Childhood Obesity: Factors Affecting Physical Activity		 
(06-DEC-06, GAO-07-260R).					 
                                                                 
The latest data show continued increases in rates of childhood	 
obesity. For example, obesity rates for children 6 to 11 years	 
old are estimated to have increased from 15.1 to 18.8 percent	 
between 1999 and 2004. The Department of Health and Human	 
Services estimates that 20 percent of children and youth in the  
United States will be obese by 2010. There are numerous negative 
health outcomes and financial consequences related to childhood  
obesity. Researchers have found that childhood obesity is	 
associated with a number of disorders including hypertension,	 
insulin resistance, sleep apnea, menstrual abnormalities, and	 
orthopedic problems. According to one estimate, insured children 
treated for obesity are approximately three times more expensive 
for the health system than the average insured child. Some	 
researchers have suggested that childhood obesity is largely the 
result of a decline in regular physical activity. In our October 
2005 report, we surveyed experts on the key strategies to include
in the design or implementation of a program to prevent or reduce
childhood obesity. The program strategy identified by experts as 
most important was "increasing physical activity." Congress asked
us to provide information on the factors affecting physical	 
activity in children.						 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-07-260R					        
    ACCNO:   A63927						        
  TITLE:     Childhood Obesity: Factors Affecting Physical Activity   
     DATE:   12/06/2006 
  SUBJECT:   Adolescent health					 
	     Children						 
	     Health care planning				 
	     Health statistics					 
	     Medical research					 
	     Obesity						 
	     Physical fitness					 
	     Preventive health care services			 
	     Research reports					 

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GAO-07-260R

   

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December 6, 2006

The Honorable Bill Frist
Majority Leader
United States Senate

Subject: Childhood Obesity: Factors Affecting Physical Activity

Dear Senator Frist:

The latest data show continued increases in rates of childhood obesity.^1
For example, obesity rates for children 6 to 11 years old are estimated to
have increased from 15.1 to 18.8 percent between 1999 and 2004.^2 The
Department of Health and Human Services estimates that 20 percent of
children and youth in the United States will be obese by 2010. There are
numerous negative health outcomes and financial consequences related to
childhood obesity. Researchers have found that childhood obesity is
associated with a number of disorders including hypertension, insulin
resistance, sleep apnea, menstrual abnormalities, and orthopedic problems.
According to one estimate, insured children treated for obesity are
approximately three times more expensive for the health system than the
average insured child.^3

Obesity results from an imbalance between the amount of energy consumed
and the amount of energy expended. While there are many elements that
affect the energy balance (for example, genetics, growth, and physiology),
children and their parents can influence both energy consumed through diet
and energy expended through physical activity. Some researchers have
suggested that childhood obesity is largely the result of a decline in
regular physical activity. In our October 2005 report,^4 we
surveyed experts on the key strategies to include in the design or
implementation of a program to prevent or reduce childhood obesity. The
program strategy identified by experts as most important was "increasing
physical activity."

^1Some experts use the term obesity to refer to children and adolescents
who have a body mass index (BMI) that is at or above the sex-specific 95th
percentile for their age on the BMI charts developed by the Centers for
Disease Control and Prevention (CDC) in 2000. CDC uses the term
overweight, instead of obese, to describe children and adolescents with
this BMI range.

^2C.L Ogden, M.D. Carroll, L.R. Curtin, M.A. McDowell, C.J. Tabak, and
K.M. Flegal, "Prevalence of Overweight and Obesity in the United States,
1999-2004," JAMA, vol. 295, no. 13 (2006). These data are for children at
or above the 95^th percentile of BMI for age and sex.

^3Thomson Medstat, Childhood Obesity: Costs, Treatment Patterns,
Disparities in Care, and Prevalent Medical Conditions, 2006,
http://www.medtstat.com/pdfs/childhood_obesity.pdf, (downloaded Nov. 3,
2006). Thomson Medstat used medical claims to estimate total health care
spending for children who receive a diagnosis of obesity.

^4GAO, Childhood Obesity: Most Experts Identified Physical Activity and
the Use of Best Practices as Key to Successful Programs, GAO-06-127R
(Washington, D.C.: Oct. 7, 2005).

You asked us to provide information on the factors affecting physical
activity in children. Enclosure I contains the information we provided to
your staff at our November 15, 2006, briefing.

To carry out our work, we conducted a literature review. We selected 53
articles that described work focused on factors affecting rates of
physical activity for school-aged children, published from 2003 through
2006. Enclosure II is a bibliography of the materials we reviewed. To
select the articles, we reviewed study abstracts identified in your
request letter and conducted a literature search of five databases.^5 We
focused on studies of children and adolescents and excluded studies of
infants and preschool-aged children. For purposes of this report, we use
the term obese to refer collectively to the terms obese and overweight,
which were both used by authors. We supplemented the studies with
information obtained from organizations that recently published
information on childhood obesity including the Institute of Medicine and
the Trust for America's Health. Our literature search was not exhaustive,
and for this report we did not discuss all of the articles we reviewed,
but instead highlighted selected articles to provide examples of findings.
We conducted our work from August 2006 through November 2006 in accordance
with generally accepted government auditing standards.

In summary, the articles we reviewed identified a number of factors
affecting levels of physical activity in children. We categorized the
factors presented in the articles we reviewed into three
groups--demographic factors, cognitive and behavioral factors, and
community factors. Demographic factors include socioeconomic status and
race. Cognitive and behavioral factors include attitudes, beliefs, and
perceptions and sedentary behaviors.^6 Community factors include the built
environment^7 and school-based physical activity. The articles and
additional materials we reviewed identified additional research needs,
such as using objective measures of physical activity and sedentary time.
The body of research we examined suggests that multiple factors that
affect physical activity among children may contribute to childhood
obesity.

                                   - - - - -

As we agreed with your office, unless you publicly announce the contents
of this report earlier, we plan no further distribution until 30 days
after the date of this letter.

^5We also contacted several experts in the field to help us identify
relevant literature.

^6Sedentary behaviors include, for example, television watching, video
game playing, and computer use.

^7The built environment is broadly defined to include land use patterns,
the transportation system, and design features that together provide
opportunities for travel and physical activity.

At that time, this report will be available at no charge on the GAO Web
site at http://www.gao.gov. Contact points for our Offices of
Congressional Relations and Public Affairs may be found on the last page
of this report.

If you and your staff have any questions or need additional information,
please contact me at (202) 512-7101, or [email protected] . Major
contributors to this report were Linda Kohn, Assistant Director; Shannon
Slawter; and Julie Thomas.

Sincerely yours,

Cynthia A. Bascetta
Director, Health Care

Enclosures

Enclosure I

Enclosure II

                                  Bibliography

Articles included in GAO's review

Arluk, S.L., J.D. Branch, D.P. Swain, and E.A. Dowling. "Childhood
obesity's relationship to time spent in sedentary behavior." Military
Medicine, vol. 168, no. 7 (2003): 583-586.

Bauer, K.W., Y.W. Yang, S.B. Austin. "`How can we stay healthy when you're
throwing all of this in front of us?' Findings from focus groups and
interviews in middle schools on environmental influences on nutrition and
physical activity." Health Education & Behavior, vol. 31, no. 1 (2004):
34-46.

Braza, M., W. Shoemaker, and A. Seeley. "Neighborhood design and rates of
walking and biking to elementary school in 34 California communities."
American Journal of Health Promotion, vol. 19, no. 2 (2004): 128-136.

Centers for Disease Control and Prevention. "Participation in high school
physical education--United States, 1991-2003." Morbidity and Mortality
Weekly Report, vol. 53, no. 36 (2004): 844-847.

Cottrell, L., E. Spangler-Murphy, V. Minor, A. Downes, P. Nicholson, and
W.A. Neal. "A kindergarten cardiovascular risk surveillance study:
CARDIAC-Kinder." American Journal of Health Behavior, vol. 29, no. 6
(2005): 595-606.

Datar, A. and R. Sturm. "Physical education in elementary school and body
mass index: evidence from the Early Childhood Longitudinal Study."
American Journal of Public Health, vol 94, no. 9 (2004): 1501-1506.

Davison, K.K., L.A. Francis, and L.L. Birch. "Reexamining obesigenic
families: parents' obesity-related behaviors predict girls' change in
BMI." Obesity Research, vol. 13, no. 11 (2005): 1980-1990.

De Bourdeaudhuij, I., J. Lefevre, B. Deforche, K. Wijndaele, L. Matton,
and R. Philippaerts. "Physical activity and psychosocial correlates in
normal weight and overweight 11 to 19 year olds." Obesity Research, vol.
13, no. 6 (2005): 1097-1105.

Deforche, B.I., I.M. De Bourdeaudhuij, and A.P. Tanghe. "Attitude toward
physical activity in normal-weight, overweight and obese adolescents."
Journal of Adolescent Health, vol. 38, no. 5 (2006): 560-568.

Dowda, M., R.R. Pate, G.M. Felton, R. Saunders, D.S. Ward, R.K. Dishman,
and S.G. Trost. "Physical activities and sedentary pursuits in African
American and Caucasian girls." Research Quarterly for Exercise and Sport,
vol. 75, no. 4 (2004): 352-360.

Elgar, F.J., C. Roberts, L. Moore, and C. Tudor-Smith. "Sedentary
behaviour, physical activity and weight problems in adolescents in Wales."
Public Health, vol. 119, no. 6 (2005): 518-524.

Epstein, L.H., J.N. Roemmich, R.A. Paluch, and H.A. Raynor. "Physical
activity as a substitute for sedentary behavior in youth." Annals of
Behavioral Medicine, vol. 29, no. 3 (2005): 200-209.

Fleming-Moran, M. and K. Thiagarajah. "Behavioral interventions and the
role of television in the growing epidemic of adolescent obesity - Data
from the 2001 Youth Risk Behavior Survey." Methods of Information in
Medicine, vol. 44, no. 2 (2005): 303-309.

Going, S., J. Thompson, S. Cano, D. Stewart, E. Stone, L. Harnack, C.
Hastings, J. Norman, and C. Corbin. "The effects of the Pathways Obesity
Prevention Program on physical activity in American Indian children."
Preventive Medicine, vol. 37, no. 6 (2003): S62-S69.

Gomez, J.E., B.A. Johnson, M. Selva, and J.F. Sallis. "Violent crime and
outdoor physical activity among inner-city youth." Preventive Medicine,
vol. 39, no. 5 (2004): 876-881.

Gordon-Larsen, P., P. Griffiths, M.E. Bentley, D.S. Ward, K. Kelsey, K.
Shields, and A. Ammerman. "Barriers to physical activity - Qualitative
data on caregiver-daughter perceptions and practices." American Journal of
Preventive Medicine, vol. 27, no. 3 (2004): 218-223.

Gordon-Larsen, P., M.C. Nelson, P. Page, and B.M. Popkin. "Inequality in
the built environment underlies key health disparities in physical
activity and obesity." Pediatrics, vol. 117, no. 2 (2006): 417-424.

Graf, C., B. Koch, S. Dordel, S. Schindler-Marlow, A. Icks, A. Schueller,
B. Bjarnason-Wehrens, W. Tokarski, and H.G. Predel. "Physical activity,
leisure habits and obesity in first-grade children." European Journal of
Cardiovascular Prevention and Rehabilitation, vol. 11, no. 4 (2004):
284-290.

Hesketh, K., E. Waters, J. Green, L. Salmon, and J. Williams. "Healthy
eating, activity and obesity prevention: a qualitative study of parent and
child perceptions in Australia." Health Promotion International, vol. 20,
no. 1 (2005): 19-26.

Jago, R., T. Baranowski, I. Zakeri, and M. Harris. "Observed environmental
features and the physical activity of adolescent males." American Journal
of Preventive Medicine, vol. 29, no. 2 (2005): 98-104.

Janssen, I., W.F. Boyce, K. Simpson, and W. Pickett. "Influence of
individual- and area-level measures of socioeconomic status on obesity,
unhealthy eating, and physical inactivity in Canadian adolescents."
American Journal of Clinical Nutrition, vol. 83, no. 1 (2006): 139-145.

Janssen, I., P.T. Katzmarzyk, W.F. Boyce, M.A. King, and W. Pickett.
"Overweight and obesity in Canadian adolescents and their associations
with dietary habits and physical activity patterns." Journal of Adolescent
Health, vol. 35, no. 5 (2004): 360-367.

Jefferson, A. "Breaking down barriers - examining health promoting
behaviour in the family. Kellogg's Family Health Study 2005." Nutrition
Bulletin, vol. 31, no. 1 (2006): 60-64.

Kautiainen, S., L. Koivusilta, T. Lintonen, S.M. Virtanen, and A.
Rimpelae. "Use of information and communication technology and prevalence
of overweight and obesity among adolescents." International Journal of
Obesity, vol. 29, no. 8 (2005): 925-933.

Kelly, L.A., J.J. Reilly, A. Fisher, C. Montgomery, A. Williamson, J.H.
McColl, J.Y. Paton, and S. Grant. "Effect of socioeconomic status on
objectively measured physical activity." Archives of Disease in Childhood,
vol. 91, no. 1 (2006): 35-38.

Kimm, S.Y.S., N.W. Glynn, R.P. McMahon, C.C. Voorhees, R.H.
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participation among sedentary adolescent girls." Medicine & Science in
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Mabry, I.R., D.R. Young, L.A. Cooper, T. Meyers, A. Joffe, and A.K.
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Miech, R.A., S.K. Kumanyika, N. Stettler, B.G. Link, J.C. Phelan, and V.W.
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Nichols-English, G.J., C.R. Lemmon, M.S. Litaker, S.G. Cartee, Z. Yin, B.
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