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  • The Future of Minority Health and Health Disparities Research

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    Disparities in Obesity Require Multilevel Approaches Multilevel Approaches Require More Research

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    Co-authored by
    Tanya Agurs-Collins, Ph.D., RD
    Health Behaviors Research Branch
    Division of Cancer Control and Population Sciences
    National Cancer Institute, NIH

    Susan Persky, Ph.D.
    Associate Investigator and Head of the Communication, Attitudes, and Behavior Unit
    Immersive Virtual Environment Testing Area, Social and Behavioral Research Branch
    National Human Genome Research Institute, NIH

    As part of the NIMHD special issue New Perspectives to Advance Minority Health and Health Disparities Research, we and our co-authors focused on designing and assessing multilevel interventions to improve minority health and reduce health disparities.1 Multilevel interventions, based on the socioecological framework2, involve intervening on at least two levels of influence at the same time. We chose this topic because multilevel interventions are an extremely challenging and often expensive undertaking that require myriad decisions and plans, yet it is becoming clear that such interventions are a necessary approach for overcoming great disparities evident in the public’s health, particularly for conditions like obesity.

    Obesity is a risk factor for several chronic diseases, including cancer. Approximately 40% of the general U.S. population is classified as having obesity. When racial and ethnic differences are examined, the highest obesity rates are found among African Americans (54.8%), followed by Hispanics (50.6%), Whites (38%), and Asian Americans (14.8%).3 These disparity rates are related in part to major changes in the food and built environments, resulting in excessive consumption of energy-dense foods and physical inactivity, which is more prevalent in minority communities. Although multilevel approaches are taking hold in this area, we still have a long way to go in addressing gaps between majority and minority populations.

    Numerous interventions aimed at reducing calorie intake and increasing physical activity have focused on individual-level factors among various racial/ethnic populations. These interventions often hinge on the notion that if we educate individuals about what comprises a healthy diet and enough physical activity, they will change their behavior, resulting in the reduction of obesity. By now, we are well aware that weight and obesity are extremely complex and that this individual approach is insufficient. However, current interventions don’t often consider factors beyond the individual’s control. For example:

    • Recommendations to eat a rainbow of fruits and vegetables are useless when these foods are out of reach for financial reasons.
    • Suggestions to increase home cooking are not feasible when people commute hours to jobs in high-cost areas.
    • Telling people to avoid ultra-processed foods is no match for the incessant stream of advertisements and snack formulations to make those items hyperpalatable.
    • Children’s health education can’t be fully effective in schools without physical education and recess.

    It’s clear that obesity simply cannot be addressed at the individual level alone, so it is crucial to mount community, neighborhood, and policy-level interventions in combination.

    Efforts to study multilevel interventions are certainly emerging. Take, for example, a church-based multilevel obesity intervention with African Americans and Latinos that targets individuals (cooking and nutrition classes), the congregation (fruit and vegetable garden), and the community (mapping of food and physical activity environments). This study found significant weight loss, less weight gain, and healthier diets as a result;4 however, the study had a limited ability to assess intervention effects, due to small sample size, loss of a control church, and uncertainties related to intervention dose and duration.

    Another study addressed individuals’ diet and physical activity, groups via civic engagement, and community factors through grocery store audits, environmental assessments, and development of a community guide. This intervention produced significant reductions in body mass index (BMI) and cardiovascular risk factors among rural women in medically underserved areas5 but was not designed to evaluate civic engagement’s independent and additive effects. In another example, researchers targeted African American youth–caregiver dyads in low-income areas. The researchers intervened at recreation centers and small food stores and provided interpersonal support through peer mentoring,6 producing modest reductions in children’s BMI percentiles, but were unable to alter the food environment.

    Interventions like these highlight the complexity inherent in undertaking multilevel interventions. As we point out in the paper, there is much work needed to develop multilevel intervention strategies to push forward intervention development, methodology, and evaluation approaches. We challenge researchers to build teams that can develop the needed strategies to enable interventions that broadly consider levels of influence to identify the mechanisms and pathways that effectively reduce health disparities.

    References

    1. Agurs-Collins, T., Persky, S., Paskett, E.D., Barkin, S.L., Meissner, H.I., Nansel, T.R., Arteaga, S.S., Zhang, X., Das, R., and Farhat, R. (2019). Designing and Assessing Multilevel Interventions to Improve Minority Health and Reduce Health Disparities. American Journal of Public Health, 109(S1), S86-S93. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6356127/.
    2. Stevens, , Pratt, C. Boyington, J., Nelson, C., Truesdale, K. P., Ward, D. S., Lytle, L., Sherwood, N.E., Robinson, T. N., Moore, S., Barkin, S. Cheung, Y.K., Murray, D. M. (2017). Multilevel Interventions Targeting Obesity: Research Recommendations for Vulnerable Populations. American Journal of Preventive Medicine, 53(1), p.115-124. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5571824/
    3. Hales C.M., Carroll M.D., Fryar C.D., Ogden C. L. (2017). Prevalence of Obesity Among Adults and Youth: United States, 2015-2016. NCHS Data Brief (288), p 1-8. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/29155689.
    4. Derose, K.P., Williams, M.V., Florez, K.R., Griffin, B.A., Payan, D.D., Seelam, R., Branch, C.A., Hawes-Dawson, J., Mata, M.A., Whitley, M.D., Wong, E.C. (2019). Eat, Pray, Move: A Pilot Cluster Randomized Controlled Trial of a Multilevel Church-Based Intervention to Address Obesity Among African Americans and Latinos American Journal of Health Promotion 33(4) P. 586-596. Retrieved from https://journals.sagepub.com/doi/full/10.1177/0890117118813333.
    5. Seguin, R.A., Paul, L., Folta, S.C., Nelson, M.E., Strogatz, D., Graham, M., Diffenderfer, A., Eldridge, G., Parry, S. A., (2018). Strong Hearts, Healthy Communities: A Community-Based Randomized Trial for Rural Women. Obesity (Silver Spring, 26(5), P. 845-853. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5915907/.
    6. Shin, A., Surkan, P. J., Coutinho, A.J., et. al., (2015). Impact of Baltimore Healthy Eating Zones: An Environmental Intervention to Improve Diet Among African American Youth. Health Education & Behavior, 42 (IS) p. 97S-105S. Retrieved from https://journals.sagepub.com/doi/pdf/10.1177/1090198115571362.

  • The Future of Minority Health and Health Disparities Research Blog Series

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    Understanding Health Disparities through the Life Course
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    By Arline T. Geronimus, Sc.D.
    Professor, Health Behavior and Health Education, School of Public Health
    Research Professor, Population Studies Center, Institute for Social Research
    University of Michigan


    My monozygotic twins—now young men—never engaged in parallel play with each other. Parallel play is a type of toddler-to-preschool play where, even though two or more children are in the same room or even the same sandbox, they each remain absorbed in their own personal activity and do not interact. Yet before they could walk or talk, my sons delighted in playing together, cooperating on projects, and putting on musical performances that they would end by bowing in unison, each one’s arm around the other’s waist. They scaled higher heights, literally, than playing alone. We found them lying on the tops of our highest kitchen cabinets, giggling together, when they were 2. Even strapped into their stroller, they enacted perfectly synchronized and complexly coordinated routines we called “stroller surfing,” which were at once wonderful and hair-raising to watch and noticeably enchanting to passersby.

    My sons were then—and they remain to this day—among the most engaged, charismatic, sociable, and creative people I have known. Most likely being twins had something—maybe even a lot—to do with this. While causality is hard to prove, I often think that their continuing creativity and ability to work things out owes much to having been able to play interactively from the beginning. Maybe it was a twin thing, but it set in motion positive recursive processes.

    As part of the NIMHD visioning process on life course approaches to causes of health disparities, we began with members in parallel play. We all agreed that life course approaches are critical to understanding the development and perpetuation of social inequities in health, but we came with strong ideas based on our own scholarly histories on what a life course approach was and why it mattered. Our first instinct was to turn to parallel play rather than do the harder, more creative work of integrating our different perspectives, evidence bases, and scholarly commitments. Working together over several months and iterations to produce one analytic essay on the etiology of health disparities through a life course lens, we set the stage for a more integrated theoretical and scientific approach.1

    We established that our different perspectives on the life course could be categorized as developmental and structural. The developmental life course approach is theorized in the developmental origins of health and disease (DOHaD) hypothesis. It focuses attention on the role of critical and sensitive developmental stages in shaping later life health. Gene–environment interactions during fetal, infant, early childhood, and adolescent development produce the biological architecture that at a minimum heavily influences and perhaps even programs later life health. The rationale is that heightened plasticity in these early periods enables environmental exposures or deficiencies to more profoundly affect development than at other times, with enduring effects. Mechanistically, adverse uterine or childhood environments activate epigenetic modifications during these highly plastic periods that remain consequential across the life span.2

    The structural life course approach can be encapsulated by the theory of weathering3, a cumulative stress perspective grounded in social research. It proposes that different social identity groups— identified by race, ethnicity, religion, sexual orientation, gender, socioeconomic position, place, immigrant status, et cetera—have different lived experiences that are structured in part by history, policies, power dynamics, and dominant cultural frameworks. These frameworks influence the distribution, cadence, and intensity of life course demands and stressors across various social groups, as well as the coping resources these groups have available. Mechanistically, the structural perspective focuses on the health effects of physiological stress processes that are chronically activated in marginalized groups and the persistent high-effort coping this requires of them, especially in the young adult through middle ages, when family leadership roles are assumed. The resultant stress-mediated wear and tear on important body systems and cellular integrity precipitate accelerated aging, the dysregulation of body systems by midlife, and the early onset of chronic diseases of aging.4

    Although they have different emphases and draw on different scientific frames and skills, these two perspectives are not mutually exclusive. For some overlapping and some different reasons, each perspective is hard to prove.5 In parallel play, advocates of each perspective make a case for causal evidence of that perspective, yet neither case is subject to constructive cross-examination by the other, and neither benefits from the skills and knowledge the other may have to fill in gaps.

    Moreover, refinements of theory, empirical tests, and translation of findings to promote heath equity will surely benefit from the deep integration of both perspectives, including interdisciplinary work across the biomedical and social sciences—and even the humanities to discern important historical, policy, and ethnographic influences on lived experience that shape health across the life course.5

    But scientists with different backgrounds, skill sets, and perspectives continue to parallel play. And worse, power dynamics apply to favor biomedical research, inasmuch as substantially more resources are awarded to elucidating the developmental compared with the structural perspective. Meanwhile, population health inequities persist and, in some areas, have grown. We in the scientific community could take a note from my 2-year-old sons. Engaging in interactive play can lead to more creative, enchanting, and productive synergies than continuing to parallel play in the same sandbox.


    References

    1. Jones, N. L., Gilman, S. E., Cheng, T. L., Drury, S. S., Hill, C. V., & Geronimus, A. T. (2019). Life course approaches to advance the understanding of the causes of health disparities. American Journal of Public Health, 109(S1), S48–S55. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6356123/
    2. Gluckman, P. D., Hanson, M. A., Cooper, C., & Thornburg, K. L. (2008). Effect of in utero and early-life conditions on adult health and disease. New England Journal of Medicine, 359(1), 61–73. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3923653/
    3. Geronimus, T., Pearson, J. A., Linnenbringer, E. P., Schulz, A. J., Reyes, A., Epel, E. S., . . . Blackburn, E. H. (2015). Race/Ethnicity, poverty, urban stressors and telomere length in a Detroit community-based sample. Journal of Health and Social Behavior, 56(2), 199–224. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4621968/
    4. Geronimus, T. (2013). Deep integration: Letting the epigenome out of the bottle without losing sight of the structural origins of population health and disease. American Journal of Public Health, 103(S1), S56–S63. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3786760/


  • New Blog Series on the Future of Minority Health and Health Disparities Research

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    This blog series includes perspectives from authors of the American Journal of Public Health supplement, New Perspectives to Advance Minority Health and Health Disparities Research. The supplement highlights strategies to stimulate research for improving minority health and closing the gap in health disparities.
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    By Nancy Jones, Ph.D., M.A.
    Scientific Program Officer, Community Health and Population Sciences
    National Institute on Minority Health and Health Disparities


    In 2015, the National Institute on Minority Health and Health Disparities (NIMHD) began an initiative to create a scientific vision to transform minority health and health disparities. I served as a co-chair for one of the three pillars for the visioning process with several other NIMHD colleagues and guest editor for a supplement of the American Journal of Public Health (AJPH), entitled New Perspectives to Advance Minority Health and Health Disparities Research.

    The science visioning initiative sought to do something that had not been done before: tackle health disparities across diseases. Health disparities arise from multiple upstream factors from the sociocultural and physical/built environments interacting with downstream behavioral and biological mechanisms. These pathways result in worse health outcomes for many diseases and conditions for racial/ethnic minorities and other health disparity populations. Often, scientific visioning at the National Institutes of Health (NIH) develops research strategies to address a single disease or condition. This visioning process envisioned a roadmap that can catalyze research to understand and address health disparities across multiple diseases and conditions.

    Thus, NIMHD brought together experts from a range of scientific disciplines and worked with Institutes, Centers, and Offices from across NIH. The goal was to identify research strategies to be able to better measure health disparities, to fill knowledge gaps in the causes of health disparities, and to determine what types of interventions are the most likely to reduce and eventually eliminate health disparities. With input from hundreds of stakeholders, through committees, workshops, and direct public input through a request for information, 30 research strategies emerged. It is hard to convey how daunting yet energizing the visioning process was. First, it was truly awe-inspiring to appreciate the rich diversity and unparalleled passion of those who identify as minority health and health disparity researchers. As the convener, NIMHD facilitated connecting scientific experts who had never interacted before and watched them discover how their research intertwined. For example, researchers focused on early life stage mechanisms were interacting with researchers who were experts on the adult and geriatric life stages; genetic and molecular biologists interacted with population and social scientists; and mental health scientists interacted with cardiovascular disease scientists. These scientific experts and community stakeholders demonstrated determination and personal investment to bridge historical scientific silos, muck through field-specific scientific lingo, and defy self-promoting priorities to advance strategies that can provide universally applicable research findings.

    In January 2019, 30 cross-cutting strategies were announced through the AJPH supplement. Several themes arose across the 30 strategies. Here are a few:

    • Prioritizing the crucial role that upstream social determinants, as well as racism and other forms of discrimination, play in shaping health and health disparities
    • Using system and transdisciplinary approaches necessary to address the complex, dynamic interactions of multiple multilevel determinants that result in health disparities
    • Using a life course perspective that accounts for how the lived experience across human development influences health
    • Exploring key common biological systems and pathways operating in many diseases and conditions that are influenced by social, environmental, and cultural factors
    • Examining the role that the health care system can play in addressing or exacerbating health disparities

    Dr. Nancy Jones

    It can be disheartening to consider how entrenched health disparities are. However, this science vision gives me hope. As we move toward celebrating a milestone year for the Institute and its predecessors in 2020, NIMHD will host a special blog post series from authors of these essays and editorials to discuss how to operationalize the vision.

    My personal request is that all minority health and health disparities researchers take a few moments each month to ponder the strategies and envision how you personally can put them into action in your own research. At NIMHD, we continue to be deeply grateful for all those who took part in the visioning process, because we know the effort it required to bring the supplement to completion. But we are even more grateful for the talented, inspiring researchers who are committed to make the NIMHD vision—an America in which all populations will have an equal opportunity to live long, healthy, and productive lives—a reality.