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1 Copyright is owned by the Author of the thesis. Permission is given for a copy to be downloaded by an individual for the purpose of research and private study only. The thesis may not be reproduced elsewhere without the permission of the Author.

2 Dietary acculturation of Chinese in the Manawatu in association with risk factors for type 2 diabetes A thesis presented in partial fulfillment of the requirements for the degree of Master of Science in Nutritional Science at Massey University, Palmerston North, New Zealand. Ying Jin December, 2007

3 Abstract Acculturation is known to affect migrants' dietary habits and eating patterns. To evaluate the influence on the diets of Chinese migrants who have settled in New Zealand and its relation to risk factors for type 2 diabetes mellitus, a total of 46 self-selected participants took part in this 2006 dietary acculturation study in the Manawatu region. The majority was from Mainland China, and more than 40% of the entire group had a family history of diabetes, which was possibly the underlying motivation for them to take part in this study. In addition, Chinese participants were less likely to visit their preferred General Practitioners regularly, unless they felt unwell, when compared to New Zealand population. The participants' acculturation levels were evaluated by the Suinn-Lew Asian Self-identify scale, and most of the participants identified themselves as Asian. The entire group was divided into two acculturation groups (Low and High) by using a cut-off point (2.0) from the acculturation scores. Three demographic variables, arrival age, residency length, and current age, were investigated. It was significant that the residency length was negatively associated with the acculturation score (P< 0.001). Participants who had younger arrival ages gained higher acculturation scores; they had become more acculturated to Western culture. Food frequency questionnaires and 24-hour dietary recalls were used to collect the participants' dietary information. The participants with high acculturation scores were more likely to consume Western-style foods more frequently, and to have sedentary lifestyles. In contrast, participants with low acculturation scores were more likely to have traditional eating patterns. In addition, participants with high acculturation scores consumed morning or afternoon tea more frequently than those people in the low acculturation group (P < 0.05); having morning or afternoon tea is popular in New Zealand. Breakfast was the first meal to be Westernised among the study participants. One of the significant findings was

4 that energy intakes from dietary fat were 36.4% (females) and 38.6% (males), and these were higher than the recommended less than 35% of total energy intake from fat. Also, low dietary intakes of vitamin D, calcium and folate, together with an extreme high sodium intake, were observed in the study group. To provide additional data, body weight, height, waist and hip circumferences were measured in this study. The BMI values, waist circumference and W/H ratio were used as markers of risk factors for heart diseases and diabetes. Based on the Chinese Standards for BMI and waist circumference, more than 50 percent of male participants were considered as either overweight or obese. Furthermore, females with low acculturation scores had greater BMI values than those in the high acculturation group (P < 0.05). Three blood tests, fasting plasma glucose (FPG), HbA 1 c and total cholesterol (TC) values were measured among 33 participants, and two of them were found to have abnormal FPG and HbA 1 c accordingly were referred to their preferred General Practitioners. 11

5 Acknowledgements I wish to express my appreciation to my current supervior, Dr Jane Coad, for her patience, encouragement, and constant support in my study. Also, I am grateful for the assistance and helpful advice from my previous supervisor, Dr Jeanne Lawless, particularly, at the commencement of my study. l also give my sincere gratitude to my participants who devoted their precious time and shared their thoughts w ith me, l hope this research has helped them with improving their healthy di ets and li festyles. ln particular, I give great thanks to John W yatt and Sara Bolter, who have been both thoughtful and generous. Throughout my study period, their love, support and encouragement helped me sustain my enthusiasm for this research project. l acknowledge all my collegues in the office room, technician Chris Booth, statistical assistance from Dr Patrick Morel, and IT help from Matt Levin. I am grateful to my parents, for their continuing love, support both spirit and financial, and for their help and understanding while completing this study. lll

6 Table of Contents Abstract... i Acknowledgements... iii Table of Contents... iv L 1st. o ff" 1gu res... vn.. List of Tables... ix Chapter 1 INTRODUCTION... 1 Chapter 2 LITERATURE REVIEW Background Acculturation The relationship between acculturation and dietary changes Dietary acculturation Acculturation, dietary acculturation and health C hinese traditional food habits J Meal composition Different cuisine Ingredients and commonly used foodstuffs Cooking methods Dietary changes of Asians after moving to Western countries Nutrition transition Dietary changes during nutrition transition Other influences caused by nutrition transition Prevalence of type 2 diabetes mellitus Prevalence of type 2 diabetes mellitus in the world Incidence ofniddm in China Prevalence of type 2 diabetes mellitus among Asians in Western countries Risk factors for type 2 diabetes mellitus General potential risk factors Dietary factors Lifestyles Chinese immigrants in New Zealand l Chinese population in New Zealand Health status of Chinese migrants in New Zealand Chapter 3 METHODOLOGY Human Ethics Application Pilot study I V

7 3.3 Subjects' recruitment Data collection Dietary assessment Food Frequency Questionnaire hour dietary recalls Primar y Questionnaire Acculturation scale Physical activity levels Demographic questions Body Measurements Blood tests Data processing Chapter 4 RES UL T S Sample descriptions Demographic characteristics Socioeconomic characteristics General health Acculturation levels Food eating patterns l Meal eating patterns Food items consumed by the participants based on the food frequency questionnaire Physical activity levels Body 1neasure1nents Blood test results Dietar y intake Group dietary intakes Dietary intakes in high and low acculturation groups Summary Chapter 5 DISCUSSION Sample characteristics Acculturation levels Dietary acculturation and food eating patterns Meal eating patterns Food choices information from 24 hours d ietary recalls Food choices information from the food frequency questionnaire Body measurements Physical activity Dietary intakes Energy intake and distribution Carbohydrates and dietary fibre intakes M icronutrients and minerals intakes Blood tests results v

8 5.8 Integration with acculturation levels l High acculturation group Low acculturation group High and low acculturation groups Increased risk for diabetes Dietary fat intake Carbohydrate and dietary fibre intake Micronutrient and mineral intakes Body measurements and blood test results Phys ical activity levels Limitations of the study Chapter 6 CONCLUSION and RECOMMENDATIONS Bibliography APPENDIX A Human Ethics Approval APPENDIX B Advertisements and fliers used in recruitment (English and Chinese) APPENDIX C Participants' consent form (English) APPENDIX D Participants' information sheet (English and Chinese) APPENDIX E Health checklist form APPENDIX F Subjects ID and Contact form (English and Chinese) APPENDIX G Primary questionnaire (English and Chinese) APPENDIX H Food Frequency Questionnaire (English and Chinese) APPENDIX I Hour Dietary Recalls Form APPENDIX J Photos used in Food Frequency Questionnaire and 24-Hour Dietary Recalls APPENDIX K Chinese food photos and Chinese Food Composition Table APPENDIX L Blood test report form (English and Chinese) VI

9 List of Figures Figure 2-1 Proposed Model of dietary acculturation Figure Acculturation scores between females (F) and males (M) Figure The correlation between acculturation scores and residency length Figure The correlation between acculturation scores and age Figure The correlation between acculturation scores and arrival ages Figure Arrival ages between low and high acculturation levels Figure Residency length between low and high acculturation levels Figure Ages between low and high acculturation levels Figure Histogram of scores Figure Histogram of scores in males Figure Histogram of scores in females Figure PLS Std Coefficient Plot Figure PLS Loading Plot Figure Differences in oil consumption Figure Meat consumed by the participants Figure Meat consumed by both acculturation groups Figure Histogram of BMI vaues in Groups Land H Figure Total cholesterol levels in different PAL level groups Figure Total cholesterol levels in acculturation groups Figure Median cholesterol levels in different groups Figure Total cholesterol in income and education groups Figure Group energy intakes Figure Total energy intakes from fat Figure Cholesterol intakes in gender groups Figure Types of fat intakes in male and female groups Figure Energy intakes from types of fat in females Figure Energy intakes from types of fat in males Figure Protein and dietary fibre intakes in different age groups Figure Macronutrients intakes in females Figure Females' types offatty acid and total fat intakes Figure Females' energy distribution Figure Males' macronutrient intakes Vil

10 Figure Males' energy distribution Figure Males' total fat and types of fat intakes Figure J-1 Three sizes of solid food intakes used for portion sizes in the FFQ Figure J-2 Portion sizes of lipid food items (left side: 250ml, right side:180ml) in FFQ Figure J-3a Small, medium and large portion sizes of food in one standard plate Figure J-3b Small, medium and large portion sizes of food in one standard ball Figure J-4 Meat and vegetables models used in 24-hour dietary recalls Figure J-5 Nuts and dessert models Figure J-6 Cooking measurements for estimating portion sizes during 24hour dietary recalls Vlll

11 List of Tables Table Age characteristics of the participants Table Gender of the participants Table Original Countries of the participants Table Residency length of the participants in New Zealand Table Arrival ages of the participants Table Demographic characteristics of Group L and Group H Table Income levels Table Employment status Table Living arrangements Table Socio-economic status between both acculturation groups Table Differences in socioeconomic status (%) Table General health status Table Frequency of visiting GPs Table General health status in Group L and Group H Table Acculturation scores of the participants Table Different acculturation scores between genders Table Answers from Q 30 and Q 31 in the Primary Questionnaire Table Answers from Q 32 in the Primary Questionnai re Table Different acculturation scores by residency length in New Zealand Table Different acculturation scores by ages Table Different scores of participants' arrival ages Table Food eating patterns from 24-hour dietary recalls Table Cooking oil consumed by both acculturation groups (Low and High) Table Percentages of participants ate different servings of fruits Table Percentages of participants consumed types of vegetables Table Participants ate servings of fruits and types of vegetables in Groups Land H Table Food eating patterns between both acculturation groups Table Percentages of participants consumed dairy products (%) Table Dairy products consumption in acculturation and gender groups (%) Table Frequency in consuming bread in four groups (%) Table Frequency of consuming carbohydrate in d ifferent acculturation groups (%). 91 Table Percentages of people eating pasta, rice and porridge at least weekly(%) Table Percentages of people eating meats at least once a week (%) IX

12 Table Meat intakes in acculturation and gender groups(%) Table Percentages of participants eating meat products at three frequencies Table Percentages of people eating meat products at least once a week(%) Table Fish intakes in different acculturation and gender groups Table Percentages of people consuming fish/shellfish at least once a week (%) Table Intakes of the most popular vegetables in NZ by four groups (%) Table Percentages of people consuming vegetables at least once/week (%) Table People consuming Chinese vegetables at least once/week(%) Table Participants ate Chinese vegetables in acculturation (Ace) groups (%) Table Percentages of participants eating stirfry vegetables/vegetables soups (%) 102 Table Percentages of consumption of beverages at least three times a week (%) Table Percentages of females consuming beverages at varied frequencies (%) Table Percentages of males consuming beverages at varied frequencies (%) Table Frequency of cooking ingredients in different groups (%) Table Percentages of participants eating table spreads at least once a week(%) Table Percentages of people consuming fast foods at least once per week (%) Table Percentages of participants consuming fast food at varied frequencies(%) 109 Table Participants in gender and acculturation (Ace) groups ate cooking oils (%). 110 Table4.4.1 Physical activity levels by gender Table total time spent in minutes on sedentary activities per day Table Time spent in different physical activities Table Time spent in physical activities Table Physical activity levels in different socioeconomic groups Table Physical activity time in different acculturation groups Table Percentages of participants in different degrees of activities Table BMI in the New Zealand standard and Chinese standard Table Female body measurements Table Male body measurements Table Body measurements in both acculturation groups Table (1) Body measurements in females between two acculturation groups Table (2) Body measurements in males between two acculturation groups Table Being overweight and obesity by using different standards of BMI levels Table BMI and being overweight and obesity by the Chinese standard Table Percentages of participants being overweight or obese in both groups Table Percentages of participants having "at risk" waist circumferences Table "At risk" waist circumferences in different acculturation groups Table Percentages of participants having " at risk" BMI, Waist and WHR values x

13 Table Blood test results in males and females Table Blood tests in Low and High acculturation groups Table Total cholesterol levels in different groups Table Blood tests results in different socioeconomic groups Table Total cholesterol results in different socioeconomic groups Table Group energy and macronutrients intakes (n=44) Table Female and male groups' energy and macronutrient intakes Table Female and male groups' fat and sugar intakes Table Percentages of energy from types of fat Table Different percentages of total energy intakes from types of fat Table (1) Protein and dietary fibre intakes in participants aged 30 to 50 years Table (2) Protein and dietary fibre intakes in participants aged 50 to 70 years Table Female and male groups' micronutrient intakes Table Micronutrient intakes in females and males Table Female and male groups' mineral intakes Table Comparisons of mineral intakes Table (1) Micronutrient intakes in females and males aged years Table (2) Micronutrient intakes in females and males aged years Table Energy and macronutrient intakes among female acculturation groups Table Energy and macronutrient intakes of males in both acculturation groups Table Micronutrient intakes of females with low and high acculturation Table Micronutrient intakes of males with low and high acculturation Table Mineral intakes of females with low and high acculturation Table Mineral intakes of males with low and high acculturation Xl

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