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Racial and Ethnic Disparities in Adult Obesity in the United States: CDC’s Tracking to Inform State and Local Action

Racial and Ethnic Disparities in Adult Obesity in the United States: CDC’s Tracking to Inform... PREVENTING CHRONIC DISEASE PUBLIC HEALTH RESEARCH, PRACTICE, AND POLICY Volume 16, E46 APRIL 2019 ESSAY Racial and Ethnic Disparities in Adult Obesity in the United States: CDC’s Tracking to Inform State and Local Action Ruth Petersen, MD, MPH1; Liping Pan, MD, MPH1; Heidi M. Blanck, PhD1 Accessible Version: www.cdc.gov/pcd/issues/2019/18_0579.htm disparities exist by the age of 2 (6). If nothing else is done in the United States beyond what is being done now, simulated growth Suggested citation for this article: Petersen R, Pan L, Blanck HM. trajectories that model today’s children show that over half (59% Racial and Ethnic Disparities in Adult Obesity in the United of today’s toddlers and 57% of children aged 2 to 19) will have States: CDC’s Tracking to Inform State and Local Action. Prev obesity at age 35 (7). Early feeding patterns, including how babies Chronic Dis 2019;16:180579. DOI: https://doi.org/10.5888/ are fed and how caregivers use food in response to an infant’s pcd16.180579. mood, affect acute growth, future eating patterns, and the risk of obesity (8). Similarly, family and caregiver modeling of healthy behaviors, food offerings, and active playtime, as well as charac- PEER REVIEWED teristics of neighborhoods such as walkability and traffic volume, The Centers for Disease Control and Prevention (CDC) plays a may affect children’s nutrition and physical activity habits (9,10). key role in tracking data on the burden of obesity and its related As sectors come together to reduce the obesity epidemic, we are racial and ethnic disparities to provide information that can high- aware how challenging success will be due to factors such as 1) light areas where state and local actions are most needed. Until the contributing risk factors of genetic and biological attributes; 2) further innovations allow for measured data on height and weight individual behaviors (parenting styles, dietary patterns, physical to be available for all states, self-reported data are the best source activity levels, medication use, sleep, stress management); and 3) for understanding where the burden of obesity is highest among community and societal factors that influence individual, family, different populations. This understanding is critical given that the and collective access to healthy, affordable foods and beverages; prevalence of obesity is increasing among adults in the United access to safe and convenient places for physical activity; and ex- States (1). As such, obesity continues to put a strain on overall posure to the marketing of unhealthy products (2). health status, health care costs, productivity, and the capacity for deployment and readiness of military personnel. Adults with By using self-reported data of height and weight from the Behavi- obesity often have multiple-organ system complications from the oral Risk Factor Surveillance System, CDC’s Division of Nutri- condition and, as a result, are more at risk for heart disease, stroke, tion, Physical Activity, and Obesity (DNPAO) has published state- type 2 diabetes, and multiple types of cancers (2). The estimated specific obesity maps since 1999. Obesity is defined as a body annual medical cost of obesity in the United States was $147 bil- mass index (a person’s weight in kilograms divided by the square lion in 2008 (3). Compared with spending for someone of normal of height in meters) of 30.0 or higher. These maps have shown the weight, medical spending for a person with obesity was $1,429 growing epidemic that has affected our nation from coast to coast. higher (42% higher) per year (3). Adult obesity decreases pro- Although the data collection methods changed in 2011, which ductivity, and the cost of lost productivity is between $3.4 and somewhat limits our ability to assess trends, the 2017 data contin- $6.4 billion per year (4). Adult obesity also increases the risk of ue to show that obesity prevalence among adults remains high workplace injuries (2). Obesity among young adults limits the eli- across the country (Figure 1). The state-specific prevalence ranges gibility for many to serve in our military, given the weight stand- from a low of 22.6% in Colorado to a high of 38.1% in West Vir- ards for recruitment that nearly 1 in 4 young adults are not able to ginia (11). meet (5). Among many other factors, the risk of adult obesity is greater among adults who had obesity as children, and racial and ethnic The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S. Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors’ affiliated institutions. www.cdc.gov/pcd/issues/2019/18_0579.htm • Centers for Disease Control and Prevention 1 PREVENTING CHRONIC DISEASE VOLUME 16, E46 PUBLIC HEALTH RESEARCH, PRACTICE, AND POLICY APRIL 2019 Figure   1. Prevalence of self-reported obesity among US adults, by state and territory, Behavioral Risk Factor Surveillance System (BRFSS), 2017. Obesity was defined as a body mass index of 30 or higher based on self-reported weight in kilograms divided by the square of the height in meters. Prevalence estimates reflect changes in BRFSS methods that started in 2011. These estimates should not be compared to prevalence estimates before 2011. No area had a prevalence of <20%, and all had sufficient data to determine prevalence. For the past 4 years, CDC has published more detailed state and territorial maps that combine 3 years of data to create stable estim- ates of self-reported adult obesity by race/ethnicity. These maps help demonstrate the geographic and racial/ethnic disparities in obesity burden. Although the previously released overall state-spe- cific maps demonstrate where obesity may be influencing health, health care costs, well-being, and productivity across states and re- gions, the racial and ethnic maps for 2015 through 2017 illustrate that the negative effects are disproportionately burdensome for particular populations. Combined data for 2015 through 2017 al- lowed for assessment by major racial/ethnic categories and found that non-Hispanic black adults had the highest prevalence of obesity (38.4%) overall, followed by Hispanic adults (32.6%) and non-Hispanic white adults (28.6%). To identify areas of highest burden, we used a cut point of 35%. We chose this cut point be- cause it was a somewhat natural breaking point in the data and roughly reflected areas with the highest burden. By using this cut point, we found that overall, 31 states and the District of Columbia had an obesity prevalence of 35% or higher among non-Hispanic Figure   2. Prevalence of self-reported obesity among non-Hispanic white, non- black adults; 8 states had an obesity prevalence of 35% or higher Hispanic black, and Hispanic adults, by state and territory, Behavioral Risk among Hispanic adults; and only 1 state had an obesity preval- Factor Surveillance System, 2015–2017. Obesity was defined as a body mass index of 30 or higher based on self-reported weight in kilograms divided by the ence of 35% or higher among non-Hispanic white adults (Figure square of the height in meters. Prevalence estimates reflect changes in 2). BRFSS methods that started in 2011. These estimates should not be compared to prevalence estimates before 2011. Areas are indicated as having insufficient data if they had a sample size of less than 50 or a relative standard error (dividing the standard error by the prevalence) of 30% or more. The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S. Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors’ affiliated institutions. 2 Centers for Disease Control and Prevention • www.cdc.gov/pcd/issues/2019/18_0579.htm PREVENTING CHRONIC DISEASE VOLUME 16, E46 PUBLIC HEALTH RESEARCH, PRACTICE, AND POLICY APRIL 2019 level by targeting early obesity risk through system changes in the What Causes These Disparities? ECE setting through state licensing, state subsidy, or state quality rating systems. States may pair these efforts with promoting the Although the exact causes of these differences in obesity are not use of food reimbursement programs for meals that meet minim- all known, they likely in part reflect differences in social and eco- um nutritional standards among centers serving low-income chil- nomic advantage related to race or ethnicity (12). This concept dren. In addition, state health departments may work to set a aligns with other, more general statements about health disparities standard for implementation of food service guidelines so other explaining that disparities are “closely linked with social, econom- government entities, work sites, park and recreation centers, and ic, and/or environmental disadvantage” and show the effect where hospitals can follow that example and obtain the needed technical groups of people “have systematically experienced greater social assistance for spreading implementation. State health department and/or economic obstacles to health . . . based on their racial or grantees may also work across sectors (such as the transportation ethnic group” (13). Underlying risks that may help explain dispar- and community planners) to improve environmental supports for ities in obesity prevalence among non-Hispanic black and the His- physical activity through the implementation of master plans and panic populations could include lower high school graduation land-use interventions. These efforts to increase access to safe and rates, higher rates of unemployment, higher levels of food insecur- convenient places for physical activity are generally targeted to ity, greater access to poor quality foods, less access to convenient geographical areas with the highest burden of obesity and chronic places for physical activity, targeted marketing of unhealthy foods, disease. Such efforts can include connecting neighborhoods with and poor access to health care or referrals to convenient com- sidewalks, paths, bike routes, and public transit that lead to local munity organizations that aid family-management or self-manage- schools, parks and recreation centers, and local businesses. ment resources (14–17). DNPAO manages 2 additional public health practice programs What Is DNPAO Doing to Address that have had success in reducing the risk factors for obesity in These Disparities? populations with the greatest disparities. These programs include the Racial and Ethnic Approaches to Community Health From a large number of high-quality applicants, in 2018 DNPAO (REACH) program and the High Obesity Program (HOP). The competitively funded 16 state health departments (or a similar en- REACH program focuses on improving health for racial and eth- tity), 15 land grant colleges and universities, and 31 community- nic groups with the highest disease burden. Obesity reduction focused grantees to work over the course of 5 years with multiple among the black population is often a key goal for REACH recipi- sectors and coalitions to prioritize and implement best practices to ents. For example, from 2008 through 2012, 14 REACH grantees increase healthy eating and active living to prevent obesity and implemented strategies to address disparities in obesity among other chronic diseases. With technical assistance from DNPAO black populations. These strategies included expanding healthy public health specialists and subject matter experts, grantees use a food choices in grocery stores, creating neighborhood farmers menu of evidence-based strategies and performance metrics to de- markets, implementing Complete Street policies, and improving velop their implementation plan, work plan, and evaluation pro- walkability and safety of neighborhood streets. The prevalence of cess. To obtain the largest public health impact from limited re- obesity decreased about 1 percentage point in these REACH com- sources, grantees are asked to focus their work on populations that munities, but not in the comparison populations during the same have the greatest disparities and needs. Strategies for DNPAO time (18). grantees include establishing healthy nutrition standards in set- tings such as workplaces, hospitals, early care and education Land grant universities in states where counties have more than a (ECE), after-school and recreational programs, and faith-based or- 40% prevalence of adult obesity are eligible to apply for HOP. ganizations; working with food vendors, distributors, and produ- These grantees work in predominantly rural areas where residents cers to increase procurement and sales of healthier foods; improv- may have less access to healthy foods and fewer opportunities to ing programs and systems at the state and local level to increase be physically active, which may increase their risk of obesity access to healthier food; and implementing community planning (19–21). HOP grantees use the same menu of DNPAO evidence- and transportation plans that support safe and accessible physical based strategies to improve nutrition and physical activity to re- activity by connecting sidewalks, paths, bike routes, public transit duce obesity and other chronic diseases; however, they might tail- with homes, ECE, schools, parks and recreation centers, and other or their implementation plan given the rural nature of their target everyday destinations. population with the highest risk of obesity. Examples include work at the Texas AgriLife Extension (Texas A&M University), As an example of reaching vulnerable individuals, state health de- which established a farmers market at a local community center to partment grantees may focus obesity prevention efforts at a state The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S. Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors’ affiliated institutions. www.cdc.gov/pcd/issues/2019/18_0579.htm • Centers for Disease Control and Prevention 3 PREVENTING CHRONIC DISEASE VOLUME 16, E46 PUBLIC HEALTH RESEARCH, PRACTICE, AND POLICY APRIL 2019 help increase access to fresh produce. Since the creation of this national burden of obesity. In addition to public health, many part- market, more than 800 community members purchased over ners are needed, including policy makers, state and local organiza- 12,000 pounds of fresh fruits and vegetables. Another example is tions, business and community leaders, ECE, schools, industry, the work of the extension staff in Ouachita County (University of federal agencies, health care systems and providers, payers, faith- Arkansas) at a low-income housing complex to improve access to based organizations, community planners, food growers and dis- physical activity for residents with limited mobility. They identi- tributors, families, and individuals. Using combined approaches, fied a walking path and developed signs to indicate how many laps these partners should strive to best improve the ability to prevent equaled a half-mile. Eighty-four percent of residents now walk obesity and its consequences for those with the burden. Such regularly and use the path at least 1 or 2 times a week (22). multisector partnerships can create positive changes at the com- munity level to promote healthy eating and active living in areas What’s Next? where individuals may be at risk for obesity because of where they live and work. These focus areas could include making it easier Implementing approaches that take into account racial and ethnic for families with children to buy healthy, affordable foods and disparities is critical to addressing the high burden of obesity and beverages near their homes; helping to provide access to safe, free its many negative consequences. Although a population-based ap- drinking water in places such as community parks, recreation proach is needed to increase availability and access to healthy areas, child care centers, and schools; helping local schools open foods and beverages and safe and convenient places for physical up gyms, playgrounds, and sports fields during nonschool hours so activity for all Americans, targeted approaches are needed to ad- more children can safely play; increasing the number of safe and dress the risks that drive the disparities. Such an approach will accessible sidewalks and bike paths to schools, parks and every- mean taking into account food insecurity, safe drinking water, and day destinations; and helping schools and ECE providers use best cultural nutrition and physical activity patterns as well as environ- practices for improving nutrition and increasing physical activity. mental and policy contexts that influence the risk. Efforts may Demonstrated success in these approaches would be reductions in need to include more attention to upstream determinants of health the disparities in upstream indicators (ie, improved community or attributes of the communities where the populations with the and behavioral determinants of health) and reductions in the highest burden live. The findings linking neighborhood features to obesity burden that is evident in CDC’s childhood obesity data one’s health status illustrate how a community can influence risk and the maps above. of many chronic health conditions, including obesity. For ex- DNPAO is committed to supporting efforts to reduce racial and ample, a study of neighborhoods in 3 US metropolitan regions ethnic disparities in obesity by continuing to share what is work- (San Diego, Seattle, and Baltimore) from 2009 to 2010 assessed ing through partners and grantees, to develop tools that aid com- pedestrian environment features for walkability factors (eg, dens- munity engagement and the implementation of evidenced-based ity). The study found that “across all three regions, low-income interventions, and to track obesity and its risk factors. Each sector neighborhoods and neighborhoods with a high proportion of ra- and organization has a role to play in being part of the solution. To cial/ethnic minorities had poorer aesthetics and social elements reduce the current disparities that exist in the burden of obesity, all (eg, graffiti, broken windows, litter) than neighborhoods with parts of society need to relentlessly and intentionally work to ad- higher median income or fewer racial/ethnic minorities” (20). dress the causes of these disparities to help give all a fair chance at Likewise, if marketing of unhealthy products and/or fast-food es- health. tablishments are unequally distributed across a community or are clustered near schools, communities may consider addressing this Acknowledgments issue paired with improving healthy offerings (16,23,24). For indi- viduals from the groups with the largest disparities, it is also im- No financial support was received for this work. The findings and portant to focus attention on enhancing access to and reimburse- conclusions of this report are those of the authors and do not ne- ment for quality health care services for growth assessment and cessarily reflect the official position of CDC. obesity screening, and for persons with obesity and disease risk, appropriate referral to evidence-based healthy weight or predia- Author Information betes management programs and other treatment modalities (25,26). Corresponding Author: Ruth Petersen, MD, MPH, National Center for Chronic Disease Prevention and Health Promotion, Centers for In isolation, DNPAO resources, equivalent to $0.31 investment Disease Control and Prevention, 4770 Buford Hwy, MS S107-5, per American per year, will not be able to prevent obesity among at-risk Americans nor reduce the racial and ethnic disparities in the The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S. Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors’ affiliated institutions. 4 Centers for Disease Control and Prevention • www.cdc.gov/pcd/issues/2019/18_0579.htm PREVENTING CHRONIC DISEASE VOLUME 16, E46 PUBLIC HEALTH RESEARCH, PRACTICE, AND POLICY APRIL 2019 Atlanta, GA 30341-3717. Telephone: 770-488-6001. Email: 12. Krueger PM, Reither EN. Mind the gap: race/ethnic and rpetersen@cdc.gov. socioeconomic disparities in obesity. Curr Diab Rep 2015; 15(11):95. Author Affiliations: 1National Center for Chronic Disease 13. US Department of Health and Human Services. National Prevention and Health Promotion, Centers for Disease Control and stakeholder strategy for achieving health equity. https:// Prevention, Atlanta, Georgia. www.minorityhealth.hhs.gov/npa/files/Plans/NSS/ CompleteNSS.pdf. Accessed September 12, 2018. 14. Romieu I, Dossus L, Barquera S, Blottière HM, Franks PW, References Gunter M, et al. Energy balance and obesity: what are the main drivers? Cancer Causes Control 2017;28(3):247–58. 1. Hales CM, Carroll MD, Fryar CD, Ogden CL. Prevalence of 15. University of Wisconsin Population Health Institute. County obesity among adults and youth: United States, 2015–2016. health rankings key findings 2018. http:// NCHS Data Brief 2017;(288):1–8. www.countyhealthrankings.org/explore-health-rankings/ 2. Centers for Disease Control and Prevention. Adult obesity rankings-reports/2018-county-health-rankings-key-findings- causes and consequences. https://www.cdc.gov/obesity/adult/ report. Accessed September 12, 2018. causes.html. Accessed September 14, 2018. 16. University of Connecticut Rudd Center for Food Policy and 3. Finkelstein EA, Trogdon JG, Cohen JW, Dietz W. Annual Obesity. Increasing disparities in unhealthy food advertising medical spending attributable to obesity: payer-and service- targeted to Hispanic and black youth. http:// specific estimates. Health Aff (Millwood) 2009; uconnruddcenter.org/files/Pdfs/ 28(5):w822–31. TargetedMarketingReport2019.pdf. Accessed January 19, 4. Trogdon JG, Finkelstein EA, Hylands T, Dellea PS, Kamal- Bahl SJ. Indirect costs of obesity: a review of the current 17. US Department of Agriculture, Economic Research Service. literature. Obes Rev 2008;9(5):489–500. Interactive charts and highlights. 2018. https:// 5. Mission Readiness. Too fat to fight: retired military leaders www.ers.usda.gov/topics/food-nutrition-assistance/food- want junk food out of America’s schools. http:// security-in-the-us/interactive-charts-and-highlights/. Accessed cdn.missionreadiness.org/MR_Too_Fat_to_Fight-1.pdf. September 12, 2018. Accessed September 14, 2018. 18. Liao Y, Siegel PZ, Garraza LG, Xu Y, Yin S, Scardaville M, et 6. Pan L, Freedman DS, Sharma AJ, Castellanos-Brown K, Park al. Reduced prevalence of obesity in 14 disadvantaged black S, Smith RB, et al. Trends in obesity among participants aged communities in the United States: a successful 4-year place- 2–4 years in the Special Supplemental Nutrition Program for based participatory intervention. Am J Public Health 2016; Women, Infants, and Children — United States, 2000–2014. 106(8):1442–8. MMWR Morb Mortal Wkly Rep 2016;65(45):1256–60. 19. National Advisory Committee on Rural Health and Human 7. Ward ZJ, Long MW, Resch SC, Giles CM, Cradock AL, Services. Social determinants of health: National Advisory Gortmaker SL. Simulation of growth trajectories of childhood Committee on Rural Health and Human Services Policy Brief, obesity into adulthood. N Engl J Med 2017;377(22):2145–53. January 2017. https://www.hrsa.gov/advisorycommittees/rural/ 8. Healthy Eating Research. Feeding guidelines for infants and publications/nac_brief_social_determinants_health.pdf. young toddlers: a responsive parenting approach feeding. Accessed September 14, 2018. https://healthyeatingresearch.org/research/feeding-guidelines- 20. Thornton CM, Conway TL, Cain KL, Gavand KA, Saelens for-infants-and-young-toddlers-a-responsive-parenting- BE, Frank LD, et al. Disparities in pedestrian streetscape approach/. Accessed September 14, 2018. environments by income and race/ethnicity. SSM Popul Health 9. Davison KK, Lawson HA, Coatsworth JD. The Family- 2016;2:206–16. centered Action Model of Intervention Layout and 21. Grimm KA, Moore LV, Scanlon KS; Centers for Disease Implementation (FAMILI): the example of childhood obesity. Control and Prevention. Access to healthier food retailers — Health Promot Pract 2012;13(4):454–61. United States, 2011. MMWR Suppl 2013;62(3):20–6. 10. Ding D, Sallis JF, Kerr J, Lee S, Rosenberg DE. Neighborhood 22. Centers for Disease Control and Prevention. State and local environment and physical activity among youth: a review. Am programs. High Obesity Program (2014–2018). https:// J Prev Med 2011;41(4):442–55. www.cdc.gov/nccdphp/dnpao/state-local-programs/hop-1809/ 11. Centers for Disease Control and Prevention. Adult obesity past-program.html. Accessed January 22, 2019. prevalence maps. https://www.cdc.gov/obesity/data/ prevalence-maps.html. Accessed September 23, 2018. The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S. Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors’ affiliated institutions. www.cdc.gov/pcd/issues/2019/18_0579.htm • Centers for Disease Control and Prevention 5 PREVENTING CHRONIC DISEASE VOLUME 16, E46 PUBLIC HEALTH RESEARCH, PRACTICE, AND POLICY APRIL 2019 23. Kwate NO, Yau CY, Loh JM, Williams D. Inequality in obesigenic environments: fast food density in New York City. Health Place 2009;15(1):364–73. 24. Kwate NO, Loh JM. Separate and unequal: the influence of neighborhood and school characteristics on spatial proximity between fast food and schools. Prev Med 2010;51(2):153–6. 25. Grossman DC, Bibbins-Domingo K, Curry SJ, Barry MJ, Davidson KW, Doubeni CA, et al. Screening for obesity in children and adolescents: US Preventive Services Task Force recommendation statement. JAMA 2017;317(23):2417–26. 26. Centers for Disease Control and Prevention. Childhood Obesity Research Demonstration (CORD) 1.0. https:// www.cdc.gov/obesity/strategies/healthcare/cord1.html. Accessed January 8. 2019. The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S. Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors’ affiliated institutions. 6 Centers for Disease Control and Prevention • www.cdc.gov/pcd/issues/2019/18_0579.htm http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Preventing Chronic Disease Pubmed Central

Racial and Ethnic Disparities in Adult Obesity in the United States: CDC’s Tracking to Inform State and Local Action

Preventing Chronic Disease , Volume 16 – Apr 11, 2019

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PREVENTING CHRONIC DISEASE PUBLIC HEALTH RESEARCH, PRACTICE, AND POLICY Volume 16, E46 APRIL 2019 ESSAY Racial and Ethnic Disparities in Adult Obesity in the United States: CDC’s Tracking to Inform State and Local Action Ruth Petersen, MD, MPH1; Liping Pan, MD, MPH1; Heidi M. Blanck, PhD1 Accessible Version: www.cdc.gov/pcd/issues/2019/18_0579.htm disparities exist by the age of 2 (6). If nothing else is done in the United States beyond what is being done now, simulated growth Suggested citation for this article: Petersen R, Pan L, Blanck HM. trajectories that model today’s children show that over half (59% Racial and Ethnic Disparities in Adult Obesity in the United of today’s toddlers and 57% of children aged 2 to 19) will have States: CDC’s Tracking to Inform State and Local Action. Prev obesity at age 35 (7). Early feeding patterns, including how babies Chronic Dis 2019;16:180579. DOI: https://doi.org/10.5888/ are fed and how caregivers use food in response to an infant’s pcd16.180579. mood, affect acute growth, future eating patterns, and the risk of obesity (8). Similarly, family and caregiver modeling of healthy behaviors, food offerings, and active playtime, as well as charac- PEER REVIEWED teristics of neighborhoods such as walkability and traffic volume, The Centers for Disease Control and Prevention (CDC) plays a may affect children’s nutrition and physical activity habits (9,10). key role in tracking data on the burden of obesity and its related As sectors come together to reduce the obesity epidemic, we are racial and ethnic disparities to provide information that can high- aware how challenging success will be due to factors such as 1) light areas where state and local actions are most needed. Until the contributing risk factors of genetic and biological attributes; 2) further innovations allow for measured data on height and weight individual behaviors (parenting styles, dietary patterns, physical to be available for all states, self-reported data are the best source activity levels, medication use, sleep, stress management); and 3) for understanding where the burden of obesity is highest among community and societal factors that influence individual, family, different populations. This understanding is critical given that the and collective access to healthy, affordable foods and beverages; prevalence of obesity is increasing among adults in the United access to safe and convenient places for physical activity; and ex- States (1). As such, obesity continues to put a strain on overall posure to the marketing of unhealthy products (2). health status, health care costs, productivity, and the capacity for deployment and readiness of military personnel. Adults with By using self-reported data of height and weight from the Behavi- obesity often have multiple-organ system complications from the oral Risk Factor Surveillance System, CDC’s Division of Nutri- condition and, as a result, are more at risk for heart disease, stroke, tion, Physical Activity, and Obesity (DNPAO) has published state- type 2 diabetes, and multiple types of cancers (2). The estimated specific obesity maps since 1999. Obesity is defined as a body annual medical cost of obesity in the United States was $147 bil- mass index (a person’s weight in kilograms divided by the square lion in 2008 (3). Compared with spending for someone of normal of height in meters) of 30.0 or higher. These maps have shown the weight, medical spending for a person with obesity was $1,429 growing epidemic that has affected our nation from coast to coast. higher (42% higher) per year (3). Adult obesity decreases pro- Although the data collection methods changed in 2011, which ductivity, and the cost of lost productivity is between $3.4 and somewhat limits our ability to assess trends, the 2017 data contin- $6.4 billion per year (4). Adult obesity also increases the risk of ue to show that obesity prevalence among adults remains high workplace injuries (2). Obesity among young adults limits the eli- across the country (Figure 1). The state-specific prevalence ranges gibility for many to serve in our military, given the weight stand- from a low of 22.6% in Colorado to a high of 38.1% in West Vir- ards for recruitment that nearly 1 in 4 young adults are not able to ginia (11). meet (5). Among many other factors, the risk of adult obesity is greater among adults who had obesity as children, and racial and ethnic The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S. Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors’ affiliated institutions. www.cdc.gov/pcd/issues/2019/18_0579.htm • Centers for Disease Control and Prevention 1 PREVENTING CHRONIC DISEASE VOLUME 16, E46 PUBLIC HEALTH RESEARCH, PRACTICE, AND POLICY APRIL 2019 Figure   1. Prevalence of self-reported obesity among US adults, by state and territory, Behavioral Risk Factor Surveillance System (BRFSS), 2017. Obesity was defined as a body mass index of 30 or higher based on self-reported weight in kilograms divided by the square of the height in meters. Prevalence estimates reflect changes in BRFSS methods that started in 2011. These estimates should not be compared to prevalence estimates before 2011. No area had a prevalence of <20%, and all had sufficient data to determine prevalence. For the past 4 years, CDC has published more detailed state and territorial maps that combine 3 years of data to create stable estim- ates of self-reported adult obesity by race/ethnicity. These maps help demonstrate the geographic and racial/ethnic disparities in obesity burden. Although the previously released overall state-spe- cific maps demonstrate where obesity may be influencing health, health care costs, well-being, and productivity across states and re- gions, the racial and ethnic maps for 2015 through 2017 illustrate that the negative effects are disproportionately burdensome for particular populations. Combined data for 2015 through 2017 al- lowed for assessment by major racial/ethnic categories and found that non-Hispanic black adults had the highest prevalence of obesity (38.4%) overall, followed by Hispanic adults (32.6%) and non-Hispanic white adults (28.6%). To identify areas of highest burden, we used a cut point of 35%. We chose this cut point be- cause it was a somewhat natural breaking point in the data and roughly reflected areas with the highest burden. By using this cut point, we found that overall, 31 states and the District of Columbia had an obesity prevalence of 35% or higher among non-Hispanic Figure   2. Prevalence of self-reported obesity among non-Hispanic white, non- black adults; 8 states had an obesity prevalence of 35% or higher Hispanic black, and Hispanic adults, by state and territory, Behavioral Risk among Hispanic adults; and only 1 state had an obesity preval- Factor Surveillance System, 2015–2017. Obesity was defined as a body mass index of 30 or higher based on self-reported weight in kilograms divided by the ence of 35% or higher among non-Hispanic white adults (Figure square of the height in meters. Prevalence estimates reflect changes in 2). BRFSS methods that started in 2011. These estimates should not be compared to prevalence estimates before 2011. Areas are indicated as having insufficient data if they had a sample size of less than 50 or a relative standard error (dividing the standard error by the prevalence) of 30% or more. The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S. Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors’ affiliated institutions. 2 Centers for Disease Control and Prevention • www.cdc.gov/pcd/issues/2019/18_0579.htm PREVENTING CHRONIC DISEASE VOLUME 16, E46 PUBLIC HEALTH RESEARCH, PRACTICE, AND POLICY APRIL 2019 level by targeting early obesity risk through system changes in the What Causes These Disparities? ECE setting through state licensing, state subsidy, or state quality rating systems. States may pair these efforts with promoting the Although the exact causes of these differences in obesity are not use of food reimbursement programs for meals that meet minim- all known, they likely in part reflect differences in social and eco- um nutritional standards among centers serving low-income chil- nomic advantage related to race or ethnicity (12). This concept dren. In addition, state health departments may work to set a aligns with other, more general statements about health disparities standard for implementation of food service guidelines so other explaining that disparities are “closely linked with social, econom- government entities, work sites, park and recreation centers, and ic, and/or environmental disadvantage” and show the effect where hospitals can follow that example and obtain the needed technical groups of people “have systematically experienced greater social assistance for spreading implementation. State health department and/or economic obstacles to health . . . based on their racial or grantees may also work across sectors (such as the transportation ethnic group” (13). Underlying risks that may help explain dispar- and community planners) to improve environmental supports for ities in obesity prevalence among non-Hispanic black and the His- physical activity through the implementation of master plans and panic populations could include lower high school graduation land-use interventions. These efforts to increase access to safe and rates, higher rates of unemployment, higher levels of food insecur- convenient places for physical activity are generally targeted to ity, greater access to poor quality foods, less access to convenient geographical areas with the highest burden of obesity and chronic places for physical activity, targeted marketing of unhealthy foods, disease. Such efforts can include connecting neighborhoods with and poor access to health care or referrals to convenient com- sidewalks, paths, bike routes, and public transit that lead to local munity organizations that aid family-management or self-manage- schools, parks and recreation centers, and local businesses. ment resources (14–17). DNPAO manages 2 additional public health practice programs What Is DNPAO Doing to Address that have had success in reducing the risk factors for obesity in These Disparities? populations with the greatest disparities. These programs include the Racial and Ethnic Approaches to Community Health From a large number of high-quality applicants, in 2018 DNPAO (REACH) program and the High Obesity Program (HOP). The competitively funded 16 state health departments (or a similar en- REACH program focuses on improving health for racial and eth- tity), 15 land grant colleges and universities, and 31 community- nic groups with the highest disease burden. Obesity reduction focused grantees to work over the course of 5 years with multiple among the black population is often a key goal for REACH recipi- sectors and coalitions to prioritize and implement best practices to ents. For example, from 2008 through 2012, 14 REACH grantees increase healthy eating and active living to prevent obesity and implemented strategies to address disparities in obesity among other chronic diseases. With technical assistance from DNPAO black populations. These strategies included expanding healthy public health specialists and subject matter experts, grantees use a food choices in grocery stores, creating neighborhood farmers menu of evidence-based strategies and performance metrics to de- markets, implementing Complete Street policies, and improving velop their implementation plan, work plan, and evaluation pro- walkability and safety of neighborhood streets. The prevalence of cess. To obtain the largest public health impact from limited re- obesity decreased about 1 percentage point in these REACH com- sources, grantees are asked to focus their work on populations that munities, but not in the comparison populations during the same have the greatest disparities and needs. Strategies for DNPAO time (18). grantees include establishing healthy nutrition standards in set- tings such as workplaces, hospitals, early care and education Land grant universities in states where counties have more than a (ECE), after-school and recreational programs, and faith-based or- 40% prevalence of adult obesity are eligible to apply for HOP. ganizations; working with food vendors, distributors, and produ- These grantees work in predominantly rural areas where residents cers to increase procurement and sales of healthier foods; improv- may have less access to healthy foods and fewer opportunities to ing programs and systems at the state and local level to increase be physically active, which may increase their risk of obesity access to healthier food; and implementing community planning (19–21). HOP grantees use the same menu of DNPAO evidence- and transportation plans that support safe and accessible physical based strategies to improve nutrition and physical activity to re- activity by connecting sidewalks, paths, bike routes, public transit duce obesity and other chronic diseases; however, they might tail- with homes, ECE, schools, parks and recreation centers, and other or their implementation plan given the rural nature of their target everyday destinations. population with the highest risk of obesity. Examples include work at the Texas AgriLife Extension (Texas A&M University), As an example of reaching vulnerable individuals, state health de- which established a farmers market at a local community center to partment grantees may focus obesity prevention efforts at a state The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S. Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors’ affiliated institutions. www.cdc.gov/pcd/issues/2019/18_0579.htm • Centers for Disease Control and Prevention 3 PREVENTING CHRONIC DISEASE VOLUME 16, E46 PUBLIC HEALTH RESEARCH, PRACTICE, AND POLICY APRIL 2019 help increase access to fresh produce. Since the creation of this national burden of obesity. In addition to public health, many part- market, more than 800 community members purchased over ners are needed, including policy makers, state and local organiza- 12,000 pounds of fresh fruits and vegetables. Another example is tions, business and community leaders, ECE, schools, industry, the work of the extension staff in Ouachita County (University of federal agencies, health care systems and providers, payers, faith- Arkansas) at a low-income housing complex to improve access to based organizations, community planners, food growers and dis- physical activity for residents with limited mobility. They identi- tributors, families, and individuals. Using combined approaches, fied a walking path and developed signs to indicate how many laps these partners should strive to best improve the ability to prevent equaled a half-mile. Eighty-four percent of residents now walk obesity and its consequences for those with the burden. Such regularly and use the path at least 1 or 2 times a week (22). multisector partnerships can create positive changes at the com- munity level to promote healthy eating and active living in areas What’s Next? where individuals may be at risk for obesity because of where they live and work. These focus areas could include making it easier Implementing approaches that take into account racial and ethnic for families with children to buy healthy, affordable foods and disparities is critical to addressing the high burden of obesity and beverages near their homes; helping to provide access to safe, free its many negative consequences. Although a population-based ap- drinking water in places such as community parks, recreation proach is needed to increase availability and access to healthy areas, child care centers, and schools; helping local schools open foods and beverages and safe and convenient places for physical up gyms, playgrounds, and sports fields during nonschool hours so activity for all Americans, targeted approaches are needed to ad- more children can safely play; increasing the number of safe and dress the risks that drive the disparities. Such an approach will accessible sidewalks and bike paths to schools, parks and every- mean taking into account food insecurity, safe drinking water, and day destinations; and helping schools and ECE providers use best cultural nutrition and physical activity patterns as well as environ- practices for improving nutrition and increasing physical activity. mental and policy contexts that influence the risk. Efforts may Demonstrated success in these approaches would be reductions in need to include more attention to upstream determinants of health the disparities in upstream indicators (ie, improved community or attributes of the communities where the populations with the and behavioral determinants of health) and reductions in the highest burden live. The findings linking neighborhood features to obesity burden that is evident in CDC’s childhood obesity data one’s health status illustrate how a community can influence risk and the maps above. of many chronic health conditions, including obesity. For ex- DNPAO is committed to supporting efforts to reduce racial and ample, a study of neighborhoods in 3 US metropolitan regions ethnic disparities in obesity by continuing to share what is work- (San Diego, Seattle, and Baltimore) from 2009 to 2010 assessed ing through partners and grantees, to develop tools that aid com- pedestrian environment features for walkability factors (eg, dens- munity engagement and the implementation of evidenced-based ity). The study found that “across all three regions, low-income interventions, and to track obesity and its risk factors. Each sector neighborhoods and neighborhoods with a high proportion of ra- and organization has a role to play in being part of the solution. To cial/ethnic minorities had poorer aesthetics and social elements reduce the current disparities that exist in the burden of obesity, all (eg, graffiti, broken windows, litter) than neighborhoods with parts of society need to relentlessly and intentionally work to ad- higher median income or fewer racial/ethnic minorities” (20). dress the causes of these disparities to help give all a fair chance at Likewise, if marketing of unhealthy products and/or fast-food es- health. tablishments are unequally distributed across a community or are clustered near schools, communities may consider addressing this Acknowledgments issue paired with improving healthy offerings (16,23,24). For indi- viduals from the groups with the largest disparities, it is also im- No financial support was received for this work. The findings and portant to focus attention on enhancing access to and reimburse- conclusions of this report are those of the authors and do not ne- ment for quality health care services for growth assessment and cessarily reflect the official position of CDC. obesity screening, and for persons with obesity and disease risk, appropriate referral to evidence-based healthy weight or predia- Author Information betes management programs and other treatment modalities (25,26). Corresponding Author: Ruth Petersen, MD, MPH, National Center for Chronic Disease Prevention and Health Promotion, Centers for In isolation, DNPAO resources, equivalent to $0.31 investment Disease Control and Prevention, 4770 Buford Hwy, MS S107-5, per American per year, will not be able to prevent obesity among at-risk Americans nor reduce the racial and ethnic disparities in the The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S. Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors’ affiliated institutions. 4 Centers for Disease Control and Prevention • www.cdc.gov/pcd/issues/2019/18_0579.htm PREVENTING CHRONIC DISEASE VOLUME 16, E46 PUBLIC HEALTH RESEARCH, PRACTICE, AND POLICY APRIL 2019 Atlanta, GA 30341-3717. Telephone: 770-488-6001. Email: 12. Krueger PM, Reither EN. 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Journal

Preventing Chronic DiseasePubmed Central

Published: Apr 11, 2019

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