Abstract
Purpose:
Determine prevalence of overweight and obesity as reported in Head Start Program Information Reports.
Design:
Serial cross-sectional census reports from 2012–2018.
Setting:
Head Start programs countrywide, aggregated from program level to state and national level.
Subjects:
Population of children enrolled in Head Start with reported weight status data.
Measures:
Prevalence of overweight (body mass index [BMI] ≥85th percentile to <95th percentile) and obesity (BMI ≥95th percentile).
Analysis:
Used descriptive statistics to present the prevalence of overweight and obesity by state. Performed unadjusted regression analysis to examine annual trends or average annual changes in prevalence.
Results:
In 2018, the prevalence of overweight was 13.7% (range: 8.9% in Alabama to 20.4% in Alaska). The prevalence of obesity was 16.6% (range: 12.5% in South Carolina to 27.1% in Alaska). In the unadjusted regression model, 34 states and the District of Columbia did not have a linear trend significantly different from zero. There was a statistically significant positive trend in obesity prevalence for 13 states and a negative trend for 3 states.
Conclusion:
The prevalence of obesity and overweight in Head Start children remained stable but continues to be high. Head Start reports may be an additional source of surveillance data to understand obesity prevalence in low-income young children.
Keywords: pediatric obesity, pediatric overweight, Head Start, early childhood education, low-income households, young children, underserved populations, population health
Purpose
Children living in low-income households are at higher risk for obesity (BMI at or above the 95th percentile) and overweight (BMI at the 85th percentile to less than the 95th percentile) than children living in higher-income households.1,2 Establishing healthy growth patterns in early childhood is particularly important, as obesity tracks from childhood to adulthood. In one study, obesity at age 5 had a positive predictive value of 67% for the presence of obesity at age 50.3 Head Start is a federally funded program that promotes school readiness, early childhood development, and well-being for more than 750,000 U.S. children aged 3–5 years annually, most of whom are from families with incomes below the federal poverty level.4,5 Head Start programs are required to submit a Program Information Report (PIR) with information on the socioeconomic status and health of program enrollees each year.6 In 2012, programs were required to add the weight status of participating children. According to the 2016 Head Start Health Manager Descriptive Study, about 86% of program managers reported that obesity and overweight among enrolled children is a major concern.7 The publicly available PIR could possibly be considered as a tool for surveillance of obesity and overweight among low-income young children. Our study examined PIR data to describe the prevalence of obesity and overweight among Head Start enrollees by state.
Methods
Design
Head Start PIR data are used to meet congressional reporting requirements per Section 650 of the Head Start Act.8 The PIR is an annual census report consisting of information about the children, family, staff, and services of the Head Start program. It presents aggregate demographic, socioeconomic, and health data.6 This analysis abstracted data from serial cross-sectional census reports of the Head Start population, as PIR reports, from 2012–2018.
Sample
All Head Start enrollees with available data are included in PIR census reports. We did not include PIR data for children enrolled in Early Head Start, and the PIR excludes children in Head Start with missing BMI data (range: 0.0% in the District of Columbia to 6.9% in Illinois in 2018). The number of children missing BMI data was calculated by subtracting the total number of children with BMI data from the total number of enrollees. Overall, the total number of children ranged from a high of 906,194 in 2012 to a low of 759,791 in 2018.
Measures
All children enrolled in Head Start are required to have a clinical physical exam during which the height, weight, age, and sex of the child are recorded.9 Alternatively, height and weight are measured by Head Start program staff, for which there is no standard measurement protocol. This information is added to Head Start program records and used to calculate BMI percentile, which is then used to determine mutually exclusive weight status categories (underweight, healthy weight, overweight, and obesity). These categories are defined for children as follows: underweight = BMI less than the 5th percentile for age and sex, healthy weight = BMI at the 5th percentile to less than the 85th percentile for age and sex, overweight = BMI at the 85th percentile to less than the 95th percentile for age and sex, and obesity = BMI at or above the 95th percentile for age and sex.10 This information is uploaded to the electronic Head Start Enterprise System and subsequently reflected in the annual PIR as an aggregate prevalence of each weight status category for all children in each participating Head Start program. Data for the program, state, and national level are publicly available. The PIR form, detailed reports, and full data sets are accessible on the Office of Head Start Program Information Reports website.6
For the present study, state-level aggregate data on children’s weight status were abstracted from the Health Services Report, which also contains information on health insurance, medical homes, immunization services, dental services, and mental health services. Data from the BMI section of the report included the percentage of children in each of the 4 weight status categories, by enrollment year, as well as the total number of children with BMI data.
Analysis
The reported number and percentage of children in the weight status categories of overweight and obesity were abstracted for each state from 2012 through 2018; these figures were abstracted for all 4 weight status categories, including healthy weight and underweight, for 2018. We present prevalence figures for overweight and obesity during 2012–2018 by state, using descriptive statistics calculated with Microsoft Excel. In addition, we examined the trend of overweight and obesity prevalence nationally and within each state by performing a simple linear regression analysis with overweight or obesity prevalence as the dependent variable and year as the continuous independent variable. The coefficient from the regression analysis represents the annual trend or average annual change in overweight or obesity prevalence during 2012–2018. Regression analysis was performed using Stata/MP 15.1 statistical software (StataCorp LLC, College Station, TX).
Results
In 2018, overall prevalence for each weight status category for children enrolled in Head Start in all 50 states and the District of Columbia was as follows: underweight, 5.3% (range = 2.3% in Alaska to 10.6% in the District of Columbia); healthy weight, 64.4% (range = 50.3% in Alaska to 73.1% in Alabama); overweight, 13.7% (range = 8.9% in Alabama to 20.4% in Alaska); and obesity, 16.6% (range = 12.5% in South Carolina to 27.1% in Alaska) (Table 1).
Table 1.
Prevalence of Weight Status Categoriesa Among U.S. Children Enrolled in Head Start, by State, Head Start Program Information Report, 2018b.
| State/District | No. of Children | % Underweight | % Healthy Weight | % Overweight | % Obesity |
|---|---|---|---|---|---|
| Overall | 759,791 | 5.3 | 64.4 | 13.7 | 16.6 |
| Alabama | 14,170 | 4.5 | 73.1 | 8.9 | 13.5 |
| Alaska | 2,793 | 2.3 | 50.3 | 20.4 | 27.1 |
| Arizona | 15,928 | 5.1 | 63.9 | 14.3 | 16.7 |
| Arkansas | 8,157 | 5.6 | 62.3 | 14.4 | 17.7 |
| California | 84,878 | 5.0 | 64.4 | 13.5 | 17.1 |
| Colorado | 9,478 | 6.2 | 66.5 | 12.4 | 14.9 |
| Connecticut | 5,875 | 4.4 | 61.5 | 15.2 | 18.8 |
| Delaware | 1,888 | 4.5 | 61.6 | 12.7 | 21.2 |
| District of Columbia | 5,486 | 10.6 | 65.6 | 11.1 | 12.7 |
| Florida | 36,894 | 5.8 | 65.1 | 11.9 | 17.2 |
| Georgia | 22,005 | 6.2 | 68.0 | 11.2 | 14.6 |
| Hawaii | 2,652 | 5.5 | 66.7 | 13.0 | 14.8 |
| Idaho | 3,317 | 4.1 | 65.4 | 16.3 | 14.1 |
| Illinois | 30,303 | 5.2 | 63.0 | 13.9 | 17.9 |
| Indiana | 14,125 | 5.0 | 62.7 | 15.3 | 17.0 |
| Iowa | 6,358 | 3.7 | 60.5 | 17.3 | 18.5 |
| Kansas | 6,529 | 6.0 | 63.1 | 14.6 | 16.2 |
| Kentucky | 13,992 | 5.4 | 63.5 | 13.7 | 17.4 |
| Louisiana | 19,355 | 6.1 | 65.6 | 13.4 | 14.9 |
| Maine | 2,638 | 4.1 | 59.8 | 17.6 | 18.5 |
| Maryland | 8,544 | 5.5 | 67.7 | 12.1 | 14.8 |
| Massachusetts | 11,646 | 3.5 | 60.6 | 16.2 | 19.7 |
| Michigan | 27,069 | 6.1 | 62.7 | 14.6 | 16.6 |
| Minnesota | 12,170 | 5.0 | 61.3 | 15.9 | 17.8 |
| Mississippi | 22,023 | 7.2 | 60.0 | 12.3 | 20.5 |
| Missouri | 13,153 | 6.3 | 62.0 | 14.7 | 16.9 |
| Montana | 4,296 | 4.7 | 62.7 | 18.9 | 13.7 |
| Nebraska | 4,043 | 4.0 | 62.5 | 15.4 | 18.0 |
| Nevada | 3,182 | 5.3 | 68.0 | 13.4 | 13.3 |
| New Hampshire | 1,395 | 2.4 | 60.0 | 18.2 | 19.4 |
| New Jersey | 12,857 | 5.9 | 61.0 | 14.1 | 18.9 |
| New Mexico | 7,846 | 6.1 | 66.2 | 13.2 | 14.6 |
| New York | 48,287 | 4.8 | 68.9 | 12.7 | 13.6 |
| North Carolina | 19,549 | 5.7 | 64.4 | 13.4 | 16.6 |
| North Dakota | 2,629 | 3.9 | 65.3 | 16.1 | 14.7 |
| Ohio | 33,560 | 5.8 | 63.0 | 14.2 | 17.0 |
| Oklahoma | 15,612 | 4.6 | 66.8 | 13.6 | 14.9 |
| Oregon | 13,929 | 3.4 | 64.5 | 16.1 | 16.0 |
| Pennsylvania | 33,789 | 5.3 | 64.2 | 14.1 | 16.3 |
| Rhode Island | 2,363 | 3.2 | 61.0 | 11.9 | 23.8 |
| South Carolina | 11,594 | 7.2 | 69.8 | 10.4 | 12.5 |
| South Dakota | 4,092 | 4.6 | 61.3 | 17.1 | 17.0 |
| Tennessee | 17,502 | 4.9 | 65.6 | 13.2 | 16.3 |
| Texas | 66,819 | 4.7 | 65.2 | 13.4 | 16.6 |
| Utah | 5,623 | 7.7 | 65.1 | 13.6 | 13.5 |
| Vermont | 1,110 | 4.1 | 58.7 | 17.5 | 19.6 |
| Virginia | 14,017 | 5.7 | 62.7 | 14.5 | 17.0 |
| Washington | 12,185 | 3.4 | 61.3 | 16.5 | 18.8 |
| West Virginia | 7,663 | 6.2 | 63.3 | 14.8 | 15.8 |
| Wisconsin | 12,833 | 4.5 | 61.0 | 16.1 | 18.4 |
| Wyoming | 1,590 | 4.3 | 68.3 | 14.3 | 13.1 |
Weight status based on BMI-for-age percentile (kg/m2) defined as follows: underweight ≤5th percentile, healthy weight = 5th to <85th percentile, overweight = 85th to <95th percentile, and obesity: ≥95th percentile.
Percentages may not sum to 100% due to rounding.
Table 2 shows the prevalence of obesity among Head Start participants by state from 2012–2018. Overall, we found a 0.20 percentage point (95% confidence interval 0.09–0.31) annual increase in unadjusted obesity prevalence among Head Start participants, which is a small but significant positive linear trend (p <0.01). Out of 50 states and the District of Columbia, we found a positive significant trend in 13 states and a negative significant trend in 3 states. In 34 states and the District of Columbia, the trend was not significantly different from zero, meaning there was no positive or negative trend that was statistically significant.
Table 2.
Prevalence of Obesitya Among U.S. Children Enrolled in Head Start, by State and Year, Head Start Program Information Reports, 2012–2018.
| 2012 | 2013 | 2014 | 2015 | 2016 | 2017 | 2018 | 2012–2018 | |||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| State/District | No. of children | % Obesity | No. of children | % Obesity | No. of children | % Obesity | No. of children | % Obesity | No. of children | % Obesity | No. of children | % Obesity | No. of children | % Obesity | Average Annual Changeb | 95% Confidence Interval |
| Overall | 906,194 | 15.5 | 895,743 | 15.6 | 850,645 | 16.2 | 858,627 | 16.5 | 819,997 | 16.3 | 787,402 | 16.7 | 759,791 | 16.6 | +0.20** | [0.09, 0.31] |
| Alabama | 18,031 | 13.0 | 17,980 | 12.6 | 16,979 | 15.1 | 16,723 | 15.7 | 16,620 | 15.1 | 14,448 | 13.8 | 14,170 | 13.5 | +0.14 | [−0.47, 0.75] |
| Alaska | 3,155 | 25.7 | 3,203 | 23.8 | 3,009 | 25.0 | 2,986 | 27.5 | 2,889 | 27.0 | 2,819 | 24.5 | 2,793 | 27.1 | +0.27 | [−0.43, 0.97] |
| Arizona | 18,921 | 15.8 | 18,807 | 16.6 | 17,088 | 17.3 | 18,143 | 17.7 | 17,557 | 17.4 | 16,686 | 17.4 | 15,928 | 16.7 | +0.16 | [−0.14, 0.46] |
| Arkansas | 10,090 | 16.7 | 10,639 | 16.1 | 9,789 | 17.2 | 9,734 | 17.4 | 8,895 | 17.4 | 8,864 | 17.9 | 8,157 | 17.7 | +0.24* | [0.07, 0.42] |
| California | 110,075 | 18.6 | 109,624 | 18.5 | 104,393 | 18.7 | 104,291 | 18.3 | 96,441 | 17.9 | 89,585 | 17.9 | 84,878 | 17.1 | −0.23** | [−0.36, −0.10] |
| Colorado | 11,418 | 10.8 | 11,282 | 12.5 | 11,522 | 13.6 | 11,227 | 13.5 | 10,596 | 13.5 | 9,595 | 13.6 | 9,478 | 14.9 | +0.51** | [0.19, 0.84] |
| Connecticut | 7,775 | 13.9 | 7,694 | 16.5 | 6,843 | 18.0 | 6,660 | 16.9 | 5,878 | 17.3 | 5,780 | 18.8 | 5,875 | 18.8 | +0.66* | [0.18, 1.14] |
| Delaware | 1,265 | 19.3 | 1,269 | 16.9 | 1,251 | 21.7 | 1,249 | 21.8 | 2,087 | 20.4 | 2,018 | 18.8 | 1,888 | 21.2 | +0.29 | [−0.60, 1.19] |
| District of Columbia | 3,833 | 16.3 | 2,761 | 14.7 | 6,326 | 10.7 | 5,972 | 9.1 | 5,415 | 12.3 | 5,521 | 13.8 | 5,486 | 12.7 | −0.39 | [−1.60, 0.81] |
| Florida | 37,263 | 16.5 | 36,593 | 17.4 | 37,563 | 18.1 | 38,242 | 17.8 | 37,205 | 17.1 | 37,604 | 17.3 | 36,894 | 17.2 | +0.03 | [−0.24, 0.30] |
| Georgia | 25,237 | 15.2 | 25,054 | 15.6 | 23,667 | 16.5 | 24,075 | 15.4 | 23,525 | 16.3 | 21,212 | 15.1 | 22,005 | 14.6 | −0.11 | [−0.44, 0.23] |
| Hawaii | 3,035 | 16.7 | 3,126 | 12.6 | 3,041 | 13.4 | 3,090 | 14.2 | 3,033 | 13.7 | 2,753 | 15.4 | 2,652 | 14.8 | +0.01 | [−0.72, 0.73] |
| Idaho | 3,745 | 13.9 | 3,736 | 13.2 | 3,422 | 15.1 | 3,611 | 13.3 | 3,552 | 14.3 | 3,333 | 16.3 | 3,317 | 14.1 | +0.21 | [−0.31, 0.74] |
| Illinois | 43,537 | 13.8 | 42,747 | 16.7 | 40,656 | 18.4 | 40,060 | 18.6 | 36,460 | 17.4 | 34,982 | 17.3 | 30,303 | 17.9 | +0.45 | [−0.25, 1.14] |
| Indiana | 16,091 | 16.1 | 14,965 | 18.1 | 15,165 | 18.1 | 15,676 | 19.6 | 14,855 | 19.5 | 14,392 | 18.5 | 14,125 | 17.0 | +0.17 | [−0.47, 0.82] |
| Iowa | 7,630 | 17.6 | 7,479 | 17.7 | 6,771 | 18.1 | 6,892 | 19.3 | 6,623 | 18.4 | 6,332 | 19.3 | 6,358 | 18.5 | +0.22 | [−0.04, 0.49] |
| Kansas | 8,742 | 17.9 | 8,462 | 16.0 | 6,834 | 17.8 | 7,817 | 16.2 | 7,391 | 17.1 | 6,772 | 17.4 | 6,529 | 16.2 | −0.11 | [−0.52, 0.30] |
| Kentucky | 16,974 | 18.5 | 17,385 | 19.5 | 16,709 | 19.3 | 16,803 | 20.5 | 16,016 | 18.5 | 15,620 | 18.1 | 13,992 | 17.4 | −0.25 | [−0.71, 0.22] |
| Louisiana | 21,737 | 10.5 | 22,207 | 11.4 | 20,877 | 12.0 | 21,806 | 11.5 | 20,979 | 12.6 | 18,527 | 14.2 | 19,355 | 14.9 | +0.69** | [0.41, 0.97] |
| Maine | 3,503 | 16.0 | 3,181 | 17.4 | 2,772 | 18.5 | 2,890 | 18.8 | 2,741 | 17.4 | 2,726 | 17.5 | 2,638 | 18.5 | +0.24 | [−0.20, 0.67] |
| Maryland | 11,037 | 11.3 | 10,693 | 12.5 | 10,357 | 14.0 | 9,997 | 13.5 | 9,850 | 12.5 | 8,567 | 14.8 | 8,544 | 14.8 | +0.49* | [0.07, 0.90] |
| Massachusetts | 13,806 | 19.0 | 13,516 | 19.0 | 11,858 | 20.3 | 12,819 | 19.4 | 12,362 | 19.0 | 11,955 | 20.1 | 11,646 | 19.7 | +0.11 | [−0.16, 0.37] |
| Michigan | 36,876 | 15.4 | 37,134 | 14.4 | 34,032 | 16.1 | 31,576 | 16.6 | 30,702 | 16.4 | 27,739 | 16.7 | 27,069 | 16.6 | +0.30* | [0.02, 0.59] |
| Minnesota | 14,305 | 18.6 | 14,212 | 18.2 | 13,388 | 18.4 | 13,532 | 18.7 | 13,170 | 19.1 | 12,798 | 20.4 | 12,170 | 17.8 | +0.1 | [−0.33, 0.53] |
| Mississippi | 27,958 | 19.5 | 27,797 | 18.0 | 24,953 | 17.2 | 26,217 | 18.5 | 20,881 | 19.6 | 22,529 | 20.1 | 22,023 | 20.5 | +0.34 | [−0.15, 0.84] |
| Missouri | 18,558 | 18.4 | 18,201 | 18.9 | 16,693 | 18.6 | 16,901 | 18.7 | 15,000 | 18.2 | 13,567 | 18.8 | 13,153 | 16.9 | −0.18 | [−0.48, 0.12] |
| Montana | 4,490 | 14.1 | 4,583 | 13.1 | 4,350 | 11.8 | 4,198 | 16.6 | 4,435 | 14.8 | 4,351 | 13.7 | 4,296 | 13.7 | +0.11 | [−0.67, 0.89] |
| Nebraska | 5,087 | 16.8 | 5,029 | 17.7 | 4,615 | 18.2 | 4,732 | 16.7 | 4,399 | 18.0 | 4,058 | 18.7 | 4,043 | 18.0 | +0.19 | [−0.13, 0.51] |
| Nevada | 3,730 | 19.1 | 3,701 | 13.1 | 3,416 | 11.4 | 3,165 | 13.2 | 3,382 | 12.9 | 3,083 | 12.2 | 3,182 | 13.3 | −0.63 | [−1.76, 0.49] |
| New Hampshire | 1,712 | 18.3 | 1,699 | 15.2 | 1,515 | 16.1 | 1,489 | 18.9 | 1,493 | 19.1 | 1,437 | 19.6 | 1,395 | 19.4 | +0.54 | [−0.14, 1.22] |
| New Jersey | 16,313 | 13.4 | 13,951 | 12.9 | 13,311 | 13.6 | 13,826 | 16.7 | 13,894 | 14.8 | 13,162 | 19.1 | 12,857 | 18.9 | +1.08** | [0.43, 1.72] |
| New Mexico | 8,990 | 15.0 | 8,858 | 14.0 | 8,332 | 14.8 | 8,331 | 14.2 | 8,208 | 14.4 | 8,006 | 15.1 | 7,846 | 14.6 | +0.02 | [−0.20, 0.24] |
| New York | 56,329 | 12.0 | 54,191 | 11.1 | 54,527 | 11.4 | 54,473 | 11.1 | 53,817 | 12.2 | 51,499 | 13.0 | 48,287 | 13.6 | +0.34 | [−0.00, 0.67] |
| North Carolina | 22,360 | 14.3 | 22,570 | 15.5 | 21,516 | 15.1 | 21,367 | 16.3 | 19,698 | 17.8 | 19,959 | 18.4 | 19,549 | 16.6 | +0.55* | [0.10, 1.00] |
| North Dakota | 3,147 | 19.0 | 3,224 | 19.5 | 2,932 | 17.6 | 3,152 | 17.1 | 2,981 | 17.3 | 2,808 | 18.3 | 2,629 | 14.7 | −0.56* | [−1.09, −0.02] |
| Ohio | 42,347 | 14.3 | 42,280 | 15.1 | 37,599 | 15.9 | 36,938 | 15.9 | 35,916 | 15.8 | 34,549 | 16.9 | 33,560 | 17.0 | +0.41** | [0.25, 0.58] |
| Oklahoma | 17,904 | 12.6 | 18,007 | 13.6 | 16,868 | 14.7 | 16,460 | 14.2 | 16,304 | 14.2 | 16,073 | 14.5 | 15,612 | 14.9 | +0.29* | [0.05, 0.54] |
| Oregon | 13,912 | 17.2 | 14,124 | 17.0 | 13,915 | 17.5 | 14,283 | 17.1 | 13,976 | 18.1 | 14,383 | 17.8 | 13,929 | 16.0 | −0.05 | [−0.40, 0.30] |
| Pennsylvania | 37,349 | 11.8 | 36,958 | 12.6 | 33,763 | 13.8 | 36,751 | 15.6 | 34,122 | 14.7 | 34,730 | 15.4 | 33,789 | 16.3 | +0.71** | [0.39, 1.03] |
| Rhode Island | 2,861 | 18.7 | 2,771 | 19.7 | 2,381 | 20.2 | 2,736 | 20.1 | 2,690 | 18.8 | 2,523 | 18.5 | 2,363 | 23.8 | +0.41 | [−0.44, 1.26] |
| South Carolina | 13,021 | 12.7 | 13,352 | 11.4 | 13,126 | 15.6 | 13,127 | 12.3 | 12,144 | 12.4 | 11,839 | 11.9 | 11,594 | 12.5 | −0.1 | [−0.81, 0.61] |
| South Dakota | 4,569 | 14.1 | 4,524 | 15.0 | 3,929 | 17.0 | 4,141 | 18.5 | 4,267 | 16.7 | 4,192 | 17.5 | 4,092 | 17.0 | +0.48 | [−0.10, 1.06] |
| Tennessee | 18,679 | 16.0 | 18,511 | 16.7 | 17,367 | 16.6 | 17,952 | 18.5 | 17,975 | 18.3 | 17,234 | 18.6 | 17,502 | 16.3 | +0.23 | [−0.31, 0.77] |
| Texas | 75,545 | 15.6 | 74,815 | 15.1 | 72,063 | 14.5 | 72,536 | 16.4 | 71,315 | 16.0 | 70,441 | 16.1 | 66,819 | 16.6 | +0.23 | [−0.06, 0.53] |
| Utah | 6,517 | 15.4 | 6,535 | 14.3 | 6,117 | 14.4 | 6,318 | 13.7 | 6,229 | 12.9 | 5,989 | 13.1 | 5,623 | 13.5 | −0.34* | [−0.58, −0.10] |
| Vermont | 1,391 | 20.1 | 1,360 | 16.8 | 1,190 | 15.0 | 1,242 | 17.3 | 1,169 | 19.8 | 1,083 | 20.9 | 1,110 | 19.6 | +0.41 | [−0.63, 1.45] |
| Virginia | 14,612 | 15.8 | 14,568 | 14.6 | 14,095 | 17.8 | 14,450 | 14.5 | 14,163 | 14.1 | 14,123 | 15.6 | 14,017 | 17.0 | +0.07 | [−0.66, 0.79] |
| Washington | 14,154 | 16.4 | 13,948 | 16.6 | 13,563 | 18.5 | 13,438 | 18.5 | 12,750 | 18.4 | 12,300 | 19.5 | 12,185 | 18.8 | +0.46* | [0.15, 0.77] |
| West Virginia | 8,285 | 12.6 | 8,287 | 13.4 | 7,803 | 12.5 | 7,972 | 15.2 | 8,036 | 15.3 | 7,782 | 16.9 | 7,663 | 15.8 | +0.69** | [0.26, 1.12] |
| Wisconsin | 16,349 | 17.0 | 16,215 | 17.3 | 14,584 | 17.8 | 14,777 | 17.8 | 14,244 | 17.1 | 13,452 | 18.2 | 12,833 | 18.4 | +0.19* | [0.00, 0.38] |
| Wyoming | 1,944 | 8.5 | 1,935 | 12.5 | 1,810 | 11.5 | 1,784 | 10.9 | 1,667 | 14.1 | 1,622 | 11.3 | 1,590 | 13.1 | +0.5 | [−0.27, 1.27] |
Weight status based on BMI-for-age percentile (kg/m2), with obesity defined as BMI ≥95th percentile.
Average Annual Change is measured in absolute percentage points and represents the coefficient from the simple linear regression;
= p < 0.05,
= p < 0.01,
= p < 0.001.
Significant values, with p < 0.05 by linear regression, are in bold.
Table 3 shows the prevalence of overweight among Head Start participants by state from 2012–2018. We did not find an overall significant linear trend in overweight prevalence among Head Start participants, unadjusted for covariates. Out of all 50 states and the District of Columbia, we found a positive significant trend in 4 states and a negative significant trend in 5 states. In 41 states and the District of Columbia, the trend was not significantly different from zero, meaning there was no positive or negative trend that was statistically significant.
Table 3.
Prevalence of Overweight (OW)a Among U.S. Children Enrolled in Head Start, by State, Head Start Program Information Reports, 2012–2018.
| 2012 | 2013 | 2014 | 2015 | 2016 | 2017 | 2018 | 2012–2018 | |||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| State/District | No. of children | % OW | No. of children | % OW | No. of children | % OW | No. of children | % OW | No. of children | % OW | No. of children | % OW | No. of children | % OW | Average Annual Changeb | 95% Confidence Interval |
| Overall | 906,194 | 13.7 | 895,743 | 13.5 | 850,645 | 13.4 | 858,627 | 13.3 | 819,997 | 13.3 | 787,402 | 13.4 | 759,791 | 13.7 | −0.01 | [−0.10, 0.08] |
| Alabama | 18,031 | 10.3 | 17,980 | 10.9 | 16,979 | 10.7 | 16,723 | 10.4 | 16,620 | 10.4 | 14,448 | 9.5 | 14,170 | 8.9 | −0.26* | [−0.49, −0.03] |
| Alaska | 3,155 | 20.1 | 3,203 | 22.2 | 3,009 | 19.5 | 2,986 | 21.0 | 2,889 | 21.4 | 2,819 | 19.8 | 2,793 | 20.4 | −0.07 | [−0.57, 0.43] |
| Arizona | 18,921 | 13.5 | 18,807 | 14.0 | 17,088 | 13.7 | 18,143 | 13.3 | 17,557 | 14.1 | 16,686 | 13.9 | 15,928 | 14.3 | +0.09 | [−0.06, 0.25] |
| Arkansas | 10,090 | 12.8 | 10,639 | 12.8 | 9,789 | 13.9 | 9,734 | 13.9 | 8,895 | 14.3 | 8,864 | 13.3 | 8,157 | 14.4 | +0.22 | [−0.03, 0.47] |
| California | 110,075 | 15.2 | 109,624 | 14.6 | 104,393 | 14.1 | 104,291 | 13.2 | 96,441 | 13.2 | 89,585 | 13.2 | 84,878 | 13.5 | −0.31* | [−0.54, −0.09] |
| Colorado | 11,418 | 12.8 | 11,282 | 12.5 | 11,522 | 13.2 | 11,227 | 12.7 | 10,596 | 12.3 | 9,595 | 12.2 | 9,478 | 12.4 | −0.1 | [−0.24, 0.05] |
| Connecticut | 7,775 | 14.6 | 7,694 | 13.8 | 6,843 | 13.8 | 6,660 | 14.7 | 5,878 | 16.2 | 5,780 | 17.3 | 5,875 | 15.2 | +0.40 | [−0.10, 0.90] |
| Delaware | 1,265 | 11.3 | 1,269 | 13.1 | 1,251 | 14.5 | 1,249 | 15.5 | 2,087 | 13.8 | 2,018 | 12.6 | 1,888 | 12.7 | +0.09 | [−0.64, 0.82] |
| District of Columbia | 3,833 | 12.0 | 2,761 | 13.9 | 6,326 | 18.1 | 5,972 | 11.3 | 5,415 | 16.1 | 5,521 | 11.5 | 5,486 | 11.1 | −0.34 | [−1.74, 1.06] |
| Florida | 37,263 | 12.2 | 36,593 | 12.6 | 37,563 | 12.2 | 38,242 | 12.5 | 37,205 | 12.1 | 37,604 | 12.0 | 36,894 | 11.9 | −0.08 | [−0.18, 0.02] |
| Georgia | 25,237 | 13.1 | 25,054 | 12.4 | 23,667 | 12.1 | 24,075 | 11.7 | 23,525 | 11.0 | 21,212 | 10.7 | 22,005 | 11.2 | −0.36** | [−0.54, −0.19] |
| Hawaii | 3,035 | 14.7 | 3,126 | 11.8 | 3,041 | 13.4 | 3,090 | 13.3 | 3,033 | 12.8 | 2,753 | 12.4 | 2,652 | 13.0 | −0.16 | [−0.61, 0.29] |
| Idaho | 3,745 | 15.2 | 3,736 | 15.0 | 3,422 | 15.2 | 3,611 | 14.7 | 3,552 | 14.0 | 3,333 | 15.2 | 3,317 | 16.3 | +0.09 | [−0.26, 0.44] |
| Illinois | 43,537 | 11.8 | 42,747 | 13.7 | 40,656 | 14.3 | 40,060 | 14.0 | 36,460 | 13.7 | 34,982 | 13.4 | 30,303 | 13.9 | +0.18 | [−0.20, 0.56] |
| Indiana | 16,091 | 15.6 | 14,965 | 15.0 | 15,165 | 14.3 | 15,676 | 13.9 | 14,855 | 14.9 | 14,392 | 14.5 | 14,125 | 15.3 | −0.05 | [−0.36, 0.26] |
| Iowa | 7,630 | 17.0 | 7,479 | 16.6 | 6,771 | 17.3 | 6,892 | 16.7 | 6,623 | 16.4 | 6,332 | 16.1 | 6,358 | 17.3 | −0.04 | [−0.27, 0.20] |
| Kansas | 8,742 | 16.0 | 8,462 | 14.4 | 6,834 | 15.6 | 7,817 | 15.2 | 7,391 | 13.7 | 6,772 | 14.5 | 6,529 | 14.6 | −0.21 | [−0.55, 0.13] |
| Kentucky | 16,974 | 14.7 | 17,385 | 14.1 | 16,709 | 14.6 | 16,803 | 14.3 | 16,016 | 13.8 | 15,620 | 13.7 | 13,992 | 13.7 | −0.16* | [−0.28, −0.05] |
| Louisiana | 21,737 | 9.5 | 22,207 | 9.8 | 20,877 | 9.8 | 21,806 | 10.1 | 20,979 | 11.0 | 18,527 | 11.4 | 19,355 | 13.4 | +0.57** | [0.27, 0.88] |
| Maine | 3,503 | 18.0 | 3,181 | 17.0 | 2,772 | 16.3 | 2,890 | 15.6 | 2,741 | 15.8 | 2,726 | 17.5 | 2,638 | 17.6 | −0.02 | [−0.52, 0.47] |
| Maryland | 11,037 | 13.3 | 10,693 | 11.5 | 10,357 | 13.1 | 9,997 | 11.4 | 9,850 | 11.6 | 8,567 | 12.3 | 8,544 | 12.1 | −0.12 | [−0.51, 0.26] |
| Massachusetts | 13,806 | 17.8 | 13,516 | 17.0 | 11,858 | 16.9 | 12,819 | 17.3 | 12,362 | 15.8 | 11,955 | 16.5 | 11,646 | 16.2 | −0.25* | [−0.47, −0.02] |
| Michigan | 36,876 | 14.2 | 37,134 | 13.1 | 34,032 | 13.5 | 31,576 | 14.4 | 30,702 | 14.2 | 27,739 | 14.0 | 27,069 | 14.6 | +0.13 | [−0.10, 0.37] |
| Minnesota | 14,305 | 16.7 | 14,212 | 15.1 | 13,388 | 17.2 | 13,532 | 14.8 | 13,170 | 16.0 | 12,798 | 16.9 | 12,170 | 15.9 | 0 | [−0.48, 0.48] |
| Mississippi | 27,958 | 14.8 | 27,797 | 11.7 | 24,953 | 12.8 | 26,217 | 11.3 | 20,881 | 11.8 | 22,529 | 12.0 | 22,023 | 12.3 | −0.28 | [−0.81, 0.25] |
| Missouri | 18,558 | 15.4 | 18,201 | 14.7 | 16,693 | 14.8 | 16,901 | 14.8 | 15,000 | 14.4 | 13,567 | 15.0 | 13,153 | 14.7 | −0.07 | [−0.21, 0.08] |
| Montana | 4,490 | 17.8 | 4,583 | 14.3 | 4,350 | 15.7 | 4,198 | 15.2 | 4,435 | 15.9 | 4,351 | 16.3 | 4,296 | 18.9 | +0.27 | [−0.51, 1.04] |
| Nebraska | 5,087 | 14.9 | 5,029 | 15.0 | 4,615 | 14.9 | 4,732 | 14.7 | 4,399 | 15.4 | 4,058 | 14.8 | 4,043 | 15.4 | +0.06 | [−0.08, 0.19] |
| Nevada | 3,730 | 15.5 | 3,701 | 15.8 | 3,416 | 12.2 | 3,165 | 12.8 | 3,382 | 14.3 | 3,083 | 14.1 | 3,182 | 13.4 | −0.27 | [−0.91, 0.36] |
| New Hampshire | 1,712 | 18.5 | 1,699 | 15.2 | 1,515 | 17.3 | 1,489 | 16.9 | 1,493 | 17.8 | 1,437 | 18.2 | 1,395 | 18.2 | +0.2 | [−0.36, 0.76] |
| New Jersey | 16,313 | 12.2 | 13,951 | 10.2 | 13,311 | 10.4 | 13,826 | 11.9 | 13,894 | 12.2 | 13,162 | 13.0 | 12,857 | 14.1 | +0.47 | [−0.03, 0.96] |
| New Mexico | 8,990 | 14.2 | 8,858 | 13.5 | 8,332 | 13.2 | 8,331 | 13.4 | 8,208 | 12.5 | 8,006 | 13.1 | 7,846 | 13.2 | −0.16 | [−0.36, 0.04] |
| New York | 56,329 | 12.9 | 54,191 | 13.1 | 54,527 | 12.4 | 54,473 | 11.9 | 53,817 | 12.4 | 51,499 | 12.4 | 48,287 | 12.7 | −0.07 | [−0.27, 0.12] |
| North Carolina | 22,360 | 11.9 | 22,570 | 12.6 | 21,516 | 12.2 | 21,367 | 12.3 | 19,698 | 13.2 | 19,959 | 12.4 | 19,549 | 13.4 | +0.18 | [−0.02, 0.38] |
| North Dakota | 3,147 | 18.7 | 3,224 | 15.8 | 2,932 | 15.2 | 3,152 | 15.0 | 2,981 | 16.8 | 2,808 | 14.9 | 2,629 | 16.1 | −0.29 | [−0.92, 0.35] |
| Ohio | 42,347 | 13.7 | 42,280 | 14.5 | 37,599 | 13.6 | 36,938 | 13.2 | 35,916 | 14.2 | 34,549 | 14.0 | 33,560 | 14.2 | +0.04 | [−0.19, 0.27] |
| Oklahoma | 17,904 | 12.5 | 18,007 | 12.8 | 16,868 | 13.7 | 16,460 | 13.5 | 16,304 | 13.4 | 16,073 | 14.3 | 15,612 | 13.6 | +0.21* | [0.02, 0.41] |
| Oregon | 13,912 | 15.3 | 14,124 | 16.7 | 13,915 | 15.7 | 14,283 | 15.6 | 13,976 | 16.6 | 14,383 | 16.8 | 13,929 | 16.1 | +0.12 | [−0.16, 0.41] |
| Pennsylvania | 37,349 | 11.5 | 36,958 | 11.1 | 33,763 | 12.2 | 36,751 | 13.2 | 34,122 | 13.1 | 34,730 | 12.3 | 33,789 | 14.1 | +0.40* | [0.08, 0.71] |
| Rhode Island | 2,861 | 16.1 | 2,771 | 15.3 | 2,381 | 19.7 | 2,736 | 24.8 | 2,690 | 25.8 | 2,523 | 19.6 | 2,363 | 11.9 | +0.07 | [−2.61, 2.76] |
| South Carolina | 13,021 | 10.9 | 13,352 | 10.0 | 13,126 | 11.8 | 13,127 | 10.8 | 12,144 | 9.9 | 11,839 | 9.1 | 11,594 | 10.4 | −0.19 | [−0.59, 0.22] |
| South Dakota | 4,569 | 13.9 | 4,524 | 18.4 | 3,929 | 15.1 | 4,141 | 15.1 | 4,267 | 15.3 | 4,192 | 16.4 | 4,092 | 17.1 | +0.21 | [−0.56, 0.97] |
| Tennessee | 18,679 | 11.9 | 18,511 | 12.5 | 17,367 | 13.0 | 17,952 | 11.9 | 17,975 | 12.3 | 17,234 | 12.5 | 17,502 | 13.2 | +0.11 | [−0.12, 0.35] |
| Texas | 75,545 | 14.5 | 74,815 | 13.3 | 72,063 | 12.3 | 72,536 | 13.5 | 71,315 | 12.5 | 70,441 | 13.2 | 66,819 | 13.4 | −0.12 | [−0.48, 0.24] |
| Utah | 6,517 | 11.8 | 6,535 | 12.2 | 6,117 | 13.0 | 6,318 | 12.4 | 6,229 | 11.5 | 5,989 | 12.9 | 5,623 | 13.6 | +0.19 | [−0.13, 0.51] |
| Vermont | 1,391 | 15.0 | 1,360 | 17.9 | 1,190 | 14.1 | 1,242 | 16.5 | 1,169 | 15.7 | 1,083 | 17.0 | 1,110 | 17.5 | +0.26 | [−0.41, 0.93] |
| Virginia | 14,612 | 13.6 | 14,568 | 13.5 | 14,095 | 12.4 | 14,450 | 12.0 | 14,163 | 13.9 | 14,123 | 14.3 | 14,017 | 14.5 | +0.21 | [−0.23, 0.64] |
| Washington | 14,154 | 16.4 | 13,948 | 16.4 | 13,563 | 16.4 | 13,438 | 16.7 | 12,750 | 16.7 | 12,300 | 16.5 | 12,185 | 16.5 | +0.03 | [−0.04, 0.09] |
| West Virginia | 8,285 | 11.0 | 8,287 | 10.6 | 7,803 | 11.0 | 7,972 | 11.6 | 8,036 | 11.9 | 7,782 | 13.1 | 7,663 | 14.8 | +0.62** | [0.27, 0.96] |
| Wisconsin | 16,349 | 15.5 | 16,215 | 16.1 | 14,584 | 15.9 | 14,777 | 15.4 | 14,244 | 15.0 | 13,452 | 16.2 | 12,833 | 16.1 | +0.04 | [−0.20, 0.27] |
| Wyoming | 1,944 | 10.0 | 1,935 | 13.6 | 1,810 | 13.6 | 1,784 | 13.0 | 1,667 | 14.8 | 1,622 | 13.0 | 1,590 | 14.3 | +0.46 | [−0.17, 1.09] |
Weight status based on BMI-for-age percentile (kg/m2), with overweight defined as BMI 85th to <95th percentile.
Average Annual Change is measured in absolute percentage points and represents the coefficient from the simple linear regression;
= p < 0.05,
= p < 0.01,
= p < 0.001.
Significant values, with p < 0.05 by linear regression, are in bold.
Discussion
This article is the first to combine all available BMI data from the Head Start PIR from 2012, when BMI measurements were added to the annual PIR, with data through 2018 and to examine trends in overweight and obesity among Head Start participants in all 50 states and the District of Columbia. The overall prevalence of obesity among young children enrolled in Head Start was 16.6% in 2018. This percentage is higher than the estimated obesity prevalence of 13.9% among U.S. children aged 2–5 years at all household income levels, according to the 2015–2016 National Health and Nutrition Examination Survey (NHANES).11 In our analysis, 43 states had an obesity prevalence higher than 13.9%. This difference could be in part because NHANES data include children aged 2–5 years from all income levels, whereas most Head Start participants are from families with low incomes.
Our study also found different percentages than another federal program for low-income children, the Supplemental Nutrition Assistance Program for Women, Infants, and Children (WIC). The WIC program has a Participants and Program Characteristics (WIC PC) census survey that collects participant data in even-numbered years. The Centers for Disease Control and Prevention collaborates with the U.S. Department of Agriculture to use the WIC PC as a source of obesity data for low-income children aged 2–4 years.12 In 2016, the national prevalence of obesity in the WIC PC for children aged 2–4 years was 13.9% overall (range: 7.9% in Utah to 19.8% in Alaska). Our findings for the same year were about 3 percentage points higher; however, our study includes slightly older children (aged 3–5 years). The overall overweight prevalence among children aged 2–4 years who were enrolled in the WIC program in 2016 was about 15.2% (range: 12.1% in Utah to 19.7% in South Dakota).13
Our analysis, which focused on the trend in unadjusted obesity prevalence among Head Start participants, found that the trend was not significantly different from zero in 34 states and the District of Columbia. However, 13 states had a positive trend and 3 states had a negative trend, and these trends were statistically significant. We also found an overall small but significant positive linear trend in obesity prevalence among Head Start participants. These findings can be considered with other findings on the prevalence of obesity in young low-income populations. For example, national PIR data show that, in 2016, approximately 400,000 families enrolled in Head Start also received WIC benefits. Although the two populations are not identical, overlap exists. In contrast to our study, Pan et al. found that the obesity prevalence among WIC participants aged 2–4 years declined in 41 states and U.S. territories during 2010–2016.12 Differences in findings between this study and the WIC PC survey could be due to differing time periods and data analysis techniques.
Limitations exist in this study. First, the BMI data in the PIR come from either healthcare professionals or Head Start personnel, and it is undetermined what proportion of the data originate from each source. In addition, there are currently no standard anthropometric protocols or training required for Head Start personnel who collect BMI data; thus there might be measurement error. In contrast, the WIC PC survey has highly standardized protocols and published data that show reliability and validity.13,14 Second, although BMI data are reported at the individual Head Start program level, these values are subsequently classified into weight categories and reported in aggregate to the state level. Because individual-level data are not available, we cannot verify whether weight status was appropriately documented for individual children. In addition, data cleaning is not performed after entry into the Head Start Enterprise System. Further, we did not adjust for covariates when calculating the annual increase in the prevalence of obesity and overweight because of the lack of individual-level data and certain demographic variables (e.g., sex). Thus, trends could be explained by demographic changes in the Head Start population over time. Finally, Head Start participation declined for most states over the 7-year period that we studied, and we are unsure if these declines are affected by a factor, such as age of enrollees, that could also affect the prevalence estimates. Nevertheless, these estimates are still valuable.
The early development of healthy habits is crucial to help children grow optimally and maintain good health. Stakeholders could use publicly available Head Start data to understand the prevalence of obesity among young children from low-income households who are enrolled in early education programs. There are approximately 1,700 Head Start programs across the country, located in every state and U.S. territory.15 Performance measures were updated in 2016, and programs are now required to promote good nutrition and physical activity to help prevent obesity, through various ways including standards related to nutrition service requirements and through the teaching and learning environment to promote learning about nutrition and physical activity throughout their daily activities.9,16 These efforts may help improve developmental and physical outcomes for low-income children enrolled in Head Start. According to one study including data between 2005–2013,17 preschool-aged children who entered Head Start with overweight or obesity had a significantly improved and healthier BMI by kindergarten age than comparison groups. The comparison groups included children who received Medicaid, and those not on Medicaid; the children enrolled in Medicaid were more similar demographically and by weight status to children in Head Start than the children who were not enrolled in Medicaid. Those who entered Head Start underweight also had a higher BMI increase than comparison groups. The study’s authors concluded that, at the end of the observation period, children with overweight or obesity who were enrolled in Head Start were significantly less overweight than children in the comparison groups. In another study, Head Start programs implemented the Coordinated Approach to Child Health Early Childhood (CATCH EC) program, which focuses on healthy nutrition and physical activity. Data obtained from 2012–2014 show that children in this program demonstrated significantly lower BMI z-scores and BMI percentiles than children in comparison Head Start programs in the same target population with a similar weight status after the 1-year intervention period.18 The environment provided in early care and education (ECE) settings such as Head Start may contribute to the development of healthy eating and physical activity habits, as well as improved social and academic outcomes. Approximately 73% of U.S. children aged 3–5 years are in nonparental care on a weekly basis,19 which highlights the importance of the ECE setting and programs such as Head Start in helping children develop healthy habits and establish a healthy weight.
Childhood obesity is a pressing public health problem, and it is projected that almost 60% of children today will have obesity at age 35 years.20 In this analysis we found the prevalence of obesity and overweight in Head Start children to be stable, but continues to be high. This projection underscores the importance of using available state data to develop plans for action. CDC continues to work with other federal agencies, states, and researchers to provide data on risk factors and to support ECE efforts to improve health among children.13,21 Our assessment and future PIR analyses could potentially help all 50 states and the District of Columbia plan and highlight the need for healthy growth and obesity interventions for low-income families. Finally, the data may be useful for a state and national stakeholders to monitor obesity and overweight prevalence over time in this unique population.
So What? Implications for Health Promotion Practitioners and Researchers.
What is already known on this topic?
Head Start enrollees are often children living in low-income households, who are at higher risk for obesity and overweight than children living in higher-income households.
What does this article add?
This article is the first to combine all available BMI data from the annual Head Start Program Information Report (PIR) from 2012, when body mass index measurements were added to the PIR, with data through 2018 and to examine trends in overweight and obesity among Head Start participants in all 50 states and the District of Columbia.
What are the implications for health promotion practice or research?
Available state data may be used to develop plans for action to support efforts to improve health among young children; plan and highlight the need for healthy growth and obesity interventions for low-income families; and may be useful for state and national stakeholders to monitor obesity and overweight prevalence over time in this unique population.
Acknowledgments
We would like to thank Marco Beltran, Jesse Escobar, Linda Green-berg, and Theresa Rowley of the Administration for Children and Families, U.S. Department of Health and Human Services, for their contributions to this manuscript.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
Footnotes
Declaration of Conflicting Interests
The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.
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