This blog post was originally written in July 2020 for the #Obsm Blog and corresponding #Obsm Twitter chat on racism, racial disparities & obesity lead by Dr. Sylvia G-Bollie.
The recent acts of racism in the United States have been a painful reminder that though American slavery may have ended in 1865, the racist ideology that helped to foster slavery remains embedded in American culture and systems. Sadly, the healthcare system is not immune to the effects of racism.
Specifically, in obesity medicine, the impact of racism can be seen in many ways. Here we will discuss the: disparities in African American obesity rates, diagnosis of obesity, the historical impact of racism, and cultural beauty standards.
Overview
According to the most recent NHANES data from the National Center for Health Statistics non-Hispanic African American women have the highest obesity prevalence at a rate of 54.8%. Among men, non-Hispanic African Americans report an obesity prevalence of 36.9%. These numbers are in stark contrast to the obesity rates for non-Hispanic white (38%) and non-Hispanic Asian women (14.8%) and men (10.2%)[1]. The cause of high obesity rates amongst African Americans is multifactorial. In addition to lifestyle factors such as physical activity and diet, potential contributors to obesity in African Americans include genetic variation, socio-economic status, and psychosocial factors[2]. Racism has been studied in its role in African American obesity. Specifically, systemic racism impacts access to high-quality foods and environments that facilitate physical activity and healthy lifestyles. Living with racism is also stressful and causes oxidative stress and inflammation which contributes to individual obesity. The most common way obesity is clinically diagnosed is by either BMI (Body Mass Index or weight in kilograms divided by height in meters squared), waist circumference, or body fat percentage[3]. There have been racial differences noted in the use of BMI. Specifically for African Americans, BMI tends to over-estimate being overweight between a BMI of 25- 29.9 kg/ m2 due to higher levels of lean muscle mass in African Americans. Also, there has been conflicting data with some studies showing that, compared to normal BMI (18.0-24.9 kg/m2), people who are overweight (BMI 25-29.9kg/m2) have a lower all-cause mortality. Moreover, grade 1 obesity (BMI 30-35 kg/m2) may not be associated with higher mortality[4]. Whereas more recent studies have shown that even at a non-obesity BMI or “healthy” BMI 18- 24.9kg/m2, African Americans have higher levels of “obesity-related” disease such as type 2 diabetes, hypertension, and heart disease[5]. Critics point to this discordance in BMI data as evidence of the racial bias in using BMI as a measurement tool.
Historical Weight Bias
In her historical narrative “Fearing the Black Body: The Racial Origins of Fat Phobia,” Dr. Sabrina Strings highlights the historical shift from the full-figured body type being considered the standard of beauty as slavery and racism increased globally. She convincingly argues that the ideal of thinness became associated with white purity and moral rectitude as a means of dehumanizing Black people who generally were naturally more full-figured[6]. As slavery progressed, the “Mammy[7]” figure emerged as the prototype of the happy subservient African American woman. Interestingly this caricature was always depicted as having obesity. I think the lasting influence of the Mammy caricature is that, in part, obesity is overlooked and underdiagnosed in African American women because of the false narrative that Black women are not interested in addressing the health ramifications of obesity.
This is a good place to discuss the difference between the preferred body type by African American (or Black) beauty standards and the impact on weight-related health goals. Despite a racially biased emphasis on slenderness, fuller figured bodies have long been celebrated in Black communities. Specifically, Black women with full busts, large buttocks with a proportionately smaller waist are recognized as having the idealized body[8]. It is important to be mindful of this beauty standard when suggesting treatment for medical obesity due to health implications. When discussing medical obesity, I have often had patients tell me “I don’t want to be too skinny.” Just as with severe obesity, a low body weight or drastic rapid weight loss is also associated with cultural stigma in Black communities. Rapid weight loss and low body weight amongst the Black community is colloquially associated with disease and mental health concerns.
Clinical Implications
It is clear there are racial differences as well as disparities associated with African American obesity rates. Furthermore, it is undeniable that faulty racist ideology has facilitated bias and disparities in obesity diagnosis and treatment. In The Racist Roots of Fighting Obesity, Strings and Bacon assert “blaming Black women’s health conditions on ‘obesity’ ignores …critically important sociohistorical factors. It also leads to a prescription long since proved to be ineffective: weight loss….The most effective and ethical approaches for improving health should aim to change the conditions of Black women’s lives: tackling racism, sexism, and weightism and providing opportunity for individuals to thrive[9]” Strings and Bacon’s assertion only provides a partial solution to improve African American health. As a Black woman and physician, I have personally and professionally seen the deleterious health effects of obesity that extends beyond subjective aesthetics. I agree that forcing individuals to conform to specific body type that is rooted in racism, classism, and sexism to fit a faulty social stereotype is unhealthy and potentially harmful. However, given the evidence of the increased all-cause mortality associated with obesity especially at BMI >35kg/m25 it would be a disservice not to address obesity in African Americans. Dr. Strings’ work does not invalidate the need for obesity treatment in African American patients with obesity-related disease. Rather it reemphasizes that obesity treatment must comprehensively address nutrition, physical activity, behavior, and medication (if needed)[10]. Additionally, for African Americans (and Black people globally) it is critical to incorporate the effects of personal and systemic racism as well as other psychosocial factors into treatment planning to truly create lasting weight loss and optimal health.
Where to Go From Here
As we tackle deep-seated racism and the associated health disparities it is a deeply painful and uncomfortable time. As a physician who is a black woman, this has been an emotional time filled with personal reflection and introspection. I’ve had to reflect on both how systemic racism has impacted how I am treated and how I was educated to treat others. Racial bias has impacted all of us. This is a difficult realization, but it can be the impetus for growth and positive change. We have a historical opportunity to rectify the medical narrative regarding obesity in African Americans and develop effective tools to optimize health for generations to come.
