A Clearer Understanding of Obesity in Women
By Gerald T. Keegan,MD, FACS, Emeritus Staff, Scott & White Clinic and Hospital; Former Professor of Surgery (Urology), Texas A&M University School of Medicine. Dr. Keegan is a stockholder in AstraZeneca, Glaxo Wellcome, and Pfizer.
Source: Blixen CE, et al. What women want: Understanding obesity and preferences for primary care weight reduction interventions among African-American and Caucasian women. J Natl Med Assoc 2006;98:1160-1170.
Abstract: The purpose of this study was to explore attitudes and perceptions of obesity, and identify preferences for weight-management interventions by African-American and Caucasian women who were followed in general internal medicine clinics. Surveys exploring these issues were mailed to African-American (n = 240) and Caucasian (n = 240) women with a BMI of ≥ 30 kg/m2. Caucasian women felt past weight-loss efforts were helped by weight-loss programs significantly more than African-American women (P < 0.001); African-American women were more likely to feel that their cultural background contributed to their weight gain than did Caucasian women (P = 0.001). African-American women expressed a higher need for one-on-one counseling with their physician (P < 0.001) as well as group meetings with the dietician, physician, and other women (P = 0.004) than did Caucasian women. African-American women also felt it was more important for weight-loss programs to have information on food common to their culture than did Caucasian women (P < 0.001). Differences in cultural background and preferences about weight-loss interventions have important policy implications for how the U.S. health care system provides care to an ever-increasing multicultural population with a national epidemic such as obesity.
Comments
There are differences in the prevalence of obesity between gender and race. Among men, racial/ethnic groups do not differ significantly in the prevalence of obesity or overweight. However, among women, obesity and overweight prevalence are highest among non-Hispanic black women. Although more than half (53.2%) of non-Hispanic black women aged 40 years or older are obese and more than 80% are overweight, prevalence rates for Caucasian women are 34.2% and 61%, respectively.1 These gender and racial disparities raise questions about the health outcomes of African-American women—a group at increased risk for obesity-related diseases, such as diabetes, hypertension, hypercholesterolemia, stroke, and heart disease.2 Some studies suggest that genetic factors and a low metabolic rate play a role in African-American females being overweight or obese while other studies have examined the body image of African-American females. Other studies show that African-American females consider overweight bodies more attractive.3,4
The authors of this article are courageous to explore the relationship between race and culture in obesity, especially in an era in which we tend to try to treat all problems uniformly. Health professionals continue to need to evaluate their patients in terms of race, social situation, and cultural background. It is well known that certain diseases in particular populations have had protective as well as deleterious effects and that such traits have been genetic. Examples are sickle-cell disease in Africans and thalassemia in Southern Europeans, which have particular protective effects against malaria. Scientists and anthropologists have speculated that the survival of the genes contributing to diabetes are related to the ability of the individual with diabetes to get sudden bursts of energy from elevated blood sugar in a hostile environment. Other traits, such as the particular foul odor of sweat in certain societies, have been felt to be related to the ability to repel insects.
This excellent article, filled with tables and heavily referenced, explores the underlying sociocultural issues that influence obesity and consequent related diseases in women, especially African-American women. As clinicians we are continually acutely reminded of the severity of diseases including diabetes, hypertension, heart disease, depression, and weight-related arthritis to mention just a few. We also are continually reminded of the difficulty both for the patient and the health care professional in trying to solve the problem. It is not unusual to have an African-American woman tell you that she has been on one diet after the other and followed each conscientiously and has never been able to lose significant amounts of weight. Although the article nicely points to the fact that African-American women, in contrast to Caucasian women, were more likely to feel that their cultural background contributed to their weight gain, it has always been a suspicion that multiple other factors including genetics, heredity, and a process of natural selection contribute to the condition.
From the standpoint of attitudes, African-American women are more comfortable with a higher body weight since it is socially and culturally more acceptable. Indeed, from an anthropological standpoint, excessive body weight and truncal obesity may have been a desirable and protective condition in the recent past. Although it is very laudable to analyze the social and cultural aspects underlying obesity in our society, it is also important the see these issues in the context of the biologic factors that normally control body weight. There is significant compelling evidence that there are individual differences in susceptibility to obesity and that this is based on strong genetic determinants. Population-based association and linkage studies have highlighted a number of loci at which genetic variation is associated with obesity and related phenotypes and the identification and characterization of monogenic obesity syndromes has been particularly fruitful. The general opinion is that the hereditary factors that predispose to obesity are related to metabolic rate of the ability to transform excess calories into adipose tissue.
Recent studies, however, suggest that monogenic defects causing human obesity actually disrupt hypothalamic pathways and have a profound effect on satiety and food intake. The major impact of genes on human obesity is just as likely to directly impact hunger, satiety, and food intake rather than metabolic rate or nutrient partitioning and may represent a hereditary neuro-behavioral disease.5
To extend this concept a bit more, obesity in African-American women may be a cultural-biologic disease process. The presence of truncal obesity in Africa is considered by many to be an adaptive physiological trait for women living in hot environments since it allows them to maximize their surface-area/volume ratio while maintaining enough fat to facilitate hormonal homeostasis and subsequent menstruation and fertility. With fat deposited heavily in the truncal areas the limbs are left lean enough to radiate heat efficiently. Additionally in a society that in the recent past was almost solely dependent on the seasonal environments for nutrition, the ability to live off stored fat was beneficial. Such African women also were able to reproduce more efficiently and the end result may have been the selection of a genetic determinant for such characteristics. A similar genetic-cultural phenomenon may be present in the Pima Indians of Arizona who have a very high incidence of obesity with associated diabetes and heart disease.6
This article is particularly important in pointing out the particular problems in African-American women. The ultimate solution to the problem must be directed at making young African-American women aware of the data and taking definitive educational efforts toward modifying diet and behavior at an early age. Such efforts need to be directed at making African-American girls aware of the uniqueness of their history and culture, the sorts of disease processes to which they may be susceptible, and the methods of preventing these diseases in order to live a more productive life.
References
1. Flegal KM, et al. Prevalence and trends in obesity among U.S. adults, 1999–2000. JAMA 2002;288:1723-1727.
2. Allison DB, et al. Obesity among African American women: Prevalence, consequences, causes, and developing research. Womens Health 1997;3:243-274.
3. Kumanyika SK. Obesity in minority populations: An epidemiologic assessment. Obes Res 1994;2:166-182.
4. Flynn K, Fitzgibbon M. Body images and obesity risk among black females: A review of the literature. Ann Behav Med 1998;20:13-24.
5. O'Rahilly S, Farooqi IS. Genetics of obesity. Philos Trans R Soc Lond B Biol Sci 2006;361:1095-1105.
6. Schulz LO, et al. Effects of traditional and western environments on prevalence of type 2 diabetes in Pima Indians in Mexico and the U.S. Diabetes Care 2006;29:1866-1871.
Keegan GT. A clearer understanding of obesity in women. Altern Ther Women's Health 2006;8(11):85-86.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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