ERIC EJ852398: Stemming Racial and Ethnic Disparities in the Rising Tide of Obesity

7 Pages·2003·0.12 MB·English

by  ERIC

Stemming Racial and Ethnic Disparities
in the Rising Tide of Obesity
Steven R. Hawks and Hala N. Madanat
ABSTRACT
At the national level, obesity and obesity-related illnesses are increasing dramatically. As with many other public
health problems, some racial and ethnic populations are disproportionately affected. This article presents current
information on the prevalence and consequences of obesity for racial and ethnic groups in the United States and
evaluates race/culture-specific causes of obesity for these populations. After analysis of various interventions that
attempt to address this problem, a full-spectrum, three-pronged model for eliminating racial and ethnic disparities
in obesity is presented and discussed. It is argued that a comprehensive population model, with a balance between
downstream, midstream, and upstream interventions is necessary. Examples of culturally appropriate interven-
tions that address the behavioral, social, and environmental determinants of obesity at each of these levels are
presented. Using the tools of sound theory, appropriate methods, and cultural sensitivity, health educators are in a
unique position to provide leadership to this effort.
As with many other public health prob- amination Survey (NHANES) II and III the presence of obesity within the sample
lems in the United States, some racial and (1980–1994) was similar for all age, gender, was associated with a higher risk of diabe-
ethnic groups bear a disproportionate and racial groups, the NHANES III break- tes, arthritis, hypertension, and cancer
burden in relation to obesity. This article down by race and gender shows significant (Ostir, Markides, Freeman, & Goodwin,
summarizes racial and ethnic disparities in differences (Flegal, Carroll, Kuczmarski, & 2000). Perceptions of personal health and
the area of obesity, analyzes current preven- Johnson, 1998). Of particular interest in self-report measures of health are also
tion efforts, and proposes a comprehensive Figure 1 is the finding that racial and eth- more negative among overweight ethnic
model that may be useful in narrowing the nic disparities within the adult population youths than among normal weight youth.
gap. Based on available obesity data, it ap- are primarily limited to females, with higher Among Native Americans, those youths
pears that unfavorable racial disparities in the rates of obesity among African American who were overweight were twice as likely to
United States are most evident for Native and Hispanic females.
American, African American, and Hispanic It is not surprising that given higher
populations as compared with Caucasians. prevalence rates among several racial and Steven R. Hawks, EdD, MBA, and Hala N.
Therefore, this article focuses primarily on ethnic populations, higher rates of obesity- Madanat, MS, are with the Department of
these groups, and the phrase “racial and eth- related illness are also developing. One Health Science, College of Health and Human
nic groups” refers to these populations. sample of 3,050 Mexican Americans Performance, 229-L Richards Building,
Although the sharp rise in obesity be- revealed levels of obesity that were much Brigham Young University, Provo, Utah 84602;
tween National Health and Nutrition Ex- higher than the general population, and E-mail: [email protected].
90 American Journal of Health Education — March/April 2003, Volume 34, No. 2
Steven R. Hawks and Hala N. Madanat
Caucasians and African Americans
Figure 1. Percentage of Obese U.S. Adults by Race and Gender
(Gannon, DiPietro, & Poehlman, 2000). The
(NHANES III, 1988-1994)
authors concluded that two-thirds of re-
viewed studies demonstrated lower RMR
Male values, although one-third found lower
Female TDEE values, among African American
40
37
subjects. Such findings begin to build a case
35 33.6 that genuine metabolic differences seem to
exist among different racial groups, perhaps
30
as influenced by generational exposure to
25 24 food scarcity.
20.4 20.9 20.7 As a result of such biological adapta-
20 tions, patterns of fat deposition may also
differ among various racial populations.
15 Body fat, especially abdominal fat, is the
primary risk factor in relation to body size,
10
and the usefulness of body mass index
(BMI) as a health indicator depends in part
5
on its relationship to levels of body fat. A
0 recent meta-analysis of published data
evaluated the relationship between percent-
WHITE AFRICAN AMERICAN HISPANIC
age body fat and BMI values among differ-
ent racial groups and concluded that
equivalent body fat levels produced signifi-
report health concerns as nonoverweight exposure to seasonal food shortages over cantly different BMI values. In some popu-
youths (Neumark-Sztainer, Story, Resnick, multiple generations has naturally selected lations (e.g., Indonesians, Thais, Ethiopi-
& Blum, 1997). metabolic mechanisms that support high ans) the level of obesity in terms of
In relation to socioeconomic conse- levels of fat deposition, low levels of energy percentage body fat was reached at a much
quences, it has been found that obesity is expenditure, and a preference for energy lower BMI compared with recommended
associated with lower wages, reduced occu- dense foods (Neel, 1999). As modern social cut-off values. Likewise, it was concluded
pational achievement, and lower probabili- environments provide increasingly easy that cut-off levels higher than the current
ties of marriage for both African American access to high fat/high sugar foods, with value of 30 kg/m2 might be justified for Af-
and Caucasian women (Averett & limited incentives for activity, the expected rican Americans and Polynesians
Korenman, 1999). A multidimensional result is obesity. (Deurenberg, Yap, & van Staveren, 1998).
body image that is less focused on weight Biology and Obesity These findings may help account for
or size, however, may provide protection for Different levels of exposure to seasonal reported differences in ideal BMI for
some African American women against the food scarcity over many generations, and racially diverse groups. One study found
loss of self-esteem that is often seen among resulting metabolic adaptations, may help that the BMI associated with minimum
overweight Caucasian women. Conse- explain racial differences in propensity for mortality was 27.1 for African American
quently, there may be less preoccupation weight gain when exposed to certain social men, 26.8 for African American women,
with dieting and fewer cases of eating dis- environments (Krosnick, 2000). For ex- 24.8 for Caucasion men, and 24.3 for
orders among African American women ample, this perspective may help explain why Caucasion women. The authors argue that
(Flynn & Fitzgibbon, 1998). some ethnic groups, such as the Pima Indi- for each of the four race/sex groups there
ans of Northern Arizona, develop higher is a wide range of BMIs consistent with
CONTRIBUTING FACTORS rates of obesity than other ethnic groups low mortality with little evidence to suggest
TO OBESITY when placed in similar environments. that the optimal BMI is at the lower end
Increasingly, it is the interface between One literature review attempted to of the distribution for any subgroup
human biology and the social environment explain higher levels of obesity among Af- (Durazo-Arvizu, McGee, Cooper, Liao, &
that is being blamed for rising levels of rican Americans by analyzing resting meta- Luke, 1998).
obesity (Goran & Weinsier, 2000). Specifi- bolic rate (RMR) and total daily energy ex- Culture, Beauty, and Obesity
cally, it has been hypothesized that repeated penditure (TDEE) differences between In addition to biological predispositions
American Journal of Health Education — March/April 2003, Volume 34, No. 2 91
Steven R. Hawks and Hala N. Madanat
for obesity, powerful cultural influences nes identified wider social meanings that tables of contents for the American Journal
have evolved that favor larger body sizes. In made personal behavior change in these of Clinical Nutrition, the International Jour-
societies where food was scarce (the case for areas very difficult (Thompson, Gifford, & nal of Obesity, Obesity Research, and Obe-
much of human history), obesity may have Thorpe, 2000). For example, fat and salt sity Reviews also were searched. Using
been socially preferred as an indication of were seen as key ingredients for meals that McKinlay’s model, selected studies were
wealth, social status, and good health fostered closeness with families and friends, then categorized as downstream, mid-
(Brown, 2001). In support of this hypoth- whereas meals that met dietary guidelines stream, or upstream. There were no up-
esis, a recent study found that in 80% of were seen as cold and clinical. Different cat- stream interventions found in the literature
developing countries (where food is less egories of physical activity were also iden- that were specific to racial or ethnic groups.
abundant), the social ideal for both male tified, each with its own cultural meaning. Representative downstream and midstream
and female beauty was overweight As argued by the authors of the study, it studies are presented and discussed in fol-
(Treloar et al., 1999). It has been a relatively is difficult to change behaviors by appeal- lowing paragraphs.
recent development, most often in cultures ing to health benefits without considering Downstream
that have an abundance of food, that the larger social and cultural contexts in
In relation to obesity prevention and
socioeconomic status and attractiveness which the behaviors occur (Thompson et
management interventions that involve ra-
have come to be associated with thinness al., 2000). Diet composition and activity
cial and ethnic groups, most were down-
(Brown, 2001). levels among racial and ethnic groups in the
stream in that they primarily promoted in-
For some minority women a large body United States are also influenced by power-
dividual behavior change as the desired
size may not carry the same stigma that ful social variables that have little to do with
outcome. A representative example of this
many Caucasian females associate with it. concerns for health. Differential eating hab-
approach is the Bariatrics Clinic at Howard
The cultural emphasis on thinness may be its are further influenced by place—such as
University Hospital, which was initiated to
diminished or completely lacking for many residing in the inner city or on a reserva-
help low-income African American adults
ethnic groups who refute thinness as a norm tion or in a developing country—which
with low literacy skills (Kaul & Nidiry,
limited to Caucasian women (Flynn & may determine access to and availability of
1999). Essential components of the inter-
Fitzgibbon, 1998). As has been found in healthful foods and opportunities for activ-
vention included nutrition education, ex-
developing cultures, the deprivations of ity (Thompson et al., 2000).
ercise, and behavior modification in rela-
poverty that are experienced by many
tion to food intake. The strength of the
minority groups in the United States may INTERVENTION ANALYSIS
program included an individualized design
also support a cultural preference for large
A Review of Obesity Prevention that took into account such factors as lit-
bodies as a symbol of health and power
Approaches eracy level, food preferences, family dynam-
(Flynn & Fitzgibbon, 1998).
To consider a broad range of potential ics, lifestyle, and availability of resources.
The Culture of Food and Activity obesity interventions, McKinlay’s popula- Although the study reported low dropout
It has been hypothesized by some that tion-based model may be useful (McKinlay, rates and significant weight loss (an aver-
racial and ethnic women have higher BMIs 1995). Using this approach, public health age of 14 pounds over 7 weeks), the pro-
simply because they have lower activity interventions can be assigned to one of gram included only 16 participants, and the
levels and higher consumption of energy three categories. Those programs that duration of the intervention was limited. No
dense foods (Flynn & Fitzgibbon, 1998). If emphasize the individual, as in many be- follow-up data on long-term weight loss
true, this could merely be an artifact of pov- havior change programs, are referred to as maintenance was provided.
erty (limited opportunities for activity downstream interventions. Those interven- Other weight loss studies reported in the
and healthy diets due to low income or un- tions that have a community orientation, literature included similar program compo-
safe environments). Yet studies so far have such as school and work site programs, are nents, but with different levels of emphasis
failed to demonstrate a clear relationship termed midstream. Finally, those that ad- on cultural sensitivity, nutrition education,
between socioeconomic status and obesity dress health problems at the broadest popu- physical activity, behavior modification, or
among minority groups (Dietz, 2000). An lation level (via public policy, national me- adult learning strategies (Domel, Alford,
alternative hypothesis for explaining racial dia, and broad economic measures) are Cattlett, & Gench, 1992; Kumanyika &
differences in activity level and diet com- considered upstream. Charleston, 1992; Pleas, 1988). Within the
position might consider the various cultural Using appropriate key words, a Medline general population, downstream weight-
roles that food and activity play within eth- search was conducted to find articles deal- loss programs that focus on personal behav-
nic communities. ing with obesity management programs ior change in the areas of diet composition
An ethnographic study of diet and ac- that focused on racial and ethnic popula- and activity levels demonstrate modest
tivity practices among Australian Aborigi- tions between 1990 and the present. The short-term success, but so far few have been
92 American Journal of Health Education — March/April 2003, Volume 34, No. 2
Steven R. Hawks and Hala N. Madanat
shown to exert substantial impact among Wilson, Smith, & Leonard, 1991). tural values and build on existing traditions.
large numbers of participants over the long Upstream Fourth, racial and ethnic differences in
term (Bronner & Boyington, 2002; Miller, National promotion of the food guide the genetic, environmental, and cultural
1999). Among the programs that included pyramid and improvements in food label- causes of obesity should be evaluated and
African Americans (and that collected fol- ing have been the primary upstream mea- understood before national dietary recom-
low-up data), there is evidence that over a sures aimed at dietary improvements. Some mendations or body size standards are
12-month period African American partici- research suggests that females, those with established. BMI standards, for example,
pants tend to regain weight more rapidly higher education, and individuals who are seem to be questionable as they fail to cor-
and experience less long-term weight loss concerned about their personal health are respond with lowest mortality rates for dif-
than their Caucasian counterparts (Wing & more likely to use food labels, but there is ferent ethnic groups (Deurenberg et al.,
Anglin, 1996). Given these findings, it is no evidence that food labels have signifi- 1998). Additionally, conflicting data fail to
questionable whether downstream pro- cantly improved the nutrition of large num- support the appropriateness of some dietary
grams that emphasize individual behavior bers of people (Kreuter, Brennan, Scharff, fat recommendations among different cul-
change, even if culturally sensitive, will by & Lukwango, 1997). There have been no tures and populations (Seidell, 1998).
themselves produce long-term reductions reports of upstream interventions or pro- Fifth, obesity prevention and manage-
in obesity at the population level. grams intended to reduce obesity-related ment programs must be offered in ways that
are sensitive to different cultural ideals for
Midstream disparities among racial and ethnic groups.
body size, while at the same time avoiding
Several midstream interventions re-
ported in the literature dealt with obesity PRINCIPLES OF INTERVENTION complicity with the fashion industry.
Racial and ethnic disparities in adult obe-
prevention among Native Americans in the The foregoing discussion suggests cer-
sity are limited primarily to females (see
school setting. An ongoing intervention that tain principles that may be useful in guid-
Figure 1). One positive disparity may be the
builds on earlier successes is the Pathways ing obesity prevention efforts among racial
reduced impact of being overweight on
program developed through a collaboration and ethnic groups. First, the goal of inter-
self-esteem found among many minority
of universities, Native American nations, vention outcomes for racial and ethnic
women (Flynn & Fitzgibbon, 1998). It
schools, and families (Davis et al., 1999). groups should relate to diet composition
would be unfortunate if obesity control
Designed for third-, fourth-, and fifth-grade and activity levels, rather than BMI, weight-
efforts merely reinforced the media
Native American students, the program loss, or other measures of body size. This is
message that personal worth and thinness
focuses on individual, behavioral, and because (a) adult body size is difficult to
are synonymous, and thereby undermined
environmental factors that correlate with change once obesity develops; (b) attempts
the self-confidence of overweight minority
obesity by merging constructs from social to alter adult body size may do more harm
women while doing little to improve their
learning theory with Native American cus- than good; and (c) ideal body size (as rep-
health status.
toms and practices. The multifaceted pro- resented by lowest mortality BMI) is a mov-
gram includes four components: physical ing target that depends on age, gender, and
A POPULATION MODEL
activity, food services, classroom curricu- race. At the same time, it may be possible
lum, and family involvement. Needs assess- to significantly alter body fat levels and The population model proposed in this
ment research used qualitative and quanti- improve health status without correspond- article calls for a balance between down-
tative data to identify and rank behavioral ing weight loss (Sullivan & Carter, 1985). stream, midstream, and upstream interven-
risk factors to be targeted by the interven- Second, because the prevention of obe- tions that have well-defined objectives, clear
tion. Pathways is currently being evaluated sity is more cost-effective than attempts at theoretical foundations, and culturally ap-
as part of a multisite, 3-year randomized reversal, and because childhood obesity propriate methodologies. (Theories listed in
trial to determine the impact on activity rates among racial and ethnic children are Table 1 are not meant to be exhaustive, but
level, diet composition, levels of obesity, and growing rapidly, the primary focus of merely represent the diversity of theories
obesity-related illness. immediate efforts should be on mid- and available to health educators.)
Midstream interventions geared toward upstream strategies that can prevent obe- Downstream Interventions
adults, such as work site wellness programs, sity among minority children (Goran & It is ironic that although the primary
seldom focus on racial or ethnic groups. Weinsier, 2000). determinants of obesity seem to be bio-
One exception is the report of a weight-loss Third, successful interventions must take logical and environmental, the bulk of
competition among adult members of a into account the culture-specific context of prevention and management efforts have
Zuni community that resulted in positive food and activity (Thompson et al., 2000). focused on the individual. This approach
metabolic changes in the short term, but Programs can then approach dietary and ac- may provide useful information and
follow-up data were not provided (Heath, tivity changes in ways that complement cul- skills to motivated individuals, but an
American Journal of Health Education — March/April 2003, Volume 34, No. 2 93
Steven R. Hawks and Hala N. Madanat
Table 1. Population Model for Reducing Racial and Ethnic Disparities in Obesity
Targets Objectives Theory Methods
Downstream Provide individuals Stages of change; Culturally sensitive...
Individuals with knowledge and health beliefs; Nutrition education;
Families skills to maintain planned behavior; physical education,
Self-help groups a healthy weight. reasoned action personal counseling
Midstream Use organizational Social cognitive Multicomponent,
Schools channels and natural theory meshed with collaborative
Work site environments to racial/ethnic customs interventions in
Communities mediate diet/activity. and practices community settings
Upstream Use macro policy Diffusion theory Coalition building;
Public media and environmental advocacy;
Economic base interventions to help social marketing;
National policy change social norms. communications
overemphasis on personal behavior change behavior change programs that are cultur- On the other hand, one notable im-
may also contribute to victim blaming and ally sensitive (Bartholomew, Parcel, & provement is a substantial increase in
negative stereotypes in relation to obesity Kok, 1998). Such programs, many of which work sites that have wellness programs,
(Hawks & Gast, 1998). are beginning to develop, will provide one from 22% in 1985 to 42% in 1992 (U.S. De-
As mentioned above, the social mean- component of a balanced, three-pronged partment of Health and Human Services,
ing of food and activity needs to be consid- effort to reduce racial and ethnic dispari- 1993). Work site food service programs that
ered in the design and implementation of ties in obesity. offer a greater diversity of fruits and veg-
downstream interventions that target racial Midstream etables at a reduced cost can increase con-
and ethnic populations (Thompson et al., The second prong of the model calls for sumption of healthful foods (Jefferey,
2000). Modifications that incorporate regu- substantial strengthening of midstream French & Raether, 1994). In other commu-
lar food intake may be preferable to restric- programs that can take advantage of insti- nity settings there is evidence that physician
tive diets that largely eliminate traditional tutional and organizational structures to counseling at health care sites and educa-
foods (Bronner & Boyington, 2002). Reten- positively change community environments tional programs at point-of-purchase
tion and positive long-term outcomes for that influence diet and activity. One posi- settings can significantly increase knowl-
programs might be improved by including tive example is the Native American Path- edge and change nutrition behaviors
community partners such as churches or ways program described previously (Davis (Marcus & Forsyth, 1999). A missing com-
other trusted social organizations that can et al., 1999). At the same time that students ponent of current community efforts is the
motivate and facilitate long-term participa- receive instruction in relation to diet and large-scale implementation of culturally
tion in educational programs (Kumanyika activity, the school environment is changed sensitive methods and theories in work site,
& Charleston, 1992; Tuggle, 2000). The to include increased levels of physical school site, health care, and community set-
use of lay facilitators and peer educators activity and better food choices through tings that serve substantial racial and eth-
may further enhance cultural sensitivity school food services. As parents and fami- nic minority populations.
and cost-effectiveness (Williams, Belle, lies are also brought into the program, the Upstream
Houston, Haire-Joshu, & Auslander, 2001). student is provided with the overall educa- In general, the role of upstream inter-
Incorporating group support, family inter- tional, environmental, and social support ventions is to use mass media, economic
action, individual skill development, and necessary to prevent obesity. As a nation incentives, and national policy to alter
adult learning principles may further en- we are unfortunately moving in the oppo- social norms and physical environments
hance the success of downstream programs site direction; only 25% of American high that contribute to obesity. Even though
that work with ethnic groups (Bronner & schools offered daily physical education there will be many barriers to the develop-
Boyington, 2002). classes in the United States in 1995, down ment of such upstream interventions, other
Health education is well positioned to from 42% in 1991 (President’s Council on developed countries are beginning to
design and implement theoretically driven Physical Fitness and Sports, 1996). pursue upstream measures with success
94 American Journal of Health Education — March/April 2003, Volume 34, No. 2
Steven R. Hawks and Hala N. Madanat
(Milio, 1998). In the United States there is able to address obesogenic social environ- and optimal body mass index in a sample of the
growing support for greater public health ments at numerous levels. U.S. population. American Journal of Epidemi-
involvement in the development of na- ology, 147, 739–749.
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