Racial and Ethnic Disparities in Adult Obesity Across Food and Physical Activity Environments in the United States: A Multilevel Analysis

Background: Adult obesity remains a critical public health issue in the United States, with marked disparities across racial and ethnic groups. Minority populations are often disproportionately exposed to unhealthy food and physical activity environments, yet little is known about how these exposures modify associations with obesity risk. Methods: We applied multilevel modeling to data from 3,194 U.S. counties across 50 states and the District of Columbia (2014–2024). County- and state-level measures of food and physical activity environments were examined in relation to adult obesity prevalence, with cross-level interactions tested between racial/ethnic population composition and key environmental variables (e.g., fast-food density, grocery access, supercenter prevalence, low-income low-access rates). Analyses were stratified by American Indian or Alaska Native (AIAN), Asian, Hispanic, Native Hawaiian or Other Pacific Islander (NHPI), Non-Hispanic Black (NHB), and Non-Hispanic White (NHW) populations. Results: Significant cross-level interactions were observed for counties with higher AIAN, NHB, and Hispanic populations. Fast-food restaurant density was more strongly associated with adult obesity in counties with larger AIAN and NHB populations. Convenience store counts were positively associated with obesity prevalence in counties with higher NHW populations. Conclusions: Associations between food environments and adult obesity vary by racial and ethnic composition. Geographic and demographic context should be incorporated into public health strategies in order to promote equity and lessen disparities in the prevention of obesity.