Volume 2: No.
4, October 2005
Obesity, Health Disparities, and Prevention Paradigms: Hard Questions and
Shiriki Kumanyika, PhD, MPH
Suggested citation for this article: Kumanyika S. Obesity, health
disparities, and prevention paradigms: hard questions and hard choices. Prev
Chronic Dis [serial online] 2005 Oct [date cited]. Available from: URL:
In public health, because of our commitment to advocacy, there is always the danger of becoming a
believer — becoming so convinced about the issues one is pursuing that it becomes
difficult to consider new information objectively. Although a degree of
subjectivity is inherent in all scientific inquiry, one who believes
missing opportunities to progress based on new insights, or, worse, one may introduce bias into inquiry —
selectively evaluating data or studying the
question in a way that favors a certain answer. I find myself increasingly
preoccupied with these considerations as my work on obesity and minority
health takes me into policy arenas where I must sometimes advocate for and
defend a particular position. While issues of objectivity are relevant to
public health generally, I find them particularly pertinent to obesity, health
disparities, and prevention because — for different reasons — all three of
these topics can be polarizing and politically charged.
The politically charged nature of obesity research in an ethnic context first drew my attention at a 1984 National
Institutes of Health (NIH) workshop I attended. A black woman researcher
vociferously accused a workshop presenter (a white man) of racism and stereotyping when
he interpreted a slide as showing the “well-known finding” that black
women have a greater prevalence of obesity than white women. As an onlooker, I
realized that the presenter might have been right, but that the ability to
openly study, discuss, and ultimately solve the problem of obesity among black
women was constrained by the sensitivities associated with obesity and the
politics associated with being black in America. I decided then to take this
issue on (1). As a black woman researcher, I would be in a politically safer
and perhaps even strategic position to press for more attention to these
issues. The key research questions were obvious — what was the reason for
the high prevalence, and what could be done about it? However, these obvious
questions have not had obvious answers, even to date, and the topic is still
difficult to talk about without getting into trouble. But I press on, treating
the topic with caution and respect, because I continue to be distressed,
personally, at seeing my own reference group so affected. To guard against the
danger of being too much of a believer, I sometimes, as here, find it useful
to play the contrarian to my own position on the
importance of obesity prevention in the African American community. Through
this process of self-challenge, I push back against my own subjectivity to gain
a clearer understanding of what the issues are in African American health and how best to approach them
from a holistic perspective.
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Confronting the Issue
The obesity prevalence data for black women are, by now, all too familiar.
Seventy-seven percent of black women are in the overweight or obese (defined
as having a body mass index [BMI] ≥25 kg/m2) range, and 50% are
in the obese range (BMI ≥30) (2). The severity of obesity among black
women is also greater than average when judged by the 15% who have a BMI of
≥40 (the Class III or “extremely” obese range) (2). The variation in
obesity with socioeconomic status (SES) must be considered when comparing
blacks and whites, but the higher obesity prevalence in black than white women
is seen at all levels of typical SES indicators such as education and income
(3). The problem is not confined to adults. Among black girls, the high
prevalence of obesity is of relatively recent onset but seems to have caught
up with and passed the prevalence of obesity among white girls (4,5).
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The Political Nature of Health Disparities
When then U.S. Secretary of Health and Human Services Margaret Heckler
released the Report of the Secretary’s Task Force on Black and Minority
Health in 1985, obesity was among the modifiable risk factors associated with
leading causes of “excess deaths” (6). Excess deaths were defined as the
numbers of deaths observed in specific minority populations that were in
excess of those that would be expected on the basis of age- and sex-adjusted
data for the majority white population (6). Six causes of excess deaths
were identified — cardiovascular diseases (CVDs), cancers, homicide–suicide–intentional
injuries, diabetes, infant mortality, and cirrhosis of the liver. Obesity was
specifically linked to CVD and diabetes.
Who or what is to blame for these disparities is a political issue. Do the
disparities reflect a failing of society to provide everyone with an equal
opportunity to be healthy? Do they reflect institutionalized patterns whereby
certain racial/ethnic groups are systematically left open to abuse (e.g.,
structural violence), as argued by Paul Farmer (7)? Or are the excess deaths
thought to be attributable to inherent
defects (e.g., eugenics) or moral/behavioral failings of the affected
populations — too much risk due to too much “bad behavior”? When
Secretary Heckler released the task force report, the message was framed in
terms of individually modifiable risk factors (i.e., more toward the “bad
behavior” than the “bad society” type of explanation). Here was the
clarion call for minority populations to change their behavior, to
modify their risk factors that would cause their disparities to
However, the pervasiveness of disparities affecting diverse racial/ethnic minority
populations across the spectrum of health outcomes speaks loudly to the point
that structural factors are also involved. It is not simply their behavior
that needs changing. The dialectic around health disparities continues to
focus on equity and social justice and on the fallacy of interpreting as
genetic the systemic, biologically relevant, and transmissible health effects
of responses to institutionalized racism and social disadvantage (8,9). From a
minority health advocacy perspective, the disparities are the hard evidence of
decades of oppression and mistreatment. The greater the disparity, the more
legitimate the demand for political focus and funding from Washington.
Each minority population is left to make sure that the particular disparities
relevant to their situation receive sufficient attention — a somewhat
depressing competition for who can be seen to have the worst health profiles.
The irony in this scenario is that to succeed in reducing the disparities is
to risk falling off of the radar screen.
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Asking the Hard Questions
There have always been naysayers about the importance of obesity to health.
Nevertheless, I was shocked to hear Paul Campos, author of The Obesity Myth
(10), invoke data on the lack of association between obesity and mortality
among black women to buttress his case that the current level of public health
attention to obesity is misguided (11). I knew the data to which he referred
and strongly disagreed with his interpretation. Like the aforementioned
confrontation at the NIH workshop in 1984, this moment led me to consider the
potential validity of Campos’ argument and to challenge my own
preconceptions. Taking up the gauntlet thrown down by Campos and incorporating
my continuing concerns, I have framed the four hard questions that follow.
1) Do we really know that obesity poses a risk to health in African
The answer depends in part on how one defines health risks (i.e., in terms
of mortality or both mortality and morbidity) and how the data are analyzed. The
higher mortality of African Americans from obesity-related conditions such as CVD, diabetes, and certain types of cancer (12) does not necessarily mean that
obesity is a key factor driving these rates. Obesity could be “present but
not guilty,” since these diseases have multifactorial causation, and one
might readily conclude this from data in which mortality rates for African
Americans at the lean and obese ends of the BMI continuum are compared (13).
The slope is often surprisingly flat along most or all of the BMI range —
which was the point made by Campos. The expectation, based on data for whites,
is to see increasing mortality with increasing BMI. However, the association
between BMI and mortality is weaker in blacks than in whites in most or all
relevant data sets — for a variety of possible reasons that have been
discussed in a thoughtful review by June Stevens (13). Similar to her, my
sense has been that comparisons of relative risks across ethnic groups with
grossly different mortality profiles can be misleading. Mortality rates are
higher in African Americans than in whites across the entire BMI distribution,
and the mix of causes of death differs by ethnicity. Furthermore, death rates
reflect not only disease incidence but also all of the other variables that
influence when death occurs among people who have a disease — timing of
diagnosis, the access to and quality of treatment, adherence to treatment, comorbid conditions, non-disease-related causes of death, and other less
well-defined social and environmental factors that are reflected in death
rates and that differ between blacks and whites. My concern is that there is
an over-reliance on associations between obesity and mortality without also
considering effects of obesity on disease and disability.
Selection of indicators for comparing BMI-related risks in ethnic groups
with different disease and death rates is not straightforward (14). As with
comparisons of the obesity–mortality associations across age groups (15), the
risk in the obese relative to the lean is influenced by the rates in the lean
reference group. Stevens illustrates this by noting that comparisons based on
the rate difference (i.e., the rate in those with high BMI minus the rate in
those with low BMI) give a different impression. Such comparisons show the
absolute numbers of people affected in the groups being compared (which are
higher in the groups with higher overall death rates) (Table) (13). Dr
Stevens comments: “Most notably, it appears that the relatively smaller
increase in the obesity-associated relative rate of mortality in African
Americans compared with whites should not be interpreted to mean that obese
African Americans have a lower risk of death than obese whites” (13). She points out that the largest difference in death rates between black
and white women is not in the obese group but rather in the normal weight
group (Table). However, in spite of the lower relative risk, it is
difficult to conclude that obesity and, presumably, obesity-related
morbidities in black women are making no contribution to their
If one concedes that disease and disability are an important part of the
picture, then there is strong evidence that obesity can worsen the health of
both African American women and men. This evidence comes from studies that
show increased rates of development of disease and disability in those with
high BMI levels compared with leaner counterparts (16-19). Furthermore, some
randomized controlled trials have reported equivalent or better improvements
in risk factors or decreases in rates of disease occurrence in association
with weight loss in African Americans compared with whites (20-23). So, I
conclude that we are on solid ground in considering obesity as a health
problem in African American communities.
2) Will the increased focus on obesity further stigmatize African Americans?
Controversial images of overweight black women have been with us for
decades: depictions of Aunt Jemima (24) or the role of Mammy in Gone
With the Wind. Kathleen LeBesco, author of a recent book about
cultural and political aspects of attitudes toward obese people, argues that
the current slimness craze is rooted in an effort to stigmatize groups such as
African American and Mexican American women (25). Although I disagree with LeBesco’s line of reasoning, her assertions are a grim reminder of the
combined impact of stigma related to race and weight.
This is truly a catch-22. If nothing is said or done about obesity
among black women, the problem and its health consequences cannot be
addressed. On the other hand, when attention is drawn to the high prevalence
of obesity among black women, denigrating stereotypes of black women that are
already deeply embedded in American culture (24) may be enhanced. I am
not sure how we can work around this issue.
3) What can we really promise with respect to the benefits of weight loss?
The promise of health benefits from weight loss cannot be fulfilled without
effective weight loss programs. We still know very little about how to control
weight over the long term, and we know even less about how to control weight
among African Americans and other ethnic minority populations (26,27). Studies from which a direct comparison can be made between weight loss results
for black and white participants suggest that the best treatments do not work
as well in blacks as in whites (27). Evidence about biological explanations
for this difficulty with losing weight is not convincing (28), whereas
explanations based on environmental and behavioral determinants are convincing,
but these factors are not easy to change (27). Culturally adapted weight loss programs,
where they have been evaluated, have not met with overwhelming success,
although such programs may be well received and culturally salient (27). There
might be effective programs in communities, but few community programs have
Studies to identify effective strategies for obesity prevention and
treatment in black and other minority communities are just emerging. The most
we can promise for the time being is willingness to work with communities in
the development and evaluation of potentially effective programs. Waiting with
hands folded because we do not have the perfect solution is not an option, but
frustrating communities with ineffective programs is also not a good
4) Is obesity really a high priority in the face of other health disparities?
Obesity and obesity-related conditions are clearly not the only important
health disparities occurring within the complicated and changing societal
context affecting African American communities (12,29,30). Those of us in the
nutrition, physical activity, and obesity fields must face the question of
whether, for the overall good of the black community, for example, some of the
resources devoted to obesity would be more appropriately placed elsewhere.
Take data on women’s health, for example. While it is true that heart
disease, stroke, and diabetes — all of which are obesity related — are the
three leading causes of death for black women and affect large numbers of
black women, the more dramatic disparities relative to white women are in
conditions that threaten black women in their prime: the risk of developing
acquired immunodeficiency syndrome (AIDS) (incidence ratio of about 20 to 1 for blacks vs whites), maternal
mortality, or homicide (both with a ratio of about 4 to 1 for blacks vs
whites) (31). The black–white gap in infant mortality, with a ratio of about
2 to 1, also persists as a continuing reminder of the ethnic differences in
life chances from conception onward. There is no obvious answer to the
question of which of these problems is the most important. They are all
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Facing the Hard Choices
So far, I have been taking the view of an African American researcher. When
I view these issues as a member of the African American community at large,
the hard questions become a set of hard choices that black communities face.
Do African American community advocates and community members set priorities based on
their perceptions of social injustice, that is, on statistics
about how bad things are relative to whites, or on the immediate goal of
avoiding day-to-day pain and suffering? Does it sound ridiculous to tell people about the risk of death from
obesity-related diseases somewhere down the road when there are frequent
reminders of the risk of death right outside? People in communities should not
have to choose among various problems, all of which are pressing at some
level, simply because we scientists and professionals have bureaucratized
ourselves along problem-specific lines. In reality, multiple conditions or
health outcomes coaffect the same individuals, families, and communities and
have common underlying causes. It is we who must find ways to address multiple
problems in an integrated manner as they are experienced in
Another difficult choice for communities is whether or not to attack problems as
they appear on the surface — the symptoms — without demanding attention to
the underlying ills that continue to erode communities and the quality of the
lives therein (32). Overeating, for example, is a complex behavior that
contributes to the obesity problem among black women (33,34). Superficially
this problem can be approached with counseling about how to eat less, but
black women may want help in addressing the underlying factors that promote
overeating: the excess availability of high-calorie foods, particularly in
segregated neighborhoods that have a deficit of supermarkets and a surfeit of
fast food restaurants (35-37); food insecurity (38); and the need to cope with
stresses stemming from racism (8,9). Worse, the superficial solutions, such as
behavioral counseling without environmental amelioration, may very well create
guilt and frustration associated with knowing, but somehow not doing, what is
needed for weight control.
Whether to risk damage to a positive self-image by
making body size issues more a problem for black women is an additional
dilemma. Populations with a history of oppression have, of
necessity, honed their ability to be self-accepting to a fine art in order to
survive, to buffer mistreatment and derogatory images from outside the
community (e.g., the idea that maybe society does not love us, but we can
love ourselves). Some obese black women may have a strong self-image that
transcends weight issues and is somewhat resistant to the mainstream
stigmatization of weight. Emphasizing weight issues within African American
communities, in which nearly 80% of women would be targeted as overweight or
obese, would raise the potential for harmful effects on self-esteem. Attitudes
among African Americans and other populations with a history of economic
stress and deprivation include some that equate being heavier with being
healthier relative to thin people. Thin people may be seen as wasting away due
to illness or addictions, leading to attitudes that are less negative about
excess weight than in the mainstream (39,40). Spiritually, African Americans
may be counseled to “be satisfied with what God gave you” or, practically,
to “make the best of what you have” (41). Personal acquiescence is also a
survival skill among the oppressed.
The call for culturally adapted programs raises the issue of cultural
relativism. A purely relativistic approach would be to attempt to formulate
weight control programs and interventions in the context of the cultural
perspectives in African American communities, under the assumption that these
cultural perspectives are not only valid but also dominant considerations for
achieving salience and effectiveness of programs that address eating behaviors
and physical activity lifestyles. The extreme opposite would be the “cultural
imposition” (42) of a mainstream perspective about weight control onto
African American communities. My current hypothesis (or
hope) is that there may be some effective blend of strong, culturally valid programmatic
conceptualizations or adaptations with strong behavioral change strategies
from mainstream programs, but I
have not yet had time to put this to the test.
Finally, there is the question of how we prioritize the areas of obesity
prevention and weight stabilization. Weight stabilization makes
sense as the first step on the path toward decreasing obesity
prevalence over the longer term and thereby decreasing the incidence and
consequences of CVD and diabetes. However, the longer we wait to implement preventive
strategies, the longer the continuing influx of people into the overweight and
obese categories. Ultimately, when African American communities consider the
potential reduction in the health burden and costs as well as improvements in
quality of life that effective obesity treatment might bring, simply holding
the line with the current high rates of overweight and obesity will not
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A part of the uncertainty in moving forward with preventive strategies may
be the somewhat politically charged debate about the best choice of prevention
paradigms (43,44). One paradigm conceives of the progression to obesity on a
continuum where those who are not yet obese but who are above normal weight
are pre-obese (i.e., in the range below the clinical horizon or
threshold that defines obesity). The term pre-obesity labels a substantial proportion of the population, and particularly of
ethnic minority populations, as having a condition that requires medical
treatment. Other paradigms take a health promotion or
population health approach, focusing on whole populations and advocating
approaches whose goal is to shift the entire BMI distribution to have a lower
mean (45). Population health approaches emphasize the need for social change
and political will to effect improvement in the environments for achieving or
maintaining energy balance (e.g., policies and programs that make lower
calorie food options or smaller food portions more available and affordable
and that increase opportunities for being physically active while decreasing
sedentary time). Population- focused approaches are also termed “upstream”
approaches because the levers involved are several layers removed from “downstream”
— the level of individual choices — where the problems become visible
The dominant paradigm in the United States has been the treatment of the individual.
There is a lot of support for and often a high comfort level with individually
oriented approaches. They are closer to what many in the health care field
have been trained to do, which is to treat disease, and they are easier to
evaluate with familiar research designs such as randomized controlled trials.
These approaches are also politically safe and do not directly challenge the
commercial vested interests with a stake in the current obesogenic
environment. They do not raise the particularly American sensitivity for
possible infringement on choice that might accrue from large-scale
environmental or policy changes. Furthermore, the individually oriented
approaches emphasize “personal responsibility” as the first principle of
solving societal problems, the view that Dr Heckler espoused when she
released the report of the Task Force on Black and Minority Health in 1985. Of
course, this is also the view associated with “blaming the victim.”
I agree that individuals should be held accountable for their actions.
However, all actions happen in context. When the environment is so heavily
loaded toward fattening the population, the range of eating and physical
activity choices available to consumers is slanted in an undesirable
direction. It is very consumer unfriendly, and perhaps even cruel, to put the
burden entirely on consumers to foster the needed shift in the demand-supply
curves that relate to obesity, particularly for consumers in disadvantaged
communities where the range of choices may be especially unfavorable and where
most of the economic and political forces involved are far beyond their
personal or aggregate control. I strongly favor a population-oriented paradigm
that selectively incorporates programs for individuals.
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Looking back at the questions I posed, I say with confidence that obesity
is a serious health problem in the black community. The need for action is
even more compelling when the implications of the rise of obesity in African
American children are factored in. However, with respect to other questions,
the answers become a lot less obvious. Great care must be taken in any public
campaign on the obesity issue not to stigmatize anyone, especially children,
for whom the self-esteem and long-term attitudinal and behavioral issues are
even more complicated than for adults, and especially in populations who face
daily onslaughts to their self-esteem related to prejudice and discrimination.
As for interventions, I think the message is clear that we need to
either figure out ways to generate effective obesity interventions in the
black community and in other communities of color where excess risk is
observed, or we should get out of the business. We have to offer more, much
more, than we do now.
While I personally think obesity deserves a high priority in African
American communities, I would leave the decision about how to prioritize to
the communities themselves. Professionally, we should work more holistically
with communities so that they don’t have to choose between obesity and other
problems, especially since, from a practical perspective, the more immediate
issues always win out when people have limited means and no real choice. It
would also help to identify subgroups at high obesity-related health risk from
a phenotypic perspective. Not much has been done in this arena. Being able to
identify which population subgroups are most likely to develop the health
problems associated with obesity may become important when working with
communities in which so many people are obese.
Referring to the hard choices, I conclude with the sobering thought that
the cultural and psychosocial benefit-to-risk ratio of a major campaign to
address obesity in the black community, and perhaps other communities as well,
is not at all clear. Raising awareness and concern about obesity may render
people in communities of color less satisfied with themselves and less able to
cope with one more thing for which we cannot yet offer a good solution. This
is a reason for serious reflection as we go forward.
Adapted from the author’s keynote lecture for the Charles C.
Shepard Science Awards ceremony, Centers for Disease Control and Prevention
and Agency for Toxic Substances and Disease Registry, Atlanta, Ga, June 21,
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Dr Kumanyika is supported, in part, by National Institutes of Health (NIH) Grant No. P60 MD000209, under the Project EXPORT program.
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Corresponding Author: Shiriki Kumanyika, PhD, MPH, Professor of
Epidemiology, Department of Biostatistics and Epidemiology, University of
Pennsylvania School of Medicine, CCEB, 8th Floor Blockley Hall, 423
Guardian Dr, Philadelphia, PA 19104-6021. Telephone: 215-898-2629.
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