Obesogenic behaviors in U.S. school children across geographic regions from 2003-2007

doi:10.4236/ojpm.2011.12005

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Vol.1, No.2, 25-33 (2011)

doi:10.4236/ojpm.2011.12005

Open Journal of Preventive Medicine

Obesogenic behaviors in US school children across

geographic regions from 2003-2007

Susan B. Sisson1*, Stephanie T. Broyles2, Danielle R. Brittain3, Kevin Short1

1University of Oklahoma Health Sciences Center, Oklahoma City, USA; *Corresponding author: susan-sisson@ouhsc.edu

2Pennington Biomedical Research Center, Baton Rouge, USA;

3University of Northern Colorado, Greeley, USA.

Received 5 May 2011; revised 14 July 2011; accepted 31 July 2011.

ABSTRACT

Background: increasing levels of obesity are

likely associated with obesogenic behaviors

such as physical activity (PA) and media time.

Examination of regional and state differences in

meeting recommendations for obesogenic be-

haviors would be useful for understanding con-

current variations in prevalence of childhood

obesity. Therefore the purpose of this study was

to analyze the prevalence of boys and girls

meeting vigorous physical activity (VPA), daily

media (TV/video viewing/video game playing)

recommendations, and association with over-

weight and obesity across regions of the US

between 2003 and 2007. Methods: data from the

2003 and 2007 National Survey of Children’s

Health (n = 109,151; 55,540 in 2003 and 53,611 in

2007; 51.3% boys, mean (SE) age 11.5 (0.02)

years) were used. Prevalence of meeting week-

day media (≤2 hr/day) and VPA (≥3 days/week of

minimum 20 minutes) recommendations were

calculated. Logistic regression analyses were

used to examine differences across regions,

dates, sexes, and obesity status. Results: in

2007, the range for met the recommendations

among regions was 74.2% - 82.1% for VPA and

77.2% - 83.7% for media viewing. The regions

with the highest positive behavior levels were

Alaska and Hawaii for VPA and both the North-

east and West regions for media viewing. In

2007 fewer children met media viewing recom-

mendations than in 2003 (78.3% versus 83.6%,

respectively, p < 0.0001) but those meeting VPA

recommendations increased (74.6% versus 79.2%,

p < 0.0001). In most states girls were less likely to

meet VPA guidelines, and boys were less likely

to meet media guidelines. The adjusted odds of

being overweight or obese, in those children

aged 10 years and older, were 1.13 (95% CI: 1.05,

1.21) for 0 - 2 days/wk of VPA versus 3 - 7

days/wk and 1.27 (1.17, 1.37) for > 2hr/day ver-

sus ≤ 2 hr/day of media time. Further, the inter-

action between media time and VPA had a sig-

nificant (p < 0.0001) association with being

overweight or obese. Conclusions: obesogenic

behaviors vary by region in the US, appear to be

changing over time, and are associated over-

weight and obesity status, though differences

between boys and girls are stable.

Keywords: Media Time; Vigorous Physical Activity;

Behavioral Epidemiology; Trends; Geographic

Diff er ences

1. INTRODUCTION

In 2007-2008, nearly one-third (31.7%) of children in

the US were overweight or obese (≥85th percentile for

height and weight), a significant increase from previous

decades [1,2]. The prevalence of overweight status var-

ies across geographical regions, with higher rates in

Southeastern states (41.3%) and lower rates in the Cen-

tral Rocky Mountain states (28.1%) [3]. The differences

in obesity rates across regions may reflect corresponding

variation in obesogenic behaviors.

Behaviors such as physical activity (PA) [4-6] and

television (TV) viewing [7-10] have been shown to have

independent and combined [11-14] impacts on over-

weight and obesity. Examination of regional and state

differences in meeting recommendations for obesogenic

behaviors would be useful for understanding concurrent

variations in prevalence of childhood obesity and pro-

viding support for lifestyle behavior change research and

interventions [3]. Daily lifestyle behaviors such as PA

and TV viewing are often used in obesity prevention

strategies. Differences in PA and TV between boys and

girls have been well established [15,16] and may play

S. B. Sisson et al. / Open Journal of Preventive Medicine 1 (2011) 25-33

critical roles in the targeted health behavior change. Re-

cent research from Whitt-Glover [17] reports sex differ-

ences in the social-ecological correlates of PA and sed-

entary behaviors. With different individual, family and

community variables associated with participation in

obesogenic behaviors between boys and girls, interven-

tions must be designed to address the appropriate target

behaviors, policies and environmental constructs.

To examine whether children’s PA, operationalized as

vigorous physical activity (VPA), and TV viewing vary

among regions of the US and whether these behaviors

have changed, at the population level, over time, we

analyzed data from the National Survey of Children’s

Health (NSCH). NSCH was designed to produce state

and national prevalence estimates for a variety of physi-

cal, emotional, and behavioral health indicators in chil-

dren 0 to 18 years of age [18]. Separate surveys were

administered in a similar manner in 2003 and 2007,

permitting a cross-sectional examination of changes in

obesogenic behaviors over this time. The purpose of this

study was to determine the prevalence of children ages 6

to 18 years old in the NSCH who achieved the recom-

mended amount of weekly VPA and/or daily media (TV/

video viewing/video game playing). Further, we exam-

ined whether the prevalence of these behaviors varied 1)

across geographic regions of the US, 2) between boys

and girls, and 3) between 2003 and 2007, and 4) their

association with overweight status. We hypothesize that

there will be geographic, gender and survey year differ-

ences in obesogenic behaviors. Since the prevalence of

obesity has been reported to be on the rise [1,2] it is

logical to presume that from 2003 to 2007 changes in

obesogenic behaviors would support this shift (i.e.,

higher daily media and lower VPA).

2. METHODS

Data from the 2003 and 2007 National Survey of

Children’s Health (NSCH) were used for this study. The

NSCH was sponsored by the Maternal and Child Health

Bureau and the National Center for Health Statistics

[18-21]. Telephone interviews were conducted using

computer assisted telephone interviewing technology

between January 2003 and July 2004 and April 2007 and

July 2008 with the parent or guardian who knew most

about a specific randomly-selected child. The NSCH

data are freely available online (http://www.cdc.gov/

nchs/about/major/slaits/nsch.htm) [19,20]. NCHS Re-

search Ethics Review Board approved these procedures.

The analytic sample size for the current study was

109,151 children (55,540 in 2003 and 53,611 in 2007;

51.3% boys, mean (SE) age 11.5 (0.02) years). Inclusion

criteria were being six years of age or older, attending

public or private school (i.e., not home-schooled or not

enrolled in school), and having no missing values for

variables of interest. Demographic and descriptive char-

acteristics used as covariates included age, sex, ethnicity

(Non-Hispanic White [NHW], Non-Hispanic Black

[NHB], Hispanic, and other), poverty (≤100%, 101% -

299%, ≥300%), family structure (two parent biologi-

cal/adopted, two parent step family, single mother, other).

Parent-reported body mass index (BMI) data were

available only on those aged 10 and older [18] and were

classified according to Center for Disease Control per-

centiles for overweight (≥85th percentile) and obesity (≥

95th percentile) [22].

There were minor changes in the questions used to

query daily behaviors over time. In 2003, the daily me-

dia question was: “On an average school day, about how

many hours does [child] usually watch TV, watch videos,

or play video games?” In 2007, the wording of the ques-

tion was revised to ask: “On an average weekday, about

how many hours does [child] usually watch TV, watch

videos, or play video games?” Responses were in num-

ber of hours per day in both surveys. The American

Academy of Pediatrics’ media recommendation of ≤2

hr/day was used for the current analyses [23]. In both

2003 and 2007, the question on VPA was: “During the

past week, on how many days did [child] exercise or

participate in a physical activity for at least 20 minutes

that made [him/her] sweat and breathe hard?” In 2003,

some examples of activities were included along with

the question, but in 2007 the list of activities was used

only in case of extra explanation. Responses for the VPA

question were recorded as the number of days per week.

The VPA recommendation level for the current analyses

was defined as ≥3 days/week of at least 20 minutes of

activity. We chose this criterion to be congruent with the

recommendation for vigorous PA in the Federal Physical

Activity Guidelines, which is 60 minutes per week [24].

The region of the country was recorded as Northeast,

Midwest, South-Atlantic, South-Central, West, Alaska,

and Hawaii. This assignment was based primarily on the

four areas defined by the US Census Bureau [25]. There

was a sum of 50 states plus Washington DC yielding 51

municipalities.

Data analyses were performed using logistic regres-

sion (PROC SURVEY LOGISTIC) to account for com-

plex sampling designs and participant weights. A series

of logistic regression models were used to answer

whether there was regional variation in obesogenic be-

haviors. Since boys and girls have different patterns of

VPA and media as previously reported [15,16], all

analyses were conducted stratified by sex. The first

model produced crude odds ratios by examining only the

obesogenic behavior (i.e., media or VPA) and correlate

(i.e., region of U.S.) of interest. Model 2 adjusted for

S. B. Sisson et al. / Open Journal of Preventive Medicine 1 (2011) 25-33

potential confounders—age, ethnicity, sex, poverty level

and survey year (2003 and 2007). The referent region

was selected to be that with the highest prevalence of

meeting the recommendation. For VPA, the referent was

Alaska and for media, the referent was the West region.

Wald Chi Square tests generated were used to determine

if obesogenic behaviors varied across regions, between

2003 and 2007, and between boys and girls, and if there

was a year-by-sex interaction. To examine the associa-

tion of these obesogenic behaviors with weight status,

adjusted odds of being overweight or obese were calcu-

lated for those 10 years and older (BMI was only avail-

able for 10 - 18 year olds; total n = 75,427, 2003 n =

38,081, 2007 n = 37,346) for the interaction between

media time and VPA for each state. Additionally, ad-

justed prevalence of combined overweight and obesity

was calculated. SAS 9.2 software and procedures were

used with weights and complex study design strata and

cluster variables provided by NSCH.

To geographically examine the relationship between

the prevalence of meeting media or VPA recommenda-

tions and whether or not that prevalence changed from

2003 to 2007, each state was classified discretely into

one of six categories by subtracting the 2003 prevalence

from the 2007 prevalence. A high or low prevalence of

meeting media and VPA recommendations in 2007 was

defined by being above or below the median prevalence

for each behavior. Having a stable prevalence from 2003

to 2007 was defined as being within two percentage

points, while increasing or decreasing prevalence was

defined as a change of more than two percentage points.

Each discrete category of high or low prevalence and

change from 2003 to 2007 was calculated for boys and

girls and media and VPA separately and integrated with

ArcGIS to create four maps that present each state’s

prevalence of obesogenic behavior and how that behav-

ior has changed from 2003 to 2007.

3. RESULTS

Descriptive characteristics of the total sample for

2003 and 2007 are available in Tab le 1. The prevalence

of children in the U.S. meeting the American Academy

of Pediatrics recommendations for media time (≤2

hr/day) on weekdays was 80.9% for the combined sam-

ple, and decreased from 83.6% in 2003 to 78.3% in 2007

(p < 0.0001; Figure 1). For VPA, 76.9% of the com-

bined sample met the recommendation (≥3 days/week of

minimum 20 minutes of vigorous activity), although this

prevalence increased from 74.6% in 2003 to 79.2% in

2007 (p < 0.0001; Figure 1). When meeting VPA and

media recommendations were combined for 2007,

63.7% of children met both media and VPA recommend-

dations while 6.2% met neither. Approximately 16% met

Table 1. Descriptive characteristics of the combined sample,

2003 survey and 2007 survey for children aged 6 - 18 in the

National Survey of Children’s Health.

Va ri ab le Total Sample

(n = 109,151)

2003 only

(n = 55,540)

2007 only

(n = 53,611)

Age yr (SE) 11.5 (0.02) 11.5 (0.02) 11.6 (0.04)

Male (%) 51.3 51.4 51.3

Ethnicity (%)

NHW 66.1 69.4 63.0

NHB 15.6 14.9 16.2

Hispanic 9.9 8.1 11.7

Other 8.4 7.6 9.1

Poverty level (%)

<100% 13.9 13.4 14.4

100% - 299% 38.2 38.8 37.6

≥300% 47.9 47.8 48.0

Family structure (%)

2 biological or adop-

tive parents 60.8 58.7 62.7

2 parent-blended

families 11.6 12.4 10.7

Single parent 21.7 23.9 19.6

Other 6.0 5.0 7.0

Volume of media

per day (%)

None/day 6.4 7.2 5.6

<1 hour/day 16.1 16.8 15.4

≥1 hr and ≤2 hr/day58.4 59.6 57.2

>2 hr/day 19.1 16.4 21.7

Meeting media

recommendation (%)

≤2 hr/day (yes) 80.9 83.6 78.3

>2 hr/day (no) 19.1 16.4 21.7

Child has rules about

TV (%) 86.3 86.1 86.6

Vigorous physical

activity per week (%)

0 - 1 days/week 13.4 14.9 12.0

2 - 3 days/week 23.5 25.2 21.9

4 - 5 days/week 29.3 29.3 29.4

6 - 7 days/week 33.8 30.7 36.7

Meeting Vigorous

physical activity

recommendation (%)

0 - 2 days/week (no)23.1 25.4 20．9

3 - 7 days/week (yes)76.9 74.6 79.2

the VPA recommendations but not the media and 15%

met the media recommendations but not the VPA.

The prevalence of children meeting VPA and media

recommendations ranged from 74.2% - 82.1% and

77.2% - 83.7%, respectively, across regions of the coun-

try (Ta bl e 2). Table 2 also contains the prevalence esti-

mates and odds ratios (95% confidence intervals) for the

crude and adjusted (age, ethnicity, sex, poverty level,

survey year) logistic regression models for each region

of the US for both obesogenic behaviors. For VPA, at the

population level (Model 1), Midwest (OR; 95% CI; 0.76;

0.65 - 0.88), Northeast (0.63; 0.54 - 0.73), South Atlantic

(0.70; 0.60, 0.81), South Central (0.76; 0.65, 0.89), and

West regions (0.79; 0.67, 0.94) had a lower likelihood of

meeting recommendations of being active for at least

20 minutes ≥3 days per week compared with Alaska

S. B. Sisson et al. / Open Journal of Preventive Medicine 1 (2011) 25-33

Figure 1. Prevalence of meeting me-

dia and activity recommendation by

gender in 2003 and 2007.

Table 2. Prevalence estimates and odds ratios for meeting vig-

orous physical activity (≥3 day/wk) and media (≤2 hr/day)

recommendations by region of the US for children.

Va ri ab le s Prevalence

Estimate

Model 1 OR

(95% CI)

Model 2 OR

(95% CI)

3 – 7 day/wk

physical activity

Region

Alaska 82.1% referent referent

Hawaii 80.5% 0.90 (0.75, 1.09) 0.97 (0.79, 1.19)

West 78.4% 0.79 (0.67, 0.94)* 0.79 (0.66, 0.94)*

South Central 77.7% 0.76 (0.65, 0.89)* 0.77 (0.65, 0.91)*

Midwest 77.6% 0.76 (0.65, 0.88)* 0.69 (0.59, 0.81)*

South Atlantic 76.2% 0.70 (0.60, 0.81)* 0.67 (0.57, 0.78)*

Northeast 74.2% 0.63 (0.54, 0.73)* 0.57 (0.49, 0.67)*

≤2 hr media

Region

West 83.7% referent referent

Northeast 83.3% 0.97 (0.85, 1.11) 0.98 (0.85, 1.11)

Alaska 83.1% 0.96 (0.80, 1.16) 0.97 (0.80, 1.17)

Midwest 81.0% 0.83 (0.74, 0.94)* 0.85 (0.75, 0.96)*

Hawaii 80.9% 0.83 (0.69, 0.99)* 0.84 (0.69, 1.02)

South Atlantic 78.9% 0.73 (0.64, 0.83)* 0.88 (0.77, 1.01)

South Central 77.2% 0.66 (0.58, 0.75)* 0.81 (0.70, 0.93)*

*Denotes significance. Listed in order of highest to lowest prevalence of

meeting VPA or media recommendations. Model 1 includes region of coun-

try only for crude odds ratios. Model 2 includes region of country and

covariates (age, ethnicity, sex, poverty level, survey year) for adjusted odds

ratios. States in the West include AZ, CA, CO, ID, MT, NV, NM, OR, UT,

WA, and WY; Northeast include ME, NH, VT, MA, RI, CT, NY, NJ, and PA;

Midwest include IL, IN, IA, KS, MI, MN, MO, NE, ND, SD, OH, and WI;

South Atlantic include FL, GA, NC, SC, VA, WV, MD, DC, and DE; South

Central include AL, KY, MS, TN, AR, LA, OK and TX.

(referent). These findings were similar even after ac-

counting for regional differences in the demographic

characteristics of the children sampled (Model 2). For

media, at the population level (Model 1), Midwest (0.83;

0.74 - 0.94), Hawaii (0.83; 0.69 - 0.99), South Atlantic

(0.73; 0.64 - 0.83) and South Central (0.66; 0.58 - 0.75)

regions had lower likelihood of meeting recommenda-

tions of ≤2 hr/day compared to the West (referent).

However, after adjusting for regional demographic dif-

ferences (Model 2), only Midwest (0.85; 0.75 - 0.96) and

South Central (0.81; 0.70 - 0.93) had lower likelihood of

meeting recommendations.

Figure 2 depicts, for each state, the 2007 prevalence

of meeting media (panels A-B) and VPA recommenda-

tions (panels C-D) and change in prevalence from 2003

to 2007 for boys and girls separately. The state-by-state

prevalence estimates of meeting VPA and media rec-

ommendations for boys and girls and by year are shown

in Ta b l e 3 (VPA) and Ta bl e 4 (media). The prevalence

of children meeting media recommendations decreased

in most states (34/51 states for girls and 40/51 states for

boys), while the prevalence of meeting VPA recommen-

dations was either stable (11/51 states for girls and 19/51

states for boys) or increasing (39/51 states for girls and

31/51 states for boys) from 2003 to 2007. For both sur-

vey years combined, girls were more likely than boys to

meet media recommendations (i.e., boys were more

likely to exceed 2 hours per day, p < 0.0001). This dif-

ference between girls and boys in media time did not

change over the two survey years (p = 0.59). In contrast,

girls were less likely to meet VPA recommendations (i.e.,

girls were more likely to perform less than 3 days per

week of VPA, p < 0.0001). This difference between boys

versus girls in meeting VPA recommendations did not

change over the two survey years (p = 0.62), as depicted

in Figure 1.

Within individual states, the interaction between sex

and survey year only reached significance for South

Carolina for prevalence of meeting VPA recommenda-

tions and in Virginia for prevalence of meeting media

recommendations. In South Carolina, the prevalence of

meeting VPA recommendations increased from 2003 to

2007 for girls (63.3% to 76.6%) and slightly decreased

for boys (80.2% to 79.9%). In Virginia, the prevalence of

meeting media recommendations increased (80.4% to

81.5%) for boys and decreased for girls (86.3% to

77.4%). There were no significant interactions between

sex and survey year within any of the national regions.

The adjusted odds of being overweight or obese, in

those children aged 10 years and older, were 1.13 (95%

CI: 1.05,1.21) for 0 - 2 days/wk of VPA versus 3 - 7

days/wk and 1.27 (95% CI: 1.17,1.37) for >2hr/day ver-

sus ≤2 hr/day of media time. Prevalence of overweight

and obesity is presented along state-by-state obesogenic

behaviors in Table 3. Further, the interaction between

media time and VPA had a significant (β = 0.40 ± 0.06

SE, χ2 = 39.95, p < 0.0001) association with being over-

eight or obese for the nation. When each state was w

S. B. Sisson et al. / Open Journal of Preventive Medicine 1 (2011) 25-33

Figure 2. Change in meeting media and vigorous physical activity recommendations in boys (A&C) and girls (B&D) from 2003-

2007.

examined individually, 13 of the 51 states had a signifi-

cant interaction between media and VPA on overweight

and obesity status; available for relevant states in Table

Openly accessible at

4. DISCUSSION

The primary finding of this study was that there are

regional and gender differences in the prevalence of

meeting VPA (≥3 days/week of minimum 20 minutes)

and media (≤2 hr/day) recommendations in children

aged 6 to 18 years in the US Girls were more likely to

meet the media recommendation but not VPA. Further-

more, there were changes in the prevalence of meeting

media and VPA recommendations between survey years

2003 and 2007. Generally, the prevalence of meeting

VPA recommendations was stable or increased while the

prevalence of meeting media recommendations de-

creased. Obesogenic behaviors were also significantly

associated with overweight status for the nation as a

whole and for some individual states.

These obesogenic behaviors individually and com-

bined were associated with overweight status for the

nation as a whole and for some states, but not every in-

dividual state. These findings support some, [10,11,13]

but not all, previous studies [26]. The regional differ-

ences in obesogenic behaviors shown in the present

study may partially explain the geographic variations in

children’s overweight status; states that have a higher

prevalence of meeting recommendations may have lower

levels of overweight and obesity [3]. For example, in

2007 69% boys in Mississippi, met TV viewing and 81%

met VPA recommendations concurrent prevalence of

overweight of obesity was 45.1% (approximately 15%

higher than the national average). In 2007, 85% of boys

in Vermont met media and 87% met VPA recommenda-

tions. Concurrent prevalence of overweight and obesity

was 25.1% (approximately 6% lower than national av-

erage). These data are examples of the geographic dis-

parities in obesogenic behavior associated with over-

S. B. Sisson et al. / Open Journal of Preventive Medicine 1 (2011) 25-33

Table 3. Prevalence estimates of meeting vigorous physical

activity recommendations by state for 2003 & 2007.

2007 2007 2003

Prevalence ≥ 3day/wk ≥3 day/wk

Overweight

Vigorous

Physical

Activity

Vigorous

Physical

Activity

State Obesity Boys Girls Boys Girls

United States 30.8 83.0 75.1 a 79.6 69.4 a

Alaska 34.2 90.1 82.7

a 79.8 75.4

Alabama 36.5 86.8 79.4

b 85.4 76.3 b

Arkansas 36.5 85.2 72.5

a 83.6 67.3

Arizona 27.8 79.4 72.0

a 80.1 73.0

California 26.9 81.7 77.3 81.2 75.2

Colorado 25.2 86.0 75.8

a 79.4 72.3

Connecticut 26.4 81.8 70.7

a 75.7 65.7

Washington,

DC 35.1 72.7 64.5 a 75.9 59.3

Delaware 31.7 79.3 69.9

a 77.3 64.0

Florida 33.3 81.1 70.8

b 81.5 67.9

Georgia 35.4 82.5 70.1

a 82.2 69.0

Hawaii 28.2 84.9 82.2

a 82.9 71.8 a

Iowa 26.6 82.5 76.6 82.5 71.5

Idaho 27.4 83.8 74.7

a 75.8 73.4

Illinois 35.4 81.7 76.5 77.7 69.9 b

Indiana 29.2 84.9 76.6

b 75.7 70.5

Kansas 32.0 84.7 74.5

a 83.9 75.4 a

Kentucky 36.2 78.6 72.8 79.4 66.2

Louisiana 36.6 83.4 73.3

a 82.4 73.3

Massachusetts 31.0 84.7 74.8 a 76.0 67.5

Maryland 29.2 81.5 74.6 73.4 62.3 a

Maine 28.5 85.1 82.3 77.2 68.4 a

Michigan 30.4 83.7 74.1

a 78.4 65.0

Minnesota 21.5 88.9 79.8

a 79.9 74.4

Missouri 30.5 83.4 80.4 80.5 72.4

Mississippi 45.1 81.7 70.5

a 78.0 70.5 b

Montana 25.4 84.6 82.1 81.4 76.2

North Carolina 33.9 86.2 80.4 82.3 70.1

North Dakota 26.5 87.0 79.1 a 81.5 74.7 b

Nebraska 30.5 87.6 76.6 a 81.2 75.7

New Hampshire 29.8 82.7 75.3 b 76.0 65.5

New Jersey 31.8 82.5 75.1 77.6 58.7 a

New Mexico 32.5 78.5 74.0 80.0 66.1

Nevada 31.4 82.3 71.8

b 79.8 74.3

New York 32.7 79.9 72.3 b 78.7 61.4 a

Ohio 33.2 86.2 75.8

a 77.6 66.3 a

Oklahoma 39.6 83.2 75.3

b 83.6 70.6

Oregon 23.0 83.9 79.6 83.1 77.2 b

Pennsylvania 28.0 82.1 76.9 75.8 63.2

Rhode Island 25.9 84.2 76.7 a 70.3 64.4

South Carolina 32.7 79.9 76.6 80.2 63.3 a

South Dakota 27.7 82.3 76.7 77.3 69.6

Tennessee 37.3 82.2 77.0 77.0 63.8 a

Texas 29.4 83.3 74.0 81.0 74.1

Utah 21.7 84.3 67.1

a 77.9 66.9

Virginia 30.1 80.2 72.2

b 80.8 71.4 a

Vermont 25.1 87.4 82.4 82.7 69.9 a

Washington 29.1 86.6 76.8

a 79.5 72.6

Wisconsin 28.2 87.4 77.6

a 79.3 74.9

West Virginia 37.1 84.0 75.7 a 84.5 74.8

Wyoming 25.5 87.0 80.8 b 81.6 73.8

Sex differences (Wald Chi Square): a p < 0.01, b p < 0.05. The analytic

sample size for each state ranged from 754 in Utah to 1326 in Missouri for

2003 and from 832 in California to 1173 in New Hampshire for 2007. The

sample for calculation of prevalence of overweight and obesity was limited

to those 10 years of age and older (n = 37,346 in 2007 vs. 55,540 in 2003

and 53,611 in 2007).

Table 4. Prevalence estimates of meeting media (TV/video

viewing/video game playing) recommendations by state for

2003 & 2007.

2007 2003

≤2 hr/day TV/viedo ≤2 hr/day TV/viedo

State Boys Girls Boys Girls

United States 75.7 81.0a 81.8 85.6a

Alaska 79.7 82.9 81.5 88.7b

Alabama 72.1 76.6 80.7 77.2

Arkansas 73.3 74.7 76.4 82.4

Arizona 75.8 79.8 83.3 87.2

California 78.5 82.9 83.2 88.2

Colorado 81.6 85.2 86.7 91.2

Connecticut 81.3 85.2 87.2 89.4

Washington, DC70.5 72.9 76.5 74.1

Delaware 79.7 79.9 80.1 85.5b

Florida 64.5 77.4b 82.3 85.8

Georgia 71.5 77.5 83.9 83.9

Hawaii 77.7 84.4b 80.4 81.5

Iowa 77.2 82.5 84.1 89.2b

Idaho 85.3 86.5 87.0 89.4

Illinois 79.2 79.7 79.2 84.3

Indiana 74.9 78.7 79.7 84.8

Kansas 78.6 78.7 87.4 87.0

Kentucky 76.7 80.4 76.4 82.2

Louisiana 69.6 69.6 73.8 76.0

Massachusetts 81.7 87.0 82.7 88.1b

Maryland 76.2 85.6a 82.4 85.8

Maine 82.3 83.8 86.3 92.6a

Michigan 73.9 77.7 80.3 84.9

Minnesota 83.7 90.5b 88.1 90.6

Missouri 75.4 85.4a 79.1 83.6

Mississippi 69.0 68.2 79.4 71.8b

Montana 81.7 89.9a 86.3 91.0b

North Carolina78.1 81.4 79.7 80.7

North Dakota 81.1 85.5 87.3 87.7

Nebraska 77.8 86.1b 86.8 90.5

New Hampshire81.6 90.3a 85.6 90.0

New Jersey 78.1 83.3 83.9 85.5

New Mexico 76.6 85.3 86.3 85.4a

Nevada 73.6 79.9 75.3 85.4

New York 77.3 84.0 84.7 88.5

Ohio 73.9 75.2 78.6 82.4

Oklahoma 73.6 79.7 76.9 83.6b

Oregon 78.0 86.3b 82.7 88.4b

Pennsylvania 73.9 82.7 79.9 84.0

Rhode Island 84.0 87.5 85.0 88.3

South Carolina68.7 76.8b 76.7 79.3

South Dakota 82.6 81.7 84.8 87.6

Tennessee 66.5 79.3a 78.6 85.3b

Texas 70.8 80.2 80.8 84.6

Utah 80.5 90.9a 84.2 92.5a

Virginia 81.5 77.4 80.4 86.3

Vermont 85.0 89.9 90.2 90.9

Washington 79.2 87.4b 85.8 91.1b

Wisconsin 81.0 83.2 86.0 89.1

West Virginia 75.1 78.6 76.8 85.4a

Wyoming 87.2 88.3 88.0 88.0

Sex differences (Wald Chi Square): a p<0.01, b p<0.05. The analytic sample

size for each state ranged from 754 in Utah to 1326 in Missouri for 2003

and from 832 in California to 1173 in New Hampshire for 2007. The sam-

ple for calculation of prevalence of overweight and obesity was limited to

those 10 years of age and older (n = 37,346 in 2007 vs. 55,540 in 2003 and

53,611 in 2007).

weight and obesity status. The interaction of VPA and

media had a significant association with overweight and

S. B. Sisson et al. / Open Journal of Preventive Medicine 1 (2011) 25-33

Tab le 5 . Association of the interaction of VPA and media on

overweight and obesity for states in 2003 & 2007.

Parameter

Estimate SE χ2 p

Alaska 0.40 0.06 39.95 <0.0001

Arizona 1.26 0.35 12.7 <0.001

Florida 0.74 0.29 6.48 0.01

Georgia 1.00 0.36 7.47 0.006

Idaho 0.74 0.27 7.74 0.005

Illinois 0.56 0.27 4.29 0.04

Michigan 0.53 0.25 4.53 0.03

Missouri 0.62 0.25 6.06 0.02

Mississippi 0.90 0.26 15.9 <0.001

North Carolina 0.83 0.27 9.64 0.02

New Hampshire 0.59 0.26 5.06 0.02

Wisconsin 0.78 0.28 7.51 0.006

Wyoming 0.71 0.30 5.54 0.02

The sample for calculation of prevalence of overweight and obesity was

limited to those 10 years of age and older. Each analysis was adjusted for

age, poverty level, family structure and survey year.

obesity for several states such that as children were less

active and had higher media, overweight was higher. We

predict this relationship was not observed in more states

due to the increase in prevalence of meeting VPA rec-

ommendations by many states.

Our findings also demonstrate a higher prevalence of

meeting VPA recommendations (76.9%) compared with

the 1999-2007 Youth Risk Behavior Surveillance System

(YRBSS) (64.0%), although the YRBSS examined high

school students [27] and daily VPA has been reported to

decline with age during childhood and adolescence.

Furthermore, there appears to be significant changes in

obesogenic behaviors in children between 2003 and

2007. In the majority of individual states (31/51 states

for boys and 39/51 states for girls) the percentage of

children who met VPA recommendations increased,

which was contrary to our original hypothesis. However,

our findings support previous work by Sturm, [28] who

reported that from 1981 to 1997 sports participation in-

creased by 73 minutes/week for 3 to 12 year olds. How-

ever, findings from the YRBSS from 1999 to 2007

showed no change in VPA in high school students [27].

The age of the children sampled may impact these find-

ings; it is possible that younger children may be more

active or even improving while older children may be

maintaining the same level of VPA.

Conversely, in the majority of individual states (39/51

states for boys and 34/51 states for girls) prevalence of

meeting media recommendations decreased from 2003

to 2007 (i.e., more children exceeded ≥ 2 hr/day); con-

gruent with our original hypothesis. The prevalence of

meeting media recommendations was higher in the cur-

rent study than two previous national reports which

ranged from 65% - 71% [7,27]. Furthermore, Lowry et

al. [27] reported an increase in the prevalence of chil-

dren meeting media recommendations from 1999 to

2007 (57% to 67%) in a national sample of high-school

students. It is plausible that age is interacting with these

health behaviors since our study examined ages six to 18

while the study by Lowry et al. [27] was conducted in

high school students. We also focused on differences

between boys and girls in obesogenic behaviors for each

state. Overall, boys were more likely to exceed media

recommendations, and girls were more likely attain in-

sufficient VPA. These findings support previous reports

that boys are more physically active, but also spend

more time watching TV than girls [16].

To our knowledge, state and national prevalences of

participation in obesogenic behaviors have not been re-

ported for children 6 - 18 years. A strength of this study

is the nationally representative sample collected at two

time points. Additionally, information on media and VPA

time was collected similarly at each time point albeit

with different national samples of children. There are

also some limitations which need to be addressed. These

data are cross-sectional so no inference about causality

or temporal changes at the individual-level can be as-

sessed. Information was self-reported by a parent proxy

using questions that have not been tested for psychomet-

ric properties, rather than by the child, which may im-

pact the accuracy of the data collected. However, parent

proxy has been reported to be an acceptable measure of

participation in VPA [29] and TV viewing [30] and all

questions were reviewed by an expert panel [18]. Fur-

thermore, a recent review [30] reported that only 7% of

instruments used to assess TV viewing had been tested

for reliability and validity. The authors recognize the

strength of well-tested and designed measures; however,

the wealth of available information on this nationally

representative sample of children supersedes this limita-

tion. Another limitation maybe the wording of the survey

item related to VPA which could lead to an overestima-

tion of children meeting recommendations in the current

study. The question on VPA asked whether a minimum

of 20 minutes was performed per day rather than 60

minutes per day, as stated in the Federal Physical Activ-

ity Guidelines, [24] although the definition of VPA was

congruent with that assessed in the YRBSS [27]. An-

other potential issue that could lead to the underestima-

tion of excessive TV viewing is that time spent with me-

dia was limited to weekdays only. Children have been

reported to spend 40% - 55% more time viewing TV on

weekends compared with weekdays [31].

The fact that volume of media use appears to be in-

creasing over time is concerning, as TV viewing has a

hypothesized impact on prevalence of overweight and

obesity, independent of participation in VPA [10], al-

though not all studies are in agreement [26]. In fact, a

recent study reported that an exercise-to-TV viewing

S. B. Sisson et al. / Open Journal of Preventive Medicine 1 (2011) 25-33

ratio of 2.5:7 hours/week was necessary to protect

against developing overweight in adolescents [32]. Some

recent interventions to decrease TV viewing in children

were successful and resulted in reduced body mass index,

even in the absences of an increase in moderate-to-vig-

orous PA [33,34]. The hypothesized pathways whereby

TV viewing impacts overweight status are still being

investigated and include 1) decreased PA, as media time

may displace time that would otherwise be used for

sports or other forms of active play, 2) promotion of

snacking during TV time, 3) increased daily caloric con-

sumption and consumption of fast food spurred by ex-

posure to child-focused advertising, and 4) lowered

metabolic rate during TV viewing compared to sponta-

neous play [30,35].

In conclusion we found significant geographic differ-

ences in the prevalence of meeting VPA and media rec-

ommendations in US children and that these behaviors

were associated with higher odds of overweight or obe-

sity status. Additionally, the present study shows that the

prevalence of meeting obesogenic behavior recommen-

dations changed from 2003 to 2007. In general, more

states met VPA recommendations in 2007 than in 2003

while fewer states met the media recommendations in

2007 than in 2003. Understanding state and regional

prevalence and trends could be used by public health

researchers and practitioners to create regionally tailored

interventions and monitor progress over time. However,

approaches should address the unique correlates of ac-

tivity and sedentary behaviors [17]. Further work is now

needed to understand why the prevalence of obesogenic

behaviors is shifting and how they affect health and dis-

ease.

5. ACKNOWLEDGEMENTS

There was no funding for this project.

Declaration of Competing Interests

There are no conflicts of interest.

Author’s Contributions

SBS was involved with the conception, design, data acquisition, ana-

lyses and interpretation of the data as well as manuscript preparation.

STB was involved with the conception, design, analyses and interpre-

tation of the data as well as manuscript preparation. KRS and DRB

were involved in interpretation and presentation of data and analyses as

well as manuscript preparation.

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