Psychosociocultural Contributors to Maladaptive Eating Behaviors in African American Youth: Recommendations and Future Directions

Abstract

Childhood overweight and obesity disproportionately affects African Americans, and these children benefit less from standard pediatric weight management treatment programs compared to other racial/ethnic groups. Maladaptive eating behavior has been identified as a behavioral contributor to obesity and is also associated with the development of nonrestrictive eating disorders over time. Unique psychosociocultural factors have been identified that may promote higher risk for maladaptive eating behaviors in African American children beyond the effects of economic disparity. To best treat this group, it is important for practitioners to have a thorough understanding of these factors. We review several of these considerations and describe ways they may interact to contribute to the subsequent development of maladaptive eating behaviors and increased weight. Recommendations are made regarding how attention to these factors could be incorporated into current pediatric weight management treatments to better serve this population via a patient-centered care approach. Future directions will also be discussed.

‘. . . 76.2% of African American adults are overweight or obese compared to 67.2% of Caucasians. Notably, these disparities persist across socioeconomic lines.’

Childhood overweight and obesity is a nationwide health concern that affects 31.8% of children ages 2 to 19 years old ¹ and is associated with a multitude of negative physical and mental health outcomes. Increased weight is directly related to the development of metabolic syndrome, ² and children ^* who are overweight or obese are more likely to suffer from both internalizing and externalizing psychological disorders.^3-6

The disparity in obesity prevalence, with 35.2% of African American ^† children being classified as overweight or obese compared to 28.5% of Caucasian children, mirrors the disparity in obesity prevalence among African American adults—76.2% of African American adults are overweight or obese compared to 67.2% of Caucasians. ¹ Notably, these disparities persist across socioeconomic lines. ⁷

While ultimately obesity reflects an unbalanced energy equation, in that energy intake is greater than energy expenditure,^8,9 the causal chain leading to this outcome is complex. ¹⁰ Therefore, when identifying contributors to childhood obesity, it is essential to consider a wide range of factors that affect the developing child, and how these factors interact to promote higher energy input and lower output.^10-13 For example, in the current obesogenic environment, unhealthy foods are easy to acquire quickly and cheaply, ¹⁴ particularly in low-income areas that have been unduly affected by social influences resulting in changes to the built and food environment.^15,16 Lack of exposure to healthier foods may promote learned preferences for unhealthy foods, ¹⁷ which interfere with efforts to promote healthier choices by making new behaviors feel aversive or punitive. Furthermore, obesogenic environments may provide few safe opportunities to be physically active.^18-20 Media also influences childhood obesity via exposure to advertisements of unhealthy foods and screen time interfering with motivation to exercise as well as with sleep patterns.^21,22 Such factors may be of even greater concern in children of lower socioeconomic status who are also members of minority groups. ¹⁰ For example, there is ample evidence of targeted media marketing strategies of unhealthy foods to African American and Hispanic youth.^23,24

As important as environmental factors are in addressing the childhood obesity crisis, psychological and behavioral factors that contribute to eating behaviors, understood from a sociocultural lens, should also be considered.^25-27 When these factors are addressed via interventions for child weight management, they may enhance children’s response to weight loss interventions.^10,12 These factors may be especially important to consider for African American children because current interventions for pediatric weight management programs are not effectively serving this group ²⁸ —indeed, many of the existing interventions were not developed or validated with African American populations in mind.

The purpose of this article is to discuss psychosociocultural indicators that may confer risk that contributes to the development of maladaptive eating behaviors and obesity in African American children. Relevant literature from adult and child samples will be included as there is relatively little research specifically on weight concerns among African American children. ^* We argue that the confluence of these factors has specific implications for intervention programs which typically have difficulty engaging with African American children and their families effectively ²⁹ (See Table 1). More specifically, we will:

Table 1.

Psychosociocultural Contributors to Maladaptive Eating Behavior in African American Youth: Recommendations and Future Directions.

Factor	Description	Recommendation	Future direction
Psychosocial
Disparate Stressors	Race-based stress, higher likelihood of living in poverty, food scarcity/restriction, acculturative stress	• Carefully assess the role of psychosocial stressors across the socioeconomic status spectrum as it relates to eating behavior and be willing to adapt or augment standard treatments to better account for these contributors to eating and weight. Such adaptations or augmentations can include, but are not limited to, the addition of a culturally competent behavioral health specialist to process relevant stressors, referral to applicable support groups, or supplemental social services.	• Further explore how socioeconomic status affects the experience of stress and parenting behaviors
Parental Stress, Parenting Behaviors, and Child Feeding Behavior	Authoritarian parenting style and its impact on child feeding	• Share basic parenting strategies (ie, validation, positive reinforcement, consistency in parenting behaviors) with caregivers of children with eating and weight concerns. Provide referrals to individual therapy or support groups for caregivers who appear to be having difficulty managing stress.
Cultural
Food Type and Beliefs about the Role of Food	Cultural food staples prepared with high amounts of sugar, fat, and salt Food representing togetherness and health	• Utilize culturally sensitive food recommendations that take into account the potential for financial limitations.129–131 • We recommend that appetite awareness interventions focusing on internal statues of hunger and satiety128,132,133 be explored as an adjunct to standard pediatric weight management treatment.	• Additional qualitative research on what types of interventions would promote increased flexibility around preferred foods, as well as willingness to experiment with different health behaviors
Coping and Health Behaviors	Food associated with emotion Present-focused time orientation Support from community around health behaviors	• When working with families be aware of the potential developmental nature of influential cultural factors and practice cultural humility by listening and validating patient experiences. Take a collaborative approach to care to increase patient’s comfort level in the treatment space. Determine individual’s unique motivation for change.	• Additional research regarding the salience of cultural factors and how they interact with socioeconomic and assimilatory differences
Body Type Ideals	Flexible body type ideals with variation in body satisfaction based on level of acculturation to the mainstream		• Development of body image and eating disorder measures that are normed within African American youth
Mistrust of the Formal Medical System	Skepticism due to history of the medical system doing harm	• Given the historical strength of African American social networks, utilize family and community-focused interventions. Such approaches could increase treatment buy-in as individuals are able receive support via familiar outlets when embarking on difficult behavior change. Guided self-help interventions within a stepped care model may also aid in increasing patient’s comfort with treatment.	• Continued exploration of the effectiveness of community-based interventions for eating and weight

1. Define maladaptive eating behaviors (MEBs) and discuss its prevalence in African American children.

2. Review the efficacy of existing pediatric weight management treatments for African American children.

3. Describe psychosocial-behavioral factors that may confer increased risk for MEBs in African American children, with particular focus on psychosocial stress and its interaction with socioeconomic status, food scarcity/restriction, and parenting/child feeding factors.

4. Address specific cultural factors such as food type preferences and the role of food, the influence of coping and health behavior, body type ideals, and history of mistrust with the formal medical system, that may work together to influence motivation and engagement in pediatric weight management treatment.

5. Outline recommendations for intervention and future directions with a focus on patient-centered approaches, or care that centers the “preferences, needs, and values” of the patient.^30,31

Maladaptive Eating Behaviors

Maladaptive eating behaviors have been defined in children as eating due to emotional states, fatigue/boredom, and external factors. Emotional eating most commonly occurs in the context of “depression, anxiety, loneliness, and anger.” ³² Negative affect is correlated with stress ³³ and is one pathway through which emotional eating may develop and/or be maintained.^34-36 Furthermore, eating triggered by the experience of fatigue/boredom may due to the desire to want distance from aversive self-focus. ³⁷ External eating is defined as “eating in response to food-related stimuli, regardless of [one’s] internal state of hunger or satiety.” ³⁸ Given that engaging in these eating behaviors is related to increased risk of overweight and obesity, ³² as well as clinically significant binge eating behaviors over time, ³⁹ it is important to explore the various contextual factors thought to underlie their development.^40,41

African American youth may be at increased risk for developing maladaptive eating behaviors given the disparities we see in clinical eating disorder prevalence. Binge eating disorder is the most common eating disorder in all racial/ethnic groups, ⁴² but is more prevalent in African American adolescents than Caucasian adolescents. ⁴³ In a 2007 epidemiological study of 1170 Black (defined as African American, or descendants of the US slave trade, and Caribbean Blacks) adolescents, 12-month prevalence estimates of eating disorders suggested that binge eating disorder was most prevalent, followed by bulimia nervosa, and then anorexia nervosa. ⁴⁴ This finding was replicated in a subsequent study by Taylor and colleagues in which they found that binge eating disorder was the most common eating disorder among African Americans adults and adolescents. ⁴⁵ Schulte and colleagues report higher rates of endorsed food addiction in African American adolescents compared to community samples. ⁴⁶ These findings corroborate the lower prevalence of restrictive eating disorders in African Americans when considered alongside other ethnic groups. ⁴⁷

Existing Treatment Outcomes

Existing pediatric weight management interventions yield mixed outcomes for all racial/ethnic groups. A meta-analysis by Stice et al of obesity prevention programs showed that less than half of the programs reviewed showed significant effects. ⁴⁸ Interventions focused on children and adolescents resulted in larger effects than studies composed of preadolescents. The results suggested that participant ethnicity may moderate treatment effects, with studies with solely African American participants seldom showing significant improvements over the control group.^48,49 A review and meta-analysis by Kamath et al found that obesity prevention programs for ages 2 to 18 had no significant impact on BMI compared to control groups, ⁴⁹ whereas a 2008 meta-analysis of randomized controlled trials found that lifestyle intervention programs had small to moderate treatment effects on BMI, with a slightly greater effect if parents were involved with treatment. ⁵⁰ Neither of the latter 2 studies analyzed differences in treatment outcome based on race/ethnicity. In a pediatric weight management program for high-risk youth, Skelton and colleagues report similar treatment outcomes for racial/ethnic minority children (ie, improvement in weight status and cardiovascular risk factors) as for Caucasian children. The study authors report that the intervention was tailored to each family and there was sensitivity to providing culturally relevant information. ⁵¹

Failure to address contextual factors can contribute to treatment barriers ⁵² that ultimately affect outcomes. ⁵³ Key factors that contribute to attrition rates in pediatric weight management programs appear to be related to logistical issues ⁵⁴ and parent and/or child dissatisfaction with the program. ⁵⁵ Familial stressors and racial/ethnic minority status are also associated with higher attrition rates.^28,56-60 Racial disparities have also been noted in amount of weight lost ⁶¹ and knowledge about weight-related comorbidities and perceptions of risk. ⁶² In summary, African American children are at increased risk for poor treatment outcomes. This may reflect lack of attention to environmental and cultural factors that impact attitudes around food and weight.

Psychosocial Factors

The African American social context displays strength in the face of adversity ⁶³ and nurtures strong family systems. ⁶⁴ However, macrosystemic factors have been identified that confer increased risk for disparate outcomes in both physical and mental health. Treatment outcomes are likely to benefit when clinicians appreciate those factors and reconcile the existing structure and content of interventions.

Psychosocial Stressors and Eating Behavior

Increased stress is related to increased weight^34,65,66 and obesity risk ⁶⁷ in all ethnic groups. However, heightened stress is well documented within minority populations and is thought to be related to discrimination as well as lower social and economic standing due to a history of systemic oppression.^68-71 Indeed, African American children experience increased stressors related to experiencing developmentally normative stressors in addition to race-based stress ⁷² and, oftentimes, strain related to increased risk of living in poverty. ⁷³ This additional burden can lead to emotional difficulties such as anxiety and depression. ⁷⁴ Among African American youth, in particular, posttraumatic stress symptoms are often believed to be related to this confluence of disparate social factors and historical trauma. ⁷²

Individuals under chronic stress are likely to develop coping strategies that provide short-term relief from distress but have significant negative consequences over time (ie, perhaps overeating being one these coping strategies). ³⁴ This is in part due to how stress negatively affects executive functioning by way of impact to neurobiological structures and function. ⁷⁵ Executive functioning deficits have been related to children’s propensity to engage in external eating ⁷⁶ and to weight status.^77-79

Furthermore, for all youth, stressful experiences coupled with a slim repertoire of adaptive coping strategies may lead to persistent emotional eating as a way to cope with negative affect.^34,80 Notably, research indicates that African American children may endorse eating as a coping strategy more often than Caucasian children. ⁸¹ Similar to all racial/ethnic groups, ⁸² Orihuela and colleagues report that in a prospective study of African American adolescents, emotion regulatory difficulties were related to eating to cope or conform to a group. ⁸³ The use of unhealthy behaviors, such as eating, to cope may be often chosen in low-income, high-stress areas due to accessibility and quick downregulation of the stress response. Researchers have surmised that although the possible heightened use of such coping strategies in African Americans may offer some protection against the development, or typical clinical presentation, of some mental disorders as well as the reduction in general psychological distress, this style of coping may partially explain the heightened rates of physical health disparities we see in this group,^30,84,85 which includes overweight, obesity, and its related sequelae.

The Impact of Socioeconomic Status

Despite poor socioeconomic conditions often cited as a stressor for African Americans, research suggests that stress and physical health disparities persist across socioeconomic status indicators within this group.^86-89 Therefore, differences in exposure to obesogenic environments cannot be the only contributor to social and behavioral factors leading to disparities in overweight and obesity. Factors such as the physiological impacts of stress and maladaptive coping behaviors may play an additive role in the development of eating behaviors and weight concerns in a subset of African American families who may not have to navigate the environmental realities of poverty but perhaps are experiencing chronic stressors and/or emotional concerns due to experiences such a perceived discrimination^90-93 and acculturative stress. ⁹⁴ Thus, concerted focus on psychological factors related to obesity and eating behavior may be helpful for understanding the development of obesity in African American children across the socioeconomic spectrum.

Food Scarcity/Restriction

For African American children living in lower socioeconomic status environments, it is important to reflect on the possible role of occasional or even chronic food restriction as a stressor that can lead to child maladaptive eating behavior^95,96 and subsequent obesity. ⁹⁷ In adults, food insecurity is associated with increased vulnerability to binge and overeating as well as other eating disorder pathology. ⁹⁸ A 2017 study led by Kral et al reported that food insecurity was related to more external eating and more eating with less regard to appetite cues. ⁹⁹ In African American children who are more likely to live in poverty, ⁷³ involuntary food restriction due to the effects of food scarcity may be a potential risk factor for some children that needs to be considered. If access to food is unpredictable or restricted to certain times, children might be more likely to eat whenever food is available (ie, external eating) rather than learning to depend on their internal cues of hunger and satiety. ¹⁰⁰

• Recommendation 1: Carefully assess the role of psychosocial stressors across the socioeconomic status spectrum as it relates to eating behavior and be willing to adapt or augment standard treatments to better account for these contributors to eating and weight. Such adaptations or augmentations can include, but are not limited to, the addition of a culturally responsive ^* behavioral health specialist to process relevant stressors, referral to applicable support groups, or supplemental social services.

Parental Stress, Parenting Behaviors, and Child Feeding Behavior

Psychosocial stress experienced by caregivers can also affect child eating behaviors by way of parenting style and child feeding behavior. The literature regarding parenting practices across racial/ethnic lines has been mixed. Some work suggests that African American parents use more authoritarian general parenting techniques, perhaps due to contextual necessity,^101,102 but may be less involved in parenting as it pertains to child eating behavior. ¹⁰³ However, the use of Eurocentric parenting norms in the research literature may not best capture the impact of different parenting styles for African American children. ¹⁰⁴

Nonetheless, literature suggests that parental feeding practices high in restriction and control are related to more weight gain and higher weight status.^105,106 Recent work suggests that the relation between these variables may depend on child weight status and maybe even racial/ethnic status. For example, Stromberg and colleagues suggest that in a community sample of African American parent-child dyads, parent-reported restrictive feeding mediated the relation between child body mass index (BMI) and healthy weight control behaviors. ¹⁰⁷ Studies of treatment-seeking youth, on the other hand, suggest that African American parents may use more pressure to eat feeding strategies. ¹⁰⁸

Furthermore, research indicates there may be a direct relationship between authoritarian parenting and child eating due to negative affect. For example, Assari and colleagues found that high maternal support was protective against weight gain over a 12-year period among African American female young adults. When all other variables were controlled for (ie, age, family structure, and family socioeconomic status), maternal support was the only significant predictor of lower BMI over time. This study is particularly compelling in that it was a longitudinal study with a large sample. ¹⁰⁹ Mason reports that African American adolescents who report experiencing more parental firm control are more likely to engage in emotional eating. ¹¹⁰ These are important findings given the research suggesting that African American parents may be more likely to use authoritarian parenting techniques. ¹⁰²

Notably, income variations are important to consider. Limited literature on African American parents of higher income status and how income may affect their parenting behavior exists. ¹¹¹ Given the contextual necessity argument, perhaps African American families with higher incomes have less need to utilize authoritarian parenting strategies, leading to a different relationship between parenting style and child feeding. ¹¹² Overall, the literature is mixed on the relationship between parenting, parent feeding practices, and child eating behavior in African American parent-child dyads, but such factors may have important implications for pediatric weight management treatment with families. It will be important to continue to assess the relationship between stress and parenting behaviors across the socioeconomic status spectrum for African American families.

• Recommendation 2: Share basic parenting strategies (ie, validation, positive reinforcement, consistency in parenting behaviors) with caregivers of children with eating and weight concerns. Provide referrals to individual therapy or support groups for caregivers who appear to be having difficulty managing stress.

Cultural Factors

An understanding of cultural factors, or attitudes and behaviors shared by a particular group, is useful when considering motivations that may drive children and families to seek treatment for weight management versus not ¹¹³ and, ultimately, change health behaviors. ¹¹⁴

Food Type and Beliefs About the Role of Food

Socialization around food in the African American community comes from a historical context in which much resilience and adaptation was displayed. For example, discarded foods by slave owners were repurposed out of necessity. As a result, cultural food staples tend to be prepared with high levels of salt, sugar, and fat. Many of these foods are now thought of as delicacies, celebratory essentials, and a source of ethnic pride.^30,115-117 Furthermore, because of previous scarcity, abundant and rich foods have long been associated with “status,” and “wealth,” and the provision of these highly palatable foods to family members and guests promoted family cohesion.^70,115 For some, this rich history may be a key component to food selection and beliefs about the role of food. For example, literature suggests that some African American adults have considered cultural food practices to be about togetherness, as well as health.^115,118 Indeed, the high caloric content of these foods may have been quite adaptive historically when individuals were more active out of necessity. ²⁰ However, in today’s obesogenic environment, the adverse impact of eating these foods regularly is important to consider when taking into account the research on salt, sugar, and fat consumption, their potential for dependence, and subsequent impact on health.^119,120 Socioeconomic stratification by race is also a likely contributor to greater intake of foods high in sugar, fat, and salt, given differences in the availability of foods that have less of these ingredients by zip code. ¹²¹

These socialization factors may contribute to learned preferences for certain highly palatable foods in children, as well as for larger portion sizes and feelings of being quite sated (ie, overfull). Related to involuntary food restriction as well as the potential role of poverty addressed previously, if it is expected that food provided should be eaten as an effort not to waste, and as to not disrespect the person providing the food, ¹²² one may expect more external eating behaviors to develop. Such influences from family and loved ones could reasonably contribute to dysregulated eating behavior. In the research literature, this is sometimes described as “pressure to eat” eating strategies and can negatively affect eating behavior over time. ¹²³ Similarly, Goldschmidt and colleagues (2018) report in a study of diverse youth using ecological momentary assessment that “influence of others” contributed to overeating severity. ¹²⁴ Few existing interventions focus on regulating eating behavior in children, and none to our knowledge have been studied in African American children. Appetite Awareness interventions may be promising as they encourage focus on appetite signals to regulate eating behavior. The intervention’s focus is less on environmental factors, which suggests long-term benefits independent of the food environment. ¹²⁵ Appetite Awareness is also congruent with present-focused orientation, a well-studied aspect of African American worldview, ¹²⁶ as it relates to beliefs around dieting. ¹²⁷ Although not yet assessed in African American children, this intervention has been found to be feasible and preliminarily efficacious in African American women. ¹²⁸ This intervention may work well as an adjunct to standard pediatric weight management treatment.

In sum, food type and beliefs about the role of food, born out of an oppressive social context and symbolic of strength and adaptivity, may be challenging for children with vulnerabilities to developing maladaptive eating behaviors and obesity. Additional qualitative work is needed to explore what types of interventions would promote increased flexibility around preferred foods.

• Recommendation 3: Utilize culturally sensitive food recommendations that take into account the potential for financial limitations.^129-131

• Recommendation 4: We recommend that appetite awareness interventions focusing on internal statues of hunger and satiety^128,132,133 be explored as an adjunct to standard pediatric weight management treatment.

Coping and Health Behaviors

A sociocultural context where food is eaten during times of high emotion, whether it be positive or negative, may point to this behavior becoming a form of managing psychological distress. The incorporation of food during emotion-laden events is not uncommon in many racial/ethnic minority cultures.^115-117,134 Although this practice is not inherently maladaptive, for children at risk for dysregulated eating behaviors ¹³⁵ or emotion regulation difficulties, ⁸² a strong tradition of eating in the context of high emotion may contribute to learning to eat to cope with negative affect ¹³⁶ or external eating behaviors. ¹³⁷

Cultural attitudes may also impact one’s willingness to engage in health interventions. As aforementioned, Oney and colleagues (2015) report on cultural attitudes as they relate to eating behaviors in African American adults. They found that African Americans who endorsed higher present-focused time orientation engaged in less dieting behavior than those who endorsed high future-oriented cultural values (more valued in Western culture). ¹²⁷ Furthermore, a study by Hargreaves and colleagues found that cultural beliefs and influences often overrode efforts to adopt a healthier lifestyle. ¹³⁸ James found in a qualitative study assessing food choices in African American adults that participants reported that eating “healthy” would mean giving up a part of their culture. Participants also noted lack of support from friends and relatives in changing their eating habits ¹²² —this has also been reported in a community sample of mothers of African American preschoolers. ¹³⁹ Markedly, more work on cultural factors and how they interact with socioeconomic and assimilatory differences is critical in understanding the nuanced associations between culture, coping, and the use of health behaviors for African American youth. Clinically, providing space to hear about cultural influences on eating behavior and problem-solving how to overcome potential barriers can promote an environment of collaboration that may better promote behavior change.

Body Type Ideals

Research suggests that body image plays a role in influencing motivation to change eating behaviors. Early work suggests that members of the African American community may have a more flexible range of body sizes that are acceptable in addition to higher body appreciation compared to Caucasians.^116,140-144 However, more recent work suggests body image ideals are quite nuanced and depend on a variety of sociocultural factors within group. ¹⁴⁵

Much work has explored this topic across developmental periods. A study by Kimm and colleagues found a significant negative relationship between adiposity and self-esteem in 9- and 10-year-old African American girls. ¹⁴⁶ Bucchianeri and colleagues found that of all racial/ethnic groups, African American children had the lowest rates of body image dissatisfaction among a group of racially and ethnically diverse teens. ¹⁴⁰ These findings have also been reported in young adults. A 1992 study comparing African American and Caucasian college students found that African Americans reported body ideals that were larger than those of Caucasian females. ¹⁴⁷ Some work even suggests that being perceived as “too thin” can have negative connotations in the community. ¹⁴⁸ It has been proposed that this effect may be due to positive weight-related messages passed along to children across development based on the weight norms in their community. ¹⁴⁹

On the other hand, very recent work suggests disordered weight control behaviors are not uncommon in racial/ethnic minority groups across the lifespan. ¹⁵⁰ For example, within a large sample of African American girls, body dissatisfaction mediated the relation between dieting behaviors and restricting/purging behaviors. ¹⁵¹ Furthermore, some literature reports that increased weight and body dissatisfaction were related in African American college females. ¹⁵² Bodell and colleagues suggest that disordered eating behaviors may emerge earlier in African American girls but then decrease over time. ¹⁵³ Other work suggests the opposite or no differences between racial/ethnic groups. Lim and colleagues report no significant differences in disordered eating behaviors in a treatment seeking sample of African American and Caucasian youth, ¹⁰⁸ and a 2019 study led by Cheng reported that there were no racial/ethnic differences in risk factors for disordered eating among a sample of young women with body image concerns. ¹⁵⁴

External social influences may influence body image and eating behaviors over time. Qualitative work has shown that socialization in primarily Caucasian environments may lead to a body type ideal more akin to mainstream culture. ¹⁵⁵ Indeed, body type ideals may be more closely related to racial identity and level of acculturation as opposed to race alone. ¹³⁴ For example, Cotter and colleagues report that African American college women who identified most strongly with their ethnic identity reported more body appreciation and fewer concerns with eating, shape, and weight. ¹⁵⁶ These findings suggest that body image ideals for African Americans may have shifted some over time due to assimilatory influences. Therefore, taking care to understand how body image factors into eating behaviors within the family system may be worthwhile in when considering motivators of behavior change.

Given that the psychometric properties of many common eating disorder measures have not been assessed in African American youth, ¹⁵⁷ more research is needed to further assess the ways in which cultural norms confer risk and resilience in the development of eating disorders in this group. ⁴⁷ Critically, variation in these cultural norms may delay identification of higher than average weight gain during childhood and thus delay intervention-seeking. As an extension to this point, research indicates caregivers often underestimate their child’s weight status ¹⁵⁸ as do children themselves. ¹⁵⁹ This is notable given child weight is associated with attrition. ⁵⁵ This suggests that later-identified maladaptive eating behavior and increased weight may be more difficult to treat. It will be necessary to develop measures of body image and disordered eating normed within African American youth to gain a better understanding of the relation between these variables and how they may change over time.

• Recommendation 5: When working with families be aware of the potential developmental nature of influential cultural factors and practice cultural humility by listening and validating patient experiences. Take a collaborative approach to care to increase the patient’s comfort level in the treatment space. Determine the individual’s unique motivation for change.

Mistrust of the Formal Medical System

Due to conceivable skepticism of medical authorities, hesitation about the initiation of recommended health behaviors in the African American community is not uncommon. ¹¹⁸ Indeed, the formal medical system has a history of doing harm to African Americans communities^30,160; therefore, there may be distance between health provider and patient. For example, studies suggest that there is often a disconnect between messages health care providers feel they are delivering regarding weight and how patients receive those messages. A qualitative study by Ward and colleagues found that in a sample of African American adults classified as obese, patients noted wanting more of an individual approach to working on weight management issues. The study reported that patients had negative feelings regarding language use (ie, use of the word “obese”), and variable opinions were expressed on the manner and timing of weight-related such discussions. Very mixed reactions were reported on the use of “scare tactics” about the health consequences of obesity by providers. ¹⁶¹ This literature highlights the potential beliefs held within the social and familial environments of African American children in pediatric weight management programs, perhaps affecting follow through with treatment recommendations. Work pertaining to African American youth eating and weight management would benefit from continued exploration of community-based intervention to leverage the strength of existing support networks, and to give credence to medical authorities. Extensive social support networks are a strength within African American communities and may be important to leverage to best serve group health needs. ¹⁶² Furthermore, wider dissemination of self-help interventions may help increase patient’s amenability to treatment and lay the foundation for more intensive treatment if necessary.^163-166

• Recommendation 6: Given the historical strength of African American social networks, utilize family and community-focused interventions. Such approaches could increase treatment buy-in as individuals are able to receive support via familiar outlets when embarking on difficult behavior change. Guided self-help interventions within a stepped care model may also aid in increasing patient’s comfort with treatment.

Conclusion

African American children come from strong ecological systems that have been affected by a legacy of oppression. Researchers would do well to work with this group to identify unique risk and protective factors that affect their health behaviors. Collaborating successfully with African American patients and families requires education about psychological and behavioral variables, understood from a sociocultural lens, that may affect family engagement in pediatric weight management programs. The confluence of cultural factors may be subtle but significant, as cultural influences vary greatly depending on an individual’s level of acculturation and exposure to different views of health and wellness. Nonetheless, research suggests that as a group, African American children remain at greater cumulative risk supporting the need to adapt current weight management interventions.

Future work would do well to continue soliciting feedback from African American children and families to best inform treatment development (eg, qualitative assessment of focus groups) ¹⁶³ as well as utilizing cultural strengths such as family and support systems to enhance existing treatments. Adopting a patient-centered, culturally responsive, care approach may be particularly necessary to encourage African American families to collaborate with a medical system that has historically neglected to address their unique needs. Finally, exploring feasible, cost-effective approaches that may be more individualized and self-directed may be particularly amenable to this population. For example, guided self-help interventions^164–167 within a stepped care model may do well to help aid in initial behavior change.