Occidental College

MEND Obesity: How Perceptions Can Inform Best Practices

Lillian Krovoza, Zoe Hamilton, Keegan McChesney, Samarah Jackson, Jarron Brady Urban and Environmental Policy 304: Research Methods

Professor Shamasunder November 22, 2013

INTRODUCTION Obesity is a fast-growing epidemic that has struck the United States and has prompted

scholarly ventures to understand the underlying causes of obesity in order to identify ways to

mitigate the issue. There are various systematic and individual factors that play into this

epidemic, including access to nutritious food and adequate exercise, race, gender, age,

socioeconomic status, and cultural perceptions. In our research, we focused on a specific

population in Pacoima, California, a predominantly Latino/a city with particularly high rates of

obesity. The population we focused on were members of Meeting Every Need with Dignity

(MEND), an organization committed to helping very low-income people in Pacoima “attain self-

reliance and contribute to society as caring human beings” (MEND 2013). The purpose of our

study was to answer the questions, “How do clients at MEND perceive obesity?” and “What

kinds of culturally and community appropriate programs could MEND implement to

appropriately and effectively address obesity among clients?” In answering these questions, we

hope to inform MEND’s ability to effectively mitigate the obesity problem among the members

of the MEND community.

In the following sections of the paper, we will first provide background for the obesity

problem at MEND. Next, we will review of the existing literature on the correlation between

demographic factors and obesity, the Latino Health Paradox, food access and obesity, exercise

access and obesity, and perceptions of obesity. Then, we will present our methodology, as well

as our recommendations for MEND regarding revised “Healthy Living” education and exercise

programs, and adding incentives for the patients to participate.

BACKGROUND

The prevalence of obesity in the United States has been a significant problem for the past

few decades. The rate of obesity has been increasing since 1976. This obesity epidemic has been

characterized by disparities across gender, age, socioeconomic status and race. According to data

from the Center for Disease Control and Prevention, one-third of US adults are obese. The data

also shows that prevalence of obesity differs across gender, with 56.6% of females being obese

and 69.9% of males being obese (Center for Disease Control and Prevention, 2013). The

percentages also varied in regard to race, with 49.5% of the Black population being obese, 39.1%

of the non-white Hispanic population being obese, and 34.3% of the White population being

obese (Center for Disease Control and Prevention, 2013). The heightened prevalence of obesity

in the United States has put more emphasis on chronic obesity-related diseases, such as

cardiovascular disease, diabetes, and stroke. It has also led to heightened health care costs.

The neighborhood of Pacoima lies within the San Fernando Valley in Los Angeles

County. The population according to the 2000 census is 75,014 persons and in 2008 according to

the LA Department of City Planning, the population rose to 81,318 persons. Pacoima is primarily

Latino, at 85.6%. It is 7.2% black, 4.6% white, 1.9% Asian, and 0.8% other. 45% of people are

foreign born, which is high for the county (LA Mapping). In comparison to both the city and

county, it is not a particularly diverse neighborhood. The median household income in 2008

dollars is about average for the city of Los Angeles, but low for Los Angeles county, at $49,066,

and the average household size is 4.6 (LA Mapping).

Pacoima is lacking in green space, which is necessary for residents in order to stay active

and exercise. The recommended ratio is 4 acres per 1,000, but Pacoima only has .6 acres per

1,000 people (Pacoima Beautiful). So, ideally, there would be 400 acres of park space. This lack

space overlaps with the facts that 1 in 4 Pacoima residents suffer from heart disease and 6.3% of

the neighborhood suffers from diabetes as the park space shortage translates to less space for

people to be physically active. 17% of all adults in Pacoima are obese, while that number is 29%

among youth, which is among the bottom quartile in LA County (Pacoima Beautiful).

Furthermore, Pacoima ranks 70th in LA County among number of violent crimes per

10,000 people (LA Times). The crime rate affects how safe residents feel in their neighborhood,

which lends to a lack of desire to be physically active. In the case of Pacoima, access to exercise

is not only stunted by the lack of available physical spaces, but also the residents’ perceptions of

the limited spaces that do exist as unsafe.

Strides are being made to improve these issues in the neighborhood of Pacoima, in terms

of green space, complete streets, and community involvement. A current project that is being

worked on is the Caminos del Pueblo/Complete streets campaign, in which the goal is to improve

the biking and walking infrastructure in Pacoima, and to make the city safer, while create more

opportunities for physical activity (Pacoima Beautiful). In September, Pacoima residents pushed

for a cleaner and safer environment by setting up Parklets in parking spaces--showing the need

or more green space. MEND’s Home Garden project is another way in which the community members are

thinking creatively to improve their lives. In a town where many folks rely on food banks for

their meals, MEND wanted to help and teach people how to become self-sufficient through

learning about their food. A grant by the Wells Fargo Foundation has allowed MEND to teach

nutrition and gardening classes, and provide gardening materials for their clients (MEND 2013).

This program is empowering because it lets people provide for themselves and be less reliant on

service providers. Luke Ippoliti, assistant director of the MEND food bank says that: “Helping

residents grow their own food is a way for them not to need us any more,” and Carnelio Artego,

a resident involved in the program, says that the ability to grow his own food “is paradise,”

(MEND 2013).

LITERATURE REVIEW

In order to answer our research questions, “How do clients at MEND perceive obesity?”

and “What kinds of culturally and community appropriate programs could MEND implement to

appropriately and effectively address obesity among clients?” it is important to outline the

literature that is relevant to the topic. Due to the health disparities across demographic

populations, this literature review will first cover how obesity adversely affects different

demographic populations--distinguished by race, gender, age, and socioeconomic status. Then, to

address the fact that MEND participants in general represent a very specific population the

review will go on to describe the literature on the Latino Health Paradox, which will further

inform our research, specifically on the health of the Latino population. Next, we will outline the

literature connecting obesity to access to food and physical activity, which will help us to

understand some common barriers to a healthy lifestyle. The literature review will conclude

with an overview of literature on the perceptions of obesity.

Obesity and Demographics

The studies in the literature regarding the correlation between certain demographic

factors--specifically, race, gender, age, and socioeconomic status--and obesity are typically

consistent in their conclusions. We will discuss the general consensus in the literature that

obesity is more prevalent in people of color, women, people of low socioeconomic status, and

people at certain ages are especially vulnerable. The majority of the literature, however, does not

address the relation between one particular demographic and obesity. Rather, they tend to

explain the relationships between multiple demographic factors and obesity at once. This has

lead to some difficulty in deciphering how obesity relates to particular communities individually.

Race and Obesity

Much of the literature that addresses the obesity epidemic in the US recognizes that it is a

problem that has gotten worse across different races, genders, ages and socioeconomic statuses,

however, the question that many of them aim to answer is “How do these communities

experience this problem differently?” In order to answer this question, many studies look at the

relationship between race and obesity. The literature that covers race and obesity addresses the

topic from either a broad perspective or a narrow perspective. The broader literature addresses

the question by comparing multiple racial groups at once and tends to also tie in other

demographic factors such as gender and socioeconomic status. Wang and Beydoun take this

approach in “The Obesity Epidemic in the United States--Gender, Age, Socioeconomic,

Racial/Ethnic, and Geographic Characteristics: A Systematic Review and Meta-Regression

Analysis” (2007). This article, alongside studies like those by Paeratakul et al--which aims to

explain the correlation between obesity related illnesses and race--and Baskin et al.--which notes

the obesity disparities across racial groups--shows how certain demographic factors correlate

with higher or lower obesity rates, but does not address the particular causes of the disparities

across these groups.

On the other hand, some literature addresses obesity and race on a much more narrow

level and aim to explain the causes of the discrepancies across race and other demographic

factors. The studies by Kaplan et al., Lin et al., and Popkin et al. are among the type of studies

that fall into this category of literature. Each of these particular studies address the relationship

between the length of time Hispanic immigrants have been living in the US and obesity. These

studies each aim to describe the role of acculturation in perpetuating obesity-inducing behaviors

among immigrants of particular races through looking at things such as eating patterns and

overall health. In focusing on more narrow race categories, the studies are able to create the basis

off of which to launch specific responses to the obesity epidemic. On the topic of acculturation

of immigrants to the United States, for example, these studies conclude that the higher the

generation in the country, the more likely a person is to be obese. For example, a third-

generation Latino immigrant is more likely to be obese than a first-generation Latino immigrant.

Furthermore, these types of studies conclude that the longer an individual immigrant lives in the

United States, the more likely they are to become obese due mainly to changes in diet.

This narrow conception is also present in studies, such as Burke et al’s “Race, Ethnicity

and the Puzzle of Gender Specificity.” This particular study, similar to broader studies,

recognized that there are disparities along racial lines, but further addressed the phenomena by

focusing in on Black and White women’s experiences, which allowed the comparison

of incentives to avoid obesity between these communities. This study identified that the

incentives for overweight Black women to lose weight differ from those for white women, which

implies that the way that the way to address obesity in different populations should be tailored to

how different populations perceive obesity.

The Intersection of Gender and Race in Obesity

An interesting finding that arose in many pieces of literature is that race is very

significant when observing obesity prevalence in women, however with men, race is not

particularly significant. There are different perceptions of obesity across races that women have,

but men do not. One example that arose often is that “Black women face weaker incentives than

white women to avoid being obese” including health-related incentives and sociocultural

incentives (Burke, 2). The gaps in various aspects of life when looking at white men and black

men are much less than the gaps between white women and black women, looking at the same

determinants. Combining the information learned throughout these pieces of literature, one can

conclude that obesity is not more or less prevalent by gender, however, other determinants like

race and socioeconomic status have much higher disparities with women than they do with men.

Age and Obesity

Literature regarding the relationship between gender and obesity oftentimes focuses on

particular age ranges. One study conducted in South America (where obesity is typically less

prevalent than in the United States), concluded that prevalence of obesity in boys, ages 7-14, is

“directly associated with father’s education level, mother’s age, and parents’ nutritional status,

and inversely with mother’s education level and number of daily meals” (Bernardo, 291). For

girls, ages 7-14, obesity is “associated directly with parents’ nutritional status and the

schoolchildren’s age, and inversely with consumption of risk foods” (Bernardo, 291).

It is the general conclusion that prevalence of obesity/overweight increases with age,

however, there is rising information about the child obesity epidemic. From the 1960’s to 2004,

adult obesity prevalence increased from 13% to 32% and is currently, 66% of adults are

overweight or obese (Wang, 6). One study about obesity prevention interventions claimed,

“middle-school aged children are becoming the largest age group of all overweight and obese

children, with rates having tripled in the last three decades” due to dietary habits, sedentary time

and physical exercise (Stevens, 233). Currently, 16% of children and adolescents are overweight

or obese and 34% are at risk of becoming overweight or obese (Wang, 6). To address the

childhood obesity epidemic, there have been several “interventions” attempted in middle school

systems. According to the study mentioned above, girls, when compared to boys, tend to have

better reactions to these interventions (Stevens, 235). Literature is limited when searching for

obesity in association with adult ages, and determining at what age obesity is most prevalent.

According to one study, fathers have the most prevalence of obesity at ages 40 and over, while

the prevalence of obesity in mothers is typically between the ages of 20 and 39 years old

(Bernardo, 295). Other articles do not place obesity into an age-based timeframe such as this,

their conclusions are more generalized than this particular article’s findings .

The Latino Health Paradox

When considering the health of minority groups in the United States it is extremely

important to understand the complexities they come with beforehand. Within the Latino

community in particular, there are differences that many people are aware of without research

experience such as how to distinguish the various subgroups. The focus organization MEND and

the service recipients for example are not all US born and are not all from Mexico, making health

differences worthy of exploration. This fact reveals that it is quite hard to group all of Latino’s

together because there is no monoculture, in turn complicating the efficacy of studies that seek to

identify things such as risks for obesity. When health research started to accelerate on Latino

health in the 1960’s much work had been done on other immigrants throughout United States

history. With previous ideas of assimilation and “culture learning” established, researchers

assumed that the same findings could be applied to the Latino community, a thought that proved

short sighted. It did not take long for people to recognize that the Latino community did not hold

a strong health patterns as say the African Community. Immigrants and U.S. born Latinos were

showing quite different susceptibilities to issues such as obesity and made it unacceptable to not

account for this in research, giving rise to the “Latino health paradox” or “Latino morality

paradox”. When studying the perceptions of obesity for MEND recipients it is very crucial to

take the research on the Latino health paradox into account. MEND services several different

Latino subgroups that differ in their rates of acculturation and daily lifestyle. If residential

isolation, language use, and ethnic preferences are not considered then it makes formulating a

curriculum very difficult to compose.

Much of the research that worked to explain the Latino Health Paradox used the

assimilation theory provided by Robert E. Park. Park’s theory of assimilation in short argues that

assimilation with immigrant groups is inevitable, countering other theorists and researches that

made assimilation out to be a choice in the United States. According to Park, by the end of their

lifetimes immigrants will adopt the “middle-class cultural patterns of largely white Protestant,

Anglo-Saxon origins” or the “core culture” (Lara 369). Scholar Milton Gordon borrows from

Robert E. Park and the European assimilation model to break down how people should think

about assimilation with Latinos. Gordon advocates for the thinking of assimilation as a

segmented process, not one that just happens out of context. Though Gordon does not give more

weight to one factor over the other, as a study would, he does explicitly list them. The first

variable is the “human capital” possessed by the immigrant group, which takes into account their

education, wealth, and type of skills. The second variable is the policies of government

institutions and the attitude possessed by the natives towards immigrants. Lastly, structure and

resources of the immigrant community upon arrival and over time completes the triangle of

variables on assimilation. In order to bridge the gap between Park’s inevitable theory of

assimilation and Gordon’s segmented theory, many researchers place “culture learning” in the

middle. Culture learning is also a step-by-step process that starts by thinking of assimilation as

the “acquisition of language, food choice, dress, music, sports, etc. (Lara 374). The learning of

new facts that eventually replace the old facts closely related to cultural history and tradition

along with different food consumption and media use account for the first stage. Secondly,

language preference and use coupled with preferred ethnicity of friends and spouses are

considered. The last stage is different from the other two in that it provides an alternative in the

narrative by considering the maintenance of cultural norms and the nonlinear adoptions of new

norms. It does not debate the premise of inevitability with assimilation, rather it hints at the fact

that there are certain immigrants that can maintain cultural norms that are mutually exclusive to

that of the “core culture” in the country they reside.

What the three stage model of “culture learning” exposes is the argument that Latinos

assimilate very differently, which inherently calls for different methods with varying dimensions.

“Unidimensional definitions, sometimes referred to as a zero sum game, assume that the

acculturation experience occurs along a linear continuum from not acculturated (total immersion

in the culture of origin) to completely acculturated (total immersion in the dominant or host

culture)” (Cabasso 129). Such thinking is convenient and easy to track because measuring

language use can be considered over time and it moves typically in one direction, more of one

culture over time. In Measuring Acculturation: Where We Are and Where We Need to Go,

Leopoldo Cabassa points out that before getting to the Latino community exclusively the

unidimensional theoretical model operates under the assumption that only the immigrant

community has to assimilate to the host country. If one were to consider the enclaves of Latinos

in Los Angeles a case could definitely be made that the “natives” have had to assimilate to

Latino culture through learning Spanish, shopping at local tiendas, and eating more Mexican

cuisines. The unidimensional model is heavily reliant behavioral and attitudinal areas, which

give way to language acquisition, family beliefs, and language use. Other scholars operating

under this model use time based measures, deducing the extent of acculturation from the amount

of exposure to the host culture.

The bi-dimensional model tries to improve the model of the unidimensional model by first

assuming that assimilation happens under the conservation of the original culture and the

adherence to the new host culture. The conservation of the culture or origin is a unique addition

because it places emphasis on the individual’s maintenance of his or her culture, rather than

measuring the community as a whole. Berry and Sam created a body of work that conceptualized

the bi-dimensional model and stressed the strategies for acculturation. Assimilation, separation,

integration, and marginalization are all factors and pays even closer attention to the whole

experience of an individual over time. Separation operates under the idea that an individual pays

careful attention to their culture and rejects the host culture as best as possible. Integration

accounts for seeing the value in both cultures and trying to simultaneously embody them whereas

marginalization is the exclusion of someone from both their immigrant culture and the host

culture by choice or force. Though these factors do a great job at providing a stronger framework

for studies that have since followed the unidimensional model, it is not the best model of

thinking. By presenting personal choice as such a dominant factor in the strategies one is

completely removing them from the context in which they are utilized. The Latino community in

Los Angeles differs completely by freedom of action than Latinos in rural parts of Arizona.

Critical attention must then be given to studies that operate under the bi-dimensional framework

because the methods are only as efficient as the premise they operate under.

With such a multi-faceted concept as the Latino Health Paradox, there is clearly no one

perfect to research it but the methods employed must be as diverse as possible to capture the

varying results. Socioeconomic status (SES), gender, time in the country, language use, and

education are all categories often explored and controlled for in most studies but they do not tell

the entire story. Ming Wen and Thomas Maloney recently released their study, which takes a

look at the effect of residential isolation on the risk for obesity in the unlikely state of Utah.

Latino-white residential isolation was compared to judge whether isolation could be a mitigating

factor. Wen and Maloney used many of the same tools used to explore the health effects

associated with black-white residential isolation, with the addition of separating U.S. born

Latinos and immigrants. As a whole, Latinos are more vulnerable to obesity once residing in a

homogenous area of other Latinos. At the very least these findings raises some key questions and

reveals key distinctions that must be considered. The generalizations to be deduced are definitely

up for debate considering Utah varies quite differently from other states that hosts larger

enclaves of Latinos in terms of quality of health.

Food Access and Obesity

Existing literature that points to the association between the food environment (i.e.,

number of grocery stores compared to fast food chains and corner stores, price of food, etc.,

travel distance required to reach food) of a place and obesity rates. A poor food environment

includes one with limited access to grocery stores (due to proximity or price), and an abundance

of high-calorie food joints. A good food environment includes one with many supermarkets

(where produce is typically fresher, less expensive, and more abundant than at corner stores) that

are relatively accessible (and not just by car). Studies have shown that supermarkets are more

abundant among higher income communities, while for lower income communities,

supermarkets are more sparse (Cummins and Macintyre 2005). Neighborhoods with limited

food access are especially prevalent among low-income and minority populations, which may be

one explaining factor behind why low-income populations suffer from higher rates of obesity.

In communities with poor food access, either corner stores or fast food joints frequently

replace grocery stores. Corner stores rarely have fresh produce—and when they do, it is typically

sold at higher prices than at supermarkets. Lack of fresh produce and increased exposure to fast

food craft an environment where healthy foods are hard to find, and calorie dense foods are

displayed blatantly. Individuals in communities with poor food access are more likely to eat

lower quality food, with fewer nutrients and higher caloric density (Ford and Dzewaltowski

2008). While there is a correlation between poor food access and higher levels of obesity, there is

no proof of causation. Likely, poor food access is paired with a variety of other factors to

contribute to obesity, such as: income, the built environment, and education (Cummins and

Macintyre 2005).

Access to Physical Activity

A variety of literature focuses on the role of physical activity in relation to obesity. Many

pieces of literature claim that the amount of physical activity and exercise one gets in directly

related to health and body fat. Physical activity is also beginning to be accepted by scholars as a

major contributor to national public health and well-being. However, some literature disagrees

with the importance of physical activity in relation to health and obesity, arguing “while it is

probable that some level of physical activity has some health benefits for some people, there is

little else that we can say with any certainty in this area” (Davidson, 381). The role of physical

activity as a determinant for obesity is difficult to prove and opinions differ about its importance.

Many studies also found a strong correlation between age, race, sociocultural and socioeconomic

status and access to physical activity.

Childhood obesity is a major concern and a variety of literature has focused on physical

activities ability to combat it. Childhood obesity rates are increasing at an alarming rate (Trost et

al.). Many studies have used scientific data to determine general guidelines and

recommendations for the amount of exercise children of different ages should participate in. The

guidelines and recommendations are generally accepted and agreed upon, but the percentage of

children meeting these guidelines is highly contested, due to the fact that it is difficult to

measure. Many studies also point to the importance of schools in ensuring minimum levels of

exercise are met, primarily through the role of teachers, physical education classes and avoidance

of an obesogenic environment (Davidson, 381-390). Studies found that compared to their non-

obese counterparts, obese middle-school students participated in significantly less physical

activities throughout the day, has less self-efficacy for physical activities, and were less likely to

report that their father was physically active (Trost et al.).

Adults face a variety of different challenges when it comes to physical activity and

exercise. Nutrition and physical activity are often intertwined when it comes to an individual’s

health and well being. Intrapersonal, environmental and social factors have a large influence on

physical activity in older adults in both urban and rural areas (McNaughton et al., 6). Most

studies concluded that physical inactivity among adults is a major determinant in health and

obesity. The more physical activity an individual participates in, the more likely one is to be of a

healthy weight. People with access to areas of physical activities, such as parks, gyms, and

walking and bike paths, will be more likely to participate in daily exercise and therefore have

better overall health. Socioeconomic status and race also strongly correlate to adult levels of

physical activity.

Racial and ethnic identification correlates strongly with different obesity and physical

activity patterns. Specifically, a growing number of literature has focused on the rapidly

increasing Latin American pollution. Socio-demographic factors that affect this population

include income level, a dependence on emergency services, access to healthcare and health

insurance, and education level. Stroke and cardiovascular diseases are the leading cause of death

among Latin Americans, 33.3% of women and 26.9% of men (Vaughn 2). In addition “factors,

obesity and physical inactivity have been reported to be more prevalent among Latin American

women than other ethnic groups” (Vaughn 2). According to an American Heart Association

study, 68% of Mexican American women aged 20-74 are overweight (Vaughn 3). Latina women

also have low levels of physical activity in comparison to other demographics. However, studies

have shown that increased levels of physical activity and exercise, such as walking, can have

long term solutions such as decreased blood pressure, cholesterol and obesity (Vaughn 42).

Perceptions of Obesity

Perceptions of obesity are highly correlated with socio-cultural factors and vary

according sex, race/ethnicity, and socioeconomic factors. Perceived overweightness is higher

among women, whites, individuals with higher BMIs, and those with higher income and

education levels—even though obesity rates are higher among blacks and Hispanics, and those

with lower income and education levels (Bray et. Al 2002). Research shows that being

overweight in the Latino community is more normalized and viewed as a positive thing than in

the mainstream media and white community, due to a prominent discourse that being curvy is

beautiful. Thus, these cultural acceptances may be used as an reason to avoid weight loss (Anahí

et. Al 2009).

Studies have shown that Hispanic mothers may not recognize their children as being

overweight, and consequently, may not take steps to intervene in their children’s consumption

habits. A study by Hackie and Bowles discovered that among Hispanic mothers of obese

children in Southern Nevada, only 39% of mothers recognized that their children had weight

problems; only half had taken steps to modify their children’s diets. This shows that many

Hispanic women may not recognize that their children are overweight, and thus when designing

intervention strategies, it’s should not be assumed that the parents recognize their children’s

overweight status, or that they see a need for intervention (Bowles, Hackie, and Mary 2007).

Other studies have tried to explain alternate metrics used in communities of color to

define what a healthy weight is. One particular study that represents this category of literature is

Jain et al’s study, “Why Don’t Low-Income Mothers Worry About Their Preschoolers Being

Overweight?” In addition to identifying the way in which people of color perceive particular

weights as either healthy or unhealthy, this study also considers the influence of socioeconomic

status on these perceptions. The study reported that instead of relying on standard growth charts,

such as the BMI scale, people in these communities consider how their children are treated by

their peers, their ability to be physically active, and how their children measure up in relation to

family members as suitable metrics for measuring their child’s health. This data may be useful

for MEND to keep in mind as they design programs for mothers; in addressing weight loss

among clients with children, they should be sure to include an education portion that addresses

accurate and effective ways for parents to measure the health of their children.

There are various perceived barriers to weight loss among the Latino population. A 2012

study by Agne et. al demonstrated the overwhelming contribution that mental health factors (i.e.

social isolation, depression, stress) have on obesity. In this study, the women associated the

stress and isolation they felt upon immigrating to America with their obesity. Other factors that

contribute to obesity include: difficulty balancing work, household work, family, and self health,

lack of time, and the perception that their husbands do not see a need for intervention. This study

informs us that contributing factors to obesity among MEND clients may include: the stress of

undetermined food supply, worry over their safety, the wellbeing of their children, and other

stresses that come with living in a state of poverty.

METHODOLOGY

Our research began by reviewing literature surrounding obesity issues, including:

perceptions of obesity, correlations between certain demographic groups and obesity rates, the

connection between obesity and access to food and exercise and the Latino Health Paradox.

Between two separate occasions, the group conducted 13 oral surveys with MEND participants.

These specific days were chosen so that our study would overlap with the MEND’s food

program and clinic visits, which attracts a lot of participants to the facility and provided students

with a larger group to work with.

Students asked to interview clients as they were waiting to receive services. The

individuals selected for interviews were chosen at random and included both women and men.

Students did not limit the participant group to those identified as obese or overweight, men or

women, or any particular cultural/ethnic group. The goal was to get a holistic view of MEND

participant’s perceptions of obesity.

Interviewees were asked a series of 23 survey questions by the students with follow up

questions asked when necessary. The surveys consisted of 12 demographical questions and 11

open ended, health and perception related questions. Participants were told that they had the

option to not answer any questions they felt uncomfortable or not prepared to answer. Answers

were recorded by the students. There are two students in the group that can speak fluent Spanish.

There were three aides from MEND available to help with Spanish to English translations for the

students who are not fluent in Spanish.

RESULTS AND ANALYSIS

At MEND, we were able to interview 13 clients as they waited their turn at the clinic. Out

of those we interviewed, 11 were female and 2 were male. Almost all were foreign born: eight

were from Mexico, one from El Salvador, one from Brazil, and two from the US. The median

age among those surveyed was 49 years (a number slightly brought down by two outliers, a 20

year old and a 25 year old). Their education levels typically ranged between 4th and 11th grade,

although some patients had no education, and one had completed college.

Perceptions of Obesity

Our interviews revealed that nearly every client knew more or less what it took to lead a

healthy lifestyle (eat nutritious foods, exercise). Other noted factors that indicate a healthy

lifestyle include: being self-sufficient, not being inhibited from doing something due to weight,

not getting sick, and also being free of mental health concerns (stress, anxiety, job security). Five

participants perceived themselves as healthy, and eight perceived themselves as unhealthy, but

nearly everyone wanted to pursue a healthier lifestyle via more exercise and healthier eating

habits. Everyone recognized that being overweight or obese was a serious health hazard; they

cited that it lead to things like hypertension, high blood pressure, loss of strength, diabetes, and

early death. Nearly all participants noted that maintaining a healthy body weight is important in

terms of health—not for looks. Additionally, we noticed that many patients were suffering from

diabetes—probably one of the main reasons they were at the clinic in the first place—and that

they used diabetes as an indicator that they were not healthy. When we asked the question of

whether or not they perceived themselves as healthy, they noted diabetes as a factor of being

unhealthy.

Barriers

Primary barriers as revealed from the interviews include: financial limitations, lack of

motivation, physical limitations, and competing priorities. Among interviewees, healthy food is

associated strongly with higher prices—and 12/13 of interviewees cited that their income was

“not enough” to meet basic needs and necessities. Thus, understandably, interviewees said they

would like to buy healthier foods, but that they are just too expensive. Price was seemingly the

only obstacle to healthy foods in terms of food access; otherwise, people noted that there are

various places nearby (including a Food 4 Less) that sold fresh fruits and vegetables.

Limited time and competing priorities are other factors that prohibit a healthy

lifestyle. Many of these patients are so overwhelmed with other things—such as paying the bills,

securing a job, working, taking care of their family, etc., that they don’t have enough time in the

day to make for exercise. There perceive their other responsibilities and obligations to be me

more time sensitive and important.

Motivation was cited as a significant contributor to the amount of exercise one partakes

in. Some folks cited that there were no barriers to physical activity as long as you had the

motivation to get out there; you don’t need any special equipment for running or jumping jacks.

Those who didn’t partake in as much physical activity said that motivation and positivity were

difficult to muster, and thus the drive to get out and be active was lacking. But, there was a

general consensus that if they had the motivation to work out, other barriers could be

surmounted. These findings show the importance of the somewhat intangible mental barriers.

Many folks had limited exercise options due to their physical condition. One woman was

confined to a wheel chair, but others suffered from hypertension, bad knees, overweight status,

general aging, and more. Folks who suffered injuries were typically limited to very certain

exercises, such as walking. Some of these folks wished they could exert themselves more fully,

but were limited due to their physical situations.

RECOMMENDATIONS FOR MEND

We have compiled various suggestions that we believe will help the MEND obesity

program be optimally successful. Most of the clients had heard of or been to the nutrition and

cooking classes at MEND and found them helpful; they suggested that these programs continue

to be offered and expanded upon. Education is key—people need to be knowledgeable so they

can learn to make healthy choices for themselves, and so that they feel empowered and like they

have control over their bodies. Because so many clients were reluctant to buy healthy foods

because of its perceived high cost, it would be good to do a series of cooking classes showing

people how they can prepare their own healthy meals on a budget. For example—a $3 or less

cooking series would be a big hit, and there are plenty of meals that can be prepared for that

little. Also, it would be a good idea to work with folks to sign them up for food stamp services,

both to alleviate pressure on MEND’s food services, and also to instill self-sufficiency. Showing

clients step by step how to apply will significantly help those who may not know how to access

the SNAP (Supplemental Nutrition Assistance Program) benefits.

In designing workout and healthy eating programs, MEND should incorporate

community and family into the practice when possible. One woman we interviewed brought up a

very good point that in her opinion, people in Pacoima don’t know their neighbors and are very

isolated--from the people who live close by. Since many patients also cited a the lack of

motivation as a barrier, MEND should try and incorporate a community aspect into the

programs, to build community while getting people active. For example, there’s the idea for a

door-to-door walking program. In this program, MEND could map out Pacoima and pinpoint

where people who want to participate in an exercise program live. Then, establish routes, where

people could go on walks to each others houses, picking up and dropping off walkers as they

make their way around. Or to at least create a map of where people live, so that if someone’s

looking for a workout buddy, they can look to the map to see who is close and ready to get

active.

Another way to involve the community in the program would be to have community “get

active” days. For example, a semi-annual “Olympic Games” competition where members make

teams and compete in relay races, hula hoop competitions, short/long distance runs, obstacle

courses, etc.; these would all get people excited about physical activity. Furthermore, it would

help people meet other active members of their community--who knows, someone could meet

their next work-out buddy at an Olympic game. Another idea is to create a basketball team or

baseball team for those interested in team sports.

Many of the folks we interviewed had large families, and some cited that their family is a

source of motivation for them to lead a healthy lifestyle Frequently, people noted that their

families were suffering from unhealthy lifestyles as well, and they worried about them because

of that. Building family exercise plans, where they could work out together, and rely on each

other for continued motivation and support could prove extremely effective. Fun events like

family bike rides on Saturday mornings and family Zumba classes are a good place to start. For

the parents who are concerned about their own health and the health of their children, this is an

excellent way for them to get fit while simultaneously leading a good example for their kids.

Since continued motivation is such an important aspect in every step of the weight loss,

we cannot stress enough that sustained encouragement and support that must be incorporated

throughout the length of the program (and beyond). One suggestion is to have a “biggest loser”

type competition and board/display. A large display in the clinic lobby that highlights a monthly

“biggest loser” (in weight-loss, that is) would be an excellent public display for people to share

their weight loss successes. MEND could also congratulate them with incentives such as

additional services, coupons to the clothing store downstairs, or his/her pick for the next recipe at

cooking class, for example. These incentives would help keep the participants on track, and

would get non-participants interested in the program.

Lastly, MEND should do what it can to offer their programs and services at a wide

variety of dates and times. For people who live outside of Pacoima and who bus in to get

services, it’s difficult for them to make week-day programs. Offering the same programs both

during the week and on the weekends would allow folks with a varied schedules to attend.

CONCLUSION

To conclude, the research team must readdress our original research questions: “How do

clients at MEND perceive obesity? and “What kinds of culturally and community appropriate

programs could MEND implement to appropriately and effectively address obesity among

clients?” Through conducting oral surveys with MEND clients, examining demographics and

performing extensive research on the subject, we have concluded that perceptions of obesity at

MEND vary among person, but have similar themes. Most participants perceive obesity as a

pressing problem--both for themselves and for their families--and understand what steps need to

be taken in order to combat obesity. It also seems as though perceptions were not strongly

influenced by mainstream media, in the sense as the participants understood the importance of

weight loss as a necessity for a healthy lifestyle, not as a standard for beauty. In general, patients

viewed their health as less than optimal, but they faced barriers--both mental and physical--that

prevented them from living optimally healthy lives. Barriers such as time, access, affordability

and current health status were some of the main constraints expressed. When barriers were not

present, participants expressed their desire and willingness to participate in a healthy lifestyle.

In retrospect, our research team would change some of our methodology. One problem

we found was in the limited amount of surveys we were able to conduct. Due to the distant

MEND location (minimum 30 minute drive) and conflicting schedules, we were only able to

interview 13 MEND participants. While these surveys provided us with insight into the

perceptions of obesity within the MEND population, our small sample size was hard to

generalize and apply to broader research. In connection to the Latino Health Paradox in

particular, our sample size was far too small to isolate the variety of perceptions from different

Latin American countries and of different generational origins. Were we to conduct a similar

research project again, we would devise a way to get easier access to MEND participants,

possibly through phone interviews, Skype sessions, or written surveys that they could fill out in

our absence as well as give ourselves more time to complete all the interviews at MEND.

ACKNOWLEDGEMENTS

We would like to extend our thanks the MEND organization, Andrea Bañuelos and the

translators for our their help, guidance and dedication to the cause.

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