A Case for an AAPI 5 a Day and Physical Activity Campaign

Marjorie Kagawa-Singer, PhD, MN, RNUCLA School of Public Health and

Asian American Studies Dept.

California Asian American Nutrition and Physical Activity Campaign

API Demographics in California

• The Asian American1 population in California by 56% since 1999.

• California: 4.2 million Asian and Pacific Islanders (API) = ~35% of the total US AAPIs.

• AAPIs = 11% of California’s population and >4% of total US population.

• Census projections reveal that the national API population will increase to 6.2% by 2025.(http://ca.rand.org/stats/popdemo/popprojUS.html)

Census data, population projections1 Non-Hispanic, Asian alone or in combination with one or more raceshttp://quickfacts.census.gov/qfd/states/06000.html

Asian population in US and California

From 1992 to 2001, Overweight Increased Most Sharply for California API Low-Income Children, Increasing from 5.9% to 13.4%

35%43%

50%60%

127%

0%

20%

40%

60%

80%

100%

120%

140%

AN/AI Latino Black White Asian/PI

AN/AILatinoBlackWhiteAsian/PI

Overweight = BMI > 95th percentile. Overweight is comparable to obesity in adults. * Children 5 - >20 years oldSource: California Dept. of Health Services, Children’s Medical Services Branch, California Pediatric Nutrition Surveillance System

Percent change of overweight, low-income CA children*

9.0

8.5

5.9

4.53.93.33.12.62.3

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

40.0

45.0

50.0

NHANES III and NHANES1999-2000

Perc

ent o

f Tot

al A

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aily

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French fries

Potato chips, cornchips, popcornHamburgers

Pizza

Cake, sweet rolls,donuts, pastryAlcoholic beverages

White bread, rolls,bagels, etc.Misc desserts andsweetsSoft drinks, frut-flavored drinks

Block, J Food Comp Analysis, 2004,

More Than 40% of U.S. Calories Came from Sweets, Soda, Refined Grain, and High Fat,

High Salt Burgers, Pizza, and Chips

Cancer by Acculturation…or is it assimilation?• Breast cancer: Migrants from Japan to Hawaii assume the cancer rate of host country within one or two generations.

•45 year old Japanese American women living in San Francisco are 5 times more likely to develop breast cancer than Japanese women living in Japan.

•Environmental factors and movement to US larger factor in increasing breast cancer than genetic risk.

(McPherson K, British Medical Journal, 2000)

Obesity by Acculturation• Rate of overweight among immigrant API increases with number of years in the US.

• Obesity more than doubled between first and second generation Asian-American adolescents.

• For both Hispanic and Asian groups, children born outside the U.S. showed less obesity than those born in US of immigrant parents. Acculturation effect is especially strong for Asians.

•1996 Medical Expenditure Survey shows: Black, Latino, and API adolescents more overweight.

Haas JS, American Journal of Public Health, 2003

Popkin BM, American Society for Nutritional Sciences, 1997

Greatest Impact on Children

Susan L. Roberts, JD, MS, RD

Drake University Agricultural Law Center

Energy Intake – The Sugar Example

OBESITY EPIDEMIC FACTORS

Refined Sugar HFCS Other Total

1966 97.3 lbs. 0 15.6 lbs. 113 lbs.

2001 64.4 lbs. 62.6 lbs. 20.3 lbs. 147 lbs.

Haley et. Al., USDA, ERS, June 2003.

Annual Per Capita Sweeteners Increased by 34 lbs. = 59,737 Kcal = 71 CP

Overweight/Obesity: Asian-Specific Health Issues

• Evidence mounting: BMI overweight and obesity cut-points are too high

for people of Asian descent = 30 BMI

For Asian Americans = 28 BMI• Higher risk for Type 2 diabetes and CVD• Greater risk for CANCER?!

• And what about the kids?

Soft drink intake for children aged 2-17 increased 65 percent between 1989-91 and 1994-95

100 extra kcal/day = 10 lbs extra weight/year

05

10152025303540455055606570

1989-91 1994-95

Tea

spoo

ns/d

ay

Morton J. Fam Econ Nutr Rev 1998;11(3) CSFII 1989-91 versus 1994-95, 1-day data set

148 kcal9 tsp. sugar

244 kcal15 tsp.

Japan China Korea Malaysia Taiwan

64 oz.800 kcal59 tsp sugar

32 oz.400 kcal29 tsp

32

…and the social norm for serving size grows…and grows

44 oz.550 kcal41 tsp

16 oz.200 kcal14.5 tsp

Supersizing can add 1200 calories to a fast food meal…and costs only pennies

Producing super-sized children

“Colonel Sanders’ March on China”Time Asia, Nov. 17, 2003

Marketing to communities of color is very strong - http://www.i-am-asian.com/

Ad campaign“i am asian”

Chinese Lunar New Year Celebration, San Francisco/2004

Marketing Doesn’t Stop at the U.S. Border

Kentucky Fried Chicken in Japan and China

McDonalds in China

Low-Income Asian subgroups in California

Asian subgroups in California

Total number of individuals per

subgroup

Total number of individuals

below 185% FPL

% of individuals below 185% FPL

Asian alone (all groups combined 3,634,242 934,475

55,383

46,100

34,205

158,778

232,853

1,725

57,235

25.7%

*Hmong alone 68,364 81.0%

Cambodian alone 70,341 65.5%

Laotian alone 56,237 60.8%

*Vietnamese alone 441,684 35.9%

*Chinese alone 963,601 24.2%

Other specified Asian alone 7,557 22.8%

Asian Indian alone 303,475 18.9%Census 2000 data*Target of API formative research project

Sample Selection Criteria

Ethnicity: Chinese, Hmong, and Vietnamese

Poverty: Below 185% federal poverty levelSites: Los Angeles, San Francisco, Fresno,

Sacramento, Elk Grove, Little Saigon, San Jose

Participants: 116 Adult FG Participants, age 25-80105 Youth FG Participants, age 11-1415 Key Informants, age 25-62

236 Total

Community Partners

UC Extension, Berkeley

Kai Ming Head Start Stone

Soup

Hmong Women’s Heritage Association

Chinatown Service Center

Vietnamese American Cancer Foundation

Target Communities

Chinese Hmong Vietnamese TotalMale Female Male Female Male Female

Adult 4 36 5 39 4 28 116Youth 17 16 18 22 10 22 105Key Informant 2 3 2 3 2 3 15

236Adult Age Range: 25-80 years old (all 1st generation)

Youth Age Range: 8-14 years old

K.I. Age Range: 25-62 years old

Two overall goals for campaign from CAANPAC findings:

1) Maintenance of cultural integrity and pride

2) Necessity of cultural tailoring

Common Health Beliefs of Chinese, Hmong and Vietnamese

Importance of F&V consumption and PA for general healthHealth includes concept of harmonious family and balance Healthy foods = fresh foods: pesticide-free, recently picked/slaughtered, hormone-free, non-frozen, not cannedConcept of “warm” and “cool” foodsHome-cooked meals healthier than eating out

Definitions of HealthCOMMONALITIES:• Eating healthy/nutritious foods like F&V• Eating a variety of foods (Food Pyramid)• Mental & emotional stability• Being physically active• Having a harmonious family • Concept of Balance

CULTURE SPECIFIC:• Hmong and Chinese:

• Good hygiene/cleanliness • Having good environment (air quality, free of dirt and germs

• Chinese:• Longevity and money • Regular eating times • Adequate sleep/rest

• Vietnamese:Being independent and able to provide for one’s family

Healthy Foods

COMMONALITIES:• Fresh foods (pesticide free, hormone-free, non-frozen, not

canned , recently picked/slaughtered)• Fruits and Vegetables• Meats (fish, pork, chicken)• Rice/noodles

CULTURE SPECIFIC:• Chinese, Vietnamese: Soybean products• Chinese: Yogurt, Eggs• Hmong: Breads

Unhealthy FoodsCOMMONALITIES:

Dried/preserved foods (dried meats, Ramen noodles)

Excessive meatsExcessive sweets (candy, sweet cereals)Fast foods/Fried foods (hamburgers, French fries, chips, fried chicken)Foods with pesticides/fertilizers/hormonesFrozen foods

CULTURE SPECIFIC:Chinese, Viet: Excessively salty/spicy foodVietnamese: Fish Sauce/MSG Chinese: Potatoes – “high in carbs”

Shrimp, Crab, Fish w/out scales – “high cholesterol”

Cultural Interpretations of Food

Concept of “Warm” and “Cool”FoodsWarm and cool foods should be eaten separately (Chinese) Cold water and foods shouldn’t be eaten by women because it affects reproductive system “abnormal periods”

Home cooked meals healthier than eating out

Fast food ~ McDonalds, KFC, and Chinese take-out

Fruits & VegetablesCommonly Eaten Fruits:

Most frequently mentioned : Bananas and OrangesChinese: Grapes, pears, watermelons, lychees,etc.Hmong: Guava, mango, pineapple, kiwis, etc. Vietnamese: Durian, rose apple, jackfruit, rambutan, etc.

Commonly eaten Vegetables:Traditional vegetables and common U.S. vegetablesChinese: Bok choy, Chinese greens, Chu san (Bamboo

shoots), Kai lan (Chinese broccoli)Hmong: Beans, cabbage, broccoli, corn, mustard and

collard greens, eggplant, peas, and squashVietnamese: Ong Choy and Rau Den (Viet spinach)

Fruits & Vegetables% of Respondents Who Said Children ACTUALLY Eat 5 Or More Svgs of F&V a Day*

*General trends. Total number of respondents vary between each age and ethnic group

Youth Adult

Chinese 21% 40%

Hmong 64% 40%

Vietnamese 31% 17%

Fruits & Vegetables% of Respondents Who Said Children SHOULD Eat 5 Or More Svgs of F&V a Day*

*General trends. Total number of respondents vary between each age and ethnic group

Youth Adult

Chinese 55% None knew

Hmong 89% None knew

Vietnamese 43% None knew

Fruits & VegetablesTime of Day/FAV

COMMONALITIES:• Fruit eaten throughout the day as a snack or after dinner as dessert• Vegetables usually served at every meal

Benefits of FAVCOMMONALITIES:• Contains vitamins and minerals• Provide energy and strength

DIFFERENCES:• Chinese:

• Fiber – easy to digest and prevents constipation • Make people beautiful

• Hmong: Prolongs life

• Hmong and Chinese: Prevent sickness and diseases

Physical ActivityTypes of PACOMMONALITIES:• Sports (e.g. Baseball, Football, Volleyball, etc.)• House work/cleaning, mowing the lawn, etc.• Playing with friends• Walking, Tai Chi

CULTURE SPECIFIC: • Chinese: Squash,

Table Tennis,Skateboarding, Tae Kwon Do

• Hmong: Hunting, Tulu, Kato, Stretching • Vietnamese: Meditation

Physical Activity

% of Respondents Who Said Children SHOULD Do 60 min or more of PA a Day*

*General trends. Total number of respondents vary between each age and ethnic group

Youth Adult

Chinese 92% 90%

Hmong 60% 13%

Vietnamese 64% 0%

Physical Activity

% of Respondents Who Said Children ACTUALLY Do 60 min or more of PA a Day*

*General trends. Total number of respondents vary between each age and ethnic group

Youth Adult

Chinese 77% 69%

Hmong 59% 67%

Vietnamese 93% 40%

Physical ActivityFrequencyChinese: 5 days a weekHmong: 3.2 days a weekVietnamese: “occasionally” to everyday

LocationCOMMONALITIES:

Backyards/home or friend’s homeNeighborhood streetsParks and PlaygroundsSchool

CULTURE SPECIFIC:Chinese: Beaches

Community-based agencies Vietnamese: GymsChinese & Hmong: Recreation facilities, YMCA

Faith-based organizations

Physical ActivityConcerns re: ObesityChinese:• Most KI and a few parents expressed concerns• Change in eating habits• Excessive use of television and computersHmong:• Substantial number of parents and children

experienced weight gain since moving to U.S.• American food and physical activityVietnamese:• Some children were or are becoming overweight• Unfamiliar with foods consumed at school

BarriersTo F&V Consumption

COMMONALITIES:• Eating at fast food restaurants• Feeding kids what they want to eat (unhealthy foods)• Lack of money• Lack of time/energy to prepare meals

CULTURE SPECIFIC:Chinese: * Lack of information regarding importance of F&V

* Availability of certain F&V in markets * Poor quality and limited selection at school

Chinese and Hmong* Children dislike taste of certain F&V

Vietnamese and Hmong* Lack of land/gardens to grow certain F&V

Barriers to Physical Activity/Exercise:

COMMONALITIES:Distraction from academic studiesBelieve girls should not play aggressive sportsEnvironmental safety (e.g. bad air quality, pollution, gangs, crime, and unsafe neighborhoods)Lack of time and energy to participateLack of community resources and access to nearby parks & recreational facilitiesLanguage barriersLittle information about PA programs

CULTURE SPECIFIC:Hmong: Individual Safety– bodily injuries Vietnamese: Too much time on computers, TV, video games Chinese: Lack of knowledge about rec. amt of PA timeChinese & Hmong: Too expensive to enroll children in programs

Ways to Encourage/MaintainF & V Consumption:COMMONALITIES

Highlight importance of eating F&V dailyCreative cooking to include F&V in every mealEducate parents and children about proper nutrition and benefits of F&VHave family dinners & create positive eating environmentParents serve as role modelsPurchase/serve more F&VTeach children at an early age to eat F&V

Ways to Encourage/MaintainPhysical Activity:

All groups agreed:Reinforce tradition of family activities with childrenProvide low-cost or free supervised physical activities in the communityImprove access to parks and playgrounds

Strategies and SuggestionsMediaCOMMONALITIES:• In-language TV and radio• Parents: commercials/PSAs between 6pm-8pm• Use networks/programs children enjoy watching

(e.g. cartoons)• Shock campaigns (e.g. Truth.com)• Using animation, celebrities, and/or athletes to

market the message (e.g. Got Milk?)• Billboards and signs also mentioned

CULTURE SPECIFIC:• Chinese: In language newspapers • Hmong: In language health videos • Vietnamese: In language TV and radio

Common Strategies and SuggestionsEducational Materials/Workshops & Classes

In-language materialsVisual: pamphlets, stickers, health videos,

posters, book covers, key chainsAudio: Radio, incorporate music/jingleMore pictures, less wordsEducational classes

Locations for Education/OutreachChurches/templesCommunity-based agenciesDoctor’s offices/clinicsHealth fairsAsian SupermarketsSchools

Strategies and SuggestionsHealth Information MessengersCOMMONALITIES:

Parents (mothers)TeachersCommunity health outreach worker/social workersCommunity/religious leadersDoctors, Nurses, Nutritionists, Health educators

CULTURE SPECIFIC:Chinese: Celebrities and Athletes Hmong: Counselors, Friends/PeersChinese & Hmong: PTA

Maintenance of cultural integrity and pride

Lack of knowledge of benefits of traditional culturalactivities, foods and family practices to pass on to their childrenLack of knowledge of healthy mainstreamAmerican foods, sports and family expectationsLack of time default of convenience of American style meals and foodsChildren preferred (enjoyed) traditional foods and family timeBlending of traditional and American style foods –congee and hot dogs, “Shalom Shanghai”

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Our Next Step…Pilot & unveil Asian 5 a Day campaign!!!

“Counter” market the American diet & sedentary lifestyleProtect traditional diets, PA, view of balance &

healthCampaigns in-language Chinese (Cantonese and

Mandarin), Vietnamese and HmongTarget moms to stop erosion of health for kids