This document discusses obesity and overweight issues among U.S. Latinos, highlighting definitions of obesity, measurement methods like BMI, and trends in obesity prevalence from 1985 to 2003. It emphasizes the high prevalence of obesity in specific ethnic groups, notably among African-American females and Hispanic Americans. The document also explores contributing factors such as poverty, acculturation, exercise, and dietary habits, noting that lifestyles adopted in the U.S. can lead to increased BMI over time.

1. Obesity, Latinos, and Diet Daniel Santibanez, MPH Department of Public Health University 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.

2. 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.

3. 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 85 th percentile to 95 th percentile Overweight: BMI-for-age ≥ 95 th percentile There is no established definition of obesity in children

4. 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.

5. 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)

7. The Increase in Overweight and Obesity Among Adults

8. 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.

9. 1996 2003 Obesity Trends* Among U.S. Adults BRFSS, 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. 1991

10. Obesity Trends* Among U.S. Adults BRFSS, 1985 (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person) No Data <10% 10%–14%

11. Obesity Trends* Among U.S. Adults BRFSS, 1986 (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person) No Data <10% 10%–14%

12. Obesity Trends* Among U.S. Adults BRFSS, 1987 (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person) No Data <10% 10%–14%

13. Obesity Trends* Among U.S. Adults BRFSS, 1988 (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person) No Data <10% 10%–14%

14. Obesity Trends* Among U.S. Adults BRFSS, 1989 (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person) No Data <10% 10%–14%

15. Obesity Trends* Among U.S. Adults BRFSS, 1990 (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person) No Data <10% 10%–14%

16. Obesity Trends* Among U.S. Adults BRFSS, 1991 (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19%

17. Obesity Trends* Among U.S. Adults BRFSS, 1992 (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19%

18. Obesity Trends* Among U.S. Adults BRFSS, 1993 (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19%

19. Obesity Trends* Among U.S. Adults BRFSS, 1994 (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19%

20. Obesity Trends* Among U.S. Adults BRFSS, 1995 (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19%

21. Obesity Trends* Among U.S. Adults BRFSS, 1996 (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19%

22. Obesity Trends* Among U.S. Adults BRFSS, 1997 (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% ≥20

23. Obesity Trends* Among U.S. Adults BRFSS, 1998 (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% ≥20

24. Obesity Trends* Among U.S. Adults BRFSS, 1999 (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% ≥20

25. Obesity Trends* Among U.S. Adults BRFSS, 2000 (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% ≥20

26. Obesity Trends* Among U.S. Adults BRFSS, 2001 No Data <10% 10%–14% 15%–19% 20%–24% ≥25% (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person)

27. (*BMI  30, or ~ 30 lbs overweight for 5’4” person) No Data <10% 10%–14% 15%–19% 20%–24% ≥25% (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person) Obesity Trends* Among U.S. Adults BRFSS, 2002

28. Obesity* Trends Among U.S. Adults BRFSS, 2003 (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% ≥25%

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

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32. Increase in Overweight and Obesity Prevalence Among U.S. Adults by Racial and Ethnic Group CDC. Center for Health Statistics. National Health and Nutrition Examination Survey. American Obesity Association 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%

33. Increase in Overweight Prevalence Among U.S. Adults (Ages 20 -74) by Racial/Ethnic Group and Gender CDC. Center for Health Statistics. National Health and Nutrition Examination Survey. American Obesity Association Men Prevalence Women Prevalence Racial/ Ethnic Group 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%

34. Increase in Obesity Prevalence Among U.S. Adults (Ages 20 -74) by Racial/Ethnic Group and Gender CDC. Center for Health Statistics. National Health and Nutrition Examination Survey. American Obesity Association Men Prevalence Women Prevalence Racial/ Ethnic Group 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%

35. Increase in Severe Obesity (BMI ≥40) Prevalence Among U.S. Adults (Ages 20 and older) by Racial/Ethnic Group and Gender CDC. Center for Health Statistics. National Health and Nutrition Examination Survey. American Obesity Association Men Prevalence Women Prevalence Racial/ Ethnic Group 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%

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

37. Florida: Prevalence of Overweight*, by race or ethnicity *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 Ethnicity % Overweight 95% CI ( ±) Hispanic 58.1 4.3 White, non-Hispanic 54.0 2.0 Black, non-Hispanic 71.8 5.3

38. Florida: Prevalence of Obesity*, by race or ethnicity *Obesity is defined as having a body mass index of ≥ 30 Source: Behavioral Risk Factor Surveillance System (BRFSS), 2001. Mortality and Morbidity Weekly Report. August 23, 2003. 52(SS08); 1-80 Ethnicity % Obese 95% CI ( ±) Hispanic 17.1 3.3 White, non-Hispanic 18.5 1.6 Black, non-Hispanic 32.8 6.1

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

40. Florida: 2000 BRFSS, Adults Overall Hispanic Black, non-Hispanic White, 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%

41. Florida: 2000 BRFSS, Adults Percent Obese Age 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%

42. 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

43. 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

44. 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

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

46. Diagnostic Criteria for Metabolic Syndrome Source: ATP III. Bethesda: National Institutes of Health, 2001 *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 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

47. 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

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

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

50. 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.

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

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

54. Florida: Prevalence of No Leisure-time Physical Activity in the Past Month Source: Behavioral Risk Factor Surveillance System (BRFSS), 2001. Mortality and Morbidity Weekly Report. August 23, 2003. 52(SS08); 1-80 Ethnicity % No Activity 95% CI ( ±) Hispanic 40.9% 4.3 White, non-Hispanic 23.1% 1.6 Black, non-Hispanic 33.2% 5.3

56. Working with Puerto Ricans and Cubans Puerto Ricans and Cubans NY, FL, NJ, PA, CT, MA: Puerto Ricans Miami & Tampa, FL: Cubans

57. 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

58. Grains and Starchy Foods 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)

59. Grains and Starchy Foods 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

60. 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”)*

61. 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

62. Fruits Common Oranges Bananas Pineapples Watermelon Lemons, limes Mangoes Other Papaya Guava Cherimoya/soursop/anon Coconut Tamarind

63. 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

64. 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

65. 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

66. 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

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

68. Common Puerto Rican Dishes Ripe plantain and ground beef/ vegetable “lasagna” ( pastelon ) or “rolls” ( piononos ) Thick soupy rice ( asopao ) Rice with squid ( calamares )

69. 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

70. 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 )

72. Puerto Rican Food Guide Pyramid

73. Issues High fat intake from fats (oils, frying), poultry, beef, dairy intake Low dairy, fruit and vegetable intake

74. 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

75. Mexican-American Diet Patterns Traditional diet Varies greatly according to regions Blend of pre-Columbian, French, and Spanish diets American foods introduced in recent years

76. Mexican-American Traditional Diet CARBOHYDRATES (similar in most regions) corn/ corn products - mainstay in all regions beans (black - coastal regions/south; pinto - north/central) Breads - “pan dulce” rice

77. Counseling for Dietary Change “ Healthy eating guidelines better met by Mexican-born than U.S. born” Encourage return to healthy aspects of traditional cooking Fresh fruit, fresh fruit drinks Salads, vegetables Beans, legumes

78. Mexican-American Traditional Diet 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)

79. Mexican-American Traditional Diet FRUITS/VEGETABLES Wide variety fresh fruits consumed regularly (all regions) Fresh fruit drinks (“batidos”, “aguas frescas”) Cooked salads, pickled vegetables (“escabeche”), lime juice dressing

80. Mexican-American Traditional Diet Cooking Methods Frying (lard) Steaming, wrapped in leaves (coastal regions, southern regions) Stewing - “moles” (all regions) Meal Patterns 4-5 meals/day, “merienda”

81. 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

82. 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

83. 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

84. 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

85. Counseling for Dietary Change Use “modified” traditional favorites Carnitas, 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