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OF OBESITY IN
MANAGEMENT
LOW-INCOME AFRICAN AMERICANS
Lalita Kaul, PhD, RD, and Joseph J. Nidiry, MD
Washington, DC
The Bariatrics Clinic at Howard University Hospital was initiated to help low-income
African-American adults with low literacy skills in obesity control. Fourteen African-American
women and two men participated in the study. Essential components of the treatment includ-
ed nutrition education, exercise, and behavior modification related to food intake. The nutri-
tion education component involved teaching nutritional needs, taking into account low liter-
acy skills, low economic status, and individual food preferences. A realistic diet plan was
based on individual needs, economic status, availability of food, likes and dislikes, lifestyle,
and family dynamics. On average, patients lost 2 lb a week on this program. On average,
a 1 4-lb weight loss occurred in seven weeks. There has been a 10% dropout from this pro-
gram as opposed to drop out rates of 40% to 50% with other treatments. The main reasons
for the success of this program is that it is individualized and is sensitive to food preferences.
(J Natl MedAssoc. 1999;91 :139-143.)
Key words: obesity * hypertension individual is not classified as obese. Body fat can be
*behavior modification estimated by determining the thickness of subcuta-
neous tissues with calipers. Other anthropometric
The treatment of obesity remains one of the most measurements using flexible steel tape include the cir-
difficult problems in clinical medicine. Obesity is asso- cumference of the chest, abdomen, buttocks, thigh,
ciated with hypertension, increased incidence of car- calf, ankle, biceps, and forearm.
diovascular disease, diabetes mellitus, respiratory dis- There are two types of obesity: hyperplastic-char-
tress, gallbladder disease, surgical risk, complications acterized by increased number of fat cells and hyper-
during pregnancy, and psychosocial incapacity.1-3 trophic-characterized by enlarged fat cells. Hyper-
Insurance companies commonly define overweight plastic obesity is common in children whereas hyper-
as 10% to 20% more than ideal weight. An individual trophic obesity is more common in adult-onset obesi-
weighing :20% than his or her ideal weight is consid- ty.4 The age at which the adipose cell number is fixed
ered obese. A more useful definition of obesity is is not known. However, once the number of adipose
based on the amount ofadipose tissue in an individual cells is fixed, it cannot be changed by weight loss; only
as compared to the muscle mass. For example, a foot- the size of these cells can change with weight loss or
ball player may be considered overweight by normal weight gain. Therefore, hyperplasia of adipose cells at
standards but the proportion ofmuscle mass is greater an early age can set the stage for later obesity.
than adipose tissue. From a clinical point ofview, this Adipose tissue contains 72% fat, 23% water, and
small quantities of protein and mineral salts. One
pound of adipose tissue represents 3500 kcal. An
From the Department of Community Health and Family Practice, individual consuming an excess of500 kcal daily will
Howard University College of Medicine, Washington, DC. Requests gain one pound in one week. It requires only one
for reprints should be addressed to Dr Lalita Kaul, Howard University serving of apple pie and one oatmeal cookie to sup-
College of Medicine, 520 W St, NW, Washington, DC 20059. ply the additional 500 kcal every day. Weight gain or
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 91, NO. 3 139
OBESITY IN LOW-INCOME AFRICAN AMERICANS
Table 1. Daily Log of Behavior Activity Related restructuring of eating and exercise habits are
to Food Intake important in successful permanent weight reduction.
The Department of Community Health and
1. Date Family Practice at Howard University College of
2. Day Medicine has developed a program for weight
3. Food reduction. Most patients who come to the family
4. Amount practice clinic are African Americans who are
5. Time started eating hypertensive or diabetic. Weight reduction is impor-
6. Time finished eating tant for medical reasons rather than cosmetic rea-
7. Location of eating sons. A team approach is used in the treatment of
8. With whom eaten obesity. Teams consists of a physician, nutritionist,
9. Activity while eating and a nurse. The primary objective of this program
10. Mood before and during eating is to control obesity in low-income African-
11. How hungry before eating (1, 2, 3, 4, 5, 6*) American adults with low literacy skills.
12. How full after eating (1, 2, 3, 4, 5, 6t)
*1=very hungry. MATERIALS AND METHODS
tl=very full. Sixteen African-American obese patients weigh-
ing >220% above the desired body weight participat-
loss also is influenced by variations in water balance ed in the program. Fourteen patients were women
and some changes in protein-rich tissues. and two were men. The participants in the clinic
It has been reported that African Americans have resided in Washington, DC, and were generally
a high incidence of obesity, thus making black from lower-income strata. The mean weight of
women particularly more susceptible to hyperten- patients was 263 lb.
sion.5-9 It was further reported that prevalence of obe- Medical history was gathered from each patient's
sity in both white and black women was associated record. In addition, each patient was administered
with lower incomes. A longitudinal study of former laboratory tests to determine plasma levels of triglyc-
African-American medical students, now practicing erides, triiodothyronine (T3), thyroxine (T4), glucose,
physicians for an average of 22.5 years, has shown blood urea nitrogen (BUN), uric acid, cholesterol,
that 59% ofthose who became obese during the study high-density lipoprotein (HDL), and low-density
were hypertensive compared with 40% of the lipoprotein (LDL). The results ofthese tests were used
nonobese, 36% ofthose initially obese only, and 45% in planning a nutrition education program.
of those obese on both occasions. The investigators Aretrospective nutritional history was obtained by
suggest that weight control is an important nonphar- taking dietary history and cross checking with market
macologic hypertension risk-reduction measure.10 order. This procedure is more accurate than the 24-
Weight reduction has become a $10 billion hour recall method. Patients were given forms to log
industry. Various programs promise to help individ- their daily food intake, as well as the time and place,
uals lose weight with drugs, devices, special foods, concurrent activities, emotions, and people present
and fad diets." Some individuals resort to such (Table 1). Patients were asked to keep this log to help
extremes as prolonged fasts, jaw wiring, intestinal them learn to identify situations that stimulate eating.
bypass surgery, and stomach stapling. Patients were asked questions about their activity pat-
About 80% to 90% ofdieters who follow fad diets tern. Sedentary persons were encouraged to have
regain the lost weight. Myers and Young'2 have used gradual and nonstrenuous changes in routine activi-
the term "the rhythm method of girth control." ties. The diet diary was checked weekly.
Here, a individual loses several pounds and gains Arealistic individualized diet plan was developed
them back. Most of the fad diets are nutritionally for each patient based on medical history, medica-
unbalanced, and some may be dangerous to an indi- tions taken, individual needs, economic status, avail-
vidual's health. Such diets generally offer very little ability of foods, likes, dislikes, and lifestyle. Conse-
choice to the dieter, and the individual regains the quently, patients were taught to buy inexpensive low-
weight after returning to the previous eating habits. calorie foods, again mindful of their likes, dislikes,
Various studies have shown that in addition to a low- and allergies. This plan was reviewed weekly to
calorie diet, adoption of long-term goals and a ensure that patients' favorite foods were not com-
140 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 91, NO. 3
OBESITY IN LOW-INCOME AFRICAN AMERICANS
pletely removed from the diet. One patient
remarked, "Is this my diet? This includes most ofmy
favorite foods." were taught to make adjust- Table 2. Social Demographic and Physiological
Patients with families Characteristics of Obese Individuals
ments in meal patterns with minimum disruption of Characteristics No.* (O)
the eating patterns of other family members. Patients
also were given suggestions about food shopping and Age
methods for preparing low-calorie foods. <30 years 1 (6.3)
Hypertensive, obese patients were given suggestions 30-39 years (-)
for preparing low-sodium and low-fat diets. Patients 40-49 years 5(31.3)
also were encouraged to eat three meals daily. 50-59 years 5 (31.3)
Patients who were not used to this regimen were 60-69 years 5(31.3)
trained gradually to change their eating patterns.
Spacing of meals was adjusted according to the Sex
patients' lifestyles. An attempt was made to make Female 14 (87.4)
minimum change in the type of food patients pre- Male 2 (12.5)
ferred. If many changes were needed in the diet, the Activity
changes were incorporated gradually to minimize Sedentary 16 (100)
stress to the patient. Patients were taught to plan their Nonsedentary -(-)
diet according to the availability of foods at home.
Patients were assisted in setting realistic goals in Marital status
terms ofthe desirable weightloss over aperiod oftime. Single 9 (56.3)
For example, it would not be realistic for a patient Married 1 (6.3)
weighing 250 lbs to weigh 120 lbs just because that is Separated 3 (18.8)
the "ideal weight" set by the insurance company. Divorced - (-)
Patients were encouraged to eat all of their meals Widowed 3 (18.8)
in the same place. They were discouraged from Family history of obesity
watching television or talking on the phone while None 3 (18.8)
eating. It also was recommended that they eat at the One parent 5 (31.3)
same time each day. Many obese people tend to eat Both parents (-)
irregularly and at unplanned times. Other behavior Don't know 8 (50)
modification suggestions included prolonging eating
time by putting the knife and fork down between Previous dieting
bites. These behavior modification suggestions No 8 (50)
along with others were individualized according to Yes 8 (50)
each patient's lifestyle. Medical problems
Another component of our program is exercise.
Exercise has been shown to have an appetite-sup- Hypertension 13 (81.2)
pressing effect and reduce feelings of anxiety that Diabetes/hypertension 3 (18.8)
prompt many individuals to overeat. There are two Favorite foods
kinds ofphysical activities: activities that are aerobic, Sweets 8 (50)
such as swimming or running, and activities that are Sodas 1 (6.3)
anaerobic, such as calisthenics and weight lifting. Fried foods 4 (25.0)
Optimal results can be achieved by constant and low Bread (-)
levels of aerobic activities. The anaerobic exercises Potato chips 1 (6.3)
may even be harmfuil to hypertensive patients since Alcohol 1 (6.3)
they tend to raise both systolic and diastolic blood Others 1 (6.3)
pressures. *Total number of patients in the study: 16.
All patients in this study were sedentary and
spent most of their time sitting and watching televi-
sion. They were encouraged to make gradual
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 91, NO. 3 141
OBESITY IN LOW-INCOME AFRICAN AMERICANS
Table 3. Progress of Weight Loss During Seven patients. Patients' ages ranged between 27 and 69
Weeks in 16 Obese Patients years. Ninety-three percent of the patients were
Initial Weight After Total Weight between the ages of 40 and 69 years. All patients
Patient Weight 7 Weeks Loss in 7 were sedentary. Fifty-six percent ofthe patients were
No. (1b) (lb) Weeks (lb) single, and 37% were either separated or widowed.
1 190 177 13 Eighty-one percent ofthe patients had hypertension,
2 190 184 6 and 19% of the patients had both hypertension and
3 272 260 12 diabetes. Fifty percent of the patients liked sweets
4 274 256 18 and 25% liked fried foods.
5 283 278 5 Table 3 shows the progress of weight loss during
6 374 340 34 a seven-week period. Initial mean weight ofpatients
7 165 150 15 was 263 lb. There was an average weight loss of
8 276 262 14 about 14 lb. On average, patients lost 2 lb per week.
9 243 226 17 Table 3 also shows the statistical significance of dif-
10 212 203 9 ference in weight loss as determined by t-tests. The
11 334 325 9 patients served as their own controls.'4
12 228 215 13
13 222 213 9 DISCUSSION
14 393 279 24 Maintenance ofa stable weight largely depends on
15 279 260 19 an individual's ability to make daily adjustments in
16 365 351 14 his or her food consumption. Many individuals con-
Mean±SD 263±54 249±56 14* tinue to gain weight because they do not adjust their
*Highly significant, P<.01 appetites to reduced energy requirements resulting
from many labor-saving devices in as well as outside
the home.
changes in their routine activities such as using the Studies15"16 indicate that African-American women
stairs instead of elevators, parking several blocks tend to gain weight rapidly in their prime years. It is
from their destination, and getting off the bus a cou- believed that a diet high in fat and salt is responsible
ple of stops earlier. In addition, patients were given for this weight gain. Cultural factors also play a role
suggestions for aerobic exercises based on their in obesity among African-American women. Accord-
interests. The program does not have an exercise ing to some studies, l19 African American women are
physiologist on the team at this time. However, less preoccupied with losing weight than white
patients are referred to facilities, eg, their neighbor- women. Many ofthe patients who come to our clinic
hood YMCA, for the exercise component. do not feel their weight is a problem. They come to
Exercise also is important in maintaining muscle the clinic because they have been referred by their
tissue and tone during a weight reduction program. primary physician because of hypertension or dia-
Aerobic exercise (at least five times a week) and a betes. According to a study by Kumanyika et al,20
low-calorie, high-fiber diet cause faster loss of body African American women experience a lesser nega-
fat and less loss of lean muscle compared with only tive social enviroment about being overweight than
a weight reduction diet and no exercise. Patients white women. Most ofthe women in our clinic do not
were encouraged to join group exercise programs. wish to be very thin.
They were discouraged from using passive exercise
devices since they are ineffective in producing CONCLUSION
weight loss or loss of selected fat deposits.13 Our program at the Bariatrics Clinic is different
from other programs because it is designed for low-
RESULTS income African Americans with low literacy skills.
Table 1 outlines the daily log of behavioral activ- The success ofour program is based on a completely
ity related to food intake. This form is kept short and individualized procedure that takes into account food
simple so that patients are not discouraged about fill- preferences, family dynamics, lifestyle, and availabil-
ing out lengthy forms. ity of resources to buy foods. Unlike other diet pro-
Table 2 shows demographic characteristics of the grams, we do not give standard diet sheets but we do
142 JOURNALOF THE NATIONAL MEDICAL ASSOCIATION, VOL. 91, NO. 3
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