To document the prevalence of severe obesity and associated risk in the HEALTHY cohort

Baranowski, Tom

DeBar, Lynn L.

Edelstein, Sharon

Kaufman, Francine R.

Marcus, Marsha D.

Schneider, Margaret

Siega-Riz, Anna Maria

Staten, Myrlene A.

Virus, Amy

Yin, Zenong

PubMed

Carolina Digital Repository

Severe Obesity and selected risk factors in a sixth grade multi-racial cohort: the HEALTHY studyMarsha D. Marcus, PhD,University of Pittsburgh School of MedicineTom Baranowski, PhD,Baylor College of MedicineLynn L. DeBar, PhD, MPH,Kaiser Permanente Center for Health ResearchSharon Edelstein, ScM,George Washington University Biostatistics CenterFrancine R. Kaufman, MD,Keck School of Medicine, University of Southern CaliforniaMargaret Schneider, PhD,University of California at IrvineAnna Maria Siega-Riz, PhD, RD,University of North Carolina School of Public HealthMyrlene A. Staten, MD,National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of HealthAmy Virus, RD, andCenter for Obesity Research and Education, Temple UniversityZenong Yin, PhDUniversity of Texas at San AntonioAbstractPurpose—To document the prevalence of severe obesity and associated risk in the HEALTHYcohort.Methods—6,365 students were assessed at school-based screenings.Results—6.9% of students were severely obese. Severe obesity was associated with elevatedcardiometabolic risk and race/ethnicity.Conclusions—Severe obesity is common and requires preventive intervention.©2010 Society for Adolescent Medicine. Published by Elsevier Inc. All rights reserved.Corresponding Author and Reprint Requests: Marsha D. Marcus, PhD, Western Psychiatric Institute and Clinic, 3811 O’Hara Street,Pittsburgh, PA 15213, marcusmd@upmc.edu, 412-246-6371, 412-246-6370 [FAX].Conflicts of Interest: None.Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to ourcustomers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review ofthe resulting proof before it is published in its final citable form. Please note that during the production process errors may bediscovered which could affect the content, and all legal disclaimers that apply to the journal pertain.NIH Public AccessAuthor ManuscriptJ Adolesc Health. Author manuscript; available in PMC 2011 December 1.Published in final edited form as:J Adolesc Health. 2010 December 1; 47(6): 604–607. doi:10.1016/j.jadohealth.2010.04.017.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptKeywordsobesity; hyperinsulinism; glucose intolerance; hyperlipidemia; hypertensionIntroductionIncreasing rates of pediatric obesity (1) have stimulated the development of preventionprograms to minimize obesity and related morbidities. HEALTHY was an NIDDK-funded,three-year intervention designed to reduce risk factors for type 2 diabetes [i.e., Body MassIndex (BMI) ≥ 85th percentile for age and sex, fasting glucose ≥ 100 mg/dL, and fastinginsulin ≥ 30 μU/mL] in a diverse sample of US school children. We recently reportedbaseline data for the HEALTHY cohort of 6,358 6th grade students, which documented highrates of obesity and diabetes risk factors (2). In this report, we focus on baseline datarelating to the sub-group of students with severe obesity [BMI ≥ 99th percentile for age andsex (3)]. The prevalence of severe obesity also has increased (4), and approximately 4% ofAmerican children have a BMI ≥ 99th percentile (3). Severe obesity is a robust predictor ofmedical and psychosocial morbidity, as well as persistence of obesity into adulthood (4).Thus, we examined rates of severe obesity in the HEALTHY 6th grade cohort, and therelation between severe obesity, and cardiometabolic risk factors and race/ethnicity.MethodsForty-two middle schools with ≥ 50% of minority children or students eligible for free/reduced lunch were recruited at 7 US centers. Sixth grade students were invited to healthscreenings in fall 2006; 57.6% of students enrolled. The study was approved by theInstitutional Review Boards at each site, and parent consent and child assent were obtained.Assessment methods were reported previously (5). Height, weight, waist circumference andblood pressure were measured, and fasting blood draws were obtained to assess metabolic(glucose, insulin) and additional cardiovascular (total cholesterol, LDL, HDL, triglycerides)risk factors. BMI percentile for age and sex was calculated using the CDC program (6,7).Youth with BMI ≥ 85th but < 95th percentile were classified as overweight and those ≥ 95thbut <99th percentile as obese. Students with BMI ≥ 99th percentile were classified asseverely obese. Blood was analyzed by Northwest Lipid Metabolism and Diabetes ResearchLaboratories, University of Washington, Seattle.Ethnicity and race were self-reported. Students checking ‘Hispanic or Latino’ ethnicity wereclassified as Hispanic (n=3376); non-Hispanics choosing only ‘Black or African American’race were classified as Black (n=1254); non-Hispanics choosing only ‘White’ race wereWhite (n=1197); all other response categories (n<140 each) were combined into ‘Other.’ Aparent or guardian reported family history of diabetes.Generalized linear mixed models (SAS Proc GLIMMIX) that included a random effect forschool to adjust for clustering of children within schools were used to examine the relationbetween risk factors, and levels of BMI and race/ethnicity categories.ResultsStudents (N=6,358) averaged 11.8 years (SD = 0.6) and 48% were male. The number andpercent of students in the BMI categories are presented in Table 1. There were 441 students(6.9%) in the severely obese category (Mean BMI = 35.2 kg/m2 ± 3.7). Rates of severeobesity differed by sex (7.5% of boys and 6.4% of girls, p = 0.007). Severe obesity alsoMarcus et al. Page 2J Adolesc Health. Author manuscript; available in PMC 2011 December 1.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author Manuscriptvaried by ethnic group with rates of 4.9%, 8.0%, and 7.3% for White, Black and Hispanicyouth, respectively (p<.0001). Rates of severe obesity also differed as a function of race/ethnicity and sex (p = 0.01) with the highest rates observed in Black girls (8.7%) andHispanic boys (8.2%), and lowest rates among White girls (4.1%) and boys (5.8%).Table 2 shows the percent of students with a family history of type 2 diabetes andcardiometabolic risk factors within BMI percentile categories (all p’s <0.001). In general,the prevalence of risk increased as a function of BMI percentile. Severely obese childrenwere more likely than those with more moderate obesity (i.e., BMIs 95-< 99th percentile) tohave a family history of diabetes, elevated waist circumference and insulin levels, and lowHDL-cholesterol and high blood pressure. Table 2 also documents that among severelyobese youth, risk varied as a function of racial/ethnic group, with Hispanic students havinghighest rates of elevated insulin, and White students having highest rates of elevated totalcholesterol and blood pressure.DiscussionData from the HEALTHY study document that 6.9% of a diverse sample of US sixthgraders were severely obese, a rate notably higher than the 4% reported among 5-17 year oldBlack and White children participating in the Bogalusa Heart Study (3). As shown inprevious studies (4), the prevalence of severe obesity varies markedly by race/ethnicitygroup. In the current study, we observed rates of 4.9%, 8.0%, and 7.3% for White, Blackand Hispanic youth, respectively, which are higher across all racial/ethnic groups than thosederived from the 1999-2002 NHANES data (4). Although differences in sampling mayexplain differences in prevalence across studies, the current findings provide compellingevidence of high rates of severe obesity in American middle school children. Indeed, theaverage BMI of the severely obese children in the HEALTHY cohort was 35.2 kg/m2, alevel consistent with adult Class 2 obesity (8).Among severely obese children, patterns of risk varied by race/ethnicity, which replicatesfindings of previous investigations (9). Specifically, Hispanic students had highest rates ofrisk for type 2 diabetes, White youth had a differentially high risk for elevated totalcholesterol and high blood pressure, while Black youth were less likely to have low HDL orelevated triglycerides. These data provide additional documentation of variations in riskacross racial/ethnic groups and demonstrate that even among severely obese youth, there aredifferent patterns of risk in children of different racial/ethnic backgrounds.Rates of severe obesity have increased more rapidly than those of moderate obesity in adults(10), and the current investigation suggests that there may be a similar pattern among USpublic school students. Severe pediatric obesity is thought to require aggressive intervention,which raises the question of whether school-based prevention programs such as HEALTHYwill benefit this sub-group of children. Thus, it will be important to evaluate whether publichealth efforts that target multiple environmental and behavioral factors to decrease pediatricoverweight, in general, also will reduce increases in severe obesity.AcknowledgmentsThis work was completed with funding from NIDDK/NIH grant numbers U01-DK61230, U01-DK61249, U01-DK61231, and U01-DK61223 to the STOPP-T2D collaborative group, with additional support from the AmericanDiabetes Association.HEALTHY AcknowledgmentsWe wish to thank the administrations, faculty, staff, students, and their families at the middle schools and schooldistricts that participated in the HEALTHY study.Marcus et al. Page 3J Adolesc Health. Author manuscript; available in PMC 2011 December 1.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptThe following individuals and institutions constitute the HEALTHY Study Group (* indicates principal investigatoror director):STOPP-T2D Study Chair Childrens Hospital Los Angeles: F.R. KaufmanField Centers Baylor College of Medicine: T. Baranowski*, L. Adams, J. Baranowski, A. Canada, K.W. Cullen,M.H. Dobbins, R. Jago, A. Oceguera, A.X. Rodriguez, C. Speich, L.T. Tatum, D. Thompson, M.A. White, C.G.Williams Oregon Health & Science University: L. Goldberg*, D. Cusimano, L. DeBar, D. Elliot, H.M. Grund, K.Kuehl, S. McCormick, E. Moe, J.B. Roullet, D. Stadler Temple University: G.D. Foster* (Steering CommitteeChair), J. Brown, B. Creighton, M. Faith, E.G. Ford, H. Glick, S. Kumanyika, J. Nachmani, J. Rosen, L. Rosen, S.Sherman, S. Solomon, A. Virus, S.L. Volpe, S. Willi University of California at Irvine: D. Cooper*, S. Bassin, S.Bruecker, D. Ford, P. Galassetti, S. Greenfield, J. Hartstein, M. Krause, N. Opgrand, Y. Rodriguez, M. SchneiderUniversity of North Carolina at Chapel Hill: J.S. Harrell*, A. Anderson, T. Blackshear, J. Buse, J. Bridgman, A.Gerstel, C. Giles, W. Hall, A. Jessup, P. Kennel, R. Matthews, R.G. McMurray, D. Rubin, A.M. Siega-Riz, M.Smith, A. Steckler, A. Zeveloff University of Pittsburgh: M.D. Marcus*, M. Carter, S. Clayton, B. Gillis, K.Hindes, J. Jakicic, R. Meehan, R. Noll, T. Songer, J. Vanucci, E.M. Venditti University of Texas Health ScienceCenter at San Antonio: R. Treviño*, A. Garcia, D. Hale, A.E. Hernandez, I. Hernandez, C. Mobley, T. Murray, K.Surapiboonchai, Z. YinCoordinating Center George Washington University: K. Hirst*, K.L. Drews, S. Edelstein, L. El ghormli, L.S.Firrell, M. Huang, P.K. Feit, S.L. Mazzuto, T. Pham, A. WheelerProject Office National Institute of Diabetes and Digestive and Kidney Diseases: B. Linder*, C. Hunter, M. StatenCentral Blood Laboratory University of Washington Northwest Lipid Metabolism and Diabetes ResearchLaboratories: S.M. Marcovina*References1. Ogden CL, Flegal KM, Carroll MD, Johnson CL. Prevalence and trends in overweight among USchildren and adolescents, 1999-2000. JAMA 2002;288:1728–1732. [PubMed: 12365956]2. HEALTHY Study Group. Risk factors for type 2 diabetes in a 6th grade multi-racial cohort: theHEALTHY study. Diabetes Care 2009;32:953–955. [PubMed: 19196888]3. Freedman DS, Mei Z, Srinivasan SR, Berenson GS, Dietz WH. Cardiovascular risk factors andexcess adiposity among overweight children and adolescents: the Bogalusa Heart Study. J Pediatr2007;150:12–17. [PubMed: 17188605]4. Freedman DS, Khan LK, Serdula MK, Ogden CL, Dietz WH. Racial and ethnic differences insecular trends for childhood BMI, weight, and height. Obesity 2006;14:301–308. [PubMed:16571857]5. STOPP-T2D Prevention Study Group. Presence of diabetes risk factors in a large US eighth-gradecohort. Diabetes Care 2006;29:212–217. [PubMed: 16443862]6. Centers for Disease Control National Center for Health Statistics. A SAS program for the CDCgrowth charts. available online at http://www.cdc.gov/nccdphp/dnpa/growthcharts/sas.htm7. Centers for Disease Control National Center for Health Statistics. 2000 CDC growth charts for theUnited States. available online at http://www.cdc.gov/growthcharts8. National Institutes of Health. Clinical Guidelines on the Identification, Evaluation and Treatment ofOverweight and Obesity in Adults: The Evidence Report. Washington, DC: National Institutes ofHealth; 1998.9. Weiss R, Dziura J, Burgert TS, Tamborlane WV, Taksali SE, Yeckel CW, et al. Obesity and themetabolic syndrome in children and adolescents. New Engl J Med 2004;350:2362–74. [PubMed:15175438]10. Sturm R. Increases in morbid obesity in the USA: 2000-2005. Public Health 2007;121:492–496.[PubMed: 17399752]Marcus et al. Page 4J Adolesc Health. Author manuscript; available in PMC 2011 December 1.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptMarcus et al. Page 5Table 1Number and percent of students in BMI Percentile categories by sex and race/ethnicityBoysGirlsBMI PercentileHispanic N %Black N %White N %Other N %Total N %Hispanic N %Black N %White N %Other N %Total (N)<85 [Normal Weight]685 43.05319 55325 52.59120 50.631449921 51.54336 49.78351 60.31166 56.271774≥85-<95 [Overweight]307 19.3100 17.24120 19.4249 20.68576373 20.87131 19.41120 20.6256 18.98680≥95-<99 [Obese]468 29.42120 20.69137 22.1749 20.68774379 21.21149 22.0787 14.9556 18.98671≥99 [Severely Obese]131 8.2341 7.0736 5.8319 8.02227114 6.3859 8.7424 4.1217 5.76214Total1591580618237302617876755822953339J Adolesc Health. Author manuscript; available in PMC 2011 December 1.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptMarcus et al. Page 6Table 2Percent of students with risk factors for diabetes and CVD by BMI percentile and risk factors among severely obese students by race/ethnicityFamilyHistory Type 2DiabetesWaist ≥ 90percentileGlucose > 100mg/dlInsulin ≥ 30μU/mLTotal Chol ≥170 mg/dlLDL > 110mg/dlHDL < 35mg/dlTrig > 110mg/dlHigh Blood PressureBMI Percentile%%%%%%%<8512.40.2413.50.82610.91.111.58.9≥85-<9516.518.715.5331.418.24.325.49.8≥95-<9921.384.520.213.435.521.78.840.720.3≥9928.599.522.54034.120.116.444.331.6p value< 0.001< 0.0010.0003< 0.001< 0.001< 0.001< 0.001< 0.001<0.001p value [≥95-<99 vs.≥99*]0.006< 0.0010.268< 0.0010.6410.556< 0.0010.172< 0.001BMI ≥99 [SeverelyObese]FamilyHistory Type 2DiabetesWaist ≥ 90percentileGlucose > 100mg/dlInsulin ≥ 30μU/mLTotal Chol ≥170 mg/dlLDL > 110mg/dlHDL < 35mg/dlTrig > 110mg/dlHigh Blood PressureRace/Ethnicity%%%%%%%%Hispanic32.399.622.845.728.813.319.754.128.6Black23.810022.630.435.529.037.518.328.9White20.998.323.3305033.92053.348.3p value0.180.980.990.0120.0070.00010.023<0.0010.0105J Adolesc Health. Author manuscript; available in PMC 2011 December 1.

Severe Obesity and Selected Risk Factors in a Sixth Grade Multiracial Cohort: The HEALTHY Study

http://dx.doi.org/10.1016/j.jadohealth.2010.04.017

Severe Obesity and Selected Risk Factors in a Sixth Grade Multiracial Cohort: The HEALTHY Study

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