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    Human Culture and the Global Epidemic of Obesityby Steven R. Hawks, EdD

    During the past year, academic assignments havetaken me from China to Romania to the Philip-pines to Zimbabwe. Along the way, I have observedlocal diets, activity levels, and obesity prevalence. Ithas been interesting to observe the role of humanculture as perhaps the most significant force underly-ing the global obesity epidemic. This article brieflydescribes the prevalence of global obesity, outlinesits development from a cultural perspective, andoffers recommendations for the prevention and man-agement of the epidemic.

    Prevalence and consequencesof global obesityBased on rising levels of obesity in developed coun-tries and the unexpected growth of obesity rates inmany developing countries, it is now believed thatthere are as many overnourished individuals on theplanet (1.1 billion) as there are undernourished (1.1hillion i.! As undernutrition slowly continues todecline, overweight will soon have a clear upper hand.

    For a condition to achieve epidemic status, ittypically must spread rapidly and generate a higherthan expected number of cases. At both national andglobal levels, obesity (body mass index> 30) seemsto qualify for epidemic status. Obesity is on the risein virtually all developed countries. In the US, forexample, the prevalence of obesity increased by 55percent between 1980 and 1994 (from 14.5-22.5%).In most European countries, the prevalence of obe-sity is anywhere from 10 to 25 percent, and the ratehas increased by as much as 10 to 40 percent in thepast 10 years. The most dramatic increase has beenin England, where the prevalence rate doubled from8 to 16 percent between 1980 and 1995.2

    Although obesity prevalence data for many devel-oping countries are still sparse, regional studies indi-cate that obesity is a particular problem among urbanwomen. This is exemplified by high obesity ratesamong this group in such areas as Cape Peninsular,Republic of South Africa (44%), Kuwait (44%), SaudiArabia (28%), and Brazil (13%). Although obesityprevalence rates remain low in many Asian countries,they are also rising rapidly. In China, for example, thenational obesity prevalence quadrupled among men(0.3-1.2%) and nearly doubled among women(0.9-1.7%) between 1989 and 1992. In Shanghai, the

    adult prevalence rate is 12.6 percent, similar to manyEuropean nations.?

    As the world population continues to put onweight, the health and economic impacts areexpected to be significant. As one example, the Inter-national Diabetes Federation predicts that the num-ber of persons with diabetes worldwide will doubleto 300 million by 2025, with 75 percent of thegrowth occurring in developing nations. 1 Anotherexample is seen in China, where the economic costof overnutrition is already greater than the cost ofundernutrition.s

    It is not surprising then that global obesity isexpected to be one of the world's most pressing pub-lic health problems in the future. At the same time, ifglobal obesity is going to be used as a primary gaugeof population health, it is important to understandand address it at the broadest level possible.

    Human culture and thesocial environment of obesityThe public health literature is increasingly supportiveof the position that obesity is expressed in response tocertain social environments." Yet the nature of suchenvironments is seldom given more than a cursoryreview. It is possible that human culture, as developedby anthropologic theory, may be an ideal lens for tak-ing a closer look at obesogenic social environments.

    Although there is no consensus for a single defini-tion of culture, it is useful to think of it in terms ofsocially shared aspirations and the generally acceptedmeans for achieving them. In other words, membersof a cohesive culture will by and large agree on themost appropriate goals for life, the underlying philos-ophy that supports those goals, and the differentpaths that might be expected to lead to the realizationof those goals. One useful model that supports thisconcept of culture includes three components: eco-nomic mode of production, social order, and beliefs.'

    As depicted in Figure 1, the economic mode ofproduction serves as a foundation for social organi-zation, which, in turn, supports the ideology orbeliefs that guide the aspirations of the society. In anongoing cycle, cultural beliefs continually influencethe evolution of economic modes of production andpatterns of social organization-all of which mayimpact obesity.

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    Beliefs

    So ci al O rd er

    Figure 1 Model of human culture. (Adapted f rom Brown.5)

    Economic productionEconomic modes of production include the activitiesand technologies that cultures devise to producefood, clothes, shelter, and other goods and to gener-ate material wealth among the populace. The processof "development," as it relates to less-developedcountries, has been promoted primarily through theavenue of free-market, Western-style economicgrowth. The result has been an ongoing shift fromsmall-scale, rural, agrarian means of production tourban, industrialized means of production.

    For many, the adoption of an urban, industriallifestyle involves a nutrition transition from self-pre-pared, homegrown produce to commercially pre-pared, processed convenience foods that are pur-chased from a shelf. Traditional diets high in fruits,vegetables, grains, and fiber give way to diets high infat, sugar, and salt. At the same time, activity levelsgo down due to a higher number of sedentary occu-pations in the city.:' In fact, the mechanized urbaninfrastructure, with its automobiles, public trans-portation, elevators, and escalators, seems intention-ally designed for the reduction of activity.Successful economic growth in large urban cen-ters also results in food surpluses that become avail-able to individual families at ever-lower prices. Forexample, a surge in global vegetable oil productionover the past four decades has added 30 g of fat tothe average diet on the planet. The cost of a diet con-taining 20 percent of calories from fat was cut in half(in constant dollars) during the same time period. 1

    Social orderIf a free-market economy based on industrializationbecomes the most desired means of economic pro-duction, the way is paved for a more complex socialorder that is highly stratified and subdivided intomany different classes. Social class then becomes apowerful force in determining a wide variety ofbehaviors, including those related to diet and activ-ity. In fact, cultural patterns of social class tend tocount more than individual behaviors in predictingthe consumption of certain types of food, the socialrole that food plays, and the meaning and desirabil-ity of various types of activity'

    For example, among low-income groups indeveloped countries like the US, high-fat food takeson a significant cultural role in relationships (per-haps due in part to a lack of food security). Socialand family occasions tend to center around food,and food becomes a form of escape and relaxation.For higher-income groups, however, food restrictionis the accepted norm, and other outlets are found forbuilding relationships and relaxing.

    In developing countries, the reverse may be true.High-income groups indulge in a variety of energy-dense foods as a display of status. In many develop-ing countries, it seems clear that patronizing a fast-food establishment was a source of pride and status.In the same countries, food restriction among thepoor is dictated by economic circumstance ratherthan by choice.

    A further impact that a free-market, industrializedeconomy exerts on social organization is the emphasison corporate profitability. The food industry seeks toenhance profitability by promoting energy-dense,highly processed foods to children. By adding salt,sugar, and fat (and otherwise processing foods andthus enhancing their taste and value), more foods canbe sold for a higher profit. By targeting children (eg,Happy Meals), lifelong customers can be recruited. Inan unregulated environment, a proliferation of fast-food establishments that patronize children can beexpected. Not surprisingly, the first sign that greetedme at a train station in rural Romania was the goldenarches of McDonald's. Likewise, I was able to take asingle picture in Manila that included McDonald's,Kentucky Fried Chicken, Pizza Hut, and a local fast-food establishment all crowded into one small area.BeliefsCultural beliefs provide the philosophical justifica-tion for social aspirations. In relation to obesity, fat-ness has significant cultural meaning in terms of sex-ual desirability, self-worth, and the perceivedcapacity for maternity and nurturance. In the vastmajority of developing countries, an overweightbody size is associated with wealth, prosperity, desir-ability, and high status." In Nigeria, young girls areplaced in fattening huts to enhance their marriage-ability; likewise, heavier brides in Kenya receive ahigher bride wealth. In Ethiopia, thin women aresaid to have "dog hips," and among the HavasupaiIndians in the southwest US, a fat woman may standon the back of a thin girl so that the latter will beblessed with larger thighs like her benefactoress.'

    It has only been in developed countries duringthe last century that thinness has come to be equatedwith beauty. This is probably due to the reality that

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    for beauty, like other commodities, rarity increasesvalue. In cultures where it is easy to be overweight,thinness becomes the desired trait. Where it is easyto be thin, most often because of food scarcity, heav-iness becomes the criteria for beauty." Nevertheless,most of the world's population falls in the thinnesscategory. It is not easy for many populations tobecome overweight. Accordingly, in those countriesthat are undergoing the various dietary and healthtransitions discussed previously, a further influencethat encourages obesity is a cultural ideology thatfavors large body sizes.

    Prevention and managementof global obesityThe current emphasis on free-market industrializa-tion, consumerism, and profitability as the primarymeans for achieving world development has led to aglobal culture characterized by increasingly similarmodes of economic production, patterns of socialorder, and cultural beliefs. It would seem that thesethree components of human culture are the primarycause of the global epidemic of obesity.

    Table 1 summarizes the impact that each ofthese cultural inputs has on the development of obe-sity and then offers cultural countermeasures thatwill be necessary if global obesity is to be dealt within a meaningful way.

    The fact that virtually all cultures value healthprovides a common starting point for managingglobal obesity. Good health, as a cultural aspiration,must be promoted along with proper nutrition andadequate activity as the proper means for achievinghealth. At this point, it becomes straightforward towork back through the cultural forces that work

    against good nutrition and activity and find new cul-tural avenues for promoting them.

    Given that our modes of economic productionpromote inactivity, a conscious effort must be madeto provide outlets and motivation for increasedactivity at schools and worksites (fitness centers, cen-tral stairways, physical and nutrition education,etc.). Communities must be planned that includeadequate walking and biking trails, parks, recreationcenters, and fitness facilities. The inexpensive, high-fat food surpluses that have been made available byeconomic development must be counterbalancedwith tasty, nutritional alternatives that are readilyavailable at restaurants, cafeterias, and public cater-ing services at schools and worksites.

    Although it poses many challenges, the foodindustry must be regulated through national policiessimilar to those imposed on the tobacco industry.Poor diet is second only to tobacco use as a pre-ventable cause of death. Yet there is very little regu-lation of the food industry in terms of advertising,and the food industry is not held liable for the healthconsequences of its products. Additionally, the valueof traditional diets (rather than fast food) must bepromoted as the ideal means for bonding withinsocial classes and as a means for preserving culturalidentity. Subsidies for healthy, traditional foods, incombination with taxes on nutritionally poor foods,would certainly help the cause. Finally, nutritioneducation must be mass-marketed as a nationalmedia priority to offset the influence of the ever-growing fast-food culture.In terms of cultural beliefs, it may be comfortingto know that almost any body size might find a cul-ture somewhere in the world that would honor it asthe ideal. Somewhere, we would all be beautiful. As

    TABLE 1 Cultural model for the prevention and management of obesityCultural Input Impact on Obesity Cultural CountermeasuresEconomic productionFree-market economyIndustrialization

    Urbanization, mechanization, rising income,cheaper foods, sedentary lifestyles, leisure,loss of traditional diets

    Walking/biking trails, activity centersat work, central stairways, schoolactivity programs

    Social orderDivision into classesCorporate profiteering

    Aggressive food ads target children, food asa source of status, more food processing(adding fat, sugar, salt), food as a socialbond or a means of escape/relaxation

    National policies that regulate foodads, subsidies for nutritional foods,cultural support for traditional diets,mass nutrition education

    Cultural beliefsBody size = beauty If food is scarce, big is better; if food isplentiful, thin is beautiful (both viewsmay promote obesity)

    Promote health at any size, focus onnutrition and fitness-not size

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    a happy medium, we need to work toward a globalculture that honors the value of individuals irrespec-tive of body size. Consciously trying to alter bodysize for the sake of enhancing social acceptability islikely to lead to frustration, disappointment, andunhealthy practices." On the other hand, attempts toimprove health through increased activity and betternutrition (regardless of body size) are an achievableand meaningful goal.

    ConclusionA global movement will be necessary to halt risinglevels of obesity. The movement will need to be sen-sitive to the cultural influences that promote obesitywhile at the same time trying to create new culturalbeliefs and environments that assertively promotehealthy nutrition and activity. Success will requirethe combined efforts of national governments, publichealth agencies, health and nutrition educators, andthe medical field. Without this level of effort, theglobal epidemic of obesity will continue to spreadout of control. 8

    References1. Gardner G, Halweil B. Overfed and underfed: the global

    epidemic of malnutrition. Washington, DC: WorldwatchInstitute, 2000.

    2. Brown D. About obesity. International Obesity TaskForce [on-line]. http://www.obesite.chaire.ulaval.ca/IOTF.htm (accessed July 23, 2001).

    3. Popkin B. The nutrition transition and obesity in thedeveloping world. J Nutr 2001; 131:871S-873S.

    4. Poston W, Foreyt J. Obesity is an environmental issue.Atherosclerosis 1999; 146:201-209.

    5. Brown P. Culture and the evolution of obesity. Hum Nat1991; 2:31-57.

    6. Treloar C, Porteous J, Hassan F, et al. The cross-culturalcontext of obesity: an INCLEN multicentre collaborativestudy. Health Place 1999; 5:279-286.

    7. Hawks S. Making peace with the image in the mirror:spiritual solutions for inner acceptance and self-esteem.Salt Lake City, UT: Deseret Books, 2001.

    8. Nestle M, Jacobson M. Halting the obesity epidemic: apublic health policy approach. Public Health Rep 2000;115:12-24.

    Steven R. Hawks, EdD, is an associate professor of healthsciences at Brigham Young University, Provo, UT.

    Editorial (continued from page 81)a cause of eating disorders, and detrimental to per-sonal health. On the other hand, health at any sizesupporters have been accused of making accusationswithout scientific evidence while overlooking theexisting data.

    If one were to look at the two paradigms simul-taneously, one would see that both paradigms havethe same major flaw. Both paradigms are subscribingto the philosophy that "one treatment fits all."Those who believe that weight loss through restric-tive dieting and exercise is the means to health con-tinue to search for that one optimal diet and exerciseprogram that will solve the obesity problem. Theygive no consideration as to how cultural influencesof various racial and ethnic groups might prohibit orundermine certain aspects of diet and exercise pro-gramming for weight loss. The proponents of thehealth at any size paradigm, on the other hand,assume that all obese individuals have a problematic

    relationship with food, that all obese persons havebody image disparagement, that all obese peoplehave low self-esteem, and that all of the obese willrespond to cognitive behavior therapy. In otherwords, the health at any size approach is focused onCaucasian women with a single psychological pro-file. Although individuals of other cultures may notexperience the same psychological impact of obesityas Caucasian women, the incidence of obesity occursdisproportionately in other racial/ethnic groups.

    Accordingly, Ann Jacob and Steven Hawksaddress some culturally sensitive issues and proposealternative approaches for the treatment of obesity invarious racial/ethnic groups. It seems that culturallysensitive, community-based interventions that can beindividualized will be the key to fighting the globalepidemic of obesity.Wayne C. Miller, PhD

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    Considerations for Healthy Weight Managementin Diverse Populations

    by Steven R. Hawks, EdD

    An ongoing goal of the health professions is toreduce racial and ethnic disparities for a widevariety of health conditions, including 0besi ty.

    Although disparity clearly exists among racial/ethnicgroups in relation to the prevalence of obesity, thereis room for debate as to how that disparity should beaddressed. In an attempt to clarify the debate, thisarticle summarizes racial and ethnic differences inobesity prevalence, reviews corresponding health andsocioeconomic consequences, and analyzes causalfactors for obesity from the perspective of race andethnicity. Implications for healthy weight manage-ment among racial/ethnic groups are presented.

    Racial and ethnic disparities in obesityThe only national, randomized sample that usesactual height/weight measurements to estimate obesityprevalence is the National Health and NutritionExamination Survey (NHANES) conducted by theCenters for Disease Control. NHANES defines obesityin terms of body mass index (BMI) with cutoff valuesof 25 to 29.5 signifying overweight and 30 or higherrepresenting obesity. The most recent NHANES data(NHANES III, 1988-1994) indicate a national obesityprevalence of 22.5 percent, which represents a 55 per-cent increase over the 14.5 percent level reported inNHANES II (1976-1980).

    The increase in obesity between NHANES II andIII was similar for all age, gender, and racial/ethnicgroups. As shown in Figure 1, however, the NHANESIII breakdown by race/ethnicity and gender showsmajor differences. Racial and ethnic disparities withinthe adult population are primarily limited to women,with significantly higher rates of obesity amongAfrican-American and Hispanic women. For men, theprevalence remains consistent at 20 to 21 percentregardless of race.

    Consequences of obesityThe health consequences associated with higher lev-els of obesity among racial/ethnic groups have notbeen clearly established. On the one hand, the PimaIndians of Northern Arizona are often cited as theclassic example of obesity-related harm being experi-enced by a racial/ethnic group. The Pima are gener-ally considered to be the fattest population in the fat-

    test country in the world, and they also have thehighest rates of diabetes. 1On the other hand, a recent prospective studyreported that a high BMI was not predictive ofincreased mortality for African-American men andwomen' The authors concluded that "the risk associ-ated with a high BMI is greater for Caucasians thanfor African-Americans and that African-Americanmen and women with the highest BMI values hadmuch lower risks of death than Caucasians, which didnot differ significantly from the reference of 1.00."Even though women in racial-ethnic groups in the UShave higher rates of obesity, it is not conclusive that alarger body size (independent of other factors) is pre-dictive of ill health or premature death in all groups.

    In relation to the socioeconomic consequences ofobesity, one prospective study found that for bothAfrican-American and Caucasian women, obesity wasassociated with lower wages, reduced occupationalachievement, and lower probabilities of marriage.However, it was concluded that cultural differences inrelation to ideal body types might protect African-American women from the self-esteem loss associatedwith obesity among Caucasians.' Other authors havesuggested that African-American women may be pro-tected from weight-related body dissatisfaction becauseof a multidimensional body image that is less focusedon weight or size as such. Consequently, althoughcertain socioeconomic penalties are still associatedwith obesity among African-American women, thereseems to be less preoccupation with dieting and fewercases of eating disorders in this group."

    Race and the biologicaldeterminants of obesityIn general, experts agree that obesity is a function ofheredity, social environment, and individual lifestyle.In the past, most obesity experts have been in agree-ment that metabolic factors, as determined by hered-ity, are the most important determinants of obesity.'But, increasingly, it is the interface between humanbiology and the social environment that is receivingthe most attention.f Relevant biological variablesthat may vary by race/ethnicity and that may interactwith obesity include resting metabolic rates (RMRs),energy expenditure, and patterns of fat deposition.

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    4 0 - r - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - ,DMaie Female

    20

    30~------------------

    10

    o ....L.. __ .L-_Caucasian Black Mexican

    Figure 1 Percentage of obese us adults by race and gender(NHANES III, 1988-1994).

    Elements of the social environment that may interactwith race and obesity include the relationshipbetween body size and social status and the socialmeaning of food and activity.The thrifty geneIt has been hypothesized that repeated human expo-sure to famine over multiple generations has natu-rally selected metabolic mechanisms that supporthigh levels of fat deposition, low levels of energyexpenditure, and a preference for energy-densefoods." When placed in modern social environmentsthat include easy access to high-fat/high-sugar foods,with limited incentives for activity, the expectedresult is obesity. (Ironically, this model of obesitycausation places little emphasis on individual choice,and yet the focus of most weight management pro-grams has been on changing personal behavior.)

    Since differen t racial/ethnic groups have hadvastly different experiences with famine over longperiods of time, it is to be expected that resultingmetabolic adaptations might influence their propen-sity for weight gain when exposed to new environ-merits." This evolutionary perspective may explainwhy the Pima Indians have developed higher rates ofobesity and diabetes than their Navajo or Apacheneighbors when exposed to similar environmentalconditions during recent history.Metabolic differencesOne literature review attempted to understand higherlevels of obesity among African Americans by analyz-ing RMRs and total daily energy expenditure (TDEE)differences between Caucasians and African Ameri-cans." The authors concluded that for African-Ameri-can participants, two-thirds of reviewed studiesdemonstrated lower RMR values, whereas one-third

    found lower TDEE values. Such studies begin to builda case that genuine metabolic differences seem to existbetween different racial and ethnic groups, perhapsowing to the forces of natural selection as influencedby differential exposure to prehistoric famines.Fat depositionIn response to similar evolutionary pressures, differ-ent patterns of fat deposition may have developedamong racial and ethnic populations. Body fat, espe-cially abdominal fat, is the true risk factor in relationto body size, and the usefulness of BMI as a healthindicator depends in part on its consistent relation-ship to specific levels of body fat. A recent meta-analysis evaluated the relationship between percentbody fat and BMI among different racial/ethnicgroups and concluded that equivalent body fat levelsproduced significantly different BMI values whencompared between racial/ethnic groups. Obesity, asmeasured by percent body fat, was reached at muchlower BMI levels in some populations than the rec-ommended cutoff value of 30. Likewise, it was con-cluded that obesity cutoff levels higher than a BMI of30 might be justified for other racial/ethnic groups.l?

    Not surprisingly, additional research has con-firmed a wide range of ideal BMI values (associatedwith lowest mortality) for different racial/ethnicgroups.I! For example, the ideal BMI for African-American women is 26.8, which is well above theestablished overweight BMI cutoff of 25.0. On theother hand, the ideal BMI for Caucasian women is24.3. Although specific BMI guidelines have beenestablished for the US population in general, theremay also be considerable variation in ideal BMIbased on age and gender, either within or amongracial/ethnic groups. Accordingly, blanket assump-tions about the health consequences associated witha specific range of BMI values may be inappropriatewhen dealing with diverse populations.Race and the cultural determinantsof obesityIn addition to biologic predispositions for obesity,powerful cultural influences have evolved that mayfavor larger body sizes. In societies where food isscarce (the case for much of human history), obesitymay be socially preferred as an indication of wealth,social status, and good health. In support of thishypothesis, one study found that in 80 percent ofdeveloping countries (where food resources are morelikely to be scarce), the social ideal for both maleand female beauty was overweight. 12

    It has only been a recent development, most oftenin cultures that have an abundance of food, that

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    socioeconomic status and attractiveness have come tobe associated with thinness for women. In the US,middle- and upper-class Caucasian females exhibit astrong preference for thinness and engage in behaviors(many of them unhealthy) that are expected to resultin a slender figure. The cultural emphasis on thinnessmay be diminished or completely lacking for manyracial/ethnic groups in the US who refute thinness as anorm limited to upper-class Caucasian women. As hasbeen found in other cultures, the deprivations ofpoverty experienced by many racial/ethnic groups inthe US may further support a cultural preference forlarge bodies as a symbol of health and power. Theprevalence of 0besi ty among African-Americanwomen may be explained in part by a cultural prefer-ence for overweight bodies.P

    Ithas been hypothesized that racial/ethnic womenmay have higher BMIs owing to lower activity levelsand higher consumption of energy-dense foods. Suchbehaviors may be biologically driven, as discussedabove, or may merely represent the challenges ofpoverty (limited opportunities for activity and healthydiets because of low income or unsafe environments).A third alternative, however, is that these behaviorsmay represent the different cultural roles that food andactivity can play within racial/ethnic communities.

    Beyond health values, diet composition and activ-ity levels within a society are intimately connected to avariety of social meanings and relationships. Anethnographic study of diet and activity practicesamong Australian Aborigines identified wider socialmeanings that made personal behavior change in theseareas very difficult.!" For example, fat and salt wereseen as key ingredients for meals that fostered close-ness with families and friends, whereas meals that metdietary guidelines were seen as cold and clinical. Dif-ferent categories of physical activity were also identi-fied, each with its own cultural meaning.

    As argued by the authors of the study, it is diffi-cult to change behaviors by appealing to health ben-efits without understanding and considering thelarger social and cultural contexts in which thebehaviors OCCUr.14As with Australian Aborigines,diet composition and activity levels among racial/ethnic groups in the US are undoubtedly influencedby powerful social variables that have little to dowith concerns for personal health.

    Implications for healthyweight managementThe foregoing discussion raises several issues thathave implications for how the health professionsshould address racial/ethnic disparities in obesity.

    First, racial/ethnic disparities in the prevalence of obe-sity are generally limited to women. According toNHANES III, rates of obesity among men remain sur-prisingly consistent across racial groups. Second, thehealth impact of a larger body size (BMI) may not besignificant for women from some racial/ethnic groups(eg, the ideal BMI for African-American women is26.8, well into the established overweight range). Thismay be attributable to biologic differences in RMR,energy expenditure, and fat deposition that makestandardized BMI categories unreliable indicators ofhealth status among diverse populations. Third,whereas most women seem to experience some nega-tive socioeconomic consequences in relation to a largebody size, women from some racial/ethnic groups maybe protected against size-related loss of self-esteemowing to a broader, multidimensional definition ofbeauty that may tolerate or even promote larger bodyshapes. Finally, there are a variety of cultural valuesthat influence food and activity choices that may tran-scend personal health values.

    As we design a plan of action for reducing racial/ethnic disparities in obesity, the following points areworthy of consideration:1. The actual degree of racial/ethnic disparity in

    obesity, as reflected in the NHANES data, maynot be accurate or meaningful. The research lit-erature is consistent in demonstrating a widevariety of ideal BMI values among differentracial/ethnic groups. Disparities that are mea-sured using a single BMI standard are thereforemisleading. Unless these differences are properlyconsidered, the goal of reducing racial/ethnicdisparities in BMI begins with an unknown gap.

    2. Disparities in body size may not represent themost salient health threat to racial/ethnic groups.Rather, disparities in health status are far morelikely to be a function of society-wide inequali-ties in income, education, and environment, aswell as genetic diversity-not body size.

    3. The morbidity and mortality associated withobesity are primarily a function of biologic fac-tors (unique to each racial/ethnic group) inter-acting with new social environments, as in thecase of the Pima Indians of Northern Arizona.But drawing general conclusions about the rela-tionship between obesity and illness and thenapplying them to all racial/ethnic groups isunwarranted given the unique evolutionary his-tory and biologic adaptation of each group.

    4. Personal weight loss programs that target mem-bers of racial/ethnic groups are not likely to havea meaningful impact on obesity at the popula-

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    tion level but may serve to undermine the self-esteem of women who are made to feel that theirbody size is unacceptable.

    5. Community-level interventions should focus onimproved nutrition and opportunities for activ-ity in school, community, and worksite settings.Programs should involve broad-based participa-tion from the affected populations and should bepresented in culturally sensitive ways that sup-port traditional values associated with food andactivity without stigmatizing large body shapes.

    6. Many in the health field are now arguing force-fully that obesity is a problem caused by an"obesogenic" social environment that includesrampant junk-food advertising, an overabun-dance of fast-food establishments, and limitedopportunities for activity.f A national policyapproach that alters the most negative aspects ofthe social environment will potentially benefit allcitizens, including racial/ethnic groups.

    7. It may be far more meaningful to prevent thedevelopment of obesity among racial/ethnicgroups by targeting the determinants of obesityamong their youth rather than attempting to sig-nificantly alter adult body size once established.

    ConclusionAlthough the national goal to reduce racial/ethnicdisparities in health outcomes is appropriate, it mustbe pursued with caution in the area of obesity. Obe-sity disparities are largely limited to women who, insome cases, may experience minimal threats to theirhealth and who may have a cultural preference (or atleast tolerance) for larger body sizes. Focused effortsthat promote weight reduction among these womenmay offer little chance for health improvement butmay be a potent factor in lowering self-esteem, dis-torting body image, and increasing diet obsessionsand eating disorders. Rather than supporting culturaldiversity and the well-being of minority women, suchefforts may merely represent a repressive form ofacculturation into the pervasive "culture of thinness"that characterizes the majority population.

    Itwould be much better to proceed slowly withculturally sensitive, community-based interventionsand changes in national policy while rememberingthe Hippocratic maxim to "first do no harm" as westrive to reduce racial/ethnic disparities in obesity.One way to do this is to target behaviors that areknown to improve health status rather than focus onchanging body size. For example, one recent studyconcluded that high levels of physical activity wereassociated with lower odds of non-insulin-dependent

    diabetes mellitus among all racial and ethnic groupsand that the relationship may be even stronger inHispanic subjects. IS Community infrastructures andnational policies that promote increased activity willlikely go further in the promotion of ethnic healththan will efforts to alter body size.References1. Krosnick A. The diabetes and obesity epidemic among

    the Pima Indians. N J Med 2000; 97:31-37.2. Calle EE, Thun MJ, Petrelli JM, et al. Body-mass index

    and mortality in a prospective cohort of U.S. adults. NEnglJ Med 1999; 341:1097-1105.

    3. Averett S, Korenman S. Black-white differences in socialand economic consequences of obesity. Int JObes 1999;23:166-173.

    4. Neff LJ, Sargent RG, McKeown RE, et al. Black-whitedifferences in body size perceptions and weight manage-ment practices among adolescent females. J AdolescHealth 1997; 20:459-465.

    5. Bray GA, DeLany J. Opinions of obesity experts on thecauses and treatment of obesity: a new survey. Obes Res1995; 3(Suppl4 ):419S-423S.

    6. Poston WS, Foreyt JP. Obesity is an environmental issue.Atherosclerosis 1999; 146:201-209.

    7. Neel JV. Diabetes mellitus: a "thrifty" genotype rendereddetrimental by "progress"? 1962 Bull World HealthOrgan 1999; 77:694-703.

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    Steven R. Hawks, EdD, is an associate professor of healthsciences at Brigham Young University, Provo, UT.

    92 Healthy Weight Journal, November/December 2001