PAPER Prevalence of overweight in a triethnic pediatric population of San Antonio, Texas

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1 (2001) 25, 409±416 ß 2001 Nature Publishing Group All rights reserved 0307±0565/01 $ PAPER Prevalence of overweight in a triethnic pediatric population of San Antonio, Texas MK Park 1 *, SW Menard 2 and J School eld 3 1 Department of Pediatrics, School of Medicine, University of Texas Health Science Center, San Antonio, Texas, USA; 2 School of Nursing, University of Texas Health Science Center, San Antonio, Texas, USA; and 3 Department of Computing Resources, University of Texas Health Science Center, San Antonio, Texas, USA OBJECTIVES: To investigate the prevalence of overweight among different ethnic and gender groups of children and adolescents in the San Antonio, Texas, area and to compare the prevalence with that of the US national gures. DESIGN: Cross-sectional study SUBJECTS: A total of 7208 schoolchildren in kindergarten through 12th grade. There were 4215 Mexican American (MA) (58.5%), 2040 non-hispanic white (NHW) (28.3%) and 953 African American (AA) (13.2%) subjects. MEASUREMENTS: Weight, height and skinfold thicknesses. RESULTS: The body mass index (BMI, kg=m 2 ) values of MA boys were almost consistently and signi cantly (P < 0.05) larger than NHW boys and showed a tendency to be larger than AA boys, beginning as early as age 6 and continuing through age 17. Although rarely signi cant, a similar trend in ethnic difference was also noted for girls, with the smallest BMI seen in NHW girls. The subscapular skinfold thickness (SST) for MA boys and girls was signi cantly (P < 0.05) larger than that for NHW counterparts and showed a tendency to be larger than AA counterparts. No signi cant ethnic differences were present in the triceps skinfold thickness (TST) for girls, but MA boys' TST were occasionally larger (P < 0.05) than other ethnic-gender groups. Girls' TST were frequently larger (P < 0.05) than boys for each ethnic groups. Using the population data from the National Health and Nutrition Examination Survey (NHANES) I as reference, the prevalence of overweight (BMI 95th percentile) was greater in MA (15 ± 28%) and AA (11 ± 29%) boys and girls than in NHW (7 ± 17%) counterparts. The combined prevalence of overweight and `at risk of overweight' (BMI > 85th percentile) was much larger in MA boys (40 ± 50%), MA girls (34 ± 52%), and AA girls (33 ± 51%) than other subgroups. The onset of overweight is quite early, starting at 5 ± 6 y of age, especially in girls. Compared to the data from national surveys, the prevalence of overweight found in this study is higher than reported nationally. We found a marked increase in the skinfold thickness, especially SST for boys, but the increase is less for girls. CONCLUSIONS: The prevalence of overweight is higher in MA boys and girls and AA girls than other ethnic-gender groups in the San Antonio, Texas, area. The prevalence of childhood overweight in the San Antonio area is higher than national gures. The ndings of increasing prevalence and early onset of childhood overweight are concerning, because these are known risk factors for diabetes and diseases of many other organ systems. Measures to prevent, reduce or treat childhood obesity are urgently needed. (2001) 25, 409 ± 416 Keywords: body mass index; ethnicity=race; Mexican Americans; African Americans; obesity=overweight; skinfold thickness *Correspondence: MK Park, Department of Pediatrics, University of Texas Health Science Center, 7703 Floyd Curl Drive, San Antonio, TX , USA. parkm@uthscsa.edu or parkm@uthscsa.dcci.com Received 27 August 1999; revised 4 September 2000; accepted 4 October 2000 Introduction The increasing prevalence of obesity in the last two decades in adults 1,2 as well as children and adolescents 3±6 is a national concern. Although ethnic differences exist, the increase in the prevalence of overweight is seen across ethnic and gender groups. 2,4 ± 7 Obesity is more prevalent in Mexican American (MA) and African American (AA) adults 1,8 ± 10 and children 5,8,11,12 than non-hispanic white (NHW) counterpart. Ethnic differences are also found with fat patterning. Central (truncal) fat distribution is strongly

2 410 associated with hyperinsulinemia and type 2 diabetes as well as other cardiovascular (CV) risk factors in adults 2,13,14 and children. 15 ± 17 This pattern of fat distribution is more prevalent in AA and MA adults and children relative to NHW. 18,19 Because blood pressure levels are known to be correlated with body size, 20,21 anthropometric measurements were part of the San Antonio Children's Blood Pressure Study, which was conducted in children kindergarten through 12th grade from the San Antonio, Texas, area, during the periods of 1991 ± 1995 and 1996 ± Although the national trends of ethnic differences in the prevalence of obesity are known, the same information is lacking for this region in which Mexican Americans are the majority. The purposes of this portion of the report were (1) to examine the prevalence of overweight for each ethnic and gender group in a triethnic pediatric population, (2) to examine whether ethnic differences seen in adults are present in children, and (3) to compare the prevalence of obesity in this region with that of national surveys. Methods (A) Subject population and recruitment This study was carried out in school children enrolled in kindergarten through 12th grade, in three selected school districts in the San Antonio, Texas, area. The initial phase of the San Antonio Children's Blood Pressure Study began in the fall of 1991 as a 4-y study (until 1995) to collect data from a biethnic population of MA and NHW children and adolescents. This phase of the study involved the South San Antonio Independent School District (ISD) and the Schertz- Cibolo-Universal City ISD. For a triethnic comparison, the study was extended in 1996 (to 1998) to include the San Antonio ISD to collect data primarily from African American (AA) children. The Schertz-Cibolo-Universal City ISD is a suburb of San Antonio with the majority of its students being non-hispanic white (66.0%). The student body of the South San Antonio ISD is mostly Mexican American (94.0%). All schools in these two ISD were studied. There were four elementary schools, two middle schools, and one high school in the Schertz-Cibolo-Universal City ISD and 10 elementary schools, three middle schools, and two high schools in the South San Antonio ISD. Only three elementary schools, two middle schools and one high school were selected from the San Antonio ISD to recruit primarily African American children. Although the socioeconomic status was not clearly evaluated, participation in the school lunch program is an indicator of the socioeconomic status. Free school lunch program participation in each school district was as follows: (1) South San Antonio ISD Ð 95%; (2) Schertz-Cibolo-Universal City ISD Ð 25.9%; and (3) San Antonio ISD Ð 100%. The School Boards of the three ISDs agreed to allow data collection in their schools. Parental consent was obtained and the child was also asked for his=her assent before data were collected. The letter and the consent forms were in English and Spanish. The Institutional Review Board of the University of Texas Health Science Center at San Antonio approved the research protocol. Ethnic classi cation for African American (AA) children was made by the staff observer. The classi cation of Mexican American (MA), non-hispanic white (NHW), non-mexican Hispanics, and others was based on a previously published algorithm because MAs have different genetic makeup from other Hispanics. 22 Scoring of the algorithm was done by computer so that the actual classi cation of children as MA, NHW or other was independent of observers' judgment. Weight and height were measured to calculate BMI. Weight was measured with a scale calibrated daily with standard weights. Weight without shoes or heavy garments was measured to the nearest 0.25 pound and converted to kg later. Height without shoes was measured with the child standing straight against a 3 m rule taped to the wall and squared at the base with the oor. With the child looking straight ahead at an indicated point on the opposite wall, and heels, buttocks and occiput touching the wall, the edge of a plastic right triangle was positioned perpendicular to the meter rule to be touching the top of the head, with hair pushed down. The height was measured to the nearest 0.1 cm. Triceps skinfold thickness was measured over the back of the right upper arm at the midpoint with the arm pendant. A full thickness pinch of skin was grasped horizontally 1 cm above the midpoint, and the skinfold thickness was read immediately after applying Lange calipers (square tipped). The calipers were released and the measurement recorded to the nearest 1 mm. Subscapular skinfold thickness was measured by pinching a full thickness of skin below the caudal end of the right scapula in the back, using the Lange calipers in the same manner as above. The Lange calipers were checked monthly for tension and measurement accuracy. Data so collected were entered into a database. Statistical analyses were performed using the SAS Software (SAS Institute Inc., Cary, NC) by the Computing Resources Department of the University of Texas Health Science Center at San Antonio, Texas. Children whose ethnic group was other then AA, MA and NHW were excluded from the statistical analyses, although they were included in data collection as required by the school districts. The remaining children were divided into six subgroups by ethnicity and gender. The mean and standard deviation (s.d.) of BMI and skinfold thicknesses were computed for each ethnic-gender group. Statistical tests for signi cant ethnic and gender differences in these variables were performed by Analysis of Variance followed by the Bonferroni test for each age group (age at last birthday in years). Statistical signi cance was accepted at the 5% level in this study. The prevalence of overweight in this population was computed using the reference data of BMI from the NHANES I. 23,24 BMI and skinfold thickness data from this study were compared with the results of national surveys.

3 Results Data from 1006 subjects were excluded from analyses because of ethnicity or race other than AA, MA and NHW (n ˆ 612), ages older than 17 y (n ˆ 299), and incomplete data (n ˆ 95). Data from a total of 7208 children ranging in age from 5 to 17 y are included in the statistical analysis (Table 1). The number of MA children was much larger (58.5%) than that of NHW (28.3%) and AA (13.2%) children. The over-sampling of MA children could not be avoided because the school district policy required that every child who wanted to participate be screened. Despite our best efforts, a disproportionately small number of AA children participated in the study. The participation rate was 74% for the Table 1 Number of study subjects according to age groups, ethnicity and gender Age Girls Boys group (y) AA MA NHW AA MA NHW Total 5 ± ± ± ± ± ± Total (%) (7.9%) (30.8%) (14.8%) (5.3%) (27.7%) (13.5%) (100%) AA ˆ African American; MA ˆ Mexican American; NHW ˆ non-hispanic white. Schertz-Cibolo-Universal City ISD, 66% for the South San Antonio ISD, and 49% for the selected schools in the San Antonio ISD. Body mass index The BMI values of MA girls were almost always signi cantly (P < 0.05) larger than those of NHW girls (Table 2). The BMI values of MA and AA girls were not signi cantly different. MA boys had consistently and signi cantly (P < 0.05) larger BMI values than did NHW boys throughout the ages studied (Table 2). MA boys showed a strong tendency to have larger BMI values than AA boys, with statistical signi cance attained frequently. No signi cant gender difference was found for BMI (Table 2). Overall, the BMI values of NHW girls were the smallest and those of MA boys the largest. Skinfold thicknesses The subscapular skinfold thickness (SST) values of MA girls and boys were almost consistently and signi cantly (P < 0.05) larger than those of NHW counterparts and showed a tendency to be larger than those of AA boys and girls (Table 3). One exception to this was the SST value of AA girls ages 15 ± 17 y which was signi cantly larger (P < 0.05) than that of MA and NHW girls. With regards to the triceps skinfold thickness (TST), no signi cant ethnic differences were present for girls, although MA girls tended to have 411 Table 2 BMI (kg=m 2 ) (mean s.d.) according to ages, ethnicity and gender, with results of statistical tests Girls Boys Signi cance* Age (y) AA MA NHW AA MA NHW Ethnic Gender 5± c,d,f NS 7± c,d,f NS 9 ± f NS 11 ± c,f NS 13 ± c,d,f NS 15 ± c,f NS *Signi cantly different (P < 0.05); NSˆ not signi cant.. a ˆ AA girls vs MA girls; b ˆ AA girls vs NHW girls; c ˆ MA girls vs NHW girls; d ˆ AA boys vs MA boys; e ˆ AA boys vs NHW boys; f ˆ MA boys vs NHW boys; g ˆ AA girls vs AA boys; h ˆ MA girls vs MA boys; i ˆ NHW girls vs NHW boys. (Not all symbols are used.) Table 3 Subscapular skinfold thickness (mm) (mean s.d.) according to ages, ethnicity and gender, with results of statistical tests Girls Boys Signi cance* Ages (y) AA MA NHW AA MA NHW Ethnic Gender 5± c NS 7± c,d,f i 9 ± f i 11 ± c,f NS 13 ± c,d,f g 15 ± b,c,f g,h,i *Signi cantly different (P < 0.05): the symbols used are the same as in Table 2. (Not all symbols are used.). NS ˆ not signi cant.

4 412 the larger values than other ethnic groups (Table 4). MA boys had the largest TST, with occasional statistical signi cance attained. The TST of girls were often signi cantly (P < 0.05) larger than those of boys in all three ethnic groups (Table 4). Prevalence of overweight by BMI Figures 1 and 2 show the prevalence of overweight in the triethnic pediatric population of the San Antonio, Texas, area compared with the age- and gender-speci c 85th and 95th percentile cut-off points of the NHANES I population data. 23,24 Overweight in children and adolescents is de ned as those with BMI values at or greater than the 95th percentile of the reference value. 25 Those children whose BMI is between the 85th percentile and the 94th percentile are de ned as `at risk of overweight'. 25 By this de nition, the expected prevalence of overweight in a reference population should be 5% and that of `at risk' should be 10%. For girls, the combined prevalence of overweight and `at risk' is much higher in AA and MA girls than NHW girls (Figure 1). The combined prevalence ranges between 33% and 51% for AA girls, between 34% and 52% for MA girls, and between 22% and 38% for NHW girls. The prevalence of overweight (BMI > 95th percentile) is much lower in NHW girls (8 ± 17%) than the other ethnic groups (15 ± 29% for AA Figure 1 Prevalence of overweight and `at risk of overweight' for girls. The current data were compared with the population reference data of the National Health and Nutrition Examination Survey I (NHANES I) (1971 ± 1974). girls and 15 ± 27% for MA girls). The prevalence of `at risk of overweight' in NHW adolescent girls (13 ± 22%) tends to be lower than that in the other ethnic groups (Figure 1). An early onset of marked overweight occurring in AA and MA girls at ages 5 and 6 is noteworthy. Table 4 tests Triceps skinfold thickness (mm) (mean s.d.) according to ages, ethnicity and gender, with results of statistical Girls Boys Signi cance* Age (y) AA MA NHW AA MA NHW Ethnic Gender 5± d h 7 ± d,e g,h 9 ± f i 11 ± NS NS 13 ± NS g,h,i 15 ± f g,h,i *Signi cantly different (P < 0.05): the symbols used are the same as in Table 2. (Not all symbols are used.). NS ˆ not signi cant. Table 5 Comparison of prevalence of overweight (%) between NHANES III and the present study (with reference data from NHES cycles II and III) > 85th percentile > 95th percentile (`at risk' overweight) (overweight) Ages Sex (y) Ethnicity NHANES III This study Percentage difference NHANES III This study Percentage difference Females 6 ± 11 AA MA NHW ± 17 AA MA NHW Males 6 ± 11 AA MA NHW ± 17 AA MA NHW The reference data from NHES cycles II (1963 ± 1965) and III (1966 ± 1970) were kindly provided by Dr Robert J Kuczmarski of National Center for Health Statistics, Hyattsville, MD.

5 from NHANES III. In all, 35 ± 47% of MA boys and girls and AA girls have BMI greater than the 85th percentile in this study, in comparison to the gures reported by Troiano et al from the NHANES III (between 20 and 33%). 5 The difference in the prevalence between these two studies is striking. The percentage difference in the prevalence of BMI > 85th percentile (the combined prevalence of overweight and `at risk') is on average 134%, with a high of 180%. The percentage difference for the prevalence of overweight (BMI > 95th percentile) is on average 148%, with a high of more than 200% (Table 5). 413 Figure 2 Prevalence of overweight and `at risk of overweight' for boys. The current data were compared with the population reference data of the NHANES I (1971 ± 1974). For boys, the combined prevalence of overweight and `at risk' is highest in MA boys (40 ± 50%), with almost half of adolescents having BMI values greater than 85th percentile of the reference value. 23,24 The combined prevalence is lower for AA boys (23 ± 36%) and NHW boys (22 ± 37%) (Figure 2). Note that the onset of overweight is quite early in boys as well as in girls. MA boys have the highest prevalence of overweight (BMI > 95th percentile) with the ranges between 21 and 28%. Among boys, the lowest prevalence of overweight is seen in NHW subjects (range of 7 ± 16%). For AA boys, the prevalence of overweight ranges between 11 and 27%. The overall prevalence of `at risk' ranges between 7% and 26% (Figure 2). AA boys had a lower prevalence of `at risk' than the other ethnic groups. Comparisons with national gures In Table 5, the prevalence reported by Troiano et al 5 and that found in this study are compared. For both studies, the reference values used (National Health Examination Survey (HES) cycles II and III) and the age breakdown are the same. The prevalence of overweight and `at risk of overweight' in this study is much higher than that reported by Troiano et al 5 Table 6 Changing trends in the mean values of the subscapular skinfold thickness (%) Girls Boys Age group (y) AA a MA b NHW a AA a MA b NHW a 6± ± ± ± Reference values used for the computation are the mean values: a from NHANES I; b from HHANES. Changes in skinfold thicknesses The mean values of the SST in this study were compared with the race-speci c 50th percentile values from NHANES I data for AA and NHW boys 26 and AA and NHW girls. 27 The reference values for MA children were from the Hispanic Health and Nutrition Examination Survey (HHANES), 28 since the ethnicity-speci c MA data are not available from NHANES I. The increase in the SST was modest in girls of 6 ± 11 y and less in older girls (Table 6). There was almost no increase in the SST in NHW girls aged 12 ± 17 y. AA and MA girls showed much larger percentage increases than NHW girls. The SST was markedly increased in boys of all ages, with a larger increase seen in AA and MA boys than in NHW boys (Table 6). The largest increase (70 ± 128%) is seen in AA boys. In comparison with 50th percentile values for TST from NHANES I (1971 ± 1974) for AA and NHW children 26 and from HHANES (1982 ± 1984), 28 for MA children, there was a small percentage increase in the TST in girls 6 ± 11 y for all ethnic groups. However, for MA and NHW girls aged 12 ± 17, there was an actual percentage decrease (13 ± 20%) in this measurement. In AA adolescent girls the value increased (not shown). For boys, there was a modest increase (9 ± 48%) in the percentage change in all ages studied. The increase was most marked in AA boys and least so in NHW boys. Discussion Our data show (a) that an increase in the prevalence of overweight is seen in all ethnic and gender groups, as has been reported nationally, 6,12 (b) that there are several important ethnic differences in BMI and skinfold thickness measurements in children and adolescents, and (c) that the magnitude of the increase in the prevalence is greater in this study than has been reported nationally. MA boys and girls often have larger BMI values than NHW counterparts while AA children, especially girls, have BMI values equally as large as MA girls. Data from NHANES II, 29 NHANES III, 6 and HHANES 28 show the same ethnic differences in BMI as noted above among the three ethnic groups of children. These three national surveys 28 ± 30 also show the same pattern of ethnic differences in BMI among the three ethnic groups of adults. With regard to the SST, MA children tended to have larger values than other ethnic groups and

6 414 NHW girls had the smallest SST measurements. NHANES II 29 and HHANES 28 surveys also showed the same pattern of ethnic differences in the SST in adults as found in this study, with white women having the lowest SST. Thus, the results of our study show that the ethnic differences in BMI and the fat distribution pattern reported in the adult are already established as early as 5 ± 6 y of age. There has been a dramatic (8%) increase in the prevalence of overweight in the last two decades, more precisely between the period of 1976 ± 1980 (NHANES II) and 1988 ± 1991 (NHANES III, phase I). 1 Flegal et al 30 reported the prevalence of obesity (de ned as body mass index (BMI, kg=m 2 ) 30) to be 22% of men and 24.9% of women in the NHANES III (1988 ± 1994). The prevalence was higher in Mexican American (MA) men (25.4%) than white (20%) and African American (AA) (21.3%) men and it was higher in MA women (34.2%) and AA women (30%) than white women (22%). Parallel with the increase in prevalence of obesity in adults, 1 an alarming increase in the prevalence of childhood obesity has occurred during the same period in the USA. 3,4,6 Troiano et al, 5 reported the prevalence of obesity (called overweight in pediatrics, BMI 95th percentile) from the NHANES III study (1988 ± 1994) to be 10 ± 12% for NHW and AA boys and 15 ± 17% for MA boys. It was 14 ± 16% for AA and MA girls and 9% for white girls, 6 showing the same ethnic trend as reported in the adults. 30 Thus, the trends in ethnic difference are the same for adults and children in the NHANES III 5,30 and in our triethnic pediatric population in the San Antonio area. This rapid increase in the prevalence of obesity is concerning because many obese children become obese adults 31,32 and, once established, obesity is dif cult to treat. It becomes a chronic condition with complications of many organ systems, 2 including cardiovascular diseases, type 2 diabetes mellitus, gallbladder disease, osteoarthritis, sleep apnea, and certain types of cancer. 2,33,34 None of the treatment modalities available will cure the condition. 33 At best, the condition is palliated on continued treatment at an enormous cost. In 1995, the total cost attributable to obesity amounted to $99.2 billion. 35 Approximately $51.6 billion of these dollars (5.7% of the national health expenditure) were direct medical costs. 35 Unlike adults, obesity-related diseases are rarely manifested in children and adolescents. However, some of these children have already shown signs of chronic complications of obesity, such as type 2 diabetes, usually not seen until middle age. 36 Many of these children may actually have high blood pressure, high cholesterol, and other diseases in their early stages, 17,37 ± 39 and are at risk for psychosocial dysfunction. 40 Many diseases, including coronary artery disease, are silent during childhood and adolescence, but there is strong evidence that coronary artery `clogging' is going on during childhood. 41 The early onset of overweight seen in this study is also concerning. The onset of overweight may be even earlier in the preschool-age group, which we did not study. Reports from the US 42 and the UK 43 indicate that some preschool children are already obese. Hernandez et al 42 reported 32% of children in a Head Start program to be overweight. Reilly et al 43 reported that 20% of 4-y-old children in the UK were overweight. Therefore, the prevention and=or remediation of obesity is an important measure that could prevent cardiovascular diseases, hypertension 32 diabetes 36 and other diseases in youth and thus should be started in childhood. 41,44 Interventions during childhood are more likely to have long-term success. 44 The reasons for the higher prevalence of overweight in this area are not entirely clear. It may be a local phenomenon, as San Antonio is dubiously known as the third `fattest' city in the country. 45 It may also re ect a continued increase in the prevalence of overweight since the completion of the NHANES III (1991 ± 1994), but this is unlikely at least for MA and NHW children because our data collection was only 1 y later than the national survey. Most of the data on AA children were, however, obtained 4 ± 5 y later (in 1996 to 1998) than the NHANES III and may re ect the continued increase in obesity rather than the local phenomenon. Thus, the reasons for the higher prevalence of obesity in this region may be a combination of the two possibilities. The strength of this study is that it was carried out in a triethnic population by a small number of investigators, so that a direct comparison of anthropometric data is possible among the three ethnic groups. The weaknesses of the study includes (a) a disproportionately small number of AA children participated and an over-sampling of MA children (59%) was unavoidable because of the required policy of School Districts to collect data from all volunteering students, (b) the participation rate was less than optimal, (c) data collection from predominantly AA students lagged 2 y, (d) detailed information on the socioeconomic status or the level of acculturation are lacking, and (e) no information is available on the difference between participants and nonparticipants. Small numbers of AA subjects in the study may have resulted in a less than ideal situation for statistical analyses for this particular ethnic group. The socioeconomic and acculturation status would undoubtedly have contributed to the ethnic difference shown in this study. 46 ± 48 The prevalence of obesity and its ethnic differences obtained in this study may not be appropriate for other regions. In conclusion, we found in this study an early onset of childhood obesity and an early establishment of the adult pattern of ethnic differences in BMI and central fat distribution. The reports of childhood onset of type 2 diabetes 36 and cardiovascular risk factors 17,49 are particular concerns. The prevention and=or remediation of overweight is an important measure that could prevent hypertension, 32,50 diabetes, 36 and other diseases in young adults and these efforts should be started in childhood. 41 Acknowledgements The authors wish to thank the school board members, superintendents, school teachers, and nursing staff of the South

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