Eating as a cultural expression of caring among Afro-Caribbean and African American Women: Understanding the cultural dimensions of obesity

Abstract

Background

Obesity is a growing problem in the United States that is disproportionately increasing among persons of African Americans, yet little is know about the cultural factors that relate to dietary patterns, obesity and exercise among African Americans and other groups of African descent. The purpose of this paper is to examine the cultural context under which physical activity, healthy eating and weight management is viewed among African American and Caribbean American women.

Methods

Four focus groups were conducted of Afro-Caribbean and African American women (age 40 and older) between May and July of 2007 to explore cultural factors related to physical activity, healthy eating and weight management.

Results

Cultural variation was observed among Afro-Caribbean and African American woman in terms of indigenous traditions of food and preparation. These traditions influenced how they approached eating, views of obesity and exercise. At the same time community and economic factors influence the availability of healthy eating and exercise alternatives.

Conclusions

In the development of interventions to improve obesity among persons of African descent it may be important not to assume that one size fits all in terms of community based interventions

Obesity is a growing problem in the United States that is disproportionately increasing among persons of African Americans^1,2,3,4 The CDC ⁵ reports that between 1995 and 2005 the national obesity prevalence rate has increased from 15.3 to 23.9 percent, At the same time, the highest prevalence rate was highest for Non-Hispanic blacks (33.9 percent), followed by Hispanics (26.5 percent), then Whites (22.6 percent). In addition to research that supports the increase in obesity among African Americans, there is also research that supports the notion that there is an increase in obesity among persons of African descent throughout the Diaspora with the westernization of cultures. Fraser⁶ reports a dramatic change in lifestyle and socioeconomic status and rates of obesity in Barbados following their independence in 1966. He reports that a similar gradient between obesity and economic developed was found in comparing persons of African descent between the United States, Nigeria, Barbados, the Cameroon and Jamaica. Untreated extreme Obesity can lead to mortality due to obesity and heart disease⁷ Obesity has also been reported as a contributor to the rise in health care expenditures in the United States⁸ T

In the face of these challenges, a multitude of efforts have been proposed to address the problem of obesity. The CDC⁹ reports several effective community and school based strategies for reducing weight and increasing physical activity which include nutrition education, physical activity "prescription," and behavioral skills development and training. While these are viewed as global based approaches, it maybe possible that there is a need for more cultural based approaches when working with specific populations. For example, Nemesure, and colleagues¹⁰ reports that cultural factors were correlated with trends in obesity among Barbados born citizens of African Origin. Fraser noted that one of the contributing factors to obesity in the Caribbean has been the tradition going back to Africa, where obesity was viewed as healthy and fat women were viewed as preferential to thin women.⁶ Lin, Bermudez and, Tucker¹¹ (2003) reports that acculturation was positively associated with eating habits among Puerto Rican and Dominican elders. These studies suggest that there may be underlying cultural factors that may contribute to eating behaviors, exercise behaviors. The purpose of this paper is to examine the cultural context under which physical activity, eating and exercise is viewed among African American and Caribbean American women.

Method

The convenience sample consisted of 26 African American and Afro-Caribbean women (age 40 and older) participated in one of four focus groups that was conducted over a three month period (May through July of 2007) to explore factors related to their food and cooking preferences, eating habits and physical activity. Focus group members were solicited by advertising in local newspapers and Afro Caribbean community events to recruit the target sample. Focus groups were divided based on ethnicity (African American and Afro-Caribbean) and socioeconomic status (working/lower income and middle/upper income). The focus group discussions were face-to-face, guided by a semi-structured interview guide that addressed the following areas: cooking traditions, eating preferences, physical activity and perceptions of body weight and obesity (see table 1). The intent was to gain details about the nature and complexity of patterns of obesity between Afro-Caribbean and African American women. Additional data included a background questionnaire that consisted of the following attributes: age, zip code, educational level, income, ethnicity, body weight and height.

Table 1.

Focus Group Questions

What is good health? How do you perceive good health? How do you practice good health in your daily lifestyle? Perception of body image-How do you perceive body weight (fat/large and thin/small)? Perception of Illness/disease-how does weight relate to illness? Health Information-Where do you go to get information about health? Comfort Food/Traditional cooking-What food traditions are passed down through your family? Do you prepare them any differently than your elders? Life Style-how does your job, family and community responsibilities influence your physical activity or good healthy eating practices? What is obesity? How do you define obesity? What causes obesity? How do you define being over-weight What do you see are the positive and negaitve effects of being overweight What is your definition of “thin” Do you feel you need to lose weight Have you made attempts to lose weight? What types of efforts have been made? What do you think the relationship is between obesity and other illnesses/disease? What natural remedies (folk remedies)do you use to stay healthy and to lose weight What makes a healthy diet (in terms of food groups)? What makes an unhealthy diet (in terms of food groups)? What are your preferences for fast foods? What is your typical physical activity each/day Do you want to learn about how to lose weight and stay healthy? What are your sources of health information? What are your preferred sources of health information? What type of information (on weight loss) do you want

Source: University of Maryland Center for Health Disparities Research Project, University of Maryland School of Medicine

Each focus group session were audio-taped, lasted for approximately 1.5–2 hours and held at a community-based organization located in Baltimore City. An evaluator and focus group moderator, in the presence of two community-based leaders, facilitated focus group sessions. The evaluator implemented the semi-structured interview and was assisted by a moderator who welcomed participants, prompted participants’ input, and recorded pertinent verbal and non-verbal behavior. At the start of the focus group, participants were provided an informed consent form. Following completion of the interview, participants completed the background questionnaire.

Data Analysis

Each focus group session were tape-recorded and then transcribed verbatim. Constant comparison method (Strauss & Corbin, 1998) was used to organize and analyze thematic codes and categories. Data was analyzed by a team of African American and Afro-Caribbean researchers across each ethnic group and across income/class statuses. It is relevant to note that names are not used in this report to protect the privacy of the interviewees; however, identification of ethnicity and class were important to address variations; therefore the following acronyms were used after participants’ quotes: African American women, working class (AAWC); Afro-Caribbean women, working class (ACWC); African American women, middle income (AAMC); Afro-Caribbean women, middle income (ACMC).

Results

Sample Description

A total of 26 participants was involved in the study. Of these 12 were African Americans, middle and working class; and 14 Afro-Carribean women, middle and working class. The age range of African American, working class (AAWC) were 53–60 with reported weight in pounds of 146 to 286; of those with weights at 200 or above (n=3), reported that at their last doctor’s visit they were spoken to about their weight. The age range of African American, middle class (AAMC) were 41–56 with reported weight in pounds ranging from 148–270; most (n=5), reported that at their last doctor’s visit they were spoken to about their weight. Among Afro-Carribean women, working class (ACWC), ranged in age from 31–62 with reported weight in pounds ranging from 120–250; most (n=5), reported that at their last doctor’s visit they were spoken to about their weight. Afro-Caribbean women, middle income (ACMC) ranged in age from 52–60 with reported weight in pounds ranging from 146–215; most (n=4), reported that at their last doctor’s visit they were spoken to about their weight. All participants had obtained a high school degree or higher.

Focus Group Findings

Questions used to guide the focus groups that were conducted for this study are listed in Table 1. Responses to selected questions from this study guide discussed in this paper because they focused directly on the issue of culture and obesity. Quotes were provided where possible to provide examples of a given theme. There is overlap and an interrelated relationship among themes. When there were differences in findings based on income and/or ethnicity, it is noted within the report. When there is minimal variation across these areas, the richest quotes which reflect both ethnic groups are highlighted.

Passing of Family Traditions

Participants shared stories about their family traditions of cooking, food preparation and their family health history which shaped their eating habits and health behaviors. They shared how these passing of family traditions are not healthy for sedentary lifestyle of 21^st century African Americans and that modifications in food preparation were essential for maintaining a healthy lifestyle. In the excerpts below, African Americans share how their family medical history altered their perception and health behaviors.

My father died of renal failure and his two sisters and two brothers all died of renal failure. I went to the doctor with him at the renal center and I asked the doctor and he explained that the high blood pressure and diabetes with the medication they take weakens the kidney and at that point, I decided I was not going to get high blood pressure or diabetes. But he [father] knew that he had bad habits and kept the bad habits for sometime but when he got to a point of no return, than he was ready to stop the bad habits so I made a conscious decision that I was going to eat healthy and drink a lot of water. I was just not going to allow myself to fall into a lot of bad habits that is going to cause me to be sick, especially since I know my family has a history. (AAMC)

With me personally, I don’t eat any sodium because my mom and dad died from massive stroke and I know straight up that if I eat sodium and I don’t eat the things I am suppose to eat than that’s it for me! (AAWC).

African American women readily noted that their grandparents and great grandparents passed on traditions of food preparation that may not be healthy for their current lifestyle and that traditional foods were high in caloric intake because physical activity was a normal part of their lives; thereby reducing the negative affects of foods high in cholesterol.

You have to admit the lifestyle what we were taught [referring to food and preparation of meals] is not the life style that is going to keep us here longer and I think one of the reasons so many years ago that my grandparents lived so long is because they worked so hard, physical labor. I don’t do that! [group laughter] (AAMC).

I think the bottom line is we have been taught to eat a certain way and prepare our food a certain way. Some of it is passed down by word of mouth, and part of it is passed on by observation and part of it was handed to us because we didn’t have refrigeration a long time ago so we have to preserve our meats with salts. We have built up this taste for salt and your taste buds are right on the tip of your tongue and once you taste that salt you really don’t know what the food taste like. You are being de-sensitized with that salt. We have picked up those habits of using a lot of sodium with our food and it’s something that stays with us. (AAWC)

African American women recognized that based on their family’s medical history and cooking traditions, they had to make lifestyle choices and changes that would alter their health behaviors:

The lifestyle in which we live in my household, we choose not to eat a lot of sweets. Just being around family and hearing about how one is living and the aliments they are living with each and every day and my family history, which is diabetes on both sides. I made a choice to say that I need to eat differently because I see what they are suffering with…(AAMC).

There are family members who still think it’s a treat to have hog and chitlins and they still eat that. I know I did when I was young and liked it. Now, I know its not good…Every once and a while I am going to eat fried chicken but I am not going to eat it like my mother who use to say ‘Sunday ain’t Sunday without a piece of fried chicken’. You know I re-discipline myself so that I don’t have to have fried chicken every Sunday….(AAWC).

Preserving Family Traditions

Among Afro-Caribbean women (ACW) family cooking traditions and lifestyle differed vastly from African American women. Afro-Caribbean women set the context by sharing how their indigenous community encompassed an active lifestyle and more relaxed pace of living; natural and healthier food choices and the physical activity of food preparation was a form of exercise. ACW felt it was important to preserve their family traditions and lifestyle for it was a healthier alternative to adopting American lifestyle. ACW felt preserving these family traditions was difficult in American society. As portrayed below, ACW describes the cultural context of their indigenous communities by reminiscing about how their communities were less stressful and allowed them a relaxed life style:

In the island, we have fiesta, gives you a break in the day. In this country, you work every day! The lifestyle is so different [referring to indigenous community]. It’s more laid back. You are less stressed.

In the island and other countries is where you work to live but here [referring to United States] you are living to go to work!

They further noted that their indigenous lifestyle of food choice and preparation consisted of healthy ingredients and physical activity was involved which was a form of exercise:

In the island we do a lot of physical work. We walked a lot of miles and then you had to wash, sweep, working in gardens, vegetable gardens [everyone chimes in agreement]. There is a lot of physical activity.

When I think of healthy eating, I think of the food from different food groups and back home, you will always eating something from each group, the problem is what we have is with the portion size but general we go in the back and pick our food, its fresh, pure organic, no fertilized. We get fresh milk from cows, fresh oranges right outside the kitchen door, but the problem is the portion size, it’s larger. I also think going back to home is that we are picking our food, so even thought the portions are much larger, you are working for it, physically.

As depicted, their cooking is rooted in their Caribbean culture and family traditions are preserved. ACW shared traditional foods they cooked in United States were mostly healthy, consisted of “leafy vegetables, greens, spinach, pumpkin, and squash” and main staple was salt fish (cod fish):

My most current favorite meal is something I created all by myself and I need a name for it. I am going to call it Caribbean stuffed shrimp. It is so good. It is simply. I brought some salt fish…you call it cod fish… from the Caribbean store than I cut up broccoli, cauliflower, smokies, carrots, and olive oil with ginger, pieces of ginger makes it pop! [everyone laughs]. I put it all in pot with oil than I toss it in and add a green salad. Oh, my god! It’s so good! You are free to use my recipe.

Well my favorite is white dumpling with spinach, some papaya and mackerel, it’s a kind of salted fish, something like salt fish, and you got to soak it, broil it.

For me, my favorite is the dumpling with cod fish, fried plantains on the side.

My favorite remains the meal of my childhood as I was growing up on a Sunday pretty much everyone would be cooking rice and peas, glazed chicken, macaroni and cheese. You can guarantee meat on a Sunday. Sunday we have to eat the meal, whatever the meal. It’s a tradition.

Salt fish (cod fish), Fungi, ‘co co’, mackerel, stew chicken and dumplings, rice and peas, chick and peas; curry chicken, spinach and okra, pig tails and ox tails were a few home cooked favorites. Modifications in food involved “pepper rice in oven and instead of pig tails we use smoked turkey but it doesn’t taste the same”. ACW noted pork was a favorite, especially around the holidays and “there is no substitute for pork [everyone laughs in agreement]…if it’s a traditional meal that has pork, we keep it like that. We just don’t cook it as often”.

ACW were in agreement that moving to United States changed their lifestyle and affected their food choices and preparation. They noted that access to Caribbean food was possible due to the various African, Asian and Caribbean markets located in their city; however, the pace of American lifestyle was very different from their indigenous communities. Furthermore, American food consisted of chemicals, dyes and pesticides. ACW described how they became ill when they first ate American food because it was contaminated with chemicals and dyes. They described a tradition of cleaning their food to avoid ingestion of large amounts of chemicals:

Going back to my home town, the way they eat is not refined or processed. I think here [referring to United States] when you talk about healthy food, it’s still corrupted, it’s not healthy. It’s refined, not healthy. For us, we like it fresh from the farm. We pick our fruit and vegetables. It’s not mixed with chemicals.

For example the meat, most people have their own live stock, your goat, sheep and cows. You kill your own food and at the end of next week my neighbor is going to kill their cow so that is fresh meat. You have your own cows. So the meat is not affected with the preservatives.

In answer to your question [prompted by evaluator about how they deal with chemically treated food], there is a cleaning process. What we do is clean things thoroughly. Wash it with lime. Fruits and vegetables we scrubbed them. Like when you buy a mango here, it does not even taste the same. In the Caribbean you pick a mango, the heart is still beating [everyone laughs]. Here food is packaged for supply and demand and because of that things have to be preserved.

The following quotes capture Afro-Caribbean women comparing their indigenous community to American community and how lifestyle offered a healthier way of being:

Back on the island, I know and my aunt and she is up by five in the morning and leaving for work by 7:00. She has already cooked rice, peas and fish, and she has taken her lunch. They have taken the time to prepare those food but here it’s like you end up just eating anything.

Back in Caribbean, the main meal is at noon time so you eat and by evening time and its really early between 4 and 6 you are eating supper. At night you are drinking tea and piece of bread so it’s really light at night time and than you go to bed really early.

Going back to Antiqua, my mother walked everyday. She walked from market to Howardington Hospital. Aunts and uncles. They look healthy. Their energy level is high. My uncle rides a bicycle. He didn’t drive. There back home, we walk for a purpose, for food. For here [referring to United States] we are walking for exercise. In the Caribbean, here is purpose of the walk, for work, to get food. Here [in United States] you have to schedule it, you have to schedule the walking, biking. You have to say Monday, Wednesday, I am going to go to the gym or walking. You have to schedule it.

The above excerpts indicate Afro-Caribbean women are trying to hold onto their family traditions and preserve healthy living in a community context that they perceive as stressful and fast paced.

DISCUSSION

This paper offers preliminary findings regarding differences and similarities between African American and Afro Caribbean women in terms of their eating and exercise habits. Findings from the focus groups re-affirmed the importance of recognizing both the similarities and the cultural variations across the African Diaspora that can effect health education interventions. In terms of similarities across the groups, one of the common themes across the two populations was the observation that fresh organic produce was not accessible in across these communities, which effected the eating habits of respondents. A second common theme across both populations was the adaptation of healthy food substitutes for traditional meals. In this case, as the participants become more aware of the unhealthy ingredients that were part of traditional dishes, they sought out healthy substitutes for these ingredients. A third common theme that appeared across all the groups was the effect of the lack of exercise and recreational choices for the participants. Participants were consistently frustrated by the lack of exercise facilities in their communities or other places where their can exercise. These findings suggest that both groups were aware of what was needed in terms of health living, however they encountered barriers in terms of finding the means to access the foods they needed or the programs they needed in order to support living healthy. This finding is similar to findings from other studies regarding the assessment of African American and Afro-Caribbean women regarding their knowledge of healthy behaviors. In one study, Walcott-McQuigg¹² reported that African American, Caucasian, Mexican American and Puerto Rican women reported similar experiences in their wishes to control their weight, even though there were differences across cultures regarding how the acceptance of their body size. In a second study, Brown and colleagues¹³ found that while African American and Afro Caribbean women had a high degree of knowledge regarding risk factors and symptoms for asthma, breast cancer, heart disease and sexually transmitted diseases, they did not necessarily report in engaging in healthy behavior.

In addition to the common themes reported above, differences were also noted in terms of exercises habits between the populations as well as the effects of acculturation on the health of Afro-Caribbean.. For example, while this was not a consistent theme in the focus groups for the African American women, participants in the Afro-Caribbean women focus groups reported being accustomed to walking everyday. A second difference between the two groups was the reflection among the Afro-Caribbean focus group participants that they were used to eating foods that are not refined or processed. However, it should be noted that these participants reported changes in their eating and exercise habits as a result of coming to the United States. This change process is similar to studies of acculturation and obesity among Latinos immigrants where factors such as exposure to high portion meals, energy dense foods, mass media regarding food and sedentary life styles were perceived as being part and parcel to the acculturation process¹⁴

These findings suggest that health interventions that focus on persons of African descent may need to focus on the influence of historical factors (slavery and its role in transmitting expectations around weight and eating), trends in sedentary practices, and cultural expectations around eating and exercise in the development of health education programs. It may also require the consideration of the gap between knowledge of health behavior and what is needed to create a change in behavior. This is in sync with the recommendations from the African American Collaborative Obesity Research network which suggests that research in this area needs to better capture perceptions of eating and physical activity that are reflective of African American communities; examining the role of food availability and marketing in food consumption; and examining the role of cultural and structural change in the community as it effects health¹⁵.

Limitations

Given that the majority of the findings from this study came from qualitative data, one must be careful not to generalize the findings to all Afro-Caribbean and African American women. Rather, the important implication here is that the data helps us to understand that we need to know more about the context of the interactions between partners in order to design more viable, effective interventions.