Relation of Self-image to Body Size and Weight Loss Attempts in Black Women

Transcription

1 American Journal of Epidemiology Copyright 1998 by The Johns Hopkins University School of Hygiene and Public Health All rights reserved Vol. 148, No. 11 Printed in U.S.A. Relation of Self-image to Body Size and Weight Loss Attempts in Black Women The CARDIA Study Nikki M. Riley, 1 Diane E. Bild, 1 Lawton Cooper, 1 Pamela Schreiner, 2 Delia E. Smith, 3 Paul Sorlie, 1 and J. Kevin Thompson 4 It has been suggested that the prevalence of obesity in black women is high partly because self-image in black women is not strongly dependent on body size. To determine associations between self-image, body size, and dieting behavior among black women, the authors assessed an Appearance Evaluation Subscale (AES) score (range, 1-5), a Body Image Satisfaction (BIS) score (range, 2-11), and reported dieting behavior in a population-based sample of 1,143 black women aged years from the fourth follow-up examination ( ) of the Coronary Artery Risk Development in Young Adults (CARDIA) Study. er AES and BIS scores indicate poorer self-image and lower body size satisfaction, respectively. After adjustment for age, education, smoking, and physical activity, women in the lowest, middle, and highest tertiles of body mass index (weight (kg)/height (m) 2 ) had mean AES scores of 3.7, 3.3, and 2.9, respectively (p < 0.001), and mean BIS scores of 7.8, 6.7, and 5.9, respectively (p < 0.001). After additional control for body mass index as a continuous variable, both AES and BIS scores were inversely related to ever dieting, current dieting, and previous weight loss of 10 pounds (4.5 kg) or more in all tertiles of body mass index. These results suggest that among black women, a higher body mass index is associated with poorer self-image and lower body size satisfaction and that these perceptions may be an avenue to promoting weight control. Am J Epidemiol 1998; 148: blacks; body constitution; body image; body mass index; self concept; weight loss; weight perception; women The prevalence of obesity among US black women is almost twice that of white women (1). This presents a major public health concern because of the associations between obesity, hypertension, diabetes mellitus, and other health conditions (1-10). Although a fuller figure may be considered a positive attribute within the black community (2, 11), the health risks of excessive weight are well recognized (12, 13). Many studies have examined behavioral factors related to obesity in black women and white women (14-17). These studies have suggested that the higher Received for publication February 25, 1997, and accepted for publication April 10, Abbreviations: AES, Appearance Evaluation Subscale; BIS, Body Image Satisfaction; CARDIA, Coronary Artery Risk Development in Young Adults. 1 Division of Epidemiology and Clinical Applications, National Heart, Lung, and Blood Institute, Bethesda, MD. 2 Division of Epidemiology, School of Public Health, University of Minnesota, Minneapolis, MN. 3 Division of Preventive Medicine, School of Medicine, University of Alabama at Birmingham, Birmingham, AL 4 Department of Psychology, College of Arts and Sciences, University of South Florida, Tampa, FL. prevalence of obesity among black women may be due to fewer educational and financial resources (15), cultural influences leading to a deemphasis of the thin body type in the black community (12, 18, 19), low physical activity levels (16), and ineffective dieting behavior (12, 16, 20). These data also suggest that one reason for the high prevalence of obesity in black women may be that self-image in black women is not strongly dependent on body size (12, 15, 18, 19, 21). Although suggestive, most of these studies were not population-based, tending to draw convenience samples from college campuses (18, 19, 22), and comparison with white women has obscured a focus on black women. Few studies have explored relations of self-image, body size, and dieting behavior within black women to identify culture-specific associations with self-image. Therefore, psychosocial factors related to the high prevalence of obesity in the black female population may not have been fully addressed, and potentially important motivating factors (or lack thereof) for dieting behavior in black women remain poorly understood. 1062

2 Self-image and Dieting Behavior in Black Women 1063 Body image and body weight satisfaction were recently examined in a population-based cohort of young adult men and women in the Coronary Artery Risk Development in Young Adults (CARDIA) Study (23). Notably, black women and white women demonstrated similar levels of satisfaction with their body size, despite greater obesity in the black women. Black women evaluated their overall appearance more positively than did white women. The current study extends the previous analysis and examines associations between self-image, obesity, and dieting behaviors among black women. MATERIALS AND METHODS The baseline CARDIA examination ( ) assessed 5,115 women and men from four US population centers (Birmingham, Alabama; Chicago, Illinois; Minneapolis, Minnesota; and Oakland, California), including 1,480 black women. Participants aged years were randomly sampled from the total community or from selected census tracts, except in Oakland, where a health plan membership was used. Study design details have been published previously (24). Participants Participants in the CARDIA Study have been followed with serial examinations. The data used in the current analysis were obtained from the fourth examination ( ) and included 1,143 black women aged years, which represents 77 percent of the black women who originally enrolled in the study. At baseline, participants who attended the fourth examination were older (24.6 vs years, p ) and better educated (13.2 vs years, p < ) than those who did not attend. Participants who attended the fourth examination were as likely to be current dieters at baseline as nonattenders (9.2 percent vs. 8.7 percent, p = 0.82) but were somewhat more likely to report having ever been on a weight-reducing diet (40 percent vs. 34 percent, p 0.08). However, there were no differences between attenders and nonattenders in body mass index (26.0 vs. 25.6, p = 0.37). Measures Weight (to the nearest 0.2 kg) and height (to the nearest 0.5 cm) were measured using a calibrated balance-beam scale and a vertical ruler while the participant stood in light clothing without shoes. Body mass index was calculated as weight in kilograms divided by the square of height in meters. Sociodemographic data (age, education, marital status, employment status, and income) and information on dieting behavior and self-image were obtained from selfadministered questionnaires. The Appearance Evaluation Subscale (AES), a measure of conceptual self-image, was derived from the Multidimensional Body-Self Relations Questionnaire (25). Participants responded on a Likert scale (18) (scored 1-5) to seven statements about satisfaction with overall appearance. AES scores for the total sample ranged from 1.0 to 5.0, with tests of normality indicating only a slight deviation from normality. The AES scale has demonstrated excellent psychometric qualities, with an internal consistency of Cronbach's alpha = 0.88 among adult women (26, 27). A lower AES score is associated with a poorer self-image. The Body Image Satisfaction (BIS) score was derived from the Figure Rating Scale (27, 28), which presents images of nine figures ranging from very thin to very heavy. The discrepancy between the figure selected as ideal and the current body size was utilized as the BIS score. The BIS scores were linearly transformed, so that the direction of the BIS scores corresponded with that of the AES scores, by subtracting the BIS score from the constant 8 (the difference between the numbers of the highest and lowest figures). The 2-week test-retest reliability for the ideal rating is 0.71 (29), indicating a strong internal consistency of the BIS score. The BIS scores for the total sample ranged from 2 to 11, with normality tests indicating only a slight deviation from normality. BIS scores ranging from 2 to 7 indicate a desire to be thinner, while BIS scores ranging from 9 to 11 indicate a desire to be heavier; a BIS score of 8 indicates a woman who is satisfied with her body size. A physical activity score was calculated for the past year from a questionnaire which yielded participation rates for 13 activity categories, as well as an estimate of energy expenditure for each activity. The scale has demonstrated reliability and validity for the population studied (30). Scores ranged from 0 to 1,385, and the distribution was markedly right-skewed. Therefore, scores for physical activity were based on natural logarithm-transformed values and are presented as geometric means. Smoking was defined as current, former, or never smoking on the basis of self-report. Dieting behaviors were measured by affirmative responses to the questions "Have you ever been on a weight-reducing diet?" and "Are you on such a diet now?". Each participant was also asked the number of times she had previously lost 10 or more pounds (4.5 kg). Responses were categorized as having lost 10 or more pounds on one or more occasions or not having done so.

3 1064 Riley et al. Statistical analyses Analyses included participants with body mass index data and either an AES score (n = 1,078) or a BIS score (n = 1,087). To determine whether self-image, dieting behavior, and other characteristics differed by body mass index, means and proportions for each variable were calculated by tertile of body mass index. Differences across body mass index tertiles for categorical data were tested by Cochran-Mantel-Haenszel analysis, and differences in continuous variables were determined by analysis of variance. Relations between self-image measures and body mass index, with body mass index as an independent variable, were additionally analyzed after adjustment for age, log physical activity, education, and smoking, with analysis of covariance. Multiple logistic regression models were constructed to determine whether self-image predicted dieting behavior within each tertile of body mass index. Because of the broad range of body mass indices within each tertile, body mass index was also included as a continuous variable in models predicting dieting behavior within each body mass index tertile, to control for residual confounding. Tests for interactions between body mass index tertile and self-image in the predictions of dieting behavior were conducted. In all of these models, adjustments for smoking, age, physical activity levels, and education were made because of their potential relations to body mass index (4, 14, 31) and their possible role as confounders. Additional adjustments for marital status (married, widowed, divorced, separated, and never married), parity, full-time employment (no or yes), and annual income (eight categories) were included in other analyses. Only 11 percent of the women expressed a desire to be heavier, based on their BIS scores. Thus, a separate logistic regression analysis excluding women who had BIS scores greater than 8 (indicating a desire to be heavier (n = 124)) was conducted to determine whether the results would be affected. The Statistical Analysis System (version 6.10) was used for the analyses (SAS Institute, Inc., Cary, North Carolina). RESULTS Spearman correlations demonstrated that AES and BIS scores were positively correlated (r = 0.52, p < ). Univariate analyses Age was significantly associated with body mass index, with older women having higher body mass indices (table 1). Educational level did not vary statistically by body mass index. Women with higher body mass indices reported lower levels of physical activity and were less likely than women with lower body mass indices to be current smokers, but these relations did not reach statistical significance. A higher proportion of women in the lowest body mass index category had no children. Income levels less than $12,000, current marital status, and full-time employment did not vary significantly by body mass index. Women with higher body mass indices were much more likely to report currently being on a weight-reducing diet, having ever been on a weight-reducing diet, and previously losing 10 or more pounds on one or more occasions (p < for each factor). Multivariate analyses After adjustment for education, age, log physical activity, and smoking, both AES and BIS scores decreased significantly with increasing body mass index (table 2). Thus, significant differences in self-image evaluation were evident among the body mass index groups. The results of logistic regression analyses represent the odds of each dieting behavior's being associated with a 1-unit increase in self-image as measured by AES or BIS within each tertile of body mass index, after adjustment for age, education, smoking, physical activity, and body mass index as a continuous variable. The overall adjusted odds ratios for AES were 0.61, 0.75, and 0.67 for having ever been on a weightreducing diet, current dieting, and weight loss of 10 pounds or more, respectively. The overall adjusted odds ratios for BIS were 0.65, 0.74, and 0.77 for having ever been on a weight-reducing diet, current dieting, and weight loss of 10 pounds or more, respectively. This suggests that the prevalence of each dieting behavior decreases with increasingly positive evaluations of self-image. Within each tertile of body mass index, both AES and BIS were inversely associated with having ever been on a weight-reducing diet (figure 1). The odds ratios for current dieting in relation to AES and BIS were similar to those for having ever been on a weightreducing diet. For BIS, the inverse association with having ever been on a weight-reducing diet and current dieting weakened with increasing tertile of body mass index. Previous weight loss of 10 pounds or more was inversely associated with AES and BIS in all tertiles of body mass index, and, as with the other two previous dieting variables, the relation between weight loss of 10 pounds or more and BIS tended to weaken with increasing tertile of body mass index. Further adjustment for marital status, parity, employment status, and income level did not significantly change the odds ratios for each dieting behavior model. When

4 Self-image and Dieting Behavior in Black Women 1065 TABLE 1. Demographic data and prevalence of dieting behavior and weight loss attempts in black women, by tertile of body mass index, CARDIA* Study, Demographic characteristic Mean body mass index Mean age (years) Mean years of education Smoking status (%) Current smoker Nonsmoker Ex-smoker Physical activity scoreh No children (%) Annual income <$12,000 (%) Married (%) Employed full-time (%) Weight loss information* Ever having been on a weightreducing diet (%) Currently being on a weightreducing diet (%) Previous weight loss of 10 pounds (4.5 kg) at least once (%) ( ) 21.7(2.0) 31.1 (3.8) 13.9 (2.1) Tertile of body mass index! ( ) (n=368) 27.6 (1.9) 31.6 (3.8) 13.9 (2.0) ( ) (n - 368) 37.7 (5.9) 32.0 (3.8) 13.7(1.9) P value} * CARDIA, Coronary Artery Risk Development in Young Adults, t Weight (kg)/height (m)*. $ Overall p value across tertiles of body mass index, by analysis of variance and chi-square contingency table analysis (test for an association between dieting behavior, weight loss attempts, and tertile of body mass index). Numbers in parentheses, standard deviation. H Geometric mean. # The proportions for the entire population sample for having ever been on a weight-reducing diet, current dieting, and weight loss of 10 pounds or more were 42.9%, 9.9%, and 56.7%, respectively, for the low, middle, and high tertiles of body mass index. women with BIS scores greater than 8 were removed, changes in the odds ratios for AES were trivial. Significant interactions occurred between the low and middle tertiles of body mass index (p = 0.004) and AES, as well as between the high and low (p < ) and high and middle (/? = 0.005) tertiles of body mass index and BIS, in predicting having ever been on a weight-reducing diet (figure 1). Additionally, interactions occurred between the middle and high tertiles of body mass index (/? = 0.028) and AES and between the low and high tertiles of body mass index (p = 0.040) and BIS in predicting currently being on a weight-reducing diet. An interaction also occurred between the low and high tertiles of body mass index (p = 0.009) and BIS in predicting weight loss of 10 pounds or more. These interactions suggest that relations between self-image and dieting behaviors differed by level of body mass index. DISCUSSION This study demonstrated strong relations between body mass index and self-image and between selfimage and weight loss attempts at each level of obesity in a population-based sample of young adult black women. The data from this study indicate that, within their own subgroup, black women exhibit a wide range of self-image. The most overweight women had the lowest AES and BIS scores. Conversely, the leanest women had the highest AES and BIS scores. Among black women in these data, obesity is associated with poorer self-image and lower body size satisfaction, and these perceptions are related to dieting behavior. The variations in self-image associated with obesity among black women in this study demonstrated patterns similar to those of white women (32, 33). In the CARDIA Study, white women had adjusted AES

5 1066 Riley et al. TABLE 2. Mean Appearance Evaluation Subscale (AES) and Body Image Satisfaction (BIS) scores in black women, by tertile of body mass index, CARDIA* Study, AES score Unadjusted Adjusted^ Interquartile range BIS score Unadjusted Adjusted! Interquartile range (15.&-24.6) Tertile of body mass indext ( ) ( ) P value! * CARDIA, Coronary Artery Risk Development in Young Adults. t Weight (kg)/height (m)*. $ p < for tertiles of body mass index by analysis of variance and covanance. AES score was based on the following statements: 1. My body is sexually appealing. 2. Most people would consider me good-looking. 3. I like my looks just the way they are. 4. I like the way I look without my clothes. 5.1 like the way my clothes fit me. 6.1 dislike my physique. 7.1 am physically unattractive. H Adjusted for age, education, smoking, and log physical activity scores of 3.5, 2.9, and 2.5 in the low, middle, and high body mass index groups, respectively (p < , R 2 = 0.29), using the same body mass index cutpoints as the tertile cutpoints used for the black women, with adjustment for age, education, smoking, and physical activity. The results were very similar to those seen in these black women (table 2), although the contribution of body mass index to the total variability in AES (R 2 ) was higher in the white women. Adjusted BIS scores for the white women were 7.1, 6.3, and 5.4 for the low, middle, and high body mass index groups, respectively (p < , R 2 = 0.35). Again, this relation is similar to, though somewhat weaker than, that seen among the black women. Therefore, black women in BMI Tertile AES BIS : i Odds ratio FIGURE 1. Adjusted odds ratio for having ever been on a weightreducing diet associated with a 1 -unit increase in Appearance Evaluation Subscale (AES) score and Body Image Satisfaction (BIS) score in 1,143 black women, by tertile of body mass index (BMI) (weight (kg)/height (m) 2 ), Coronary Artery Risk Development in Young Adults Study, BMI tertiles: (low), (middle), and (high). Odds ratios were adjusted for age, education, BMI, smoking, and log physical activity. Bars, 95% confidence interval. 10 the CARDIA Study expressed discontent with their body size in a manner similar to that of CARDIA white women. These findings argue against a lack of relation between serf-image and body size in black women and provide only limited support for the contention that a more positive physical self-image in black women explains their higher prevalence of obesity. The AES score measures a multidimensional affective evaluation of physical appearance, whereas the BIS score is a unidimensional measure of physical self-image which compares perceived body size with desired body size. The observed weakening of the relations between BIS scores with increasing obesity, but not between AES and dieting across increasing levels of obesity, implies that AES and BIS are measuring different psychological constructs. The BISobesity-dieting relation suggests that there may be a body size threshold above which concern about body size diminishes, as does motivation to lose weight. Methodological limitations of the current study include the lack of reliability and validity of the BIS measure in black women. However, excellent internal consistency of the AES measure for CARDIA black women was demonstrated by a Cronbach's alpha value of 0.82 (23). Body image satisfaction is a single-item measure; therefore, internal consistency could not be determined. Thus, the simplicity and content of both measures suggest high content validity in this sample. The limited number of geographic sites included in this study may limit the generalizability of our findings. CARDIA participants reside in urban areas primarily and may not reflect the attitudes and behaviors of persons living in other regions. Inclusion of a variable for study center in the analyses did not change the

6 Self-image and Dieting Behavior in Black Women 1067 results (data not shown), which suggests that geography was not a confounder. Although 23 percent of the black women in CARDIA did not return for the examination from which these data were obtained, there was no difference in baseline body mass index between those who returned and those who did not, suggesting that there was little response bias. Another concern is that, since the proportion of participants who were dieting was high, the odds ratios generated are not equivalent to relative risks (34, 35). However, we made no attempt to predict dieting behavior; rather, we were attempting to identify correlates of dieting behavior. Some of these findings may also be applicable to obesity prevention, another approach to obesity control that might be more successful than programs designed to produce weight loss. In addition, modification of other cardiovascular disease risk factors must still be addressed in order to reduce risk for cardiovascular disease in black women, whose cardiovascular disease mortality rates exceed those of white women by more than 20 percent (36). These results do not support previous speculation that a complete disassociation between self-image and body size contributes to the higher prevalence of obesity among black women. As was noted above, previous studies have suggested a variety of explanations for the higher prevalence of obesity in black women (2, 11, 14-16). Black women with higher body mass indices do tend to be aware of the dangers of excessive obesity and its health risks, and they tend to make multiple attempts to lose weight but have lower success rates than white women (12, 15). It is important to understand the psychological factors associated with body image in minority populations. Perceptions of self-image and body image could be responses to social and cultural beliefs about the "ideal" body size, and may motivate dieting or weight control behavior. Unfortunately, previous measures developed to understand self-image and body image disturbance have been designed primarily from Caucasian samples and may not apply to ethnically diverse populations (37). Therefore, measures used to test self-image and body image should be developed in ethnically diverse samples. The influence of "environmental stressors" has been offered as a partial explanation for the high prevalence of obesity among black women. Recent work by black women's health advocates suggests that eating problems (overeating) often relate to women's struggles against oppression and could be regarded as coping mechanisms for dealing with the negative societal influences of racism, sexism, poverty, and physically or sexually abusive relationships (38). Clearly, these hypotheses warrant further research. There are very few obesity prevention and treatment programs designed specifically for black women (39, 40). Reasons for this may include the lower socioeconomic status of black women, the inaccessibility of health care and education for black women, and an inability to implement and adhere to exercise programs because of inadequate resources and unsafe environments. Persons designing obesity prevention and weight loss programs targeting black women need to recognize the complex issues regarding acculturation of black women, not only in the majority society but within the black subculture as well. Prevention and treatment programs would benefit from an understanding of the strong sense of community and family within black culture and should implement strategies at the individual, family, and community levels (21). Further studies and proposed intervention programs for obese black women must address not only genetic, physiologic, and socioeconomic factors but also the influence of self-image and body image on the prevalence, prevention, and treatment of obesity in black women. The current study suggests that improved self-image may be an avenue to promoting weight control in black women. ACKNOWLEDGMENTS This research was supported by the National Heart, Lung, and Blood Institute under a pre-irta [Intramural Research Training Award] Fellowship (no. TP-HL-1000). The CARDIA Study is carried out as a collaborative study supported by contracts NO1-HC-48047, NO1-HC-48048, NO1-HC-48049, NO1-HC-48050, and NO1-HC from the National Heart, Lung, and Blood Institute. The authors thank Jane Chen, Jeanette Duggan, Joan Pinsky, Dr. Teri Manolio, Linda Sellers, Phyliss Sholinsky, and Michael Wolz for their assistance with this project. REFERENCES 1. Kuczmarski RJ. Prevalence of overweight and weight gain in the United States. Am J Clin Nutr 1992;55(suppl):495s-502s. 2. Villarosa L, ed. Body and soul: the black women's guide to physical health and emotional well-being. New York, NY: HarperPerennial, 1994:4. 3. Pi-Sunyer FX. Health implications of obesity. Am J Clin Nutr 1991;53(suppI):1595s-603s. 4. Myers HF, Kagawa-Singer M, Kumanyika SK, et al. Panel III: behavioral risk factors related to chronic diseases in ethnic minorities. Health Psychol 1995; 14: Legato MJ. Coronary artery disease in women. Int J Fertil Menopausal Stud 1996;41: Clark LT, Karve MM, Rones KT, et al. Obesity, distribution of body fat and coronary artery disease in black women. Am J Cardiol 1994;73:895-6.

7 1068 Riley et al. 7. Freedman DS, Williamson DF, Croft JB, et al. Relation of body fat distribution to ischemic heart disease: The National Health and Nutrition Examination Survey I (NHANES I) Epidemiologic Follow-up Study. Am J Epidemiol 1995;142: Liu K, Ruth KJ, Flack JM, et al. Blood pressure in young blacks and whites: relevance of obesity and lifestyle factors in determining differences. The CARDIA Study. Circulation 1996;93: Wattigney WA, Webber LS, Srinivasan SR, et al. The emergence of clinically abnormal levels of cardiovascular disease risk factor variables among young adults: The Bogalusa Heart Study. Prev Med 1995;24: Tinker LF. Diabetes mellitus a priority health care issue for women. J Am Diet Assoc 1994;94: Brink PJ. The fattening room among the Annang of Nigeria. Med Anthropol 1989;12: Kumanyika S, Wilson JF, Guilford-Davenport M. Weightrelated attitudes and behaviors of black women. J Am Diet Assoc 1993;93: Kumanyika SK, Charleston JB. Lose weight and win: a church-based weight loss program for blood pressure control among black women. Patient Educ Couns 1992;19: Burke GL, Savage PJ, Manolio TA, et al. Correlates of obesity in young black and white women: The CARDIA Study. Am J Public Health 1992;82: Allan JD, Mayo K, Michel Y. Body size values of white and black women. Res Nurs Health 1993;16: Kumanyika SK. Obesity in black women. Epidemiol Rev 1987;9: Kumanyika SK, Obarzanek E, Stevens VJ, et al. Weight-loss experience of black and white participants in NHLBIsponsored clinical trials. Am J Clin Nutr 1991;53(suppl): 1631S-8S. 18. Rucker CE, Cash TF. Body images, body size perceptions, and eating behaviors among African-American and white college women. Int J Eat Disord 1992;12: Powell AD, Kahn AS. Racial differences in women's desires to be thin. Int J Eat Disord 1995;17: Kumanyika SK. Special issues regarding obesity in minority populations. Ann Intern Med 1993; 119: Klesges RC, DeBon M, Meyers A. Obesity in African American women: epidemiology, determinants, and treatment issues. In: Thompson K, ed. Body image, eating disorders, and obesity: an integrative guide for assessment and treatment. Washington, DC: American Psychological Association, 1996: Harris SM. Racial differences in predictors of college women's body image attitudes. Women Health 1994;21: Smith DE, Thompson JK, Raczynski JM, et al. Body image among men and women in a biracial cohort: The CARDIA Study. Int J Eat Disord 1997 (in press). 24. Friedman GD, Cutter GR, Donahue RP, et al. CARDIA: study design, recruitment, and some characteristics of the examined subjects. J Clin Epidemiol 1988;41: Brown TA, Cash TF, Mikulka PJ. Attitudinal body-image assessment: factor analysis of the Body-Self Relations Questionnaire. J Pers Assess 1990;55: Stormer SM, Thompson JK. Explanations of body image disturbance: a test of maturational status, negative verbal commentary, social comparison, and sociocultural hypotheses. Int J Eat Disord 1996; 19: Thompson JK. Assessing body image disturbance: measures, methodology, and implementation. In: Thompson K, ed. Body image, eating disorders, and obesity: an integrative guide for assessment and treatment. Washington, DC: American Psychological Association, 1996: Stunkard AJ, Sorenson T, Schulsinger F. Use of the Danish adoption register for the study of obesity and thinness. In: The genetics of neurological and psychological disorders. New York, NY: Raven Press, 1983: Thompson JK, Altabe MN. Psychometric qualities of the Figure Rating Scale. Int J Eat Disord 1991;10: Jacobs DR, Hahn LP, Haskell WL, et al. Validity and reliability of short physical activity history: CARDIA and the Minnesota Heart Health Program. J Cardiopulm Rehabil 1989; 9: Kahn HS, Williamson DF, Stevens JA. Race and weight change in US women: the roles of socioeconomic and marital status. Am J Public Health 1991 ;81: Striegel-Moore RH, Wilfley DE, Caldwell MB, et al. Weightrelated attitudes and behaviors of women who diet to lose weight: a comparison of black dieters and white dieters. Obes Res 1996;4: Thomas VG. Body-image satisfaction among black women. J Soc Psychol 1989; 129: Wilcosky TC, Chambless LE. A comparison of direct adjustment and regression adjustment of epidemiologic measures. J Chronic Dis 1985;38: Flanders WD, Rhodes PH. Large sample confidence intervals for regression standardized risks, risk ratios, and risk differences. J Chronic Dis 1987;40: Liao Y, Cooper RS, Cao G, et al. Mortality from coronary heart disease and cardiovascular disease among adult U.S. Hispanics: findings from the National Health Interview Survey (1986 to 1994). J Am Coll Cardiol 1997;30: Altabe MN. Issues in the assessment and treatment of body image disturbance in culturally diverse populations. In: Thompson K, ed. Body image, eating disorders, and obesity: an integrative guide for assessment and treatment. Washington, DC: American Psychological Association, 1996: Thompson BW. "A way outa no way": eating problems among African-American, Latina, and white women. Gender Society 1992;6: Bowen DJ, Tomoyasu N, Cauce AM. The triple threat: a discussion of gender, class, and race differences in weight. Women Health 1991;17: Melnyk MG, Weinstein E. Preventing obesity in black women by targeting adolescents: a literature review. J Am Diet Assoc 1994;94: