Reflections on healthy eating and suggestions for future health promotion programs from African American women
Financial support: This research was supported by grants from the National Institute of Nursing Research (K23NR014661)
Conflict of interest: No conflict of interest has been declared by the authors.
Purpose:
Obesity is highly prevalent in the United States (US), affecting about 40% of adults. African American women have the highest rate of obesity (66%) in the US compared with other racial ethnic groups, with 4 out of 5 being either overweight or obese (Abraham et.al., 2013). Obesity is one of the leading causes of health problems such as type 2 diabetes, stroke, cancer, pain, and cardiovascular disease (Williams et.al., 2015). Despite significant efforts in the treatment of obesity, the prevalence of obesity continues to increase annually and is expected to increase nationally and globally (Hruby & Hu, 2016).
Understanding obesity as a complex socio-bio-behavioral phenomenon requires examining multiple perspectives, such as biological, cultural, psychosocial, and environmental factors (Micklesfield et.al., 2013). However, limited studies focus on African American women’s perceptions of the cause of obesity and the impact of their lifestyle, specifically eating patterns and weight gain (Sutherland, 2013). In one study, African American women regarded eating as a cultural expression of caring and believed their past generation passed on traditions of food preparation that may not necessarily be healthy, ultimately leading to poor health outcomes and obesity (Swierad et.al., 2017). However, these studies do not explore African American women’s reflection around past and current eating pattern and their changes over time, perception on the cause of obesity, and current barriers to healthy eating. Thus, the purposes of this study are to explore: 1) middle-aged African-American women’s perception of their eating patterns from childhood to adulthood, 2) current barriers to healthy eating, and 3) their suggestions for future health promotion programs for healthy eating and obesity management.
Methods:
This is a secondary data analysis of a mixed methods study exploring the obesity-risk behaviors of African American women and the relationships of these factors with social and physical neighborhood environments. Eligibility criteria for participants included: (1) women over 21 years of age, (2) self-reported Black or African American, and (3) able to speak and read in English. We excluded individuals who reported disabilities or acute/terminal conditions that affect daily physical activity (e.g., terminal cancer, dialysis), and active psychiatric illnesses such as thought disorders in the past 6 months. Institutional review board approval and written informed consent, were obtained. Twenty-one participants completed an individual interview (mean interview time: 56 minutes) and received a $40 gift card. Semi-structured interviews were conducted about health behaviors, living situation, her reflection on lifestyle change over time, current barriers to healthy eating, and their suggestions for future health programs. All participants also completed a survey that included sociodemographic data and perceived health status. Body weight and height were measured three times using a portable electronic scale and stadiometer. Body mass index (BMI) was calculated as weight (kg)/height squared (m2). Interviews were conducted in participant’s home or her church depending on the participant’s convenience, audio-recorded, and transcribed verbatim. Transcribed interviews were entered into Atlas.ti, a qualitative software program used to organize and manage the qualitative data. Each interview transcript was coded via line-by-line coding and codes were collapsed into recurrent themes. Rigor and credibility were endured by independent analysis of data by members of the research team experienced in qualitative analysis, and interpretative consensus of findings during research team meetings.
Results:
The mean age of the 21 participants was 51.7 years (SD 12.74). The majority of participants completed some college (85%). Annual household income was reported as follows: about 33.3% reported $0-$39,999, 42.8% $40,000-$79,999, and about 10% reported $80,000 or higher. The mean BMI was 33.1 kg/m2 (SD 5.69), 38.1% were overweight (BMI 25-30 kg/m2) and 61.9% were obese (BMI>30 kg/m2). For perceived health status, 0% reported excellent health, 38.1% very good, 14.3% good, 43% fair, and 4.8% poor health status.
We identified four common themes in their eating patterns from childhood to adulthood: 1) healthy eating during their childhood as a result of their family who practiced healthy eating, 2) weekend and holiday overeating patterns with family members, 3) change in eating due to busy parents, participant’s financial independence and their own work schedule in young adulthood, and 4) needs to adopt healthy eating practice in middle adulthood.
Many participants stated that they were raised in a family with healthy eating practices. Parents or grandparents harvested their own fresh vegetables in a home garden or worked on a farm as workers in southern states of the U.S. Thus, they were naturally provided with fresh vegetables and fruits leading to healthy eating. Participants stated that their childhood foods typically consisted of hot, home-cooked meals, baked and boiled food, and vegetables from the garden. With such healthy eating pattern, more than half of the participants described themselves as being fit and skinny during childhood.
When growing up, they maintained a close relationship with other relatives and had large family gatherings on weekends and holidays. Despite their daily healthy eating patterns in their families, they would overeat and have poor portion control at family gathering days. Many participants also mentioned that every Sunday they had big meals at grandparents’ home. Participants shared their good memories of their grandmothers and mothers who prepared meals for the entire family that included grits, fried food, and buttermilk biscuits. Participants stated that they were expected to finish all the food on the plate by their grandparents and parents.
For some participants, eating patterns began to change from childhood to young adulthood due to their busy parents’ lifestyle. Often, their working mothers did not have time to prepare meals. Many participants did not have knowledge or resources to make their own food and consumed fast or convenient foods. Also, when the participants started working, they tended to ear unhealthy snacks, fried food, and processed food. With financial independence and a busy lifestyle including long workdays, participants chose whatever was convenient for them and they tended to eat without thinking whether the food was healthy or unhealthy —mostly quick, grab-and-go food from a nearby fast food restaurant or corner store.
As they entered middle adulthood, more than half of the participants had been trying to eat healthy, balanced meals by staying away from “bad” food. They expressed that their motivation to adopt a healthy eating pattern was from their personal experiences. Some had witnessed close friends who had passed away from stroke, cancer, and which one described as “a jarring experience.” Participants emphasized the need to start focusing on themselves, specifically on their unhealthy eating patterns. They defined healthy eating as consumption of food in moderation, foods such as green vegetables and fruits, balancing healthy and unhealthy foods, and “no fried food”.
Participants also reported several barriers to healthy eating: competing demands in managing their chronic disease co-morbidities, busy lifestyles and lack of time, lack of knowledge and resources on healthy eating, and lack of motivation. To address these barriers, they suggested some future health promotion programs for obesity management. About half of the participants recommended a free community-based education class on healthy eating, healthy cooking, and strategies for effective portion control. Other suggestions included a fun, entertaining physical activity group that incorporates music and dancing and a “processing group” where participants could share their personal stories on difficulties related to healthy eating and ways to change their eating behaviors.
Conclusion:
This study highlighted middle-aged African American women’s perception on changes in eating patterns throughout their life that they thought influenced their current body weight. They expressed current barriers to healthy eating, and suggestions for future obesity management programs. Future obesity program should target current barriers to healthy eating by incorporating culturally tailored lifestyle components to effectively improve obesity and promote healthy lifestyle for African American women.