Special ReportRacial and Ethnic Disparities in ObesityBack to Report
Inequities in access to healthcare, the quality of care received and opportunities to make healthy choices where people live, learn, work and play all contribute to the rates of obesity being higher for Latino adults and children compared to Whites. Also contributing to the higher rates of obesity is the fact that Latino communities experience higher rates of hunger and food insecurity, limited access to safe places to be physically active and targeted marketing of less nutritious foods.1,2 Latinos are the fastest growing population in the United States — it is estimated that nearly one in three children will be Latino by 2030 — so addressing these disparities is essential for the well-being of individuals and families and to help contain skyrocketing U.S. healthcare spending and increase the nation's productivity.3
Strategies to address these disparities must include a sustained and comprehensive approach — targeting the challenges that stem from neighborhoods, schools, workplaces and marketing environments that make it difficult to access healthy affordable foods and be physically active.
Nearly one in four Latino households are considered food insecure (when having consistent access to adequate food is limited by lack of money or other resources), compared with 11 percent of White households.9 Approximately 23 percent of Latino families are living in poverty,10 and over the past 30 years in the United States, White families have earned $2 for every $1 that Latino families earned.11
A number of studies have shown that when Latino families do not have enough money for everyone to eat full and nutritious meals, there is an increased risk of obesity, particularly among the children in the household.12 Latino children consume higher amounts of sugar-sweetened beverages than other children,13 and one study in Houston, from 2000 to 2004, found that two out of every three foods Latino children consumed included pizza, chips, desserts, burgers or soda/juice.14 In part, this is because there is a link between income and food choice — often the less expensive options that are purchased to help stretch budgets are lower in nutritional quality. Low-income Latino families spend about one-third of their income on food, and much of the food purchased is calorie-dense, low in fiber and high in fat, sodium and carbohydrates.15
Lack of access to healthy foods in neighborhoods is also a problem. Greater accessibility to supermarkets is consistently linked to decreased rates of overweight and obesity.16 Studies have found that there is less access to supermarkets and nutritious, fresh foods in many urban and lower-income neighborhoods and less healthy items are also often more heavily marketed at the point-of-purchase through product placement in these stores.17,18 Latino neighborhoods have one-third the number of supermarkets as non-Latino neighborhoods.19 According to the 2013 YRBS, 9.3 percent of Latino youths did not eat vegetables during the prior week, compared to 4.5 percent of White youths.20
In addition to food access issues at home and in their neighborhoods, Latino students also tend to have increased access to unhealthy foods at school.21 A number of studies have found that schools with a higher proportion of Latino students tend to have weaker policies regarding access to competitive foods in schools, and may be less likely to implement nutritional guidelines for competitive foods.22
Several factors can prevent many Latinos from participating in programs that could provide increased access to healthier choices. Health education and programs — including ones designed to improve nutrition, increase activity and prevent obesity-related health problems — are often not made available in Spanish and not sensitive to cultural differences. In addition, many health education workers have not been trained to work with Latino populations. Often access to needed programs is further impeded when immigration status is related to eligibility for different nutrition and health programs, or when potential beneficiaries fear involvement of immigration officials. There can be limited information and lack of understanding by the potential participants and the workers in the programs themselves, who also may not be trained to understand how to provide services for people of different immigration status or for Spanish speakers. Finally, there exists a history of issues and stigma within systems, which can make it harder for many Latinos to choose to take advantage of available benefits. In 2011, 34.9 percent of all Latinos were eligible for SNAP but only 21.4 percent received benefits.23,24
Latinos are a major and increasing target for food marketers, particularly due to their increasing proportion of the U.S. population and relative spending power. Studies have found that 84 percent of youth-targeted food advertising on Spanish-language TV promotes food of low nutritional value. Between 2010 and 2013, fast food restaurants increased their overall advertising expenditures on Spanish-language TV by 8 percent. Latino preschoolers viewed almost one fast food ad on Spanish-language TV every day in 2013, a 16 percent increase from 2010. In addition, low-income Latino neighborhoods have up to nine times the density of outdoor advertising for fast food and sugary drinks as high-income White neighborhoods,25 and Latino children are more likely to attend a school that is close to fast-food restaurants and convenience stores.26
Physical activity is important for maintaining a healthy energy balance.27 Studies have found trends showing Latinos often have less access to safe places to play or be active.
In 2011, Latino adults were 30 percent less likely to engage in physical activity as Whites.28 According to the 2013 YRBS, 16.2 percent of Latino youth did not participate in at least one hour of daily physical activity during the prior week, compared with 12.7 percent of White youth.29
Only one-third of Latinos live within walking distance of a park — compared with almost half of all Whites. Elementary schools with a majority of Latino students are less likely than those with a majority of White students to have 20 minutes of recess daily or 150 minutes of physical education a week.30 Latino children are less likely to be in after-school activities where they are physically active, due to factors including cost of participation, transportation and language barriers.31 And, more than 80 percent of Latino neighborhoods did not have an available recreational facility, compared to 38 percent of White neighborhoods, according to a 2003 to 2004 study.32
A number of nutrition assistance programs, including SNAP, the WIC program, CACFP and school meal programs, can help increase access to affordable food and provide education about how to eat healthier food on a limited budget.
Active Living Logan Square was designed to increase physical activity among Latino children in Chicago and promote partnerships between school administrators, local policymakers and community members. With city approval, the partnership piloted three Open Streets events, closing four to eight miles of road to motorized vehicles, for use by over 10,000 residents from five diverse communities, in order to help create safe, inviting places for physical activity in a predominantly Latino urban community. Today, additional pilot programs have been launched throughout the country. Part of the success of the program is attributed to the use of social and culturally competent media among planners and program staff, and the delivery of information to the residents by other bilingual community members.47
New York City's Healthy Bodega Initiative recruited approximately 1,000 bodegas to increase their offerings of low-fat milk and 450 bodegas to increase their offerings of fruits and vegetables. The city provided promotional and educational materials to encourage consumers to buy the healthier products and call on their local bodega to participate. The campaign led to increased sales of low-fat milk in 45 percent of participating bodegas, increased sales of fruits in 32 percent of participating bodegas, and increased sales of vegetables in 26 percent of bodegas.48
Healthy RC Kids Partnership focused on Southwest Cucamonga, a predominantly Latino community in California with high rates of poverty, where two-thirds of residents are considered obese or overweight. The area had few neighborhood amenities — there were no grocery stores selling fresh produce and residents had limited access to safe, open space for physical activity. Healthy RC Kids was established by the city and included collaboration with residents and more than 50 community stakeholders to identify barriers to healthy eating and active living. As a result, more community gardens and farmers' markets were created and the City Council amended the development code to allow vacant land to be used to grow produce and to allow farmers' markets in expanded areas of the city. This eventually led to a new farmers' market in Rancho Cucamonga and plans to open one in Southwest Cucamonga. A United Way grant allowed the Partnership to implement the "Bringing Health Home Program," which provides matching subsidies of up to $50 a month to help Southwest Cucamonga residents purchase fresh produce at local farmers' markets. The city also provides incentives and information for farmers' markets to accept payments from food assistance program recipients.49
In an effort to gain greater understanding of the food environment among Latino families, NCLR conducted a video and story-banking project that captured the experiences of Latino parents and caregivers around the country in feeding their families. The stories feature individuals who range from multigenerational U.S. citizens to first-generation immigrants raising their U.S.-born children. Respondents talked to NCLR about buying and preparing food, community resources and the health of their children. The interviews help gain perspective into the barriers Latinos face in feeding their families and strategies for how to improve nutrition, ranging from monthly budgeting to learning to cook traditional cultural foods in healthier ways.
Promotores play an important role in promoting community-based health education and prevention in a manner that is culturally and linguistically appropriate, particularly among populations that have been historically underserved and uninsured.51 Promotores are especially important because they typically share the ethnicity, language, socioeconomic status and life experience of the community members they serve.52
Evidence shows that promotores help improve intervention outcomes. A systematic review of evidence-based obesity treatment interventions for Latino adults in the U.S. found that the two interventions with the largest effect sizes used promotores.53 Both studies involved promotores as the intervention implementers in the community.54,55
In 2011, HHS launched the Promotores de Salud Initiative in an effort to educate the Latino community about available healthcare services and other benefits made possible by the ACA. Since the launch, the HHS Promotores de Salud Steering Committee has worked to improve Latino access to health information and services.56
Salud America! is an RWJF-funded research network that aims to prevent obesity among Latino children. Since the start of Salud America! in 2007, the network has developed essential scientific evidence, research, communications and a wealth of information to raise awareness of Latino childhood obesity, build the field of researchers working to reduce the epidemic and empower stakeholders to take action and create change.
Salud America! works to improve Latino children's health by targeting six key areas that could make the greatest advances in reducing obesity in the least amount of time: sugary drinks, healthier marketing, active play, active spaces, better food in the neighborhood and healthier school snacks.
Salud America! launched a Growing Healthy Change initiative to bring together evidence, new policies, success stories, social media and resources to help individuals and communities develop capacity to create healthy policy changes in the six key areas. The Growing Healthy Change website allows you to input your address and find concrete policy initiatives happening in your neighborhood, school, city or state to improve nutrition, physical activity and marketing aimed at Latino kids. The website also offers many resources, success stories and videos of real-life Salud Heroes of change to inspire and help individuals, groups and communities to create their own change.
Salud America!: The RWJF Research Network to Prevent Obesity Among Latino Children
Comer Bien. National Council of La Raza
Office of Minority Health, U.S. Department of Health and Human Services
Fact Sheet: Overweight and Obesity Among Latino Youths, Leadership for Healthy Communities (available in English and Spanish)
On behalf of Trust For America's Health and Salud America!, Greenberg Quinlan Rosner Research conducted a set of 10 one-on-one, in-depth interviews among public health leaders in Latino communities across the country. The participants represent both the public and private sectors and include academics, health professionals and community and business leaders, among others. The study was designed to assess barriers to and identify solutions for reducing and preventing obesity in Latino communities. All interviews were conducted between April 22 and May 1, 2014.
Health leaders interviewed for the study are acutely aware of how the Latino community is disproportionately affected by America's obesity epidemic — but they are also optimistic about how well-thought-out and effectively implemented policies can help achieve better health. Overall, they feel the general policy approaches that have been identified for how to respond to the obesity epidemic are on the right track but policy development is only half the battle, and the implementation of those policies has been relatively limited in the Latino community.
The interviews revealed two core issues that must be addressed to improve implementation:
Barrier: Socioeconomic factors amplify the barriers that can get in the way of physical activity and access to healthy food.
Recommendation: Help make healthier choices easier by increasing access to and opportunities for physical activity and healthy eating — but don't stop there.
The leaders in the Latino communities were very supportive of a wide range of obesity prevention policy approaches — ranging from healthy food financing initiatives to improving the built environment to improving nutrition and activity in schools to improving and increasing public education initiatives to supporting shared-use agreements to allow members of the community to have access to school and community centers for recreational purposes during off-hours.
But they unanimously agreed that: 1) more resources are needed to support these efforts; 2) these programs must become more focused and efficient, and also be developed within the context of programs that address other socioeconomically linked issues, such as quality housing, education, crime reduction and transportation; and 3) efforts must proactively engage members of the community. For example, instead of just opening schools for community use during non-school hours, soccer leagues, walking clubs, community cooking classes and other organized social programs should be developed so the community has a way to make use of these expanded resources.
In addition, a number of the leaders recommended focusing on solutions that improve health along with overall quality of life, including:
"The obstacles are finances, which is not unique. But we also have less access to healthy food; stores don't have healthy products."
"The built environment doesn't make healthy choices easy for individuals. There aren't safe parks for kids to play. As a result, poor choices are made. We need safe and fun recreational activities."
"We have healthy food in close proximity, but we don't have AFFORDABLE, healthy food."
"Awesome. Improving nutrition and increasing activity for young children, such as through efforts or regulations in daycare centers] would work, because little kids want to be part of the group. Make it social."
"[Making water available as an alternative to sugary drinks is] good, but there needs to be a lot more. You need infrastructure — new pipes because the water tastes bad or is unsafe. You need education on why water is better."
"Good. But [shared-use agreements] would be most effective if schools have an active role in organizing and supporting it."
"I would definitely support [shared-use agreements], and I think it would work. I think a significant number of people in my community can't afford a gym, so it's important for them to have access. A place to walk, do laps, get moving. But there's also a need to have a structure and organization in place — groups walking together, for example. We need to put a motivation and structure in place, along with access."
Barrier: Education and cultural differences contribute to less knowledge about nutrition and activity. Many people do not understand which options are healthier or why they should choose healthier options. This is reinforced by disproportionate marketing of unhealthy foods in these communities.
Recommendation: Keep educating and raising awareness; make it relevant to people's lives.
The Latino health leaders emphasized that simply putting the physical resources into place is not enough. Physical resources need to go hand-in-glove with education campaigns that focus on how to eat healthier and be more physically active — and how eating well and being active can be enjoyable, help reduce stress, and lower risk for or help manage type 2 diabetes and other chronic diseases. The health leaders noted the importance of personal responsibility, but also acknowledged that there needs to be increased education about which resources are available and how to be healthy, including how to make healthy choices easier even within the context of economic constraints. In fact, increasing education was viewed as even more important to give people the tools and information about resources to combat economic barriers — particularly to actively promote healthy foods in areas where unhealthy options are often more easily available and viewed as cheaper.
Neither cultural nor language barriers were raised organically during the interviews, but when asked directly, the leaders responded that cultural issues in particular contribute to obesity. For instance, many Latino families work to maintain cultural food traditions, but then the problem is exacerbated by habits rooted in U.S. culture, including driving more instead of walking, adopting bigger portion sizes, buying more processed foods or using less healthy ingredients because they are readily available. While the leaders acknowledge that immigration status can impact access to healthcare, they universally agreed that the bigger concern is that the less healthy habits adopted by many immigrants after they come to the United States have a negative impact on their health. The leaders largely reported that most of the information about nutrition and physical activity was available in both Spanish and English, but they were concerned about getting useful information in a sustained and supportive way to the people who could most benefit from it.
The health leaders stressed the importance of tailoring policies and approaches in ways that make better nutrition and increased physical activity relevant to people's daily lives. For instance, one participant explained that some activities, like soccer and dancing, are often more popular, are more social and have more cultural resonance than others, such as weightlifting.
Investing in a social component for obesity prevention initiatives is also important. A number of health leaders raised concerns about a lack of social cohesion in the Latino community, which takes away the motivation to learn from others, positive peer pressure influences and the ability to join in community activities. For example, shared-use agreements can help serve as an impetus for getting members of the community together and creating groups like recreational sports, walking or exercise groups, or cooking clubs, where healthy activities are combined with positive social experiences.
"There definitely needs to be more education for kids, but also older adults. We need to make it part of normal daily activities, integrate it into school and home life. They need to hear this message everywhere, that it's OK and important — they need to hear at school, church, at the doctor, in retail, on TV and in the media. A lot of times there are resources, but people don't know about them."
"The question is how to improve while still retaining cultural aspects — you can be healthy eating Latino food."
"As an immigrant, I think it's more about a later adoption of unhealthy, American eating habits. The longer you're here, you start to pick up on unhealthy habits like fast food."
"We have failed a lot. But what has finally worked is the social aspect. We created social programs where we eat together, exercise together, play, laugh, experience life together. And while we're gathering, we tackle the issues that contribute to obesity."
"We need people to come together. There almost needs to be a social pressure that everyone feels, that they need to get on board. There has to be a social element."
"The programs most embraced are the ones that are free and open to everyone. Also the ones that are fun. People want to feel better — they may not know they need to lose weight or have diabetes, but they are willing to try riding a bike to feel better generally. Fun and accessible, people will respond to."
Barrier: Programs and efforts often 1) are based on short-term initiatives or grants and 2) do not include community input or leadership recruitment, coordination with other efforts within the given community or partnership building at the outset. As a result, programs do not gain traction and are not sustainable.
Recommendation: Make sustainability, continuity and community input primary goals at the outset.
Health leaders emphasized that if people from the communities themselves are not empowered to have ownership of obesity-prevention initiatives, the programs are not viable. Currently, there is not a systemic or widely successful replicable model for how to create empowerment and leadership within local communities. There is a weak connection to state and national entities, where the local groups are appreciative of resources, but there is also a feeling that these organizations and funding mechanisms tend to drop in and out, leaving local leaders overwhelmed and unable to create lasting change alone.
At the same time, local communities also need support and technical assistance that the national and state groups can provide. Policies must strike a balance that allows local leaders to identify priorities and approaches that are most appropriate within their own community and also builds on the expertise and support provided by national research and initiatives.
In addition, many times new initiatives are introduced without considering existing programs, resources and expertise in a given community. These initiatives are not coordinated with or built on existing local efforts, identified priorities or the culture of a given area. Health leaders expressed that improved coordination and context would help programs be more efficient and gain traction more quickly with community members who are already invested. For instance, if a community has worked hard to build a crime reduction effort that has gained momentum and community engagement within a neighborhood, then it would be most efficient to find ways to build physical activity programs, such as neighborhood walking programs or improving parks, within the context of that existing movement.
Health leaders also emphasized the need to consider the sustainability of programs over time, rather than focus on short-term initiatives. This requires thinking about ongoing funding opportunities, tying new resources with ongoing programs and creating partnerships within a community to ensure that communities are fully invested in efforts. Getting upfront input and ownership is also key to sustainability. The leaders expressed the importance of letting the community itself be part of the oversight and evaluation of a program to ensure efforts are efficiently and effectively meeting the community's goals. The fact that resources are scarce and critical, but often not well spent, is a great source of frustration.
"A lot of things are two-year grants that just go away. Those are not successful."
"Making individuals part of the process. Build community participation so it doesn't stop when the grant is over. The question is how do we get a relatively small grant to have an afterlife?"
"There are a lot of people doing similar things. Some groups take ownership and that's great. But there's not a lot of communication between groups trying to do the same thing. It creates duplication."
"Right now there is a lot of activity going on across the country, but it's very chaotic. And within each community there's not typically much alignment of interests. Resources get diluted quickly. Or there are too many things being done with too few resources. There's too much going on and not enough coordination and organization."
"The things that work are when the programming includes training the community members and empowering people who participate so they can take over. Need to encourage them to go on and start their own walking club."
"The only way is if the people who participate take ownership. It's not fair to fund two-year programs — results won't happen in that short a window. There needs to be longer periods of time to implement and educate. We need time to start to see the benefits — once people see that they can take ownership and go help others."
"We often fail to identify natural community leaders that can organize and mobilize people."
"We don't need national groups to prescribe the remedy, but we do need help in determining a roadmap for achieving it."
"What makes it work is a very well-oiled and coordinated infrastructure — at the national level or local level — but the best examples are happening at both levels. The infrastructure has the money and know-how to provide support to local communities.
"We need to define what each sector is doing so it's in synergy with what other sectors are doing. So everyone's action is coordinated instead of being a mixed basket."
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