Challenging Dogma - Spring 2009

Tuesday, May 5, 2009

Recognizing Differences in Racial Minorities: Using Social Sciences to Combat Childhood Obesity- Caitlin Quinn

The obesity epidemic plagues America as a whole, as there is not one race, community, or state not affected by the issue. When looked at more closely however, it becomes evident that one of the fastest growing groups are black and Hispanic children. Furthermore, not only do many weight loss trials fail to include this population, those that do have poor results. In the previous paper I addressed that public health obesity interventions are failing minority children because they fail to recognize the difference between racially diverse groups. The following paper will illustrate that by recognizing differences in the home environment, school environment, and sociocultural perception of weight will allow for the creation of obesity interventions that will be successful for minority children.
Home Environment
With more minority families living below poverty and in segregated neighborhoods compared to whites, it should be no surprise that they face different challenges when it comes to being healthy (1). With lacking supermarket access and areas to play safely outside, public health interventions such as the Fruits and Veggies More Matters campaign and Physical Activity Guidelines for Americans do not apply to people living in these communities (2). In the next two sections I will propose that the limited supermarket access can be overcome using the Community Mobilization approach, while the lack of physical activity can be addressed using Maslow’s Hierarchy of Need.
Supermarket Access
Minorities living in poor communities are well aware that they are unable to afford and or gain access to fresh fruits and vegetables. Just because this population has a higher obesity rate does not mean that they actively choose not to eat fruits and vegetables. Using a Community Mobilization approach to address this issue therefore, would not only help families learn ways to make these children healthier but will also empower them to become advocates for their communities. For this intervention I propose that campaigns already advocating healthy eating such as the More Matters campaign develop “lesson plans” which can be used in communities that lack the ability to feed their children a variety of fruits and vegetables. These materials would cover topics such as how to stretch shopping budgets, alternatives to buying fresh fruits and vegetables, and ways to preserve groceries. The lessons can be disseminated to community leaders who could in turn create groups where families can come each week and learn as well as discuss how to overcome the challenges of healthy eating. Each week the sessions will end with a cooking demonstration using inexpensive ingredients that will then be tasted amongst the group. Not only will the meal be a way to demonstrate that you can eat healthy on a budget, but it will also act as an incentive to come to the class. It is important that these classes be taught by members of the community rather than a doctor or social worker from the outside because the people attending these sessions have to feel that the facilitator can relate to the frustrations and challenges of not being able to feed healthy meals to their children.
Using a group setting to pass on this information has several benefits. For one it will bring together parents who share the common goal of making their children healthy, which can help to form social networks. These networks may be useful in coming up with ways to carpool to grocery stores so that people without transportation can feel comfortable asking for help. Also, the social mobilization approach is popular for empowering the people who take part to make a change (3). In this case the change may be lobbying for a supermarket to be put into the community. If community members can convince supermarket companies that the store is needed, and will be supported, developers may be more willing to build in the area. I feel that this approach is the best solution to the lack of supermarkets because it teaches skills needed to keep children healthy even in less than ideal circumstances.
Physical Activity in Unsafe Neighborhoods
Forty-six percent of Americans consider their neighborhoods unsafe, with minorities twice as likely to report living in unsafe areas (4). Often minority children living in these neighborhoods are unable to play outside after school or afford the equipment needed to play on a team sport. Unfortunately these issues are often ignored in interventions aimed at getting kids to become more active. In the MyPyramid for children safety issues are ignored as if all children live in safe environments.
Maslow’s Hierarchy of Need is often used as a way to track an adult’s journey to self actualization. What is often forgotten is that children also have inherent needs that they strive to fulfill especially the need for safety (5). Using the hierarchy, commercials can be developed that address the different needs of children. For example commercials can show children dancing in their bedrooms or having jumping jacks competitions with a sibling or friend could encourage kids to be physically active without worrying about their safety outside.
Using this approach will be effective for one key reason; it has been shown that minority children watch more television than their white counterparts, and therefore would most likely be reached through this approach (6). The commercials could even depict a child shutting off the television to dance to the radio or having the jumping jacks contest during the show’s commercial breaks. Using Maslow’s Hierarchy, children will be able to achieve their need for safety while still having fun and getting healthy.
School Environment
Just as much of the minority population live in segregated communities, minority children often attend under funded schools, lacking the ability to provide the healthiest food choices (7). In the previous paper the issue of vending machines generating a large income for these schools while providing high calorie and fat items, as well as the inability of these schools to provide extra fruit and vegetables through the Department of Defense Program was addressed. To solve these issues I suggest Diffusion of Innovation be used to introduce healthy alternatives to the vending machines, while the Organizational Change approach be used to change school lunches .
Vending Machines
Stonyfield Farms has created a Do it Yourself Vending Machine Makeover Guide which recognizes how important revenue from the vending machines are, and gives a list of over 300 healthy alternatives which can be put in the machines (8). This outlet coupled with the Diffusion of Innovation approach can make for a smooth and successful vending machine makeover. Using this approach, a select group of children can be chosen to taste test the new foods and then used to serve as the early adopters who introduce the rest of the students to the new items (9). Coupling this approach with contests such as which class can collect the most empty milk or water bottles can make it seem more like a game than a method to get children healthier. Diffusion of Innovation will work well within school settings because children are always looking to try “cool” new things, so as long as there is a group who is on board to being with the rest should be soon to follow. The other benefit to this approach is that under funded schools who need vending machines the most will not have to worry about losing such a great source of revenue.
School Lunch Program
Although it is hard to develop an intervention targeting the USDA and the Department of Defense there are some approaches that may help get more fruits and vegetables into under funded schools. Using an Organizational Change approach, schools that are unable to purchase extra produce from the DOD can band together to lobby for support. Further, they could work together and buy directly from farmers at a lower price since they would be buying in such large quantities. The Organizational Change approach would help with this situation because multiple schools with the same goals would have a chance to come together and lobby for a change (10).
Sociocultural Perception of Weight
Medically obesity is viewed as “bad” or unhealthy because of the health issues associated with it. Using this medical approach then, it is no wonder why public health interventions aimed at obesity are evaluated in terms of weight lost. When you look into different cultures however, it becomes clear that not all view overweight as a bad thing. In order then to successfully design interventions that incorporate minority children it is important that you understand what they and their parents view as unhealthy. In order to design such an intervention Cultural Anthropology can be used to plan an approach targeting obesity.
Cultural Anthropology can be used to identify the eating patterns of minority children and their parents. It can also be used to look into what parents see as unhealthy in terms of their children, and how they define appropriate weight (3). This is useful because as was seen in the last paper, some mothers view their children as overweight only when a condition such as asthma or trouble walking develops.
Using this approach, an example of an intervention is one that targets problems associated with obesity such as Type 2 Diabetes. There are no cultures or races to my knowledge that view this disease as positive so it seems likely that it is something they would want to prevent in their children. The intervention could provide information on the dangers of diabetes and how it can be prevented. Since prevention comes from eating healthfully and exercising, the hope is that children at risk will lose weight in the process. By making obesity prevention a secondary measure more families of minorities may be willing to participate since weight is not the primary focus.
Public Health has failed minority children in the past because they overlooked the differences between races. The home and school environments as well as sociocultural perceptions of weight need to be looked at when designing interventions targeting obesity. Using social, cultural, and environmental theories when developing new approaches will help close the gap of racial disparities not only when it comes to obesity rates but for health in general.

1. Williams DR, Collins C. Racial Residential Segregation: A Fundamental cause of Racal Disparities in Health. Public Health Reports 2001; 116: 404-416
2. Brown MR. Supermarket blackout- lack of quality grocery stores in black communities (pp 9-8). In: Black Enterprise. New York, NY: Earl G. Graves Publishing Co, 1999.
3. Edberg M. Social, cultural, and environmental theories (Part II) (pp. 65-76). In: Edberg M, Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Sudbury, MA: Jones and Bartlett Publishers, 2007.
4. Bush CL, Pittman S, McKay S, et al. Park-based obesity intervention program for inner-city minority children. Journal of Pediatrics 2007; 151: 513-517.
5. Investing in Children. Maslow’s Hierarchy of Needs. 2006.
6. Kumanyika S. Special issues regarding obesity in minority populations. Annals of Internal Medicine 1993; 119: 650-654
7. Orfield G, Eaton SE. Dismantling desegregation: the quiet reversal of Brown v. Board of Education. New York: New Press, 1996.
8. Stonyfield Farms. Menu for Change. 2003.
9. Edberg M. Social, cultural, and environmental theories (Part I) (pp. 52-64). In: Edberg M, Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Sudbury, MA: Jones and Bartlett Publishers, 2007.

Failure to Recognize Differences in Racial Minorities: Public Health Failures in Addressing Childhood Obesity- Caitlin Quinn

In a country of surplus is it any surprise that obesity is the most talked about epidemic facing Americans? The rise in obesity rates especially among children has made it so that the coming generation will be the first in history not to outlive their parents. Among children aged 6-11 obesity has risen from 6.5 to 17% in the past 30 years. For adolescents aged 12-19 the prevalence has more than tripled from 5 to 17.6% (1). Dividing this overall statistic amongst different races it becomes clear that children from minority groups have higher rates of obesity. NHANES 2002 shows that Mexican American boys have the highest rates of obesity at 26.5% between the ages of 6 and 11, and 24.7% of those aged between 12 and 19. Among the female population, African American girls have the highest rates of obesity at 22.8 and 23.6% respectively. These percentages can be put into prospective when compared to rates of obesity amongst white children with about 14% of boys and 12% of girls classifying as obese (2).
Although obesity is prevalent in all three racial groups, it is clear that minority children are more commonly afflicted by the disease. My question then is why are the public health interventions that have been developed to fight obesity in children applicable only to white, middle class adolescents? In the following paper I will show how the minority populations are largely being ignored by the move to put an end to childhood obesity. The failure comes in the lack of attention given to three major factors affecting the lives of many minority children: home environments, school environments, and sociocultural differences on weight perception.
Home environment
The US Census Bureau reports that as of 2007 24% of African Americans and 20% of Hispanics were below the poverty line, compared to 8% of whites (3). Living below poverty means that these people are unable to live in ideal neighborhoods or attend the best schools, which can have major implications when trying to implement a health intervention. Residential segregation has been identified as central to the racial inequalities in America. Although policies that once limited the worst neighborhoods for minorities are now outlawed, national statistics show that 66% of blacks remain in these segregated neighborhoods today (4). Living in largely segregated areas have many implications that have been ignored by public health interventions, including lack of supermarkets, and recreational facilities.
The Fruits and Veggies More Matters campaign emphasizes the importance of eating at least five servings of fruits and vegetables each day (5). What is not addressed however is the fact that for people living in poor communities supermarkets that carry quality produce at competitive prices are hard to come by. Often, several modes of transportation are needed to find a grocery store, or residents are limited to what is available at the nearest Seven-Eleven (6). The More Matters campaign fails minority children because it is using the Theory of Reasoned Action as its base, which states that someone’s intention to do a behavior comes from their attitude towards the behavior. If the person sees the outcome of the behavior as positive, and feels it would be well accepted by others, the behavioral intention will be high (7). Although this is a nice thought, many children of minority and their parents want to be healthy and eat well, but are unable to do so because of where they live. It is astonishing to me that the More Matters website does not even address issues associated with where to buy less expensive produce, or how families on a budget can still eat fruits and vegetables. You would think that a national campaign to stop the obesity epidemic would target more than white middle class families. This is a prime example of how intention does not always lead to behavior, and the failure that comes when public health professionals ignore the different populations within America.
Forty-six percent of Americans in the US consider their neighborhoods unsafe, with minorities twice as likely to report living in an unsafe area than whites (8). Consequently, it is not as easy for children living in such unsafe neighborhoods to walk to the nearest playground, or ride bikes down the street, thus getting the exercise they need. As part of a focus group addressing overweight in urban African American youth, one mother stated “You got crime that’s going on where we’re leery of letting them go out down the street” (9). Reports have also shown that there are less parks, fields, and pools in inner city neighborhoods (4).
The Physical Activity Guidelines for Americans says a child should get at least 60 minutes of physical activity a day. Within this 60 minutes there should be at least three days each week the child is participating in muscle strengthening as well as bone strengthening activities. The guidelines give a list of ways parents can get their kids more active such as letting them walk or bike to school, buying them equipment that encourages physical activity, and enrolling them in team sports (10). What is completely void in these recommendations is what a child can do if there is no money to sign up for a sport or the neighborhood is not safe enough to play outside. In the previously mentioned focus group a mother said “My daughter, she would like to enroll in karate classes and a ballet class… but I just couldn’t afford it. I couldn’t afford it”(9). This mother knows that these classes would help her child but because she cannot afford them she is at a loss as to how to help her child lose weight.
The new USDA food pyramid for kids adopted the motto “Eat right. Exercise. Have fun”, and displays children riding bikes, playing soccer, walking the dog, and even playing basketball in wheelchairs (11). While it is wonderful children with disabilities are being recognized, this poster fails to show any type of indoor activity children can do to stay active. If minority children, especially those living in unsafe neighborhoods see this poster how are they supposed to relate to it? These two public health programs make it seem as if it is impossible to get any type of exercise inside a home. In order for all children to be able to relate to these messages, activities such as dancing to a radio or to the TV, or having a push-up contest with friends should be shown.
The USDA’s pyramid and the CDC’s guideline for physical activity mirror the common theme seen in public health where social factors along with formative research are ignored (12). By trying to target all children in America with one intervention, black and Hispanic children are marginalized.
School environment
In the previous section, today’s existence of racial segregation was highlighted. Unfortunately, racial segregation in neighborhoods has also affected public schools. Generally, schools with a high proportion of African American and Hispanic children are often under funded, and in poor communities, which has major implications for the health of their students (13).
In order to generate revenue, schools throughout the US have put in vending machines which typically sell calorie dense, but nutrient poor snacks and drinks. These vending machines can often raise up to $10,000 per year to be used as the school sees fit (14). The revenue that comes from these vending machines is often used to fund field trips, needed supplies, and foodservice operations. With the recognition of the obesity epidemic in children, there have been numerous attempts to get rid of vending machines in schools throughout the US, with at least 30 states considering legislations banning the machines (15). The problem with state wide bans is that they are not taking into consideration how much some under funded schools rely on the revenue. Further complicating matters, current research published in the Journal of the American Dietetic Association shows that children of minority are more likely to purchase soft drinks from school vending machines (16). Applying these findings, it becomes evident that schools with high proportions of black and Hispanic students, not only rely on vending machines more, but also generate more revenue from them when compared to mostly Caucasian populated schools. It is essential that state legislators look into the facts before putting state wide bans on vending machines in schools because it could have detrimental effects in some districts. Although it would seem that since minorities are more apt to buy soda at school, banning these products would be a step in the right direction, it is essential that funding be available to replace the revenue.
The National School Lunch Program is not known for its healthy options. Although it is regulated by the USDA, it is nearly impossible to enforce the sale of foods that entirely meet the USDA guidelines. A common complaint is that the traditional school lunches are severely lacking in fruits and vegetables. In response to this, the USDA partnered with the Department of Defense (DOD) to develop a program that supplies fresh fruits and vegetables directly to school districts (17). Since its implementation in the mid 90’s, DOD-Fresh has provided up to 900 different products to schools across the country. The major downfall of this program is that it only serves schools that can pay for it. In order to receive the program benefits, schools need to purchase the products using lunch cash reimbursements, and children’s payments. Basically, due to a lack of federal funding, underprivileged school districts are unable to participate in the program. Here is an example of how minorities are being left out again as they are overlooked when trying to better the nutrition environment of school systems.
With 95% of children attending school in the US, it plays a key role in the development of healthy eating habits. School based prevention programs have the potential to markedly reduce the prevalence of childhood obesity through the promotion of healthful eating, but it seems that government and state based prevention programs mostly benefit the less afflicted schools. The children who need these programs most are the ones who are being marginalized simply because they do not attend the right schools.
Sociocultural perception of weight
Mass media and even physicians’ reliance on BMIs to assess overweight and obesity make it so that any outsider would think American’s highly value thin figures. Even research on childhood obesity looks mostly on reducing pounds rather then focusing on the real reasons someone is overweight in the first place. Since the thin ideology is so engrained in our society I do not think many people stop to realize that not all Americas view being overweight with such negative connotations.
Shifting away from the solely medical based theories on why being overweight is “bad”, socially based research has revealed that race is a major factor in how one perceives their body. In a study that took place in ethnically diverse high schools across the United States, ninth and tenth graders were shown pictures of models in popular magazines, “White girls, despite their criticism, are stilled harmed by the images because they believe that others find the images important… Minority girls do not identify with ‘white’ media images nor believe that significant others are affected by them” (18). Other studies have found that African American and Hispanic adolescents report greater comfort with their bodies than white adolescents, and are less likely to stigmatize weight problems and to equate attractiveness with thinness (19).
In communities where most members are obese, it is likely that there are actually positive attitudes about being overweight. Puerto Rican mothers for example, often want heavier children because they interpret thinness as a sign that the child is sick or improperly cared for (20). Similarly, African American parents of overweight children were more likely to recognize their children as overweight only when a health problem such as trouble breathing was involved. Otherwise they classified their children as having a “larger frame”, and thus not applying to any charts (9). These views make it clear as to why campaigns based on traditional behavior theories like the Health Belief Model, or the Theory of Reasoned Action are unsuccessful. These theories are based off the assumptions that being obese is not the social norm, people have a negative attitude toward obesity, and people understand the severe consequences with being overweight (21). These assumptions however are just that – assumptions. If any formative research had been done it would have been clear that there is no cookie cut answer for any problem.
Public health interventions addressed toward children are so focused on winning the battle on obesity, they have failed to recognize that by making weight the primary issue, they are losing the interest of the population who needs the most help. These national campaigns need to recognize that not all Americans view obesity the same. In order to really be effective in the delivery of any intervention they should focus more on curing the health problems related to obesity, rather than obesity itself.
Ignoring differences in home, school, and sociocultural environments has led to the development of public health interventions that simply do not apply to children of racially diverse backgrounds. In order to treat and prevent childhood obesity in minorities all issues that apply the population will have to be considered, as well as the role they play in thwarting the success of the program (22). It simply is not enough to tell a child to ride a bike to get exercise, nor is it to recommend five servings of fruits and vegetables a day. Despite substantial intervention efforts racial and ethnic disparities in adolescent obesity continue to grow (23). This paper has shown that rates will continue to increase unless public health professionals take the time to recognize the differences embedded in this population.
1. Center for Disease Control and Prevention. Make a Difference at you School. Atlanta, GA: Center of Chronic Disease Prevention and Health Promotion, 2008
2. National Center for Health Statistics. Trends in the Health of Americans. Hyattsville, MD: NHANES, 2004.
3. US Census Bureau. People and Families in Poverty by Selected Characteristics: 2006-2007. Suitland MD: US Census Bureau.
4. Williams DR, Collins C. Racial Residential Segregation: A Fundamental cause of Racal Disparities in Health. Public Health Reports 2001; 116: 404-416.
5. Center for Disease Control. Fruits and Veggies Matter. Atlanta, GA: Center of Chronic Disease Prevention and Health Promotion, 2008.
6. Brown MR. Supermarket blackout- lack of quality grocery stores in black communities (pp 9-8). In: Black Enterprise. New York, NY: Earl G. Graves Publishing Co, 1999.
7. Edberg M. Individual health behavior theories (pp. 35-49). In: Edberg M, Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Sudbury, MA: Jones and Bartlett Publishers, 2007.
8. Bush CL, Pittman S, McKay S, et al. Park-based obesity intervention program for inner-city minority children. Journal of Pediatrics 2007; 151: 513-517.
9. Burnet DL, Plaut AJ, Ossowski K, et al. Community and family perspectives on addressing overweight in urban African American youth. Journal of General Internal Medicine 2007; 23: 175-179.
10. Center for Disease Control and Prevention. Making Physical Activity a part of a Child’s Life. Atlanta, GA: Centers for Disease Control and Prevention.
11. US Department of Agriculture. My Pyramid for Kids. Washington DC: USDA, 2005.
12. Edberg M. On health behavior- An introduction (pp. 1-9). In: Edberg M, Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Sudbury, MA: Jones and Bartlett Publishers, 2007.
13. Orfield G, Eaton SE. Dismantling desegregation: the quiet reversal of Brown v. Board of Education. New York: New Press, 1996.
14. United States General Accounting Office. School Lunch Program: Efforts Needed to Improve Nutrition and Encourage Healthy Eating. Washington, DC: GAO, 2003.
15. CNN. School Vending Machines losing favor. New York, NY: CNN.

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