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The Prevalence of Obesity in Ethnic Admixture Adults
Cheryl L. Albright1, Alana D. Steffen2, Lynne R. Wilkens2, Brian E. Henderson3 and Laurence N. Kolonel2
Objective: To determine whether the prevalence of obesity in ethnic admixture adults varies systematically from the average of the prevalence estimates for the ethnic groups with whom they share a common ethnicity. Methods and Procedures: The sample included 215,000 adults who reported one or more ethnicities, height, weight, and other characteristics through a mailed survey. Results: The highest age-adjusted prevalence of overweight (BMI ≥ 25) was in Hawaiian/Latino men (88%; n = 41) and black/Latina women (74.5%; n = 79), and highest obesity (BMI ≥ 30) rates were in Hawaiian/Latino men (53.7%; n = 41) and Hawaiian women (39.2%, n = 1,247). The prevalence estimates for most admixed groups were similar to or higher than the average of the prevalences for the ethnic groups with whom they shared common ethnicities. For instance, the prevalence of overweight/obesity in five ethnic admixtures—Asian/white, Hawaiian/white, Hawaiian/Asian, Latina/white, and Hawaiian/Asian/white ethnic admixtures—was significantly higher (P < 0.0001) than the average of the prevalence estimates for their component ethnic groups. Discussion: The identification of individuals who have a high-risk ethnic admixture is important not only to the personal health and well-being of such individuals, but could also be important to future efforts in order to control the epidemic of obesity in the United States.
Obesity (2008) 16, 1138–1143. doi:10.1038/oby.2008.31

There is a growing epidemic of obesity in the United States and there are significant differences in the prevalence of obesity across ethnic groups. National data showed that 70% of blacks, 73% of Mexican Americans, and 62% of Non-Hispanic whites were overweight (BMI ≥ 25), with differences by gender and age (1). Obesity can place ethnic minority populations at increased risk for chronic diseases, such as type 2 diabetes, cancer, and hypertension (2). Participants in research studies are typically classified as one race or ethnicity; thus, the prevalence of obesity in individuals who report two or more races, or a specific ethnic admixture, is rarely reported. However, due to changes in the reporting of multiple ethnicities/races in the US 2000 Census (3) and in the epidemiological studies (4), risk factor data on individuals with more than one ethnicity are now possible. There have been only a few investigations of obesity in individuals with an ethnic admixture. The percentage of Hawaiian or Polynesian ancestry among mixed-race Hawaiians was found to have a significant positive association with BMI, after adjusting for age, physical activity, and total energy intake (5). Direct comparisons of the obesity rates in individuals with a single race vs. those with an ethnic admixture have not been made. Both Hawaii and California have multiethnic populations and

high rates of obesity in specific ethnic groups (6,7). Also, in the 2000 US Census, 20% of the people living in Honolulu and 5% of people in Los Angeles reported two or more ethnicities. This compares to a lower proportion of 2% for the entire United States (3); however, the number of people with a multiethnic admixture is growing across the country (8). The primary aim of this article is to determine whether the prevalence of overweight and obesity in individuals with an ethnic admixture varies systematically from the prevalences of each specific monorace groups with whom they share a common ethnicity or race, as well as the average of the prevalence estimates for all their shared race/ethnic groups.
Methods study population In the early 1990s, a large population-based cohort of adult men and women aged 45–75 years in 1993, who lived in Hawaii and southern California (primarily Los Angeles County), was established to examine risk factors for cancer in a multiethnic population (9). Five main ethnic groups/races—African Americans or blacks (B), Japanese Americans (J), Latinos (L), Hawaiians (H), and non-Hispanic whites (W)—were targeted for the study. Institutional review boards at the University of Hawaii and University of Southern California reviewed and approved all study protocols. Recruitment to the cohort took place between 1993 and 1996, detailed information on the cohort is available elsewhere (9).

1 Prevention and Control Program, Cancer Research Center of Hawaii, University of Hawaii, Honolulu, Hawaii, USA; 2Epidemiology Program, Cancer Research Center of Hawaii, University of Hawaii, Honolulu, Hawaii, USA; 3Norris Comprehensive Cancer Center, Keck School of Medicine, University of Southern California, Los Angeles, California, USA. Correspondence: Cheryl L. Albright (calbright@crch.hawaii.edu)

Received 1 June 2007; accepted 21 August 2007; published online 28 February 2008. doi:10.1038/oby.2008.31
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Subjects were recruited to the study by mail and entered the cohort by completing a self-administered 26-page questionnaire. The study, called the Multiethnic Cohort (MEC), included 215,251 adult men and women. Response rates by ethnicity and gender were as follows: African Americans: 25.5% women, 20.0% men; Japanese: 51.3% women, 46.3% men; Hawaiians: 42.4% women, 36.1% men; Latinas: 21.3% women, 18.6% men; and whites: 47.0% women, 39.1% men (9). The education and marital status distributions within sex-ethnic groups for our respondents were similar to those from the 2000 census information, suggesting our samples are broadly representative (9). The questionnaire included information on current height, weight, diet (quantitative food frequency), smoking, alcohol use, physical activity, and other cancerrelated risk factors. The MEC baseline questionnaire collected ethnicity or race information in such a manner that individuals could report more than one race/ethnicity. Participants were instructed to mark all racial/ ethnic identities that applied among the following categories: black or African American, Chinese, Filipino, Hawaiian, Japanese (includes Okinawan), Korean, Mexican or other Hispanic, white, and other (specific ethnicity written in by the respondent). While five ethnic groups were targeted, 12,455 individuals of other ethnicities/races responded, such as Chinese, Filipino, Korean, Indian, and Samoan. Approximately 10% of the entire sample (N = 21,062) reported two or more ethnicities; however, a larger percentage of the Hawaii-based sample listed more than one ethnicity (15%, N = 15,830) compared to the Los Angeles sample (5%, N = 5,232). Of those reporting more than one ethnicity, 0.8% reported five or more ethnic groups, 4.7% reported four ethnicities, 29.0% reported three ethnicities, and 65.5% reported two ethnicities. Owing to limited sample sizes for individuals with four or more ethnic combinations, this investigation focused on participants listing three or fewer of these coded ethnic/racial categories.
statistical analyses The purpose of the analysis was to compare the prevalence of overweight and obesity between individuals reporting one race/ethnic group (i.e., monorace) and those reporting more than one race/ethnicity group (multiracial/ethnic admixture). Analyses were conducted in SAS version 9.1. All analyses examined men and women separately. We formed ethnic groups that were homogeneous on BMI distribution and that covered as many cohort members as possible. For instance, we found BMI distributions for Japanese, Chinese, and Koreans were similar, so they were collapsed into an Asian group. A detailed description of the methods we used to combine specific ethnic groups into homogeneous groups is reported elsewhere (10). Using this method, our final ethnic/ racial categories included the following five monorace categories: Asian Americans (Chinese, Japanese, Korean) (A); black or African American (B); Hawaiian (H); Mexican or other Hispanic, including Puerto Rican (Latino; L); white (W), as well as the combinations of two or three of these racial/ethnic groups. Filipinos could not be included in Asians, and Samoans could not be included with Hawaiians, because they were heavier. We classified individuals as overweight if their BMI ≥25, and obese if their BMI ≥30 (11). The prevalence and its s.e. were adjusted for age by the poststratification method using 10-year age categories (12). Then, the prevalence of an ethnic admixture was tested, using a Wald test in logistic regression, to determine whether it was significantly different from the prevalence of each component monorace and the average of those monoraces/ethnic admixtures that shared a common ethnicity or race. We adjusted the type I error rate by considering only P value’s <0.0001 as statistically significant. Results

The MEC sample had a mean age of ~60 years at baseline, most (67%) were married, >80% were US born, most (>80%) were

table 1 Prevalence of overweight/obesity by ethnic admixture/monorace
Men Ethnic group/ admixture A AW B BL BLW BW H HA HAW HL HLA HLW HW L LA LW W %Overweight (s.e.)* Sample size 26,792 403 11,755 52 0 171 1,261 1,328 1,428 41 38 57 1,331 21,192 32 1,205 22,211 BMI ≥ 25 43.2 (0.3) 52.9 (2.5)*** 64.1 (0.4) 75.8 (6.2) 0 60.1 (3.8) 78.2 (1.2) 68.3 (1.3)**,***H,A 72.7 (1.2)** ***
, A,W A

Women %Obese (s.e.)* BMI ≥ 30 6.3 (0.1) 16.0 (1.8)** ***
, A

%Overweight (s.e.)* Sample size 30,871 572 19,905 79 36 376 1,247 1,522 2,035 30 54 69 1,865 22,275 81 1,417 25,473 BMI ≥ 25 26.6 (0.3) 45.0 (2.1)** ***
, A

%Obese (s.e.)* BMI ≥ 30 5.0 (0.1) 16.1 (1.5)**,***A 34.4 (0.3) 28.5 (5.0) 18.6 (7.1) 27.9 (2.3)***W 39.2 (1.4) 23.6 (1.1)**,***H,A 28.1 (1.0)**,***H,A,W 28.6 (8.5) 23.3 (6.4)***A 30.6 (5.4)***W

19.3 (0.4) 17.8 (5.6) 0 14.5 (2.8) 38.2 (1.3) 26.3 (1.2)**,***H,A 25.6 (1.1)** ***
, H,A,W

71.4 (0.3) 74.5 (5.1) 57.4 (8.1) 60.9 (2.5)***B,W 70.4 (1.3) 55.2 (1.3)**,***H,A 62.9 (1.1)** ***
, H,A,W

88.1 (5.2) 66.9 (8.4) 79.9 (5.6)***W 73.4 (1.2)** ***
, W

53.7 (8.6)***L 29.9 (7.6)***
, A

58.7 (8.2) 66.1 (6.6)***
, A

41.0 (7.0)***L,W 30.4 (1.2)** *** 17.0 (0.3) 13.8 (6.6)
H,W

73.2 (5.7)***W 67.0 (1.1)** *** 64.8 (0.3) 54.7 (5.5)***A 62.3 (1.3)** ***
, W W

33.4 (1.1)**,***W 24.6 (0.3) 9.5 (3.3) 24.7 (1.1)**,***W 15.7 (0.2)

67.7 (0.3) 57.0 (9.6) 66.3 (1.4)*** 55.1 (0.3)
W

16.3 (1.1) 13.6 (0.2)

43.1 (0.3)

A, Asian; B, black; H, Hawaiian; L, Latino; W, white. *Proportions adjusted for age strata. **Prevalence for admixture significantly (P < 0.0001) different from the average of the prevalence rates for its component ethnic groups. ***Prevalence for admixture significantly (P < 0.0001) different from the monorace(s) identified in superscript.

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table 2 Prevalence of overweight/obesity by age group and ethnic admixture/monorace Men Ethnic group/ admixture A 40–49 50–59 60–69 70–79 AW 40–49 50–59 60–69 70–79 B 40–49 50–59 60–69 70–79 BL 40–49 50–59 60–69 70–79 BW 40–49 50–59 60–69 70–79 H 40–49 50–59 60–69 70–79 HA 40–49 50–59 60–69 70–79 HAW 40–49 50–59 60–69 70–79 HLA 40–49 50–59
a a a a a a a

Women %Obese (s.e.) BMI ≥ 30 11.1 (0.5) 8.5 (0.3) 4.3 (0.2) 1.9 (0.2) 16.6 (2.6) 20.0 (3.5) 16.0 (5.2) Sample size 4,858 8,142 11,555 6,316 252 209 84 27 %Overweight (s.e.) BMI ≥ 25 30.3 (0.7) 30.2 (0.5) 24.8 (0.4) 20.7 (0.5) 43.7 (3.1) 47.4 (3.5) 51.2 (5.5) 29.6 (9.0) 70.0 (0.8) 73.6 (0.6) 72.2 (0.5) 67.0 (0.7) %Obese (s.e.) BMI ≥ 30 7.6 (0.4) 6.7 (0.3) 3.4 (0.2) 2.8 (0.2) 18.3 (2.4) 20.1 (2.8) 17.9 (4.2) 3.7 (3.7) 36.3 (0.9) 38.2 (0.6) 33.5 (0.6) 27.7 (0.7)

%Overweight (s.e.) Sample size 4,075 6,761 9,532 6,424 211 130 50
a

BMI ≥ 25 51.8 (0.8) 51.6 (0.6) 39.0 (0.5) 29.2 (0.6) 58.3 (3.4) 60.0 (4.3) 54.0 (7.1)

1,479 3,153 4,282 2,841

65.3 (1.2) 66.9 (0.8) 63.8 (0.7) 58.7 (0.9)

19.8 (1.0) 22.7 (0.7) 18.7 (0.6) 14.2 (0.7)

3,045 6,007 6,723 4,130

23 66.7 (9.8) 8.3 (5.8) 28
a

73.9 (9.4) 75.0 (8.3)

26.1 (9.4) 39.3 (9.4)

24
a

49 59.4 (8.8) 60.9 (5.9) 69.0 (6.1) 78.9 (2.4) 85.6 (1.7) 77.7 (2.1) 65.5 (4.0) 73.8 (2.6) 73.9 (2.0) 66.6 (2.4) 56.8 (3.9) 76.5 (2.1) 82.4 (1.6) 71.9 (2.3) 54.1 (4.8) 12.5 (5.9) 14.5 (4.3) 8.6 (3.7) 46.6 (2.9) 50.0 (2.4) 32.8 (2.4) 20.7 (3.4) 31.2 (2.7) 37.0 (2.2) 21.9 (2.1) 12.3 (2.6) 32.3 (2.3) 35.7 (2.1) 22.4 (2.2) 8.3 (2.6) 93 130 104 286 456 364 141 354 512 470 186 689 754 434 158 23

65.3 (6.9) 61.3 (5.1) 59.2 (4.3) 59.6 (4.8) 76.6 (2.5) 76.8 (2.0) 67.9 (2.5) 58.9 (4.2) 56.8 (2.6) 65.4 (2.1) 52.8 (2.3) 40.9 (3.6) 62.1 (1.8) 68.4 (1.7) 62.0 (2.3) 55.7 (4.0) 43.5 (10.6)

40.8 (7.1) 34.4 (5.0) 19.2 (3.5) 22.1 (4.1) 46.5 (3.0) 48.7 (2.3) 34.1 (2.5) 26.2 (3.7) 28.0 (2.4) 32.8 (2.1) 18.7 (1.8) 13.4 (2.5) 34.1 (1.8) 35.1 (1.7) 24.9 (2.1) 17.1 (3.0) 26.1 (9.4)

32 69 58 294 432 390 145 298 479 389 162 405 544 370 109

table 2 continued on next page
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table 2 (continued)
Men Ethnic group/ admixture 60–69 70–79 HLW 40–49 50–59 60–69 70–79 HW 40–49 50–59 60–69 70–79 L 40–49 50–59 60–69 70–79 LA 40–49 50–59 60–69 70–79 LW 40–49 50–59 60–69 70–79 W 40–49 50–59 60–69 70–79 4,396 6,928 7,044 3,843 52.3 (0.8) 58.2 (0.6) 56.9 (0.6) 48.8 (0.8) 13.6 (0.5) 16.0 (0.4) 13.8 (0.4) 9.1 (0.5) 5,043 8,223 7,950 4,257 37.9 (0.7) 44.4 (0.5) 45.4 (0.6) 41.0 (0.8) 16.0 (0.5) 17.8 (0.4) 16.1 (0.4) 11.1 (0.5) 102 333 571 199 73.5 (4.4) 71.2 (2.5) 63.9 (2.0) 55.8 (3.5) 21.6 (4.1) 23.4 (2.3) 12.3 (1.4) 7.0 (1.8) 169 481 588 179 68.0 (3.6) 64.2 (2.2) 60.5 (2.0) 57.0 (3.7) 36.1 (3.7) 24.3 (2.0) 20.4 (1.7) 23.5 (3.2)
a a a a a a a a

Women %Obese (s.e.) BMI ≥ 30 Sample size
a a

%Overweight (s.e.) Sample size
a a

%Overweight (s.e.) BMI ≥ 25

%Obese (s.e.) BMI ≥ 30

BMI ≥ 25

24 23
a a

87.5 (6.9) 73.9 (9.4)

37.5 (10.1) 47.8 (10.7)

325 404 423 179 2,264 7,286 8,823 2,819

81.2 (2.2) 80.9 (2.0) 70.9 (2.2) 58.1 (3.7) 71.9 (0.9) 73.2 (0.5) 65.8 (0.5) 58.4 (0.9)

40.6 (2.7) 37.6 (2.4) 27.9 (2.2) 13.4 (2.6) 19.7 (0.8) 20.6 (0.5) 15.3 (0.4) 11.6 (0.6)

451 612 586 216 2,758 8,489 8,456 2,572 23 30 21
a

69.4 (2.2) 73.5 (1.8) 66.6 (2.0) 54.6 (3.4) 64.6 (0.9) 67.7 (0.5) 64.9 (0.5) 59.6 (1.0) 43.5 (10.6) 40.0 (9.1) 57.1 (11.1)

39.5 (2.3) 40.4 (2.0) 29.7 (1.9) 23.1 (2.9) 25.5 (0.8) 27.5 (0.5) 24.0 (0.5) 19.9 (0.8) 8.7 (6.0) 10.0 (5.6) 14.3 (7.8)

Groups: BWL and LH—both men and women, and LA, HLW, HLA—men only, had ≤20 people in each age group—data not shown. A, Asian; B, black; H, Hawaiian; L, Latino; W, white. a n ≤ 20.

nonsmokers, and over half had graduated from high school. More detailed demographic information about the MEC sample is available elsewhere (9). Table 1 lists the gender-specific prevalence estimates of obesity and overweight for the 12 ethnic admixture groups and five monorace groups, adjusted for age. Table 2 lists the prevalences for each of four age categories (i.e., 45–49, 50–59, 60–69, and 70–75); however, the prevalences for age groups consisting of very small sample sizes (e.g., ≤20 individuals) is not reported.
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For the entire sample, the age-adjusted prevalence of overweight for men was 66.8% and 59.4% for women. The highest prevalence of overweight was for Hawaiian/Latino men (88%,) and black/Latina women (74.5%). The highest prevalence of obesity occurred in Hawaiian/Latino men (53.7%) and Hawaiian women (39.2%). The prevalence of obesity in men and women with Asian/white, Hawaiian/white, Hawaiian/Asian, Latina/ white, and Hawaiian/Asian/white ethnic admixtures was significantly higher (P < 0.0001) than the average prevalence of the ethnic groups with whom they share a common ethnicity/race
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(see Table 1). The admixed groups are generally significantly different from one or more of their constituent monorace groups; the pairwise comparisons are also indicated in Table 1. For example in women, the prevalence of obesity for Asian/white women is 16.1% which is greater than the average prevalence for the Asian and white women groups, and significantly greater than the Asian prevalence (5%) but not white (15.7%). Across all of the ethnic admixtures, the prevalences for both overweight and obesity were similar to or higher than the average of the prevalence estimates for their shared ethnicities; in contrast, none of the admixture prevalences were less than the average of their component ethnicities. We conducted adjusted analyses using dietary measures of energy intake, percent of energy from carbohydrates and protein, physical activity, history of serious illness, and whether born outside of the United States. The pattern of prevalence differences indicated in Table 1 were also found in these models at the P < 0.05 level or less, though there was some attenuation of effect, as would be expected with fewer degrees of freedom and a smaller sample size due to missing values on some of the various measures. There were some covariates that were influential in explaining differences. For men, education, caloric intake, percent of calories from fat, and percent of calories from ethanol reduced those differences shown as significant in Table 1 by an average of 6%. For women, these same covariates plus physical activity reduced differences by an average of 15%. Across all the ethnic groups the prevalence of overweight/ obesity was lower for the oldest age group (70–79, Table 2). Within each age group, monorace Hawaiians had the highest prevalence of obesity.
discussion

This analysis was one of the first large-scale investigations of the prevalence of obesity in adults who reported two or three specific ethnic or racial heritages. The overall prevalence data for overweight revealed that 43–88% of the men were overweight (6–54% were obese), and 27–70% of the women were overweight (5–39% were obese). The ethnic groups with the highest proportion of overweight/obese individuals (BMI ≥ 25) were Hawaiian/Latino men (88%) and black/Latina women (74%). The prevalence of overweight in our monoraces was similar to a national sample (12); however, our prevalences were lower than similar, gender and ethnic specific prevalence estimates from National Health and Nutrition Examination Surveys collected in 1999–2000 (13). The age and socioeconomic status levels in the MEC were similar to those in the nationwide samples. However, the timings of the surveys (1993–1996 for the MEC, 1999–2000 for National Health and Nutrition Examination Survey) may explain the difference in the prevalences. Additionally, because other health behaviors such as smoking are lower in Hawaii and California compared to the national smoking rate, people living in these two states could be more health conscious (14). Our results have implications for future health disparities research and potentially for risk reduction efforts in high-risk ethnic minority populations. The proportion of people with two or more ethnic heritages will grow substantially in the future (15). Thus, a higher prevalence of obesity in individuals with specific
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ethnic admixtures could translate into higher rates of obesityrelated chronic diseases and possibly mortality. If there was a mechanism for identifying biracial patients with the greatest risk for obesity-related illnesses, health care providers could screen them for obesity-related comorbidities (e.g., fasting glucose, hypertension) in order to provide early treatment and appropriate preventive care or referral options to modify health behaviors linked to obesity. Such efforts would not only contribute to the reduction in health disparities among ethnic minorities, it could also improve the current and future health and well-being of biracial individuals. One methodological limitation of this study is its reliance on self-reported height and weight. Investigations of the correlation between self-reported weight and objectively measured weight have showed extremely high correlations across many populations, including ethnic minorities (16). When inconsistencies have been found, two factors: age (>70 years), and low social economic class were associated with misclassification of weight (17,18). Only 17.7% of our sample was >70 at enrollment and 18.5% had a manual labor job. Thus, we do not anticipate there was a substantial bias with respect to BMI or the classification of obesity. Furthermore, measurement error would not bias our results unless the racial/ethnic groups misclassify BMI by different degrees. The agreement of overweight levels exhibited in the MEC and those based on measured height and weight from national surveys provides evidence against differential bias. Finally, we could not quantify the amount of genetic contribution or “blood quantum” attributable to each specific race/ ethnicity in individuals with an ethnic admixture. Blood quantum among Hawaiians has been positively associated with BMI (19). In a survey by the Hawaii Department of Health (http://www.hawaii.gov/health/statistics/brfss/hhs/index. html), 42.4% of part-Hawaiians reported being <25% Hawaiian. However, our data show that regardless of their Hawaiian blood quantum level, more part-Hawaiians were obese compared to the average prevalence estimates of their component ethnicities. Controlling for psychosocial and lifestyle factors did not attenuate the differences in prevalence between ethnic admixtures and monorace adults. However, a high caloric intake (e.g., calories from fat and alcohol) and exercise did modestly decrease this difference, and could be important factors for future interventions to control obesity in mixed-race individuals. Investigating obesity in specifically defined ethnic admixtures is important to the ongoing efforts to control the obesity epidemic and will grow even more important as the proportion of biracial people in the United States increases in the future.
AcknowledgMents
This research was supported by three National Institutes of Health grants: R37 CA054281 to L.N.K. for the Multiethnic Cohort Study; P30 CA 71789 to Dr Willem-Vogel for the Cancer Research Center of Hawaii; and R25 CA090956 to Dr Maskarinec for the Post-doctoral training program that supported A.S. All three grants are funded by the National Cancer Institute.

disclosuRe
The authors declared no conflict of interest.
© 2008 The Obesity Society
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3. 4. 5.

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