OBESITY is a global epidemic that affected approximately 36.5% US adults between 2011 and 2014, and 32.8% of adults were overweight between 2013 and 2014.1,2 Obesity is higher in certain groups of people such as African Americans (48.1% are obese) than the general population.3 Also, 42% of women living below the 130% poverty level suffer from obesity, compared with 29% who are living at or above the 350% poverty level.4 There are a number of comorbidities associated with obesity such as diabetes, cardiovascular disease, and some cancers.5 Because of these comorbidities, individuals with obesity (body mass index [BMI] ≥30kg/m2) have an increased mortality rate from all causes compared with an individual with a BMI between 20 and 25 kg/m2.5 Furthermore, obesity is expensive. In 2008, about $147 billion was spent on medical expenses associated with obesity in the United States.6 Because of the comorbidities and expenses related to obesity, it is important to try to understand problematic eating behaviors that may promote weight gain and obesity especially in communities with a low-income ethnically diverse population because of the increased percentage of obesity.
Some eating behaviors, such as eating in the absence of hunger, overeating, and loss of control over consumption, have been studied. These eating behaviors appear to be found in individuals with obesity.7–13 Research has found that individuals who were lean or normal weight expressed more nutrition knowledge, were more health conscious, prioritized buying fruits and vegetables, and ate by internal cues more than those who were overweight or obese.7,9,10 Also, those who are overweight or obese have been shown to exercise less, eat in the absence of hunger, overeat and emotionally eat, and express enjoyment of eating and a greater liking of a variety of foods more than those who are lean or normal weight.7–10,14 These results suggest that problematic eating behaviors may be more prevalent in the obese population. Thus, the purpose of this research was to investigate eating behaviors of women who were lean or normal weight (referred to as W-L/N) and women who were overweight or obese (referred to as W-O/O) and to explore whether problematic eating behaviors were more common among W-O/O than W-L/N using focus group methodology, actual heights and weights data, and measuring taste preferences and palatable eating motives. Focus group methodology has been used in previous research to fill gaps in nutrition information.15–18
Qualitative data (focus group discussions), supplemented with quantitative data (a taste test and Palatable Eating Motives Scale [PEMS]) were used with African American (n = 45) women, aged 18 to 64 years. Low-income African Americans were chosen as the focus of this study because of the increased obesity rate in the population. Participants were recruited in their communities through flyers and in-person at libraries, WIC (Women, Infants, and Children) offices, community centers, community schools, hot meal sites, and food shelves. Participants were asked whether they qualified for any food assistance programs offered in their communities such as Supplemental Nutrition Assistance Program, WIC, or children who received free or reduced lunch during the recruitment process to recruit low-income individuals. At the focus groups, women gave written consent, had actual heights and weights measured, completed forms, and participated in a group discussion. Cash compensation was provided for 90 minutes their time. The university's institutional review board approved this study.
Eight focus groups with an average of 5 women (range of 2-8 women) were conducted by 2 researchers trained in focus group methodology. One researcher led the focus group, while the other researcher took notes during the focus group. Questions were developed on the basis of previous literature and discussion with researchers in the eating behavior field.7–10 Focus group questions were created to gain insight about eating/exercise habits among African American W-L/N versus W-O/O. Audio recordings of discussions were transcribed verbatim. The same researchers who conducted the focus groups coded each transcription separately using Kreuger's open coding method, reconciled any differences, and organized codes into themes and subthemes.19 Quotes were organized into a table that separated W-L/N from W-O/O for each theme.
Palatable Eating Motives Scale
The PEMS assessed reasons for consuming palatable foods to explore whether these women ate highly palatable foods for reasons other than hunger. The survey consists of 20 questions (Table 1) asking when palatable foods are consumed and explores 4 motives: coping, reward, social, and conformity.20 Each motive included 5 questions. Motive scores were calculated by taking the average response of each question within the motive.21
Women were asked to taste 5 different snack foods varying in sweetness and saltiness (salted peanuts, M&M's milk chocolate candies, green grapes, brownies, and regular potato chips) to test for differences in food preferences. These foods were chosen because they vary in sweet/saltiness and in nutritional value. The degree of liking of each food was measured using the Labeled Magnitude Scale. The Labeled Magnitude Scale was developed as a way to measure taste sensation.22 Women were asked to mark their degree of liking of the food on the Labeled Magnitude Scale that went from most imaginable dislike to greatest imaginable like after each taste. Women were asked to take a drink of water to clear their palate after tasting each item. Researchers measured the distance from the beginning of the scale line to the mark made by the participants with a ruler to determine the degree of liking.22
Anthropometric data collection
Actual heights and weights were assessed using a portable stadiometer and calibrated digital scale. Participants were measured without shoes and outdoor clothing. Measurements were taken twice and the maximum height measured and averaged weight were used. These measurements were used to calculate BMI (kg/m2). Body mass index categories were less than 18.5 kg/m2 (lean or underweight), 18.5 to 24.9 kg/m2 (normal weight), 25 to 29.9 kg/m2 (overweight), and 30 kg/m2 or greater (obese).
Data were entered into SPSS for Windows Statistical Analysis Software Package Version 22. Independent t tests compared W-L/N (BMI: <25 kg/m2) with W-O/O (BMI: ≥25 kg/m2) to analyze differences in demographic, the PEMS, and the taste test data.
Sample characteristics are shown for 45 African American women. The mean age was 45 years. The W-L/N had statistically larger household sizes (Table 2).
Palatable Eating Motives Scale
The PEMS assessed reasons for consuming palatable foods. Mean responses and motive scores can be seen in Table 1. The coping score to feel more confident was significantly higher for W-L/N than for W-O/O, indicating that food helps W-L/N feel more confident. The W-L/N also scored higher for “gives pleasant feeling,” suggesting that W-L/N eat for pleasure more than W-O/O. Social scores between W-L/N were significantly higher than those between W-O/O, specifically to make gatherings fun and to celebrate special occasions, suggesting that W-L/N eat palatable foods to be social more so than W-O/O. Overall, the results of PEMS suggest that W-L/N eat for hedonic reasons more than W-O/O, which contrasts what was said in the focus groups.
Sweet versus salty preference
Preference for sweet or salty food was mixed between W-L/N and W-O/O. However, W-L/N identified fruits as sweet foods they liked; as one said, “Sweets. I like bananas ... I eat that every day” (BMI: 19.2 kg/m2). In contrast, W-O/O tended to like sweets such as ice cream, pastries, and candy; as a woman stated, “Sweet foods ... I want chocolate. I want ice cream” (BMI: 27.1 kg/m2). The W-O/O who liked fruits had lower BMIs than the rest of the W-O/O. Liking vegetables was also mentioned more frequently by W-L/N. The W-L/N often said phrases such as, “Yeah, I love veggies” (BMI: 20.0 kg/m2) or “...Oh yeah, vegetables. I eat my vegetables fresh. I like em with stir fry...” (BMI: 23.4 kg/m2). Vegetables were mentioned much less by W-O/O.
The results of the taste testing found that W-L/N liked grapes (18.5 cm) best, followed by M&M's (17.6 cm), then brownies (17.2 cm), then potato chips (16.9 cm), and lastly peanuts (15.3 cm). Similarly, W-O/O liked grapes (18.4 cm) best, followed by potato chips (17.0 cm), then peanuts (15.6 cm), then brownies (14.1 cm), and lastly M&M's (13.7 cm). The W-L/N had significantly higher scores for liking of M&M's than W-O/O.
Five themes identified through focus groups were as follows: (1) Internally and externally motivated eating differs between BMI status, (2) concept of health affects eating habits according to BMI status, (3) reasons for exercise is related to BMI status, (4) reaction to stress is related BMI status, and (5) factors that determine body size are different between BMI status.
Theme 1: Internally and externally motivated eating differs between BMI status. Internal hunger cues stimulated eating for W-L/N, whereas external environmental cues found throughout their communities influenced eating behaviors among W-O/O. The subthemes that emerged were deciding when to start and stop eating, overeating, food thought frequency, and occurrence of forgetting to eat. The W-L/N ate mostly when they felt hungry. One woman stated, “I eat because I be hungry” (BMI: 20.8). In contrast, W-O/O often reported eating in the absence of hunger, as this woman reported, “I eat about when I feel like the urge. Like I'm not even hungry” (BMI: 36.4 kg/m2). These data show that W-L/N ate when hungry, while W-O/O ate in response to other factors.
How women decided when to stop eating differed between women of different sizes. The W-L/N stopped eating once they felt full, listening to internal cues, as reflected by 1 woman,
I don't like the feeling of being overfull ... I don't even like getting overfull on [chips] cause my body just doesn't like to hold a lot of grease. So I eat to the point where I'm comfortable and I can stop.... (BMI: 20.8 kg/m2).
In contrast, W-O/O talked of overeating on a regular basis, as one stated “We all go out [to restaurants]... Yeah, but I sit there all day long. I don't think I ever get full. My jaw get tired” (BMI: 33.2 kg/m2). The W-L/N constantly reported listening to internal hunger cues and were less influenced by external environmental cues than W-O/O.
The W-L/N also thought about food less frequently. One woman stated, “I don't ever think about food. I just eat when I'm hungry. I never think about food” (BMI: 18.4 kg/m2). In contrast, W-O/O thought about food frequently, with food often a topic of conversation. As one said, “I think about [food] a lot. I like to eat every hour. I am thinking about food. When I'm walking down the streets, I'm looking at the restaurants.... Where can I stop at?” (BMI: 27.7 kg/m2). When discussing going out to social gatherings, W-O/O thought more of the food days before the event, but W-L/N thought of the event, contrasting with the PEMS finding that W-L/N eat palatable foods at social events. The W-O/O were often preoccupied by food thoughts but W-L/N rarely thought of food.
Another difference between women of different sizes was forgetting to eat. Forgetting to eat was often verbalized by W-L/N. As one woman said,
I don't think I start thinking about food until my stomach grrrrr. Sometimes I forget to eat. I thought I ate and I probably haven't eaten all day, so I just be sitting there, I hear grrrr. Did I eat something? (BMI: 24.5 kg/m2).
Conversely, W-O/O reported that they rarely forgot to eat. Forgetting to eat, food thought frequency, and factors that influence eating differed between W-O/O and W-L/N.
Theme 2: Concept of health affects eating habits according to BMI status. Eating for health was common among W-L/N and less common among W-O/O. The subthemes that developed were food as a nutrient versus food as pleasure and acceptance of a larger body size. The W-L/N discussed using food as a nutrient, whereas the W-O/O used food for pleasure. Eating nutritiously was motivated by health benefits and avoidance of disease for W-L/N. One woman explained “I'm mindful though of what it is I eat because my blood pressure, I'm affected by what I eat, my blood pressure is. I really like bacon. I've had to discipline myself with how much of it I eat” (BMI: 20.8 kg/m2). Health and prevention of disease were a common motivator of nutritious eating among W-L/N.
In contrast, health was not a concern for the majority of W-O/O. The few W-O/O who desired to eat healthy expressed barriers to doing so such as current health problems, lack of time, or cost, as one mentioned
...I know what I'm supposed to eat. I know what's best for me but when it comes to finances and what you can afford, you go down the fresh produce aisle, they're sky-rocketed.... A lot of times I know what I'm supposed to get but you end up getting the canned goods. They got sodium in it (BMI: 31.6 kg/m2).
Cost, lack of time, and current health issues were common obstacles to consuming healthy foods for W-O/O.
The W-O/O often discussed eating for pleasure, which differed from the PEMS findings in that W-L/N ate for pleasure more than W-O/O. However, in focus group discussions, comments such as “I just got to be in that kitchen and wherever I go if I don't have any money, I have attitude because I'm going to eat. I ain't hungry. I just want to eat” (BMI: 33.8 kg/m2) were common among W-O/O. Also, these women showed more acceptance of a larger body size as seen by this quote “We big boned you know” (BMI: 36.6 kg/m2). In contrast to the PEMS findings, W-L/N emphasized the importance of a healthy lifestyle, while W-O/O emphasized how much they enjoy eating.
Theme 3: Reason for exercise is related to BMI status. Exercise habits were also different between W-L/N and W-O/O. The W-L/N exercised for health benefits. As 1 woman stated, “For my health and keep my body going and energy. I do yoga. I do squats in the morning. I do walking. Those are the basic ones I do” (BMI: 23.1 kg/m2). The W-L/N also indicated that they enjoyed exercise. One woman reported, “I like [exercise]. It's not like a regular it's a yoga studio. It's a lot of dancing... it's fun...” (BMI: 23.7 kg/m2). The W-O/O reported being less active. For them, physical activity was done if required to watch their children and walk places because they lacked transportation, as one said, “I walk everywhere. Limited funds so what I can afford. I [walk] because I have to [because of no transportation]” (BMI: 27.1 kg/m2). The W-L/N saw exercise as enjoyment, a hobby, and a way to relieve stress, whereas W-O/O saw exercise as a chore.
Theme 4: Reaction to stress is related to BMI status. The W-L/N coped with stress differently than W-O/O. Subthemes that emerged were the use of comfort foods and the use of sedentary activities versus nonsedentary activities during stress. Some W-O/O used food as a coping mechanism as one woman explained, “If I'm feeling stressed or depressed I find my comfort in food... I'll eat anything... I open that refrigerator a hundred times... I'm not even hungry. It's the stress” (BMI: 36.4 kg/m2). Other W-O/O used sedentary activities to handle stress such as lying down, praying, or talking through their stress. One woman stated, “When I'm stressed out, I'm lying down” (BMI: 29.7 kg/m2). In contrast, W-L/N mostly handled stress through physical activity, such as walking or working out. One woman reflected, “I'll stretch or I dance a lot...I love dancing. It's a stress reliever” (BMI: 18.4 kg/m2). The W-L/N were more active during stressful times than W-O/O. This finding contradicts the results of the PEMS in that W-L/N had higher coping scores, meaning that they turn to food as a coping mechanism more than W-O/O.
Theme 5: Factors that determine body size are different between BMI status. Women of different sizes believed that body size was determined by different factors. W-L/N believed that body size was mostly determined by controllable factors such as eating habits and physical activity levels. One woman explained,
I think it's pretty much like people's eating habits. The genetics, I think it could be but from that point of view, with a mom and a child, if a mother's overweight the child might be more prone to be overweight because of the mother's eating habits (BMI: 20.3 kg/m2).
The W-O/O believed that body size was mostly influenced by uncontrollable factors such as genetics as woman mentioned, “I look at all my aunties, my mother. Every single aunt has big legs and big butt. That's genetic. So how come my grandma has big legs. So it is what it is...” (BMI: 32.4 kg/m2). Another common reason for body size was medication, as one woman explained, “My weight gain comes from because ... they put me on a steroid ... it's not the food I'm consuming, it's the medication. You don't even have to eat nothing cause it's a steroid. It gonna make you gain weight” (BMI: 36.4 kg/m2). Difficult life situations were also regularly stated as a reason for body size among W-O/O. One woman said, “Some people are depressed. Some people are addicts. Some people have physical disabilities. Some people have mental disabilities. [Body size is] just kind of what's going on with that person” (BMI: 25.6 kg/m2). The W-O/O believed that body size was determined by less modifiable factors, while W-L/N thought that body size was a result of modifiable lifestyle factors.
This study adds to the literature by investigating eating behaviors using qualitative methodology and including low-income African American W-L/N and W-O/O. Key findings of this study were as follows: (a) W-L/N did not overeat, thought of food less often, forgot to eat, responded to internal hunger cues, and did not eat in the absence of hunger, indicating less characteristics of problematic eating behaviors in contrast to W-O/O, who overate frequently, constantly thought of food, ate in the absence of hunger, and responded to external environmental cues, (b) W-L/N ate nutritious foods and exercised for health reasons, whereas W-O/O were not motivated by health to consume nutritious foods or exercise, (c) W-L/N used nonsedentary activities to cope with stress but W-O/O used sedentary activities or food to cope with stress, and (d) W-L/N viewed body size as modifiable, whereas W-O/O saw body size caused by genetics or side effects of medication.
The results of this study indicated strong eating behavior differences among W-L/N and W-O/O. The W-L/N reported less problematic eating behaviors; for example, they listened to internal hunger cues rather than external environmental cues. Specifically, they ate only when hungry and rarely overate because they were able to stop eating once full. Previous research found that individuals who were lean or normal weight ate on the basis of internal cues, eating only when hungry, and rarely overeating.7,9 Also, food seemed less of a priority for W-L/N, as they did not think of food often, and many W-L/N simply forgot to eat because they were busy. Other research indicated that adolescents and adults with lower BMIs were less preoccupied with food,23,24 similar to the findings in this study. However, the PEMS results suggest that W-L/N ate for hedonic reasons more than W-O/O. In contrast, findings from the focus groups suggest that W-L/N were able to stop eating once full, whereas W-O/O could not stop eating and would often overeat.
In contrast, W-O/O expressed more problematic eating behaviors. They reported that they responded to external environmental cues, ate in the absence of hunger, had a difficult time stopping eating, overate on a regular basis, and frequently thought of food. The W-O/O emphasized the frequency of their food thoughts, eliminating the chance to ever forget about eating. Earlier research has shown that those who are overweight are more likely to have food-related thoughts during the day.23,24 Increased food thoughts in those who are overweight or obese could stem from earlier dieting and restricting foods, as the frequency of food thoughts increases during starvation and food restriction associated with dieting,25,26 consistent with this research.
These data also indicated that W-O/O frequently ignored internal satiety cues and ate in the absence of hunger. Eating in the absence of hunger, or eating palatable foods beyond satiation, has been researched in both adults and children and indicates that it is predictive of higher BMIs throughout the life cycle.27–29 Eating in the absence of hunger occurs during emotional eating and when food is readily available.11,12,30 Higher scores on the PEMS have been linked with larger BMIs suggesting that women with larger BMIs often eat for hedonic reasons instead of hunger.20,21,31 This contradicts what the PEMS found in this study. The PEMS has been validated only in young college students and may not be appropriate to use with less educated, low-income, or middle-aged or minority populations. Consuming food because of its availability rather than hunger has been positively correlated with BMI and food insecurity.12,26,32 Similarly, W-O/O discussed eating in the absence of hunger when food was available.
Another possible reason for eating in the absence of hunger would be eating for pleasure rather than hunger, as the results of this study indicated. The W-O/O discussed how much they enjoyed eating and that sometimes they ate for pleasure, even though they were not hungry. Because eating is pleasurable, it was difficult for W-O/O to stop eating; a problem often observed in the overweight population.7,9 This lack of control leading to overeating could be due to weakened satiety signals in individuals who are overweight or obese, or because external environmental factors overcome internal satiety cues.33,34 Eating behaviors that could lead to obesity, such as overeating, and eating in the absence of hunger were discussed by W-O/O in this study.
This study also found that health influences eating and exercise habits based on BMI. The W-L/N consumed fruits and vegetables and exercised to maintain a healthy weight and avoid diseases. Other research indicated that women who were lean or normal weight were more health aware, which reflected in their eating choices.7,9,10,14 Research has also indicated cost as a barrier to eating healthy foods for women who were overweight or obese but less for women who were lean or normal weight.7,9 Furthermore, research has found adults who are overweight or obese to be more sedentary than adults who are lean or normal weight.9,35,36 Food choices and activity levels appear to be influenced by health benefits based on BMI status and could contribute to the differing BMI statuses among participants.
Women also had different stress-coping mechanisms based on weight status. Most W-L/N reported losing their appetite and eating less during stress. Dammann and Smith8 also found that African American women with lower BMIs tended to lose weight during stressful times. Results from this study indicated that these women performed nonsedentary activities to cope with stress including working out or walking. In contrast, W-O/O used food or sedentary activities to cope with stress. They often described themselves as emotional eaters. Depressed, low-income women are particularly at risk for using food to cope with negative emotions as emotional eating has been linked to depressed, low-income women.37 Other research has reported overeating as a coping mechanism and that emotional eating was common among women who were overweight or obese.7–10,13 Similarly, higher scores on the PEMS for the coping category have been associated with larger BMIs.20,21,31 Other common ways W-O/O coped with stress were with sedentary activities such as sleeping, lying down, watching TV, or praying. These different coping mechanisms may help explain the difference in BMIs seen in these participants.
These data suggest that perceptions about causal factors for obesity differ by weight category. Most W-L/N saw body size as modifiable and attributed body size to lifestyle choices, including choices about food intake and physical activity. However, W-O/O felt that body size was mostly influenced by factors beyond their control such as metabolism, genetics, medication, depression, and stressful situations, and that eating habits and physical activity had little to do with body size. Dressler and Smith9 found that women from both BMI categories believed that genetics greatly influenced body size, whereas Lin et al38 found that low-income women who attributed body size to genetics had larger BMIs, consistent with the findings of this study.
In conclusion, this study adds to the literature by comparing the eating behaviors, reasons for consuming highly palatable foods, and taste preference among low-income African American W-L/N and W-O/O using focus group methodology, PEMS, and a taste test. The results suggest that problematic eating behaviors such as overeating, constantly thinking of food, and eating in the absence of hunger are common among W-O/O and a lifelong problem. Ways of handling stress and exercise habits were also different among W-O/O and W-L/N. The W-L/N might have been overweight at some point but most reported having no weight problems making comments such as, “I have always been on the skinny side....” Preferences and eating habits could be a result of previous behavior change. Although participants were not specifically asked about previous weight trends, the open discussion allowed for some insights around past weights. The W-O/O often discussed always struggling with weight or with their weight yo-yoing, whereas W-L/N did not. The PEMS results of this study contradicted what was said in the focus groups and other studies that have used PEMS. This difference could be from a difference in sample population. The PEMS may not be culturally appropriate for African Americans, low-income populations, or middle-aged women as this scale has been validated only with college students. Further research is needed to know whether the PEMS is valid to use in minority populations, middle aged populations, and less educated populations. Findings from this study are insightful to obesity and eating behavior research, but some limitations exist. The results may not be generalizable to the entire population because only African American women in the area participated.
Findings from this study indicated that problematic eating behaviors that may lead to obesity seemed to be more prevalent in W-O/O than in W-L/N; however, how to stop these eating behaviors is still uncertain. Stopping such eating behaviors is crucial because these behaviors lead to weight gain and unhealthy relationship with food. Furthermore, parents can play a large role in children's eating behaviors.39 Therefore, problematic eating behaviors such as overeating or stress eating can be learned by children from parents, putting children at risk for unhealthy eating behaviors and becoming overweight as an adult. Simply teaching these individuals to avoid such eating behaviors and listen to internal hunger cues rather than external environmental cues has not been effective as 1 review suggested that only 20% of individuals who successfully lose weight are able to maintain that weight loss for a year,40 and patients are more likely to regain more weight with time.40,41 This suggests that different methods of treatment are needed for individuals with obesity.
Perhaps other treatments are needed to assist individuals with obesity control their weight. The weight control registry could be helpful to individuals with obesity. This program could give insight to how certain individuals managed to keep weight off long term. A study of the weight control registry showed that weight regain was associated with decreases in leisure time caloric expenditure and self-weighing frequency, and those with a longer history of weight maintenance were more likely to participate in long-term follow-ups.42 This could indicate that long-term behavioral changes and follow-ups may help individuals control their weight.
One other method of treatment to consider would be to help these individuals manage internal hunger/satiety signals using drug therapy to alter the brain's reward system. However, current research regarding drug therapy has not been successful. Medications such as rimonabant, taranabant, and topiramate have been shown to help individuals lose weight but cannot be used because of adverse health effects including psychiatric and gastrointestinal issues,43,44 indicating the need for further drug-therapy research.
Furthermore, this research explores eating and exercise behaviors in a low-income African American community where health disparities such as a larger percentage of obesity are common. This research suggests differences in eating and exercise behaviors among W-L/N and W-O/O. Future research may focus obesity prevention programs that look further into these differences among W-L/N and W-O/O and ways W-L/N are able to remain at a healthy weight in a community where healthy weights are less common. Further research can also search for ways to incorporate ways W-L/N use to remain at a healthy weight into W-O/O lifestyles. Also, more research is needed to learn how to avoid obesity in the general population and how to help individuals with obesity focus on internal satiety cues through drug or behavioral therapy to control their weight.
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