Obesity and the African-American adolescent in Mississippi: an overview.

Abstract: Obesity is one of the most common conditions seen in medical practice, and is one of the most difficult to treat. This condition is often perceived as a cosmetic problem, but it is associated with a number of chronic medical conditions including, but not limited to, heart disease, hypertension, and dyslipidemia. Youth obesity has increased at an alarming rate in the United States and in other developed countries around the world. Given the high prevalence of obesity among adults in the United States, it is not surprising that pediatric obesity is also on the rise. The current trends in obesity among African-American adolescents in the state of Mississippi remain alarming and disheartening. Since obesity starts in early childhood and extends into the adolescent years and possibly into adulthood, behavior modification is the key to preventing the onset of obesity in all population groups.

Key Words: African-Americans, obesity, rural

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The Surgeon General of the United States has estimated the total cost of overweight and obesity in the United States in 2000 at nearly 10% of US health care expenditures. (1) This is more than 12 times the yearly cost of HIV/AIDS prevention and care in Africa, Asia, and Latin America. (2) Most distressing is that overweight and obesity is increasing in almost every age group, (3) and many of those who have it are unaware or indifferent to its consequences. (4)

Obesity may be perceived as just a cosmetic problem, but it is in fact linked with a number of serious, chronic medical conditions. Even in youth, it is associated with heart disease, hypertension, dyslipidemia, and mental health problems that can persist into adulthood, resulting in increased mortality rates at earlier ages. Given the high and increasing prevalence of obesity among adults in the United States, (5) it is not surprising that adolescent obesity is also on the rise. In the past 25 years, the proportion of overweight adolescents has tripled. (6) In 2001, the proportion of US high school students who were overweight or at risk of being so was nearly one in four. (7)

The current trends in obesity are even more pronounced among African-American adolescents in the state of Mississippi, and the failure to alter these trends is alarming and disheartening. In 2001, nearly 1 in 3 African-American adolescents in Mississippi was obese or at risk of being so, (7) with higher rates for those living in rural areas such as the Mississippi Delta.

In this review, we discuss the prevention and implications of adolescent obesity, and explore the risk factors that set the stage for weight gain. We then examine the latest national survey data and what it reveals about obesity and how it correlates with Mississippi, especially among African Americans. The paper closes with a review of what must be done to stem the rise of the overweight among Mississippi adolescents.

Obesity Among Adolescents in the United States

Definition, prevalence, and implications

The proportion of overweight adolescents appears to be greater in the United States than in almost any other Western country. (8) This is not surprising, for the increase in overweight children and adolescents has been well documented in a series of nationally representative surveys covering nearly 40 years. (9,10) This trend mirrors the growing prevalence of obesity in adults. (11)

Overweight is best defined by body mass rather than by absolute weight or clinical judgment. (12) The body mass index (BMI), calculated as weight in kilograms divided by height squared in meters, is used by health care professionals to identify persons who are or who may be at risk for becoming overweight. Because normal body mass varies with age, BMI-for-age growth charts are used to identify abnormal growth patterns. (13) Persons at or above the 95th percentile are classified as "obese" or "overweight"; those between the 85th and 95th percentiles are "at risk" of becoming so. The terms applied to these percentiles may vary, but the growth pattern they represent is acknowledged to mirror excess body mass for height and to reflect an increased risk of the health consequences arising from it. (14) In this review, we will use the terms "overweight" and "obesity" interchangeably.

According to national survey data collected in 1999 and 2000, 30% of US adolescents ages 12 to 19 were overweight or at risk of being so (Table 1). At least 1 in 8 was overweight in every sex and ethnic group. The highest prevalence of overweight was among Mexican-American boys and African-American girls, among whom more than 1 in 4 was over-weight. The percentage of overweight adolescents more than tripled in the 37 years between the earliest and latest surveys (Table 2). The growing trend in overweight was evident in Hispanics, African-Americans, and whites, as shown in earlier studies, (15) demonstrating that obesity is a problem across all cultures and ethnic groups in the United States.

In adults, obesity is associated with increasing blood pressure, type 2 diabetes, and abnormal levels of total cholesterol. These associations have also been established in younger persons. (14) A study of more than 9,000 children, 5 to 17 years of age, found that those with a BMI at the 85th percentile or higher were 2.4 times more likely to have elevated levels of total cholesterol. (16) There was also a higher risk of elevated systolic and diastolic blood pressures, high low-density lipoprotein and high-density lipoprotein cholesterol, and fasting insulin. More than half (58%) of the overweight children had at least one risk factor for cardiovascular disease. Similarly, a recent study revealed that obese children and adolescents had significantly higher casual and ambulatory blood pressures than the nonobese. (17) A comparable result has been reported for children as early as elementary school. (18) These early signs of risk are not benign; overweight adolescent males are more than twice as likely to die of coronary heart disease as adults than are lean adolescent males. (19)

In an extensive and critical review of the literature, Reilly et al (14) noted other well-documented associations between overweight and disease. Asthma and type 1 and type 2 diabetes are more prevalent in children and adolescents who are overweight. Evidence for comorbidity of polycystic ovarian syndrome and a variety of other conditions is accumulating. Psychologic morbidity is also a widespread health problem linked to overweight, with obese adolescents more likely to have psychologic and psychiatric problems. (20)

Obesity in youth does not necessarily or even usually resolve with age. A study of 854 health maintenance organization members in Washington State discovered that obese adolescents had an odds ratio of 17.5 for obesity in the early years of adulthood, even after taking the BMI of the parent into account. (21) Furthermore, adolescent obesity was more likely to persist into adulthood than childhood obesity.

Risk factors for overweight

Many children in the United States have a high-fat, high-calorie diet. Moreover, many adolescents with working parents are alone after school and at mealtime. Convenient prepackaged meals, which are usually high in calories, may constitute dinner. Snacks, sweets, soft drinks, and sweetened beverages can make up a significant fraction of the diet; all these have been linked to obesity. (22,23) School meals are also typically high in calories. (24) On the other hand, overweight children are not always overeaters, although many foods they enjoy are high in calories. For example, a child who consumes an extra 200 calories per day by eating a small bag of chips or a 1.25-ounce chocolate bar can gain one-half pound per week, resulting in a 26-pound weight gain over 1 year. To support the idea that overeating is not the single cause of obesity, consider that the US mean energy intake for children and adolescents did not change radically between the 1970s and the NHANES III survey in 1988 to 1994 (except for adolescent females), and the percentage of this intake from total and saturated fat actually declined. (23) Yet the proportion of overweight children and adolescents virtually tripled in that period.

Inactivity is another contributor to overweight in the United States. In 2001, only half the high school students participated in physical education classes. (24) Outside of school, watching television, a frequent diversion during inactivity, has been linked to overweight in several studies. In the NHANES III survey (1988 to 1994), prevalence of over-weight was lowest among males and females 8 to 16 years old who watched at most 1 hour of television daily. (25)

On the other hand, the relation is not clear-cut. Watching television more than 2 hours daily was predictive of over-weight among several groups of female high school students, but not among African-American females. In fact, television viewing was associated with greater physical activity in African-American males. (26) In a study of North Carolina adolescents, (27) the relation between watching television and BMI was neutralized by adjustment for ethnicity and socioeconomic status (SES). Time spent watching television was associated with being sedentary and eating an inadequate quantity of fruits and vegetables daily, (26) so the effect may depend on the extent to which it reinforces other behaviors that contribute to weight gain. The role of vigorous or sustained physical activity is also somewhat unclear. High-intensity activity for as little as 3 days weekly has been associated with a decreased risk of overweight in males but not in females after adjustment for ethnicity and SES. (27)

The National Longitudinal Study of Adolescent Health, with more than 13,000 participants, defined "overweight" as BMI at or above the 85th percentile, adjusted for age and sex. When the study examined ethnicity and socioeconomic factors and their contribution to overweight, a complex pattern was again observed. Although overweight prevalence decreased with increased SES among white females, it showed the inverse relation for African-American females, so that the overweight prevalence gap between African-American and white females widened in the higher SES categories. Among males, this disparity was smallest at average SES levels. (28) These results highlight the role of race and ethnicity in discussions of overweight, which are in turn inextricably linked to SES. This is explored in data from the 1996 iteration of a nationally representative sample of more than 8,600 families. (29) In this large study, the rates of overweight for white and African-American adolescents were similar. Poverty was actually associated with a lower prevalence of overweight, but lack of health insurance or having public insurance doubled the odds ratio associated with prevalence of overweight. This latter relation was not observed for children but only for adolescents. An investigation of 10- to 16-year-olds in North Carolina that included a large proportion of rural students found that SES and ethnicity were critical variables in risk of overweight, stronger than the influence of viewing television at least 2 hours daily. (27)

Although obesity is a national problem, the factors that encourage it vary among ethnic groups. Cultural perceptions influence weight gain, and they may be the most difficult and unique aspect to address in dealing with adolescent obesity. Factors such as body perception and imagery, eating habits, and cultural norms all have an impact on body size, especially in the African-American community. To explore the cultural perception of weight among adolescents, Dietz (30) conducted focus groups among African-American, Mexican, and white male and female teenagers, both normal weight and obese, to understand the beliefs and concerns related to overweight, eating, and physical activity. Among male teens, perceptions of being healthy or overweight were congruent across ethnicities. However, among teenage females, perceptions were noticeably different. African-American girls believed that they were healthy regardless of their weight.

Finally, the genetic and environmental contributions of the family also influence risk of overweight. Children living with obese mothers are apparently at a greater risk for development of obesity. In one study of 15- to 17-year-old adolescents, having at least one obese parent doubled the risk of being an obese adult regardless of the adolescent's own obesity status. (21)

The African-American Adolescent in Mississippi

Mississippi is neither a rich nor a privileged state. Twenty-one percent of the population are not high school graduates. Median household income in the state is only $20,000, and the poverty rate is 25%. A little more than one third of the state (36.6%) is African-American, with 61.4% considered white. (31) According to census data, 7.7% of the population of Mississippi is between the ages of 10 and 14 years, with another 8.2% between the ages of 15 and 19 years.

The limited resources in the state underline the need to find effective tools to determine gaps in public health and ways to address them. In this section of the overview, data from the Youth Risk Behavior Surveillance System (YRBSS) are used to describe Mississippi adolescents and how they compare across ethnic groups. We address factors that might influence the risk of overweight and discuss recent trends in these factors, as well as steps that have been or should be taken to address the troubling increase in obesity and related morbidity.

The YRBSS monitors health risk behavior among high school students (grades 9 to 12) in public and private schools across the United States. These behaviors include tobacco use, dietary habits, physical activity, alcohol and other drug use, risk-related sexual activity, and behavior that contributes to unintentional injuries and violence. The YRBSS tracks these biannually and provides comparable national, state, and local data, including online reports with data for selected subpopulations. The results are thus representative of adolescent students in grades 9 to 12 in their respective geographic areas.

The latest YRBSS in Mississippi, in 2001, involved 1,806 Mississippi students in 28 public schools. The response rate was 74% for schools, 89% for students, and 66% overall. Students completed a self-administered, anonymous, 87-item questionnaire. Survey procedures were designed to protect the privacy of students by allowing for anonymous and voluntary participation. Technical details are available from the Centers for Disease Control and Prevention. (32)

The trends observed for obesity in Mississippi adolescents are a reflection of trends occurring in the United States, as noted in Tables 1 and 2. Comparing current Mississippi data with these national figures (Fig. 1), 29.4% of Mississippi adolescents were overweight or at risk of being so, compared with 24.1% in the United States as a whole; however, in the African-American population, the US percentage was actually greater than in Mississippi: 32.4% versus 33.8%. This advantage is of little comfort when one notes that nearly 1 African-American adolescent in 3 in Mississippi was in the danger zone for obesity. A notable difference between whites and African-Americans in the state was apparent (26.8% versus 32.4%). Despite this, the perception among African-American adolescents that they are overweight has generally declined (Fig. 2). Fewer African-American than white adolescents viewed themselves as overweight in every survey since 1993, although the converse was true. This demonstrates the importance of cultural perceptions in the battle against obesity.

A similar picture appears when one considers the percentage of adolescents who stated that they were trying to lose weight (Fig. 3). In 1993, 24% more whites than African-Americans were trying to lose weight. As the years progressed, this gap widened until 40% more white than African-American adolescents were trying to lose weight in 2001. Similarly, a smaller percentage of African-American than white adolescents failed to adjust their eating habits to maintain or lose weight (32% versus 45%, respectively in 2001). (33) Again, the action was inverse to the need.

Data on adolescent physical activity show a somewhat brighter picture. Figure 4 gives the percentage of students who exercised or participated in vigorous physical activity for at least 20 minutes in 3 of the 7 days before the survey. For African-Americans, the percentage of adolescents participating was lower than for whites in every year. However, the African-American proportion is rising, and the gap between the two races has become smaller. There are generally similar results for muscle strengthening/toning activity and for any physical activity at all. More African-American than white students attend physical education class daily (24.9% versus 20.9% in 2001). Unfortunately, however, nearly 1 in 5 African-American adolescents (18.8%) failed to engage in even moderate physical activity in 2001. This may be due to limited opportunity. Overall, in Mississippi, less than one third of all adolescent students (31.7%) attended a physical education class even once per week in this year.

Perhaps the most noted trend among Mississippi adolescents, particularly those who are African-American, is in the number of hours of television watched per day. In 2001, the difference between both races for watching 3 or more hours of television on an average school day was dramatically different; only 36.5% of whites watched television for such extended periods, whereas double that percentage (73.5%) of African-American adolescents did so (Fig. 5). Similar data were obtained in 1999, corroborating the results of another national survey. (34)

What Needs to Be Done

Decreasing the prevalence of obesity among African-American adolescents in Mississippi requires focusing on the key risk factors and correcting them through behavior modification, decreasing caloric intake, increasing physical activity, and education. The Dietary Guidelines for Americans recommend that children and adolescents choose a healthy assortment of foods that include vegetables, fruits, grains, fat-free or low-fat milk products, fish, lean meat, poultry, and beans. The guidelines also advise children and adolescents to get at least 60 minutes of physical activity daily, whereas inactive play forms such as television viewing and computer games should be kept to a minimum. The YRBSS has provided insights into patterns of behavior that are far from these guidelines, showing that unhealthy dietary habits and inadequate physical activity are frequent among adolescents, especially African-Americans living in Mississippi. This knowledge about adolescent behavior is critical in addressing the growing epidemic of overweight and obesity within the state.

The predominantly rural nature of Mississippi brings a unique set of risks into play that contributes to the obesity problem. The Mississippi Delta, which comprises 11 counties in the northwest part of the state, is an example. Although the Delta has a rich history, its residents are among some of the most underserved in the state. Nearly two thirds of the population is African-American, whereas one third is white (65% versus 34%). In 1997, the median household income for residents living in the Delta was $19,985. Only 18.5% of African-Americans have a high school diploma compared with 28.1% of whites. An estimated 60% or more of the residents live below the poverty level. Although access to adequate health care is a problem throughout the entire state, this trend is amplified in the Delta. Lack of grocery stores in the area also makes it difficult for residents to obtain fresh fruits and vegetables or other healthy foods. There are few schools in the region with required physical education classes. In addition, few projects have been conducted with the intent of increasing physical activity levels, improving dietary behaviors, and increasing general health awareness among adolescents. Given these conditions, adolescents living in the Delta are at higher risk for becoming obese than their counterparts throughout the rest of the state. Another example of the problems of rural Mississippi can be seen in the results of a recent study using a sample of 113 African-American children in the rural town of Canton, Mississippi. Nearly half of both boys and girls (46%) were overweight or at risk of being so. Medical histories of grandparents were marked by overweight and diabetes, stroke, and heart disease. (35)

There is a strong need for more prevention at a very young age, since the obese child will probably become an obese adolescent and ultimately, an obese adult. (36) However, if overweight/obesity or the risk of it is already present, then appropriate intervention should be readily available for this age group to prevent further weight gain as well as onset of hypertension and dyslipidemia in the adolescent population. This comorbidity is not only a fear but a current reality, for as of July 1, 2000, Mississippi Medicaid had recorded payments for a total of 3,563 youths with a primary or secondary diagnosis of hypertension, diabetes, or both.

To date, intervention efforts by public health officials and researchers have had minimal success in Mississippi. Selected programs, such as the Governor's Commission on Physical Fitness and Sports, do strive to increase the level of physical activity for all Mississippians, and there has been a slow increase in the number of Mississippi adolescents participating in physical activities. However, there are few such programs in the state, and this deficiency, especially in certain areas, makes it harder for residents who want to become fit to find places to do so. Sedentary behavior is also common in the schools. Some schools simply do not have the required physical education courses to offer students. At home, the amount of time that African-American adolescents devote to activities such as television viewing is high. Although the exact contribution of television viewing to risk of obesity is being debated, it is clear that it occupies time that could be spent engaging in physical activity. (37) In any case, a sedentary lifestyle continues to be a major obstacle on the path to weight loss for African-American adolescents.

Overweight or the risk of it is easier to recognize than to treat. Attempts that focus on the individual often fail, and health care professionals are discouraged by these outcomes. (38) Furthermore, the reimbursement of treatment for pediatric obesity is problematic. (39) Individual treatment efforts are not enough to combat the growing problem of obesity in Mississippi, especially in the Delta and other rural areas; community development is crucial. (40) School-based health education must address modifiable risk factors such as unhealthy dietary habits and inactivity. More recreation facilities are needed in the state. Both parents and adolescents must be shown the importance of increasing physical activity and consumption of healthier foods in a culturally and regionally specific manner. (41) Furthermore, health insurance and medical care must be readily available for residents, including coverage for obesity treatment. There should also be an increase in the number of health care providers to adequately serve adolescents. Culturally and regionally tailored interventions must be implemented to increase adolescent awareness concerning obesity and to address harmful cultural perceptions of overweight and health. Finally, economic development to combat poverty is essential.

Obesity and overweight are difficult and frustrating to treat. However, there are reports that well-conducted programs based on public health principles can reduce indices of overweight. (12) Using these as a focus, and with community action and support, the obesity epidemic in Mississippi and indeed in the entire United States can be attacked. The alternative--inaction and impaired health in adolescents, especially those who are African-American--is not acceptable.

Table 1. Percentage of US adolescents 12-19 years of age who are
overweight or at risk of overweight by sex and race/ethnic group
1999-2000 (a)

Sex and race/ethnic                Overweight     Overweight or at risk
group                                  %             of overweight %

All boys                             15.5                  30.5
Non-Hispanic Caucasian               12.8                  27.4
Non-Hispanic African-American        20.7                  35.7
Mexican-American                     27.5                  44.2
All girls                            15.5                  30.2
Non-Hispanic Caucasian               12.4                  25.4
Non-Hispanic African-American        26.6                  45.5
Mexican-American                     19.4                  43.5
All adolescents                      15.5                  30.4
Non-Hispanic Caucasian               12.7                  26.5
Non-Hispanic African-American        23.6                  40.4
Mexican-American                     23.4                  43.8

(a) Source: CDC National Center for Health Statistics; available at
http://www.cdc.gov/nchs/products/pubs/pubd/hestats/overwght99.htm

Table 2. Percentage of overweight US adolescents ages 12-19 for selected
years 1963-1965 through 1999-2000 (a)

Years                                               %

1963-5; 1966-70                                    4.6
1971-4                                             6.1
1976-80                                            5.0
1988-94                                           10.5
1999-2000                                         15.5

(a) Source: CDC National Center for Health Statistics; available at
http://www.cdc.gov/nchs/data/hus/tables/2002/02hus071/pdf

Ethnicity                                 Percent

United States                              24.1
White (US)                                 21.3
African-American (US)                      33.8
Mississippi                                29.4
White (MS)                                 26.8
African-American (MS)                      32.4

Fig. 1 Percentage of US and Mississippi adolescents overweight or at
risk in 2001, by ethnic group. (33)

Note: Table made from bar graph.

                          Percent
Year             White           African-American

1993             36.7                 27.9
1995             29.4                 24.7
1997             30.2                 21.5
1999             33.4                 25.8
2001             31.3                 21

Fig. 2 Percentage of Mississippi adolescents describing themselves as
overweight (1993 to 2001) by ethnic group. (33)

Note: Table made from bar graph.

                          Percent
Year             White           African-American

1993             42                   34.3
1995             40.5                 31.8
1997             44.8                 32.9
1999             44.4                 37.4
2001             47.8                 34.1

Fig. 3 Percentage of Mississippi adolescents trying to lose weight (1993
to 2002) by ethnic group. (33)

Note: Table made from bar graph.

                          Percent
Year             White           African-American

1993             59.6                 52.6
1995             56.6                 47.4
1997             57.7                 49.7
1999             59.6                 51.2
2001             56.7                 53.6

Fig. 4 Percentage of Mississippi adolescents participating in some
vigorous physical activity (1993 to 2001) by ethnic group. (33)

Note: Table made from bar graph.

                             Percent
Ethnic Group           1999           2001

White                  42.5           36.5
African-American       72.7           73.5

Fig 5. Percentage of Mississippi adolescents who watch 3 or more hours
of television on an average school day (1999 and 2001) by ethnic group.
(33)

Note: Table made from bar graph.

Acknowledgments

The authors thank Dr. Ruth Little of Epidemiology Services International, Dr. Shelia Davis, Sandra Evans, and LaToya Williams for their editorial revisions and support for this manuscript.

Accepted January 15, 2004.

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RELATED ARTICLE: Key Points

* Culturally and regionally specific interventions must be implemented to successfully combat adolescent obesity.

* Community development is crucial for the success of any youth-focused weight control program.

* Behavior modification (dietary and physical activity) is key to preventing the onset of obesity and other conditions such as diabetes, heart disease, and hypertension.

Gail D. Hughes, DRPH, MPH, Gloria A. Areghan, MSN, CSNP, and Bern 'Nadette Knight, MSPH 

From the Department of Preventive Medicine and Division of General Internal Medicine, University of Mississippi Medical Center, Jackson, MS.

Funded by a UMMC Intramural Research Grant.

Reprint requests to Dr. Gail D. Hughes, Department of Preventive Medicine and Division of General Internal Medicine, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS 39216-4505. E-mail: [e-mail]