Lifecourse approach to racial/ethnic disparities in childhood obesity

Eliminating racial/ethnic disparities in health and health care is a national priority, and obesity is a prime target. During the last 30 y in the United States, the prevalence of obesity among children has dramatically increased, sparing no age group. Obesity in childhood is associated with adverse cardio-metabolic outcomes such as hypertension, hyperlipidemia, and type II diabetes and with other long-term adverse outcomes, including both physical and psychosocial consequences. By the preschool years, racial/ethnic disparities in obesity prevalence are already present, suggesting that disparities in childhood obesity prevalence have their origins in the earliest stages of life. Several risk factors during pregnancy are associated with increased risk of offspring obesity, including excessive maternal gestational weight gain, gestational diabetes, smoking during pregnancy, antenatal depression, and biological stress. During infancy and early childhood, rapid infant weight gain, infant feeding practices, sleep duration, child's diet, physical activity, and sedentary practices are associated with the development of obesity. Studies have found substantial racial/ethnic differences in many of these early life risk factors for childhood obesity. It is possible that racial/ethnic differences in early life risk factors for obesity might contribute to the high prevalence of obesity among minority preschool-age children and beyond. Understanding these differences may help inform the design of clinical and public health interventions and policies to reduce the prevalence of childhood obesity and eliminate disparities among racial/ethnic minority children.     

The built environment and risk of obesity in the United States: Racial–ethnic disparities

Using data from the 2003–2008 waves of the continuous National Health Nutrition Examination Survey merged with the 2000 census and GIS-based data, this study conducted genderspecific analyses to explore whether neighborhood built environment attributes are significant correlates of obesity risk and mediators of obesity disparities by race–ethnicity. Results indicate that the built environment is a significant correlate of obesity risk but is not much of a mediator of obesity disparities by race–ethnicity. Neighborhood walkability, density, and distance to parks are significant covariates of obesity risks net of individual and neighborhood controls. Gender differences are found for some of these associations.     

Income disparities in perceived neighborhood built and social environment attributes

The present study explored whether perceived neighborhood environmental attributes associated with physical activity differ by neighborhood income. Adults aged 20–65 years (n=2199; 48% female; mean age=45 years; 26% ethnic minority) were recruited from 32 neighborhoods from the Seattle, WA and Baltimore, MD regions that varied in objectively measured walkability and neighborhood income. Perceived built and social environment variables were assessed with the Neighborhood Environment Walkability Scale. There were neighborhood income disparities on 10 of 15 variables. Residents from high-income neighborhoods reported more favorable esthetics, pedestrian/biking facilities, safety from traffic, safety from crime, and access to recreation facilities than residents of low-income areas (all p's <0.001). Low-income neighborhoods may lack amenities and safety attributes that can facilitate high levels of physical activity for both transportation and recreation purposes.     

The role of health insurance coverage in reducing racial/ethnic disparities in health care

Research showing racial/ethnic disparities in medical care obtained by people with comparable insurance has raised questions about the extent to which health insurance improves opportunities for care. To assess whether insurance expansions could be expected to reduce racial/ethnic disparities in access to care, this paper reviews evidence from studies specifically designed to quantify the contribution of health insurance to racial/ethnic disparities in access. The studies provide evidence that a sizable share of the differences in whether a person has a regular source of care could be reduced if Hispanics and African Americans were insured at levels comparable to those of whites.     

County characteristics and racial and ethnic disparities in the use of preventive services

BACKGROUND: Studies examining predictors of preventive service utilization generally focus on individual characteristics and ignore the role of contextual variables. To help address this gap in the literature, the present study investigates whether county-level characteristics, such as racial and ethnic composition, are associated with the use of preventive services. METHODS: Data from the Medical Expenditure Panel Survey and the Area Resource Files (1996-1998) are used to identify the individual- and county-level predictors of five types of preventive services (n = 49,063). RESULTS: County racial or ethnic composition is associated with the utilization of certain preventive services, net of individual-level characteristics. Specifically, individuals in high percent Hispanic counties are more likely to report cholesterol screenings, while those in counties with more blacks are more likely to have regular mammograms. Moreover, county racial or ethnic composition modifies the relationship between individual race or ethnicity and preventive use. In particular, Hispanic individuals who reside in high percent black counties report higher levels of utilization for most preventive services compared to Hispanics living in other counties. CONCLUSIONS: Physical and social environments are key determinants of health behaviors and outcomes. Future studies should take into account the racial or ethnic composition of an area and how this interacts with individual race or ethnicity when investigating predictors of preventive care use.     

Decomposing racial/ethnic disparities in influenza vaccination among the elderly

While persistent racial/ethnic disparities in influenza vaccination have been reported among the elderly, characteristics contributing to disparities are poorly understood. This study aimed to assess characteristics associated with racial/ethnic disparities in influenza vaccination using a nonlinear Oaxaca–Blinder decomposition method. We performed cross-sectional multivariable logistic regression analyses for which the dependent variable was self-reported receipt of influenza vaccine during the 2010–2011 season among community dwelling non-Hispanic African–American (AA), non-Hispanic White (W), English-speaking Hispanic (EH) and Spanish-speaking Hispanic (SH) elderly, enrolled in the 2011 Medicare Current Beneficiary Survey (MCBS) (un-weighted/weighted N = 6,095/19.2million). Using the nonlinear Oaxaca–Blinder decomposition method, we assessed the relative contribution of seventeen covariates – including socio-demographic characteristics, health status, insurance, access, preference regarding healthcare, and geographic regions – to disparities in influenza vaccination. Unadjusted racial/ethnic disparities in influenza vaccination were 14.1 percentage points (pp) (W–AA disparity, p < 0.001), 25.7 pp (W–SH disparity, p < 0.001) and 0.6 pp (W–EH disparity, p > .8). The Oaxaca–Blinder decomposition method estimated that the unadjusted W–AA and W–SH disparities in vaccination could be reduced by only 45% even if AA and SH groups become equivalent to Whites in all covariates in multivariable regression models. The remaining 55% of disparities were attributed to (a) racial/ethnic differences in the estimated coefficients (e.g., odds ratios) in the regression models and (b) characteristics not included in the regression models. Our analysis found that only about 45% of racial/ethnic disparities in influenza vaccination among the elderly could be reduced by equalizing recognized characteristics among racial/ethnic groups. Future studies are needed to identify additional modifiable characteristics causing disparities in influenza vaccination.     

The changing landscape for the elimination of racial/ethnic health status disparities

The elimination of racial/ethnic health status disparities is a compelling national health objective. It was etched in sharp relief by the 1985 report of the U.S. Department of Health and Human Services Secretary's Task Force on Black and Minority Health and considerable attention has been devoted to the problem since that report. But the problem persists, disparities are not fully explained and effective policies to reduce them have been elusive, a situation presenting both opportunities and challenges. Important advances towards reducing racial/ethnic health disparities may be made by better understanding the complex bidirectional relationship between and among the multiple factors, biological and non-biological, influencing morbidity and mortality. The landscape in which these influences are felt is anything but static. In this paper selected components of the landscape that are critical to the elimination of racial/ethnic health status disparities are reviewed. These factors underscore the importance of adopting and maintaining a perspective on health disparities that encompasses a broad array of health determinants.     

Changes in racial/ethnic disparities in the prevalence of Type 2 diabetes by obesity level among US adults

Objective. Ethnic minority status and obesity are two independent risk factors for Type 2 diabetes (T2D). There is no clear understanding of how they may have interacted and influenced disparities in T2D prevalence over time. This study examined the trends in racial/ethnic disparities in the prevalence of T2D by weight status among US adults.

Methods. We used nationally representative data from the National Health and Nutrition Examination Surveys I (1971–1975), II (1976–1980), and III (1988–1994), and 1999–2004 among 49,574 adults aged 20–74 years. The prevalences of diagnosed and undiagnosed T2D were estimated by race/ethnicity groups (non-Hispanic White, non-Hispanic Black, and Mexican American) and body mass index (BMI) groups (normal, 18.5–24.9; overweight, 25–29.9; obese, 30–34.9; severely obese, ≥35). We used logistic regression controlling for age, gender, and education to estimate the odds ratio of T2D across race/ethnicity and BMI groups.

Results. Trends in racial/ethnic disparities in prevalence of diagnosed T2D varied by BMI. Normal weight group saw increasing racial disparities. In the overweight group, ethnic disparities worsened as diabetes prevalence increased 33.3% in Whites, compared to 60.0% in Blacks, and 227.3% in Mexican Americans. Minimal racial/ethnic disparities were observed in obese and severely obese groups over time. In contrast to diagnosed diabetes, overall racial/ethnic disparities in undiagnosed T2D declined in all BMI groups.

Conclusions. Racial/ethnic disparities in diabetes prevalence have become most pronounced among normal and overweight groups. Eliminating racial/ethnic disparities in diabetes will require prevention efforts not only in obese minority individuals, but also in normal and overweight minority individuals.     

Relationship of neighborhood social determinants of health on racial/ethnic mortality disparities in US veterans—Mediation and moderating effects

Objective

To examine mediation and moderation of racial/ethnic all-cause mortality disparities among Veteran Health Administration (VHA)-users by neighborhood deprivation and residential segregation.

Data sources

Electronic medical records for 10/2008-9/2009 VHA-users linked to National Death Index, 2000 Area Deprivation Index, and 2006-2009 US Census.

Study design

Racial/ethnic groups included American Indian/Alaskan Native (AI/AN), Asian, non-Hispanic black, Hispanic, Native Hawaiian/Other Pacific Islander, and non-Hispanic white (reference). We measured neighborhood deprivation by Area Deprivation Index, calculated segregation for non-Hispanic black, Hispanic, and AI/AN using the Isolation Index, evaluated mediation using inverse odds-weighted Cox regression models and moderation using Cox regression models testing for neighborhood*race/ethnicity interactions.

Principal findings

Mortality disparities existed for AI/ANs (HR = 1.07, 95%CI:1.01-1.10) but no other groups after covariate adjustment. Neighborhood deprivation and Hispanic segregation neither mediated nor moderated AI/AN disparities. Non-Hispanic black segregation both mediated and moderated AI/AN disparities. The AI/AN vs. non-Hispanic white disparity was attenuated for AI/ANs living in neighborhoods with greater non-Hispanic black segregation (P = .047). Black segregation's mediating effect was limited to VHA-users living in counties with low black segregation. AI/AN segregation also mediated AI/AN mortality disparities in counties that included or were near AI/AN reservations.

Conclusions

Neighborhood characteristics, particularly black and AI/AN residential segregation, may contribute to AI/AN mortality disparities among VHA-users, particularly in communities that were rural, had greater black segregation, or were located on or near AI/AN reservations. This suggests the importance of neighborhood social determinants of health on racial/ethnic mortality disparities. Living near reservations may allow AI/AN VHA-users to maintain cultural and tribal ties, while also providing them with access to economic and other resources. Future research should explore the experiences of AI/ANs living in black communities and underlying mechanisms to identify targets for intervention.

     

Social anatomy of racial and ethnic disparities in violence

We analyzed key individual, family, and neighborhood factors to assess competing hypotheses regarding racial/ethnic gaps in perpetrating violence. From 1995 to 2002, we collected 3 waves of data on 2974 participants aged 8 [corrected] to 25 years living in 180 Chicago neighborhoods, augmented by a separate community survey of 8782 Chicago residents.The odds of perpetrating violence were 85% higher for Blacks compared with Whites, whereas Latino-perpetrated violence was 10% lower. Yet the majority of the Black-White gap (over 60%) and the entire Latino-White gap were explained primarily by the marital status of parents, immigrant generation, and dimensions of neighborhood social context. The results imply that generic interventions to improve neighborhood conditions and support families may reduce racial gaps in violence.     

Rethinking race/ethnicity, income, and childhood asthma: racial/ethnic disparities concentrated among the very poor

OBJECTIVE: Past studies of the prevalence of childhood asthma have yielded conflicting findings as to whether racial/ethnic disparities remain after other factors, such as income, are taken into account. The objective of this study was to examine the association of race/ethnicity and family income with the prevalence of childhood asthma and to assess whether racial/ethnic disparities vary by income strata. METHODS: Cross-sectional data on 14,244 children aged <18 years old in the 1997 National Health Interview Survey were examined. The authors used logistic regression to analyze the independent and joint effects of race/ethnicity and income-to-federal poverty level (FPL) ratio, adjusting for demographic covariates. The main outcome measure was parental report of the child having ever been diagnosed with asthma. RESULTS: Bivariate analyses, based on weighted percentages, revealed that asthma was more prevalent among non-Hispanic black children (13.6%) than among non-Hispanic white children (11.2%; p<0.01), but the prevalence of asthma did not differ significantly between Hispanic children (10.1%) and non-Hispanic white children (11.2%; p=0.13). Overall, non-Hispanic black children were at higher risk for asthma than non-Hispanic white children (adjusted odds ratio [OR]=1.20; 95% confidence interval [CI] 1.03, 1.40), after adjustment for sociodemographic variables, including the ratio of annual family income to the FPL. Asthma prevalence did not differ between Hispanic children and non-Hispanic white children in adjusted analyses (adjusted OR=0.85; 95% CI 0.71, 1.02). Analyses stratified by income revealed that only among children from families with incomes less than half the FPL did non-Hispanic black children have a higher risk of asthma than non-Hispanic white children (adjusted OR=1.99; 95% CI 1.09, 3.64). No black vs. white differences existed at other income levels. Subsequent analyses of these very poor children that took into account additional potentially explanatory variables did not attenuate the higher asthma risk for very poor non-Hispanic black children relative to very poor non-Hispanic white children. CONCLUSIONS: Non-Hispanic black children were at substantially higher risk of asthma than non-Hispanic white children only among the very poor. The concentration of racial/ethnic differences only among the very poor suggests that patterns of social and environmental exposures must overshadow any hypothetical genetic risk.     

Swimming pool drownings among US residents aged 5-24 years: understanding racial/ethnic disparities

OBJECTIVE: We examined circumstances surrounding swimming pool drownings among US residents aged 5 to 24 years to understand why Black males and other racial/ethnic groups have high drowning rates. METHODS: We obtained data about drowning deaths in the United States (1995-1998) from death certificates, medical examiner reports, and newspaper clippings collected by the US Consumer Product Safety Commission. RESULTS: During the study period, 678 US residents aged 5 to 24 years drowned in pools. Seventy-five percent were male, 47% were Black, 33% were White, and 12% were Hispanic. Drowning rates were highest among Black males, and this increased risk persisted after we controlled for income. The majority of Black victims (51%) drowned in public pools, the majority of White victims (55%) drowned in residential pools, and the majority of Hispanic victims (35%) drowned in neighborhood pools (e.g., an apartment complex pool). Foreign-born males also had an increased risk for drowning compared with American-born males. CONCLUSIONS: Targeted interventions are needed to reduce the incidence of swimming pool drownings across racial/ethnic groups, particularly adult supervision at public pools.     

Community Health Centers and racial/ethnic disparities in healthy life.

This study examined disparities in health status among individuals of different racial and ethnic groups cared for by the nation's community health centers (CHCs) and compared these results with the findings for individuals using non-CHC sites as their usual source of care. The sample consisted of CHC users from the 1994 CHC User Survey and non-CHC users from the 1994 National Health Interview Survey. Bivariate comparisons were made between individuals' race/ethnicity and their experience of healthy life, an integrated measure that incorporates both activity limitation and self-perceived health status. Multiple regressions were followed to examine the independent association of race/ethnicity with healthy life experience for both CHC and non-CHC users while controlling for sociodemographic correlates of health. Among CHC users, racial and ethnic minorities did not have worse health than whites, but among non-CHC users there were significant racial and ethnic disparities: whites experienced significantly healthier life than both blacks and non-white Hispanics. These findings persisted after controlling for sociodemographic correlates of health. The results indicate that while racial/ethnic disparities in health persist nationally, these disparities do not exist within CHCs, safety-net providers with an explicit mission to serve vulnerable populations.     

Measuring racial and ethnic health care disparities in Massachusetts

Reducing racial and ethnic disparities in the quality of health care is a national policy priority; collecting race and ethnicity data from patients is a necessary first step in identifying and addressing these disparities. Recognizing this, Boston and Massachusetts recently enacted race and ethnicity data collection regulations affecting all acute care hospitals in the city and state. This paper describes the regulations and early lessons learned from implementing these data collection efforts in three areas: the design of data collection tools, uses of the data for eliminating disparities, and the role of the policy process in such efforts.