Background
Obesity prevalence is increasing in the US and is particularly prevalent among Black Americans. Increasing clinical and policy attention focuses on the role of education and income in disparities. Prior evidence linked education to lower obesity prevalence among Black and Hispanic men. Understanding heterogeneity in the relationships between these factors and obesity may guide interventions and shed further light on the role of these factors in health broadly.

Methods
We use the 2019 National Health Interview Survey (NHIS) to examine the relationships between obesity (body mass index ≥ 30), education, and per-capita household income among US adults. Stratifying by race, ethnicity, and sex, we use logistic regression to identify varying effects of education and income on the likelihood of having obesity conditional on age.

Results
Among Black men, increasing education is not associated with higher levels of obesity. This contrasts sharply with Hispanic men, non-Black non-Hispanic men, and Black women, among whom the odds ratios for having obesity are 0.48, 0.56, and 0.53 with a college degree (p<0.01), and contrasts with older evidence. Regarding income, among non-Black non-Hispanic men, doubling income lowers odds of obesity (OR=0.87, p<0.01). Over 50% of this relationship is education related – conditional on education; the odds ratio rises to 0.94 (p<0.05). The income-obesity relationship runs in the opposite direction among black men. Doubling income is related to a 1.15x increase in the odds of obesity (p<0.1). Among Hispanic men, income and obesity are unrelated. Among non-Black non-Hispanic women, the income-obesity relationship is stronger– decreasing odds by 0.74x when income doubles. Among Black and Hispanic women, the odds of having obesity decline by 0.85x and 0.79x, respectively, when income doubles (p<0.01).

Conclusion
Education and income are considered fundamental social determinants of health. Concerning obesity, their role is not straightforward, varying substantially by race and sex. Black men stand out in this regard, as education is unrelated to obesity, and higher-income raises the risk of obesity, contrasting with every other demographic group. Clinical and policy efforts which address economic and education-linked determinants of health are not likely to alone be sufficient in closing obesity disparities by race.

Examining race, ethnicity, and gender disparities in obesity by socioeconomic status in the United States

Public Health and Health Policy

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