REPORT OF THE BOARD OF TRUSTEES
B of T Report 6 - A-04
Subject:
Culturally Responsive Dietary and Nutritional Guidelines
Presented by:
William G. Plested III, MD, Chair
Referred to:
Reference Committee D
(Jerome C. Cohen, MD, Chair)
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Resolution 428, Obesity and Culturally Competent Dietary and Nutritional Guidelines, adopted by the
AMA House of Delegates in June 2003, asks:
That our AMA and its Minority Affairs Consortium (MAC) study and recommend
improvements to the U.S. Department of Agriculture's (USDA) Dietary Guidelines for
Americans and Food Guide Pyramid so these resources fully incorporate cultural and
socioeconomic considerations as well as racial and ethnic health disparity information in
order to reduce obesity rates in the minority community.
That our American Medical Association (AMA) report its findings and recommendations
to the AMA House of Delegates by its 2004 Annual Meeting.
The serious health implications resulting from the increased prevalence of obesity in the US is
addressed in depth in CSA Report 8 (A-04), currently before the House of Delegates. This Board of
Trustees report responds more specifically to the interrelated issues of cultural competence and racial
and ethnic health disparities and obesity. It recommends that our AMA adopt policy and take
appropriate actions to promote the development of culturally effective dietary and nutritional
guidelines to effectively address obesity, particularly among racial and ethnic minority patient
populations.
Health Implications of Obesity
The rise of obesity and overweight among the US population is fraught with serious implications for
our patients and the public health, as well as the health care system and the US economy. The
prevalence of obesity has increased substantially over the last two decades. According to the Centers
for Disease Control and Prevention, an estimated 59 million people aged 20 years and older, 31
percent of US adults, were defined as obese, i.e., having a body mass index (BMI) of 30 or more.
A study published in the January 1, 2003 issue of the Journal of the American Medical Association
(JAMA) reported that the prevalence of obesity in 2000 was 20.9 percent, an increase of 5.6 percent
from the previous year. The JAMA study also showed that overweight and obesity were significantly
associated with diabetes, high blood pressure, high cholesterol, asthma, arthritis, and poor health
status.
Even more alarmingly, the percentage of children and adolescents now defined as overweight has
more than doubled since the early 1970’s. More than 10 percent of preschool children ages 2 to 5 are
overweight, up from 7 percent in 1994. The US Surgeon General has said that the high incidence of
overweight and obesity among young people is the greatest threat to public health today,
foreshadowing a maturing generation plagued by serious associated disease complications.
B of T Report 6 - A-04 - page 2
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A study of the national costs attributed to overweight and obesity estimated that medical expenses
accounted for 9.1 percent of total US medical expenditures in 1998 and may have reached as high as
$78.5 billion. According to the U.S. Department of Agriculture (USDA), healthier diets may prevent
$71 billion per year in medical costs, lost productivity and premature deaths caused by coronary heart
disease, cancer, stroke, and diabetes mellitus.
Obesity and its health complications contribute to persistent racial and ethnic health disparities in the
United States. The obesity rate among racial and ethnic minorities in the U.S. has increased
disproportionately in comparison to whites. African-American and Latino children are more likely to
become obese than white children. Among adults, obesity and overweight prevalence is highest
among non-Hispanic black women. More than half of non-Hispanic black women aged 40 years or
older were obese and more than 80 percent were overweight. In light of these staggering statistics, the
U.S. Department of Health and Human Services, the AMA, and other medical organizations are
focusing new attention on obesity as a pervasive public health issue affecting Americans, particularly
those of racial and ethnic minority populations.
Obesity is a contributing factor that can lead to premature death in diet-related diseases such as
coronary heart disease, cancer, stroke, and diabetes mellitus. These diseases disproportionately affect
African American, Hispanic and American Indian communities in comparison to other racial and
ethnic groups in the U.S. According to the U.S. Department of Agriculture (USDA), healthier diets
may prevent $71 billion per year in medical costs, lost productivity and premature deaths caused by
coronary heart disease, cancer, stroke, and diabetes mellitus.
Racial and ethnic minorities, along with low-income individuals, may not make healthy food choices
due to their socioeconomic status and cultural norms. A study published in The Journal of Preventive
Medicine reports a high correlation between lower income and minority neighborhoods having less
access to supermarkets and a greater incidence of unhealthy diets than non-minority or higher income
neighborhoods. Research also has shown that local food environments impact healthy eating choices
and that poor and minority communities do not have equal access to the variety of healthy food
choices available to non-minority and wealthy communities. In a sample of neighborhoods from
Mississippi, North Carolina, Maryland, and Minnesota, white neighborhoods, when compared to
African American neighborhoods, had 4 times more supermarkets offering a wide variety of healthy
foods.
The obesity epidemic disproportionately affects the health status of racial and ethnic minorities.
Physicians need culturally effective tools to assist their patients with managing their weight and to
assist them in making healthier food choices in communities where healthier foods may not be readily
available. Creativity and a collaborative multicultural approach are needed to effectively coach and
empower patients to make appropriate nutritional and dietary decisions to improve their health and
manage their weight.
The Role of the AMA and Organized Medicine
Organized medicine has a pivotal role in combating the obesity epidemic as a disease state that
intersects all medical specialties. Addressing obesity will improve the overall health of patients and
help reduce racial and ethnic health disparities in diseases such as coronary heart disease, cancer,
stroke, and diabetes mellitus. Eliminating racial and ethnic health disparities will improve health care
for all patients and reduce overall health care costs in the U.S.
B of T Report 6 - A-04 - page 3
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Our AMA is addressing these interrelated issues with policies and directives (listed on the last page of
this report) and programs that call upon physicians to incorporate cultural competence in their
practices, eliminate health disparities and address the obesity epidemic. Our AMA MAC has
identified obesity and its complications as a major health risk disproportionately affecting minority
populations and worked with the National Medical Association (NMA) to introduce Resolution 428,
Obesity and Culturally Competent Dietary and Nutritional Guidelines, at the June 2003 AMA House
of Delegates meeting.
Our AMA entered an ongoing Memorandum of Understanding (MOU) with the U.S. Department of
Health and Human Services that directly supports the goals of Healthy People 2010 to improve the
health of the nation and eliminate racial and ethnic health disparities. This commitment has led our
AMA to develop opportunities in cooperation with the NMA and other organizations. This includes
the convening of the Federation Task Force on Health Disparities which is working to develop a
national plan for eliminating disparities. Other recent AMA activities include the Roadmaps for
Clinical Practice publication, Assessment and Managing of Adult Obesity: A Primer for Physicians,
educational sessions at the Annual and Interim meetings, and the Working Group on Childhood
Obesity. By providing such forums for the major stakeholders in this effort to reduce obesity and
eliminate racial and ethnic health disparities, our AMA is highlighting the role and responsibilities of
organized medicine in improving the health of our nation.
Recommendations for the USDA Dietary Guidelines for Americans and Food Guide Pyramid
The leading nutritional and dietary guidelines are developed and distributed by the United States
Department of Agriculture (USDA). The current USDA’s Dietary Guidelines for Americans and
Food Guide Pyramid will be revised and made available in 2005.
The current USDA guides do not include foods that are staples in many minority communities, such
as ghee, bok choy, greens, yams, tofu, lentils, plantains, and fish sauce. Tortillas are the only ethnic
food listed in either of the current USDA guides. By incorporating more ethnic foods and ingredients
throughout the revised guides, the relevance and usefulness of the new guides to minority populations
would increase substantially.
Socioeconomic factors are also not directly addressed in the existing USDA guides. They do not
include low-cost options to fresh fruits and vegetables, lean meats, sources of calcium, and whole
grains. Suggesting low-cost options such as frozen, dried, and canned foods would help low-income
Americans to make healthier food choices. Additionally, the two guides should include multicultural
symbols to depict one “serving size”. For example, the guides could reference a deck of cards, half of
a small tortilla, or four strips of meat to depict one “serving size” along with using the existing
measurements of “cups” and “ounces”.
Additional research is needed to identify effective strategies for delivering culturally effective care
when treating overweight and obese patients. While research indicates a need for culturally sensitive
nutritional and dietary guidelines to combat obesity and improve overall nutrition, there is not a
consensus among experts on which methods are most effective in delivering culturally effective care
to minority patients. More data are needed on best practices and in exploring weight management
efforts and outcomes among ethnic and racial minorities in comparison to their white counterparts.
B of T Report 6 - A-04 - page 4
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Conclusions
With the impending revision of the USDA guides, there is an opportunity for the AMA to provide
recommendations to the USDA for improving the cultural responsiveness and effectiveness of the
guidelines as a strategy for combating obesity in minority populations. In addition, there will be an
important future role for the AMA in assisting physicians to incorporate the revised guidelines into
their practices.
The most effective way for individuals to manage body weight and improve their overall health is by
increasing daily physical activity, reducing caloric intake, and selecting healthier foods. Individuals
could better manage their nutritional and dietary goals if the healthy foods and ingredients typically
consumed in their cultures were included in physician recommendations and in the USDA nutritional
and dietary guidelines. Overweight and obese patients may comply with nutritional and dietary
guidelines if the guidelines are relevant to their lifestyle and culture. A broader range of foods and
ingredients should be included in the USDA guides to assist physicians in delivering culturally
effective guidelines to aid patients in their weight management goals.
Our AMA and its MAC should continue to monitor emerging research on these interrelated issues and
provide input to the USDA on its 2005 Dietary Guidelines for Americans and Food Guide Pyramid.
In addition, our AMA should continue its ongoing efforts to eliminate racial and ethnic health
disparities, recognize obesity as a national epidemic and suggest ways to improve and utilize the
USDA guidelines in physician practices to deliver culturally effective care for all patients.
Recommendations
The Board of Trustees recommends that the following recommendations be adopted, and that the
remainder of this report be filed.
1. That our American Medical Association reaffirm that obesity in children and adults is a major
public health problem in the United States. (Reaffirm HOD Policy)
2. That our AMA recognize that racial and ethnic disparities exist in the prevalence of obesity and
diet-related diseases such as coronary heart disease, cancer, stroke, and diabetes and recommends
that physicians use culturally responsive care to improve the treatment and management of
obesity and diet-related diseases in minority populations. (New HOD Policy)
3. That our AMA support the use of cultural and socioeconomic considerations in all nutritional and
dietary research and guidelines in order to treat overweight and obese patients. (New HOD
Policy)
4. That our AMA and its Minority Affairs Consortium (MAC) encourage the United States
Department of Agriculture (USDA) Food Guide Pyramid Reassessment Team to include
culturally effective guidelines that include listing an array of ethnic staples and use multicultural
symbols to depict serving size in their revised Dietary Guidelines for Americans and Food Guide
Pyramid. [Directive to Take Action]
B of T Report 6 - A-04 - page 5
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5. That our AMA and its MAC seek ways to assist physicians with applying the final United States
Department of Agriculture (USDA) Dietary Guidelines for Americans and Food Guide Pyramid
in their practices as appropriate. [Directive to Take Action]
6. That our AMA and its MAC monitor existing research and identify opportunities where organized
medicine can impact issues related to obesity, nutritional and dietary guidelines, racial and ethnic
health disparities as well as assist physicians with delivering culturally effective care. (Directive
to Take Action)
Appendix – Related AMA Policies
H-150.953 Obesity as a Major Public Health Program
D-60.990 Exercise and Healthy Eating for Children
H-440.902 Obesity as a Major Health Concern.
H-295.897 Enhancing the Cultural Competence of Physicians
H-295.905 Promoting Culturally Competent Health Care
H-350.965 Culturally Effective Health Care
H-350.976 Improving Health Care of American Indians
H-350.967 Eliminating Health Disparities
H-350.974 Racial and Ethnic Disparities in Health Care
D-350.996 Strategies for Eliminating Minority Health Care Disparities.
Fiscal Note: Within Current Budget
References available from the Department of Women and Minority Services