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«AN ASIAN INDIAN DIETARY ACCULTURATION MEASURE: INSTRUMENT DEVELOPMENT AND VALIDATION By Sumathi Venkatesh A DISSERTATION Submitted to Michigan State ...»

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AN ASIAN INDIAN DIETARY ACCULTURATION MEASURE: INSTRUMENT

DEVELOPMENT AND VALIDATION

By

Sumathi Venkatesh

A DISSERTATION

Submitted to

Michigan State University

in partial fulfillment of the requirements

for the degree of

Human Nutrition – Doctor of Philosophy

ABSTRACT

AN ASIAN INDIAN DIETARY ACCULTURATION MEASURE: INSTRUMENT

DEVELOPMENT AND VALIDATION

By Sumathi Venkatesh Background: Asian Indian adults in the U.S. (~1% of the total population) have a high prevalence of type 2 diabetes (ranging from 17%-29%) and other diet-related problems. A key associative factor could be unhealthy changes in dietary practices because exposure to the host culture may potentially negatively change dietary behaviors and food preparation practices (dietary acculturation). An assessment of dietary acculturation using an appropriate and culturally sensitive measure is therefore critical for understanding if and how dietary changes occur in those who relocate to another country. This will facilitate the efficacy of culturally sensitive interventions.

Specific aims: The three specific aims of this study were: (i) to qualitatively examine the factors influencing the dietary acculturation behaviors of Asian Indian adults in the U.S., (ii) to develop a culturally sensitive, reliable and valid Asian Indian Dietary Acculturation Measure (AIDAM), and (iii) to examine the relationship between AIDAM scores and the risk for type 2 diabetes among Asian Indians.

Methods: For specific aim 1, eight audio-taped focus group discussions (2-5 members/ group) and assessment of typical weekday and weekend 24 hour dietary recalls were conducted with 30 Asian Indian adults in Michigan. Verbatim focus group transcripts and dietary recalls were qualitatively analyzed for generating themes. To accomplish specific aim 2, themes that evolved from the focus group discussions were used to generate items for the AIDAM, which was revised by 10 experts in nutrition/survey research and pre-tested with 12 Asian Indians. A web-based ii study was conducted with 225 Asian Indians in the U.S. to determine the reliability and validity of AIDAM. A Rasch rating scale model was used to determine reliability and construct validity.

To achieve specific aim 3, the Finnish Diabetes Risk Score (FINDRISC), a validated tool to determine diabetes risk in 10 years was completed with the web-survey. The associations between AIDAM and FINDRISC scores were examined using correlations and relative risk ratios.

Results: The key reported factors that emerged relative to modification of traditional eating behaviors were: social independence, social network influences, increased health awareness, substandard taste and increased cost of Asian Indian foods, time constraints, and convenience (specific aim 1). These findings were used for generating AIDAM items. The estimates from Rasch model analysis showed the 50 item AIDAM to be a reliable and valid measure with reliability of 0.88. The infit and outfit MNSQ statistics of the items were within the range of 0.58 – 0.61 indicating good model fit (specific aim 2). Comparison of AIDAM with FINDRISC scores showed that adaptation to the U.S. dietary practices by Asian Indians (AIDAM scores 2.8) increased the likelihood of developing type 2 diabetes (relative risk 1.6, confidence interval 1.02-2.51) (specific aim 3).

Conclusion: This dissertation: (i) documented dietary behaviors and influential factors of Asian Indian adults over time in the U.S., (ii) utilized findings for the development of a validated dietary acculturation assessment tool, and (iii) showed the association of AIDAM with type 2 diabetes risk. These findings are relevant for nutrition/health professionals to better understand Asian Indian food choices over time and health implications.

–  –  –

I am very thankful to my academic advisor Dr. Lorraine Weatherspoon who was very approachable as a mentor and was a great support for me both academically and otherwise. My sincere thanks to my guidance committee members Dr. Lorraine Weatherspoon, Dr. Won Song, Dr. Beth Olson, and Dr. Thomas Conner for their expert comments and inputs, which enhanced the quality of this research. I would like to acknowledge Dr. Marsha Carolan, Dr. Shabnam Momin, and Dr. Deepa Handu for revising the focus group guide for the qualitative piece of my dissertation, and Dr. Sudha Raj, Dr. Karmeen Kulkarni, Ms. Moushumi Mukherjee, Ms. Parul Shah, Ms. Rita Batheja, Dr. Ranjita Misra, Ms. Padmini Balagopal, Ms. Karen Clark, Dr. Ryan Bowles, and Dr. Merley Mathew who were the expert reviewers of the dietary acculturation instrument. I thank the Blue Cross Blue Shield Foundation of Michigan, the Michigan State University Graduate School, and The Alliance for Graduate Education and the Professoriate for providing funding support for my research. Last but not the least; I thank my family in India and a special thanks to my husband Dr. Venkatesh Balan and my daughters Supritha and Samyuktha for all the love and support.

–  –  –

LIST OF TABLES

LIST OF FIGURES

CHAPTER 1 - INTRODUCTION





I. Background

II. Specific aims

III. Significance

CHAPTER 2 - REVIEW OF LITERATURE

I. Theoretical Model for Dietary Acculturation

II. Dietary Patterns of Asian Indians relocated to other countries

III. Measures of Acculturation for Asians and Relation to Food

IV. Scales used for Asian Indians

V. Measures of Dietary Acculturation

VI. Dietary Acculturation Measure for Asian Indians

VII. Justification for a Dietary Acculturation Scale

VIII. Type 2 Diabetes Prevalence and Risk Factors

CHAPTER 3 - METHODS

CHAPTER 4 - RESULTS

I. Manuscript 1 (specific aim 1)

Abstract

Introduction

Methods

Focus group guide

Typical day dietary recalls

Data analysis

Results

Sample Characteristics

Typical weekday and weekend dietary intake of participants

Thematic findings

Facilitators of dietary acculturation

Facilitators of traditional food consumption

Discussion

Social independence

Social network influences for consuming non-Indian foods

Increased health awareness

Sub-standard taste and increased cost of Asian Indian snacks/ restaurant foods............. 66 Ability to cook Asian Indian foods, time constraints and convenience

Strengths and limitations

vi Conclusion

II. Manuscript 2 (specific aim 2)

Abstract

Introduction

Methods

Asian Indian Dietary Acculturation Measure (AIDAM)

Food frequency questionnaire

Data analysis

Results

Sample Characteristics

AIDAM: Model fit, reliability and validity

Correlation between AIDAM and AI-FFQ and NI-FFQ scores

Relationship of AIDAM with participant sociodemographic characteristics and AI-FFQ and NI-FFQ scores

Discussion

Strengths and limitations

Conclusion

III. Manuscript 3 (specific aim 3)

Abstract

Introduction

Methods

Asian Indian Dietary Acculturation Measure (AIDAM)

The Finnish Diabetes Risk Score (FINDRISC)

Data analysis

Results

Sample characteristics

Participants’ FINDRISC scores

Relation between FINDRISC and AIDAM

Discussion

Strengths and limitations

Conclusion

CHAPTER 5 - SUMMARY

APPENDICES

Appendix 1 - IRB approval

Appendix 2 - Research flyer

Appendix 3 - Research participant informed consent form (A)

Appendix 4 - Sociodemographic survey

Appendix 5 - Focus group questions

Appendix 6 - 24-hour dietary recall

Appendix 7 – Expert review of focus group guide

Appendix 8 - Codebook for focus group analysis

vii Appendix 9 – Expert review of Asian Indian Dietary Acculturation Measure (AIDAM) and food frequency questions

Appendix 10 – Asian Indian Dietary Acculturation Measure (AIDAM) pilot test results (n=12)

Appendix 11 – Location of residence of web-survey participants (n=225)

Appendix 12 – Comparison of demographic profile of Asian Indians participants and nonparticipants

Appendix 13 - Research participant informed consent form (B)

Appendix 14 - Questions on demographic characteristics, diet, and general health.............. 145 Appendix 15 - Food frequency assessment

Appendix 16 - The Finnish Diabetes Risk Score (FINDRISC) assessment

Appendix 17 – Validated Asian Indian Dietary Acculturation Measure (AIDAM)............... 153 Appendix 18 – Participant responses to the food frequency questionnaire

BIBLIOGRAPHY

–  –  –

Table 1. Focus group questions based on the PRECEDE model

Table 2. Participant characteristics (n=30)

Table 3. Participant consumption of non-Indian, common, and Asian Indian foods (n=30).

...... 42 Table 3 (cont’d)

Table 4. List of Asian Indian and non-Indian foods in the Food Frequency Questionnaire.

........ 81 Table 5. Sample characteristics (n=191)

Table 6: Descriptives and Rasch fit statistics of the Asian Indian Dietary Acculturation Measure (AIDAM) (n=191)

Table 6 (cont’d)

Table 6 (cont’d)

Table 7. Sociodemographic predictors of dietary acculturation as measured by Asian Indian Dietary Acculturation Measure (AIDAM)

Table 8. Participant characteristics (n=153)

Table 9. Finnish Diabetes Risk Score (FINDRISC) components by dietary acculturation level (n=153)

Table 10. The association (relative risk) between Asian Indian Dietary Acculturation Measure (AIDAM) and Finnish Diabetes Risk Score (FINDRISC) (n = 153)

Table 11. Codebook for focus group analysis

Table 11 (cont’d)

Table 11 (cont’d)

Table 12. Asian Indian Dietary Acculturation Measure (AIDAM) – pilot test results (n=12).

.. 139 Table 13: Mean scores for the Asian Indian Dietary Acculturation Measure (AIDAM) – pilot test results (n=12)

Table 13 (cont’d)

–  –  –

Table 15. Comparison of demographic profile of participants with non-participants (n=1350) 143 Table 16.

Participant responses for the food frequency questionnaire

Table 16 (cont’d)

Table 16 (cont’d)

–  –  –

Figure 1. Proposed Model of Dietary Acculturation

Figure 2. Figure showing the two phases of data collection

Figure 3. Person/item map for the 50 item Asian Indian Dietary Acculturation Measure (AIDAM)

Figure 4. Research flyer for focus group recruitment

Figure 5. The Finnish Diabetes Risk Score (FINDRISC) assessment

–  –  –

I. Background Diet-related health disparities exist in the United States (U.S.) as evidenced by the disproportionately high rates of chronic diseases such as type 2 diabetes, hypertension, and cardiovascular disease among racial/ ethnic minority populations (Cowie et al., 2009, Egan et al., 2010, Jolly et al., 2010). Asian Indians, the second largest Asian group in the U.S., constitute nearly 1% (3.2 million) of the U.S. population (U.S. Census Bureau, 2012). A high prevalence of diet-related chronic diseases, especially type 2 diabetes and cardiovascular disease and their risk factors have been documented among Asian Indians living in other countries when compared to the host population (Anand et al., 2000, Beckles et al., 1986, Dowse et al., 1990, Kanaya et al., 2010, Marine et al., 1969, Misra et al., 2010b, Simmons et al., 1992, Thai et al., 1987, Venkataraman et al., 2004, Zimmet et al., 1983). Dietary acculturation could be a possible explanation for the high prevalence of type 2 diabetes and associated complications among Asian Indians who relocate to the U.S.

When two or more cultures come into contact, psychological and cultural changes occur at individual and group levels termed acculturation (Berry, 2005). Dietary acculturation is the process that reflects the extent to which members of a migrating group adopt the eating patterns/ practices of their new environment (Satia-Abouta et al., 2002). Immigration and relocation potentially influence the acquisition of varying levels of new dietary behaviors. It is well known that individuals who immigrate/ relocate to other countries could have an altered dietary intake (compared to their native/ home country) by including new foods available in the host country or exclusion of foods consumed in the home country, which could be a consequence of dietary acculturation (Dixon et al., 2000, Hubert et al., 2005, Jonnalagadda and Diwan, 2002, Raj et al., 1999). These changes may or may not be healthful. Therefore it is important to study if and how these changes occur and whether or not they result in healthy outcomes.

Methodologies currently used in the assessment of dietary behaviors/ patterns are subject to certain limitations. Traditionally, diet and acculturation were independently captured using different assessments to study dietary acculturation behaviors. Dietary assessment tools generally encompass dietary recalls, food frequency questionnaires, or food diaries. These measures will provide information about the nutrients and types of foods commonly consumed, but may not serve as a measure of the changes that take place after relocation to another country. Similarly, general acculturation scales or single item proxy measures (e.g. fluency in host language or duration in the host country) have been widely employed in nutrition research to examine the association between host country adaptation or lifestyle changes and specific health outcomes of interest. However, these measures are limited from a dietary behavior perspective. There is specifically a lack of culturally sensitive measures for use with Asian Indians that are solely designed for the purpose of assessing the dietary acculturation level.



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