Journal of Physical Activity and Health, 2015, 12, 875 -878 http://dx.doi.org/10.1123/jpah.2013-0303 © 2015 Human Kinetics, Inc.
ORIGINAL RESEARCH
Contextual Influences on Weight Status Among Impoverished Adolescents: Neighborhood Amenities for Physical Activity and State Laws for Physical Education Time Requirements April Y. Oh, Erin Hennessy, Kate E. McSpadden, and Frank M. Perna Purpose: This study examines the relationship between state laws for physical education and neighborhood amenities for physical activity on weight status in adolescents of low socioeconomic status. Methods: Data from 2 national data sources: Classification of Laws Associated with School Students (CLASS) and the National Survey of Children’s Health (NSCH) were combined and analyzed. Results: Multinomial regression models found that adolescents in states with strong PE law were associated with a lower odds of being obese [OR = 0.63 (0.41, 0.97)]; however, when PE law and neighborhood amenities were included, only neighborhood amenities were associated with lower odds of obesity, but also greater odds of overweight status. Conclusions: This study emphasizes the potential significance of state laws on low SES groups to combat obesity; as well as the potential differential effects of local level factors, and alignment with policy goals for healthy weight. Keywords: obesity, overweight, policy, low social class
Maintaining an adequate level of physical activity (PA) has been associated with healthy weight, maintenance of weight loss,1 and greater likelihood of PA in adulthood.2 Examining factors affecting PA in early adolescence are important because children show the sharpest decline in PA during the middle school transition.3 Because adolescents spend a large portion of their time in school, state law mandating physical education (PE) has been viewed as a policy target to increase children’s PA and favorably influence childhood obesity status.4,5 Recent school health guidelines also recommend strong policy requirements to increase the average amount and quality of PE, which may facilitate transfer of learning and engagement of PA outside of school.6 Features of the local built environment, such as neighborhood amenities, (ie, walkability7 and access to facilities8), provide opportunities for PA outside of the school day. As such, PE policy and the built environment have been identified in social ecological models as major macro and local level factors, respectively, hypothesized to promote PA and maintain healthy weight.9,10 While school policy and neighborhood characteristics appear to be key leverage points separately, their potential joint effect among low socioeconomic status (SES) groups has not been investigated. This research may be particularly important for low SES adolescents who may have fewer opportunities for PA beyond those in their neighborhood and school7,11,12 and are at the greatest risk for being overweight or obese.13,14 This research brief reports on a subsample evaluation of the cross-sectional relationship between state laws for physical
Oh ([email protected]) and Perna are with the National Cancer Institute, Division of Cancer Control and Population Science, Health Communication and Informatics Research Branch, Rockville, MD. Hennessy is with the Clinical Monitoring Research Program, Frederick National Laboratory for Cancer Research, Leidos Biomedical Research, Inc., Frederick, MD. McSpadden is with the National Catholic School of Social Services, Catholic University of America.
education and neighborhood amenities for PA on adolescent weight status among low socioeconomic status adolescents. We hypothesized a greater likelihood of healthy weight middle school students living in states with a PE time requirement and living in neighborhoods with more neighborhood amenities for PA. Because social ecological models suggest a relationship between factors at the macro and local levels, we first examined the effect of state PE policy on adolescent weight status. In a second model, we added the local level factor to determine the effect of neighborhood amenities on weight status and reexamined the effect of PE policy on weight status.
Methods This study combines data from 2 national data sources: Classification of Laws Associated with School Students (CLASS)15 and the National Survey of Children’s Health (NSCH).16 Detailed information about both data sets can be found elsewhere.15,16 Briefly, CLASS scores codified PE laws for each of the 50 states and the District of Columbia in relation to National Association for School Physical Education standards.17 The National Survey of Children’s Health is a telephone survey of children between the ages of 0 to 17. Children were selected to be nationally representative and representative of the state from which they were sampled. Information regarding the sampling and methodology has been published elsewhere.18 Data from CLASS 2005 and NSCH 2007 were merged based on state identification number. CLASS 2005 data were used to allow for a minimum 1-year lag time, from codified law to enactment and implementation. Inclusion criteria for analyses were NSCH respondents between the ages of 11 to 14 that reported attending public school. Respondents who did not report height and weight or who were underweight, were excluded from the analyses. Because neighborhood amenities are correlated with SES19 and the specific nature of our research question, the sample for analysis included 1,895 adolescents of low SES who were below the Federal Poverty level (FPL).
875
876 Oh et al
Downloaded by Purdue Univ on 09/17/16, Volume 12, Article Number 6
Variables Demographic characteristics included in this study were age, gender, and race/ethnicity. State PE law variable was measured as the absence of state law requirement (CLASS score 0 = no state law; 1 = recommendation but no requirement for PE) or presence of a state law requiring PE time (where CLASS scores were 2 = requires PE or requires PE < 90 minutes per week; 3 = requires PE 90 to 149 minutes per week; 4 = requires PE 150 to 224 minutes per week; or 5 = requires PE ≥ 225 minutes per week) in middle schools. Neighborhood amenities score was calculated as the number of amenities reported in the adolescents’ neighborhoods. These included availability of the following amenities: sidewalks, parks/playgrounds, recreation centers and libraries as places to be active or destinations to walk to that were reported in the NSCH.7 Scores were counts of the number of available amenities ranged from 0 to 4, where 0 = 0 amenities in the neighborhood, 1 = 1 amenity, 2 = 2 amenities, 3 = 3 amenities, and 4 = 4 amenities. Weight status was calculated based on parent-reported height and weight in the NSCH. The NSCH calculated a variable in the dataset classifying children as underweight, healthy weight, overweight and obese based on standard calculations accounting for gender and age and percentiles using 2000 CDC growth charts.19
Table 1 Study Demographics of Middle School Aged Children Included in Analyses (n = 1895), United States % (SE)* Age Sex, male
Mean = 12.61 (1.11) 51.7
Race/ethnicity Non-Hispanic White
32.1 (2.2)
Non-Hispanic Black
27.6 (2.0)
Hispanic
31.3 (2.7)
Non-Hispanic other/multi
7.6 (1.1)
Body weight status Normal
50.5 (2.5)
Overweight
19.3 (1.9)
Obese
31.2 (2.4)
Neighborhood amenities 0 amenities
4.8 (0.1)
1 amenity
7.7 (0.1)
2 amenities
14.9 (0.1)
Analysis
3 amenities
25.8 (0.1)
In multinomial logistic regression models, weight status was regressed on demographic characteristics and PE law, and a second set of models tested the addition of neighborhood amenities in predicting weight status.
4 amenities
46.7 (0.2)
Results
Physical education laws Presence of law
25.7 (0.1)
Absence of law
74.3 (0.1)
* Weighted percent and standard error, unless otherwise indicated.
Table 1 reports the demographic characteristics for this sample. The mean amenities score was 2.9 (range 0 to 4). A total of 31.2% of adolescents in the sample were classified as obese and 25.7% of adolescents lived in states with a PE law requirement. After controlling for covariates, having a PE law requirement was significantly associated with lower odds of being obese but was unrelated to being overweight (Table 2, Model 1). When PE law and neighborhood amenities were both included in the model, PE law requirement was not significant and neighborhood amenities was associated with a lower odds of being obese but also a greater likelihood of being overweight (Table 2, Model 2). The interaction between PE law and neighborhood amenities was not significant (model not shown).
Discussion This study took advantage of 2 unique national data sets to explore the singular and joint relationships of weight status with state laws for PE and neighborhood amenities supportive of PA among adolescents below the poverty level. Presence of state laws requiring PE time was associated with lower obesity. This finding suggests the potential for state PE laws to support healthy weight among low SES subgroups who are at the greatest risk for obesity. For the low SES adolescents in this study, having a state law requiring PE, can offer additional opportunities and learning experiences for students to be active.15 The relationship observed with obesity but not with overweight could reflect study limitations given the smaller sample size for the overweight group. However, this finding also suggest other hypotheses to explore such as exploring the role of physical
activity in weight maintenance in nonobese and preservation of weight loss maintenance in obese low SES populations21,22 and the amount of actual physical activity that occurs during PE. In addition, the complex relationship between energy intake and expenditure suggest that these findings for PE law could be further explored in conjunction with school nutrition policies. Similar to prior work, greater neighborhood amenities at the local level lowered adolescents’ odds of being obese,13 and remained significant, whereas presence of PE laws were not significant in models containing both factors. The presence of local amenities for PA are more proximal than state PE law and may complement and enhance adolescents’ activity and practice of skills learned in PE. However, the higher odds of overweight associated with greater neighborhood amenities suggest there may be other neighborhood factors correlated with walkability that may promote overweight such as greater access to shops, stores and restaurants that may sell sugary and salty snacks and meals.22,23 There are several limitations to this study. First, this study was a cross sectional analysis. Therefore, determining a causal relationship between state PE policy and weight status was not possible. Second, this study does not account for district-level school policies which may have a stronger relationship between neighborhood amenities and weight. Third, the neighborhood amenities were parent versus adolescent reported. Despite these limitations, this study does suggest other potential opportunities for research exploring state level school health laws and adolescent health outcomes over time and offers an example of how state policy data from CLASS could be linked with other secondary datasets to examine relationships over
JPAH Vol. 12, No. 6, 2015
JPAH Vol. 12, No. 6, 2015
877
b
a
0.62 (0.51, 0.77)
Age
1.30 (0.61, 2.77)
0.93 (0.59, 1.48)
1.29 (0.62, 2.68)
1.76 (0.85, 3.63)
1.51 (0.90, 2.53)
0.88 (0.73, 1.06)
0.95 (0.58, 1.54)
0.87 (0.67, 1.12)
0.69 (0.45, 1.06)
1.22 (0.58, 2.57)
3.18 (1.77, 5.69)
1.98 (1.24, 3.18)
0.62 (0.50, 0.77)
0.77(0.50, 1.19)
Obese vs healthy weight
1.33 (0.97, 1.81)
0.95 (0.59, 1.54)
1.11 (0.52, 2.35)
1.75 (0.85, 3.62)
1.32 (0.78, 2.24)
0.88 (0.73, 1.07)
0.94 (0.58, 1.53)
Overweight vs healthy weight
Models regressed weight status on gender, age, race/ethnicity, and state law requiring physical education. Models regressed weight status on gender, age, race/ethnicity, state law requiring physical education, and number of neighborhood amenities for physical activity.
Neighborhood Amenities
Physical Education Law (ref: no requirement)
0.63 (0.41, 0.97)
3.17 (1.79, 5.61)
NH Mixed Race/Other
2.07 (1.29, 3.32)
NH Black
Hispanic
Race/ethnicity (ref: NH White)
0.84 (0.55, 1.29)
Gender (ref:male)
Overweight vs healthy weight
Adjusted OR and 95% CI
Adjusted OR and 95% CI Obese vs healthy weight
Model 2b
Model 1a
0.94(0.79, 1.13)
0.79 (0.51, 1.23)
1.26(0.57, 2.77)
2.70 (1.49, 4.88)
2.14 (1.33, 3.44)
0.63 (0.52, 0.78)
0.90 (0.57, 1.42)
Obese vs healthy weight
1.24(1.00, 1.54)
1.02 (0.63, 1.65)
1.28 (0.61, 2.65)
1.71 (0.81, 3.58)
1.52 (0.91, 2.55)
0.88 (0.74, 1.07)
0.96 (0.57, 1.60)
Overweight vs healthy weight
Unadjusted OR and 95% CI
Table 2 Multinomial Regression Models Examining Weight Status, Physical Education Laws, and Neighborhood Amenities, Reporting Odds Ratios and 95% Confidence Intervals for Low SES Adolescents (n = 1865), United States
Downloaded by Purdue Univ on 09/17/16, Volume 12, Article Number 6
878 Oh et al
time. CLASS and NSCH are both public use datasets and have corresponding years of data collection which allow for exploration of relationships between policy and individual health outcomes across years. Future studies could explore this research question over multiple years of data and across domains of PE and nutrition policy. Findings from this research brief suggest that neighborhood amenities for PA may be more proximally but differentially related to weight status than are laws for PE among low SES students. These students are likely to attend low SES schools with limited resources for equipment and quality PE unless required by law.20,21 Findings from this study emphasize the importance of considering the potential interplay of state laws and local level factors on weight status among adolescents from a low SES background.
Downloaded by Purdue Univ on 09/17/16, Volume 12, Article Number 6
Acknowledgments This project has been funded in whole or in part with federal funds from the National Cancer Institute, National Institutes of Health, under Contract No. HHSN261200800001E. The content of this publication does not necessarily reflect the views or policies of the Department of Health and Human Services, nor does mention of trade names, commercial products, or organizations imply endorsement by the U.S. Government.
References 1. Jakicic JM. The effect of physical activity on body weight. Obesity (Silver Spring). 2009;17:S34–S38. PubMed doi:10.1038/oby.2009.386 2. Telama R. Tracking of physical activity from childhood to adulthood: a review. Obes Facts. 2009;2:187–195. PubMed doi:10.1159/000222244 3. Matthews CE, Chen KY, Freedson PS, et al. Amount of time spend in sedentary behaviors in the Unites States, 2003-2004. Am J Epidemiol. 2008;167:875–881. PubMed doi:10.1093/aje/kwm390 4. Kim J. Are physical education-related state policies and schools’ physical education requirement related to children’s physical activity and obesity? J Sch Health. 2012;82:268–276. PubMed doi:10.1111/j.17461561.2012.00697.x 5. Cawley J, Meyerhoefer C, Newhouse D. The impact of state physical education requirements on youth physical activity and overweight. Health Econ. 2007;16:1287–1301. PubMed doi:10.1002/hec.1218 6. Centers for Disease Control and Prevention. School health guidelines to promote healthy eating and physical activity. MMWR. 2011;60:1– 74. PubMed 7. Singh KG, Siahpush M, Kogan MD. Neighborhood socioeconomic conditions, built environments, and childhood obesity. Health Aff. 2010;29:503–512. PubMed doi:10.1377/hlthaff.2009.0730 8. Dunton GF, Kaplan J, Wolch J, Jerrett M, Reynolds KD. Physical environmental correlates of childhood obesity: a systematic review. Obes Rev. 2009;10:393–402. PubMed doi:10.1111/j.1467-789X.2009.00572.x
9. Sallis JF, Cervero RB, Ascher W, et al. An ecological approach to creating active living communities. Annu Rev Public Health. 2006;27:297– 322. PubMed doi:10.1146/annurev.publhealth.27.021405.102100 10. Ding D, Sallis JF, Kerr J, et al. Neighborhood environment and physical activity among youth: a review. Am J Prev Med. 2011;41:442–455. PubMed doi:10.1016/j.amepre.2011.06.036 11. Johnston LD, Delva J, O’Malley PM. Sports participation and physical education in american secondary schools: current levels and racial/ ethnic and socioeconomic disparities. Am J Prev Med. 2007;33:195– 208. PubMed doi:10.1016/j.amepre.2007.07.015 12. Lovasi GS, Hutson MA, Guerra M, Neckerman KM. Built environments and obesity in disadvantaged populations. Epidemiol Rev. 2009;31:7–20. PubMed doi:10.1093/epirev/mxp005 13. O’Dea JA, Nguyen Hoang TD, Dibley MJ. Plateau in obesity and overweight in a cross sectional study of low, middle and high socioeconomic status schoolchildren between 2004 and 2009. Int J Public Health. 2001;56:663–667. PubMed doi:10.1007/s00038-011-0280-6 14. Voorhees CC, Catellier DJ, Ashwood JS, et al. Neighborhood socioeconomic status and non school physical activity and body mass index in adolescent girls. J Phys Act Health. 2009;6:731–740. PubMed 15. National Cancer Institute. Classification of Laws Associated with School Students. (http:www.class.cancer.gov). Accessed May 2012. 16. National Survey of Children’s Health. Rockville (MD): U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau; 2007. http:// childhealthdata.org/learn/NSCH. 17. Mâsse LC, Chriqui JF, Igoe JF, et al. Development of a physical education–related state policy classification system (PERSPCS). Am J Prev Med. 2007;33:S264–S276. PubMed doi:10.1016/j. amepre.2007.07.019 18. Blumberg SJ, Foster EB, Frasier AM, et al. Design and operations of the National Survey of Children’s Health, 2007. Vital Health Stat 1. 2012;(55):1–149. 19. Kuczmarski RJ, Ogden CL, Grummer-Strawn LM, et al. 2000 CDC growth charts: United States. Vital Health Stat. 2002;246:1–190. 20. Chaput J, Klingenberg L, Rosenkilde M, Gilbert J, Tremblay A, Sjodin A. Physical Activity Plays an Important Role in Body Weight Regulation. J Obes. 2011;2011:pii: 360257. PubMed doi:10.1155/2011/360257 21. Vermorel M, Lazzer S, Bitar A, et al. Contributing factors and variability of energy expenditure in non-obese, obese, and post-obese adolescents. Reprod Nutr Dev. 2005;45:129–142. PubMed doi:10.1051/ rnd:2005014 22. Morland KB, Evenson KR. Obesity prevalence and the local food environment. Health Place. 2009;15:491–495. PubMed doi:10.1016/j. healthplace.2008.09.004 23. Jennings A, Welch A, Jones AP, et al. Local food outlets, weight status, and dietary intake: associations in children aged 9-10 years. Am J Prev Med. 2011;40(4):405–410. PubMed doi:10.1016/j. amepre.2010.12.014
JPAH Vol. 12, No. 6, 2015
ORIGINAL RESEARCH
Contextual Influences on Weight Status Among Impoverished Adolescents: Neighborhood Amenities for Physical Activity and State Laws for Physical Education Time Requirements April Y. Oh, Erin Hennessy, Kate E. McSpadden, and Frank M. Perna Purpose: This study examines the relationship between state laws for physical education and neighborhood amenities for physical activity on weight status in adolescents of low socioeconomic status. Methods: Data from 2 national data sources: Classification of Laws Associated with School Students (CLASS) and the National Survey of Children’s Health (NSCH) were combined and analyzed. Results: Multinomial regression models found that adolescents in states with strong PE law were associated with a lower odds of being obese [OR = 0.63 (0.41, 0.97)]; however, when PE law and neighborhood amenities were included, only neighborhood amenities were associated with lower odds of obesity, but also greater odds of overweight status. Conclusions: This study emphasizes the potential significance of state laws on low SES groups to combat obesity; as well as the potential differential effects of local level factors, and alignment with policy goals for healthy weight. Keywords: obesity, overweight, policy, low social class
Maintaining an adequate level of physical activity (PA) has been associated with healthy weight, maintenance of weight loss,1 and greater likelihood of PA in adulthood.2 Examining factors affecting PA in early adolescence are important because children show the sharpest decline in PA during the middle school transition.3 Because adolescents spend a large portion of their time in school, state law mandating physical education (PE) has been viewed as a policy target to increase children’s PA and favorably influence childhood obesity status.4,5 Recent school health guidelines also recommend strong policy requirements to increase the average amount and quality of PE, which may facilitate transfer of learning and engagement of PA outside of school.6 Features of the local built environment, such as neighborhood amenities, (ie, walkability7 and access to facilities8), provide opportunities for PA outside of the school day. As such, PE policy and the built environment have been identified in social ecological models as major macro and local level factors, respectively, hypothesized to promote PA and maintain healthy weight.9,10 While school policy and neighborhood characteristics appear to be key leverage points separately, their potential joint effect among low socioeconomic status (SES) groups has not been investigated. This research may be particularly important for low SES adolescents who may have fewer opportunities for PA beyond those in their neighborhood and school7,11,12 and are at the greatest risk for being overweight or obese.13,14 This research brief reports on a subsample evaluation of the cross-sectional relationship between state laws for physical
Oh ([email protected]) and Perna are with the National Cancer Institute, Division of Cancer Control and Population Science, Health Communication and Informatics Research Branch, Rockville, MD. Hennessy is with the Clinical Monitoring Research Program, Frederick National Laboratory for Cancer Research, Leidos Biomedical Research, Inc., Frederick, MD. McSpadden is with the National Catholic School of Social Services, Catholic University of America.
education and neighborhood amenities for PA on adolescent weight status among low socioeconomic status adolescents. We hypothesized a greater likelihood of healthy weight middle school students living in states with a PE time requirement and living in neighborhoods with more neighborhood amenities for PA. Because social ecological models suggest a relationship between factors at the macro and local levels, we first examined the effect of state PE policy on adolescent weight status. In a second model, we added the local level factor to determine the effect of neighborhood amenities on weight status and reexamined the effect of PE policy on weight status.
Methods This study combines data from 2 national data sources: Classification of Laws Associated with School Students (CLASS)15 and the National Survey of Children’s Health (NSCH).16 Detailed information about both data sets can be found elsewhere.15,16 Briefly, CLASS scores codified PE laws for each of the 50 states and the District of Columbia in relation to National Association for School Physical Education standards.17 The National Survey of Children’s Health is a telephone survey of children between the ages of 0 to 17. Children were selected to be nationally representative and representative of the state from which they were sampled. Information regarding the sampling and methodology has been published elsewhere.18 Data from CLASS 2005 and NSCH 2007 were merged based on state identification number. CLASS 2005 data were used to allow for a minimum 1-year lag time, from codified law to enactment and implementation. Inclusion criteria for analyses were NSCH respondents between the ages of 11 to 14 that reported attending public school. Respondents who did not report height and weight or who were underweight, were excluded from the analyses. Because neighborhood amenities are correlated with SES19 and the specific nature of our research question, the sample for analysis included 1,895 adolescents of low SES who were below the Federal Poverty level (FPL).
875
876 Oh et al
Downloaded by Purdue Univ on 09/17/16, Volume 12, Article Number 6
Variables Demographic characteristics included in this study were age, gender, and race/ethnicity. State PE law variable was measured as the absence of state law requirement (CLASS score 0 = no state law; 1 = recommendation but no requirement for PE) or presence of a state law requiring PE time (where CLASS scores were 2 = requires PE or requires PE < 90 minutes per week; 3 = requires PE 90 to 149 minutes per week; 4 = requires PE 150 to 224 minutes per week; or 5 = requires PE ≥ 225 minutes per week) in middle schools. Neighborhood amenities score was calculated as the number of amenities reported in the adolescents’ neighborhoods. These included availability of the following amenities: sidewalks, parks/playgrounds, recreation centers and libraries as places to be active or destinations to walk to that were reported in the NSCH.7 Scores were counts of the number of available amenities ranged from 0 to 4, where 0 = 0 amenities in the neighborhood, 1 = 1 amenity, 2 = 2 amenities, 3 = 3 amenities, and 4 = 4 amenities. Weight status was calculated based on parent-reported height and weight in the NSCH. The NSCH calculated a variable in the dataset classifying children as underweight, healthy weight, overweight and obese based on standard calculations accounting for gender and age and percentiles using 2000 CDC growth charts.19
Table 1 Study Demographics of Middle School Aged Children Included in Analyses (n = 1895), United States % (SE)* Age Sex, male
Mean = 12.61 (1.11) 51.7
Race/ethnicity Non-Hispanic White
32.1 (2.2)
Non-Hispanic Black
27.6 (2.0)
Hispanic
31.3 (2.7)
Non-Hispanic other/multi
7.6 (1.1)
Body weight status Normal
50.5 (2.5)
Overweight
19.3 (1.9)
Obese
31.2 (2.4)
Neighborhood amenities 0 amenities
4.8 (0.1)
1 amenity
7.7 (0.1)
2 amenities
14.9 (0.1)
Analysis
3 amenities
25.8 (0.1)
In multinomial logistic regression models, weight status was regressed on demographic characteristics and PE law, and a second set of models tested the addition of neighborhood amenities in predicting weight status.
4 amenities
46.7 (0.2)
Results
Physical education laws Presence of law
25.7 (0.1)
Absence of law
74.3 (0.1)
* Weighted percent and standard error, unless otherwise indicated.
Table 1 reports the demographic characteristics for this sample. The mean amenities score was 2.9 (range 0 to 4). A total of 31.2% of adolescents in the sample were classified as obese and 25.7% of adolescents lived in states with a PE law requirement. After controlling for covariates, having a PE law requirement was significantly associated with lower odds of being obese but was unrelated to being overweight (Table 2, Model 1). When PE law and neighborhood amenities were both included in the model, PE law requirement was not significant and neighborhood amenities was associated with a lower odds of being obese but also a greater likelihood of being overweight (Table 2, Model 2). The interaction between PE law and neighborhood amenities was not significant (model not shown).
Discussion This study took advantage of 2 unique national data sets to explore the singular and joint relationships of weight status with state laws for PE and neighborhood amenities supportive of PA among adolescents below the poverty level. Presence of state laws requiring PE time was associated with lower obesity. This finding suggests the potential for state PE laws to support healthy weight among low SES subgroups who are at the greatest risk for obesity. For the low SES adolescents in this study, having a state law requiring PE, can offer additional opportunities and learning experiences for students to be active.15 The relationship observed with obesity but not with overweight could reflect study limitations given the smaller sample size for the overweight group. However, this finding also suggest other hypotheses to explore such as exploring the role of physical
activity in weight maintenance in nonobese and preservation of weight loss maintenance in obese low SES populations21,22 and the amount of actual physical activity that occurs during PE. In addition, the complex relationship between energy intake and expenditure suggest that these findings for PE law could be further explored in conjunction with school nutrition policies. Similar to prior work, greater neighborhood amenities at the local level lowered adolescents’ odds of being obese,13 and remained significant, whereas presence of PE laws were not significant in models containing both factors. The presence of local amenities for PA are more proximal than state PE law and may complement and enhance adolescents’ activity and practice of skills learned in PE. However, the higher odds of overweight associated with greater neighborhood amenities suggest there may be other neighborhood factors correlated with walkability that may promote overweight such as greater access to shops, stores and restaurants that may sell sugary and salty snacks and meals.22,23 There are several limitations to this study. First, this study was a cross sectional analysis. Therefore, determining a causal relationship between state PE policy and weight status was not possible. Second, this study does not account for district-level school policies which may have a stronger relationship between neighborhood amenities and weight. Third, the neighborhood amenities were parent versus adolescent reported. Despite these limitations, this study does suggest other potential opportunities for research exploring state level school health laws and adolescent health outcomes over time and offers an example of how state policy data from CLASS could be linked with other secondary datasets to examine relationships over
JPAH Vol. 12, No. 6, 2015
JPAH Vol. 12, No. 6, 2015
877
b
a
0.62 (0.51, 0.77)
Age
1.30 (0.61, 2.77)
0.93 (0.59, 1.48)
1.29 (0.62, 2.68)
1.76 (0.85, 3.63)
1.51 (0.90, 2.53)
0.88 (0.73, 1.06)
0.95 (0.58, 1.54)
0.87 (0.67, 1.12)
0.69 (0.45, 1.06)
1.22 (0.58, 2.57)
3.18 (1.77, 5.69)
1.98 (1.24, 3.18)
0.62 (0.50, 0.77)
0.77(0.50, 1.19)
Obese vs healthy weight
1.33 (0.97, 1.81)
0.95 (0.59, 1.54)
1.11 (0.52, 2.35)
1.75 (0.85, 3.62)
1.32 (0.78, 2.24)
0.88 (0.73, 1.07)
0.94 (0.58, 1.53)
Overweight vs healthy weight
Models regressed weight status on gender, age, race/ethnicity, and state law requiring physical education. Models regressed weight status on gender, age, race/ethnicity, state law requiring physical education, and number of neighborhood amenities for physical activity.
Neighborhood Amenities
Physical Education Law (ref: no requirement)
0.63 (0.41, 0.97)
3.17 (1.79, 5.61)
NH Mixed Race/Other
2.07 (1.29, 3.32)
NH Black
Hispanic
Race/ethnicity (ref: NH White)
0.84 (0.55, 1.29)
Gender (ref:male)
Overweight vs healthy weight
Adjusted OR and 95% CI
Adjusted OR and 95% CI Obese vs healthy weight
Model 2b
Model 1a
0.94(0.79, 1.13)
0.79 (0.51, 1.23)
1.26(0.57, 2.77)
2.70 (1.49, 4.88)
2.14 (1.33, 3.44)
0.63 (0.52, 0.78)
0.90 (0.57, 1.42)
Obese vs healthy weight
1.24(1.00, 1.54)
1.02 (0.63, 1.65)
1.28 (0.61, 2.65)
1.71 (0.81, 3.58)
1.52 (0.91, 2.55)
0.88 (0.74, 1.07)
0.96 (0.57, 1.60)
Overweight vs healthy weight
Unadjusted OR and 95% CI
Table 2 Multinomial Regression Models Examining Weight Status, Physical Education Laws, and Neighborhood Amenities, Reporting Odds Ratios and 95% Confidence Intervals for Low SES Adolescents (n = 1865), United States
Downloaded by Purdue Univ on 09/17/16, Volume 12, Article Number 6
878 Oh et al
time. CLASS and NSCH are both public use datasets and have corresponding years of data collection which allow for exploration of relationships between policy and individual health outcomes across years. Future studies could explore this research question over multiple years of data and across domains of PE and nutrition policy. Findings from this research brief suggest that neighborhood amenities for PA may be more proximally but differentially related to weight status than are laws for PE among low SES students. These students are likely to attend low SES schools with limited resources for equipment and quality PE unless required by law.20,21 Findings from this study emphasize the importance of considering the potential interplay of state laws and local level factors on weight status among adolescents from a low SES background.
Downloaded by Purdue Univ on 09/17/16, Volume 12, Article Number 6
Acknowledgments This project has been funded in whole or in part with federal funds from the National Cancer Institute, National Institutes of Health, under Contract No. HHSN261200800001E. The content of this publication does not necessarily reflect the views or policies of the Department of Health and Human Services, nor does mention of trade names, commercial products, or organizations imply endorsement by the U.S. Government.
References 1. Jakicic JM. The effect of physical activity on body weight. Obesity (Silver Spring). 2009;17:S34–S38. PubMed doi:10.1038/oby.2009.386 2. Telama R. Tracking of physical activity from childhood to adulthood: a review. Obes Facts. 2009;2:187–195. PubMed doi:10.1159/000222244 3. Matthews CE, Chen KY, Freedson PS, et al. Amount of time spend in sedentary behaviors in the Unites States, 2003-2004. Am J Epidemiol. 2008;167:875–881. PubMed doi:10.1093/aje/kwm390 4. Kim J. Are physical education-related state policies and schools’ physical education requirement related to children’s physical activity and obesity? J Sch Health. 2012;82:268–276. PubMed doi:10.1111/j.17461561.2012.00697.x 5. Cawley J, Meyerhoefer C, Newhouse D. The impact of state physical education requirements on youth physical activity and overweight. Health Econ. 2007;16:1287–1301. PubMed doi:10.1002/hec.1218 6. Centers for Disease Control and Prevention. School health guidelines to promote healthy eating and physical activity. MMWR. 2011;60:1– 74. PubMed 7. Singh KG, Siahpush M, Kogan MD. Neighborhood socioeconomic conditions, built environments, and childhood obesity. Health Aff. 2010;29:503–512. PubMed doi:10.1377/hlthaff.2009.0730 8. Dunton GF, Kaplan J, Wolch J, Jerrett M, Reynolds KD. Physical environmental correlates of childhood obesity: a systematic review. Obes Rev. 2009;10:393–402. PubMed doi:10.1111/j.1467-789X.2009.00572.x
9. Sallis JF, Cervero RB, Ascher W, et al. An ecological approach to creating active living communities. Annu Rev Public Health. 2006;27:297– 322. PubMed doi:10.1146/annurev.publhealth.27.021405.102100 10. Ding D, Sallis JF, Kerr J, et al. Neighborhood environment and physical activity among youth: a review. Am J Prev Med. 2011;41:442–455. PubMed doi:10.1016/j.amepre.2011.06.036 11. Johnston LD, Delva J, O’Malley PM. Sports participation and physical education in american secondary schools: current levels and racial/ ethnic and socioeconomic disparities. Am J Prev Med. 2007;33:195– 208. PubMed doi:10.1016/j.amepre.2007.07.015 12. Lovasi GS, Hutson MA, Guerra M, Neckerman KM. Built environments and obesity in disadvantaged populations. Epidemiol Rev. 2009;31:7–20. PubMed doi:10.1093/epirev/mxp005 13. O’Dea JA, Nguyen Hoang TD, Dibley MJ. Plateau in obesity and overweight in a cross sectional study of low, middle and high socioeconomic status schoolchildren between 2004 and 2009. Int J Public Health. 2001;56:663–667. PubMed doi:10.1007/s00038-011-0280-6 14. Voorhees CC, Catellier DJ, Ashwood JS, et al. Neighborhood socioeconomic status and non school physical activity and body mass index in adolescent girls. J Phys Act Health. 2009;6:731–740. PubMed 15. National Cancer Institute. Classification of Laws Associated with School Students. (http:www.class.cancer.gov). Accessed May 2012. 16. National Survey of Children’s Health. Rockville (MD): U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau; 2007. http:// childhealthdata.org/learn/NSCH. 17. Mâsse LC, Chriqui JF, Igoe JF, et al. Development of a physical education–related state policy classification system (PERSPCS). Am J Prev Med. 2007;33:S264–S276. PubMed doi:10.1016/j. amepre.2007.07.019 18. Blumberg SJ, Foster EB, Frasier AM, et al. Design and operations of the National Survey of Children’s Health, 2007. Vital Health Stat 1. 2012;(55):1–149. 19. Kuczmarski RJ, Ogden CL, Grummer-Strawn LM, et al. 2000 CDC growth charts: United States. Vital Health Stat. 2002;246:1–190. 20. Chaput J, Klingenberg L, Rosenkilde M, Gilbert J, Tremblay A, Sjodin A. Physical Activity Plays an Important Role in Body Weight Regulation. J Obes. 2011;2011:pii: 360257. PubMed doi:10.1155/2011/360257 21. Vermorel M, Lazzer S, Bitar A, et al. Contributing factors and variability of energy expenditure in non-obese, obese, and post-obese adolescents. Reprod Nutr Dev. 2005;45:129–142. PubMed doi:10.1051/ rnd:2005014 22. Morland KB, Evenson KR. Obesity prevalence and the local food environment. Health Place. 2009;15:491–495. PubMed doi:10.1016/j. healthplace.2008.09.004 23. Jennings A, Welch A, Jones AP, et al. Local food outlets, weight status, and dietary intake: associations in children aged 9-10 years. Am J Prev Med. 2011;40(4):405–410. PubMed doi:10.1016/j. amepre.2010.12.014
JPAH Vol. 12, No. 6, 2015
