The Problem. The preponderance of fast food restaurants in low-income neighborhoods—especially near schools—poses a significant challenge in the fight to reduce childhood obesity. According to findings from a study of middle and high school students in California ("Proximity of Fast-Food Restaurants to Schools and Adolescent Obesity." American Journal of Public Health, 99(3): 505–510, 2009. Available online.), students with fast food restaurants within a half mile of their school ate less fruits and vegetables, consumed more sugared soda and were more likely to be overweight or obese than students whose schools were not near fast food restaurants.
What factors are associated with the clustering of fast food restaurants close to schools? Do these restaurants seek out the most populated neighborhoods? Or, are they more likely to cluster around schools serving minority or poor children? Naa Oyo A. Kwate, PhD, set out to find some answers.
RWJF Approach. The Robert Wood Johnson Foundation (RWJF) is committed to reversing the childhood obesity epidemic by 2015 and has established several programs to achieve that goal. Its Health Eating Research program supports research about environmental and policy strategies with potential to promote healthy eating among children. The program places special emphasis on research about children at greatest risk for obesity: Black, Latino, American Indian, Alaska Native, Asian-American and Pacific Islander children and children who live in lower-income communities. Target populations include young people ages 3 to 18 and their families.
Inspired by a university. Academics loomed large in Naa Oyo Kwate's early life. Kwate was born of Ghanaian parents and raised in Chicago's Hyde Park section. Her walk to and from public grammar school took her through the campus of the University of Chicago. It made an impression. "Even though I didn't know what went on exactly," she says, "just the idea of the campus and all that studying!" Though Kwate always enjoyed school, she did not start out dreaming to be an academic or a researcher. "I wanted to be a doctor," she says.
On-the-job experiences shape a career. Kwate attended Carleton College, a small liberal arts school in Northfield, Minn. A freshman psychology course sparked her interest and prompted her to major in psychology. Later in college, Kwate worked as an intern with a clinical social worker at Chicago's Cook County Hospital and thought she'd found her career. She sat in on therapy sessions and intake interviews, most often with children and their families. "I got the idea of what clinical practice in mental health was like," she says. "And, I thought it was amazing."
That experience led Kwate to consider a career as a clinical psychologist. Other undergraduate experiences further refined Kwate's career goals, exposing her to research methods and to Black issues. A Black history class taught by professor Harry M. Williams, PhD, proved critical in shaping her interests. "I was interested in the African-American experience from a scholarly standpoint," she says. "I did my senior thesis on collective self-esteem of Black children."
When it came time to choose a graduate school, however, Kwate still had her sights set on a career in clinical psychology.
New York City/A researcher emerges. Kwate chose St. John's University in New York City for her graduate work. As a self-proclaimed "city kid," she looked forward to life in a big city again. Kwate had a show on the college radio station at Carleton and considered herself a hip-hop aficionado. Among her favorite groups were Public Enemy and Eric B. and Rakim. "New York was sort of the mecca land for hip-hop," she says.
But, it was more than her taste in music that drew Kwate to New York. "St. John's had many things going for it," she says. The university offered a children's track in clinical psychology, a field of interest to Kwate. It also offered psychology professor and author Beverly Greene, PhD. Greene would have a lasting effect on Kwate. Greene saw a burgeoning writing talent in the young graduate student, and offered lots of encouragement. "I guess I wrote relatively well," Kwate says humbly.
An externship at a New York City hospital proved critical in refocusing Kwate's career towards understanding racial identity and the relationship between race and health. "I was struck by the amount of chronic illness that both the children and their care-givers face," she says. "So I became more interested in trying to understand how social position affected health overall as opposed to only mental health."
After receiving her doctorate in 2002, Kwate accepted a post-doctoral position at The Mt. Sinai School of Medicine in Manhattan, and began working in cancer prevention. "I got some training in behavioral medicine, chronic illness in terms of cancer and that type of thing," she says.
It was at Mt. Sinai where Kwate came to connect her concern for helping people with her desire to analyze and understand how race and culture affect health. "Some of the research I was doing at Mt. Sinai, such as racial identity, reflected earlier interests in graduate school."
In 2004, Kwate began work as an associate research scientist for the Department of Sociomedical Sciences at Columbia University's Mailman School of Public Health. Two years later, she became an assistant professor. From a childhood walking across a campus on her way to school, to Carleton College and Harry William's Black history classes, to a faculty position at Columbia University, Kwate's journey to academia was complete. "There was never any doubt after Columbia," she says of her academic career choice.
Making the connection with RWJF. In December 2006, Kwate learned of a collaboration between RWJF's Healthy Eating Research program and its New Connections: Increasing Diversity of RWJF Programming initiative. New Connections is a national program that aims to expand the diversity of perspectives that informs RWJF programming and to introduce early-career researchers and scholars from historically disadvantaged and underrepresented communities to RWJF and one another.
In 2006, Healthy Eating Research released a special solicitation targeted to researchers eligible for New Connections grants. The special solicitation focused on children's food environments and policies in selected community settings: preschool, child-care, school and after-school environments, as well as nearby food outlets. "I applied because the opportunity to participate in the joint programming of New Connections and Healthy Eating Research was unique," says Kwate. "I was attracted not only by the funding that would allow my research, but the community of scholars and mentors that comprise the program." Kwate's study was funded in September 2007.
Fast food outlets in New York City. Kwate started by examining the location of fast food restaurants in New York City neighborhoods. She learned that predominately Black areas in the city had higher densities of fast food outlets than predominately White areas. She also learned that high-income Black areas had similar exposure to fast food as low-income Black areas. Race and not income, therefore, was the determining factor of fast food density.
Armed with the knowledge that fast food outlets are more common in Black neighborhoods overall, Kwate set out to explore whether this situation had implications for childhood obesity. The aim of her Healthy Eating Research project was to examine whether fast food outlets clustered near schools, and specifically whether they were more likely to cluster near schools in Black, Latino or low-income neighborhoods.
The New York City Board of Education provided a list of all schools in New York City and the Department of Health and Mental Hygiene provided access to its restaurant inspection database. "We were able to map where all the schools are and where all the fast food is," she says. "Then we looked at that relationship to see whether fast food restaurants are in close proximity to schools more than they would be if they were just random."
Kwate also examined areas around schools in Black neighborhoods. She reasoned that if there was a disproportionate clustering of fast food restaurants near these schools, then large cohorts of Black children were being exposed to unhealthy foods, and perhaps deliberately so.
The first part of the study focused on public elementary schools and public high schools. But Kwate was also interested to learn whether there was a difference in the prevalence of fast food outlets located near public schools versus private schools. "We hypothesized that public schools might be more targeted than private schools," she says.
Results: Fast food outlets cluster near schools. New York City has a lot of fast food restaurants, a factor that had to be accommodated. "One can assume," Kwate says, "that if there are 10 million fast food restaurants, the reason why they're close to schools is because there are just so many restaurants, and not because there's some sort of special relationship." Even after statistically accounting for that possibility, Kwate noted, "You still see this relationship that fast foods are closer to schools than would be expected by chance. It was striking," she says.
Especially in Black neighborhoods. Although her hypothesis and previous literature led Kwate to expect disproportionate clustering of fast food restaurants around schools in Black neighborhoods, the strength of the associations surprised her. "We found that [public elementary] schools with high proportions of White students have the lowest exposure [to fast food restaurants]. Only schools with low proportions of White students and high proportions of Black students have high exposure."
She also found that "elementary schools, both public and private, that were in low income areas, had more fast food restaurants in close proximity than those in high income areas."
Kwate noted some differences between public versus private schools. She found that at distances less than 250 meters from public or private elementary schools, there is little difference in the prevalence of fast food outlets. At greater distances, however, public elementary schools had 1.25 times as many fast food restaurants as would be expected, even after controlling for zoning and other factors.
"What the study tells us," Kwate says, "is that children at the highest risk for obesity in New York City, which would be Black and Latino students, face food environments that are markedly different than their predominantly White and higher income counterparts. This doesn't bode well for their health trajectories and the portrait of obesity in New York City."
A bigger vision for a better solution. Kwate hopes that studies like hers will start people thinking about change on levels both obvious and systemic. "In a perfect world, it wouldn't affect only restaurant policy and other policies such as zoning," she says, "but also the upstream determinants…. I think the forces of institutional racism that produced the policies in the first place are really where we have to direct our energies."
An award-winning investigator and a new job. Kwate, with her colleague Ilan H. Meyer, PhD, has since received a 2008 grant under RWJF's Investigator Awards in Health Policy Research national program, to investigate the impact of meritocratic ideology in the U.S. on Black health. The Investigator Awards program supports researchers whose crosscutting and innovative ideas promise to contribute meaningfully to improving health and health care policy. It provides one of the few funding opportunities for investigator-initiated projects that are broad in scope, innovative in approach and have national policy relevance. "I feel blessed to be an RWJF grantee," she says. "They really fund amazing work and it gives me an opportunity to meet talented scholars."
In September 2010, Kwate became an associate professor in the Departments of Human Ecology and Africana Studies at Rutgers University in New Brunswick, N.J.
RWJF perspective. Healthy Eating Research solicits scientifically rigorous, solution-oriented proposals from investigators representing diverse disciplines and backgrounds. The program's overall aims are to identify the most promising strategies likely to have important population-level impacts and to provide decision- and policy-makers with evidence to guide and accelerate effective action to reverse childhood obesity.
RWJF Distinguished Fellow and Senior Scientist C. Tracy Orleans, PhD, notes, "The Healthy Eating Research Program provides decision-makers and key policy-makers with evidence they can use to improve children's nutrition and access to healthy foods. In collaboration with other RWJF research program and with other national research, Healthy Eating Research is building a new field of research and new body of evidence to guide national obesity prevention efforts. Our focus is on understanding and changing the policy and environmental drivers of the childhood obesity epidemic, especially in the lower-income and racial/ethnic communities at highest risk. National Program Director Dr. Mary Story has provided pioneering vision and leadership that are critical to the program's success. And Marlene Schwartz, PhD's, exceptional research and leadership offer a great example of ways in which Healthy Eating Research's empowering grants and field building activities are making it possible for outstanding scholars from many disciplines and backgrounds to change the national food policy landscape."
At the annual grantee meeting, researchers, policy-makers, advocates, funders and others come together to share study findings and the latest thinking and research methods related to healthy eating and childhood obesity prevention. Healthy Eating Research also develops research briefs and syntheses and commissioned papers that address major policy issues in childhood obesity.
Launched in 2005, RWJF envisioned New Connections as a program that would be the premiere network for connecting researchers from historically underrepresented groups with the goal of joining forces to address the nation's most pressing social problems in health and health care. New Connections has the added value of increasing the diversity of perspectives informing the Foundations' programming efforts. The goal of New Connection is to help early- and mid-career scholars develop their talents and expertise to match their drive and enthusiasm. By supporting a more diverse group of emerging and midcareer scholars, we are creating an increasingly robust and innovative conversation about our nation's health and healthcare, while also strengthening these scholars' abilities to contribute and be a part of this dialogue.
While the need to address disparities in care is well known, few strategies for reducing disparities have been studied systematically.
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