Challenging Dogma - Spring 2008

...Using social sciences to improve the practice of public health

Wednesday, April 23, 2008

A New Discrimination For A New Millenium? – Elizabeth Gifford

Adult obesity is a major public health concern in the United States today. Since 1980, the obesity prevalence has more than doubled. In 2005-2006, more than 34% of people over the age of 20 were obese (1). There have been many interventions to try to address the behavior that leads to this condition, from individual to societal efforts, but they have not yielded much success. One such effort at changing behavior was a proposed law in Mississippi that would ban obese people from eating in restaurants. The proposed state law, presented by Representative W.T. Mayhall, would give the Mississippi Department of Public Health the authority to prescribe the criteria for determining whether or not a person is obese and provide this information to food establishments (2).

The law may have been proposed with the best of intentions, especially when, in 2005 Mississippi had the highest prevalence of obesity in the United States: 30.3% of Mississippians were obese (3), unfortunately, it does little in the way of helping the problem.

It is understandable that someone would have an impulse to enact a law like this. There are numerous research studies linking obesity to many different health risks such as cardiovascular disease and diabetes. Another problem linked to obesity is the associated costs; obesity related sicknesses cost the country an estimated $117 billion in 2000 (1) To address this epidemic at the societal level such a policy level change can be effective when it takes into account the target populations needs and services available to them. However, it is clear that this law is limited in the scope and the level of resources to actually work in making change. This intervention by power of coercion simply focuses on shaming the individual into a diet, by force, and therefore ignores the real reasons obesity is such a problem in Mississippi. This intervention does not take into account the social culture of Mississippi, nor does it give those that are banned the skills and tools to replace the eating habits that contribute to their obesity. Perhaps using the theory of reasoned action as a basis for the intervention, rather than power of coercion, would create a more comprehensive approach to intervening in the State’s obesity epidemic.

Law Ignores Southern Culture
After World War II, the amount of black middle-class people rose dramatically in the south and with that came a time of cultural development (4). Most importantly, cultural development was based around food and the traditions people grew up with from their ancestors. Those ancestors included Africans who came over during the slave trade, those emancipated and also those that lived through the civil rights movements. Soul food is a term that came out of the civil rights movement and the desire to create an independent identity for black American’s (4). Black Americans would frequently gather and cook the traditional foods such as fried chicken and cornbread while catching up on the day to day family matters. This is an important aspect to southern culture and a tradition that has been handed down from generation to generation. A law that bans people from eating in restaurants completely misses the target population in this instance. In Mississippi, 72% of African Americans are overweight compared with 62% of white Americans.(5) One answer to this trend in obesity is the deep rooted culture in food and social gatherings among this group. They aren’t necessarily going out to restaurants to eat, but gathering together, cooking large meals with relatively unhealthy food while eating throughout the day.

The law does nothing to educate people about how to practice healthful dietary and lifestyle choices that they could fit into their culture. Teaching people about portion control or how to replace the unhealthy traditional food with healthier options would be more beneficial to this group. Also, teaching people about exercise and its effects on weight loss would help. Because group dynamic is so important to the Mississippi culture, an intervention that stresses exercise at the group level might have an impact on obesity. Those implementing an intervention could recruit families to go on walks together, which may be beneficial on a societal level when other families begin to see the healthy changes in their lifestyles. This part of the intervention would show families that a walk together can achieve the same level of cohesiveness as chatting over platefuls of food. Simply banning people from eating in a restaurant does not mean they will go on a diet. Giving people the skills and knowledge on how to lose weight will have more of an impact on their weight loss. The U.S. Preventive Services Task Force found that counseling and person-to-person meetings that were aimed at educating people on weight loss were highly effective (6).

Food is the root of Southern culture. Food is a means to get together with family, have guests over, or show concern for those that may be going through difficulties. While social gatherings often involve food in most cultures, the importance of food in Southern culture seems more prominent (7). A proposed law to intervene on the obesity epidemic in this state would benefit from taking this into account.

Law Ignores Individual Barriers
The underlying objective of this proposed law is to reduce obesity by losing weight with increased exercise and healthier eating. Unfortunately, there are many barriers to exercising and eating more nutritional foods. Such barriers may be on a societal or an individual level. While many people may want to lose weight by exercising or eating better, they often face barriers that are difficult to overcome. The proposed law does not take into account the barriers people face on a daily basis when it comes to losing weight.

Limited income may contribute to increased weight gain. While Mississippi was the leading state for obesity, it had the lowest median income in 2006, with the average household making $34,343; $14,000 less than the average household in the United States (8). The Commissioner of Massachusetts recently stated that currently, low SES families are at greater risk for increased weight gain, which is a new phenomenon within the last decade. From the statistics on obesity and income in Mississippi, it is clear the trend is not limited to Massachusetts.

Families in lower social economic status may have limited or no health insurance. Unfortunately, having limited health insurance means less access to the tools to help lose weight, such as subsidized weight loss programs, that many often find through their health insurance or jobs. 18% of Mississippians were not covered by health insurance during 2004-2006, which is higher than the average uninsured rate of the United States (9). An overweight parent who is not insured and living at the poverty level must sacrifice healthful options for the food they can afford. Those types of foods are usually canned goods, high in preservatives or other less healthy options.

Being in a lower social economic status does not translate into eating out in restaurants often. People with limited income may be more concerned with putting food on the table at home than eating out in a restaurant. The proposed bill does not take into account those with limited income. Nor does it take into account recent research correlating obesity with lower income. An intervention focusing on those living in lower social economic communities would be more beneficial.

Other barriers an individual might face are medical conditions. One such medical condition is arthritis; in fact, being overweight is a risk factor for arthritis (10). Obese people are more likely to have joint pain. Once these types of problems occur, people may not want to embark on an exercise program because it physically hurts them. Asthma is also a condition known to be worse in obese individuals. Obese people were more likely to be at higher risk for daily symptoms of asthma compared to less overweight people (11). Medical conditions like these are difficult to live with, let alone start a weight loss program. While many physicians hope that it is conditions like these that will push people to lose weight for the sheer fact that doing so can lower the risk of them (12), for the obese individual, it’s easier said than done.

Self Efficacy
One more barrier to losing weight for an individual is the idea of self efficacy. Self efficacy is defined as a” person’s belief in his or her ability to take the action (13).” In other words, this is the idea that someone thinks they can move forward with action because they have the skills and the knowledge to carry out the action. Simply eating less and some minimal exercising does not necessarily mean losing weight. It’s likely that people embarking on a weight loss program may try this route at first and find that it is difficult to stick with, most likely due to the barriers described above or for other environmental barriers that will be discussed later. They may not know that eating correctly, instead of eating less, is more important to losing weight. In order for people to lose weight, they need to feel like they can by being equipped with the appropriate tools and knowledge.

One study found that individuals with increased self efficacy were more apt to lose weight (14). This study found that using the correct intervention, and targeting self efficacy and barriers, women were more likely to meet physical activity recommendations and lose weight. The proposed law does not take into account the barriers, nor does it replace the barriers with skills that the individual needs in order to overcome them.

Law Ignores Environmental Barriers
It is doubtful that Boston Sports Clubs and Whole Foods Markets will be found in rural Mississippi. Research studies tell us that environmental resources are important factors to take into account when trying to change behavior. Without resources that are both available and affordable, overweight people will find it difficult to begin a weight loss program while living in lower income areas.

While Mississippi is the 5th most rural state in the United States (8) the metro areas grew at twice the pace of rural areas in Mississippi in 2000 (15). That growth includes people leaving the rural areas for the metro cities, as well as people moving in from out of state. Growth like this also means job growth in cities, but job loss in rural areas due to a diminishing population. Because there are less job available, there will be a higher poverty level, which the statistics show. 19% of Mississippians were living below the poverty level, while the average percentage for the United States was 12% (16). Rural Mississippi is also known for jobs in farming and textiles, not nutritionists and Personal Trainers that are mostly found in higher populated areas such as the big cities. This means that finding such gyms and programs to help with weight loss will not be in abundance in rural towns, but in the bigger cities of Mississippi. Because of these limited resources and lack of access to services, such as gyms, it is vital that when planning an intervention for obesity, it uses state and national programs to target the rural areas. Simply using organizations at a local level, that in some cases, may not exist due to the rural conditions, will not be enough to make a dent in the obesity problem. If such organizations do exist on a local level, state funded programs should equip them with tools, education and services that will target the populations most in need of help.

What Would Help?
The proposed law would have benefited from taking into account the social norms and barriers, and come up with an appropriate intervention that would have targeted population most in need, while giving them the skills to aid in weight loss. Studies exist proving that people want to lose weight and will work at it under the right conditions. Researchers have concluded interventions should focus on addressing behavioral strategies, barriers and self efficacy to increase physical activity and improve weight loss (14).

The Theory of Reasoned Action takes into account all that the proposed law misses. The theory is based on the idea that behavioral intention comes from a person’s attitude towards the behavior and their perception of social norms associated with that behavior. The most important aspect in this theory is the social norms. Southern culture revolves around food and if the norm is to eat and drink in social situations and that an individual may feel shunned by the group if they do not participate, that individual will likely not follow through on the intended behavior.

Targeting overweight people is not without risk. According to the U.S. Preventive Services Task Force, one risk is the societal stigma attached to being labeled as obese (6). Some people may have feelings of self doubt and depression with this label. Embarrassing those that are turned away from restaurants can be harmful to one’s mental health. When using an appropriate intervention, the task force says that the benefits of targeting that group far outweigh the risks of being overweight (6). By including education, counseling and meetings, this could help overcome the stigma and help those who would benefit from weight loss the most.

Representative Mayhall may have had good intentions in mind when proposing this law by trying to bring the problem of obesity to light, but it is not the most effective intervention. It does not take into account the southern culture and most importantly, it does not give people the tools and skills to help them lose weight.

While using the Theory of Reasoned Action would have been more beneficial, it is not to say that a power of coercion approach could not have worked under different circumstances. A state law could have taken into account the state funds that are designated for weight loss programs. Policy makers who distribute funds at a local and state level could have been educated about the rural Mississippians who have a higher rate of obesity and lack the resources to aid in weight loss. Armed with this knowledge, they could build up the food and nutrition assistance programs that are so vital to this population and often their only source of education about nutrition. Under a proposed law, state funds could be allocated for case workers or advocates to hit local areas and provide support and education which, in turn, could lead to support groups and an overall sense of healthy living among the local population. State funds through a proposed law could also be allocated to build parks or paths for walking or running. Using a law to build an obesity intervention can work when taking into account the social norms and barriers of the target population but proposing a law that bans people from eating in restaurants misses a host of factors and does not contribute to weight loss at all. It is unlikely that obese people are in such a condition because of the food they eat in restaurants alone.

Tailoring an intervention to account for all of the factors discussed would be most beneficial. Of course, there may still be barriers, but continuing to tailor an intervention based on those findings will prove to be the most helpful in the long run. Discriminating against obese people by banning them from restaurants is not helpful; it’s shameful, especially given the history of the South.

1. Centers for Disease Control: Chronic Disease Prevention. Physical Activity and Good Nutrition: Essential Elements to Prevent Chronic Diseases and Obesity. 2006.

2. House Bill 282. Representatives Mayhall, Read, Shows. Regular Sesion; January 25, 2008.
3. Center for Disease Control and Prevention. Morbidity and Mortality weekly Report. September 15, 2006; Vol 55: pp.985-988.
4. Henderson L. Ebony Jr! and “Soul Food”: The Construction of Middle-Class African American Identity Through the Use f Traditional Southern Foodways. University of Wisconsin-Milwaukee. Melus [0163-755X] yr:2007; vol: 32 iss: 4.
5. Centers for Disaease Contro and Prevention. Behavioral Risk Factor Surveillance System Survey Data, 2005. unpublished data. Accessed April 23, 2008 at
6. U.S. Preventive Services Task Force. The Nation’s Health 34(1), 2004.
7. Associated Content. Relating Eating Habits to Lifestyle and Values. Eric Loveday. Accessed April 23, 2008 at
8. Beaulieu L, Guillory F, Rubin S, Teater B. Mississippi: A Sense of Urgency. Southern Rural Development Center and MDC, Inc. 2002. Accessed April 23, 2008 at
9. U.S. Census Bureau. Income, Poverty and Health Insurance Coverage in the United States: 2006. Issued august 2007.
10. Felson DT, Zhang Y, Hannan MT, et al. Risk factors for incident radiographic knee osteoarthritis in the elderly: the Framingham Study. Arthritis Rheum. 1997;40:728-733.
11.Vortmann M. BMI and health status among adults with asthma. Obesity. 2008; 16(1):146-152.
12. Felson DT, Chaisson CE. Understanding the relationship between body weight and osteoarthritis. Baillieres Clinical Rheumatology. 1997; 11:671-681.
13. Edberg M. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Sudbury, MA. Jones and Bartlett Publishers, 2007.
14. Gallagher K, et al. Psychosocial factors related to physical activity and weight loss in overweight women. Med Sci Sports Exerc. 2006; 38(5): 971-980.
15. Renkow M. Population, Employment and Mobility in the Rural South. Southern Rural Development Center Policy Series. February 2004, No 3. Accessed April 23, 2008 at
16. U.S. Census Bureau. State and Country Quickfacts. Accessed April 23, 2008 at

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