Religiosity and Excess Weight among African American Adolescents: The Jackson Heart KIDS Study

Abstract

Recent studies suggest that religion and spirituality can yield health benefits for young African Americans. We examined the relationship between religious practices, spirituality, and excess weight among African American adolescents (N=212) residing in the Deep South. Results from Modified Poisson regression analysis indicate that adolescents who prayed daily had a lower prevalence of excess weight (PR=0.77 [95% CI: 0.62-0.96]) than those who did not. This relationship was only significant for 12-15 year old participants in age-stratified analysis. These findings suggest that preventive interventions offered to children and younger adolescents can have implications for weight status across the lifespan.

Scholars have been interested in the relationship between faith-oriented factors and health for centuries. More recently, a growing segment of health scientists have begun to consider the implications of religion and spirituality (R/S) on physical health. While it is generally thought that R/S can be beneficial for an individual’s overall health and well-being, results from recent studies have been mixed. The obesity literature in particular, is exemplary in that some studies have found religiosity (i.e., the outward expression of social, doctrinal, and denominational links to organized religion) to be associated with lower obesity risk and prevalence (Cline & Ferraro, 2006; Gillum, 2006a, 2006b; Koenig, King, & Carson, 2012). Whereas other studies have found religious practices to have no effect, or in some cases, to be associated with an increased risk for obesity in adults (Dodor, 2012; Feinstein, Liu, Ning, Fitchett, & Lloyd-Jones, 2010; Ferraro, 1998; Godbolt, Vaghela, Burdette, & Hill, 2017; Kim, Sobal, & Wethington, 2003; Sack, 2001). There are multiple explanations for these conflicting findings, including the use of imprecise concepts and contextually inappropriate measures of R/S that can confound results (Bruce, Beech, Griffith, & Thorpe, 2016; Bruce, Martins, et al., 2017; Underwood & Teresi, 2002).

Recent narrative and systematic reviews assert that new insights will emerge from studies that examine links between health outcomes and specific domains of religious or spiritual engagement as well as those that focus on populations for which the associations between faith-oriented factors and health appear to be salient (Maselko & Kubzansky, 2006). Obesity can be an important focus area in the next generation of research linking R/S and health due to its increasing prevalence among diverse populations with strong faith-oriented attachments and beliefs. Weight reduction and weight gain prevention have been the focus of many health-based interventions that take place in religious settings (i. e., churches, mosques, temples) and incorporate religious tenants or practices (Duru, Sarkisian, Leng, & Mangione, 2010; Godbolt et al., 2017; Lancaster, Carter-Edwards, Grilo, Shen, & Schoenthaler, 2014). This line of research underscores the importance of religious practices such as church attendance or prayer for adults; however, studies examining the relationship between faith-oriented factors and obesity-related outcomes in children and adolescents are scarce (Bruce et al., 2016; Dill, 2017; Limbers, Young, Bryant, & Stephen, 2015).

African Americans as a group have the strongest identification with, and attachment to, religious and spiritual communities (Godbolt et al., 2017; Pattillo-McCoy, 1998; Pew Research Center., 2009, 2016); as well as proportionately high risks for obesity and obesity-related diseases (e. g., hypertension, type 2 diabetes mellitus, chronic kidney disease, cardiovascular disease) (Bruce et al., 2013; Bruce, Beech, et al., 2017; Norris & Nissenson, 2008; Thorpe et al., 2014). Evidence from the National Study on Youth and Religion, a nationally representative longitudinal study of adolescents in the United States, indicates that religious and spiritual issues are important to this population as a majority of sample members indicate that they believe God and religion is important in their lives (Denton, Pearce, & Smith, 2008; Smith & Denton, 2009; Smith, Denton, Faris, & Regnerus, 2002). It has been suggested that R/S can promote well-being and protect adolescents from poor health (Bridges & Moore, 2002; Dill, 2017; Regnerus, 2007; Regnerus, Smith, & Fritsch, 2003). The bulk of these studies however focus on risky behaviors such as unprotected sex, alcohol consumption, and illicit drug use.

Obesity is a significant health concern, as the prevalence of obesity among 12-19-year-old individuals has quadrupled over the past 30 years (Ogden, Carroll, Kit, & Flegal, 2014); and the upward trend for African Americans adolescents has been even sharper. The adverse health impact of obesity is significant among young African Americans given the elevated risks for the early onset and accelerated progression of chronic diseases among this group. It is important to determine if R/S has implications for obesity among African American children and adolescents, as there is an urgent need for culturally sensitive interventions designed to reduce disparities in the risks for obesity among African American youth. The purpose of this study was to examine the relationship between religious practices, spirituality, and excess weight among a sample of African American adolescents residing in the Deep South.

METHODS

Data are from the Jackson Heart KIDS Pilot Study (JHS-KIDS), an observational examination of the development of obesity, metabolic and CVD-related risk factors among African American adolescents in the greater Jackson, Mississippi area (Beech, Bruce, Crump, & Hamilton, 2017; Bruce, Beech, Griffith, & Thorpe Jr., 2015; Bruce et al., 2016; Bruce, Beech, et al., 2017; Burton, Wilder, Beech, & Bruce, 2017). Eligible participants were adolescents aged 12-19 years who were either children or grandchildren of individuals enrolled in the Jackson Heart Study (JHS), the largest epidemiological study of cardiovascular disease among African Americans in the United States. After receiving approval from the University of Mississippi Medical Center Institutional Review Board, the research team used multiple methods to recruit participants through contact with JHS participants.^4,22 Interested parents or grandparents called the study phone number and answered screening questions to ensure eligibility. Two hundred twelve adolescents and an accompanying parent or grandparent participated in the pilot study.

Adolescent participants had their blood pressure, height, and weight measured, and were asked to complete self-administered surveys during the study visit. Blood pressure readings were obtained by trained staff with a random zero sphygmomanometer.²³ Participant surveys contained several psychosocial (i.e., religiosity/spirituality) and health behavior (i.e., nutrition, physical activity) measures. The parent/grandparent present at the study visit, regardless of their participation in the JHS, had their BP, height, and weight measured, and completed the Child Feeding Questionnaire if the child participant lived with them.

Study Variables

Outcome Variable

Excess weight was defined by weight status categories based on body mass index (BMI) cut points specified by the Childhood Obesity Working Group of the International Obesity Taskforce (Vidmar, Carlin, Hesketh, & Cole, 2004). Participant measured height and weight were used to calculate crude BMI (BMI=weight in kilograms / height in meters²) and were collected using a Shorr Height Measuring Board and a Seca 770 Model scale, respectively. Two measurements were taken and averaged to ensure accuracy. The weight status categories were derived by transforming crude BMI to z-scores using the lambda-mu-sigma (LMS) method, allowing for the development of smoothed growth using the curves and the efficient calculation of z-scores simultaneously (Flegal & Cole, 2013; Vidmar et al., 2004). Z-scores were standardized to the reference population for participants’ age and sex using the 2000 Centers for Disease Control and Prevention Growth Reference in the United States (Kuczmarski et al., 2002; Ogden, Wei, Curtin, & Flegal, 2010). The two categories for 12-18 year old study participants were normal weight (BMI < 85^th percentile) and overweight or obese (BMI ≥ 85^th percentile). The two weight status categories for study participants aged 19 were normal weight (BMI <25), overweight or obese (BMI ≥ 25).

Key Independent Variables

The primary independent variables of interest were religious practice and spirituality. Religious practice was measured with two variables: weekly church attendance and daily prayer. Weekly church attendance was derived from the question, “In general, how often do you attend the main worship services of your church or otherwise participate in organizational religion (such as watching services on TV, listening to services on the radio, participating in Bible study groups, etc.)?” The response options ranged from “not at all” to “nearly every day”. Individuals with responses once per week, two or three time per week, or nearly every day were coded 1; all other responses were coded 0. Daily prayer was derived from the question, “Within your religious or spiritual tradition, how often do you pray privately or meditate in places other than at church, mosque, temple, or synagogue?” The response options for this item ranged from “never” to “more than one a day”. Individuals responding that they prayed once per day or more than once per day were coded 1; all other responses were coded 0.

Spirituality was measured by the short version of the Daily Spiritual Experience Scale (DSES) (Underwood & Teresi, 2002). The DSES was developed to assess ordinary daily experiences rather than beliefs or behaviors (Fetzer Institute. & National Institute on Aging Working Group., 2003; Underwood & Teresi, 2002). Six domains of the inner experiences with the transcendent were measured through statements assessing the frequency of the following experiences:(1) “I feel God’s presence”,(2) “I feel strength and comfort in my religious or spiritual tradition”, (3) “I feel deep inner peace and harmony”, (4) “I desire to be closer to or in union with God”, (5) “I feed God’s love for me, directly or through others”, and (6) “I am spiritually touched by the beauty of creation” The response categories ranged from “never” (coded 0) to “many times a day” (coded 5). Responses were summed to create a composite score (range = 0 – 30). The Cronbach’s alpha for the DSES in this sample was 0.87.

Other Covariates

Weight management was represented by variables derived from two questions regarding attempts through diet and physical activity, respectively:(1) “Have you ever eaten less food, fewer calories, or food low in fat to lose weight or to keep from gaining weight?”, and (2) “Have you ever exercised to lose weight or to keep from gaining weight?” “Yes” responses were coded “1” and “no” responses were coded “0”. Sex was a dichotomous variable indicating whether respondents were female (coded 0) or male (coded 1). Age was also a dichotomous variable indicating whether participants were 12-15 (coded 0) or 16-19 (coded 1) years of age.

Statistical Approach

Percentages and mean and standard deviations were calculated to characterize the total sample. Chi-square and Student’s t tests were performed to assess the proportional and mean differences by age for the variables in the study, respectively. Because the prevalence of obesity in the sample was greater than 10%, we conducted a Modified Poisson regression with robust standard errors to estimate prevalence ratios (PR) and corresponding 95% confidence intervals (McNutt, Wu, Xue, & Hafner, 2003; Thorpe, Parker, Cobb, Dillard, & Bowie, 2017; Zou, 2004). We estimated the relationship between excess weight and religious practice and spirituality for the total sample and by age. For all analyses, p values less than or equal to 0.05 were considered statistically significant. All statistical tests were two-sided. All statistical analyses were completed using STATA statistical software, Version 15.

RESULTS

The distribution of the select characteristics of African American adolescents in the Jackson Heart Kids Pilot Study for the total sample and by age is displayed in Table 1. There were 212 adolescents in the sample, with approximately half being male (49.5%); and over half (53.8%) being overweight or obese. A large proportion of the adolescents engaged in religious practices: 55.2% reported daily prayer and 77.2% reported attending church weekly. Participants also reported a spirituality score of 18.7 ± 6.3, suggesting that they, on average, have spiritual experiences most days. There were no significant age differences as it relates to any of the variables in the study.

Table 1.

Distribution of Characteristics of African American Adolescents in the Jackson Heart Kids Pilot Study for the Total Sample and by Age.

Variable		Age
	Total Sample	12-15 years old	16-19 years old
	N=212	N=119	N=93	p-value
Excess Weight [%]	53.8	53.8	53.8	.998
Male [%]	49.5	51.3	47.3	.568
Age
12-15 years old	56.1	--	--
16-19 years old	43.9	--	--
Manage weight through exercise [%]	74.5	78.2	69.9	.171
Manage weight through diet [%]	48.6	47.1	50.5	.615
Daily prayer [%]	55.2	54.6	55.9	.851
Weekly church attendance [%]	72.6	76.5	67.7	.157
Spirituality Score [mean ± sd]	18.7 ± 6.3	18.3 ± 6.2	19.3 ± 6.5	.270

Note: Excess weight was those adolescents who were overweight or obese.

Adjusted prevalence ratios for the relationship between excess weight and religiosity and spirituality among African American adolescents are shown in Table 2. Adjusted for age, male gender, and management of weight through exercise or diet, those African American adolescents who reported praying daily had a lower prevalence of excess weight (PR=0.77 [95% CI: 0.62-0.96]) than those who did not report praying daily. When examining this relationship by age, among African American adolescents between the ages of 12 and 15, those who reported praying daily had a lower prevalence of excess weight (PR=0.73 [95% CI: 0.54-0.97]) than those who did not report praying daily. Among those African American adolescents between the ages of 16 and 19, there was no difference between those who reported praying daily and those who did not report praying daily in the prevalence of excess weight (PR=0.84 [95% CI: 0.61-1.15]), and there was no association between report of spirituality and prevalence of excess weight PR=0.99 [95% CI: 0.98-1.01].

Table 2.

Relationship between Excess Weight Status and Religiosity and Spirituality among 212 African American Adolescents in the Jackson Heart Kids Pilot Study for the Total Sample, and by Age

Variable	Total Sample	12-15 years old	16-19 years old
	PRa (95% CIb)	PRa (95% CIb)	PRa (95% CIb)
Daily prayer	0.77 (0.62 – 0.96)	0.73 (0.54 – 0.97)	0.84 (0.61 – 1.15)
Weekly church attendance	1.24 (0.93 – 1.64)	1.41 (0.91 – 2.20)	1.08 (0.76 – 1.54)
Spirituality score	0.99 (0.98 – 1.01)	0.99 (0.96 – 1.02)	0.99 (0.97 – 1.02)

^aPR=prevalence ratio;

^bCI=confidence interval.

Models adjusted for age, male gender, manage weight through exercise, and manage weight through diet.

DISCUSSION

This study examined the association of R/S factors with excess weight in a sample of 212 adolescents who were descendants of Jackson Heart Study participants. We found that daily prayer was associated with a lower prevalence of the study participants being overweight or obese. This relationship varied by age as the inverse relationship between daily prayer and excess weight was statistically significant for 12-15 year-old sample members but not for older adolescents (16-19 year-olds) in the study.

Our findings contribute to the evidence linking R/S with the enhanced well-being and overall positive outcomes of adolescents. Recent qualitative studies have found that prayer was an important religious and spiritual practice for African American adolescents (Breland-Noble, Wong, Childers, Hankerson, & Sotomayor, 2015; Dill, 2017). In these studies, prayer was a practice employed by youth to cope with stress emerging from personal circumstances, family affairs, peer conflicts, and community conditions (Breland-Noble et al., 2015; Dill, 2017). Our study extends this line of research in that it examines how prayer can positively influence excess weight among African American adolescents. Childhood obesity is a contributing factor in the development of chronic diseases over the life course, and our pilot study of African American adolescents residing in the Southern United States presents evidence that daily prayer among this group is linked with a lower likelihood of being overweight or obese for at least a portion of their lifecourse. Results from this study suggest the need to examine if religious or spiritual practices during adolescence can potentially improve the health trajectory of African Americans.

Prayer is an important component in a number of religious and spiritual traditions as this expression of faith is exhibited during corporate worship services and emphasized in dogma and sacred texts. This practice has been associated with positive health outcomes in many studies; however, the results have been far from definitive. Prayer has multiple forms (e. g., devotional, intercessory, petitionary) and additional research is needed to examine the degree to which each can have implications for health and well-being. Further, the meaning and use of prayer among individuals and populations can vary considerably. A recent critical review of studies examining the health impact of private prayer on outcomes of hospitalized patients found that the benefits of prayer were limited to individuals with high levels of religiosity (Hollywell & Walker, 2009). African Americans make up the most religious group in the United States (Pew Research Center., 2009) and prayer and other R/S practices are embedded within their religious and daily lives(Dill, 2017); yet, the relationship between prayer and health outcomes among this group has been vastly understudied. For this population, prayer has been an accessible resource through which individuals can seek strength, comfort, guidance, protection, and healing from a power greater than themselves. It could also be a source of resilience against the stigma of obesity that can lead to people either being more comfortable being obese or more motivated to lose weight and improve overall health and well-being. Results from our study suggest that asset-based studies examining the relationship between faith-oriented practices, including prayer, and health outcomes among at-risk populations can be fruitful.

Although our results pointed to an association between R/S factors and excess weight among African American adolescents, there are some limitations worth noting. The data for this study were collected from a small sample of African American adolescents who live in the Deep South and are descendants of individuals enrolled in a longitudinal study. As such, generalizability of the results is limited. Data were only collected once; therefore, causal inferences could not be determined. Only a limited number of independent variables could be included in regression analysis because of the small sample size, thereby limiting the number of potential confounding factors considered. The independent variables in this study are drawn from a self-administered surveys; therefore, the usual limitations associated with self-report data (i.e., recall bias, social desirability) also apply to this study (Crockett, Schulenberg, & Petersen, 1987). However, our cohort represents a high-risk population in the state with the greatest burden of cardiovascular disease (El-sadek, Zhang, Vargas, Funchess, & Green, 2015; Roth et al., 2018) suggesting our findings could have broader relevance.

Conclusion

Religion and spirituality are important parts of life for many African Americans, and participation in R/S practices have been linked to healthy attitudes and behaviors that result in beneficial health consequences (Knox, Langehough, Walters, & Rowley, 1998; Rew & Wong, 2006; Zullig, Ubbes, Pyle, & Valois, 2006). However, research in this vein has tended to focus on adults; additional theoretical and empirical research is warranted to further elucidate the function of R/S practices among children and adolescents. The present study is one of the first to examine the association between R/S and excess weight among African American adolescents in the Deep South. These findings suggest that preventive interventions offered to children and younger adolescents may have a strong impact on those with excess weight—which may have implications for weight status across the lifespan. Because R/S is such an important aspect of life in the African American community, particularly those living in the South, faith-based health interventions that utilize a “whole family” approach and are inclusive of children and adolescents should be considered.