Obesity and CultureAndres J. Pumariega, M.D.Professor and Chair, Department of PsychiatryCooper School of Medicine at Rowan University

African Americans (45 states and DC): Prevalence of 23.0% to 45.1%, with 40 states having an obesity prevalence of ≥30%, including 5 states (Alabama, Maine, Mississippi, Ohio, and Oregon) with a prevalence of ≥ 40%.

Latino/Hispanics (50 states and DC): Prevalence of obesity ranged from 21.0% to 36.7%, with 11 states having an obesity prevalence of ≥ 30%.

Non-Hispanic whites (50 states and DC): Prevalence of obesity ranged from 9.0% to 30.2%, mean rate of 26.2 %, with only one state (West Virginia) having a prevalence of ≥ 30%; 5 states (California, Colorado, Connecticut, Hawaii, and New Mexico and DC had an obesity prevalence of < 20%

American Indians- 40.8 %, not much data across tribes and reservation dwelling.

Asian-origin: 9.3 %, age and gender adjusted. Range of 2.8 % (Korean) to 14.1 % (Filipino). Some select Asian-origin populations in Oceania have high rates (e.g. Marshall Islands- 50 % prevalence in men and women).

Roughly 500 million adults are obese; almost 10 % of men and 14 % of women globally, nearly double the rate of obesity in 1980. Nearly 1.5 billion adults were overweight or obese (defined as a BMI of 25 or higher).

Central and South America (2008): > 30 % of women in Central and Southern Latin America were obese; about 25 % of men in Southern Latin America and 20 % of men in Central Latin America.

Obesity rates in “Australasia” (Australia and New Zealand) similar to U.S. and Canada—about 25 % for men and women. In Oceania, the average BMI has climbed by 1.3 units per decade over the past three decades; 15 to 20 % of men and 25 to 30 % of women are obese.

Bangladesh and other countries with significant threats of under-nutrition—Cambodia, China, India, Nepal, and Vietnam—have seen prevalence of overweight and obesity in women increase from the 1990s - mid-2000s, from 3.5 to 38.5 % a year.

Obesity rates in some Arab Gulf countries rival or exceed those in the U.S.: In Saudi Arabia, 28 % of men and 44 % of women are obese, and 66 % of men and 71 % of women are overweight or obese. In Kuwait, 36 % of men and 48 % of women are obese, while 74 % of men and 77 % of women are overweight or obese.

In Africa there is wide regional and national variation. For example, in 2008 the average BMI among men in the Democratic Republic of the Congo was 19.9—the lowest in the world, yet in South Africa, men had an average BMI of 26.9—on par with the average BMIs in Canada (27.5) and the U.S. (28.5).

Average BMI in men has been rising a bit more rapidly in Western and Central Europe than in Eastern Europe and Central Asia (0.6, 0.4, 0.2, and 0.2 units per decade, respectively). Average BMI in women stayed relatively stable in Eastern and Central Europe and Central Asia— some of very few places on the globe to report such a trend—and increased by 0.4 units per decade in Western Europe.

Goal et al (2004): Study of 32,374 respondents, 14% immigrants.– The prevalence of obesity was 16% among immigrants and 22% among US-

born individuals. – The age- and sex adjusted prevalence of obesity was 8% among immigrants

living in the United States for < 1 year, but 19% among those in the U.S. for > 15 years.

– Adjusting for age, SES, and lifestyle, living in the U.S. for 10 to 15 and > 15 years was associated with BMI increases of 0.88 and 1.39, respectively. The association for 15 years or more was significant for all immigrant subgroups except foreign-born blacks.

– Immigrants were less likely than US-born individuals to report discussing diet and exercise with clinicians (18% vs 24%, P.001; 19% vs 23%, P.001, respectively).

– These differences were not accounted for by sociodemographic characteristics, illness burden, BMI, or access to care among some subgroups of immigrants.

Goal et al, JAMA. 2004;292:2860-2867

Factors contributing to racial and ethnic differences in obesity. – Differences in composition and hedonics of traditional diets – Differences in traditional vs. current activity levels (work, leisure)– Food as social basis for interaction– Food as cultural symbolism – Differences in individual attitudes and cultural norms related to

body weight and body image– Differences in access to affordable, healthful foods and safe

locations to be physically active– Thrifty gene and phenotype theories: Harsh famine conditions led

to genetic selection for efficient metabolisms and low metabolic rates

Differential food preferences– Taboos (meat type, spices, insects, pets, primates, organ

parts, mixing or handling of particular foods)

Food attitudes and beliefs – Functional beliefs (sustenance, special properties), ethos

(symbolic meaning), taste preferences/ avoidance

– Innate and learned taste preferences and aversions

– Aroma memory and symbolic associations (to cultural environment, psychological)

On a 9 point hedonic scale, Americanstudents rated potato chips and caramel corn the highest and chicken feet the lowest

Chinese students rated chicken feet the highest and sharp cheddar the lowest. (farther apart the foods the greater the hedonic differences)

Lundahl, D., Sensory and Cognitive Aspects of Food Preference, Oregon State University

Impact of acculturation and immigration– Socioeconomic

Change in socioeconomic status greater food portions, reduced physical labor

– Psychological Cultural symbolism of traditional foods and hesitancy to give up in face of

assimilation Body image dissonance and dissatisfaction dieting greater obesity Seeking of psychological comfort with traditional foods Insufficient hedonics of mainstream (esp. processed) foods increased

consumption?

– Biological Thrifty gene theory (see previous) Physiological impact of acculturation stress: High acculturation and high

neuroticism high allostatic load desensitization of hypothalamic CRF system and attenuation of cortisol awakening response higher adiposity

Use of the DSM 5 Cultural Formulation1) Cultural identity of the individual, (racial, ethnic, or cultural groups; involvement with

the culture of origin versus host culture, religion, SES, migrant background, and sexual orientation.

2) Cultural conceptualization of illness (influence of cultural beliefs on experience, conceptualization, and expression of symptoms; includes cultural syndromes, idioms of distress, explanatory models of illness, emotional norms, perceived severity, meaning of distressing experiences, and methods of coping).

3) Psychosocial stressors and cultural features of vulnerability and resilience, (key stressors and supports in the socio-cultural environment; such as religion, family, and social supports). Modulated by cultural interpretations, family structure, developmental tasks, and social context.

4) Cultural features of the relationship between the individual and the clinician (dynamics of difference based on cultural, socio-economic, language, and social status that may cause differences in communication and influence diagnosis and treatment. Includes discrimination and racism that impact on trust within the clinical encounter, problems in eliciting symptoms and misunderstanding cultural significance, and difficulty in therapeutic alliance.

5) Overall cultural assessment summarizing the implications of the above aspects for diagnosis, plan of care, and other clinically relevant issues.

Use of AACAP Practice Parameters Evaluate and address barriers (economic, geographic, bureaucratic, insurance, cultural beliefs,

stigma, etc.) that may prevent access to services. Evaluate in language of proficiency for patient/ family; recognize impact of dual language

competence on adaptation/functioning. Awareness by clinician of own cultural biases to prevent stereotyping or cognitive shortcuts that

may interfere with objective clinical judgment. Awareness by clinician of cultural differences in development, expressions of distress, or

symptomatic presentation, and consider them in formulation and diagnosis. Evaluate the history of immigration-related trauma and community trauma (violence, abuse,

domestic violence) experienced by the child and family, and incorporate approaches in treatment. Evaluate the level of acculturation and presence of acculturation stress and intergenerational

acculturation family conflict, and address these in treatment. Make special efforts to include family members and key members of traditional extended families,

such as grandparents or other elders, in assessment, treatment planning, and treatment. Evaluate and incorporate cultural values, beliefs and attitudes in treatment interventions that

can enhance participation in and effectiveness of treatment. Clinicians should treat culturally diverse patients and their families in familiar settings within

their communities whenever possible. Support parents to develop appropriate behavioral management skills consonant with culture. Preferentially use psychological and pharmacological interventions with evidence for the ethnic/

racial population the child and family belong to. Address ethnopharmacological factors (pharmacogenomic, dietary, herbals) that may influence

response to medications or their experience of side effects.

Translation of culturally informed approach to Obesity– Access: Address access to psychological and preventive services (dietary

counseling, exercise) – Language: Definitions of terms within language of origin and cultural

values of terminology– Normative: Understand meaning of food in culture, role of family and

community, unique hedonics, culturally syntonic focus of activity/ exercise (drumming, dancing, sports)

– Acculturation stress: Address psychological impact on individual, role of food in seeking comfort, address body image issues, binge eating.

– Interventions: Practical, here and now, practical; incorporate traditional cultural activities, dietary counseling around preparation and consumption of traditional foods, emphasize family involvement.

– Evidence-based practices: Interventions to address Acculturative Family Distancing, group approaches that enhance mutual support.

– Pharmacological: Use of natural herbals, drug interactions, metabolism.

Seo Ji Chung, Oregon State University, Accessed 3/20/ 14

(Note: Similar process used by U.S. multinationals abroad for food production)

Obesity Prevention Source. Harvard School of Public Health. http://www.hsph.harvard.edu/obesity-prevention-source/obesity-trends/obesity-rates-worldwide/#References

Obesity and Asian-Americans. The Office of Minority Health, U.S. DHHS. http://minorityhealth.hhs.gov/templates/content.aspx?ID=6458

Obesity and American Indians. The Office of Minority Health, U.S. DHHS. http://minorityhealth.hhs.gov/templates/content.aspx?ID=6457

Mangold, et al. Neuroticism, acculturation, and the cortisol awakening response in Mexican-American adults. Hormones and Behavior 61(1): 23-20, 2012.

Lundahl, D., Sensory and Cognitive Aspects of Food Preference, Oregon State University. http://www.camo.com/rt/pdf/brochure/unscrambler/Crosscltr499.pdf. Last accessed 3/ 20/ 2014.

Seo Ji Chung. Asian Sweetner Study. Oregon State University. http://www.camo.com/rt/pdf/brochure/unscrambler/Crosscltr499.pdf. Last accessed 3/ 20/ 2014.

Popkin, B. The Changing Face of Global Diet and Nutrition. In: Brownell, K. & Gold, M. (Eds.) Food and Addiction: A Comprehensive Handbook. Oxford University Press.

Rozin, P. (1999). Preadaptation and the puzzles and properties of pleasure. In D. Kahneman, E. Diener & N. Schwarz (eds.). Well being: The foundations of hedonic psychology. (Pp. 109- 133). New York: Russell Sage.