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Chapter 1. Literature review

1.1 Introduction

Iranians constitute one of the new and emerging migrant groups in Australia (Immigration

Museum Of Victoria 2008). Migrants from culturally and linguistically diverse (CALD)

backgrounds were found to be at the increased risk of obesity and obesity-related chronic

diseases (Dijkshoorn, Nierkens & Nicolaou 2008; Gellner & Domschke 2008; Kirchengast &

Schober 2005; Renzaho,Swinburn & Burns 2008). However, there are few published studies

documenting post-migration nutritional profile of Iranian migrants. Identifying any healthaspects of this migrant group requires a basic knowledge of their home country, immigration

history, demographic, social and economic characteristics.

In this chapter, drawing on the most recent available statistical data, I provide an outline of

relevant pre-migration social context. In addition, a summary of national and international

epidemiology, predisposing factors and health consequences of obesity is presented. The

focus of this summary is CALD communities, especially Iranian migrants.

1.1.2 Iranians: a historical and international perspective

Persia1 was home to one of the worlds oldest major civilization, covering thousand of years

society - dating back to 10000 BC(123independenceday 2007). It embraced Iran, Azerbaijan,

Afghanistan, Pakistan, Turkmenistan, Tajikistan, Uzbekistan, the eastern part of turkey and

Iraq (Economic Experts 2009; kamrani 2006). In addition, Middle East, Greece and central

Asia were ruled by the first Persian Empire. This led to a considerable variety in ethnic and

linguistic backgrounds of Iranians(Economic Experts 2009; Iranica 2004). The majority of

Iranians are from Persian ethnic group (51%) and speak Parsi (Farsi) (123independenceday

2007; Kwintessential 2004; The Central Intelligence Agency 2009). Common religion in Iran

is Islam (98%). Non - Muslim minorities in Iran include Zoroastrians, Jews, Bahais,

Mandeans, and Christians(Cline 2009; The Central Intelligence Agency 2009).

1 Prior to 1932 Iran was officially known as Persia( The Central Intelligence Agency 2009).

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The family planning program was prohibited after the revolution in 1980 resulted to a huge

rise in fertility and population growth rate. Iran has the second largest population, after

Egypt, in the Middle East and North Africa region (The World Bank 2009). According to

census data total population of Iran in 2008 was 66,429,284 (World Bank Development

Indicators 2008; The Central Intelligence Agency 2009). Demographic data demonstrate that

the majority of Iranians are between 15-64 years old with the median age of 27 years (male:

26.8 years and female: 27.2 years (2009 Est.)). Data also shows that male and female

population are relatively equal (U.S. Census Bureau 2008,2009; Larsen 2003; Near 2008).

Figure 1.1Population Pyramids of Iran, 2008

Source: U.S Census Bureau, International Data Base.

A notable feature of the demograohic of Iran is the high literacy rate which is about 82.3% of

adults and 96.6% of yought (United Nation 2009; UNESCO institute for Statistic 2009) .

82.3% of adults and 96.6% of youth are literate. According to the statistics released by the

Ministry of Science, Research and Technology in 2004, 2117471 students enrolled in tertiary

education institutions in Iran of those 53.94% were female and 46.06% were male (Ministry

of Science Research and Technology 2005). This means 30% of the population of tertiary age

are in tertiary education (UNESCO Institute for Statistic 2009)

Life expectancy in Iran is 71.14 years for total poulation (male: 69.65 years and female:

72.72 years (2009 Est.)) (The Central Intelligence Agency 2009).

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Iran is charcterictic as a country with a medium Human Development Index2 (HDI). HDI for

Iran is 0.782,which gives the country a rank of 88th out of 182 countries with data(United

Nation 2009).

Particular political and economic struggle existing in Iran encourage Iranians specially youth

to consider leaving their country in search for a better future (BBC News 2009; Salehi-

Isfahani 2008). Three main waves of Iranians` migration have been identified since 1950.

The first wave called academic years was between 1950 and1979 after the world war II.

During these years industrial revolution, technological and academic advancement inspired

middle and upper-class families to send their children to the western countries for higher

education. The second wave of immigration called political years followed the Islamic

revolution in Iran in 1979. Dramatic changes in social and political conditions heightened by

the revolution were key factors that forced a large number of politicians, religious minorities,

academics and professionals to leave Iran. Finally, the third wave of migration has expanded

over the last three decades. Unsuitable social conditions such as lack of liberty and social

security, cultural restriction, inequalities facing the non Muslim minorities, as well as

overload production of professionals, low level of investment on research culture and

development are the main reasons for leaving home country. For the time being Iran has the

highest rate of brain drain among 91 developed and developing countries. It is estimated that

every year more than 150,000 educated Iranians leave Iran (Hakimzadeh 2006; Iran Daily

2005; Esfandiari 2004).

1.1.3 Iranians in Australia

Iranians migration to Australia is relatively recent (Hakimzadeh 2006; Museum Victoria

2008). According to the Australian Department of Immigration and Citizenship (2008),

23575 Iranians are resident in Australia. Iranians constitute 4500 of 5 340 300 Victorias

resident population which means 0.4% of overseas born population in this state (Australian

Bureau Of Statistics 2008b; Department of Immigration and Citizenship 2008).

Demographic characteristic

2 HDI looks beyond GDP to a broader definition of well-being. It dose provide a broadened prism for viewing

human progress and the complex between income and well-being. Therefore HDI gives a more complete picture

than income (United Nation 2009).

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Significant increasing in the number of Iranians settled in Victoria was after Iranian kingdom

collapse in1978 and the eight - year war between Iraq and Iran. In 1981 Australia a special

Humanitarian assistance program for Bahai fleeing persecution in Iran. As a result, Iranian

population in Victoria increased almost 4 times from 583 in 1980s to 2230 in 1990s. In

addition to other immigration classes such as Skilled Stream of Australias Migration

Program, Iranians migration to Victoria enhanced %20 from 2001 to 2006 (Department of

Immigration and Citizenship 2008; Immigration Museum Of Victoria 2008).

Data presented in table 1.1.3 indicate that the majority of Iranian population in Australia are

young adults. Children and teenagers less than 15 years old make up 7.43% percent of this

population. The population of 55 year old and over include 20% which is much lower

proportion compared to young adults in this community. Male and female population

constitute relatively equal proportion(Australian Bureau Of Statistics 2008a). Two dominant

religions of Iranian people in Victoria are Islam (38%) and Bahai (30%). The majority of

Iranian population in Victoria lives in the suburbs of Manningham and Whitehorse. Iranian

society of Victoria (ISOV) and Iranian cultural school in East Doncaster are the two major

organizations support Iranian community in Victoria (Immigration Museum 2008).

Socio economic characteristic

There is no specific statistics about such factors as level of education, income, and household

size of Iranian migrants in the most recent report of the Department of Immigration and

Citizenship in 2008 (Australian Bureau Of Statistics 2008b; Department of Immigration and

Citizenship 2008).Nevertheless, Victorian Immigration Museum provided evidence that

Iranian community in Victoria has a high proportion of bachelor and post graduate degrees

compared to the whole population of Victoria (Immigration Museum 2008). This report is

similar to the American survey report in 2009 (US Census Bureau`s American Fact finder

2009).

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Table 1.1.3 Iran- Born Population in Australia, Victoria and Melbourne based on sex and age distribution

Age groups

Australia

0-4

years

5-14

years

15-24

years

25-44

years

45-54

years

55-64

years

65-74

years

75-84

years

85 years

and overTotal

male 78 760 1,526 4,149 2,039 1,135 580 391 79 10,737

female 71 812 1,682 4,651 2,243 1,363 620 290 78 11,810

total 149 1,572 3,208 8,800 4,282 2,498 1,200 681 157 22,547

Victoria

male 21 162 355 944 437 260 97 44 13 2,333

female 21 167 311 833 392 207 104 60 5 2,100

total 42 329 666 1,777 829 467 201 104 18 4,433

Melbourne

male 15 135 337 872 422 252 90 38 12 2,173

female 20 135 290 779 374 194 98 57 8 1,955

total 35 270 627 1,651 796 446 188 95 20 4,128

(Australian Bureau Of Statistics 2008a)

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1.2 Overweight and Obesity

1.2.1 Obesity3and its health consequences

Fundamentally increased consumption of more energy-dense, nutrient poor- foods, combined

with reduced physical activity lead to increased amount of body fat accumulates in body

tissues. It may be either total body fat or a particular depot of body fat (World Health

Organization 2009). Adverse health consequences of obesity associate with fat mass amount

and its distribution (Allison et al. 2008; Bordowitz, Morland & Reich 2007; Kopelman 2000;

World Health Organization 2009).

Obesity, especially central obesity, is a major factor for metabolic syndrome and some

serious diet-related diseases such as diabetes mellitus, cardiovascular diseases, dyslipidaemia,

hypertension, strokes, various forms of cancers and some causes of mortality (Alberti,

Zimmet & Shaw 2005; Daryani et al. 2005; Dietz 1998b; Fauci et al. 2008; Kumar et al.

2005; Lipson & Omidian 1992; Polivy & Herman 1987; Yusuf et al. 2004). Some

psychological consequences of obesity include social and psychological stress, increased risk

of negative self-steam, social isolation as well as negative influences on career and family

income (Dietz 1998a; Wndell et al. 2004).

In view of ethnicity a number of methods and classifications have been developed to define

and measure body fatness, overweight and obesity among adults (Flegal 1990; Kopelman

2000; Kuczmarski & Flegal 2000; U.S. Preventive Services Task Force 2003).

Some of them are discussed below.

1.2.2 Measurement of fat mass

A number of techniques, such as bioelectrical impedance, dual-energy X-ray absorptiometry,

and total body water can measure body fat, but it is impractical to use them routinely

(Billewicz, Kemsley & Thomson 1962; Flegal 1990; Kopelman 2000; Kuczmarski & Flegal

2000; U.S. Preventive Services Task Force 2003). The most practical methods such as body

3 Obesity is the state of being well above normal body weight for someone of the same age, gender, height and

ethnicity.

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mass index (BMI) and waist circumference provide valuable information about body fatness

(Kopelman 2000).

Body Mass Index (BMI)

BMI is simply weight adjusted for height (BMI; in kg/m2) (WHO 2010). It is largely

independent of height, providing an equitable comparison between short and tall population

groups (11 and 12 az WHO BMI). is a practical, easy to measure and widely-used method

for obesity screening (Deurenberg, Weststrate & Seidell 2007; Gray & Fujioka 1991; U.S.

Preventive Services Task Force 2003). It can be used for epidemiological purposes and

comparisons within and across populations (U.S. Preventive Services Task Force 2003;

WHO expert 2004). Several studies have shown that BMI is an indirect measure butcorrelates highly with body fat percentage in the majority of the adult population (Flegal

1990; Kuczmarski & Flegal 2000) . Increased BMI associates with raising in adverse health

effects such as hypertension, dyslipidemias, and diabetes (Willett, Dietz & Colditz 1999,

Mascie )..

Despite advantages outlined in the previous paragraph, BMI has some limitations that should

be considered;

BMI does not take into account "fitness"4 which inversely associates with mortality

independent of the BMI (Wei et al. 1999; Wessel et al. 2004; Wong et al. 2004).

BMI is related to both percentage of body fat and total body fat(Gray & Fujioka 1991).

However it does not account body fat distribution which is an independent risk factor for

health outcomes (Huang et al. 1998; Walker, Whincup & Shaper 2004).

The relation between BMI and the percentage of body fat depends on age and sex(11-12-17-

22 az WHO Expert). Older people generally have a higher proportion of internal fat than

younger people, and women have more fatmass than men(Deurenberg, Weststrate & Seidell

2007). But in the interest of simplicity the same BMI cut-off point is use for all persons of

both sexes aged 18 years and older (Philip 2004).

Some expert have argued that The relation between BMI and the percentage of body fat

differs across ethnic groups. BMI is a good indicator of the body fat percentage in white

4 Fitness means weight of muscle versus the weight of fat in a heavily muscled individual.

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adults in Europe and North America. Nicholas Mascie However it is less appropriate for

other populations who differ in body build and body proportions (Nicholas Mascie). For

example the association between BMI and percentage of body fat differs in Indonesians,

Japanese, Polynesians, Singaporean, Chinese, Malays, and Indians, and African groups

compared with Caucasians5. Nicholas Mascie, (A WHO expert) , (Wang et al., 1994).

(Swinburn 1999 refer:20 az WHO hast). There are also some studies which did not find

differences in the relation between BMI and percentage of body fat among ethnic groups,

such as Beijing, Chinese and Dutch Caucasians (A WHO expert, Nicholas Mascie).

Consistent with the previously discussed data about the relation between BMI and body fat

some studies in Singapore, Hong Kong, (26 28 az WHO), China (29 az WHO), Korea,

Philippine and Taiwan(WHO Expert) found that the possibility for having at least one risk

factor for cardiovascular disease or metabolic syndrome was high at lower BMIs than the

current BMI cut off point for overweight( 25). Back in Iran, a study claimed that the

prevalence of metabolic syndrome in normal weight Iranian adults was 10.5% which was

significantly higher than in normal weight participants in the U.S (5.4%). This study also

found that 75% of participants had at least one risk factor for metabolic syndrome. This

finding was similar to data from Singaporean and Asian Indian population (Hadaegh 2007).

(31 az WHO).This study was the first and the only study conducted in Iran that assessed risk

factors for metabolic syndrome in a normal- weight Iranian population. On the other hand it

did not propose a clear BMI cut-off point with respect to the observed risks for overweight

among Iranian adults.

Moreover on the basis of available data in Asia, WHO expert meeting in 2002 confirmed that

Asians, generally, have a higher percentage of body fat, risks of metabolic syndrome and

heart disease at lower BMIs than Caucasians. However the panel stated that for the public

health purposes and comparisons within and across populations BMI cut-off points do not

need to be redefine for each population separately. Therefore, the current WHO BMI cut-off

points (Table1.2.2) should be kept as international classification. The panel also,

recommended that where possible, in the population with a high tendency to central obesity

5Caucasians: A member of the peoples traditionally classified as the Caucasian race, esp. those peoples having

light to fair skin: no longer in technical use.

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and increased risk of metabolic syndrome, waist circumference should be used to clarify

action levels on the basis of BMI. (A WHO expert)

Table 1.2.2: The International Classification of adult overweight and obesity according to

BMI

Classification BMI(kg/m2)

Principal cut-off points Additional cut-off points

Normal range 18.50 - 24.9918.50 - 22.99

23.00 - 24.99

Overweight 25.00 25.00

Pre-obese 25.00 - 29.9925.00 - 27.49

27.50 - 29.99

Obese 30.00 30.00

Obese class I 30.00 - 34-9930.00 - 32.49

32.50 - 34.99

Obese class II 35.00 - 39.9935.00 - 37.49

37.50 - 39.99

Obese class III 40.00 40.00

Source: Adapted from WHO, 1995, WHO, 2000 and WHO 2004.

Iranian migrants overweight measurement

Based on the results from studies conducted among different ethnic groups and WHO expert

meeting in 2002 considering a proper cut off pint for overweight and obesity for Iranians, I

will use the most common graded classification of overweight and obesity that applies to both

men and women and to all adult age groups which has been proposed by the world health

organization (WHO) expert committee in 1997 and established in 2000 (Table1.2.2)6

(Robert et al 2000; Kopelman 2000; World Health Organization 2000). Also considering

6 Data presented above reflect knowledge acquired from epidemiological studies in western countries.

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Iranians predisposition to abdominal obesity and its health consequences, I will measure

waist circumferences of study participants as well as their body mass index.

Waist circumference7

Central obesity8 is assessed by waist circumference cut off (Alberti, Zimmet & Shaw 2005;

Yusuf et al. 2004). It is an approximate index of intra-abdominal fat mass and total body fat.

Numerous studies show that changes in waist circumference reflect changes in risk factors for

cardiovascular disease and other forms of chronic diseases (Philip 2004). However the risks

seem vary in different ethnic groups. It has been strongly recommended that ethnic group-

specific cut offs for waist circumference should be incorporated into the defining of

overweight and obesity (World Health Organization 2010; Lear 2009; Delavari et al. 2009;Snehalatha, Viswanathan & Ramachandran 2003; Tan et al. 2004). Apparently Iranians are

not exception from this suggestion. Accordingly, a number of studies obtained dissimilar

waist circumference cut off points in the Middle Eastern countries which are different from

each other and from the Euripides cut off point that is currently used for the Middle Eastern

population (Al-Lawati et al. 2008; Bouguerra et al. 2007; Delavari et al. 2009; Mansour, Al-

Hassan & Al-Jazairi 2007; Mirmiran, Esmaillzadeh & Azizi 2004). Moreover it has been

suggested that the European cut-offs of waist circumference be used for the Middle Eastern

population, such as Iranians, until more specific data become available (Alberti, Zimmet &

Shaw 2005; Grundy et al. 2005; Lear 2010). Existing data show an increase in predisposing

factors for cardiovascular disease and other components of metabolic syndrome in Euripides

with a waist circumference 102 cm for men, and 88 cm for women (Kopelman 2000; Lear

2010; World Health Organization 2010; Lear 2009; Delavari et al. 2009; Snehalatha,

Viswanathan & Ramachandran 2003; Tan et al. 2004) ).

In this section I would focus on the obesity epidemiology covering the Persian Gulf then Iran

in particular. Then I would move on to summarise the obesity profile of migrants for the

Persian gulf to developed countries and contrast this with the pattern of Iranian migrants.

7 Waist circumference: midwaybetween the lowest rib and the iliac crest (Han et al 1995)

8 Central or abdominal obesity is the accumulation ofvisceral fat resulting in an increase in waist size.

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1.2.3 Epidemiology of obesity9

In 1998, the World Health Organization (WHO) recognized obesity as a major worldwide

public health epidemic which was contributing to a wide range of health and social

consequences (Deckelbaum & Williams 2001; Dietz 1998b; Kumanyika et al. 2002; Must

1996). Despite characteristic differences in worldwide distribution, overweight and obesity

have become an epidemic issue in most societies during the last two decades (Pi-Sunyer

1993; Troiano & Flegal 1998). Across the globe one billion adults have body mass index

(BMI) exceeding 25, and about 300 million of those considered as obese (World Health

Organization 2007). The World Health Organization (WHO) Eastern Mediterranean Region

reported that as a result of marked changes in the pattern of living in many countries of the

Region, particularly countries of the Persian Gulf Cooperation committee, Overweight and

obesity have risen 2-fold or more since 1980.

1.2.3.1 Obesity in Iran

Regional comparision:

Iran is located in the Middle East with the second highest obesity rate worldwide. Especially

among women, the highest BMI and waist-to-hip ratio were recorded in the Middle East

(James 2004; World Health Organization(WHO) 2009; Yusuf et al. 2004; Musaiger 2004).

Figure presents a comparison among 12 countries in the Eastern Mediterranean

region. This figure indicates that Iran has the third highest overweight and obesity in the

region after Bahrain and Saudi Arabia. Among women the prevalence of overweight and

9 This is an abbreviated literature review. Therefore international studies have not been given their full

attention, but will be comprised in-full in the final thesis literature review. In addition this literature review has

been focused on adults obesity, because my thesis will look at 25-64year old Iranian migrants in Victoria.

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obesity in Iran is relatively similar to that in Saudi Arabia. On the other hand it is

significantly higher than that in Lebanon, Oman and Jordan, and lower than that in Bahrain

and Libya. Among men overweight and obesity in Iran is lower than Saudi Arabia but similar

to that in Bahrain, and higher than all other selected countries.

Figure The prevalence of overweight and obesity among adults in selected countries in the

Eastern Mediterranean region

Source: (khatib 2004)

National survey:

National studies conducted during the past 20 years (Ghassemi, Harrison & Mohammad2006; Mohammadpour-Ahranjani et al. 2007, Kelishadi 2007) provide evidence for a

dramatic increasing in overweight and obesity in Iran. The rate of overweight and obesity

have increased significantly from 35.9% in 1999 ( Ghassemi 2002) to 59.4% in

2008( Delavari et al 2009).

According to nationwide studies overweight and obesity, particularly abdominal obesity, are

significantly more prevalent in women than men (Delavari et al. 2009; Esteghamati et al.

2008; Mohammadpour-Ahranjani et al. 2007). Prevalence of overweight among Iranian

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women and men was about 36.1% and 32.1% respectively. Overall, 25.1% of the population

studied was obese, with a higher prevalence in women than in men (33.3% vs. 17.2%,

respectively) (Delavari et al. 2009). (Figure.)

Figure 1.2.3.1 Obesity in Iranian adults

(Delavari et al. 2009)

In addition the prevalence of overweight and obesity varied by age. Both men and women

showed a higher BMI around fifties (Azizi, Azadbakht & Mirmiran 2005; Pishad 1996;

Dastgiri et al 2006).

Other studies reported a high prevalence of metabolic syndrome (Mets) with its considerable

burden on the middle-aged population in Iran (Esteghamati et al. 2008; Zabetian, Hadaegh &

Azizi 2007). For example, while metabolic syndrome10 in American and Australian adults has

been estimated to be 25% and 20% respectively(Cameron, Shaw & Zimmet 2004; Ford, Giles

& Dietz 2002), this syndrome averaged 33% among Iranian adults (Azizi et al. 2003).

A number of studies have provided evidence that obesity and overweight in Iran, specifically

among women, are equal or even higher than Europe and the United States (Alireza et al.

2007; Azizi, Azadbakht & Mirmiran 2005; Delavari et al. 2009; Malekzadeh et al. 2005;

Rashidy-Pour et al. 2009). In order to be relevant I present a comparison of the national

studies on the prevalence of overweight and obesity between Iran and three other countries in

2008 figure. This chart indicates that among men the prevalence of overweight in Iran is

10 Prevalence of the metabolic syndrome according to the ATPIII definition

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lower than the United States of America, Australia and the United Kingdom. On the other

hand, Iranians women have the highest prevalence of overweight among selected countries.

For them obesity prevalence is lower than the U.S, but significantly higher than that for

women in Australia and the U.K. More specifically, Iranian women are significantly more

overweight and obese than Australian women. On the contrary, for men the prevalence of

overweight and obesity is higher in Australia than that in Iran.

Figure The percentage of overweight and obesity among adults in a selected number of

countries based on sex distribution

Source: Centres for disease control and prevention 2009; World Health Organization 2008; Delavari et al, 2009)

Also, figure . compares overweight and obesity trends between Iranians and Australians

form 1999 to 2007. This graph shows that in 1999, while half of Australia adults were either

overweight or obese, 35.9% of Iranian adults experienced overweight or obesity.Since then

the prevalence of overweight and obesity rose significantly in both countries. However

overweight and obesity have been an enormously increased in Iran and Iranians were getting

much quicker overweight or obese compare to Australians. In conclusion while Australians

were more likely to be overweight or obese than Iranians in 1999, after 8 years Iranians seem

to be more vulnerable to being either overweight or obese. In 2008, Iranians relatively

reached to the same level of overweight and obesity as Australians did (59.2% vs. 61.3%).

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Figure.The prevalence of overweight and obesity among adults in Iran and Australia from 1999 to 2007

Source: (World Health Organization 2009; Australian Bureau Of Statistics 2008; Rashidy-pour et al. 2009; Kelishadi et al.

2007; Delavari et al. 2009; Ghassemi et al. 2002).

More specifically, figureand compare the trend of overweight and obesity with age

between Iranian and Australian adults. Similar to the previous graph,.., Iranian women are

significantly more either overweight or obese than Australian women. On the contrary, for

men the prevalence of overweight and obesity is higher in Australia than that in Iran.

The first graph shows that for Iranian men the pattern of obesity prevalence with age is

relatively similar to that in Australian men. The highest obesity rate occurred around fifties.

There was a graduate increases in the prevalence of obesity with age till the 45-54 age group,

and then the figure decreased slowly. Conversely, the first graph also shows that for Iranian

and Australian men, overweight does not follow a similar pattern with age. Iranian men had

the highest prevalence of overweight in the 45-54 age range (39.3%). On the other hand, for

Australian men the trend of overweight dipped at the same age range.

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The second graph shows that the pattern of overweight and obesity is relatively similar

among Australian women. This trend increase gradually until 35-44 age group, and continued

to increase but more sharply till late adult hood. For Iranian women the prevalence of obesity

increased dramatically until the 35-44 age group, and then continued to increase but more

slowly, and then reach to a peak around fifties (34.8%). This figure began to decline and drop

to 31% around sixties. In conclusion we can see that the patterns of overweight and obesity

with age did not have a similar pattern in both sex in Iran and Australia. For Iranians both

men and women had the highest obesity prevalence in the 45-54 age group. Similarly for

Iranian men the highest prevalence of overweight, and for Australian men the highest

prevalence of obesity occurs in the 45-54 age group, But for Iranian women the highest

prevalence of overweight recorded around forties.

Figure The prevalence of overweight and obesity among men adults in Iran and Australia

by age group

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Figure The prevalence of overweight and obesity among women adults in Iran and

Australia by age group

Obesity among migrants (table)

A number of studies declared that level of acculturation and length of stay correlated

positively with obesity (Kaushal 2009; Renzaho, AMN, Swinburn & Burns 2008; Shahnaseri

& Bergan 1994). Although the prevalence of overweight is relatively low among some

immigrant groups, it is likely to rise as time passes. Therefore, the prevalence of overweight

and obesity is higher among long term migrants (11 or more) than more recent immigrants.

(health Canada)) .For example, A study in Columbia University of New York pointed out that

some ethnic groups experience increasing in obesity rate. This prevalence is higher for those

who have migrated at a younger age (Kaushal 2009). Additionally a study on 61 Iranian

women migrants in Sydney found that length of residency associated with weight gain

(Shahnaseri & Bergan 1994). Other studies have shown that keeping an element of traditional

values is associated with lower rates of obesity and sedentary behaviours among Mexican

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Americans, African Americans, African migrants in Australia, south East Asian migrants to

America etc. Whereas, among Arabic immigrants born in the Middle East and who

immigrated to south eastern Michigan (Jaber et al, Diabetes Care 26:20102014, 2003);

South Asian Indians in the United States (see for example Kanaya et al 2009 Metabolic

Syndrome and Related Disorders ...) etc. have found that keeping an element of traditional

culture is associated with greater waist-hip ratio, and obesity-related chronic diseases. A

similar study claimed that in Mexican-American increased acculturation accompanied with a

significant decline in obesity prevalence (Park et al. 2008).

These studies demonstrated that western culture poses a potential change to migrant

overweight and obesity. Nonetheless, among both recent and long term immigrants, ethnic

differences were apparent. For example,even when the effect of age, household income,

education and physical activity were taken into account, East/southeast Asian immigrant men

and women generally had lower overweight than did white immigrants. Regardless of when

they immigrated, black women had higher overweight compared with white immigrant

women. (health Canada)) These finding mirror those of previous Canadian and American

studies. (26,43,44 az health Canada))

Migrants experience a higher risk of obesity compared to local born individuals (Daryani et

al. 2005; Dijkshoorn, Nierkens & Nicolaou 2008; Gadd et al. 2005; Gellner & Domschke

2008; Haas et al. 2003; Kirchengast & Schober 2005; Nelson, Chiasson & Ford 2004;

Renzaho, AMN, Swinburn & Burns 2008; Sundquist 1997). For example a number of studies

found that African Americans, Asian Indians and Blacks living in the united Kingdome have

higher rate of obesity than local-born population (Landman & Cruickshank 2001; Misra &

Ganda 2007). Similar studies conducted in the United States demonstrate stepwise raise in

prevalence of obesity among men and women from different Diaspora (Bates et al. 2008;

Bhatnagar et al. 1995; Fujimoto et al. 1994; Khan, Sobal & Martorell 1997; Lee et al. 1994;

Luke et al. 2001; McKeigue et al. 1988; Misra & Ganda 2007; Popkin & Udry 1998;

Wahlqvist 2002). Other studies in the Netherlands, Sweden and Germany found above-

average rate of obesity for migrant originated from different ethnic groups (Carballo, M.,

Divino & Zeric 1998; Carballo, M & Mboup 2005; Dijkshoorn, Nierkens & Nicolaou 2008;

Thorburn 2005; Will, Zeeb & Baune 2005). A limited number of studies provide evidence

that BMI of Iranian, especially women, migrated to western countries is higher than local

population (Daryani et al. 2005; Koochek et al. 2007). For example a Health survey

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demonstrated a higher BMI in women from Iran (26.34.59) compare to Swedish women

(24.73.35) (Daryani et al. 2005).

These studies suggest that BMI status of migrants is less favourable than local population.

However, there are differences between the various groups of migrants regarding to their

BMI status back home. For example, study in Norway accounted the prevalence of

overweight and obesity in ethnic and gender differences. Among 600 Iranian migrants, 58.4%

of women (38.2% overweight, 20.2% obese) and 71.2% of men (57.7% overweigh, 13.5%

obese) were either overweight or obese (Kumar et al. 2005). Comparing to nation studies in

Iran (Delavari et al. ) this study shows that while women are more likely to be overweight

than men in Iran, this disadvantage disappears post migration, and men seem to be more

vulnerable to being overweight. In addition, the prevalence of obesity decreased among both

men and women post migration.

Many studies conducted in multicultural countries reported that increasing in BMI may result

from transitions away from cultural diets and lifestyle patterns to a more western diet and

sedentary life or the ways in which settlement process erode hard (Fennelly, 2007), or

some combination of the two. However, there is insufficient evidence on why some former of

migrants but not others experience more weight gain than general population. Some experts

in public health argue that acculturation is an important and understandable variable which

may help to find an answer for this question (Korzenny & Abravanel 1998).

Obesity in culturally and linguistically different (CALD) population in Australia

Australia is ranked as having one of the highest adult obesity rate among countries with high

human developmental index (Statistic. 2007). Figure 1.2.3.2presents an international

comparison among six countries. This figure indicates that the prevalence of overweight inAustralia is similar to that in the Unites States of America, Canada and the United Kingdome.

On the other hand it is significantly higher than that in France and Japan. Obesity in Australia

is lower than the US, but similar to both the UK and Canada (Biggs 2006).

Figure 1.2.3.2 The prevalence of overweight and obesity among persons in 15 years or

over in selected countries

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Adopted: (Biggs 2006)

World Health Organization (WHO) estimated 75.7% of males and 66.5% of females in

Australia will be overweight by 2010, in addition 28.4% of adult males and 29.1% of adult

females will be obese(Biggs 2006).

These data show that the prevalence of overweigh and obesity are not only increasing, they

are accelerating in Australia. Additionally it is obvious that migrant population are not

exception in this current trend.

A number of studies have identified this phenomenon across different ethnic groups inAustralia. Most of these studies showed gaining weight among migrants which was

significantly higher than for those with Australian origin (Ke et al. 2008; Renzaho, AMN,

Swinburn & Burns 2008). For examplea study of 8-9 year old children from Sydney schools

demonstrated that children of South East Asian (SEAsian) had significantly a higher rate of

overweight and obesity than those with Australian origin (Ke et al. 2008). More recently a

cohort involved 29799 men and women aged 35-39 years in Melbourne showed a wide

spread weight gain across different ethnic groups(Ball et al. 2007).A migrant health survey

conducted in Adelaide analysed that 46.5% of migrant from non-English speaking (NES)

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countries had a BMI which classified them as overweight or obese. However migrants from

the Middle East11 were not statistically more overweight or obese than migrants born in the

UK/Ireland and total of NES countries (Taylor, A et al. 1996-97).

Literature review shows a growing tendency in the number of studies undertaken regarding

the nutritional status and obesity prevalence among refugees and migrants in Australia.

However I couldnt get any specific data demonstrated overweight and obesity of Iranians in

Victoria. After reviewing relevant national and international data, I found only one report

presented in the 18 annual scientific meeting of Nutritional Society of Australia in 1994,15

years ago, conducted only on 61 Iranian women resident in Sydney. This study declared over

44% prevalence of BMI in excess of 25 among participants (Shahnaseri & Bergan 1994).

However the prevalence of obesity had not been specified. In addition the number of

participants was too small to make assumptions.

In this section I will embark on exploring predisposing factors pre and post migration. I will

use the ecological model and acculturation theory for structure the argument.

1.2.4 Potential underlying causes of obesity on the subject of migration

(Predisposing factors pre and post migration)

Aetiology of obesity

Obesity does not have a simple uniform aetiology.Obesity is often multifactorial, based on

both genetic and environmental factors which result behaviour that lead to obesity (Bulik,

Sullivan & Kendler 2003; Egger & Swinburn 1997; Kopelman 2000; Kumar et al. 2005;

Nicolaou et al. 2008; Pi-Sunyer 1993; Troiano & Flegal 1998). At the most basic, individual

level, obesity is caused by an excess of total body fat (Swinburn & Ravussin 1993) which

results from energy intake that exceeds energy usage (Spiegelman & Flier 2001). However at

a social level increasing rate of obesity is felt to be due to obesogenic factors in the

environment(Egger & Swinburn 1997; Hill & Peters 1998; Swinburn, Egger & Raza

1999).Obesogenic factors in the environment are not only easily accessible diet, increased

reliance on cars and mechanized manufacturing but comprising environmental changes

11 Iran is in the Middle East.

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which directly and/or indirectly influence community`s attitudes, values, and behaviour

related to food habit and physical activity (Booth & Samdal 1997). This profound effect of

changing manner and behaviour of different individuals when they are placed in a new

environment should not be ignored in any study of environmental factors influence on obesity

(Renzaho, AMN, Swinburn & Burns 2008; Swinburn, Egger & Raza 1999).

Theoretical approach

This thesis is based on two theoretical approaches, the acculturation theory and an adapted

ecological model for obesity. In addition the ANGELO framework12 (The analysis grid for

environments linked to obesity) is mentioned, since the study variables can be selected more

objective. The acculturation theory hypothesises that changing in aspects of lifestyle (e.g.dietary habits and patterns of physical activity) may develop some obesogenic environmental

factors for migrants (Li & Pawlish, 1998; Renzaho, 2003). An adapted ecological model for

obesity (Figure 1.2.4) talks about environment which directly or indirectly influence

communitys attitude, values and behaviour related to food habits and physical activity

(Swinburn, Egger & Raza 1999). Environmental factors which influence on energy balances

have been sighted by the ANGELO framework. In order to be relevant, Such factors include

physical (via physical activity and sedentary behaviour), economic (via income and

employment status ), and socio-cultural (via knowledge, attitudes, habits and beliefs) (Kumar

et al. 2005; Swinburn, Egger & Raza 1999).Put in simple terms, these relate to both food and

activity (the two mediators of obesity) which mediate the effects of the broader environments

on body fat levels.

Figure 1.2.4 An ecological paradigm for understanding over fatness and obesity

12 This model seems to provide an easily-understood framework to highlight potential causes of obesity

(Swinburne, Egger & Raza 1999).

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Adopted: (Egger & Swinburn 1997)

Therefore this thesis will focus on four important determinants of overweight and obesity in

Iranian migrants in Victoria; Diet and physical activity as the energy balance equations, the

perception of overweight as an important underlying motivator for weight gain, and

acculturation as an antecedent to obesity of migrants. These factors are the basis of my study

that can help us to understand how acculturation mediates weight gain among Iranian

migrants in Victoria.

In the following paragraphs I talk about some potential determinants of acculturation level of

diet, physical activity and body perception among CALD communities, especially Iranian

migrants. Gaps in the knowledge and concluding remarks will be presented followed by the

main aims and research question that form my hypothesis of this thesis.

1.2.4.1 Acculturation

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Acculturation is defined as a process in which groups of individuals having different cultures

adapt to the attitudes and/or behaviours of another group (Alba & Nee 1997; Boas 1940;

Korzenny & Abravanel 1998; Redfield, Linton & Herskovits 1936; Taylor, D 1991).

Probably the first academic account of acculturation appears in Platos Laws written in the 4 th

century BC (Berry 2003b). Increasingly, the importance of acculturation has been recognized

in the social sciences, sociology, psychology, epidemiology, and public health. Since then,

scholars in different disciplines have developed more than 100 different theories of

acculturation (Berry et al. 1987; Boas 1940; Born 1970).

Models, scales and measurements of acculturation

The two most common models of acculturation theory are the unidirectional model (UDM) ora linear model and the bidirectional model (BDM) or a two-dimensional model. The linear

model is based on the assumption that a strong ethnic identity is not possible among those

who become involved in the mainstream society and that acculturation is inevitably

accompanied by a weakening of ethnic identity. Alternatively, the two-dimensional model

suggests that both relationship with traditional or ethnic culture and relationship with new or

dominant culture play important roles in the process of acculturation (Flannery 2001).Using

two-dimensional model, Berry has suggested that there are four possible outcomes of the

acculturation process: assimilation (movement toward the dominant culture), integration

(synthesis of the two cultures), separation (reaffirmation of the traditional culture), and

marginalization (alienation from both cultures) (Berry et al, 1980; 2003).

Figure 1.2.4.1 Four acculturation strategies based on two issues

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Adopted: (Berry 2003a)

Acculturation scales have been developed for different ethnic groups. Most of those scales

used to measure acculturation include items on second-language proficiency. Some scales

also assess friendship choices, food, music or movie preferences, cultural awareness, ethnic

pride, place of birth, and ties of people in country of origin (Korzenny & Abravanel 1998).

In terms of the relationship between main language spoken at home and nutritional status in

4-5-year old children of Australian immigrants, Renzaho and colleagues claimed that use of

English language at home may be a protective factor for normal weight in young African

boys (Renzaho et al. 2009).When detailed information is unavailable the percentage of one's

lifetime spent in the host country (length of residency) and one's age at the time of

immigration should be good indicators of an individual's level of acculturation (Kaushal

2009).

Measuring of acculturation was developed by Berry and Kim which yes, no answers to the

issue of maintaining cultural identity and yes, no answers to the issue of participating in the

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larger society define, respectively, the construct of integration (yes, yes), assimilation(no,

yes), separation (yes, no), and marginalization (no, no). Since the four constructs are equally

selective, agreement to items about one construct should impede agreement to the

corresponding items about the other three (Hunt, Schneider & Comer 2004; Iman 2008).

Which acculturation scale dose explains the strongest correlations with relevant criteria?

To date, only a few researchers have empirically compared the UDM and BDM in the same

study. In a comparison of the unidirectional and bidirectional models of acculturation

Flannery and colleagues (2001) assert that none of the acculturation models (or scales) was

consistently superior to the other models. Instead, scientist in different disciplines should

select the acculturation model that best matches their research topic and their population.Results from this analysis confirmed that the advantages of BDM scale are producing slightly

larger findings with migrants` preference, cultural knowledge, ethnic identification and more

generative than UDM. BDM is ideal for second-generation migrants whereas UDM is ideal

for first-generation immigrants. However UDM can only describe one outcome of

acculturation-assimilation (Flannery 2001).

Acculturation and Health

Acculturation is currently widely used as a variable in health research. Acculturation scales

designed to quantify the extent to which individuals embrace mainstream versus ethnic

culture. These figures are then correlated with measures of the health outcomes of interest

(Hunt, Schneider & Comer 2004). Hazuda and colleagues (1988) developed the most

comprehensive measure of acculturation for use in health services and epidemiological

research. Hazuda`s scales are based on a theoretical model that views acculturation as a

multi-dimensional process involving language, cultural beliefs and values (Hazuda et al.1988).

Early studies of the level of acculturation in health identified a healthy migrant effect. In

the case of Western societies this effect implies that first generation migrants are often

healthier than local residents. Overtime this effect tend to diminish as the health of migrants

converges to the host country`s norm (Finch & Vega 2003; Harris 1999; Hernandez &

Charney 1998; Muening & Fahs 2002; Neria 2000; Salomaa et al. 2000; Sundquist 1994,

1995).

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World Health Organization (WHO) classified health as physical, mental and social wellbeing

(Breslow 1972). Epidemiological evidence suggests that changing in living condition

(migration) and difficulties adjusting to a new culture (resettlement) may influence the three

aspects of health (Beiser, Turner & Ganesan 1989; Gerritsen et al. 2006; Ghaffarian 1998;

Hyman 2004; Lipson & Omidian 1992; Proust 1971).

Similarly a growing body of literature describes the healthy migrant phenomenon

the fact that on many measures, first-generation immigrants are often healthier than

local- born residents.1-4 Over time, however, the migrant health advantage diminishes

dramatically. The healthy migrant phenomenon has been well documented in

America,Canada, Australia, and several Western European countries.14-18There is

evidence that changes in lifestyle are factors accounted fora deterioration in some

indicators of health after immigrants 7,16,20-22disturbance of migrants health situation (He

et al. 1991; Hicks LS 2003) describe the change from health advantages to disadvantages

of immigrants as a function of acculturation.23 The more they become like us,

immigrants fail to maintain their initial health advantages. (Fennelly, 2007)

. For example, the prevalence of overweight and obesity is higher among long term migrants

(11 or more) than more recent immigrants. This finding supports the notion that a healthy

immigrant effect fades within a decade for all ethnic group.Thus, although the prevalence of

overweight is relatively low among some immigrant groups, it is likely to rise as time passes.

The increase in BMI may result from transitions away from cultural diets and lifestyle

patterns to a more western diet and sedentary life and ways in which the settlement

process wears down hardiness and resilience. (Fennelly, 2007), or some combination of

the two. Nonetheless, among both recent and long term immigrants,ethnic differences were

apparent. Even when the effect of age,household income,education and physical activity were

taken into account East/southeast Asian immigrant men and women generally had lower

overweight than did white immigrants. Regardeless of when the immigrated,black women

had higher overweight compared with white immigrant women. These finding mirror those

of previous Canadian and American studies. (26,43,44 az health Canada)) Despite many

studies conducted in multicultural countries reported that obesity is the main health issue

among migrants; there is insufficient evidence on why some former of migrants but not

others experience more weight gain than general population. Considering its relevance for

body weight, body size preference, food habits and physical activity among migrants, some

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experts in public health argue that acculturation is an important and understandable variable

which may help to find an answer for this question (Korzenny & Abravanel 1998).

Specifically they experience a higher risk of obesity compared to local born individuals

(Daryani et al. 2005; Dijkshoorn, Nierkens & Nicolaou 2008; Gadd et al. 2005; Gellner &

Domschke 2008; Haas et al. 2003; Kirchengast & Schober 2005; Nelson, Chiasson & Ford

2004; Renzaho, AMN, Swinburn & Burns 2008; Sundquist 1997). For example a number of

studies found that African Americans, Asian Indians and Blacks living in the united

Kingdome have higher rate of obesity than local-born population (Landman & Cruickshank

2001; Misra & Ganda 2007). Similar studies conducted in the United States demonstrate

stepwise raise in prevalence of obesity among men and women from different diaspora (Bates

et al. 2008; Bhatnagar et al. 1995; Fujimoto et al. 1994; Khan, Sobal & Martorell 1997; Lee

et al. 1994; Luke et al. 2001; McKeigue et al. 1988; Misra & Ganda 2007; Popkin & Udry

1998; Wahlqvist 2002). Other studies in the Netherlands, Sweden and Germany found above-

average rate of obesity for migrant originated from different ethnic groups (Carballo, M.,

Divino & Zeric 1998; Carballo, M & Mboup 2005; Dijkshoorn, Nierkens & Nicolaou 2008;

Thorburn 2005; Will, Zeeb & Baune 2005). A limited number of studies provide evidence

that BMI of Iranian, especially women, migrated to western countries is higher than local

population (Daryani et al. 2005; Koochek et al. 2007). For example a Health survey

demonstrated a higher BMI in women from Iran (26.34.59) compare to Swedish women

(24.73.35) (Daryani et al. 2005). Another study in Norway accounted the prevalence of

overweight and obesity in ethnic and gender differences. Among 600 Iranian migrants, 58.4%

of women (38.2% overweight, 20.2% obese) and 71.2% of men (57.7% overweigh, 13.5%

obese) were either overweight or obese (Kumar et al. 2005). Comparing to nation studies in

Iran (Delavari et al. ) this study shows that while women are more likely to be overweight

than men in Iran, this disadvantage disappears post migration, and men seem to be more

vulnerable to being overweight. In addition, the prevalence of obesity decreased among both

men and women post migration.

These studies suggest that BMI status of migrants is less favourable than that of the

indigenous population. However, there are differences between the various groups of

migrants regarding to their BMI status back home.

For example a number of studies declared that level of acculturation and length of stay

correlate positively with obesity (Kaushal 2009; Renzaho, AMN, Swinburn & Burns 2008;

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Shahnaseri & Bergan 1994). A study on 61 Iranian women migrants in Sydney found that

length of residency associated with weight gain (Shahnaseri & Bergan 1994). Additionally a

study in Columbia University of New York pointed out that some ethnic groups experience

increasing in obesity rate. This prevalence is higher for those who have migrated at a younger

age (Kaushal 2009). In contrast a claimed that in Mexican-American increased acculturation

accompanied with a statistically significant linear decline in obesity (Park et al. 2008).

These findings support the proposition that western culture poses a potential risk to migrant

overweight and obesity.

Acculturation and health

World Health Organization (WHO) classified health as physical, mental and social wellbeing

(Breslow 1972). Epidemiological evidence suggests that changing in living condition

(migration) and adjusting to a new culture (acculturation) may influence the three aspects of

health (Beiser, Turner & Ganesan 1989; Gerritsen et al. 2006; Ghaffarian 1998; Hyman 2004;

Lipson & Omidian 1992; Proust 1971).

Acculturation is currently used as a variable in health research. Acculturation scales designed

to quantify the extent to which individuals embrace mainstream versus ethnic culture.

These figures are then correlated with measures of the health outcomes of interest (Hunt,

Schneider & Comer 2004). Hazuda and colleagues (1988) developed the most comprehensive

measure of acculturation for use in health services and epidemiological research. Hazuda`s

scales are based on a theoretical model that views acculturation as a multi-dimensional

process involving language, cultural beliefs and values (Hazuda et al. 1988).

A growing body of literature describes the healthy migrant phenomenon. This

phenomenon has been well documented in America, Canada, Australia, and several

Western European countries.14-18 In the case of Western societies this effect implies that

first generation migrants are often healthier than local residents 1-4. As a function of

acculturation, this effect tend to diminish, and the health of migrants converges to the host

country`s norm 237,16,20-22(He et al. 1991; Hicks LS 2003) (Fennelly, 2007). (Finch & Vega

2003; Harris 1999; Hernandez & Charney 1998; Muening & Fahs 2002; Neria 2000; Salomaa

et al. 2000; Sundquist 1994, 1995).

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Acculturation and obesity-the evidence

Acculturation and obesity risk factors

1.2.4.2 Acculturation and food consumption (e.g. Dietary acculturation)

Diet and physical activity are the two undeniable key factors should be considered among

causes of overweight and obesity. Currently strong support developed for the hypothesis that

changing in aspects of lifestyle (e.g., dietary habits, physical activity patterns) of particularmigrant group may affect the development of specific obesogenic environment13 factors

among this group (Hunt, Schneider & Comer 2004; Li & Pawlish 1998; Swinburn, Egger &

Raza 1999). For instance studies of food habits and traditional dietary practice of Iranian

migrants in Sydney found considerable changes in food habits for those subjects who resided

more than 4 years in Australia. The most visible changes in food habits were an increase

frequency in consumption of white bread and beef (Landman & Cruickshank 2001;

Shahnaseri & Bergan 1994).

Back in Iran, although the general food pattern of population fell in the acceptance range, the

trend in the past 30 years shows a significant increase in fat consumption (Malekzadeh et al

2005; Kimiagar et al 2000). Thecharacteristic of the Iranian diet is dependency on bread and

rice as major energy sources. Of the total energy intake about 66% comes from carbohydrates

and 22% comes from fats. This consumptionof high-carbohydrate diets (mostly from refined

sources) and fats as well as increased interest of the community in a more westernized diet

containing junk and fast food mightpresent some reasons for a high prevalence of overweight

and obesity in Iran (Esmaillzadeh& Azadbakht 2008;Kelishadi et al 2003; Kimiagar et al

2000; Ghassemi2002; Malekzadeh et al 2005).

Acculturation and Physical activity

13 Obesogenic environment is the place of abundance of food along with limited opportunities for physical

activity that is likely to promote weight gain (Swinburn, Egger & Raza 1999).

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When physical activity was assessed, With acculturation, migrants generally found to be less

active and to have greater BMI than their counterparts in host countries (Scott & Worsley

1994). For example Daryani et al found that Iranian women aged 3564 years In Sweden had

significantly less physical activity during leisure time compared with Swedish-born women.

Such findings were consistent with other studies of food habit and physical activity in

multicultural populations both in Australia and other countries (Bauman et al. 2002; Egger &

Swinburn 1997; Keski-Rahkonen 2005; Landman & Cruickshank 2001; Li & Pawlish 1998;

Lindstrom & Sundquist 2001; Nicolaou et al. 2008; Renzaho, AM & Burns 2006; Shahnaseri

& Bergan 1994). Other studies have shown that keeping an element of traditional values is

associated with lower rates of obesity and sedentary behaviours among Mexican Americans,

African Americans, African migrants in Australia, south East Asian migrants to America etc.

Back in Iran; When physical activity was assessed a number of studies demonstrated that

increased tendency to sedentary lifestyle due to lack of adequate exercise and decreased walking is

significant among Iranians, especially women (Kelishadi et al 2003, 2007; Malekzadeh et al

2005; Azizi, Salehi, Etemadi& Zahedi-Asl 2003).

1.2.4.3 Acculturation and Socio economic status (SES)

The association of socio economic status and obesity among migrants has not been yet well

straightforward. Within migrant groups both negative and positive association between

educational level and obesity have been observed (Erp-Baart et al. 2001; Irala-Estevez et al.

2000; Lv & Cason 2004; Panagiotakos et al. 2008; Reijneveld 1998). For example in

Sweden, Iranian women with low educational status had higher mean BMI than those with

high educational status. However a significant association between educational level andobesity was not declared for men (Wndell et al. 2004). Socio economic status (SES)

There are enough evidence showed that socio-economic positions (income, educational level

and employment status) are important determinants of the two mediators of obesity (dietary

quality and physical activity quantity) (Bakhshi, Enayatollah et al. 2008; Bakhshi, E. et al.

2008; Batty & Leon 2002; Danielzik et al. 2004; Everson et al. 2002; Gutirrez-Fisac et al.

2004; Hajian-Tilaki & Heidari 2007; Kelishadi et al. 2003; Maddah et al. 2003; McLaren

2007; Panagiotakos et al. 2004; Rashidy-Pour et al. 2009).

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These factors have been extensively investigated in different countries. For example, higher

levels of education and high income associate with lower prevalence of obesity in western

countries, on the contrary a reverse maybe seen in non western countries (Kopelman 2000).

Although Iran is a non western country with a medium human developmental index

(medium-HDI), obesity patterns in Iran are more like western (high-HDI) countries (Bakhshi,

Enayatollah et al. 2008; Bakhshi, E. et al. 2008; Chinikar, Maddah & Hoda 2006; Frezza et

al. 2008; Kelishadi et al. 2003; Maddah et al. 2003). For example, a number of studies on

obesity showed a negative association between obesity ,especially central obesity, and social

economical status (SES)when education and/or employment status were used as the indicator

for SES(Bakhshi, E. et al. 2008; Gutirrez-Fisac et al. 2004; Hajian-Tilaki & Heidari 2007;

Panagiotakos et al. 2004; Rashidy-Pour et al. 2009). On the other hand some studies provide

evidence that high economic index (high income) associated with high obesity prevalence

(McLaren 2007; Bakhshi; 2008). This seems contradictory but we do not think so, usually in

Iran economy and business are controlled by low educated people. Therefore we cannot say

that high educated people in Iran are in welfare compared with low educated people

(Bakhshi; 2008

1.2.4.3 Acculturation and Body size preference

With acculturation it is generally expected that migrants will adopt the body size ideals of

their host peers (Choudry & Mumford 1992; Fichter et al. 1983; Nasser 1997). Subsequently,

evidence found higher rates of body shape concerns in individuals from non-Western cultures

who have migrated to the West, compared with individuals who have stayed in their native

culture (Crago, Shisslak & Estes 1996; Dounchis, Hayden & Wilfley 2001; Goldman et al.

1991; Keel & Klump 2003; Polivy & Herman 1987; Shaw et al. 2004; Wildes, Emery &

Simons 2001). Converse to such findings, a study focused on comparing Iranian women in

Iran with those who have migrated to Los Angeles argued that there is no evidence to suggest

college-aged women in Iran have fewer symptoms of body dissatisfaction than their

counterparts in Los Angeles. More acculturation to Western norms was not associated with

more symptoms of body dissatisfaction (Abdollahi & Mann 2001).

Despite many studies conducted in multicultural countries reported that obesity is the main

health issue among migrants; there is insufficient evidence on why some former of migrants

but not others experience more weight gain than general population. Considering its

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relevance for body weight, body size preference, food habits and physical activity among

migrants, some experts in public health argue that acculturation is an important and

understandable variable which may help to find an answer for this question (Korzenny &

Abravanel 1998).

It is well identified that body imageplays an important role in weight (Flynn & Fitzgibbon

1998; Friedman et al. 2002; Thomas 1989). One component of body image is satisfaction

with body size. More specifically, if larger body size is preferred, individuals would be less

likely to see themselves as being overweight which would eventually be a barrier for weight

control. In order to be relevant, wether Iranians prefer larger bodies and associate these with

prosperity and health it may in turn explain the higher prevalence of overweight and obesity

in Iran.

A number of studies showed that body size concern is traditionally more prevalent in Western

cultures (Crago, Shisslak & Estes 1996; Dounchis, Hayden & Wilfley 2001; Goldman et al.

1991; Keel & Klump 2003; Polivy & Herman 1987; Shaw et al. 2004; Wildes, Emery &

Simons 2001). Back in Iran, in a study compared the body image of young adult Iranians,

with the same aged Americans, consistent with expectation, although women had less

positive views of their bodies than men in both samples, Iranians viewed their bodies more

positively than Americans (Akiba 1998).

Iran is categorized as a country with a medium human developmental index (medium-HDI).

However obesity patterns in Iran are more like high-HDI countries (Bakhshi, Enayatollah et

al. 2008; Bakhshi, E. et al. 2008; Chinikar, Maddah & Hoda 2006; Frezza et al. 2008;

Kelishadi et al. 2003; Maddah et al. 2003). For example, a number of studies on obesity

showed a negative association between obesity ,especially central obesity, and social

economical status (SES)when education and/or employment status were used as the indicator

for SES(Bakhshi, E. et al. 2008; Gutirrez-Fisac et al. 2004; Hajian-Tilaki & Heidari 2007;

Panagiotakos et al. 2004; Rashidy-Pour et al. 2009).

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1.3. Concluding remarks and gaps in the knowledge

In summary my literature review has highlighted that:

Iranians, particularly highly educated individuals, are representative of a growing number of

migrants to Australia.

Iranians have a high prevalence of obesity, especially abdominal obesity, and its health

consequences prior to migration. They come from the Middle East which is the region with

the second highest prevalence of overweight and obesity in the world.

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Iranian adults in Iran have a higher rate of overweight and obesity compared to their

Australian counterparts.

Some migrants from countries with low or medium-HDI14 to high-HDI are at increased risk

for obesity and its health consequences.

A number of anthropometric studies on different migrant groups indicated a rapid weight

gain after migration which positively correlated with length of stay in the host country.

A limited data about the effect of migration on food habits and physical activity patterns are

available. These data demonstrated that the majority of ethnic groups show a significant

adaptation to obesogenic behaviours (e.g. consumption of more energy-dense and nutrient

poor-foods as well as less physical activity).

Existing models which describe the effect of migration on increasing BMI are based on

studies conducted on migrants who move from poor, low educated countries to wealthy, high

educated countries. However there is a paucity of understanding about the effect of migration

on the BMI of communities with high SES backgrounds, and from countries with a higher

BMI than the host country.

More specifically,

Lack of understanding about the effect of migration on the BMI of Iranians who move from

an environment where the population is highly educated, has high personal wealth and higher

average BMI to an environment where the population is also highly educated and has high

personal wealth but lower average BMI.

Lack of understanding about the effect of changing religious slash political environment asa major socio cultural domain for particular migrants. For example Iranian migrants,

especially women, may be much more concerned about their body size, food habits and

physical activity patterns after migration because they have lost the religious constraints.

Therefore based on the literature, my personal experience and observations as an Iranian in

Australia I propose a study on Iranian migrants in Australia. This research will provide a

unique and interesting example and outcomes for evidence-based, culturally appropriate

14human developmental index

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obesity prevention actions in Iran as well as an insight to obesogenic socio-cultural factors

other in the Middle Eastern countries which have the same socio-cultural status. If the BMI of

Iranians goes down after migration, the models of acculturation on obesity may need to be

revised. It may have implication for obesogenic factors which are changeable in Iran and

other societies that mirror the same socio cultural and economic status. In addition, the result

of this thesis can provide valuable data to reveal the effect of migration and other factors such

as acculturation on the BMI, physical activity patterns and food habits among a growing

ethnic community in Australia.

1.4. Purpose: Aim and objectives

The goals of this research are;

1. To understand the experience that Iranian migrants had in relation to food habits,

physical activity patterns, body size perceptions and weight changes after migration to

Australia.

2. To quantify the BMI and its related factors, and acculturation level in Iranian

migrants.

3. To understand the effect of acculturation, particularly changing the religiousenvironment, on BMI and its related factors in Iranian migrants.

The overall research question is:

What is the acculturation effect on Iranian migrants in Australia in terms of BMI

and its determinants, and how does their particular situation (educated migrants from

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a country of high obesity to a country of lower prevalence furthers the model of

acculturation for obesity?

More specifically, I will focus on the below questions and hypotheses:

RQ1: What experiences do Iranians have about changes in their eating habits, physical

activity patterns, body perceptions and weight after migration to Australia?

Hypotheses 1:

Compared to Iran;

a. They are more concerned about their body size

b. They are more physically active

c. They have more healthy food habits15

d. They have more tendency to be fit

e. They have lost the religious/political environment

RQ2: What is the relationship between BMI and its determinants, and acculturation level of

Iranian migrants in Australia?

Hypotheses 2:

a. Iranian migrant adults classified as having an assimilation and integrated acculturation

outcome would generally have the lowest levels of obesity, unhealthy food habits, and

sedentary behaviours

b. Iranian migrant adults with separated and marginalised identities would have the

highest rates of obesity, sedentary behaviours and unhealthy food habits

15consumption of less energy-dense and nutrient poor-foods

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Or simply

Assimilation and integration among Iranian migrant adults will be associated with

lower levels of obesity, unhealthy food habits, and sedentary behaviours when compared

to separation and marginalisation"

In answering the research questions, the objectives of the research are to:

1. Conduct a qualitative study to understand the experiences of Iranian migrants on

bodyweight changes and related determinants.

2. Develop and test an appropriate questionnaire based on qualitative study, for

measuring acculturation level of Iranian migrants (Acculturating Rating Scale for

Iranian migrants in Australia)

3. Conduct a quantitative survey on a group of Iranians in Victoria (measuring BMI,

waist circumference, food habits, physical activity patterns and acculturation level) to

assess the relation between acculturation level and BMI and its determinants.

4. Analyse the critical elements of the pathway of changing BMI after migration for

Iranians (change trees).

5. Apply findings to the existing model of acculturation measurement (BDM) and

obesity.

More specifically;

a. To find out the perception of overweight of Iranian migrants in

Victoria.

b. To detect BMI and waist circumference of Iranian adults in Victoria.

c. To provide a baseline data of food habits of Iranian adults in Victoria.

d. To illustrate the types & frequency of sedentary behaviour and

physical activity of this target group.

e. To measure the level of acculturation of this group.

f. To assess the relation between BMI and their acculturation level.

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g. To assess the relation between waist circumference and their

acculturation level.

h. To clarify the influence of level of acculturation on food habits of

Iranians in Victoria.

i. To explain the effect of level of acculturation on type and frequency of

physical activity in this group.

2.1 Rational

2.1.1 Practical significance:

In the literature review it was suggested that Iranian migrants are at theincrease risk for obesity specially abdominal obesity and it`s health

consequences.However, there is a gap in understanding about the effect of

acculturation on overweight and obesity among Iranian population who came

to Australia as refugees or immigrants. Given this lack of research the present

thesis is the first systematic nutritional screening of Iranian Australians

which aims to concentrate on nutritional status regarding to acculturation level

of this group.

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References