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Background: Temporary work assignments in the United States (US) are widely considered to have negative health outcomes on Asians mostly due to adverse changes in diet and exercise, though there is little research on this phenomenon. This study investigated the impact of lifestyle changes on the biological and psychological health and health behaviours of Japanese people on temporary assignments in the US. Methods: In this cross sectional survey, we distributed a 38 item self-administered questionnaire addressing health habits, mental health function, lifestyle changes and dietary habits to adult Japanese patients presenting for general physicals at a family medicine clinic serving Japanese patients. We conducted simple statistics and regression analysis between length of stay and other health outcomes to determine whether length of residence in the US was predictive of negative lifestyle changes. Results: Most participants reported increased caloric intake, weight gain, and less exercise. They also reported increased time with family. More women than men reported physical symptoms and anxiety related to stress. Smoking and alcohol intake were essentially unchanged. No associations were identified between length of residence in the US and health lifestyle habits or other health outcomes. Conclusion: Negative lifestyle changes occur in diet and exercise for overseas Japanese people, but a positive change in increased family time was found. Women appear to be at a greater risk for somatic disorders than men. As duration of stay does not appear predictive of adverse changes, clinicians should advise patients going abroad of these risks regardless of the term of the work assignment. Page 1 of 6 (page number not for citation purposes) Asia Pacific Family Medicine 2009, 8:7 http://www.apfmj.com/content/8/1/7 the study period were eligible to participate. We offered Introduction An individual's health behaviours including eating habits, participation to all Japanese employees and their adult exercise, rest, smoking, and alcohol consumption affect family members who met enrolment criteria from May 16 the development of many diseases [1-6]. Due to social, to August 31, 2001. cultural and environmental differences, Asians who live overseas for temporary work assignments will likely expe- One week prior to their scheduled HME, we sent partici- rience sudden lifestyle changes. Based on clinical observa- pants by mail an invitation to participate and a survey tions, these sudden lifestyle changes are suspected to be instrument (both written in Japanese). Interested subjects related to adverse health outcomes. Due to the globaliza- were advised to complete the survey instruments prior to tion of business, an increasing number of Japanese people the visit. Comprehensive, project specific, written are transferred to other countries where there may be informed consent was obtained at the time of the HME enormous environmental pressures to change their health visit. The sample included individuals who were already behaviours and adjust to a different culture It has been registered as patients, and individuals who newly regis- estimated that there are about 300,000 Japanese people tered as patients, though the purpose of the visit when the living in the United States (US), and two-thirds of them survey was conducted was to have a HME. are on temporary assignment for business We asked each participant to complete a questionnaire Health professionals caring for Japanese people need with items addressing demographics, personal health information about the influence of lifestyle changes in habits including diet , physical activity , tobacco order to guide their counselling efforts to promote healthy use, alcohol consumption (assessed with CAGE  and behaviours. While previous authors have addressed the Kurihama Alcoholism Screening Test (KAST) -an influence of temporary assignment on lifestyle changes, instrument developed and standardized in Japan), mental these reports have been printed in Japanese and most are health status (using the GHQ28-General Health Ques- not published as original research [9-14] Previous sentinel tionnaire, standardized Japanese version) , their life- research such as the Ni-Hon-San study attributes differ- style changes after coming to the US and any changes in ences in coronary heart disease and cerebrovascular dis- chronic medical problems. To assess dietary habits, we ease among Japanese people living in Japan and Hawaii to asked participants to record their dietary intake one week- differences in dietary protein and animal fat . Subse- day and one weekend day. We distributed a diet record quent epidemiological studies have further explored life- manual in which common Japanese foods were listed by style factors as contributors to differences in coronary popular names, and with examples of standard quantities artery calcification in Japanese men in Hawaii and Japan for each food listed.  and stroke in Finland and Japan  though such studies have primarily focused on cardiovascular disease Data were analyzed using SPSS (Statistical Package for (CVD). Social Sciences). In our analysis, we analyzed data from men and women separately because men are immersed in Given this relatively narrow focus on CVD in previous US society through their workplace, whereas women, usu- research, we sought to investigate the influence of lifestyle ally housewives, are more likely to be socially isolated changes on both the biological and psychological health because of language and transportation issues. To deter- affecting Japanese people on temporary overseas assign- mine whether length of residence in the US was an impor- ment in the US. We hypothesized there would be adverse tant factor, we conducted regression analysis between dietary changes (higher caloric intake) and reduced phys- length of stay and other health outcomes. ical activity, but decreased alcohol intake and tobacco use due to fewer occasions to drink alcohol for business and The Institutional Review Board of the University of Mich- an anti-smoking work environment, respectively. igan Health System approved this project. Materials and methods Results In this cross-sectional survey, participants answered struc- We distributed the questionnaire to 128 patients. Nine tured questions about their lifestyle changes and health individuals cancelled their appointments and ten were behaviours after coming to the US. The investigation was excluded because they had been in the US for less than 12 conducted through the University of Michigan Japanese months, and one declined participation. As a result, 108 Family Health Program (JFHP) . This family medicine (response rate 84.4%) patients were included in the anal- program serves the needs of Japanese families who are in ysis. The demographics of the participants are listed in the US on temporary assignment. Subjects who had been Table 1. All male participants were company employees in the US for one or more years and presented for a health who were accompanied by family members. maintenance examination (HME) from the JFHP during Page 2 of 6 (page number not for citation purposes) Asia Pacific Family Medicine 2009, 8:7 http://www.apfmj.com/content/8/1/7 Table 1: Participant demographics of overseas Japanese men and holism using the KAST standard while 1 in 5 men were women in Michigan, USA positive by CAGE questionnaire using a score of 2. N = 108 Male Female Mental Health With regard to mental health status (Table 4), about one- Number 63 45 Age third of female participants reported more than moderate range 27–61 27–60 somatic symptoms, and scored positively for anxiety and average ± SD 40.1 37.2 insomnia. When we compared mental health scores for Height (average ± SD) cm 169.9 ± 4.9 158.0 ± 4.9 men and women, women were more likely to have phys- Weight (average μ ± SD) kg 69.6 ± 7.1 52.8 ± 7.4 ical symptoms related to stress than men. BMI (average ± SD) kg/m 24.2 ± 2.5 21.2 ± 3.2 Employee 63 2 Self-reports of Lifestyle Changes Marital status single 1 1 Participants' self-reports of lifestyle changes are depicted married 62 44 in Table 5. More than half of participants reported have children 55 37 increased energy intake, body weight, and time that they spent with their family. On the other hand, most stated snacking between meals, alcohol consumption, tobacco Diet & Exercise use, working hours, overtime and office visits to a doctor The daily energy intake and exercise of participants are were almost the same as when they lived in Japan. depicted in Table 2. The daily energy intake from fat is greater than one third of total energy intake among men Lengths of stay and health outcomes and women on weekdays and weekends. Some partici- We examined for an association between length of resi- pants commented they had fewer opportunities to eat fish dence in the US and health lifestyle habits and other in the US than in Japan. A few participants among men health outcomes. In our regression analysis, we found no and women expended more than 10% of their energy of statistical differences. daily activities by exercising. Moreover, only 20% expended more than 10% of their total daily energy Discussion expenditure through the combined activities of exercising Japanese people on temporary assignment in the US and commuting. Many participants reported walking less reported lifestyle changes that influenced their health in the US because they drive from their garage to the park- behaviours and health indices. Adverse changes included ing lot of their company. increased energy intake, body weight, and decreased phys- ical activity as hypothesized. Psychiatric illness was low, Smoking and Alcohol though higher among women than men. Most chronic The smoking and drinking habits of participants are pre- medical problems were unchanged. To our surprise, over- sented in Table 3. About one third of the male participants all smoking and drinking levels did not appear to change, formerly smoked and another third were current smokers. but the pattern of drinking changed. Most female participants reported having never smoked. Nine in 10 males and 1 in 2 females reported drinking The physical activity and dietary data revealed less physi- alcohol. About 1 in 10 men had positive screen for alco- cal activity and more energy intake from fat. Miyazaki et al reported that the Body Mass Index (BMI) of many Table 2: Total energy intake and daily exercise of overseas Japanese men and women in Michigan, USA Male Female Total p-value (N = 63) (N = 45) (N = 108) Total energy intake and percentage from fat weekdays energy (kcal) 1813 1796 1806 0.41 % fat 36.5 34.8 35.8 0.40 weekends energy (kcal) 1851 1684 1781 0.27 % fat 35.5 36.6 35.3 0.76 Daily exercise as percentage of total daily physical activity n (%) n (%) n (%) 0% 10 (16) 12 (27) 22 (20) 0.16 1 to <10% 50 (79) 30 (67) 80 (74) 0.14 10% and more 3 (5) 3 (7) 6 (6) 0.69 Page 3 of 6 (page number not for citation purposes) Asia Pacific Family Medicine 2009, 8:7 http://www.apfmj.com/content/8/1/7 Table 3: Exercise, smoking and alcoholism of overseas Japanese men and women in Michigan, USA Male Female Total p-value (N = 63) (N = 45) (N = 108) n (%) n (%) n (%) Smoking status current smoker 20 (32) 3 (7) 23 (21) <0.01 former smoker 22 (35) 1 (2) 23 (21) <0.01 never smoked 21 (33) 41 (91) 62 (57) <0.01 Drinking status 57 (90) 25 (56) 82 (76) <0.01 Positive alcoholism screen* CAGE 14 (22) 0 (0) 14 (13) <0.01 KAST 6 (10) 0 (0) 6 (6) 0.04 * positive screen defined by CAGE2; KAST0 Japanese people on temporary assignment overseas (3–5 men in the sample is also consistent with US Department years) tended to decrease regardless of country. In our of Health and Human Services reports of women being study however, these Japanese people in the US reported nearly twice as likely as men to experience depression increasing body weight. While most participants reported . Most women participants accompanied their hus- eating Japanese food almost every day, men in this sample bands to the US and many had children. Wives likely face might be affected more by lifestyle changes in the US such different difficulties related to language, culture and rais- as increased fat consumption and less walking due to their ing children than their husbands encounter in the work- greater direct participation in US society through the place. These data emphasize the importance of workplace. Although the mean BMI in the participants developing mental health support systems, especially for increased by self-report, it did remain within a normal women. range. Still the duration of stay was relatively short (the average was 33 months) and it is plausible it could reach We did not find an association with length of time lived an abnormal range after longer duration, though this is in the US and health lifestyle habits and health outcomes, speculative. even though many participants reported many behav- ioural changes after moving from Japan. The lack of asso- Women had more physical symptoms related to stress and ciation between duration of living in the US and lifestyle insomnia than men. The low rate of depression found is changes and health outcomes may be attributed to the rel- somewhat surprising given previous research demonstrat- atively narrow variation in the number of years in the US, ing similar rates of depression in Japan and other coun- or the event of just moving to US might affect the lifestyle tries on standardized screening instruments in primary changes of all similarly. clinics [24,25], and from Japanese clinics revealing high rates of somatic symptoms, and physical symptoms asso- A potential limitation of this research is selection bias. The ciated with depression in about 13–15% of patients [26- study was conducted exclusively in Southeastern Michi- 28]. This discrepancy in symptom versus depression gan. Japanese people on work assignment here are usually reports is similar to research conducted in international affiliated with the automotive industry and may not be clinics where patients with depression who had only representative of overseas employees who are assigned in physical symptoms ranged from 45–95% with 11% deny- other US regions. Second, the self-reported changes may ing depression despite direct questioning . The trend be influenced by recall bias and it is difficult to assess how for higher psychological symptoms among women than this might differ according to length of stay. Participants Table 4: Mental heath assessment based on GHQ scores of overseas Japanese men and women in Michigan, USA Positive mental illness screen* Male Female Total p-value (N = 63) (N = 45) (N = 108) n (%) n (%) n (%) Somatic symptoms 6 (10) 13 (29) 19 (18) <0.01 Anxiety/insomnia 9 (14) 12 (27) 21 (20) 0.11 Social distress 6 (10) 6 (13) 12 (11) 0.54 Depression 1 (2) 2 (4) 3 (3) 0.57 *mental illness screen based on GHQ Page 4 of 6 (page number not for citation purposes) Asia Pacific Family Medicine 2009, 8:7 http://www.apfmj.com/content/8/1/7 Table 5: Self-reported lifestyle changes in Michigan, USA Compared to life in Japan: Participants responding Much/somewhat more Almost the same Somewhat/much less N = 108 n n (%) n (%) n (%) Calorie intake 107 71 (65) 30 (28) 6 (6) Hours with family 104 65 (63) 29 (28) 10 (10) Body weight 107 60 (56) 32 (30) 15 (14) Overtime work 64 21 (33) 23 (36) 20 (31) Snacking between meals 103 34 (33) 67 (65) 2 (2) Physical exercise 108 30 (30) 32 (30) 46 (43) Working hours (includes housework) 105 30 (29) 44 (42) 31 (30) Alcohol consumption 81 23 (28) 45 (56) 13 (13) Number of vacation days 81 23 (28) 32 (40) 26 (32) Number of sick/family days 67 14 (21) 27 (40) 26 (39) Number of cigarettes 22 3 (14) 10 (48) 9 (43) Number of office visits to a doctor 103 5 (5) 64 (62) 34 (33) Chronic medical problem(s) 24 3 (13) 14 (58) 7 (29) who have been in the US less time might be more aware and physical inactivity appear to be the greatest risks. Sur- of lifestyle changes and their influence than individuals prisingly, even a short duration carries this risk. Future for who more time has elapsed. However, the latter group research should examine the generalizability of these find- may have more stability in their changes. Third, we did ings to other populations. Prospective studies that include not include children as participants. biomarkers are needed to conclusively illustrate if dura- tion of assignment is associated with worse outcomes. A prospective cohort study with baseline biomarker assessments prior to departure, periodically after arrival Summary of implications for GPs abroad, and after return to Japan could more definitively In the global economy, an increasing number of Asians travel abroad for work, yet little research has addressed document the impact of overseas assignment on the life- style changes of Japanese people and permit calculation of what lifestyle changes will affect them. Among Japanese absolute risk as a consequence of all lifestyle changes. A people on temporary assignment in the US, most reported larger sample size is needed to examine more fully less negative lifestyle changes such as increased caloric intake, prevalent problems such as smoking behaviours and weight gain, and less exercise. A positive outcome of living mental illness. Clinical data on BMI, laboratory values, in the US was an increase in time to spend with the family. caloric data analysis correlated with self-reports could More women than men reported physical symptoms and lead to a better understanding of the occurrence and pat- anxiety related to stress. Smoking and alcohol intake were terns of health behaviour changes. The impact of lifestyle essentially unchanged. Duration of assignment abroad changes on children, particularly given the epidemic of was not predictive of these changes. While this sample was childhood obesity in the US, should be investigated in limited to Japanese patients, other Asians who travel to future research. the US may be at risk for similar lifestyle changes. General practitioners can promote the health of their patients who After coming to the US, these Japanese people experienced go abroad by counselling them about potential health many lifestyle changes. Adverse changes included risks of lifestyle changes. increased energy intake, body weight, and decreased phys- ical activity as we expected. A beneficial change was the Competing interests increased time with family. Some reported increased time The authors declare that they have no competing interests. with their family on holidays because they worked fewer holidays compared to Japan. None reported worsening of Authors' contributions chronic medical problems. KK and JS contributed to the conception and study design, performed data analysis, interpretation. KS contributed to These data confirm widespread perceptions among Asians the conception and study design, and data collection. that there are adverse health risks due to lifestyle changes MDF contributed to the conception and study design, during temporary work assignments in the United States. data collection, and critical editing of the manuscript. NB Clinicians who provide care for patients who go abroad participated in the study design and critical revision of the for assignments in the US have an opportunity to counsel manuscript. about potential adverse health changes and can promote healthy behaviours. Increased caloric intake, weight gain All authors read and approved the final manuscript. Page 5 of 6 (page number not for citation purposes) Asia Pacific Family Medicine 2009, 8:7 http://www.apfmj.com/content/8/1/7 23. Ezoe S, Morimoto K: Behavioral lifestyle and mental health sta- Acknowledgements tus of Japanese factory workers. Prev Med 1994, 23(1):98-105. 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Asia Pacific Family Medicine – Springer Journals
Published: Jul 16, 2009
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