Addressing Structural Racism Is Critical for Ameliorating the Childhood Obesity Epidemic in Black Youth

Abstract

Racism and childhood obesity are both pervasive factors adversely affecting the health and wellbeing of children and adolescents in the United States. The association between racism and obesity has been touched upon in the literature; yet most work has focused on a few dimensions of intersectionality of these two domains at one time. The renewed focus on structural racism as the primary contributor to distress of Black individuals in the United States has highlighted the urgency of identifying the contributions of racism to the childhood obesity epidemic. The current article is not a complete review of the literature, rather, it is meant to take a broad narrative review of the myriad ways in which racism contributes to the obesity epidemic in Black youth to serve as a call to action for more research, prevention, and intervention. The current article illustrates how a number of mechanisms for the etiology and maintenance of obesity are heavily influenced by racism and how addressing racism is critical for ameliorating the childhood obesity epidemic.

Introduction

Broadly defined, racism and racial discrimination stem from inequitable power and privilege among racial/ethnic groups, resulting in differential access to resources and opportunities.^1,2 Structural racism is defined as systems-level practices, norms, rules, and laws which maintain inequity based on race.³ Structural racism is therefore a product of longstanding discriminatory beliefs, practices, and policies that are enforced and reinforced at institutional, political, and cultural levels. Importantly, structural racism drives disparate health outcomes through limited opportunities (e.g., education, access to healthy food, safe neighborhoods for walking, etc.), economic disadvantage, and inequitable access to health care for persons of color.^3–5 At the individual level, these inequities are associated with increased risk for disease and decreased opportunity to engage in healthy lifestyle behaviors.

In a recent policy statement, the American Academy of Pediatrics acknowledged the role of racism in child health and wellbeing.⁶ Extant literature indicates that racism is a core social determinant of physical (e.g., hypertension, dysregulated sleep, endocrinological dysfunction, excess weight) and psychological (e.g., depression, anxiety, conduct problems, substance use/abuse) health outcomes in children and adolescents.^2,6,7 Of note, such findings suggest that mental health symptoms (e.g., chronic stress) associated with racial discrimination present sooner and more clearly than physical symptoms.^2,7,8 For example, Madubata et al. reported that even subtle forms of racial discrimination were associated with suicidal ideation among Black and Latinx youth.⁹ Considering the demonstrated linkages between adverse childhood experiences (ACEs) and negative adult health outcomes,¹⁰ it is critical to illuminate how the accumulation of racist and discriminatory experiences creates additive risk to health outcomes such as obesity.¹⁰

Structural Racism and Obesity Etiology and Maintenance

Obesity, with its physical and psychological sequelae, is one of the most pressing public health concerns affecting children and adolescents today. Black youth bear a disproportionate burden of obesity and its chronic comorbidities.¹¹ The etiology of obesity is highly complex, influenced by internal and external factors that affect energy intake and expenditure. A number of research groups and organizations have proposed frameworks for identifying the mechanisms by which obesity is developed and maintained. For example, Brown et al. (2015) describe the Ecological Model of Childhood Obesity, illustrating the layers of factors from the child, family, and community levels, including ethnicity, food and recreation access, neighborhood, school, and socioeconomic factors.¹² Also in 2015, The Obesity Society produced an infographic on Potential Contributors to Obesity¹³ that describes the complex interaction between internal and external contributors to excess energy intake and poor energy expenditure. A decade before these contributions, the African American Collaborative Obesity Research Network (AACORN) called upon researchers to address the obesity epidemic among African Americans.¹⁴ In their call to action, AACORN highlighted the need for research to determine influences of social factors on the obesity epidemic. Since that time, evidence has accumulated linking sociocultural mechanisms and obesity. However, common factors identified across theoretical models of the development of obesity and the impact of racism on these mechanisms have not been examined together.

The current article uses well-researched pathways to childhood obesity proposed by Brown et al.¹² and the Obesity Society,¹³ and what is currently known about how structural racism directly and indirectly impacts these contributors to obesity. The result of the intersection of racism and contributors to obesity may well be the significantly increased risk to Black youth for development of obesity. In fact, racism may be one of the largest potential root causes of our current public health crisis of obesity. Racism is therefore one of the most important targets for obesity prevention. The current article reviews some of these key linkages between structural racism and obesity among Black children and adolescents as a means of stimulating discussion and research to address these dual contributors to poor health outcomes in Black youth. The current article is not meant to be a systematic review or in-depth examination of each of these factors; rather, it is intended to highlight the multiple pathways to obesity driven by racism to guide the field into further study, reflection, and action. Moreover, we focus on Black youth as the majority of existing research has focused on this population. There are many other populations (e.g., Latinx, Indigenous) also disproportionately impacted both by racism and obesity with whom more research must be conducted. We begin with examples from the larger societal and community factors identified by the Ecological Model of Childhood Obesity, then present examples from familial and intraindividual-level factors. We conclude with an overview of the impact of structural racism on obesity treatment.

Causal Factors

Economic Factors

Economic forces are a powerful influence on individual behavior and closely linked, historically and currently, with both overt and covert racism. Racial capitalism, a term coined in the 1980s,¹⁵ refers to the fact that exploitation of non-White populations has conferred, and continues to confer, economic advantage to White populations. This confluence of racism and economics plays a large role in current health disparities¹⁶ and systems, which contribute to the etiology and maintenance of obesity. For example, racism is associated with housing segregation,¹⁷ access to quality preventive health care, and access to resources, including healthful food and physical space.^16,18 Economic incentive to maintain racial inequities maintains these systems that contribute significantly to the disparity in rates of obesity in Black populations.¹⁸

Socioeconomic status (SES) is closely linked with racism, through policies and practices such as redlining, less access to loans/ability to build wealth, and lack of equal access to education and employment opportunities.¹⁹ On its own, SES is associated with significant health inequities, but even accounting for SES, race, and racism appeared to be linked to poor health outcomes with disease burden being greater in Black children as compared with their White counterparts at lower levels of SES.^19,20 Moreover, obesogenic environments (i.e., fewer grocery stores, fewer fruits/vegetables in grocery stores, less access to recreational activities, and more fast food restaurants) have been linked to outcomes of racism, such as proportion of individuals in a community owning a home, having a lower income, and reduced likelihood of having a college education.^21,22 In other words, structural racism, alone and through its insidious effect on SES, are documented to impact the food and exercise environment, disease burden, and rates of obesity.

Food advertisement is also a powerful economic tool for manipulating the behavior of groups of people. This is particularly true of children who lack the maturity to think critically about the messages they are receiving.²³ Indeed, the American Academy of Pediatrics released guidelines noting the association of food advertising to higher obesity rates and lower quality diets.²³ What is particularly striking and concerning is that there is a concerted, targeted effort to aim these advertising campaigns to Black children and adolescents.^23–25 This includes foods/beverages known to contribute to obesity etiology and maintenance, such as sugar-sweetened beverages.²⁶

The economics of food availability in the context of racism is notable and maintained by the economic advantage conferred upon the White population. Given the association of these factors and risk for development and maintenance of obesity, these economic forces will need to be combatted by changing policies and laws (e.g., zoning laws, community input on local economic development, and tax incentives) to improve this situation.²¹

Food and Beverage Environment

Structural racism plays a significant role in what foods are available in the community, compounded by the intersection of race/ethnicity with poverty.²⁷ For example, there are fewer grocery stores with less access to fresh produce and more fast food restaurants in areas that have a higher percentage of Black residents.^21,28,29 Having less access to supermarkets has been associated with higher BMI in adolescents with the relationship being stronger in Black than White youths.³⁰ In rural areas, having access to fast food increases the frequency of adults eating fast food for non-White residents more than for White residents.³¹ Research has also supported that Black families are traveling further to shop to meet their nutritional needs.^32,33 Indeed, the fact that food environment is so closely linked to race/ethnicity led Bell et al. (2019) to propose that structural racism plays a role in the establishment of an obesogenic environment and contributes to a higher percentage of obesity in ethnic/racial minority groups.²¹

Importantly, beyond structural racism contributing to differences in the food landscape and availability among Black communities, research has also linked experiences of discrimination to food accessibility. For example, Black families who had to travel farther to shop for their groceries were more likely to experience discrimination or poor treatment during those shopping experiences than those whose grocery stores were closer to their own communities.³³ Among Black mothers, those reporting more experiences of discrimination also had higher levels of food insecurity, poorer physical health, and more symptoms of depression.³⁴

These findings are striking because they provide a context for the noted differences in food consumption and eating behaviors in the home that are associated with obesity. For example, Black families are having fewer home-cooked meals^35,36 and are less likely to have someone in the home that cooks.³⁷ Black youth report fewer family meals than White youth³⁸ and Black youth are more likely than White youth to eat while watching a screen or have access to electronics at meal times.^39,40 Black youth reported less access to fruits and vegetables in the home³⁸ and more sugar-sweetened beverages⁴¹ than White youth. Having less access to healthy foods secondary to structural racism creates barriers to providing healthy foods in the home and in return can lead to greater consumption of unhealthy foods and risk for higher BMI, with related comorbidities.

Physical Environment

The physical environment is a glaring example of the impact of racism on childhood obesity particularly in its relationship with physical activity. Research has long indicated that neighborhood-level SES is related to obesity, eating behaviors, and physical activity.⁴² The ability to engage in physical activity in part depends on the presence and perceived safety of opportunities for physical activity within one's neighborhood. Obesity-related interventions that do not account for the physical environment are likely to miss a significant barrier to the improvement of a child's wellbeing. Specifically, research has found that even when accounting for factors such as family income, age, gender, education level, and race/ethnicity, individuals living in lower SES neighborhoods have greater odds of obesity.⁴³ In addition to living in lower SES neighborhoods, an individual's perception of the physical environment is significant. Adolescents have reported perceived environmental barriers to physical activity, including difficulties with transportation, safety of the neighborhood, and expense.⁴⁴ Prins et al.⁴⁵ supported the importance of the perceived environment noting that perceived environment was a more significant predictor of physical activity than the objective data of the environment.

Furthermore, the duration and timing in which one lives in a physical environment that may be disadvantaged is important. For example, Blacks are more likely than Whites to have a longer duration living in disadvantaged neighborhoods, and living in a disadvantaged neighborhood during the adolescent years is a more significant predictor for young adult obesity than living in a disadvantaged neighborhood as a young child.⁴⁶ This work was further supported by Nicholson and Browning who found this relationship was most significant for girls.⁴⁷

Maternal/Developmental Factors

Structural racism practices that impact youth weight status begin before a child is even conceived. For example, housing segregation is linked to higher rates of maternal smoking in Black women, which in turn has been linked to childhood obesity.⁴⁸ Housing segregation may also be a factor in exposure to prenatal air pollution, more commonly detected in Black or low SES communities, which can negatively impact fetal development.^49,50 Another route through which maternal factors influence childhood obesity and are impacted by structural racism is delayed prenatal care, preterm birth, and birth through Cesarian delivery (C-section), all of which disproportionately impact Black women.⁵¹ Importantly, exposure to discrimination and racism have both been associated with greater likelihood of preterm birth and delayed prenatal care.⁵¹ Remarkably, studies have found that skin tone may moderate this relationship and posit that microaggressions of colorism may drive this association.⁵² Structural racism has also been linked to stress from various sources such as stigma, discrimination, financial, or employment-based stress.^53–56 Maternal stress during development is linked to child weight through a number of pathways.⁵³ For example, children with overweight and obesity or those in low-income households whose parents are under stress have higher instances of fast food consumption and lower rates of physical activity.

The association between breastfeeding and childhood obesity is also affected by racism. For example, experience of racism is associated with lower odds of breastfeeding beyond 3–5 months.^57,58 Moreover, housing segregation is also associated with lower rates and duration of breastfeeding.⁵⁷ Taken together, racism has an impact on a number of maternal factors that influence the development of childhood obesity.

Psychological Factors

Psychological contributors to obesity are often cyclical. For example, the relationship between depression and obesity is difficult to untangle as one can be both cause and effect of the other.^59,60 When considering the intersecting influence of structural racism and discrimination, the role of psychology in the etiology and maintenance of obesity is even more complex. Despite mental health parity being a significant public health priority in the United States, disparities in access to mental health services persist.^61,62 Structural policies like residential segregation and Medicaid expansion may limit capacity to address psychological conditions that predispose or exacerbate excess weight among Black youth (e.g., depression, anxiety, stress, hyperactivity/inattention, disordered eating).⁶³ Nondiagnostic psychosocial consequences of obesity, such as negative self-image, weight-related teasing and bullying, and poor health-related quality of life also merit culturally appropriate prevention and intervention strategies, which are currently lacking.

Considering the longitudinal patterns of obesity, comorbid psychological concerns must be addressed early. As stated previously, Black children and adolescents may experience higher levels of psychological stress due to racially motivated discrimination.⁹ Binge eating disorder, which often begins as a pattern of eating in excess to manage stress or to soothe negative emotions, is the most common specific eating disorder among Black youth.⁶⁴ Although emotional eating is not restricted to youth with obesity, continued engagement with such maladaptive coping strategies increases risk.^65,66 Caregiver stress is also implicated. Researchers have found that exposure to ACEs, recently better understood to include trauma and adverse experiences linked to racism,^67,68 is linearly related with weight status, with earlier exposure increasing risk for obesity later in life.^69,70 Such findings suggest that individual-level intervention is not enough. Rather, strategies such as parent training and capitalizing on members of the community (e.g., church leaders, community center workers, school-based professionals) may hold promise to more adequately address the overlapping influences of racial inequity, psychological distress, and childhood obesity.

Biological/Medical Factors

The heritability of obesity is well researched and therefore it has been tempting in the past to attribute the racial/ethnic disparities in obesity to this genetic predisposition. However, given that race is a social construct, not a biological one, the evidence linking increased risk for obesity due solely to race/ethnicity is unsupported. For example, the “thrifty gene hypothesis” posits that obesity has evolved from genes that were beneficial in their ability to store food during time of abundance for potential future food shortages.⁷¹ However, this theory has been debunked.⁷² More likely is the role of epigenetics, or how the structure of genes are altered in response to environmental factors,^72,73 although more research needs to be done in this area. Additionally, stress appears once again to be the foundation on which racism affects health, wellbeing, and obesity. Indeed, stress has been associated with hormonal changes within the body that are suggested to lead to the development of obesity.⁷⁴ This phenomenon has been given a name—the “weathering hypothesis.”⁷⁵ Recent research illustrates how cumulative experiences of discrimination and segregation, particularly in childhood and adolescence, predict inflammation, which is associated with obesity as well as a number of other chronic illnesses.^76,77

Racial Discrimination and Obesity Treatment

Racial discrimination limits access to obesity treatment options⁷⁸ due to the structural racism prevalent in the health care system. Specifically, resources and opportunities for health care are differentially allocated to groups that are devalued through interrelated process across multiple subsystems.⁷⁹ For example, reduced socioeconomic opportunities for stigmatized groups keep these communities in lower-income areas where health care is more limited, and specialty care, such as interdisciplinary treatment, is unavailable.⁸ In fact, most pediatric obesity treatment programs are associated with academic medical centers, which may not be proximal to many disadvantaged communities. Transportation costs, limited time off work, lack of health insurance coverage, and other barriers disproportionately affect the ability of underserved groups to attend obesity treatment programs at the intensity level required for program success.⁸⁰

For every type of therapeutic intervention in the United States, ranging from highly technical procedures to the most basic forms of diagnostic and treatment interventions, Blacks receive fewer procedures and poorer quality medical care than Whites.⁸¹ This is true even after health insurance, SES, severity of disease, comorbidities, and health care facility type are taken into account. More recent studies highlight the persistence of racial inequities in access to care.⁸² This disparity in health care access may be related in part due to the lower ratio of primary care doctors in racially diverse neighborhoods than in other areas, even after adjusting for demographic factors, SES, and health behaviors.⁴³ Moreover, historical and justified distrust of the medical community can result in decreased adherence to care.⁸³ Primary care is a gateway to specialty care services, including pediatric obesity treatment. Implicit bias on the part of health care providers may be a likely contributor as well,⁸¹ as the possibility of assumptions based on race for causes of obesity and likelihood of success in treatment can be affected by implicit bias.

Even when underrepresented minorities are referred and have access to treatment, the outcomes may be less optimal. An interdisciplinary team offers family-based lifestyle and behavioral interventions and access to bariatric surgery. A recent review found reduced treatment response to both health-related behavioral changes and surgery in racial and ethnic minorities.⁷⁸ Lifestyle changes may be difficult as Black children lose less weight than White children in behavioral lifestyle intervention treatments.⁸⁴ As noted above, less access to grocery stores, more access to fast food,⁸⁵ and increased likelihood of food insecurity,⁸⁶ may make it significantly harder for Black families to adhere to lifestyle suggestions regarding diet. Importantly, choices of less nutritious options among Black parents are often not a result of lack of knowledge about healthy foods but rather the perception of the cost of healthy foods⁸⁷ or access to those foods.⁸⁵ Cultural preferences and traditions may also play a role in food choice.⁸⁸ If obesity treatment providers do not recognize and acknowledge this, they may convey through words or tone, a blame for parents for lack of knowledge or willingness to adhere to recommendations.

In addition to suboptimal response to lifestyle interventions, racial minorities have limited access to bariatric surgery, due to geographic location that impacts access as well as Medicare/Medicaid reimbursement policies,⁸⁹ and lower rates of referrals.⁹⁰ Although Black adults often have less optimal outcomes, including longer surgical times, more complications, higher readmission, and increased mortality,⁹¹ studies to date with adolescents have found comparable weight loss outcomes across racial groups.^90,92 Therefore, to access bariatric surgery as a potential treatment for severe obesity, reducing barriers to surgery for Black adolescents should be addressed.

Treatment Approaches

The current article illustrates the numerous ways racism and the systems that maintain racism, contribute directly to the etiology and maintenance of childhood obesity. How, then, should we be addressing the obesity epidemic, so intertwined with racism in the United States? Treatment approaches should be considered on societal, group, and individual levels to truly tackle the root causes of obesity and associated health disparities. On a societal level, we need to address the policies, practices, and laws that result in housing segregation, unequal access to quality education, wealth, and health care, substandard maternal and early childhood care for Black mothers and children, and inadequacy of resources directed toward these communities.

Merely improving the SES of Black families (e.g., through policies, education systems, reparations, etc.) will be an important start, but will not be sufficient in addressing the racism crisis. The stressors and challenges associated with climbing the economic ladder in the context of structural racism can also have a negative impact on the health of Black families, highlighting the importance of eliminating discrimination.²⁰ Moreover, within the medical field, racism and its impact on health needs to be an explicit point of discussion in research articles, consensus statements, and evaluations of interventions need to directly address racism, rather than simply mentioning racial/ethnic/cultural differences and factors.⁹³ As recently as 2008, in consensus statements on the association of race, ethnicity, and culture on childhood obesity, cultural differences were noted and highlighted as important considerations, but racism itself was never noted as a key driver of these racial and ethnic differences in obesity rates and treatment outcomes.⁹⁴

When considering how we design, implement, and test obesity interventions, we must also consider racism as an important factor and address it directly in interventions.⁹⁵ Additionally, interventions need to be evaluated for differential benefit to non-White populations, so that interventions do not serve to widen the health disparities by having greater benefit for White children and adolescents. Cultural tailoring⁹⁶ should be utilized in intervention development and evaluation to ensure that interventions are appropriate for underserved populations. Community-based participatory research may be another important way to reduce racism in the design, implementation, and evaluation of research so that we meet the needs of the Black populations in addressing the obesity epidemic.⁹⁷

On an individual level, treatments may need to directly address racial trauma, using empirically supported treatments such as Trauma-Focused Cognitive Behavioral Therapy.⁹⁸ Practitioners, including physicians, nurses, psychologists, and dietitians, should also be well trained in implicit bias, cultural humility, and culturally responsive treatment, ensuring that their patients feel comfortable discussing how racism and racial discrimination are associated with obesity and associated physical and behavioral health comorbidities.

Examples of previous interventions which have worked well for Black youth provide important insights for future development and implementation of culturally appropriate obesity treatments. One theme that appears to be important is the delivery of the intervention in accessible spaces. A review of school-based interventions delivered in predominantly Black schools have evidenced improvements to eating, physical activity, and reductions in obesity.⁹⁹ Another example of success in this area is delivery of interventions and prevention programs in Black faith-based institutions. A review of this approach found that these interventions were often provided for all, regardless of weight status, delivered by a member of the community, and addressed both physical activity and nutrition.^100,101 The content of these interventions may vary, but delivery of messages within a trusted institution with a broad reach presents as key in ensuring participation and limiting drop-out, which is a factor believed to be a key contributor to the disparities seen between Black and White participants in behavioral lifestyle programs for obesity.¹⁰²

Future Steps

There is ongoing need to study the links between discrimination, racism, and their direct and indirect impact on health behaviors and health outcomes. Research that helps identify the feedback loops that perpetuate increased risk of obesity in Black youth (e.g., how increased access to unhealthy food options leads to caregivers and youth purchasing more of the unhealthy food, thereby increasing the likelihood that the establishment will continue to offer unhealthy food options)¹⁰³ will be necessary to establish policies and processes to disrupt these patterns. Research on the effectiveness of sensitivity training and implicit bias training will help elucidate how to best train health care providers in providing effective care to Black communities. Research will also have to include other groups at risk for experiencing structural racism and obesity to evaluate whether these factors are similar or unique to particular groups.

Although it is beyond the scope of the current article, it is also essential to note that the intersectionality between racism and weight stigma is of utmost importance,¹⁰⁴ affecting the emotional and physical wellbeing of Black youth. Additional research also needs to address the intersection of race and weight stigma, the cumulative impact of these two types of stigma, and its role in the etiology and maintenance of obesity.

As previously mentioned, policy and structural changes are needed to tackle the multifaceted nature of the increased risk for obesity in Black youth. Increasing access to healthy foods by lowering costs through subsidies or other means, providing incentives for business to move into or stay in food deserts and offer healthy food options, and investing in free and high-quality food through schools can be considered. Investing in the built environment and expanding free or low-cost recreational programs can increase access to physical activity. Eliminating the disadvantages Black caregivers have in employment, housing, loan/financial opportunities, etc. will allow caregivers to improve the wellbeing of the whole family. Policy changes around access to health care is another area of necessity. Policies around using effective implicit bias training and education on disparities in health care access and outcomes has the potential to improve the delivery of care. Increasing access to specialty care services in lower income neighborhoods is necessary and can be accomplished in a number of ways (e.g., satellite clinics, improved transportation access, expanded telehealth options, and coverage). Improving the covered benefits and reimbursement of Medicaid/Medicare will also be necessary to allow Black youth access to appropriate levels of obesity treatment (e.g., nutrition counseling, multidisciplinary treatment, bariatric treatment, etc.)

Importantly, Black communities need to be involved in the policy-making process so that the policies address the issues from the community perspective instead of being speculated by outside parties. These policies will need to be evaluated for success in making structural changes and analyzed for unintended consequences. This will be a difficult and ongoing process, but necessary to the health and wellbeing of Black youth.

Conclusion

Among the most critical approaches to addressing the relationship between structural racism and child obesity are advocacy and collaboration. More often than not, the persons affected by racism have reduced power to navigate the causal factors that put them at increased risk for obesity and related deleterious health outcomes. The framework of this article provides specific areas in which to direct collaborative advocacy efforts, a precursor to structural and policy change. Advocacy can take many forms, including partnership with community leaders to address causal factors, evidence-based screening of experiences of racism with responsive follow-up protocols, and preemptive implementation of strengths-based approaches that promote a positive self-concept. Such strategies will be key to development and implementation of effective and culturally appropriate prevention and intervention efforts.

To conclude, the multifactorial connection between racism and obesity for Black youth in the United States is well established and clear. It is not enough to continue to admire the problem, as it is past due for the recommended changes to come to fruition. Black children and families deserve a unified commitment to equity and wellness by the continual dismantling of the factors of structural racism that have increased obesity and its related outcomes.

Footnotes

Authors' Contributions

Drs. E.R.M. and E.T.B. conceptualized the project, organized the writing, drafted components of the article, and reviewed and revised the article. Drs. A.C., E.G., M.S., and W.W. contributed to the writing of the article, and reviewed and revised the article. Dr. A.R.B. contributed to the writing, conceptualization, and oversight of the final product and conclusions drawn. All authors approved the final article as submitted and agree to be accountable for all aspects of the work.

Funding Information

No funding was received for this article.

Author Disclosure Statement

No competing financial interests exist.

References

Paradies

, Ben

, Denson

, et al. Racism as a determinant of health: A systematic review and meta-analysis. PLoS One, 2015; 10:e0138511.

Priest

, Paradies

, Trenerry

, et al. A systematic review of studies examining the relationship between reported racism and health and wellbeing for children and young people. Soc Sci Med, 2013; 95:115–127.

Gee

, Ford

. Structural racism and health inequities: Old issues, new directions. Du Bois Rev, 2011; 8:115–132.

Shavers

, Shavers

. Racism and health inequity among Americans. J Natl Med Assoc, 2006; 98:386–396.

Bailey

, Krieger

, Agénor

, et al. Structural racism and health inequities in the USA: Evidence and interventions. Lancet, 2017; 389:1453–1463.

Trent

, Dooley

, Dougé

. The impact of racism on child and adolescent health. Pediatrics, 2019; 144:e20191765.

Cave

, Cooper

, Zubrick

, Shepherd

CCJ

. Racial discrimination and child and adolescent health in longitudinal studies: A systematic review. Soc Sci Med, 2020; 250:112864.

Hall

, Lemak

, Steingraber

, Schaffer

. Expanding the definition of access: It isn't just about health insurance. J Health Care Poor Underserv, 2008; 19:625–638.

Madubata

, Spivey

, Alvarez

, et al. Forms of racial/ethnic discrimination and suicidal ideation: A prospective examination of African American and Latinx Youth. J Clin Child Adolesc Psychol, 2019:1–9.

10.

Felitti

VJ.

Adverse childhood experiences and adult health. Acad Pediatr, 2009; 9:131–132.

11.

Hales

, Carroll

, Fryar

, Ogden

. Prevalence of obesity among adults and youth: United States, 2015–2016. NCHS Data Brief, 2017; 288:1–8.

12.

Brown

, Halvorson

, Cohen

, et al. Addressing childhood obesity: Opportunities for prevention. Pediatr Clin North Am, 2015; 62:1241–1261.

13.

Society

. Potential Contributors to

Obesity

. 2015. Available at https://www.multibriefs.com/briefs/tos/TOS010616.php Last accessed December 14, 2020.

14.

Kumanyika

, Gary

, Lancaster

, et al. Achieving healthy weight in African-American communities: Research perspectives and priorities. Obes Res, 2005; 13:2037–2047.

15.

Robinson

Black Marxism: The Making of the Black Radical Tradition. Chapel Hill, NC: University of North Carolina Press, 1983.

16.

Laster Pirtle

WN.

Racial capitalism: A fundamental cause of novel coronavirus (COVID-19) pandemic inequities in the United States. Health Educ Behav, 2020; 47:504–508.

17.

Chea

, Kim

. Examining spatial disparities of obesity: Residential segregation and the urban–rural divide. Prof Geograph, 2020; 72:206–218.

18.

Alkon

, Bowen

, Kato

, Young

. Unequally vulnerable: A food justice approach to racial disparities in COVID-19 cases. Agric Human Values, 2020; 37:535–536.

19.

Williams

, Priest

, Anderson

. Understanding associations among race, socioeconomic status, and health: Patterns and prospects. Health Psychol, 2016; 35:407–411.

20.

Assari

Family income reduces risk of obesity for White but not Black children. Children (Basel), 2018; 5:73.

21.

Bell

, Kerr

, Young

. Associations between obesity, obesogenic environments, and structural racism vary by county-level racial composition. Int J Environ Res Public Health, 2019; 16:861.

22.

Yusuf

, Dongarwar

, Yusuf

, et al. Social determinants of overweight and obesity among children in the United States. Int J MCH AIDS, 2020; 9:22–33.

23.

Radesky

, Chassiakos

YLR

, Ameenuddin

, et al. Digital advertising to children. Pediatrics, 2020; 146:e20201681.

24.

Fleming-Milici

, Harris

, Sarda

, Schwartz

. Amount of Hispanic youth exposure to food and beverage advertising on Spanish- and English-language television. JAMA Pediatr, 2013; 167:723–730.

25.

Harris

, Shehan

, Gross

, et al. Food Advertising Targeted to Hispanic and Black Youth: Contributing to Health Disparities. University of Connecticut: Hartford, CT, 2015.

26.

Harris

, Fleming-Milici

, Kibwana-Jaff

, Phaneuf

. Sugary Drink FACTS 2020 Sugary Drink Advertising to Youth: Continued Barrier to Public Health Progress. University of Connecticut: Hartford, CT, 2020.

27.

Jang

, Kim

. Remedying food policy invisibility with spatial intersectionality: A case study in the Detroit metropolitan area. J Public Policy Market, 2018; 37:167–187.

28.

James

, Arcaya

, Parker

, et al. Do minority and poor neighborhoods have higher access to fast-food restaurants in the United States?. Health Place, 2014; 29:10–17.

29.

Ohri-Vachaspati

, DeWeese

, Acciai

, et al. Healthy food access in low-income high-minority communities: A longitudinal assessment-2009–2017. Int J Environ Res Public Health, 2019; 16:2354.

30.

Powell

, Auld

, Chaloupka

, et al. Associations between access to food stores and adolescent body mass index. Am J Prev Med, 2007; 33(4 Suppl):S301–S307.

31.

Dunn

, Sharkey

, Horel

. The effect of fast-food availability on fast-food consumption and obesity among rural residents: An analysis by race/ethnicity. Econ Hum Biol, 2012; 10:1–13.

32.

Kwate

, Loh

, White

, Saldana

. Retail redlining in New York City: Racialized access to day-to-day retail resources. J Urban Health, 2013; 90:632–652.

33.

Zenk

, Schulz

, Israel

, et al. Food shopping behaviours and exposure to discrimination. Public Health Nutr, 2014; 17:1167–1176.

34.

Phojanakong

, Brown Weida

, et al. Experiences of racial and ethnic discrimination are associated with food insecurity and poor health. Int J Environ Res Public Health, 2019; 16:4369.

35.

Masters

, Stanek Krogstrand

, Eskridge

, Albrecht

. Race/ethnicity and income in relation to the home food environment in US youth aged 6 to 19 years. J Acad Nutr Diet, 2014; 114:1533–1543.

36.

Newman

, Tumin

, Andridge

, Anderson

. Family meal frequency and association with household food availability in United States multi-person households: National Health and Nutrition Examination Survey 2007–2010. PLoS One, 2015; 10:e0144330.

37.

Taillie

LS.

Who's cooking? Trends in US home food preparation by gender, education, and race/ethnicity from 2003 to 2016. Nutr J, 2018; 17:41.

38.

Granner

, Sargent

, Calderon

, et al. Factors of fruit and vegetable intake by race, gender, and age among young adolescents. J Nutr Educ Behav, 2004; 36:173–180.

39.

Fulkerson

, Loth

, Bruening

, et al. Time 2 tlk 2nite: Use of electronic media by adolescents during family meals and associations with demographic characteristics, family characteristics, and foods served. J Acad Nutr Diet, 2014; 114:1053–1058.

40.

Trofholz

, Tate

, Loth

, et al. Watching television while eating: Associations with dietary intake and weight status among a diverse sample of young children. J Acad Nutr Diet, 2019; 119:1462–1469.

41.

Dodd

, Briefel

, Cabili

, et al. Disparities in consumption of sugar-sweetened and other beverages by race/ethnicity and obesity status among United States schoolchildren. J Nutr Educ Behav, 2013; 45:240–249.

42.

Fan

, Wen

, Li

. Associations between obesity and neighborhood socioeconomic status: Variations by gender and family income status. SSM Popul Health, 2020; 10:100529.

43.

Black

, Macinko

. Neighborhoods and obesity. Nutr Rev, 2008; 66:2–20.

44.

Isgor

, Powell

. Availability of commercial physical activity facilities and physical activity outside of school among high school students. J Phys Act Health, 2011; 8:707–715.

45.

Prins

, Oenema

, van der Horst

, Brug

. Objective and perceived availability of physical activity opportunities: Differences in associations with physical activity behavior among urban adolescents. Int J Behav Nutr Phys Act, 2009; 6:70.

46.

Kravitz-Wirtz

Temporal effects of child and adolescent exposure to neighborhood disadvantage on Black/White disparities in young adult obesity. J Adolesc Health, 2016; 58:551–557.

47.

Nicholson

, Browning

. Racial and ethnic disparities in obesity during the transition to adulthood: The contingent and nonlinear impact of neighborhood disadvantage. J Youth Adolesc, 2012; 41:53–66.

48.

Bell

, Zimmerman

, Mayer

, et al. Associations between residential segregation and smoking during pregnancy among urban African-American women. J Urban Health, 2007; 84:372–388.

49.

Gray

, Edwards

, Schultz

, Miranda

. Assessing the impact of race, social factors and air pollution on birth outcomes: A population-based study. Environ Health, 2014; 13:4.

50.

Morello-Frosch

, Jesdale

. Separate and unequal: Residential segregation and estimated cancer risks associated with ambient air toxics in

U.S

. metropolitan areas. Environ Health Perspect, 2006; 114:386–393.

51.

Bower

, Geller

, Perrin

, Alhusen

. Experiences of racism and preterm birth: Findings from a pregnancy risk assessment monitoring system, 2004 through 2012. Womens Health Issues, 2018; 28:495–501.

52.

Slaughter-Acey

, Sneed

, Parker

, et al. Skin tone matters: Racial microaggressions and delayed prenatal care. Am J Prev Med, 2019; 57:321–329.

53.

Baskind

, Taveras

, Gerber

, et al. Parent-perceived stress and its association with children's weight and obesity-related behaviors. Prev Chronic Dis, 2019; 16:E39.

54.

Hunte

, Williams

. The association between perceived discrimination and obesity in a population-based multiracial and multiethnic adult sample. Am J Public Health, 2009; 99:1285–1292.

55.

Cozier

, Wise

, Palmer

, Rosenberg

. Perceived racism in relation to weight change in the Black Women's Health Study. Ann Epidemiol, 2009; 19:379–387.

56.

Krieger

Racial and gender discrimination: Risk factors for high blood pressure?. Soc Sci Med, 1990; 30:1273–1281.

57.

Griswold

, Crawford

, Perry

, et al. Experiences of racism and breastfeeding initiation and duration among first-time mothers of the Black women's health study. J Racial Ethn Health Disparities, 2018; 5:1180–1191.

58.

Robinson

, Fial

, Hanson

. Racism, bias, and discrimination as modifiable barriers to breastfeeding for African American women: A scoping review of the literature. J Midwifery Womens Health, 2019; 64:734–742.

59.

Reeves

, Postolache

, Snitker

. Childhood obesity and depression: Connection between these growing problems in growing children. Int J Child Health Hum Dev, 2008; 1:103–114.

60.

Small

, Aplasca

. Child obesity and mental health: A complex interaction. Child Adolesc Psychiatr Clin N Am, 2016; 25:269–282.

61.

Marrast

, Himmelstein

, Woolhandler

. Racial and ethnic disparities in mental health care for children and young adults: A national study. Int J Health Serv, 2016; 46:810–824.

62.

Moore

KL.

Mental health service engagement among underserved minority adolescents and young adults: A systematic review. J Racial Ethn Health Disparities, 2018; 5:1063–1076.

63.

Rojas-Velasquez

, Pluhar

, Burns

, Burton

. Nonsuicidal self-injury among African American and Hispanic adolescents and young adults: A systematic review. Prev Sci, 2021; 22:367–377.

64.

Taylor

, Caldwell

, Baser

, et al. Prevalence of eating disorders among Blacks in the National Survey of American Life. Int J Eat Disord, 2007; 40 Suppl:S10–S14.

65.

de Zwaan

Binge eating disorder and obesity. Int J Obes Relat Metab Disord, 2001; 25 Suppl 1:S51–S55.

66.

Kamody

, Thurston

, Pluhar

, et al. Implementing a condensed dialectical behavior therapy skills group for binge-eating behaviors in adolescents. Eat Weight Disord, 2019; 24:367–372.

67.

Bernard

, Calhoun

, Banks

, et al. Making the “C-ACE” for a culturally-informed adverse childhood experiences framework to understand the pervasive mental health impact of racism on Black youth. J Child Adolesc Trauma, 2020; 14:233–247.

68.

Cronholm

, Forke

, Wade

, et al. Adverse childhood experiences: Expanding the concept of adversity. Am J Prev Med, 2015; 49:354–361.

69.

Elsenburg

, van Wijk

KJE

, Liefbroer

, Smidt

. Accumulation of adverse childhood events and overweight in children: A systematic review and meta-analysis. Obesity (Silver Spring), 2017; 25:820–832.

70.

Gardner

, Feely

, Layte

, et al. Adverse childhood experiences are associated with an increased risk of obesity in early adolescence: A population-based prospective cohort study. Pediatr Res, 2019; 86:522–528.

71.

Speakman

JR.

Thrifty genes for obesity, an attractive but flawed idea, and an alternative perspective: The ‘drifty gene’ hypothesis. Int J Obes (Lond), 2008; 32:1611–1617.

72.

Krueger

, Reither

. Mind the gap: Ace/ethnic and socioeconomic disparities in obesity. Curr Diab Rep, 2015; 15:95.

73.

Wright

, Jarvis

, Pachter

, Walker-Harding

. “Racism as a public health issue” APS racism series: At the intersection of equity, science, and social justice. Pediatr Res, 2020; 88:696–698.

74.

Lupien

, King

, Meaney

, McEwen

. Child's stress hormone levels correlate with mother's socioeconomic status and depressive state. Biol Psychiatry, 2000; 48:976–980.

75.

Geronimus

AT.

The weathering hypothesis and the health of African-American women and infants: Evidence and speculations. Ethn Dis, 1992; 2:207–221.

76.

Simons

, Lei

, Beach

SRH

, et al. Discrimination, segregation, and chronic inflammation: Testing the weathering explanation for the poor health of Black Americans. Dev Psychol, 2018; 54:1993–2006.

77.

Cuevas

, Ong

, Carvalho

, et al. Discrimination and systemic inflammation: A critical review and synthesis. Brain Behav Immun, 2020; 89:465–479.

78.

Byrd

, Toth

, Stanford

. Racial disparities in obesity treatment. Curr Obes Rep, 2018; 7:130–138.

79.

Williams

, Cooper

. Reducing racial inequities in health: Using what we already know to take action. Int J Environ Res Public Health, 2019; 16:606.

80.

Force

UPST.

Screening for obesity in children and adolescents US preventive services task force recommendation statement. JAMA, 2017; 317:2417–2426.

81.

Smedley

, Stith

, Nelson

. Unequal Treatment: Confronting Raacial and Ethnic Disparities in Health Care. Washington, DC: National Academies Press, 2003.

82.

Purnell

, Calhoun

, Golden

, et al. Achieving health equity: Closing the gaps in health care disparities, interventions, and research. Health Aff (Millwood), 2016; 35:1410–1415.

83.

Abel

, Efird

. The association between trust in health care providers and medication adherence among Black women with hypertension. Front Public Health, 2013; 1:66.

84.

Goode

, Styn

, Mendez

, Gary-Webb

. African Americans in standard behavioral treatment for obesity, 2001–2015: What have we learned?. West J Nurs Res, 2017; 39:1045–1069.

85.

Cozier

, Yu

, Coogan

, et al. Racism, segregation, and risk of obesity in the Black Women's Health Study. Am J Epidemiol, 2014; 179:875–883.

86.

Berkowitz

, Berkowitz

TSZ

, Meigs

, Wexler

. Trends in food insecurity for adults with cardiometabolic disease in the United States: 2005–2012. PLoS One, 2017; 12:e0179172.

87.

Acheampong

, Haldeman

. Are nutrition knowledge, attitudes, and beliefs associated with obesity among low-income Hispanic and African American women caretakers?. J Obes, 2013; 2013:123901.

88.

Kumanyika

SK.

Environmental influences on childhood obesity: Ethnic and cultural influences in context. Physiol Behav, 2008; 94:61–70.

89.

Wallace

, Young-Xu

, Hartley

, Weeks

. Racial, socioeconomic, and rural-urban disparities in obesity-related bariatric surgery. Obes Surg, 2010; 20:1354–1360.

90.

Nunez Lopez

, Jupiter

, Bohanon

, et al. Health disparities in adolescent bariatric surgery: Nationwide outcomes and utilization. J Adolesc Health, 2017; 61:649–656.

91.

Hui

, Roberts

, Thompson

, et al. Outcomes of bariatric surgery in African Americans: An analysis of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) data registry. Obes Surg, 2020; 30:1–11.

92.

Mackey

, Wang

, Harrington

, Nadler

. Psychiatric diagnoses and weight loss among adolescents receiving sleeve gastrectomy. Pediatrics, 2018; 142:e20173432.

93.

Boyd

, Lindo

, Weeks

, McLemore

. On racism: A new standard for publishing on racial health inequities. Health Affairs Blog 2020. https://www.healthaffairs.org/do/10.1377/hblog20200630.939347/full/ (Last accessed July 2, 2020).

94.

Caprio

, Daniels

, Drewnowski

, et al. Influence of race, ethnicity, and culture on childhood obesity: Implications for prevention and treatment: A consensus statement of Shaping America's Health and the Obesity Society. Diabetes Care, 2008; 31:2211–2221.

95.

Aaron

, Stanford

. Is obesity a manifestation of systemic racism? A ten-point strategy for study and intervention. J Intern Med, 2021; 290:416–420.

96.

Kreuter

, Lukwago

, Bucholtz

, Clark

, Sanders-Thompson

. Achieving cultural appropriateness in health promotion programs: Targeted and tailored approaches. Health Educ Behav, 2003; 30:133–146.

97.

Kumar

, Kidd

, Li

, et al. Using the community-based participatory research (CBPR) approach in childhood obesity prevention. Int J Child Health Nutr, 2014; 3:170–178.

98.

Phipps

, Thorne

. Utilizing trauma-focused cognitive behavioral therapy as a framework for addressing cultural trauma in African American children and adolescents: A proposal. Prof Counselor, 2019; 9:35–50.

99.

Robinson

, Webster

, Whitt-Glover

, et al. Effectiveness of preschool and school-based obesity prevention interventions in African American youth: A literature review. Obes Rev, 2014; 15:5–25.

100.

Maynard

MJ.

Faith-based institutions as venues for obesity prevention. Curr Obes Rep, 2017; 6:148–154.

101.

Maynard

, Baker

, Harding

. Exploring childhood obesity prevention among diverse ethnic groups in schools and places of worship: Recruitment, acceptability and feasibility of data collection and intervention components. Prev Med Rep, 2017; 6:130–136.

102.

Whitt-Glover

, Kumanyika

, Haire-Joshu

. Introduction to the special issue on achieving healthy weight in black American communities. Obes Rev, 2014; 15 Suppl 4:1–4.

103.

Mui

, Ballard

, Lopatin

, et al. A community-based system dynamics approach suggests solutions for improving healthy food access in a low-income urban environment. PLoS One, 2019; 14:e0216985.

104.

Himmelstein

, Puhl

, Quinn

. Intersectionality: An understudied framework for addressing weight stigma. Am J Prev Med, 2017; 53:421–431.