Childhood Obesity
Factors Affecting Physical Activity Gao ID: GAO-07-260R December 6, 2006The latest data show continued increases in rates of childhood obesity. For example, obesity rates for children 6 to 11 years old are estimated to have increased from 15.1 to 18.8 percent between 1999 and 2004. The Department of Health and Human Services estimates that 20 percent of children and youth in the United States will be obese by 2010. There are numerous negative health outcomes and financial consequences related to childhood obesity. Researchers have found that childhood obesity is associated with a number of disorders including hypertension, insulin resistance, sleep apnea, menstrual abnormalities, and orthopedic problems. According to one estimate, insured children treated for obesity are approximately three times more expensive for the health system than the average insured child. Some researchers have suggested that childhood obesity is largely the result of a decline in regular physical activity. In our October 2005 report, we surveyed experts on the key strategies to include in the design or implementation of a program to prevent or reduce childhood obesity. The program strategy identified by experts as most important was "increasing physical activity." Congress asked us to provide information on the factors affecting physical activity in children.
Obesity results from an imbalance between the amount of energy consumed and the amount of energy expended. While there are many elements that affect the energy balance (for example, genetics, growth, and physiology), children and their parents can influence both energy consumed through diet and energy expended through physical activity. In summary, the articles we reviewed identified a number of factors affecting levels of physical activity in children. We categorized the factors presented in the articles we reviewed into three groups--demographic factors, cognitive and behavioral factors, and community factors. Demographic factors include socioeconomic status and race. Cognitive and behavioral factors include attitudes, beliefs, and perceptions and sedentary behaviors. Community factors include the built environment and school-based physical activity. The articles and additional materials we reviewed identified additional research needs, such as using objective measures of physical activity and sedentary time. The body of research we examined suggests that multiple factors that affect physical activity among children may contribute to childhood obesity.
GAO-07-260R, Childhood Obesity: Factors Affecting Physical Activity
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December 6, 2006:
The Honorable Bill Frist:
Majority Leader:
United States Senate:
Subject: Childhood Obesity: Factors Affecting Physical Activity:
Dear Senator Frist:
The latest data show continued increases in rates of childhood
obesity.[Footnote 1] For example, obesity rates for children 6 to 11
years old are estimated to have increased from 15.1 to 18.8 percent
between 1999 and 2004.[Footnote 2] The Department of Health and Human
Services estimates that 20 percent of children and youth in the United
States will be obese by 2010. There are numerous negative health
outcomes and financial consequences related to childhood obesity.
Researchers have found that childhood obesity is associated with a
number of disorders including hypertension, insulin resistance, sleep
apnea, menstrual abnormalities, and orthopedic problems. According to
one estimate, insured children treated for obesity are approximately
three times more expensive for the health system than the average
insured child.[Footnote 3]
Obesity results from an imbalance between the amount of energy consumed
and the amount of energy expended. While there are many elements that
affect the energy balance (for example, genetics, growth, and
physiology), children and their parents can influence both energy
consumed through diet and energy expended through physical activity.
Some researchers have suggested that childhood obesity is largely the
result of a decline in regular physical activity. In our October 2005
report,[Footnote 4] we surveyed experts on the key strategies to
include in the design or implementation of a program to prevent or
reduce childhood obesity. The program strategy identified by experts as
most important was "increasing physical activity."
You asked us to provide information on the factors affecting physical
activity in children. Enclosure I contains the information we provided
to your staff at our November 15, 2006, briefing.
To carry out our work, we conducted a literature review. We selected 53
articles that described work focused on factors affecting rates of
physical activity for school-aged children, published from 2003 through
2006. Enclosure II is a bibliography of the materials we reviewed. To
select the articles, we reviewed study abstracts identified in your
request letter and conducted a literature search of five
databases.[Footnote 5] We focused on studies of children and
adolescents and excluded studies of infants and preschool-aged
children. For purposes of this report, we use the term obese to refer
collectively to the terms obese and overweight, which were both used by
authors. We supplemented the studies with information obtained from
organizations that recently published information on childhood obesity
including the Institute of Medicine and the Trust for America's Health.
Our literature search was not exhaustive, and for this report we did
not discuss all of the articles we reviewed, but instead highlighted
selected articles to provide examples of findings. We conducted our
work from August 2006 through November 2006 in accordance with
generally accepted government auditing standards.
In summary, the articles we reviewed identified a number of factors
affecting levels of physical activity in children. We categorized the
factors presented in the articles we reviewed into three groups--
demographic factors, cognitive and behavioral factors, and community
factors. Demographic factors include socioeconomic status and race.
Cognitive and behavioral factors include attitudes, beliefs, and
perceptions and sedentary behaviors.[Footnote 6] Community factors
include the built environment[Footnote 7] and school-based physical
activity. The articles and additional materials we reviewed identified
additional research needs, such as using objective measures of physical
activity and sedentary time. The body of research we examined suggests
that multiple factors that affect physical activity among children may
contribute to childhood obesity.
As we agreed with your office, unless you publicly announce the
contents of this report earlier, we plan no further distribution until
30 days after the date of this letter.
At that time, this report will be available at no charge on the GAO Web
site at [Hyperlink, http://www.gao.gov]. Contact points for our Offices
of Congressional Relations and Public Affairs may be found on the last
page of this report.
If you and your staff have any questions or need additional
information, please contact me at (202) 512-7101, or bascettac@gao.gov.
Major contributors to this report were Linda Kohn, Assistant Director;
Shannon Slawter; and Julie Thomas.
Sincerely yours,
Signed by:
Cynthia A. Bascetta:
Director, Health Care:
Enclosures:
GAO Congressional Briefing:
Childhood Obesity: Factors Affecting Physical Activity:
Briefing Outline:
Introduction:
Objective, scope, and methodology:
Factors affecting physical activity:
Additional research needs:
Concluding observations:
Introduction:
The latest data show continued increases in rates of childhood
obesity.[Footnote 8] HHS estimates that 20% of children and youth in
the U.S. will be obese by 2010.
There are numerous negative health outcomes and financial consequences
related to childhood obesity.
According to one estimate, total health care spending for children who
receive a diagnosis of obesity is approximately $750 million per
year.[Footnote 9]
Obesity results from an imbalance between the amount of energy consumed
and the amount of energy expended.
Children and their parents can influence both energy consumed through
diet and energy expended through physical activity.
Some researchers have suggested that childhood obesity is largely the
result of a decline in regular physical activity.
For our October 2005 report, Childhood Obesity. Most Experts Identified
Physical Activity and the Use of Best Practices as Key to Successful
Programs (GAO-06-127R), we surveyed experts on the key strategies to
include in the design or implementation of a program to prevent or
reduce childhood obesity. The program strategy identified by experts as
most important was "increasing physical activity."
Objective, Scope, and Methodology:
Our objective in this briefing is to summarize the relevant literature
about the factors affecting levels of physical activity among children
that may contribute to childhood obesity.[Footnote 10] We will also
discuss additional research needs identified in the literature.
In our review of the literature, we did not examine research that
addresses whether there have been decreases in the physical activity of
children over time, a trend which some researchers dispute.
We reviewed study abstracts identified in the request letter and
conducted a literature search of five databases.[Footnote 11]
We selected 53 studies that described new work focused on factors
affecting rates of physical activity for children, published from 2003
through 2006.
We supplemented the studies with information obtained from
organizations such as the Institute of Medicine (IOM), the Trust for
America's Health, and The Robert Wood Johnson Foundation.
We conducted our work from August 2006 through November 2006 in
accordance with generally accepted government auditing standards.
Limitations of our work:
* Literature search was not exhaustive.
* We will not discuss all of the articles that we reviewed, but instead
highlight selected articles to provide examples of findings.
Factors Affecting Physical Activity:
*We grouped the factors affecting physical activity into three
categories:
* Demographic factors:
* Cognitive and behavioral factors:
* Community factors:
Demographic Factors:
Socioeconomic status (SES):
* Studies tied low SES to physical inactivity.
Race/ethnicity:
* While several studies included race/ethnicity as a variable, they
focused on other factors, which we will discuss later.
Cognitive and Behavioral Factors:
Attitudes, beliefs, and perceptions:
* Among other factors, studies identified lack of motivation, self-
consciousness, and concerns about not being good enough as contributing
to reduced physical activity.
* Studies found some differences between white and African-American
girls in their attitudes and perceptions about physical activity.
* Studies found that adolescents who were obese perceived more barriers
to physical activity than adolescents who were not.
Family and social influences:
* Studies found that parental and social support for physical activity
was associated with increased physical activity.
Sedentary behaviors[Footnote 12]
* Studies differed in their findings on the relationship between
sedentary behaviors and obesity, but not all of them explained the
relationship between sedentary behaviors and physical activity.
* Some studies found that increases in sedentary behaviors are
associated with decreases in physical activity.
* Studies reported differences in sedentary behavior patterns by gender
and the influence of family on children's television viewing habits.
Community Factors:
General/safety:
* One study found that adolescents in older suburban communities engage
in more physical activity.
* One study found that adolescents in unsafe neighborhoods engage in
less physical activity.
Built environment[Footnote 13]
* Studies found that environmental characteristics, such as lack of
streetlights and the need to cross busy roads, were negatively related
to children's physical activity, including walking and biking to
school.
Availability of venues for physical activity:
* One study found that lack of venue (e.g., sports areas, swimming
pools, parks) was related to lower rates of physical activity.
* Studies found that areas of low SES and high minority populations had
fewer venues for physical activity.
School-based physical activity:
* School-based physical education policies vary widely by state, school
district, and school.
Additional Research Needs:
The literature we reviewed contained two commonly suggested themes for
research improvement:
* Study design:
- longitudinal instead of cross-sectional:
- venue affordability, quality, and usage instead of venue availability
only:
* Measurement:
- objective measures of physical activity and sedentary time:
- other measures, such as health status:
IOM and the Transportation Research Board also identified additional
needs, including:
* Need for additional evaluations to provide evidence for new or
modified programs or policies:
* Built environment:
- need to develop better ways to measure the built environment -need to
connect data on the built environment to data on health and physical
activity:
Concluding Observations:
Reversing trends in childhood obesity requires an understanding of the
factors affecting children's energy imbalance, including their physical
activity levels.
The articles we reviewed identified a number of factors affecting
levels of physical activity in children.
The body of research we examined suggests that multiple factors that
affect physical activity among children may contribute to childhood
obesity.
[End of Section]
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(290567):
FOOTNOTES
[1] Some experts use the term obesity to refer to children and
adolescents who have a body mass index (BMI) that is at or above the
sex-specific 95th percentile for their age on the BMI charts developed
by the Centers for Disease Control and Prevention (CDC) in 2000. CDC
uses the term overweight, instead of obese, to describe children and
adolescents with this BMI range.
[2] C.L Ogden, M.D. Carroll, L.R. Curtin, M.A. McDowell, C.J. Tabak,
and K.M. Flegal, "Prevalence of Overweight and Obesity in the United
States, 1999-2004," JAMA, vol. 295, no. 13 (2006). These data are for
children at or above the 95TH percentile of BMI for age and sex.
[3] Thomson Medstat, Childhood Obesity: Costs, Treatment Patterns,
Disparities in Care, and Prevalent Medical Conditions, 2006,
[Hyperlink, http://www.medtstat.com/pdfs/childhood_obesity.pdf],
(downloaded Nov. 3, 2006). Thomson Medstat used medical claims to
estimate total health care spending for children who receive a
diagnosis of obesity.
[4] GAO, Childhood Obesity: Most Experts Identified Physical Activity
and the Use of Best Practices as Key to Successful Programs, GAO-06-
127R (Washington, D.C.: Oct. 7, 2005).
[5] We also contacted several experts in the field to help us identify
relevant literature.
[6] Sedentary behaviors include, for example, television watching,
video game playing, and computer use.
[7] The built environment is broadly defined to include land use
patterns, the transportation system, and design features that together
provide opportunities for travel and physical activity.
[8] Some experts use the term obesity to refer to children and
adolescents who have a body mass index (BMI) for age that is at or
above the sex- specific 95th percentile of the BMI charts developed by
the Centers for Disease Control and Prevention in 2000.
[9] Thomson Medstat used medical claims to estimate total health care
spending for children who receive a diagnosis of obesity. Children who
received a diagnosis of obesity are a small subset of the percentage of
children who are considered obese. Thomson Medstat estimates that
children treated for obesity are roughly three times more expensive for
the health system than the average insured child.
[10] For our literature review, we focused on studies of children and
adolescents and excluded studies of infants and preschool-aged
children. For purposes of this briefing, we use the term obese to refer
collectively to obese and overweight children.
[11] We also contacted several experts in the field to help us identify
relevant literature.
[12] Sedentary behaviors include, for example, television watching,
video game playing, and computer use.
[13] The built environment is broadly defined to include land use
patterns, the transportation system, and design features that together
provide opportunities for travel and physical activity.
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