OBESITY IN LOW INCOME
AFRICAN AMERICAN ADULTS
A New York City Literature Review
Dr. Ediri J. Brume
2010
Umeå International School of Public Health
Umeå University
Sweden
Name of your supervisors Kjerstin Dahlblom
Kristina Lindvall
My sincere gratitude to my family for their support through my
masters program especially to my father. I strive to make you
proud each day.
My gratitude to Kjerstin and Kristina, my supervisors for all
their efforts as without them this would not have been remotely
possible.
ii
Abstract
Introduction: Obesity is a serious problem in the United States. The etiology of
obesity is more complex than low exercise and excessive eating. Obesity is related
to two out of three of the major causes of death in the USA. African-Americans
have the highest prevalence of obesity both in the city and in the country. About
30% of African-Americans in New York are obese. Low income is also largely
associated with obesity in the USA.
Aim: The purpose of this study is to explore the manifestation of obesity in New
York city especially in the adult African-American population. Income and
obesity are explored through various factors in the African -American residents.
Methods: A literature review was performed taking 27 articles from Pubmed and
Cinahl databases and government websites. They were screened to exclude
children and the elderly and articles published before year 2000. 27 articles were
selected and reviewed based on their relevance to this study.
Results and Discussion: Factors discussed from reviewing the selected articles
include neighbourhood, cheap unhealthy foods, culture and behaviour,
advertising, place of birth, barriers to physical exercise. Several studies report
that there were more supermarkets in non-Black neighbourhoods while more fast
foods in Black neighbourhoods. These neighbourhoods have very high obesity
rates and were labelled “toxic environments”. Cheaper foods and food insecurity
paradoxically promote obesity as unhealthier foods cost less. African Americans
were more comfortable with increased body weights as compared to the Whites
exemplified by the traditional obesogenic meal “soul food”. Advertising tends to
promote obesity as it specifically targets African-Americans in fast and unhealthy
foods with minimal advertisements on fruits and vegetables. Foreign-born born
African-Americans were shown to have lower obesity figures but this is related to
length of stay and educational status in the USA. Finally, African-American
women were less physically active as compared to other races as physical
activities were perceived as unfeminine among them. Costs of gyms and cost of
keeping fit were not given as excuses in studies of physical activities in those with
low incomes.
iii
Contents
1.
Acknowledgments
2
Abstract
3
Abbreviations/Definitions
5
INTRODUCTION
1.1
Description of Obesity
6
1.2
Diagnostic Criteria and Types of Obesity
7
1.3
Diseases Related to Obesity
8
1.4
Obesity in America
8
1.5
Obesity Distributions of African Americans
by Income.
9
Purpose of Study
11
1.6
2.
METHODS
3.
SETTING
3.1
4.
12
New York City Background
13
FACTORS AFFECTING OBESITY DISTRIBUTION
4.1
Neighbourhood
16
4.2
Cheaper unhealthy food
18
4.3
Lifestyle and behaviour
19
4.4
Advertising
19
4.5
Place of Birth
20
4.6
Barriers for physical activity
21
5.
DISCUSSION
23
6.
CONCLUSION
26
7.
APPENDIX AND REFERENCES
27
iv
Abbreviations and definitions
Words /
Abbreviations
Definitions
CDC
Centers for Disease Control and Prevention
Cholecystitis
Inflammation of the gall bladder
DVT
Deep Vein Thrombosis
Dysfunctional
Uterine Bleeding
Abnormal Uterine bleeding in the absense of organic disease
Dyslipidemia
Abnormality in lipid levels in the body
Endometrial Cancer
Cancer of the lining of the womb
Gout
A disease of the joint
MTA
Metropolitan Transport Authority
NYC
New York City
Osteoarthritis
Degenerative disease of joints
Pickwickian
Syndrome
A disease condition of longstanding hypoventilation due to
obesity
Pulmonary Embolism Acute Lungs disease caused by blot clots in its vessels
Sleep Apnea
Momentary cessation of breathing during sleep
Stress Incontinence
Unintentional leakage of urine caused by any increase in
abdominal pressure like coughing
Note that African American and Black American will be used interchangeably in this thesis.
1
1.1 Description of Obesity
Obesity has been defined in many forms. The Oxford reference dictionary defines obesity as
“the condition of being extremely fat or overweight”.1 Medically, obesity is defined as “a
complex multi-factorial chronic disease that develops from an interaction of genotype and
environment.”2
Obesity has been attributed to several medical conditions such as genetic disorders,
Cushing's syndrome, Polycystic ovarian syndrome, hypothyroidism, steroid medications,
antidepressant and contraceptive drugs.2Although with these several causes, it must be duly
noted that they only precipitate obesity. A common agreement among medical experts is that
obesity is caused by consuming more calories than the body burns and the excess being
stored as fat, which is the theory behind obesity surgery.3 Regular physical activity is the ideal
way of burning calories.4
Obesity is a major problem in both developing and developed countries. It is a major strain
on health budgets especially in the USA were about 100 billion dollars is spent yearly to curb
it. Recent estimations show that about 63.4% of Americans and 57.8 of New Yorkers are
either overweight or obese.2,5
Obesity in developed and developing countries has been shown to be strongly related to
income. In the developing countries, it is a problem among the rich while in the developed
countries it is a problem among the poor.6 Although, it should be noted that prevalence
among the rich is vastly increasing in developing countries.6
Researchers have suggested that obesity is a problem among the poor in the USA as foods
with more calories per gram tend to cost a lot less than healthy foods like fruits and
vegetables.7 Also, with the growing fast food industry and more Americans eating away from
home, unhealthy high fat foods are becoming more and more accessible and affordable.
Research has also shown that these fast food restaurants serve foods that contain high
amounts of unsaturated fats that contribute markedly to these overwhelming obesity figures
in the USA.8
2
1.2 Diagnostic Criteria and Obesity Types
Obesity can be measured in several ways, the most popular being the Body Mass Index, BMI.
How this is measured is shown below.
BMI = WEIGHT(KG) / HEIGHT (M2)
BMI also categorizes obesity (Table 1).
Table 1. BMI categories4
Weight Class
BMI
Class
Underweight
<18
-
Normal
18-24.9
-
Overweight
25-29.9
-
Mild Obesity
30-34.9
I
Moderate Obesity
35-39.9
II
Extreme Obesity
>40
III
Super Obesity
>50
Other measures of obesity include;
Weight
Waist to Hip Ratio values of >0.88 in women and >0.94 in men are considered requirements
for weight control as they have an increased visceral adipose tissue.9
3
Waist circumference (waist circumference >102 cm for men and >88cm for women are
strongly associated with metabolic disease)10
1.3 Diseases Related to Obesity
Obesity is a major problem in the USA both directly and indirectly as obesity plays a role in
two out of three of its top three causes of death (heart disease, cancers and stroke). It should
be noted that obesity directly reduces a persons productivity at work and has been linked to
more days off work compared to a normal weight individual.11 Obesity in severe cases can be
associated with knee problems that can confine individuals to wheel chairs which further
reduces work productivity. It must be said that apart from causes that will be discussed
below, the obese have an increased risk for depression.12
Obesity indirectly causes several serious conditions which significantly increase mortality
and morbidity among this group (Table 2).
Table 2. Common causes of morbidity and mortality due to obesity.2,4
Cardiovascular and
Neurological Systems
Hypertension, Coronary Artery Disease, DVT , Neurological
Stroke
Pulmonary System
Sleep Apnea, Pickwickian Syndrome, Pulmonary Embolism
Gastrointestinal System
Cholecystitis, Hernias, Reflux
Musculoskeletal System
Osteoarthiritis, Gout
Endocrine and
metabolic Systems
Diabetes, Dyslipidemia
Genitourinary System
Dysfunctional Uterine Bleeding, Stress incontinence
Cancer
Breast, Endometrial, Colon, Gall Bladder
1.4 Obesity in America
Obesity is a serious problem in America today precipitated by the increase in consumption of
high fat food and sugar foods together with reduced physical activity.7
4
Obesity rates have increased tremendously especially in the southern states between 19852008 (Figure 1 and 2). States like Mississippi, Alabama and Tennessee which had obesity
rates of 10-15% in 1990 have more than doubled to over 30% obesity rates as of 2008. The
big states like New York, Illinois, California, Florida with less than 10% obesity figures in
1985 have also more than doubled to between 20-24% in 2008. It is relevant to mention that
New York State had figures in the 25%-29% range in 2007 but dropped back to the 20-24%
in 2008. People with lower income are heavily affected as unhealthy foods are much cheaper
than healthy foods. Therefore, low income has an obesogenic effect.13
Figure 1. USA Obesity figures 1985.13
New York State =
5
Figure 2. USA Obesity figures 2008.13
1.5 Obesity Distributions of African Americans by Income
There have been several studies on obesity and income or inequalities and income but these
focus on the general population as few focus on the income levels of minorities.14 Several of
these studies have shown that high incomes and high education are both inversely related to
an individual’s body mass index.15 These have shown that inequality is a major problem and
could actually be one of the major risk factors for obesity. And as countries like Japan,
Austria, Netherlands and Scandinavian countries where inequalities are not as large, there
seems to be much lower obesity rates than the United States.15
Studies also show that the minorities are the hardest hit with obesity in the New York and in
the United States with numbers so high it is the second most preventable cause of death in
the United States next to smoking. It would be both interesting and necessary to understand
the relationship between obesity and income in one of these minorities, the Black American
population.7,16
Fast increasing obesity rates among minorities, particularly among the Black population
need reinforced addressing. This is certainly one of the factors that contribute to the higher
mortality figures among this population as compared to the majority population. The only
preventable factor that causes more death than obesity is cigarette smoking.15
Studies showed that yes, there is a significant difference in obesity among different income
classes in the New York but this difference is more significant among the majorities (the
White Americans). Among the Black Americans, there is a variation with sex. The male sex
tend to follow the trend of developing countries which is those with higher income tend to be
obese. For women, income was not really associated with obesity rates except in the 30-49
6
age group which seemed to be similar to the white group.15 Why are there obesity differences
in races when the social inequalities are similar between these groups?
Studies show that the differences in income among the obese are not as noticeable in Blacks
as are they are in Whites.7,16 What are the factors that are preventive in the high income
Whites that are absent in high income Blacks and how can this information be used to
establish uniformity among both ethnic groups and income levels? Factors that seem to have
a major role to play in these differences and alternatives or areas that require further
research will be suggested.7,16
1.6 PURPOSE OF STUDY
As a medical student, working with an obesity surgeon in Sheffield, UK was my initial
exposure to obesity. This developed my interest in obesity, one of the worlds major
epidemics.
With this background, it was impossible ignore the high prevalence of obesity in the United
States of America during a medical rotation there.
With the fast increasing obesity rates and obesity related diseases in the USA and several
parts of the world, I deem it necessary to highlight the problem of obesity especially that
associated with the low income status young African America.
It is well known and several articles have proved that the poorer you are as an adult
American, the more likely you are to be obese. Marching through the streets of Manhattan
you would struggle to find an obese person, but take the train down to the Bronx and you
would see a sharp contrast in body figures which is especially obvious in the African
Americans. Why is this so? Why should lower income result in obesity and what may be the
cause of this? The main question of this research is;
Why do African-Americans have the highest obesity rates and how does this
relate to income?
7
The objectives of this thesis are to ;
•
Explore the manifestation of obesity in the developed world more specifically in New
York city, USA.
•
Focus on obesity among the African American ethnic group and associations with
income.
•
Discuss issues considered to be the biggest factors contributing to obesity.
•
Propose areas that would need further research and analysis .
2 METHODS
In this thesis, a literature review was conducted. Articles were collected mostly from online
searches and search databases.
Reasons for choosing this method include,
•
To explore different factors contributing to obesity.
•
To explore areas where research is lacking and suggest topics that need more
research.
I utilized mainly Pubmed and CINAHL databases to collect articles for this thesis. On
CINAHL , search for obesity yielded 24,856 articles and on Pubmed it yielded 131,199. I
decided to filter my search results by race and New York which significantly narrowed results
to 228 on CINAHL and 285 on Pubmed. From these I included articles published after year
2000. I also included some articles listed in the references of those articles. Articles relating
to pregnant women, children and the elderly were excluded which narrowed it down to 124
sources on CINAHL and 180 Pubmed. I eventually narrowed down and hand picked 27
8
sources which were full texts and related to this paper. I did not filter for income as it yeilded
too few sources. I also got data from the following reputable sources.
1. www.cdc.gov
2. www.nyc.gov
Most articles were based on other factors especially race as associated with obesity than
they were with income. I will discuss these factors further in the coming chapters.
Articles selected for the review are compiled in a table (Appendix 1).
3 SETTING
3.1 New York City Background
New York city is the most populated city in the United States with a 2008 population of
8,308,163 people (table 3, table 4) . It consists of five boroughs Manhattan, Queens,
Brooklyn, Bronx and Staten Island. It is considered to be the financial capital of the United
States.17
Table 3. New York city population data17
Total Population
8, 308, 163
100.00%
Female
Male
4, 344, 343
3, 963, 820
47.70%
52.30%
White
Black American
American Indian or Alaska Native
Asian
Native Hawaiian or other Pacific islander
Some other Race
Two or more races
3, 704, 243
2, 086, 566
29, 569
976, 807
4, 941
1, 328, 394
177, 643
44.60%
25.10%
0.40%
11.80%
0.10%
16.00%
2.10%
Hispanics (of any race)
2, 287, 905
15.10%
9
Table 4. New York City Population Data by Boroughs17.
Bronx
White
318,365.00
0.23%
Black or African American
489,835.00
0.35%
American Indian and Alaska Native
11,442.00
0.01%
Asian
52,706.00
0.04%
1,482.00
0.00%
Some other race
547,096.00
0.40%
Hispanic (of any race)
709,326.00
0.51%
Native Hawaiian and Other Pacific
Islander
Total Bronx Population
1,382,793.00
Brooklyn
White
1,137,683.00
0.45%
906,576.00
0.36%
13,082.00
0.01%
241,084.00
0.10%
1,092.00
0.00%
Some other race
283,326.00
0.11%
Hispanic (of any race)
500,958.00
0.20%
Black or African American
American Indian and Alaska Native
Asian
Native Hawaiian and Other Pacific
Islander
Total Brooklyn Population
2,539,617.00
Manhattan
White
945,281.00
0.58%
Black or African American
276,411.00
0.17%
14,631.00
0.01%
186,205.00
0.12%
2,110.00
0.00%
American Indian and Alaska Native
Asian
Native Hawaiian and Other Pacific
Islander
10
Some other race
251,405.00
0.16%
Hispanic (of any race)
401,816.00
0.25%
Total Manhattan Population
1,624,225.00
Queens
White
1,047,031.00
0.46%
458,289.00
0.20%
19,708.00
0.01%
502,360.00
0.22%
2,377.00
0.00%
Some other race
300,479.00
0.13%
Hispanic (of any race)
602,549.00
0.26%
Black or African American
American Indian and Alaska Native
Asian
Native Hawaiian and Other Pacific
Islander
Total Queens Population
2,278,482.00
Staten Island
White
373,957.00
0.77%
51,339.00
0.11%
2,043.00
0.00%
37,864.00
0.08%
222.00
0.00%
Some other race
24,490.00
0.05%
Hispanic (of any race)
73,256.00
0.15%
Black or African American
American Indian and Alaska Native
Asian
Native Hawaiian and Other Pacific
Islander
Total Staten Island Population
483,046.00
New York city has a very noticeable discrepancy in social statuses as the elite and higher
income New Yorkers live in Manhattan and downtown Brooklyn and the poorer population
live in the Bronx and parts of Brooklyn and Queens. The discrepancy in body weight in these
areas is obvious with the poorer regions having higher overweight and obese proportions
compared to the richer areas.18 It should be noted that over 20% of New Yorkers live below
poverty level compared with the 12% national average.16
11
Data from the CDC shows that 35.2% of New Yorkers are overweight and 22.6% are obese.13
(figure 3). Also, the same data shows, 31.1% of African Americans are obese compared with
28.2% Hispanic, 18.5% whites and 7.0% Asian.18 (figure 4)
The transportation system, MTA is one of the best in the world. It consists of surface and
underground trains, buses and taxis than run 24 hours a day and transport about 6 million
passengers a day.19
Figure 3. NYC Community Health Survey 2008. Percentage of Population who were obese by
neighbourhood.18
12
Figure 4. Showing Racial Obesity Trends in New York city.18
Figure 5. Map of New York City.20
13
4 FACTORS AFFECTING OBESITY DISTRIBUTION
4.1 Neighborhood as an Obesogenic factor
While associating income to obesity status among African Americans in New York city,
neighbourhood is know to play a vital role. From government statistical data, obesity rate in
the poorer New York city neighbourhoods in the Bronx (26-44%), and parts of Brooklyn(2644%) are significantly higher than obesity proportions than the neighbourhoods in the richer
central Manhattan (8-20%). But note that these poorer neighbourhoods also have significant
number of blacks compared to the richer neighbourhoods.7
Boardman et al stated from their study that black neighbourhoods had higher obesity rate
than white neighbourhoods. But this racial difference disappears after controlling for income
and neighbourhood obesity prevalence.21 At the time of this study, the average
neighbourhood obesity rate was 14.7%. Results showed that non black neighbourhoods
compared to black neighbourhoods had a much lower obesity rate. Less than 10% of these
non black neighbourhoods had more than over a quarter of people being obese as compared
to 37% of black neighbourhoods having over a quarter of people being obese.
As poor neighbourhood dwellers are three times as likely to be obese than the average
American, the researcher controlled for income level of the neighbourhood and found that
although richer areas have lower obesity rates than poorer areas, richer black neighbourhood
areas tended to have a greater obesity rate than poorer non black neighbourhood.21 This
result suggests that neighbourhood race might have a greater effect on obesity than
neighbourhood income.21
A USA study showed that there are four times more supermarkets in white neighbourhoods
as compared to black neighbourhoods while black neighbourhoods had more fast food
restaurants than white neighbourhoods.22 A study in Chicago suggested that fast food
restaurants tend to rather accumulate around suburban areas in which the dwellers were on
mid to high income levels.23 Although this might be true in Chicago, further reading suggests
it applies mainly to the class of children in schools in that vicinity.
In New York city, one study showed that the determining factor for fast food location was
based on the percentage of blacks living there.24 The association was far more than income of
residents as there were also vast amounts of fast food restaurants in residing areas of affluent
blacks. On the other hand, healthier fast foods like the food chain “Subway” was more
common in white neighbourhoods.24 Other concentrations of fast food restaurants included
14
Times Square, Union square and highly commercial areas with few residents so they were
excluded from the study.
A very interesting but controversial study suggested the cause of black neighbourhood
obesity was from both persistent black and white race segregation combined with fast food
companies targeting blacks consumer.25 African Americans have increasingly found it
difficult to break into white neighbourhoods. African Americans, including graduates from
colleges and of higher social and economic statuses also tend to live collectively in these black
populated neighbourhoods. A survey showed that high income African Americans live in
neighbourhoods 30% poorer than White Americans on the same economic level. Then, as
there are more fast food restaurants than supermarkets in these neighbourhoods all over the
USA, it seems to show that these companies tend to target the black race.25
On a study on East Harlem New York, it was discovered that only 18% of supermarkets had
the five recommended food types (as seen in table 5) compared to 56% supermarkets in the
upper east side. There were also less vegetables and fruit, less heart healthy food products in
East Harlem. Not only are these stores fewer in number, they are also in very inconvenient
locations as compared to the upper east side. This has given East Harlem and other similar
neighbourhoods the label “toxic environment.26
Table 5. Recommended healthier food types by the American Diabetic Association27
The five recommended food types
1. Low–carbohydrate or high–fiber bread
2. Low- or nonfat milk
3. Fresh fruit
4. Fresh green vegetables
5. Diet soda or club soda
Individuals living closer to supermarkets had less obesity rates compared to those living
closer to convenience stores as people who live in neighbourhoods in the vicinity of
supermarkets consume more fruits and vegetables.28 Studies initially showed that although
poorer neighbourhoods have higher fast foods densities, but this was not so in poorer black
neighbourhoods.25,28 It is worth mentioning that walkability of a neighbourhood tends to
decrease obesity rates in poor neighbourhoods as walking on street walks and in shopping
malls are major outlets for physical activity. Accessibility to gyms and sports facilities if in
good condition also tend to decrease obesity levels.28 However, one study showed that
walkability only affected the BMI of the richer population and had no statistical effect on the
poorer population.29 The effect of walkability on Americans was shown by another study to be
countered by an increase in unhealthy billboards.30
15
4.2 Unhealthier foods cost less
Dinour LM et al suggested several ways cheaper unhealthy foods could result in obesity.
•
Food insecurity status among low income children and adolescents has been
suggested to lead to obese adults. (Food insecurity status exists “whenever the
availability of nutritionally adequate and safe foods or the ability to acquire
acceptable foods in socially acceptable ways is limited or uncertain)
•
The low cost of high energy foods, make them more attractive among the poor leading
to higher calorie per gram of food intake resulting in higher obesity rates.
•
Also, poorer households with food insecurity tend to take less fruits and vegetables as
compared to richer households also contributing to obesity.
•
Poverty causing less surplus food could psychologically lead to preoccupation with
food and eventually binge eating.14
This binge eating was observed with the food stamp program where families get food stamps
allocated monthly. They tend to binge eat early in the month and are preoccupied with foods
towards the end of the month when the stamps have been depleted.14
Dietary advice suggests that healthy eating involves cutting down on sugars and oils and
switch to fruits and vegetables which apparently cost ten times more. Several low income
families in New York spend about $100 a week per households on food for approximately
four people. This makes it very difficult to afford healthy foods and may then involuntarily
increase the trend of eating unhealthy food among people with low income.7
The growing trend of fast food in the USA is one of the major contributors to obesity
especially among the poor. Food expenditures on food away from home increased from 38%
to 41% in 2001 describing how rapid the industry is growing. Reasons for this growth include
the increased working hours especially among the poor who have to work multiple jobs to
keep up.31
A survey of 9,872 adults aged above 20, 26.5% declared eating fast foods. These group ate
more saturated fat, more sugar, more carbonated drinks less water, less milk and less
vegetables than the other group that preferred to eat at home. Fast food consumption was
more common among the younger group and less in the older group. Not surprisingly, fast
food consumption was higher among African Americans especially among African American
men.31 Surprisingly, it was stated that the richer, suburban dwellers were likely to eat out
than eat in. Most of the food eaten outside the home consists of fast foods more often than
not.31 Being overweight was also strongly associated with eating out especially fast foods.31
16
Fast foods include foods like burgers, fried chicken and fries, basically foods you have to pay
for before you consume and you would usually have very little choices.
4.3 Cultural and Behavioural factors
Studies have suggested that the African American population tends to eat unhealthier foods
than other races.32 A 30 year survey showed that blacks have consumed lower levels of
vegetables, potassium and calcium than whites.32 A popular culture among several black
communities is to eat “soul food” on most social gathering in particular after church. This
Soul food is the traditional Black American meal which is high in saturated fat and and salt.
This is considered to contribute to the high obesity rates.22
Another research has suggested that perceived discrimination and racism among Black
women in the Caribbean was associated with increased obesity.33 Vine et al however found
different results showing decreased waist to hip ratios in African American Women with
perceived discrimination which warrants further study.34
An interesting study was performed by Gluck et al attempting to compare race and cultural
influences on eating habits. They prepared two questionnaires, Figure rating scale and
Eating habits Questionnaire attempting to compare perception of ideal weight to eating
habits. Results showed that African Americans were culturally more comfortable with higher
Body Mass Indexes (BMI) than Asians or Caucasians and this was so even after controlling
for BMI.35 And hence, they are less eager to take the necessary steps to curb overweight and
obesity problems.35
4.4 Black targeted Advertising
Advertising is another factor that should be looked into as a cause of Black obesity. Not only
has fast food restaurants been strategically placed in these black populated neighbourhoods,
Black and Latino American targeted advertising has played a major role in promoting
consumption among the blacks.30 There were five times as many alcoholic (high calorie
beverage) billboards in Latin and Black American neighbourhoods compared to white
neighbourhoods with less health promoting billboards than these neighbourhoods.30 Several
studies have shown that strong disparities exist for black and Latino Americans when it
comes to advertising.36 From magazines to billboards, from Television commercials to
internet advertisements have been shown to specifically target these minority groups. The
messages transmitted in these advertisements promote unhealthy lifestyles while much less
17
emphasis is focused on healthy lifestyles and keeping fit compared to media instruments
directed to White Americans.36 Advertisements for fruits and vegetables were barely found in
advertising instruments directed to blacks and Hispanics.30 Most of the adverts found
pertaining to fruits and vegetables was found directed to high income areas mostly populated
by Whites Americans.30 Very few advertisements promote physical activity and active
lifestyles among these populations. This might also contribute to the indifference in personal
fitness and weight in these groups.
4.5 Place of Birth
Another important point regarding obesity in African Americans is the comparison between
American born and foreign-born Black Americans. Studies have shown that USA-born
Americans have higher obesity rates (25.3%) compared with foreign-born Americans
(19.8%). Although it should be duly noted that USA-born Americans have slightly lower
overweight figures of 33.9% compared with 36.6% for foreign-born.18 Obesity figures for
Black Americans are 35.9% for USA-born and 26.5% for foreign-born.18
From the discussion above, foreign-born Americans generally have lower BMI figures. These
figures tend to be affected by these several factors;37
•
Duration of Stay in the USA: The longer they stay in the USA the higher the likelihood
of being obese. The rate tends to increase the fastest in the first 5 years of migrating
than in other years
•
University education: The presence of a bachelor’s degree made a huge difference.
Those with a bachelors degree did not see any statistically significant change no
matter the duration while those without saw the fastest changes in body weight.
•
Race: Hispanics and Black foreign-born Americans tend to have higher obesity
figures while in Whites and Asians no statistically significant change was seen.
•
Age at migration into the USA: The younger the foreign-born Americans the higher
the chance of becoming obese. This was observed the most in Hispanic immigrants.
•
Sex: Females are at a higher risk of becoming Obese compared with their males
counterparts of the same age and sex.
It should be duly noted that among all the foreign-born Americans, those of the Black race
have the highest obesity rates. This shows that the risk of being obese associated with being
black also affects foreign-born Americans although at lower levels than USA-born
Americans. This supports the ideology that being Black does increase your chances of being
obese.37,38
18
Another study suggested a theory called the “healthy immigrant effect” which has to be
taken into consideration when comparing the differences between foreign-born and USAborn Americans. It explains that immigrants are not chosen at random but are selected based
on what they can bring into the economy. These immigrants tend to be healthier and hence
confound the results making us assume that foreign-born Americans are indeed less obese.39
4.6 Barriers to Physical Activities
Physical activities levels are much lower among minorities especially the Black race. In fact
the Black females are the worst affected in that they are more likely to be uninvolved in any
physical activity than all the others and they do not feel bad about it.40 More so, they do not
see this as being unattractive as they believe that Black men tend to like more round figured
women.40
Another study suggested African American women in denser neighbourhoods with accessible
transportation like New York city tend to walk more than those who live in widespread
neighbourhood.41 This suggests Black New Yorkers should have a higher physical activity
level than Black Americans in other cities.41
Black and Hispanic women's different attitudes towards exercise compared to White
American women can be seen as early as eight years of age. On one hand factors like societal
pressure to look slim, interest in competitive sports, education, employment and self efficacy
tend to push these races towards exercise.42 While on the other hand, stronger factors like
cultural beliefs make them feel otherwise. Most feel that it is unfeminine and others feel that
taking care of the family has a higher priority and hence they have no time. And when they
do visit the gym, they see all the white women as being “too Barbie dolly” as stated in one of
the interviews. Also these groups do not really have active female family models to look up
to. Finally, African American young women do not personally find being slim as attractive as
hence they are less pressured to succumb to the social norms of being skinny with little
waists.42
Few studies have focused on- African American men and physical activity. One study
showed that men are twice as likely to be physically active than women. Men who were more
educated, leaner, non-smokers and possessed self-efficacy were more likely to be physically
active while men who were depressed, uneducated, unorganized, with less social support and
who had fewer active family and friends were less likely to be physically active.43
In a qualitative study via focused group discussions, subjects reasons for not being physically
included; high cost, low motivation/laziness and lack of sufficient time.44
19
In most of these studies, cost of gyms were barely mentioned and in one qualitative study,
subjects believed that even individuals in the lower socio-economic status could find a way to
be physically active and maintain a healthy body weight.
Wang et al studied the VO2 max (a fitness test) of 3,250 individuals aged 20-49 and of three
different races, non Hispanic blacks, non Hispanic whites and Hispanics. There was a
significant difference in the women as the black women were the least active of the group.45
This suggests lower participation in physical activities and can suggest another reason why of
the high obesity prevalence. However, the fitness of the men was not too different and the
writer did not consider it as causative factor in men.
5 DISCUSSION
As initially stated, obesity is caused by calorie overload that is not compensated with relevant
exercise.3 This might sound simple but it is a much more complex process. As discussed,
several complicated factors are related to the development of obesity. Income and race are in
some way related to most of these factors.
The obese tend to be unhealthier and have less chances of acquiring income than the non
obese.46 Studies in the USA and in Europe have showed that educated obese individuals
make less money that their thinner counterparts.47 Therefore, being obese markedly
influences an individual's income and being poor markedly influence an individuals weight
status hence a a continuing cycle.
Supermarkets vs Fast Food Restaurants
The articles have shown that a persons neighbourhood contributes to a persons BMI
especially the African American in New York city. Some neighbourhoods were even labelled
“toxic environments”.26 Boardman et al suggested higher prevalence of obesity in Black
neighbourhoods.21 Further, another research showed that income had less influence as richer
black neighbourhoods were relatively more obese than poorer White neighbourhoods.21 This
is suspected to be due to neighbourhood racial segregation.25 It is suggested though, that this
area should develop more research.
There was a lot of research on supermarkets and fast food restaurants in White and Black
neighbourhoods. Individuals who lived closer to supermarkets tend to be less obese. Fast
food industries particularly target African-American neighbourhoods.22,25 Could this targeted
20
advertising be a result of the high demand or could the high demand be a result of the
advertising? It would be interesting to research further.
Walkability was said to be higher in bigger more organized towns and thereby, New York
residents should have much lower obesity rates than other cities. I believe the billboard
effect ( where billboards tend to reduce the effect of walkability) might play a role and more
research should analyse this.28,29 If the billboards are taken away or if they are used to
promote healthier foods, would this have a strong effect? This can be answered by more
research.
Food Stamps, Cheap Food
Dinour et al suggested “food insecurity” as a risk factor for obesity.14 Not only did it improve
chances of children becoming obese adults, it showed that the poorer population tend to eat
high caloric foods which are cheaper and less fruits and vegetables which tend to be dearer.14
Food stamps were also suggested to be involved in a cycle of binge eating on acquiring the
stamps and preoccupation with food when they are depleted which eventually leads to more
binge eating on reacquiring stamps.14 Food stamps is a welfare program where low income
families are given these stamps monthly in order to acquire food.14 These results strongly
associate obesity to poverty. It would be interesting to study what would happen if food
stamps could only purchase certain types of foods (healthier foods).
“Soul food” seems to play a major role in obesity being the traditional African-American food
combined with the low consumption of vegetables.22 Perhaps, healthier preparations of these
foods can be attempted and the effect analysed. Discrimination and racism initially suggested
to be a risk was found to be preventive in the African-American population.34 However, as
results appear to go in different directions, further studies are needed. Also, it should be
noted that racism and discrimination should never be condoned.
More research is needed on how aware the affected individuals are about proper healthy
diets, and cheaper alternatives.
Media Effect
With more fast foods stores strategically placed in Black neighbourhoods it would not be
surprising that advertisements of these types of food will be higher in these neighbourhoods
while fruits and vegetable are advertised less in these neighbourhoods compared to White
neighbourhoods.30,36 Policy advocacy at local and state level is suggested and more research
is warranted.
21
For example when the famous R and B star, “Justin Timberlake” was used as a spokes person
for Mcdonalds with the theme “I'm loving it”. This appealed to fans of this star, most of
which are Black Americans to patronize Mcdonalds, the most famous fast food restaurant.
More role models especially Black celebrities are continually being placed in Black magazines
and other advertising sources and this exposure plays a significant role in unhealthy food
choices made.36 An attempt to use celebrities for healthier advertisements and advocate for
their abstinence from unhealthier ones is warranted.
Healthy Immigrant Effect
Under this factor, the effect of place of birth on being obese was explored. USA-born
individuals had higher obesity rates than foreign-born but lower overweight figures and
Blacks had the highest rates among foreigners.18
Other factors also affected an individual's weight status included duration of stay,
educational level, age at migrating, sex of immigrant and race of immigrant.37,38
It should be noted and more research is needed to determine if immigrants are actually less
obese than USA-born individuals because of “the healthy immigrants effect” in which
immigration laws actually select most of the immigrants based on what they can bring into
the society and are usually the healthier ones.39
Exercise Attitudes
Attitudes to exercises was different in different races especially among the women. The Black
women were the least active.40 Black American women were found to be less fit than other
races in a fitness test.45 They were also the least interested and least motivated to engage in
physical activity due to a different perception of body image.40,42
An unfeminine perception of physical activities were also found among Black women. The
Black men on the other hand were twice as active than the black women. Further studies are
needed to find other motivators for physical activity than body shape and size for instance,
focus on being physically active for your children and your health. The association with
income here did not suffice as costs of gyms were never mentioned as hindrances to
partaking in physical activities although more educated men were more likely to be
physically active.43,44 “Self-efficacy” was also mentioned as being proportional to partaking in
physical activities in both men and women.44
22
Limitations
There was no clear cut definition for income among New York city residents in the articles.
Too few articles discussed the risk of low income in Black Americans, rather race was
discussed as a risk in almost every article.
There was no clear cut definition for age as individuals were listed as adults, young adults,
children and elderly in most articles.
So of my research articles involved secondary data to enable me able to get an ample amount
of information.
6 CONCLUSION
Obesity is a complex process that involves more than eating more calories than burned. The
findings from this thesis show that race and ethnicity play very important roles in an
individual's weight status. Income also plays a role but it is not as pronounced as race and
ethnicity. However, the effect of low income on BMI in Black Americans is highly
understudied and more research is needed in this area. The factors discussed do indeed play
significant roles in an individual's risk of being obese but these studies also need to be
studied more in depth.
23
APPENDIX A
No No (ref) Authors
Title 1 7 Drewnoski A. Obesity, Diets and Social Review of 16 articles Inequalities, retrieved from online databases. 2 14 Dinour LM et al Food Insecurity‐Obesity Systematic review from Paradox: a Review of articles through online the Literature and the databases from 1990‐2006. Role Food Stamps May Play. 3 15 Zhanga Q et al 4 16 Van Wye G et al Obesity and Diabetes in Analytical Study with data To characterize trends in Prevalence of both diabetes New York City from community health Obesity among New York city and obesity increased in new survey (New York) and BRFSS residents york city and the USA. (USA) Socioeconomic inequality of obesity in the United States: do gender, age, and ethnicity matter? Methods
Purpose Results
To show the relationship of obesity with income and education. The lower the food budget the Income is strongly related to obesity. higher unhealthy foods are consumed as unhealthy foods are cheaper. But an increased food budget does not guarantee a healthy diet. To explain the correlation Correlation exist between food between food insecurity and insecurity and obesity in adults obesity. especially in women but not in children Data from the National It assess socio‐economic Health and Nutrition inequality in obesity among Examination Survey III, 1988– American adults aged 18‐60. 1994 was utilised 24
Comments Gender, age, and ethnicity could be important factors on socioeconomic inequality in obesity. Community health survey is a random digit dial telephone survey of about 10,000 New York city adults above 18 years of age. 5 21 Boardman JD et Race Differentials in al Obesity; The Impact of Place 6 22 Sankofa J et al. News Coverage of Diet‐ Health Report from articles Related Health retrieved from online Disparities Experienced databases. by Black Americans: A Steady Diet of Misinformation. Exploring factors that Many factors that are usually influence dietary behaviours are also significant are less among blacks. stressed by the media and need exposure so they can become part of the solution. 7 23 Austin SB Clustering of Fast Food Restaurants Around Schools : A Novel Application of Spatial Statistics to the Study of Food Environments. They utilized geocoded databases of restaurant and school addresses to examine locational patterns of fast‐
food restaurants and kindergartens and primary and secondary schools in Chicago, To characterize school neighbourhood fast food environments proximal to schools. The median distance from any school in Chicago to the nearest fast‐food restaurant was about 5 minutes walk. 8 24 Kwate NAO et al Inequality in Obesogenic Environments ; Fast Food Density New York City Fast food density in the 5730 census block groups comprising of the five boroughs The aim is to investigate the racial and socioeconomic correlates of fast food density in New York City. The results highlight the importance of policy level interventions to address disparities in food environments as a key goal in obesity prevention. The data analyzed was collected from NHIS which is a national survey on non institutionalized individuals with data from 402,154 respondents in a five year period. 25
Analyzing the race differentials in obesity at both the individual level and neighbourhood level. Race differentials were completely attenuated after controlling for poverty rate and neighbourhood obesity prevalence 9 25 Kwate NAO Fried Chicken and Fresh Apples; Racial Segregation as a Fundamental Cause of Fast Food Density in Black Neighbourhoods 10 26 Galvez MP et al Race and Food Store Availability in an Inner‐
city Neighbourhood. 11 28 Lovasi G et al 12 29 Lovasi G et al. 13 30 Yancey AK et al A Cross‐Sectional Prevalence Study.
Prevalence Study of Ethnically Targeted and Data collected from NHANES, National Restaurant association. Method not well detailed Exploring race‐based residential segregation as a fundamental cause of fast food density in Black neighborhoods. The food industry and inequalities in its markets and patterns of consumption contribute to health disparities in Black neighbourhoods Prevalence Study utilizing a working survey. To examine whether census blocks either 75% African American or 75% Latino are associated with food store availability, as compared with racially mixed census blocks, in East Harlem, New York. Inequities in food store availability exist by race/ethnicity in East Harlem, New York. Built Environments and Systematic Review from Obesity in several databases. 23 articles Disadvantaged were selected from 817. Populations To understand how obesity‐
related health disparities relate to obesogenic built environments. Evidence suggested disadvantaged groups were living in worse environments with respect to food stores, places to exercise, aesthetic problems, and traffic or crime‐
related safety. Effect of Individual or Neighborhood Disadvantage on the association between Neighbourhood and Walkability and BMI. Walkability only affected the To test whether the association between walkable high income and healthier environments and lower body populations. mass index (BMI) was stronger within disadvantaged groups. Height and weight were measured in a diverse sample of 13102 adults living throughout New York City from 2000‐2002. To explore if Blacks, Latinos and people living in low income neighbourhoods are 26
The density of advertising varied by zip code area race/ethnicity, with African General Audience Outdoor Obesity‐
Related Advertising. disproportionately exposed American zip code areas having to advertising of high calorie the highest advertising low nutrient foods, sedentary densities. life styles and transportation. 14 31 Bowman SA et Fast Food Consumption USDA’s 1994 to 1996 al of US Adults: Impact of Continuing Survey of Food Energy and Nutrient Intakes by Individuals (CSFII Intakes and Overweight 1994–1996) data was used . Status. To compare the diet quality and overweight status of free‐living adults, ages 20 years and older, grouped based on their fast food intake status. A small, but significant, positive association was seen between fast food consumption and overweight status. 15 32 Kant AK et al Tracking changes in Black–
White differentials in dietary to help understand the contribution of diet to these disparities. Dietary intake trends in blacks and whites was similar, suggesting previously identified dietary risk factors that differentially affect Black Americans have not improved in a relative sense. To examine whether perceived chronic discrimination is Perceived
Trends in Black White Differentials in Dietary Intake of US Adults. 16 33 Hunte HER et al. Data from NHANES 1971‐
2002 was analyzed from self reported intakes in non Hispanic Blacks and White Americans. The Association Multivariate multinomial Between Perceived logistic regression and logistic
discrimination and Obesity in a Population‐ regression analyses. Based Multi‐racial and Multi‐ethnic adult sample. related to excess body fat accumulation in a random, multi‐ethnic, population based unfair treatment was associated with increased abdominal obesity. sample of US adults. 17 34 Vines AI et al Associations of Abdominal Fat With Perceived Racism and Multiple logistic regression model on 447 African‐
American women through 27
Waist‐to‐hip ratio (WHR) High perceived racism was used to examine associations associated with a low WHR between excess abdominal while daily stress was Passive Emotional Responses to racism in African‐American Women. telephone interviews on perceived racism. 18 36 Prevalence Study.
Duerksen SC et Health disparities and al Advertising Content of Women's Magazines: A Cross‐Sectional Study. 19 37 Kaushal N et al Adversities of Acculturation? Prevalence of Obesity Among Immigrants. The researcher created synthetic cohorts of immigrants using the NHIS 1990‐2004 data. fat and perceived racism (a chronic stressor) and daily stress. associated with a high WHR.
To explore if variations exist in health‐related advertisements and health promotion cues among lay magazines catering to Hispanic, African American and Caucasian women. African American and Hispanic magazines readers were exposed to fewer health‐
promoting advertisements and more health‐diminishing advertisements. To study factors in immigrants associated with prevalence of obesity by their length of stay in the US. Obesity in those with a BA degree did not change significantly while it increased in those without. 20 38 Cunningham SA Health of Foreign‐born et al People in the United States: A Review. Systematic Review of articles from various medical databases. 71 articles were picked from 247 after several exclusion criteria. This studies the pattern of immigrant health in the US compared to US‐born individuals. Immigrants are healthier by
many but not all measures of health upon arriving to the US. 21 39 Antecol H et al Unhealthy Assimilation: Why Do Immigrants Converge to American Data from NHIS from 1989 to 1996 which includes 120,000 individuals and 45,000 households. Here, the purpose is to study the healthy immigrant effect along with the progression to American BMI levels. Females almost completely converge to American BMIs in 10 years while men do so in 15 years. 28
Health Status Levels? 22 40 Survey Research Protocol.
McArthur LH et Race and Sex al Differences in College Student Physical Activity Correlates. 23 41 Coogan PF et al Prospective Study of Urban Form and Physical Activity in the Black Women's Health Study. About 59,000 women were To assess the neighbourhood Women in densely populated recruited from Black women urban form and physical areas had higher association health study ( a prospective activity in women. with utilitarian walking and cohort) based on subscription decreased when they moved to to “essence” magazine. less dense areas 24 42 D'Alonzo KT et Cultural Beliefs and al Attitudes of Black and Hispanic College‐Age Women Toward Exercise. Focus group interviews.
25 43 Bopp M et al Qualitative Study. Individuals To explore influences on randomly selected from 20 physical activity of African‐
church rosters and American Men an Women. participated in a telephone survey. Factors Associated with Physical Activity Among African‐American Men and Women. 29
To asses race/sex differences Students exercised an average among college students in of 3.5 days a week with black physical activities. females exercising the least. To assess cultural knowledge that affects exercise behaviours among Black an d Hispanic college age women. Black women enjoyed competitiveness of exercise but felt pressure to conform to white beauty standards. Hispanic women felt exercise unfeminine. Employment, income, self‐
rating of health, Physical Activity self‐efficacy and enjoyment, and fruit and vegetable intake were positively associated with increased physical activity in men and women. Other positive factors in women were education, physical activity programs in churches and attempting weight loss. 26 44 Johnson RL et al A Qualitative Perspective of Barriers to Health‐promoting Behaviours of African Americans. Qualitative Study via focus group discussion. Exploring, in a qualitative perspective, barriers to health promoting behaviors in African‐Americans. Factors that resulted include cost, lack of discipline, lack of motivation, lack of time. 27 45 Wang C et al A sample of 7,437 adults aged 20–49 years were examined at a mobile examination center. To describe the distribution of cardiorespiratory fitness and its association with obesity and leisure‐time physical activity (LTPA) for adults 20–49 years of age without physical limitations or indications of cardiovascular disease. Non‐Hispanic black women had lower fitness levels than did non‐Hispanic white and Mexican‐American women. Regardless of gender or race/ethnicity, people who were obese had a significantly lower estimated maximal oxygen uptake than did non obese adults. Cardiorespiratory Fitness Levels Among US Adults Aged 20‐49 Years of Age: Findings from the 1999‐2004 National Health and Nutrition Examination Survey. 30
7 REFERENCES
(1)
"Obesity, n." OED Online. Sept 2009. Oxford University Press. 14 Apr. 2010
<http://dictionary.oed.com/cgi/entry/00329024>
(2)
Avunduk, C. (2008). Obesity. In: Mitchell CW; Howes S Manual of
Gastroenterology: Diagnosis and Therapy. 4th ed. Philadelphia: Lippincott
Williams & Wilkins. 476-483.
(3)
CDC. (2009). Overweight and Obesity. Available:
http://www.cdc.gov/obesity/causes/index.html. Last accessed 8 April 2010.
(4)
Shils ME; (2006). Modern Nutrition in Health and Disease. Philadelphia:
Lippincott Williams & Wilkins. 1030-1031.
(5)
CDC. (2008). Prevalence and Trends Data Nationwide (States and DC) - 2008
Overweight and Obesity (BMI). Available:
http://apps.nccd.cdc.gov/brfss/display.asp?cat=OB&yr=2008&qkey=4409&st
ate=UB. Last accessed 8 April 2010.
(6)
Ziraba AK; Fotso JC; Ochako1 R. (2009). Overweight and Obesity in Urban
Africa: A Problem of the Rich or the Poor?. BMC Public Health. 9 (1), PMID:
20003478
(7)
Drewnowski A; Obesity, Diets and Social Inequalities. (2009 ).Nutrition
Reviews. Vol. 67 (1), 36–39.
(8)
Block JP; Scribner RA; DeSalvo KB. (2004;). Fast Food, Race/Ethnicity, and
Income. American Journal of Preventive Medicine. 27 (3), 211-217.
(9)
Lemieux S; Prud’homme D; Bouchard C; Tremblav A; Despr JP. (1996). A
Single Threshold Value of Waist Girth Identifies Normal Weight and
Overweight Subjects With Excess Visceral Adipose Tissue. American Journal of
Clinical Nutrition . 64 (1), 685-93
(10) Pengelly CD, Morris J. (2009 ). Body Mass Index and Weight distribution. Scott
Med J.. 54(3) (3), 17-21
(11)
Rodbard HW et al. ( 2009). Impact of Obesity on Work Productivity and Role
Disability in Individuals With and At Risk for Diabetes Mellitus.. Am J Health
Promo. 23 (5), 353-360
31
(12) . Luppino FS, de Wit LM, Bouvy PF, Stijnen T, Cuijpers P, Penninx BW, Zitman
FG.. (2010). Overweight, Obesity, and Depression: A Systematic Review and
Meta-analysis of Longitudinal Studies. Arch Gen Psychiatry. 67 (3), 220-229
(13) CDC. (2009). USA Obesity Trends by State 1985 - 2008. Available:
http://www.cdc.gov/obesity/data/trends.html#County. Last accessed 14 March
2010
(14) Dinour LM, Bergen D,. (2007). The Food Insecurity–Obesity Paradox: A
Review of the Literature and the Role Food Stamps May Play. Journal of the
American Dietetic Association. 107 (11), 1952-1961.
(15) Zhanga Q; Wang Y. (2004). Socio-economic Inequality of Obesity in the United
States: Do Gender, Age, and Ethnicity Matter?. Social Science & Medicine. 58
(1), 1171–1180.
(16) Van Wye G, Kerker BD, Matte T, Chamany S, Eisenhower D, Frieden TR, et al..
(2008). Obesity and Diabetes in New York City 2002 and 2004. Prev Chronic
Dis . 5 (2), 1-11
(17)
American Community Survey. (2006 - 2008). ACS Demographic Estimates.
Available:
http://factfinder.census.gov/servlet/ACSSAFFFacts?_event=Search&geo_id=
&_geoContext=&_street=&_county=new+york+city&_cityTown=new+york+ci
ty&_state=&_zip=&_lang=en&_sse=on&pctxt=fph&pgsl=010. Last accessed
10 April 2010
(18)
New York City Department of Health and Mental Hygiene. (2008). Overweight
and Obesity 2008. Available: https://a816healthpsi.nyc.gov/epiquery/SASStoredProcess/guest?_PROGRAM=%2FEpiQu
ery%2FCHS%2Fchs2008a&var=bmicat3&crude=crude. Last accessed 20
March 2010.
(19)
Mediabridge Infosystems, Inc. (1994-2010). New York City Transportation.
Available: http://www.ny.com/transportation/. Last accessed 11 Apr 2010.
(20) http://www.residentialnyc.com/borough/borough.html
(21)
Boardman JD, Onge JMS. (2005). Race Differentials in Obesity: The Impact of
Place. Journal of Health and Social behaviour. 46 ( 3), 229-243.
(22) Sankofa J, Johnson-Taylor WL. (2007). News Coverage of Diet-related Health
Disparities Experienced by Black Americans:next term A Steady Diet of
Misinformation. Journal of Nutrition Education and Behaviour. 39 (2), S41S44.
32
(23) Austin SB, Melly SJ, Sanchez BN, Patel A, Buka S, and Gortmaker SL,. (2005).
Clustering of Fast-Food Restaurants Around Schools: A Novel Application of
Spatial Statistics to the Study of Food Environments. American Journal of
Public Health. 95 (9), 1575-1581.
(24) Kwate NAO, Yau C, Loh J, Williams D. ((2009)). Inequality in Obesigenic
Environments : Fast Food Density in New York City. Health &Place. 15 (1),
364–373.
(25) Kwate NAO. (2008). Fried Chicken and Fresh Apples: Racial Segregation as a
Fundamental Cause of Fast Food Density in Black Neighborhoods. Health &
Place. 14 (1), 32–44
(26) Galvez MP, Morland K, Raines C, Kobil J, Siskind J, Godbold J and Brenner B..
(2007). Race and Food Store Availability in an Inner-city Neighbourhood.
Public Health Nutrition. 11 (6), 624–631.
(27) Horowitz CR; Colson KA; Hebert PL, Kristie Lancaster K. (2004). Barriers to
Buying Healthy Foods for People With Diabetes: Evidence of Environmental
Disparities . American Journal of Public Health . 94 (9), 1549-1554.
(28) Lovasi G, Hutson A, Guerra M. (2009). Built Environments and Obesity in
Disadvantaged Populations. Epidemiologic Reviews. 31 (1), 7-20.
(29) Lovasi G, Neckerman K, Quinn J, Weiss C,. (2009). Effect of Individual or
Neighbourhood Disadvantage on the Association Between Neighbourhood
Walkability and Body Mass Index. American Journal of Public Health. 99 (2),
279-284.
(30) Yancey AK, Cole BL. (2009). A Cross-Sectional Prevalence Study of Ethnically
Targeted and General Audience Outdoor Obesity-Related Advertising. The
Milbank Quarterly. 87, (1), 155–184.
(31) Bowman SA, Vinyard BT. (2004). Fast Food Consumption of U.S. Adults:
Impact on Energy and Nutrient Intakes and Overweight Status. Journal of the
American College of Nutrition. 23 (2), 163-168.
(32) Kant AK, Graubard BI, Kumanyika, SK . (2007). Trends in Black–White
Differentials in Dietary Intakes of U.S. Adults, 1971–2002. American Journal
of Preventive Medicine. 32 (4), 264-272.
(33) Hunte HER, Williams DR. (2009). The Association Between Perceived
Discrimination and Obesity in a Population-based Multiracial and Multi-ethnic
Adult Sample.. American Journal of Public Health . 9 (7), 1285-1292
33
(34) Vines AI; Baird DD; Stevens J; Hertz-Picciotto I; Light KC; McNeilly M. (2007).
Associations of Abdominal Fat with Perceived Racism and Passive Emotional
Responses to Racism in African American Women.. American Journal of
Public Health. 97 (3), 526-530.
(35) Gluck ME, Allan Geliebter A. (2002). Racial/Ethnic Differences in Body Image
and Eating Behaviours. Eating Behaviour. 3 (2), 143-151.
(36) Duerksen SC, Mikail A, Tom L, Patton A, Lopez J, Amador X, Vargas R,
Victorio M, Kustin B, Sadler GR. (2005). Health Disparities and Advertising
Content of Women's Magazines: A Cross-Sectional Study. BMC Public Health.
85 (5), PMC1208907
(37) Kaushal N. (2008). Adversities of Acculturation? Prevalence of Obesity Among
Immigrants. Health Economics. 18 (3), 291–303.
(38) Cunningham SA, Ruben JD, Narayan KMV . (2008). Health of foreign-born
people in the United States: A review. Health & Place. 14 (1), 623–635.
(39) Antecol H, Bedard K. ( 2006). Unhealthy Assimilation: Why Do Immigrants
Converge to American Health Status Levels. Demography. 43 ( 2), 337–360.
(40) McArthur LH, Raedeke TD. (2009). Race and Sex Differences in College
Student Physical Activity Correlates. American Journal of Health behaviour .
33 (1), 80-90 .
(41) Coogan PF, White LF, Adler TJ, Hathaway KM, Palmer JR, Rosenberg L.
(2009). Prospective Study of Urban Form and Physical Activity in the Black
Women's Health Study. American Journal of Epidemiology. 170 (9), 1105-1117.
(42) D'Alonzo KT, Fischetti N. (2008). Cultural Beliefs and Attitudes of Black and
Hispanic College-Age Women Toward Exercise. J Transcult Nurs. 19 (2), 175183.
(43) Bopp M; Wilcox S; Laken M;, Butler K: Carter RE; McClorin L; Yancey A. (
2006). Factors Associated with Physical Activity Among African-American Men
and Women. American Journal of Preventive Medicine. 30 (4), 340–346.
(44) Johnson RL; Nies MA. (2005). A Qualitative Perspective of Barriers to Healthpromoting Behaviours of African American. The ABNF Journal. 16 (2), 39-41 .
(45) Wang C, Haskell WL, Farrell SW, LaMonte MJ, Blair SN, Curtin LR, Hughes
JP, Burt LV. (2010). Cardiorespiratory Fitness Levels Among US Adults 20–49
Years of Age: Findings From the 1999–2004 National Health and Nutrition
Examination Survey. American Journal of Epidemiology . 171 (4), 426-435.
34
(46) Friedman RR. (2009). Weight Bias: A Social Justice Issue A Policy Brief .
Available:
http://www.yaleruddcenter.org/resources/upload/docs/what/reports/RuddBri
efWeightBias2009.pdf. Last accessed 14 April 2010.
(47) Sarlio-Lähteenkorva S, Lissau I and Lahelma E. (2006). The Social Patterning
of Relative Body Weight and Obesity in Denmark and Finland . The European
Journal of Public Health. 16 (1), 36-40
35