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  1. 1. Unit I Introduction Today, our country faces many health related issues as a result of poor diet and nutrition. Whether young or old, the diets of most Americans need improvement. Dietary patterns in the United States are associated with increased risks of diseases such as Coronary Heart Disease (CHD), cancer, stroke, diabetes, hypertension, obesity and osteoporosis.1 Poor diet and nutrition in America contribute to 71 million per year in medical costs, loss productivity and value of premature deaths associated with conditions. Each year, over thirty-three billion dollars in medical costs and nine billion dollars in lost productivity due to heart disease, cancer, stroke, and diabetes are attributed to diet. Americans enjoy one of the most bountiful and affordable food supplies in the world. Yet, with this abundance comes an over consumption of total fat and saturated fat; under consumption in the fruit, vegetable and grain groups; in addition, variety in the diet is limited and intakes of total fat and saturated fat are above recommended levels.2 The Dietary Guidelines and Food Guide Pyramid (see Appendix A) recommends the selection of foods from a variety of food groups, the choice of a diet that is low in fat, saturated fat, cholesterol, and moderate use of salt and sodium. The Food Guide Pyramid is an outline of what to eat each day, and it calls for a variety of food and nutrients. Fruits and vegetables provide essential vitamins, minerals, fibers, and other substances that are associated with good health. Low fat diets rich in fiber-containing grain products, fruits, and vegetables may reduce the risk of heart disease and some types of cancer. Very few Americans meet the majority of 1 Weisburger, J.H (1997). Dietary fat and risk of chronic disease: Mechanistic insights from experimental studies. Journal of the American Dietetic Association, 97 (suppl.), S16-S-23. 2 Baranowski T, Smith M. Hearn MD, Lin LS: Adult consumption of fruits and vegetables and fat-related practices vary by meal and day of week. American Journal of Health Promotion 1998; 12: 162-164 Dietary Guidelines for Americans: Report of the Dietary Guidelines Advisory Committee on the Dietary Guidelines for Americans. www.health.gov/dietaryguidelines/. 1
  2. 2. recommendations of the Food Guide Pyramid or the Dietary Guidelines. Only three percent of all individuals meet four of the five recommendations for the intake of grains, fruits, vegetables, milk products, and meat and bean groups. Only one fourth of U.S. adults eat the recommended servings of fruits and vegetables each day.3 Unfortunately, poor eating habits are usually established during childhood. More than sixty percent of young people eat too much fat, and less than twenty percent eat the recommended servings of fruits and vegetables. It is important to improve the American diet and monitor nutritional intake. Eating patterns are important indicators of the nutrition status of the U.S. population. Nutrition status is in turn associated with a number of health conditions known to be important determinants of mortality and morbidity in the population.4 It influences the capacity of humans to perform their general physical and psychological well-being. For these reasons, eating patterns and observed changes in eating patterns have broad implications for food and nutrition policy. Eating right is vital to promoting health and reducing the risk for death or disability due to chronic diseases such as heart disease, certain cancers, etc. In fact, it has been estimated that dietary changes could potentially reduce cancer deaths in the United States by as much as thirteen percent. Nutrition plays a major role in the life of a person beginning from birth to adulthood. Nutrition is fundamental to a sense of well-being, and to meet the growth, development and activity needs of children and youth. In the beginning, the responsibility for the health and well being of children begins with parents. This includes eating healthy, eating regularly and getting proper nutrients to make them grow big and strong. Once they grow up, the responsibility is on them to obtain proper nutrition. Eating proper foods and maintaining a proper diet is necessary for one’s health as well as their appearance. Now more than ever, we’ve seen more young 3 Krebs-Smith SM, Cook A, Subar AF, Cleveland L., Friday J: U.S. Adults’ Fruit and Vegetable Intakes, 1989-1991: A Revised Baseline for the Healthy People 2000 Objective. American Journal of Public Health 1995;85:1623-1629. 4 Guthrie, J.F., B. Derby and A. Levy. (1994). Fruit and Vegetables: Their importance in the American diet. Food review. U.S. Department of Agriculture. Vol. 15, pp35-39. 2
  3. 3. people suffering from obesity, overweight, diabetes and even high cholesterol. Communities, schools and parents must work together to help students develop attitudes and skills for healthy eating. It’s important to create supporting environments, encouraging children and youth to make informed choices. This helps children to establish patterns for healthy living that will be carried into adulthood. This helps children to establish patterns for healthy living that will be carried into adulthood. The most beneficial way of doing this is by combining healthy eating habits with proper nutrition intake. Once this pattern becomes regular, adding to the overall healthy lifestyle by bringing in exercise and physical activity will make for an overall better person. What we eat has a significant impact on our health, quality of life and longevity. In the U.S., high intakes of fat and saturated fat, and low intakes of calcium and fiber-containing foods- such as whole grains, vegetables, and fruits, are linked to several chronic health conditions that can impair the quality of life and hasten mortality. Diets are more significant in the risk of CHD, cancer, and stoke- the three leading causes of death in the United States. The role of nutrition and diet in reducing the risk of chronic disease has been well documented.5 By improving diet and eating habits, one must also increase physical activity to prevent many chronic illnesses. The relationship between physical activity and health are numerous and complex. The American Health Association (AHA) identified physical inactivity as an independent risk factor for the development of coronary heart disease. A trend for decreased physical activity levels in older African-American adults, especially women, has been reported. The physical activity and fitness levels of African-American men and women were found to be low. Research revealed that the pattern of inactivity had been established as early as ninth grade. Increasing opportunities for physical activity, including multiuse trails, will help more people be active. Physical activity is a major problem in the United States with many Americans living 5 National Research Council. (1989) Diet and health: Implications for reducing chronic disease risk. Washington, D.C: National Academy Press. 3
  4. 4. sedentary lives. Forty percent of adults in the United States do not participate in any leisure-time physical activity.6 Less than one third of adults engage in the recommended amounts of physical activity (at least thirty minutes most days). In 2000, health care costs associated with physical inactivity were more than seventy-six billion dollars. If ten percent of adults began a regular walking program, 5.6 billion dollars in heart disease costs could be saved. Moreover, every dollar spent on physical activity programs for older adults with hip fractures results in a 4.40 cents return. Increased physical activity will alleviate many of the health concerns within our society today. Physical activity contributes to weight loss, especially when combined with calorie reduction. Regular physical activity is extremely helpful for the prevention of overweight and obesity. Regular physical activity is very important in maintaining weight loss. In addition to weight control, physical activity helps prevent heart disease, control cholesterol levels and diabetes, slows bone loss associated with advancing age, lowers the risk of certain cancers, and helps reduce anxiety and depression.7 Factors found to be associated with increased physical activity include a sense of personal control, regular participation in organization and groups, interpersonal support and belief in efficacy of preventive health behavior. Education also plays a major role as individuals learn the importance or proper diet and nutrition. Now, more than ever, the American people have become interested in improving their health. The increased attention now being paid to exercise, nutrition, environmental health and occupational safety testify to their interest and concern with health promotion and disease prevention. Americans are increasingly more health-conscious, and much of this attention is 6 Fletcher GF, Blair SN, Blumenthal J, Caspersen C, Chaitman B, Epstein S, Falls H, Siavarajan ES, Froelicher VF, Pina IL. Statement on exercise: benefits and recommendations for physical activity programs for all Americans. Circulation. 1992;86:340-344. Kohl HW, Blair SN, Paffenbarger RS, Macera CA, Kronenfeld JJ. A mail survey of physical activity habits as related to measured physical fitness. American Journal of Epidemiology. 1988; 127(6): 1228-1239 7 CDC, Behavioral Risk Factor Surveillance System. Journal of Women’s Health (1998), 7, 1125-33. 4
  5. 5. focused on what they eat. Some of the reasons for this trend are an aging population, increased access to knowledge through the internet, other media, and the popularizing of results from numerous nutrition studies.8 More importantly, public health has become an important aspect in our society. Americans are expanding their view of health care from “corrective” medicine (seeing doctors when a problem arises) to include “preventive medicine” and self-care through eating and exercise. In addition, misuse of alcohol and drugs exacts a substantial toll of premature death, illness and disability. The growth in the use of both alcohol and drugs among the Nation’s, youth have raised particular concern. Problems resulting from these trends are substantial-but preventable.9 Affluence, changes in lifestyle, greater employment of women, smaller households, increased accessibility to commercial food establishments, and increased availability of highly processed foods have influenced the U.S. population’s food consumption patterns. Researchers believe that these factors have led to over-consumption of such dietary components as fat, cholesterol, refined carbohydrate, and sodium. In addition, there is a major problem with nutrient deficiency.10 Although the U.S. is primarily on the whole, a wealthy and overfed nation, fifteen percent of the population lives below the poverty level; a level based on the ability to purchase a minimally nutritious diet.11 A combination of recession, unemployment and some budget decisions has had a negative impact on the ability of many people to obtain an adequate diet. Research has also shown that the problem still exists, as reflected in the continuing increase 8 Glanz K, Basil M, Maibach E, Goldberg J, Snyder D: Why Americans Eat What They Do: Taste, Nutrition, Cost, Convenience, and Weight Control Concerns as Influence on Food Consumption. Journal of the American Dietetic Association 1998;98:1118-1126. 9 Kann L., Warren W, Collins JL, Ross J, Collins B. Results from the national school-based 1991 Youth Risk Behavior Survey and progress toward achieving related health objectives for the nation. Public Health Reports. 1993; 108 (suppl.1):47-56. 10 Block, G., & Subar, A. (1992). Estimates of nutrient intake from a food frequency questionnaire: The 1987 National Health Survey. Journal of the American Dietetic Association. 92., 969-977. 11 Turrell G. Structural, material and economic influences on the food purchasing choices of socioeconomic groups. 1996;20:611-7. 5
  6. 6. in people depending on emergency food centers. There was an average twenty percent increase in emergency food recipients between 1983 and 1984, with more than 61 percent of centers reporting that more than fifty percent of their clients were families with children.12 Eating patterns can be influenced by the food supply and the changing ways that people acquire food. Eating patterns also may change in response to changes in personal preferences, which are influenced by an array of complex social, economic, psychological conditions. In general eating patterns are shaped by ways people react to and process information, their interactions with others, and culture.13 A more complete understanding of these factors may lead to improvements in intervention and education programs and to better monitoring of nutrition and health status of the population. There is an increase in food eaten away from home which has led to a national health threat. The percentage of food dollars spent on away-from-home food consumption increased from twenty-seven percent in 1960 to more than thirty-three percent in the 1970s.14 This amount has exceeded forty percent since the mid 1980s. Often times, the nutrient intake is lower when meals are eaten away from the home. The fast-food industry is a lucrative business and plays off the working people. The industry is aware of the fact that the majority of people would rather not spend excessive amounts of time being unproductive while eating, fast-food restaurants provide easy access to their grease and salt. With the advent of the drive-through window, customers can now order their meals from the comfort of their cars without even moving a muscle. This life is very unhealthy because not only is there intake of unwholesome food, but there is no exercise to burn the calories.15 One of the problems with the fast food industry is that 12 U.S. House of Representatives Select Committee of Hunger. Obtaining food: Shopping constraints of the poor. U.S. Government Printing Office, Washington DC, 1987. 13 Patterson BH, Harlan LC, Black G, Kahle L. Food choices of Whites, Blacks and Hispanics: Data from the 1987 National Health Interview Survey. Nutrition and Cancer. 1995; 23105-119. 14 U.S. Department of Agriculture and U.S. Department of Health and Human Services. (1990) Dietary Guidelines for Americans. Washington, DC: U.S. Government Printing Office. 15 Ibid 6
  7. 7. it has created a centralized, industrialized food system, which is very vulnerable to spreading diseases. Each day in the United States, roughly two-hundred thousand people become sick by food borne diseases, many of those related to fast-food consumption. Out of those who get sick, nine-hundred are hospitalized and fourteen die annually.16 Meat infected with E-coli and other pathogens are distributed far and wide because of industrialized production. E-coli are the leading cause of kidney failure of children under five. When it comes to the discussion of restaurant, we must not forget one important aspect of health and safety: the employees. The lack of cleanliness of the behind the scenes are often overlooked. Fast-food chains tend to hire unskilled immigrant laborers who end up working in unsafe conditions not knowing how to ask for improvements. Overworked, illiterate workers do not understand the importance of good hygiene, and they often pick up meat off the floor as well as use dirty utensils. Breast cancer is the number one killer among women aged thirty-five through fifty-four. According to experts, it as well other deadly diseases such as diabetes and heart disease may be influenced by unhealthy diets. Thirty percent of all tumors in breast, prostate and colon cancer are related to nutrition.17 The problem lies in the fact that we eat too much food rich in fat. This is especially prevalent in the U.S., where a large percentage of these calories and fat comes from the unhealthy menus of fast food restaurants. As Americans eat out more and more frequently, they become accustomed to those oversized portions, thinking these portions are normal when they are not. An alternative to eating the traditional three meals a day is to eat five or six smaller meals throughout the day. This has been proven to be a healthier way to giving the body the most efficient way to use energy, allowing it time to digest the smaller amounts of food. 16 Ibid 17 Patterson BH, Block G: Food choices and the cancer guidelines. American Journal of Public Health (1998); 86:1394-1400. 7
  8. 8. The body can use protein most efficiently if it is consumed frequently during the day. Small meals make better use of the nutrients than two or three large meals. Fast food companies totally contradict this habit by serving large quantities of food. They have “Super Size” options not caring how long it will take their customers to digest their meal. The high caloric content of these large servings leads to weight gain for regular fast food customers. This in turn leads to obesity which may cause dangerous health problems.18 Fast food chains fail to alert their customers to the hazardous high calories and fat content of the food they offer. Fast food is much like an addictive drug and causes many health problems among Americans. It is easily accessible and inexpensive, making it very habit-forming. Knowing that there are over 300,000 fast food restaurants in the United States does not help solve this problem. Evidence is increasing that onset of ill health is strongly linked to influence in physical, social, economic and family environments.19 Such influences in the physical environment that increase risk include contamination of air; water; and food; workplace hazards; radiation exposure; excessive noise; dangerous consumer products; and unsafe highway design. Factors in the socio-economic environment which affect health include income level, housing, and employment status. For many reasons, the poor face more and different health risks than people in higher income groups; inadequate medical care with too few preventive services; more hazardous physical environments; greater stress with less education; more unemployment or unsatisfying job frustrations; and income inadequate for good nutrition, safe housing, and other basic needs. 18 Frazao, E. High costs of poor eating patterns in the United States. America’s Eating habits: Changes and Consequences. Washington, DC: U.S. Department of Agriculture. Agriculture Information Bulletin. No. 750; 1999. 19 Baranowski,T. , Perry, C.L., & Parcel, G.S (1997). How individuals, environments, and health behavior interact. In K. Glanz, F. Marcus Lewis, & B. Rimer (eds). Health Behavior and Health Education: Theory, Research and Practice. 2nd ed. (pp. 153-178). San Francisco: Jossey Bass. 8
  9. 9. Family relationships also constitute an important environmental component for health. Drastic alterations may occur in family circumstances as spouses die or separate, children leave home, or an elderly parent move in. An abrupt major change in social dynamics can create emotional stress sever enough to trigger serious physical illness or even death. On the other hand, loving family support can contribute to mental and physical well-being and provide a stable, nurturing atmosphere within which children can grow and develop in a healthy manner. Behavioral habits play critical roles in the development of many serious diseases and in injuries from violence and automobile accidents. Many of today’s most pressing health problems are related to excesses of smoking, drinking, faulty nutrition, overuse of medication, fast driving and relentless pressure to achieve. In fact, of the ten leading causes of death substantially reduced if persons at risk improved just five habits: diet, smoking, lack of exercise, alcohol abuse, and use of anti-hypertensive medication.20 Because risk factors interact in different ways, population groups which differ because of geographic location, age, and/or socioeconomic strata can experience substantial variability in disease incidence. Heredity determines basic biological characteristics and these maybe of a nature to increase risk for certain diseases.21 Heredity plays a part in susceptibility to some mental disorders, infectious disease, and common chronic diseases such as certain cancers, heart disease, lung disease, and diabetes, in addition to disorders more generally recognized as inherited, such as hemophilia and sickle cell anemia. Poor diets among Americans have not only caused risks of many diseases, but have contributed to the growing number of Americans who are overweight and obese. This is especially prevalent in children, which has sounded a public health alarm. Obesity stands among 20 Lee, Phillip R., Estes, Carroll R. The Nations’ Health, Third Edition (1990). 21 Rozin P. Human Food Selection: The interaction of biology, culture and individual experience, in Barker LM (Ed): The Psychology of Human Food Selection. Westport, Avi; 1982:225-254. 9
  10. 10. many health challenges continuing to confront us as a nation. Our modern environment has allowed this condition to rise above alarming rates becoming a highly pressing health problem. Although obesity may not be an infectious disease, it has reached epidemic proportion in the United States. Obesity has increased between both genders and among all population groups. In 1999, an estimated sixty-one percent of U.S adults were overweight or obese, and thirteen percent of children and adolescents were overweight.22 In addition, thirty-four percent of adults between the ages of twenty and seventy-four were obese. Approximately fifty-nine million adults are obese in America. Today, there are nearly twice as many overweight children and almost three times as many overweight adolescents as there were in 1980. Those children aged sixteen to nineteen make up fifteen percent who are obese which totals about nine million young people. Because of these tragic trends, roughly three hundred thousand deaths each year in the U.S are associated with overweight and obesity. Obesity in children is increasing and appears to be related to inadequate physical activity. Twenty-five percent of children and youth are sedentary; much of this can be blamed on the television and video games. There are also a myriad of eating disorders amongst our young people. Unhealthy body images contribute to disordered eating patterns. Among teens and young adults, one to two percent suffers from anorexia nervosa and three to five percent from bulimia. Inadequate nutrition affects the long-term development of children and youth. Evidence shows that there is a strong association between obesity and diseases such as heart disease, hypertension, hyper-lipidemia, and non-insulin dependent diabetes mellitus, certain types of cancer, stroke, arthritis, breathing problems, psychological disorders (depression) 22 Mokdad, AH., Serdula, MK, Dietz, WH., Bowman. (1999). The spread of the obesity epidemic in the United States, 1991-1998. Journal of the American Medical Association, 282 16), 1519-1522. 10
  11. 11. and overall mortality.23 Obesity, defined as an excess percentage of body fat, has become a real health problem and is causing Americans millions of dollars. The annual hospital costs for children and adolescents related to obesity were one hundred and twenty seven million dollars during 1997 through 1999. This was an increase of thirty-five million from 1979 through 1981. In 2000, the total cost of obesity in the United States was estimated to be roughly one hundred and seventy billion dollars. Sixty one billion dollars went directly towards medical costs and fifty-six billion went towards treatment costs. Among U.S adults in 1996, thirty-one billion dollars of treatment costs and seventeen percent of direct medical costs was spent on cardiovascular disease related to obesity.24 To understand obesity and overweight, we must discuss such measures as body weight and Body Mass Index (BMI).25 Typically, recommended or ideal body weight is defined as the weight for an individual of medium frame for a given height and gender; overweight is defined as twenty percent or more above the ideal weight for a medium frame person of a given gender and height. Moreover, weight above twenty percent over ideal is linked with greater levels of morbidity and mortality.26 The Body Mass Index is also used to define obesity. A Body Mass Index of twenty-seven is equivalent to twenty percent over recommended body weight on the weight tables. It is most commonly used to define obesity in both men and women. Studies have shown that BMI significantly correlates with total body fat content for the majority of individuals. 23 Flegal KM, Carroll MD, Ogden CL, Johnson CL. Prevalence and trends in obesity among U.S. adults, 1999- 2000.Journal of the American Medical Association. 2002;288 (14): 1723-1727. 24 Frazao, E. High costs of poor eating patterns in the United States. America’s Eating habits: Changes and Consequences. Washington, DC: U.S. Department of Agriculture. Agriculture Information Bulletin. No. 750; 1999 25 Sanchez, A.M., Reed, D.R., & Price, R.A. (2000). Reduced mortality associated with body mass index (BMI) in African Americans relative to Caucasians. Ethnicity and Disease, Volume 10.24-30. 26 Kumanyika S. Diet and nutrition and their influences on the morbidity/mortality gap. Annals of Epidemiology 1993; 3:154-158. 11
  12. 12. If left unabated, overweight as well as obesity may cause as many deaths as cigarette smoking. Disparities in overweight and obesity prevalence exist in many segments of the population based on race and ethnicity, gender, age, and socioeconomic status. Overweight and obesity are particularly common among minority groups and those with lower family income. Interventions to decrease the rate of obesity and overweight in America should be a collective effort from the health care system, policy makers, employers, schools, parents, and the community as a whole. Self-health maintenance also plays a major role in deterring obesity in our nation. One should try to make long-term changes in their eating and physical activity habits. Physical activity contributes to weight loss, especially when combined with calorie reduction. Weight loss is critical for those individuals suffering from obesity and overweight. A ten percent weight loss will reduce an overweight person’s lifetime medical costs by twenty-two hundred to fifty-three hundred dollars. The lifetime medical costs of five diseases and conditions (hypertension, diabetes, heart disease, heart disease, stroke, and high cholesterol) among moderately obese people are ten thousand dollars higher than among people at a healthy weight. Other factors contribute to obesity that must be considered. Research shows those children who are over breast-fed are fifteen to twenty-five percent less likely to become overweight and those who are breast-fed for six months are twenty to forty percent less likely.27 For young and old adults, reducing the time spent watching television appears to be effective for treating and preventing obesity. Increased physical activity for overweight patients reduces many of the illnesses associated with obesity, helps maintain weight and helps prevent weight gain. Culture plays a major role in health maintenance. There are countless conflicts that occur in the health-care delivery arena predicated on cultural misunderstandings are related to universal 27 Yanovski, Susan. (1997). Director of Obesity and Eating Disorder Research. North American Association for the Study of Obesity [On-line]. Available: www.detroitnews.com. 12
  13. 13. situations, such as verbal and nonverbal language misunderstandings.28 The necessity to provide cultural care- professional health care that is culturally sensitive, culturally appropriate, and culturally competent- is essential as we enter the new millennium, and this demands that providers must be able to access and interpret the given patient’s health beliefs and practices. Cultural care offers the perspective of health-care delivery as it enables the provider to understand from a cultural perspective, the manifestations of the patient’s health-care beliefs and practices. People from one cultural group differ biologically (physically and genetically) from members of other cultural groups: body build and structure; skin color; enzymatic and genetic variations; susceptibility to disease; nutritional variations. The origins of African Americans began on the West Coast of Africa where they were taken as slaves. Black Americans also have origins from many other African countries, West Indian Islands, Dominican Republic, Haiti, and Jamaica. European origin stems from Germany, England, Italy, Ireland Former Soviet Union, and all other European countries. Their primary reliance is on “Modern Western” health care delivery systems. Remaining traditional health and illness beliefs and practices may also be observed. Some remaining traditional folk medicine and homeopathic medicine are also observed. The key to maintaining health is, however, the family and social support systems. Spiritual health is maintained in the home with family closeness-prayer and celebrations. Rights of passage and kindred occasions are also family and community events. The strong identity with and connections to the “home” community are a great part of traditional life and the life cycle, and factors that contribute to health and well-being.29 28 Mutchler, Jan E. & Jeffrey A.Burr (1991). Racial differences in health and health care services utilization in later life: The effect of socioeconomic status. Journal of Health and Social Behavior, Vol.32:342-56. 29 Bullough, B. & Bullough, V.L. Poverty, Ethnic Identity and Health Care. New York Appleton-Century- Crofts (1972), pp.39-41. 13
  14. 14. There are environmental control issues which factor into health care delivery. Traditional health and illness beliefs may continue to be observed by traditional people. Persons from ethno- cultural traditions may reject the use of western medications. The person may elect to use traditional medications and seek the services of a traditional herbalist. Our nation must be aware of the dimensions and complexities involved in caring for people from diverse cultural backgrounds. All health care providers must be culturally competent where the total content of a client’s situation is understood. They must first understand their own cultural values and biases. Then, they should acquire basic knowledge of cultural values, health beliefs and practices for the client groups served. Physicians should also be respectful of, interested in, and understanding of other cultures without being judgmental. Interpretative services would be very useful in health environment. Cultural competence involves a set of knowledge, skills, and attitudes that allows individuals, organizations, and systems to work effectively with diverse racial, ethnic, religions, and social groups, is an inherent component of this mandate. Contrary to belief, many people have continued to carry on the traditional customs and culture from their native lands. Health and illness beliefs are deeply entwined within the cultural and social beliefs that people have. To understand health and illness beliefs and practices, it is necessary to see each person in his or her own unique socio-cultural world. Culture plays a major role among social organizations and the family structure. The family structure for African Americans usually involves many single-parent female headed households; large extended family networks; strong affiliations within community and other community social organizations to include the Greek Associations such as Alpha Kappa Alpha and Sigma Phi Beta. Caucasian groups tend to come from nuclear and extended families. They are mostly apart of Judeo-Christian religions and are connected with community social organization. 14
  15. 15. Overall, a person’s culture to include historical background and practices has a major impact on their health and behavior. Disease usually results from an interaction between genetic endowment and the individual’s total environment. The relative contributions vary from disease to disease. Major risk factors for the common chronic diseases are environmental and behavioral- therefore amenable to change. American society has been plagued with many diseases linked to behavior and diet. At the end of 2002, it was estimated that there were 281,931 persons living with HIV/AIDS (Acquired Immune Deficiency Syndrome) in the thirty states which have a history of confidential name-based HIV reporting.30 The actual number of persons in the U.S. with HIV/AIDS could be much higher, mainly because many people are unaware of their HIV status. The proportion of AIDS cases among women in the District of Columbia has increased threefold over the last decade, rising from eleven percent of adult cases in 1991 to thirty-three percent in 2001. Alcoholism is another disease affecting the lives of many Americans. Alcohol is the number one drug problem in America.31 Forty-three percent of Americans have been exposed to alcoholism in their families. Nearly one out of four Americans admitted to hospitals have alcohol problems or are undiagnosed alcoholics being diagnosed for alcohol related consequences. Up to forty percent of all industrial fatalities and forty-seven percent of industrial injuries can be linked to alcohol consumption and alcoholism. Alcohol is a factor in half of all motor vehicle fatalities, half of all homicides, and one- third of all suicides and results in a loss of fifteen billion dollars in work productivity, cirrhosis of the liver, malnutrition, lowered resistance to infectious diseases, gastrointestinal irritations, muscle diseases and tremors, brain and nervous system damage, and physical problems in 30 Chronic diseases and their risk factors [On-line] Available: http://www.cdc.gov/ncdphp/statbook/.html 31 Ibid 15
  16. 16. children born of mothers who drink.32 Five of the ten leading causes of death- heart and cerebrovascular diseases, diabetes mellitus, arteriosclerosis, and cirrhosis of the liver-are diet related. Eating right is vital to promoting health and reducing the risk for death or disability due to chronic disease such as heart disease, certain cancers, diabetes, stroke, and osteoporosis. As diseases of nutritional deficiency have diminished, they have been replaced by diseases of dietary excess and imbalance- problems that now rank among the leading causes of death touch the lives of most Americans. Other problems stemming from dietary excess are: high blood pressure, obesity, dental diseases, arthrosclerosis, and gastrointestinal diseases.33 Obesity is a major risk factor for each of these chronic diseases. Diabetes mellitus is a disease in which the body does not produce or properly utilize the hormone insulin and therefore cannot properly convert carbohydrate sources in the die to energy. Diabetes is the seventh leading underlying cause of death in the United States.34 There are two major forms of diabetes: insulin dependent (Type 1) and non-insulin dependent (Type 2). Type 1 diabetes is an autoimmune disease occurring most frequently in children and young adults. The more common form of diabetes, Type 2, accounts for more than ninety- ninety-five percent of diabetes cases and is associated with obesity and sedentary lifestyle as well as genetic predisposition.35 It is a disease in which blood sugar levels are above normal. High blood sugar is a major cause of early death, heart disease, kidney disease, stroke, and blindness. More than eighty percent of people with type 2 diabetes are overweight. One factor may be that being overweight causes cells to change, making them less effective at using sugar from the blood, putting stress on the cells that produce insulin. 32 Ibid 33 Dietary fat and risk of chronic disease: Mechanistic insights from experimental studies. Journal of the American Dietetic Association, 97 (suppl.), S16-S23. 34 American Diabetic Association, 1999. 35 Ibid 16
  17. 17. Most of the food we consume is turned into glucose (sugar) for our bodies to use for energy. Insulin helps glucose into our body cells. A diabetic person either doesn’t make enough insulin or cannot use its own insulin very well. The most common types of diabetes include Type 2, Type 1, and gestational (occurs during pregnancy). Type 2 affects ninety to ninety five percent of people with diabetes, usually appearing after age forty. People with diabetes may have some or none of the following symptoms: frequent urination, excessive thirst, unexplained weight loss, extreme hunger, blurry vision, tingling or numbness in hands and feet, recurring fatigue, very dry skin, slow-healing sores, or more infections than usual. If not well managed, diabetes can seriously impact a person’s quality of life. Complications, many of which are preventable, include the following: heart disease, stroke, blindness, kidney failure, foot or leg amputations, nerve damage, and complications of pregnancy. Diabetes contributed to 209, 664 deaths in the United States in 1999 and is the sixth leading cause of death. Roughly seventeen million people in the United States, or 6.2 percent of the population, have diabetes.36 Unfortunately, about one third of these are not aware that they have the disease. The risk factors for Type 1 diabetes include autoimmune disease, genetic predisposition, and environmental factors. Type II diabetes is more likely to develop in people who are older, are obese, have a family history of diabetes, have a prior history of gestational diabetes, are physically inactive, and belong to a certain racial or ethnic group. African- Americans, Hispanic/Latino Americans, American Indians, Alaska Natives, and some Asian-Americans and Pacific Islanders are at particular high risk for Type 2 diabetes. Research studies in the United States and abroad have found that lifestyle changes can prevent or delay the onset of Type 2 diabetes among high-risk adults. People with diabetes must develop a life-long commitment to regular medical care and diabetes self-management.37 36 Ibid 37 Ibid 17
  18. 18. Treatment for diabetes is aimed at keeping blood glucose near normal levels at all times. Those persons diagnosed with diabetes must balance three important things: what they eat and drink, how much physical activity they do, and what diabetic medication they take (prescribed diabetic pills or insulin). Controlling blood pressure is very important for diabetic individuals. Treatment must be individualized and address medical, emotional, cultural, and lifestyle issues. Potential barriers to treatment and preventive services include lack of financial resources, linguistic barriers, limited access to transportation, lack of physical activity due to unsafe neighborhoods, and lack of healthy food choices. Communities within the United States can overcome some of these barriers by using community health workers to serve as bridges between community members and health care systems. Community health workers communicate and model healthy lifestyle choices in culturally and linguistically appropriate ways. Heart disease is the leading killer across most racial and ethnic minority communities in the United States, accounting for around one quarter of all deaths in 2001.38 Heart disease means that the heart and circulation (blood flow) are not functioning normally. If you have heart disease, you may suffer from a heart attack, congestive heart failure, sudden cardiac death, angina (chest pain), or abnormal heart rhythm. During a stroke, blood and oxygen do not flow normally to the brain, possibly causing paralysis or death. Heart disease is the leading cause of death in the U.S., and stroke is the third leading cause. Heart disease is the leading cause of death for people over the age of twenty-five and is largely preventable through behavioral changes. Those persons who are overweight are more likely to suffer from high blood pressure, high levels of triglycerides (blood fats) and LDL cholesterol (a fat-like substance often called the “bad cholesterol.” These are all risk factors for heart disease and stroke. In addition, people 38 Kingston, R.S., & Smith, J.P. (1997). Socioeconomic status and racial and ethnic differences in functional status associated with chronic diseases. American Journal of Public Health, 87(5), 805-810. 18
  19. 19. with more body fat have higher blood levels of substances that cause inflammation. Inflammation in blood vessels may raise heart disease risk. Losing five to fifteen percent of your weight can lower your chances for developing heart disease or having a stroke. Weight loss may improve your blood pressure, triglyceride, and cholesterol levels; improve how your heart works and your blood flows; and decrease inflammation throughout your body. African Americans suffer the most from the disease. About forty percent of African American men and women have some form of heart disease, compared to thirty percent of white men and twenty-four percent of white women. African Americans are also twenty-nine percent more likely to die from the disease than Whites.39 While Hispanics die from heart disease at a lesser rate than Whites, Mexican American women are diagnosed with the condition more frequently than White females. Mexican Americans, who make up the largest share of the U.S. Hispanic population, also suffer in greater numbers from overweight and obesity than Whites, two of the leading risk factors for heart disease. More than twenty-fiver percent of deaths in the Asian Indian community are caused by heart disease. In 1999, almost one hundred and eight million Adult Americans were overweight or obese. Cancer is the second leading cause of death in the United States.40 Cancer occurs when cells in one part of the body, such as the colon, grow abnormally or out of control, possibly spreading to other parts of the body, such as the liver. Being overweight may increase the risk of developing several types of cancer, including cancers of the colon, esophagus, and kidney. Overweight is also linked with uterine and postmenopausal breast cancer in women. Gaining weight during adult life increases the risk for several of these cancers. Being overweight also may increase the risk of dying from some cancers. Eating or physical activity habits may also 39 Ford, E.S., Ahluwahlia I.B., Galuska, D.A. Social relationships & cardiovascular disease risk factors: Findings from the National Health & Nutrition Examination Survey. Preventive Medicine (2000); 30:83-92. 40 National Cancer Institute. Cancer Control Objectives for the Nation: 1985-2000. NIH Publication 86-2880, Number 2. (1986). Washington, DC., U.S. Department of Health and Human Services. 19
  20. 20. contribute to cancer risk. Weight loss, healthy eating habits, and physical activity habits, may lower cancer risk. Adequate restful sleep, like diet and exercise, is critical to good health. Sleep allows your body to rest and restore energy, while at the same time carry out important physiological and psychological functions that affect your physical and mental well-being. Another condition associated with diet, nutrition and health is sleep apnea. Obstructive sleep apnea, the most common form of apnea, occurs when airflow is blocked, often due to narrowing of the airway by excess tissue (typically as a result of obesity), enlarged tonsils or a large uvula (the small fleshy pendulum of tissue that hangs from the back portion of the soft palate on the roof of the mouth). A person who has sleep apnea may suffer from daytime sleepiness, difficulty concentrating, and even heart failure. Research continues to demonstrate that untreated, the condition results in serious health consequences and unfortunately, the number of undiagnosed and untreated patients remains large. Sleep apnea is a serious, potentially life-threatening condition that is far more common than generally understood. It is characterized by brief interruptions of airflow during sleep. The effort to breathe greatly increases when air cannot flow easily into the nose or mouth. This causes a suction force in the upper part of the airway. This can result in heavy snoring or a pause in airflow, low levels of oxygen and increased levels of carbon dioxide in the blood, which in turn may cause an arousal from sleep. With each abrupt change from deep sleep to light sleep, a signal is sent from the brain to the upper airway muscles to open the airway; normal breathing is resumed, often with a loud snort or gasp. Frequent arousals, although necessary for breathing to restart, prevent restorative, deep sleep. Drinking alcohol or taking sleeping pills increases the frequency and duration of breathing pauses by sedating the brain and preventing the arousal. 20
  21. 21. Sleep apnea occurs in all age groups and both sexes but is more common in men. However, it simply may be under diagnosed in women. As many as eighteen million people in the U.S. suffer from sleep apnea.41 Four percent of middle-aged men and two percent of middle- aged women experience sleep apnea along with excessive daytime sleepiness (EDS), and the rate of sleep apnea increases in women over age fifty. Although not everyone who snores has this condition, if you snore loudly and also are overweight, have high blood pressure, or have some physical abnormality in the nose, throat or other part of the upper airway and are excessively sleepy, you may well have sleep apnea. This sleep disorder seems to run in some families, suggesting a possible genetic predisposition to the condition. The risk for sleep apnea is higher for people who are overweight. A person who is overweight may have more fat stored around his or her neck. This may make the airway smaller. In addition, fat stored in the neck and throughout the body can produce substances that cause inflammation. Inflammation in the neck may be a risk factor for sleep apnea. Weight loss usually improves sleep apnea. Weight loss may help to decrease neck size and lessen inflammation. Osteoarthritis is a common joint disorder linked with obesity and overweight. There are more than one hundred different kinds of arthritis, which literally means joint inflammation. About forty-three million Americans are afflicted, and more than half of those have osteoarthritis, by far the most common form, especially among older people. Sometimes called degenerative joint disease, osteoarthritis affects 12.1 percent of U.S. adults, or 20.7 million people.42 As with other types of arthritis, women are at higher risk than men for the condition. 41 Rissanen, A., & Fogelholm, M. (1999). Physical activity in the prevention of other morbid conditions associated with obesity: Current evidence and research issues. Medicine and Science in Sports & Medicine, 31(11). S635-S645. 42 Ibid 21
  22. 22. Osteoarthritis mostly affects the cartilage, the slippery tissue that covers the ends of bones in a joint. Healthy cartilage allows bones to glide over one another and absorbs energy from the shock of physical movement. In osteoarthritis, the surface layer of cartilage breaks down and wears away. This allows bones under the cartilage to rub together, causing bone swelling and loss of motion of the joint. Over time, the joint may lose its normal shape. Also, bone spurs — small growths called osteophytes — may grow on the edges of the joint. Bits of bone or cartilage can break off and float inside the joint space, which can causes more pain and damage. Osteoarthritis most often affects the joints of the knees, hips, and lower back. Unlike some other forms of arthritis, osteoarthritis only affects joints, and not internal organs. Osteoarthritis is directly affected by a person’s weight and size. Extra weight may place extra pressure on joints and cartilage, causing them to wear away. In addition, people with more body fat may have higher blood levels of substances that cause inflammation. Inflammation at the joint may raise the risk for osteoarthritis. Weight loss can decrease stress on your knees, hips, and lower back, and lessen inflammation in your body. Losing weight may greatly improve the symptoms of osteoarthritis. Gallbladder disease is a common condition that affecting an estimated twenty million Americans, mainly women, although men can suffer too. The symptoms vary widely from discomfort to severe pain which mainly begins after food. In severe cases the patient can suffer from jaundice, nausea and fever. The most common reason for gallbladder disease is gallstones. Gallstones are solid stones formed in the gall bladder from cholesterol, bile salts and calcium. They can vary in size from a few millimeters to a few centimeters Gallstones are formed when bile contains too much cholesterol. The excess cholesterol forms crystals from which gallstones are made. Gallstones are seen in all age groups but they are rare in the young. 22
  23. 23. The possibility of developing gallstones increases with age. The following groups are considered to be at increased risk: people who have relatives with gallstones; obese people; people with a high blood cholesterol level; women who take drugs containing estrogen, eg contraceptive pills; people with diseases such as chronic intestinal inflammation (Crohn's disease and ulcerative colitis). There is growing evidence that fatty liver disease, previously believed to be a harmless condition, may seriously damage the liver. A recent study conducted at the Johns-Hopkins University School of Medicine using data from the Third National Health and Nutrition Examination Survey (NHANES-III) indicates that nonalcoholic fatty liver disease (NAFLD) might be very common in the United States.43 NAFLD is now being recognized as a spectrum of liver disorders from sample fatty infiltration (steatosis) to inflammation necrosis (steatohepatitis), to fibrosis and cirrhosis that is virtually indistinguishable from acute alcoholic liver disease. Fat may accumulate in the liver with extreme weight gain or diabetes mellitus. Fatty liver can also occur with poor diet and certain illnesses, such as tuberculosis, intestinal bypass surgery for obesity, and certain drugs such as corticosteroids. A patient has fatty liver when the fat makes up at least ten percent (10%) of the liver. It is usually diagnosed when one of the above conditions is being investigated. A liver biopsy is performed to confirm the condition. Because NAFLD has not been considered a harmful condition, it has not been thought to be necessary to treat. If the condition was brought on by obesity, weight loss is suggested; if by diabetes, diet and insulin treatment is recommended. The benefits of these treatments, however, have not yet been proven. 43 Block G, Wakimoto P, Block T. A revision of the Block Dietary Questionnaire and database, based on NHANES III data. American Journal of Epidemiology (1998). 23
  24. 24. In light of recent evidence, the medical community will have to rethink how it diagnoses, treats, and prevents NAFLD. Now in America the common cause of abnormal liver enzymes is nonalcoholic fatty liver disease. The 1988 - 1994 NHANES-III data, indicate that as many as twenty-nine percent of adults in the United States have abnormal liver enzymes. The report shows that for a majority of these abnormal tests (84 percent) an identifiable cause can not be found (such as hepatitis-B or -C). NAFLD is surmised to be the cause for the unidentifiable cases. It is now presumed that 24 percent of the population has NAFLD. The disease is associated with age and obesity. It is most common in men, post-menopausal women, and people of African and Hispanic ancestry. In 1997, chronic liver disease, cirrhosis, was the tenth leading cause of death in the United States. Approximately ten percent of cirrhosis-related deaths are attributed to cirrhosis of unknown underlying cause. Although further research is needed, recent evidence suggests that some of these causes may stem from NAFLD. A chronic disease affecting Americans in the United States is sickle cell anemia. This serious disease affects some 70,000 people and is a source of concern for over two million people, who have the sickle cell trait that could be passed on to their children.44 The disease predominantly affects African-American, African, Hispanics, Caribbean and South American persons in the United States. One out of every four hundred African-American newborns in the United States is affected by sickle cell anemia. The disease is marked by the formation of blood cells in an abnormal crescent shape. The misshapen blood cells of sickle cell patients contain an unusual form of hemoglobin and release a large amount of it into the blood plasma. These irregularly shaped cells clot and constrict blood flow or even the arteries. Also, normal-shaped blood cells with “sickled” hemoglobin are more likely to stick. Clotting often 44 Lee, Phillip R., Estes, Carroll R. The Nations’ Health, Third Edition (1990 24
  25. 25. occurs in the arms and legs, causing a sharp pain that lasts for several hours. Blood clots in the head and neck may lead to a stroke, a top cause of death among young sickle cell sufferers. Pain is the hallmark clinical manifestation of sickle cell disease. Severe pain can occur in patients as young as six months of age, and may continue throughout a person’s life. The inherited condition can cause bouts of severe pain, particularly in the joints and limbs, and can damage the lungs, kidneys and other vital organs. The pain can be managed effectively, as long as barriers to adequate pain assessment and management are overcome. Management of this disabling condition often runs headlong into prejudice, a lack of financial resources and some difficult social and medical realities. Many of the diseases mentioned greatly affect the African-American population; more so than their white counterparts. Some of these diseases are listed among the ten leading causes of death in African American adults. African or Black Americans are the nation’s largest emerging majority population, constituting twelve percent of the population of the United States.45 Most members of the present African American community have their roots in Africa, and the majority descends from people who were brought here as slaves from the west coast of Africa.46 The Civil War ended slavery, but in many ways, it did not emancipate blacks. Daily life after the war was fraught with tremendous difficulty, stripping black people, according to custom, of their basic civil rights. In the South, black people were overtly segregated, most living in conditions of extreme hardship and poverty. Those who migrated to the North over the years were subject to all the problems of fragmented urban life: poverty, racism, and covert segregation.47 The background and history of African Americans must be considered when discussing eating patterns and health. Although times have changed, many African Americans have 45 Gutman, H.G. The Black Family in Slavery and Freedom, 1750-1925 (New York: Pantheon, 1976). 46 Ibid 47 Ewbank, D.C. (1987). The history of black mortality and health before 1940. The Milbank Quarterly. 65(1): 100- 128. 25
  26. 26. maintained the same eating patterns as their ancestors. We are not all created equal when it comes to our health. Each of us has a unique genetic and cultural heritage that makes us more- or- less susceptible to certain illnesses and medical conditions. While our genetic inheritance can be linked to each individual genetic inheritance, African Americans not only share a common history, but some common health traits as well. Unfortunately, to be black in America is to be at a medical disadvantage compared to people of other races. As a group, African Americans suffer disproportionately from serious chronic illnesses, including heart disease cancer, stroke, liver disease, diabetes, respiratory disease and AIDS.48 The historic problems of the black community need to be appreciated by the health-care provider who attempts to distance modern practices and traditional health and illness beliefs. All too often, mainstream medical doctors don’t understand or appreciate the subtle but important differences between their black and non-black patients. Rather than treat the unique needs of the individual, many physicians use a one-size-fits-all approach to healing that does not address the special health care needs of their African American patients. The eating habits and food purchasing practices of African Americans may be associated with the increased incidence of hypertension, cardiovascular disease, and diabetes in later life. These chronic disease risk factors are commonly explained by dietary habits and African Americans may be at higher risk from these factors compared to Whites. The food that is eaten and the methods for preparing it contribute to people’s health. African Americans consume less fruits and vegetables, dietary fiber, calcium, and potassium, while they consume fatty meats, salt, and dietary cholesterol in excess.49 While the health profile of other ethnic groups is 48 Kumanyika, S. Diet and chronic disease issues in minority populations. Journal of Nutrition Education (1990);22:89-95. 49 Popkins, B., Siega-Riz A, Haines, P.A. A comparison of dietary trends among racial and socioeconomic groups in the United states. New England Journal of Medicine (1996);335:716-720. Livingston, I.L., ed. Handbook of Black American Health. Westport, CT: Greenwood Press, 1994. 26
  27. 27. improving, the prognosis for African Americans is deteriorating. According to statisticians, there is an 8.5 year difference in the median survival rate between white and black males and a 5.9 year gap between white and black females.50 Since the turn of the century, life expectancy at birth in the U.S. had generally increased for all races. However, from 1984 to 1989, life expectance for whites increased while life expectancy for blacks decreased.51 For black males, the most significant factor was an increase in HIV infection and homicide. For black females, spread of HIV infection, diabetes, and pneumonia contributed to the death toll. African Americans are more likely than people of other races to die a premature death. In addition to the death rates, African Americans suffer more often than other races from both chronic and acute illnesses. The age adjusted death rate from heart disease were twenty-seven percent greater in black men than white men and a remarkable fifty-five percent in black women than white men. An estimated three million African Americans have diabetes, which adds up to one in every ten persons.52 Blacks are fifty-five percent than whites to have diabetes; the disease is especially prevalent in black women. Of the more than 500,000 people stricken with lupus, nine out of ten are women ages fifteen to forty-five and three out of five are black. Sickle Cell disease strikes one out of twelve African Americans. Blacks are affected by infertility nearly one and a half times more often than whites. African Americans and Latinos together total twenty- one percent of the population, but they account for forty-six percent of the U.S. AIDS cases so far.53 High blood pressure is twice as common in blacks as in whites, affecting one in three blacks. African American children are twice as likely as white children to die before their first birthday. For each one thousand black babies born in the U.S, nineteen die by age one, 50 Carter, Chelsea (2000). Black and white death rates are not just a matter of health-care access. Metro@ Augusta. [On-line]. Available: http://www.augustachronicle.com/stories/040298/met/htm 51 Ibid 52 Roseman, J.M. (1995). Diabetes in Black Americans. In Diabetes in America. Washington, DC. U.S Government Printing Office, NIH Publication No. 85-1468. 53 Chronic diseases and their risk factors [On-line] Available:http://www.cdc.gov/ncdphp/statbook/.html 27
  28. 28. compared with eight of one thousand white babies. This pattern has existed for more than forty years. African Americans develop cancer about ten percent more often than the general population with mortality rates twenty to forty percent higher. One of the key reasons for poor mortality rates linked to cancer is due to the fact that the cancer is often undetected until it reaches a more advanced- and less curable- stage. The overall diet for blacks plays a major role in the high cancer rate. African Americans accounted for thirty-nine percent of the drug abuse- related emergency room visits reported to the Drug Abuse Warning Network of the National Institute on Drug Abuse in 1988. Toughly seventy-five percent of the nation’s two to two and a half million heroin addicts are clack. Studies estimate that at least seventy five thousand African Americans die each year of manageable diseases. The gap in health status between white and black Americans was very significant. More than sixty thousand excess deaths occurred per year for blacks compared to the general population. African Americans need the knowledge, desire, and willingness to take better care of ourselves with education being they key.54 To improve the overall health of African Americans, we must all work together to increase individual and community responsibility for health, stress comprehensive health education, place emphasis on prevention and primary care, and push for universal access to health care services. African Americans must also strive to avoid risky behavior: smoking, drinking, taking drugs, using weapons, being overweight, reluctance to exercise, and eating unhealthy foods, among others. Statement of the Problem: 54 Bailey, Eric J. (1987) Socio-cultural factors and health care-seeking behavior among Black Americans. Journal of the American Medical Association. Vol.79:389-92. 28
  29. 29. What nutritional health problems based on eating patterns are associated with African-Americans between the ages of twenty and sixty-five who attend church regularly? Significance of the Study: This research is highly important for any individual wanting to improve their health, especially African Americans. Our nation is suffering health wise because of poor nutrition, behavior, and poor physical activity. In January 2000, the United States Department of Health and Human Services (USDHHS) released Healthy People 2010. This work identified the successes and weaknesses of the nation in the area of health promotion and disease prevention.55 Study revealed that only five of the objectives established in Healthy People 2000 were met, one of which is related to the availability of reduced-fat foods. There is even less progress today than ten years ago on the nutrition-related objectives such as the prevalence of obesity. The fact that obesity has now become an “epidemic” proves how unhealthy Americans are. These trends will only worsen if effective measures are not taken to improve the statistics. Proper nutrition plays a major role in the quality of life. It is with hopes that this study awakens the reader to his or her health prompting an emphasis on self health maintenance. The gripping fact is that everyone has the ability to prevent diseases just by altering their behavior and diet. If each person improved their diet and health, our nation would be positively impacted physically, socially, financially. A nation whose basic nutritional needs are met is healthier, more productive and can focus its energies on educational attainment, improved housing, enhanced medical care, and the provision of goods and services associated with a highly developed society. This research will address the eating and behavior patterns of both 55 USDHHS, 2000 29
  30. 30. Americans and African Americans. This research will also correlate a relationship between diet patterns and spiritual wellness. The gap in health status and risk factors for diet-related diseases is even wider in many segments of the population depending upon socio-demographic factors.56 While the overall health of Americans need improvement, African-Americans lag far behind due to many socioeconomic factors, behavior, educational status, inadequate access to health care, etc. The health of African Americans is in a much poorer state when compared with non-African Americans. African Americans need much improvement in their nutritional health status. Investigation of the eating habits of African Americans since 1960 indicated that their diets lacked the variety of foods required to supply sufficient quantities of vitamins and minerals and other significant classes of nutrients needed by the body.57 Overweight and obesity are precursors to many chronic diseases. To alleviate the problems of both obesity and chronic diseases in the African American population, a clearer understanding of the health promoting behaviors that could prevent these conditions are essential. This study will discuss the connection (if any) between the church and the wellness of church members, specifically amongst African Americans. Research indicates that the role of the Black church is a growing interest in the background of developing culturally appropriate interventions. America is going through a physical war in Iraq while also dealing with the many religious battles (especially considering the terrorist attacks of 2001 and the 2004 presidential election). This research will discover any correlations between the spiritual well being and physical well being of a person, revealing if one impacts the other. This study is more significant for African American church goers due to the fact that their state of health needs 56 Bailey, Eric J. (1987) Socio-cultural factors and health care-seeking behavior among Black Americans. Journal of the American Medical Association. Vol.79:389-92 57 Ibid 30
  31. 31. much more improvement. This study should motivate those who attend church regularly to examine their health and seek ways to improve their health by modifying eating patterns, diet and behavior. This study should also serve as a tool for the leaders of the church to place as much emphasis on its members to improve their physical health as they do on the spiritual. Definition of Terms: 1. Health / Wellness - The World Health Organization defines health as a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. Health is a cumulative state, to be promoted throughout life in order to ensure that the full benefits are enjoyed in later years. Good health is vital to maintain an acceptable quality of life in older individuals and to ensure the continued contributions of older person’s to society. 2. Nutrition - by definition, is the way our bodies take in and use food. Foods that are great sources of nutrition are called nutrients. There are six different types of nutrients: Carbohydrates, fats, proteins, vitamins, minerals, water. Nutrients give us energy, growth, help repair body tissues, and regulate body functions. Therefore each nutrient can be vital to your health. Good nutrition can prevent many chronic illnesses and diseases. 3. Eating Patterns - describes the eating frequency, the temporal distribution of eating events across the day, breakfast skipping, and the frequency of eating meals away from home. Eating patterns includes what a person consumes, when they consume and the quantity they consume. Research shows that eating patterns affect physical health and is linked with obesity and other diseases. 4. Problems – problems greatly affecting African Americans due to poor nutrition/eating patterns, genetics, socioeconomic factors (income), and other behavioral factors such as smoking, drinking, etc. Problems or diseases associated with eating patterns include but is not limited to: obesity, overweight, diabetes, CHD, cancer (certain types), liver disease, stroke, osteoarthritis, etc. With behavior modifications, these conditions can be lessened and even avoided. Other problems plaguing African Americans are drug and alcohol abuse, HIV/AIDS, homicide (especially black males), etc. 5. Church Regularly – before defining both terms, it is important to understand what is church. The term “church” implies that an otherwise qualified organization bring people together as the principle means of accomplishing its exempt purpose. To be a “church” a religious organization must engage in the administration of sacerdotal functions and the conduct of religious worship in accordance with the tenets and practices of a particular religious body. Those attending church regularly do so at least once a week. Most persons, especially African Americans, attend church on Sundays and bible study on a weekday. Delimitations: 31
  32. 32. This study was delimited to literate, English-speaking adults twenty years old and older. Subjects were identified primarily from the population of a local congregation in the suburban Washington metropolitan area. Subjects were interviewed during a special church service celebrating the Thanksgiving holiday. It is important to note that many of the respondents were eating while survey was administered. However, this had no influence on their responses. Overall, this study focuses on diet and nutrition and their effect on the health of Americans. Moreover, this study deals with the health patterns of African Americans attending church on a regular basis. The research reveals that the health of African Americans in the U.S. is in far worse shape when compared with their Caucasian counterparts. This study stresses the need for improvement in the African American diet to ensure quality of life; a life free of chronic illnesses and diseases. Overview : This unit serves the purpose of introducing to the reader the current state of health and nutrition of Americans. It also explores the risk factors that come from poor nutrition. Nutrition is essential for growth and development, health, and well-being. It plays a critical role in decreasing chronic disease risk, especially when experienced by African Americans, who suffer disproportionately from premature death, disease, and disabilities due to do poor diet and nutrition. Health statistics differ greatly between African Americans and Whites in the United States. Many African Americans face tremendous social, economic, cultural and other barriers to optimal health. It is well known that a high quality diet will decrease the prevalence of chronic disease. Dietary changes have been implicated in the management of chronic diseases, such as hypertension, diabetes, cardiovascular disease, coronary heart disease, obesity, and stroke. Consuming a high quality diet means increasing fruit and vegetable intake, thereby increasing dietary fiber, reducing total fat and saturated fat, and decreasing sodium intake for management of salt sensitive hypertension. This unit provides a very detailed background providing a framework for the study. 32
  33. 33. Unit II Review of Related Literature This unit presents a review of literature related to the purpose of the study. Good eating patterns are vital to a person’s physical well being and quality of life. Individual health behaviors, lifestyle practices, environmental and psychosocial stresses, and availability of health care resources al contribute to health promotion behaviors among vulnerable populations. Over time, poor eating patterns along with behavior can cause risk for chronic illnesses such as cardiovascular disease (CHD), obesity, cancer, diabetes, hypertension, osteoarthritis, and the like. The health state of most Americans needs much improvement, with a major emphasis on the African American population. African Americans have more health problems when compared with their white counterparts. Public health data show that African–Americans have not adopted health-promoting behaviors of diet and exercise. Interventions are needed to 33
  34. 34. alleviate health problems associated with African Americans. This study will explore the existing factors affecting African Americans in relation to eating patterns and religion. Research suggests a correlation between spirituality and the health promoting behaviors in African Americans. Included are several studies dealing with nutrition, eating patterns and other related factors affecting Americans, specifically, African Americans. Subtopics include nutrition/dietary behavior, obesity, diseases, spirituality, and African American health Nutrition/ Dietary Behavior Nutrition and dietary behavior are vital components in the overall physical health of a person. Healthy lifestyle changes such as eating low-fat, high fiber diets, and increasing physical activities can help maintain desirable body weight and decrease risk of chronic diseases, ensuring quality of life. Lasting dietary change is more likely to be achieved when individuals are actively involved. For instance, taking responsibility and learning skills for management of dietary habits are strategies that perpetuate the adoption of positive behaviors. Several research studies have been done to ascertain client knowledge of nutrition. A survey done on 606 cardiac patients assessed their understanding of the role nutrition plays in heart disease.58 The results showed that the majority of the clients stated they viewed nutrition as important and that it played an important role in the development of their disease process. An assessment was done that addressed concerns about healthful dietary practices59 . The study revealed that dietary behavior change is recognized as being a complex process that is affected by many factors and current understanding of mediating variables that affect the process and its outcome is far from adequate. 58 Plous, S., Chesne, R.B., & McDowell, A.V. (1995). Nutrition Knowledge and Attitudes of Cardiac Patients. Journal of the American Dietetic Association, 95(4). 442-446 59 Berry, Norma Falleta, PhD, 1989 Identification and Assessment of Concerns About Healthful Dietary Practices. Texas A & M University pp. 206-207 34
  35. 35. Another body of research evolved that focused on concerns that people have when they are involved in change processes. The Concerns Based Adoption Model has provided the conceptual framework for many of these studies. The purposes of this study were to determine whether concerns theory can be extended to the realm of dietary behavior and to develop an instrument to assess healthful dietary practice concerns of adults. Healthful dietary practices were defined as the Dietary Guidelines for Americans, and when applicable to specific individuals, other dietary guidelines recommended by health care providers. The data indicate that differences in overall intensity of concern may be related to whether respondents follow healthful dietary practices to manage a health problem. In contrast, data can also indicate maintained health and that difference in relative intensity among various stages of concern reported by respondents may be related to the reason for changing to healthful dietary practices. These results also suggest that a Stages of Healthful Dietary Practice Concern Questionnaire would provide a valid and reliable assessment of adults’ healthful dietary practice concerns. Nutrition plays a significant role in maintaining health and preventing chronic disease is supported by numerous studies. The National Cancer Institute (NCI) lists possible cancer- preventive foods and ingredients in a pyramid (see Appendix). Generally, there is a multitude of phyto-chemicals (“phyto” means “plant”) present, most of which are believed to have cancer- preventive properties. Many of the phyto-chemicals involved are anti-oxidative in nature, meaning they prevent deleterious effects of oxidation. The NCI estimates that thirty-five percent of cancer deaths may be related to dietary factors, and that more cancer deaths are attributable to diet than to any other cause, including tobacco and alcohol. Since 1992, the NCI and the Produce for Better Health Foundation, Inc. has been sponsoring the “5-A-Day” Program, which encourages consumers to consume at least five servings of fruits and vegetables daily. The Food Guide Pyramid outlines what we should consume each day. There are many Americans who fail 35
  36. 36. to meet the majority of recommendations of the Food Guide Pyramid or the Dietary Guidelines for Americans. A document entitled Promoting Health/Preventing Disease: Objectives for the Nation (U.S. Department of Health and Human Services [USDHHS], 1980) marked the acknowledgement by the federal government of the importance of nutrition on the health of the nation. In addition, they launched an era of health planning by the nation, individual states and local communities to set measurable objectives related to health education initiatives for 1990. In January 2000, the USDHHS released Healthy People 2010, which identified the nation’s successes and weaknesses in the area of health promotion and disease prevention. Unfortunately, only five of the twenty-seven nutrition objectives established in Health People 2000 were met, one of which is related to the availability of reduced-fat foods. Progress toward some of the other nutrition objectives was demonstrated including increased fruit, vegetable, and grain consumption, reduction in total fat and saturated fat, and availability of nutrition information labels on food. In 1988, approximately sixty percent of packaged foods regulated by the Food and Drug Administration (FDA) had nutrition labeling, an increase from forty-two percent in 1978. The Nutrition Labeling and Education Act of 1990 required nutrition labeling on most products regulated by the FDA, including fresh fruits, vegetables, and fish.. The U.S. Department of Agriculture (USDA) has proposed nutrition labeling for the products it regulates. According to the National Center for Health Statistics, there is even less progress today than ten years ago on nutrition-related objectives such as reduced prevalence of obesity. The gap in health status and risk factors for diet-related diseases is even wider in many segments of the population depending upon socio-demographic factors. 36
  37. 37. One of the most important factors when discussing good eating patterns and nutrition stems from the consumption of fruits and vegetables. Eating vegetables and fruits on a regular basis or selecting vegetables and fruits over less healthful food has been found to be associated with many factors. Dietary behavior has been extensively researched and its literature has been recently reviewed. Reviews of researchers examining psychosocial, developmental and biological determinants of food preferences will be further discussed.60 Much of the literature points to perceived difficulty of preparation and time needed for preparation, perceived lack of social support, expense perishability, sole responsibility for shopping, lack of nutrition knowledge and outcome expectations (which include perceived susceptibility and threat of disease, benefits and barriers)61 as consistent mediators of vegetable and fruit consumption. Reluctance to give up preferred food was one of the most frequently given reasons for not achieving or maintaining a healthful diet. In addition the beliefs that vegetable and fruit consumption decreases the risk of diseases, and that what one eats is important to one’s health, were associated with a healthful diet. Primary determinants of vegetable and fruit intake for low-income families were cost, taste, texture, appearance, convenience, quality (freshness), safety and the effort to eat healthy. Researchers suggest that barriers to vegetable and fruit consumption included cost and quality of fresh vegetable and fruit, perceived storage difficulties, perceived likelihood of spoilage, lack of availability in local stores and difficulty in changing behavior.62 Influences can also vary by food. In several studies, taste (which most often include odor and texture) more than perceived 60 Drewnowski A, Rock CL: The Influence of Genetic Taste Markers on Food . American Journal of Clinical Nutrition 1995;62:506-511 61 Baranowski, T. (1990) Reciprocal Determinism at the Stages of Behavior Change: An Integration of Community. Personal and Behavioral Perspectives. International Quarterly of Community Health Education:10 (4), 297-327 62 Reicks M, Randall JL, Haynes BJ: Factors Affecting Consumption of Fruits and Vegetables by Low-Income Families. Journal of the American Diabetic Association 1994;94:1309-1311 37
  38. 38. health effects and fattening characteristics was associated with vegetable and fruit consumption, particularly for low-income families. In another study, socio-economic status did little to explain vegetable and fruit consumption among low-income women participating in a federally- funded nutrition program, Women, Infants and Children (WIC).63 In this study, self-efficacy was the strongest predictor of vegetable and fruit consumption, followed by food-related attitudes, perceived barriers to consumption and social support. Sensitivity to bitter taste is heritable trait. Some perceive the taste of phenylthiocarbamide (PTC) and 6-n-propylthiouracil (PROP) as bitter, whereas others consider them tasteless. Phenylthiocarbamide tasters find raw cruciferous vegetables, such as broccoli, cabbage and brussel sprouts to taste bitter. Food consumption varies substantially by age. Research suggests that as one ages, sensitivity to the bitter taste of 6-n-propylthiouracil found in many bitter foods increased.64 Obesity/ Environmental Factors Obesity, defined as an excess percentage of body fat, has become an epidemic in the United States and other nations, affecting 54.9 percent of American adults. It substantially raises the risk of morbidity from numerous diseases, and poses a major public health challenge. The World Health Organization (WHO) reports that more than half of the adult population is overweight, and a quarter are clinically obese. Several scholars assert that obesity is the second leading cause of preventable death.65 The World Health Organization proposed a classification system for body weight based on body mass index. This classification system serves as a useful tool for international comparisons of obesity, facilitates monitoring changes associated with 63 Havas S, Anliker J, Damron D, Langenberg P, Ballesteros M, Feldman R; Final Results of the Maryland WIC 5- A-Day Promotion Program. American Journal of Public Health. 1998; 88:1161-1167. 64 Drewnowski A: Taste Preferences and Food Intake. Annual of Nutrition 1997;17:237-253 65 Ross, R., Jensen, I., & Tremblay, A. (2000). Obesity Reduction Through Lifestyle Modification. Canadian Journal of Applied Physiology. 25(1), 1-18. 38
  39. 39. major lifestyle alterations, and is based on a large body of clinical data.66 Body fat can be assessed by several measures including hydrostatic weighing, skin fold thickness measurement, CT scan or MRI.67 Most commonly however, body fat is estimated by life tables or body mass index calculations. The Metropolitan Life Insurance Company (1984) has generated tables of recommended weight ranges for a given gender, height, and body-build (small, medium or large). Tables are based on individual’s weights between ages twenty-five and twenty-nine years who later had the lowest mortality rates in a given year; the most recent tables available were calculated in 1984. Weight above twenty percent over ideal is associated with greater levels of morbidity and mortality. Although obesity is a multifaceted chronic illness, studies show that body weight is a function of energy balance.68 Weight gain occurs when one takes in more calories than one expends. Researchers also state that daily energy expenditure is contingent upon three components: resting metabolic rate, the thermic effect of food, and the energy expended in physical activity.69 According to these scholars, the thermal effect of food differs within and between individuals and the resting metabolic rate is, in part, genetically influenced. Additionally, research with twins revealed that genetic contribution to body fatness was fifty percent to seventy percent, whereas their research with family genetics revealed that such genetic contribution to fatness was approximately twenty-five percent to fifty percent.. Yet, they suggest that these factors contribute minimally to the development of obesity.70 The primary factor in the development of obesity is the consumption of more energy than that which is expended. 66 Bouchard, C., & Blair, S. (1999). Introductory comments for the consensus on physical activity and obesity. Medicine & Science in Sports & Medicine, 31(11). S498-S501. 67 Bray, George. Dietary Guidelines: The Shape of Things to Come Journal of Nutrition Education, S97-99,1980 68 Hill, J., & Melanson, E.L. (1999). Overview of the determinants of overweight and obesity: Current evidence and research issues. Medicine & Science in Sports Medicine, 31(11), S515-S521 69 Ibid 70 Ibid 39
  40. 40. Using a definition of obesity based on body mass index, two surveys (The Second National Health and Nutrition Examination Survey (NHANES II) in 1976-1980 Hispanic HANES in 1982-1984) indicated the prevalence of obesity among persons aged twenty to seventy-four years to be approximately twenty-four percent among men and twenty-seven percent among women. These prevalence estimates were virtually unchanged from the early 1960s. Based on the most recent data available, the prevalence of overweight was lowest among non-Hispanic white women (25%) and highest among non-Hispanic black women (44%). In general, the prevalence of overweight among women was inversely related to socioeconomic status. Among men, the prevalence of overweight was lowest among non-Hispanic whites (24%) and highest among Mexican Americans (30%). Obesity has been cited as an important health issue for most minority populations, especially lower income women in certain minority groups.71 Obesity is a major problem for African-American and Hispanic women. The prevalence of obesity has been associated with metabolic factors, such as lower metabolic rate in African-American women and with lifestyle or behavioral factors, such as consumption of high fat diets. Both African American men and women have lower resting metabolic rates; however obesity is a problem noted primarily in African-American women.72 It is asserted that the obesity noted in African American women is not due to lower resting metabolic.73 The most prominent theory regarding the obesity epidemic is the effect of modernization (technology that decreases physical energy expenditures) and its intake and physical activity.74 In 1994, it was purported that there were thirty-four million obese Americans. 71 Kumanyika, S.(1990). Diet and chronic disease issues for minority populations. Journal of Nutrition Education, 22 (2), 89-96. 72 Hill, J., & Melanson, E.L. (1999). Overview of the determinants of overweight and obesity: Current evidence and research issues. Medicine & Science in Sports Medicine, 31(11), S515-S521 73 Ibid 74 Bouchard, C., & Blair, S. (1999). Introductory comments for the consensus on physical activity and obesity. Medicine & Science in Sports & Medicine, 31(11). S498-S501 40
  41. 41. In addition, thirty-six percent of these Americans were black women, and sixty percent of middle-age black women were overweight.75 Studies also purported that black women are less likely to participate in weight loss programs, more likely to drop out of these programs when they do participate, and less likely than other groups to lose weight related to such participation.76 A lack cultural sensitivity in the design of most weight loss programs was offered as a possible explanation for the lack of participation among black women. Although statistical reports indicate that African American women have a higher prevalence for obesity and its associated co-morbidities (American Heart Association [AHA], 2001: Centers for Disease Control and Prevention [CDC], 2000, very few research studies focusing on dietary or exercise modification have included African American women.77 The prevalence of obesity in the United States has increased substantially in the last two decades, particularly relative to other countries. National surveys in the United States confirm that increases in prevalence of overweight and obesity have occurred within a short period of time. The most recent data derived from the Behavioral Risk Factor Surveillance System show that 19.8 percent of US adults are obese, defined as having a body mass index (weight (kg)/height (m)2 ) equal to or greater than 30 kg/m2 , which percentage reflects a 61 percent increase since 1991. Obesity, in turn, is a precursor to several major health problems, including, but not limited to, diabetes mellitus, coronary heart disease, and sleep-breathing disorders. The Seasonal Variation of Blood Cholesterol Study (SEASONS), a large prospective study, was designed to quantify the magnitude and timing of seasonal changes in blood lipids and to identify the major factors contributing to this variation including diet and physical activity. We have used 75 Kanders, B.S., Ullman, J.P., Foreyt, Heymsfield, S.B., Heber, D., Elashoff. (1994) The Black American lifestyle intervention (BALI): The deign of a weight loss program for working class African American women. Journal of the American Dietetic Association. 94 (3), 310-312 76 Ibid 77 Yancey, A., Miles, O., McCarthy, W.J., Sandoval, G., Hill, J., & Harrison, G (2001). Differential response to targeted recruitment strategies to fitness promotion research by African American women of varying body mass index. Ethnicity and Disease. 11, 115-123. 41
  42. 42. cross-sectional data from this study to evaluate the relation between eating patterns and obesity, while controlling for the effects of physical activity and energy intake. Results from the study support the hypothesis that eating patterns are associated with obesity even after controlling for total energy intake and physical activity. A lower obesity risk was observed among subjects reporting larger numbers of eating episodes per day. In contrast, skipping breakfast was associated with increased risk of obesity, as was increasing the proportion of either breakfast or dinner eating away from home. However, the temporal distribution of eating events across the day was not related to obesity. Environment is an important factor when considering a person’s health. Literature in the field of education historically has suggested that the affective state of the earner toward the subject matter of a learning experience can have significant impact on the outcome of that experience. Recommendations consistently appear regarding the consideration of the mental set of the learner in educational planning. Likewise, in health education, nutrition education and nutritional counseling literature, personal or private factors such as awareness, interest, attitudes, and feelings are cited as principal factors of influence on behavioral outcomes. In the late nineteenth and early twentieth centuries, members of the Progressive Education Movement stressed that learning should center in students’ interests and needs.78 During the 1920’s and 1930’s, study discussed the importance of self-efficacy. Self-efficacy refers to the cognitive and behavioral factors related to an individual’s perception of his or her ability to make lifestyle changes. Research has shown that self-efficacy is an important mediator between knowledge, attitudes, skills, and subsequent behavior change, and that self-efficacy can be modified through particular behavior change strategies.79 78 Butts, R.F., & Cremin, L.A. (1953,1964). A history of education in American culture. NY: Holt, Rinehart and Winston 79 Bandura, A. (1977). Self Efficacy: Toward a unifying theory of behavioral change. Psychology Review. 84, 191- 215 42
  43. 43. The environment influences the individual to behave in a certain way. The most basic environmental component that influences an individual’s behavior is the physical environment. In the context of dietary intake, the physical make-up of the home and the physical resources within it may influence one’s dietary intake. Some physical environments may enhance certain behaviors while others act as barriers. For example, the ability to adequately store food influences consumption of certain food groups such as fruits and vegetables.80 Inadequate food preparation equipment also limits the number and types of foods consumed.81 The physical environment may also extend outside the home to include components such as location of convenience and grocery stores, fast food and other restaurants, and foods available at school, work sites, and entertainment venues such as movie theatres and sporting events. An assessment done by researchers measured dietary intake via a telephone survey in a total of 5,654 persons living in twelve communities.82 In addition, the availability of healthful products (i.e., high fiber and low fat) in these same twelve communities was also assessed. Significant correlations were reported between the availability of healthful food choices in the physical environment and the reported healthfulness of individual diets. For example, the amount of shelf space in the grocery store allotted to low-fat milk was significantly correlated to reported consumption of low-fat milk. There was also a relationship between grocery store healthfulness scale and lower reported intakes of dietary fat. While this association was not statistically significant, the relationship was in the appropriate direction. 80 Campbell, C., & Desjardin, E. (1989) A model and research approach for studying the management of limited food resources by low-income families. Journal of Nutrition Education, 21 (4) 162-170 Reicks, M., Randall, J., & Haynes, B.J. (1994). Factors affecting consumption of fruits and vegetables by low- income families. Journal of the American Dietetic Association, 94 (11), 1309-1311 81 Keenan, D.P., Abu Sabha, R., Sigman-Grant, M. (1999). Factors perceived to influence dietary fat reduction behaviors. Journal of Nutrition Education, 31, 134-144 82 Cheadle, A., Psaty, B.M., Curry, S., Wagner, E., Diehr, P., Koepsell, T., & Kristal, A. (1991). Community level comparisons between the grocery store environment and individual dietary practices. Preventive Medicine, 20, 250- 261. 43
  44. 44. It is important to note that in those communities where there was increased availability of healthful products, and subsequently more healthful dietary intake, individuals living in these communities had higher levels of education (a proxy for socioeconomic status in numerous studies). The authors note that perhaps those with higher education levels may demand the presence of more healthful food choices in the grocery stores. Disease Research conducted in the second half of the century emphasizes the important relationship between dietary intake and chronic disease prevalence. Dietary factors, such as excessive dietary intake of fats and low intake of fiber, fruits and vegetables have been linked to four of the ten leading causes of death in the United States including Type 2 diabetes, coronary heart disease, stroke and certain cancers. Dietary habits may also contribute to an increased risk of obesity, an independent risk factor for the aforementioned chronic illness. Nutrition plays a critical role in decreasing chronic disease risk experienced by African Americans. It is well known that a high quality diet will decrease the prevalence of chronic disease. Dietary changes have been implicated in the management of chronic disease, more specifically, hypertension, diabetes, cardiovascular disease, coronary heart disease, and stroke. Consuming a high quality diet means increasing fruit and vegetable intake, thereby increasing dietary fiber (>25 grams), reducing total fat (>30%) and saturated fat (<10%), increasing complex carbohydrates thus increasing whole grains and dietary fiber, and decreasing sodium intake for management of salt-sensitive hypertension.83 Many chronic diseases can be controlled by healthy habits and diet change (Position of ADA, 2002). 83 Furumoto-Dawson AA, Pandey DK, Elliot WJ, de Leon CFM, AlHani AJK, Hollenberg S, Camba N, Wicklund R, Black HR. Hypertension in women: the Women Take Heart Project. Journal of Clinical Hypertension. 2003;5 (1): 38-46 44
  45. 45. It has been widely reported that the majority of cancers are caused by environmental risk factors, particularly those related to lifestyle. Environmental factors include tobacco, alcohol use, physical activity, obesity and diet. Demographic characteristics are considered risk factors because they act as proxies for states and behaviors that often can not be directly measured, but are often determinants of disease. Reported socio-demographic factors associated with cancer incidence and mortality is age, sex, and socio-economic status. Of the known determinants of health in general and specifically for cancer, socio-economic status may be the most robust and consistent. In a review of cervical cancer, the incidence of cervical, stomach and lung cancers, were consistently greatest among low socio-economic status and high socio-economic groups.84 Socio-economic status is a composite index that typically included measures of income, education and/or occupation. An extensive review of epidemiological research concluded that nearly two-thirds of cancer deaths are preventable. Lifestyle combined with genetic susceptibility may be true determinants of cancer risk for most people. Cancer is the second most common cause of death in the United States. While obesity and diets high in fat are associated with several types of cancers, including colorectal and breast cancer, the specific relationship between dietary risk factors and cancer is still unclear according to the Center for Disease Control. Research indicates that a relationship may exist between excess calorie and saturated fat intake and increased risk of colon cancer.85 Some researchers have discovered that low fiber intake places individuals at increased risk for colorectal cancer while others do not support this hypothesis.86 84 Schiffman MH, Brinton LA: The Epdemiology of Cervical Carcinogenesis. Cancer 1998; Supplement, 76:1888-1901 85 Slattery, M.L., Caan, B.J., Potter, J.D., Berry, T.D., Coates, A., Duncan, D., & Edwards, S.L. (1997). Dietary energy sources and colon cancer risk. American Journal of Epidemiology, 145, 199-210. 86 Fuchs, C.S., Giovannucci, E.L., Colditz, G.A., Hunter, D.J., Stampfer, M.J., Rosner, B., Speizer, F.E., & Willett, W.C. (1999). Dietary fiber and the risk of colorectal cancer and adenoma in women. New England Journal of Medicine, 340, 169-176. 45

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