Thesis 11.15.11

The Efficacy of the National Survey of Children’s Health at assessing childhood obesity risk in children ages 10-17 years.

1

INTRODUCTION

Childhood Obesity:

31.7% of 2-19 year old children in the U.S. are overweight/obese.

Overweight/obese children are more likely to be overweight/obese into adulthood.

Research indicates several parental factors may contribute to childhood obesity.

2

Reference: 3, 17

Childhood Obesity Models

Several models used to depict variables involved in childhood obesity:

Socio-Economic Model

Ecological Systems Theory

Model of Societal/Environmental Factors Affecting Childhood Obesity

3

Parental Influence on Childhood Obesity

Tabacchi G, Giammanco S, Guardia ML, Giammanco M. (2007) A review of the literature and a new classification of the early determinants of childhood obesity: from pregnancy to the first years of life. Nutrition Research, 27, 587-604.

4

National Survey of Children’s Health (NSCH)

National Survey of Children’s Health

Sponsored by the Maternal and Child Health Bureau.

Assesses the physical and emotional health of children ages 0-17.

Age of children chosen for study (10-17 years)

State and Local Area Integrated Telephone Survey (SLAITS):

Used to determine the emotional and physical healthstatus, as well as, children’ access to medical care and insurance in the U.S.

NSCH overview (www.cdc.gov/SLAITS/NSCH)

5

http://www.cdc.gov/SLAITS/NSCH

Rationale

Childhood obesity is a growing problem.

Identification of contributing factors can lead to effective intervention efforts.

NSCH is a fairly new surveillance system

Initiated in 2003

Potential to aid in future intervention efforts

6

Purpose

To investigate the extent of variables measured by NSCH that are predictive of childhood obesity risk in children ages 10-17 years.

7

8

What Research Says…

Parents’ Obesity

Genetic factors Higher genetic predisposition when

parents are obese.

Greater risk when both parents are overweight.

Lifestyle factors Parents with higher BMI scores may

live obesity-promoting lifestyles

Parent physical activity: strong positive predictor of childhood inactivity.

References: 26, 29

9

Maternal Pregnancy Nutrition

‘Fetal Origins Theory’ The Dutch Famine: Early

1900’s

Higher rates of Obesity in women exposed to famine in 1st and 2nd trimesters: ‘Thrifty Phenotype Hypothesis’

Diet Composition Low Protein

High fat/cholesterol

Low/High Calorie: Infant and mother weight gain

References: 96, 98, 99, 10, 11, 12, 13

10

Maternal Practices of Breastfeeding and Weaning

Breastfeeding vs formula feeding

Rapid ‘catch-up growth’

Age of weaning

World Health Organization (WHO): > 6 mos

Department of Health (DOH): > 4 mos

Infant’s developmental progress

References: 100, 84-86, 6, 10, 11, 8, 91, 90, 87, 88

11

Parental Employment Status

Shift away from traditional dynamic: Father = breadwinner and mother stays home. Both parents lead busy lifestyles.

Research has shown mothers working more hours more likely to have overweight children.

However, two incomes may result in access to healthier choices.

References: 3, 17, 18

12

Parental Education

Higher parental education linked to higher physical activity in children.

Research indicates inverse relationship between childhood obesity and education level of head of household.

Parents who are educated on the importance of health may be more inclined to make healthier choices for their families.


13

Socioeconomic Status

Research is inconsistent. Studies looking at nutrient level

data found little association.

Studies looking at specific food groups found relationships.

One study found SES positively related to fruit/vegetable consumption and negatively related to fast food consumption.

Study by Ogden, et al found childhood obesity prevalence decreases as income increases, however, most obese children are not low income.


14

Single Mother or No-worker Father

Journal of Pediatrics: middle school children with unemployed father had increased risk compared to working fathers.

Children of single mothers or unemployed parents more likely to develop obesity.

References: 1, 2

15

Attitudes of Mother

Mother’s mental and emotional characteristics

Mother’s perception of Child’s weight

Mother’s concern for her child’s weight from personal experience

Maternal restriction

References: 60-62, 68, 63, 64, 73, 82, 70, 72

16

Number of Siblings

Children of the same family will learn the same food culture

However, others argue that each child is different

Weight status of child

Concern of mother for child increases pressure to eat or restrict to change food culture

Genetic and environmental factors influence food culture and weight

References: 50, 52, 57, 59

17

Religion and Beliefs

No direct research literature

Participation in religion is inversely related to increased body weight

Stress-coping mechanism, social support and doctrine itself

Some religions promote dietary restriction Catholicism, Judaism, Seventh Day Adventists

What about prayer, reading your bible?

References: 43, 46, 48, 41, 49

18

Built Environment

Grocery store access Linked with open space and width

of streets

Physical activity level varies based on: SES Housing and neighborhood

characteristics Presence of parks and

walking/biking paths Age of parks

Sex of child Distance from school

Friends in the area Parent’s perception of

neighborhood safety

References: 120, 121, 125, 127, 129

19

OUR Model20

Methodology

Study Design

Non-experimental

Analytical

Key Variables:

Dependent: BMI

Independent: Childhood Obesity Factors

IRB Approval Level - Exempt

21

Statistical Procedures

Data available for use through the NSCH. Analyzed using SPSS version 19.

Computed Frequencies and Chi Square.

Variables were recoded.

22

Sample Population Results23

45,897 Children aged 10-17 made up the study 23,866 Males 21,985 Females

Other Descriptive Statistics available: Federal Poverty level based on SCHIP qualification Family structure Parental Marital/Cohabitation Status Parent Social Support Religious service attendance Parental physical activity per week Parental Mental and Emotional Health Status Parental General Health Parent Stress Coping Ability Parent-Child Relationship Status

24

4940 10.8%

4673 10.2%

5380 11.7%

5861 12.8%

6088 13.3%

6720 14.6%

6952 15.1%

Child's Age

10

11

13

14

15

16

17

21,97552.1%

23,85547.9%

Sex of Child

Male

Female

Child Statistics

25

4935 10.9%

31,88070.7%

4632 10.3%

1897 4.2%

1776 3.9%

Ethnicity/Race

Hispanic

White

Black

Multi-racial

Other

2186 5.0%

29,121 66%

6754 15.3%

6040 13.7%

Child's BMI

Underweight

Healthy Weight

Overweight

Obese

Child Statistics

26

20,67245.0%

16,45235.8%

6043 13.2%

2729 5.9%

Number of Siblings

1

2

3

4+

20,67145.0%

14,77432.2%

8921 19.4%

1315 2.9%

214 0.5%

Birth Position

1

2

3

4

5

Siblings

Family Members27

33,42872.8%

9656 21.0%

2806 6.1%

Respondent Relationship to Child

Mother

Father

All Other

29,24164.1%

4910 10.8%

8027 17.6%

3446 7.6%

Family Structure

Two Parent; Biological/AdoptedTwo Parent; Step Family

Single Mother; No Father presentOther Family Type

Education28

3261 7.8%

9209 21.9%

29,49970.3%

Mother Education Level

Less than High School

High School Graduate

More than High School

2676 7.6%

8414 23.9%24,128

68.5%

Father Education Level

Less than High School

High School Graduate

More than High School

Income29

41,25690.9%

4107 9.1%

Parent Empolyment status at least 50 out

of past 52 weeks

Yes

No

4824 10.5%

7378 16.1%

15,57633.9%

18,11939.5%

Federal Poverty Level based on DHHS

Guidelines

0-99% FPL

100-199% FPL

200-399% FPL

400% FPL +

30

Results of Hypothesis Testing

Maternal General Health Status

Hₒ1a: There is no association between childhood obesity and maternal general health status.

REJECTED(p value = .000)

Maternal General Health Status

Health Status Excellent Very Good and

GoodFair and poor Total

Underweight and Healthy Weight

8787 (30.2%) 17773 (61.2%) 2501 (8.6%) 29061 (100.0%)

Overweight and Obese

2458 (21.2%) 7437 (64.2%) 1686 (14.6%) 11581 (100.0%)

Total 11245 (27.7%) 25210 (62.0%) 4187 (10.3%) 40642 (100.0%)

31

Paternal General Health Status

Hₒ1b: There is no association between childhood obesity and paternal general health status.

REJECTED (p value = .000)

Paternal General Health Status

Health Status ExcellentVery good and

goodFair and poor Total


7259 (28.9%) 16219 (64.6%) 1635 (6.5%) 25113 (100.0%)


1946 (21.3%) 6195 (67.9%) 981 (10.8%) 9122 (100.0%)

Total 9205 (26.9%) 22414 (65.5%) 2616 (7.6%) 34235(100.0%)

32

Maternal Physical Activity Level

Hₒ2a: There is no association between childhood obesity and maternal physical activity level.


Mother’s days of Physical Activity (PA) per week


Overweight and Obese Total

0 days of PA 6253 (68.0%) 2948 (32.0%) 9201 (100.0%)

1 to 4 days of PA 15467 (72.7%) 5808 (27.3%) 21275 (100.0%)

5 to 7 days of PA 7217 (72.4%) 2749 (27.6%) 9966 (100.0%)

33

Paternal Physical Activity Level

Hₒ2b: There is no association between childhood obesity

and paternal physical activity level.


Father’s days of Physical Activity (PA) per week

Underweight and Healthy Weight Overweight and Obese Total

0 days of PA 4425 (70.4%) 1859 (29.6%) 6284 (100.0%)

1 to 4 days of PA 11738 (75.4%) 3837 (24.6%) 15575 (100.0%)

5 to 7 days of PA 8733 (72.4%) 3321 (27.6%) 12054 (100.0%)

34

Maternal Mental and Emotional Health

Hₒ3a: There is no association between childhood obesity and maternal mental and emotional health status.

ACCEPTED (p value = .929)

Maternal Mental and Emotional Health Status


Good

Fair and poor Total

Underweight and

Healthy Weight

10324 (35.3%) 17252 (58.9%) 1691 (5.8%) 29267 (100.0%)

Overweight and

Obese

4192 (35.3%) 6993 (58.8%) 698 (5.9%) 11883 (100.0%)

Total 14516 24245 2389 41150

35

Paternal Mental and Emotional Health

Hₒ3b: There is no association between childhood obesity and paternal mental and emotional health status.


Paternal Mental and Emotional Health Status


Good

Fair and poor Total

Underweight and

Healthy Weight

9773 (39.2%) 14136 (56.8%) 996 (4.0%) 24905 (100.0%)

Overweight and

Obese

3991 (39.5%) 5702 (56.4%) 409 (4.0%) 10102 (100.0%)

Total 13764 19838 1405 35007

36

Paternal Perceptions of Child Health

Hₒ3c: There is no association between childhood obesity and parental perceptions of child health status.


Parent’s Perception of Child health Status

Parent reported

child health

status

ExcellentVery Good and

GoodFair and poor Total

Underweight and

Healthy Weight

21273 (68.0%) 9471 (30.3%) 557 (1.8%) 31301 (100.0%)

Overweight and

Obese

6493 (50.8%) 5743 (44.9%) 553 (4.3%) 12789 (100.0%)

Total 27766 15214 1110 44090

37

Maternal Education Level

Hₒ4a: There is no association between childhood obesity and maternal education status.


Mother Highest Education Level Completed

Education Level

Completed

Less than high school

12 years/high school graduate

More than high school

Total


1639 (5.7%) 5846 (20.2%) 21411 (74.1%) 28896 (100.0%)


1217 (10.6%) 3018 (26.3%) 7262 (63.2%) 11497 (100.0%)

Total 2856 (7.1%) 8864 (21.9%) 28673 (71.0%) 40393 (100.0%)

38

Paternal Education Level

Hₒ4b: There is no association between childhood obesity and paternal education status.


Father Highest Education Level Completed

Education Level

Completed

Less than high school

12 years/high school graduate

More than high school

Total


1405 (5.6%) 5433 (21.8%) 18095 (72.6%) 24933 (100.0%)


1002 (11.1%) 2678 (29.7%) 5348 (59.2%) 9037 (100.0%)

Total 2407 (7.1%) 8120 (23.9) 23443 (69.0%) 33970 (100.0%)

39

Parent Employment Status

Hₒ5a: There is no association between childhood obesity and parent employment status.


Was anyone in the household employed at least 50 weeks out of the past 52 weeks?

Employment Status No Yes Total


2341 (7.6%) 28656 (92.4%) 30997 (100.0%)


1467 (11.6%) 11168 (88.4%) 12635 (100.0%)

Total 3808 (8.7%) 39824 (91.3%) 43632 (100.0%)

40

Parent Income

Hₒ6a: There is no association between childhood obesity and household poverty level based on DHHS guidelines.


Poverty level of this household based on DHHS guidelines

0-99% Federal Poverty Level

100-199% Federal Poverty

Level

200-399% Federal Poverty

Level

400% Federal Poverty Level

or greaterTotal


2436 (7.8%) 4453 (14.2%) 10673 (34.1%) 13745 (43.9%) 31307 (100.0%)


1891 (14.8%) 2539 (19.8%) 4459 (34.9%) 3905 (30.5%) 12794 (100.0%)

Total 4327 (9.8%) 6992 (15.9%) 15132 (34.3%) 17650 (40.0%) 44101 (100.0%)

41

Parent Income

Hₒ6b: There is no association between childhood obesity and household poverty level based on SCHIP qualifications.


Poverty level of this household based on DHHS guidelines based on SCHIP qualifications

0-99% Federal Poverty Level

100-199% Federal

Poverty Level

200-399% Federal

Poverty Level

400% Federal Poverty Level

or greaterTotal


6889 (22.0%) 5551 (17.7%) 5122 (16.4%) 13745 (43.9%) 31307 (100.0%)


4430 (34.6%) 2513 (19.6%) 1946 (15.2%) 3905 (30.5%) 12794 (100.0%)

Total 11319 (25.7%)

8064 (18.3%) 7068 (16.0%) 17650 (40.0%) 44101 (100.0%)

42

Parental Marital Cohabitation Status

Hₒ7a: There is no association between childhood obesity and parental marital cohabitation status.


Marital/Cohabitation Status of Child's Parent(s) in the Household

Married Cohabitating NeitherNo parents in the household

Total


23905 (76.8%) 1241 (4.0%) 5008 (16.1%) 954 (3.1%) 31108 (100.0%)


8462 (66.7%) 757 (6.0%) 2848 (22.4%) 623 (4.9%) 12690 (100.0%)

Total 32367 (73.9%) 1998 (4.6%) 7856 (17.9%) 1577 (3.6%) 43798 (100.0%)

43

Parental Legal Status

Hₒ7b: There is no association between childhood obesity and parental legal status.


Derived: Legal Marital Status of Child's Parent(s) in the Household

Married Separated Divorced WidowedNever

Married

No Parents in

HouseholdTotal


23905 (76.8%)

708 (2.3%)

3146 (10.1%)

442 (1.4%)

1961 (6.3%)

954 (3.1%)

31116 (100.0%)


8462 (66.7%)

449 (3.5%)

1514 (11.9%)

255 (2.0%)

1391 (11.0%)

623 (4.9%)

12694 (100.0%)

Total 32367 (73.9%)

1157 (2.6%)

4660 (10.6%)

697 (1.6%)

3352 (7.7%)

1577 (3.6%)

43810 (100.0%)

44

Family Structure

Hₒ7c: There is no association between childhood obesity and family structure.


Type of family structure in household

Two parent, biological or

adopted

Two parent, step family

Single mother, no father present

Other family type

Total


20872 (67.0%) 3299 (10.6%) 4829 (15.5%) 2148 (6.9%) 31148 (100.0%)


7234 (56.9%) 1473 (11.6%) 2851 (22.4%) 1156 (9.1%) 12714 (100.0%)

Total 28106 (64.1%) 4772 (10.9%) 7680 (17.5%) 3304 (7.5%) 43862 (100.0%)

45

Number of Siblings

Hₒ8a: There is no association between childhood obesity and number of siblings.


How many people less than 18 years old live in this household

Children in

Household1 2 3 4 Total

Underweight

and Healthy

Weight

14095

(45.0%)

11305

(36.1%)

4106 (13.1%) 1800 (5.7%) 31306

(100.0%)

Overweight

and Obese

5900 (46.1%) 4505 (35.2%) 1645 (12.9%) 744 (5.8%) 12794

(100.0%)

Total 19995 15810 5751 2544 44100

46

Birth position of Siblings

Hₒ8b: There is no association between childhood obesity and birth position of siblings.


Birth position of the child relative to other children in the household

Birth

Position1 2 3 4 5 Total

Underweigh

t and

Healthy

Weight

14095

(45.0%)

10314

(32.9%)

5916

(18.9%)

865 (2.8%) 116 (.4%) 31306

(100.0%)

Overweight

and Obese

5900

(46.1%)

3842

(30.0%)

2612

(20.4%)

364 (2.8%) 76 (.6%) 12794

(100.0%)

Total 19995 14156 8528 1229 192 44100

47

Family Meals

Hₒ9a: There is no association between childhood obesity and number of family meals.


In the past week, on how many days did all family members living in the household eat a meal together?

Days per week 0 1 to 4 5 to 7 Total


1483 (4.8%) 12181 (39.0%) 17551 (56.2%) 31215 (100.0%)


616 (4.8%) 4656 (36.5%) 7490 (58.7%) 12762 (100.0%)

Total 2099 (4.8%) 16837 (38.3%) 25041 (56.9%) 43977 (100.0%)

48

Neighborhood Parks and Walking Paths

Hₒ10a: There is no association between childhood obesity and the presence of neighborhood parks and walking paths.


Does a park or playground area exist in your neighborhood?

No Yes Total

Underweight and

Healthy Weight

6388 (20.6%) 24652 (79.4%) 31040 (100.0%)

Overweight and Obese 2569 (20.3%) 10108 (79.7%) 12677 (100.0%)

Total 8957 34760 43717

49

Presence of Sidewalks and Walking Paths

Hₒ10b: There is no association between childhood obesity and the presence of walking paths.


Do sidewalks or walking paths exist in your neighborhood?

No Yes Total

Underweight and

Healthy Weight

8876 (28.6%) 22172 (71.4%) 31048 (100.0%)


Total 12455 31264 43719

50

Neighborhood Safety

Hₒ10c: There is no association between childhood obesity and neighborhood safety.


How often does your child feel safe in your community or neighborhood?

Never Sometimes Usually Always Total

Underweight

and Healthy

Weight

569 (1.8%) 2734 (8.8%) 10587 (34.2%) 17098 (55.2%) 30988

(100.0%)

Overweight

and Obese

229 (1.8%) 1188 (9.4%) 4242 (33.5%) 6985 (55.2%) 12644

(100.0%)

Total 798 3922 14829 24083 43632

51

Religious Service Attendance

Hₒ11a: There is no association between childhood obesity and religious service attendance.


About how often does the child attend a religious service?

None

At least once

per year but

less than

once per

month

At least

once per

month but

less than

once per

week

At least

once per

week but

less than

daily

Daily Total

Underweight

and Healthy

Weight

4850

(15.6%)

4094

(13.2%)

5886

(18.9%)

15947

(51.3%)

312 (1.0%) 31089

(100.0%)

Overweight

and Obese

1974

(15.5%)

1549

(12.2%)

2430

(19.1%)

6631

(52.2%)

125 (1.0%) 12709

(100.0%)

Total 6824 5643 8316 22578 437 43798

52

Parental Social Support

Hₒ11b: There is no association between childhood obesity and parental social support.


Is there someone that you can turn to for day-to-day emotional help with parenthood/raising

children?

Definitely and

somewhat agree

Somewhat and

definitely disagreeTotal

Underweight and

Healthy Weight

28313 (92.1%) 2444 (7.9%) 30757 (100.0%)


Total 39818 3479 43297

53

Parental Stress Coping Skills

Hₒ11c: There is no association between childhood obesity and parental stress coping skills.


In general, how well do you feel you are coping with the day to day demands of

parenthood/raising children?

Very well and

somewhat well

Not very well and not

very well at allTotal

Underweight and

Healthy Weight

30739 (98.5%) 479 (1.5%) 31218 (100.0%)


Total 43286 680 43966

54

Parent-Child Relationship Status

Hₒ11d: There is no association between childhood obesity and parent-child relationship status.


How well can you and your child share ideas or talk about things that really matter?

Very well and

somewhat well

Not very well and not

very well at allTotal

Underweight and

Healthy Weight

21289 (97.5%) 550 (2.5%) 21839 (100.0%)


Total 30021 799 30820

55

Conclusions of NSCH Variables56

Not Addressed Needs Improvements Addressed

Conclusions

NSCH has room for growth

NSCH has a narrow scope of variables measured that are predictive childhood obesity risk.

10 out of 25 variables measured adequately

10 out of 25 variables notmeasured adequately

5 out of 25 variables need revisions

57

DISCUSSION

Strengths Large sample size

Randomized sample size

Large variety of topics

Limitations Random digit dialing

Self reported data

Bias?

Potential for non-response bias exists: the sample interviewed differed from the targeted child population in a systematic fashion

Lack of continuous data for all age groups

58

RECOMMENDATIONS for Changes to NSCH

Alternate selection method Eliminate SLAITS as selection method

Adding cell phones

Increase variability of sample by over-sampling minorities Hispanic/African American populations

Low income

Housing type

Education Level

All data for all ages Breastfeeding/Age of Weaning

59

QUESTIONS?60

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