Part 1: A Systematic Review to Describe Existing Cultural Adaptations in Lifestyle, Nutrition, and Physical Activity Programs for Native Hawaiian, CHamoru, and Filipino Populations

TL;DR

This study reviews lifestyle programs adapted for Native Hawaiian, CHamoru, and Filipino populations to address obesity and related health issues.

Contribution

The study systematically reviews cultural adaptations in health programs for underrepresented Pacific Islander and Filipino populations.

Findings

29 articles described culturally adapted interventions for Native Hawaiian, CHamoru, and Filipino populations.

Most interventions combined nutrition and physical activity and targeted pre-diabetes, hypertension, and obesity.

Fewer interventions included CHamoru populations, suggesting a need for more research in this area.

Abstract

This research aims to describe existing evidence on the availability of culturally adapted lifestyle, nutrition, and physical activity programs among Native Hawaiian, CHamoru, and Filipino populations who are affected by obesity at rates higher than the general US population, contributing to poorer health outcomes. Addressing this disparity requires programs that are culturally adapted and grounded for these specific populations. A comprehensive description of the availability of lifestyle interventions for Native Hawaiians, Pacific Islanders, and Filipinos is missing in the literature. A systematic literature review was performed in July 2025 to gather articles that included lifestyle (nutrition and/or physical activity) interventions addressing obesity and/or related chronic diseases and that utilized one or more cultural adaptations for Native Hawaiian, CHamoru, and/or Filipino populations. Data were extracted, and methodological quality, social ecological model (SEM) level, and risk for bias was assessed. Twenty-nine articles met inclusion criteria. Interventions addressed pre-diabetes (n = 7), hypertension (n = 7), and/or obesity (n = 5) and included combined nutrition and physical activity (n = 16). Sixteen articles included interventions culturally adapted for Filipino populations only, 7 for Native Hawaiians only, 6 for both Native Hawaiians and Filipinos, and 2 included CHamorus. The most common combination of approaches were interventions that incorporated individual, interpersonal, and community SEM levels (n = 17). Intervention components were reflective of culturally relevant physical activities (n = 16) and nutrition (n = 11). Based on this research, there is a need for additional research to include CHamoru communities and interventions to be tested in geographic locations where these populations have migrated.

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1. Introduction

Excessive body fat or obesity is a leading risk factor for diabetes, heart disease, stroke, and some forms of cancer. Obesity is a consequence of multiple, interwoven factors across levels of the social ecological model (SEM). The SEM can be used to describe factors across individual, interpersonal, community, organizational, and policy levels that influence diet and physical activity, which influence the risk of obesity [1]. Lifestyle programs that involve multiple SEM sectors of influence have shown promise to treat or prevent obesity and to be sustained long term [2,3,4,5]. Rates of obesity among Native Hawaiian, Filipino, and CHamoru adults are greater than White counterparts in the US and its territories [6,7,8]. This disparity may contribute to poorer health outcomes observed in Native Hawaiian, Filipino, and CHamoru populations compared to other groups [9].

Most obesity interventions have been developed and tested to serve broad populations, lacking the cultural nuances and foods unique to Native Hawaiian, CHamoru, and Filipino populations. Native Hawaiians, CHamorus, and Filipinos living in the United States (US) and territories have experienced a rapid nutrition transition over the last century, where dietary and physical activity practices have shifted because of an altered food system [10,11,12]. Furthermore, traditional Pacific Islander diets consisted predominantly of tropical fruits, vegetables, and seafood, which are not readily accessible today [13]. A recent study among CHamoru and Filipino adults in Guam revealed that foods contributing the most energy to the total diet were highly processed and lacking essential nutrients, such as white rice, sugar-sweetened beverages, fried food, and sausages [7]. Another study found that the diets of Native Hawaiian men and women were less nutritious compared to non-Hispanic Whites in the US, which is in contrast to traditional Native Hawaiian diets [14,15].

There is a wealth of evidence demonstrating that programs to improve lifestyle, diet, and physical activity can treat or prevent adult obesity [16]. There is also evidence that culturally informed programs are an effective way to develop meaningful and lasting programs among indigenous populations and minority groups that suffer disproportionately from chronic diseases related to diet and physical activity [17,18,19,20]. Native Hawaiians and CHamorus are both Pacific Islanders [21] that are indigenous to the Hawaiian Islands and the Mariana Islands—including Guam—respectively. Filipinos and CHamorus share a similar history related to the Spanish influence in both the Philippines and Guam, respectively [22,23,24]. Due to migration for agriculture and urban development, Filipinos make up a large part of the Asian population in Hawaiʻi [25], a US state, and Guam, a US territory [23,26]. Together Native Hawaiians, CHamorus, and Filipinos are grounded in similar cultural values of collectivism as well as a complex cultural history involving colonialism [27,28,29].

Connecting and reconnecting with culture for indigenous populations are emerging as key components to promote healthy lifestyle behaviors [30]. More specifically, culturally adapted and grounded approaches to program delivery involving indigenous populations have been applied to obesity, diabetes, and heart disease, yet have still not been comprehensively explored for Native Hawaiian, CHamorus, and Filipinos throughout the US in particular [31,32,33].

This systematic literature review aims to describe culturally adapted nutrition and physical activity programs designed for Native Hawaiian, CHamoru, and Filipino populations living in the US and its territories. Specifically, it describes the strategies utilized to adapt programs to be culturally appropriate for Native Hawaiian, CHamoru, and Filipino populations and identifies levels of the SEM addressed in each program.

2. Materials and Methods

This systematic review conforms to standardized guidelines for conducting and reporting on systematic reviews, specifically the Preferred Reporting Items for Systematic Reviews and Meta Analyses Protocols (PRISMA) guidelines [34]. A search of peer-reviewed literature was conducted in collaboration with an experienced librarian in July 2025 using the following online databases: PubMed, ProQuest, and EBSCO (CINAHL, Academic Search Complete, an Health Source: Nursing/Academic Edition). Search strategies used the same key words applied to each ethnic group, including variations of diet and physical activity programs for reducing body fat. The search terms are listed in Table 1. Screening of articles for duplicates and eligibility criteria was managed using Rayyan, a web and mobile app for systematic reviews [35]. Included articles’ bibliographies were reviewed for additional relevant and eligible articles. A total of 3 researchers were responsible for screening articles (n = 2), data extraction (n = 3), and quality appraisal (n = 2). Two additional researchers were consulted if there were questions about screening, data extraction, or quality appraisal.

2.1. Inclusion Criteria

Screening for inclusion criteria was conducted through reviews of the title, abstract, and full text, which was conducted by 2 researchers independently. Discrepancies between researchers on inclusion criteria were resolved through discussion and, in some cases, a third researcher review. The systematic review included peer-reviewed studies published in English from January 2001–July 2025. Articles were included if they employed a lifestyle (i.e., nutrition and/or physical activity) program that included 1 or more cultural adaptations and were delivered to Native Hawaiian, CHamoru, and/or Filipino populations. Both spellings of Chamorro and Chamoru were included throughout, and for this publication, the spelling CHamoru is used. Programs that focused on Pacific Islanders as an aggregated group were excluded to maintain cultural and contextual specificity. Aggregation can obscure distinct cultural and health determinants of Filipino, CHamoru, and Native Hawaiian populations, limiting the relevance and precision of findings. Quantitative and qualitative studies were included, as were experimental and quasi-experimental study designs. Programs had to include outcome measures related to diet, nutrition, exercise, or physical activity. Cultural adaptations were defined as explicitly incorporating Native Hawaiian, CHamoru, or Filipino values, norms, beliefs, and/or language in the program [36]. Cultural adaptations and sensitivity structures were assessed as surface or deep and the presence of 8 unique elements, respectively. Cultural adaptations were classified as surface level if they included minor changes, such as changing out phrases or images to better relate to the target population. Meanwhile, deep adaptations were those that were grounded in cultural values and worldviews more salient with the target population or community [37]. Cultural sensitives included 8 elements; language, persons, metaphors, content, concepts, goals, methods, and context. Language refers to the use of culturally appropriate terms; persons relates to those involved, including facilitators or peers with similar ethnic/racial backgrounds; metaphors refer to shared concepts within the population; content reflects cultural knowledge and values; concepts align with the population’s culture; goals are supportive of adaptive values from the culture of origin; methods incorporate adaptation of treatment methods; and context acknowledges cultural trauma or stress [37].

2.2. Data Extraction

Data from included articles were extracted and entered by 3 researchers who were trained on the review protocols. Data included the author name(s); publication year; title; database; sample size; study design; program description and length; delivery setting; geographic location of the study; outcomes measured and tools used; sex, age (mean and range), and ethnic group(s) of the study population; cultural adaptation strategies used (i.e., language, persons, metaphors, content, concepts, goals, methods, context), with the description in [37]; cultural sensitivities employed (i.e., surface or deep) [36]; SEM level(s) the program addressed (i.e., individual, interpersonal, community, organization, or policy); and main results.

2.3. Quality Appraisal

The Joan Briggs Institute (JBI) critical appraisal tools for randomized control trials (RCT) and quasi-experimental studies were used to assess the methodologic quality and risk of bias for all articles [38]. The JBI RCT appraisal tool includes 13 questions that assess bias related to selection and allocation of participants; administration of the program/exposure; assessment, detection, and measurement of the outcome; participant retention; as well as statistical conclusion validity measures. The JBI quasi-experimental appraisal tool includes 9 questions that assess bias related to temporal precedence of the cause and effect; selection and allocation of a control group; confounding factors; administration of the program/exposure; assessment, detection, and measurement of the outcome; participant retention; as well as statistical conclusion validity.

Two trained researchers reviewed all articles in this study and applied appropriate critical appraisal tools independently; discrepancies in scoring were resolved by an additional researcher. Each criterion was reviewed, and scores were calculated by assigning a 1 for “yes” responses and “0” for all other responses. A total score was calculated for each article (sum of scores for the criteria), and the average total score was calculated across reviewers [24]. The highest potential score for JBI RCT appraisals was 13, and the highest potential total score for the JBI quasi-experimental appraisals was 9, with a higher score indicating higher quality.

3. Results

A total of 1088 articles were identified from the database search (Figure 1). After duplicates were removed (n = 93), 995 articles were screened for eligibility (title and abstract). Eligible articles (n = 144) were screened with full-text reviews (136 identified from the original database search and 8 identified from reviews of citations). Of the 144 articles that underwent a full-text review, 29 met the inclusion criteria.

3.1. Characteristics of Studies Included

Table 2 contains detailed characteristics for all included articles (n = 29) [8,32,39,40,41,42,43,44,45,46,47,48,49,50,51,52,53,54,55,56,57,58,59,60,61,62,63,64,65]. Approximately half of the articles were published between 2016–2025 (n = 16) [8,32,39,40,41,44,48,49,50,51,53,58,62,63,64,65]. Most programs were designed to address hypertension (n = 7) [32,48,50,58,61,62,64] or pre-diabetes (n = 7) [39,45,47,52,53,55,56]. Fifty-five percent of programs included combined nutrition and physical activity components (n = 16) [8,39,40,42,43,44,45,46,47,52,54,55,56,57,59,61]. Sixteen articles included programs culturally adapted for Filipino populations only [8,32,39,40,41,42,43,45,52,53,54,61,62,63,64,65], 7 for Native Hawaiians only [44,48,49,50,51,55,58], 6 adapted for both Native Hawaiians and Filipinos [46,47,56,57,59,60], and 2 included CHamorus [37,43]. Programs primarily took place in Hawaiʻi (n = 15) [43,44,45,46,47,48,49,50,52,55,56,57,58,59,60], with 7 in California [8,39,40,42,51,64,65] and 7 on the East Coast of the US continent [32,41,53,54,61,62,63], with no programs delivered on Guam.

Regarding the SEM level targeted for the programs, all programs, at a minimum, addressed the individual level, and all but 4 articles addressed additional SEM levels [54,55,60,65]. The most common combination of approaches were programs that incorporated individual, interpersonal, and community levels (n = 14) [8,39,40,41,43,44,48,52,53,56,58,59,61,62]. Policy level changes were only addressed by one program [32].

All programs incorporated multiple cultural adaptation strategies, with 7 articles utilizing all strategies (Table 2) [32,43,45,49,50,52,62]. The “persons” strategy was the most commonly utilized adaptation, with only 1 article not including it [60]. Meanwhile, “metaphors” were incorporated the least (n = 12) [32,42,43,44,45,48,49,50,52,58,59,62]. Nineteen of the programs included both surface and deep culturally sensitive adaptations [8,32,39,40,41,42,43,45,46,47,48,49,50,51,52,56,58,61,62].

Eighteen of the programs had a duration between 3 and 6 months [8,32,39,40,44,46,47,48,49,50,51,52,55,56,59,61,62,63]. The second highest frequency of duration was between 12 and 24 months (n = 5) [42,43,53,57,58]. Programs lasting less than 3 months were the least common (n = 5) [45,50,54,64,65].

3.2. Summary of Culturally Adapted Lifestyle Program Components

The lifestyle program components were reflective of culturally relevant physical activity and nutrition, summarized in Table 3. These included physical activity adaptations to include dance (i.e., hula, traditional Filipino dance, Zumba^®^, or cha cha) (n = 10) [8,39,40,41,42,48,49,50,58,63], walking (n = 5) [8,39,40,42,65], and gardening (n = 3) [32,33,34]. Regarding nutrition, the primary cultural adaptation was the inclusion of traditional and commonly consumed foods from Filipino, Native Hawaiian, and CHamoru cultures (n = 14) [8,32,39,40,44,47,48,52,53,56,57,59,61,64]. Many program components were developed or adapted using CBPR or community-engaged approaches (n = 17) [8,32,39,40,41,44,45,46,47,48,49,50,54,58,59,61,63]. Additional cultural adaptations included reliance upon trusted individuals within the community (e.g., trained peer educator, community health worker, lay leader, or community champion) to deliver the program (n = 21) [8,32,39,40,41,42,43,44,45,48,49,50,51,52,54,55,58,62,63,64,65], programs implemented in a familiar vernacular (e.g., native language of participants or plain or “local” language) (n = 26) [8,32,39,40,41,42,43,44,45,46,47,48,49,50,51,52,53,55,56,57,60,61,62,63,64,65], and/or programs delivered in settings familiar to the participants (n = 9) [32,41,42,44,45,52,60,61,63]. Culturally grounded programs implemented deep structure cultural sensitivity adaptations that built on shared values, such as family and collectivism (n = 16) [8,39,40,41,43,44,45,46,47,52,56,57,59,60,61,63].

3.3. Quality of Research Studies

The quality assessment scores for RCTs ranged from 2 to 10, with an average score of 7.4 and median score of 7 (n = 13) [8,39,40,42,45,46,48,49,50,54,57,58,59]. The quality assessment scores for quasi-experimental studies ranged from 2 to 8, with an average score of 7.3 and median score of 8 (n = 16) [32,41,43,44,47,51,52,53,55,56,60,61,62,63,64,65]. All 13 RCTs lacked blinding of treatment allocation [8,39,40,42,45,46,48,49,50,54,57,58,59]. A majority of quasi-experimental studies lacked control groups (n = 14) [32,41,43,44,47,51,53,55,60,61,62,63,64,65], yet all studies utilized reliable measures to determine impact.

4. Discussion

This systematic review identified a recent increase in research related to culturally adapted programs for diabetes prevention and control for Filipinos, CHamorus, and Native Hawaiians. The rising incidence and prevalence of pre-diabetes, gestational diabetes mellitus, and type 2 diabetes mellitus among Asian Pacific Islanders, which is inclusive of Filipinos, CHamorus, and Native Hawaiians, may have prompted the growth of literature [66,67,68,69]. Also noted is the disparity in literature for CHamoru adults and Native Hawaiians and Filipinos, where there continues to be gaps in programs including CHamoru adults living in Guam and across the continental US. Lastly, this systematic review found that multi-level programs and use of multiple cultural adaptation strategies was prevalent in the literature. This is in alignment with the collectivist culture of all three groups and is operationalized in the programs identified through the inclusion of family members, community organizations, and group-based activities [27].

Pre-diabetes was the most common health condition addressed by the included studies. The target populations, Native Hawaiian, Filipino and CHamoru, experience type 2 diabetes at disproportionately higher rates as compared to non-Hispanic whites; thus, primary prevention by addressing pre-diabetes has been the focus of many programs [66]. In recent years, the efforts of initiatives such as the National Diabetes Prevention Program (DPP) have led to the increased adoption of these programs as well as the development of cultural adaptations for those who experience higher risk, such as Asian and Pacific Islander populations, yet there are none for Filipinos or CHamorus [47,70,71]. Other common conditions from the systematic review included cardiovascular disease, hypertension, prehypertension, diabetes, and obesity. Lacking from the literature search results were lifestyle programs designed for persons diagnosed with cancer, cancer survivors, or chronic kidney disease, all of which disproportionately affect the target populations [72,73].

Common cultural adaptations among programs included showcasing foods commonly consumed in the target population (nutrition) and dance (physical activity). For example, many programs adapted for Filipino populations addressed frequent utilization of high sodium condiments (e.g., soy sauce and fish sauce) for hypertension control. Hula was a commonly applied adaptation to physical activity programs for Native Hawaiians. In addition, most programs included complementary cultural adaptations, such as navigating social norms and cultural expectations and the health care system resources available to participants.

The geographic locations that were represented in this study match where there are concentrated populations of the groups of interest in the US or its territories [74,75]. In addition to needing greater representation of CHamoru populations in research, more programs are needed in additional locations where these populations reside. For example, in the most recent 2020 US Census report, CHamoru was the third largest sub-group within the broader Native Hawaiian Pacific Islander population (with Native Hawaiian and Samoan being the first and second) in the US at 10.2% [25]. Filipinos were the third largest population within the Asian group in the same year [25]. In terms of where these populations reside in the US, San Diego County, California, was home to the largest CHamoru population at 27.8%. For Native Hawaiians, Honolulu County has the largest population of Native Hawaiians (77.1%) in the country, but over the past few years this has decreased by 8%, with Clark County, Nevada, and San Diego County, California, having the largest Native Hawaiian populations outside of the state of Hawaiʻi. Similarly, San Diego County, California, and Honolulu County, Hawaiʻi, had the largest populations, with Filipinos at 41.6% and 42.9% of all Asians, respectively [25]. These statistics offer a justification for expanding the development and testing of culturally adapted programs for CHamoru and Native Hawaiian populations in new areas, such as San Diego and Clark County, Nevada.

Including cultural adaptive strategies can be effective in promoting a healthy lifestyle as well as a critical strategy to preserving and perpetuating cultural practices in populations who are relocating, as is the case with Native Hawaiians [18]. Acculturation, which occurs when a population migrates and takes on the new host culture, is associated with excessive body weight, sedentary behavior, and poor diet [76,77].

The body of literature identified from this study may inform the development of programs to address other health conditions for Native Hawaiian, Filipino, and CHamorus, particularly if culturally adapted approaches are shown to be effective in improving target behavioral outcomes. For example, many programs in this study addressed interpersonal and community levels of the SEM, which is in line with other research findings that identified family (interpersonal) and community values (cross-cutting factors) to be of high importance when working with Native Hawaiian, Filipino, and CHamoru breast cancer survivors [78,79]. However, a key gap in this literature is policy level programs, which are key to long-term sustained changes in health.

Additionally, over half of the articles included relatively short program durations, between 3 and 6 months, in comparison to nationally recognized lifestyle change programs, such as the DPP, which is a 12-month program. However, a 12-week DPP adapted for Native Hawaiians, Partners in Lifestyle Programs Ohana Lifestyle Program, yielded significant weight loss results among pilot study participants, despite being delivered in a reduced length of time, which was found to be more desirable for the Native Hawaiian community members [57]. Focus groups conducted with Native Hawaiian, Filipino, and CHamoru breast cancer survivors similarly found that a 10-week lifestyle program would be most desirable [55].

To the authors knowledge, this is the first systematic literature review conducted that aims to describe the availability of high quality, culturally adapted, lifestyle programs for Native Hawaiians, CHamorus, and Filipinos. The reliance on PRISMA guidelines is a strength of this study, as is the utilization of multiple reviewers in extracting data and assessing quality. A key limitation of this work is the subjective nature of classifying the cultural adaptations. The authors overcame this through training reviewers, using published definitions for consistency, and a classification process which relied upon independent reviewers; nonethless, some of the articles lacked detailed descriptions of the cultural adaptations, which made the process difficult for reviewers. In addition, this review did not aim to describe the effectiveness of the programs included. A future meta-analysis might aid in strengthening the evidence on the impact of these culturally adapted programs.

5. Conclusions

Findings from this review can be used to design effective and relevant health and lifestyle programs for these populations in communities where Native Hawaiians, Filipinos, and CHamorus reside. More studies including CHamoru communities and that are conducted in geographic locations where populations in this study are living are warranted. Programs that include cultural values and practices of communities are needed to elicit sustainable lifestyle changes to address health disparities.