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Hawaii Med J. Jul 2011; 70(7 suppl 1): 16–20.
PMCID: PMC3158452
Poorer General Health Status in Children is Associated with being Overweight or Obese in Hawai‘i: Findings from the 2007 National Survey of Children's Health
Kristen Teranishi, MS, Donald K Hayes, MD, MPH,corresponding author Louise K Iwaishi, MD, and Loretta J Fuddy, ACSW, MPH
Family Health Services Division, Hawai‘i State Department of Health, Honolulu, HI (K.T., D.K.H., L.K.I., L.J.F.)
John A. Burns School of Medicine, University of Hawai‘i, Honolulu, HI (K.T., D.K.H., L.K.I.)
corresponding authorCorresponding author.
Correspondence to: Donald Hayes MD, MPH Family Health Services Division Hawai‘i Department of Health 3652 Kilauea Ave Honolulu, HI 96816 Ph: (808) 733-8360 Fax: (808) 733-8369 Email: Don.hayes/at/doh.hawaii.gov
Obesity is a widespread national issue that affects the health and well-being of millions of people; particular attention has been focused on the burden among children. The National Survey of Children's Health data from 2007 was used to examine the relationship of child health status and unhealthy weight (overweight/obese defined as body mass index in ≥85th percentile) among 874 children aged 10 to 17 years of age in Hawai‘i. In particular, the parentally reported child's general health status was assessed comparing those with a poorer health status (defined as “good/fair/poor”) to those with a better one (defined as “excellent/very good”). Descriptive analysis and multiple logistic regression analysis examined risk for overweight/obese with child's general health status, accounting for gender, race, and socioeconomic factors. More children with a poorer health status (46.5%; 95%CI=33.2–60.2) were overweight/obese compared to those of better health status (25.8%; 95%CI=21.9–30.2). Estimates of overweight/obese were high in Native Hawaiian/Pacific Islander (38.6%; 95%CI: 28.9–49.4), multiracial (30.9%; 95%CI=24.2–38.6) children, and children whose parents had less than 12 years education (56.8%; 95%CI=32.8–78.0). Multivariate logistic regression modeling showed a 2.92 (95%CI=1.52–5.61) greater odds for overweight/obese status in children with a poorer health status compared to those of better health status after accounting for age, race, gender, and parental education. Gender, race, and parental education were also significant factors associated with overweight/obese in the final adjusted model. It is important that children that are overweight or obese receive appropriate health screenings including assessments of general health status. Children in high risk socioeconomic groups should be a particular focus of prevention efforts to promote health equity and provide opportunities for children to reach their potential.
Obesity affects the health and well-being of millions of people and is associated with chronic disease. Childhood obesity defined as having a body mass index (BMI) for age in the 95th percentile or higher, is of increasing concern as rates have tripled in the last forty years.1 The prevalence of pediatric obesity is a growing problem in the US with estimates from a national population based survey showing an increase from 14.8% in 2003 to 16.4% in 2007.2 Some of the known dangers and long term effects related to obesity in children include a higher risk for type 2 diabetes, cardiovascular problems, asthma, and cancer.3 Childhood obesity may have other impacts on the development of children as well. For example, worsening perception of body weight is related to worse mental health outcomes among adolescents.4 Children that are overweight or obese are more likely to have low self-esteem and be at risk for lower educational attainment and increased likelihood of depression compared to those that are not overweight or obese.57 Identifying risk factors and associations with childhood obesity can help in the development of policies and programs to slow and reverse the growing burden.
General health status is a measure of how individuals perceive their health and has been associated with mortality for a variety of populations so it is commonly used in national surveys.8 The general health status of children as perceived by parents may be a useful measure of the child's overall health and ability to function and has been included in both the 2003 and 2007 National Survey of Children's Health (NSCH).9 Nationally in the 2007 NSCH, the parents of 84.4 percent of children under 18 years of age reported that their child's health was excellent or very good with some variation by child's race/ethnicity and the parents own general health status.9 One study that looked at the same measure of general health status used in the NSCH identified the presence of multiple risk factors such as race, social class, health insurance coverage, and maternal mental health was associated with risk for developmental delay and a poorer general child health status.10
The relationship between a child's weight status and parental report of their child's general health status is unclear. A study of Australian primary school children showed that parents were more likely to report a poorer health and well-being for overweight and obese children compared to those that were of normal weight using a 50 item parent completed measurement.11 That study defined general health as a “subjective assessment of overall health and illness, past, present and future,” but did not provide any other details on the actual measurement.11 There have been no studies that we located relating the parental report of their child's general health and weight status using the excellent-to-poor rating scale used in the NSCH. The aim of this analysis is to assess the relationship between child health status and overweight or obese status in Hawai‘i using the 2007 NSCH data. A secondary purpose of this analysis is to highlight disparities in childhood overweight or obese status among race and socio-economic groups in Hawai‘i using this survey data.
The National Survey of Children's Health (NSCH) is a population based parentally-reported telephone survey conducted in 2003 and 2007 by the Centers for Disease Control and Prevention's (CDC) State and Local Area Integrated Telephone Survey (SLAITS) program.12 Almost 2,000 interviews were completed in each of the 50 states and the District of Columbia. Response rates averaged 46.7% nationally and was 42.2% in Hawai‘i. Over 80 indicators of child health status were addressed by the NSCH. The responses are weighted to reflect estimates representative for each state's population. The publicly available 2007 dataset of 91,642 interviews includes de-identified information on respondents' children, of which 1,822 were from Hawai‘i.
Weight status was based on BMI adjusted for age and gender. It was calculated from the parental reports of child's current height and weight and was only available for 874 children 10 to 17 years of age (n=36 excluded in age group due to missing information on height or weight). BMI was classified into two categories for this analysis: (1) Overweight /Obese (85th percentile and above) and (2) Not Overweight/Obese (84th percentile and under).
Age was categorized in two four year age groups (10–13 years and 14–17 years) as the question used to calculate BMI was only available for children 10–17 years of age. Parent-reported racial categories for their children included Asian only, White only, Black only, Native Hawaiian/Pacific Islander (NH/PI) only, and multiracial (any combination of more than one race). Gender categories included boys and girls. Federal poverty level (FPL) tailored for Hawai‘i was grouped as <100%, 100–199%, 200–399%, and ≥400%. Insurance types were public, private, and uninsured. Primary household language was categorized as English or non-English. Greatest level of education of any parent was grouped into <12 years, 12 years, or >12 years. Parent nativity was categorized as (1) at least one parent born in the United States, or (2) neither parent born in the United States.
Parents were asked to describe their child's general health based on a five-point Likert-type scale. Responses of “excellent” and “very good” were grouped together distinct from responses of “good,” “fair,” and “poor,” which combined was used to reflect a poorer health status. This dichotomization of child's general health status was done due to the distribution of responses and to distinguish children who are reported by their parents to be in the lowest 3 response categories from the rest. For the remainder of this report these response categories will be referred to as “good/fair/poor” to reflect a poorer health status and “excellent/very good” to reflect a better health status.
Descriptive statistics including prevalence estimates and 95% confidence intervals (95%CI) were calculated. A multivariate logistic regression analysis assessed the relationship between childhood overweight/obese status and general child health status with several potential covariates. A model building strategy to find the most parsimonious model was used which resulted in the final model controlling for age, race, gender, and parental education. The relative standard error (RSE) was calculated by dividing the prevalence estimate by its standard error and expressed as a percentage. A standard threshold of RSE>30% was used for designating an estimate as inadequate for reliability and precision, and these estimates were suppressed in the tables. Sampling weights, which adjusted for factors such as non-response and demographics, were applied and used to reflect Hawai‘i's population of non-institutionalized children under 18 years of age. SAS (version 9.2) and SUDAAN (version 10.0) statistical software was used for the analysis in order to account for the survey's complex sampling design. Significant testing was set at a probability of p <0.05.
Data showed that over one third of children in Hawai‘i represented by this survey were multiracial, nearly a quarter were White only, about 1 in 5 were Asian only, and just under 1 in 5 were NH/PI children (Table 1). Most children lived above 200% FPL and received private health insurance. Most (94.5%) children lived in households where English was the primary language. Over three fourths of all children had at least one parent that received >12 years of education. About 25% of children did not have a parent born in the United States. Just over a quarter of children had a good/fair/poor general health status.
Table 1
Table 1
Population and Overweight/Obese Prevalence Estimates by Selected Characteristics among Children 10–17 Years of age in Hawai‘i, 2007 NSCH
Data represented by this survey showed that statewide an estimated 28.5% of children were overweight/obese. Many NH/PI only (38.6%), multiracial (30.9%), and to a lesser extent White only (25.0%) children were overweight/obese compared to Asian only children (16.5%) (Table 1). More boys (32.5%) than girls (24.2%) were overweight/obese. A high proportion of overweight/obese children were living at <100%FPL (39.8%), were covered under public insurance (37.9%), and had parents whose highest education level was <12 years (56.8%). Nearly a half of children that were overweight/obese (46.5%) had a parental report of good/fair/poor health status compared to just a quarter of children that were not overweight/obese (25.8%).
Children in poorer overall health (good/fair/poor) were 2.49 times more likely to be overweight/obese compared to those in better (excellent/very good) health (Table 2). After adjustment for age, race, gender, and highest level of parent education, children in poorer overall health (good/fair/poor) were 2.92 times more likely to be overweight/obese compared to those in better (excellent/very good) health.
Table 2
Table 2
Association Between Overweight/Obese Children and General Child Health Status among children 10–17 years of age in Hawai‘i, 2007 NSCH
Compared to Asian only children, NH/PI only children were 3.04 times, and multiracial children were 2.31 times as likely to be overweight/obese in the adjusted model. Also, in the final model, boys were 1.94 times more likely than girls to be overweight/obese. Children whose parents' highest level of education was <12 years were 4.40 times more likely to be overweight/obese compared to children who had at least one parent with >12 years of education.
This analysis demonstrated that a poorer child health status as reported by parents was associated with children being overweight or obese. The analysis also estimated that 28.5% of children 10–17 years of age in the sample for Hawai‘i were overweight or obese. Further, some race and socioeconomic groups exceed this overall estimate for the state and represent key groups that specific interventions could decrease the burden of obesity in children. Obesity is complex and is influenced by genetic and hormonal factors that affect the regulation of appetite and energy balance, environmental factors, neurological factors, and socioeconomic factors.13 Childhood obesity increases risk for diabetes, cardiovascular illness including heart disease and hypertension, and respiratory complications such as asthma, ultimately affecting quality of life.13,14 The impact of obesity has been at the forefront of national concern because of its affect on health and its sizable contribution to rising medical spending.15
In the analysis a poorer overall health status was associated with a child being overweight/obese. A child who is not physically or emotionally well, for instance, may have difficulties in leading an active lifestyle and therefore may be at higher risk of being overweight/obese. The adjusted analysis presented here indicated an almost three times higher risk of being overweight/obese in children who were in poorer (good/fair/poor) general health compared to those in better (excellent/very good) general health. The relationship between overall health status as a whole and childhood obesity at the national level has not been well characterized in the literature, and this study is meant to add to the body of literature. A national study, however, involving an adjusted analysis in an adult population showed that obese adults were 1.42 times more likely to have worse quality of life including general health status.16 The analysis would be in agreement by showing that children with a poorer general health status are at increased risk to also be overweight or obese. There has been little published related to the validity of proxy reported general health status for children that is central to this analysis and national morbidity surveys of children, but one study we located found variation in parental reporting of child health status among three subspecialty clinics.17 They showed the strongest association existed among those with children with a chronic disease (pediatric rheumatology center) who had previously been healthy compared to those with a disability following a neonatal event (neonatal follow up program, and Spina Bifida program).17 The analysis included children with special health care needs, but sample size limitations did not allow us to evaluate this specific group by weight status.
In the analysis, childhood overweight/obese in this survey population in Hawai‘i was estimated to be 28.5% which falls below the national average of 31.6% for children 10 to 17 years of age.2 A limitation of the representativeness of the estimates from this survey are due to the low response rate of 42% for Hawai‘i and the reliance of the survey on only sampling homes with land-based telephones. A greater proportion of households are relying only on cellular phone technology with an estimated 17.5% of households in 2008 living in wireless only homes with the rate expected to continue to increase.25 There are substantial demographic differences with those that are younger, those living in poverty, those renting, and men more likely to be in these wireless only homes,25 so the estimates shown in the NSCH data is not representative of all children living in Hawai‘i, particularly among those of lower socioeconomic status. However, it is important to share the findings related to many of these indicators with this limitation in mind. The analysis showed some disparities in children that were overweight/obese among those with a poorer health status, boys, racial minority groups, and children whose parents have limited education, indicating that these factors have a unique contribution to the risk for overweight/obese even after accounting for differences among these factors. Many of these types of disparities seen in Hawai‘i have also been reported nationally, especially in relation to gender, race, and insurance type using the same data set,2 and will be briefly discussed.
The analysis showed that NH/PI and multiracial children in Hawai‘i are at higher risk for being overweight/obese. The risk remained significant after adjusting for age, gender, parental education, and overall health status. Further delineation to look at individual Native Hawaiian or Other Pacific Islander groups, or common categories of multiracial children was not possible from the NSCH data set. Hawai‘i has an ethnically diverse population with approximately a third of mothers and nearly a third of fathers that have had a child in Hawai‘i and are themselves multiracial.18 Consequently, a higher percentage of births and children would be expected to be multiracial in Hawai‘i than shown in the data represented in the 2007 NSCH, and highlights an important limitation about the collection of race information as well as the representativeness of this data. In analysis of data from Hawai‘i, it is preferable to differentiate Native Hawaiian from other Pacific Islanders, and to better clarify the large multiracial population present in the state. These refinements were not possible due to limitations in the NSCH dataset. Consequently, it is hard to determine the usefulness of the federal race groups as reported in the data set to population interventions in Hawai‘i.
Gender may be related to overweight/obese due to many factors including differences in fat composition and distribution, physical activity, diet type, and impact of family environment.19 For instance, one study of 3,421 children showed overweight prevalence higher in boys (29.1%) than girls (27.9%), with boys tending towards eating fatty foods compared to girls with less engagement in physical activity.20 National data showed boys as 1.42 times (adjusted) more likely to be overweight/obese compared to girls using the same population based data set that we used in the analysis.2 The adjusted analysis using Hawai‘i data showed an even stronger relationship with boys being 1.94 times more likely to be overweight/obese compared to girls after accounting for child health status, age, race, parental education.
Socioeconomic status including income level and education tends to show association with obesity although many studies focus on the adult obese population.13 However, reporting of income is often under-reported and confounded by large amounts of unknown or missing data. For comparisons to national data, the analysis focused on parental education to reflect socio-economic status.21,22 Limited parent education may be related to children being overweight/obese but may depend on other social determinants of health such as the particular community in which a child lives, household income, or where a mother was born.23 The adjusted analysis showed that level of parental education remained significant after adjustment for child health status, age, gender, and race.
The present analysis and data has several limitations, some of which have already been described. The NSCH uses data from parental self-report, which may be subject to validity and bias issues. For instance self-report by adolescents of height and weight in the context of overweight/obese can generate biased responses in the calculation of weight status.24 In fact the NSCH 2007 data suppressed BMI for children under 10 years old because they found that parental report for those under 10 years of age significantly underestimated height in pre-school and elementary school students.12 Secondly, the methodology used for the 2007 NSCH is based on the response of those homes with a land-based telephone line so the estimates of overeweight/obesity are likely to be under estimated in this data. Thirdly, some population groups were relatively small (e.g., Black only, uninsured, non-English speaking, county of residence) so limited interpretation could be made based on estimates in these groups. Lastly, this study was cross sectional and did not allow an assessment of the relationship between parentally reported general child health status and overweight/obese weight status over time.
The causes of childhood obesity are complex and some potential areas that have been suggested to reduce this burden include lifestyle modifications such as increasing physical inactivity, decreasing availability and intake of fast foods, decreasing viewing of television, decreasing use of video games, and decreasing internet usage.26 The analysis identified that a poorer child health status reported by the parent was associated with the child being overweight/obese using cross sectional data and may represent another potential factor to focus on to improve the health status of children. Efforts to understand the role of parentally reported child health status and its temporal relationships to the overall treatment and prevention of childhood obesity are needed before specific recommendations can be made. It will be important to ensure that children that are overweight or obese receive appropriate health screenings including an assessment of general health status to address potential co-morbidities. Children in high risk socioeconomic groups should be a particular focus of prevention efforts to promote health equity and provide opportunities for children to reach their potential.
Acknowledgments
This manuscript would not be possible without the public use file and descriptive documents of NSCH data provided by the State and Local Area Integrated Telephone Survey, NCHS/CDC and Maternal and Child Health Bureau, HRSA.
Footnotes
Conflicts of Interest: None
Disclosure Statement
Data was retrieved as a public use file provided by the State and Local Area Integrated Telephone Survey, NCHS/CDC. Data analysis, preparation of tables, and writing for the manuscript was completed by Kristen Teranishi with input, guidance, and revision suggestions from Donald Hayes. All authors reviewed and approved and/or edited all aspects of the manuscript. No companies are mentioned in this manuscript nor do any of the authors have relationships with any companies.
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