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Journal Issue: Childhood Obesity Volume 16 Number 1 Spring 2006

Targeting Interventions for Ethnic Minority and Low-Income Populations
Shiriki Kumanyika Sonya Grier

Understanding and Closing the Gap

Effectively addressing ethnic and socioeconomic disparities in childhood obesity requires understanding which causes of obesity might be especially prevalent or intensified in ethnic minority and low-income populations; understanding how aspects of the social, cultural, and economic environments of minority and low-income children might magnify the effects of factors that cause obesity; and determining which changes in those environments would help most to reduce obesity. In what follows, we discuss these issues in relation to media and marketing influences, community food access, built environments, schools, and home environments, noting in each case how factors that may promote obesity are particularly likely to affect low-income and minority youth.

Media and Marketing
Research suggests that low-income and ethnic minority youth are disproportionately exposed to marketing activities.25 A Kaiser Foundation report found that among children eight to eighteen years old, ethnic minorities use entertainment media more heavily than majority youth do. African Americans and Hispanics spend significantly more time watching TV and movies and playing video games than do white youth.26 African American youth also watch on-screen media (TV, DVDs, videos, movies) more than Hispanics and whites do, and Hispanics watch such media significantly more than whites do. Television is especially prevalent in African American and low-income households. Media use differs, as well, by socioeconomic status. Low-income children watch TV for more hours and have significantly higher levels of total media exposure than higher-income children.27 Consumers in low-income households, who are heavy viewers of daytime television, are more likely to view television advertising as authoritative and as helpful in selecting products, and they may prefer it to print media.28

Because of their heavy media use, ethnic minority and low-income youth are exposed to a great deal of food advertising at home. Research has found that such advertising can affect children's food preferences after even brief exposure.29 A study of media use among Latino preschoolers confirmed just how influential such commercials can be. Sixty-three percent of mothers said that in the past week their preschooler had asked for a toy advertised on television, 55 percent reported that their preschooler had asked for an advertised food or drink, and 67 percent noted that their preschooler had asked to go to an advertised store or restaurant.30 Older elementary school children exposed to television commercials for sweets and other snacks were more likely to choose candy and sugary drinks and less likely to choose fruit and orange juice when offered a snack.31

Most research on food advertising, however, does not focus on ethnic minority or low-income youth. A systematic review of the effects of food promotion on children examined more than 100 articles, fewer than six of which dealt explicitly with ethnic minority or low-income children.32 Experimental evidence, however, indicates that ethnic minorities seem especially responsive to targeted ads.33 African American adolescents, for example, identify with black characters in advertisements, and they rate advertisements featuring these characters more favorably.34 Such responses may lead them to buy and consume less nutritious food products when advertised by these characters.

Ethnic minority and low-income children may also be exposed to a different mix of information than are other children. Content analyses of television advertising have found that shows featuring African Americans have more food commercials than do general prime-time shows and that these commercials feature more energy-dense foods.35 Advertisements for such products appear to be particularly effective in increasing children's total caloric consumption.36 Advertisements in African American adult magazines are also dominated by low-cost, low-nutrition, energy- dense foods, and the magazines are less likely to contain health-oriented messages.37 Similarly, a content analysis of the products advertised to low-income consumers found that most featured food and drinks, largely items such as cookies and other snacks.38 Such an imbalanced information environment makes it harder for parents to know about and to provide more healthful options.

Food and food-related images, such as body size, are also pervasive in various media. A content analysis of movies—and ethnic minorities watch movies more often than whites do—found stereotypical food-related behaviors with respect to body shape, gender, and ethnic background.39 More healthful, low-fat foods often appeared in scenes involving well-educated and affluent characters. Overweight characters were underrepresented, but when they did appear, they ate more high-fat, high-calorie foods than did their thinner counterparts. There is no evidence, however, on whether the movies' representation of food and food-related images affects how children perceive themselves or alters the foods they consume.

More research on the specific marketing environments of ethnic minority and low-income consumers is urgently needed. Policymakers and practitioners should consider policy interventions, including strengthening marketing and advertising guidelines in ways that reduce the overexposure of all children to marketing for high-calorie, high-fat foods.40 Because ethnic minority and low-income children are exposed to more media than other children, policies that improve marketing and advertising may be most beneficial for these groups of children. Researchers have also suggested that schools can reduce the negative effects of advertising on minority and low-income children by teaching media literacy courses that make children aware of the many messages they receive daily from the media and how those messages can affect their attitudes and behavior.41

Food Access and Availability
The characteristics of communities in which ethnic minority and low-income children live may affect the foods that are available for their consumption. Compared with more affluent communities, minority and low-income communities have fewer than average supermarkets and convenience stores that stock fresh, good-quality, affordable foods such as whole grains or low-fat dairy products and meats.42 A 1995 study estimated that supermarket flight from the inner cities left the typical low-income neighborhood with 30 percent fewer supermarkets than higher-income areas. At least one study that included a large cohort of African Americans has linked supermarket availability directly to fruit and vegetable intake.43

With fewer supermarkets available, low-income minority families may be more likely to shop in small corner stores or bodegas. These stores tend to offer markedly less healthful foods in lower-income neighborhoods, as demonstrated in a New York study comparing in-store food availability in low-income, minority East Harlem and the adjacent, affluent Upper East Side.44 Prices of more healthful foods may also be higher in bodegas and corner stores than in supermarkets. One study reported that although lowfat milk was available in more than two-thirds of the bodegas in areas where residents were less educated, had lower incomes, and were Latino, some such stores charged more for low-fat milk than for regular milk.45 Evidence shows that higher prices for more healthful foods have an effect on children's weight. A recent study based on a nationally representative sample of elementary school children concludes that children living in areas with lower prices of fruits and vegetables had significantly lower gains in BMI between kindergarten and third grade. Further, these effects were larger for children in poverty, children who were obese or overweight in kindergarten, and Asian and Hispanic children.46 This evidence is consistent with that from a study of low-income women in Baltimore that found the cost of fresh produce kept them from eating more fruits and vegetables.47

African American and low-income neighborhoods also have many fast-food restaurants. A recent study found that African American adults ate more fast foods than did whites, perhaps because of their greater availability.48 A study in New Orleans found that black neighborhoods had more fast-food restaurants per square mile than did white neighborhoods.49 Another study found that areas of South Los Angeles with fewer African American residents (8 percent on average) were twice as likely as areas with more African Americans (36 percent on average) to have full-service rather than limited-service, fast-food restaurants.50

Studies of parents' attitudes toward fast-food restaurants highlight the problems that may be produced by having fast-food outlets nearby as well as the reasons why fast-food outlets are popular among low-income families. Hispanic women in a low-income community reported that the overabundance of fast-food restaurants and their intensive marketing interfered with their ability to exercise control over their children's eating habits. They also reported that acculturation to fast food caused their children to reject more healthful, traditional Hispanic foods.51 But Latino women in a California study preferred fast-food restaurants and especially valued their family- and child-friendly aspects.52

On the important question of whether living near fast-food restaurants increases the chance that children become obese, the evidence is inconclusive. Research has found that foods served in fast-food outlets are much more energy-dense and have a higher fat content than meals consumed at home.53 Furthermore, there is a correlation between fast-food consumption and body weight, at least among adults. In a survey of women aged twenty to seventy years in North Carolina, those who reported eating at fast-food restaurants “usually” or “often” had higher energy and fat intakes and higher body mass indexes than those who reported eating at them “rarely” or “never.”54 In the Coronary Artery Risk Development in Young Adults (CARDIA) Study, which followed for fifteen years a group of young adults aged eighteen to thirty at the time of enrollment, those who ate at fast-food restaurants more than twice a week weighed an average of 4.5 kilograms more than those who ate in them less than once a week.55

This evidence suggests that if children who live close to fast-food outlets consume more fast food, they may be more likely to become obese. But the few studies that specifically examine how the proximity of fast-food outlets affects children's fast-food consumption and their weight status do not find a connection. Living close to fast-food restaurants was not linked with being overweight among three- to five-year-old children in Cincinnati or to the self-reported frequency of fast-food restaurant use among seventh- to twelfth-grade students in Minnesota.56 Researchers require more evidence, based on children from more geographical regions and age groups, before they can draw a definitive conclusion on this issue.

Built Environments
Where and how often children and adolescents engage in physical activity depends on the physical design and quality of their neighborhoods.57 In low-income urban communities, the built environment affects children's physical activity much more than it affects that of adults. Because many adults do not own cars and must depend on public transportation, they often have to be physically active just to get to and from work or shopping.58 By contrast, for safety reasons, parents may restrict their children's outdoor activities by using a combination of TV and easy access to snack foods to get children to go straight home from school and stay there. Children's limited access to parks and recreational facilities may also curtail their physical activity.59 Neighborhood or community constraints on children's physical activity are likely to vary regionally and across ethnic groups. In low-income communities, family work schedules, discretionary time, money, and car ownership may make it hard for parents and caregivers to transport children to sports and other recreational activities, suggesting the need to develop nearby after-school or community-based, supervised programs.

Despite the logic that inadequate opportunities for physical activity should adversely affect children's weight, the evidence on this issue is limited. Several observational studies have failed to link children's weight status to the availability of neighborhood parks or to parental perceptions about safety.60 A better approach would be to study direct links between specific neighborhood-based physical activity options and the types and amounts of physical activity in which children engage, taking into account how their family or home life, as well as the neighborhood's social organization, affects their access to these options. Additional research on this topic that focuses on low-income and minority children is needed.

School Settings
Schools offer opportunities for improving children's nutrition, increasing their physical activity, and preventing obesity. But schools in inner-city or low-income communities may be unable to take advantage of these opportunities, as most obesity-prevention initiatives proposed to date require significant funding and some depend on a school's physical facilities and neighborhood characteristics.61 In addition, school officials, teachers, and parents have many competing priorities, such as new academic accountability standards and efforts to prevent drug abuse and violence.

Research on whether schools in low-income areas are less able to provide students with healthful foods or physical activity options is inconclusive. Several reports have compared environmental quality, resources, and per-student spending in schools with differing community income or differing shares of minority students. A report by the U.S. General Accounting Office (GAO) focused on such school problems as inadequate or unsatisfactory buildings, building features, or environmental conditions as well as expenses above the national average. Schools reporting the most problems in all areas were large schools, central-city schools, schools in the western United States, schools with populations of at least 50.5 percent minority students, and schools with 70 percent or more poor students.62 The differences, however, were often not striking, and the greatest variations were often by state.

A Centers for Disease Control and Prevention analysis addressed general health and safety issues as well as conditions and policies with more direct implications for physical activity and nutrition. It included athletic facilities and playground equipment, kitchen facilities and equipment, the presence of a cafeteria, soft drink vending contracts, and junk food promotion.63 Contrary to expectation, schools in urban areas, schools with a high share of minority children, and schools with a low share of college- bound students were not worse off than other schools. Schools with the best health-protective environments turned out to be elementary schools, public schools, and larger schools.

Poorer children benefit from the National School Lunch and National School Breakfast Programs. These food programs, which provide free or reduced-price meals to low-income children, disproportionately enroll minority children. In 2004, in fourth grade, for example, nearly 70 percent of African American students, as against 23 percent of whites, were eligible for free or reduced-price lunches. Nearly half of African American students, as against only 5 percent of whites, attended schools where most children are eligible for subsidized meals.64 Because these meals must meet federally set nutritional standards, these programs offer an opportunity to improve the nutrition of low-income minority children.

Although poorer children are eligible for free or reduced-price lunches in school, many schools offer a wide variety of “competitive” foods that do not meet nutritional standards. Schools that participate in the school lunch program face some federal restrictions on what foods they can serve during lunch periods in the school cafeteria, and many states and school districts are imposing additional standards.65 But children can often purchase sodas and high-fat, high-sugar foods at school. As noted by the Government Accountability Office, these unregulated competitive foods undermine the school breakfast and school lunch programs, with negative nutrition implications for the children, but they may generate substantial revenue for the schools.66 The GAO report does not indicate whether schools with limited resources depend more on revenue from competitive food sales than do wealthier schools. If they do, limitations on competitive food sales may impose a relatively larger burden on low-income schools. More research on this topic is needed. If in fact low-income schools will be disproportionately harmed by restrictions on competitive foods, then new regulations on competitive food sales might be coupled with compensatory financing for the schools most harmed.

In addition to restricting the sales of less healthful foods, many schools are considering interventions to promote the consumption of more nutritious foods. Some of these initiatives may be more effective in schools serving low-income children than in schools with more resources. For example, an intervention that lowered the prices of fruits and vegetables had a greater impact in inner-city schools than in suburban schools and suggests that making nutritious foods more accessible in these schools can increase demand.67 In-school free fruit and vegetable distribution should be of particular benefit to low-income children, who have less access to fruits and vegetables than their more affluent counterparts. Such approaches as salad bars with links to local farmers' markets or even student gardening programs could also be useful.68 But before any such programs can begin on a large scale, comparative analysis of the availability of the community resources required for feasibility is essential.

Home and Family Settings
Another important question for researchers analyzing ethnic and socioeconomic disparities in childhood obesity is whether differences in home environments contribute to differences in child obesity rates. There are various underlying reasons why parenting practices may differ across ethnic and socioeconomic groups. Minority and low-income households have a higher share of female-headed families, lower parental education, and higher rates of teen parenting, all of which may profoundly affect the home environment.69 Economic insecurity can influence food choices directly, by encouraging the purchase of cheaper, energy-dense foods, and indirectly, by producing psychosocial stress that affects parenting.70 The higher prevalence of obesity among adults in minority and low-income populations may also affect children's weight status.71 Maternal obesity and diabetes, both relatively more common among minority women, may predispose children to obesity.72 In addition, obesity among parents may affect both the weight norms their children develop and the modeling of eating behaviors and physical activity they observe.

In what follows, we focus on three aspects of the home environment—breast-feeding, television viewing, and parental attitudes and behaviors. Each may be of particular importance for the development of obesity in ethnic minority and low-income children and may be amenable to change through targeted interventions.

Breast-feeding. Although breast-feeding rates for all groups have increased notably in recent years, disadvantaged minority groups still have lower rates than others.73 As of 2001, the rates of breast-feeding for African American infants were 53 percent in-hospital and 22 percent at age six months. For Hispanics, the rates were 73 percent in-hospital and 33 percent at six months, whereas for whites, the rates were 72 percent in-hospital and 34 percent at six months.74 High rates of teen pregnancy may contribute to lower breast-feeding rates, early introduction of solid foods, and early feeding of high-sugar foods for African American infants.75 In another article in this volume Ana Lindsay and several colleagues note that the evidence on whether children who are breast-fed longer are less likely to become obese is inconclusive. Instead, mothers who choose to breast-feed may be more likely to adopt other behaviors that reduce the chance of obesity. Nonetheless, the link between longer breast-feeding and a lower risk of obesity, combined with the other well-documented benefits of breast-feeding, argues for efforts to increase breast-feeding among ethnic minority families.

Television viewing. TV watching may contribute to obesity by increasing sedentary behavior, increasing snacking while watching TV, and exposing children to advertisements for unhealthful foods and beverages.76 The Institute of Medicine has recommended that parents restrict their children's television watching to fewer than two hours a day.77

Television's pervasive role in the lives of minority and low-income children, however, may make it hard for parents to turn off the TV. As noted, ethnic minority and low-income children have, as a group, high average levels of television viewing. African American households that can afford them are more likely than others to have premium channels and to have three or more TV sets.78 Interestingly, the lower their parents' education, the higher the likelihood that a child will have a VCR or DVD in the bedroom. African American children are also more likely than whites to report having televisions in their bedrooms, along with DVDs, cable and satellite connections, premium channels, and video game consoles. Youth from the lowest income group are the most likely to have their own television sets. Watching television during meals is also more common in families with lower parental education, or lower income, as well as among Hispanics and African Americans. The National Heart, Lung, and Blood Institute Growth and Health Study found that eating while watching TV was more common among African American girls. This practice is also linked with reported higher caloric intake.79

Developing interventions, possibly school- or child care center–based, to help low-income and minority parents reduce their children's TV time is important. Such interventions could also teach parents to help their children learn to evaluate critically the advertisements and programs they see at home.

Parental attitudes and behaviors. Efforts to get parents to pay closer attention to their children's weight and BMI can be controversial, because some parents can become overly restrictive about their children's food intake. Addressing childhood obesity issues with parents in minority and lower-income communities requires particular sensitivity to differences in attitudes about weight that may be the products of culture or economic insecurity.

Societal attitudes about weight may be changing as more and more adults become overweight and obese. But in communities where most women or adults are obese, as in many ethnic minority and low-income communities, attitudes, norms, behaviors, and cultural influences may be in equilibrium with a high level of obesity. There may be a mixture of positive and negative attitudes about being overweight, especially where people who are thin are thought to be sick, addicted to drugs, too poor to have enough to eat, or to risk “wasting away” in the case of food shortage or of serious illness.80 In such environments, parents and other family members may consider being overweight as normal, perhaps determined by heredity. Shapeliness, robustness, and nurturing qualities may be standards of female attractiveness that encourage the overall acceptance of people who—by BMI standards—are otherwise considered overweight or obese. One study found that African American girls were more likely than white girls to try to gain weight, largely because their parents told them they were too thin.81

Several child feeding attitudes or practices that are theoretically associated with obesity development are common among low-income mothers. Among them are heightened concerns about a child being hungry; greater difficulty withholding food from a child, even one who has just eaten; and concern about underweight even if a child is above normal weight.82 Focus groups have found that low-income parents may see their overweight or obese children as “thick or solid.” And other family members might challenge parents if they try to control their child's diet.83 The view that “a fat child is a healthy child” or that children's weight follows a natural trajectory where heavy children will “grow out of it” may be more common among families that are food insecure or where hunger concerns are part of a group's identity.

In spite of such cultural differences, programs to motivate and educate low-income parents and caregivers in diverse ethnic minority populations about how to promote healthful eating and physical activity in their children, combined with programs for the children themselves, have yielded promising results.84 Childhood obesity-prevention programs should also work with parents on their own weight issues. By promoting an understanding of the core principles of energy balance and by helping parents model the targeted nutrition and physical activity behaviors for their children, such programs could lead to favorable changes at home. Given the challenges of parenting in low-income communities, these programs should lessen rather than increase the stresses on parents by helping them and their children in ways that go beyond eating and physical activity. For example, after-school programs could include tutoring and time to do homework in addition to providing healthful snacks, dance, and active play.85 Working with girls and their mothers together—counseling mothers about weight control and having them interact with their daughters—may be particularly effective for African American preadolescent or adolescent girls.86 The ideal program simultaneously addresses many issues, including empowerment strategies, in the community, school, and home.