IN REVIEW

Disparities in Obesity:Prevalence, Causes, and Solutions

Patricia B. Crawford, DrPH, RDMay-Choo Wang, DrPH, RD

Sarah Krathwohl, MPHLorrene Ritchie, PhD, RD

ABSTRACT. Obesity rates are rising in the United States; less obvious,but equally alarming, are the increased disparities in the rates. Rates ofchange for racial/ethnic minorities are significantly greater than those ofwhites, making it critical for those in the obesity field to better under-stand the differentially changing food and physical environments that

Patricia B. Crawford, DrPH, RD, is Co-Director, Center for Weight and Health, andCooperative Extension Specialist and Adjunct Professor, School of Public Health andDepartment of Nutritional Sciences and Toxicology, University of California, Berkeley.

May-Choo Wang, DrPH, RD, is Co-Director, Center for Weight and Health, and Ad-junct Assistant Professor, School of Public Health, University of California, Berkeley.

Sarah Krathwohl, MPH, is Research Assistant, Center for Weight and Health, Schoolof Public Health, University of California, Berkeley.

Lorrene Ritchie, PhD, RD, is Associate Researcher, Center for Weight andHealth, University of California, Berkeley.

Address correspondence to: Patricia B. Crawford, 9 Morgan Hall, Department ofNutritional Sciences and Toxicology, University of California, Berkeley, Berkeley,CA 94720-3140 (E-mail: crawford@socrates.berkeley.edu).

Journal of Hunger & Environmental Nutrition, Vol. 1(1) 2006Available online at http://www.haworthpress.com/web/JHEN

© 2006 by The Haworth Press, Inc. All rights reserved.doi:10.1300/J477v01n01_03 27

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are at the root of these recent trends. The solution to stemming the risingobesity epidemic must be a coordinated multi-level environmental ap-proach, involving multiple solutions from various government, localcommunity, school, health care, and other groups. Only then can dispari-ties in obesity be reduced. [Article copies available for a fee from TheHaworth Document Delivery Service: 1-800-HAWORTH. E-mail address:<docdelivery@haworthpress.com> Website: <http://www.HaworthPress.com> © 2006 by The Haworth Press, Inc. All rights reserved.]

KEYWORDS. Obesity, overweight, low-income, minority, child, adult,racial/ethnic disparity, food, physical activity

INTRODUCTION

Obesity is a growing problem for both adults and children in theUnited States affecting disproportionate numbers of ethnic minoritiesand low-income populations. The purpose of this paper is two-fold: (1)to review obesity prevalence and trends, and primary risk factors withan emphasis on ethnic and socioeconomic disparities; and (2) to providerecommendations for addressing the obesity epidemic with an emphasison prevention among disadvantaged populations. Critical gaps in thescientific literature remain which need to be addressed in order to fullyunderstand the complexities in the etiology of obesity and to design themost responsive interventions; however, costs to society are too great todelay action. Present evidence is sufficient to point to numerous strate-gies for the urgent development and implementation of programs thatwill reduce the prevalence of obesity.

INCREASING OVERWEIGHT AND OBESITY IN THE U.S.

Nearly two-thirds of the U.S. adult population is either overweight orobese (defined as having a body mass index or BMI � 25 kg/m2). Ap-proximately half of these (30 percent) are obese (defined as having aBMI ≥ 30 kg/m2).1 Although different definitions are used to classifyweight status for adults vs. children, the national data for children are ofequal concern. Among children aged 6 through 19 years, 31 percent areat risk for overweight (defined as having a BMI � 85th percentile),about half of whom are overweight (defined as having a BMI > 95thpercentile).1

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These unprecedented figures are in large part due to very recentweight gains. Between 1960 and 1980 little change in the prevalence ofoverweight and obesity occurred among adults. In contrast, overweighthas increased by 40 percent and obesity has doubled since the 1980s(Figure 1).1-4 The timing of increase in children’s prevalence of over-weight mirrors that for adults (Figure 2).5 Overweight rates changed lit-tle between 1963 and 1980, while rates for overweight tripled between1980 and 2002 among children and adolescents. These dramatic shiftsin weight status reflect substantial changes in our environment, one thatpromotes over-consumption of calories and a reduction in energy ex-penditure, and one that is at least as, if not more, potent in children com-pared to adults.

RACIAL/ETHNIC VARIATIONS IN OVERWEIGHTAND OBESITY

Marked disparities in overweight and obesity occur across ethnicgroups. In the U.S., the prevalence of overweight and obesity is higherin African American women and Hispanic women than White women(Figure 3).1,5 Among children, the prevalence of overweight is higher

In Review 29

806040

20

0

45

13

48

15

47

15

56

23

65

30

1960-1962 1971-1974 1976-19801988-19941999-2002

OverweightObese

Per

cent

(%)

FIGURE 1. Trends in Overweight and Obesity Among Adults

20

15

10

5

0

4 5 46 7

5

11 11

1616

Per

cent

(%)

1963-19701971-1974 1976-1980 1988-94 1999-2002

ChildrenAdolescents

FIGURE 2. Trends in Overweight Among Children and Adolescents

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among African Americans and Mexican Americans compared withWhites (Figure 4).1,6 While no nationally representative data exist forNative Americans, aggregate data from numerous smaller studies showrates of obesity and overweight are higher than for Whites.7-10

The U.S. is becoming more ethnically diverse. In the 1990 census,roughly 76 percent of the population was comprised of non-HispanicWhites, while in the 2000 census only about 69 percent were non-His-panic Whites.10 During this period, rates of overweight and obesity in-creased more for African American and Mexican American adults thanfor their non-Hispanic White counterparts.1 Likewise, among childrenand adolescents rates of increase were lowest for non-Hispanic Whitechildren and greatest for Mexican American and African Americanchildren after the age of 6 (Figures 5 and 6).5 The prevalence of over-weight for 6-11 year old children steadily increased between 1976-80 to1988-94 for both genders and all racial/ethnic groups. Rates again in-creased for all between 1988-94 and 1992-2002; however BMI units ofincrease were greatest for African American children and MexicanAmerican boys (4.7-9.0 kg/m2) and lowest for White children and Mex-ican American girls (1.8-3.3 kg/m2). For youth between the ages of 12

30 JOURNAL OF HUNGER & ENVIRONMENTAL NUTRITION

80

60

40

20

0

Per

cent

(%)

White Black MexicanAmerican

28.2 33.227.9

49

27.338.4

1999-2002Men

1999-2002Women

FIGURE 3. Obesity in Adults by Gender and Racial/Ethnic Group

Per

cent

(%) 40

20

0

14.3 12.917.9

23.2 25.518.5

32.6 31.7

White(1999-2002)

AfricanAmerican

(1999-2002)

MexicanAmerican

(1999-2002)

NativeAmerican

(1990-2000)

Boys

Girls

FIGURE 4. Overweight in Children by Sex and Racial/Ethnic Group

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and 19 years, the last decade saw increasing disparities between Whiteand non-White youth (Figure 6).5 For example, among adolescents,units of BMI (kg/m2) increase between 1988-94 and 1999-2002 rangedfrom 3 to 3.8 for White youth to over twice that amount, 6.5 to 10.6 forMexican American and African American youth.

The high rates of overweight among Hispanic children have particularsignificance for the overall rates of overweight in the United States sincethis is the fastest growing ethnic group within the population. It is alsonoteworthy that time lived in the U.S. is associated with overweight; only26 percent of first generation Hispanic adolescents are overweight com-pared with 33 percent of second and third generation Hispanics.11

SOCIOECONOMIC VARIATIONSIN OVERWEIGHT AND OBESITY

Socioeconomic status (SES), independent of race/ethnicity, is an es-tablished predictor of various health outcomes including overweightand obesity.12,13 In the early part of the 20th century, higher rates of obe-

In Review 31

50

4030

20

10

0

Per

cent

(%)

AfricanAmerican

Girls

WhiteGirls

MexicanAmerican

Girls

AfricanAmerican

Boys

WhiteBoys

MexicanAmerican

Boys

NHANES II(1976-80)

NHANES III(1988-94)

NHANES(1999-2002)

11.217

22.8

5.29.8

13.19.815.3 17.1

6.812.3

17

6.110.714 13.3

17.526.5

FIGURE 5. Prevalence of Overweight Among Children 6 to 11 Years (1978-2002)

50

4030

20

100

Per

cent

(%)

AfricanAmerican

Girls

WhiteGirls

MexicanAmerican

Girls

AfricanAmerican

Boys

WhiteBoys

MexicanAmerican

Boys

NHANES II(1976-80)

NHANES III(1988-94)

NHANES(1999-2002)

10.716.3

23.6

4.68.912.7

8.813.4

19.9

6.110.7

18.7

3.811.614.6

7.714.1

24.7

FIGURE 6. Prevalence of Overweight Among Children 12 to 19 Years (1978-2002)

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sity were observed among those with high SES, particularly among menand children. In the later part of the century, however, this trend re-versed with higher rates observed among low SES adults and children.14

These higher rates of overweight/obesity experienced by lower socio-economic individuals are generally observed in all racial/ethnic groups;however, SES has a lesser effect on overweight/obesity in minoritiesthan in non-Hispanic Whites.

While obesity is more prevalent among adults with less educationand lower income, its effects are clearer in women than in men.15 Menwith incomes below the poverty line are only slightly more likely to beobese (21.7 percent versus 17.7 percent), and in fact, slightly less likelyto be overweight than men in the highest income group. In contrast,women whose incomes are below the poverty line are considerablymore likely to be overweight than women earning higher incomes, andare more than twice as likely to be obese (28.7 percent versus 13.7 per-cent). In a study of young adults, ages 16-28 years, poverty and low pa-rental education were associated with obesity in White and Hispanicwomen, but not in men.16 No associations were observed in AfricanAmerican women either, suggesting that race/ethnicity modifies the ef-fects of gender on obesity risk.

Studies of children have also reported racial/ethnic differences in therelationship between SES and weight status, with the differences morepronounced for girls than for boys.10,17,18,19 Among White children, aninverse association between SES and weight status has been consis-tently observed among both boys and girls.17 However, among AfricanAmerican children, no association is apparent for boys or girls.17

Among Hispanic children, overweight prevalence is higher in boysfrom middle and high income families than boys from low income fami-lies, while it is similar across all socioeconomic groups in girls.

The pathways by which race/ethnicity and SES may relate to weightstatus appear to be complex and are not yet fully elucidated.20 Culturaldifferences in acceptable body size and preference for thinness may par-tially explain racial/ethnic differences in the associations of SES withweight status.21 Studies suggest greater acceptance of larger body sizesamong African American and Hispanic women22,23 and that this accep-tance declines with acculturation.24 Cultural traditions can also stronglyinfluence eating and physical activity behaviors related to obesity. Forexample, traditional cultural connectivity and support has been shownto ameliorate the limitations associated with inadequate financial re-sources for healthful food.25

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Most studies of SES in relation to obesity have been cross-sectional,precluding making conclusions about the direction of the relationship,which may be bidirectional. Several mechanisms for explaining the as-sociation between SES and weight status suggest that SES acts onweight. One explanation is based on the framework that higher educa-tion provides the educational and social network helpful for improvinghealth behaviors.26 Another suggests that having more income simplyallows greater access to healthy food choices, opportunities for exer-cise, and better access to health care.27 A third suggested mechanism isthat low SES has a significant psychosocial impact on health28 and thatchronic psychological stresses may contribute to emotional eating.29

However, obesity may also contribute to lower earning potential andconsequently reduced economic status through size discrimination.Size-based stereotypes are evident even among young children.30 Obe-sity has been associated with a reduced likelihood of marriage, and withemployment and wage disparities.31,32 After controlling for householdincome and grades, parents have been found to provide less college sup-port for overweight as compared to thinner children.33 In one longitudi-nal study of young adults, in comparison to their thinner counterparts,obese individuals experienced a persistent reduction in wages over thefirst 20 years of their careers.34

MODIFIABLE CONTRIBUTORS TO THE OBESITY EPIDEMIC

Although genetics play an important role in weight status, genesalone do not explain the recent acceleration in obesity rates. To betterunderstand the accelerating rates it is important to examine changes inthe environment that may be associated with changes in weight-relatedbehaviors.

A Changing Food Environment

Changes in our family life, daily activities, employment, and changesin our commutes all affect our patterns of eating. Increased portion sizesand energy density of our foods have undoubtedly contributed to the ris-ing per capita calorie consumption documented over the last 20 years.35

Even very small increases in caloric intake over time can ultimately re-sult in significant weight gain. For example, an inadvertent increase ofjust 50 calories per day can result in a 5 pound gain in body weight in ayear.

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Convenience foods, high in fat, sugar, salt, and calories, are increas-ingly commonplace in our society. Annual increases in the variety offood products available in the market are staggering; in 1995 alone,16,900 new food and beverage products were introduced.36 Obesitypromoting energy dense foods provide an inexpensive source of calo-ries37 and are frequently consumed at the expense of more nutrient-dense foods, increased calorie consumption, and reduced micronutrientintake.38 Both children and adults are eating more frequently as a resultof increased snacking,39 often contributing to increased consumption ofhigh calorie foods of low nutritional value. Energy dense, nutrient poorfoods selected because they are inexpensive and readily available maybe promoting obesity in our economically disadvantaged population.

Frequent consumption of food from fast food restaurants has been as-sociated with adiposity. Both adolescents and young adults are obtain-ing less of their energy intake at home and more at restaurants and fastfood places.40 Portion sizes have also increased30 and patrons are oftenencouraged to purchase meals that contain more calories through“value” marketing or “super sizing.” Further, fast food and restaurantfoods are typically calorically dense, nutrient poor, and highly palat-able41 and frequent patronage has been associated with diets high in fatand calories.42 Children who eat at fast food establishments two or moretimes a week are more likely to increase their relative BMI than thosewho patronize fast food establishments once a week or less.43 Similarly,adults who more frequently eat restaurant food are more likely to haveincreased body fat.44 On average, African Americans eat fast food moreoften than Whites;45 acculturation among Asian American and Hispan-ics is also related to increased fast food restaurant patronage.46 Further,low-income and predominantly African American neighborhoods tendto have a substantially higher density of fast food restaurants thanhigher income and White neighborhoods.47,48

Increased sweetened beverage consumption is clearly contributing tothe rise in obesity levels.49 Over the last 20 years it has been estimatedthat increased sweetened beverage consumption has lead to a rise in in-take of approximately 80 calories/per capita. NHANES III data indicatethat sweetened beverages have replaced milk as the primary beveragefor many children, with African American and Hispanic adolescentsconsuming more sweetened beverages than White adolescents,6 differ-ences that can begin as early as toddlerhood.50 Consumption increasesare attributed in part to the very low cost of high fructose corn syrup.51 Itmay be physiologically more difficult to compensate for energy con-sumed as a liquid than as a solid,52 resulting in daily increased energy

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intake with consumption of sugar-sweetened beverages.53 Positive as-sociations with sweetened beverage consumption and overweight havebeen observed in ethnically diverse children.54 Declining dietary cal-cium levels may put children at increased obesity risk55 as well as otherhealth risks, including increased osteoporosis risk later in life.56

Low consumption of fruits and vegetables has been found to be in-versely associated with childhood overweight.57 Lower intakes of fruitsand vegetables are reported by persons of low SES58 and ethnic minori-ties.59 Both the cost of fruits and vegetables and the lack of availabilityin low-income neighborhoods may contribute to lower intakes.60-62 Inone study, intake of fruits and vegetables increased by 32% for each ad-ditional supermarket in the census tract, providing strong evidence thatthe local food environment impacts the diets of residents.63 Health pro-moting fruits and vegetables can be a costly way of obtaining caloriesand persons of low income, by necessity, seek economical ways of ob-taining calories.

A Changing Physical Activity Environment

Changes in how we live and work impact not only how we eat butalso the number of calories we burn. Television, computers, the auto-mobile, and labor-saving devices of all kinds have all been implicated inour increasingly sedentary lifestyles. Additionally, reductions in physi-cal education in schools as well as outdoor play, walking, and bikinghave contributed to an inactive generation of children.

Physical activity confers many health benefits; however, the majorityof adults in the U.S. are not physically active enough to reap such re-wards.64 Physical activity is inversely associated with overweight re-gardless of gender and racial/ethnic group.65 Physical inactivity ishigher among African American and Mexican American adults thanWhites.66 In a study of ethnically diverse adolescents, a low level of vig-orous physical activity was a significant risk factor for high BMI67 His-panic and African American students (11.2 percent and 12.9 percent,respectively) were significantly more likely to report no vigorous ormoderate physical activity compared to White students (8.2 percent).68

Leisure time physical activity has been shown to decline in both AfricanAmerican and White girls ages 9-19, but the decline for African Ameri-can girls is greater.18 Fitness testing of 5th, 7th, and 9th grade students inCalifornia, for example, found fewer White children unfit (33.5 per-cent) as compared to Latino (44.5 percent) and African American chil-dren (46 percent),69 corroborating other findings that on average ethnic

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minority children participate in less physical activity than Whitechildren.

In recent years, schools have reduced physical activity programs, of-ten citing the need to cut non-academic programs due to budgetary con-straints. Nationally, the number of students participating in physicaleducation (PE) classes has notably decreased;70 only 8.0% of elemen-tary schools, 6.4% of middle/junior high schools, and 5.8% of seniorhigh schools currently require daily PE.71 Emergent research points todisparities in access to physical activity facilities as risk factors forphysical inactivity and overweight. Public housing complexes tend tohave limited access to healthful foods, as well as limited resources forphysical activity.72 Lower income and minority neighborhoods fre-quently have fewer parks and other facilities for physical activity andthose that are available often have lower quality, appeal, and safety fac-tors which substantially deter usage by residents.73-75 Parental concernsabout neighborhood crime and safety deter children from playing out-side and walking to school.76

Ethnic differences are greater for sedentary than for moderate to vig-orous physical activity. Data from ethnically diverse adolescentsshowed that, with the exception of Asian females, minority youth hadconsistently higher levels of sedentary activity.50,77-79 Sedentary activ-ity, particularly in the form of TV viewing, now dominates the leisuretime of many. A direct association between TV viewing and increasesin BMI may be a result of the combination of inactivity and low levelsof physical activity.80 Consistent associations between TV hours andoverweight have been observed.81-83 TV/video viewing time was higheramong African American and Hispanic versus White children and in-creased with the child’s age.85,86 For each additional hour of watchingTV per day, a preschool child’s odds of being at risk for overweight in-creased by 6 percent.87 Children who had a TV in their bedroom wereeven more likely to be overweight than those who did not. Further, Afri-can American and Hispanic children were more likely to have a TV intheir bedroom than White children.

The impact of television viewing may be more significant thanvideogame playing because it can reduce energy expenditure and in-crease energy intake. TV influences the type and amount of foods con-sumed by viewing children.88 A typical child watches about 40,000commercials on TV each year, a number that has doubled during theyears that have seen a large increase in the rate of pediatric overweight.Commercials increase children’s request for and consumption of thehighly advertised food products.89-91 Fast foods, snack foods, and

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highly sugared foods are among the most heavily advertised items onchildren’s television programs. Few advertisements promote the intakeof health-related foods or physical activities. Indeed, TV viewing inchildren has been related to a higher intake of fats, sweets, salty snacks,and fast food, and a lower intake of fruits and vegetables.92,93 TV view-ing has also been related to increased energy intake among adults.32

Disturbing is the finding from content analyses that television program-ming marketed at African Americans, for example, has significantlymore food and beverage advertisements for unhealthful foods than gen-eral market programming, including programming targeting chil-dren.94,95

SOLUTIONS TO THE OBESITY EPIDEMIC

Prevention Is a Priority. Treatment of overweight is important to pre-vent the co-morbidities associated with excessive weight. However,prevention programs must be a societal priority. Population preventionprograms with very small impacts greatly outweigh the benefits of treat-ment programs targeting patients on an individual basis. Avoiding un-healthy habits before they are adopted is less challenging than reversingalready entrenched ones. Further, population prevention programs po-tentially benefit all regardless of weight status since less than 5% of theU.S. population eats according to the dietary guidelines96 and less thanone-third report adequate levels of physical activity.97

Health Education Needs Are Changing. Health education, particu-larly in the development of media savvy consumer skills, has neverbeen more necessary. Mass media, including Internet sources, are in-creasingly accessible and influential sources of health information.98

There are more health-related magazines and journals, books and audio-visual productions every year, nearly 100 national organizations, andcountless web-based sources of information.99 Americans spend bil-lions of dollars yearly in the weight loss market. How to critically evalu-ate health claims and distinguish between sound and questionableadvice is paramount. In addition, due to increasing market place choicesand competing demands, focus needs to be not merely on what to do,but how to do it. The concept that ‘all foods fit,’ while demonstrablytrue as evidenced by our collective expansion of waistlines, has notproven to be very useful consumer guidance. Instead, how to preparehealthy meals, shop for, select, and store healthy foods, how to orderhealthy foods in restaurants on a limited budget, and how to model

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healthy behaviors to children are examples of practical tips that con-sumers are lacking.

Environmental Change Is a Priority. Recent increases in obesityclearly point to environmental determinants; emphasis must be placedon changing our surroundings and creating new ones that are not onlysupportive of healthy lifestyles, but promote healthful choices. The rec-ommendations listed in Table 1 were formulated in part from several re-cent reviews including the Task Force on Community PreventiveServices on school and worksite interventions for overweight,100 andthe American Dietetic Association Position Paper on family, school,and community-based intervention for pediatric overweight.101 Prioritywas given to those recommendations that impact the environment foroverweight prevention among the greatest number of low-income andhigh risk populations.

Solutions Must Involve All Sectors of Society. Because the determi-nants of obesity are numerous and complex, attempts to address thisgrowing problem require a coordinated multi-faceted and multi-levelapproach. Proactive roles for all sectors of society–health care, schools,community, governmental agencies, and policy makers–must be in-cluded as shown in Table 1.

Health Care. Prevention must play a more important role in ourhealth care system. Weight loss is difficult and maintenance ofweight loss is even more challenging. Health care providers shouldtake a proactive approach, tracking the BMI of their patients and pro-viding “prescriptions” for healthy food consumption and exercise.Providers who work with young women should encourage healthyweight gain and eating during pregnancy, monitoring for gestationaldiabetes in at-risk mothers and promoting breastfeeding, both ofwhich have been shown to be protective measures against childhoodoverweight.102-105

Schools. Schools are a logical target for health promotion interven-tions in children and their families. Schools offer many advantages in-cluding a ready-made learning environment through the classroom,activities through physical education courses, and food supplied on sitethrough school cafeterias. School-based programs should target chil-dren’s behaviors through classroom-oriented activities and environ-mental changes (i.e., increase physical activity in physical educationclasses or change the foods offered in the school cafeteria). Individualschools and school districts should be supported in their attempts to pro-vide nutritious foods to their students. Schools need adequate financialsupport so they are not dependent on corporate sponsorship that pro-

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In Review 39

TABLE 1. Recommended Actions to Reduce Disparities in Obesity by Sector

Health care and health care providers:1. Provide tools needed to include risk for becoming overweight as an integral part of stan-

dard medical care.

2. Support educational interventions as an integral part of standard medical care.

3. Support educational interventions that provide early parent education concerning the riskfactors for overweight, and appropriate nutrition and physical activity for developing chil-dren.

4. Develop and implement clinic-based programs that utilize clinically proven and scientifi-cally tested approaches for disadvantaged populations.

5. Develop a payment system and referral network for nutrition and physical activity coun-seling.

6. Offer health expertise to schools and assist with and setting school policies.

7. Partner with community organizations for health fairs, health education, and screeningevents.

Schools and educators:1. Support parent education concerning healthy lifestyles.

2. Monitor the school environment with respect to nutrition and physical activity.

3. Promote and implement coordinated school health programs and curricula that includephysical activity, school foodservice, classroom curriculum, health services, and staffwellness.

4. Support creating a healthy nutritious school environment by providing options for schoolmeals that meet USDA/Dietary Guidelines, regulating competitive foods and vending inschools and at school events, and making healthful foods available at school and schoolevents.

5. Encourage non-food incentives for academic achievement and positive behavior.

6. Support provision of increased opportunities for physical activity during the school day toachieve at least one hour of physical activity per day, and encourage physical activitiesthat are developmentally appropriate and inclusive.

7. Support media uses and messages in school that promote healthy eating and physicalactivity.

8. Teach critical thinking skills related to advertising for foods, diets, and other health-relatedproducts and services.

Community stakeholders:1. Support coordinated school health in grades K-12.

2. Support adequate school financing so that schools do not have to rely on sales of un-healthy foods on school premises.

3. Support public policy initiatives to encourage financial compensation for medical monitor-ing of overweight risk.

4. Encourage financial support for the creation of safe environments to promote physicallyactive lifestyles.

5. Advocate for nutritional menu information at restaurants.

6. Promote media campaigns to promote increased physical activity and healthy eating.

7. Support food labeling, packaging policies, and restaurant policies that provide appropri-ate portion sizes.

8. Advocate for federal regulations of media exposure and advertising to children.

9. Advocate for federal legislation to add fruit and vegetables to the WIC food package.

10. Advocate for changes in zoning to promote healthful environments.

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motes the consumption of less nutritious foods and beverages. Further,adequate funding must be made available for physical education pro-grams that reach all youth. Less participation in physical activities inschool physical education experienced by low-SES children106 may bea contributor to their higher obesity rates.

Community and Governmental Agencies. Community and govern-mental organizations, particularly those whose clientele includes low-income families and ethnic minorities, should play an active role inoverweight prevention. Girls from food-insecure households who par-ticipated in the Food Stamp Program and the national school lunch andbreakfast programs reduced their odds of being at risk for overweightby 68 percent when compared with food-insecure girls in nonparticipat-ing households.107 The WIC program, serving low-income mothers andyoung children can be an important venue for the provision of obesityprevention information for families.108

Governmental bodies that set broad policy goals and determine fi-nancial priorities can provide leadership in dealing with the issues ofchildhood obesity. Local government through its zoning and regulationauthority can positively impact access to nutritious foods in low-incomecommunities. State governments are becoming increasingly involvedwith legislation regulating school food and physical education require-ments.

CONCLUSION

While the media focus on the increase in obesity rates, little is knownabout the increasing disparities in the prevalence of obesity. The mostrecent data show significantly higher rates of increase for AfricanAmericans and Mexican Americans than Whites. Of most concern arethe dramatic obesity disparities during the childhood years. Even thedegree of tracking from childhood to adult obesity is greater for AfricanAmerican children with predictive values of 84 and 82 percent for girlsand boys, respectively, versus 65 percent and 71 percent for White chil-dren.109 With the high obesity rates of childhood showing high predic-tive values in tracking, we can expect continual increases in adultobesity, with all of the associated co-morbidities. While the trajectoryof weight change often accelerates during the middle of the adult years,it is not clear how heavy adults will become when their obesity is initi-ated in childhood. The answer to this question will become obvious in

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the next decade when the surge of overweight children from the 1980sand 1990s approach middle age.

As increases in obesity are a relatively recent phenomenon, it is be-lieved that the interaction between biological and social factors is op-erating in a changing environment that is increasingly conducive toinducing obesity. We must examine environmental changes which im-pact racial, ethnic, and economic groups differentially, changes medi-ated by differences in resources and education. When crises inunemployment or family income, housing or medical care arise, thenexercising with children may seem less important to families. Whenmoney for all necessities is short, then spending more for fresh fruitsand vegetables may seem unimportant to families. Different patterns ofdietary intake have been demonstrated to result, at least in part, fromcost factors and poor food access. The negative impact of an energydense, nutrient poor diet is exacerbated by lower physical activity in thelives of many low-income individuals.

It is clear that environmental and societal changes to promote healthyweights are the most effective way to reach low income, immigrant, andracially/ethnically diverse populations. Specific examples of actionablesteps to reduce disparities in obesity are listed in Table 1. Further, thereare resource centers, such as the University of California at Berkeley’sCenter for Weight and Health, which specifically address ways to re-duce disparities in obesity. On the national level, initiatives such as theChild Nutrition and WIC Reauthorization Act of 2004 are likely to im-pact school environments, and the recent report by the Institute of Medi-cine on food marketing to children is likely to impact the mediaenvironment for our nation’s youth.

Prevention of obesity is unlikely to succeed if we do not focus on theenvironment where people live and the context within which they makedecisions. We must acknowledge that the increases in obesity were notcaused by people taking less personal responsibility for their well-beingand, accordingly, obesity will not be reduced by an appeal for people totake more personal responsibility for their actions. Our nation’s eco-nomic and social environment must support people in their actions to-ward achieving and maintaining healthy lifestyles. Without this, we willall pay the future social and economic costs for conditions that are theconsequences of an overweight society. In the words of one expert, “Ifyou have malaria, you drain the swamp. If you have death on the roads,you impose seatbelts . . . Like any epidemic, we need to change the envi-ronment.”110

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Received: November, 2005Revised: April, 2006

Accepted: May, 2006

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