Tanya Agurs-Collins, Ph.D., RD
Health Behaviors Research Branch
Division of Cancer Control and Population Sciences
National Cancer Institute, NIH
Susan Persky, Ph.D.
Associate Investigator and Head of the Communication, Attitudes, and Behavior Unit
Immersive Virtual Environment Testing Area, Social and Behavioral Research Branch
National Human Genome Research Institute, NIH
Disparities in Obesity Require Multilevel Approaches
Multilevel Approaches Require More Research
As part of the NIMHD special issue New Perspectives to Advance Minority Health and Health Disparities Research, we and our co-authors focused on designing and assessing multilevel interventions to improve minority health and reduce health disparities.1 Multilevel interventions, based on the socioecological framework2, involve intervening on at least two levels of influence at the same time. We chose this topic because multilevel interventions are an extremely challenging and often expensive undertaking that require myriad decisions and plans, yet it is becoming clear that such interventions are a necessary approach for overcoming great disparities evident in the public’s health, particularly for conditions like obesity.
Obesity is a risk factor for several chronic diseases, including cancer. Approximately 40% of the general U.S. population is classified as having obesity. When racial and ethnic differences are examined, the highest obesity rates are found among African Americans (54.8%), followed by Hispanics (50.6%), Whites (38%), and Asian Americans (14.8%).3 These disparity rates are related in part to major changes in the food and built environments, resulting in excessive consumption of energy-dense foods and physical inactivity, which is more prevalent in minority communities. Although multilevel approaches are taking hold in this area, we still have a long way to go in addressing gaps between majority and minority populations.
Numerous interventions aimed at reducing calorie intake and increasing physical activity have focused on individual-level factors among various racial/ethnic populations. These interventions often hinge on the notion that if we educate individuals about what comprises a healthy diet and enough physical activity, they will change their behavior, resulting in the reduction of obesity. By now, we are well aware that weight and obesity are extremely complex and that this individual approach is insufficient. However, current interventions don’t often consider factors beyond the individual’s control. For example:
- Recommendations to eat a rainbow of fruits and vegetables are useless when these foods are out of reach for financial reasons.
- Suggestions to increase home cooking are not feasible when people commute hours to jobs in high-cost areas.
- Telling people to avoid ultra-processed foods is no match for the incessant stream of advertisements and snack formulations to make those items hyperpalatable.
- Children’s health education can’t be fully effective in schools without physical education and recess.
It’s clear that obesity simply cannot be addressed at the individual level alone, so it is crucial to mount community, neighborhood, and policy-level interventions in combination.
Efforts to study multilevel interventions are certainly emerging. Take, for example, a church-based multilevel obesity intervention with African Americans and Latinos that targets individuals (cooking and nutrition classes), the congregation (fruit and vegetable garden), and the community (mapping of food and physical activity environments). This study found significant weight loss, less weight gain, and healthier diets as a result;4 however, the study had a limited ability to assess intervention effects, due to small sample size, loss of a control church, and uncertainties related to intervention dose and duration.
Another study addressed individuals’ diet and physical activity, groups via civic engagement, and community factors through grocery store audits, environmental assessments, and development of a community guide. This intervention produced significant reductions in body mass index (BMI) and cardiovascular risk factors among rural women in medically underserved areas5 but was not designed to evaluate civic engagement’s independent and additive effects. In another example, researchers targeted African American youth–caregiver dyads in low-income areas. The researchers intervened at recreation centers and small food stores and provided interpersonal support through peer mentoring,6 producing modest reductions in children’s BMI percentiles, but were unable to alter the food environment.
Interventions like these highlight the complexity inherent in undertaking multilevel interventions. As we point out in the paper, there is much work needed to develop multilevel intervention strategies to push forward intervention development, methodology, and evaluation approaches. We challenge researchers to build teams that can develop the needed strategies to enable interventions that broadly consider levels of influence to identify the mechanisms and pathways that effectively reduce health disparities.
- Agurs-Collins, T., Persky, S., Paskett, E.D., Barkin, S.L., Meissner, H.I., Nansel, T.R., Arteaga, S.S., Zhang, X., Das, R., and Farhat, R. (2019). Designing and Assessing Multilevel Interventions to Improve Minority Health and Reduce Health Disparities. American Journal of Public Health, 109(S1), S86-S93. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6356127/.
- Stevens, , Pratt, C. Boyington, J., Nelson, C., Truesdale, K. P., Ward, D. S., Lytle, L., Sherwood, N.E., Robinson, T. N., Moore, S., Barkin, S. Cheung, Y.K., Murray, D. M. (2017). Multilevel Interventions Targeting Obesity: Research Recommendations for Vulnerable Populations. American Journal of Preventive Medicine, 53(1), p.115-124. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5571824/
- Hales C.M., Carroll M.D., Fryar C.D., Ogden C. L. (2017). Prevalence of Obesity Among Adults and Youth: United States, 2015-2016. NCHS Data Brief (288), p 1-8. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/29155689.
- Derose, K.P., Williams, M.V., Florez, K.R., Griffin, B.A., Payan, D.D., Seelam, R., Branch, C.A., Hawes-Dawson, J., Mata, M.A., Whitley, M.D., Wong, E.C. (2019). Eat, Pray, Move: A Pilot Cluster Randomized Controlled Trial of a Multilevel Church-Based Intervention to Address Obesity Among African Americans and Latinos American Journal of Health Promotion 33(4) P. 586-596. Retrieved from https://journals.sagepub.com/doi/full/10.1177/0890117118813333.
- Seguin, R.A., Paul, L., Folta, S.C., Nelson, M.E., Strogatz, D., Graham, M., Diffenderfer, A., Eldridge, G., Parry, S. A., (2018). Strong Hearts, Healthy Communities: A Community-Based Randomized Trial for Rural Women. Obesity (Silver Spring, 26(5), P. 845-853. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5915907/.
- Shin, A., Surkan, P. J., Coutinho, A.J., et. al., (2015). Impact of Baltimore Healthy Eating Zones: An Environmental Intervention to Improve Diet Among African American Youth. Health Education & Behavior, 42 (IS) p. 97S-105S. Retrieved from https://journals.sagepub.com/doi/pdf/10.1177/1090198115571362.