Doctoral Thesis / Dissertation, 2014, 223 Pages
Doctoral Thesis / Dissertation
Factors Influencing Obesity
Story’s Social Ecological Framework
Individual Factors Influencing Obesity and Health in Midlife AAW
II LITERATURE REVIEW
Obesity and Health
Biological Factors: Menopausal Status
Onset and Timing of Menopausal Transition
Perceptions of Menopausal Transition
Psychological Wellbeing and HealthRelated Quality of Life
Socioeconomic Factors and Menopausal Transition
Socioeconomic Factors and Obesity
Cultural Perceptions of Obesity and African American Women
African American Women’s Perceptions of Obesity,
Body Size and Image
Dietary Habits &Nutritional Factors
Nutrition and Food Preparation
Demographic Factors 51 Rurality and Health Status
The Rural Environment
Interventions in Rural Communities
III RESEARCH DESIGN AND METHODS
Research Question 2
Research Question 3 64 Procedure
Data Collection66 Major Study Variables
Behavioral Factors 72 Demographic Variables
Descriptive Findings on Sample
Descriptive Findings on Dependent Variables
Descriptive Findings on Independent Variables
Descriptive Findings on Cognitive Factors
Descriptive Findings on Behavioral Factors
Research Question 2
Body Mass Index
Obesity Related Chronic Health Conditions
Discussion of the Findings
Limitations of the Study
Implications of the Study for Nursing
Implication of the Study for Research
LIST OF REFERENCES
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 ObesityRelated Chronic
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. Twoway 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 ObesityRelated 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 APOB
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 ScaleDepression CESD
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. KiloCalories K/Cal
30. Luteinizing Hormone LH
31. LowDensity 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
I dedicate this dissertation to my husband Charles Kilgore. In the face of adversities your love, trust, patience support, and stubborn insistence made possible the completion of this work. I also dedicate this dissertation to my children Gary Beharie, Karensa Harris, Nicole Browne, Darien Browne, and CharlesJulius as a reminder that learning is a lifelong endeavor.
Bestowing honor to the name of my late father Roy Augustus Beharie.
I give thanks and praises to Jehovah for grace and mercies, my health and strength, my peace and clarity of mind. Also, I would like to express my gratitude to all the people who have aided and uplifted me through this my final academic journey. This dissertation would not have reached completion without the expert guidance of my chair, Dr. JoAnne Youngblut, who took me under her wings when I was left to fly solo. I’m very grateful for her expertise in family health and diverse populations, research methods, and statistics. Dr. Youngblut’s mentorship and patience, through numerous edits transformed my writing skills. It has been an honor and a privilege to take this journey with you at my side.
I wouldlike to thank my committee members: Dr. Dorothy Brooten for her gentle encouragement, expertise in health care services, and knowledge of university systems; Dr. Luz Porter for her expertise in ‘cultural’ research, and for always being available to listen as well as offer guidance from first meeting at the National Coalition of Ethnic Minority Nurse Associations conference;last (but not least) Dr. Marcia Magnus, for her soulful encouragement and guidance as well as her expertise in nutrition and African American health care.
Special thanks to my peers in the doctoral nursing program who supported and encouraged me. My deepest gratitude to Dr. Carmen Caicedo my classmate and friend who have been extremely supportive and helpful. Carmen, I could not have navigated the university systems without your arms and legs. I will always be grateful for your gentle and sincere assistance. Lynn Seagraves you are invaluable to this program, a rock unmoved by the turbulent ebbs and flow of FIU. I thank you for all your help. To my research assistants, Mrs. Vernetta Fredericks and Mrs. Yewande Afolabi, thank you for your time and patience; for journeying into rural South Carolina and never complaining when our subjects failed to keep their appointment and gave us false telephone numbers.
My love and gratitude to my mother, Mrs. Peggy Beharie, my brothers David, Joel, and Robert, and my sister Audrey (in USA and England) for their love and support.
To my prayer worriers, Mr. and Mrs. Yomi and Shola Okanlowan, and Mrs. Dupe Adebayo, thank you for your never ending prayers and unwavering belief. My extended family: Mrs. Lubertha Russell, Lucy GriderBradley, and Maxine O’Brien; Mr. Theo Dunnaville; Dr. Barbara Holder, Mrs. Marge Snipes, and Dr. Ann Morris; Dr. Gregory Singleton, and Dr. Dwayne and Mrs. Celeste Duckett I thank you for your assistance and endless words of support.
Again, I’m in debt to my husband for his unselfish and quiet support, which included his courage to live without me for two years while I was away studying in Florida, you are awesome. Finally, thanks to all the health care organizations that allowed me access for recruitment: The Regional Medical Centers, Family Health Centers, Inc. Cornerstone Community church, and New Mount Zion Baptist church in Orangeburg; Mount Carmel Baptist church in St. Matthew; Drs. Padgett, and McAlhaney in Bamberg; and Dr. Singleton in Orangeburg, South Carolina.
Abbildung in dieser Leseprobe nicht enthaltenfried foods1 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 normalweight 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.
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 obesityrelated 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 obesityrelated 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 prevalenceof 51% for AAW and 33% for European American women (EAW) (Freedman, 2011).
Menopausal AAW (aged 4059) 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; WalkerSterling, 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, & SiegaRiz, 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 obesityrelated 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 obesityrelated disease and occur in urban areas, more research is warranted to understand the influence of these variables on the health (BMI and obesityrelated 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 obesityrelated chronic health conditions) in premenopausal 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 wellcooked 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 lowincome AAW (EicherMiller, 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 selfesteem (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, timelimited experience to be endured in midlife (Huffman, Myers, Tingle, & Bond, 2005) and others perceive it as liberating (Im et al., 2009b; Im, 2009a; LindhAstrand, 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 (EicherMiller 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 lowincome 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 highincome 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 nonmetropolitan 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 19502010 [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 highincome 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 feastorfamine (eating as much food as possible when it is available) eating patterns. This approach to food subsequently increases their risk for obesity (EicherMiller 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, & SuttonTyrrell, 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 lowcost restaurants, takeout 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 obesityrelated 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 obesityrelated 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 obesityrelated 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 microlevel factors and one macrolevel factor influence dietary and behavioral patterns which affect health and nutritional status (Story, Kaphingst, RobinsonO’Brien, & Glanz, 2008). The three microlevel factors are individual, social, and physical, while the one macrolevel factor is the environment. Individual microlevel 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 physicalenvironmental 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).
Abbildung in dieser Leseprobe nicht enthalten
The proposed study will focus on the relationships between individual demographic, cognitive, behavioral, and biological factors that influence the health (BMI and obesityrelated chronic health conditions) of menopausal and premenopausal AAW residing in nonmetropolitan 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 saltbased 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 microlevel 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 obesityrelated chronic health conditions) of menopausal and premenopausal AAW.
Among rural and very rural AAW:
1. Are there main and interaction effects of menopausal status (premenopausal vs. menopausal) and rural status (rural vs. very rural) on cognitive factors, behavioral factors, and health outcomes (BMI, and obesityrelated chronic health conditions)?
2. Are health outcomes (BMI, and obesityrelated 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 obesityrelated 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 obesityrelated 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 obesityrelated 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 2529.9, and normal weight as a BMI between 1824.9 (Ogden & Carroll, 2010a; USDHHS, 2010). Body mass index is not gender specific, and does not measure percentile bodyfat 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 healthrisk 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 (WalkerSterling, 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, 20012002; 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, & ChapmanNovakofski, 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 lowdensity 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 crosssectional 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 selfesteem across their life span, their risk for new onset depression is increased (Bromberger et al., 2009; Marsh, Templeton, Ketter, & Rasgon, 2008; KowaleskiJones & ChristieMizell, 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 lowincome 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 (AlQutob, 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), andlasts 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) crosssectional 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 nonobese 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 nonsmoking 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; LindhAstrand 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, timelimited 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 healthrelated 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; LindhAstrand 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 selfperception, quality of life and morbidity rates.
Increased serum cholesterol levels and BMI are agerelated 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 lowdensity cholesterol (LDLC), Apolipoprotein B [ApoB] levels, and the risk of coronary heart disease (Bittner, 2009) and stroke in AAW (Rosenberg, Palmer, Rao, &AdamsCampbell, 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 microarchitecture 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 preand postmenopause (Sowers et al., 2006; Rousseau, & McCool, 1997; ZeiglerJohnson 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 multiethnic 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 selfesteem (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, multiethnic study of 506 women (AA = 302), urine estrone glucuronide, FSH, testosterone, and cortisol levels, menstrual calendars, and the Center for Epidemiology ScaleDepression (CESD) 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 multiethnic sample of 3,302 women aged 42 to52 years, Bromberger et al. (2007) concluded that women were more likely to experience depression during early and late perimenopause and postmenopause 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.
African American women make up 13.1% of all women in the U.S., and are living longer than in previous decades (MMWR, 2009). However, they also experience obesityrelated chronic health conditions that contribute to some of the highest mortality rates in the U.S. (Freedman, 2011; Waggoner et al., 2008). The increased morbidity reported among AAW decreases their healthrelated quality of life (HRQOL) (Angel & Angel, 2006; Freedman, 2002), and increases healthcare costs during MT and aging (Karp, 2007; Lewis, 2009; Owens et al., 2008; Utian, 2005).
Inconsistencies exist concerning the effects of physical, psychosocial, and demographic factors on HRQOL in women experiencing MT (Avis et al., 2005, 2009; Freedman, 2002; Gallicchio, Miller, Zacur, & Flaws, 2009; Gracia et al., 2007). Generalization of HRQOL experiences across racial and ethnic groups of women is difficult given women’s unique social, economic, and physical experience. A number of studies found that women experience (psychosocial) adjustments to major and life changing events during MT such as (a) empty nest syndrome, divorce or being singlehead of household; (b) career change, job loss or retirement, and (c) parenting of grandchildren or caring for elderly parents, that can all affect women’s quality of life (Avis et al., 2009b; Gold et al., 2000; Sommer et al., 1999). The addition of these lifeadjustments to psychophysiologic and hormonal changes increases the risks for depression, CVD, sexual dysfunction, and menopausal symptoms (Avis et al., 2005; Gracia et al., 2007; Randolph et al., 2003) that can dramatically affect AAW’s HRQOL and health outcomes.
Women experiencing MT commonly report symptoms of myalgia, fatigue, bodyimage change, obesity, irritability, memory loss, VMS, sexual dysfunction, and anxiety that affect their health (Avis et al., 2005; Palmer et al., 2003). Among AAW the lack of social support (Angel,& Angel, 2006), and being single, a parent, head of household, and of low SES (i.e., low income, poor housing, and inability to purchase basic goods) contribute to AAW’s increased anxiety (Glazer et al., 2002) affecting their HRQOL during MT (Glazer et al., 2002). However, Avis and associates’ (2009b) study examined HRQOL during MT and suggested that MT did not affect HRQOL after adjusting for menopausal symptoms, and medical condition. Although research supports differences in most AAW’s socioeconomic and health status across the lifespan as being consistently worse than other major ethnic groups (Gary, Campbell, & Serlin1996; Gold et al., 2006b; Keppel et al., 2008; Ogden et al., 2010b), it is unclear whether menopausal transition differentially affects the HRQOL in AAW.
The inconsistencies presented by these findings suggest a need for research exploring relationships between physical and cognitive factors and their relationship to variations in SES; such research would contribute to understanding the main and interactional effectsinfluencing the HRQOL experienced by menopausal AAW.
In summary most menopausal research has utilized multiethnic samples and longitudinal designs to determine physical and psychological ‘changes’ (Dillaway, 2005, p. 2) that occur during MT phases (Dennerstein & Soares 2008; Freeman et al., 2007a; Gracia et al., 2007; Gold et al., 2006a). The primary focus for many of these comparative studies was the determination of the biological markers for menopause, cultural differences in symptoms, and variations in the menopausal phases linking biological markers (i.e., E2, FSH, LH) to psychosocial and physical differences across racial and ethnic groups. However, few studies employed qualitative designs to explore the multidimensional aspects and totality of AAW’s psychosocial experiences, cultural beliefs and expectations during MT (Appling, Paez, & Allen, 2007; Im, 2007).
Although findings in most studies recognize a relationship between demographic factors (i.e., education, income, employment, marital status and place of residence) and increased obesity, findings in many of these studies are inconclusive (Fitzgibbon, 2008; Gold et al., 2006b; MMWR, 2009). Flynn and Fitzgibbons (1998) suggested that AAs who experience poverty are more likely to idealize heavier body types that could lead to obesity. In addition, overeating may be an ‘insurance against hunger’ for many lowincome AAW (Kumanyika et al., 2008). Results in the (2004) study by Patt et al., among a socioeconomic crosssection of 496 AAW living in northeastern U.S., suggested that lower SES was not associated with higher BMI, and demographic factors did not affect levels of obesity. Consistent with these findings, Welch and associates (2004) found that a multiethnic sample of 524 fourthgraders, from urban and rural environments, showed no association between race, location, and weight. However, these studies did not include rural AAW, whose health outcomes are reported as being consistently worse than those of other American women across the life span (USDHHS, 2010; Gary, Yarandi, & Rivers, 2001). Neither were these studies conducted in the southeastern U.S., that has the highest rates of obesity, and obesity related chronic conditions that occur among rural residents and are related to socioeconomic factors (Kumanyika et al., 2008; Dis, 2002).
African American women who live in South Carolina are among the lowest socioeconomic groups in the nation and experience high unemployment, employment in low paying industries, limited access to health care, little or no medical insurance (SCBCB, 2003), and less access to transportation. All of these difficulties impede access to health and social services. Forty percent (22,779) of all women in SC are unmarried and although only 15 % (660,000) of SC’s population were considered in poverty, female headed household accounted for 32% (211, 200) of this proportion (American Community Survey, 2007). Gold et al. (2000) surveyed a multiracial/ethnic sample of 16,065 women (Japanese, Chinese EAW and AA) aged 40 to 55 years who were experiencing MT and who were enrolled in the Study of Women Health Across the Nation from 19951997 to determine what demographic and lifestyle factors were related to menopausal symptoms. They found that AAW who had difficulty paying for basics (odds ratios = 1.152.05) and who considered themselves less physically active than other women their age (odds ratios = 1.242.33), reported more MT symptoms. Additionally, results from the (2002) crosssectional, prospective cohort study by Wise et al. of (N= 603) premenopausal women aged 36 to 45 years, residing in Boston indicated that childhood and adult SES was associated with lifetime SES and onset of perimenopause. The incidence of perimenopause was also 1.75 times higher (95% CI 1.10 to 2.79) and median age at onset was 1.2 years younger (44.7 v 45.9 years) for women reporting childhood and adult economic distress compared with women reporting no lifetime economic distress. These studies suggest that adverse socioeconomic conditions may be associated with increased comorbidity for AAW experiencing MT.
Kumanyika et al. (2008) found that higher prevalence of obesity occurs not only in low, but also in highincome AAW. In contrast, Baltus (2005) examined the association between gender, race, SES, and weight among a group of 1186 AA men and 1137 AAW over 34 years. Baltus found SES was strongly associated with higher BMI, and that demographic factors did affect obesity levels in the lowincome group. These findings, supporting increased obesity among lowincome AAW, were consistent with the results in the (2007) study by Malpede et al. that explored racial factors related to beliefs about weight among AAW and EAW. Although research supports an association between adverse socioeconomic conditions and increased comorbidity for obese AAW, Salsberry and Reagan’s (2009) comparative study of the influence of childhood and adult economic status on midlife obesity in Mexican, EAW, and AAW, reported that having a past disadvantaged economic status increased risk for midlife obesity among Mexican and EAW, but not for AAW. These findings indicate that socioeconomic variables must be considered within the context of cultural and ethnic norms. More research aimed at exploring links between socioeconomic factors, rurality, and obesity among AAW is essential for developing culturally appropriate programs.
The principal attitudes and behaviors that characterize the functioning of a group are considered its culture. These distinctive traits or worldviews (i.e., thoughts, beliefs, perceptions) are believed to govern rules of moral conduct that influence social interactions (i.e., family structure, roles) in racial, ethnic, and social groups (Adamopoulos & Kashima, 1999). These socially transmitted behaviors, patterns of assumption, beliefs, and practices unconsciously frame and guide the decisions and behaviors of a group (Campo & Mastin, 2007; Gore, 1999). African Americans perceptions of body size and obesity permeate across age groups. A number of researchers reported that among school and college age AA children, and caregivers of AA children, these groups chose larger figures to represent their ideal body size and were happiest with their body size and image (Rucker & Cash, 1991; Wang, Liang, & Chen. 2009; Welch et al., 2004; YoungHyman, Herman, & Schlundt, 2000).
For most AAs, a socially transmitted belief is that women should have larger and fuller figures (Flynn & Fitzgibbon, 1998; Wolfe, 2000). In an attempt to provide an explanation of the historical, cultural and psychosocial factors influencing obesity among AAW in the U.S., Johnson and Broadnax (2003) suggested that, historically, AAW with “fuller figure, broader hips, fleshy and large” bodies represented good healthy bodies which were (a) conducive to bearing healthy children (b) working hard, (c) nurturing and supporting their family (p.69). These fullfigured, fleshy AAW were prized by AA men for marriage and by slave owners for breeding; they served as a vehicle to increase the slave owner’s economic wealth by producing healthy babies. Many AAW embraced the “Mammies” physique that required their acquiescence to gross obesity, a necessary protection from the advances of slave owners and to negate the slave owners’ wives’ superstition about sexual relations occurring between the mammies and their husbands (Johnson & Broadnax, 2003).
The preference for AAW with full figures also permeates the popular media today, where AAW (e.g. Beyoncé Knowles, Oprah Winfrey, Patti Labelle, Star Jones, Monique, Sherri Shepherd, Whoopi Goldberg, and Wendy Williams) are celebrated role models who refute the idealized, thin body image of American beauty. However, Tirodkar and Jain (2003) found that on television one in four AA actors were obese compared to one in 50 nonAA actors. This likely reinforces the idea among AA people that obesity is acceptable (Campo & Mastin, 2007; Gillen & Lefkowitz, 2009; Parescoli, 2007). These findings indicate that history, environment, and cultural perception are factors supporting obesity in AAW. More research is warranted to explore the relationship between societal values and the perceptions of overweight and obese AAW.
Research findings suggested that AA men prefer overweight, fleshy, and fullfigured women, who they consider sincere, hardworking, and good mothers and companions. Whereas, AAW’s fitting the ideal (thinner) body statue are looked upon with superstition (Glasser, Robnett & Feliciano, 2009; Parasecoli 2007). Parasecoli (2007) suggested that AA men associate overweight and obese AAW with comfort, stability, and increased sexual and gastronomic pleasures. These findings suggest the need for research on the links between historical and popular cultural values to determine psychological and cultural factors influencing AAW’s ready acceptance of the larger body image.
The American cultural ideal for women with an ‘ultrathin body’ (Flynn & Fitzgibbons, 1998) is not a cultural attribute embraced by AAW (Berens, 2010; ChandlerLaney et al., 2009; Parasecoli, 2007; Williams, 2009). In contrast, most AAW perceive the larger derriere as ideal and celebrate their ‘chunky’ and abundantly fleshy bodies, bodies that are revered in AA communities (Kumanyika, Wilson & GuilfordDavenport, 1993; Parasecoli, 2007). Many AAW consider increased weight and change in body image/size following child birth, menopause, and advancing age, as a natural occurrence to be celebrated (Kumanyika et al., 1993). Obese and overweight AAW perceive themselves as attractive and smaller than their actual body size, weight, or BMI (Baturka et al., 2000; Stevens et al., 1994), even when they meet the criteria for being overweight or obese (ChandlerLaney et al., 2009; Moore et al., 2010). ChandlerLaney et al. (2009) suggested that AAW’s perceptions of body size were not influenced by the perception of women from other racial/ethnic groups.
Although most obese AAW report a dislike for the negativity associated with obesity, many do not consider themselves obese; as one AA woman lamented, “when you are fat you can’t get into the chair, tub, bathroom…you can’t get around, that’s when you know you are obese” (Bramble et al., 2009, p.63). Researchers have found that AAW associate negative connotations with the word “obese” when used to describe body size (Thomas et al., 2009; Ward, Gray, & Paranjape, 2009). One woman stated, “I do not like the word obese…[the] negativity…I would rather be called fat” (Bramble et al., 2009, p.63). Among a group of teenage AAW, the word obesity was only considered applicable to people who weighed between 300 and 700 pounds and were seen on television (Dietz, 2001). However, ambivalence and dissatisfaction about being obese and being labeled as such did not affect most AAW’s preferences for large derrieres and thicker thighs as their culturally ideal body image (Beren, 2010; Parasecoli, 2007).
Perceptions of obesity and body size differ between AA and EA women (Moore et al., 2010; Bramble et al., 2009). Unlike EA women, most AAW do not perceive thinner stature as ideal (Fallen & Rozin, 1985) and are less concerned with dieting (Baturka et al., 2000) and less influenced by others’ perceptions of their body size (ChandlerLaney et al., 2009). Conflicting cultural factors hindering AAW’s weight loss efforts facilitate overeating (Connolly, 2011); these may be women’s satisfaction with larger body size, increased weight and the perception (cognition) that an increased body size is a healthy part of menopause, aging, and pregnancy (Beren, 2010; Brooten et al., 2012; DiLillo et al., 2004). Additionally, Parescoli (2007) reported that AA men encourage AAW to maintain fleshy bodies to have “large derrieres” and maintain “healthy weight” (p110). It is likely that the preferences of AA men are factors affecting AAW’s perceptions of ‘healthy’ weight and thus impeding their weight loss efforts (Kumanyika et al., 2008; Steese et al., 2006; Thomas et al., 2009). Other cognitive factors influencing obesity levels are the perceptions of many AAW that BMI calculations are inaccurate representations of their weight and body size (Bramble et al., 2009; Brown, 2009; Moore et al., 2010) and poor “health” (status) the primary prerequisite for weight loss (Befort, Thomas, Daley, Rhode, & Ahluwalia, 2008). It is likely that these perceptions are influencing AAW’s selfimage and unhealthy eating habits. Understanding how rural and very rural menopausal, AAW perceive body image/size is important for identifying ways to combat obesity in this group. Furthermore, many AA’s are reported to have a ‘livefortoday mentality’ that make healthy diets and PA unappealing methods for offsetting chronic disease (Nelson, 2009; Eyler et al., 2002; Steeves, Bassett, Thompson, Fitzhugh, 2012). This approach to life may provide an explanation for AAW’s perception that the increased energy levels required for PA, are similar to the physical activities of daily living (ADL), and health is the ability to be active enough to perform ADL (Martin et al., 2010). Research on the influence of these factors on obesity among rural AAW is minimal.
Although most studies reported overweight and obese AAW as being comfortable, accepting, and satisfied with their larger body size (DiLillo, Gore, Jones, Balentine & West, 2004; Welch, 2004), there is increased ambivalence among young AA adults who are concerned about being overweight and obese. Recently a number of researchers reported that among high school and college AA students with increased BMIs, most perceived themselves as overweight and obese and were more likely to be dieting (Drane, Paxton, & Valois, 2004; Yost, KrainovichMiller, Budin, & Norman, 2010). This suggests that among younger generations of AAW perceptions about body size and image are changing.However, while AAW acknowledged familiarity with weight loss measures and the need to maintain a healthy weight (Yost et al., 2010), many reported that their desire for a fuller figure was to please their significant others (Allan, 1998; Demarest & Allen, 2000; Gore, 1999; Parasecoli, 2007). These studies suggest that cultural beliefs, perceptions, and social pressures in the environment are factors influencing obesity among AAW rather than mainstream identification with obesity and body image/size.
Low PA levels are a major factor influencing increased BMI and obesity levels among AAW in the U.S. (Kumanyika et al., 1993; Richter et al., 2002). Studies have found that obese AAW experience lower levels of general wellbeing and exercise performance (Patt et al., 2004; CDC, 2001) and these characteristics are influenced by their perceived selfefficacy (Eyler et al., 2002a). Additionally many AAW’s decreased participation in PA is due to (a) their negative perceptions about PA, (b) lack of time because of social and cultural pressures, (c) increased time spent on hair care, and (d) lower resting metabolic rate (Albu et al. 1997; Harley et al., 2009; Thomas et al., 2009). Furthermore, younger rather than older AAW, and those with higher education and income levels reported increased participation in PA for weight control and vanity rather than to avoid illhealth (Eyler, et al., 2003; Young, He, Harris, & Mabry, 2002)
Cultural factors are reported to hinder obesityrelated intervention among AAs. These include the perception of health as the ability to be active and declining health as an inevitable condition of aging (DraytonBrooks & White, 2004). Martin et al. (2010) found that among a group of older AAs, being healthy was defined as ‘‘being able to work…to get up and do things for yourself [and ] go where you want to…have no pain…that means being healthy all over” (p. 316). Furthermore, many AAW perceive PA and work as being similar, and consider leisuretime as time for resting and not performing PA. Many AAW do not participate in leisuretime PA (structured group exercise or strenuous housework), and are not overly concerned about being obese;since obesity is not considered unattractive in the AA community (Airhihenbuwa et al., 1995; Eyler et al., 2002a; Kumanyika et al., 1993; Sanderson, Littleton, & Pulley, 2002).
However, AAW did report increased motivation for PA when they exercised with a friend or in groups (Young et al., 2002). The latter was highly favored in women who attended religious establishments; some reported that praying and spiritual guidance were important for weight loss, and healthrelated activities were important for sustaining their weight (Davis et al., 2005a). Young et al. (2002) suggested that AAW are becoming more active because of reasons related to health and vanity. But the level of PA in AAW is still below CDC recommendations (Eyler et al. 2002a; 2002b); Kumanyika (2002) posits sociocultural barriers pertaining to attitudes and perceptions, and lack of PA models are factors influencing obese AAW’s limited success at weight loss.
These findings suggest that because there are numerous cultural factors related to AAW’s perceptions, selfefficacy and motivation for PA, further research is warranted to establish their impact on obesity levels. Studies that motivate AAW to modify perceptions and behaviors about PA, and perceptions of leisure time and work and for increasing their participation in group activities is lacking. Also, lacking are culturally specific PA models developed for obese AAW in places of work and worship that provides health and, or financial incentives. Since few studies have included rural AAW, experiencing MT, research is necessary to establish the influence of menopausal status on PA and obesity levels, in rural AAW .
Nutritional and educational deficits, unhealthy eating habits, and inactivity are factors attributed to increased overweight and obesity among AAW (Fitzgibbon et al., 2008; Thompson et al., 2009). Although AAs have been in the U.S. for hundreds of years, Kittler and Sucher (2008) proposed that acculturation changes related to culturallybased food practices and habits are among the last to change. These beliefs support James’ (2004) findings that AAs considered healthy eating an adoption of the dominant culture and therefore a departure from their own.African Americans, similar to other minority groups, consider food and the sharing of food an expression of nurturing, socialization and caring (Airhihenbuwa et al., 1996; Bramble et al., 2009). Older AAs prefer to eat at home and consider eating as a spiritual or intimate event exclusively for the invited and family. Social events like church meetings, dinners, cookouts, and family reunions encourage familial socialization and communal eating where traditional foods are prepared and shared, and where “everybody cooks, and everybody eats”(Gore, 1999, p.77). Changes to traditional recipes are not encouraged or supported by the AA family and the community (James, 2004).
Food choices for AAs are generational and influenced by the cultures of Africa, conditions experienced during slavery, and access, availability and affordability of food items (Ard et al., 2005; James, 2004; Airhihenbuwa et al., 1996). Airhihenbuwa et al. (1996) reported that among a crosssection of AA males and females, food choices were passed down through successive generation and still influenced by slavery. Participants in the study concurred that “they ate what their parents ate [including] fried and spicier types of foods, [and] we took garbage and made it into a meal” (p. 251). The high intake of smoked, salted, and nitritecured animal byproducts, used when AAs could not access or store healthier foods, persists (James, 2004). Thus, the food choices and preparation techniques for most AAW stem from matriarchal practices established during slavery, when cooking with soul meant boiling frying, and roasting to optimize the flavor of the cheapest cuts of meat (i.e., ham, pork, and animal intestine); and cooking corn, sweet potatoes, and leafy vegetables until very tender (Ard et al., 2005; James, 2004).
The practice of cooking with soul include cooking with lots of saltbased spice, using one pot to cook a meal, overcooking vegetables with ham hocks and adding sugar (resulting in low fiber and high fat content), and drinking pot liquor (Henderson, 2007). Cooking with soul alsomeans (a) cooking chicken with the skin intact and coating meats in wheat or corn flour, and deepfrying, (a) garden produce (b) seafood – shrimp, fish, catfish, (c) meats chitterlings, pork chops, and salted pork fatback until crispy, (Airhihenbuwa et al., 1996; James, 2004; Jefferson et al., 2010). Roasted or barbequed meats high in fats (pork or beef ribs) required the addition of sauces that contained mustard, sugar, and saltbased spices to enhance the taste (Jefferson et al., 2010). Thus the high nutritional fat content of many AA meals is influenced by the practices of not trimming meat fats, eating fatback, reusing oils, and using fats for enhancing foods that are lacking in flavor (Airhihenbuwa et al., 1996). Additionally, starches and sweets such as bread, sweet potato and fruit pies, cakes, rice, potatoes, and macaroni with cheeses are dietary staples in the kitchen of many AAW (Airhihenbuwa et al., 1996; James, 2004; Jefferson et al., 2010).
These techniques (a) ensured digestion of the least desirable types of foods (b) provided a diet that ensured AAs had at least minimal caloric energy to perform hard labor, and (c) nurtured the spirit and comforted the soul. Today, hard labor is the exception and not the norm for many AAW who adhere to unhealthy diets (James, 2004; WalkerSterling, 2005). Although research suggests that AAs’ food choices, preparation techniques, and culinary practices maintain kinship and group identity, they also hinder the adoption of healthier food choices and preparation techniques (Kittler & Sucher, 2008).
Rural AAW are engaged in more cultural and lifestyle eating and snacking on sweets. ‘Lifestyle eating’ is an eating pattern characteristic of the AA culture: eating large Sunday meals, having meat and starch for every meal, and eating together only on weekends (Hargreaves et al., 2002; Sims et al., 2008). Findings in Hargreaves et al. (2002) study among 40 rural AAW in Tennessee supported increased snacking, missing meals, and using more frozen, prepackaged, and convenience foods when preparing meals. Additionally, Schlundt et al. (2003) reported that levels of education were associated with snacking and lowfat eating. In contrast, Evans et al. (2009) found that levels of education did not decrease the amount of fats consumed by urban, midlife AAW women, ages 45 to 64. Whether lifestyle eating is the same for rural AAW, residing in SC is unknown.
The dietary intake of many young adult AAW is similar to those of other minority groups in the U.S. (HamiltonMason, Hall, & Everett,2009; James, 2004; Satia et al., 2004) consisting of fast and convenient foods that are high in caloric but low in nutritional values.Satia et al. (2004) surveyed 658 AA participants (59% female, 37% college graduates, 75% overweight/obese), with a mean age of 43.9 (SD=11.6), in North Carolina to explore dietary intake, demographics, psychosocial behaviors, and eating habits related to frequency of eating in fast food restaurants. Findings suggested that differences in education levels, knowledge of the Food Guide Pyramid, and ability to purchase healthy foods were significantly related to less eating at fast food restaurants. Consumption of fast foods and eating in restaurants are related to social and cultural pressures, including lack of time, work schedule, housework, cleaning, caring for children and family members (HamiltonMason et al., 2009; James, 2004). The time taken by these activities is compounded by the plethora of lowcost and conveniently located fast food establishments that contribute to the increase in obesity levels among AAW (Kumanyika et al., 2008; Morland et al., 2002). These issues are further compounded by the popular AA media (magazines) that focus primarily on “fad diets and a reliance on God or faith” for assistance in weight and diet management (Campo & Mastin, 2007, p. 229). In addition, television focuses on unhealthy foods during peak viewing hours (Pratt & Pratt, 1996; Tirodkar & Jain, 2003). Sankofa and JohnsonTaylor (2007) suggested that much of the American media focuses on cultural and behavioral factors (i.e., criminal acts, negative sociocultural behaviors) and disregards pertinent information (i.e., healthy foods, environmental, affordability, and access to products) necessary for improving the health outcomes in AAs. This suggests that perception of healthy foods, preferences, dietary practices and food preparations are cultural factors leading to increased obesity among AAW. A step toward determining the cognitive disconnect among nutrition, diet, obesity, and health outcomes would provide information that increases the contextual understanding of these relationships among AAW.
Research suggests that lifestyle behaviors and familial responsibilities affect AAW’s mental health (i.e. depression, and physiological wellbeing) status and influence health (i.e. BMI and obesityrelated chronic health conditions) outcomes, which impact their morbidity levels (Kim et al., 2009; Young et al., 2002). Social pressures resulting from life style (i.e. time needed for work and preparation of nutritious meals) and familial responsibilities are factors influencing food preparation techniques, and eating habits; they also affect the nutritional values of many foods consumed by AAW (Baturka et al., 2000; Jefferson et al., 2010; Hargreaves et al., 2002; Richter et al., 2002).
Historically, food preparation techniques for many AAW stem from matriarchal practices established during slavery (Airhihenbuwa et al., 1995) as noted previously. Currently, many rural AAW adhere to diets high in animal fats, sugar, salt, and starch (Thompson et al. 2009). In their study of AfroCaribbean and AAW aged 40 years and older, Bramble and associates (2009) examined cultural factors related to PA, healthy eating, and weight management. They concluded that tradition, food habits, and perceptions of obesity differ among ethnic groups.
Eating habits differ among groups of AAs by age and demographic locations. Deitz (2001) reported that, in a focus group data of AAW ages 18 to 35, healthy eating was described as consuming three meals a day with foods from the four food groups (protein, fats, carbohydrates, and dairy). However, Hargreaves et al. (2002) reported that many AAW in their study did not adhere to three meals a day; instead, eating patterns for most were influenced by health concerns, appetite, and convenience. Women reported snacking between meals, missing meals, emotional eating, and eating food they considered unhealthy throughout the day (Hargreaves et al., 2002).
Many AAW considered a ‘good’ diet the ability to have a full plate, eat meat, and not have to fill up on starches (James, 2004). These findings are in contrast to the new U.S. Department of Agriculture and U.S. Department of Health and Human Services guidelines recommends meals with smaller portions, less meat, more fruits and vegetables, and grain (USDA & USDHHS, 2010). Guidelines that concur with research suggesting that consuming 5 or 6 small meals and eating the largest, and most caloric dense meal earlier in the day increased satiety and metabolism (Castro, 2004; Yunsheng et al., 2003).
Fitzgibbon et al. (2008) found that among 213 obese AAW ages 30 to 65 years, enrolled in the Obesity Reduction Black Intervention Trial (ORBIT), the treatment and control groups’ mean kcal energy intake at baseline ranged from 2374 (SD=984) to 2458 (SD= 1088). The percentage of nutrients (kcal) intake was M=44.5% (SD=8.3) carbohydrates, M=41.8% (SD= 6.6) fats, M=12.1% (SD=2.4) saturated fat, and M=15.1% (SD= 3.3) proteins, these percentages exceeded recommended intake based on the 1992 Food Guide Pyramid (Fitzgibbon et al., 2008). These AAW consumed less of their kcal for each food group servings than thedaily U.S. Recommended Dietary Allowance (RDA)(2010) for fruits including juices, (M=1.3%, SD= 1.0), and fiber (M=8.7g/1000, SD= 3.5), dairy milk, yogurt, and cheese (M=1.0, SD= 0.8), grains bread, cereal, rice, and pasta (M=4.8, SD= 2.9); and more kcal from vegetables (M=3.4 (SD=2.0), meats (M=3.2, SD=1.9), fats/oils and sweets (M=3.7, SD=2.0). These findings are consistent with findings from other researchers (Dietz, 2001; Wilson, Musham & McLellan, 2004).
Gaston and associates (2011), reported that the portion size for food consumed by AAW was larger and with more calories than that recommended by the U.S. Food and Drug Administration (USFDA), Dietary Guidelines for Americans, USDA & USDHHS (2005) and may influence high caloric intake. A study of 351 midlife AAW of various bodyweights enrolled in the Prime Time Sister Circles (PTSC) program examined relationships among SES, psychological factors, and health behaviors (i.e., physical exercise, eating patterns). Results indicated that of the obese women in the study, few (16%) regularly observed their food portion size, 11.5% counted caloric intake, and only 5.7% measured their food portion. Most reported regularly eating fried and fast foods (53.8%) and highcalorie sweets (59.1%) (Gaston, Porter, & Thomas, 2007).
Results from the 1995 to 2005 Black Women’s Health Study (BWHS) used to explore the effects of restaurant foods on incidence of diabetes, among 44,072 participants, suggest that consumption of foods prepared outside the home increased from 18% to 32% of total calories intake (Krishnan et al., 2010). The highest to lowest foods prepared outside the home were (a) fried chicken, (b) Mexican, (c) Chinese, and (d) fried fish; however, pizza consumption declined from 10% to 4% weekly (Krishnan et al., 2010).
Eating at fast foods restaurants negatively influence nutritional intake, and increase obesity levels in AAW. In Satia et al. (2004) study, participants who ate at fast food restaurants decreased their vegetable intake (p<0.05), but increased total fat intake (p<0.0001) from 28.3g for infrequent eaters to 39.0g for frequent eaters. Frequent eaters at fast food restaurants were younger, physically inactive, obese, never married, and nonconsumers of multivitamins (Satia et al., 2004). In addition to consuming more fast and restaurant prepared foods, AAW reported increased use of frozen, prepackaged, and convenience foods when preparing meals (Hargreaves et al., 2002). These changes supports AAW’s shift towards diets lower in grains and folates and higher in saturated fats, sugars, and starches that are nutritionally dense (Dammann, & Smith, 2009; Gary et al., 2004; Hargreaves et al., 2002).
Studies exploring the nutritional values for foods consumed by AAW focus on either excessive or insufficient nutrient intake, such as calcium found in dairy foods, minerals, and vitamins from fruits and vegetables, and carbohydrates and saturated fats that disproportionately influence disease outcomes among AAW (Blanchard, 2009; Kannan et al., 2010; Sharma et al., 2009). Lacking are studies to determine where, what and how AAW spend funds for food allocation. Such studies are necessary for developing interactive educational tools that instruct AAW in basic nutritional science that are no longer mandatory in preschool through 12 grades (Briggs, Safaii, & Beall, 2003).
Research findings in a number of dietary studies that included micronutrient intake suggest that AAW consume less calcium than EA women (Blanchard, 2009; Kannan et al., 2010; Teegarden, 2003; Wooten & Price, 2004) and a prevailing perception by many AAW that they are lactose intolerant influences their consumption of low calcium dairy products (Blanchard, 2009; Dore et al., 2001; Kannan, et al., 2010). Lactose intolerance has been reported as a factor that leads to low consumption of calcium rich dairy foods that are also high in vitamin D (necessary for those who spend little time in the sun) (Blanchard, 2009; Kannan et al., 2010). Consequently, many AAW omit calcium rich dairy foods, resulting in dietary calcium levels lower than the current RDA of 1,000 to 1,200 milligram (mg) daily for adults 19 years and older (USDA, 2005; 2010). Such a diet reduces the potential benefits gained from consuming three to four daily servings of the lowfat dairy foods (Blanchard, 2009; Kannan et al., 2010; Teegarden, 2003; Wooten & Price, 2004) that have been found to reduce chronic diseases (i.e., obesity, hypertension, diabetes, atherosclerosis, and osteoporosis) affecting AAW, promote weight loss in obese persons (Blanchard, 2009; Wooten & Price, 2004) and increase the longterm risk for lower BMD levels at midlife. In addition, Houston et al. (2005) reported that among a group of AA and EA women, dairy, fruit, and vegetable intakes were inversely associated with lower extremities limitation and impaired ADL, among AAW.
Results from studies by Kannan et al. (2010) and McCrary et al. (2005) indicated that a higher percentage of AAs’ energy came from consuming carbohydrates and sodas; but their diet was lower in supplemental vitamins of A, C, D, and E, as well as calcium and magnesium. Lower levels of vitamin supplements consumed by AAs hindered the growth of intestinal microflora belonging to clostridia cluster IVX, which may be a contributory factor to the increased levels of colon cancer among AAs (McCrary et al., 2005). In addition, Johnson, Ralston and Jones (2010) found that a sample of 20 AAW in South Carolina consumed less water than women of other ethnic groups. A diet low in water affects the synthesis and bioavailability of all other macro and micronutrients in the body.
However, among middleclass suburban and urban AAW with higher SES residing in affluent neighborhoods facilitates the adoption of acculturation factors that influence their perceptions of healthy foods and modifies preparation techniques and eating habits (Baltus, 2005; Kumanyika et al., 2008; Ogden et al., 2010b). These relationships do not pertain to lowincome rural and urban AAW whose food preparation techniques and eating habits are affected by food insecurities, cost, preference, and preparation techniques that remain traditional (Airhihenbuwa et al., 1996; Henderson, 2007; James, 2004).
More than in previous years, AAW similar to women of other ethnic groups are consuming more fast and convenience foods; that are readily available, easier and faster to prepare than conventional cooking techniques, but are caloriedense (Dammann, & Smith, 2009; Gary et al., 2004; Shankar & Klassen, 2001). The abundant variety of these available foods effect foodchoice patterns and traditional preparation techniques that may influence AAW’s inability to consume a balanced nutritional diet (Henry et al., 2003) or conversely, the traditional food preparation techniques practiced by many AAW may influence their fast food and convenience food choices.
In case, AAW’s burgeoning obesity levels and risk for obesityrelated chronic conditions influenced by both cultural and socioeconomic factors (DraytonBrooks, & White, 2004; Hargreaves et al., 2002). The paucity of knowledge on nutritional intake, food preparation, and eating habits of AAW, especially those in rural areas, signals the need for research on the relationship between nutrition intake and food preparation factors and obesity. Although more studies are exploring obesity and its relationship to health and PA among AAW (Beydoun et al., 2009; Thompson et al., 2009), most are interventional, conducted in urban settings, and report high attrition rates. In many ethnically diverse studies, samples of rural AAW are noticeably smaller or absent (BeLue, TaylorRichardson, Lin, Riveria, & Grandison, 2006; Smith et al., 2007). Research focusing on links between obesity and menopause among rural AAW is lacking. Consequently, research in this area is necessary for increasing understanding of the relationship between perceptions of obesity, actual body image/size, and dietary habits, and the health of rural, menopausal AAW.
In the US, people who live in urban inner cities and in populated rural areas have increased risk for poverty, poor health, and mortality than suburban residents (Dis, 2002). Thus, place of residence (house, apartment, with/without access to safe environment for PA, transportation, adequate street lightings, and access to healthy food supply) and demographic location (living in southeastern verses northern regions of US, or living in rural and very rural verses urban areas) play significant roles in the health of AAW. Research findings support higher morbidity and mortality rates for AAs living in inner cities and populated rural areas (Jackson et al., 2005; Miniño, Xu, Kochanek, & TejadaVera, 2009). In Rural southern regions of the US where more than half of the AA population resides, mortality rates for AAs are highest (Jackson et al., 2005; Miniño et al., 2009).
Rural women are described as having a higher rate of obesity than their urban counterparts (Eberhardt & Pamuk, 2004; Janssen et al., 2008), but lack adequate health care, are employed in low paying light industries, and agricultural and service industries that affects their health outcomes with respect to chronic disease (Kahng, 2010; Appel et al., 2002; Murray et al., 2006). In 2011, the population in SC was estimated at 4,679,230; of these 28.1% (1,299,727) reported being AA (U.S. Census Bureau Quick facts, 2012).
Among rural residents in South Carolina, 48% of all rural residents are hospitalized out of county versus 19% in urban areas. Rural AA residents were 12% more likely to die from a stroke, and 57% more likely to die from diabetes than rural EA residents. Very rural AA residents were 70% more likely to die from diabetes than were very rural EA residents. Compared to AAs in urban environments, very rural AA residents were 37% more likely to die from heart problems, 44% more likely to die from a heart attack, 52% were more likely to be hospitalized for hypertension, 18% were more likely to visit the ER and 55% were more likely to be hospitalized out of county. For mental health conditions, 81% of rural residents and 89% of very rural residents are hospitalized out of county versus 33% in urban areas. Additionally, 54% of South Carolina’s uninsured rural residents are nonEA and more than 18% of rural residents who visit the emergency room have no source of insurance (SCORH Report, 2005).These results suggest increased morbidity and mortality, and unequal access to health care that influence health outcomes for rural residents in SC.
The rural environment differs from the urban environment in that rural areas have (a) increased exposure to herbicides, Freon and medicine, (b) contaminated ground water – from wells, and (c) low population density, (SCBCB, 2003), as well as cesspools for sewage, unpaved/dirt roads, lack of sidewalks, lack of garbage pickup and the need to use of city county dumps, and inadequate street lighting and exercise facilities (SCBCB, 2003; Patterson et al., 2004; Wilbur et al., 2009). In contrast, urban environments have: (a) increased exposure to carbon dioxide and radiation, (b) high population density, and lack of green space, and (c) structural decay (Lopez & Hynes, 2006; Murray et al., 2006). Although these have not been shown to affect levels of obesity among AAW. South Carolina ranks second for multiple myeloma, third for oral/pharynx and esophagus, fourth for pancreas, eight for cervical, and eleventh for stomach cancers (Johnson et al., 2005). Lacking is collaborative nursing research describing environment factors that influence morbidity and mortality levels of rural residents. Future studies must examine air pollution (i.e., herbicides, insecticides), and contamination of ground and well waters (i.e., Freon, chemicals) released from light manufacturing industries (Landmeyer, & Campbell, 2010) and their influence on the high cancer, CVD, and respiratory disease rates reported for SC residents (Johnson et al., 2005).
In socially disadvantaged areas, such as most rural areas, AAs frequently experience increased poverty, unequal distributions of quality and healthy food choices, and a lack of adequate facilities for physical activity, which are precipitatory factors for obesity (Baker et al., 2006; Morland & Filomena, 2006). Findings in a number of studies support (a) more overcrowding in homes/facilities, (b) more PA facilities but not enough affordable access to these facilities, (c) insufficient, and poor quality educational and health programs, (d) poor quality foods, (e) unsafe public transportation, and (d) lack of health care access and open spaces for PA as factors influencing increased obesity levels in AAW (Dis, 2002; Davis et al., 2005a; Eyler et al., 2002a; Richter et al., 2002). Thus, the lack of access to affordable physical activity programs, inadequate time to participate in programs, and lack of familial encouragement and support are sociocultural factors related to increased obesity among urban AAW (Eyler et al., 2002a; Young et al., 2002).
Interventional research among obese, rural AAW is sparse because most studies on obesity includes urban AAW. Rural AAW are seldom included, and while some research finds increased obesity among highincome AAW, many of the studies fail to provide information to differentiate between residence and other demographic factors. In addition, most studies in rural communities are designed as quasiexperimental interventions that include communitybased participatory research (CBPR) approaches for building community capacity and increasing social support and individual behavioral change for increased ownership of issues (AndersonLoftin et al., 2005; Johnsonet al., 2010; ParraMedina et al., 2010; Zoellner et al., 2011).The majority of studies reviewed explore factors related to ethnic and racial differences in obesity levels, and psychosocial and health issues affecting AAs. Because of this, it is unclear if findings on obesity among urban AAW are applicable to rural AAW. Although both groups of women share some similar cultural experiences, such as low income and single heads of household, the contribution of a rural environment is unknown. Also unknown is whether rural and urban AAW share similar views about weight, food preparation and eating habits, or experiences of menopausal transition. Research supports familial and cultural practices (dietary, lifestyle, and social) as generational (Jefferson, et al 2010). Fewer studies focused on cultural factors related to increased obesity, dietary habits, and beliefs unique to AAW in the southeastern U.S., that hinder adoption of healthier practices. Therefore, it is important to determine the role of culture and environment as a step toward understanding obesity among AAW.
This review of the literature was conducted to explore whether sociocultural factors such as dietary habits, food preference, and preparation techniques influence obesity and morbidity levels in AAW. Cultural beliefs and practices concerning obesity, and menopausal transition reported by AAW are also explored.
Two out of three Americans are overweight or obese and obesityrelated chronic conditions negatively affect health outcomes for a number of diseases (CDC, 2010; McCrary et al., 2005; Moorman et al., 2009; Warren et al., 2012). The increasing cost for obesityrelated chronic conditions is expected to increase proportionally with rates of obesity and aging (Finkelstein, Fiebelkorn, & Wang, 2003; Finkelstein et al., 2009). With more AAs than EAs being obese (MMWR, 2009; Ogden & Carroll, 2010a), and more than half AAs being 20 years of age or older, the related morbidity levels for AAW are high (Freedman, 2011; MMWR, 2009; Ogden et al., 2010b) and costly.
Menopausal AAW (aged 40 64) have the highest levels of grade two and grade three BMI among ethnic groups of women in the U.S. (Flegal et al., 2012). In the southern U.S. one in ten AAW are morbidly obese (BMI greater than 40 kg/m2) (Jackson et al., 2005; WalkerSterling, 2005) and South Carolina had one of the highest obesity rates with more than 66 percent of all adults being overweight or obese. Most were AAs (76 percent), 80 percent were women and more than 40 percent live in rural areas (CDC, 2010; SCDHEC, 2008b).
Although there are studies exploring the relationships among obesity, health status (diabetes, hypertension, cardiovascular diseases, and some cancers), physical activity (PA) and dietary intake among AAW (Beydoun et al., 2009; Thompson et al., 2009), most are conducted in metropolitan urban settings, feature racially diverse samples that have small subsamples and often report high attrition rates for AAW (Annesi & Whitaker, 2008; Gerber et al., 2009; Kannan et al., 2010; Kumanyika et al., 2005). The findings clearly indicate that high obesity levels in menopausal AAW influence their morbidity rates, but culturally specific studies that describe sociocultural and obesityrelated factors influencing menopausal AAW living in rural areas are lacking.
Sociocultural factors are reportedly influenced by history, traditions, perceptions, and behaviors of AAW. They include perceptions of healthy and unhealthy foods, PA, body size, and obesity, as well as eating habits, food preparation techniques, and portion sizes (Airhihenbuwa et al., 1996; Fitzgibbon et al., 2008; Jefferson et al., 2010; Thompson et al., 2009). Although some research suggests that sociocultural factors influence both the foods chosen and consumed by AAW (Patt et al., 2004; Satia et al., 2004), Bramble et al. (2009), and Henderson (2007) reported that practices varied among AAW according to their geographic location and SES. Lacking is sufficient research to determine the influence of demographic factors (geographic location, and SES) on sociocultural factors related to dietary habits, PA, and obesity in rural AAW.
African American woman’s perceptions of their weight derive from a number of sources that include AA men preference for overweight, fleshy, and fullfigured women (Parasecoli, 2007) who are associated with comfort, stability, sincerity, hard work, good mothers, and increased sexual and gastronomic pleasures. Research in this area, however, is sparse. Befort and associates (2008) concluded that negative health conditions were the factors most likely to motivate AAW to modify dietary, PA practices, and address lifestyle challenges that led to improved health. However, more research is necessary for understanding AAW’s perceptions and motivations for maintaining a larger body size in light of the evidence that obesity is associated with increased morbidity. Results of such studies might elucidate barriers and point to why there is little success for most dietary and PA interventions developed specifically for AAW (Fitzgibbon et al., 2008; Hill, 2009; Rimmer et al., 2009).
Some studies suggest that during menopausal transition the health of many AAW and EA women is influenced by biological changes in hormone levels (Bromberger et al., 2009; Pinkerton & Zion, 2006; Segraves & Woodard, 2006; Soules et al., 2001). But unlike EA women, most AAW reported increased levels of vasomotor and depressive symptoms, and decreased psychological wellbeing during the transition to menopause factors contributing to their increased obesity and morbidity levels (Bromberger et al., 2009; Garcia et al., 2007; Palmer et al., 2003; Pratt & Brody, 2008; Strickland, 2000). These findings support variations in menopausal women’s experiences and indicate inconsistencies in evidence supporting universal symptomatology across racial and ethnic groups (Gold et al., 2000; Huffman et al., 2005 (Beydoun et al., 2009; Bromberger et al., 2009; Thompson et al., 2009; Avis et al., 2009b). Research that describes associations among menopausal status, sociocultural perceptions and practices, and levels of obesity is warranted to determine their influence on the health of AAW.
Increased levels of obesity linked to hormonal changes during MT also influence CVD, hypertension, diabetes, and dyslipidemia status (Sower et al 2005, 2007; Budoff et al., 2006) and symptomology for metabolic syndrome is well known (Kirkendoll et al., 2010). Few studies, however, have explored associations between AAW’s high levels of hypertension, diabetes, dyslipidemia, and increased waist circumference for metabolic syndrome during MT (Kirkendoll et al., 2010). To increase the quality of healthcare more research to link these variables would help to educate clinicians for improving diagnosis of metabolic syndrome.
Nutritional and educational deficits, unhealthy eating habits, and inactivity are cited as factors attributed to obesity in AAW (Fitzgibbon et al., 2008; Thompson et al., 2009). Most AA’s adhere to diets high in animal fats, sugar, salt, starch, and use traditional food preparation techniques that increase Kcal value (Brooten et al., 2012; James, 2004; Thompson et al., 2009). Although, older AAW report eating most of their meals at home (Gore, 1999; James, 2004) the nutritional value of many homeprepared meals is typically lacking (Houston et al., 2005; Jefferson et al., 2010). Sociocultural factors such as history, cultural beliefs about foods, lifestyle eating (Hargreaves et al., 2002; Sims et al., 2008) and the communal sharing of traditional foods at social events are all contributory factors, and influence levels of CVD, hypertension, and dyslipidemia among AAW.
Education levels did not influence fat consumption levels in a group of AAW in one study (Evans et al., 2009). However, other research reported that acculturated middleclass, suburban and urban AAW adopted food preparation techniques and eating habits prevalent in their neighborhoods (Baltus, 2005; Kumanyika et al., 2008; Ogden et al., 2010b) which suggests that SES and environment do make a difference.
Most AAW do: (a) consume larger food portions, (b) don’t measure portion size, (c) eat more meals outside the home, and (d) use more prepared, frozen and tinned foods during meal preparation (Gaston et al., 2011; Kishnan et al., 2010). These studies support sociocultural, and demographic factors as influencing dietary habits, food choices and preparation techniques in AAW (Baltus, 2005; Kumanyika et al., 2008; Ogden et al., 2010b), and support differences in eating habits based on demographic location (Deitz, 2001). No study, however, describes the relationships of these factors among rural and very rural, menopausal AAW.
Low PA levels below CDC recommendations (Eyler et al. 2002a; 2002b) are also a major factor influencing increased BMI and obesity levels among AAW (Eyler et al., 2002a; Kumanyika et al., 1993; Richter et al., 2002). DraytonBrooks and White (2004) reported that most AAW perceive health as the ability to be active and declining health as an inevitable condition of aging. Many AAW also perceived being overweight and obese as attractive (Airhihenbuwa et al., 1995; Eyler et al. 2002a; Kumanyika et al., 1993; Sanderson et al., 2002). These findings are consistent with a number of researchers who suggest that AAW’s decreased PA participation is due to negative perceptions and behaviors about PA such as (a) time spent away from work is for resting – not strenuous exercise, (b) lack of time to exercise, (c) increased time spent on hair care, (d) perceptions about obesity, and (e) lower resting metabolic rate (Albu et al. 1997; DraytonBrooks & White, 2004; Harley et al., 2009; Thomas et al., 2009). Although the literature supports sociocultural barriers, attitude and perceptions as factors influencing lack of PA studies focused on similar factors among menopausal AAW are lacking.
Gaps in the research also suggest that future studies must explore rural AAW’s perceptions of what constitutes a healthy diet and what type PA model is necessary to decrease obesityrelated chronic health conditions in this group (Gillan, Humphries, & Naquin, 2011; Henderson & Ainsworth, 2000; McAllister et al., 2010).
Though the number of communitybased obesity interventions developed specifically for AAW is increasing, few interventions are effective at decreasing and maintaining healthy weights among obese AAW and even fewer are effective among rural AAW (AgursCollins et al., 2009; Bronner & Boyington, 2002; Van Duyn et al., 2007). Reasons suggested include inconsistencies with AAW’s own perceptions of what constitutes a healthy diet and PA, as well as findings that AAW’s perceptions are influenced by ethnicity, region, cultural and religious beliefs which are reported to affect the validity and reliability of many obesity interventions (Bronner & Boyington, 2002; Gillan et al., 2011; Henderson & Ainsworth, 2000; McAllister et al., 2010).
While the influence of SES on the health status of most AAW (education and income levels, employment, and marital status) is supported (Fitzgibbon, 2008; James, 2004; MMWR, 2009; Morland et al., 2002). Few studies reported on the influences of SES, and place of residence (rurality) on obesity and morbidity levels (Kumanyika et al., 2008; Dis, 2002). Even though demographic factors are linked to variable access to nutritional foods and rural residents’ ability to engage in PA, studies describing rural AAW perceptions of their living environments and the effects of sociodemographic variability on food choice and availability, and dietary intake are particularly lacking.
The paucity of noninterventional studies (Palmer et al., 2003) aimed at exploring the relationships among culture, behavior, biology (menopausal transition), and demographic factors among AAW (Smith et al. 2007) residing in rural and very rural areas of the U.S. is a gap the proposed research aims to address. Such information is necessary to aid development and delivery of more culturally appropriate healthcare for ethnically diverse women.
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
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