African-American women at risk

About 10 years ago, APA Past-President Suzanne Bennett Johnson, PhD, noticed an alarming trend in her University of Florida diabetes clinic: Many black children were developing Type 2 diabetes — a preventable, largely obesity-related disease that she'd only previously seen in adults. "Then I learned that 50 percent of African-American women develop Type 2 diabetes in their lifetime. That's simply unacceptable," Johnson said at the Summit on Obesity in African American Women and Girls, an event that brought about 90 obesity researchers, health professionals and community leaders to the University of the District of Columbia on Oct. 22–23.

The first major collaboration between APA and the Association of Black Psychologists (ABPsi), the summit was "a call to action," said ABPsi President Cheryl Grills, PhD. "The issues facing the African-American community are immense, but if we don't have our health, not much else matters," she said.

The obesity epidemic has affected all Americans, but it has hit African-American women the hardest, said speaker Cynthia Ogden, PhD, an epidemiologist at the Centers for Disease Control and Prevention. Almost 60 percent of black women are obese, compared with 32 percent of white women and 41 percent of Hispanic women. The trend is decreasing black women's life expectancy and increasing their chances of developing a host of ailments, including diabetes, cardiovascular disease and arthritis, Johnson noted.

The data also show a curious trend, Ogden said. White and Hispanic women with higher socioeconomic status and more education seem somewhat protected from rising obesity rates, but that doesn't hold true for black women. "It's not just the low-income African-American population that's experiencing this problem," Ogden said.

There are many possible causes for the disparity, and even more for the overall obesity epidemic, presenters said. But one thing is sure: To make a difference, psychologists will need to collaborate with one another and with experts from other disciplines. To that end, the summit organizers will create a report and work with presenters and other attendees to develop a list of concrete action items that all can agree to support, both of which will be available at ABPsi and APA's Public Interest Directorate. "The summit is a first step," said Gwendolyn Keita, PhD, one of the lead organizers and executive director of APA's Public Interest Directorate.

"If we are really going to solve this problem, we are going to have to be on interdisciplinary research teams, we are going to have to partner with community leaders and we are going to have to find allies ... every step of the way," Johnson said.

Origins of an epidemic

Over the past 20 years, the United States has become an overweight nation, Johnson said. America's skyrocketing body mass index is the result of a host of factors that have made junk food and fast food inexpensive while making fresh fruits and vegetables comparatively more expensive.

"Your tax dollars are actually helping to create this obesogenic environment," said Johnson.

In addition, with more women working out of the home, families are eating out much more, Johnson said. "If you're working all the time, you don't have time for meal planning and cooking," she said. As a result, 42 percent of today's family food budget goes toward eating out, as compared with 21 percent in the 1960s. Even more alarming, 30 percent of U.S. children eat fast food every day, and 50 percent of adults eat it at least once a week, Johnson said.

"Many African-American community contexts are contributing factors in the current health crisis," added Grills. "Issues of food and recreation justice and high levels of racial and environmental stress are creating the perfect storm for rising rates of obesity."

African-American women have been hit hardest by the obesity epidemic, regardless of their socioeconomic status, said James Jackson, PhD, who directs the University of Michigan's Institute for Social Research. One possible reason behind the disparity is the "stress of being a black woman in a white man's world," Jackson said. His research, published in the American Journal of Public Health, shows that black women often buffer themselves from the chronic stress of racism and supporting entire family systems though high calorie "comfort food."

"If you take that away without giving them some other coping mechanism for all the other stress in their lives, you are going to have a case of depression by the end of the year," Jackson said, noting that blacks tend to have better mental health but poorer physical health relative to whites.

Geographical factors, such as high crime and few supermarkets in many African-American neighborhoods, also contribute to obesity disparities, said Dustin Duncan, ScD, a research fellow at the Harvard School of Public Health. Duncan has found that women who are afraid to go out at night take an average of 1,107 fewer steps each day than women who feel safe in their neighborhoods. In another study, Duncan found that more parks didn't correlate with reduced BMI, perhaps because they had become meeting places for drug dealers and criminals. "We suspect that the quality of the parks really matters," he said.

Educating black communities about the causes of the epidemic will be an important first step in helping communities fight back, said Emerson College health communication and behavioral science professor Angela Cooke-Jackson, PhD, MPH.

"So often, as black people, we are talked about but not talked to," she said. "We need to give black women a voice and give them agency. Tell them how stress is affecting them, and tell their communities what they are up against."

Interventions that work

Empowering black women to lead healthier lives is precisely the goal of "Prime Time Sister Circles," a 12-week program developed by former Assistant Surgeon General Marilyn Gaston, MD, and clinical psychologist Gayle Porter, PhD. So far, their program has helped more than 2,000 women lead healthier lives in Chicago, Philadelphia, Tampa, Fla., and Orlando, and throughout Maryland and the greater Washington, D.C., area.

Each "Sister Circle" consists of 23 middle-aged women who meet once a week — often in a church basement or community center — to support one another and share strategies for managing stress and taking better care of their health. Trained group leaders, usually women from the community who have graduated from past circles, facilitate discussions on a variety of topics. Visiting experts also lead discussions on stress management, nutrition and physical activity. But one of the toughest lessons is convincing the participants, most of whom are Christian, that it's OK to take care of themselves, Porter said.

"As Christian women, we're taught that taking care of our own health is selfish," Porter said.

The circles are changing behaviors, Gaston says. One participant, for example, told her grandson that she would begin eating healthier. Later, the grandson removed a bag of Cheetos from her shopping cart and told the check-out clerk, "My nana isn't buying any of this because she is going to live to see my grandchildren," Gaston recalled.

Creating supportive groups of women is also at the heart of "Sisters Together: Move More, Eat Better," a national program that also brings together small groups of African-American women to brainstorm ways to improve their health, said Leslie Curtis of the National Institute of Diabetes and Digestive and Kidney Diseases, part of the National Institutes of Health. The program identified a surprising barrier to exercise: hair. African American women, the group participants said, sometimes avoid exercising in order not to undo expensive hairstyles. To address that barrier, Curtis and her colleagues reached out to hairstylists and developed a brochure with tips for maintaining African-American hair while leading an active lifestyle.

Promoting healthy eating and physical activity in culturally sensitive ways has also been key to the success of "Challenge," an obesity-prevention program developed by Maureen Black, PhD, a psychologist and professor in the department of pediatrics at the University of Maryland School of Medicine. The first Challenge program, conducted in the homes of urban teens using college-age mentors, reduced the excessive weight gain that often occurs in adolescence. The second Challenge program, based in Baltimore middle schools, has enlisted the "cool," older students to lead the way.

"We recruited the popular eighth-grade girls to promote a healthier school environment, through healthy snack posters, physical activities such as jump rope sessions on the lawn, and culminating in a Health Fair," Black said.

At the suggestion of the students, the researchers also invited a rapper from west Baltimore to perform a song about healthy eating. The study is in progress, but it looks like the school's culture has changed, Black said.

"This intervention was at the community level, but it's going to take interventions at all levels to beat the obesity epidemic," said Black.

That includes fighting for policy changes that encourage healthy eating and exercise, Johnson said. "Psychologists also need to advocate for policies that increase access to affordable, healthy foods and recreation and that deal with the myriad environmental stressors that affect black women and girls," Grills added.

"My dream is ... we can work together and do something serious about this problem," Johnson said.