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 Table of Contents  
Year : 2018  |  Volume : 2  |  Issue : 4  |  Page : 98-105

Ethnic inequalities in cardiovascular disease risk: Strength of ethnic identity predicts obesity prevalence in late adolescence

1 Collaboration for Outcomes Research and Evaluation (CORE), Faculty of Pharmaceutical Sciences, University of British Columbia; Centre for Health Evaluation and Outcomes Science, Providence Healthcare Research Institute, St. Paul's Hospital, Vancouver, BC, Canada
2 Department of Psychology, Faculty of Arts, University of British Columbia, Vancouver, BC, Canada
3 Centre for Health Evaluation and Outcomes Science, Providence Healthcare Research Institute, St. Paul's Hospital, Vancouver, BC, Canada
4 Department of Behavioural Neuroscience, Faculty of Science, University of British Columbia, Vancouver, BC, Canada
5 Centre for Health Evaluation and Outcomes Science, Providence Healthcare Research Institute, St. Paul's Hospital; Epidemiology, Biostatistics and Public Health Practice (EBPHP), School of Population and Public Health, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada

Date of Web Publication30-Oct-2019

Correspondence Address:
Dr. Annalijn I Conklin
University of British Columbia, 2405 Westbrook Mall, Vancouver, BC
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/hm.hm_36_19

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Background: Cardiovascular diseases are a leading cause of death globally, and a major risk factor is obesity in early age groups. Obesity in children and youth is a growing public health concern, and inequalities exist across social groups. Evidence on ethnic disparities in obesity risk is mixed, and little is known about ethnicity and obesity in late adolescence. Moreover, broad ethnic identity categories may be less informative for understanding disparities in obesity risk than the psychosocial process of ethnic identity development during this unique developmental period. Differences in the salience of ethnic identity seem particularly relevant to examining obesity inequalities in multicultural, multigenerational settings. Aims and Objectives: To examine the gender-specific associations of strength of ethnic identity with the obesity prevalence in ethnically diverse urban youth from British Columbia (BC), Canada. Materials and Methods: Cross-sectional study of an adolescent cohort with self-reported data on ethnic identity, sociodemographics, height and weight using regression modeling with interaction terms. Results: Above-average ethnic identity was associated with the higher obesity prevalence in young men only. Multivariable-adjusted models showed that young men reporting the strongest ethnic identity had 57% higher odds of being obese (odds ratio 1.57 [95% confidence interval: 1.05–2.37]). Conclusion: Associations varied by gender and ethnic group: stronger ethnic identity was significantly associated with the higher obesity prevalence in young men from Asian and Indigenous cultural heritage, whereas young women from Indigenous backgrounds with stronger ethnic identity showed a nonsignificant lower obesity prevalence. Future research directions and public health program implications are discussed.

Keywords: British Columbia Adolescent Substance Use Survey cohort, cardiovascular disease inequalities, ethnicity, pediatric obesity, self-concept

How to cite this article:
Conklin AI, T. Tam AC, Yao CA, R. Guo SX, Richardson CG. Ethnic inequalities in cardiovascular disease risk: Strength of ethnic identity predicts obesity prevalence in late adolescence. Heart Mind 2018;2:98-105

How to cite this URL:
Conklin AI, T. Tam AC, Yao CA, R. Guo SX, Richardson CG. Ethnic inequalities in cardiovascular disease risk: Strength of ethnic identity predicts obesity prevalence in late adolescence. Heart Mind [serial online] 2018 [cited 2022 Dec 2];2:98-105. Available from: http://www.heartmindjournal.org/text.asp?2018/2/4/98/270069

  Introduction Top

Heart and stroke diseases are a significant global burden and a leading cause of death among women in Canada.[1] A major cardiovascular disease (CVD) risk factor is childhood and adolescent body mass index (BMI).[2] Child and adolescent obesity is a global epidemic[3] and a national crisis in Canada: over 25% of young Canadians have excess body weight, and current trends are projected to result in 70% of adults aged 40 years having excess weight by 2040.[4] Clinically measured obesity in children and youth has tripled from 3% to 9% between the late 1970s and early 2000s, with the fastest rise seen in youth aged 12–17 years (from 14% to 29%).[5] Thus, the CVD burden will likely continue. Of significance for CVD prevention is the strong social gradients in risk factors, particularly the inequalities in obesity. For example, obesity is 2.5 times higher among young people of Indigenous origin (living off-reserve) than among non-Indigenous youth and is twice as prevalent among boys than girls.[6] Notably, the Canadian Cardiovascular Society identifies obesity as a potential route for heart failure prevention among both South Asian and Indigenous populations.[7]

Although ethnicity is an important social determinant of obesity, higher obesity among minority ethnic groups is not consistently reported in the literature,[8] and ethnic disparities in obesity also appear to vary by gender.[9] We need better assessment and understanding of the complex relationship between ethnic identity and obesity to improve CVD prevention and tackle extant inequalities in CVD risk factors. Available evidence to inform health and social policy and services is limited to ethnic disparities in obesity among new immigrants,[10],[11],[12],[13] and no studies to date compare ethnic differences in obesity among adolescents living in a multiethnic, multigenerational community context. Since individuals within and between ethnic groups differ in their exploration and commitment to their ethnicity, the strength of ethnic identity deserves research attention as an important dimension of an adolescent's sociocultural life that may provide more accurate information about ethnic disparities in obesity prevalence.[14]

Ethnic identification results from a psychosocial process, wherein an individual aligns their self with their heritage culture by exploring and affirming the subjective label of one's personal identity.[15] A stronger ethnic identity in adolescents could affect the obesity prevalence by providing health-related psychological and social resources, including self-esteem, values and a sense of belonging, and purpose and pride. Greater exploration of ethnic identity among rural Indigenous youth was linked to a positive later body image in young men.[16] Similarly, greater overall ethnic identification was correlated with lower weight-related concerns and lower body dissatisfaction among young Māori women.[17] Other research supports the protective effects of messages of pride and feelings of community support on psychosocial outcomes in ethnic minority youth and on health-related quality of life in minority obese youth.[18],[19] In addition, a strong connection to one's culture and heritage could affect adolescents' weight through traditional practices that are health-promoting (e.g., more nutritious food intakes in Cherokee youth)[20] or health-harming (e.g., less exercise in British-Asian girls or sugary and fast food as reward/punishment in Chinese families).[21],[22]

The subjective attachment and sense of belonging to one's ethnocultural group have implications for public health programming as these factors appear to be critical to the successful use of “culture as prevention and intervention” for adolescents with chronic conditions such as diabetes and asthma.[23],[24],[25] Despite ample health disparities research showing strong differences in obesity by gender and ethnicity,[26],[27] the strength of ethnic identification in obesity risk is under-studied and is rarely considered together with gender.[28] The promise of “culture as prevention and intervention” as a strategy to tackle inequalities in CVD risk factors depends on better assessment and understanding that goes beyond the simple categorization of young people into broad ethnicity groups. Thus, we aimed to determine whether strength of ethnic identity was linked to adolescent obesity using an ethnically diverse population-based cohort in British Columbia (BC), Canada. We hypothesized that stronger ethnic identification would be related to lower obesity levels and that associations will differ by gender and ethnic group.

  Materials and Methods Top


Participants provided written informed consent based on school district procedures before completing online surveys on their own time or during school-scheduled computer time. The British Columbia Adolescent Substance Use Survey (BASUS) cohort study was approved by the University of British Columbia Behavioural Research Ethics Board (#H08-02841).

Study design

We used prospective data from the population-based BASUS cohort of youth aged 13–18 years who volunteered to participate. With support from the Ministry of Education School Districts and Secondary School administrators, the cohort recruited volunteer adolescents through 86 secondary schools covering the complete geography of the province, with school-specific response rates averaging 20% (range: 2%–100%).[29] Participants self-reported on the strength of ethnic identification (n = 1236) and sociodemographics (n = 973) in Wave 5 (Fall 2011), and on weight and height (n = 1575) in Wave 6 (Spring 2012), with a study sample of 795 participants with complete data at both waves. The distributions of sociodemographic and health characteristics were similar between our analyzed sample and the whole cohort. [Supplementary Table 1[Additional file 1]].


Strength of ethnic identification

We measured ethnic identification overall and by subcomponent using the Multigroup Ethnic Identity Measure-Revised (MEIM-R) that comprised six statements with five-point Likert scale response options from “strongly disagree” to “strongly agree.” We averaged the Likert response items to calculate an overall score (n = 1236) and two subscale scores (exploration, n = 1282; commitment n = 1246), with higher scores indicating stronger ethnic identification.[15],[30] To aide interpretation, each continuous score was mean-centered (range: −2, 2). Quintiles of the overall score were used for descriptive statistics ( first quintile represents the lowest MEIM-R score).

Obesity prevalence

We used self-reported data on height and weight at the 6-month follow-up to calculate BMI (kg/m2). We classified participants either obese (>97th percentile) or nonobese (3rd to 97th percentile) based on gender- and age-specific BMI percentiles in standard Canadian growth charts. We excluded participants (n = 61) who were underweight (i.e., BMI below the 3rd percentile: Female <16.1 kg/m2, male <16.2 kg/m2) or who had extreme obesity (i.e., BMI outside chart values: Female >41.5 kg/m2, male >40.5 kg/m2) that is strongly determined by genetic factors[31] and disproportionately affects specific ethnic groups.[32]


We included the following covariables in the main analysis: Ethnicity (White [reference], Asian, Indigenous, or others [Latino, Black, and Other]); maternal education (Undergraduate or above (reference), some college/trade school, high school, below high school); and pubertal stage (post-pubertal [reference], late pubertal, mid-pubertal, early pubertal, and prepubertal). Pubertal stage was used to control for development-related weight change,[33] and derived from questions on sex-specific development (e.g., body hair) following an established method.[34] Sensitivity analyses included additional covariables: Perceived relative family income (far above average/quite a bit above average (reference), slightly above average, average, slightly below average, quite a bit/far below average); depression (Center for Epidemiological Studies Depression (CESD score ≥24);[35] sleep deprivation (i.e., <8 h of sleep/night); and lifestyle factors (hours of sport and screen time, tobacco use, and sugar/caffeine intake).

Statistical analysis

Frequencies and means (standard deviation [SD]) described baseline sociodemographic and health characteristics across overall ethnic identification. A correlation matrix assessed interrelationships of the three MEIM-R scores [Supplementary Methods [Additional file 2]].[15],[30],[36],[37],[38],[39] Our a priori strategy for the main cross-sectional analysis was to assess the association between strength of ethnic identity and obesity prevalence in adolescent girls and boys. Separate logistic regression models, serially conditioned on pubertal stage (Model B), ethnicity (Model C), maternal education (Model D), used interaction terms to confer the advantage of large sample size when data are sparse,[40] and were run twice with alternate coding of the male/female variable (female = 0/male = 1 and female = 1/male = 0) to generate gender-specific estimates. We used postestimation calculation of average marginal effects and graphical representation to reveal gender differences in the relationship between strong ethnic identity and obesity prevalence. Main results are reported as odds ratios (ORs) and 95% confidence intervals (95% CI) (beta-coefficients available in [Supplementary Table 2 [Additional file 3]]. The final analytic sample size ranged from 795 to 820, as complete responses varied depending on the MEIM-R question.

Results were tested for robustness through additional conditioning on relative family income, depression, and health behaviors. We respecified models to replace maternal education with perceived family income which might be more reliably reported. We respecified models to include overweight in the dependent variable. We further considered that main results may still vary by ethnicity despite the MEIM-R being validated for comparing multiple ethnic groups, since a stronger commitment to the dominant Anglo-Canadian culture could differ psychologically from stronger commitment to a minority culture in Canada. Hence, secondary analyses reexamined gender-specific associations for White, Asian, and Indigenous ethnic groups using dichotomized ethnicity variables in three-way interaction terms. All analyses were done in Stata 13.1 StataCorp. 2013. Stata statistical software: Release 13. College Station, TX: StataCorp LP and all results are reported by gender in accordance with the federal funder's mandate for health research.[41],[42]

  Results Top

Our sample averaged 14.8 years of age (SD 0.6), with 60% females and 50% White followed by 37% Asian and 10% Indigenous. Most adolescents were in good or excellent health (68%), had a university-educated mother (46%), and were in relatively higher-income families (45%). Overall, 15% of the study sample was considered overweight and 7% were in the obese category. About 12% of adolescents had the strongest overall ethnic identification, 9% had the highest exploration and 14% had the highest commitment scores. [Table 1] shows the variation in sociodemographic and health characteristics across increasing strength of overall ethnic identity. A lower proportion of adolescents who reported the strongest ethnic identification were female, had White ethnicity, and were not sleep deprived, whereas a higher proportion rated their health as very good/excellent at baseline and were classified as obese at follow-up. [Supplementary Table 3 [Additional file 4]] and [Supplementary Table 4 [Additional file 5]] show the social patterning of across levels of the exploration and commitment subcomponents of ethnic identity.
Table 1: Descriptive characteristics across quintiles of overall ethnic identification among young people in the BASUS cohort

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Gender-specific associations between strength of ethnic identity and obesity prevalence

Multivariable-adjusted analyses showed a statistically significant association between ethnic identification and obesity prevalence in young men only. [Table 2] shows that young men had significantly higher odds of being obese with an increasing strength of ethnic identification overall (OR 1.57 [95% CI: 1.05–2.37]) and by subcomponents of exploration (1.46 [1.01–2.11]) and commitment (1.56 [1.05–2.33]). By contrast, there were no associations in young women, but the difference from young men was not statistically significant. [Figure 1] illustrates the gender differences in the main association between increasing strength of ethnic identity and the predicted mean probability of having obesity. On average, predicted obesity levels were highest (22%) among young men with the most above-average ethnic identification and were lowest (5%) among young men with the most below-average ethnic identification. Results were similar after sensitivity analyses, but overall ethnic identification was not linked to obesity in young men when additionally adjusting for depression and lifestyle factors, or including overweight; however, stronger exploration and overweight/obesity was significant in young women [Supplementary Table 5 [Additional file 6]].
Table 2: Odds ratios (95% confidence interval) of self-reported obesity status across increasing strength of ethnic identification in late adolescence

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Figure 1: Predicted probabilities of obesity associated with greater strength of ethnic identification in young men (left panels) and young women (right panels) in the British Columbia Adolescent Substance Use Survey cohort. Marginal effects of overall ethnic identification mean-centered scores (a), exploration subscale scores (b), and commitment subscale scores (c), adjusted for pubertal stage, ethnicity, and maternal education

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Potential effect modification for Asian and Indigenous ethnic groups

Our secondary analyses revealed potential ethnic group differences in the gender-specific association of ethnic identity strength and obesity prevalence [Figure 2]. For young men with the strongest ethnic identity, mean obesity levels were predicted at 30% for those from Asian backgrounds and 15% for non-Asian counterparts [Figure 2]a. The gender-specific patterns were most notable for the Indigenous groups; a small positive association was seen among young men from Indigenous backgrounds, but stronger ethnic identification predicted lower obesity levels in Indigenous young women [Figure 2]b.
Figure 2: Ethnic differences in the predicted probabilities of obesity associated with strength of overall ethnic identification in young men (left) and young women (right) in the British Columbia Adolescent Substance Use Survey cohort. Marginal effects of mean-centered scores adjusted for pubertal stage, ethnicity, and maternal education. (a) Blue, Asian; red, non-Asian, (b) Blue, Indigenous; red, non-Indigenous, (c) Blue, White; red, non-White

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  Discussion Top

This cross-sectional population-based study examined whether the strength of ethnic identity was linked to adolescent obesity using gender-based analysis. Our main results are striking as they do not support our main hypothesis that stronger ethnic identification is protective of obesity status, until both gender and ethnic group are considered simultaneously. In general, we found that stronger ethnic identification overall and by subcomponent was linked to higher levels of obesity but only in young men, supporting our hypothesis of gender differences. The positive association appeared to be primarily driven by the strong commitment component of the ethnic identification process, which reflects young men feeling a strong sense of belonging and attachment to their own ethnic group, and also understanding what that membership means. Our hypothesis of ethnic variation was also supported and differed by gender; results suggested that stronger ethnic identity was linked to higher obesity in both Asian and Indigenous young men, but associations were null or inverse in Asian and Indigenous young women, respectively.

These findings need to be understood in terms of the meaning of commitment and exploration in the context of ethnic identity. Commitment has been described as attachment or internalized affiliation to the group;[43] in other words, an emotional connection or gravitation towards the group.[43],[44] In contrast, exploration of identity is grounded in the interactions and engagement, rather than the feelings of belonging one has with members of one's ethnic group.[30] Associations with the obesity prevalence were stronger for young men's commitment to their ethnic identity and thus engagement in traditional foods and eating practices may play a role. Cuisine and foods that are traditional to one's ethnic group are considered to be an integral part of one's ethnic identity and cultural celebrations typically involve traditional eating practices.[45],[46] Although adolescents who are eating home-cooked traditional meals often believe these meals are more healthy,[46],[47] it is important to recognize that not all traditional diets are healthy.[48] In Canada, the Asian population constitutes an estimated 29% of the BC population and 47% of the largest city, Vancouver. The most prominent Asian groups include Chinese (21%), East Indian (10%), and Filipino (6%),[49] with distinct differences in traditional diets and associated CVD risk.

Of significance to this study, the traditional cooking practices of many South and Southeast Asians often involve higher overall intakes of saturated fats associated with the regular use of coconut oil, palm oil, and ghee (i.e., clarified butter).[50] A review of the Indian diet showed regional patterns with more sugary diets in Eastern and Southern India that are related to greater body size.[51] By contrast, a more traditional Chinese diet is characterized by mostly rice, red meat, white meat, and leafy vegetables, which has been associated with lower of obesity in children and youth compared to counterparts eating a less traditionally Chinese diet.[52] It is also important to note that an in-group bias exists in some ethnicities where the food beliefs of the head of households reflect what children ought to, and do, consume. As our sample of Asian adolescents is likely dominated by Chinese backgrounds, it is notable that older Chinese-Canadian adults believe the Chinese diet is more healthy than a Western diet and older adults typically influence the household's eating behavior to include a traditional diet.[53] A final consideration for the healthfulness of traditional dies is the availability of ethnic foods which may be limited to processed products that are imported to Canada and that could lower the quality of the traditional diet and negatively affect weight. In addition, there are gender-normative food beliefs that boys ought to eat more[22] and that overweight is not unhealthy,[47] which could lead to overfeeding and negative metabolic consequences for young men's obesity status in particular.

Null findings about stronger ethnic identity and obesity in young women might be explained by girls' behaviors to achieve a gender-specific ultrathin beauty ideal that dominates media and marketing not only in Western societies[54],[55] but also in many Asian countries.[56] That is, regardless of the strength of their attachment to their ethnic group, there is an overarching pressure from global popular culture to conform to a thin body size ideal that, for many, requires weight control behaviors. The countereffect on weight of mainstream ideals or weight control behaviors is an area for further investigation to better understand if they diminish the association between strength of ethnic identity and obesity in adolescent girls. However, it is possible that strength of ethnic identity is linked to obesity in young women from certain ethnic backgrounds. In the Canadian context, stronger ethnic identification appeared to predict lower levels of obesity among Indigenous young women. A recent systematic review of diets among Canadian Indigenous youth showed that the dominant foods consumed are purchased/market foods and not traditional foods.[57] Evidence suggests that traditional foods among Indigenous groups are beneficial in providing nutrients that are otherwise missed in market foods.[58],[59] Thus, as food production is typically a social role assigned to women, young women from Indigenous backgrounds with strong ethnic identification may have greater exposure to traditional food practices and consume a healthier diet, leading to less obesity.

The preliminary evidence from this study illustrates the importance of developing a more nuanced understanding of ethnic inequalities in adolescent obesity through explicit attention to the complex interrelationships between ethnic group, strength of ethnic identity, and gender. This work suggests that it may be beneficial to Indigenous youth for school curriculum to integrateFirst Peoples Principles of Learning and traditional food practices. Culturally tailored interventions for specific Asian ethnicities might include family-based education on healthy eating practices. That is, culture-based programs and interventions to reduce inequalities in CVD risk factors among youth should consider adopting differential approaches across subpopulations. However, findings should be replicated to support future strategies seeking to use “culture as prevention and intervention.”

Limitations and future research

Recall or social desirability bias could affect our self-reported exposures and outcomes. The underestimation of the obesity prevalence from self-reported height and weight is well known, but this study aimed to assess how contextual factors link to obesity, for which relative rank in BMI categories is a useful measure. Notably, the BMI distributions of this study are similar to larger, more representative health studies in BC where BMI was also calculated from reported height and weight.[60] Our limited number of ethnic groups did not allow us to adjust for the diversity of Indigenous peoples (e.g., First Nations, Métis, Inuit) or Asian subgroups (e.g., South Asians, East Asians, Pacific Islanders). However, measurement error would lead to underestimation of coefficients due to nondifferential misclassification bias and thus findings are conservative. Residual confounding remains a source of bias in the results, as other factors, such as girls' parity status, were not collected and could confound the association. Missing data predominantly on covariables may have introduced selection bias in our study, although our analyzed sample appeared to be representative of the full cohort apart from a slightly higher proportion of young men with university-educated mothers and from Asian backgrounds, and slightly lower proportion of young men from Indigenous backgrounds (Supplementary Materials). Nevertheless, loss of sample size likely limited the power to detect a significant result for the effect modification of ethnicity.

This study's strengths include the prospective data from a population-based adolescent cohort that is representative of the broader population of diverse youth in BC, and the adjustment of several known confounders including ethnicity and socioeconomic status. We used pubertal stage derived from sex-specific development questions as a better proxy than age for development-related weight gain given the known gender differences in pubertal timing[61],[62] and individual variability around maturation.[33] This work advances the evidence base in several notable ways. First, we examined the strength of ethnic identification overall and by subcomponent rather than generic ethnicity so as to improve our assessment and understanding of ethnic inequalities in CVD risk factors. Second, we focused on late adolescents (13–17 y) who have a unique developmental period of constructing the self-concept and negotiating identity beliefs including food practices. Third, the novel exposure measure of MEIM-R allows for meaningful comparisons to be drawn across ethnic groups.[15] Finally, we contributed a critical gender perspective on the role of strength of ethnic identification and adolescent obesity, with potential modification by ethnicity.

  Conclusion Top

This study is the first to demonstrate a significant cross-sectional association between the psychosocial process of ethnic identification and obesity in late adolescence and to show clear gender differences that may also vary by ethnicity. Strong commitment to ethnic identity was linked to higher obesity levels in healthy young men in Canada, particularly from Asian backgrounds, but to lower obesity levels in healthy young women from Indigenous backgrounds. Future work should improve the evidence by including more distinct ethnic minority groups and examining young people in other settings. Research is also needed on the longitudinal changes in body weight for better causal inferences about the formation of ethnic identification during a young person's development cycle and its impact on obesity among other CVD risk factors. More detailed knowledge of the feeding practices of parents who strongly identify with their heritage could inform future public health interventions that incorporate the head of households and the cultural context to improve weight and CVD outcomes in young people.


The authors wish to thank the participants of the BASUS cohort study. We also acknowledge the partial funding support from the University of British Columbia.

Financial support and sponsorship

This study received partial funding support from the UBC Work Learn Program summer 2017 (Projects 170278 & 170279).

Conflicts of interest

There are no conflicts of interest.

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