Expanding the obesity research paradigm to reach African American communities

Obesity is more prevalent among African Americans and other racial and ethnic minority populations than among whites. The behaviors that determine weight status are embedded in the core social and cultural processes and environments of day-to-day life in these populations. Therefore, identifying effective, sustainable solutions to obesity requires an ecological model that is inclusive of relevant contextual variables. Race and ethnicity are potent stratification variables in U.S. society and strongly influence life contexts, including many aspects that relate to eating and physical activity behaviors. This article describes a synthesis initiated by the African American Collaborative Obesity Research Network (AACORN) to build and broaden the obesity research paradigm. The focus is on African Americans, but the expanded paradigm has broader implications and may apply to other populations of color. The synthesis involves both community and researcher perspectives, drawing on and integrating insights from an expanded set of knowledge domains to promote a deeper understanding of relevant contexts. To augment the traditional, biomedical focus on energy balance, the expanded paradigm includes insights from family sociology, literature, philosophy, transcultural psychology, marketing, economics, and studies of the built environment. We also emphasize the need for more attention to tensions that may affect African American or other researchers who identify or are identified as members of the communities they study. This expanded paradigm, for which development is ongoing, poses new challenges for researchers who focus on obesity and obesity-related health disparities but also promises discovery of new directions that can lead to new solutions.     

Family‐focused physical activity,diet and obesity interventions in African–American girls: a systematic review

Obesity interventions that involve family members may be effective with racial/ethnic minority youth. This review assessed the nature and effectiveness of family involvement in obesity interventions among African–American girls aged 5–18 years, a population group with high rates of obesity. Twenty‐six databases were searched between January 2011 and March 2012, yielding 27 obesity pilot or full‐length prevention or treatment studies with some degree of family involvement and data specific to African–American girls. Interventions varied in type and level of family involvement, cultural adaptation, delivery format and behaviour change intervention strategies; most targeted parent–child dyads. Some similarities in approach based on family involvement were identified. The use of theoretical perspectives specific to African–American family dynamics was absent. Across all studies, effects on weight‐related behaviours were generally promising but often non‐significant. Similar conclusions were drawn for weight‐related outcomes among the full‐length randomized controlled trials. Many strategies appeared promising on face value, but available data did not permit inferences about whether or how best to involve family members in obesity prevention and treatment interventions with African–American girls. Study designs that directly compare different types and levels of family involvement and incorporate relevant theoretical elements may be an important next step.     

Sodium Reduction and Weight Loss in the Treatment of Hypertension in Older Persons: A Randomized Controlled Trial of Nonpharmacologic Interventions in the Elderly (TONE)

Context.— Nonpharmacologic interventions are frequently recommended for treatment of hypertension in the elderly, but there is a paucity of evidence from randomized controlled trials in support of this recommendation. Objective.— To determine whether weight loss or reduced sodium intake is effective in the treatment of older persons with hypertension. Design.— Randomized controlled trial. Participants.— A total of 875 men and women aged 60 to 80 years with systolic blood pressure lower than 145 mm Hg and diastolic blood pressure lower than 85 mm Hg while receiving treatment with a single antihypertensive medication. Setting.— Four academic health centers. Intervention.— The 585 obese participants were randomized to reduced sodium intake, weight loss, both, or usual care, and the 390 nonobese participants were randomized to reduced sodium intake or usual care. Withdrawal of antihypertensive medication was attempted after 3 months of intervention. Main Outcome Measure.— Diagnosis of high blood pressure at 1 or more follow-up visits, or treatment with antihypertensive medication, or a cardiovascular event during follow-up (range, 15-36 months; median, 29 months). Results.— The combined outcome measure was less frequent among those assigned vs not assigned to reduced sodium intake (relative hazard ratio, 0.69; 95% confidence interval [CI], 0.59-0.81; P<.001) and, in obese participants, among those assigned vs not assigned to weight loss (relative hazard ratio, 0.70; 95% CI, 0.57-0.87; P<.001). Relative to usual care, hazard ratios among the obese participants were 0.60 (95% CI, 0.45-0.80; P<.001) for reduced sodium intake alone, 0.64 (95% CI, 0.49-0.85; P=.002) for weight loss alone, and 0.47 (95% CI, 0.35-0.64; P<.001) for reduced sodium intake and weight loss combined. The frequency of cardiovascular events during follow-up was similar in each of the 6 treatment groups. Conclusion.— Reduced sodium intake and weight loss constitute a feasible, effective, and safe nonpharmacologic therapy of hypertension in older persons.      

The context for choice: health implications of targeted food and beverage marketing to African Americans

Targeted marketing of high-calorie foods and beverages to ethnic minority populations, relative to more healthful foods, may contribute to ethnic disparities in obesity and other diet-related chronic conditions. We conducted a systematic review of studies published in June 1992 through 2006 (n = 20) that permitted comparison of food and beverage marketing to African Americans versus Whites and others. Eight studies reported on product promotions, 11 on retail food outlet locations, and 3 on food prices. Although the evidence base has limitations, studies indicated that African Americans are consistently exposed to food promotion and distribution patterns with relatively greater potential adverse health effects than are Whites. The limited evidence on price disparities was inconclusive.     

What “Price” Means When Buying Food: Insights From a Multisite Qualitative Study With Black Americans

Objectives. We explored the role of price in the food purchasing patterns of Black adults and youths.Methods. We analyzed qualitative data from interviews and focus groups with socioeconomically diverse, primarily female, Black adults or parents (n = 75) and youths (n = 42) in 4 US cities. Interview protocols were locality specific, but all were designed to elicit broad discussion of food marketing variables. We performed a conventional qualitative content analysis by coding and analyzing data from each site to identify common salient themes.Results. Price emerged as a primary influence on food purchases across all sites. Other value considerations (e.g., convenience, food quality, healthfulness of product, and family preferences) were discussed, providing a more complex picture of how participants considered the price of a product.Conclusions. Food pricing strategies that encourage consumption of healthful foods may have high relevance for Black persons across income or education levels. Accounting for how price intersects with other value considerations may improve the effectiveness of these strategies.In recent years, increasing attention has been given to the role that the marketing of high-calorie, low-nutrient foods and beverages has in the development of obesity, especially childhood obesity.1,2 Marketing is multifaceted, including the types of products available, where they are available, where and how they are promoted, and what they cost (the “marketing mix”).3 Food marketing variables shape the environments in which food preferences develop and in which consumers make purchasing decisions. These variables must be understood to design policies and programs to facilitate calorically and nutritionally appropriate eating patterns.Although much of the concern about food marketing has focused on children, evidence suggests that food and beverage marketing practices contribute to the higher-than-average risk of obesity and other diet-related diseases in Black persons at all ages.4,5 Black persons are more likely than White persons to be exposed to advertising and other promotions for high-calorie, low-nutrient foods and beverages, and less likely to encounter promotions for healthier alternatives.6–9 In addition, on average, Black neighborhoods have relatively fewer retail food stores that offer a wide variety of foods and relatively more fast-food outlets than other types of restaurants compared with predominantly White neighborhoods.10–15 A higher percentage of Black than White Americans have incomes near the poverty line16 and are, therefore, also affected by the disproportionate promotion and availability of high-calorie, low-nutrient foods in lower-income neighborhoods.10,13,15,17 However, the excess risks of obesity and other diet-related diseases in Black persons are not confined to the lower-income segment of the population.18–21The objective of this study was to explore the role of price in the food purchasing patterns of Black adults and youths. Price is among the strongest, if not the strongest, influences on food purchases (particularly among low-income consumers) and on caloric overconsumption.22,23 Food price may affect caloric consumption through the types or quantities of foods purchased. For example, people may buy relatively inexpensive snack foods and convenience foods that are high in fat and sugar.24 They also may feel less guilty about buying unhealthy foods if they are discounted and may eat relatively more of the products acquired at low cost or stockpiled because of quantity discounts.22,23 Price is mentioned routinely as a major influence on food purchasing decisions by Black consumers and by consumers in general.22,25–31 However, compared with other aspects of marketing, ways in which the price of products affects diet-related disparities experienced by Black adults and youths have been less well studied.Although the foods available and marketed in Black neighborhoods are relatively less healthful compared with foods marketed in White neighborhoods, available evidence does not support the hypothesis of systematic differences in food prices between Black and White neighborhoods.9,32–35 Yet these price comparison studies have not adjusted for neighborhood differences in income, which would determine what prices residents might consider affordable. Nor have they considered several other factors such as the mix of retail outlets available, availability of time and transportation to shop in other neighborhoods, price discounts, consumer food preferences, or food-specific or more general shopping patterns, all of which might influence what people buy at a given cost.22,36 This dearth of comprehensive inquiry calls for a deeper understanding of the role of food prices in purchasing behavior among Black consumers, which will inform potential marketing-related strategies for addressing obesity.     

Overall and minority-focused recruitment strategies in the PREMIER multicenter trial of lifestyle interventions for blood pressure control

Recruitment strategies employed by four clinical centers across the US and a coordinating center were examined to identify successful overall and minority-focused recruitment strategies for the PREMIER multicenter trial of lifestyle changes for blood pressure control. The goal was to recruit 800 adults (40% African Americans) with systolic blood pressure of 120–159 mmHg and diastolic of 80–95 mmHg, not taking antihypertensive medication. Clinical centers used combinations of mass distribution of brochures, mass media, email distribution lists, screening events, and a national website. Culturally appropriate strategies for African Americans were designed by a Minority Implementation (MI) committee. Diversity training was provided for study staff, and African Americans were included in the study design process. Main recruitment outcomes were number overall and number of African Americans recruited by each strategy. Of the 810 randomized PREMIER participants, 279 (34%) were African American with site-specific percentages of 56%, 46%, 27%, and 8%. Of African Americans recruited, 151 (54%) were from mass distribution of brochures (mailed letter, flyer included in Val-Pak coupons, or other), 66 (24%) from mass media (printed article, radio, TV story or ads, 52 (19%) from word of mouth, and 10 (3%) from email/website and screening events combined. Yields for Non-Hispanic Whites were 364 (69%) from brochures, 71 (13%) from mass media, 49 (9%) from word of mouth and 47 (9%) from email/website and screening events. Mass distribution of brochures was relatively more effective with Non-Hispanic Whites, while African Americans responded relatively better to other recruitment strategies.