CENTRAL CALIFORNIA CHILDREN’S INSTITUTE

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CENTRAL CALIFORNIA CHILDREN’S INSTITUTEThe Central California Children’s Institute is dedicated to improving the well-being and quality of life for all children,youth, and their families in the Central California region. The objectives of the Central California Children’s Institute areto (a) study health, education, and welfare issues that affect children and youth in the Central California region; (b)provide an informed voice for children and youth in the region; (c) develop policy and programs, and foster communication and collaboration among communities, agencies, and organizations; and (d) enhance the quality and effectiveness ofcommunities, agencies, and organizations that provide services to children, youth, and their families.Additional information about the Central California Children’s Institute, its programs and activities (including this report),health related calendar, and academic as well as community resources may be found at http://www.csufresno.edu/ccchhs/CI/Central California Children’s InstituteCentral California Center for Health and Human ServicesCollege of Health and Human ServicesCalifornia State University, Fresno1625 E. Shaw Avenue, Suite 146Fresno, CA 93710-8106559-228-2150Fax: 559-228-2168This report may be downloaded from http://www.csufresno.edu/ccchhs/CI/SUGGESTED CITATIONGreer, F., Rondero Hernandez, V., Sutton, P., & Curtis, K. A. (2004). Obesity and physical inactivity among childrenand adolescents in the San Joaquin Valley. Fresno: Central California Children’s Institute, California State University,Fresno.COPYRIGHT INFORMATIONCopyright 2004 by California State University, Fresno. This report may be printed and distributed free of charge foracademic or planning purposes without the written permission of the copyright holder. Citation as to source, however, isappreciated. Distribution of any portion of this material for profit is prohibited without specific permission of the copyright holder.2

AcknowledgmentsAcknowledgmentsThis publication represents the efforts of many individuals. It would not have been possible without the assistance of thefollowing individuals. We express our appreciation to each of them.Research SupportConnie CuellarShelley HoffCopyeditorPeter HammarPhotographyAdi SusantoThe California EndowmentGraphic DesignBecky Ilic- Media Cube DesignLeadership and Project SupportCarole Chamberlain, Program Officer, The California EndowmentLeeAnn Parry, Community Benefits Manager, Kaiser Permanente Central California Service AreaBenjamin Cuellar, Dean, College of Health and Human Services, California State University, FresnoJeromina Echeverria, Provost and Vice President for Academic Affairs, California State University, FresnoRegional Advisory Council, Central California Children’s InstituteThis study was funded by a grant from The California Endowment. The printing of this report was provided by KaiserPermanente Central California.3

ExecutiveExecutive Summary SummaryObesity is a risk factor for many health problems, regardless of a person’s age. Children who are overweight, however,face a greater risk of health problems, including Type 2 diabetes, high blood pressure, high blood lipids, asthma, sleepapnea, and orthopedic problems, than do their non-overweight peers. They may also experience psychosocial problems,such as social stigma, discrimination, and low self-esteem. Overweight in children and adolescents can also be associated with medical care costs, which often extend into adulthood.This report includes a study of factors that contribute to the understanding of the prevalence of overweight amongchildren and adolescents in the San Joaquin Valley. Current literature related to childhood obesity was reviewed andpublicly available data sets were used to study this problem. The 2001 California Health Interview Survey (CHIS) dataon childhood obesity and related factors are featured in this report. These data were analyzed in relationship to age,gender, ethnicity, socioeconomic status, place of residence (urban vs. rural settings), and physical inactivity, includingsedentary behaviors such as television viewing. Results for the San Joaquin Valley were also examined in relationship tostate and national findings.Based on the 2001 CHIS, almost one in eight or 40,000 adolescents ages 12-17 were overweight, and two out of threeadolescents in the San Joaquin Valley did not participate in sufficient moderate physical activity. Differences existedbetween ethnic groups in both the prevalence of overweight and in physical inactivity patterns; Black and Latino adolescents had higher rates of overweight and higher rates of physical inactivity than did White adolescents. In addition, overone third of adolescents ages 12-17 in the Valley watched more than two hours of television per weekday. Furthermore,one in six overweight adolescents lived in the most impoverished households.Data evaluated in this report indicate that the prevalence of overweight among children and adolescents is increasing atan alarming rate across the nation. The same holds true for the San Joaquin Valley. To ensure a healthier future forchildren and adolescents and address the magnitude of the problems associated with overweight in children and adolescents, immediate attention is needed and broad efforts in nutrition education, physical activity, and obesity preventionmust be taken. This report includes recommendations for action and interventions that communities can implement.4

TableTable of Contentsof ContentsCentral California Children’s Institute. 2Acknowledgments. 3Executive Summary. 4List of Tables. 6List of Figures. 6Introduction.7Terminology. 8Methodology.9Findings.12Implications. 22Discussion. 22Recommendations. 24Conclusion.255

ListList of Tablesof Tables1. Criteria for At Risk for Overweight and Overweight. 92. Overweight Among Adolescent Ages 12-17 by Gender, 2001. 143. National and State Overweight Rates Among Children and Adolescents. 154. Overweight Among Adolescents Ages 12-17 by Federal Poverty Level, 2001. 155. Overweight Among Adolescents Ages 12-17 by Place of Residence, 2001. 166. Adolescents Ages 12-17 Not Engaging in Sufficient Vigorous Physical Activity, 2001. 177. Adolescents Ages 12-17 Not Engaging in Sufficient Moderate Physical Activity, 2001. 178. Adolescents Ages 12-17 Not Engaging in Sufficient Vigorous Physical Activity by Gender, 2001. 189. Adolescents Ages 12-17 Not Engaging in Sufficient Moderate Physical Activity by Gender, 2001. 1810. Adolescents Ages 12-17 Not Engaging in Sufficient Vigorous Physical Activity by Ethnicity, 2001. 1911. Adolescents Ages 12-17 Not Engaging in Sufficient Moderate Physical Activity by Ethnicity, 2001. 1912. Children and Adolescents Ages 3-17 Watching Television on Weekdays More Than Two HoursPer Day by Ethnicity, 2001. 20ListList of Figuresof Figures1. San Joaquin Valley Child and Adolescent Population Ages 0-17, 2000. 122. San Joaquin Valley Child and Adolescent Population Ages 0-17 as a Percentage of Total Population, 2000. 123. Race/Ethnicity of Children and Adolescents Ages 0-17 in the San Joaquin Valley, 2000. 134. Overweight and Non-Overweight Children and Adolescents Ages 3-17 Watching Television onWeekdays More Than Two Hours Per Day, 2001. 206

IntroductionIntroductionThis report has four principal objectives: (1) to present anoverview of childhood obesity and related factors thataffect the health of children and adolescents who residein the San Joaquin Valley; (2) to provide a basis for understanding this condition and its prevalence in the Valley; (3) to present relevant issues that require further investigation; and (4) to facilitate community discussionsabout regional data on childhood obesity. Various regional,state, and national sources of data on childhood obesityand physical inactivity have been used to summarize current knowledge about overweight among children and adolescents.The prevalence of childhood overweight is increasingacross the United States. Overweight children are at riskfor health problems that can follow them into adulthood,such as Type 2 diabetes, high blood pressure, high bloodlipids, asthma, sleep apnea, and orthopedic problems (Dietz& Robinson, 1998; U.S. Department of Health and Human Services, 2001). Overweight children are hospitalized more often than are children of healthy weight (Wang& Dietz, 2002), and it is estimated that 50% of overweightchildren remain overweight and obese as adults (Dietz &Robinson, 1998).Health problems related to overweight in a child havebeen divided into three major categories (Must & Strauss,1999). The first category of health problems includes theimmediate health consequences, such as orthopedic abnormalities, asthma, sleep apnea, and gallstones. An increase in pediatric overweight appears to coincide withan increase in childhood diabetes. Non-insulin-dependentdiabetes reportedly increased 10 fold between 1982 and1994, and more than 90% of new diagnoses were adolescent patients who were overweight (Pinhas-Hamiel etal., 1996).The second category includes the progressive development of cardiovascular risk factors as the overweight childdevelops and grows. Studies have shown that overweightchildren are 9 to 10 times more likely to have high bloodpressure in adulthood than are non-overweight children.This elevated blood pressure may start as early as 5 yearsof age (Must & Strauss, 1999).The third category of health problems includes long-termcomplications, such as heart disease, atherosclerosis, colon cancer, arthritis, and general problems with daily living activities. It has been discovered that the relative riskof dying prematurely increased 1.5 to 2 times among individuals who were overweight as children, compared withindividuals who were not overweight as children (Greger& Edwin, 2001; Must & Strauss, 1999).In addition to physical health problems related to overweight and obesity, overweight children may also experience psychosocial problems, such as social stigma, discrimination, and low self-esteem. Children as young as 6years of age ascribe negative terms to overweight peers,which can affect a child’s body image and self-esteem(Must & Strauss, 1999).Overweight and physical inactivity among children andadolescents are also associated with increased medicalcare costs, which can extend into adulthood. The annualhospital costs for overweight-related conditions in youthsaged 6 to 17 years tripled, from 35 million during 19791982 to 127 million during 1997 (Wang & Dietz, 2002).Overweight and obesity are also associated with a 36%increase in inpatient and outpatient costs and a 77% increase in the cost of medications. Currently, the healthcare costs of obesity in adulthood far exceed the costsassociated with smoking and problem drinking (Sturm,2002; Wang & Dietz, 2002). In 2000, the total cost ofoverweight and obesity was estimated to be 117 billion.(U.S. Department of Health and Human Services, 2002).The estimated cost of this condition in California alone isestimated at 14.2 billion (U.S. Department of Health andHuman Services, 2001).7

TerminologyTerminologyThe terms body mass index (BMI), obesity, at risk foroverweight, overweight, and obese are used throughoutthis report. They are generally used to describe body composition or the proportion of body mass to body fat. In thisreport, they are defined as follows:Body Mass Index (BMI)—A ratio measurement ofweight to height that is used to categorize children as underweight, normal, at risk for overweight, or overweight,defined as the weight in kilograms divided by the height inmeters squared (Centers for Disease Control and Prevention [CDC], 2004b).Obesity—Refers to an excessively high amount of bodyfat or adipose tissue in relation to lean body mass (Skunkard& Wadden, 1993).Overweight—Age- and gender-adjusted BMI at or abovethe 95th percentile (CDC, 2004b).8At risk for overweight—Age- and gender-adjusted BMIabove the 85th and below the 95th percentile (CDC,2004b).Obese— For children and adolescents, the terms obeseand overweight are synonymous, meaning that both theseterms are defined by age- and gender-adjusted BMI at orabove the 95th percentile. Among children and adolescents, even though overweight roughly corresponds to theobese BMI range for adults (Diamant, Babey, Brown, &Chawla, 2003), potentially negative connotations associated with the term “obesity” make “at risk for overweight,”and “overweight” the preferred scientific terms whenreferring to young people whose excess body weight posesmedical risks (CDC, 2004c).

MethodologyMethodologyData SourcesThis report uses secondary data and prevalence estimatesabout childhood overweight and physical inactivity fromthe 2001 California Health Interview Survey (2001 CHIS;UCLA Center for Health Policy Research, 2004). The2001 CHIS was a telephone survey of California communities that was conducted in six languages by the Center for Health Policy Research at the University of California, Los Angeles School of Public Health between November 2000 and September 2001. Households with children ages 0-17 in the San Joaquin Valley and other communities in the state were randomly selected. Telephoneinterviews were conducted with the adult who had themost knowledge about the child under age 12 about whomdata were being gathered, as well as one adolescent age12-17, if living in the same household. Responses to questions about weight and height and other health conditionsand behaviors were collected during these interviews.These responses were used to calculate county-level estimates for the prevalence of overweight in the eight counties of the San Joaquin Valley, Fresno, Kern, Kings,Madera, Merced, San Joaquin, Stanislaus, and Tulare. Thetables and figures in this report contain estimates of theextent of overweight and physical inactivity from the 2001CHIS and other data sources.The report examined several secondary sources of dataother than the 2001 CHIS. This section defines and describes the interview and survey databases that are referred to in the report and the methods used to collectthese data. A summary of criteria for overweight or obesity and comments on how the data from each sourcecompares to 2001 CHIS data are presented in Table 1,followed by a description of the databases.Table 1Criteria for At Risk for Overweight and OverweightData SourceFITNESSGRAM Criteria for At Risk forComparison to 2001Criteria for OverweightOverweightCHIS CriteriaAbove the Healthy FitnessAbove the Healthy FitnessDifferentZone for Body Composition* Zone for Body Composition*CalTEENS85-94th Percentile of AgeGender BMIAt and above 95th Percentileof Age-Gender BMISameNHANES85-94th Percentile of AgeGender BMIAt and above 95th Percentileof Age-Gender BMISamePedNSS85-94th Percentile of AgeGender BMIAt and above 95th Percentileof Age-Gender BMISameCDC85-94th Percentile of AgeGender BMIAt and above 95th Percentileof Age-Gender BMISame*The Healthy Fitness Zone for Body Composition is calculated based on BMI and skin fold thickness.FITNESSGRAM . The 2001 FITNESSGRAM datawere collected by the California Department of Education and analyzed by the California Center for PublicHealth Advocacy (2002). The FITNESSGRAM is a database of variables assessing physical performance andbody composition for fifth, seventh, and ninth graders.Data were collected by classroom teachers in 6,837schools, and the results were categorized according tostate assembly district. The FITNESSGRAM definedoverweight as any score that was above the Healthy Fitness Zone for Body Composition. This definition variesfrom that of the CDC, which determines overweight based9

on BMI. The FITNESSGRAM study determined fitnessby measuring the child’s aerobic capacity, using runningand walking tests.California Teen Eating and Exercise Nutrition Survey (CalTEENS). The CalTEENS is a random-digit-dialtelephone survey regarding nutrition and exercise amongadolescents in the State of California. The survey collected and analyzed data on a representative sample ofCalifornia adolescents ages 12-17. Adolescents were interviewed using a simple structured 24-hour recall surveythat identified nutritional intake, physical activity habits,height, weight, and television viewing behavior. The survey began in 1998 and is conducted every two years. Thedata used in this report comes from the 1998 CalTEENSsurvey, which included 1,213 randomly selected 12- to17-year-olds (Foerster et al., 2000).National Health and Nutrition Examination Survey(NHANES). The NHANES is an annual survey conducted by the National Center for Health Statistics forthe Centers for Disease Control. The sampling plan wasdesigned to provide estimates representative of the U.S.population. The NHANES provided nationally representative data to estimate the prevalence of major diseases,nutritional disorders, and potential health risk factors. Thesurvey procedure included a home interview and a standardized physical examination. Trained technicians measured the participants’ body weight and height with standardized equipment and procedures. Beginning in 1999,NHANES became a continuous survey. The data used inthis report is drawn from the results of the 1999-2000NHANES reported by Ogden, Flegal, Carroll, and Johnson(2002) and is based on the responses and measurementsof 4,722 children ages birth through 19 years.Pediatric Nutrition Surveillance System (PedNSS).The PedNSS is a child-based public health surveillancesystem that monitors the nutritional status of low-incomechildren in federally funded maternal and child health programs. Data for more than 5 million children are collectedat public health clinics and then collated at the state leveland submitted to the CDC for analysis. This report usesdata from the 2001 PedNSS which includes children enrolled in the following federally funded programs: SpecialSupplemental Nutritional Program for Women, Infants andChildren (WIC), Early and Periodic Screening, Diagnosis10and Treatment (EPSDT) Program, Title V Maternal andChild Health Program, and Head Start program, amongothers. Other sources of information not reflected in Table1 were also used for this report. They do not appear inTable 1 because they do not use the BMI as a unit ofmeasure:Youth Risk Behavior Surveillance System (YRBSS).The YRBSS includes national, state, and local school-basedsurveys of representative samples of 9th through 12th gradestudents. The YRBSS includes a survey, entitled the YouthRisk Behavior Survey (YRBS), administered by the CDCevery two years. The YRBSS surveys were developed in1990 to monitor priority health-risk behaviors that contribute markedly to the leading causes of death, disability,and social problems among youth in the United States.Students completed a self-administered questionnaire during one class period and recorded their responses in abooklet or on an answer sheet that was then scanned bycomputer. This report uses findings from the 2001 YRBSS,which included 13,601 students nationwide.California Children Healthy Eating and ExercisePracticed Survey (CalCHEEPS). The CalCHEEPSsurvey was administered by the California Departmentof Health Services in conjunction with the Public HealthInstitute. It was administered to identify dietary and physical activity practices, knowledge, and attitudes towardnutrition and physical activity among California children.In 1999, the survey was mailed to California householdswith children ages 9-11. Follow-up telephone calls weremade to households selected to receive the survey, andparents were requested to keep a two-day diet and physical activity diary for their children. The sample for the1999 CalCHEEPS survey totaled 814 participants.National Longitudinal Study of Adolescent Health (AddHealth). Add Health is a longitudinal study involving anationally representative, school-based sample of 17,766adolescents in grades 7-12 (ages 11-21) in the UnitedStates. In-school surveys and in-home surveys of adolescents provided data about the physical activity of the respondents. In-home surveys of parents provided income,educational, and other socio-demographic data (GordonLarsen, Popkin, & McMurray, 2000).

Measurement Issues in Overweight andObesityThe scientific literature on overweight and obesity reflectsa wide range of criteria and definitions used to assessoverweight and obesity in children and adolescents. Likewise, various techniques used to assess body compositionare also reported in the literature.The technique most often employed by health care practitioners is the Body Mass Index (BMI), because it represents a ratio of weight to height. In children and adolescents, body dimensions change over the years as theygrow. Girls and boys also differ in their ratio of weight toheight as they mature (Hammer, Kramer, Wilson, Ritter& Dornbusch, 1991). This is why BMI for children, alsoreferred to a BMI-for-age, is gender and age specific(CDC, 2004b). BMI-for-age is evaluated using percentile cutoff points to compare values for a given child withvalues for other children of the same age and gender froma national reference sample (CDC, 2004c).Although the use of BMI as an accurate assessment ofbody composition among adults is controversial, its useamong children and adolescents is considered appropriate. An adult with an exceptional amount of muscle massmay be categorized as obese simply because his or herweight-to-height ratio would be higher compared to theratio of a person with less muscle mass. Although BMI isnot a perfect method for assessing body compositionamong adults, it has been reported as a scientifically validmeasure for estimating body fat in children. Values obtained from the BMI are comparable to values obtainedusing more precise yet relatively inaccessible techniques,such as dual energy x-ray absorptiometry (DEXA) (Dietz& Robinson, 1998; Pietrobelli et al., 1998). Furthermore,BMI can be interpreted using gender- and age-specificpercentile standards for persons up to age 20. BMI tableswere developed by the National Center for Health Statistics and are available from the CDC (2004a).Data LimitationsThe 2001 CHIS was conducted using a random sampleof the San Joaquin Valley population. The numbers andpercentages presented in this report are therefore weightedestimates of the prevalence of overweight and physicalinactivity among children and adolescents ages 0-17.When relatively small numbers of survey participants areused to generate population estimates, some error is al-ways introduced. To mitigate the effects of such sampling bias, CHIS researchers used special weighting procedures. However, in some cases, the level of potentialerror is such that the estimate is unavailable or is considered unstable. In some instances in this report, unstableestimates are presented along with stable estimates forthe purpose of comparison among groups of data. Theauthors recognize this limitation of the data presented andencourage the reader to use caution in interpreting estimates and percentages identified as unstable.The authors also recognize the potential bias of the selfreport data for the 2001 CHIS, as well as for the othersurveys examined in this report. The reliability and validity of self-report data as it relates to height and weightimpacts studies of the prevalence of overweight and obesity. Surveys, such as the CHIS, rely on self-reported information that is generally gathered during personal interviews, telephone interviews, and mail questionnaires. Although self-report data are certainly better than no dataat all, several studies have suggested that self-report dataas they relate to height and weight, as well as physicalactivity habits, are generally unreliable. Most studies ofthis nature have reported that height is over-reported andweight is under-reported (e.g., Goodman, Hinden, &Khandelwal, 2000; Roberts, 1995; Rowland, 1990; Wang,Patterson, & Hills, 2002). Thus, the calculation of BMIbased on self-report contributes to bias and ultimately theunderestimation of the prevalence of overweight and obesity (Roberts, 1995). Also, bias in self-reports of weightand height is much more extensive among overweightand obese individuals than it is among normal or underweight individuals (Goodman et al., 2000; Rowland, 1990;Wang et al., 2002). These findings have been reportedfor both adolescent and adult samples (Goodman et al.,2000; Roberts, 1995; Rowland, 1990; Wang et al., 2002).Despite the varying criteria used in reports or the inherent biases of self-reported responses, the data suggestthat there is a significant problem in regard to the prevalence of overweight among children and adolescents. Furthermore, regardless of the tools used to collect the information, every report addressing the issue of overweightand obesity across the nation has concluded that today’schildren and adolescents are much more overweight thanwere children and adolescents from previous generations.11

FindingsFindingsCharacteristics of the San Joaquin ValleyThe San Joaquin Valley is comprised of an area in Central California extending over 27,000 square miles, with arapidly growing population that exceeds 3.2 million people(U.S. Census Bureau, 2003d). Approximately one millionchildren under the age of 18 live in the San Joaquin Valley(see Figure 1), representing approximately one third ofthe population within each county in the San Joaquin Valley region (see Figure 2; U.S. Census Bureau, 2003c).Figure 1San Joaquin Valley Child and Adolescent Population, Ages 0-17, 2000Source: U.S. Census Bureau, Census 2000 (2003c)Figure 2San Joaquin Valley Child and Adolescent Population Ages 0-17 as aPercentage of Total Population, 2000Source: U.S. Census Bureau, Census 2000 (2003c)12

The San Joaquin Valley is one of the most culturally andethnically diverse areas in the nation and research evidence suggests that overweight is more common amongspecific population subgroups. For example, national dataindicate that between 1986 and 1998, overweight increasedsignificantly and steadily among children, regardless ofrace. However, overweight increased faster and moreprominently among African American children (22%) andHispanic children (22%), as compared to non-HispanicWhite children (12%, Strauss & Pollack, 2001). Thus, theethnic diversity in the San Joaquin Valley may contributeto the obesity problem within this region. Figure 3 illustrates the racial and ethnic diversity of the children andadolescents in the San Joaquin Valley.Figure 3Race/Ethnicity of Children and Adolescents Ages 0-17 inthe San Joaquin Valley, 2000Source: U.S. Census Bureau, Census 2000 (2003b)In the San Joaquin Valley, one quarter to one third of children ages 0-17 live in poverty (U.S. Census Bureau,2003a). It has been suggested that socioeconomic statuscan be a predictor of overweight in childhood. Severalreports have provided data that indicated an inverse relationship between socioeconomic status and childhood obesity. In other words, children from poorer families tend tobe overweight at a higher rate and are at a higher risk forbecoming overweight than are children from wealthierfamilies. Furthermore, these data indicate that socioeconomic status affects other factors related to childhoodoverweight, such as nutritional intake and physical activity habits (DeLany, Bray, Harsha, & Volaufova, 2002;Kimm, Gergen, Malloy, Dresser, & Carroll, 1990; Laitinen,Power, & Jarvelin, 2001; McMurray et al., 2000). Socioeconomic status and its impact on childhood overweightare discussed in more detail later in this report.School NutritionResearch evidence has shown that poor diet and physicalinactivity play important roles in child weight gain (Berkeyet al., 2000; Rowlands, Eston, & Ingledew, 1999). Forexample, meals provided through the National SchoolLunch Program are required by law to be balanced andnutritious. However, on average, meals offered by thisprogram and the School Breakfast Program have beenshown to exceed the dietary guidelines for total fat andsaturated fat as a percentage of food energy (Ritchie etal., 2001). In Califo

Obesity—Refers to an excessively high amount of body fat or adipose tissue in relation to lean body mass (Skunkard & Wadden, 1993). Overweight—Age- and gender-adjusted BMI at or above the 95th percentile (CDC, 2004b). At risk for overweight— Age- and gender-adjusted BMI

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