Obesity in Urban America
1.Country of choice (5 points)
During the past three decades, the United States has witnessed a dramatic increase in the prevalence of obesity, which has become a public health crisis (US Department of Health and Human Services, Public Health Service 2001, Ogden, Carroll, Curtin, et al. 1999 –2004).
Obese persons have an increased risk for diabetes, (Marmot, 2005), cardiovascular disease, (Kim, Millen, Gershamn, Irwin 2000) cancer, (Tarlov 1996) and mortality (WHO 2007, Summary of proceedings 2006). Obesity and overweight rates are increasing rapidly in the United States (Berkman, Kawachi, 2003, Kawachi, Berkman 2003). In 2000, approximately 20.1% of the adult population was obese and 36.7% was overweight. Similarly, the current National Health and Nutrition Examination Survey (1999–present) found that the percentage of obese adults increased from 22.9% between 1988 and 1994 to 30.5% between 1999 and 2000 (McCarthy 2000). Childhood obesity rates also increased between 1988 to 1994 and 1999 to 2000 from 7.2% to 10.4% among children aged 2 to 5 years (Marmot, Wilkinson 2006).
The southern states were the first to have more than 20% of their adult populations obese, higher rates of obese and overweight adults have spread to all areas of the country (Davis, 2006, Edelman, Mitra 2006). Many of the metropolitan areas that have the highest levels of urban sprawl are located in the South.
This suggest the first links between levels of urban sprawl and the risk for being obese or overweight.
Urban sprawl: is often loosely defined, and complicating these definitions is confusion among causes, consequences, and attributes of urban sprawl. Urban sprawl is idefined as an overall pattern of development across a metropolitan area where large percentages of the population live in lower-density residential areas. The causes of urban sprawl are not well identified but include affluence that enables households to purchase larger houses on larger lots, cultural values that reject urban living and emphasize automobile use, inexpensive land values that support urban sprawl–dependent lifestyles, and government policies that promote urban sprawl (McLafferty, Grady 2005, Last 2001, Collins 2004).
Overweight and Obesity: Obese or overweight status is usually determined by the body mass index (BMI) formula (weight in kilograms divided by height in meters squared); adults are considered overweight when their BMI is greater than 25 and obese when their BMI is greater than 30 (National Institutes of Health (NIH) 1998, Willett W, Dietz W, Colditz G 1999). BMI was calculated with respondents’ self-reported heights and weights.
ll- Public health inequity (5 points)
Creating health equity is a guiding priority and core value of American Public Health Association (APHA). By health equity, we mean everyone has the opportunity to attain their highest level of health. How do we achieve health equity? We address the conditions in which people are born, grow, live, work, learn and age. These social determinants of health are shaped by the distribution of money, power and resources that include employment, housing, education, health care, public safety and food access (Braveman 2011). Inequities are created when barriers prevent individuals and communities from accessing these conditions and reaching their full potential. Inequities differ from health disparities, which are differences in health status between people that are related to social or demographic factors such as race, gender, income or geographic region. Health disparities are one way we can measure our progress toward achieving health equity.
lll- Relationship between Country and Public Health Inequity (10 points)
Health inequalities in the United States as a nation are the worst of all wealthy developed countries: Americans die younger and suffer worse health than people in over 30 other nations. The situation is not improving despite enormous expenditures on medical services, with the US paying close to half of the world’s health care bill. The reasons for these health inequalities relate to the political economy of the nation, rooted in its founding history and overlaid with recent changes wrought by neo-liberalism. Sixty years ago the nation was one of the world’s healthiest, but as a consequence of political choices that have increased the wealth of a few, everyone’s health has suffered. The US provides many lessons for other countries that want to avoid this health catastrophe.
lV – Description of Social Determinants of Health in the country
(list at least four social determinants of health in that country you selected. Please be very specific (10 pt.);
The complex, integrated, and overlapping social structures and economic systems that are responsible for most health inequities. These social structures and economic systems include the social environment, physical environment, health services, and structural and societal factors. Social determinants of health are shaped by the distribution of money, power, and resources throughout local communities, nations, and the world (Commission on Social Determinants of Health 2008).
Determinants of Health
The social determinants of health as well as race and ethnicity, sex, sexual orientation, age, and disability all influence health. Identification and awareness of the differences among populations regarding health outcomes and health determinants are essential steps towards reducing disparities in communities at greatest risk.
Factors that contribute to a person’s current state of health. These factors may be biological, socioeconomic, psychosocial, behavioral, or social in nature. Scientists generally recognize five determinants of health of a population:
Physical environment. Examples: where a person lives and crowding conditions
Social environment. Examples: discrimination, income, and gender
Biology and genetics: Examples: sex and age
Health services. Examples: Access to quality health care and having or not having health insurance
(Preamble to the Constitution of the World Health Organization, U.S. Department of Health and Human Services 2009).
V- Explanation of Specific Health Determinants (40 points)
A full understanding of the role of the urban environment in shaping the health of populations requires consideration of different features of the urban environment that may influence population health. The study of the social determinants of health (SDH) is embedded in the recognition that the solutions to poor health, material deprivation, lack of access to health care, clean water, sanitation, and the like are not simply alleviated with the provision of resources or technical assistance (Marmot 2005) Rather, it is the understanding that when available, access to resources and technical assistance is often socially determined (Kim, Millen, Gershman, Irwin, 2000).
The focus of this paper will be SDH in urban settings. In simplest terms, social determinants are, the social characteristics in which living takes place (Tarlov 1996). The determinants include unemployment, unsafe workplaces, urban slums, globalization and lack of access to health systems (WHO 2005) SDH also include social factors such as place of residence, race and ethnicity, gender, and socioeconomic status (Summary of proceedings 2006).
1-Social determinant 1 and health inequity: Physical environment
Place of residence and an individual’s status within the place are important determinants of health in urban settings. Industrial activity can have significant impact on cities with respect to pollution, and less expensive housing is often found in areas with less desirable physical environments. Natural and manmade disasters have also affected health in neighborhoods (e.g., environmental pollutants in lower Manhattan after 9/11), cities (e.g., methyl isocyanate gas in Bhopal, India), and regions (e.g., 2004 Indian Ocean tsunami, Hurricane Katrina).
It is important to recognize that the place of residence is situated within a particular social milieu that can have substantial impacts on health in terms of exposure and access to care. Slum dwellers are often a particularly vulnerable group for a variety of reasons including precarious or nonexistent land tenure, (Davis 2006) lack of urban resource infrastructure (Edelman, Mitra 2006) and tenuous relationships with governments and law enforcement (Davis, 2006). Immigrants living in ethnic enclaves within cities may have different experiences than immigrants living in areas in which they are among the minority, or there is no majority. For example, a study of immigrant mothers in New York City (USA) noted substantial differences in geographical access to prenatal clinics by country of origin.
2-Social determinant 1 and health inequity: Social Environment
Race and ethnicity are constructs that classify population groups based upon economic, social, cultural, behavioral and biologic factors (Last 2001) there are no generally agreed upon definitions, (Collins 2004) and the terms are often used interchangeably ( National 2005). The associations between race/ethnicity and health are complex and often multifactorial. Some population groups are more likely to have specific diseases because of allelic inheritance (e.g., Tay Sacks disease among Ashkenazi Jews). In other cases, differences in rates of disease among groups are related to differences in likelihood of exposure or access to care.
Racism is discrimination based on race or ethnicity. Racism can affect heath by restricting access to material resources; educational, economic, and occupational opportunities; and health and social services (Williams 2003). It has also been hypothesized that stress resulting from experiencing racism is associated with health outcomes (Williams, Neighbors HW, Jackson 2003, Tull, Sheu, Butler, Cornelious 2005).
3-Social Determinant 1 and health inequity: Biology and genetics
The examination of gender as an SDH is not simply the comparison of disease and exposure for women vs men. Gender moves beyond the biology of being male and female and focuses on the roles and norms of men and women in a given society (Phillips, 2005). When thinking about gender as an SDH, it is important to distinguish between women’s and men’s health (restricted to women and men, respectively, and focusing on their particular health needs) and the role of gender as a social construct that shapes personal health behaviors and health-related societal structures.
When gender is considered in the context of SDH, this generally refers to women’s social position in society and reduction of gender inequalities in health outcomes, access to health services, access to educational and employment activities, etc. The need for gender equality and women’s empowerment has been a key focus in the global response to HIV/AIDS as underscored by recent language in the United Nations General Assembly Special Session (UNGASS) 2006 resolution (Political, 2006) which pledged to eliminate or reduce gender inequalities, gender-based abuse, violence, and discrimination and increase the capacity of women and adolescent girls to protect themselves from the risk of HIV infection.
The SDH are key to understanding the way in which cities affect the health of populations. SDH are important, generally, yet, can have different effects in different settings from urban to rural, between countries, between cities, and within cities.
4- Social Determinant 1 and health inequity:
Access to health and social service: Persons of lower socioeconomic status and minority populations are more likely to live in urban areas and are more likely to lack health insurance (Merzel). Thus, these populations face barriers to care, receive poorer quality care, and disproportionately use emergency systems. Other commonly represented populations in cities are undocumented immigrants and transient populations. The high prevalence of individuals without health insurance or citizenship creates a greater burden on available systems. This often leads to vast disparities in health care outcomes as well as a two-tiered health care system where insured individuals have access to preventive and routine health care while marginalized populations utilize “safety-net” emergency room care.
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Vl. Explanation of Association Between the health (30 points)
1.The association between health literacy and health inequity using epidemiologic studies only
Health literacy is a complex phenomenon that involves skills, knowledge, and the expectations that health professionals have of the public’s interest in and understanding of health information and services. Health information and services are often unfamiliar, complicated, and technical, even for people with higher levels of education. People of all ages, races, incomes, and education levels—not just people with limited reading skills or people for whom English is a second language—are affected by limited health literacy. According to research from the U.S. Department of Education, only 12 percent of English-speaking adults in the United States have proficient health literacy skills. The impact of limited health literacy disproportionately affects lower socioeconomic and minority groups (Kutner, Greenberg, Jin, & Paulsen, 2006).
2. The association between cultural awareness and health inequity using epidemiologic studies only.
Results of the 2010 U.S. Census suggest that as the growth of Black, Hispanic and Asian ethnic groups continues to accelerate, there will be a “minority majority” as early as 2042, when Hispanics (of any race) will comprise 24 percent of the population, Blacks 15 percent and Asians 8 percent (United 2000-2050). This majority of racial/ethnic minorities will occur even earlier (2023) among children and adolescents (United 2000-2050). Addressing their health needs, especially in the face of growing evidence of continued and severe health disparities for many racial/ethnic groups, is challenging for health care and public health. Knowledge of the range and complexity of health disparities has evolved as a result of data collection on race and ethnicity in epidemiologic surveillance and research (Ruffin, 2010).
In addition, epidemiologists have long been involved in policy efforts to address health disparities beyond the conduct, analysis, interpretation and dissemination of health data. These efforts have included preparation of governmental reports (Malone, Center for Disease Control 2012, U.S. Department of Health Human Service 2012), managing policy offices (U.S. Department of Health & Human Services. The Office of Minority Health 2012), identifying priorities for initiatives (Clinton, U.S. Department of Human Services 2020, U.S. Department of Health & Human Services.2012), and providing policy guidance (Office of Management).
3.The association between life expectancy in the country you selected and the health inequity using epidemiologic studies only.
Obesity is associated with an increased risk of death. Adams et al. estimated the risk of death in a prospective cohort of more than 500,000 U.S. men and women after 10 years of follow-up, and reported that, among patients who had never smoked, the risk of death is increased by 20% to 40% in overweight patients and by 2- to 3-fold in obese compared with normal-weight patients (Adams, Schatzkin, Harris et al. 2006).
Obesity is also associated with increased a numerous chronic diseases, including diabetes, hypertension, heart disease, and stroke (Field 2001). Furthermore, obesity is linked to several digestive diseases, including gastroesophageal reflux disease (GERD) and its complications (e.g. erosive esophagitis, Barrett’s esophagus and esophageal adenocarcinoma), colorectal polyps and cancer, and liver disease (e.g. non-alcoholic fatty liver disease, cirrhosis and hepatocellular carcinoma) (American College).
Because of the increased risk of death and the increased risk of costly chronic diseases associated with obesity, the obesity epidemic places a large financial burden on the economy. The U.S. Department of Health and Human Services has estimated the total economic cost of overweight and obesity in the United States to be close to $117 billion using data from 1995, updated to 2001 dollars (Niddk). However, because the prevalence of overweight and obesity has increased since 1995, the costs today are likely to be considerably higher than previous estimates. Trogdon et al. estimated that the total indirect cost was $65.67 billion in the United States for 1999, based on data from a systematic review (Trogden). A recent study by Finkelstein et al. projected the annual medical spending due to overweight and obesity approached $92.6 billion in 2002 (Finkelstein 2004), or about 9% of US health expenditures.

Vll- Description of Two current efforts in the country to reduce health inequities (20 points).
Effort 1: For decades, Tennessee’s childhood obesity rates have steadily increased, while equity gaps between Black and White children widen. In Tennessee, 43.9 percent of African American children are obese compared with 21.1 percent of White children (Tennessee Department of Education 2008-2009). To address childhood obesity, the NAACP Tennessee State Conference developed an advocacy action plan that expands existing competitive foods guidelines in Jackson-Madison and Haywood County School Districts.
Effort2: Nutrition assistance programs can help lower-income families gain access to more affordable food and provide information about healthy eating. In 2011, more than 3.9 million African American families received SNAP benefits, (U.S. Census Bureau 2011) and, as of 2012, 20 percent of women and children enrolled in the WIC program were African American (WIC Programs 2012). Programs such as SNAP-Ed, a partnership between USDA and the states that provides education to help families learn how to eat healthier within a limited budget, and revisions to the WIC food packages that include healthier options, have resulted in increased consumption of more nutritious foods among participants (Food Research and Action Center 2013, Bridging the Gap and Salud America 2003).
Vlll- Explanation of development of health policy (20 point) It is likely that reducing obesity will require policy changes that improve the food and physical activity defaults for all Americans, not just targeted individuals. Some environmental policies such as physical activity promotion and efforts to improve access to healthy foods are unlikely to meet resistance. However, recent experience suggests that implementing some of the policies with the greatest potential benefit public health will be politically difficult

A great deal of work is occurring on obesity prevention policies, including nutrition policies in schools, policies to encourage consumption of water in lieu of sugared beverages, changes in zoning laws to change the food landscape, and programs to improve the built environment. Here, we discuss 2 areas that have been identified as strategies(Gortmaker,Swinburn, Levy, Mabry, Finegood et.al 2011, Vos, Carter , Barendregt, Mihalopoulos, Veerman et.al 2010. Sassi , Cecchini , Lauer, Chisholm. 2009) for cost-effective population-level change: taxe on sugary drinks and restrictions on marketing to children.
1-Factors to take into consideration
Obesity is caused by a complex interaction between the environment, genetic predisposition, and human behavior.
Factors 1 Environmental factors are likely to be major contributors to the obesity epidemic. It is certain that obesity develops when there is a positive imbalance between energy intake and energy expenditure, but the relative contribution of these factors is poorly understood. Evidence supports the contribution of both excess energy intake and decreased energy expenditure in the obesity epidemic (Kant, Graubard, 1971 -1975, Prentice, Jebb 1995). Kant et al. used dietary data from four consecutive NHANES studies consisting of 39,094 adults in the United States to show that the temporal trends in the increase of the quantity and energy density of foods consumed by adults parallel the increasing prevalence of obesity in the U.S. population (Kant, Graubard, 1999-1975). Data from the Central Statistical Office show that car ownership and television viewing, proxy measures of physical inactivity, closely parallel the rising trends in obesity in England (Prentice, Jebb, 1995). Using data from NHANES, Dietz et al. demonstrated that the prevalence of obesity increased by 2% for each additional hour of television viewed (Dietz, Gortmarker, 1985).
There is also evidence that the relative availability and price of different food products affect food consumption, (Holsten, 2008), and that the built environment, such as quality of local parks, affects the level of physical activities in a community (Kipke, Iverson, Moore, 2007). These findings not only emphasize the impact of environmental factors on the obesity epidemic but also indicate that policies affecting the availability of high-caloric-density food, the cost of fruits and vegetables, and the built environment may contribute to the obesity epidemic.
Factors 2- In addition to environmental factors, there is genetic predisposition to obesity. It is known that single gene mutations are responsible for rare forms of monogenic obesity (leptin (LEP), leptin receptor (LEPR), melanocortin-4 receptor (MC4R), and pro-opiomelanocortin (POMC)) (Andreasen, Andersen, 2009). However, there is growing evidence that common genetic variants or single-nucleotide polymorphisms (SNP) may play an important role in the obesity epidemic. These SNPs have modest effects on an individual susceptibility to common forms of obesity, but due to their high frequency, they can have a large contribution to obesity on the population level (Tiret, Poirier, Nicaud, et al 2002). Frayling et al. was the first to use a genome-wide association (GWA) study to identify a SNP located in the fat mass and an obesity-associated gene (FTO) that is associated with an increases risk of common obesity (The finding that the FTO gene variant is a risk factor for common obesity has now been replicated in multiples studies ( Hunt, Stone, Xin, et al, 2008, Haupt, Thamer, Machann et al 2008, Andreason, Stender-Petersen, Mogensen, et al 2008). . FTO was initially identified in a GWA study to be associated with an increased risk of type 2 diabetes mediated through an effect BMI. In a GWA study of 38,759 patients, Frayling et al. found that a person who is homozygous for the risk allele (rs9939609 A allele) had a 1.67-fold increased odds of obesity when compared with those who do not have the risk allele (Frayling, Timpson, Weedon, et al 2007).
Factories 3- There is growing recognition that social networks may have an important role in the obesity epidemic. Christakis et al., explored the hypothesis that obesity may spread through social networks by evaluating an interconnected social network of more than 12,000 people from the Framingham Heart Study to examine the effects of weight gain among friends, siblings, and spouses (Christakis, Fowler 2007). They found that a person’s risk of becoming obese increased by 57% if a friend became obese. The association was smaller among siblings and spouses: the risk of becoming obese increased by 40% and 37% if a person had a sibling or spouse who became obese, respectively (Christakis, Fowler 2007). By exploring the role of social networks and obesity, this study showed that the obesity epidemic is affected by the complex interaction between the environment, genetic factors, and human behavior (e.g., passive permission).
*Cultural: design and development

(THIS IS ESSAY WORTH 60 POINTS)

To help reduce health disparities, culturally appropriate and relevant health promotion programs are needed for ethnically diverse populations to improve health behaviors and promote participant recruitment, engagement, and retention (Bender & Clark, 2011). Culturally appropriate obesity interventions are shown to be effective in improving health behaviors within diverse communities (Deitrick et al., 2010; Haire-Joshu et al., 2008). In contrast, culturally inappropriate interventions can be ineffective, perplexing, or offensive (Marin, 1993).
Designing culturally appropriate intervention programs requires cultural sensitivity, taking into account the ethnic/cultural characteristics of the target population. This includes cultural values, beliefs, and behaviors; social dynamics and family structure; literacy and education level; and economic status and the built environment (Bender & Clark, 2011).
What is Culture and Cultural Competence?
All people are cultural beings. Culture is learned, shared, and transmitted from one generation to the next, and it can be seen in a group’s values, norms, practices, systems of meaning, ways of life, and other social regularities (Kreuter et al., 2003). Familial roles, communication patterns, beliefs relating to personal control, individualism, collectivism, spirituality and other individual, behavioral, and social characteristics may help define culture for a given group if they have special meaning (Kreuter et al., 2003). Cultural competence is defined in many different ways: some think of it as cultural sensitivity while others speak of anti-bias and still others consider it a cross-system, comprehensive approach which embeds culture into care. Most descriptions contain common threads, including the ideas that developing cultural competence is a process; culture is learned; and self-awareness is critical.
Improving health behaviors may be less effective if investigators disregard the need for cultural adaptation or inadequately adapt interventions (Marin, 2006). Some ethnic groups may perceive culturally inappropriate interventions as confusing, irrevant, and/or offensive (Castro, Barrera, & Martinez, 2004; Marin, 2006), resulting in less participant engagement, compliance, and retention.
Given the wide variability within and among cultural groups, investigators may not have the cultural competence to effectively adapt an intervention for a particular ethnic group. For example, African American and Hispanic designations consist of multiple distinct subgroups defined not only by race, but also by regional, national, and continental origin (Kreuter, Lukwago, Bucholtz, Clark & Sanders-Thomason, 2003; Office Of Minority Health, 2009), such as Puerto Ricans and Columbians. Clinicians and investigators have expressed limited awareness of published guidelines for culturally adapting interventions and translating materials (Cluss et al., 2010; Sanders Thompson et al., 2008), supporting the need for standardized guidelines.
Development of culturally equivalent versions of original measures (e.g., surveys, questionnaires, and interview guides) is needed to accurately determine the effectiveness of interventions with different cultural groups (Castro et al., 2004). Simply translating a measure verbatim into the ethnic group’s dominant language is insufficient for adapting key constructs, concepts, and content, thus invalidating the measure (Ramirez, Ford, Stewart, & Teresi, 2005; Martinez, Ainsworth, & Elder, 2008). Diverse ethnic populations differ in cultural perspectives, and many original constructs and concept measures may not be commonly shared or understood unless they are appropriately translated (Castro et al., 2004).
Translated instruments should be: (a) equivalent to the original instrument; (b) culturally, conceptually, and contextually relevant for the intended audience; and (c) reliable and valid. Invalid measures (do not reflect original concepts) and unreliable instruments (inconsistent across settings) (Creswell 2009) may bias results, leading to irrelevant, ineffective, and financially wasteful policies and health services for ethnic minority groups (Davidson & Knafl, 2006; Ramirez et al., 2005).
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