Obesity Literacy and Culture among African American Women in Florida Ivette A. López, PhD; Patricia Q. Boston, DrPH; Matthew Dutton, PhD; Chauneva Glenn Jones, MPH; M. Miaisha Mitchell, BS; Helene Vilme, MPH Objective: To explore causal explanations of obesity among African-American women of diverse weight across the life spectrum. Methods: In-depth interviews were conducted with adult African-American women of healthy weight (N = 10), overweight (N = 10), and obese weight (N = 20) to evaluate the relationship between causal explanations of obesity and weight. Results: Generally overlooked dimensions of health definitions were discovered. Differences in weight definitions were detected between women of different weights. Terminology,

L

ong-term overweight and obesity is a major health hazard among females of all ages, as approximately two-thirds of reproductiveaged women in the United States are currently overweight or obese.1-5 Obesity presents a sex health inequity encased in a racial/ethnic disparity. Non-Hispanic black women have the highest age-adjusted rates of obesity (49.5%) among all racial categories.6 Lack of weight control is the driving force behind the epidemic of diabetes, and other weight-related disparities disproportionately affecting African-American women7 are well-documented.8-10 Nationally, among women over the age of 20 who are overweight or obese, 52.9% are African Americans; 3 out of 4 African-American women are overweight or obese.11-13 Explanations of obesity often employ social-ecological frameworks, due to the multiple levels of influence on behaviors throughout the lifespan.14 Ivette A. López, Associate Professor, Institute of Public Health, Florida A&M University, Tallahassee, FL. Patricia Q. Boston, State Cultural and Linguistic Competency Coordinator, Florida Department of Children and Families, Tallahassee, FL. Matthew Dutton, Assistant Professor, Institute of Public Health, Florida A&M University, Tallahassee, FL. Chauneva Glenn Jones, Eligibility Self-Sufficiency Specialist, Florida Department of Children and Families, Tampa, FL. M. Miaisha Mitchell, Executive Director, Greater Frenchtown Revitalization Council, Tallahassee, FL. Helene Vilme, Graduate Assistant, Institute of Public Health, Florida A&M University, Tallahassee, FL. Correspondence Dr López; [email protected]

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symptoms, and solutions to obesity were detected between the women of different weights and public health recommendations. Conclusion: Identified causal discrepancies will help bridge the disconnection between public health recommendations and African-American women’s perceptions with tailored interventions. Key words: explanatory models, Kleinman, cultural competency, causal explanations, stress Am J Health Behav. 2014;38(4):541-552 DOI: http://dx.doi.org/10.5993/AJHB.38.4.7

In Florida, among non-Hispanic white women, 52.2% are overweight or obese whereas 78.2% of non-Hispanic African-American women are overweight or obese.15 In Leon County, the geographic population of interest that contains the capital city of Tallahassee, Florida and 2 major universities, overweight or obesity rates among African-American women are lower, at 69%. In this Florida county, the African-American population is larger than the national average (13%). The risk for diabetes is disproportionately high for these populations as well, and these rates are climbing. In Leon County, the rates of diabetes are over 40% higher among African-American women than white women.16 Studies that explore variations between the health perspectives and life circumstances of the individual are underrepresented in current literature.17 Similarly, congruence or dissonance between lay and practitioner perspectives on the origins and treatment of obesity could possibly explain the well-documented low rates of compliance with medical prescriptions and prevention recommendations.18-20 Culture plays a key role in obesity and overweight personal factors, including attitudes, perceptions, knowledge, and norms regarding weight, eating, and activity behaviors, among others.21 However, the role culture plays has been relegated to a less influential place in health education.22 Distrust and lack of a common language between professionals and the public hamper conventional public health communication and education pathways regarding weight, especially in

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Obesity Literacy and Culture among African American Women in Florida minority communities.23 This is evidenced in a national survey of women’s awareness of cardiovascular health (with a significant number of women of color) that found most respondents were unaware of healthy preventive factors.24 Few studies have examined personal causal explanations of weight among African-American women.25-31 The crux of noncompliance seems to be inter-connected to the one-way understanding of disease and treatment: the one that leans toward organizational milieus.32,33 Efforts to make health establishment information clear are futile without addressing attitudes and beliefs that influence the desirable behaviors, as individuals and communities have their own beliefs of what causes disease and wellness.32 Until those beliefs are uncovered, the expectations of both sides will continue to clash, while the source of this clash remains unknown and unaddressed. Prescriptive and directive exchanges with patients may be efficient but are not always effective, especially in the case of treatments that demand trust from patients.34,35 Finding those sources of conflict between health professional advice and personal causal explanations can lead to unifying their impact. Purpose The purpose of this small, self-contained study was to determine causal explanations of obesity inequities among African American women from the perspective of African American women. Three research questions were explored: (1) What is the weight terminology used among African-American women in Tallahassee, Florida? (2) Are the explanatory models of weight of African-American women influenced by their personal weight status? and (3) Are African-American women’s explanations of obesity aligned with authorities in public health? Equipped with this contextual information, conflicting beliefs or culturally dissonant messages can be targeted for clarification. Sound science-based programs can be built to reach African-American women with culture-centered life-saving information regarding weight and effective chronic disease control. In an era of rapid development and social change, cultural meanings and behavioral change associated with ill health and disease management also will change.36,37 Investigations centered on increasing essential understanding of conditions affecting African-American populations are highly important. Obesity studies that focus on a highrisk population (African-American women) merit ongoing, below-the-surface investigation. This paper summarizes study findings and makes recommendations for future research and interventions. METHODS Explanatory Models and Qualitative Research on the Experience of Obesity Explanatory models (EMs) refer to concise statements of illness beliefs that are collected via ethnographic or qualitative methods. The EMs can be

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from both professional and lay informants, and despite their widespread application, little is known about local concepts and self-perceptions of obesity among African-American women, or about explanatory models and beliefs regarding weight issue etiology.37 Further, coping strategies for weight self-regulation among African-American women are also understudied.38 This study explored and described the phenomenon of weight with both rich detail and rigor that employed qualitative research methods. The cornerstone of the study is the cultural context of obesity expounded in explanatory models (EMs) of African-American women that have healthy weight and those who are overweight. We then compared and contrasted the AfricanAmerican women-identified health behaviors and perceptions with 2 public health explanatory models of weight control definitions and prescribed behaviors aimed at women of color available in a national Office of Women’s Health (http://womenshealth.gov/minority-health/african-americans/ obesity.html) and to the adult American public in general from the Centers for Disease Control and Prevention (CDC) at http://www.cdc.gov/obesity/ adult/index.html. Kleinman39 originated an explanatory model that included 8 dimensions to grasp causal understanding of disease, set forth with the goal of inserting cultural competence to the practice of medicine. Causal interpretation of events has been highlighted by diverse research literature focused on African-American populations, from conflict narratives in the 1930s40 to early literacy.41 Kleinman’s concept of EMs of illness was used as the theoretical framework, and grounded theory methods were used to sample, collect, and analyze data. Causes, symptoms, treatment, and social significance of obesity are some of the Kleinman-influenced themes the study highlights.42 To evaluate the relationship between causal explanations of obesity and weight status, in-depth interviews of 40 adult African-American women of healthy (normal) and poor (overweight and obese) weight control were conducted. Instrumentation The in-depth interview guide evolved from both a review of published literature and the Kleinman model. Most questions were open-ended to promote discussion around key study topics (eg, terms used to refer to weight problems). Probes were used to elicit further information. The instrument was pilot-tested in September 2010 with a convenience sample (N = 20) of African-American women. It progressed through 3 iterations before interviews with the actual study sample. The interview guide followed Kleinman’s major themes, and consisted of 27 questions and subsequent probes. The first codebook was based on the interview guide, but was revised continuously with each new interview, and the early interviews were recoded based on the final set of codes.

Lopez et al We employed a community-based organization in the Tallahassee area in the recruitment of AfricanAmerican women. The research team consisted of the community-based organization consultant, 2 graduate students, and the principal investigator who is a professor at a local historically black college/university. The community-based organization physically housed the in-depth interviews. This face-to-face, more conversational technique is desirable with African-American women, as this format accommodates the development of rapport and ease to explore this topic. The principal investigator developed training for the interview process and employed role-playing to enhance the preparation of the interviewers, as well as conducted the data analysis in collaboration with her doctoral student. Both interviewers were African-American women, a masters and a doctoral student of public health (since graduated) who received training directly from the principal investigator and her community partners to minimize intercultural bias in the data collection. Ultimately, in-depth interviews were conducted with 40 African-American women between January 2011 and November 2011. The interviews ranged between 30 minutes and 2 hours with most interviews lasting around one hour. In addition to the question responses, biological measures of height and weight were obtained, and their BMI determined using the CDC BMI calculator.43 A second reviewer coded the interviews independently to assess inter-rater reliability (85%). Differences were discussed and resolved via consensus while the codebook and definitions were modified to reflect changes. Transcripts were loaded into Atlas.ti and codes were assigned to relevant passages. Once all transcripts were coded, we employed Atlas.ti to extract coded passages for interviews.

dicates an abnormality, and preferred instead that the word overweight be used for obesity. I mean, a little over, that’s not too bad. Obese is way out of control, out more extreme. 37 years old, 43.6 BMI What is considered insulting is obese, although generally the emic definition of overweight is what health professionals would term obese. That is what makes obesity different (from overweight)…they are really bad, like those folks on TV that cannot get out of bed. 26 years old, 32.8 BMI The most acceptable or preferred term was having a ‘weight issue.’ As for the term normal weight, most participants felt that the normal weight scales (for their weight) are for other people, not African Americans. The weight that is described as normal was described as “white” or “European.”

RESULTS Weight Terminology Of African American Women (Findings for Research Question 1) Most of the women had neutral terms to describe overweight. They ranged from tempering terms (‘a little thick’) to more pejorative terms (‘pig,’ ‘glut’). For the word obese, the women had consistently negative meanings. Overweight was generally acceptable. A minority of participants felt overweight was just an attenuating term for obesity, that they were mostly synonymous. Those who were opposed to obesity objected to the term because it in-

Components of Explanatory Models of Weight from African-American Women and the Influence of Weight Status in Causal Explanations (Findings for Research Question 2) Causes of weight problems. The women thought that the main cause of struggles with weight among African-American women was stress, either not handling it well, or being surrounded by it. The women were at either end of the spectrum of locus of control when it came to causes of weight; they either felt the causes of weight problems were inside or outside their control (Table 1). A majority of the women felt that the stress caused their weight problems itself. Almost half of the women felt that the stress caused them to eat more or make poor eating choices. Some of the women also felt that the stress was causing them to eat too fast. All these causes were tied with stress in their personal relationships, children, and work. The rest of the causes the women detected were lack of other healthy behaviors, like exercise or nutritious eating. Most linked their lack of healthy diet and exercise to their lack of time for themselves, given their home, work, and children responsibilities. More than half of the women identified their culture and financial survival as the reason for health problems among African Americans: due to the unhealthy food preferences and appreciation for “meat on the bones” even in children, as well as to their economic conditions mandating unhealthy choices like fast food. A few of the women cited experience of domestic violence and abuse as the cause for weight problems. When asked what experiences make AfricanAmerican women struggle with weight, the women described many issues, ranging from lack of time to exercise or prepare foods, and low income and pregnancy. The most cited experiences were emotional or mental health, stressful life, and family. The emotional or mental health responses centered

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Sample The sample included non-institutionalized, female residents of Leon County, Florida who selfidentified as African Americans, were between the ages of 21 and 71, and were capable of performing physical exercise. A targeted snowball sampling strategy was applied with the help of the community-based organization. Less than half of the sample (10) had healthy weight, 10 were overweight, and 20 were obese (N = 40).

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Table 1 Locus of Control of Stress and Weight among African-American Women Internal Control

External Control

Not knowing how to handle stress Not concentrating on self Overeating to relax Not eating what’s correct Lack of exercise, couch potato Food we eat, eating the wrong foods, not eating the right combo of foods Sodium and fat intake Not enough exercise Lack of knowledge Lack of self esteem Eating fast, speed eating Eating late, alone, secret eating Don’t monitor what kids eat like nobody monitored what we ate Dieting and binging

Stress, relationship issues, stressed by men and children Stress, problems at work, hard life Lack of time, to exercise, children’s activities. Depression, how you were raised, culture AA women are prone genetically to be bigger, Genes Glands Lack of education programs for us Upset by others, so we eat The way we ate growing up Everyday survival, economic conditions We thought babies weren’t healthy if not fat Domestic violence, working harder, abuse

on depression, and anxiety, where relationships are affected directly or indirectly, and/or have repercussions on eating behaviors.

Stressful experiences are denoted as part of the experience of overeating, and as causal to the behaviors associated to weight problems.

Relationships, instability, grief, separation, can go both ways, also these can cause weight loss… 37 years old, BMI 30.6

Trials, tribulations, stress related cause you to eat food constantly. 58 years old, BMI 31.6

Depression, anxiety, job issues, lack thereof, spousal/relationship issues. 52 years old, BMI 53.5 The survival of abuse, experience of anxiety, decrease of self-esteem, experience of being an African-American woman, and relationship conflicts are also associated by the women as causal to the experience of weight problems. Rape, rejection, media tells the world that beauty is fair skin, blond hair, blue eyes, if you are colonized then you are not beautiful…no one cares about your needs. 54 years old, BMI 41.3 They have experienced molestation, bad relationships, abusive spouse or boyfriend, death… 68 years old, BMI 26.4 Abuse, loneliness, feel like we have to have someone/anybody and overeating when we don’t. 44 years old, BMI 37.2 Not a cool question. So many issues, never just one or 2 things…Sexual assaults, parents compensate with foods and snacks, domestic violence, working harder, eating to feel in control. 53 years old, BMI 31.6

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Stress, trying to please others, not willing to limit food, lack of discipline. 39 years old, BMI 23.7 Symptoms of weight problems. When asked what the symptoms of weight problems were, the women identified physical signs, physical impairments, appearance, and stigma. Among the physical signs was the fluctuation in weight over time (“yoyo-ing”, “up and down”). This was viewed as the earliest sign, and was identified by the women who had healthy weights. Those who had higher weight tended to cite diseases and impairments. Overweight women tended to report appearance. Regarding physical impairments, the women cited shortness of breath, difficulty walking or going up steps, inability to stand for long periods of time, inability to cross legs or tie shoes, not being able to do things they were used to, and the appearance of diseases. Appearance referred to not liking what one sees in the mirror, when clothes do not fit as one wants, and having 3 or more sizes of clothing in the closet. Finally, stigma included themes like having people notice when a person has difficulty with their weight, such as when one cannot buckle a seatbelt, cannot fit into a seat in theater, or having people stare. Help seeking and medical advice. More than half of the study participants did not see a doctor about their weight. About one-third of the women saw a doctor about their weight, followed by about one-fourth who sought help from no one. Also,

Lopez et al about one-fourth sought help from God, and a few from a relative or friend. When asked what has your doctor ever said to you about your weight, half of the women were told to lose weight. However, none of them cite specific, complete directions or direct assistance. Almost one in 4 reported not being told anything regarding their weight, while almost onethird were told to be physically active, especially to walk. All of these women were obese or overweight. A couple of women were told to cut back on specific nutrients, mostly salt, sugar, or starches. Further doctor’s advice surrounded losing weight included: That I could lose 5 lbs. 21 years old, BMI 31.1 He said I am heavy and wanted me to go to 160 pounds. 48 years old, BMI 31.4 You must get out of the 300’s! 44 years old. BMI 41 Of all the women interviewed, only 3 indicated comprehensive information had been provided by a physician, including referring her to a program, providing an educational brochure with advice on physical activity and eating healthy, and recommending a nutrition class to attend. Education about the prevention of weight problems. Participants reported no early education on the prevention of obesity, and especially nothing that was tailored to them. Even through their primary, middle, and high school years, their education about healthy habits was limited. Not until my late 40s, early 50s that I had health problems did I become food conscious. Doctor gave me information then. 71 years old, 25 BMI When asked: ‘Who taught you how to control your weight,’ nearly all participants said no one. The rest, a minority, said their doctor. When asked: ‘Who taught you to be active,’ more than half of participants said father or male significant other. The rest said mother or TV (Oprah, Dr. Oz, The Doctors). Social Support to Address Weight Problems When women were asked: Who supports you to be the weight you want to be? the overwhelming response was no one, reported by almost 2 out of 3 women. The second most reported was me/ self. The rest of the participants reported: mother/father, friends, husband, reading God’s word, people at work, children/grandchildren, auntie, media, pharmacist, drill sergeant, and doctor, with one person reporting each. “No one” was the most widely stated answer of women with obese weight, followed by “reading God’s word,” and pharmacist. “Me/Self,” was indicated my most of the women with normal weight, followed by “mother/father,”

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and “doctor.” Normal Weight Table 2 reflects the women’s perception of a normal weight for their height compared to the actual normal weight for their height. Women of healthy weight were more likely to estimate their work accurately or to underestimate normal weight; 9 of the 10 women in this group either correctly estimated or underestimated the upper end of normal weight for their height. All 10 of these women’s perceptions of normal weight were within 10 pounds of the true range of normal weight values as indicated in BMI tables. Overweight women’s perceptions of a normal weight were less likely to match the upper end of the BMI scale. Seven of the 10 women overestimated the true normal range for their height. Overestimations of the true normal weight limit ranged from 2 to 29 pounds. Obese women were even more likely to overestimate the true normal weight range for their height. One of these participants did not know the normal weight for her height and only one of the 20 obese women who participated underestimated the upper end of normal weight. The 18 remaining women overestimated normal weight for their height by anywhere from 3 to as much as 102 pounds. Women at a healthy weight were more likely than overweight and obese women to know the appropriate weight for their height. Overweight women were slightly more likely than obese women to know the appropriate weight for their height. Feelings about Weight When asked: How do you feel about your weight? the women were almost evenly split between feeling OK/Good/Comfortable about it, and feeling ambivalent. A minority of the women felt that they Don’t like it/Terrible. Feeling OK/Good did not always match weight control, as the women who had some of the highest BMIs felt OK or Good, and normal weight women were alright/OK/comfortable. I don’t know…I have always been large. I would like to be a size 18, am about a 22 now. 41 years old, 55 BMI 170 is ideal for me. Don’t want to be too small, not skinny or fat. 26 years old, 32.8 BMI I want to gain. I don’t know why it bothers people, my size… 71 years old, 18.6 BMI The women’s negative or positive feelings did not seem to be linked to their age, nor their weight status. Solutions to Weight Problems When asked: How do you think we can solve the weight problems in the African American community, the women reflected on their lack of knowledge

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Table 2 Believed, Normal and Actual Weight with Calculated Body Mass Index Believed Normal Weighta

Normal Weight Upper Endb

Actual Weight

Body Mass Index

Believed Normal Weighta

135

137

142.4

23.7

135

140

134

126

21.6

120-125

131

131

165

167

165

130

137

134

Normal Weight Upper Endb

Actual Weight

Body Mass Index

140

115

18.6

135

137

148

24.6

24.9

165

167

162

24.2

24.7

120

120

120

24.9

23.6

135

137

134

23.6

Normal Weight and Body Mass Index (BMI) 18.5-24.9

Overweight and Body Mass Index (BMI) 25.0-29.9

N = 10

N = 10

120

122

132.4

26.7

130

128

154

28.2

140-150

140

162

26.1

135

131

149

26.4

140

131

162.8

28.8

115-120

125

149

28.2

140-160

131

147.2

26.1

165

137

171

28.5

130

122

138.2

27

145

134

151.8

26.1

150

128

173

31.6

215

155

221.4

265

163

305.4

220

137

150

134

Obesity and Body Mass Index (BMI) 30.0 and Above N = 20 160-165

134

195

33.5

36.8

140

137

321.6

53.5

47.8

155-160

140

195.8

31.6

223.4

37.2

165

146

245.6

37.3

190.8

32.7

170

134

191

32.8

IDK

122

383.6

55

195-200

134

254

43.6

140-145

134

199

34.2

150

120

167

33.7

150

134

183.6

31.5

140

115

186

40.2

150-170

134

252.6

43.4

150-160

128

220

40.2

150

157

184

30.6

175-180

134

190

32.6

Note. a This refers to the weight women perceive to be normal for their height. b This refers to the maximum weight indicated for a Normal BMI.

about how to cook, eat, or exercise better, in the context of lasting lifestyle change. Solution ideas included teaching people how to cook better, to give cooking demonstrations, or to show how to be active “in normal life.” Go to malls, street, bus stops, educate, be examples, mentors. Free seminars, meetings, groups, show me. 42 years old, 31.4 BMI Need places to find out about weight that don’t charge and sell you food. 68 years old, 26.4 BMI The necessary education was described as involving both individuals and communities. The

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individuals in this sample were oriented to the solutions being for all African Americans, not just themselves or their families. Breaking the silence, talking about this as an important issue in health, teach how to talk with family member, like teaching them how to not do drugs. 65 years old, 25.4 BMI Health education across all communities, not just the communities that can afford it, or have a YMCA nearby. Southside, start there. 51 years old, 25 BMI Normal The women felt there was a disconnect between

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Low Consonance

Table 3 Consonance Comparison of Weight Causal Explanations: Public Health Recommendations and African-American Women Weight Theme

Centers for Disease Control and Prevention (CDC)

Office of Women’s Health (OWH)

African American Women Wisdom

BMI measures of normal, overweight or obese weight

For adults, overweight and obesity ranges are determined by using weight and height to calculate a number called the “body mass index” (BMI). BMI is used because, for most people, it correlates with their amount of body fat. • An adult who has a BMI below 18.5 is considered underweight. • An adult who has a BMI between 18.5 and 24.9 is considered of normal weight. • An adult who has a BMI between 25 and 29.9 is considered overweight. • An adult who has a BMI of 30 or higher is considered obese.

Obesity or overweight is measured with a body mass index (BMI). The taller you are, the more weight you can carry. And shorter people can’t carry as much weight. So, the BMI shows the relationship of weight to height. For instance, if you are 5 feet 4 inches tall and weigh 145 pounds, your BMI is 25. But if you are 5 feet 4 inches tall and weigh 174 pounds, your BMI is 30. Women with a BMI of 25 to 29.9 are considered overweight. Women with a BMI of 30 or more are considered obese. All people 18 years or older who have a BMI of 25 or more are at risk of early death and disability from being overweight or obese.

BMI? That is not for African Americans… weights are too low. 37 years old, 30.6 BMI

There are a variety of factors that play a role in obesity. This makes it a complex health issue to address. Behavior, environment, and genetic factors may have an effect in causing people to be overweight and obese. • Overweight and obesity result from an energy imbalance. This involves eating too many calories and not getting enough physical activity. • Body weight is the result of genes, metabolism, behavior, environment, culture, and socioeconomic status. • Behavior and environment play a large role causing people to be overweight and obese. These are the greatest areas for prevention and treatment actions.

You can become overweight or obese when you eat more calories (KAL-ohrees) than you use. A calorie is a unit of energy in the food you eat. Your body needs this energy to function and to be active. But if you take in more energy than your body uses, you will gain weight. Many factors can play a role in becoming overweight or obese. These factors include: • Behaviors, such as eating too many calories or not getting enough physical activity • Environment and culture • Genes Overweight and obesity problems keep getting worse in the United States. Some cultural reasons for this include: • Bigger portion sizes • Little time to exercise or cook healthy meals • Using cars to get places instead of walking

Stress, relationship issues. 20 years old, 32.7 BMI

Low Consonance

Causes of weight problems

Even at my lightest I could never be in what they call the normal 26 years old, 32.8 BMI That BMI range is for Europeans. 48 years old, 31.4 BMI If the standards work for African Americans, need to convince us. Use African Americans to explain to us why BMI and weight charts are not just for European Americans. Folks think European American standards don’t work on us 41 years old, 55 BMI

Depression, eating habits, how you were raised, what we say is healthy really isn’t. Cultural, dang mind about different things about eating. 60 years old, 33.5 BMI Self-esteem, lack of exercise, not enough time for self. 62 years old, 40.2 BMI Finances with what they eat. Not having access to healthy foods. 65 years old, 43.4 BMI Not a cool question. So many issues, never just one or two things. Sexual assaults, parent compensate with foods and snacks for problems… 50 years old, 31.1 BMI Bad eating choices, lack of exercise, lack of knowledge about healthy eating… 26 years old, 32.8 BMI (continued on next page)

the public health standards and objectives and their lives as African-American women, and would most often use air quotes when referring to “normal” ranges of weight or BMI. This came out several times during the interviews, but especially within the weight problem definitions, and most specifically, with what constitutes normal weight. If the standards work for African Americans, need to convince us. Use AAs to explain to us why BMI and weight charts are not just for European Americans. Folks think European standards don’t work on us. 41 years old, 55 BMI We been like this and now they come and tell us we have a weight problem. I feel like they

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now European American telling them about concerns. (African Americans) are prone genetically to be bigger, and we cannot weigh the same, I don’t think. 57 years old, 28.5 BMI Another area of solutions was the offering of physical activity opportunities as part of a collective approach, where exercise is something that is normally seen. Form ‘Take walk after you eat’ clubs. 73 years old, 18.6 normal Neighborhood safety was also cited as a reason why activity is hard, and community approaches as how it can be overcome.

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Table 3 (continued) Consonance Comparison of Weight Causal Explanations: Public Health Recommendations and African-American Women Weight Theme

Nothing

Low Consonance

Symptoms

Centers for Disease Control and Prevention (CDC)

Office of Women’s Health (OWH) Find out your body mass index (BMI). BMI is a measure of body fat based on height and weight. People with a BMI of 25 to 29.9 are considered overweight. People with a BMI of 30 or more are considered obese.

African American Women Wisdom

Physical signs yo-yoing, up and down over time, like a year, weight fluctuates. 71 years old, 21.BMI Appearance Just looking in the mirror. Clothes don’t fit you. Going to another size when you buying clothes. 60 years old, 33.5 BMI Physical impairments Problems with heart, cholesterol high, pressure high, short of breath, walking with difficulty. 21 years old, 26.4 BMI

Low Consonance

Stigma …people stare, kids hollering, ‘oh mommy, she’s fat. 62 years old, 40.2 BMI Seeking medical advice / Medical advice regarding weight

Nothing

If you need to lose weight, ask your doctor to help you with a weight-loss plan that includes healthy meal planning and physical activity.

Never considered my weight a medical issue. Never been told that. 37 years old, 43.6 BMI Most of the time they don’t have our best interest at heart… 54 years old, 41.3 BMI Therapist that helps me with my thinking. Also my MD that tells me no carbs, no diabetes. 52 years old, 53.5 BMI …prior doctor was obese and didn’t bother explaining anything about weight issues… 62 years old, 40.2 BMI (continued on next page)

Acting as a community, we can take care of each other, protect our children and selves from 74 registered sex offenders by my house, that’s influencing lack of exercise in me. 54 years old, 41.3 BMI Most of the women felt solutions had to begin with the African-American youth. They felt that the schools had to be a part of changes, in particular, active physical education (PE) classes. Hey, active PE and recess every day or most days. No more once a week PE, and sometimes show movies. 50 years old, 37.3 BMI The inequities in health according to income were common throughout the study. All of the women felt that the obstacles to healthier behaviors begin with income or other access limitations (transportation).

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More organic foods for the poor, free gyms, support groups for the poor. 41 years old, 55 BMI Solutions from the women also included addressing the aspects of weight in African-American women that they perceived were tied to mental aspects. Begin to care for each other and care for ourselves. 54 years old, 41.2 BMI Support each other, women only groups. 50 years old, 37.3 BMI Get minds right 41 years old, 55 BMI Discrepancies between African-American women’s explanatory models of obesity and those of the

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Table 3 (continued) Consonance Comparison of Weight Causal Explanations: Public Health Recommendations and African-American Women Weight Theme

High Consonance

Solutions

Centers for Disease Control and Prevention (CDC) Obesity is a complex problem that requires a strong call for action, at many levels, for both adults as well as children. The U.S. Government can: Promote change • A new CDC program, Communities Putting Prevention to Work,* is designed to improve nutrition and physical activity and prevent and control obesity by changing policies and environments. CDC recently provided $139 million to 50 states and $373 million to 30 communities and tribes to fund programs to reverse the obesity epidemic. States can: • Provide supermarkets and farmers’ markets with incentives to establish their businesses in low-income areas and to offer healthy foods. • Expand programs that bring local fruits and vegetables to schools, businesses, and communities. • Support hospital programs that encourage breastfeeding. • Adopt policies that promote bicycling and public transportation. Communities can: • Create and maintain safe neighborhoods for physical activity and improve access to parks and playgrounds. • Advocate for quality physical education in schools and childcare facilities. • Encourage breastfeeding through peer-to- peer support programs. • Support programs that bring local fruits and vegetables to schools, businesses, and communities. All people can: • Eat more fruits and vegetables and fewer foods high in fat and sugar. Drink more water instead of sugary drinks. • Limit TV watching in kids to less than 2 hours a day and don’t put one in their room at all. Support breastfeeding. • Promote policies and programs at school, at work, and in the community that make the healthy choice the easy choice. • Try going for a 10-minute brisk walk, 3 times a day, 5 days a week.

Office of Women’s Health (OWH) If you are overweight or obese, losing weight can lower your risk of many health problems. And physical activity is one key part of weight loss and keeping a healthy weight. Health benefits are gained by doing the following each week: Aerobic activity that includes: 2 hours and 30 minutes of moderate-intensity aerobic activity or 1 hour and 15 minutes of vigorousintensity aerobic activity or A combination of moderate and vigorous aerobic activity and Muscle-strengthening activities on two or more days of the week This physical activity should be in addition to your routine activities of daily living, such as cleaning or spending a few minutes walking from the parking lot to your office. If weight loss is your goal, you may need to spend more time doing aerobic activity to see the effects. Eating healthy meals that focus on portion control also plays a role in weight loss and keeping a healthy weight. If you need to lose weight, ask your doctor to help you with a weight-loss plan that includes healthy meal planning and physical activity.

public health establishment are focused on rejection of weight categories as intended for all people, causes of weight problems, help seeking, and medical advice. A summary of these findings appear in Table 3.

African American Women Wisdom

Making oneself a priority …we need to find the time and to make the time to exercise a priority, like my life depends on it… 37 years old, 32.6 BMI Food traditions The food I grew up loving and looking forward to eating, they can only be for holidays. I don’t want this fat for my kids. With them, we eat yogurt, salad, broiled fish, fruits, nuts. No soda! 53 years old, 36.8 BMI Community involvement Social thing has to be added, like make it a family or community thing…to be healthy, to be happy. 65 years old, 43.4 BMI Buying clubs to go outside of the Southside to shop for better foods. The foods in the Southside are fattening and delicious. 71 years old, 28.8 BMI Medical advice Doctors need to tell us more about weight issues, like I never get told anything but ‘hmmm, you gained weight.’ I don’t get any orders or strict ideas. 52 years old, 53.5 BMI Social support Women need support, support for all ladies who are doing their best, and are stressed to the max. 21 years old, 32.7 BMI We need to work on discipline, not planning, not eating breakfast, not cooking… 37 years old, 30.6 BMI Mental health (missing from federal recommendations) Using food to medicate. We are normally not the one to need someone. Not taking care of self is the problem, the start… 57 years old, 28.5 BMI Getting our mind right, too much stress is what make me eat and eat, so I can sleep. 39 years old, 23.7 BMI

DISCUSSION Health researchers have attempted to predict

and explain non-adherence to obesity and multiple chronic disease medical protocols by investigating a variety of sociodemographic variables that have multiple levels of influence on minority populations.44-46 In analyzing the weight causal explanations of these women, we found that the construction of weight-related themes is largely influenced by their racial experience through history (ie, a re-

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Obesity Literacy and Culture among African American Women in Florida flection of slavery influencing how they cook today), culture-related behaviors (ie, food preparation and consumption), and socio-economic status (ie lack of access to healthy foods and physical activity settings). The women felt success in weight loss or control was elusive to African-American women due to social injustice factors. These differences were outlined in Table 3, where the public health recommendations and African-American women’s wisdom are compared and contrasted. Chiefly, we found that the body mass index was not widely accepted among women who were overweight and obese, as these women perceived those weights as not applicable to African-American women. Further, the public health recommendations consistently overlooked the social support and mental health aspects of weight including stress, anxiety, and depression. The finding that African Americans whose BMIs indicate them to be overweight and obese are less likely to know their normal weight is supported by existing research. Researchers analyzed data of the National Health and Nutrition Examination Survey (NHANES) and found that less than half of the study participants (45%) who fell in the overweight classification knew their weight status.47 Similarly, 66% of the participants who were classified as obese did not know it. Among African Americans, awareness of weight status is also low. Moreover, Bleich48 found that even when race concordance is present, weight education is worse among African-American patients even when their doctors are also African Americans. In the present study, the women with highest weight were much less aware of their normal weight according to height. These women also were least likely to have received medical advice with regards to weight. When the women received medical advice regarding their weight problems, it was discrete advice on diet or exercise, and when it centered on eating behaviors, it focused on avoiding certain foods, or moving more. Advice tended to be limited and not focused on comprehensive lifestyle changes. Bleich48 had similar findings, and established that this is true with the overall American population, as only 30% of obese Americans actually receive an obesity diagnosis, and only one-third are advised by their doctor to lose weibment was not linked to better weight, as others have determined.49 The women who provided most of the solutions to weight were older, and were concerned with preventing the consequences of weight in their grandchildren. In turn, the causal explanations of African-American women of normal weight range were most similar to the public health agencies’ recommendations. The findings regarding stress are also supported in the existing literature.50-52 Stress is largely normalized in the African-American population and among women in particular. Lack of social support from friends, family, and health professionals was revealed by the women. Among the largest women in the study, there seemed to be an ac-

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ceptance of weight, where social support was actually determined to have a strong negative influence on unhealthy behaviors.53-55 The fact that medical professional advice was provided by women with normal weight as a motivating factor suggests that it is a variable needing further study. Regarding role models, the women expressed there were not many, and when asked who came to mind when they thought about someone who controlled their weight well, a long pause ensued. The only role models were First Lady Michelle Obama, or male relatives (father, husband, brother). Strengths The causal explanations approach uncovered the rich information necessary for tailored weight control education in an African-American community. To our knowledge, this is a unique approach to compare public health recommendations with the women’s wisdom on weight management. The Kleinman model approach helped to identify gaps in cultural competence and health literacy from both sides. Using this knowledge, public health messages and interventions can be created specifically to resonate with the African-American community. Limitations The present study had limitations. Due to time constraints it was not possible to interview the women regarding their weight history along with their current weight status. Future studies should consider capturing this information for a broader view of the changes in weight perspective across the life spectrum. This study was exploratory in its examination of causal explanations of weight in an understudied population. Further study of family weight history and social influence should be conducted. Conclusion Health professionals, including primary care physicians and pharmacists should be educated to remind the women of the value of weight control at each appointment. Most of the women expressed not having received medical advice regarding their weight, at least not comprehensive weight loss or management advice. Principally, health professionals must address the need to know and aim to meet the body mass index weight ranges among people of all races and ethnicities. This finding needs particular emphasis in this African-American community. Health educators must consider that segmenting by weight status may be essential to adequate receipt of tailored educational messages and interventions. Information sources must include community presenters, public service announcements, and electronic sources. The women in this study expressed that community organizations are trusted sources of information. The women also identified the need to include politicians in education

Lopez et al regarding weight, to go beyond the personal health habits, and into the availability of comprehensive services, as well as healthy food offerings in poor neighborhoods.

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Human Subjects Statement The study protocol (including informed consent forms, interview guide, survey and all other materials) was reviewed and approved by the Institutional Review Board of Florida Agricultural and Mechanical University. Conflict of Interest Statement The researchers have no conflicts of interest to report. Funding for the project was provided by the Faculty Research Awards Program at Florida A&M University. References

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