Angela Odoms-Young, PhD

Assistant Professor

University of Illinois at Chicago

College of Applied Health Sciences

Department of Kinesiology and Nutrition

Social and Cultural Determinants of

Food Choice: Implications for

Promoting Dietary Change in

Underserved Communities

Diet, nutrition and the prevention of chronic diseases

Report of the joint WHO/FAO expert consultation

“The diets people eat, in all

their cultural variety, define to

a large extent people’s health,

growth and development.”

Diet and Health

Dietary factors are:

Estimated to account for approximately 30% cancers

in industrialized countries and about 20% in developing

countries.

Linked to multiple CV risk factors, including both

established risk factors (systolic and diastolic blood

pressure, LDL/HDL cholesterol levels, and glucose

levels) and novel risk factors (e.g., inflammation).

Associated with an increase risk of obesity including

consumption of energy dense foods, snacking, SSB

consumption.

Source: Diet, nutrition and the prevention of chronic diseases Report of the

joint WHO/FAO expert consultation; WCRF-AICR Diet and Cancer Report,

ACS, AHA

Summary of Strength of Evidence that Might

Promote/Protect Against Weight Gain and Obesity

(WHO/FAO, 2004)

Age-adjusted Death Rate for leading causes of death

in the United States -2010 (CDC, 2013)

Age-adjusted Death Rate for leading causes of death

in the United States -2010 (CDC, 2013)

Percentages of adults aged 19+ years whose usual intakes of each food

group are equal to or above the minimum recommended amounts by race,

NHANES 2001-2004

Source: Kirkpatrick et al., 2012. J Acad Nutr Diet. 2012 May;112(5):624-635

.

Source: Kirkpatrick et al., 2012. J Acad Nutr Diet. 2012 May;112(5):624-635

Percentages of adults aged 19+ years whose usual intakes of solid fats,

and added sugars are within (equal to or lower than) guidelines by race,

NHANES 2001-2004

Female Weight Status by Race/Ethnicity

United States 2011-2012

Source: Flegal et. al., 2014

Male Weight Status by Race/Ethnicity

United States 2011-2012

Source: Flegal et. al., 2014

Disparities in Dietary/Health

Outcomes Blacks generally are at greater risk

for diet-related diseases as

compared to whites

E.g. Type 2 Diabetes in UK, Canada,

and US; Obesity in the US (UK

higher BMI but adiposity unclear;

increasing risk among South

Africans, Australia immigrants, etc.)

Nutrition Transition in Africa with

increase in non-communicable

diseases (NCDs)

Higher rates of related issues such

as food insecurity (in U.S. 25% vs.

11.4%)

Sources: NCHS, 2012; Ogden et al., 2012; Renzaho et al., 2004, 2006; Delisle, 2010;

Obesity and Country of Origin

Source: Luke A. Nutritional consequences of the African diaspora.

Annu Rev Nutr. 2001;21:47-71.

“…everything about eating

including what we consume, how

we acquire it, who prepares it and

who’s at the table – is a form of

communication rich with meaning.”

“Our attitudes, practices and rituals

around food are a window into our

most basic beliefs about the world

and ourselves”

Harris, Lyon and McLaughlin,

2005 (The Meaning of Food)

Social and Cultural Foodways

Reflect how members of society understand

the world

Shared set of symbols and practices that

bind individuals and families into groups

History and adaptation to the environment

Surface Structure (languages, music,

food, etc.) vs. Deep Structure

(culture, social, historical forces, etc.)

Peripheral, Constituent-involving,

Evidential, Linguistic, Sociocultural

Cultural Paradigms

Source: Resnicow et al., 199; Kreuter et al., 2003

Disparities in Dietary/Health

Outcomes

Traditional diets have positive and negative

aspects.

Blacks in UK (similarly Caribbean

Immigrants vs. US born) have better diets

More traditional/immigrant diets associated

with healthier outcomes in UK and

Australia

Traditional US soul food diet viewed as

unhealthy but relationship to obesity and

chronic disease unclear)

Cultural/Social Determinants

Identity and Autonomy

Eurocentric/Westernized

Illustrate social status: ‘‘nakula kizunguni’’ mean,

‘‘eating like a white person’’- ex. African

immigrants in Australia, Renzaho, 2004)

Black Redefined/Afrocentric

Maintain cultural/historical identity, resist racism,

create separate cultural spaces: “Black ways of

eating”- ex. African Americans, Surinamese, Afro

Canadians, Beagan and Chapman, 2012;

Kohinor et al. 2011; Odoms-Young, 2008; Ahye,

Devine, and Odoms-Young 2006; Kumanyika et

al., 2006; Liburd 2003)

Body and Embodiment

“More than a tangible, physical object..a mere

skeleton wrapped in muscles and stuffed with

organs”

“The body is also an enormous

vessel of meaning of utmost

significance to personhood

and society”

Waskul and Vannini, 2006

Cultural Food and Body

Classifications Classification Food Body

Medical Disease States Healthy/Unhealthy;

Obese/Lean

Nutrition Food Groups; Nutrients Adequacy/Inadequacy

Preferences Like/Dislike Ideal/Unacceptable

Geographic American Southern Body

Value Minimal Cost/High Cost Functionality

Life stage Child Meals/Senior

Meals

“Baby Fat”

Spiritual/Ritual Taboo Moral/Immoral

Social Working Class/Upper

Class

Working Class

Bodies/Upper Class Bodies

Cultural/Social Determinants

Food, Health, Well-being, and the Body

Eurocentric/Westernized

Physical well-being (Beagan and Chapman,

2012)

Nutrient focused

Physiology (Fatness associated with illness and

disgust)

Cultural/Social Determinants

Food, Health, Well-being, and the Body

Black Redefined/Afrocentric

Social /Spiritual well-being (Beagan and

Chapman, 2012; Kohinor et al. 2011; Ahye,

Devine, and Odoms-Young 2006; Kumanyika et

al., 2006; Renzaho, 2004 , Liburd 2003)

Unknown factors

Lack of trust of Western recommendations

Functional/Personhood

Resistance/Difference/Acculturation (Williams et

al., 2013; Swami et al., 2012; Shoneye et al.

2011)

Cultural Change

Plasticity is the ability of humans to change their

behavior in response to environmental demands.

Innovation

A new variation on an existing cultural pattern that is

subsequently accepted by others members of the

society.

Diffusion

The spread of cultural elements from one culture to

another through cultural contact.

Social and economic change usually results in

alterations in food patterns.

Pathways to Health Disparities

Health

outcomes

Prevalence

Incidence

Burden of

disease,

disability,

injury, or

death.

Health care

access

Coverage

Quality of

care (i.e.

differences

in

preventive,

diagnostic,

and

treatment

services).

Disparities in

health

Disparities in

health care Disparities in health

promoting resources

Employment

Income

Education

Social Context

Place of

Residence

Neighborhood

Resources (i.e.

parks, grocery

stores)

Historical Disadvantage and

Physical Contexts/Environments

Cultural/Historical Trauma and Slavery

Poverty

Stress

Food Insecurity/Economic Deprivation

Low Food Access/Neighborhood Food

Availability

Food Marketing

I did not receive much whipping,

but suffered greatly for want of

sufficient and proper food. My

master allowed his slaves a peck

of corn, each, per week,

throughout the year and this we

had to grind into meal in a hand

mill for ourselves. We had a

tolerable supply of meat for a

short time, about the month of

December, when he killed his

hogs. After that season we had

meat once a week, unless bacon

became scarce, which very often

happened, in which case we had

no meat at all.

FOOD AS OPPRESION AND

DISCRIMINATION

J

Source: Jerome, 1967

Low Access

Low Affordability

High Exposure to Marketing

Cycles of Food Deprivation and

Overeating High Levels of Stress

Poverty: Risk for Poor Diets

Food Resources, Socioeconomic Status,

and Race/Ethnicity

Low-income neighborhoods consistently associated with low availability of fruits and vegetables, poor quality fruits and vegetables, more corner/convenience stores, fewer supermarkets, and more fast food restaurants.

African American neighborhood consistently associated with low availability of fruits and vegetables, poor quality fruits and vegetables, more corner/convenience stores, fewer supermarkets, and more fast food restaurants.

Cotterill and Franklin, 1995; Morland et al., 2002; Moore and Roux, 2006; Powell et al.,

2007; Lisabeth et al., 2010; Gordon et al., 2011

Communities of color

targeted for unhealthy

food marketing.

Studies that examine

the intersection of social

conditions and

characteristics and food

resources have been

limited.

Food Resources, Socioeconomic Status,

and Race/Ethnicity

“Ghetto Groceries”

1960’s to late 1970’s Marketing Literature

Example

Sexton (1971) “Comparing the cost of food to Blacks and Whites—A survey”

Sexton (1971) “Groceries in the Ghetto”

Studivant (1968) “Better deal for ghetto shoppers”

US. House of Representatives Government Operations Committee (1968) “Consumer problems of the poor: Supermarket operations in low-income areas and the federal response: Hearings”

CAPLOVITZ'S MODEL OF GHETTO

CONSUMER PROBLEMS (1963)

Caplovitz, David. The Poor Pay More. New York: The Free Press, 1963.

Petrof (1970)

Potential Approaches

Culturally-tailored/Community-based Interventions

(Kreuter, 2003)

Change in Food Assistance Policy (Odoms-Young et.

al., 2013; Hillier et al., 2012; Whaley et al., 2012;

Zenk et al., 2012; Andreyeva et la., 2011)

University Partnerships/Consortium (Delisle et al.,

2010)

Economic Incentives (Kim and Kawachi, 2006;

Powell and Chaloupka, 2009)

Improve Healthy Food Availability (ex. Healthy Fresh

Food Financing)

DOING ME! SISTERS WORKING TOGETHER FOR A HEALTHY MIND AND BODY

Background: Previous Research

Individual Behavior Change Interventions Have Shown

Minimal Success at a population.

Most Nutrition Interventions “Downstream” vs. “Upstream”.

Individual Dietary Decisions Take Place in Daily Life (Social

and Environmental Contexts).

Limited Understanding of How Contexts Influence Diet-

related Health Outcomes.

Background: Previous Research

75% of the studies either did not report an ethnic

breakdown or did not include a substantial number of

black/African-American participants.

Black/African-American participants often less successful

at losing weight than white women.

Body image, family roles, spiritual and religious beliefs,

social-cultural history, identity, and food preference are

important factors to consider for weight loss and

maintenance

Source: Fitzgibbon et al., 2008; Fitzgibbon et al., 2012

Doing Me! Sisters Standing Together

for a Healthy Mind and Body

4 month weight loss intervention in low-income

African American neighborhood in Chicago

Based on the Obesity Reduction Behavioral

Intervention Trial-ORBIT (NCI: Fitzgibbon)

University-based vs. Community-based

Targets women 30-65 years of age

Funded by American Cancer Society-Illinois Division

(PI: Odoms-Young)

Setting: Englewood

Englewood: Social Context

Among Chicago Community Areas with the highest

% living below poverty

% childhood poverty

% housing vacancies

% unemployment

% very low birth weight

Mortality rate for cancer, heart disease (WE),

diabetes (E), and stroke

Source: City of Chicago Department of Public Health Community

Health Inventory, 2006

Doing Me! Vs. ORBIT ORBIT Doing Me!

Design 24 week weight loss + 1 year

maintenance intervention + weekly

MI during active phase/monthly

during maintenance

16 week weight loss+ weekly

resource calls

Setting University-based Community-based

Cultural Adaptation Culturally Targeted Culturally-Community Targeted

Staff African American Staff African American and Community

Staff

Eligibility City wide Englewood (surrounding)

35-65 years of age 30-65 years of age

BMI 30-50 BMI 30-44 (plan to expand to 50)

Advisory Board None Professional/Community

Theory Social Cognitive Theory Social Cognitive Theory

Doing Me! Adaptation *new 1. Introduction

Tools for Effective Weight Loss

Dietary and physical activity Guidelines, food diaries, MyPlate

1. Learn how to self-

monitor

2. learn how to reduce

calories

Self-monitoring

Setting

Priorities/Readiness to Change/Sleep*

Time management/stress, getting

enough sleep, Mindful Eating (element of mindfulness-based stress reduction)

1. learn how to

manage stress

2. learn how the

amount of sleep you

get affects weight

gain/loss

3. learn how to be

aware when you are eating

Motivation, culture

Meal Planning/My Plate Planning a well-balanced meal for self and family

1. learn how to plan a

well-balanced meal for

self

2. learn how to

substitute favorite

foods for healthier

foods

3. learn how to use

MyPlate for healthy

4. learn how plan before you shop

Food preparation,

calorie intake,

labeling, My Plate,

culture

Doing Me! Adaptation *new 1. Introduction

Grocery Store/Food Labels(Lab)

How to make smarter

choices and stretch your

dollar

1. learn how to make healthy

decisions on a limited budget

2. learn how to choose produce

Shopping, labeling

Portion Control Portions, Food Labels 1. learn what a serving size is

2. observe what a typical portion is

and what it should be

3. learn how to read a food label

for macronutrients

4. learn what an appropriate portion

is

5. learn why portions matters

6. identify methods/tools for measuring/estimating portions

Self-monitoring,

labeling, food

preparation, My Plate, food groups

Physical Activity-What’s

Enough/Exercise Myths/Hair*

Role of physical activity in

weight loss, lifestyle

activities versus exercise,

Guidelines, Hair Maintenance

1. learn physical activity’s role in

weight loss

2. learn the difference between

lifestyle activities versus exercise

3. understand how much exercise

is needed for weight loss

4. teach the difference between

frequency and duration

5. learn how to find target heart

rate

Benefits of physical

activity, barriers to

physical activity, culture

Doing Me! Adaptation 1. Introduction

Hair*

Goal Setting/Check-

in/Rate your diet and exercise patterns

How to set realistic goals, review

weight loss and behavior change progress to date

1. how to set realistic

weight-loss and

nutrition goals

2. Review progress to date

Motivation, culture

Coping with adverse

childhood trauma/Coping

in crisis/ dealing with discrimination*

Stress management, using meditation/spirituality

Self-monitoring, motivation, culture

Cancer and Overall Health Screening and guidelines 1 learn about

screening resources

2. learn what

screenings to receive

and how frequently

Self-monitoring

Doing Me! Adaptation 1. Introduction

Extreme meal make over (Lab)*

Healthy substitutes 1. learn how to make

a favorite meal healthier

Shopping, cooking, calorie intake, culture

Fast Food and Dining Out Identify pros and cons of fast food.

Making better choices when eating on the run

1. increase

awareness of

fat/calories in fast food

items

2. identify lower fat

and caloric fast food

options

Self-monitoring,

shopping, calorie intake, labeling

Overflow

Doing Me!: Outcomes and

Measures

Anthropometrics (Weight, Height, WHR)

Diet (24 hour recall)

Physical Activity (Accelerometer)

Blood Pressure

Environmental (Shopping Behaviors, NEWS,

Perceived Food Environment, Home Food

Availability, USDA Food Security)

Psychosocial Measures (Black Superwomen,

Mindfulness, CRYSIS, Unfair Treatment, Perceived

Stress, Spirituality)

Methods: Doing Me! Study

Design Randomized=60

8-Month Assessment 8-Month Assessment

Intervention

(4 months) Control Newsletters

(4 months)

4-month Assessment 4-month Assessment

Intervention Group=30 Wait List Control

Group=30

Intervention (2 months) Intervention (2 months)

Doing Me!: Design

Design

45 minutes instruction /45 minutes physical activity

Membership: Weight Room, Fitness Classes, Child

Programs

Case Resource Manager: Weekly calls to address

resource barriers (food security, transportation,

housing, gas/lights, caregiving)

BMI Classes

Class I Class II Class 3

30% 26% 44%

Income

Occupation

<$40,000 56% Employed 59%

$40,000 or > 44% Unemployed 41%

Education

Assistance

<= High

School 34% Yes 53%

Some College

/more 66% No 47%

Baseline Sample Characteristics

Baseline Weight Perceptions

Measure % (n=60)

Perception of Overweight 68% Overweight

31% Very Overweight

Weight Most Important Concern in Life (1st /2nd ) 62%

Interfere with Daily Activities 20%

Weight a Health Problem 85%

Weight Does Not Interfere with Physical Activity 75%

Baseline Weight Perceptions

Measure % Very/Mostly

Dissatisfied (n=60)

Face 15%

Hair 21%

Lower Torso 48%

Mid Torso 90%

Upper Torso 46%

Muscle Tone 72%

Weight 89%

Overall Appearance 25%

Baseline Psychosocial Measures

Measure Mean (SD) (n=60) Minimum Maximum

John Henryism

(0-48)

38.8 (5.6) 26 48

Acute Unfair

Treatment (0-9)

2.4 (2.1) 0 8

Everyday Unfair

Treatment (0-40)

12.3 (6.0) 0 28

Adverse Childhood

Experiences

(0-10)

2.7 (2.7) 0 10

Baseline Top 5 Most Reported Events

of CRISYS

Questions % Class I Class II Class III

Did your hear violence

outside of your home? 58.1% 33.3% 30.6% 36.1%

Did you look for job? 46.9% 30% 26.7% 43.3%

Did anything happen in your

neighborhood or home that

made you feel unsafe?

42.8% 33.3% 26% 40.7%

Did you see drug dealing in

your building or

neighborhood?

38.1% 33.3% 20.8% 45.8%

Did your income decrease by

a lot? 37.5% 33.3% 25% 41.7%

CRISYS and Weight Class (Baseline) BMI Class I BMI Class II BMI Class III

Crisys overall 8.7 8.2 10.5**

Financial 1.5 2.3 2.5

Legal .28** .06 .43**

Career .95 1.1 .85

Relationships .58 .88 .88

Safety in the Home .32** .06 .48**

Safety in the

Community

2.2 1.8 2.0

Medical Issues(Self) .24 .18 .46*

Medical Issues

(others)

1.1* .24 1.1*

Home Issues .53** .47 .96**

Authority .32 .47 .54

Prejudice .58 .47 .54

Stress 5.5 4.7 6.4

*P-value – 0.05

**P-value – 0.01

Implications, Conclusions, Next

Steps

Interventions in Black women show limited

success

Need for community-based, culturally

appropriate interventions that combine

historical, cultural, environmental, and

psychosocial

Test efficacy of community adaptation of

evidence-based intervention