Why does CHOICES focus on health disparities and equity?

Every child should have opportunities to grow up at a healthy weight. Obesity is at historically high levels among children,1 and there are growing disparities in levels of obesity by gender, race, ethnicity, geography, and income.2 These disparities are driven by many forces, including commercial determinants leading to increased intake of highly processed and marketed foods and drinks, as well as structural racism and social and economic determinants of health.3,4,5

CHOICES focuses on policy and programmatic strategies with strong evidence for effectiveness. Effective strategies can reduce health disparities and improve health equity. CHOICES projects the impacts of strategies in the overall population and in certain population groups to document effective strategies that can improve both overall population health and health equity.

 

How can strategies be implemented to reduce health disparities and improve equity?

Strategies may reduce health disparities and improve health equity in different ways:

      1. The strategy can be delivered to population groups most at risk for poor health outcomes, with the least access to environments and support for healthy behaviors, or with higher rates of poor health outcomes.
      2. The strategy can be delivered to all, or almost all, of the population and improve health behaviors and outcomes that are most prevalent among population groups at high risk for poor health outcomes.

 

Which population groups does CHOICES use to project the impact of strategies?

CHOICES reports the impacts of strategies by race/ethnicity and income groups. Results are summarized for four race/ethnicity groups and four income groups, based on available data and national reporting standards. Some income groups correspond with eligibility for federal nutrition assistance programs, as noted below.

Race/ethnicity

      • Black or African American, not Hispanic or Latino
      • Hispanic or Latino
      • White, not Hispanic or Latino
      • All Other Races, not Hispanic or Latino
        • This category includes people who identify as American Indian/Alaska Native, Asian, Native Hawaiian or Pacific Islander, Multi-racial, or another race/ethnicity not represented in the other three categories.

Income: household income as a percentage of the federal poverty level (FPL)

      • <130% FPL
        • At this level, individuals are eligible for the Supplemental Nutrition Assistance Program (SNAP); the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC); and free school meals via the National School Lunch and School Breakfast Programs
      • 131-185% FPL
        • At this level, individuals are eligible for WIC and reduced-price school meals via the National School Lunch and School Breakfast Programs
      • 186-350% FPL
      • >350% FPL

Given limitations in available data, we may not present all estimates by the categories, despite the potential for important disparities and inequities for specific population subsets. For example, given the limited sample sizes in national- and state-level surveillance systems and program enrollment reports, CHOICES does not examine more detailed race/ethnicity or ancestry groups or income groups within a race/ethnicity group (e.g., people of Hispanic or Latino ethnicity who live in households with lower vs. higher income).

 

What metrics does CHOICES use to document the impacts of strategies on health disparities and equity?

To document the impact of strategies on health disparities and equity, CHOICES focuses on two metrics:

      1. Cases of obesity prevented in each population group, total, and per 100,000 people. This metric describes how many people in each population group would not have obesity if the strategy were implemented. The rate per 100,000 people is used to understand how big the projected impact is in population groups of different sizes.
        1. How to interpret results: When the number of cases of obesity prevented for a population group is greater than zero, CHOICES projects improved health for that group. Groups with a higher rate per 100,000 are projected to experience a greater health benefit.
      2. Ratio of cases of obesity prevented per 100,000 in each population group compared to a reference population. This metric shows how many people in each population group would not have obesity if the strategy were implemented compared to the effect in a reference group, for the same size population in each group. It is used to understand how big the projected impact is in a population group compared to another group.
        1. How to interpret results: When the ratio is greater than 1.0 for a population group, CHOICES projects improved health equity for that group compared with the reference group. A ratio greater than 1.0 means the group is projected to experience a greater health benefit due to larger reductions in obesity prevalence compared to the reference group.

 

What reference groups are used and why?

To compare impacts of strategies by race/ethnicity group, CHOICES uses the White, not Hispanic or Latino group as the reference group. To compare the impacts of strategies by income group, CHOICES uses the highest income group (household income >350% of the federal poverty level) as the reference group. These reference groups are used because they represent the race/ethnicity and income groups with the lowest obesity levels on average nationwide, so they have the most favorable obesity health outcomes attained in the U.S. population. Comparing health outcomes in race/ethnicity and income groups with higher obesity levels on average nationwide to these reference groups allows CHOICES to document how much closer to the lowest attained obesity levels a higher risk population group could get if a strategy were implemented.

 

References
      1. Hu K, Staiano AE. Trends in Obesity Prevalence Among Children and Adolescents Aged 2 to 19 Years in the US From 2011 to 2020. JAMA Pediatr. 2022 Oct 1;176(10):1037-1039.
      2. Ward ZJ, Bleich SN, Cradock AL, Barrett JL, Giles CM, Flax C, Long MW, Gortmaker SL. Projected U.S. State-Level Prevalence of Adult Obesity and Severe Obesity. N Engl J Med. 2019 Dec 19;381(25):2440-2450.
      3. Kumanyika SK. A Framework for Increasing Equity Impact in Obesity Prevention. Am J Public Health. 2019 Oct;109(10):1350-1357.
      4. Bleich SN, Ard JD. COVID-19, Obesity, and Structural Racism: Understanding the Past and Identifying Solutions for the Future. Cell Metab. 2021 Feb 2;33(2):234-241.
      5. Swinburn BA, Sacks G, Hall KD, McPherson K, Finegood DT, Moodie ML, Gortmaker SL. The global obesity pandemic: shaped by global drivers and local environments. Lancet. 2011 Aug 27;378(9793):804-14.