Steps to eliminate inequities in preventing, treating obesity
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Researchers should consider six key questions to design an effective and culturally relevant weight-loss intervention that will reach and include historically underrepresented groups, according to a speaker.
The pathway from obesity risk to treatment outcomes is influenced by disparities in the development of obesity, the uptake of treatment and the response to treatment, Monica L. Baskin, PhD, professor of preventive medicine at the University of Alabama at Birmingham Heersink School of Medicine, said during a virtual presentation at ObesityWeek 2021. Social determinants of health, including the built environment and socioeconomic factors, as well as physiology, all play a role in weight gain and obesity risk, she said.
Baskin said weight gain and seeking obesity treatment is influenced by disparities in treatment due to language, transportation, income, literacy and geography in addition to provider communication.
“One size does not fit all,” Baskin told Healio. “It is imperative to understand the sociocultural context of the target audience and tailor interventions to match that reality.”
Race, exposures and weight gain
Higher obesity rates are associated with Black and Hispanic adults living in racially segregated communities, people living in rural vs. urban communities, those who live in so-called “food deserts” with limited access to grocery stores, or “food swamps” with a high proportion of fast-food restaurants.
Native American, Pacific Islander, Black and Hispanic people are also more likely to experience food insecurity compared with Asian and white individuals, Baskin said. Exposure to multiple stressors, such as childhood adversity, acute life events, financial strain and lifetime discrimination, also explain some race differences in obesity prevalence, Baskin said.
“Differences in weight-related attitudes, obesity stigma and cultural perceptions of body size may lead to less utilization of weight-loss interventions among Black women, who may not view weight as a problem until at a higher BMI,” Baskin said. “We also know that Black patients are less likely than white patients to get weight-loss advice, and there may be practices within the health system itself that limit referrals, particularly for those from socioeconomically disadvantaged backgrounds.”
Weight-loss outcomes with behavioral, medical or surgical interventions also differ by race; Black participants in lifestyle intervention studies consistently lose less weight than their white counterparts, Baskin said. Similarly, racial and ethnic minorities respond to bariatric surgery with less weight loss and are more likely to experience surgery complications.
“The overall inequities that we see are a reflection of multilevel disparities, many of which are social rather than biological determinants,” Baskin said.
Designing ‘culturally relevant’ interventions
To increase representation in any weight-loss trial, researchers should utilize a two-level cultural tailoring framework that factors in “surface structure,” like language, music, food and demographics, and “deep structure,” incorporating a group’s core values, faith, understanding of illness and economics.
Baskin said a culturally relevant intervention, defined as an intervention that seeks to understand and appreciate the diverse ethnic and cultural experience of a target population, should align intervention content and approach with cultural knowledge about norms, beliefs and attitudes. Researchers should consider six key questions:
Who is the target population? Members of the target population should be part of the research from start to finish, Baskin said. They can inform research questions, help develop methods used, help with data collection and interpretation and the dissemination of findings. “That approach also helps with other critical questions, like who is or are the most credible interventionists?” Baskin said. “Hearing directly from members of the target audience is critical to help you figure out who is best to deliver the intervention.”
What factors are most relevant to your primary outcome? It is critical that selected outcomes make sense to the target population and will offer information they want or can use, Baskin said. Researchers should also take note of barriers and facilitators to successful outcomes.
“Understand what is going to help or get in the way of a successful intervention,” Baskin said. “Are there factors in the built environment? Are there challenges in the social environment?”
When is the best time to intervene? Timing is important in any community-based trial, Baskin said. Researchers should consider what else might be going on in the community that may influence outcomes and participation in any intervention.
Where will you deliver the intervention? Many communities may have convenient, local facilities to deliver a program, but researchers must talk with potential participants about their use, Baskin said.
“We learned that one public community center we wanted to use had a long history of discrimination and denying access to Black residents in the past,” Baskin said. “Some of our older participants could not even see themselves going to that location, because of that history. As a result, we adjusted and changed our location prior to starting that program so we could ensure everyone felt comfortable.”
How will you measure success? There are factors beyond a P value to consider when measuring the success and sustainability of an intervention, Baskin said.
“How effective is your intervention in reaching the population you are looking for?” Baskin said. “What was the percent of enrollment vs. the number of people you actually reached out to? What is the diversity of participants and what is their overall satisfaction? There are other measures of success that need to be incorporated into interventions and certainly reported on when you publish your study findings.”
Why might this be important? “Why are you doing this research? It is not so you can get another grant or a high-impact publication or the promotion or tenure that you deserve,” Baskin said. “There are other factors for why their participant in an intervention might be important.”
Move beyond diversity statements
Racial and ethnic diversity among clinicians and researchers does not reflect larger society, and that affects any intervention as well as patient care, Baskin said. Institutions must move beyond “beautifully crafted statements on diversity” and take bold, impactful steps to recruit, train, develop and advance a diverse biomedical workforce, Baskin said.
“Diversity, equity and inclusion leads to better solutions for complex behavioral problems, like obesity," Baskin said.
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Baskin ML. Addressing inequities in the prevention and treatment of obesity — the role of research. Presented at: ObesityWeek; Nov. 1-5, 2021 (virtual meeting).
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