Opportunities to Address Obesity Disparities Among High-Risk Latino Children and Adolescents

Abstract

Purpose of Review

This review highlights obesity-related disparities among Latino children and adolescents, discusses the social determinants of health (SDoH) that drive disparities, and presents case studies of strategies for reducing disparities and promoting health equity.

Recent Findings

Recommended strategies for reducing obesity-related disparities include the use of culturally grounded programming, multi-sector collaborations, and technology. We present two exemplar studies that demonstrate that integrating cultural values and enhancing the overall cultural fit of prevention programs can increase engagement among high-risk Latino families. We also examine the use of multi-sector collaborations to build community capacity and address key SDoH that impact health behaviors and outcomes. Our last example study demonstrates the utility of technology for engaging youth and extending the reach of prevention strategies in vulnerable communities.

Summary

To address growing obesity-related disparities, there is an urgent need to develop and test these strategies among high-risk, vulnerable populations like Latino children and adolescents.

Introduction

The prevalence of pediatric obesity in the USA continues to increase in all age groups, particularly among Latino children and adolescents who exhibit higher levels of obesity (25.8% vs 18.5% general population) and severe obesity (12.4% vs 7.9% general population) [1, 2]. While obesity-related disparities affect many racial and ethnic subgroups, Latino youth represent about 23% of the pediatric population and are the fastest growing pediatric subgroup in the USA [3]. Therefore, this review will focus specifically on the Latino population as this group remains underrepresented in research and underserved in many communities. It is estimated that 55% of children and 80% of adolescents with obesity will continue to have obesity as they transition into adulthood [4]. This significantly increases their risk for obesity-related chronic diseases as well as lifetime medical costs, which are 42% higher for those with obesity compared to those without obesity [5]. Eliminating racial and ethnic minority health disparities could reduce direct medical costs by an estimated $230 billion dollars [6]. Unfortunately, the literature on obesity prevention strategies and interventions for high-risk Latino children and adolescents remains limited, and disparities in obesity in this rapidly growing population continue to widen [7–9]. This article will provide a brief overview of obesity-related disparities among Latino children and adolescents, discuss contributing social and contextual factors, and present case studies of promising strategies for reducing disparities and promoting health equity in this key demographic.

Disparities in Obesity-Related Diseases

The presence of childhood obesity is associated with more than 29 developmental, physical, and psychosocial health complications [10]. In regard to physical consequences, Latino youth are disproportionately burdened by the metabolic syndrome (16.4% Mexican American youth vs 5.4% in non-Latino White youth), which represents a clustering of obesity and related risk factors (e.g., hypertension, dyslipidemia, and impaired glucose metabolism) [11]. These risk factors prospectively predict the development of type 2 diabetes and cardiovascular diseases (CVD) [11–13]. Indeed, Latino youth with obesity exhibit early signs of these disease processes as indicated by high rates of prediabetes and subclinical atherosclerosis [14, 15]. More proximal than future risk of T2D and CVD among Latino youth is non-alcoholic fatty liver disease, which impacts nearly 50% of Latino youth with obesity [16, 17]. Although the physical health consequences of obesity are alarming from a clinical perspective, it is the psychosocial and emotional consequences that may be most important and proximally perceived to children and adolescents. Although not specific to Latinos, children and adolescents with obesity experience weight-based stigma and discrimination, which can lead to feelings of depression, social isolation, and body image dissatisfaction [10, 18]. Several studies have also established that Latino adolescents with obesity report decreased health-related quality of life compared to youth without obesity, which can have long-term consequences for psychosocial health [16, 19]. Impairments to psychosocial health such as poor quality of life can increase cardiometabolic disease risk factors further contributing to the complications associated with obesity [20].

Drivers of Obesity Disparities

In addition to the complex interplay between individual biological and behavioral factors associated with the development of pediatric obesity, it is clear that broader social and contextual influences contribute to obesity and related chronic diseases [21–24]. Furthermore, obesity-related health disparities are rooted in structural inequalities defined as the personal, interpersonal, institutional, and systemic drivers that “structure” differential or unequal access to health promotion and disease prevention opportunities [25–27]. This may include policies, healthcare, race, and other domains in which systematic disadvantages exist for one group of individuals compared to another group of individuals [27]. These inequalities or structural differences give rise to root causes or social determinants of health (SDoH), which are displayed in the inner circle of the conceptual model presented in Figure 1 [25, 26]. SDoH are defined as the conditions in which people live, worship, work, and go to school that ultimately shape health outcomes [27]. For example, structural factors such as restrictive immigration policies contribute to SDoH such as limited employment opportunities, limited access to public services, and fear and stress regarding immigration law enforcement [27]. Latino immigrant workers perform a disproportionate amount of unskilled, high-risk jobs that typically do not provide benefits including health insurance [28, 29]. Nearly two-thirds of undocumented Latino immigrants lack health insurance, and many are not eligible for public insurance programs [27, 30]. Furthermore, anti-immigration social and political rhetoric as well as immigration law enforcement is also linked to reduced participation in other public and social welfare programs among Latino families [27, 30]. Lack of access to assistance programs can have consequences such as food insecurity, which is associated with obesity in Hispanic youth [31, 32]. A study among immigrant Mexican American households reported a 10% increase in food insecurity after the passage of immigration-related legislation [33]. Although upstream of traditional determinants of obesity (e.g., individual behaviors), structural inequalities such as immigration policy contribute to SDoH that are interdependent and can have a combined effect on downstream weight-related outcomes.

Figure 1.

Conceptual model of community-driven solutions to address structural inequities and social determinants of health. Source: National Academies of Science, Communities in Action: Pathways to Health Equity

Addressing obesity disparities requires strategies and interventions to consider the SDoH that disproportionately burden minority adolescents [34, 35]. Unfortunately, current strategies for addressing SDoH are not well defined, and existing frameworks focus on the identification of upstream SDoH and how they are linked with downstream health outcomes [34]. For example, the Increasing Equity Impact in Obesity Prevention framework put forth by Kumanyika provides important approaches to increasing health equity in upstream policy, systems, and environmental change strategies to directly address or account for SDoH [25, 36–38]. Such “root changes” to policies and systems are desperately needed, and efforts should be ongoing. However, they can be politically challenging and costly and may take generations to improve health outcomes [21]. Developing interventions that carefully consider SDoH in their design while integrating plans for sustainability and scaling may show more immediate promise in reducing obesity-related disparities in Latino children and adolescents [34, 39].

Opportunities to Reduce Obesity Disparities

Culturally Grounded Programming

The US Preventive Services Task Force has identified that the most successful obesity prevention programs for addressing disparities among minority youth are those that are culturally grounded in the beliefs, values, and circumstances specific to the group of interest [40, 41]. Culture is a key driver of health beliefs, practices, and behaviors that is associated with obesity and related disease risk in Latino youth [42–44]. Because culturally grounded interventions reflect the characteristics of the specific culture, they are recognized as critical for increasing the reach, engagement, and effectiveness of disease prevention strategies among minority populations [43, 45]. Unfortunately, few culturally grounded obesity and related chronic disease prevention interventions have been developed and tested among high-risk Latino children and adolescents [43, 44, 46].

Barrera et al. identified several prominent approaches for developing culturally grounded disease prevention interventions [47]. The first approach involves cross-collaboration and knowledge exchange between researchers and community stakeholders to ground the intervention. Investigators provide knowledge on theory, behavior change techniques, and add rigor in evaluation, while community stakeholders provide critical knowledge on important elements of the culture and local context that can be leveraged to enhance uptake and efficacy [47]. As a case study for this approach, we present Every Little Step Counts (ELSC), a culturally grounded diabetes prevention program for Latino adolescents with obesity [48–51]. Developed by a Latino-serving, safety-net clinic in Phoenix, AZ, in response to the growing number of Latino children and adolescents being referred for diabetes screening, ELSC was grounded in the needs, resources, and context of the local community as a way to increase access to health promotion and diabetes prevention programming for an underserved population. Trust, respect, and personal interactions were prioritized to enhance rapport with the community, and bilingual/bicultural health educators were trained to deliver the curriculum [52]. Researchers were invited to collaborate, with the goal of adding a rigorous evaluation component to the program and further explicating key evidenced-based behavioral skills training and strategies within a unified conceptual model [53]. While cultural fit was already a consideration, the team worked collaboratively to operationalize components from evidenced-based diabetes prevention programs into the cultural context of Latino families. For example, the partnership identified the need to emphasize cultural strengths that focused on family unit. “Familismo or familism” and “collectivism” are central and important cultural values that refer to the importance of the family unit and influence identity, involvement, and decision-making [53, 54]. Thus, these cultural values became leverage points for promoting behavior change and were integrated into the intervention. Program content and materials were delivered in a family-centered manner focusing on family roles and responsibilities that support behavior change in youth [48, 53]. Activities were also family focused such as youth and parents planning and preparing a healthy family meal together [48]. Youth set behavioral goals, and families were encouraged to discuss challenges to goal attainment while sharing strategies for overcoming challenges [48]. The intervention led to significant improvements in obesity-related outcomes as well as self-reported quality of life [55]. Furthermore, family social support was a key mediator in the intervention [56].

Another approach to developing culturally grounded interventions includes cultural adaptations of existing evidence-based interventions. In this approach, the core elements of an evidence-based intervention are retained, while cultural values and contextual factors are integrated into the intervention material and implementation strategies [45, 47]. This approach is exemplified in the Papas Saludables, Niños Saludables (PSNS) study, a 9-week family-based lifestyle intervention for Latino fathers and children (5–11 years) [57, 58]. PSNS was adapted from the Australian Healthy Dads, Healthy Kids program, which has demonstrated clinically meaningful weight loss among fathers and significant improvements in physical activity and dietary intake among children [59]. Given the high prevalence of obesity among Latino men, a cultural adaptation of this effective, evidence-based program had high potential for reaching Latino fathers and their children to reduce obesity-related health disparities [58, 60]. The process of culturally adapting Healthy Dads, Health Kids was guided by the Ecological Validity Model proposed by Bernal and Sáez-Santiago, which recommends adaptations across eight dimensions: program goals, concepts, methods, content, persons, metaphors, language, and context [45]. Program adaptations were conducted iteratively in collaboration with expert panels, which included a professional panel consisting of researchers with expertise in health promotion and parenting among Latino fathers and families, and a family panel, which consisted of Latino mothers, fathers, and their children. Formative qualitative work conducted with Latino families revealed that “familism” and “collectivism” were important cultural values; however, more nuanced “deep structure” subthemes emerged such as perceptions of gender roles in caretaking and providing for one’s family [58]. For example, Latino fathers believed their main role was to provide and be the “breadwinner” for their family. Providing for one’s family is a strong Latino cultural value; however, Latino men are more likely to work physically demanding jobs with nontraditional working hours that may limit opportunities for engaging with their children around health behaviors [61]. Participants also reported that beliefs in traditional gender roles may differentiate the way that fathers interact with sons as compared to daughters [58]. To address these important cultural values, the intervention was adapted to include group discussions about the importance of parenting among fathers and strategies for modeling and supporting health behaviors for both sons and daughters. The program was implemented on the weekend at times when fathers were able to attend, and implementers emphasized that leisure physical activity could reduce work-related stress from physically demanding jobs. Quality time with one’s children was emphasized as opposed to quantity of time. To further build cohesion, participating fathers were encouraged to recognize that there are other Latino fathers like them who want to build close relationships with their children [57]. In feasibility testing, PSNS demonstrated high attendance (72%) and exceptional satisfaction (100%) among families [57]. The intervention will be further refined and tested in a family randomized group-treatment trial. This example highlights how integrating cultural values and contextual factors into existing evidence-based intervention strategies can increase engagement, even among traditionally underrepresented populations like Latino fathers [61].

In addition to demonstrating effectiveness among school-aged children and adolescents, culturally grounded interventions have also been used to successfully engage younger Latino pre-school-aged children and families [62, 63]. In all of these examples, community engagement is an overlapping theme critical for developing culturally grounded disease prevention programs [21, 39]. These approaches can increase understanding and respect for cultural practices and contextual factors that contribute to health disparities as well as the ones that promote resilience and serve as potential leverage points for amplifying health behaviors and preventing disease [47]. An important next step in the progress of culturally grounded prevention interventions is to identify how cultural components and adaptations contribute to intervention outcomes [47]. This information can shed light on the underlying mechanisms by which culturally grounded interventions “work” to improve behaviors and outcomes. Identifying intervention mechanisms or critical ingredients can also be used to expand or adapt existing behavioral theories to increase the fidelity and fit within cultural subgroups [64].

Multi-sector Collaborations

The breadth and complexity of SDoH require multi-sector partnerships that extend beyond the healthcare system to include multiple stakeholders across sectors (e.g., health, housing, transportation, environment, and economy) [22, 35, 65]. The primary goal of clinic-community partnerships is to optimize the strengths, resources, and knowledge within the partners to address a health and research priority within the community [66, 67]. In doing so, this approach can lead to the development of comprehensive, multi-level interventions that are accessible, sustainable, and tailored to meet the needs of the population of interest while considering SDoH [26, 68, 69]. Pairing clinical efforts with community resources is a recognized strategy for considering SDoH and reducing obesity disparities, yet few clinic-community partnership focused on obesity are described in the literature [21, 70].

Building upon the success of ELSC described above, the intervention was adapted for Latino families with younger children (8–12 years) and anchored in a predominantly Latino community. The partnership was extended to connect a Federally Qualified Health Center (FQHC) with a nearby YMCA through support from a State Health Department [55]. Providers and staff from the FQHC were engaged through monthly provider meetings, a research coordinator was embedded within the clinic, and the electronic medical record (EMR) was modified to facilitate recruitment and foster communication with providers [55]. Participants (children and parents) completed a clinic visit with their provider before and after the intervention, and a mid-intervention report was uploaded to the EMR to update clinicians of their progress toward achieving their behavioral health goals and study outcomes (e.g., HbA1c, BMI). Partnering with an FQHC in a low-income community reduced barriers to healthcare access for the many adult participants who were uninsured. As was often the case, participating youth were established patients; however, 60% of parents did not have a regular healthcare provider. In response, we developed a system for establishing all participating parents as patients at the FQHC, providing a pathway for them to see a primary care provider prior to enrollment in the program [55]. The YMCA served as the delivery site for the 12-week program. The mission and vision of the Valley of the Sun YMCA is to build strong kids, strengthen families, and bring communities together. They are committed to creating an inclusive environment for everyone by providing financial aid and assistance for memberships [71]. Connecting to the YMCA provided families with a safe physical activity resource that was accessible within their community. To further embed the ELSC program within the YMCA’s existing infrastructure and services, they began providing family-based exercise classes and provided classroom space for health educators to deliver nutrition education [55]. As families completed the program, we identified “Champion Families” or families with high levels of attendance and engagement. These Champion Families were invited to return to the program and assist the research team in leading and implementing the program among a new cohort of families. This allowed us to build capacity and empower families with the knowledge and skills to assist other families in their community. This study resulted in significant decreases in body fat percentage and significant improvements in quality of life among children and adults as well as significant reductions in HbA1c among adults [55]. The promising findings from the development and testing of the ELSC intervention support the use of multi-sector partnerships to develop multi-level, lifestyle interventions that are culturally congruent, build community capacity, consider SDoH, and represent more efficacious models of disease prevention that address disparities in high-risk populations [55].

Without multi-sector collaborations that consider social and environmental factors that impact health behaviors and disease outcomes, current attempts to reduce obesity disparities will be limited [21]. In these partnerships, the community’s capacity to deliver prevention services is strengthened, while clinical efforts and preventive services can be extended into vulnerable communities [21]. In doing so, these partnerships facilitate the translation of prevention efforts into “real-world” settings expediting the translation of research to high-risk, health-disparate populations with the greatest need [72, 73]. To advance the use and implementation of clinic-community partnerships, there is a greater need for increased models and frameworks to guide the development, evaluation, and reporting on these types of partnerships [74]. Ultimately, a reimbursement model or payment system will be necessary to facilitate scaling and sustainability of such promising collaborations.

Technology-Based Strategies

Technology-based interventions include the delivery of behavior change and disease prevention interventions using digital devices with Internet or wireless remote capabilities and are recommended as a strategy for overcoming SDoH that limit participation in in-person interventions [28, 65, 75, 76]. For some high-risk youth and families, these SDoH include lack of transportation, nontraditional parent work schedules, and additional needs like childcare for younger siblings [35]. However, technology allows for interventions to be remotely delivered directly to adolescents in their home environment reducing the need for transportation and allowing for more flexible scheduling for working parents [77–79]. Additional strategies used to target SDoH like food insecurity and limited access to physical activity resources include the use of personalized notifications [79]. For example, interventions that utilize Geographic Information Systems Technology can notify participants of affordable food resources and safe physical activity resources in their neighborhood environment [79]. Personalized text messages are another tool that has been used to foster social support and cohesion between participants and implementers regardless of geographical distance [78]. Many of these strategies can be cost-effective because they leverage devices like smartphones that may already be owned by the participant [80]. While the digital divide persists across racial and ethnic subgroups in regard to laptop ownership and access to high-speed Internet, Latino and non-Hispanic White youth report the same level of smartphone ownership (71%) [81]. Today’s adolescents were exposed to technology at an earlier age and are the highest users of digital devices and text-message communication, and 94% access the Internet on a daily basis [82, 83]. Thus, in addition to being a potential strategy for overcoming SDoH, technology-based strategies and interventions are age-appropriate for delivering obesity and disease prevention interventions [84, 85]. Unfortunately, minority youth in vulnerable communities remain underrepresented in technology-based studies [34].

To develop technology-based strategies that are considerate of SDoH, the population of interest should be involved in every phase of the development and design process to ensure that the intervention meets the needs and fits the context of the population [79, 85]. Capturing the behavioral and technology use patterns within the youth’s social, built, and political environments provides an avenue for increasing the engagement, satisfaction, and cultural appropriateness of the intervention [85, 86]. However, few studies have engaged youth in the design and development of technology-based interventions [82, 87, 88]. The “TXT Me!” study developed by Thompson et al. is an exemplar study that adds support for the inclusion of underrepresented minority adolescents in the development process [89]. This study was a 12-week intervention that used a personal activity tracker and text messages grounded in the self-determination theory to increase physical activity among an ethnically diverse (27% Latino/36% Black) population of adolescents (14–17 years). Participants completed a web-based survey focused on topics such as engagement with family around activity, perceptions of using an activity tracker, the frequency and type of text messages desired, and their motivation and personal values associated with physical activity. This survey was followed by an in-depth interview to clarify survey responses and ensure that results were interpreted as intended [89]. This information was used to guide the implementation of the text message intervention. For example, youth felt it would be ideal to receive messages before school between 6am and 8am. Youth responded to questions about their cell phone access, discussed their family data plans, and shared information on family rules about texting such as no use of profanity. Youth expressed that text messages should be short (<160 characters) and include emoticons and exclamation points. Participants found that messages highlighting the values of “being responsible,” “being healthy,” and “being successful” promoted a sense of connectedness, a central component of the self-determination theory. This formative research resulted in the development of a library of over 70 text messages that were acceptable among teens and aligned with family social environment around physical activity and family rules regarding text messaging. These text messages were piloted in a 12-week feasibility study. Youth found the text messages engaging (85%), motivational (55%), and increased daily physical activity [90]. This study demonstrates that partnering with youth in the development process can lead to an engaging, cost-effective intervention that leverages familiar and convenient technology to promote physical activity [90, 91].

Technology-based strategies and interventions have high potential to change the way health promotion programs are delivered and can extend the reach of disease prevention strategies in vulnerable communities impacted by SDoH [34]. Interventions, including the example presented above, have demonstrated that text messaging and social media have shown promise for improving diet and physical activity behaviors among youth [92, 93]. Additionally, several studies have developed telehealth or web-based obesity prevention programs and found this approach to be feasible and acceptable among adolescents [94–97]. Even video game systems which are typically thought of as drivers of sedentary behaviors can be used to improve health behaviors through health-focused video games and exergames [91, 98, 99]. However, this area of research is still evolving, and findings have been inconclusive [100]. There is a clear need to develop and test technology-based obesity prevention strategies among high-risk, minority youth and to develop and implement these strategies in a manner that considers the SDoH while engaging the family unit rather than a single individual [22, 35]. Strategies to consider SDoH from the exemplar studies presented have been summarized and presented in Table 1.

Table 1.

Strategies to consider SDoH in health promotion and disease prevention from example interventions among Latino youth.

SDoH	Strategy
Culture	Bilingual/bicultural health educators conduct screening, data collection, and implement intervention content and materials in Spanish/English Culturally grounded intervention content and curriculum that integrates Latino cultural values, norms, and traditions
Access to prevention services	Collaborate with community-based clinics in geographic areas with high Hispanic populations to implement programs at no cost to uninsured or publicly insured youth and families Collaborate with stakeholders to build or leverage existing community resources liked the YMCA to deliver programs in high-risk communities Foster patient-provider relationships through clinic visits before and after the intervention and through progress reports
Access to healthcare	Develop systems to link families with primary care settings such as processes for establishing care or accessing health promotion and disease prevention opportunities
Social cohesion/family support	Deliver content in a family-focused manner with family-focused activities Foster social support within and between families. For example, encourage youth to work with parents on setting behavior goals and ask families to share barriers to behavior goals with the group Use technology such as messaging apps (i.e., WhatsApp) or social media to build social networks and connect participants to each other and to implementers
Health literacy	Deliver health education and skills building in a culturally appropriate manner that acknowledges language and cultural values Foster hands-on activities and active learning around health behaviors and outcomes. For example, ask families to plan and cook a healthy meal together Use technology platforms such as messaging apps or social media to increase access to health promotion and materials
Transportation	Provide transportation assistance to data collection appointments and intervention sessions in the form of bus fare or ride share vouchers Develop resources near accessible public transportation options such as trains or bus stops Use technology like videoconferencing platforms to extend the reach of programming regardless of geographical spaces
Access to physical activity resource	Increase access to safe physical activity resources by delivering programs at safe, trusted, resources within the community such as community centers Use technologies like Geographical Information Systems to identify safe, physical activity resources in the participant’s neighborhoods

Conclusion

Improving health equity is a health priority, and meeting this objective requires that we reduce obesity and disease disparities in high-risk populations [26]. Central to reducing obesity disparities in high-risk populations like Latino children and adolescents is the development of prevention interventions and strategies that consider the SDoH that exacerbate disparities, limit health behaviors, and contribute to disease outcomes [22]. We have presented three distinct avenues for doing this, including the use of culturally grounded programming, multi-sector partnerships, and technology-based approaches. In the exemplar studies presented, we demonstrated how these strategies can be used to successfully engage Latino families in effective prevention efforts. Community collaboration is a common thread that links the examples presented and could be considered essential for moving the field. Investigators should rigorously evaluate the impact of interventions and strategies that carefully consider SDoH on health behaviors and outcomes to advance our understanding of effective strategies for reducing obesity disparities in high-risk groups. As evidence builds, it may be leveraged to inform policies and programs that can address the SDoH that underpin disparities in order to achieve health equity at the population level.