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