in Michigan's African American Women › documents › AAObesityreportc...Obesity among African American women by education level MI BRFSS, 1996-2000 combined 34.5 31.8 24.5 36.540

A Report of the

Healthy Lifestyles Initiative

An Epidemic of

Overweight and Obesity

in Michigan'sAfrican American Women

An Epidemic of Overweight and Obesity


inside this report:inside this report:

An Epidemic of Overweight and Obesity ..................................................................................1

Fighting the Michigan Epidemic ...................................................................................................6

The Plan: Objectives, Recommendations and Strategies ................................................8

Appendix 1: Factors Contributing to Overweight and Obesity inAfrican American Women ......................................................................................................... 11

Appendix 2: Inventory of Programs, Services and Supports ..................................... 15



Members

Charlene AckerGenesee County Community Action AgencySubcommittee: Behavior

Katherine AlaimoUniversity of MichiganSchool of Public HealthSubcommittee: Policy/Environment

Marilyn AndersonSoutheast Michigan Diabetes OutreachSubcommittee: Behavior

W. Jeffrey ArmstrongEastern Michigan UniversityDepartment of Health, Physical Education,Recreation and DanceSubcommittee: Policy/Environment

Marvin B. AustinCalhoun County Board of CommissionSubcommittee: Policy/Environment

Lee BellUniversity of MichiganSchool of Public HealthSubcommittee: Communications

Judith BensonBattle Creek Health SystemMinority HealthSubcommittee: Behavior

Tyrone BynumBlack PerspectiveSubcommittee: Communications

Gail CampanaMichigan Association of Health PlansSubcommittee: Communications

Johnnie CarterJohn D. Dingell VA Medical CenterSubcommittee: Behavior

Marvin T. CatoCommunity Health InstitutesDetroit Medical CenterSubcommittee: Communications

Sungsoo ChoKellogg CompanySubcommittee: Policy/Environment

Lisa ChoateAmerican Heart AssociationSubcommittee: Communications

Donna M. ClarkeAmerican Cancer SocietySubcommittee: Behavior

Mary CocanougherNorthwest Health Empowerment CenterSubcommittee: Behavior

Kim CovingtonWZZM 13Subcommittee: Communications

Amber DixonJohn D. Dingell VA Medical CenterSubcommittee: Behavior

Michael D. EberleinMichigan Department of TransportationSubcommittee: Policy/Environment

Deanna M. EdwardsGreater Lansing Urban LeagueSubcommittee: Communications

i


Gloria J. EdwardsUniversity of Michigan Health SystemSubcommittee: Policy/Environment

Nancy GoodwinDetroit Health DepartmentSubcommittee: Behavior

Sandra HillMichigan Department of AgricultureSubcommittee: Policy/Environment

Marion E. HubbardWayne County ExtensionSubcommittee: Policy/Environment

Marlene HulteenMichigan Health & Hospital AssociationSubcommittee: Communications

Dorothy JenkinsDetroit Public SchoolsSubcommittee: Behavior

Linda JimenezGet Active DetroitSubcommittee: Policy/Environment

Charlene JohnsonMichigan Neighborhood PartnershipSubcommittee: Behavior

Srimanthi KannanUniversity of Michigan Nutrition ProgramSchool of Public HealthSubcommittee: Policy/Environment

Edie KiefferUniversity of MichiganSchool of Public HealthSubcommittee: Behavior

E. Yvonne LewisFaith Access to CommunityEconomic DevelopmentSubcommittee: Communications

Mary E. MadiganNational Kidney Foundation of MichiganSubcommittee: Behavior

Charlene McNarySisters CyclingSubcommittee: Policy/Environment

Robin NwankwoUniversity of Michigan Medical SchoolSubcommittee: Behavior

Hayward S. PennyCommunity Health InstitutesDetroit Medical CenterSubcommittee: Behavior

Vicki PrestonRadio One DetroitSubcommittee: Communications

Dolores RawlingsGalilee Missionary Baptist ChurchWellness MinistrySubcommittee: Behavior

Thomas M. ReischlUniversity of MichiganSchool of Public HealthSubcommittee: Evaluation

LaTesha RichardsonMichigan Osteopathic AssociationSubcommittee: Behavior


Members

i i


Lisa M. Roth-EdwardsCalhoun County Health DepartmentSubcommittee: Communications

Sharon P. SheldonUniversity of Michigan Health System MFitHealth Promotion DivisionSubcommittee: Policy/Environment

Debi SilvermanMichigan Dietetics AssociationSubcommittee: Behavior

Jamie SneadGenesee County Health DepartmentSubcommittee: Policy/Environment

Bertha StewartBorgess Medical CenterSubcommittee: Behavior

Paris Watson TaylorNational Kidney Foundation of MichiganSubcommittee: Behavior

Amy ThompsonGenesee County Health Department–WICSubcommittee: Behavior

Velonda ThompsonBE-FIT, Inc.Subcommittee: Behavior

Oretta M. ToddArthritis Foundation, Michigan ChapterSubcommittee: Behavior

Angela VergesYpsilanti Township Recreation Dept.Subcommittee: Policy/Environment

Lorraine J. WeatherspoonMichigan State UniversityCommunity NutritionSubcommittee: Behavior

Karen Patricia WilliamsMichigan State UniversitySubcommittee: Communications

Mary E. WilliamsDelta Sigma Theta Sorority, Inc.Subcommittee: CommunicationsSophie J. Womack, MDSubcommittee: Policy/Environment

Michigan Department ofCommunity Health

Division ofChronic Disease & Injury Control

Staff Participants

Judith V. AndersonSubcommittee: Policy/Environment

Shannon M. CarneySubcommittee: Behavior

Sue D’IsabelSubcommittee: Behavior

Rochelle HurstSubcommittee: Communications

Quentin J. MooreSubcommittee: Communications

Karen PetersmarckSubcommittee: Policy/Environment


Members

i i i

An Epidemic of Overweight and ObesityAn Epidemic of Overweight and Obesity


Across the United States. . .

An epidemic of overweight and obesity poses aformidable public health threat for all racial andethnic groups, both sexes and all ages. Morethan one in two Americans is either overweightor obese (Oster et al. 1999). According to theCenters for Disease Control (CDC,) 38.8 millionAmerican adults (19.8%) were obese in 2000.This represents a dramatic increase of 61%since 1991. An additional 71.9 million Americanadults (36.7%) were overweight.

The epidemic nature of obesity can be seen onmaps of prevalence among states over the lastdecade. In 1991, only 4 of 45 statesparticipating in the Behavioral Risk FactorSurveillance Survey (BRFSS) had obesity rates of15 to 19 percent, and none showed ratesgreater than 20 percent. Only nine years later,all 50 states with the exception of Colorado hadrates of 15 percent or higher, with obesity ratesin 22 of 50 states climbing to 20 percent ormore.

Obesity Trends* Among U.S. AdultsBRFSS, 1991

(*BMI ≥ 30, or ~ 30 lbs overweight for 5’4” woman)

Source: Mokdad A H, et al. J Am Med Assoc 2001;286:10

No Data <10% 10%-14% 15-19% ≥20%

Obesity Trends* Among U.S. AdultsBRFSS, 2000

(*BMI ≥ 30, or ~ 30 lbs overweight for 5’4” woman)

Source: Mokdad A H, et al. J Am Med Assoc 2001;286:10

No Data <10% 10%-14% 15-19% ≥20%

An Epidemic ofOverweight and Obesity

Definitions:

Overweight is defined as a bodymass index (BMI) of 25 to 29.9 andobesity as a BMI of 30 or greater.

BMI = weight in kg/(height inmeters)2

O v e r w e i g h ta n d O b e s i t y

No Data:

No Data:

1


Consequences and CostsAs overweight and obesity rates continue ashocking climb in the United States, so dorelated health consequences and costs. Inaddition to an increased risk of overallmortality—an estimated 300,000attributable deaths per year (NIH 1998)—obesity is associated with increased risk fora host of acute and chronic conditions(Mokdad et al. 2003).

Obesity and its associated medicalconditions place a serious strain on thehealth care system. The estimated totaleconomic cost of obesity in 1995 was $99.2billion (Harnack et al. 2000). By 2000, theestimate rose to $117 billion, $61 billion indirect costs and $56 billion indirect (U.S.DHHS 2001). Direct costs includepreventive, diagnostic and treatmentservices. Indirect costs refer to wages lostthrough illness, disability or death.

It would be possible to reduce such coststhrough lifestyle improvements. Physicalinactivity and unhealthy eating representprimary, and preventable, risk factors forobesity. According to the U.S. Department ofAgriculture, healthier diets could prevent at least$71 billion per year in medical costs, lostproductivity, and lost lives. Likewise, CDCestimates that if all physically inactive Americansbecame active, annual medical cost savingswould be about $77 billion.

In our society, obesity and overweight also havesocial implications. In addition to the health andeconomic consequences, overweight individualsmay suffer from social stigmatization anddiscrimination, experience poor body image andhave low self-esteem.

Obesity is associated withincreased risk for a hostof acute and chronicconditions...

Obesity is Associated with an Increased Risk of:Obesity is Associated with an Increased Risk of:Obesity is Associated with an Increased Risk of:Obesity is Associated with an Increased Risk of:Obesity is Associated with an Increased Risk of:! premature death! type 2 diabetes! heart disease! stroke! hypertension! gallbladder disease! osteoarthritis (degeneration of cartilage and bone in

joints)! sleep apnea! asthma breathing problems! cancer (endometrial, colon, kidney, gallbladder, and

postmenopausal breast cancer)! high blood cholesterol! complications of pregnancy! menstrual irregularities! hirsutism (presence of excess body and facial hair)! stress incontinence (urine leakage caused by weak

pelvic floor muscles)! increased surgical risk! psychological disorders such as depression! psychological difficulties due to social stigmatization

Adapted from www.niddk.nih.gov/health/nutrit/pubs/statobes.htm

In Michigan . . .

In 1991, Michigan was one of four states withobesity rates higher than the rest of the nation.This trend has persisted over time, as the rateof obesity in Michigan has remained consistentlyhigh in comparison to the rest of the U.S.Michigan BRFSS data indicate that in 2001almost one quarter of adults (24.7%) wereobese, more than double the rate in 1987

2


(12.2%). If ratescontinue to climb, almostone-third (31.5%) ofMichigan adults will beobese by 2010.

Although not as stark anincrease, the prevalenceof overweight amongMichigan adults alsocontinues to rise, from32.2% in 1987 to35.7% in 2001. Ratesof overweight are moreconsistent with the restof the nation.

A Heavy BurdenChronic diseases related to obesity can bedeadly. Michigan ranks among states with thehighest rates of cardiovascular disease (CVD.)In 2000, heart disease and stroke—twodiseases that account for the majority of CVD—claimed 33,263 Michigan lives, 38% of alldeaths. CVD is Michigan’s number one killerand a significant cause of illness, hospitalizationand disability.

Likewise, diabetes takes a toll on the health ofMichigan’s citizens. Prevalence rates, deathrates and rates of complications have beenincreasing steadily in Michigan over the lastdecade. An estimated 491,000 Michiganadults suffer from diabetes (MI BRFSS 1998).Many will experience serious complications ofthe disease including blindness, kidney failure,and lower-extremity amputation. In 2000,diabetes was the sixth leading cause of death,taking 2,612 lives.

Source: 2000 Michigan Resident Death File,Division for Vital Records & Health StatisticsMichigan Department of Community Health

Prevalence of overweight and obesity among

Michigan and U.S. adults, CDC BRFSS trend data, 1990 - 2000

0 5

10 15

20 25

30 35

40 45

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000

% MI overweight (not obese) U.S. overweight (not obese) MI obese U.S. obese

Leading Causes of Death, 2000 Michigan Residents

Heart Disease

Cancer

Stroke

Chronic Lower Resp. Disease Unintentional Injuries

Diabetes Mellitus

Other

3

Lifestyle FactorsDespite high rates of obesity-related chronicdisease, most Michigan adults have not takensteps to improve their eating or activity habits.Poor diet and physical inactivity are primary, andpreventable, risk factors for overweight andobesity. If energy consumption (calories) isgreater than energy expenditure (activity,) theresult is weight gain.

Data from the Michigan BRFSS indicate thatalmost one quarter of Michiganadults are physically inactive duringtheir leisure time and about threequarters (74.6%) do not participatein regular leisure time physicalactivity (at least 30 minutes ofphysical activity five or more timesper week.) Less than one quarter(22.8%) report eating at least fivefruits and vegetables per day (MIBRFSS 2000)—an importantindicator of a healthy diet.

Within the population of AfricanAmerican women, there are segments atgreater risk for high obesity rates.

EducationThere is an inverse relationship

between rates of obesity and

education levels. As education

levels rise, obesity rates fall.

Population Segments atHigh RiskOverweight and obesity affect all demographicand age groups, but segments of the Michiganpopulation have unusually high rates. Rates ofobesity among African Americans, especiallywomen, are particularly high compared to otherpopulation groups. In 1999, 35.9% of AfricanAmerican were obese, an increase of 146%compared to 1987.

Obesity among African American women by education level

MI BRFSS, 1996-2000 combined

34.5 31.8

24.5

36.5

0

10

20

30

40

< HS HS graduate Some college College graduate

%

4An Epidemic of Overweight and Obesity

0

10

20

30

40

% Obese

BlackWomen

BlackMen

WhiteMen

WhiteWomen

MI Obesity Rates 1987, 1999, and 2001

198719992001

AgeCertain age groups also experiencehigher rates of obesity. Theprevalence of overweight does notchange dramatically until after age44, when it jumps approximately tenpercentage points. Obesity rates,however, begin to climb earlier.Between the 18-24 year-old agegroup and the 25-34 year-old agegroup, the absolute increase ofobesity is 6.8%. It remains roughlythe same in the 35-44 year-old group,increases to its highest level in the 45-54 year-old group, and then begins todecline after age 55.

Physical InactivityLike the broader US and Michiganpopulations, African American womendo not get enough exercise. However,levels of inactivity are morepronounced among African Americanwomen.

Eating HabitsAbout two-thirds (66.2%,) of AfricanAmerican women who are overweight or obeseindicate that they are trying to lose weight (MIBRFSS 1996-2000 Combined). Althoughincreased consumption of fruits, vegetables andwhole grain products are effective weightmanagement techniques, only 20.7% of AfricanAmerican women report eating the minimumrecommended 5 servings of fruits andvegetables per day. In 2000, only 5.6% ofAfrican American women reported consuming 3or more servings of whole grain foods per day(MI BRFSS 2000).

Weight status among African-American women by age, Michigan BRFSS, 1996-2000 combined

0 5

10 15 20 25 30 35 40 45

18-24 25-34 35-44 45-54 55+ age

% Overweight Obese

No Leisure-Time Physical Activity by Race-Sex GroupsMI BRFSS 1996-2000 combined

41.8

24.427

20.8

0

5101520

2530354045

Black Females White Females Black Males White Males

%

Rates of obesity among AfricanAmericans, especially women, areparticularly high compared toother population groups.

5 An Epidemic of Overweight and Obesity


% African Americans in Michigan by County

PopulationLandscapesMichigan’s racial landscape is nothomogenous.

" 95% of African Americans inMichigan live in 12 counties

" 55% (776,236) of AfricanAmericans in Michigan live in Detroit

" Flint has the second highestpopulation of African Americans inMichigan (over 70,000 residents)

Living in urban areas may restrictthe availability of healthy foodsources and safe, convenient,affordable sites for physical activity.

Fighting the Michigan Epidemic . . .

Fighting an epidemic requires a plan and resources. In 2001, the Michigan Department of CommunityHealth (MDCH) applied for and received a grant from the Centers for Disease Control to fund thedevelopment of a state plan to prevent and control overweight and obesity in a focused populationthrough healthy eating and physical activity. The effort, named the Healthy Lifestyles Initiative,convened a 52-member Statewide Planning Committee to guide the production of a focused stateplan to combat overweight and obesity. The committee members, listed inside the front cover of thisreport, represented organizations with expertise in physical activity, healthy eating, minority issues,research, communications and community development.

6


continued

The committee divided into threesubcommittees to explore specific issues indetail.

" Behavior

" Policy and Environment

" Communications

Over six months, with staff help from MDCH,the committee

1) Determined that African American women,the highest risk segment, should be thepriority population addressed in thestrategic plan.

2) Reviewed existing data and literature andoffered expert information about factorscontributing to overweight and obesity inthis population. (See Appendix 1)

3) Produced an inventory of programs andservices related to physical activity, healthyeating, and/or obesity, focused onMichigan counties with the highestpercentage of African American residents.(See Appendix 2)

4) Identified the main barriers to AfricanAmerican woman being active and eatingwell.

5) Developed and prioritized strategies tofacilitate healthy eating and physicalactivity.

6) Provided recommendations for creation ofa state plan.

Fighting the Michigan Epidemic . . .

7

Go

es A Lo

ng

Wa

y

The Good News–A Little

Goes A Long Way

Experts agree that modest weight

loss, in the range of 10 % of ones’

initial body weight, procures signifi-cant health benefits (Oster et al.

1999; NIH 1999). Depending on age,

gender, and initial BMI, maintaining aweight loss of 10% can reduce the

probable number of years one might

have hypertension, high bloodcholesterol and type 2 diabetes;

decrease the anticipated lifetime

occurrence of coronary heart diseaseand stroke; increase life expectancy;

and diminish the expected lifetime

medical care costs due to selectobesity-related diseases by

thousands of dollars (Oster et al.

1999).


Intermediate Objectives

1. By 2005, decrease the percentage of AfricanAmerican women who are sedentary (no leisure-time physical activity) from 42% (1996-2000BRFSS Combined) to 33% (half-way betweencurrent levels of inactivity for African Americanwomen and the rest of the Michigan population).The objective will be monitored through physicalactivity modules of BRFSS. Oversampling will beconsidered to better estimate percentages ofpriority population.

2. By 2005, improve by at least 10 % frombaseline, the proportion of African Americanwomen engaged in healthy eating practices, asdetermined by a variety of healthy eating measures(fruit and vegetable intake, fiber consumption,percent of fat in diet, etc.) combined into onehealthy eating indicator. Baseline to be determinedfrom results of the 2002 Special Nutrition Survey,available in early 2003. The objective will bemonitored by future administration of a similarspecial survey in 2005.

Recommendations

1. Communications and Education

Recommendation: Contribute to anatmosphere supportive of a healthy lifestyle byproviding positive messages and information aboutnutrition, physical activity, and healthy weight lossstrategies to African American women.

Strategies:

A. Launch a multifaceted, culturally sensitivecommunication campaign addressingphysical activity, healthy eating andoverweight/obesity.

The Plan

In developing the state plan, consideration wasgiven to whether a strategy addressed an identifiedbarrier and if it involved partnerships withorganizations already engaged in promotingphysical activity and healthy eating for the targetpopulation. Additionally, strategies were selectedbased on their potential to reach a large number ofthe population and effectively change behavior.Strategies were prioritized according to theexpected immediacy of their implementation andimpact as well as their importance in achieving planobjectives.

GoalImprove the health and well being of African Americanwomen in Michigan by halting the rise in obesity ratesthrough increased levels of physical activity and healthyeating.

Long-term ObjectiveBy 2007, slow the rise in obesity rates amongAfrican American women.

Baseline 5-Year Trend MeasuresMI BRFSS

Year Prevalence (%)1997 29.9 (+7.3)1998 33.5 (+8.1)1999 35.9 (+8.0)2000 32.3 (+7.6)2001 36.5 (+6.4)

8


Michigan’s Community Self-AssessmentInventory and develop plans to reduce localpolicy and environmental barriers tophysical activity.

C. Guide communities with high populationsof African Americans in using Michigan’sNutrition Environment Assessment Tool(NEAT) to assess and address local policyand environmental barriers to healthyeating.

3. Programs

Recommendation: Provide culturallyappropriate opportunities to learn how to beactive, eat healthfully, and achieve/maintain ahealthy weight.

Strategies:

A. In collaboration with Michigan’s AfricanAmerican faith community, implement acomprehensive faith-based initiative forimproving physical activity and healthyeating.

B. Partner with the MDCH CardiovascularHealth, Nutrition and Physical ActivitySection to expand use of their communityleader guide which serves as a complementto the Healthy Food, Healthy Soulcookbook.

4. Health Care Providers/Systems

Recommendation: Increase the percentage ofhealthcare providers counseling African Americanfemale patients in a culturally sensitive manner onoverweight/obesity (Baseline: 10.4% foroverweight African American women and 45.7%for obese African American women.)

9

B. Partner with the National KidneyFoundation of Michigan to explore use ofadditional messages and information in theHealthy Hair Starts with a Healthy Body beautysalon program.

C. Partner with the MDCH CardiovascularHealth, Nutrition and Physical ActivitySection to tailor 5 A Day messages forAfrican American women and expand usethrough traditional and nontraditionaloutlets in the counties with highest targetpopulations.

D. Partner with the Greater Detroit AreaHealth Council coalition of organizationsfocused on implementing a physical activitycampaign entitled Motown in Motion.

2. Supportive Communities

Recommendation: Facilitate social, policy andenvironmental changes to ensure that communitiesimprove physical activity and healthy eatingenvironments.

Strategies:

A. Provide training on social, policy andenvironmental change to priority areacommunities in collaboration with theMDCH Cardiovascular Health, Nutritionand Physical Activity Program (e.g.,walkable communities training, statewidepolicy and environmental changeconference, training on NutritionEnvironment Assessment Tool, etc.)

B. Guide communities with high populationsof African Americans to implement


Strategies:

A. Design and conduct innovative trainings forhealthcare providers on issues related tocultural sensitivity in counseling on weightissues and the NHLBI guidelines.

B. Establish, disseminate, and promote coremeasures for obesity to serve as a qualitybenchmark for healthcare providers.

C. Empower patients to initiate conversationsabout weight loss with their providers.

D. Work in partnership with managed careorganizations to develop strategiesthat lead to a method of reimbursementfor weight management counseling by anutritionist or dietitian.

5. Surveillance, Epidemiology andEvaluation

Recommendation: Establish methods andsystems to gather and disseminate data and monitortrends for overweight/obesity, healthy eating andphysical activity, specifically for African Americanwomen.

Strategies:

A. Implement special surveys, as needed,through the Healthy Lifestyles Initiative andthrough partnerships (e.g., NutritionProgram Special Survey and PreventionResearch Center Flint Community Survey.)

B. Continue to implement BRFSS withweight, physical activity and nutritionmodules and consider oversampling, asnecessary.

C. Prepare burden of obesity document,update periodically and disseminate.

D. Work with the MDCH CardiovascularHealth, Nutrition and Physical Activity

Section to develop a statewide web-baseddatabase of local policy and environmentalindicators.

6. Resources and Infrastructure

Recommendation: Increase resources andexpand infrastructure for obesity prevention andcontrol.

Strategies:

A. Establish a statewide steering committeecomposed of key stakeholders to guideimplementation of obesity prevention andcontrol strategies and determine additionalmethods of enhancing resources.

B. Engage in strategic planning with otherchronic disease sections in order tostreamline efforts to address obesityprevention, physical activity and nutrition.

C. Continue to devote resources to theHealthy Lifestyles Initiative positions toassure adequate state-level infrastructure.

7. Research

Recommendation: Using a social marketingframework, implement and evaluate pilotproject(s) for the priority population that impact(s)overweight/obesity through physical activity andhealthy eating.

Strategies:

A. Implement a healthcare provider pilotproject that seeks to promote culturallyappropriate counseling on weight andstudies the effect of support offered by acommunity health advocate.

B. Enhance community supports for physicalactivity by addressing community walkabilitythrough a vacant land use education project.

10


women who took part in community focusgroups in Flint, and strategic planning members,all indicated that there are not enough AfricanAmerican women delivering messages abouthealthy eating, physical activity, and weightmanagement. In particular, focus groupparticipants said that an African Americanwoman who had personally struggled with herown weight and was someone like them (not amedia celebrity) was best suited to provide themwith information.

Finally, we make poor use of multiple channels ofcommunication. Several methods ofcommunication exist beyond traditional mediaranging from interpersonal, such as between ahairdresser and client, to delivery through smallsocial settings, such as churches and sororities.Both traditional and nontraditional channelsshould be used to reach women in places theywill be most receptive to a message.

We are not communicating effectively withAfrican American women regarding physicalactivity and healthy eating.

There is a perceived lack of appropriate rolemodels and culturally adapted informationpresented in a manner, style and language thatis well received. Anderson (1995) discusses thefact that health messages developed formainstream America, or for the AfricanAmerican community as a whole, may notresonate well with underserved AfricanAmericans who tend to view the health systemwith distrust and may not place emphasis onpreventive practices. Data from Michigan focusgroups that explored communication issues,conducted in partnership with the NationalKidney Foundation of Michigan, confirm this.Almost half of the participants reactednegatively to a health-oriented message thatstressed the medical consequences of beingoverweight. Messages that emphasized thepositive personal nature of physical activity andhealthy eating were better received.

Formative research also highlighted theinadequacy of message delivery, mainly inregards to the spokesperson. The AfricanAmerican women who participated in thecommunication focus groups, African American

Appendix 1:

1.

Factors Contributing to Overweight and Obesityin African American Women

Obesity is a multifaceted problem. A variety of factors stimulates and perpetuates the obesity epidemic. Thesefactors are explored below with an emphasis on weight management, physical inactivity and unhealthy eating asthey relate to Michigan’s African American women. The information is a synopsis of current literature, formativeresearch conducted through community focus groups and the results of brainstorming with the Statewide PlanningCommittee during strategic planning.

11


The living environment of many AfricanAmerican women in Michigan is not supportiveto physical activity and healthy eating.

Our environment has undergone significantchanges over the last thirty years and is a likelycontributor to increasing rates of obesity. Theimpact of the environment in promoting orpreventing physical activity is extensive.Opportunities for physical activity as an integralpart of our daily lives have been impacted bytelevision, labor saving devices, unsafe andunpleasant neighborhoods, computers at work,and increased automobile use (Schmitz andJeffery 2000).

The problem intensifies in Michigan’s urbanareas, where the majority of African Americanresidents live. Economic distress has resulted inurban blight. The Flint focus groups revealedthat personal safety is a big concern. ManyAfrican American women cited groups hangingout on corners or in parks, shootings, and othercrimes as reasons they feel uncomfortablebeing active outside. Additionally, sidewalks indisrepair, poor lighting, accumulated garbage,heavy traffic, lack of tree-lined streets and well-tended yards make the neighborhood uninvitingfor outdoor exercise. Limited options for indoorexercise also contribute to an environment illsuited for regular activity.

Changes in the food environment supportincreased consumption of high fat, high caloriefoods. Portion sizes continue to grow; thecurrent average size of a ready-to-eat chocolatechip cookie exceeds the USDA standard portionsize by 700% (Young and Nestle 2002).

As a whole, people are also eating out more andcooking at home less. In the 1970s about 20%

of the food dollar was spent on food eaten awayfrom home. In 1990, about 33% of foodspending in African American households wasfor food eaten away from home (Harnack et al.2000). That is compared to 35% in 1998(Blisard and Harris 2001). This trend wasconfirmed in focus groups where womenindicated that busy lives made the convenienceand low cost of fast foods appealing. Thetemptation of high fat, calorie-rich foods existsaround every turn and in places that would haveonce been odd locations for snacks: gasstations, book shops, all-purpose retail stores,etc.

Michigan’s urban areas experience a morepronounced impact on the food environment. Inaddition to the bleak environment describedabove, there is a lack of inner city grocery storeswith an adequate supply of fresh produce andother healthy options at affordable prices. Astudy done in Philadelphia suggests that limitedaccess to supermarkets is connected to a highrate of diet-related mortality in many low-incomePhiladelphia neighborhoods (Food Trust 2001).In Michigan, an abundance of inner city cornermarkets with poor quality produce at high pricesis the only option for many women who don’thave transportation available to travel to bettergrocery stores in the suburbs.

2.

12


It is perceived that healthcare providers arenot effectively addressing the needs of AfricanAmerican women in regards to physicalactivity, healthy eating and overweight/obesity.

The literature suggests that advice from aphysician may be an important factor forstimulating behavior changes that will result inweight loss among overweight and obesepatients (Writing Group 2001; Simons-Mortonet al. 1998; Bowerman et al. 2001; Marcus etal. 1997; Calfas et al. 1996). However, only10% of overweight African American womenand 46% of obese African American womenreport that their doctor has advised them tolose weight (MI BRFSS 1996, 1998, and 2000combined). These low percentages representmissed opportunities for obesity prevention.Lack of time, training, reimbursement, andeducational materials are seen as majorbarriers to healthcare providers in offeringcounseling on activity, diet and weight loss(Ammerman et al. 1993; Kushner 1995; Longet al. 1996; Pinto et al. 1998).

Results from focus groups with AfricanAmerican women in Flint confirmed thatphysician counseling would be important inmotivating many Michigan women to try to loseweight. According to the BRFSS, overweight andobese individuals who receive advice from theirphysician are more likely to report trying to loseweight than those not being advised.

In addition to low levels of counseling, strategicplanning members felt strongly that healthcareproviders were not communicating with AfricanAmerican women in a sensitive and effectivemanner about their weight. This wassubstantiated in the communication focusgroups. As stated by one woman: “The problemwith seeing the doctor is they always say youhave to lose weight, but they don’t know howtough that is. I just don’t hear it anymore whenthe doctor says that.”

Personal characteristics and concerns cancontribute to physical inactivity and unhealthyeating.

On an individual level, self-efficacy is stronglylinked with physical activity (Sherwood andJeffrey 2000). A woman might engage inphysical activity if confident in her skills andabilities to perform the activity and to overcomeany initial barriers. She is more likely to persistin overcoming barriers to physical activity ifconvinced that physical activity offers benefitsworthy of her efforts.

Contributors to physical inactivity identifiedthrough formative research and in the literatureinclude low motivation, life stressors, self-imagewhile being active, lack of time/competingpriorities, no one to exercise with, and havingchildren (Sherwood and Jeffrey 2000; Nies et at.1999).

Taste preferences ranked highest amongselected factors affectingeating habits for AfricanAmericans. They ranked costsecond, followed byconvenience, nutrition, andweight control (Glanz et al.1998). The perception thathealthier foods do not taste

Proportion of Individuals Trying to Lose Weight by Weight Statusand Physician Advice, Michigan BRFSS 2000 ( ± 95% confidenceinterval limits)

Overweight ObeseAdvised by doctor to lose weight 75.8 (+9.4) 83.5(+5.5)Not advised by doctor to lose weight 47.1(+3.9) 69.5 (+5.3)

3.

4.

13


5.

good, cost more, and may be inconvenient topurchase or prepare represents a criticalbarrier to healthy eating. Formative researchalso uncovered individual factors such as usingfood to cope with stress and trends likeincreased soda consumption.

Cultural and social issues can impact adoptionof healthy behaviors.

Overweight and obesity are not viewed negativelyby all cultures. Some studies have shown thatAfrican American women are more comfortableat higher body weights than their Caucasiancounterparts, and may not be subject to thesame social consequences due to greatercultural acceptance of overweight and obesity(Kumanyika et al. 1993; Flynn and Fitzgibbon1998). Although positive self-image at allweights is desirable, it may inhibit initiation andmaintenance of weight loss (Kumanyika et al.1993). However, formative research suggeststhat this social tolerance may be waning, as thefocus group participants often cited appearanceas a motivator for weight loss. Stevens,Kumanyika, and Keil state: “The challenge to thepublic health community is to encourage weightreduction when appropriate without forcing onBlack women a negative self-image and neuroticpreoccupation with weight.” (Stevens et al.1994)

African American women in Michigan livepredominantly in urban areas. The stress ofliving, working, and raising a family in these areascan negatively impact healthy behaviors.Sherwood and Jeffery point out the possibleinverse relationship between stress and physical

activity (Sherwood and Jeffrey 2000) andformative research suggests that stress canlead to improper eating for the sake of comfort.

Traditional African American cooking is popularand although often rich in taste, may also behigh in fat. Psychological factors related tocultural identity and self-image may presentstrong motivation to keep these foods in the diet(Kumanyika et al. 1991). Although formativeresearch shows that many younger AfricanAmerican women do not cook soul food veryoften, they still enjoy it when prepared by theirmothers or grandmothers.

The challenge to the public health

community is to encourage weight

reduction when appropriate without

forcing on Black women a negative

self-image and neurotic preoccupation

with weight. (Stevens et al. 1994)

“

”

14


Appendix 2:Inventory of Programs, Services and SupportsTo identify existing activities in Michigan for prevention and control of overweight and obesity throughphysical activity and healthy eating, the Statewide Planning Committee and MDCH staff completed aninventory of programs, services and community supports. The inventory—using a variety of methodsincluding mailings, phone calls, internet exploration and informants—focused on areas of the statewith the highest percentages of African American residents. Although not a comprehensive list, theinventory highlights important programs that might be enhanced or expanded and potentialcollaboration partners for the Healthy Lifestyles Initiative.

Inventory Highlights

Description

Search Your Heart is an American Heart Association kitdesigned for African American churches to address physicalactivity, nutrition, blood pressure and strokeHealth-related programs in church-based settings wereidentified in a few counties, including Wayne (Detroit) wherethe MI Neighborhood Partnership has established a faith-based outreach network

A variety of physical facilities (recreation centers) andprograms (classes, open gym times, etc.) are available inmany communities of interestNo information on utilization of facilities and programs byAfrican American women

Many areas have used enhancement funds to addressenvironmental issues that impact physical activity throughbeautification, trail development, sidewalk improvement,lighting, etc.

Malls in many of the priority counties have walking programsThe Arthritis Foundation has a comprehensive mall-walkingkit and has initiated a mall-walking program in some of thepriority counties

Programs, Services &Supports

Faith-based Initiatives

Parks & Recreation

“Transportation EquityAct for the 21st Century”Grants

Mall-walking Programs

#

#

#

#

#

#

#

15


MDCH CardiovascularHealth Programand Governor s Councilon Physical Fitness,Health & Sports

Motown in Motion

Project FRESH

Healthy Food, HealthySoul Cookbook

Statewide NutritionPrograms

Diabetes Outreach

Promoting Active Communities self-assessmentdeveloped to catalogue policies and environmentalsupports for physical activityMini-grants for assessment, planning, implementationWalkable Communities trainings offered

The Greater Detroit Area Health Council has created acoalition of partners in Southeastern Michigan who areworking together to create a communication campaignfocused on improved physical activity

Provides WIC participants/low-income seniors withcoupons for farmers’ marketsAlmost all priority counties participate in the programIn 2002, over 33,000 WIC participants received coupons

Provides ways of modifying some favorite soul foodrecipes to make them more healthyOver 60,000 copies of editions 1-3 distributed with 4thedition recently printedLeaders guide available to accompany cookbook anddevelop skills to use the cookbook in the community

WIC: Provides supplemental foods, nutrition education,social services/health care referrals to low-income,pregnant, breastfeeding, postpartum women and childrento age 5EFNEP (15 counties – mostly priority counties): Helpslow-income families with children improve adequacy ofdiets through increased knowledge and skillsFNP: Provides nutrition education to residents eligible orreceiving food stamps

Regional networks have been established and existthroughout Michigan in partnership with churches,community centers, senior centers, etc.Southeastern Michigan DON activities include HealthySoul Food Program which reached 593 AfricanAmericans (80% female) in 2001

#

#

#

#

#

#

#

#

#

#

#

#

#

#


16


Healthy Hair Starts witha Healthy Body

Health Plans

Media (highlights)

Social MarketingProjects (originallyfunded by MichiganPublic Health Institute)

Worksites (mostlyWashtenaw County -Ypsilanti)

National Kidney Foundation of MI program in citieswith a high percentage of African American womenStylists are trained to conduct “health chats” with theirclients in an effort to reduce rates of diabetes, kidneydisease, and cardiovascular diseaseOver 3,500 clients reached since 1999

Many offer varying levels of nutrition counseling andobesity programs as part of care or disease managementNone have obesity programs targeted to AfricanAmericansSome expressed interest in partnership

Print: African American Magazine reaches 15,000predominantly AA readers per month; health is 1 of 4main topics addressedRadio: WFLT Flint area. Gospel programming with 3shows per week that address health issues. Audienceprimarily African American women.TV: Carol Greer New Images Cable Show frequently doeshealth-related shows and has a particular interest inAfrican American women’s health issues

African Americans Take Charge of Your Health:Designed to influence nutrition and physical activitybehaviors of African Americans 30-54 in Calhoun CountyTake the Pledge: Move More, Eat Better: OaklandCounty program designed to increase fruit and vegetableintake and increase physical activityMany worksites offer no supports for healthy eating/physical activity

Weight Watchers is a popular program for worksites toofferA few more progressive sites include subsidizedmemberships to off-site exercise facilities, lowfat/healthyofferings in vending machines or cafeterias, walkingclubs, flex time, etc.

#

#

#

#

#

#

#

#

#

#

#

#

#

#


17


African AmericanHealth Initiative

Detroit (highlights)

Out-of-StateProgram— SistersTogether (Boston)

Kalamazoo initiative composed of health-relatedcommunity-based organizations, ministerial alliance,African American churches, local public health andhospitalsAnnual health fair; train lay health promoters in AfricanAmerican churches; sponsor education on diabetes, heartdisease, cancer diet and exercise

Kettering/Butzel Health Initiative: Main activities includechurch-based nursing programs; enhancement of primarycare access; community health education; expansion ofprevention programsHealth Empowerment Centers (Northwest and Nolan/State Fair): Community-based health resource centersoffering wide variety of physical activity and nutritionopportunities from support groups, to screenings, toaerobicsEastside Village Health Worker PartnershipCommunity garden serving 20 families per yearProduce mini-market (low/no-cost produce sold at 2 localcenters) reaching about 1,000 families per yearWalking clubs (20 women with diabetes): partnership withpolice dept for safetyHeart Healthy Cooking Classes taught by SEMDON twicea year (150 individuals)

Encourages African American women 18-35 to maintain ahealthy weight through physical activity and healthy eating

Program includes a planning guide and kit to helporganizations plan, promote, implement and evaluatecommunity health awareness programs

#

#

#

#

#

#

#

#

#

#

#


18


REFERENCES

1. Ammerman AS et al. Physician-based diet counseling for cholesterol reduction: current practices,determinants, and strategies for improvement. Prev Med. 1993; 22(1):96-109.

2. Anderson NB. Appealing to Diverse Audiences: Reaching the African-American Community. J Natl MedAssoc. 1995; 87:647S-649S.

3. Blisard N and J. Michael Harris. Household Food Spending by Selected Demographics in the 1990s. EconomicResearch Service/USDA. August 2001. ERS Agriculture Information Bulletin No. 773.

4. Bowerman S et al. Implementation of a primary care physician network obesity management program.Obes Res. 2001; 9(Suppl 4):321S-325S.

5. Calfas KJ, Long BJ, Sallis JF, Wooten WJ, Pratt M, Patrick K. A controlled trial of physician counseling topromote the adoption of physical activity. Prev Med. 1996; 25(3):225-33.

6. Flynn JK, Fitzgibbon M. Body Images and Obesity Risk Among Black Females: A Review of theLiterature. Ann Behav Med. 1998; 20:13-24.

7. Glanz K, Basil M, Maibach E, Goldberg J, Snyder D. Why Americans eat what they do: taste, nutrition,cost, convenience, and weight control concerns as influences on food consumption. J Am Diet Assoc.1998; 98(10):1118-26.

8. Harnack LJ, Jeffery RW, Boutell KN. Temporal trends in energy intake in the United States: an ecologicperspective. Am J Clin Nutr. 2000; 71:1478-84.

9. Kumanyika S, Wilson JF, Guilford-Davenport M. Weight-Related Attitudes and Behaviors of BlackWomen. J Am Diet Assoc. 1993; 93:416-422.

10. Kumanyika SK, Obarzanek E, Stevens VJ, Hebert PR, Whelton PK. Weight-Loss Experience of Black andWhite Participants in NHLBI-Sponsored Clinical Trials. Am J Clin Nutr. 1991; 53:1631S-1638S.

11. Kushner RF. Barriers to providing nutrition counseling by physicians: a survey of primary carepractitioners. Prev Med. 1995; 24(6):546-52.

12. Long BJ et al. A multisite field test of the acceptability of physical activity counseling in primary care:project PACE. Am J Prev Med. 1996; 12(2):73-81.

13. Marcus BH et al. Training physicians to conduct physical activity counseling. Prev Med. 1997; 26(3):382-8.

14. Mokdad AH, Ford ES, Bowman BA, Dietz WH, Vinicor F, Bales VS, Marks JS. Prevalence of Obesity,Diabetes, and Obesity-Related Health Risk Factors. JAMA. 2003; 289(1): 76-9.

15. National Institutes of Health, National Heart, Lung, and Blood Institute. Clinical guidelines on theidentification, evaluation, and treatment of overweight and obesity in adults. September 1998. NIHPublication No. 98-4083.

19 An Epidemic of Overweight and Obesity


continued

16. Nies MA, Vollman M, Cook T. African American Women’s Experiences with Physical Activity in theirDaily Lives. Public Health Nurs. 1999; 16:23-31.

17. Oster G, Thompson D, Edelsberg J, Bird AP, Colditz GA. Lifetime health and economic benefits of weight lossamong obese persons. Am J Public Health. 1999;89(10):1536-42.

18. Pinto BM, Goldstein MG, DePue JD, Milan FB. Acceptability and feasibility of physician-based activitycounseling. The PAL project. Am J Prev Med. 1998; 15(2):95-102.

19. Schmitz MK, Jeffery RW. Public Health Interventions for the Prevention and Treatment of Obesity. MedClin North Amer. 2000; 84:491-512.

20. Sherwood NE, Jeffery RW. The Behavioral Determinants of Exercise: Implications for Physical ActivityInterventions. Annu Rev Nutr. 2000; 20:21-44.

21. Simons-Morton DG, Calfas KJ, Oldenburg B, Burton NW. Effects of interventions in health care settingon physical activity or cardiorespiratory fitness. Am J Prev Med. 1998; 15(4):413-30.

22. Stevens J, Kumanyika SK, Keil JE. Attitudes toward body size and dieting: differences between elderlyblack and white women. Am J Public Health. 1994; 84(8):1322-5.

23. The Food Trust. Food for every child: The need for more supermarkets in Philadelphia. Philadelphia, PA.

24. The Writing Group for the Activity Counseling Trial Research Group. Effects of physical activitycounseling in primary care. JAMA. 2001; 286(6): 677-87.

25. U.S. Department of Health and Human Services. The Surgeon General’s call to action to prevent anddecrease overweight and obesity. [Rockville, MD]: U.S. Department of Health and Human Services,Public Health Service, Office of the Surgeon General; [2001]. Available from: U.S. GPO, Washington.

26. Young LR, Nestle M. The contribution of expanding portion sizes to the US obesity epidemic. Am JPublic Health. 2002; 92(2):246-9.

RERERENCES

20An Epidemic of Overweight and Obesity

An Epidemic of Overweight and ObesityAn Epidemic of Overweight and Obesity

MDCH is an equal opportunity employer, services and programs provider.

December 2002

Documents

in Michigan's African American Women › documents › AAObesityreportc...Obesity among African American women by education level MI BRFSS, 1996-2000 combined 34.5 31.8 24.5 36.540