Is obesity a manifestation of systemic racism? A ten-point strategy for study and intervention

Abstract

Aaron DG, Stanford CF (Food and Drug Administration, Cambridge; Massachusetts General Hospital, Boston, MA, USA). Is obesity a manifestation of systemic racism? A ten-point strategy for study and intervention.

In the recent past, there has been rising attention to systemic racism. The ensuing discussions have largely focused on COVID-19 and policing. Despite long-standing disparities in obesity across racial and ethnic groups and obesity’s important role in COVID-19 disparities, there has been minimal attention to whether obesity itself could be a manifestation of systemic racism. Nor has there been serious policy attention dedicated to alleviating obesity and its disproportionate burden on BIPOC (Black, Indigenous, and People of Color). We discuss whether obesity’s disproportionate harms to BIPOC may be attributed to systemic racism, and we provide a ten-point strategy for studying and solving the core public health issues at the intersection of obesity and systemic racism.

Introduction

The disparate impact of COVID-19 on BIPOC (Black, Indigenous, and People of Color), as well as the tragic deaths of George Floyd and Breonna Taylor in the United States, have angered much of the American public about the existence of deepseated systemic racism. Many articles have discussed why BIPOC are more likely to contract and die from COVID-19 [1-4]. Obesity has emerged as one important risk factor [5,6]. Razieh and colleagues found that high body mass index (BMI) explains a significant portion of racial COVID-19 disparities [7]. Given long-known disparities in obesity across race, as well as obesity’s salient impact on BIPOC during the COVID-19 pandemic, one might have expected more discussion of whether obesity itself might be rooted in systemic racism. Yet discussions of systemic racism and racial disparities have largely focused either on policing or on COVID-19 without significant consideration of obesity. Unlike in the United Kingdom, which recently announced several measures to mitigate obesity while explicitly noting the importance of racial disparities [8], the United States has not followed suit. Furthermore, several news outlets have published articles arguing that fighting obesity is racist in that it stigmatizes Black bodies, and body acceptance would better promote racial equality [9,10]. The popular discourse on obesity and race has at times been counterproductive for the health of BIPOC. Now, it is time to press the question: Can obesity and its negative health impacts be traced to systemic racism?

We do not aim to suggest that obesity as a whole is secondary to systemic racism as obesity is endemic in the United States in all races [11], but researchers have noted disparities in obesity and its treatment across racial and ethnic groups. Currently, 49.6% of non-Hispanic Black adults have obesity, compared with 42.4% of US non-Hispanic white adults [12]. And yet Black patients are less likely to receive a diagnosis of obesity compared to non-Hispanic white patients [13]. This underdiagnosis often leads to inadequate treatment of the disease.

In the setting of COVID-19, obesity increases the risk for poor outcomes [5,14]. Several mechanisms have been proffered, including altered physiology, obesity-induced inflammation and immune dysfunction [15,16]. Obesity causes a chronic inflammatory state through upregulation of multiple cytokines [15,17]. Inflammatory markers and cytokine release are both associated with more severe cases of COVID-19 [18]. Further, obesity is associated with increased levels of angiotensin-converting enzyme 2 (ACE2) [19], which is the binding site for the novel coronavirus, and obesity is associated with worse lung function [20]. Obesity’s complications, including hypertension, diabetes and cardiovascular disease, are prevalent among people with severe cases of COVID-19 [21], and they disproportionately affect BIPOC. All in all, racial inequalities in COVID-19 may be indivisible from inequalities in obesity and related health conditions. And because Black Americans are exposed to the virus with greater frequency [3,22], disparities could have multiplicative effects.

However, the health disparities of obesity must be viewed in the context of a recent article arguing that researchers ‘routinely fail to interrogate racism as a critical driver of racial health inequities’ [23]. The article urged reviewers to ‘[r]eject articles on racial inequities that fail to rigorously examine racism’ [23]. Without such analysis, researchers and clinicians are prone to making unfounded assumptions that health disparities are biological or inherent to BIPOC [23,24]. On the other hand, if systemic racism plays a significant role in obesity, then identifying it could galvanize public support for remediation of racial health inequities and remind clinicians that obesity is preventable and treatable – not innate.

There are compelling arguments that the disparate impact of obesity on BIPOC can be traced to the circumstances in which they are conceived, grow up and live. We know that BIPOC suffer chronic stress from experiencing racism in their environments, which can increase the severity of obesity [25]. BIPOC children who develop overweight or obesity will likely suffer from it into adulthood [25]. For BIPOC who want help losing weight, they have a harder time accessing health care [26]. There is real and perceived systemic racism within medicine when they do access care [27].

Geographic inequality is significantly associated with heightened risk of obesity, diabetes and cardiovascular disease [28]. Recently, there has been increasing discussion of not just food deserts, but food swamps, or areas dense with sellers of processed and fast food [29]. Marginalized BIPOC are more likely to live in food swamps [29] and are therefore the disproportionate targets of sellers of unhealthy items. More than 20 000 dollar stores have popped up largely in poor communities, displacing grocery stores with ultra-processed foods [30]. Even with access to a supermarket, processed food is usually cheaper than fruits or vegetables [31]. This fact is no accident, but a product of government choosing to subsidize and boost revenue for industrial food processors [32] and slant the price landscape for BIPOC. Ultra-processed foods have been found to lead to higher calorie consumption and greater weight gain than matched foods comparable in calories, sugar, fat and fibre [33]. These inequalities, leading minorities to consume more ultra-processed food, are difficult to disconnect from the country’s history of redlining, de facto segregation, white flight and other potential causes of physical separation of minorities, as well as the corporate entities that profit based on junk food sales.

These companies are the same ones that engage in disproportionate marketing towards BIPOC. Processed food companies particularly target Black and Hispanic children [34]. Unfortunately, those who cannot afford fruits and vegetables due to historical disadvantage are more likely to purchase a cheap alternative, especially when given compelling marketing claims specifically designed to make them believe they should buy a product. Systemic racism can find itself not just in government actions, but in private parties who stand to gain from encouraging a group to adopt dangerous behaviours. Although marketing is a large contributor to obesity across all socioeconomic groups [11], the disproportionate burden on BIPOC suggests systemic racism may be at play.

Despite the above considerations with regard to obesity and race, it remains common to blame and stigmatize both people with obesity [35] and BIPOC. About 80% of Americans believe people with obesity are primarily responsible for their obesity [36]. Similarly, a full 50% of white Americans believe that racial disparities in jobs, income and housing can be eliminated if Black people tried hard enough [37]. These personal responsibility narratives aim to convey that the locus of change is at the personal, not the systemic, level. Several prominent professors have called this type of thinking a ‘dispositionism epidemic’ – an epidemic of people and their internal dispositions being blamed for their problems so that we, as a society, do not have to take responsibility for various forms of privilege [38].

Even before COVID-19, it is unfortunate that there was not more policy attention devoted to obesity. Obesity is its own disease with a recognized complex pathophysiology, which includes alterations in the body’s hormonal and cell signalling pathways, which often creates a disordered body state called metabolic syndrome [39]. The hallmark of these metabolic changes is insulin resistance. Obesity is associated with more than 200 chronic diseases such as heart disease and stroke, various types of cancer including pancreatic cancer, breast cancer, and endometrial cancer, and liver disease [40]. Between 65% and 85% of people with obesity have fatty liver disease [41]. And any discussion of obesity must include diabetes, a rising problem. According to the Centers for Disease Control and Prevention (CDC), 34.1 million American adults had diabetes in 2018, and the rate is 56% higher for Black adults than white adults [42]. The immense costs – to lives, health and wealth – of leaving obesity unprevented and untreated are exacerbated for BIPOC. Efforts to pass the Treat and Reduce Obesity Act [43] have been unsuccessful.

Given obesity’s severe harms, the disproportionate burden on BIPOC and an international legacy of systemic racism that makes any racial disparity suspicious for being human-caused, the intersection of obesity and racism is ripe for new research.

The authors suggest we take collective responsibility for obesity by tackling the social determinants of health in earnest. We, the authors, offer a 10-point strategy to study and solve the core public health issues at the intersection of obesity and systemic racism.

1. Conduct intersectional research on obesity and racism, rather than solely on obesity and race, and consider whether obesity, like police violence and COVID-19, is another aspect of structural racism that hurts Black and Brown communities.

2. Alleviate chronic stress associated with racism, such as by reducing economic inequality, reinforcing the social safety net, and strengthening non-discrimination protections.

3. Expand obesity medicine as a specialty and offer financial support and mentorship for BIPOC who want to enter this field.

4. Provide all Americans access to comprehensive health coverage, including obesity care. Only 1% of patients who meet criteria for metabolic and bariatric surgery, a potent tool to treat severe obesity [44], and only 2% of the persons who meet criteria for anti-obesity medications receive such therapies in the United States [45]. To improve insurance coverage for obesity care, the U.S. Treat and Reduce Obesity Act (TROA) [43] is currently before Congress. The law has had bipartisan support but has yet to become law.

5. Educate providers on the importance of treating obesity in BIPOC and what therapies are available.

6. Ensure broad access to healthy food by loosening the recently tightened requirements on the Supplemental Nutrition Assistance Program (formerly food stamps), and broadly subsidizing healthy food, supermarkets, produce stands and farmer’s markets in disadvantaged areas.

7. Propose further taxation of processed, non-nutritious and obesogenic foods. Taxation is an increasingly discussed method which increases price, reduces consumption [46] and can improve health equity, especially if proceeds are reinvested in BIPOC communities.

8. Acknowledge the ease with which we attribute responsibility for obesity to people suffering from the disease, especially BIPOC, and consider more thoroughly the systemic factors leading to disadvantage.

9. Appreciate that obesity is not a ‘Black’ problem, but it is significantly worse for Black Americans and other BIPOC. We adopt the framing of Dr. Marisa Dowling and Congresswoman Robin Kelly, who framed COVID-19 racial disparities as ‘a crisis within a crisis’ [4]. Similarly, obesity of BIPOC is an epidemic within an epidemic.

10. Foreground the lived experiences of BIPOC living with obesity, and form cross-connections with social movements.

George Floyd reminded many Americans about the importance of addressing systemic racism. The officer’s knee on George Floyd’s neck is an image that stays with us in the American consciousness. Advocates for racial equality should consider whether obesity and chronic disease may be another ‘knee’ on BIPOC’s necks.