Available online at www.sciencedirect.com
Physiology & Behavior 94 (2008) 61 – 70
www.elsevier.com/locate/phb
Environmental influences on childhood obesity:
Ethnic and cultural influences in context
Shiriki K. Kumanyika ⁎
Department of Biostatistics and Epidemiology, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania 19104, USA
Department of Pediatrics (Gastroenterology, Nutrition Section), University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania 19104, USA
Received 10 August 2007; accepted 15 November 2007
Abstract
Ethnicity is associated with differences in food-related beliefs, preferences, and behaviors, and cultural influences may contribute to the higher
than average risk of obesity among children and youth in U.S. ethnic minority populations. However, cultural attitudes and beliefs are not the only
potential source of ethnic variation in childhood obesity prevalence and should not be studied in isolation. Demographic, socio-structural, and
environmental variables must also be considered. Available evidence indicates ethnic differences along several pathways that may increase risks of
obesity development during gestation, infancy, childhood and adolescence. These include above-average prevalence of obesity in adult females
and of maternal diabetes during pregnancy, parental attitudes and practices that may lead to overfeeding children, above-average levels of
consumption of certain high calorie foods and beverages, and inadequate physical activity. Environments with lower than average neighborhood
availability of healthful foods and higher than average availability of fast food restaurants, along with exposure to ethnically targeted food
marketing may contribute to reliance on high calorie foods and beverages, and these foods may be socially and culturally valued. Attitudes about
and environmental contexts for physical activity are also relevant. Increasingly, it is acknowledged that individual behaviors and lifestyles, e.g.
food choices or child feeding practices, are responsive to the ecological contexts in which they are practiced. Focusing attention on the fluid
interactions of cultural influences with contextual factors, of recognized importance for the study of childhood undernutrition, can also lead to
further understanding of how to address ethnic disparities in childhood obesity.
© 2007 Elsevier Inc. All rights reserved.
Keywords: Ethnic group; Ecological models; Health disparities; Socio-cultural factors; Child development; Parental feeding practices
1. Introduction
No discussion of environmental influences on obesity is
complete without consideration of cultural factors. Attitudes
and behaviors related to body size and shape have long been
understood as culturally defined [1,2]. The cultural context of
food and eating is equally well-established [3–6]. Types and
amounts of food and beverages, flavors, textures, food
combinations, and traditional uses and meanings of food mark
⁎ Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania School of Medicine, 8th Floor Blockley Hall, 423 Guardian Drive,
Philadelphia PA 19104-6021, USA. Tel.: +1 215 898 2629; fax: +1 215 573
5311.
E-mail address: [email protected].
0031-9384/$ - see front matter © 2007 Elsevier Inc. All rights reserved.
doi:10.1016/j.physbeh.2007.11.019
differences among ethnic groups and societies, convey symbolic meanings, create social interactions, and define pleasure
and punishment. Furthermore, in every cultural tradition there
are concepts of how food relates to health, which foods are
deemed harmful and which are protective [3]. These cultural
influences apply to eating patterns of adults as well as what
and how adults feed their children and how the children are
socialized to choose foods for themselves. These cultural aspects of food are universal, yet their expressions differ greatly
among populations, classes and groups, shaped and conditioned
by interactions with the physical environment as well as sociopolitical and economic trends and events [3–6].
Cultural beliefs and practices related to food and feeding
vary among ethnic groups, and these differences may contribute
to different patterns of obesity in children and youth, related to
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S.K. Kumanyika / Physiology & Behavior 94 (2008) 61–70
their ethnicity. This is increasingly important for public health
because the prevalence of obesity among children and youth in
U.S. ethnic minority populations [7–9] is even higher than for
children in the U.S. population as a whole. Also, the numbers
of children in some of these populations are increasing. In
addition, ethnic comparisons on food intake variables of relevance to childhood obesity may offer clues to the importance
of these variables for the whole population, providing “natural
experiments” that provide for more variation than can be observed within any one ethnic group. For example, specific child
feeding behaviors prevalent in populations with higher than
average obesity prevalence suggest that these behaviors may be
important explanatory variables in obesity causation.
Ethnic group variations in the epidemiology of childhood
obesity are described in the lead article in this symposium [10].
Other articles discuss environmental effects on childhood obesity from developmental and behavioral perspectives related to
gestation, parental feeding practices and various environmental stimuli to eating as they may affect food preferences, satiety mechanisms, and actual food intake [11–13]. This article
highlights evidence about related ethnic group variations and
how cultural and other environmental variables that vary among
ethnic groups may interact. Brief background is provided on
relevant characteristics of U.S. racial/ethnic minority populations, followed by selected data on influences on childhood
obesity in these populations during gestation, infancy, childhood, and adolescence and discussion of cultural and environmental influences.
2. Background
2.1. Racial/ethnic classifications
The classifications used to define racial/ethnic minority
populations are based on self-categorizations as reported in the
U.S. census data [14] or in similarly collected data from health
services or health program records. These categories are used to
track and report many social, economic, and health indicators
for racial/ethnic subpopulations of interest within the United
States, and they change over time to keep pace with changes in
population demographics [14,15]. The familiar, broad classifications are black/African American [used interchangeably],
Hispanic/Latino [also used interchangeably], American Indian
and Alaska Native, Native Hawaiian, Asian American and
Pacific Islander. Hispanic/Latino is an ethnic grouping that
overlaps with the other, “racial”, categories but is usually pooled
across racial categories and treated as a substitute classification
with the footnote that Hispanics and Latinos may be of any race.
These broad categories are not homogeneous and must
be interpreted with caution. The majority of black/African
Americans are U.S. born, but this category may include people
with origins in the Caribbean and Africa. Hispanics/Latinos
include U.S. born and immigrant populations with origins from
Mexico, Puerto Rico, Cuba, Central and South America, and
Spain [16]. American Indians and Alaska Natives include
hundreds of different, federally-recognized groups with origins
and residence throughout the United States on tribal lands or in
other communities. Asian Americans include people with
origins from all parts of Asia and were, until recently, classified
together with Pacific Islanders. However, many health indicators differ markedly for Asians and Pacific Islanders, and it is
helpful when these groups are reported separately. Pertinent
here, the prevalence of obesity in Asian Americans and Pacific
Islanders (tends to be at opposite poles (lower than average and
higher than average, respectively) [8]. In addition, standard
definitions for obesity may underestimate weight related health
risks in Asian Americans and overestimate them in Pacific
Islanders [17].
2.2. Interpretation of racial/ethnic differences
Racial classifications imply a biological basis, but the biological significance of these classifications and the validity of
using them as proxies for genetic variations is questioned increasingly, particularly as we now have the tools to explore
genetic differences directly [15,18]; also see the article by
Fernandez in this symposium [19]. On the other hand, the sociopolitical significance of these classifications is increasingly
recognized [15]. That is, the commonly used racial and ethnic
categories are valid but not necessarily in ways that might
usually be assumed when racial differences are mentioned. To
the extent that these categories identify “minority status” rather
than simply identifying sources of ethnic diversity, they are
associated with the social and political disadvantages that
accrue from neglect or discrimination on the basis of race or
ethnicity. While some aspects of minority status are independent
of social class [20], being in a minority population impacts
negatively on social position. Racial/ethnic minorities in the
United States are generally more likely than whites to live in
poverty and to be undereducated and underemployed [16]. Such
social and economic disadvantage is not necessarily dependent
on being in a numerical minority. The aggregate size of the
racial/ethnic minority populations is increasing and will exceed
50% in the coming decades [21]. In some states “minorities” are
numerically already in the majority.
Ethnic differences include variations in cultural attitudes and
practices but also reflect many other factors on which minority
populations differ, among themselves and from the majority,
white populations. These factors include differences in the
geographic region of residence or degree of urbanization, family
size and type and household composition, health care access
and health related behaviors, and neighborhood characteristics,
including safety, number and type of services available, and the
degree of racial/ethnic segregation. Segregation is highest for
African Americans [22], worsens poverty qualitatively [23] and
generally limits personal choices as well as flexibility in exercising those choices [24,25].
The table gives examples of differences in census indices of
socioeconomic status (SES) and maternal–infant health variables for four aggregate minority populations, based on U.S.
year 2000 census data from urban areas, which were 50.7%
white, 25.4% black, 16.3% Hispanic, and 5.8% Asian [26]. SES
differences are evident. The higher percentage of single-mother
households among African Americans and, to a lesser extent,
S.K. Kumanyika / Physiology & Behavior 94 (2008) 61–70
Hispanics are noteworthy. Also, low birthweight is more frequent in African Americans, and teen pregnancy is more
common in both blacks and Hispanics. Early prenatal care is
less common in all three of the ethnic minority groups shown.
2.3. Ethnic differences in obesity prevalence
As described in the epidemiological overview by Adair [18],
data from the National Health and Nutrition Examination
Survey (NHANES) show higher than average obesity prevalence in non-Hispanic black and Mexican American children
compared to non-Hispanic white children at most ages [7].
In boys the excess obesity is apparent primarily in Mexican
Americans ages 2 through 11, compared to non-Hispanic black
or white boys in those age groups. In girls, excess obesity is
apparent in both non-Hispanic black and Mexican American
girls at all ages and is particularly marked among non-Hispanic
black girls compared to other girls at ages 6 through 19. This
suggests that the predisposing factors leading to excess obesity
may differ by gender as well as developmental timing. These
prevalence differences reflect steeper than average rates of
increase in obesity in Mexican American and particularly nonHispanic black children during the past three decades [27], and
especially in children ages 6 and over.
The NHANES only reports ethnicity specific data for nonHispanic blacks and whites and Mexican Americans. Surveys
of selected community or school based populations, cohort studies, or health system data [28–33] clearly show an excess risk of
obesity affecting Hispanic/Latino children generally as well as
American Indian, Native Hawaiian, and Samoan children at
various ages. With the exception of African American girls,
excess obesity observed among children in ethnic minority
compared to non-Hispanic white children was often noted
prior to recognition of the obesity epidemic [34]. Factors predisposing to obesity in African American children may, therefore, reflect relatively recent social–cultural and environmental
changes to a greater extent than in some of the other populations
of color.
In contrast to the other ethnic minority populations, obesity
prevalence is often found to be lower than average in Asian
American children [29,33]. However, this does not necessarily
mean that Asian American children are at commensurately
lower health risks. BMI levels are not synonymous with body
fatness levels, and fatness levels at any given body weight level
are higher, on average, in Asian Americans than whites [35].
Data for adults suggest that the health risks of obesity in Asian
Americans may become evident at BMI levels lower than the
usual cutoffs used to define obesity [17]. Hence, factors that
predispose to or protect against excess weight gain in Asian
American children are still of potential interest.
Obesity prevalence also varies by SES, but ethnic differences
are often observed even within SES categories [36,37]. Wang
and Zhang [38] point out that the associations of SES with
obesity are not the same in all groups. For example, these
authors found that the inverse association of SES with obesity
that is usually seen in females in westernized countries is only
seen in white girls; obesity prevalence is seen to increase with
63
increasing SES in black girls. Overall, however, associations of
SES related variations in obesity in the U.S. population appear
to be diminishing [9].
In immigrant populations, obesity prevalence increases
across generations and with longer duration of residence in
the United States. For example, in data from a large study of
U.S. adolescents from diverse ethnic groups, the likelihood of
being obese was twice as high among both Hispanic and Asian
Americans who were born in the United States compared to
those born elsewhere and newly immigrating [39]. Indirectly,
this underscores the fact that ethnic differences in obesity are
strongly determined by environmental factors.
3. Racial/ethnic group differences in factors linked to
childhood obesity
3.1. Gestation and early infancy
Maternal obesity and diabetes are associated with having
higher birthweight infants. Although this could reflect a genetic
predisposition in the mother transmitted to the infant, other
mechanisms related to fetal exposures to circulating glucose or
metabolic programming of appetite or energy balance regulation are also possible [40–42]. Whatever, the mechanism,
maternal obesity and diabetes may explain some of the higher
risk of childhood obesity in minority populations. The
prevalence of obesity is higher among African American,
Hispanic/Latino, and Native American women compared to
white women [7,43,44], and the prevalence of diabetes during
pregnancy is also higher among women in these ethnic groups
as well as in some subgroups of Asian American women [45]
(See Fig. 1). Excess pregnancy weight gain, which is more
common among black than white women, for example [46],
may also increase the likelihood of having infants with high
birthweight [40]. However, as noted previously (see Table 1),
African American women are at marked excess risk of having
infants with low rather than high birthweight [44]; the
significance of maternal weight status in the development of
early obesity in African American children is unclear. Low
birthweight has been associated with subsequent risks of central
obesity but not necessarily generalized obesity occurring during
childhood.
A study of adolescent overweight according to environmental temperature at birth provides clues to factors that might
operate during gestation to predispose to excess weight in
adolescent African American girls [47]. The study was
motivated by evidence of a possible relationship between
obesity development and season of birth based on animal data
and some observations in humans. Data on weight, height, birth
date, and birth place were obtained by self-report from 1100
school children ages 15 to 19 in Philadelphia. For the 578
students who were born in Philadelphia, the information on
birth date was linked to archived meteorological records for the
Philadelphia area. Results indicated that being overweight was
correlated with higher environmental temperatures in the 2nd
and 3rd trimesters of gestation and at birth, in females but not
males. The association of overweight with higher (N versus ≤
64
S.K. Kumanyika / Physiology & Behavior 94 (2008) 61–70
Fig. 1. Age-adjusted diabetes rate among women during pregnancy 1993–95 per 1000 live births. Source: Office of Research on Women's Health. Office of the
Director, National Institutes of Health, Women of Color Health Data Book, 2002 Fig. 53 (data are from MMWR 47(20):408–14) [See Ref. [45]].
13.2°C [56°F]) environmental temperature at birth was
statistically significant in the African American but not white
females: relative risk 2.51 (95% Confidence Interval 1.07–5.91)
and relative risk 1.94 (0.61–1.94) in African American and
white females, respectively. The authors noted several possible
mechanisms leading to differential effects on fetal appetite
regulation or fat deposition—variations in melatonin levels
associated with day length or effects of environmental temperature or seasonal changes on maternal carbohydrate and fat
intake. Given the gender specificity of the association, mechanisms that might impact differently on females and males in
utero would be of particular interest.
Rapid weight gain in the first year of life may predispose to
obesity development in childhood or later adulthood, regardless
of birthweight [48–50]. For example, Stettler retrospectively
analyzed the prevalence of overweight (CDC 95th percentile) at
age 7 years in a cohort of more than 19,000 children born at full
term (which excluded considerations related to preterm birth)
according to the rate of weight gain during the first 4 months of
life [48]. A significant increased risk of being overweight at age
7 (odds ratio 1.38 (CI 1.32–1.44 per 100g weight gained per
month) was observed. This association was present in each
quintile of birth weight, after adjustment for several confounding factors. The persistence of this association after control for
attained weight at 1 year of age suggested that this effect was
not simply due to tracking of weight from early infancy to age 7.
Whether the determinants of the rate of weight gain were
genetic (e.g., expression of an underlying predisposition to
obesity), were based on developmental factors acting in utero,
or related to infant feeding practices cannot be determined. In
particular, the data from this cohort did not include sufficient
information to allow analysis of the role of breastfeeding.
Breastfeeding may protect against the development of childhood obesity, although the issue continues to be debated [50,51].
Even where such protection may be found among whites, the
potential protective effects of breastfeeding in African Americans
Table 1
Selected socioeconomic status and maternal–infant health status indices in 1990 and 2000 in U.S. cities, by ethnicity
Race/
ethnicity
Year of U.S.
census and
percent
change
Education
Adults ages
25+ without
high school
diploma
Adults ages
25+ with any
college
attendance
% living
below
100%
poverty
% children
under age 18
living in
poverty
% families
headed by
single
mothers
% families
headed by
single mothers
in poverty
% live
births of
low birth
weight
% live births
to teen
mothers
(b20)
% live births
with mothers
receiving early
prenatal care
White
1990
2000
% change
1990
2000
% change
1990
2000
% change
1990
2000
% change
20.7
16.5
−20.4
32.3
25.1
−22.4
39.1
42.8
9.7
25.1
23.6
−6.2
53.5
60.0
12.2
40.7
46.1
13.3
38.5
34.8
− 9.6
58.2
59.8
2.8
11.5
11.5
0.1
30.3
26.5
−12.6
24.4
23.9
− 2.1
23.4
18.8
−19.7
14.6
13.9
− 5.0
41.2
35.3
− 14.3
30.5
29.3
− 3.9
25.3
19.4
− 23.5
9.3
10.3
11.4
34.5
36.2
4.9
18.4
17.7
− 4.1
9.0
8.6
− 4.7
3.3
3.0
− 7.8
18.6
15.6
−16.3
10.1
8.1
−19.6
4.3
3.0
−30.1
6.1
6.8
11.8
13.6
13.1
−3.4
6.5
6.6
2.2
7.0
7.8
10.4
9.4
8.1
− 13.6
23.9
20.6
− 13.9
18.1
17.2
− 5.3
6.7
6.2
− 8.0
82.9
87.6
5.6
62.0
74.2
19.6
63.8
71.9
12.7
72.0
81.3
13.0
Black
Hispanic
Asian
Poverty and family composition
Maternal–infant health
SOURCE: Anrdulis, Dennis P. Moving beyond the status quo in reducing racial and ethnic disparities in children's health. Public Health Reports 2005;120:370–377
[See Ref. [26]].
S.K. Kumanyika / Physiology & Behavior 94 (2008) 61–70
and Latinos are less evident [52,53]. This may relate in part to the
duration of breastfeeding. Some data suggest that short duration
of breastfeeding (i.e., less than 3 months) may be a risk factor for
overweight, while only the longer duration breastfeeding is
protective [52]. In addition, there may be cultural differences in
the type of breastfeeding, e.g., whether exclusive or in
combination with formula feeding and early introduction of
solid foods, or in other risk factors for overweight that can
overwhelm any protective effects of breastfeeding [52,54].
If breastfeeding is an important determinant, then the lower
rates of breastfeeding observed in African Americans may
contribute to childhood obesity development. In national data
for 2001, 33.7% of African American infants were breastfeed
for 3 months or more, compared to 49.7 of white infants and
54.3% of Hispanic infants [55]. However, lower income women
in minority populations (as well as in whites) who participate in
the Special Supplemental Nutrition Program for Women,
Infants, and Children (WIC) may be generally less likely than
their peers to breastfeed [56]. In the Ross Laboratories survey
data for 2003, the percent of mothers breastfeeding at 6 months
among non-WIC participants was 44, 36, 37, and 51% for
white, black, Hispanic, and Asian American women, respectively, but was 20, 15, 26, and 33 among the WIC participants in
these groups. Although WIC mothers may be advised to breastfeed, WIC policies that provide more benefits to mothers who
feed infant formula may counteract this advice [54]. In addition, the higher rates of teen pregnancy in African Americans
and Latinos may contribute to lower breastfeeding rates, since
mothers under age 20 years at the time of the baby's birth are the
least likely to breastfeed for 3 months or more [55].
Following are two additional examples of cultural attitudes
about body weight and what constitutes appropriate infant
feeding. Baughcum and colleagues [57] explored child feeding
practices in focus groups with WIC mothers in Northern
Kentucky. The sample was primarily white, highlighting that
cultural attitudes related to weight and overfeeding are identified not only in ethnic minority populations but also in high risk
populations defined by income or rural residence. Some African
American mothers were included but findings were not reported
separately for this group. The mothers in this study did not indicate awareness of an upper limit to acceptable infant weight.
They believed that it was better for infants to be heavier and that
heavier and faster growing infants were healthier and better
cared for. They also expressed a fear that infants would not
get enough to eat unless given cereal and other solid foods
early on—earlier than recommended by health professionals.
In fact, they tended to feed children who seemed to be hungry even if they knew that the child had just eaten, and they
were concerned about children being underweight even when
they were clearly not in the underweight range. Mothers
expected their children to be hungry if they themselves were
hungry and found it more convenient to feed infants the same
types of foods eaten by adults. Food was also used by these
mothers to reward children's behaviors or to calm them when
they were fussy.
Bentley [58] conducted in depth interviews with African
American mothers recruited from WIC programs in Baltimore,
65
Maryland, limiting the sample to those 13 to 20 years of age,
living with their own mothers, and having their first child, with
children newborn through age 24 months at the time of the
interview. Both mothers and maternal grandmothers were
interviewed multiple times. Interviews were guided by a conceptual model that prompted for influences of cultural beliefs
about parenting, social support provided by the grandmother,
the mother's own resources and sources of stress as interrelated
influences on the pattern of infant feeding, and the additional
influence of the child's temperament or appetite on the feeding
pattern. The results confirmed the prevalence of the cultural
norm to feed cereal in the infant's bottle from as early as 1 to
2weeks of age and to feed other semi-solid foods within the first
month of life. Grandmothers often dominated decisions about
what infants were fed, having particular influence when actually
responsible for or involved directly in caregiving.
3.2. Childhood and adolescence
As discussed by other authors in this symposium [12,13] and
reviewed elsewhere [59] determinants of obesity during childhood and adolescence may include child feeding practices,
parental decisions about the types of foods available in the home
and their children's access to these foods, children's consumption of high fat foods and soft drinks, social interactions around
food, amount of TV watching, sports participation or active
recreation, and influences of parents as role models related to
eating, physical activity, and body size. All of these variables
may contribute to the high risk of obesity among children in one
or more minority populations or at least are worthy of further
study in this respect [60]. Some examples follow.
In the National Heart, Lung, and Blood Institute Growth and
Health Study, fast food consumption was associated with higher
caloric consumption [61]. Black girls in this cohort consumed
more fast food than white girls and had higher fat consumption
than white girls at a given level of fast food consumption. The
physical activity levels of the black girls were markedly lower
compared to white girls [62]. In the California Health Interview
Survey both soft drink consumption and fast food consumption
were highest in African American and Latino compared to white
and Asian adolescents [63]. Data from a comprehensive, nationally representative survey of 8th, 10th, and 12th graders also
reported higher levels of several obesity promoting behaviors
(breakfast skipping, low intake of fruits and vegetables, and
high levels of TV watching) in black and Hispanic compared to
white children, often independent of SES [64]. Eating at fast
food restaurants was associated with higher rates of childhood
overweight in Mexican American school children in San Diego,
whereas eating in Mexican restaurants was protective [65].
Higher levels of TV watching in black and Hispanic children
have been reported in other surveys of media use [66,67]. TV
watching may predispose to obesity because it is a physically
inactive pastime and also because it exposes children to advertisements for high calorie foods and may therefore lead to
increased intake of high calorie foods.
Although the optimum parental feeding style for obesity
prevention has not been clarified, key objectives are to preserve
66
S.K. Kumanyika / Physiology & Behavior 94 (2008) 61–70
any innate appetite regulatory mechanisms that may be present
in childhood (e.g., not forcing children to eat when they are not
hungry or after they feel that they have had enough) and to offer
nutritious foods such as milk, fruits and vegetables in preference
to soft drinks, chips, French fries, and candy [12,13]. Potentially
relevant ethnic and cultural differences in infant feeding styles
[57,58] have already been noted. There may also be important
ethnic differences in feeding styles during preschool and school
age years, e.g., parent- versus child centered [68] or authoritative versus authoritarian [69] and in how various feeding
strategies related to obesity development.
Parental concern about children's weight may be one
element of feeding styles, e.g., lack of perception that the
child is overweight or a perception that a normal weight child is
underweight may predispose to overfeeding. This possibility is
supported by data from focus groups with WIC mothers of
preschool children, in Cincinnati, Ohio [70]. Most (13 of 18)
women in the focus groups were African American. Most were
overweight or obese and had children in the overweight or
obese range. The mothers were asked questions such as: How
do you know a child is at a healthy weight? What are the
warning signs that a child is becoming overweight? What
does the word obese mean to you? What causes a child to be
overweight? Whose responsibility is the control of eating?
Responses indicated that the mothers did not accept growth
charts as the basis for determining their children's weight and
that having a large body size was culturally acceptable as long
as the children were healthy, active, had good self-esteem and
were not teased by their peers. The mothers saw physical inactivity as related to weight but perhaps limited by rather than a
cause of overweight. Difficulties in restricting food related to
concern about withholding food from a child who claimed to be
hungry, use of food as a parenting tool or reward, pride in being
able to afford treats, and–in some cases–challenges to their
authority by the child's father or grandmother.
In addition, the excess of obesity among women in ethnic
minority populations creates a socio-cultural milieu in which
obesity is normative in children's female role models. This applies
even for women in their 20's and 30's, the likely ages of parents of
young children. Based on NHANES data for adults aged 20 to 39
years in the 2003–2004 survey [7], 50.3% of black women are
obese (i.e., have a BMI of 30 or above) and 15.7% are in the
extremely obese category (i.e., have a BMI of 40 or above). Obesity
and extreme obesity occur in 35.7 and 8.6% of Mexican American
women in this age range, but only 23.8 and 6.4%, respectively in 20
to 39 year old non-Hispanic white women. Rates of obesity do not
differ as much in men in these ethnic groups, although the
prevalence of obesity (32.3 and 32.7%, respectively) in 20 to 39
year old non-Hispanic black and Mexican American men exceeds
the 27% in white men in this age range. Furthermore, relatively
more black men (7.1%) compared to Mexican American (1.9%) or
white (3.9%) men in this age range have BMI levels in the
extremely obese category. Leisure time physical activity levels of
African American and Hispanic adults are generally lower in
comparison to those of whites, especially in females [71,72],
suggesting that family engagement of children in sports and active
recreation may be limited.
4. Environmental contexts
The question posed in this article is to what extent to the
ethnic differences in obesity relate to cultural factors–in the
sense of culturally influenced attitudes and beliefs–and to what
extent they relate to other aspects of environments differentially
affecting ethnic minority populations in comparison to white
populations. As noted in the Introduction, this is not really a
case of “either/or”. The expression of these cultural influences is
in a dynamic, fluid interaction with the surrounding social and
environmental contexts. In some cases factors in these contexts
may enhance cultural predispositions. In other cases they may
limit or prevent the expression of cultural preference. In
addition, both cultural and environmental influences may
interact with biological determinants of obesity.
4.1. Socio-cultural environments
As implied by the data highlighted in the previous section,
aspects of the socio-cultural environments of some U.S. ethnic
groups appear to favor obesity development. The cultural acceptability of overeating may be conditioned by past or recurrent economic deprivation, i.e., “feasting” whenever food is
available [4]. Cultural wisdom related to avoiding hunger may
be strongly entrenched, while wisdom related to avoiding
obesity has not yet evolved. The most highly valued foods may
be those that are associated with the ability to survive, that were
scarce or unaffordable in the past, e.g., meat, fats, and sugars,
and that are emotionally rewarding. Many of these foods are
also associated with high social status and, therefore, strongly
desired as symbols of integration into the mainstream society or
of upward social mobility. These preferences and values may
persist for generations even when these “status foods” become
cheap and abundant. The intrinsically rewarding nature of fat
and sweet perpetuates their intake [12]. In addition, data for
African Americans suggest a heightened sensory preference for
sweet foods [73,74], which may further reinforce consumption
of these foods.
With respect to body image, the absence of prominent
cultural practices related to weight control may be due in part to
body size values that are positive or neutral to large body size.
Body image attitudes that may be permissive for obesity development have been clearly documented in African Americans
[70,75–78] although not necessarily in other minority populations. In studies with African Americans, body image attitudes that are relatively tolerant of excess weight are readily
elicited in qualitative studies, although at a community level
these attitudes probably co-exist with more typical perceptions of excess weight as negative. Being heavy is not considered synonymous with being unattractive and does not
necessarily damage self-esteem, even in adolescent girls [79].
Being too thin may be equated with being ill (e.g., having
cancer, tuberculosis, or HIV/AIDS) or being a drug user or, at
best, having limited fat stores to draw on in the event of illness
or “hard times” when money to buy food might be scarce.
Overweight may be viewed as a problem only when it is
clearly linked to health problems. These types of attitudes about
S.K. Kumanyika / Physiology & Behavior 94 (2008) 61–70
large body size may apply to any population where accumulation of excess fat is only seen when people are relatively healthy
and food secure [2]. As discussed in the next section, such
attitudes may be particularly likely to predispose to obesity
when high calorie foods and beverages are abundant, in excess of the typical person's caloric needs, are low in cost, and
are heavily marketed.
Culturally determined attitudes also influence physical
activity and inactivity. Interest in sports or traditions of being
physically active may be favorable to children's activity levels
when safe options for physical activity are available and
affordable. On the other hand, the prevailing cultural value for
television and automobiles as status symbols and signs of
economic sufficiency (e.g., being able to afford a car or buy a
TV for the child's bedroom) may predispose to sedentary
behavior. Populations who see being physically active as
“work” may seek sedentary rest and relaxation when possible
even though their jobs may not require physical activity [80].
67
Federal nutrition policies geared to providing a nutrition
safety net, e.g., the policies that support the school and child
care feeding programs, food stamps, and WIC, can theoretically
help to mitigate the risks of childhood obesity development
[90,91]. However, although such policies have become better
aligned with goals for dietary quality, the challenge of how one
leverages nutrition policy to also support goals for appropriate
caloric intake has yet to be met. For example, the food pattern
used as the basis for the Food Stamp program uses questionable
assumptions about the time that low income families will spend
in food preparation [92]. Reducing time in food preparation
raises the cost of food and increases reliance on foods with
higher caloric content. Other policies or policy gaps related to
school feeding programs may disadvantage children in ethnic
minority groups, who are more likely to be income eligible for
school feeding programs, e.g., policy gaps that allow high
calorie snack foods or beverages to be sold in competition with
the school lunch program or that provide insufficient opportunities for physical activity [90,91].
4.2. Physical environments
5. The culture–environmental interaction
There is increasing awareness that physical environments
can influence obesity development generally [81,82] and also
that physical environments are less favorable to weight control in communities in which ethnic minority children live. Less
neighborhood access to supermarkets or other retail outlets
that provide access to a mix of healthful food products at reasonable cost and higher than average exposure to fast food restaurants have been documented in ethnic minority and low
income communities [60,83,84]. Potential exposure to (urban)
violence when outdoors and lack of access to supervised recreational facilities, or the cost of admission to recreational
facilities may keep children from being physically active. In
addition, when advertising of high calorie–low nutrition foods
is seen as a part of the physical environment, current targeted
marketing practices add to the contextual risks for obesity development [60]. Several studies that have examined the frequency and content of food advertisements in television markets
with a high viewership of African American children have documented the higher than average occurrence of food ads and
higher proportion of ads for high calorie snack foods, soft drinks
and candy in comparison to ads in predominantly white markets
[85–87].
4.3. Economic and policy environments
Given the disproportionate prevalence of poverty in minority
populations, aspects of the economy and economic policy that
relate to the potential to avoid caloric overconsumption are
relevant to ethnic differences in risks of childhood obesity. Even
though food has become relatively inexpensive, the price
structure of the food supply is such that the least expensive
foods are those with the highest energy density [88]. This means
that people with limited discretionary incomes or unstable
incomes may rely on foods with high energy density [89], and
these foods increase the likelihood of passive overconsumption
and, therefore, weight gain.
Cultural influences on the predisposition to childhood obesity suggest the need for culturally-tailored interventions
[91,93,94]. However, in designing potential interventions we
must ask how important it is to focus solely on cultural attitudes
and beliefs as potential targets for change versus focusing on the
circumstances that give rise to or support certain of these
cultural variables. Cultural influences are not static variables
that occur independently of the environmental contexts in which
they are embedded and with which they interact [95]. Therefore,
consideration of ethnic differences in obesity must always refer
to relevant social, economic, policy, and media influences.
Increasingly, it is acknowledged that individual behaviors
related to obesity, e.g. food choices or child feeding practices,
are responsive to the contexts in which they are practiced
[82,96]. As discussed by Wachs [97] elsewhere in this symposium, we have traditionally explored these contextual issues
in relation to undernutrition. Focusing attention on interactions
of cultural influences with contextual factors may also yield
new insights about how to intervene effectively to reduce disparities in obesity prevalence among children and youth, particularly when potentially relevant biological context variables
are incorporated as well [98].
Potential culture–environment interactions and interdependence
can be illustrated by considering the home environment. The home
is the innermost level of environmental influence on children's
behaviors where combined socio-cultural, physical, economic and
policy influences are experienced. Parent/caregiver influences at
home are particularly important for preschool and school age
children; adolescents have more behavioral autonomy and access
to food. Characteristics of minority and low SES households that
may especially influence the context for parenting include the
higher proportions of female-headed households, lower parental
education levels and higher rates of teen parenting shown in the
table. Family ecologies may be characterized by connectedness to
extended family members and direct involvement of grandparents
68
S.K. Kumanyika / Physiology & Behavior 94 (2008) 61–70
or elders in child rearing [58,99] to a greater extent in ethnic
minority than white families. Also noted previously, the higher
levels of obesity in ethnic minority families, especially among
women, are a direct influence in the social context for obesity in
terms of role models and weight norms.
The ability and, indirectly, the motivation of parents to
provide healthful foods and beverages are influenced by food
availability and access and by other market-related variables.
The willingness to provide healthful foods will also be influenced by underlying cultural attitudes and habitual practices.
Some attitudes that might predispose to consumption of high
fat, high calorie foods can potentially be reshaped by a combination of changes in the food-related media and marketing
environments. Other attitudes may relate to perceptions based
on historical experiences, ethnocultural beliefs and values, or
economic factors, including food insecurity, and they may be
associated with core survival skills. These attitudes and
perceptions, which may be more deeply held and reinforced
by elders involved in caregiving or when giving advice to
parents, may pose particular challenges or opportunities for
obesity prevention in ethnic minority families with respect to
their willingness to create more obesity protective environments. The receptivity to advice from health professionals may
be limited if it contradicts the advice of elders, and it may also
be limited generally by distrust in the health care system [100].
In addition, parents, families, and children in ethnic minority
populations are likely to have higher than average levels of
direct or indirect (i.e., by association or ethnic identification)
exposure to environmental and psychological stress, e.g.,
associated with racial discrimination, violence, economic stress,
concerns about economic security and personal safety, and
perceived inability to improve one's life circumstances or those
of one's children [23,101]. Day to day stress may be overlaid
onto chronic stress caused by a sociopolitical history of
oppression or social disruption, or factors related to immigration
that are either retained in cultural memory or actively
considered when processing experiences with the U.S. society
as a whole. How this stress is experienced will vary from person
to person and among different ethnic groups. It is relevant here
because of the possibility that coping strategies may include the
use of food—a not uncommon strategy and one that may indeed
be effective for reducing stress [102–104]. Use of food for
coping and the associated metabolic reactions may predispose
to the deposition of abdominal fat and related metabolic
aberrations, possibly increasing levels of obesity and related
diseases during adulthood and predisposing to gestational
transmission of obesity.
6. Conclusion
The observation that childhood obesity is more prevalent in
ethnic minority populations is likely to reflect differences in a
combination of factors that result in: 1) excess obesity and
diabetes in adult females in these populations; 2) consequent
effects on gestational environments and social norms with
respect to establishing or expressing an underlying predisposition to gain excess weight; 3) infant and child feeding practices
likely to result in excess consumption of calories; and 4) culturally and environmentally influenced food intake and physical
activity patterns that result in excess weight gain beginning in
childhood and adolescence. This combination of factors includes
culturally influenced attitudes and beliefs but also includes
adverse environmental exposures that are more common in
ethnic minority populations than in others—particularly for
the low income segment of minority populations. Recognizing
the contributions of environmental variables that are rooted in
the social structure and, therefore, beyond the control of individuals is key to understanding the nature of solutions that will
be needed to impact upon the relevant pathways of excess risk.
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