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.