Environmental Factors and Risk of Childhood Obesity Sharon Kandris, MA 1 & Gilbert Liu, MD,MS 2 1...

Environmental Factors and Environmental Factors and Risk of Childhood ObesityRisk of Childhood Obesity

Sharon Kandris, MASharon Kandris, MA11 & Gilbert Liu, MD,MS & Gilbert Liu, MD,MS22

11 The Polis Center at Indiana University-Purdue University at Indianapolis The Polis Center at Indiana University-Purdue University at Indianapolis

2 2 Children’s Health Services Research,Children’s Health Services Research, Department of Pediatrics at Indiana University Department of Pediatrics at Indiana University

Obesity Trends* Among U.S. AdultsObesity Trends* Among U.S. AdultsBRFSS, 1985BRFSS, 1985

(*BMI 30, or ~ 30 lbs overweight for 5’4” woman)

Source: Mokdad AH.

No Data <10% 10%-14% 15-19% 20%



No Data <10% 10%-14% 15-19% 20%

Source: Mokdad AH.



Source: Mokdad A H, et al. J Am Med Assoc2000;284:13

No Data <10% 10%-14% 15-19% 20%



Source: Mokdad A H, et al. J Am Med Assoc2001;286:10

No Data <10% 10%-14% 15-19% 20%

BackgroundBackground

Environmental factors that increase caloric intake and Environmental factors that increase caloric intake and decrease energy expenditure seem to underlie the decrease energy expenditure seem to underlie the rapid increases in obesity prevalencerapid increases in obesity prevalence

The current U.S. environment is characterized by an The current U.S. environment is characterized by an essentially unlimited supply of convenient, essentially unlimited supply of convenient, inexpensive, palatable, energy-dense foods coupled inexpensive, palatable, energy-dense foods coupled with a lifestyle requiring negligible amounts of with a lifestyle requiring negligible amounts of physical activity for subsistence.physical activity for subsistence.

1970’s obesity was associated with higher socioeconomic status in early childhood, and lower SES in adolescent females

1980’svery disparate reporting on the relationship between SES and obesity

1990’s2.2-fold increased incidence of childhood obesity in children living in dilapidated living conditions.

2000’schildren from low income families had an almost threefold increased risk of developing obesity.

BackgroundBackground

Hypothesis Hypothesis

Controlling for individual demographics, Controlling for individual demographics, childhood obesity is more prevalent in regions childhood obesity is more prevalent in regions where the social milieu does not support where the social milieu does not support healthy lifestyleshealthy lifestyles

Social Milieu Factors Related to Social Milieu Factors Related to Healthy LifestyleHealthy Lifestyle

Lower Lower

Median IncomeMedian Income

Decreased Physical ActivityDecreased Physical ActivityLess access to facilities for physical activityLess access to facilities for physical activityLess leisure time for physical activityLess leisure time for physical activity

Less Healthful DietLess Healthful DietGreater use of high-calorie convenience foodsGreater use of high-calorie convenience foodsLower consumption of fruits and vegetablesLower consumption of fruits and vegetables

Lower Lower Educational Educational AttainmentAttainment

More More

Single-parent Single-parent householdshouseholds

Higher CrimeHigher Crime A perception of one’s neighborhood as unsafe A perception of one’s neighborhood as unsafe poses a barrier to physical activityposes a barrier to physical activity

ApproachApproach1.1. Study design: Cross-sectional Study design: Cross-sectional

2.2. Regenstrief Medical Record System, Indiana University Regenstrief Medical Record System, Indiana University Medical GroupMedical Group

3.3. Patients ages 4-18y who had simultaneously documented Patients ages 4-18y who had simultaneously documented heights and weights in calendar years 1996 – 2000 heights and weights in calendar years 1996 – 2000

4.4. Categorized by BMI percentiles into overweight (>85Categorized by BMI percentiles into overweight (>85thth – 95 – 95th th

percentile for age-adjusted norms) and obese (>95percentile for age-adjusted norms) and obese (>95thth percentile) percentile)

5.5. Using GIS, we linked study subjects with community-level Using GIS, we linked study subjects with community-level socioeconomic data (2000 U.S. Census) using census block socioeconomic data (2000 U.S. Census) using census block groupsgroups as the indexas the index

Statistical AnalysisStatistical AnalysisLogistic regression examining association between obesity and:Logistic regression examining association between obesity and:

Individual-level variablesIndividual-level variables1.1. Age Age 2.2. Gender Gender 3.3. Ethnicity Ethnicity

Community-level variables Community-level variables 1.1. Median family income Median family income

Extremely low, Very low, Low, Middle, Moderate & Upper* Extremely low, Very low, Low, Middle, Moderate & Upper*

2.2. Proportion of adults without HS degree Proportion of adults without HS degree 3.3. Proportion of single-parent households Proportion of single-parent households 4.4. Crime rate per square mileCrime rate per square mile5.5. Linguistic isolationLinguistic isolation

*[*[HUD definitions adjusted for Indianapolis median family incomesHUD definitions adjusted for Indianapolis median family incomes]]

Distribution of BMI (n=17,871)Distribution of BMI (n=17,871)

Normal weight……………..11,133 (62%)Normal weight……………..11,133 (62%)Overweight………………….2,893 (16%)Overweight………………….2,893 (16%)Obese………………………..3,845 (Obese………………………..3,845 (2222%)%)

Distribution of BMI by Gender (n=17,871)Distribution of BMI by Gender (n=17,871)

Total (%)

BoyNormal OverweightObese

8455 (47) 5396 (64)1296 (15)1763 (21)

GirlNormalOverweightObese

9416 (53) 5737 (61)1597 (17)2082 (22)

TotalNormalOverweightObese

11133 (62)2893 (16)

3845 (22)

Distributions of BMI Distributions of BMI by Ethnicity and Gender (n=17,871)by Ethnicity and Gender (n=17,871)

Black (%) White (%) Hispanic (%)

Other (%)

MaleNormalOverweightObese

3246 (65)734 (15)

1021 (20)

1820 (63)450 (16)620 (21)

198 (54)

76 (21)94 (16)

132 (67)

36 (18)28 (14)

FemaleNormalOverweightObese

3396 (60)996 (17)

1302 (23)

2041 (63)519 (16)660 (21)

185 (57)

55 (17)82 (26)

115 (64)

27 (15)38 (21)

Summary Statistics on Age and Census Summary Statistics on Age and Census Block Group IndicatorsBlock Group Indicators

Mean & Standard DeviationMean & Standard Deviation

AgeAge 10.4 10.4 ±± 4.2 4.2

Median Family IncomeMedian Family Income $32,561 $32,561 ±± 12,406 12,406

Proportion of Adults without Proportion of Adults without HS diplomaHS diploma

29.3% 29.3% ±± 14.7 14.7

Proportion of single-parent Proportion of single-parent householdshouseholds

28.9% 28.9% ±± 14.3 14.3

Crime rate per square mileCrime rate per square mile 604.1 604.1 ±± 428.6 428.6

Distribution of Obesity by AgeDistribution of Obesity by Age %Obese

0

0.05

0.1

0.15

0.2

0.25

0.3

4 5 6 7 8 9 10 11 12 13 14 15 16 17 18

%Obese

Distribution of Obesity by Income Distribution of Obesity by Income LevelLevel

%Obese

0

0.05

0.1

0.15

0.2

0.25

ExtremelyLow

Very Low Low Middle Moderate Upper

%Obese

Factor Estimate 95% Confidence Interval

Ethnic and Gender Subgroups White Male White Female Hispanic Male Hispanic Female Black Male Black Female Others Male Others Female

1.0000.931

1.3741.437

0.9551.059

0.6541.097

Reference Group(0.822, 1.055) (1.050, 1.799)(1.114, 1.852) (0.852, 1.070)(0.948, 1.184) (0.433, 0.987)(0.756, 1.592)

Point Estimates and 95% Confidence Intervals

for Odds Ratios by Ethnicity and Gender

Factor Estimate 95% Confidence Interval

Income categories Extremely low income Very low income Low income Moderate income Middle income Upper income

1.4411.5501.4711.3451.3351.000

(1.104, 1.881) (1.265, 1.898)(1.212, 1.785)(1.078, 1.677)(1.071, 1.664)Reference Group

Point Estimates and 95% Confidence Intervals for Odds Ratios by Income Levels

Summary of FindingsSummary of Findings

1.1. Inverse association between the median Inverse association between the median family income of a census block group and family income of a census block group and the incidence of obese children in the census the incidence of obese children in the census block groupblock group

2.2. A child’s risk of obesity differs according to A child’s risk of obesity differs according to individual characteristics such as age, race individual characteristics such as age, race and gender. and gender.

Used Geographic Information Systems (GIS)Used Geographic Information Systems (GIS)

Observed spatial relationship between obesity Observed spatial relationship between obesity and environmental variablesand environmental variables

Compared block groups with high prevalence Compared block groups with high prevalence of obesity to those with low and mapped of obesity to those with low and mapped against environmental variablesagainst environmental variables

Identified “High-Risk” AreasIdentified “High-Risk” Areas

Spatial AnalysisSpatial Analysis

High Risk NeighborhoodsHigh Risk Neighborhoods

High RiskHigh Risk NeighborhoodsNeighborhoods

In General:In General: Near IndustryNear Industry Poor Access to Open SpacePoor Access to Open Space Few Grocery StoresFew Grocery Stores ImpoverishedImpoverished Large Hispanic populationLarge Hispanic population

Next StepsNext StepsNew VariablesNew Variables

EnvironmentalEnvironmental Land use typeLand use type Air and water qualityAir and water quality Hazardous SubstancesHazardous Substances Grocery StoresGrocery Stores Ethnic Food StoresEthnic Food Stores Fast Food DensityFast Food Density

Individual-levelIndividual-level:: Insurance StatusInsurance Status

New Analysis MethodsNew Analysis Methods

Year-by-yearYear-by-yearGeostatistical AnalysisGeostatistical AnalysisAdvanced Spatial AnalysisAdvanced Spatial Analysis

Next StepsNext Steps

Develop Education and/or Intervention Strategies Through Develop Education and/or Intervention Strategies Through Continued Involvement in Community InitiativesContinued Involvement in Community Initiatives

» P.E. for the 21P.E. for the 21stst Century Charter School, Indianapolis, IN Century Charter School, Indianapolis, IN

» Youth Movement InitiativeYouth Movement Initiative

Community InitiativesCommunity InitiativesNationalNational

– Pediatric Academic SocietiesPediatric Academic Societies– American College of Sports MedicineAmerican College of Sports Medicine– National Association of State High School AssociationsNational Association of State High School Associations

LocalLocal– Strategic Thinking on Obesity CoalitionStrategic Thinking on Obesity Coalition– West Side Community OrganizationWest Side Community Organization– Additional Funding Support (NIH)Additional Funding Support (NIH)

» Indiana State Department of HealthIndiana State Department of Health» State ToxicologistState Toxicologist» Local ResearchersLocal Researchers

Contact UsContact Us

Sharon [email protected]

Gil [email protected]

Environmental Factors and Risk of Childhood Obesity Sharon Kandris, MA 1 & Gilbert Liu, MD,MS 2 1...

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