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Addressing Obesity in African American Communities: Expanding

the Paradigm

www.aacorn.org

Shiriki KumanyikaUniversity of Pennsylvania School of MedicineCornell University Community Nutrition Seminar April 21, 2008

OverviewAudio will start with the next slide

• Context • Expanded causal paradigm• AACORN’s expanded paradigm• Follow up

– Linking AACORN’s paradigm to broader community issues

– Linking AACORN’s paradigm to mainstream obesity research

– Using paradigm to drive research design and implementation

In the News: U.S. Population Is Now One-Third Minority

• (May 2006) New U.S. Census Bureau estimates for 2005 show that 98 million people in the United States —about 33 percent of the total U.S. population of 296.4 million—are part of a racial or ethnic minority group. In addition, 45 percent of children under age 5 are minorities.

Population reference bureau www.prb.org

% of U.S. Non-Hispanic Black Men And Women Above Overweight And Obesity Cutoffs: 1999-2002

BMI 40 +

BMI 30 +

BMI 25 +

BMI 40 +

BMI 30 +

BMI 25 +

50.3

50.6

46.6

49.0

82.2

81.5

70.3

77.2

Women

3.0

2.9

4.1

3.4

14.030.572.260 y +

15.129.765.040-59 y

11.824.755.420-39 y

13.527.962.920 y +

Men

Source: Hedley et al, JAMA 2004;2847-2850 (June 16)BMI 25+= overweight or obese BMI 30+= obese (Class I, II, or III)BMI 40+= Class III or extremely obese

% of U.S. Non-Hispanic Black Boys and Girls Above Overweight and Obesity Cutoffs: 1999-2002

GirlsBoys

41.9

37.9

25.6

40.1

BMI > 85th

percentile

23.618.732.112-19 y

22.817.029.76-11 y

9.68.020.92-5 y

23.217.931.06-19 y

BMI > 95th

percentileBMI > 95th

percentileBMI >85th

percentile

Source: Hedley et al, JAMA 2004;2847-2850 (June 16)

BMI 85th percentile and over = at risk of overweight BMI 95th percentile and over = overweight

Trends in Adult Obesity

0

10

20

30

40

50

60

0

10

20

30

40

50

60Black Male Mexican American MaleWhite Female Black FemaleMexican American Female White Male

Percent

1960-62 1971-74 1976-80 1988-94 1999-2000

Obj. 19-2

Note: Data are for ages 20 years and over, age adjusted to the 2000 standard population. Obesity is defined as BMI >= 30.0. Source: National Health Examination Survey, National Health and Nutrition Examination Surveys I, II, III and 1999-2000, NCHS, CDC..

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Trends in the prevalence (%) of overweight in American children and adolescents during 1976-2002, by sex and ethnicity (Younger Children)

6.1

10.7

14.0

6.8

12.3

17.0

13.3

17.5

26.5

0

5

10

15

20

25

30

1976-80 1988-94 1999-02

Prev

alen

ce (%

)

White, non-Hispanic

Black, non-Hispanic

Mexican Am

5.2

9.8

13.1

11.2

17.0

22.8

9.8

15.3

17.1

0

5

10

15

20

25

30

1976-80 1988-94 1999-02

Prev

alen

ce (%

)

White, non-Hispanic Black, non-Hispanic Mexican Am

Boys (6-11 y) Girls (6-11 y)

Data sources: CDC, 2003; Hedley et al, 2004 Wang & Kumanyika, 2007

3.8

11.6

14.6

6.1

10.6

18.7

7.7

14.1

24.7

0

5

10

15

20

25

1976-80 1988-94 1999-02

Prev

alen

ce (%

)

White, non-Hispanic Black, non-Hispanic Mexican Am

4.6

8.9

12.7

10.7

16.3

23.6

8.8

13.4

19.9

0

5

10

15

20

25

1976-80 1988-94 1999-02

Prev

alen

ce (%

)

White, non-Hispanic Black, non-Hispanic Mexican Am

Adolescent boys (12-19 y) Adolescent girls (12-19 y)

Wang & Kumanyika in press

Trends in the prevalence (%) of overweight in American children and adolescents during 1976-2002, by sex and ethnicity (Adolescents)

The shifting distributions of BMI of five population groups of men and women aged 20-59 years derived from 52 surveys in 32 countries.

14 16 18 20 22 24 26 28 30 32 34 36 38 40 42 440.00

0.02

0.04

0.06

0.08

0.10

0.12

0.14Probability density

Body Mass index (kg/m )2Source: Rose, G. (1991) .

Population BMI Change Schematic Representations of BMI Distribution Models

Body mass index

Perc

ent of popula

tion

Body mass index

Perc

ent of popula

tion

U.S. children & youth U.S. adults

Source: Flegal KM, Troiano RP. 2000. Int J Obes Relat Metab Disord24:807-818.

Global Prevalence of Overweight in GirlsPrior to 1990

< 5 %

≥30%

Self Reported data

25-29.9%

20-24.9%

15-19.9%

10-14.9%

5-9.9%

% Overweight

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Global Prevalence of Overweight in Girls2000-2006

< 5 %

≥30%

Self Reported data

25-29.9%

20-24.9%

15-19.9%

10-14.9%

5-9.9%

% Overweight

Global Prevalence of Overweight in BoysPrior to 1990

< 5 %

≥30%

Self Reported data

25-29.9%

20-24.9%

15-19.9%

10-14.9%

5-9.9%

% Overweight

Global Prevalence of Overweight in Boys2000-2006

< 5 %

≥30%

Self Reported data

25-29.9%

20-24.9%

15-19.9%

10-14.9%

5-9.9%

% Overweight

Paradigm shift• Obesity levels reflect changes in

society– Economic development– Modernization and technology– Urbanization– Food production and marketing – Patterns of media use– Women’s roles

FACTORSINTERNATIONAL

Development

Globalizationof

markets

SchoolFood &Activity

WORK/SCHOOL/

HOME

Infections

Labour

Worksite Food & Activity

LeisureActivity/Facilities

Agriculture/Gardens/Local markets

COMMUNITY/LOCALITY

Health Care

System

PublicSafety

PublicTransport

Manufactured/ImportedFood

Sanitation

NATIONAL/REGIONAL

Food & Nutrition

Urbanization

Education

Health O

ITY

PREVALE

INDIVIDUAL

EnergyExpenditure

POPULATION

%OBESE

OR

UNDERWTSocial Security

Transport

Family &Home

Nationalperspective

Media &Culture

Food intake :

Nutrient density

Media programs

& advertising

Source: International Obesity Task Force [www.iotf.org]see Kumanyika S et al International Journal of Obesity 2002;26:425-36

OBESITY

PREVALENCE

Causal Web of Societal Processes influencing the population prevalence of obesity

Excess environmental risk in communities of color: Access

• Targeted marketing• Excess fast food outlets• Few supermarkets• Limited shelf choices in groceries• Availability of high-fat food• Less private transportation• Poorer public transportation

Yancey AK, Kumanyika SK, et al. review. Preventing Chronic Disease Available from: URL: http://www.cdc.gov/pcd/issues/2004/jan/03_0012.htm

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Excess environmental risk in communities of color: Economics

• Low neighborhood demand for low cal/low fat foods

• Low family incomes and cash flow• Other household expenses• Little home-grown food• Financial incentives offered to under-

resourced schools by commercial cafeteria vendors

Yancey AK, Kumanyika SK, et al. review. Preventing Chronic Disease Available from: URL: http://www.cdc.gov/pcd/issues/2004/jan/03_0012.htm www.aacorn.org

AACORN’s Purpose and Rationale

To improve the quality, quantity, and effective translation of research to address weight issues in African American communities

Extremely low representation of African American issues in the obesity and related literatures, coupled with extremely high need for attention to obesity and related issues in the African American community

Potential benefits of a cross-mentoring model for African American scholars with relevant interests

Need for an expanded obesity research paradigm

www.aacorn.org

African American Collaborative Obesity Research Network (AACORN)

Researchers across the US with diverse interests and expertise related to African American health, especially food, nutrition, weight, weight related health problems and women’s health

African American and selected other scholars

Early career scholars, established scholars, and scholars in training

Community research partners

AFRICAN AMERICANCOLLABORATIVE OBESITY RESEARCH NETWORK

Achieving Healthy Weight in African American Communities:Interdisciplinary Research Directions

Second Annual Scientific Meeting & Workshop

Sponsored by the Division of Nutrition and Physical ActivityCenters for Disease Control and Prevention

August 9 – 10, 2004Wyndham Hotel Downtown

www.aacorn.org

Research Focus: What is the Question?

Interventions on eating, physical

activity, andweight in African

Americans

www.aacorn.org Joanne Banks-Wallace, RN, PhD

“In order to gain the most out of this session, I encourage each of you to lay aside the usual framework that you use to take in information at scientific meetings and imagine that you have awakened, like Dorothy and Toto, and found yourself in Oz, where all that you know no longer governs all that is…”

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www.aacorn.org

Expanded Knowledge Domains

*Focus of traditional obesity research

Balance of

Calorie Intake

and Output*

Historical & Social

Contexts

Physical & Economic

Environments

Cultural & Psychosocial

Processes

• Aesthetic, moral, religious, and social values

• Collective psychology• Literary expressions

• Historical legacy• Social processes

in families andcommunities • Media and

marketing• Built environment • Food costs

Balance of

Calorie Intake

and Output*

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Research Lenses: Who is Looking? Listening?

African Americansin researched communities

African American researchers

Researchers in general

and researchsponsors

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• Community and family life (content)

• Historical legacy and core values (content)

• Ethnographic and literary content analysis (methods)

• Engaging communities(methods)

• Leveraging insider status (methods)

Research Contentand Methods

Expanded Knowledge Domains

Balance ofCalorie Intakeand Output*

*Focus of traditional obesity research

Balance of

Calorie Intake

and Output*

Cultural & Psychosocial

Processes

Historical & Social

Contexts

Physical & Economic

Environments

Where does this lead us?

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Community and Family Life

Community-specific environmental influencesCommunity structure and organizationWomen as a central focusHeterogeneity

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Jarrett… Qualitative sociological research, Chicago South Side

Gaining a sense of contexts, routines, and rhythmsAll types of family structures and family dynamicsFamilies “subsidizing” communitiesResource pools, daily routinesStrong normative support for self-sacrificing mothers

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Sheftall…literary works cited

Becky W. Thompson, Black Female, Hungry and HurtingRetha Powers, Fat is a Black Woman’s Issue (Essence, 1989)bell hooks, Sisters of the YamGloria Naylor, Linden HillsAlice Walker, MeridianGayle Pemberton, The Hottest Water in ChicagoToni Morrison, The Bluest EyeJune Jordan, Free Flight (in Passion, New Poems)

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One response

Is America ready for African Americans to be healthy?

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Historical Legacy and Core Values

Historical importance of trustCollective trauma

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McGary…spiritual and philosophical underpinning

What can we learn from the methods and teaching of philosophy?Recognize three important African American community values—

Loyalty (rationale and empirically validated)TrustworthinessJustice

Framed as rights of individuals and groups(“non-consequentialist” view), not justice in terms of the good of society as a whole (consequentialistview)

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James Myers…Collective Psyche

Importance of cultureUniqueness of African American experienceEmphasis on achieving optimal healthCollective and individual adaptationsChanges across generations

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Ethnographic and literary content analysis

Ethnographic research methodsLiterary representations of African American life

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Engaging Communities

Community members as equal research partnersCommunity strengthsBenefits to researched communities

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Leveraging Insider Status

Trust and credibilityConnections to communities of referenceObjectivity and expectationsSocial and professional support

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• Community and family life (content)

• Historical legacy and core values (content)

• Ethnographic and literary content analysis (methods)

• Engaging communities(methods)

• Leveraging insider status (methods)

Research Content& Methods

Expanded Knowledge Domains

Focus of traditional obesity research

Balance ofCalorie Intakeand Output*

Cultural & Psychosocial Processes

Historical & Social Contexts

Physical & Economic

Environments

Interventions on eating, physical

activity, andweight in African

Americans

ResearchFocus

ResearchLenses

African Americansin researchedcommunities

African American researchers

Researchersin general

andresearch sponsors

Progression toward more effective research to improve weight and quality of life in African American communities

Energy Balance

AACORN’S Expanded Obesity Research Paradigm

© African American Collaborative Obesity Research Network

Outline

• Context • Expanded causal paradigm• AACORN’s expanded paradigm• Follow up

– Linking AACORN’s paradigm to broader community issues

– Linking AACORN’s paradigm to mainstream obesity research

– Using paradigm to drive research design and implementation

Participatory Research on African American Community Weight Issues: Defining the State of the Art

• 2nd National Invited Workshop: August 2006– CBPR concepts and principles and potential

implementation regarding weight interventions– What constitutes a successful research project

to community residents? – What is involved in conducting research in

communities?

Participatory Research on African American Community Weight Issues: Defining the State of the Art

– Community priorities other than obesity (e.g., housing, violence and incarceration) that may be more immediate than those related to obesity and how these interface with efforts to address obesity; and

– Model CBPR programs (on any topic)– Views of funders and scientific journal editors

Linking to obesity research mainstream (examples)

• Cultural and psychosocial processes

• Historical and social contexts

• Physical and economic environments

• Overeating and stress

• Information• Health services

• Built environment

• Price• Marketing

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Research Design and Implementation

• Commitment to CBPR• Think Tanks• Broader Literature Reviews• Consultant Pool• Visibility and Critical Mass

www.aacorn.org