Examining Racial And Ethnic Disparities In The Prevalence And Treatment Of Obesity

Obesity is a chronic and complex disease characterized by excess body fat.

Many factors contribute to obesity. There’s a social bias that obesity is a lifestyle disease entirely within your control — but that’s not true.

Obesity is an ongoing and significant health issue around the world. It’s on the rise in the US, where there are racial and ethnic disparities in the disease’s prevalence and treatment.

Understanding the state of obesity in the US

Obesity is quite common in the US, with over 40% of adults experiencing obesity, as reported in studies from 2017–2020. Almost three-quarters of Americans have obesity or are overweight.¹

Between 1999 and 2000, obesity rates were lower — around 30%. In addition to the overall rates of obesity rising, the incidence of severe obesity has increased nearly two-fold in the last 20 years.²

So, what is obesity? Obesity is a chronic disease characterized by excess body fat that presents a health risk. The disease is characterized by a body mass index of over 30.³ ⁴

Obesity can lead to other health issues such as joint pain, increased risk of early mortality and cancer, and even sleep issues. These are known as comorbidities. They may occur because of obesity or can cause the disease themselves.

Other issues can arise from the personal impact of being obese. People with obesity are more likely to experience harmful interactions during social events and be treated negatively in media campaigns or even by healthcare providers. People with obesity can be exposed to social discrimination that harms their emotional, mental, and physical health.⁵ ⁶

Obesity is typically diagnosed according to body mass index (BMI). This calculation involves dividing a person’s body mass (weight) by their height squared, ranking the results.

Classes of obesity

Obesity is subdivided into the following classes:⁷

• Class I: BMI 30.0–34.9kg/m

• Class II: BMI 35.0–39.9kg/m

• Class III: BMI ≥40kg/m

• Class IV: BMI ≥50kg/m

• Class V: BMI ≥60kg/m

• Underweight: BMI <18.5kg/

• Normal: BMI 18.5–24.9kg/m

• Overweight: BMI 25.0–29.9kg/m

• Obese: BMI ≥30.0kg/m

For people who fall near the edge of a BMI bracket, healthcare providers may choose to use waist circumference or hip-to-waist ratios to diagnose obesity instead. These account more specifically for fat placement and are useful for determining obesity-related diseases.⁸

Obesity rates can differ according to age as well as many other factors, such as race, body composition, and socioeconomic status. Among people aged under 20 years, obesity prevalence has been reported as 19.7%.⁹

Racial and ethnic disparities in obesity prevalence

Obesity is a complex condition. Experts still don’t fully understand all its causes. However, research shows that certain racial and ethnic groups are more susceptible to obesity than others.

Non-Hispanic Black adults are the most likely to experience obesity, with a rate of 49.9%. Non-Hispanic Black women have the highest prevalence, at 57%. Hispanic adults follow next, with 45.6% prevalence, then White adults with 41.4% prevalence. The group least likely to experience obesity is non-Hispanic Asian adults, with an obesity prevalence of only 16.1%.¹⁰

It’s also worth noting that even at the same BMI level, Mexican-American people and non-Hispanic Asian people are more likely to have higher levels of body fat and metabolic disease than other groups.¹¹

These rates can also be stratified by income and educational level, but this is challenging due to the complexity of socioeconomic factors. As a general trend, people with higher levels of education have lower levels of obesity.¹²

Some important factors to consider include the ability to purchase healthy foods, access to healthcare, the ability to exercise in open areas safely, cultural impacts on eating habits, and genetics.

Factors contributing to racial and ethnic disparities in obesity

It’s crucial to understand how social, economic, genetic, and racial factors can contribute to racial and ethnic disparities in obesity prevalence. 

Genetics

One of the most common factors contributing to obesity is one we have no control over: genetics.

Your genetic risk for obesity also interacts with your environment and lifestyle habits. So, if you are often exposed to unhealthy foods, you may gain more weight than others exposed to the same foods. This is how researchers know genetics plays a role and interacts with environmental and behavioral factors.¹³ ¹⁴ 

You could be affected by genetic-driven behaviors, such as your rate of eating or even your body’s ability to know when it’s full. Genetics also plays a significant role in the metabolism of food, like the proportion of food stored as fat or the ability to use these stored fats as fuel.¹⁵

Genetics alone can’t account for the increase in obesity prevalence seen over the past two decades. Genetic changes occur extremely slowly. Generally, anyone who has a significant family history of obesity may wish to proactively control other risk factors, such as diet and exercise.¹⁶

In addition, groups with higher levels of obesity, such as African American or Black populations, have a higher risk of developing comorbidities or chronic disease later in life.¹⁷

Prenatal factors

Risk factors for childhood obesity can arise during pregnancy.

Maternal body weight and nutrition are among the most important factors that affect an infant’s metabolic programming. Furthermore, the mother’s gestational weight gain, smoking status, and diabetes status are associated with increased childhood obesity rates in infants.¹⁸ ¹⁹

Social factors

Obesity is known to highly impact groups of lower socioeconomic status. For instance, people living in poverty are more likely to experience childhood obesity, a trend that’s increasing over time.²⁰

A primary factor thought to be responsible is lower levels of exercise in children living in poverty. Limited exercise may be due to fewer comprehensive exercise programs in schools, less access to after-school extracurricular activities, and less access to safe and appropriate outdoor spaces.²¹

Some studies have shown that disparities in obesity prevalence according to wealth can occur in children as young as five years. Children of such a young age cannot be held accountable for their own disease management, emphasizing that obesity is a serious public health issue.²²

The overall prevalence of obesity is also changing, with rates stabilizing in some racial and social groups and climbing in others. Over time, this will likely cause health disparities between racial and socioeconomic groups to become more significant. Disparities in the prevalence of comorbidities will likely increase too.²³

Access to healthy food

Consuming healthy food is one of the best ways to prevent and manage obesity. However, access to healthy foods, such as fresh fruit and vegetables, differs by location and socioeconomic status.

Social and racial disparities in the availability of healthy food may be a significant driver of obesity in different populations. The cost of healthy food is often significantly higher than unhealthy options. The time it takes to source and prepare healthy meals is another factor. Access to grocery stores should also be considered, as the availability of affordable public transport and other factors can influence this.

A study identified a correlation between the number of Black residents in an area, household income, and the number of fast-food restaurants. Researchers identified 1.5 fast-food restaurants per square mile in predominantly White neighborhoods and 2.4 in predominantly Black neighborhoods.²⁴

At the same time, healthy food stores and outlets are more available in wealthier areas. Several studies have noted that having a supermarket in a neighborhood is associated with a lower prevalence of obesity.²⁵

However, even when adjusted for environmental factors like access to supermarkets, obesity rates in low-income groups remain higher than in wealthier groups. This means your income dictates your risk for obesity, despite your location.

Ultimately, even if you live in a healthy environment for food, it won’t make a difference if you can’t afford to access it. Your distance to a store and the price of the food it sells have also been linked to higher obesity rates. Neighborhoods that lack sustainably priced healthy food options are known as “grocery deserts.”²⁶ ²⁷ ²⁸

Neighborhood characteristics

Characteristics like the amount of available green space, walkability, crime levels, and residential segregation also affect your risk of obesity. And, as mentioned above, not having a supermarket in your neighborhood is a significant risk factor.²⁹ ³⁰

For enhanced livability, city planners and councils should consider these factors when planning neighborhoods.

Neighborhood characteristics that increase risk for obesity are more prevalent in low-income areas and those predominantly populated by minority groups. This partially explains why there are racial and ethnic disparities in obesity rates.

Early childhood health

Rates of childhood obesity are much higher in racial and ethnic minority groups.³¹

The rate at which an infant gains weight significantly impacts their chance of developing childhood obesity. This is particularly true pre-kindergarten, when the impacts of parental choices are most consequential.³²

In non-Hispanic White children, the duration of breastfeeding has been shown to positively affect a child’s risk of developing obesity.³³

Other factors, such as fruit and vegetable consumption and the amount of time spent watching TV, are less important for explaining racial differences in childhood obesity.³⁴

According to a review and meta-analysis, people who had obesity as a child are about five times more likely to have obesity as an adult. 55% of children with obesity will still have the disease during adolescence, and 80% of these adolescents will still have obesity during adulthood. Furthermore, around 70% of adults with obesity will still have the disease past the age of 30. Hence, obesity onset in childhood often poses a significant challenge to managing the disease in adulthood.³⁵

It’s important to note that 70% of adults with obesity did not have the disease during childhood. This suggests that childhood obesity is not a standalone risk factor.

Cultural factors

Culture greatly impacts the prevalence of obesity, which may partly explain racial and ethnic disparities in obesity rates.

For instance, different cultures vary in how they value body image. What is perceived as an ideal body image in one culture isn’t necessarily the same as in another culture. Cultural beliefs about body image may be transferred from one generation to the next, influencing an individual’s behaviors (and consequently their risk factors for obesity).³⁶

Another area of cultural influence is food consumption. Traditional foods in some cultures are healthier than others, placing different races and ethnicities at varying risk for obesity.³⁷

Culture also influences attitudes toward obesity. For example, research shows Hispanic people are more likely to believe their child is healthy when they have obesity. Meanwhile, there are disparities between racial and ethnic groups regarding awareness of obesity and its associated health risks.³⁸

Healthcare disparities in obesity treatment

Racial and ethnic disparities in healthcare are well documented. These can include both disparities in gaining access to care and disparities in the treatment options available.³⁹ 

Barriers to accessing obesity treatment for minority communities

Accessing healthcare is known to be more difficult for people from minority communities for several reasons.⁴⁰

Health insurance coverage disparities

People with obesity are around 25% more likely to use government-funded insurance options like Medicare and Medicaid than commercial or private options.⁴¹

In addition, these government-funded services only cover around 40% of patients with obesity.

Cultural coverage in healthcare

Cultural differences can significantly impact obesity prevalence, particularly childhood obesity. At the same time, minority groups report lower levels of satisfaction with their care.⁴²

Several factors, including historic and ongoing racism in the healthcare system and a lack of representation among healthcare professionals, can make minority groups less likely to seek healthcare. This is problematic because minority groups have an inequitable burden of chronic disease, including diseases associated with obesity.⁴³

Increasing access to healthcare in minority communities is crucial for addressing disparities in the prevalence and treatment of obesity.

Language barriers

People from minority racial and ethnic backgrounds are underrepresented in healthcare. For instance, while Black or African American people represent 13.6% of the US population, they only make up 5% of doctors. While American Indian and Alaskan Native people form 1.3% of the population, only 0.3% of doctors are from this racial and ethnic group. Hispanic or Latino people make up 19.1% of the US population, while only 5.8% of doctors have this same background.⁴⁴ ⁴⁵

When people cannot speak to a doctor who represents their culture and language, they may be less likely to attend medical appointments and have lower health literacy. This can result in missed opportunities to identify risk factors for obesity and less awareness of potential treatments and the risks associated with the disease.

More representation of minorities in the healthcare field would help with this, as would increasing the availability of interpreters. However, research reveals that only 48% of patients who needed an interpreter say they always or usually have one.⁴⁶

Disparities in obesity treatment options

Racial and ethnic minorities are underrepresented in clinical trials. Since your race and ethnicity can influence your risk factors for obesity and your response to treatment, a lack of appropriate research can result in ineffective treatment options.⁴⁷

Bariatric surgery

Surgery is an effective option for reducing obesity — in particular, reducing the effects of obesity in terms of comorbid diseases. However, it’s quite an expensive procedure, particularly as it requires time off work. As such, bariatric surgery is more common in patients who live in higher-income areas.⁴⁸

Recent research observed that the postoperative mortality rate for bariatric surgery is higher in Black people compared to White people. There are also racial and ethnic disparities between the causes of mortality, showing more representative research needs to be done.⁴⁹

Behavioral and lifestyle interventions

Behavioral and lifestyle interventions are often the first line of defense against obesity. Despite this, some studies have shown that even when the changes are able to reduce weight, they may be less effective at reducing cardiometabolic risk factors.⁵⁰

These behavioral interventions are important for helping to reduce the impact of obesity on other diseases, such as diabetes, but may be difficult for anything other than a moderate amount of weight loss.

Significant weight loss often requires multiple components, such as diet, physical activity, and long, intensive treatment options that simply may not be available to everyone.⁵¹

Culturally tailored programs are especially important for making sustainable, long-term lifestyle changes. Without the support of a culturally sensitive group, such as family or friends, it’s unlikely that changes will last over a year.⁵²

Pharmacotherapy

Many medications can actually cause weight gain. These are called obesogenic medications. Examples of such medications include antidepressants, anti-diabetic medications, and beta-blockers.⁵³

Obesogenic medications should be avoided, where possible, in people with obesity. Measuring the desired clinical effects against possible adverse effects, such as weight gain, is recommended. If you need an obesogenic medication, your doctor should prescribe the lowest effective dose.⁵⁴

A study observed that people with low socioeconomic status were more likely to be given medications that cause obesity, regardless of other factors. Socioeconomic status is closely linked to race and ethnicity. Insurance status, access to care, and quality of care are factors that contribute to these disparities.⁵⁵

Furthermore, medications that promote weight loss are generally more expensive than those that cause it. One anti-obesity medication, semaglutide (Wegovy), is used for chronic weight management in adults with obesity or those who are overweight with at least one weight-related condition. This medication costs around $1,500 a month, so affordability is a barrier.⁵⁶ ⁵⁷ ⁵⁸

People from minority racial and ethnic groups are more likely to have a lower socioeconomic status, meaning high costs can prevent them from accessing weight-loss medications.

For children with obesity, some anti-obesity medications have lower rates of prescription in Hispanic and Latino youths, which may indicate that they’re not able to access the same interventions as their White counterparts. One reason for this could be prohibitive costs. Others may include cultural mistrust of healthcare providers and a reluctance to give children weight-control medication.

Addressing racial and ethnic disparities in obesity

Obesity rates continue to climb in the US. High levels of obesity are caused by a combination of many factors, including several that are beyond your control. Your race is one such example — being Black or Hispanic increases your risk of obesity.

It’s important to prioritize national interventions through policy changes that make access to healthcare more equitable. National and federal objectives should include updating access to insurance and obesity treatments through Medicare or Medicaid as well as private insurance through ACA. Advocacy for these programs is needed to create reform and overcome cultural differences.

Interventions are also needed on a local level. Examples include prioritizing the development of open, green spaces and ensuring residents can easily access supermarkets that sell healthy, affordable food.

Local or national school-based interventions may also help combat childhood obesity rates. Other possible community interventions include providing focused coaches or high-impact intervention courses at affordable rates for at-risk individuals. Their aim should be to increase the well-being of people experiencing obesity in minority populations or of people in low socioeconomic areas.

It’s also important to highlight that the healthcare profession needs to focus on being able to overcome cultural or racial differences, which may be contributing to disparities in obesity rates.

The lowdown

People in minority groups are especially vulnerable to obesity through both a historic lack of inclusion in clinical research and healthcare services and an ongoing disparity in socioeconomic status.

Wealth has been strongly linked to obesity, so focusing new policies, investments, and resources on people in low-income areas will be key to reducing obesity rates overall. 

Childhood obesity is another ongoing problem. It raises the risk of adulthood obesity. Early and effective interventions need to be developed to avoid this and give all children the best chance of living a full, healthy life.