Doctoral Thesis / Dissertation, 2014, 223 Pages
Doctoral Thesis / Dissertation
MENOPAUSE, RURALITY, AND OBESITY IN RURAL AFRICAN AMERICAN WOMEN
Colleen Marcia Kilgore
In the US, one in every eight deaths is due to an obesity-related chronic health condition (ORCHC). More than half of African American women (AAW) 20 years old or older are obese or morbidly obese, as are 63% of menopausal AAW. Many have ORCHC that increase their morbidity and mortality and increase health care costs. In 2013, 42.6 percent of AAs living in South Carolina (SC) were obese. The purpose of this cross-sectional study was to identify the cognitive, behavioral, biological, and demographic factors that influence health outcomes (BMI, and ORCHC) of AAW living in rural SC. A sample of 200 AAW (50 in each of the 4 groups of rurality by menopausal status), 18-64 years, completed the: Menopausal Rating Scale (symptoms); Body Image Assessment for Obesity (self-perception of body); Mental Health Inventory; Block Food Frequency Questionnaire; Eating Behaviors and Chronic Conditions, Traditional Food Habits, and Food Preparation Technique questionnaires – and measures for Body Mass Index.
Most rural, and premenopausal AAW were single and not living with a partner. Premenopausal women had significantly higher educational levels. Sixty percent of AAW had between 1 and 5 ORCHC. Most AAW used salt based seasonings, ate deep fried foods 1 to 3 times a week, and ate outside the home 1 to 3 times a month. Few AAW knew the correct daily serving for grains and dairy, and most consumed less than the recommended daily serving of fruits, vegetables and dairy. Morbidly obese AAW used more traditional food preparation techniques than obese and normal-weight AAW. Rural, and menopausal AAW had significantly higher morbid obesity levels, consumed larger portions of meats and vegetables, and reported more body image dissatisfaction than very rural AAW, and premenopausal AAW, respectively. Controlling for socioeconomic factors the relationships between perceptions of body images, psychological distress, and psychological wellbeing remained significant for numbers of ORCHC.
1. Descriptive Statistics Comparing Rural and Very Rural Status
2. Descriptive Statistics Comparing Menopausal and Premenopausal Status
3. Descriptive Statistics of BMI and the Number of Obesity-Related Chronic Health Conditions
4. Descriptive Statistics of Cognitive Factors
5. Descriptive Statistics of Knowledge of Healthy Eating
6. Descriptive Statistics of Behavioral Factors
7. Descriptive Statistics of Eating Behaviors
8. Two-way ANOVA of Cognitive and Behavioral Factors Grouped by Menopausal Status and Rural Status
9. Main and Interaction Effects of Menopausal and Rural Status on Behavioral Factors
10. Main and Interaction Effects of Menopausal Status and Rural Status on BMI Categories
11. Main and Interaction Effects - Numbers of Obesity-Related Chronic Conditions by Menopausal Status and Rural Status
12. BMI and Cognitive and Behavioral Factors With and Without Covariate
13. Chronic Health Conditions and Cognitive and Behavioral Factors With and Without Covariate
1. African American – AA
2. African American Women – AAW
3. Analysis of Variance – ANOVA
4. Analysis of Covariance – ANCOVA
5. Apolipoprotein – B – APO-B
6. Body Image Assessment of Obesity – BIAO
7. Body Image Dissatisfaction – BID
8. Block Food Frequency Questionnaire – BFFQ
9. Bone Mineral Density – BMD
10. Body Mass Index – BMI
11. Cardiovascular Disease – CVD
12. Center for Disease Control and Prevention – CDC
13. Center for Epidemiology Scale-Depression – CES-D
14 Collaborative Institute Training Initiative – CITI
15. Community Based Participatory Research – CBPR
16. Current Body Image – CBI
17. Eating Behaviors and Chronic Condition Questionnaire – EBCCQ
18. Estrogen Replacement Therapy – ERT
19. European American – EA
20. European American Women – EAW
21. Emergency Room – ER
22. Estrogen – E2
23. Florida International University – FIU
24. Follicular Stimulating Hormone – FSH
25. Gastroesophageal Reflux Disease – GERD
26. Health Related Quality of Life – HRQOL
27. Hormone Replacement Therapy – HRT
28. Ideal Body Image – IBI
29. Kilo-Calories – K/Cal
30. Luteinizing Hormone – LH
31. Low-Density Cholesterol – LDL -C
32. Menopausal Rating Scale – MRS
33. Menopausal Transition – MT
34. Mental Health Inventory – MHI
35. National Health and Nutrition Examination Survey – NHANES
36. Obesity Reduction Black Intervention Trial – ORBIT
37. Physical Activity – PA
38. Principal Investigator – PI
39. Research Assistant – RA
40. Reasonable Body Image – RBI
41. Recommended Dietary Allowance – RDA
42. Regional Medical Centers – RMC
43. Research Question – RQ
44. Socioeconomic Status – SES
45. South Carolina – SC
46. Story’s Social Ecological Framework – SSEF
47. Unites States – U.S.
48. United States Department of Agriculture – USDA
49. United States Food and Drug Administration – USFDA
50. United States Department of Health and Human Services – USDHHS
51. Vasomotor Symptoms – VMS
In the United States (U.S.), two out of every three American adults are overweight (body mass index [BMI] between 25 and 29.9 kg/m2), obese (BMI between 30 and 39.9 kg/m2), or morbidly obese (BMI greater than 40 kg/m2), and one in every eight deaths is due to an obesity-related illness (Surgeon General, 2003). Obesity is an excess in body weight that occurs due to an imbalance between the number of kilocalories (kcal) consumed and used in activity and is influenced by behavior, environment, culture and genes (Kelemen et al., 2010; Matthews et al., 2001; U.S. Department of Health and Human Services [USDHHS], 2010). Obesity is associated with negative health outcomes such as hypertension, diabetes, asthma, sleep apnea, some cancers (i.e., colorectal, breast, endometrial), cardiovascular diseases, depression, and metabolic syndrome (Ford, Giles & Dietz, 2002; McCrary, Lin, Boushey, & Sinha 2005; Moorman et al., 2009; Waggoner, Stokes, Romero, & Casale 2008; Warren, Wilcox, Dowda, & Baruth, 2012; Zhu et al., 2005). The economic impact of obesity-related diseases has almost doubled the nation’s healthcare expenditures from $78.5 billion in 1998, to an estimated $147 billion in 2008 (Finkelstein, Trogdon, Cohen, & Dietz, 2009). Nationally, more African American women (AAW) than European American women (EAW) are obese (MMWR, 2009; Ogden & Carroll, 2010a). More than half of African American women (AAW) 20 years of age or older are obese, and the related morbidity levels are high (Freedman, 2011; MMWR, 2009; Ogden, Lamb, Carroll, & Flegal, 2010b). Data from 2005 to 2008 of the National Health and Nutrition Examination Survey (NHANES 111) supported obesity prevalence of 51% for AAW and 33% for European American women (EAW) (Freedman, 2011).
Menopausal AAW (aged 40-59) have the highest levels of obesity (62.7%) and morbid obesity (23.0%) among ethnic groups of women (Hispanic and AAW) in the U.S. (Flegal, Carroll, Kit, & Ogden, 2012; USDHHS, 2010). Few menopausal AAW have healthy weight. In the southern U.S., 1 in 10 AAW is morbidly obese (Jackson, Doescher, Jerant, & Hart, 2005; Walker-Sterling, 2005). South Carolina has one of the highest obesity rates among states in the U.S (Trust for America Health & the Robert Wood Johnson Foundation, 2009); more than 60% of all adults in South Carolina are obese or overweight (South Carolina Department of Health & Environmental Control [SCDEHC], 2011). Of these, 76% are AAs, 80% are women, and more than 40% live in rural areas (SCDEHC, 2008; CDC - Behavioral Risk Factor Surveillance System [BRFSS], 2010; Warren et al., 2012). Of the 46 counties in South Carolina, Bamberg County ranks 5th for highest adult obesity rates and 7th for poorest health outcomes. Calhoun County ranks 6th for highest adult obesity rates and 23rd for poorest health outcomes Orangeburg County ranks 6th for highest adult obesity rates and 2nd for poorest health outcomes (County Health Ranking & Road Maps, 2012).
Individual factors for increased obesity among AAW include sociocultural, biological, and demographic (Bromberger et al., 2009; Fitzgibbon et al., 2008; Jefferson et al., 2010; Kumanyika et al., 2008). Sociocultural influences on obesity among AAW include cognitive factors (i.e., perceptions body size/image, mental health, and knowledge of healthy eating) (Bromberger et al., 2009; Fitzgibbon et al., 2008; Gracia et al., 2007; Jefferson et al., 2010), and behavioral factors (i.e., choice of foods, portion size, eating habits, and food preparation techniques) (Airhihenbuwa et al., 1996; Fitzgibbon et al., 2008; James, 2004; Thompson et al., 2009), factors that are influenced by history, traditions and culture (Johnson & Broadnax, 2003). These sociocultural perceptions, practices and habits of many AAW are embraced across socioeconomic groups and influence their food choice and consumption (Patt, Yanek, Moy & Becker, 2004; Satia, Galanko, & Siega-Riz, 2004). However, they vary among AAW according to demographic factors (geographic location, and socioeconomic status [SES] - income, education, employment, and marital status) (Bramble, Cornelius, & Simpson, 2009; Henderson, 2007). Biological influences for obesity include menopausal status and increased vasomotor and depressive symptoms experienced during menopausal transition [MT] (Bromberger et al., 2009; Garcia et al., 2007). For most AAW, transition to menopause has been reported to last ten or more years which affects their health, obesity and morbidity levels (Bromberger et al., 2009; Gracia et al., 2007; Palmer et al., 2003; Pratt & Brody, 2008; Strickland, 2000). The health (BMI and obesity-related chronic health conditions) of many AAW is influenced by SES (Fitzgibbon, 2008; James, 2004; MMWR, 2009; Morland, Wing, Diez Roux, & Poole., 2002), and place of residency - (rural and urban) both of which impact obesity levels for AAW (Baltus, 2005; James, 2004; Morland et al., 2002). Kumanyika et al. (2008) and Dis (2002) reported that in the southeastern U.S., the highest rates of obesity and its related chronic conditions (physical and mental) occur among rural residents and are related to socioeconomic factors. Unknown is the impact of rurality (i.e. rural and very rural residency) on obesity among AAW. Since most obesity studies focus on obesity-related disease and occur in urban areas, more research is warranted to understand the influence of these variables on the health (BMI and obesity-related chronic health conditions) of AAW.
The purpose of this study is to describe the impact of demographic, cognitive, behavioral, and biological factors on health (BMI and obesity-related chronic health conditions) in pre-menopausal and menopausal AAW living in rural South Carolina.
The diets consumed by most AAW have been influenced by diets consumed by their ancestors (Johnson & Broadnax, 2003). These diets are high in animal fats, sugars, salt, starches and nitrates, and low in fresh fruits, vegetables, grains, and water (Airhihenbuwa et al., 1996; Brooten, Youngblut, Golembeski, Magnus, & Hannan, 2012; James, 2004; Thompson et al., 2009) which amplifies the risk for obesity and related conditions linked to increased morbidity. In addition, food preparation and cooking techniques for many AAW stem from matriarchal practices established during slavery (Airhihenbuwa, Kumanyika, Agurs, & Lowe, 1995) when AAs had to enhance the flavors for foods of poorer nutritional value by employing cooking techniques now considered “cooking with soul” (Ard, Skinner, Chen, Aickin, & Svetkey, 2005; James, 2004). The practice of cooking with soul involves cooking salted, fried, battered or barbequed meat, fish, and vegetable products, and flavoring well-cooked vegetables with animal fats (Airhihenbuwa et al., 1996; James, 2004; Jefferson et al., 2010). It is uncertain whether the practice of consuming large portion sizes stems from slavery or experiences of being economical with available resources, acting as “insurance” against hunger for many low-income AAW (Eicher-Miller, Mason, Abbott, McCabe, & Boushey, 2009; Henderson, 2007; Kumanyika et al., 2008). However, most AAW consume foods in larger portion sizes than those recommended by the U.S. Food and Drug Administration (2005), increasing caloric intake and obesity levels (Gaston, Porter, & Thomas, 2011) with a negative impact on their health outcomes (Waggoner et al., 2008).
Two major transitional periods in women’s lives are menarche and menopause. These periods are often associated with increased physical, psychological and emotional changes in women’s lives (Palmer et al., 2003; Segraves, & Woodard, 2006). African American women enter MT an average of ten years earlier than EA women (Palmer et al., 2003), are living longer than in previous decades (MMWR, 2009) and experience increased negative health outcomes (Waggoner et al., 2008). Negative health outcomes for these AAW include greater (a) fatigue (Gracia et al., 2007), (b) depression (Bromberger et al., 2009; Pratt & Brody, 2008), (c) anxiety and low self-esteem (Cohen, Soares, Vitonis, Otto, & Harlow, 2006), (d) and obesity (Nelson et al., 2008) than found in EA women. During MT, AAW also experience more hair growth, aggressive behavior, sexual dysfunctions (Avis et al., 2009a, 2009b; Im, 2009; Shelton, Lees, & Groff, 2002), and vasomotor symptoms (VMS) (Gold et al., 2006a) than women of other ethnic groups in the U.S. The experience of MT varies considerably. Some AAW regard it as a natural, time-limited experience to be endured in midlife (Huffman, Myers, Tingle, & Bond, 2005) and others perceive it as liberating (Im et al., 2009b; Im, 2009a; Lindh-Astrand, Hoffman, Hammar, & Kjellgren, 2007).
The significant increases in obesity and subsequent morbidity among menopausal AAW when compared to EA women (Bromberger et al., 2009; Cohen et al., 2006; Gracia et al., 2007) warrant research regarding perception of body size, dietary habits, menopausal symptoms, and depression among menopausal women.
Demographic factors in this study are SES and rurality. Higher morbidity generally is associated with lower SES, but among AAW, morbidity is common across all SES levels (Gold et al., 2006b). Socioeconomic factors influencing the health of AAW include levels of income, education, employment, and marital status (Glazer et al., 2002; Morland et al., 2002; James, 2004; Fitzgibbon, 2008; MMWR, 2009). Being single, a parent, head of household, and of low SES (i.e., low income, unemployed, less educated) contribute to AAW’s increased anxiety (Glazer et al., 2002), thus influencing obesity levels and health (Eicher-Miller et al., 2009; Glazer et al., 2002; Weerts & Amoran, 2011). With more AAW than EAW experiencing food insecurities (Weerts & Amoran, 2011), the diets of many low-income AAW women are of poorer diet quality (as defined by the Dietary Reference Intakes and Healthy Eating Index) than EAW (Champagne et al., 2004).
Lower socioeconomic status is strongly associated with higher BMI and research supports high obesity levels in AAW of low SES (Baltus, 2005). Current research also supports high levels of obesity occurring among middle and high-income AAW (Ogden et al., 2010b). Although findings in most studies support the contribution of demographic factors (i.e., education, income, employment, marital status and residency) to increased obesity, these variables (Fitzgibbon, 2008; Gold et al., 2006b; MMWR, 2009) have not been considered within a context of cultural and ethnic norms. Research aimed at exploring links between obesity among AAW and socioeconomic factors is essential for developing culturally appropriate programs.
More than half the AA population reside in the south and eastern regions of the U.S., (i.e., Mississippi, Louisiana, Florida, Georgia, North Carolina, South Carolina) and more than 41% of South Carolina’s population are AAs (U.S. Census Bureau, 2010). The AAW living in non-metropolitan areas of low population density (<25,000 as rural, and < 10,000 as very rural) had an increased risk for poverty (Kumanyika et al., 2008; South Carolina Budget and Control Board [SCBCB]; South Percentage Estimate of Population Urban 1950-2010 [Appendix A]; The Rural Health Report [RHR] – 2005 [Appendix B]). African American women in rural environments also reported increased food insecurity, obesity, and chronic conditions that influence their poor health outcomes across the lifespan (Strickland, 2000; Yadrick et al., 2001; Dis, 2002; Kumanyika et al., 2008). Kumanyika et al. (2008) found that higher prevalence of obesity occurs in both low and high-income AAW. In rural areas, differences in health and obesity levels were influenced, in part, by lack of resources and local poverty. In contrast, Patt et al. (2004) found that lower SES was not associated with higher BMI, and demographic factors did not affect levels of obesity, among a group of urban women.
Low SES increases barriers to the purchase of healthy food items, as many AAW living in rural areas (and less affluent urban areas) tend to purchase and eat cheaper food items that are high in calories to satiate their feast-or-famine (eating as much food as possible when it is available) eating patterns. This approach to food subsequently increases their risk for obesity (Eicher-Miller et al., 2009; Weerts & Amoran, 2011). Although women living in rural areas experience similar chronic disease outcomes to their urban counterparts, women living in rural areas have a higher rate of obesity (Appel, Harrell, & Deng, 2002; Murray et al., 2006; Eberhardt, & Pamuk, 2004; Janssen, Powell, Crawford, Lasley, & Sutton-Tyrrell, 2008). Women in rural areas also have (a) exposure to herbicides, Freon, and chemicals from the manufacturing of chemicals, plastics and medications, (b) contaminated ground water (James, Landmeyer, & Campbell, 2010; South Carolina Budget & Control Board, 2003), and (c) inadequate street lighting, pedestrian areas, and exercise facilities (Patterson et al., 2004). In contrast, those living in urban environments often experience (a) exposure to carbon dioxide and radiation, (b) lack of green space, and (c) structural decay (Lopez & Hynes, 2006; Murray et al., 2006). Unlike AAW living in some urban areas, most rural AAW experience limited food choice influenced by: (a) targeted commercial marketing of food products high in fats, sugars, and starch, (b) limited access to affordable fresh fruits and vegetables, and (c) the high cost of dietary staples (Baker, Schootman, Barnidge, & Kelly, 2006; Grier & Kumanyika, 2008). Additionally, research found that proliferation of fast food and/or low-cost restaurants, take-out facilities, vending machines, microwave ovens, and convenience and grocery stores influence obesity levels in areas populated by AAs (Hargreaves, Schlundt, & Buchowski, 2002). It is important to conduct further research in this area with AAW living in rural and very rural South Carolina because of the state’s very high obesity rate.
The lack of research on sociocultural and demographic factors influencing obesity among rural AAW is a major factor prompting the conduct of studies aimed at AAW. Most research on obesity includes urban AAW, but seldom rural AAW. Because of this, it is unclear if findings on obesity among urban AAW are applicable to AAW residing in rural areas. Although urban and rural AAW, share some similar cultural experiences such as low income and being single heads of households, the contribution of a rural environment to obesity is unknown. Specifically, it is not known whether rural, very rural, and urban AAW share similar sociocultural perceptions and behaviors for body size and images; and mental health; knowledge of healthy eating, food choice, preparation techniques, and eating habits; or experiences of menopausal transition. Research on the importance of these factors for rural AAW is needed.
Compared to EAW and urban AAW, research on obesity among rural AAW is limited (Yanek et al., 2001). Many studies are more than ten years old, report high attrition rates, and do not reflect the current state of research and delivery of healthcare (Annesi & Whitaker, 2008; Gerber et al., 2009; Kannan et al., 2010; Kumanyika et al., 2005). Although the number of obesity research studies among AAW has increased, much of this literature focuses on the influence of obesity on related health factors (i.e., asthma, cancer, depression, diabetes, hypertension, menopause, sleep apnea, and birth outcomes) with some evidence to support the negative effects of unhealthy diets and lack of physical activity (PA) on quality of life and morbidity and mortality levels in AAW (Hollis et al., 2008; Kicklighter et al., 2007; Svetkey et al., 2008). To date there are no studies exploring the influence of rurality, socioeconomic, cognitive, and behavioral factors, and menopausal symptoms on the health of AAW living in rural areas.
In summary, research is needed to understand the impact of demographic, cognitive, behavioral and biological factors on the health (BMI and obesity-related chronic health conditions) of AAW living in rural areas. The paucity of knowledge on nutritional intake, food preparation, and eating habits of rural AAW signals the need for research describing the relationship between these factors and BMI and obesity-related chronic health conditions in AAW. Information gained from this study will address this gap and provide data necessary for developing culturally appropriate interventions for assisting AAW in modifying their diets and adopting healthier eating habits. The research is necessary for stemming obesity-related chronic health conditions among AAW residing in rural areas.
The framework that guides this study is derived from Story’s Social Ecological framework (SSEF) for creating healthy food and eating environments. The SSEF posits that three micro-level factors and one macro-level factor influence dietary and behavioral patterns which affect health and nutritional status (Story, Kaphingst, Robinson-O’Brien, & Glanz, 2008). The three micro-level factors are individual, social, and physical, while the one macro-level factor is the environment. Individual micro-level influences in the proposed study are defined as those factors which relate to (a) behaviors - food choices, food preparation techniques, portion size, and eating habits, (b) cognition – perceptions of body image/size, mental health, and knowledge of healthy eating, (c) biological – menopausal symptoms, and (d) demographic – SES, and rurality. These factors are expected to influence behaviors that have an impact on dietary intake. Second is the social factor, which connects AAW to their environment (i.e., family and community) through social norms that influence individual perceptions and actions. Third is the physical-environmental factor, which refers to the places where people eat or procure food, live or exercise, and their associated living contexts (i.e., home, work sites, shops, and schools) which act as barriers that hinder or opportunities to facilitate healthy eating. Finally, at the macro or distal environmental level are factors that indirectly influence dietary intake and thus have an impact on obesity levels. These include food production, marketing and promotion; distribution systems; economic price structures; and agriculture policies (Story et al., 2008).
The proposed study will focus on the relationships between individual demographic, cognitive, behavioral, and biological factors that influence the health (BMI and obesity-related chronic health conditions) of menopausal and premenopausal AAW residing in non-metropolitan rural and very rural environments.
Individual Cognitive factors hypothesized to directly and indirectly influence the health of AAW include perceptions of body image/size, mental health status, and knowledge related to healthy eating. African American women are reported to underestimate their body size and consider larger body sizes as more culturally acceptable. Thus, many AAW favor larger and fleshier bodies (Kumanyika et al., 2008; Parescoli, 2007; Thomas et al., 2009). Additionally, AAW report increased psychological distress and depression influenced by family responsibilities and knowledge of healthy eating (Bromberger et al., 2009; Jefferson et al., 2010; Kim et al., 2009; Palmer et al., 2003).
Individual Behavioral factors posited to directly affect the health of AAW include food choices, portion size, preparation techniques, and eating habits. Food choices influence the types and frequency of foods eaten - including traditional foods high in fats, sugar, salts, and starch, and low in fruits and vegetables. Increased consumption of foods prepared outside the home (i.e., fried chicken, Mexican, Chinese, and fried fish (Krishnan et al., 2010) and eating at fast foods restaurants (Satia et al., 2004) al., 2002) influence the health of AAW.
Many AAW consume large portion sizes of foods and prefer high fat, salted, and cured meats. Common AAW’s food preparation techniques include the use of salt-based seasoning, coating meats and vegetables in flour and/or batter, frying and barbecuing foods, and boiling vegetables with animal fat until soft (Jefferson et al., 2010; Krishnan et al., 2010).
Eating habits of many AAW are influenced by – types and frequency of foods eaten, age, demographic locations, convenience, health concerns, and appetite (Deitz, 2001; Thompson, et al., 2009). Eating habits include consuming three meals a day, eating a full plate, eating meat at every meal, snacking between meals, missing meals, emotional eating, and eating food they considered unhealthy (high in fats, sugar, salts, and starch, and low in fruits and vegetables) throughout the day (Hargreaves et al., 2002; James, 2004).
The Individual Biological factors hypothesized to have a direct and indirect effect on health of midlife AAW is the level of menopausal symptoms (i.e., vasomotor symptoms, anxiety level, depressive mood, irritability, and exhaustion).
Individual Demographics factors hypothesized to directly and indirectly influence the health of AAW include education, employment, income, marital status, and rurality. These factors have an impact on the types of foods eaten and preparation techniques used among AAW, and levels of dietary knowledge which have an impact on AAW’s ability to choose, purchase, and consume healthy food items. Demographic factors are believed to affect AAW’s health and increase morbidity. A number of studies have explored the eating habits and dietary intake of AAW, but most are conducted in urban areas and none have compared these variables in ‘rural’ and ‘very rural’ AAW. Story’s micro-level individual factors provide a framework for the relationships of specific demographic, cognitive, behavioral, and biological factors on the health of rural and very rural AAW.
The independent variables represented by each of Story’s four factors are (a) cognitive – perceptions of body image/size, mental health, and knowledge of healthy eating, (b) behavioral – food choices, preparation techniques, portion size, and eating habits, (c) biological – symptoms of menopause, and (d) demographic – education, income, employment, marital status, and rurality. The outcome variable is the health (BMI and obesity-related chronic health conditions) of menopausal and premenopausal AAW.
Among rural and very rural AAW:
1. Are there main and interaction effects of menopausal status (pre-menopausal vs. menopausal) and rural status (rural vs. very rural) on cognitive factors, behavioral factors, and health outcomes (BMI, and obesity-related chronic health conditions)?
2. Are health outcomes (BMI, and obesity-related chronic health conditions) related to cognitive factors and behavioral factors?
3. Do these relationships remain when socioeconomic factors are controlled?
The magnitude and associated costs of addressing obesity-related chronic conditions in the U.S. continue to mount and will increasingly impact the nations’ economy (Karp, 2007; Lewis, 2009; Owens, Lukes, & Umland, 2008). The obesity problem is particularly important for AAW who are reported to have the highest adjusted rates of obesity and morbidity compared with other major ethnic groups (Brown, 2009; Flegal et al., 2012; Moore, Harris, & Wimberley, 2010). Significant increases in obesity levels influence chronic disease levels in menopausal age AAW and will impact their future need for care services with their increasing age (Bittner, 2009; McCarthy et al., 2007; Utian, 2005; Yancy, Benjamin, Fabunmi, & Bonow, 2005). This review of the literature was conducted to explore whether cultural factors such as dietary habits, food preference, and preparation techniques were factors reported to influence obesity levels in AAW. African American women’s cultural beliefs concerning sexuality and weight gain with regard to childbirth, marriage, and increasing age are also explored as are the menopausal experiences reported by AAW; these are compared to those of women from diverse ethnicities in order to ascertain the influence of MT on the health of AAW. It was hypothesized that AAW’s socioeconomic status and residence in rural and very rural areas where there is less access to facilities for PA and good quality nutrition (fresh fruits and vegetables), but increased access to cheap prepared foods may all be factors influencing dietary intake and levels of obesity.
The review of the AAW and obesity literature included articles published between January, 1990 and November, 2012 from refereed nursing, social science, allied health journals and books; these were searched through databases including CDC WONDER, CINAHL, EBSCO, MEDLINE, MERLIN, OVID, PsycINFO, PUBMED Central, and PROQUEST. Investigated were English language studies in which AAs and black participants were women. Keywords used in the search singularly or in combination were: culture, climacteric, depression, dieting, dietary modification, nutrition, eating, exercise, food habits, menopause, menopause transition, midlife, perceptions, perimenopause, obesity, obese, overweight, PA, rural, social, economic, urban, social, interventions and tested. Qualitative and quantitative research in which obese AAW participated was investigated. Additional searches of these databases were conducted to identify the presence of conceptual and theoretical frameworks used in obesity research and practice among AAW. Hard copies and electronic versions of tables of contents for obesity, cultural eating habits, and menopause were scanned from relevant articles. Additional literature sources were obtained by reviewing the literature cited in the reference lists of relevant articles for understanding obesity, culture, eating habits, and menopause in AAW.
Although the literature related to obesity is extensive and more research is being conducted among AAW, research among rural and very rural AAW remains sparse. The relationships between health (BMI and obesity-related chronic health conditions), and the role played in these relationships by socioeconomic, cognitive and demographic factors among this segment of the AA population is the focus of this chapter. The review begins with discussion of the nature of obesity in AAW, followed by research relevant to the variables presented in this study’s conceptual framework. The dependent variable is health (BMI, and obesity-related chronic health conditions), with particular emphasis on menopausal status; SES as indicated by income, education, employment, and marital status; the impact of cognitive variables on obesity including perceptions of the body, mental health status, and knowledge of healthy eating; the role of behavioral variables including food choice, portion size, eating habits and food preparation habits, and finally, the impact of rurality on health. Research on the influence of each independent variable on the health of AAW is reviewed in the context of discussion of these variables.
Obesity is described in western culture as excess body weight, which occurs because of an imbalance between inactivity and number of K/Cal consumed (Ogden, Carroll, McDowell, & Flegal, 2007; Surgeon General, 2003). The BMI is a standard index of weight adjusted for the height of an individual. Obesity and extreme obesity are defined as a BMI greater than or equal to 30 and 40 respectively, overweight as a BMI between 25-29.9, and normal weight as a BMI between 18-24.9 (Ogden & Carroll, 2010a; USDHHS, 2010). Body mass index is not gender specific, and does not measure percentile body-fat or allow for ethnic or age differences in body size (National Institute of Health, 1998).
African American women, however, often negate BMI’s usefulness for measuring overweight and obesity (Brown, 2009). Findings in a number of studies support AAW’s perception of BMI as an inaccurate representation of AAW’s weight and body size (Bramble et al., Cornelius & Simpson, 2009; Moore et al., 2010). Stevens, Cai and Jones (2002) explored whether the BMI cutoff point of 30 kg/m2, used to determine associated health-risk in EAW, was valid for AAW. They suggested that the BMI cutoff points for associated health risks differed among ethnic groups, and variations in BMI cutoffs were dependent on estimated risk and outcome for each condition (e.g. diabetes, hypertension, and hypertriglyceremia). However, Muennig, Jia, Lee and Lubetkin (2008) reported that mortality rates increased for AAW at BMI’s ≥30kg/m2, and at BMI ≥25kg/m2 for EAW. These findings indicate the need for additional research to determine the relevance of BMI for assessing obesity levels and determining risk factors among AAW.
More than half of AAW aged 20 years or older are obese (Freedman, 2011; MMWR, 2009; Ogden & Carroll, 2010a; Santoro et al., 2004). Furthermore, more obese AAW reside in the southern U.S. (Baturka, Hornsby, & Schorling, 2000) where one in 10 midlife AAW is morbidly obese (Walker-Sterling, 2005). Among AAW, obesity increases with age and life transitions such as parity and menopause, and has been linked to increased menstrual cycle length, fibroids, depression and cancers (Beydoun et al., 2009; Freeman et al., 2001; Gracia, et al., 2007; Santoro et al., 2004; Report of the Advisory Committee on Research on Women’s Health, 2001-2002; Wilbur et al., 2009). Most obese persons experience increased variability in biological marker levels for cholesterol, glucose and bone density indices that impact diabetes, CVD, activity, and morbidity levels (CDC, 2009a; Patt et al., 2004; Segraves & Woodard, 2006; Sowers et al., 2007). These negative outcomes are also implicated by changes in cardiovascular, respiratory, and endocrine disease that have an impact on levels of morbidity and mortality among AAW (American Heart Association [AHA], 2004; Kumanyika et al., 2008; Tilghman, 2003; Williams, 2009).
Although osteoporosis and its related mortality are low among AAW (Castro et al 2005; Pothiwala, Evans, & Chapman-Novakofski, 2006), Castro et al. (2005) reported that among an ethnically diverse group of obese women (mean BMI of 30.6 kg/m2), mean age 58.3 ± 0.24 years, AAW had significantly higher odds of low-density mineral levels (BMD) compared to EAW [OR 1.015 (1.007–1.14) for every unit increase in BMI ≥ 30kg/m2 (Castro et al., 2005). These findings suggest that age and obesity effect levels of BMD among AAW.
In addition to biological changes, a cross-sectional study by Bromberger et al. (2009) reported a significant prevalence of obesity and depression among diverse groups of menopausal AAW while other studies suggest that because AAW suffer more psychological mood change, distress, anxiety and low self-esteem across their life span, their risk for new onset depression is increased (Bromberger et al., 2009; Marsh, Templeton, Ketter, & Rasgon, 2008; Kowaleski-Jones & Christie-Mizell, 2010). A possible explanation for the link between distress and increased obesity was suggested by Wiczinski et al. (2009), who argued that psychological (dis)stress results from the stigma of being overweight and the inability to lose weight, while the material stress – stress to the skeletal system caused from carrying around excess body fat - resulted in chronic physiological stress which may influence mobility.
Factors attributed to increased obesity among AAW include unhealthy eating habits (Thompson, et al., 2009), educational and nutritional deficits, and lack of exercise (Fitzgibbon et al., 2008). Substance abuse, medication use, metabolic imbalances (CDC, 2009a; 2009b), and depression (Beydoun et al., 2009) play a role. These factors affect rural and very rural AAW’s functional and health status by lowering their PA levels (Harley et al., 2009) thus increasing their risk of obesity. Other factors contributing to obesity among AAW include (a) increased body weight perceived as a healthy part of menopause and aging (Stevens, Kumanyika & Keil, 1994), (b) the perception that the BMI is not representative of AAW’s body weight (Brown, 2009), and (c) traditional AA diet high in fats, starches, salt and sugars (Jefferson et al., 2010). Additionally, Dammann and Smith (2009) suggested that a lack of understanding and disconnect between diet and health [status] has led to increased incidence and prevalence of obesity among low-income groups - a problem common in rural AAW. Nelson (2009) suggested that AAs did not connect present behaviors to the prediction of future consequences, and these issues could be a contributing factor to high obesity rates among AAW who lack “future time perspective” (p. 2). This may help to explain the seeming disconnect between obesity and negative health outcomes, and the lack of awareness of links between diet, health and obesity reported in AAW by some researchers (Dammann & Smith, 2009; Dore, Yarborough, & Fournet, 2001; Moore et al., 2010).
These findings suggest that research on the possible link between cognitive factors such as perception of body size/weight and behavioral variables such as food habits is warranted to (a) increase understanding among nurses and other health care providers, (b) assist AAW in modifying and valuing healthier lifestyles, and (c) reverse the current trend of increasing levels of obesity which are linked to increasing morbidity for AAW (Beydoun et al., 2009). In the following section the role of biological factors pertaining to menopause are considered in order to identify the interactions between these and the cognitive and behavioral factors that are associated with negative health outcomes.
Menopause signals permanent cessation of all ovarian activities and is considered the culmination of the transition from fertility to infertility. Menopausal transition is the process that describes that journey. The journey is hallmarked by erratic menstrual cycles and is the “period that begins when a woman experiences variations in the menstrual cycle length, rise in Follicular Stimulating Hormone [FSH] and decline in Estrogen E2] and ends with the final menstrual period” (Soules et al., 2001, p.876). The three phases of MT are defined as (1) premenopausal (regular menses), (2) perimenopausal (increasingly irregular menses for more than seven days from their normal cycle, and periods of amenorrhea), and (3) postmenopausal (amenorrhea for 12 consecutive months) (Soules et al., 2001).
The menopausal period is one of major transitions in the lives of women (Huffman et al., 2005; Rice, 2005) and is associated with physical, psychological and emotional changes (Palmer et al., 2003; Pinkerton, & Zion, 2006; Segraves & Woodard, 2006). During the next 5 to 10 years, it is estimated that around 21 million women will experience menopause, of which 3.5 million will be AAW (Rice, 2005; Strickland, 2000). Negative changes in hormonal and biological markers during MT are linked to an increased risk of cardiovascular disease (Matthews et al., 2009; Sowers et al., 2005), CVD, osteoporosis, and breast cancer (Matthews et al., 2009; Sowers et al., 2006; Underwood, Richards, Bradley, & Robertson, 2008; Zhu et al., 2005). For AAW other risk factors during MT include nutritional habits, physical inactivity, and increased BMI, all of which influence depression levels (Avis et al., 2001; Bromberger et al., 2009; Nelson et al., 2008). Additionally, differences in cultural attitudes and beliefs about transition to menopause affect AAW’s perceptions and management of their menopausal experience (Im et al., 2009; Nixon, 1998; Nixon, Mansfield, Kittell & Faulkner, 2001; Sampselle, Harris, Harlow & Sowers, 2002; Strickland, 2000).
Research supports differences and commonalities among racial and ethnic groups in the onset of MT (Rousseau, & Gottlieb, 2004) that are affected by genetic, environmental, cultural and nutritional factors (Al-Qutob, 2001; Pinkerton, & Zion, 2006). The median age of onset to MT varies from 49.6 to 51 years for most American women across ethnic groups (Grady, 2006; Fantry et al., 2005; Palmer et al., 2003), and lasts approximately four years (Landgren et al., 2004).
Reports link early MT among AAW to depression, smoking and socioeconomic factors (Bromberger et al., 2007; Greenberg, Leongand, & Birnbaum, 2001; Wise, Krieger, Zierler, & Harlow, 2002). A number of studies indicate variations in the onset and length of time that AAW spend transitioning to menopause (Gary, Yarandi & Rivers, 2001; Palmer et al., 2003). Research has also found that AAW spend a longer period in this transition than women of all other ethnic groups living in the U.S. Results from Palmer et al. (2003) cross-sectional study of 17,070 AAW aged 35 to 55 years, to determine the age of natural menopause, suggested that earlier onset to MT occurred among non-obese AAW who smoked cigarettes and used contraceptives. The study also indicated that AAW enter MT between the ages of 40 and 54 years and experience erratic menstrual cycles 2 to 10 years prior to cessation of menstruation (Palmer et al., 2003). Strickland (2000), in an earlier study, has described these variations in menstrual cycle as occurring in AAW around the ages of 42 to 54 years while Gary et al. (2001), reported that in a sample of 206 women in the southern U.S., transition to menopause occurred between the ages of 40 and 60 years. These findings suggest that MT spans 10 or more years and occurs later in non-smoking and obese AAW, much longer than Landgren and associates’ (2004) findings that MT lasts approximately four years among women across all ethnic groups in the U.S.
Research finds differences in women’s cultural perceptions, attitudes, and beliefs about the transition to menopause (Dillaway, Byrnes, Miller, & Rehan, 2008; Huffman et al., 2005; Sharps, Oguntimalide, Saling & Yun, 2003; Im et al., 2009b; Lindh-Astrand et al., 2007). Familial and cultural practices (dietary, lifestyle, and social practices) that are generational and vary across and within cultures, influence women’s’ beliefs, attitudes, and habits (Jefferson et al., 2010). African and Asian American women, unlike EAW, believed the journey to menopause increased their acceptance of physiological change occurring in MT and aging (Sampselle et al., 2002). Whereas, EAW consider MT a harbinger of old age (Sampselle et al., 2002) that must be fought in order to maintain their identities, youth, levels of beauty (Dinnerstein, & Weitz, 1998) and community respect. African and Asian American women reported increased levels of familial and community respect, and Asian American women reported increasing honor attached to MT (Sommer et al., 1999; Im & Meleis, 1999)
African American women’s attitudes and beliefs about MT affect their perception of menopause and influence their ability to successfully transition to menopause. Findings from Nixon’s (1998) study exploring the perceptions of 50 midlife AAW, and Huffman and associates’ (2005) study exploring menopausal symptoms and attitudes of 226 AAW suggest that AAW considered transition to menopause as a natural, time-limited midlife transition that must be endured. Nixon (1998) reported that some AAW believed in “enduring it” (p.168) and “staying strong” (p.167) while getting through MT; others believed they were losing their minds. African American women believed that their MT journey experiences increase their acceptance of physiological and psychological changes occurring during MT and aging (Sampselle et al., 2002). However, although AAW during MT reported increased levels of familial and community respect (Sommer et al., 1999), they also described themselves as not feeling like a woman during the menopausal phase (Huffman et al., 2005).
To cope with MT changes, most women in Nixon’s study reported relying on friends, spiritual beliefs and the use of natural remedies to combat MT symptoms. A subsequent study by Nixon et al. (2001), among 44 rural AAW, indicated that demanding familial responsibilities forced many women to ignore their menopausal symptoms and internalize their health-related needs by “staying strong” (p.87) during MT. In contrast, findings from the study by Sampselle et al. (2002), among 30 AA and EAW, which explored midlife development and perception of menopause, concluded that AAW welcomed menopause and considered it liberation from the fears of pregnancy and monthly menstrual cycles. The perception of being liberated from menstrual cycles and childbearing is a common belief among women worldwide (Im et al., 2009a; Im, 2009b; Lindh-Astrand et al., 2007).
These studies illustrate the dynamic relationship between societal belief and women’s values regarding the experience of menopause. Lacking are studies aimed at clarifying inconsistencies of how the role of families and communities affect AAW’s perceptions of what constitutes a ‘real’ woman, childbearing and sexual functioning, and the extent of familial support during MT. Qualitative studies exploring the role of cultural beliefs about aging, beauty, and management of MT are needed to determine how these factors affect AAW’s self-perception, quality of life and morbidity rates.
Increased serum cholesterol levels and BMI are age-related physiological markers in AAW (Freeman et al., 2001; Yancy et al., 2005) that appear linked to variability in hormones responsible for transition to menopause (Freeman et al., 2001; Guthrie et al., 2004). These hormonal changes are also reported to increase women’s total and low-density cholesterol (LDL-C), Apolipoprotein B [Apo-B] levels, and the risk of coronary heart disease (Bittner, 2009) and stroke in AAW (Rosenberg, Palmer, Rao, & Adams-Campbell, 1999).
The literature provides conflicting information linking stroke and metabolic syndrome in women to variability in FSH, inhibin (A, B) ratio, and testosterone during menopausal transition (Janssen et al., 2008; Landgren et al., 2004). Reported incidences and prevalence of metabolic syndrome in AAW is low, and very little research exists exploring these links (Ford et al., 2002). Findings, in Kirkendoll et al.’s (2010) focus group of 30 AAW found that AAW experience increased levels of dyslipidemia, BMI, blood pressure and glucose that are all major components of metabolic syndrome. Negative changes in biological markers are also linked to decreased physical activity levels that predispose AAW to additional risks for CVD, strokes, diabetes and hence higher morbidity levels (Beydoun et al., 2009; Bromberger, Harlow, Avis, Howard, & Cordal, 2004; Budoff et al., 2006; Kirkendoll et al., 2010; Williams, 2009).
Increased risk factors for osteoporosis occur in the postmenopausal phase for AAW and are linked to biological markers for BMI and serum cholesterol levels (Sowers et al., 2005; 2007). Deterioration of bone micro-architecture is measured by BMD levels and is used to measure biological markers for osteoporosis and fractures of the lower extremities during menopause and aging (Bohannon, 1999). Research has found that AAW have lower levels of serum calcium, Vitamin D (Pothiwala et al., 2006), cholesterol, and higher BMD levels during pre-and post-menopause (Sowers et al., 2006; Rousseau, & McCool, 1997; Zeigler-Johnson et al., 1998). However, Bohannon (1999) found that although AAW began menopause with high BMD levels these rapidly decline during the postmenopausal phase and result in increased risk of osteoporosis. Findings from Castro and associates’ (2005) retrospective study examining BMD levels among a multi-ethnic sample of 3,206 postmenopausal women, aged 50 years and older, indicated that AAW’s BMD levels decreased with each unit increase in BMI. The compound effects of increased BMI in AAW (Santoro et al., 2004; Zhu et al., 2005) and declining BMD are increased risk factors for osteoporosis and fractures in obese postmenopausal AAW (Castro et al., 2005). There studies suggest that menopausal AAW’s hormonal changes increase their cholesterol and BMI levels, and lower vitamin and mineral levels and place them at increased risk for CVD, strokes, osteoporosis, and metabolic syndrome.
Harley and associates (2009) reported that changes in these biological markers affect AAW’s functional and health status by lowering their levels of PA. Inactivity is reported to increase AAW’s risk for obesity, and depression (Segraves & Woodard, 2006; Avis et al., 2005); hypertension and diabetes (AHA, 2004; Appel et al., 2002; Go et al., 2013); and metabolic syndrome (Kirkendoll et al., 2010). Lacking are studies among larger samples of AAW aimed at exploring the association among changes in biological markers (i.e., BMI, serum cholesterol), inactivity and dietary practices.
Increased physiologic and psychosocial changes in women’s lives are correlated with increased risk and variability in levels of depression during each phase of MT (Bromberger et al., 2004, 2009, 2011; Avis et al., 2005; Fugate et al., 2008; Van de Velde, Bracke, & Levecque, 2010). The decline in E2, variability in cortisol levels, and increase in FSH and testosterone levels are linked to increased depression during MT (Avis et al., 2005; Bromberger et al., 2011; Freeman, Sammel, Lin, & Nelson, 2006; Fugate et al., 2008; Gold et al., 2006a). In AAW, variability in these hormone levels are linked to increased anxiety, and irritability and low self-esteem (Cohen et al., 2006; Gracia et al., 2007).
Among the major ethnic groups in the U. S., AAW experience high levels of depressive disorders (Bromberger et al., 2004). Findings in the (2001) study by Avis et al. suggest that AAW experience increased levels of depressive symptoms (mood), but lower levels of psychosomatic disorders. The reported differences in levels and types of depression experienced by women during MT suggest the need for more research focused on links between sociocultural factors, psychological distress and increased depressive mood states in AAW.
Fugate et al. (2008) and Marsh et al. (2008) suggested that increased VMS in the late MT phases was associated with the prevalence of depression among AAW. In Fugate’s (2008) longitudinal, multi-ethnic study of 506 women (AA = 302), urine estrone glucuronide, FSH, testosterone, and cortisol levels, menstrual calendars, and the Center for Epidemiology Scale-Depression (CES-D) scale were measured to determine the relationship between depression and MT among a subset of AAW. Results from this analysis indicated that depression increased with age, and more depressed mood occurred during the late MT stage; these depressive changes were related to VMS. In a similar longitudinal study, examining depression in a multi-ethnic sample of 3,302 women aged 42 to-52 years, Bromberger et al. (2007) concluded that women were more likely to experience depression during early and late perimenopause and post-menopause phases of transition or when using HRT/ERT. These findings suggest a relationship between depression and MT and indicate variability in symptom occurrence, types, and levels of depression during the early and late menopausal phase that merit further investigation among AAW.
Most menopausal women experience sexual dysfunction and decreased libido attributed to variability in E2 and changes in ratios of FSH and testosterone (Avis et al., 2005, 2009a). However, Avis and associates’ (2009a) study found that AAW considered sex very important and engaged in more vaginal sex for pleasure and to relieve tension than women of other ethnicities during MT. Findings in a number of studies support a high percentage of AAW reporting single status or not having a partner (Avis et al., 2009a; Cain, et al., 2003). The findings suggested that sociocultural and demographic variables (that include single status) may affect levels of stress in women across ethnic groups.
Research Paper (postgraduate), 10 Pages
Seminar Paper, 21 Pages
Master's Thesis, 84 Pages
Master's Thesis, 65 Pages
Bachelor Thesis, 58 Pages
Doctoral Thesis / Dissertation, 31 Pages
Research Paper (undergraduate), 28 Pages
Master's Thesis, 99 Pages
Bachelor Thesis, 77 Pages
Bachelor Thesis, 45 Pages
Research Paper (undergraduate), 15 Pages
Research Paper (postgraduate), 10 Pages
Seminar Paper, 21 Pages
Master's Thesis, 84 Pages
Master's Thesis, 65 Pages
Bachelor Thesis, 58 Pages
Doctoral Thesis / Dissertation, 31 Pages
Research Paper (undergraduate), 28 Pages
Master's Thesis, 99 Pages
Bachelor Thesis, 77 Pages
Bachelor Thesis, 45 Pages
Research Paper (undergraduate), 15 Pages
GRIN Publishing, located in Munich, Germany, has specialized since its foundation in 1998 in the publication of academic ebooks and books. The publishing website GRIN.com offer students, graduates and university professors the ideal platform for the presentation of scientific papers, such as research projects, theses, dissertations, and academic essays to a wide audience.
Free Publication of your term paper, essay, interpretation, bachelor's thesis, master's thesis, dissertation or textbook - upload now!