Journal of Transcultural Nursing

http://tcn.sagepub.com/ The Integral Role of Food in Native Hawaiian Migrants' Perceptions of Health and Well-Being
Jane H. Lassetter J Transcult Nurs 2011 22: 63 DOI: 10.1177/1043659610387153 The online version of this article can be found at: http://tcn.sagepub.com/content/22/1/63

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The Integral Role of Food in Native Hawaiian Migrants Perceptions of Health and Well-Being
Jane H. Lassetter, PhD, RN1

Journal of Transcultural Nursing 70 22(1) 63 The Author(s) 2011 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/1043659610387153 http://tcn.sagepub.com

Abstract Purpose: Obesity is prevalent among Native Hawaiians, but the relationship between food and perceptions of health and well-being is not well understood. The purpose was to explore the role of food in Native Hawaiians perceptions of health and well-being. Design: A qualitative descriptive design was used. Twenty-seven Native Hawaiian participants in Las Vegas took part in semistructured interviews. Results: Participants expressed that food can be dangerous to health. However, eating Hawaiian food seems to relieve homesickness, and they occasionally indulge in binge overeating. Conclusions: Hawaiian food plays an important role in participants health and well-being. Participants concurrent attraction to Hawaiianstyle food and desire to avoid unhealthy food create a challenging struggle. Implications for Practice: To support cultural connectedness, Native Hawaiians can be encouraged to expend consumed calories in physical activity as their ancestors did. Discussing nutrition from a family framework might be helpful to Native Hawaiians. Keywords family health, transcultural health, qualitative method, nutrition, food, diet, migration, health promotion, health perception, well-being

Introduction
Obesity is highly prevalent in the Native Hawaiian population. Many researchers and health care providers in Hawaii are trying to curb the tide of Native Hawaiian obesity and the related devastating illnesses (Boyd, 2006; Fujita, Braun, & Hughes, 2004; Grandinetti, Kaholokula, Theriault, Mor, & Chang, 2007; Hughes, 2001; Kim, Park, Grandinetti, Holck, & Waslien, 2008; Leslie, 2001; Ochner, Salvail, Ford, & Ajani, 2008). However, many Native Hawaiians do not live in Hawaii. According to the U.S. Census Bureau (2000), approximately 60% (239,655) of the 401,162 respondents who identified themselves as Native Hawaiian alone or in combination with one or more Pacific Islander groups or other races lived in Hawaii. The other 40% resided on the U.S. mainland (U.S. Census Bureau, 2001a). Las Vegas, Nevada, was one mainland location with a growing number of Native Hawaiians. In fact, so many Native Hawaiians migrated to Las Vegas that it earned the nickname of the ninth Hawaiian Island (Reeder, 1999). Between the 1990 and 2000 Censuses, the Native Hawaiian population in Nevada grew by more than 400% to 8,264 (Association of Asian Pacific Community Health Organizations, n.d.; U.S. Census Bureau, 1990, 2000, 2001b).

Despite the number of Native Hawaiians residing in the mainland, no literature was located on their weight-related health challenges. Although Native Hawaiians who migrate to the U.S. mainland are not international migrants, their transoceanic migration may give them some similarities to international migrants to the United States who tend to gain weight after migration (Lassetter & Callister, 2009). Given the seriousness and complexity of obesity-related diseases, this as an area worthy of research. As part of a larger qualitative study on Native Hawaiian migrants perceptions of health and well-being, the purpose of this article is to explore how food influences the perceptions of health and well-being of Native Hawaiian migrants in Las Vegas.

Background
Historical records suggest that ancient Native Hawaiians were large, strong, and fit from their challenging physical work and
1

Brigham Young University, Provo, UT, USA

Corresponding Author: Jane H. Lassetter, Brigham Young University, 424 SWKT, Provo, UT 84602-5544, USA Email: jane_lassetter@byu.edu

64 healthy diet consisting of low-fat and high-carbohydrate foods (Fujita et al., 2004; Hughes, 2001). Some historians slightly contradict this, stating that being overweight was accepted and even encouraged among early Native Hawaiians, especially women. Women with high social standing in ancient Hawaii had plentiful access to food, so they tended to be heavier than women with lower social standing. Correspondingly, being overweight was perceived as attractive (Ochner et al., 2008; Pukui, Haertig, & Lee, 1972). Pukui et al. noted, An ideally beautiful woman had a face as round and full as the moon (p. 7), and it was especially important for royal women to be large. For instance, one princess would eat 13 coconut pies at a time. In contrast, ancient Native Hawaiian men tried to maintain healthy weights to improve their agility in battle (Pukui et al., 1972). There is little debate about the current health status of the Native Hawaiian population. In recent years, their overall health status has been among the poorest of all ethnic groups in Hawaii (Fujita et al., 2004; Palafox, Buenconsejo-lum, Riklon, & Waitzfelder, 2002). In 2007, Hawaiis total prevalence of being overweight or obese was 54%, with Native Hawaiians having the highest prevalence (70%) among included ethnic groups (Hawaii Department of Health, 2009). Likewise, the prevalence of diabetes was also much higher for Native Hawaiians than for Caucasians (68.4 vs. 51.3 per 1,000), and Native Hawaiians were 5.7 times more likely than Caucasians (216 vs. 38 per 1,000) to die with diabetes as an underlying or contributing cause of death (Hawaii Department of Health, 2009; Hirokawa et al., 2004). Additionally, there are disparities in life expectancies between various ethnic groups (Caucasian, Chinese, Filipino, Native Hawaiian, and Japanese) in Hawaii. In 1990, the most recent year with life expectancy data based on ethnicity, Hawaiis life expectancies ranged from 83 years for Chinese residents to 72 years for Native Hawaiians, the shortest life expectancy (Busch, Easa, Grandinetti, Mor, & Harrigan, 2003; Hawaii Department of Health, 2006). Many factors contribute to health disparities such as those faced by Native Hawaiians. Some are nonmodifiable risk factors, such as age, race, and genetics, but other risk factors can be modified. These include barriers to accessing health care, some health care providers lack of cultural competence, and some patients distrust of the Western health care system. Other modifiable risk factors are the result of important lifestyle choices: exercise, diet, and avoidance of harmful substances, such as tobacco and alcohol in excess. If ignored, modifiable risk factors can lead to a cascade of health problems. For example, people who lead a sedentary lifestyle and consume more calories than they use are at risk for obesity, hypertension, and diabetes. In turn, hypertension and diabetes contribute to heart disease and stroke, which can lead to premature death. Goldman et al. (2009) found that preventing cardiovascular risk factors, such as obesity and diabetes, could improve health, increase longevity, and decrease lifetime health care

Journal of T ranscultural Nursing 22(1) expense. For a person 51 or 52 years of age, they calculated that successful prevention of obesity would add 0.85 year to a life span and be worth $51,750 per capita. Prevention of diabetes would add 3.17 years to a lifespan and be worth $198,018 per capita (Goldman et al., 2009). It is expected that effective interventions for populations with high prevalence of obesity and diabetes, such as Native Hawaiians, would add life years and be economically wise. Foundational information for such interventions includes understanding Native Hawaiians nutrition and dietary practices. Native Hawaiians understanding of the connection between health and nutrition has been explored. Native Hawaiian college students in Oahu acknowledged that a nutritious diet is essential to good health and understood that how food is grown and produced affects its nutritional value. They also perceived their ancestors diet and lifestyle as healthier than their own (Boyd, 2006). Understanding what constitutes a healthy diet is not necessarily reflected in daily choices. Comparing the food preferences of Native Hawaiian, Filipino, Japanese, and Caucasian people living on the island of Hawaii, Kim et al. (2008) found Native Hawaiian participants ate more Hawaiian-style and other ethnic foods than Japanese or Caucasian participants. Hawaiian-style foods are popular in contemporary Hawaii; they are influenced by several cultures and tend to be calorie dense. In association with their food preferences, Native Hawaiian participants had the highest calorie intake of the included ethnic groups and significantly higher body mass index and waist-to-hip ratios than either Japanese or Caucasian participants (Kim et al., 2008). In an effort to intervene with Native Hawaiian obesity, researchers developed diet plans specifically for this population. Most research on the impact of culturally appropriate diet interventions for Native Hawaiians was conducted in the 1990s and early 2000s. In a culturally sensitive way, researchers incorporated healthy elements of the ancient, traditional Hawaiian diet. This traditional diet differs from the contemporary Hawaiian-style diet; the traditional Hawaiian diet consists of a high amount of complex carbohydrates (78%), a moderate amount of protein (12%), and a small amount of fat (10%; Fujita et al., 2004). Two of the most well-known Native Hawaiian dietary interventions, the Waianae Diet Program and the Ulieo Koa Program, incorporated cultural beliefs supportive of health and well-being. Program participants learned about their ancestors diet and the health value of various plants. Raw or steamed vegetables and leaves indigenous to Hawaii, such as breadfruit, sweet potato, and taro, were emphasized (Fujita et al., 2004; Hughes, 2001; Leslie, 2001; Shintani & Hughes, 1995). After reviewing these diet programs, Fujita et al. (2004) determined that such programs appeal effectively to Native Hawaiians cultural pride. Participants valued the family and community involvement integral to these programs and felt inspired by what they learned about their ancestors diet and lifestyles.

Lassetter Dietary interventions have helped Native Hawaiians achieve some weight loss. On the Waianae Diet Program, participants lost an average of 17 pounds in a 3-week period. In addition, participants reduced their blood glucose, triglycerides, cholesterol, and blood pressure (Leslie, 2001; Shintani & Hughes, 1995). They maintained a 15-pound weight reduction over a 7-year period (Shintani, Beckham, Tang, OConnor, & Hughes, 1999) but were heavy at the 7-year follow-up, weighing about 245 pounds. To be considered a medically significant weight loss, participants needed to lose 10% of their preprogram weight, and few achieved this benchmark (Fujita et al., 2004). Thus, additional elements need to be addressed to help overweight and obese Native Hawaiians achieve and maintain sufficient weight loss to avoid devastating illnesses. One way to determine what might help is to ask Native Hawaiians how food affects their perceptions of health and well-being.
Table 1. Participant Demographics Characteristic Age (in years) by decade 20s 30s 40s 50s 60s Gender Female Male Marital status Married Single Years since migration 0.33-5 >5-10 >10-15 >15-40 Educational attainment Graduated from high school Some college or technical school Graduated from technical school Graduated from college Graduate degree Employment status Unemployed Employed N 4 5 6 10 2 11 16 18 9 14 9 2 2 5 10 4 5 3 5 22

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% 14.8 18.5 22.2 37.0 7.4 40.7 59.3 66.6 33.3 51.9 33.3 7.4 7.4 18.5 37.0 14.8 18.5 11.1 18.5 81.5

Method Design
A qualitative descriptive design was selected because so little is known about Native Hawaiian migrants perceptions of health and well-being and the role of food therein. Intensive, semistructured interviews conducted in natural settings and guided by interpretive constructionist philosophy were well suited to this study. Rather than responding to a predetermined set of choices with assumed uniform meaning, as in a quantitative descriptive study (Rubin & Rubin, 2005), participants were able to explore the topic fully and share personal insights without predetermined bias. Another important design benefit is the flexibility to adjust the interview guide based on ongoing data analysis (Polit & Beck, 2006; Sandelowski, 2000).

Participants Approval and Recruitment

After receiving institutional review board approval from Brigham Young University and Oregon Health and Science University, recruitment and data collection occurred between April and September 2007. Recruitment flyers were placed at Hawaiian restaurants and businesses throughout Las Vegas. Additionally, several participants told others about the study, and some of them participated. To qualify for participation, recruits had to be adults (18 years and older) who had lived in Hawaii before migrating to Las Vegas and had to identify themselves as Native Hawaiian. Only one qualified recruit failed to attend a scheduled interview; all others participated.

to Las Vegas between 4 months and 39 years (Mdn = 5 years) before taking part in the study. Participants claimed between 10% and 75% Hawaiian blood quantum (M = 42.5%); none claimed to be full-blooded Native Hawaiian. Most participants (n = 20) migrated from Oahu; the other participants migrated from the islands of Maui, Kauai, Molokai, and Hawaii. All participants graduated from high school, and 7 graduated from college. Demographic characteristics of participants are presented in Table 1.

Data Collection
Each participant was interviewed one time in a location of his or her choice. Interview locations throughout Las Vegas included participants homes (18), restaurants (6), or places of employment (3). Each in-depth, semistructured interview lasted 1 to 1 hours. Interviews were audiorecorded and carefully transcribed by the researcher. Field notes were completed within 3 hours after each interview on observable data, including information about the community and interview settings; descriptions of participants attire, demeanor, and nonverbal communication; and observations of cultural practices. The interview guide was based on review of the literature and was evaluated by a Native Hawaiian research assistant for cultural appropriateness and understandability and revised

Description of the Sample

The 27 participants (11 females and 16 males) ranged in age from 23 to 62 years (M = 40 years) and migrated from Hawaii

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Table 2. Pertinent Questions From the Interview Guide 1. How has your health changed since moving to Las Vegas? If changes, what do you think led to the changes? 2. How have your health habits (what you do to stay healthy) changed since moving to Las Vegas? If changes, what do you think led to the changes? 3. In what ways, if any, has your health improved since moving to Las Vegas? 4. In what ways, if any, has your health declined since moving to Las Vegas? 5. What would you have done differently in Hawaii to stay healthy? 6. What cultural health practices (including dietary habits) that affect your health were you able to bring with you from Hawaii? 7. What cultural health practices might be helpful to Native Hawaiians living in Las Vegas? 8. Thinking about the things we have discussed so far, how would you define good health? Is there anything else that determines good health? 9. How has your move affected what brings you joy and gives meaning to your life? 10. In what ways has your lifestyle changed since moving to Las Vegas? Has your diet changed?

Journal of T ranscultural Nursing 22(1) Categorizing and coding were the next steps in data analysis, aided by NVivo7 software. Participant responses were initially divided into health and well-being categories. Then data were coded according to topic by identifying, grouping, and labeling related segments (Morse & Richards, 2002). Next, analytic coding was done and involved coding around the topic to establish its significance and meaning (p. 120). Finally, coding for themes occurred as the researcher identified underlying meaning that ran through the data without being confined to specific segments (Morse & Richards, 2002). Rigor was maintained by following Meadows and Morses (2001) components of rigor: verification, validation, and validity. Verification is internal to inquiry (p. 189) and is evidenced in the study design, which allowed the researcher to move fluidly between recruitment, data collection, and analysis. This fluid design was essential because the most significant feature that makes qualitative research a systematic and rigorous process is the iterative data collection and data analysis (p. 198). In addition, data collection continued until saturation was reached in all major themes and categories, which further supports verification of the study. Validation was accomplished by using techniques to ensure the study remained sound while in progress (Meadows & Morse, 2001). For instance, during member checks, participants scrutinized interpretive summaries, clarified meaning, and expounded on their experiences. Validity is one of the outcome goals of a project (Meadows & Morse, 2001, p. 197) and implies there is little or no reason to doubt the findings. Validity of this study is supported by rich description of evidence sustaining the conclusions of the study.

accordingly. Sample questions are presented in Table 2. With regard to food, participants were specifically asked what dietary habits they brought with them from Hawaii. Participants also discussed their dietary habits in response to other, more general questions, such as how their health habits changed after migrating to Las Vegas. To determine how participants perceived health, they were asked to define good health. Then to reduce potential confusion about the difference between good health and well-being, the researcher explained that, for the purpose of this study, well-being is defined as what brings joy and gives meaning to life and asked participants what brought them joy and gave meaning to their lives. Confidentiality of the data was carefully guarded. To protect confidentiality, each participant was assigned a code name, and all identifying information was removed from the data during transcription. Tapes and interview transcripts were separately and securely stored in the researchers office in a locked filing cabinet.

Results
There was an interesting dichotomy surrounding food. Several participants identified food as dangerous when discussing health and acknowledged a connection between obesity and health risks. However, many also associated eating, especially Hawaiian-style food, with a soothing calmness that enhanced well-being. Results are presented in two categories: the role of food in perceptions of health and the role of food in perceptions of well-being.

Data Analysis
Analysis began by repeatedly listening to audiorecordings of the interviews, carefully transcribing them verbatim, and repeatedly reading the transcripts. These processes focused attention on participants inflections and responses, enhanced understanding, and helped refine future interviews. For example, when the researcher learned about specific Hawaiian community events, such as the annual hoolaulea, she asked about them in remaining interviews.

The Role of Food in Perceptions of Health

Participants closely associated health and nutrition. This category has the following themes: health depends on what you eat, challenges with nutrition advice, and overeatinga culturally sanctioned indulgence. Health depends on what you eat. Many participants defined health in terms of diet and exercise. Some applied this to Native Hawaiians in general, but others perceived the connection between food and health as personal, as this participant explained,

Lassetter As soon as I get sick, or if she [his wife] gets sick, I honestly start to think, Are we exercising? Are we eating right? . . . . I dont get sick very often. When I do get sick, I ate a lot. . . . I honestly tend not to get sick when I eat well and I exercise. He perceived a strong connection between health, nutrition, and exercise on a personal level and felt empowered to manage his health through diet and exercise. Other participants acknowledged the connection between diet and health but felt they had little control over longestablished eating habits. For example, one woman found eating nutritiously especially challenging at Hawaiian cultural events. She explained, You go to the kine [referring to the cultural event] and first it is Oh, the food! Oh look, theyve got malasadas [fried pastries], so you go over there and buy some. And then he [her husband] says, Oh, oxtail soup, so he go over there and go get some oxtails. . . . Stuff that basically we should stay away from. Fundamentally, she understood that fried, fatty foods were not good for her, but it was very difficult to change lifelong eating habits. Challenges with nutrition advice. Such deeply ingrained habits can contribute to participants resistance to nutrition education. This was especially evident when participants did not know health care providers well. For example, one participant disregarded nutrition advice given during an emergency department visit. She explained, He started telling me about what I should or shouldnt eat and about exercising. And I was like, OK, whatever. I mean, I guess I understand that he was doing his job, but it was like, You know what, thats my business what I eat. Although this encounter did not go well, her regular health care provider eventually persuaded her to attend a nutrition class. Unfortunately, she felt discouraged by what was taught. She said, Im sitting in class looking at just a little, this much of that, and half a cup of this and half a cup of that. And Im thinking, Lady, you crazy! Ill be hungry after eating half a cup of this and half a cup of thatIll be hungry in another half an hour or an hour. OvereatingA culturally sanctioned indulgence. Overeating is a culturally sanctioned indulgence many participants enjoyed. One participant described this by saying, Kanak attack is the way they say it in Hawaii, but the English way of saying Kanak attack is Hawaiian paralysis. They just eat. You dont

67 eat till youre full. They say you eat till youre tired. Thus, when Native Hawaiians eat, especially at gatherings, they often overeat to the point of exhaustion. Most participants found food more affordable in Las Vegas. This led to regular indulgence in large portions of food. One participant explained food preparation by saying, We dont know how to cook little! Everythings in big pots! When we first moved here, it was crazy. . . . You go to the store, five cucumbers for a dollar, how many pounds tomatoes for a dollar, three heads cabbage for a dollar. You go, Wow! Like her, several participants expressed excitement about grocery prices in Las Vegas. This often led to buying too much food and then eating it to avoid wasting it. In addition to lower grocery prices, participants enjoyed the abundance of relatively inexpensive restaurants in Las Vegas, including Hawaiian restaurants. One man explained, As soon as I got here, I realized all these foods that I love, theyre cheap! Theres so much Hawaiian food! And all these foods are, of course, not necessarily good for you. I mean, once and a while, thats not gonna kill you. In this exemplar, the notion is again evident that some Hawaiian-style foods are unhealthy. He tried to compensate by only eating it once and a while. Though Hawaiian food seemed especially tempting, other restaurants were also appealing. Regarding his tendency to overeat at buffets, one man quipped, They used to call me buff man when I came here, and now they call me buffet man. I picked up about 30 pounds, but, you know, I can still walk. Less expensive food in Las Vegas and the culturally accepted practice of overeating combine to create an atmosphere that participants enjoyed in spite of acknowledged health risks.

The Role of Food in Perceptions of Well-Being

On an intellectual level, participants understood what they ate influenced their health. On emotional and social levels, however, food played an important role in well-being. Themes in this category are positive emotions from eating and food as a social lubricant. Positive emotions from eating. Participants all related positive emotions associated with eating, especially Hawaiian food. Many experienced a sense of calm and a cultural connection, as one participant expressed, When I eat Hawaiian food or poi [mashed taro] or whatever, it rejuvenates me. It gives me the strength, the mana [supernatural power], the power. If I eat Hawaiian food, its like, Okay, I dont miss it anymore.That kind of feeling. But then, you always do.

68 Although he longed to visit Hawaii, his finances prohibited such travel and seldom allowed him to eat in Hawaiian restaurants, which he called the next best thing to visiting Hawaii. Occasionally this participant received Hawaiian food from a coworker. As he related these experiences, there was a reverent, spiritual tone to his expression. He stated, It [the poi] is soits like gold! He [coworker] has friends from Hawaii that . . . brings him some . . . and he gives it to me, and I treasure it. . . .When youre eating it, you smell the trees. I used to love to go up in the mountains and just walk and just sit down and lean against the trees . . . and you miss that. The food you eat, it just brings you back. In addition to enjoying the food itself and the patriotic recollections it awakens, his coworkers willingness to share his precious commodity seems to strengthen their friendship. Hawaiian food as a social lubricant. Food and friendship also merge in Las Vegas many Hawaiian restaurants. They are not only access points for Hawaiian food; they are also likely locations to connect with other Native Hawaiians, as one participant shared, That is how I see them [Native Hawaiians in Las Vegas] feeling very connected to where they came from is by the food they eat. And another thing toothat [Hawaiian restaurants] is where the Hawaiians gather. So, they know theyre gonna run into somebody from Hawaii. I mean, how could you not? Hawaiian food is integral to Native Hawaiian culture, and it provides a social lubricant that brings Native Hawaiians together and helps establish friendships. Thus, the role of Hawaiian food and restaurants may be even more important to well-being in Las Vegas than it is in Hawaii, where they are more likely to connect regularly with other Native Hawaiians. It is noteworthy that participants simultaneously recognized Hawaiian-style food as essential to well-being and dangerous to health. They battled internally with their desire to experience the cultural connectedness from eating this food, yet not over indulge and hasten serious disease consequences. One participant offered an idea that could be helpful to others, Ill be full, but Ill still wanna eat more. And to be honest, I will. . . . I try to eat healthy things and just keep eating till Im tired . . . lots of salads, low fat this, low sodium this, and all these things. So, when I eat more, I may get the calories but not necessarily the things like cholesterol. The calories I can burn off. The cholesterolits a little tougher.

Journal of T ranscultural Nursing 22(1) He found a compromise that seemed to work for him. He minimized participation in Kanak attack by carefully selecting what he eats and exercising to compensate for excess calories.

Discussion
Food has an integral role in participants perceptions of health and well-being. Like Kim et al.s (2008) participants in Hawaii, participants in this study crave Hawaiian-style food and routinely overeat. This suggests food is important to well-being wherever Native Hawaiians live, but it may have added importance for migrants. Without a comparison group in Hawaii, this cannot be a definitive conclusion. However, participants identified amelioration of homesickness as an important benefit of eating Hawaiian-style food. This benefit is probably not experienced by Native Hawaiians in Hawaii. Relief from homesickness may enhance the desire to eat Hawaiian-style food after migration. Although participants were not asked about weight loss efforts, they might be receptive to culturally focused interventions, such as the previously discussed Waianae Diet Program and Ulieo Koa Program. When planning and implementing similar dietary programs for Native Hawaiian migrants, it would be helpful to remember that Hawaiian-style food may alleviate homesickness. Collaborating with Native Hawaiian migrants to find alternative ways to alleviate homesickness could improve the success of program participants. In addition, such dietary programs would face unique challenges on the mainland. Most important, vegetables and greens indigenous to Hawaii are not readily available in Las Vegas. Although their high cost was an issue for Native Hawaiians in Hawaii (Leslie, 2001), their limited availability in Las Vegas makes the cost even higher. A possible solution is less expensive substitutes, such as tomatoes, broccoli, and Chinese cabbages, which can replace traditional taro and sweet potato leaves (Leslie, 2001). Teaching appropriate substitutions would help migrants who are willing to incorporate their ancestors dietary habits. Additionally, Kim et al. (2008) found Native Hawaiians perceived Hawaiian-style foods as healthy because they often include vegetables. However, these foods are commonly prepared with animal fat and canned processed meats. To reduce the fat content in their diet, Native Hawaiian migrants could be taught the importance of cutting out excess fat from meats and removing the skin from chicken before cooking it (Kim et al., 2008). To further support cultural connectedness, Native Hawaiian migrants could be encouraged to expend calories, as their ancestors did, in strenuous physical activities. The Waianae Diet Program and the Ulieo Koa Program both incorporate exercise as an important component, and it is worthy of emphasis in similar interventions in the U.S. mainland. Participants in this study enjoyed a variety of exercise from walking and working out to exercise with a distinctly Hawaiian flavor, such as outrigger canoeing and hula (ancient Hawaiian dance).

Lassetter Hawaiian Civic Clubs throughout the United States provide opportunities for traditional Hawaiian exercise. For example, the Las Vegas Hawaiian Civic Club sponsors outrigger canoeing activities and competitions at Lake Mead. Several participants participated in hula schools throughout Las Vegas. Some hula schools travel to Hawaii to compete in hula festivals, which could be an added incentive for regular, strenuous exercise. Additionally, outrigger canoeing and hula provide opportunities to learn about Hawaiian culture and socialize with other Native Hawaiians.

69 at ease. Additionally, discussing nutrition from a family framework rather than from an individual risk perspective might be more agreeable to Native Hawaiians (McGrath & Edwards, 2009). Future research is needed to identify other effective approaches in teaching Native Hawaiians about nutrition.

Summary
Food plays an integral role in Native Hawaiian culture, health, and well-being. Participants understood that overeating and eating food with little nutritional value are not good for their health. However, indulging in Kanak attack, a culturally sanctioned practice of overeating and experiencing relief from homesickness while eating Hawaiian-style food are important to many Native Hawaiian migrants well-being. These emotional aspects of eating need to be addressed in efforts to decrease obesity among Native Hawaiians. Acknowledgments
I am grateful to my participants for their insights and my dissertation committee for their guidance throughout this research. Members of my dissertation committee were Nancy Press, PhD; Sheila Kodadek, PhD, RN; Joan H. Baldwin, DNSc, RN, AHN; and Lynn C. Callister, PhD, RN, FAAN.

Implications for Future Research and Clinical Practice

There are several implications for research from this study. Future research on Native Hawaiian migrants efforts to lose weight would help clarify the emotional experiences associated with eating, especially in excess. Then dietary interventions could be refined to more thoroughly address this issue. Another area to explore is Native Hawaiian cultural perceptions of body size. It may be that the ancient preference for larger bodies still lingers in contemporary Hawaiian culture and mitigates the Western stigma associated with being overweight (Ochner et al., 2008). One way perceptions of ideal body size could be explored is to interview Native Hawaiian parents about their perceptions of ideal body size for children. This could lead to interventions targeted at the developmental period when nutritional habits are established. Clark (2006) conducted a similar study with Hispanic mothers and learned helpful information to apply in dietary interventions in that population. Meanwhile, nurses should remember Native Hawaiian migrants experience relief from homesickness when they eat their ethnic foods, and this can contribute to unhealthy weights. Dietary interventions, such as the Waianae Diet Program and the Ulieo Koa Program, appeal to Native Hawaiians cultural pride; therefore, similar programs in the U.S. mainland may help overweight Native Hawaiian migrants. The exercise component of these successful programs can also be incorporated into interventions and recommendations. For instance, nurses can stress that when Native Hawaiians indulge in Kanak attack, they should eat low-calorie foods and exercise sufficiently to expend their increased energy intake. Teaching these ideas might help, but teaching them to never participate in Kanak attack will likely be resisted or completely ignored. Finally, nurses have to get acquainted with Native Hawaiian patients before collaborating on ways to improve their diet. Participants in this research resisted teaching from unfamiliar health care providers. Similarly, Fujita et al. (2001) recommended avoiding terms such as obesity or obese because they are objectionable to Native Hawaiians and might alienate them. Whenever possible, a few minutes should be taken to discuss a Native Hawaiian patients family before discussing health issues; this is culturally appropriate and may put the patient

Declaration of Conflicting Interests

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

Funding
The author(s) disclosed receipt of the following financial support for the research and/or authorship of this article: Funding for this research included a Deans Award from Oregon Health & Science University School of Nursing and a Research Grant from Brigham Young University College of Nursing.

References
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