Unique perspectives on the obesogenic environment.

We all live in an obesogenic environment. 1 The availability of high energy dense, palatable, inexpensive food is only surpassed by the mechanized labor-saving and entertainment devices designed to keep us from moving too much. We have evolved from a society of hunter–gatherers to a society of drivethrough picker-uppers. A number of factors likely determine our responses to the obesogenic environment, including level of exposure, resources available, and our biologic predisposition to energy imbalance. Despite the individual variation in these factors, certain patterns of obesity prevalence have developed over time, with a higher prevalence being noted in African American women. Reasons for a seemingly higher susceptibility of African American women to the obesogenic environment are unclear; equally unclear are the reasons for their differential response to treatment. Papers in this issue of the Journal of General Internal Medicine by Lynch et al. and Barnes et al. identify factors that influence African American women and their interaction with the obesogenic environment. 2,3 The perspective provided by each group, from examining attitudes about bariatric Surgery to struggles related to weight maintenance, is a unique contribution to the literature. Lynch et al. identified themes of lack of time and access to resources, issues regarding control, and identification with a larger body size. Women also expressed fears and concerns about the effects of bariatric Surgery and held perceptions that surgical treatment for obesity was an extreme measure. 2 Barnes et al. reported that a key difference between African American women who maintain a significant weight loss and those who regain weight may be their individual ability to counter the environment of home, family, and friends that appears to be additive to the obesogenic environment. 3 Are these barriers unique to African Americans or is it the response to these barriers that is unique? For example, most people might agree that lack of insurance coverage is a barrier to weight management because health insurance usually will not pay for weight control services. This barrier seems to be less specific to African American women and, at some level, could be considered a part of the overall obesogenic environment. It is important however, to consider the sociocultural context through which this barrier may be perceived by African American women. Some of our recent work suggests that African American and white women have distinctly different perceptions of how they should deal with their weight based to a significant degree on their racial identity. 4 African American women routinely suggested that their cultural environment was permissive for, and in many instances even promoted, weight gain (Fig. 1). Conversely, white women suggested that they consistently receive prompts to be thin because thinness is highly valued by members of their racial group. The sociocultural context is important to consider because it provides the lens through which the barrier is perceived by the individual and influences the response to that barrier. Therefore, the lack of insurance coverage for weight control services is perceived in the context of limited personal resources to dedicate to weight loss and a general sense that other members of the African American community do not necessarily value thinness. Balanced against other financial responsibilities and a low perceived value for the investment, losing weight using one’s personal resources becomes low on the priority list. Therefore, it is likely that the barrier is uniquely perceived, and the response to that barrier is partially a function of that unique perspective. Appreciation of the unique perspective of African American women is a key concept shared between the articles in this edition of the Journal of General Internal Medicine. While achieving a lower body weight may be important at an individual level for a given African American woman, many of the cultural norms African American women identify with suggest that being “skinny” is not truly critical to one’s happiness, health, and personal sense of well being. As a result, the energy required to overcome the initial inertia associated with challenging the obesogenic environment is significantly increased. At this point, the increased effort required to make or sustain the behavior change appears daunting, while conversely, a response that is similar to that of other members of the group would result in a sense of belonging and identity. This sense of group identity is particularly important because being a member of an ethnic minority group limits the opportunities for identifying with a wider array of groups, particularly outside of the racial boundaries. Going against the perceived cultural norms within the ethnic minority group can make one even more of a “minority.”