The ISS (Insulin Secretion and Sensitivity) differential equation model has been previously shown to provide simultaneous estimates of SI and BCF during an oral glucose tolerance test. Using the Federal Women’s Study, we adapted the ISS model to fit glucose and insulin dynamics and estimate SI and BCF during mixed meal tests. Our goal was to develop an effective, straightforward, and reliable tool that would be simpler to use than currently available approaches that require technically challenging deconvolution methods to assess BCF. The ISS model for mixed meal tests strongly correlated with oral glucose tolerance tests and gold-standard estimates from intravenous glucose tolerance tests and were reliable when using a shortened 2-hour MMT protocol. The ISS model is versatile, publicly available, and expands the toolbox for assessing post-prandial glucose-insulin homeostasis.

Diagnostic reproducibility of diabetes was substantial (ҝ-statistic = 0.74, 95%CI: 0.58-0.90) in 154 African descent individuals with 1 h-OGTTs performed 10 ± 7d (mean ± SD) apart. Diabetes was diagnosed in 34 individuals with 65%(22/34) detected at both visits (non-switchers) and 35%(12/34) at one visit (switchers). With insulin resistance greater in non-switchers, 1 h-OGTT reproducibility may be better if insulin resistance present.

INTRODUCTION:As type 2 diabetes (T2D) prevalence increases in the USA and Africa, factors from both regions affect African immigrants. OBJECTIVE:T2D in African immigrants was characterized by examining: (a) insulin deficiency and insulin resistance; (b) phenotypic presentation; (c) sociodemographic factors. METHODS:In 633 African immigrants (male: 62%, age 39±11, (mean±SD), range 20-70 years), body mass index (BMI): 27.8±4.6, range 18.8-46.2 kg/m2), weight gain information was collected, BMI and waist circumference (WC) measured and OGTT performed. Insulin resistance was defined by the lowest quartile of the Matsuda Index (≤2.80); insulin secretion by the Insulin Secretion Index (ISI). Insulin deficiency was defined as less than the maximum ISI in participants with T2D without IR (0.430). WC thresholds defined central obesity (men: WC ≥94 cm; women ≥80 cm). RESULTS:Normal glucose tolerance, pre-diabetes and T2D occurred in 61%, 32% and 7%, respectively. Three subtypes of T2D were identified: insulin-deficient-T2D (ID-T2D) in 45%, insulin-resistant-T2D (IR-T2D) in 30%, insulin-deficient+insulin-resistant (ID+IR-T2D) in 25%. ID+IR-T2D had the highest glucose concentrations (all p<0.05), whereas insulins were highest in IR-T2D (all p<0.01). Phenotypic differences by T2D subtype were identified. In the ID-T2D group, 20% of participants had a healthy weight and central obesity occurred in 55%. In the IR-T2D and ID+IR-T2D groups, 100% had central obesity and a BMI in either the overweight or obese categories. Sociodemographic factors specifically, weight gain, sedentary lifestyle and percent married, increased across glucose tolerance category (p values <0.01) but did not differ by T2D subtype (p≥0.3). CONCLUSIONS:Spanning the BMI spectrum from normal to obese, African immigrants have three subtypes of T2D. Weight gain was greatest in immigrants who developed T2D but did not differ by subtype. As life in America promotes weight gain, sharing information about the consequences of weight gain with all Americans, both native and foreign-born, is key to T2D prevention and treatment.

G6PD deficiency (G6PD-D) variants are associated with lower hemoglobin A1c (HbA1c) concentrations, raising concerns about the diagnostic efficacy of HbA1c for abnormal glucose tolerance (Abnl-GT) in Africans, in whom risk of G6PD-D and Abnl-GT is high. G6PD-D is assessed using genotyping or an enzymatic assay, but because G6PD-D is X-linked, the enzymatic assay is necessary for determining status for women heterozygous for deficiency variants. We assessed: 1) ability of HbA1c to detect Abnl-GT by G6PD-D; 2) concordance of genotyping and enzymatic assay for G6PD-D in sub-Saharan Africans living in the US. 534 participants of the Africans in America study were included, with HbA1c ranging from 3.1-11.3%. Abnl-GT determined by HbA1c (≥5.7%) was compared to the diagnostic standard, the oral glucose tolerance test (fasting glucose≥100 mg/dL and/or 2h glucose≥140 mg/dL). G6PD-D status was determined by genotype (n = 263), enzymatic assay (n = 83), or both (n = 188). G6PD-D could not be determined for 13 women heterozygotes with only genotype data. In the remaining participants, HbA1c was 0.9% lower among those with G6PD-D (4.6 ± 0.5; range 3.1-5.6) compared to those with normal G6PD activity (5.5 ± 0.6; range 4.2-11.3; P < 0.001). Glucose concentrations did not differ between groups. HbA1c sensitivity and specificity for Abnl-GT were 0% (0/17) and 100% (37/37) among those with G6PD-D, and 50% (98/195) and 80% (217/272) among those with normal activity. After excluding women heterozygotes, concordance for G6PD-D detection by genotype and the enzymatic assay was 100%. G6PD-D was associated with ~0.9% lower HbA1c in this study, leading to a failure of HbA1c to identify Abnl-GT in these participants. Such a dramatic difference in a screening tool could have consequences in practice, including late diagnosis, undertreatment, and increased complications among those with G6PD-D. Additionally, the results for the enzymatic assay were perfectly concordant with the genotype results for G6PD-D. However, as genotype alone cannot predict G6PD-D in heterozygous women, the enzymatic assay was more informative.

CONTEXT:The gold-standard clamp measurements for insulin sensitivity (cSI), β-cell function (cBCF), and disposition index (cDI = cSI × cBCF) are not practical in large-scale studies. OBJECTIVE:We sought to 1) validate a mathematical model-derived DI from oral glucose tolerance tests (OGTT) with insulin (mDI) and without (mDI-woI) against cDI and oral disposition index (oDI) and 2) evaluate the ability of the novel indices to detect prediabetes and type 2 diabetes (T2D). METHODS:We carried out a secondary analysis of previously reported cross-sectional observational studies. The Insulin Sensitivity and Secretion mathematical model for glucose-insulin dynamics was applied to 5-point and 3-point OGTTs synchronized with hyperinsulinemic-euglycemic and hyperglycemic clamps from 130 youth with obesity (68 normal glucose tolerance [NGT], 33 impaired glucose tolerance [IGT], 29 T2D). RESULTS:Model-derived DI correlated well with clamp DI (R = 0.76 [logged]). Between NGT and IGT, mDI and mDI-woI decreased more than oDI and cDI, (60% and 59% vs 29% and 27%), and by receiver operating characteristic analysis were superior at detecting IGT compared with oDI and cDI (area under the curve [AUC] 0.88-0.87 vs 0.68-0.65), as was mean glucose (AUC 0.87). CONCLUSION:mDI-woI is better than oDI or the labor-intensive cDI for detecting dysglycemia in obese youth. Bypassing insulin measurements with mDI-woI from the OGTT provides a cost-effective approach for large-scale epidemiological studies of dysglycemia in youth.

Objectives Body image is integral to culture and influences health behaviour. In sub-Saharan African countries, body image preference is in flux. To facilitate research on attitudes about body size in Africans, our goal was to provide a central resource of the figure rating scales which have previously been used in African countries.Design A scoping review was conducted.Data sources Five databases were accessed: PubMed, Web of Science, Embase, Global Health Database and African Index Medicus.Eligibility criteria (1) Study conducted in a sub-Saharan African country; (2) used a figure rating scale to assess body image; (3) enrolled adults; (4) published in English between 1983 and 12 April 2024.Data extraction and synthesis 842 articles were flagged, and 63 articles identified as appropriate for inclusion.Results These 63 studies were conducted in 14 African countries and used 23 different figure rating scales. These 23 scales were developed in: USA or Australia: 39% (9/23); Europe: 35% (8/23); Africa: 26% (6/23). A description of each scale is provided including: (a) number of images, (b) sex (ie, women only, men only or both women and men), (c) silhouette orientation (ie, frontal only or frontal and lateral views), (d) population used to develop the scale and (e) the African country which used each scale.Conclusions Using this review, investigators can optimise their choice of an existing figure rating scale or use the information as background to build a new one.

Introduction and Objective: Genetic association studies report lower A1C levels with G6PD deficiency (G6PD-D). A1C is used as a diagnostic test for abnormal glucose tolerance (AbnlGT), a summary term for diabetes and prediabetes. It is critical to assess the clinical impact of G6PD-D on the diagnostic efficacy of A1C in populations in whom deficiency variants are common and risk of AbnlGT is high, such as Africans. G6PD-D is X-linked and caused primarily by the G6PD A- haplotype in Africa. G6PD-D can be assessed by either genotyping or clinical assay. We determined: 1) the ability of A1C to detect AbnlGT by G6PD-D status; 2) concordance of genotyping and the clinical assay in 506 African-born Blacks enrolled in the Africans in America study (men: 61% (308/506). Methods: AbnlGT was diagnosed by the OGTT. G6PD-D was assessed by genotype only (n=263), genotype and assay (n=188) or assay only (n=55). G6PD-D clinical assay used qualitative visual fluorescence screening in whole blood. A1C ≥5.7% was the threshold for AbnlGT. Results: G6PD-D status was indeterminant in 13 women who were heterozygous for G6PD A- and did not have the assay. In the remaining 493 participants, AbnlGT occurred in 41% (201/493) and G6PD-D in 10% (51/493). G6PD-D prevalence in men and women were: 14% (43/308) v 4% (8/185) P<.001. A1C levels with and without G6PD-D were: 4.6 ± 0.5, (range 3.1 - 5.6) v 5.5 ± 0.6 (range 4.2 - 11.3), P<.001). With G6PD-D, A1C sensitivity and specificity for AbnlGT detection were: 0% (0/16) and 100% (35/35), resp. Without G6PD-D, A1C sensitivity and specificity were: 50% (93/185) and 79% (202/257), resp. Participants with both genotyping and the assay (n=188), concordance for G6PD-D detection was 100%. Conclusion: G6PD-D lowered A1C levels by 0.9%. These falsely low A1C levels could lead to late diagnosis of AbnlGT and complications. Overall, as the assay can detect deficiency in women heterozygous for G6PD A-, the assay for G6PD was more informative than genotyping. A.R. Bentley: None. K. Ntabadde: None. K. Balahali: None. K. Ekoru: None. C. DuBose: None. D.B. Sacks: Other Relationship; Sebia, Trinity. A.A. Adeyemo: None. C.N. Rotimi: None. A.E. Sumner: None.

Introduction and Objective: Sleep quality affects cardiometabolic health and is adversely affected by stress. Stress may be magnified in the African immigrant community by the move from a majority to a minority population as well as the age of immigration and income. Due to the paucity data on sleep quality in African immigrants, we evaluated in 322 African-born Blacks enrolled in the Africans in America study (male 57%): (a) sleep quality; (b) the influence of stress, age of immigration, gender and income on sleep quality; (c) the association between adverse health, specifically type 2 diabetes (T2D) and sleep quality. Methods: The Pittsburgh Sleep Quality Index (PSQI) and Cohen’s Perceived Stress Scale (PSS) were used to assess sleep and stress in the month prior to enrollment. Low income was defined as <45k/year. All participants were ≥20y at enrollment. Childhood immigration was defined by arriving in the United States <18y. Regression analyses was performed with PSQI as the dependent variable and PSS, income, gender and age of immigration as independent variables. OGTT were performed to determine the relationship between poor sleep quality (PSQI>5) and T2D. Results: The mean age of participants was: 40±11y (mean±SD), range 20-70y. The frequency of Childhood (Child-I) and Adult immigrants (Adult-I) were: 18% (57/322) and 82% (265/322), resp. PSQI was higher in Child-I than Adult-I (6±4 vs 5±3,P=0.023). Neither PSS nor income differed by age of immigration (both P>0.9). In the regression analyses, PSQI was adversely affected by PSS (P=0<.001), age of immigration (P=0.013), and income (P=0.072). Gender had no effect (P=0.508). The prevalence of diabetes tended to be higher in the group with poor sleep quality (10% vs 6%, P=0.156). Conclusion: Poor sleep quality in African Immigrants is modified not only by stress and income but also by arriving in the United States as a child. Determining the lifetime impact of age of immigration on sleep quality and its association with the development of T2D are worthy of study. E.A. Huefner: None. M. Sayed: None. G.G. Smith: None. K. Ntabadde: None. K. Meda: None. C. DuBose: None. P.L. Whitesell: None. A.E. Sumner: None.

Introduction and Objective: Type 2 diabetes (T2D) is rapidly increasing in Africa. To optimize screening strategy and initial care, both the phenotypic presentation and physiologic determinants must be delineated. Our goals were to determine in African-born Blacks living in America: (a) glucose tolerance status, and (b) in individuals with newly diagnosed T2D, both the phenotype and balance between beta-cell insufficiency (BCI) and insulin resistance (IR). Methods: Glucose tolerance status was determined by a frequently-sampled OGTT in 633 African-born Blacks living in America (male: 62% (394/633), age 39±11, (mean±SD), range 20-70y), BMI: 27.7±4.6, range 18.8-46.2 kg/m2). IR was defined by the lowest quartile of the population distribution of the Matsuda Index (≤2.8). Insulin secretion was assessed with the Insulin Secretion Index (ISI: AUC-insulin/AUC-glucose). In individuals with T2D, BCI was defined by ISI<0.43 in the absence of IR (Matsuda>2.8). Results: T2D, prediabetes and NGT occurred in 7% (44/633), 32% (203/633) and 61% (386/633), resp. Three different physiologic types of DM were identified: BCI-only 45% (20/44), IR-only 29% (13/44), IR+BCI 25% (11/44). Age and gender did not vary by T2D type (both P≥0.4). In the 3 groups with T2D, BMI was: 26.8±2.9, 32.3±4.6, 32.2±3.9 kg/m2 (P-value for trend <0.001); WC was: 92±7,105±8, 106±9 cm (P-value for trend <0.001). AUC-glucose during the OGTT was highest in IR+BCI (P<0.001). AUC-insulin was lower in both the BCI-only and IR+BCI groups than IR-only (both P<0.001). Conclusion: Three physiologic types of T2D were identified: BC-only, IR-only and BCI+IR only. As BCI-only was the most common type of T2D and occurs often in the nonobese, Africans without obesity should be included in screening paradigms. Further, while the BCI-only group are often nonobese and the BC+IR group obese, both groups need early intervention with insulin. K. Ntabadde: None. E.A. Huefner: None. M. Sayed: None. G.G. Smith: None. K. Balahali: None. C. DuBose: None. A. Sherman: None. A.E. Sumner: None.

Introduction and Objective: Body size preference is influenced by both globalization and education and affects health behavior. Recent data on body size preferences of African Immigrant (Afr-Im) and African American (AA) women are lacking. Hence, in a pilot study of 23 Afr-Im and 23 AA women matched for age (40±16, (mean±SD) range 20 - 68y) and BMI (29.9+5.7, 20.2 - 42.4 kg/m2), we compared wish body size, body size dissatisfaction and basic demographics. Methods: The Stunkard Figure Rating Scale has 9 silhouettes with each corresponding to a BMI category: underweight (Silhouettes 1 & 2), normal weight (Silhouettes 3 & 4), overweight (Silhouettes 5 & 6 & 7) and obese (Silhouettes 8 & 9). Each woman chose 2 silhouettes, 1 for wish body size and 1 for perceived body size. Body size dissatisfaction was determined by the difference in silhouette number between wish and perceived body size. Results: The African regions of birth of the Afr-Im were: West 44% (10/23), East 44% (10/23), Central 13% (3/23). BMI distribution of the participants was: obese 37% (17/46); overweight 37% (17/46); normal weight 26% (12/46), and underweight 0% (0/46). Wish body size did not differ by ethnicity (P=0.737). Wish body size for Afr-Im women were: obese 0% (0/23), overweight 22% (5/23), normal weight 74% (17/23), and underweight 4% (1/23). Wish body size for AA women were: 0% (0/23), 13% (3/23), 83% (19/23) and 4% (1/23), respectively. Dissatisfaction due to feeling too large in Afr-Im and AA women occurred in 70% (16/23) vs 57% (13/23), (P=0.606). College graduation rates in Afr-Im and AA women were: 74% (17/23) vs 70% (16/23), P=0.743). Conclusion: In this cohort of highly educated Afr-Im and AA women, attitudes toward body size preference did not vary by ethnicity and the most favored BMI was normal weight. G.G. Smith: None. E.A. Huefner: None. M. Sayed: None. C. DuBose: None. M.F. Horlyck-Romanovsky: None. A.E. Sumner: None.

Introduction and Objective: The International Diabetes Federation suggests replacing the 2-h plasma glucose (PG) ≥200 mg/dL with a 1-h PG ≥209 mg/dL for diagnosing type 2 diabetes (T2D). However, in the Africans in America cohort, the sensitivity of the 1-h PG ≥209 mg/dL threshold was only 67%. Additionally, fasting plasma glucose (FPG) >126 mg/dL alone captured few cases, as most individuals had abnormal 2-h PG values. To enhance T2D detection with 1-h PG in Africans, we evaluated the sensitivity and specificity of three criteria: (a) 1-h PG ≥209 mg/dL, (b) FPG ≥100 mg/dL, and (c) FPG ≥100 mg/dL with 1-h PG ≥209 mg/dL. Methods: OGTT were performed in 641 African-born Blacks enrolled in the Africans in America cohort (male: 62% (396/641), age: 39±11y (mean±SD), BMI: 27.8±4.6 kg/m2. African regions of birth: West 49%, East 32%, Central 17%, Southern Africa 2%). Glucose tolerance status of the participants was previously unknown. T2D was diagnosed based on 2-h PG of ≥200 mg/dL. Results: Prevalence of newly diagnosed T2D, prediabetes and normal glucose tolerance were: 7% (45/641), 32% (204/641) and 61% (392/641), respectively. The sensitivity and specificity of the 1-h PG≥209 mg/dL-alone criterion were 67% and 89%, respectively. Using the FPG≥100 mg/dL alone, the sensitivity increased to 76%, while specificity remained at 89%. Combining FPG≥100 mg/dL and 1-h PG≥209 mg/dL, further improved sensitivity to 84%, with specificity of 87%. The combined approach demonstrated significantly higher sensitivity compared to 1-h PG ≥209 mg/dL-alone (P=0.008); whereas the difference between FPG -alone and the combined tests approached significance (P=0.125). Conclusion: Combining 1-h PG and FPG enhances the detection of T2D in Africans and supports reducing the OGTT from 2-h to 1-h. K. Lakhani: None. E.A. Huefner: None. M. Sayed: None. G.G. Smith: None. K. Ntabadde: None. C. DuBose: None. M. Bergman: None. R. Jagannathan: None. A.E. Sumner: None.

Introduction and Objective: Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD) is the leading cause of chronic liver disease in the U.S., yet data on MASLD among U.S. immigrants, particularly African immigrants are limited. We aimed to assess the prevalence and predictors of MASLD in African immigrants in the Africans in America cohort. Methods: In 610 African-born Blacks without significant alcohol intake (0-6 drinks/week), [male:60% (369/610), age:39±11y (mean±SD), BMI:27.7±4.6kg/m2], MASLD was defined as Hepatic Steatosis Index (HSI) > 36 in the presence of at least one cardiometabolic risk factor (any criterion of metabolic syndrome). The HSI is an algorithm that incorporates BMI, AST/ALT ratio, sex, diabetes status to predict hepatic steatosis. Glucose tolerance status was assessed using the OGTT. Demographic and metabolic factors were compared between participants with and without MASLD using Wilcoxon rank-sum and chi-squared tests, as appropriate. Results: The prevalence of MASLD was 55% (333/610) and did not vary by sex: males 52% (193/369) vs females 58% (140/241), p=0.16. Participants with MASLD were older, with a median age (IQR) of 39y[33-49] vs 34y[28-42], p<0.01 and had lived longer in the U.S (11[4-20] vs 8y[3-17], p=0.05). Compared to people without MASLD, more participants with MASLD had an annual income ≥ 40k (56% v 47%, p=0.02). MASLD was associated with a higher prevalence of hypertension (38% vs 24%), abnormal glucose tolerance (47% vs 27%), both p<0.01. Participants with MASLD exhibited higher markers of adiposity (BMI, waist circumference, visceral adipose tissue), and a worse lipid profile: higher LDL cholesterol, lower HDL cholesterol, and higher triglycerides, all p<0.01. Conclusion: Over half of the African immigrants in this cohort met criteria for MASLD, highlighting the need for further evaluation. Key predictors included older age, longer duration of U.S. residence, higher income, abnormal glucose tolerance, and dyslipidemia. K. Ntabadde: None. E.A. Huefner: None. M. Sayed: None. G.G. Smith: None. C. DuBose: None. A.E. Sumner: None.

Diagnosing diabetes by shortening the OGTT to 1-h and substituting 1-h post-load glucose (PG) ≥ 209 mg/dL for 2-h PG≥200 mg/dL has been proposed. One-hour PG≥209 mg/dL is from a meta-analysis without any African-descent populations. Our data suggest 1-h PG≥183 mg/dL maybe more optimal for Africans. As with waist circumference guidelines, population-specific thresholds may be appropriate.

Background: With the prevalence of abnormal glucose tolerance (Abnl-GT) soaring in sub-Saharan Africa, there is a growing appreciation that the major etiology of Abnl-GT in Africans may be beta-cell failure rather than insulin resistance (IR). As optimal therapy depends on etiology, distinguishing between beta-cell failure and IR is critical. However, identifying IR with formulas such as the Matsuda Sensitivity Index which requires insulin to be assayed in plasma, is expensive and rarely available in medical clinics in most African countries. Therefore, our goal was to use data from the Matsuda Index as the diagnostic standard, and determine how well the widely available, low-cost Triglyceride-Glucose Index (TyG) performs in distinguishing between beta-cell failure and IR in Africans with Abnl-GT. Methods: OGTTs and fasting triglyceride (TG) levels were obtained in 589 African immigrants living in the Washington DC area (Male: 64%, Age: 39±11, (mean±SD) range 20 -69y; BMI 27.9±4.5 kg/m 2 range 19.5-41.9). Glucose tolerance status was determined by ADA criteria for the OGTT. IR was defined as the lowest quartile of the population distribution of the Matsuda Index (≤2.89). As a primary etiology, beta-cell failure was defined as Abnl-GT in the absence of IR. Insulin secretion was calculated using the insulinogenic index. The formula for TyG was: ln(fasting glucose & fasting TG)/2. IR by TyG was defined by the highest quartile of its distribution across the cohort(≥3.38). Results: Abnl-GT occurred in 39% (228/589) of the enrollees. Among participants with Abnl-GT, the prevalence of beta-cell failure and IR were: 59% (134/228) vs. 41% (94/228), P <0.001, respectively. Compared to Africans with Abnl-GT and IR, Africans with Abnl-GT and beta-cell failure had less IR & lower insulin secretion (both P<0.001). Overall, with data from the Matsuda Index as the diagnostic standard, TyG correctly identified the etiology of Abnl-GT in 90% (205/228) of the participants with Abnl-GT, specifically 93% (125/134) with beta-cell failure and 85% (80/94) of participants with IR. Conclusions: As the TyG correctly identified the etiology of Abnl-GT in 90% of Africans, it may be a feasible, economically viable alternative to the Matsuda Index in determining whether Africans with Abnl-GT have beta-cell failure or IR. With correct information about Abnl-GT etiology, therapy for can be optimized.

Purpose: Body image affects health practices. With acculturation superimposed on globalization, 21st century body size preferences of African immigrants, one of the fasting growing populations in the United States, are unknown. Therefore, in African immigrants living in America we assessed: 1) body size preference; and 2) body size dissatisfaction. Methods: Participants chose two silhouettes from the Stunkard Figure Rating Scale: one for body size preference and one for perceived body size. Each silhouette corresponds to a BMI category: (a) Underweight: 1 and 2; (b) Normal weight: 3 and 4; (c) Overweight: 5, 6 and 7; (d) Obesity: 8 and 9. Dissatisfaction was defined as the difference between silhouette numbers for perceived and preferred body size. Results: Characteristics of the 412 participants were: women: 42% (174/412), age 40 +/- 11y (mean +/- SD), range 20-69 y, BMI 27.9 +/- 4.6, range 19.5-47.3 kg/m2. 2 . As a body size of preference, no one (0/412) chose obese silhouettes. Normal weight silhouettes were chosen as their body size of preference by 75% (131/174) of women and 60% (143/238) of men. Overweight silhouettes were chosen as their preferred body size by 11% (19/174) of women and 26% (62/238) of men. Combining normal and overweight silhouettes into one group, 86% (150/174) of women and 86% (205/238) of men preferred to be either normal or overweight. Underweight silhouettes were preferred by 14% (24/174) of women and 14% (33/238) of men. Dissatisfaction because body size was too large occurred in 78% (135/174) of women and 53% (126/238) of men. Dissatisfaction because body size was too small occurred in 6% (11/174) of women and 16% (38/238) of men. Conclusion: African immigrants prefer body sizes which are normal or overweight. However, and presumably attributable to the combined influence of globalization and acculturation, a worrisome fraction of African immigrants favor an underweight silhouette. Plain Language Summary: Understanding the attitudes of Africans towards body size is important because these attitudes affect health behaviors. The 20th century consensus was that Africans viewed large body sizes as a sign of the health, beauty, fertility, and prosperity. In addition, underweight silhouettes were viewed with fear and considered to be a sign of poverty, malnutrition, and HIV infection. In the 21st century, African attitudes towards body size are unknown. African immigrants are a rapidly growing segment of the American population. Their attitudes toward body size are influenced by both globalization and acculturation. In our cohort, we found 86% of the Africans living in America wanted to be either normal or low range overweight. However, and very concerning, 14% of African immigrants chose underweight silhouettes to represent their body size of preference. As weight loss programs are brought forward in and by African communities living in the United States, the emphasis must be on achieving a healthy weight and not glorification of underweight silhouettes.