public health writing question and need the explanation and answer to help me learn.
Write an essay of ~750 words (maximum 1000 words) summarizing the reading. Your response paper should include: 1) the main message of the reading, 2) an overview/explanation of the biological concepts being described (e.g., underlying biological mechanisms of the public health problem), and 3) the scope of the public health problem, including 1 – 2 sentences on outlook (i.e., implications for further research, intervention, or public health policy). The use of 2 – 3 outside sources to support your points is required and you MUST reference all sources – using AMA format (superscripted numbers in-text and then the list of corresponding numbered references at the end of the text).
Requirements: 750-1000 words
REVIEWARTICLEChildhoodobesitywithinthelensofracismNancyT.Browne|EricA.Hodges1|LeighSmall2|JuliaA.Snethen3|MarilynFrenn4|SharonY.Irving5,6|BonnieGance-Cleveland7|CindySmithGreenberg81UNC-ChapelHillSchoolofNursing,ChapelHill,NorthCarolina,USA2MichiganStateUniversityCollegeofNursing,EastLansing,Michigan,USA3UniversityofWisconsin-Milwaukee,CollegeofNursing,Milwaukee,Wisconsin,USA4MarquetteUniversityCollegeofNursing,Milwaukee,Wisconsin,USA5PediatricNursing,UniversityofPennsylvaniaSchoolofNursing,Philadelphia,Pennsylvania,USA6PediatricCriticalCare,Children’sHospitalofPhiladelphia,Philadelphia,Pennsylvania,USA7UniversityofColoradoAnschutzMedicalCampus,Aurora,Colorado,USA8CollegeofHealthandHumanDevelopment,CaliforniaStateUniversity,Fullerton,California,USACorrespondenceNancyT.Browne,25AndrewsAvenue,Falmouth,ME04105,USA.Email:nancytkacz@sbcglobal.netSummaryDespitedecadesofresearchandamultitudeofpreventionandtreatmentefforts,childhoodobesityintheUnitedStatescontinuestoaffectnearly1in5(19.3%)chil-dren,withsignificantlyhigherratesamongBlack,Indigenous,andPeopleofColourcommunities.Thisnarrativereviewpresentssocialfoundationsofstructuralracismthatexacerbateinequityanddisparityinthecontextofchildhoodobesity.TheNationalInstituteofMinorityHealthandHealthDisparities’ResearchFrameworkguidestheexplicationofstructurallyracistmechanismsthatinfluencehealthdisparitiesandcontributetochildhoodobesity:biologicandgenetic,healthbehaviours,chronictoxicstress,thebuiltenvironment,raceandculturalidentity,andthehealthcaresystem.Strategiesandinterventionstocombatstructuralracismanditseffectsonchildrenandtheirfamiliesarereviewedalongwithstrategiesforresearchandimplica-tionsforpolicychange.Fromourcriticalreviewandreflection,thesubtleandoverteffectsofsocietalstructuressustainedfromyearsofracismandtheimpactonthedevelopmentandresistantnatureofchildhoodobesitycompelconcertedaction.KEYWORDSACEs,childhoodobesity,microaggressions,racism,socialdeterminantsofhealth,weightbias1|INTRODUCTIONANDCONTEXTChildhoodobesityisapublichealthcrisisintheUnitedStates,disproportionatelydistributedamongBlack,Indigenous,andPeopleofColour(BIPOC)youth.TheprevalenceofobesityinU.S.youth(through2018)is19.3%1withunderrepresentedpopulations(AmericanIndian/AlaskaNative[29.7%],2Hispanic[25.6%],1non-HispanicBlack[24.2%],1andNativeHawaiianorOtherPacificIslander[10%at2yearsofage;23%at8yearsofage])3rep-resentinghigherrates.Non-HispanicWhiteandAsianchildrenshowlower,althoughconcerning,rates(16.1%and8.7%,respectively).1Obesityisoftenviewedasapersonal‘failing’bychildrenandtheirparents.Designatedadiseasein2013,4currentresearchdemonstratesthatbiologicmechanismscoupledwithenvironmen-talinfluencesarecomplexanddynamiccontributorstoobesity.InBIPOCcommunities,thecontributionofsocialdeterminantsofhealth(SDoH),healthdisparities,andstructuralracismtochronicdiseaseisincreasinglyrecognized.Whileauthorshavelargelydis-creditedabiologicalbasisforrace,5,6thesocialconstructofraceandracismcarryconsequencesdirectlyandindirectlyimpactinghealth.7,8ThepurposeofthisnarrativereviewistoexploresocialfoundationsofstructuralracismcontributingtoSDoHwhichexacerbateinequityanddisparityinthecontextofchildhoodobesity.Ourchoiceofwordsmatters,particularlyrelatedtoracismandobesity,whicharesensitiveandemotionallychargedsubjects.9BIPOCisthetermchosentodescribeseveralunder-representedgroups.Whilethese(andother)groupssharesimilaradversitiesincludingracismandhistoricaltrauma,theirindividual,community,andculturalexperiencesareunique.Theterm‘structuralracism’isusedtoencompassdistalprocessesintheframeworkguidingthismanuscriptandisinclusiveofsystemicandinstitutionalformsofracism.Received:15July2021Revised:28November2021Accepted:3December2021DOI:10.1111/ijpo.12878PediatricObesity.2022;17:e12878.wileyonlinelibrary.com/journal/ijpo©2021WorldObesityFederation1of9https://doi.org/10.1111/ijpo.12878
2|THEORETICALFRAMEWORK:CONCEPTUALIZATIONOFTHEIMPACTOFRACISMONCHILDHOODOBESITYTheNationalInstituteofMinorityHealthandHealthDisparities’ResearchFramework10(NIMHD)includesawidearrayofstructuraldeterminantsofhealthprovidingafoundationforpromotinghealthequitythroughexaminingminorityhealthandhealthdisparities.Thismulti-dimensionalmodelconsidershealthoutcomesandhowtheyareaffectedthroughintersectionsofdomainsandlevelsofinfluence.TheNIMHDmodelwasadaptedtoexaminechildhoodobesityandthepotentialinfluencersassociatedwithstructuralracism(Figure1).Themajorityofchildhoodobesityresearchfocusesontheproximalprocessesoftheadaptedmodelwithlimitedexaminationofthedistalprocesses.Thisreviewfocusesonthedomainsofinfluenceonindi-vidualhealthandtheimmediateenvironmentthatsurroundschildren(theproximalprocesses).Toxicstress(theresultofongoingracismandweightdiscrimination)fitsinboththepersonalandinterpersonallevelsoftheNIMHDmodel.Thedomainsofinfluenceonanindividual’shealth,discussedfurtherinsubsequentsections,includeaseriesofareas:biologic,behavioural,physical/builtenvironment,socioculturalenvironment,andhealthcaresystems.Othersocietalsystems(e.g.,education,justice,andeconomicbarriers)alsocontributetotheimpactofracismonchildhoodobesityandareoutsidethescopeofthismanuscript.Theinterpersonal,community,andsocietallevelsofinfluenceexistoutsideofandencompasstheindividual’spersonallevelofinflu-ence.Proximalprocessesforchildreninvolvedirectinteractionswithcaregivers,extendedfamily,schoolenvironment,andsocialnetworkswhichmaybetheprimarydriversofanindividual’sdevelopment.However,weproposethattheconsiderationofmoredistalinfluencesintheformofracism,structuralandhistorical,arealsoimportant,astheyinfluenceandshapeproximalprocesses.Assessmentoffactorsrelatedtochildhoodobesity,includingstructuralracism,mayprovidenewinsightsfororiginalresearchandinnovativeinterventions.3|BACKGROUNDDespiteinnumerableeffortsaimedatreducingtheprevalenceofchildhoodobesity,datatrackedfrom1971to2018establishthesteadyincreaseofobesityinchildrenaged2–19years.1Equallydisturbingisthesharpincreaseinsevereobesityinthe2-to5-year-oldandadolescentagegroups.11Manystructuralandsocietalfactors,alongwiththetoxicstressassociatedwithracismandadversechildhoodexperiences(ACEs),increasetheriskofchildhoodobesity.12StructuralracismhasbeendeclaredapublichealththreatandcrisisbytheAmericanPublicHealthAssociationandCentersforDiseaseControlandPrevention.ACEs(persistent,traumatic,andstressfuleventsbornebychildrenandadolescents)areinclusiveofactsofracismandweightdiscrimina-tion13andareassociatedwithobesityandunhealthyweightbehav-iours.14ACEsmayincludedownstreamresultsofstructuralracismincludingpoverty,foodinsecurity,unsafelivingandplayenvironmentsinfluencedbyredliningandzoninglaws,microaggressions,parentalseparationspecificallyfromincarceration,andwitnessedracialFIGURE1Theoreticalframework:conceptualizationoftheimpactofstructuralracismonchildhoodobesity.AdaptedfromReference102of9BROWNEETAL.
violence.Deathofaparent,severeeconomichardship,andcumula-tiveACEsarestronglypredictiveofchildhoodobesity.144|MECHANISMSTHATCONTRIBUTETOHEALTHDISPARITIESAddressingpaediatricobesity-relatedhealthdisparitiesrequiresanexplorationofthemechanismscontributingtoinequities.TheLifeCourseHealthDevelopmentFrameworkexplainshowsociallypat-ternedphysical,environmental,andsocioeconomicexposuresatdiffer-entstagesofhumandevelopmentcontributetoanindividual’shealthwithinandacrossgenerations.15,16Healthtrajectories(positiveandnegative)developoveranindividual’slifetimeasaconsequenceofmul-tiplebiological,genetic,behavioural,social,andeconomicdeterminants.Socialdisadvantagetriggersrepeatedactivationofphysiologicalstressresponsesthreateningalterationsinmetabolism.17Prolonged,repeatedchallengestometabolichomeostasisincreasetheriskofdiseasesusceptibilityandpromoteearlyonsetofchronicdiseasessuchasobesity.The‘WeatheringHypothesis’isanexampleofhowstructuralmechanismsinfluencehealthdisparities,suggestingthatcumulative,stress-mediatedresponsesinfluencecellularintegrity.18Intergenerationaltransmissionofhealthdisparitiesandstressmediatedresponsesleadtoacceleratedbiologicalaging,dysregulationofbodysystems,earlyonsetofchronicillness(suchasobesity),disability,andprematuredeath.165|INFLUENCESOFSTRUCTURALRACISMONCHILDHOODOBESITY5.1|BiologicalandgeneticdomainofinfluenceGrowingevidencesupportsthedeleteriouseffectsofracismonthebio-logicalfunctioningofchildren.Thehypothalamic–pituitary–adrenal(HPA)axisisacentralneuroendocrinesystemthatcontrolsthebody’sstressresponsealongwithenergybalanceandimmunefunction.Toxicstress(prolongedactivationofstressresponse)resultsinhyper-physiologiclevelsofcortisolandHPAaxisinjuryaffectingenergyregulationandnor-malimmuneresponse.17Theeffectoftoxicstressonthiscomplexsystemleadstohormonaldysregulation,increasedinflammation,andincreasedallostaticload(AL).19Researchershaveobservedasignificantassociationbetweenthetoxicstressofdiscrimination(racial,overweight)andincreasedallostaticloadinadults.20Similarresearchinchildrenfoundsig-nificantdifferencesinALbyrace/ethnicitywiththehighestALinHis-panicandBlackchildren.HigherALlevelswereassociatedwithhigherBMI,totalbodyfatmass,waistcircumference,andpercentbodyfat.21Negativesocialandenvironmentalexposuresimpacthealththroughepigeneticchanges.16Oneepigeneticfactorassociatedwithearly-lifeadversityistelomerelength(TL).TelomeresarebasepairsofDNAproteincomplexesthatprotecttheendsofchromosomesfromshorteninganddeterioration.Toxicstressfromearly-lifepsychosocialstressorsacceleratesshorteningofTLwhichincreasesvulnerabilitytoearlyonsetofchronicdiseases,suchasobesity.225.2|Healthbehavioursdomainofinfluence5.2.1|DevelopmentalChildren,dependingontheirageanddevelopment,havevaryingdegreesofdependenceontheirfamily,surroundingindividuals,andtheircommunitywhichdirectlyinfluencestheirpersonalhealthbehaviours.23Autonomyindecisionmakingisinfluencedbyethnicity,culture,andsocietalexpectations.24Youngchildrengraduallydevelopself-awarenessandcontrolovertheirhealthbehaviourssuchaschoosinghealthyfoodandengaginginphysicalactivities.Adolescentsestablishtheirownhealthbehavioursinsteadofthebehaviourspredeterminedbythefamilialunitwheregenerationalandculturalsystemsimpactthefamilysystem.Withexperience,theadolescentbeginstounderstandthegreatercon-textandimplicationsofethnicorculturalidentitywithinthestruc-tureoftheirfamily,community,andsocietyfurtherinfluencingdecisions.5.2.2|Racism,weightdiscrimination,andtoxicstressRaceisahierarchical,socialconstructwithoutgeneticbasis.Racismreferstosystemicpracticesthatrankgroupsofpeopleassuperiortoothersthroughtheimplementationofsocialnormssupportedbytheideologyofsuperiorityandpower.Racismisrecognizedasaffectingneighbourhoods,foodsystems,andaccesstohealthpromotingactiv-ities.Discriminationistheprejudicialtreatmentofgroupsofpeoplesolelybasedontheirspecifiedcharacteristics.Exposuretounrelent-ingracismanddiscriminationimpactschildrenpsychosociallyandphysiologically,addingincrementallytotoxicstresslevelsandallostaticload,factorsthatcanleadtoobesity.25Evidencesupportstherelationshipoftoxicstressfromracismandweightbiaswithsubsequenthealthoutcomes.8,26,27Microaggressions(verbalorbehaviouraloffencesthatimpartnegative,hostile,orderog-atoryinsults)playaroleintheimpactofracismonchildhoodobe-sity.28Micro-aggressivebehavioursarebriefandintentional,indicatingapowerimbalance.Microaggressionsareinnuendosthatdismisstheexperiencesofothers,denyingtheeffectsthatrace,socie-talinequities,andhealthstatus(inclusiveofweight)haveonanindi-vidual’sexistence.29Lilienfeldcriticizedtheconceptualbasisofmicroaggressionsasbeingmisinterpretedbyminoritygroupmemberswithanabsenceofconnectivitytopsychologicalscience.30However,Williamsarguesthatmicroaggressionsarewelldefined,decisivelylinkedtoprejudiceinoffenders,andnegativelyaffectmentalhealthout-comesinrecipientindividuals.31Thereactiontothemicro-aggressionreflectstheexperiencesoftherecipientindividualorgroup.Forchildreninvaryingstagesofphysical,psychosocial,andcognitivedevelopment,persistentmicroaggressionscontributetotoxicstressanddetrimentallyimpactsocialandhealthoutcomes,includingobesity.26BROWNEETAL.3of9
5.3|Physical/builtenvironmentandsocioculturaldomainsofinfluenceInthecontextoftheenvironmentalandsocioculturaldomains,struc-turalracismisovertaswellascovert.Overtformsofstructuralracismareevidentinthelackoftransportation,healthyfoodaccess,andphysicalactivityopportunitiesincommunities,alldetrimentaltochil-drenmaintainingahealthyweight.32Covertformsofstructuralracisminthebuiltenvironment(suchasredlining)resultinsegregation,pov-erty,andreducedSDoH.Povertyaffectsthesocietalaspectsofthephysicalenvironmentandisoftendeterminedbyyearsofstructuralracismacrossgenerationslimitingeducational,occupational,andeco-nomicopportunities.Thefamily’slocationofresidenceisdirectlyinfluencedbytheeducationandemploymentoftheparents/adultsandtheincomeoftheentirefamilyunit.Structuralracisminfluencesthecommunityenvironment,threateningchildren’shealthinmultiple,complexassociations.ForcommunitiesofBIPOCresidents,environmentsareoftenassoci-atedwithsafetyconcerns,socialisolation,decreasedamountofgreenspace,limitedaccesstobandwidthfortechnology,andreducedaccesstohealthcare.Thechild’senvironmentcompoundsexistingtensionsandhistoricaltraumathataddtotoxicstress.Greenspace,whichreducesstresswhileimprovingphysicalactiv-ityopportunities,islackinginmanyBIPOCcommunitiesincreasingobesityrisk.33,345.3.1|AvailabilityofhealthyfoodManyunderservedcommunitiesareconsidered‘food-deserts’,withoutsupermarketsincloseproximity.Residentsofthesecommunitiesarereliantonneighbourhoodconveniencestoreswhichoftenstocklow-cost,high-energy,highlyprocessedfoods.A2016USDAstudyexam-inedhowobesityrateswereinfluencedbyindividual-,household-,andneighbourhood-levelfactors.35Theresearchersconcludedthatneighbourhoodfoodenvironmentfactors,suchasfooddesertstatus,wereassociatedwithincreasedoddsofoverweightandobesity.5.3.2|LanguageproficiencyChildrenwithlimitedEnglishproficiencyaremorelikelytoexperiencepersonalandstructuraldiscrimination.36Personaldiscriminationincludeshurtfulcommentswhenverballyexpressingthemselvesinasecondlanguage.DeridinglimitedEnglishproficiency,oraccent,isamicroaggressionandmaybeinterpretedasracism.36InastudybyZhangandcolleagues,LatinochildrenexperiencingdiscriminationrelatedtolimitedEnglishproficiencyexhibitedpsychologicaldistresswhichfurtherexacerbatedtheirallostaticloadandtoxicstressburden.37LoweducationalexpectationofachildwithlimitedEnglishlanguageskillisanexampleofstructuraldiscriminationwiththechild’scognitiveandsocialabilitiesoftenunderestimatedorignored,furtherthreateningachievementofpotentialgrowth.365.3.3|CulturalidentityChildrenbegintounderstandtheircultureandsociallyassignedracialandethnicidentityinearlychildhood.38Ethnic/culturalidentitydevel-opmentemergesfromsocializationoftraditionswithinthechild’shome.38Ethnicityandculturalmessagingwithinthefamilyfostersthedevelopmentofstrongself-esteemandethnicpride,apresumedpro-tectivemechanism.38However,whenchildrenfromunderservedpopulationsmovefromthesafetyoftheirfamilialenvironmenttointeractwithinthegreatercommunity,theybecomevulnerabletoexperiencingracismanditsnegativeeffectsonself-esteem.39A2011studyexaminedyoungchildren’sexperiencesofracismanditseffectsonself-esteem,hypothesizingthatapositiveethnicidentitycouldmediatethenegativeself-esteemeffectsfromracismexposure.39TheinvestigatorsfoundthatHispanicandnon-HispanicBlackchildrenreportedasignificantamountofsocialstressafterexposuretoracismwhichnegativelyaffectedtheirself-esteem,supportingtheconnectionbetweenracism,stress,anddecreasedself-worth.However,researchersfoundthatchildrenbenefitwhenintegratingtheirfamilialculturalidentitywiththecommunityenvironmentwheretheyreside.38Apositiveculturalorientationinthechild’sethnicidentitygroupmaybeprotectiveofself-esteem.39,405.4|HealthcaresystemdomainofinfluenceAlthoughtheAffordableCareActhasreducedracialandethnicdisparities,41structuralracismandpovertycontinuetolimitaccesstohealthinsuranceandhealthcare.Latinoandnon-HispanicBlackyouth,aswellasotherunder-representedgroups,havelessaccesstohealthcareduetopoorornon-existentinsurancecoveragewhichnegativelyimpactshealthoutcomes.42,43LimitedaccesstohealthcaremayleadBIPOCindividualstoseekhealthsupportoradvicefromafamilymember,friend,orcol-leaguethatmaynotbeevidencebased.Frequently,gapsinfamilysupportexist,asBlackparentsaremorelikelytohavelostachildbyage30andaspousebyage60overtheirWhitecounterparts.44BlackchildrenarethreetimesmorelikelythanWhitechildrentohavelostamotherbytheageof10,creatingtheneedforincreasedassistanceandsupportthatmaybelackinginachild’scommunity.BIPOCindividualsoftenencounterimplicitbiasfromhealthcareprofessionalswhichstiflesaccessandutilizationofhealthcare.Acli-nician’simplicitbiasisevidencedbyineffectivecommunicationandpotentiallysubstandardqualityofcare.45Mostclinicianslikelydonotfeeltheiractionsareracist.However,researchofhealthcareproviderssuggestsimplicitbiasesexist46necessitatingacknowl-edgementtoprovideeffective,traumainformedhealthcareandreducehealthdisparities.AcademicpaediatricfacultyandleadershipmaydemonstrateunconsciousracialbiasestowardBIPOCindivid-uals,whichimpactscareforchildren,includingthosewithobesity.47Healthcareproviders’implicitbias,bothracialandweight,hasa4of9BROWNEETAL.
negativeinfluenceonclinician-patientinteractionandpotentiallyinfluencestreatmentdecisions.48Addressingbiasinthehealthcarefieldisneededtoreducehealthcaredisparitiesandimprovehealthoutcomes.6|DISCUSSIONThispaperfocusesontheeffectsofracismonchildrenwithobesity,whomayalsofaceadditionalformsofdiscrimination,includingweightbias,addingtoexistingtoxicstressandallostaticload.27Microaggressions(interpersonal),macroaggressions(structural),ACEs,andotherformsofracismandinequityareongoingformanychildrenwithobesity,resultinginharmfulphysiologicalandpsychosocialhealthoutcomes.Effortstocombatracismandobesitydiscriminationfollowsimilarthemesintheliterature.Acommonapproachfromthebullyinglitera-turedescribesthecomplexrelationshipbetweenthetriadofrecipient,bystander,andbully/perpetrator.49,50Olweus49andSueetal.50advo-catethatempowermentofthebystanderisakeyinterventiontostoptheperpetuationofracism.Puhlandcolleaguesutilizethetriadrela-tionshiptodescribeweightrelateddiscriminationinterventionsandalsostressthepivotalroleofthebystander.51Racismanddiscrimination,aswellasSDoH,impactthehealthofchildren,adolescents,families,andcommunities.52Toreducetoxicstressassociatedwithstructuralracism,healthcareprovidersinclinicalpractice,research,education,andpolicydevelopment,mustaddressanddismantlestructuralracismtopositivelyimpactchildren’shealth,includingchronicconditionssuchasobesity.Thedevelopmentofsuc-cessfulinterventionsstartswithintrospectionofone’sownbiases.Becomingconsciousofone’sbiases(bothimplicitandexplicit)andhowtheyimpactone’sviewoftheworldandrelationshipsareessen-tialfirststepsinpracticingantiracism.Strategiestomitigateornegatetheharmfulpsycho-socialandphysiologicaleffectsofracism,50includemicro-interventions(per-sonalandinterpersonallevel),macro-interventions(structural/policylevels),andcounter-ACEinterventions.50,53Micro-andmacro-interventiontoolsenhancefeelingsofcontrolandself-efficacyfortherecipientandbystanderbyprovidingresponsesthatdisarmperpetra-tors.Counter-ACEinterventions(i.e.,apositiverelationshipinwhichthechildfeelssafe)supporthealthydevelopmentandmitigatetheeffectsofACEs.53Groundedinresiliencetheory,counter-ACEinter-ventionspromotehealthydevelopmentwhenchildrenareexposedtorisk,adversity,andtoxicstress.54Researchsuggeststhatproactiveuseofcounter-ACEinterventionsreduceshealthrisksandimprovesrela-tionalskillsinstrumentalinmitigatingtheeffectsoftoxicstress.55,56Antiracistpracticesmustbedevelopedandimplementedincaredelivery,research,education,andpolicytoreducehealthoutcomeinequities.57Todevelopanti-racistpractices,educatorsmustbeout-spokenabouttheneedtodiversifyourstudents,faculty,andleadersincludinghealthcareprofessionals.Healthcarecurriculamustberevisedtobeculturallyresponsiveandinclusiveindismantlingthe‘statusquo’ofsystemicracismanddiscrimination.Providersneedtoactivelyengageinconversationsaboutimplicitbiasandracism,listentocolleagues’thoughts,andrespecteachother’sfeelings.Toachievehealthequity,participationofallvoices,includingthosewithsocietalprivilege,isneededinthedismantlingofstructuralracisminclinicalpractice,research,educationalsystems,andpolicydevelopment.58Thereisadifferencebetweennon-racistandanti-racistbehav-iour,withthelattermoreeffectiveinchangingthedynamicofinter-ventionsaddressingactsofracismanditstoxicstresseffects.Anti-racistbehaviourisactionorientedandpurposefulinclearlystatingwhereonestandswhenwitnessingmicroaggressionsorotheractsofracism.50Theuseofanti-racistbehaviourhasagreaterpositiveimpactthannon-racistbehaviour,whichispassive,internalinnature,andnotreadilyapparenttoothers.50Anti-racistcareinterventionsapplytoallformsofdiscrimination,includingweight,andtothesocialstructuresthatinfluenceenvironmentandculture.50Suggestedanti-racistinterventionsbyrecipientorbystanderarelistedinTable1.50AsstatedbyKendi,‘…theonlywaytoundoracismistoconsistentlyidentifyanddescribeit–andthendismantleit’.59Potentialconsequencesofanti-racistinterventionsarebestman-agedbytherecipientandbystander,decidingwhichmicroaggressionstoaddress.50Discriminationisoftenunrelenting;addressingeachinci-dentcanbeexhausting.Termed‘battlefatigue’,thisconceptdescribeshowdiscriminatoryactions(racism,weightbias)chronicallyimpactanindividual’sstressresponse.60Self-careisthetoppriorityandframedasthe‘choice’ofthetriadmember(particularlytherecipient)tostepawayfromaspecificencounter.Potentialactionsmustconsiderthedynamicsofthoseinvolved,thesafetyofthescenario,andtherelation-shipwiththeperpetrator,particularlyrelatedtopower.TABLE1StrategiestodisarmmicroaggressionsGoalStrategyMaking‘invisible’visibleAskforclarificationofcommunicationwherenegativeintentisclearbutunspokenDisempowertheinnuendoby‘naming’itForcethosewithpowerandprivilegetoconsidertherolestheyplayintheperpetuationofoppressionDisarmmicro/macroaggressionsExpressdisagreementandmakeclearwhereyoustandStatevaluesandsetlimitsInterruptharmfulcommunicationandredirectconversationEducatetheperpetratorDifferentiatebetweenintentofremarkanditsimpactPromoteempathyPromoteadvantagesofdiversitySeekexternalinterventionAlertandreportactionstothosewithpowertointerveneMaintainopen,supportiveenvironmentKeepallsafe,evenifmicroaggressionneedstobeignoredUnderstandpowerdynamicsinsituationSource:Sueetal.50BROWNEETAL.5of9
6.1|Linkinganti-racismandweightmanagementstrategiesTheeffectsoftoxicstressareathreattoachild’simmediateandlong-termhealth.Paediatricweightmanagementintensivelifestyletherapy(ILT)guidelinesstressbehaviouralsupportasacornerstoneofobesitytreatment,focusingbothonthechild’simmediateandcom-munityenvironment.TheILTbehaviouralcomponentbuildstherapeu-ticrelationships,supportsfamilyinitiatives,andaddressesSDoHwiththegoalofstressreduction.Guidanceaddressingthetoxicstresseffectsfromracismandweightstigmaonchildrencomesfromseveralsources.ThreepolicystatementsfromTheAmericanAcademyofPediatrics(AAP)describetheimpactofracism,52thestigmaofobesity,61andtoxicstress56onpaediatrichealth.TheAAPcallsforpaediatricproviderstousetraumainformedcarepracticestosupporthealingandmitigatetheeffectsoftoxicstressincludingracismandobesitydiscrimination.62SpecificAAPstrategiesthatpromoterelationalhealthatthefamilyandcom-munitylevelsaresummarizedinTable2.Anadditionalpositionstate-mentfromtheNationalAssociationofPediatricNursePractitionersTABLE2CaregiverandproviderstrategiestopreventandmitigatetoxicstressinchildrenActionsPracticetraumainformedcare(TIC)RealizeUnderstandbroadimpactoftraumaUnderstandshortandlong-termimpactofACEsandtoxicstressondevelopmentandhealthShiftperspectivefrom‘whatiswrongwithyou?’to‘whathappenedtoyou?’ACEshavephysiological,biological,psychological,social,andspiritualeffectsonchildrenRecognizeSignsandsymptomsoftraumainfamiliesUseopenendedquestionsScreenfortraumaforeverychild,everyvisitAssessforphysiological,biological,psychological,social,andspiritualeffects:suicidality,depression,anxiety,substanceabuse,self-injuriousbehaviour,developmentaldelay,sleepdisorders,disorderedeating,andrelationalhealth.Tool:paediatricACEsscreeningandrelatedlife-eventsscreenerRespondCoordinationofresponsetotraumaparticularlywithfamily,community,andhealthcaresystemsAnticipatoryguidance:resiliencepromotion,ACEseducation,consistencyinparentingskillsResistre-traumatizationUniversaltraumaprecautionsforbothcaregiversandcarereceiversApproachallchildrenandfamilieswithtraumauniversalprecautionsmindsetTICandresiliencytrainingforallpersonnelinteractingwithchildrenandfamiliesPromoteacultureofTICinorganizationsandcommunitiesDevelopresiliencyinchildrenandfamiliesAssess(everychild,everyvisit)ACEsDevelopmentalmilestonesFamilyandpeerrelationshipsCaregivermentalhealthSocialDeterminantsofHealthEducationPromoteprotectivefactorsMitigateriskfactorsEnhanceadaptationskillsSupportpositiveparentingskills:nurturing,belonging,rolemodelling,familyorganization,familystructure,andritualsEmphasizestressmanagementskilldevelopment;self-awarenessPromoteself-careProblem-solvingEmotionalskillbuildingHope,faith,optimismSelf-confidenceSelf-efficacyandidentityNote:AdaptedfromGarneretal.,56Goddard,62andNationalAssociationofPediatricNursePractitionersetal.636of9BROWNEETAL.
encouragesstrategiesthatstrengthenresilienceinchildrentomitigatetheimpactofACEs,aidinginsuccessfuladaptationtochallengesthreateningfunction,survival,ordevelopment.63Useofcounter-ACEinterventions,followingtheHOPE(HealthOutcomesfromPositiveExperiences)framework,promoteshealthypsychosocialdevelopment,whilemitigatingconditionsthatexacer-batethetoxicstressofracialandweightdiscrimination.53TheHOPEFrameworkemphasizesthatchildandparentwell-beingareinsepara-ble,thereforepositiveinterventionsmustpromotenotonlythehealthofthechildbutalsohealthoftheparent,andthechild–parentrela-tionship.Positivechild/parentinterventionsincludepromotionofnur-turingrelationships,safeandequitableenvironments,asenseofconnectedness,andstrengtheningofrelationalandemotionalskills.52Vigilancebyindividualsregardingintentionalactsorlatentdis-criminationalsointensifiestoxicstresswithinflammatory-relatedhealthconsequences.64Individualsexperiencingfrequentdiscrimina-tionareoftenhighlyvigilantoftheseacts.Traumainformedcarethatimprovesawarenessofvigilant-reactantfeelingsandofferseffectivecopingstrategiesimprovesself-regulationofstress.Promotionofchil-dren’sculturalidentityandprideprovidesadditionalresourcestocounteractthestressofracismandweightdiscrimination,potentiallycombatingtheirphysiologicimpact.7|FUTURERESEARCHANDINTEGRATIONINTOPUBLICPOLICYThisreviewcallsforfurtherexplorationoftherelationshipbetweentoxicstressfromweightstigmaandracismwithdevelopmentofobe-sityinchildhood.Areasofstudyinclude:identifyingtheeffectivenessofmediatorsontherelationshipbetweenthetoxicstress(racismandweightbias)andenergymanagementinreducingchildhoodobesity;determiningstrategiestoeliminateinequitiesinSDoHdesignedtoreducetheeffectsoftoxicstress;anddevisinginterventionstoelimi-nateracialandweightbiasamonghealthprofessionalsastheyimpactchildhoodobesity.Intheperformanceofthisresearch,FreyandYoung65offerupdatedguidancerangingfromstudydesigntothereportingofraceandethnicityinmedicalandsciencejournals.Healthprofessionalsmustconsiderthepotentialramificationsofanyrace-relatedorracecomparativeresearchandgaugeclinicalandsocialcon-sequences,includingtheaggravationofexistinginequalities.Inclusionofsuchonlyservestoperpetuatecurrentsocietalmisbeliefs.8|CONCLUSIONStructuralracismisafactorinSDoHandexacerbatesinequityanddis-parityinthecontextofchildhoodobesity.Racismandweightrelateddiscriminationaretwoexampleswherehierarchiesarecreatedanddifferencesbetweengroupsimplyinferiority.Thebiasanddiscrimina-tionconnectionbetweenracismandchildhoodobesityiscomplexwithtoxicstressunderpinningsandshortandlong-termhealthconse-quences.Therelationshipofracismtochildhoodobesityiscompelling,invokingstressorsthattriggerneuroendocrineresponsesthatrenderthediseaseofobesitynearlyintractable.Theshort-andlong-termeffectsoftoxicstressonchildren’shealthlastalifetime.Anunderstandingofthemultiplicativeeffectsofseparatebutadditivesourcesoftoxicstressisnecessarytodevelopstrategicinterventionsaddressingtheeffectsofracismonchildrenatriskfororexperiencingobesity.Structuralracismmustbeeradicatedgloballytoachieveequityandeliminatedisparities.Thisendeavourisadauntingtaskrequiringstrategicplanningandimplementationbyindividualsatalllevelsofglobalsociety.Childrenwithobesityultimatelybenefitfromasoci-etyrestructuredtoreducetoxicstressandimproveSDoH.Healthcareprovidershavetheopportunityandobligationtoleadsocietalrestructuringthroughpractice,research,education,andpol-icydevelopment.CONFLICTOFINTERESTNoconflictofinterestwasdeclared.AUTHORCONTRIBUTIONSAllauthorswereinvolvedintheconceptionofthearticle,contributedtotheliteraturesearchesandidentificationofpertinentarticles,writ-ingofmanuscript,criticallyreviewedthemanuscript,andhadfinalapprovalofthesubmittedversion.ORCIDNancyT.Brownehttps://orcid.org/0000-0002-5728-6623REFERENCES1.FryarCD,CarrollMD,AffulJ.Prevalenceofoverweight,obesity,andsevereobesityamongchildrenandadolescentsaged2–19years:UnitedStates,1963–1965through2017–2018.NCHSHealthE-Stats.2020.AccessedOctober2021.https://www.cdc.gov/nchs/data/hestat/obesity-child-17-18/obesity-child.htm2.BullockA,SheffK,MooreK,MansonS.ObesityandoverweightinAmericanIndianandAlaskaNativechildren,2006-2015.AmJPublicHealth.2017;107(9):1502-1507.doi:10.2105/AJPH.2017.3039043.NovotnyR,FialkowskiMK,LiF,etal.Systematicreviewofpreva-lenceofyoungchildoverweightandobesityintheUnitedStates-affiliatedPacificRegioncomparedwiththe48contiguousstates:TheChildren’sHealthyLivingProgram.AmJPublicHealth.2015;105(1):e22-e35.doi:10.2105/AJPH.2014.3022834.KyleTK,DhurandharEJ,AllisonDB.Regardingobesityasadisease:evolvingpoliciesandtheirimplications.EndocrinolMetabClinNorthAm.2016;45(3):511-520.doi:10.1016/j.ecl.2016.04.0045.AmericanMedicalAssociation.Eliminationofraceasaproxyforancestry,genetics,andbiologyinmedicaleducation,researchandclinicalpracticeH-65.953:apolicystatement.AmericanMedicalAssociation.2020.AccessedOctober2021.https://policysearch.ama-assn.org/policyfinder/detail/race?uri=%2FAMADoc%2FHOD.xml-H-65.953.xml6.FlanaginA,FreyT,ChristiansenSL.AMAManualofStyleCommittee.Updatedguidanceonthereportingofraceandethnicityinmedicalandsciencejournals.JAMA.2021;326(7):621-627.doi:10.1001/jama.2021.133047.CookWK,TsengW,BautistaR,JohnI.Ethnicity,socioeconomicstatus,andoverweightinAsianAmericanadolescents.PrevMedRep.2016;4:233-237.doi:10.1016/j.pmedr.2016.06.010BROWNEETAL.7of9
8.DickersonDL,BrownRA,KleinDJ,AgnielD,JohnsonC,D’AmicoEJ.OvertperceiveddiscriminationandracialmicroaggressionsandtheirassociationwithhealthriskbehaviorsamongasampleofurbanAmer-icanIndian/AlaskaNativeAdolescents.JRacialEthnHealthDisparities.2019;6(4):733-742.doi:10.1007/s40615-019-00572-19.Glossaryforunderstandingthedismantlingstructuralracism/promotingracialequityanalysis.Roundtableoncommunitychange.TheAspenInstituteAccessedMay10,2021.https://www.aspeninstitute.org/wp-content/uploads/files/content/docs/rcc/RCC-Structural-Racism-Glossary.pdf10.AlvidrezJ,CastilleD,Laude-SharpM,RosarioA,TaborD.Thenationalinstituteonminorityhealthandhealthdisparitiesresearchframework.AmJPublicHealth.2019;109(S1):S16-S20.doi:10.2105/AJPH.2018.30488311.SkinnerAC,RavanbakhtSN,SkeltonJA,PerrinEM,ArmstrongSC.PrevalenceofobesityandsevereobesityinUSChildren,1999-2016.Pediatrics.2018;141(3):e20173459.doi:10.1542/peds.2017-345912.AaronDG,StanfordFC.Isobesityamanifestationofsystemicracism?Aten-pointstrategyforstudyandintervention.JInternMed.2021;290(2):416-420.doi:10.1111/joim.1327013.WissDA,BrewertonTD.Adversechildhoodexperiencesandadultobesity:asystematicreviewofplausiblemechanismsandmeta-analysisofcross-sectionalstudies.PhysiolBehav.2020;223:112964.doi:10.1016/j.physbeh.2020.11296414.LynchBA,AgunwambaA,WilsonPM,etal.Adversefamilyexperi-encesandobesityinchildrenandadolescentsintheUnitedStates.PrevMed.2016;90:148-154.doi:10.1016/j.ypmed.2016.06.03515.HalfonN,HochsteinM.Lifecoursehealthdevelopment:aninte-gratedframeworkfordevelopinghealth,policy,andresearch.MilbankQ.2002;80(3):433-iii.doi:10.1111/1468-0009.0001916.JonesNL,GilmanSE,ChengTL,DrurySS,HillCV,GeronimusAT.Lifecourseapproachestothecausesofhealthdisparities.AmJPublicHealth.2019;109(51):S48-S55.17.TimperK,BrüningJC.Hypothalamiccircuitsregulatingappetiteandenergyhomeostasis:pathwaystoobesity.DisModelMech.2017;10(6):679-689.doi:10.1242/dmm.02660918.GeronimusAT.TheweatheringhypothesisandthehealthofAfrican-Americanwomenandinfants:evidenceandspeculations.EthnDis.1992;2(3):207-221.19.BergerM,SarnyaiZ.”Morethanskindeep”:stressneurobiologyandmentalhealthconsequencesofracialdiscrimination.Stress.2015;18(1):1-10.doi:10.3109/10253890.2014.98920420.MillerHN,LaFaveS,MarineauL,StephensJ,ThorpeRJJr.Theimpactofdiscriminationonallostaticloadinadults:anintegrativereviewofliterature.JPsychosomRes.2021;146:110434.doi:10.1016/j.jpsychores.2021.11043421.CedilloYE,MurilloAL,FernándezJR.Theassociationbetweenallostaticloadandanthropometricmeasurementsamongamultiethniccohortofchildren.PediatrObes.2019;14(6):e12501.doi:10.1111/ijpo.1250122.CoimbraBM,CarvalhoCM,MorettiPN,MelloMF,BelangeroSI.Stress-relatedtelomerelengthinchildren:asystematicreview.JPsychiatrRes.2017;92:47-54.doi:10.1016/j.jpsychires.2017.03.02323.BeachamBL,DeatrickJA.Adaptingthefamilymanagementstylesframeworktoincludechildren.JPediatrNurs.2019;45:26-36.doi:10.1016/j.pedn.2018.12.00624.YatesJF,deOliveiraS.Cultureanddecisionmaking.OrganBehavHumDecisProcess.2016;136:106-118.doi:10.1016/j.obhdp.2016.05.00325.BrodyGH,LeiMK,ChaeDH,YuT,KoganSM,BeachSRH.PerceiveddiscriminationamongAfricanAmericanadolescentsandallostaticload:alongitudinalanalysiswithbufferingeffects.ChildDev.2014;85(3):989-1002.doi:10.1111/cdev.1221326.WilliamsDR.Stressandthementalhealthofpopulationsofcolor:advancingourunderstandingofrace-relatedstressors.JHealthSocBehav.2018;59(4):466-485.doi:10.1177/002214651881425127.PuhlRM,LessardLM.Weightstigmainyouth:prevalence,conse-quences,andconsiderationsforclinicalpractice.CurrObesRep.2020;9(4):402-411.doi:10.1007/s13679-020-00408-828.SueDW,CapodilupoCM,TorinoGC,etal.Racialmicroaggressionsineverydaylife:implicationsforclinicalpractice.AmPsychol.2007;62(4):271-286.doi:10.1037/0003-066X.62.4.27129.PaladCJ,YarlagaddaS,StanfordFC.Weightstigmaanditsimpactonpaediatriccare.CurrOpinEndocrinolDiabetesObes.2019;26(1):19-24.doi:10.1097/MED.000000000000045330.LilienfeldSO.Microaggressions.PerspectPsycholSci.2017;12(1):138-169.doi:10.1177/174569161665939131.WilliamsMT.Microaggressions:clarification,evidence,andimpact.Per-spectPsycholSci.2020;15(1):3-26.doi:10.1177/174569161982749932.BaileyZD,KriegerN,AgénorM,GravesJ,LinosN,BassettMT.Struc-turalracismandhealthinequitiesintheUSA:evidenceandinterven-tions.Lancet.2017;389(10077):1453-1463.doi:10.1016/S0140-6736(17)30569-X33.DelaFuenteF,SaldíasMA,CubillosC,etal.Greenspaceexposure:associationwithType2diabetesmellitus,physicalactivity,andobe-sity:asystematicreview.IntJEnvironResPublicHealth.2020;18(1):97.doi:10.3390/ijerph1801009734.SchulzAJ,OmariA,WardM,etal.Independentandjointcontribu-tionsofeconomic,socialandphysicalenvironmentalcharacteristicstomortalityintheDetroitMetropolitanArea:astudyofcumulativeeffectsandpathways.HealthPlace.2020;65:102391.doi:10.1016/j.healthplace.2020.10239135.ChenD,JaenickeEC,VolpeRJ.Foodenvironmentsandobesity:householddietexpenditureversusfooddeserts.AmJPublicHealth.2016;106(5):881-888.doi:10.2105/AJPH.2016.30304836.AdairJK.Theimpactofdiscriminationontheearlyschoolingexperi-encesofchildrenfromimmigrantfamilies.2015.Washington,DC:MigrationPolicyInstitute.https://www.migrationpolicy.org/research/impact-discrimination-early-schooling-experiences-children-immigrant-families37.ZhangW,HongS,TakeuchiDT,MossakowskiKN.LimitedEnglishproficiencyandpsychologicaldistressamongLatinosandAsianAmericans.SocSciMed.2012;75(6):1006-1014.doi:10.1016/j.socscimed.2012.05.01238.NelsonDS,GerrasJM,McGlumphyKC,etal.RacialdiscriminationandlowhouseholdeducationpredicthigherbodymassindexinAfricanAmericanyouth.ChildObes.2018;14(2):114-121.doi:10.1089/chi.2017.021839.Dulin-KeitaA,HannonL,FernandezJR,CockerhamWC.Thedefiningmoment:children’sconceptualizationofraceandexperienceswithracialdiscrimination.EthnRacialStud.2011;34(4):662-682.doi:10.1080/01419870.2011.53590640.Serrano-VillarM,CalzadaEJ.Ethnicidentity:evidenceofprotectiveeffectsforyoung,Latinochildren.JApplDevPsychol.2016;42:21-30.doi:10.1016/j.appdev.2015.11.00241.ChenJ,Vargas-BustamanteA,MortensenK,OrtegaAN.RacialandethnicdisparitiesinhealthcareaccessandutilizationundertheAffordableCareAct.MedCare.2016;54(2):140-146.doi:10.1097/MLR.000000000000046742.OrtegaAN,McKennaRM,ChenJ,AlcaláHE,LangellierBA,RobyDH.Insurancecoverageandwell-childvisitsimprovedforyouthundertheAffordableCareAct,butLatinoyouthstilllagbehind.AcadPediatr.2018;18(1):35-42.doi:10.1016/j.acap.2017.07.00643.CaveL,CooperMN,ZubrickSR,ShepherdCCJ.Racialdiscriminationandchildandadolescenthealthinlongitudinalstudies:asystematicreview.SocSciMed.2020;250:112864.doi:10.1016/j.socscimed.2020.11286444.UmbersonD,OlsonJS,CrosnoeR,LiuH,PudrovskaT,DonnellyR.Deathoffamilymembersasanoverlookedsourceofracialdisadvan-tageintheUnitedStates.ProcNatlAcadSciUSA.2017;114(5):915-920.doi:10.1073/pnas.16055991148of9BROWNEETAL.
45.vanRynM,BurgessDJ,DovidioJF,etal.Theimpactofracismoncli-niciancognition,behavior,andclinicaldecisionmaking.DuBoisRev.2011;8(1):199-218.doi:10.1017/S1742058X1100019146.GonzalezCM,KimMY,MarantzPR.Implicitbiasanditsrelationtohealthdisparities:ateachingprogramandsurveyofmedicalstudents.TeachLearnMed.2014;26(1):64-71.doi:10.1080/10401334.2013.85734147.JohnsonTJ,EllisonAM,DalembertG,etal.Implicitbiasinpediatricacademicmedicine.JNatlMedAssoc.2017;109(3):156-163.doi:10.1016/j.jnma.2017.03.00348.FitzGeraldC,HurstS.Implicitbiasinhealthcareprofessionals:asystematicreview.BMCMedEthics.2017;18(1):19.doi:10.1186/s12910-017-0179-849.OlweusD,ed.BullyingatSchool:WhatWeKnowandWhatWeCanDo.Blackwell;1993.50.SueDW,AlsaidiS,AwadMN,GlaeserE,CalleCZ,MendezN.Disarmingracialmicroaggressions:microinterventionstrategiesfortargets,Whiteallies,andbystanders.AmPsychol.2019;74(1):128-142.doi:10.1037/amp000029651.PuhlRM,PetersonJL,LuedickeJ.Strategiestoaddressweight-basedvictimization:youths’preferredsupportinterventionsfromclass-mates,teachers,andparents.JYouthAdolesc.2013;42(3):315-327.doi:10.1007/s10964-012-9849-552.TrentM,DooleyDG,DougéJ,SectiononAdolescentHealth;CouncilonCommunityPediatrics;CommitteeonAdolescence.Theimpactofracismonchildandadolescenthealth.Pediatrics.2019;144(2):e20191765.doi:10.1542/peds.2019-176553.SegeRD,HarperBC.RespondingtoACEswithHOPE:healthout-comesfrompositiveexperiences.AcadPediatr.2017;17(7S):S79-S85.doi:10.1016/j.acap.2017.03.00754.ZimmermanMA,StoddardSA,EismanAB,CaldwellCH,AiyerSM,MillerA.Adolescentresilience:promotivefactorsthatinformpreven-tion.ChildDevPerspect.2013;7(4):1-9.doi:10.1111/cdep.1204255.CrandallA,BroadbentE,StanfillM,etal.Theinfluenceofadverseandadvantageouschildhoodexperiencesduringadolescenceonyoungadulthealth.ChildAbuseNegl.2020;108:104644.doi:10.1016/j.chiabu.2020.10464456.GarnerA,YogmanM,CommitteeonPsychosocialAspectsofChildandFamilyHealth,SectiononDevelopmentalandBehavioralPediatrics,CouncilonEarlyChildhood.Preventingchildhoodtoxicstress:partneringwithfamiliesandcommunitiestopromoterela-tionalhealth.Pediatrics.2021;148(2):e2021052582.doi:10.1542/peds.2021-05258257.KoschmannKS,JeffersNK,HeidariO.”Ican’tbreathe”:acallforantiracistnursingpractice.NursOutlook.2020;68(5):539-541.doi:10.1016/j.outlook.2020.07.00458.BeardKV,JulionWA.Doesracestillmatterinnursing?ThenarrativesofAfrican-Americannursingfacultymembers.NursOutlook.2016;64(6):583-596.doi:10.1016/j.outlook.2016.06.00559.KendiIX.HowtoBeanAntiracist.OneWorld;2019:9.60.FranklinJD,SmithWA,HungM.RacialbattlefatigueforLatina/ostu-dents:aquantitativeperspective.JHispanicHighEduc.2014;13(4):303-322.doi:10.1177/153819271454053061.PontSJ,PuhlRM,CookSR,SlusserW,SectiononObesity;ObesitySociety.Stigmaexperiencedbychildrenandadolescentswithobesity.Pediatrics.2017;140(6):e20173034.doi:10.1542/peds.2017-303462.GoddardA.Adversechildhoodexperiencesandtrauma-informedcare.JPediatrHealthCare.2021;35(2):145-155.doi:10.1016/j.pedhc.2020.09.00163.NationalAssociationofPediatricNursePractitioners,SpratlingR,CavanaughN,DerouinA,DirksM,SearcyL.Buildingresilienceinchildhoodandadolescence.JPediatrHealthCare.2019;33(5):A11-A13.64.HimmelsteinMS,YoungDM,SanchezDT,JacksonJS.Vigilanceinthediscrimination-stressmodelforBlackAmericans.PsycholHealth.2015;30(3):253-267.doi:10.1080/08870446.2014.96610465.FreyT,YoungRK.Correctandpreferredusage.In:ChristiansenS,IversonC,FlanaginA,etal.,eds.AMAManualofStyle:AGuideforAuthorsandEditors.11thed.OxfordUniversityPress;2020:505-550.Howtocitethisarticle:BrowneNT,HodgesEA,SmallL,etal.Childhoodobesitywithinthelensofracism.PediatricObesity.2022;17(5):e12878.doi:10.1111/ijpo.12878BROWNEETAL.9of9
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