The past few years were filled with many emotions as we adjusted to living through the COVID-19 pandemic. In the US we were also forced to face the lingering impact of residual racism. The negative impact of racism on the present transformed the murmurs of #BlackLivesMatter into a roar that transcends racial lines in the US and beyond. Sadly, the US healthcare system is not immune to the effects of racism. Specifically, in obesity medicine, the impact of racism in part manifests as discrepancies in BMI (Body Mass Index) measurement and disproportionate obesity rates in African American women, which will be discussed in this article. I will also discuss the historical impact of racism, cultural beauty standards, and the clinical implications for obesity treatment in Black women.
Obesity in the African-American Population
According to the most recent NHANES data from the National Center for Health Statistics, non-Hispanic African American women have the highest obesity prevalence at a rate of 54.8%. Interestingly among men, non-Hispanic African Americans report an obesity prevalence of 36.9%. These numbers are lower than non-Hispanic white men (38%) (NCHS, 2017). In addition to lifestyle factors such as physical activity and diet, there are several potential causes of high obesity rates that are unique to African American women including:
- Body Mass Index (BMI) Discrepancies: the BMI is the most commonly used tool for obesity diagnosis in the US. BMI is calculated using the total body weight in kg divided by height in meters squared. Fundamentally, BMI cannot distinguish between lean body mass (LBM) and body fat percentage (BF) given its use of total body weight. Racial and ethnic variation in BMI has been well documented. One of the reasons for this difference is varying levels of body fat and lean body mass (LBM or muscle mass). Specifically, Black people have more LBM at higher BMIs. This means that the BMI tends to overestimate Black people as being overweight when, in actuality, their BMI is high because of muscle mass and not increased body fat associated with obesity. A BMI Chart that corrects for race and ethnicity has been proposed by Dr. Fatima Cody Stanford (Cody-Stanford, 2018).
- Racism: The role of racism has been studied in African American obesity. Specifically:
- Food access: systematic racism impacts access to high-quality foods by creating food insecurity and “food deserts.” (Odoms-Young, 2018)
- Environmental safety and health: racially influenced laws and practices can lead to unsafe environments that become a barrier to physical activity and healthy lifestyles. (Cody-Sanford, 2018)
- Chronic stress levels: living with racism is stressful and causes oxidative stress and inflammation which contributes to individual obesity over time. (van der Valk, 2018)
Cultural Beauty Standards
To better serve African American and Black women with obesity, it is important to appreciate differences in ethnic beauty standards and the impact on weight-related health goals. Despite a racially biased emphasis on slenderness, fuller figured bodies have long been celebrated in Black communities. (Strings, 2019). Specifically, Black women with full busts and large buttocks with a proportionately smaller waist are recognized as having the idealized body (Kwao, 2018). It is important to be mindful of this beauty standard when suggesting medically necessary obesity treatment. When discussing medical obesity, I have often had patients tell me “I don’t want to be too skinny” and aim for what I call a “happy weight*” outside of the “normal” BMI range. Objectively, Ard, et. al found that compared to a Caucasian American cohort, African-American women “had less social pressure to be thin” (Ard,et. al 2013).
Clinical Implications
It is clear there are racial differences as well as disparities associated with obesity rates in African American women. Moreover, it must be acknowledged that faulty racist ideology has facilitated bias and disparities in obesity diagnosis and treatment. As a Black woman and physician, I have personally and professionally seen the deleterious health effects of obesity that extend beyond subjective aesthetics. I agree that forcing individuals to conform to specific body types that are rooted in racism, classism, and sexism to fit a faulty social stereotype is unhealthy and potentially harmful. However, given the evidence of the increased all-cause mortality associated with obesity, especially at BMI >35kg/m2, it would be a disservice not to address obesity in African Americans. Rather the complicated history of obesity diagnosis in African American women reemphasizes that obesity treatment must be personalized for all people with obesity.
Treatment must comprehensively address personal experiences such as racial trauma, nutrition, physical activity, behavior, and, if needed, therapeutic interventions such as medication or bariatric surgery to truly create lasting weight loss and optimal health.
Additionally, for African Americans and Black people it may be useful to:
- Assess waist circumference and/or body fat percentage in the diagnosis of obesity at all times.
- Use a modified BMI scale such as that proposed by Dr. Fatima Cody Stanford and her colleagues, [link source: especially if waist circumference and body fat percentage aren’t clinically available.
- Consider cultural standards of beauty when determining a patient’s individualized weight goals.
Join Dr. Sylvia Gonsahn-Bollie, MD during her session, Obesity and Black Women: What Are We Missing? During Obesity Medicine 2022 Conference in Atlanta, GA. Register Now and Save up to $300 with Early-bird Pricing. Learn more now.
