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Encouraging Physical Activity in Minorities

Eliminating Disparities by 2010

Carlos J. Crespo, DrPH, MS

THE PHYSICIAN AND SPORTSMEDICINE - VOL 28 - NO. 10 - OCTOBER 2000


In Brief: Healthy People 2000 and Healthy People 2010 are programs designed to measure and encourage physical activity for all Americans, regardless of race, ethnic group, or economic status. The objective of these programs is to reduce and eliminate disparity between population groups in terms of promoting health and preventing illness, disability, and death. Physicians need to consider the unique needs and constraints of minority patients when giving advice and prescribing exercise regimens. Some patients, for example, might do best in community-sponsored recreational activities.

The cultural diversity of the US population makes it difficult to promote a single, "one-size-fits-all" fitness and health program. Inequities exist between racial or ethnic groups, and several factors come into play when we look at ways to ensure equal access to healthy lifestyles. Physicians need to be aware of these inequities, as well as how to tailor exercise advice to the needs of individual patients.

Changes in US Demographics

The demographic outlook of the US population is rapidly changing to the point where non-Hispanic whites will no longer be the largest racial or ethnic group (because Hispanics can be of any race, data are most often presented for non-Hispanic whites, non-Hispanic blacks, and Hispanics). In fact, the US Census Bureau projects that by the middle of this century, more than half the population will be composed of racial or ethnic minorities who historically have experienced lower economic growth and poorer health conditions than non-Hispanic whites (1-7). Current health estimates have failed to provide a complete health profile of all racial or ethnic groups in the United States; however, current data for non-Hispanic blacks and Hispanics reveal increasing health disparities (2,5,6).

The population of the United States can be divided into five major racial or ethnic groups: whites, blacks, Hispanics, Asian and Pacific Islanders, and American Indian and Alaska natives. As with other major ethnic groups, there are wide diversities among ethnic subgroups of American Indians, Alaska natives, Asian-Pacific Islanders, blacks, and Hispanics. Moreover, pilot data from the 2000 census suggest that about 2% of respondents report having mixed ethnic heritage (8). Educational, geographic, language, and even cultural differences also distinguish not only the major ethnic groups, but also the subgroups (1,2).

Gathering Data on Physical Activity

The National Center for Health Statistics (NCHS) is part of the Centers for Disease Control and Prevention (CDC) and monitors the health of the nation through a variety of surveys and surveillance systems. The NCHS has tracked health indicators of the US population to produce updates on the national health objectives (eg, Healthy People 2000 and 2010). Some of the surveillance systems used to monitor progress were the National Health Interview Survey (NHIS), a yearly survey with an in-person interview, and the National Health and Nutrition Examination Survey (NHANES), an in-person interview and health examination conducted since 1960. In addition, the CDC's National Center for Chronic Disease Prevention and Health Promotion provides physical activity estimates for each state using data collected via telephone interviews (9-11).

To illustrate the prevalence of physical inactivity in minority populations within the context of the Healthy People 2010 report, and to provide a descriptive epidemiologic characterization of the disparities in physical inactivity between non-Hispanic whites and racial or ethnic minorities, we studied data from the 1991, 1995, and 1997 NHIS, the 1996 Behavioral Risk Factor Surveillance System (BRFSS), and the Third National Health and Nutrition Examination Survey (NHANES III), conducted between 1988 and 1994 (2,4,6,9,12). The latter was designed to oversample blacks and Mexican Americans to produce reliable estimates when studying ethnic groups in subsets, for example, age-groups, education, income, and occupation.

Eliminating Disparities by 2010

Health disparities among different segments of the population include differences that occur by gender, race or ethnicity, education, income, disability, residence in rural localities, or sexual orientation (11). One of the major goals of Healthy People 2000 was to reduce health disparities (table 1). The aim of Healthy People 2010 is to eliminate those disparities. The 2010 objectives reflect the scientific advances that have taken place over the past 20 years and have one single, overarching purpose: to promote health and prevent illness, disability, and premature death, while increasing the quality and years of healthy life for everyone.


TABLE 1. Prevalence of No Leisure-Time Physical Activity (No LTPA) in US Adults 18 Years and Older and Target Goals for Healthy People 2000 and 2010
Healthy People 2000 Healthy People 2010


No LTPA Baseline, 1991 1995 Target Baseline, 1997* Target

Non-Hispanic Whites** 24% 23% 15% 36% 20%

Non-Hispanic Blacks 28% 28% 20% 52% 20%

Hispanics 34% 31% 25% 54% 20%

American Indian/Alaska Native 29% 23% 21% 46% 20%

Asian Pacific Islanders 42% 20%

*During 1997, the questions used to assess participation in vigorous and light-to-moderate physical activity changed from those used in 1985-1995 National Health Interview Survey (NHIS) data.

**Baseline for non-Hispanic whites was established using the 1985 NHIS; prevalence estimates for 1985 and 1991 were both 24%.

Data from the NHIS, 1991-1997


Physical activity is one of the 10 leading health indicators identified by Healthy People 2010 (table 2) from all the health objectives and focus areas. Within the physical activity and fitness area of Healthy People 2010 are 15 objectives. This categorization shows that physical activity remains at the top of the public health agenda and underscores the need to allocate valuable resources to eliminate the gap between those who are active and those who are not (11). The aim of public health officials and healthcare professionals is to move people from the inactive category to those who participate in some kind of physical activity most days of the week (11,13).


TABLE 2. Leading Health Indicators, According to the Healthy People 2010 Report

Adequate physical activity
Healthy body weight
No tobacco use
No substance abuse
Responsible sexual behavior
Mental health
Lack of injury and violence
Environmental quality
Immunization
Access to healthcare


Differences in race or ethnicity show that minorities suffer disproportionately from chronic diseases that are more commonly observed among persons who are physically inactive (12-15). For example, blacks suffer disproportionately from higher rates of heart disease, stroke, and certain cancers than whites. Also, physical inactivity has been recognized as an independent major risk factor for heart disease. Hispanics (especially Mexican Americans and Puerto Ricans) and American Indians have very high rates of type 2 diabetes (12). While information about biological and genetic predispositions could explain some of these health disparities, it is the interaction between societal and other environmental factors that can provide better clues on how to prevent diseases and reduce the levels of physical inactivity observed in minority populations (12-14).

Inactivity in Ethnic Minorities

Although our main goal is to increase the percent of the general population who are physically active, assessment of physical activity and physical fitness (V*o2 max) can be complicated and unfeasible in population-based studies. Physical inactivity is easier to measure and may be easier to monitor, track, and compare in multiple population-based surveys. Thus, given the major challenges involved in accurately assessing varied levels of participation in physical activity and the lack of a national survey to assess maximal aerobic capacity in all segments of society, we used physical inactivity or no leisure-time physical activity (no LTPA) as the main health indicator to eliminate the disproportionate number of racial or ethnic minorities who are inactive when compared with non-Hispanic whites.

Physical inactivity during leisure time, or no LTPA, is a term indicating that interviewees reported that they do not engage in any of the activities from a list of 8 to 17, depending on the survey (9-12). These activities included jogging, dancing, gardening, calisthenics, aerobics, weight lifting, cycling, swimming, or any other sport or physically active hobby not mentioned. If interviewees answered that they did not participate in any activity, they were classified as physically inactive or no LTPA.

Regional differences (figure 1) show that on average, physical inactivity is highest in the Southeast, followed by the Northeast, Midwest, Southwest, and lowest in the Northwest. Coincidentally, the percentage of the population that is black is highest in the southeastern states followed by the northeastern states. On the other hand, 85% of Mexican Americans live in the Southwest, where physical inactivity rates were found to be the lowest. A possible explanation is that data collected during the BRFSS is from a telephone survey that did not collect a representative sample of minority groups (15). Also, telephone coverage among Mexican Americans and in rural areas is lower than among non-Hispanic whites and in urban areas.

[Figure 1]

The NHANES III study was designed to obtain a national representative sample of blacks and Mexican Americans. NHANES III found the highest prevalence of physical inactivity among non-Hispanic blacks and Mexican Americans (figure 2). In fact, the prevalence of physical inactivity among both Mexican American men and women of any age group is greater than the prevalence of physical inactivity observed among non-Hispanic whites ages 70 to 79 years (14). Physical inactivity increases as people get older, but for Mexican Americans, participation in physical inactivity during leisure time is very high very early in their adult lives.

[Figure 2]

Social Class and Inactivity

Differences in social class are hypothesized to be one of the main reasons why health disparities exist in minority populations (1-3,5,6). Measurement of social class and its relation to health indicators is complex. Education is mostly related to health behavior; income is mostly associated with the things we can buy such as health insurance, prescription medication, and access to healthcare (2,12). Table 3 shows that regardless of educational attainment or household earnings, both non-Hispanic blacks and Mexican Americans were more physically inactive than non-Hispanic whites. This may be partially explained because they may engage in more manual occupations that require higher energy expenditures than non-Hispanic whites with the same education and income levels (16).


TABLE 3. Age-Adjusted Prevalence of No LTPA Among Non-Hispanic White, Non-Hispanic Black, and Mexican American Men and Women Ages 20 Years and Older According to Social Class
Non-Hispanic Whites Non-Hispanic Blacks Mexican Americans



Social Class Indicator N Mean + SE N Mean + SE d Whites N Mean + SE d Whites d Blacks

Men
Education Completed (yr)

< 12 1,192 22 + 2.1 913 33 + 2.4 P<0.001 1,579 40 + 1.6 P<0.001 P<0.05

12 1,062 15 + 1.3 765 22 + 2.3 P<0.05 466 20 + 3.8

13 to 15 624 13 + 1.6 394 21 + 3.2 267 13 + 2.5

>16 821 7 + 1.1 193 14 + 2.7 P<0.01 120 14 + 4.0


Annual Household Income

< $10,000 282 22 + 4.5 423 40 + 3.4 P<0.001 379 43 + 2.6 P<0.001

$10,000 - $19,999 887 21 + 2.0 691 27 + 2.3 850 42 + 1.3 P<0.001 P<0.001

$20,000 - $34,999 906 15 + 1.6 490 20 + 2.6 530 23 + 3.3 P<0.05

$35,000 - $49,999 594 10 + 1.4 280 20 + 2.7 P<0.05 230 19 + 3.8

>$50,000 1,065 10 + 1.1 416 20 + 2.4 P<0.001 478 31 + 3.5 P<0.001 P<0.001


Women
Education Completed (yr)

<12 1,295 36 + 3.1 990 51 + 2.4 P<0.001 1,487 59 + 1.5 P<0.001 P<0.01

12 1,559 25 + 1.4 1,018 45 + 2.3 P<0.001 557 34 + 2.8 P<0.001 P<0.05

13 to 15 804 15 + 1.5 482 32 + 3.1 P<0.001 249 19 + 3.2 P<0.001

>16 709 14 + 1.5 260 30 + 3.2 P<0.001 106 24 + 6.0 P<0.001


Annual Household Income

< $10,000 566 30 + 3.1 675 46 + 3.9 P<0.001 464 60 + 2.6 P<0.001 P<0.001

$10,000 - $19,999 1,025 27 + 2.0 786 47 + 2.2 P<0.001 808 54 + 2.0 P<0.001 P<0.001

$20,000 - $34,999 949 22 + 2.0 531 38 + 2.2 P<0.001 478 43 + 3.7 P<0.001 P<0.05

$35,000 - $49,999 622 16 + 1.8 264 32 + 3.2 P<0.001 217 27 + 3.6 P<0.001

>$50,000 1,250 20 + 1.5 515 43 + 2.8 P<0.001 459 41 + 2.6 P<0.001

LTPA = leisure-time physical activity

d Whites = statistical difference from whites

d Blacks = statistical difference from blacks

Data from the Third National Health and Nutrition Examination Survey, 1988-1994 (12).


A recent report (16) using data from the 1990 NHIS studied the percentage by race or ethnicity of employed adults who reported participation in leisure-time physical activities who also reported hard occupational physical activity. Table 4 shows that non-Hispanic whites have the lowest levels of physical inactivity during leisure time, the highest percentage of adults meeting the recommended guidelines of moderate physical activity for 30 minutes 5 or more days a week, and the lowest percentage of employed adults who engage in heavy work for 5 or more hours a day. Hispanics, however, reported engaging more frequently in highly physically active jobs for 5 or more hours a day than non-Hispanic whites or blacks and had the highest levels of no LTPA (15).


TABLE 4. Percentage of Employed White, Black, and Hispanic Adults who reported No LTPA, Moderate LTPA, and Hard Occupational Physical Activity
Racial or Ethnic Group No LTPA Moderate LTPA (30 min, 5 day/wk) > 5 Hr/Day of Hard Occupational Activity

Non-Hispanic whites 22.3 (20.9-23.7) 32.3 (31.2-33.4) 21.9 (20.9-22.9)

Non-Hispanic blacks 28.8 (25.9-31.7) 30.3 (28.2-32.4) 30.1 (27.6-32.7)

Hispanics 33.9 (30.4-37.4) 26.6 (23.3-32.5) 33.0 (30.1-33.6)

Adapted from Centers for Disease Control and Prevention: Prevalence of Leisure-Time and Occupational Physical Activity Among Employed Adults: United States. MMWR 2000;49:420-425.

LTPA = leisure-time physical activity


We examined the prevalence of no LTPA by different categories of occupation using the US Census Occupational Classification Codes provided by NCHS and by information on retirement status and on homemakers (12). We divided NHANES III participants into six occupational classifications (only five are graphed in figure 3; the last category was too diverse to be meaningful): white-collar professionals; white-collar other, which includes those working in technical jobs and in offices; blue-collar workers who engage in mostly manual labor, farming, and unskilled jobs; retirees; homemakers; and those in other pursuits such as students or the unemployed.

[Figure 3]

Our results indicate that regardless of their occupational status, the prevalence of physical inactivity continued to be highest among both non-Hispanic black and Mexican American women. For men, however, those who work in the "white-collar other" category had physical inactivity levels that were similar across all racial or ethnic groups. Among those who reported being in white-collar professional occupations, non-Hispanic black and Mexican American men had twice the age-adjusted rates of inactivity observed among non-Hispanic whites. Blue-collar workers' prevalence of physical inactivity was lowest among non-Hispanic white men, followed by non-Hispanic black men, and highest among Mexican American men. Retired Mexican American men reported being more active than non-Hispanic white or black retired men. The sample size of non-Hispanic white men who reported being homemakers was too small to provide meaningful estimates (12).

Other Factors

From the data reviewed here, it is clear that women are less active than men in all racial or ethnic groups. We examined if marital status was related to physical inactivity during leisure time (12). Our results illustrate that married men, especially non-Hispanic white and black men, have the lowest age-adjusted prevalence of no LTPA when compared with formerly married and never married men. For women, however, the prevalence of physical inactivity was not related to marital status. Prevalence estimates for non-Hispanic white and black women and Mexican American women did not change substantially whether they were married or not. Thus, married men may be at an advantage with regard to participation in LTPA, partially because they may have more free time to engage in recreational pursuits. Working mothers are working more hours to earn the same salary as men, subtracting valuable time from the little free time available to exercise. While the number of hours that husbands spent at work has not changed in the past 25 years, the number of hours that wives spent at work has increased by 92% during that time (17).

One study (18) found that older women might be more fearful of engaging in leisure-time physical activity if they perceived that the crime rate in their neighborhood was high. This barrier was less significant among men. Since minorities tend to live in areas with high poverty, the interaction between poverty, area of residence, and changes in physical activity in minority populations is of research interest. Findings from the Alameda County Study (19) suggest that these factors are linked and deserve further validation in other communities.

Further research is needed to understand the specific social and environmental barriers that interfere with racial and ethnic minorities feeling able to exercise freely in their neighborhoods. Other promising areas of research to increase participation in physical activity among women and minorities may include access to affordable fitness facilities, child care, crime prevention, and culturally appropriate social marketing (17-21).

Targeted Advice for Minorities

The prevalence of physical inactivity is higher in women than in men, but it is highest among minority women. We know that the types of physical activities in which racial or ethnic minorities prefer to participate are different from those of non-Hispanic whites (2). For example, social dancing was consistently one of the top 5 physical activities reported among non-Hispanic black and Mexican American men and women and also among non-Hispanic white women. Non-Hispanic white men reported golf as one of their top 10 activities, and black men and Mexican American men reported basketball, baseball, and soccer as popular activities. Walking and gardening consistently ranked in the top 3 activities listed for all groups (3); however, the advice to "go for a walk" cannot be generalized to all segments of society since certain neighborhoods may be perceived as less safe than others.

Healthy People 2000 recognized the importance of clinicians counseling about physical activity. Unfortunately, fewer than 15% of all clinicians formulated an exercise plan for their patients (10), and only 25% of internists did so. All estimates were well below the goal of 50%. Healthy People 2010 does not include an objective to track the percent of physicians who advise their patients about exercise, yet it is clear that for racial or ethnic minorities, the advice of a clinician to adopt an active lifestyle is important. Moreover, it is imperative that clinicians take into account the different environments that surround the lives of minorities. Culturally appropriate advice may include empathetic suggestions that take into account the patients' preferred activities rather than "telling" them to exercise. Racial and ethnic minorities typically hold in high esteem family relationships, faith-based organizations, social gatherings, and respect for authority. Clinicians, health educators, and fitness specialists should use these social and cultural institutions as frameworks in planning exercise programs for patients of various racial and ethnic groups.

Next Steps for Healthy People 2010

The national health objectives for the year 2010 provide an excellent opportunity for clinicians to intervene at the individual as well as community level. The physical activity objectives provide target goals to increase physical activity among all racial or ethnic groups, both genders, and all age groups. Children are advised to engage in fewer sedentary pursuits such as watching television. There are objectives for communities to support and facilitate walking and bicycling trips, and for schools to increase the number and quality of physical education classes. In contrast to previous national health objectives, the target goal for each objective will be the same for all racial or ethnic groups. Thus, an active lifestyle will be a major priority for all segments of society.

References

  1. Changing America: indicators of social and economic well-being by race and Hispanic origin. Council on Economic Advisors 1998, Washington, DC, Document no. PR 42.8:C 36 0851-J. 9-1998
  2. Crespo CJ, Keteyian SJ, Heath GW, et al: Leisure-time physical activity among US adults: results from the Third National Health and Nutrition Examination Survey. Arch Intern Med 1996;156(1):93-98
  3. US Census Bureau. https://www.census.gov/prod/1/pop/p25-1130/p251130z.pdf. Accessed September 12, 2000
  4. Winkleby MA, Kraemer HC, Ahn DK, et al: Ethnic and socioeconomic differences in cardiovascular disease risk factors: findings for women from the Third National Health and Nutrition Examination Survey, 1988-1994. JAMA 1998;280(4):356-362
  5. Montgomery LE, Carter-Pokras O: Health status by social class and/or minority status: implications for environmental equity research. Toxicol Ind Health 1993;9(5):729-773
  6. National Center for Health Statistics: Socioeconomic Status and Health Chartbook in Health, United States, 1998. Hyattsville, MD, Public Health Service, 1998, DHHS publication no. (PHS) 98-1232
  7. Adams-Capmbell LL, Rosenberg L, Washburn RA, et al: Descriptive epidemiology of physical activity in African-American women. Prev Med 2000;30(1):43-50
  8. Cohn D: Census race question has limited impact: Survey finds that about 2% of respondents report having mixed heritage. The Washington Post, July 30, 2000. Metro section, page C-8
  9. National Center for Health Statistics: Plan and operation of the Third National Health and Nutrition Examination Survey, 1988-1994 Hyattsville, MD, Public Health Service, 1994, DHHS publication no. (PHS) 94-1308
  10. National Center for Health Statistics: Healthy People 2000 Review, 1998-1999. Hyattsville, MD, Public Health Service, 1999, DHHS publication no. (PHS)99-1256
  11. Healthy People 2010: Understanding and Improving Health. Pittsburgh, US Government Printing Office, 2000, stock no. 017-001-00543-6 or at https://www.health.gov/healthypeople
  12. Crespo CJ, Smit E, Andersen RE, et al: Race/ethnicity, social class and their relation to physical inactivity during leisure time: results from the Third National Health and Nutrition Examination Survey, 1988-1994. Am J Prev Med 2000;18(1):46-53
  13. US Department of Health and Human Services: Physical Activity and Health: A Report of the Surgeon General. Atlanta, 1996, US Department of Health and Human Services, Centers for Disease Control and Prevention, stock no. 017-023-00196-5
  14. Kington RS, Smith JP: Socioeconomic status and racial and ethnic differences in functional status associated with chronic diseases. Am J Public Health 1997;87(5):805-810
  15. Chronic Diseases and Their Risk Factors: The Nation's Leading Causes of Death. A report with expanded State-by-State Information, 1999, pp 29-30. Atlanta, US Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion. Available at https://www.cdc.gov/nccdphp/statbook98/statbook.htm. Accessed September 12, 2000.
  16. Prevalence of leisure-time and occupational physical activity among employed adults: United States, 1990. MMWR Morb Mortal Wkly Rep 2000;49(19):420-425
  17. Berry JM: Moms spend more hours on paid jobs. The Washington Post, May 25, 1999, Business section, page E-1
  18. Neighborhood safety and prevalence of physical inactivity: selected states, 1996. MMWR Morb Mortal Wkly Rep 1999;48(7):143-146
  19. Yen IH, Kaplan GA: Poverty area residence and changes in physical activity level: evidence from the Alameda County Study. Am J Public Health 1998;88(11):1709-1712
  20. Crespo CJ, Andersen RE, Smit E, et al: Acculturation and physical inactivity during leisure time among Mexican-Americans, abstracted. Med Sci Sports Exerc 2000;32(5 suppl):S260
  21. Andersen RE, Franckowiak SC, Zuzak KB, et al: Community intervention to encourage stair use among African-American commuters, abstracted. Med Sci Sports Exerc 2000;32(5 suppl):S38

Dr Crespo is a professor in the department of Social and Preventive Medicine at the State University of New York at Buffalo. Address correspondence to Carlos J. Crespo, DrPH, MS, State University of New York, Dept of Social and Preventive Medicine, 270 Farber Hall, Buffalo, NY 12412; e-mail to [email protected].


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