Adolescent Health Disparities

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Adolescent Health Disparities the Sociocultural
EnvironmentImproving outcomes for future
generations

• Antronette K. (Toni) Yancey, MD, MPH
• Professor, Department of Health Services
• Co-Director, Center to Eliminate Health
  Disparities
• UCLA School of Public Health
• www.ph.ucla.edu/cehd
• www.toniyancey.com

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Presentation Outline

• Overview of disparities definitions
• Sociocultural, physical, and economic
  environmental risk in underserved communities
• Social ecological intervention models
  underscoring recent PH successes
• Specific examples of UCLA CEHD research projects
  addressing policy environmental solutions to
  adolescent health disparities building on
  cultural assets

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Research Team/Collaborators

• UCLA Bill McCarthy, PhD Brian Cole, DrPH
  Jabar Akbar, MPH Minal Patel, MPH Georgina
  Agyekum, MPH
• Samuels Assoc Sarah Samuels, DrPH Sarah
  Stone-Francisco Liz Schwarte Lisa Craypo
• UT Jerome Williams, PhD Chiquita Collins, PhD
• UC Davis Diana Cassady, PhD
• LAC DHS Paul Simon, MD, MPH Eloisa Gonzalez,
  MD, MPH Jonathan Fielding, MD, MPH, MBA
• CA DHS Desiree Backman, DrPH Sue Foerster
• UPenn Sonya Grier, PhD Amy Hillier, PhD
  Shiriki Kumanyika, PhD, MPH
• Georgia Tech Craig Zimring, PhD, Gayle Nicoll,
  PhD, Keith Jundanian
• CDC Bill Kohl, PhD

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Years of Potential Life Lostby Ethnicity (per
100,000)
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U.S. Childhood Obesity Epidemic Trends
Obesity prevalence in U.S. children and
adolescents by age and time frame, 1963-2004
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Type 2 Diabetes Incidence Among Adolescents

• 1982 0.7 / 100,000 per year
• 1994 7.2 / 100,000 per year
• 2004 13.9-16.0 / 100,000 per year

gt20-fold increase
Sources Pinhas-Hamiel O et al. J Pediatr
1996128608-15 Daniels et al, Circulat
20051111999-2012
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Potential Influence on Life Expectancy

• For the first time in thousands of years, this
  generation of children may live shorter lives
  than their parents
• Chances of developing diabetes at birth for
  African-American and Latino children is about
  twice that of white children (1 in 2 vs. 1 in
  4)
• Olshansky et al., NEJM 2005352(11)1138-45
• Daniels et al, Circulat 20051111999-2012

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Staying healthy is easier for some than for
others

• UPPER SES LOWER SES
• Education College GED or HS
• Housing Own / Safe Rent / Safe?
• Physical activity Gyms /Parks Few
  parks, move insecure
• Advertising Sparse Pervasive
• Neighborhood stores Fruit/Veg, food
  secure Drugs/Alcohol, food insecure
• Police Helpful Abusive
• Healthcare Private Doc
  ER, VA
• Sick leave Accrued
  None
• Leisure priority Exercise Rest
• Work conditions Safe, hi decis.
  lat., Hazardous, lo decis. lat., no flex
  time no flex time
• Child care Nanny/hi-qual facil. Family/neigh
  bor, lo-qual facil.
• Elder/disabled care HHW/hi-qual
  facil. Family/neighbor, lo-qual facil.
• Criminal just. sys. Little contact Much contact
• Premature MM Low High

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Excess physical environmental risk in underserved
communities

• targeted/exploitative marketing
• excess fast food outlets
• few supermarkets
• limited healthful shelf choices poorer quality
  produce
• high-fat food availability (home, church
• poorer public/less private transportation

• distance to private fitness facilities
• few worksite fitness opportunities
• few/poor neighborhood recreation facilities
• lesser neighborhood safety
• poorer public/less private transportation
• Adapted from Kumanyika S. Obesity in Minority
  Populations. In Fairburn G Brownell K, Eating
  Disorders and Obesity. A Comprehensive Handbook,
  2002.

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Buford Highway projectEstimating projected
increases in walking
Increased walking based on improved walkability
Before
After
Avg LOS D (4.1) Estd LOS B-
(2.4) Avg min. walked/week 51 Estd
min. walked/week 62 -175
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Excess economic environmental risk in underserved
communities

• low neighborhood demand for healthy food choices
• low family incomes
• other household expenses
• little homegrown food
• financial incentives for under-resourced schools
  by commercial vendors

• limited investment in parks/recreation facilities
• fitness facility fees
• cost of exercise equipment
• less stable employment patterns
• fewer trained PE instructors
• larger PE classes
• poorly equipped facilities

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Excess sociocultural environmental risk in
underserved communities

• traditional cuisine/cultural anchoring
• prevalent obesity/norms
• body image ideals
• female roles
• fasting-feasting/
• (perceived) food insecurity
• higher stressor levels/ comfort foods

• cultural attitudes about PA, rest
• fears about safety
• female roles
• cultural reverence for cars
• hairstyle-related concerns about sweating
• increased screen time

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Obesity as social contagion

• Social network analysis of 32
• years of Framingham cohort study
• data on 12,000 adults? weight
• gain/loss/maintenance over time influenced by
  friends family, extending to 3 degrees of
  separation, independent of immediate physical
  environment (Christakis Fowler, NEJM, 2007)
• Concluded that each individual influences the
  social norm for her/his circle
• Thinness as well as obesity contagious

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Need for Focus on Behavior vs. Weight

• Cultural influences on obesity definition
• Behavioral economics (immediate availability
  usually governs choices)
• Human tendency to do better when we feel
  better, not worse, about ourselves (obesity
  stigma)
• Increasing risk of bulimia and other eating
  disorders among youth with unrealistic body image
  ideals
• Evolutionary hard-wiring
• Stress management/mood elevation benefits
• Suggests need to focus on re-integrating PA
  increasing healthy food availability, appeal,
  pricing competitiveness

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SB19 Early Implementation Study Baseline
demographics
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Distribution of dieting classification, by
BMI-for-age
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OR 0.79, 95 CI .72, .86, p lt .0001,
controlling for age, gender and subsidized lunch
eligibility
N 1,767 7th graders
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Health behavior correlates of not trying to
control weight

• Those not trying to control weight vs. other diet
  status categories ate fast food less often (p
  .04), ate sports bars less often ( p .004),
  drank sports drinks less often (p .001), drank
  sweetened juices less often (p .02) and
  participated in more minutes of physical activity
  in PE class (p .03). They also did better
  academically than other students (p .005).

note logistic regression models included age,
gender and meal subsidy eligibility as covariates
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Capturing targeted media influence

• Social action theory (Kumanyika Ewart) and
  social learning theory (Bandura) emphasize
  influence of role modeling and social comparisons
  with like others on self-efficacy and behavior

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Physical Inactivity Levels TV viewing/computer
use, L.A. County Adults, 1999
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Media Project six-city outdoor advertising
content analysis

• Funded by CA DHS, UT, Penn, NYU RWJF
• Cities LA, Philadelphia, Austin, Sacramento,
  Fresno, New York City
• Comparing high low SES predominantly black,
  Latino, white neighborhoods (all 6 categories
  not available in all cities, e.g., high SES black
  in Sacramento and Fresno)
• Utilizing secondary data from CHIS, LACHS,
  grocery store scanner (MOU with major supermarket
  chain) purchase data for correlational analyses

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Media Project six-city outdoor advertising
content analysis

• Digital cameras and GPS units used to record a
  photo and location coordinates of all ads in zip
  code
• Electronic abstraction form captures domains
  including content, size, nature of appeal,
  density, visibility, ethnicity of subjects,
  weight status of subjects

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Preliminary findings

• Absence of billboards and near-absence of other
  outdoor advertising in affluent white
  neighborhoodsexisting ads unrelated to weight
• Essentially no outdoor advertising of
  PA-promoting goods services in any community,
  but large amount sedentary entertainment
  transportation ads in low-income communities
• Pervasiveness of advertising in low-income white
  Latino communities, but more fast food,
  sugar-sweetened and alcoholic beverages in latter
• City of LA has moratorium on new billboards, but
  in low-income Latino comm., large of new side
  of building ads similarly framed
• Findings must be interpreted in light of
  historical covenants, fewer ads trad. In
  unincorp. areas

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Preliminary Findings
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Unhealthy Food Ad Density near Schools/Day Care
Centers( within ¼ mi of sugary beverage/fast
food ads)
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Definitions
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Definitions (cont.)
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Representative sample of 749 LA adolescents
Yancey A, Siegel J, McDaniel K. Role models,
ethnic identity, and health-risk behaviors in
urban adolescents. Archives of Pediatrics and
Adolescent Medicine.
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Findings regarding sports figures

• Just over half (56) of 12-17 year olds
  identified a role model
• Sports figures were the second largest category
  of role models selected (22 parents, 18 sports
  figures)
• 72/73 of adolescents choosing sports figure role
  models were boys
• Athletes or sports figures influence was as
  positive as that of other figure role models on
  self-esteem, grades and ethnic identityknown
  role models were most influential

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Influence of Wanting to Look Like Media Figures
on Adolescent PA

• Cross-sectional mailed survey of to national
  sample of 5061 boys and 6545 girls 9-16 years old
• TV magazine categories incl. sports,
  including plurality of boys but infrequent girls
  sports media use
• 46 of girls and 27 of boys reported making at
  least some effort to look like figures in the
  media
• Adj. for age, BMI, Tanner stage, and race/
  ethnicity, total PA levels higher by 0.7 and 1.2
  hrs/wk in girls and boys, respectively, for every
  1 (out of 5) category increase in wanting to look
  like media figure
• Taveras EM, Rifas-Shiman SL, Field AE et al. J
  Adol Health 200435(1)41-50.

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Thin is NOT in, according to the new hip hop
standard
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Capturing targeted media influence

• A TV content analysis study found that more than
  4 times as many black prime time actors were
  overweight as actors on general audience shows
• Tirodkar MA, Jain A. Food messages on African
  American television shows.Am J Public Health
  200393439-41.

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Capturing targeted media influence

• Ethnic differences in valuation of thinness may
  influence decisions of advertisers and casting
  directors, distorting TV reality
• Less erosion of exercise self-efficacy,
  especially if depict PA
• May reinforce cultural norms of excess weight,
  influencing body habitus ideals aspirations of
  young people

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Shift in health promotion field (Spectrum of
Prevention)

• The most effective and sustainable PH
  intervention approaches of the past two decades
  are the more upstream ones (structural/environme
  ntal vs. individual-level), involving social norm
  change
• Tobacco control
• Alcohol consumption and driving
• Littering recycling
• Seat belt child safety seat usage

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Spectrum of PreventionHealth behavior change
model

• Level 1 Strengthening individual knowledge
  and skills
• Level 2 Promoting community education
• Level 3 Educating service providers
• Level 4 Fostering coalitions and networks
• Level 5 Changing organizational practice
• Level 6 Influencing policy and legislation

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Population Obesity Control Sample litmus test

• Identifying policy/environmental change vs.
  individual/family change strategies
• Does it rely on each participants
  motivation/volition each time PA occurs?
• If one person leaves organization, does any
  element remain?
• Does it reflect some substantial degree of
  organizational investment, i.e. time or ?

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Professional Athletes Council
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About PAC
Who is PAC?

• First-ever pro athletes collaboration focused on
  reversing the rising trend of youth obesity
• 32 professional athletes signed on with and
  endorsing PAC

Jerry Stackhouse
Allen Rossum
Paul Pierce
T.J. Duckett
Kasey Kahne
Ron Washington
Kym Hampton
Cobi Jones
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Instant Recess
PAC Assets

• Inspired and adapted from UCLA/LA County
  Department of Public Health Lift Off! series
• (www.ph.ucla.edu/cehd/activity_breaks)
• Aims to make prolonged sitting as socially
  unacceptable as smoking, or drinking driving
• Focused on policy and environmental change in two
  types of settings in which athletes most likely
  to have substantial influence and
  credibilitysporting events/ stadiums and
  schools/after-school programs
• Increase visibility through introduction of
  Instant Recess breaks into half-time shows of
  games, and healthy meal/snack options into
  concessions

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Instant Recess

• Pilot program being launched in California in
  partnership with the California Department of
  Health, UCLA School of Public Health and the
  Public Health Institute
• Projected to reach more than 2200 public schools,
  including gt1.5 million students (most eligible
  for free/reduced price lunches
• First DVD prototype completed May 2007
• Features Allen Rossum, Kym Hampton (WNBA NY
  Liberty), Jason Kidd (NBA NJ Nets) and Lamar Odom
  (NBA LA Lakers)

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Instant Recess

• DVD/CD package tool kit to help educators
  re-integrate recess or PA enjoyment back into
  school curriculum
• 10 minutes of athlete-led activity experiences or
  brief structured exercises involving simple
  aerobic/resistance movements to music
• Teacher guide with tips for sustaining interest
  of youth beyond Instant Recess
• Emphasizes not only the importance of physical
  activity and eating nutritious foods, but also,
  more subtly, academic excellence and setting and
  striving to achieve socially constructive
  aspirations

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Critical need for Instant Recess is evident in
recently released California Physical Education
and Physical Activity StudyAvailable at
www.calendow.org
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California School Physical Activity Physical
Education (PE) Assessment Study

• Foundation (TCE) funded, 3-year study
• Random sample of 10 school districts from the CDE
  Public School Directory stratified by region of
  the state (southern, central, northern), tertile
  of Fitnessgram scores SES
• Average district12,000 students, incl. 43
  Latino and 53 White
• Mean FRPL eligibility 58 (SES measure)
• 100 incentive for participation
• 77/200 schools responded (38.5 response rate,
  R26.7-58.8)

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CA PA/PE Assessment Study

• Three data collection methods
• Principals (or most knowledgeable designee)
  survey45 principals, 48 PE teachers
• Environmental audit of random sample of
  responding schools (facilities, recess, PE class)
• Stakeholder survey (e.g., teachers, PTA members,
  school board members, fitness-related non-profit
  organization staff)

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Principal survey findings

• Participation rates lowest among kindergartners
  10th-12th graders
• Lowest rates of adherence to mandated PE minutes
  in primary grades, K-3rd (CA state policy 200
  min/10 d elementary, 400 min/10 d secondary)
• Mean student-to-teacher ratio in PE classes is
  41-52
• Only 2 in 5 elementary schools report that they
  had certified PE instructors

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Sample

• Aimed for 3 schools in 10 school districts (some
  replacements due to recruiting problems and
  absence of elementary schools in one High School
  Districts)
• 2 classes observed by at least one rater at each
  school
• 18 classes at 9 elementary schools
• 20 classes at 10 middle schools
• 20 classes at high school
• Additional observations for training and
  inter-rater reliability assessment
• Intervals originally coded as 0 (student cannot
  be observed) were recoded as 2 (standing)

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Avg. amount of PE class time in MVPAby school
level
School Level
The amount of P.E. class time that students were
physically active was slightly higher in higher
grades but there was a great variation within
each school level.
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Avg. amount of PE class time in MVPA by
district avg. Fitnessgram scores (aerobic, state
tertile)
Amount of P.E. class time that students were
physically active was greater in outdoor classes
than indoor classes.
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PE class time in MVPA by FRPL-eligible by
district avg. Fitnessgram score
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Avg. amount of PE class time in MVPAby class
size (secondary schools only)
N6
N12
N12
N10
Class Size
The amount of P.E. class time that students were
physically active was less in larger classes.
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Rel. between PE Quality (class t in MVPA) API
Score in High Low SES Schools
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PAAC/TAKE10! Best evidence for IR feasibility
Group RCTcollaboration between University of
Kansas ISLI 40 schools (gt70 free/reduced
lunch eligibility rates) in three Kansas
citiesKansas City, Lawrence, Topeka Incorporate
10-minute PA breaks into regular academic
lessons, e.g., math, science, English
curricula Accumulate 90-100 minutes per week of
PA in addition to PE recess (constrained in
low-resource/-performance schools) No additional
teacher preparation time Changes
environment Participation mandatory Training
through existing in-service mechanismlittle
added cost Easily perpetuated and replicated FUN!
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InterventionAverage PAAC Minutes/Week At the End
of Year 1
Minutes per week
These values are averages across all intervention
schools
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Average PAAC Min/Week Average PAAC Min/Wk At
the End of Year 2
Minutes per week
Months
These values are averages across all intervention
schools
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Instant Recess

• DVD excerpt
• movement break demonstration
• www.ph.ucla.edu/cehd
• www.athletescouncil.com
• www.phi.org/pac

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Community Cost-Sharing
We must be the change we wish to see in the
world. --Mahatma Gandhi