Body Image and Modifiable Weight Control Behaviors Among Black Females: A Review of the Literature

Abstract

Black women are at high risk for obesity and obesity-related health problems (1). Nearly 50% of black women compared to 30% of white women are obese (2,3). While many women who attempt to lose weight do so through caloric restriction and/or physical activity, smoking has been identified as an alternate strategy used for weight loss among black women with weight concerns or body image concerns (4). Nicotine's suppression of body weight facilitates initiation and maintenance of smoking among women (5,6,7). Despite the deadly health risks associated with tobacco use, 23.1% of women smoke (8). Female smokers are more likely to report smoking cigarettes to control weight (6,9) and less likely to quit smoking due to weight concern (10). Perkins et al. and Pirke and Laessle note that women tend to suffer more postcessation weight gain than men (as cited in Copeland) (11). Smoking cessation is less likely among women who fear postcessation weight gain or benefit from weight control when smoking. Additionally, women with the intention to control body weight by restrictive eating are more likely to smoke to control appetite and weight (12). Black women tend to have lower rates of smoking cessation and physical activity and higher dietary fat intake (13,14,15). Factors contributing to low prevalence of weight management among black women need to be identified for the development of appropriate interventions. Less reported social pressure to achieve thinness and greater perceived attractiveness at higher body weights may limit motivation for healthy weight management among many black women. The 2003–2008 National Health and Nutrition Examination Survey found weight control through physical activity or dietary change to be positively associated with weight perception (odds ratio women 3.74; 95% confidence interval 2.96, 4.73) (16). Several authors assert that historical black-white differences in ideal female body image (17) and acceptance of overweight (18) may contribute in part to explaining racial differences in weight loss efforts and modifiable weight management behaviors. It has been indicated that black women have a high prevalence of obesity partly because self-image is not strongly dependent on body size (19). Body shape perception often varies by race and gender with blacks generally perceiving their bodies as lighter than indicated by their BMI (20). An understanding of factors such as body image and their relationship to weight loss behaviors is necessary to promote healthier lifestyles. This review investigates the association between body image satisfaction and dietary behavior, physical activity, and smoking as tools for weight control among black women. Due to the paucity of literature focusing solely on black women, this article considers both the experiences of black women alone and with other groups. Studies were identified through computerized searches of biomedical and psychological databases, namely PubMed, CINAHL, Psych Abstracts, Science Direct, and Web of Science and manual searches of article bibliographies focusing on dietary behaviors, physical activity, and smoking/alternative weight control techniques since 1990. Searches were performed on recurring authors and in recurring journals for additional articles on the topics. Variations of the term “body image,” including “body dissatisfaction,” “satisfaction,” and “esteem,” as well as “size,” “shape,” and “weight” were sought. Searches included these terms in combination with the target health behaviors, namely diet, physical activity, and smoking. The search was limited to studies including black or African-American females. We did not restrict our search to only studies that investigated ethnic differences because it is our aim to understand body image as it relates to health behaviors among black women to determine whether it may be a factor to address in designing interventions. We were not specifically investigating racial differences in regards to body image. Additionally, we found that many studies did not distinguish results by race or ethnicity. Thirty-one articles have been cited in this article. The list may not be exhaustive. Some identified articles were excluded for several reasons. Studies investigating dietary disorders were omitted as well as those that did not evaluate body image in association with the health behaviors. Findings and critiques of the remaining articles follow. Over the last decade, several seminal papers have documented the positive association between components of body image dissatisfaction and dieting frequency or dieting status among US adults and adolescents. An accumulating body of research has directly evaluated the relationship between dimensions of body image and dieting behavior or dieting status specifically in black women (see Table 1). Two studies bear mentioning first as findings have acknowledged the importance of identifying potential within group variation among black women with respect to dieting and body image disturbance (see Table 1). Kumanyika and colleagues were among the first to begin to clarify the link between dieting and weight satisfaction in a large sample of black women from the Washington DC community (1). Results showed that less satisfaction with weight and a history of dieting were more likely among the overweight women. Similarly, among black female participants in the CARDIA multisite investigation, a positive relationship between dimensions of body dissatisfaction and dieting for weight reduction was evidenced across BMI tertiles despite women of greater BMI reporting poorer body image (19). It is unclear however, whether results varied by study site. A series of cross-sectional studies assessed body image (using diverse instrumentation) among multiethnic samples of self-identified dieters inclusive of appreciable numbers of black females (21,22,23,24,25,26). In both adults and adolescents few differences in body image disturbance were observed between black and white female dieters (Table 1). This parity was particularly evident when analyses were adjusted for covariates correlated with both dieting status and body image perceptions (e.g., age, BMI regardless of race (21,23,25). Only a few studies to date have examined these relationships including nondieting controls as a comparison (22,24). In one early report, adolescent dieters residing in the Midwest irrespective of race, gender, and actual overweight status typically endorsed more disturbed body image attitudes relative to nondieting peers (24). Similarly, in a more recent investigation conducted in Los Angeles, both black and white adult female chronic dieters exhibiting high dietary restraint reported greater distortions in aspects of body image than nondieting females and male chronic dieters (22). However, these results were not controlled for BMI, age, or socioeconomic status. Another series of cross-sectional investigations compared the relationship between dimensions of body image and dietary restraint/dieting in ethnically diverse groups of black and white adult and adolescent females. Again, it appears that in general, the correlations between these factors are robust independent of age and race in community (22,27,28,29,30) and in-patient (26) samples. Notable exceptions, however, were observed in a few instances where patterns of relationships between indicators of poor body image and dieting behavior differed between women of both racial groups (Table 1 and see refs. 26,28,29). Interestingly, the one investigation in which no significant relationship emerged between components of body dissatisfaction and dieting among black females was conducted in the southern US region (26). A few recent reports have begun to explore the association between measures of body image and various dietary consumption patterns among black females and others (Table 2; please see Ard et al., for a description of findings using qualitative methodology) (31). Dependent variables included frequency of skipping meals (32,33), fast food consumption (34), and composite measures of dietary weight control (35) in predominantly black or ethnically diverse samples spanning a spectrum of ages and US regions. Components of body image disturbance tended to covary positively with poorer nutritional content (35) and behavior patterns (36) and negatively correlated with healthy dietary intake (37) with some exceptions (38,39). However, BMI and other socioeconomic status variables were not consistently controlled in analyzing these relationships. There have been varied findings regarding the association between body satisfaction and participation in physical activity (see Table 3). One study identified body image as a motivating factor for engaging in physical activity (14). Taylor et al. (14) investigated reasons for adolescent girls' participating or not participating in physical activity. Focus groups of black and Latina girls revealed that concerns with body image facilitated physical activity. The girls reported that extra body fat and size affected how they felt about themselves. Some noted positive effects of exercise were “keeping your right size,” “a flat stomach,” and “losing weight” as well as the desire to be skinny like the people on the exercise programs on TV and to lift weights to give shape to your body. Although there is qualitative evidence of body image being a motivating factor for physical activity, several other studies have found that low body satisfaction is associated with low physical activity. In a 5-year longitudinal study of socioeconomically and ethnically diverse adolescents, Neumark-Sztainer and colleagues (40) found that lower body satisfaction predicted lower levels of physical activity among females. Separate findings for black and white females were not presented. However, results were weighted by ethnicity, race, and socioeconomic status of respondents. Similarly, Yancey et al. (41) found that overweight black women and men were less likely to perceive themselves to be overweight than overweight Latinos or whites. Average weight blacks and Latinos who perceived themselves as being overweight were more likely to be sedentary than their white counterparts. In subgroup analyses by race/ethnicity, black and Latina women were grouped together due to small numbers (41). In another study, adolescents who perceived themselves as overweight were less likely to engage in physical activity despite trying to lose weight. Exercising was the method more often reported by whites than by other racial and ethnic groups (32). Some studies support the notion of cultural acceptance of fatness suggesting that blacks are less likely to engage in weight loss behaviors due to acceptance of large body shapes (42,43). Kelly et al. (33,42) found that black girls were more likely than white girls to report high body satisfaction. Results suggested that adolescent girls with high body satisfaction were less likely to use healthy or unhealthy weight control behaviors, including exercise, eating more fruits and vegetables, and eating fewer sweets and high-fat foods (42). Similarly, Mabry and colleagues (43) found that black adolescent girls demonstrated more acceptance and self-esteem with regards to having a larger body size than their white peers. This acceptance was associated with less participation in physical activity (43). Although many investigators are concerned with the impact of body image satisfaction on engagement in physical activities, others have investigated the opposite relationship. Some studies have found participation in physical activity to lead to improved body image (20,44,45,46). In a convenience sample with 60% black women Smith and Michel found that pregnant women who participated in an aquatic aerobic program reported improved body image scores. While analyses were not stratified by race/ethnicity, the diversity of the sample suggested that this association was true across race and ethnic groups (44). Likewise, Miller and Levy found that female athletes exhibited significantly more positive body image self-concept than female nonathletes (45). Again, results were not stratified by race. In a biracial population of young adults aged 18.5–35 in Bogalusa, LA, physical activity was not found to be a significant predictor of body image perception (20). While both black women and white women expressed negative body image views that countered the cultural tolerance of fatness theory attributed to black women, these groups expressed differences in ideal weight-loss methods. White women emphasized physical activity whereas black women emphasized food characteristics with no mention of physical activity (46). Some studies investigated both body image and physical activity but did not assess the association between these two factors; however, racial/ethnic differences were noted. Studies suggest that there is no significant difference between blacks and whites over age 22, whereas white teens and college-aged women are more dissatisfied with their looks than black women at this age (47). Perry et al. found that white girls had greater physical activity whereas black girls had higher ideal body sizes and greater body satisfaction than white girls. There was no significant difference between black girls and Hispanic girls on body satisfaction or physical activity (48). Contrarily, another study found that black women had higher ideal body image and more sedentary behaviors than Latin-American women (49). While there is evidence of contrary findings of the relationship between body image and physical activity and differences by race/ethnicity, in general the association tends to vary by age. Several researchers have examined the relationship between body image and smoking among females. However, the sample sizes of many of these studies assessing the role of body image on decisions to start smoking or smoking cessation included few blacks. King (13) noted that researchers had not examined the role of tobacco use for weight management among black women. Several clinical trials regarding tobacco cessation have assessed the impact that body image or weight image has in influencing smoking patterns among females. The studies can be separated into two types—those examining smoking initiation or smoking cessation. Several cross-sectional studies examined whether perceptions of attractiveness influenced smoking behaviors (50,51,52). Findings suggest that women smokers felt less attractive and disliked their bodies more than nonsmokers (52) (Table 4). Women with weight concern were more likely to smoke to achieve a smaller figure. Knauss and colleagues (50) found that female smokers considered other smokers to be more attractive and rated smoking as appealing. Utilization of media (magazines and television) may encourage smoking among weight-concerned adolescents. Carson surveyed 967 12th graders to examine whether exposure to media and drive for thinness influenced smoking among this population. Teens who read fashion, entertainment, and gossip magazines were more likely to be current smokers. The authors asserted that smoking is used by these teens in order to maintain a thin figure (51). Among studies of smoking for weight management, few studies have assessed the use of smoking for weight management among black women (53). An earlier review of barriers to smoking cessation among minority women did not include weight control as a barrier to quitting smoking (13). Many prior studies included small numbers of blacks. However, four studies examined the relationships between smoking and weight concern among larger numbers of black females. Several clinical trials have assessed factors affecting smoking cessation among black females. One study examined smoking cessation among blacks with HIV/AIDS (54). Another examined smoking cessation among low-income blacks (55). Both found black females with less weight concern were more likely to smoke. Only one study has assessed the role of weight concerns in smoking initiation among black females (53). Whereas 5.6% of African-American women initiated smoking as a result of weight concern, 11.3% of white women felt that weight was an important factor in smoking initiation. Using data from the National Longitudinal Survey of Youth (NLSY97) Cawley and colleagues (56) found that adolescent females with a higher BMI who were trying to lose weight were more likely to initiate smoking than the females who did not consider themselves overweight. Results were not stratified by race. Several studies assessed whether weight concern reduced smoking cessation among black women. Pomerleau et al. (53) found that overweight black smokers were less willing to risk weight gain by quitting smoking and concluded that weight concerns may motivate black women as powerfully as white women to continue to smoke. Two studies found that the majority of black female smokers were not concerned about postcessation weight gain (54,57). Obese black females were least concerned about postcessation weight gain. In contrast, another study reported that black female smokers were concerned about postcessation weight gain (56). Concerns about body shapes or the fear of postcessation weight gain differ from those of white females, yet have influenced some black women's decisions about smoking cessation. Further efforts must be made to provide weight gain education and prevention among black females (57). Numerous studies have investigated the association between body image and modifiable weight-loss behaviors among black females. In general, body dissatisfaction was found to be associated with poorer health behaviors. Females who were dissatisfied with their bodies were more likely to practice poor nutritional behaviors and less likely to participate in physical activity or to stop smoking. There were variations in findings due to race, age, and overweight status. Notable aspects of some previous studies regarding body image and weight control measures were the use of diverse populations, longitudinal study designs, and the consideration of inverse relationships. Several studies of body image and dieting behavior are particularly noteworthy for their methodological rigor of executing prospective longitudinal study designs (34,57) and for strategically sampling from both traditionally underrepresented groups in health research (e.g., ethnically diverse female hospital workers in an urban locale: (55) and from large regional segments of the US adolescent population (36,58,59). With small numbers of black females generally included in body image studies, two studies on smoking cessation are also noteworthy for investigating large groups of black females (54,57). The women in these studies were low-income, and in one study, the black women were HIV-infected. The bidirectional association between components of body image and weight control behaviors was highlighted by physical activity studies which investigated the impact of body image satisfaction on participation in physical activity(14,40,41,42,43,60) as well as the inverse influence of physical activity on body satisfaction (38,39,40,42) to assess motivators and barriers to weight control. Contrary to the strengths of a few studies, many studies suffered from analytical, methodological, and inclusion deficiencies. Little is known about the bidirectional relationship between changes in specific weight control behaviors and shifts in how black females may perceive their bodies and whether these patterns correspond with those reported by white females in this country. Most studies were cross-sectional in nature and unable to infer a clear directional relationship. The variations in findings of the associations suggest the need for more longitudinal research to clarify the directionality of this association. Additionally, there was great variation in measures of body image and classifications for dieting and physical activity status and perception. Most studies utilized a measure of self-perceived body image or weight status. It has been found that black females tend to be more accepting of larger bodies and generally underestimate their actual weight status with those who are overweight less likely to perceive themselves as overweight compared to other races (41,61). Those who are overweight perceive themselves as normal weight, and the obese consider themselves overweight (61). This discrepancy suggests the need for more culturally tailored programs to increase self-awareness of weight status, health consequences, and healthy lifestyle changes. Many studies on body image were mainly conducted on white females. Unfortunately, only small percentages of black females were usually included in the studies, therefore making any efforts to test for the potential differential impact of race on the relationship between measures of body image and behaviors untenable. Most authors discussed general findings irrespective of race (59,62), used race simply as a sociodemographic control variable versus testing it as a possible effect modifier (35,58), or tended to prefer emphasizing differences observed due to gender (37,59) or to overweight status (58). Additionally, studies were performed on a broad range of age cohorts suggesting an influence of body image throughout the stages of development and the need for further studies at each age level. Further investigation into differences by race/ethnicity within various age groups is needed. To design appropriate interventions to reduce obesity among black females it is necessary to understand whether body image is gaining influence in promoting dietary, physical activity, and smoking changes within the context of weight control. Based on the review of the literature offered here, the current state of the evidence is insufficient to adequately address this question at present. There are several factors to consider in improving the quality of the research produced and therefore strengthening confidence in the validity and applicability of findings. Chief among these is the need for greater attention to designing prospective longitudinal studies that would provide a more robust test of how dimensions of body image may act as determinants of weight control behaviors among black females. Additionally, with perceived overweight as well as high satisfaction with body image both being associated with more sedentariness, this presents quite a challenge for identifying motivators for black females to engage in health-promoting activities. A central question to target in future efforts is: What factors may modify the impact of weight and body dissatisfaction on engaging in dieting, physical activity, and smoking cessation among black females? The current review has provided some preliminary clues that may be involved in further delineating important individual differences in this line of research. These include overweight status (1), level of acculturation to mainstream US culture (22), and likely regional variation in the value placed on weight loss and tuning into feelings about the body as a mechanism of change (35,39). It is our hope that this critique may serve as a preliminary roadmap for both existing and future qualitative and quantitative research in this area to be effectively translated into culturally attuned healthy weight management promotion efforts among ethnically diverse females. The authors declared no conflict of interest.