Blacks, Latinos, and Native Americans are experiencing disproportionate burdens of SARS-CoV-2 infections, hospitalizations, and deaths (Covid-19).one Similar disparities are seen in other countries where minority groups face barriers to accessing health, education and social services, as well as affordable and healthy food. These marked manifestations of inequities in health have arisen as a result of a set of tests that link obesity and chronic obesity-related diseases, such as hypertension, diabetes and cardiovascular diseases, conditions that disproportionately affect disadvantaged populations, with severe Covid-19 results. Although the factors underlying racial and ethnic disparities in Covid-19 in the United States are multifaceted and complex, long-standing disparities in nutrition and obesity play a crucial role in the health inequalities that develop during the pandemic.
A healthy diet, rich in fruits and vegetables and low in sugar and high calorie processed foods, is essential for health. The ability to eat a healthy diet is largely determined by access to affordable and healthy food, as a consequence of the conditions and environment in which one lives. In the United States, poor diet is the leading underlying cause of death, as it has overtaken tobacco use in related mortality.two A study of dietary trends among US adults between 1999 and 2012 showed an overall improvement in the American diet, and the proportion of people reporting a low-quality diet decreased from 55.9% to 45.6 %; However, additional analyzes revealed persistent or worsening disparities in nutrition based on race or ethnicity, education, and income level.3
These disparities in nutrition are driven by socioeconomic, educational, and environmental disadvantages that have historically plagued vulnerable communities and persist today. For example, food insecurity affects approximately 11% of U.S. households, but is more common in black, Latino, and Native American households (www.ers.usda.gov/topics/food-nutrition-assistance / food-security-in-the-us / key-statistics-graphics.aspx). People experiencing food insecurity and living in food deserts may have predominantly access to low-cost, energy-dense processed foods. Barriers to accessing high-quality, nutritious food, in turn, are important factors in people’s body mass index. The overall prevalence of obesity among American adults is 42.4%, but black (49.6%), Native American (48.1%), and Latino (44.8%) adults are disproportionately affected, according to the Centers for Disease Control and Prevention. Obesity, in turn, is linked to numerous chronic diseases, including cardiovascular disease and diabetes, conditions that contribute significantly to mortality and disability-adjusted life years in the United States.two And that also disproportionately affects underserved racial and ethnic populations.
Health disparities in nutrition and obesity closely correlate with the alarming racial and ethnic disparities related to Covid-19. The age-adjusted hospitalization rates for Covid-19 among Native Americans and African-Americans are approximately five and four and a half times those of American whites, respectively. Latin Americans have been hospitalized at a rate approximately four times higher than that of American whites. Reports from numerous cities and states, such as Chicago and Michigan, indicate that African Americans account for a proportion of Covid-19 mortality that is more than double the proportion of black residents in their geographic area.
Among the five boroughs of New York City, the rate of hospitalizations and deaths related to Covid-19 is highest in the Bronx.4 4 Compared to the other districts, the Bronx has higher rates of obesity and chronic disease due to the disproportionate amount of poverty and food insecurity; These disparities make the district’s predominantly black and Latino residents more vulnerable to the devastating effects of Covid-19.
Social determinants of health as the root cause of racial and ethnic health disparities, including severe negative results from Covid-19.
The social determinants of health, obesity, chronic disease, and severe negative Covid-19 outcomes are all interrelated.
In the current pandemic, the intersection between communicable and noncommunicable diseases has resulted in a public health emergency. Several pathophysiological mechanisms may explain the greater virulence of Covid-19 in patients with obesity. Obesity is a state of low-grade chronic systemic inflammation, which may predispose patients to the severe “cytokine storm” characteristic of Covid-19. Furthermore, adipose tissue can serve as a reservoir for SARS-CoV-2 due to its high levels of expression of the angiotensin-converting enzyme 2, perpetuating the spread to other organs. Furthermore, obesity may be a common denominator of associated coexisting conditions and underlying socioeconomic factors linked to worse Covid-19 outcomes. These underlying mechanisms require further research to inform prevention and treatment. But to address this urgent public health problem, the confluence of obesity, the serious Covid-19 outcomes, and health disparities based on race and ethnicity must be examined in the context of social determinants of health (see diagram)
Non-medical factors and conditions that influence health include economic stability, physical environment, racism and ethnic discrimination, education, access to nutritious food, the social and community context, and access to health services.5 5 These factors have contributed in real time to the disparities in the Covid-19 pandemic, as the risk of infection has been increased by overcrowded conditions and the inability to work from home, both barriers to social distancing. Upstream forces, including lack of access to healthy food, the preponderance of low-quality nutrition, and higher rates of food insecurity, result in a higher prevalence of obesity and chronic disease, and are therefore responsible ultimately the increased morbidity and mortality of Covid -19 in disadvantaged populations.
Racial and ethnic health disparities often stem from structural racism. Unequal policies, practices and systems arising from historical injustices impact on affected communities; Discrimination in employment and education, poor housing, barriers to receiving high-quality health care, and neighborhood designs that limit physical activity lead to adverse health effects and are shaped by structural racism. At the same time, the unconscious biases of healthcare professionals can have unintended detrimental effects on the quality of care that Black, Latino, and Native American patients receive, which may be further amplified by the challenges of the pandemic.
Observational studies and randomized trials addressing the factors underlying severe Covid-19 presentations in people with obesity and metabolic dysfunction need to be prioritized and include black, Latino and Native American populations. Furthermore, to minimize the risk of Covid-19 infection among people living in disadvantaged communities with high rates of obesity and chronic disease, public health policies and social support services must be coordinated quickly. The current crisis justifies the creation of a national organization dedicated to addressing Covid-19’s racial and ethnic health disparities, to elucidate the challenges and mobilize the necessary resources.one
In the long term, comprehensive interventions that address the social determinants of health and structural racism, and policies that ensure universal access to high-quality, affordable health care for all Americans are imperative. The American College of Physicians has outlined a multidisciplinary approach to address the social determinants of health,5 5 which advocates for the reduction of socioeconomic inequalities, the integration of social determinants of health in medical education, local and federal financing of social services, and the expansion of research efforts. Uniting behind these principles and paying vigilant attention to unconscious biases can bring about real change.
The US healthcare system needs a renewed and growing focus on health inequities, inclusion, resilience, and prevention of chronic disease. Public health policies and legislative initiatives that reduce food insecurity and food deserts in vulnerable communities are urgently needed to address the determinants of health. The 2018 US Farm Bill, which spends nearly $ 90 billion annually on agricultural and food programs, includes provisions for nutrition disparities, but we require more innovative strategies and greater commitment to eliminate racial inequalities and ethnicities within the US food system The cost of the Covid-19 pandemic cannot be undone, but recognizing these disparities offers an opportunity to meet the public health challenge of health inequity and unite in a vision for a healthier, fairer and more equitable nation.
