Spinner J. What is making Black women fat? An examination of the impact of race and racism as contributing factors to overweight and obesity health disparities. HPHR. 2021;35.
Compared to other racial and ethnic minority groups, Black women have higher rates of overweight and obesity (OVO). While many reasons exist for these high rates of OVO, this article takes a deeper look into the social determinants of health that contribute to OVO, focusing on the impact of race and racism, while also providing tangible strategies that can help close the health disparity gap.
Race and racism have been long standing issues in America, leading to Black women being marginalized and disenfranchised for generations. Due to historical abuses and discriminatory policies, Black women may live in areas that lack access to quality school systems, nutritious food options, culturally competent health care providers, safe housing or greenspace to engage in physical activity, for example. All of which can lead to unhealthy decision making leading to unwanted weight gain and chronic diseases like diabetes or hypertension. Even for affluent and well-educated Black women, the negative impact of racism can still be felt.
To combat this problem, action-oriented, forward-thinking solutions need to be implemented at all levels to ensure Black women can live in communities that support healthy decision-making practices. Public Health Practitioners should focus their efforts on advocating and implementing policies that enable Black women to make healthy decisions at all levels, designing and implementing culturally relevant health education and promotion programs and resources that meet the needs of Black women, and training healthcare providers and others to provide culturally competent care and services for Black women to support healthy weight management.
Overweight and obesity continues to be a challenging and pressing public health problem. Black women have the highest rates of overweight and obesity (OVO); 80.6% compared to 78.8% of Hispanic women and 64.8% of non-Hispanic White women. These OVO health disparities are consistent regardless of education and income status (Centers for Disease Control and Prevention, 2019).
While there are many factors that feed into the equation of why Black women are bearing the burden of this epidemic, one key contributor is racism. Diseases do not discriminate, but the system in which Black women receive care does. Moving forward, public health practitioners, medical professionals, policy-makers, and others working to address this problem need to recognize that race and racism are critical areas that should not be overlooked and should be tackled head-on. We cannot be afraid to utter the words “racism” or continue to ignore the effect it has on health outcomes.
We can no longer live in a world where we pretend to be “color-blind” and think that everyone is treated equal, when in fact we need to be focused on creating equity-based solutions that meet the health needs of Black women. Health equity as defined by the Center for Disease Control and Prevention is when every person has the ability to “attain his or her full health potential” and no one is “disadvantaged from achieving this potential because of social position or other socially determined circumstances. Therefore, solutions to reduce OVO disparities should address the root causes of OVO and as a result, produce culturally tailored strategies that resonate with Black women so they can better manage their weight. Patient-centered care, where Black women are involved in making informed decisions about their health with their healthcare team, is also imperative to moving the needle forward. One-size-fits-all approaches rarely work, which is why we are seeing a push for precision medicine and personalized medicine.
Black women experience many social inequities— one of which is racism— which is one contributing factor to the social determinants of health. Social determinants of health are those conditions in which people live, work, play, and worship (Office of Disease Prevention and Health Promotion, 2020). Of concern is the impact racism has on Black women’s ability to effectively prevent, manage, or treat obesity. This article will delve deeper into the intersection of race, racism, and weight status (e.g., overweight/obesity) among Black women living in America, highlighting strategies to address this problem and providing historical context of how the problem arose.
Obesity is a complex medical condition that has a myriad of causes, some modifiable and others non-modifiable. Non-modifiable factors are things that people cannot change, such as genetics. Modifiable factors, on the other hand, can be controlled by the individual; examples include physical activity and food consumption. Most people living with OVO struggle for long periods of time or even their whole life to manage and/or maintain a healthy weight. Carrying excess weight can oftentimes trigger long-term health issues such as diabetes, hypertension, or high cholesterol, which can lead to heart disease- the number one cause of death in the United States. Living with OVO can take a toll on mental health, exacerbating mental health issues, such as depression and anxiety (Bertakis & Azari, 2005), and lead to social isolation, worse maternal outcomes (infertility, preterm births), and/or self-deprecating behaviors, such as making fun of one’s self, as a coping mechanism. Treating and managing these conditions puts an increased financial strain on the healthcare system ($147B spent annually) and worse yet, contributes to increased morbidity and mortality in the Black community (Bertakis & Azari, 2005; Bhaskaran, 2014; Centers for Disease Control [CDC], 2016, 2020; Cawley & Meyerhoefer, 2012; Finkelstein et al., 2009; Luppino et al., 2010; National Heart Lung and Blood Institute, 2012; Shook et al., 2014; Thomas et al., 2007; Tremmel et al., 2017; Trogdon et al., 2008; Ul-Haq et al., 2012; Whitaker et al., 2014; Winston et al., 2014).
While the equation for managing weight is simple —calories in versus calories out— the reality remains that it is much more complicated and nuanced. The ability to engage in healthy behaviors is often governed by social determinants of health, which, in many cases, are outside of a person’s control. Approximately 40% of health outcomes are directly related to these social and economic factors. Other factors that contribute to health outcomes include health behaviors (30%), clinical care (20%), and the physical environment (10%). Given that social determinants of health are the dominant factors leading to poor health outcomes, it is important to invest resources to address these issues (Braveman et al., 2011; Magnan, 2017; Shook et al., 2014; Trust for Americas Health, 2014). One of those factors that are of concern is the impact of racism on weight management.
There is a growing body of evidence that documents the connection between racism and poor health outcomes (Paradies, 2015). Racism happens when a group of people, particularly people of color or marginalized groups, are antagonized, discriminated against, and subjected to prejudice because of the color of their skin. The underlying premise is to infer that one group of people is inferior to another group simply based on skin color or on race. This type of detrimental thinking and the actions that result from it, lead to the inequitable distribution of power, influence, access to resources, and opportunities that further widen the health disparities gap (Paradies, 2015).
Race is complex and evolves over time. The concept of race inherently embodies the “sociopolitical and economic struggle enacted against specific groups of people” (Knox-Kazimierczuk et al., 2018, p. 371). Race is a social construct that does not have a biological meaning and was designed to separate groups and thus, perpetuate racism. It is a weak proxy at best, to describe genetic diversity. Sadly, it has been used as a divisive tool to create a system of oppression that makes it hard for Black women to thrive and live healthy lives.
In this country, race and race relations have been long-standing issues since slavery. Oftentimes, Black people are viewed as violent, lacking motivation, or lazy, and this is associated with higher body mass index rates, which is the primary measure of obesity (Knox-Kazimierczuk et al., 2018). Two terms that help frame this issue are racial salience and racial regard, both of which can impact weight status. Racial salience is the extent to which a person’s race is a relevant part of their self-concept; racial regard is a person’s affective and evaluative judgement of their race (Knox-Kazimierczuk et al., 2018). Racial identity can be associated with how a person interacts and engages with a group, and this is connected to the adoption of similar food practices, such as the consumption of high-density foods and beverages (Knox-Kazimierczuk et al., 2018).
Racism, whether overt or covert, can take on many forms but ultimately leads to damaging practices, policies, and laws that can negatively impact the health of Black women. This can result in resources and opportunities like employment, health insurance, culturally competent healthcare providers, or bank-financed loans to secure business or properties being deliberatively withheld and made difficult to access. The lack of these resources further perpetuates the cycle of disadvantage and disenfranchisement (Braveman et al., 2011), and this can lead to Black women living in neighborhoods that may lack basic resources, such as quality schools, safe and reliable transportation and housing, access to green space for physical activity, and quality food options (e.g., grocery stores or farmer’s markets) that have fresh and healthy food choices, and all of these are social determinants of health, which lead to high rates of OVO.
Chronic exposure to racism, whether overt or covert, can lead to increased levels of stress for many Black women (Braveman et al., 2011). This type of stress is known as allostatic load, which is an accumulation of physiologic stress and can be a contributor to obesity (Tan et al., 2017). Ironically, living with persistent chronic stress is more harmful than withstanding one major traumatic, stressful event. In the case of enduring long-term stress, the body never has an opportunity to fully restore itself and heal (Braveman et al., 2011). Daily challenges of living as a Black woman in America, coupled with managing a household, finances, medical, and relationship issues, among others, can be stressful. Allostatic load is related to the weathering hypothesis first presented by public health researcher, Arline Geronimus in 1992. Weathering refers to the deterioration of the health of Black people due to the experiences of marginalization and social or economic adversity (Geronimus et al., 2006; Tan et al., 2017). Being chronically exposed to racism and socioeconomic adversity is harmful and slowly eats away at one’s health, leaving behind an unhealthy body ladled with chronic diseases. Enduring stress can result in increased levels of stress hormones (e.g., cortisol) and inflammation, changes in how sugar is processed, and increased abdominal fat (a predictor of chronic disease risk). Coping with stress can lead to unhealthy eating habits, the lack of motivation to engage in physical activity, and poor sleep habits, leading to unwanted weight gain.
The question at hand is, how can Black women get adequate care in a system that is designed to set them up to fail—physically, mentally, and emotionally? The U.S. infrastructure is rooted in racist laws, policies, and actions that have historically led to an interlocking system of oppression that leaves Black women disadvantaged, unable to have equitable access to quality healthcare, education, and income opportunities for example, that can support healthy decision-making.
Racism is a contributor to the disproportionate rates of OVO among Black women. These documented health disparities are challenging to erase with the amount of historical baggage that needs to be overcome. Since the beginning of time, Black women have been marginalized, ignored, and mistreated. Having to constantly endure this type of stress can take an emotional toll on one’s body, leading to poor health outcomes and unhealthy decisions regarding maintaining a healthy weight (e.g., emotional eating).
Let us take a deeper look into a few policies and practices contributing to health disparities for Black women. Below are three examples of how such disparities are created, recognizing that many more exist.
Zip codes determine life expectancy and health status (Robert Wood Johnson Foundation, n.d.). Redlining is one of many historical practices that have created a wealth gap in the United States due to discriminatory practices that denied Black people access to services (e.g., financial) based on their race. A prime example is the denial of loans and access to credit to Black people by mortgage lenders or charging Black people higher interest rates to purchase homes. It can also happen when real estate agents refuse to show certain homes to people of color. There were literal red lines drawn on city maps to indicate certain neighborhoods where institutions did not want to lend money to residents, who were mostly Black. The Fair Housing Act of 1968 was established to prohibit these types of discriminatory practices. However, the effects of these practices can still be felt today. These effects include the lack of home ownership, resulting in more Black women living in communities that are typically disinvested in and characterized by food deserts with an overabundance of liquor and corner stores lacking quality food.
While the Affordable Care Act of 2010 made health insurance coverage accessible to millions of Americans, the health insurance gap still exists for Blacks. Black people are less likely than their White counterparts to have health insurance coverage and are also less likely to seek out medical care due to the exorbitant costs of care to prevent, treat, and/or manage chronic diseases, such as obesity, and their associated risk factors (Buchmueller & Levy, 2020). Healthcare is a basic human right that everyone should have, regardless of race. Access to care leads to earlier screening and prevention efforts that can help proactively address OVO and its associated risk factors.
Institutional racism has been the ugly thorn in America’s healthcare system for generations. These systems have allowed for physicians’ implicit biases to remain unchecked over time. Implicit bias, which is the unconscious acting on internal biases that are based on prejudices and stereotypes and occur when a person has a preference for or aversion to a group of people, can oftentimes be rooted in moral judgements and cultural biases instead of science and research (Stanford et al., 2018). The level and quality of care a person receives can be greatly diminished if the provider has implicit biases (Stanford et al., 2018). For example, a physician may spend less time interacting with a patient or humiliate a patient due to their weight or race, ultimately reducing the person’s ability or willingness to interact with the healthcare system and seek weight loss services (Teachman & Brownell, 2001; Thomas et al., 2007, Hart et al., 2016; Stanford & Kyle, 2018). Bias goes both ways, impacting the level of care given by the physician and hindering the patient’s ability to engage with the medical care system.
The examples presented here are the tip of the iceberg; many more exist that need to be addressed. However, they highlight and show how unresolved systemic issues can continue to have damaging effects on Black women’s health and wellness. Realizing health equity will only be possible when culturally relevant, forward-thinking solutions are implemented at the individual, organizational, community, and systems/policy level that enable and support Black women to make healthier decisions.
There are many strategies that can be implemented to address OVO health disparities. Below are three examples of strategies that can help solve the OVO related health disparities problem for Black women:
Social and cultural factors are major driving forces that influence Black women’s ability to adopt healthy behaviors to manage their weight. Weight management programs and resources should focus on how and why Black women make decisions. There needs to be a concerted focus on incorporating motivating factors that influence health behaviors, many of which are driven by social and cultural factors. Embracing Black women’s values and traditions, such as collectivism and socialization, cooking soul food, and values around healthy bodies (not skinny bodies) can enhance health promotion efforts and help lead to sustainable behavior change. Black women’s culture should be celebrated and included as part of the program or materials developed. They should also be engaged at the inception of the program to ensure the materials and resources meet their needs. Images that reflect their diversity in terms of skin colors, body types, and hair textures for example should be appropriately embedded into the materials so they can see a reflection of themselves and better connect with the content. Also, easy-to-read the plain language, familiar colloquialisms, and other cultural terminology and references should also be included. The goal is to make the material relatable and action-oriented while preserving their cultural identity to allow space to adapt traditions and cultural norms into healthier practices.
This is not a new concept but a strategy that can be employed at the systems level. However, it can be hard to implement because it requires work from multiple sectors, especially those that are not traditionally designed to address health outcomes (e.g., transportation or education). Notable organizations like the American Public Health Association and the World Health Organization have supported this framework. There needs to be an all-hands-on-deck approach to ensure that all sectors can effectively connect Black women to credible and authentic resources that address their unique needs. Policies that address the environmental conditions in which Black women live (e.g., social determinants of health), need to be enacted across all sectors. For example, zoning laws should be mindful of grocery store placement to ensure equitable access. Transportation needs to be reliable and accessible. Housing should be safe, affordable, and conducive to health (e.g. adequate lighting and walking paths or playgrounds). Health insurance should be available to all regardless of employment status (which is where most people gain access to health insurance). These are a few examples of how health in all policies can address the health needs of Black women. Regardless of socioeconomic status, Black women should not have to endure living in food deserts and lack access to transportation, education, and safe housing, etc. due to the aftermath of detrimental policies (e.g., redlining) that have prevented Black women from having equitable access to education, housing, and income—all of which impact their health status.
Providers need to understand and be educated on why Black women are at increased risk for OVO. A diverse workforce that is reflective of the community being served is important to improve health outcomes. Research shows that Black patients have better provider relationships with providers who look like them, likely because they share a common cultural background. Medical education curricula need to focus on training physicians to address their implicit biases and to become more culturally aware. Doing so will improve their communication with patients, increase adherence to treatment plans, and improve health outcomes overall.
The culmination of implementing culturally relevant and timely studies, policies, and programs that address the social determinants of health—the root causes of OVO—will bring about the change we need to realize a future of healthy Black women.
The findings from this article were supported in part by my doctoral research, which examined the social and cultural factors that impact the weight status of Black women living in Prince George’s County, Maryland. This research uncovered insights into Black women’s decision-making processes around managing their weight through their health behaviors (e.g., physical activity and eating habits). As part of the literature review, race, racism and the connection to stress were salient driving forces of OVO in Black women. This article takes a deeper look into those factors and provides tangible solutions to address this epidemic. As a public health strategist, it is my mission to ensure that equitable resources, materials, and programs are created and disseminated to help reduce health disparities and ensure Black women are able to live their healthiest and fullest lives.
My career has been dedicated to interacting and engaging with diverse stakeholders and leading equity-driven conversations that have real-world impact. Solving the obesity crisis, reducing health disparities, and improving health equity is a tremendous feat, but progress can be made if we work collectively. After such efforts, we can start to see real improvements in the environments where Black women live, work, play, and worship. Hence, they will be able to make informed decisions about their health, leading to a reduction in OVO rates and chronic diseases, ultimately leading to healthier communities and better qualities of life.
Dr. Jovonni Spinner is a results-driven, award winning visionary public health strategist committed to improving health equity across the life span. She creates culturally competent health education and training programs and leads equity-driven conversations advocating for minority health. She builds multi-sector partnerships and oversees long-term strategic plans, guided by scientific evidence and regulatory policy to implement balanced decisions.
While at the Food and Drug Administration, she uses a people-centric leadership style to inspire and boost team performance, build organizational culture, facilitate change management, and nurture talent. All while shifting mindsets of colleagues and advising senior leadership to use an equity lens to address health disparities, policies and systematic change.
She has led state and national health programs like the FDA’s Diversity in Clinical Trials Initiative, NIH’s Community Health Worker Health Disparities Initiative, and Virginia’s Vaccines for Children Program; reaching millions of consumers to help each make better informed health decisions, obtain health services, and advocate for healthier communities.
She is an alum of Virginia Commonwealth, Emory, and Morgan State Universities; remains active in her community serving on nonprofit boards, writing women’s health articles, mentoring early-career professionals, and serving as a public health adjunct professor.