Obesity among Latinx people in the United States: A review

Internal factors

Internal factors specific to the Latinx population, such as genetic and epigenetic factors, are associated with obesity and obesity‐related comorbidities, particularly when exposed to an obesogenic environment.

Single‐nucleotide polymorphisms have been identified that are associated with obesity, fat distribution, waist circumference, triglyceride levels, and insulin resistance in Mexican American people [20, 21]. A genome‐wide association study in European and Mexican participants identified three Mexican‐specific single‐nucleotide polymorphisms that were associated with high triglyceride levels [21]. These included the SIK family kinase 3 (SIK3) risk variant rs139961185, which delayed triglyceride clearance after fatty meals [21]. However, environmental factors appear to influence the development of obesity despite similar genetic predisposition within ethnic heritage groups, as illustrated by the higher BMI of Pima Indian people in Arizona (a more affluent environment) compared with those in a remote location in Mexico (living a more traditional lifestyle) [22].

Environmental factors

Environmental factors, such as diet and exercise, also provide challenges in obesity management. A traditional Latinx diet tends to be high in carbohydrates, representing approximately 50% of energy intake across Latinx backgrounds [6]. Diet quality (based on the Healthy Eating Index) varies by background, with better overall dietary quality among people with Mexican, Dominican, and Central American heritage, compared with other Latinx groups [23]. As lower diet quality is associated with obesity, this highlights the need for nutritional interventions to manage obesity in Latinx people.

Access to healthy foods is key in weight management among Latinx people. Food insecurity is associated with obesity in Latina women [24]. In an urban sample, a majority of Latina women reported regularly not having enough money to buy food, and half had been told to change their diet but could not afford to do so [25].

Acculturation of Latinx people to US behaviors and practices is associated with worse diet quality [26]. Similarly, length of residency in the United States predicts moderate and extreme obesity among Latinx people, suggesting that prolonged exposure to the environment in Latinx communities in the United States is a major risk factor for obesity [27]. Among Mexican American people, the association between obesity and length of residency in the United States is mediated primarily by sedentary behavior, suggesting that physical activity interventions may limit the development of obesity [28].

Individual socioeconomic status also predicts obesity and related comorbidities. Among Latinx people, greater household income is associated with lower obesity rates, and higher educational attainment is associated with lower risk of obesity and greater chance of weight loss success [29, 30]. However, the direction and magnitude of the association between socioeconomic status and obesity vary between Latinx groups [29].

Cultural factors

Cultural factors are key contributors to the complexity of obesity management in Latinx people. For example, there are cultural disparities in body ideal, with a larger, curvy body considered acceptable, or even desirable, in many Latinx communities, in contrast with the slender body ideal of the United States [31]. This may contribute to Latinx people who have overweight or obesity being less likely to perceive themselves as having overweight than non‐Latinx White people [32].

Family dynamics play a role in obesity management in Latinx people. In Latinx communities, the extended family is typically considered more important than the individual, and people often seek advice, including on health care matters, from a large number of family members (reviewed by Caballero et al. [33]). In Latinx families, mothers and grandmothers are typically the primary caretakers of many family matters, including health care (reviewed by Caballero et al. [33]). Parental influence impacts obesity management in children, with parenting style, feeding practices, and modeling of healthy behaviors all influencing a child's eating behavior and BMI [34]. When managing obesity among Latinx people, it is therefore critical to understand the family dynamics and to include key family members in discussions and decisions on treatment.

Health care provider factors

Health care provider–related factors can affect obesity management in Latinx communities. There are insufficient health care providers with a Latinx background, with only 4.4% of US physicians in 2013 identifying as Hispanic or Latinx [35]. The shortage of Latinx health care providers can lead to language barriers between Latinx people and their health care providers, which can negatively impact the management of obesity and related comorbidities [36]. Limited English proficiency among Latinx patients is associated with lower receipt of advice about diet and exercise [36].

Access to health care is limited owing to the high rate of uninsured people in the US Latinx population, with 16.1% uninsured in 2017 compared with 6.3% of non‐Latinx White people [37]. This contributes to the lower utilization of bariatric surgery by Latinx people compared with non‐Latinx White people with obesity [38] and likely also to the lower use of antiobesity medications (AOMs) in this population [39]. Lack of health insurance coverage may lead to increased medication‐induced weight gain, as some older, less expensive medications (particularly medications for T2D), may be more obesogenic than newer, more expensive options [19].

Ethnic disparities are also evident in existing clinical criteria, which tend to be developed for broader populations and which may not be appropriate for Latinx populations. For example, the waist circumference threshold to define abdominal obesity as a risk factor for coronary heart disease does not appear to be appropriate for Latina women. The waist circumference cutoff point for optimal discrimination appears higher for Latina women compared with the general population, leading to an overestimate of the prevalence of metabolic syndrome in this group [40].

Dietary and lifestyle interventions

Interventions that create new models of a healthy diet and lifestyle among matriarchs and patriarchs are key to obesity management in the Latinx population.

Medical and surgical interventions

AOMs can be beneficial in obesity management in Latinx people. Among Mexican American women with obesity, 1 year of orlistat treatment in addition to a culturally tailored lifestyle intervention was associated with weight loss and reductions in waist circumference, total cholesterol, and low‐density lipoprotein compared with waitlist controls [48].

In post hoc analyses of phase 3 studies, weight loss with liraglutide and semaglutide was similar between Latinx and non‐Latinx populations [49, 50, 51]. However, withdrawal rates were numerically higher among Latinx versus non‐Latinx participants [49]. The response to lifestyle intervention in the placebo group was also numerically lower among Latinx participants [49], emphasizing the need for culturally targeted interventions.

In phase 3 trials evaluating the efficacy of semaglutide or phentermine‐containing AOMs, the proportion of Latinx participants was low (12%–20%) [52, 53, 54, 55], highlighting a need for more data in the Latinx population. As with the general population [56] and veteran population [57], determining obesity phenotypes within the Latinx population may help to enhance weight loss and minimize variability in AOM response.

Bariatric surgery can also be beneficial for Latinx people with obesity. Following bariatric surgery, weight loss and BMI reduction were similar between Latinx people and non‐Latinx White people [58, 59], and no differences in terms of mortality, morbidity, hospital length of stay, or costs were observed [60]. However, it has been found that metabolic syndrome is less likely to resolve following bariatric surgery in Latinx adults than non‐Latinx White adults [61]. Although the reasons for this are unknown, it is possible that more severe cardiometabolic disease in Latinx people may lead to impaired metabolic processes that are less responsive to weight loss following surgery [61].

Implementation of personalized, culturally sensitive intervention strategies

Intervention strategies are likely to be most successful when personalized to the individual, with cultural factors a key consideration for Latinx‐targeted interventions.

Ideally, interventions should include bilingual and bicultural staff members who are familiar with the participant's cultural background [62]. Dietary interventions should be adjusted to suit a Latinx diet and more specifically, the diet of the participant's regional background [62].

Understanding family dynamics and including key family members is critical to successful intervention. As matriarchs are typically the primary caretakers in Latinx families (reviewed in Caballero et al. [33]), their participation may be particularly important. However, among Mexican American women, these same familial values can negatively impact weight loss and adherence to interventions [63]. It is important that these cultural aspects are discussed with the individual and not assumed [62], in order to target the intervention to the individual.

The heterogeneity of the Latinx population should also be acknowledged when developing and implementing intervention strategies, as this can impact factors including health care utilization, food choices, and language preference [62] (Table 1). It is also important to understand the acculturation process and consider an individual's level of acculturation, as dietary patterns and food choices typically change on immigration to the United States [64]. However, few studies distinguish between Latin backgrounds, except for Mexican American, as the largest Latinx group in the United States.

When managing obesity, health care providers must be clear when explaining to patients that the concern with obesity is not about being “large” or “fat” but that it involves having excess dysfunctional adipose tissue, which results in disease with comorbidities and complications. Similarly, the aim of treatment is not simply “being thinner,” which may not be desired within the Latinx community, but to prevent and treat obesity‐related diseases. Health care providers should emphasize the importance of screening for obesity‐related conditions, such as T2D, as the prevalence of undiagnosed comorbidities can be high among Latinx people [65].

Programs directed at Latinx patients with T2D have been successful and provide lessons for reaching underserved minority groups in the management of obesity [66]. Factors that were associated with improved outcomes in this population included cultural relevance, longer intervention period, tailoring for low literacy, multimodal implementation (e.g., a combination of in‐person and telephone delivery), and social and familial elements [66].