Associations between Obesity, Obesogenic Environments, and Structural Racism Vary by County-Level Racial Composition

Obesity and Cardiovascular Disease: A Scientific Statement From the American Heart Association

The global obesity epidemic is well established, with increases in obesity prevalence for most countries since the 1980s. Obesity contributes directly to incident cardiovascular risk factors, including dyslipidemia, type 2 diabetes, hypertension, and sleep disorders. Obesity also leads to the development of cardiovascular disease and cardiovascular disease mortality independently of other cardiovascular risk factors. More recent data highlight abdominal obesity, as determined by waist circumference, as a cardiovascular disease risk marker that is independent of body mass index. There have also been significant advances in imaging modalities for characterizing body composition, including visceral adiposity. Studies that quantify fat depots, including ectopic fat, support excess visceral adiposity as an independent indicator of poor cardiovascular outcomes. Lifestyle modification and subsequent weight loss improve both metabolic syndrome and associated systemic inflammation and endothelial dysfunction. However, clinical trials of medical weight loss have not demonstrated a reduction in coronary artery disease rates. In contrast, prospective studies comparing patients undergoing bariatric surgery with nonsurgical patients with obesity have shown reduced coronary artery disease risk with surgery. In this statement, we summarize the impact of obesity on the diagnosis, clinical management, and outcomes of atherosclerotic cardiovascular disease, heart failure, and arrhythmias, especially sudden cardiac death and atrial fibrillation. In particular, we examine the influence of obesity on noninvasive and invasive diagnostic procedures for coronary artery disease. Moreover, we review the impact of obesity on cardiac function and outcomes related to heart failure with reduced and preserved ejection fraction. Finally, we describe the effects of lifestyle and surgical weight loss interventions on outcomes related to coronary artery disease, heart failure, and atrial fibrillation.

The Moderating Effects of the Families Improving Together (FIT) for Weight Loss Intervention and Parenting Factors on Family Mealtime in Overweight and Obese African American Adolescents

Few studies have integrated positive parenting and motivational strategies to address dietary outcomes such as frequency of family mealtime. The Families Improving Together (FIT) for Weight Loss trial was a randomized group cohort trial (n = 241 dyads) testing the efficacy of integrating a motivational plus family weight loss (M + FWL) intervention for healthy eating and weight loss in overweight and obese African American adolescents. The current study tested the interaction of parenting styles (responsiveness, demandingness) and parental feeding practices (restriction, concern about child’s weight, pressure to eat) and the FIT intervention on frequency of family mealtime over 16 weeks. Multilevel modeling demonstrated significant interactions between the group-based treatment and responsiveness (p = 0.018) and demandingness (p = 0.010) on family mealtime. For the group-based M + FWL intervention, increased responsiveness and reduced demandingness were associated with increased frequency of family mealtime from baseline to 16 weeks. There was also a negative association between parental restriction and frequency of family mealtime, but a positive association between parental concerns about their adolescent’s weight and frequency of mealtime. These findings are the first to demonstrate that an authoritative or nurturing parenting style moderated intervention effects for improving the frequency of family mealtime in overweight and obese African American adolescents.

Contribution of Adipose Tissue Oxidative Stress to Obesity-Associated Diabetes Risk and Ethnic Differences: Focus on Women of African Ancestry

Adipose tissue (AT) storage capacity is central in the maintenance of whole-body homeostasis, especially in obesity states. However, sustained nutrients overflow may dysregulate this function resulting in adipocytes hypertrophy, AT hypoxia, inflammation and oxidative stress. Systemic inflammation may also contribute to the disruption of AT redox equilibrium. AT and systemic oxidative stress have been involved in the development of obesity-associated insulin resistance (IR) and type 2 diabetes (T2D) through several mechanisms. Interestingly, fat accumulation, body fat distribution and the degree of how adiposity translates into cardio-metabolic diseases differ between ethnicities. Populations of African ancestry have a higher prevalence of obesity and higher T2D risk than populations of European ancestry, mainly driven by higher rates among African women. Considering the reported ethnic-specific differences in AT distribution and function and higher levels of systemic oxidative stress markers, oxidative stress is a potential contributor to the higher susceptibility for metabolic diseases in African women. This review summarizes existing evidence supporting this hypothesis while acknowledging a lack of data on AT oxidative stress in relation to IR in Africans, and the potential influence of other ethnicity-related modulators (e.g., genetic-environment interplay, socioeconomic factors) for consideration in future studies with different ethnicities.

Development and Feasibility of an Obesity Prevention Intervention for Black Adolescent Daughters and Their Mothers

Black female adolescents and women have disproportionately higher rates of obesity than their racial/ethnic counterparts. There is an urgent need to address obesity prevention in Black adolescent females through interventions that enhance lifestyle physical activity and improve dietary behaviors. Middle adolescence presents an important opportunity to strengthen the daughter-mother bond and improve healthy behaviors such as physical activity and dietary intake. Because of the intersection of adolescent development, culture and structural racism, it is essential to include mothers; however, this approach is understudied in the literature. This pre-pilot proof of concept study, Black Girls Move, was conducted using a 12-week pre-post within-subjects design to assess feasibility of conducting and delivering the BGM intervention, program satisfaction, and ability to obtain outcome measures in Black ninth and tenth grade daughters and their mothers. Twenty-two dyads were recruited and 14 dyads completed baseline assessments; however, only eight daughters and their mothers attended the first session and remained for the entire study. All dyads had valid objective and self-reported physical activity data. However, two of eight daughters and one mother provided self-reported dietary data that were considered invalid. All individual sessions were rated highly. Excellent attendance, retention, and satisfaction among participants suggest that we succeeded in developing an accepted, culturally relevant intervention. This lifestyle intervention would be strengthened by modifications to recruitment and retention, as well as incorporation of a computerized dietary assessment tool, a tailored dietary app for self-monitoring, and increased photo-based and group homework activities.

Effects of Parenting and Perceived Stress on BMI in African American Adolescents

OBJECTIVE

This study set out to examine the role of parenting practices in protecting or exacerbating the negative effects of parent and adolescent stress on adolescent body mass index (BMI) over time. Separate longitudinal models were conducted to evaluate how parenting practices interacted with parental perceived stress and adolescent perceived stress in predicting adolescent BMI.

METHODS

Baseline data were collected from 148 African American adolescents (Mage = 12.93, SD = 1.75; Mz-BMI = 0.78, SD = 0.50; MBMI%-ile = 96.7, SD = 3.90) and their caregivers (Mage = 44.45, SD = 8.65; MBMI = 37.63, SD = 8.21) enrolled in the Families Improving Together for Weight Loss trial. Adolescents self-reported their perceptions of caregiver parenting style and feeding practices. Both caregivers and adolescents self-reported their perceptions of chronic stress. BMI for parents and adolescents was assessed objectively at baseline and 16 weeks post-intervention.

RESULTS

Hierarchical regression models predicting adolescent BMI z-score (z-BMI) indicated a significant interaction between parental perceived stress and parental pressure to eat. Simple slopes analyses demonstrated that for those parents that exhibit higher pressure to eat, parent stress was positively associated with adolescent z-BMI.

CONCLUSIONS

These findings provide preliminary support suggesting that certain parenting practices interact with chronic stress on adolescent weight-related outcomes and that future interventions may consider integrating these factors.

Structural racism, racial inequities and urban-rural differences in infant mortality in the US

Background

While evidence shows considerable geographic variations in county-level racial inequities in infant mortality, the role of structural racism across urban–rural lines remains unexplored. The objective of this study was to examine the associations between county-level structural racism (racial inequity in educational attainment, median household income and jail incarceration) and infant mortality and heterogeneity between urban and rural areas.

Methods

Using linked live birth/infant death data provided by the National Center for Health Statistics, we calculated overall and race-specific 2013–2017 5-year infant mortality rates (IMRs) per 1000 live births in every county. Racially stratified and area-stratified negative binomial regression models estimated IMR ratios and 95% CIs associated with structural racism indicators, adjusting for county-level confounders. Adjusted linear regression models estimated associations between structural racism indicators and the absolute and relative racial inequity in IMR.

Results

In urban counties, structural racism indicators were associated with 7%–8% higher black IMR, and an overall structural racism score was associated with 9% greater black IMR; however, these findings became insignificant when adjusting for the region. In white population, structural racism indicators and the overall structural racism score were associated with a 6% decrease in urban white IMR. Both absolute and relative racial inequity in IMR were exacerbated in urban counties with greater levels of structural racism.

Conclusions

Our findings highlight the complex relationship between structural racism and population health across urban–rural lines and suggest its contribution to the maintenance of health inequities in urban settings.

Promoting Healthy Eating and Regular Physical Activity in Low-Income Families Through Family-Centered Programs: Implications for Practice

Research concerning children who are overweight has historically focused on providing services to the affected individuals, and limited attention has been paid to their families. Further, childhood obesity prevention and clinical programs continue to be impacted by contextual factors that increase the likelihood of attrition when targeting underserved populations. This paper provides data with relevance for interventions aimed at promoting healthy eating and regular physical activity with low-income families. Participants in a childhood obesity exploratory study provided recommendations to improve programs by reflecting on specific family and contextual issues related to children who are overweight and obese. Following a thematic analysis approach, we conducted semi-structured interviews with 16 low-income, single, female parents. All participants had, at the time of the interview, at least one overweight or obese child between the ages of 3 and 8. We report the critical role of context in the etiology and challenges of childhood obesity among disadvantaged populations. Findings also highlight the need for interventions to be culturally relevant and sensitive and to create opportunities to address and discuss participant experiences of discrimination, cultural factors, and family of origin influences. Interventions that do not address these contextual factors run the risk of being unsuccessful. Our findings are important for mental and public health professionals who are interested in the direct provision of services using a combination of social determinants of systemic perspectives.

Measuring Structural Racism and Its Association With BMI

INTRODUCTION

Structural racism has attracted increasing interest as an explanation for racial disparities in health, including differences in adiposity. Structural racism has been measured most often with single-indicator proxies (e.g., housing discrimination), which may leave important aspects of structural racism unaccounted for. This paper develops a multi-indicator scale measuring county structural racism in the U.S. and evaluates its association with BMI.

METHODS

County structural racism was estimated with a confirmatory factor model including indicators reflecting education, housing, employment, criminal justice, and health care. Using Behavioral Risk Factor Surveillance Survey data (2011-2012) and a mixed-effects model, individual BMI was regressed on county structural racism, controlling for county characteristics (mean age, percentage black, percentage female, percentage rural, median income, and region). Analysis occurred 2017-2019.

RESULTS

The study included 324,572 U.S. adults. A 7-indicator county structural racism model demonstrated acceptable fit. County structural racism was associated with lower BMI. Structural racism and black race exhibited a qualitative interaction with BMI, such that racism was associated with lower BMI in whites and higher BMI in blacks. In a further interaction analysis, county structural racism was associated with larger increases in BMI among black men than black women. County structural racism was associated with reduced BMI for white men and no change for white women.

CONCLUSIONS

The results confirm structural racism as a latent construct and demonstrate that structural racism can be measured in U.S. counties using publicly available data with methods offering a strong conceptual underpinning and content validity. Further study is necessary to determine whether addressing structural racism may reduce BMI among blacks.

Race, racism and disparities in obesity rates in the US

Click here to view the Letter to the Editor by Gower et al.

Psychosociocultural Contributors to Maladaptive Eating Behaviors in African American Youth: Recommendations and Future Directions

Childhood overweight and obesity disproportionately affects African Americans, and these children benefit less from standard pediatric weight management treatment programs compared to other racial/ethnic groups. Maladaptive eating behavior has been identified as a behavioral contributor to obesity and is also associated with the development of nonrestrictive eating disorders over time. Unique psychosociocultural factors have been identified that may promote higher risk for maladaptive eating behaviors in African American children beyond the effects of economic disparity. To best treat this group, it is important for practitioners to have a thorough understanding of these factors. We review several of these considerations and describe ways they may interact to contribute to the subsequent development of maladaptive eating behaviors and increased weight. Recommendations are made regarding how attention to these factors could be incorporated into current pediatric weight management treatments to better serve this population via a patient-centered care approach. Future directions will also be discussed.

Self-Rated Health and Structural Racism Indicated by County-Level Racial Inequalities in Socioeconomic Status: The Role of Urban-Rural Classification

Recent attention to the interrelationship between racism, socioeconomic status (SES) and health has led to a small, but growing literature of empirical work on the role of structural racism in population health. Area-level racial inequities in SES are an indicator of structural racism, and the associations between structural racism indicators and self-rated health are unknown. Further, because urban-rural differences have been observed in population health and are associated with different manifestations of structural racism, explicating the role of urban-rural classification is warranted. This study examined the associations between racial inequities in SES and self-rated health by county urban-rural classification. Using data from County Health Rankings and American Communities Surveys, black-white ratios of SES were regressed on rates of fair/poor health in U.S. counties. Racial inequities in homeownership were negatively associated with fair/poor health (β = -0.87, s.e. = 0.18), but racial inequities in unemployment were positively associated with fair/poor health (β = 0.03, s.e. = 0.01). The associations between structural racism and fair/poor health varied by county urban-rural classification. Potential mechanisms include the concentration of resources in racially segregated counties with high racial inequities that lead to better health outcomes, but are associated with extreme black SES disadvantage. Racial inequities in SES are a social justice imperative with implications for population health that can be targeted by urban-rural classification and other social contextual characteristics.

Wealth and Obesity Among US Adults Entering Midlife

OBJECTIVE

This study examines the relationship between wealth and obesity among adults entering midlife and whether this relationship varies by sex, race, and measure of wealth.

METHODS

The data were obtained from the National Longitudinal Survey of Youth 1979 (NLSY-79). Population-averaged models were used to examine the associations between multiple measures of wealth and obesity among 6,979 respondents while controlling for education, occupation, income, and relevant sociodemographic variables.

RESULTS

The analysis found a robust association between wealth and midlife obesity as well as heterogeneity in the wealth-obesity association across sex, race, and measure of wealth. With the exception of black men, net worth generally had a significant and inverse relationship with obesity. The net worth-obesity association was largest among women and was driven primarily by home value, in addition to savings and debt for black women. Although home value was significant for white men, the components of wealth were generally unrelated to obesity among men.

CONCLUSIONS

The association between wealth and obesity was generally robust but also complex, depending on sex, race, and measure of wealth. Research that does not consider multiple components of wealth may overlook the importance of economic resources in shaping obesity rates in the US population.

Neighborhoods to Nucleotides - Advances and gaps for an obesity disparities systems epidemiology model

Purpose of Review

Disparities in obesity rates in the US continue to increase. Here we review progress and highlight gaps in understanding disparities in obesity with a focus on the Hispanic/Latino population from a systems epidemiology framework. We review seven domains: environment, behavior, biomarkers, nutrition, microbiome, genomics, and epigenomics/transcriptomics. We focus on recent advances that include at least two or more of these domains, and then provide a real world example of data collection efforts that reflect these domains.

Recent Findings

Research into DNA methylation related to discrimination and microbiome relating to eating behaviors and food content is furthering understanding of why disparities in obesity persist. Environmental and neighborhood level research is uncovering the importance of exposures such as air and noise pollution and systematic or structural racism for obesity and related outcomes through behaviors such as sleep.