Topic:
SCHOOLS (GENERAL); CHILD HEALTH; HEALTH (GENERAL); JUVENILES; NUTRITION;
Location:
JUVENILES; SCHOOLS - HEALTH;

OLR Research Report


June 19, 2002

 

2002-R-0529

CHILDHOOD OBESITY

 

By: Saul Spigel, Chief Analyst

You asked for information on childhood obesity, particularly in Connecticut.

SUMMARY

The prevalence of overweight American children nearly doubled in the past 20 years and nearly tripled for adolescents. As of 1999, 13% of six- to –11 year olds and 14% of 12- to –19 year olds were overweight. Connecticut youths showed a lower prevalence: 9.1% of Connecticut high school students were overweight. The federal Centers for Disease Control and Prevention (CDC) calls child and adult obesity levels a public health epidemic.

Childhood obesity has been linked to increased risk for type 2 (non-insulin dependent) diabetes; sleep apnea; high blood pressure and cholesterol, both of which are linked to heart disease; asthma; orthopedic and skin disorders; and psychological problems.

Nationally, annual hospital costs for children and youth due to obesity and its associated diseases increased more than 300% over the past 20 years, according to a new study. The authors estimate that the total cost of obesity-related hospitalization rose from $35 million in 1979-81 to $127 million in 1997-99. Costs for Connecticut are not available; the Office of Fiscal Analysis is currently examining ways to determine them.

Observers generally agree that two factors are responsible for the growth in childhood obesity: increased fast food, junk food, and soda consumption and reduced physical activity. Some fast food meals can account for nearly an entire days' recommended calorie and fat consumption. Teenage boys who drink soda drink nearly a quart a day while teenage girls consume over a pint a day. As kids consume more fast food and soft drinks, they consume less milk, fruit, and vegetables. Some people cite fast food meals in schools and students' unfettered access to food vending machines as partly responsible for this problem.

Physical activity among children has decreased. Nationally, the percentage of students who attended daily physical education classes dropped from 42% in 1995 to 29% in 1999. Connecticut students may be in worse shape than their peers. A CDC reports shows fewer than 10% attend daily physical education classes; the average elementary student gets less than 40 hours a year of physical education instruction.

States have taken two approaches to dealing with childhood obesity: reducing the availability of non-nutritive foods in schools and increasing kids' physical activity. California prohibits selling soda and fruit drinks with less than 50% fruit juice in elementary schools and limits their sale in middle schools, (2) prohibits selling junk food snacks during elementary school breakfasts and lunches, and (3) restricts selling such snacks in middle schools. The Texas Education Agency, following legislative authorization, called for students to participate in at least 30 minutes of physical activity a day or 135 minutes a week. A Kentucky bill to ban soft drink and candy sales and restrict fast food sales was defeated this year by a combination of industry and school opposition.

In Connecticut, State Department of Education (SDE) regulations prohibit schools from allowing soft drinks or candy to be sold anywhere in the building for 30 minutes before or after a subsidized school meal. The Public Health Department (DPH) has received a CDC grant to establish an obesity prevention and control program. It is using the funds to create a surveillance program and work with various groups to develop intervention and prevention programs. A bill to create a permanent nutrition policy task force and establish three school nutrition pilot programs in which sales of fruit and vegetables were encouraged and carbonated beverage sales limited failed this year.

CHILDHOOD OBESITY PREVALENCE IN U.S. AND CONNECTICUT

The prevalence of overweight children in the U.S. nearly doubled in the past 20 years (1976-80 to 1999); it nearly tripled for adolescents. As of 1999, 13% of American six- to 11- year olds and 14% of 12- to –19 year olds are overweight, according to the CDC.

Obesity is typically measured using a body mass index (BMI, a person's weight divided by his height squared). The standard categories are underweight (BMI under 18.5), normal (18.5 to 24.9), overweight (25 to 29.9) and obese (over 30). Table 1 shows some examples.

Table 1: Measuring Obesity (pounds)

Height

Underweight

Normal

Overweight

Obese

5'3”

<104

104 -140

141 - 168

>169

5'6”

<115

115 -154

155 - 185

>186

5”9”

<126

126 -168

169 - 202

>203

Source: Rand Corporation

A lower percentage of Connecticut youth are overweight compared to their counterparts elsewhere. The CDC says that 9.1% of Connecticut high school students were overweight in 1999. Boys were almost twice as likely as girls to be overweight (11.3 to 6.8%). And 15% of youths between age 10 and 24 were at risk of becoming overweight. (The CDC report, the Behavioral Risk Factor Surveillance Survey (BRFSS) uses self-reported information, so the data are based on how much the students said they weighed, not on their measured weight.) By comparison, the BRFSS reports 16.5% of Connecticut adults are obese.

However, a 2000 study that reviewed Hartford public school student's health assessments found significantly higher levels of obesity than the BRFSS. The study, conducted as part of the Hartford Health Department's “Diabetes Call to Action,” found 13% of kindergarteners, 24% of sixth graders, and 21% of 10th graders were obese. And 10% of kindergarteners and18% of sixth and 10th graders were at risk of becoming overweight. Unlike the BRFSS, this study found no gender differences.

HEALTH AND COST CONSEQUENCES OF CHILDHOOD OBESITY

Increased Risk for Disease

Obesity in children has been linked to increased risk for type 2 (non-insulin dependent) diabetes; sleep apnea; high blood pressure and high cholesterol, both of which are linked to heart disease; asthma and bronchial hyperactivity; orthopedic disorders such as bowed legs, twisted shins, and bad hips; skin disorders like heat rashes and skin inflammations; and psychological problems, including depression.

More than half of all obese six-year olds will become obese adults. This linkage increases to 70% for obese adolescents and 80% if one or more parent is overweight or obese. Adults who were overweight as children may be at greater risk for coronary heart disease, cardiovascular disease, type 2 diabetes, gallbladder disease, stroke, high blood pressure, osteoarthritis, and colon and breast cancers.

In Connecticut, DPH estimated in 1999 that obesity and diet contributed to 11% of all deaths in the state.

Diabetes. The American Diabetes Association reports a surge in children diagnosed with type 2 diabetes. While type 2 accounted for fewer than 4% of childhood diabetes cases in 1990, it now accounts for between 8 and 45% of newly diagnosed cases, depending on the age group (it is more frequent among 10- to 19-year olds) and race studied (minority groups have an especially high rate). The association asserts that 85% of the children diagnosed with type 2 diabetes are obese.

We could not locate data specifically on type 2 diabetes among Connecticut children, but some data indicate a general increase in diabetes (type 1 or juvenile diabetes and type 2) occurrence in this age group. Hospital discharges for children up to age 19 where diabetes was the primary diagnosis increased by 15% between 1991 and 1996 (255 discharges to 294) and by 12% for all discharges where diabetes was diagnosed (371 to 414)(DPH, Connecticut Diabetes Surveillance, 2000).

Health-Related Costs

Costs for Children. Nationally, annual hospital costs for children and youth due to obesity and its associated diseases increased more than 300% over the past 20 years, according to a new study. The study compared hospital discharges for six- to 17-year olds between 1979 and 1981 with those between 1997 and 1999 for obesity and for diabetes, sleep apnea, gallbladder disease, and other conditions when obesity was listed as a secondary diagnosis. The authors found that the absolute number of hospital discharges increased for all these diagnoses, except diabetes, as did their proportion relative to all discharges.

Children with these conditions stayed in the hospital nearly twice as long in 1997 to 1999 as they did in the 1979 to 1981 period. And they stayed in the hospital longer than the average hospitalized child. The total days of care associated with childhood obesity rose from 152,000 in 1979-81 to 310,000 in 1997-99.

The authors estimate that the total cost of obesity-related hospitalization rose to $127 million in 1997-99 from $35 million in 1979-81, measured in 2001 constant dollars. They believe that their estimates are conservative since they do not consider the cost of physician visits and medication (Wang and Dietz, “Economic Burden of Obesity in Youths Aged 6 to 17 Years, 1979-1999,” Pediatrics, May 2002).

Costs for Adults. As noted above, over 50% of all obese six-year olds will become obese adults. A 1998 study determined that obesity's economic cost in the U.S. amounted to $99.2 billion dollars in 1995 or 5.7% of all U.S. health expenditures. Approximately $51.6 billion were in direct medical costs (personal health care; doctor, hospital, and allied health service care; and medication), while indirect economic losses (lost output due to days off and diminished or lost future wages due to illness and death) amounted to $47.6 billion.

The authors estimated the prevalence of various diseases attributable to obesity (type 2 diabetes; coronary heart disease; gallbladder disease; breast, endometrial, and colon cancer; and osteoarthritis) and applied that prevalence to economic costs other researchers had determined for those diseases. Obesity-related diabetes accounted for nearly two-thirds of all costs (Wolf and Colditz, “Current Estimates of the Economic Cost of Obesity in the United States,” Obesity Research, March 1998).

A more recent study asserts that adult obesity outranks both smoking and problem drinking in its detrimental effects on health and health costs. A Rand Corporation economist examined the effects of obesity, smoking, problem drinking, and aging on chronic medical conditions, heath-related quality of life, hospital and ambulatory care visits, and medication use. He found that obesity had significantly greater effects on the number of chronic conditions and quality of life indicators than current or past smoking or drinking. Its effects were similar to 20 to 30 years of aging.

The study concluded that obesity increases inpatient and ambulatory care costs by 36% and medication costs by 77% compared with a person of normal weight. In contrast, 20 years' aging increases service costs 20% and medication costs 105%, while smoking increases care costs 21% and medication 28 to 30%. In terms of absolute costs, an obese person spends about $400 a year more than the average in inpatient and ambulatory care costs; a smoker about $230; and a problem drinker, $150 (Sturm, “The Effects of Obesity, Smoking, and Drinking on Medical Problems and Costs,” Health Affairs, March/April 2002).

CAUSES OF CHILDHOOD OBESITY

Researchers generally agree that two factors are most responsible for the growth in childhood obesity: increased consumption of fast food and snack food and reduced physical activity.

Food-Related Causes

Fast Foods. A single fast food meal can supply a sizable portion of a child's recommended daily calorie and fat intake. The U.S. Department of Agriculture (USDA) recommends daily calorie intake for different age groups and that no more than 30% of these calories come from fat. Table 2 shows its recommendations.

Table 2: Calorie and Fat Intake Recommendations

USDA Calorie and Fat Recommendations for

Children and Teens

Recommended Age

Total Calories per Day

Total Grams of Fat

2 to 6 year olds

1600

53

 

2000

65

7 to 12 year olds & teen girls

2200

73

 

2500

80

Teen boys

2800

93

Table 3 shows the calorie and fat content of some common fast foods.

Table 3: Fast Food Calorie and Fat Content

Item

Calories

Grams of Fat

% of Calories from Fat

% of Daily Calorie Requirement*

Bacon Cheeseburger

870

35

36

40

Small Fries

210

10

43

10

Regular Fries

370

20

49

17

Bean Burrito

380

12

28

17

Chicken Quesadilla

410

19

42

19

Personal Size Pepperoni Pizza

670

29

39

30

1 slice Cheese Pizza

175

5.5

28

8

6” Roast Beef Sub

300

5

15

14

* based on 2,200 calories per day

Soft Drinks. Soft drinks are another major source of calories for children. A 20-ounce bottle of cola, now the standard, contains 230 calories. A report by the advocacy group Center for Science in the Public Interest (CSPI), claims that children start drinking soft drinks at a very young age, and consumption increases through young adulthood. It says 20% of one- and two-year olds drink an average of seven ounces of soft drinks daily. Almost half of all six- to 11-year olds drink soda, averaging 15 ounces a day. Boys age 12 to 19 who drink soda, the most avid consumers of all, drink nearly a quart (28.5 ounces) a day. Teenage girls who drink soft drinks consume over a pint of soda a day (CSPI, Liquid Candy, 1998).

The center says soda consumption among teens has increased over the past 20 years, especially among boys, as table 4 shows.

Table 4:  Trends In Soft Drink Consumption By 12- To 19-Year-Olds Who Drink Soft Drinks

Year

Ounces per Day

 

Boys

Girls

1977-78

16

15

1987-88

23

18

1994-96

28

21

Source: Center for Science in the Public Interest from USDA Nationwide Food Consumption Survey, 1977-78;  Continuing Survey of Food Intakes by Individual,

1987-88, 1994-96.

Fruit, Vegetable, and Milk Consumption Drops. A corollary to children and teen's increased fast food and soft drink intake is their failure to eat more nutritious foods. But Connecticut kids may eat better than their peers elsewhere. CDC's 1999 Youth Risk Behavior Study (YRSB) showed that fewer than 25% of high school students nationally reported eating the USDA's recommended five servings daily of fruits and vegetables (this data is not available for Connecticut). But the survey showed that 87% of Connecticut students had eaten fruit in the previous week and 75% had eaten vegetables, slightly above national figures.

And as teens' soft drink consumption increased, their milk consumption dropped by more than 40%. Twenty years ago, boys consumed more than twice as much milk as soft drinks, and girls consumed 50% more. By 1994-96, these patterns had reversed; both boys and girls drank twice as much soda as milk. Boys drank about 28 ounces of soda a day, but only 10 ounces of fluid milk. Girls consumed about 12 ounces of soda daily, but less than eight ounces of milk (CSPI, Liquid Candy). The 1999 YSRB showed that only one in five Connecticut adolescents drank three or more glasses of milk daily, slightly below the national median of 21% (CDC, YRBS, 1999).

Role of Schools. Some observers hold schools culpable for some of these nutritional deficits. They point particularly to the growing presence in schools of fast food vendors and vending machines that compete with nutritional school lunch programs.

Many schools receive income from fast food, snack, and soft drink sales to supplement their budgets. McDonalds and Taco Bell now provide meals in some school cafeterias. The Christian Science Monitor reported that 98% of high schools, 75% of middle schools, and 40% of elementary schools house vending machines (“Lunch Money Dilemmas: M&Ms or Meatloaf,” May 16, 2002). Nationwide, an industry study found that schools get $750 million a year from companies that sell snack or processed food in schools (New York Times, “In Bid to Improve Nutrition, Schools Expel Soda and Chips,” May 20, 2002). And “pouring rights” contracts give soft drink companies exclusive rights to market their beverages in schools and during school events like football games and give schools a percent of the proceeds—the more soda kids drink the more money the school gets.

Lack of Physical Activity

Children in the United States are less fit than they were a generation ago, the American Heart Association asserts. Nationally, the CDC's YRBS reported that the percentage of students who attended daily physical education classes dropped from 42% in 1995 to 29% in 1999. (But, it reported, the percentage of students who attended at least one

class a week increased during the same period to 56% from 49%.) It reported 65% of high school students exercised vigorously three days a week, while 27% reported moderate exercise in that period.

Physical education is one of Connecticut's prescribed courses of study (CGS 10-16). But Connecticut students may be in worse shape than their counterparts. The CDC says fewer than 10% attend daily physical education classes (although nearly 76% attend at least once a week). SDE data show elementary and middle school students averaged less than two physical education sessions per week during 2000-01. Elementary students averaged between 36 and 40 instructional hours a year and middle school students, 56. SDE says these data “should raise concerns.”

Connecticut high school students must obtain at least one physical education credit to graduate (CGS 10-221a). SDE notes that most school districts (62%) require only this minimum. And, it says, enrollment in physical education classes drops over the course of a high school student's four years; while about 94% of ninth and 10th graders must take these courses, fewer than 60% of seniors are required. This is a national trend (SDE, Condition of Education 2000-01).

Television, video games, and computers also contribute to the sedentary life. The American Heart Association claims children, on average, spend 17 hours a week watching TV (and that does not include video games and computers). Nationally, the YRSB says, 43% of students watch more than two hours of television a day. In Connecticut, though, that figure is just 38%.

ADDRESSING THE CAUSES OF OBESITY

Other States

Given the two leading causes of childhood obesity, states have taken two approaches to solving it: reducing the availability of non-nutritive foods during school and increasing kids' physical activity levels.

California. California has been addressing both nutrition and physical activity in schools for several years.

● In 1999, the legislature prohibited school boards from granting exclusive pouring rights without a public hearing (AB 117).

● In 2001, it (1) prohibited the sale of soda and fruit drinks with less than 50% fruit juice in elementary schools and limited their sale in middle schools, (2) prohibited the sale of junk food snacks during elementary school breakfasts and lunches, and (3) restricted the sale of such snacks in middle schools (SB 19). These provisions take effect January 1, 2004.

● The same legislation created a pilot program for 10 school districts that ban (a) soda sales in middle and high schools during the school day and (b) sales of high fat, high sugar foods. Participating districts receive enhanced school lunch reimbursement and state grants. They must set up advisory committees to make recommendations on nutritional standards, use of fresh foods, improving physical education curricula, and other related topics.

● A proposed two-cent per can tax on soda in cans (11 cents for a two-liter bottle) died this May in the face of opposition from the industry and taxpayer groups. The revenue would have been split among schools that voluntarily banned junk food sales, obesity prevention and elementary school health and fitness programs, and dental care programs (SB 1520).

● The legislature is currently considering three bills related to physical education. One requires the State Board of Education to set standards for physical education instruction and monitor districts' programs (AB 1793). A second requires districts to send home results of mandated fitness tests and requires 11th and 12 graders who fail it to take physical education classes (SB 1597). The third requires the results of the fitness tests to be incorporated into a school's academic performance index (a school report card the state board compiles) (SB 1868).

Texas. In 2001, the legislature authorized the State Board of Education to require elementary school students to participate in daily physical activity. It also required the Texas Education Agency (TEA) to make a coordinated health program available to each school district (SB 19). In March 2002, the TEA issued guidelines to implement this law calling for students to participate in at least 30 minutes a day or 135 minutes a week.

New TEA guidelines also call for Texas schools to follow the USDA rule on the sale of food with “minimal nutritional value” that compete with school meals. This optional rule (which Connecticut follows, see below) prevents the sale of soda, gum, and candy in cafeterias and other eating locations during breakfast and lunch. But Texas still allows sales from vending machines in other areas, Connecticut does not.

Early in 2001, the University of Texas School of Public Health began surveying over 11,000 students to determine the prevalence of obese and overweight Texas children. The survey asks them about their weight and height, eating habits, physical activity levels, and attitudes about food and weight. The results have been submitted to a peer-reviewed publication and are not yet publicly available.

Kentucky. Lieutenant Governor Henry, a physician, created a task force in spring 2001 to address type 2 diabetes and overweight children. As a result of that task force, legislation was introduced this year to (1) ban the sale of soft drinks, certain fruit juice, candy, and gum in vending machines and school stores and by school groups as fundraisers; (2) restrict the sale of fast food items in school cafeterias; (3) upgrade training and continuing education requirements for school food service administrators; and (4) create a legislative task force to address further childhood obesity and type 2 diabetes issues.

The bill (HB 553) was heavily opposed by school boards, which stood to lose money from such sales, and the vending machine industry. A 2002 University of Kentucky study of 339 schools revealed that 97% of high schools, 88% of middle schools, and 44% of elementary schools allowed students access to vending machines and school stores during the school day. It found that vending machine sales provided an average of $9,700 a year to high schools, $5,900 to middle schools, and $3,150 to elementary schools. School store sales added even more—$7,700 for high schools, $13,200 for middle schools, and $6,000 for elementary schools. The bill was rejected after opponents amended the bill to make the ban a local option (Louisville Courier-Journal, March7, 2002 and April 16, 2002).

Connecticut

Obesity Prevention and Control Program. In September 2000, DPH received a CDC grant to establish an obesity prevention and control program. During its first year, DPH focused on developing the program's infrastructure, particularly identifying organizations to work with it to develop an obesity surveillance system and to implement nutrition and physical activity interventions.

The surveillance system will determine the incidence and prevalence of overweight and obesity and related risk factors, identify data gaps and existing programs and services, assess relative needs among various populations and communities, and serve as the basis for a state plan.

Five work groups will address interventions in communities, healthcare settings, schools, worksites, and the food industry. The school work group will look at the physical education curriculum, school food services practice, and recess policies. The healthcare group will promote current guidelines for screening, assessment, treatment, and referral of overweight and obese patients. It would also look at reimbursement issues related to service provision, education and counseling, and referrals. The industry group will work with the food (including vending machine operators, fast food outlets, supermarkets) and fitness industries to promote increased physical activity and improved nutritional practices.

In its second year (2001-02), DPH is working to (1) maintain and strengthen the state infrastructure for obesity prevention and control; (2) design, pilot, and evaluate a community-level model for obesity prevention and control; and (3) develop a mechanism to track environmental and policy changes and outcomes related to promoting increased physical activity and improved nutritional practices.

School Nutrition. Connecticut law limits candy and soda's competition with school meals. SDE regulations prohibit schools from allowing soft drinks or candy to be sold anywhere in the building for 30 minutes before or after a federally or state-subsidized school breakfast or lunch. These regulations also require that income from food sales anywhere in the building during that period be used to benefit the subsidized food program (Conn. Agency Regs, 10-215b-1, and –23).

During the 2002 session, the Public Health Committee favorably reported a bill modeled on California's SB 19. sSB 584 would have created a permanent, nine-member task force to adopt a nutrition policy for the state and to help reduce and prevent childhood obesity and type 2 diabetes. It also would have required SDE, in consultation with DPH, to establish three school nutrition pilot programs in which sales of fruit and vegetables were encouraged and carbonated beverage sales limited. The Senate passed the bill after an amendment on the last day of the session removed the pilot projects, but the bill died on the House calendar.

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