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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 ...

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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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...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 american adults with literacy skills control fourteen women two men participated study essential components treatment includ ed nutrition education exercise behavior modification related food intake nutri tion component involved teaching nutritional needs taking into account liter acy economic status individual preferences a realistic diet plan based on availability likes dislikes lifestyle family dynamics average patients lost lb week this program weight loss occurred seven weeks there has been dropout from pro gram as opposed drop out rates other treatments main reasons for success is that it individualized sensitive natl medassoc key words hypertension not classified obese body fat can be estimated by determining thickness subcuta neous tissues calipers anthropometric remains one most measurements usin...

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