Consensus Statement Authors

1
Consensus Statement Authors
Influence of Race, Ethnicity Culture on
Childhood Obesity

• Sonia Caprio, MD
• Dept. Pediatrics, Yale U of School, Medicine
• Stephen Daniels, MD, PhD
• Dept. Pediatrics, U of Colorado
• Adam Drewnowski, PhD
• Dept. Epidemiology, Medicine, U of Washington
• Francine Kaufman, MD
• Dept. Pediatrics Communications U of Southern
  Cal.

• Lawrence Palinkas, PhD
• Dept. Social Work, Anthropology Preventive
  Medicine, U of Southern Cal.
• Arlan Rosenbloom, MD
• Dept. Pediatrics, U of Fla.
• Jeffrey Schwimmer, MD
• Dept., Pediatrics, U of Cal. San Diego, CA

2
Consensus Statement Questions
Influence of Race, Ethnicity Culture on
Childhood Obesity

• What are the prevalence, severity and
  consequences of childhood obesity across
  race/ethnicity in the US?
• How might socio-economic factors influence
  racial/ethnic differences in childhood obesity?
• What are the biological and cultural factors
  associated with racial/ethnic differences in
  childhood obesity?
• What are the implications of race/ethnicity on
  the prevention of childhood obesity?
• What are the implications of race/ethnicity on
  the treatment of childhood obesity?

3
Definitions
Influence of Race, Ethnicity Culture on
Childhood Obesity

• Obesity Body weight that confers health risk, in
  children BMI 95th percentile (data derived in
  1970)
• Race Ethnicity Social constructs, constantly
  evolving, categorizes populations on basis of
  shared characteristics
• Race Biologic genes, skin color, observable
  features
• Ethnicity Shared language, ancestry, religious
  traditions, dietary preferences and history

4
What are the prevalence, severity and
consequences of childhood obesity across
race/ethnicity in the US?
Influence of Race, Ethnicity Culture on
Childhood Obesity

• Obesity prevalence tripled since 1980

Severe obesity prevalence of BMI 30 Boys 39
NA 14 W and AA Girls 14 NA 10 W 18 AA
JAMA 20062951549-1555 JAMA 20082992401-2405
5
How might socio-economic factors influence
racial/ethnic differences in childhood obesity?
Influence of Race, Ethnicity Culture on
Childhood Obesity

• Socio-economic factors likely exert a profound
  influence on health
• Usually assessed by self-reported parental
  education and income levels
• Percent poverty and poverty-to-income ratios used
  to stratify by income groups
• Focus on current income masks underlying
  disparities in material resources, (e.g. car,
  house) and accumulated wealth
• Access to resources and services not equivalent
  for given level of education or income
• Community influences access to healthy foods,
  opportunities for physical activity, quality of
  schools, time allocation and commuting time

6
How might socio-economic factors influence
racial/ethnic differences in childhood obesity?
Influence of Race, Ethnicity Culture on
Childhood Obesity

• Major racial differences in wealth at a given
  level of income
• Whites in the bottom quintile of income had some
  accumulated resources, African Americans in the
  same income quintile had 400 times less,
  essentially none
• There are further race-dependent differences in
  income by different levels of education, as well
  as differences in neighborhood poverty at
  different levels of income

7
How might socio-economic factors influence
racial/ethnic differences in childhood obesity?
Influence of Race, Ethnicity Culture on
Childhood Obesity

• Three critical SES constructs Money, place and
  time
• Hypothesis Low cost of widely available
  energy-dense but nutrient-poor foods
• Fast food consumption is associated with
  energy-dense diets and to higher energy intake
  overall
• Lower cost foods make up a greater proportion of
  the diet of lower income persons
• USDA studies female recipients of food
  assistance had more energy-dense diets, consumed
  fewer vegetables and fruit, and were more likely
  to be obese

8
How might socio-economic factors influence
racial/ethnic differences in childhood obesity?
Influence of Race, Ethnicity Culture on
Childhood Obesity

• Three critical SES constructs money, Place and
  time
• Area-base SES measures, poverty levels, property
  taxes, house values, more objective ways to
  assess wealth or e deprivation of neighborhood
• Living in high-poverty areas associated with
  higher obesity and diabetes - after controlling
  for individual education, occupation, income
• Harvards Geocoding Study census tract poverty
  more powerful predictor of health outcomes than
  race/ethnicity
• In LA youth obesity associated with economic
  hardship level and park area per capita

9
How might socio-economic factors influence
racial/ethnic differences in childhood obesity?
Influence of Race, Ethnicity Culture on
Childhood Obesity

• Three critical SES constructs money, place and
  Time
• The allocation of time resources by individuals
  and households depends on socio-economic status
• Common tradeoff concerning diet selection is
  between time and money
• Thrifty Food Plan (TFP) recommended diet at 27
  per person per week, but requires approx. 16
  hours of food prep per week
• A typical working American woman spends only 6
  hours per week on food prep and a non working
  woman spends 11 hours

10
What are the biological and cultural factors
associated with racial/ethnic differences in
childhood obesity?
Influence of Race, Ethnicity Culture on
Childhood Obesity

• Biological factors may, in part mediate
  racial/ethnic and SES differences in childhood
  obesity
• Low SES or discrimination by race or ethnicity
  may result in increased stress.
• Stress has direct effect on hypothalamic-pituitary
  -adrenal (HPA) axis - elevation of plasma
  cortisol, implicated in obesity

11
What are the biological and cultural factors
associated with racial/ethnic differences in
childhood obesity?
Influence of Race, Ethnicity Culture on
Childhood Obesity

• Relationships between stress and illness differ
  by race/ethnicity, in part due to differences in
• The genes or gene variants that would support
  this hypothesis have not been identified
• Exposure to social/environmental stressors
• Degree to which environment, SES and
  discrimination appraised as stressful
• Culturally appropriate strategies for coping
• Biological vulnerability to stress
• A thrifty genotype may confer an advantage in
  an energy-poor environment, and a disadvantage in
  an energy dense environment

12
What are the biological and cultural factors
associated with racial/ethnic differences in
childhood obesity?
Influence of Race, Ethnicity Culture on
Childhood Obesity

• A number of studies have found differences in fat
  distribution, insulin sensitivity and secretion,
  lipids, and regulatory hormone/cytokine secretion
  between racial/ethnic groups
• AA less visceral and hepatic fat compared to W, H
• H lower insulin sensitivity than W, and higher
  compensatory insulin levels
• AA and H children lower insulin sensitivity than
  W
• AA higher circulating insulin levels than W due
  to more robust beta cell response to glucose and
  decreased clearance of insulin in the liver
• AA lower rates of basal lipolysis compared to
  whites
• AA lower levels of adiponectin than W

13
What are the biological and cultural factors
associated with racial/ethnic differences in
childhood obesity?
Influence of Race, Ethnicity Culture on
Childhood Obesity

• Culture, unlike instinct, is learned is
  distributed within a group in that not everyone
  possesses the same knowledge, attitudes, or
  practices enables us to communicate with one
  another and behave in ways that are mutually
  interpretable, and exists in a social setting
• Among the shared understandings embodied by a
  culture are those pertaining to obesity including
  understanding its Cause, Course, Cure and
  whether it is Illness

14
What are the biological and cultural factors
associated with racial/ethnic differences in
childhood obesity?
Influence of Race, Ethnicity Culture on
Childhood Obesity

• Cultural variation is impacted by
• Migration of new groups
• Residential segregation of groups defined by
  culture, race and ethnicity
• Maintenance of original language
• Second generation of immigrants
• Formal social organizations (religious
  institutions, clubs, community or family-based
  associations)
• Globalization
• Acculturation

15
What are the biological and cultural factors
associated with racial/ethnic differences in
childhood obesity?
Influence of Race, Ethnicity Culture on
Childhood Obesity

• Globalization Social process in which the
  constraints of geography on social and cultural
  arrangements recede
• Globalization can impact obesity by
• Promotion of travel (low-income population
  migration to high-income countries)
• Trade (production and distribution of high-fat,
  energy-dense food and investment in food
  processing and retailing across borders
• Communication (promotional food marketing)

16
What are the biological and cultural factors
associated with racial/ethnic differences in
childhood obesity?
Influence of Race, Ethnicity Culture on
Childhood Obesity

• Acculturation Changes of original cultural
  patterns of one or more groups when they come
  into continuous contact with one another
• Acculturation can impact obesity by
• Encouraging the abandonment of traditional
  beliefs and behaviors that minimize the risk of
  overweight
• Adoption of beliefs and behaviors that increase
  the risk of obesity

17
What are the biological and cultural factors
associated with racial/ethnic differences in
childhood obesity?
Influence of Race, Ethnicity Culture on
Childhood Obesity

• Globalization and Acculturation impact
  preferences for certain foods and forms of
  leisure/physical activity, as well as educational
  and economic opportunities
• First generation Asian and Latino adolescents
  consume higher amounts of fruits and vegetables
  and lower amounts of soda compared to whites
• Succeeding generations of Asians continue this
  pattern
• By the third generation, Latinos nutrition is
  poorer than whites

18
What are the Implications of Race/Ethnicity in
the Prevention of Childhood Obesity?
Public Policy
Government
Laws
Community
Parks Recreation
Neighborhood
Regulations
Organizational
Health Care
Media
Faith Organizations
Culture
Schools
Interpersonal
Community Organizations
Food Industry
Values
Family
INDIVIDUAL
19
What are the Implications of Race/Ethnicity in
the Prevention of Childhood Obesity?
Influence of Race, Ethnicity Culture on
Childhood Obesity

• The role of the primary care provider
• Discuss obesity risk Recommendations of the AAP
  and AMA
• Stage 1 Prevention Plus
• BMI 85-94th
• Goal - weight maintenance
• Decreasing BMI as age and height increases
• Advice
• Follow 5-2-1-0 protocol
• Eat breakfast, limit meals outside of home
• Duration of brief focused discussion varies based
  on childs risk of obesity, culture, education
  level, and SES
• Plot BMI show the plot over time explain
  meaning of BMI, BMI percentile, and upward
  crossing of percentiles
• Training in cultural competency to understand
  specific barriers and influence of culture and
  society on health behaviors
• Anticipatory guidance and motivational
  interviewing

20
What are the Implications of Race/Ethnicity in
the Prevention of Childhood Obesity? A Life
Cycle View
Influence of Race, Ethnicity Culture on
Childhood Obesity

• The perinatal and newborn period
• Race/ethnicity and SES influence timing, number
  and interval between pregnancies, and risk for
  GDM
• Excessive weight gain and failure to lose weight
  between pregnancies - risk for GDM
• LGA and SGA - risk for obesity and
  obesity-related diseases in childhood,
  particularly in poor populations
• Access to prenatal care, optimal nutrition,
  efforts to reduce prenatal stress, and counseling
  to avoid alcohol, drugs and cigarettes.
• Breast-feeding decreases the incidence of obesity
  in childhood, and in the mother who nurses
• A meta-analysis - inverse relationship between
  the duration of breast-feeding and the risk of
  becoming overweight

21
What are the Implications of Race/Ethnicity in
the Prevention of Childhood Obesity?
Influence of Race, Ethnicity Culture on
Childhood Obesity

• Food and PA habits established early in life
• Toddlers need to learn self-regulation
• Difficult concept for cultures that have food
  beliefs around set meals and pre-determined
  quantities of food
• Lifestyle patterns influenced by parental role
  modeling, and the childs environment must
  provide access to healthy foods and encourage
  appropriate physical activity
• Health care providers should convey caloric needs
  of children, concepts of healthy eating and the
  importance of physical activity

TV in their bedrooms

• 32 of 2-7 year olds
• 65 of 8-18 year olds

22
What are the implications of race/ethnicity on
the treatment of childhood obesity?
Influence of Race, Ethnicity Culture on
Childhood Obesity

• Guidelines exist to identify, evaluate, and treat
  obese children little is known about the effect
  of race/ethnicity on outcomes
• Disparities in access to quality health care
• Disparities in access, affordability and
  acceptance of nutrition and PA recommendations
• Programs to date mainly in white, middle class
  children
• Racial/ethnic differences in response to
  medications, behavior modification, and surgery

23
What are the implications of race/ethnicity on
the treatment of childhood obesity?
Influence of Race, Ethnicity Culture on
Childhood Obesity

• What questions remain?
• Additional studies, with better measurements, are
  needed to help resolve the current uncertainty
  about the effect of socioeconomic status on
  health outcomes, and the interplay between SES
  and race/ethnicity.
• More research needed to better understand the
  stressors associated with race/ethnicity and SES,
  and better measures are needed to quantify the
  biological effects of stress.

24
What are the implications of race/ethnicity on
the treatment of childhood obesity?
Influence of Race, Ethnicity Culture on
Childhood Obesity

• Culture influences the risk of obesity in
  children and cultural differences may account, in
  part, for the disparities in childhood obesity.
• The influence of race/ethnicity and culture on
  preventive efforts in the clinical health care
  setting and in the public health domain requires
  further understanding and evaluation.
• Fundamental questions regarding childhood obesity
  treatments remain and should be a research
  priority
• Need to identify robust markers of risk for poor
  outcomes and determine whether such markers
  differ by race or ethnicity.
• Need to determine how to effectively deliver the
  appropriate care, including ways to tailor
  behavioral interventions to suit an individuals
  culture and environment.
• Need to understand cost.