The Appalachia describes a region of the continental United States that includes 420 counties in 13 states and home to over 25 million people (ARC, 2017). This region is generally considered to be disadvantaged due to the dearth of human, financial and technical resources that impact on social determinants of health in the region (ARC, 2017). This disadvantage has been attributed to the geographical isolation, low household income, declining tax base and disproportionate social and economic distress in the region (ARC, 2017). The region has a majority non-Hispanic white population with African Americans constituting a minority of 9.1% of the population (ARC, 2017).
Obesity is an ongoing epidemic in the United States with an estimated 39.8% (2 in 5) American adults said to be obese (Fryar, Carroll, & Ogden, 2018). This worrisome obesity rate is even worse among African Americans with an age-adjusted obesity rate of persons older than 20 estimated at 48%.(Speaks, 2016) This epidemic is particularly worse in African American women with 56.5% prevalence. (Speaks, 2016) Also, the proportion of obese adults was higher in Appalachia than what is seen in the rest of country (Beatty et al., 2019). This should not come as a surprise given the poor social determinants in the region.
Obesity has been identified as a risk factor for cardiovascular, endocrine, musculoskeletal conditions and cancers (Pi-Sunyer, 2009; Kinlen, Cody, & O’Shea, 2018). It should then come as no surprise that African Americans are more likely to die from heart disease and cancer than non-Hispanic Whites with lower obesity prevalence (CDC, 2019). While there are documented numbers for African American obesity prevalence and its complications in the US, it however seems there is a dearth of data when it comes to African American obesity in the Appalachia. A 2019 Kentucky report indeed showed higher obesity rates among blacks compared to other races. Given the poor social determinants in the Appalachia and the overall adult obesity rates in the Appalachia, it may be safe to infer that African American obesity likely mirrors the national picture and the Kentuckian study and may even be worse.
Unfortunately, the burden of obesity also comes with great cost both to the individuals and the community. Given the already disadvantaged socioeconomic position of African Americans and more so in the Appalachia, further expenses on healthcare costs associated with obesity worsens the group’s socioeconomic standing with attendant consequences.
Determinants of African American Obesity in the Appalachia
While the African American race is an independent determinant of obesity (Lincoln, Abdou, & Lloyd, 2014), other social factors have been established as contributors to obesity. These social factors include poverty as determined by low income, low educational attainment, unemployment (Noonan, Velasco-Mondragon, & Wagner, 2016). On all these indices, African Americans in the United States do not fare well and this is also likely to be the picture in disadvantaged Appalachia especially given the abysmal picture of these social factors in the Appalachia.
To put things into perspective, although we do not have numbers for African Americans in the Appalachia, the numbers for the Appalachia in general will make one infer that the national picture may even be worse in the Appalachia where the median household income is estimated as just 83% of the US average, poverty in the region is about 16.3% poverty rate compared to 14.6% US average and just over 25% of Appalachian adults aged 25-64 have a bachelor’s degree compared to the US average of 32% (Pollard & Jacobsen, 2019). With poverty comes the inability to eat healthy which is one of the contributing factors to obesity. Educational attainment has a direct relationship with income, therefore, the low earning power of African Americans might be partly explained by lower educational attainment which itself is a determinant of obesity.
Asides social factors, environmental factors may also contribute to the obesity epidemic among African Americans in the Appalachia. African Americans live in poor neighborhood with the highest rates of homicide that reduces the likelihood of engaging in beneficial outdoor exercise around the neighborhood because of safety concerns. Worse still, these neighborhoods are often food deserts without easy access to supermarkets that sell fresh and healthy foods (Gaskin et al., 2014).
Certain cultural norms have been reported of the Appalachia that might contribute to health inequities among African Americans in the region and one of such norm is the fatalistic outlook among Appalachians (Deskins et al., 2006). A whooping thirty percent of African Americans believe that their health is dependent upon fate(Noonan et al., 2016). This cultural belief of health linked to fate coupled with the distrust of formalized medical systems which is also an entrenched culture in the Appalachia will impact health-seeking behaviors negatively.
Having identified the social, environmental and cultural factors that contribute to obesity epidemic in African Americans in the Appalachia, interventions specifically designed to address these determinants will help reduce the obesity burden in this population.
Of the papers reviewed during this literature review (Martinez et al., 2016; Lin et al., 2015; Rodney P. Joseph et al., 2015; R. P. Joseph, Casazza, & Durant, 2014; Wilbur et al., 2008; Kim et al., 2008; Whitt-Glover, Hogan, Lang, & Heil, 2008; Parker, Coles, Logan, & Davis, 2010; Goldfinger, Arniella, Wylie-Rosett, & Horowitz, 2008), social cognitive theory was mostly used as the health behavior theory underlying these interventions. although other theories like the health belief model (HBM), socio-ecological model (SEM), transtheoretical model and self-regulation theory were also used but to a lesser extent.
The application of the social cognitive theory in obesity interventions should not be surprising given the theory’s emphasis on the dynamic interactions between the person, environment and the behavior which are all factors that particularly contribute to obesity as highlighted under the determinants of obesity in the previous paragraph. Another observation from the review was the use of faith-based interventions and participation of more women. Both findings should come as no surprise given that African Americans are considered the most religious of US races (David, 2018)