On a global scale, obesity is the single biggest risk factor contributing to poor health outcomes, reduced quality of life, increased health care costs and is a major contributor to chronic disease and disability (eg, type 2 diabetes mellitus).1 New Zealand has one of the highest obesity rates in world. Three in ten adults (aged 15+ years), or 31% of the total population of New Zealand were obese (ie, having a body mass index (BMI) kg/m2 >30).2 Pacific people residing in New Zealand have the highest prevalence of obesity based on the BMI definition (68%), and within the adolescent age group (15-24 year olds), 21% were classified as being obese, and the rate increases with age.2 Thus, in New Zealand, obesity disproportionately affects Pacific people, compared to the general population.Pacific people comprise approximately 7% of the total population in New Zealand.3 Much of the previous work has been conducted among older Pacific people, who have established high risk factors for a range of medical conditions such as stroke, cardiovascular disease, and type 2 diabetes mellitus, for which obesity is a risk factor. However, there is a growing amount of work conducted among adolescents and youth, who span a wide age range (aged 8-22 years).4-6 There is scant research that has focused on young Pacific people in the 16-24 year age group, who comprise 19% of the total Pacific population.7 For this paper, aligned to the New Zealand Census data, we have defined youth according to the 16-24-year-old range. This is an important age group, because they have the independence and capacity to understand their own, as well as their families, social realities,8,9 and if given the opportunity, they could make a unique contribution to addressing issues relating to their social and cultural environment, which may have an important impact on pathways contributing to obesity. In this paper, we proposed to take a social-ecological approach examining obesity that includes environmental influences, which has been defined, according to Swindburn and Eggers (1999), as: the sum of influences that the surroundings, opportunities, or conditions of life have on promoting obesity in individuals or populations.10 The current study focused specifically on the social (including parts of the ecological), cultural and historical pathways, where the biggest gap in the knowledge base was recognised.11Previous research has examined how social changes could affect the health and well-being of young people aged 13-18 years, in particular, the role of family meals .12 Results from the Youth 07 Survey highlighted similar findings from international evidence, that shared family meals provide: opportunities for building family relationships;13 consumption of healthy food;13,14 and protection against indicators of depression or risk-taking behaviours.15 Approximately 30% of Pacific adolescents reported infrequently sharing meals with their families, compared to 20% of European adolescents, and this was partially explained by economic deprivation.16 However, the national survey results do not provide any mechanisms for understanding how, who, and why, or the number of shared meals required, in order to promote better health and well-being, and protection against obesity. The survey is also limited in understanding the Pacific culture of food and family structure (for example, traditionally, Pacific children tend to eat separately from the adults). Few reported studies have investigated the role of the social-cultural determinants of the obesogenic environment, which is defined as; physiological, behavioural, and environmental factors such as social marketing strategies of persuasive and pervasive food, that drive the obesity environment.17 To our knowledge, there is limited data on the social-cultural determinants (eg, social-peer interactions and support, family relationships, racism and discrimination) of overall health and well-being in relation to socioeconomic position, cultural nativity, and acculturation, particularly in the 16-24-year-old age group, and among young Pacific people. Social-cultural determinants were highlighted by Durie,11 as well as others,18 as playing a potentially important role having some causal basis in the acculturation process.Arguably, if the biological risk factors were the only drivers of ethnic differences in all-cause mortality, then Pacific people should have the highest mortality rates.19 For the most part, investigating Pacific culture and its benefits on health is necessary, but it is often defined and investigated differently, thus making comparisons between studies difficult.20,21 Exploring culture and health encompassed in a broader social-ecological spectrum (eg, indigenous knowledge), may provide important information that can point to innovative ideas for intervention, be culturally acceptable for a specific age group, and actionable in relation to policy development and implementation. Indigenous knowledge encompasses life experiences developed over generations and include: culturally coded ways of communication; preservation and reproduction of the arts; genealogical ties; and close integration with the environment. Much of this knowledge is continued and sustained through churches, communal gatherings, reciprocal exchange of goods, ceremonial occasions and transference of stories and values to the younger generation.22,23 Due to the strong nature and structure of Pacific people and their cultures, Pasifika youth are more likely to have this indigenous knowledge embedded very early on in life and sustained through their communal and familial gatherings.The aim of this study was to explore the social-cultural determinants of the obesogenic environment among young Pacific people aged 16-24 years living in New Zealand. The investigation included documenting lived experiences of obesity and body size, relationship of cultural values and beliefs regarding food, and the impact of these experiences as they relate to the participants. The 16-24 year age group was selected for several reasons. It: (i) comprises approximately 19% of the total Pacific population in New Zealand8 and 21% of this age group are obese;24 (ii) is regarded as a critical period for developing a basis for better health, and good health-promoting behaviours;8 and (iii) is an age group that has the capacity to take up early prevention and intervention strategies if the opportunity is available,25-29 because they have the independence to make lifestyle changes, that not only will improve their own future health status, but it will also have long-term implications for the wellbeing of future generations of Pacific peoples. The origins of this study, Chewing the facts on fat (CTFF), provides an overall understanding integrating knowledge drawn from social, cultural and historical data that can be translated later into actionable knowledge (eg, development of resources) specifically for Pacific people. The project received ethical approval from the Central Health and Disability Ethics Committee, New Zealand (13/CEN/22).MethodsThe current paper presents, in part, findings from the work conducted in the first phase of the study. We conducted in-depth interviews among a convenience sample of 30 Pacific participants (16-24years). The number of interviews required for the study was based on purposive sampling, determined on the basis of theoretical saturation, which may be achieved from anywhere between 15-20 interviews.30-32 However, we elected to conduct up to 30 interviews for each phase, which is more than sufficient as an exploratory study. The youth were recruited and invited to participate through two primary health care providers in two different locations: Wellington and Auckland, New Zealand. Both providers played an important role in the recruitment and follow-up of the participants throughout the initial part of the study. The trained research assistants, of whom were both registered nurses and youth counsellors also resided and worked at the collaborating health providers, contacted Pacific youth who: (i) self-identified as being Pacific youth between the aged 16-24 years; (ii) had one living parent and grandparent or care-giver that was of Pacific ethnicity; and (iii) were enrolled at the participating Primary Health Organisations in Wellington or Auckland, New Zealand. From here onwards, we will refer to the young Pacific people as Pasifika youth.Overall, there were three phases of the study. However, for the purpose of this paper, we will be presenting the findings from phase one of the project. Phase one included a 90-minute interview by a trained Pacific research assistant. All interviews were conducted face-to-face and in English. Each participant had access to a copy of the questionnaire during the interview, so they could refer to the questions during the interview. Where possible, questions were drawn from validated and/or previously used questionnaires. The questionnaire comprised information on demography, cultural perspectives, living arrangements, and a range of health behaviours such as sleep hygiene and quality, cigarette smoking habits, diet and nutrition (over a 7-day period).Age and ethnicity were defined and self-identified, respectively, at the time of the interview. Deprivation was assessed using the New Zealand Deprivation Index 2013 measure,33 a small area based measure of deprivation derived from the 2013 Census, which uses nine variables (benefit income, employment, household income, communication, transport, support, qualifications, living space and home ownership) from the Census to place small area blocks on a deprivation scale from 1 to 10, with 10 representing the most deprived 10% of New Zealand areas, while 1 represents the 10% least deprived areas. For analyses, deprivation was categorised into quintiles combining deciles 1-2, 3-4, 5-6, 7-8 and 9-10.Education achievement was dichotomised into whether participants left school with some measured national level of school qualifications (eg, NCEA) and those who obtained post-school qualifications (ie, Trade Course Certificates, Diplomas).The research assistants measured and reported each participant s weight and height, from which BMI was determined. For this study, we used the international standard cut-offs in defining obesity.34 BMI was analysed as a continuous variable, with a BMI of 25-29.9 kg/m2 and \u226530kg/m2 defined as being obese and overweight, respectively.35 Waist-to-hip circumference was also measured, from which the waist-hip ratio (WHR) was determined, to provide a measure of central adiposity, indicating associated risk of incident cardiovascular events.36 We also calculated the waist-to-height ratio (WHtR), as an adjunct measure of central obesity, which is less prone to measurement error than WHR.37,38As a novel aspect, we also collected receipts of purchased food from the participants over a 1-week period, to explore actual food purchasing behaviours, in order to obtain a snapshot of what and where Pasifika youth were spending their money. Although obtaining a snapshot of these behaviours is not a novel approach in the public health research context, the use of purchased receipts is new and different. This is the first time that a geographic information system (GIS) tool has been used to map the food receipts as a proxy measure of describing purchasing behaviours of Pasifika youth. In previous studies, geocodes of urban and residential neighbourhoods and fast-food and convenient store outlets using straight line buffers were used to examined their proximities to stores.39-42 For the current study, we wanted to examine how best to use GIS and receipts as an actual measure of food purchasing behaviours within the Pasifika youths local and residential obesogenic environment. We used the ArcGIS 10.1 tool to input the receipt information and produced depictions of purchases of food and snacks over a 7-day period, collected from the participants. The food purchases were grouped into four categories: $100; $25-99; $10-24; and <$10.Due to the exploratory nature of this study, cultural perspectives on dietary lifestyle and influence on body size underwent thematic analyses, and the responses were grouped and coded according to the main themes drawn out from the analyses. We also grouped analogous themes of responses where open questions were asked to describe or explain beliefs and perspectives. We managed the trustworthiness of the qualitative data at phase three of the study, at a workshop, where we presented the preliminary findings of the overall project to the participants as a process of validating the content. The participants did not identify any issues or discrepancies or misleading inferences from our analysis.Self-examination of perceived body size was investigated by utilising somatotype pictures, which was used in a previous study that was pretested among Pacific people.43 They are presented in Figure 1. The participants were asked to select the image that best reflects their perceived current body size and then to select a perceived ideal body size, with a space provided for participants to explain their selections, as appropriate.Figure 1: Somatotype body size types.The acculturation tool used in this study was developed by researchers of the Kohala Health Research Project,44 and it was included in this project because it is a validated tool among adult Native Hawaiians examining similar health outcomes (metabolic health problems).44 Following the Kohala Health Research Project, we analysed the responses by grouping the summed responses into the following categories: integrated (high affiliation with Pacific heritage and mainstream culture); tradition (high affiliation with Pacific heritage only); assimilated (high affiliation with mainstream culture only); and marginalised(low affiliation with both Pacific heritage and mainstream culture). A copy of the full questionnaire is available from the authors on request.ResultsDetails of the participant s characteristics are described in Table 1. A wide range of pan-Pacific ethnic groups were represented, indicating a diversity of Pacific ethnic groups in the younger generation of Pacific peoples in New Zealand. Samoans were the largest self-identified ethnic group in this study sample. The participants presented with minor co-morbidities, with only 20% presenting with treatment of asthma symptoms. In terms of socio-economic position, almost half of the study sample resided in the highest deprivation quintile.33Table 1: Distribution of participant characteristics.\r\n \r\n \r\n \r\n Characteristics\r\n \r\n N\r\n \r\n %\r\n \r\n \r\n \r\n Sex\r\n \r\n \r\n \r\n Male\r\n \r\n 11\r\n \r\n 36.7\r\n \r\n \r\n \r\n Female\r\n \r\n 19\r\n \r\n 63.3\r\n \r\n \r\n \r\n Ethnicity\r\n \r\n \r\n \r\n NZ European\r\n \r\n 3\r\n \r\n 10\r\n \r\n \r\n \r\n M\u0101ori\r\n \r\n 1\r\n \r\n 3.3\r\n \r\n \r\n \r\n Samoan\r\n \r\n 14\r\n \r\n 46.7\r\n \r\n \r\n \r\n Cook Island M\u0101ori\r\n \r\n 3\r\n \r\n 10\r\n \r\n \r\n \r\n Tongan\r\n \r\n 7\r\n \r\n 23.3\r\n \r\n \r\n \r\n Niuean\r\n \r\n 4\r\n \r\n 13.3\r\n \r\n \r\n \r\n Chinese\r\n \r\n 5\r\n \r\n 16.7\r\n \r\n \r\n \r\n Indian\r\n \r\n 1\r\n \r\n 3.3\r\n \r\n \r\n \r\n Other\r\n \r\n 9\r\n \r\n 30\r\n \r\n \r\n \r\n Education\r\n \r\n \r\n \r\n Obtained school qualifications\r\n \r\n 22\r\n \r\n 73\r\n \r\n \r\n \r\n Obtained qualifications since leaving school\r\n \r\n 13\r\n \r\n 43\r\n \r\n \r\n \r\n Co-morbidities\r\n \r\n \r\n \r\n Asthma\r\n \r\n 6\r\n \r\n 20\r\n \r\n \r\n \r\n Psychological problem\r\n \r\n 1\r\n \r\n 3.3%\r\n \r\n \r\n \r\n Sleep problem\r\n \r\n 1\r\n \r\n 3.3\r\n \r\n \r\n \r\n Other conditions: Eczema\r\n \r\n 2\r\n \r\n 6.6\r\n \r\n \r\n \r\n NZ Dep2013 (quintiles)\r\n \r\n \r\n \r\n 1-2\r\n \r\n 2\r\n \r\n 6.6\r\n \r\n \r\n \r\n 3-4\r\n \r\n 4\r\n \r\n 13.3\r\n \r\n \r\n \r\n 5-6\r\n \r\n 1\r\n \r\n 3.3\r\n \r\n \r\n \r\n 7-8\r\n \r\n 9\r\n \r\n 30\r\n \r\n \r\n \r\n 9-10\r\n \r\n 14\r\n \r\n 46.7\r\n \r\n \r\n \r\n \r\n \r\n N\r\n \r\n Mean\r\n \r\n \r\n \r\n Body Weight\r\n \r\n \r\n \r\n Weight\r\n \r\n 30\r\n \r\n 90.5kg\r\n \r\n \r\n \r\n Height\r\n \r\n 29\r\n \r\n 170.4cm\r\n \r\n \r\n \r\n Waist\r\n \r\n 26\r\n \r\n 95.4cm\r\n \r\n \r\n \r\n Hip\r\n \r\n 26\r\n \r\n 113.1cm\r\n \r\n \r\n \r\n BMI\r\n \r\n 29\r\n \r\n 31.0kg/m2\r\n \r\n \r\n \r\n WHR\r\n \r\n 26\r\n \r\n 0.84\r\n \r\n \r\n \r\n WHtR\r\n \r\n 25\r\n \r\n 0.6\r\n \r\n \r\n \r\n Domestic Environment\r\n \r\n \r\n \r\n Rooms in house\r\n \r\n 30\r\n \r\n 5.6\r\n \r\n \r\n \r\n People living in house\r\n \r\n 29\r\n \r\n 5.9\r\n \r\n \r\n \r\nTable 2: Cultural perspectives.\r\n \r\n \r\n \r\n Questions\r\n \r\n N\r\n \r\n %\r\n \r\n \r\n \r\n Do you have cultural-spiritual beliefs?\r\n \r\n \r\n \r\n Yes\r\n \r\n 25\r\n \r\n 83\r\n \r\n \r\n \r\n No\r\n \r\n 5\r\n \r\n 16.7\r\n \r\n \r\n \r\n Do the cultural-spiritual beliefs influence body size perceptions?\r\n \r\n \r\n \r\n Yes\r\n \r\n 9\r\n \r\n 30\r\n \r\n \r\n \r\n No\r\n \r\n 20\r\n \r\n 66.7\r\n \r\n \r\n \r\n Missing\r\n \r\n 1\r\n \r\n 3.3\r\n \r\n \r\n \r\n Select the body size that you perceive looks most like you now?\r\n \r\n \r\n \r\n Size 2\r\n \r\n 4\r\n \r\n 13.3\r\n \r\n \r\n \r\n Size 3\r\n \r\n 6\r\n \r\n 20\r\n \r\n \r\n \r\n Size 4\r\n \r\n 9\r\n \r\n 30\r\n \r\n \r\n \r\n Size 5\r\n \r\n 6\r\n \r\n 20\r\n \r\n \r\n \r\n Size 6\r\n \r\n 5\r\n \r\n 16.7\r\n \r\n \r\n \r\n Select your ideal body size?\r\n \r\n \r\n \r\n Size 2\r\n \r\n 7\r\n \r\n 23.3\r\n \r\n \r\n \r\n Size 3\r\n \r\n 11\r\n \r\n 36.7\r\n \r\n \r\n \r\n Size 4\r\n \r\n 7\r\n \r\n 23.3\r\n \r\n \r\n \r\n Size 5\r\n \r\n 5\r\n \r\n 16.7\r\n \r\n \r\n \r\n Acculturation scores\r\n \r\n \r\n \r\n Integrated\r\n \r\n 24\r\n \r\n 80\r\n \r\n \r\n \r\n Traditional\r\n \r\n 2\r\n \r\n 6.7\r\n \r\n \r\n \r\n Assimilated\r\n \r\n 3\r\n \r\n 10\r\n \r\n \r\n \r\n Marginalised\r\n \r\n 1\r\n \r\n 3.3\r\n \r\n \r\n \r\nAll participants lived in homes with approximately five rooms per house on average, and the number of people living in these homes ranged from one to 13 persons.The youthfulness attribute of this study was reflected by their educational status as being predominantly school-level achievements being reported, and four of the 30 are currently attending university institutions to attain higher education status.In describing the study participants, on average they are heavy in weight (90.5kg) and tall in height (170.4cm), thus reporting a higher BMI (range: 20.9-49.4kg/m2), and a relatively high WHR (mean: 0.8; range: 0.7-0.9) and WHtR (mean: 0.56; range 0.4-0.7). The WHO cut-off for WHR for men is \u22650.9 and \u22650.8 for women.38 In our study, for the WHtR scores \u22640.5 is deemed healthy.37A large proportion (80%) of the participants assessed their acculturation mode as being integrated , indicating this study sample as having a high degree of affiliation with both their Pacific heritage and the mainstream culture.Over 80% of the participants have strong connections with their communities, as characterised by their strong affiliation with a church group, heavily placed values in spiritual beliefs, and participation in community affairs. This is common of New Zealand Pacific and other youth (school-aged) in general.45,46 However, when asked if their cultural and spiritual beliefs influence the food they eat, the majority (66%) of the participants reported that their belief systems do not have an influence on the food they eat. Six participants did not answer this question. For the remainder of participants who reported that their spiritual beliefs do have an influence, we grouped similar responses into two main themes: (i) spiritual beliefs influence food, because it is part of the Pasifika culture (n=10), personal interactions generally involve a reciprocal exchange of food (or money); and (ii) it is part of the culture of the church (n=9), including traditional activities such as, weddings, Sunday school, White Sunday (n=9).Self-examination of perceived current and ideal body sizes depicted from Figure 1, indicated that the majority of participants regarded size four as being their perceived current body size, and size three as being their perceived ideal body size. A large proportion (66.7%) of the participants agreed that their cultural beliefs do not influence body size perceptions. Only eight participants said that being big is normal and healthy, from a Pasifika perspective. Five of these eight people reported that being big in body size is not an important social issue, and nor is it regarded as a health priority. Alternatively, other viewpoints from 22 participants reported that having a big body is not healthy , with a similar number (n=21) agreeing that a big body size has the propensity for poor health. A small number of the participants (n=4) supported a cultural perspective as a way of thinking that inhibits people s views of how health and body size are perceived. That is, cultural viewpoints can impede living a healthier lifestyle and being receptive to new knowledge, although this was not a strong indicator in this study.Based on the acculturation tool used in this study, the majority of the participants were reportedly: integrated (80%), followed by assimilated (10%), traditional (6.7%), and marginalised (3.3%). This indicates that for Pasifika youth in this study, most of them have equally strong affiliations to their Pasifika, and the mainstream culture.By observing the food purchasing behaviours of Pasifika youth by entering their spontaneous and weekly food purchases, the GIS tool illustrates exploratory patterns that differ between the Auckland and Wellington-based youth, as seen in Figures 2 (Auckland) and 3 (Wellington). In particular, the Auckland youth bought food only within their immediate neighbourhood, and the Wellington youth purchased food across a diverse range of food outlets and across a larger geographic distance, in some cases over 10kms from their home address (individual data not presented here).Figure 2: Food purchasing patterns for Pacific youth, Auckland, New Zealand.Figure 3: Food purchasing patterns for Pacific youth, Wellington, New Zealand.DiscussionThe findings presented here provide interesting social-cultural perspectives of obesity from Pasifika youth in New Zealand. Many of the findings are in agreement with what has been previously reported on known obesity risk factors associated with poor health outcomes for Pacific people, in general.3,26,28,29 However, some important new patterns of behaviour and knowledge were found that may be beneficial for researchers to consider when developing obesity intervention and preventative strategies, particularly for populations that have a strong affiliation with their culture, regardless of being obese or having a large body size.Before discussing these, we acknowledge that the study has some limitations, particularly as it is primarily exploratory in nature and involved a small number of study participants. However, in this discussion segment, we would like to highlight the knowledge gained from this study.Although, the quantitative findings are subjected only to the participants of this study, we wanted to observe how participants with high or low WHtR rated across the different modes of acculturation. The results showed that 55% of participants with an integrated acculturation mode had a high WHtR (>0.5), indicating that this group of Pasifika youth have an unequivocally strong affiliation with the mainstream and Pasifika cultures. The strong connection towards the mainstream culture was expected, particularly as 50% of Pasifika children and youth are born in New Zealand.3 An interesting aspect of this finding is to determine whether the move away from traditional Pasifika cultures alone is due to acculturation, which may play an important role in weakening traditional values and lifestyle.47 This is important, because it is thought that indigenous Pasifika cultures could provide protection for optimal health and wellbeing for their own people. For example, according to the New Zealand Mental Health Survey (Te Rau Hinengaro), Pacific-born people who migrated to New Zealand at an older age (18+ years) have a lower prevalence of mental disorders, compared to New Zealand-born Pacific people.48 The participants perceptions of their cultural context and spiritual beliefs having less or no influence on their body size and the types of food they eat support the interesting aspect highlighted above. There was also a good indication that the youth participants have a good knowledge base of the serious health consequences of being overweight or having a large body size.For those who perceived that Pasifika culture and spiritual beliefs do have an influence on body size, our crude thematic analyses highlighted that our Pasifika participants have a greater acceptance of large body sizes based on a spiritual foundation (ie, that we were created in the image of God). Having a thinner body size was less tolerated and often denoted sickness. However, the participants reported that being big attracts social risks (eg, being teased and feeling embarrassed). These same participants also rated themselves as being marginalised, according to the acculturation tool.Increased body weight is a known risk factor for long-term non-communicable diseases, such as cardiovascular disease26,28 and diabetes.1,29 However, the study participants presented with a higher than average BMI (WHR and WHtR) scores, and this is compounded by the presence of other known proximal factors (high deprivation and comorbidity), which illustrates time and again the poor health outcomes projected for Pasifika people, and particularly that of the younger generation.1,24,49,50Our study highlighted the impact of social and cultural factors within their immediate obesogenic environment. Firstly, participant perceptions in relation to perceived and ideal body sizes demonstrated that there is an unequivocal awareness and knowledge among this group of participants about the impending poor health outcomes, secondary to obesity. While the youth identified themselves as having bigger somatotype body sizes, they also viewed themselves as havi

On a global scale, obesity is the single biggest risk factor contributing to poor health outcomes, reduced quality of life, increased health care costs and is a major contributor to chronic disease and disability (eg, type 2 diabetes mellitus).1 New Zealand has one of the highest obesity rates in world. Three in ten adults (aged 15+ years), or 31% of the total population of New Zealand were obese (ie, having a body mass index (BMI) kg/m2 >30).2 Pacific people residing in New Zealand have the highest prevalence of obesity based on the BMI definition (68%), and within the adolescent age group (15-24 year olds), 21% were classified as being obese, and the rate increases with age.2 Thus, in New Zealand, obesity disproportionately affects Pacific people, compared to the general population.Pacific people comprise approximately 7% of the total population in New Zealand.3 Much of the previous work has been conducted among older Pacific people, who have established high risk factors for a range of medical conditions such as stroke, cardiovascular disease, and type 2 diabetes mellitus, for which obesity is a risk factor. However, there is a growing amount of work conducted among adolescents and youth, who span a wide age range (aged 8-22 years).4-6 There is scant research that has focused on young Pacific people in the 16-24 year age group, who comprise 19% of the total Pacific population.7 For this paper, aligned to the New Zealand Census data, we have defined youth according to the 16-24-year-old range. This is an important age group, because they have the independence and capacity to understand their own, as well as their families, social realities,8,9 and if given the opportunity, they could make a unique contribution to addressing issues relating to their social and cultural environment, which may have an important impact on pathways contributing to obesity. In this paper, we proposed to take a social-ecological approach examining obesity that includes environmental influences, which has been defined, according to Swindburn and Eggers (1999), as: the sum of influences that the surroundings, opportunities, or conditions of life have on promoting obesity in individuals or populations.10 The current study focused specifically on the social (including parts of the ecological), cultural and historical pathways, where the biggest gap in the knowledge base was recognised.11Previous research has examined how social changes could affect the health and well-being of young people aged 13-18 years, in particular, the role of family meals .12 Results from the Youth 07 Survey highlighted similar findings from international evidence, that shared family meals provide: opportunities for building family relationships;13 consumption of healthy food;13,14 and protection against indicators of depression or risk-taking behaviours.15 Approximately 30% of Pacific adolescents reported infrequently sharing meals with their families, compared to 20% of European adolescents, and this was partially explained by economic deprivation.16 However, the national survey results do not provide any mechanisms for understanding how, who, and why, or the number of shared meals required, in order to promote better health and well-being, and protection against obesity. The survey is also limited in understanding the Pacific culture of food and family structure (for example, traditionally, Pacific children tend to eat separately from the adults). Few reported studies have investigated the role of the social-cultural determinants of the obesogenic environment, which is defined as; physiological, behavioural, and environmental factors such as social marketing strategies of persuasive and pervasive food, that drive the obesity environment.17 To our knowledge, there is limited data on the social-cultural determinants (eg, social-peer interactions and support, family relationships, racism and discrimination) of overall health and well-being in relation to socioeconomic position, cultural nativity, and acculturation, particularly in the 16-24-year-old age group, and among young Pacific people. Social-cultural determinants were highlighted by Durie,11 as well as others,18 as playing a potentially important role having some causal basis in the acculturation process.Arguably, if the biological risk factors were the only drivers of ethnic differences in all-cause mortality, then Pacific people should have the highest mortality rates.19 For the most part, investigating Pacific culture and its benefits on health is necessary, but it is often defined and investigated differently, thus making comparisons between studies difficult.20,21 Exploring culture and health encompassed in a broader social-ecological spectrum (eg, indigenous knowledge), may provide important information that can point to innovative ideas for intervention, be culturally acceptable for a specific age group, and actionable in relation to policy development and implementation. Indigenous knowledge encompasses life experiences developed over generations and include: culturally coded ways of communication; preservation and reproduction of the arts; genealogical ties; and close integration with the environment. Much of this knowledge is continued and sustained through churches, communal gatherings, reciprocal exchange of goods, ceremonial occasions and transference of stories and values to the younger generation.22,23 Due to the strong nature and structure of Pacific people and their cultures, Pasifika youth are more likely to have this indigenous knowledge embedded very early on in life and sustained through their communal and familial gatherings.The aim of this study was to explore the social-cultural determinants of the obesogenic environment among young Pacific people aged 16-24 years living in New Zealand. The investigation included documenting lived experiences of obesity and body size, relationship of cultural values and beliefs regarding food, and the impact of these experiences as they relate to the participants. The 16-24 year age group was selected for several reasons. It: (i) comprises approximately 19% of the total Pacific population in New Zealand8 and 21% of this age group are obese;24 (ii) is regarded as a critical period for developing a basis for better health, and good health-promoting behaviours;8 and (iii) is an age group that has the capacity to take up early prevention and intervention strategies if the opportunity is available,25-29 because they have the independence to make lifestyle changes, that not only will improve their own future health status, but it will also have long-term implications for the wellbeing of future generations of Pacific peoples. The origins of this study, Chewing the facts on fat (CTFF), provides an overall understanding integrating knowledge drawn from social, cultural and historical data that can be translated later into actionable knowledge (eg, development of resources) specifically for Pacific people. The project received ethical approval from the Central Health and Disability Ethics Committee, New Zealand (13/CEN/22).MethodsThe current paper presents, in part, findings from the work conducted in the first phase of the study. We conducted in-depth interviews among a convenience sample of 30 Pacific participants (16-24years). The number of interviews required for the study was based on purposive sampling, determined on the basis of theoretical saturation, which may be achieved from anywhere between 15-20 interviews.30-32 However, we elected to conduct up to 30 interviews for each phase, which is more than sufficient as an exploratory study. The youth were recruited and invited to participate through two primary health care providers in two different locations: Wellington and Auckland, New Zealand. Both providers played an important role in the recruitment and follow-up of the participants throughout the initial part of the study. The trained research assistants, of whom were both registered nurses and youth counsellors also resided and worked at the collaborating health providers, contacted Pacific youth who: (i) self-identified as being Pacific youth between the aged 16-24 years; (ii) had one living parent and grandparent or care-giver that was of Pacific ethnicity; and (iii) were enrolled at the participating Primary Health Organisations in Wellington or Auckland, New Zealand. From here onwards, we will refer to the young Pacific people as Pasifika youth.Overall, there were three phases of the study. However, for the purpose of this paper, we will be presenting the findings from phase one of the project. Phase one included a 90-minute interview by a trained Pacific research assistant. All interviews were conducted face-to-face and in English. Each participant had access to a copy of the questionnaire during the interview, so they could refer to the questions during the interview. Where possible, questions were drawn from validated and/or previously used questionnaires. The questionnaire comprised information on demography, cultural perspectives, living arrangements, and a range of health behaviours such as sleep hygiene and quality, cigarette smoking habits, diet and nutrition (over a 7-day period).Age and ethnicity were defined and self-identified, respectively, at the time of the interview. Deprivation was assessed using the New Zealand Deprivation Index 2013 measure,33 a small area based measure of deprivation derived from the 2013 Census, which uses nine variables (benefit income, employment, household income, communication, transport, support, qualifications, living space and home ownership) from the Census to place small area blocks on a deprivation scale from 1 to 10, with 10 representing the most deprived 10% of New Zealand areas, while 1 represents the 10% least deprived areas. For analyses, deprivation was categorised into quintiles combining deciles 1-2, 3-4, 5-6, 7-8 and 9-10.Education achievement was dichotomised into whether participants left school with some measured national level of school qualifications (eg, NCEA) and those who obtained post-school qualifications (ie, Trade Course Certificates, Diplomas).The research assistants measured and reported each participant s weight and height, from which BMI was determined. For this study, we used the international standard cut-offs in defining obesity.34 BMI was analysed as a continuous variable, with a BMI of 25-29.9 kg/m2 and \u226530kg/m2 defined as being obese and overweight, respectively.35 Waist-to-hip circumference was also measured, from which the waist-hip ratio (WHR) was determined, to provide a measure of central adiposity, indicating associated risk of incident cardiovascular events.36 We also calculated the waist-to-height ratio (WHtR), as an adjunct measure of central obesity, which is less prone to measurement error than WHR.37,38As a novel aspect, we also collected receipts of purchased food from the participants over a 1-week period, to explore actual food purchasing behaviours, in order to obtain a snapshot of what and where Pasifika youth were spending their money. Although obtaining a snapshot of these behaviours is not a novel approach in the public health research context, the use of purchased receipts is new and different. This is the first time that a geographic information system (GIS) tool has been used to map the food receipts as a proxy measure of describing purchasing behaviours of Pasifika youth. In previous studies, geocodes of urban and residential neighbourhoods and fast-food and convenient store outlets using straight line buffers were used to examined their proximities to stores.39-42 For the current study, we wanted to examine how best to use GIS and receipts as an actual measure of food purchasing behaviours within the Pasifika youths local and residential obesogenic environment. We used the ArcGIS 10.1 tool to input the receipt information and produced depictions of purchases of food and snacks over a 7-day period, collected from the participants. The food purchases were grouped into four categories: $100; $25-99; $10-24; and <$10.Due to the exploratory nature of this study, cultural perspectives on dietary lifestyle and influence on body size underwent thematic analyses, and the responses were grouped and coded according to the main themes drawn out from the analyses. We also grouped analogous themes of responses where open questions were asked to describe or explain beliefs and perspectives. We managed the trustworthiness of the qualitative data at phase three of the study, at a workshop, where we presented the preliminary findings of the overall project to the participants as a process of validating the content. The participants did not identify any issues or discrepancies or misleading inferences from our analysis.Self-examination of perceived body size was investigated by utilising somatotype pictures, which was used in a previous study that was pretested among Pacific people.43 They are presented in Figure 1. The participants were asked to select the image that best reflects their perceived current body size and then to select a perceived ideal body size, with a space provided for participants to explain their selections, as appropriate.Figure 1: Somatotype body size types.The acculturation tool used in this study was developed by researchers of the Kohala Health Research Project,44 and it was included in this project because it is a validated tool among adult Native Hawaiians examining similar health outcomes (metabolic health problems).44 Following the Kohala Health Research Project, we analysed the responses by grouping the summed responses into the following categories: integrated (high affiliation with Pacific heritage and mainstream culture); tradition (high affiliation with Pacific heritage only); assimilated (high affiliation with mainstream culture only); and marginalised(low affiliation with both Pacific heritage and mainstream culture). A copy of the full questionnaire is available from the authors on request.ResultsDetails of the participant s characteristics are described in Table 1. A wide range of pan-Pacific ethnic groups were represented, indicating a diversity of Pacific ethnic groups in the younger generation of Pacific peoples in New Zealand. Samoans were the largest self-identified ethnic group in this study sample. The participants presented with minor co-morbidities, with only 20% presenting with treatment of asthma symptoms. In terms of socio-economic position, almost half of the study sample resided in the highest deprivation quintile.33Table 1: Distribution of participant characteristics.\r\n \r\n \r\n \r\n Characteristics\r\n \r\n N\r\n \r\n %\r\n \r\n \r\n \r\n Sex\r\n \r\n \r\n \r\n Male\r\n \r\n 11\r\n \r\n 36.7\r\n \r\n \r\n \r\n Female\r\n \r\n 19\r\n \r\n 63.3\r\n \r\n \r\n \r\n Ethnicity\r\n \r\n \r\n \r\n NZ European\r\n \r\n 3\r\n \r\n 10\r\n \r\n \r\n \r\n M\u0101ori\r\n \r\n 1\r\n \r\n 3.3\r\n \r\n \r\n \r\n Samoan\r\n \r\n 14\r\n \r\n 46.7\r\n \r\n \r\n \r\n Cook Island M\u0101ori\r\n \r\n 3\r\n \r\n 10\r\n \r\n \r\n \r\n Tongan\r\n \r\n 7\r\n \r\n 23.3\r\n \r\n \r\n \r\n Niuean\r\n \r\n 4\r\n \r\n 13.3\r\n \r\n \r\n \r\n Chinese\r\n \r\n 5\r\n \r\n 16.7\r\n \r\n \r\n \r\n Indian\r\n \r\n 1\r\n \r\n 3.3\r\n \r\n \r\n \r\n Other\r\n \r\n 9\r\n \r\n 30\r\n \r\n \r\n \r\n Education\r\n \r\n \r\n \r\n Obtained school qualifications\r\n \r\n 22\r\n \r\n 73\r\n \r\n \r\n \r\n Obtained qualifications since leaving school\r\n \r\n 13\r\n \r\n 43\r\n \r\n \r\n \r\n Co-morbidities\r\n \r\n \r\n \r\n Asthma\r\n \r\n 6\r\n \r\n 20\r\n \r\n \r\n \r\n Psychological problem\r\n \r\n 1\r\n \r\n 3.3%\r\n \r\n \r\n \r\n Sleep problem\r\n \r\n 1\r\n \r\n 3.3\r\n \r\n \r\n \r\n Other conditions: Eczema\r\n \r\n 2\r\n \r\n 6.6\r\n \r\n \r\n \r\n NZ Dep2013 (quintiles)\r\n \r\n \r\n \r\n 1-2\r\n \r\n 2\r\n \r\n 6.6\r\n \r\n \r\n \r\n 3-4\r\n \r\n 4\r\n \r\n 13.3\r\n \r\n \r\n \r\n 5-6\r\n \r\n 1\r\n \r\n 3.3\r\n \r\n \r\n \r\n 7-8\r\n \r\n 9\r\n \r\n 30\r\n \r\n \r\n \r\n 9-10\r\n \r\n 14\r\n \r\n 46.7\r\n \r\n \r\n \r\n \r\n \r\n N\r\n \r\n Mean\r\n \r\n \r\n \r\n Body Weight\r\n \r\n \r\n \r\n Weight\r\n \r\n 30\r\n \r\n 90.5kg\r\n \r\n \r\n \r\n Height\r\n \r\n 29\r\n \r\n 170.4cm\r\n \r\n \r\n \r\n Waist\r\n \r\n 26\r\n \r\n 95.4cm\r\n \r\n \r\n \r\n Hip\r\n \r\n 26\r\n \r\n 113.1cm\r\n \r\n \r\n \r\n BMI\r\n \r\n 29\r\n \r\n 31.0kg/m2\r\n \r\n \r\n \r\n WHR\r\n \r\n 26\r\n \r\n 0.84\r\n \r\n \r\n \r\n WHtR\r\n \r\n 25\r\n \r\n 0.6\r\n \r\n \r\n \r\n Domestic Environment\r\n \r\n \r\n \r\n Rooms in house\r\n \r\n 30\r\n \r\n 5.6\r\n \r\n \r\n \r\n People living in house\r\n \r\n 29\r\n \r\n 5.9\r\n \r\n \r\n \r\nTable 2: Cultural perspectives.\r\n \r\n \r\n \r\n Questions\r\n \r\n N\r\n \r\n %\r\n \r\n \r\n \r\n Do you have cultural-spiritual beliefs?\r\n \r\n \r\n \r\n Yes\r\n \r\n 25\r\n \r\n 83\r\n \r\n \r\n \r\n No\r\n \r\n 5\r\n \r\n 16.7\r\n \r\n \r\n \r\n Do the cultural-spiritual beliefs influence body size perceptions?\r\n \r\n \r\n \r\n Yes\r\n \r\n 9\r\n \r\n 30\r\n \r\n \r\n \r\n No\r\n \r\n 20\r\n \r\n 66.7\r\n \r\n \r\n \r\n Missing\r\n \r\n 1\r\n \r\n 3.3\r\n \r\n \r\n \r\n Select the body size that you perceive looks most like you now?\r\n \r\n \r\n \r\n Size 2\r\n \r\n 4\r\n \r\n 13.3\r\n \r\n \r\n \r\n Size 3\r\n \r\n 6\r\n \r\n 20\r\n \r\n \r\n \r\n Size 4\r\n \r\n 9\r\n \r\n 30\r\n \r\n \r\n \r\n Size 5\r\n \r\n 6\r\n \r\n 20\r\n \r\n \r\n \r\n Size 6\r\n \r\n 5\r\n \r\n 16.7\r\n \r\n \r\n \r\n Select your ideal body size?\r\n \r\n \r\n \r\n Size 2\r\n \r\n 7\r\n \r\n 23.3\r\n \r\n \r\n \r\n Size 3\r\n \r\n 11\r\n \r\n 36.7\r\n \r\n \r\n \r\n Size 4\r\n \r\n 7\r\n \r\n 23.3\r\n \r\n \r\n \r\n Size 5\r\n \r\n 5\r\n \r\n 16.7\r\n \r\n \r\n \r\n Acculturation scores\r\n \r\n \r\n \r\n Integrated\r\n \r\n 24\r\n \r\n 80\r\n \r\n \r\n \r\n Traditional\r\n \r\n 2\r\n \r\n 6.7\r\n \r\n \r\n \r\n Assimilated\r\n \r\n 3\r\n \r\n 10\r\n \r\n \r\n \r\n Marginalised\r\n \r\n 1\r\n \r\n 3.3\r\n \r\n \r\n \r\nAll participants lived in homes with approximately five rooms per house on average, and the number of people living in these homes ranged from one to 13 persons.The youthfulness attribute of this study was reflected by their educational status as being predominantly school-level achievements being reported, and four of the 30 are currently attending university institutions to attain higher education status.In describing the study participants, on average they are heavy in weight (90.5kg) and tall in height (170.4cm), thus reporting a higher BMI (range: 20.9-49.4kg/m2), and a relatively high WHR (mean: 0.8; range: 0.7-0.9) and WHtR (mean: 0.56; range 0.4-0.7). The WHO cut-off for WHR for men is \u22650.9 and \u22650.8 for women.38 In our study, for the WHtR scores \u22640.5 is deemed healthy.37A large proportion (80%) of the participants assessed their acculturation mode as being integrated , indicating this study sample as having a high degree of affiliation with both their Pacific heritage and the mainstream culture.Over 80% of the participants have strong connections with their communities, as characterised by their strong affiliation with a church group, heavily placed values in spiritual beliefs, and participation in community affairs. This is common of New Zealand Pacific and other youth (school-aged) in general.45,46 However, when asked if their cultural and spiritual beliefs influence the food they eat, the majority (66%) of the participants reported that their belief systems do not have an influence on the food they eat. Six participants did not answer this question. For the remainder of participants who reported that their spiritual beliefs do have an influence, we grouped similar responses into two main themes: (i) spiritual beliefs influence food, because it is part of the Pasifika culture (n=10), personal interactions generally involve a reciprocal exchange of food (or money); and (ii) it is part of the culture of the church (n=9), including traditional activities such as, weddings, Sunday school, White Sunday (n=9).Self-examination of perceived current and ideal body sizes depicted from Figure 1, indicated that the majority of participants regarded size four as being their perceived current body size, and size three as being their perceived ideal body size. A large proportion (66.7%) of the participants agreed that their cultural beliefs do not influence body size perceptions. Only eight participants said that being big is normal and healthy, from a Pasifika perspective. Five of these eight people reported that being big in body size is not an important social issue, and nor is it regarded as a health priority. Alternatively, other viewpoints from 22 participants reported that having a big body is not healthy , with a similar number (n=21) agreeing that a big body size has the propensity for poor health. A small number of the participants (n=4) supported a cultural perspective as a way of thinking that inhibits people s views of how health and body size are perceived. That is, cultural viewpoints can impede living a healthier lifestyle and being receptive to new knowledge, although this was not a strong indicator in this study.Based on the acculturation tool used in this study, the majority of the participants were reportedly: integrated (80%), followed by assimilated (10%), traditional (6.7%), and marginalised (3.3%). This indicates that for Pasifika youth in this study, most of them have equally strong affiliations to their Pasifika, and the mainstream culture.By observing the food purchasing behaviours of Pasifika youth by entering their spontaneous and weekly food purchases, the GIS tool illustrates exploratory patterns that differ between the Auckland and Wellington-based youth, as seen in Figures 2 (Auckland) and 3 (Wellington). In particular, the Auckland youth bought food only within their immediate neighbourhood, and the Wellington youth purchased food across a diverse range of food outlets and across a larger geographic distance, in some cases over 10kms from their home address (individual data not presented here).Figure 2: Food purchasing patterns for Pacific youth, Auckland, New Zealand.Figure 3: Food purchasing patterns for Pacific youth, Wellington, New Zealand.DiscussionThe findings presented here provide interesting social-cultural perspectives of obesity from Pasifika youth in New Zealand. Many of the findings are in agreement with what has been previously reported on known obesity risk factors associated with poor health outcomes for Pacific people, in general.3,26,28,29 However, some important new patterns of behaviour and knowledge were found that may be beneficial for researchers to consider when developing obesity intervention and preventative strategies, particularly for populations that have a strong affiliation with their culture, regardless of being obese or having a large body size.Before discussing these, we acknowledge that the study has some limitations, particularly as it is primarily exploratory in nature and involved a small number of study participants. However, in this discussion segment, we would like to highlight the knowledge gained from this study.Although, the quantitative findings are subjected only to the participants of this study, we wanted to observe how participants with high or low WHtR rated across the different modes of acculturation. The results showed that 55% of participants with an integrated acculturation mode had a high WHtR (>0.5), indicating that this group of Pasifika youth have an unequivocally strong affiliation with the mainstream and Pasifika cultures. The strong connection towards the mainstream culture was expected, particularly as 50% of Pasifika children and youth are born in New Zealand.3 An interesting aspect of this finding is to determine whether the move away from traditional Pasifika cultures alone is due to acculturation, which may play an important role in weakening traditional values and lifestyle.47 This is important, because it is thought that indigenous Pasifika cultures could provide protection for optimal health and wellbeing for their own people. For example, according to the New Zealand Mental Health Survey (Te Rau Hinengaro), Pacific-born people who migrated to New Zealand at an older age (18+ years) have a lower prevalence of mental disorders, compared to New Zealand-born Pacific people.48 The participants perceptions of their cultural context and spiritual beliefs having less or no influence on their body size and the types of food they eat support the interesting aspect highlighted above. There was also a good indication that the youth participants have a good knowledge base of the serious health consequences of being overweight or having a large body size.For those who perceived that Pasifika culture and spiritual beliefs do have an influence on body size, our crude thematic analyses highlighted that our Pasifika participants have a greater acceptance of large body sizes based on a spiritual foundation (ie, that we were created in the image of God). Having a thinner body size was less tolerated and often denoted sickness. However, the participants reported that being big attracts social risks (eg, being teased and feeling embarrassed). These same participants also rated themselves as being marginalised, according to the acculturation tool.Increased body weight is a known risk factor for long-term non-communicable diseases, such as cardiovascular disease26,28 and diabetes.1,29 However, the study participants presented with a higher than average BMI (WHR and WHtR) scores, and this is compounded by the presence of other known proximal factors (high deprivation and comorbidity), which illustrates time and again the poor health outcomes projected for Pasifika people, and particularly that of the younger generation.1,24,49,50Our study highlighted the impact of social and cultural factors within their immediate obesogenic environment. Firstly, participant perceptions in relation to perceived and ideal body sizes demonstrated that there is an unequivocal awareness and knowledge among this group of participants about the impending poor health outcomes, secondary to obesity. While the youth identified themselves as having bigger somatotype body sizes, they also viewed themselves as havi