ORIGINAL PAPER

Acculturation, Body Perception, and Weight Status AmongVietnamese American Students

Jin Young Choi • Jessica Hwang • Jenny Yi

Published online: 13 April 2011

� Springer Science+Business Media, LLC 2011

Abstract The effects of acculturation, body perception,

and health behaviors on weight status among Vietnamese

American students in Houston, Texas were examined

for our research. A survey was mailed to 600 randomly

selected Vietnamese American students at one university,

and 261 complete surveys (response rate, 43.5%) were used

for final analyses. Respondents were classified as over-

weight or normal weight based on the World Health

Organization recommended overweight cutoff for Asians

(BMI of 23 kg/m2). About 32% of respondents were

overweight. Men, undergraduate students, and those with

an acceptable body perception were more likely to be

overweight. Nativity and its interaction with length of US

residence were significant predictors of weight status after

controlling for other variables. Foreign-born respondents

were less likely to be overweight than US-born respon-

dents, but the risk of being overweight with increasing

years of US residence was much greater for the foreign-

born than for the US-born. The results suggest the need for

culturally tailored overweight and obesity prevention pro-

grams for Vietnamese Americans.

Keywords Asian Americans � Acculturation �Immigrants � Obesity � Overweight

Introduction

Obesity has become epidemic in the United States. More

than one-third of adults and about one-sixth of children are

obese, and about two-thirds of adults are overweight or

obese in the United States [1, 2]. Obesity has negative

health and social consequences. As a second leading cause

of preventable death, obesity related diseases accounted for

nearly 17% of all US deaths in 2000 [3]. Obesity increases

the risk of heart disease, stroke, hypertension, diabetes, and

some types of cancer [4]. The increased health care

demands related to health consequences of overweight and

obesity induce elevated health care costs which account for

nearly 10% ($117 billion) of total US medical expenditures

in 2000 [5].

During the past three decades, obesity has increased in

all social groups, but the prevalence of obesity differs

across groups. Higher obesity rates are found among racial

and ethnic minorities as well as socioeconomically disad-

vantaged populations [6–9]. For example, non-Hispanic

blacks and Hispanics have 51% and 21% greater preva-

lences of obesity, respectively, than non-Hispanic Whites

[6]. Individuals with low income and educational attain-

ment tend to have higher obesity rates and disease risk

[10]. Immigrants, the new arrivals in particular, tend to

have lower BMI and lower obesity rates than US-born

individuals despite their disadvantaged socio-economic

characteristics [7, 11–13]. Several empirical studies have

supported that this epidemiological paradox [14] is partly

due to a immigrant effect, positing that immigrants have an

initial body composition advantage through self-selective

J. Y. Choi (&)

Department of Sociology, Sam Houston State University, Box

2446, Huntsville, TX 77341-2446, USA

e-mail: jyc002@shsu.edu

J. Hwang

Department of General Internal Medicine, The University of

Texas MD Anderson Cancer Center, Houston, TX, USA

e-mail: jphwang@mdanderson.org

J. Yi

Health Program, Department of Educational Psychology,

University of Houston, Houston, TX, USA

e-mail: jyi@mail.coe.uh.edu

123

J Immigrant Minority Health (2011) 13:1116–1124

DOI 10.1007/s10903-011-9468-3

immigration of healthier people [7, 15, 16]. However, the

initial lower BMI of newly arrived immigrants erodes and

increases with acculturation and longer years of residence

in the United States [11, 12, 15, 17–21]. For example,

second and third generation immigrants are more likely

than first generation immigrants to be obese [13, 22]. Even

among first generation immigrants, those who have spent

less than 10 years in the US have a significantly lower BMI

than those with a longer duration of residence [11]. Within

10–15 years after arrival, the BMI of immigrants tend to

converge to the BMI of natives despite variations in the

level of convergence by gender and race/ethnic origins

[23].

Acculturation is a process of adaptation to the new

environment and culture in the host society [21]. In this

process, immigrants might adopt a less healthy American

diet with higher intake of fat as well as a sedentary life-

style. This in turn contributes to immigrants’ nutritional

transition and an increased risk of unhealthy body com-

position and obesity [17, 21, 24–26]. Immigrants may also

adopt social norms and standards related to ideal body

image, weight, and shape of the dominant culture. Adop-

tion of US norms and culture influences attitudes and

health practices as well as increases body weight among

immigrants [27].

Asian Americans, one of the fastest growing popula-

tions, generally have been documented to have a lower

BMI than other racial and ethnic groups [8, 12, 28–31].

However, Asian populations have a higher percentage of

body fat and a greater risk of developing chronic diseases

than do Whites with the same BMI [32, 33]. For example, a

higher prevalence of type 2 diabetes and cardiovascular

disease were found among Asian Americans with a BMI

lower than 25 kg/m2 [28, 33–35] as compared with Whites

with the same BMI. Based on the need to provide adequate

public health actions on risks related to weight status in

Asian populations, the World Health Organization (WHO)

expert committee recommended different BMI cut-offs for

Asians. The new BMI cut-offs recommended for Asians

lowered the thresholds to BMI \ 18.5 kg/m2 for under-

weight, BMI C 23 kg/m2 for overweight, and

BMI C 27.5 kg/m2 for obesity [25]. Moreover, over-

weight- and obesity-related negative health conditions such

as diabetes, hypertension, and cardiovascular diseases have

also increased in this population [11, 28, 36–39]. Given the

population growth of Asian Americans as well as their

higher risk for adverse health conditions at a given BMI, it

is crucial to address the issues of obesity among Asian

Americans. However, there is a paucity of research on

obesity in this population [23]. Moreover, most of the

studies on obesity in Asian Americans tend to lump various

Asian and Pacific Islander groups into one category in spite

of group differences in obesity prevalence [40, 41]. A

relatively small number of studies have examined the

factors associated with overweight and obesity among

specific Asian American subgroups [12, 24, 41].

Vietnamese Americans are the fourth largest Asian

subgroup and the second fastest growing Asian subgroup in

the United States [42]. Most Vietnamese Americans are

either first or second generation. About 55% have limited

English proficiency [43]. They have the largest proportion

of children among Asians and have substantially lower

educational attainment and income compared to other

Asian subgroups [43]. Despite their lower prevalence of

obesity, they have comparable prevalence rates of stroke

and hypercholesterolemia as compared to non-Hispanic

Whites [44]. Considering the large number of Vietnamese

Americans in the US and their risk for obesity-related

diseases, it is important to address obesity among this

subgroup of young adults when lifestyle modification and

prevention may reduce future risk of disease.

Young immigrants may adopt American cultural norms

and lifestyles more quickly than older immigrants. In

particular, college represents an important life transition

period that involves residential or financial independence

from parents, labor force participation, and marriage [45].

In this period, people experience decreased parental influ-

ence and increased peer influence as well as changes in

financial resources, which may cause behavioral changes

related to negative health outcomes, such as changes in

diet, physical activities, and risk behaviors [45]. Further-

more, body weight and shape are important concerns for

students, and thus, various weight management methods

are adopted and practiced [46]. However, few studies have

been conducted concerning the effects of body perception

on weight status in the context of acculturation among

young immigrants. Therefore, this study is to estimate the

prevalence of overweight among Vietnamese American

students using the WHO recommended BMI cutoff for

Asians (BMI of 23 kg/m2) and to examine the effects of

acculturation and body perception on weight status. We

conducted a survey of Vietnamese American college stu-

dents in Houston, Texas, where Vietnamese Americans are

the largest subgroup of Asian Americans in Texas (23.2%)

[47].

Methods

Participants

After approval was obtained from the University of

Houston Institutional Review Board, a mail survey was

conducted for the Vietnamese American students aged

18 years and older enrolled at the University of Houston

during the 2003–2004 academic year. Using a composite

J Immigrant Minority Health (2011) 13:1116–1124 1117

123

list of Vietnamese surnames [48], 1,610 students with

Vietnamese surnames were identified in the University of

Houston Telephone Directory, which lists student names

and addresses. From these listings, 600 students were

randomly selected for the study. Fifty-one surveys were

returned because of insufficient addresses, and 288 surveys

were incomplete or not returned. A total of 261 completed

surveys (a total response rate of 43.5%) were used for

analysis.

Survey Development and Administration

The cover letter and survey questionnaire were developed

in English. The cover letter included information about the

nature of the project, assurance of confidentiality, and

instructions for completing and returning surveys. The

survey questionnaire was revised after a pilot test was

conducted with 20 Vietnamese American students for

appropriateness of idiom use, accuracy, and sensitivity of

the survey questions. The cover letter and survey ques-

tionnaire were mailed to the randomly selected students

with an enclosed self-addressed, stamped envelope. To

ensure confidentiality, the participant identification infor-

mation was removed from the completed survey. It took

approximately 10 minutes to complete the survey.

Survey Content

The survey included questions related to socio-demo-

graphic characteristics, acculturation, body weight, height,

body perception, and health behaviors. Socio-demographic

characteristics included age, gender, student status, and

living arrangement. Acculturation was measured by four

indicators: nativity, years of US residence, Vietnamese

language fluency, and self-perception of Americanization.

Nativity was defined by the country of birth of a respondent

and categorized into two groups: foreign-born and

US-born. For those who were born in the US, their years of

US residence were considered to be the same number as

their age. An interaction variable of nativity with years of

US residence was created to estimate the differential effect

of years of US residence on body weight by nativity.

Vietnamese language fluency was based on respondents’

self-assessment of their Vietnamese speaking and writing

skills and had three levels: not at all, fairly well, and very

well. Self-perception of Americanization was measured in

three levels: very Vietnamese, equally Vietnamese and

American, and very American.

BMI was calculated based on self-reported body weight

and height. From the calculated BMI, respondents were

classified based on the WHO recommended BMI cut-offs

for Asians as follows: BMI \ 18.5 kg/m2 for underweight,

BMI C 23 kg/m2 for overweight, and BMI C 27.5 kg/m2

for obesity [33]. Due to the small number of observations,

underweight respondents were included in the ‘‘normal

weight’’ category. Respondents in the overweight and

obesity categories were combined and labeled ‘‘over-

weight.’’ Thus, a dichotomous weight status variable was

created as follows: normal weight (BMI \ 23 kg/m2) and

overweight (BMI C 23 kg/m2). In addition to self-reported

weight status, respondents’ perception about their own

body weight was asked. Their responses were measured at

two levels: acceptable and not acceptable.

With respect to health behaviors, respondents were

asked about current cigarette smoking, drinking, weekly

exercise, and nutritional adequacy of diet. Regular exercise

was measured by the frequency of weekly exercise for at

least 20 minutes: less than once, 1–3 times, and 4 times

and more. Respondents were asked to assess their own

nutritional adequacy of diet, and their responses were

measured at four levels: poor, fair, good, or excellent. After

preliminary analysis, the responses were regrouped into

two categories: poor/fair and good/excellent.

Statistical Analyses

The survey data were analyzed using SPSS, version 15.0

(SPSS Inc., Chicago IL). Descriptive statistics were used to

summarize the sample characteristics. Bivariate analyses

including Pearson’s chi-square and t-test were performed to

examine the relationship between weight status and socio-

demographic characteristics, acculturation, body percep-

tion, and health behaviors, respectively. Finally, logistic

regression analysis was conducted to identify the predictors

of weight status of Vietnamese American students and to

estimate the effects of these predictors after controlling for

other independent variables.

Results

The respondents’ characteristics by nativity are summa-

rized in Table 1. Overall, 31.8% of respondents were

overweight based on the WHO recommended cut-offs for

Asian of 23 kg/m2. When we applied the global WHO cut-

offs of 25 kg/m2, we found that 16.9% of the respondents

were overweight. A higher proportion of US-born respon-

dents (39.4%) were overweight. Although most respon-

dents were normal weight (68.2%), 64% of respondents

reported that their body weight was not acceptable. In the

further analyses, 73.3% of the foreign-born with normal

body weight and 68.8% of the US-born with normal body

weight had a negative perception about their body weight

(data not shown in Table 1).

The average years of US residence among foreign-born

respondents was 14.6 years (SD = 5.5). With respect to

1118 J Immigrant Minority Health (2011) 13:1116–1124

123

language fluency, 72.4% of foreign-born respondents

reported fluency in Vietnamese at the fairly well or very

well levels, while 62.2% of US-born respondents reported

that they could neither speak nor write Vietnamese.

Overall, most respondents identified themselves as equally

Vietnamese and American (60.8%) or very American

(32.3%). While a majority of foreign-born respondents

identified themselves as equally Vietnamese and American

(79.1%), most US-born respondents identified themselves

as either very American (57.9%) or equally Vietnamese and

American (41.3%). There were also group differences in

health behaviors. A substantial proportion of the US-born

Table 1 Respondents’

characteristics by nativity

Notes: Values in table are

numbers of respondents

(percentages) except for age and

years of US residence which are

reported in mean years

(standard deviation)a Years of residence in the US

was considered the same as age

because these respondents were

born in the US

Characteristics Foreign-born

N = 134 (51.3)

US-born

N = 127 (48.7)

Total

N = 261 (100)

Body weight

Normal (BMI \ 23 kg/m2) 101 (75.4) 77 (60.6) 178 (68.2)

Overweight (BMI C 23 kg/m2) 33 (24.6) 50 (39.4) 83 (31.8)

Body perception

Acceptable 46 (34.3) 48 (37.8) 94 (36.0)

Not acceptable 88 (65.7) 79 (62.2) 167 (64.0)

Demographic characteristics

Gender

Male 51 (38.1) 62 (48.8) 113 (43.3)

Female 83 (61.9) 65 (51.2) 148 (56.7)

Age 22.90 (3.62) 21.54 (2.25) 22.24 (3.10)

Student status

Undergraduate 108 (80.6) 114 (89.8) 222 (85.1)

Graduate 26 (19.4) 13 (10.2) 39 (14.9)

Living arrangement

On/off campus housing 35 (26.1) 26 (20.6) 61 (23.5)

Parent/guardian’s home 99 (73.9) 100 (79.4) 199 (76.5)

Acculturation

Years of US residence 14.61 (5.50) 21.54 (2.25)a 18.06 (5.57)

Vietnamese fluency

Not at all 37 (27.6) 79 (62.2) 116 (44.4)

Fairly well 31 (23.1) 35 (27.6) 66 (25.3)

Very well 66 (49.3) 13 (10.2) 79 (30.3)

Self-perception of Americanization

Very Vietnamese 17 (12.7) 1 (0.8) 18 (6.9)

Equally Vietnamese & American 106 (79.1) 52 (41.3) 158 (60.8)

Very American 11 (8.2) 73 (57.9) 84 (32.3)

Health behaviors

Current cigarette smoking

Yes 23 (17.2) 33 (26.0) 56 (21.5)

No 111 (82.8) 94 (74.0) 205 (78.5)

Current alcohol use

Yes 72 (54.1) 92 (72.4) 164 (63.1)

No 61 (45.9) 35 (27.6) 96 (36.9)

Adequacy of nutrition

Poor/fair 89 (66.4) 79 (62.7) 168 (64.6)

Good/excellent 45 (33.6) 47 (37.3) 92 (35.4)

Weekly exercise

Less than once 50 (37.3) 41 (32.3) 91 (34.9)

1–3 times 64 (47.8) 51 (40.2) 115 (44.1)

C4 times 20 (14.9) 35 (27.6) 55 (21.1)

J Immigrant Minority Health (2011) 13:1116–1124 1119

123

respondents reported both negative as well as positive

health behaviors. The proportion of US-born respondents

who currently drink alcohol and smoke cigarettes was

higher than the foreign-born respondents, while at the same

time, a higher proportion of US-born respondents reported

frequent exercise as compared to their foreign-born

counterparts.

Table 2 presents the relationships between selected

respondent characteristics and weight status. Gender and

student status were significantly related to weight status.

Table 2 Bivariate analysis for

weight status

* P \ 0.05; ** P \ 0.01

Notes: Values in table are

numbers of respondents

(percentages) except for age and

years of US residence which are

reported in mean years

(standard deviation)

Characteristics Weight status

Normal

(BMI \ 23 kg/m2)

Overweight

(BMI C 23 kg/m2)

Demographic characteristics

Gender**

Male 57 (50.4) 56 (49.6)

Female 121 (81.8) 27 (18.2)

Age 22.30 (3.03) 22.10 (3.25)

Student status*

Undergraduate 146 (65.8) 76 (34.2)

Graduate 32 (82.1) 7 (17.9)

Living arrangement

On/off campus housing 43 (70.5) 18 (29.5)

Parent/guardian’s home 135 (67.8) 64 (32.2)

Acculturation

Nativity*

Foreign-born 101 (75.4) 33 (24.6)

US-born 77 (60.6) 50 (39.4)

Years of US residence* 17.41 (5.64) 19.43 (5.18)

Vietnamese fluency**

Not at all 65 (56.0) 51 (44.0)

Fairly well 53 (80.3) 13 (19.7)

Very well 60 (75.9) 19 (24.1)

Self-perception of Americanization*

Very Vietnamese 12 (66.7) 6 (33.3)

Equally Vietnamese & American 118 (74.7) 40 (25.3)

Very American 47 (56.0) 37 (44.0)

Health behaviors

Current cigarette smoking

Yes 33 (58.9) 23 (41.1)

No 145 (70.7) 60 (29.3)

Current alcohol use*

Yes 104 (63.4) 60 (36.6)

No 73 (76.0) 23 (24.0)

Adequacy of nutrition

Poor/fair 118 (70.2) 50 (29.8)

Good/excellent 59 (64.1) 33 (35.9)

Weekly exercise*

Less than once 64 (70.3) 27 (29.7)

1–3 times 84 (73.0) 31 (27.0)

C4 times 30 (54.5) 25 (45.5)

Body perception**

Acceptable 51 (54.3) 43 (45.7)

Not acceptable 127 (76.0) 40 (24.0)

1120 J Immigrant Minority Health (2011) 13:1116–1124

123

About half of the male respondents were overweight,

compared to 18.2% of the females. A higher proportion of

graduate students than undergraduate students tended to be

in the normal BMI range. All of the acculturation indica-

tors were significantly related to weight status. The over-

weight rate was significantly higher for the US-born than

foreign-born respondents. Those who were overweight

tended to have lived longer in the US. The highest rates of

overweight respondents were found among those who

identified themselves as very American and who had the

least Vietnamese language fluency. The lowest overweight

rates were found among those who identified themselves as

equally Vietnamese and American and those with fair

Vietnamese language fluency.

Concerning health behaviors, drinking behavior and

exercise were significantly related to weight status. Current

drinkers were more likely to be overweight than non-

drinkers. The highest overweight rate was found among

respondents who exercised 4 times or more per week.

Cigarette smoking status and self-reported nutrition status

were not significantly associated with being overweight.

Positive body perception had a significant relationship with

a higher proportion of overweight. Only 24% of respon-

dents with negative body perception were overweight,

compared to 45.7% of those with positive body perception.

The result of the logistic regression model for weight status

is presented in Table 3. Men were 4.6 times as likely as

women to be overweight (95% confidence interval

[CI] = 2.2–9.4). Graduate students were significantly less

likely than undergraduate students to be overweight

(OR = 0.3, 95% CI = 0.1–1.0). Among acculturation indi-

cators, only nativity and its interaction with years of residence

were significant after controlling for other variables. Foreign-

born respondents were significantly less likely to be over-

weight than US-born respondents. The main effect of years of

US residence was not statistically significant, but its inter-

action with nativity was significantly related to weight status.

It indicates that there are differential effects of years of

residence on weight status by nativity. The odds of being

overweight with increased years of residence in the US

was significantly greater for the foreign-born than for the

US-born. None of the health behaviors were significant after

controlling for demographic characteristics and acculturation

variables. An acceptable body perception was a strong pre-

dictor of overweight. Those who had positive body percep-

tion were 3.1 times as likely as were those who had negative

body perception to be overweight (95% CI = 1.6–6.0).

Discussion and Conclusion

The prevalence of overweight and obesity has been

reported to be much lower among Asian Americans (8.1%

for obese and 27.5% for overweight but not obese) [49]

than in the general US population (34.3% for obesity and

32.7% for overweight but not obese) [50]. However, most

of the reports were based on the WHO global standard cut-

off points. Wang et al. [51] argued that the use of WHO

global standard cut-off points for Asian Americans would

underestimate their risk of obesity-related health problems,

and this would create a gap in the prevention of chronic

diseases because Asian Americans have a greater risk of

health problems than do Whites with the same BMI [32,

33].

Our study examined weight status of Vietnamese

American students using the WHO recommended BMI

cutoff for Asians (BMI of 23 kg/m2) and the effects of

acculturation and body perception on their weight status.

We found that about 32% of our respondents were either

overweight or obese. This was much higher than the esti-

mate (16.9%) if we had used the global WHO BMI cut-off

of 25 kg/m2, consistent with the study of Wang and col-

leagues [51].

Our study findings highlighted the importance of some

acculturation variables and body perception to predict

overweight among Vietnamese American students.

Table 3 Multivariate logistic regression analysis for overweight

among vietnamese students

Variable OR (95% CI)

Age 1.1 (0.9 1.3)

Male** 4.6 (2.2 9.4)

Graduate student* 0.3 (0.1 1.0)

Live with parents 0.9 (0.4 2.0)

Foreign-born* 0.0a (0.0 0.7)

Years of US residence 0.8 (0.6 1.1)

Foreign-born 9 length of US residence* 1.3 (1.0 1.7)

Vietnamese fluency [not at all]

Fairly well 0.5 (0.2 1.1)

Very well 0.6 (0.2 1.8)

Self-perception of Americanization [medium]

Low 1.0 (0.3 4.0)

High 1.2 (0.5 3.0)

Good/excellent nutrition 1.1 (0.5 2.3)

Weekly exercise [less than once]

1–3 times 0.7 (0.3 1.6)

[4 times 0.9 (0.3 2.5)

Current cigarette smoking 0.8 (0.4 1.8)

Current alcohol use 1.4 (0.6 2.8)

Acceptable body perception** 3.1 (1.6 6.0)

Notes: OR = odds ratio; CI = confidence interval

* P \ 0.05; ** P \ 0.01a The odd ratio of the foreign born is 0.002. Due to rounding up in the

100th decimal place, it is reported 0.0 in the table

J Immigrant Minority Health (2011) 13:1116–1124 1121

123

Consistent with the results of other studies [11, 12, 17, 20,

27, 38], our study confirmed the important roles of nativity

and years of US residence on weight status. Nativity and its

interaction with years of US residence were significantly

associated with weight status after controlling for other

variables. That is, the foreign-born Vietnamese American

students were less likely to be overweight than the US-born

counterpart, but the foreign-born tended to become over-

weight more quickly than the US-born with increasing

years of residence in the United States. The greater risk of

being overweight with years of US residence among the

foreign-born might enable them to catch up with the BMI

level of the US-born counterpart. This result might be

explained by theories of the healthy immigrant effect and

BMI convergence due to unhealthy assimilation. Immi-

grants have an advantage in their initial body composition

during their early stage of immigration, but this advantage

erodes over time and converges toward the American BMI

in spite of variations across racial and ethnic groups [7, 11,

12, 15–21, 23].

The interesting results were found in the effects of other

acculturation variables on weight status. From the bivariate

analyses, weight status differed significantly by levels of

Vietnamese language fluency and self-perceived Ameri-

canization. The highest rates of normal weight were found

among respondents who were moderately acculturated in

terms of language and Americanization. These findings

imply that bicultural students’ ability to function compe-

tently in two cultures might be positively related to their

health status, in line with Ryder and colleagues’ finding

[52] that biculture is the most beneficial to the health of

immigrants. The concept of selective acculturation might

also explain the beneficial aspects of biculture. Yeh and

colleagues [53] argued that selective acculturation can have

beneficial effects on weight status by encouraging immi-

grants to retain healthful behaviors of their culture of origin

while acquiring the healthful behaviors of their new cul-

ture. In the multivariate analysis, however, the effects of

language fluency and ethnic identity on weight status were

not significant. This finding suggests that those accultura-

tion variables may influence weight status through other

variables such as nativity, years of residence, body per-

ception, and health behaviors.

While none of the health behaviors were statistically

significant in the multivariate analysis, health behaviors

such as drinking behavior and weekly exercise were sig-

nificantly associated with weight status in bivariate analy-

ses. Weekly exercise, in particular, had an interesting

relationship with weight status in bivariate analysis. There

was a much higher prevalence of overweight respondents

who exercised 4 times or more per week, compared to

those who exercised 1–3 times per week and those who

exercised less than once per week. This might be related to

the inverse causation between weight status and exercise.

That is, those who were overweight tended to exercise

more in an attempt to control their weight than those with

normal weight. Both drinking behavior and weekly exer-

cise, however, were no longer statistically significant in

multivariate analysis. This might be explained by possible

correlation between health behaviors and acculturation

[39].

Body perception contributed greatly to weight status of

Vietnamese American students. Those who were satisfied

with their body weight were more likely to be overweight.

According to the CDC report in 2009 [6], difference in

cultural norms regarding body weight and size is one of the

possible explanations that account for existing disparity in

the prevalence of obesity across groups. For example, both

non-Hispanic Black and Hispanic women were more sat-

isfied with their body size than non-Hispanic White

women; the former racial groups had a higher prevalence

of obesity [54]. Asian American girls tended to perceive

themselves as being overweight even when they were not

[55]. The relationship between body perception and weight

status might be also explained by difference in weight

control practices. Brener et al. [56] found that high school

students who were overweight but did not perceive them-

selves as overweight were less likely to engage in weight

control practices. That is, those with positive body per-

ception were less likely to try to lose weight [54, 56, 57].

The limitations of this study should be acknowledged.

Although a random sampling method was used to generate

a representative sample, the sampling frame was a single

university. Thus, caution is required in generalizing our

findings to Vietnamese Americans in general or other

Asian American students. Also, the data were collected by

a self-administered mail survey, which yields a lower

response rate and incomplete surveys. Although informa-

tion about individuals who did not return surveys is not

available, it is possible that those who did not return or

complete the surveys may be different from respondents in

regard to certain characteristics (e.g. acculturation). This

might bias estimated coefficients. Other limitations relate

to measurements. This study used self-reported height and

weight to construct BMI. Several studies have documented

systematic measurement errors related to those self-repor-

ted measures [58–60]. According to Brener et al. [60], high

school students’ self-reported weight tended to be lower

and their self-reported height tended to be higher than the

measured ones. Biases related to self-reported measures

varied by gender, race, and ethnicity. Female students

tended to underreport their weight, while male students

tended to overreport their height. White students were more

likely to overreport their height than other race/ethnic

group students. The systematic bias related to self-reported

measures could affect the percentages of students classified

1122 J Immigrant Minority Health (2011) 13:1116–1124

123

as overweight. This study also used a self-reported measure

of nutrition which could be subjected to potential cultural

biases and social desirability effect biases. Also, our

acculturation measures, which have frequently been used in

other studies, may not have fully captured the multidi-

mensional aspects of acculturation. Moreover, although

economic factors (e.g. income) might have direct and

indirect effects on overweight/obesity, such factors were

not included in the analyses because they were not avail-

able in the survey.

Despite these limitations, this study has significant

implications for future research and public health policy.

Further investigation is necessary to understand the

mechanism accounting for the effects of nativity on body

weight perception, which in turn influences weight status

and weight control practice for Asian Americans. With

increased years of residence in the United States, foreign-

born individuals may experience conflicts between ideal

body image and unhealthy lifestyles of dominant culture.

These conflicts may lead foreign-born, young individuals

to participate in unhealthy weight loss practices [46].

This study suggests the importance of offering culturally

relevant health education in US schools that serve large

Vietnamese and other Asian American populations. At the

same time, health care professionals should maintain a

cultural awareness when they interact with Asian American

patients and should consider following an adjusted BMI. In

particular, culturally sensitive overweight and obesity

prevention programs should be tailored to the foreign-born

population, focus on establishing healthy body perception,

and encourage positive health practices (e.g. the mainte-

nance of traditional cultural dietary habits and exercise).

Such interventions should begin among children and young

adults so that they can learn to make appropriate decisions

and lifestyle modifications to help prevent chronic diseases.

With the growing number of foreign-born individuals in

the US, early education about lifestyle modification may

represent an important opportunity to prevent obesity and

obesity-related chronic illnesses as well as to develop

culturally appropriate weight management and control

practices.

References

1. Ogden CL, Carroll MD, Curtin LR, Lamb MM, Flegal KM.

Prevalence of high body mass index in US children, adolescents,

2007–2008. JAMA. 2010;303(3):242–9.

2. Flegal KM, Carroll MD, Ogden CL, Curtin LR. Prevalence and

trends in obesity among US adults, 1999–2008. JAMA. 2010;

303(3):235–41.

3. Mokdad AH, Marks JS, Stroup DF, Gerberding JL. Actual causes

of death in the United States, 2000. JAMA. 2004;291(10):

1238–45.

4. Visscher TL, Seidell JC. The public health impact of obesity.

Annu Rev Public Health. 2001;22:355–75.

5. US Department of Health and Human Services. The Surgeon

General’s call to action to prevent and decrease obesity. 2001.

Rockville, MD: US Department of Health and Human Services,

US Public Health Service, Office of the Surgeon General.

http://www.surgeongeneral.gov/topics/obesity/calltoaction/Callto

Action.pdf. Accessed Feb 1 2010.

6. Center for Disease Control (CDC). Differences in prevalence of

obesity among Black, White, and Hispanic adults—United States,

2006–2008. MMWR. 2009;58(27):740–4. http://www.cdc.gov/

mmwr. Accessed Feb 1 2010.

7. Hao L, Kim J. Immigration and the American obesity epidemic.

Int Migr Rev. 2009;43(2):237–62.

8. Wang Y, Beydoun MA. The obesity epidemic in the United

States-gender, age, socioeconomic, racial/ethnic, and geographic

characteristics: a systematic review and meta-regression analysis.

Epidemiol Rev. 2007;29:6–28.

9. Zhang Q, Wang Y. Trends in the association between obesity and

socioeconomic status in US adults: 1971–2000. Obes Res. 2004;

12:1622–32.

10. Gordon-Larsen P, Adair LS, Popkin BM. The relationship of

ethnicity, socioeconomic factors, and overweight in US adoles-

cents. Obes Res. 2003;11(1):121–9.

11. Goel MS, McCarthy EP, Phillips RS, Wee CC. Obesity among

US immigrant subgroups by duration of residence. JAMA. 2004;

292:2860–7.

12. Lauderdale DS, Rathouz P. Body mass index in a US national

sample of Asian Americans: effects of nativity, years since

immigration and socioeconomic status. Int J Obes Relat Metab

Disord. 2000;24(9):1188–94.

13. Popkin BM, Udry JR. Adolescent obesity increases significantly in

second and third generation US immigrants: the National Longi-

tudinal Study of Adolescent Health. J Nutr. 1998;128:701–6.

14. Abraı́do-Lanza AF, Armbrister AN, Florez KR, Aguirre AN.

Toward a theory-driven model of acculturation in public health

research. Am J Public Health. 2006;96(8):1342–6.

15. Jasso G, Massey DS, Rosenzweig MR, Smith JP. Immigrant

health: selectivity and acculturation: In: Anderson NB, Bulatao

RA, Cohen B, editors. Critical perspectives on racial and ethnic

differences in health in late life. Washington, DC: National

Academy Press; 2004. pp. 227–66.

16. Pallon A, Arias E. Paradox lost: explaining the Hispanic adult

mortality advantage. Demography. 2004;41(3):385–415.

17. Chen JL, Kennedy C. Factors associated with obesity in Chinese-

American children. Pediatr Nurs. 2005;31(2):110–5.

18. Chen JL, Wu Y. Cardiovascular risk factors in Chinese American

children: associations between overweight, acculturation, and

physical activity. J Pediatr Health Care. 2008;22(2):103–10.

19. Liou D, Bauer KD. Exploratory investigation of obesity risk and

prevention in Chinese Americans. J Nutr Educ Behav. 2007;39:

134–41.

20. McDonald JT, Kennedy S. Insights into the ‘healthy immigrant

effect’: health status and health service use of immigrants to

Canada. Soc Sci Med. 2004;59(8):1613–27.

21. Nielsen SJ, Siega-Riz AM, Popkin BM. Trends in energy intake

in the US between 1977 and 1996: similar shifts seen across age

groups. Obes Res. 2002;10:370–8.

22. Singh GK, Kogan MD, Yu SM. Disparities in obesity and over-

weight prevalence among US immigrant children and adolescents

by generational status. J Commun Health. 2009;34:271–81.

23. Antecol H, Bedard K. Unhealthy assimilation: why do immi-

grants converge to American health status levels? Demography.

2006;43(2):337–60.

24. Bates LM, Acevedo-Garcia D, Alegrı́a M, Krieger N. Immigra-

tion and generational trends in body mass index and obesity in the

J Immigrant Minority Health (2011) 13:1116–1124 1123

123

United States: results of the National Latino and Asian American

Survey, 2002–2003. Am J Public Health. 2008;98(1):70–7.

25. Cho J, Juon HS. Assessing overweight and obesity risk among

Korean Americans in California using World Health Organiza-

tion body mass index criteria for Asians. Prev Chronic Dis.

2006;3(3):A79.

26. Levy A. Rational eating: can it lead to overweightness or un-

derweightness? J Health Econ. 2002;21(5):887–99.

27. Gordon-Larsen P, Harris KM, Ward DS, Popkin BM. Accultur-

ation and overweight-related behaviors among Hispanic immi-

grants to the US: the National Longitudinal Study of Adolescent

Health. Soc Sci Med. 2003;57:2023–34.

28. McNeely MJ, Boyko DJ. Type 2 diabetes prevalence in Asian

Americans. Diabetes Care. 2004;27(1):66–9.

29. Nelson T, Gortmaker S, Subramanian S, Cheung L, Wechsle H.

Disparities in overweight and obesity among US college students.

Am J Health Behav. 2007;31(4):363–73.

30. Nicdao E, Hong S, Takeuchi D. Prevalence and correlates of

eating disorders among Asian Americans: results from the

National Latino and Asian American Study. Int J Eat Disord.

2007;40:S22–6.

31. Yeh M, Fahs M, Shelley D, Yerneni R, Parikh NS, Burton D.

Body weight and length of residence in the US among Chinese

Americans. J Immigr Minor Health. 2009;11:422–7.

32. Deurenberg P, Yap M, van Staveren WA. Body mass index and

percent body fat: a meta analysis among different ethnic groups.

Int J Obes Relat Metab Disord. 1998;22:1164–71.

33. World Health Organization Expert Consultation. Appropriate

body-mass index for Asian populations and its implications for

policy and intervention strategies. Lancet. 2004;363:157–63.

34. Pan WH, Flegal KM, Chang HY, Yeh WT, Yeh CJ, Lee WC.

Body mass index and obesity-related metabolic disorders in

Taiwanese and US whites and blacks: implications for definitions

of overweight and obesity for Asians. Am J Clin Nutr. 2004;

79:31–9.

35. Wildman RP, Gu D, Reynolds K, Duan X, He J. Appropriate

body mass index and waist circumference cutoffs for categori-

zation of overweight and central adiposity among Chinese adults.

Am J Clin Nutr. 2004;80:1129–36.

36. Ball K, Crawford D. Socioeconomic status and weight change in

adults: a review. Soc Sci Med. 2005;60(9):1987–2011.

37. Dey AN, Lucas JW. Physical and mental health characteristics of

US- and foreign-born adults: United States, 1998–2003. Adv

Data. 2006;369:1–19.

38. Kaplan MS, Huguet N, Newsom JT, McFarland BH. The asso-

ciation between length of residence and obesity among Hispanic

immigrants. Am J Prev Med. 2004;27(4):323–6.

39. Singh GK, Siahpush M. Ethnic-immigrant differentials in health

behaviors, morbidity and cause specific mortality in the United

States: an analysis of two national data bases. Hum Biol. 2002;

74(1):83–109.

40. Yates A, Edman J, Aruguete M. Ethnic differences in BMI and body/

self-dissatisfaction among Whites, Asian subgroups, Pacific Island-

ers, and African-Americans. J Adolesc Health. 2004;34:300–7.

41. Davis J, Busch J, Hammatt Z, Novotny R, Harrigan R, Grandi-

netti A, Easa D. The relationship between ethnicity and obesity in

Asian and Pacific Islander populations: a literature review. Ethn

Dis. 2004;14:111–8.

42. Reeves TJ, Bennett CE. The Asian and Pacific Islander popula-

tion in the United States. Washington, DC: US Census Bureau;

Current Population Reports P20–540. 2003.

43. US Census Bureau. The American Community-Asians: 2004.

The American Community Survey Reports. Washington, DC: US

Department of Commerce; 2007. http://www.census.gov/prod/

2007pubs/acs-05.pdf. Accessed 1 Feb 2010.

44. Nguyen TT, Liao Y, Gildengorin G, Tsoh J, Bui-Tong N, McPhee

SJ. Cardiovascular risk factors and knowledge of symptoms

among Vietnamese Americans. J Gen Intern Med. 2009;24(2):

238–43.

45. Hogan DP, Astone NM. The transition to adulthood. Ann Rev

Soc. 1986;12:109–30.

46. Wharton CM, Adams T, Hampl JS. Weight loss practices and

body weight perceptions among US college students. J Am Coll

Health. 2008;56(5):579–84.

47. US Census Buearu. ACS demographic and housing estimates:

2006–2008. American Factfinder; 2008. http://factfinder.census.

gov. Accessed March 1 2010.

48. Adopt Vietnam. Vietnamese family names Web page. http://

www.adoptvietnam.org/vietnamese/names-family.htm. Accessed

9 August 2005.

49. Barnes PM, Adams PF, Powell-Griner E. Health characteristics of

the Asian adult population: United States, 2004–2006. Advance

data from vital and health statistics. Hyattsville, MD: National

Center for Health Statistics; 2008. p. 394. http://www.cdc.gov/

nchs/data/ad/ad394.pdf. Accessed 15 Oct 2010.

50. CDC. Prevalence of overweight, obesity and extreme obesity

among adults: United States, trends 1960–62 through 2005–2006.

Health E-Stat; 2008. http://www.cdc.gov/nchs/data/hestat/over

weight/overweight_adult.htm. Accessed 15 Oct 2010.

51. Wang LH, Chen YC, Chung AK, Poon G, Polong L, Tam CF.

Age, gender and ethnic differences in prevalence of overweight

and obesity in Asian American college students and their parents

using different BMI cutoffs. Coll Stud J. 2007;41(3):583–600.

52. Ryder AG, Alden LE, Paulhus DL. Is acculturation unidimen-

sional or bidimensional? a head-to-head comparison in the pre-

diction of personality, self-identity, and adjustment. J Pers Soc

Psychol. 2000;79:49–65.

53. Yeh MC, Viladrich A, Bruning N, Roye C. Determinants of

Latina obesity in the US: the role of selective acculturation.

J Transcult Nurs. 2009;20:105–15.

54. Millstein RA, Carlson SA, Fulton JE, Galuska DA, Zhang J,

Blanck HM, Ainsworth BE. Relationships between body size

satisfaction and weight control practices among US adults.

Medscape J Med. 2008;10(5):119.

55. Kemper KA, et al. Black and white females’ perception of ideal

body size and social norms. Obes Res. 1994;2(2):117–26.

56. Brener ND, Eaton DK, Lowry R, McManus T. The association

between weight perception and BMI among high school students.

Obes Res. 2004;12(11):1866–74.

57. Wang Y, Liang H, Chen X. Measured body mass index, body

weight perception, dissatisfaction and control practices in urban,

low-income African American Adolescents. BMC Public Health.

2009;9:183–95.

58. Fortenberry JD. Reliability of adolescents’ reports of height and

weight. J Adolesc Health. 1992;13:114–7.

59. Goodman E, Hinden BR, Khandelwal S. Accuracy of teen and

parental reports of obesity and body mass index. Pediatrics.

2000;106:52–8.

60. Brener ND, McManus T, Galuska DA, Lowry R, Wechsler H.

Reliability and validity of self-reported height and weight among

high school students. J Adolesc Health. 2003;32(4):281–7.

1124 J Immigrant Minority Health (2011) 13:1116–1124

123