Changes in Prevalence of Overweight and in ... - Wiley Online Library

Changes in Prevalence of Overweight and in Body Image among Fijian Women between 1989 and 1998 Anne E. Becker,*† Stephen E. Gilman,‡§ and Rebecca A. Burwell¶

Abstract BECKER, ANNE E., STEPHEN E. GILMAN, AND REBECCA A. BURWELL. Changes in prevalence of overweight and in body image among Fijian women between 1989 and 1998. Obes Res. 2005;13:110 –117. Objective: To investigate changes in prevalence of overweight and obesity and in body image among ethnic Fijian women in Fiji during a period of rapid social change and the relationship between changes in body image and BMI. Research Methods and Procedures: The study design was a multiwave cohort study of BMI in a traditional Fijian village over a 9.5-year period from 1989 to 1998. Cohorts were identified in 1989 (n ⫽ 53) and in 1998 (n ⫽ 50). Selection criteria included Fijian ethnicity, female gender, age of at least 18 years, and residence in a specific coastal Fijian village in 1989 and 1998, respectively. Assessments consisted of measurement of height and weight, collection of demographic data by written survey, and administration of the Nadroga Language Body Image Questionnaire. Results: The prevalence of overweight and obesity was significantly different between the cohorts, increasing from 60% in 1989 to 84% in 1998 (p ⫽ 0.014). In addition, the age-adjusted mean BMI was significantly higher in 1998 compared with 1989 (p ⫽ 0.011). Finally, there were significant between-cohort differences in multiple measures of body image, which were mostly independent of BMI.

Received for review February 12, 2004. Accepted in final form November 10, 2004. The costs of publication of this article were defrayed, in part, by the payment of page charges. This article must, therefore, be hereby marked “advertisement” in accordance with 18 U.S.C. Section 1734 solely to indicate this fact. *Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts; †Department of Social Medicine, Harvard Medical School, Boston, Massachusetts; ‡Department of Society, Human Development, and Health, Harvard School of Public Health, Boston, Massachusetts; §Centers for Behavioral and Preventive Medicine, Brown Medical School, Providence, Rhode Island; ¶Department of Psychology, University of Denver, Denver, Colorado. Address correspondence to Anne E. Becker, Director, Adult Eating and Weight Disorders Program, Massachusetts General Hospital, WAC 816, 15 Parkman Street, Boston, MA 02114. E-mail: [email protected] Copyright © 2005 NAASO

110

OBESITY RESEARCH Vol. 13 No. 1 January 2005

Discussion: At 84%, the prevalence of overweight and obesity in this community sample of Fijian women is among the highest in the world. The dramatically increased prevalence over the 9.5-year period studied corresponds with rapid social change in Fiji and significant shifts in prevailing traditional attitudes toward body shape. Key words: Fiji, social change, modernization, body image

Introduction The prevalence of obesity has been increasing throughout the Pacific over the past few decades, including in Tonga (1), Western Samoa (2,3), and the Cook Islands (4). Although this parallels the increasing prevalence reported in westernized nations such as the U.S. (5,6) and Australia (7), the increase is superimposed on an obesity prevalence that is among the highest reported in the world (8). Indeed, a meta-analysis examining BMI and ethnicity reported a mean BMI of 29.7 kg/m2 among Polynesians, the highest among all ethnic groups compared (including white, black, Ethiopian, Chinese, Thai, and Indonesian) (9). Obesity rates have been especially high among Pacific women (8,10,11). For example, in a 1991 survey of Western Samoans, between 56% and 74% of women in various areas of the country were obese (3); the prevalence of overweight or obesity among Tongan women has been found to be 84% (12), and the prevalence of obesity among Fijian women has been reported as 63.0% (13). Among adults in New Zealand, 71.7% of female Pacific Islanders are obese, and 41.9% of female Maori are obese compared with just 14.6% of women of European descent (14). Since 1973, the BMI among Tongans has increased 11.9% among men, to a mean of 30.2 kg/m2, and has increased 19.4% among women, to a mean of 33.8 kg/m2 (1). Similarly, in Rarotonga, the Cook Islands, there has been an increase in rates of obesity from a 14% prevalence among men and 44% among women in 1966 to 52% among

Overweight and Body Image in Fijian Women, Becker, Gilman, and Burwell

men and 57% among women in 1996 (4). The increasing prevalence of obesity and concomitant increased risk of cardiovascular disease and diabetes in the Pacific (8,15,16) place an additional and unacceptable burden on health care resources there. Because rapid social and economic changes have swept Pacific Island nations over the past several decades, several studies have investigated how modernization has contributed to risk. Rates of obesity are consistently higher in urban compared with rural areas in developing countries, including in China (17,18), Saudi Arabia (19), and Thailand (20). The higher prevalence of obesity in urban settings has also been reported throughout the Pacific (8), including in Western Samoa (3,11), Papua New Guinea (21), Micronesia, Kiribati, Vanuatu, and Fiji (22,23). Modernization has also been found to be associated with increased prevalence of obesity in both Samoa (10,24,25) and Papua New Guinea (26). Shifts in physical activity (21) and diet seem to underlie these relationships, in part, although changes in dietary composition vary substantially, and no specific change in dietary patterns has emerged as consistently associated with obesity in the Pacific (22,27,28). Modernization in the Pacific has also been associated with changing body image ideals. That is, in contrast to the traditional preference for larger body size (29 –33), recent studies have documented a shift toward preferences for smaller body sizes across diverse Pacific Island populations (11,34 –36). However, to our knowledge, the association between these shifting preferences in body ideals and obesity has not previously been evaluated. Understanding how these changes in body image may affect behavioral patterns associated with obesity (and eating disorders) may assist in the development of preventive and interventional public health strategies in these populations at high risk for obesity and associated diseases. Fiji is an archipelago of over 300 islands located on the cultural and geographic border of Melanesia and Polynesia. Slightly greater than one-half of the population (393,000) is of ethnic Fijian (indigenous Pacific Islander) origin. Previous ethnographic work has established that traditional Fijian attitudes toward food, dieting, weight, body esthetic ideals, and reshaping the body are substantially distinct from Western attitudes. For example, a number of cultural traditions strongly support robust appetites and body shapes, including local norms that encourage hearty consumption of relatively calorie-dense foods, esthetic ideals favoring robust bodies, the centrality of food presentation and feasts as facilitators of social exchange and networks, and local illness categories that formalize vigilance for weight or appetite loss. Of particular relevance to this study, previous ethnographic data demonstrated that Fijian women traditionally did not express motivation for weight loss or reshaping the body and that body satisfaction was high among them as recently as the late 1980s (33,37).

Fiji is currently undergoing a period of rapid social change in the context of modernization, increasing participation in the global economy, and exposure to Western ideas, values, and media images. The Nadroga coast is one of Fiji’s primary tourist attractions and has supported wageearning jobs for ethnic Fijians, although the majority of Fijians continue to support themselves primarily through agriculture. Village homes in this area began to access electricity in the mid-1980s but have accessed broadcast television only since 1995. The partial shift from subsistence agriculture to wage-earning work has gradually allowed increased access to imported products. However, despite many changes associated with better transportation, electrification, consumption of Western-style processed foods (38), and imported media, ceremonial traditions have persisted, and village life retains key traditional elements. This study investigated the changes in prevalence of obesity in an ethnic Fijian population in rural western Fiji over the years 1989 to 1998, a decade that was characterized by the increasing electrification of rural areas, the introduction of television, and other economic and social changes. In addition, this study investigated the association between changes in traditional attitudes toward the body and obesity among ethnic Fijian women in Fiji.

Research Methods and Procedures Study Design The change in prevalence of obesity and changes in attitudes relevant to body shape satisfaction were investigated in two separate cohorts of ethnic Fijian adult women residing in a traditional Fijian village. The first cohort was obtained in 1989 and the second in 1998, ⬃9.5 years later. The study was approved by the Harvard Medical School Office for Research Subject Protection. In addition, data collection during each of the waves was approved by the Fiji Research Committee. This secondary data analysis is contextualized with ethnographic participant observational and interview data in the village under study in 1988 to 1989, 1994 to 1995, and 1998; results of these studies have been published elsewhere (33,36,37,39). Subjects Subjects were recruited by announcement and door-todoor canvassing in the same Fijian village in 1989 (n ⫽ 53) and in 1998 (n ⫽ 50). Inclusion criteria included residence in the same rural village in Nadroga (population estimated at 289) (Fiji Islands Statistics Bureau, personal communication), Fijian ethnicity, female gender, and age ⱖ 18 years. Assessments Subjects were weighed and measured in light (tropical weather) clothing without shoes. Raw weight data were corrected for estimated weight of clothing by subtracting 1 OBESITY RESEARCH Vol. 13 No. 1 January 2005

111


Table 1. Items and anchors from the Nadroga Language Body Image Questionnaire Item no. 1 2 3 4 5 6 7 8 9

Item and English translation

Anchors and translation

I vei kodaki lemu taletakinia mulala? Valevu 7 6 5 4 3 2 1 Burasia How well do you like your body? Very much 7 6 5 4 3 2 1 Dislike I bau marautakinia he majuatakinia mulala? Marautakinia 7 6 5 4 3 2 1 Majuatakinia Are you happy/proud of your body or ashamed of it?* Like it/proud of it 7 6 5 4 3 2 1 Ashamed of it O bau vinasia me hilanihila mulala? Valevu 1 2 3 4 5 6 7 Sikai hara ga Would you like to trade your body for another? Very much 1 2 3 4 5 6 7 Not at all O bau vinasia mo vihautakinia kemu ibulibuli? Valevu 1 2 3 4 5 6 7 Jua hara ga Would you like to change your shape? Very much 1 2 3 4 5 6 7 Don’t want to at all E rewa mo bau vihautakinia kemu ibulibuli? Valevu 1 2 3 4 5 6 7 Tasi rewa Is it possible for you to change your shape? Very much 1 2 3 4 5 6 7 Not possible O bau tovolia ho mo vihautakinia? Valevu 1 2 3 4 5 6 7 Tasi vahila Have you tried to change (your shape)? Very much 1 2 3 4 5 6 7 Never I bau dau kawaitakinia na kemu ibulibuli? Valevu 1 2 3 4 5 6 7 Sikai vahila How much do you care about your shape? Very much 1 2 3 4 5 6 7 Never I bau dau vakawaia na kemu ibulibuli? Valevu 1 2 3 4 5 6 7 Sikai vahila How critical are you of your shape? Very much 1 2 3 4 5 6 7 Never I bau dau vakawaia na kedru ibulibuli na ecola? Valevu 1 2 3 4 5 6 7 Sikai vahila How critical are you of others’ shapes? Very much 1 2 3 4 5 6 7 Never

* Some items translate poorly into English but were developed for idiomatic relevance to the Fijian linguistic and cultural context.

kg from each weight; this weight along with measured height was used to calculate BMI for each subject. Body satisfaction and attitudes toward aspects of body size and shape were assessed with a questionnaire developed for a related study. This questionnaire was designed to be a self-report but was read to subjects by a Nadroga language speaker when requested, and oral responses were recorded. Culturally and linguistically appropriate, Likert-style questions were formulated based on the first author’s previous ethnographic research and with the input of ethnic Fijian informants (Table 1). Specifically, questions elicited attitudes and practices concerning diet and weight relative to local cultural traditions. Questions were translated into the Nadroga language and back-translated into English to establish conceptual equivalence. Questions to assess demographic data and increased food intake were developed in the same manner but differed slightly in format and response options between the 1989 and 1998 waves of data collection. For example, in 1989, an increase in reported food intake was assessed by asking, “have you tried to increase what you eat?” whereas in 1998, the question was changed slightly to “have you ever tried to change how much you eat to change your weight?” In the former cohort, all response options except “never” were coded as affirma112


tive, and in the latter, only responses indicating that the respondent had changed her diet to gain weight were coded as affirmative. Data Analysis Cohort differences in BMI, attitudes toward body shape satisfaction, and subjective report of increased food intake were examined. Standard definitions of overweight (BMI ⱖ 25 kg/m2) and obesity (BMI ⱖ 30 kg/m2) were used. Although the use of higher cut-off points (BMI ⱖ 26 kg/m2 and ⬎32 kg/m2 for overweight and obesity, respectively) have been proposed for some Polynesian populations (40), these have not yet been established for Fijians who are of Melanesian origin. Differences in proportions were assessed using ␹2 tests and corresponding exact p values. Correlations between BMI and body image were also compared between cohorts. Student’s t tests were used to evaluate differences in means across cohorts. Mean differences in responses to items from the Body Image Questionnaire were also evaluated by using linear regression models to adjust for BMI. The underlying dimensionality of the nine items from the Body Image Questionnaire was also investigated using factor analytic methods. We determined the number of factors to retain based on the number of eigenvalues ⬎ 1 and by examining the scree plot of the eigenvalues (both

* NS, not significant.

How well do you like your body? Are you happy/proud of your body or ashamed of it? Would you like to trade your body for another? Would you like to change your shape? Is it possible for you to change your shape? Have you tried to change (your shape)? How much do you care about your shape? How critical are you of your shape? How critical are you of others’ shapes? Summary measures of body image Body satisfaction (items 1 and 2) Desire to reshape body; belief body can be reshaped (items 3 to 6) Level of interest in body shape (items 7 to 9)

Item 4.8 (2.0) 4.8 (2.0) 3.4 (2.2) 3.9 (2.4) 4.1 (2.2) 4.7 (2.3) 3.7 (2.2) 3.2 (2.1) 3.9 (2.6) 4.8 (1.8) 4.1 (1.8) 3.6 (1.8)

5.9 (1.5) 4.9 (2.1) 3.2 (2.0)

1998 Mean (SD)

5.7 (1.7) 6.0 (1.6) 4.3 (2.6) 4.5 (2.7) 5.1 (2.2) 5.5 (2.0) 2.7 (2.3) 3.1 (2.3) 3.9 (2.3)

1989 Mean (SD)

Table 2. Scores on the Nadroga Language Body Image Questionnaire

0.034 NS

0.002

0.014 0.0009 0.059 NS 0.018 0.057 0.021 NS NS

Student’s t test for difference in means between cohorts (p)

1998 Correlation with BMI (p) ⫺0.42 (0.002) ⫺0.36 (0.011) ⫺0.10 (NS) ⫺0.32 (0.023) ⫺0.17 (NS) ⫺0.07 (NS) ⫺0.06 (NS) ⫺0.08 (NS) ⫺0.10 (NS) ⫺0.42 (0.002) ⫺0.19 (NS) ⫺0.10 (NS)

1989 Correlation with BMI (p) ⫺0.33 (0.022) ⫺0.17 (NS*) ⫺0.14 (NS) ⫺0.17 (NS) ⫺0.11 (NS) ⫺0.21 (NS) 0.08 (NS) ⫺0.07 (NS) ⫺0.09 (NS) ⫺0.24 (0.098) ⫺0.19 (NS) ⫺0.04 (NS)



113


approaches yielded the same number of factors) (41). The factor solution was then rotated to identify the items that corresponded to each factor, which were averaged together to produce summary scores. In addition to between-cohort differences, we examined associations between BMI and variables of interest (i.e., education and increased food intake) across subjects in both cohorts to take advantage of a larger sample size. Because television was not introduced to this area until 1995, the association between BMI and frequency of television viewing could be investigated only for the 1998 cohort.

Results Between-Cohort Comparisons Mean ages of the two cohorts were 41.8 years (SD ⫽ 16.9; range, 19 to 80) in 1989 and 37.5 (SD ⫽ 12.0; range, 19 to 63) in 1998 and did not differ significantly. The percentage of each cohort with at least some secondary education did increase significantly, however, having risen from 36.7% in 1989 to 62.0% in 1998 (p ⫽ 0.02). Broadcast television was unavailable to the 1989 cohort, whereas 84% of the 1998 cohort accessed televised programs in their home. The prevalence of overweight or obese subjects (i.e., subjects with BMI ⱖ 25 kg/m2) differed significantly between cohorts, having increased from 60.0% in 1989 to 84.0% in 1998 (p ⫽ 0.014). Unadjusted mean BMI also increased from 27.7 kg/m2 (SD ⫽ 4.2) to 29.4 kg/m2 (SD ⫽ 4.8) during this time period (p ⫽ 0.058). Adjusting for age, the mean BMI of the 1998 cohort was 2.17 kg/m2 higher than that of the 1989 cohort (p ⫽ 0.011). In addition, the proportion of subjects with BMI ⱖ 30 kg/m2 increased from 30.0% in 1989 to 44.0% in 1998, and the proportion of subjects with BMI ⱖ 35 kg/m2 increased from 4.0% in 1989 to 14.0% in 1998, although neither of these differences was statistically significant. Mean scores on six of nine body image measures were different between the 1989 and 1998 cohorts (Table 2). Specifically, these differences reflected decreased concern about body shape (item 7), increased endorsement of the (non-traditional) concept that body shape can be changed (item 5) (33,42), decreased body satisfaction (items 1 and 2), a greater interest in trading one’s body for another (item 3), and more effort toward changing body shape (item 6) in the 1998 cohort than in the 1989 cohort. We examined whether these cohort differences in responses to the Body Image Questionnaire were attributable to BMI differences between the two cohorts by estimating a linear regression model for each of the nine items from the Body Image Questionnaire. Each item was regressed on cohort (1989 vs. 1998) and BMI. All but one of these cohort differences in body image measures were independent of BMI. After adjusting for BMI, the between-cohort difference in item 1 114


(“How well do you like your body?”) was reduced by approximately one-third (from 0.92 to 0.69). The independence from BMI suggests that these differences between cohorts may reflect shifts in prevailing cultural patterns concerning body image that are independent of increased weight and body size. In addition, indicators of negative body image were more closely aligned with higher BMI in the 1998 cohort than in the 1989 cohort. Although only one of the body image measures was significantly correlated with BMI in the 1989 cohort [body satisfaction; correlation coefficient (r) ⫽ ⫺0.33], three were significantly correlated with BMI in the 1998 cohort (body satisfaction, r ⫽ ⫺0.42; amount of pride in body shape, r ⫽ ⫺0.36; and desire to change body shape, r ⫽ ⫺0.32). These correlations were of a similar magnitude and direction when analyzed separately by age group (data not shown). There was a moderate to high degree of correlation among the nine items measuring attitudes toward body image. Factor analysis was used to investigate the underlying dimensionality of these items for the purpose of constructing summary measures of body image for further analysis. Results suggested three underlying factors, representing the following dimensions: body satisfaction (items 1 and 2 from Table 2), desire to reshape body and belief that the body can be reshaped (items 3 to 6 from Table 2), and level of interest in body shape (items 7 to 9 from Table 2). Summary measures of these dimensions were created by taking the mean of the items corresponding to each factor. Each of the summary measures demonstrated a high degree of internal consistency (Cronbach’s ␣ ⫽ 0.87, 0.74, and 87 for factors 1, 2, and 3, respectively); the low to moderate correlation among the three factors is further evidence of the distinct aspects measured by the Body Image Questionnaire (correlation between factors 1 and 2, r ⫽ 0.32; factors 1 and 3, r ⫽ 0.01; factors 2 and 3, r ⫽ 0.41). Two of these summary measures—interest in changing body shape and body satisfaction—were significantly different between the 1989 and 1998 cohorts (p ⫽ 0.034 and 0.002, respectively), indicating a higher degree of interest in changing body shape and lower level of body satisfaction in 1998 than in 1989. Although comparative data on dietary intake and intention to lose weight were not available, data from similar questionnaire items on a subjective appraisal of increasing food intake were available and analyzed for both cohorts. Given the traditional veneration of robust appetites and bodies, increasing food intake can be seen as a proxy for traditional (vs. modern) values reflected in diet. The prevalence of having increased food intake at some time was significantly greater among the 1989 cohort than the 1998 cohort (43.4% as compared with 6.0%; p ⬍ 0.001). Associations with BMI across Both Cohorts Associations between BMI and increased food intake, television viewing, and educational attainment were also


examined. BMI was significantly lower (in the full sample and in the 1989 and 1998 cohorts individually) for subjects with some secondary education (mean BMI ⫽ 30.0 kg/m2 for subjects with primary education only vs. 27.1 kg/m2 for subjects with some secondary education, p ⫽ 0.002). In addition, a report of increased food intake was significantly associated with lower BMI across both cohorts (mean BMI ⫽ 26.3 kg/m2 for subjects reporting increased food intake compared with 29.3 kg/m2 for subjects not reporting increased food intake, p ⫽ 0.004); a similar pattern was observed for both cohorts individually. As noted above, television was introduced to this area of Fiji in 1995, so the 1989 cohort was unexposed to television in contrast to the 1998 cohort, which had been exposed to it for 3 years. Although television viewing was quite common in the 1998 cohort, with the entire sample reporting at least 1 night per week of television viewing and 50% of the sample watching television 3 or more nights per week, there was no association between frequency of viewing and BMI.

Discussion These data illustrate the significant increase in the prevalence of overweight and obesity between two cohorts of ethnic Fijian women drawn from similar populations approximately 1 decade apart. By design, the cohorts were chosen to have identical composition with respect to residence in the same traditional Fijian village, Fijian ethnicity, adult age, and female gender but did differ with respect to general exposure to modernization. Modernization is defined here as lifestyle changes that make use of imported goods, technologies, ideas, and values concomitant with social, economic, and political change resulting from participation in the global economy and partnerships. As expected, given the rapid development of rural Fiji, a significantly greater percentage of the sample had attained secondary education in the 1998 cohort. Our primary objective was to investigate the relation between change in body image measures and overweight in ethnic Fijian women. Elsewhere, attention to the effects of modernization on Pacific obesity has been focused on changes in dietary composition and in physical activity (49), whereas the impact of changing body image on obesity has not yet been studied. Although we did not evaluate dietary composition or physical activity in our cohorts, we note that a substantial increase in the daily caloric intake among Fijians (concomitant with economic change) had already taken place decades before this study (e.g., intake increased from 2098 kcal/d in 1952 to 3853 kcal/d in 1963) (43). Moreover, the per capita total caloric intake was actually lower in 1998 (2739 kcal/d) as compared with 1985 (2819 kcal/d) (38). Therefore, although dietary changes must be considered as a partial explanation for the increased prevalence of overweight and obesity, alternative or additional

changes in the social environment must be strongly considered. Among these, a possible decrease in physical activity must be considered given the shift from subsistence agriculture to a cash economy in Fiji and the increased availability of motorized transport. In addition to weight changes, primary between-cohort differences in this study include several body image measures. Previous research in the Pacific by other investigators has demonstrated a shift in body image as well. For example, Brewis et al. (11) found that Samoans, with elevated BMI and obesity rates, endorsed thin ideal body weights, demonstrated body weight dissatisfaction, and engaged in attempts to lose weight. However, those who were overweight were no more likely to endorse these attitudes and engage in weight loss attempts than their thinner counterparts and did not consider themselves obese. In another study comparing Western Samoan and Australian women matched on weight and height, Wilkinson et al. (44) found similar attitudes toward body weight in the two groups. However, the relationships between these shifts in body image and increasing BMI have not been established. By contrast, in this study, a relationship was found between increased BMI and lower body satisfaction in both cohorts. Moreover, a new significant association among several additional body image parameters emerged in the 1998 cohort (an inverse association between pride in body shape and the body satisfaction factor and high BMI and a positive association between desire to reshape the body and high BMI), suggesting that body satisfaction and interest in reshaping the body either became more culturally salient or more tied to an awareness of body weight over time. A causal or directional relationship cannot be established between body image and BMI in this study. Given that traditional Fijian values support robust appetites and bodies, efforts to reduce weight by either diet or exercise have traditionally been discouraged (33). Thus, the apparently emerging association of body dissatisfaction with high BMI, the desire to reshape heavier bodies, and the locally emerging notion that body can actually be reshaped signal new possibilities for motivating ethnic Fijians to maintain healthy body weight. On the other hand, a negative impact of the association between lower body satisfaction and desire to change body shape and higher BMI cannot be excluded. For example, our previous research demonstrated a significant association between binge eating (i.e., as clinically defined in the DSM-IV) (45) and both an increased concern with body shape and a lifetime history of BMI ⬎ 35 among ethnic Fijian women in Fiji (42). We have also previously reported an association between television exposure and disordered eating attitudes and behaviors in an adolescent female Fijian population (36). We suggest that it is plausible that body image changes concomitant with increasing modOBESITY RESEARCH Vol. 13 No. 1 January 2005

115


ernization in Fiji may contribute to overweight through an increase in disordered eating that leads to excess calorie intake. This may be especially true in an environment such as Fiji in which consuming large quantities of food has been traditionally culturally sanctioned and dietary choices are calorie dense (33). Limitations of this study include the lack of formal data on energy intake and expenditure that would have allowed a more complete picture of contributors to risk for overweight. Moreover, the relatively small size of the two cohorts precludes a fully comprehensive analysis of all possible factors that may have contributed to the changes in the prevalence of overweight and obesity over time. Finally, women from one specific village in Nadroga may not be representative of other rural ethnic Fijian women. However, rural ethnic Fijians are highly culturally homogeneous, by virtue of shared social rituals and traditions, as well as frequent opportunities to reaffirm cultural solidarity across villages (46 – 48). Although the prevalence of obesity in the 1998 cohort, 44%, is not as high as the 63% reported in a sample of Fijian women from 30 to 39 years of age described in a recent study by Tomisaka et al. (13), the combined prevalence of overweight and obesity of 84% in our 1998 cohort is comparable to or higher than that reported in other Pacific populations (49). Indeed, both the significant increase in prevalence and the absolute prevalence of overweight and obesity in 1998 suggest major public health concerns for Fiji (49). A clearer understanding of all of the changes in the social environment underpinning the increased prevalence of overweight will be essential for developing appropriate interventions and preventive measures in this population (50). Specifically, further research on the emerging changes in body image in Fiji in larger, possibly more representative, samples will clarify the relation among modernization, changing body image, and overweight there. Undoubtedly, such research will suggest more effective public health interventions in Fiji—and elsewhere—for the treatment and prevention of overweight and obesity.

Acknowledgments We thank the late Tui Sigatoka, Ratu Jocame Rokomatu, and the Tui Sigatoka, Sr. Joana Rokomatu, for gracious facilitation of data collection; Paul Geraghty and the late Cema Rokomatu (University of the South Pacific) for assistance with development, translation, and back-translation of assessments for this study; and Kesaia Navara for assistance in data collection. Funding for this study was partially provided by a Milton Fund grant (to A.E.B.). Data collection for each of the cohorts was funded by a Fulbright IIE Fellowship (to A.E.B.) and by an Irene Pollin Fellowship in Memory of Cherry Adler (to A.E.B.), respectively. 116


References 1. Duarte NL, Colagiuri S, Palu T, Wang XL, Wilchen DE. A 45-bp insertion/deletion polymorphism of uncoupling protein 2 in relation to obesity in Tongans. Obes Res. 2003;11:512–7. 2. Flegal KM. The obesity epidemic in children and adults: current evidence and research issues. Med Sci Sports Exerc. 1999;31:S509 –14. 3. Hodge AM, Dowse GK, Toelupe P, Collins VR, Imo T, Zimmet PZ. Dramatic increase in the prevalence of obesity in western Samoa over the 13 year period 1978 –1991. Int J Obes Relat Metab Disord. 1994;18:419 –28. 4. Ulijaszek SJ. Increasing body size among adult Cook Islanders between 1966 and 1996. Ann Hum Biol. 2001;28:363–73. 5. Mokdad A, Serdula MK, Dietz WH, Bowman BA, Marks JS, Koplan JP. The spread of the obesity epidemic in the United States, 1991-1998. JAMA. 1999;282:1519 –22. 6. Flegal KM, Carroll MD, Kuczmarski RJ, Johnson CL. Overweight and obesity in the United States: prevalence and trends, 1960-1994. Int J Obes. 1998;22:39 – 47. 7. Cameron AJ, Welborn TA, Zimmet PZ, et al. Overweight and obesity in Australia: the 1999 –2000 Australian Diabetes, Obesity, and Lifestyle Study (AusDiab). Med J Aust.2003; 178:427–32. 8. Hodge AM, Dowse GK, Zimmet PZ, Collins VR. Prevalence and secular trends in obesity in Pacific and Indian Ocean island populations. Obes Res. 1995;3(Suppl 2):77– 87s. 9. 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. 10. Bindon JR, Baker PT. Modernization, migration and obesity among Samoan adults. Ann Hum Biol. 1985;12:67–76. 11. Brewis AA, McGarvey ST, Jones J, Swinburn BA. Perceptions of body size in Pacific Islanders. Int J Obes Relat Metab Disord. 1998;22:185–9. 12. Duarte NL, Colagiuri S, Palu T, Wang XL, Wilchen DE. Obesity, type II diabetes and the beta 2 adrenoceptor gene Gln27Glu polymorphism in the Tongan population. Clin Sci. 2003;104:211–5. 13. Tomisaka K, Lako J, Maruyama C, et al. Dietary patterns and risk factors for type 2 diabetes mellitus in Fijian, Japanese and Vietnamese populations. Asia Pac J Clin Nutr. 2002;11: 8 –12. 14. Metcalf PA, Scragg RK, Willoughby P, Finau S, TipeneLeach D. Ethnic differences in perceptions of body size in middle-aged European, Maori and Pacific people living in New Zealand. Int J Obes Relat Metab Disord. 2000;24:593–9. 15. Shmulewitz D, Auerbach SB, Lehner T, et al. Epidemiology and factor analysis of obesity, type II diabetes, hypertension, and dyslipidemia (syndrome X) on the Island of Kosrae, Federated States of Micronesia. Hum Hered. 2001;51:8 –19. 16. Bullen C, Tipene-Leach D, Vander Hoorn S, Jackson R, Norton R, MacMahon S. Ethnic differences in blood pressure: findings from the Fletcher Challenge-Auckland University Heart and Health Study. N Z Med J. 1996;109:395–7. 17. Popkin BM. The nutrition transition and obesity in the developing world. J Nutr. 2001;131:871–3S. 18. Stookey JD, Adair L, Stevens J, Popkin BM. Patterns of long-term change in body composition are associated with


19.

20.

21.

22.

23.

24.

25.

26.

27.

28.

29. 30.

31.

32.

33.

diet, activity, income and urban residence among older adults in China. J Nutr. 2001;131:2433– 40S. Al-Nuaim AR, Al-Rubeaan K, Al-Mazrou Y, Al-Attas O, Al-Daghari N, Khoja T. High prevalence of overweight and obesity in Saudi Arabia. Int J Obes Relat Metab Disord. 1996;20:547–52. Sakamoto N, Wansorn S, Tontisirin K, Marui E. A social epidemiologic study of obesity among preschool children in Thailand. Int J Obes. 2001;25:389 –94. Yamauchi T, Umezaki M, Ohtsuka R. Influence of urbanisation on physical activity and dietary changes in Huli-speaking population: a comparative study of village dwellers and migrants in urban settlements. Br J Nutr. 2001;85:65–73. Taylor R, Badcock J, King H, et al. Dietary intake, exercise, obesity and non-communicable disease in rural and urban populations of three Pacific Island countries. J Am Coll Nutr. 1992;11:283–93. Russell-Jones DL, Hoskinsm P, Kearney E, et al. Rural/ urban differences of diabetes-impaired glucose tolerance, hypertension, obesity, glycosolated haemoglobin, nutritional proteins, fasting cholesterol and apolipoproteins in Fijian Melanesians over 40. Q J Med. 1990;74:75– 81. Bindon JR, Zansky SM. Growth patterns of height and weight among three groups of Samoan preadolescents. Ann Hum Biol. 1986;13:171– 8. McGarvey ST. Obesity in Samoans and a perspective on its etiology in Polynesians. Am J Clin Nutr. 1991;53(Suppl 6)1586 –94s. Hodge AM, Dowse GK, Koki G, Mavo B, Alpers MP, Zimmet PZ. Modernity and obesity in coastal and highland Papua New Guinea. Int J Obes Relat Metab Disord. 1995;19: 154 – 61. Lako JV, Nguyen VC. Dietary patterns and risk factors of diabetes mellitus among urban indigenous women in Fiji. Asia Pac J Clin Nutr. 2001;10:188 –93. Galanis DJ, McGarvey ST, Quested C, Sio B, AfeleFa’amuli SA. Dietary intake of modernizing Samoans: implications for risk of cardiovascular disease. J Am Diet Assoc. 1999;99:184 –90. Oliver D. Ancient Tahitian Society. Honolulu, HI: University of Hawaii Press; 1974. Howard A. Questions and answers: Samoans talk about happiness, distress, and other life experiences. In: Baker P, Hanna J, Baker T, eds.) The Changing Samoans: Behavior and Health in Transition. New York: Oxford University Press; 1986, pp. 174 –202. Mackenzie M. The pursuit of slenderness and addiction to self-control. In: Weininger J and Briggs GM, eds. Nutrition Update. 2nd vol. New York: John Wiley & Sons; 1985. Pollock NJ. Cultural elaborations of obesity: fattening practices in Pacific societies. Asia Pac J Clin Nutr. 1995;4:357– 60. Becker AE. Body, Self, and Society: The View from Fiji. Philadelphia, PA: University of Pennsylvania Press; 1995.

34. Craig PL, Swinburn BA, Matenga-Smith T, Matangi H, Vaughan G. Do Polynesians still believe that big is beautiful? Comparison of body size perceptions and preferences of Cook Islands, Maori and Australians. N Z Med J. 1996;109:200 –3. 35. Ben-Tovim DI. Is big still beautiful in Polynesia? Lancet. 1996;348:1047– 8. 36. Becker AE, Burwell RA, Gilman SE, Herzog DB, Hamburg P. Eating behaviours and attitudes following prolonged television exposure among ethnic Fijian adolescent girls. Br J Psychiatry. 2002;180:509 –14. 37. Becker AE. Nurturing and negligence: working on others’ bodies in Fiji. In: Csordas T, ed. Embodiment and Experience. Cambridge, UK: Cambridge University Press; 1994; pp. 100 – 15. 38. National Food and Nutrition Centre. Fiji Food Balance Sheet. Suva, Fiji: National Food and Nutrition Centre; 2001. 39. Becker AE. Television, disordered eating, and young women in Fiji: Negotiating body image and identity during rapid social change. Cult Med Psychiatry. 2004;28:533–59. 40. Swinburn BA, Ley SJ, Carmichael HE, Plank LD. Body size and composition in Polynesians International. J Obes. 1999;23:1178 – 83. 41. Cattell RB. The scree test for the number of factors. Multivariate Behav Res. 1966;1:245–76. 42. Becker AE, Burwell RA, Navara K, Gilman SE. Bingeeating and binge-eating disorder in a small-scale indigenous society: the view from Fiji. Int J Eat Disord. 2003;34:423–31. 43. South Pacific Commission. The Effect of Urbanisation and Western Diet on the Health of Pacific Island Populations: Technical Paper No. 186. Noumea, New Caledonia: South Pacific Commission; 1984, pp. 24 –26. 44. Wilkinson JY, Ben-Tovim DI, Walker MK. An insight into the personal and cultural significance of weight and shape in large Samoan women. Int J Obes. 1994;18:602– 6. 45. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Association; 1994, p. 731. 46. Sahlins M. Moala: Culture and Nature on a Fijian Island. Ann Arbor, MI: University of Michigan Press; 1962. 47. Ravuvu A. Vaka i Taukei: The Fijian Way of Life. Suva, Fiji: Institute of Pacific Studies of the University of the South Pacific; 1983. 48. Ravuvu A. The Fijian Ethos. Suva, Fiji: Institute of Pacific Studies of the University of the South Pacific; 1987. 49. Gill T, Hughes R, Tunidau-Schultz J, Nishida C, Galea G, Cavalli-Sforza L. Obesity in the Pacific: Too Big to Ignore. Noumea, New Caledonia: Secretariat of the Pacific Community; 2002. 50. Snowden W, Schultz JT. Cultural attitudes and perceptions of selected issues and practices related to health and NDCs in the Pacific. Noumea, New Caledonia: Secretariat of the Pacific Community; 2001.


117