Những điều cần biết về chỉ số BMI

International Journal of Obesity (2000) 24, 1188±1194
ß 2000 Macmillan Publishers Ltd All rights reserved 0307±0565/00 $15.00
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Body mass index in a US national sample of
Asian Americans: effects of nativity, years since
immigration and socioeconomic status
DS Lauderdale1* and PJ Rathouz1
1

Department of Health Studies, University of Chicago, Chicago, IL 60637, USA

OBJECTIVE: To examine body mass index (BMI) and the proportion overweight and obese among adults age 18 ± 59 in
the six largest Asian American ethnic groups (Chinese, Filipino, Asian Indian, Japanese, Korean, Vietnamese), and
investigate whether BMI varies by nativity (foreign- vs native-born), years in US, or socioeconomic status.
DESIGN: Cross-sectional interview data were pooled from the 1992 ± 1995 National Health Interview Survey (NHIS).
SUBJECTS: 254,153 persons aged 18 ± 59 included in the 1992 ± 1995 NHIS. Sample sizes range from 816 to 1940 for
each of six Asian American ethnic groups.
MEASUREMENTS: Self-reported height and weight used to calculate BMI and classify individuals as overweight
(BMI  25 kgam2) or obese (BMI  30 kgam2), age, sex, years in the US, household income and household size.
RESULTS: For men, the percentage overweight ranges from 17% of Vietnamese to 42% of Japanese, while the total
male population is 57% overweight. For women, the percentage overweight ranges from 9% of Vietnamese and
Chinese to 25% of Asian Indians, while the total female population is 38% overweight. The percentage of Asian
Americans classi®ed as obese is very low. Adjusted for age and ethnicity, the odds ratio for obese is 3.5 for women
and 4.0 for men for US - vs foreign-born. Among the foreign-born, more years in the US is associated with higher risk
of being overweight or obese. The association between household income for women is similar for US-born Asian
Americans and Whites and Blacks, but is much weaker for foreign-born Asian Americans.
CONCLUSIONS: While these data ®nd low proportions of Asian Americans overweight at present, they also imply the
proportion will increase with more US-born Asian Americans and longer duration in the US.
International Journal of Obesity (2000) 24, 1188±1194
Keywords: Asian Americans; body mass index; obesityaethnology; acculturation; socioeconomic factors

Introduction
The public health signi®cance of obesity derives
largely from its well-documented associations with
chronic conditions such as diabetes mellitus, osteoarthritis and hypertension, conditions whose prevalence
varies by race and ethnicity. The percentage of obese
adults has increased markedly in recent decades. In
the Third National Health and Nutrition Examination
Survey (NHANES III), conducted from 1988 to 1994,
the proportion of the adult population in the United
States with body mass index (BMI, kgam2) of 25 or
higher was approximately 54%.1 That proportion
varied substantially by the racial and ethnic categories
available in NHANES III (non-Hispanic White, nonHispanic Black and Mexican American), with 67% of
Mexican Americans, 63% of Blacks and 53% of
Whites overweight (BMI  25). Obesity (BMI  30)

*Correspondence: DS Lauderdale, Department of Health
Studies, University of Chicago, 5841 S. Maryland Avenue, MC
2007, Chicago, IL 60637, USA.
E-mail:
Received 27 September 1999; revised 4 April 2000; accepted
18 April 2000

similarly varied by ethnicity and race, with 21% of
White, 30% of Black, and 28% of Mexican American
adults found to be obese.
There is a paucity of national data on the health
status of Asian Americans, a numerous, rapidly
increasing, and ethnically diverse minority group.

NHANES III, for example, over sampled Mexican
Americans and Blacks, but not Asian Americans. Nor
can one distinguish Asian Americans in the publiclyreleased ®les, since they are classi®ed as `Other'.
Further, there are no other national data collections
with physical examinations and suf®cient numbers to
characterize BMI and obesity of Asian Americans.
Our knowledge of this and other cardiovascular risk
factors among Asian Americans derives disproportionately from the study of one ethnic group in an
environment atypical of the US as a whole, Japanese
Americans in Hawaii. Mortality data from the
National Center for Health Statistics suggest that
Asian Americans in general are a uniquely healthy
group with the highest life expectancy in the country.2
However, since the majority of Asian American adults
are foreign-born, the question arises of whether Asian
American good health is owing to a `healthy immigrant' effect. The two most frequently presented


Asian American body mass index
DS Lauderdale and PJ Rathouz

explanations for a `healthy immigrant' effect are (1)
the self-selection of people able to and choosing to
immigrate, and (2) the maintenance of healthy behaviors associated with a traditional lifestyle, including
diet and physical activity.
In this study, as one indicator of whether lifestyle
risk factors for chronic diseases are associated with
nativity (ie US-born vs foreign-born) for Asian Americans and whether risk factors change for the foreignborn following immigration, we use national interview data to examine variation in BMI, the proportion
overweight and the proportion obese for the six major
Asian American ethnic groups (Chinese, Filipino,

Japanese, Asian Indian, Korean and Vietnamese).
We ask whether BMI and the odds of being overweight or obese vary by nativity. Among the foreignborn, we further investigate whether BMI and the
odds of being overweight or obese vary with years
since immigration. Finally we examine whether the
association between socioeconomic status and BMI is
the same for Asian Americans as it is for Whites and
Blacks.

Methods
Data

The National Health Interview Survey (NHIS) is a
nationally representative annual cross-sectional interview survey conducted by the National Center for
Health Statistics (NCHS). The target population is
civilian, non-institutionalized residents of the US. The
sampling plan follows a multistage area probability
design that permits the representative sampling of
households. Data are collected through a personal
household interview conducted by interviewers
employed and trained by the US Bureau of the
Census according to procedures speci®ed by NCHS.
Translators are used to collect information from
persons with limited English pro®ciency.
NHIS data are collected annually in 36,000 ± 47,000
households from 92,000 ± 125,000 persons.3 The
annual response rate is greater than 90%. Beginning
in 1992, the NHIS added Asian ethnic group detail to
the `race' item for Japanese, Chinese, Filipino, Asian
Indian, Korean and Vietnamese. These six groups
together comprise about 90% of the Asian American

population. Then in 1996, the categories for the three
smaller groups, Asian Indian, Korean and Vietnamese, were combined into the `other Asian and Paci®c
Islander' group for data release. Because the number
of Asian Americans surveyed in each ethnic group in
one single year is as few as 100, we combine data
from the 1992 ± 1995 NHIS to achieve adequate
sample sizes of subjects with maximum ethnic
detail.4 ± 7 This study includes persons aged 18 ± 59 y
of age. Persons 60 and older are not included both
because health effects of BMI may differ for the
elderly and because BMI may increasingly re¯ect
the consequences of ill-health as age increases.

Among the core questions asked of each member of
sampled households are raceaethnicity, age, sex,
height, weight, years in US for the foreign-born
( ` 1 y, 1 ± 5, 5 ± 10, 10 ± 15, b 15 y), household
income and household size. We re-categorize years
in the US as less than 5 y, 5 ± 15 y and 15 y or more.
We categorize income by $10,000 increments up to
$50,000 or greater, the highest category collected by
NHIS. Income is adjusted for household size in
regression models. We use household income rather
than education as an indicator of socioeconomic status
in this study because equating the number of years of
school for persons educated in the US and the dissimilar educational systems in each Asian country is
clearly problematic. We calculate the BMI by converting height and weight to the metric system and
calculating kgam2 for each subject. Persons with
missing data for height, weight, age, race or sex are
not included in this study (approximately 2% of

sample). Approximately 15% of records lack household income data, and they are omitted only from the
analyses using that variable.

1189

Analysis

Data collected in the NHIS are obtained through a
multistage complex sample design involving both
strati®cation and clustering. Moreover, the sampling
frame for the NHIS is redesigned every 10 y, and there
were two major changes to the sampling design
beginning in 1995: an increased number of primary
sampling locations to permit estimation at the state
level, and oversampling of the Hispanic population in
addition to the prior oversampling of the Black
population. Since this study pools data from the
1992 ± 1995 NHIS, the change in sampling frame
introduces an additional level of complexity to the
estimation procedures. Extrapolating from NCHS
guidelines for combining 1994 and 1995 data, all
four years were concatenated into a single data set,
with each year read independently and treated as a
stratum. Stratum and primary sampling unit variables
were created for 1995 to be consistent with previous
years.
Exploratory data analysis was carried out with
STATA (Stata corporation, College Station, TX).
Then, prevalence estimates and logistic and linear
regression models were ®tted with the SUDAAN

software package (Research Triangle Institute, Triangle Park, North Carolina), as recommended by the
NCHS. Using the method of generalized estimating
equations, SUDAAN ®ts models and obtains standard
errors that correctly account for multistage strati®ed
sampling designs. Regression parameter estimates are
consistent and, if the covariance model is correctly
speci®ed, ef®cient. Even if the covariance model
is misspeci®ed, however, the robust standard errors
are correct, and hence con®dence intervals will have
the correct coverage probabilities. Although the
International Journal of Obesity


Asian American body mass index
DS Lauderdale and PJ Rathouz

1190

population of main interest in this study is Asian
Americans aged 18 ± 59, no NHIS observations were
deleted since analysis of subsetted data may result in
incorrectly computed standard errors.8 Instead, the
subpopulation option (SUBPOPN) in SUDAAN procedure was used to target a subdomain from the full
design database.

Results
There were 7263 Asian Americans aged 18 ± 59 in the
six major ethnic groups interviewed by the NHIS from
1992 ± 1995 (Table 1). By ethnic group, the numbers
ranged from 816 Korean to 1940 Chinese. As expected

from the immigration history,9 a large majority of each
group except the Japanese is foreign-born. For each of
the Korean, Vietnamese and Asian Indian groups, less
than 10% and fewer than 100 persons were US-born.
Among the foreign-born, the subjects were distributed in
roughly equal numbers into the three categories of years
in the US (Table 2). Overall, 26% had been in the US
fewer than 5 y, 42% from 5 to 15 y, and 33% for more
than 15 y, and these percentages were generally similar
across ethnic groups.
Figures 1 and 2 display box-and-whisker plots of
BMI for men and women by race category. All of the
Asian American groups have lower median BMI than
the White or Black groups. There is, however, signi®cant variation among Asian American groups. For
men, the Japanese and Filipino have higher median
BMI than the other groups, while for women it is the
Filipino and Asian Indian groups with higher median
BMI. For both men and women, the Vietnamese have
the lowest median BMI.
Table 1 Distribution of six Asian American ethnic groups by
birthplace for persons aged 18 ± 59, from the National Health
Interview Survey, 1992 ± 1995, based on the unweighted sample
Ethnicity

Foreign-born

Chinese
Filipino
Korean
Vietnamese

Japanese
Asian Indian

1636
1399
747
888
342
1041

All Asian

6053 (83.3%)

(84.3%)
(83.1%)
(91.5%)
(98.1%)
(41.1%)
(95.9%)

Native-born
304
284
69
17
491
45

Total

(15.7%)
(16.9%)
(8.46%)
(1.9%)
(58.9%)
(4.1%)

1940
1683
816
905
833
1086

1210 (16.7%)

7263

Table 2 Distribution of six Asian American ethnic groups by
years in the United States for foreign-born persons aged 18 ± 59,
from the National Health Interview Survey, 1992 ± 1995, based on
the unweighted sample
Ethnicity
Chinese
Filipino
Korean
Vietnamese
Japanese
Asian Indian

All Asian
International Journal of Obesity

`5y
437
256
169
258
142
305

(26%)
(19%)
(23%)
(28%)
(39%)
(29%)

1567 (26%)

5 ± 15 y
770
567
301
422
74
461

(44%)
(40%)

(39%)
(45%)
(20%)
(43%)

2595 (42%)

b 15 y
469
591
297
244
141
292

(29%)
(42%)
(38%)
(27%)
(41%)
(28%)

2034 (33%)

BMI, proportion overweight and proportion obese
are all higher for US-born Asian Americans than for
the foreign-born, and the effect is similar for men and
women. For Asian American men, adjusting for age
and ethnicity, mean BMI is 1.31 kgam2 (95%
CI ˆ 0.90 ± 1.72) lower for the foreign-born than the

native-born. For women, the difference in mean BMI
is 1.14 kgam2 (95% CI ˆ 0.77 ± 1.51). Adjusting for
age and ethnicity, the odds ratio of being overweight
for the US-born compared to the foreign-born is 1.85
for men (95% CI ˆ 1.52 ± 2.26) and 1.94 for women
(95% CI ˆ 1.46 ± 2.58), and the odds ratio for obese is
4.03 (95% CI ˆ 2.40 ± 6.78) for men and 3.51 (95%
CI ˆ 1.74 ± 7.10) for women. Among the foreign-born,
the odds of being overweight or obese increases for
Asian Americans with longer duration in the US
(Table 3).
Finally we examine whether the association
between socioeconomic status, measured as family
income (adjusted for family size), and BMI is the
same for Asian Americans as it is for Blacks and
Whites. Using the same 4 y of NHIS, we ®nd that
family income is strongly inversely related to BMI for
women. The magnitude and direction of the association is very similar for White and Black women
(Table 4). For White women, each $10,000 in
income is associated with a BMI 0.55 kgam2 lower,
or a total difference of 2.75 kgam2 between the highest
and lowest income categories. For Black women, BMI
is 0.59 kgam2 lower per $10,000, a difference of
2.95 kgam2 between the highest and lowest income
categories. For White men, there is a very small
inverse association between family income and
BMI, 0.03 lower per $10,000. For Black men, there
is a modest positive association, with BMI 0.07 higher
for each $10,000 family income. For US-born Asian
American women, there is also a strong inverse

association between BMI and income, although the
magnitude of the association, 0.38 kgam2 for each
$10,000 income, is somewhat smaller than for White
and Black women. There is no signi®cant association
for US-born Asian American men, while the point
estimate, 0.06, suggests a modest positive association
and is similar to the point estimate for Black men. The
inverse association between income and BMI, however, is very weak and of marginal statistical signi®cance for foreign-born Asian American women, just
0.06 kgam2 per $10,000 income. For foreign-born
Asian American men, the positive association is
somewhat greater than for other men, 0.11 per
$10,000 income, and the trend is highly signi®cant.
When years in the US is also entered into the model,
the positive association is attenuated.

Discussion
We have found that BMI and the proportions overweight and obese are lower among each of the Asian
American ethnic groups than the US population in


Asian American body mass index
DS Lauderdale and PJ Rathouz

1191

Figure 1 Body mass index for men by race categories from the National Health Interview Survey, 1992 ± 1995. Each box corresponds
to the interquartile range of the data, the 25th to 75th percentiles, and the line in the middle is the median. The line above the box
extends to the largest data point less than or equal to the 75th percentile plus 1.5 times the interquartile range. The lower line is formed
analogously. Observations beyond this are individually plotted. However, the ®gure does not display values greater than a BMI of 40.

Figure 2 Body mass index for women by race categories from the National Health Interview Survey, 1992 ± 1995. Each box
corresponds to the interquartile range of the data, the 25th to 75th percentiles, and the line in the middle is the median. The line
above the box extends to the largest data point less than or equal to the 75th percentile plus 1.5 times the interquartile range. The
lower line is formed analogously. Observations beyond this are individually plotted. However, the ®gure does not display values
greater than a BMI of 40.
International Journal of Obesity


Asian American body mass index
DS Lauderdale and PJ Rathouz

1192

Table 3 The effect of duration in US on odds of overweight and obese for foreign-born Asian American
men and women, adjusted for age and ethnicity
Overweight

Years in US
`5y
5 ± 15 y
b 15 y

Obese

Men

Women

Men

Women

OR (95% CI

OR (95% CI)

OR (95% CI)

OR (95% CI)

0.62 (0.48 ± 0.80)
0.81 (0.67 ± 0.98)
1.00 (ref)

0.77 (0.55 ± 1.08)
0.98 (0.76 ± 1.26)
1.00 (ref)

0.63 (0.31 ± 1.28)
0.69 (0.40 ± 1.19)
1.00 (ref)

0.28 (0.11 ± 0.70)
0.50 (0.27 ± 0.92)
1.00 (ref)

OR ˆ odds ratio. CI ˆ con®dence interval.

Table 4 The effect of household income on body mass index
Men

a

White
Blacka
US 7 born Asian Americanb
Foreign 7 born Asian Americanb
a

Women

b coef®cient
per $10,000

P-trend

b coef®cient
per $10,000

P-trend

7 0.3
0.07
0.06
0.11

0.008
0.016
0.664
0.004

7 0.55
7 0.59
7 0.38
7 0.06

` 0.001
` 0.001
0.002
0.046

Adjusted for age and family size.
Adjusted for age, family size and ethnicity.

b

general. However, the proportions do vary by ethnicity and nativity. US-born Asian Americans are signi®cantly more likely to be obese or overweight than
the foreign-born. Among the foreign-born, the number
of years spent in the US is directly related to the risk
of being overweight or obese. For White and Black
women in the US, there is a strong inverse association
between BMI and economic status. This association is
also seen for US-born Asian American women,
although the effect is weaker. However, there is
only weak evidence of an association between economic status and BMI for foreign-born Asian American women. There is a positive association between
BMI and economic status for foreign-born Asian
American men.
This study has several methodologic limitations, the
most signi®cant of which is that height and weight are
self-reported. Previous studies have assessed the

validity of self-reported height and weight, and generally the level of agreement between self-report and
measured height and weight has been found to be very
high.10 However, there is evidence of modest systematic bias towards under-reporting weight and overreporting height.11,12 Such systematic mis-reporting
would underestimate prevalence of overweight and
obesity, which are calculated relative to ®xed BMI
values. Nonetheless, the prevalence of overweight
found in the examination-based NHANES III data
(collected 1988 ± 1994) for persons age 20 ± 741 is in
close agreement with the prevalence calculated for
1992 ± 1995 NHIS for the same age range. Speci®cally, Flegel et al reported from NHANES III a crude
prevalence overweight of 60% for men and 51% for
women. From NHIS, the crude prevalence is 61% for
International Journal of Obesity

men and 51% for women. Because the emphasis in
this study is on comparisons and relative measures,
systematic mis-reporting would be less of a limitation
than mis-reporting which was related to variables
under investigation, such as nativity or ethnicity.
While there is some evidence from the UK that quality
of self-report may vary by demographic factors,13 we
are unaware of studies which have investigated the
validity of self-reported height and weight for the
foreign-born or for Asian Americans. Another limitation to this study is that conclusions regarding the
effect of years since immigration are based on crosssectional rather than longitudinal data, possibly confounding acculturation with cohort effects related to
year and age at immigration. We cannot examine the
effect of age at immigration in models which already
include age and years in the US. Finally, sample sizes
for US-born Korean, Vietnamese and Asian Indian
Americans are too small, even combining 4 y of

NHIS, to permit ethnicity-speci®c evaluations of
nativity. Our study is limited by the use of current
household income (adjusted for family size). This
measure may not re¯ect lifetime socioeconomic
status (SES) as well for the foreign-born as the USborn. The highest income category in the NHIS is
$50,000 and higher, which fails to distinguish gradations among those with high incomes.
Despite these limitations, this study addresses a
remarkable lack of information concerning the
health of Asian Americans. The immigration history,
both the proportion US-born and the years of peak
immigration, is different for each Asian American
group. Since both ethnicity and immigration status
(nativity and duration in the US) may be related to


Asian American body mass index
DS Lauderdale and PJ Rathouz

health, the ability to stratify Asian Americans by both
ethnicity and immigration status is key to avoiding
unmeasured confounding of one by the other. The
NHIS provides the opportunity to study a few health
indicators for nationally-representative samples of the
six largest Asian American ethnic groups. With no
oversampling of Asian Americans in the NHIS, individual years do not provide adequate sample size for
most analyses, nor do the supplements, such as the
1992 Cancer Control Supplement, which are administered to a subsample of respondents. We overcome
this limitation by combining several years of data.
To our knowledge, only one previous project has
investigated BMI and obesity in a multi-ethnic Asian

American population with ethnicity-level detail.
Klatsky and Armstrong14 assessed cardiovascular
risk factors among Asian Americans who volunteered
for an examination at a northern California prepaid
heath plan between 1978 and 1985. Their data, which
include both mean BMI and proportion with BMI
greater than 24.4 (overweight), are presented for
Chinese, Japanese, Filipino and other Asian. The
proportions overweight are very similar to the proportions found in the NHIS data. For Chinese, 27% of
men and 13% of women were overweight; for Filipinos, 42% of men and 26% of women were overweight; and for Japanese, 38% of men and 18% of
women were overweight. They also found evidence of
increased odds of being overweight for those born in
the US, although the effect was only statistically
signi®cant for men. Further evidence of a nativity
effect for BMI comes from the National Longitudinal
Study of Adolescent Health. Popkin and Udry found
that US-born Asian American adolescents (in aggregate) were more than twice as likely to be overweight
as the foreign-born adolescents.15
The association between SES and obesity has been
studied in diverse cultures, with generally consistent
®ndings.16 In developed countries, there is a strong
inverse association between SES and obesity for
women and no consistent association for men. In
developing countries, by contrast, there is a positive
association for both men and women; the higher
prevalence of obesity among those with greater
wealth likely re¯ects both greater access to food and
a related cultural preference for physical evidence of
such access.17 The SES effects we have found for USborn Asian Americans conform to expectations for
persons in a developed country. The lack of association for foreign-born women and the moderate positive association for foreign-born men suggest an effect

intermediate in direction between those of developed
and developing countries.
The health signi®cance of BMI in part derives from
its correlation with adiposity. Several previous studies
have investigated whether the ability of BMI to
predict percentage body fat varied by ethnicity. Gallagher and others found that, while the association
between BMI and adiposity did vary by age and sex, it
did not differ between Black and White adults in a

study conducted in New York City.18 Comparing BMI
and percentage body fat for Asians and Whites, Wang
and others did ®nd some differences.19 Asians,
although mean BMI was lower, had higher percentage
body fat and more upper-body subcutaneous fat. In a
meta-analysis which included data for three Asian
groups, Deurenberg and others found that the percentage body fat was higher than predicted at low BMI
levels for Chinese. Body fat was underestimated
across all BMI levels for Thais and Indonesians.20 In
a study of women in Hawaii, Novotny and others
found that Asian women had a greater percentage of
body fat than did White women with the same BMI.21
One implication of such data is that the accepted cutoff values for overweight and obese may be less
appropriate for Asian American populations in terms
of their association with heart disease and proximal
risk factors such as hypertension, glucose intolerance
or lipid pro®les.
While the proportions overweight and obese are
much lower for Asian Americans than other racial
categories at present, the strong associations with
birthplace and years since immigration suggest these

proportions may increase signi®cantly as the demography of the population shifts, with increased duration of residence in the US and a higher proportion
US-born. The limited data concerning the correlation
between BMI and adiposity suggest that health effects
of BMI may differ for Asian Americans. Higher levels
of BMI could have a signi®cant impact on morbidity
and mortality.

1193

Acknowledgements

We thank Ye Luo, PhD, for computer programming
and Kate Pickett, PhD, for comments on the manuscript. Data were presented in part at the annual
meeting of the Society for Epidemiological Research
(Baltimore MD, June 1999).
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