Unraveling common threads in obesity risk among racial/ethnic minority and migrant populations.

BACKGROUND: Epidemic obesity poses a major threat to global health. This phenomenon reflects the inability of the average person to cope, biologically and behaviorally, with environmental contexts that promote caloric overconsumption and inadequate caloric expenditure. There is still much to be learned about how to improve these contexts nationally and within-countries for sociodemographic groups with above-average obesity risks. METHODS: Higher obesity risks relative to respective white majority populations were identified among diverse indigenous, other native-born, or migrant 'racial' or ethnic minority (hereafter, ethnic minority) populations in the United States, Canada, Australia, New Zealand, and the Netherlands, using publicly available national survey data or other sources. Cross-national comparisons were of interest for identifying common risk pathways associated with social and economic inequities. Potential explanations were explored through a narrative review of peer-reviewed literature, informed by the World Health Organization's Conceptual Framework for Action on The Social Determinants of Health. MAIN FINDINGS: Identifying viable solutions to the high risk of obesity in ethnic minority populations in these high-income countries requires examination of national-level social, economic, and health system contexts, food systems, and built environments for physical activity, as well as patterns of social stratification and cultural biases related to ethnicity, migration, and other determinants of social disadvantage. These factors can be linked to mediators of exposure or vulnerability to obesity-related risks, such as poverty, being an 'outsider', stress and trauma resulting from historical and current oppression, exposure to bias and discrimination, related biological or behavioral consequences, and inadequate health and social care. CONCLUSIONS: Focusing on ethnic minority populations in high-income countries is critical for public health efforts to address epidemic obesity. Mitigating intersecting risk pathways arising from stratification and bias based on ethnicity and migrant status should be prominent in these efforts.

Supplement overview: what the Healthy Communities Study is telling us about childhood obesity prevention in U.S. communities.

The Healthy Communities Study (HCS), conducted between 2010 and 2016, tells a real-world story of how childhood obesity prevention efforts have unfolded in 130 U.S. communities. The study documented nearly 10,000 current and past community policies and programs (CPPs) and assessed dietary and physical activity behaviors, weight, height, and waist circumference of more than 5,000, 4- to 15-year-old children. The articles in this HCS supplement describe the variables created to characterize the CPPs, CPP relationships with children's behavioral and weight status, other analyses of interest, and recruitment challenges. Findings suggest that many of the strategies being implemented work as intended to improve children's behaviors and weight status. However, of concern, findings also indicate lesser reach to children in demographic groups at highest risk of obesity. Overall, the HCS insights can guide the next phase of efforts to strengthen existing CPPs and motivate other, novel approaches to combating childhood obesity.

Prevention of excess weight gain in paediatric primary care: beverages only or multiple lifestyle factors. The Smart Step Study, a cluster-randomized clinical trial.

BACKGROUND: Insufficient evidence exists to support obesity prevention in paediatric primary care. OBJECTIVES: To test a theory-based behaviour modification intervention delivered by trained paediatric primary care providers for obesity prevention. METHODS: Efficacy trial with cluster randomization (practice level) and a 12-session 12-month sweetened beverages decrease intervention or a comprehensive dietary and physical activity intervention, compared with a control intervention among children ages 8-12 years. RESULTS: A low recruitment rate was observed. The increase in body mass index z-score (BMIz) for the 139 subjects (11 practices) randomized to any of the two obesity interventions (combined group) was less than that of the 33 subjects (five practices) randomized to the control intervention (-0.089, 95% confidence interval [CI]: -0.170 to -0.008, P = 0.03) with a -1.44 kg weight difference (95% CI: -2.98 to +0.10 kg, P = 0.095). The incidences of obesity and excess weight gain were lower in the obesity interventions, but the number of subjects was small. Post hoc analyses comparing the beverage only to the control intervention also showed an intervention benefit on BMIz (-0.083, 95% CI: -0.165 to -0.001, P = 0.048). CONCLUSIONS: For participating families, an obesity prevention intervention delivered by paediatric primary care clinicians, who are compensated, trained and continuously supported by behavioural specialists, can impact children's BMIz.

Introduction to the special issue on achieving healthy weight in black American communities.

The prevalence of obesity is high in the United States, and highest among racial and ethnic minority groups. This special issue of Obesity Reviews is based upon evidence reviews prepared for and presented at a national invited workshop convened by the African American Collaborative Obesity Research Network (AACORN) in August of 2012. A set of potential topics was developed, a priori, and AACORN network members and colleagues with relevant expertise were invited to lead evidence reviews. The result is 10 articles focused on providing a comprehensive picture of what is known and unknown about interventions to prevent and treat obesity or improve weight-related behaviours in African American adults and children. Evidence reviews included in this special issue focus on children and adolescents (n=2); adults from various perspectives (n=5); eHealth interventions (n=1); interventions within faith organizations (n=1); and environmental and policy change interventions (n=1). Overall, the reviews show a small evidence base for research on African Americans and call for additional prioritization of funding to include studies that can inform action and bring progress in obesity prevention and treatment in African Americans on par with the scope and seriousness of the problem.

Examining the evidence for policy and environmental strategies to prevent childhood obesity in black communities: new directions and next steps.

Exposure to physical and policy environments that limit availability, affordability and appeal of healthy eating and active living options is higher for U.S. blacks than whites. This may contribute to high risk of obesity in black communities and limit effectiveness of preventive interventions. Here, we assess applicability to black Americans of findings from a prior evidence review system designed to accelerate the discovery and application of policy and environmental strategies for childhood obesity prevention and assess external validity. The database included 600 peer-reviewed articles reporting data from 396 sets of studies (study groupings) published from January 2000 through May 2009 and pertained to 24 types of policy and environmental strategies. Only 33 study groupings (~8%) included ≥ 50% black Americans or reported subgroup analyses. Of 10 evaluation studies for interventions rated as effective for all populations in the primary review, 8 suggested effectiveness of child-focused interventions in school or child care settings for obesity- or physical activity-related outcomes in black Americans. Overall findings highlight the need for rigorous evaluations of interventions that reach black children in community or institutional settings, and conceptual frameworks and research designs geared to identifying ethnic or ethnicity-income group differences in intervention effects.

What works for obesity prevention and treatment in black Americans? Research directions.

Obesity prevalence in black/African American children and adults of both sexes is high overall and compared with US whites. What we know, and do not know, about how to enhance the effectiveness of obesity prevention and treatment interventions in African Americans is the focus of the 10 articles in this special issue of Obesity Reviews. The evidence base is limited in quantity and quality and insufficient to provide clear guidance. With respect to children, there is relatively consistent, but not definitive support for prioritizing the systematic implementation and evaluation of child-focused interventions in pre-school and school settings and outside of school time. For adults or all ages, developing and refining e-health approaches and faith-based or other culturally and contextually relevant approaches, including translation of the Diabetes Prevention Program intervention to community settings is indicated. Major evidence gaps were identified with respect to interventions with black men and boys, ways to increase participation and retention of black adults in lifestyle behaviour change programmes, and studies of the impact of environmental and policy changes on eating and physical activity in black communities. Bold steps related to research funding priorities, research infrastructure and methodological guidelines are recommended to improve the quantity and quality of research in this domain.

Hypertension and risk of uterine leiomyomata in US black women.

BACKGROUND: Previous studies have found a positive association between hypertension and risk of hysterectomy-confirmed uterine leiomyomata (UL). The association of hypertension with UL confirmed by ultrasound or other surgery is less clear. METHODS: The present study evaluated the association of hypertension with UL incidence according to confirmation method (hysterectomy, other surgery or ultrasound) in the Black Women's Health Study, 1997-2007. We collected prospective data every 2 years on physician-diagnosed hypertension and UL in 22 530 premenopausal women. Validation sub-studies confirmed 99 and 96% of hypertension and UL self-reported diagnoses, respectively. Cox regression was used to estimate incidence rate ratios (IRRs) and 95% confidence intervals (CIs) for the association of hypertension and UL, adjusting for potential confounders. RESULTS: During 172 162 person-years of follow-up, there were 6447 incident cases of UL confirmed by ultrasound (n = 5111), hysterectomy (n = 670) or other surgery (n = 666). Treated hypertension was associated with UL confirmed by hysterectomy (IRR = 1.32, 95% CI: 1.06, 1.63), but it was not associated with UL confirmed by ultrasound (IRR = 1.05, 95% CI: 0.96, 1.16) or other surgery (IRR = 1.13, 95% CI: 0.88, 1.46). CONCLUSIONS: Treated hypertension was associated with UL confirmed by hysterectomy, but not UL confirmed by other methods (other surgery or ultrasound). These data suggest it is premature to conclude that hypertension is related to an increased risk of UL. Additional studies are needed to assess whether the association with hysterectomy-confirmed UL can be explained by other sources of bias, such as patient or physician preferences for specific types of medical care.

Sodium reduction for hypertension prevention in overweight adults: further results from the Trials of Hypertension Prevention Phase II.

Sodium reduction is efficacious for primary prevention of hypertension, but the feasibility of achieving this effect is unclear. The objective of the paper is detailed analyses of adherence to and effects of the sodium reduction intervention among overweight adults in the Trials of Hypertension Prevention, Phase II. Sodium reduction (comprehensive education and counselling about how to reduce sodium intake) was tested vs no dietary intervention (usual care) for 36-48 months. A total of 956 white and 203 black adults, ages 30-54 years, with diastolic blood pressure 83-89 mmHg, systolic blood pressure (SBP) <140 mmHg, and body weight 110-165% of gender-specific standard weight were included in the study. At 36 months, urinary sodium excretion was 40.4 mmol/24 h (24.4%) lower in sodium reduction compared to usual care participants (P<0.0001), but only 21% of sodium reduction participants achieved the targeted level of sodium excretion below 80 mmol/24 h. Adherence was positively related to attendance at face-to-face contacts. Net decreases in SBP at 6, 18, and 36 months of 2.9 (P<0.001), 2.0 (P<0.001), and 1.3 (P=0.02) mmHg in sodium reduction vs usual care were associated with an overall 18% lower incidence of hypertension (P=0.048); were relatively unchanged by adjustment for ethnicity, gender, age, and baseline blood pressure, BMI, and sodium excretion; and were observed in both black and white men and women. From these beneficial but modest results with highly motivated and extensively counselled individuals, sodium reduction sufficient to favourably influence the population blood pressure distribution will be difficult to achieve without food supply changes.

Dose-response of sodium excretion and blood pressure change among overweight, nonhypertensive adults in a 3-year dietary intervention study.

A cross-sectional dose-response relationship between sodium intake and blood pressure (BP) has been demonstrated, but evidence for a graded longitudinal effect is limited. Evaluation of BP response to sodium reduction was assessed in a 3-year lifestyle dietary intervention trial. BP changes at 18 and 36 months after enrollment were analysed according to concurrent quantitative changes in sodium excretion and by categories of success in sodium reduction among 1157 men and women, ages 30-54 years, with a diastolic BP (DBP) 83-89 mmHg, systolic BP (SBP) <140 mmHg, body weight 110-165% of sex-specific standard weight, and valid baseline urinary sodium excretion. Participants were randomized to a Sodium Reduction intervention (n=581) or Usual Care (n=576). From a 187 mmol/24 h baseline mean sodium excretion, net decreases were 44 mmol/24 h at 18 months and 38 mmol/24 h at 36 months in Sodium Reduction vs Usual Care. Corresponding net decreases in SBP/DBP were 2.0/1.4 mmHg at 18 months, and 1.7/0.9 mmHg at 36 months. Significant dose-response trends in BP change over quintiles of achieved sodium excretion were seen at both 18 (SBP and DBP) and 36 (SBP only) months; effects appeared stronger among those maintaining sodium reduction. Estimated SBP decreases per 100 mmol/24 h reduction in sodium excretion at 18 and 36 months were 2.2 and 1.3 mmHg before and 7.0 and 3.6 mmHg after correction for measurement error, respectively. DBP changes were smaller and nonsignificant at 36 months. In conclusion, incremental decreases in BP with lower sodium excretion were observed in these overweight nonhypertensive individuals.

Minority women and advocacy for women's health.

US minority health issues involve racial/ethnic disparities that affect both women and men. However, women's health advocacy in the United States does not consistently address problems specific to minority women. The underlying evolution and political strength of the women's health and minority health movements differ profoundly. Women of color comprise only one quarter of women's health movement constituents and are, on average, socioeconomically disadvantaged. Potential alliances may be inhibited by vestiges of historical racial and social divisions that detract from feelings of commonality and mutual support. Nevertheless, insufficient attention to minority women's issues undermines the legitimacy of the women's health movement and may prevent important advances that can be achieved only when diversity is fully considered.

Minisymposium on obesity: overview and some strategic considerations.

The high and still increasing prevalence of obesity in US children, adolescents, and adults poses a major economic and health threat to our society. The three reviews in this minisymposium on obesity explore the health issues by: 1) describing the public health impact of obesity; 2) examining the multiple and complex environmental influences on eating and physical activity patterns; and 3) considering how the development of obesity during childhood and adolescence can be prevented through interventions in school, family, and primary care settings. This overview explains the importance, for effective long-term obesity prevention and control, of intersectoral policy and environmental initiatives-in addition to behavior change approaches aimed at individuals. The need for public health professionals to influence and operate within a variety of non-health sectors such as transportation, education, urban planning, and commerce may be seen as the greatest barrier but may also be the greatest opportunity.

A comparison of knowledge and attitudes about diet and health among 35- to 75-year-old adults in the United States and Geneva, Switzerland.

OBJECTIVES: This study compared responses of US and Geneva residents to items on analogous questionnaires concerning knowledge and attitudes about diet and health. METHODS: Comparable data were available from 2 population-based sample surveys: the Cancer Control Supplement of the 1987 National Health Interview Survey and the 1994 Bus Santé 2000 in Geneva, Switzerland. Samples included 10,366 US respondents and 698 Geneva respondents, aged 35 to 74 years. The analysis involved descriptive statistics, contingency tables, and linear regression models. RESULTS: In both the United States and Geneva, health consciousness was greater among women and more highly educated persons than among other groups. Compared with Americans, Genevans assigned more importance to avoiding salt, sugar, and overweight (odds ratio = 1.6, 2.9, and 5.9, respectively) and less importance to lowering cholesterol (odds ratio = 0.6). Genevans were more likely to recognize the relatively high fiber content of lettuce, carrots, and apples. Recognition of low-fat foods was slightly better in the United States. CONCLUSIONS: Knowledge and attitudes differed despite high general diet and health awareness in both populations. Identifying why generally similar dietary guidance messages are embraced to different extents across cultures may facilitate global implementation.

Coronary heart disease in African Americans.

African Americans have the highest overall mortality rate from coronary heart disease (CHD) of any ethnic group in the United States, particularly out-of-hospital deaths, and especially at younger ages. Although all of the reasons for the excess CHD mortality among African Americans have not been elucidated, it is clear that there is a high prevalence of certain coronary risk factors, delay in the recognition and treatment of high-risk individuals, and limited access to cardiovascular care. The clinical spectrum of acute and chronic CHD in African Americans is similar to that in whites. However, African Americans have a higher risk of sudden cardiac death and present more often with unstable angina and non-Q-wave myocardial infarction than whites. African Americans have less obstructive coronary artery disease on angiography, but may have a similar or greater total burden of coronary atherosclerosis. Ethnic differences in the clinical manifestations of CHD may be explained largely by the inherent heterogeneity of the coronary syndromes, and the disproportionately high prevalence and severity of hypertension and type 2 diabetes in African Americans. Identification of high-risk individuals for vigorous risk factor modification-especially control of hypertension, regression of left ventricular hypertrophy, control of diabetes, treatment of dyslipidemia, and smoking cessation--is key for successful risk reduction.

Cultural identity and health lifestyles among African Americans: a new direction for health intervention research?

OBJECTIVES: To assess associations of cultural and personal identity variables with socioeconomic status (SES) and health lifestyle in African Americans. DESIGN: Cross-sectional. METHODS: A questionnaire administered to 333 African Americans, ages 40-70 years, at enrollment in a nutrition education study assessed: African-American cultural identity (15 items scored 1 [low] to 4 [high]); reference group (two questions about perceived success in the Black or White way of life-scored as bi-cultural if "yes" to both); personal identity (4 items on: self-concept as attractive, self-confident, satisfied and friendly-scored 1 [no/not sure] or 2 [yes]); and selected demographic and lifestyle variables. RESULTS: Cultural identity factors reflecting participation in and belonging to African-American culture and bi-cultural reference group were related to higher SES, lower fat diets, not smoking, current drinking, and higher leisure time physical activity (cultural identity only), particularly in women (P<.001 to P = .06). Associations of cultural identity with physical activity and of bi-cultural reference group with low-fat eating and not smoking (females) remained significant at P<.05 after adjustment for SES. CONCLUSIONS: A greater emphasis is needed on aspects of cultural identity that are positively related to health lifestyles as distinct from aspects that might act as barriers.

Maintenance of dietary behavior change.

Reducing dietary fat, saturated fat, and sodium and increasing intakes of dietary fiber and fruits and vegetables are important for cardiopulmonary risk reduction. Behaviorally, these dietary changes are very challenging, and in different ways. Fewer than half of U.S. adults have diets meeting recommended intakes of these constituents, and many do not see a need to align their diets with recommendations. Various nutrition education and behavioral counseling approaches have been shown to facilitate changes in fat, fiber, sodium, and fruits and vegetables, but primarily in research settings and among the highly motivated. Practice-based and interdisciplinary studies are needed to refine strategies to effect long-term dietary changes, to differentiate behavioral issues for changes involving additions versus deletions from the diet, and to elucidate the roles of sensory, psychosocial, and contextual factors in adoption and maintenance.

Outcomes of a cardiovascular nutrition counseling program in African-Americans with elevated blood pressure or cholesterol level.

OBJECTIVE: To evaluate a cardiovascular nutrition education package designed for African-American adults with a wide range of literacy skills. DESIGN: Comparison of a self-help group and a full-instruction group; each group received nutrition counseling and clinical monitoring every 4 months. SUBJECTS: Three hundred thirty African-American adults, aged 40 to 70 years, with elevated cholesterol level or high blood pressure were randomly assigned to the self-help or full-instruction group; 255 completed the 12-month follow-up. INTERVENTIONS: Counseling to reduce intake of dietary fat, cholesterol, and sodium was based on Cardiovascular Dietary Education System (CARDES) materials, which included food-picture cards, a nutrition guide (self-help and full-instruction group), a video and audiotape series, and 4 classes (full-instruction group only). MAIN OUTCOME MEASURES: Changes in lipid levels and blood pressure after 12 months. STATISTICAL ANALYSES PERFORMED: Primary analyses consisted of repeated-measures analysis of variance to examine effects of time and randomization group on outcomes. RESULTS: Total cholesterol and low-density lipoprotein cholesterol level decreased by 7% to 8% in the self-help and full-instruction groups of men and women (P < .01). The ratio of total cholesterol to high-density lipoprotein cholesterol (HDL-C) decreased in both groups of women and in the men in the full-instruction group (P < .01). In full-instruction and self-help participants with elevated blood pressure at baseline, systolic blood pressure decreased by 7 to 11 mm Hg and diastolic blood pressure decreased by 4 to 7 mm Hg (P < .01). Outcomes did not differ by literacy scores but were positively related to the reported initial frequency of using CARDES materials. APPLICATIONS/CONCLUSIONS: These results suggest that periodic nutrition counseling based on CARDES materials used for home study can enhance management of lipid levels and blood pressure in African-American outpatients.