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Health  Equity  Issues  Related  to  Childhood  Obesity  

 Session  I:  Overview  of  the  Science  Clemencia  M.  Vargas,  D.D.S.,  Ph.D.  

Co-­‐authors:  Elsie  M.  Stines,  D.N.P.,  C.R.N.P.  Herta  S.  Granado,  B.S.  

November  3,  2016  Washington,  DC  

Disclosure  and  Presentation  Support  

The  author  and  co-­‐authors  have  no  financial  or  other  conflicts  of  interest  to  disclose    This  presentation  was  supported  by  a  grant  from  the  Robert  Wood  Johnson  Foundation  

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To  answer  the  question:  

What  are  the  health-­‐equity  issues  that  relate  to  disparities  in  childhood  (under  age  12)  obesity?    

Purpose  of  this  Review  

*  Definition  of  Equity:  Attainment  of  the  highest  level  of  health  for  all  people  *  Therefore,  attaining  equity  requires:  Eliminating  health  disparities  by  improving  the  health  of  disadvantaged  groups.  

Health  Equity    

Graphic  Concept:  Froehle  C.  Graphic  Source:  King  County,  WA  http://kingcounty.gov/elected/executive/constantine/priorities/building-­‐equity.aspx  

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Prevalence  of  Obesity  in  Children  by  Age  and  Race,  NHANES  2011-­‐2012  

 

30%  

25%  

20%  

15%   10%  

2-­‐5  years  

6-­‐11  years  

12-­‐19  years  

2-­‐19  years  

5%  

0%  All   Non-­‐Hispanic    Non-­‐Hispanic    Non-­‐Hispanic   Hispanic  

white   black   Asian  

Source:  Ogden,  Carroll,  Kit  ,  Flegal.  Prevalence  of  childhood  and  adult  obesity  in  the  United  States,  2011-­‐2012.  JAMA  2014;311(8):806-­‐814      

Social  Determinants  of  Obesity  Inequalities    

Adapted  from  Friel  S,  Chopra  M,  Satcher  D.  Unequal  weight  oriented  policy  responses  to  the  global  obesity  epidemic.  BMJ  2007;335:1241-­‐1243  

Macrosocial  Context  Sociopolitical,  Sociocultural,  Socioeconomic,  and  Socioenvironmental  Context  

Inequalities  in  Obesity  Rates  

Individual  Level  Factors  Food  Nutrient  intake  Energy  expenditure  Psychological  factors  Biological  factors  Health  literacy  

Social  Stratification  Income  Education    Occupation  Sex  Ethnicity  

Food  Environment  Natural  and  Build  Environment  Social  Environment  Trade  agreements  Urban  design  Financial  capacity/  Distribution  School  environment  Poverty  Production  Land  use  Living  conditions  Processing  Transportation  mode  Transport  access  Advertising  Public  facilities  Remoteness  Price  Market  access  Social  support  Food  deserts    Social  cohesion  Food  insecurity    Working  practices  School  food    Eating  habits  

   Social  norms      Time  

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*  Addresses  broader  topics  than  a  systematic  review    *  Includes  different  types  of  study  designs  *  Studies  would  not  be  comparable    

*  Does  not  include  analysis  of  quality  of  the  studies  *  Identifies  gaps  in  the  literature    

Scoping  Study  or  Review  

Source:    Arksey  H,  O’Malley  L.  2005.  Scoping  studies:  toward  a  methodological  framework.  International  Journal  of  Social  Research  Methodology  8(1):19-­‐32    

Stage  1:  Discussing  and  refining    the  research  question  Stage  2:  Literature  search  

*  Preliminary  searches  to  define  comprehensiveness  of  the  study  *  Inclusion/exclusion:  US,  <12  yr  olds,  English,  published  2005+    Preference  given  to  systematic  reviews  *  Key  words:  Obesity  or  overweight,  children  with  words  for  each  factor  *  Used  RefWorks  and  searched  Medline,  PubMed,  and  Web  of  Science  

Stage  3:  Review  and  selection  of  references  Stage  4:  Chart  to  extract  information.  Added  snow  ball    search  and  

excluded  redundant  references    Stage  5:    Summary  and  qualitative  thematic  analysis  (content  analysis)  

Scoping  Review  Process  

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References  Selection  Process    

 Final  Number  of  References  =  39  

Food  environment    16  Natural  built  environment    11  Social  environment  12  

 

   

Redundant  References  Removed  =  10  

Food  environment    4  Natural  built  environment    2  Social  environment  4    

 

 Snow  Ball  Technique  =  13  

Food  environment    4  Natural  built  environment    4  Social  environment  5  

 

 After  Reviewing  the  Articles  =  36  

Food  environment    16  Natural  built  environment    9  Social  environment  11  

 

 Initial  Selection  Based  on  Abstracts  =  351  Food  environment    152  Natural  built  environment    144  Social  environment  55    

Food  Advertisement  *  Affects  food  preferences  and  selection  *  Discordance  between  health  recommendations  

and  marketing  Price  *  Healthy  food  is  more  expensive  Access  to  Healthy  Food  *  No  association  between  food  desert  and  obesity  Food  Insecurity  *  No  association  with  obesity  (role  of  SNAP)  School  Food  *  Breakfast=low  BMI  *  Food  served=obesity  *  Competitive  food=obesity  Trade  Agreements  *  Strong  influence  on  diet,  obesity  in  the  other  

countries        

Results:  Food  Environment  

What  is  a  Food  Desert?  

•  No  grocery  stores  •  No  farmers  market  •  Surrounded  by  fast  food,  junk  food,  or  food  high  in  sugars  and  fats  

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Food  accessibility    *  Vehicle  ownership,  public  transit,  walkability,  neighborhood  safety  

Physical  activity  *  Access  to  recreational  facilities,  walkability,  safe  

neighborhoods=more  physical  youth    *  Limited  options  for  outdoor  activities  =  Higher  screen  time  *  Ethnic  minorities  higher  screen  time  (50%  more  than  whites)=obesity  

Results:  Natural  and  Built  Environment  

Poverty  *  Poor=obesity      *  “parents  try  to  stretch  their  dollar”  Social  Cohesion  *  Similar  background=  low  obesity  Social  Norms  *  Ideal  weight  à  stigma  Time  to  Prepare  Meals  *  Insufficient  time  for  working  mothers  to  cook=higher  obesity  Living  Conditions    *  Having  cooking  supplies  

Results:  Social  Environment  

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*  Strong  association  among  macrosocial  context  and    environments  with  childhood  obesity.  *  The  increase  in  obesity  over  the  past  25  years  cannot  be  explained  by  genetic  or  biological  changes  given  the  short  period  of  time.        "an  obesogenic  environment  that  promotes        inactivity  and  overeating”+  

*  This  strong  social  aspect  of  obesity  must  be  considered  when  seeking  for  solutions  to  address  the  problem.  

 

Discussion  

+Source:  Johnson.  The  nation’s  childhood  obesity  epidemic:  Health  disparities  in  the  making.  CYF  News,  7(2).  2012.  

*  The  only  food  environment  elements  that  were  not  consistently  associated  with  obesity  were  food  insecurity  and  food  deserts.  *  Safety  is  paramount  to  the  built/natural  environment.  *  Critical  to  have  transportation  to  buy    groceries  in  other  places  and  to  access  recreation  sites.  * Methodological  limitations:  definitions,  statistical  techniques,  study  design,  confounding  variables.  

Discussion  

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*  Factors  that  could  affect  food  insecurity  such  as  social  support  and  living  conditions  *  Housing  conditions  such  as  functional  kitchen,  water  supply,  sharing  kitchen  area  and  cooking  utensils    *  Parents’  time  available  for  cooking,  grocery  shopping,  and  exercise  *  Healthy  food  requires  more  resources:  price,  processing,  preservation  *  Physical  activity  in  public  schools  

Gaps  in  the  Literature  

Oral  Health  Professionals  *  Support  policy  that  will  

reduce  health  disparities  Community  *  Community  gardens  or  

farmers  markets    *  Snacks  and  food  available  at  

healthcare  facilities  *  Work  with  local  business  to  

replace  unhealthy  rewards    *  Walking  routes  to  schools  *  Repurpose  of  space  for  

physical  activity,  walkability  

Decreasing  the  Effect  of  Disparities    

Schools  *  Health  curriculum  *  School  food    *  School  gardens  Oral  Health  Practices  and  Clinics  *  Obtain  and  discuss  BMI  with  

families    *  Start  a  conversation  about  

healthy  food  and  exercise    

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Parents  *  Participate  in  policy  making  work  *  Improve  family  members  financial  

skills  to  reduce  food  insecurity  *  Encourage  healthy  habits  with  

healthy  rewards  *  Participation  in  school  activities    *  Limit  children’s  screen  time  –  but  

need  alternatives  *  Limit  weight  related  stigma:  

emphasize  what  the  body  can  do  rather  than  how  it  looks  

Decreasing  the  Effect  of  Disparities    

Objective:  To  eliminate  disparities  Regulations  -­‐  Policies    *  Hurdles    *  Lack  of  support  *  Financial  limitations  *  Legal  *  Chances  *  Stakeholders  participation  *  Political  buy-­‐in  /  political  will  

 

Addressing  Obesity  Equity  Issues  

Source:  Hayne  CL,  Moran  PA,  Ford  MM.  2004.  Regulating  environments  to  reduce  obesity.  Journal  of  Public  Health  Policy  25(3/4):391-­‐407.    

Graphic  Concept:  Froehle  C.  medium.com/@CRA1G/the-­‐evolution-­‐of-­‐an-­‐accidental-­‐meme  ddc4e139e0e4#.judgmo98z  

Equality Equity No Barriers

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* Most  food  environment  elements  were  associated  with  obesity,  except  food  insecurity  and  food  deserts    *  Unfavorable  built/natural  and  social  environments  are  associated  with  obesity  *  Oral  health  professionals  have  a  role  in  community,  schools,  and  their  practices  to  reduce  effect  of  disparities  *  Reducing    macro-­‐contextual  disparities  is  required  to  address  childhood  obesity  equity  issues  * Most  equity  issues  could  be  addressed  with  policies  

 

Conclusions  

Questions?  

Thank  You!