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Published in final edited form as: Curr Obes Rep. 2024 Jan 3;13(1):98–106. doi: 10.1007/s13679-023-00538-9

The Role of Racism in Childhood Obesity

Ralph I Lawton 1, Fatima Cody Stanford 1,2,3
PMCID: PMC10939728  NIHMSID: NIHMS1967896  PMID: 38172479

Abstract

Purpose of Review

Obesity rates continue to rise among children and have shown persistent racial disparities. Racism plays a potentially essential and actionable role in these disparities. This report reviews some mechanisms through which racism may shape childhood obesity.

Recent Findings

From the youngest ages, disparities in childhood obesity prevalence are already present. Racism may shape intergenerational and prenatal factors that affect obesity and various stressors and environments where children grow up. The relationships between clinicians and patients may also be shaped by everyday racism and legacies of past racism, which may affect obesity prevalence and treatment efficacy.

Summary

Comprehensive data on the extent to which racism shapes childhood obesity is limited. However, compelling evidence suggests many ways through which racism ultimately does affect childhood obesity. Interventions to address racism at multiple points where it shapes childhood obesity, including intergenerational and prenatal mechanisms, may help to close disparities.

Keywords: Childhood obesity, Racism

Introduction

Obesity is the most prevalent chronic disease among children in the USA. In the latest complete NHANES data from 2017 to 2020, approximately 19.7% of children 2–19 years old have obesity, defined as BMI-for-age at or above the 95th percentile based on the CDC 2000 growth charts, a proportion that has risen from 16.8% in 2007–2008 [1-3]. Similar patterns are observed in severe obesity, defined as over 120% of age-and-sex-specific obesity thresholds, rising from 1.2% in 1976–1980 to 4.9% in 2015–2016, and 6.1% in the 2017–2018 NHANES data [4]. At the same time, childhood obesity is much more prevalent among Hispanic and non-Hispanic Black children than non-Hispanic white or Asian children. In 2001–2002, Hispanic and non-Hispanic Black children had obesity rates of approximately 15%, while non-Hispanic white children had obesity rates of roughly 10% [5]. In the most recent nationally representative data, Hispanic children, non-Hispanic Black children, non-Hispanic Asian children, and non-Hispanic White children have obesity rates of 26.2%, 24.8%, 9.0%, and 16.6%, respectively (Fig. 1).

Fig. 1.

Fig. 1

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Children with obesity by race and ethnicity

These disparities emerge at the youngest ages and persist as children age—among children between the ages of 2 and 5: 20.7% of Hispanic children have obesity, 12.5% of Black children have obesity, and 9.9% of White children have obesity, and between the ages of 12–19, 27.8% of Hispanic children have obesity, 29.1% of Black children, and 19% of White children do. These disparities, even at early ages, appear to increase over time, with higher growth rates among non-Hispanic Black children [6]. However, while disparities persist into older ages, disparities narrow somewhat as children age. Longitudinal data suggest that many of these initial disparities derive from infancy, where different trajectories of rapid infant weight gain lead to rapidly emerging inequalities that persist, and data since 1978 suggests that the majority of changes in obesity incidence have been occurring before age 5 [7, 8].

Children with obesity have worse psychosocial health, depression, physical function, and self-esteem [9-11]. To some extent, these may mediate the effects of obesity on poorer schools and downstream economic performance [12-15]. Childhood obesity, primarily but not entirely due to the increased risk of adult obesity, is related to cardiovascular disease, type 2 diabetes, cancers, and earlier mortality [16, 17]. To the extent that childhood obesity has adverse concurrent and life-long impacts on health and well-being, understanding how racism shapes disparities in obesity prevalence is essential.

The significant and persistent racial disparities in childhood obesity raise essential questions about the potential mechanisms at play. In this discussion, we focus on the role of racism in childhood obesity, as potentially manifested due to explicit and systemic racism [18]. Among adults, the manifestations of racism in chronic diseases like obesity are often thought about as a consequence of a lifetime of exposure to the stressors and effects of racism [19-21]. Given that much of the onset of racial disparities in children occurs at the youngest ages, this finding is not fully aligned with mechanistic results in adults. Thus, we critically examine the mechanisms by which racism may shape obesity prevalence in children and discuss the implications therein.

Mechanisms Through Which Racism Can Shape Obesity Prevalence

Racism can shape health outcomes, including childhood obesity, in myriad ways, from individual behaviors to how racism shapes children's environments in [22]. Obesity is a chronic condition that can be shaped at any point over the life course; how racism shapes childhood obesity is further complicated by its ability to act at different stages of a child’s development. While these categories are substantially intertwined, we first will discuss some of how racism may directly shape physiology that can increase the likelihood of childhood obesity, then discuss some of the ways socio-economic, behavioral, and environmental forces can shape childhood obesity, discuss the role of racism by health practitioners, and finally tie these together by discussing the potential for intergenerational transmission.

Physiologic Effects of Chronic Stressors Related to Racism and Discrimination

A critical way racism is known to shape the likelihood of obesity is through repeated activation of the hypothalamic-pituitary-adrenal (HPA) axis. The HPA-axis, often associated with adaptation to stressful events, helps to maintain stability through change, or “allostasis” [23]. Repeated activation of the HPA-axis, including dealing with the ramifications of direct interpersonal discrimination or the broader effects of systemic racism, can contribute to allostatic load—the burden of repeated and potentially inefficient allostasis [24-27]. Increased allostatic load is thus a key mechanism through which chronic stressors, including racism, can manifest to raise the likelihood of obesity [28, 29].

These effects have been explored extensively in adults as a mechanism through which racism can manifest in health. Seminal work by Geronimus and colleagues has documented “weathering” patterns with age and allostatic load—suggesting cumulative burdens of lifelong exposure to racism in part shapes differences in chronic disease risk, including for obesity [20, 30, 31]. Other work documents the dose-response effects of time spent in America on the health of Black adults, suggesting exposure to racism may play a role [32].

These effects are not explored as thoroughly in children. To some extent, the fact that most of the disparities in childhood obesity emerge at young ages, with some convergence as children age, may suggest that the effects of allostatic load related to cumulative individual exposures to racism play a limited role in the disparities in childhood obesity. While several studies have indicated that allostatic load may be higher in Black children and young adults and are also higher in children with higher BMI, evidence linking disparities in allostatic load, let alone racism-attributed allostatic load, at young ages, to the development of childhood obesity is not strong [33-35].

One possible way allostatic load may continue to affect the emergence of childhood obesity is through prenatal exposure to maternal stresses. Prior evidence has suggested stronger age gradients in birthweight for Black women, consistent with a “weathering” hypothesis. However, study designs linking allostatic load to neonatal outcomes have been mixed and limited partly by sample selection and challenges with the temporality of measurement [31, 36-38]. Further evidence on the transmission of stressors related to racism in-utero and a close study of allostatic load at young ages may be highly yielded to shed additional light on the potential ways in which racism manifests in childhood obesity prevalence.

Racism in the Treatment of Childhood Obesity and the Response to Treatment

One of the most direct mechanisms by which racism can shape the prevalence of childhood obesity is through practices and patient interactions by physicians and other clinicians. Particularly with pediatric patients, the treatment of obesity is complex. Management may vary by facility, location, and age but generally includes behavioral and lifestyle interventions, pharmacologic interventions, and bariatric surgery. For all these interventions, racism can shape the intensity with which obesity is treated in pediatric populations and the efficacy therein. Nonetheless, practice intensity should be focused on the right choice and intensity of treatment—disparities in treatment may arise from the overtreatment of privileged populations and the undertreatment of other populations [39].

The first-line treatment for obesity, especially in pediatric populations, is lifestyle modification and behavioral therapy. These often include changes in diet to embrace healthy options with fruits, vegetables, and lean proteins, as well as lower the calories consumed. Other changes often include increased physical activity and limited screen time [40, 41]. More intensive lifestyle interventions are often more effective, with limited evidence for interventions with less than 26 contact hours [42]. Estimates for the efficacy of lifestyle interventions in pediatric populations range from 0.17 to 0.99 BMI-for-age Z-score [43]. In the most recent randomized trial of family-based lifestyle interventions in primary care settings, often considered the most effective, 27% of participating children had a BMI z-score reduction over 0.25 [44•]. Notably, in this trial, White children experienced substantially stronger effects than Black children, a consistent finding in other trials of lifestyle interventions [45].

Racism may be essential in pediatric patients’ heterogeneous responses to lifestyle interventions. Successful interventions may require access to parks and other open spaces, access to which is shaped by the manifestations of racism in urban planning and socio-economic status, potentially linked to persistent consequences of redlining that disproportionately affect minority populations in the USA, among other forces [46-48]. These environmental forces may be particularly impactful for young children, whose primary sources of physical activity are less likely to come from organized sports and events [49].

Recent literature uncovers an additional potential mechanism in the heterogeneous response to lifestyle interventions. An innovative study design by Frakes and Gruber leverages migration to study the causal ramifications of racial concordance between primary care physicians and patients in the US military, finding improved chronic disease outcomes for Black patients who receive a racially concordant provider, primarily through improved medication use and adherence [50•]. While not specific to the pediatric population, substantial evidence on improved patient responses to concordant physicians suggests that, for various reasons, primary care and lifestyle interventions among non-White patients may be shaped by racism in some form. A long literature, including randomized evidence from Alsan et al., has documented how the legacy of racism in medical practice in the USA has fomented distrust that may shape the management of chronic outcomes [51-53]. Other vital components of culturally-competent care may also be provided more effectively by concordant physicians [52]. Such forces may shape not just the responses to the treatment of obesity but the prevention of obesity itself as a chronic disease in childhood. In this context, affirmative efforts to bridge the legacies and expectations created by historical and current racism and work to ensure culturally competent care may help improve responses to obesity treatment in diverse populations. However, there is still a long way to go on this front, and even context-specific interventions that pull in specific coaching and tailored community-based resources have not shown to be more effective than standard lifestyle interventions [54].

For children with moderate or severe obesity, metabolic and bariatric surgery is the most effective tool for treatment [55, 56]. The American Academy of Pediatrics (AAP) and the American Society of Metabolic and Bariatric Surgery (ASMBS) support referrals for pediatric patients with severe obesity. Nonetheless, while over the years 2009–2017, the proportion of Black patients undergoing bariatric surgery increased from 12.1 to 15.8%, utilization remains significantly below that of White patients based on the number of pediatric patients in nationally representative data that would qualify for surgery [57, 58]. Black children who undergo bariatric surgery are more likely to have pre-existing conditions like hypertension, sleep apnea, and asthma and have higher preoperative BMI. Despite this, and in contrast with evidence from adults, reductions in BMI after surgery are similar across racial groups, and there is no evidence for higher rates of complications [59]. However, there is minimal long-term evidence of disparities (or the lack thereof) in outcomes after surgery, and many differences in adult outcomes emerged after the one-year timepoint [60].

While racism appears unlikely to substantially shape surgical and post-surgical outcomes, it may play a substantial role in utilizing disparities through various mechanisms. One critical dimension concerns the locations where surgeries to treat obesity in children are being conducted. Increasingly, these surgeries are being performed at major academic hospitals, particularly in the Northeast of the USA, even though the prevalence of childhood obesity is higher in the South, particularly among Black patients [58]. Further, bariatric surgery has stringent authorization policies, which may contribute to relatively less utilization among publicly insured, disproportionately non-white patients [55].

Increasingly, pharmacologic interventions for pediatric obesity, notably GLP-1 agonists, are being shown to be safe and effective [61•]. While their use in tandem with or replacing bariatric surgery remains unclear, they are remarkably effective, with an average BMI decrease of 16.1% in a recent randomized trial of semaglutide in pediatric patients [61•]. Disparities in the pediatric use of new pharmacologic interventions like GLP-1 agonists must be more specific and studied. However, in the adult population, GLP-1 agonists are more likely to be utilized by White patients and those with higher household income [62]. Racism may shape disparities in utilization by many exact mechanisms as other interventions, including disparate access—especially for drugs that remain in short supply or differences in physician trust when initiating a new medication.

Health Behavior, Diet, and Environment

Racism further shapes many of the individual-level health behaviors and dietary factors that are associated with the development of obesity in childhood.

Given the early emergence of disparities in childhood obesity, breastfeeding and formula-feeding are often discussed as potentially crucial in high infant weight gain [8]. Breastfeeding has been associated with lower weight gain velocity and BMI—in a longitudinal study that separated modes of consumption from type of consumption, infants who were exclusively formula fed had BMIs 0.45 units higher than those exclusively breastfed. However, the effects are diminished somewhat when breastmilk is fed from a bottle [63]. Nonetheless, it is not clear that associations of breastfeeding with lower rates of childhood obesity are causal. Some studies have suggested that breastfeeding rather than formula feeding gives infants more control over satiety and promotes appetite regulation. In contrast, other studies have pointed to differences in nutritional content in breastmilk [63-65]. Other studies note that breastfeeding is linked to higher incomes and that parents who need to return to work are significantly less likely to breastfeed, effects that are hard to parse empirically from the impact of breastfeeding [66, 67].

Nonetheless, in 2019, data from over 3 million births in the national vital statistics system documented significant disparities by race in the initiation of breastfeeding, from over 90% of Asian mothers to 87% of Hispanic mothers, 86% of non-Hispanic White mothers, and 74% of non-Hispanic Black mothers [68]. Racism may potentially play an essential role in these disparities. Non-Hispanic Black mothers, and to a lesser extent Hispanic mothers, are significantly more likely to be single parents, for whom employment needs may be more salient and may intervene with breastfeeding [69, 70]. This may be in large part due to manifestations of racism in earnings inequality, which is linked to a decreased likelihood of union formation, as well as due to inadequate economic support for single mothers or robust paid family leave policies, which may work to mitigate disparities [70]. Another way racism may shape the likelihood of initiating breastfeeding is through knowledge about breastfeeding. Non-Hispanic White mothers have been shown to have higher mean breastfeeding knowledge than Hispanic and non-Hispanic Black mothers [71]. This may be due to various reasons but maybe another extension of limited primary care access and trust in primary-care-level providers. Interventions in hospitals in the Southern USA to implement the “Ten Steps to Successful Breastfeeding” found that the tailored community and hospital-level interventions increased the rate of breastfeeding overall and decreased the disparity in breastfeeding initiation between African American and White mothers by 9.6 percentage points [72••, 73].

A variety of nutritional factors after breastfeeding and formula feeding stop are associated with the development of childhood obesity. Intake of sugar-sweetened beverages like sodas and juices is associated with higher BMIs in children [74, 75]. Higher consumption of processed and fast food is also associated with childhood obesity and increased BMI, potentially through increased portion sizes [76]. Data from a prospective, pre-birth cohort study found that after age 2, Black and Hispanic children had 4 and 2.5 times higher odds of consuming sugar-sweetened beverages and had 1.65 and 3.14 times higher odds of consuming fast food [77]. Two potential channels through which racism may shape these disparities are the lower relative costs of processed foods and neighborhood exposures. Foods with lower nutritional value cost less per calorie than healthier diets and are more likely to be selected by buyers with lower household income [78]. Neighborhood exposures and food supply also shape the diets of their residents. While careful studies leveraging household moves and supermarket entry to identify the causal effects of neighborhood environments have found evidence that nutritional inequality in adults is primarily due to differences in demand for different foods, there is reason to believe that neighborhood factors may play a vital role in childhood obesity [79]. Several studies, including the instrumental-variables approach isolating causal effects of fast-food restaurants, found that localization near schools is linked to higher obesity rates at those schools [80, 81]. Other studies suggest that even if demand for unhealthier types of food is persistent across the life course, early life food exposures can determine healthier or less-healthy diets over time. Using the end of rationing after World War II in the UK, Gertler and Gracner found early life sugar exposure led to higher sugar consumption across the life course and increased diabetes and chronic disease [82•]. School meals have shown to be a promising way to improve nutritional equality despite different environmental exposure, and improved diet quality through regulation of school meals has been associated with lower childhood obesity prevalence [83]. In the aftermath of the Healthy Hunger-Free Kids Act, dietary quality improved substantially for kids at all income levels, with impacts of school meals essential for disadvantaged children [84].

Physical activity and sleep are both linked significantly to the development of childhood obesity [85]. Hispanic, non-Hispanic Black, and non-Hispanic Asian children were all found to be less likely to have greater than 1 h a day of physical activity than non-Hispanic White children [85]. Black, Hispanic, and Asian children were also found to sleep less than White children, with the most significant gaps between 6 months through 7 years old [86]. Racism may play an essential role in these disparities through the different environments in which children of other races grow up. Higher poverty and non-White neighborhoods are often less safe and pleasurable for outdoor activity [87, 88]. Areas with greater levels of disadvantage are also associated with higher light, noise, and air pollution, which can adversely affect sleep quality [89, 90]. Sleep and physical activity disparities may also be linked tightly to some extent, as higher physical activity is protective against shorter sleep duration in children and adolescents [91].

Intergenerational Effects

A critical potential mechanism by which racism may affect childhood obesity is through maternal exposure and possible intergenerational effects. These are mainly of interest given the early ages at which racial disparities in childhood obesity emerge.

One possible way that intergenerational effects of racism may manifest is through prenatal conditions and birth weight. Both small- and large-for-gestational-age at birth have been linked to the development of childhood obesity and metabolic syndrome. However, meta-analyses suggest that the links between small birth weight and childhood obesity may not be as strong [92, 93]. Nonetheless, non-Hispanic Black adults have a much higher likelihood of low birth weight than non-Hispanic White adults [94]. Consistent with a “weathering” mechanism that implicates allostatic load and cumulative HPA-axis activation, Black women have a steeper age pattern in the relationships between older age and low birth weight [31].

Mechanistically, this is somewhat puzzling, as high maternal BMIs may be causally associated with higher birthweight and gestational size [95]. While non-Hispanic Black and Hispanic women have higher BMIs than non-Hispanic White women, children of non-Hispanic Black and Hispanic women are more likely to have low birth weight and then, by the ages of 2–5, have elevated rates of childhood obesity. This could be potentially attributed to other sequelae of maternal obesity than direct effects on birthweight, including changes in adipocyte metabolism and appetite regulation [96]. More broadly, traumatic exposures, environmental forces, and the impact of racism on physiology are transmittable across generations and may continue to shape obesity risk in childhood [97-99].

Conclusion

Racism, directly and indirectly, affects many of the critical factors that underpin substantial disparities by race in the prevalence of childhood obesity. These disparities are present at the earliest childhood ages, suggesting various mechanisms may play an important role. While the direct impacts of racial discrimination and often-discussed mechanisms involving allostatic load and “weathering” are inconsistent with the early onset of disparities, these may continue to play an important role as children age and impacts from these forces on maternal health and wellbeing may transmit to children. Other potential mechanisms involving relationships between healthcare providers and patients may also play an essential role in both the intensity of obesity treatment and the efficacy of treatment, particularly lifestyle interventions. Historic racism by the medical establishment and differences in cultural norms between medical practitioners and patients continue to shape disparities in outcomes. Legacies of racism and ongoing racism that affect where children of different races live may play an important role through the environmental forces at play. Environments play an essential role in forming healthy dietary habits and preferences, affect physical activity through the prevalence or absence of safe spaces, and shape children’s sleep and development through noise and air pollution, affecting childhood obesity. The broad array of mechanisms by which racism shapes childhood obesity is daunting but suggests tractable ways to improve outcomes for the population. Ongoing comprehensive research will continue to shed light on the mechanisms by which disparities emerge at early ages, and innovative policy interventions that target racism at every step where it may manifest have already shown promise in closing disparities.

Funding

This study was supported by the National Institutes of Health NIDDK U24 DK132733, NIDDK UE5 DK137285 and P30 DK040561 (FCS).

Footnotes

Conflict of Interest Dr. Fatima Cody Stanford has served as a paid consultant/advisor for Novo Nordisk, Eli Lilly, Pfizer, Boheringer Ingelheim, Currax, Gelesis, Rhythm, Calibrate, Sweetch, Vida Health, and Ilant Health.

Human and Animal Rights and Informed Consent This article does not contain any studies with human or animal subjects performed by any of the authors.

References

Papers of particular interest, published recently, have been highlighted as:

• Of importance

•• Of major importance

  • 1.Hales CM, Fryar CD, Carroll MD, Freedman DS, Ogden CL. Trends in obesity and severe obesity prevalence in us youth and adults by sex and age, 2007–2008 to 2015–2016. JAMA. 2018;319(16):1723–5. 10.1001/jama.2018.3060. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 2.Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of childhood and adult obesity in the United States, 2011–2012. JAMA. 2014;311(8):806–14. 10.1001/jama.2014.732. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 3.Ogden CL, Flegal KM. Obesity and socioeconomic status in adults: United States. 2010;2005–2008:50. [PubMed] [Google Scholar]
  • 4.Claire Wang Y, Gortmaker SL, Taveras EM. Trends and racial/ethnic disparities in severe obesity among US children and adolescents, 1976–2006. Int J Pediatr Obes. 2011;6(1):12–20. 10.3109/17477161003587774. [DOI] [PubMed] [Google Scholar]
  • 5.Rossen LM, Schoendorf KC. Measuring health disparities: trends in racial–ethnic and socioeconomic disparities in obesity among 2- to 18-year old youth in the United States, 2001–2010. Ann Epidemiol. 2012;22(10):698–704. 10.1016/j.annepidem.2012.07.005. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 6.Cunningham SA, Hardy ST, Jones R, Ng C, Kramer MR, Narayan KMV. Changes in the incidence of childhood obesity. Pediatrics. 2022;150(2):e2021053708. 10.1542/peds.2021-053708. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 7.Anderson PM, Butcher KF, Schanzenbach DW. Understanding recent trends in childhood obesity in the United States. Econ Hum Biol. 2019;34:16–25. 10.1016/j.ehb.2019.02.002. [DOI] [PubMed] [Google Scholar]
  • 8.Isong IA, Rao SR, Bind MA, Avendaño M, Kawachi I, Richmond TK. Racial and ethnic disparities in early childhood obesity. Pediatrics. 2018;141(1):e20170865. 10.1542/peds.2017-0865. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 9.Friedlander SL, Larkin EK, Rosen CL, Palermo TM, Redline S. Decreased quality of life associated with obesity in school-aged children. Arch Pediatr Adolesc Med. 2003;157(12):1206–11. 10.1001/archpedi.157.12.1206. [DOI] [PubMed] [Google Scholar]
  • 10.Rankin J, Matthews L, Cobley S, et al. Psychological consequences of childhood obesity: psychiatric comorbidity and prevention. Adolesc Health Med Ther. 2016;7:125–46. 10.2147/AHMT.S101631. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 11.King JE, Jebeile H, Garnett SP, Baur LA, Paxton SJ, Gow ML. Physical activity based pediatric obesity treatment, depression, self-esteem and body image: a systematic review with meta-analysis. Ment Health Phys Act. 2020;19:100342. 10.1016/j.mhpa.2020.100342. [DOI] [PubMed] [Google Scholar]
  • 12.Sahoo K, Sahoo B, Choudhury AK, Sofi NY, Kumar R, Bhadoria AS. Childhood obesity: causes and consequences. J Family Med Prim Care. 2015;4(2):187–92. 10.4103/2249-4863.154628. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 13.Cawley J. The economics of obesity. NBER. https://www.nber.org/reporter/2013number4/economics-obesity. Published December 2013. Accessed 27 Mar 2023. [Google Scholar]
  • 14.Mocan NH, Tekin E. Obesity, self-esteem and wages. 2009. 10.3386/w15101. [DOI] [Google Scholar]
  • 15.Schwimmer JB, Burwinkle TM, Varni JW. Health-related quality of life of severely obese children and adolescents. JAMA. 2003;289(14):1813–9. 10.1001/jama.289.14.1813. [DOI] [PubMed] [Google Scholar]
  • 16.Maffeis C, Tatò L. Long-term effects of childhood obesity on morbidity and mortality. Horm Res. 2004;55(Suppl. 1):42–5. 10.1159/000063462. [DOI] [PubMed] [Google Scholar]
  • 17.Biro FM, Wien M. Childhood obesity and adult morbidities. Am J Clin Nutr. 2010;91(5):1499S–1505S. 10.3945/ajcn.2010.28701B. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 18.Braveman PA, Arkin E, Proctor D, Kauh T, Holm N. Systemic and structural racism: definitions, examples, health damages, and approaches to dismantling. Health Aff. 2022;41(2):171–8. 10.1377/hlthaff.2021.01394. [DOI] [PubMed] [Google Scholar]
  • 19.Crimmins EM, Seeman TE. Integrating biology into the study of health disparities. Popul Dev Rev. 2004;30:89–107. [Google Scholar]
  • 20.Geronimus AT, Hicken M, Keene D, Bound J. “Weathering” and age patterns of allostatic load scores among Blacks and Whites in the United States. Am J Public Health. 2006;96(5):826–33. 10.2105/AJPH.2004.060749. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 21.Forde AT, Crookes DM, Suglia SF, Demmer RT. The weathering hypothesis as an explanation for racial disparities in health: a systematic review. Ann Epidemiol. 2019;33:1–18.e3. 10.1016/j.annepidem.2019.02.011. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 22.Alvidrez J, Castille D, Laude-Sharp M, Rosario A, Tabor D. The National Institute on Minority Health and Health Disparities Research Framework. Am J Public Health. 2019;109(S1):S16–20. 10.2105/AJPH.2018.304883. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 23.McEWEN BS. Stress, adaptation, and disease: allostasis and allostatic load. Ann N Y Acad Sci. 1998;840(1):33–44. 10.1111/j.1749-6632.1998.tb09546.x. [DOI] [PubMed] [Google Scholar]
  • 24.McEWEN BS, Seeman T. Protective and Damaging effects of mediators of stress: elaborating and testing the concepts of allostasis and allostatic load. Ann NY Acad Sci. 1999;896(1):30–47. 10.1111/j.1749-6632.1999.tb08103.x. [DOI] [PubMed] [Google Scholar]
  • 25.Thomas MD, Michaels EK, Reeves AN, et al. Differential associations between everyday versus institution-specific racial discrimination, self-reported health, and allostatic load among black women: implications for clinical assessment and epidemiologic studies. Ann Epidemiol. 2019;35:20–28.e3. 10.1016/j.annepidem.2019.05.002. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 26.Walsemann KM, Pearson J, Abbruzzi E. Education in the Jim Crow South and Black-White inequities in allostatic load among older adults. SSM Popul Health. 2022;19:101224. 10.1016/j.ssmph.2022.101224. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 27.Miller HN, LaFave S, Marineau L, Stephens J, Thorpe RJ. The impact of discrimination on allostatic load in adults: an integrative review of literature. J Psychosom Res. 2021;146:110434. 10.1016/j.jpsychores.2021.110434. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 28.Seeman TE, McEwen BS, Rowe JW, Singer BH. Allostatic load as a marker of cumulative biological risk: MacArthur studies of successful aging. Proc Natl Acad Sci. 2001;98(8):4770–5. 10.1073/pnas.081072698. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 29.McEwen BS. Allostasis and allostatic load: implications for neuropsychopharmacology. Neuropsychopharmacology. 2000;22(2):108–24. 10.1016/S0893-133X(99)00129-3. [DOI] [PubMed] [Google Scholar]
  • 30.Geronimus AT, Hicken MT, Pearson JA, Seashols SJ, Brown KL, Cruz TD. Do US Black women experience stress-related accelerated biological aging? Hum Nat. 2010;21(1):19–38. 10.1007/s12110-010-9078-0. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 31.Geronimus AT. Black/white differences in the relationship of maternal age to birthweight: a population-based test of the weathering hypothesis. Soc Sci Med. 1996;42(4):589–97. 10.1016/0277-9536(95)00159-X. [DOI] [PubMed] [Google Scholar]
  • 32.Doamekpor LA, Dinwiddie GY. Allostatic load in foreign-born and US-born Blacks: evidence from the 2001–2010 National Health and Nutrition Examination Survey. Am J Public Health. 2015;105(3):591–7. 10.2105/AJPH.2014.302285. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 33.Cedillo YE, Murillo AL, Fernández JR. The association between allostatic load and anthropometric measurements among a multiethnic cohort of children. Pediatr Obes. 2019;14(6):e12501. 10.1111/ijpo.12501. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 34.Cullin JM. Biological normalcy and body fat: obesity prevalence, fat stigma, and allostatic load among late adolescents and young adults. Am J Biol Anthropol. 2023. Aug;181(4):575–587. 10.1002/ajpa.24752. Epub 2023 Apr 25. [DOI] [PubMed] [Google Scholar]
  • 35.Calcaterra V, Vinci F, Casari G, et al. Evaluation of allostatic load as a marker of chronic stress in children and the importance of excess weight. Front Pediatr. 2019. Aug 7;7:335. 10.3389/fped.2019.00335. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 36.Premji SS, Pana GS, Cuncannon A, Ronksley PE, Dosani A, Hayden KA, Lalani S, Musana JW, Shaikh K, Yim IS; Maternal-infant Global Health Team (MiGHT) Collaborators in Research. Prenatal allostatic load and preterm birth: a systematic review. Front Psychol. 2022. Oct 4;13:1004073. 10.3389/fpsyg.2022.1004073. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 37.Barry MC, Zimmer C, Halpern CT. Biomarkers of pre-pregnancy allostatic load and subsequent adverse birth outcomes. SSM Popul Health. 2022;18:101099. 10.1016/j.ssmph.2022.101099. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 38.Morrison S, Shenassa ED, Mendola P, Wu T, Schoendorf K. Allostatic load may not be associated with chronic stress in pregnant women, NHANES 1999–2006. Ann Epidemiol. 2013;23(5):294–7. 10.1016/j.annepidem.2013.03.006. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 39.Baicker K, Chandra A, Skinner JS, Wennberg JE. Who you are and where you live: how race and geography affect the treatment of Medicare beneficiaries. Health Aff. 2004;23(Suppl2):VAR-33. 10.1377/hlthaff.var.33 [DOI] [PubMed] [Google Scholar]
  • 40.Minges KE, Chao A, Nam S, Grey M, Whittemore R. Weight Status, gender, and race/ethnicity: are there differences in meeting recommended health behavior guidelines for adolescents? J Sch Nurs. 2015;31(2):135–45. 10.1177/1059840514554089. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 41.Styne DM, Arslanian SA, Connor EL, et al. Pediatric obesity—assessment, treatment, and prevention: an endocrine society clinical practice guideline. J Clin Endocrinol Metab. 2017;102(3):709–57. 10.1210/jc.2016-2573. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 42.Thornton RLJ, Hernandez RG, Cheng TL. Putting the US preventive services task force recommendation for childhood obesity screening in context. JAMA. 2017;317(23):2378–80. 10.1001/jama.2017.3434. [DOI] [PubMed] [Google Scholar]
  • 43.Rajjo T, Mohammed K, Alsawas M, et al. Treatment of pediatric obesity: an umbrella systematic review. J Clin Endocrinol Metab. 2017;102(3):763–75. 10.1210/jc.2016-2574. [DOI] [PubMed] [Google Scholar]
  • 44.•. Epstein LH, Wilfley DE, Kilanowski C, et al. Family-based behavioral treatment for childhood obesity implemented in pediatric primary care: a randomized clinical trial. JAMA. 2023;329(22):1947–56. 10.1001/jama.2023.8061. This recent randomized trial sets a standard for practical interventions for childhood obesity - family centered and in primary care settings. It also finds lower efficacy among Black children enrolled.
  • 45.Johnson VR, Acholonu NO, Dolan AC, Krishnan A, Wang EHC, Stanford FC. Racial disparities in obesity treatment among children and adolescents. Curr Obes Rep. 2021;10(3):342–50. 10.1007/s13679-021-00442-0. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 46.Schell CJ, Dyson K, Fuentes TL, et al. The ecological and evolutionary consequences of systemic racism in urban environments. Science. 2020;369(6510):eaay4497. 10.1126/science.aay4497. [DOI] [PubMed] [Google Scholar]
  • 47.Satcher LA. Multiply-deserted areas: environmental racism and food, pharmacy, and greenspace access in the Urban South. Environ Sociol. 2022;8(3):279–91. 10.1080/23251042.2022.2031513. [DOI] [Google Scholar]
  • 48.Nardone A, Rudolph KE, Morello-Frosch R, Casey JA. Redlines and greenspace: the relationship between historical redlining and, 2010 greenspace across the United States. Environ Health Perspect. 129(1):017006. 10.1289/EHP7495. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 49.Timmons BW, Naylor PJ, Pfeiffer KA. Physical activity for pre-school children — how much and how? This article is part of a supplement entitled Advancing physical activity measurement and guidelines in Canada: a scientific review and evidence-based foundation for the future of Canadian physical activity guidelines co-published by Applied Physiology, Nutrition, and Metabolism and the Canadian Journal of Public Health. It may be cited as Appl. Physiol. Nutr. Metab. 32(Suppl. 2E) or as Can. J. Public Health 98(Suppl. 2). Appl Physiol Nutr Metab. 2007;32(S2E):S122–S134. 10.1139/H07-112. [DOI] [PubMed] [Google Scholar]
  • 50.•. Frakes MD, Gruber J. Racial concordance and the quality of medical care: evidence from the military. 2022. 10.3386/w30767. This study leverages an innovative migration-based study design to causally identify returns to physician-patient racial concordance in chronic disease management.
  • 51.Alsan M, Wanamaker M. Tuskegee and the health of Black men. Q J Econ. 2018;133(1):407–55. 10.1093/qje/qjx029. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 52.Alsan M, Garrick O, Graziani G. Does diversity matter for health? experimental evidence from Oakland. Am Econ Rev. 2019;109(12):4071–111. 10.1257/aer.20181446. [DOI] [Google Scholar]
  • 53.Bajaj SS, Stanford FC. Beyond Tuskegee — vaccine distrust and everyday racism. N Engl J Med. 2021;384(5):e12. 10.1056/NEJMpv2035827. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 54.Taveras EM, Marshall R, Sharifi M, et al. Comparative effectiveness of clinical-community childhood obesity interventions: a randomized clinical trial. JAMA Pediatr. 2017;171(8):e171325. 10.1001/jamapediatrics.2017.1325. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 55.Armstrong SC, Bolling CF, Michalsky MP, et al. Pediatric metabolic and bariatric surgery: evidence, barriers, and best practices. Pediatrics. 2019;144(6):e20193223. 10.1542/peds.2019-3223. [DOI] [PubMed] [Google Scholar]
  • 56.Pratt JSA, Browne A, Browne NT, et al. ASMBS pediatric metabolic and bariatric surgery guidelines, 2018. Surg Obes Relat Dis. 2018;14(7):882–901. 10.1016/j.soard.2018.03.019. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 57.Nunez Lopez O, Jupiter DC, Bohanon FJ, Radhakrishnan RS, Bowen-Jallow KA. Health disparities in adolescent bariatric surgery: nationwide outcomes and utilization. J Adolesc Health. 2017;61(5):649–56. 10.1016/j.jadohealth.2017.05.028. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 58.Bouchard ME, Tian Y, Linton S, et al. Utilization trends and disparities in adolescent bariatric surgery in the United States 2009–2017. Child Obes. 2022;18(3):188–96. 10.1089/chi.2021.0201. [DOI] [PubMed] [Google Scholar]
  • 59.Steinberger AE, Youngwirth LM, Kim SE, et al. Adolescent bariatric surgery: racial disparities in 30-day outcomes using the MBSAQIP from 2015 to 2018. Obes Surg. 2021;31(8):3776–85. 10.1007/s11695-021-05500-z. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 60.Wood MH, Carlin AM, Ghaferi AA, et al. Association of race with bariatric surgery outcomes. JAMA Surg. 2019;154(5):e190029. 10.1001/jamasurg.2019.0029. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 61.•. Weghuber D, Barrett T, Barrientos-Pérez M, et al. Once-weekly semaglutide in adolescents with obesity. N Engl J Med. 2022;387(24):2245–57. 10.1056/NEJMoa2208601. A recent randomized trial of pharamcologic therapy for childhood obesity shows high efficacy.
  • 62.Eberly LA, Yang L, Essien UR, et al. Racial, ethnic, and socioeconomic inequities in glucagon-like peptide-1 receptor agonist use among patients with diabetes in the US. JAMA Health Forum. 2021;2(12):e214182. 10.1001/jamahealthforum.2021.4182. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 63.Azad MB, Vehling L, Chan D, et al. Infant feeding and weight gain: separating breast milk from breastfeeding and formula from food. Pediatrics. 2018;142(4):e20181092. 10.1542/peds.2018-1092. [DOI] [PubMed] [Google Scholar]
  • 64.Brown A, Lee M. Breastfeeding during the first year promotes satiety responsiveness in children aged 18–24 months. Pediatr Obes. 2012;7(5):382–90. 10.1111/j.2047-6310.2012.00071.x. [DOI] [PubMed] [Google Scholar]
  • 65.Katzmarzyk PT, Barlow S, Bouchard C, et al. An evolving scientific basis for the prevention and treatment of pediatric obesity. Int J Obes. 2014;38(7):887–905. 10.1038/ijo.2014.49. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 66.Beauregard JL, Hamner HC, Chen J, Avila-Rodriguez W, Elam-Evans LD, Perrine CG. Racial disparities in breastfeeding initiation and duration among U.S. infants born in 2015. MMWR Morb Mortal Wkly Rep. 2019;68(34):745–748. 10.15585/mmwr.mm6834a3. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 67.Jones KM, Power ML, Queenan JT, Schulkin J. Racial and ethnic disparities in breastfeeding. Breastfeed Med. 2015;10(4):186–96. 10.1089/bfm.2014.0152. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 68.Chiang KV, Li R, Anstey EH, Perrine CG. Racial and ethnic disparities in breastfeeding initiation — United States, 2019. MMWR Morb Mortal Wkly Rep. 2021;70(21):769–774. 10.15585/mmwr.mm7021a1. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 69.Baker RS. Ethno-racial variation in single motherhood prevalences and penalties for child poverty in the United States, 1995–2018. Ann Am Acad Pol Soc Sci. 2022;702(1):20–36. 10.1177/00027162221120759. [DOI] [Google Scholar]
  • 70.Mclanahan S, Percheski C. Family structure and the reproduction of inequalities. Ann Rev Sociol. 2008;34:257–76. [Google Scholar]
  • 71.Alghamdi S, Horodynski M, Stommel M. Racial and ethnic differences in breastfeeding, maternal knowledge, and self-efficacy among low-income mothers. Appl Nurs Res. 2017;37:24–7. 10.1016/j.apnr.2017.07.009. [DOI] [PubMed] [Google Scholar]
  • 72.••. Merewood A, Bugg K, Burnham L, Krane K, Nickel N, Broom S, Edwards R, Feldman-Winter L. Addressing racial inequities in breastfeeding in the southern United States. Pediatrics. 2019;143(2):e20181897. doi.org/ 10.1542/peds.2018-1897. This innovative study documents the rollout of comprehensive initiatives to increase the initiation of breastfeeding in a series of hospitals in the Southern US. While the results may have implications for obesity, it also provides large-scale evidence that typifies the type of comprehensive, community and hospital-based interventions that may address the manifestations of racism at multiple points.
  • 73.Hemingway S, Forson-Dare Z, Ebeling M, Taylor SN. Racial Disparities in sustaining breastfeeding in a baby-friendly designated Southeastern United States hospital: an opportunity to investigate systemic racism. Breastfeed Med. 2021. Feb;16(2):150–155. 10.1089/bfm.2020.0306. Epub 2021 Feb 4. [DOI] [PubMed] [Google Scholar]
  • 74.Wang YC, Bleich SN, Gortmaker SL. Increasing caloric contribution from sugar-sweetened beverages and 100% fruit juices among US children and adolescents, 1988–2004. Pediatrics. 2008;121(6):e1604–14. 10.1542/peds.2007-2834. [DOI] [PubMed] [Google Scholar]
  • 75.Ludwig DS, Peterson KE, Gortmaker SL. Relation between consumption of sugar-sweetened drinks and childhood obesity: a prospective, observational analysis. Lancet. 2001;357(9255):505–8. 10.1016/S0140-6736(00)04041-1. [DOI] [PubMed] [Google Scholar]
  • 76.Bowman SA, Gortmaker SL, Ebbeling CB, Pereira MA, Ludwig DS. Effects of fast-food consumption on energy intake and diet quality among children in a national household survey. Pediatrics. 2004;113(1):112–8. 10.1542/peds.113.1.112. [DOI] [PubMed] [Google Scholar]
  • 77.Taveras EM, Gillman MW, Kleinman K, Rich-Edwards JW, Rifas-Shiman SL. Racial/ethnic differences in early-life risk factors for childhood obesity. Pediatrics. 2010;125(4):686–95. 10.1542/peds.2009-2100. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 78.Darmon N, Drewnowski A. Contribution of food prices and diet cost to socioeconomic disparities in diet quality and health: a systematic review and analysis. Nutr Rev. 2015;73(10):643–60. 10.1093/nutrit/nuv027. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 79.Allcott H, Diamond R, Dubé JP, Handbury J, Rahkovsky I, Schnell M. Food deserts and the causes of nutritional inequality. Q J Econ. 2019;134(4):1793–844. 10.1093/qje/qjz015. [DOI] [Google Scholar]
  • 80.Alviola PA, Nayga RM, Thomsen MR, Danforth D, Smartt J. The effect of fast-food restaurants on childhood obesity: a school level analysis. Econ Hum Biol. 2014;12:110–9. 10.1016/j.ehb.2013.05.001. [DOI] [PubMed] [Google Scholar]
  • 81.Currie J, DellaVigna S, Moretti E, Pathania V. The effect of fast food restaurants on obesity and weight gain. Am Econ J Econ Pol. 2010;2(3):32–63. 10.1257/pol.2.3.32. [DOI] [Google Scholar]
  • 82.•. Gertler P, Gracner T. The sweet life: the long-term effects of a sugar-rich early childhood. 2022. 10.3386/w30799. This study creatively uses changes in early life sugar availability due to rationing to examine the long-term effects on health, and the persistence of dietary preferences formed in childhood.
  • 83.Taber DR, Chriqui JF, Powell L, Chaloupka FJ. Association between state laws governing school meal nutrition content and student weight status: implications for new USDA school meal standards. JAMA Pediatr. 2013;167(6):513–9. 10.1001/jamapediatrics.2013.399. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 84.Smith TA, Mojduszka EM, Chen S. Did the new school meal standards improve the overall quality of children’s diets? Appl Econ Perspect Policy. 2021;43(4):1366–84. 10.1002/aepp.13074. [DOI] [Google Scholar]
  • 85.Haughton CF, Wang ML, Lemon SC. Racial/ethnic disparities in meeting 5-2-1-0 recommendations among children and adolescents in the United States. J Pediatr. 2016;175:188–194.e1. 10.1016/j.jpeds.2016.03.055. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 86.Peña MM, Rifas-Shiman SL, Gillman MW, Redline S, Taveras EM. Racial/ethnic and socio-contextual correlates of chronic sleep curtailment in childhood. Sleep. 2016;39(9):1653–61. 10.5665/sleep.6086. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 87.Franzini L, Taylor W, Elliott MN, et al. Neighborhood characteristics favorable to outdoor physical activity: disparities by socioeconomic and racial/ethnic composition. Health Place. 2010;16(2):267–74. 10.1016/j.healthplace.2009.10.009. [DOI] [PubMed] [Google Scholar]
  • 88.Carroll-Scott A, Gilstad-Hayden K, Rosenthal L, et al. Disentangling neighborhood contextual associations with child body mass index, diet, and physical activity: the role of built, socioeconomic, and social environments. Soc Sci Med. 2013;95:106–14. 10.1016/j.socscimed.2013.04.003. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 89.Fuller-Rowell TE, Curtis DS, El-Sheikh M, Chae DH, Boylan JM, Ryff CD. Racial disparities in sleep: the role of neighborhood disadvantage. Sleep Med. 2016;27–28:1–8. 10.1016/j.sleep.2016.10.008. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 90.Johnson DA, Billings ME, Hale L. Environmental determinants of insufficient sleep and sleep disorders: implications for population health. Curr Epidemiol Rep. 2018;5(2):61–9. 10.1007/s40471-018-0139-y. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 91.Gillis BT, Shimizu M, Philbrook LE, El-Sheikh M. Racial disparities in adolescent sleep duration: physical activity as a protective factor. Cultur Divers Ethnic Minor Psychol. 2021;27(1):118–22. 10.1037/cdp0000422. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 92.Hong YH, Lee JE. Large for gestational age and obesity-related comorbidities. J Obes Metab Syndr. 2021;30(2):124–31. 10.7570/jomes20130. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 93.Yu ZB, Han SP, Zhu GZ, et al. Birth weight and subsequent risk of obesity: a systematic review and meta-analysis. Obes Rev. 2011;12(7):525–42. 10.1111/j.1467-789X.2011.00867.x. [DOI] [PubMed] [Google Scholar]
  • 94.Thompson JA, Suter MA. Estimating racial health disparities among adverse birth outcomes as deviations from the population rates. BMC Pregnancy Childbirth. 2020;20(1):1–7. 10.1186/s12884-020-2847-9. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 95.Tyrrell J, Richmond RC, Palmer TM, et al. Genetic evidence for causal relationships between maternal obesity-related traits and birth weight. JAMA. 2016;315(11):1129–40. 10.1001/jama.2016.1975. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 96.Oken E. Maternal and child obesity: the causal link. Obstet Gynecol Clinics. 2009;36(2):361–77. 10.1016/j.ogc.2009.03.007. [DOI] [PubMed] [Google Scholar]
  • 97.Buss C, Entringer S, Moog NK, et al. Intergenerational transmission of maternal childhood maltreatment exposure: implications for fetal brain development. J Am Acad Child Adolesc Psychiatry. 2017;56(5):373–82. 10.1016/j.jaac.2017.03.001. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 98.Jones NL, Gilman SE, Cheng TL, Drury SS, Hill CV, Geronimus AT. Life course approaches to the causes of health disparities. Am J Public Health. 2019;109(S1):S48–55. 10.2105/AJPH.2018.304738. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 99.Santavirta T, Santavirta N, Gilman SE. Association of the World War II Finnish evacuation of children with psychiatric hospitalization in the next generation. JAMA Psychiat. 2018;75(1):21–7. 10.1001/jamapsychiatry.2017.3511. [DOI] [PMC free article] [PubMed] [Google Scholar]

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