010 Census shows Asians are fastest-growing race group. Retrieved from http://2010.census.gov/news/ releases/operations/cb12-cn22.html U. S. Department of Health and Human Services, National Heart, Lung, Blood Institute/National Institutes of Health (NHLBI/NIH). (2004, March). Filipinos take it to heart: A how-to guide for bringing heart health to your community. Retrieved from http://www.nhlbi.nih.gov/health/ prof/heart/other/filipinos tith.pdf World Health Organization (WHO). (2011a). Global database on body mass index. Retrieved from http://apps.who.int/bmi/index.jsp WHO. (2011b). Waist circumference and waist-hip ratio: Report of a WHO expert consultation, Geneva, 8–11 December 2008. Retrieved from http://whqlibdoc. who.int/publications/2011/9789241501491 eng.pdf Yang, E. J., Chung, H. K., Kim, W. Y., Bianchi, L., & Song, W. O. (2007). Chronic diseases and dietary changes in relation to Korean Americans’ length of residence in the United States. Journal of the American Dietetic Association, 107(6), 942–50. doi:10.1016/j.jada.2007.03.005 Zimmet, P., Alberti, G., & Shaw, J. (2005). A new IDF worldwide definition of the metabolic syndrome: The rationale and the results. Diabetes Voice, 50(3), 31–33.

630

Supporting Information Additional Supporting Information may be found in the online version of this article at the publisher’s website: Table S1. Dietary intake glossary of terms.