Abstract
Background:
Childhood obesity is one of the foremost threats to population health in the United States (U.S.) leading to the emergence of co-morbidities and increased healthcare cost. We explore the influence of selected social determinants of health (SDOH) on overweight and obesity among U.S. children.
Methods:
We utilized the National Survey of Children’s Health (NSCH) 2016-17 dataset for this analysis. Overweight was defined as Body Mass Index (BMI) ≥ 85th to<95th, while obesity was defined as BMI ≥95th percentile for age and sex. Based on the literature and pathway plausibility, we examined several SDOH variables as predictors of childhood overweight or obesity in the US. Survey log-binomial regression models were built to generate prevalence ratio (PR) estimates to capture the associations between SDOH and overweight or obesity.
Results:
About 30.6 million children were surveyed of which 9.5 million (31.0%) were either overweight or obese. The likelihood of obesity was elevated among non-Hispanic Black and Hispanic children (PR = 1.53; 95% CI = 1.01-2.31) and (PR = 1.50; 95% CI = 1.18-1.90) respectively. Overweight was more frequent in younger children, children of single parents, and children who lived in a neighborhood with no amenities. Parental attainment of college education, health insurance coverage, female gender, and language spoken in home other than Spanish were protective against overweight or obesity.
Conclusions and Global Health Implications:
SDOH represent markers of overweight or obesity in children. We recommend the development of innovative interventions using SDOH risk and protective pathways as guide to address the current epidemic of childhood overweight and obesity.
Keywords: Social determinants, Obesity, Overweight, SDOH, Children, United States
1. Introduction
1.1. Background
Childhood obesity is one of the foremost threats to population health in the United States (U.S.).1,2 Childhood obesity refers to a body mass index (BMI) at or greater than 95th percentile for age and sex, while childhood overweight is BMI at or greater than 85th to less than 95th percentile for age and sex.3 Globally, the mean standardized BMI increased by 0.32kg/m2 per decade between 1975 and 2016.4 In the U.S. and over the last three decades, the prevalence of childhood obesity has increased by more than four-folds.5 Mean obesity prevalence in children 6-11 years of age increased from 4% to 18.4%; and in children 12-19 years from 6.1% to 20.6% between 1971 to 1974,5,6 and between 2015 to 2016,7 respectively. The rising prevalence of childhood overweight and obesity is associated with the emergence of comorbidities such as obstructive sleep apnea, type 2 diabetes mellitus, dyslipidemia, hypertension, and non-alcoholic fatty liver disease.3 These comorbidities are positively correlated with the severity of obesity3 and do influence adult life morbidity and mortality.1 Additionally, psychosocial problems such as lowered self-esteem, depression, and peer discrimination are experienced by overweight and obese children.8 Furthermore, there are significant societal and economic burdens associated with the rising prevalence of childhood obesity and related comorbidities.9 The dire consequences associated with childhood obesity which progress into adulthood include poor academic and lower skill achievements, inferior outcomes in the labor market, rising healthcare costs, and increasing decline in productivity.9
Several studies have assessed the independent relationships between sociodemographic and economic factors on childhood obesity in the U.S. particularly, the influence of age, gender, race/ethnicity and socioeconomic status on childhood obesity.10-15 There are, however, fewer studies examining the association of selected social determinants such as socioeconomic, behavioral, and environmental factors on childhood overweight and obesity in the U.S.5
1.2. Objective
The aim of this study was to explore the association of selected social determinants of health (SDOH) comprising socioeconomic, behavioral, and environmental factors on overweight and obesity among children in the U.S. using nationally representative data.
2. Methods
2.1. Study Population/variables
This study utilized survey data from the National Survey of Children’s Health (NSCH) 2016-17.16 The NSCH is sponsored and directed by the Health Resources and Services Administration (HRSA) Maternal and Child Health Bureau (MCHB).16 Beginning 2016, NSCH started integrating two surveys, the previous NSCH and the National Survey of Children with Special Health Care Needs (NS-CSHCN),which were administered via web and mail (paper) instruments. The majority of the questions in the NSCH were the same in both the 2016 and 2017 surveys. Only items that were the same across both data sets were included in the combined dataset for this analysis. From 2016 onward, the NSCH is being conducted annually by the U.S. Census Bureau, and the 2017 survey was the second administration of the redesigned NSCH. The survey provides rich data on multiple factors of health and well-being (physical, emotional, and mental), access to quality health care, neighborhood, school, and social context of non-institutionalized children 0-17 years of age living in the US.
2.1.1. Sampling strategy
Households with one or more children under 18 years old were randomly sampled and contacted by mail, and one child from each household was randomly selected to be the subject of the survey. Then an adult (usually a parent or guardian) in the household who was most familiar with the child’s health and health care was invited to complete a short screener questionnaire and a more detailed age-specific topical questionnaire online or by paper. Children with special health care needs and children 0-5 years of age were oversampled in the survey. A total of 71,811 surveys were completed for 2016 and 2017 combined comprising 50,212 surveys in 2016 and 21,599 in 2017. Survey data were weighted and adjusted for the combined dataset to represent the population of noninstitutionalized children aged 0-17 years living in housing units nationally and in each state. The overall weighted response rate was 40.7% for 2016 and 37.4% for 2017. The survey data was weighted to allow for generalizations to state and national pediatric populations (Screener and Topical file), and households with children (Screener file). The final weight for selected children, household, and child screener weights were assigned to all households and children with completed screeners. 16
2.1.2. Exposure and outcome variables
Our exposures of interest were selected social determinants of health (SDOH) comprising demographic, socioeconomic, behavioral, and environmental characteristics. Demographic factors included sex categorized as male and female, age sub-grouped into 10 – 12 years, 13 – 15 years, and 16 – 17 years; and race/ethnicity categorized into non-Hispanic White, non-Hispanic Black, Hispanic and Other. Socioeconomic factors included parents’ nativity categorized into parent(s) born in the US, any parent born outside the US, other (child born in the US, parents not listed); primary household language categorized into Hispanic children with non-English primary household language, Hispanic children with English as primary household language and non-Hispanic children; family structure categorized as two parents currently married, two parents who are not currently married, single parent, other family member with no parent reported; poverty level had 4 sub-groups based on Federal Poverty Level (FPL) which were 0 – 99% FPL, 100 – 199% FPL, 200 – 399% FPL and 400% FPL and above; highest education attained by the adults in the household categorized as less than high school, high school degree or GED, some college or technical school and college degree or higher; insurance type classified as public only, private only, public and private insurance and currently uninsured. Behavioral characteristic was measured by how well the parents were able to cope with day to day demands of raising children categorized as “very well”, “somewhat well” and “not very well or not very well at all”. Environmental characteristic was measured as the number of neighborhood amenities such as: (1) sidewalks or walking paths; (2) park or playground area;(3) recreation center, community center or Boys’/Girls’ Club; (4) library or bookmobile the child had access to. The response options were no amenities, 1 amenity, 2 amenities, 3 amenities and 4 amenities.
The outcomes of interest were overweight and obesity in children 10 to 17 years. As reported in previous studies that parents typically overestimate height and underestimate weight of children younger than 10 years of age,28 the BMI for children under the age of 10 years was therefore, not reported in the survey.
2.2. Statistical Analysis
We conducted weighted bivariate analysis using Pearson’s Chi-squared test to determine the association between various exposure variables and overweight or obesity. To adjust for confounders, we ran weighted survey log binomial logistic regression which generated prevalence ratio (PR) estimates for the association between our exposure and outcome variables. We constructed three models separately for (1) overweight only; (2) obese only; and (3) overweight or obese. All tests of hypotheses were two-tailed with a type 1 error fixed at 5%.
2.3. Ethical Approval
This study was approved as exempt by the Institutional Review Board of Baylor College of Medicine.
3. Results
A total of 30.6 million children aged 0-17 years were surveyed. Of these, 9.5 million children aged 10-17 years were either overweight or obese (31.0%). The prevalence of children classified as overweight only, and obese only was 15.19% and 15.77% respectively.
3.1. Sociodemographic Characteristics
Table 1 shows overall distribution and prevalence of demographic, socioeconomic, and environmental characteristics comparing children that were overweight or obese versus those that were non-overweight. Chi-square test revealed statistically significant differences (p < 0.0001) across all selected variables. Children that were overweight or obese were more likely to be boys (53.8%), in the 10-12 years age group (40.4%), Hispanic (30.2%), living with a single parent and more likely to be living with an adult with high school degree or GED (25.2%) compared to their non-overweight counterparts. There was a dose- response relationship observed between obesity and poverty level with rising prevalence of obesity/overweight with incremental poverty levels (P < 0.0001).
Table 1.
Socio-demographic characteristics of U.S. children 10-17 years according to non-overweight and overweight or obesity status
| Characteristics | Non-over weight (BMI <85th) n=21159491 | Proportion %=69.0 | Overweight or obesity (BMI 85th to ≥95th) n=9485994 | Proportion %=31.0 | p-value | Prevalence# |
|---|---|---|---|---|---|---|
| Demographic characteristics | ||||||
| Sex | <0.0001 | |||||
| Male | 10556223 | 49.9% | 5107233 | 53.8% | 32.6% | |
| Female | 10603268 | 50.1% | 4378761 | 46.2% | 29.2% | |
| Age | <0.0001 | |||||
| 10-12 years | 7377725 | 34.9% | 3832750 | 40.4% | 34.2% | |
| 13-15 years | 8198336 | 38.7% | 3502254 | 36.9% | 29.9% | |
| 16-17 years | 5583430 | 26.4% | 2150990 | 22.7% | 27.8% | |
| Race/ethnicity | <0.0001 | |||||
| NH-White | 11926308 | 56.4% | 4109161 | 43.3% | 25.6% | |
| NH-Black | 2516748 | 11.9% | 1681717 | 17.7% | 40.1% | |
| Hispanic | 4558876 | 21.5% | 2863638 | 30.2% | 38.6% | |
| Others | 2157559 | 10.2% | 831478 | 8.8% | 27.8% | |
| Socioeconomic characteristics | ||||||
| Parents’ nativity | <0.0001 | |||||
| Parent (s) born in US (at least one parent) | 14435674 | 68.2% | 5968120 | 62.9% | 29.3% | |
| Any parent born outside US (at least one parent) | 5372948 | 25.4% | 2579730 | 27.2% | 32.4% | |
| Other (child born in U.S, parents not listed) | 1137829 | 5.4% | 802192 | 8.5% | 41.3% | |
| Primary household language (PHHL) | <0.0001 | |||||
| Hispanic children, non-English PHHL | 1811395 | 8.6% | 1171059 | 12.3% | 39.3% | |
| Hispanic children, English PHHL | 2656967 | 12.6% | 1613537 | 17.0% | 37.8% | |
| Non-Hispanic child | 16520820 | 78.1% | 6568862 | 69.2% | 28.4% | |
| Family structure | <0.0001 | |||||
| Two parents currently married | 14702781 | 69.5% | 5466241 | 57.6% | 27.1% | |
| Two parents, not currently married | 1408492 | 6.7% | 755553 | 8.0% | 34.9% | |
| Single parent (mother or father) | 3061135 | 14.5% | 1991738 | 21.0% | 39.4% | |
| Other family type, no parent reported | 1720667 | 8.1% | 1094497 | 11.5% | 38.9% | |
| Poverty level | <0.0001 | |||||
| 0-99% FPL | 3636078 | 17.2% | 2331532 | 24.6% | 39.1% | |
| 100%-199% FPL | 4117300 | 19.5% | 2263631 | 23.9% | 35.5% | |
| 200%-399% FPL | 5709372 | 27.0% | 2629827 | 27.7% | 31.5% | |
| 400% FPL or above | 7696741 | 36.4% | 2261004 | 23.8% | 22.7% | |
| Highest education of household adult | <0.0001 | |||||
| Less than high school | 1763797 | 8.3% | 1321308 | 13.9% | 42.8% | |
| High school degree or GED | 3732854 | 17.6% | 2394485 | 25.2% | 39.1% | |
| Some college or technical school | 4623420 | 21.9% | 2512813 | 26.5% | 35.2% | |
| College degree or higher | 10897275 | 51.5% | 3186337 | 33.6% | 22.6% | |
| Insurance type | <0.0001 | |||||
| Public only | 5007232 | 23.7% | 3460596 | 36.5% | 40.9% | |
| Private only | 13543873 | 64.0% | 4520148 | 47.7% | 25.0% | |
| Currently uninsured | 1305664 | 6.2% | 710410 | 7.5% | 35.2% | |
| Public and private insurance | 888280 | 4.2% | 572593 | 6.0% | 39.2% | |
| Behavioral characteristic | ||||||
| Parents’ coping with day to day demands of raising children | <0.0001 | |||||
| Very well | 13821997 | 65.3% | 6267432 | 66.1% | 31.2% | |
| Somewhat well | 6833958 | 32.3% | 2979310 | 31.4% | 30.4% | |
| Not very well or not very well at all | 298814 | 1.4% | 122042 | 1.3% | 29.0% | |
| Environmental characteristic | ||||||
| Neighborhood amenities* | <0.0001 | |||||
| Neighborhood does not contain any amenities | 2250267 | 10.6% | 1155408 | 12.2% | 33.9% | |
| Neighborhood contains 1 amenity | 2075021 | 9.8% | 1122736 | 11.8% | 35.1% | |
| Neighborhood contains 2 amenities | 3300468 | 15.6% | 1362376 | 14.4% | 29.2% | |
| Neighborhood contains 3 amenities | 4675674 | 22.1% | 2127837 | 22.4% | 31.3% | |
| Neighborhood contains all 4 amenities | 8134344 | 38.4% | 3343060 | 35.2% | 29.1% | |
Total of some variables not 100% because missing values were excluded.
Neighborhood amenities are 1) sidewalks or walking paths, 2) park or playground area, 3) recreation center, community center or Boys’/Girls’ Club, 4) library or bookmobile
# Prevalence of overweight/obesity
Table 2 presents the characteristics of children who were overweight only or obese only. Compared to those who were overweight, obese children were more likely to be Hispanic (22.5%), to speak a language other than English at home (23.8%), to live with a single parent (21.6%), and to come from a poorer household (22.9%). Obese children were also more likely to have a parent with less than high school educational attainment (25.0 % versus17.8%).
Table 2.
Weighted prevalence (%) of overweight or obesity among U.S. children aged 10-17 years
| Characteristics | Overweight only | Overweight prevalence (15.2%) | p-value | Obesity only | Obesity prevalence (15.8%) | p-value |
|---|---|---|---|---|---|---|
| Demographic characteristics | ||||||
| Sex | <0.0001 | <0.0001 | ||||
| Male | 49.1% | 14.6% | 58.4% | 18.0% | ||
| Female | 50.9% | 15.8% | 41.6% | 13.4% | ||
| Age | <0.0001 | <0.0001 | ||||
| 10-12 years | 40.1% | 16.6% | 40.7% | 17.5% | ||
| 13-15 years | 39.6% | 15.8% | 34.3% | 14.2% | ||
| 16-17 years | 20.3% | 12.2% | 25.0% | 15.6% | ||
| Race/ethnicity | <0.0001 | <0.0001 | ||||
| NH-White | 28.6% | 17.9% | 31.7% | 20.6% | ||
| NH-Black | 45.3% | 13.2% | 41.4% | 12.5% | ||
| Hispanics | 15.9% | 17.6% | 19.5% | 22.5% | ||
| Others | 10.2% | 15.9% | 7.4% | 11.9% | ||
| Socioeconomic characteristics | ||||||
| Parents’ nativity | <0.0001 | <0.0001 | ||||
| Parent (s) born in US | 63.7% | 14.5% | 62.2% | 14.7% | ||
| Any parent born outside US | 27.2% | 15.9% | 27.1% | 16.5% | ||
| Other (child born in U.S, parents not listed) | 7.7% | 18.5% | 9.2% | 22.9% | ||
| Primary household language (PHHL) | <0.0001 | <0.0001 | ||||
| Hispanic children, non-English PHHL | 9.9% | 15.4% | 14.7% | 23.8% | ||
| Hispanic children, English PHHL | 17.8% | 19.4% | 16.3% | 18.4% | ||
| Non-Hispanic child | 70.9% | 14.3% | 67.7% | 14.2% | ||
| Family structure | <0.0001 | <0.0001 | ||||
| Two parents, currently married | 60.0% | 13.8% | 55.4% | 13.3% | ||
| Two parents, not currently married | 8.0% | 17.2% | 7.9% | 17.7% | ||
| Single parent (mother or father) | 19.3% | 17.8% | 22.6% | 21.6% | ||
| Other family type, no parent reported | 11.2% | 18.6% | 11.8% | 20.3% | ||
| Poverty level | <0.0001 | <0.0001 | ||||
| 0-99% FPL | 20.7% | 16.2% | 28.3% | 22.9% | ||
| 100%-199% FPL | 22.4% | 16.3% | 25.3% | 19.1% | ||
| 200%-399% FPL | 28.1% | 15.7% | 27.3% | 15.8% | ||
| 400% FPL or above | 28.7% | 13.4% | 19.1% | 9.3% | ||
| Highest education of household adult | <0.0001 | <0.0001 | ||||
| Less than high school | 11.8% | 17.8% | 16.0% | 25.0% | ||
| High school degree or GED | 22.5% | 17.1% | 27.9% | 22.0% | ||
| Some college or technical school | 25.7% | 16.8% | 27.3% | 18.5% | ||
| College degree or higher | 39.3% | 13.0% | 28.1% | 9.6% | ||
| Insurance type | <0.0001 | <0.0001 | ||||
| Public only | 32.8% | 18.0% | 40.0% | 22.8% | ||
| Private only | 53.8% | 13.9% | 41.7% | 11.2% | ||
| Public and private insurance | 3.4% | 10.8% | 8.6% | 28.4% | ||
| Currently uninsured | 7.7% | 17.7% | 7.3% | 17.5% | ||
| Behavioral characteristic | ||||||
| Parents’ coping with day to day demands of raising children | <0.0001 | <0.0001 | ||||
| Very well | 64.0% | 14.8% | 68.1% | 16.4% | ||
| Somewhat well | 33.5% | 15.9% | 29.4% | 14.5% | ||
| Not very well or not very well at all | 1.2% | 13.0% | 1.4% | 16.0% | ||
| Environmental characteristic | ||||||
| Neighborhood amenities* | <0.0001 | <0.0001 | ||||
| Neighborhood does not contain any amenities | 12.7% | 17.4% | 11.6% | 16.5% | ||
| Neighborhood contains 1 amenity | 11.3% | 16.5% | 12.3% | 18.6% | ||
| Neighborhood contains 2 amenities | 14.6% | 14.6% | 14.1% | 14.6% | ||
| Neighborhood contains 3 amenities | 22.0% | 15.0% | 22.9% | 16.2% | ||
| Neighborhood contains all 4 amenities | 34.7% | 14.1% | 35.7% | 15.0% | ||
Total of some variables not 100% because missing values were excluded.
Neighborhood amenities are 1) sidewalks or walking paths, 2) park or playground area, 3) recreation center, community center or Boys’/Girls’ Club, 4) library or bookmobile
3.2. Prevalence of Overweight and Obesity
Table 3 provides the estimates for the association between SDOH and overweight or obesity, overweight only, and obesity only. The probability of overweight or obesity was higher in children 10-12 years 34% (95% CI = 16%-56%) and 13-15 years 12% (95% CI = 96%-29%)] respectively, using children 16-17 years as referent category. Children who lived with a single parent had a greater probability of being overweight or obese 32% (95% CI = 12%-55%) compared to those having two parents who were currently married. Similarly, compared to children who lived in neighborhoods containing all 4 amenities, those who lived in neighborhoods having one or less amenity, were 27% (95% CI = 2%-58%) more likely to be overweight or obese. Conversely, factors protective of being overweight or obese included; children who lived with an adult with more than 12 years of education (PR= 0.57; 95% CI= 0.42-0.79) and having private health insurance (PR=0.71; 95% CI= 0.59-0.87) (Table 3).
Table 3.
Adjusted prevalence ratio model for social determinants of health in overweight or obesity, overweight only and obesity only among U.S. children aged 10-17 years
| Characteristics | Overweight or obese adjusted PR | p-value | Overweight only adjusted PR | p-value | Obese only | Adjusted PR P value |
|---|---|---|---|---|---|---|
| Demographic characteristics | ||||||
| Sex | ||||||
| Male | Reference | |||||
| Female | 0.88 (0.78-0.99) | 0.15 | 1.10 (0.94-1.27) | 0.23 | 0.74 (0.63-0.87) | <0.0001 |
| Age | ||||||
| 16-17 years | Reference | |||||
| 10-12 years | 1.34 (1.16-1.56) | <0.0001 | 1.45 (1.20-1.74) | <0.0001 | 1.12 (0.92-1.36) | 0.26 |
| 13-15 years | 1.12 (0.96-1.29) | <0.0001 | 1.35 (1.11-1.64) | <0.0001 | 0.89 (0.73-1.08) | 0.25 |
| Race/ethnicity | ||||||
| NH-White | Reference | |||||
| NH-Black | 1.41 (1.01-1.98) | 0.03 | 1.12 (0.72-1.74) | 0.61 | 1.53 (1.01-2.31) | 0.04 |
| Hispanic | 1.52 (1.25-1.85) | 0.04 | 1.29 (1.00-1.65) | 0.05 | 1.50 (1.18-1.90) | <0.0001 |
| Multiracial/NH-other | 1.11 (0.92-1.34) | <0.0001 | 1.29 (1.03-1.62) | 0.03 | 0.89 (0.69-1.14) | 0.34 |
| Socioeconomic characteristics | ||||||
| Parents’ nativity | ||||||
| Parent (s) born in US | Reference | |||||
| Any parent born outside US | 0.90 (0.74-1.09) | 0.27 | 1.02 (0.81-1.29) | 0.88 | 0.83 (0.63-1.08) | 0.17 |
| Other (child born in U.S, parents are not listed) | 1.08 (0.71-1.65) | 0.29 | 0.80 (0.46-1.41) | 0.45 | 1.43 (0.87-2.36) | 0.16 |
| Primary household language (PHHL) | ||||||
| Hispanic children, non-English PHHL | Reference | |||||
| Hispanic children, English PHHL | 1.09 (0.75-1.57) | 0.72 | 1.32 (0.82-2.11) | 0.25 | 0.88 (0.56-1.37) | 0.57 |
| Non-Hispanic child | 0.56 (0.51-0.63) | 0.45 | 0.88 (0.61-1.26) | 0.49 | 0.53 (0.38-0.74) | <0.0001 |
| Family structure | ||||||
| Two parents currently married | Reference | |||||
| Two parents not currently married | 1.05 (0.80-1.37) | 0.74 | 1.06 (0.76-1.48) | 0.73 | 1.02 (0.74-1.40) | 0.92 |
| Single parent (mother or father) | 1.32 (1.12-1.55) | <0.0001 | 1.26 (1.03-1.54) | 0.03 | 1.22 (0.99-1.50) | 0.06 |
| Other family type, no parent | 1.11 (0.81-1.52) | 0.52 | 1.45 (0.93-2.25) | 0.1 | 0.78 (0.54-1.13) | 0.19 |
| Poverty level | ||||||
| 0-99% FPL | Reference | |||||
| 100%-199% FPL | 1.06 (0.85-1.31) | 0.62 | 1.09 (0.84-1.41) | 0.52 | 1.01 (0.78-1.31) | 0.93 |
| 200%-399% FPL | 1.22 (0.97-1.53) | 0.09 | 1.20 (0.88-1.64) | 0.25 | 1.15 (0.86-1.55) | 0.34 |
| 400% FPL or above | 1.02 (0.81-1.27) | 0.89 | 1.15 (0.86-1.55) | 0.34 | 0.85 (0.64-1.13) | 0.27 |
| Highest education of household adult | ||||||
| Less than high school | Reference | |||||
| High school degree or GED | 0.98 (0.71-1.36) | 0.91 | 0.99 (0.63-1.54) | 0.96 | 0.99 (0.69-1.43) | 0.97 |
| Some college or technical school | 0.86 (0.62-1.19) | 0.36 | 0.95 (0.61-1.48) | 0.81 | 0.86 (0.60-1.23) | 0.40 |
| College degree or higher | 0.57 (0.42-0.79) | <0.0001 | 0.77 (0.50-1.20) | 0.25 | 0.52 (0.37-0.75) | <0.0001 |
| Insurance type | ||||||
| Public only (government assistance) | Reference | |||||
| Private only | 0.71 (0.59-0.87) | <0.0001 | 0.91 (0.72-1.17) | 0.47 | 0.65 (0.50-0.84) | <0.0001 |
| Public and private insurance | 0.95 (0.68-1.33) | 0.75 | 0.59 (0.41-0.85) | <0.0001 | 1.31 (0.87-1.98) | 0.20 |
| Currently uninsured | 0.78 (0.57-1.08) | 0.14 | 1.02 (0.68-1.55) | 0.91 | 0.68 (0.46-1.01) | 0.06 |
| Behavioral characteristic | ||||||
| Parents’ coping with day to day demands of raising children | ||||||
| Very well | Reference | |||||
| Somewhat well | 0.96 (0.85-1.08) | 0.48 | 1.07 (0.91-1.26) | 0.4 | 0.87 (0.75-1.02) | 0.08 |
| Not very well or not very well at all | 0.85 (0.56-1.27) | 0.42 | 0.98 (0.63-1.52) | 0.92 | 0.79 (0.49-1.26) | 0.32 |
| Environmental characteristic | ||||||
| Neighborhood amenities* | ||||||
| Neighborhood contains all 4 amenities | Reference | |||||
| Neighborhood does not contain any amenities | 1.20 (1.00-1.45) | 0.05 | 1.32 (1.03-1.69) | 0.03 | 1.02 (0.80-1.28) | 0.89 |
| Neighborhood contains 1 amenity | 1.27 (1.02-1.58) | 0.03 | 1.22 (0.91-1.65) | 0.18 | 1.20 (0.90-1.59) | 0.21 |
| Neighborhood contains 2 amenities | 1.00 (0.84-1.19) | 0.97 | 1.06 (0.87-1.30) | 0.57 | 0.95 (0.75-1.21) | 0.69 |
| Neighborhood contains 3 amenities | 1.08 (0.92-1.26) | 0.36 | 1.12 (0.92-1.35) | 0.26 | 1.01 (0.81-1.25) | 0.94 |
Total of some variables not 100% because missing values were excluded.
Neighborhood amenities are 1) sidewalks or walking paths, 2) park or playground area, 3) recreation center, community center or Boys’/Girls’ Club, 4) library or bookmobile
Prevalence of overweight only
In the adjusted model for overweight only, compared to children 16-17 years, children 10-12 years and those 13-15 years had a 45% (95% CI=20%-74%) and 35% (95% CI= 11%-64%) higher probability of being overweight respectively. Likewise, compared to non-Hispanic Whites, the probability of overweight in Hispanic and multiracial children were 29% (95% CI=0%-65%) and 29% (95% CI= 3%-62%) greater, respectively. Additionally, children who lived with a single parent (PR=1.26; 95% CI= 1.03-1.54) compared to those who lived with two married parents, as well as children who lived in a neighborhood with no amenities (PR= 1.32; 95% CI= 1.03-1.69) compared to children who lived in a neighborhood with all four amenities were also more likely to be overweight. Inversely, having private and public insurance coverage protected children from being overweight (PR = 0.59; 95% CI = 0.41-0.85) compared to children who had public insurance/government assistance only (Table 3).
Prevalence of obesity only
The likelihood of obesity was 53% and 50% greater among non-Hispanic Black and Hispanic children compared to their White counterparts. The strongest protective factors against childhood obesity include female gender (PR = 0.74; 95% CI = 0.63-0.87), non-Hispanic speaking primary household language (PR = 0.53; 95% CI = 0.38-0.74) compared to non-English speaking Hispanic child, parental attainment of college education or higher (PR = 0.52; 95% CI = 0.37-0.75) compared to having less than high school education, and having private insurance coverage only (PR = 0.65; 95% CI = 0.5-0.84) as compared to having public insurance only (Table 3).
4. Discussion
The aim of this study was to understand and detail the potential influence of SDOH on childhood and adolescent overweight and obesity using a nationally representative sample in the United States. Our study showed that 31% of children in our study population were either overweight or obese; this finding is in consonance with previous studies which reported that the prevalence of overweight or obesity was between 30.9 - 34.0%.17,19 More specifically, the prevalence of overweight in our study was 15.2 %, depicting similar findings with previous studies.6,19,20 However, other studies18,21,22 showed that the prevalence of overweight was between 28.8-33.4%. Furthermore, we established that the prevalence of obesity was 15.8%, similar to previous findings5,17-23 indicating a leveling of obesity since 2007. It is worth to note that the prevalence of overweight and obesity varied between studies as a result of geographic variation,24 methodology,25 and differences in types of unit of analysis used (individual vs. state vs. national level).19
Our study found that selected sociodemographic and environmental factors were associated with a higher probability of being overweight or obese. Concerning demographic factors, we observed that being a female child predicted less likelihood of obesity; a finding consistent with some studies conducted prior to 2016.5-7,23,25 However, contrary to our results, some other studies either reported no difference in obesity prevalence between the sexes17,23 or found females to be at increased risk for childhood obesity.14 In addition, in relation to age, our adjusted model showed that younger children (age groups 10-12 and 13-15 years) were significantly more likely to be overweight. However, it was interesting that we did not observe any association between obesity and age, in contrast to the findings of Skinner et al.18 and Ogden14 who reported that obesity significantly increased with age. Our observations of a strong association between overweight and age are concordant with findings reported in previous studies.5,7,8
The findings in this study showed that the SDOH that could possibly protect a child from being overweight or obese were consistent with those of previous studies specifically, language spoken in the home other than Spanish (obesity only),5,26 parental attainment of college degree or higher (overweight or obese),5,14,20,25 and the possession of private or public insurance coverage.25,26 These protective socioeconomic determinants may provide children from these families the resources and opportunity of attaining and maintaining healthier physical and mental life styles. An interesting finding was that we, however, did not find poverty level to be an associated determinant of overweight or obesity. This finding was contrary to earlier studies showing that high income was less predictive of overweight or obesity.1,5,22,26 To our knowledge, this is the first study to examine parent’s nativity as well as a parent’s ability to cope with day-to-day demands of raising children in association with the social determinants of overweight or obesity. However, our analysis did not portray these two SDOH factors to be statistically significant predictors. Our results in relation to environmental characteristics confirm previous studies that children living in neighborhoods with no access to sidewalks or walking paths were more predisposed to obesity or overweight. 1,22,25
Limitations
An important limitation in our study is that the data collected by NSCH was cross-sectional in nature, and that limited our ability to establish a temporal relationship between our exposures and outcomes. Nonetheless, the findings provide important information regarding the role of SDOH on childhood obesity.
Recommendation for Further Studies
Further research to clarify the relationship between overweight/obesity and SDOH in children is needed. Since overweight and obesity are multi-factorial in origin, in order to impact and bring about a reduction in their prevalence, it is crucial to develop effective preventive strategies aimed at addressing the relevant SDOH. We recommend the development of innovative multilevel individualized- as well as community-customized interventions using SDOH risk and protective pathways as guide to address the current childhood overweight and obesity epidemic.
5. Conclusion and Global Health Implications
The results of our study evidently illustrate that demographic, socioeconomic, and environmental characteristics represent important determinants of overweight and obesity in U.S. children. Our study showed that due to possible effective changes at the individual level, initiatives by schools and other communities, at the state, national, and global levels, the prevalence of obesity and overweight in the U.S appeared to have plateaued in 2016 and 2017.17,27,28 More work needs to be done as the social determinants of overweight and obesity in children have significant national and global implications relating to racial/ethnic disparities, population-based policy development, funding allocation, and prevention of overweight and obesity in childhood and subsequently in adulthood.
Acknowledgements
None.
Footnotes
Conflicts of Interest: The authors declare that they have no conflicts of interest.
Financial Disclosure: This was a non-funded research.
Funding/Support: None.
Ethics Approval: This study was approved as exempt by the Institutional Review Board of Baylor College of Medicine.
References
- 1.Wang Y. Cross-national comparison of childhood obesity:the epidemic and the relationship between obesity and socioeconomic status. International Journal of Epidemiology. 2001;30(5):1129–36. doi: 10.1093/ije/30.5.1129. [DOI] [PubMed] [Google Scholar]
- 2.Koplan JP, Liverman CT, Kraak VA Preventing Childhood Obesity. Health in the Balance. Washington (DC): National Academies Press; 2005. [PubMed] [Google Scholar]
- 3.Kumar S, Kelly AS. Review of childhood obesity:from epidemiology, etiology, and comorbidities to clinical assessment and treatment. In Mayo Clinic Proceedings. 2017;92(2):251–265. doi: 10.1016/j.mayocp.2016.09.017. [DOI] [PubMed] [Google Scholar]
- 4.Abarca-Gómez L, Abdeen ZA, Hamid ZA, Abu-Rmeileh NM, Acosta-Cazares B, Acuin C, Adams RJ, Aekplakorn W, Afsana K, Aguilar-Salinas CA, Agyemang C. Worldwide trends in body-mass index, underweight, overweight, and obesity from 1975 to 2016:a pooled analysis of 2416 population-based measurement studies in 128·9 million children, adolescents, and adults. Lancet. 2017;390(10113):2627–2642. doi: 10.1016/S0140-6736(17)32129-3. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Singh GK, Kogan MD, Van Dyck PC, Siahpush M. Racial/ethnic, socioeconomic, and behavioral determinants of childhood and adolescent obesity in the United States:analyzing independent and joint associations. Annals of Epidemiology. 2008;18(9):682–695. doi: 10.1016/j.annepidem.2008.05.001. [DOI] [PubMed] [Google Scholar]
- 6.Ogden CL, Flegal KM, Carroll MD, Johnson CL. Prevalence and trends in overweight among US children and adolescents 1999-2000. The Journal of the American Medical Association. 2002;288(14):1728–1732. doi: 10.1001/jama.288.14.1728. [DOI] [PubMed] [Google Scholar]
- 7.Hales CM, Fryar CD, Carroll MD, Freedman DS, Ogden CL. Trends in obesity and severe obesity prevalence in US youth and adults by sex and age 2007-2008 to 2015-2016. The Journal of the American Medical Association. 2018;319(16):1723–1725. doi: 10.1001/jama.2018.3060. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Au N. The health care cost implications of overweight and obesity during childhood. Health Services Research. 2012;47(2):655–676. doi: 10.1111/j.1475-6773.2011.01326.x. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Finkelstein EA, Ruhm CJ, Kosa KM. Economic causes and consequences of obesity. Annual Review of Public Health. 2005;26:239–257. doi: 10.1146/annurev.publhealth.26.021304.144628. [DOI] [PubMed] [Google Scholar]
- 10.Miech RA, Kumanyika SK, Setler N, Link BG, Phelan JC, Chang VW. Trends in the association of poverty with overweight among US adolescents 1971-2004. The Journal of the American Medical Association. 2006;295:2385–2393. doi: 10.1001/jama.295.20.2385. [DOI] [PubMed] [Google Scholar]
- 11.Goodman E, Slap GB, Huang B. The public health impact of socioeconomic status on adolescent depression and obesity. American Journal Public Health. 2003;93:1844–1850. doi: 10.2105/ajph.93.11.1844. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Goodman E. The role of socioeconomic status gradients in explaining differences in US adolescents'health. American Journal Public Health. 1999;89:1522–1528. doi: 10.2105/ajph.89.10.1522. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Gordon-Larsen P, Adair LS, Pokin BM. The relationship of ethnicity, socioeconomic factors, and overweight in US adolescents. Obesity Research. 2003;11:121–129. doi: 10.1038/oby.2003.20. [DOI] [PubMed] [Google Scholar]
- 14.Ogden CL, Fryar CD, Hales CM, Carroll MD, Aoki Y, Freedman DS. Differences in obesity prevalence by demographics and urbanization in US children and adolescents 2013-2016. The Journal of the American Medical Association. 2018;319(23):2410–2418. doi: 10.1001/jama.2018.5158. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.Powell LM, Wada R, Krauss RC, Wang Y. Ethnic disparities in adolescent body mass index in the United States:the role of parental socioeconomic status and economic contextual factors. Social Science &Medicine. 2012;75(3):469–476. doi: 10.1016/j.socscimed.2012.03.019. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.National Survey of Children's Health Child and Adolescent Health Measurement Initiative. Data Resource Center for Child and Adolescent Health supported by the U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA), Maternal and Child Health Bureau (MCHB) 2016-2017. [Accessed April 18 2019]. Available at: https://www.childhealthdata.org/browse/survey .
- 17.Wang Y, Beydoun MA. The obesity epidemic in the United States—gender, age, socioeconomic, racial/ethnic, and geographic characteristics:a systematic review and meta-regression analysis. Epidemiologic Reviews. 2007;29(1):6–28. doi: 10.1093/epirev/mxm007. [DOI] [PubMed] [Google Scholar]
- 18.Skinner AC, Perrin EM, Skelton JA. Prevalence of obesity and severe obesity in US children 1999-2014. Obesity. 2016;24(5):1116–1123. doi: 10.1002/oby.21497. [DOI] [PubMed] [Google Scholar]
- 19.Wang Y, Wang JQ. A comparison of international references for the assessment of child and adolescent overweight and obesity in different populations. European Journal of Clinical Nutrition. 2002;56(10):973–982. doi: 10.1038/sj.ejcn.1601415. [DOI] [PubMed] [Google Scholar]
- 20.Carey FR, Singh GK, Brown HS, III, Wilkinson AV. Educational outcomes associated with childhood obesity in the United States:cross-sectional results from the 2011-2012 National Survey of Children's Health. International Journal of Behavioral Nutrition and Physical Activity. 2015;12(1):1129–1136. doi: 10.1186/1479-5868-12-S1-S3. S3:2001;30(5) [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21.Borrell LN, Graham L, Joseph SP. Associations of Neighborhood Safety and Neighborhood Support with Overweight and Obesity in US Children and Adolescents. Ethnicity &Disease. 2016;26(4):469. doi: 10.18865/ed.26.4.469. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22.Singh GK, Kogan MD, van Dyck PC. Changes in State-Specific Childhood Obesity and Overweight Prevalence in the United States From 2003 to 2007. Archives of Pediatrics &Adolescent Medicine. 2010;164(7):598–607. doi: 10.1001/archpediatrics.2010.84. [DOI] [PubMed] [Google Scholar]
- 23.Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of obesity and trends in body mass index among US children and adolescents 1999-2010. The Journal of the American Medical Association. 2012;307(5):483–490. doi: 10.1001/jama.2012.40. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24.Guedes DP, Rocha GD, Silva AJ, Carvalhal IM, Coelho EM. Effects of social and environmental determinants on overweight and obesity among Brazilian schoolchildren from a developing region. Revista Panamericana de Salud Pública. 2011;30(4):295–302. [PubMed] [Google Scholar]
- 25.Grow HM, Cook AJ, Arterburn DE, Saelens BE, Drewnowski A, Lozano P. Child obesity associated with social disadvantage of children's neighborhoods. Social Sciences &Medicine. 2010;71(3):584–591. doi: 10.1016/j.socscimed.2010.04.018. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 26.Flores G, Tomany-Korman SC. The language spoken at home and disparities in medical and dental health, access to care, and use of services in US children. Pediatrics. 2008;121(6):e1703–1714. doi: 10.1542/peds.2007-2906. [DOI] [PubMed] [Google Scholar]
- 27.Doak CM, Visscher TL, Renders CM, Seidell JC. The prevention of overweight and obesity in children and adolescents:a review of interventions and programmes. Obesity Reviews. 2006;7(1):111–136. doi: 10.1111/j.1467-789X.2006.00234.x. [DOI] [PubMed] [Google Scholar]
- 28.Long MW, Ward ZJ, Resch SC, Cradock AL, Wang YC, Giles CM, Gortmaker SL. State-level estimates of childhood obesity prevalence in the United States corrected for report bias. International Journal of Obesity. 2016;40(10):1523. doi: 10.1038/ijo.2016.130. [DOI] [PMC free article] [PubMed] [Google Scholar]