Abstract
Introduction
The influence of culture on body mass index (BMI) and obesity within the African American population is an underexplored area in the literature. Therefore, this study explored the extent to which cultural identity was associated with BMI and obesity among African Americans and whether the association of cultural identity with obesity differed between males and females.
Methods
Participants were African Americans (n = 304) who responded to an online survey. BMI was calculated using self-reported weight and height; a BMI ≥ 30 indicated obesity. Sex assigned at birth was measured by self-report, and identification with African American culture was assessed using scores from six Black Identity Classification Scale (BICS) subscales. Primary analyses were conducted using a series of linear and logistic regression analyses.
Results
In almost all cases, BICS was not associated with BMI and obesity among all African Americans, but moderation analyses revealed that stronger identification with certain subscales of BICS, such as Afrocentrism, Black Americanism, and Racial Salience, was associated with an increase in the odds of obesity for males and not for females.
Conclusions
Study findings suggest that culture may influence obesity differently among males and females. Uncovering mechanisms linking cultural identification to obesity will provide novel contributions to behavioral interventions designed to reduce obesity within the African American population.
Keywords: Obesity, African American, Culture, Identity, Health Disparities
Introduction
African Americans have the highest rate of obesity in the United States and are 40% more likely to die from obesity-related comorbidities than Whites [1, 2]. Notably, the rate of obesity varies considerably within the African American population; African American females are 1.53 times more likely to be obese than African American males [3], which contributes to African American females having a greater risk of mortality, higher medical costs from hospitalizations, decreased productivity in the work setting, and lost wages than males [4]. Previous research has shown African American females prefer “curvier” body sizes [5, 6], and there is a greater cultural acceptance of “curvier” body sizes and high-fat and high-caloric food within the African American community (James 2004; Liburd 2003; Befort et al. 2008). It is important to understand whether cultural identification contributes to body mass index (BMI) and obesity and whether it explains the significant obesity gap between African American males and females.
The Black Identity Classification Scale (BICS) was created to assess the rich heterogeneity of African American cultural experience. The six core components of African American culture/identity, according to BICS, are African Americans who: are Assimilated (i.e., place little importance on being a member of a racial or ethnic group), Afrocentric (i.e., feels connected with their African heritage), Black American (i.e., feels connected to African American people and culture), Bicultural (i.e., values ability to connect with and successfully interact with both Black and White people), or Multicultural (i.e., appreciates and feels connected to persons from diverse racial, ethnic, and cultural orientations), and Cultural Mistrust (i.e., mistrusts White people and White society). Research on BICS has shown that the Afrocentric and Black American subgroups have the highest favorable ratings for “soul food,” and the Assimilated group has the lowest rating for soul food [9] Soul food is rich and flavorful meals prepared with high fat, sugar, and sodium levels for flavor [5, 7, 8]. Frequent consumption of these meals is associated with obesity and obesity-related diseases [10, 11]. However, no studies have used the BICS to explore whether cultural identity is associated with obesity among African Americans.
The primary purpose of this study is to use BICS to explore the association of cultural identity with BMI and obesity among African American males and females. Based on the literature, we hypothesize that greater identification with certain aspects of the African American culture will be associated with higher BMI and obesity. For example, it is hypothesized that greater identification with Afrocentrism or Black American culture will be associated with greater BMI and odds of obesity. In contrast, greater identification with Biculturalism or Multiculturalism will be associated with lower BMI and lower odds of obesity. Secondarily, the association between cultural identity and obesity will differ between males and females. In particular, African American females who identify more with aspects of the African American culture, such as Afrocentrism or Black American culture, will have greater BMI and odds of obesity than African American males with similar levels of cultural affinity towards certain aspects of the African American culture.
Methods
Data utilized in the current analyses were collected as part of an ongoing cohort study focused on the behavioral health of African Americans living in Oklahoma. The University of Oklahoma Health Sciences Center Institutional Review Board approved the study, and informed consent was obtained from all participants.
A full description of the study procedures has been published previously [12, 13] Participants were recruited for this study via Facebook advertising between March 2021 and November 2021. Eligible participants were (a) 18 years or older, (b) self-identified as Black/African American, and (c) residing in Oklahoma (verified by driver’s license). There were no other inclusion/exclusion criteria for the cohort study. A total of 2,363 adults started the screening process, and 51.25% (n = 1,211) completed the process. Among those who completed the screening process, 3 people were removed from the sample because they were below the age of 18, 96 adults were removed because they did not self-identify as Black/African American, 1 adult was removed because they completed the screening process twice, and 807 adults failed to upload a copy of their Oklahoma driver’s license. The remaining 304 adults (25%) met the study criteria and signed an informed consent form before enrolling in the cohort study. Participants completed their first survey immediately after qualifying for the study and were compensated with a $50 gift card for survey completion. All data utilized in the current study were collected during the initial study survey.
Measures
Dependent Variable
The primary dependent variables were BMI and obesity, which were measured using self-reported height and weight. Responses on these items were used to calculate each participant’s BMI, using the standard formula: weight (kg) / [height (m)]2. BMI scores were categorized to compare participants who were classified as not obese (0; BMI < 30) with those who were obese (1; BMI ≥ 30).
Independent Variable
The independent variable, cultural identification, was measured using BICS. BICS is a validated scale that captures different aspects of Black/African American culture (Davis et al. 2010). BICS has six subscales that are measured using 31 items with a “Strongly Disagree (0)” to “Strongly Agree (6)” 7-point Likert response scale: (1) African culture (e.g., “I feel a strong emotional connection to Africa.”), (2) Black American culture (e.g., “When I watch television, I usually watch Black television shows.”), (3) Bicultural (e.g., I feel comfortable interacting with both Black and Whites.”), (4) Multicultural (e.g., “I care deeply about the needs of other groups such as Native Americans, Whites, Latinos, and Asian Americans.”), (5) Racial Salience (e.g., “Being Black is an important part of my self-image.”), and (6) Cultural Mistrust (“e.g., “Many White politicians deliberately pass laws designed to block the progress of Blacks.”). Total scores from each subscale were averaged, and higher scores suggested greater identification with that specific aspect of the African American cultural experience.
Moderator Variable
Self-reported sex assigned at birth was the independent variable (0 = Female, 1 = Male).
Covariates
Age (years), education (completed college, post-graduate or professional school [ref], completed some college, associate’s, degree or technical school, or completed high school degree, GED, or less), and annual household income (≥$100,000 [ref] vs. $50,000 – $99,999, vs. ≤ $49,999), were all measured via a self-report and included as covariates in analyses.
Plan of analysis
Twenty-eight (9.2%) participants had missing data for BMI and obesity because they did not provide information about their weight (n = 28). This prevalence of missingness has been shown in other research [14]. We conducted a sensitivity analysis to determine the extent to which sociodemographic characteristics (age, sex, education, and income) were associated with missingness for obesity status (0 = not missing data, 1 = missing data). Only age was associated with missing data for BMI (OR = 1.03 [95% CI = 1.00, 1.06]). Because the missingness was less than 10% and only one sociodemographic characteristic was associated with missingness, the primary analysis was conducted with completed cases only (N = 276).
Descriptive statistics were generated for independent and dependent variables and covariates, and bivariate comparisons using t-tests and chi-squared analysis were conducted to explore differences in these variables by sex. Multivariable linear and logistic regression analyses examined the associations of (1) BICS subscales with BMI and (2) BICS subscales with obesity. Moderation analyses were conducted to explore whether the observed association between BICS subscales and obesity was moderated by sex using the PROCESS macro (Model 1; Hayes and Rockwood 2017; Hayes 2015; SAS 2013). The PROCESS macro used linear regression models to inferentially test and estimate the magnitude of the moderated effect and provided the proportion of the variance of the dependent variable attributable to the moderated effect(s) [15, 16]. Significant interactions were probed in the PROCESS macro using the pick-a-point approach. All analyses included the aforementioned covariates and were completed in SAS 9.4 [17].
Results
As shown in Table 1, more females (n = 238) than males (n = 65) were in the sample. Participants were, on average, 41.9 years of age (SD ± 13.5), and age did not differ between males and females. More than half of the sample (n = 176, 57.9%) had completed college, post-graduate or professional school, and more females completed these programs than males (59.7% vs. 51.5%, p < 0.01). There were no significant differences in annual household income or the prevalence of homeownership between males and females. Participants had an average BMI of 33.9 (SD ± 9.1), and females had a higher BMI than males (34.6 vs. 31.1, p < 0.01). More than half of the sample was defined as obese (n = 170, 55.9%), and the prevalence of obesity was nonsignificantly higher among females than males (58.4% vs. 47.0%; p = 0.24).
Table 1.
Sample characteristics
| Characteristic | n (%) or M (SD) |
|||
|---|---|---|---|---|
| Total (n = 304) |
Males (n = 66) |
Females (n = 238) |
p | |
| Age | 41.9 ± 13.5 | 40.7 ± 14.0 | 42.2 ± 13.3 | .42 |
| Education | ||||
| High school diploma, GED, or did not finish high school | 28 (9.2%) | 13 (19.7%) | 15 (6.3%) | < .01 |
| Some college, associate’s degree or technical school | 99 (32.6%) | 18 (27.3%) | 81 (34.0%) | |
| At least bachelor’s degree, postgraduate, or professional school | 176 (57.9%) | 35 (51.5%) | 142 (59.7%) | |
| Missing | 1 (0.3%) | 1 (1.5%) | 0 (0.0%) | |
| Annual household income | ||||
| $0 – $49,999 | 60 (19.7%) | 13 (19.7%) | 47 (19.8%) | .07 |
| $50,000 – $99,999 | 99 (32.6%) | 27 (40.9%) | 72 (30.3%) | |
| ≥ $100,000 | 144 (47.4%) | 25 (37.9%) | 119 (50.0%) | |
| Missing | 1 (0.3%) | 1 (1.5%) | 0 (0.0%) | |
| Homeownership | ||||
| Own | 123 (40.5%) | 31 (47.0%) | 92 (38.7%) | .08 |
| Rent | 141 (46.4%) | 24 (36.4%) | 117 (49.2%) | |
| Other | 39 (12.8%) | 10 (15.2%) | 29 (12.2%) | |
| Missing | 1 (0.3%) | 1 (1.5%) | (0.0%) | |
| BMI | 33.9 ± 9.1 | 31.1 ± 7.5 | 34.6 ± 9.4 | < .01 |
| Obesity status | ||||
| No | 106 (34.9%) | 27 (40.9%) | 79 (33.2%) | .24 |
| Yes | 170 (55.9%) | 31(47.0%) | 139 (58.4%) | |
| Missing | 28 (9.2%) | 8 (12.1%) | 20 (8.4%) | |
| Black Identity Classification Scale | ||||
| Afrocentrism | 3.2 ± 1.1 | 3.5 ± 1.1 | 3.2 ± 1.1 | .03 |
| Black Americanism | 4.3 ± 1.1 | 4.3 ± 1.1 | 4.3 ± 1.1 | .72 |
| Biculturalism | 4.3 ± 1.2 | 4.4 ± 1.1 | 4.3 ± 1.1 | .51 |
| Multiculturalism | 4.5 ± 1.1 | 4.6 ± 1.1 | 4.4 ± 1.0 | .29 |
| Racial Salience | 4.6 ± 1.3 | 4.5 ± 1.3 | 4.6 ± 1.3 | .63 |
| Cultural Mistrust | 4.6 ± 1.0 | 4.3 ± 1.1 | 4.6 ± 1.0 | .01 |
Average scores on the subscales for BICS were 3.2 (SD ± 1.1) for Afrocentrism, 4.3 (SD ± 1.1) for Black Americanism, 4.3 (SD ± 1.2) for Biculturalism, 4.5 (SD ± 1.1) for Multiculturalism, 4.6 (SD ± 4.6) Racial Salience, and 4.6 (SD ± 1.3) for Cultural Mistrust. There were significant differences between African American males and females on 2 of the 6 BICS subscales: Males identified more with Afrocentrism than females (3.5 vs. 3.2, p = 0.02), and males had less Cultural Mistrust than females (4.3 vs. 4.6, p = 0.02). Scores on the other Black Identity Classification Scale subscales did not differ between males and females (see Table 1 for details).
Primary Analyses
Results from multivariable linear regression analyses showed that cultural identity, as measured by subscales from BICS, was not associated with BMI. These analyses also showed that males consistently had lower BMI than females after controlling for cultural identity and other covariates (see Table 2). Results were nearly identical for obesity status when the analyses were repeated using multivariable logistic regression analyses, except that the Racial Salience subscale was associated with greater odds of obesity (OR = 1.23 [95% CI = 1.02, 1.49]). There was no significant difference in the odds of obesity between females and males across all logistic regression models (see Table 3).
Table 2.
Association of cultural identity and sex with body mass index among African Americans
| Variable | Model 1 |
Model 2 |
Model 3 |
Model 4 |
Model 5 |
Model 6 |
||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| β | SE | p | β | SE | p | β | SE | p | β | SE | p | β | SE | p | β | SE | p | |
| Black Identity Classification Scale | ||||||||||||||||||
| Afrocentrism | 0.64 | 0.50 | .20 | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - |
| Black Americanism | - | - | - | 0.28 | 0.52 | .59 | - | - | - | - | - | - | - | - | - | - | - | - |
| Biculturalism | - | - | - | - | - | - | 0.45 | 0.48 | 0.34 | - | - | - | - | - | - | - | - | - |
| Multiculturalism | - | - | - | - | - | - | - | - | - | 0.68 | 0.54 | .21 | - | - | - | - | - | - |
| Racial Salience | - | - | - | - | - | - | - | - | - | - | - | - | 0.61 | 0.42 | .15 | - | - | - |
| Cultural Mistrust | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | 0.93 | 0.58 | .11 |
| Sex | ||||||||||||||||||
| Female | REF | REF | REF | REF | REF | REF | ||||||||||||
| Male | −3.27 | 1.38 | .02 | −3.03 | 1.37 | .03 | −3.07 | 1.37 | .03 | −3.24 | 1.38 | .02 | −3.12 | 1.37 | .02 | −2.83 | 1.38 | .04 |
| Age (years) | 0.01 | 0.04 | .84 | 0.01 | 0.04 | .87 | 0.00 | 0.04 | .93 | 0.01 | 0.04 | .78 | 0.01 | 0.04 | .86 | 0.01 | 0.04 | .80 |
| Household income | ||||||||||||||||||
| $100,000 or more | REF | |||||||||||||||||
| $50,0000 and $99,999 | 0.06 | 1.55 | .97 | 0.27 | 1.54 | .86 | 0.35 | 1.54 | .82 | 0.23 | 1.54 | .88 | 0.26 | 1.54 | .87 | 0.12 | 1.54 | .94 |
| $0 and $49,999 a year | 0.31 | 1.50 | .84 | 0.34 | 1.51 | .82 | 0.41 | 1.51 | .79 | 0.24 | 1.50 | .87 | 0.24 | 1.50 | .88 | 0.11 | 1.51 | .94 |
| Education | ||||||||||||||||||
| Completed college, post-graduate or professional school | REF | REF | REF | REF | REF | REF | ||||||||||||
| Completed some college, associate’s degree or technical school | 1.15 | 1.23 | .35 | 1.23 | 1.23 | .32 | 1.35 | 1.23 | .27 | 1.35 | 1.23 | .27 | 1.31 | 1.23 | .29 | 1.31 | 1.22 | .28 |
| Completed high school degree, GED, or less | −2.76 | 2.09 | .19 | −2.70 | 2.10 | .20 | −2.80 | 2.10 | .18 | −2.35 | 2.12 | .27 | −2.38 | 2.11 | .26 | −2.14 | 2.13 | .31 |
n = 276
Bolded text indicated significance (p < 05)
Table 3.
Association of cultural identity and sex with obesity among African Americans (0 = Not obese, 1 = Obese)
| Variable | Model 1 aOR (95% CI) |
Model 2 aOR (95% CI) |
Model 3 aOR (95% CI) |
Model 4 aOR (95% CI) |
Model 5 aOR (95% CI) |
Model 6 aOR (95% CI) |
|---|---|---|---|---|---|---|
| Black Identity Classification Scale | ||||||
| Afrocentrism | 1.13 (0.90,1.41) | - | - | - | - | - |
| Black Americanism | - | 1.08 (0.86, 1.36) | - | - | - | - |
| Biculturalism | - | - | 1.11 (0.90, 1.37) | - | - | - |
| Multiculturalism | - | - | - | 1.06 (0.83, 1.35) | - | - |
| Racial Salience | - | - | - | - | 1.23 (1.02, 1.49) | - |
| Cultural Mistrust | - | - | - | - | - | 1.14 (0.88, 1.49) |
| Sex | ||||||
| Female | REF | REF | REF | REF | REF | REF |
| Male | 0.63 (0.34, 1.16) | 0.66 (0.36, 1.20) | 0.65 (0.36, 1.19) | 0.65 (0.35, 1.19) | 0.64 (0.35, 1.17) | 0.68 (0.37, 1.24) |
| Age (years) | 1.00 (0.98, 1.02) | 1.00 (0.98, 1.02) | 1.00 (0.98, 1.02) | 1.00 (0.98, 1.02) | 1.00 (0.98, 1.02) | 1.00 (0.98, 1.02) |
| Household income | Household income | Household income | Household income | Household income | Household income | Household income |
| $100,000 or more | REF | REF | REF | REF | REF | REF |
| $50,0000 and $99,999 | 0.76 (0.38, 1.54) | 0.79 (0.39, 1.59) | 0.81 (0.40, 1.62) | 0.80 (0.40, 1.59) | 0.78 (0.39, 1.58) | 0.78 (0.39, 1.56) |
| $0 and $49,999 a year | 0.76 (0.38, 1.51) | 0.77 (0.39, 1.51) | 0.78 (0.39, 1.54) | 0.76 (0.38, 1.50) | 0.74 (0.37, 1.47) | 0.74 (0.37, 1.47) |
| Education | ||||||
| Completed college, post-graduate or professional school | REF | REF | REF | REF | REF | REF |
| Completed some college, associate’s degree or technical school | 1.34 (0.76, 2.34) | 1.35 (0.77, 2.36) | 1.39 (0.79, 2.43) | 1.38 (0.79, 2.41) | 1.38 (0.79, 2.43) | 1.38 (0.79,2.41) |
| Completed high school degree, GED, or less | 1.02 (0.40, 2.56) | 1.03 (0.41, 2.60) | 1.01 (0.40, 2.53) | 1.05 (0.41, 2.68) | 1.16 (0.45, 2.96) | 1.11 (0.43, 2.84) |
n = 276
Bolded text indicated significance (p < 05)
Moderation analyses highlighted the presence of moderation for 3 of the 6 BICS subscales (see Fig. 1): the Afrocentrism (b = 0.62, SE = 0.29, p = 0.01), Black Americanism (b = 0.71, SE = 0.30, p = 0.02), and Racial Salience (b = 0.85, SE = 0.31, p = 0.01) subscales were associated with obesity among males and females differently. In particular, greater identification with Afrocentrism was associated with an increase in the odds of obesity among African American males (b = 0.59, SE = 0.25, p = 0.02), whereas greater identification with Afrocentrism was not associated with the odds of obesity among females (b = −0.03, SE = 0.13, p = 0.84). The same pattern of association was observed for the Black Americanism and Racial Salience subscales (see Fig. 1). There was no evidence that obesity among African American males and females was moderated by identification with Multiculturalism (b = -−0.34, SE = 0.29, p = 0.24), Biculturalism (b = 0.13, SE = 0.26, p = 0.62), and Cultural Mistrust Subscales (b = 0.31, SE = 0.32, p = 0.34) of BICS (see supplementary materials for more details).
Fig. 1.
Differences in the probability of obesity between African American females and males based on the strength of identification with Afrocentrism and Black Americanism (top) and Racial Salience (bottom). Females are the reference category. Illustrations are based on analytical models that included
Discussion
The primary purpose of this study was to explore the association of cultural identity with BMI and obesity among African Americans. The study findings were contrary to our original hypotheses. In almost all cases, BICS was not associated with BMI and obesity among all African Americans, but moderation analyses revealed that stronger identification with certain subscales of BICS, such as Afrocentrism, Black Americanism, and Racial Salience, was associated with an increase in the odds of obesity for males and not for females. These findings highlight the importance of understanding how culture influences obesity differently among males and females within the African American community.
The prevalence of obesity among African Americans is generally higher among females than males [3]. However, our study highlights how identification with the African American culture can modify the risk of obesity for African American males relative to females, which adds to limited research exploring the relations of cultural factors with obesity among African Americans [18, 19] Various other racial and ethnic groups have influenced African American culture in the United States [20] and BICS incorporate beliefs about Biculturalism and Multiculturalism (i.e., assimilation) to reflect the acceptance and integration of other cultural experiences. Biculturalism and Multiculturalism beliefs may be associated with health-related behaviors that are not associated with obesity or even protect against obesity. For instance, soul food is deeply embedded within beliefs about Afrocentrism and Black Americanism, but African Americans who express more Biculturalism and Multiculturalism beliefs may have different dietary behaviors or consume less or no food traditionally associated with the African American identity [20].
Cultural practices surrounding food preparation and dietary choices may explain why certain components of African American culture were associated with obesity among males but not females. Soul foods are rich and flavorful meals prepared with high levels of fat, sugar, and sodium for flavor [5, 7, 8], and frequent consumption of these meals is associated with obesity and obesity-related diseases [10, 11]. Soul food is also generally served at large family gatherings, and family events surrounding food are a quintessential part of African American traditions [5, 7, 8, 21]. Research has shown that people eat more in groups than when they are alone [22]. African American females are responsible for preparing and cooking meals for family dinners and gatherings [5, 7, 8, 21], and these meals are eaten frequently by the entire family [23]. However, males in the African American community are generally served first and receive the largest portions [24]. African American males who eat larger portions and enjoy eating at family gatherings surrounded by loved ones may consume more calories, leading to weight gain and increased obesity risk. In contrast, African American females may be less at risk for obesity because they may eat smaller portions and have fewer opportunities to eat with others because they were responsible for cooking the meal, which is often done alone or in a small group [24]. In addition, the cultural practice of food preparation is considered a method conveying love and celebrating African American culture [8], and the rejection of food is seen as a rejection of love [8]. Therefore, choosing healthier food options or deviating from traditional recipes may be perceived as accepting the dominant culture and rejecting African American culture [7].
Limitations
There are a few limitations to this study. First, the cross-sectional design of the present study precluded us from addressing causality; a plausible alternative explanation for study findings could be that African American males who are obese could feel more accepted and embraced by their community and adopt more cultural attitudes and beliefs. Longitudinal research will be needed to demonstrate the causal direction of the observed associations. Second, height and weight were measured using self-report, which means that the prevalence of obesity within the sample may be biased downward [25]. Further, Johnson et al. found that African American females are more likely than white females to overestimate their height and underestimate their weight, and African American males are less likely to overestimate their height and underestimate their weight than white males, which means that the prevalence of obesity among African American females and males in this sample may also be systematically biased [26]. Third, there was more than 10% missingness for obesity, primarily because participants did not disclose their current weight, similar to other cross-sectional research [14]. Previous prospective research has demonstrated that people who weigh more are less likely to self-report their current weight than people who weigh less [27]. Fourth, these data were collected from a non-random sample of individuals recruited primarily through social media. More than 50% of the study sample were college or postgrad graduates and earned more than $50,000 per year; therefore, this study sample was not representative of African Americans in the general population, which means study effect sizes may not be generalizable. The present study was concerned with highlighting associations of variables within this study sample, and future studies should aim to improve sampling methods to derive better estimates of effect sizes. Last, BICS can generate up to 16 unique groups within the African American population, but this study primarily focused on the six core identity components [9] partially captured by using the average score from each sub-scale. Researchers are encouraged to explore the BICS and its subgroups more deeply using a longitudinal research design with more objective measures of obesity and a larger, more representative sample of African Americans.
Conclusion
The influence of culture on obesity within the African American population, especially among males, is an underexplored area in the literature, and there are many opportunities for future research. For example, more research is needed to determine whether cultural identity is tied to health beliefs and health-related behavior [28], and whether there are cognitive and behavioral differences between females and males based on the degree of identification with the African American culture. Mixed methods research may be especially helpful for deeply exploring how culture influences health beliefs, decisions, and outcomes of African American males. Uncovering the mechanisms, such as dietary behavior, that link culture with obesity will provide novel contributions to behavioral interventions designed to reduce obesity within the African American population.
Supplementary Material
Funding
The research was primarily supported by Oklahoma Tobacco Settlement Endowment Trust contract number R22-02. Additional support was provided by the National Cancer Institute (P30CA225520) and the National Institute on Minority Health and Health Disparities (K01MD015295).
Footnotes
Declarations
Supplementary Information The online version contains supplementary material available at https://doi.org/10.1007/s40615-023-01615-4.
Ethical Approval Informed consent was obtained from all individual participants included in the study. Procedures performed in this study involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments (or comparable ethical standards). The study procedures were also approved by the Institutional Review Board of the Oklahoma University Health Sciences Center.
Competing Interests All authors declare that they have no affiliations with or involvement in any organization or entity with any financial interest (such as honoraria; educational grants; participation in speakers’ bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing arrangements), or non-financial interest (such as personal or professional relationships, affiliations, knowledge or beliefs) in the subject matter or materials discussed in this manuscript.
Data Availability
Data that support the findings of this study are available from the corresponding author upon reasonable request.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
Data that support the findings of this study are available from the corresponding author upon reasonable request.