Bodyweight Misperception by Chinese American Females Influenced by Cultural and Social Ideals: Implication for Home Health Care

Abstract

Bodyweight misperception results from the desire to achieve an ideal body emphasized by cultural mores and societal norms. It is sustained by the desire to be cultural compliant, especially for ethnic minority women such as Chinese American females. Through cultural beliefs, these women’s self-perceived weight status is distorted, which strengthens the impact of bodyweight misperception in their daily life as poor physical health, distressed psychosocial health, risky and unsafe health practices and behaviors, and diminished quality of life. Evidently, bodyweight misperception promotes maladaptive health behaviors. However, bodyweight misperception is barely captured in the current science about women’s health, and is minimally explored in research about Chinese American females’ desire and efforts to achieve the ideal body type. Therefore, the purpose of this literature review was to explore (1) body weight perception, (2) the factors associated with it, and (3) the negative health consequences triggered by it, in Chinese American females. Studies confirm that Chinese American females shape their body weight perception by internalized cultural ideals, acculturative stress, mass media, and social pressures. They overestimate their body weight more than underestimate it as evident by frequent weight-loss attempts. This internalized bodyweight misperception affects their physical and psychological health, with undesirable consequences on their quality of life. Home health care professionals interact closely with patients from diverse cultural backgrounds; remaining culturally sensitive is crucial in their practice. Knowledge from this literature review emphasizes the need for culturally appropriate weight management strategies for the delivery of competent home health care to Chinese American females.

Keywords

Chinese American bodyweight misperception weight dissatisfaction body image cultural competency home health care

Introduction

Traditionally, bodyweight misperception has been observed as a prevalent occurrence among both adults and adolescences in the Western modern society.^1-3 Conceptually, it is the discordance between the desired body weight and the actual body weight when comparing the self-report weight and the actual body mass index (BMI).^4,5 Bodyweight misperception is prevalent among adults in the United States, with almost 50% underestimating their body weight and a little over 20% overestimating their body weight.⁶ Clearly, there is a dislike of one’s body weight with a preferential desire for a smaller body weight than the reality.

Currently, the incidents of bodyweight misperception are being observed beyond the Western culture and infiltrating others such as the Chinese in the past decade. In fact, bodyweight misperception is a growing health issue among the Chinese population living inside and outside of mainland China. With Chinese American adults in New York City, one third of the 162 participants (32%) misperceived their body weight.⁷ Of 902 adult female college students in mainland China, 46% demonstrated bodyweight misperception.⁸ Bodyweight misperception has been evident in 40% of 3,923 Chinese adolescents⁹ and 65% of adolescent girls surveyed in mainland China.¹⁰ Likewise, normal weight adolescent girls in Taiwan and Hong Kong were more likely to overestimate their body weight than boys,¹¹ or be dissatisfied with their body size.¹²

There is this growing displeasure with one’s body weight in the Chinese culture, which is associated with psychological and physical conditions such as anxiety, low self-esteem, depression, and harmful weight management behaviors,^4,8,10 all of which are factors that may potentiate quality of life (QoL) impairments. Moreover, these findings indicate a possible relationship between bodyweight misperception and its effects on health status and health behaviors. Unfortunately, Chinese American females (CAFs) are often not included in mainstream research exploring bodyweight misperception, which could be problematic because various culture-bound characteristics may play complex roles in determining an individuals’ body perception.^13,14

The purpose of this literature review was to explore the meaning of bodyweight misperception for CAFs by (1) providing an overview about body weight perception, (2) identifying contributing factors of bodyweight misperception, and (3) describing its effects on physical and psychological health status. As home health care professionals work with a variety of ethnically and culturally diverse populations; this knowledge could contribute to appropriate weight management strategies that emphasize the provision of culturally competent care in home health settings.

Definition of Bodyweight Misperception

When a person reports a desired body weight category that does not match with the calculated BMI, he or she is considered as having bodyweight misperception. Conversely, if a person reports a desired bodyweight category that matches with the calculated BMI category, he or she is considered as having concordant weight perception. Bodyweight misperception is classified into two categories: “Weight overestimation”–a perceived body weight higher than the measured BMI category; and “weight underestimation”–a perceived body weight lower than the measured BMI category. The magnitude of the bodyweight misperception, especially in terms of the sub-categories, can be determined by a categorizing scale^1,10,15 (Table 1).

Table 1.

Categories of Bodyweight Misperception.

Bodyweight misperception categories	Self-perceived weight status	Objective BMI-based weight status (kg/m²)
Underestimation	“underweight”	Normal weight; Overweight
Underestimation	“normal weight”	Overweight
Overestimation	“overweight”	Normal weight; Underweight
Overestimation	“normal weight”	Underweight
Correct Estimation	Self-Perceived Weight Status = Objective BMI-Based Weight Status

The formula for the standardized BMI is the weight in kilograms divided by measured height in meters squared (kg/m²). A BMI of 18.5 to 24.9 kg/m² equates to healthy/normal weight, whereas a BMI less than 18.5 kg/m² reflects underweight, a BMI of 25-29.9 kg/m² equals overweight with a BMI of 30 kg/m² or greater classified as obese (Table 2).¹⁶ However, the standardized BMI is not suitable for Asians. Asians have a high propensity for developing visceral fat, which is not reflected in the conventional BMI cut point for measuring body composition.¹⁷ Therefore, a revised classification scale has been devised specifically for persons of Asian descent (Table 2).^18,19

Table 2.

Comparison Between the Universal BMI Cutoff Ranges and the Revised BMI Cutoff Ranges for Asians.

Weight status categories	Universal BMI cutoff range (kg/m²)^a	Revised BMI cutoff range for Asians^b (kg/m²)
Underweight	<18.5	<18.5
Normal/healthy weight	18.5-24.9	18.5-22.9
Overweight	25.0-29.9	23.0-27.4
Obese	≥30	≥27.5
Morbidly Obese	≥40	—

Note. BMI = body mass index.

BMI using the standard formula of weight in kilograms divided by measured height in meters squared (kg/m²). Recommended by the Centers for Disease Control and Prevention.¹⁶

Recommended by the World Health Organization.¹⁹

Overview of Body Weight Status and Perception Among Chinese Female

Factors contributing to body weight variation for Chinese female adults (Table 3) include age,^7,20 marital status,^20,23 educational attainment,^7,20 and subjective health status.²² These factors often occur in patterns and over a certain period of time resulting in them being possible predictors for Chinese females’ bodyweight misperception. For Chinese females with bodyweight misperception (Table 4), overestimation was more commonly observed than underestimation in both adults and adolescents.^7,8,10 The act of weight-loss attempts was the most frequently reported predictor of bodyweight misperception.^8,10

Table 3.

Literature Findings: Average Body Weight, BMI, and Contributing Factors to Body Weight Variation Among Chinese/Chinese American Females.

Study	Average bodyweight (lbs.)	Average BMI (kg/m²)^a	Study design	Sample size & settings	Factors correlated with weight status/ BMI
Huang²⁰	Not reported	2004: 23.09 2006: 23.03 2009: 23.13 2011: 23.55	Data collected from the China Health and Nutrition Survey (CHNS): an ongoing longitudinal survey in 2004, 2006, 2009, and 2011	10,900 Chinese women and 9,857 Chinese men aged 18 to 55, from 11469 households sampled in 8 provinces in China	Age, gender, marital status, educational attainment, employment status, level of healthy weight knowledge, metabolic equivalents per week
Jackson et al.²¹	Not reported	19.84	A descriptive and cross-sectional study; data collected via a self-reported survey in 2014	456 Chinese undergraduate female students over age 18 from a large university in Chongqing	Eating/body image concerns (disordered eating and fatness concerns)
Liu et al.⁷	143.40	24.30	A descriptive and cross-sectional study	162 Chinese Americans (84 women) over age 21 sampled in a community health center in New York	Gender, age, educational attainment
Tang et al.²²	123.46	23.52	Data requested from the China Kadoorie Biobank (CKB) study: a prospective cohort study between 2004 - 2008	130,418 Chinese men and 196,533 Chinese women aged 30 to 79 years sampled in five urban and five rural areas in China	Self-rated health
Wang et al.¹⁴	115.37	19.86	A descriptive and cross-sectional study	425 Chinese college students (254 female) aged between 19 and 26 years in Beijing, China	Not investigated
Yeh et al.²³	Not reported	22.08	Cross-sectional study; base line data collected from a National Cancer Institute-funded longitudinal study	2,537 Chinese Americans aged 18 to 75 years sampled in two communities in New York City	Age, marital status, level of acculturation, primary language, employment status, length of residence in the United States

Note. BMI = body mass index; CHNS = China Health and Nutrition Survey; CKB = China Kadoorie Biobank.

BMI using the standard formula of weight in kilograms divided by measured height in meters squared (kg/m²).

Table 4.

Literature Findings: Bodyweight Misperception Among Chinese/Chinese American Females.

Study	Participants with weight misperception (%)^a	Study design	Sample size & settings	Factors correlated with weight misperception
Liu et al.⁷	Underestimation: 6.2 Overestimation: 9.9 Consistent estimation: 35.8	A descriptive and cross-sectional study	162 Chinese Americans (84 women) over age 21 sampled in a community health center in New York	Gender, age, educational attainment
Tanenbaum et al.⁸	Underestimation: 6.5 Overestimation: 31.5 Consistent estimation: 54	A cross-sectional analysis was conducted with data from the China Seven Cities Study	902 female subjects aged 18 to 25 years from seven cities in mainland China in 2003	Overweight status, weight management practices and attempts, weight goals
Yan et al.¹⁰	Underestimation: 13.6 Overestimation: 48.9 Consistent estimation: 37.5	A descriptive and cross-sectional study	2641 youth aged 13 to 18 years at two schools in Wuhan, Hubei, China, during the late spring/early summer of 2016	Weight-loss attempts, eating behaviors

Bodyweight misperception is determined by the agreement or disagreement between actual body mass index and self-perceived weight status.

Societal and Cultural Contributing Factors

Internalization of Cultural Ideals

Cultural ideals may have shaped CAFs’ perception and attitude toward their weight status.¹³ The Eastern culture values a substantially heavier physique as it symbolizes auspiciousness, family fertility, and prosperity in females; wealth, wellness, and happiness in males; and the family’s high social status in children.²⁴ Therefore, it is not uncommon for Asian Americans, especially the first-generation immigrants, to underestimate their body weight.^24,25 In fact, overweight adults in China reported a higher level of self-perceived health status than those of normal weight.²⁶ In addition, each distinct culture has its own standard for physical attractiveness; thus, a person’s desired body weight and body image are reflective of the cultural preferences rather than an accurate measure of one’s body weight.^27-29

Mass Media Influence

The pursuit of the ideal physical appearance portrayed in the mass media has clearly become an emerging problem among the generation of Chinese females (adolescents and adults).^{8,14,25,30,31} While the traditional cultural beliefs still thrive in some rural and less developed parts of mainland China, these traditional ideals are gradually being replaced by a partiality for a slimmer physique in females due to urbanization and the influence of the mass media.^8,32 This shift in cultural beliefs and the ideal physical appearance are attributable to the impact of marketing an unrealistic and unattainable ideal physical appearance through mainstream advertisement/media, social media, and modern pop culture.^14,33 Chinese female adolescents are constantly exposed to the waiflike body type as the ideal physical appearance promoted in the modern beauty industry and media, which significantly facilitates their susceptibility to body image dissatisfaction and its outcome—bodyweight misperception.^14,21

Acculturation Stress

Acculturative stress is conceptualized as the continuous stressful experience associated with the challenges and difficulties immigrants encounter while adapting to the host culture.^27,34 CAFs (and women of other Asian cultures) experience unique stressors during acculturation such as gender role strain and model minority labels, exacerbating body image dissatisfaction and bodyweight misperception.¹³ These established acculturative stressors lead to eating disorders, body dissatisfaction, and bodyweight misperception among ethnic minority groups in the United States.^35,36 Parental and family acculturation have been described as a contributing factor to bodyweight misperception for adolescents from Asian immigrant families.³⁷ It is hypothesized that the family dynamics become distressed from the incongruent pace of acculturation between parents and children. Consequently, the newer generation minorities have a higher susceptibility to a distorted perception of body image attributed to family conflicts.³⁷ Thus, the impact of acculturative stress on the well-being of ethnic minorities is quite robust and potentially a significant contributor to bodyweight misperception.

Social Pressure

The underlying mechanisms leading to bodyweight misperception manifest as a series of experiences influenced by social pressure.^{25,30,32,21,38,39} Specifically, individuals’ self-evaluation of their body is often distorted by the societal subjective and unrealistically high expectations and the internalized appraisal of one’s attributes defined by external stimuli within social settings.³⁹ Chinese Americans share common values and customs with other Asian cultures, which include collectivism, communitarianism, and emphasis on discipline and social order.^26,38,40 CAFs might feel stressed to adhere to the predominant Western ideal body image as they adapt to the American culture, especially Chinese immigrants coming from cultures that accentuate connecting with the community.^24,26 Communally bounded CAFs reside in a homogenous society so that their concept of “self” is derived from social desirability, other’s perceptions, and cultural norms.^27,21,39 As such, CAFs are apt to compare themselves to their acquired or viewed images of the host culture’s ideal physical appearance that establishes these females’ desired physical appearance and attractiveness; and, in turn, these females develop body image dissatisfaction driven by their bodyweight misperception.^8,27,36

Consequences of Bodyweight Misperception in Chinese Females

Bodyweight misperception has a devastating impact on anyone’s physical and psychological health, which is enormously evident in Chinese females. For Chinese adolescent girls, bodyweight misperception leads to psychological distress such as anxiety,¹⁴ depressive symptoms, and perceived stress.²⁵ Furthermore, Chinese adolescent girls feel compelled to “take action” with unhealthy weight-loss practices with the determination to address their dissatisfaction with their bodies—all influenced by bodyweight misperception.^{8,10,11,14,41}

Both weight underestimation and overestimation have undesirable consequences on an adult’s awareness of the aspects for health-related QoL.^3,5,42 Adults with bodyweight misperception have an impaired QoL, engage in unhealthy lifestyle practices, develop an impaired self-perceived health status, and achieve a body weight such as obesity that contributes to the onset of chronic diseases.^5,20,43 In fact, bodyweight misperception was a significant indicator of obesity for elderly Chinese Americans because they would underestimate their body weight although the BMI indicated that they were “obese.”⁷ Chinese Americans do not have a higher prevalence of obesity when compared with other minority groups; however, they have an increased susceptibility to chronic diseases such as cardiovascular disease and diabetes mellitus,⁴⁰ which are interdependent with weight perception and weight control practices—easy outcomes with bodyweight misperception.^7,41

For females of diverse ethnic backgrounds such as Chinese Americans, bodyweight misperception is attributed to the unique cultural perceptive and daily stressors in their lives. Social and cultural factors contributing to bodyweight misperception for CAFs include internalization of cultural ideals, mass media influence, acculturative stress, and social pressure. A model illustrating the relationship between the contributing factors, bodyweight misperception, and health consequences is developed based on the aforementioned literature findings (Figure 1). This model may serve as an assessment guideline for home health care professionals to determine CAFs’ body weight perception, physical health, and psychosocial health from a cultural and social perspective.

Figure 1.

Relationship of bodyweight misperception, associated factors, and the consequences.

Application of Findings

CAFs have a distinct set of cultural beliefs which influence how they perceive health and illness.^13,14,41 In order to tailor interventions that support healthy weight perception and attainment among this population, understanding how the internalization of cultural ideals, the influences of mass media, acculturative stress and social pressure are reflected on body weight perception are necessary. Potential weight management interventions for CAFs could incorporate cognitive-behavioral therapy, acculturative stress management strategies, and culturally appropriate nutrition and physical activity programs.^44,45

Bodyweight misperception can impact a person’s lifestyle and health-related behavior, which are crucial determinants of health.^5,42 Both underestimation and overestimation of one’s body weight pose a high risk for poor physical health and psychosocial dysphoria.^8,14,25,41 For instance, the leading indicator of health status, a measurement of the Health-Related Quality of Life (HRQoL) concept, can be negatively impacted from the effect of bodyweight misperception on overall physical, psychological well-being, life-satisfaction, and quality of living, dimensions of HRQoL.⁴⁶ Bodyweight misperception maintains a controlling effect on the overall health status that is measured as a decrease in the generic QoL instrument “EQ-5D,” which has a composite score for the five dimensions of HRQoL.⁴⁷ In home health settings, the EQ-5D can be included as a health outcome measurement tool to evaluate the multidimensional effects of body weight perception on both physical and psychosocial health.^5,43

Accuracy of body weight perception should be promoted among CAFs. For instance, older generation Chinese Americans should be educated about the relationship between body weight status and chronic health conditions such as malnutrition and obesity. Furthermore, as BMI might not be the most accurate indicator to measure body composition among Asian Americans, a more reliable scale for measuring weight status such as bodyfat percentages may be used for weight assessment in this population.⁴⁸

Home health care professionals are uniquely situated to assist in the gratification of an ethnically diverse patient’s physical, emotional, and spiritual needs through mutual trust. Home health care professionals, particularly nurses, often interact closely with the patients across the continuum of care. Home health nurses must offer culturally competent care, by developing an awareness of cultural differences and performing cultural assessment during the provision of home health care.

Perceptions and attitudes toward body weight and weight management practices could also depend on a person’s life experience, socioeconomic status, and educational attainment.²⁰ It is therefore imperative for home health care professionals to gain a better understanding of CAFs’ concepts of health and illness, realizing that perception of weight status may vary among each individual within the same cultural group.

Conclusion

There are several main concepts surrounding weight perception among CAFs. Life stressors, cultural idealization, and social pressure play significant roles in determining an individual’s self-perceived weight status. As overweight and bodyweight misperception are becoming more prevalent health issues in the United States, encouraging appropriate weight management practices and realistic body weight perception are prioritized to ensure the overall well-being of the United States’ diverse population. In addition, current interventions on health weight management need to be culturally sensitive so that persons who respect their culture (i.e., CAFs) can receive adequate weight management. Future studies should continue to examine the unique culture-specific factors that influence CAFs’ body weight perception, as well as their perceived barriers to weight management. Additional efforts should be made to promote accurate weight perceptions, weight management, and the proper management of chronic conditions associated with body weight status among CAFs.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Wing Lam Tock

References

Langellier

Glik

Ortega

Prelip

ML.

Trends in racial/ethnic disparities in overweight self-perception among US adults, 1988-1994 and 1999-2008. Public Health Nutr. 2015;18(12):2115-2125.

Tarasenko

Asgari-Majd

Cottrell-Daniels

Yan

Zhang

. More overweight adolescents think they are just fine: generational shift in body weight perceptions among adolescents in the U.S. Am J Prev Med. 2015;49(5):670-677.

Rancourt

Thurston

Sonneville

Milliren

Richmond

. Longitudinal impact of weight misperception and intent to change weight on body mass index of adolescents and young adults with overweight or obesity. Eat Behav. 2017;27:7-13.

Wang

Liu

, et al. The association between BMI and body weight perception among children and adolescents in Jilin City, China. PLoS ONE. 2018;13(3):e0194237.

Park

Lee

Hwang

Kwon

JW.

The impact of weight misperception on health-related quality of life in Korean adults (KNHANES 2007-2014): a community-based cross-sectional study. BMJ Open. 2017;7(6):e016098.

Dorsey

Eberhardt

Ogden

CL.

Racial/ethnic differences in weight perception. Obesity (Silver Spring). 2009;17(4):790-795.

Liu

, et al. Accuracy of body weight perception and obesity among Chinese Americans. Obes Res Clin Pract. 2016;10(suppl 1):S48-S56.

Tanenbaum

Felicitas

, et al. Overweight perception: associations with weight control goals, attempts, and practices among Chinese female college students. J Acad Nutr Diet. 2016;116(3):458-466.

Niu

Seo

Lohrmann

DK.

Weight perception and dietary intake among Chinese youth, 2004-2009. Int J Behav Med. 2014;21(4):691-699.

10.

Yan

Oniffrey

, et al. Body weight misperception and its association with unhealthy eating behaviors among adolescents in China. Int J Environ Res Public Health. 2018;15(5): E936.

11.

Ting

Huang

Chien

KL.

Association between weight status and depressive symptoms in adolescents: role of weight perception, weight concern, and dietary restraint. Eur J Pediatr. 2012;171(8):1247-1255.

12.

Knowles

Ling

Thomas

Adab

McManus

AM.

Body size dissatisfaction among young Chinese children in Hong Kong: a cross-sectional study. Public Health Nutr. 2015;18(6):1067-1074.

13.

Brady

Kaya

Iwamoto

Park

Fox

Moorhead

Asian American women’s body image experiences: a qualitative intersectionality study. Psychol Women Quarter. 2017;41(4):479-496.

14.

Wang

Liang

, et al. Body image attitude among Chinese college students. Psych J. 2018;7(1):31-40.

15.

Yang

Turk

Allison

James

Chasens

Body mass index self-perception and weight management behaviors during late adolescence. J Sch Health. 2014;84(10):654-660.

16.

Centers for Disease Control and Prevention. Healthy weight: about adult BMI. https://www.cdc.gov/healthyweight/assessing/bmi/adult_bmi/index.html. Updated 2017. Accessed August 20, 2019.

17.

Hsu

Araneta

Kanaya

Chiang

Fujimoto

BMI cut points to identify at-risk Asian Americans for type 2 diabetes screening. Diabetes Care. 2015;38(1):150-158.

18.

Jih

Mukherjea

Vittinghoff

, et al. Using appropriate body mass index cut points for overweight and obesity among Asian Americans. Prev Med. 2014;65:1-6.

19.

WHO Expert Consultation. Appropriate body-mass index for Asian populations and its implications for policy and intervention strategies. Lancet. 2004;363(9403):157-163.

20.

Huang

CC.

Healthy weight knowledge and body size disparities in Chinese adults. Am J Health Behav. 2016;40(5):545-554.

21.

Jackson

Jiang

Chen

Associations between Chinese/Asian versus Western mass media influences and body image disturbances of young Chinese women. Body Image. 2016;17:175-183.

22.

Tang

Zhao

The association between self-rated health and different anthropometric and body composition measures in the Chinese population. BMC Public Health. 2017;17(1):317.

23.

Yeh

Fahs

Shelley

Yerneni

Parikh

Burton

Body weight and length of residence in the US among Chinese Americans. J Immigr Minor Health. 2009;11(5):422-427.

24.

Liou

Bauer

Obesity perceptions among Chinese Americans: the interface of traditional Chinese and American values. Food, Culture & Society. 2010;13(3):351-369.

25.

Xie

Chou

Spruijt-Metz

, et al. Longitudinal analysis of weight perception and psychological factors in Chinese adolescents. Am J Health Behav. 2011;35(1):92-104.

26.

Noh

Kim

Yang

Park

Cheon

Kwon

YD.

Body mass index and self-rated health in East Asian countries: comparison among South Korea, China, Japan, and Taiwan. PLoS ONE. 2017;12(8):e0183881.

27.

Claudat

White

Warren

CS.

Acculturative stress, self-esteem, and eating pathology in Latina and Asian American female college students. J Clin Psychol. 2016;72(1):88-100.

28.

McLeod

Bates

Heard

Bohnert

Santiago

CD.

Parent perceptions of child weight status in Mexican-origin immigrant families: an investigation of acculturation, stress, and coping factors. J Immigr Minor Health. 2018;20(2):441-447.

29.

Pai

Contento

Parental perceptions, feeding practices, feeding styles, and level of acculturation of Chinese Americans in relation to their school-age child’s weight status. Appetite. 2014;80:174-182.

30.

Chen

Jackson

Gender and age group differences in mass media and interpersonal influences on body dissatisfaction among Chinese adolescents. Sex Roles. 2012;66(1):3-20.

31.

Tan

Fuller-Tyszkiewicz

Utpala

, et al. Western cultural identification explains variations in the objectification model for eating pathology across Australian Caucasians and Asian women. Front Psychol. 2016;7:1578.

32.

Warren

Rios

RM.

The relationships among acculturation, acculturative stress, endorsement of Western media, social comparison, and body image in Hispanic male college students. Psychol Men Mascul. 2013;14(2):192-201.

33.

Holland

Tiggemann

A systematic review of the impact of the use of social networking sites on body image and disordered eating outcomes. Body Image. 2016;17:100-110.

34.

Greenwood

Adshead

Jay

Immigrant women’s experiences of acculturative stress: ordinary privileges, overt discrimination, and psychological well-being. Psychol Women Quarter. 2017;41(4):497-512.

35.

Kwan

Gordon

Minnich

AM.

An examination of the relationships between acculturative stress, perceived discrimination, and eating disorder symptoms among ethnic minority college students. Eat Behav. 2018;28:25-31.

36.

Kroon Van Diest

Tartakovsky

Stachon

Pettit

Perez

The relationship between acculturative stress and eating disorder symptoms: is it unique from general life stress?

J Behav Med. 2014;37(3):445-457.

37.

Gee

Peebles

Golden

Storfer-Isser

Heinberg

Horwitz

SM.

Language spoken at home and parental birthplace moderate the association of race/ethnicity and distorted weight perception. Clin Pediatr (Phila). 2012;51(12):1155-1163.

38.

Frederick

Kelly

Latner

Sandhu

Tsong

Body image and face image in Asian American and white women: examining associations with surveillance, construal of self, perfectionism, and sociocultural pressures. Body Image. 2016;16:113-125.

39.

Sutter

Nishina

Witkow

Bellmore

Associations between adolescents’ weight and maladjustment differ with deviation from weight norms in social contexts. J Sch Health. 2016;86(9):638-644.

40.

Wong

Dixon

Gilbride

Kwan

Stein

RA.

Measures of acculturation are associated with cardiovascular disease risk factors, dietary intakes, and physical activity in older Chinese Americans in New York City. J Immigr Minor Health. 2013;15(3):560-568.

41.

Baillie

Copeland

AL.

Disordered eating and body image in Chinese and Caucasian students in the United States. Eat Behav. 2013;14(3):314-319.

42.

Heard

Scuffham

Ratcliffe

Whitty

JA.

The association between misperceptions around weight status and quality of life in adults in Australia. Health Qual Life Outcomes. 2017;15(1):53.

43.

Choi

Shin

Park

Lee

The association between body weight misperception and psychosocial factors in Korean adult women less than 65 years old with normal weight. J Korean Med Sci. 2015;30(11):1558-1566.

44.

Chesla

Chun

Kwong

, et al. Cultural adaptation of the group lifestyle balance program for Chinese Americans. Diabetes Educ. 2016;42(6):686-696.

45.

Tucker

Butler

Kaye

, et al. Impact of a culturally sensitive health self-empowerment workshop series on health behaviors/lifestyles, BMI, and blood pressure of culturally diverse overweight/obese adults. Am J Lifestyle Med. 2014;8(2):122-132.

46.

Office of Disease Prevention and Health Promotion. Health-related quality of life. Healthy People. https://www.healthypeople.gov/2020/topics-objectives/topic/health-related-quality-of-life-well-being. Updated 2019. Accessed August 20, 2019.

47.

Balestroni

Bertolotti

EuroQol-5D (EQ-5D): an instrument for measuring quality of life. Monaldi Arch Chest Dis. 2012;78(3):155-159.

48.

Gier

Khoury

Kirk

Kist

Siegel

BMI versus body composition as measures of success in a clinical pediatric weight management program. Med Sci Sport Exer. 2018;50:837.