Trends in Abdominal Obesity Among US Children and Adolescents

Trends in Abdominal Obesity Among US Children andAdolescents

WHAT’S KNOWN ON THIS SUBJECT: Previous studies showed thatprevalence of abdominal obesity among US children andadolescents increased significantly between 1988–1994 and 2003–2004. However, little is known about recent time trends inabdominal obesity since 2003–2004.

WHAT THIS STUDY ADDS: In 2011–2012, 17.95% of children andadolescents aged 2 to 18 years were abdominally obese definedby waist circumference. The prevalence of abdominal obesityleveled off among US children and adolescents from 2003–2004 to2011–2012.

abstractOBJECTIVES: Previous studies showed that prevalence of abdominalobesity among US children and adolescents increased significantlybetween 1988–1994 and 2003–2004. However, little is known aboutrecent time trends in abdominal obesity since 2003–2004.This studywas to provide recent updated national estimates of childhood abdom-inal obesity and examine the trends in childhood abdominal obesityfrom 2003 to 2012.

METHODS: Data were from the National Health and Nutrition Examina-tion Survey (NHANES) conducted during 5 time periods (2003–2004,2005–2006, 2007–2008, 2009–2010, and 2011–2012). A total of 16 601US children and adolescents aged 2 to 18 years were included. Abdom-inal obesity is defined as a waist circumference (WC) $ gender- andage-specific 90th percentile based on data from NHANES III (1988–1994)and a waist-to-height (WHtR) $0.5, respectively.

RESULTS: In 2011–2012, 17.95% of children and adolescents aged 2 to18 years were abdominally obese defined by WC, and 32.93% of thoseaged 6 to 18 years were abdominally obese defined by WHtR. Mean WCand WHtR and prevalence of abdominal obesity kept stable between2003–2004 and 2011–2012, independently of gender, age, and race/ethnicity. However, there was a significant decrease in abdominalobesity among children aged 2 to 5 years.

CONCLUSIONS: The prevalence of abdominal obesity leveled off amongUS children and adolescents from 2003–2004 to 2011–2012. Pediatrics2014;134:e334–e339

AUTHORS: Bo Xi, MD,a Jie Mi, MD,b Min Zhao, MD,c TaoZhang, MD,a Cunxian Jia, MD,a Jiajia Li, MD,d Tao Zeng, MD,e

and Lyn M. Steffen, PhD,f on behalf of Public Health YouthCollaborative and Innovative Study Group of ShandongUniversity (PHYCISG-SDU)aDepartments of Epidemiology and Health Statistics, cNutritionand Food Hygiene, dSocial Medicine and Health ServiceManagement, and eToxicology, School of Public Health, ShandongUniversity, Jinan, China; bDepartment of Epidemiology, CapitalInstitute of Pediatrics, Beijing, China; and fDivision ofEpidemiology and Community Health, School of Public Health,University of Minnesota, Minneapolis, Minnesota

KEY WORDSabdominal obesity, waist circumference, waist-to-height ratio,children

ABBREVIATIONSCI—confidence intervalCVD—cardiovascular diseaseNHANES—National Health and Nutrition Examination SurveyOR—odds ratioWC—waist circumferenceWHtR—waist-to-height ratio

Drs Xi, Mi and Steffen conceptualized and designed the studyand drafted the initial manuscript; Drs Zhao and Zhang carriedout the initial analyses and reviewed and revised themanuscript; Drs Jia, Li, and Zeng designed the data collectioninstruments, coordinated data collection, and critically reviewedthe manuscript; and all authors approved the final manuscriptas submitted and agree to be accountable for all aspects of thework.

www.pediatrics.org/cgi/doi/10.1542/peds.2014-0970

doi:10.1542/peds.2014-0970

Accepted for publication May 20, 2014

Jie Mi, MD, Department of Epidemiology, Capital Institute ofPediatrics, 2 Ya Bao Road, Beijing, 100020 China. E-mail:[email protected]

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

Copyright © 2014 by the American Academy of Pediatrics

FINANCIAL DISCLOSURE: The authors have indicated they haveno financial relationships relevant to this article to disclose.

FUNDING: This study was supported by the Scientific ResearchOrganization Construction Project of Shandong University (grant21320074615021).

POTENTIAL CONFLICT OF INTEREST: The authors have indicatedthey have no potential conflicts of interest to disclose.

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Childhood obesity is a serious publichealth problem worldwide, includingin the United States.1 BMI is the mostwidely recognized surrogate of obesity,but it does not provide informationabout the distribution of body fat.2 An-thropometric measures such as waistcircumference (WC) and waist-to-heightratio (WHtR), used for defining abdominalobesity, are better than BMI for predictingrisk for hypertension, type 2 diabetes,metabolic syndrome, cardiovascular dis-ease (CVD), and all-cause mortality.3,4 Im-portantly, the US National Institutes ofHealth recommends screening of WC forhealth risk, especially in overweight orobese adults (BMI$25.0 kg/m2).5

To prevent and control an epidemic ofobesity, it is necessary to monitor sec-ular trends in obesity through pop-ulation surveillance. Abdominal obesityamong US children and adolescents in-creaseddramatically from1988–1994 to1999–2004 according to the NationalHealth and Nutrition Examination Sur-vey (NHANES) III and the continuousNHANES 1999–2004.6 However, it is un-clear whether abdominal obesity hascontinued to increase since 2004.

Using the most recent national datafrom NHANES since 2004, we examinedthe secular trends of WC, WHtR, andabdominal obesity among children andadolescents aged 2 to 18 years in theUnited States.

METHODS

Design and Subjects

The NHANES population is a complex,multistage probability sample of UScivilian, non-institutionalized adultsand children; details have been de-scribed elsewhere.1 The NHANES since1999 has been conducted annually bythe National Center for Health Statis-tics of the Centers for Disease Controland Prevention. A questionnaire wasadministered during the home in-terview, and physical measurementsincluding weight, height, and WC were

measured at the mobile examinationcenter. Written informed consent wasobtained from parents and/or childrenaged 2 to 18 years. The NHANES wasapproved by the National Center forHealth Statistics Ethics Review Board.

Measurements and Definitions

Height, weight, and WC were obtainedusing standardized protocols and cali-brated equipment.1,6 Height was mea-sured to the nearest 0.1 cm withoutshoes using a portable stadiometer.1

WC was measured by using a steelmeasuring tape to the nearest 0.1 cm atthe high point of the iliac crest at mini-mal respiration when the participantwas in a standing position.6 Abdominalobesity is defined as WC equal to orabove the gender- and age-specific 90thpercentile based on data from NHANES III(1988–1994).7 In addition, a WHtR $0.5defined abdominal obesity for youth aged6 to 18 years, because this cutoff mayoverestimate the prevalence of abdomi-nal obesity in children aged 2 to 5 years.8

Statistical Analysis

Differences in distributions of gender,age, and race/ethnicity between 5 cyclesurveys were tested by using a x2 test.Time trends in mean WC and WHtR andprevalence of abdominal obesity from2003–2004 to 2011–2012 were exam-ined by usingmultiple linear regression

or logistical regression model, respec-tively, with consideration of age, gender,and race/ethnicity, when applicable.Multiple logistical regression analysiswas also used to assess the effect ofsurvey years, age, gender, and race/ethnicity on risk for abdominal obesity.P , .05 was considered statisticallysignificant. Statistical analysis wasperformed by using SPSS version 13.0(SPSS, Inc, Chicago, IL).

RESULTS

Characteristics of the StudyPopulation

Table 1 shows the characteristics ofstudy population between 5 surveyperiods (2003–2004, 2005–2006, 2007–2008, 2009–2010, and 2011–2012). Thedistribution of gender was homoge-neous between 5 periods (P. .05) butthere were significant differences inthe proportions of age- and race/ethnicgroups (both P , .001).

Trends in Mean WC and WHtRAmong US Children andAdolescents

Mean WC and WHtR remained stableamong US children and adolescents from2003–2004 to 2011–2012 for each surveyand by age, gender, and race/ethnicgroup, except for non-Hispanic blacks,whose WCmarginally increased (Table 2).

TABLE 1 Characteristics of US Children and Adolescents Aged 2 to 18 Years, NHANES 2003–2004 to2011–2012

2003–2004 2005–2006 2007–2008 2009–2010 2011–2012 P value

All, n 3595 3849 3005 3104 3048Age group, %2 to 5 y 21.6 23.5 27.1 26.7 26.2 0.436 to 11 y 26.5 28.5 39.0 37.5 40.512 to 18 y 51.8 48.0 33.9 35.8 33.4

Gender, %Boys 50.3 50.1 52.1 51.6 51.0 ,0.001Girls 49.7 49.9 47.9 48.4 49.0

Race/ethnicity, %Non-Hispanic white 27.3 26.6 31.7 33.1 21.8 ,0.001Non-Hispanic black 34.7 31.0 25.2 19.6 30.0Mexican American 29.7 33.3 25.6 28.3 19.5Other race 8.2 9.2 17.5 19.1 28.7

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Trends in Prevalence of AbdominalObesity Among US Children andAdolescents

In 2011–2012, 17.95% of children andadolescents aged 2 to 18 years wereabdominally obese (defined by WC);32.93% of those aged 6 to 18 years wereabdominally obese (defined by WHtR).Compared with 2003–2004, the preva-lence of abdominal obesity in 2011–2012, as defined byWC andWHtR, did notchange in the total population or by age,gender, and race/ethnic group, exceptfor children aged 2 to 5 years (Table 3).

Influence of Demographic Factorson Abdominal Obesity Among USChildren and Adolescents

As shown in Table 4, compared withchildren aged 2 to 5 years, those aged

6 to 11 years (odds ratio [OR], 1.79; 95%confidence interval [CI], 1.60–1.99) and12 to 18 years (OR, 1.48; 95% CI, 1.33–1.65) were more likely to be abdomi-nally obese defined by WC. In addition,girls (boys as referent: OR, 1.15; 95% CI,1.06–1.24) andMexican American (non-Hispanic white as referent: OR, 1.38;95% CI, 1.25–1.53) were more likely tohave abdominal obesity. Similar resultswere found when using WHtR $0.5 todefine abdominal obesity (Table 4).

DISCUSSION

In the current study, trends in meanWC and WHtR and the prevalence ofabdominal obesity remained stableamong US children and adolescentsfrom 2003–2004 to 2011–2012, whichis consistent with the level trends in

obesity (defined by BMI) from 2003–2004 to 2011–2012 in this young pop-ulation.1 Our findings have importantpublic health implications, because ab-dominal obesity is a better indicator ofmany chronic diseases such as hyper-tension, diabetes, CVD, and death thangeneral obesity. Although the preva-lence of abdominal obesity leveled offover the past nine years among USchildren and adolescents, it is stillhigh, being nearly 18% (defined by WC)in participants aged 2 to 18 years and33% (defined by WHtR) in those aged 6to 18 years, suggesting an urgent needfor lifestyle modifications to lowerabdominal obesity.

The stable trends in mean WC andWHtR and prevalence of abdominalobesity were consistent in each age,

TABLE 2 Trends in Mean WC (SE) and WHtR (SE) Among US Children and Adolescents Aged 2 to 18 Years, NHANES 2003–2004 to 2011–2012

2003–2004 2005–2006 2007–2008 2009–2010 2011–2012 AbsoluteIncrease

P forTrend

Mean SE Mean SE Mean SE Mean SE Mean SE

WC, cmAll 68.15 0.19 68.15 0.18 68.25 0.21 68.22 0.21 68.43 0.21 0.28 0.33Age group2 to 5 y 51.58 0.17 51.07 0.16 51.17 0.17 51.26 0.16 51.05 0.17 20.53 0.136 to 11 y 65.73 0.35 64.82 0.33 64.93 0.31 64.72 0.32 65.48 0.31 20.25 0.7112 to 18 y 80.42 0.33 81.21 0.33 81.22 0.45 81.32 0.43 81.18 0.45 0.76 0.13

GenderBoys 68.13 0.27 67.98 0.26 68.26 0.29 68.14 0.29 68.62 0.29 0.49 0.21Girls 68.18 0.27 68.32 0.26 68.25 0.30 68.30 0.29 68.22 0.30 0.04 0.94

Race/ethnicityNon-Hispanic

white68.45 0.35 67.57 0.34 68.31 0.35 67.57 0.34 68.65 0.42 0.20 0.98

Non-Hispanicblack

67.94 0.35 67.48 0.36 67.91 0.45 68.96 0.50 68.64 0.41 0.70 0.04

Mexican American 69.10 0.36 70.48 0.33 69.59 0.42 69.60 0.39 70.16 0.48 1.06 0.82WHtRAll 0.492 0.001 0.493 0.001 0.493 0.001 0.492 0.001 0.493 0.001 0.001 0.13Age group2 to 5 y 0.509 0.001 0.506 0.001 0.507 0.001 0.508 0.001 0.505 0.001 20.004 0.146 to 11 y 0.486 0.002 0.481 0.002 0.483 0.002 0.480 0.002 0.485 0.002 20.001 0.9212 to 18 y 0.488 0.002 0.494 0.002 0.494 0.003 0.493 0.002 0.494 0.003 0.006 0.05

GenderBoys 0.485 0.002 0.485 0.002 0.487 0.002 0.486 0.002 0.487 0.002 0.002 0.42Girls 0.500 0.002 0.502 0.002 0.499 0.002 0.499 0.002 0.499 0.002 20.001 0.42

Race/ethnicityNon-Hispanic

white0.494 0.002 0.489 0.002 0.493 0.002 0.487 0.002 0.492 0.003 20.002 0.21

Non-Hispanicblack

0.480 0.002 0.479 0.002 0.479 0.003 0.485 0.003 0.484 0.003 0.004 0.10

Mexican American 0.505 0.002 0.514 0.002 0.509 0.003 0.508 0.002 0.509 0.003 0.004 0.76

Time trends in mean WC and WHtR from 2003–2004 to 2011–2012 were examined by using multiple linear regression model, with adjustment for age, gender, and race/ethnicity, whenapplicable.

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gender, and race/ethnic group, exceptfor children aged 2 to 5 years, in whoma decreasing trend was observed.Notably, girls, adolescents, andMexicanAmerican youth were more abdomi-nally obese than boys, children, andnon-Hispanic whites, respectively. Theyouth in specific subgroups shouldbe targeted as high priority for in-tervention efforts to reduce abdominalobesity.

Data on recent trends of abdominalobesity are few in children and ado-lescents. A previous NHANES studyshowed that WC and the prevalenceof abdominal obesity in US childrenaged 6 to 11 years significantly in-creased from 1988–1994 to 1999–2002.9 The increasing trends werefurther extended when NHANES 2003–2004 data were also examined.6 The

Australia national surveys conductedin 1985, 1995, and 2007 showed thatabdominal obesity in children in-creased at a faster rate than obesitydefined by BMI during the past 2 de-cades.10 Liang et al found significantlyincreased obesity and abdominalobesity in Chinese school-aged chil-dren enrolled in the China Health andNutrition Survey from 1993 to 2009.11

Notably, data from Korean NutritionHealth and Nutrition ExaminationSurvey indicated that abdominal obe-sity leveled off in boys but decreasedin girls aged 10 to 19 years between2001 and 2005.12

It is well accepted that eating foodsrich in energy, intake of sweetenedbeverage, lack of physical activity, andmore time spent in sedentarybehaviors (TV/video viewing, com-

puter use) are main risk factors forobesity. Notably, during the periods of2001–2010, time of TV viewing andconsumption of sweets and sweet-ened beverages decreased, and dayswith at least 1 hour of physical ac-tivity, intake of fruits and vegetables,and frequency of eating breakfastsignificantly increased among USadolescents aged 11 to 16 years.13

These findings may in part explainwhy the prevalence of abdominalobesity did not increase but remainedstable between 2003–2004 and 2011–2012.

The prevalence of abdominal obesity(WC $90th percentile for age andgender in NHANES III) was 18% amongUS children and adolescents aged 2 to18 years in 2011–2012, which wassimilar to the prevalence of obesity

TABLE 3 Trends in the Prevalence of Abdominal Obesity (%, SE) Among US Children and Adolescents Aged 2 to 18 Years, NHANES 2003–2004 to 2011–2012

2003–2004 2005–2006 2007–2008 2009–2010 2011–2012 AbsoluteIncrease

P forTrend

% SE % SE % SE % SE % SE

WC $90th percentileAll 18.33 0.65 18.65 0.63 19.40 0.72 18.27 0.69 17.95 0.70 20.38 0.59Age group2 to 5 y 15.83 1.31 13.80 1.15 14.13 1.22 13.15 1.17 10.90 1.10 24.93 0.016 to 11 y 23.17 1.37 21.06 1.23 21.76 1.21 21.89 1.21 21.82 1.18 21.35 0.9812 to 18 y 16.90 0.87 19.61 0.92 20.90 1.27 18.29 1.16 18.78 1.22 1.88 0.26

GenderBoys 17.63 0.90 17.02 0.86 18.91 0.99 16.80 0.93 17.12 0.96 20.51 0.98Girls 19.04 0.93 20.29 0.92 19.93 1.05 19.83 1.03 18.81 1.01 20.23 0.53

Race/ethnicityNon-Hispanic

white19.23 1.26 15.66 1.14 19.64 1.29 14.42 1.10 17.17 1.46 22.06 0.21

Non-Hispanicblack

16.52 1.05 16.43 1.07 16.23 1.34 20.10 1.63 17.38 1.25 0.86 0.06

Mexican American 20.11 1.23 24.06 1.19 22.08 1.49 21.16 1.38 24.45 1.76 4.34 0.28WHtR $0.5All 34.81 0.90 35.34 0.88 35.46 1.02 34.48 1.00 32.93 0.99 21.88 0.30Age group6 to 11 y 33.65 1.53 30.54 1.39 32.51 1.37 32.13 1.37 30.74 1.31 22.91 0.8012 to 18 y 35.41 1.11 38.19 1.13 38.86 1.53 36.94 1.45 35.59 1.50 0.18 0.35

GenderBoys 30.70 1.22 30.88 1.20 32.32 1.40 31.00 1.35 29.77 1.35 20.93 0.33Girls 39.06 1.31 39.85 1.28 38.76 1.49 38.17 1.46 36.24 1.45 22.82 0.71

Race/ethnicityNon-Hispanic

white35.32 1.74 30.28 1.65 34.98 1.85 25.51 1.61 31.42 2.03 23.9 0.08

Non-Hispanicblack

28.47 1.43 28.18 1.46 28.06 1.86 32.54 2.18 28.48 1.77 0.01 0.11

Mexican American 42.47 1.69 47.30 1.61 43.96 2.11 43.52 1.95 46.64 2.40 4.17 0.13

Time trends in prevalence of abdominal obesity from 2003–2004 to 2011–2012 were examined by using a multiple logistical regression model, with adjustment for age, gender, and race/ethnicity, when applicable.

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(BMI $95th percentile for age andgender according to the Centers forDisease Control and Preventiongrowth charts) in the same period(17%).1 To date, there is not a generalconsensus defining abdominal obesityat the national level. Thus, we wereunable to compare our results tothose in other countries. In addition,the prevalence of abdominal obesity(WHtR $0.5) was 33% among adoles-cents aged 6 to 18 years in 2011–2012,which was comparable to the preva-lence of overweight in the same period(34%).1 WHtR is a simple measure of

abdominal obesity, independent of ageand gender. Based on results for theassociation between WHtR and cardio-metabolic risk in adults, a cutoff forWHtR of 0.5 is recommended.14 Indeed,WHtR has been reported as a betterindicator of risk for CVD than BMI orWC.3,4 Moreover, the message of “keepyour waist to less than half your height”is attractive for public health policy.

The current study has 3 strengths.First, we used national data that arerepresentative of US children andadolescents. Second, the data col-lectors were trained using standard

procedures, and quality controlmeasures guaranteed the reliabilityof study results. Third, although thetrends for abdominal obesity inNHANES 1999–2004 was previouslyreported, we reported the trends for4 additional survey cycles (2005–2006, 2007–2008, 2009–2010, and2011–2012). However, 2 limitationsshould be noted. First, WC $90thpercentile for age and gender inNHANES III was used to define ab-dominal obesity, which impeded ourability to compare our results withthose of other studies. Second, wedid not analyze the influencing fac-tors including dietary and lifestylehabits that may affect the trends inabdominal obesity, and further stud-ies are warranted to examine thetrends of environmental factors andwhether they influence abdominalobesity.

CONCLUSIONS

The prevalence of abdominal obesityleveled off among US children andadolescents from 2003–2004 to 2011–2012, independent of age, gender, andrace/ethnicity. However, the preva-lence of abdominal obesity is high;therefore, appropriate dietary intakeand physical activity should be furtheremphasized to combat the obesityepidemics.

ACKNOWLEDGMENTSWe thank the US National Center forHealth Statistics, Centers for DiseaseControl and Prevention, for providingdata collection and analysis of files.We also thank Dr Shuangshuang Lifrom the Public Health Youth Collab-orative and Innovative Study Groupof Shandong University (PHYCISG-SDU) for helping with analysis of thedata.

TABLE 4 Influencing Demographic Factors of Abdominal Obesity Among US Children andAdolescents Aged 2 to 18 Years From 2003–2004 to 2011–2012

OR 95% CI P value

WC $90th percentileSurvey period2003–2004 1.02005–2006 1.01 0.90–1.14 0.832007–2008 1.09 0.96–1.23 0.202009–2010 1.00 0.88–1.13 0.982011–2012 1.00 0.88–1.14 0.98

Age group2 to 5 y 1.06 to 11 y 1.79 1.60–1.99 ,0.00112 to 18 y 1.48 1.33–1.65 ,0.001

GenderBoys 1.0Girls 1.15 1.06–1.24 0.001

Race/ethnicityNon-Hispanic white 1.0Non-Hispanic black 0.99 0.88–1.10 0.80Mexican American 1.38 1.25–1.53 ,0.001

WHtR $0.5Survey period2003–2004 1.02005–2006 1.01 0.91–1.13 0.842007–2008 1.10 0.97–1.24 0.142009–2010 1.01 0.90–1.14 0.812011–2012 1.01 0.89–1.14 0.87

Age group6 to 11 y 1.012 to 18 y 1.29 1.19–1.39 ,0.001

GenderBoys 1.0Girls 1.42 1.31–1.53 ,0.001

Race/ethnicityNon-Hispanic white 1.0Non-Hispanic black 0.88 0.79–0.97 0.01Mexican American 1.78 1.61–1.97 ,0.001

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DOI: 10.1542/peds.2014-0970; originally published online July 21, 2014;Pediatrics

SteffenBo Xi, Jie Mi, Min Zhao, Tao Zhang, Cunxian Jia, Jiajia Li, Tao Zeng and Lyn M.

Trends in Abdominal Obesity Among US Children and Adolescents  

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Trends in Abdominal Obesity Among US Children and Adolescents  

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