Measuring Structural Racism and Its Association With BMI


      Structural racism has attracted increasing interest as an explanation for racial disparities in health, including differences in adiposity. Structural racism has been measured most often with single-indicator proxies (e.g., housing discrimination), which may leave important aspects of structural racism unaccounted for. This paper develops a multi-indicator scale measuring county structural racism in the U.S. and evaluates its association with BMI.


      County structural racism was estimated with a confirmatory factor model including indicators reflecting education, housing, employment, criminal justice, and health care. Using Behavioral Risk Factor Surveillance Survey data (2011–2012) and a mixed-effects model, individual BMI was regressed on county structural racism, controlling for county characteristics (mean age, percentage black, percentage female, percentage rural, median income, and region). Analysis occurred 2017–2019.


      The study included 324,572 U.S. adults. A 7-indicator county structural racism model demonstrated acceptable fit. County structural racism was associated with lower BMI. Structural racism and black race exhibited a qualitative interaction with BMI, such that racism was associated with lower BMI in whites and higher BMI in blacks. In a further interaction analysis, county structural racism was associated with larger increases in BMI among black men than black women. County structural racism was associated with reduced BMI for white men and no change for white women.


      The results confirm structural racism as a latent construct and demonstrate that structural racism can be measured in U.S. counties using publicly available data with methods offering a strong conceptual underpinning and content validity. Further study is necessary to determine whether addressing structural racism may reduce BMI among blacks.
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        • Fryar CD
        • Carroll MD
        • Ogden CL
        Prevalence of overweight, obesity, and extreme obesity among adults: United States, trends 1960–1962 through 2009–2010.
        Published 2012
        • Hales CM
        • Fryar CD
        • Carroll MD
        • Freedman DS
        • Ogden CL
        Trends in obesity and severe obesity prevalence in U.S. youth and adults by sex and age, 2007–2008 to 2015–2016.
        JAMA. 2018; 319: 1723-1725
        • Flegal KM
        • Panagiotou OA
        • Graubard BI
        Estimating population attributable fractions to quantify the health burden of obesity.
        Ann Epidemiol. 2015; 25: 201-207
        • Ogden CL
        • Carroll MD
        • Kit BK
        • Flegal KM
        Prevalence of childhood and adult obesity in the United States, 2011–2012.
        JAMA. 2014; 311: 806-814
        • Ailshire JA
        • House JS
        The unequal burden of weight gain: an intersectional approach to understanding social disparities in BMI trajectories from 1986 to 2001/2002.
        Soc Forces. 2011; 90: 397-423
        • Bailey ZD
        • Krieger N
        • Agénor M
        • Graves J
        • Linos N
        • Bassett MT
        Structural racism and health inequities in the USA: evidence and interventions.
        Lancet. 2017; 389: 1453-1463
        • Hicken MT
        • Kravitz-Wirtz N
        • Durkee M
        • Jackson JS
        Racial inequalities in health: framing future research.
        Soc Sci Med. 2018; 199: 11-18
        • Jones CP
        Levels of racism: a theoretic framework and a gardener's tale.
        Am J Public Health. 2000; 90: 1212-1215
        • Gee GC
        • Ford CL
        Structural racism and health inequities: old issues, new directions.
        Du Bois Rev. 2011; 8: 115-132
        • Phelan JC
        • Link BG
        Is racism a fundamental cause of inequalities in health.
        Annu Rev Sociol. 2015; 41: 311-330
        • Variyam JN
        • Blaylock J
        • Lin B-H
        • Ralston K
        • Smallwood D
        Mother's nutrition knowledge and children's dietary intakes.
        Am J Agric Econ. 1999; 81: 373-384
        • Bower KM
        • Jr Thorpe RJ
        • Rohde C
        • Gaskin DJ
        The intersection of neighborhood racial segregation, poverty, and urbanicity and its impact on food store availability in the United States.
        Prev Med. 2014; 58: 33-39
        • Powell LM
        • Slater S
        • Chaloupka FJ
        • Harper D
        Availability of physical activity-related facilities and neighborhood demographic and socioeconomic characteristics: a national study.
        Am J Public Health. 2006; 96: 1676-1680
        • Geronimus AT
        Black/white differences in the relationship of maternal age to birthweight: a population-based test of the weathering hypothesis.
        Soc Sci Med. 1996; 42: 589-597
        • Simons RL
        • Lei MK
        • Beach SRH
        • et al.
        Discrimination, segregation, and chronic inflammation: testing the weathering explanation for the poor health of black Americans.
        Dev Psychol. 2018; 54: 1993-2006
        • National Research Council
        Measuring racial discrimination.
        National Academies Press, Washington, DC2004
        • Chang VW
        • Hillier AE
        • Mehta NK
        Neighborhood racial isolation, disorder and obesity.
        Soc Forces. 2009; 87: 2063-2092
        • Bower KM
        • Jr Thorpe RJ
        • Yenokyan G
        • McGinty EE
        • Dubay L
        • Gaskin DJ
        Racial residential segregation and disparities in obesity among women.
        J Urban Health. 2015; 92: 843-852
        • Kershaw KN
        • Albrecht SS
        • Carnethon MR
        Racial and ethnic residential segregation, the neighborhood socioeconomic environment, and obesity among blacks and Mexican Americans.
        Am J Epidemiol. 2013; 177: 299-309
        • Pool LR
        • Carnethon MR
        • Goff Jr, DC
        • Gordon-Larsen P
        • Robinson WR
        • Kershaw KN
        Longitudinal associations of neighborhood-level racial residential segregation with obesity among blacks.
        Epidemiology. 2018; 29: 207-214
        • Bell CN
        • Kerr J
        • Young JL
        Associations between obesity, obesogenic environments, and structural racism vary by county-level racial composition.
        Int J Environ Res Public Health. 2019; 16: 861
        • Piontak JR
        • Schulman MD
        School context matters: the impacts of concentrated poverty and racial segregation on childhood obesity.
        J Sch Health. 2016; 86: 864-872
        • Houle B
        The effect of incarceration on adult male BMI trajectories, United States, 1981–2006.
        J Racial Ethn Health Disparities. 2014; 1: 21-28
        • Williams DR
        • Williams-Morris R
        Racism and mental health: the African American experience.
        Ethn Health. 2000; 5: 243-268
        • Centers for Disease Control and Prevention
        Overview: BRFSS 2012.
        2013 (Published July 15, Accessed February 9, 2018)
        • Massey DS
        • Denton NA
        The dimensions of residential segregation.
        Soc Forces. 1988; 67: 281-315
        • Zhang X
        • Holt JB
        • Yun S
        • Lu H
        • Greenlund KJ
        • Croft JB
        Validation of multilevel regression and poststratification methodology for small area estimation of health indicators from the Behavioral Risk Factor Surveillance System.
        Am J Epidemiol. 2015; 182: 127-137
        • Enders CK
        • Tofighi D
        Centering predictor variables in cross-sectional multilevel models: a new look at an old issue.
        Psychol Methods. 2007; 12: 121-138
        • VanderWeele TJ
        • Knol MJ
        A tutorial on interaction.
        Epidemiol Method. 2014; 3: 33-72
        • Gallagher MW
        • Brown TA
        Introduction to confirmatory factor analysis and structural equation modeling.
        in: Teo T Handbook of Quantitative Methods for Educational Research. Sense Publishers, Rotterdam, Netherlands2013: 287-314
        • McAdams MA
        • Van Dam RM
        • Hu FB
        Comparison of self-reported and measured BMI as correlates of disease markers in U.S. adults.
        Obesity. 2007; 15: 188-196