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Esa M. Davis, MD, MPH, Jeanne M. Clark, MD, MPH, Joseph A. Carrese, MD, MPH, Tiffany L. Gary, PhD and Lisa A. Cooper, MD, MPH

Esa M. Davis is with the Department of Family Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio. Jeanne M. Clark, Joseph A. Carrese, and Lisa A. Cooper are with the Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Md. Jeanne M. Clark, Tiffany L. Gary, and Lisa A. Cooper are with the Welch Center for Prevention, Epidemiology and Clinical Research and the Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Md. Lisa A. Cooper is also with the Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health.

Correspondence: Requests for reprints should be sent to Esa M. Davis, MD, MPH, Department of Family Medicine–Research Division, Case Western Reserve University, 11001 Cedar Ave, Suite 306, Cleveland, OH 44106 (e-mail: edw6{at}case.edu).

	ABSTRACT

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Focus groups stratified by race and socioeconomic status were used to examine obese women’s experiences with weight-loss methods. Six themes emerged: failure of weight maintenance, use of psychological and spiritual approaches, role of family influences and societal expectations, role of African American subculture, method affordability, and racial differences in weight-loss methods. Tailored weight-management interventions for women, particularly African Americans and those of low socioeconomic status, should account for features of African American subculture and address affordability concerns, include maintenance strategies that incorporate psychological and spiritual principles, and target family attitudes and behaviors.

	INTRODUCTION

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The disproportionate obesity burden among African American and poor women is well documented, yet weight management has been particularly challenging in these high-risk populations.^1–4 African American women are less likely to participate in weight-loss programs and are less likely to have weight-loss success.^5–10 Likewise, poor women appear to be less motivated toward weight management.^9,11,12 To help design effective weight-loss interventions, we explored racial and socioeconomic factors influencing obese women’s weight-management practices.

	METHODS

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Race- and gender-concordant moderators led 4 focus groups of obese women sampled from a large employer in Maryland. Focus groups were stratified by race and educational attainment, which was used as a proxy for socioeconomic status (SES). We invited nonpregnant African American and White women aged 20 to 65 years with body mass indices greater than 30 kg/m² to a 90-minute discussion on their past and current experiences with weight-loss practices and how their race, social class, and educational level affected personal weight-management efforts.

Audiotapes were transcribed verbatim, and participants’ names were replaced with codes. We coded the transcripts according to concepts of grounded theory.^13,14 Two investigators independently read each transcript in its entirety and marked distinct comments that could be categorized into themes. A third investigator adjudicated differences in theme assignment between the first reviewers. Themes and comments underwent independent second review for relevancy and consistency by 2 other investigators; this process resulted in consolidation of some themes and separation of others into subthemes. Agreement between first- and second-stage reviewers was 94%. After second-stage adjudication, all reviewers agreed on the final taxonomy. We used QRS NUD*IST computer software (QRS International PTY Ltd, Melbourne, Australia) to facilitate content analysis and data management.

	RESULTS

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Table 1 shows participants’ sociodemographic characteristics. Among 88 respondents, 53 were eligible, and 27 participated (51% response rate). Participants and nonparticipants did not differ by race, age, education, or body mass index status. Women were mostly nonsmokers (n = 17) and currently trying to lose weight (n=20). Table 2 includes the following 6 major themes and representative quotations.

1. Failure of weight maintenance. All of the women attempted weight loss with various methods, including diets, diet pills, exercise, and alternative methods such as hypnosis and fasting. Most women achieved modest short-term weight loss. Their inability to sustain weight loss was often attributed to minimal weight-maintenance strategies in many existing weight-loss programs. They preferred weight-loss methods that incorporated a weight-maintenance focus to prevent them from weight cycling and relapse.
   
2. Psychological and spiritual approaches. The inability to sustain weight loss over a long period fueled significant negative emotions, including pain, desperation, frustration, and boredom. Women in all 4 groups wanted their emotional and psychological concerns to be remediated in weight-management programs. African American women preferred to have these concerns remediated through spiritual means.
   
3. Family influence and societal expectations. Women believed that their negative feelings about weight management and being overweight stemmed from the influence of their family of origin and from societal standards learned during childhood. White women described receiving societal pressure to be thin and family input that being overweight was unacceptable. Some African American women described being teased about being overweight, but others recalled being pressured by family members to accept being overweight. African American women, like White women, expressed negative body image views that differed from the cultural tolerance of fatness theory attributed to African American women.¹⁵ Both African American and White women believed that the societal expectation of thinness was difficult for them to achieve.
   
4. African American subculture hinders weight management. American cultural support of sedentary lifestyles, excessive food availability, and media influences appeared to make weight loss challenging for all 4 groups. However, African American women in both SES groups identified African American cultural influences, including settings (e.g., church, sorority meetings); cultural food types (e.g., collard greens, fried chicken), preparation, and abundance; and beliefs and expectations about foods (e.g., focus on food in social gatherings) that further complicated successful weight management.
   
5. Affordability concerns limit weight-management efforts. All the groups discussed the expense of weight-loss practices, but the lower SES groups expressed a higher level of cost concern; they believed that affordability limited their weight-management efforts despite their desire to lose weight.
   
6. Racial differences in ideal weight-loss methods. White women emphasized physical activity and did not mention food characteristics, whereas African American women emphasized food characteristics such as taste, texture, and types in their ideal weight-loss method and made no references to physical activity.
   

	DISCUSSION

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These findings have specific implications for weight-management interventions. Our subjects indicated that short-term weight loss is achievable, yet maintaining weight loss is difficult. Most studies, however, focused on short-term weight loss.^7,16–19 Future interventions should emphasize weight-maintenance strategies to prevent weight cycling and relapse. The array of negative emotions described suggests that weight-loss interventions should incorporate behavioral and psychological strategies. Because spirituality appears important to African American women, programs targeting this population might incorporate spiritual messages and methods. Participants’ reports of the influence of negative family input during childhood on weight perceptions suggest that health professionals should encourage adults to provide positive messages to children regarding eating patterns, food selection, and body weight.

Contrary to conventional thinking, African American women in our sample were dissatisfied with being overweight.^15,20–23 A cultural tolerance of fatness has been ascribed to African Americans as a group; however, this study suggested that any one individual’s acceptance of his or her own weight is influenced by internal (e.g., attitudes, social norms) and external factors (e.g., social support, resources to engage in weight-loss practices). As previous studies suggested, cultural settings such as church and cultural beliefs about foods have implications for dietary and lifestyle interventions targeting this population.^16,17,24 A few focus group studies have explored attitudes toward physical activity and eating patterns among mixed groups (weight, age, and gender) of African Americans.^25–27

Our study’s unique focus was obese women’s weight-loss efforts and experiences because weight-reduction treatment is recommended in this group. Our results provided further insights regarding emotional and psychological factors that make weight-loss practices challenging for obese women. Our results also provided insights into the failure of existing weight-loss strategies to facilitate better weight-loss maintenance. The racial differences in ideal weight-loss method components identified in this study should prompt further investigation into factors such as attention to taste and cultural appropriateness of food and hindrances to physical activity for African American women. Finally, creative strategies that educate low SES women on cost-effective ways to eat healthy and engage in physical activity are needed.

This small focus group study may have limited generalizability to other populations and settings. Because our study did not focus on differences in perceptions of acceptable weight between African American and White women, or between low and high SES women, we may have missed some cultural and social perceptions regarding weight and body image. Notwithstanding these limitations, this study found that African American and low SES women desire weight loss and identified opportunities for tailoring interventions for these high-risk populations.

	Acknowledgments

 
This project was supported by grants from the Robert Wood Johnson Foundation (grant # RWJ 038904) and the National Research Service Award (grant # NIH-5-T32-HP10025-09). E.M. Davis was a Robert Wood Johnson Clinical Scholar at Johns Hopkins University at the time this work was conducted. T.L. Gary is supported by a grant from the National Institute of Diabetes and Digestive and Kidney Diseases (U01-DK57149-05S1). L.A. Cooper is supported by a grant from the National Heart, Lung, and Blood Institute (R01-HL6943).

We especially thank our research assistants Rachel Fogel and Susan Shultz for all their hard work in recruitment; our moderators Dr Karan Cole and Bernellyn Cary; and Drs Neil Powe, Leon Gordis, and Kurt Stange.

Human Participant Protection
This study was approved by the Johns Hopkins University institutional review board.

	Footnotes

 
Peer Reviewed

Contributors
E. M. Davis and L. A. Cooper conceptualized the study; acquired, analyzed, and interpreted the data; reviewed the article; and supervised all aspects of study implementation. J. M. Clark helped conceptualize the study, analyzed and interpreted the data, and reviewed the article. J. A. Carrese and T.L. Gary analyzed and interpreted the data and reviewed the article.

Accepted for publication November 16, 2004.

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