A A Culture and Cultural Differences
Culture influences all human behavior and dialectically shapes social institutions and social interactions among populations groups and individuals. Culture has many definitions, but all embody the underlying concept of implicit and explicit guidelines that are inherited and shared by members of a particular society or societal subgroup (6,7). These guidelines define''how to view the world, how to experience it emotionally, and how to behave in it in relation to other people, to supernatural forces or gods, and to the natural environment'' (7). These cultural perspectives are identifiable and transmitted from one generation to the next through distinctive symbols, language, and rituals. Of particular relevance to cross-cultural treatment issues, cultural influences on behavior tend to be relatively invisible. Certain types of behavior seem universal, natural, and nonnegotiable to those influenced by a given culture (7). In fact, the influence of culture often becomes evident only when cultural differences are encountered, e.g., in interactions between individuals or groups that have contrasting beliefs, expectations, or values related to a particular issue; that is, one might not perceive that one is operating within a culture until one has to operate outside of it.
Table 1 lists examples of culturally determined values and beliefs (8-14). Some of these variables, such as worldview or spirituality, are overarching and form the context for other elements. Differences between cultures on specific topics, sometimes termed ''cultural distance,'' are often a matter of degree or emphasis. However, the sum total of cultural differences may result in qualitatively different ways of approaching life and day-to-day transactions. Furthermore, cultural norms, e.g., what is considered usual, expected, or appropriate, result from the interaction of cultural values and beliefs with environmental variables such as the social structure and the availability of commodities such as food and health care.
There is a general concern within the field of behavior change that the available methods are not sufficient to produce long-term improvements in lifestyle risk factors related to diet and physical activity, including obesity, as well as cigarette smoking (15). The need for effective long-term weight control strategies has become especially urgent in light of recent increases in obesity
Cultural Differences in Treatment Table 1 Examples of Culturally Determined Values and Beliefs
1. Worldview—how person views himself or herself in relation to the environment; the types of explanatory models used to understand day to day occurrences and to make sense of life experiences
2. Spirituality—beliefs in God, belief in the supernatural, sense of destiny and control over one's life; view of life, death and afterlife
3. Harmony—view of oneself as interdependent with the environment; desire to dominate the environment; responsibility of the individual to humanity; sense of interconnectedness or discreteness of the various aspects of one's life; consumption and sharing of resources
4. Health and reproduction—concepts of wellness and optimal performance; disease and illness; food and sustenance; procreation
5. Interdependence—of people, individuals' freedoms and responsibilities, social orientation vs. individualistic orientation; definition of family (e.g., nuclear family; extended family; biologic vs. socially defined kinship); definitions of self-reliance; expectations for caregiving; gender roles
6. Rhythm—sense of rhythmic nature to life; role of seasons; orientation to rhythms, music, dance in behavior and overall approach to life.
7. Affect and cognition—importance of rationality; importance of emotion; degree to which emotion and thinking are considered separate; role of emotions and rationality in social relations
8. Individualism and communalism—separateness of self; uniqueness of individuals; social conformity; importance of individual expression; degree of interdependence with others
9. Linearity—value of order and step-by-step progression; acceptance of chaos and unpredictability
10. Vitality—energy of living; fullness of participation in all aspects of life
11. Interpersonal relationships—views about conflict and aggression; value for cooperation; ways of conveying approval/ disapproval or social support
12. Status orientation—value of education and material possessions
13. Work orientation—work ethic; industriousness; work as self-definition; work as economic necessity
14. Approaches to technology—attitudes toward computers; attraction to new inventions; support of research and development activities
15. Communication styles—relative value of oral and written communication; directness of communication; body language
16. Time perspective—orientation to clock time or to events; future orientation or present orientation; history as a basis for reflection
prevalence (16,17). At the ecological level, this upward trend in prevalence can be directly linked to cultural norms and social structural factors that encourage and maintain chronic overconsumption of calories and physically inactive lifestyles (17,18). The most obvious trends are those related to food portion sizes (e.g., supersizing of food packaging and restaurant portions), use of automobiles, television watching, use of computers, and sedentary forms of recreation (19,20). These trends are embedded in a synergism between cultural values (e.g., for individual choice, free-market activity, and consumerism) and the social structure (e.g., production, availability, and aggressive marketing of large quantities of high-calorie foods and technological advances resulting in labor-saving devices and electronic communications that have economic benefits for society) (21). Thus, in the United States and in other countries where similar societal trends and cultural shifts have occurred, obesity treatment occurs in a context where there are strong societal forces promoting weight gain and potentially counteracting individual attempts to lose weight or maintain weight loss (22).
Thus, we are now attempting to treat obesity in a situation in which both being overweight and the eating and activity behaviors that lead to being overweight, although not normal in a physiologic sense, are normative; that is, those who do not maintain adequate weight control now outnumber those who do. The difficulty of maintaining self-control of behaviors related to eating and physical activity has increased from prior times partly because people are bombarded with consumption stimuli via the mass media, and partly because they are receiving mixed signals about eating, physical activity, and weight. Both the social structure and many current cultural norms favor day-to-day (e.g., not just on occasional holidays and at celebrations) behaviors that are highly obesity promoting, whereas obesity itself is still viewed as problematic.
C Obesity in Ethnic Minority Populations in the United States
1 Minority Populations
Last (23) defines an ethnic group as follows:
A social group characterized by a distinctive social and cultural tradition, maintained within the group from generation to generation, a common history and origin, and a sense of identification with the group. Members of the group have distinctive features in their way of life, shared experiences, and often a common genetic heritage. These features may be reflected in their health and disease experience (23:44).
Ethnicity is often a more appropriate designation than ''race,'' which purports to describe a biologically homogeneous group (24). Variations in cultural perspectives of different ethnic groups have always been of some interest for biomedicine in comparisons across societies (25,26). Cultural issues are receiving more attention in the United States as the population becomes more diverse (24,27). There is considerable ethnic, socioeconomic, and sociocultural diversity within the broad minority population categories used by the U.S. Census Bureau. From a sociopolitical perspective, what these groups have in common is being ''nonwhite'' or ''Hispanic,'' whereas the majority population is defined as whites who do not indicate Hispanic ethnicity. Stated from a behavioral intervention perspective, minority populations encompass those subgroups that are viewed as sufficiently different from the U.S. mainstream population and are therefore potentially less well served by programs designed with the majority in mind (28). The more distinct the language and cultural characteristics of the population from the mainstream, the greater the implied need for special considerations. However, if only by virtue of residence in the U.S. society, members of ethnic minority populations are also—to varying degrees—participants in the mainstream U.S. culture and influenced by mainstream cultural variables through media, workplace interactions, and other forms of social exchange. Thus, ethnicity and ''minority'' status are addional rather than necessarily alternative cultural influences. There are many cultural similarities among minority populations. Both the similarities and the differences must be considered.
Not all social and behavioral differences among ethnic minority populations and the majority are attributable to cultural values and beliefs. There are also differences in sociodemographic indicators such as: the percentage who are foreign born, fertility rates, life expectancy, household and family structure, educational achievement, occupations, neighborhood characteristics, income distribution, health insurance coverage, and interactions with the health system (24,27,29). It is therefore difficult to separate ethnic differences that are culturally determined from those due to sociodemographic factors, particularly those related to social structural factors such as poverty or discrimination that differentially affect minority populations. Moreover, there are culturally determined differences in attitudes and behaviors according to factors such as gender, age, geographic region, religious affiliation, and occupation within all populations. Each individual is, therefore, potentially influenced by a range of interrelated cultural and social structural variables. Behaviors of individuals in ethnic minority populations reflect a blend of the cultural perspectives to which they are exposed.
The prevalence of obesity is higher among black, Hispanic, American Indian, and Pacific Islander populations in the United States than among non-Hispanic whites, especially among women (16,30,31) (see Fig. 2), and this high prevalence is associated with a high burden of diabetes and other obesity-related diseases (32-37). Data for children in these minority populations also suggest trends of increasing prevalence of obesity (38,39) and type 2 diabetes beginning early in life (40). Excess obesity in minority populations has led to explicit concerns about ethnic group differences in the factors that predispose to obesity and in the ability to effectively prevent and treat obesity in these populations. It is possible that the prevalence of a biological predisposition to gain weight is higher in the ethnic groups that exhibit such a high prevalence of obesity. However, to date this has not been established (3,41). What has been established, for example, from comparisons of Pima Indians and of African-descent individuals living in different environments (42,43), is that the predisposition to obesity is only expressed under permissive environmental circumstances.
Table 2 lists examples of culturally influenced variables that are specifically relevant to obesity treatment (44). As shown, these include variables that determine underlying or usual eating and physical activity patterns and assumptions about how food and activity relate to health as well as those that are specific to weight. As discussed elsewhere (3), cultural attitudes that favor a I larger body image or at least do not support a strong drive to become thin can be documented for several ethnic minority populations (45). Overweight and obe- < sity are especially normative in those minority populations where it affects half or two-thirds of adults and
where the link between obesity and poor health outcomes is not always recognized (46,47). That illnesses | associated with thinness or wasting (e.g., cancer, tuberculosis, or AIDS) are prominent in the health profiles of minority populations (29) may perpetuate the sense that
Table 2 Examples of General and Weight-Specific, Culturally Influenced Attitudes and Perceptions Relevant to Weight Management
Food, activity, and health in general
Medicinal or health promoting properties of food; health-related food restrictions Symbolic meanings and social uses of food Food and flavor preferences and aversions Fasting and food deprivation
Food portions; leaving food on plate; satiety
Overeating; food and coping style
Physiological effects and health benefits of physical activity, exercise, and rest Food-related social roles Role constraints related to gender, age, social position, and work Preferred types of leisure time activity
Ideal, acceptable, and undesirable body sizes and shapes Definitions of thinness and fatness Perceived determinants of weight status Importance of personal body size and shape and relationship to self-concept Functional and health effects (positive and negative)
of being at a given weight Priority given to weight management Ways to lose or gain weight or influence body shape, including role of diet and exercise Standards of personal attractiveness Perceived social pressure to lose or gain weight
Inclination toward low-fat diets, diet pills, or purging
being heavy is healthier than being thin, particularly among low-income women (47,48).
Several aspects of body image, dieting, and dieting motivations appear to differ by ethnicity (49,50). However, there are also striking similarities in the prevalence of dieting across ethnic groups (51-54). That is, although there are clearly body image differences that alter the motivation and context for obesity treatment, there is substantial diversity in these attitudes within minority communities as well as substantial evidence of strong weight loss motivations—even if of a differential quality than in the white population (54-56). For example, in the analysis of national survey data reported by Serdula et al. (54), Hispanic men and women were significantly more likely than white men and women to be trying to lose weight. Body image may be the most dissimilar across ethnic groups in women who are not overweight or obese. In most or all populations and even where there are positive cultural values for large body size, those who are overweight or obese seems to be less satisfied with their weight than those who are lean (55,56). Wolfe (57) has criticized the amount of attention given to cultural attitudes of black women, suggesting that it detracts attention from the many societal factors that predispose black women to gain weight and the need to address these in an attempt to control obesity.
As shown in Table 2, there are many culturally influenced attitudes and behaviors related to food and activity that have implications for weight but that are not driven primarily by body image or weight concerns. Norms about food, activity, and health are defined and continually reinforced within cultures—for example, the concept of what constitutes having enough food or feasting when food is abundant to anticipate possible food shortages, how food should be flavored, what combinations of food can be eaten together, what physical activities are appropriate for children but not for adults or for males but not females, the importance of inactivity (e.g., rest), or how one should cope with stress and restore physical and mental balance (45,5860). The cultural embeddedness of food and the role of food as a carrier of ethnic identity and vehicle for social expression and social interactions is the subject of a large anthropological literature (45,61-63) that, if taken seriously, can be very daunting to anyone who seeks to change food habits. Nevertheless, weight and health risk reduction considerations can only be viewed logically as superimposed onto these more basic attitudes and as competing with other day-to-day survival and quality-of-life priorities. Priority on weight reduction relative to other health or survival concerns may be lower for the medically obese in ethnic or socioeconomic status groups for which body size and shape are less central to self-image or social acceptance or where some aspects of large body size (shapeliness, muscularity, strength) improve social acceptance or status. As discussed below, there may also be less congruency between basic attitudes and beliefs related to food and activity in minority populations and those advised for weight management.
Compared to the U.S. white population, minority populations are experiencing social and economic transitions from relative poverty, food shortages, and lifestyles that involved significant physical labor to circumstances in which there are more than sufficient amounts of food readily available to even the poorest segment of society and limited demand for physical work (64-67). Although cultural perspectives change, they tend to follow societal changes after a considerable time lag. Thus, the food and activity-related cultural perspectives of ethnic minority populations may still be primed to promote survival under prior circumstan-ces—simplistically, to feasting and resting from hard work rather than restricting food and seeking extra physical work. Such perspectives would heighten the vulnerability to obesity in the current environment in which food and activity-related survival needs have been reversed from prior times. For example, poor food security—defined as worrying about having access to sufficient food—has been associated with an excess of overweight in women, and the prevalence of overweight was generally highest among women in the lowest income categories (68).
National surveys do not necessarily show higher energy intakes in minority populations compared to whites (69). One reason for this may be a differentially high level of energy underreporting in ethnic minority populations compared to whites. Conclusive evidence of differences in energy balance requires data on both energy intake and energy expenditure. Data for minority populations are strongly indicative of higher than average levels of physical inactivity (70-72). Excess obesity could, therefore, result even if energy intakes in minority populations were not high in comparison to those of less obese populations. Physical activity questionnaires may have differential validity in populations with different leisure time and occupational activity lifestyles. However, in black women, for example, the finding of lower activity compared to white women has been corroborated in studies using objective measures of physical activity (73,74).
Those with the least latitude in personal choices have the greatest lifestyle constraints (75). Thus, when the society at large has an overabundance of obesity-promoting forces, the potential deleterious effects may be intensified in minority populations. U.S. communities continue to be ethnically segregated (27). Most individuals in minority populations live in communities where the other residents are also minorities, whereas most non-Hispanic whites live in predominantly white communities. Constraints of particular importance in minority communities may include too few supermarkets and neighborhood or workplace physical fitness facilities, too many fast food establishments or food vendors selling high-fat foods at low prices, and high neighborhood crime rates that discourage outdoor activities (71,76-78). Media exposure may also be particularly detrimental (79,80). For example, a recent analysis of food advertising on prime-time television found that the shows oriented to blacks had significantly more food commercials per 30-min segment and that more of these commercials were for high calorie-low nutrient density foods (80). These authors also noted that more of the characters on the black-oriented shows were overweight—perhaps reflecting the prevalence of obesity in the community but also reinforcing the concept that obesity is normative. That is, the high prevalence of obesity in minority populations is in itself an important contextual factor potentially influencing obesity treatment.
Finally, the reproductive and health status profiles of minority populations may predispose to weight gain and physical inactivity. Fertility rates are higher in minority women than white women (24), predisposing to pregnancy-related weight gain. The amount of weight that is gained and retained with each pregnancy may also be higher (81). In addition, the high prevalence of obesity-related health problems such as diabetes or osteoarthritis may interact with age-related social role perceptions to limit, or be perceived as limiting, participation in physical activity.
In summary, living circumstances, eating and activity practices, and related attitudes vary among ethnic groups, leading to potential differences in weight loss motivations and in the way that obesity treatment programs will be received and adhered to. Relevant factors include the psychosocial receptivity to food restriction, body image issues, the congruency between behavior change recommendations and accustomed habits, feasibility of recommended changes, and social network and community support for lower calorie eating or increased physical activity.
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