Hawaii Journal of Public Health VOLUME 3, ISSUE 1 MARCH 2011 Table of Contents Page ORIGINAL ARTICLES Body Ideals and Body Dissatisfaction Among a Community Sample of Ethnically Diverse 1 Adolescents on Kauai, Hawaii Niide, T.K., Davis, J., Tse, A.M., Derauf, C., Harrigan, R.C., & Yates, A. Eating Disorders Risk among White, Japanese, Chinese, Filipino, and Hawaiian Students 8 Attending the University of Hawaii Lynch, W.C., Eldridge, G., Edman, J.L., & Yates, A. Areca (Betel) Nut Chewing Practices in Micronesian Populations 19 Paulino, Y.C., Novotny, R., Miller, M.J., & Murphy, S.P. Diabetes Self-Management Support Needs and Concerns for the Future Among Employed 30 Adults on Oahu Nishita, C.M., Uehara, D.L., & Tom, T. Social and Demographic Factors Associated with Diabetes and Hypertension in Hawaii: 36 Multinomial Logit Model Min, H. PUBLIC HEALTH DISCUSSIONS Health Care Reform Truths Revealed 42 Riffle, R. EDITORIALS Discrimination in Hawaii and the Health of Micronesians 55 Yamada, S. Hawaii Journal of Public Health ● Volume 3 ● Issue 1 This page is intentionally left blank. ORIGINAL ARTICLE Body Ideals and Body Dissatisfaction Among a Community Sample of Ethnically Diverse Adolescents on Kauai, Hawaii Tiffany K. Niide, MD, PhD1, 2, 3; James Davis, PhD1; Alice M. Tse, PhD, APRN4; Chris Derauf, MD1; Rosanne C. Harrigan, EdD, MS, APRN-Rx1; Alayne Yates, MD5 Abstract Introduction: Body dissatisfaction (BD), a risk factor for eating disorders, is occurring at younger ages and among a wide range of socioeconomic and cultural groups. Objective: To describe body ideals and prevalence of body satisfaction among an ethnically diverse population of male and female students in Hawaii. Methods: An anonymous cross-sectional survey including biographical information and the figure drawing screen was distributed to 7th through 12th grade students. Results: Of the 1330 completed surveys, 19% of students were significantly dissatisfied with their bodies. Males were at greater risk than females for total BD (25.8% vs. 13.3%; p<0.001) and for BD in the direction of wanting to be larger (11.3% vs. 2.3%; p<0.001). Males and females were at similar risk for BD in the direction of wanting to be thinner (14.6% vs. 11.6%; p=0.11). Prevalence of BD in the direction of wanting to be thinner was significantly different (p<0.05) among ethnic groups. There were no significant differences in BD based on grade level or SES. Conclusions: BD exists among nearly 1 out of 5 adolescents, with differing patterns for males and females, and with certain ethnic groups being at higher risk. Implications: Studies to understand risk and protective factors by sex and among different ethnic groups may help generate tailored prevention strategies. Further research is needed to better understand the mechanisms underlying the bidirectional BD seen in males and potential outcomes. 1 University of Hawaii, John A. Burns School of Medicine 2 Department of Health, Child and Adolescent Mental Health Division, Kauai Family Guidance Center 3 Corresponding Author; Direct correspondence to Tiffany Kuulei Niide MD, PhD 4-1558 Kuhio Hwy Kapaa, HI 96746 [email protected] 4 University of Hawaii, School of Nursing and Dental Hygiene 5 University of Hawaii Hawaii Journal of Public Health ● Volume 3 ● Issue 1 1 Introduction exposure to neutral images.18 Trying to look like media images was also found to predict bulimic symptoms among Definition and Consequences of Body Dissatisfaction adolescent females.15 International studies show the link between exposure to Western ideals and increasing rates of Body dissatisfaction (BD) is typically defined as the eating disorder risks, symptoms, and disorders in many difference between one’s perceived body (size and shape) countries.19-21 and one’s ideal body; the larger the discrepancy, the greater the degree of BD. BD is a major clinical concern Clearly, BD is linked to a number of adverse health as it is becoming more prevalent among youth and is outcomes and is occurring at younger ages among diverse associated with a multitude of negative physical and groups. For this reason, we were interested in exploring the psychological outcomes.1-12 BD is one of the most robust BD among youth in Hawaii, which has not yet been risk factors for eating disorders1, which are often cited reported in the literature. Hawaii has a unique blend of as having the highest morbidity and mortality of the cultures and ethnicities, and despite their geographic mental health illnesses.2-5 BD is associated with weight isolation, we hypothesized that Kauai students would have gain and obesity by increasing binge eating6,7 and significant rates of BD. Due to differences in cultural decreasing levels of physical activity.8,9 BD also values and ideals surrounding food, body image and health, influences self-esteem and mood, prospectively we also hypothesized differences in BD patterns and predicting negative affect10, onset of depressive associations based on ethnicity. Our specific aims were to symptoms11, and increased suicide attempts.12 describe body ideals along with the prevalence and patterns of body dissatisfaction among an ethnically diverse Pathways to BD population of male and female adolescents. BD is influenced by a variety of factors including Participants and Methods individual, family, peer, and social attributes. Individual physical characteristics exert independent Setting influence on BD. For example, BMI is strongly correlated with BD and is a predictor for future BD.13 Kauai, a rural outer island of Hawaii, has a population of Height and weight also independently predict BD and approximately 60,000 with a rich blend of different cultures eating disorder scores, with absolute values being and ethnicities. Given previous research showing that predictive for boys and comparative values being eating disorders tend to have their onset in adolescence2,22, predictive for girls.14 Pubertal development and Tanner our target population consisted of community students in stage predict onset of bulimic purging behaviors in grades 7-12. There are 6 public schools under the Kauai adolescent females.15 Psychological characteristics such District of the Department of Education that serve 7th as self-esteem and negative affect both predict BD and through 12th grade. There are also small private schools in higher eating disorder scores in children.13, 14 each of the major areas of the island. Family environment and values also play an important Procedures role in BD. Children’s perceptions of parental concern This project was approved by the University of Hawaii IRB. about weight predict eating disorder scores for boys and The Department of Education Kauai district superintendent girls.14 Having a father with high levels of BD predicts and the principals of 4 of the private schools on the island girls’ dieting and weight change behaviors, and parental were approached and agreed to participate in the study. over-control of eating behavior is associated with higher Consent and assent forms were distributed to all of the 7- levels of thin body preoccupation and social pressure to 12th graders in these schools, either in their homeroom or be thin.16 science/health class. Those who signed and returned the Peer perceptions, actions, and behaviors also affect BD. forms properly were given a 4-page survey, which was filled Weight-related teasing by peers increases risk of future out in the classroom. The survey was anonymous and BD in early adolescent females.13 BD is also associated included one page of biographical information and 3 short with having peers who are currently dieting13 and screening tools, including the figure drawing screen. predicted by perceived pressure to be thin from peers.17 Measures Socio-cultural environment and media exposure have 1. Demographic data were obtained by asking each student long been implicated in BD and resulting pathological their age, sex, school type (private or public), grade level, eating behaviors. The media portrays images of thin living situation, and socioeconomic status.23 Given the women and muscular men with the connotation that multiracial population in Hawaii, students were asked to having this ideal body equates with being lovable, write down their race and to list them all. They were then successful, and happy. A randomized controlled study asked to write down the race they most identified with. The of college females found that exposure to thin-ideal latter was used in the analysis. magazine images increased BD when compared to Hawaii Journal of Public Health ● Volume 3 ● Issue 1 2 Table 1: Student characteristics as the outcomes. Sex, ethnicity, school type, and parental CHARACTERISTIC NUMBER (%) education were selected as the relevant independent Sex: variables. Grade level, SES, and number of working parents Male 579 (43.6%) were not found to be significantly associated with BD, and were thus not included in the models. The reference Female 748 (56.4%) population was the Caucasian females who responded to the Grade: survey, given previous research indicating increased rates 7 382 (28.9%) of BD among females and most studies having a majority of 8 352 (26.6%) Caucasian participants. 9 177 (13.4%) 10 140 (10.6%) Results 11 133 (10.0%) 12 138 (10.4%) Sample: Out of 2336 consent forms that were sent out, 57% School: (1330) were returned completed properly, with parent Public 1190 (89.5%) consent and student assent signed. Table 1 describes the characteristics of the student sample. Private 139 (10.5%) Live with: Figure 1: Description of Ideal Body Preference by Gender Mom only 251 (19.0%) Dad only 70 (5.3%) Both 879 (66.4%) Other 124 (9.4%) Number of working parents: 0 45 (3.4%) 1 332 (25.0%) 2 949 (71.6%) Number of parents with college: 0 319 (24.9%) 1 415 (32.5%) 2 545 (42.6%) Ethnicity: Filipino 320 (24.0%) 1=thinnest body figure, 10=largest body figure Caucasian 315 (23.7%) Hawaiian 302 (22.7%) Figure 2: Percentage of Students with Total Body Japanese 155 (11.7%) Dissatisfaction (BD), BD in the Direction of Wanting to be Portuguese 42 (3.2%) Thinner, and BD in the Direction of Wanting to be Larger Chinese 29 (2.2%) Other 167 (12.7%) 2. Body Ideals and Body Dissatisfaction: The figure drawing screen is a commonly used and validated instrument to assess body dissatisfaction. A series of nine progressively larger figures adapted from the Stunkard24 figures were presented. The students were asked to choose the figure that most looked like them (perceived body) and then to choose the figure they would most like to look like (ideal body). Analysis: Descriptive statistics were calculated for all variables. Chi-squared statistics were calculated to assess the statistical significance of differences in total BD based on ethnicity, sex, grade level, SES, and also Body Ideals: Figure 1 depicts ideal body figure chosen on by direction of BD (e.g., wanting to be thinner or larger). the figure rating scale by gender. The student was asked to Logistic regression models used total body indicate which of the nine figures they most wanted to look dissatisfaction, BD in the direction of wanting to be thinner, and BD in the direction of wanting to be larger like (ideal body). The figure drawing screen showed that most females narrowly clustered around a preference for Hawaii Journal of Public Health ● Volume 3 ● Issue 1 3 Logistic Regression Models: Table 2 Table 2: Odds ratios ( 95% confidence intervals) for wanting to be thinner or depicts the odds ratios for wanting to wanting to be larger by ethnicity and gender be thinner and wanting to be larger by DIRECTION OF ethnicity and gender. Separate DISSATISFACTION ETHNICITY FEMALES MALES regression models were fit for females Wanting to be thinner Chinese 5.7 (1.7, 18.7) a 0.8 (0.1, 6.8) and males for both the wanting to be Filipino 1.2 (0.6, 2.7) 1.9 (0.9, 3.8) Hawaiian 2.7 (1.3, 5.4) a 1.5 (0.7, 3.2) thinner and wanting to be larger Japanese 1.8 (0.7, 4.5) 1.3 (0.6, 3.1) outcomes. Models included all of the Portuguese 2.7 (0.8, 9.2) 5.7 (1.9, 17.2) a listed ethnicities. No Chinese girls or Other 1.4 (0.5, 3.5) 1.5 (0.6, 3.4) Portuguese boys wanted to be larger Caucasian 1.0 1.0 and, as a consequence, Chinese girls Wanting to be larger Chinese -- b 0.8 (0.1, 6.3) and Portuguese boys were omitted Filipino 1.4 (0.4, 5.1) 1.1 (0.5, 2.3) from the logistic regression model for Hawaiian 0.5 (0.1, 2.8) 1.5 (0.7, 3.1) wanting to be larger. Neither omitted Japanese 1.9 (0.4, 8.7) 1.1 (0.5, 2.6) group was significantly different (p < Portuguese 6.7 (1.4, 32.1) a -- b 0.05) from Caucasians of the same Other 1.1 (0.2, 6.2) 1.0 (0.4, 2.4) gender in wanting to be bigger, as Caucasian 1.0 1.0 assessed by Fisher’s exact tests. BD a p < 0.05 in the direction of wanting to be Separate regression models were fit for females and males for both the wanting to be thinner and thinner was predicted by being wanting to be larger outcomes. Models included all of the listed ethnicities. b No Chinese girls or Portuguese boys wanted to be larger and, as a consequence, Chinese girls and Hawaiian or Chinese for females Portuguese boys were omitted from the logistic regression model for wanting to be larger. Neither (OR=2.7, CI=1.3-5.4; OR=5.7, CI=1.7- omitted group was significantly different (p < 0.05) from Caucasians of the same gender in wanting 18.7) and by being Portuguese for to be bigger, as assessed by Fisher’s exact tests. males (OR=5.7, CI=1.9-17.2). BD in the 3rd body type (38.8%). 12.5% preferred to be like the the direction of wanting to be larger among all students was second figure and 0.3% desired the thinnest figure. The predicted by being male (OR=5.0, CI=2.9-8.4) and for males had a slightly wider spread and chose slightly females by being Portuguese (OR=6.7, CI=1.4-32.1). larger figures. The majority (42.5%) chose the fourth figure, followed by the fifth (22.3%) and third (19.9%), Figure 3: Percentage of Students with Body Dissatisfaction only 2.1% of males desired to look like the thinnest in the Direction of Wanting to be Thinner by Ethnicity figure. Body Dissatisfaction: Based on previous research25, a difference of 2 or more body sizes between one's ideal and current body was considered sufficient for significant body dissatisfaction. The standard deviation of this sample was 1.4, thus those with a difference of 2 body sizes or greater were more than one standard deviation from the mean. Of the 1330 completed surveys, 19% of students were significantly dissatisfied with their bodies. Figure 2 depicts unadjusted significant BD by gender. Males were at greater risk than females for total BD (25.8% vs. 13.3%; p<0.0001) and for BD in the direction of wanting to be larger (11.3% vs. 2.3%; p<0.0001). Boys and girls were at similar risk for BD in the direction of wanting to be thinner (14.6% vs. 11.6%; p=0.11). Boys were just as likely to be dissatisfied in the direction of wanting to be Table 3 describes the odds ratios for total BD associated thinner (14.6%) as they were to be dissatisfied in the with student and family characteristics. Gender, parental direction of wanting to be larger (11.3%). education, and ethnicity were included in a single logistic regression model. Predictors for total BD included being The unadjusted association between ethnicity and BD male (OR=2.2, CI=1.6-2.9), being Hawaiian or Portuguese in the direction of wanting to be thinner is shown in (OR=1.8, CI=1.1-2.7; OR=2.8, CI=1.3-6.1), and a lack of Figure 3. Prevalence of BD in the direction of wanting parental attainment of any college education (OR=01.4, to be thinner was statistically different among ethnic CI=1.0-2.0). groups, with Caucasians having the lowest BD. There were no significant differences in BD based on grade level, type of school, or SES. Hawaii Journal of Public Health ● Volume 3 ● Issue 1 4 also found that boys were equally likely to be Table 3: Odds ratios ( 95% confidence intervals (CIs)) for dissatisfied in either direction, wanting to be thinner total body dissatisfaction by gender, education, and ethnicity (14.6%) or wanting to be larger (11.3%). These results VARIABLE ODDS RATIO (95% CI) replicate the bidirectional nature of BD in males seen in Gender at least two previous studies. Male college freshman Male 2.2 (1.6, 2.9) a have similar rates of desiring to lose weight (40%) and Female 1.0 desiring to gain weight (45%).29 Similarly, male Parental education adolescents have been shown to be “as likely to want to No college 1.4 (1.0, 2.0) a be heavier as lighter.”25 There is little known about the Some college 1.0 associated risks and naturalistic outcomes of BD in Ethnicity Portuguese 2.8 (1.3, 6.1) a males. Different pathways may lead to unhealthy Chinese 2.1 (0.8, 5.3) eating attitudes and behaviors for boys compared to Hawaiian 1.8 (1.1, 2.7) a girls and further research would help find key targets Filipino 1.4 (0.9, 2.2) for interventions. Exploring other dangerous behaviors Japanese 1.4 (0.8, 2.3) among boys (bulking agents, pro-hormones, and steroid Caucasian 1.0 use etc) that may be associated with BD and desiring to a p < 0.05 gain weight is another potential area for future study. Gender, parental education, and ethnicity were included in a single logistic Little is known about future consequences of BD in regression model. males as they complete adolescence and move into Discussion and Clinical Implications adulthood. The externalizing behaviors more frequently seen in males, such as substance abuse, aggression or This is the first study to examine BD among an conduct disturbance, might be considered as potential ethnically diverse population of youth living in Hawaii. outcomes for future prospective studies. Despite the diverse ethnic and cultural groups represented in this study, the ideal figures chosen by In this study, the Caucasian group had the lowest risk of Kauai adolescents were similar to other studies, and BD compared to the multiple other ethnic groups. This may also replicate the pattern of females clustering around a be due in part to the absence of an ethnic “majority” in figure approximately one size smaller than the Hawaii; the state has a diverse population including many males.25,26 Overall, we found a high portion of people of mixed ethnicity. Once key factors were controlled adolescents (19%) who were significantly dissatisfied for, such as parental education and SES, the Hawaiian, with their bodies. This finding is supported by recent Portuguese, and Chinese subgroups remained at a literature showing that children and teens are significantly higher risk of BD. There are likely many exhibiting BD, risky dieting behaviors and attitudes, as social and cultural (and possibly genetic) factors that relate well as eating disorders more frequently and at earlier to these findings. The meaning and cultural significance of ages.3,27,28 In our sample there was no significant food and health among groups may be different. There may difference among the grade levels, suggesting that by also be discordance between familial expectations and the time students reach seventh grade, BD is already a societal pressures that lead to confusion and dissatisfaction. common concern. These results are similar to findings Little is known about BD and eating disorders in some of in the US and Canada that have shown body image these groups and exploration with qualitative as well as concerns in childhood and early adolescence.28,29,30 To quantitative research is warranted. Previous studies have truly prevent the onset of BD, primary prevention also shown higher rates of BD, chronic dieting, and bulimic programs would need to begin in elementary school. behaviors (binge eating, purging, and diuretic use) among This also suggests that by middle school, a significant US minorities.32-34 The myth of eating disorders as percentage of students already have body image afflictions of wealthy Caucasian females is further refuted concerns and thus primary and secondary prevention in this study and others as BD and eating pathology are approaches may be needed in that age group. documented among a wider variety of socioeconomic and cultural groups.32-34 International studies also give Our results also show that overall, boys are at greater examples of pervasive BD in Japan, China, Norway, risk for total BD and wanting to be larger, and at Canada, Britain, Australia, and others.25,28,35-37 As our world similar risk to females for BD in the direction of becomes increasingly interconnected, so, too, will we share wanting to be thinner. This supports recent findings of and be impacted by acculturative ideals regarding body significant BD among boys. A recent review of body shape, size and beauty. image in boys examined 17 articles finding BD to be a common concern that is associated with significant Limitations distress.31 Males also exhibit dangerous behaviors and eating pathology, being only slightly less likely than This study was an anonymous cross-sectional survey, and girls to engage in bulimic behaviors (self-induced thus cannot evaluate causality, simply associations. There vomiting or laxatives) in an effort to lose weight.32 We were no measures linking BD to poor outcomes directly in Hawaii Journal of Public Health ● Volume 3 ● Issue 1 5 this study, although the literature has clearly shown boys and girls to be culturally effective in reaching our links to concurrent and future negative outcomes in increasingly multicultural population. Beyond individual many well-controlled studies, as reviewed above. This and family interventions to promote healthy body image, study shows that BD is a significant concern among changes in policy and media will also need to be addressed. adolescents of the Pacific region; however, these authors Acknowledgements: This project was sponsored in part feel there is a need for further qualitative as well as by Florelle’s Ohana, the University of Hawaii (UH) quantitative research to further explore the Department of Psychiatry, and the UH Department of relationships found in this study between ethnicity and Pediatrics through University Clinical, Education & BD as well as the specific issues related to male BD. Research Associates (D55HP05143/Derauf, Health Conclusion Resources Service Administration; U.S. Department of Interior, Pacific Telehealth and Technology Hui, contract To our knowledge, this is the first study to examine BD #1435-04-03-CT-87084) and by grant number 1 R25 among the adolescents of the US Pacific region. These RR019321, “Clinical Research Education and Career results emphasize the pervasive nature of body image Development (CRECD) in Minority Institutions.” National problems affecting youth, boys as well as girls, from a Center for Research Resources National Institutes of variety of cultural and socioeconomic groups. Studies to Health. examine risk and protective factors among different groups may help tailor prevention strategies that Special thanks to: Henrietta Gwaltney, Founder of should be targeting both sexes. This study also Florelle’s Ohana, the students and faculty of the Koko'okolu highlights the bidirectional nature of BD among males. Fellowship and Masters in Clinical Research Program, and Further research on BD in males to understand the especially to all of the Kauai students, schools, and etiologic pathways, potential consequences, and community for their participation and support of this modifiable risk factors is warranted. 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Disordered eating patterns, body image, self-esteem, and physical activity in Hawaii Journal of Public Health ● Volume 3 ● Issue 1 7 ORIGINAL ARTICLE Eating Disorders Risk among White, Japanese, Chinese, Filipino, and Hawaiian Students Attending the University of Hawaii Wesley C. Lynch PhD1,2; Galen Eldridge, MS1; Jeanne L. Edman3; Alayne Yates, MD4 Abstract Objective: To assess ethnic differences in eating disorder (ED) risk factors among college students attending the University of Hawaii (UH). Based on existing literature, it was predicted that Japanese, Filipino, Chinese and Hawaiian participants, regardless of gender, would be at equal or greater risk for eating disorders than their White counterparts. Method: Undergraduate students (n = 895, 61% female) from six UH campuses comprising six ethnic groups, White (29.2%), Japanese (18.6%), Filipino (13.1%), Hawaiian (10.7%), Chinese (3.7%), and Mixed ethnicity (24.8%), completed demographic items and a variety of ED risk assessment instruments. Results: Contrary to prediction, Japanese, Filipino, Chinese, and Hawaiian women appear to be at lower ED risk than White women. Specific differences among female ethnic groups are noted. In addition, young men may manifest ED risk in unique ways. For example, Filipino men express weight and performance concerns that are unrelated to body mass index (BMI), whereas among Hawaiian men, weight concerns, dieting, and body dissatisfaction are all strongly correlated with BMI. Conclusions: Ethnicity and gender differences must be considered when dealing with ED risks among young non-White adults living in Hawaii. Implications: Such differences may provide important clues to the appropriate diagnosis and/or treatment of eating- and weight-related disorders. Keywords: Eating disorders, risk factors, ethnic differences, male, female, Hawaiian, Japanese, Chinese, Filipino, White, Eating Attitudes Test, McKnight Risk Factor Survey, Self-Loathing Subscale, Figure Rating Scale. 1 Montana State University, Department of Psychology 2 Corresponding Author; Direct correspondence to Wesley C. Lynch, PhD Department of Psychology, Montana State University, Bozeman, MT 59717 [email protected] 3 Cosumnes River College, Sacremento, California 4 University of Hawaii at Manoa Hawaii Journal of Public Health ● Volume 3 ● Issue 1 8