aetna presentation obesity

Obesity, Latinos, and Diet

Daniel Santibanez, MPHDepartment of Public HealthUniversity of North Florida

This is part 4 of an 8 part series of seminars on Hispanic Health Issues brought to you by the University of North Florida’s Dept. of Public Health, College of Health, a grant from AETNA, and the cooperation of

Duval County Health Department. For more information or register for the seminars, please call 620-1289.

Overweight and Obesity Defined

Overweight: refers to an excess of body weight compared to set standards.

Obesity: having a very high amount of body fat in relation to lean body mass.

A person can be overweight without being obese. However, many people who are overweight are also obese.

Childhood Overweight Defined

BMI-for-Age growth charts are used for children and teens because of their rate of growth and development

At risk for overweight: BMI-for-age 85th percentile to 95th percentile

Overweight: BMI-for-age ≥ 95th percentile

There is no established definition of obesity in children

Measuring Overweight and Obesity

Body Mass Index: Measures weight in relation to height, and is closely related to body fat.

Waist Circumference: Individuals who carry fat around their waist are more likely to develop health problems than those who carry fat mainly in the hips and thighs, even if their BMI falls in the normal range.

High risk: more than 35 inches for women and 40 inches for men.

Body Mass Index (BMI)

Body Mass Index (BMI): a measure of an adult’s weight in relation to his or her height, specifically the adult’s weight in kilograms divided by the square of his or her height in meters.

Underweight: BMI Below 18.5

Normal: BMI Between 18.5 and 24.9

Overweight: BMI between 25 and 29.9

Obesity: BMI above 30

Severe Obesity: BMI Above 40

Weight in Kilograms

(Height in meters) (Height in meters)

The Increase in Overweight and Obesity Among Adults

Obesity Trends Among U.S. Adults Between 1985-2003 The data shown in these maps were collected through

CDC’s Behavioral Risk Factor Surveillance System (BRFSS). Each year, state health departments use standard procedures to collect data through a series of monthly telephone interviews with U.S. adults.

Prevalence estimates generated for the maps may vary slightly from those generated for the states by BRFSS (http://aps.nccd.cdc.gov/brfss) as slightly different analytic methods are used.

19961991

2003

Obesity Trends* Among U.S. AdultsBRFSS, 1991, 1996, 2003

(*BMI 30, or about 30 lbs overweight for 5’4” person)

No Data <10% 10%–14% 15%–19% 20%–24% ≥25%

Source: Behavioral Risk Factor Surveillance System, CDC.

Obesity Trends* Among U.S. AdultsBRFSS, 1985

No Data <10% 10%–14%

(*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person)


No Data <10% 10%–14%



No Data <10% 10%–14% 15%–19%



No Data <10% 10%–14% 15%–19% ≥20



No Data <10% 10%–14% 15%–19% 20%–24% ≥25%


(*BMI 30, or ~ 30 lbs overweight for 5’4” person)

No Data <10% 10%–14% 15%–19% 20%–24% ≥25%



Obesity* Trends Among U.S. AdultsBRFSS, 2003


No Data <10% 10%–14% 15%–19% 20%–24% ≥25%

Source: Smith et al. Circulation. 2005; 111:e134-e139

Epidemiology of Obesity

Obesity has been increasing across all U.S. groups since 1980

Ethnic disparities are prevalent

Obesity prevalence is highest among: African-American Females Hispanic Americans (esp. Mexican-Americans and Puerto

Ricans) Native Americans and Asians/Pacific Islanders

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CDC. Center for Health Statistics. National Health and Nutrition Examination Survey. American Obesity Association

Increase in Overweight and Obesity Prevalence Among U.S. Adults by Racial and Ethnic Group

Overweight Prevalence Obesity Prevalence

Racial/ Ethnic Group

1988 to 1994 1999 to 2000 1988 to 1994 1999 to 2000

Mexican-American

67.4% 73.4% 28.4% 34.4%

Black

(non- Hispanic)

62.5% 69.6% 30.2% 39.9%

White

(non- Hispanic)

52.6% 62.3% 21.2% 28.7%


Increase in Overweight Prevalence Among U.S. Adults (Ages 20 -74) by Racial/Ethnic Group and Gender

Men Prevalence Women Prevalence


1988 to 1994 1999 to 2000 1988 to 1994 1999 to 2000

Mexican-American

69.4% 74.4% 69.6% 71.8%

Black

(non- Hispanic)

58.2% 60.1% 68.5% 78%

White

(non- Hispanic)

61.6% 67.5% 47.2% 57.5%


Increase in Obesity Prevalence Among U.S. Adults (Ages 20 -74) by Racial/Ethnic Group and Gender



1988 to 1994 1999 to 2000 1988 to 1994 1999 to 2000

Mexican-American

24.4% 29.4% 36.1% 40.1%

Black

(non- Hispanic)

21.3% 28.8% 39.1% 40.1%

White

(non- Hispanic)

20.7% 27.7% 23.3% 30.6%


Increase in Severe Obesity (BMI ≥40) Prevalence Among U.S. Adults (Ages 20 and older) by Racial/Ethnic Group and Gender



1988 to 1994 1999 to 2000 1988 to 1994 1999 to 2000

Mexican-American

1.1% 2.4% 4.8% 5.5%

Black

(non- Hispanic)

2.4% 3.5% 7.9% 15.1%

White

(non- Hispanic)

1.8% 3% 3.4% 4.9%

Source: Flegal et al. Nutrition Reviews. 2004; 62(7): S144-S148.

Florida: Prevalence of Overweight*, by race or ethnicity

Ethnicity % Overweight 95% CI (±)

Hispanic 58.1 4.3

White, non-Hispanic 54.0 2.0

Black, non-Hispanic 71.8 5.3

*Overweight is defined as having a body mass index of ≥ 25 and ≤ 29.9

Source: Behavioral Risk Factor Surveillance System (BRFSS), 2001. Mortality and Morbidity Weekly Report. August 23, 2003. 52(SS08); 1-80

Florida: Prevalence of Obesity*, by race or ethnicity

Ethnicity % Obese 95% CI (±)

Hispanic 17.1 3.3

White, non-Hispanic 18.5 1.6

Black, non-Hispanic 32.8 6.1

*Obesity is defined as having a body mass index of ≥ 30


Source: Fla. Dept of Health, Florida Obesity Prevention Program

Florida Adults: Behavioral Risk Factors Surveillance Systems (BRFSS) In 2000, 53.9% of Florida adults were overweight and obese

(approx. 6,650,395 adults). By 2002, increased to 57% Of those, 18.7% or ~2,307,280 adults are obese Prevalence of overweight among adults in Fla. has increased by

53.9% since 1986 Obesity prevalence has increased 91% since 1986

The overweight/obesity is increasing in men, women, and children of all ages and of all races/ethnicities

Florida: 2000 BRFSS, AdultsOverall Hispanic Black, non-

HispanicWhite, non-Hispanic

% Overweight 35.2%

% Obese 18.7% 20.2% 29.7% 17.0%

Men: % Overweight 42.8%

Men:

% Obese 18.95% 17.5% 23.5% 18.9%

Women: % Overweight 24.8%

Women:

% Obese 18.7% 22.8% 34.5% 15.3%

Florida: 2000 BRFSS, Adults

Percent ObeseAge Overall Hispanic Black,

non-Hispanic

White,

non-Hispanic

18 – 29 years 13.8% 11.8% 20.1% 11.8%

30 – 44 years 21.2% 19.2% 31.3% 19.0%

45 – 64 years 23.9% 26.9% 37.4% 21.1%

Over 65 years 15.8% 23.3% 25.2% 13.8%

Florida Youth: The Youth Risk Behavior Survey, 2001 (YRBS)

14.2% of high school students are at risk of overweight and 10.4% are overweight.

13.2% of girls are at risk of overweight and 6.8% are overweight

15.1% of boys are at risk of overweight and 13.7% are overweight

More than 50% do not participate in any physical education at school

Florida Youth: The Youth Risk Behavior Survey, 2001 (YRBS) 20.3% reported eating 5 or more servings of

fruits or vegetables in the past 7 days

65.5% reported watching TV for 2 or more hours on an average school day.

32.8% of high school students reported playing video games or using the computer for fun on an average school day

Obesity Risk Factors

Obesity is a risk factor for many chronic conditions including: Diabetes Hypertension High cholesterol Stroke Heart Disease Certain cancers Arthritis

Of these, diabetes is most closely linked to obesity

Source: The rising tide of metabolic syndrome. Postgraduate Medicine. Dec 2004; 116(6):54-57

Source: ATP III. Bethesda: National Institutes of Health, 2001

Diagnostic Criteria for Metabolic Syndrome

Feature Criterion*

Abdominal Girth

Men

Women

Waist Circumference

> 102 cm (>40 in)

> 88 cm (35 in)

Fasting plasma HDL-C

Men

Women

< 40 mg/dL (< 1.04 mmol/L)

< 50 mg/dL (< 1.29 mmol/L)

Fasting plasma triglycerides ≥ 150 mg/dL (≥ 1.69 mmol/L)

Fasting blood glucose** ≥ 110 mg/L (≥ 6.1 mmol/L)

Blood pressure ≥ 130/ ≥ 85 mm Hg

*A diagnosis of metabolic syndrome is made if a patient has three or more of the criteria listed.

**The American Diabetes Association recently set a cut point of ≥ 100 mg/dL at which persons are considered to have impaired fasting glucose

Metabolic Syndrome Prevalence

An est. 55 million US adults have Metabolic Syndrome

Jumps to 64 million when revised value for impaired fasting glucose is used

Affects 6.4% of U.S. adolescents aged 12-19

Accounts for slightly more than 32% of all overweight adolescents

Rates differ across all ethnic groups

Highest overall prevalence found in Mexican Americans

Source: The rising tide of metabolic syndrome. Postgraduate Medicine. Dec 2004; 116(6):54-57

The associations of poverty, acculturation, exercise, and diet to BMI implicate societal as well as individual contributors to obesity among U.S. Latinos.

Causes for Obesity Among Latinos

Attitudes About Obesity Vary Across Cultures

Where thinness is associated with extreme poverty, deprivation, or wasting diseases, obesity may be viewed as a symbol of social stature, prosperity, and robustness.

Goel et al. JAMA. 2004; 292(23):2860-67.

Obesity Among Immigrants

Longer duration of residence in U.S. is associated with higher BMI

After 10 years of residence, BMI increases substantially

May reflect acculturation and adoption of the U.S. lifestyle

May also be response to the physical environment of the U.S.

Unger et al. Journal of Community Health. 2004; 29(6):467

Acculturation Among Latino Adolescents

Acculturation to the U.S. is associated with a lower frequency of physical activity and higher frequency of fast-food consumption.

Why?

Preference for activities and foods classified as “American,” such as watching TV and playing video games, and eating fast foods such as hamburgers and pizzas

Florida: Prevalence of No Leisure-time Physical Activity in the Past Month

Ethnicity % No Activity 95% CI (±)

Hispanic 40.9% 4.3

White, non-Hispanic 23.1% 1.6

Black, non-Hispanic 33.2% 5.3


Working with Puerto Ricans and Cubans

Puerto Ricans and Cubans

NY, FL, NJ, PA, CT, MA: Puerto Ricans

Miami & Tampa, FL: Cubans

Grains and Starchy Foods

Cuban & Puerto Rican Crusty loaves – French, Italian, Cuban bread Hot and dry cereals Sweet potato (batata-PR/boniato-C) and potato Tanier (yuca) Cocoyam or dasheen or taro (malanga) Yautia blanca or yautia lila Ripe plantains fried, baked or boiled


Cuban & Puerto Rican Green plantains, fried thick (tostones) or thin/chips

(platanutres-PR/mariquitas-C)

Green plantain with pork cracklings (mofongo-PR/fufu-Cuban)

Soups with mixed root vegetables (viandas) and meats (sancocho-PR/ajiaco-C)


Cuban Pureed green plantain – base

for soup Boiled then fried yucca

Puerto Ricans Green bananas, boiled, with

olive oil and onions Pureed green plantain as

dumplings in soups

Complementary Foods

Puerto Ricans Red beans and white rice Red beans with white rice Yellow rice with pigeon peas

(gandules)

Cuban Black beans and white rice Black beans with white rice:

“congri” (“with gray”)*

Vegetables

Salads: lettuce, tomato, cabbage, avocado common as side dishes

Tomatoes, onions, peppers with garlic, olives, olive oil, bay leaf, capers, and coriander used to season food

Pumpkin, corn, green beans common side dishes

Fruits

CommonOrangesBananasPineapplesWatermelonLemons, limesMangoes

OtherPapayaGuavaCherimoya/soursop/anonCoconutTamarind

Meat and Other Protein Foods

Puerto Rican and Cuban A variety of legumes, including

chickpeas in stews, soups Steaks - thin cut, sautéed or fried Seasoned roast pork or cubed and fried Eggs, poultry, fish, shrimp Paella

Fried Grains and Meat/Protein Combinations

Puerto Rican Fritters mashed potato stuffed with

ground meat (rellenos de papa)

green banana and tanier puree stuffed with ground meat (alcapurrias)

Codfish fritters (bacalaitos)

Both Groups Meat pies

Cuban Fritters ham or

chicken croquettes

Extended/Combination Dishes

Puerto Ricans and Cubans Chicken and rice Rice and codfish Rice with “Ropa Vieja” (Old Clothes -- seasoned

shredded beef) Rice with pork or ham pieces Cuban sandwich Spanish omelet

Extended/Combination Dishes

Puerto Rican Pastel: dough of green plantain,

tanier, green banana, filled with a seasoned cooked pork mixture boiled banana leaf or parchment paper

Cuban Tamal: ground corn and/or

cornmeal, filled with a seasoned cooked pork mixture boiled in a husk

Common Cuban Dishes

Beef roast (boliche) Squid (calamares) Fish soup or broth (caldo de pescado) Marinated fish (escabeche) Stewed minced meat (picadillo)

Common Puerto Rican Dishes

Ripe plantain and ground beef/ vegetable “lasagna” (pastelon) or “rolls” (piononos)

Thick soupy rice (asopao) Rice with squid (calamares)

Desserts

Puerto Rican and Cuban Flan Rice pudding Rum cake Vanilla custard

Cuban Pudin Diplomatico -

Bread style pudding with fruit

Puerto Rican Bunuelos - beignets,

usually topped with honey

Beverages

Puerto Ricans and Cubans Coffee with milk Hot chocolate

Cuban Expresso Expresso with a small

amount of milk and sugar (“Cortadito”)*

Fruit/milk shakes (Batido)

Puerto Rican Food Guide Pyramid

Issues

High fat intake from fats (oils, frying), poultry, beef, dairy intake

Low dairy, fruit and vegetable intake

Acculturation

More varied diet BMI increasing Younger groups’ food patterns related to external

influences Acculturated PR consume more American foods Younger Cuban women had a higher proportion of

energy from fat

Mexican-American Diet Patterns Traditional diet

Varies greatly according to regionsBlend of pre-Columbian, French, and Spanish dietsAmerican foods introduced in recent years

Mexican-American Traditional Diet

CARBOHYDRATES (similar in most regions)corn/ corn products - mainstay in all regionsbeans (black - coastal regions/south; pinto -

north/central)Breads - “pan dulce”rice

Counseling for Dietary Change

“Healthy eating guidelines better met by Mexican-born than U.S. born”

Encourage return to healthy aspects of traditional cookingFresh fruit, fresh fruit drinksSalads, vegetablesBeans, legumes


PROTEIN Fish/Shellfish (coastal regions) Goat/Beef/Pork (North/Central

regions) Poultry (all regions) Beans (southern regions, all)

DAIRY fresh cheeses, fresh cream “Batidos” (central regions)


FRUITS/VEGETABLESWide variety fresh fruits consumed regularly (all

regions)Fresh fruit drinks (“batidos”, “aguas frescas”)Cooked salads, pickled vegetables (“escabeche”),

lime juice dressing


Cooking MethodsFrying (lard)Steaming, wrapped in leaves (coastal regions,

southern regions)Stewing - “moles” (all regions)

Meal Patterns4-5 meals/day, “merienda”

Dietary Changes Due to Acculturation/ Migration Rice and Bean Consumption Consumption of Fresh Fruit Use of Lard (replaced with vegetable oil) Use of sweetened and/or carbonated

beverages vs. fresh fruit drinks Saturated Fat consumption

Dietary Changes Due to Acculturation/ Migration

Food Items Added with Acculturation

White Bread Mayonnaise/ Salad Dressing Cookies/Cakes Ice Cream Tang/Kool-Aid Vegetable Oil/Margarine

Traditional Items

Pan Dulce Dry Salad/ Lemon

Juice/Pickling Pan Dulce Fruit-based “ices” Fresh Fruit drinks Lard

Dietary Changes Due to Acculturation/ Migration Mexicans in U.S. less likely to recognize low-fat

cuts of meat

Mexicans in U.S. less likely to use low-fat dairy products

Mexicans in U.S. less likely to identify low-fat foods

Dietary Changes Due to Acculturation/ Migration Traditional Mexican-American diet tends to be low in

Calcium and Iron

Mexican-Americans eat more fiber than all other Hispanics and non-Hispanics

Traditional Central-American diet may also be low in protein

With acculturation/migration diets may also be low in folate, Vit A, Vit C, and Zinc

Counseling for Dietary Change

Use “modified” traditional favoritesCarnitas, rice, beans

Traditional dishes made with less saturated fat, sodium, and sugar

Identify low-fat cuts of meat –substitutes

Low-fat dairy Fresh cheeses: panela, cotija, queso fresco

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