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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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