Man Leading a Donkey in Front of the Palais de Justice, Tangier

Recognizing Systemic Racism in Obesity Care

This is not hard to see. But recognizing and dealing with effects of systemic racism in obesity care is not so easy. Black and Hispanic communities have a much higher prevalence of obesity and its complications. But they have much less access to effective obesity care. The outcomes for that care are worse in these groups. As with everything else in obesity, many factors play a role. However, a common thread in obesity care and its outcomes ties to systemic racism.

Long-Standing and Systemic

Writing in Cell Metabolism, Sara Bleich and Jamy Ard explain this common thread. In fact, they note that many years of systemic inequalities have produced disparities in the burden of chronic diseases, including obesity:

“Long-standing systemic inequalities – fueling unequal access to critical resources such as healthcare, housing, education, and employment opportunities – are largely responsible for the significant race disparities in obesity and COVID-19. Because of this legacy, public health emergencies like the COVID-19 pandemic disproportionately impact communities of color, exacerbated by high rates of pre-existing chronic diseases like obesity.”

Social and Economic Disparities Manifest in Health

Race is not a biological construct. It is social and cultural. However, systemic racism translates those social and cultural into different biological outcomes. Racism and discrimination quite literally make people sicker. It is a biological stress response to toxic social and cultural factors.

And thus we can easily see differences in responses to obesity care. A lifetime of living with racism has an effect on physiology. For example, Nawfal Istfan et al documented that African American patients having bypass surgery enjoyed less metabolic benefit from the surgery than non-Hispanic Whites. Though Black patients also tend to have less weight loss than Whites, this difference does not fully account for the different metabolic responses.

Systems of Care

When you get right down to it, systems of obesity care subtly but systematically favor White women. These are the people who enroll in clinical trials for new obesity treatments. In the landmark study of semaglutide published last week, for example, less than six percent of the patients were Black.

Adolescent bariatric surgery can be life changing for the teens who really need it. But most of the patients who receive it are White. Even though obesity disproportionately affects Black and Hispanic teens, they are half as likely to receive surgery as White teens. Numa Perez et al show us that health insurance might explain some of this, but the problem goes well beyond health disparities. Likewise, in adults, Stella Tsui et al find significant economic disparities in access to bariatric surgery. Growth in the use of gastric sleeves primarily benefited patients in high-income zip codes. In lower income zips, patients who did get surgery were more likely to receive less effective options.

Change is possible. For example, Hamlet Gasoyan et al document a substantial increase in Black and Hispanic patients receiving bariatric surgery after Pennsylvania expanded its Medicaid program. But they also saw that patients relying only on Medicare – with no supplemental insurance – were still at a disadvantage.

Far from Simple to Solve

The effects of systemic racism on obesity care are indeed complex. They will not be simple to resolve. But recognizing them and committing to change is a good first step.

Click here for a new systematic review of disparities in obesity and here for the perspective of Bleich and Ard. For perspective on health equity in diabetes and endocrinology, click here

Man Leading a Donkey in Front of the Palais de Justice Tangier, Painting by Henry Ossawa Tanner / WikiArt

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February 15, 2021