A multi-level exploration of obesity and disparities: the neighborhood, family, and healthcare system

Background: Obesity imposes a significant burden on both the healthcare system and society. Additionally, racial/ethnic and socioeconomic disparities in obesity are well established. Addressing the correlates and consequences of obesity and the disparities observed in obesity is a national priority, but solutions are complex and require multi-level approaches. This dissertation examined the role of contextual factors from three different levels – the neighborhood, the family, and the healthcare system – on the correlates and consequences of obesity and racial/ethnic and socioeconomic disparities in obesity outcomes and quality of care. Objectives: This dissertation examined factors from the neighborhood, family, and healthcare provider in three separate studies. The objective of Paper 1 was to assess the cross-sectional relationships between obesity-related diet behaviors and weight status outcomes with characteristics of the neighborhood environment in adults stratified by individual race/ethnicity. The objective of Paper 2 was to assess the longitudinal relationship between changes in early childhood obesity-related behaviors and weight status outcomes with changes in the frequency of fathers’ child caregiving involvement from age 2 to age 4, and whether family socioeconomic status modified these associations. The objective of Paper 3 was to assess the cross-sectional relationship between parent-reported provider communication quality (outcome) and child obesity status, and whether parent obesity status or child race/ethnicity modified these associations. Data Sources: Data for Paper 1 came from a representative sample of Californian adults from the 2011 – 2013 California Health Interview Study (CHIS) merged to U.S. Census data, and a commercial business data set (InfoUSA) through census tract identifiers. Paper 2 used data on children collected at age 2 to age 4 from the Early Childhood Longitudinal Survey – Birth Cohort (ECLS-B), a nationally representative survey of children born in 2001 who were followed from birth until entry into kindergarten. Data for Paper 3 came from parents with children between the ages of 6 and 12 who participated in the nationally representative Medical Expenditures Panel Survey (MEPS) for 2011 – 2013. Methods: In Paper 1 (neighborhood), I fit race/ethnicity stratified multi-level linear, logistic, and negative-binomial regression models to determine the association between obesity outcomes of obesity-related behaviors (fruit, vegetable and soda consumption) and weight status (BMI and obesity status) and characteristics from three neighborhood environments (sociodemographic, social, built), while controlling for respondent-level characteristics. Racial/ethnic sub-groups in this analysis included: non-Hispanic (NH) Whites, NH African Americans, Hispanics, and NH Asians. For Paper 2, I fit linear and logistic multivariable child fixed-effects models to determine how changes in early childhood obesity-related behaviors (TV viewing and soda consumption) and weight status (BMI z-score, overweight or obesity status, and obesity status) from age 2 to 4 were associated with changes in fathers’ child caregiving involvement and decision-making and the modifying effects of family SES. For Paper 3, I fit multivariable logistic regression to examine the association of parent-reported provider communication quality (explaining well, listening carefully, showing respect, and spending enough time) with child obesity status and the modifying effects of parent obesity and child race/ethnicity. Results: There is evidence that factors from each of the contextual levels examined in this study – neighborhood, family, and health system – were associated with obesity; however these relationships were complex when examined in different race/ethnicity or socioeconomic status groups. Among neighborhood level measures, lower educational attainment was associated with worse obesity-related behavior and weight status outcomes for all race/ethnicity groups. However, more features of the neighborhood sociodemographic, social, and built environment were associated with obesity behaviors and outcomes among NH Whites than the other race/ethnicity groups. At the family level, increases in paternal caregiving involvement, specifically in the frequency that they took children outside to play (OR = 0.70, p = 0.03) and the number of physical caregiving tasks they performed on a daily basis (OR = 0.67, p = 0.003), were associated with a reduction in odds of childhood obesity from age 2 to age 4. Family socioeconomic status modified few of these relationships. At the healthcare system level, parents of obese children were more likely to report that their child’s provider always listened carefully (OR=1.40, p = 0.002) and spent enough time (OR=1.32, p = 0.027) than parents of non-obese children. Among non-obese parents, those with obese children were more likely to report that providers always listened carefully (OR=1.75, p