Brody School of Medicine at East Carolina University

At the end of the session participants will

• Describe weight loss experiences of AA women as described in research literature • List strategies that lead to a positive weight loss experience for AA women • Have brainstormed how weight management experiences for AA women in eastern NC might be improved Kolasa ECU Family Medicine 2007

Who is in this session?

What hope to learn?

Quick Reminder of Definition of Obesity (NIH) and types of evidence based interventions CLASS BMI DIET EXERCISE Y DRUG SURGERY Overweight + 2 risk factors 25.0 29.9 or ↑ girth Overweight + co-morbidity Obesity I 27.0-29.9

30.0-34.9

Y Y Y Y Obesity II Obesity III 35.0-39.9



40 Y Y Y Y Y* Y * (Reminder: Normal BMI is 18.5 to 24.9.)

Kolasa ECU Family Medicine 2007

Steps in Obesity Management

-

adults & children • • Assess BMI and waist circumference Consider treatable causes of obesity ( e.g. meds, hypothyroidism, Cushing’s syndrome) • • • Assess co-morbidities (HTN, DM, sleep apnea, etc) Determine if pt is ready and motivated to address wt Assess current dietary and physical activity habits. Have patient keep diary.

• Negotiate dietary and physical activity changes, set mutual, incremental goals (There is no one best diet for everyone but there are safe and effective strategies) • Provide education (including Internet resources;) possibly refer to Registered Dietitian for more information.

(Based on NIH Obesity assessment and treatment guidelines.) Kolasa ECU Family Medicine 2007

No single best diet prevention/treatment. But there are known nutrient needs that must be met for long term health

• http://www.nationalacademies.org/iom.fnb

• Minimum Carbohydrate: 130g daily (45-65% of total calories) • Fat: 20-35% of calories • Protein: 10-35% of calories • Dietary Fiber: 14 g/1,000 cal • 1 Hour Physical Activity Daily (wt maintenance) • Added sugar should not exceed 25% of calories (WHO says 10%) Kolasa ECU Family Medicine 2007

Estimated Caloric Requirements To lose 1 pound of body fat per week, increase activity or decrease calorie intake by 250-500 calories per day

Gender

Child Female Male

Age (years)

2-3 4-8 9-13 14-18 19-30 31-50 51+ 4-8 9-13 14-18 19-30 31-50 51+

Sedentary

1,000 1,200 1,600 1,800 2,000 1,800 1,600 1,400 1,800 2,200 2,400 2,200 2,000 From

Dietary Guidelines for Americans 2005.

Available at http://www.health.gov/dietaryguidelines/dga2005/document/pdf/dga2005.pdf

Activity Level Moderately Active

1,000-1,400 1,400-1,600 1,600-2,000 2,000 2,000-2,200 2,000 1,800 1,400-1,600 1,800-2,200 2,400-2,800 2,600-2,800 2,400-2,600 2,200-2,400

Active

1,000-1,400 1,400-1,800 1,800-2,200 2,400 2,400 2,200 2,000-2,200 1,600-2,200 2,000-2,600 2,800-3,200 3,000 2,800-3,000 2,400-2,800 Kolasa ECU Family Medicine 2007

An example of medical value of weight loss… Changes in Medical Risk Factors, By Percentage of Body Weight Lost 5%-10% (n = 651) Reduction in: Total cholesterol Triglycerides –8.1% –12.9% Fasting blood glucose –4% Systolic BP (mm Hg) Diastolic BP (mm Hg) –4 –3

Source: HMR, 2007

11%-15% (n = 623) –12% –21.7% –6.9% –6 –5 16%-20% (n = 501) >20% (n = 789) –13.2% –22.5% –19.5% –40.7% –6.7% –6 –12.5% –12 –5 –9

Kolasa ECU Family Medicine 2007

2005 By 2058, everyone in US will be obese if rates rise at same pace they have over the last several years BMI > 30, or ~ 30 lbs. overweight for 5'4" person 2005 In one survey” 67% Americans say tried to diet to lose weight at least once in last 5 years. 66% said they failed

Kolasa ECU Family Medicine 2007

By definition most AA in ENC are overweight/obese

60% 50% 40% 30% White Af Amer 20% 10% 0% Underwt Normwt Overwt Obese

From Cummings et al. REACH study Hertford, Martin, Pitt and Duplin Counties, 2005.

The evidence says AA women need to work toward a healthier weight • Studies show AA women less likely than white women to participate in weight loss programs (ref 7) – 28% vs 40% in one study

The dominant culture has laughed and cried with the weight struggles of cartoon characters like Cathy

Kolasa ECU Family Medicine 2007

All have watched Oprah and her weight

Is the African American Experience different?

African American Women’s Weight Loss Experience

• Less likely to participate in weight loss programs (28% vs 40% in one study) –

Exercise for wt loss less (37% vs 48%)

•

Even less as number of children go up

–

More likely to use maladaptive behaviors (Ref 2)

•

More likely if other friends, relatives use pills, laxatives

•

Don’t report to doctor

• Less likely to be motivated by appearance than whites, but can be motivated by clothes not fitting; want to “look good” in clothes • Try losing weight by decreasing fried foods, decreasing sweets, increasing exercise, skipping meals, fasting on water or juice, using laxatives, using liquid meals, use diet pills, join a weight loss program; rarely on medically prescribed low fat (Ref 6) Kolasa ECU Family Medicine 2007

African American Women’s Weight Loss Experience cont’d

• • • •

Less likely to have success than Caucasians in same program (Ref 7, 11)

–

Reasons are largely unexplained

–

AA cite less personal motivation at outset

– –

AA less likely to continue exercising AA more likely to be frustrated with insufficient results Generates feelings of pain, desperation, frustration, boredom Those who are successful report feeling better and having more energy Those successful don’t have “good food” “bad food” concepts

Kolasa ECU Family Medicine 2007

Americans trying to lose weight who fail say it’s because

• 80% don’t exercise • 59% blame metabolism • 45% splurge on favorite foods • 44% no self discipline • 41% snack too much • 33% overeat at meals • 31% eat for emotions • 30% eat too much high fat food • 28% don’t make good choices at restaurants • 19% only watch fat intake and not calories • 14% only watch calories but not fat intake How is this same/different for AA women?

Kolasa ECU Family Medicine 2007

Stages of Change for Weight Loss

Stages of change % Do you believe you would have more energy if you lost weight?

Do you believe life would be less stressful if you lost weight?

Do you believe you would look better in clothes if you lost weight?

46 44 Do you believe you would feel better about yourself if you lost weight?

Do you believe you would be healthier if you lost weight?

Mean pros scale score (SD) 46 1.8

PC C 30 19 58 23 82 48 70 78 78 1.5

P 47 98 66 91 87 92 1.0

4 A 80 60 100 80 60 1.3

From Hawkins, 2001

Stages of Change for Weight Loss

Stages of change % I think the type of food that I eat affects my weight To keep from gaining weight, I need to exercise To keep from gaining weight, I need to watch what I eat After I go off a diet, I always put back on the weight The will of God affects my weight Weight runs in my family and affects my weight Other people think I should lose weight My mother thinks I should lose weight My doctor thinks I should lose weight My friends think I should lose weight My husband / boyfriend thinks I should lose weight My sisters think I should lose weight 26 30 14 25 33 5 20 26 PC 30 60 84 86 40 15 30 26 39 58 18 38 26 C 17 85 89 100 63 10 45 48 61 78 36 48 59 P 47 88 97 100 69 40 40 0 40 60 0 60 0 A 4 60 80 100 60

p

0.006

0.050

0.001

0.006

0.16

0.11

0.012

0.011

0.001

0.004

0.022

0.059

From Hawkins, 2001

6 Themes in Wt Loss Experience

• Failure of weight maintenance • Use of psychological and spiritual approaches • Role of family influences and social expectations • Role of African American subculture • Method of affordability • Racial differences in weight loss methods – From Ref 3 Kolasa ECU Family Medicine 2007

1. Failure of Wt Maintenance

• Achieve modest short term wt loss • Need weight maintenance strategies incorporated into the program. “They don’t teach you how to maintain” – Local experience. Ask for maintenance programs but then don’t commit. So, how do we get people to stay in for more than 12 weeks?

Kolasa ECU Family Medicine 2007

2. Psychological and spiritual approaches

• Desire to have concerns remediated through spiritual means – Church based improved adherence (Ref 9) • Praying • Fasting • Detox and Cleansing • Exercise to gospel music • Begin group classes with prayer Kolasa ECU Family Medicine 2007

What to Do?

• Describe spiritual approaches – What can churches do • Increasing identity between counselors and participants – Successful losers as peer counselors – Use only AA instructors (Ref 7) – Use buddy system for relapse prevention (Ref 10) Kolasa ECU Family Medicine 2007

See Success Stories

www.eatsmartmovemorenc.com

• Board of Elder’s adopted a policy statement supporting healthier eating among members • Monthly fellowship gathering designated for healthy eating and PA • New equipment purchased • Members encouraged to bring fruits and vegetables to covered dish dinners • Provided fruit snacks to youth programs • Health tips included in congregational newsletter • Work continuing today by partnering with a neighboring congregation to hire a parish nurse • Pastor critical Grace Lutheran Church Concord, NC

3. Family influences and societal expectations

• Pressured by families to accept being overweight. “Big Boned” “voluptuous” • Many do not conceptualize overweight in negative terms (Ref 1) • What friends think is important (Ref 5) • Some have negative body image views even though culture appears to tolerate fatness – Studies support larger woman but not obese • Women move to “preparation” when BMI> 35 (Ref 5) – Do not perceive health and social consequences of obesity – Not accepting dominant culture’s definition of overweight to guide weight loss methods (Ref 4) Kolasa ECU Family Medicine 2007

What to do

• Address ambivalence about weight • Encourage parents to give positive messages to children about weight and physical activity and healthy eating • Teach relationship between weight and health Kolasa ECU Family Medicine 2007

4. AA subculture hinders weight management

• Impact may vary among individuals • “eating and sharing is a black thing” • Support of sedentary lifestyles – Fear sweating or bulking up; don’t want hair messed up • Settings: focus on food in social settings including church, sorority • Cultural food types (fried chicken, collard greens, fatty snacks) • Role of caregiver: use of fast food, “too tired to exercise” Kolasa ECU Family Medicine 2007

What to Do

• Afro-centric principles: interdependence, spirituality, connection to one’s ancestry, social support, importance of family • Take care of self so can take care of others • Capitalize on social support – Enhances perceived control/self efficacy (Ref 10) – Pray for other participants – Rewards for group rather than individual goal meeting – Share a meal at sessions (Ref 7) – Include families/children • Healthy food preparation in cultural and social gatherings rather than changing food – ESMM policy guidelines. www.eatsmartmovemorenc.com

– Cookbooks and brochures Kolasa ECU Family Medicine 2007

Can order Photo copy Reproducible Masters WIN@info.

Niddk.nih.gov

1-877-946-4627 Fit and Fabulous As you Mature http://www.hsph.harvard.edu/sisterstogether/ Kolasa ECU Family Medicine 2007

Can we make messages materials/programs more appealing to AA women?

• Do materials need to show AA women?

• How edit tips on eating better?

– Start day with breakfast – Eat more fruits and vegetables – Eat less meat – Choose non fat milk, yogurt, cheese – Choose whole grain more often – Drink less soda, sweet tea or other drinks

Try lower fat versions of favorite foods, instead of

• Fried chicken _______________ • Ham hocks, salt pork, fat back _________ • French fries_________________

5. Affordability

• May not have the $ that day to go to weight watchers or programs • Healthy food thought of as expensive • Safe places to be physically active Kolasa ECU Family Medicine 2007

What to Do?

• How can we educate, especially women with limited resources?

• What cultural adaptations are needed?

Kolasa ECU Family Medicine 2007

6. Racial differences in ideal weight loss methods

• Not interested in physical activity – Need demonstrations (Ref 7) • Emphasis on acceptable food characteristics (texture, taste) – Like less information and more demonstration (Ref 7) Kolasa ECU Family Medicine 2007

What to Do?

• Frame physical activity as a social activity • Cooking demonstrations. Don’t cut out but alter food preparation Kolasa ECU Family Medicine 2007

Before you start to walk, do the stretching exercises shown here. Remember not to bounce when you stretch. Perform slow movements and stretch only as far as you feel comfortable.

When you choose a hairstyle for your active life, consider:

- Natural hairstyles hold up to frequent shampoos.

- Short hair is easy to wash and wear.

- Short hair can be dried and styled quickly or slicked back with gel.

- Locks are easy to care for.

- Long hair can be pulled back for a new look.

- Blunt cuts or Bobs look great wrapped or curled and can stay styled after workouts.

FEELING FIT 4 LOOKING FINE Kolasa ECU Family Medicine 2007

Other thoughts on how to address these themes?

• Failure of weight maintenance • Use of psychological and spiritual approaches • Role of family influences and social expectations • Role of African American subculture • Method of affordability • Racial differences in weight loss methods Kolasa ECU Family Medicine 2007

What opportunities do we have in eastern North Carolina

1.

2.

3.

4.

5.

References

Black MM et al. Overweight adolescent AA mothers gain weight in spite of intentions to lose weight. JADA. 2006;106:80-87.

Breitkopf CR, Berenson AB. Correlates of weight loss behaviors among low income African American, Caucasian, and Latina Women. ACOG. 2004;103:231.

Davis EM, Clark JM, Gary TL, Cooper LA. Racial and socioeconomic differences in the weight-loss experiences of obese women. AJPH. 2005;95:1539 Gore SV. African American women’s perceptions of weight: paradigm shift for advanced practice. Holist Nurs PRact. 1999;13:71-79.

Hawkins DS et al. Stages of change and weight loss among rural African American women. Obesity research.2001;9:59.

Kolasa ECU Family Medicine 2007

6.

7.

James DCS. Gender differences in body mass index and weight loss strategies among African Americans. JASA. 2003;103:1360.

Karanja N. Steps to soulful living: a weight loss program for AA women. Enthnicity & disease. 2002;12:363-371.

8.

Newton RL Weight management in African American Women: practical issues. Obesity Management. 2005;243.

9.

Sbrocco T. et al. Church based obesity treatment for AA women improves adherence. Enthnicity & Dis. 2005;15:246.

10.

Wolfe WA A review: maximizing social support & disease. 2004;14:212-218.

—a neglected strategy for improving wt management with AA women. Ethnicity 11.

Young DR, et al. Motivations for exercise and weight loss among AA women. Ethnicity & Health 2001;6:227-245.

Kolasa ECU Family Medicine 2007

Resources

• http://win.niddk.nih.gov/publications/mature.htm

. Fit and Fabulous as you Mature.

• http://www.modep.buffalo.edu/assets/docs/healthy_down_home_cookin.pdf

. Healthy Down Home Cookin •

Heart-Healthy Home Cooking African American Style.

629-3255 (TTY).

National Institutes of Health (NIH) Publication No. 97-3792, 1997. This pamphlet tells how to prepare your favorite African American dishes in ways that will help protect you and your family from heart disease and stroke, and includes 20 tested recipes. Available from the NHLBI for $3.00; call (301) 592-8573 or (240) •

Down Home Healthy Cookin’.

National Cancer Institute (NCI), reprinted 2000. This pamphlet features 12 recipes for traditional African-American foods modified to be low in fat and high in fiber —but still tasty. Available free from NCI; call 1-800-4-CANCER or 1-800-332-8615 (TTY).

Kolasa ECU Family Medicine 2007