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10.1177/0095798404266062
Alleyne,
LaPoint
OF BLACK
/ BLACK
PSYCHOLOGY
ADOLESCENT
/ AUGUST
GIRLS 2004
Obesity among the U.S. population represents a major health risk for individuals. The sequelae include disease, disability, and premature death, all of
which affect the family, community, and society. Researchers, policy makers,
practitioners, and advocates in fields such as public health, medicine, nutrition, nursing, psychology, sociology, education, social work, and law have
sounded alarms that obesity rates and associated health risks have reached an
epidemic among both children and adults in academic publications as well as
the media. The impact of obesity on the nations health was highlighted in the
Healthy People 2010 report, which focused on the importance of healthy
weight, the burden of poor weight management and subsequent illnesses and
reductions in quality of the life and life expectancy, the difficulties in weight
control, and health targets to be achieved by the year 2010 (U. S. Department
of Health and Human Services, 2000).
JOURNAL OF BLACK PSYCHOLOGY, Vol. 30 No. 3, August 2004 344-365
DOI: 10.1177/0095798404266062
2004 The Association of Black Psychologists
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CONCEPTUALIZATIONS
AND DEFINITIONS OF OBESITY
There are several complicated definitions and conceptualizations of obesity. One simple and accurate definition of obesity is that it is the result of an
energy imbalance where energy intake has exceeded energy expenditure over
a considerable period (World Health Organization [WHO], 1997). Physical,
social, and other environmental factors influence behavior. A combination of
behavioral, genetic, and hormonal factors determines excessive dietary intake and low physical activity, both of which result in the energy imbalance
that causes obesity as shown in Figure 1.
It is essential to have measures of obesity that can be compared internationally and also be used to identify groups and individuals who may be at
risk of increased morbidity and morality. There are essentially two measures
commonly used to define obesity. The first is the Body Mass Index (BMI),
the weight in kilograms divided by the square of the height in meters. The
normal range for adults is between 18.5 and 24.9, and any value above 25 is
regarded as overweight and preobese; obesity is classified as a BMI equal to
or greater than 30. There is increasing interest in the use of waist circumference adjusted to local norms of a given country as a measure of obesity
because it has been suggested that many of the complications of obesity are
strongly correlated with high rates of abdominal fat (WHO, 1997). The second way to define obesity is the use of the waist:hip ratio (WHR), the ratio of
ENVIRONMENTAL
Social
Genetics
Hormonal
Physical
BEHAVIOR
Excessive
Dietary
Intake
Low
Physical
Activity
Energy Imbalance
OBESITY
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Porter, personal communication, April 15, 2003). This situation can occur
when Black advocates criticize and protest commercial messages or products
that they deem inappropriate for Black consumers. Often, these kinds of
actions are viewed as Black people airing dirty linen or as Black-on-Black
criticism and may be met with varying degrees of resistance by marketers,
corporate owners, and celebrity endorsers of products, as well as by Black
community members and leaders (LaPoint, 2004). Socially tolerant attitudes
toward overweight and obese women may influence attitudes of Black adolescent girls toward acceptingboth in themselves and in othersbeing
overweight and obese. The challenge for Black adolescent girls, women,
their families, health professionals, and other stakeholders is to reduce obesity and its health consequences without creating unhealthy views of body
image, attitudes toward food, and eating patterns (Baskin, Ahluwalia, &
Resnicow, 2001).
PREVALENCE OF OBESITY
The prevalence of obesity increases with age, particularly among women
(Williamson, Kahn, Remington, & Anda, 1990). Recent data showed that the
prevalence of obesity rose from 19.8% to 20.9% of American adults between
2000 and 2001, and currently, more than 44 million Americans are obese
(Centers for Disease Prevention and Control, 2003). Blacks had higher rates
of obesity (31.1%) than did members of other ethnic groups (Mokdad et al.,
2003). Of particular relevance is that obesity is more prevalent among Black
women, with evidence coming from successive National Health and Nutrition Examination Surveys conducted in 1976 through 1980, 1988 through
1994, and 1999 through 2000. The prevalence rates for Black adult females
20 years and older for the three surveys were 31.0%, 39.1%, and 50.8%,
respectively. For White adult females, for the same periods, percentages were
15.4%, 23.3%, and 30.6% (National Center for Health Statistics, 2002).
Children have not escaped this epidemic, and data show an alarming prevalence of obesity in preschool children (Ebbeling et al., 2002). Using the 85th
percentile of triceps skin-fold thickness as a measure of child obesity in the
late 1960s, rates were 27.1% for children ages 6 to 11 and 21.9% for those
ages 12 to 17. Twenty years later, the prevalence of obesity in the adolescents
had increased to 39%, and overall, the children were heavier (Gortmaker,
Dietz, Sobol, & Wehler, 1987). Between 1986 and 1998, being overweight,
defined as a BMI greater than the 95th percentile for age and sex, increased
significantly among Black children. By 1998, the prevalence had increased
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to 21.5% among Black children and with 12.3% for non-Hispanic White
children. Not only was there a difference between the two time points, but in
1998, the overweight children were significantly heavier as compared to
those in 1986. Thus, the number of overweight children is increasing rapidly,
particularly among Black children of both sexes (Strauss & Pollack, 2001).
One of the most extensive reviews describing obesity among girls comes
from the Bogalusa Heart Study (Freedman, Kettel-Khan, Srinivasan, &
Berenson, 2000). They conducted a cross-sectional analysis of various characteristics of 4,542 Black and 4,542 White girls, ages 5 to 17 years between
1973 and 1994. Black girls, on average, were 1 to 3 kilograms heavier than
were White girls of similar ages, but when these findings were adjusted for
height, the mean relative weight of Black girls was significantly greater than
that of White girls only after they had passed the age of 13. It is mainly after
Black girls enter adolescence that the weight differential with their White
counterparts appears. This does not, in any way, negate the well-cited research that individuals who are obese in childhood are more likely to remain
obese through adolescence and adulthood.
Another study also reports this phenomenon for children and adolescents
(Kimm et al., 2001). However, this study showed a significant difference
between Black and White youth starting from age 9 through age 19. These
two data sets were collected on different samples using different methods.
The Freedman et al. (2000) study consisted of seven cross-sectional studies
of school children from 1973 to 1994 in a rural population from southern
states. The Kimm et al. (2001) study was a longitudinal (panel) study of participants ages 9 to 10 at first visit (1987 and 1988) with annual measurements
for 10 years (1996 and 1997) in urban and suburban communities. Using the
Black:White ratio of the percentage of obesity in Black and White adolescent
females from the Freedman and the Kimm studies, Black adolescent females
were more obese than White adolescent girls. Black females in the age group
of 12 to 19 years are consistently more obese than their White counterparts
across five time periods from 1963 to 2000 (National Center for Health Statistics, 2002).
CAUSES OF OBESITY
The determinants of being overweight and obese must clearly examine the
reasons why the body takes in more energy than it consumes. There is considerable debate over the roles of specific hormones that may alter appetite and,
thus, lead to continued overintake. We focus on the most important determi-
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nants of these energy intake and output regulators as being genetic traits and
the social environment. It must be clear, however, that obesity cannot be considered to be the result of either genetic or social factorsobesity is a complex interplay between them.
GENETIC FACTORS
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to increasing weight gain and obesity among those Black people who crossed
the ocean (Wilks et al., 1996).
But not all the evidence points in this direction. Investigation of families
of obese European and Black women suggests that there is a similar level of
hereditability of obesity in the two groups (Price, Reed, & Guido, 2000). The
relative importance of genetic, social, and environmental causes of obesity is
more than a matter of scientific curiositya predominance of the former factors will make efforts at control that much more difficult. Despite our insistence on obesity resulting from an interplay of genetic and social factors, the
rapid increase in the prevalence of obesity in recent years, which is too short a
time for significant genetic modification in populations, must focus more on
the role of the social and environmental factors, factors that obviously can
change more rapidly.
SOCIAL AND SOCIOECONOMIC FACTORS
Several social and socioeconomic factors have been associated with obesity. Thus, it seems relevant to cite social and economic factors relating obesity and Black adolescent girls, especially because one third of Black children live in poverty (LaPoint, 2003a). Findings vary considerably on the
relationship between socioeconomic status and obesity. Sobal and Stunkard
(1989) found only a weak correlation between socioeconomic status (SES)
and obesity generally. Women of higher SES were less obese in developed
countries, whereas in developing countries, there was a positive correlation
between SES and obesity. The relationship between SES and obesity in adolescent girls comes from a comprehensive analysis of the National Longitudinal Study of Adolescent Health, where data were collected from 13,113
adolescents. Changes in family income had a limited effect on the disparities
in overweight prevalence between Black and White adolescent girls. Overweight prevalence decreased as SES increased in White girls; among Black
girls, it remained elevated or tended to increase.
The disparity in overweight prevalence increased as the populations improved their SES. The interpretation of these and similar studies indicates
that in wealthier homes, there was more obesity among Black females as
compared with White females. This finding may be related to the perception
of ideal body size and efforts to attain it among different ethnic groups.
Young Black females report fewer eating disorders and are less likely to diet
because of concerns with obesity and body shape than their White counterparts (White, Kohlmaier, Varnado-Sullivan, & Williamson, 2003). However,
there may be a gradient effect among Black females who are, in fact, heterogeneous. One study of young Black girls showed that those females in higher
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duction of cortisol from the adrenal gland. The end result is a metabolic syndrome that includes resistance to insulin and increase in abdominal obesity
(Bjorntorp & Rosmund, 2000). Given the prevalence of abdominal obesity in
Black Americans, it is tempting to speculate on the relevance of these findings to that group. There is evidence, however, that this phenomenon exists in
Afro-Caribbean women where internalized racism, with attendant stress, is
associated with increases in blood pressure and abdominal obesity (Tull
et al., 1999).
The response to acute stress stimulates emotions that induce increased
intake of food generally as well as food that is more likely to cause obesity.
More chronic stress may result in increased food intake as well as difficulty
with weight control. In addition, there is a complex hormonal response to
stress that results in abdominal obesity with higher risk of cardiovascular disease and diabetes. This discussion is also applicable to Black adolescent
girls. Adolescence is a stressful transitional life stage during which many
biological and psychosocial changes occur. Black adolescent girls often experience stress related to structural barriers of race, SES (Dixon, 1996), and
gender similar to Black women. These stressful life conditions could lead to
overeating and subsequent overweight and obesity.
NUTRITIONAL FACTORS
Nutritional factors related to dietary intake may be controlled by hormones. The hormone leptin, which is secreted by fat cells, may regulate body
weight and energy expenditure through direct action on the central nervous
system. Leptin levels are higher in obese people, suggesting a resistance to
hormonal action. Leptin levels are higher in Blacks than in Whites in a population sample, but for equal degrees of obesity, there is no difference in these
levels between the two groups (Danadian, Suprasongsin, Janosky, &
Arslanian, 1999; Ruhl & Everhart, 2001). Other factors may affect excessive
dietary intake. These include children consuming less when they are allowed
to serve themselves versus when served by others (Fisher, Rolls, & Birch,
2003); children consuming more because of supersized food portions served
in homes and restaurants, especially in fast-food venues (Nielsen & Popkin,
2003); and childrens exposure to a variety of negative food marketing practices (Center for Science in the Public Interest [CSPI], 2003).
PHYSICAL ACTIVITY FACTORS
355
weight gain. However, the situation is compounded by the fact that they also
indulge in less physical activity. The daily leisure physical-activity time was
measured (Kimm et al., 2002) prospectively in Black girls and White girls,
ages 9 to 10 years to 18 to 19 years. Activity declined with time in both
groups but was significantly greater in the Black girls. By the time they had
reached adolescence, 56% of the Black girls and 31% of the White girls
reported no habitual leisure-time activity. As expected, the degree of overweight was greater among less active girls (Kimm et al., 2002). Another
important finding was that pregnancy was a significant contributor to the
decrease in physical activity in Black girls. An additional finding was a significant difference in television viewing, with Black youth watching television or videos for an average of 20.4 hours weekly as compared to 13.1 hours
for White youth (Gordon-Larsen, McMurray, & Popkin, 1999). This differential may mean that Black youth are exposed to more commercial advertising for unhealthy products, including low-nutrition foods (LaPoint, 2003a).
CONSEQUENCES OF OBESITY
The most important sequelae of the overweight are the noncommunicable
diseases: non-insulin-dependent diabetes mellitus, cardiovascular disease,
and hypertension. The extent to which the relative risk for these diseases is
increased with obesity is fairly constant throughout the world. However, data
indicate that Black people have a higher prevalence, particularly those with
Type 2 diabetes. The risk of other diseases, such as cardiovascular disease
and stroke is also higher, and the risk of these diseases increases steadily with
the degree of obesity.
DIABETES MELLITUS RISKS
Between 1991 and 2001 there has been an increase of obesity and diabetes
in the United States by 74% and 61%, respectively, indicating the strong correlation between obesity and diabetes (Mokdad et al., 2003). Black adults are
2 to 3 times more likely to develop diabetes than are White adults. The distribution of fat is also related to the risk of developing diabetes. Fat above the
waist is a stronger risk factor than fat below the waist, and Blacks tend to
develop upper-body fat that increases their risk of diabetes. Obesity may only
be a part of the answer for diabetes in Blacks because when compared with
Whites with the same levels of obesity, age, and SES, Blacks still have higher
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self-adequacy among 2,205 Black and White girls ages 9 and 10. Obesity was
assumed to have a negative impact on self-esteem, given the social stigma it
carries in Western society. They found that adiposity had a negative impact
on the level of self-esteem in girls as young as 9 to 10 years and significant
racial differences in these relationships with the magnitude of the effect of
adiposity less in Black girls (Kimm et al., 1997). They found a more pronounced racial difference on one of their psychosocial measures, social
acceptance, and an absence of variation in the scores across the entire range
of adiposity among Black girls as compared to a significant inverse relationship among White girls (Kimm et al., 2002). They suggested that this apparent absence of perceived social rejection because of obesity was consistent
with the hypothesis that there exists, among Black people, a tolerance toward
obesity. They also cautioned researchers to use measures that are valid and
reliable in measuring self-esteem among populations of color (Kimm et al.,
2002).
358
STRUCTURAL
INTERVENTION
Commercial
Regulation
ENVIRONMENT
Public Health
Info rmation on
Lifestyle
Social
Marketing
BEHAVIOR
Recreation
Opportunities
INDIVIDUAL
INTERVENTION
Family
Support
Decrease
Dietary
Intake
Increase
Physical
Activity
Energy Balance
PREVENTION/REDUCTION
OF OBESITY
Figure 2:
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