brief reports nature publishing group

Epidemiology

Prevalence of Obesity Among Children

With Chronic Conditions
Alex Y. Chen1, Sue E. Kim2, Amy J. Houtrow3 and Paul W. Newacheck4

New evidence suggests that children with chronic conditions may be predisposed to overweight and obesity. This
study provides prevalence estimate of obesity for children and adolescents with select chronic conditions. We
analyzed reported height and weight and the corresponding BMI from 46,707 subjects aged 10–17 years collected
by the National Survey of Children’s Health (NSCH-2003). Our main outcome measure was the prevalence of obesity
(defined as ≥95th percentile of the sex-specific BMI for age growth charts), adjusted for underlying demographic
and socioeconomic factors. We found that the prevalence of obesity among children 10–17 years of age without a
chronic condition was 12.2% (95% confidence interval (CI) 11.5–13.0); the prevalence of obesity for children with
asthma was 19.7% (19.5–19.9); with a hearing/vision condition was 18.4% (18.2–18.5); with learning disability was
19.3% (19.2–19.4); with autism was 23.4% (23.2–23.6); and with attention-deficit/hyperactivity disorder was 18.9%
(18.7–19.0). Our findings suggest that children 10–17 years of age with select chronic conditions were at increased
risk for obesity compared to their counterparts without a chronic condition.

Obesity (2009) 18, 210–213. doi:10.1038/oby.2009.185

The prevalence of childhood obesity in the United States has
increased at an alarming rate. It has been declared an “epi-
demic” and a “public health crisis” (1,2). In the past two dec-
ades, the prevalence of obesity doubled in adults ≥20 years and
the prevalence of overweight tripled among children and ado-
lescents 6–19 years of age (3–5). Increase in childhood obesity
has been seen in all racial/ethnic and gender groups, as well as
across socioeconomic strata (3–5).
Traditionally, the term “overweight” has been applied to chil-
dren whose BMI is ≥95th percentile, based on the sex-specific
BMI for age growth charts (3,4,6,7). However, recent expert
committee recommendations (Institute of Medicine and
American Academy of Pediatrics) suggested use of the term
“obesity” for children with BMI ≥95th percentile to reflect the
correlation of high BMI with excess body fat among children
and to emphasize the clinical risk of such weight status (8,9).
Obesity can affect all children, even children with exist-
ing chronic conditions and disabilities. There is growing evi-
dence of a link between obesity and various chronic conditions
(10–13). Bandini et al. reported that children with develop-
mental conditions are found to have high prevalence of obes-
ity, which emphasizes the importance of health promotion and
obesity prevention in this population (13). Furthermore, we
speculate that children with chronic conditions and disabilities
may be at risk for under-management of their obesity because
of increased attention devoted to their existing ­illnesses (12,14).
Obesity has also been shown to contribute to poorer condition-
specific outcomes (10,15). Therefore, special consideration
should be given to children with chronic conditions or devel-
opmental disabilities when examining risks and interventions
for childhood obesity. To date, only one national study meas-
ured obesity prevalence among children with developmental
disorders (13). Our study expands on existing work by provid-
ing a national estimate of obesity prevalence among children
with various chronic conditions using data from the National
Survey of Children’s Health.
Methods
Data source
We used the 2003 National Survey of Children’s Health (NSCH),
a cross-sectional national survey for our analysis. The NSCH is a
random-digit-dial population-based household landline telephone
survey sponsored by the Maternal and Child Health Bureau and con-
ducted by the National Center for Health Statistics at the Centers for
Disease Control and Prevention (16). Between January 2003 and July
2004, 102,353 detailed child-level phone interviews were conducted
in 102,353 households. One child 0–17 years of age was randomly
selected for detailed interview in each eligible household that con-
tained age-eligible children. The survey respondent was the parent or
guardian most knowledgeable about the child’s health and health care;
however, the parent/guardian responses were not verified by adminis-
trative or medical records. The overall response rate was 55.3%, which

1
Children’s Hospital Los Angeles, Department of Pediatrics, University of Southern California, Los Angeles, California, USA; 2MDRC, Oakland, California, USA;
3
Department of Pediatrics, University of California at San Francisco, San Francisco, California, USA; 4Institute for Health Policy Studies, University of California at
San Francisco, San Francisco, California, USA. Correspondence: Alex Y. Chen (achen@chla.usc.edu)
Received 17 December 2008; accepted 4 May 2009; published online 11 June 2009. doi:10.1038/oby.2009.185

210 VOLUME 18 NUMBER 1 | january 2010 | www.obesityjournal.org

 brief reports

1930739x, 2010, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1038/oby.2009.185 by Cochrane Mexico, Wiley Online Library on [14/03/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Epidemiology

is the product of the screener completion rate (the randomly generated Results
telephone number was ­successfully screened as eligible—e.g., reached Our study included 46,707 children 10–17 years of age. Table 1
household with children), the interview completion rate, and the reso-
summarizes the prevalence of each specific condition exam-
lution rate (the phone number belongs to the household). Although
the NSCH collected data on children from birth to 17 years of age, we ined. For select chronic physical conditions, the prevalence of
reported BMI and obesity rates in children 10–17 years of age because asthma was 14.9%, the prevalence of multiple ear infections
parent-reported height and weight are more reliable for this age group was 2.6%, and the prevalence of diabetes was 0.5%. For select
than for younger children (17). Therefore our study sample consisted developmental conditions, the prevalence of learning disability
of 46,707 10–17-year-old children with reported height and weight
was 13.0%, the prevalence of significant developmental delay
data from the NSCH.
or impairment was 3.5%, and the prevalence of autism was
Chronic conditions 0.5%. For behavioral conditions, the prevalence of attention-
We examined select chronic conditions commonly experienced by deficit/hyperactivity disorder was 10.2%. Approximately 24.9%
­children, including physical, developmental, emotional, and behavioral
(n = 11,561) of the children studied had one chronic condition,
conditions. Survey respondents were asked about the presence of chronic
conditions for the subject child as follows: “has a doctor or health pro- 12.7% (n = 5,982) had two chronic conditions, and 13.6% (n =
fessional ever told you…” and “during the past 12 months, have you 6,451) had more than two chronic conditions.
been told by a doctor or other health care professionals….” The NSCH Prevalence of obesity among children with chronic condi-
­collected parent-report data on a wide array of conditions based on a list tions is presented in Table 2. Overall, the prevalence of obesity
used in the National Health Interview Survey. However, some of these
was 14.8%. The adjusted prevalence of obesity among children
conditions may not be truly “chronic.” Among conditions collected by
the NSCH, we selected chronic conditions using the Chronic Condition 10–17 years of age without a chronic condition was 12.2% (95%
Indicator developed by the Agency for Healthcare Research and Quality. confidence interval (CI) 11.5–13.0). The adjusted prevalence of
The Chronic Condition Indicator categorizes ICD-9-CM diagnosis into obesity for children with common chronic conditions was: for
one of two categories: chronic vs. not chronic. The Chronic Condition children with asthma—19.7% (95% CI 19.5–19.9); for children
Indicator algorithm was developed based on the work by Hwang et al. in
with learning disability—19.3% (95% CI 19.2–19.4); and for
2001, which used a physician panel to categorize acute and chronic con-
ditions (18). Of note, a child may be identified by the survey respondent
as having more than one chronic condition. Table 1 Prevalence (per 100 population) of select chronic
conditions among children 10–17 years of age
Variable definition Prevalence
Consistent with expert committee recommendations, we defined Conditions Unweighted N (s.e.) Descriptiona
­obesity for children as ≥95th percentile BMI for age and sex (8,9).
BMI is calculated by taking a child’s weight in kilograms divided by All children 46,707 —
(10–17 years old)
the square of his/her height in meters (kg/m2). BMI is widely consid-
ered as the best clinical overweight criterion for children because BMI Physical
measures in childhood track well into adulthood for developing ­obesity
Asthma 6,909 14.9 (0.29) Ever
(7,19). Percentile comparison are based on the sex-specific BMI for age
growth charts from the Centers for Disease Control and Prevention Severe 3,768 8.4 (0.23) Past
(5,20). For multivariate models, we included sociodemographic pre- headache/ 12 months
dictors that were identified in previous publications as associated with migraine
childhood obesity (3,4): we categorized age as 10–13 years of age and Ear/vision 1,410 3.2 (0.15) Ever
14–17 years of age; gender dichotomously as male and female; race/ problemsb
ethnicity as non-Hispanic white, non-Hispanic black, Hispanic, multi-
Multiple ear 1,115 2.6 (0.13) Past
ethnic, and other; income as <100% Federal Poverty Level, 100–199%
infection 12 months
Federal Poverty Level, 200–399% Federal Poverty Level, and ≥400%
Federal Poverty Level; family structure as two-parent household and Diabetes 261 0.5 (0.06) Ever
other; parental education as less than high school and high school or Developmental
higher; and region as Northeast, Midwest, South, and West.
Learning 5,945 13.0 (0.28) Ever
Analysis disabilityb
Using bivariate analyses, we first determined the prevalence of ­childhood DD/physical 1,718 3.5 (0.15) Ever
obesity by each condition as was observed in the study population with- impairment
out adjustment. Then, we estimated the prevalence of children who
Speech 872 2.1 (0.12) Past
were ≥95th percentile for BMI for each identified chronic condition problemsb 12 months
using multivariate regression models to adjust for age, gender, race/
ethnicity, income, family structure, parental education, and region. We Autism 247 0.5 (0.05) Ever
used the coefficient estimates from the multivariate regression models Behavioral/emotional
to obtain the predicted probability of being obese for each condition or
category of conditions, adjusted for all the sociodemographic variables ADHD 4,848 10.2 (0.24) Ever
previously mentioned. Taylor-Series linearization was used for vari- ADHD, attention-deficit/hyperactivity disorder; DD, developmental disability.
ance estimation. All analyses were performed with the sample weight a
Past 12 months—derived from survey item “during the past 12 months, have
provided by the NSCH to adjust for nonresponse, noncoverage, and you been told by a doctor or other health care professional that [he/she] had…;”
Ever—derived from survey item “has a doctor or health professional ever told
nontelephone households. All analyses were performed using STATA you that [he/she] has…” bEar/vision problems include only those that “cannot be
(version 9.0, Stata, College Station, TX) software. This study received corrected by by glasses or contacts”; learning disability include problems per-
exemption for public use data with no identifiable information from ceived by teachers and educators in addition to health professionals; and speech
Children’s Hospital Los Angeles institutional review board. problems include stuttering, stammering, etc.

obesity | VOLUME 18 NUMBER 1 | january 2010 211

brief reports

1930739x, 2010, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1038/oby.2009.185 by Cochrane Mexico, Wiley Online Library on [14/03/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Epidemiology

Table 2 Unadjusted and adjusted prevalence (per 100 In addition to the known effects of environmental and
population) of obesity among children 10–17 years of age s­ ocioeconomic settings influencing people’s dietary patterns and
Adjusted physical activity level, certain chronic conditions and disease
Unadjusted prevalence processes can also lead to increased caloric intake and decreased
prevalence of of obesitya activity among children. Previous studies have suggested that
Explanatory variables obesity (95% CI) (95% CI)
children suffering from attention-deficit/hyperactivity disorder,
Conditions depression/anxiety, and behavior/conduct disorders have more
All children (10–17 years old) 14.8 (14.3–15.4) 14.8 (14.7–15.0) difficulty with self-regulation and thus may be more likely to
Physical overeat than other children (21). Children with developmental
Asthma 20.4 (18.8–22.2) 19.7 (19.5–19.9) disorders may experience a higher prevalence of obesity as a
result of unusual dietary patterns and fewer opportunities to
Severe headache/migraine 17.6 (15.7–19.7) 17.6 (17.5–17.6)
engage in physical activity. In addition, because of the energy
Ear/vision problems b
19.6 (16.0–23.7) 18.4 (18.2–18.5)
and effort required in managing a childhood chronic illness,
Multiple ear infection 28.8 (24.6–33.3) 27.1 (27.0–27.3) these children and parents may have to overcome larger barri-
Diabetes 26.5 (19.2–35.4) 26.4 (26.1–26.7) ers and more complications in order to maintain a life style of
Developmental healthy dieting and physical fitness.
Learning disabilityb 20.4 (18.5–22.3) 19.3 (19.2–19.4)
Children with certain chronic conditions may need to be
managed with long-term medications. Long-term use of ­several
DD/physical impairment 22.4 (18.8–26.3) 22.4 (22.2–22.5)
medications has been found to cause weight gain in some
Speech problemsb 20.0 (16.0–24.8) 17.7 (17.6–17.8) people e.g., corticosteroid for autoimmune disorders, organ
Autism 21.1 (14.9–29.0) 23.4 (23.2–23.6) transplantation, etc.; antiseizure medication such as valproate;
Behavioral/emotional antidepressants and other psychotropic medications (including
ADHD 19.0 (17.1–21.2) 18.9 (18.7–19.0)
lithium); insulin in type 2 diabetes; and some β-blockers. These
may the reasons why children with certain conditions are asso-
A child may be identified by the survey respondent as having more than one
chronic condition. ciated with higher rates of obesity.
ADHD, attention-deficit/hyperactivity disorder; DD, developmental disability. Interestingly, although somewhat puzzling as well, we found
a
Adjusted for age, gender, race/ethnicity, income, parental education, family
structure, and region. bEar/vision problems include only those that “cannot be
that chronic ear infection is associated with higher prevalence
corrected by by glasses or contacts”; learning disability include problems per- of obesity in children 10–17 years of age. The mechanism for
ceived by teachers and educators in addition to health professionals; and speech this connection is still being elucidated; however, there is newly
problems include stuttering, stammering, etc.
presented evidence to support a biological/physiological link
between chronic ear infection and increased risk of obesity in
children with attention-deficit/hyperactivity disorder—18.9% children (22).
(95% CI 18.7–19.0). Among physical conditions examined in Our study has several limitations. First, because of the
this study, the prevalence of obesity was highest for children cross-sectional nature of the NSCH data, we are limited in
with diabetes and multiple ear infections (Table 2). Among our ­ability to make inferences about the causal relationship
developmental conditions examined, children with autism had between chronic conditions and childhood obesity. Second, we
the highest adjusted prevalence of obesity. Differences in the only examined older children and adolescents, therefore our
prevalence of obesity between children without chronic con- results cannot be generalized to younger children with chronic
dition and children with select chronic conditions remained ­illnesses. Furthermore, because of the self-report nature of
after adjustment for age, sex, race/ethnicity, family income, the NSCH data and our study sample being restricted to older
family structure, parental education, and region. ­children and adolescents, we reported higher rates of chronic
conditions and our estimation probably approximates the life-
Discussion time prevalence of select conditions. Third, a proportion of
In this study, we examined the prevalence of obesity among children suffer from more than one chronic condition, some
children with select chronic conditions. Our results showed of these conditions may be correlated, thus the prevalence
that children with select chronic conditions have higher rates of obesity attributable of each select condition should not be
of obesity than children without any underlying condition. viewed as due to the independent effect of a specific condi-
Our findings also suggest that the higher prevalence of obesity tion (they may be the result of multiple comorbid conditions).
among children with chronic conditions is not attributable to Fourth, our study did not comprehensively examine the preva-
the sociodemographic factors associated with having a chronic lence of obesity for all pediatric chronic conditions. Lastly,
condition. Rather, other factors may be in play. Previous stud- Centers for Disease Control and Prevention growth charts/
ies showed that adults with disabling conditions (10–12) and BMI percentiles were based on data when BMI for age were
children with certain developmental disorders (13,21) may be stable among children, and thus they may not accurately depict
at increased risk for obesity. Our study provides a more com- current distributions of BMI for age (20). Additionally, BMI is
prehensive estimation of obesity prevalence among children a relative measure that provides no direct information about
with a wide array of chronic conditions. body composition or fat distribution (which are also important

212 VOLUME 18 NUMBER 1 | january 2010 | www.obesityjournal.org


predictors of obesity-related disease) (20). Furthermore, height
and weight values from the NSCH were reported rather than
measured—although a study by Goodman et al. suggested that
teen-reported height and weight (as well as parent-reported
height and weight), although not entirely accurate, can be
used to “categorically” assess weight status in adolescents (96%
accuracy) (23).
Currently, very little is known about the health ­maintenance
and health promotion needs of chronically ill children.
Although their chronic conditions may or may not be life-
threatening, development of comorbidities such as overweight
and obesity may significantly impede their long-term health
and quality of life. Additional work is needed to study the
comorbidities associated with pediatric chronic conditions and
some of the challenges these children may face in maintaining
a healthy and active life style. We hope that our findings can
stimulate future research work and interventions to address
these problems among children with chronic ­conditions and
disabilities.
Acknowledgment
Dr Chen is supported by a career development grant (K23-HD047270) from
the National Institutes of Health.
Disclosure
The authors declared no conflict of interest.
© 2009 The Obesity Society
References
1. Lobstein T, Baur L, Uauy R. Obesity in children and young people: a crisis in
public health. Obes Rev 2004;5 Suppl 1:4–104.
2. Kimm SY, Obarzanek E. Childhood obesity: a new pandemic of the new
millennium. Pediatrics 2002;110: 1003–1007.
3. Ogden CL, Flegal KM, Carroll MD, Johnson CL. Prevalence and trends
in overweight among US children and adolescents, 1999–2000. JAMA
2002;288:1728–1732.
4. Hedley AA, Ogden CL, Johnson CL et al. Prevalence of overweight and
obesity among US children, adolescents, and adults, 1999–2002. JAMA
2004;291:2847–2850.
5. Ogden CL, Carroll MD, Curtin LR et al. Prevalence of overweight and obesity
in the United States, 1999–2004. JAMA 2006;295:1549–1555.
obesity | VOLUME 18 NUMBER 1 | january 2010 213
brief reports
1930739x, 2010, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1038/oby.2009.185 by Cochrane Mexico, Wiley Online Library on [14/03/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Epidemiology
6. Barlow SE, Dietz WH. Obesity evaluation and treatment: Expert Committee
recommendations. The Maternal and Child Health Bureau, Health Resources
and Services Administration and the Department of Health and Human
Services. Pediatrics 1998;102:E29.
7. Whitlock EP, Williams SB, Gold R, Smith PR, Shipman SA. Screening and
interventions for childhood overweight: a summary of evidence for the US
Preventive Services Task Force. Pediatrics 2005;116:e125–e144.
8. Barlow SE. Expert committee recommendations regarding the prevention,
assessment, and treatment of child and adolescent overweight and obesity:
summary report. Pediatrics 2007;120 Suppl 4:S164–S192.
9. Krebs NF, Himes JH, Jacobson D et al. Assessment of child and adolescent
overweight and obesity. Pediatrics 2007;120 Suppl 4:S193–S228.
10. Ells LJ, Lang R, Shield JP et al. Obesity and disability—a short review. Obes
Rev 2006;7:341–345.
11. Lidstone JS, Ells LJ, Finn P et al. Independent associations between weight
status and disability in adults: results from the Health Survey for England.
Public Health 2006;120:412–417.
12. Weil E, Wachterman M, McCarthy EP et al. Obesity among adults with
disabling conditions. JAMA 2002;288:1265–1268.
13. Bandini LG, Curtin C, Hamad C, Tybor DJ, Must A. Prevalence of overweight
in children with developmental disorders in the continuous national
health and nutrition examination survey (NHANES) 1999–2002. J Pediatr
2005;146:738–743.
14. Wilber N, Mitra M, Walker DK et al. Disability as a public health issue:
findings and reflections from the Massachusetts survey of secondary
conditions. Milbank Q 2002;80:393–421.
15. Bamgbade OA, Rutter TW, Nafiu OO, Dorje P. Postoperative complications
in obese and nonobese patients. World J Surg 2007;31:556–60;
discussion 561.
16. van Dyck P, Kogan MD, Heppel D et al. The National Survey of Children’s
Health: a new data resource. Matern Child Health J 2004;8:183–188.
17. MCHB. Overweight and Physical Activity Among Children: A Portrait of
States and the Nation 2005. <http://www.mchb.hrsa.gov/overweight/intro.
htm>. Accessed 10 May 2007.
18. Hwang W, Weller W, Ireys H, Anderson G. Out-of-pocket medical spending
for care of chronic conditions. Health Aff (Millwood) 2001;20:267–278.
19. Dietz WH, Robinson TN. Use of the body mass index (BMI) as a measure of
overweight in children and adolescents. J Pediatr 1998;132:191–193.
20. Ebbeling CB, Ludwig DS. Tracking pediatric obesity: an index of uncertainty?
JAMA 2008;299:2442–2443.
21. Curtin C, Bandini LG, Perrin EC, Tybor DJ, Must A. Prevalence of overweight
in children and adolescents with attention deficit hyperactivity disorder and
autism spectrum disorders: a chart review. BMC Pediatr 2005;5:48.
22. Bartoshuk LM. Ear infections: a source of taste damage. In: American
Psychological Association Annual Convention, 14 Aug 2008, Boston, MA.
Session 1251 Symposium: Ear Infections, Taste Perception, and Obesity.
23. Goodman E, Hinden BR, Khandelwal S. Accuracy of teen and parental
reports of obesity and body mass index. Pediatrics 2000;106:52–58.