ABSTRACT: Overweight and obesity are epidemic in the United States. Obesity is a risk factor for numerous conditions, including diabetes, hypertension, high cholesterol, stroke, heart disease, certain types of cancer, and arthritis (1). More than one fourth of U.S. women are overweight and more than one third are obese. Women living in urban settings, irrespective of demographics or income, are particularly vulnerable to becoming overweight or obese because of limited resources for physical activity and healthy food choices. Therefore, there is a need for clinicians and public health officials to address not only individual behaviors but also environmental issues in their efforts to reduce the epidemic of obesity in this particular group of the population.
Overweight and obesity are epidemic in the United States.Obesity is a risk factor for numerous conditions, including diabetes, hypertension, high cholesterol, stroke, heart disease, certain types of cancer, and arthritis (1). More than one fourth of U.S. women are overweight and more than one third are obese (1). Although all women are at high risk of obesity, minority women and women in low-income and urban areas are particularly at risk (2). It is estimated that 80% of females aged 15 years and older lived in urban areas in 2008 (3). Each year, 83% of live births occur in urban cities and regions across the United States. The demographic characteristics of women living in urban communities are diverse and complex. Racial composition and poverty rates vary by both the level of urbanization and parameters unique to the geographic region. In the United States, 54% of women living in urban areas are non-Hispanic whites and 45% are minorities or women of color (4). Poverty rates are highest in large urban areas, particularly in the Northeast and Midwest regions (5). Despite the regional diversity in specific social and economic characteristics, urban women across the United States face some unique barriers to healthy living. Overweight and obesity in urban women may be exacerbated by additional barriers to physical activity and healthy eating, collectively referred to by social scientists and urban and public health planners as the built environment (6, 7).
Identifying Women Who Are Overweight and Obese
The World Health Organization and the National Heart Lung and Blood Institute (NHLBI) classify overweight and obesity based on body mass index (BMI), defined asweight in kilograms divided by the square of height in meters (kg/m2) (8, 9). A healthy or desirable BMI foradults is between 18.9 and 24.9. An adult is considered overweight if the BMI is between 25.0 and 29.9 and obese if the BMI is greater than or equal to 30.The term morbid obesity is still used by the International Classification of Diseases, 9th Revision, Clinical Modification, to refer to a BMI greater than 35, but the NHLBI recommends more respectful alternatives such as “stage III,” “extreme obesity,” or “clinically severe obesity” (10). Clinicians can access an online BMI calculator at the NHLBI web site (http://www.nhlbisupport.com/bmi/).
Overweight and Obese Women in Urban Communities
National data on rates of overweight and obesity in urban settings are limited. The Behavioral Risk Factor Surveillance System and the Pregnancy Risk Assessment Monitoring System are based on self-reported height and weight and may underestimate the prevalence of overweight and obesity (11, 12). In addition, although the National Health and Nutrition Examination Survey provides data based on actual measures of individuals' height and weight across regions, its data on urban or rural areas within regions are limited (13).
A 2001 Centers for Disease Control and Prevention (CDC) health report showed obesity rates as high as 24% in the Midwest and 19–20% in the South and Northeast. These data likely underestimate current trends, particularly in low-income and minority communities because data were aggregated from broad geographic regions that included cities and surrounding suburban areas (5). The CDC data also show that physical inactivity, a primary risk factor for overweight and obesity, varies substantially among women in different geographic settings (5).
Challenges for Overweight and Obese Urban Women
There is growing recognition that the built environment, which encompasses a range of physical and social characteristics that make up the structure of a community, influences lifestyle behaviors and obesity, particularly among adult women (14, 15). Access to healthy foods and designated areas for walking and other physical activities can substantially improve the health of urban communities.
The availability of large supermarket chains or grocery stores within a designated area influences food choicesand healthy eating among urban-based women (16). Several studies show that large supermarkets with a variety of food choices often are located several miles outside of the city, requiring a car or long bus rides (16–18). Among women in low-income urban communities, there are multiple challenges to healthy food selections. The primary food retailers in many urban neighborhoods are small, individually owned, corner markets with limited selections of fresh fruits, vegetables, or low-fat dairy products (19). A high number of fast food restaurants and convenience stores per square mile in low-income urban neighborhoods is another challenge (20). These restaurants and stores offer quick, low-cost meals, but the menu is composed primarily of high-calorie, high-fat foods that further contribute to or exacerbate obesity among urban women. The higher portion sizes and high-fat content of fast foods can be related to increasing obesity rates (20). The cost of healthier selections also is contributory (ie, a bag of potato chips costs approximately 20% less than the same portion of raw carrots).
The limited availability of healthy food choices in low-income urban communities is emphasized in a study conducted in Baltimore, MD (21). Using the healthy food availability index, a novel measure of food selection used by social scientists, healthy food selections were mapped across 159 census tracts and 226 food stores in Baltimore. Forty-three percent of low-income communities were in the bottom third of accessibility to healthy food compared with 13% of high-income urban neighborhoods. Further assessments of food distribution by census tracts and zip codes are necessary to monitor improvements in accessibility and modifications in dietary intake. Local and state policies that encourage supermarkets to broaden the availability of food choices in all communities is another important step in supporting healthy eating habits.
Physicians may find it difficult to explain the disadvantages of consuming fast foods during a 10–15 minute office visit, especially when other problems must be addressed or the patient is not yet considering a lifestyle change. Motivational interviewing is a useful technique to improve patient–physician communication and elicit positive changes in patient behavior. Information on the principles and practice of motivational interviewing can be found in the American College of Obstetricians and Gynecologists (the College) Committee Opinion Number 423, “Motivational Interviewing: A Tool for Behavior Change” (22). Educating patients about the calories consumed with fast food is an important step. Assisting the patient in comparing the number of daily calories she needs with the number of calories in convenient food items may be helpful. Calorie information of some fast food chains is listed on their web sites and in some chain locations. Assisting the patient in identifying healthy options at popular fast food chains such as grilled or skinless chicken, a salad or other side vegetable selection, along with alternate food sources, such as a local farmers' market, may be helpful in the motivational process.
Achieving the recommended amount of daily physical exercise (30–60 minutes per day) is another aspect of the built environment that challenges women in urban settings (23, 24). Development of safe neighborhood walking paths and maintenance of accessible sidewalks in high traffic areas may increase physical activity. Research results document a direct correlation between sidewalk accessible streets and pedestrian activity in urban neighborhoods. Limited access to public parks or recreational centers within individual neighborhoods is another barrier to physical activity. Personal safety may prohibit outdoor activities. Some urban neighborhoods contain a safe, one to two block area bordered by several blocks of high crime activity. Although a park or walking trail may be a short distance from their homes, women may be reluctant to use such facilities if they are afraid of crime. Community resources, such as the YMCA or community swimming pools, are alternative, safe venues. Strategies to improve viable, safe pedestrian activity in urban neighborhoods are necessary for women to sustain a healthy level of activity.
Current Initiatives to Reduce Obesity in Urban Settings
Policy decisions about transportation options, land use and development, and community design influence the accessibility of healthy foods and the level of physical activity. These planning decisions may increase the convenience of purchasing healthy foods and create safe neighborhood venues for walking and leisure activities. Examples of recent initiatives led by state governments, academic centers, and community organizations include the following:
- The Well-Integrated Screening and Evaluation for Women Across the Nation (WISEWOMAN) Program, a state-level initiative supported by the CDC, equips low-income adult women, aged 45–64 years and at risk of cardiovascular disease, with lifestyle modification skills to improve dietary intake and physical activity in urban and rural communities in 21states (http://www.cdc.gov/WISEWOMAN/brochure.htm).
- The University of Colorado, in collaboration with community organizations and neighborhood residents, has transformed unused land lots into community gardens and open space for physical activity.
- The Upper Falls Community of Rochester, New York,developed collaborations to bring a full service supermarket to a neighborhood that previously had no grocery store.
- New York City's Health Department amended the city Health Code to require the posting of calorie counts by chain restaurants on menus, menu boards, and item tags (http://www.nyc.gov/html/doh/downloads/pdf/cdp/calorie_compliance_guide.pdf).
These along with other initiatives can be found at http://www.preventioninstitute.org/builtenv.html.
Recommendations for the Obstetrician–Gynecologist
Addressing obesity and lifestyle behaviors during a busy clinical office session is challenging to the obstetrician–gynecologist. The following steps can help initiate a dialogue about lifestyle modifications between the patient and her physician:
- Discuss healthy lifestyle behaviors at each visit. Multiple discussions can facilitate an open dialogue and opportunities to develop weight loss strategies. Additional information is available in the College's Committee Opinion Number 319, “The Role of the Obstetrician–Gynecologist in the Assessment and Management of Obesity” (25).
- Encourage discussions of physical activity and the range of food choices available in local neighborhoods during prenatal and postpartum visits. Information on obstetric management of obesity during pregnancy can be found in the College's Committee Opinion Number 315, “Obesity in Pregnancy” (26).
- Use motivational interviewing techniques to assist women in developing a long-term commitment to weight loss and healthy living. Additional information is available in the College's Committee Opinion Number 423, “Motivational Interviewing: A Tool for Behavior Change” (22).
- Advocate for the development of a free wellness program at your hospital.
- Partner with your hospital's community liaison office to advocate for further construction of safe, accessible outdoor recreational areas.
- Volunteer to represent your hospital at community initiatives to increase supermarkets or improve recreational venues in the city.
- Encourage patients to consider shopping at farmers' markets, if few grocery stores are available to them.
- Support city and state health department efforts to expand data collection and improve surveillance of trends in obesity and other chronic conditions.
- Encourage your hospital administration to partner with nutritionists, social workers and community-based fitness clubs (eg, YMCA) to provide a multifaceted approach to lifestyle behavior change.
- Collaborate with other clinicians to encourage local grocery store owners to expand the selection of fruits and vegetables and to encourage development of farmers' markets.
- Display handouts, when possible, in examination rooms or the reception area with recommendations for daily calorie intake and physical activity.
- Provide materials on preparation of low calorie meals (available free of charge from the National Institute of Diabetes and Digestive and Kidney Diseases [http://www.niddk.nih.gov/]).
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- U.S. Census Bureau. Available at: http://www.census.gov. Retrieved January 25, 2010.
- National Center for Health Statistics. Health, United States, 2008: with special feature on the health of young adults. Hyattsville (MD): NCHS; 2009. Available at: http://www.cdc.gov/nchs/data/hus/hus08.pdf. Retrieved January 25, 2010.
- National Center for Health Statistics. Health, United States, 2001: with urban and rural health chartbook. Hyattsville (MD): NCHS; 2001. Available at: http://www.cdc.gov/nchs/data/hus/hus01.pdf. Retrieved January 26, 2010.
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- Centers for Disease Control and Prevention. Behavioral Risk Factor Surveillance System. Available at: http://www.cdc.gov/brfss. Retrieved January 25, 2010.
- Centers for Disease Control and Prevention. Pregnancy Risk Assessment Monitoring System (PRAMS): home. Available at: http://www.cdc.gov/prams. Retrieved January 25, 2010.
- National Center for Health Statistics. National Health and Nutrition Examination Survey. Available at: http://www.cdc.gov/nchs/nhanes.htm. Retrieved January 25, 2010.
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