Socioeconomic Factors Impacting Obesity Care: Identifying and Addressing Challenges in Clinical Practice

| December 1, 2018

by Katie Chapmon, MS, RD

Kaiser Permanente, West Los Angeles Medical Center in Los Angeles, California.

Funding: No funding was provided for this article.

Disclosures: The author reports no conflicts of interest relevant to the content of this manuscript.

Abstract: Individual health behaviors, clinical care, and physical environment are all influenced by social and economic factors. Research shows that populations with lower socioeconomic status are more likely to have poor self-reported health, lower life expectancy, and suffer from more chronic conditions, including obesity, when compared with those of higher socioeconomic status. When treating a patient with obesity, barriers related to socioeconomic status should be considered because these largely impact the ability to engage in health-promoting behaviors. The safety and surroundings of one’s built environment often dictate a patient’s food selection and level of physical activity. Another factor that can potentially affect medical care is health literacy, the degree to which individuals have the capacity to obtain, process, and understand basic health information, and services needed to make appropriate health and medical decisions. This article discusses ways in which healthcare professionals can provide support and empathy and apply strategies to address a variety of socioeconomic challenges with their patients.

Keywords: obesity, socioeconomic status, physical activity, food environment, built environment


While obesity is medically classified using body mass index (BMI) and presence of type 2 diabetes mellitus (T2DM), one of the most prevalent obesity-related comorbidities, the bigger picture of individual health status encompasses much more. According to the World Health Organization (WHO), “health is a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.”1 The multidisciplinary treatment approach to obesity embraces this definition, addressing all three components in which obesity is closely linked. For instance, obesity can impact an individual’s physical function, causing musculoskeletal pain, reduced muscle strength, and limitations in movement.2 Obesity is also a risk factor for mood disorders (e.g., depression, anxiety) and vice versa.3 The negative impact of obesity on social well-being, which comprises social integration, acceptance, contribution, actualization, and coherence,4 can be seen through the lens of social stigma, but also in how socioeconomic status can potentially dictate an individual’s access to the highest attainable standard of health, which WHO states is “one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition.”5

Though a lesser discussed issue in obesity treatment, identifying and addressing socioeconomic challenges with our patients might enhance the overall care we provide. This article discusses ways in which we, as health professionals, can provide support and empathy and apply strategies to address a variety of patient challenges in our daily interactions.

Socioeconomic Challenges

Individual health behaviors, clinical care, and physical environment are all influenced by social and economic factors. Socioeconomic status can either support or constrain healthful behaviors. This might include the inability to easily access health-promoting foods, especially if an individual lives in a neighborhood where such foods are not easily available or affordable. Similarly, there might be constraints to exercise if he or she lives in a neighborhood where safety or outside space is an issue.6

Second, social or economic disadvantage affects not only the ability to access clinical care, but also the quality of care received. Work hours, work sick-leave policies, clinic hours, transportation, and childcare issues can make seeing a healthcare professional difficult. Furthermore, evidence shows that those with lower educational attainment, those with lower incomes, and minorities all receive lower quality healthcare.6

Third, social and economic factors drive one’s exposure to a healthy or unhealthy physical environment. For example, education level largely determines employment choices, which in turn largely dictates income level. These factors greatly influence the probability of being able to afford to live in a health-supporting and safe physical environment, afford healthier food choices, or might affect healthcare quality and access and, potentially, patients’ health beliefs.7,8 Socioeconomic status also affects an individual’s ability to obtain vitamins and medications, which can be essential to one’s health outcomes.

Environmental Challenges

Built environment. Our “built environment,” defined as “the physical parts of where we live and work” (e.g., homes, buildings, streets, open spaces, infrastructure) impacts individual health. The Centers for Disease Control and Prevention (CDC) reoprt that the built environment influences a person’s level of physical activity. For example, inaccessible or nonexistent sidewalks and bicycle or walking paths contribute to sedentary habits, which are linked to obesity, cardiovascular disease, diabetes, and some types of cancer.9,10

Growing evidence reinforces the link between obesity and one’s built environment. A recent systematic review found that a variety of neighborhood features, including walkability and greater access to physical activity facilities and supermarkets, were associated with lower risk of obesity, while access to fast food outlets has been linked with greater obesity risk.11

Built environments that support or hinder obesity-protective behaviors also appear to follow a socioeconomic gradient.8 Neighborhoods of lower socioeconomic status might contain fewer recreational facilities, poorer environments for walking, and fewer walking or cycling trails. Since the mid-1990s there has been a rapidly growing body of literature of a neighborhood’s effects on health. For example, creating accessible healthy public spaces (e.g., green space) might have a positive effect on health-related behavior of all people, regardless of their socioeconomic status.12,13

Rural versus urban environments. Differences can also be seen between physical features of rural and urban areas. Befort et al14 reviewed findings from the 2005–2008 National Health and Nutrition Examination Survey (NHANES) to compare obesity among adults in rural and urban areas of the United States. The major finding of this study was that the prevalence of obesity remained significantly higher among rural compared to urban adults controlling for demographic, diet, and physical activity variables. This was the first study comparing rural and urban obesity prevalence using BMI weight status classification based on measured height and weight.14

As ways of life change, new data on health continue to emerge. Although rural residents traditionally consume high-fat, high-calorie diets, this is potentially offset by high-caloric expenditure during vigorous physical labor required to maintain land (e.g., farming, landscaping). However, changes over the past 30 years, such as increased mechanization of rural occupations, has reduced these levels of caloric expenditure, impacting weight-related health of rural residents, especially the younger generation.15

Tips and strategies. Suggest patients try to do the following:

  • Find an alternate location for physical activity (e.g., indoor activities or local recreation center)
  • Add challenges during the activities of daily living. For example, take the stairs, walk farther, take a 10-minute exercise break at work
  • Try an app or website to find public spaces
  • Start a walking group. There might be people from the same neighborhood, or support group who want to go for a walk or participate in a group activity.

Food selection

The relatively low cost of fast foods, as well as other energy-rich and low nutrient content food in comparison to pricing of fruits, vegetables, whole grains, low-fat milk products, and lean meats, is a barrier that may affect food selection. The actual retail food environment might also present barriers to healthy eating in areas where healthier foods and beverages are less available. Interestingly, differences in store composition across communities might partially explain observed differences in relative availability of products. Inequities in the actual spatial accessibility of supermarkets and other retail food stores, such as convenience stores, are well documented, with low-income, rural, and central-city communities having less access to supermarkets, for example.16

Furthermore, the specific foods available within an individual’s local environment might be stronger influences on diet and weight than the quantity of different store types. Although supermarkets might be considered as a positive influence on healthy body weight due to their provision of healthy foods, this might also vary across supermarkets and neighborhoods. For example, there is evidence that supermarkets in neighborhoods of high socioeconomic status assign a greater proportion of space to healthy (e.g., fruit and vegetables) versus energy-dense foods and drinks, compared to supermarkets in other neighborhoods.11,16,17

Zenk et al18 proposes that improving the relative availability of healthier alternatives in small stores might be particularly critical in low-income communities without supermarkets and grocery stores. In those areas where supermarkets are available, dedicated space to healthier food choices might need to be expanded.

There is variation among the United States regions in overall dietary intake. Individuals in the South and West consume more dietary cholesterol than those in the North or the East. Southerners consume the lowest amount of fiber compared to other regions. Ethnicity also plays a role in overall dietary intake, as an individual’s culture and/or family traditions surrounding food drive choices.19,20

Tips and strategies

  • Know where people shop—supermarket or convenience store—and educate on where healthier items might be located
  • Explore the possibility to have healthier food items delivered or to grow their own produce
  • Provide financially conscious food choices with practical ideas for preparation
  • Educate on the difference between the meal cost of bulk cooking at home versus fast food to demonstrate potential lower cost and health benefits
  • Educate on and assist with enrollment in medication or vitamin financial support programs

Access to Clinical Care

Populations with lower socioeconomic status are more likely to have poor self-reported health, lower life expectancy, and suffer from more chronic conditions when compared with those of higher socioeconomic status. They also receive fewer diagnostic tests and medications and have limited access to healthcare due to cost and coverage.21

The United States Preventive Services Task Force recommends that all patients be screened for obesity and, if needed, receive weight loss advice. However, the prevalence of such advice is low and varies by patient demographics.22 A 2016 study published in Prevention of Chronic Disease23 aimed to describe the determinants of receiving weight-loss advice among a sample with a high proportion of low-income, racial/ethnic minority individuals. It found that income was a significant predictor of whether or not adults with overweight or obesity receive weight loss advice after adjustment for demographic variables, health status, and insurance status.23

Literacy

Another factor that can potentially affect medical care is literacy. Health literacy is defined as “the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health and medical decisions.” People with limited health literacy often lack knowledge or have misinformation about the body as well as the nature and causes of disease. Without this knowledge, they might not understand the relationship between lifestyle factors and various health outcomes. Culture also affects how people communicate, understand, and respond to health information. Health professionals can contribute to cultural health literacy by recognizing the cultural beliefs, values, attitudes, traditions, language preferences, and health practices of diverse populations, and applying that knowledge to produce a positive health outcome. For many individuals with limited English proficiency (LEP), the inability to communicate in English is the primary barrier to accessing health information and services. Health information for people with LEP needs to be communicated plainly in their primary language, using words and examples that make the information understandable.

Literacy, on the other hand, can be defined as “a person’s ability to read, write, speak and compute and solve problems at levels necessary to develop one’s knowledge and potential.” A person who has limited or low literacy skills often has a barrier to accessing health information and services. It can be difficult for them to find what they need, then understand what they find, as well as act upon that understanding. Low literacy has been linked to poor health outcomes and decreased skills in managing health and preventing disease. For example, socioeconomic status might influence fruit and vegetable consumption, but purchasing decisions also involve nutrition knowledge and health literacy, as well as social roles and cultural norms related to health and nutrition.24,25

Tips and strategies. As practitioners, we can respectfully guide the connection between patient action and behaviors with their health outcomes. The following are suggestions to address this challenge in clinical practice:

  • Use nonprinted or visually based teaching materials
  • Design documents using common language
  • Have printed materials available in other languages
  • Focus the content on a patient’s actions or behaviors that will result in the desired health outcome rather than on detailed facts
  • Ask your patients to repeat the information they just heard using their own words.

Conclusion

Many of the clinical challenges discussed here seem to be inter-related. The following paragraph from an article by Hermann et al26 published in BMC Public Health provides a good breakdown of this relationship:

“Educational attainment may specifically influence racial/ethnic disparities in overweight/obesity trends as it has been shown to shape an individual’s SES and access to resources (e.g., grocery stores with fresh produce) and opportunities (e.g., sidewalks for physical activity) that afford or compromise healthy lifestyles and weight status through historical and pervasive differential acquisition of occupations, incomes, and neighborhood choices. Supportive relationships and social support, self-image related to desired weight, knowledge of nutrition, and access to tools for weight control are also likely contributors to observed disparities.”

There are a variety of factors—social, environmental, and biological—that contribute to health differences. Most of the research on nutrition and health disparities has focused on the cultural, socioeconomic, and structural differences in ethnic groups, and attempts to explain these observed socioeconomic disparities, particularly in obesity, have primarily focused on the role of energy-balance behaviors, and to a lesser extent, on psychosocial factors, such as stress, self-esteem, and the social environment, including culture, social networks, norms, and support.

Even when socioeconomic status is controlled for, disparities remain. Neighborhood and other environmental factors, as well as differential access to healthcare, also influence health status. Unfortunately, research on the genetic and biological bases for these disparities is currently limited; however, it is possible that a variation in diet, behavior, and the social and physical environment by ethnic groups might differentially influence gene expression.  This might partially explain why we see such variation in health and weight even with some controlled factors.27 We have more to learn about the relationship between health and overall life factors. In the meantime, we can use our current knowledge and expertise to guide our patients to positive outcomes.

References

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