Neighborhood context and racial/ethnic differences in young children's obesity: structural barriers to interventions

Social Determinants and Health Behaviors: Conceptual Frames and Empirical Advances

Health behaviors shape health and well-being in individuals and populations. Drawing on recent research, we review applications of the widely applied "social determinants" approach to health behaviors. This approach shifts the lens from individual attribution and responsibility to societal organization and the myriad institutions, structures, inequalities, and ideologies undergirding health behaviors. Recent scholarship integrates a social determinants perspective with biosocial approaches to health behavior dynamics. Empirical advances model feedback among social, psychological and biological factors. Health behaviors are increasingly recognized as multidimensional and embedded in health lifestyles, varying over the life course and across place and reflecting dialectic between structure and agency that necessitates situating individuals in context. Advances in measuring and modeling health behaviors promise to enhance representations of this complexity.

Where there's smoke: Cigarette use, social acceptability, and spatial approaches to multilevel modeling

I contribute to understandings of how context is related to individual outcomes by assessing the added value of combining multilevel and spatial modeling techniques. This methodological approach leads to substantive contributions to the smoking literature, including improved clarity on the central contextual factors and the examination of one manifestation of the social acceptability hypothesis. For this analysis I use restricted-use natality data from the Vital Statistics, and county-level data from the 2005-9 ACS. Critically, the results suggest that spatial considerations are still relevant in a multilevel framework. In addition, I argue that spatial processes help explain the relationships linking racial/ethnic minority concentration to lower overall odds of smoking.

Associations of family and neighborhood socioeconomic characteristics with longitudinal adiposity patterns in a biracial cohort of adolescent girls

Although many studies have examined the relationship of adiposity with neighborhood socioeconomic context in adults, few studies have investigated this relationship during adolescence. Using 10-year annual measurements of body mass index, expressed as z-scores (BMIz), obtained from 775 black and white participants of the National Heart, Lung, and Blood Institute Growth and Health Study, a prospective cohort study of girls from pre- to postadolescence, we used multilevel modeling to investigate whether family socioeconomic status (SES) and neighborhood socioeconomic characteristics (measured by census-tract median family income) explain variation in BMIz trajectory parameters. Analyses controlled for pubertal maturation. We found that lower SES was associated with higher overall levels of BMIz for both white and black girls. Additionally, lower-SES black girls had a more sustained increase in BMIz during early adolescence and reached a higher peak compared to higher-SES black girls and to white girls. Neighborhood income was associated with BMIz trajectory for black girls only. Unexpectedly, among black girls, living in higher-income neighborhoods was associated with higher overall levels of BMIz, controlling for SES. Our findings suggest that neighborhood socioeconomic characteristics may affect adolescent BMIz trajectories differently in different racial/ethnic groups.

Race/ethnic disparities in early childhood BMI, obesity and overweight in the United Kingdom and United States

OBJECTIVE

Racial/ethnic patterning in the risk of obesity and overweight has been observed in early childhood; however, little research has compared these disparities between the United Kingdom (UK) and United States (US) using detailed ethnic classifications. We use comparable nationally representative cohort studies to examine racial/ethnic disparities in mean body mass index (BMI) and in the odds of obesity/overweight in the UK and US. The contribution of sociodemographic, cultural and family routine factors are assessed.

METHODS

Data on BMI, obesity and overweight in 5-year-old children from the MCS (Millennium Cohort Study) and ECLS-B (Early Childhood Longitudinal Study, Birth Cohort) were examined. We investigated race/ethnic disparities in mean BMI and in the odds of obesity and overweight, as compared to normal weight. We assessed the independent contribution of sociodemographic, cultural and family routine factors to observed disparities.

RESULTS

In the UK, after adjustment for sociodemographic, cultural and family routine factors and maternal BMI, we found Black Caribbean children to have higher odds ratio (OR=1.7, confidence interval (CI)=1.1-2.6), Pakistani children to have lower odds of obesity (OR=0.60, CI=0.37-0.96) and Black African children were more likely to be overweight (OR=1.40, CI=1.04-1.88). In the US, in fully adjusted models, there were no race/ethnic disparities in children's odds of obesity and overweight.

CONCLUSION

Disparities for Bangladeshi children in the UK and Mexican, other Hispanic and American Indian children in the US can be explained by socioeconomic disadvantage, whereas a range of cultural and family characteristics partially explain disparities for other groups in the UK. Future public health initiatives focused on reducing risk of overweight and obesity should consider the diverse socioeconomic and cultural profiles of all race/ethnic groups.

Obesity-related behaviors of US- and non-US-born parents and children in low-income households

OBJECTIVE

To examine differences in obesity-related behaviors by parental US-born status among low-income, minority families participating in Healthy Habits, Happy Homes, an intervention trial to improve household routines for childhood obesity prevention. Evidence suggests lower obesity risk among adult immigrants, but research is inconclusive regarding the influence of having a non-US-born parent on childhood obesity.

METHOD

We sampled 57 US-born and 64 non-US-born families of children aged 2 to 5.9 years living in the Boston area. At baseline, parents reported their own screen time, physical activity, diet, and sleep as well as their children's behaviors. We used linear and logistic regression to examine the association of parental US-born status with obesity-related behaviors.

RESULTS

Mean (SD) body mass index z score was 0.94 (1.16), and it did not differ between the groups. After adjusting for parental education and child race/ethnicity, children of non-US-born (vs US-born) parents had later bedtimes (0.81 hours later; 95% confidence interval [CI], 0.37-1.25) and wake-up times (0.56 hours later; 95% CI, 0.16-0.95) and engaged in less active play (0.15 fewer hr/d; 95% CI, -0.28 to -0.01). Non-US-born (vs US-born) parents had less screen exposure.

CONCLUSION

In this cross-section of low-income, urban families, having a parent born outside the United States was associated with a profile of risk and protective behavior; adjustment for education and race/ethnicity removed the protective associations of parental nativity with child behavior. Obesity-related differences in behaviors and home environments should be considered when designing interventions targeting low-income communities with a high proportion of non-US-born participants.

Neighbourhood economic deprivation explains racial/ethnic disparities in overweight and obesity among children and adolescents in the U.S.A

BACKGROUND

Low-income and some racial and ethnic subpopulations are more likely to suffer from obesity. Inequities in the physical and social environment may contribute to disparities in paediatric obesity, but there is little empirical evidence to date. This study explored whether neighbourhood-level socioeconomic factors attenuate racial and ethnic disparities in obesity among youth in the U.S.A. and whether individual-level socioeconomic status (SES) interacts with neighbourhood deprivation.

METHODS

This analysis used data from 17,100 youth ages 2-18 years participating in the 2001-2010 National Health and Nutrition Examination Survey linked to census tract-level socioeconomic characteristics. Multilevel logistic regression models were used to examine neighbourhood deprivation in association with odds of obesity (age-specific and sex-specific body mass index percentile ≥95).

RESULTS

The unadjusted prevalence of obesity was 15% among non-Hispanic white children and 21% among non-Hispanic black and Mexican-American children. Adjustment for individual-level SES neighbourhood deprivation and the interaction between these two factors resulted in a 74% attenuation of the disparity in obesity between non-Hispanic black and non-Hispanic white children and a 49% attenuation of the disparity between Mexican-American and non-Hispanic white children. There was a significant interaction between individual-level SES and neighbourhood deprivation where higher individual-level income was protective for children living in low-deprivation neighbourhoods, but not for children who lived in high-deprivation areas. Conversely, area deprivation was associated with higher odds of obesity, but only among children who were above the poverty threshold.

CONCLUSIONS

Future research on disparities in obesity and other health outcomes should examine broader contextual factors and social determinants of inequities.

Women's Health: Racial and Ethnic Health Inequities

Starting in the late 1980s and throughout the 1990s, reports appeared in the literature describing the poor health status and poor health outcomes experienced by minority populations, especially blacks, in the United States. Additionally, attention was brought to the limited access to health services for minority populations. These reports prompted Congress to request the Institute of Medicine (IOM) to conduct a study to assess differences in the kinds and quality of healthcare received by US racial and ethnic minorities and nonminorities. The study culminated in the report Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care.(1) Among the recommendations included in the report published in 2003 is a need for (1) change in legal, regulatory, and policy interventions and (2) health systems interventions. The committee extended the recommendations to include (3) implementation of programs to enhance individual education and empowerment, (4) a need for research into identifying racial and ethnic disparities and the development of and assessment of intervention strategies, and (5) a need to integrate cross-cultural education into the training of all health professionals.(1) Subsequent to this report, there has been an increase in efforts to increase diversity among healthcare providers and research investigators.(2) The American Association of Medical Colleges (AAMC) continues to encourage recruitment of minorities to careers in medicine, to stress the importance of a diverse medical school faculty and administration, and to graduate culturally competent healthcare providers who will decrease health disparities and improve health equity. Additionally, as noted by Ginther et al in 2011, there continues to be a need to increase diversity at the National Institutes of Health (NIH) not only among the workforce but also among the recipients of awards.(3) To this end, the NIH has established the Working Group on Diversity in the Biomedical Research Workforce to monitor the efforts of the NIH to increase diversity and to suggest remedies.(4.)

Obesity and the risk of chronic rhinosinusitis, allergic rhinitis, and acute otitis media in school-age children

OBJECTIVES/HYPOTHESIS

To determine if obesity is a significant risk factor for acute otitis media (AOM), allergic rhinitis (AR), or chronic rhinosinusitis (CRS) in children and to understand the potential otolaryngological implications of childhood obesity.

STUDY DESIGN

Cross-Sectional Analysis.

METHODS

The 2006 and 2008 the Medical Expenditure Panel Survey was utilized to identify school-aged children with AOM, AR, and/or CRS. Risk factors for the diagnoses extracted included standard demographics and the presence or absence of obesity. Multivariate analyses were conducted for associations between childhood obesity and AOM, AR, and CRS.

RESULTS

42.1 million (95% CI, 40.4-44.2) school-age children (unweighted N = 10623) were sampled in 2006 and 2008. There was a slight male predominance (51.0% [95% CI, 49.8-52.2]). Of these patients, 2.2 million (95% CI 1.9-2.4) received a diagnosis of AOM, 4.0 million (95% CI 3.6-4.4) received a diagnosis of AR, and 1.7 million (95% CI 1.4-1.9) received a diagnosis of CRS. Approximately 9.3 million (95% CI 8.7-10.0) children were obese, representing 22.2% (95% CI 21.0-23.3) of the U.S. population (age 6-17). Utilizing an adjusted multivariate model, childhood obesity was found to be associated with AOM (odds ratio, 1.44; [95% CI 1.08-1.93]; P = 0.033). Significant associations between obesity and AR (OR 1.14; [95% CI 0.88-1.47]; P = 0.60) or obesity and CRS (OR0.73; [95% CI 0.48-1.10]; P = 0.79) were not identified.

CONCLUSION

Childhood obesity appears to be associated with the development of AOM; however, an association between obesity and AR or CRS was not demonstrated. Given that in the United States nearly one-fourth of all children seeking health care are obese, these data may have important preventative care implications.

LEVEL OF EVIDENCE

2C.

Immigrant enclaves and obesity in preschool-aged children in Los Angeles County

While neighborhood environments are increasingly recognized as important contributors to obesity risk, less has been reported on the socio-cultural aspects of neighborhoods that influence obesity development. This is especially true among immigrants, who may lack the necessary language skills to navigate their new living environments. In this study, we tested the hypothesis that young children of immigrants would be at lower obesity risk if they lived in neighborhoods where neighbors share the same language and culture. Using 2000 Census data and 2003-2009 data from the Special Supplemental Nutrition Program for Women, Infants and Children in Los Angeles County, we examined the relation between BMI z-scores in low-income children aged 2-5 years (N = 250,029) and the concentration of neighborhood residents who spoke the same language as the children's mothers. Using multi-level modeling and adjusting for child's gender and race/ethnicity, household education, neighborhood socioeconomic status, and year the child was examined, we found that percent of neighborhood residents who spoke the same language as the child's mother was negatively associated with BMI z-scores. This relation varied by child's race/ethnicity and mother's preferred language. The relation was linear and negative among children of English-speaking Hispanic mothers and Chinese-speaking mothers. However, for Hispanic children of Spanish-speaking mothers the relation was curvilinear, initially exhibiting a positive relation which reversed at higher neighborhood concentrations of Spanish-speaking residents. Our findings suggest that living in neighborhoods where residents share the same language may influence obesity-related behaviors (namely diet and physical activity) possibly through mechanisms involving social networks, support, and norms.