Exploring Foods of the Pacific: Cultural Food Identity in the US Affiliated Pacific Region.

Indigenous peoples of the Pacific have seen major shifts in dietary patterns due to foreign colonization, which introduced an array of new foods. Today, foods considered traditional and acculturated are consumed in various extents. However, the definitions and identity of traditional versus acculturated foods has become unclear as many introduced foods have been incorporated into Pacific cultures. The purpose of this study was to capture culturally relevant definitions of traditional, acculturated, and locally grown foods among 10 jurisdictions of the US-Affiliated Pacific (USAP) region with a focus on fruits and vegetables. Questionnaires were used to capture definitions of these terms, and to identify a list of foods (n=121) as traditional, acculturated, and/or locally grown in addition to classify them into food groups (ie, fruit, vegetable, starch, and/or grain). For the most part, definitions of traditional, acculturated, and locally grown were agreed upon by participating USAP jurisdictions, with some supplementary caveats presented by different jurisdictions. More foods were identified as acculturated (n=75) than traditional (n=37). Fruits (n=55) were the most frequent designation and about a third were vegetables (n=44). The majority of the jurisdictions reported growing at least half of the food items. This is the first study to identify and classify foods of the Pacific from the perspective of those indigenous to the USAP region. Understanding these similarities and differences in how food is classified and identified, through the lens of those from the Pacific, is crucial for nutrition education, and understanding what foods are locally grown is important for future sustainability.

Consumption of Traditional Fruits and Vegetables among Children in the US-Affiliated Pacific Region.

Background: Traditional Pacific diets have many health benefits, including maintenance of a healthy weight and prevention of various diseases. Few studies have evaluated the frequency at which traditional diets are consumed in the Pacific, especially among children. Objectives: This study examined the frequency of traditional and acculturated fruit and vegetable (F&V) intake among children in the US-affiliated Pacific (USAP) region. Methods: Diet records of 3319 children ages 2 to 8 y old were analyzed for frequency of traditional or acculturated F&V intake within USAP jurisdictions of American Samoa, Commonwealth of the Northern Mariana Islands (CNMI), Federated States of Micronesia (FSM; FSM island states include Chuuk, Kosrae, Pohnpei, and Yap), Guam, Hawaii, Republic of the Marshall Islands (RMI), and Republic of Palau. Results: Of the 95,304 food items recorded among participating children in the USAP jurisdictions, 15.2% were F&Vs. Of the 10 jurisdictions, children in the islands of Chuuk, Kosrae, Yap, and Pohnpei recorded the highest frequencies of traditional F&V intake relative to their total F&V intake (67.8%, 64.8%, 56.7%, and 52.5%, respectively). American Samoa and RMI recorded moderate frequency of traditional F&V intake (38.9% and 46.4%, respectively), whereas children in Hawaii, Guam, and CNMI recorded the lowest frequencies of traditional F&V intake relative to their total F&V intake (10.4%, 12.4%, and 15.3%, respectively). Children in Hawaii, Guam, Palau, and CNMI recorded high frequencies of acculturated F&V intake (37.8%, 31.2%, 34.5%, and 27.9%, respectively). Conclusions: Overall, children in the USAP jurisdictions participating in this study recorded a low frequency of F&V intake. The differences in traditional F&V intake found between the USAP islands may be due to variation in economic income level and external influences on social and cultural norms among the island populations and variations of cost, accessibility, and convenience of each category of food to each island's population.

Social Disparities in Health Literacy in the United States.

Health literacy has been identified as a contributor to both health disparities and social determinants of health. There is significant overlap in demographic characteristics of those who are at risk for health disparities and low health literacy. This study expanded the research on health literacy and disparities by quantifying the social disparities within health literacy using a relatively new methodology. We analyzed data from the 2013 Health Information National Trends Survey (N = 1,675). The Extended Gastwirth Index was used to determine the disparities in health literacy. Participants who were female, age 18 to 34 years, White, highly educated (postbaccalaureate), and with incomes ≥$200,000 had the highest health literacy and served as the reference groups. Males, age 35 to 49 years, who had high school graduates, and people who were Hispanic and with incomes between $50,000 and $74,999 had the highest disparities in health literacy. Income (∼30%) and education (∼37%) were the highest contributors to overall disparities in health literacy, whereas sex (∼3%) was the lowest contributor. The overwhelming contribution of income and education to disparities in health literacy and the range of disparities within these demographic characteristics highlight populations that could benefit from tailored interventions to improve their health literacy. [HLRP: Health Literacy Research and Practice. 2019;3(1):e47-e52.].

The relationship between food parenting practices, parental diet and their adolescents' diet.

OBJECTIVE: To determine whether parents' and adolescents' dietary behaviors for fruits and vegetables [FV], junk foods, and sugar sweetened beverages [SSBs] align with parents' food parenting practices for these behaviors. DESIGN: Data from the Family Life, Activity, Sun, Health and Eating (FLASHE), a cross-sectional, internet-based study, were analyzed. PARTICIPANTS: Parent and adolescent dyads (n = 1859) representative of the general U.S. MAIN OUTCOME MEASURES: Dependent variables: adolescent and parental dietary behaviors. INDEPENDENT VARIABLES: parents' food parenting practices for FV, SSBs, and junk food were assessed. ANALYSIS: General linear models with test of equal slopes were used to test study aims. RESULTS: Parents' diets and food parenting practices were consistent with their dietary behaviors. For their adolescents, parenting practices for FV consumption was positively related to adolescents' FV consumption, but parents/caregivers' rules/limits to avoid junk food/SSBs were positively related to adolescents' junk foods and SSBs consumption. CONCLUSIONS AND IMPLICATIONS: Continued parental modeling of dietary practices is important during adolescence. Future analyses should investigate adolescents' perceptions of parents' practices and behaviors as well as their exposure from other sources and their effect on adolescent (dietary) decision-making.

Areca (betel) nut chewing practices of adults and health behaviors of their children in the Freely Associated States, Micronesia: Findings from the Children's Healthy Living (CHL) Program.

BACKGROUND: Chewing areca (betel) nut has been deemed carcinogenic. The practice has become a public health concern in Micronesia. The Children's Healthy Living (CHL) Program included an areca (betel) nut questionnaire in a survey of household characteristics in the Freely Associated States (FAS). This paper describes areca (betel) nut chewing practices of adults and the health behaviors of their children. METHODS: A cross-section of 1200 children (2-8 year-olds) and their caregivers in Chuuk, Kosrae, Pohnpei, Republic of Palau, Republic of the Marshall Islands (RMI), and Yap were recruited. Socio-demographics, adult areca (betel) nut chewing practices, and other health behaviors of children and adults were assessed. Child anthropometric measurements were collected to estimate weight status. RESULTS: The FAS areca (betel) nut chewing prevalence was 42%, ranging from 3% (RMI) to 94% (Yap). Among chewers, 84% added tobacco, 97% added slaked lime, 85% added betel leaf, and 24% mixed the components with alcohol. Among FAS children, 95% practiced daily teeth-brushing and 53% visited the dentist annually. Compared to non-chewing households, areca (betel) nut chewing households were more likely to have very young children enrolled, more highly educated adults, and members that used tobacco and alcohol. CONCLUSION: The FAS areca (betel) nut chewing prevalence (42%) is above the world prevalence of 10-20%, with wide variability across the islands. The oral health findings in this study may inform future oral cancer prevention programs or policies. Regular monitoring of areca (betel) nut use is needed to measure the impact of such programs or policies.

Collecting wrappers, labels, and packages to enhance accuracy of food records among children 2-8 years in the Pacific region: Children's Healthy Living Program (CHL).

The aim was to describe differences in dietary outcomes based on the provision of food wrappers, labels or packages (WLP) to complement data from dietary records (DR) among children from the US Affiliated Pacific. The WLP were intended to aid food coding. Since WLP can be associated with ultra-processed foods, one might expect differences in sodium, sugar, and other added ingredients to emerge. Dietary intakes of children (2-8 y) in Alaska, Hawai'i, Commonwealth of the Northern Mariana Islands, and Guam were collected using parent/caregiver completed 2-day DR. Parents were encouraged to collect WLP associated with the child's intake. Trained staff entered data from the DRs including the WLP when available using PacTrac3, a web application. Of the 1,868 DRs collected and entered at the time of this report, 498 (27%) included WLP. After adjusting for confounders (sex, age, location, education, food assistance), the DRs with WLP had significantly higher amounts of energy (kcal), total fat, saturated fat, added sugar, and sodium. These results suggest the inclusion of WLP enhanced the dietary intake data. The intake of energy, fat, added sugar and sodium derived from processed foods and foods consumed outside the home was better captured in children who had WLP.

The influence of energy standardisation on the alternate Mediterranean diet score and its association with mortality in the Multiethnic Cohort.

The alternate Mediterranean diet (aMED) score is an adaptation of the original Mediterranean diet score. Raw (aMED) and energy-standardised (aMED-e) versions have been used. How the diet scores and their association with health outcomes differ between the two versions is unclear. We examined differences in participants' total and component scores and compared the association of aMED and aMED-e with all-cause, CVD and cancer mortality. As part of the Multiethnic Cohort, 193 527 men and women aged 45-75 years from Hawaii and Los Angeles completed a baseline FFQ and were followed up for 13-18 years. The association of aMED and aMED-e with mortality was examined using Cox's regression, with adjustment for total energy intake. The correlation between aMED and aMED-e total scores was lower among people with higher BMI. Participants who were older, leaner, more educated and consumed less energy scored higher on aMED-e components compared with aMED, except for the red and processed meat and alcohol components. Men reporting more physical activity scored lower on most aMED-e components compared with aMED, whereas the opposite was observed for the meat component. Higher scores of both aMED and aMED-e were associated with lower risk of all-cause, CVD and cancer mortality. Although individuals may score differently with aMED and aMED-e, both scores show similar reductions in mortality risk for persons scoring high on the index scale. Either version can be used in studies of diet and mortality. Comparisons can be performed across studies using different versions of the score.

Quality assurance of data collection in the multi-site community randomized trial and prevalence survey of the children's healthy living program.

BACKGROUND: Quality assurance plays an important role in research by assuring data integrity, and thus, valid study results. We aim to describe and share the results of the quality assurance process used to guide the data collection process in a multi-site childhood obesity prevalence study and intervention trial across the US Affiliated Pacific Region. METHODS: Quality assurance assessments following a standardized protocol were conducted by one assessor in every participating site. Results were summarized to examine and align the implementation of protocol procedures across diverse settings. RESULTS: Data collection protocols focused on food and physical activity were adhered to closely; however, protocols for handling completed forms and ensuring data security showed more variability. CONCLUSIONS: Quality assurance protocols are common in the clinical literature but are limited in multi-site community-based studies, especially in underserved populations. The reduction in the number of QA problems found in the second as compared to the first data collection periods for the intervention study attest to the value of this assessment. This paper can serve as a reference for similar studies wishing to implement quality assurance protocols of the data collection process to preserve data integrity and enhance the validity of study findings. TRIAL REGISTRATION: NIH clinical trial #NCT01881373.

Validation of the Actical Accelerometer in Multiethnic Preschoolers: The Children's Healthy Living (CHL) Program.

This study aimed to determine the validity and reliability of the Actical accelerometer for measuring physical activity (PA) in preschool children of mixed ethnicity, compared with direct observation via a modified System for Observing Fitness Instruction Time (SOFIT) protocol and proxy parental reports (PA Logs). Fifty children in Hawai'i wore wrist-mounted accelerometers for two 7-day periods with a washout period between each week. Thirty children were concurrently observed using SOFIT. Parents completed PA Logs for three days. Reliability and validity were measured by intra-class correlation coefficient and proportions of agreement concurrently. There was slight agreement (proportion of agreement: 82%; weighted Kappa=.17, P <.001) between the accelerometer and SOFIT as well as between the accelerometer and the PA Logs (proportions of agreement: 40%; weighted Kappa=0.15, P <.001). PA logs underestimated the PA levels of the children, while the Actical was found to be valid and reliable for estimating PA levels of multiethnic, mixed ethnicity preschoolers. These findings suggest that accelerometers can be objective, valid, and accurate physical activity assessment tools compared to conventional PA logs and subjective reports of activity for preschool children of mixed ethnicity.

Recruitment Strategies and Lessons Learned from the Children's Healthy Living Program Prevalence Survey.

The US Affiliated Pacific region's childhood obesity prevalence has reached epidemic proportions. To guide program and policy development, a multi-site study was initiated, in collaboration with partners from across the region, to gather comprehensive information on the regional childhood obesity prevalence. The environmental and cultural diversity of the region presented challenges to recruiting for and implementing a shared community-based, public health research program. This paper presents the strategies used to recruit families with young children (n = 5775 for children 2 - 8 years old) for obesity-related measurement across eleven jurisdictions in the US Affiliated Pacific Region. Data were generated by site teams that provided summaries of their recruitment strategies and lessons learned. Conducting this large multi-site prevalence study required considerable coordination, time and flexibility. In every location, local staff knowledgeable of the community was hired to lead recruitment, and participant compensation reflected jurisdictional appropriateness (e.g., gift cards, vouchers, or cash). Although recruitment approaches were site-specific, they were predominantly school-based or a combination of school- and community-based. Lessons learned included the importance of organization buy-in; communication, and advance planning; local travel and site peculiarities; and flexibility. Future monitoring of childhood obesity prevalence in the region should consider ways to integrate measurement activities into existing organizational infrastructures for sustainability and cost-effectiveness, while meeting programmatic (e.g. study) goals.

Associations of key diet-quality indexes with mortality in the Multiethnic Cohort: the Dietary Patterns Methods Project.

BACKGROUND: Healthy dietary patterns have been linked positively with health and longevity. However, prospective studies in diverse populations in the United States addressing dietary patterns and mortality are limited. OBJECTIVE: We assessed the ability of the following 4 diet-quality indexes [the Healthy Eating Index-2010 (HEI-2010), the Alternative HEI-2010 (AHEI-2010), the alternate Mediterranean diet score (aMED), and the Dietary Approaches to Stop Hypertension (DASH)] to predict the reduction in risk of mortality from all causes, cardiovascular disease (CVD), and cancer. DESIGN: White, African American, Native Hawaiian, Japanese American, and Latino adults (n = 215,782) from the Multiethnic Cohort completed a quantitative food-frequency questionnaire. Scores for each dietary index were computed and divided into quintiles for men and women. Mortality was documented over 13-18 y of follow-up. HRs and 95% CIs were computed by using adjusted Cox models. RESULTS: High HEI-2010, AHEI-2010, aMED, and DASH scores were all inversely associated with risk of mortality from all causes, CVD, and cancer in both men and women (P-trend < 0.0001 for all models). For men, the HEI-2010 was consistently associated with a reduction in risk of mortality for all causes (HR: 0.75; 95% CI: 0.71, 0.79), CVD (HR: 0.74; 95% CI: 0.69, 0.81), and cancer (HR: 0.76; 95% CI: 0.70, 0.83) when lowest and highest quintiles were compared. In women, the AHEI and aMED showed large reductions for all-cause mortality (HR: 0.78; 95% CI: 0.74, 0.82), the AHEI showed large reductions for CVD (HR: 0.76; 95% CI: 0.69, 0.83), and the aMED showed large reductions for cancer (HR: 0.84; 95% CI: 0.76, 0. 92). CONCLUSION: These results, in a US multiethnic population, suggest that consuming a dietary pattern that achieves a high diet-quality index score is associated with lower risk of mortality from all causes, CVD, and cancer in adult men and women.

Ethnicity and acculturation: do they predict weight status in a longitudinal study among Asian, Hispanic, and non-Hispanic White early adolescent females?

BACKGROUND: The prevalence of overweight and obesity among adolescents has increased over the past decade. Prevalence rates are disparate among certain racial and ethnic groups. This study sought to longitudinally examine the relationship between overweight status (≥85th percentile according to the Centers for Disease Control and Prevention growth charts) and ethnic group, as well as acculturation (generation and language spoken in the home) in a sample of adolescent females. METHODS: Asian (n=160), Hispanic (n=217), and non-Hispanic White (n=304) early adolescent girls participating in the multistate calcium intervention study with complete information on weight, ethnicity, and acculturation were included. Multiple methods of assessing longitudinal relationships (binary logistic regression model, linear regression model, Cox proportional-hazards regression analysis, and Kaplan-Meier survival analysis) were used to examine the relationship. RESULTS: The total proportion of girls overweight at baseline was 36%. When examining by ethnic group, the proportion varied with Hispanic girls having the highest percentage (46%) in comparison to their Asian (23%) and Non-Hispanic White (35%) counterparts. Although the total proportion of overweight was 36% at 18 months, the variation across the ethnic groups remained with the proportion of Hispanic girls becoming overweight (55%) being greater than their Asian (18%) and non-Hispanic White (34%) counterparts. However, regardless of the statistical approach used, there were no significant associations between overweight status and acculturation over time. CONCLUSION: These unexpected results warrant further exploration into factors associated with overweight, especially among Hispanic girls, and further investigation of acculturation's role is warranted. Identifying these risk factors will be important for developing targeted obesity prevention initiatives.

Dietary isoflavone intake is not statistically significantly associated with breast cancer risk in the Multiethnic Cohort.

Given the high intake levels of soya and low incidence rates of breast cancer in Asian countries, isoflavones, substances with an oestrogen-like structure occurring principally in soyabeans, are postulated to be cancer protective. In the present study, we examined the association of dietary isoflavone intake with breast cancer risk in 84,450 women (896 in situ and 3873 invasive cases) who were part of the Multiethnic Cohort (Japanese Americans, whites, Latinos, African Americans and Native Hawaiians) with a wide range of soya intake levels. The absolute levels of dietary isoflavone intake estimated from a baseline FFQ were categorised into quartiles, with the highest quartile being further subdivided to assess high dietary intake. The respective intake values for the quartiles (Q1, Q2, Q3, and lower and upper Q4) were 0-< 3·2, 3·2-< 6·7, 6·7-< 12·9, 12·9-< 20·3, and 20·3-178·7 mg/d. After a mean follow-up period of 13 years, hazard ratios (HR) and 95% CI were calculated using Cox regression models stratified by age and adjusted for known confounders. Linear trends were tested by modelling continuous variables of interest assigned the median value within the corresponding quartile. No statistically significant association was observed between dietary isoflavone intake and overall breast cancer risk (HR for upper Q4 v. Q1: 0·96 (95% CI 0·85, 1·08); P trend = 0·40). While the test for interaction was not significant (P=0·14), stratified analyses suggested possible ethnic/racial differences in risk estimates, indicating that higher isoflavone intakes may be protective in Latina, African American and Japanese American women. These results are in agreement with those of previous meta-analyses showing no protection of isoflavones at low intake levels, but suggesting inverse associations in populations consuming high amounts of soya.

Ethnic differences and predictors of colonoscopy, prostate-specific antigen, and mammography screening participation in the multiethnic cohort.

PURPOSE: Given the relation between screening and improved cancer outcomes and the persistence of ethnic disparities in cancer mortality, we explored ethnic differences in colonoscopy, prostate-specific antigen (PSA), and mammography screening in the Multiethnic Cohort Study. METHODS: Logistic regression was applied to examine the influence of ethnicity as well as demographics, lifestyle factors, comorbidities, family history of cancer, and previous screening history on self-reported screening participation collected in 1999-2002. RESULTS: The analysis included 140,398 participants who identified as white, African American, Native Hawaiian, Japanese American, US born-Latino, or Mexican born-Latino. The screening prevalences overall were mammography: 88% of women, PSA: 45% of men, and colonoscopy: 35% of men and women. All minority groups reported 10-40% lower screening utilization than whites, but Mexican-born Latinos and Native Hawaiian were lowest. Men were nearly twice as likely to have a colonoscopy (OR=1.94, 95% CI=1.89-1.99) as women. A personal screening history, presence of comorbidities, and family history of cancer predicted higher screening utilization across modalities, but to different degrees across ethnic groups. CONCLUSIONS: This study confirms previously reported sex differences in colorectal cancer screening and ethnic disparities in screening participation. The findings suggest it may be useful to include personal screening history and family history of cancer into counseling patients about screening participation.

Inherited or Behavior? What Causal Beliefs about Obesity Are Associated with Weight Perceptions and Decisions to Lose Weight in a US Sample?

Objectives. To identify the extent to which (1) beliefs about obesity and obesity-related behaviors distinguish individuals based on weight perception (WP) and (2) beliefs about obesity predict perceived health status and WP and how these in turn predict decisions to try to lose weight. Method. 7456 noninstitutionalized US adults (Mage = 54.13, SDage = 16.93; 61.2% female; 75.9% White) completed the 2007 Health Information National Trends Survey. Multinomial logistic regressions and structural equation modeling were used to accomplish study objectives. Results. Age, gender, information-seeking, health status, belief that obesity is inherited, and knowledge of fruits and vegetables recommendations distinguished participants based on WP. Beliefs about obesity predicted health status, WP, and trying to lose weight in the general model. The models varied based on gender, race/ethnicity, education, and weight misperception. Conclusion. This study supports the role of beliefs about obesity, WP, and health perceptions in individuals' decisions and actions regarding weight management. This study increases our understanding of gender, race/ethnicity, education, and weight misperceptions differences in decisions to lose weight. This knowledge may lead to targeted interventions, rather than "one size fits all" interventions, to promote health and prevent obesity.