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Changes in dietary behaviors of Greeks and Greek-Americans living in Tarpon Springs, Florida

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Title:
Changes in dietary behaviors of Greeks and Greek-Americans living in Tarpon Springs, Florida
Creator:
Kurtz, Cora Sweigart
Publication Date:
Language:
English
Physical Description:
ix, 192 leaves : ill. ; 28 cm.

Subjects

Subjects / Keywords:
Age groups ( jstor )
Blood ( jstor )
Cholesterols ( jstor )
Diet ( jstor )
Disease risks ( jstor )
Ethnic groups ( jstor )
Ethnicity ( jstor )
Fats ( jstor )
Food ( jstor )
Questionnaires ( jstor )
Anthropology thesis Ph. D
Diet in disease ( lcsh )
Dissertations, Academic -- Anthropology -- UF
Greek Americans -- Nutrition -- Florida -- Tarpon Springs ( lcsh )
Greeks -- Nutrition -- Florida -- Tarpon Springs ( lcsh )

Notes

Thesis:
Thesis (Ph. D.)--University of Florida, 1990.
Bibliography:
Includes bibliographical references (leaves 182-190)
General Note:
Typescript.
General Note:
Vita.
Statement of Responsibility:
by Cora Sweigart Kurtz.

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University of Florida
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University of Florida
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Copyright [name of dissertation author]. Permission granted to the University of Florida to digitize, archive and distribute this item for non-profit research and educational purposes. Any reuse of this item in excess of fair use or other copyright exemptions requires permission of the copyright holder.
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AHH0478 ( NOTIS )

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CHANGES IN DIETARY
GREEK-AMERICANS LIVING


BEHAVIORS
IN TARPON


OF GREEKS
SPRINGS,


AND
FLORIDA


CORA


SWEIGART


KURTZ


A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL
* THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT














ACKNOWLEDGEMENTS


Thanks


to Dr.


Leslie


Sue


Lieberman,


committee


chairperson,


whose


understanding,


patience,


support,


critiques


and


guidance


led


me through


the


maze


of higher


education


and


learning


so that


I could


realize


this


accomplishment.


Thanks


also


the


other


members


committee:


H.R.


Bernard,


Dean


Spring


(through


the


qualifying


exams),


Armelagos,


(for


the


dissertation


review),


Shireman


and


Crandall


who


each


added


a unique


dimension


learning


experiences.


Without


the


enthusiasm


and


time


devoted


members


the


Tarpon


Springs


community,


this


study


could


not


have


been


a reality.


am deeply


indebted


to Father


Tryfon


Theophilopoulos


and


Zula


Hourdas,


the


secretary,


the


Saint


Nicholas


Greek


Orthodox


Church


for


their


cooperation


supporting


the


purposes


the


study


making


public


announcements


the


church


services


and


publishing


the


Greek


and


English


versions


the


study


summary


the


church


bulletin;


to Naomi


Patterson


for


recruiting


Greeks


and


Greek-Americans


participate


the


study;


Maria









Greek


Orthodox


Church;


Chryse


Flowers,


who


introduced


the


editor


the


local


weekly


newspaper


so that


I could


submit


data


a copy


collection


and


study


summary


helping


for


publication


me collect


names


prior


persons


participate


the


study


following


a church


service;


the


Helen


Ellis


Hospital


administration,


especially


to Jerry


Touchton,

Emmerson,


Director


Coordinator


Community


Relations,


Volunteers,


for


and


Ruby


their moral


support


and


assistance


with


lending


me the


Reflotron


machine,


allowing


me to participate


the


Cholesterol


Screening


and


Health


Fair


recruit


participants


the


study


and


collect


data,


assigning


a bilingual


phone


operator


the


switchboard


make


calls


potential


participants


and


for


assigning


volunteer


retired


nurses


to help


with


the


finger


sticks


and


running


the


Reflotron


machine


for


the


cholesterol


analysis;


and


to all


the


others


from


the


Tarpon


Springs


community


who


helped


with


the


coordination


the


study


and


participated


the


study.


Thanks


are


also


appropriate


Jeff


Glor,


for


his


assistance


with


the


computer


data


analysis;


to Elias


Stassinos


for


the


back


translation


the


Greek


translation


the


questionnaire


to English;


and


friend,


Don


Higler,


for


his


encouragement


throughout


this


endeavor.











TABLE OF CONTENTS


page


ACKNOWLEDGEMENTS.IN...................................

LIST OF ABBREVIATIONS.................................


vii


ABSTRACTS .......... .. ........................ ...

CHAPTERS


INTRODUCTION..


Diet and Heart Disease....................

Ethnicity.o.............................****

Research Goals..............................


REVIEW OF THE LITERATURE....................


Ethnicity..................................

The Greek and Greek-American Diet...........

Diet and Risk of CHD........................

Nutrition Intervention......................


Pilot Study.................................

The Research Site...........................

Sample......................................

Data Collection.............................

Data Analysis..............................

Variables....................................


- ----I -


METHODSr








Demographic Characteristics................


Eating Preferences Affecting Food Use.......

Frequency of Food Intakes...................


The 24-Hour Recall......................... 103

Risk Factors for CHD........................ 113

5 DISCUSSION.................................. 127

Adaptive Pressures on Food Use.............. 128

Ethnic Change....... ... ................ 129

Eating Preferences and Diet Changes......... 132

Dietary Changes and CHD Risk Factor Status.. 134

Implications for Nutrition Intervention..... 140

6 CONCLUSIONS........ ...................... 142

APPENDICES............................................ 145

A NEWSPAPER ADVERTISEMENT OF STUDY............ 146

B QUESTIONNAIRE............................... 147

C EATING PREFERENCES OF ETHNIC GROUPS......... 168

D FOOD FREQUENCIES............................ 175

REFERENCES. ............... ... ...... ...... .. .. 182

BIOGRAPHICAL SKETCH................................... 191


Ethnicity....,....,...,.,..,














List


Abbreviations


BMI = body
BP = blood
CA = cancer
Ca/Phos = c


mas
pre


index
sure


alcium


phosphorus


ratio


Card
CHD
chol
CSI
Cult
Diab
GA =
GR =-
gms
HBP
HDL
ht =
K =
kg
kcal
LDL
MANO
max-
mg -
mg/d
am =
N =
Na =
Nati
NG =


NHAN
pk =
Pro
PUFA
Reli
RNA/
SAS
SES
SFA
TV -


= cardiac (heart) medi
= carbohydrate
= cholesterol
= cholesterol-saturated
= culture
I diabetes
Greek-American
Greek
= grams
= high blood pressure m
= high density lipoprot
height
potassium
Kilograms


= 1
)VA
EPA
: mi
1l =


31


cation


index


education
ein


Calories
ow density lipoprotein
= multi-variate analysis
= maximum-ecosapentanoic
lligram
milligrams per deciliter


millimeters
umber
sodium
= national
non-Greek


naennutP.


ES = National Health an
cigarette pack
- protein
= polyunsaturated fatt
= religion
DNA = ribonucleic acid
= Statistical Analysis
= socioeconomic status
= saturated fatty acids
* television


d


y


of variance
acid


(cholesterol


blood


pressure


Examination


values)
reading)


Survey


acid


/ deoxyribonucleic
Systems


acid














Abstract


of the


Dissertation


University


Requirements


Presented


of Florida


for


the


Degree


the


Partial


Doctor


Graduate


Fulfillment


School


the


Philosophy


CHANGES


IN DIETARY


GREEK-AMERICANS


LIVING


BEHAVIORS


TARPON


OF GREEKS
SPRINGS,


AND
FLORIDA


Cora


Sweigart


Kurtz


May


1990


Chairperson:


Leslie


Sue


Lieberman,


Ph.D.


Major


Department:


Anthropology


A cultural


ecological


model


was


used


analyze


infrastructural,


structural


and


demographic


factors


that


influence


dietary


behaviors


and


subsequent


coronary


heart


disease


(CHD)


risk


status


Greek


immigrants,


25-74


years,


the


United


States.


Greeks


were


chosen


because


they


provide


a natural


experiment


persons


who


migrated


from


country


with


a low


a high


mortality


rate


CHD.


the


diet


becomes


more


"Americanized,


" previous


studies


showed


that


the


risk


OlD


increased


among


Greek


immigrants.


Subj ects


were


recruited


a community-wide


cholesterol


screening,


a health


fair,


a Greek


church


and


Greek


organizations


during


the


Fall


1988


and


Spring


1989.








weighed


and


measured,


had


blood


pressures


checked


and


had


finger


stick


for


blood


that


was


analyzed


cholesterol.


The


self-administered


questionnaire


elicited


demographic


and


CHD

and


risk


factor


cooking


information,


preferences,


ethnic


a food


attitudes,


frequency


and


restaurant

24-hour


recall.


Results


indicated


that


Greek-Americans


had


significantly


lower


(p=less


than


.05)


cholesterol


values


(f=205


mg/dl)


than


non-Greeks


(R=220


mg/dl).


Age


had


positive


relationship


(p=.04)


with


blood


cholesterol


for


the


Greeks


and


non-Greeks.


Structural


factors


that


were


operationalized


measure


commercial


influences,


e.g.,


purchasing


foods


and


drinks


advertised


on TV,


using


newspaper


coupons


for


food


purchases


and


using


recipes


from


popular


magazines


were


strong


predictors


(p=.024)


increasing


cholesterol


values


the


Greeks.


Non-Greek


cholesterol


values


were


not


significantly


influenced


infrastructural


and


structural


factors.


sedentary


lifestyle


was


predictive


higher


(R-square=10,


p=.0007)


cholesterols


among


the


non-Greeks


and


the


absence


a chronic


disease


diagnosis


was


predictive


low


(R-square=11,


p=.0017)


cholesterol


levels.


Nutrition


educators


would


benefit


from


considering


the


varying


infrastructural


and


structural


influences


on food








populations


who


have


increased


their


risk


for


CHD


and


other


chronic


diseases.














CHAPTER


INTRODUCTION


Diet


and


Heart


Disease


Since


the


mid-1960s,


epidemiological


evidence


has


accumulated,


explanatory


pointing


variables


dietary


the


behaviors


increased


risk


as one


the


coronary


heart


disease


(CHD).


In 1980


and


1985,


the


United


States


government


published


dietary


goals


recommending


reduced


intakes


(especially


saturated


fat),


sugar,


and


salt,


with


increased


intakes


complex


carbohydrates


and


fiber


protect


against


CHD


risk.


1988,


the


Surgeon


General's


Report


research


on Nutrition


on the


and


role


Health


diet


(DHHS


health


1988)


summarized


promotion


and


the


disease


prevention.


For


the


two


out


three


adult


Americans


who


not


smoke


or drink


excessively,


the


choice


what


eat


seems


to influence


long-term


health


prospects


more


than


any


other


behavior.


The


relationship


dietary


and


cholesterol


CUD


supported


clinical,


epidemio-


logical,


metabolic,


and


animal


evidence.


These


studies


strongly


indicate


that


the


formation


of atherosclerotic


lesions


coronary


arteries,


which


contribute


the


risk










and


LDL


cholesterol,


turn,


are


increased


diets


high


total


and


saturated


fat


but


decreased


diets


containing


polyunsaturated


and/or


monounsaturated


fat.


I chose


to systematically


describe


changes


dietary


behaviors


among


Greek


immigrants


and


Greek-Americans


living


Tarpon


Springs,


Florida,


for


this


study


because


the


population


standardized


Greece


death


has


rate


a low-risk


CHD


for


229.8


CHD.


per


The


age-


100,000


the


Unite<

Keys


States


(1980)


and


found


85.1

the


per 100,000

CHD mortality


Greece


rate


(WHO


1986)


a United


States


male


cohort


40-59


years


to be


5.69 times


higher


than


that


a matched


Greek


cohort.


Greek


immigrants


the


United


States


are


adopting


traditional


American


dietary


practices,


thus


increasing


their


CHD


risk


status


(Christakis


1981).


Preservation


the


traditional


diet


has


been


identified


with


lowered


risk


coronary


heart


disease


for


Greek-Americans


(Christakis


et al.


1965


and


Keys


1980)


and


other


ethnic-Americans,


e.g.


, Japanese


(Robertson


et al.


1977).


However,


there


are


few


systematic


studies


the


natural


dietary


changes


which


occur


among


individuals


response


situational,


economic,


technological,


and


media


influences.











Acculturation


and


assimilation


into


an industrialized


host


society


that


promotes


consumption


mass-produced


foods


alters


health


specific


practices.


dietary


The


components,


multiple


life


forces


styles,


that


and


work


related


hold


consumption


channels


predictable


enough


to maintain


food-industry


profits


paradoxically


narrow


human


choice


and


the


opportunity


resist


the


trend


the


guise


increasing


convenience,


ease,


and


"freedom"


(Mintz


1985:211)


Acculturation


research


provides


a means


for


observing


how


immigrants,


when


confronted


with


altered


food


consumption


environments


, utilize


adaptive


strategies


cope


with


the


new


conditions.


the


process


adaptation,


new


food


behaviors


and


concepts


about


food


emerge


(Bennett


1976).


Identification


with


ethnic


origins


individuals


who


place


a high


importance


on ethnic


cohesiveness


and


dietary


practices


may


advantageous


the


maintenance


and


adoption


of health


promoting


food


behaviors.


Ethnicity


and


other


factors


lead


intracultural


variation


human


food


patterns


and


nutritional


status


within


populations


with


ostensibly


similar


sociocultural


environments.


The


key


understanding


diet


and


nutritional


status


an ethnic


community


to delimit


dietary


heterogeneity


and


address


the


alternative


ways


which










Dietary


differences


this


study


were


not


treated


random


and


idiosyncratic


phenomena,


but


rather


characteristics


broad


patterns


food


use


which


Bennett


(1976)


terms


a cultural


instrumental

ecological


behavior.

analysis


" Bennett


incorporate


a framework

es three


domains:


thought,


the


mental


rules


thinking


that


develop


via


the


process


experience


and


thinking


about


experience,


e.g.,


attitudes,


values,


logic


and


structures;


interhuman


activity,


the


observed


individual


and


group


rules


of behavior


that


govern


relationships,


e.g


interaction,


consensus,


conflict,


affiliation,


individualism,


and


reciprocity;


adaptation,


the


patterns


and


rules


individual


and


group


social


adjustment


and


behavioral change

maintaining status


the


quo,


course


e.g


of realizing


., coping,


goals


adjustment,


adaptation,


adaptive


strategies,


achievement,


compromise


and


fulfillment


The


distinction


between


interhuman


activity,


adaptation,


primarily


descripti


analytic.

ve while


Interhuman


adaptation


activity


explanatory


Adaptive


behavior


further


divides


into


two


levels


analysis:


microsocial,


which


views


behavior


specific


contexts


purpose,


e.g.,


innovative,


manipulative,


coping,


characterized


both


a formal,










social

culture


system


or institution.


manifest


level


Pareto


as "residues"


(1916)

that i


referred


includedd


artifacts,


language,


stories,


rites,


rituals


and


ceremonies.


He called


the


latent


level


operation,


"derivations"


the


hidden


code


concepts)


behind


statements.


A cultural


ecological


framework


was


used


identify


underlying


conditions


and


factors


which


were


adaptive


maladaptive


dietary


behaviors


terms


of health


consequences.


Dietary


behaviors


this


study


were


viewed


as the


result


a conscious


or unconscious


decision-making


process


within


a specific


context


which


offered


alternatives


and


imposed


constraints


on choice.


A feedback


system


further


supported


or modified


this


decision


process


(Bennett


1976).


In this


research,


I addressed


the


diet-health


status


Greek


immigrants


and


Greek-Americans


(especially


relation


CHD


risk)


stemming


from


dietary


changes


that


accompany


assimilation


into


the


American


society.


The


direction


and


extent


an immigrant


s assimilation,


a large


extent,


believed


result


from


forces


attraction


(positive


and


negative)


generated


the


social


organization


ethnic


communities


and


their


capacity


to attract


and


hold


members


within


their


social


boundaries


(Breton


1964).










descendants


of the


cultural


behavior--language,


norms,


customs--of


the


new


society.


Assimilation,


his


definition,


implies


the


entrance


the


ethnics


into


the


very


fabric--social


cliques,


business


life,


civic


associations,


and,


eventually,


the


families--of


the


society.


While


acculturation


usually


proceeds


faster


than


assimilation,


believes


that


acculturation


has


probably


lagged


behind


the


Greek-American


population.


If his


assumption


true,


then


dietary


practices


Greek-Americans


Tarpon


Springs


have


changed


more


slowly


than


their


macrosocial


adaptation


the


American


social,


business


and


civic


institutions.


Research


Goals


The


key


goals


this


study


are


a description


dietary


patterns


emphasizing


determined


inter-ethnic


and


a complex


intra-ethnic


set


variables


heterogeneity


and


a cultural


ecological


framework


that


stresses


the


importance


the


social


as well


as the


material


environment;


and


delineation


variations


diet


as adaptive


strategies


among


Greeks,


Greek-Americans


and


non-Greeks.


(Figure


page


(DeWalt


1983,


DeWalt


and


Pelto


1976,


Goode


1984).


A related


objective


emphasize


the


multifactorial











U- -UD


IrMnASrUCTUZu n ACTO -^.


LIKE it FO


OOD USPAT


Figure 1
Food


-1:
and


Ecological Influences on


Diet-Related


Disease


INHERENT INDIVIDUAL
RISK FACTORS


LIFESTYLE
RISK FACTORS


Health Status/
CHD Risk


IIPlOeC


m0










life


style


factors


that


may


make


the


occurrence


CHD


more


probable


(Figure


page


(Beaton,


1976).


Dietary


patterns


and


other


CHD


risk


factors


are


analyzed


technological


indicative


identify


interactions


influences.

adaptive or


These


between

observed


maladaptive


ethnic


and


patterns


behaviors


are


that


affect


CHD


risk


factor


status.


The


observed


systematic


trends


dietary


pattern


changes


among


aggregates


Greek


and


Greek-American


individuals,


compared


non-Greeks,


are


useful


predicting


future


dietary


changes.


Such


predictions


could


serve


as a marketing


tool


for


designing


nutrition


intervention


program


Greeks


and


Greek-Americans,


identifying char

to incorporating


who


are


acteristics

directed d


increased


persons


dietary


risk


who


changes


for


are

into


CHD,


most amenable

their food


behaviors.


Health


planners


may


find


this


study


useful


when


developing


guidelines


for


health-related


behavior


changes


that


deal


with


a complexity


of food


consumption


behaviors


among


ethnic


populations


that


have


also


increased


their


risk


CHD


and


other


chronic


diseases.














CHAPTER


REVIEW


OF THE


LITERATURE


American


anthropologists


the


first


half


the


twentieth


century


viewed


culture


as an ideational,


superorganic


construct.


They


were


less


concerned


with


material


technical


culture


and


focused


more


on values,


social


structure,


and


ideational


data


(Bernard


and


Pelto


1987)


Humans


were


thought


have


distinctive


idea


systems


and


cultural


definitions


things


like


food


which


influenced


their


behaviors.


Behavioral


differences


among


distinct


social


groups


and


communities


were


believed


result


from


differences


culturally-based


idea


systems.


Extension of this

conclusion (which


notion

became


cultural


causality


an assumption


our


was


the


culture)


that


order


change


behavior,


including


food


consumption


behavior,


culture


(that


ways


thinking


about


things


like


food)


had


to change.


Mead


(1955)


supported


this


educational


model


behavioral


change,


and


this


model


continues


to be supported


among


nutrition


educators


today


(Pelto


1981)










technological


influences


on human


behavior.


Harris


(1979)


example,


described


his


view


how


ideational


and


material


variables


interact


to influence


human


behavior.


contrast


to the


idealist


approach


which


defines


social


and


cultural


phenomena


from


an in-group


(emic)


perspective,


Harris


focuses


on access


resources,


biological


determinants,


and


technological,


and


energy


factors


causal


influences


on both


human


behavior


and


culture.


Bernard


and


Pelto


(1987),


the


book


Technoloav


and


Social


Change,


collected


essays


which


lent


support


the


technoenvironmental


theory


how


human


lifeways


are


shaped.


Anthropologists


and


other


social


scientists


continue


describe


the


relationship


of technological


changes


changes


social


relations,


cultural


values,


attitudes,


and


psychological


functioning.


This


reorientation


culture


change


raises


two


important


concerns:


What


the


role


the


individual


social


change?


and


Is technology


necessarily


"good


for"


people


(Bernard


and


Pelto


1987)?


Mintz


(1985:13)


recognized


that


the


precise


ways


which


culture


change


occurs


are


not


fully


understood.


hypothesized


earlier


that


recurrent


historical

sequences.


changes r

Profound


epeat


or re-enact


changes


dietary










relationships


between


separate


cultures.


Cultural


"meaning"


, in


his


view,


arises


from


cultural


applications


uses.


Thus,


symbolic


meaning


emerges


as a consequence


interacting


external


factors,


e.g


, economic,


political


and


material,


that


give


relevance


or meaning


to the


symbol.


In this


context,


observed


behaviors


are


viewed


explanatory


codes


within


an environmental


milieu


that


can


read


(decoded)


as a "product


the


production.


Ethnicity


Definition


Ethnic


studies


prior


the


1970s


focused


on external


observations


an ethnic


group.


Ethnic


groups


were


seen


minority


cultures


that


had


temporary


differences


with


the


larger


society.


With


time,


the


process


linear


assimilation


would


cumulatively


completed


(Newman


1978)


and


the


ethnic


group


would


integrated


into


the


host


society.


More


recently,


investigators


have


defined


ethnic


groups


as liasoned


individuals


who


share


common


cultural


and


social


affiliations


within


a multicultural,


multiethnic


context (Cohen

inclusion and


1978).

exclusion


Ethnic


group


criteria


for


members


determine


themselves


and


significant


others.


This


broader


definition


of ethnicity


suggests


that


ethnic


groups


can


live


symbiotic


adaptation










Ethnicity


and


Culture


Harwood


(1981)


views


ethnicity


as a broader


phenomenon


than


culture.


standards,


the


While

range


ethnicity


social


marked


situations


certain


and


cultural


cultural


expressions


for


the


ethnic


group


more


varied.


Ethnic


groups


are


not


limited


one


culture


context


but


interact


multiple


alliances


within


their


environments


(Wolfe


1966)


For


example,


Isajiw


(1978)


described


a culture


layer


that


shared


widely


numerous


ethnic


groups


within


Canadian


society


(this


example


could


apply


the


United


States,


as well)


The


technological


culture


shared


many


communities


and


individual


There


a value


placed


on the


products


technology,


the


people


who


have


access


them


and


the


use


new


technologies.


Technology's


common


language


spoken


less


as a symbol


of identity


than


as a


practical


means


of attaining


the


products


of the


technologi-


culture.


This


culture


layer


either


works


together


with


other


culture


layers


or it


contradictory


and


conflicts


with


the


ethnic


group's


values.


Ethnic


group


members


determine


whether


include


or exclude


from


their


ranks.


Criteria


for


Ethnic


MembershiD


Ethnic


membership


criteria


may


perceived


differently


members


than


non-members.


To non-members,


group










(Dreidger


1978).


Discarding


these


sible


ethnic


practices


referred


Moskos


(1989)


as acculturation.


From


an internal


perspective,


ethnic


group


members


are


aware


different


coalitions


and


social


ties


among


the


membership.


Social


ties,


such


as friendships,


marriages,


and


business


relationships


not


form


via


a single


focus


alliance


with


fellow members,


but


incorporate


multiple


dimensions


interaction


with


individuals


from


inside


and


outside


the


ethnic


boundary


(Wolfe


1966)


Breton


(1978:61)


described


these


ethnic


ties


as partially


overlapping


"intersecting


circles"


which


individuals


belong.


One


circle


may


include


kinship


and


friendship


ties


and


another


circle


may


represent


occupational,


religious


and


political


affiliations.


A small


number


group


members


may


share


liasions


both


circles,


but


the


maj ority


members


share


these


ties


with


either


different


fellow


ethnics


or with


individuals


from


outside


the


ethnic


group.


Moskos


(1989)


describes

business


the

and


trend


toward


political


ties


the establishment

with individuals


of social,

and


organizations


outside


the


ethnic


group


as assimilation


into


a host


society.


Acculturation


usually


precedes


assimilation


into


a host


society.


For


Greek


immigrants,


however,


Moskos


(1989)


observed


that


assimilation


generally


has


preceded










The


Ethnic


Boundary


A major


aspect


the


ethnic


group


the


creation


and


maintenance


boundary.


Goode


(1984)


described


the


boundary


as permeable


(open


outside


influence)


closed

members


(socially

relate t


impenetrable).


o significant


Within


objects


the


and


boundary,


according


ascriptive


behaviors.


The


social


bond


that


shared


members

to the


provides

alienation


a sense


experienced


peoplehood


when


that


immigrants


an antidote


arrive


new


culture.


While


local


communities,


families,


clubs


and


unions


offer


membership


ties,


they


not


provide


the


continuum


of identity


with


an individual's


cultural


and


social


roots


that


the


immigrant


desires.


The


degree


boundary


permeability


determines


the


number


outside


alliances


the


ethnic


group


will


tolerate.


For


political


and


economic


purposes,


ethnic


boundaries


are


often


permeable.


Moskos


(1989)


believes


that


motivation


toward


assimilation


Greeks


into


United


States


society


linked


with


a desire


economic


ascendancy


and


political


representation.


Newman


(1978)


described


relationships


among


ethnic


members


as subgroup


and


segments


fluctuating


with


assimilative


inter-group


and


alliances,


divergent


coalitions,


relationships


within


the


larger


ethnic


boundary.


These


ethnic


segments










Ways


Ethnicity


Cohen


(1978)


suggested


that


situational


ethnicity


may


operationalized


represent


the


interaction


two


more


people


from


separate


groups


which


labels


are


used


signify


sociocultural


differences


between


them.


the


emergence


and


persistence


ethnic


differences


believed


to be non-random,


determine

Goode


then


qualities


et al.


questions


and


(1984) ,


about


variations


utilized


the


factors


can


concept


which


examined.


cultural


ecological


influences


on intra-group


diversity


for


studying


persistence


and


change


an immigrant


ethnic


group's


definition


and


food


practices.


They


identified


differences


the


processes


boundary


strengthening


(social


closure)


and


boundary


permeability


(open


outside


influence),


relation


to rules


for


food


use


among


Italian-Americans


Philadelphia.


They


observed


that


contact


with


supermarkets,


communication

industrial wo


media,


rkplaces


restaurants,

tended to d


school


decrease


lunches,


the


and


importance


ethnic


food


usage


and


increased


the


importance


the


American


structure


of meal


formats


(menus)


and


meal


cycles


(patterning


the


use


different


meal


formats


over


time--day,


week,


week-end,


annual


holiday


cycle


and


life


cycle).


Household


differences


dietary


behaviors


were


Studvina










indicator


ethnic


continuity


was


household


ranking


roles


and


the


rights


of members


to negotiate


menu


selections.


These


decision-making


actions


were


mediated


shared


rules,


situational


pressures,


and


personal


preferences.


Greek


and


Greek-American


Ethnic


Identity


Scourby

foreign-born


(1979)

Greeks


observed


New


that


York


United


City


States


maintained


and

strong


religious


and


national


ties,


as observed


affiliations


with


the


Greek


Orthodox


Church


and


social


organizations


which


promoted


dance,


music


and


cuisine.


her


study


three


generations


Greek


immigrants,


she


observed


generational


differences


internal


perceptions


ethnic


identity.


Study


respondents,


when


asked


to identify


themselves


with


ethnic


labels,


indicated


weakening


identities


with


being


Greek.


First


generation


Greeks


tended


identify


with


Greek


or Greek


Orthodox


labels.


Second


generation


respondents


thought


themselves


Greek-American,


while


a discernible


trend


called


American


was


evident


the


third


generation


respondents.


The


number


inconsistencies


observed


with


individual


ethnic


identity


underscored


the


notion


that,


from


the


perception


an ethnic


member,


much


of ethnic


identity i


- a a


1










however,


the


majority


of Greeks


New


York


City


maintained


relatively


strong


attachment


ties


to their


ethnic


religion


and


nationality,


despite


their


identification


with


being


American.


Moskos


(1989


reported


that


the


Greek


Church


America


the


serves


"prime


both


definer


a religious


of Greek


and


social


ethnicity


function


this


and


country


" He


observed


that


the


American


generations


Greek-Americans


are


many


ways


more


Greek


Orthodox


than


their middle-class


Greek


contemporaries


Greece.


While


these


differences


create


social


distances


between


Greek-Americans


and


newly


arrived


Greeks


(Greeks


who


arrived


the


United


States


within


the


past


five


years),


there


are


shared


similarities


their


continuing


conservative


views


about


family


and


personal


matters.


While


adapting


where


necessary


order


accommodate


the


achievement


standards


the


larger


society,


the


approximate


one


million


Greek-Americans


(Moskos


1989


have


maintained


a remarkable


degree


communal


and


family


cohesiveness.


The


ethnic


anchor


for


Greek


immigrant


families


has


been


the


promotion


the


Greek


language


among


their


children


(Moskos


1989).


Greek-Americans,


however,


have


been


less


concerned


with


promoting


the


Greek


language


and


have










Greece.


An estimated


majority


American-born


Greeks


have


visited


their


ancestral


homeland


at least


once.


Moskos


(1989)


identified


three


subgroups


of Greeks


the


United


States:


an older


immigrant


group


who


came


America


before


World


War


or in


the


years


immediately


following;


a more


recent


wave


of immigrants


who


came


to the


United


States


since


the


lifting


of the


immigrant


restrictions


1966;


and


the


children


and


grandchildren


Greek


immigrant


parents


who


constitute


the


Greek-American


communities.


While


each


these


groups


claim


varying


degrees


allegance


Greece,


the


majority


estimated


four


out


five;


Moskos


1989


share


an ethnic


commitment


a common


Hellenic


heritage


and


affiliation


with


the


Greek


Orthodox


Church.


Ethnic


ties


among


Greeks


and


Greek-Americans


can


viewed


as primary


and


secondary


relationships.


Primary


ties


are


informal


and


intimate.


They


involve


networks


among


individuals


and


families.


Secondary


ties


describe


more


formal


or casual


relationships


that


deal,


often


bureaucratically,

Greek-Americans,


with

ethnic


segmented a

activities


alliances. Among

frequently involve


segmented


or secondary


ties:


church


attendance,


voluntary


association


membership,


eating


Greek-cui sine


restaurants,










actively


involved


the


Greek-American


community.


Secondary


group


affiliation


can


define


Greek


ethnic


identity


as much


as primary


group


affiliations.


As generations


become


more


removed


(e.g


third


and


fourth


generations)


from


the


Greek


homeland,


Greek


ethnicity


not


so much


matter


cultural


transmission,


but


one


voluntary


participation


Greek-American


institutional


life.


Greek


culture


among


the


two


or more


generations


removed


may


new


emergent


brand


of Hellenism


in America.


Yet,


certain


forms


of Greek


ethnic


identity--a


Greek


Orthodoxy


within


the


framework


American


religious


pluralism,


attachments


old


country


foods


and


dances,


ungrammatical


Greek,


the


whole


system


kinship


life--continue.


The


Greek


and


Greek-American


Diet


Bread,


olives,


olive


oil,


fruits,


nuts,


and


legumes


are


staples


the


Greek


diet.


Vegetables


are


common


and


meats


are


used


less


frequently


than


the


American


diet.


Milk


rarely


drunk


but


used


instead


dairy


products


such


yogurt


and


feta


cheese.


Desserts


are


very


sweet


and


are


consumed


as snacks


or with


lunch


and


dinner.


Greek


coffee


strong


and


laced


with


sugar.


Religious


and


social


occasions


which


are


include


marked


or exclude


special,


the


traditional


serving


food


certain


practices


foods










masquerading


and


kite-flying


known


as apokria--the


equivalent


the


western


carnival


and


"farewell


to meat"


(Nickles


1969)


During


the


forty


day


Lenten


fast,


no red


meat,


chicken,


fish,


cheese,


dairy


products


or eggs


are


eaten.


eliminated


during


Holy


Week,


the


week


prior


to the


Orthodox


Easter


(personal


communication


1982


and


1989).


Protein


intake


among


Greeks


appears


to be


adequate


with


no observed


significant


deficiencies.


Mineral


intakes


for


iron


and


calcium


are


below


the


United


States


Recommended


Dietary


Allowances


both


before


and


after


immigration


to the


United


States


(Newman


1986)


Valassi


(1962)


studied


food


habits


and


food


practices


Greek


immigrants


to the


United


States


as compared


to the


habits


and


practices


non-migrants


their


respective


regions


origin


Greece.


She


also


studied


the


food


behavior


of Greek-Americans


as a group


the


United


States


Valassi


observed


differences


between


Greek


immigrants


and


younger


generation


Greek-American


food


preferences.


Meal


composition


Greeks


followed


the


traditional


patterns


and


timing


meal


practices


Greece.


Greek-Americans


conformed


more


to the


meal


patterns


of Americans.


American-born


Greeks


preferred


less


time-consuming


recipes










Greek-Americans


tended


"Americanize"


the


cooking


methods,


ingredients,


and


seasonings


Greek


recipes.


Freedman


and


Grivetti


(1984)


observed


similar


trends


among


reported


Greek-American


significant


women


Sacramento,


covariations


among


California.


items


They


such


respondent


generation,


composition


meals,


and


timing


food


intake.


They


identified


a strong


trend


abandonment


traditional


Greek


dietary


patterns


and


the


adoption


American


food


practices


third


generation


Greek-Americans.


Moskos


(1989)


noted


that


food


central


importance


among


dishes,


Greeks


and


olive


Greek-Americans.


and


vinegar


Greek


salads,


foods,


cheese


e.g.,


pie,


lamb


and


variety


Greek


pastries,


are


used


for


social


gestures


hospitality


as well


as nourishment.


survey


Costantakos


(1987)


found


that,


even


among


third


generation


Greek-Americans,


four


out


five


individuals


still


regard


Greek


food


as being


very


much


part


their


diet.


Adaptation


the


American


diet


involves


Thanksgiving


compromises


stuffed


For

turkey


example,


will


the t

found


traditional


on the


American


table


beside


a dish


feta


cheese


and


kalamata


olives.


Greek


immigrants,


however,


have


adopted


the


"American


highball" in


preference


ouzo


or Greek


whiskies


(Moskos











Thus,


while


some


studies


suggest


that


intra-group


variations


dietary


behaviors


follow


a linear


acculturation


model


for


Greek


immigrants


the


United


States


which


ethnic


food


patterns


weaken


with


generations,


this


characteristic


does


not


appear


apparent


Greek


immigrants


general.


On the


contrary,


Goode


(1984)


showed


that


situational


and


structural


factors


may


influence


individual


behavior


Mediterranean


immigrants


the


United


States,


but


may


not


weaken


the


shared


sociocultural


rules


or break


down


the


old


system


entirely.


Interpreting


intra-group


variation


and


the


structural


factors


that


determine


can


help


to explain


the


cultural


traditions.


dynamic


Viewed


both

from


continuity


this


and


change


perspective,


ethnic


ethnic

food


systems


are


eating


patterns


which


are


socially


mediated,


transmitted,


and


reinforced.


an ethnic


group


remains


relatively


closed,


then


the


structure


the


food


system


continues


transmitted


and


reinforced


through


social


interactions


and


social


sanctions.


Diet


and


Risk


of CHD


Epidemiological


studies


(Christakis


1981


and


Kurtz


1982)


suggest


that,


as the


Greek


diet


becomes


more


westernized,


risk


factor


status


for


OlD)


increases


among










lipoprotein


(HDL)


cholesterol


and


increased


triglycerides


were


observed


Greek-American


boys


aged


14-16


years


compared w

generation


ith


Greek


Greek


cohorts


boys


the


the


United


same


age.


States


Second


more


nearly


resembled


the


age-matched


American


boys'


LDL


and


triglyceride


patterns


than


did


the


serum


profiles


Greek


boys


who


immigrated


to the


United


States


with


their


families.


Ferro-Luzzi


(1984)


demonstrated


a similar


increase


CHD


risk


factors


with


an experimental


westernization


Experimentally


of the


increased


Mediterranean


dietary


diet


content,


southern


and


Italy.


altered


saturated-to-polyunsaturated


ratio,


increased


total


serum


cholesterol


and


LDL


both


men


and


women,


and


reduced


HDL


values


women.


The

Research


Surgeon

Council


General


s Report


s Report

(1989)


(1988)

on diet


and

and


the


National


health


found


the


association


between


dietary


fat,


especially


saturated


fat,


and


cholesterol


with


CHD


highly


supported


scientific


evidence.


Grundy


(1989)


further


elucidated


this


relationship


describing


the


effects


monounsaturated


fatty


acids


plasma


lipids


and


lipoproteins.


The


"active"


nutrient











cholesterol-lowering


may


"neutral.


" Its


observed


beneficial


lowering


effect


LDL


cholesterol


may


attributed


the


low


dietary


saturated


fat,


since


saturated


has


been


shown


animal


studies


suppress


the


receptor-mediated


clearance


LDL.


Stearic


acid,


a saturated


fat,


does


not


raise


total


cholesterol


or LDL


(Bonanome


and


Grundy


1988).


In contrast,


palmitic

converted


acid


(another


to oleic


acid


saturated


more


fat),


slowly


which


than


appears


stearic


to be


acid,


raises


certain


LDL


levels.


foods


which


While


are


this


high


observation


stearic


may


acid


suggest


(e.g


that


beef


cocoa


butter)


are


acceptable


for


a cholesterol-lowering


diet,


most


foods


containing


stearic


acid


also


contain


relatively

containing


large


quantities


saturated


fats,


palmitic

general,


acid.


are


Thus,


reduced


foods


for


cholesterol-lowering


effect


(Grundy


1989).


Linoleic


acid


has


been


shown


previous


equations


(Keys


et al.


1965


and


Hegsted


1965)


have


a greater


cholesterol-lowering


effect


than


monounsaturates.


High


intakes


polyunsaturated


fatty


acids,


however,


will


also


reduce


HDL


cholesterol


levels.


HDL


lowering,


contrast,


was


not


observed


with


oleic


acid


diets


(Mattson


and


Grundy


1985).










LDL


cholesterol


(Spady


and


Dietscky


1988).


This


action


similar


to the


described


effects


Grundy


dietary


(1989)


saturated


Decreasing


the


fats,


dietary


cholesterol

receptor ac


and


saturated


tivity


liver


fats,

cells


therefore,


and


increases


conversely


the


lowers


LDL


the


LDL


concentration


the


blood


(Connor


1989).


Connor


. (1989)


devised


a cholesterol-saturated


index


(CSI)


as a means


predicting


the


potential


food


or a diet


raise


the


total


and


LDL


cholesterol.


low


indicates


low


cholesterol


and


saturated


fat


content


a food


or diet


and


a decreased


risk


of CHD.


A high


suggests


an increased


potential


risk


for


CHD.


The


traditional


Mediterranean


diet


approximately


35-40%


and


rich


monounsaturated


(primarily


oleic)


fatty


acids


(Grundy


1989).


Whether


this


diet


or the


United


States


recommended


diet


(DHHS


1988


and


NRC


1989)


and


approximately


oleic


acid


preferable


for


decreasing


risk


CHD


not


known.


The


current


American


diet,


which


contribute


calories


an increased


from


risk


fat,


CHD


known


because


high


ratio


saturated


fats


(DHHS


1988).


the


saturated


and


cholesterol


contents


the


diet


have


a greater


cholesterol-lowering


effect


than










lowest


also


cholesterol


more


values.


indicative


Lower

lowered


total

CHD


fat

risk


intakes


than


would


a higher


diet


that


contains


predominantly


monounsaturated


fatty


acids.


Nutrition


Intervention


Ethnic


Populations


Research


methods


used


to describe


dietary


behaviors


ethnic


groups


may


also


useful


the


analysis


transactions


among


any


socially


bounded


group


whose


social


network


includes


the


sharing


a food


system.


Community


nutrition


research


would


benefit


from


studying


the


cultural


dynamics


food


behavior


continuity


and


change


before


designing


intervention


strategies


for


decreasing


dietary


risk


factors


CHD


and


other


chronic


diseases.


Pelto


(1981)


suggested


that


the


application


approaches


from


anthropology


nutrition


education


research


can


provide


the


following


components:


Participant
ethnographic
community ne
social units
The collect
data.


observation to establish the
context--the characteristics
ighborhood, school, and other


on


qualitative


and


of the
relevant


quantitative


The development of a broad data base, with
collection of information on a wide range of
variables.
The use of observational (intrusive or reactive)
and unobtrusive measures as well as data
collection techniques that rely on interviews.
The development of new data collection tools not
Anr 1 tv1 ott waan aS Sajt 4aan bC -nA ir tn.4 at 1 a










design


levels of analysis:
and beyond to the b
The use of methods
preserve the express
community and avoid
inherent in the use


The


use


that


includes


data


or


individual, family,
roader society.
of statistical analy


sion
the
of


multivariate


elucidate the interact
affect people's dietary


I several
community,

rsis which


of variability within
assumptions of homogen
averages.
statistical techniques
ons among factors that
behavior.


the
eity

to


The


long-term


goal


of such


research


would


produce


information


and


analyses


about


the


effect


technological,


material,

behaviors


health


and


ideological


which,


policy


turn,


influences


would


development.


on community


contribute


integrating


dietary


effective


data


on ethnic


food


patterns


and


disease


morbidity/mortality


with


nutrition


education,


government


guidelines


could


translated


into


dietary


recommendations


for


various


ethnic-American


populations.


research














CHAPTER

METHODS


Pilot


Study


Introduction


A pilot


study


was


conducted


on a small


sample


of Greeks


and


Greek-Americans


living


Gainesville,


Florida,


during


late


Spring


and


early


Summer


1986.


The


purposes


the


pilot


study


were


to test


Parts


'-III


a questionnaire


which


were


devised


collect


data


that


describe


demographic


characteristics,


dietary


practices,


and


frequencies


food


use


among


study


subjects,


and


test


whether


the


instrument


was


sensitive


enough


register


trends


aggregate


groupings


the


study


population.


Methods


Subjects


were


enlisted


community


group


functions


and


individual


contacts.


Group


participants


were


recruited


from


a Sunday


morning


Greek


Orthodox


Church


service,


from


joint


business


meeting


the


Greek


Student


Club


and


the


Greek-American


Student


Club


the


University


Florida,


and


from


a meeting


the


Gainesville


Greek


Women's


Auxiliary.


Individuals


were


recruited


at their


place










frequented


Greeks


and


Greek-Americans


who


live


Gainesville.


Subjects


willingly


filled


out


the


study


questionnaire.


Only


two


females


refused


participate


the


study


Ten


male


and


ten


female


Greek


(n=7)


and


Greek-Americans


(n=13)


participated


the


pilot


study


Ages


ranged


from


20-79


years.


Arrangements


attending


the


group


meetings


Gainesville


were


facilitated


through


the


suggestions


and


invitation

University


of a Visiting


Florida.


Greek


Professor


I attended


the


Classics


community


at the


functions


and


gave


a questionnaire


and


pencil


Greeks


and


Greek-Americans


attendance.


Questionnaire


directions


were


self-explanatory.


No coaching


was


volunteered.


A few


questions


were


asked


the


subjects


clarify


some


the


written


questions.


Subjects


took


between


20-30


minutes


each


answer


the


questionnaire


and


handed


upon


completion.

Results


Greeks,


States


Greece


who


between


more


were


17-32


recently,


family

years.


members,

Greek si


between


lived


.ngles


years


ago.


the


emigrate


Greek


United

d from


family


members


lived


Gainesville


an average


16.5


years,


while


singles


averaged


years


Gainesville.


Previous










Families


averaged


persons


and


singles


persons


per


household


unit.


Family


households


were


composed


average


of 1.2 students,


ranging


from


preschool


through


university


Singles


were


university


students


and


only


two


single


subjects


had


full


or part-time


employment.


Years


education


completed


ranged


from


a Ph.D.


degree.


Neither


age


nor


gender


appeared


influence


Greek


Greek-American


eating


practices


and


food


preferences.


Socioeconomic


status


comparisons,


as reflected


type


employment


and


years


education


completed,


showed


distinguishing


trends


either.


The


majority


subjects


observed


yearly


religious


fasts


and


commemorated


Greek


holidays


with


special


Greek


foods.


One


Greek-American


and


one


Greek


male


reported


never


observing


religious


fasts.


Likewise,


one


Greek-American


female


and


one


Greek


female


did


not


practice


this


religious


observance.


These


individuals,


except


for


one


person,


did


observe


the


Greek


holidays


some


way,


however.


Whether


this


represents


individual


preference


or would


indicative


a trend


a larger


study


population


could


not


determined.


The


most


obvious


differences


eating


practices


and


food


preference


became


apparent


when


Greeks


and










vending


machines.


The


majority


Greek-American


families


preferred


the


alternative


choices


eating


out.


This


trend


was


less


pronounced


with


the


Greek


and


Greek-American


singles.


home,


Greeks


prepared


more


their


dishes


with


Greek


ingredients


and


fewer


with


convenience


foods


than


did


the


Greek-Americans.


Greek


families


showed


a greater


preference


for


feta


cheese,


white


bread,


olive


oil,


olives,


Greek


peppers,


spinach-cheese


pie,


Greek


pastries,


yogurt,


and


Greek


coffee


than


did


their


Greek-American


counterparts.


Greek-American


families,


on the


other


hand,


exhibited


stronger


preferences


cheeses


other


than


feta,


peanut


butter,


meat,


potatoes,


rice


and


pastas,


mayonnaise


or salad


dressing,


milkshakes,


doughnuts,


danish,


coffee


cake


and


other


American


pastries,


potato


chips,


whole


milk


(some


preferred


skim


milk),


chocolate


milk,


koolade


or soft


drinks.


Greek


singles


reported


never


eating


french


toast,


pancakes,


or waffles


and


preferred


eggs


more


frequently


than


did


the


Greek-American


singles.


They


however,


prefer


doughnuts,


danish,


and


coffee


cake


more


frequently


than


both


Greek


singles


family


prefer


members


yellow


and


Greek-American


vegetables,


singles.


cream


and


Greek


yogurt,


contrast


the


preference


Greek-American


singles.










rice,


potato


chips,


and


American


pastries.


In addition,


they


consumed


the


following


foods


more


frequently


than


did


the


Greek


singles:


fish,


poultry,


olives,


low-fat


milk,


herbal


teas


and


diet


drinks.


Conclusions


The


observed


technological


and


comparisons


convenience


suggest


the


factors


influence


determining


dietary


behaviors,


the


and


comparison


also


suggest


groups.


Greek


varying


families


degrees


showed


change


the


among


greatest


ethnic


preferences


the


dietary


pattern.


Greek


singles,


while


still


showing


a preference


for


Greek


foods,


made


some


changes


the


direction


a more


Americanized


diet.


Greek-American


family


members


had


accepted


American


dietary


practices.


Greek-American


singles,


while


choosing


American-type


foods,


showed


evidence


attempting


limit


their


intake


accordance


with


the


United


States


government


dietary


goals


for


a lower


fat


intake.


Except


for


the


Greek-American


observations


singles'


represent


dietary


a trend


patterns,


Greek


dietary


these


behaviors


the


direction


acceptance


the


American


practices


associated


with


increased


risk


CHD.


A larger


sample


will


test


whether


this


apparent


trend


dietary


change


significant.










Greek-Americans


substituting


the


reference


Greek


versus


Italian,


as used


Roches


(1984)


modification


Sandberg's


group


cohesiveness


scale.


In order


adapt


the


statements


to a non-ethnic


population


(the


non-Greek


cohort),


statements


were


broadened


to include


attitudes


about


ethnic


behaviors


and


feelings


general.


For


example,


the


statement


"Jokes


about


Greeks


bother


me"


was


changed


to "Jokes


about


ethnic


people


bother


me.


Subjects

a printed


to pilot-test

announcement p


the


questionnaire


osted


the


were


Information


solicited

Desk,


Alachua


General


Gainesville,


Hospital

during


Center


the


Health


summer


and


1988.


Fitness,


Twelve


the


fifteen


subjects,


who


volunteered


to test


the


questionnaire,


returned


their


completed


questionnaires.


Respondents


were


also


asked


report


the


length


time


required


to complete


the


entire


questionnaire


and


comment


regarding


any


ambiguously-worded


questions


Subjects


represented


a diversity


health-conscious,


middle-class,


Gainesville


residents.


Three


subj ects


were


students


the


University


Florida


and


three


were


employed


there.


One


subj ect


was


a restaurant


owner,


one


worked


a hospital,


one


subj ect


was


an elementary


art


teacher,


another


was


a homemaker,


and


two


were










The


time


required


complete


the


entire


questionnaire


ranged


from


15-90


minutes,


with


an average


of 38 minutes


per


subject.


Comments


about


question


ambiguity


focused


most


the


Ethnic


Culture


Questionnaire.


The


comments


predominantly


addressed


a dislike


for


the


forced-choice


scale.


only


They


other


order


preferred


consistency


which


the


have


among


smoking


a "no


the


opinion"


comments


questions


were


category


referred


addressed.


The


to the


These


situations


were


remedied


using


a score


3.5 when


statements


the


Ethnic


Culture


Questionnaire


were


not


answered


a subject.


A "no


opinion"


category


was


not


added


because


the


scale


was


originally


designed


as a


forced-choice


response.


I chose


the


scale


because


was


previously


tested


with


other


ethnic


groups


(Roche


1984)


Questions


referring


smoking


behaviors


were


rearranged


accommodate


subjects'


suggestions.


The


Research


Site


Tarpon


Springs


located


on the


West


Coast


Florida,


Pinellas


County,


along


the


Gulf


Mexico.


It's


first


settlers


were


A.W.


Ormond


and


his


daughter,


Mary,


1876.


was


founded


1882


Anson


P.K.


Safford


and


promoted


a resort.


In 1890,


John


Cheney


started


the


sponge


industry


the


waters


the


Gulf


Mexico


(Tarpon


Springs










Florida.


More


than


2,000


Greeks


(mostly


men)


had


established


themselves


the


colony


the


beginning


World


War


Tarpon


Springs


became


the


world's


largest


sponge


producer


until


the


end


World


War


During


this


thirty


year


period,


Greek


culture


prospered


American


flourished


setting


the


Greek


wealth


the


coffeehouses


sponge


and


industry.


nightclubs

The


population


majority


Tarpon


Springs


was


Greek.


Unlike


any


other


Greek


enclave


the


United


States,


became


immigrant

Nicholas


Greek

(named


Town.


the


The


Greek


patron


Orthodox


saint


Church,


seafarers)


Saint

, was


established


1907


(Moskos


1989).


Two


decline


factors


after


caused


World


the


War


sponge


the


industry's


discovery


prosperity


a method,


1939,


to convert


wood


waste


pulp


into


synthetic


sponge


reduced


the


demand


for


natural


sponges;


and


a major


outbreak


of a disease,


known


as "red


tide"


which


struck


the


west


coast


Florida


1947,


decimated


the


sponge


beds.


In the


1960s,


the


Tarpon


Springs


sponge


industry


began


a comeback.


Once


again,


Kalymnos


divers


began


migrating


Tarpon


Springs


(Bernard,


1987)


the


late


1970s,


Greeks


and


Greek-Americans


represented


approximately


one-third


the


total


population


Tarpon


Springs.


While


the


non-Greek










The


majority


Greek


immigrants,


however,


were


more


likely


to find


employment


the


local


Greek


restaurants


or shops


(Moskos


1989).


Small


numbers


Greek-American


retirees


from


the


north


(several


score


a year,


Moskos


1989:26)


also


entered


the


Greek


community


the


Tarpon


Springs


area.


The


original


Greek


settlement


was


concentrated


area


known


as "fishtown,


(Moskos


1989:26)


bordered


Pinellas


and


Tarpon


Avenues


and


Dodecanese


Boulevard


This


area


remains


predominantly


Greek


today.


Newer


Greek


arrivals,


Greek


retirees


from


the


North,


and


more


affluent


Greeks


live


the


surrounding


suburbs


Tarpon


Springs


and


surrounding


towns


(personal


observation


and


verbal


communication


with


personnel


the


Chamber


of Commerce)


The


largest


age


group


the


estimated


population


Pinellas


County


1989


was


the


over-65


age


group


whites


(University


Florida


Bulletin


89-90,


1989).


Twenty-eight


per


cent


the


white


population


years


age


or older.


Retirees


from


the


upper


mid-West


and


middle


Atlantic


States


account


the


majority


persons


this


age


group.


Blacks


compose


only


the


estimated


total


population.


The


estimated


population


Tarpon


Springs


18,000


the


(Polk


white


Directory


population


1987).


The


estimates.


Th


Greeks

e most


are


included


recently


published










the


Greek


population


(according


personal


communication


with


the


Church


Secretary)


because


there


are


several


Greek


Churches


the


surrounding


towns


where


Greeks


from


Tarpon


Springs


are


members.


Thus,


the


membership


roll


for


one


church


would


underrepresent


the


actual


number


Greeks


who


live


Tarpon


Springs.


Samole


The


study


sample


was


obtained


from


the


Greek


population


Tarpon


Springs


and


the


surrounding


areas.


A comparison


group


of non-Greeks,


from


the


same


geographic


area,


was


also


studied.

adults,

Greeks,


The

aged

who w


sample


25-7

ere


was


years


Greek


divided


age.


into t

Group


immigrants


three


groups


was


Group


a sample


was


a sample


53 Greek-Americans


(born


the


United


States


Greek


descent)


Group


was


composed


a sample


non-Greeks.

a Greek or


Any


non-Greek,


Greek-American


who


was


married


excluded


from


or living


the


with


non-Greek


group.


An attempt


was


made


obtain


a random


sample


from


Tarpon


Springs.


"fishtown"


area


Streets


and


were


surrounding


randomly

a suburbs


selected

SNames


from

and


the

phone


numbers


for


persons


living


on the


selected


streets


were


obtained


from


the


Polk


Directory


(1987).


A Greek-American










briefly


described


the


study


and


asked


persons


within


the


selected


age


ranges


to participate


the


study


making


appointment


come


the


Walk-In


Care,


Holiday,


Florida


(the


out-patient


Springs)


on one


clinic


two


Helen


Ellis


week-ends.


Hospital,


the


eighteen


Tarpon


persons


who


scheduled


an appointment


time


and


date


to participate


the


study,


only


five


actually


came


the


study


collection


site.


None


the


participants


were


Greek


Greek-Americans.


Reminder


calls


were


made


the


remaining


persons


but


they


were


unable


participate.


participated


a live


talk


show


at the


local


Greek


radio


station


the


day


before


calls


were


being


made,


an attempt


stimulate


interest


the


study


and


participation


among


the


Greeks.


Greek


callers


to the


radio


station


during


the


talk


show


spoke


enthusiastically


about


the


study


and


inquired


about


how


and


where


they


could


participate.


Alternate


arrangements


for


recruiting


study


participants


were


negotiated


with


the


Administrator


and


Director


Community


Relations


at the


Helen


Ellis


Hospital,


Tarpon


Springs.


They


permitted


me to


attend


community-wide


cholesterol


screening


and


a health


fair,


which


they


were


sponsoring,


recruit


subj ects


and


collect


data


for


the


study


Special


arrangements


were


made


with










Greek


community


attend


these


events


and


participate


the


study.


The


cholesterol


screening


was


held


a large


corridor


the


Tarpon


Springs


Mall,


October


12-16,


1988.


The


health


fair


was


held


the


Ignatius


Church's


social


hall,


Tarpon


Springs,


March


1989.


A data


collection


site


was


also


set


the


community


hall


Saint


Nicholas


Greek


Orthodox


Church


on Sunday,


April


1989.


Greeks


and


Greek-Americans,


who


attended


the


church


service


on that


day,


were


asked


to participate


the


study


following


the


morning


service.


The


persons


study


who


sample


are


was


more


probably


biased


health-conscious


being


than


the


composed


average


person


the


total


population


or had


been


told


on a


previous


occasion


that


their


cholesterol


value


was


elevated.


To test


representativeness


the


sample,


data


from


the


study


were


compared


with


a similar


age


group


persons


from


NHAINES


II(DHHS


1986-87),


a large


representative


sample


the


United


States


population.


Table


describes


these


comparisons


40).


The


significant


difference


the


cholesterol


values


for


the


total


samples


and


between


the


males


Tarpon


Springs


and


NHANES


may


be explained


the


significant


differences


observed


between


the


Greek-Americans


and











Table


Data


comparisons


with


NHANES


Ages 25-74 years


N Greek Study Range N NHANES Range
Cholesterol mg/dl mg/dl mg/dl ag/dl


Total


-369


9096


135-330


Males


-306


Femal


118-369


4302


4794


219


-307


225


135-330


Blood


Pressure


Total


Systolic
Diastoli


79.0


90-176
49-106


9096
9096


-186


72-103


Males


Systolic
Diastolic


-175


56-106


4302
4302


-183


75-105


Females
Systolic
Diastoli


76.5


90-176
49-105


4794
4794


111-188


71-10


Wt(kg)/Ht(meters-squared)


Total
Males
Femal


28.1
28.2


18.2-44


.0-44


18.2-44


9045
4302
4743


19.2-43


25.9*


28.4


.2-33


19.8-43


*=significance


at 1


significance


ess
ess


than
than


Tarpon


Springs


sample


had


a health-conscious


bias


because


subjects


were


recruited


health


screening


events


. They


may


have


decreased


their


cholesterol


levels


because


previous


elevated


l vel.-


+ns










a regular


schedule.


The


significantly


lower


diastolic


level


and


the


lower


values


the


range


for


women


may


suggestive


these


the


exercise


positive


practices.


consequences


Males,


that


however,


result


had


from


higher


Tarpon


Springs.


Data


Collection


Four


primary


methods


were


used


for


data


collection.


First


a period


of participant


observation


was


used


develop


an appropriately


worded


questionnaire


and


provide


context


for


interpreting


the


data


from


the


survey.


Initial


introductions


key


people


within


the


Greek


community


were


facilitated


a recently


retired


nurse


supervisor


from


the


local


Health


Department.


During


a two


day


visit


to Tarpon


Springs,


March


1988,


she


arranged


meetings


and


introductions


with


the


local


priest,


a Greek


physician,


a Greek


restaurant


owner,


an influential


business


man,


who


associated


with


the


sponge-diving


industry,


and


women,


who


could


the


Greek


translation


of the


questionnaire


and


help


with


the


data


collection.


Continuing


contacts


were


maintained


with


these


persons


throughout


the


data


collection


period.


Publicity


and


advertisement


contacts


regarding


the


data


collection


times


were


made


with


presidents


the


men's


and


women's


Helenic


Benevolent


Associations,


local


Greek










elicit


participation


study


from


those


attending.


Naomi


Patterson


recruited


subjects


from


the


organization


for


younger
member.


Greeks,

A study


the


Philoptohos


summary


and


Society,


which


announcements


both


she


English


and


Greek


were


added


as supplements


the


Church


Bulletin


prior


to data


gathering


events.


The


priest,


Father


Tryfon,


made


verbal


announcements


at the


respective


services.


was


introduced


the


editor


a local


weekly


newspaper,


The


Leader


Today,


Chryse


Flowers,


a Greek-American


some


prominence


the


community.


A description


study


appeared


1988


morning


on the


(Appendix


service


front


page


Mrs.


with


the


Flowers


me at Saint


paper Sa

attended


Nicholas


turday,


the


Greek


October


Sunday


Orthodox


Church,


October


1988,


to help


recruit


subjects


and


ask


them


attend


the


cholesterol


screening


and


participate


the


study


the


Tarpon


Springs


Mall,


October


12-16.


Greek


physician,


was


contacted


prior


the


data


collection


times


and


asked


to lend


his


influence


encouraging


Greeks


and


Greek-Americans


participate


the


study.


The


second


data


collection


method


was


self-administered


questionnaire


(Appendix


The


questionnaire


wasr


composed


five


parts


and


was


given


each


subj ect


the


data


collection


site.


Each


subj ect


was










fill


out


at home


for


later


pick-up


or return


an agreed


upon


location.


Of the


total


number


subjects,


who


participated


the


study,


returned


the


completed


questionnaire.


Greeks


had


the


lowest


questionnaire


completion


rate


(27%).


The


self-administered


questionnaire


provided


data


concerning:


Demographic


Smoking
Health


and


information


exercise


history


Frequency


Greek-American


Social


Eating, f
A food fr
A 24-hour


visits


cohesion


ood


eque


behaviors


Greece,


Greek


scale


purchasing, an
ncv check-list


food r


d


food


use


preferences


ecall


Third,


individual


height


and


weight


measurements


were


obtained.


Height


was


measured


inches


having


the


participant


stand,


without


shoes,


on a specially-designed


platform


attached


to a portable


Accustat


Stadiometer,


marketed


Genentech,


Inc.


Weights


were


obtained


having


the


participants


stand,


without


shoes,


on a Sears


Electronic


Bath


Scale,


Model


6414


The


scale


weighs


to the


nearest


half


pound


Two


5-pound


dumb


bells


were


used


test


the


accuracy


the


scale


weight


before


and


between


data


collection


events.


The


dumb


bells


consistently


weighed


9.5


pounds


at each


weighing.


Height


inches


was


converted










(kg)/height


(meters-squared)


was


used


compute


body


mass


index


(BMI).


The

blood


fourth method

pressure and


assessed


total


the


blood


physiological


cholesterol.


parameters


Subjects


reported


information


about


hypertension


and


cardiac


disease,


with


any


respective


medications


taken,


Part


I of


the


questionnaire.


Questions


relating


a family


history


hypertens ion,


cardiac


disease,


diabetes


and


cancer


were


addressed


the


questionnaire


relation


their


parents


and


children


s medical


historic


es.


Blood


pressures


were


obtained


use


an automatic


sphygmomanometer


with


a digital


print-out


(Biomega


423b,


marketed


Biomega


Corporation),


which


was


loaned


me for


the


study


the


director


the


Alachua


General


Hospital


Center


Health


and


Fitness,


where


was


employed


part-time.


The


digitally-read


numbers


were


advantageous


reducing


subjectivity


associated


with


human


hearing


and


interpretation.


Visually-read


numbers


can


also


transcribed


with


greater


reliability


than


verbal


data.


Participants


were


seated


with


the


right


arm


cuffed


and


positioned


a right


angle.


The


right


forearm


rested


on a


stable


surface


appropriate


height.


Blood


cholesterol


values


were


obtained


from


a digital










Relations,


Helen


Ellis


Hospital,


Tarpon


Springs.


Volunteer


retired


nurses


assisted


with


the


blood


drawing


the


cholesterol


screening


and


health


fair.


I hired


a dietitian


from


Gainesville


assist


with


the


blood


drawing


and


trained

Orthodox


her


run


Church


the


data


cholesterol


collection


analysis


site,


April


the G

1989.


;reek

The


State


Florida


issued


a regulation,


effective


January


1989,


stating


that


only


trained,


licensed


medical


technologists


may


blood


drawings


and


run


the


analysis


cholesterol


at cholesterol


screenings.


Laura


Phillips,


the


MRS


Licensure


Office,


Jacksonville,


Florida,


assured


phone


that


research


would


exempt


under


Regulation


483031


I did


not


collect


money


from


the


subjects


give


them


information


about


their


cholesterol


values


writing.


Drops


of blood


were


obtained


from


a finger


stick


and


absorbed

analyzed


onto


a calibrated


the


chemistry


chem

unit.


strip,

Chem


which

strips


was machine

were compared


with


standards


validate


the


machine


analysis.


Cholesterol


values


obtained


this


method


were


reported


previous


studies


vary


within


the


true


value


the


standard


sample


(Brown


1988


and


Sedor


et al.


1987).


This


range


similar


to the


daily


variation


3-5%


that


has











greater


than


140/90


mm and


to have


cholesterol


values


re-evaluated


the


blood


cholesterol


level


was


greater


than


mg/dl.


They


were


instructed


see


a physician


the


level


was


greater


than


mg/dl


(NIH


Consensus


Conference


on Cholesterol


1985).


Sources


error


data


collection


technicrues


Ethnicity


measurement


problems


common


problem


with


ethnicity


measures


the


paucity


standardized


instruments


which


measure


degrees


which


members


an ethnic


group


are


committed


to the


group


and


traditions


(Roche


1984).


More


frequently,


studies


(e.g.


Sassen-Koob


1979;


Woodrum


et al.


1980;


Cheung


1981)


use


descriptive


analyses


based


on observed


presence


absence


characteristics,


investigator,


classify


determined


individuals


the


into


respective


ethnic


categories.


Another

standardized


problem with

measures that


ethnicity

allow cr


scales


oss-ethnic


a lack


comparisons.


For


example,


studies,


like


that


Burnam


(1987),


employed


analytical


techniques


check


internal


validity


their


acculturation


scale.


It's


use,


however,


has


been


limited


Mexican-Americans


and


has


not


been


tested


cross-ethnic


studies.










Italian-Americans


(Crispino


1980


and


Roche


1984).


Cross-comparisons


among


findings


from


the


three


studies


suggest


good


external


validity


the


scale;


and


Questions


addressed


on Sandberg


s group


cohesiveness


scale


are


similar


to those


addressed


Scourby


(1979)


her


study


ethnicity


among


three


generations


Greek-Americans


New


York


City.


Thus,


the


Sandberg


group


cohesiveness


scale


provides


data


that


are


comparable


cross-culturally


with


other


ethnic-Americans


and


comparable


with


findings


from


a similar


Greek-American


ethnicity


study


The


scale


(Appendix


Part


II of


the


study


questionnaire)


consists


thirty


statements


that


measure


participant


attitudes


toward


various


aspects


the


ethnic


group.


Three


subscales


(cultural,


national,


and


religious)


identify

cultural


intergroup

subscale e


similarities


licits


and


attitudes


differences.


about


The


traditions,


language,


music,


and


history


the


group.


The


national


subscale


focuses


on the


sense


peoplehood


shared


group


members


with


questions


about


the


ethnic


neighborhood,


being


comfortable


with


fellow-ethnics,


not


changing


one's


name,


being


able


someone


count


the


same


on ethnic


peers


nationality,


and


for


help,


voting


marrying


for


candidates


the


same


ethnic


background.


The


religious


subscale










Dietary


measurement


problems


A major


problem


with


the


development


dietary


instruments


population


studies


the


need


for


tools


that


can


readily


and


inexpensively


used


with


large


numbers


subjects


and


which


yield


accurate


information


about


usual


dietary


patterns


(James


et al.


1981;


Block


1982;


Gray


1984).


Sources


error


can


potentially


introduced


during


data


collection,


quantitative


processing,


and


interpretation


(Algert


and


Stumbo


1986).


The


24-hour


recall


method


one


the


most


widely


used


techniques


for


collecting


dietary


information


average


group


dietary


intakes


(Block,


1982)


has


also


been


criticized


being


unrepresentative


of usual


intake.


Beaton


et al.


(1983)


for


example,


found


the


major


source


variance


between


and


within


subj ect


differences


from


day


day.


As part


the


Seven


Countries


Study


(Keys


1980),


systematic


comparisons


dietary


surveys


were


examined.


Increasing


the


number


24-hour


measurements


was


not


found


reduce


intra-individual


variation,


but


rather,


provided


more


reliable


estimation


an individual's


preferences,


validity

their co


the


mparison


data

s was


was

tha


assumed.

t the in


An important


itra-individual


finding


variation,


- a -


A










an attempt


to further


define


reliability


reported


intakes,


Jeor


(1983),


demonstrated


similar


intra-


and


inter-subject


variability


reported


foods


but


insignificant


differences


mean


daily


nutrient


intake


when


compared


with


the


nutrient


analysis


one-week


and


three-week


food


logs.


Protein


was


the


only


nutrient


change


when


days


the


week


were


compared.


The


interaction


between


nutrient


intakes


for


weeks


and


days


the


week


was


significant


only


calories


and


fat.


Thus,


would


appear


that


24-hour


nutrient


data


can


representative


a group's


intake.


as Young


(1960)


concluded

sampling


after


studying


techniques


variation


(24-hour


recall


between t

, dietary


three


dietary


history,


and


7-day


record),


the


24-hour


recall


provided


the


same


values


as the


seven-day


record


when


used


with


groups


least


fifty


persons


and


when


a 10%


error


rate


was


acceptable.


A confounding


measurement


error


with


24-hour


recalls


the


conversion


of foods


nutrients.


There


inherent


error


any


nutrient


data


base.


Climate,


harvesting,


handling,


values


food

given


processing


foods


and


preparation


(Witschi


affect


1981)


nutrient


At present,


standard


data


base


containing


USDA


food


composition


data


and


manufacturers'


data


provide


the


best


values


on which


to base










populations


residing


outside


the


United


States


(Adelman


. 1985)


The


food


frequency


questionnaire


an easier


and


quicker


method


than


the


24-hour


recall.


While


does


not


assess


actual


quantities


consumed,


may


achieve


a more


representative


pattern


usual


intake


foods


(Chu


1984)


Karinpaa


and


Seppanen


(1983)


demonstrated


that


agreement


between


a food


frequency


questionnaire


and


24-hour


recall


foods


was


were


high


reported


foods


more


commonly


frequently


eaten


during


a meal.


the


Snack


24-hour


recall


the


interview.


checklist


Mullen


or frequency


(1984)


method


also


produced


observed


greater


that


agreement


with


observations


of foods


eaten


at a meal


than


for


meal


accompaniments


(e.g.,


nuts


and


seeds).


Used


together,


the


food


frequency


questionnaire


and


the


24-hour


with


recall


additional


provide


a cross-check


information


on dietary


foods

pattern


reported


and


along


food


practices


(Christakis


1978).


general,


descriptions


usual


dietary


intakes


are


more


reliable


when


the


dietary


questionnaire


used


with


a 24-hour


recall


(Alford


and


Ekvall


1984).


The


problem


informant


inaccuracy


a critical










behaviors


being


measured.


Bernard


et al.


(1984)


observed


that


comparisons


between


what


people


say


they


do and


observations


what


they


do bear


little


resemblance


Bradburn


(1983)


refers


the


types


bias


which


affect


how


subjects


respond


interviews


as "response


effects,


" of


which


there


are


three


classes:


deliberate
information
divulging c


memory


errors
for t
certain


embellishment


h


errors,


communication


e purpose o
information


or omission


impress
to the i


ing


or not


interviewer,


errors.


Variation


response


effects


may


influenced


the


data


gathering


perceived


role


task,


the


the


interviewer's


community,


and


performance


characteristics


the


research


subject.


Bradburn


(1983)


noted


that


the


empirical


literature


suggests


that


characteristics


the


data


gathering


task


are


the


major


influence


on response


effects.


Bradburn


(1983)


further


described


comparisons


instrument


administration


methods.


Face-to-face


interviews,


telephone,


and


self-administered


questionnaires


have


high


variance


with


no consistent


direction


their


biases.


Self-administered


forms


appear


to be slightly


superior


for


items


requiring


definite


information,


questions


requiring










Face-to-face


interviewing


allows


for


use


cue


cards


visual


aids


to improve


recall.


Increased


motivation


may


also


come


from


the


interviewer


being


with


the


respondents


person


encourage


them


take


time


consider


the


questions


carefully.


The


time


"window"


involved


recall


reported


affect


the


size


memory


errors


(Bradburn


1983


and


Bernard


et al.


1984) .


The


more


recent


the


recall


period


-g.,


24-hours

Bernard


informant


vs a week),


et al.


the


(1984),


accuracy


more


however,


could


accurate


the


observed


accounted


information.


that


for


only


this


factor


their


data


on recall


of communications.


Can


validity


dietary


information


improved


obtaining


weighed


samples


foods


eaten


when


compared


with


estimates


of dietary


recall?


Studies


from


the


Seven


Countries


Study


(Keys,


1980)


and


Todd


(1983)


conclude


that


the


weighed


sample


method


does


not


significantly


improve


one-day


subj ect


group


reporting


dietary


accuracy.


record


Todd


a reasonable


found


estimate


(within


15%)


the


weighed


intake.


Both


methods


had


considerable


inter-


and


intra-subject


variability.


Keys


concluded


that


the


difficulty


and


expensiveness


collecting


replicates


all


meals


eaten,


compared


with


the










Household


refuse


analysis


(Rathj e


1984)


and


biochemical


markers


(Christakis,


1981


and


Willett


1983)


have


been


used


test


the


validity


reported


dietary


intakes.


The


increasing


percentage


the


food


dollar


on away-from-home


food


consumption


the


United


States


(greater


than


40%;


Morgan


and


Goungetas


1986)


limits


the


usefulness


household


refuse


analysis


verifying


informant


accuracy


While


certain


biochemical


markers


(e.g. ,


adipose


tissue


and


erythrocyte


fatty


acids


, plasma


carotene


and


alpha-tocopherol


level


have


been


shown


confirm


reported


dietary


estimates


of these


respective


dietary


nutrients,


analysis


biochemical


parameters


not


exist


for


nutrients.


Blood


cholesterol


levels,


while


not


a direct


measure


of dietary


or cholesterol


intakes,


are


a useful


clinical


parameter


for


identifying


persons


who


may


ingesting


high


saturated


and


cholesterol


foods.


Thus,


best,


recall


data


can


only


interpreted


estimates


group


trends


and


patterns.


Because


the


goal


this


research


focus


on dietary


patterns


of aggregate


subgroups


that


may


suggestive


increased


risk


CHD,


averages


dietary


intakes


saturated


fat,


cholesterol,


calories,


and


fiber


will


compared


with


the


subgroups


who


have


elevated


cholesterol


values


as a validity


check.










per


subject.


Food


models


were


available


for


memory


prompting


and


standardize


serving


sizes.


This


one


quantitative

differences


measurement


between


several


limited


dec


dietary


visions about

information


measurement

gathering


times.


Prototypes


of Greek


and


American


diets


were


a proxy


for


time


this


cross-sectional


study.


Greek


and


American


diet


prototypes


were


built


from


nutrition


surveys


and


food


consumption


studies


from


the


1960s


the


present.


(Studies


Greek


et al.


dietary


1965;


practices


include:


Ashton-Vouyoucalos


1975


Valassi

; Keys


1962;

1980;


Christakis

Lieberman


and


Gardner


1980;


Kurtz


et al.


1982;


Freedman


and


Grivetti


1984.


Studies


American


dietary


practices


include:


Ten-State


Nutrition


Survey


1968-1970;


HANES


1971-73


and


1979;


Nationwide


Food


Consumption


Surveys


1977-78,


1985-86;


Food


and


Nutrition


Board


1986).


A Greek


version


the


questionnaire


was


available


for


those


subjects


who


cannot


read


English.


Back


translation


the


study


questionnaire


was


performed


two


Greek-speaking


translators.


The


Greek


version


was


translated


from


the


English


version


Maria


Pantelis,


a Greek


immigrant


who


lives


Tarpon


Springs.


She


also


owns


a Greek-type


typewriter


so that


the


questionnaire


could


typed


with


Greek


alphabet


characters.


The


back


translation


English










words


or the


questions.


His


comment,


however,


was


that


the


Greek


language


constantly


changing


and


for


that


reason


assumed

mother'


the


age


original

, because


translation


of the


was


phrasing


done


used.


someone


His


his


observation


was


true,


but


since


most


the


subjects


would


also


the


age


of the


original


translator,


the


translation


was


kept


originally


interpreted.


Some


Greeks


Group


1 could


not


read


either


Greek


or English.


A family


member


verbally


translated


the


questionnaire


them


from


the


English


version.


Back


translation


minimizes


errors


associated


with


assymetrical


intrepretations


a source


language


into


target


language.


Loyalty


one


language,


usually


the


source


language,


dominates


assymetrical


interpretations.


assume


that


two


languages


could


equivalent


fails


recognize

Back


the


fundamental


translation,


issue


while


not


culture


without


differences.


limitations,


method


identifying


translation


asymmetry


The


most


common


error


back


translation


results


from


dictionary-equivalent


redundancy


(Warner


and


Campbell


1970


and


Berkanovic


1980).


To test


the


validity


the


dietary


data,


market


trends


were


observed


through


informal


interviews.


A sample










managers,


grocery


shoppers


and


restaurant


patrons.


One


restaurant


manager


and


one


grocery


store


manager


would


not


allow


me to interview


their


patrons.


Grocery


managers


were


interviewed

frequently


about f

reported


requency


study


inventory


subjects.


turnover

Restaurant


items


managers


were


interviewed


about


type


patrons


and


popularity


menus


served.


Grocery


shoppers


and


restaurant


patrons


were


interviewed


their


about


respective


their


perceptions


communities.


Reported


food

food


behaviors


frequencies


were


grouped


into


the


food


groups


fruits


and


vegetables,


beverages,

comparing


grains,


mean


dairy,


frequencies


protein,

of the


fats

total


and sweets.

study sample


T-tests


food


group


and


mean


frequencies


the


validity


sample


food


group


indicated


no significant


differences


for


the


food


groups


except


the


protein


and


sweets


groups.


Mean


for


protein


the


study


sample


was


higher


(p=less


than


.05)


than


the


validity


sample.


The


reported


frequency


mean


for


sweets


was


lower


(p=less


than


.05)


the


study


sample


than


the


validity


sample.


Overweight


was


defined


terms


the


body


mass


index


(BMI),


as used


N HA N ES


(DHHS


1987).


Overweight


men


had


a BMI


equal


or exceeding


27.8;


and


were


severely


overweight


the


equaled


or was


greater


than


31.1.










overweight


as a BMI


equal


or greater


than


the


85th


percentiles


men


and


women


ages


20-29


years


as the


reference


population.


Nutrient


analysis


of foods


reported


on the


24-hour


recalls


were


performed


with


The


Nutritionist


Data


Base,


Version


4.5,


1989,


marketed


N-Squared


Computing,


Salem,


Oregon.


The


data


base


derived


from


a documented


USDA


data


base,


manufacturers


' data


and


recipes


that


are


frequently


updated.


Greek


foods


and


recipes


were


analyzed


using


either


similar


foods


and


recipes


or analyzing


recipes


individual


ingredients


contained


the


data


set.


Mortality


data


major


cardiovascular


diseases


Tarpon


Springs,


1987,


were


obtained


from


the


Florida


Department


Public


of Health


Health


and


Statistics


Rehabilitation


Section,


Services


Jacksonville,


(HRS),

Florida.


One


hundred,


fourteen


deaths


were


attributed


major


cardiovascular


diseases


during


1987,


with


them


from


heart


disease.


Forty-four


deaths


were


reported


from


chronic


ischemic


heart


disease


(CHD)


Tarpon


Springs.


Twenty


the


diD


deaths


were


among


white


males


and


twenty


were


white


females.


These


44:18,000


figures


or 240


per


would


account


100,000.


for


These


a mortality


data


are


rate


not


standardized


for


age.


Comparing


them


the










I attempted


to obtain


a mortality


breakdown


deaths


persons


from


Greek


descent,


but


found


the


task


to be


impossible


because


data


are


not


recorded


according


to ethnic


identity.


Morbidity


not


recorded


for


CHD


the


State


vital


records


or estimated


with


any


reliability


Tarpon


Springs


physicians.


Data


Analysis


Research


questions


addressed


this


study


include:


Are there systematic change
observed dietary behaviors
a. Gender (Male vs Female)
b. Age groups
c. Ethnicity (Greek, Greek
non-Greek)


patterns
among...


-American,


the


and


I compared with...
a. Number of year
Greek)
b. Socioeconomic
c. Marital status
to a Greek vs
Greek-American
d. Composition of
alone vs in a


s


living


the


status
and ethnicity
to a non-Greek,


United


mix,
if


the household, e
multigenerational


States


e.g.,
Greek


married
or


.g., living
family unit?


Is there an
processes, i
convenience,
cultural pre
practices in


observable
.e., which
and infra
ferences,
relation


pattern between structural
promote technology and
structural processes, i.e.,
social norms, and religious
to change adoption patterns?


Are the observed dietary behaviors associated with
a deviation from the traditional Greek diet and
indicative of increased risk of coronary heart
disease, as characterized by the American diet?

Variables


when


when


A










living


the


Tarpon


Springs


area.


Part


l of


the


questionnaire


provided


these


data.


Socioeconomic


status


was


determined


with


an SES


clustering


system


described


Schneider


(1986).


In contrast


the


Ho 1ingshead


scale


which


an ideologically


based


measure


the


status


level


the


working


members


a household,


the


SES


clustering


system


defines


class


as operationally


and


theoretically


different


from


status.


Inherent


the


Hollingshead


scale


the


concept


that


class


represents


the


economic


relationship


individuals


goods

Status


and


opportunities


groupings


are


for


thought


income


a market


to represent


economy


lifestyle


and


prestige


attributed


individuals


society


Schneider,


on the


other


hand,


utilizes


a Marxian


concept


class


which


views


class


as the


primary


element


influencing


individual'


role


place


an individual


the


fill


social


the


hierarchy.


production


The


process


particular


and


relationship


to others


the


economic


hierarchy


will


influence


his/her


access


the


social


product


society,


including


which


neighborhoods


they


live


and


schools


they


attend,


life


chances,


and


through


socialization


particular


social


place,


world


view"


(Schneider


1986


:211).


She


views


the


nature


a particular


class


society


within










SES


level,


clusters


occupation,


utilize

self r


variables


reported


which


ethnicity


include

. and r


education


elevance


ethnicity.


The


variable


statistically


derived


cluster


analysis.


Social


cohesion


scores


were


determined


according


each


of the


three


subgroups:


cultural,


national


and


religious


components


of ethnicity.


A total


score


the


thirty


items


were


referred


as the


attitudinal


ethnicity


score.


The


lower


the


score,


the


greater


indication


commitment


the


group.


Preference


American


foodways


was


operationalized


measure


preference


eating


American


steakhouses,


fast


food


restaurant


eating,


and


cooking


home


with


"American-style"


recipes.


Use


convenience


foods


and


microwave


oven,


preference


discontinuation


eating


individually,


the


family


eating


out


meal


deli's


specialty

behaviors


diners

which


or from


vending


represented


machines


convenience


reflected


and


technological


motivation.


Commercial


influences


were


measured


questions


regarding


the


frequency


food


purchases


because


coupon


use,


TV advertising,


or recipe


collection


from


popular


women


s magazines.


Continuity


Greek


dietary


practices


was










coffee

e.g.,


house,

olive c


and


Ii]-


preference


Greek


peppers,


cooking


feta


with


cheese


Greek


(all


foods,


are


available


grocery


stores


Tarpon


Springs)


Infrastructural


variables,


e.g.,


ethnicity,


included


data


about


frequency


observance


of religious


fasts


and


Greek/ethnic


holidays.


Parts


and


the


study


questionnaire


addressed


these


variables.


The


food


and


nutrient


patterns,


addition


eating


times


reported


Parts


IV and


V of


the


questionnaire,


were


compared


with


the


Greek


and


American


diet


prototypes


further


describe


abandonment


or persistence


Greek


dietary


behaviors

Springs.


among


Greeks


Variables,


and


e.g


Greek-Americans


., type


fat,


Tarpon


percentages


complex


carbohydrate


and


protein


consumed,


were


used


describe


the


degree


Americanization


the


dietary


patterns


and


adoption


dietary


practices


associated


with


increased


risk


coronary


heart


disease.


The


hypothesis


tested


whether


the


observed


dietary


patterns


demonstrate


persistence


ethnic


identity


and


food


practices


or change


relation


demographic,


technical/material,


and


infrastructural


influences.


Data


regarding


obesity,


elevated


blood


pressure,


and


elevated


serum


cholesterol


were


used


validate


and


explain


risk


S ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ .. -A e -ArS---


A


hl --


r I


I


-L L


..










interactions


among


the


study


variables


the


respective


ethnic


groups.


Significant


variance


between


and


among


aggregate


groups


of individuals


and


ethnic


groups


were


used


to describe


observed


differences


dietary


behaviors


and


risk


factor


status.














CHAPTER

RESULTS


Inference


Tests


Data


were


collected


between


October


1988


and


April


1989


from


Greeks,


Greek-Americans


and


non-Greeks


who


live


the


Tarpon


Springs


area.


Two


hundred,


twenty-six


persons,


aged


25-74


years,


participated


the


study.


One


hundred


and


twenty-eight


persons


(57%)


completed


the


entire


questionnaire,


thus


providing


explanatory


variables


the


study


Comparisons


between


the


two


groups


(Group


l=those


who


did


not


complete


the


questionnaire


and


Group


2=those


who


did


complete


the


questionnaire)


revealed


differences


between


their


body


mass


index


(BMI=weight


kgs/height


meters-squared),


blood


pressure


and


cholesterol


values


(Table


64).


There


were


no significant


differences


between


the


two


groups


Body


Mass


Index


(BMI)


or blood


cholesterol


levels


Differences


blood


pressure


values


were


highly


significant


the


.036


level


for


the


systolic


pressure


and


the


.005


level


the


diastolic


values.


Therefore,


data


for


the


two


groups


were


not


combined


for


further


analyses.


m












Table


4-1:


Comparisons


not


and


those


data


who


collected


did


answer


fro
the


ii


those


who


did


questionnaire


T-Test


Variable


Group


Group


p-values


28.9


0.077


kg/meters-squared


Blood


Pressure


Systolic
Diastolic


Hg)
4.8


*0.036
*0.005


79.0


Cholesterol


226.9


0.077


(ag/dl)


*=significant at less than .05
Group l=Those who did not complete the questionnaire
Group 2=Those who did complete the questionnaire


questionnaire,


did


not


fall


outside


the


ranges


of values


for


the


persons


who


completed


the


questionnaire


entirely


so their


data


were


included


with


the


group


persons


who


did


fill


out


the


questionnaire.


The


total


ethnicity


score


and


subscales


(culture,


religion,


national),


age,


cholesterol,


systolic


blood


pressure,


diastolic


blood


pressure


and


were


further


tested


see


whether


they


met


the


assumption


normality.


The


probability


that


each


these


variables


had


L normal










skewed


(1.04;


kurtosis


1.58)


the


opposite


direction,


however


both


had


p-values


less


than


and


could


accepted


under


the


normal


distribution


assumption.


Demoaraohic


Characteristics


of the


Sample


The


socioeconomic


(SES)


clustering


system


described


Schneider


(1986)


revealed


two


clusters


with


representative


groupings


persons


from


lower


and


higher


SES


categories.


These


groups


reflect


the


educational


level


achieved,


the


degree


skill,


autonomy,


supervision


and


type


employment


which


defines


an individual


s place


within


the


local


social


hierarchy.


Table


identifies


these


SES


groupings


ethnic


group.


Table


SES


cluster


ethnic


group


Ethnic


Group


Lower


Frequency


Row


SES


Higher


SES


Total


Percent


Greek


Greek-American


Non-Greek


54.4


45.6


Total


Persons with missing values were omitted from the
comparisons.


The


Chi-scuare


test


independence


had


a value


r.


ur











differences


SES.


Greeks


had


a higher


proportion


study


subjects


the


higher


SES


group.


Non-Greeks


had


a higher


percentage


persons


the


lower


SES


cluster.


The


clusters


revealed


a significant


(p-0.000)


relationship


with


age.


The


younger


age


group


(25-49


years)


contained


persons


from


the


lower


SES


group


and


from


the


higher


SES


cluster.


The


older


age


group


(50-74


years)


contained


a higher


proportion


persons


from


the


lower


SES


group


(30%


lower


SES


and


higher


SES).


Subjects


were


asked


report


age


decade


25-29,


30-39,


etc.)


Mean


age


for


Greeks


fell


within


the


fifties,


for


Greek-Americans


and


non-Greeks,


mean


age


fell


within


the


forties.


Because


the


small


cell


size


when


analyzing


age


with


other


variables


a multivariate


analysis,


age


was


subdivided


into


two


grouping.


Group


represented


those


persons


who


were


less


than


years


age.


Group


two


was


composed


persons


50-74


years


age.


Table


illustrates


the


age


groupings


ethnic


group.


The


Likelihood


Ratio


Chi-square


had


a value


6.155


with


2 degrees


freedom


and


a p-value


0.046,


indicating


that


ethnic


group


had


a significant


effect


age


grouping.


In later


analyses


where


age


had


a significant












Table 4-3: Ethnic group by age group

Ethnic Group Age Group
Frequency 25-49 50-74 Total
Row Percent years years

Greek 9 13 22


Greek-American


40.9


70.5


59.1


29.5


Non-Greek


Total


were


combined,


thus


allowing


a more


even


age


and


frequency


distribution


between


Greek


and


non-Greek


comparisons.


Each


age


group


had


a higher


proportion


females


than


males.


Table


describes


the


gender


composition


each


age


group


ethnic


group.


Study


subjects


had


lived


the


Tarpon


Springs


area


between


1-74


years.


Thirty-five


percent


reported


living


the


area


for


four


years


or less.


Half


them


were


new


the


area


within


the


past


years.


Sixty-two


the


study


participants


lived


Tarpon


Springs


for


or more


years.


Three-fourths


of the


Greek


subjects


were


born


Kalymnos,


the


island


home


the


original


divers


who


founded


--~~- -











Table 4-4: Gender by age and ethnic group

Gender Ethnic Group Age Group Total
Frequency 25-49 50-74
Row Percent years years

Female Greek 8 9 17
47.1 52.9

Male Greek 1 4 5
20.0 80.0

Female Greek-American 23 9 32
71.9 28.1

Male Greek-American 8 4 12
66.7 33.3

Female Non-Greek 20 15 35
57.1 42.9

Male Non-Greek 14 16 30
46.7 53.3

Total 74 57 131


five


years.


One


these


persons


lived


Tampa


prior


moving


to Tarpon


Springs.


The


other


person


immigrated


directly


from


Athens


and


living


with


a family


member


Tarpon


Springs.


Seventy-two


percent


of the


Greek


ethnic


group


lived


the


United


States


years


or longer


Ethnicity


Among


the


Greeks,


had


visited


Greece


within


the


past


five


years.


Twenty-eight


percent


reported


that


they


visited


Greece


more


than


three


times


during


that


period.










them


had


visited


Greece


more


than


once


or twice


during


that


time.


Greeks


and


Greek-Americans


differed


the


number


religious


fasting


occasions


that


they


kept.


Fifty-eight


percent


Greeks


compared


with


twenty-four


percent


Greek-Americans


reported


fasting


weekly.


Only


one


Greek


and


three


Greek-Americans


never


fast.


Three


non-Greek


persons


reported


fasting


weekly


and


69 percent


reported


never


fasting.


Yearly


holiday


festivities


were


celebrated


with


special


foods


67 percent


the


Greek


ethnic


group


and


95 percent


of the


Greek-Americans


contrast,


only


46 percent


of the


non-Greeks


used


special


holiday


foods


celebrate


yearly


festivities.


Ethnic


group


cohesiveness


was


apparent


among


the


Greeks


and


Greek-Americans


from


their


ethnicity


scores.


The


lower


the


numerical


score


for


each


scale,


the


greater


the


commitment


to the


ethnic


group.


The


means


for


each


subscale


were


consistently


lower


the


Greeks


than


for


the


Greek-Americans.


Scores


for


the


non-Greeks


were


higher


than


either


the


Greek


ethnic


group


scores.


Scores


for


one


subscale


were


predictive


the


scores


on the


other


subscales


among


the


Greek


ethnic


groups


but


not


among


the










cohesiveness


scores.


The


exception


was


the


national


score


Greek-Americans.


While


Greek-Americans


reported


observing


holidays


with


special


foods


more


frequently


than


Greeks,


this


finding


may


reflect


a tendency


among


the


Greek-Americans


participate


both


Greek


and


American


holiday

holidays


festivities.


both


The


Greeks


use


and


special


foods


Greek-Americans


to celebrate


correlates


with


the


lower


national


scores


(greater


national


cohesiveness)


for


the


two


Greek


ethnic


groups.


During


the


time


of the


data


collection,


two


Greeks


were


running


elected


offices.


Governor


Dukakis


was


pre


sidential


candidate


and


United


States


Congressman


Bilirakis


was


campaigning


for


re-election.


While


a few


study


participants


showed


strong


agreement


or disagreement


with


the


question


inquiring


about


voting


for


candidates


the


same


ethnic


background,


no overall


election


opinion


bias


was


detected


among


the


majority


subjects'


responses


this


question.


Table


(p.71)


describes


the


ethnic


scoring


differences


between


the


study


groups


and


their


respective


score


correlation


coefficients.


Ethnicity


subscores


were


compared


to Roche's


(1984)


ethnicity


scores


obtained


from


two


samples


Italians


and











Table 4-5: Ethnicity scores by ethnic group

Correlation
Ethnic coefficients
Scale Group N Mean Range Cult Reli Nati

Culture GR 18 16.4 11.0-24.5 0.65 0.62
GA 40 19.7 10.0-35.0 0.78 0.58
NG 66 30.2 15.0-60.0 0.10 0.23

Religion GR 18 19.3 10.0-30.0 0.65 0.63
GA 40 23.0 10.0-43.0 0.78 0.69
NG 66 32.9 19.0-56.0 0.10 0.21

National GR 18 23.3 11.0-34.0 0.62 0.63
GA 40 30.1 14.0-45.0 0.58 0.69
NG 66 35.1 17.5-47.0 0.23 0.21

GR=Greek
Cult=Culture GA=Greek-American
Reli=Religion NG=Non-Greek
Natl=National



Table 4-6: Greek ethnic subscale comparisons with
Italian-American subscale scores

Greek Italian
Scale N Group Score N Group Score

Culture 18 GR 16.4 52 IT 27.6
40 GA 19.7 49 IA 28.2
66 NG 30.2 27 AM 35.4

Religion 18 GR 19.3 52 IT 35.1
40 GA 23.0 49 IA 36.1
66 NG 32.9 27 AM 41.5

National 18 GR 23.3 52 IT 32.4
40 GA 30.1 49 IA 32.0
66 NG 35.1 27 AM 39.7

GR=Greek IT=Italian
f>l=fTraalr-karT*I ran ThaT+al I jan-amarI{ r an










The


lower


scores


for


Greeks


and


Greek-Americans


Tarpon


Springs,


compared


to the


Italians


and


Italian-Americans


Providence,


not


surprising.


The


tourist


industry


Tarpon


Springs


promotes


the


Greek


culture


Greek


and


Greek-American


businesses


(e.g.,


sponge-diving,


curio


shops


and


Greek


restaurants)


are


obvious


throughout


the


town.


The


hourly


chimes


from


Saint


Nicholas


Greek


Orthodox


Church


a constant


reminder


the


Hellenic


influence


the


environment.


(The


ringing


hourly


chimes


the


local


church


a common


practice


Greece).


Identification


with


the


Greek


culture


has


economic


benefits


Tarpon


Springs.


Comparisons


between


the


two


studies


show


consistent


trends.


Italians


who


immigrated


the


United


States


scored


lower


on each


subscale


than


the


Italian-Americans.


Each


Italian


culture


group


score


scored


was


lower


lowest


than


the


both


American


Greeks


and


group.


Italians


The


and


the


national


score


was


highest.


Religion


appeared


less


influential


fostering


group


cohesiveness


among


the


Italian


groups


than


among


the


Greek


groups.


This


observation


consistent


with


Moskos'


(1989:34)


observation


that


the


Greek


Orthodox


Church


the


focus


the


immigrant


Greek


communities


the


United


States.


Scourby


(1979)


also










Eating


Preferences


A f fectinar


rood


Use


The


Greek


group


showed


a high


preference


for


eating


at Greek

individual


restaurants

Is almost n


(47%


ever


daily)


eat


. Only

a Greek


two


Greek


restaurant.


The


highest


percentage


(46%)


Greek-Americans


eat


a Greek


restaurant


only


monthly.


The


Greeks


reported


rarely


eating


at other


ethnic


restaurants


(58%


"almost


never")


or eating


an American


steakhouse


or fast


food


restaurant


(25%


- 33%


"infrequently").


Half


of the


Greek


sample


never


eat


fast


food


restaurant


and


never


eat


foods


purchased


from


a vending


machine


(Appendix


The


Greek-American


group's


restaurant


preferences


were


similar


to the


preferences


the


non-Greeks.


Approximately


half


the


persons


these


two


respective


ethnic


groups


an ethnic


or American


restaurant


monthly.


One-fourth


to one-third


persons


each


group


a fast


food


restaurant


either


weekly


or monthly


Greek-Americans


showed


a higher


preference


(35%


monthly)


for


eating


a deli


or submarine


sandwich


shop


compared


with


the


non-Greek


s preference


(25%


monthly).


Like


their


Greek


counterparts,


Greek-Americans


almost


never


ate


foods


purchased


from


a vending


machine


(92%)


contrast,


only


non-Greeks


never


ate


foods


purchased


from


a vending










home


daily


a common


household


meal.


A similar


percentage


these


persons


report


using


basic


ingredients


their


cooking.


Differences


food


preparation


patterns


were


apparent


from


the


use


convenience


foods.


Seventy-three


percent


the


Greeks


report


never


using


convenience


foods


and


only


them


use


a daily


combination


convenience


foods


and


basic


ingredients.


Half


the


non-Greeks


use


combination


convenience


foods


and


basic


ingredients


daily


compared


less


than


one-third


the


Greek-Americans


Non-Greeks


use


a microwave


oven


more


frequently


than


the


Greeks


or Greek-Americans.


Two-thirds


the


non-Greek


persons


reported


using


daily


or weekly


compared


the


Greek-Americans,


who


use


daily


or weekly


Eighty


percent


use


the


a microwave


Greeks

oven.


and


Only


the

of th


Greek-Americans

e non-Greeks re


never


ported


never


using


a microwave


oven


cook


home.


Type


meals


prepared


also


showed


differing


trends


between


the


ethnic


groups.


Greeks


use


"Greek


style"


recipes


(83%


daily)


and


Greek


ingredients


(75%


daily).


Slightly


greater


than


one-third


the


Greeks


never


eat


"American


style"


recipes


home.


As expected,


the


majority


non-Greeks


use


"American


style"


recipes


daily.


One-fourth










reported


never


eating


"Greek


style"


recipes


or using


Greek


ingredients


foods


prepared


home.


Greek-Americans


show


greater


diversity


how


meals


are


prepared


home.


Two-thirds


them


(40%


daily


and


weekly)


use


"Greek


style"


recipes


and


them


(28%


daily


and


weekly)


use


Greek


ingredients


the


foods


they


prepare


home.


While


still


maintaining


some


the


Greek


food


preparation


methods,


half


them


(28%


daily


and


weekly)


report


cooking


"American


style"


home.


Commerical


influences


(e.g.,


TV advertisements,


coupon


use


and


collection


recipes


from


magazines)


were


much


more


evident


among


non-Greeks


and


Greek-Americans


than


among


the


Greek

report


ethnic

never


group. Se

purchasing


venty-one


food


percent


or drinks


of the


advertise


Greeks

d on TV


collecting


magazine


recipes.


Half


(50%)


them


not


use


coupons


with


food


purchases.


contrast


the


non-Greeks


and


Greek-Americans


purchased


foods


that


were


advertised


on TV either


weekly


or monthly


(non-Greeks,


weekly


and


monthly;


Greek-Americans,


23%


weekly


and


monthly).


Forty-six


percent


non-Greeks


report


not


being


influenced


TV advertisements


their


food


purchases


and


Greek-Americans


not


purchase


foods


advertised


Two-thirds


the


non-Greeks


and


Greek-Americans,










the


non-Greeks


never


use


coupons


while


shopping


for


groceries.


Greek-Americans


and


non-Greeks


collect


recipes


from


popular


magazines.


Fifty-eight


percent


the


non-Greek


group


collect


recipes


from


popular


magazines


monthly


or more


often.


Fifty-four


percent


the


Greek-Americans


collect


recipes

magazine


either

recipe


monthly


or yearly.


learn


prepare


Greek-Americans


American


may


holiday


use

foods.


Operationalized


Comparisons


Dietary


Preferences


In order


operationalized


preferences,


elucidate

categories


convenience


these

of Gr


and


trends


eek


their


or American


commercial


dietary


influences,


the


questions


were


scored


assigning


the


categorical


responses


corresponding


scored


numbers.


monthly


Responses


persons


Daily


, yearly


within


was


and


each


given


almost


ethnic


a score


never


and


weekly


scored


numerical


grouping


were


totaled


and


averaged


so that


scores


fell


with


the


scoring


range


for


each


category.


Table


describes


these


scoring


comparisons


77).


The


aggregate


response


scores


within


the


ethnic


groups


suggest


differing


levels


of preference


for


Greek


or American


dietary


practices,


convenience


and


commercial


influences.


Trends


were


evident


between


the


two


Greek


groups


as well.











Table 4-7: Averaged eating preference responses by ethnic
group

Averaged Eating Preference Responses
Ethnic Group Almost
Frequency Daily Weekly Monthly Yearly Never
Percent

Greek Dietary Preference
Greek 1 11 1 0 0
8.3 74.9 8.3 0.0 0.0

Greek-American 2 24 12 00
5.3 63.3 31.6 0.0 0.0

Non-Greek 2 24 26 2 0
3.8 44.8 48.3 3.8 0.0

American Dietary Preference
Greek 1 3 6 2 0
8.3 25.0 49.9 16.7 0.0

Greek-American 7 19 9 1 2
18.5 50.0 23.8 2.6 5.3

Non-Greek 23 23 6 2 0
42.6 42.6 11.2 3.8 0.0

Convenience Preference
Greek 0 1 3 6 2
0.0 8.3 24.9 49.9 16.7

Greek-American 2 6 16 8 6
5.3 15.8 42.1 21.0 15.8

Non-Greek 0 13 26 13 2
0.0 24.3 48.2 24.2 3.7

Commercial Preference
Greek 0 0 6 2 4
0.0 0.0 50.0 16.6 33.3

Greek-American 0 9 19 10 0
0.0 23.7 50.0 26.3 0.0










preferences,


the


Greek-Americans


demonstrated


a slightly


greater


preference


Greek


than


for


American


foodways.


Non-Greeks

practices


revealed


a trend


occasionally


(the


toward pr

non-Greek


referring


group


Greek


was


dietary


composed


a variety


persons


from American,


Italian,


German


and


other


European


backgrounds).


The


trend


for


commercial


preference


was


higher


among


non-Greeks


when


compared


either


Greeks


Greek-Americans.


Greeks


were


least


influenced


convenience.


To determine

interrelationships


whether

among


these


the


trends


study


could


variables,


explain

a factor


analysis


(containing


the


eating


preference


variables


and


other


study


variables)


was


performed.


Three


factors


were


retained


because


they


met


the


prior


communality


estimate


1.0.

was


The initial

used because


factor


the


method,


rotated


with


varimax


principle


and


components,


standardized


scoring


coefficients


did


not


explain


any


additional


variance.


Factor


the


Ethnicity


Factor,


explained


6.34%


the


variance.


Variables


that


had


a loading


or greater


were


preference


for


"Greek


style"


recipes,


Greek


recipe


ingredients,


the


ethnicity


subscores


for


culture,


religion










Factor


the


Medical


Factor,


explained


.57%


the


variance.


This


factor


will


be described


later


the


section


pertaining


risk


factors


CHD


(page


121).


Factor


the


Commercial


Factor,


explained


3.57%


the


variance


and


had


a loading


on commercial


dining,


e.g


eating


ethnic


and


fast


food


restaurants,


a deli


submarine


sandwich


shop,


from


a vending


machine


and


purchasing


foods


which


are


advertised


on TV.


None


the


factors


explained


a high


proportion


of the


variance


.48%)


among


the


variables.


These


factors


were


tested


later


a multivariate


regression


analysis


determine


whether


they


could


explain


any


variance


the


blood


cholesterol


values.


These


findings


are


presented


the


section


on blood


cholesterol


(page


121).


Freauencv


Food


Intakes


Reported


monthly


frequencies


intakes


were


grouped


into


the


following


food


groups


and


compared


(Appendix


Quoted


percentages


refer


monthly


frequencies


unless


stated


otherwise.


Dairy


Food


Grou,


Within


the


dairy


food


group,


Greek-Americans


(54%)


and


Greeks


(47%


weekly,


monthly)


reported


consuming


whole


milk more


frequently


than


non-Greeks


(30%).


The


Greek










(63%)


compared


their


skim


milk


(42%)


and


whole


milk


(30%)


consumption


pattern.


Cheeses


were


the


most


frequently


consumed


food


within


the


dairy


food


group.


Greek-Americans


consumed


feta


cheese


(89%)


and


other


cheeses


(93%)


most


frequently


when


compared


with


the


Greeks


(72%


feta


and


other


cheeses)


and


non-Greeks


(34%


feta


and


other


chee


ses) .


Yogurt


was


consumed


more


frequently


Greeks


(72%)


than


Greek-Americans


(66%)


or non-Greeks


(41%)


Frozen


yogurt


was


eaten


less


frequently


A high


proportion


Greeks


(83%),


Greek-Americans


(84%)


and


non-Greeks


(79%)


almost


never


ate


frozen


yogurt.


Ice


cream


was


consumed


more


frequently


than


milk


ethnic


groups.


Greek-Americans


reported


the


highest


(78%)


cream


consumption,


followed


non-Greeks


(64%)


and


Greeks


(56%)


Comparisons


with


the


Greek


Diet


Greeks


previous


studies,


consumed


most


their


dairy


foods


the


form


yogurt


(Valassi


1962)


and


cheese


(Christakis

consumption


1965)


Greece


was


The


unpopularity


thought


Valassi


milk


(1962)


attributable


insufficient


quantities


before


the


war


and


poor


sanitation.


Lack


pasteurization,


except


large










customarily


boiled


and


drunk


hot


with


sugar


added,


consumed


more


frequently


than


cow's


milk


rural


areas


Greece.


Greek-Americans


the


United


States


continued


prefer


yogurt


and


feta


cheese


(Valassi


1962


and


Costantakos


1987).


Vendors


sell


ice


cream


the


warmer


months


(April


September)


Greek


towns


and


rural


villages


(personal


observation


and


communication


1982)


Greek


immigrants


and


Greek-Americans


enjoy


ice


cream


the


United


States


throughout


the


year


(Valassi


1962).


Greeks


Tarpon


Springs


appear


to be


consuming


more


milk


than


Greeks


Greece


(Quantities


were


not


indicated


the


food


frequency,


so amounts


each


consumption


time


may


low)


The


24-hour


recall


indicates


that


Greeks


consume


most


their


milk


with


cereal


or coffee.


Like


Greeks


and


Greek-Americans


previous


studies,


preference


for


feta


cheese,


yogurt


and


cream


found


among


both


Greeks


and


Greek-Americans


Tarpon


Springs.


Comparisons


with


the


American


Diet


Nationwide


food


consumption


studies


(CSFII


1985)


indicate


that


whole


milk


consumption


decreased


among


United


States


men


between


1977


and


1985


and


among


United


States


women


(Popkin


1989)


during


the


same











low


who


or skim


consumed


milk


whole


(CSFII


milk


1985)


and


compared


who


with


preferred


44%


low


women


fat


skim


milk


one


of four


non-consecutive


days


(CSFII


1986).


Cheeses


were


consumed


United


States


women


(71%)


and


men


(33%)


more


frequently


than


yogurt


(12%women;


men)


per


individual


an average


day


(CSFII


1985


and


1986).


The


pattern


dairy


food


intake


among


the


non-Greek


group


Tarpon


Springs


similar


to reported


intakes


these


foods


the


nationwide


consumption


studies.


Sixteen


percent


the


non-Greeks


Tarpon


Springs


reported


consuming


whole


milk


daily,


while


reported


a daily


intake


Cheeses


of low


were


milk


consumed


and


less


preferred


frequently


skim


feta


milk


daily


and


other


cheeses


daily)


Five


percent


the


non-Greeks


reported


daily

Grain


consumption


Food


yogurt.


Grouo


Bread


Greek-Americans


consumed


than


more


frequently


non-Greeks.


Greeks


White


bread


and


used


most


frequently


the


Greeks


(71%


weekly


and


53%


daily).


Thirty-five


percent


the


Greeks


also


consume


brown


bread


daily.


Greek-Americans


and


non-Greeks


have


a greater


preference


for


brown


bread


(92%


Greek-American;


non-Greek)


Fifty-five


percent


Greek-Americans


and










Greek-Americans


(36%)


and


Greeks


(24%)


than


non-Greeks


(19%)


Specialty


breads,


e.g


doughnuts,


danish


and


coffee


cakes,


however,


are


preferred


more


frequently


Greek-Americans


(65%)


and


non-Greeks


(64%)


than


Greeks


(44%)


Two-thirds


(67%)


the


Greeks


eat


breakfast


cereals


but


non-Greeks


(89%)


and


Greek-Americans


(87%)


consume


cereal


more


frequently


Other


grains,


e.g.,


pasta


and


rice


are


also


consumed


more


frequently


Greek-Americans


(100%


pasta


and


rice)


and


non-Greeks


(97%


pasta;


92%


rice)


than


Greeks


(94%


pasta;


rice).


Comparisons


with


the


Greek


Diet


Greece,


bread


an indispensable


part


every


meal


(Valassi


1962)


Bread


usually


eaten


plain,


without


butter


or jelly,


and


used


to absorb


the


and


juices


from


salads


and


main


dishes


(personal


communication


and


observation


1982).


Specialty


breads,


e.g


., muffins,


biscuits


and


sweet


rolls


are


unknown


Greece


(Lieberman


and


Gardner


1980).


Pasta


eaten


plain


with


tomato


sauce


or in


combination


with


meat,


as in


pastitsio.


Rice


characteristically


prepared


as pilaf


or mixed


with


meat


and


seasonings


and


made


into


a stuffing


for


dolmathes


(Valassi


1962


and


Nickles










Greek-Americans,


however,


while


continuing


to have


a high


preference


bread,


have


also


adopted


the


consumption


doughnuts,


danish


and


coffee


cakes.


Pasta


and


rice


are


consumed


more


frequently


than


breakfast


cereals


Greeks.


Greek-American


consumption


patterns


of these


foods


more


nearly


resembles


the


non-Greek


preferences.


Connariaona


with


American


Diet


Consumption


yeast


breads


and


rolls


decreased


among


men,


aged


19-50,


between


1977


(82%


per


day)


and


1985


(74%


per


day).


Sixty-six


percent


women


reported


consuming


yeast


breads


and


rolls


on the


study


day


1985


(CSFII


1985


and


1986).


Other


baked


goods


were


consumed


a frequency


rate


of 52%


daily


men


(CSFII


1985)


and


women


(CSFII


1986)


Daily


cereal


and


pasta


intakes


were


reported


of the


19-50


year


old


men,


with


the


reported


intake


being


from


ready-to-eat


cereals


(CSFII


1985).


comparable


age


group


women


consumed


cereal


and


pasta


(66%)


at least


once


during


four


non-consecutive


days


with


them


consuming


ready-to-eat


cereals


(CSFII


1986).


Twenty-five


consisting


percent


mainly


men


grain


reported


(CSFII


consuming


1985)


mixed


and


dishes,


women


(CSFII


1986)


consumed


grain


dishes.


a


the










national


intakes.


Prior


to the


data


collection


periods


the


study


Tarpon


Springs,


news


was


released


regarding


the


benefit


oat


bran


reducing


serum


cholesterol


levels.


Informal


conversations


with


the


study


participants


indicated


that


they


had


increased


their


consumption


oatmeal,


other


oat


bran


cereals


and


oat


bran


baked


goods


This


increased


awareness


of oat


bran


a cholesterol-lowering


property


may


account


non-Greek


the


study


increased


intake


population


of cereal


Tarpon


Springs


among


when


the


compared


with


the


intake


cereals


reported


the


earlier


national


studies.


Fruits


and


Veaetables


Food


Grout


All


three


ethnic


groups


consumed


citrus


fruit


and


juices


frequently


(100%


non-Greek;


Greek-American;


monthly


and


weekly


Greek).


Only


a few


Greeks


(6%)


and


Greek-Americans


(5%)


never


consumed


citrus


fruits


or juices.


A high


proportion


of each


ethnic


group


also


consumed


other


fruits


and


juices


(97%


non-Greek;


Greek-American;


Greek)


Fruit


punch


or drink


was


consumed


most


frequently


Greek-Americans


(58%),


followed


non-Greeks


(46%)


and


Greeks


(41%).


Fifty-nine


percent


the


Greeks


almost


never


consumed


fruit


punch


or drink


compared


the


Greek-Americans


(31%),


who


had


the


smallest


proportion










Potatoes


were


unanimously


consumed


frequently


three


ethnic


groups.


persons


from


any


the


three


ethnic


groups


reported


never


consuming


potatoes.


Salty


snack


food


varieties,


e.g.,


potato


chips


and


corn


chips


were


consumed


most


frequently


non-Greeks


(67%).


Half


the


Greek-Americans


consumed


snack


food


varieties


monthly


compared


to 29%


Greeks,


who


consumed


these


foods.


Greeks


consumed


salad


frequently


(59%


daily


and


weekly).


Slightly


more


than


half


(55%)


the


Greek-Americans


consumed


green


salads


daily


and


almost


all


Greek-Americans


(95%)


consumed


green


salads


weekly.


Green


salad


consumption


was


reported


less


frequently


the


non-Greek


group


(44%


daily


and


weekly).


Eight


percent


the


non-Greeks


reported


never


having


green


salads


compared


no Greeks


or Greek-Americans


who


never


consumed


green


salads.


Greeks


preferred


yellow vegetables,


e.g.,


squash


and


carrots


(100%)


the


green


vegetables,


e.g.,


broccoli,


spinach,

more gre


and


sen


green


(100%)


beans

than v


(94%).


yellow


Greek


(91%)


-Americans


vegetables.


consumed

Non-Greeks


had


a high


preference


for


both


types


vegetables


(98%


green;


100%


yellow).


Intakes


olives


and


Greek


peppers


were


reported


more










preferences


these


foods


(49%


olives


and


Greek


peppers)


Twenty-eight


percent


the


Greeks


and


the


non-Greeks


compared


with


the


Greek-Americans


never


consumed


(56%)


olives.


never


Half


consumed


the


Greek


Greeks


peppers,


(50%)


while


and


only


non-Greeks


one-third


(34%)


of the


Greek-Americans


reported


never


having


Greek


peppers.


Comparisons


with


the


Greek


Diet


Consumption


of fruit


common


Greece.


Most


the


time,


fruit


(Valassi


1962;


sliced or

Lieberman


peeled


and


and


Gardner


eaten


raw


1980).


as a dessert


The


Greek


population


has


continued


enjoy


fruits,


especially


citrus


fruits,


Tarpon


Springs.


A greater


proportion


Greek-Americans


have


more


readily


adopted


fruit


punches


and


fruit


drinks.


Potatoes,


Greece,


are


characteristically


fried


with


olive


a frying


pan


and


eaten


mealtime,


rather


than


as a snack.


The


custom


having


potatoes


primarily


for


meals


has


continued


among


the


Greeks


Tarpon


Springs.


Greek-Americans


report


consuming


potato


chips


occasionally,


but


not


with


the


same


frequency


as the


non-Greeks.


In Greece,


Greeks


enjoy


a variety


raw


and


cooked


vegetables.


Raw


salads


are


served


daily


(Valassi


1962;










Greeks


and


Greek-Americans


not


as indispensable


an item


with


each


meal


as in


Greece.


Together


with


green


and


yellow


vegetable


consumption,


vegetable


intakes


are


greater


for


Greeks


and


Greek-Americans


Tarpon


Springs


than


for


non-Greeks


The


higher


preference


for


olives


and


Greek


peppers


Greek-Americans,


selective


compared


preference


with


type


Greeks,


olive


may


and


due


pepper


a more


consumed.


For


example,


Cretan


olives


not


look


or taste


the


same


olives


grown


on the


mainland


Greece


(personal


observation


and


communication


1982)


Greeks


Tarpon


Springs


may


prefer


only


the


type


olive


that


native


their


region


origin


Greece,


therefore


limiting


the


selection


olives


Tarpon


Springs.


Greek-Americans,


on the


other


hand,


may


enjoy


types


of olives


and


find


them


more


readily


available


Comparisons


with


any


the


grocery


American


store.


Diet


Fruit


intake


for


men


(CSFII


1985)


increased


eleven


percent


between


1977


and


1985.


For


women,


there


was


reported


increase


during


the


comparable


time


period


(Popkin


1989).


Twenty-three


percent


men


(CSFII


1985)


reported


women


daily


(CSFII


fruit


1986)


or fruit


reported


juice


consuming


consumption


fruit


and


on the


29%

study


A


A










compared


persons


the


national


studies,


may


associated


with


the


availability


fresh


fruits


and


the


promotion


orange


juice


Florida.


Fresh


fruits


grow


private


lawns


and


vine-ripened


produce


marketed


year


road-side


stands


Tarpon


Springs


and


the


surrounding


areas.


Vegetable


consumption


increased


for


men,


aged


19-50,


and


4.9%


women


between


1977


and


1985


(CSFII


1985


men


and


Popkin


consumed


1989).


vegetables


on the


Eighty


survey


-five


day


percent


1985.


the


Potatoes


were


consumed


and


tomatoes


42%.


Only


consumed


dark-green

vegetables.


vegetables


and


Sixty-nine


reported


percent


ate


eating


other


deep-yellow


vegetables.


Forty-one


percent


women,


aged


19-50,


consumed


potatoes


and


more


women


ate


dark-green


(11%)


and


deep-yellow


(11%)


vegetables


than


men.


Tomatoes


and


other


vegetables


were


and


consumed


respectively


women


(CSFII


1986).


Non-Greeks


Tarpon


Springs


demonstrated


a stronger


preference


vegetables


than


the


national


studies


indicate


(57%


green


vegetables


and


yellow vegetables


daily).


Potatoes


were


eaten


less


frequently


(22%


potatoes


and


potato


chips


daily)


The


availability


fresh


produce


Florida


may


account


for


the


increased


preference


for










indicative


a selection


bias


for


foods


associated


with


health


among


the


non-Greek


group


the


study


Protein


Food


GrouD


Fish


was


consumed


more


frequently


(100%)


than


poultry


(89%)


or meat


(83%)


the


Greek


group.


The


preference


Greek-Americans


for


fish


(100%


and


poultry


(98%)


was


nearly


equal.


The


frequency


meat


consumption,


Greek-Americans,


was


Non-Greeks


consumed


poultry


(97%)


preference


to fish


(94%)


and


meat


(91%)


Eleven


percent


the


Greeks


never


ate


meat


and


reported


never


eating


poultry.


contrast


no Greek-American


never


consumed


meat


or fish


and


only


never


consumed


poultry


Eight


percent


the


non-Greeks


never


eat


meat


and


reported


never


eating


fish


or poultry.


Seventy-seven


percent


the


Greeks


consumed


eggs


compared


to 85%


the


Greek-Americans


and


the


non-Greeks.


Lentils,


chickpeas


and


dried


beans


were


consumed


more


frequently


the


Greeks


(89%)


than


the


non-Greeks


(83%)


and


Greek-Americans


(78%).


Fourteen


percent


the


non-Greeks


reported


never


consuming


legumes


compared


the


Greek-Americans


appeared


who


interpre


never

t the


consumed

question


them.


Non-Greeks


as consumption


baked


beans


while


the


Greeks


and


Greek-Americans


responded










Greek-Americans


consumed


moderately


(59%)


Fifty-nine


percent


the


Greeks


never


consumed


peanut


butter


compared


the


non-Greeks


(25%)


and


Greek-Americans


(21%)


who


report


never


eating


Taramosalata,


called


"Greek


caviar,


" is


rarely


consumed


Greeks


(18%)


and


Greek-Americans


(11%).


Ninety-four


percent


the


non-Greeks


never


ate


Several


non-Greek


participants


asked


me what


this


food


was


while


they


were


answering


the


questionnaire.


Comparisons


with


the


Greek


Diet


Fish


well-liked


and


eaten


frequently


areas


Greece


which


are


bordered


water


(Valassi


1962).


Lamb


and


pork


are


meats


that


are


eaten


more


frequently


than


beef


Greece.


Poultry


and


eggs


are


used


soups


and


main


dishes.


The


quantities


meat


consumed


Greece


are


less


than


the


United


States


(Newman


1986).


Lentils


are


often


referred


as "the


meat


the


poor"


Greece.


Beans,


peas,


lentils


and


chickpeas


are


used


extensively


Greece


(Valassi


1962).


Greeks


and


Greek-Americans


Tarpon


Springs


reported


consuming


fish,


poultry


and


meat


more


frequently


than


lentils.


Simopoulos


(1989)


reports


that


eggs


Greece


contain


substantial


amounts


fatty


acids,


compared


eggs


4 ~ .


a


a. S


a


I -




Full Text

PAGE 1

CHANGES IN DIETARY BEHAVIORS OF GREEKS AND GREEK-AMERICANS LIVING IN TARPON SPRINGS, FLORIDA By CORA SWEIGART KURTZ A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY UNIVERSITY OF FLORIDA 1990

PAGE 2

ACKNOWLEDGEMENTS Thanks go to Dr. Leslie Sue Lieberman, my committee chairperson, whose understanding, patience, support, critiques and guidance led me through the maze of higher education and learning so that I could realize this accomplishment. Thanks go also to the other members of my committee: Dr. H.R. Bernard, Dean A. Spring (through the qualifying exams), Dr. G. Armelagos, (for the dissertation review), Dr. R. Shireman and Dr. L. Crandall who each added a unique dimension to my learning experiences. Without the enthusiasm and time devoted by members of the Tarpon Springs community, this study could not have been a reality. I am deeply indebted to Father Tryfon Theophilopoulos and Zula Hourdas, the secretary, at the Saint Nicholas Greek Orthodox Church for their cooperation in supporting the purposes of the study by making public announcements at the church services and publishing the Greek and English versions of the study summary in the church bulletin; to Naomi Patterson for recruiting Greeks and Greek-Americans to participate in the study; to Maria Pantelis for translating the questionnaire to Greek and helping with data gathering at the Community Center of the ii

PAGE 3

Greek orthodox Church; to Chryse Flowers, who introduced me to the editor of the local weekly newspaper so that I could submit a copy of my study summary for publication prior to data collection and for helping me collect names of persons to participate in the study following a church service; to the Helen Ellis Hospital administration, especially to Jerry Touchton, Director of Community Relations, and Ruby Emmerson, Coordinator of Volunteers, for their moral support and assistance with lending me the Reflotron machine, allowing me to participate in the Cholesterol Screening and Health Fair to recruit participants for the study and collect data, for assigning a bilingual phone operator at the switchboard to make calls to potential participants and for assigning volunteer retired nurses to help with the finger sticks and running the Reflotron machine for the cholesterol analysis; and to all of the others from the Tarpon Springs community who helped with the coordination of the study and participated in the study. Thanks are also appropriate for Jeff Glor, for his assistance with the computer data analysis; to Elias Stassinos for the back translation of the Greek translation of the questionnaire to English; and to my friend, Don Higler, for his encouragement throughout this endeavor. iii

PAGE 4

TABLE OF CONTENTS page ACKNOWLEDGEMENTS. . ii LIST OF ABBREVIATIONS................................. vi ABSTRA.CT vii CHAPTERS 1 2 3 4 INTRODUCTION. Diet and Heart Disease Ethnicity Research Goals REVIEW OF THE LITERA.TURE Ethnicity ....................... 1 1 2 6 9 11 The Greek and Greek-American Diet........... 19 Diet and Risk of CHD . . . . . . . . . . Nutrition METHODS. Intervention. . . . . . . . . . . . . . . . . . . Pilot Study . . . . . . . . . . . . . The Research Site. . . . . . . . . . . . . . Sample . . . . . . . . . . . . . . Data Collection. . . . . . . . . . . . . . . Data Analysis. . . . . . . . . . . . . . . . Variables . . . . . . . . . . . . . . . RESULTS .............................. 22 26 28 28 34 37 41 58 58 63 Inference Tests............................. 63 iv

PAGE 5

Demographic Characteristics................. 65 Ethnicity................................... 68 Eating Preferences Affecting Food Use....... 73 Frequency of Food Intakes................... 79 The 24-Hour Recall .......................... 103 Risk Factors for CHD ........................ 113 5 DISCUSSION. . . . . . . . . . . . . . . . . 127 Adaptive Pressures on Food Use .............. 128 Ethnic Change .............................. 129 Eating Preferences and Diet Changes ......... 132 Dietary Changes and CHD Risk Factor Status .. 134 Implications for Nutrition Intervention ..... 140 6 CONCLUSIONS. . . . . . . . . . . . . . . . . 142 APPENDICES ........................................... A NEWSPAPER ADVERTISEMENT OF STUDY ........... 145 146 B QUESTIONNAIRE. . . . . . . . . . . . . . . . 14 7 C EATING PREFERENCES OF ETHNIC GROUPS ......... 168 D FOOD FREQUENCIES ............................ 175 REFERENCES. . . . . . . . . . 18 2 BIOGRAPHICAL SKETCH................................... 191 V

PAGE 6

List of Abbreviations BMI = body mass index BP= blood pressure CA= cancer Ca/Phos = calcium to phosphorus ratio Card= cardiac (heart) medication CHO= carbohydrate chol = cholesterol CSI = cholesterol-saturated fat index Cult= culture Diab= diabetes GA= Greek-American GR= Greek gms = grams HBP = high blood pressure medication HDL = high density lipoprotein ht= height K = potassium kg= kilograms kcal= Calories LDL = low density lipoprotein MANOVA = multi-variate analysis of variance max-EPA= maximum-ecosapentanoic acid mg= milligram mg/dl = milligrams per deciliter (cholesterol values) mm= millimeters (of mercury; blood pressure reading) N = number Na= sodium Natl= national NG= non-Greek NHANES = National Health and Examination Survey pk= cigarette pack Pro= protein PUFA = polyunsaturated fatty acid Reli = religion RNA/DNA= ribonucleic acid/ deoxyribonucleic acid SAS= Statistical Analysis systems SES= socioeconomic status SFA = saturated fatty acids TV= television U.S.= United States USDA= United States Department of Agriculture wk= week wt= weight x = mean vi

PAGE 7

Abstract of Dissertation Presented to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy CHANGES IN DIETARY BEHAVIORS OF GREEKS AND GREEK-AMERICANS LIVING IN TARPON SPRINGS, FLORIDA By Cora Sweigart Kurtz May 1990 Chairperson: Leslie Sue Lieberman, Ph.D. Major Department: Anthropology A cultural ecological model was used to analyze infrastructural, structural and demographic factors that influence dietary behaviors and subsequent coronary heart disease (CHO) risk status of Greek immigrants, 25-74 years, in the United States. Greeks were chosen because they provide a natural experiment of persons who migrated from a country with a low to a high mortality rate for CHO. As the diet becomes more "Americanized," previous studies showed that the risk of CHO increased among Greek immigrants. Subjects were recruited at a community-wide cholesterol screening, a health fair, a Greek church and Greek organizations during the Fall of 1988 and Spring 1989. Twenty-two Greeks, 44 Greek-Americans and 65 non-Greeks participated by completing the study questionnaire, were vii

PAGE 8

weighed and measured, had blood pressures checked and had a finger stick for blood that was analyzed for cholesterol. The self-administered questionnaire elicited demographic and CHD risk factor information, ethnic attitudes, restaurant and cooking preferences, a food frequency and 24-hour recall. Results indicated that Greek-Americans had significantly lower (p=less than .05) cholesterol values (~=205 mg/dl) than non-Greeks (2=220 mg/dl). Age had a positive relationship (p=.04) with blood cholesterol for the Greeks and non-Greeks. structural factors that were operationalized to measure commercial influences, e.g., purchasing foods and drinks advertised on TV, using newspaper coupons for food purchases and using recipes from popular magazines were strong predictors (p=.024) of increasing cholesterol values for the Greeks. Non-Greek cholesterol values were not significantly influenced by infrastructural and structural factors. A sedentary lifestyle was predictive of higher (R-square=l0, p=.0007) cholesterols among the non-Greeks and the absence of a chronic disease diagnosis was predictive of low (R-square=ll, p=.0017) cholesterol levels. Nutrition educators would benefit from considering the varying infrastructural and structural influences on food behavior change. These factors could be incorporated into the development of intervention programs for various ethnic viii

PAGE 9

populations who have increased their risk for CHD and other chronic diseases. ix

PAGE 10

CHAPTER 1 INTRODUCTION Diet and Heart Disease Since the mid-1960s, epidemiological evidence has accumulated, pointing to dietary behaviors as one of the explanatory variables in the increased risk of coronary heart disease (CHD). In 1980 and 1985, the United States government published dietary goals recommending reduced intakes of fat (especially saturated fat), sugar, and salt, with increased intakes of complex carbohydrates and fiber to protect against CHD risk. In 1988, the Surgeon General's Report on Nutrition and Health (DHHS 1988) summarized the research on the role of diet in health promotion and disease prevention. For the two out of three adult Americans who do not smoke or drink excessively, the choice of what to eat seems to influence long-term health prospects more than any other behavior. The relationship of dietary fat and cholesterol to CHD is supported by clinical, epidemio logical, metabolic, and animal evidence. These studies strongly indicate that the formation of atherosclerotic lesions in coronary arteries, which contribute to the risk of CHD, is increased in proportion to levels of total and low density lipoprotein (LDL) cholesterol in blood. Total 1

PAGE 11

2 and LOL cholesterol, in turn, are increased by diets high in total and saturated fat but decreased by diets containing polyunsaturated and/or monounsaturated fat. I chose to systematically describe changes in dietary behaviors among Greek immigrants and Greek-Americans living in Tarpon Springs, Florida, for this study because the population in Greece has a low-risk for CHO. The age standardized death rate for CHO is 229.8 per 100,000 in the United States and 85.1 per 100,000 in Greece (WHO 1986). Keys (1980) found the CHO mortality rate of a United States male cohort 40-59 years to be 5.69 times higher than that of a matched Greek cohort. Greek immigrants to the United States are adopting traditional American dietary practices, thus increasing their CHO risk status (Christakis et al. 1981). Preservation of the traditional diet has been identified with lowered risk of coronary heart disease for Greek-Americans (Christakis et al. 1965 and Keys 1980) and for other ethnic-Americans, e.g., Japanese (Robertson et al. 1977). However, there are few systematic studies of the natural dietary changes which occur among individuals in response to situational, economic, technological, and media influences. Ethnicity Immigrants are faced with an unfamiliar diversity of food which alters food choices and levels of consumption.

PAGE 12

3 Acculturation and assimilation into an industrialized host society that promotes consumption of mass-produced foods alters specific dietary components, life styles, and related health practices. The multiple forces that work to hold consumption in channels predictable enough to maintain food-industry profits paradoxically narrow human choice and the opportunity to resist the trend in the guise of increasing convenience, ease, and "freedom" (Mintz 1985:211). Acculturation research provides a means for observing how immigrants, when confronted with altered food consumption environments, utilize adaptive strategies to cope with the new conditions. In the process of adaptation, new food behaviors and concepts about food emerge (Bennett 1976). Identification with ethnic origins by individuals who place a high importance on ethnic cohesiveness and dietary practices may be advantageous in the maintenance and adoption of health promoting food behaviors. Ethnicity and other factors lead to intracultural variation in human food patterns and nutritional status within populations with ostensibly similar sociocultural environments. The key to understanding diet and nutritional status in an ethnic community is to delimit dietary heterogeneity and address the alternative ways in which individuals, families, and groups pr9cure food, and decide among the multiple food choices and food use patterns.

PAGE 13

4 Dietary differences in this study were not treated as random and idiosyncratic phenomena, but rather as characteristics of broad patterns of food use which Bennett (1976) terms "instrumental behavior." Bennett's framework for a cultural ecological analysis incorporates three domains: 1) thought, the mental rules of thinking that develop via the process of experience and thinking about experience, e.g., attitudes, values, logic and structures; 2) interhuman activity, the observed individual and group rules of behavior that govern relationships, e.g., interaction, consensus, conflict, affiliation, individualism, and reciprocity; 3), adaptation, the patterns and rules of individual and group social adjustment and behavioral change in the course of realizing goals or maintaining status quo, e.g., coping, adjustment, adaptation, adaptive strategies, achievement, compromise and fulfillment. The distinction between interhuman activity, and adaptation, is analytic. Interhuman activity is primarily descriptive while adaptation is explanatory. Adaptive behavior further divides into two levels of analysis: a). microsocial, which views behavior in specific contexts of purpose, e.g., innovative, manipulative, coping, characterized by both a formal, or manifest, and informal, or latent, level of operation, depending on the sanctioned values of the group; and b). macrosocial, the meaning of specific behaviors to the larger

PAGE 14

5 social system or institution. Pareto (1916) referred to a culture's manifest level as "residues" that included artifacts, language, stories, rites, rituals and ceremonies. He called the latent level of operation, "derivations" or the hidden code (or concepts) behind statements. A cultural ecological framework was used to identify underlying conditions and factors which were adaptive or maladaptive dietary behaviors in terms of health consequences. Dietary behaviors in this study were viewed as the result of a conscious or unconscious decision-making process within a specific context which offered alternatives and imposed constraints on choice. A feedback system further supported or modified this decision process (Bennett 1976). In this research, I addressed the diet-health status of Greek immigrants and Greek-Americans (especially in relation to CHO risk) stemming from dietary changes that accompany assimilation into the American society. The direction and extent of an immigrant's assimilation, to a large extent, is believed to result from forces of attraction (positive and negative) generated by the social organization of ethnic communities and their capacity to attract and hold members within their social boundaries (Breton 1964). Moskos (1989) distinguishes between acculturation and assimilation in describing Greek-Americans. He views acculturation as the acquisition by the immigrants and their

PAGE 15

6 descendants of the cultural behavior--language, norms, customs--of the new society. Assimilation, in his definition, implies the entrance of the ethnics into the very fabric--social cliques, business life, civic associations, and, eventually, the families--of the society. While acculturation usually proceeds faster than assimilation, he believes that acculturation has probably lagged behind in the Greek-American population. If his assumption is true, then dietary practices of Greek-Americans in Tarpon Springs have changed more slowly than their macrosocial adaptation to the American social, business and civic institutions. Research Goals The key goals in this study are a) a description of dietary patterns determined by a complex set of variables emphasizing inter-ethnic and intra-ethnic heterogeneity and a cultural ecological framework that stresses the importance of the social as well as the material environment; and b) a delineation of variations in diet as adaptive strategies among Greeks, Greek-Americans and non-Greeks. (Figure 1, page 7), (DeWalt 1983, DeWalt and Pelto 1976, Goode et al. 1984). A related objective is to emphasize the multifactorial nature of risk factors that affect the development of CHO. Diet is examined within this context as one of the indirect

PAGE 16

Diet Health Status/ CBD !wk f ... llMtrihllH 611a1Paltan. ~"'9c6hep Figure 1-1: Ecological Influences on Food and Diet-Related Disease INHERENT INDIVIDUAL RISK FACTORS .,_ ...... LIFESTYLE RISK FACTORS Qsvet ---Figure 1-2: Health Status/ CHD Risk 7

PAGE 17

life style factors that may make the occurrence of CHO more probable (Figure 2, page 7), (Beaton, 1976). 8 Dietary patterns and other CHD risk factors are analyzed to identify interactions between ethnic and technological influences. These observed patterns are indicative of adaptive or maladaptive behaviors that affect CHD risk factor status. The observed systematic trends in dietary pattern changes among aggregates of Greek and Greek-American individuals, compared to non-Greeks, are useful in predicting future dietary changes. Such predictions could serve as a marketing tool for designing a nutrition intervention program for Greeks and Greek-Americans, who are at increased risk for CHD, by identifying characteristics of persons who are most amenable to incorporating directed dietary changes into their food behaviors. Health planners may find this study useful when developing guidelines for health-related behavior changes that deal with a complexity of food consumption behaviors among ethnic populations that have also increased their risk for CHD and other chronic diseases.

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CHAPTER 2 REVIEW OF THE LITERATURE American anthropologists in the first half of the twentieth century viewed culture as an ideational, superorganic construct. They were less concerned with material technical culture and focused more on values, social structure, and ideational data (Bernard and Pelto 1987). Humans were thought to have distinctive idea systems and cultural definitions of things like food which influenced their behaviors. Behavioral differences among distinct social groups and communities were believed to result from differences in culturally-based idea systems. Extension of this notion of cultural causality was the conclusion (which became an assumption in our culture) that in order to change behavior, including food consumption behavior, culture (that is, ways of thinking about things like food) had to change. Mead (1955) supported this educational model of behavioral change, and this model continues to be supported among nutrition educators today (Pelto 1981). During the 1960s and 1970s, ecological theorists in anthropology reconsidered the materialistic and 9

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10 technological influences on human behavior. Harris (1979) for example, described his view of how ideational and material variables interact to influence human behavior. In contrast to the idealist approach which defines social and cultural phenomena from an in-group (emic) perspective, Harris focuses on access to resources, biological determinants, and technological, and energy factors as causal influences on both human behavior and culture. Bernard and Pelto (1987), in the book Technology and Social Change, collected essays which lent support to the technoenvironmental theory of how human lifeways are shaped. Anthropologists and other social scientists continue to describe the relationship of technological changes to changes in social relations, cultural values, attitudes, and psychological functioning. This reorientation to culture change raises two important concerns: 1) What is the role of the individual in social change? and 2) Is technology necessarily "good for" people (Bernard and Pelto 1987)? Mintz (1985:13) recognized that the precise ways in which culture change occurs are not fully understood. He hypothesized that historical changes repeat or re-enact earlier recurrent sequences. Profound changes in dietary consumption patterns (e.g., use of sugar in the United Kingdom in the 18th and 19th century) were the consequences of non-random forces that created a world economy and shaped

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11 relationships between separate cultures. cultural "meaning", in his view, arises from cultural applications and uses. Thus, symbolic meaning emerges as a consequence of interacting external factors, e.g., economic, political and material, that give relevance or meaning to the symbol. In this context, observed behaviors are viewed as explanatory codes within an environmental milieu that can be read (decoded) as a "product of the production." Ethnicity Definition Ethnic studies prior to the 1970s focused on external observations of an ethnic group. Ethnic groups were seen as minority cultures that had temporary differences with the larger society. With time, the process of linear assimilation would be cumulatively completed (Newman 1978) and the ethnic group would be integrated into the host society. More recently, investigators have defined ethnic groups as liasoned individuals who share common cultural and social affiliations within a multicultural, multiethnic context (Cohen 1978). Ethnic group members determine inclusion and exclusion criteria for themselves and significant others. This broader definition of ethnicity suggests that ethnic groups can live in symbiotic adaptation with their environments without losing their unique cultural and social identities.

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12 Ethnicity and culture Harwood (1981) views ethnicity as a broader phenomenon than culture. While ethnicity is marked by certain cultural standards, the range of social situations and cultural expressions for the ethnic group is more varied. Ethnic groups are not limited to one culture context but interact in multiple alliances within their environments (Wolfe 1966). For example, Isajiw (1978) described a culture layer that is shared widely by numerous ethnic groups within Canadian society (this example could apply to the United States, as well). The technological culture is shared by many communities and individuals. There is a value placed on the products of technology, the people who have access to them and the use of new technologies. Technology's common language is spoken less as a symbol of identity than as a practical means of attaining the products of the technologi cal culture. This culture layer either works together with other culture layers or it is contradictory and conflicts with the ethnic group's values. Ethnic group members determine whether to include or exclude it from their ranks. Criteria for Ethnic Membership Ethnic membership criteria may be perceived differently by members than by non-members. To non-members, group adherence is marked by language use, endogamy, choice of friends, participation in religious functions or institutions, parochial schools and voluntary organizations

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13 (Dreidger 1978). Discarding of these visible ethnic practices is referred to by Moskos (1989) as acculturation. From an internal perspective, ethnic group members are aware of different coalitions and social ties among the membership. Social ties, such as friendships, marriages, and business relationships do not form via a single focus of alliance with fellow members, but incorporate multiple dimensions of interaction with individuals from inside and outside the ethnic boundary (Wolfe 1966). Breton (1978:61) described these ethnic ties as partially overlapping or "intersecting circles" to which individuals belong. One circle may include kinship and friendship ties and another circle may represent occupational, religious and policical affiliations. A small number of group members may share liasions in both circles, but the majority of members share these ties with either different fellow ethnics or with individuals from outside the ethnic group. Moskos (1989) describes the trend toward the establishment of social, business and political ties with individuals and organizations outside the ethnic group as assimilation into a host society. Acculturation usually precedes assimilation into a host society. For Greek immigrants, however, Moskos (1989) observed that assimilation generally has preceded acculturation into the United States society.

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14 The Ethnic Boundary A major aspect of the ethnic group is the creation and maintenance of its boundary. Goode et al. (1984) described the boundary as permeable (open to outside influence) or closed (socially impenetrable). Within the boundary, members relate to significant objects and according to ascriptive behaviors. The social bond that is shared by its members provides a sense of peoplehood that is an antidote to the alienation experienced when immigrants arrive in a new culture. While local communities, families, clubs and unions offer membership ties, they do not provide the continuum of identity with an individual's cultural and social roots that the immigrant desires. The degree of boundry permeability determines the number of outside alliances the ethnic group will tolerate. For political and economic purposes, ethnic boundaries are often permeable. Moskos (1989) believes that motivation toward assimilation of Greeks into United States society is linked with a desire for economic ascendancy and political representation. Newman (1978) described relationships among ethnic members as subgroup segments with inter-group alliances, coalitions, and fluctuating assimilative and divergent relationships within the larger ethnic boundary. These ethnic segments utilize different ways to promote or resist assimilation and change (Van den Berghe 1969).

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15 Ways of Studying Ethnicity Cohen (1978) suggested that situational ethnicity may be operationalized to represent the interaction of two or more people from separate groups in which labels are used to signify sociocultural differences between them. If the emergence and persistence of ethnic differences is believed to be non-random, then questions about factors which determine its qualities and variations can be examined. Goode et al. (1984), utilized the concept of cultural ecological influences on intra-group diversity for studying persistence and change in an immigrant ethnic group's definition and food practices. They identified differences in the processes of boundary strengthening (social closure) and boundary permeability (open to outside influence), in relation to rules for food use among Italian-Americans in Philadelphia. They observed that contact with supermarkets, communication media, restaurants, school lunches, and industrial workplaces tended to decrease the importance of ethnic food usage and increased the importance of the American structure of meal formats (menus) and meal cycles (patterning of the use of different meal formats over time--day, week, week-end, annual holiday cycle and life cycle). Household differences in dietary behaviors were predictable from such variables as the composition of the household, an individual's stage in the domestic cycle, one's generational cohort, and activity patterns. An

PAGE 25

16 indicator of ethnic continuity was household ranking of roles and the rights of members to negotiate menu selections. These decision-making actions were mediated by shared rules, situational pressures, and personal preferences. Greek and Greek-American Ethnic Identity Scourby (1979) observed that United States and foreign-born Greeks in New York City maintained strong religious and national ties, as observed in affiliations with the Greek Orthodox Church and social organizations which promoted dance, music and cuisine. In her study of three generations of Greek immigrants, she observed generational differences in internal perceptions of ethnic identity. study respondents, when asked to identify themselves with ethnic labels, indicated weakening identities with being Greek. First generation Greeks tended to identify with Greek or Greek Orthodox labels. Second generation respondents thought of themselves as Greek-American, while a discernible trend to be called American was evident by the third generation respondents. The number of inconsistencies observed with individual ethnic identity underscored the notion that, from the perception of an ethnic member, much of ethnic identity is an unconscious and ambivalent experience. The individual reacts to positive and negative judgments that influence orientation toward or away from the ethnic group. overall,

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17 however, the majority of Greeks in New York City maintained relatively strong attachment ties to their ethnic religion and nationality, despite their identification with being American. Moskos (1989:67) reported that the Greek Church in America serves both a religious and social function and is the "prime definer of Greek ethnicity in this country." He observed that the American generations of Greek-Americans are in many ways more Greek Orthodox than their middle-class Greek contemporaries in Greece. While these differences create social distances between Greek-Americans and newly arrived Greeks (Greeks who arrived in the United States within the past five years), there are shared similarities in their continuing conservative views about family and personal matters. While adapting where necessary in order to accommodate to the achievement standards of the larger society, the approximate one million Greek-Americans (Moskos 1989:2) have maintained a remarkable degree of communal and family cohesiveness. The ethnic anchor for Greek immigrant families has been the promotion of the Greek language among their children (Moskos 1989). Greek-Americans, however, have been less concerned with promoting the Greek language and have concentrated more on instilling interest and pride in the Greek heritage and the Greek Orthodox faith. An appreciation of Greek heritage is fostered by a trip back to

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18 Greece. An estimated majority of American-born Greeks have visited their ancestral homeland at least once. Moskos (1989) identified three subgroups of Greeks in the United States: an older immigrant group who came to America before World War II or in the years immediately following; a more recent wave of immigrants who came to the United States since the lifting of the immigrant restrictions in 1966; and the children and grandchildren of Greek immigrant parents who constitute the Greek-American communities. While each of these groups claim varying degrees of allegance to Greece, the majority (an estimated four out of five; Moskos 1989:67) share an ethnic commitment to a common Hellenic heritage and affiliation with the Greek Orthodox Church. Ethnic ties among Greeks and Greek-Americans can be viewed as primary and secondary relationships. Primary ties are informal and intimate. They involve networks among individuals and families. Secondary ties describe more formal or casual relationships that deal, often bureaucratically, with segmented alliances. Among Greek-Americans, ethnic activities frequently involve segmented or secondary ties: church attendance, voluntary association membership, eating in Greek-cuisine restaurants, and episodic participation in social, cultural, and political gatherings. American-born Greeks may have strong primary ties with non-Greeks while simultaneously be ing

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19 actively involved in the Greek-American community. Secondary group affiliation can define Greek ethnic identity as much as primary group affiliations. As generations become more removed (e.g., third and fourth generations) from the Greek homeland, Greek ethnicity is not so much a matter of cultural transmission, but one of voluntary participation in Greek-American institutional life. Greek culture among the two or more generations removed may be a new emergent brand of Hellenism in America. Yet, certain forms of Greek ethnic identity--a Greek Orthodoxy within the framework of American religious pluralism, attachments to old country foods and dances, ungrammatical Greek, the whole system of kinship life--continue. The Greek and Greek-American Diet Bread, olives, olive oil, fruits, nuts, and legumes are staples in the Greek diet. Vegetables are common and meats are used less frequently than in the American diet. Milk is rarely drunk but used instead in dairy products such as yogurt and feta cheese. Desserts are very sweet and are consumed as snacks or with lunch and dinner. Greek coffee is strong and laced with sugar. Religious and social occasions are marked by special, traditional food practices which include or exclude the serving of certain foods (Newman 1986 and Ashton-Vouyoucalos, 1975). Many foods are eliminated from the diet for special religious fasts. For example, the Easter season begins with a time of

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20 masquerading and kite-flying known as apokria--the equivalent of the western carnival and "farewell to meat" (Nickles 1969). During the forty day Lenten fast, no red meat, chicken, fish, cheese, dairy products or eggs are eaten. Oil is eliminated during Holy Week, the week prior to the Orthodox Easter (personal communication 1982 and 1989). Protein intake among Greeks appears to be adequate with no observed significant deficiencies. Mineral intakes for iron and calcium are below the United States Recommended Dietary Allowances both before and after immigration to the United States (Newman 1986). Valassi (1962) studied food habits and food practices of Greek immigrants to the United States as compared to the habits and practices of non-migrants in their respective regions of origin in Greece. She also studied the food behavior of Greek-Americans as a group in the United States Valassi observed differences between Greek immigrants and younger generation Greek-American food preferences. Meal composition of Greeks followed the traditional patterns and timing of meal practices in Greece. Greek-Americans conformed more to the meal patterns of Americans. American-born Greeks preferred less time-consuming recipes for food preparation. While they enjoyed special Greek dishes and desserts on special occasions and holidays,

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21 Greek-Americans tended to "Americanize" the cooking methods, ingredients, and seasonings of Greek recipes. Freedman and Grivetti (1984) observed similar trends among Greek-American women in Sacramento, California. They reported significant covariations among items such as respondent generation, composition of meals, and timing of food intake. They identified a strong trend of abandonment of traditional Greek dietary patterns and the adoption of American food practices by third generation Greek-Americans. Moskos (1989) noted that food is of central importance among Greeks and Greek-Americans. Greek foods, e.g., lamb dishes, olive oil and vinegar salads, cheese pie, and a variety of Greek pastries, are used for social gestures of hospitality as well as nourishment. A survey by Costantakos (1987) found that, even among third generation Greek-Americans, four out of five individuals still regard Greek food as being very much a part of their diet. Adaptation to the American diet involves compromises. For example, the traditional American Thanksgiving stuffed turkey will be found on the table beside a dish of feta cheese and kalamata olives. Greek immigrants, however, have adopted the "American highball" in preference to ouzo or Greek whiskies (Moskos 1989:96). Unlike the Greek custom of drinking only with food, second and third generations of Greek-Americans are increasingly drinking "American style"--without food.

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22 Thus, while some studies suggest that intra-group variations in dietary behaviors follow a linear acculturation model for Greek immigrants to the United States in which ethnic food patterns weaken with generations, this characteristic does not appear to be apparent for Greek immigrants in general. On the contrary, Goode et al. (1984) showed that situational and structural factors may influence individual behavior of Mediterranean immigrants to the United States, but may not weaken the shared sociocultural rules or break down the old system entirely. Interpreting intra-group variation and the structural factors that determine it can help to explain the cultural dynamic of both continuity and change in ethnic traditions. Viewed from this perspective, ethnic food systems are eating patterns which are socially mediated, transmitted, and reinforced. If an ethnic group remains relatively closed, then the structure of the food system continues to be transmitted and reinforced through social interactions and social sanctions. Diet and Risk of CHO Epidemiological studies (Christakis et al. 1981 and Kurtz et al. 1982) suggest that, as the Greek diet becomes more westernized, risk factor status for CHO increases among Greeks and Greek-Americans in the United States. Significant differences in risk factor status, e.g., increased serum LDL cholesterol, decreased high density

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lipoprotein (HDL) cholesterol and increased triglycerides were observed in Greek-American boys aged 14-16 years as compared with Greek cohorts of the same age. Second generation Greek boys in the United States more nearly resembled the age-matched American boys LDL and triglyceride patterns than did the serum profiles of Greek boys who immigrated to the United States with their families. 23 Ferro-Luzzi et al. (1984) demonstrated a similar increase in CHD risk factors with an experimental westernization of the Mediterranean diet in southern Italy. Experimentally increased dietary fat content, and altered saturated-to-polyunsaturated fat ratio, increased total serum cholesterol and LDL in both men and women, and reduced HDL values in women. The Surgeon General's Report (1988) and the National Research Council's Report (1989) on diet and health found the association between dietary fat, especially saturated fat, and cholesterol with CHD to be highly supported by scientific evidence. Grundy (1989) further elucidated this relationship by describing the effects of monounsaturated fatty acids on plasma lipids and lipoproteins. The "active" nutrient (Grundy 1989:530) when diets are high in monounsaturates, relative to saturated fats, may be the saturated fat. He believes that the monounsaturated fat's effect on

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24 cholesterol-lowering may be "neutral." Its observed beneficial lowering effect of LDL cholesterol may be attributed to the low dietary saturated fat, since saturated fat has been shown in animal studies to suppress the receptor-mediated clearance of LDL. Stearic acid, a saturated fat, does not raise total cholesterol or LDL (Bonanome and Grundy 1988). In contrast, palmitic acid (another saturated fat), which appears to be converted to oleic acid more slowly than stearic acid, raises LDL levels. While this observation may suggest that certain foods which are high in stearic acid (e.g., beef fat and cocoa butter) are acceptable for a cholesterol-lowering diet, most foods containing stearic acid also contain relatively large quantities of palmitic acid. Thus, foods containing saturated fats, in general, are reduced for a cholesterol-lowering effect (Grundy 1989). Linoleic acid has been shown in previous equations (Keys et al. 1965 and Hegsted et al. 1965) to have a greater cholesterol-lowering effect than monounsaturates. High intakes of polyunsaturated fatty acids, however, will also reduce HDL cholesterol levels. HDL lowering, by contrast, was not observed with oleic acid diets (Mattson and Grundy 1985). Dietary cholesterol has been shown, in animals, to suppress hepatic LDL receptor activity, decrease removal of LDL from the blood and thus, increase the concentration of

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25 LDL cholesterol (Spady and Dietscky 1988). This action is similar to the effects of dietary saturated fats, as described by Grundy (1989). Decreasing the dietary cholesterol and saturated fats, therefore, increases the LDL receptor activity of liver cells and conversely lowers the LDL concentration in the blood (Connor et al. 1989). Connor et al. (1989) devised a cholesterol-saturated fat index (CSI) as a means of predicting the potential of a food or a diet to raise the total and LDL cholesterol. A low CSI indicates low cholesterol and saturated fat content of a food or diet and a decreased risk of CHD. A high CSI suggests an increased potential risk for CHD. The traditional Mediterranean diet is approximately 35-40% fat and is rich in monounsaturated (primarily oleic) fatty acids (Grundy 1989). Whether this diet or the United States recommended diet (OHHS 1988 and NRC 1989) of 30% fat and approximately 15% oleic acid is preferable for decreasing risk of CHO is not known. The current American diet, which is 37% of calories from fat, is known to contribute to an increased risk of CHO because of its high ratio of saturated fats (OHHS 1988). If the saturated fat and cholesterol contents of the diet have a greater cholesterol-lowering effect than monounsaturated fats, then Greeks in this study whose diets reflect low intakes of these nutrients, irrespective of high monounsaturated fat intakes, will most likely have the

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26 lowest cholesterol values. Lower total fat intakes would also be more indicative of lowered CHO risk than a higher fat diet that containes predominantly monounsaturated fatty acids. Nutrition Intervention in Ethnic Populations Research methods used to describe dietary behaviors of ethnic groups may also be useful in the analysis of transactions among any socially bounded group whose social network includes the sharing of a food system. Community nutrition research would benefit from studying the cultural dynamics of food behavior continuity and change before designing intervention strategies for decreasing dietary risk factors of CHO and other chronic diseases. Pelto (1981) suggested that the application of approaches from anthropology to nutrition education research can provide the following components: 1) Participant observation to establish the ethnographic context--the characteristics of the community neighborhood, school, and other relevant social units. 2) The collection of qualitative and quantitative data. 3) The development of a broad data base, with collection of information on a wide range of variables. 4) The use of observational (intrusive or reactive) and unobtrusive measures as well as data collection techniques that rely on interviews. 5) The development of new data collection tools not only for measurement of food intake but also for measuring beliefs, values, and attitudes about food. 6) A multidisciplinary research team that includes community participation.

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27 7) A research design that includes data on several levels of analysis: individual, family, community, and beyond to the broader society. 8) The use of methods of statistical analysis which preserve the expression of variability within the community and avoid the assumptions of homogeneity inherent in the use of averages. 9) The use of multivariate statistical techniques to elucidate the interactions among factors that affect people's dietary behavior. The long-term goal of such research would be to produce information and analyses about the effect of technological, material, and ideological influences on community dietary behaviors which, in turn, would contribute to effective health policy development. By integrating data on ethnic food patterns and disease morbidity/mortality with nutrition education, government guidelines could be translated into dietary recommendations for various ethnic-American populations.

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CHAPTER 3 METHODS Pilot study Introduction A pilot study was conducted on a small sample of Greeks and Greek-Americans living in Gainesville, Florida, during late Spring and early Summer 1986. The purposes of the pilot study were 1) to test Parts I-III of a questionnaire which were devised to collect data that describe demographic characteristics, dietary practices, and frequencies of food use among study subjects, and 2) to test whether the instrument was sensitive enough to register trends in aggregate groupings of the study population. Methods Subjects were enlisted at community group functions and by individual contacts. Group participants were recruited from a Sunday morning Greek Orthodox Church service, from a joint business meeting of the Greek Student Club and the Greek-American Student Club at the University of Florida, and from a meeting of the Gainesville Greek Women's Auxillary. Individuals were recruited at their place of business and employment (a Greek restaurant and Shands Hospital). Study sites represented the major places 28

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29 frequented by Greeks and Greek-Americans who live in Gainesville. Subjects willingly filled out the study questionnaire. Only two females refused to participate in the study. Ten male and ten female Greek (n=7) and Greek-Americans (n=l3) participated in the pilot study. Ages ranged from 20-79 years. Arrangements for attending the group meetings in Gainesville were facilitated through the suggestions and invitation of a Visiting Greek Professor in Classics at the University of Florida. I attended the community functions and gave a questionnaire and pencil to Greeks and Greek-Americans in attendance. Questionnaire directions were self-explanatory. No coaching was volunteered. A few questions were asked by the subjects to clarify some of the written questions. Subjects took between 20-30 minutes each to answer the questionnaire and handed it in upon completion. Results Greeks, who were family members, lived in the United States between 17-32 years. Greek singles emigrated from Greece more recently, between 5-8 years ago. Greek family members lived in Gainesville an average of 16.5 years, while singles averaged 3.5 years in Gainesville. Previous residence locations in the United States and outside of Gainesville included: Berkley, California, Fort Myers, Florida, and Tarpon Springs, Florida.

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30 Families averaged 3.2 persons and singles 1.7 persons per household unit. Family households were composed of an average of 1.2 students, ranging from preschool through university. Singles were university students and only two single subjects had full or part-time employment. Years of education completed ranged from 13 to a Ph.D. degree. Neither age nor gender appeared to influence Greek or Greek-American eating practices and food preferences. Socioeconomic status comparisons, as reflected in type of employment and years of education completed, showed no distinguishing trends either. The majority of subjects observed yearly religious fasts and commemorated Greek holidays with special Greek foods. One Greek-American and one Greek male reported never observing religious fasts. Likewise, one Greek-American female and one Greek female did not practice this religious observance. These individuals, except for one person, did observe the Greek holidays in some way, however. Whether this represents individual preference or would be indicative of a trend in a larger study population could not be determined. The most obvious differences in eating practices and food preference became apparent when Greeks and Greek-Americans were subdivided into fami~y units and single households. Greek families showed stronger preferences for ethnic restaurants than for fast food restaurants, deli's or

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31 vending machines. The majority of Greek-American families preferred the alternative choices of eating out. This trend was less pronounced with the Greek and Greek-American singles. At home, Greeks prepared more of their dishes with Greek ingredients and fewer with convenience foods than did the Greek-Americans. Greek families showed a greater preference for feta cheese, white bread, olive oil, olives, Greek peppers, spinach-cheese pie, Greek pastries, yogurt, and Greek coffee than did their Greek-American counterparts. Greek-American families, on the other hand, exhibited stronger preferences for cheeses other than feta, peanut butter, meat, potatoes, rice and pastas, mayonnaise or salad dressing, milkshakes, doughnuts, danish, coffee cake and other American pastries, potato chips, whole milk (some preferred skim milk), chocolate milk, koolade or soft drinks. Greek singles reported never eating french toast, pancakes, or waffles and preferred eggs more frequently than did the Greek-American singles. They do, however, prefer doughnuts, danish, and coffee cake more frequently than both Greek family members and Greek-American singles. Greek singles prefer yellow vegetables, ice cream and yogurt, in contrast to the preference of Greek-American singles. Greek-American singles, like their Greek-American family member counterparts, prefer cheeses other than feta, peanut butter, mayonnaise or salad dressing, meat, potatoes,

PAGE 41

rice, potato chips, and American pastries. In addition, they consumed the following foods more frequently than did the Greek singles: fish, poultry, olives, low-fat milk, herbal teas and diet drinks. Conclusions 32 The observed comparisons suggest the influence of technological and convenience factors in determining dietary behaviors, and also suggest varying degrees of change among the comparison groups. Greek families showed the greatest ethnic preferences in the dietary pattern. Greek singles, while still showing a preference for Greek foods, made some changes in the direction of a more Americanized diet. Greek-American family members had accepted American dietary practices. Greek-American singles, while choosing American-type foods, showed evidence of attempting to limit their fat intake in accordance with the United States government dietary goals for a lower fat intake. Except for the Greek-American singles dietary patterns, these observations represent a trend in Greek dietary behaviors in the direction of acceptance of the American practices associated with increased risk of CHO. A larger sample will test whether this apparent trend in dietary change is significant. The non-Greek questionnaire was also pilot-tested primarily for the purpose of testing the Ethnic culture Scale. The ethnicity scale was first adapted for Greeks and

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33 Greek-Americans by substituting the reference to Greek versus Italian, as used in Roches's (1984) modification of Sandberg's group cohesiveness scale. In order to adapt the statements to a non-ethnic population (the non-Greek cohort), statements were broadened to include attitudes about ethnic behaviors and feelings in general. For example, the statement "Jokes about Greeks bother me" was changed to "Jokes about ethnic people bother me." Subjects to pilot-test the questionnaire were solicited by a printed announcement posted by the Information Desk, Alachua General Hospital Center for Health and Fitness, Gainesville, FL, during the summer of 1988. Twelve of the fifteen subjects, who volunteered to test the questionnaire, returned their completed questionnaires. Respondents were also asked to report the length of time required to complete the entire questionnaire and to comment regarding any ambiguously-worded questions. Subjects represented a diversity of health-conscious, middle-class, Gainesville residents. Three subjects were students at the University of Florida and three were employed there. One subject was a restaurant owner, one worked in a hospital, one subject was an elementary art teacher, another was a homemaker, and two were self-employed. Ages ranged from the 20 1 s ~o the 50's. Four subjects were 25-29 years of age, 3 were in their J0's, 4 in their 40's, and one was 50-60 years of age.

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34 The time required to complete the entire questionnaire ranged from 15-90 minutes, with an average of 38 minutes per subject. Comments about question ambiguity focused most on the Ethnic culture Questionnaire. The comments predominantly addressed a dislike for the forced-choice scale. They preferred to have a "no opinion" category. The only other consistency among the comments referred to the order in which the smoking questions were addressed. These situations were remedied by using a score of 3.5 when statements in the Ethnic culture Questionnaire were not answered by a subject. A "no opinion" category was not added because the scale was originally designed as a forced-choice response. I chose the scale because it was previously tested with other ethnic groups (Roche 1984). Questions referring to smoking behaviors were rearranged to accommodate subjects' suggestions. The Research Site Tarpon Springs is located on the West Coast of Florida, in Pinellas County, along the Gulf of Mexico. It's first settlers were A.W. Ormond and his daughter, Mary, in 1876. It was founded in 1882 by Anson P.K. Safford and promoted as a resort. In 1890, John K. Cheney started the sponge industry in the waters of the Gulf of Mexico (Tarpon Springs Chamber of Commerce, 1986). In 1906, two sponge-diving brothers from the Island of Kalymnos, Greece, discovered the sponge beds and founded the Greek colony in Tarpon Springs,

PAGE 44

35 Florida. More than 2,000 Greeks (mostly men) had established themselves in the colony by the beginning of World War I. Tarpon Springs became the world's largest sponge producer until the end of World War II. During this thirty year period, Greek culture prospered in its American setting. Greek coffeehouses and nightclubs flourished in the wealth of the sponge industry. The population majority in Tarpon Springs was Greek. Unlike any other Greek enclave in the United States, it became an immigrant Greek Town. The Greek Orthodox Church, Saint Nicholas (named for the patron saint of seafarers), was established in 1907 (Moskos 1989). Two factors caused the sponge industry's prosperity to decline after World War II: 1) the discovery of a method, in 1939, to convert wood waste pulp into synthetic sponge reduced the demand for natural sponges; and 2) a major outbreak of a disease, known as "red tide" which struck the west coast of Florida in 1947, decimated the sponge beds. In the 1960s, the Tarpon Springs sponge industry began a comeback. Once again, Kalymnos divers began migrating to Tarpon Springs (Bernard, 1987). By the late 1970s, Greeks and Greek-Americans represented approximately one-third of the total population in Tarpon Springs. While the non-Greek population grew rapidly during these years, small numbers of Greek immigrants continued to arrive. Some young Greek men came to work in the town's small sponge and shrimp fleet.

PAGE 45

36 The majority of Greek immigrants, however, were more likely to find employment in the local Greek restaurants or shops (Moskos 1989). Small numbers of Greek-American retirees from the north (several score a year, Moskos 1989:26) also entered the Greek community in the Tarpon Springs area. The original Greek settlement was concentrated in an area known as "fishtown," (Moskos 1989:26) bordered by Pinellas and Tarpon Avenues and Dodecanese Boulevard. This area remains predominantly Greek today. Newer Greek arrivals, Greek retirees from the North, and more affluent Greeks live in the surrounding suburbs of Tarpon Springs and in surrounding towns (personal observation and verbal communication with personnel at the Chamber of Commerce). The largest age group in the estimated population of Pinellas County in 1989 was the over-65 age group of whites (University of Florida Bulletin No. 89-90, 1989). Twenty-eight per cent of the white population is 65 years of age or older. Retirees from the upper mid-West and middle Atlantic States account for the majority of persons in this age group. Blacks compose only Bl of the estimated total population. The estimated population in Tarpon Springs is 18,000 (Polk Directory 1987). The Greeks are included in the white population estimates. The most recently published data (Census 1980) noted that more than 2,000 persons in Tarpon Springs are Greek-speaking. The membership roll at Saint Nicholas Greek Orthodox Church is not a good estimate

PAGE 46

37 of the Greek population (according to personal communication with the Church Secretary) because there are several Greek Churches in the surrounding towns where Greeks from Tarpon Springs are members. Thus, the membership roll for one church would underrepresent the actual number of Greeks who live in Tarpon Springs. Sample The study sample was obtained from the Greek population in Tarpon Springs and the surrounding areas. A comparison group of non-Greeks, from the same geographic area, was also studied. The sample was divided into three groups of adults, aged 25-74 years of age. Group 1 was a sample of 66 Greeks, who were Greek immigrants. Group 2 was a sample of 53 Greek-Americans (born in the United States of Greek descent). Group 3 was composed of a sample of 103 non-Greeks. Any non-Greek, who is married to or living with a Greek or Greek-American was excluded from the non-Greek group. An attempt was made to obtain a random sample from Tarpon Springs. Streets were randomly selected from the "fishtown" area and surrounding suburbs. Names and phone numbers for persons living on the selected streets were obtained from the Polk Directory (1987). A Greek-American bilingual High School senior, who worked the evening shift at the Helen Ellis Hospital switchboard, made calls to 150 households from this list and, according to instructions,

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38 briefly described the study and asked persons within the selected age ranges to participate in the study by making an appointment to come to the Walk-In Care, Holiday, Florida (the out-patient clinic of Helen Ellis Hospital, Tarpon Springs) on one of two week-ends. Of the eighteen persons who scheduled an appointment time and date to participate in the study, only five actually came to the study collection site. None of the participants were Greek or Greek-Americans. Reminder calls were made to the remaining 13 persons but they were unable to participate. I participated in a live talk show at the local Greek radio station the day before calls were being made, in an attempt to stimulate interest in the study and participation among the Greeks. Greek callers to the radio station during the talk show spoke enthusiastically about the study and inquired about how and where they could participate. Alternate arrangements for recruiting study participants were negotiated with the Administrator and Director of Community Relations at the Helen Ellis Hospital, Tarpon Springs. They permitted me to attend a community-wide cholesterol screening and a health fair, which they were sponsoring, to recruit subjects and collect data for the study. Special arrangements were made with Naomi Patterson, a Greek-American who is the electrocardiogram supervisor at the Helen Ellis Hospital, to promote and provide transportation for persons from the

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39 Greek community to attend these events and participate in the study. The cholesterol screening was held in a large corridor at the Tarpon Springs Mall, October 12-16, 1988. The health fair was held in the st. Ignatius Church's social hall, Tarpon Springs, March 31, 1989. A data collection site was also set up in the community hall at Saint Nicholas Greek Orthodox Church on Sunday~ April 9, 1989. Greeks and Greek-Americans, who attended the church service on that day, were asked to participate in the study following the morning service. The study sample was probably biased by being composed of persons who are more health-conscious than the average person in the total population or had been told on a previous occasion that their cholesterol value was elevated. To test for representativeness of the sample, data from the study were compared with a similar age group of persons from NHAINES II(DHHS 1986-87), a large representative sample of the United States population. Table 3-2 describes these comparisons (p. 40). The significant difference in the cholesterol values for the total samples and between the males in Tarpon Springs and NHANES may be explained by the significant differences observed between the Greek-Americans and Non-Greeks in Tarpon Springs. A larger proportion of the Tarpon Springs study sample was composed of Greek-Americans than the NHANES sample. Another explanation may be that the

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Table 3-2: Data comparisons with NHANES Ages 25-74 years N Greek Study Range Cholesterol mg/dl mg/dl Total 126 Males 46 Females 80 Blood Pressure Total 212.5 197.2 220.3 mm Systolic 128 129.1 Diastolic 128 79.0 Males Systolic 46 135.2 Diastolic 46 83.2 Females Systolic 82 126.0 Diastolic 82 76.5 118-369 118-306 118-369 mm 90-176 49-106 101-175 56-106 90-176 49-105 BMI Wt(kg)/Ht(meters-squared) Total Males Females 128 46 82 28.1 28.2 28.0 18.2-44.3 21.0-44.3 18.2-44.1 *=significance at less than .01 +=significance at less than .05 9096 4302 4794 9096 9096 4302 4302 4794 4794 9045 4302 4743 N NHANES mg/dl 222.1* 219.0* 225.2 mm 130.0 80.6 132.2 82.4 128.0 78.8+ 27.2+ 25.9* 28.4 40 Range mg/dl 135-330 144-307 135-330 mm 117-186 72-103 123-183 75-105 111-188 71-102 19.2-43.7 19.2-33.7 19.8-43.7 Tarpon Springs sample had a health-conscious bias because subjects were recruited at health screening events. They may have decreased their cholesterol levels because of a previous elevated level. Some of the females in the Tarpon Springs sample reported that they were runners and exercised aerobically on

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41 a regular schedule. The significantly lower diastolic level and the lower values in the BMI range for women may be suggestive of the positive consequences that result from these exercise practices. Males, however, had higher BMI's in Tarpon Springs. Data Collection Four primary methods were used for data collection. First a period of participant observation was used to develop an appropriately worded questionnaire and to provide context for interpreting the data from the survey. Initial introductions to key people within the Greek community were facilitated by a recently retired nurse supervisor from the local Health Department. During a two day visit to Tarpon Springs, March 1988, she arranged meetings and introductions with the local priest, a Greek physician, a Greek restaurant owner, an influential business man, who is associated with the sponge-diving industry, and women, who could do the Greek translation of the questionnaire and help with the data collection. Continuing contacts were maintained with these persons throughout the data collection period. Publicity and advertisement contacts regarding the data collection times were made with presidents of the men's and women's Helenic Benevolent Associations, local Greek organizations. Helen Makroulakis, president of the women's organization, invited me to speak about diet and cholesterol at their monthly noon meeting, October 6, 1988, and to

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42 elicit participation in my study from those attending. Naomi Patterson recruited subjects from the organization for younger Greeks, the Philoptohos Society, of which she is a member. A study summary and announcements in both English and Greek were added as supplements to the Church Bulletin prior to data gathering events. The priest, Father Tryfon, made verbal announcements at the respective services. I was introduced to the editor of a local weekly newspaper, The Leader Today, by Chryse Flowers, a Greek-American of some prominence in the community. A description of my study appeared on the front page of the paper Saturday, October 8, 1988 (Appendix A). Mrs. Flowers attended the Sunday morning service with me at Saint Nicholas Greek Orthodox Church, October 9, 1988, to help recruit subjects and ask them to attend the cholesterol screening and participate in the study at the Tarpon Springs Mall, October 12-16. A Greek physician, was contacted prior to the data collection times and asked to lend his influence by encouraging Greeks and Greek-Americans to participate in the study. The second data collection method was a self-administered questionnaire (Appendix B). The questionnaire was composed of five parts and was given to each subject at the data collection site. Each subject was encouraged to complete the questionnare at the data site. Because of the length of the questionnaire (20 pages) some subjects refused to complete it at the site, but agreed to

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43 fill it out at home for later pick-up or return to an agreed upon location. Of the total number of subjects, who participated in the study, 57% returned the completed questionnaire. Greeks had the lowest questionnaire completion rate (27%). The self-administered questionnaire provided data concerning: 1) Demographic information 2) Smoking and exercise behaviors 3) Health history 4) Frequency of visits to Greece, if Greek or Greek-American 5) Social cohesion scale 6) Eating, food purchasing, and food use preferences 7) A food frequency check-list 8) A 24-hour food recall Third, individual height and weight measurements were obtained. Height was measured in inches by having the participant stand, without shoes, on a specially-designed platform attached to a portable Accustat Stadiometer, marketed by Genentech, Inc. Weights were obtained by having the participants stand, without shoes, on a Sears Electronic Bath Scale, Model 6414. The scale weighs to the nearest half pound. Two 5-pound dumb bells were used to test the accuracy of the scale weight before and between data collection events. The dumb bells consistently weighed 9.5 pounds at each weighing. Height in inches was converted to meters by computer and weight in pounds was computer-converted to kilograms. The formula: Weight

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44 (kg)/height (meters-squared) was used to compute body mass index (BMI). The fourth method assessed the physiological parameters of blood pressure and total blood cholesterol. Subjects reported information about hypertension and cardiac disease, with any respective medications taken, in Part I of the questionnaire. Questions relating to a family history of hypertension, cardiac disease, diabetes and cancer were addressed in the questionnaire in relation to their parents and children's medical histories. Blood pressures were obtained by use of an automatic sphygmomanometer with a digital print-out (Biomega 423b, marketed by Biomega Corporation), which was loaned to me for the study by the director of the Alachua General Hospital center for Health and Fitness, where I was employed part-time. The digitally-read numbers were advantageous in reducing subjectivity associated with human hearing and interpretation. Visually-read numbers can also be transcribed with greater reliability than verbal data. Participants were seated with the right arm cuffed and positioned in a right angle. The right forearm rested on a stable surface of appropriate height. Blood cholesterol values were obtained from a digital read-out on a portable chemistry unit (Reflotron, marketed by Biodynamic Corp of Indianapolis, Indiana). The machine was loaned to me for the study by the Director of Community

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45 Relations, Helen Ellis Hospital, Tarpon Springs. Volunteer retired nurses assisted with the blood drawing at the cholesterol screening and health fair. I hired a dietitian from Gainesville to assist with the blood drawing and trained her to run the cholesterol analysis at the Greek Orthodox Church data collection site, April 9, 1989. The State of Florida issued a regulation, effective January 1989, stating that only trained, licensed medical technologists may do blood drawings and run the analysis for cholesterol at cholesterol screenings. Laura Phillips, in the HRS Licensure Office, Jacksonville, Florida, assured me by phone that my research would be exempt under Regulation 483031 #3, if I did not collect money from the subjects or give them information about their cholesterol values in writing. Drops of blood were obtained from a finger stick and absorbed onto a calibrated chem strip, which was machine analyzed in the chemistry unit. Chem strips were compared with standards to validate the machine analysis. Cholesterol values obtained by this method were reported in previous studies to vary within 51 of the true value of the standard sample (Brown 1988 and Sedor et al. 1987). This range is similar to the daily variation of 3-51 that has been observed with blood cholesterol levels (Garcia and Moody 1989). Recommendations for seeing a physician to have their blood pressure re-checked were made if the values were

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46 greater than 140/90 mm and to have cholesterol values re-evaluated if the blood cholesterol level was greater than 220 mg/dl. They were instructed to see a physician if the level was greater than 240 mg/dl (NIH Consensus Conference on Cholesterol 1985). sources of error in data collection techniques Ethnicity measurement problems A common problem with ethnicity measures is the paucity of standardized instruments which measure degrees to which members of an ethnic group are committed to the group and its traditions (Roche 1984). More frequently, studies (e.g., Sassen-Koob 1979; Woodrum et al. 1980; Cheung 1981) use descriptive analyses based on observed presence or absence of characteristics, determined by the respective investigator, to classify individuals into ethnic categories. Another problem with ethnicity scales is a lack of standardized measures that allow cross-ethnic comparisons. For example, studies, like that of Burnam et al. (1987), employed analytical techniques to check internal validity of their acculturation scale. It's use, however, has been limited to Mexican-Americans and has not been tested in cross-ethnic studies. I chose to use Sandbergs group cohesiveness scale (Sandberg 1972) for two reasons: 1). It was tested originally with Polish-Americans and later with

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47 Italian-Americans (Crispino 1980 and Roche 1984). Cross-comparisons among findings from the three studies suggest good external validity for the scale; and 2). Questions addressed on Sandberg's group cohesiveness scale are similar to those addressed by Scourby (1979) in her study of ethnicity among three generations of Greek-Americans in New York City. Thus, the Sandberg group cohesiveness scale provides data that are comparable cross-culturally with other ethnic-Americans and comparable with findings from a similar Greek-American ethnicity study. The scale (Appendix B: Part II of the study questionnaire) consists of thirty statements that measure participant attitudes toward various aspects of the ethnic group. Three subscales (cultural, national, and religious) identify intergroup similarities and differences. The cultural subscale elicits attitudes about traditions, language, music, and history of the group. The national subscale focuses on the sense of peoplehood shared by group members with questions about the ethnic neighborhood, being comfortable with fellow-ethnics, not changing one's name, being able to count on ethnic peers for help, marrying someone of the same nationality, and voting for candidates of the same ethnic background. The religious subscale inquires about the importance of the ethnic church, religious traditions and religious education.

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48 Dietary measurement problems A major problem with the development of dietary instruments for population studies is the need for tools that can be readily and inexpensively used with large numbers of subjects and which yield accurate information about usual dietary patterns (James et al. 1981; Block 1982; Gray 1984). Sources of error can potentially be introduced during data collection, quantitative processing, and interpretation (Algert and Stumbo 1986). The 24-hour recall method is one of the most widely used techniques for collecting dietary information on average group dietary intakes (Block, 1982). It has also been criticized for being unrepresentative of usual intake. Beaton et al. (1983) for example, found the major source of variance to be between and within subject differences from day to day. As part of the Seven Countries Study (Keys 1980), systematic comparisons of dietary surveys were examined. Increasing the number of 24-hour measurements was not found to reduce intra-individual variation, but rather, provided a more reliable estimation of an individual's preferences, if validity of the data was assumed. An important finding of their comparisons was that the intra-individual variation, obtained by repeated surveys on the same individual, was of the same order of magnitude as the inter-individual variation within a group.

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49 In an attempt to further define reliability of reported intakes, st. Jeer et al. (1983), demonstrated similar intra and inter-subject variability of reported foods but insignificant differences in mean daily nutrient intake when compared with the nutrient analysis of one-week and three-week food logs. Protein was the only nutrient to change when days of the week were compared. The interaction between nutrient intakes for weeks and days of the week was significant only for calories and fat. Thus, it would appear that 24-hour nutrient data can be representative of a group's intake. Or, as Young (1960) concluded after studying variation between three dietary sampling techniques (24-hour recall, dietary history, and 7-day record), the 24-hour recall provided the same values as the seven-day record when used with groups of at least fifty persons and when a 10% error rate was acceptable. A confounding measurement error with 24-hour recalls is the conversion of foods to nutrients. There is inherent error in any nutrient data base. Climate, harvesting, handling, food processing and preparation affect nutrient values in given foods (Witschi et al. 1981). At present, a standard data base containing USDA food composition data and manufacturers' data provide the best values on which to base this research. Use of these data as a universal standard for all foods and nutrients is not always desirable, however, especially when analyzing dietary intakes of

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populations residing outside the United States {Adelman et al. 1985). 50 The food frequency questionnaire is an easier and quicker method than the 24-hour recall. While it does not assess actual quantities consumed, it may achieve a more representative pattern of usual intake of foods {Chu et al. 1984). Karinpaa and Seppanen {1983) demonstrated that agreement between a food frequency questionnaire and 24-hour recall was high for foods commonly eaten at a meal. Snack foods were reported more frequently during the 24-hour recall interview. Mullen et al. (1984) also observed that the checklist or frequency method produced greater agreement with observations of foods eaten at a meal than for meal accompaniments (e.g., nuts and seeds). Used together, the food frequency questionnaire and the 24-hour recall provide a cross-check of foods reported along with additional information on dietary patterns and food practices {Christakis 1978). In general, descriptions of usual dietary intakes are more reliable when the dietary questionnaire is used with a 24-hour recall (Alford and Ekvall 1984). The problem of informant inaccuracy is a critical factor to consider in survey research. A primary problem with data collection is to evaluate how accurately any recall method of collecting information resembles the

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behaviors being measured. Bernard et al. (1984) observed that comparisons between what people say they do and observations of what they do bear little resemblance. Bradburn (1983) refers to the types of bias which affect how subjects respond to interviews as "response effects," of which there are three classes: 1) deliberate errors of embellishment or omission of information for the purpose of impressing or not divulging certain information to the interviewer, 2) memory errors, 3) communication errors. 51 Variation in response effects may be influenced by the data gathering task, by the interviewer's performance or perceived role in the community, and by characteristics of the research subject. Bradburn (1983) noted that the empirical literature suggests that characteristics of the data gathering task are the major influence on response effects. Bradburn (1983) further described comparisons of instrument administration methods. Face-to-face interviews, telephone, and self-administered questionnaires have high variance with no consistent direction in their biases. Self-administered forms appear to be slightly superior for items requiring definite information, questions requiring little interpretation, and items thought to be threatening or sensitive. Telephone interviews, in general, yield results similar to those obtained in personal interviews.

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52 Face-to-face interviewing allows for use of cue cards or visual aids to improve recall. Increased motivation may also come from the interviewer being with the respondents in person to encourage them to take time to consider the questions carefully. The time "window" involved in recall is reported to affect the size of memory errors (Bradburn 1983 and Bernard et al. 1984). The more recent the recall period (e.g., 24-hours vs a week), the more accurate the information. Bernard et al. (1984), however, observed that only 6% of informant accuracy could be accounted for by this factor in their data on recall of communications. Can validity of dietary information be improved by obtaining weighed samples of foods eaten when compared with estimates of dietary recall? Studies from the Seven Countries Study (Keys, 1980) and Todd et al. (1983) conclude that the weighed sample method does not significantly improve subject reporting accuracy. Todd et al. found a one-day group dietary record to be a reasonable estimate (within 15%) of the weighed intake. Both methods had considerable interand intra-subject variability. Keys concluded that the difficulty and expensiveness of collecting replicates of all meals eaten, compared with the modest error reduction obtained, did not justify use of the weighing method of data collection.

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53 Household refuse analysis (Rathje 1984) and biochemical markers (Christakis, 1981 and Willett et al. 1983) have been used to test the validity of reported dietary intakes. The increasing percentage of the food dollar on away-from-home food consumption in the United States (greater than 40%; Morgan and Goungetas 1986) limits the usefulness of household refuse analysis in verifying informant accuracy. While certain biochemical markers (e.g., adipose tissue and erythrocyte fatty acids, plasma carotene and alpha-tocopherol levels) have been shown to confirm reported dietary estimates of these respective dietary nutrients, analysis of biochemical parameters do not exist for all nutrients. Blood cholesterol levels, while not a direct measure of dietary fat or cholesterol intakes, are a useful clinical parameter for identifying persons who may be ingesting high saturated fat and cholesterol foods. Thus, at best, recall data can only be interpreted as estimates of group trends and patterns. Because the goal of this research is to focus on dietary patterns of aggregate subgroups that may be suggestive of increased risk of CHO, averages of dietary intakes of saturated fat, cholesterol, calories, and fiber will be compared with the subgroups who have elevated cholesterol values as a validity check. Methods for improving questionnaire validity One self-administered questionnaire, using both the food frequency checklist and 24-hour recall, was utilized

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54 per subject. Food models were available for memory prompting and to standardize serving sizes. This one quantitative measurement limited decisions about measurement differences between several dietary information gathering times. Prototypes of Greek and American diets were a proxy for time in this cross-sectional study. Greek and American diet prototypes were built from nutrition surveys and food consumption studies from the 1960s to the present. (Studies of Greek dietary practices include: Valassi 1962; Christakis et al. 1965; Ashton-Vouyoucalos 1975; Keys 1980; Lieberman and Gardner 1980; Kurtz et al. 1982; Freedman and Grivetti 1984. Studies of American dietary practices include: Ten-State Nutrition survey 1968-1970; HANES 1971-73 and 1979; Nationwide Food Consumption Surveys 1977-78, 1985-86; Food and Nutrition Board 1986). A Greek version of the questionnaire was available for those subjects who cannot read English. Back translation of the study questionnaire was performed by two Greek-speaking translators. The Greek version was translated from the English version by Maria Pantelis, a Greek immigrant who lives in Tarpon Springs. She also owns a Greek-type typewriter so that the questionnaire could be typed with Greek alphabet characters. The back translation to English was translated by a Greek graduate student, Elias Stassinos, who attended the University of Florida. He had no difficulty understanding the meanings and intent of the

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55 words or the questions. His comment, however, was that the Greek language is constantly changing and for that reason he assumed the original translation was done by someone his mother's age, because of the phrasing used. His observation was true, but since most of the subjects would also be the age of the original translator, the translation was kept as originally interpreted. Some Greeks in Group 1 could not read either Greek or English. A family member verbally translated the questionnaire to them from the English version. Back translation minimizes errors associated with assymetrical intrepretations of a source language into a target language. Loyalty to one language, usually the source language, dominates in assymetrical interpretations. To assume that two languages could be equivalent fails to recognize the fundamental issue of culture differences. Back translation, while not without limitations, is a method for identifying translation asymmetry. The most common error in back translation results from dictionary-equivalent redundancy (Warner and Campbell 1970 and Berkanovic 1980). To test the validity of the dietary data, market trends were observed through informal interviews. A sample of twenty subjects were selected from locations where study subjects reported shopping for groceries or eating out. Subjects included grocery store managers, restaurant

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56 managers, grocery shoppers and restaurant patrons. One restaurant manager and one grocery store manager would not allow me to interview their patrons. Grocery managers were interviewed about frequency of inventory turnover of items frequently reported by study subjects. Restaurant managers were interviewed about type of patrons and popularity of menus served. Grocery shoppers and restaurant patrons were interviewed about their perceptions of food behaviors in their respective communities. Reported food frequencies were grouped into the food groups: fruits and vegetables, beverages, grains, dairy, protein, fats and sweets. T-tests comparing mean frequencies of the total study sample by food group and mean frequencies of the validity sample by food group indicated no significant differences for all of the food groups except the protein and sweets groups. Mean for protein in the study sample was higher (p=less than .OS) than the validity sample. The reported freqency mean for sweets was lower (p=less than .OS) for the study sample than for the validity sample. Overweight was defined in terms of the body mass index (BMI), as used in NHANES II (DHHS 1987). overweight men had a BMI equal to or exceeding 27.8; and were severely overweight if the BMI equaled or was greater than 31.1. Women were overweight if the BMI was equal to or greater than 27.3 and were severely overweight if the value was equal to or exceeded 32.3. This definition defines

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57 overweight as a BMI equal to or greater than the 85th percentiles of men and women ages 20-29 years as the reference population. Nutrient analysis of foods reported on the 24-hour recalls were performed with The Nutritionist III Data Base, Version 4.5, 1989, marketed by N-Squared Computing, Salem, Oregon. The data base is derived from a documented USDA data base, manufacturers' data and recipes that are frequently updated. Greek foods and recipes were analyzed by using either similar foods and recipes or analyzing recipes by individual ingredients contained in the data set. Mortality data for major cardiovascular diseases in Tarpon Springs, 1987, were obtained from the Florida Department of Health and Rehabilitation Services (HRS), Public Health Statistics Section, Jacksonville, Florida. One hundred, fourteen deaths were attributed to all major cardiovascular diseases during 1987, with 98 of them from heart disease. Forty-four deaths were reported from chronic ischemic heart disease (CHO) in Tarpon Springs. Twenty of the CHO deaths were among white males and twenty were white females. These figures would account for a mortality rate of 44:18,000 or 240 per 100,000. These data are not standardized for age. Comparing them to the age-standardized mortality rate in Greece (WHO 1986) of 85.1 per 100,000 is not a true comparison because the data are not age or ethnicity-standardized.

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58 I attempted to obtain a mortality breakdown of deaths of persons from Greek descent, but found the task to be impossible because data are not recorded according to ethnic identity. Morbidity is not recorded for CHO by the State vital records or estimated with any reliability by Tarpon Springs physicians. Data Analysis Research questions addressed in this study include: 1) Are there systematic change patterns in the observed dietary behaviors among a. Gender (Male vs Female) b. Age groups c. Ethnicity (Greek, Greek-American, and non-Greek) when compared with a. Number of years living in the United States (if Greek) b. Socioeconomic status c. Marital status and ethnicity mix, e.g., married to a Greek vs to a non-Greek, if Greek or Greek-American d. Composition of the household, e.g., living alone vs in a multigenerational family unit? 2) Is there an observable pattern between structural processes, i.e., which promote technology and convenience, and infrastructural processes, i.e., cultural preferences, social norms, and religious practices in relation to change adoption patterns? 3) Are the observed dietary behaviors associated with a deviation from the traditional Greek diet and indicative of increased risk of coronary heart disease, as characterized by the American diet? variables Demographic variables included: gender, age, socioeconomic status, type of household, and (number of years living in the United states, if Greek) number of years

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59 living in the Tarpon Springs area. Part I of the questionnaire provided these data. Socioeconomic status was determined with an SES clustering system described by Schneider (1986). In contrast to the Hollingshead scale which is an ideologically based measure of the status level of the working members of a household, the SES clustering system defines class as operationally and theoretically different from status. Inherent in the Hollingshead scale is the concept that class represents the economic relationship of individuals to goods and opportunities for income in a market economy. Status groupings are thought to represent lifestyle and prestige attributed to individuals by society. Schneider, on the other hand, utilizes a Marxian concept of class which views class as the primary element influencing an individual's place in the social hierarchy. The particular role an individual fills "in the production process and relationship to others in the economic hierarchy will influence his/her access to the social product of society, including which neighborhoods they live in and schools they attend, life chances, and through socialization in a particular social place, world view" (Schneider 1986:211). She views the nature of a particular class society within an historical perspective and as a continuum of ethnicity, value systems, and current situations.

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60 SES clusters utilize variables which include education level, occupation, self reported ethnicity, and relevance of ethnicity. The SES variable is statistically derived by cluster analysis. Social cohesion scores were determined according to each of the three subgroups: cultural, national and religious components of ethnicity. A total score of the thirty items were referred to as the attitudinal ethnicity score. The lower the score, the greater indication of commitment to the group. Preference for American foodways was operationalized to measure preference for eating in American steakhouses, fast food restaurant eating, and cooking at home with "American-style" recipes. Use of convenience foods and a microwave oven, discontinuation of the family meal in preference to eating individually, eating out at deli's or specialty diners or from vending machines reflected behaviors which represented convenience and technological motivation. Commercial influences were measured by questions regarding the frequency of food purchases because of coupon use, TV advertising, or recipe collection from popular women's magazines. Continuity of Greek dietary practices was operationalized to represent frequency of participation in ethnic dining, e.g., eating at a Greek restaurant, choosing cuisines of similar ethnicity-Mediterranian, eating in a

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61 coffee house, and preference for cooking with Greek foods, e.g., olive oil, Greek peppers, feta cheese (all are available in grocery stores in Tarpon Springs). Infrastructural variables, e.g., ethnicity, included data about frequency of observance of religious fasts and Greek/ethnic holidays. Parts II and III of the study questionnaire addressed these variables. The food and nutrient patterns, in addition to eating times reported in Parts IV and V of the questionnaire, were compared with the Greek and American diet prototypes to further describe abandonment or persistence of Greek dietary behaviors among Greeks and Greek-Americans in Tarpon Springs. Variables, e.g., type of fat, percentages of complex carbohydrate and protein consumed, were used to describe the degree of Americanization of the dietary patterns and adoption of dietary practices associated with increased risk of coronary heart disease. The hypothesis tested whether the observed dietary patterns demonstrate persistence of ethnic identity and food practices or change in relation to demographic, technical/material, and infrastructural influences. Data regarding obesity, elevated blood pressure, and elevated serum cholesterol were used to validate and explain risk factor status. Multivariate analysis models using Statistical Analysis Systems (SAS) programs, and including analysis of covariance, was used to describe the

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62 interactions among the study variables in the respective ethnic groups. Significant variance between and among aggregate groups of individuals and ethnic groups were used to describe observed differences in dietary behaviors and risk factor status.

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CHAPTER 4 RESULTS Inference Tests Data were collected between October 1988 and April 1989 from Greeks, Greek-Americans and non-Greeks who live in the Tarpon Springs area. Two hundred, twenty-six persons, aged 25-74 years, participated in the study. One hundred and twenty-eight persons (57%) completed the entire questionnaire, thus providing explanatory variables for the study. Comparisons between the two groups (Group l=those who did not complete the questionnaire and Group 2=those who did complete the questionnaire) revealed differences between their body mass index (BMI=weight in kgs/height in meters-squared), blood pressure and cholesterol values (Table 4-1 p. 64). There were no significant differences between the two groups for Body Mass Index (BMI) or blood cholesterol levels. Differences in blood pressure values were highly significant at the .036 level for the systolic pressure and at the .005 level for the diastolic values. Therefore, data for the two groups were not combined for further analyses. Data from three persons, who partially completed the 63

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64 Table 4-1: Comparisons of data collected from those who did not and those who did answer the questionnaire T-Test Variable Group 1 Group 2 p-values N= 98 128 BMI 28.9 27.6 0.077 kg/meters-squared N= 95 128 Blood Pressure (mm Hg) Systolic 134.8 129.1 *0.036 Diastolic 83.5 79.0 *0.005 N= 57 126 Cholesterol 226.9 212.5 0.077 (mg/dl) *=significant at less than .05 Group l=Those who did not complete the questionnaire Group 2=Those who did complete the questionnaire questionnaire, did not fall outside the ranges of values for the persons who completed the questionnaire in its entirely so their data were included with the group of persons who did fill out the questionnaire. The total ethnicity score and its subscales (culture, religion, national), age, cholesterol, systolic blood pressure, diastolic blood pressure and BMI were further tested to see whether they met the assumption of normality. The probability that each of these variables had a normal distribution about the mean was accepted because their p-values were within a range of less than .01-1.0. Age had a slight skewness (.OS; kurtosis -1.63). Body mass was

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skewed (1.04; kurtosis 1.58) in the opposite direction, however both had p-values of less than .01 and could be accepted under the normal distribution assumption. Demographic Characteristics of the Sample 65 The socioeconomic (SES) clustering system described by Schneider (1986) revealed two clusters with representative groupings of persons from lower and higher SES categories. These groups reflect the educational level achieved, the degree of skill, autonomy, supervision and type of employment which defines an individual's place within the local social hierarchy. Table 4-2 identifies these SES groupings by ethnic group. Table 4-2: SES cluster by ethnic group Ethnic Group Lower SES Higher SES Total Frequency Row Percent Greek 5 13 18 27.7 72.2 Greek-American 28 13 41 68.3 31.7 Non-Greek 37 31 68 54.4 45.6 Total 70 57 127 Persons with missing values were omitted from the comparisons. The Chi-square test of independence had a value of 8.329 with 2 degrees of freedom and a p-value of 0.016, indicates that there are significant ethnic group

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66 differences in SES. Greeks had a higher proportion of study subjects in the higher SES group. Non-Greeks had a higher percentage of persons in the lower SES cluster. The SES clusters revealed a significant (p-0.000) relationship with age. The younger age group (25-49 years) contained 15% of persons from the lower SES group and 41% from the higher SES cluster. The older age group (50-74 years) contained a higher proportion of persons from the lower SES group (30% lower SES and 13% higher SES). Subjects were asked to report age by decade (e.g., 25-29, 30-39, etc.). Mean age for Greeks fell within the fifties, for Greek-Americans and non-Greeks, mean age fell within the forties. Because of the small cell size when analyzing age with other variables in a multivariate analysis, age was subdivided into two grouping. Group 1 represented those persons who were less than 50 years of age. Group two was composed of persons 50-74 years of age. Table 4-3 (p. 67) illustrates the 2 age groupings by ethnic group. The Likelihood Ratio Chi-square had a value of 6.155 with 2 degrees of freedom and a p-value of 0.046, inidicating that ethnic group had a significant effect on age grouping. In later analyses where age had a significant effect, these analyses were controlled for age. When the Greek and Greek-American groups did not have significantly different effects on a parameter, these two ethnic groups

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Table 4-3: Ethnic group by age group Ethnic Group Age Group Frequency 25-49 50-74 Row Percent years years Greek 9 13 40.9 59.1 Greek-American 31 13 70.5 29.5 Non-Greek 34 31 52.9 47.1 Total 74 57 were combined, thus allowing for a more even age and frequency distribution between Greek and non-Greek comparisons. 67 Total 22 44 65 131 Each age group had a higher proportion of females than males. Table 4-4 (p. 68) describes the gender composition of each age group by ethnic group. Study subjects had lived in the Tarpon Springs area between 1-74 years. Thirty-five percent reported living in the area for four years or less. Half of them were new to the area within the past 9 years. Sixty-two of the study participants lived in Tarpon Springs for 9 or more years. Three-fourths of the Greek subjects were born in Kalymnos, the island home of the original divers who founded the Greek colony in Tarpon Springs. More recent immigrants came from Athens, Agia and Patras. Two persons in the Greek ethnic group immigrated to the United States within the past

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Table 4-4: Gender by age and ethnic group Gender Ethnic Group Frequency Row Percent Female Greek Male Greek Female Greek-American Male Greek-American Female Non-Greek Male Non-Greek Total Age Group 25-49 50-74 years 8 47.1 1 20.0 23 71.9 8 66.7 20 57.1 14 46. 7 74 years 9 52.9 4 80.0 9 28.1 4 33.3 15 42.9 16 53.3 57 Total 17 5 32 12 35 30 131 five years. One of these persons lived in Tampa prior to moving to Tarpon Springs. The other person immigrated directly from Athens and is living with a family member in Tarpon Springs. Seventy-two percent of the Greek ethnic group lived in the United States 25 years or longer. Ethnicity 68 Among the Greeks, 611 had visited Greece within the past five years. Twenty-eight percent reported that they visited Greece more than three times during that period. In contrast, only 40% of the Greek-Americans reported that they had visited Greece within the past five years and only 15%

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69 of them had visited Greece more than once or twice during that time. Greeks and Greek-Americans differed in the number of religious fasting occasions that they kept. Fifty-eight percent of Greeks compared with twenty-four percent of Greek-Americans reported fasting weekly. Only one Greek and three Greek-Americans never fast. Three non-Greek persons reported fasting weekly and 69 percent reported never fasting. Yearly holiday festivities were celebrated with special foods by 67 percent of the Greek ethnic group and 95 percent of the Greek-Americans. By contrast, only 46 percent of the non-Greeks used special holiday foods to celebrate yearly festivities. Ethnic group cohesiveness was apparent among the Greeks and Greek-Americans from their ethnicity scores. The lower the numerical score for each scale, the greater the commitment to the ethnic group. The means for each subscale were consistently lower for the Greeks than for the Greek-Americans. Scores for the non-Greeks were higher than either of the Greek ethnic group scores. Scores for one subscale were predictive of the scores on the other subscales among the Greek ethnic groups but not among the non-Greeks. The practice of fasting and holiday celebration with special foods compared positively with the ethnic group

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70 cohesiveness scores. The exception was the national score for Greek-Americans. While Greek-Americans reported observing holidays with special foods more frequently than Greeks, this finding may reflect a tendency among the Greek-Americans to participate in both Greek and American holiday festivities. The use of special foods to celebrate holidays by both Greeks and Greek-Americans correlates with the lower national scores (greater national cohesiveness) for the two Greek ethnic groups. During the time of the data collection, two Greeks were running for elected offices. Governor Dukakis was a presidential candidate and United States Congressman Bilirakis was campaigning for re-election. While a few study participants showed strong agreement or disagreement with the question inquiring about voting for candidates of the same ethnic background, no overall election opinion bias was detected among the majority of subjects' responses to this question. Table 4-5 (p.71) describes the ethnic scoring differences between the study groups and their respective score correlation coefficients. Ethnicity subscores were compared to Roche's (1984) ethnicity scores obtained from two samples of Italians and Italian-Americans who lived in suburbs of Providence, Rhode Island. Table 4-6 compares the two study scores (p. 71).

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71 Table 4-5: Ethnicity scores by ethnic group Ethnic Scale Group N Mean Culture GR 18 16.4 GA 40 19.7 NG 66 30.2 Religion GR 18 19.3 GA 40 23.0 NG 66 32.9 National GR 18 23.3 GA 40 30.1 NG 66 35.1 GR=Greek Cult=Culture GA=Greek-American Reli=Religion NG=Non-Greek Natl=National Correlation coefficients Range cult Reli Natl 11.0-24.5 0.65 0.62 10.0-35.0 0.78 0.58 15.0-60.0 0.10 0.23 10.0-30.0 0.65 0.63 10.0-43.0 0.78 0.69 19.0-56.0 0.10 0.21 11. 0-34. 0 0.62 0.63 14.0-45.0 0.58 0.69 17.5-47.0 0.23 0.21 Table 4-6: Greek ethnic subscale comparisons with Italian-American subscale scores Greek Italian Scale N Group Score N Group Score culture 18 GR 16.4 52 IT 27.6 40 GA 19.7 49 IA 28.2 66 NG 30.2 27 AM 35.4 Religion 18 GR 19.3 52 IT 35.1 40 GA 23.0 49 IA 36.1 66 NG 32.9 27 AM 41.5 National 18 GR 23.3 52 IT 32.4 40 GA 30.1 49 IA 32.0 66 NG 35.1 27 AM 39.7 GR=Greek IT=Italian GA=Greek-American IA=Italian-American NG=Non-Greek AM=American

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72 The lower scores for Greeks and Greek-Americans in Tarpon Springs, compared to the Italians and Italian-Americans in Providence, is not surprising. The tourist industry in Tarpon Springs promotes the Greek culture. Greek and Greek-American businesses (e.g., sponge-diving, curio shops and Greek restaurants) are obvious throughout the town. The hourly chimes from Saint Nicholas Greek Orthodox Church is a constant reminder of the Hellenic influence in the environment. (The ringing of hourly chimes at the local church is a common practice in Greece). Identification with the Greek culture has economic benefits in Tarpon Springs. Comparisons between the two studies show consistent trends. Italians who immigrated to the United States scored lower on each subscale than the Italian-Americans. Each Italian group scored lower than the American group. The culture score was lowest for both Greeks and Italians and the national score was highest. Religion appeared to be less influential in fostering group cohesiveness among the Italian groups than among the Greek groups. This observation is consistent with Moskos (1989:34) observation that the Greek Orthodox Church is the focus of the immigrant Greek communities in the United States. Scourby (1979) also observed strong ties with the Greek Orthodox Church among the Greek community in New York City.

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73 Eating Preferences Affecting Food Use The Greek group showed a high preference for eating at Greek restaurants (47% daily). Only two Greek individuals almost never eat at a Greek restaurant. The highest percentage (46%) of Greek-Americans eat at a Greek restaurant only monthly. The Greeks reported rarely eating at other ethnic restaurants (58% "almost never") or eating at an American steakhouse or fast food restaurant (25% 33% "infrequently"). Half of the Greek sample never eat at a fast food restaurant and 90% never eat foods purchased from a vending machine (Appendix C). The Greek-American group's restaurant preferences were similar to the preferences of the non-Greeks. Approximately half of the persons in these two respective ethnic groups ate at an ethnic or American restaurant monthly. One-fourth to one-third of persons in each group ate at a fast food restaurant either weekly or monthly. Greek-Americans showed a higher preference (35% monthly) for eating at a deli or submarine sandwich shop compared with the non-Greek's preference (25% monthly). Like their Greek counterparts, Greek-Americans almost never ate foods purchased from a vending machine (92%). By contrast, only 48% of non-Greeks never ate foods purchased from a vending machine. Slightly greater than three-fourths (87% Greek, 77% Greek-American, and 75% non-Greek) of the sample gather at

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74 home daily for a common household meal. A similar percentage of these persons report using basic ingredients in their cooking. Differences in food preparation patterns were apparent from the use of convenience foods. Seventy-three percent of the Greeks report never using convenience foods and only 27% of them use a daily combination of convenience foods and basic ingredients. Half of the non-Greeks use a combination of convenience foods and basic ingredients daily compared to less than one-third of the Greek-Americans. Non-Greeks use a microwave oven more frequently than the Greeks or Greek-Americans. Two-thirds of the non-Greek persons reported using it daily or weekly compared to 42% of the Greek-Americans, who use it daily or weekly. Eighty percent of the Greeks and 44% of the Greek-Americans never use a microwave oven. Only 17% of the non-Greeks reported never using a microwave oven to cook at home. Type of meals prepared also showed differing trends between the ethnic groups. Greeks use "Greek style" recipes (83% daily) and Greek ingredients (75% daily). Slightly greater than one-third of the Greeks never eat "American style" recipes at home. As expected, the majority of non-Greeks use "American style" recipes daily. One-fourth of the non-Greeks report preparing "Greek style" recipes and use Greek ingredients monthly. One-third of the non-Greeks

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75 reported never eating "Greek style" recipes or using Greek ingredients in foods prepared at home. Greek-Americans show greater diversity in how meals are prepared at home. Two-thirds of them (40% daily and 28% weekly) use "Greek style" recipes and 59% of them (28% daily and 31% weekly) use Greek ingredients in the foods they prepare at home. While still maintaining some of the Greek food preparation methods, half of them (28% daily and 31% weekly) report cooking "American style" at home. Commerical influences (e.g., TV advertisements, coupon use and collection of recipes from magzines) were much more evident among non-Greeks and Greek-Americans than among the Greek ethnic group. Seventy-one percent of the Greeks report never purchasing food or drinks advertised on TV or collecting magazine recipes. Half (50%) of them do not use coupons with food purchases. By contrast 46% of the non-Greeks and Greek-Americans purchased foods that were advertised on TV either weekly or monthly (non-Greeks, 29% weekly and 17% monthly: Greek-Americans, 23% weekly and 23% monthly). Forty-six percent of non-Greeks report not being influenced by TV advertisements in their food purchases and 35% of Greek-Americans do not purchase foods advertised on TV. Two-thirds of the non-Greeks and Greek-Americans, contrasted with 36% of the Greeks, used coupons weekly for food purchases. Eighteen percent of the Greek-Americans and

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76 14% of the non-Greeks never use coupons while shopping for groceries. Greek-Americans and non-Greeks collect recipes from popular magazines. Fifty-eight percent of the non-Greek group collect recipes from popular magazines monthly or more often. Fifty-four percent of the Greek-Americans collect recipes either monthly or yearly. Greek-Americans may use magazine recipes to learn to prepare American holiday foods. Operationalized Comparisons of Dietary Preferences In order to elucidate these trends by their operationalized categories of Greek or American dietary preferences, convenience and commericial influences, the questions were scored by assigning the categorical responses corresponding numbers. Daily was given a score of 1, weekly scored 2, monthly 3, yearly 4, and almost never scored 5. Responses for persons within each ethnic and numerical grouping were totaled and averaged so that scores fell with the 1-5 scoring range for each category. Table 4-7 describes these scoring comparisons (p. 77). The aggregate response scores within the ethnic groups suggest differing levels of preference for Greek or American dietary practices, convenience and commercial influences. Trends were evident between the two Greek groups as well. As expected, Greeks demonstrated a greater trend for Greek than American dietary preferences. While Greek-Americans showed a stronger trend than Greeks for American dietary

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77 Table 4-7: Averaged eating preference responses by ethnic group Ethnic Group Frequency Percent Greek Greek-American Daily 1 8.3 5.3 Non-Greek 2 Greek 3.8 1 8.3 Greek-American 7 18.5 Non-Greek 23 Greek 42.6 0 0.0 Greek-American 2 5.3 Non-Greek o Greek 0.0 0 0.0 Greek-American o o.o Non-Greek 3 5.6 Averaged Eating Preference Responses Almost Weekly Monthly Yearly Greek Dietary Preference 11 1 0 74.9 8.3 o.o 2 63.3 24 44.8 24 31.6 26 48.3 12 o.o 2 3.8 American Dietary Preference 3 6 2 25.0 49.9 16.7 19 50.0 23 42.6 9 23.8 6 11.2 1 2.6 2 3.8 Convenience Preference 1 3 6 8.3 24.9 49.9 6 15.8 13 24.3 16 42.1 26 48.2 Commercial Preference 8 21.0 13 24.2 0 6 2 o.o 50.0 16.6 9 23.7 20 37.1 19 50.0 20 37.1. 10 26.3 6 11.2 Never 0 o.o 0 0 0.0 0 0.0 0 o.o 2 5.3 0 o.o 2 16.7 6 15.8 2 3.7 4 33.3 0 o.o 5 9.3

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78 preferences, the Greek-Americans demonstrated a slightly greater preference for Greek than for American foodways. Non-Greeks revealed a trend toward preferring Greek dietary practices occasionally (the non-Greek group was composed of a variety of persons from American, Italian, German and other European backgrounds). The trend for commercial preference was higher among non-Greeks when compared to either Greeks or Greek-Americans. Greeks were least influenced by convenience. To determine whether these trends could explain interrelationships among the study variables, a factor analysis (containing the eating preference variables and 43 other study variables) was performed. Three factors were retained because they met the prior communality estimate of 1.0. The initial factor method, with principle components, was used because the rotated varimax and standardized scoring coefficients did not explain any additional variance. Factor 1, the Ethnicity Factor, explained 6.34% of the variance. Variables that had a loading of .so or greater were preference for "Greek style" recipes, Greek recipe ingredients, the ethnicity subscores for culture, religion and nationality, fasting and holiday celebration with special foods.

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79 Factor 2, the Medical Factor, explained 4.57% of the variance. This factor will be described later in the section pertaining to risk factors for CHD (page 121). Factor 3, the Commercial Factor, explained 3.57% of the variance and had a loading on commercial dining, e.g., eating at ethnic and fast food restaurants, a deli or submarine sandwich shop, from a vending machine and purchasing foods which are advertised on TV. None of the factors explained a high proportion of the variance (14.48%) among the variables. These factors were tested later in a multivariate regression analysis to determine whether they could explain any variance in the blood cholesterol values. These findings are presented in the section on blood cholesterol (page 121). Frequency of Food Intakes Reported monthly frequencies of intakes were grouped into the following food groups and compared (Appendix D): Quoted percentages refer to monthly frequencies unless stated otherwise. Dairy Food Group Within the dairy food group, Greek-Americans (541) and Greeks (471 weekly, OI monthly) reported consuming whole milk more frequently than non-Greeks (30%). The Greek persons, who did not consume whole milk, used skim milk (50%). Non-Greeks had a greater preference for low fat milk

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80 (63%) compared to their skim milk (42%) and whole milk (30%) consumption pattern. Cheeses were the most frequently consumed food within the dairy food group. Greek-Americans consumed feta cheese (89%) and other cheeses (93%) most frequently when compared with the Greeks (72% feta and 72% other cheeses) and non-Greeks (34% feta and 82% other cheeses). Yogurt was consumed more frequently by Greeks (72%) than by Greek-Americans (66%) or non-Greeks (41%). Frozen yogurt was eaten less frequently. A high proportion of Greeks (83%), Greek-Americans (84%) and non-Greeks (79%) almost never ate frozen yogurt. Ice cream was consumed more frequently than milk by all ethnic groups. Greek-Americans reported the highest (78%) ice cream consumption, followed by non-Greeks (64%) and Greeks (56%). Comparisons with the Greek Diet Greeks in previous studies, consumed most of their dairy foods in the form of yogurt (Valassi 1962) and cheese (Christakis et al. 1965). The unpopularity of milk consumption in Greece was thought by Valassi (1962) to be attributable to insufficient quantities before the war and poor sanitation. Lack of pasteurization, except in large cities, and lack of refrigerization in homes made milk drinking unsafe. Christakis and Kurtz (unpublished data 1980 and 1982 and Valassi 1962) observed that sheep's milk,

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81 customarily boiled and drunk hot with sugar added, is consumed more frequently than cow's milk in rural areas of Greece. Greek-Americans in the United States continued to prefer yogurt and feta cheese (Valassi 1962 and Costantakos 1987). Vendors sell ice cream in the warmer months (April to September) in Greek towns and rural villages (personal observation and communication 1982). Greek immigrants and Greek-Americans enjoy ice cream in the United States throughout the year (Valassi 1962). Greeks in Tarpon Springs appear to be consuming more milk than Greeks in Greece (Quantities were not indicated on the food frequency, so amounts at each consumption time may be low). The 24-hour recall indicates that Greeks consume most of their milk with cereal or coffee. Like Greeks and Greek-Americans in previous studies, preference for feta cheese, yogurt and ice cream is found among both Greeks and Greek-Americans in Tarpon Springs. Comparisons with the American Diet Nationwide food consumption studies (CSFII 1985) indicate that whole milk consumption decreased among United States men by 251 between 1977 and 1985 and by 111 among United States women (Popkin et al. 1989) during the same time period. Low fat and skim milk consumption increased by 53% for men and 18% for women in the respective study reports. Twenty-seven percent of men, aged 19-50, consumed

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82 low fat or skim milk (CSFII 1985) compared with 44% of women who consumed whole milk and 49% who preferred low fat or skim milk in one of four non-consecutive days (CSFII 1986). Cheeses were consumed by United States women (71%) and men (33%) more frequently than yogurt (12\women: 21 men) per individual in an average day (CSFII 1985 and 1986). The pattern of dairy food intake among the non-Greek group in Tarpon Springs is similar to reported intakes of these foods in the nationwide consumption studies. Sixteen percent of the non-Greeks in Tarpon Springs reported consuming whole milk daily, while 47% reported a daily intake of low fat milk and 34% preferred skim milk daily. Cheeses were consumed less frequently (3% feta and 12% other cheeses daily). Five percent of the non-Greeks reported daily consumption of yogurt. Grain Food Group Bread is consumed more frequently by Greeks and Greek-Americans than by non-Greeks. White bread is used most frequently by the Greeks (71% weekly and 53% daily). Thirty-five percent of the Greeks also consume brown bread daily. Greek-Americans and non-Greeks have a greater preference for brown bread (92% Greek-American: 91% non-Greek). Fifty-five percent of Greek-Americans and 52% of non-Greeks consume brown bread daily compared with 38% of the Greek-Americans and 30% of non-Greeks who prefer white bread daily. Pita bread is consumed more frequently by

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-83 Greek-Americans (36%) and Greeks (24%) than by non-Greeks (19%). Specialty breads, e.g., doughnuts, danish and coffee cakes, however, are preferred more frequently by Greek-Americans (65%) and non-Greeks (64%) than by Greeks (44%). Two-thirds (67%) of the Greeks eat breakfast cereals but non-Greeks (89%) and Greek-Americans (87%) consume cereal more frequently. Other grains, e.g., pasta and rice are also consumed more frequently by Greek-Americans (100% pasta and rice) and non-Greeks (97% pasta; 92% rice) than by Greeks (94% pasta; 83% rice). Comparisons with the Greek Diet In Greece, bread is an indispensable part of every meal (Valassi 1962). Bread is usually eaten plain, without butter or jelly, and is used to absorb the oil and juices from salads and main dishes (personal communication and observation 1982). Specialty breads, e.g., muffins, biscuits and sweet rolls are unknown in Greece (Lieberman and Gardner 1980). Pasta is eaten plain with tomato sauce or in combination with meat, as in pastitsio. Rice is characteristically prepared as pilaf or mixed with meat and seasonings and made into a stuffing for dolmathes (Valassi 1962 and Nickles 1969). Greeks in Tarpon Springs continue to consume bread frequently. Specialty breads are eaten only rarely.

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Greek-Americans, however, while continuing to have a high preference for bread, have also adopted the consumption of doughnuts, danish and coffee cakes. 84 Pasta and rice are consumed more frequently than breakfast cereals by Greeks. Greek-American consumption patterns of these foods more nearly resembles the non-Greek preferences. Comparisons with the American Diet Consumption of yeast breads and rolls decreased among men, aged 19-50, between 1977 (82% per day} and 1985 (74% per day). Sixty-six percent of women reported consuming yeast breads and rolls on the study day in 1985 (CSFII 1985 and 1986). Other baked goods were consumed at a frequency rate of 52% daily by men (CSFII 1985) and 58% by women (CSFII 1986). Daily cereal and pasta intakes were reported by 27% of the 19-50 year old men, with 15% of the reported intake being from ready-to-eat cereals (CSFII 1985). A comparable age group of women consumed cereal and pasta (66%) at least once during four non-consecutive days with 39% of them consuming ready-to-eat cereals (CSFII 1986). Twenty-five percent of men reported consuming mixed dishes, consisting mainly of grain (CSFII 1985) and 261 of women (CSFII 1986) consumed grain dishes. Bread intake for the non-Greeks in Tarpon Springs was similar to bread intakes of the men and women in the USDA national study. Cereal intake was higher than the reported

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85 national intakes. Prior to the data collection periods of the study in Tarpon Springs, news was released regarding the benefit of oat bran in reducing serum cholesterol levels. Informal conversations with the study participants indicated that they had increased their consumption of oatmeal, other oat bran cereals and oat bran baked goods. This increased awareness of oat bran's cholesterol-lowering property may account for the increased intake of cereal among the non-Greek study population in Tarpon Springs when compared with the intake of cereals reported in the earlier national studies. Fruits and Vegetables Food Group All three ethnic groups consumed citrus fruit and juices frequently (100% non-Greek; 95% Greek-American; 0% monthly and 94% weekly Greek). Only a few Greeks (6%) and Greek-Americans (5%) never consumed citrus fruits or juices. A high proportion of each ethnic group also consumed other fruits and juices (97% non-Greek; 95% Greek-American; 90% Greek). Fruit punch or drink was consumed most frequently by Greek-Americans (58%), followed by non-Greeks (46%) and Greeks (41%). Fifty-nine percent of the Greeks almost never consumed fruit punch or drink compared to the Greek-Americans (31%), who had the smallest proportion of persons who almost never consumed fruit punch or fruit drinks.

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86 Potatoes were unanimously consumed frequently by all three ethnic groups. No persons from any of the three ethnic groups reported never consuming potatoes. Salty snack food varieties, e.g., potato chips and corn chips were consumed most frequently by non-Greeks (67%). Half of the Greek-Americans consumed snack food varieties monthly compared to 29% of Greeks, who consumed these foods. Greeks consumed salad frequently (59% daily and 94% weekly). Slightly more than half (55%) of the Greek-Americans consumed green salads daily and almost all Greek-Americans (95%) consumed green salads weekly. Green salad consumption was reported less frequently by the non-Greek group (44% daily and 80% weekly). Eight percent of the non-Greeks reported never having green salads compared to no Greeks or Greek-Americans who never consumed green salads. Greeks preferred yellow vegetables, e.g., squash and carrots (100%) to the green vegetables, e.g., broccoli, spinach, and green beans (94%). Greek-Americans consumed more green (100%) than yellow (91%) vegetables. Non-Greeks had a high preference for both types of vegetables (98% green; 100% yellow). Intakes of olives and Greek peppers were reported more frequently by Greek-Americans (76% olives; 47% Greek peppers). Greeks consumed more olives and Greek peppers (61% and 39% respectively) compared to the non-Greek

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87 preferences for these foods (49% olives and 32% Greek peppers). Twenty-eight percent of the Greeks and 37% of the non-Greeks compared with 8% of the Greek-Americans never consumed olives. Half of the Greeks (50%) and non-Greeks (56%) never consumed Greek peppers, while only one-third (34%) of the Greek-Americans reported never having Greek peppers. Comparisons with the Greek Diet Consumption of fruit is common in Greece. Most of the time, fruit is sliced or peeled and eaten raw as a dessert (Valassi 1962: Lieberman and Gardner 1980). The Greek population has continued to enjoy fruits, especially citrus fruits, in Tarpon Springs. A greater proportion of Greek-Americans have more readily adopted fruit punches and fruit drinks. Potatoes, in Greece, are characteristically fried with olive oil in a frying pan and eaten at mealtime, rather than as a snack. The custom of having potatoes primarily for meals has continued among the Greeks in Tarpon Springs. Greek-Americans report consuming potato chips occasionally, but not with the same frequency as the non-Greeks. In Greece, Greeks enjoy a variety of raw and cooked vegetables. Raw salads are served daily (Valassi 1962: Lieberman and Gardner 1980). While continuing to prefer green vegetable salads in Tarpon Springs, relative to the frequency of non-Greek use, green salad consumption for

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88 Greeks and Greek-Americans is not as indispensable an item with each meal as in Greece. Together with green and yellow vegetable consumption, vegetable intakes are greater for Greeks and Greek-Americans in Tarpon Springs than for non-Greeks. The higher preference for olives and Greek peppers by Greek-Americans, compared with Greeks, may be due to a more selective preference for type of olive and pepper consumed. For example, Cretan olives do not look or taste the same as olives grown on the mainland of Greece (personal observation and communication 1982). Greeks in Tarpon Springs may prefer only the type of olive that is native to their region of origin in Greece, therefore limiting the selection of olives in Tarpon Springs. Greek-Americans, on the other hand, may enjoy all types of olives and find them more readily available in any grocery store. Comparisons with the American Diet Fruit intake for men (CSFII 1985) increased eleven percent between 1977 and 1985. For women, there was no reported increase during the comparable time period (Popkin et al. 1989). Twenty-three percent of men (CSFII 1985) reported daily fruit or fruit juice consumption and 291 of women (CSFII 1986) reported consuming fruit on the study day. Two-thirds of the non-Greeks in Tarpon Springs reported consuming fruit or juice daily. This greater preference for fruits and fruit juices by the non-Greeks,

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89 compared to persons in the national studies, may be associated with the availability of fresh fruits and the promotion of orange juice in Florida. Fresh fruits grow in private lawns and vine-ripened produce is marketed all year at road-side stands in Tarpon Springs and the surrounding areas. Vegetable consumption increased by 31 for men, aged 19-50, and by 4.9% for women between 1977 and 1985 (CSFII 1985 and Popkin et al. 1989). Eighty-five percent of the men consumed vegetables on the survey day in 1985. Potatoes were consumed by 51% and tomatoes by 42%. Only 41 consumed dark-green vegetables and 6% reported eating deep-yellow vegetables. Sixty-nine percent ate other vegetables. Forty-one percent of women, aged 19-50, consumed potatoes and more women ate dark-green (111) and deep-yellow (11%) vegetables than men. Tomatoes and other vegetables were 31% and 65% consumed respectively by women (CSFII 1986). Non-Greeks in Tarpon Springs demonstrated a stronger preference for vegetables than the national studies indicate (57% green vegetables and 421 yellow vegetables daily). Potatoes were eaten less frequently (221 potatoes and 51 potato chips daily). The availability of fresh produce in Florida may account for the increased preference for vegetables among the non-Greek group in Tarpon Springs compared with the national sample. This difference may also

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90 be indicative of a selection bias for foods associated with health among the non-Greek group in the study. Protein Food Group Fish was consumed more frequently (100%) than poultry (89%) or meat (83%) by the Greek group. The preference of Greek-Americans for fish (100% and poultry (98%) was nearly equal. The frequency of meat consumption, by Greek-Americans, was 90%. Non-Greeks consumed poultry (97%) in preference to fish (94%) and meat (91%). Eleven percent of the Greeks never ate meat and 6% reported never eating poultry. By contrast no Greek-American never consumed meat or fish and only 3% never consumed poultry. Eight percent of the non-Greeks never eat meat and 3% reported never eating fish or poultry. seventy-seven percent of the Greeks consumed eggs compared to 85% of the Greek-Americans and the non-Greeks. Lentils, chickpeas and dried beans were consumed more frequently by the Greeks (89%) than the non-Greeks (83%) and Greek-Americans (78%). Fourteen percent of the non-Greeks reported never consuming legumes compared to 5% of the Greek-Americans who never consumed them. Non-Greeks appeared to interpret the question as consumption of baked beans while the Greeks and Greek-Americans responded by reporting their consumption of lentils and chickpeas. Peanut butter consumption was most frequent for the non-Greeks (71%) and least frequent for the Greeks (35%).

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91 Greek-Americans consumed it moderately (59%). Fifty-nine percent of the Greeks never consumed peanut butter compared to the non-Greeks (25%) and Greek-Americans (21%) who report never eating it. Taramosalata, called "Greek caviar," is rarely consumed by Greeks (18%) and Greek-Americans (11%). Ninety-four percent of the non-Greeks never ate it. Several non-Greek participants asked me what this food was while they were answering the questionnaire. Comparisons with the Greek Diet Fish is well-liked and eaten frequently in areas of Greece which are bordered by water (Valassi 1962). Lamb and pork are meats that are eaten more frequently than beef in Greece. Poultry and eggs are used in soups and main dishes. The quantities of meat consumed in Greece are less than in the United States (Newman 1986). Lentils are often referred to as "the meat of the poor" in Greece. Beans, peas, lentils and chickpeas are used extensively in Greece (Valassi 1962). Greeks and Greek-Americans in Tarpon Springs reported consuming fish, poultry and meat more frequently than lentils. Simopoulos (1989) reports that eggs in Greece contain substantial amounts of n-3 fatty acids, compared to eggs produced in industrialized countries. Chickens, in Greece, range and feed on the farms where purslane, a green leafy vegetable, grows wild. Purslane was found in an earlier

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92 study (Simopoulos and Salem 1986) to be one of the richest sources of n-3 fatty acids, especially docosahexaenoic acid. This fatty acid has been observed to reduce the risk of coronary heart disease. Thus, eating eggs from chickens in Greece may have a protective effect against the development of heart disease. Comparisons with the American Diet In the United States, beef consumption decreased 35% among men and 43% among women, aged 19-50 years, between 1977 and 1985 (CSFII 1985 and Popkin et al. 1989 respectively). Poultry consumption decreased by 22% for men and 8.5% for women and fish consumption increased by 50% for men and 9% among women in the same studies. Meat consumption among men was 86%, poultry consumption was reported by 16% and fish by 11% on the day of the study (CSFII 1985). Sixty-nine percent of women consumed meat, 21% reported poultry consumption and 12% consumed fish on the study day in 1986 (CSFII 1986). Thirteen percent of the non-Greeks in Tarpon Springs reported consuming meat daily and 77% weekly. Poultry was consumed by 17% of the non-Greeks daily and 91% weekly. Fish was consumed by St of the non-Greek study group daily and 72% consumed fish weekly. Poultry and fish were consumed more frequently by the non-Greeks in Tarpon Springs than by the USDA study population. This trend may have been influenced by the National Cholesterol Education Program

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93 which was released and promoted in 1988 (NIH 1988). It produced and distributed information about reducing fat and cholesterol intakes and provided suggestions and sample menus for how to achieve these goals. Media coverage of these issues was also prolific, with articles in popular magazines and public service announcements on TV. The self-selected health-conscious bias of the sample may be another explanation for this trend. Tarpon Springs is located on the Gulf of Mexico. Fish is caught and served frequently in Greek restaurants and other restaurants in the Tarpon Springs area. These environmental factors may also contribute to the higher frequency of fish consumption among the non-Greeks in the study. Fat Food Group Greeks (89%) and Greek-Americans (85%) reported frequent consumption of olive oil, compared with the non-Greek consumption (53%). Thirty-nine percent of persons in the non-Greek group never consume olive oil, while only 6\ of the Greeks and 8\ of the Greek-Americans report never using olive oil. Other vegetable oils are used frequently by all three ethnic groups. Eighty-one percent of the Greeks (0% monthly) reported consuming other oils weekly. Half (50%) of the Greek-Americans and 70\ of the non-Greeks use vegetable oils weekly.

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94 Butter is preferred more frequently by Greek-Americans (50%) and Greeks (39%) than by non-Greeks (29%). Non-Greeks consume margarine more frequently (91%) than butter. Greeks (83%) and Greek-Americans (83%) demonstrate a high preference for margarine as well. Differences become apparent between the groups in their preferences for mayonnaise or salad dressings. Thirty-one percent of the Greeks report using them compared to 85% of the Greek-Americans and 81% of the non-Greeks who consume mayonnaise or salad dressings. Greeks report never (100%) using whipped cream compared with 21% of the Greek-Americans and 27% of the non-Greeks who consume whipped cream. Ninety-four percent of the Greeks never consume non-dairy whipped toppings and only 6% use it infrequently. Twenty-eight percent of the Greek-Americans and 36% of the non-Greeks use non-dairy whipped toppings. Approximately three-fourths of the persons in each ethnic group never use coffee cream. Of the Greeks who use cream, a higher percentage (22%) prefer cream to non-dairy creamer (13%). Greek-Americans (31%) and non-Greeks (30%) prefer the non-dairy creamers to coffee cream (16% Greek-Americans and 23\ non-Greeks). Comparisons with the Greek Diet Olive oil is the predominant fat used in Greek cookery (Valassi 1962: Christakis 1965: Lieberman and Gardner 1980).

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95 Food is not considered tasteful and well-prepared unless fat has been added in large quantities. In the United States, imported olive oil is expensive. Greek immigrants and Greek-Americans use other vegetable oils in cooking when taste is not affected. Olive oil is still preferred for salads (Valassi 1962). Butter is used in some meat and vegetable dishes and in dessert making. In Greece, there is no equivalent use for whipped cream or coffee cream. Greek coffee is laced with sugar and drunk without cream (Valassi 1962; Newman 1986; personal observation, communication and sampling 1982 in Greece and 1988 in Tarpon Springs). Greeks in Tarpon Springs have a continuing preference for olive oil, although they have also adopted the use of other vegetable oils. Salads are consumed with olive oil and lemon juice dressing. Greek-Americans have included mayonnaise and salad dressings as a frequent preference. Butter is preferred by Greeks and Greek-Americans more than by non-Greeks in Tarpon Springs. However, margarine is widely accepted by all three ethnic groups. Coffee cream has been accepted by a few Greeks and even fewer Greeks consume non-dairy creamer. No whipped cream is consumed by Greeks in Tarpon Springs. Consumption patterns of these fat items by Greek-Americans more nearly resemble the non-Greek dietary patterns. Whipped cream, however, is not used by 71\ of the Greek-Americans.

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96 Comparisons with the American Diet Consumption of fats and oils by men in the United States, aged 19-50 years, increased by 6% between 1977 and 1985 (CSFII 1985). Women increased their intake of lower fat salad dressings by 2.1% and higher fat salad dressings by 1.2%. Use of butter or margarine increased by 5.8% among women, aged 19-50 years, between 1977 and 1985 (Popkin et al. 1989). Forty-one percent of the men consumed table fats and 34% consumed salad dressing on the day of the study (CSFII 1985). A similar number (40%) of women consumed table fats and salad dressings (34%) on the study day (CSFII 1986). Sixty-nine percent of non-Greeks in Tarpon Springs consumed margarine daily and 13% used mayonnaise or salad dressings. Non-Greeks in Tarpon Springs consumed more margarine but less salad dressing on the study day. The differences balanced the fat intakes so that the total fat from these sources was approximately equal to the intake reported in the national studies per day. Olive oil consumption among non-Greeks was surprisingly high. Only 39% reported never consuming olive oil. This finding suggests that the Greek environment in Tarpon Springs has influenced the increased usage of olive oil among non-Greeks who live in the area. Only 5 persons (7.6%) in the the non-Greek group were of Italian origin

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97 (none were of Spanish origin) and may have been raised with a taste preference for olive oil. Beverages A majority of persons in each of the three ethnic groups reported drinking coffee and tea (711 Greek, daily and none weekly or monthly; 801 non-Greek; 851 Greek-American). Greeks showed a greater preference for Greek coffee (63%) than Greek-Americans (29%) or non-Greeks (5% weekly and none monthly). Ninety-two percent of the non-Greeks reported never drinking Greek coffee. Greek-Americans and non-Greeks showed a greater preference for decaffeinated coffee or tea (56% Greek American; 53% non-Greek) and diet drinks or soda (59% Greek American; 64% non-Greek) than Greeks (33% decaffeinated beverages; 33% diet drinks or sodas). Sixty-one percent of the Greeks reported never drinking diet drinks or sodas. Herbal teas and hot chocolate were preferred by Greeks (28% weekly for both herbal teas and hot chocolate) and Greek-Americans (471 herbal teas and 331 hot chocolate) rather than by non-Greeks (211 herbal teas and 231 hot chocolate). Seventy-three percent of non-Greeks reported never drinking herbal teas. Preference for regular koolade or soft drinks (non-diet) was similar for each ethnic group (41% Greek-American; 441 Greek; 461 non-Greek). Non-Greeks showed a greater preference for alcoholic beverages (beer, wine, whiskey, or ouzo). Fifty-six percent

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98 of the non-Greeks drank alcholoic beverages, as compared with 41% of the Greek-Americans and 35% of the Greeks. More Greeks (53%) and Greek-Americans (41%) reported never drinking alcoholic beverages than non-Greeks (34%). Comparisons with the Greek Diet Greek coffee is the beverage usually served in Greece. It is strong with grounds in the bottom of the cup. Sugar is used to sweeten it (Newman 1986). Open markets, in Greece, display a wide selection of various herbal teas. A vendor in Crete explained the medicinal benefits attributed to each type of herb (personal communication 1982), e.g., mints for gastric upset and cleansing. Wine is made in many rural households in Greece. Kegs are stored in cool cellars (personal observation, communication and sampling 1982). Wine is served to family members five years and older with special holiday meals. Men drink alcoholic beverages at the coffeehouses, where they gather regularly. Coffeehouses are off-limits to women, so female consumption of alcoholic beverages is more limited than for men (Nickles 1969). Greeks in Tarpon Springs have accepted American coffee but have also retained a strong preference for Greek coffee. Herbal teas are used by a small proportion of Greeks. The greater number of females (77%) in the Greek ethnic group probably account for the lower reported frequency of

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99 alcoholic beverage consumption, if the Greek women are limiting the use of alcholic beverages to special occasions. Comparisons with the American Diet Ninety-one percent of men and 90% of women, aged 19-50, reported drinking coffee or tea (CSFII 1985 and 1986) daily. Regular soft drink consumption increased among men, aged 19-50 years, by 43% between 1977 and 1985. While fewer men were drinking diet soft drinks (16% diet soft drinks vs 48% regular soft drinks) the mean intake of diet soft drinks consumed increased by 494% between 1977 and 1985 (CSFII 1985). Thirty-five percent of women reported drinking regular soft drinks and twenty-three percent drank diet soft drinks on the study day in 1986 (CSFII 1986). Alcoholic beverage intake increased by 7.5% for men, aged 19-50, between 1977 and 1985. Twenty-seven percent of men reported drinking an alcoholic beverage on the study day (CSFII 1985). Fourteen percent of women drank alcoholic beverages on the study day and twenty-nine percent of women reported consuming alcoholic beverages at least once during four non-consecutive days (CSFII 1986). The majority of non-Greeks in Tarpon Springs preferred coffee or tea (70% daily and 76% weekly). Approximately one-third of them (32% daily and 39% weekly) preferred having it decaffeinated. Unlike the national sample, in Tarpon Springs, a greater percentage of non-Greeks preferred diet soft drinks rather than regular soft drinks. Alcohol

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consumption by the non-Greeks was similar to reported frequencies in the national studies. Pastries and sweets 100 Greeks showed the greatest preference for spinach cheese pie (56%) and sweet Greek pastries (61%). Sixty-four percent of the non-Greeks reported never consuming spinach cheese pie or other Greek pastries. Greek-Americans reported eating the spinach-cheese pie (44%) and other Greek pastries (35%) but with less frequency than the Greeks. Non-Greeks demonstrated a high preference for non-Greek pastries, e.g., cookies and cakes (80%). Greek-Americans (68%) and Greeks (50%) also showed a preference for non-Greek pastries. Greek-Americans and non-Greeks showed a greater preference for hard candies (40% Greek-American; 38% non-Greek) and chocolate candies (64% non-Greek; 53% Greek-American) than the Greek ethnic group (12% hard candies; 44% chocolate candies). All three of the ethnic groups consumed sugar about equally (56% Greek; 62% Greek-American; 58% non-Greek). More Greek-Americans (73%) consumed syrup or honey than Greeks (60%) or non-Greeks (57%). However, jam or jelly was preferred more frequently by non-Greeks (741) and Greek-Americans {71%) than by Greeks {47%). Almost half (47%) of the Greeks reported never consuming jam or jelly.

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101 Comparisons with the Greek Diet Greek pastries, e.g., spinach-cheese pie and sweet pastries are generally served as a snack or to guests in Greece, rather than as a dessert as with the non-Greek dietary pattern (Nickles 1969). Greek-Americans in Tarpon Springs appear to enjoy Greek pastries along with the Greek ethnic group and, like the non-Greeks, have also incorporated non-Greek pastries into some of their meals (as observed in the 24-hour recall reports in this study). Some non-Greeks appear to have taken advantage of the Greek cuisine in Tarpon Springs and have included Greek pastries into their diet patterns occasionally. Christakis et al. (1965) reported that rural Cretans produce and consume honey and grape syrup. In Tarpon Springs, honey and syrup are also part of the Greek dietary pattern. Greek-Americans had a higher preference for syrup and honey, compared to the Greek ethnic group, perhaps related to their higher intakes of pancakes and waffles which are served with syrup. Bread is consumed without jam or jelly in Greece (Valassi 1962; Lieberman and Gardner 1980). Valassi (1962) observed that Greek-Americans are adopting the use of jam or jelly with bread for breakfast. In Tarpon Springs, Greeks reported the least frequent use of jam or .jelly. Forty-seven percent of the Greeks never use jam or jelly.

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102 Candy has not been mentioned as part of the Greek diet (Valassi 1962; Christakis et al. 1965; Lieberman and Gardner 1980). Nickles (1969) observed that the Greek hostess unfailingly keeps on hand at least one kind of rich, fruity "spoon" sweet. It is a fruit syrup preparation meant to be eaten with a spoon. This spoon sweet represents a social ritual (Nickles 1969 and personal communication and sampling 1982) and appears to replace the offering of candy to guests, as might be observed in some non-Greek homes. Comparisons with the American Diet A greater proportion of women (6.1%), aged 19-50, consumed higher fat desserts in 1985 than in 1977 (Popkin et al. 1989). The proportion of men who consumed sugars and sweets decreased by 19% between 1977 and 1985 (CSFII 1985). Eighty-nine percent of women reported consuming baked goods, other than yeast breads or rolls, at least once during four non-consecutive days in 1985. Almost two-thirds of them (61.3%) consumed sugars and 35% reported eating candy (CSFII 1986). Fewer men reported eating baked goods, other than yeast breads and rolls (52.11), sugars (31.41) and candy (10.8%) on the study day (CSFII 1985). Non-Greeks in Tarpon Spings reported consuming pastries, e.g., cakes and cookies, less frequently than reported in the national studies (12.51 daily; 42.2% weekly). Sugar (32.8% daily and SOI weekly) consumption appeared to be similar to reported intakes in the national

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103 studies. (Questions asked in the national study and the Greek study were not entirely comparable, making exact comparisons impossible. The comparisons do, however, indicate similar consumption trends). Preference was higher for chocolate candy (3.1% daily; 31.3% weekly) than for hard candy (3.1% daily; 17.2% weekly) for the non-Greeks. This consumption trend appears to be similar to the USDA study reports. The trend to eat fewer baked goods by the non-Greeks in Tarpon Springs can probably be attributed to a conscious effort to decrease cholesterol levels. While the data indicate that the non-Greeks have not eliminated baked goods from their diets, data do suggest that they are limiting the consumption of these foods to fewer times per week. The 24-Hour Recall The previous sections on eating preferences and food frequency intakes indicated that the three ethnic groups followed different food use practices. The 24-hour recall summarizes these differences in terms of nutrient intakes. Table 4-8 illustrates these differences in nutrient intakes (pg. 104). While there were differences between the ethnic groups for most of the nutrients, only a few of these differences attained significance (less than .OS) when they were compared across ethnic groups. Grams of monounsaturated fatty acids (MFA p=.013) and% MFA (p=.026) were significantly higher for the Greeks and

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104 Table 4-8: Nutrient intakes reported in the 24-hour recall by ethnic group Means/ Ranges GR Ranges GA Ranges NG Ranges p N= 16 39 66 Calories 1976 437-3315 1744 582-3329 1559 602-3909 .098 CHO, gms 229 53-440 197 16-541 191 65-529 .387 Pro, gms 87 31-194 76 12-218 69 17-170 .289 Fat, gms 71 10-115 70 14-165 55 8-191 .060 % CHO kcal 45 25-58 44 12-66 48 25-73 .116 % Pro kcal 19 9-38 18 5-45 18 9-34 .877 % Fat kcal 32 3-46 35 11-62 31 8-49 .086 SFA, gms 24 4-46 21 5-49 20 3-71 .378 MFA, gms 30 3-63 27 6-88 19 2-70 .013 PUFA, gms 12 1-27 12 1-32 10 1-41 .430 % SFA kcal 11 5-19 11 4-20 11 2-26 .976 % MFA kcal 13 4-24 14 4-38 11 2-25 .026 % PUFA kcal 5 1-10 6 1-14 6 1-19 .616 Dietary Fiber, gms 14 6-28 13 1-38 11 0-32 .243 %Fiber RDA 55 25-114 52 4-151 30 0-126 .225 Alcohol, gms 4 0-30 6 0-52 5 0-98 .952 % Alcohol kcal 1 0-10 2 0-12 2 0-38 .846 per 1000 kcal Na, mg 1261 405-2146 1221 354-2118 1602 512-5044*.008 K, mg 1620 628-2781 1567 541-2910 1813 622-3794 .120 Chol, mg 114 64-146 112 28-163 123 64-184 .083 Ca/Phos 0.6 0.4-1.0 0.5 0.2-0.9 0.7 0.2-1.2 .ooo CSI 40.6 8-81 33.3 8-75 30.2 4-94 .118 -significant CholCholesterol MFA=monounsaturated fatty acids SFA=saturated fatty acids PUFA=polyunsaturated fatty acids kcalCalories Ca/Phos=Calcium to Phosphorus Ratio NaSodium CSI=Cholesterol to Saturated Fat Index K=Potassium

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105 Greek-Americans compared to the non-Greeks. Non-Greeks had significantly higher sodium (p=.008) and calcium-phosphorus ratio (p=.0004) intakes compared to the Greek-Americans. Other ethnic group nutrient differences that attained significance at a p-value less than 1.0 were: total fat intake (p=.060) and I calories from fat (p=.086) which were lowest for the non-Greek group; cholesterol per 1000 calories (p=.083) was lowest for the Greek-Americans and highest for the non-Greeks. Calorie intakes were lowest for the non-Greek group. However, one-third (33.8%) reported that they consumed less than usual during the 24-hour period before the study. By comparison, only 7.1% of the Greeks and 20.51 of the Greek-Americans reported consumed less than their usual intakes during the 24-hour recall period. There were significant ethnic (F-value=J.45, p=.035) and gender (F-value=9.21, p=.003) effects on calorie intakes. Gender is more predictive of calorie level than ethnic group. Slightly more than half (58.31) of persons in the Greek ethnic group reported that they were following a special diet plan. Thirty-six percent of them followed a diet that was prescribed by a physician. Eighteen percent of them were following a diet for weight control. Of the Greek-American persons who followed a special diet (20.5%), the greatest proportion of the diets were for weight control

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106 (15.2%). Other reported reasons for following a special diet included: physician-prescribed (10.7%) and self-prescribed (3.6%). Reasons given by the proportion of non-Greeks who followed a special diet (31.3%) included: physician-prescribed (12.7%), self-prescribed (4.8%) and weight control (12.7%). The predominant reason given for a self-prescribed diet for persons in the Greek-American and non-Greek ethnic groups was for cholesterol-lowering. The ethnic group with the highest number of persons who reported taking a multiple vitamin-mineral preparation was the non-Greek group (31.3%) followed by the Greek-Americans (15.4%) and the Greeks (9.1%). Greek-Americans had the highest proportion of persons who were taking special supplements (20.5%). Non-Greek persons (12.5%) also reported use of special supplements while Greeks reported using no special supplements. Special supplement preparations included mixtures and selected combinations of the following: brewer's yeast, lecithin, bran, metamucil, garlic, RNA/DNA, salmon oil, linseed oil, max-EPA, psylium husk fiber, beta-carotene, and self-prescribed amounts of the a-vitamins, vitamins E and C, calcium, zinc, selenium and chromium. There was a significant correlation (r-.384, p=.004) between dietary cholesterol and blood cholesterol levels for the non-Greeks. The higher the cholesterol intake the higher the blood cholesterol.

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107 Differences in the effects of nutrients on blood cholesterol were evident from comparisons among the ethnic groups. Table 4-9 describes these differences. The Greek and Greek-American ethnic groups were combined for these analyses. Table 4-9: MANOVA of the nutrient relationships with blood cholesterol by ethnic group GR & GA COMBINED NUTRIENTS (n = 47) INTERCEPT 61.30 CALORIES 0.09 CHO, gms 0.26 PRO, gms 0.62 FAT, gms 0.15 SFA, gms 0.79 MFA, gms 1.32 PUFA, gms 0.76 K/1000 kcal 0.01 NA/1000 kcal 0.09 chol, mg 0.79 CA:Phos 63.42 *=significant CHO= carbohydrate PRO= protein PARAMETER ESTIMATE NG (n = 53) -65.75 0.16 1.13 0.01 5.29 4.35 5.43 4.93 0.00 o.oo 2.46 2.62 SFA = saturated fatty acids MFA= monounsaturated fatty acids PUFA = polyunsaturated fatty acids K = potassuim NA sodium chol = cholesterol CA:Phos calcium to phosphorus ratio kcal calories P-VALUE GR & GA COMBINED .519 .393 .658 .242 .712 .500 .274 .581 .703 .628 .276 .244 NG .541 .059 .045* .986 .010* .060 .018* .022* .732 .640 .008* .930 A multi-variate analysis of variance (MANOVA) indicated that grams of carbohydrate, fat, polyunsaturated fat and dietary cholesterol had significant partial effects on blood

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108 cholesterol levels for the non-Greeks. Saturated fat had an effect on blood cholesterols of the non-Greeks but it was not highly significant in predicting cholesterol values. These nutrients were not significant predictors of the Greek cholesterol levels. Nutrient differences in the 24-hour recall between the ethnic groups can be explained by their dietary pattern preferences. Greeks and Greek-Americans continue to prefer the use of olive oil (a MFA) and "Greek style" cooking,either at a Greek restaurant or at home. The non-Greeks have reduced their total and saturated fat intakes by substituting low-fat milk for whole milk and eating less high-fat baked goods. Some of the non-Greeks have increased their use of olive oil intake and consume "Greek style" meals on occasion. Their preference for drinking milk (in amounts greater than the Greeks or Greek-Americans) and their consumption of pizza and salad dressings increase their calcium to phosphorus ratios and their sodium intakes. Comparisons with the Greek Diet The majority of studies concerning the Greek dietary pattern were descriptive and, therefore, were discussed in the food frequency section. Unpublished data from the Cross-cultural Study of Adolescent Males, aged 16-18 (Kurtz et al. 1982) were used to compare nutrient intakes of the male Greeks in Tarpon Springs with Greek and Greek-American

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cohorts in New York City. Table 4-10 describes these comparisons. The younger age group in the 1982 study accounts for the higher calorie intakes. Percents and nutrients per 1000 calories were used to facilitate more equal comparability between the other nutrients. Table 4-10: Male Greek and Greek-American nutrient comparisons with the cross-cultural study Greek study Cross-cultural Study males 25-74 years males 16-18 years Nutrient N Means N Means Calories Greek 5 2304 97 2459 Greek-Am 10 2138 183 2595* % of calories CHO GR 46.6 GR 50.1 GA 49.5 GA 48.3 Pro GR 18.4 GR 14.4 GA 13.8 GA 15.8 Fat GR 32.4 GR 35.9 GA 33.2 GA 37.3 SFA GR 10.8 GR 15.7* GA 9.0 GA 15.4* MFA GR 12.2 GR 13.6 GA 10.9 GA 13.9 per 1000 cal Sodium, mg GR 1396 GR 956* GA 1228 GA 891* Potassium, mg GR 1618 GR 3037* GA 1424 GA 3216* Chol, mg GR 118 GR 89 GA 124 GA 125 =significant at less than .05 Studentized t-tests of paired comparisons of means indicated that Greek adolescents in the New York City Cross-cultural Study did not consume significantly more 109

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110 calories than the Tarpon Springs Greek males. There was a significant difference in the calorie intakes between the two groups of Greek-Americans. Saturated fat intakes were significantly lower for the Tarpon Springs Greeks and Greek-Americans. Data for the New York City study were collected in 1980-1982. The differences in saturated fat intake may reflect the trend to decrease saturated fat that has been promoted during the time interval between data collections. Sodium intakes were significantly lower for the New York City adolescents and potassium intakes were higher. These differences may be real and reflect different food choices between the groups or may be attributable to the use of different data bases for the respective nutrient analyses. Comparisons with the American Diet Nutrient intakes of the non-Greek ethnic group were compared with available data from NHANES (Abraham et al. 1979; Block et al. 1988) and USDA Studies (CSFII 1985 and 1986). Table 4-11 (p. 111) compares these nutrients. As observed with the Greek and Greek-American comparisons, Tarpon Springs non-Greeks consumed a significantly lower percent of calories from saturated fat than the samples in NHANES and the USDA. The significantly lower calorie intakes of the Tarpon Springs non-Greeks was primarily due to the lower fat intakes. Cholesterol intakes

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111 Table 4-11: Non-Greek nutrient comparisons with nutrients from national studies Ages 25-74 years Nutrients Non-Greeks NHANES 5/N Means 5/N Means Ages 19-50 years USDA 5/N Means Calories M F 29 37 1776 1390 3718 5593 2318* 1134 1500 1136 2560* 1473 Pro, gms M F % of calories CHO M F Pro M F Fat M F SFA M F MFA M F PUFA M F per 1000 calories Na,mg M F K,mg M F Chol,mg M F Dietary Fiber, gms M F 80.3 61.0 46.2 50.0 18.0 17.9 32.5 30.2 11.9 9.9 11.1 10.4 5.4 5.8 1650 1565 1721 1885 116 128 10.8 10.8 M F 92.1 61.9 Not Available M 16.0 F 16.5 M 37.5 F 36.9 M 13.6* F 12.8* Not Available =significant at less than .OS Na=Sodium K=Potassium Chol=mgs cholesterol M F M F M F M F M F M F M F M F M F M F M F S=Sex NNumber M=Male F=Female 102* 61.5 45.3 45.9* 15.9 16.7 36.4* 36.7* 13.2* 13.4* 13.8* 13.5* 6.8* 7.2* 1470 1586 1351 1436 168 189 17.4* 10.8 were also lower for the Tarpon Springs sample. These observations may confirm the health-conscious bias of the study sample.

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112 Monounsaturated and polyunsaturated fats were significantly lower for the sample in Tarpon Springs than for the USDA sample. The significantly higher potassium intakes of the Tarpon Springs non-Greeks may be attributable to greater intakes of fresh fruits and vegetables. The similarity of the dietary fiber intakes of the females and significantly lower intakes of the males suggests that this explanation may not be adequate. Whether the reported nutrient differences between the non-Greek ethnic group and the national studies is associated with a health-conscious bias of the study group or indicative of secular trends since 1986 cannot be determined by this study. The Surgeon General's Report (1988) spawned publicity for the associations between diet and several diseases. The National Cholesterol Education Program (NHLBI AND HHS 1988) raised the consciousness of the public to large scale reduction of cholesterol values by reducing intakes of fat, especially saturated fats and dietary cholsterol. Food companies used the media and advertising promotions to tout cholesterol-lowering products. NHANES is currently collecting dietary data for an up-dated national study (personal communication 1988). When data from this study are available, these nutrient differences can be further compared for the effect of time on the reduced fat, saturated fat and cholesterol intakes of the non-Greeks in Tarpon Springs.

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Medical History 113 Risk Factors for CHO Part I of the questionnaire elicited information concerning the participant's history of chronic diseases. Table 4-12 (p. 114) describes the proportion of persons in each ethnic group who were taking medications and, if so, what kind. The second part of the table describes whether they, their parents, or their children had ever been told that they had a disease and, if so, which chronic disease. A higher proportion of the non-Greeks reported having a parent with a diagnosis of heart disease. This trend, however, did not attain significance. Exercise Practices Study participants were asked about the kinds of activity that they experienced at their work or while going about the day. Another question asked about their exercise program--whether they seldom exercised vigorously or had a regular scheduled exercise program. Table 4-13 ( p. 114) summarizes their responses. Greeks reported more activity while going about their work and day and seldom participated in a regular exercise program. Approximately one-third of the Greek-Americans and non-Greeks had sitting jobs or sat most of the day. A higher proportion of the non-Greeks (23.9%), compared to the Greek-Americans (10.0%) followed a regular exercise program at least 3 times a week.

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114 Table 4-12: Frequency of medication use and chronic diseases by ethnic group % Take Medications % Have Chronic Disease yes HBP Card Diab person CA Diab Heart BP Stroke GR 44.4 27.8 27.8 11.1 self 5.6 22.2 33.3 33.0 o.o parent 22.2 16.7 22.2 5.6 o.o child o.o 5.6 o.o 5.6 o.o GA 32.5 10.0 7.5 o.o self 7.3 2.4 12.2 19.5 o.o parent 38.5 17.9 23.1 59.0 10.3 child 0.0 5.1 5.1 7.7 o.o NG 47.1 26.5 2.9 7.4 self 7.4 a.a 4.4 35.3 5.8 parent 25.0 a.a 39.7 38.2 11.8 child 2.9 0.0 1.5 2.9 0.0 HBP=High blood pressure medication GR=Greek GA=Greek-American NG=non-Greek N=22GR; 44GA; 70NG Card=Cardiac medication Diab=Diabetes medication CA=Cancer;Diab=Diabetes; Heart=Heart Disease; BP=High Blood Pressure Note: Medications not listed in the table included: aspirin and other analgesics, oral contraceptives and allergy medications. Table 4-13: Frequencies of activity and exercise practices by ethnic group Greek Greek-American Non-Greek % % % N= 22 44 70 Activity (Work or Daily) Sit 16.7 30.0 32.4 Stand 38.9 25.0 10.3 Walk 22.2 25.0 33.8 Labor o.o 2.5 2.9 Exercise Program Seldom 55.6 30.0 28.4 Less than 1/wk o.o 35.0 17.9 3 times/wk 11.1 10.0 23.9 5 or more/wk 5.6 12.5 13.4

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115 Smoking All persons who reported that they smoked indicated that they smoked cigarettes rather than a cigar or pipe. Table 4-14 summarizes their smoking patterns by ethnic group. Table 4-14: Frequencies of smoking practices by ethnic group Greek Greek-American Non-Greek % % % N= 22 44 70 Smoke Cigarettes 5.6 9.8 30.9 Daily Amounts Less than 1/2 pk 0.0 o.o 4.4 1/2-1 pack o.o 2.4 11.8 1-2 packs 5.6 4.9 11.8 2 or more packs o.o 2.4 2.9 A greater proportion of non-Greeks smoked compared to the Greeks or Greek-Americans. Of the non-Greeks who smoked, half of them smoked more cigarettes per day than the proportion of Greeks or Greek-Americans who smoked. A large proportion of persons in all three ethnic groups did not smoke. There was a trend toward higher diastolic blood pressure with increased packs of cigarettes smoked. Mean diastolic pressure was 76.6 mm for persons who smoked less than one-half pack per day and 88.7 mm for persons who smoked 2 or more packs of cigarettes per day. Body Mass Index Body mass index (BMI) was computed and defined according to criteria used in NHANES (1987). Table 4-15

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compares the BMI classifications for the three ethnic groups. 116 Table 4-15: Body mass index classifications by ethnic group and gender Ethnic Group/Gender I I I N Mean Range Normal overweight Obese GR 22 30.71 22.65-45.80 Male (N=5) 35.0 45.0 20.0 Female (N=l7) 40.0 35.6 24.4 GA 44 28.05 18.25-39.35 Male (N=l2) 33.3 16.7 50.0 Female (N=32) 51.4 27.0 21.6 NG 70 26.91 18.22-44.27 Male (N=30) 58.1 20.9 20.9 Female (N=40) 70.5 18.0 11.5 Non-Greeks had the highest proportion of persons in the normal BMI classification. More Greek-American women were in the normal classification while more of the men were in the obese category. Greeks had a slightly higher proportion of males in the overweight classification and females in the normal category. Tukeys Studentized Range Test indicated that the BMI was significantly higher (less than .05) for Greeks than for non-Greeks (GLM p=.0138). An analysis of variance showed a significant effect of age (p=.0003) on BMI. Ethnic group and age had an interactive effect on BMI (p=.0032). Mean BMI for the Greek-Americans was not significantly different from either the Greek or non-Greek BMI means, suggesting that the interactions of age and ethnic group are more

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117 predictive of Greek and non-Greek BMis. The ethnic religion score had a significant effect (p=.008) on BMI. As the religion score decreases (showing greater identity with the Greek religion), the likelihood of finding a higher BMI increases. As expected, Pearson's correlation coefficients revealed a significant positive correlation between calories and BMI (r=.229, p=.01). The higher the reported calorie intakes, the higher the BMI. Blood Pressure Blood pressure values are described in Table 4-16 by ethnic group, gender and age group. Table 4-16: Systolic and diastolic blood pressure values by ethnic group, gender and age group Ethnic Group N Systolic Range Diastolic Range Mean mm Mean mm Greek 22 132.4 101-169 79.0 49-106 Greek-American 44 125.0 90-151 77.1 60-99 Non-Greek 70 131.8 95-176 80.5 58-104 25-49 years 50-74 years N Systolic Diastolic N Systolic Diastolic mm mm mm mm Male GR 1 101.0 56.0 4 146.5 91.5 GA 8 134 .' 5 82.4 4 134.3 80.3 NG 14 125.3 80.0 16 139.3 83.9 Female GR 8 119.1 78.5 9 141.3 76.3 GA 23 118.2 74.4 9 129.7 77.8 NG 23 139.3 83.9 17 144.8 80.2 GR=Greek GA=Greek-American NG=Non-Greek

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118 A MANOVA indicated that age group had the highest significant effect on systolic blood pressure (p=.0001) andon diastolic pressure (p=.0175). When controlling for age,ethnic group was also significant (p=.0399). When controlling for age, gender was significant at the .0388 level. Controlling for age group and gender showed the diastolic pressures to be significantly different between ethnic groups (p=.0239). Socioeconomic status had no significant effect on systolic (p=.5749) or diastolic (p=.4440) blood pressures. Pearson's correlation coefficients showed that the dietary calcium to phosphorus ratio had an inverse relationship on the systolic (r=-.345, p=.005) and diastolic (r=-.400, p=.001) readings of only the non-Greek group. The higher the calcium to phosphorus ratio, the lower the systolic and diastolic pressures of the non-Greek group in Tarpon Springs. Neither sodium nor potassium intakes, for any of the three ethnic groups, had a significant effect on the systolic or diastolic blood pressures. Low calcium to phosphorus ratios for the non-Greeks agree in part with the NHANES findings reported by Mccarron et al. (1984). Higher intakes of calcium, potassium and sodium for the NHANES sample were associated with lower mean systolic blood pressure and lower absolute risk of hypertension.

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Cholesterol Table 4-17 describes the differences in blood cholesterol values by ethnic group, gender and age group. 119 Table 4-17: Blood cholesterol by ethnic group, gender and age group Blood Cholesterol Means mg/dl N 25-49 years N 50-74 years Greek Male 1 208.0 4 189.5 Female 8 213.5 9 251.9 Greek-American Male 8 184.6 4 219.3 Female 23 190.7 9 225.6 Non-Greek Male 14 195.4 16 205.4 Female 23 223.4 17 254.3 Tukey's Studentized Range Test indicated that the difference in cholesterol means between the non-Greeks and Greek-Americans was significant with a confidence level of .95 or greater. While the mean cholesterol value for the Greek ethnic group was lower than the non-Greek value, it did not attain significance. Because cholesterol was the measure used to describe the risk factor status associated with dietary change, it was the dependent variable against which the independent variables were tested. Age, before grouping into two groups, had a significant effect (p=.0046) on cholesterol values. After grouping the ages into a younger and older group to facilitate larger cell sizes for multiple

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120 regression analyses, the difference was less clearly significant (p=.0918). Gender had a significant effect (p=.04) on cholesterol values. Women had higher cholesterol values than men in each of the age and ethnic group categories. This was an unexpected finding, especially in the younger age groups. Analyzing the HDL and LDL cholesterol fractions could identify whether the higher cholesterol values might be attributable to higher HDL levels. Socioeconomic status did not have a significant effect (p=.53) on cholesterol. Pearson's correlation coefficients showed an inverse association (r=-.593, p=.0096) with religion and cholesterol for the Greek ethnic group only. The greater the identity with the Greek religion (a lower religion score), the higher the cholesterol value. Age had an inverse relationship (r=-.609, p=.0073) with religion. The higher the age, the lower the religion score (greater identity with religion. Controlling for age in the Greek ethnic group, negated the effect of religion on blood cholesterol values. The culture score had a significant association with cholesterol (r=-.506, p=.032) for the Greek ethnic group. As the culture score decreased (more ethnic group cohesion), the cholesterol level increased. Age, as with religion, had a significant effect on the culture score (r--.478, p=.04). This relationship was not significant for the Greek-Americans or non-Greeks.

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121 When the Greek and Greek-American ethnic groups were combined, in order to have more comparable and larger numbers for the Greek and non-Greek comparisons, fasting had a significant association with cholesterol (r--.417, p=.06). The Greeks and Greek-Americans who practiced fasting frequently had higher cholesterol levels. Age also influenced this relationship. This effect was not observed with the non-Greeks (r=.08, p=.66). The factor analysis, described in the Eating Preference Section (page 79), had a loading on three factors with low explanatory power. These factors (Factor 1: Ethnicity Factor, Factor 2: Medical Factor and Factor 3: Commercial Factor) were analyzed with cholesterol as a dependent variable in a multiple regression. The Medical Factor, which had loadings on age, systolic blood pressure, medication for high blood pressure and a diagnosis of high blood pressure and cancer, had a significant effect (p=.015) on cholesterol. Together, these variables were good predictors of an elevated cholesterol. To test whether Greek food preferences or technological influences had a health effect, e.g., increased blood cholesterol, the averaged mean scores for each of the variables that defined Greek food preferences, non-Greek food preferences, convenience influences and commercial influences respectively were tested in a multivariate

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analysis by ethnic group. Table 4-18 describes these relationships. 122 Table 4-18: Infrastructural and structural food preferences on blood cholesterol levels Parameter Estimate p-value Variable GR GA GR GA N= 11 37 Intercept 79.09 320.32 0.68 0.00 GR Preference 7.14 1.05 0.21 0.50 NG Preference -12.79 2.97 0.37 0.36 Convenience 0.32 5.61 0.97 0.01* Commercial 8.66 -17.75 0.36 0.00* GR/GA NG GR/GA NG N= 49 53 Intercept 250.57 160.22 o.oo 0.00 GR Preference 0.58 1.29 0.71 0.39 NG Preference 1.62 0.74 0.62 0.85 Convenience 3.78 2.76 0.08 0.21 Commercial 9.15 2.53 0.02* 0.40 *=significant GR=Greek GA=Greek-American NG=Non-Greek Commercial influences had a significant effect on blood cholesterol levels of the Greek-Americans. The greater the influence of TV advertisement, coupons and magazine recipes on food purchases, the higher the blood cholesterols. convenience had a weak significant (p=.0083) partial effect on food patterns among the Greek-Americans. This relationship was only significant when controlling for the other variables in the MANOVA. The trend suggests that persons in the Greek-American ethnic group who are more

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123 highly influenced by convenience, e.g., eat more frequently at fast food restaurants, use convenience foods for preparing foods at home and use a microwave oven for food preparation may have lower cholesterol values. These effects were not significant for either the Greek or non-Greek ethnic groups. When the Greek and Greek-American groups were combined to increase the number of persons per cell in further multiple variate analyses, the commercial influence (p=.0239) was still apparent. The partial effect of the convenience influence weakened (p=.0811), possibly because age ranges were more comparable between the two ethnic groups. Neither a preference for Greek nor non-Greek food patterns influenced the blood cholesterol values of the three ethnic groups. To further test which variables were the best predictors of cholesterol levels, a maximum R-square stepwise regression was performed with all the study variables and two ethnic groups (Greeks and Greek-Americans were combined into one Greek group). Table 4-19 (p. 124) describes these models. The best predictive model for the Greek group cholesterol values included the age and commercial variables. Age had a positive effect. The higher the age, the greater the cholesterol value. The commercial variable (purchasing foods and beverages advertised on TV, use of coupons for grocery purchases and use of recipes seen in

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124 Table 4-19: Maximum R-square improvement for the dependent blood cholesterol value Greeks and Greek-Americans Combined N=45 Variables B-value p-value R-square Intercept Age Commercial CA:Phos Intercept Activity Diagnosis Age Heart 1 1 162.32 14.79 5.58 49.39 Non-Greeks N=52 272.77 -19.47 -59.20 10.26 16.93 .0002 .0419 .1334 .0005 .0004 .0172 .0813 Diagnosis l=Self-report of Chronic Disease Diagnosis Heart l=Self-report of Heart Disease Diagnosis CA:Phos=Calcium to Phosphorus Ratio 29 35 39 10 21 31 35 popular magazines) influenced cholesterol in a higher direction. The greater the commercial influence, the higher the blood cholesterol values. While not having a significant effect, the variable with the next greatest influence was the calcium to phosphorus ratio. This variable explained 10% of the blood cholesterol variance among the Greek ethnic group. The higher the calcium to phosphorus ratio, the higher the cholesterol values. The best predictive model for the non-Greeks included the age and activity variables. The greater the age, the higher the cholesterol values. The more active a person is

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125 in their daily activities and work, e.g., walks rather than sits, the lower the cholesterol level. The absence of a chronic disease had an inverse relationship with cholesterol. No chronic disease diagnosis is associated with lower cholesterol values in the non-Greek ethnic group. A diagnosis of heart disease had a slightly significant effect that explained an additional 41 of the variance in cholesterol levels of the non-Greek group. From a biological perspective, increasing age was a predictor of increasing blood cholesterols for both the Greek and non-Greek groups. Technological influences, especially commercial influences rather than a preference for Greek food patterns, had the greatest influence in increasing blood cholesterol levels among the Greek group. The effect of daily activities which were more physically demanding and the absence of a chronic disease diagnosis had the greatest effect on decreasing blood cholesterol values among non-Greeks. While not previously considered a risk factor for CHO, daily activities that are more physically demanding (jobs that require manual labor)may have a similar cardiovascular effect as regular exercise in reducing cholesterol levels. FUrther studies would be needed to see whether this cholesterol-reducing effect is associated with reduced levels of HDL, in contrast to the effect of regular scheduled exercise which increases HDL cholesterol (Lamon-Fava, et a 1989). The relationship of persons with

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126 no known diagnosis of a chronic disease and lower cholesterol levels suggests that attempts to reduce cholesterol values may be effective in reducing a high cholesterol value but not to the level achievable before the onset of the disease.

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CHAPTER 5 DISCUSSION In order to analyze the changes in dietary behaviors of Greeks and Greek-Americans in Tarpon Springs, it is necessary to describe the historical changes that altered the role of the ethnic group within the community. The original Greek settlement was unique, compared to Greek settlements elsewhere in the United States, because Greeks did not just represent an enclave within a larger community. They were the majority population and dominant ethnic identity in the community from the early 1900s until the end of World War II (Bernard 1987 and Moskos 1989). The precipitous decline of the sponge industry caused the economic advantage of the Greek influence to change. They gradually became part of the tourist economy, which is the dominant influence today. Ethnic symbols, remnants of a prosperous way of life for Greeks in Tarpon Springs, are now displayed like trophies for curious non-Greeks and tourists to view. Greek immigration patterns to the United states have also changed the characteristics of the Greek ethnic group in Tarpon Springs. While a core of original settlers are still prominent within the Greek community, newer arrivals from Greece, generations of Greek-Americans and Greek 127

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128 retirees from the northern states have increased the diversity within the Greek community. While obviously aware of their differences, they share pride in the time-enduring ethnic markers, e.g., the church, Greek family restaurants and other businesses, such as the curio shops and sponge diving, that are visible reminders of the common ethnic heritage that they share. The Greek ethnic group in the study contains representative persons from each of the subgroups of Greeks who live in the Tarpon Springs area. Three-fourths of the Greek group are from the island of Kalymnos, home of the founders of this Greek community. Adaptive Pressures on Food Use The climate in Tarpon Springs is similar to coastal areas of Greece. Fresh fish, fruits and vegetables are foods that are available throughout the year in Greece and in Tarpon Springs. In highland areas of Greece, vendors sell fresh produce in weekly street markets. In addition to the continuity of ethnic practices that were part of the original Greek settlement in Tarpon Springs, a great variety of familiar foods were available for consumption compared to other areas in the northern United States where some Greeks settled. Diet changes, therefore, were not an adaptive necessity for Tarpon Springs Greeks in the early to mid-1900s. Pressures to change the diet may be felt more

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129 acutely since their numbers have diminished in proportion to the increasing population of non-Greeks in the community. Informal conversations with Greek physicians and health care employees during the period of participant observation suggested that Greeks in Tarpon Springs, compared to Greeks in Greece, are overweight and more prone to diseases associated with overindulgence, e.g., diabetes and hypertension. These implications suggest that the Tarpon Springs Greeks consumed the same or additional amounts of calories and participated in less activity and exercise than Greeks in Greece. Callers to the radio talk show, when I was a guest, confirmed these observations. Increased food consumption, in this situation, was an expression of the economic advantage that the Greek immigrants realized in their new setting. Ethnic Change An overriding motivation for Greek migration to the United States, in the early 1900s, was for economic gain. The prevailing intention was to return to Greece with sufficient capital to enjoy a comfortable life (Moskos 1989). Because the Greek Orthodox Church embodied Greek historical, cultural, social and religious experiences for Greeks in Greece, the Greek settlers established Saint Nicholas Greek Orthodox Church in Tarpon Springs to foster the link with their ethnicity and homeland. Acculturation pressures, therefore, exerted little influence on Tarpon

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130 Springs Greeks, as compared with Greek immigrants in other United States settlements, because they did not look to the larger society for social acceptance. Among the Greeks who participated in the study, attitudes toward Greek cultural, religious and national identity still are strong, as evidenced by their low scores on the Ethnic culture Questionnaire subscores. Compared to ethnic group attitudes studied by Roche (1984), Greeks in Tarpon Springs have maintained stronger ethnic identities than Italian immigrants in Rhode Island. While mean scores for each subscale were higher for Greek-Americans than for Greeks, the range of scores indicate that some Greek-Americans have stronger ethnic attitudes than some Greeks (ranges of scores on the subscales consistently overlapped). The national subscale had the least overlap and higher mean subscale score for the Greek-Americans, suggesting that the Greek traditions, language, music, history and religion are more important to them than the sense of peoplehood shared by living in a Greek neighborhood, not changing one's name, feeling a duty to help a fellow ethnic or vote for a candidate of the same ethnic background. This finding confirms Moskos observation (1989) that acculturation appears to lag behind assimilation in Greek communities. There was no linear pattern of a diminishing ethnic identity as generations became more removed from Greece.

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131 The differences in how individuals viewed the role of family, place within the family hierarchy and role in transmitting the Greek culture to children were evident in how they answered questions on the questionnaire. For example, one Greek female, who chose the Greek translation of the questionnaire and answered the questions in Greek, responded to the question inquiring about whether any members of her household are non-Greek by stating that a son-in-law and daughter-in-law are American. Most of the study participants interpreted the term "household" to mean "living under the same roof." The concept of family or household, in Greece includes the extended family. Her response to the question revealed the Greek concept of household that she still holds. By contrast, a Greek-American male not only indicated that his wife was American but stated that his children are also American. A Greek-American male, who is married to a non-Greek wife, reported that he strongly agrees that children should be taught the Greek language and learn Greek dances and music. However, a Greek-American female, who was married to a non-Greek husband, showed less preference for instilling Greek traditions and practices in her children but expressed strong agreement with personal attitudes about Greek cultural practices. While the latter pair of examples may merely reflect individual preferences, they do illustrate the role Greek husbands feel in asserting moral authority

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132 within the household and the wife's attitude of acceptance of the husband's role. The higher mean score for the Greek-Americans on the ethnic subscales, compared to the means for Greeks, imply that Greek-Americans have been incorporated into a larger social circle than the Greeks. The social ties for Greek-Americans include more ties with non-Greeks, but this wider network does not exclude ties with Greeks, especially for the sharing of cultural and religious practices. Eating Preferences and Dietary Changes A core of Greek persons in the Greek ethnic group showed a strong preference for Greek foods and dietary patterns. The Greek persons did not yield to the purchase of products promoting convenience and time-saving features but rather adapted to conveniences within the Greek lifestyle, e.g., eating frequently at Greek restaurants, as a way of adapting to the emphasis on time and convenience in the American culture. As with their attitudes toward ethnic ties, Greek-Americans incorporated a wider range of food preferences into their food choices. They participated in Greek food use patterns but also assimilated some of the American food practices into their dietary behaviors. Acculturation, as observed by Moskos (1989) and Costantakos (1987), did not involve a shedding of Greek dietary practices, but rather included a larger entree of possible

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133 food choices, e.g., the custom of preparing special foods to celebrate holiday occasions. This practice continued for Greek-Americans and included Greek and American holiday celebrations. The objects of convenience and time-saving, e.g., foods from fast food restaurants, convenience foods for home preparation and a microwave oven were incorporated into the food use patterns of the Greek-Americans but not to the extent to which the non-Greeks used them. The technological influence that was most influential in increasing bloos cholesterol levels for the Greeks, especially the Greek-Americans, was the commercial influence. Media that entered the home, i.e., TV commercials, newspaper coupons and recipes from popular magazines, had the greatest impact on those dietary changes which increased blood cholesterol values. Overall, however, cholesterol levels for Greek-Americans were significantly lower than for non-Greeks. For the non-Greeks, age and a sendentary lifestyle were associated with an increased cholesterol level. The absence of a chronic disease diagnosis was predictive of lower cholesterol values. The 24-hour recall indicated that the non-Greek group had reduced their total fat and dietary levels in keeping with the Surgeon General's recommendations (1988). Commercial influences among the non-Greeks were not significant in decreasing their blood cholesterol levels.

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134 Informal conversations with persons who attended the cholesterol screening where study participants were recruited suggested that the non-Greeks had social networks for transmitting and comparing information about reducing risk of chronic diseases. Further studies are needed to investigate the social networks among the non-Greeks to determine whether this is the vehicle used for transmitting health promotion information. Dietary Changes and CHO Risk Factor Status Like their counterparts in coastal areas of Greece, the Greeks in Tarpon Springs who participated in the study continued to prefer fish to meat, fresh vegetable salads and fruits, Greek pastries, Greek coffee and olive oil, especially for salad dressing. Overall quantities of food consumed, as evidenced by the mean calorie intake for the Greek ethnic group, were high. As observed by the Greek physicians and health care workers in Tarpon Springs, the Greeks tended to be overweight and one-third of them reported having a chronic disease diagnosis. Like the Greeks in Greece, monounsaturated fats (total gram intake and percent of calories) continue to be high among the Greek study population in Tarpon Springs. There was a significant difference in the amounts of monounsaturated fats in the Greek and Greek-American diets, compared with the monounsaturated fat intakes of non-Greeks.

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135 Total fat intake, however, for the non-Greeks, was lower than for the Greeks or Greek-Americans. Monounsaturated fats did not have a significant effect on the cholesterol levels for the Greek or Greek-Americans. Variations in blood cholesterol for the non-Greeks could be partially explained by the monounsaturated and polyunsaturated fats, total fat, carbohydrates and dietary cholesterol. These findings suggest that nutrients exert varying degrees of influence on cholesterol values of differing populations. McMurray et al. (1985) observed metabolic differences in how the Tarahumara Indians of Mexico absorbed dietary cholesterol when given a challenge diet containing high cholesterol foods. They were observed to have a higher total sterol turnover primarily because of an increased bile acid output compared to when they ingested a cholesterol free diet. Cholesterol absorption has been reported to be higher for US Americans and Australians than for popula tions, such as the Tarahumara Indians, who traditionally consume low cholesterol diets. The Greek diet, consisting of high intakes of monounsaturated fats, n-3 fatty acids and dietary fiber with low saturated fats and cholesterol, may metabolically adapt Greeks to decreased CHO risk. If the diet is not greatly altered to incorporate high intakes of saturated fats and cholesterol for long periods of time, cholesterol absorption may remain low for Greek immigrants and Greek-Americans. By

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136 contrast, non-Greeks in the United States have been consuming high intakes of saturated fats and cholesterol for numbers of years, as noted in the Surgeon General's Report (DHHS 1988), by Keys (1980) and by Neville (1990). These metabolic differences in cholesterol absorption and turnover rates may explain the significant differences in cholesterol levels between the Greeks and non-Greeks in Tarpon Springs, rather than the presence of varying amounts of these nutrients in their reported diets. While this study suggests that 30-35% of calories from fat may be acceptable for keeping cholesterol within desirable ranges, if the predominant fat is monounsaturated, it cannot be conclusively stated because of the study limitations. The sample is non-random. If the non-Greeks are a health-conscious group, as the low percent of fat (31%) in their diets suggest, then their cholesterol values may be lower than cholesterol values of non-Greeks in general. The significant difference between their cholesterols and the NHANES sample confirms this assumption. Time could be another explanatory factor. This study is cross-sectional and used national survey data to 1986 as a proxy for time. If the non-Greeks reduced their saturated fat and dietary cholesterol intakes within the past three years compared to a lifetime high intake of monounsaturated fat intakes for the Greeks, then time may be a significant factor in relation to how soon this dietary change is

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137 exhibited in lowered cholesterol values. Greek-Americans had more persons in the younger age group (22.79% Greek-Americans were 25-49 years of age and 9.56% were 50-74 years; 27.21% non-Greeks were 25-49 years of age and 24.26% were 50-74 years of age). This sample bias may account for some of the differences between the Greek-American and non-Greek mean cholesterols (increasing age was significantly associated with cholesterol levels for the three ethnic groups). Further studies are needed to differentiate between ethnic groups of comparable age, who consume varying amounts of total fat, saturated fat, monounsaturated fat and dietary cholesterol for a specified time period before the role of these lipids and the metabolic adaptation of a population in the cholesterol-lowering equation can be fully elucidated. BMI and Blood Pressure Higher age among the Greek group compared to the Greek-Americans was associated with increased weight (BMI) and both increased systolic and diastolic blood pressures. Low intakes of calcium may explain the increase in systolic pressures among the Greeks. Cholesterol levels for the Greeks were slightly lower (but not significantly different) than the non-Greek mean cholesterol levels suggesting that an increased BMI and elevated blood press~res were greater predictors of CHO risk for the Greeks than the dietary fats or cholesterol. For the non-Greeks in this study, diet

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138 influenced blood pressure. A low calcium to phosphorus ratio was observed to have an increasing effect on both the systolic and diastolic pressures. Other Risk Factors Other factors that may affect risk factor status include: smoking, activity/exercise and medical history. An increased BMI is not an explanatory variable for the increased blood pressures and cholesterol values for the non-Greeks because persons in the non-Greek group had the highest proportion of persons in the normal BMI category. Smoking A higher proportion of non-Greeks (30.9%) smoke cigarettes. Half of the persons who smoked, smoked more than one pack of cigarettes a day. An increase in the number of cigarette packs smoked was associated with higher diastolic blood pressures. Activity/Exercise A sedentary job and daily activities that required little physical exertion were strong predictors of increased cholesterol values for the non-Greek group. The higher proportion of non-Greeks who participate in regular exercise three or more times a week (24% non-Greek; 10% Greek American; 11% Greek) may explain their lower body weights (BMI).

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139 Medical History Compared with the Greeks and Greek-Americans, a higher proportion of non-Greeks had parents who had a diagnosis of CHO. The absence of a chronic disease among the non-Greek sample was predictive of lower cholesterol values. A diagnosis of heart disease explained a portion of the increased cholesterol levels. While dietary reductions of fat, saturated fat and cholesterol may decrease elevated cholesterol levels, low intakes of these nutrients before the onset of disease may have a greater influence on low cholesterol values and prevention of CHO among non-Greeks. Mortality from CHO in Tarpon Springs The mortality rate from CHO in Tarpon Springs in 1987 was 240:100,000 (HRS 1987). This mortality rate is not age-adjusted so that the high proportion of persons aged 65 years and older (28%, UF Bulletin No. 89-90, 1989) accounts for the higher rate, relative to areas with a lower mean population age. This rate does suggest, however, that the mortality rate for CHO in Tarpon Springs more nearly resembles the age-adjusted United States mortality rate for CHO (229:100,000) than the age-adjusted CHO mortality rate in Greece (85:100,000: WHO 1986). How many of the persons in the Tarpon Springs CHO mortality statistics were Greek versus non-Greek could not be determined. The higher cholesterol levels for the non-Greeks in Tarpon Springs compared to cholesterols for the Greeks and the higher

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140 proportion of the population who are non-Greek would suggest that persons represented in the mortality statistics may be non-Greek. Implications for Nutrition Intervention Programs The study findings support the hypothesis that technological influences, rather than infrastructural influences, are better predictors of dietary changes among an ethnic population in a highly technical society. The adaptive diet behavior that appeared to be most influential in predicting risk of CHD, as observed by increased cholesterol levels, was the commercial influence among the Greeks, especially the Greek-Americans. Thus, structural processes within the American society had a stronger effect on food behaviors than the ethnic group's infrastructural processes, i.e., cultural practices and religious practices. While the structural and infrastructural influences were not mutually exclusive in their effects on cholesterol values, and risk factor status for CHO, they do offer insights for the design of a nutrition intervention program among Greeks in Tarpon Springs. The stronger commercial influence, that was associated with elevated blood cholesterols among the Greeks, should be an area targeted for intervention. The commercial influence among non-Greeks, however, was not associated with increased blood cholesterol levels. This observation addresses the need to design intervention

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141 programs that are specific to the food behaviors of each target group. These findings concur with Pelto's observations (1981) that approaches from anthropology can be extremely useful to nutrition educators interested in designing effective intervention programs. By determining the structural and infrastructural influences on dietary change, as interpreted by a cultural ecological analysis, marketing strategies for nutrition programs can be identified. This approach could also be useful for government agencies concerned with the development of dietary guidelines and dietary changes that promote health and prevent disease. Changes in dietary behaviors that are appropriate for specific ethnic population groups could be incorporated into the recommended guidelines.

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CHAPTER 6 CONCLUSIONS This study was designed to describe systematic changes in dietary behaviors, observed in a natural experiment, i.e., Greek immigrants and Greek-Americans living in Tarpon Springs, Florida. Greek immigrants and successive generations in the United States were chosen because the population in Greece has a low risk of CHO. By contrast, the United States population has a high mortality rate for CHO. Greek immigrants to the United States have been observed to be adopting American dietary practices in preference to the traditional diet, thus increasing their CHO risk status (Christakis 1981). The analysis of dietary changes used a cultural ecological approach to examine the ethnic food patterns (infrastructural influences) and technological (structural) influences that were operative in dietary changes and subsequent CHO risk factor status of Greek immigrants, as measured by increasing blood cholesterol levels. A questionnaire was designed to collect information from Greek, Greek-American and non-Greek ethnic groups about attitudes toward ethnicity, religion and a sense of peoplehood (culture, religion and national subscores). 142

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143 Questions dealing with preferences for Greek or American dietary practices were operationalized to measure food preferences that reflected ethnic and technological influences on their food use patterns. Food and nutrient intakes were measured in a food frequency check-list and 24-hour recall and compared to the respective Greek and American diets that are described in the literature. Risk factors for CHO, other than diet, e.g., medical history, smoking, activity/exercise, BMI, blood pressure and blood cholesterol were considered in the description of changes in CHO risk factor status. Blood cholesterol was the dependent variable because it is the measurable risk factor for which diet is an explanatory variable. The results showed a significant difference in the cholesterol levels of Greek-Americans compared with non-Greeks. Greek-Americans who participated in the study did not show an abandonment of Greek food practices but rather had incorporated a larger selection of food choices into their dietary preferences. Structural factors, e.g., commercial advertisements on TV, newspaper coupons and recipes in popular magazines, showed a strong influence in the direction of increased blood cholesterol values for the Greeks. As hypothesized, a cultural ecological analysis could differentiate adaptive influences that increased the CHO risk status of Greek immigrants in Tarpon Springs. Structural influences were influencial in Americanizing the

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144 diet and increasing the cholesterol levels of some Greeks. Increasing age was a risk factor for the Greeks, Greek-Americans and non-Greeks. Other factors that influenced lower blood cholesterol levels for non-Greeks were an active daily lifestyle that included physical exertion and the absence of a chronic disease diagnosis. These findings would benefit nutrition educators interested in the design of intervention programs for ethnic populations. Further studies are needed to test whether a cultural ecological approach will identify dietary changes among other ethnic groups who have increased their CHO risk or risk of other chronic diseases. Future studies are needed to also test whether a program design based on addressing structural influences on dietary change would increase compliance among such groups of people who are increasing their blood cholesterol levels and concommitant risk of CHO.

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APPENDIX A NEWSPAPER ADVERTISEMENT OF STUDY

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Leader Appencltx A GREEK NEWS Page 5 OFF THE FRONT PORCH Page4 I DISAGREE Page 4 I Saturday, October 8, 1988 Tarpon Springs, Florida / Vol. 84, No. _______________ ...:__ _______ _:_ __ Greek Americans that could relate sought for research new diets, heart disease Greek-Americans living in the Tarpon Springs and Palm Harbor areas have a chance beginning this week 10 join a resear ch project aimed at finding out whether their American diet puts them al greater risk or heart attack than the diets in Grccce. Palm Harbor Middle School 'Open House' is scheduled 'Open House' 10 give parents an acquaintance with their childrens dally class rout.inc is scheduled by Palm Harbor Middle School or Monday, October 10 The schoo l Is on SR 584 a t the Intersection of CR 39. It said the activities will be available, U1c school oddcd. It nslc's tl!at all par ents join it for the get acquainted opportunity. The study will be conducted by Greeks and Greek-Americans Cora Kurt7., a P h D candidate will (aged 25 64) were sclcclcd for the the Dep:u1mcn1 o f /\ntlu u polugy al study because the inc i dence of U,e University or Florida. coronary heart disease among U1is Ms Kurl7. will be al SL Nicholas age group in Greece is low Greek Orthodox Church the m o m compared with a comparable U S. ing of Sunday, Oct. 9. and w ith the p o pulat io n Hearl di s ease is the help or Chrysc Flow e rs will begin, numl>cr one cause or death among after serv i ces, 10 ob1:1in names of adult s in th e U S According to a people agreeable 10 join the study. study by Keys ( 1980), the dcall1 rate "Fo r !hose interested persons who for h e art disea~e among American will nOI l>c al the Sunday service", m.il e s i s six times highe r than Ms. Kur11. said, th ey may l eave among a s imilar group of Greek their names and a ph o ne num be r m ales. with Zula at the Church", perhaps Grctk s who emigrate to the U S .. today. however, have increased their ri s k The purpo se of U1c study, l\ls 1 0 rates simi lar to thos e for Kurt, said, i s 10 describe ch:u1gcs in /\111ericans Changes in dietary dietary behaviors which occur behaviors have been implicated as naturally among a gr oup of people one o f tl1 c f acto rs which contribute who have emigrated 10 a new 1 0 thi s in c rea se d risk of coronary country. I have chosen 10 compare heart disease. a study has shown. the observed dietary changes with A contro l group or non-Greeks ri s k for coronary heart disease in Tarp o n Sp rings (aged 25-64 becau s e there arc biol ogi cal maikers years) wi ll al s o be studied, Ms. which c:u1 be mea.sured 10 compare Kur 1 1. said Dietary behaviors anti wiU1 th e reported dietary pallerns. the biologi c a l markers of the non The s e markers arc ol>csi1y, elevat e d Greek wi ll l>c compared with data blood pre ss ure, and elevated scrum from the Greeks and Grcekcholesterol" she explained Americans in order 10 contrast differences and similarities in dietary behaviors among the study groups Ms Kurtz said the following people will benefi t fr om this study : lndi vitluals who participate in Ilic study will learn about their own ri sk fa c tors for coronary heart di sease by knowing their blood pressure reading and scrum choles1crol values Greeks and Gre e k Americans who live in Tarpon Springs will find out if they have changed their dietary behaviors in the direction of increased ri s k for coronary heart di sease Wh e n study findings arc compared with other studies of Greek immigrants in 1hc U S .. 1hc study will contribute 10 a more complete picture of heart disease risk or Greek and Greek-American communities in til e U.S Nu1ri1ionis1s and oll1cr health professionals will l ea rn about inOucn ccs in the Tarpon Springs community which were most likely t o be effective in naturally changing U1e dietary behaviors o r Greeks and S ee DIET, page 4 DIET----146 1rom page Greek-Ameri c ans TI1is knowledge will be helpful in U1 e designing of nutrition and health education programs which promote dietary c hanges that decrease risk fOl coronary heart disease and oll1cr chromic diseases, Ms Kurtz said.

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APPENDIX B NUTRITIONAL ANTHROPOLOGY QUESTI~NNAIRE This questionnaire is desir.ned so tl1at your answers will describe your lifestyle characteristics, cultural opinions, and food preferences Your responses to the questions will provide valuable information that can help to sort out patterns associated with either an increased or decr eased ri sk for heart disease. Please read each question carefully and mark the ans,.er thnt hest describes you, your opinions, and your preferences, Thank you for your participation in this study, PART I Directions: Please answer with an appropriate number or X in the space which best describes you Date I D. Number ______________ ----------------Stud y site Sex: 'I ale Female Ar,e ran ge 25-29 years 30-39 years 40-49 years 50-59 years 60-64 years Ethnicity Education: ( X onej llichest CoMpleted) Six years or less 7-1/J years --llir,h School r,raduate --/\A Der.ree --Sol'le collep.e hut no --der,ree B/\/RS Dep,ree -,1/\/ !S De o.ree --,,D/ PhO/[d3 Der,ree Greek (Corn in Greece). Please specify location of birth. Years livin~ in r.s. (if born in Greece) or Greek-American (Dorn in the U.S. of two Greek pnrents or __ years one Greek parent). Plca:-e specify ethnic orip,in of parent who is non-Greek, Household ;'/ur.iher of persons livin g in household. ---You are the.,, Husband Fri!Jend ---Wife ---Uncle Son nau~hter ---Sinr,le !lead of Household ---Grandfather ---Grandmother Aunt ---Other relative or in-law Number of nersons livin r. in household who are non-Gree k. ---Please spe~ify nationality and relationship to you. 147

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148 I,D. Number PART I Page Two Number of pe rsons in household who are students. Preschool Kinderp, artcn ---r:lemcn t ary s c hoo 1 --:li ctd le school ___ llir,h s choo 1 ___ Comm unity Colle ge or University ___ N umber of years you lived in Tarpon SprinBs, Please specify previous location, if you lived in Tarpon Sprinr,s less than five year s ___ ~umber of times you visited Greece in the last 5 years, if Greek or Greek-American. Employment Mumbcr of p e rsons in hou s ehold 1,ho are employed. Part-time Fulltime Hhere ,lo you work? '.l ult inatio nal corporation (such as: larr,e bank), federal p,overnment ---State r ovcrnment, hospital, public school, larr.e regional ----corporation, franchi se operation, larr,e law firm Local businei s establishnent employinr. more than 20 people (such as: sponr,e clivinr., touri s t industry, larr,e restaurant) Small retail establishment employinr, less than 20 people (such as: r.as station, snall restaurant, travel agency, plumber, electrician). or, arc yo u ... Self-er.ployed ---llom cr.ia ke r Full-tir.ic student llnenployed ---Retir ed ---Other. Please specify. Number of yea rs worked at present employment. Please specify reason for chanr.inr. jobs, if in present position less than 2 years Please ;inswer the followinr, CJUestions about your present position (or past position, if currently not employed) Position Title: How much choice do you have in the hours that you work, breaks, order of tasks perforr.ied, or the way you do your work? No choi ce Some personal choice in hours worked and breaks but none in the ---order of work or how a task is performed Some choice in how work is done and the way tasks are performed ---A lot of choice

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149 I.D. Number PART I Page Three !low much skill does it take to do your job? None Some, mos tly manual labor Some mos tly "Usinr, my head" A lot no you supervise or train anybody? lone ___ Some people ___ A lot of people Can you contribute in any way to the decision makinR process at your job? For example, c an you sup,ges t different ways to achieve a goal and help orr,anize work priorities? ==S ometines, in my depar tment Sometimes, in the entire company ---A lot of the time Activity Level noes your wo r k or daily activity require a lot of ? (X only on e) Sitti.nr. Standinr, ---W a 1 k i. n ~ o r o t h e r a c t iv e e x e r c i s e ---11 ea v y 1 ah or (such as : 1 if t in r, heavy obj e ct s ) In ad d ition to your normnl work or daily activity, how often do you do vir.orous exercise, lastin g 20 minutes or more, which noticeably increases your breathing (such as: wa lkin g cycli n p,, runnin r,, swinminr, dancin g )? Seldor.1 ---Les s t ha n on c e a we e k ---Thre e times a week Five or nore d ays a week Sr.iokinr, Do you snoke ... ? N o Cir,.irettes ---If yes, how many? less than pack --,;-1 pack -1-2 pac ks Cir,ar ==Pipe 2 or mo r e packs Medical Hi s tor y no you take any med ication? __ yes Plea se s pecify if yes no

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150 I.D. Number PART I Page Four Yes Uas a doctor ever told you or a family member (parent, child) that you/they have: No You Cancer Diab etes Heart Disease High Blood Pressure Stroke Pare nt Cancer Diabe tes Heart Disease Uigh Illood Pressure Stroke C'iild Cance r Diabe tes Heart Disease llir.h Blood Pressure Stroke Don't know/am adopted Don't know/have no children CO~TINUED ON NE~T PAGE

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1 I.D. Numuer GREEK CULTURE QUESTIONNAIRE 151 PART II Page Five Directions: Please X the space which best describes your opinion about each statement. 1. The puhlic schoolo should teach rnore ahout contri butions of Greek people to America. 2. I feel mo re comfo.rtahle in a Greek church. 3. We don 't need stronr, e r orr,anizations to express the view of Greek-Ame rican s 4. A Greek neir.hbo rhood is a fr i e 11 cl 1 i er place to live. 5. Orp;anizations which carry on the Greek culture are important. 6. Greek reli r,io us education is not imnortant for our children. 7. Greek music makes rne want to dance. 8. Our peonle should r,e t their familie s to the Greek church on Sunday:;. 9. ,\ feelinr, for the Greek people is "in the blood. II 0. Tarpon Sprinr,s does not need a Greek newspaper. 1. You should belonr, to the Greek church even if it is far from your home. 2. It is not all riEht to chan r,e your name. 3. I feel rno re comfortable with Greek people. the l=Stron r,ly Agree 2=Agree 3=~1ildly Ar,ree 4=!1ildly Disagree S=nisar.ree 6=Stronr,ly nisagree l 2 3 4 5 6

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I.D. Number 4. We don't need centers where our young people can learn about the Greek culture. 5. The Greek relir,ious tradition help s to strenr,then my family life. 6 He don't need to know the history of the Gree k people. 7. I would rather attend a Greek church at Christ mas 8. Joke s about G reeks bother me 9 It i s i m portant for l'le to contribute my ti me, t alent and fin a nces to the Greek church. 2 0 If you' re in trou b le, yo u cannot count on Gree k people to help you. 2 l. We s hould be willinr, to give money to preserv e the Greek tradition. 2 2. It is better to marry someone of your own : nationality. 2 3. '. I should not encourage others to belonr, to the Greek church. 2 4. I Our children should leat:n Greek d a nces and music 2 5. I prefer a church where services are in the Greek language. 6. The G r eek tradition should be carried on by our young people. 152 PART II Page Six lStronr,ly Agree 2Ar.r ee ~ !ildly Ar,ree 4Hildly Disagree S 2 Disagree 6=StronP,ly Disar,ree 1 2 3 4 5 6

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I.D. Numher 2 7. I would vote for a Greek politic.::il candidate rather than any other nation a lity re r,a r
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154 I.D. Number PART III Paee Eir,ht EATING PREFERENCES Directions: Please X the space that best describes your eating nreferences. Eatinr. out: I choose to eat l1 ~!B E R O F T I "E S Daily Weekly !-lonthly Yearly Where r.reck food is served. In ethnic re s taurants, such as: Italian, '!c::ican, Chinese. Where /1.r.ierlcan foods are served, such as: steakhouse. At fast food restaurants, such as: clrive-ins, salad bar, pizzn restaurant or burcer housr.s. At deli's and spec ialty diners, s11ch as: suh shoos From vendinr, machines. I n a coffee house. Eatinr. at l'orne: 'll' '!BER O F TI IE S naily Weekly ~lo nthl y Yearly The household r,at hers for a common rne a 1 Food served is prepared frorn basic inr.rcdients. Foods served nre a coMhination of convenience foods and basic in~redients. lost foods served are convenie nce foods. Food is nrenarecl in a micro\/nve oven. Foods are prenat'ed "Anerican style or with American re cipes I Foods are prepared I "Greek stvle or with r.rcck reciocs. I Inr,redicnt s co mmon to r. reece, I such ns: olive oil, feta cheese, are used in basic recincs. Groceries arc purchased I Please specify name of store where purchased Alr.iost Never AlMost : I ever

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I.D. Number Eatinr. at llomc: Food and drinks advertised on TV a re rurchased. Coupons for foods are clipped from the newspapers and u sed whe~~pinr for ~roceries. Recipes are collected from map. a zine s such as: Ladies llome .Journal, Redh oo k Better Homes and Gardens, and used in meal nre~ration FastinP. fo orls are eaten in keepinr. with religious observances. Special holiday r.rcek foods are prepared and eaten in season. Daily : i 1!'11l f. R OF TI '-If. S .. 11 /eekl y Monthly Yearly 155 PART I II Pap.e ~li ne Almost 'lever C O~T I HI En O'.I NEXT PACE

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I.D. ~umber FOOD FREQUENCY QUESTIONNAIRE 156 PART IV Par:e Ten Directions: Please X the space that best describes how often you eat the followinn foods. N ll'-!B E R O F T I 'IE S ,. Daily Heekly Monthly Yearly Almost :-lever Citrus fruits or juices, such as: oranr: e graEefruit 1 lemon Other fruits or juices, such as: annle near, banana Fruit punc h or drink Cereal, such as: oatme;il, cornflake s r:ranola French toast, pancakes, waffles Feta Cheese Other cheese, such as: swiss, american, cheddar 'lari;\arine --Butter Peanut butter .lam or jelly Syrup or honey Sugar ----White bre;i
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I.D. Number Potatoes (include hash browns, baked mashed, fries) Rice Spaghetti, macaroni, or other pasta Vegetable salad (include tossed and coleslaw) Mayonnaise or salad dressinr, Olive oil Other vep,etable oil, such as: corn. peanut. safflower Green Ver,etables, such as: spinach, broccoli, beans Yellow or orange vegetables, a uch as: squash, tomatoes, carrots Lentils, chickpeas, drv beans, kidney beans Olives Greek pepp e rs Ice cream Frozen yogurt Milkshakes, frostees Spinach-cheese pie (include Tirooita and Kreatopita) Potato chips, corn chips (include other salty snack foods) Greek pastries (include baklava kataife etc.) Other pastries, such as: cookies and cakes Hard candies Chocolate candies Cow's milk Low fat milk Skim milk Daily NUMBER OF TIMES 157 PART IV Page Eleven Weekly Monthly Yearly Almost Never I I I I I I I I I I I I

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I.D. Number Goat's milk Chocolate milk Yogurt Evaporated milk Condensed milk Whipped cream Non-Dairy whipped topping Coffee cream Non-Dairy creamer Regular coffee or tea Greek coffee Decaffeinated coffee or tea Herbal teas Hot chocolate Koolade or soft drinks Diet drinks or sodas Beer, wine, whiskey, ouzo Other, please specify Daily 158 PART IV Page Twelve NUMBER OF TIMES Weekly Monthly Yearly Almost Never I I I I I CONTINUED ON NEXT PAGE

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159 l.D. Number PART V Page Thirteen FOOD RE C ALL Directions: Try to remember everything you ate or drank YESTERDAY. Find the food or bevera ge in the left column and X the space in the right column, which indicates the number of servings. SEE THE FOOD MODELS FOR SERVING SIZES. Example: If you had one fried egg and french fries with catsup for lunch and two hamburg e rs for supper, you would mark the columns in this way: Hamburger/Ilun French Fries Catsup Othe~ L ~ E..t .,,,c...1r !1 1 X X X LUN C H SUPPER Servinr.s Serv i nr.s l 11 2 2 !< 3 1 1!1 2 2 1 1 X DID YOU HAVE BREAKP AST O R A HOR N I!IG SNACK YESTERDAY? Brea kfas t Morning Snack BREAKFAST A~D MOR,ING SNACK Y ES T ERDAY 3 Yes No Breakfast Horninr. Snack FOOD/BEVERAGE ServinP.s Servings 1 1! 1 2 2 !1 3 1 I 1 2 2 3 Fruit Juice Fresh Fruit Cold Cereal Cook ed Cereal Sugar I I Eggs 1 fri ed I scrambled I poached I omelet I I Sausage, ham or Bacon Hash Browns I Cheese I SpinachC h eese Pie I French Toas t Panca k es I Waffl es If you h ad French Toast, P a nc akes or Wa f fles did you add ... ? ~~;~:~in e I I I I I I I 1 I I I I I

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I.D. Number PART V Page Fourteen 160 BREAKFAST AND MORNING SNACK YESTERDAY FOOD/BEVERAGE Syrue Jam 1 Jelly Sugar Honey Bread, Rolls, Toast (White) (Dark: whole wheat 1 rye 1 etc) :iuffins Bagels Biscuits u If you had bread 1 m ff Margarine Butter Cream Cheese Jam 1 Jelly Peanut Butter Honey Danish, Sweet Rolls Baklava 1 kataife Coffee Cake Whole Milk Low Fat Milk Skim Milk Chocolate Milk Hot Chocolate Coffee Tea Decaf Coffee or Tea If you had a bevera Cream Non-Dairv Creamer Sugar SuGar Substitute Other Foods ge Breakfast MorninP, Snack Servin11s Servings 1 l 2 24 3 1 l 2 24 3 ins, or bi scuits did ou add ... ? y I I I I I I l I I I I I I I I ; I I I I I I I I I I I I I I I I I I did vou a dd ... I i I I I I I I I

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I.D. Number DID YOU HAVE LUNCH AND SUPPER YESTERDAY? FOOD/BEVERAGE Soups Broth, such as: Vegetable, Chicken Noodle, etc. Creamy, such as: Cream of Hush room, Cream of Chicken Egg-Lemon Other Soup Sandwich e s Cheese (Grilled or Plain) Egg I Egg S alad ~eat (Beef, Salami, Bolocna) Fish (Tuna, Fried Fish, Tun a Salad Poultry ( C hicken, Turkey, Chicken Sa!ad) Hot Dog/ B un Submarine, lloagie, Hero Hambur!l e r/Bun Cheeseburg e r/Bun Wliopp e r Whaler McDLT Taco Burrito Other Sandwich Main Dish e s Beef (Stea k Roast, Ribs, Hamburger/no Bun Lamb (Chop, Roast) Ham Poultry ( D uck, Chicken, Turkey) \Baked, roa s ted LUNCH AND SUPPER YESTERDAY Lunch Servings ls 1 lls 2 24 3 ls I I : i I I I I I I I I I I I I I I I I I I I I I 1 I I I I I I I I I I I I I I I I PART V Page Fifteen Lunch Supper Supper Servinr.s l ls 2 2 !1 Yes No 3 I I I I I I I I I 161 I I I I I I I I I I I I I I I I

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I D. Number _________ LU NCH AND SUPPER YESTERDAY Lunch FOOD/BEVERAGE Servinl!s Main Dishes !i 1 P1 2 2 3 Fried Chicken Fish (in clude shellfish), baked, broiled 1 raw Fried Fish Potatoes 1 162 PART V Page Sixteen Supper Servin~s 1!1 2 2 !1 3 I I I I ~m~i::~J-----'---:n;;;:, 1 1 1 1 1 1 1 11 1 1 1 I I I I P as ta ~mr:_"~:haut I i I I I I I 11 I I 11 I I I Did you add ... ? ~EEt::-~c 11 I I I 11 I 11 I I Mixtures Moussaka Souvlaki Pastitsio Lasagna, Raviol i, or Pasta Dinner Pizza :-iacaroni and Cheese Pork and Bea ns Other Salads Greek Salad Tossed Salad Potato or Macaroni Salad Other Salad I I I I I I I I I I I I I I I I I I I I I I I I I I I

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I.D. Number FOOD/BEVERAGE Did you add anythinn Mayonnaise Salad Dressing Diet Dressing Corn Oil Olive Oil Vinegar Other Vegetables Green: stringbeans, spinach, broccoli Yellow, orange,red: Carrots, beets, corn, to m a toes Other Dread or Rolls I to LUNCH AND SUPPER YESTERDAY Lunch Servings 1 1!1 2 2 3 the salad? I 1 PART V Page Seventeen Supper Servin~s 1 2 2 !1 3 163 -~-~'-"!-'--~.:....;:.e ________ f----+---+---+---------l----ll l--+--+-------------l Did you add the foll i ow Margarine Butter Olive Oil Lemon Beverages Whole Milk Low Fat Milk Skim Milk Chocolat e Milk Milkshake or Frostee Coffee Decaf Coffee or Tea Tea (Iced or Hot) Did you add . 1 Cream Non-Dairy Creame r Sugar Sugar S u bsti tute Greek Coffee Kooladc or Fruit Drink n r, to t 1e ver,eta bl es or bread ... ? I I I I I I I I I I I I I I I I I I

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I.D. Number FOOD/BEVERAGE Bever ages Soft Drink, such as: Coke 1 Pees! Diet Soft Drink Beer Wine Whiskey 1 Gin 1 Ouzo Other Bevera g e Desserts Fresh Frui t Canned F r ui t Cake 1 Cuecake Pie 1 Turnover Ice cr eam Pudding Sherbet Jello Coo kies Greek Pas tr y Other Desse rt Rum I I I I LUNCH A ND SUPP ER YESTERDAY Lunch Servings l l 2 2 3 I I I I I l 164 PART V Page Eighteen Supper Servinr,s l 2 2 3 CONTINUED ON NEXT PAGE

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I.D. Number PART V Page Nineteen DID YOU HAVE AN AFTERNOON OR EVENING SNACK YESTERDAY? Yes No Afternoon Snack Evening Snack AFTERNOON AND EVENING SNAG~ YESTERDAY Afternoon Snack Evening Snack FOOD/BEVERAGE Servinl!s Servings I I 1 1 2 2 3 !1 1 1 2 2 Fresh Fruit Canned Fruit I Ice Cream Frozen Yo(lurt Hard Candi Chocolate Candi Chewing Gum Sugarless Gum Cookies Potato Chips or Corn Chies Poecornl eretzels Crackers Cheese Peanut llutter Yogurt Milkshake or Frostee Baklava Halva Loukoumades Seanakoeita Kataife Tiroeita Kreatoeita I Nuts Whole Milk Low Fat Milk Skim ~!ilk Chocolate Milk Soft Drink (Coke, Peesi, 7-Ue) Diet Soft Drink Koolade or Fruit Drink Coffee Greek Coffee Tea {Iced or Hot)' Decaf Coffee or Tea 3 165

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I.D. Number AFTERNOON AND EVENING SNACK YESTERDAY PART V Page Twenty Afternoon Snack Evening Snack FOOD/BEVERAGE Servin12s Servin1>s I 1 l I 2 2 3 1 l 2 2 3 If you had a bevera12e did you add ... ? Cream Non-Dairy Creamer Sugar Sugar Substitute I Beer I Wine I Whiskey 2 Gin 1 Rum I Ouzo I Other Snack I I I I Yes No Did you eat about the same amount of food yesterday as you eat most days? less than If you ate differently, was it more or you usually eat? Please explain wh~------------Are you on a special diet? If yes, what kind? Who prescribed it? Do you take a daily vitamin supplement? If yes, please give the name(s). THE END 166

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APPENDIX C EATING PREFERENCES OF ETHNIC GROUPS

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f-' co EAT OUT PREFERENCES GREEK RESTAURANT 60~------------------------, 40 n 30 I w DAILY WEEKLY MONTHLY YEARLY NEVER Oreeka Greek-Americana ("') I ..... ("') I N EAT OUT PREFERENCES ETHNIC RESTAURANT ao..----------------------~ IWLY WEDtl.Y WONTMLY YEARLY NEVER QroE:a GrNk....._ __ 0No...aro EAT OUT PREFERENCES AMERICAN RESTAURANT ao..----------------------~ IWLY WEEXI.Y WON TM LY YEARLY NEVER Qroelca cz::lorHk....._ __ 0No...aro > (1) ::l p. t-" x ("')

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C) I O" (') I -..J eo 150 -40 ~o 20 10 0 EAT OUT PREFERENCES FAST FOOD RESTAURANT CAJLY WEEKLY MONTHLY YEARLY NEVER GrNlJLY WEEKLY MONTHLY YEARLY Greeke 0 Greek-Americana D Non-
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100 80 (") eo I I.O -40 20 0 EAT-IN PREFERENCE COMMON MEAL DAJLY WEEKLY MONTHLY YEARLY MONTHLY FREQUENCY GREEK E::2;l GREEK-AMERICAN CJ NON-GREEK 100 80 (") eo I O:> -40 20 0 EAT-IN PREFERENCE USE BASIC INGREDIENTS DAJLY WEEKLY MONTHLY YEARLY NEVER FREQUENCY GREEK E:2:J GREEK-AMERICAN CJ NON-GREEK ..... --.J 0

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EAT-IN PREFERENCE AMERICAN STYLE RECIPES 100,---------------, 10 . ......... ..... ... .. .. .. .. .. .. ...... .. ........... ....... ...... .. ... ......... .. . .... 80 ........ :: ... ... . . .......... .. .. ......... ........ .... .. ...... . .. ..... ..... .... .. 40 . .. .. .. : : :: ... ....... .. .... ... .... .... . . ... .. .... ... .. .......... . DALY WEEXLY MONTi..Y YEAAIY IC'.'ER FREQUENCY CREEK ITS] CREEKAMCRICNI O HON -CREEK C-10 171 EAT-IN PREFERENCE GREEK STYLE RECIPES 100.----------------, 10 10 04LY WEEKLY MOHTi..Y YEAAIY ICVEJI FREQUENCY QREEK !IlJCREEKAMERICNI CJ HON-CREEK C-11 EAT -IN PREFERENCE USE GREEK INGREDIENTS so.------------------------, DAILY WEEKLY MONTHLY YEARLY NEVER FREQUENCY l!!!I GREEK l&WJ GREEK-AMERICAN :: :::::::: j NON-GREEK C-12

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EAT-IN PREFERENCE USE CONVENIENCE FOODS 10..------------, 80 40 WC:EKLY MONTHLY YENILY NEVER FREQUENCY GREEK [il) QAC:EK-AMERICNI CJ NOH-<.AEEJ( C-13 172 EAT-IN PREFERENCE USE MICROWAVE OVEN 100....-------------, ao ... .. ..... .......... .. . ..... ... ...... : ....... ...... .. .... ... .. ....... . 80 40 .. .. ... : :: . llo\LY WEEKLY MONTHLY YEARLY FREQUENCY GREEK CITJQIIEEK-.AMEAICNI 0HOff-GAEEK C-14 EAT -IN PREFERENCE COMBINATION BASIC AND CONVENIENCE 50..-----------------------, 60 40 30 20 10 0 DAILY WEEKLY MONTHLY YEARLY NEVER FREQUENCY l!!'!j GREEK GREEK-AMERICAN : :::::::: NON-GREEK C-15

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173 EAT-IN PREFERENCE COUPON USE EAT-IN PREFERENCE MAGAZINE RECIPES 70r------------~ ao.----------------. ao ..... . .. . 50 60 ... .. .. ................ . .. .. ... ... ........ .............. ...... . .. .... .. 40 . ... .......... .... ... 30 20 . ... .. .. ....... DAILY WECXLY l,40NTNLY YEARLY NEVER DAILY WEEXLY MONTMLY YEARLY NEVER FRE:QUENCY FRE:QlJENCY GREEK [IT] GREEK-AMERICAN c::::J NON-GAE[]( GREEK fi:Il GREEK-AMERICAN O NON-GREEK C-16 C-17 EAT-IN PREFERENCE TV AD PURCHASES ao..--------------------------. 60 40 .. .. .. ... .. ......... . ........... .. . ..... 20 DAILY WEEKLY MONTHLY YEARLY NEVER FREQUENCY Im GREEK GREEK-AMERICAN 1 ::::: : : 1 NON-GREEK C1 8

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APPENDIX D FOOD FREQUENCIES

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I-' -..J V, DAIRY REPORTED FREQUENCY OF INTAKE MONTHLY OR MORE OFTEN 100r------------------------8 0 ,-. .. .. c; 60 I ,-40 Ln 20 0 FETA OTHER WHOLE LOFAT SKIM YOGURT FROZ ICE SHAKE CHEESE CHEESE MILK MILK MILK YOGURT CREAM FOOD GREEK GREEK-AMERICAN 1 :::::::: :: :::: 1 NON-GREEK > -0 -::l Cl) ::, 0.. ..... X ::::,

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GRAINS REPORTED FREQUENCY OF INTAKE MONTHLY OR MORE OFTEN 120.--------------------------~ 100 d 80 I N 60 40 20 0 CEREAL WHITE DARK DONUT PITA RICE PASTA BREAD BREAD BREAD FOOD GREEK GREEK-AMERICAN j ::>;::: : >; j NON-GREEK t--' -..J Q'\

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FRUITS AND VEGETABLES REPORTED FREQUENCY OF INTAKE MONTHLY OR MORE OFTEN 120.------------------------~ 100 e 80 I w 60 40 20 0 CITRUS OTHER FRUIT POTA POTA VEG GR YL OLIVE GREEK FRUIT FRUIT PUNCH CHIP SAL VEG VEG PEPPER FOOD GREEK GREEK-AMERICAN i >:<:< ;::i NON-GREEK f-' -...J -...J

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PROTEIN FOODS REPORTED FREQUENCY OF INTAKE MONTHLY OR MORE OFTEN 120,------------------------~ 100 ? 80 60 40 20 FISH POULT MEAT EGG P/BU TARA LENT FOOD GREEK GREEK-AMERICAN 1 ::::::::::: : ::j NON-GREEK I--' ......, CX>

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FATS REPORTED FREQUENCY OF INTAKE MONTHLY OR MORE OFTEN 100 ,----------------------------, 80 ? 60 V'I 40 20 0 I ...-:::K d .. 1 ..,,,:::1<1 1 ~r:; ;. . 1 UMll :::1<1 1 .......-rJ . l : :::: j NON-GREEK 1--' -....i \0

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BEVERAGES REPORTED FREQUENCY OF INTAKE MONTHLY OR MORE OFTEN 100 ,-------------'----------------~ 80 ? 60 (j\ 40 20 0 COFFEE GREEK DECAF HERB COCOA SOFT DIET BEER TEA COFFEE COFFEE TEA DRINK DRINK WINE FOOD 1111 GREEK GREEK-AMERICAN j:: <:}:::: j NON-GREEK I-' 00 0

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'::) I -...J PASTRIES AND SWEETS REPORTED FREQUENCY OF INTAKE MONTHLY OR MORE OFTEN 100.-------------------------~ 80 60 40 20 0 SP-CH GREEK OTHER HARD CHOC SUGAR SYRUP JAM PIE PASTRY PASTRY CANDY CANDY HONEY FOOD GREEK GREEK-AMERICAN l }}}:: I NON-GREEK I-' CX) I-'

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183 Bernard, H.R. and Pelto, P.J.,eds.: Technology and Social Change. Macmillan, New York, 1987. Blood Pressure Levels in Persons 18-74 Years of Age in 1976-80, and Trends in Blood Pressure from 1960 to 1980 in the United States. Department of Health and Human Services (Public Health Service) 86-1684, 1986. Block, G.: A review of validations of dietary assessment methods. Am. J. Epidemiol. 115:492, 1982. Block, G., Rosenberger, W.F., and Patterson, B.H.: Calories, fat and cholesterol: Intake patterns in the U.S. population by race, sex and age. Am. J. Public Health 78:1150, 1988. Bonanome, A. and Grundy, S.M.: Effect of dietary stearic acid on plasma cholesterol and lipoprotein levels. N. Engl. J. Med. 318:1244, 1988. Bradburn, N.M.: Response effects. In Rossi, P.H., Wright, J.D., and Anderson, A.B.: Handbook of Survey Research. Academic Press, New York, 13:289, 1983. Breton, R.: Institutional completeness of ethnic communities and personal relations to immigrants. Am. J. Soc. 70:193, 1964. Breton, R.: The structure of relationships between ethnic collectives. In Driedger, L., ed.: The Canadian Ethnic Mosaic. McClelland and Stewart, Toronto, 1978. Brown, W.V.: Using total plasma cholesterol values in the medical practice. Med. Manage. Dynamics 6:9, 1988. Burnam, M.A., Hough, R.L., Karna, M., Escobar, J.I., and Telles, C.A.: Acculturation and lifetime prevalence of psychiatric disorders among Mexican Americans in Los Angeles. J. Health Soc. Behav. 28:89, 1987. Cheung, Y.W.: Effect of parents on ethnic language retention by children: The case of Chinese in urban Canada. Soc. Focus 14:33, 1981. Christakis, G., ed. Nutrition Assessment in Health Programs, 4th printing. American Public Health Association, Washington, D.C., 1978. Christakis, G., Severinghaus, E.L., Maldonado, Z., Kafatos, F.C., Hashim, S.A.: Crete: A study in the metabolic epidemiology of coronary heart disease. Am. J. Cardiel. 15:320, 1965.

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184 Christakis, G., Kafatos, A., Fordyce, M., Kurtz, c., Gerace, T., Smith, J., Duncan, R., Cassady, J., and Doxiadis, S.: Cultural and nutritional determinants of coronary heart disease risk factors in adolescents: A USA-Greece Cross-Cultural Study, Preliminary results. In A.E. Harper and Davis, G.K.eds.: Nutrition in Health and Disease and International Development. Alan R. Liss, Inc., Publishers, New York, 1981. Chu, S.Y., Kolonel, N.L., Hankin, J.H., and Lee, J.: A comparison of frequency and quantitative dietary methods for epidemiological studies of diet and disease. Am. J. Epidemiol. 119:323; 1984. Cohen, R.: Ethnicity: Problem and focus in anthropology. Ann. Rev. Anthropol. 7:379, 1978. Connor, S.L., Gustafson, J.R., Artaud-Wild, S.M., Classick-Kohn, C.J., and Connor, W.E.: The cholesterol-saturated fat index for coronary prevention: Background, use, and a comprehensive table of foods. J. Am. Dietet. Assn. 89:~07, 1989. Costantakos, C.M.: The Greek American subcommunity. In Orfanos, S.D., Psomiates, H.J., and Spiradakis, J., eds.: Education and Greek Americans. Pella, New York, 1987. Crispino, J.A.: The Assimilation of Ethnic Groups, Migration Studies. Staten Island, New York, 1980. Dewalt, K.M.: Nutrition Strategies and Agricultural Change in a Mexican Community. University of Michigan Research Press, Ann Arbor, Michigan, 1983. Dewalt, K. and Pelto, G.: Food use and household ecology in a Mexican community. In T. Fitzgerald, ed.: Nutrition and Applied Anthropology. The Hague: Van Gorcum, 1976. Driedger, L., ed.: The Canadian Ethnic Mosaic. McClelland and Stewart, Toronto, 1978. Ferro-Luzzi, A., Strazzullo, P., Scaccini, C., Siani, A., Sette, s., Mariani, M.A., Mastranzo, P., Dougherty, R.M., Iacono, J.M., and Mancini, M.: Changing the Mediterranean diet: Effects on blood lipids. Am. J. Clin. Nutr. 40:1027, 1984. Freedman, M.R. and Grivetti, L.E.: Diet patterns of first, second and third generation Greek-American women. Ecol. Food Nutr. 14:185, 1984.

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185 Garcia, R.E., and Moodie, D.S.: Routine cholesterol surveillance in childhood. Pediatrics 84:751, 1989. Goode, J., Theophano, J., and Curtis, K.: A framework for the analysis of continuity and change in shared sociocultural rules for food use: the Italian-American pattern. In L.H. Brown and Mussell, K.,eds.: Ethnic and Regional Foodways in the United States: The performance of group identity. Univ of Tenn Press, Tennessee, 1984. Gray, G.E., Paganini-Hill, A., Ross, R.K., and Henderson, B.E.: Assessment of three brief methods of estimation of vitamin A and C intakes for a prospective study of cancer: Comparison with dietary history. Am. J. Epidemiol. 119:581, 1984. Grundy, S.M.: Cholesterol and coronary heart disease. J. Am. Med Assn 256:2849, 1986. Grundy, S.M.: Monounsaturated fatty acids and cholesterol metabolism: Implications for diet recommendations. J. Nutr. 119:529, 1989. Harris, M.: Cultural Materialism. Vintage Books, New York, 1979. Harwood, A., ed.: Ethnicity and Medical Care. Harvard Univ Press, Cambridge, Massachusetts, 1981. Hegsted, D.M., McGandy, R.B., Myers, M.L., and Stare, F.J.: Quantitative effects of dietary fat on serum cholesterol in man. Am. J. Clin. Nutr. 17:281, 1965. Isajiw, W.W.: Olga in Wonderland: Ethnicity in a technological society. In L. Driedger, ed.: The Canadian Ethnic Mosaic, McClelland and Stewart, Toronto, 1978. James, W.P.T., Bingham, S.A. and Cole, T.J.: Epidemiological assessment of dietary intake. Nutr. and Ca. 2:203, 1981. Karinpaa, A. and Sappenen,R.: A comparison of a self-administered dietary questionnaire and a short interview. Nutr. Res. 3:285, 1983. Keys, A.: Seven Countries: A multivariate analysis of death in coronary heart disease, Harvard Univ. Press, Cambridge, Massachusetts, 1980. Keys, A., Anderson, J.T., and Grande, F.: Serum cholesterol response to changes in the diet. Metabolism 14:747, 1965.

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186 Kurtz, c.s., Vorp, R.E., and Christakis, c.: A Cross-Cultural Study of Dietary Patterns Previously Associated with Coronary Heart Disease. Abstract, ADA Annual Meeting, San Antonio, Texas, 1982. Lamon-Fava, s., McNamara, J.R., Farber, H.w., Hill, N.S. and Schaefer, E.J.: Acute changes in lipid, lipoprotein, alipoprotein and low-density lipoprotein particle size after an endurance triathlon. Metabolism 38:921, 1989. Lieberman, L.S. and Gardner, V.C.: Sixteen Cultural Food Patterns of Florida. Florida Cooperative Extension Service, Gainesville, Florida, 1980. Mattson, F.H. and Grundy, S.M.: Comparison of dietary saturated, monounsaturated and polyunsaturated fatty acids on plasma lipids and lipoproteins in man. J. Lipid Res. 26:194, 1985. Mccarron, D.A., Morris, C.D. Henry, H.J. and Stanton, J.L.: Blood pressure and nutrient intake in the United States. Science 224:1392, 1984. McMurray, M.P., Conner, W.E., Lin, D.S., Cerqueira, M.T. and Conner, S.L.: The absorption of cholesterol and the sterol balance in the Tarahumara Indians of Mexico fed cholesterol-free and high cholesterol diets. Am. J. Clin. Nutr. 41:1289, 1985. Mead, M.: Cultural Patterns and Technical Change, Mentor, New York, 1955. Messer, E.: Anthropological perspectives on diet. Ann. Rev. Anthropol. 13:205, 1984. Mintz, S.W.: Sweetness and Power: The Place of Sugar in Modern History. Viking Penguin Inc., New York, 1985. Morgan, K.J. and Goungetas, B.: Snacking and eating away from home. In What Is America Eating? Food and Nutrition Board, National Academy Press, Washington, D.C. 1986. Moore, L.G., Van Arsdale, P., Glittenberg, J.E., and Aldrich, R.A.: The Biocultural Basis of Health: Expanding views of medical anthropology. Waveland Press, Inc., Illinois, 1980. Moskos, C.C.: Greek Americans Struggle and Success, 2nd ed., Transaction Publ., New Jersey, 1989.

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187 Mullen, B.J., Krantzler, N.J., Grivetti, L.E., Schutz, H.G.: Validity of a food frequency questionnaire for the determination of individual intake. Am. J. Clin. Nutr. 39:136, 1984. National Cholesterol Education Program. National Institutes of Health, Washington, D.C., 88-2925, 1988. National Research Council Diet and Health Report, National Academy Press, Washington, D.C., 1989. Nationwide Food Consumption Survey, 1977-78, United States Department of Agriculture, Science and Education Administration, Preliminary Report No. 2, September, 1980. Neville, J.: On matters of the heart: Past, present and future. J. Am. Dietet. Assn. 90:211, 1990. Newman, J.M.: Melting Pot: An annotated bibliography and guide to food and nutrition information for ethnic groups in America. Garland Publ Co., New York, 1986. Newman, W.M.: Theoretical perspectives for the analysis of social pluralism. In L. Driedger, ed.: The Canadian Ethnic Mosaic. McClelland and Stewart, Toronto, 1978. Nationwide Food Consumption Survey, Continuing Survey of Food Intakes of Individuals, USDA, Report Nos. 85-1 and 2, 86-3 and 4, 1985 and 1986. Nickles, H.G.: Middle Eastern Cooking. Time Life Books, New York, 1969. National Institutes of Health Consensus Development Panel Special Report: Lowering blood cholesterol to prevent heart disease, NIH Consensus Conference Statement. Arteriosclerosis 5, 1985. Pareto, v. The Mind and Society, Vol. 4, Dover Publishing, New York, 1916. Pelto, G.H.: Anthropological contributions to nutrition education research, J. Nutr. Ed. (Suppl.) 13:S2, 1981. Polk Directory, Tarpon Springs, FL.: R.L. Polk and Co., Richmond, Virginia, 1987. Popkin, B.M. Haines, P.S., and Reidy, K.C.: Food consumption trends of U.S. women: Patterns and determinants between 1977 and 1985. Am. J. Clin. Nutr. 49:1307, 1989.

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Population Studies Series, Bulletin No. 89-90: Bureau of Economic and Business Research, University of Florida, Gainesville, Florida, 1989. Rathje, W.L. and Ritenbaugh, C.K.: Household refuse analysis. Am. Behav. Sci. 28, 1984. 188 Robertson, T.L., Kato, H., Rhoads, G.G., Land, C.E., Worth, R.M., Belskey, J.L., Dock, D.S., Miyanishi, M., and Kawamoto, s.: Epidemiologic studies of coronary heart disease and stroke in Japanese men living in Japan, Hawaii, and California. Incidence of myocardial infarction and death from coronary heart disease. Am. J. Cardiol. 39:239, 1977. Roche, J.P.: Social factors affecting cultural, national and religious ethnicity. A study of suburban Italian-Americans. Ethnic Groups 6:27, 1984. Sandberg, N.C.: Ethnic Identity and Assimilation. Praeger, New York, 1972. Sassen-Koob, S.: Formal and informal association: Dominicans and Colombians in New York. Int. Migr. Rev. 14:179, 1979. Schneider, J.A.: Rewriting the SES: Demographic patterns and divorcing families. Soc. Sci. Med. 23:211, 1986. Scourby, A. Three generations of Greek Americans: A study in ethnicity. Int. Migr. Rev. 14:43, 1979. Sedor, F.A., Holleman, C.M., Schneider, K.A.: Evaluation of the Reflotron as a Cholesterol Screening System. Abstracts from the 39th National Meeting of the American Association for Clinical Chemistry, 073, 1987. Simopoulos, A.P. and Salem, N., from range-fed Greek chickens. 1989. Jr.: n-3 Fatty acids in eggs N. Engl. J. Med. 321:1412, Simopoulos, A.P. and Salem, N., Jr.: Purslane: A terrestrial source of omega-3 fatty acids. N. Engl. J. Med. 315:833, 1986. Spady, D.K. and Dietschy, J.M.: Interaction of dietary cholesterol and triglycerides in the regulation of hepatic low density lipoprotein transport in the hamster. J. Clin. Invest. 81:300, 1988. st. Jeor, S.T., Guthrie, H.A., and Jones, M.B.: Variability in nutrient intake in a 28-day period. J. Am. Dietet. Assoc. 83:155, 1983.

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190 World Health Organization Table of Mortality from Selected Causes By Country, Regional Office for Europe, Copenhagen, Denmark, 1986. Young, C.M. and Trulson, M.F.: Methodology for dietary studies in epidemiological surveys. II. Strengths and weaknesses of existing methods. Am. J. Public Health 50:803, 1960.

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BIOGRAPHICAL SKETCH My M.S. degree was awarded from Indiana University (IUPUI, Indianapolis campus) in allied health education (nutrition), August 1974 and my B.S. degree was awarded by Eastern Mennonite College in home economics (nutrition), June 1964. Upon completion of my dietetic internship at the LDS Hospital, Salt Lake City, Utah, I worked as a pediatric dietitian at the University of Iowa Hospital and Clinics, Iowa City, Iowa. Other positions included: Acting Nutrition Division Director and Adjunct Instructor, Nutrition Division, Mailman Center for Child Development, Department of Pediatrics, University of Miami School of Medicine; Nutrition Consultant for MRFIT, Dade County Health Department; Adjunct Instructor, Department of Nutrition and Dietetics, Florida International University; Research Instructor and Assistant Professor, Nutrition Division, Department of Epidemiology and Public Health, University of Miami School of Medicine; Visiting Assistant Professor, Clinical and Community Dietetics, University of Florida; Graduate Research Assistant, Department of Health Science, College of Health and Human Performance, and Clinical and Community Dietetics, College of Health Related Professions, 191

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192 University of Florida; and Nutritionist, Alachua General Hospital Center for Health and Fitness. I was awarded the Lydia J. Roberts Fellowship in Public Health Nutrition from the American Dietetic Association during the 1987-1988 school year. My research interests grew from my participation in an NHLBI-funded grant that was awarded to George Christakis, M.D., M.P.H., Director, Nutrition Division, Department of Epidemiology and Public Health, University of Miami School of Medicine. The study examined the evolution of risk factors for coronary heart disease (CHD) among adolescent boys in a low-risk country (Greece) and a high-risk country (USA)~ The findings suggested that those Greek immigrants to the U.S. who "Americanized" their diets were increasing their CHD risk, as observed by their increased total and LDL serum cholesterol and triglyceride levels.

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I certify that I have read this study and that in my opinion it conforms to acceptable standards of scholarly presentation and is fully adequate, in scope and quality, as a dissertation for the degree of Doctor of Philosophy. Leslie Sue Lieberman, Chairperson Associate Professor of Anthropology I certify that I have read this study and that in my opinion it conforms to acceptable standards of scholarly presentation and is fully adequate, in scope and quality, as a dissertation for th 7 1ree of Doctor of Philosophy. I I ( \AA}wt~ \ Russef 1 Bernard Professor of Anthropology ----I certify that I have read this study and that in my opinion it conforms to acceptable standards of scholarly presentation and is fully adequate, in scope and quality, as a dissertation for the degree of Doctor of Philosophy. George Armelagos Professor of Anthropology

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I certify that I have read this study and that in my opinion it conforms to acceptable standards of scholarly presentation and is fully adequate, in scope and quality, as a dissertation for the degree of Doctor of Philosophy. ~achel M. Shireman Professor of Food Science and Human Nutrition I certify that I have read this study and that in my opinion it conforms to acceptable standards of scholarly presentation and is fully adequate, in scope and quality, as a dissertation for the degree of Doctor of Philosophy. Lee A. Crandall "Associate Professor of Sociology This dissertation was submitted to the Graduate Faculty of the Department of Anthropology in the College of Liberal Arts and Sciences and to the Graduate School and was accepted as partial fulfillment of the requirements for the degree of Doctor of Philosophy. May, 1990 Dean, Graduate School

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