Deconstructing race and gender differences in adolescent obesity: Oaxaca-blinder decomposition

Association between weight-adjusted waist index and bone mineral density in adolescents

The negative effects of obesity and excess body fat on bone mineral density (BMD) have been widely reported. As opposed to waist circumference (WC) or body mass index (BMI), weight-adjusted waist index (WWI) is a superior method for assessing obesity. WWI also indicates centripetal obesity independently of the weight of the individual. An investigation of WWI and adolescents' BMD was conducted in this study. The National Health and Nutrition Examination Survey (NHANES) 2011-2018 provided the data for this cross-sectional investigation. In this study, weighted multivariate logit models were employed to assess the correlation between teenage BMD and WWI. Additionally, we conducted interaction tests and subgroup analysis. Through multivariate linear regression, we discovered that WWI was negatively linked with lumbar, trunk, and total BMD but not pelvis BMD in this study, which included 6828 subjects. We found that each unit increase in WWI resulted in a lumbar BMD decline of 0.04 g/cm2 (95%CI -0.04, -0.04), a trunk BMD decrease of 0.03 g/cm2 (95%CI -0.03, -0.02), and a total BMD decrease of 0.02 g/cm2 (95%CI -0.02, -0.02). In conclusion, in US teenagers, there were negative connections discovered between WWI and lumbar, trunk, and total BMD, but not pelvis BMD.

Regional trends in mental health inequalities in young people aged 16-25 in the UK and the role of cuts to local government expenditure: Repeated cross-sectional analysis using the British household panel Survey/UK household longitudinal survey

Young people's mental health globally has been in decline. Because of their low perceived need, young people's services tend to be the first cut when budgets are reduced. There is a lack of evidence on how a reduction in services and opportunities for young people is associated with their mental health. Additionally, how this may be magnified by place and the assets and challenges of place. The aim of this study is to explore trends in young people's mental health measured by GHQ-12 over time in the twelve regions of the UK. We estimated an interrupted time series model using 2010 as a break point from which there was a shift in government policy to a prolonged period of large reductions in central government funding. Repeated cross-sectional data on young people aged 16-25 is used from the British Household Panel Survey and its successor survey UK Household Longitudinal Survey. Results showed a statistically significant reduction in mental health for young people living in the North East, Wales, and the East of England. The North East was the region with the largest reduction in funding and saw the greatest reduction in young people's mental health. Next, we look at how reductions in local government expenditure related to services for children and young people: children's social services, education, transportation, and culture; explain the observed decline in mental health. We employ a Blinder-Oaxaca Decomposition approach comparing young people's mental health between 2011 and 2017. Results show a marginally statistically significant decrease in young people's mental health over this time. Unobserved factors related to transport spending and children's social services explain some of this gap. Area level factors such as deprivation, infrastructure, and existing assets need to be considered when distributing funding for young people's services to avoid exacerbating regional inequalities in mental health.

Racial disparities in breast cancer risk factors and risk management

Racial disparities in breast cancer outcomes are well described across the spectrum of screening, diagnosis, treatment, and survivorship. Breast cancer mortality is markedly elevated for Non-Hispanic Black women compared with other racial and ethnic groups, with multifactorial causes. Here, we aim to reduce this burden by identifying disparities in breast cancer risk factors, risk assessment, and risk management before breast cancer is diagnosed. We describe a reproductive profile and modifiable risk factors specific to the development of triple-negative breast cancer. We also propose that screening strategies should be both risk- and race-based, given the prevalence of early-onset triple-negative breast cancer in young Black women. We emphasize the importance of early risk assessment and identification of patients at hereditary and familial risk and discuss indications for a high-risk referral. We discuss the subtleties following genetic testing and highlight "uncertain" genetic testing results and risk estimation challenges in women who test negative. We trace aspects of the obesity epidemic in the Black community to infant feeding patterns and emphasize healthy eating and activity. Finally, we discuss building an environment of trust to foster adherence to recommendations, follow-up care, and participation in clinical trials. Addressing relevant social determinants of health; educating patients and clinicians on factors impacting disparities in outcomes; and encouraging participation in targeted, culturally sensitive research are essential to best serve all communities.

Measuring Racial Differences in Obesity Risk Factors in Non-Hispanic Black and White Men Aged 20 Years or Older

Obesity prevalence in the United States has increased drastically in the last two decades. Racial differences in obesity have emerged with the increase in obesity, with temporal trends because of individual, socioeconomic, and environmental factors, eating behaviors, lack of exercise, etc., raising questions about understanding the mechanisms driving these racial differences in the prevalence of obesity among non-Hispanic Black (NHB) and non-Hispanic White (NHW) men. Although many studies have measured obesity using body mass index (BMI), little is known about waist circumference (WC). This study examines variations in obesity among NHW and NHB using BMI and WC. We used National Health and Nutrition Examination Surveys (1999-2016) with a sample of 9,000 NHW and 3,913 NHB men aged 20 years or older. To estimate the association between the prevalence of obesity (BMI ≥30) and race, we applied modified Poisson regression; to explore and decompose racial differences, we used Oaxaca-Blinder decomposition (OBD). We found that NHW had higher abdominal obesity (WC ≥102) than NHB, but NHB were more likely to be obese (BMI ≥30) during most years, with some fluctuations. Modified Poisson regression showed that NHB had a higher prevalence of obesity (prevalence ratio [PR]: 1.11, 95% confidence interval [CI] = [1.04, 1.18]) but lower abdominal obesity (PR: 0.845; 95% CI = [0.801, 0.892]) than NHW. OBD showed that age, access to health care, smoking, and drinking contributed to the differences in abdominal obesity. The study identifies a significant increase in obesity among men over the last two decades; generalized obesity (based on BMI) was more problematic for NHB men, but abdominal obesity was more problematic for NHW men.

Explaining adult obesity, severe obesity, and BMI: Five decades of change

Obesity rates have increased across all segments of society since the late 1970s, but the reason behind population-level increases in body weight remains unclear. We used the 1971-2020 NHANES data to examine whether the observed trend in obesity prevalence is attributable to changing public health behaviors (i.e., intracohort change) or changing publics (i.e., cohort replacement). We partitioned total change in mean BMI, and rates of obesity and severe obesity, into its IC and CR components using linear and algebraic decomposition methods. We found that the IC mechanism (i.e., broad sectors of individuals changing) plays a dominant role in the overall increase in mean BMI, and obesity and severe obesity prevalence. Birth cohort membership (i.e., the CR mechanism) is also influencing mean BMI, and rates of obesity and severe obesity, but in differing ways. Specifically, the large positive IC and the small positive CR effects are amplifying one another, thus creating a steep increase in the observed rates of severe obesity. Conversely, the large positive IC effect is offset by a small negative CR effect, which created a more gradual rise in mean BMI and rates of obesity. Furthermore, we computed total change for models that entered separately sociodemographic, lifestyle, nutritional, and physical activity measures to estimate differences in mean BMI, and rates of obesity and severe obesity, among cohorts and time periods. Adjustment for all the compositional differences among the cohorts during the study period indicate that a combination of a more pronounced IC and a less pronounced CR drove the observed increase in mean BMI, and rates of obesity and severe obesity. Thus, "universal prevention" (i.e., entire community) strategies for healthy weight promotion may need to be combined with "selective prevention" (i.e., at-risk groups) and/or "targeted prevention" (i.e., at-risk individuals) approaches in order to reverse the obesity epidemic.

Drivers of Cost Differences Between Nurse Practitioner and Physician Attributed Medicare Beneficiaries

BACKGROUND

Although recent research suggests that primary care provided by nurse practitioners costs less than primary care provided by physicians, little is known about underlying drivers of these cost differences.

RESEARCH OBJECTIVE

Identify the drivers of cost differences between Medicare beneficiaries attributed to primary care nurse practitioners (PCNPs) and primary care physicians (PCMDs).

STUDY DESIGN

Cross-sectional cost decomposition analysis using 2009-2010 Medicare administrative claims for beneficiaries attributed to PCNPs and PCMDs with risk stratification to control for beneficiary severity. Cost differences between PCNPs and PCMDs were decomposed into payment, service volume, and service mix within low-risk, moderate-risk and high-risk strata.

RESULTS

Overall, the average PCMD cost of care is 34% higher than PCNP care in the low-risk stratum, and 28% and 21% higher in the medium-risk and high-risk stratum. In the low-risk stratum, the difference is comprised of 24% service volume, 6% payment, and 4% service mix. In the high-risk stratum, the difference is composed of 7% service volume, 9% payment, and 4% service mix. The cost difference between PCNP and PCMD attributed beneficiaries is persistent and significant, but narrows as risk increases. Across the strata, PCNPs use fewer and less expensive services than PCMDs. In the low-risk stratum, PCNPs use markedly fewer services than PCMDs.

CONCLUSIONS

There are differences in the costs of primary care of Medicare beneficiaries provided by nurse practitioners and MDs. Especially in low-risk populations, the lower cost of PCNP provided care is primarily driven by lower service volume.

Six-minute walk distance equation in children and adolescents with obesity

AIM

To develop a 6-minute walk-distance (6MWD) reference equation for children and adolescents with obesity, and to assess its determinant factors.

METHODS

A cross-sectional study using mixed linear and multiple regression models was conducted in 497 children (235 girls and 262 boys) aged 6-18 years with a body mass index (BMI) greater than 97th percentile. Anthropometrics and a 6-minute walk test (6MWT) were performed.

RESULTS

Mean 6MWD was 547 ± 86 m for girls and 575 ± 96 m for boys, which averaged ~80% of a reference normal-weight population matched for age and ethnicity. Age, weight and BMI were positively correlated with 6MWD whereas waist and hip circumferences (WC and HC, respectively) were negatively correlated with 6MWD for both genders. The combination of age, height, BMI and HC explained 69% of the 6MWD variability in the equation for the whole population. Moreover, the combination of age, height, HC as well as the combination of age, height, BMI and WC explained 67% and 75% of the variability in the girls' and boys' equations, respectively.

CONCLUSION

This 6MWD reference equation, which was influenced by abdominal obesity markers in a gender-specific way, extends and enhances scientific knowledge and provides useful predictive tools for the care of obese children.

Socioethnic disparities in severe maternal morbidity in Western Australia: a statewide retrospective cohort study

OBJECTIVES

To assess the scale of ethnic inequalities in severe maternal morbidity (SMM) rates and quantify the contribution of maternal characteristics to these disparities.

DESIGN

Retrospective cohort study.

SETTING

Whole-of-population linked administrative data from 2002 to 2015 in Western Australia.

PARTICIPANTS

Women with 410 043 birth events (includes all births from the same pregnancy) of 20 weeks' or more gestation, including terminations for congenital anomalies.

PRIMARY AND SECONDARY OUTCOME MEASURES

Women with SMM were identified based on a composite indicator of SMM using diagnosis and procedure codes developed for use in routinely collected data. Mothers were classified into seven ethnic groups, based on their reported ethnic origin. The associations between maternal ethnic origin and SMM were examined using a log-binomial model, which estimates risk ratios (RRs) and 95% CIs. The Blinder-Oaxaca decomposition technique was employed to partition the disparity in SMM between Aboriginal and Caucasian populations into 'explained' and 'unexplained' components.

RESULTS

During the study period, 9378 SMM cases were documented. In the adjusted model, Aboriginal (RR 1.73, 95% CI 1.59 to 1.87), African (RR 1.64, 95% CI 1.43 to 1.89) and 'other' ethnicity (RR 1.49, 95% CI 1.37 to 1.63) women were at significantly higher risk of SMM compared with Caucasian women. Teenage and older mothers and socioeconomically disadvantaged women were also at greater risk of SMM. Differences in sociodemographic characteristics explained 33.2% of the disparity in SMM between Aboriginal and Caucasian women.

CONCLUSIONS

There are distinct disparities in SMM by ethnicity in Western Australia, with a greater risk among Aboriginal and African women. While improvements in SES and a reduction in teenage pregnancy can potentially support a sizeable reduction in SMM rate inequalities, future research should investigate other potential pathways and targeted interventions to close the ethnicity disparity.

Factors That Contribute to Cost Differences Based on ICU of Admission in Neonates Undergoing Congenital Heart Surgery: A Novel Decomposition Analysis

OBJECTIVES

We leveraged decomposition analysis, commonly used in labor economics, to understand determinants of cost differences related to location of admission in children undergoing neonatal congenital heart surgery.

DESIGN

A retrospective cohort study.

SETTING

Pediatric Health Information Systems database.

PATIENTS

Neonates (<30 d old) undergoing their index congenital heart surgery between 2004 and 2013.

MEASUREMENTS AND MAIN RESULTS

A decomposition analysis with bootstrapping determined characteristic (explainable by differing covariate levels) and structural effects (if covariates are held constant) related to cost differences. Covariates included center volume, age at admission, prematurity, sex, race, genetic or major noncardiac abnormality, Risk Adjustment for Congenital Heart Surgery-1 score, payor, admission year, cardiac arrest, infection, and delayed sternal closure.Of 19,984 infants included (10,491 [52%] to cardiac ICU/PICU and 9,493 [48%] to neonatal ICU), admission to the neonatal ICU had overall higher average costs ($24,959 ± $3,260; p < 0.001) versus cardiac ICU/PICU admission. Characteristic effects accounted for higher costs in the neonatal ICU ($28,958 ± $2,044; p < 0.001). Differing levels of prematurity, genetic syndromes, hospital volume, age at admission, and infection contributed to higher neonatal ICU costs, with infection rate providing the most significant contribution ($13,581; p < 0.001). Aggregate structural effects were not associated with cost differences for those admitted to the neonatal ICU versus cardiac ICU/PICU (p = 0.1). Individually, prematurity and age at admission were associated with higher costs due to structural effects for infants admitted to the neonatal ICU versus cardiac ICU/PICU.

CONCLUSIONS

The difference in cost between neonatal ICU and cardiac ICU/PICU admissions is largely driven by differing prevalence of risk factors between these units. Infection rate was a modifiable factor that accounted for the largest difference in costs between admitting units.

Why do apprentices smoke much more than high school students? Understanding educational disparities in smoking with a Oaxaca-blinder decomposition analysis

Background

Educational disparities in daily smoking begin during adolescence and can lead to educational disparities in health among adults. In particular, vocational students including apprentices have higher daily smoking rates compared to non-vocational students. This study aimed to identify the determinants of the gap in daily smoking between French apprentices and high school students aged 17 in 2008 and in 2017.

Methods

We used data from a cross-sectional repeated survey representative of all French adolescents aged 17 in 2008 and 2017. We conducted a non-linear extension of the Oaxaca-Blinder decomposition technique and included the following variables: sociodemographic and familial characteristics, parental smoking, cannabis and alcohol use, suicidal attempt, grade repetition and money received.

Results

Daily smoking was about two times higher among French apprentices compared to high school students in 2008. This gap did not decrease between 2008 and 2017. Differences in measured characteristics between the two groups explained this gap partly, from 28.6 to 51.2%. Cannabis and alcohol use, money received and parental smoking contributed the most to the daily smoking gap.

Conclusions

Prevention programs could target cannabis and alcohol use as well as parental smoking to help decrease educational disparities in smoking status among French adolescents.

Assessing the Role of Health Behaviors, Socioeconomic Status, and Cumulative Stress for Racial/Ethnic Disparities in Obesity

OBJECTIVE

This study aimed to examine the explanatory role of health behaviors, socioeconomic position (SEP), and psychosocial stressors on racial/ethnic obesity disparities in a multiethnic and multiracial sample of adults.

METHODS

Using data from the Chicago Community Adult Health Study (2001-2003), Oaxaca-Blinder decomposition analysis was conducted to quantify the extent to which health behaviors (fruit and vegetable consumption and physical activity), SEP, and cumulative stressors (e.g., perceived discrimination, financial strain) each explained differences in obesity prevalence in Black, US-born Hispanic, and non-US-born Hispanic compared with non-Hispanic White participants.

RESULTS

SEP and health behaviors did not explain obesity differences between racial/ethnic minorities and White individuals. Having high levels of stress in four or more domains explained 4.46% of the differences between Black and White individuals, whereas having high levels of stress in three domains significantly explained 14.13% of differences between US-born Hispanic and White. Together, the predictors explained less than 20% of differences between any racial/ethnic minority group and White individuals.

CONCLUSIONS

Exposure to stressors may play a role in obesity disparities, particularly among Black and US-born Hispanic individuals. Other obesity-related risk factors need to be examined to understand the underlying mechanisms explaining obesity disparities.

Mortality Disparities in Racial/Ethnic Minority Groups in the Veterans Health Administration: An Evidence Review and Map

BACKGROUND

Continued racial/ethnic health disparities were recently described as "the most serious and shameful health care issue of our time." Although the 2014 US Affordable Care Act-mandated national insurance coverage expansion has led to significant improvements in health care coverage and access, its effects on life expectancy are not yet known. The Veterans Health Administration (VHA), the largest US integrated health care system, has a sustained commitment to health equity that addresses all 3 stages of health disparities research: detection, understanding determinants, and reduction or elimination. Despite this, racial disparities still exist in the VHA across a wide range of clinical areas and service types.

OBJECTIVES

To inform the health equity research agenda, we synthesized evidence on racial/ethnic mortality disparities in the VHA.

SEARCH METHODS

Our research librarian searched MEDLINE and Cochrane Central Registry of Controlled Trials from October 2006 through February 2017 using terms for racial groups and disparities.

SELECTION CRITERIA

We included studies if they compared mortality between any racial/ethnic minority and nonminority veteran groups or between different minority groups in the VHA (PROSPERO# CRD42015015974). We made study selection decisions on the basis of prespecified eligibility criteria. They were first made by 1 reviewer and checked by a second and disagreements were resolved by consensus (sequential review).

DATA COLLECTION AND ANALYSIS

Two reviewers sequentially abstracted data on prespecified population, outcome, setting, and study design characteristics. Two reviewers sequentially graded the strength of evidence using prespecified criteria on the basis of 5 key domains: study limitations (study design and internal validity), consistency, directness, precision of the evidence, and reporting biases. We synthesized the evidence qualitatively by grouping studies first by racial/ethnic minority group and then by clinical area. For areas with multiple studies in the same population and outcome, we pooled their reported hazard ratios (HRs) using random effects models (StatsDirect version 2.8.0; StatsDirect Ltd., Altrincham, England). We created an evidence map using a bubble plot format to represent the evidence base in 5 dimensions: odds ratio or HR of mortality for racial/ethnic minority group versus Whites, clinical area, strength of evidence, statistical significance, and racial group.

MAIN RESULTS

From 2840 citations, we included 25 studies. Studies were large (n ≥ 10 000) and involved nationally representative cohorts, and the majority were of fair quality. Most studies compared mortality between Black and White veterans and found similar or lower mortality for Black veterans. However, we found modest mortality disparities (HR or OR = 1.07, 1.52) for Black veterans with stage 4 chronic kidney disease, colon cancer, diabetes, HIV, rectal cancer, or stroke; for American Indian and Alaska Native veterans undergoing noncardiac major surgery; and for Hispanic veterans with HIV or traumatic brain injury (most low strength).

AUTHOR'S CONCLUSIONS

Although the VHA's equal access health care system has reduced many racial/ethnic mortality disparities present in the private sector, our review identified mortality disparities that have persisted mainly for Black veterans in several clinical areas. However, because most mortality disparities were supported by single studies with imprecise findings, we could not draw strong conclusions about this evidence. More disparities research is needed for American Indian and Alaska Native, Asian, and Hispanic veterans overall and for more of the largest life expectancy gaps. Public Health Implications. Because of the relatively high prevalence of diabetes in Black veterans, further research to better understand and reduce this mortality disparity may be prioritized as having the greatest potential impact. However, other mortality disparities affect thousands of veterans and cannot be ignored.

Body size reference norms and subjective weight status: A gender and life course approach

This paper uses data from The National Longitudinal Study of Adolescent to Adult Health (Add Health) to describe county-level variation in norms regarding physical weight among adolescents in the United States. We demonstrate that regardless of one's physical size, those residing in counties with a heavier weight norm are significantly less likely to see themselves as overweight than those residing in counties with a light weight norm. We further show that the local weight norm during adolescence (Wave 1) is associated with individuals' weight perceptions through adolescence and into young adulthood (Wave 4), though these associations attenuate in strength as respondents age. Our results suggest that weight norms have a stronger influence on weight perceptions among women compared to men and that the role of gender is particularly important during adolescence. We encourage life course researchers to consider the normative health environment during adolescence as an important context for understanding disparities in health and health lifestyles as people age.

Racial and Ethnic Disparities in Early Childhood Obesity

OBJECTIVES

The prevalence of childhood obesity is significantly higher among racial and/or ethnic minority children in the United States. It is unclear to what extent well-established obesity risk factors in infancy and preschool explain these disparities. Our objective was to decompose racial and/or ethnic disparities in children's weight status according to contributing socioeconomic and behavioral risk factors.

METHODS

We used nationally representative data from ∼10 700 children in the Early Childhood Longitudinal Study Birth Cohort who were followed from age 9 months through kindergarten entry. We assessed the contribution of socioeconomic factors and maternal, infancy, and early childhood obesity risk factors to racial and/or ethnic disparities in children's BMI z scores by using Blinder-Oaxaca decomposition analyses.

RESULTS

The prevalence of risk factors varied significantly by race and/or ethnicity. African American children had the highest prevalence of risk factors, whereas Asian children had the lowest prevalence. The major contributor to the BMI z score gap was the rate of infant weight gain during the first 9 months of life, which was a strong predictor of BMI z score at kindergarten entry. The rate of infant weight gain accounted for between 14.9% and 70.5% of explained disparities between white children and their racial and/or ethnic minority peers. Gaps in socioeconomic status were another important contributor that explained disparities, especially those between white and Hispanic children. Early childhood risk factors, such as fruit and vegetable consumption and television viewing, played less important roles in explaining racial and/or ethnic differences in children's BMI z scores.

CONCLUSIONS

Differences in rapid infant weight gain contribute substantially to racial and/or ethnic disparities in obesity during early childhood. Interventions implemented early in life to target this risk factor could help curb widening racial and/or ethnic disparities in early childhood obesity.