Executive SummaryBackground:South Asians are known to have a high risk of type 2 diabetes (T2D), therefor Pakistani immigrants in Norway constitute a high risk subgroup of the population. In particular, the Pakistani immigrant women exhibit a high prevalence of T2D. There is convincing evidence that T2D can be efficiently prevented by lifestyle modification in high-risk individuals. Prevention includes dietary changes, physical activity and weight control. In order to give appropriate dietary advice for making changes it is important to understand the influences that motivate food choice.Aim: The aim of the study was to explore perceptions of healthy eating among Pakistani immigrant women and how this relates to food choice and dietary patterns.Methods: The sample consisted of 197 Pakistani women aged 25-62 living in a urban area (Søndre Nordstrand) in Oslo and participating in a randomized controlled lifestyle intervention, InnvaDiab. All except for one were first generation immigrants, and the median age at immigration was 22.4 (95 % CI=21.3, 23.1). Only the baseline data were analyzed in the current study. These included demographic and socio-economic variables, command of Norwegian, intake frequencies of fruits, vegetables, fish, high fat and high sugar foods and perceptions of healthy eating (healthy/unhealthy foods, awareness the 5-a-Day recommendation, important factors guiding food choice and motivational stage for dietary change), and were assessed through a pre-coded questionnaire. Data collection was performed by means of an interview with Urdu/Punjabi-speaking interviewers. Statistical analyses with chi-square and binary logistic regression were use to analyze relationships between socio-economic and demographic variables, command of Norwegian, years of residency in Norway, dietary intake and perceptions.Findings: The results showed that vegetables were mentioned by 89 % of the women and fish by 54% as foods important in a healthy diet. As unhealthy components in the diet, sugar was mentioned by 65% and too much oil by 60 %. The large majority of the women perceived as very important/important that the children like the food (90 % of the women), that the food is healthy and balanced (89 %) and that it has little fat (88 %) when planning/cooking dinner. Furthermore, the women were asked to select the factor they perceived most influential for dinner food choices; 30 % of the women considered health aspects (e.g. healthy food/a lot of vegetables/low fat content) as most important, e.g. “health oriented”. These women had a higher intake frequency of fruits (p=0.010) and vegetables (p=0.139), and a lower intake frequency of high fat foods (p=0.014).The majority (57 %) reported that cooking food in accordance with the preferences of children/husband/other family members was most important when planning/cooking dinner meals, e.g. “managing relationship oriented”. These women reported a lower intake frequency of fruits (p=0.025) and vegetables (p<0.01), and a higher intake of high fat foods (p<0.01) as compared to the rest. Only 24 % of the women were aware of the dietary recommendations of eating five portions of vegetables a day (the 5-a-Day message). Message awareness was positively associated with years of residency in Norway (p=0.015) and degree of formal education (p=0.038). Message awareness (p=0.049) and command of Norwegian (p=0.031) predicted a higher intake frequency of vegetables when controlling for socio-economic and demographic variables. Similarly, perceiving fish as part of a healthy diet was predictive of a higher frequency of choosing fish for dinner (p<0.01) when controlling for socio-economic and demographic variables. Stages of change distributions were also associated with dietary patterns: intake frequency of fruits and vegetables was higher and intake frequency of high fat foods and high sugar foods was lower in the action stages as compared to the pre-action stages (p<0.01 for all food groups). A higher level of formal education was related to “health oriented” attitudes, being aware of the 5-a-Day message and being in the action stages for increasing vegetable consumption and reducing fat consumption.Conclusion: This study gives support to the assumption that perceptions of healthy eating, including attitudes, knowledge of recommendations, and motivational stage, relates to dietary patterns. The influence of family members was perceived as most important in food choice by most women. It also shows that within one ethnic group there were socio-economic differences with regard to perceptions of healthy eating and motivational stage. Such differences should be taken into consideration when designing health interventions and in communicating health messages among Pakistani immigrants. More research is needed to understand family influences in food habits and how healthy eating is managed in everyday food choice.