Running Head: OVERWEIGHT AND OBESITY AMONG LOW-INCOME WOMEN

Exploring Social and Behavioral Determinants: Overweight and Obesity among Low-Income Women Ashley Francis Virginia Commonwealth University

OVERWEIGHT AND OBESITY AMONG LOW-INCOME WOMEN Exploring Social and Behavioral Determinants: Overweight and Obesity among Low-Income Women Fat is now an epidemic. For the past three decades, the number of obese individuals continues to grow, making obesity one of the most challenging issues currently facing the nation. The causes of this condition are multi-faceted; leading researchers to explore various risk factors and determinants. Obesity knows no boundaries, however, low-income women are at an increased risk when compared to their higher earning and more educated peers. This paper will examine the condition of obesity in general, then will explore various social/environmental determinants and potentially modifiable behaviors in low-income women specifically. Background and Need For the past 30 years, the rate of obesity in the United States has increased exponentially. According to the CDC, 68% of Americans are currently overweight or obese. Respectively, one third of the population is obese and one third overweight (CDC, 2011). Obesity is defined as having a body mass index (BMI) of 30.0 or higher. Individuals with a BMI between the ranges of 25.0 to 29.9 are classified as overweight (CDC, 2011). A myriad of obesity and overweight causes have been established. In general, these conditions are the product of high calorie diets, inactive lifestyles, and/or genetic/health conditions which cause an energy imbalance and consequently increased body weight (CDC, 2011). Due to complications from excess body fat, overweight and obese individuals are more likely to develop diabetes, cardiovascular disease, hypertension, stroke, sleep apnea, osteoarthritis, various cancers, and a host of other diseases (CDC, 2011). Fat is financially burdensome not only to persons suffering from the overweight conditions, but also to the nation as a whole. In 2008 alone, the CDC estimated the costs of

OVERWEIGHT AND OBESITY AMONG LOW-INCOME WOMEN obesity exceeded 146 million dollars (CDC, 2011). As prevalence increases and the economy tends to spiral, the need to resolve this epidemic has never been more dire. Risk and Protective Factors Age, race, ethnicity, and sex affect the prevalence of obesity. For instance, individuals between the ages of 20 and 55 are two times as likely to become overweight, when compared with adolescents and children (CDC, 2011). Since 2007, the prevalence of obesity in women has increased and subsequently data concludes women have a higher risk of obesity than men (CDC, 2011). According to data from the 2005-2008 National Health and Nutrition Examination Survey, 51% of non-Hispanic black women ages 20 or older were obese, compared to 43% of Mexican Americans and 33% of whites confirming disproportionate representation based on ethnicity (CDC, 2011). Individuals of diverse racial backgrounds are more at risk for the development of obesity than their white counterparts (CDC, 2011). Biological considerations must also be taken into account. Prader-Willi and Bardet-Biedl are genetic syndromes which cause obesity. While genetics may predict health outcomes, the workings of both genes and behavior explain overall susceptibility to overweight and obesity, as well as potential severity. Furthermore, existing medical conditions may also put an individual at risk for the disorder, such as the presence of diabetes, Cushings disease, or hypothyroidism (CDC, 2011). Intrapersonal risks, such as those previously mentioned, may explain an individuals chances of developing obesity and overweight. However, a multitude of protective factors reduce the vulnerability for the development of these conditions. Healthy food choices such as the high intake of water, fruits, and vegetables, rather than foods high in sugar and fats, decrease the potential threat of overweight and obesity (CDC, 2011). Also, incorporating physical activity

OVERWEIGHT AND OBESITY AMONG LOW-INCOME WOMEN into daily routines may protect from becoming overweight or obese. Exercise allows individuals to utilize a more proactive life-style approach, rather than one that is sedentary-based. Additionally, there is a strong link between low risk of obesity and physician support. As individuals seek out the support and recommendations of their health care providers, the likelihood of developing these disorders decreases (CDC, 2011). Collectively, these factors serve as protection from obesity and overweight. Social and Behavioral Determinants Although demographic and biological factors can increase and decrease an individuals risk, evidence suggests social and behavioral determinants play important roles as well. Social and behavioral determinants include lifestyle and environmental characteristics, social norms, relationships, attitudes, and self-efficacy factors. Diet and Exercise: Numerous links have been established between several behavioral factors and the likelihood of being overweight or obese. Dietary behaviors are excellent predictors of obesity. Too often Americans eat out, consume large (high calorie) meals and high-fat foods, and put taste and convenience ahead of nutrition (Understanding Adult Obesity, 2008). These tendencies lead to an increased risk of obesity. Both physical inactivity and a sedentary lifestyle are directly related to higher body weights and obesity (Rennie, Johnson & Jebb, 2005). With todays rapid improvements in technology, physical activity is being replaced by more sedentary activities such as computer use, video games, and television. During these activities, not only is an individual inactive, but it is also common to consume larger portion sizes (or volumes) of food (Rennie et al., 2005). Currently, conflicting data exists regarding alcohol consumption and smoking status in relation to obesity. Some studies find an inverse relationship between smoking status and obesity, while others conclude contradictory

OVERWEIGHT AND OBESITY AMONG LOW-INCOME WOMEN results. The more accepted correlation is that smokers generally have a lower tendency towards obesity, as tobacco usage replaces consumption of high-calorie snacks. Alcohol intake has also been found to be both a positive and negative predictor of obesity. However, many studies conclude that alcohol protects against higher body fat (Yeomans, 2010). Social Factors: Additional social determinants of obesity persist. Where an individual lives is a social determinant of obesity. Generally, the risk of obesity, regardless of sex, is higher in rural areas. In urban areas, there is a higher prevalence of obesity among individuals with lower levelsof education (Jackson, Doescher & Jerant, Hart, 2005). It has also been found that education level, uninfluenced by other social factors, is significantly related to higher weight. One study found an inverse relationship between BMI and social class, where social classes were defined by income and education level. This study illustrated that lower levels of education and yearly earnings are directly related to higher body fat, specifically in women (Laitinen, Power & Jarvelin, 2001). Members of lower socioeconomic classes and residents of rural areas generally have limited access to healthier food options, athletic facilities, and/or weight-management resources centers (Understanding Adult Obesity, 2008). Community transportation has also contributed to the decrease in daily physical activity. The decrease in walking and cycling has led to an overall reduction in activity levels over time (Rennie et al., 2005). The culmination of these social and environmental determinants leads to an increased prevalence and risk of obesity for adults of lower socioeconomic levels, specifically women. Attitudes: Body image, self-perception, and societys attitude towards weight are also related to obesity. Body dissatisfaction increases as weight increases; and negative body image is more common in obese women as compared to women of normal weight (Schwartz & Brownell, 2004). It is common for obese and overweight women to underestimate their actual

OVERWEIGHT AND OBESITY AMONG LOW-INCOME WOMEN body size and feel that their weight loss goals are unattainable (Leonhard, 1998). Negative thoughts about body image and self-perception attitudes have been affected by societys attitude towards obesity and body image. The societal norm in the United States today is to portray those who are overweight and obese negatively, and to place a large emphasis on the importance of being thin (Shwartz & Brownell, 2004). Media outlets are more likely to depict obese and overweight individuals as unattractive, unpopular, and unsuccessful (Brown & Witherspoon, 2002 and Ferris, 2003). Social relationships and networks are also closely related to an individuals weight and risk of obesity. It is becoming clearer that obesity is in fact a socially influenced disease. When a close friend, spouse, or adult sibling becomes obese, a person is more likely to become obese themselves (Christakis & Fowler, 2007). Evidence also suggests that same sex friends have a greater influence on an individuals weight than friends or significant others of the opposite sex (Christakis & Fowler, 2007). Additionally, positive self-esteem, as well as positive reinforcement from family and friends, is associated with an individuals behavior. Self-efficacy: Regarding obesity specifically, self-efficacy is an individual's confidence in their ability to either manage or lose weight, and take the necessary steps to do so. Several studies have found that overweight and obese women gain self-efficacy as they lose weight (Dennis & Goldberg, 1999; Dallow & Anderson, 2003; Richman, Loughnan, Droulers, Steinbeck & Carterson, 2001). Research also indicates that beginning weight management interventions (dietary and/or exercise) with higher self-efficacy leads to increased weight loss (Dennis & Goldberg, 1999; Teixerira, Going, Houtkooper, Cussler, Metcalfe, Blew, Sardinha & Lohman, 2004; Edell, Edington, Herd, OBrien & Witkin, 2004; Martin, Dutton & Brantley, 2004).

OVERWEIGHT AND OBESITY AMONG LOW-INCOME WOMEN Therefore, it is evident that self-efficacy is a key factor in successful weight loss campaigns and interventions for women. Regarding the specific population of low-income women, adequate nutritional provisions linger at the forefront of this discussion. When individuals find themselves in impoverished circumstances, the ability to carry out consistent and positive health behaviors is ultimately compromised. Several obstacles must be overcome in order to address this growing epidemic. One barrier is the feasibility of gathering quantitative data regarding possible physical and dietary behaviors that may lead to caloric excess. National recommendations indicate that energy intake should be decreased in order to lose or maintain weight. Nutrition education is one method that can be used to meet the national recommendations. In order to implement prevention through physical activity and nutrition strategies, it is first important to recognize the barriers and risk factors that exist, specifically those for low-income women. Analyzing and segmenting the audience: The target audience discussed below was selected because of the appropriate fit with formative research findings, the integrative model, and the following segmentation characteristics: behavioral, cultural, demographic, physical, and psychographic (National Cancer Institute, 2011). Each of the previous will now be examined. Women were selected as the rate of obesity in women has been on a steady rise and currently women are at a higher risk as compared to men (CDC, 2011). Further segmentation targeted women who are currently behaving in unhealthy ways by choosing less healthy food options. The ideal behavior for these women would be to consistently recognize and choose a healthier option. Culturally, the targeted campaign will primarily reach women of African American race who are share the demographic characteristic of falling below the federal poverty level, categorizing them as low-income. African American women who are between the ages of 20-55

OVERWEIGHT AND OBESITY AMONG LOW-INCOME WOMEN years wee selected as adults in this age range have two times the risk of being overweight/obese when compared with normal weight individuals (CDC, 2011). Additionally, the emphasis on self efficacy, attitudes, skills, environmental constraints, and behavioral beliefs in the integrative model affirms the selection of this audience as previous sections describe these as important health determinants of obesity within this population. Low-income, African American women may lack adequate self-efficacy to make healthier choices in addition to possessing the attitude that eating healthy may not be important or have meaningful impacts. This population also values a curvier body image, believing it to be ideal. Collectively, these factors make selecting low-income, African American women between the ages of 20-55 as the intended audience the best choice as the proposed campaign has been developed to target characteristics of that group. An unintended (secondary) audience would be women belonging to other racial or socioeconomic groups beyond the target age bracket, who may read any campaign materials and/or learn from messages. The process of crafting messages specifically for the target audience is described below. Designing campaign messages: The target audience and theory components were driving forces behind campaign message selection and development. The title Pick this Up; Put that Down was designed to emphasize the simplicity of making healthier choices in order to build self efficacy within the target population. Originally, the brochure was designed without explicit confidence building messages. Formative research lead to a second version with clear messages such as: Eating healthy is easy, Do it because you can, Eating healthy makes you feel better, and You can pick up the right food and put down the wrong food specifically created to increase self efficacy. Another concern the brochure addresses is the high volume of environmental constraints in the target population, particularly when it comes to accessing and

OVERWEIGHT AND OBESITY AMONG LOW-INCOME WOMEN affording healthier options. The placement and simplicity of messages within the brochure to help the audience overcome these obstacles were changed after feedback was received. These messages were compiled into a more cohesive/collective fashion and were moved from the back to the inside of the brochure so they were more likely to be seen. The tips for eating healthier on a budget within the brochure acknowledge that this is a population which is more likely to use food stamps and electronic benefit transfer (EBT) cards. There are explicit suggestions to use EBT cards at farmers markets where healthier options are sold. The essence of the brochure theme is not only meant to enhance self efficacy, but also to increase the skills and abilities of the target audience to make healthier choices. A sample food that likely mirrors what the target population may be eating for each meal is provided and the catch phrases pick this up and put that down are tagged to pictures showing readers which option is the healthier choice. These images are accompanied by a brief nutritional break down of calories and fat. All messages and nutritional information were kept at a lower reading level (middle school) so that they could be easily understood by someone with little to no nutrition background. Another key component of the brochure is the testimony provided by Jennifer Hudson. Hudson was selected as a spokesperson for this campaign as recently she has faced many struggles and hardships that mirror experiences suffered by (some of) the target population. She rose up to fame from a low income household and recently worked to get healthy by changing her eating habits. She is a great role model and is easily recognized by the target audience. Her story aims to address the audiences normative beliefs and her picture was chosen to show that she is still the curvy ideal image. Hudson communicates throughout her testimony how much better she feels since losing weight and that if she can do it, so can you!. Collectively these

OVERWEIGHT AND OBESITY AMONG LOW-INCOME WOMEN brochure components aim to increase self efficacy, decrease environmental constraints, and build the skill of selecting healthier food options for low-income African American women ages 2055years.

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