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Poor Nutrient Intake and High Obese Rate in an Urban African American Population with Hypertension

Department of Nutrition and Food Science (K.-L.C.J., K.B.)
School of Nursing (O.G.M.W., N.T.A.)
Department of Internal Medicine, Wayne State University, Detroit, Michigan (J.M.F.)

Address correspondence to: Dr. K.-L. Catherine Jen, Department of Nutrition and Food Science, 3009 Science Hall, Wayne State University, Detroit, MI 48202. E-mail: cjen{at}wayne.edu

	ABSTRACT

TOP ABSTRACT INTRODUCTION MATERIALS AND METHODS RESULTS ACKNOWLEDGMENTS REFERENCES

 
Objective: To describe the nutrient intake patterns and general health conditions in an African American (AA) hypertensive population living in Detroit, MI.

Methods: Demographic, anthropometric, general health condition and 3-day dietary recalls were collected from 387 AAs in community-based settings. Only data from 342 participants who met the inclusion criteria were reported.

Results: The obesity and type 2 diabetes prevalence in this minority population were significantly higher, and both energy and nutrient intakes were significantly lower than the RDAs or those reported in NHANES. Female participants reported their highest weight at an earlier age but their body weight reduced in the older group. No such trend was observed in male participants. Both males and females consumed significantly fewer servings of fruit, vegetable and grains as recommended by USDA. As household income increased, the consumption of fruits and vegetables were also increased.

Conclusion: In order to reduce the incidence of obesity and hypertension in this minority population, dietary intervention should begin at adolescence or even earlier. DASH diet would be beneficial for this population.

	INTRODUCTION

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It is well established that a health disparity exists between African Americans (AAs) and Whites. AAs have worse health status than Whites for most chronic diseases [1,2]. The reason for this disparity is not clear. Kington and Smith reported that even though socioeconomic status explained part of the difference in functional status and chronic diseases between AAs and Whites, it only accounts for a small percentage of the difference [1]. Therefore, other factors must have played a significant role in the health disparity between the two races.

One of the chronic diseases that have a significant racial disparity is hypertension (HTN) [3,4]. It is estimated that 65 million adults in the US suffer from this disease, defined as having a systolic blood pressure (SBP) above 140 mm Hg or a diastolic blood pressure (DBP) above 90 mm Hg; taking antihypertensive medication; or being told at least twice by a physician or other health professional that you have high blood pressure [5]. AAs develop hypertension significantly earlier and more severely [5] as compared to Whites; they also suffer higher morbidity and mortality due to hypertension than Whites [5]. Many factors may contribute to this racial difference in hypertension and one of the possible differences may be nutritional status.

Differences in dietary patterns between AAs and Whites have been previously reported. Gates and McDonald observed that AA women consumed significantly less potassium and more cholesterol [6] and have lower intakes of protein, fiber, calcium and magnesium than White women [7]. In addition, significantly lower intakes of total energy, protein, carbohydrate, dietary fiber, total fat, fruits and vegetables, as well as vitamins and minerals, have been identified in AA men and women than Whites [8]. Dietary Approaches to Stop Hypertension (DASH) studies have demonstrated that diets high in fruits, vegetables and low-fat dairy products, as well as low in sodium (Na) are beneficial in managing blood pressures regardless of one's race [9]. Thus the higher percentage of AAs suffering from hypertension than Whites may be related at least in part to the low intakes of fruits, vegetables and low-fat dairy products.

Furthermore, a higher percentage of AAs reside in urban areas and have a higher poverty rate than Whites. The urban setting, low educational attainment and low socioeconomic status (SES) may limit the availability and choices of food items that are accessible to this population. Poor nutritional status may in turn predispose this population to a higher risk of chronic diseases as compared to their suburban counterparts. The present study was designed to describe the general nutrient intake and general health conditions in a hypertensive AA population residing in the inner city of Detroit, Michigan.

	MATERIALS AND METHODS

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Subjects
Participants were recruited from free blood pressure (BP) screening centers, community centers, thrift stores, drug stores, and grocery stores located on the city's east side. The first screening was used to determine if the prospective participants were hypertensive; about a week later, the second BP measurements were obtained to determine if people who were initially screened met the eligibility criteria.

The inclusion criteria were: 18 years of age; SBP 140 mm Hg or DBP 90 mm Hg (unless diabetes exists, in which case, the cut-off points were 130/80 mm Hg); living in a stable residence with a land-line telephone; good mental condition; and English fluency. Exclusion criteria included: arm circumference >17.5 inches (to ensure adequate measurement of BP with the BP cuff); mental confusion or illness, terminal cancer, advanced liver disease and/or on hemodialysis; and use of illicit drugs and/or alcohol abuse.

Study Design
Individuals who had two BP readings above the cutoff points and met the eligibility criteria were invited to participate in this study. During the data collection visit, signed informed consent was obtained. BP was measured for a third time, and immediately thereafter, a structured interview was conducted by a trained interviewer in a private room at one of the affiliated centers.

During the 2-hour data collection period, a brief physical exam was conducted. Blood pressures were measured using an electronic blood pressure monitor (Omron HEM-737 Intellisense), and body weight was measured by a Tanita digital scale (model #BWB-800S, Arlington Heights, IL). This scale was calibrated everyday using a 10-lb weight. A 24-hr dietary recall was performed in person; two more 24-hr dietary recalls were conducted by telephone after the interview. Participants were asked to report the food items consumed the previous day for breakfast, morning snacks, lunch, afternoon snacks, dinner and evening snacks. Participants were also asked to report food preparation methods and serving sizes. Food models were used during the face-to-face data collection period to assist participants to correctly estimate serving size. The interviewers were trained dietetic, nursing or other graduate students, or registered nurses.

Statistical Analysis
Only data from participants who had all 3 blood pressure readings in Stage 1 HTN (SPB: 140–159 mmHg, DBP: 90–99 mmHg) and Stage 2 HTN (SBP >160 mmHg, DBP >100 mmHg) categories were analyzed and reported here. Mean and standard errors were calculated. All statistical analyses were performed using a SPSS (version 10.0) statistical package. Student's t-tests were used to compare the difference between genders. Analyses of variance were used to analyze the difference among different age groups, education levels and income levels. The recommended intake of certain nutrients by DASH diet plan were used to compared the intakes of the current participants. When comparing the current results with the reported DASH diet, one-sample t-tests were performed. When comparing 2 percentages, z-scores were calculated. The significance level was set at p < 0.05.

	RESULTS

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Of the 342 participants, 127 were males (37.1%). The majority of the participants were older than 40 years of age and were either overweight or obese (Table 1). One hundred and twenty-two participants (35.7%) had a household income below $9,999, 126 had income between $10,000 and $29,999 (36.8%), 40 had income between $30,000 and $49,999 (11.7%) and 21 participants had household income more than $50,000 (6.1%). Household income information was not available from 33 participants.

Obesity.
The prevalence of obesity (BMI >30.0 kg/m²) was significantly higher in the current study (52.9%) than that reported in NHANES 2001–2002 (39.0%) [10]. This was true when data were analyzed based on age, educational attainment, or household income levels (Table 2). Of the male participants, 44.9% were obese, while 57.7% of the female participants were obese.

Body Weight
In this urban minority population, 81.8% of the participants were either overweight or obese. This is significantly higher than the reported 65.7% in the general population (p < 0.0001) and the 71.7% for AAs (p < 0.0001) in NHANES 2001–2004 [10]. The actual body weights of males in each age category were significantly higher than those of the NHANES 1999–2002 (Fig. 1) [12]. For female participants, the younger female participants weighed significantly more than the NHANES females. In the older participants, body weights were not different from the NHANES 1999–2002 report. Another unique observation is that for males, the highest mean body weight was observed between 20–39 years of age. There was no change in body weight in 40–59 and >60 years old males. However, for female participants, the youngest age group (20–39 years) reported the highest body weight and body weight declined continuously in the older groups.

View larger version (17K): [in this window] [in a new window]   Fig. 1. Mean body weight of male and female participants in comparison with the NHANES data.

Energy and Nutrient Intake
The energy and nutrient intake data are shown in Table 3. Male participants generally consumed more nutrients due to the higher energy intake than the female participants. Compared to RDAs, both male and female participants had significantly lower intakes of calcium (Ca), magnesium (Mg), potassium (K) and higher intakes of Na. The numbers of servings of fruit, vegetable and grains were significantly below those recommended by the DASH diet plan for both males and females.

Participants with Stage 3 HTN had significantly more Ca intake than those with Stage 4 HTN (469 ± 21 mg vs 411 ± 17, p < 0.05). They also tended to have higher fiber intake (12.4 ± 0.6 g vs 11.2 ± 0.4, p = 0.08). No other difference was found in nutrient intakes between these 2 stages.

Diabetic and non-diabetic participants consumed similar amount of the nutrients.

Effects of Education and Household Income Levels
Both education and household income levels affected nutrient intakes. Tables 4 and 5 tabulated the blood pressure, body weight and nutrient intakes according to educational attainment and income levels. For this urban minority population, higher education meant lower SBP in males and higher DBP in females. Household income levels had no effect on blood pressure. However, education levels were positively correlated with nutrient intake. Body weight, intakes of vegetables and fruits, and amount of dietary fiber increased with higher educational attainment. Participants with less than a high school education consumed the least amounts of vegetables, fruits and dietary fiber, and those with post-college education consumed the most (p's < 0.05).

Effects of Age
The ages of all participants were divided into decades (Table 6). Only 1 female was younger than 30 years of age, and her data was not included in these analyses. As the participants’ age increased, so did their SBP (Fig. 2, r = 0.19, p < 0.001). However, DBP decreased as participants aged (r = –0.53, p < 0.001). Body weight (r = –0.27, p < 0.001), energy intake (r = –0.25, p < 0.001), total protein intake (r = –0.23, p < 0.001), total fat intake (r = –0.27, p < 0.001), percent fat (r = –0.22, p < 0.001), intakes of saturated fat (r = –0.26, p < 0.01), MUFA (r = –0.17, p < 0.005), PUFA (r = –0.14, p < 0.05), cholesterol (r = –0.23, p < 0.001), Na (r = –0.23, p < 0.001) and Na/K ratios (r = –0.30, p < 0.0001) also decreased with age. The servings of fruit intake increased as they aged (r = 0.18, p < 0.005).

View larger version (17K): [in this window] [in a new window]   Fig. 2. Mean SBP and DBP based on age for male and female participants older than 30 years of age.

	DISCUSSION

It has been documented that more AAs are overweight or obese than Whites [13]. The percentages observed in the present study are even higher than the NHANES 2001–2002 for AAs of 71.7% and 39.0%, respectively [13]. These high percentages in this urban population were not unexpected. The household income and education levels affect body weight, especially in women [14,15] and the majority of the current participants were low in SES and educational attainment. However, within this population, there was no relationship between income levels and body weight, more likely due to the narrow income range observed in this study. Participants with post-college education actually had higher body weights than those with lower education levels, the opposite of the trend observed in other studies [16,17]. This discrepancy may be related to the small sample size and the higher energy intake reported in the post-college category. Participants in the highest income category also had the highest energy intake, but the difference failed to reach significance.

Both female and male participants in the youngest age category (20–39 years) had the highest mean body weight. As they aged, males maintained their body weights while female's body weights gradually decreased. This trend suggests that in order for any public health campaign for a healthy body weight in a minority population to be effective, preventing weight gain is important. It has to be aimed at the younger age group; preferably in the adolescent years before body weight has reached such a high level that weight reduction becomes extremely difficult.

Even though body weight and the overweight/obese percentages were significantly higher in this study than that reported in NHANES studies, the energy and nutrient intakes were low. Others investigators have reported similar findings [6–8]. Considering this is a hypertensive population, they should have been visiting health care providers more frequently and should have received more nutrition information than the general minority population. However, the data indicated otherwise. One possible explanation for this low energy intake/high body weight may be related to the lower energy expenditure in AAs as compared to Whites [18]. The reduction in energy expenditure in AAs includes all energy expenditure components: basal metabolic rate, total daily energy expenditure and/or physical activity energy expenditure ([19] for review). Another possibility is underreporting, which is more prevalent in overweight or obese populations [20,21]. Educational levels are also associated with the accuracy of recall [20]. Therefore, it is suspected that the participants of this study underreported their daily food intake. It should be noted that 24 hr dietary recall was used in this study, same as that used in other studies [3,8,22]. The data were collected by trained dietetic or nursing students and every effort was made to help participants remembering what was consumed in the previous day. However, even with the use of USDA's multiple-pass 24-hr recall technique, the accuracy of dietary recall was not improved in the low SES population [20]. Designing an unbiased and easy-to-adopt technique to collect dietary intake data in low SES populations remains a challenge for health professionals.

Diabetes Interventions Reaching and Educating Communities Together (DIRECT) is cross-sectional population-based project aimed to reduce the burden of diabetes in the AA communities [23]. The nutrient intake patterns of participants in Project DIRECT have been reported. In the current study population, people with high school and some college education had significantly higher intakes of fruits and vegetables as compared to the participants in Project DIRECT [24], while those with less than high school education or post-college education had similar vegetable and fruit intakes. For each household income level, AAs in Detroit consumed significantly more servings of fruits and vegetables than their counterparts in Project DIRECT. Thus, even though participants in the Project DIRECT reside in a warmer climate and may have more access to fresh fruits and vegetables, their intakes of these foods are not high. On the other hand, data collected from the Foods of Our Delta Study revealed that AAs in the Mississippi Delta region had significantly higher intakes of energy and all the nutrients examined in the current research, with the exception of dietary fiber [8]. It is apparent that AAs in different regions of the US have different energy and nutrient intake patterns. Hence, when comparing a specific study population, using the RDAs or USDA recommendations may be a preferred comparison.

As income levels were increased, servings of fruits and vegetables also increased. Fresh fruits and vegetables usually cost more to purchase and may not be readily available in some inner cities [25,26]. Fruits and vegetables are not only low in energy and fat content but also contain vital nutrients such as dietary fiber, Ca, K and Mg that may reduce the risk for chronic diseases. Results from Coronary Artery Risk Development in Young Adults (CARDIA) Study indicated that dietary fiber is a better predictor for weight gain and CVD risk factors than total or saturated fats [27]. Low intakes of fruits and vegetables may be linked to higher body weight and partially explain the disparity of health conditions of AAs in our society.

It is interesting to note that in this population, older participants consumed significantly less energy. However, servings of fruits per day were significantly increased. Since there was no difference in household income levels among the age categories (data not shown), it remains to be determined which factors induced the increased consumption of fruits in the older age groups.

A diet high in fruits and vegetables, low-fat dairy products, and low in Na (DASH diet) has been shown to reduce blood pressure in both hypertensives and normotensives [9]. The reduction in BP with DASH diet was beyond that produced by lifestyle medications alone in people older than 50 years of age, as shown in PREMIER clinical trial [22]. Thus, this urban minority population could benefit from the DASH diet in managing their BP levels. On the other hand, fresh fruit and vegetables cost more than high fat/high salt foods [14]. Detroit has the highest poverty rate among the major US cities in 2004 (33.6%) (http://factfinder.census.gov/servlet/GRTTable?_bm=y&-_box_head_nbr=R1701&-ds_name=ACS_2004_EST_G00_&-format=US-32&-CONTEXT=grt), it may not be realistic to expect this population to increase intakes of fruit and vegetable significantly. If the cost of purchasing fresh fruits and vegetables is a concern for the minority population, then strategies to educate this population about lifestyle modification should be developed.

In conclusion, for the urban hypertensive AAs participating in this study, the prevalence of obesity and diabetes were higher and the nutrient intakes were significantly lower than recommended by USDA. As income and education levels increased, more fresh fruits and vegetables were consumed. However, the intakes were still significantly below the amount recommended by the USDA. Improving the dietary recall in this minority population, making fresh fruits and vegetables readily available at affordable prices, as well as educating this inner city population about the beneficial effects of lifestyle modification and the DASH diet should be top priorities for health and government officials.

	ACKNOWLEDGMENTS

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This study was supported in part by a grant from NIH/NINR #R01NR007682 to NTA.

Received January 20, 2006. Accepted December 17, 2006.

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TOP ABSTRACT INTRODUCTION MATERIALS AND METHODS RESULTS ACKNOWLEDGMENTS REFERENCES

 

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