This dissertation is dedicated to my family who supported me and encouraged me to pursue my study. Without them, this thesis would never been accompli

Family Influences and Healthy Weight for Korean-American Preschool Children BY SO HYUN PARK B.S.N., Yonsei University, Seoul, Republic of Korea, 2004 M.S.N., Yonsei University, Seoul, Republic of Korea, 2010 THESIS Submitted as partial fulfillment of the requirements for the degree of Doctor of Philosophy in Nursing Sciences in the Graduate College of the University of Illinois at Chicago, 2014 Chicago, Illinois Defense Committee: Kathleen F. Norr, Chair and Advisor Mi Ja Kim Chang Gi Park Linda McCreary Crystal Patil, Department of Anthropology

This dissertation is dedicated to my family who supported me and encouraged me to pursue my study. Without them, this thesis would never been accomplished. ii

ACKNOWLEDGEMENTS I can do everything through him who gives me strength (Philippians 4:13). I would like to express my deepest gratitude to my advisor and mentor Dr. Kathleen F. Norr, for her excellent guidance, caring, and patience. Her wisdom, knowledge, and commitment to the highest standards inspired and motivated me. I would also like to express my gratitude to my dissertation committee for their time and expertise in guiding my study. I would like to thank Dr. Mi Ja Kim, who provided me the experience of participating in the quality of nursing doctoral education study and financially supported me during doctoral program. It was an honor to have an opportunity to working with her. I would also like to thank Dr. Chang Gi Park; he provided me not only academic support but also emotional support during my doctoral program. He always stood by me through the good times and hard times. I also sincerely appreciate Dr. Linda McCreary for guiding my research regarding family factors and helped to conduct cognitive interviews. My special appreciation goes to Dr. Crystal Patil, who helped me to identify themes from focus group interviews and gave me an opportunity to use her child s anthropometry measuring instruments. I would like to thank my parents, Jang Sung Park, and Bok Kyo Lee, and my elder brother In Gi Park. They were always there supporting me, sending me their endless love, and encouraging me with their best wishes. I also would like to thank faculty, staff, and friends at the University of Illinois at Chicago (UIC) College of Nursing. Their friendship and sincere support helped me to spend happy time in Chicago and at the UIC. Many thanks to Dr. Hyunjoo Na, Ms. Hyejeong Hong, and Dr. Hanjong Park, who were excellent research assistants for my dissertation project; without them, I could not collect my data. Thank you for my friends in Korea who always sent iii

me their encouragement and wishes. Special thanks go to Dr. Jon Mann for his time and dedication in editing all of my academic papers throughout the program. I would also like to extend my appreciation to the directors of preschools and Korean- American churches in Chicago metropolitan area, who allowed me to conduct my research at their organization. I thank all the KA mothers and their preschool-age children who participated in my study. Thanks to their time and efforts, my study has been completed. I would like to acknowledge the financial support I received from the UIC Graduate College Chancellor s Graduate Research Fellowship, the UIC College of Nursing Seth and Denise Rosen Memorial Research Award, UIC College of Nursing Virginia M. Ohlson Scholarship, UIC College of Nursing Academy of International Leadership Development Scholarship, the Global Korean Nursing Foundation Research Scholarship, and the Korean Nurses Association of Chicago Scholarship. iv

TABLE OF CONTENTS CHAPTER PAGE I. INTRODUCTION A. Background...1 B. Significance of the Study...3 C. Purpose of the Study...5 D. Methods...6 II. KOREAN-AMERICAN MOTHERS PERSPECTIVES ON CHILD REARING AND CHILD WEIGHT A. Introduction...8 B. Methods...10 1. Approach...10 2. Sample and Setting...11 3. Procedures...11 4. Data Analysis...12 C. Results...12 1. Trying to retain Korean culture in the U.S....13 2. Fulfilling the Korean mother s role without usual supports...14 3. Perception about the child s body and efforts to maintain the child s health...16 D. Discussion...19 E. Limitations...21 F. Implications...22 III. FAMILY INFLUENCES AND HEALTHY WEIGHT FOR KOREAN-AMERICAN PRESCHOOL CHILDREN A. Introduction...26 1. Family influences on childhood overweight and obesity... 28 B. Methods...31 1. Sample and Setting... 31 2. Procedures... 32 3. Measures... 32 4. Data Analysis...36 v

TABLE OF CONTENTS (continued) CHAPTER PAGE C. Result...37 1. Bivariate relationships between family factors and child overweight...37 2. Testing the conceptual model: family factors and child s BMI z-score...39 3. Logistic regression: factors related to being overweight versus normal weight...41 D. Discussion...42 E. Limitations...46 F. Implications...47 CITED LITERATURE...57 APPENDICES...65 Appendix A...66 Appendix B...70 Appendix C...72 Appendix D...87 VITA...118 vi

TABLE LIST OF TABLES PAGE I. FOCUS GROUP INTERVIEW QUESTIONS... 23 II. CHARACTERISTICS OF PARTICIPATING KOREAN-AMERICAN MOTHERS...24 III. CONCEPTS, OPERATIONAL MEASURES, AND RELIABILITY /VALIDITY... 49 IV. CHILD WEIGHT CATEGORIES... 51 V. FAMILY FACTORS AND CHILD OVERWEIGHT... 52 VI. HIERARCHICAL MULTIPLE LINEAR REGRESSION... 54 VII. MULTIPLE LOGISTIC REGRESSION OF CHILDHOOD OVERWEIGHT... 55 vii

FIGURE LIST OF FIGURES PAGE 1. Korean-American Mothers Challenges Raising Children in the United States... 25 2. Family System and Preschool-age Child Overweight: Conceptual Model. 56 viii

LIST OF ABBREVIATIONS AR BMI CDC CFQ CI FAD FNPA FST KA KNHANES NHANES OR VIA Adiposity Rebound Body Mass Index Centers for Disease Control and Prevention Child Feeding Questionnaire Confidence Interval Family Assessment Device Family Nutrition Physical Activity Family Systems Theory Korean-American Korean National Health and Nutrition Examination Survey National Health and Nutrition Examination Survey Odds Ratio Vancouver Index of Acculturation ix

SUMMARY The number of Korean-Americans (KA) and the prevalence of obesity among them are increasing, but little is known about obesity among KA preschoolers. This doctoral dissertation was conducted to explore KA family context regarding child s obesity and to examine family factors that relate to obesity among KA preschool-age children. This dissertation consists of two different manuscripts. Because there were no studies of KA mothers experiences raising children in the U.S., manuscript one describes a preliminary qualitative study carried out to better understand KA families and children s weight prior to conducting a quantitative study. The second manuscript describes a quantitative cross-sectional study testing a conceptual model to identify family factors associated with obesity among KA preschool-age children. In the first study, focus group interviews with 15 mothers were conducted. A semistructured focus group guide allowed women to share their experience in bringing up children in the U.S., their perspectives about childhood obesity, and their children s dietary habits and physical activities. The first study found that KA mothers work to retain Korean culture in the U.S. They try to fulfill high expectation of mother s role without the supports they would have in Korea. KA mothers prefer plumpness in children and are not concerned about obesity among KA children because they belive their efforts in shaping a healthy environment are protective. Culturally appropriate approaches are needed to reduce KA mothers stress and help them maintain a healthy lifestyle and appropriate weight for their children. The second study was a cross-sectional study conducted with 104 KA preschoolers and their mothers in the Chicago metropolitan area. Twenty-two percent of the KA preschoolers were overweight or obese (Body Mass Index (BMI) 85th percentile), and family factors explained x

30% of the variance in child s obesity. When the children s BMI z-scores were dichotomized (overweight/obese vs. normal/underweight), the number of children in the family and perceived child weight were positively associated with obesity, while pressure to eat, monitoring of eating, and behavior control of children were negatively associated with obesity. Parental feeding style and child weight perception should be considered when advising KAs about reducing child s overweight and obesity. Taken together, this dissertation research shows that overweight and obesity among KA preschool-age children is a substantial problem in KA communities. KA mothers make efforts to shape healthy habits in their children despite several challenges such as high role expectation and lack of supports. However, most KA mothers had a lack of awareness about obesity issue among their children. Therefore, more efforts are needed to arouse mother s attention to obesity prevention and control among KA preschool-age children. In future studies, the influence of siblings and the child s routines during their stay in formal care settings, such as preschools, should be explored to comprehensively understand factors contributing child s obesity. Longitudinal studies are needed to examine causal relationships. These results should contribute to the development of culturally appropriate intervention programs reflecting KAs unique attitudes and values toward obesity. Interventions should include enhancing supports for KA mothers, including utilizing available support though social networks such as KA churches. xi

A. Background I. INTRODUCTION Childhood obesity has both immediate and long-term negative effects on the physical and psychological health and social well-being of children (Center for Disease Control and Prevention [CDC], 2012). According to the National Health and Nutrition Examination Survey (NHANES), the number of obese children in the U.S. more than tripled during last three decades (rising from 5% to 17%) (Ogden, Carroll, Curtin, Lamb, & Flegal, 2010). The prevalence of childhood obesity increases between preschool age (ages two to five) and grade school age (ages six to eleven) (Rhee, 2008). Health problems such as type 2 diabetes and cardiovascular disease among obese children may persist not only throughout childhood but also into adulthood (McCurdy, Winterbottom, Mehta, & Roberts, 2010; Wofford, 2008). Obese children are also reported to experience a lower health-related quality of life. One study found that severely obese children have a quality of life similar to that of children diagnosed with cancer (Schwimmer, Burwinkle, & Varni, 2003). The major modifiable factors contributing to childhood obesity are known to be unhealthy dietary habits, insufficient physical activity, and sedentary behavior. Increased highfat and sugar-containing food consumption leads to higher BMI in children (Skelton, Irby, Miller, & Grzywacz, 2011). Decreased physical activities and increased screen time are associated with higher risk of being overweight and obese (Vos & Welsh, 2010). These factors are shaped within a family environment and can be changed by means of parental modeling and modification of lifestyles by family members. The familial approach to obesity prevention and control emphasizes the importance of providing healthy environments (Golan & Weizman, 2001). Family is the proximal environment

2 of children; the influence of the family is crucial to healthy child development, including healthy eating, sufficient exercise, and weight management (Sousa, 2009). The Family Systems Theory (FST) was derived from the General Systems Theory (Chibucos, Leite, & Weis, 2005). The FST involves two aspects of families: the elements comprising families and the processes existing within and between families (Chibucos et al., 2005). The FST provides a framework for examining the impact of a family system on children s health-related behaviors (Kitzman-Ulrich et al., 2010). According to the FST, family members function as a whole and have reciprocal influences. Because family members are closely interrelated, problems experienced by one family member affect all the members. The family s mutually influencing relationships may affect dietary habits and physical activity patterns among children (Berge, 2009). To guide this study, we modified the conceptual model developed by Berge (2009) based on the FST, which views the family as a system in which change in one part of the system is followed by reciprocal changes in other parts (Bowen, 1966). In the conceptual model, we have defined the family domain as consisting of the family background, family system (family structure, family functioning, and family interactions affecting the child), childcare arrangement, and child s routines. The relationships among the factors of the family system, childcare arrangement, and child s routines have not been studied, and how these factors affect overweight and obesity in KA preschool-age children has not been examined. The conceptual model in this study is presented in Figure 1 in the second manuscript.

3 B. Significance of the Study Racial and ethnic differences in risk factors for obesity begin in early childhood (Taveras, Gillman, Kleinman, Rich-Edwards, & Rifas-Shiman, 2010). The preschool years are a critical period for obesity prevention, because earlier adiposity rebound (AR), a point of maximal leanness or minimal BMI, is related to a higher risk of adult obesity. The earlier AR occurs, the greater the risk of adult obesity (Whitaker, Pepe, Wright, Seidel, & Dietz, 1998; Wofford, 2008). One study reported gender and racial/ethnic differences in AR: non-hispanic African-American children have an earlier AR than other ethnic groups such as non-hispanic Caucasian and Mexican-American, and girls in all racial and ethnic groups tended to experience AR earlier than boys (Boonpleng, Park, & Gallo, 2012). Obesity prevention should be implemented in early childhood because childhood obesity typically persists into adulthood (Gruber & Haldeman, 2009; Salsberry & Reagan, 2005). Children s dietary habits and physical activity patterns are also shaped within this period. Although the preschool period is important in this regard, few studies related to childhood obesity have focused on preschool-age children. Obesity prevention may be especially important to the health of Asian-Americans. Asian- Americans have a greater central adiposity, which may influence their greater susceptibility to chronic diseases (Wells, 2007). Therefore, although Asian-Americans have a lower prevalence of obesity compared to other ethnic groups, they are at higher risk of developing chronic diseases at the same BMI (Cho & Juon, 2006). Similar to other American children, the prevalence of obesity among Korean children also has been gradually increasing; 9.1% of preschool-age children were overweight and 9.6% were obese in 2010 (Korean Natonal Health and Nutrition Examination Survey [KNHANES],

4 2011). KAs are one of the most rapidly increasing minority populations in the U.S. ( Kim & Wolpin, 2008). In 2010, KA comprised the fifth largest subgroup among Asians, lived in the U.S. numbering more than 1.7 million (Barnes, Adams, & Powell-Griner, 2008; United Census Bureau, 2012). Most of them are concentrated in large cities such as Los Angeles (24%), New York (16%), Washington DC (7%), Chicago (5%), and San Francisco (5%) (Kim & Wolpin, 2008). Koreans place an especially strong emphasis on family and tend to maintain their traditional cultural values, customs, and language: eating Korean food, using Korean language media, and engaging in Korean organizations (Kim & Wolpin, 2008; Lee, 1995). A strong sense of family obligation continues to be reinforced for the children as they grow older (McAdoo, Martinez, & Hughes, 2005). These unique characteristics of KA family may influence family systems and development of children s lifestyle. Approximately 30% of KA adults in the U.S. were overweight or obese, and their obesity prevalence has increased with their acculturation to the U.S. (Barnes et al., 2008; Chen, Juon, & Lee, 2012; United Census Bureau, 2012). In spite of the increasing number of KAs and the increasing prevalence of obesity among Korean children and KA adults, there are no studies of how their family and childrearing patterns affect their children s weight. In addition, the voices of KA mothers regarding childrearing in the U.S. and child weight have not been heard. In summary, the increasing prevalence of childhood obesity is a major health problem, because it is related to poor health outcomes across the lifespans and it places a large economic burden on society. Previous studies have found that racial and ethnic disparities exist with regard to childhood obesity and have emphasized importance of obesity prevention during early childhood. In addition, family involvement is pivotal to reduce and prevent childhood obesity

5 among preschool-age children. However, most studies of childhood obesity have focused on school-age children, and little is known about preschool children or how family factors influence obesity during the preschool years. Moreover, despite the growing number of KAs and known obesity issues among KA adults, there are no studies of family factors and preschool children s obesity for KA families. KA families have unique characteristics influencing development of children s health and habits. Identifying the family factors that influence the obesity of KA preschool-age children will be useful in developing culturally relevant obesity prevention strategies. C. Purpose of the Study The long-term goal of the proposed research is to develop an intervention to prevent and decrease overweight and obesity among Korean-American (KA) preschool-age children. The primary purpose of the study was: (1) to explore characteristics of KA families and the prevalence of overweight and obesity among KA preschoolers, (2) to test a conceptual model based on the FST that reflects relationships between family factors and BMI z-scores among these children, and (3) to understand the clinical implications of family factors with regard to overweight and obese KA children. Little work has been done about KA family contexts regarding obesity among KA children. Therefore, two preliminary studies were conducted in preparation for addressing the primary study purpose. The first was undertaken to better understand the family context of KA in relation to childhood obesity. Focus group interviews were conducted: (1) to explore KA mothers challenges while raising their children in the U.S. and (2) to obtain KA mothers perspectives regarding childhood obesity among KA preschool-age children.

6 The second preliminary study was to provide evidence of construct reliability of the Family Nutrition Physical Activity (FNPA) instrument, a measure of child s routines, for use with KA families. Cognitive interviews were performed: (1) to develop a Korean language version of the FNPA instrument and (2) to confirm the appropriateness and comprehensibility of the translated FNPA in the KA context. D. Methods A qualitative descriptive study was conducted using three focus group interviews with a total of 15 KA mothers. Detailed information about the methods and findings of the focus group interviews is presented in Manuscript 1. Cognitive interviews were conducted to develop a Korean version of the FNPA instrument and to evaluate the cultural appropriateness, construct validity and the conceptual equivalence of the Korean and English versions of the FNPA for KAs. The FNPA was developed to assess family lifestyle factors, including the child s routines, that may contribute to childhood obesity (Ihmels, Welk, Eisenmann, & Nusser, 2009). The FNPA has never been translated into Korean or used for KA families. Therefore, the FNPA instrument was translated into Korean using a parallel blind technique (Behling & Law, 2000). The translation committee consisted of three bilingual members whose primary language is Korean and who had research experience in both Korea and the U.S. All the translation committee members had master s or doctoral degrees. Three translators independently prepared translations of the original English version into Korean. During translation, some FNPA questions were modified to reflect the KA family lifestyle while maintaining the core meaning of the questions. Subsequently, the three translators met to compare their versions and minor

7 inconsistencies were resolved to prepare a single draft version. The Korean version of the FNPA was finalized after modifying any inconsistent items. To determine comprehensibility and appropriateness, the think aloud method was used for cognitive interviews with 19 KA mothers. The principal investigator read all questionnaire items and asked how they interpreted the question. If a question was misinterpreted or confusing, the participant was asked for suggestions to improve the phrasing. FNPA questionnaire items were modified using participants suggestions to improve the items comprehension. For example, Item 20 (My child gets 9 hours of sleep a night) was modified to state "at least 9 hours of sleep. The revisions were discussed with the FNPA developer, and we agreed upon the changes to be made. We plan to write an article describing the adaptation of the instrument for KAs, including psychometric analyses using the larger survey sample. Finally, a cross-sectional study that included a survey and weight and height measurements was conducted with 104 KA mothers and their children. The methodological details of this study are presented in Manuscript 2.

8 II. Korean-American Mothers Perspectives on Child Rearing and Child Weight A. Introduction Childhood obesity is an important public health problem that is negatively associated with physical, psychological, and social well-being of children (Center for Disease Control and Prevention [CDC], 2012). Childhood obesity rates also are high among children of immigrant minority populations in the U.S., including Asian-Americans (26%) (Ike-Chinaka, 2013). The major modifiable factors contributing to childhood obesity are unhealthy dietary habits, insufficient physical activity, and sedentary behavior. All of these lifestyle factors are shaped within a family environment, especially for young children. These factors have the potential to be changed by means of parental modeling and modification of lifestyles by family members. Therefore, family contexts contributing to childhood obesity should be explored. The family is especially important for preschool-age children, yet few studies have focused on how the family affects diet, physical activity and sedentary behaviors for preschool- age children. Immigrants family structures and lifestyles differ from those of people who do not immigrate, and these differences may influence preschool-age children s health (Lee, Sobal, & Frongillo, 2000). Among Asian-Americans, childood obesity rates vary by country of origin and processes of assimilation for that group (Jain et al., 2012). The few studies that have been conducted regarding different Asian groups identified cultural factors that may affect the child s obesity. For example, in Chinese families, overfeeding children is considered a way parents show their love, and the dominant parent s unhealthy lifestyle contributes to the child s weight (Wong, 2011). In another study, Vietnamese mothers reported that they are more concerned about their children s underweight than overweight (McGarvey et al., 2006).

9 There are more than 1.7 million KAs now living in the U.S., mostly in large cities such as Los Angeles, New York, and Chicago (Kim & Wolpin, 2008; United Census Bureau, 2012). Most KAs have come to the U.S. relatively recently, within the last 50 years, after the U.S. government eased restrictions on Asian immigration in the late 1960 s. KAs place an especially strong emphasis on family and tend to maintain their traditional cultural values, and customs: eating Korean food, using Korean language media, and being active in Korean organizations in the U.S. (Kim & Wolpin, 2008; Lee, 1995). Family is treated as an extension of the self and emphasizes children s obedience to parents (Kim & Wolpin, 2008). A strong sense of family obligation continues to be reinforced to the children as they grow older (McAdoo et al., 2005). Moreover, Korean parents place high importance on providing their children with a good education; educational success becomes a serious family concern (Sohng & Song, 2004). One study reported that authoritarian control and subsequent poor communication between parents and children are sources of conflict in the KA families (Sohng & Song, 2004). These characteristics of KA family may influence childhood obesity. Although KAs are one of the most rapidly growing minority populations in the U.S., there are no studies investigating the relationship of family and childrearing patterns to children s weight (Jang & Chiriboga, 2010; Kim & Wolpin, 2008). In both Korea and among KAs, the primary caregiver of young children is almost always the mother. Responsibility for care taking is in their domain and they are well informed about their families and children (Sosa, 2012). Therefore mothers are a good source of information about their families, yet their perspectives are rarely brought into the discussion of child rearing and child weight. Moreover, mothers perspectives on children s obesity can provide information to help develop culturally

10 appropriate childhood obesity prevention. However, little is known about KA families and KA preschool-age children s obesity. The purpose of this study was to explore KA mothers challenges while raising their children in the U.S. and to obtain KA mothers perspectives regarding obesity among KA preschool-age children. B. Methods 1. Approach The goal of qualitative descriptive research is to provide a comprehensive summary of a particular group or situation about which little is currently known (Sandelowski, 2000). Therefore, a qualitative descriptive study was selected to provide a detailed description of the phenomenon of childrearing within KA families in the U.S. from the perspectives of KA mothers. A focus group interview is a group interview that involves listening to people and learning from them (Morgan, 1998). Focus groups are small groups that are homogeneous in regard to the topic of inquiry. One strength of the focus group interview is that it allows participants to respond to others perspectives and is an excellent way to elicit shared group norms as well as variations (Herman, Malhotra, Wright, Fisher, & Whitaker, 2012). Few studies explicitly focused on living experiences and challenges of KA mothers bringing up their preschool-age children in the U.S. Therefore, focus group interviews were conducted for this initial exploration of mothers concerns and opinions about their children rearing and children s obesity.

11 2. Sample and Setting Three focus group interviews with a total of 15 KA mothers were conducted between March to May 2013 in the Chicago metropolitan area. Interview participants were recruited with the assistance of the director of one preschool and the pastors of two KA churches. The inclusion criteria for the participants were as follows: (1) mothers who self-identify as KA, (2) KA mothers who have lived in the U.S. at least 5 years, and (3) KA mothers who live with their 2 to 5 year old child. The interviews were held in private rooms at the research sites to maintain participant confidentiality and avoid disturbances. 3. Procedures The University of Illinois at Chicago Institutional Review Board approved this study. We contacted the director of each organization. The directors and pastors made announcements about our study to potential participants at meetings. Once participants showed their interest in the study and provided their contact information, we contacted them individually to establish eligibility, explain the study and set the interview date. Prior to each focus group discussion, the interviewer explained the purpose and procedures of the interview, assured the participants that the discussion would be kept confidential by the interviewer and research team, and asked the participants not to talk about the discussion with others. We then obtained their signed informed consent. The principal investigator (PI) led the interviews, and a research assistant took comprehensive notes of the discussions as they proceeded. All the discussions were audiorecorded and transcribed verbatim. The interviews were conducted in Korean and lasted 60 to 120 minutes. Immediately after each focus group interview, all the participants completed a

12 background questionnaire, including age, level of highest education, and household income. All the participants received a gift card for their time and effort. A focus group interview guide was developed and followed for the interviews to identify (1) major challenges of KA mothers with regard to raising their children in the U.S., (2) perspectives of KA mothers regarding obesity among KA children, (3) the dietary habits of KA children, (4) physical activity patterns among KA children, and (5) KA family physical activities. Table 1 summarizes the focus group questions used to guide the focus group interviews. 4. Data Analysis Descriptive analysis was performed using SPSS version 20 to examine demographic characteristics of KA mothers. Qualitative content analysis, which is a dynamic form of verbal data analysis, was performed (Sandelowski, 2000). The Korean interviews were transcribed (written by the research assistant) and the PI s written transcripts based on the audio-tapes were compared for completeness and accuracy. The PI then translated Korean transcripts into English. Early coding was conducted and the final codes were identified in collaboration with two coauthors who are qualitative research experts (Norr & Patil). Codes similar in meaning were merged and then labeled as a category. Finally, primary interview themes were described and relationships between codes were found. Three major interrelated interview themes were identified. C. Results Demographic characteristics of participants are presented in Table 2. All but one of the mothers was born in Korea, all mothers were married, and lived with their husband. The mean age of the mothers was 38.53 years (range 31 to 44), and mothers had lived in the U.S. for an

13 average of 18 years (range 8 to 34). Most of them were working (73%) outside their homes, 40% had at least a master s degree, and 40% had a family household income of more than $75,000 per year. In the focus groups, KA mothers shared their challenges and experiences of raising their children in the U.S. Three themes emerged from the focus group interview discussions: (1) retaining Korean culture in the U.S.; (2) fulfilling the Korean mother s role without the supports they felt they would have in Korea; and (3) perceptions about the child s body and efforts to maintain their child s health. As depicted in Figure 1, all themes were interconnected and reflected the influences of KA culture in the American environment on child health. 1. Trying to Retain Korean Culture in the U.S. KA mothers made efforts to retain Korean culture when they are raising their children in the U.S. KA mothers pointed out that they emphasize strong relationships between family members. To maintain close relationships among family members, they intentionally engage in many activities together, including going to church together, grocery shopping, and participating together in outdoor activities. One mother said: During the weekend, there is also not enough time because children spend most of their time in Korean language school and the Catholic church and they go to piano lessons. I take my children to the park if the weather is nice, or we go to watch soccer games during soccer season. Despite their efforts to maintain family ties, mothers expressed concern about cultural gaps between their children and themselves. Mothers feel they cannot fully understand their children, because they did not grow up in the U.S.; as their children are getting older, the gaps between them are getting bigger. One mother said: Sometimes when I talk with my children, I do not understand them at all. My older child used the word grounded, and I did not know what it meant. Although I have studied

14 and lived here, I only know the dictionary meaning of words. Since I did not grow up here, there are many things that I cannot understand. My children are getting older, and the gaps between us are getting wider. Moreover, KA mothers experienced conflicts between the traditional Korean value of respect for elders and what they perceive as overindulgence by grandparents. They disagree with their children s grandparents regarding parenting styles. Grandparents do not limit their children s behaviors and provide some unhealthy food (e.g., soda or snacks). Although KA mothers disagree with these indulgences, they try not to argue with grandparents to maintain the cultural value of respect for elders. Mothers said: My father stays at home since his retirement, and my preschooler knows that her grandfather will turn on the TV for her. When she comes home, she grabs her grandfather s hand and then takes him upstairs to ask him to turn on the TV. If my children see that I have a conflict with their grandparents, they will see it as a kind of disrespect for older people. It is a kind of conflict between educating children and respecting older people. Family meals and foods are another aspect of traditional culture mothers try to maintain. Most mothers pointed out that they prefer to eat homemade Korean food because they believe it is healthier than American food. Therefore, they try to make sure that their children eat homemade Korean food (e.g., Kimchi, steamed rice, and hot soup) at home. One mother said: I try to feed my children more Korean food at home because they eat more American food as they get older. 2. Fulfilling the Korean Mother s Role Without Usual Social Supports These KA mothers said they are struggling to meet the high expectations of the mother s role in Korean culture without the usual supports they would have in Korea. All KA mothers had high cultural expectations of mother involvement in early child rearing. In Asian culture, it is considered that child s growth and development, and even academic achievement are decided by

15 mother s dedication and efforts. Therefore, KA mothers stated that they felt strongly that they must take care of all of their children s needs. Mothers said: Compared to Korea, children living here spend more time with their mothers. Although mothers are working, they stay with their children except during their working hours. Children learn lots of things from their mothers. They can also learn bad things from their mother. There are few opportunities for children to be exposed to other things, so children learn a lot from their mothers. I think Americans raise their children to be independent from the time that they are young. Americans let their children eat and sleep by themselves. However, Koreans help their children to eat, and it becomes a habit; therefore, one of my children lacks independence even though she is 4 years old. I think Asians have such habits. Still, I feed my child by following her around, and we sleep together until my child falls asleep. The strains of trying to fulfill the Korean mother role in an environment that does not share this perspective on mothering and lacks support for it leads KA mothers to feel highly stressed and guilty about their performance as mothers. One mother said: In my case, I did not cook in Korea. Then I started to cook here. I try to find one or two things that I can cook, and I feel that I have a limitation. I never learned how to cook and lack information, as I do not know what I have to cook. It takes time and effort to buy food and make it. I wish there was someone like my mother who could help me. In Korea, mothers can utilize their social support network such as relatives when they need help. In addition, there are various types of local restaurants and delivered foods available, which may reduce mother s cooking responsibilities. Children can easily engage in physical activities by walking and using public transportations. However, in the U.S., KA mothers feel they have to take the responsibilities for raising their child without such supports. Available childcare arrangements are limited because their families, including children s grandparents live in Korea. Most delivery foods available in the U.S. are unhealthy, and eating at local restaurants is inconvenient because of long distances (they have to drive to get there). Moreover, there is no place to go outdoors unless the mother drives her children. In other words, mothers wish to have more resources, which could help them when they raise their children. As one mother put it,

16 I do not have much time, so my family tries to do things together. My children come home after preschool, eat dinner, and take a bath, and then it is around 8 p.m. The schedule is too tight, so we try to spend time together as much as possible. That is why Korean mothers eat and sleep with their children when they are young. We feel sorry for our children. This situation is especially difficult for KA mothers who are working outside the home. They pointed out that they feel highly stressed and guilty about having too little time to spend with their children. Mothers said: I am a working mother, so cooking is the most problematic thing for me. I cannot make food properly, so I just feed my children anything. 3. Perceptions About the Child s Body and Efforts to Maintain the Child s Health KA mothers felt that children should look plump or chubby by the time that they are 3 years old and mothers are responsible for ensuring this. They felt that a chubby or plump toddler is healthier than a skinny child, and mothers are more concerned about their child s well-being and development rather than overweight or obesity. Most KA mothers said that they have not seen or heard about childhood obesity among KA children. KA mothers stated that they did not worry about obesity among KA children, because they consciously work to provide healthy food and encourage their children to participate in physical activities. Mothers said: I prefer to see children who are plump like a Michelin tire because my two children did not get plump. I heard that children, who are plump when they are young, become tall when they get older, so I envy them. If I fed my children at McDonald s or KFC, I would have to worry about their becoming obese. However, since I feed my children healthy food such as meat and vegetables, I think they will be fine. KA mothers think that a mother is largely responsible for her child s health. Therefore, KA mothers try to shape healthy habits for their children by providing healthy food, encouraging them to have adequate sleep time, and limiting screen time. Mothers think that they are primarily

17 responsible for feeding their children and try to make sure that their children eat well. Therefore, mothers put the highest priority on shaping their children s healthy dietary habits. Mothers try to cook homemade Korean food and when they eat outside the home, they try to go to Korean restaurants. Furthermore, many of the KA mothers interviewed stated that they mostly eat meals at home, because they believe eating at restaurants is unhealthy, expensive, and takes time. Some mothers pointed out that sometimes they struggle to provide homemade Korean food, because they have less cooking experience or skills with such foods or do not have the time to cook these meals. In addition, mothers reported that even though eating vegetables is important and necessary, cooking meat is easier and it keeps longer. So they tend to have more meat-based rather than vegetable-based meals. One mother said: In my case, although I buy vegetables there is no time to cook it. Then few days later I throw the rotten vegetables away. So I rarely buy them. Meat does not easily decay and is easy to eat, so we eat it often. All mothers pointed out they work hard to keep unhealthy foods out of their children s diet (e.g., snacks and soda). However, they noted that once children are exposed to these tastes, children request these foods at home and it is hard to control. While mothers do define promoting healthy eating as an important part of their job as mothers, they also noted that the health of family members influences how much concern they have. For example, if a grandparent has been diagnosed with a chronic disease such as diabetes or cancer, then they are much stricter about their children s diet. In other words, feeding styles are affected by family health history. Moreover, mothers mentioned that children s eating habits are affected by what those around them are eating (e.g., parents and siblings). Therefore, KA parents try to model healthy eating behaviors and avoid eating what they define as unhealthy foods, including snacks, soda, and premade foods in front of their children. Mothers said:

18 Although mothers are strict about food and feed their children well at home, once children go to school and experience new tastes such as sweet and salty foods, then they become addicted to those tastes. Even though I try not to feed my children such foods, after they started to eat them at school, then they wanted to eat them at home. Since I started to eat snacks, my children also eat more snacks. My children do not ask to have snacks, but I think they are affected by snacking. Therefore, we should be careful to set a good example. Mothers said that setting limits on their children s screen time (e.g., watching TV and playing computer games) is harder than controlling their diet and physical activity. They mentioned that most KA families do not place televisions in their children s rooms. KA parents try to implement screen time rules and the imposed limitation often creates tensions between parents and children. For example, mothers noted that they try to limit television watching or computer games to weekends. But even then, they try to limit the total amount of time spent watching TV and using the computer. One mother said: We do not allow our children to watch TV on weekdays, but we allow them to watch it during the weekend. Once I allow my children to watch TV, they want to watch it without limitation, so it is hard to control. In addition, KA mothers expressed concerns about their child s sleep. They think that children should have adequate sleep time for their growth and development. While KA parents want their children go to bed early in the evening, the children want to go to sleep late at night. Some mothers said that they sleep with their children until they fall asleep, and this makes mothers tired. Despite high attention to diet, sleep, and screen time, mothers voiced less concerned about their children s physical activities. Mothers described that they encourage physical activity in their children by registering children in formal sports programs, but that they themselves rarely participated in family outdoor physical activity and do not see physical activity as entirely their responsibility. They noted that fathers take charge of outdoor physical activity. Therefore,

19 children s outdoor physical activity is primarily determined by what the father does. For example, if a father likes to go outside, he takes his children with him for outdoor activities. As one mother explained: Whether or not children play outdoors is determined by characteristics of their fathers. If a child s father came to the U.S. when he was young or was born in the U.S., or likes sports, he goes out and plays with his children. However, as typical Koreans, we [mothers] are not used to doing physical activity, and we do not have an interest in sports. D. Discussion The purpose of this study was to identify KA mothers experiences and challenges while raising their children in the U.S., and to explore their perspectives regarding obesity among KA preschool-age children. Previous research has shown that KAs tend to maintain their traditional cultural values (Kim & Wolpin, 2008; Lee, 1995). Consistent with previous studies, KA mothers in this study made strong efforts to keep Korean cultural identities. Retaining Korean culture is the overarching theme in these KA mothers perspectives and behaviors with respect to child rearing. For example, they emphasized building strong family relationships and they intentionally engaged in family activities together to do so. These strong efforts mothers make to retain Korean culture may reflect the fact that almost all mothers in this study were born in Korea. These finding are congruent with the previous work describing KAs as accepting social order based on hierarchies of age and social status to maintain harmony, which is highly valued philosophy in Confucian cultures (Moon, 2012). However, maintaining Korean culture in the U.S., such as respecting elders and providing homemade Korean foods to their children, sometimes lead to conflicts and increased levels of stress for these mothers. In this study, KA mothers said they try not to argue with children s grandparents to maintain the cultural value of respect for elders. This tension between

20 grandparents and mothers regarding grandparents indulgence also has been identified in Chinese and Hispanic families (Herman et al., 2012; Lindsay, Sussner, Greaney, & Peterson, 2011). KA mothers expressed concern about cultural and language gaps between their children and themselves. While KA mothers tend to maintain Korean cultural identities, their children very quickly become Americanized, so that KA mothers felt they couldn t keep up with them (Zhou, 1997). In a previous study, poor communication between KA parents and children was found to result in conflict among family members (Sohng & Song, 2004). Korean immigrant mothers, whether they work outside home or not, are highly responsible for household work and raising their children (Hong & Hong, 1996). KA mothers in this study tried to meet these high expectations role. However, mothers struggled to fulfill these roles without available support resources such as a relative s childcare support. Moreover, time constraints made working mothers experience more stresses so that they sometimes indulged their children to compensate for their guilt (e.g., by allowing snacking). One study reported that lack of English fluency and lack of the usual support network available in their homeland made the task of good motherhood hard to achieve for Southeast Asian immigrant mothers (Liamputtong, 2006). KA mothers think that their child s weight and health reflect the mother s care for their child. This is consistent with previous studies with Latina mothers. The child s weight status reflects parenting skills; therefore a skinny child is seen as a sign of bad parenting and poor health (Lindsay et al., 2011). KA mothers prefer a chubby child, because they believe that chubbiness represents healthy development. This preferences for plumpness are also found among other ethnic/racial groups such as Vietnamese and Hispanics (McGarvey et al., 2006; Wong, 2011). Preferences for chubby children may lead to underestimation of their children s

21 actual weight, and this could increase the prevalence of overweight and obesity among KA children. One study of mothers from China and Korea reported that if mothers experienced food insecurity, they evaluated their child as weighing less than ideal (Van Hook & Cheah, 2012). KA mothers believed that they shaped their children s healthy environments by providing healthy foods, limiting screen time, and encouraging adequate sleep. Therefore, they felt they did not need to be concerned about obesity among KA preschool-age children. In this study, even though the majority of KA mothers are currently working outside the home, KA fathers take responsibility only for children s physical activities. This indicates that an imbalance of parents roles in child rearing still exists, reflecting gender inequalities. One study reported that KA mother s heavy burden and the lack of role sharing might negatively impact family functioning (Kim & Grant, 1997). E. Limitations This study has several limitations. A relatively small number of KA mothers, all living in one metropolitan area, participated in this study. In addition, nearly all were born in Korea, so the findings in this study may not represent KA mothers who were born and raised in the U.S. Participants also were predominately middle-class, with high education and adequate income, and living with their husbands in a two-parent household. Experiences and challenges of mothers who are second or third generation, single mothers or with low education and/or income might be different. Moreover, it should be noted that these mothers may have a tendency to idealize life in Korea and may not have a realistic understanding of the supports they would have for rearing children there.

22 F. Implications Emerging themes from this study have implications for developing effective future intervention programs. Further studies should explore how KA mothers utilize their social network when they raise their children and what types of supports they may need. Introducing new supports and utilizing available support through social networks such as KA churches or community organizations should help to reduce the excessive responsibilities of mothers, which lead to high stress and guilt. This high stress and guilt can lead mothers to engage in behaviors that do not promote health to save time and/or to make up for their lack of time with their children, such as using fast foods and giving unhealthy snacks. Providing opportunities such as support groups can help KA mothers share their challenges and obtain advice about raising their children from each other that will be beneficial. Future studies should be conducted with more diverse groups, including second and third generation KAs, and should include the father s perspectives. Families who recently immigrated from Korea may have different and greater challenges such as struggling to settle down to the new environment and not enough time to take care of their children. Therefore, understanding new immigrant families experiences is an important first step to develop supportive programs. In addition, culturally appropriate approaches are needed to help KA mothers realize that plump is not optimal for children and to increase awareness of the value of physical activity. Furthermore, awareness of cultural differences among family members (mothers and children) may be helpful when providing obesity control and prevention programs.

TABLE I FOCUS GROUP INTERVIEW QUESTIONS Can you tell me about your experiences in bringing up your children in the U.S.? Are there any things that are different in bringing up a preschool child in the U.S.? Do you think childhood overweight and obesity is a problem in the Korean-American community? Why? Why not? Is overweight a problem for preschool children? Why? Why not? Tell me what preschool children eat. Tell me what kinds of activities preschool children do. What about physical activities like walking and playing outdoors for preschoolers?

24 TABLE II CHARACTERISTICS OF PARTICIPATED KOREAN-AMERICAN MOTHERS (N=15) Mean (SD) N (%) Age (years) 38.53 (4.19) Born in Korea 14 (93.3) Living with husband 15 (100) Years lived in the U.S. 17.57 (8.67) Education level Bachelor or less Master or higher 9 (60.0) 6 (40.0) Employment Working Homemaker 11(73.3) 4 (26.7) Household income $20,000-74,999 $75,000 or more 9 (60.0) 6 (40.0)

25 FIGURE I KOREAN-AMERICAN MOTHERS CHALLENGES RASING CHILDREN IN THE UNITED STATES

III. Family Influences and Healthy Weight for Korean-American Preschool Children A. Introduction The increasing prevalence of childhood obesity is a major health concern in the U.S. and globally. The number of obese children in the U.S. more than tripled during the last three decades, rising from 5% to 17% (Ogden et al., 2010). Childhood obesity in the U.S. is responsible for $14.1 billion in annual medical costs for drug prescriptions, emergency room visits, and outpatient visits (Trasande & Chatterjee, 2009). In addition to the economic burden associated with obesity, it has both immediate and long-term negative effects on the physical and psychological health and quality of life of children. It is significantly related to development of type 2 diabetes, cardiovascular disease, and other chronic illnesses (Berenson & Heart, 2012; Crawford, Story, Wang, Ritchie, & Sabry, 2001; Daniels, 2006). In addition, obese children are stigmatized due to negative attitudes toward obesity and thus have lower levels of self-esteem and higher depression rates than non-obese children (Schwartz & Puhl, 2003; Sheslow, Hassink, Wallace, & DeLancey, 1993). These health problems may persist not only throughout childhood but also into adulthood (McCurdy et al., 2010; Wofford, 2008). Because overweight is more common than obesity and is a risk factor for becoming obese, these two groups are often combined. In this study, we used the term overweight to include overweight and obesity. There are racial/ethnic disparities in the prevalence of childhood overweight and obesity. Hispanic and non-hispanic African-American children are at a higher risk of becoming overweight and obese than other racial/ethnic groups in the U.S. (Fox & Kumanyika, 2008). Moreover, obesity among children has begun increasing in other industrialized countries. In

27 Korea, the prevalence of obesity among children has been gradually increasing in recent decades; 9.1% of preschool children were overweight and 9.6% were obese in 2010 (Korean Natonal Health and Nutrition Examination Survey [KNHANES], 2011). Asian-Americans have a lower prevalence of overweight and obesity than other racial/ethnic groups (World Health Organization [WHO] Expert Consultation, 2004) However, chronic diseases in Asian-Americans may develop at lower BMI than in other racial/ethnic groups because of Asian-Americans greater tendency toward abdominal obesity (Taveras, Gillman, Kleinman, Rich-Edwards, & Rifas-Shiman, 2010; WHO Expert Consultation, 2004). In addition, the risk of overweight and obesity among Asian- Americans increases with their time in the U.S. (Unger, Reynolds, Shakib, Spruijt-Metz, Sun, & Johnson, 2004). The number of Asians increased faster than that of any other racial group in the U.S. between 2000 and 2010 (United Census Bureau, 2012). Approximately 1.7 million KAs live in the U.S., and they are the fifth-largest subgroup among Asian-Americans (United States Census Bureau, 2013). Almost one in three KAs do not have health insurance, and approximately 30% of KA adults in the U.S. are overweight or obese (Asian and Pacific Islander American Health Forum, 2012; Barnes et al., 2008). Korean families tend to maintain Confucian values with respect to child-rearing practices and family interactions (Farver & Lee-Shin, 2000; Lee et al., 2000). These unique characteristics of KA families may influence the prevalence of childhood overweight and obesity. Understanding overweight and obesity issues among KA children is important to develop effective and culturally appropriate obesity interventions. However, the familial factors that are linked to early childhood overweight and obesity among KAs have not been studied.

28 The preschool years are a critical period for obesity prevention and control. During this period, children experience adiposity rebound (AR), which means that their body fat is at its lowest level in their entire life. Previous studies have shown that the earlier AR occurs, the greater the risk of adult obesity (Whitaker et al., 1998; Wofford, 2008). In one study, AR was found to vary according to racial/ethnic and gender differences at an early age: non-hispanic African-American children have a earlier AR than children of other ethnic groups such as non- Hispanic Caucasians and Mexican-Americans, and girls in all racial and ethnic groups tend to experience AR earlier than boys (Boonpleng et al., 2012). Moreover, children s dietary habits and physical activity patterns are shaped during the preschool period, and persist into adulthood (Gruber & Haldeman, 2009; Salsberry & Reagan, 2005). 1. Family Influences on Childhood Overweight and Obesity The family plays a pivotal role in shaping lifestyles related to childhood obesity, especially for preschool-age children. Modifiable factors contributing to obesity include excessive calorie intake, lack of physical activity, and increased sedentary behavior. Increased high-fat and sugar-containing food consumption leads to higher BMI in children (Skelton et al., 2011). Decreased physical activities and increased screen time are associated with a higher risk of being obese (Vos & Welsh, 2010). In a multilevel analysis, Boonpleng and her colleagues (2012) found that variation in childhood obesity was mostly explained at the family level (71%), followed by the school level (27%) and community level (2%). Identification of obesity risk factors within a shared family environment is necessary to provide successful intervention for obese preschool-age children (Kitzman-Ulrich et al., 2010). In addition, participation of family members in childhood obesity intervention leads to better outcomes than efforts focused on children alone (Spruijt-Metz, 2011).

29 Family factors have been found to be significantly associated with childhood obesity in previous studies. Children are more likely to be obese if they have working mothers, if they live with single parents, if the mother s educational level is low, if they have a low family income, or if they are cared for in informal care (e.g., by relatives and babysitters) (Chen & Escarce, 2010; Gibson, Byrne, Davis, Blair, & et al., 2007; Huffman, Kanikireddy, & Patel, 2010; Kang et al., 2006; Maher, Li, Carter, & Johnson, 2008; Patrick & Nicklas, 2005; Pearce et al., 2010) Acculturation is related to ethnic, racial, and cultural identity, and the degree of acculturation also may contribute to racial and ethnic disparities regarding childhood obesity (Peña, Dixon, & Taveras, 2012). However, prior research results are inconsistent with respect to the association of acculturation with childhood obesity. Family functioning is another aspect of the family environment that is related to childhood obesity (Kitzman-Ulrich et al., 2010). However, the relationships identified between family functioning and childhood obesity have been inconsistent. Some studies have found that family dysfunction is associated with greater BMI of children (Kennedy & Chen, 2004; Moens, Braet, & Soetens, 2007; Sousa, 2009). In contrast, Gibson and his colleagues (2007) did not find a significant relationship between childhood obesity and poor family functioning. Parental feeding style refers to parents approach to feeding their children, and it affects children s eating styles and weight outcomes (Johnson & Birch, 1994; Patrick, Nicklas, Hughes, & Morales, 2005). Prompting children to eat, use of rewards, and restricting access to food tend to result in intake of more food than is healthful for children (Rhee, 2008). Parents of overweight children monitor and restrict their food consumption more than parents of children who are not overweight (Moens et al., 2007). Furthermore, it has been reported that parental encouragement

30 of the choice of healthful foods through role modeling is important to establishing healthful dietary patterns for children (Tibbs et al., 2001). Previous studies have suggested that healthy child s routines are key factors in preventing childhood obesity (Slusser et al., 2012). Anderson and Whitaker (2010) analyzed a nationally representative sample of preschool-age children and found that children who had dinner with their families, had adequate nighttime sleep, and had limited television viewing time exhibited a lower prevalence of obesity. The family factors that contribute to KA childhood obesity may be different from other families because of their unique cultural attitudes and lifestyles with regard to obesity. The family systems approach provides a comprehensive perspective on families with regard to childhood obesity that can be adapted for examining KA families. According to Family Systems Theory (FST), family members function as a whole and have reciprocal influences (Chibucos et al., 2005). Therefore, the FST was chosen as the framework for this study. Recent childhood obesity research has adapted the FST to focus on the specific issue of obesity. Berge (2009) has proposed a conceptual model of family domains that correlate with child and adolescent obesity and weight-related outcomes, and this conceptual model was modified for use in this study (Berge, 2009). Factors within the family domains, including the parental, family functioning, and sibling domains, have been found to exhibit significant associations with child and adolescent obesity (Lee, 1995). Because the child s routines and the childcare arrangement may directly impact obesity in KA preschool-age children, these two factors were added to the conceptual model for this study. In addition, family background factors that have been associated with childhood obesity were included in the conceptual model. With the inclusion of the child s routines, the childcare

31 arrangement, and family background factors, the conceptual model can be used to comprehensively explore childhood obesity among KA preschool-age children. In the conceptual model, we have defined the family domain as consisting of family background, family system (family structure, family functioning, and family interactions affecting the child), childcare arrangement, and child s routines. While siblings also may be important with regard to childhood obesity, including them was beyond the scope of this study (see Figure 1). Childhood obesity is a growing health problem among all ethnic groups, but there have been few studies of preschool-age children and none of obesity among KA preschool-age children. This study focused on the family factors that related to obesity among KA preschoolage children. The purpose of this study was to identify the association between characteristics of KA families and the prevalence of obesity among KA preschoolers, and to test a conceptual model based on the FST that reflects relationships between family factors and BMI z-scores (overweight/obese status) among these children. B. Methods 1. Sample and Setting This study was conducted from May through August 2013 in the Chicago metropolitan area. A total of 104 KA mothers and their preschool-age children participated. Mothers had to meet the following inclusion criteria: (a) had lived in the U.S. for at least 5 years, (b) selfidentified as KA, and (c) lived with their preschool-age children. The mean age of the preschoolage children was about 47 months, and 60% were boys. The mothers mean age was 37.3 years, and their ages ranged from 29 to 49 years.

32 2. Procedures Study approval was obtained from the Institutional Review Board of the University of Illinois at Chicago. We contacted the directors of preschools and KA churches, and they then announced the study to potential study participants. The principal investigator (PI) and two research assistants visited each research site. The PI checked the eligibility of each KA mother participant, explained the study s purpose and procedures, and obtained informed consent from the mothers and verbal assent from their preschool-age children. Children's weights and heights were measured three times each to reduce measurement error, and the means were used in data analysis. During these measurements, the KA mothers were present to reassure their children, and a screen was used to protect children s privacy and to increase their cooperation. No children refused to allow us to measure their weights and heights. Subsequently, the KA mothers completed self-administered survey questionnaires. The questionnaires were prepared in both Korean and English versions so that participants could select their preferred language; 60 of the 104 mothers chose to complete the Korean version. Questionnaire completion took approximately 20 to 40 minutes. After the measurements and survey were completed, each KA mother received a gift card and each child received a small gift for their time and effort. 3. Measures The concepts and operational measures used in this study and their reliability and validity are summarized in Table 1. Family background factors consisted of parental employment status, level of parental education, household income, length of stay in the U.S., whether mothers are first-, second-, or third-generation immigrants to the U.S., and level of acculturation. The Vancouver Index of Acculturation (VIA) was used to measure the level of acculturation of KA mothers. The VIA is self-administered and assesses two dimensions of

33 acculturation, identification with the culture of origin and identification with American culture, including adherence to traditions, social interactions, and values (Ryder, Alden, & Paulhus, 2000). The level of measurement is an interval scale with a 9-point Likert scale ranging from 1 (strongly disagree) to 9 (strongly agree). The total scores for each subscale range from 10 to 90. The concurrent validity of the VIA was confirmed in a previous study (Ryder et al., 2000). The reliability of the VIA was established in prior studies and continued to be high in this study (Choi, Miller, & Wilbur, 2009). Family system factors included family structure, family functioning and family interactions affecting the child. Family structure factors included status as a single-parent or dual-parent family, generational composition (two-generation or three-generation), and total number of children in the household. Family functioning was assessed using the Family Assessment Device (FAD), which included seven dimensions that distinguished between healthy and unhealthy families (Epstein, Baldwin, & Bishop, 1983). The concurrent validity of the FAD was confirmed in previous studies (Aarons, McDonald, Connelly, & Newton, 2007; Epstein et al., 1983; Miller, Epstein, Bishop, & Keitner, 1985). The FAD was modified and translated into Korean; items were deleted that showed low correlation and were culturally difficult to understand (Chung, 1993). The modified Korean version of the FAD consisted of 34 items across the same seven dimensions. Higher scores indicate fewer family problems and better family functioning. In our study, the internal consistency coefficients of the FAD ranged from 0.66 to 0.87. Family interactions affecting the child included parental feeding style and parental role modeling of healthy behaviors. The Child Feeding Questionnaire (CFQ) was used to measure parental feeding style. The CFQ is a self-reporting instrument used to assess parental beliefs,

34 attitudes, and practices regarding child feeding, with a focus on obesity proneness in children (Birch et al., 2001). The construct validity of the CFQ was confirmed using confirmatory factor analysis, which confirmed that the seven-factor model fit the data well (Birch et al., 2001). The reliability of the CFQ has been established in prior studies (Birch et al., 2001; Van Hook & Cheah, 2012). The internal consistency coefficients of the Korean version of the CFQ used in this study ranged from 0.56 to 0.92. Despite the conceptual importance of healthy parental modeling, there are no established measures of this factor. Therefore, we developed healthy parental modeling index from national surveillance data such as National Health and Nutrition Examination Survey (NHANES) to assess lifestyle patterns, including dietary, physical activity, drinking, and smoking habits. Mothers were asked about their own habits as well as their husbands habits. The healthy parental modeling questions about two types of dietary habits (fruits/vegetables and salty snacks consumption) used a 4-point Likert scale (1 = less than once a day and 4 = 5 or more per day). One example of these questions is How often do you eat fruits or vegetables at home? Physical activity items also used a 4-point Likert scale (1 = Less than once a week and 4= 5 or more per week). The questions about drinking and smoking asked about habits both at home and outside the home. One example of smoking question is How many cigarettes per day do you usually smoke at your home? The frequency of drinking was asked using a question How often did you drink any type of alcoholic beverage? Summary scores for healthy parental modeling were dichotomized as indicating healthy and unhealthy modeling. Parents were considered to be doing healthy modeling if they ate vegetables/fruits at least three times per day, ate snacks less than two times a day, exercised more than three times per week, did not smoke, and did not drink alcohol.

35 The child s routines were measured using the Family Nutrition and Physical Activity (FNPA). The FNPA was developed to assess family lifestyles, including the child s routines, which may contribute to childhood obesity (Ihmels et al., 2009). The FNPA contains 20 items and uses a 4-point Likert scale (1=almost never, 2=sometimes, 3=usually, and 4=almost always); possible scores range from 20 to 80. A higher score on the FNPA implies a healthier family lifestyle. The FNPA s construct validity and predictive validity were supported in a longitudinal study (Ihmels et al., 2009). The reliability of the FNPA has been established, with a Cronbach s alpha = 0.72 (Ihmels et al., 2009). The FNPA had never been translated into Korean or used for KA families. Therefore, we translated this instrument and conducted cognitive interviews with KA mothers to confirm the appropriateness and comprehensibility of the translated FNPA in the KA context. Only minor changes were needed. The internal consistency coefficient of the Korean version of the FNPA used in this study was 0.80. Childcare arrangements included types of regular childcare arrangements and the hours of non-parental care per week. Because some children had more than one type of childcare, mothers were asked whether their child had each of four types of care (yes/no), including formal care (preschool or daycare), relative care, informal daycare by a non-relative, and parental care only, creating 5 partially overlapping dichotomous variables. Trained nurse research assistants measured children s body weight to the nearest 0.1 lb. using a portable digital weight scale (Lifesource MD, Milpitas). During weight measurements, children were dressed in light clothing and were not wearing shoes. Children s height was measured to the nearest 0.1 cm. using a portable stadiometer (Seca Stadiometer, Seca Ltd, Birmingham, UK). Ages in years and months of preschoolers were recorded to calculate BMIfor-age values. BMI was calculated as weight in kilograms divided by the square of height in

36 meters. BMI values were transformed into age- and sex-specific BMI z-scores and percentiles using 2000 CDC growth chart data (CDC, 2012). Child s overweight and obesity was defined as BMI-for-age equal to or greater than 85th percentile. In this study, normal weight children refer to children who are underweight (BMI < 5 th percentile) and normal weight (5 th percentile BMI < 85 th percentile). Overweight indicates children who are overweight (85 th percentile BMI < 95 th percentile) and obese (BMI 95 th percentile). 4. Data Analysis Statistical analyses were performed using SPSS version 20.0 and STATA version 12.0 statistical software. Descriptive statistics (percentages, means, and standard deviations) were used to describe the family factors and prevalence of overweight among the KA preschool-age children. To compare characteristics of participants in between the normal weight and overweight child groups, independent t-test and chi-square test were utilized. When the dependent variable was not normally distributed, the Mann-Whitney U test was used. Fisher s exact test was applied when the expected frequency in any cell was less than five. To test our conceptual model, we used hierarchical multiple linear regression to test the effect of each factor on the child s BMI z-score. To estimate the final model, only factors with at least some relationship with BMI z-scores (p <.20) were entered, including perceived child weight, restriction, pressure to eat, monitoring, behavior control, and child s routines. The statistical significance was set at an alpha level of.05. We also examined factors associated with children who were overweight versus those who were not, a way of looking at weight that has more practical relevance. We used multiple logistic regression to examine family factors on overweight status among children with an a priori significance level of p value of <.05.

37 C. Results 1. Bivariate Relationships Between Family Factors and Child Overweight Table 2 shows characteristics of participating KA preschool children in this study. Among children, 22% of them were overweight or obese. Table 3 shows the family characteristics expected to affect preschool children s weight for the total sample and for the children who were overweight or obese compared to those who were not. The first set of factors was the family s background characteristics. Mothers were predominately born in Korea (95 %) and were living with their husbands (97%). The mean length of their stay in the U.S. was 15 years. Approximately 30% of mothers had at least a master s degree, more than half of them (56%) were working outside the home, and about 44% had a family household income of more than $75,000 per year. Mothers had a higher level of Korean identity than American identity. The mean scores of Korean identity were 69.86 (range: 10 to 90), whereas mean American identity scores were 54.53 (range: 10 to 90), indicating a stronger identification with Korean than American culture. None of these factors was significantly related to child s overweight. Family system factors were the next component of the model and included family structure, family functioning, and parental interactions with the child (parental feeding style and parental modeling). In terms of family structure, almost all (97.1%) mothers lived with their spouse or partner. and only 8.7% of them lived in a three-generation household. The majority of mothers (80.8%) had two or more children and almost half of the children (46.6%) had an older sibling. None of these factors was significantly related to the child s weight, but the number of children showed a trend, with overweight children more likely to have two or more siblings (p =.064).

38 Family functioning was measured with seven subscales, including problem solving, communication, roles, affective responsiveness, affective involvement, behavior control, and general functioning. The general functioning subscale had the highest scores and roles had lowest scores. Problem solving, roles, behavior control, and general functioning were negatively related to child s overweight, but none of these relationships were statistically significant. Parental interactions with the child included parental feeding style and healthy parental modeling. Parental feeding style was measured with seven subscales, including perceived responsibility, perceived parent weight, perceived child weight, concern about child weight, restriction, pressure to eat, and monitoring. Among subscales of parental feeding style, perceived child weight (r =.418) and pressure to eat (r = -.244) were significantly related to child s weight. The mean score of overall parental feeding style was 3.43 (range 1 to 5). Participants had lower scores on concern about child weight, perceived child weight, and perceived parent weight, and higher scores on monitoring and perceived responsibility. There was a significant difference in perceived child weight (t = -4.610, p <.001) and pressure to eat (t = 2.551, p =.025) between normal weight and overweight groups. Mothers of overweight children perceived their child to be more overweight than those of normal weight mothers. However, normal weight children s mothers provided more restriction, pressure to eat, and monitoring than those of overweight children s mothers. Another factor was healthy parental modeling. About 76.9% of mothers showed healthy lifestyle role-modeling to their children while mothers reported that 59.2% of fathers did so. Mother modeling and father modeling were significantly correlated (r =.244), but neither of these factors significantly related to the child s weight.

39 The last two factors were child s routines at home and childcare arrangements. The mean score of child routines was 63.28. The majority of children (68.3%) were cared for in formal care settings such as preschools and daycare centers at least part of the time. Twenty three percent of children were cared for their relatives, followed by parental only care (18.4%) and non-relative informal care (e.g., baby sitter) (14.4%). There was a significant difference in formal care (χ 2 = 4.492, p =.034) between normal weight and overweight groups with overweight children more likely to be cared for in formal settings. Although child s routines was not related to child s weight, it was significantly related to healthy mother modeling (r =.223), healthy father modeling (r =.214), perceived responsibility (r =.351), control (r =.210), and monitoring (r =.333). Child s routines were also significantly related to all subscales of family functioning: problem solving (r =.264), communication (r =.353), roles (r =.276), affective responsiveness (r =.321), affective involvement (r =.296), behavior control (r =.297), and general functioning (r =.335). 2. Testing the Conceptual Model: Family Factors and Child s BMI z-score Table 4 shows the results of the hierarchical multiple linear regression to test our conceptual model. Family background and family structure factors were not included in this linear regression model. The KA families had very homogeneous backgrounds. According to the bivariate analysis in the previous section, there were no significant differences in family background factors (level of mother s acculturation, mother s education level, household income, employment status, and length in the U.S) and family structure (number of children, living with both parents, and living with relatives) between the normal weight and overweight groups. Healthy parental modeling was also excluded because these variables had no significant bivariate relationships with child weight.

40 In the first step of hierarchical multiple linear regression, seven subscales of family functioning (problem solving, communication, roles, affective responsiveness, affective involvement, behavior control, and general functioning) were entered. This model was not statistically significant [F (7, 93) =.941; p =.479] and explained only 6.6% of variance in child s BMI z-score. In step two, the seven subscales of parental feeding style (perceived responsibility, perceived parent weight, perceived child weight, concern about child s weight, restriction, pressure to eat, and monitoring) were added. The introduction of parental feeding style explained an additional 23.4% of variance in children s BMI z-score. When these factors were added, the total variance in child s BMI z-score explained by the model as a whole was 30.0%, and this model was statistically significant [F (14, 86) = 2.635; p =.003]. In the third step, formal childcare was entered; this model was statistically significant [F (15, 85) = 2.435; p =.005] and explained 30.1% of variance in child s BMI z-score. In the fourth step, we added child s routines. This model was statistically significant [F (16, 84) = 2.256; p =.009] and explained 30.1% of variance in child s BMI z-score. Perceived child weight (β =.357, p <.001) and behavior control (β = -.271, p =.037) were statistically significant. If mothers perceived their children as more overweight, children were more likely to be obese while if mothers provided more behavior control, their children were less likely to have a high BMI z-score. However, adding formal childcare and the child s routines did not increase the model s explained variance. In the final model, only variables which had p-value less than.20 were entered: affective responsiveness, affective involvement, behavior control, general functioning, perceived child weight, concern about child weight, pressure to eat, and monitoring. This model was statistically

41 significant [F (8, 92) =4.777; p <.001] and explained 29.3% of variance in child s BMI z-score. Behavior control (β = -.246, p =.026), perceived child weight (β =.355, p <.001), pressure to eat (β = -.189, p =.056), and monitoring (β = -.200, p =.043) were statistically significant. Consistent with the conceptual framework, family factors explained 30% of the variance in the children s BMI z-scores in both our complete and final (reduced) hierchical multiple linear regression. Factors related to family feeding style made the greatest contribution to the explained variation. 3. Logistic Regression: Factors Related to Being Overweight Versus Normal Weight We used multiple logistic regression to examine effects of family factors on whether children were overweight or normal weight (Table 5). The model as a whole was statistically significant (χ 2 =.008) and was explained by the fitted model (Pseudo R 2 = 0.326). Among the family factors, the number of children in the family, perceived child weight, pressure to eat, monitoring, behavior control, and child s routines were statistically relate to child s overweight. Children were more likely to be overweight if: a family had more children in their home (OR 2.46, 95% CI 1.20-5.05); the mother perceived her child as overweight (OR 20.03, 95% CI 3.28-122.10); and the family had a regular child s routines (OR 1.10, 95% CI 1.02-1.18). If mother provided more pressure to eat (OR.42, 95% CI.18-.98), monitored more to restrict unhealthy food (OR.55, 95% CI.30-1.02), or expressed and maintained standards for the behavior of children (OR.27, 95% CI.08-.92), the children were less likely to be overweight.

42 D. Discussion The purpose of this study was to explore KA family contexts and examine the relationships between family factors and childhood overweight among KA preschool-age children. In this study, 22% of KA preschool-age children were found to be overweight or obese. The proportion of overweight KA preschool-age children in this study was similar to that reported for KA preschool-age children in U.S. national data (20%) (Jain et al., 2012). This similarity suggests that our small sample reasonably represented KA preschoolers overweight. KA preschool-age children have a lower prevalence of overweight compared to other racial/ethnic groups; in previous studies, 33.1% of Hispanic preschoolers, 28.9% of Non- Hispanic Black preschoolers, and 23.8% of Non-Hispanic White preschoolers were overweight (Ogden, Carroll, Kit, & Flegal, 2012). This study tested a conceptual model based on the Family Systems Theory (FST), which assumes that family members have reciprocal relationships that influence child health. Family factors, including family functioning, parental feeding style, parental modeling, childcare arrangement, and child s routines, explained 30% of the variance in the children s BMI z-scores. Parental feeding style (23.4%) and family functioning (6.6%) were the factors that most contributed to the variance explained in the BMI-z scores. These findings are consistent with a previous study analyzing national surveillance data which found that family-level factors were the main contributing factors and explained 70% of the varience for childhood overweight (Boonpleng et al., 2012). Childcare arrangement and child s routines did not increase the model s explained variance. Our final model (which excluded the non-related variables)

43 explained 29.3% of the variance in the children s BMI z-scores. In this model, behavior control, perceived child s weight, pressure to eat, and monitoring were statistically significant. Consistent with the findings of the linear regression model using the children s BMI z- scores, a multiple logistic regression comparing overweight to non-overweight children identified similar factors. Specifically, a child was more likely to be overweight if the mother perceived her child as being overweight, if the family had more children in the home, or if the child had regular routines. A child was less likely to be overweight if the mother reported higher monitoring of unhealthy food consumption, more restriction of unhealthy food intake, and maintaining standards for the child s behavior. Although family background factors have been associated with children s overweight in prior studies, none of the family background factors was found to be related to children s weight in this study. Because of the homogeneity among the KA families included in the study, such relationships may not be evident. For example, prior studies have found that a lower level of acculturation was associated with an increased risk of childhood overweight in minority groups, but no such relationship was found in this study (Balistreri, 2010; Jiménez-Cruz, Schwartz, Bacardi-Gascon, Heyman, & Wojcicki, 2012). The reason may be that the mothers were highly similar: they were predominantly born in Korea and had a higher level of Korean cultural identification than American cultural identification. The overall mean family functioning score for the KA families in the study was higher than that of Chinese-American families in another study using the same measure (Kennedy & Chen, 2004). In addition, the KA families had lower scores for roles and behavior control subscales than for other family functioning subscales, while Chinese-American families had higher scores for the roles and behavior control subscales. This evidence suggests that different

44 Asian-American subgroups may have different family characteristics. These differences may relate to unique family structures and levels of acculturation. Therefore, future studies should separately examine Asian-American families from different countries of origin whenever possible. In the previous studies, different subscales of family functioning such as general functioning or affective responsiveness have been negatively related to higher scores of BMI of children (Kennedy & Chen, 2004; Moens et al., 2007; Sousa, 2009). That broad idea was confirmed in this study, but in our measure of family functioning only one of the seven subscales, behavior control, was significantly associated with lower children s BMI z-scores; if the family expressed and maintained standards for the behavior of its members, such as having family rules, children were less likely to be overweight. Parental feeding style (perceived child s weight, pressure to eat, and monitoring) was significantly related to children s overweight in the study sample. The mothers perception of children s weight was highly correlated (r = 0.42) with the actual children s weight. Considering that this was a cross-sectional study that measured children s BMI and other variables at one point in time, the direction of the relationship between mothers perceptions of children s weight and actual children s weight is unclear. The general body image held by KA mothers may influence their perceptions of children s weight. In Asian cultures, child overweight is typically regarded as healthy and part of normal child development. These attitudes and preferences toward overweight children are also reported among Hispanic mothers (Nobari et al., 2013; Sosa, 2012). Another study found that KA and Chinese-American mothers evaluated their children as weighing less than the ideal if the mother experienced food insecurity in her childhood (Van

45 Hook & Cheah, 2012). Such attitudes toward children s weight may influence not only parental feeding styles but also mothers misperceptions about children s weight. Many of the KA mothers reported applying pressure to eat, monitoring, and behavior control, and these behaviors were negatively related to children s overweight. These findings are inconsistent with prior research that has reported that if parents monitor and restrict children s food consumption, the children are more likely to be obese (Moens et al., 2007; Rhee, 2008). KA mothers reported relatively little concern about their children s risk of being overweight or their children s weight status, and also reported little concern about their own weight status. However, KA mothers expressed a high level of responsibility for their children s feeding and reported that they closely monitored their children s eating. This may reflect traditional cultural traits; when KA mothers monitor and restrict their children, they are behaving according to the cultural expectations of a good mother, and this attention may have a positive effect on children s eating patterns rather than a negative one. KA mothers high interest in and motivation toward their children s feeding should be considered when developing overweight intervention programs. In this study, a child was more likely to be overweight if the family had more children in the home. One prior study reported that children who had siblings spent more time in physical activities than those without siblings (Bagley, Salmon, & Crawford, 2006). However, how siblings influence a preschool child s physical activity patterns, food consumption, and weight outcomes has not been examined. Further studies should be conducted to examine siblings roles in overweight among preschool-age children. Organizing regular healthy routines is important to shaping healthy environments for children during the preschool-age period. Child s routines, including adequate nighttime sleep

46 and family meals, has been related to a lower prevalence of overweight in prior studies (Anderson & Whitaker, 2010; Carskadon, Wolfson, Acebo, Tzischinsky, & Seifer, 1998; Crawford et al., 2001; Sekine et al., 2002; Sousa, 2009; Spruijt-Metz, 2011). In contrast to these findings, child s routines have a small positive relationship to child s overweight in this study. This study included a relatively small and homogeneous sample, and the KA children may have had similar family environments and routines. In the future, more studies should be conducted with greater numbers and more diverse groups of children and their families to identify how a child s routines relate to child overweight in KA families. Moreover, future studies should explore how child s routines of KAs differ from those of other racial/ethnic groups. The childcare arrangement is a potentially important resource for shaping healthy dietary habits and physical activity patterns among preschool-age children (Robert Wood Johnson Foundation [RWJF], 2011). In this study, about 70% of the preschool-age children were cared for in formal care settings such as preschools and daycare centers. This indicates that formal care settings should be considered as important potential sites for future intervention studies. In addition, KA churches are one of the major resources for social interaction and networking among KAs; more than 70% of KAs attend KA churches (Kim & Wolpin, 2008). Therefore, collaboration with such organizations would be helpful in providing effective interventions to prevent and reduce childhood overweight among KA preschool-age children. E. Limitations There are several limitations in this study. Most KA mother participants were firstgeneration. The small number of second- and third-generation participants, a growing segment of the KA population, may underrepresent U.S.-born KA families. A cross-sectional study that

47 measures children s BMI and other variables at one point in time cannot identify causal relationships between family factors and overweight among preschool-age children. Selfadministered questionnaires were used, and the participants may have provided biased answers because of social desirability issues. Because the convenience sample of study participants was recruited from KA churches and preschools in the Chicago metropolitan area, the findings do not fully represent KA families with preschool-age children living in the U.S. F. Implications KA preschool-age children have a lower rate of overweight than children in general in the U.S. However, this rate is high (22%) and suggests that childhood overweight is a substantial problem in the KA community. Longitudinal studies should be conducted to examine causal relationships between family factors and childhood overweight. Further studies should be conducted to explore KA mothers body image and their weight perceptions about their children, which are significantly related to children s overweight. In terms of clinical implications for future interventions to reduce overweight among young KA children, health care professionals should consider the family as one unit of care and should use this strong social network to implement culturally appropriate childhood overweight prevention for KA preschool-age children. Parental feeding style and child weight perception should be considered when advising KAs about reducing childhood overweight. In addition, KA churches and preschools should be considered as important potential sites for future intervention studies. Furthermore, KA children s physical activity patterns and food intake in formal care settings such as preschools

48 and daycare centers should be measured to fully examine the factors contributing to children s overweight.

49 TABLE III CONCEPTS, OPERATIONAL MEASURES, AND RELIABILITY/VALIDIDITY Concept Operational measures Reliability and validity Acculturation Family functioning Parental feeding style Vancouver Index of Acculturation (VIA) (Ryder, Alden, & Paulhus, 2000) - two subscales (10 items each, 9-point Likert scale, scores 10-90) a. heritage culture b. mainstream culture McMaster Family Assessment Device (FAD) (Epstein, Baldwin, & Bishop, 1983) - self-reporting instrument with seven subscales with Korean-American sample (34 items, 4-point Likert scale) Child Feeding Questionnaire (CFQ) (Birch et al., 2001) - self-reporting instrument with 2 dimensions and 7 subscales (31 items, 5-point Likert scale): a. parents perceptions and concerns regarding child obesity: perceived responsibility (3 items), parent perceived weight (4 items), perceived child weight (6 items), parents concerns about child weight (3 items), b. child-feeding attitudes and practices: restriction (8 items), pressure to eat (4 items), monitoring (3 items) Reliability 1. Original: - heritage (α=0.91-0.92) - mainstream (α=0.85-0.89) 2. Korean-Americans: - heritage (α=0.79-0.85) - mainstream (α=0.83-0.86) 3. In this study - heritage (α=0.82) - mainstream (α=0.92) Validity: concurrent validity established Reliability 1. Original: α=0.72-0.92 2. Korean: α= 0.67-0.78 3. In this study: α=0.66-0.92 Validity: concurrent validity was established Reliability 1. Original: α=0.70-0.92 2. Korean-Americans: α=0.67-0.97 3. In this study: α=0.56-0.92 Validity: construct validity was established

50 Parental modeling Mother s role modeling (healthy dietary habits, including consumption of fruits and vegetables, avoidance of fatty, salty and sweet snacks; parental physical activity patterns (regular moderate exercise); parental smoking and drinking habits Items developed for this study; pretested with KA mothers to establish comprehension and content validity Child s routines Father s role modeling (same questions, reported by mother) Family Nutrition and Physical Activity (FNPA) (Ihmels, Welk, Eisenmann, & Nusser, 2009) - self-reporting instrument with 10 dimensions (4-point Likert): family meal patterns, family eating habits, food choices, beverage choices, restriction/reward, screen time behavior and monitoring, healthy environment, family activity involvement, child activity involvement, family routine * α= Cronbach s α coefficient of internal consistency reliability Reliability: 1. Original: α=0.72 2. In this study: α=0.80 Validity: construct validity and predictive validity were established

51 TABLE IV CHILD WEIGHT CATEGORIES BMI Category Percentage Underweight (< 5 th percentile) 1.9% Normal (5 th - < 85 th percentile) 75.8% Overweight (85 th - < 95 th percentile) 19.4% Obese ( 95 th percentile) 2.9%

52 Characteristic TABLE V FAMILY FACTORS AND CHILD OVERWEIGHT Total (N=104) Normal weight (N=81) Overweight (N=23) p-value Family background First generation 95.2% 95.0% 95.7% NS Mother years in the U.S. (Mean, 15.1 (9.4) 14.7 (9.7) 16.5 (8.7) SD) NS Marital Status (Married) 97.1% 97.5% 95.7% NS Mother s education More than bachelor 29.8% 28.7% 30.4% NS Mother s employment Working 55.8% 57.5% 52.2% NS Family income (per year) < 40,000 21.8% 23.7% 17.4% 40,000-75000 34.7% 32.9% 39.1% NS >75,000 43.5% 43.4% 43.5% Mother s acculturation (Mean, SD) Heritage Mainstream 69.86 (10.82) 54.53 (17.09) 69.49 (10.89) 54.30 (16.46) 71.13 (10.95) 55.04 (19.79) Family system Family structure Living with spouse or partner 97.1% 96.3% 100.0% NS Living with relatives 8.7% 8.8% 8.7% NS Number of children in family One Two Three or more Family functioning (Mean, SD) Family Assessment Device (FAD) 19.2% 62.5% 18.3% 3.10 (0.35) 22.5% 61.3% 16.2% 3.10 (0.36) 8.7% 65.3% 26.0% 3.08 (0.27) NS.064 Problem solving Communication Roles Affective responsiveness Affective involvement Behavior control General functioning* Family interaction (Mean, SD) Parental feeding style (CFQ) 3.17 (0.48) 3.10 (0.49) 2.76 (0.43) 3.20 (0.53) 3.16 (0.53) 3.02 (0.46) 3.26 (0.44) 3.43 (0.38) 3.18 (0.52) 3.12 (0.51) 2.77 (0.46) 3.18 (0.56) 3.13 (0.56) 3.04 (0.49) 3.26 (0.45) 3.44 (0.40) 3.13 (0.31) 3.03 (0.44) 2.73 (0.31) 3.23 (0.41) 3.21 (0.44) 2.93 (0.32) 3.26 (0.42) 3.38 (0.34) NS NS Perceived responsibility* Perceived parent weight 4.44 (0.60) 2.96 (0.39) 4.43 (0.63) 2.93 (0.40) 4.45 (0.53) 3.08 (0.32) NS.119

53 Perceived child weight* Concern about child weight Restriction* Pressure to eat* Monitoring Parental modeling Mother modeling (good) 2.91 (0.48) 2.48 (1.03) 3.58 (0.75) 3.47 (0.76) 4.01 (0.95) 2.80 (0.44) 2.48 (1.07) 3.60 (0.75) 3.57 (0.71) 4.08 (0.95) 3.28 (0.41) 2.51 (0.91) 3.47 (0.73) 3.14 (0.87) 3.77 (0.93) <.001 NS NS.025.178 Father modeling (good) 76.9% 59.2% 73.8% 62.0% 87.0% 52.2% NS NS Child s routines* (Mean, SD) 63.28 (7.46) 63.09 (7.75) 63.48 (6.28) NS Childcare Type of childcare Parental only Relative care Non-relative informal care Formal care (e.g., preschool) 18.4% 23.1% 14.4% 68.3% 18.8% 21.3% 17.5% 63.7% 13.0% 30.4% 4.3% 87.0% Fisher s exact test * Mann-Whitney U P values from chi-square or independent t-test, testing for differences between non-obese and overweight group NS.358.180.034

54 TABLE VI HIERARCHICAL MULTIPLE LINEAR REGRESSION Variables Model 1 a Model 2 b Model 3 c Model 4 d Final Model Intercept 1.355.560.438.404.192 Family functioning a Problem solving Communication Roles Affective responsiveness Affective involvement Behavior control General functioning.047.002 -.099.233.163 -.269* -.203.022.023 -.063.173.210 -.268* -.181.021.026 -.066.176.208 -.268* -.175.023.024 -.067.175.209 -.271* -.176 Parental feeding style b Perceived responsibility Perceived parent weight Perceived child weight Concern about child weight Restriction Pressure to eat Monitoring.001 -.045.355**.151.061 -.225* -.205 -.002 -.041.357**.155.058 -.220 -.208 -.002 -.040.357**.153.059 -.220 -.210.156.174 -.246* -.154.355**.160 -.189* -.200* Formal childcare c.022.023 Child s routines d.008 R 2.066.300.301.301.293 R 2 change.234.001.000 Sig F. Change.001.830.950 * p<.05 **p<.01

55 TABLE VII MULTIPLE LOGISTIC REGRESSION OF CHILDHOOD OVERWEIGHT Variables OR 95% CI Lower Upper Number of children in family 2.460* 1.199 5.046 Family functioning Behavior control.270*.079.919 Feeding Style Perceived child weight Restriction Pressure to eat Monitoring 20.025** 1.253.424*.552* 3.284.663.184.300 122.103 2.367.977 1.015 Child s routines 1.095* 1.018 1.179 OR: Odds Ratio, CI: Confidence Interval * p<.05 **p<.01

56 FIGURE II FAMILY SYSTEM AND PRESCHOOL-AGE CHILD OVERWEIGHT: CONCEPTUAL MODEL

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APPENDICES

66 APPENDIX A University of Illinois at Chicago Institutional Review Board Notice of Determination of Human Subject Research March 20, 2013 So Hyun Park Women, Child, & Family Health Science Women, Children, and Family Sciences 845 S Damen, M/C 802 Chicago, IL 60661 Phone: (312) 996-2270 / Fax: (312) 996-8945 Approval Notice Initial Review (Response To Modifications) RE: Protocol # 2013-0156 Family Influences and Healthy Weight for Korean-American Preschool Children Dear Ms. Park: Your Initial Review application (Response To Modifications) was reviewed and approved by the Expedited review process on March 19, 2013. You may now begin your research Please note the following information about your approved research protocol: Protocol Approval Period: March 19, 2013 - March 19, 2014 Approved Subject Enrollment #: 505 Additional Determinations for Research Involving Minors: The Board determined that this research satisfies 45CFR46.404, research not involving greater than minimal risk. Therefore, in accordance with 45CFR46.408, the IRB determined that only one parent's/legal guardian's permission/signature is needed. Wards of the State may not be enrolled unless the IRB grants specific approval and assures inclusion of additional protections in the research required under 45CFR46.409. If you wish to enroll Wards of the State contact OPRS and refer to the tip sheet. Performance Sites: UIC, Korean Martyrs' Catholic Church - Chicago Sponsor: Chancellor's Graduate Research Fellowship

67 PAF#: Not applicable Grant/Contract No: Not applicable Grant/Contract Title: Not applicable Research Protocol: a) Research Protocol; Version 1; 02/15/2013 Recruitment Materials: a) Research Flyer (English); Version 1; 02/15/2013 b) Recruitment Script for Focus Group Interview (English); Version 1; 02/15/2013 c) Recruitment Script for Survey and Child Measurement (English); Version 1; 02/15/2013 d) Recruitment Script for Cognitive Interview (English); Version 1; 02/15/2013 e) Research Flyer (Korean); Version 1; 03/13/2013 f) Announcement Script for Cognitive Interviews (English); Version 1; 03/13/2013 g) Announcement Script for Survey and Child Measurement (English); Version 1; 03/13/2013 h) Recruitment Script for Focus Group Interview (Korean); Version 1; 03/13/2013 i) Announcement Script for Focus Group Interviews (English); Version 1; 03/13/2013 Informed Consents: a) Focus Group Interview Consent (English); Version 1; 02/15/2013 b) Cognitive Interview Consent (English); Version 1; 02/15/2013 c) Focus Group Interview Consent (Korean); Version 1; 03/13/2013 d) A waiver of informed consent for the collection of identifiable data from the mother about the mother subject's partner has been granted under 45 CFR 46.116(d) for this research (minimal risk; collection of secondary parenting data from the mother) e) An alteration of consent and waiver of documentation of informed consent for recruitment/screening purposes only has been granted under 45 CFR 46.116(d) and 45 CFR 46.117(c)(2) (minimal risk; written consent/permission will be obtained from mother at enrollment) Assent: a) A waiver of child assent for the collection of data from mothers about and measurements from their infants has been granted under 45 CFR 46.116(d) (minimal risk; written permission obtained from mother; impracticable to obtain assent from infants) Parental Permission: a) Survey and Child Measurement Consent/Permission (English); Version 1; 02/15/2013 Your research meets the criteria for expedited review as defined in 45 CFR 46.110(b)(1) under the following specific categories: (4) Collection of data through noninvasive procedures (not involving general anesthesia or sedation) routinely employed in clinical practice, excluding procedures involving X-rays or microwaves. Where medical devices are employed, they must be cleared/approved for marketing. (Studies intended to evaluate the safety and effectiveness of the medical device are not generally eligible for expedited review, including studies of cleared medical devices for new indications.)

68 Examples: (a) physical sensors that are applied either to the surface of the body or at a distance and do not involve input of significant amounts of energy into the subject or an invasion of the subject's privacy; (b) weighing or testing sensory acuity; (c) magnetic resonance imaging; (d) electrocardiography, electroencephalography, thermography, detection of naturally occurring radioactivity, electroretinography, ultrasound, diagnostic infrared imaging, doppler blood flow, and echocardiography; (e) moderate exercise, muscular strength testing, body composition assessment, and flexibility testing where appropriate given the age, weight, and health of the individual, (6) Collection of data from voice, video, digital, or image recordings made for research purposes., (7) Research on individual or group characteristics or behavior (including but not limited to research on perception, cognition, motivation, identity, language, communication, cultural beliefs or practices and social behavior) or research employing survey, interview, oral history, focus group, program evaluation, human factors evaluation, or quality assurance methodologies. Please note the Review History of this submission: Receipt Date Submission Type Review Process Review Date Review Action 02/15/2013 Initial Review Expedited 02/18/2013 Modifications Required 03/13/2013 Response To Modifications Expedited 03/19/2013 Approved Please remember to: Use your research protocol number (2013-0156) on any documents or correspondence with the IRB concerning your research protocol. Review and comply with all requirements on the enclosure, "UIC Investigator Responsibilities, Protection of Human Research Subjects" (http://tigger.uic.edu/depts/ovcr/research/protocolreview/irb/policies/0924.pdf) Please note that the UIC IRB has the prerogative and authority to ask further questions, seek additional information, require further modifications, or monitor the conduct of your research and the consent process. Please be aware that if the scope of work in the grant/project changes, the protocol must be amended and approved by the UIC IRB before the initiation of the change. We wish you the best as you conduct your research. If you have any questions or need further help, please contact OPRS at (312) 996-1711 or me at (312) 996-2014. Please send any correspondence about this protocol to OPRS at 203 AOB, M/C 672. Sincerely, Sandra Costello

69 Subjects Assistant Director, IRB # 2 Office for the Protection of Research Enclosures: 1. UIC Investigator Responsibilities, Protection of Human Research Subjects 2. Informed Consent Documents: a) Focus Group Interview Consent (English); Version 1; 02/15/2013 b) Cognitive Interview Consent (English); Version 1; 02/15/2013 c) Focus Group Interview Consent (Korean); Version 1; 03/13/2013 3. Parental Permission: a) Survey and Child Measurement Consent/Permission (English); Version 1; 02/15/2013 4. Recruiting Materials: a) Research Flyer (English); Version 1; 02/15/2013 b) Recruitment Script for Focus Group Interview (English); Version 1; 02/15/2013 c) Recruitment Script for Survey and Child Measurement (English); Version 1; 02/15/2013 d) Recruitment Script for Cognitive Interview (English); Version 1; 02/15/2013 e) Research Flyer (Korean); Version 1; 03/13/2013 f) Announcement Script for Cognitive Interviews (Engish); Version 1; 03/13/2013 g) Announcement Script for Survey and Child Measurement (English); Version 1; 03/13/2013 h) Recruitment Script for Focus Group Interview (Korean); Version 1; 03/13/2013 i) Announcement Script for Focus Group Interviews (English); Version 1; 03/13/2013 cc: Barbara McFarlin, Women, Child, & Family Health Science, M/C 802 Kathleen F. Norr (faculty advisor), Women, Child & family Health Science, M/C 802

Korean-American Preschooler Research 312-996-2270 Korean-American Preschooler Research 312-996-2270 Korean-American Preschooler Research 312-996-2270 Korean-American Preschooler Research 312-996-2270 Korean-American Preschooler Research 312-996-2270 Korean-American Preschooler Research 312-996-2270 Korean-American Preschooler Research 312-996-2270 Korean-American Preschooler Research 312-996-2270 70 APPENDIX B Research Flyer (English) Family Influences and Healthy Weight for Korean-American Preschool Children Volunteers are Needed for a Research: Healthy Preschoolers in the Korean American Community The College of Nursing at the University of Illinois at Chicago is researching how families keep their preschoolers healthy. We are seeking Korean-American mothers who have a child aged 2 to 5 for a research. Please tell us about how you are bringing up your preschool child to be healthy! You are eligible for the research if you are a Korean-American mother, you live with your child aged 2 to 5, and you have lived in the United States at least 5 years If you decide to participate in the research, you will: Complete a survey that will take less than one hour Allow us to measure the weight, height, waist/arm circumference, and abdominal/arm skinfold of your child All participants who complete the research will receive a $10 Target gift card If you are interested in this research please contact So Hyun Park, MSN, RN Telephone: 312-996-2270 E-mail: spark224@uic.edu

Korean-American Preschooler Research 312-996-2270 Korean-American Preschooler Research 312-996-2270 Korean-American Preschooler Research 312-996-2270 Korean-American Preschooler Research 312-996-2270 Korean-American Preschooler Research 312-996-2270 Korean-American Preschooler Research 312-996-2270 Korean-American Preschooler Research 312-996-2270 Korean-American Preschooler Research 312-996-2270 71 APPENDIX B Research Flyer (Korean) 한인미취학아동의건강체중에미치는가족의영향 한인미취학아동의건강연구를위한 연구참가자를모집합니다 UIC 간호대학에서는한인미취학아동의건강에대한연구를진행중입니다. 2-5 세의자녀와함께거주하는어머니들의협조를부탁드립니다. 한인미취학아동을건강하게키우는것에대해이야기해주세요! 귀하께서미국에서 5 년이상거주하시고, 2-5 세자녀와함께거주하고계신어머니이시면본연구에참여가능합니다 본연구에참여하시게되면 : 1 시간정도소요되는설문지를작성하시고 연구자가미취학자녀의키와몸무게, 허리둘레와팔둘레, 복부와팔피하지방두께를측정하게됩니다 연구에참여하시는분들께타겟상품권 ($10) 을드립니다 본연구에관심이있으신분들은연구책임자박소현 ( 아래의번호 ) 에게연락주십시오 Telephone: 312-996-2270 E-mail: spark224@uic.edu APPENDIX C