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A social ecological approach to the obesity epidemic.

Abstract: The purpose of this preliminary study was to identify environmental factors that impact weight management in midlife women. A questionnaire was developed and distributed to women aged 35-65. Forty middle-aged (47.4 [+ or -] 6.6), Caucasian (82.5%) women returned completed questionnaires. Analyses included descriptive statistics and Spearman nonparametric correlations. The results suggest that a number of environmental factors affect weight management in these midlife women. Guidance regarding how to apply nutritional information to daily food choices as well as environmental interventions to promote recreational opportunities and healthy nutrition may increase the effectiveness of weight control programs in this segment of the population.


The prevalence of obesity in the United States has reached epidemic proportions (Egger and Swinburn, 1997; Mokdad et al., 1999). In the past decade, the percentage of adults categorized as obese has been steadily increasing in all states, in both sexes, and across various age groups, races, and educational levels (Mokdad et al., 1999). Current weight control strategies are not successfully containing this obesity epidemic (Egger and Swinburn, 1997; Hawks and Gast, 1998). A possible explanation for this is that weight control programs have primarily focused their interventions on individual behavior change even though experts agree that environmental factors have a substantial impact on weight status (Hawks and Gast, 1998).

Thus, a shift towards an approach that integrates behavior change strategies with environmental-based interventions is necessary. Such an approach has been used in health promotion for more than a decade and has been referred to as the social ecological approach (Richard, Potvin, and Mansi, 1998; Stokols, 1992, 1996).

Although efforts to develop and implement environmental interventions to promote healthy nutrition and physical activity have been attempted (French et al., 2001; Glanz et al., 1995; Glanz and Mullis, 1988; Sallis, Bauman, and Pratt, 1998), a greater depth of initial descriptive research is needed to identify characteristics of settings that influence weight management in various subgroups (Glanz et al., 1995; Sallis et al., 1998). Thus, the purpose of this preliminary study was to identify environmental factors that impact weight management in midlife women.



A cross-sectional design with a single measurement was used for this study.


A focus group was conducted with five middle-aged (mean age = 40 years) women to discuss various weight management strategies. The women were asked to share their opinions and experiences regarding elements in their environment that played a rote in their weight management. The following themes emerged from these discussions: nutritional knowledge, healthy food availability, and recreational opportunities. These themes were compiled into a questionnaire.

The questionnaire included a total of 69 questions, 13 of which gathered demographic information (age, race, height, weight, education, etc), while the remaining 56 used a Likert scale to address the various themes that emerged from the interviews. Participant were asked to rate statements such as "the environment strongly influences my selection of food choices" or "the community in which I live offers enough recreational opportunities" on a 1-5 scale, from "strongly agree to strongly disagree respectively.


Fifty questionnaires were distributed to women previously recruited for a study on worksite health. These women were aged between 35 and 65 years and lived in the Phoenix metropolitan region. All participants completed the questionnaires anonymously and returned them to the investigators via self-addressed pre-stamped enveloped provided by the investigators.


Descriptive statistics and Spearman's nonparametric correlations were obtained from the returned questionnaires. Means, standard deviations, and frequency tables were used to describe the sample and to identify the questions for which participants shared a common opinion. Correlations were used to examine associations between different factors.


Forty women (80%) returned the completed questionnaires. Demographics of the sample studied are shown in Table 1. The sample (n=40) consisted primarily of middle-aged, Caucasian, married women with some post-high school education. Ninety-five percent (n=38) of the participants worked full-time (i.e. 30-40 hours per week or more) and worked for others (n=37). About 60% (n=24) of them reported having flexible work hours.

Body mass index (BMI) was calculated for 38 participants who self-reported their height and weight. Eleven (29%) participants had a body mass index (BMI) ranging between 25 and 29.9, while 15 (39.5%) of them had BMI of 30 and above. Sixty-three percent (n=25) of the women reported performing at least moderate amounts of recreational activities in the past month, while only 28% (n=11) of them reported doing 20 minutes or more of vigorous aerobic activity three or more days per week.

Approximately 73% (n=29) of the participants agreed with the statement "the environment strongly influences my selection of food choices". Although 85% (n=34) of the women considered themselves knowledgeable about the food choices they made, nearly two-thirds of them (n=26) felt confused about healthy ways to eat because of the abundance of recommendations circulating. Close to 90% (n=35) of our participants agreed with the statement "what you eat can make a big difference in your chance of getting a disease, like heart disease or cancer".

When asked to report their frequency of eating in fast food restaurants, 50% (n=20) of the women reported going once a week, 23% (n=9) reported going 2-3 times per week, while 7.5% (n=3) reported going 3-5 per week. Close to 58% (n=23) of the participants reported choosing healthy food items in fast food restaurants on most occasions. About half of the subjects (n=21) felt that fast food establishments did not offer enough healthy food items, but 58% (n=23) of them believed that if they asked for healthier alternatives, the fast food establishment was accommodating.

More than two-thirds (n=27) of the women reported they would read through the information before selecting an item if fast food restaurants posted the nutritional contents of its food in an easy location or on every food item.

Sixty percent (n=24) of our participants agreed with the statement "the community in which I live offers enough recreational opportunities (bike paths, walking trails, parks, etc.)". Level of satisfaction with community recreational opportunities was significantly correlated with the amount of recreational activity reported (r=0.363, p=0.025).


The results from this preliminary study suggest that midlife women acknowledge the impact of the environment on dietary habits. Past research has provided evidence of public support for certain environmental strategies related to food consumption (French et al., 2001; Glanz et al., 1995). Together, these findings provide evidence of public readiness for environmental strategies promoting healthy eating.

A majority of out participants felt knowledgeable about their food choices, but were confused regarding which nutritional recommendations to believe. This finding supports conclusions from Glanz and colleagues (1995) that nutrition knowledge has increased in the past decades, but that most people still lack an understanding of how to apply the information.

Our subjects' awareness of the impact of nutrition on their health status is also representative of past surveys, which have shown that public awareness of nutrition's role in the cardiovascular disease process has improved substantially (Glanz et al., 1995). However, increased awareness has not consistently lead to healthier dietary practices (Glanz et al., 1995). Similarly in this study, although most participants believed unhealthy nutrition could cause disease, many of them reported eating regularly in fast food restaurants.

Many women in our study felt fast food restaurants did not offer enough healthy meals but were accommodating to healthier requests. This is consistent with past evidence that progress has been made in the food industry to supply healthier foods in response to the demand (Glanz et al., 1995). Yet, most of our participants said they would use nutritional information displayed in fast food restaurants, suggesting that point-of-purchase nutrition interventions (POP), which provide consumers with information, reminders, and reinforcement at the point of decision making to influence their choice, may be effective at promoting healthier dietary practices. Controlled studies have shown positive effects of POP on food selection, nutrition knowledge and attitudes (Glanz and Mullis, 1988).

The association between our participant's satisfaction with community recreational opportunities and their reported recreational activity levels parallels findings in children, indicating that children's activity levels are correlated with the number of play spaces dose to their homes (Sallis et al., 1998). Together, these provide evidence of the importance of providing "play spaces" to children and adults.

This study, along with previous investigations, indicates that 1) nutrition education programs should broaden their focus and include guidance on how to apply the information to daily food choices, 2) nutrition education programs alone may not be sufficient to change dietary practices even when they are effective at increasing knowledge, 3) efforts to provide recreational opportunities may promote physical activity, and 4) environmental interventions, such as offering more healthy meals in fast food restaurants or using

POP, may increase the effectiveness weight control programs.


Egger, G., Swinburn, B. (1997). An "ecological" approach to the obesity pandemic. British Medical Journal. 315. 477-480.

French, S.A., Jeffrey, R.W., Story, M., Breitlow, K.K., Baxter, J.S., Hannan, P., Snyder, M.P. (2001). Pricing and promotion efforts on low-fat vending snack purchases: the CHIPS study. American Journal of Public Health. 91, 112-116.

Glanz, K. and Mullis, R.M. (1988). Environmental interventions to promote healthy eating: a review of models, programs, and evidence. Health Education Quarterly. 15, 395-415.

Glanz, K., Lankenau, B., Foerster, S., Temple, S., Mullis, R., and Schmid, T. (1995). Environmental and policy approaches to cardiovascular disease prevention through nutrition: opportunities for state and local action. Health Education Quarterly. 22, 512-527.

Hawks, S.R. and Gast, J. (1998). Weight loss management: a path lit darkly. Health Education and Behavior. 25, 371-382.

Mokdad, A.H., Serdula, M.K., Dietz, W.H., Bowman, B.A., Marks, J.S., Koplan, J.P. (1999). The spread of the obesity epidemic in the United States, 1991-1998. Journal of the American Medical Association, 282, 1519-1522.

Richard, L., Potvin, L., and Mansi, O. (1998). The ecological approach in health promotion programmes: the views of health promotion workers in Canada. Health Education Journal. 57, 160-173.

Sallis, J.F., Bauman, A., and Pratt, M. (1998). Environmental and policy interventions to promote physical activity. American Journal of Preventive Medicine. 15, 379-97.

Stokols, D. (1992). Establishing and maintaining healthy environments. Toward a social-ecology of health promotion. American Pyschology, 47 6-22.

Stokols, D. (1996). Translating social ecological theory into guidelines for community health promotion. American Journal of Health Promotion. 10, 282-298.

Veronique Pepin, Ph.D. is affiliated with the Department of Exercise and Wellness, Arizona State University East. Shari McMahan, Ph.D. is affiliated with the Division of Kinesiology and Health Promotion at California State University Fullerton. Pamela D. Swan, Ph.D. is affiliated with the Department of Exercise and Wellness, Arizona State University East. Address all correspondence to Pamela D. Swan, Ph.D. Department of Exercise and Wellness, Arizona State University East, 7350 E. Unity Ave., Mesa, AZ 85212-0180, PHONE: 480.727.1934, FAX: 480.727.1051, E-MAIL:


Responsibility I: Assessing Individual and Community Needs for Health Education Competency B: Distinguish between behaviors that foster and those that hinder well-being Sub-competency 4: Analyze social, cultural, economic, and political factors that influence health
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Author:Swan, Pamela D.
Publication:American Journal of Health Studies
Geographic Code:1USA
Date:Mar 22, 2004
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