; Pulse
Learning Center
Plans & pricing Sign in
Sign Out
Your Federal Quarterly Tax Payments are due April 15th Get Help Now >>



  • pg 1
									                    Presented to Pulse of Asia
                                Daegu, Korea
                                April 17, 2009

     Ted Greiner, Professor of Nutrition
Dept of Human Ecology, Hanyang University
               Seoul, Korea
Not enough!
 The amount of research that has been done
  appears to me inadequate to answer many of the
  questions we might want to ask
 I will review a few of what seem to be to be fairly
  clear findings and hypotheses
 I will also present some findings, both from the
  literature and from my own students’ work
  (Chinese and Mongolians studying in Sweden)
 that often seem to raise as many questions as they
Do immigrants copy behavior of
the host population?
 Kockturk, who studied breastfeeding among
  immigrants to Sweden did not think so
 She hypothesized that they copy what they assume
  is the behavior of rich people in their home
 But a later study of Bangladeshi immigrants to
  Sweden Rehana suggested that the truth may often
  lie somewhere in between: they breastfed longer
  than Swedes but more exclusively than
  Bangladeshis in the early months
It is unclear whether:
1. Ethnic group variation occurs in
   acculturation-health relationships
2. Acculturation components vary
   differently in relationship to health
3. Biculturalism has beneficial effects on
*Quoted from Lee et al. Acculturation and health in Korean Americans.
    Social Science & Medicine 2000;51: 159-173.
     Chinese ethnic immigrants
      have better heart health
 Ethnic Chinese immigrants to Canada had
  lower age-standardized death rates from
  cardiovascular and ischemic heart disease
  and congestive heart failure for both
 All these rates were higher in Canadians,
  South Asian immigrants and other
  immigrants (and similar to each other)*
*Sheth T, et al. Cardiovascular and cancer mortality among Canadians
of European, south Asian and Chinese origin from 1979 to 1993: an
analysis of 1.2 million deaths. JAMC 1999;161(2):132-138
Chinese ethnic immigrants have
      better heart health
 Thus there was little if any “healthy
  migrant” effect.
 Death rates were not lower in Chinese for
  cerebrovascular disease.
 Findings were similar to those from USA
  and China
 The Chinese had low serum cholesterol
  levels (4.1 mmol/L)
Why is immigrant health better?
 The standard hypothesis is that immigrants
  enjoy better heart health mainly for the first
 As they adopt the lifestyle of their new country,
  their patterns of health change to become like
  that of the host country.*
 Major factors that would confound this include
  intergenerational maintenance of home-country
  dietary patterns and genetic factors.
*Time travel with Oliver Twist--towards an explanation for a paradoxically low
mortality among recent immigrants. Razum O, Twardella D. Trop Med Int
Health. 2002 Jan;7(1):4-10.
Does East Asian immigrant heart health
worsen in the West?
 The incidence of myocardial infarction was half
  that in Japanese in Japan than in Hawaii and 50%
  greater in California (CA) than in Hawaii.*
 Among Chinese in CA, cholesterol was no higher
   in those born in CA, than those born in China, but
   BMI and hypertension in men were higher;
   smoking was lower in men but higher in women.**
*Robertson TL et al. Epidemiologic studies of coronary heart disease and
stroke in Japanese men living in Japan, Hawaii and California. Incidence of
myocardial infarction and death from coronary heart disease.Am J Cardiol.
**Klatsky AL, Armstrong MA. Cardiovascular risk factors among Asian
Americans living in northern California. Am J Publ Health. 1991;81(11):1423-8.
Mechanisms of change
 High consumption of fish, soy, seaweed and vegetables
  may protect heart health and may explain why
  Okinawans are better off than other Japanese, both at
  home and abroad.*
 Chinese in N America ate more fruit and vegetables
  when living with older Chinese--who strongly prefer
  Chinese food. Younger, working Chinese felt there was
  no difference in how healthy Chinese diets are and
  found them inconvenient to prepare.**
*Yamori Y et al. Implications from and for food cultures for cardiovascular
diseases: Japanese food, particularly Okinawan diets. Asia Pac J Clin Nutr.
**Satia-Abouta J et al. Psychosocial Predictors of Diet and Acculturation in
Chinese American and Chinese Canadian Women. Ethnicity and Health
How about emigrants TO East Asia?
 I only found one relevant study, which compared local
  ethnic Chinese in Singapore with local South Asians
  (SA) and Malays (M)
 Chinese had lower death rates (age 30-69) for ischemic
  heart disease and hypertensive disease (for each sex)
  but not cerebrovascular disease*
 The Chinese had the lowest prevalence of diabetes and
  the lowest rate of cigarette smoking
 Malays had higher blood pressure
 South Asians had lower high density lipoproteins**
*Hughes K, et al. Cardiovascular diseases in Chinese, Malays, and Indians in
Singapore. I. Differences in mortality. J Epidem Comm Health. 1990;44(1):24-8.
**Hughes K, et al. II. Differences in risk factor levels. J Epidem Comm Health.

Koreans who moved to the USA
 Based on careful theoretical work and
  examining degree of acculturation better
  than most have done, Lee et al* studied
  Koreans who moved to the USA
 Regarding the impact of immigration on
  health, very few clear relationships emerged.
  (Most observed relationships seemed quite
  *Lee et al. Acculturation and health in Korean Americans. Social Science
  & Medicine 2000;51: 159-173.
Koreans who moved to the USA
 Only about half got even light exercise
 27% of men and 9% of women were
  current smokers
 The mean BMI was 24 for men and 21
  for women
 Fat intake was not related to
Koreans who moved to the USA
 The more acculturated men were
  heavier but reported being more
 But we are uncertain of their definition
  of health
 And Koreans have not been living in
  the USA for as long as other immigrant
Do ethnic East Asians respond
differently to risk factors?
 Serum cholesterol is a risk factor in Chinese in China,
  even when levels are quite low by Western
 The increased incidence of heart disease among
  Japanese living in Hawaii compared to Japan had the
  usual risk factor associations: systolic blood pressure,
  serum cholesterol, relative weight and age
 Smoking was an exception (not a risk factor)**
*Chen Z, et al. Serum cholesterol concentration and coronary heart disease in
population with low cholesterol concentrations. BMJ. 1991;303(6797):276-82.
**Robertson TL et al. Epidemiologic studies of coronary heart disease and
stroke in Japanese men living in Japan, Hawaii and California. Coronary heart
disease risk factors in Japan and Hawaii. Am J Cardiol. 1977;39(2):244-9.
Complex genetics is sometimes involved
 Canadian South Asian (SA) immigrant
  patients in rehab for coronary artery
  disease (and not taking B vitamins for
  one mo) had similar levels of plasma
  homocysteine (PH) to Canadians, but
  East Asian (EA) patients’ levels were
  lower (1/5 as many were abnormal
  (PH > 12 μmol/l)).*
*Senaratne et al. Possible Ethnic Differences in Plasma Homocysteine levels
associated with coronary artery disease between South Asian and East Asian
immigrants. Clin Cardiol 24,730-734 (2001).
Complex genetics is
sometimes involved
 Lipid subfractions, diabetes and
  hypertension levels were similar
 Vegetable intake was higher in SA than EA
 Thus PH differences could be genetic
 The relative contribution of PH in relation
  to the pathogenesis of atherosclerosis in EA
  patients appears to be negligible
Unpublished masters theses
from Uppsala
  Su Hebate. Dietary acculturation of
   Chinese residents in Uppsala. Masters
   thesis, Uppsala University Department
   of Women's and Children's Health,
  Chen Wen. Cardiovascular disease risk
   factors in Chinese residents in Uppsala,
   Sweden. Masters thesis, Uppsala
   University Department of Women's
   and Children's Health, 2004.
1. Dietary acculturation of Chinese
residents in Uppsala
 76 Chinese residents in Uppsala, Sweden were
  interviewed; data were complete on 68
 Participants were identified by a modified
  “snowball” method beginning with a list
  provided by the Chinese Association in
 Born in China but lived in Sweden > 3
  months; >18 years of age
 They were asked only about how their diets
  changed – no other dietary assessment was
 The following foods were consumed more
 in Sweden than had been in China:
  cheese (72.1%)
  butter (64.7%)
  milk (54%)
  chicken/poultry (70.6%)
  fruit (57.4%)
  coffee (61.8%)
  potato (48.5 %)
  egg (47.1 %)
Results, cont
  The following foods were consumed less
   in Sweden than had been in China:
    legumes and legume products (89.7%)
    animal fat (51.5%)
    fatty meat (52.9%)
    fish/shellfish (54.4%)
    dark green leaves vegetables (85.3%)
    other green leafy vegetables (66.2%)
    other vegetables (61.8%)
    snack food (66.2%)
    alcohol (48.5 %)
Changes in Factors that influenced
dietary habits after coming to Sweden
Factors              Increased          Same          Decreased
              N                   N            N
              %                  %             %
Concern about 22                 40             6
health        32.4               58.8          8.8
Concern about 10                 48            10
weight        14.7               70.6          14.7
Concern about 38                 21             9
price         55.9               30.9          13.2
Determinants of Dietary Change
 Many statistical tests were performed, so
  these results need to be interpreted with
 Very few of the potential associations were
  statistically significant – only the significant
  ones are reported here
 Women decreased lard consumption more
  than men (68 vs 35%)
 People living with someone else increased
  consumption of poultry and fruit more than
  those living alone
Determinants of Dietary Change
 Those with higher incomes ate more fruit
  and cheese but less legumes
 Those who had lived longer in Sweden
  increased fruit consumption more
 Those who most increased their fruit
  consumption were more likely to have
  gained weight after coming to Sweden
2. Cardiovascular disease risk factors in
Chinese residents in Sweden
 Based on interviews with a sample of 80
  individuals aged 18-64 years
 Born in China but lived in Sweden > 3 months
 Participants were identified by a modified
  “snowball” method beginning with a list
  provided by the Chinese association in
 Height, weight and blood pressure were
 81.3% thought that cardiovascular disease
  could be prevented
 Risk factors they listed (with no prompting)
   Fat in food, 58.8%
   Lack of exercise, 47.5%
   Stress, 31.3%
   Smoking, 13.8%
   obesity, 7.5%
   diabetes, 2.5%
   Hypertension, 3.8%
Results cont
 Risk factors they had:
   Smoking, 10%, but none>10 cigarettes/day;
    another 7.5% quit after arriving in Sweden
   Overweight, 11.3% (mean BMI 22.3±2.6)
   Obesity, 1.3%
   Hypertension, 13.8% (mean SBP and DBP were
    116.1±16.4mmHg and 74.9±10.9mmHg
   Free-time physical inactivity, 52.5%
   Family history of CVD, 51.3% (37.5% father;
    43.8% mother)
 Gender, age, education level, income
  level, living status and length of stay in
  Sweden were examined for links with
  risk factors
 The findings are presented in the
  following slides
CV risk factors by gender
 Gender                         Male                        Female
   n                            40                            40
 Smoking                         15                           5
 overweight                      15                           7.5
 hypertension*                  22.5                          5
 Physical inactivity            52.5                         52.5
 family history                 47.5                         55
 BMI**                       23.2±2.5         21.4±2.5
 SBP**                      121.6±15.8       110.4±15.1
 DBP**                       79.0±11.0        70.8±9.2
 Chi-square test for differences in proportions between groups. One-way ANOVA
     was used to compare means difference between groups.* p<.05; ** p<.01
CV risk factors by age
 Age in years           ≤34           35-44                ≥45
   N                    37              29                  14
Smoking              8.1                10.3               14.3
Overweight*          0                  20.7               21.4
Hypertension*        5.4                 13.8              35.7
Physical inactivity 59.5                48.3               42.9
Family history      48.9                 51.7               51.7
BMI**                21.2±1.8         23.0±3.1          23.8±2.1
SBP                 114.1±12.0       113.6±13.1        126.3±27.0
DBP*                72.2±8.7          75.1±11.0         81.5±13.7

Chi-square test for differences in proportions among groups. One-
   way ANOVA was used to compare means difference among
   groups.* p<.05; ** p<.01
CV risk factors by length of stay in Sweden
Months                  3-12          13-60         61-120           >120
 n                       24             23           19               14
Smoking                  4.2           8.7          15.8              14.3
Obesity                  4.2          13.0          15.8              14.3
Hypertension            12.5           4.3          10.5              35.7
inactivity ´            41.7          47.8        78.9               42.9
Family history          58.3          39.1        57.9                50

BMI               22.6±2.7    21.9±2.5   21.7±2.8               23.3±2.4
SBP               115.8±10.9 114.0±12.9 114.2±18.1             122.5±25.1
DBP                74.6±10.9 72.3±8.1    75.7±10.6              78.6±14.8
 Chi-square test for differences in proportion among groups. One-way ANOVA
    was used to compare means differences among groups.* p<.05; ** p<.01
Comparison of risk factors between
hypertensives and non-hypertensives
                 Hypertension        non-hypertension
N                        11                  69
BMI**                  25.0±3.4           21.9±2.2
Overweight               27.3                8.7
Never                   36.4                       89.9
Former                  27.3                        4.3
Current                 36.4                        5.8

Chi-Square test or Fisher’s exact test for the frequencies difference
   between groups. One-way ANOVA for means differences between
   groups. *P<0.05; **P<0.01.
Is moving to Sweden less harmful
to East Asians than moving to USA
 There appears to be some evidence for this
 Moving to Sweden may have reduced intakes of
  saturated fats and cholesterol, reduced smoking
  and heavy alcohol use, increased consumption of
  fruits (and whole grains), and increased physical
 But it may have reduced intake of vegetables,
  certain types of fish, soy, and seaweed
 AND, the data are far too inadequate to say for
  Thank you!
 Full text copies of these two theses and some
 published papers on obesity in China and
 Mexico can be downloaded at:


 (Or go to www.global-breastfeeding.org and
 click on “obesity” on the right side)

To top