practice, how health care professionals are trained, and research initiatives and thus has an impact on health care spaces, such as academic medical centers, and the health care system more broadly.31


In several ways, racism and its impact on


policies, interpersonal relationships, and influential factors of society (eg, edu- cational opportunities and factors influencing socioeconomic status attainment) is a primary social determinant of health, as it influences almost all social deter- minants of health mentioned in this chapter (eg, socioeconomic status, the built environment, and others). For this reason, some researchers consider racism a “fundamental cause” of health inequities.32 One hypothesis that has emerged to explain the effects of racism on individual


health outcomes is the weathering hypothesis. This hypothesis states that contin- ued exposure to social and economic disadvantage can lead to declines in physi- cal health through biological and physiological mechanisms (eg, a high allostatic load and inflammation from chronic stress).33


Stress itself, which can occur from


chronic exposure to systematic disadvantage, has three main influences on obesity development and maintenance, as seen in Box 2.1.34


BOX 2.1


The Influence of Stress on Obesity34


Stress affects self-regulation. Stress influences choices involving diet, physical activity, and sleep. The experience of stress affects neurochemistry and the microbiome.


Thus, it is imperative to recognize the influence of institutional racism on inequities in the built environment, psychosocial factors, and sociocultural norms and, subsequently, its impact on the health of individuals. The instances of racism that Black, Hispanic, American Indian, Pacific Islander, and Alaska Native patients experience can result in physiological and biological changes that influence health outcomes, specifically obesity risk.35


For example, perceived discrimination due to


race has shown an association with high blood pressure, increased cortisol levels and heightened stress response, weight change, metabolic syndrome severity, and sleep disturbances that can increase cardiometabolic risk.36-40


Socioeconomic Status and Food Insecurity


Lower socioeconomic status is associated with increased risk for the development of obesity.41


Food insecurity is one avenue through which socioeconomic status


influences obesity risk and development. Food insecurity occurs when a person has insufficient resources to purchase food, which results in a disruption of eating pat- terns and potential alterations in energy or nutrition needs; consequently, a person experiences hunger.42


enced food insecurity at some point during the year.42


In 2016, 12.3% of households in the United States experi- Black, Hispanic, American


Indian, and Alaska Native individuals experience higher rates of food insecurity than White individuals.43,44


Hispanic households experienced food insecurity in 2016.42 and Alaska Natives were twice as likely as Whites to experience food insecurity 28 S E CT ION 1 : Foundations of Treatment: The Human Element


Specifically, 22.5% of Black households and 18.5% of American Indians


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