Assessing Prevalence and Trends in Obesity: Navigating The Evidence (2016)

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Assessing Prevalence and Trends in Obesity:

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Obesity; Food and Nutrition Board; Health and Medicine Division; National
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Assessing Prevalence and Trends in Obesity: Navigating the Evidence
Committee on Evaluating Approaches to Assessing

Prevalence and Trends in Obesity
Food and Nutrition Board
Health and Medicine Division
Copyright National Academy of Sciences. All rights reserved.

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Assessing prevalence and trends in obesity: Navigating the evidence. Washington, DC:
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COMMITTEE ON EVALUATING APPROACHES TO

ASSESSING PREVALENCE AND TRENDS IN OBESITY
SHARI BARKIN (Chair), Professor of Pediatrics and William K. Warren

Foundation Endowed Chair, Department of Pediatrics, Vanderbilt
University Medical Center, Nashville, TN
CHERYL A. M. ANDERSON, Associate Professor, Department of Family
Medicine and Public Health, University of California, San Diego,
La Jolla
LYNN A. BLEWETT, Professor of Health Policy and Director, State
Health Access Data Assistance Center (SHADAC), University of
Minnesota, School of Public Health, Minneapolis
ELIZABETH GOODMAN, Associate Chief for Community-Based
Research, MassGeneral Hospital for Children and Professor of
Pediatrics, Harvard Medical School, Boston, MA
ROSS HAMMOND, Senior Fellow, Economic Studies Program and
Director, Center on Social Dynamics and Policy, The Brookings
Institution, Washington, DC
SANDRA HASSINK, Immediate Past President, American Academy of
Pediatrics and Director, American Academy of Pediatrics Institute for
Healthy Childhood Weight, Elk Grove Village, IL
AMY H. HERRING, Carol Remmer Angle Distinguished Professor of
Children’s Environmental Health, Professor and Associate Chair,
Department of Biostatistics, Gillings School of Global Public Health,
University of North Carolina at Chapel Hill
GIRIDHAR MALLYA, Director of Policy and Planning, Philadelphia
Department of Public Health, Philadelphia, PA (until September 2015)
MICHAEL G. PERRI, Dean, College of Public Health and Health
Professions, and the Robert G. Frank Endowed Professor of Clinical
and Health Psychology, University of Florida, Gainesville
EDUARDO SANCHEZ, Chief Medical Officer for Prevention, American
Heart Association, Dallas, TX
JACKSON P. SEKHOBO, Director, Evaluation, Research and Surveillance
Unit, Division of Nutrition, New York State Department of Health,
Menands, NY
SHUMEI S. SUN, W. Hans Carter Professor and Chair, Department of
Biostatistics, School of Medicine, Virginia Commonwealth University,
Richmond (from July 2015)

Consultant
DONALD HEDEKER, Professor of Biostatistics, Department of Public
Health Sciences, The University of Chicago, IL
Study Staff
MEGHAN QUIRK, Study Director
JANET MULLIGAN, Senior Program Associate for Research (until
January 2016)
ANNA BURY, Research Assistant (from December 2015)
RENEE GETHERS, Senior Program Assistant
ANN L. YAKTINE, Director, Food and Nutrition Board
vi

Reviewers
This report has been reviewed in draft form by individuals chosen

for their diverse perspectives and technical expertise. The purpose of this
independent review is to provide candid and critical comments that will
assist the institution in making its published report as sound as possible
and to ensure that the report meets institutional standards for objectivity,
evidence, and responsiveness to the study charge. The review comments
and draft manuscript remain confidential to protect the integrity of the
deliberative process. We wish to thank the following individuals for their
review of this report:
Lawrence D. Brown, University of Pennsylvania

Christina D. Economos, Tufts University
Barbara C. Hansen, University of South Florida
Shiriki Kumanyika, University of Pennsylvania Perelman School of
Medicine
Cynthia L. Ogden, Centers for Disease Control and Prevention
Louise Ryan, University of Technology Sydney
David A. Savitz, Brown University
Andrea Sharma, Centers for Disease Control and Prevention
Anna Maria Siega-Riz, University of Virginia
Marion Standish, The California Endowment
Mary T. Story, Duke University
Although the reviewers listed above have provided many constructive

comments and suggestions, they were not asked to endorse the conclusions
vii

viii REVIEWERS
or recommendations nor did they see the final draft of the report before its
release. The review of this report was overseen by Eileen T. Kennedy, Tufts
University, and Diane F. Birt, Iowa State University. They were responsible
for making certain that an independent examination of this report was
carried out in accordance with institutional procedures and that all review
comments were carefully considered. Responsibility for the final content of
this report rests entirely with the authoring committee and the institution.

Preface
Obesity prevalence and trend estimates are at the crux of informing

research, policies, and interventions. Stakeholders at the national, state,
regional, local, and community levels search for information relevant to
their particular jurisdictions to know how best to proceed. Often times,
however, the available estimates appear to provide different accounts of the
same issue. Obesity prevalence could be increasing, decreasing, or stabiliz-
ing depending on which published report is being considered. Underlying
these seemingly conflicting results are not only fundamental principles of
epidemiology and statistics, but also methodological approaches specific to
the assessment of obesity. The interplay of these factors can make interpre-
tation and application of the results challenging. It is the intent of this con-
sensus report to examine key elements that affect the meaning of an obesity
prevalence and trend estimate in order to help those seeking to use the
published reports to systematically inform the decisions they need to make.
Prior to my involvement with this consensus study, I thought review-
ing published reports was a relatively straightforward process. I relied on
my training and experiential knowledge to guide my understanding of the
findings. As a researcher who collects height and weight data on preschool-
aged children, I was well aware of how difficult it can be to measure a
young child, but also how critical it is in accurately assessing obesity sta-
tus. As a medical doctor who has seen the demographic characteristics of
my patient population change over time, I have encountered influxes and
effluxes of population groups that exhibit different levels of obesity risk and
have recognized that this has direct implications for understanding obesity
prevalence and trends in my community. Now at the end of this study, I
ix

x PREFACE
am struck by the number of factors the committee identified as having an

impact on obesity prevalence and trend estimates.
In preparing this report, the committee was primarily guided by two
perspectives. First was the viewpoint of the investigator conducting a study
that eventually leads to a published report. Second was the perspective
of those at the national, state, and local levels who use reports to inform
decision making (hereafter referred to as “end users”). The committee envi-
sioned a range of end users, including but not limited to, policy makers and
program planners at government public health agencies or nonprofit orga-
nizations; persons working in other public agencies (e.g., transportation,
planning, parks and recreation), state legislatures, and educational institu-
tions; private sector foundations and corporations; researchers and other
data generators; and health care providers and payers. Given the array of
potential end users, each with their own unique information needs and
decisions to make, the committee developed a conceptual framework for
extracting meaning from published reports that is intended to have broad
application. These two perspectives, however, do not operate in isolation,
and the committee foresees ways investigators and end users can enhance
their collaborations to improve the future of data collection, analysis, and
reporting. Advances that are on the horizon, both technological and other-
wise, have the potential to encourage these collective efforts.
The committee would like to thank those who made contributions to
this report. The Health and Medicine Division study staff included our
incredibly hard-working study director, Meghan Quirk; Janet Mulligan;
Anna Bury; and Renee Gethers. Their commitment to evidence and high
quality was evident in their everyday work. Ann Yaktine, Director of the
Food and Nutrition Board, gently guided us all toward our highest stan-
dards. The committee would also like to acknowledge the contributions of
Lynn Parker, Senior Scholar, who provided critical feedback on the report;
Anne Rodgers, who helped to organize and edit the report; Elena Ovaitt-
Weiss, who worked with the committee to design the framework; and Claire
Wang, who provided feedback during initial framework development.
This report represents the collective efforts of the committee. The
diverse perspectives—pediatrics, epidemiology, biostatistics, public health,
heath disparities, and beyond—truly enriched this final product. Each mem-
ber volunteered a substantial amount of time, with schedules that were
overbooked and that sometimes took them across the globe and different
time zones, to complete this report. The committee’s dedication to and
passion for wrapping their minds around the complexities of the topic
was apparent throughout this study process. It is one of life’s greatest joys

PREFACE xi
to work with inspirational, intelligent colleagues who push you to think

deeply. I am grateful for their dedication and hard work.
Shari Barkin, Chair

Committee on Evaluating Approaches to Assessing


Contents
Summary 1
1 Introduction 17
2 Context 27
3 Methodological Approaches to Data Collection 57
4 Comparison of Data Sources Used to Assess Obesity Prevalence

and Trends 89
5 Analytic Approaches and Considerations 123
6 Framework for Assessing Prevalence and Trends in Obesity

to Inform Decision Making 161
7 Conclusions and Recommendations 179
8 Future Directions for Filling Data Gaps 189
xiii

xiv CONTENTS
APPENDIXES
A Acronyms and Glossary 199
B Public Workshop Agenda 209
C Literature Search Approach 213
D Presentation of Findings 215
E Committee Member Biographical Sketches 279

Summary 1
The ability to answer research questions about measures of obesity prev-

alence in the population and trends in obesity among population subgroups
depends on skillful research design. Consideration also must be given to the
range of methodological approaches available and how such approaches
apply to a given problem. The conduct of a study focusing on any research
question encompasses a range of methodologies, including randomized
controlled trials and observational research: prospective and retrospective
cohort, case-control, and cross-sectional studies. Each approach has strengths
and weaknesses and the application of a given approach to a specific research
question will affect how research findings are interpreted and applied.
The current literature of reports on obesity includes estimates of preva-
lence and trends for various population groups throughout the United
States. The data sources from which these estimates are derived range from
local initiatives to national surveillance programs, differing from each other
in terms of resources, intent, funding, and approach. Data from population
surveys, school-based assessments of body mass index (BMI), electronic
health records (EHRs), and cohort studies have all been used to describe the
status of obesity in the population. Differences across analyses are driven
by the specific question(s) being asked, the quantity and quality of the data,
and the approach used by the investigators.
Challenges exist in the collection and analysis of data across population
groups and subgroups within the population. Many relate to epidemiologi-
1 Thissummary does not contain references. Citations to support statements made herein
are given in the body of the report.

2 ASSESSING PREVALENCE AND TRENDS IN OBESITY
cal and statistical issues, but not to the age of participants. Populations that
include children, however, require distinct considerations. These involve
changes in body composition due to growth, small measurement errors
that can affect weight status classification for young children, and the need
to collect information from the child’s parent or guardian, among others.
These considerations must be factored into the study design, the data col-
lection procedures, and the analytic approach. How investigators overcome
such methodological challenges affects the estimate that is produced.
Accurate and meaningful population estimates of obesity prevalence
and trends are fundamental to understanding and describing the scope of
the issue. Policy makers, program planners, and other stakeholders at the
national, state, and local levels are among those who search for reports
relevant to their population(s) of interest to inform their decision making.
The differences in the data collection, analysis, and reporting, up to this
point, have produced a body of evidence that is inconsistent. As a result,
those who use estimates of obesity prevalence or trends are challenged with
interpreting and appropriately applying information derived from reports.
STUDY TASK AND APPROACH

To better assess and apply published reports on obesity prevalence
estimates and trends and to consider strategies for future research on these
issues, the Robert Wood Johnson Foundation (RWJF) asked the National
Academies of Sciences, Engineering, and Medicine to convene an expert
committee. It requested that the committee examine the approaches to data
collection, analysis, and interpretation that have been used in recent reports
on obesity prevalence and trends at the national, state, and local levels, par-
ticularly among U.S. children, adolescents, and young adults (see Box S-1).
The committee comprehensively reviewed and assessed sources directly
relevant to its task. To be inclusive, it considered a wide range of infor-
mation from the peer-reviewed literature, along with publicly available
national, state, and local research and surveillance sources. The review
of the evidence allowed the committee to broadly examine the landscape of
data collection, analysis, and reporting related to obesity prevalence and
trends. In addition to reviewing the literature, the committee held a public
workshop that included the perspectives of investigators who collect and
analyze obesity data, along with stakeholders who rely on reports of such
analyses to inform decision making. The committee also considered public
comments received through an online submission system. From these activi-
ties, the committee developed a framework for assessing and interpreting
reports on obesity prevalence and trends and recommendations for evaluat-
ing published reports, improving future data collection efforts, and filling
data gaps.

SUMMARY 3
BOX S-1
Statement of Task
An ad hoc committee under the auspices of the National Academies of Sci

ences, Engineering, and Medicine will examine methodological approaches to
data collection, analytic procedures, and interpretation of data at the national,
state, and local levels on issues related to obesity status in U.S. populations,
principally children, up to 18 years of age, with consideration for inclusion of indi
viduals up to 21 years of age and measures of trends in obesity. The committee
will comment on data sources and limitations to data gathering among different
population groups and advantages or disadvantages to approaches associated
with recent reports on both prevalence and trend data collected at the national,
state, and local levels. The committee will also consider the best approaches
to evaluating differences in trends among diverse population groups, especially
those at social and economic disadvantage. A brief workshop summary of the
presentations and discussions at the data-gathering workshop will be prepared by
a designated rapporteur in accordance with institutional guidelines. Based on the
available evidence, the committee will develop a framework for assessing s tudies
on trends in obesity, principally among children and young adults, for policy
making and program planning purposes. The framework will guide assessment
of the strengths and weaknesses of studies on prevalence and trends in obesity
in the population groups of interest. The committee will recommend ways deci
sion makers and others can move forward in assessing and interpreting reports
on obesity trends. To guide future research, recommendations will be made on
options for improving data collection and filling data gaps.
THE LANDSCAPE OF DATA COLLECTION,

DATA SOURCES, AND ANALYTIC APPROACHES
BMI, calculated from an individual’s height and body weight, is the
prevailing measure used to determine whether a person has obesity and to
assess obesity prevalence and trends. Common data sources that capture
height and weight data include population surveys, school-based assess-
ments, clinical and public health administrative data, and cohort studies.
From a design perspective, these data sources differ from each other in the
use of and approach to sampling, the population represented, the setting in
which data are collected, and the total sample size.
Height and weight data can be obtained through direct measure, proxy-
report, or self-report. Various protocols are used to directly measure height
and weight, and differences exist in the questions used to collect reported
data. Obesity prevalence estimates based on proxy- and self-reported data
are typically not equivalent to estimates derived from directly measured
data. This affects the comparability of estimates based on data sources

using different approaches to collecting height and weight data. Despite this
limitation, specific data sources that use proxy- or self-report are filling data
gaps that would otherwise exist, especially across states and select localities.
Demographic data are used to assess the representativeness of a sample
and often serve as the basis for creating subgroups for analysis. Subgroups
analyses provide insight into who is affected, to what extent, and if trends
differ between groups. Although not all comparisons are evaluations of
health disparities, the assessment of health disparities typically rely on
demographic characteristics. The characteristics that are captured, the mea-
sures used to capture the data, and the level of specificity of the measures
vary across data sources. The differences in measures and methods make
comparisons challenging. Beyond subgroup analyses, demographic data can
also be used to help researchers and stakeholders recognize and account
for demographic shifts in a population that can affect the interpretation of
trends analyses. This consideration will continue to play an important role
as the demographic composition of the United States changes.
In analyzing data, investigators select what criterion will be used to clas-
sify obesity status. For adults, the standard cut point is a BMI of 30 kg/m2
or greater. For children, adolescents, and young adults, classification requires
comparison to a reference population. Although the 2000 Centers for Dis-
ease Control and Prevention (CDC) sex-specific BMI-for-age growth charts
are most commonly used, others exist. Use of different reference populations
can lead to estimates of prevalence that differ from each other, and as such
are not interchangeable. The way in which extreme height, weight, and/or
BMI values are identified in a dataset and subsequently handled can also
affect the prevalence estimate.
When assessing the data, investigators, policy makers, and other stake-
holders must apply a number of considerations, including an assessment of
the response rate, evaluation of missing data, and, if applicable, the weight-
ing of the sample. The bounds of statistical analyses are determined, in
part, by the sample size, which affects how the sample and the time periods
are grouped in the analysis. For trend analyses, considerations include the
beginning and end dates and time intervals used to define the trend.
FRAMEWORK FOR ASSESSING

PREVALENCE AND TRENDS IN OBESITY
The variations in the methods, data sources, and analytic approaches
used to estimate obesity prevalence and trends has made navigating and
understanding the literature challenging. Interpreting an estimate requires
attention to the details, nuances, and caveats of published reports. Evaluat-
ing studies for the purpose of informing a decision requires more than inter-
preting the statistical analysis. Appropriate application of reports involves

SUMMARY 5
consideration of how the parameters of the estimate align with a user’s spe-
cific information need. A wide range of policy makers, program planners,
and others use or seek to use reports on obesity to inform decision mak-
ing (hereafter referred to as “end users”; see Box S-2). To help end users
interpret and apply estimates, the committee offers the Assessing Prevalence
and Trends (APT) Framework (see Figure S-1). The proposed framework
provides a conceptual process for how end users can approach published
reports, consider the strengths and weaknesses of obesity data estimates,
and synthesize the information for the purposes of decision making.
The Three Phases of the Assessing Prevalence

and Trends (APT) Framework
The assessment process is separated into three phases: (1) identifica-
tion of goal or information need, (2) assessment of published report(s),
and (3) synthesis to inform decision making. Driving the assessment are
questions related to each of the framework elements. An expanded list of
questions is provided in the body of the report.
BOX S-2
Examples of Potential End Users of
Obesity Prevalence and Trends Reports
• State and local health departments

• Elected officials, state legislatures
• Community-based organizations
• Departments of education, school districts, and schools
• Public agencies (e.g., transportation, planning, parks and recreation)
• Nonprofit and philanthropic organizations
• Advocacy organizations
• Academic researchers and other data generators
• Health care providers
• Health care payers
• Private sector
NOTE: The list is not intended to be exhaustive, but rather illustrative of the range
that exists.

6
FIGURE S-1 The Assessing Prevalence and Trends (APT) Framework: Interpreting Obesity Reports. Assessment of published reports
to inform decision making is contextually framed in the end user’s intended use of the findings.

a Population refers to individuals assessed in the report.
b Methodology refers to all the elements related to study design and data collection.
c Analysis refers to all elements related to data processing, cleaning, and statistical analysis.
SUMMARY 7
Phase 1: End User’s Identification of Goal

In the first phase of the framework, end users identify their goal for
assessing the report(s). This includes a consideration of the decision to be
made as well as the need for additional information to fill gaps in the evi-
dence. Achieving clarity on their goal helps end users determine the utility
of the report findings relative to their unique information needs. End user
goals will vary in depth, complexity, and specificity.
Phase 2: Assess Published Report(s)

In the second phase of the assessment process, end users evaluate
the published report(s). The three core components of a report (popula-
tion, methodology, analysis) inform the interpretation of the estimate. The
dynamic assessment of these three components in the context of each other
provides a means for end users to consider how the approach taken in one
may have benefited or limited one or both of the other components. By the
end of the assessment of the report(s), end users should clearly understand
the parameters associated with the estimate.
Phase 3: End User’s Synthesis to Inform Decision Making

In the final phase of the assessment process, end users turn back to
their goal in order to synthesize and interpret the report(s) findings in the
context of their information needs for decision making. To accomplish this,
end users first weigh the strengths and weaknesses of each report, initially
in consideration of the report’s strengths and weaknesses generally, then in
relation to their specific information needs and decision-making priorities.
End users will categorize a given feature of a report differently, depend-
ing on their overall objective and the data gap they are trying to fill. For
example, some would consider state-representative samples a strength of
a report, while others at the community level may view this parameter as a
weakness for their particular decision-making process. Once end users have
established what the strengths and weaknesses are, they then determine
how the findings inform their decision.
UNDERLYING PRINCIPLES OF THE FRAMEWORK

The APT Framework is intended to serve as a starting point for those
who wish to better understand and apply published reports. It is grounded
in six underlying principles discussed below and summarized in Box S-3.

BOX S-3
A Summary of the Underlying Principles of the APT Framework
1. The APT Framework can be used both for assessing individual reports and for
synthesizing multiple reports.
2. A variety of end users can use the APT framework.
3. An end user’s goal informs the application of any report or reports.
4. The three core components of a published report are interdependent.
5. Questions lead the end user through the assessment process.
6. The APT Framework facilitates an assessment of the evidence to inform the
decision-making process.
The APT Framework Can Be Used Both for Assessing

Individual Reports and for Synthesizing Multiple Reports
The number of reports assessed and how they are evaluated through the
APT Framework will depend on the goal of the end user and the availability
of reports related to the goal. In some instances, the framework would be
used to assess a single report. In other instances, an end user can start by
using the framework to identify the parameters that define the individual
estimates, and then progressively consider them together. In practice, a
broader assessment of multiple reports would bolster the decision making.
However, given the limitations of the current state of the literature, the
committee recognizes that pertinent information may reside only within a
single report for certain end users’ goals.
A Variety of End Users Can Use the APT Framework

It is anticipated that end users will have various backgrounds and
expertise. The intent of the framework is to provide sufficient guidance
on the elements that affect the interpretation and application of estimates,
while remaining general enough to accommodate the diverse literature and
the broad array of decisions that may be informed by obesity prevalence
and trends reports.
An End User’s Goal Informs the Application of Any Report or Reports

Reports on obesity prevalence and trends are generally designed to
address a specific set of questions within a defined set of parameters. The
estimates presented in reports are guided not only by the question the
report’s authors sought to answer, but also by the methodologies used and

SUMMARY 9
analytic limits of the collected data. The APT Framework directs the end
user to further this line of thinking and reflect on the type of information
that is needed to inform their decision making.
The Three Core Components of a Published Report Are Interdependent

Three core components in a report inform the interpretation of an
obesity prevalence or trend estimate: the population assessed, the method-
ologies employed, and the analysis approach used. These components do
not exist or operate in isolation, but are interdependent. The assessment
of reports necessitates a fundamental understanding of each of these com-
ponents in relation to the each other. As such, appraisal of the population,
methodology, and analysis is not a linear process; rather, it is dynamic and
iterative.
Questions Lead the End User Through the Assessment Process

In each of the phases of the APT Framework, the end user is prompted
to consider pertinent guiding questions to ask, as represented by the lower
portion of the visual. The questions that appear on the figure itself serve as
a starting point, with an expanded list of potential questions to guide the
assessment provided in the body of this report. End users may find some
questions more relevant to their specific information needs than others,
and as they are thinking through the evaluative process, they may develop
questions of their own.
The APT Framework Facilitates an Assessment of the

Evidence to Inform the Decision-Making Process
In the first phase of the framework, identification of the end user’s goal
directs the assessment with the specific information need. The second phase
of the framework guides identification of the bounds of an estimate. The
final phase brings the first two phases together, and the end user considers
how that estimate compares to the information being sought. By using
the end user’s goal to contextually frame the assessment process, the APT
Framework highlights the interface between reading a report for meaning
and using the findings for a specific application.
CONCLUSIONS
The interpretation of obesity prevalence and trends estimates is contin-
gent on considerations specific to the assessment of obesity status, principles
that are founded in epidemiology and concepts that are fundamental to

statistics. This interplay of elements, which span from general to specific,

is reflected in the committee’s conclusions. Much of the available evidence
indicates that at the core of several of the current limitations are seemingly
basic challenges faced by any population-based prevalence or trends evalua-
tion. The fact that these issues exist, however, underscores the challenges of
finding viable solutions. The committee’s conclusions focus on key domains
that cut across the broad literature base. These include current sources of
data, data for specific population groups, measured versus reported data,
estimates of changes and trends over time, and interpretation of estimates.
Current Sources of Data

A wide variety of data sources capture height and weight data, but
differ from each other by design, sample size, target population(s), geo-
graphic representation (e.g., national; multiple states and localities; rural
and urban regions), and collection method. Few data sources are designed
to generate estimates of multiple states and those that do tend to describe
select population groups.
Conclusion 1: The committee concludes that existing data sources used

to estimate prevalence and trends in obesity vary by factors, including
study design, geographic representation, data collection methodolo-
gies, and overall intent. Each offers specific and distinct information
about the state of obesity. The differences between data sources, how-
ever, can limit the comparability of reports.
Data for Specific Population Groups

Investigators divide analytic samples into subgroups to determine the
extent to which obesity prevalence and trends vary within a broader popu-
lation. The factors defining the groups (e.g., span of ages, race and ethnic-
ity categories) can vary widely across reports, even those that analyze data
from the same data source. Published reports often cite inadequate sample
size as the reason for omitting one or multiple subgroups from an analysis
or combine heterogeneous groups into a single category.
Conclusion 2: The committee concludes that inclusion of subgroups

in data sources provides essential insight into how obesity prevalence
and trends estimates vary within and between population groups.
However, insufficient sample size is a primary limitation to generating
reliable estimates.

SUMMARY 11
Measured Versus Reported Data

Height and weight data used to calculate BMI are collected through
direct measurement, proxy-report, and self-report. Within each collection
approach, variability exists in the specific data collection protocol. Proxy-
and self-reported height and weight questions have been incorporated into
various population surveys in which factors such as the overall design and
mode of delivery (e.g., phone interview) do not allow for direct measure-
ment. These surveys often have large sample sizes and some have been used
to generate estimates that are compared across states and select localities.
Evidence indicates that use of proxy-reported data for young and school-
aged children generally does not lead to accurate estimates of obesity
prevalence. Limited evidence, based on different nationally representative
surveys, suggests that trends in obesity estimated from self-reported and
directly measured heights and weights among high school-aged individuals
exhibit similar patterns, albeit at different values.
Conclusion 3: The committee concludes that although all measures

have limitations, directly measured height and weight data collected
using a standardized protocol provide the best estimates of obesity
prevalence. Self- and proxy-reported height and weight data can be
used to fill data gaps and provide insight into overall obesity trends,
although these data collection methods do not produce prevalence
estimates comparable to those based on direct measure.
Estimates of Changes and Trends Over Time

Published reports assessing obesity prevalence over time have presented
findings as change (the difference between two time points) or trends (the
difference over three or more time points). Such estimates pertain only to
the specific time points included in the analyses. Trend estimates typically
become more precise and nuanced as the number of time points increases.
However, the number of time points is dependent, in part, on the reliability
of the prevalence estimates. Investigators often combine multiple years or
cycles of data to increase the reliability of the estimates used to determine
the trend, thereby reducing the number of data points. Changes to the time
interval included in the trend analyses directly affect the estimate and its
interpretation.
Conclusion 4: The committee concludes that comparability of trend

reports is enhanced when analyses use similar start and end dates and
time intervals to define the trend.

Interpretation of Estimates
Factors that affect the meaning of obesity prevalence and trends esti-
mates not only include characteristics of a data source, but also encompass
decisions made during analysis. Data sources differ with respect to who the
sample is designed to represent and who contributes data. Changes to the
sampling or data collection procedures over time affect what data are avail-
able for trend analyses. The portion of the overall sample that is used for
analysis varies across published reports for a number of reasons, including
what question(s) is being asked of the data, how the data were prepared for
analysis, and whether the sample size led to reliable estimates of prevalence.
The statistical analyses are varied and are guided by the intent of the specific
report, the quality control measures taken during data collection, the study
design from which the data were derived, and the amount of data available.
Conclusion 5: The committee concludes that appropriate interpretation

of estimates of obesity prevalence and trends requires consideration of
the population in the sample, the data collection methodologies, and
the analytic procedures together in a guided way.
RECOMMENDATIONS
Data sources that capture height and weight largely operate in isolation
or within a single surveillance system, resulting in designs and protocols that
differ from each other. Although these differences often limit comparability
of prevalence and trend estimates, their existence underscores the diverse
context in which decisions and compromises have to be made in the design,
collection, and analysis of the data. The committee offers recommendations
in three areas: assessing published reports on obesity prevalence and trends;
improving future data collection efforts; and conducting research to address
data gaps.
Assessing Obesity Prevalence and Trends Reports

Because understanding and appropriately applying estimates of obesity
prevalence and trends is a complex process, the committee provides the
APT Framework as a conceptual guide for those who seek to better under-
stand and use reports. The framework draws on the committee’s synthesis
of key considerations related to inconsistencies that exist in the literature
while simultaneously drawing on fundamental principles of epidemiology
and statistics. The committee considers determining the utility of estimates
presented in published reports a highly individualized process, guided by
the end user’s overall goal and specific information needs.

SUMMARY 13
Recommendation 1: The committee recommends that stakeholders

who use or seek to use estimates of obesity prevalence and trends to
inform policy making, program planning, and decision making follow
the Assessing Prevalence and Trends (APT) Framework to guide their
interpretation of published reports.
The committee recognizes that end users who operate at the national,
state, and local levels often have different information needs. The extent to
which available analyses meet those needs varies considerably. Individual
end users are therefore likely to have different priorities when it comes to
the strengths and weaknesses of published reports. In order to be adaptable
to a range of possible applications, the APT Framework integrates consid-
eration of the end user’s context to guide the assessment.
Future Data Collection

This report serves as an important starting point for moving toward
comparable, more unified data collection, analysis, and reporting practices.
Current practices, however, are determined by more than just the analytic
and scientific rationale presented in a published report. Factors such as cost,
existing infrastructure, and available resources play a role in the selection of
a study design and the success of its implementation. Explicit, prescriptive
guidance on specific methodologies to be used by the research and public
health surveillance communities requires consideration of the experiential
knowledge of those who fund, develop, and carry out such activities.
Recommendation 2: The committee recommends that an organization

with a track record of cross-sector leadership in the field of obesity,
such as the National Collaborative on Childhood Obesity Research or
the Robert Wood Johnson Foundation, convene relevant stakeholders
to examine and identify feasible and practical approaches to stan-
dardizing methodologies for data collection and reporting, appropri-
ate for application at the national, state, and local levels to enhance
comparability of obesity prevalence and trend analyses.
To include a range of participants, the committee recommends that

the organization(s) sponsoring the proposed activity not only be nation-
ally prominent, but also have strong ties to diverse stakeholders who
operate at the state and local levels. The organizations included in the
recommendation—the National Collaborative on Childhood Obesity

Research (NCCOR) and the Robert Wood Johnson Foundation (RWJF)—
have missions and experience that are aligned with the recommendation
goals. NCCOR and RWJF are two examples of potential conveners. How-

ever, the committee notes that other conveners or collaborators may enrich
the proposed activity as well.
The committee further recommends that a broad range of stakeholders
who operate at the national, state, and local levels participate in this
activity, including, but not limited to
• Local and state public health agencies;

• Federal governmental agencies (e.g., CDC, U.S. Department of
Agriculture, Agency for Healthcare Research and Quality);
• Community-based organizations;
• School officials (e.g., state Departments of Education; superinten-
dents; school nurses and physical education teachers);
• Academic researchers;
• Research organizations;
• Research funders;
• Obesity-oriented and public health professional organizations;
and
• Other decision makers who operate at the national, state, and local
levels.
Research to Address Gaps

The assessment of obesity prevalence and trends estimates continues to
change with technological, methodological, and statistical advancements.
Some of the inconsistencies and limitations that currently exist in the litera-
ture represent prime opportunities for improvement and progress.
Recommendation 3: The committee recommends that the research

community design and conduct studies to strengthen the evidence base
and improve methodological approaches to assessing obesity.
Because opportunities for improvement encompass a wide range of dis-

ciplines, the research community described in the recommendation includes,
but is not limited to, federally-funded researchers, clinical researchers,
social scientists, and engineers.
Specific research initiatives could include
• Evaluating how the 2000 CDC BMI-for-age growth charts can

better provide continuity to obesity classification across the life
course. The committee acknowledges that the 2000 CDC BMI-
for-age growth charts are the predominant reference currently in
use in the United States for children ages 2 years and older and

SUMMARY 15
recognizes the importance of its continued use as a platform for

comparing estimates of obesity among children and adolescents.
The committee anticipates findings from current and future initia-
tives (e.g., the Dietary Guidance Development Project for Birth to
24 Months and Pregnancy [B-24/P], the INTERGROWTH-21st
Fetal and Newborn Growth Consortium, and the Environmen-
tal Influences on Child Health Outcomes [ECHO] Program) will
inform an evidence-based consensus on how weight status should
be classified for children younger than age 2 years. Additionally,
opportunities exist to clarify when and how to best transition
young adults to the adult criterion for obesity classification.
• Identifying appropriate measures of core demographic variables—
including but not limited to race and ethnicity, socioeconomic
status, and rurality—that can be captured in a consistent manner
across various data collection efforts at the national, state, and
local levels. As the demographic landscape of the country continues
to change, it will become increasingly vital to characterize popula-
tions in ways that capture the existing diversity.
• Developing innovative, practical, and accurate tools for assessing
adiposity. Although BMI is the predominant measure of relative
weight used to classify obesity status, it is not without limitations.
For the purposes of population-based assessments, a new measure
of obesity will need to be a simple alternative that provides com-
parable or improved predictive ability, can be measured accurately
in a variety of settings, and is relevant to diverse population groups
across the life course.
• Preventing the misclassification of data from individuals with
severe obesity as biologically implausible values. Technology-
based systems that are used for direct data entry often have
features that automatically detect extreme values in height and
weight. Identification at the time of measurement allows for the
values to be corrected or properly documented. Data collection
procedures that first record measurements on paper or in sys-
tems without automatic detection of extreme values often have
limited ability to check the quality of data until entry into a
database or analysis. Opportunities exist to expand the use of
technology in data collection to enhance the accuracy of recorded
measurements.
• Identifying innovative opportunities to capture longitudinal data
throughout childhood. A variety of data sources—including EHRs
and school-based BMI assessments—are primed to be used in
novel ways to serve as the basis for or supplement longitudinal
evaluations.

CONCLUDING REMARKS
This report evaluates the strengths and weaknesses associated with
existing approaches to collecting obesity data, creating estimates of obesity
prevalence, and assessing trends. It also recommends ways to systemati-
cally assess obesity-related reports, given these strengths and weaknesses,
in order to understand and interpret the information the reports provide.

Introduction
Key Messages
• Barriers exist to understanding the obesity prevalence and
trend literature because of inconsistencies in data collection
and analysis approaches.
• To better understand, evaluate, and apply the current litera-
ture and to consider strategies for future research, the Robert
Wood Johnson Foundation asked the National Academies of
Sciences, Engineering, and Medicine to convene an expert com-
mittee to examine the approaches to data collection, analysis,
and interpretation that have been used in recent reports on
obesity prevalence and trends at the national, state, and local
levels, particularly among children, adolescents, and young
adults.
• To address its task, the committee considered a wide range of
materials from the peer-reviewed literature, along with publicly
available national, state, and local research and surveillance
sources and held a public workshop.
• This report includes an examination of current approaches to
data collection and analysis, offers a conceptual framework for
assessing and interpreting reports on obesity prevalence and
trends, and provides recommendations for evaluating reports
and improving future research initiatives.
17

Obesity has come to the forefront of the American public health

agenda. The increased attention has led to a growing interest in quantify-
ing obesity prevalence and determining how the prevalence has changed
over time. Consequently, a wide range of reports have been published that
present estimates of prevalence and trends in obesity for various population
groups throughout the United States. The data sources from which such
estimates are derived range from local initiatives to national surveillance
programs, differing from each other in terms of resources, intent, funding,
and approach. Differences extend into the analyses, which are driven by the
specific question(s) being asked, the quantity and quality of the data, and
the analytic capabilities of the investigators.
Challenges exist in the collection and analysis of data across all popula-
tion groups and in subgroups of the population. Many are rooted in epide-
miological and statistical principles, and are independent of the age of the
participants. Evaluations inclusive of children, however, have some distinct
considerations. Body composition, for instance, changes as a child grows
and maturates, which affects the way obesity status must be classified. It
can be difficult to obtain accurate measurements on young children, an age
group in which small differences can change obesity status classification.
For many studies, data collection often must include gathering information,
in part or entirely, from the child’s parent or guardian. Although far from
exhaustive, these considerations must be factored into the study design, the
data collection procedures, and the analytic approach. How investigators
overcome methodological challenges ultimately informs the interpretation
of estimates.
Accurate and meaningful estimates of obesity prevalence and trends are
fundamental to understanding and describing the scope of the issue. Policy
makers, program planners, and other stakeholders at the national, state,
and local levels are among those who search for estimates relevant to their
population(s) of interest to inform their decision making. The differences
in the collection, analysis, and interpretation of data have given rise to a
body of evidence that is inconsistent and has created barriers to applying
published reports (see examples in Box 1-1). As such, there is a need to
provide guidance to those who seek to better understand and use estimates
of obesity prevalence and trends.
STUDY CHARGE, APPROACH, AND SCOPE
Study Charge
To better understand, assess, and apply the current literature and to
consider strategies for future research, the Robert Wood Johnson Founda-
tion (RWJF) asked the National Academies of Sciences, Engineering, and

INTRODUCTION 19
BOX 1-1
Illustrative Examples: Challenges of Interpreting
Obesity Prevalence and Trends
The following highlights three examples of challenges that exist when trying to
understand an estimate of obesity prevalence or trend.
Summary of the Findings Lacks Sufficient Details
Not all reports presenting estimates provide a detailed account of the data
collection and analysis procedures. Ritzman and Elmore (2006), for example,
authored a statistical brief intended for health care professionals that described
the weight status of middle and high school students from two cycles of the North
Carolina Youth Risk Behavior Survey. A footnote explained the data were col
lected through self-report written surveys, but did not expand on how students
were selected or what statistical procedures were undertaken, which can affect
the interpretation of the findings. Although briefs and summaries of this nature
are often readily understandable to those with limited knowledge of the field, their
brevity may prevent a comprehensive assessment of the results.
Multiple Reports Generating Different Estimates
It is not uncommon to find different estimates of obesity prevalence and trends

for the same population. For instance, the prevalence of obesity among Mississippi
high school students in 2013 was estimated to be 15.4 percent (95 percent con
fidence interval [CI]: 13.1-17.9 percent) in one report (Kann et al., 2014) and
23.5 percent (95 percent CI: 20.6-26.7 percent) in another (Zhang et al., 2014).
The two reports arrived at substantially different values, in part, because the former
used self-reported height and weight and the latter used directly measured values.
Combining Population Groups
Reports often divide a sample into groups for comparisons. When the sample
size for one or more of the groups is relatively small, the estimate may not be
reliable. One option to overcome this limitation is to combine groups. A report
using data from a population-based study of 616 elementary school students, for
example, separated race into two categories: white (74.7 percent of the entire
sample) and non-white (25.3 percent of the entire sample) (Rodriguez-Colon et
al., 2011). The non-white group was composed of students identifying as Black,
Hispanic, or Asian. Combining the three race and ethnicity groups allowed the
investigators to proceed with statistical analyses, but affected the interpretation
of the calculated prevalence. The estimate reflected the group collectively, but did
not allow for interpretation for each distinct racial and ethnic group.

Medicine to convene an expert committee to examine the approaches to

data collection, analysis, and interpretation that have been used in recent
reports on obesity prevalence and trends at the local, state, and national
levels, particularly among children, adolescents, and young adults (see
Box 1-2).
Study Approach
The committee was comprised of 12 members with expertise in public
health nutrition, epidemiology, pediatrics, public policy, health disparities,
obesity prevention and treatment, statistics and biostatistics, health assess-
ment, and data collection and analysis methodologies (see Appendix E for
biographies of the committee members).
The committee performed a comprehensive review and assessment
of sources directly relevant to its task. To be inclusive, the committee
considered a wide range of materials from the peer-reviewed literature,
BOX 1-2
Statement of Task
An ad hoc committee under the auspices of the National Academies of Sci

ences, Engineering, and Medicine will examine methodological approaches to
data collection, analytic procedures, and interpretation of data at the national,
state, and local levels on issues related to obesity status in U.S. populations,
principally children, up to 18 years of age, with consideration for inclusion of indi
viduals up to 21 years of age and measures of trends in obesity. The committee
will comment on data sources and limitations to data gathering among different
population groups and advantages or disadvantages to approaches associated
with recent reports on both prevalence and trend data collected at the national,
state, and local levels. The committee will also consider the best approaches
to evaluating differences in trends among diverse population groups, especially
those at social and economic disadvantage. A brief workshop summary of the
presentations and discussions at the data-gathering workshop will be prepared by
a designated rapporteur in accordance with institutional guidelines. Based on the
available evidence, the committee will develop a framework for assessing s tudies
on trends in obesity, principally among children and young adults, for policy
making and program planning purposes. The framework will guide assessment
of the strengths and weaknesses of studies on prevalence and trends in obesity
in the population groups of interest. The committee will recommend ways deci
sion makers and others can move forward in assessing and interpreting reports
on obesity trends. To guide future research, recommendations will be made on
options for improving data collection and filling data gaps.

INTRODUCTION 21
along with publicly available national, state, and local research and sur-
veillance sources. The review of the evidence allowed the committee to
broadly examine the landscape of the collection of data and the reporting
of results related to obesity prevalence and trends. In addition to review-
ing the literature, the committee held a public workshop that included
the perspectives of investigators who collect and analyze obesity preva-
lence and trends data, along with stakeholders who rely on reports of
such analyses to inform decision making (see Appendix B for the work-
shop agenda). The committee also considered public comments received
through an online submission system. From these activities, the committee
developed a framework for assessing and interpreting reports on obesity
prevalence and trends and recommendations for evaluating published
reports, and filling data gaps improving future data collection efforts.
Scope
This report delineates the current practices, challenges, and consid-
erations related to data collection and analysis that ultimately affect the
interpretation of estimates of obesity prevalence and trends across popu-
lation groups, with a focus on children, adolescents, and young adults.
Study design and data collection options are described individually and as
they exist in a range of common data sources. Insight is offered into the
methodological approaches and analytical procedures that lead to subgroup
estimates and comparisons. Concepts related to subgroup differences are
discussed broadly and in the context of health disparities, a type of dif-
ference that exists due to social disadvantage. Because interpretation of
estimates requires the assessment of elements both narrow and broad in
scope, the committee explores analytic approaches specific to the assess-
ment of obesity and statistical considerations generally applicable to any
analyses of prevalence and trends. To synthesize the landscape of the litera-
ture and provide guidance on how to assess reports for decision making,
the committee offers a conceptual framework. Finally, by identifying the
inconsistencies that exist and exploring why they exist, the evidence pre-
sented throughout this report not only offers insight into the present state
of data collection efforts but also highlights opportunities for improvement.
Although the committee’s charge is circumscribed, the task encom-
passes tremendous complexity. To evaluate the evidence, the committee
defined the following elements of its task:
• Types of Recent Reports: Because the literature on obesity is expan-

sive and estimates reside in a variety of publication types, the com-
mittee chose to draw its evidence regarding the current practices
of “reports” primarily from peer-reviewed research and academic

journals.1 In considering population-based estimates of obesity

prevalence and trends, the committee limited the reports to those
that were observational in design, rather than interventional. The
committee, however, has made a statement on the role of interven-
tion studies in the assessment of obesity prevalence (see Box 3-1).
Although this evidence base misses some relevant publications,
such as those produced at the state and local levels, the committee
considered the impact of their omission to be minimal for sev-
eral reasons. First, the reports the committee evaluated encompass
a range of locations, geographic regions, and jurisdictions. Sec-
ond, some reports describing obesity at the local and state levels
are summaries of analyses conducted on data collected through
national surveillance systems, such as the Youth Risk Behavior
Surveillance System (YRBSS) or Pediatric Nutrition Surveillance
System (PedNSS). These summaries often present the findings, but
may not include the details of the approaches used for data col-
lection or analysis (see Box 1-1). Reports containing the primary
analyses of such data sources were included in the committee’s evi-
dence base. Because the intent of this report was not to be exhaus-
tive, the committee considered the published reports it evaluated
illustrative of the various methodological and analytic approaches
that exist in peer-reviewed literature and beyond, but recognizes
throughout that other options and approaches exist. A detailed
description of the selection of published reports can be found in
Appendix C, while summary tables of key characteristics of the
published reports can be found in Appendix D.
• Focus on Children, Adolescents, and Young Adults: Consistent
with its charge, the committee primarily evaluated data collection
and analysis methodologies in published reports that included pop-
ulation groups ages 18 years and younger. Brief discussions about
how specific methodologies differ for the assessment of children
and adults have been incorporated throughout the report, but are
not a main focus. In considering assessment of the weight status of
children, the age group birth to 2 years posed a challenge. As will
be further explained in Chapter 2 (see Box 2-1), current recom-
mendations and practices in the published literature do not sup-
port the use of the term “obesity” or the assessment of body mass
index (BMI) for the purposes of weight status classification for
this age group. Because this committee was tasked with evaluating
1 As described in Appendix C, most, but not all, of the reports were published in peer-
reviewed journals. For brevity, the reports that served as the evidence base will be referred to
as “published” throughout this report.

INTRODUCTION 23
methodologies in recent reports on obesity prevalence and trends,

the evidence base and discussions throughout largely describe the
assessment of children, adolescents, and young adults, ages 2 years
and older. Despite the relatively narrow focus, it should be kept in
mind that many of the principles of study design, data collection,
analysis, and interpretation are broadly applicable and several of
the concepts are largely independent of the participants’ age.
The intended audience of this report includes a wide range of policy

makers, program planners, and other stakeholders who seek to better under-
stand and appropriately use estimates of obesity prevalence and trends. This
includes organizations, groups, and individuals with diverse resources, skill-
sets, and expertise. Because the audience is broad, it is expected that levels
of comfort with reading and interpreting published reports will range the
gamut. This report serves as common ground, bringing together evidence
and key concepts that are intended to be widely applicable.
Many important topics are inherently linked to the content of this
report, but are beyond the scope of the committee’s task. This report serves
as an appraisal of the landscape of the literature, and is intended to facili-
tate the interpretation and application of estimates presented in published
reports. Although recommendations for advancing the field are offered,
the committee has not been charged with developing a prescriptive set of
best practices for data collection, analysis, and reporting or identifying
what resources would be required to implement changes. Furthermore, this
report is not intended to provide an overview of the etiology of obesity,
comprehensively evaluate its association with chronic disease, or provide
guidance on effective initiatives, interventions, policies, or other solutions.
Concepts related to health disparities are included, but the committee has
not been charged with examining the breadth of obesity disparities or
explaining how or why such disparities exist. Readers who are interested
in these topics should refer to the section in this chapter on Notable Past
Work for additional resources.
DEFINITIONS OF KEY TERMS

This section provides definitions of key terms that will be used through-
out this report. A full glossary can be found in Appendix A.
Obesity
Obesity describes a state of excess adiposity. Although various approaches
exist for assessing adiposity and describing obesity (see Chapter 2), published
reports on prevalence and trends most frequently use BMI. For adults, a BMI

≥30 kg/m2 is considered obese. For children, adolescents, and young adults,
a BMI must be compared to a BMI-for-age distribution seen in a reference
population and a cut point must be used for classification (see Chapter 2 and
Chapter 5). The prevailing cut point and reference population used in the
United States is the 95th percentile on the 2000 Centers for Disease Control
and Prevention (CDC) sex-specific BMI-for-age growth charts. As will be
discussed in Chapters 2 and 5, the 95th percentile describes the distribution
of the population from which the growth charts were derived, not the popu-
lation being evaluated. The prevalence of obesity within a sample different
than the reference population may be less than or greater than 5 percent.
Unless otherwise noted, the term “obesity” with respect to adults will refer
to a BMI ≥30 kg/m2 and with respect to children, adolescents, and young
adults will refer to ≥95th percentile on the CDC BMI-for-age growth charts.
Published Reports
Unless otherwise noted, the term “published report” describes a publi-
cation, peer-reviewed or otherwise, with original analysis that produces an
estimate of obesity prevalence or trend. Some publications are summaries of
primary analyses and may not contain details needed to adequately assess
the findings. In these instances, the reader is directed to the primary source
of the statistic, if available.
Estimate of Obesity Prevalence or Trend

The committee uses the phrase “estimates of obesity prevalence or
trend” or simply “estimate” to describe a statistic about the proportion or
number of individuals affected with obesity at one point in time (preva-
lence) or over time (trend).
Social Disadvantage and Health Disparities

Social disadvantage is a complex, multidimensional construct. A host of
factors, including but not limited to race, ethnicity, socioeconomic status, age,
gender, geography, religion, and sexual orientation create social disadvantage.
Many of the underlying factors have both biological and social components
(e.g., gender, race). Others are socially constructed (e.g., state boundaries).
Social disadvantage is of particular concern in relation to obesity because
disadvantage can create health disparities. The committee uses the phrase
“health disparities” to describe a health difference caused by the system-
atic marginalization, discrimination, or vulnerabilities that could be avoided
through different, more equitable circumstances (Braveman et al., 2011).

INTRODUCTION 25
End Users
The committee uses the term “end user” to describe individuals, groups,
or organizations who use reports on obesity prevalence and trends to inform
a decision.
NOTABLE PAST WORK

This report is the first consensus study conducted by the National
Academies of Sciences, Engineering, and Medicine to examine the effects
of data collection methodologies and analytic approaches on interpreting
estimates of obesity prevalence and trends. In addition to this report, a brief
summary of highlights from the committee’s public workshop has been
published (IOM, 2015b).
The Academies have previously convened and continue to engage in
activities exploring various aspects of obesity. Two earlier reports that
informed the committee’s work were Evaluating Obesity Prevention Efforts:
A Plan for Measuring Progress (IOM, 2013) and Bridging the Evidence
Gap in Obesity Prevention: A Framework to Inform Decision Making
(IOM, 2010). The Academies also have recently evaluated policy-related
strategies to preventing obesity (Early Childhood Obesity Prevention Poli-
cies [IOM, 2011a]; Legal Strategies in Childhood Obesity Prevention:
Workshop Summary [IOM, 2011b]; Local Government Actions to Pre-
vent Childhood Obesity [IOM et al., 2009]), assessed prevention efforts
(Cross-Sector Responses to Obesity: Models for Change: Workshop Sum-
mary [IOM, 2015a]; The Current State of Obesity Solutions in the United
States: Workshop Summary [IOM, 2014]; Accelerating Progress in Obesity
Prevention: Solving the Weight of the Nation [IOM, 2012]), and explored
etiology of obesity related to fetal and early life exposures (Examining
a Developmental Approach to Childhood Obesity: The Fetal and Early
Childhood Years: Workshop Summary [IOM, 2015c]).
In addition to this previous work by the Academies, the committee
was informed by stakeholder perspectives, peer-review reports on obesity
prevalence and trends, and data collection protocol manuals. This report
reviews this evidence in the following chapters.
ORGANIZATION OF THE REPORT

This introductory chapter has provided background information related
to the issues that led to the development of this study and the approach
the committee took to address the Statement of Task. Chapter 2 provides
additional contextual information related to the definition of obesity, obesity
across the lifespan, and differences in obesity status by demographic char-

acteristics. Chapter 3 discusses methodological considerations related to the

design and execution of data collection. Chapter 4 describes and compares
a range of common data sources and identifies existing gaps. Chapter 5 dis-
cusses the various analytic approaches that have been used in recent reports
and describes interpretive considerations associated with statistical analyses.
Chapter 6 presents a conceptual framework for interpreting and determining
the utility of reports on obesity prevalence and trends. Chapter 7 presents
the committee’s findings, conclusions, and recommendations. Finally, Chap-
ter 8 discusses innovations on the horizon for the field.
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Context
Key Messages
• Body mass index (BMI) is the prevailing approach used to
assess obesity status among children and adults.
• Development, growth, and maturation that occur during child-
hood and adolescence can affect the assessment of obesity status.
• For children and adolescents, BMI must be compared to a
reference population for classification, the most common of
which is the 2000 Centers for Disease Control and Prevention
BMI-for-age growth charts.
• Certain population groups appear to be disproportionately
affected by obesity. Demographic factors such as sex, age, race
and ethnicity, socioeconomic status, rurality, and geography
affect prevalence of obesity and interact with each other in
complex ways.
• Differences between groups are occurring amid changes to the
demographic landscape of the country.
To understand the utility of estimates of obesity prevalence and trends,

it is important to reflect on what these types of reports offer. Prevalence
studies describe the magnitude of the issue in one or more population groups
at a single point in time. Trends reports describe whether the prevalence is
increasing, decreasing, or staying the same in one or more population groups
27

over a defined period of time. Such information about the scope and status
of obesity within a population is descriptive and relatively circumscribed in
nature. However, it serves as key evidence for decisions related to policies,
strategies, advocacy, programs, and plans for forward progress.
Before considering specific methodological approaches and the complex-
ities associated with understanding and using such reports, several funda
mental concepts must first be considered. First is the definition of obesity.
Although many perceive it as a straightforward, dichotomous characteristic,
it can be assessed and categorized in various ways. Second is the concept of
obesity across the life course. Obesity during childhood, adolescence, and
young adulthood does not operate in isolation, and has implications for the
current and future health of the nation. Finally, the concept of subgroup
analyses is introduced. Although the prevalence of obesity can vary by a
host of factors, population-level assessments most consistently capture and
differentiate subgroups based on demographic characteristics. Framing this
concept is a discussion of social disadvantage and health disparities.
DEFINING OBESITY
Obesity is a general term that describes a state of excess adiposity (body
fat) (Krebs et al., 2007). Although this definition appears simple, it is a
condition with complex ties to biological, behavioral, and environmental
factors (Albuquerque et al., 2015; Rosenquist et al., 2015; Swinburn et
al., 1999). No single test definitively and universally identifies obesity. For
descriptive purposes, obesity must be operationalized into a metric that can
be categorized. As such, obesity status is classified based on a measure and
a criterion or cut point.
Approaches to Assessing Adiposity and Obesity Status

Obesity status is assessed in clinical, research, and public health set-
tings through a variety of approaches. Some evaluate body composition,
differentiating lean body mass from adipose tissue. Others are surrogate
measures of central (abdominal) or total adiposity. The sections that follow
provide brief overviews of different approaches to assessing adiposity and
obesity status. Discussion of specific disease outcomes in relation to some of
the measures is included to highlight how such measures are often used or
regarded in the literature. As noted in Chapter 1, however, it is beyond the
scope of this report to provide a comprehensive overview of the association
between measures of adiposity or obesity and chronic disease. Furthermore,
the intent of this section is not to be exhaustive—and indeed, approaches
other than those listed below exist. Instead, this section highlights the
challenges of using various measures of adiposity for population-based

CONTEXT 29
assessments, providing a rationale for why body mass index (BMI) is the
predominant method used in reports on obesity prevalence and trends.
Dual-Energy X-ray Absorptiometry

Dual-energy X-ray absorptiometry (DXA) estimates bone mineral den-
sity, fat mass, and lean body mass based on the attenuation of two X-rays
of differing energy levels as they pass through the body. Body composition
estimates are derived from system-specific algorithms, which can differ
between DXA machine manufacturers (Sopher et al., 2004). Various per-
cent body fat cut points have been used to classify obesity using DXA,
which further limits comparability across assessments. Although considered
accurate in estimating bone density (Wells, 2014), DXA may be less accu-
rate in providing estimates of body fat in individuals who have obesity, as
well as for those on the leaner end of the spectrum (Knapp et al., 2015;
Toombs et al., 2012). Because the machines have limits to the size of indi-
vidual who can be successfully scanned (Wells et al., 2010), DXA may not
adequately characterize entire populations, especially those with high levels
of severe obesity. The radiation dose associated with a single DXA scan is
considered safe for the general public, but not for pregnant women (Hu,
2008). DXA scans require specialized equipment and trained personnel, and
as such, are limited to the clinical setting.
Bioelectrical Impedance Analysis

In a bioelectrical impedance analysis (BIA), an electrical current is sent
through the body and the measured resistance to the current is used to cal-
culate total body water, lean body mass, and fat mass (Kyle et al., 2004a).
The measured resistance is contingent on the amount of fluid people have
in their bodies, which differs significantly on an individual basis and can be
affected by a number of factors, including hydration status, obesity status,
and recent physical exercise (Hu, 2008; Kyle et al., 2004b). Although BIA
is relatively inexpensive, portable, and non-invasive, a systematic review
conducted by Talma et al. (2013) suggests that it can suffer from measure-
ment errors and may not be suitable for assessing total body fat in children
and adolescents. Various percent body fat cut points have been used to
classify obesity using BIA.
Body Densitometry—Underwater Weighing and Air-Displacement

Plethysmography
Both underwater weighing and air-displacement plethysmography
(ADP) evaluate body composition based on body density. In underwater

weighing, body density is calculated from an individual’s weight on land,

weight under water, and total volume of water displaced (Hu, 2008). The
protocol for underwater weighing requires an individual to be fully sub-
merged, to have blown out as much air from the lungs as possible, and to
remain still while the measurement is being taken. In ADP, air is used as
the medium instead of water. ADP is safe for most individuals, whereas
underwater weighing is not appropriate for children or older adults, due
to full body submersion (Hu, 2008). Both underwater weighing and ADP
require highly specialized equipment, and trained personnel to take the
measurements. Such assessments of body density are primarily conducted
in controlled research settings.
Skinfold Thickness
Skinfold thickness assessments use calipers to measure a double fold of
the skin and subcutaneous fat (fat under the skin) at various selected sites
on the body (Hu, 2008). The caliper measurements are used in predictive
equations to assess an individual’s percent body fat. Various percent body
fat cut points have been used to classify obesity using skinfold thickness.
Although skinfold thickness measurements are inexpensive to perform,
their reliability is particularly dependent on the training and expertise of
the person taking the measurement (Oppliger et al., 1992; Shaw, 1986).
Waist Circumference
Waist circumference measurements are used to assess abdominal obe-
sity. Although it may be useful for predicting health risks, waist circumfer-
ence does not differentiate between subcutaneous fat and visceral fat (fat
around organs) and needs to be appropriately adjusted for age and BMI,
as different cut points exist for children and adults (Fryar et al., 2012;
Vazquez et al., 2007). Protocols vary in the anatomic site of where the
measurement is taken. The National Health and Nutrition Examination
Survey (NHANES) anthropometry manual, for example, instructs exam
staff to take the measurement at the top of the ilium (hip bone) (CDC,
2013). Anatomic sites used in other protocols have included directly below
the lowest rib cage, at the umbilicus (belly button), midway between the
lowest rib and the top of the ilium, and at the narrowest part of the torso
(Wang et al., 2003). The variability in the protocols used to measure waist
circumference can limit the comparability and ultimately the utility of
using waist circumference (Mason and Katzmarzyk, 2009). Furthermore,
although waist circumference percentiles have been developed using data
for U.S. children and adolescents (Fernandez et al., 2004), they are not the
only reference that exists (Freedman et al., 2015a). Various cut points and

CONTEXT 31
criteria for classifying waist circumference can lead to different estimates

of obesity prevalence (Monzani et al., 2016).
Waist-to-Hip Ratio and Waist-to-Height Ratio

Waist-to-hip ratio (WHR) and waist-to-height ratio (WHtR) are two
indices that also have been explored for their utility in defining obesity and
associated health risks. The strengths of WHR are aligned with those of
waist circumference, but as it requires two circumference measurements—
both difficult to define and standardize—it is therefore more prone to error
than is waist circumference alone (Hu, 2008; Vazquez et al., 2007). Recent
work evaluating the use of WHtR suggests a simple cut point independent
of age is sensitive in identifying children with elevated percent body fat
(Nambiar et al., 2010) and may distinguish children with higher cardio
metabolic risk (Mokha et al., 2010), although results are not conclusive
(Bauer et al., 2015). Ashwell et al. (2012), in a systematic review of the
literature, found WHtR to be a useful predictor of certain cardiometabolic
risks in adults of both sexes and across racial and ethnic groups. Ulti-
mately, the utility of WHtR is still limited by the need to measure waist
circumference.
Body Mass Index

BMI is calculated by dividing an individual’s weight in kilograms by
height in meters squared (kg/m2). BMI does not differentiate between
lean body mass and adipose tissue and does not reflect body fat distribu-
tion. Accordingly, the Centers for Disease Control and Prevention (CDC)
describes BMI as a screening tool for a person’s adiposity status rather than
being diagnostic (CDC, 2015a). For children and adolescents, standard BMI
classification criteria (discussed in the next section) can differentiate those
with high adiposity from those with lower adiposity with a moderate degree
of sensitivity and specificity (Flegal et al., 2010; Freedman and Sherry, 2009).
Although BMI serves as a proxy for adiposity, the relationship can vary
across population groups. A highly muscular athlete, for example, may
have an elevated BMI due to lean muscle mass rather than excess adipose
tissue, leading to a classification of overweight with a relatively low body
fat percentage (Ode et al., 2007). Adiposity also can vary with race and
ethnicity. Evidence suggests that at the same BMI, blacks tend to have a
lower body fat percentage than whites and some Asian populations tend to
have a higher body fat percentage than whites (Flegal et al., 2010; W agner
and Heyward, 2000; WHO Expert Consultation, 2004). Flegal et al. (2010)
also reported variation in body fatness by sex in Mexican-American chil-
dren as compared to non-Hispanic black and white populations with the

same BMI. Age also is a consideration. The use of BMI among older adults
may not adequately reflect changes in body composition, as lean body
mass has a tendency to decrease and adiposity can increase as a person
ages and can occur in weight-stable individuals (Ding et al., 2007; Hughes
et al., 2004; Zamboni et al., 2003). Finally, recommendations and prac-
tices do not currently support the use of BMI among infants and toddlers
younger than age 2 years for the purposes of weight status classification
(see Box 2-1).
In spite of its limitations, BMI has methodological advantages over
other existing approaches for the purposes of population-based assess-
ments. For example, measurement of height and weight is pervasive in
public health and medical settings, and accordingly, BMI can be readily
calculated from such administrative data. Moreover, unlike other available
approaches to assess adiposity, BMI is based on two intrinsic characteristics
(height and weight) that individuals can report about themselves or about
their children.1 As a result, questions about a participant’s height and
weight are included a variety of surveys that could not otherwise collect
directly measured height and weight data on participants (see Chapter 4).
BMI is pervasive in the obesity prevalence and trends literature for popula-
tion groups ages 2 years and older, and will therefore be the primary obesity
classification approach discussed throughout this report.
Using BMI to Classify Obesity Status

Although obesity is often thought of as dichotomous—either people
have it or they do not—its classification is based on a continuous variable
that has to be categorized. The classification approach differs for adults and
children, as discussed below.
Classification of Obesity in Adults

For adults, BMI is classified based on set ranges, and obesity is catego-
rized into classes that apply to all ages and both sexes (see Table 2-1). The
adult cut point for obesity, 30 kg/m2, has been associated with increased
risk of mortality and morbidity (Berrington de Gonzalez et al., 2010;
WHO, 1995, 2004). Some populations, particularly Asians, exhibit higher
adiposity and elevated morbidity risk at lower BMI thresholds (Gray et
al., 2011; Ko et al., 2001; Wen et al., 2009). A World Health Organiza-
tion (WHO) expert consultation recommended using additional cut points
for public health action for many Asian populations, but agreed that the
1 The
accuracy of self- and proxy-reported heights and weights is discussed in greater detail
in Chapter 3.

CONTEXT 33
BOX 2-1
Classifying Weight Status in Children Younger Than Age 2 Years
Infants and toddlers younger than age 2 years are unique when it comes to
weight status classification. The measurement of linear growth, the measure of
relative weight, and the terminology differ from those used for older children,
adolescents, and adults.
• M
easurement of Linear Growth: Standing height cannot be readily obtained
from children younger than age 2 years. Linear growth in infants and toddlers,
therefore, is assessed by measuring the length of the child lying down (recum
bent length). Recumbent length has a tendency to be greater than standing
height measurements (WHO, 2006). Although correction factors exist, the
standing height and recumbent length are not readily interchangeable.
• M
easure of Relative Weight: The Centers for Disease Control and Prevention
(CDC) recommends use of the World Health Organization (WHO) growth
charts for children ages 0 to 2 years (additional information about these
growth charts is provided in Chapter 5) (CDC, 2010). Rather than BMI-for-age,
weight-for-length is typically assessed for infants and toddlers. Weight-for-
length growth charts are sex-specific, but are independent of age—they simply
evaluate the relationship between the two measurements. To comprehensively
assess the growth of an infant or toddler, weight-for-length, weight-for-age,
and length-for-age growth charts can be used to inform each other. BMI-for-
age growth charts for infants and toddlers do exist (WHO, 2006). The CDC,
however, recommends more research is needed on the impact of recumbent
length on BMI and the relationship between high or low BMI in infancy and
early childhood and resulting health outcomes (CDC, 2015b; Grummer-Strawn
et al., 2010).
• T
erminology: The American Academy of Pediatrics (AAP) supports the use
of weight-for-length in the assessment of relative weight for children younger
than age 2 years, but indicates the term “obese” should generally not be used
for this age group (American Academy of Pediatrics Committee on Nutrition,
2014). This recommendation is reflected in the current literature, as few pub
lished reports on U.S. infants and toddlers use such terminology. Given the
measure of relative weight commonly used for this age group, “high weight-for-
recumbent length” has been used to classify high weight status in lieu of the
term “obesity” (Ogden et al., 2014), although the AAP recommends the use of
the term “overweight” for infants and toddlers exceeding the 95th percentile
on the weight-for-length growth charts (American Academy of Pediatrics Com
mittee on Nutrition, 2014).
Given the committee’s charge is to evaluate current methodologies appearing

in recent published reports on obesity prevalence and trends, the remainder of
this report does not specifically describe children younger than age 2 years for
continued

BOX 2-1 Continued
the reasons listed above. However, the concepts that are presented throughout
(e.g., challenges in measurement, selection of a reference population, analytic
considerations) are adaptable or directly applicable to assessing a report for this
age group.
Although intrinsically related to this report, evidence-based consensus on how
best to measure and categorize the weight status of children younger than age
2 years, especially as it relates to weight trajectory and lifelong health risks, is
beyond the scope of this committee’s task. Until such guidance is established,
the committee supports continued use of the weight-for-recumbent length growth
charts for monitoring infants and toddlers younger than age 2 years. Several
initiatives are currently under way exploring various aspects related to early life
growth and are poised to inform which measure(s) and terminology should be
used to classify weight status for this age group. These projects include, but are
not limited to, the Dietary Guidance Development Project for Birth to 24 Months
and Pregnancy (B-24/P), the INTERGROWTH-21st Fetal and Newborn Growth
Consortium, and the Environmental Influences on Child Health Outcomes (ECHO)
Program (NIH, 2016; Raiten et al., 2014; Villar et al., 2013).
TABLE 2-1 Classification of Adult Weight Status Using Body Mass Index
Cut Points
Classification BMI Ranges (kg/m2)
Underweight <18.5
Normal 18.5-24.9
Overweight 25.0-29.9
Obesity, Class I 30.0-34.9
Obesity, Class II 35.0-39.9
Obesity, Class III ≥40.0
SOURCE: NHLBI, 1998.
standard adult cut points be retained for international classification (WHO

Expert Consultation, 2004). Accordingly, use of the 30 kg/m2 cut point is
standard for categorizing obesity status across population groups.
Classification of Obesity in Children, Adolescents, and Young Adults

Compared to adults, using BMI to classify obesity status in children
ages 2 years and older is a more involved process. The calculated BMI must

CONTEXT 35
be compared to a classification criterion that accounts for dramatic changes

in height, weight, and body composition that occur over the course of child-
hood and vary by sex. The following sections describe the developmental
considerations that prevent the use of a single BMI cut point approach
that is used for adults and describe how reference populations are used to
classify obesity status.
Developmental Considerations Growth, development, and maturation are

hallmarks of childhood and adolescence. Although often represented by age
groupings, biologic and physiologic developmental stages do not follow
a strict chronologic timetable. A considerable amount of interpersonal
variation is considered well within the realm of normal development, as
well as observed differences between boys and girls (Ogden et al., 2011).
Two developmental periods particularly affect BMI: adiposity rebound in
preschool-aged children and puberty.
Adiposity rebound The BMI of preschool age children typically
changes in a non-linear pattern, often referred to as “adiposity rebound.”
This is a period during which a child’s height velocity should be faster than
weight velocity, resulting in a leveling or decrease in BMI until it reaches
its nadir. BMI then begins to increase in a linear fashion, typically between
ages 4 to 7 years. The timing and velocity of the rebound can be quite vari-
able (Hughes et al., 2014).
Puberty The relationship between puberty and obesity is complex
(Crocker et al., 2014). BMI increases during puberty, with a more rapid
increase during Tanner stages 1 to 3 than 4 to 5 (Xu et al., 2012). In females
but not in males, percentage of body fat increases with advancing puberty
(Xu et al., 2012). Longitudinal studies in girls have indicated that elevated
BMI in prepuberty is associated with earlier puberty onset (Davison et al.,
2003) and earlier menarche (Anderson et al., 2003). Analysis of secular
trend data show that both pubertal onset and completion are now occur-
ring at younger ages in females (Euling et al., 2008). Results from a recent
study suggest that boys who are overweight have earlier pubertal timing
than either normal weight boys or boys with obesity, and that boys with
obesity have later pubertal time than either of the other two groups (Lee
et al., 2016). Another study found an increase in likelihood of entering
puberty with increasing BMI-for-age status among girls of the same age
and race, but no such association was seen in boys (Crocker et al., 2014).
Race and ethnicity also affect pubertal timing, with African American girls
experiencing earlier pubertal initiation and menses than do white girls, with
intermediate pubertal timing for Mexican American girls. African American
boys enter puberty at earlier ages than do white boys (Herman-Giddens et
al., 1997, 2001). Ideally, to comprehensively interpret a BMI value, infor-
mation about maturation would be considered. Collecting such information

outside of the clinical setting, however, is challenging. As such, age is often

used as a proxy, with the understanding that it encompasses physiologic
heterogeneity.
Use of Reference Populations to Classify Obesity Status To account for

the changing BMI throughout childhood and adolescence, obesity s tatus is
determined through the use of a reference population. A reference popu-
lation is a defined group of individuals whose data serve as the basis
for comparisons. For the purposes of obesity classification, children and
adolescents’ BMIs are compared to the distribution seen in the reference
population, which are often visualized as growth charts (see Figure 2-1).
Although various reference populations exist (discussed in Chapter 5),
the 2000 CDC sex-specific BMI-for-age growth charts are most commonly
used to classify the obesity status of U.S. children and adolescents.2 In its
current form, obesity classification in children is statistical—that is, it is
a comparison to a distribution that previously existed in a population—
although elevated values have been associated with various health risks
(Freedman et al., 2015b; Kurniawan et al., 2014; Weberruß et al., 2015;
Weiss, 2007). Table 2-2 presents the percentile cut points used to classify
weight status based on the 2000 CDC BMI-for-age growth charts (see
Box 2-2 for description of percentile). Since 2007, children, adolescents,
and young adults who are at or exceed the 95th percentile have been clas-
sified as having obesity. When reviewing literature more than a decade old,
it is important to note that the nomenclature regarding the 95th percentile
has changed over time (see Box 2-3).
Classification of severe obesity Although the standard approaches
to classifying obesity status for children, adolescents, and young adults
typically accounts for changes in BMI that occur due to growth, ultimately
classification is still based on a single criterion (e.g., 95th percentile on the
2000 CDC BMI-for-age growth charts). Obesity status, however, has been
further classified based on how far away a value falls from the selected cut
point. A range of approaches and nomenclature have been used over the
past decade in an attempt to describe different levels of obesity in children.
The classification approaches and nomenclature of severe obesity in
children is a function of the evolution that that has taken place over time.
One previous approach was to use a higher percentile cut point (e.g., ≥99th
percentile on the CDC BMI-for-age growth charts). Given that it is not
advisable to extrapolate beyond the 97th percentile on the CDC growth
charts (Flegal et al., 2009; Kuczmarski et al., 2000), alternative methods
have emerged (Gulati et al., 2012). The prevailing cut point currently in use
2 OtherCDC growth charts exist for children ages 2 years and older, including sex-specific
weight-for-age and stature-for-age.

CONTEXT 37
FIGURE 2-1 CDC BMI-for-age growth chart for girls.

SOURCE: CDC, 2010.
is 120 percent of the 95th percentile on the CDC growth charts (Flegal et
al., 2009). Investigators have further differentiated this category by dividing
groups at 140 percent of the 95th percentile (Skinner and Skelton, 2014;
Skinner et al., 2015).

TABLE 2-2 Classification of Weight Status for Children Ages 2-19 Years
According to 2000 CDC Sex-Specific BMI-for-Age Growth Charts
Classification Percentile Cut Points
Underweight <5th
Normal Weighta 5th to <85th
Overweight 85th to <95th
Obese ≥95th
a The phrase “healthy weight” has also been used to describe this BMI-for-age percentile
range.
SOURCE: CDC, 2014.
BOX 2-2
BMI-for-Age Percentiles
A child’s BMI is typically compared to the 2000 CDC sex-specific BMI-for-

age growth charts for weight status classification. These growth charts were
developed using several cycles of nationally representative data (see Chapter 5
for additional details). The individuals who contributed data used to develop the
charts are collectively considered its reference population.
When a child’s BMI is classified, it is being compared to the distribution that
existed in the reference population used to develop the growth charts. The per
centile, therefore, represents how a child’s BMI ranked compared to the reference
population of the same sex and age (i.e., the percent that are below the observed
value). A BMI-for-age at the 95th percentile, for instance, means that 95 percent
of the reference population of the same sex and age had a BMI below that value,
while 5 percent had a BMI above that value.
BOX 2-3
Shift in Nomenclature
The term “obesity,” with respect to children, was not widely used until 2007,
although investigators occasionally applied various cut points to try to describe
children and adolescents with excess adiposity (e.g., ≥99th percentile). Before
the change, the 85th to 94.9th percentile on the 2000 CDC BMI-for-age growth
charts was considered “at risk for overweight” and ≥95th percentile was “over
weight.” Following a 2005 Institute of Medicine report (IOM, 2005) and a 2007
Expert Committee recommendation (Barlow, 2007), however, the nomenclature
for the pre-existing cut points largely transitioned to “overweight” (85th to 94.9th
percentile) and “obesity” (≥95th percentile) (Ogden and Flegal, 2010).

CONTEXT 39
OBESITY ACROSS THE LIFE COURSE

This report describes the approaches to and challenges of assessing
obesity prevalence and trends, primarily among children, adolescents, and
young adults. Although the distinction between children and adults exists for
descriptive and methodologic reasons, the scope of the obesity epidemic can-
not be fully understood without considering the entire life course. Because
childhood is not a static characteristic, but instead a life stage leading to
adulthood, it has both longitudinal and population-level implications.
Longitudinal evaluations of weight status provide insight into how obe-
sity tracks in an individual over time. Evidence from such studies indicates
that having obesity during childhood is associated with obesity status later
in life. Nader et al. (2006) for example, evaluated the longitudinal weight
status of 1,042 children and found that those who had an elevated BMI
at any point during ages 2 to 5 years were five times as likely to have an
elevated BMI at age 12 years compared to those whose BMIs were per-
sistently in the normal range during their preschool years. In a published
report on the Great Smoky Mountains Study, investigators identified four
distinct weight status paths among 991 rural youth over an 8-year period
(ages 9 to 16 years): (1) no obesity (73 percent of participants); (2) chronic
obesity (15 percent of participants); (3) childhood obesity that resolved
in adolescence (5 percent of participants); and (4) no childhood obesity
but emerging adolescent obesity (7 percent of participants) (Mustillo et
al., 2003). Furthermore, findings from the National Longitudinal Study
of Youth suggest that adolescents ages 16 and 17 years with obesity had
the highest probability of obesity at age 37 to 38 years (80 percent among
males and 92 percent among females) (Wang et al., 2008).
Obesity during childhood, however, is not the sole pathway to adult
obesity. Freedman et al. (2005), using longitudinal data from the Bogalusa
Heart Study, reported that while children who had a BMI ≥95th percentile
were likely to have obesity in adulthood, only about 20 percent of adults
with elevated weight or adiposity status had a BMI ≥95th percentile during
childhood. Similarly, analyses of National Longitudinal Study of Adolescent
Health data found that while the majority of adolescents with obesity con-
tinued to have obesity into their 20s and 30s (the assessment period), the
prevalence of obesity also increased as the cohort aged, with incident cases
occurring during adulthood (Gordon-Larsen et al., 2010).
Differences in childhood and adulthood obesity also can be considered
from a population perspective. Trends based on nationally representative data
show that prevalence is substantially higher than it was 40 years ago among
both children and adults (Fryar, 2014a,b) (see Figures 2-2 and 2-3). The
directionality of trend seen among children mirrors that of adults, although
at different levels of prevalence (approximately 17 versus 35 to 36 percent,

FIGURE 2-2 Trends in obesity among children and adolescents ages 2 to 19 years,
by sex: United States, select years 1971-1974 through 2011-2012.
NOTE: Obesity was defined as a BMI greater than or equal to the sex- and age-
specific 95th percentile from the 2000 Centers for Disease Control and Prevention
Growth Chart.
SOURCE: Fryar et al., 2014a. Figure 2-1
R03028
raster/ not editable
respectively) (Ogden et al., 2014, 2015).3 Considering children younger than
sized to fit
age 18 years currently constitute less than one-quarter of the total U.S. popu-
lation (Howden and Meyer, 2011; U.S. Census Bureau, 2016), the majority
of the more than 90 million Americans estimated to be affected with obesity
are adults (Ogden, 2015). Nevertheless, approximately 13 million children
and adolescents are estimated to have obesity in the United States.
Although the number of children and adults affected with obesity alone
is striking, the need and importance of monitoring obesity across the life
span can be further contextualized by considering its negative health effects.
Comorbidities and metabolic dysregulations associated with obesity exist
in children and adults at the population level.4 Impaired glucose tolerance
3 Estimates are based on current obesity classification criteria used in the United States,
which are different for adults and children. The differences in obesity status classification are
explained earlier in this chapter.
4 Two caveats are associated with this statement. First, chronic diseases are multifactorial.
Disease origins and progression are typically attributed to a collection of factors, not just one.
As such, obesity is one of several components of these conditions. Second, associations sum-
marize the group-wise relationship, not individual trajectories. Given the broad range of envi-
ronmental, genetic, lifestyle, and biologic factors at play, not all individuals with obesity will
develop all of the conditions and not all those affected with the conditions will have obesity.

CONTEXT 41
FIGURE 2-3 Trends in adult overweight, obesity, and extreme obesity among men
and women ages 20 to 74 years: United States, selected years 1960-1962 through
2011-2012.
NOTES: Age-adjusted by the direct method to the year 2000 U.S. Census Bureau
estimates using age groups 20 to 39 years, 40 to 59 years, and 60 to 74 years.
Figure 2-2
Pregnant females were excluded. Overweight is a BMI of 25-29.9 kg/m2; obesity is
BMI >30 kg/m2; and extreme obesity R03028
is a BMI >40 kg/m2.
SOURCE: Fryar et al., 2014b.raster/ not editable
sized to fit
and insulin resistance, for example, have been linked to weight status and
weight gain in children (Weiss, 2007). Risk of developing type 2 diabetes
is increased in men and women with obesity and appears to increase with
weight gain during adulthood (de Mutsert et al., 2014; Kodama et al.,
2014). Obesity in adulthood has been associated with structural and meta-
bolic changes linked to cardiovascular disease (Bastien et al., 2014). For
children and adolescents, evidence suggests that obesity is associated with
both an increase in cardiovascular risk factors and structural cardiovascular
changes, such as increase in vascular intimal thickness and retinal vascular
changes (Freedman et al., 2015b; Kurniawan et al., 2014; Weberruß et al.,
2015). The persistence of obesity from childhood into adulthood also may
have implications for risk of cardiovascular disease (Juonala et al., 2011).
Some data suggest an association between elevated BMI during childhood
and certain cancers, but the results far from conclusive (Park et al., 2012).
Childhood obesity also has been associated with a range of conditions
and outcomes, including obstructive sleep apnea, liver disease, orthopedic
conditions, polycystic ovarian syndrome, increased incidence of bullying
and teasing, depression, and anxiety (Barlow, 2007). Thus, measuring and

understanding obesity prevalence and trends across the lifespan has greater
implications than simply characterizing weight status of a population.
DEMOGRAPHIC FACTORS AFFECTING

THE PREVALENCE OF OBESITY
Estimates of obesity prevalence at the overall population level subsume
the variability within a population and can obscure important differences
that may exist. Subpopulations can differ in prevalence of obesity and in
relation to obesity trends over time. Subgroup analyses need to be per-
formed in order to determine who is affected, to what extent, and if trends
differ. Individuals can be categorized by any number of factors, to the
extent that data are available and the sample sizes support such compari-
sons. For the purposes of population-based assessments, however, groups
are most often defined by demographic characteristics. Although not all
comparisons are evaluations of health disparities, the assessment of health
disparities typically rely on demographic characteristics (see Box 2-4).
Subgroup comparisons shed light on differences in populations, but
these differences do not necessarily represent burden. This concept can be
illustrated with a hypothetical example. A population of 100,000 individuals
is divided into subgroups. One subgroup represents 5 percent of the popula-
BOX 2-4
Social Disadvantage and Disparities in Obesity
A health disparity is a difference that is the result of systematic marginaliza

tion, discrimination, or vulnerabilities that could be avoided through different, more
equitable social circumstances (Braveman et al., 2011). Thus, social disadvantage
lies at the heart of health disparities. Social disadvantage is a complex, multi
dimensional construct that encompasses more than just demographic character
istics. Reports on obesity prevalence and trends, however, tend to operationalize
social disadvantage in relation to several commonly measured demographic fac
tors—race, ethnicity, sex, income, parent education, and geographic area. These
factors then provide the basis for determining whether health disparities in obesity
exist by looking at differences in prevalence across subgroups.
Assessing whether disparities are present is critical for obesity prevention and
treatment, as such explorations can identify populations that may be in need of in
creased prevention and treatment resources or specifically tailored interventions.
Unless the sociodemographic information needed to perform subgroup analysis
is collected, in addition to data on weight status, reports are unable to address
whether disparities are present.

CONTEXT 43
tion and has an obesity prevalence of 20 percent (i.e., 1,000 individuals have
obesity), while another subgroup encompasses 50 percent of the population
and has a prevalence of 10 percent (i.e., 5,000 individuals have obesity). In
this scenario, because one subgroup comprises a larger portion of the total
population, the number of individuals affected in that group is larger than
the smaller subgroup with a higher prevalence. This concept of burden is not
intended to detract or diminish from assessments of differences and health
disparities. Rather, it offers contextual insight into the difference.
The following sections provide an overview of relationships between
obesity prevalence and key demographic factors. The information provided
is largely based on national-level survey data, particularly NHANES. As
will be described in Chapter 4, NHANES is the only ongoing, nationally
representative population survey that collects directly measured height and
weight data on participants of all ages. The relationships that are seen at
the national level may not exist in every state or community. To that end,
this section should be regarded as a general discussion of how individual
factors may be pertinent to obesity prevalence and trends. The committee
also acknowledges that behavioral, biological, and environmental factors
affect the prevalence of obesity, but to be consistent with its task, it has
chosen to focus only on demographic factors. Finally, the differences that
are highlighted here are occurring against a backdrop of changes to the
demographic landscape of the country (see Box 2-5). The demographic
shifts in the U.S. population not only affect the interpretation of current
estimates, but have implications for long-term assessments of the overall
population and population groups.
Sex
Obesity prevalence and trends analyses are often stratified by sex,
because sex plays a role in adiposity status. Boys and girls, for example,
have different patterns of growth throughout childhood and therefore neces-
sitate different sex-specific growth references (Kuczmarski et al., 2000).
Assessment of body composition also suggests that after age 11 years, males
generally have higher fat-free mass than do females, and females generally
have higher total body fat and percent body fat compared to males (Borrud
et al., 2010).
Nationally representative data from 2011-2012 suggest that the preva-
lence of obesity may not differ statistically between boys and girl ages
2 to 19 years, and are estimated at 16.7 percent (95 percent confidence
interval [CI]: 13.9-19.8 percent) and 17.2 percent (95 percent CI: 14.8-
19.9 percent), respectively (Ogden et al., 2014). A similar analysis using
2009-2010 data from the same survey, however, reported the prevalence for
this age group was higher among boys than girls, estimated at 18.6 percent

BOX 2-5
Demographic Shifts of the U.S. Population
Over the past several decades, the demographic composition of the country
has dramatically changed. The total U.S. population has increased, rising from
203.2 million in 1970 to 308.7 million in 2010 (Hobbs and Stoops, 2002; U.S.
Census Bureau, 2011c). Over this time, the median age of the U.S. population
also has increased, from 28.1 years in 1970 to 37.2 years in 2010. A small but
steady increase in the percentage of individuals ages 65 years and older also
has occurred (U.S. Census Bureau, 2011a). The rise in population is attributable,
in part, to an increase in net immigration since 1980, a trend that is projected to
continue through the mid-21st century (OIS, 2014).
The immigration and settling of non-U.S. born individuals has led to increased
racial and ethnic diversity in the United States. National Census data show an
increase in the percentage of those identifying themselves as part of racial and
ethnic subpopulations. In 1970, 87.5 percent of the population was non-Hispanic
white, 11.1 percent was non-Hispanic black or African American, and less than
1 percent was another race (Hobbs and Stoops, 2002). The 2010 Census data,
in contrast, showed that 63.7 percent of the population was non-Hispanic white,
12.6 percent was non-Hispanic black, 16.3 percent was Hispanic, 4.8 percent was
Asian, 0.9 percent was American Indian or Alaska Native, 0.2 percent was Native
Hawaiian and Other Pacific Islander; 6.2 was some other race; and 2.9 percent
identified as two or more races (U.S. Census Bureau, 2011b). These trends are
increasing, and population projections estimate that by 2043, the United States
will have transitioned away from any one single majority group, with several minor
ity groups making up more than 50 percent of the population. As the transition is
occurring from young to old, this shift will happen sooner in younger populations
(U.S. Census Bureau Newsroom, 2012).
(95 percent CI: 16.4-21.0) and 15.0 percent (95 percent CI: 13.3-16.8),
respectively (Ogden et al., 2012). The authors posited the sample size and
the classification approach of obesity for children could be contributing
factors to the apparent difference between sexes. In comparing prevalence
only by sex (irrespective of race, age, or other demographic factors), men
and women appear to have relatively similar obesity prevalence estimates
(Ogden et al., 2013), although some recent analyses suggest the prevalence
is slightly higher for women (Ogden et al., 2014, 2015).
Although evaluations comparing males and females are important, sex
is a variable that interacts with other sociodemographic factors. Evaluation
of prevalence or trends estimates only by sex may not result in difference,
but when combined with other factors may reveal that subgroups are dis-
proportionately affected.

CONTEXT 45
Age
Age is a required variable for assessing obesity status in children, ado-
lescents, and young adults. Because of the nonlinear course of BMI through-
out childhood, obesity status classification in this age range is dictated by
age. Age also is the determinant used to transition a young adult from the
reference population-based obesity classification approach to the single
BMI cut point (i.e., 30 kg/m2). As will be discussed in Chapter 5, this has
important implications for prevalence and longitudinal trends estimates.
National-level data indicate obesity prevalence increases across age
groups, at least through middle age. Data from 2011-2014 suggest that
obesity is more prevalent among older children (ages 6 to 11 years) and
adolescents/young adults (ages 12 to 19 years) than in preschool-aged chil-
dren (age 2 to 5 years) (Ogden et al., 2015) (see Figure 2-4). The national
data also suggest the prevalence of obesity is typically lower among younger
adults (ages 20 to 39 years) compared to older adult age groups (Ogden et
al., 2013, 2015) (see Figure 2-5). Both Figure 2-4 and Figure 2-5 exemplify
the role subgroup analyses can play in illuminating differences between
groups. Relying solely on the overall estimates (dark blue bars; i.e., ages
2-19 years, 20 years and older) does not provide insight into the variation
across age groups that the rest of the figures depicts. Such an analysis, how-
ever, does not provide specific insight into the etiology of these differences.
FIGURE 2-4 Prevalence of obesity among youth ages 2 to 19 years, by sex and age:
United States, 2011-2014.
a Significantly different from those aged 2-5 years.
SOURCE: Ogden et al., 2015.

FIGURE 2-5 Prevalence of obesity among adults ages 20 years and older, by sex
and age: United States, 2011-2014.
NOTES: Totals were age-adjusted by the direct method to the 2000 U.S. census
population using the age groups 20-39, 40-59, and 60 and older. Crude estimates
are 36.5 percent for all, 34.5 percent for men, and 38.5 percent for women.
a Significantly different from those ages 20-39 years.
b Significantly different from women of the same age group.
Despite being a continuous variable, age is typically categorized. For

nationally representative data based on measured heights and weights,
participants are often categorized into groups that may encompass very
different life stages. For example, a child age 6 years may be very different
than a pubertal child age 11 years in terms of adiposity and interpretation
of BMI. These groupings are typically a result of a decision made during the
analysis of the data, which will be further discussed in Chapter 5.
Race and Ethnicity

The prevalence of obesity differs by race and ethnicity groups. Based
on nationally representative data, obesity prevalence among those ages 2
to 19 years appears to be highest among Hispanics and in non-Hispanic
blacks, followed by non-Hispanic whites and non-Hispanic Asians (Ogden
et al., 2015) (see Figure 2-6). For adults, the highest prevalence estimates
have been observed in non-Hispanic blacks and Hispanic adults followed

CONTEXT 47
FIGURE 2-6 Prevalence of obesity among youth ages 2 to 19 years, by sex and race
and Hispanic origin: United States, 2011-2014.
a Significantly different from non-Hispanic Asian persons.
b Significantly different from non-Hispanic white persons.
c Significantly different from females of the same race and Hispanic origin.
d Significantly different from non-Hispanic black persons.
by non-Hispanic whites, and non-Hispanic Asians (Ogden et al., 2015) (see

Figure 2-7).
The interplay between race, ethnicity, and sex can be seen in both
Figures 2-6 and 2-7. For example, the obesity prevalence in non-Hispanic
Asian males ages 2 to 19 years was significantly higher than their female
counterparts. This sex difference was not seen in any of the other evaluated
racial or ethnic groups. Similarly, obesity prevalence in both non-Hispanic
black and Hispanic women ages 20 years and older was significantly higher
than of their male counterparts. This sex difference was not seen among
non-Hispanic whites or non-Hispanic Asian adults. As was discussed with
age, the subgroup comparisons bring to light differences in estimates of
obesity prevalence across the evaluated groups.
Uncovering the relationship between race, ethnicity, and obesity can be
complicated by methodologic and analytic decisions. Chapter 3 discusses
how race and ethnicity data are currently being captured, while Chapter 5
expands on the limits to data analysis by racial and ethnic groups.

FIGURE 2-7 Prevalence of obesity among adults ages 20 and older, by sex and race
and Hispanic origin: United States, 2011-2014.
NOTE: All estimates are age-adjusted by the direct method to the 2000 U.S. census
population using the age groups 20-39, 40-59, and 50 and over.
a Significantly different from non-Hispanic Asian persons.
b Significantly different from non-Hispanic white persons.
c Significantly different from Hispanic persons.
d Significantly different from women of the same race and Hispanic origin.
Socioeconomic Status
Socioeconomic status (SES) is a broad term, with “low SES” often used
as a proxy for economic disadvantage. Chapter 3 highlights the variability
in methodologies for collecting data related to socioeconomic status in
studies of obesity.
Childhood obesity estimates are often evaluated by a measure of f amilial
or community-level socioeconomic status. Measures of SES appear to inter-
act with other factors, most notably race and ethnicity. For example, Taveras
et al. (2013) reported that obesity among children ages 7 years was more
prevalent among blacks and Hispanics than among children of other races
or ethnicities, but the differences were attenuated when accounting for socio-
economic confounders and parental BMI. In a different evaluation based
on data from 1999 to 2010, the prevalence of obesity was approximately
twice as high among children who lived in a home where the adult head
of household did not complete high school (a measure often used for SES)

CONTEXT 49
compared to those whose adult head of household completed college (May

et al., 2013). The overall effect of this relationship on obesity prevalence
differed by the racial or ethnic group evaluated, with college completion
leading to the lowest prevalence estimates among non-Hispanic whites, but
not among the other racial or ethnic groups.
The relationship between SES and obesity in adults is complex and
appears to interact not only with race and ethnicity, but also with sex.
Based on 2005 to 2008 nationally representative data, obesity prevalence
was similar among men across income levels, but was significantly higher
among non-Hispanic black and Mexican American men of higher income
(Ogden et al., 2010). In contrast, higher-income women had lower preva-
lence estimates of obesity, and the overall trend was similar across races
and ethnicities, though the trend was significant only in non-Hispanic white
women (Ogden et al., 2010). The relationship is complex and it exemplifies
the need and utility of subgroup comparisons.
Rurality
Population density appears to affect the prevalence of obesity. A recent
meta-analysis reported that children living in rural areas had 26 percent
greater odds of obesity compared to children living in urban areas (Johnson
and Johnson, 2015). Rurality, like the other demographic factors, does not
operate unilaterally. For example, one study demonstrated no differences
in the obesity rates for children ages 2 to 4 years from rural and urban
areas with low SES, although multiple studies of older children of varying
SES levels have demonstrated a consistent increase in odds for obesity for
children living in rural areas compared to urban areas. Rural communities
also appear to have higher rates of adult obesity than do non-rural areas
(39.6 percent versus 33.4 percent) (Befort et al., 2012).
Geographic Location
Current data suggest that different regions of the Unites States may
be differentially affected by obesity. Evaluating geographic differences by
regions of the United States is difficult because of a general lack of valid
comparable data across states (see Chapter 4 for additional information).
State-level estimates of adult obesity based on self-reported height and
weight from the Behavioral Risk Factor Surveillance System, for example,
suggest a higher prevalence in the Southeastern United States, compared
with other regions of the country (Le et al., 2014). In contrast, data from
NHANES and the REasons for Geographic and Racial Differences in Stroke
(REGARD) study (n = 6,615 and n = 6,138, respectively), which directly

measured heights and weights, showed the highest prevalence of obesity in

the Midwest (Le et al., 2014).
SUMMARY
Childhood and adolescence is a dynamic time of growth, development,
and maturation. Body composition changes dramatically over the course
of the first two decades of life, and as such, the classification of obesity
status must be adaptive rather than static. BMI is currently the dominant
approach used for assessing obesity status. For children and adolescents,
BMI must be compared to a reference population for classification, with the
2000 CDC BMI-for-age growth charts being the most common reference
population used. Some population groups appear to be disproportionately
affected by obesity. Demographic factors used to identify such groups
include sex, age, race and ethnicity, rurality, and geography. These differ-
ences are occurring in a national population that is rapidly changing.
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Methodological Approaches
to Data Collection
Key Messages
• Data used to estimate obesity prevalence and trends have been
cross-sectional, repeated cross-sectional, and, to a lesser extent,
longitudinal in design. Longitudinal data from cohorts allow
examination of within-person changes in obesity status. A
population trend is determined by multiple data points using
obesity prevalence estimates collected uniformly over time.
• Data collection efforts are being conducted both in and beyond
the research realm. Common physical settings in which height
and weight data are being collected on children and adolescents
include schools, medical facilities, and public health programs.
• Sampling techniques are used to arrive at the group of indi-
viduals included in a dataset. Sampling procedures affect who
is included, and oversampling can allow for evaluations of
subgroups that would otherwise not have sufficient sample size
for such analyses.
• Height and weight data can be obtained through direct measure-
ment or by proxy- or self-report. Obesity prevalence estimates
derived from reported data are not equivalent to estimates calcu-
lated from direct measurement. Self-reported data may, however,
provide insights about trends, particularly among adolescents
and young adults.
57

• Demographic characteristics are collected in different ways

across data sources. For example, data sources differ in the
number of race and ethnicity categories from which partici-
pants select, the measures of socioeconomic status used, and
the approach to delineating levels of rurality.
• Changes in the distribution of exposures and sociodemographic
composition of population groups over time, especially changes
in those with a disproportionate risk of obesity, can affect the
interpretation of prevalence data. This can be accounted for in
the analysis stage only if the changes in exposures and socio
demographics are measured over time.
Through its review of the evidence, the committee identified elements

of the methodologies used for data collection that inform the interpretation
and affect the comparability of estimates of obesity prevalence and trends
in the U.S. population, particularly among children, adolescents, and young
adults. This chapter highlights key elements of the data collection process
that differ across data sources and published reports. These include the
study design, the settings for data collection, the individuals included in
the data source, and data collection methodologies. This chapter also
serves as the foundation for Chapter 4, in which specific data sources are
evaluated.
This chapter contains two terms or phrases that have the potential to
be interpreted in multiple ways. This report uses the following definitions
(a full glossary can be found in Appendix A):
• “Published reports” specifically describes the articles the committee

used as its evidence base (see Appendix C).
• “Estimate of obesity prevalence or trend” or “estimate” describes
a statistic about the proportion or number of individuals affected
with obesity at one point in time (prevalence) or over time (trend).
STUDY DESIGNS USED IN DATA SOURCES

Published reports presenting estimates of obesity prevalence or trends
have been based on analyses of cross-sectional, repeated cross-sectional,
and, to a lesser extent, longitudinal data. Data from each of the three
study designs have been used to estimate obesity prevalence. However, only
repeated cross-sectional and longitudinal data can be used to assess changes
and trends in obesity prevalence over time. In repeated cross-sectional
studies, different individuals are sampled at each time point. Longitudi-
nal designs allow for examination of obesity status from the life course

METHODOLOGICAL APPROACHES TO DATA COLLECTION 59
perspective and can be used to assess growth trajectories in children. Such

information can help contribute to a fuller understanding of intrapersonal
variation in obesity within a population. Longitudinal data, however, are
not as commonly used as cross-sectional studies due to factors such as
the expense of following a single population over a period of many years.
Existing longitudinal studies that are population-representative are gener-
ally designed to investigate risk factors for major chronic diseases, such as
cardiovascular disease (The ARIC Investigators, 1989). Accordingly, many
large, nationally representative surveys that provide data on obesity rely
on single or repeated cross-sections (see Chapter 4). A summary of the
potential advantages and disadvantages associated with each of these study
designs is presented in Table 3-1. The validity and reliability of the obesity
prevalence estimates obtained through the various study designs depend to
a large extent on the sampling design used. The committee acknowledges
that data from intervention studies also are pervasive in the published
TABLE 3-1 Potential Advantages and Disadvantages of Using Cross-

Sectional, Repeated Cross-Sectional, and Longitudinal Study Designs to
Assess Obesity Prevalence and Trends
Study Design Potential Advantagesa Potential Disadvantagesa
Cross-Sectional Can be used to assess obesity Cannot be used to determine change
prevalence at a defined time or trend in prevalence of obesity.
point in a defined population.
May be useful in determining
priority subgroups within a
population.b
Repeated Can be used to assess obesity Change in the prevalence of obesity

Cross-Sectional prevalence in a population at may be a result of demographic
different time points. shift.
Longitudinal Can be used to capture both Participant attrition likely over time.
intrapersonal (within-subject) Over time, the cohort composition
and interpersonal (between- may differ from that in the source
subject) variations. population due to migration or
aging of the source population.
NOTE: The committee acknowledges that other study designs, such as interventions, exist.
a The potential advantages and disadvantages are contingent on the population assessed, the
methodology employed, the analytic approach, and the end user seeking to apply such infor
mation. Population and methodologic considerations are discussed throughout this chapter.
The analytic considerations are more fully explored in Chapter 5, while considerations related
to end users are discussed in Chapter 6.
b Not all reports using cross-sectional data evaluate multiple groups.

BOX 3-1
Intervention Studies and Estimates of
Obesity Prevalence and Trends
A sizable portion of the obesity research literature is dedicated to intervention

studies. Intervention studies explore how participants respond to a specific treat
ment, program, or other intervention. The term “intervention study” encompasses
a variety of study designs. They can be conducted at the clinical or community
level and can vary in duration and purpose (e.g., a pilot or feasibility study versus
an effectiveness study). Intervention studies are a valuable source of evidence
about treating and preventing obesity. However, most are not designed for the
purposes of producing estimates of obesity prevalence or trends for a population
group beyond those participating in the study. The participants in intervention
studies often do not adequately represent the general population due to the
manner in which they were identified, recruited, screened, and enrolled. For inter
ventions spanning long durations, attrition can affect who is represented in the
trend data for that study.
Under most circumstances, obesity prevalence and trends statistics generated
from intervention studies will not meet the informational needs of end users seek
ing estimates describing a broad population. However, the committee acknowl
edges that due to current data gaps, prevalence values presented in intervention
studies may be the only data available for certain population groups. In these
instances, the committee advises that such data be used with caution, noting the
inherent limitations.
literature on obesity, but identified limitations in their ability to be used

for the purpose of estimating obesity prevalence or trends (see Box 3-1).
SETTINGS OF DATA COLLECTION

Common settings in which data on obesity status are currently being
collected on children, adolescents, and young adults include schools,
medical facilities and public health settings, and other research and sur-
veillance settings. The first two categories represent discrete physical loca-
tions, and their potential advantages and disadvantages are summarized in
Table 3-2. “Other research and surveillance settings” is a heterogeneous
category that encompasses settings that are often specific to a particu-
lar data source. The committee highlights illustrative examples of other
research and surveillance settings, but acknowledges that others exist
beyond those presented.

TABLE 3-2 Potential Advantages and Disadvantages Associated with

Two Data Collection Settings Common in Reports on Obesity Prevalence
and Trends
Setting Potential Advantagesa Potential Disadvantagesa
Schools Centralized location for Interpretation of FERPA can limit access to
children and adolescents. data.
Type of parental consent requested can
affect participation.
Not always possible to include students
attending school types other than public,
such as private or alternative schools.
Protocols and training provided to staff
varies.b
Clinical and Large collection of patients Generalizability of obesity prevalence and

Public Health and individuals receiving trends estimates can be limited.
Settings services at the location. Use of ICD codes instead of directly
Standardized training for measured height and weight may
data collection efforts.b underestimate estimate of obesity
prevalence.
NOTES: The committee acknowledges other settings for data collection exist. Given their
heterogeneity and specificity, other research and surveillance settings have been omitted from
this table but are discussed in the text. FERPA, Family Educational Rights and Privacy Act;
ICD, International Classification of Diseases.
a The potential advantages and disadvantages are contingent on the population assessed,
the methodology employed, the analytic approach, and the end user seeking to apply such in-
formation. Population and methodologic considerations are discussed throughout this chapter.
b Tables D-1, D-2, and D-3 in Appendix D present different protocols used to collect height
and weight data.
Schools
Approximately half of states in the United States have legislation related
to, or that allows for, school-based screening or surveillance of body mass
index (BMI) or weight status (Ruggieri and Bass, 2015). The Centers for
Disease Control and Prevention’s (CDC’s) 2014 School Health Policies and
Practices Study, which sampled a nationally representative collection of
public and private schools throughout the country, reported that slightly
more than half of sampled schools obtain and maintain information regard-
ing students’ weight status in the students’ records (overall: 54.1 percent
[95 percent confidence interval [CI]: 47.2-60.9 percent]) (CDC, 2015c). As
will be highlighted in Chapter 4, the grades assessed, number of students

evaluated, and frequency of evaluations differs across sites. Protocols, who

performs the measurements, and level of training provided to relevant staff
also differs across assessments (see Appendix D, Tables D1, D-2, and D-3),
which can affect the quality of data obtained.
Although schools have the potential to be a centralized setting for col-
lecting data on a wide variety of children and adolescents, and may serve
as a source of longitudinal data, the committee acknowledges limitations
and potential barriers also exist. Three key considerations are the protec-
tion of student privacy, parental consent, and the types of schools that are
represented by the data.
Protection of Student Privacy

Access to data placed in a student’s educational record, which can
include measurements of height and weight conducted at school or as part
of enrollment paperwork, can be limited depending on the state and the
school district’s interpretation of the Family Educational Rights and Privacy
Act (FERPA; see Box 3-2).
In an effort to protect student privacy, some school-based data col-
lection efforts compile aggregate data as opposed to individual-level data.
To arrive at an obesity prevalence estimate for districts throughout New
York State (exclusive of New York City), for example, a “School Reporter
(Nurse)” uses a tally sheet to summarize the weight status classification of
the students; the tally sheet is transmitted to the “School District Reporter,”
the sole person responsible for entering data for the entire district, who
then submits the aggregate numbers to the state using a secure reporting
system portal (New York State Center for School Health, 2015). Although
aggregate data protect the identity of the students, they limit investigators’
ability to assess the obesity prevalence relationship with individual-level
characteristics.
Parental Consent
Two types of parental consent can be used in the school setting: active
(having to take an action to opt in) and passive (participating unless an action
is taken to opt out). The use of active parental consent can dramatically
decrease student participation rates compared to passive parental consent
(CDC, 2014b). Active consent has the potential to bias results of an evalu-
ation if the group that opts in does not adequately represent the population
at large. This challenge is not unique to the assessment of obesity status in
schools (Chartier et al., 2008), and strategies have been explored for increas-
ing active consent response rates (Pokorny et al., 2001; Wolfenden et al.,
2009).

BOX 3-2
Family Educational Rights and Privacy Act (FERPA)
The Family Educational Rights and Privacy Act (FERPA; 20 U.S.C. § 1232g)
is a federal law protecting student privacy. It regulates what information can be
disclosed from records maintained by the educational institution or agency that
receives Department of Education funds. This encompasses nearly all public
schools and school districts. Consent is needed before the release of personally
identifiable information (PII). FERPA also restricts the release of information that
alone or in combination could reasonably lead to the identification of a student
with reasonable certainty (35 CFR § 99).
Certain information can be disclosed without prior consent of the parents or
eligible student (35 CFR § 99.31). One such condition is disclosures to school
officials, including teachers, with “legitimate educational interests.” Another such
condition includes disclosures to contractors, consultants, volunteers, or other
parties to whom services or functions have been outsourced by the academic
institution but who are under the direct control of the agency or institution and
the service or function would have otherwise been executed by an institutional
employee.
Of relevance to investigators of obesity prevalence and trends is the provision
about organizations “conducting studies for, on behalf of, educational agencies or
institutions” for the purposes of “developing, validating, or administering p
redictive
tests; administering student aid programs; or improving instruction” (35 CFR
§ 99.31(a)(6)). In this regulation, PII can be released without consent if the orga
nization enters a written agreement with the educational agency or institution with
the specific purpose of the study outlined. The study cannot allow for personal
identification of parents and students by those outside of the agreement and the
information must be destroyed upon completion of the study. The regulation states
the educational agency or institution “is not required to initiate a study or agree
with or endorse the conclusions or results of the study” (35 CFR § 99.31(a)(6)).
Although PII release without consent is permissible under this provision, the
preamble recommends that educational institutions and agencies de-identify the
released information, or remove names and Social Security numbers, to minimize
the potential for unauthorized disclosure (35 CFR § 99.31(a)(6)). Authorities who
run state data systems do not qualify as research organizations or school officials.
Rather, they typically fall under the audit or evaluation exception.
FERPA is subject to interpretation and can affect the ability to assess obesity
prevalence and trends in students. For example, the breadth of “legitimate edu
cational use” is determined by the district or institution. Furthermore, the concern
about being able to identify a student with reasonable certainty with the provided
information applies to weight status assessments. In some instances, a child may
be identified based on extremes in weight status, especially when small sample
sizes exist. Beyond FERPA, states and school districts can have additional regu
lations regarding student privacy, which may further limit the ability to use data
collected in the school setting.

Types of Schools Represented

School-based assessments that seek to describe a geographical region
rather than an individual school may be limited in their ability to capture
schools outside the public school system. As exemplified by the state and
local Youth Risk Behavior Surveys (YRBSs), inclusion of private, alterna-
tive, and other school types other than public is not always possible (CDC,
2013a). Considering approximately 10 percent of students in the United
States attend private schools (NCES, 2014), exclusion or inability to rep-
resent these students and those attending other school types, affects the
generalizability of the results.
Clinical and Public Health Settings

Individuals who received services at clinical settings and those who
participate in public health programs (e.g., the Special Supplemental Nutri-
tion Program for Women, Infants, and Children [WIC]) routinely have their
height and weight directly measured as a standard of practice. Data of this
nature, considered administrative data, have been used to assess obesity
prevalence and trends at different levels, from a single medical practice
(Nader et al., 2014) through large-scale assessments (Arterburn et al., 2010;
Hruby et al., 2015).
Published reports based on such data vary on what data are used to
classify obesity status. Some reports have used the International Classifi-
cation of Diseases (ICD) codes to identify those affected with obesity in
lieu of using direct measured values of height and weight (George et al.,
2011; Joyce et al., 2015; Koebnick et al., 2009). Prevalence estimates based
on ICD codes may underestimate the prevalence of obesity in adults and
children compared to other data collection methods (Al Kazzi et al., 2015;
Walsh et al., 2013).
The committee acknowledges that the use of electronic health records
(EHRs) and associated medical record databases to assess obesity preva-
lence and trends is emerging in published reports. This topic will be further
discussed in Chapter 4.
Other Research and Surveillance Settings

Other settings for capturing data related to obesity exist beyond schools,
medical facilities, and public health programs. The settings for these evalua-
tions are typically specific to the data source, and encompass both in-person
and remote data collection. Four data sources are highlighted below to
illustrate differences in such settings. Differences in specific data collection
approaches are discussed in greater detail in Chapter 4.

In-Person Data Collection

The specific physical locations in which data are collected in person
vary across data sources. The National Health Interview Survey (NHIS), for
example, is conducted in participants’ homes as a face-to-face interview but
collects only reported data (i.e., does not collect directly measured heights
and weights) (NCHS, 2015). In contrast, the National Health and Nutri-
tion Examination Survey (NHANES) uses specially designed mobile units
that travel around the country and contain state-of-the-art equipment and
laboratory space for physical assessments and biological sample collection
and processing (Zipf et al., 2013).
Remote Data Collection

Not all data used in published reports on obesity prevalence and trends
are collected in a defined physical location. Some are collected remotely.
The California Health Interview Survey, for example, is a phone-based
survey that captures height and weight data on children, adolescents, and
adults (UCLA Center for Health Policy Research, 2016). The redesign of
the National Survey of Children’s Health (NSCH), which is currently being
pretested, plans to use both mail- and Web-based data collection, with
minimal phone contact (MCHB, 2015).
INDIVIDUALS INCLUDED IN THE DATA SOURCE

The individuals who are included in the data source, and ultimately in
the analysis, are the basis of estimates of obesity prevalence and trends. Key
considerations when reviewing information about the study population and
sample include the source of the data and associated sampling approach,
size of the study sample, demographic characteristics of the study sample,
as well as the extent to which the study population was stable during the
time period when data were collected for trends analyses. The committee
identified three key features related to the individuals included in a data
source: sampling approach, sample size, and stability of the population over
time. These features vary across published reports and, in turn, affect the
interpretation of an estimate of obesity prevalence or trend.
Sampling Approach
It is typically not feasible or an efficient use of resources to measure
every individual to determine obesity prevalence and trends in a given
population. Sampling provides options to maximize generalizability and
specificity of a sample, especially when fixed resources limit the number

of individuals who can be assessed in a given period of time.1 The type

of sampling approach used will also affect the ability to generate precise
estimates of prevalence and trends in specific subgroups of interest. The
committee identified sampling approaches that appear in published reports
and considered approaches that may be used in small-scale or local settings,
but not be published in the peer-reviewed evidence base. The potential
advantages and disadvantages of the identified approaches are summarized
in Table 3-3. The committee also identified data sources in which sampling
strategies were not used because the vast majority of individuals in the
population contributed data. A description of two such examples and the
interpretation considerations associated with each are presented in Box 3-3.
When the total population is not assessed, the generalizability of result-
ing estimates of obesity prevalence and trends can become compromised
if the participants in the sample do not reflect the overall target popula-
tion. Sampling strategies can be carefully employed to prevent and correct
for bias to the extent possible. Bias can affect the prevalence and trends
estimates, and can be challenging to account for in a study. As previously
mentioned, some school-based BMI assessments may require active paren-
tal consent. Students who return a signed consent form may or may not
represent the overall student population. Calculation of response rates and
comparisons of the sampled population to the total target population can
provide insight into the representativeness of the data and facilitate adjust-
ment for potential sources of bias.
Intentional Oversampling
Intentional oversampling is a technique used across different sampling
approaches. When intentional oversampling is used, a group is sampled
at a higher proportion than it exists within the target population, which
can provide a more precise and stable estimate of prevalence for the group
that is oversampled. NHANES, for example, has oversampled a variety of
groups over the course of the survey history (Johnson et al., 2014). Since
the 2011 cycle, one such group has been non-Hispanic, non-black Asian
individuals. The 2010 Census indicated that this group comprised 4.8 per-
cent of the total U.S. population (U.S. Census Bureau, 2011). However, to
ensure enough participants identifying as Asian were evaluated, approxi-
mately 14 percent of the 2011-2014 NHANES sample were Asian (Johnson
et al., 2014).
1 For
additional information about sampling approaches, the reader is referred to “Survey
Sampling” (Kish, 1965).

TABLE 3-3 Potential Advantages and Disadvantages Associated with Sampling Approaches, for the Purposes of
Generating Estimates of Obesity Prevalence in a Population
Sampling Approach Description Potential Advantagesa Potential Disadvantagesa
Convenience Individuals are included because they May provide insight into groups Results not generalizable beyond
Sampling are easily reached and willing to that merit further evaluation. those included in the sample.
participate.
Simple Random Each individual in the population has the Represents the full population. Sample may not include enough
Sampling same probability of being selected. individuals from subpopulation
groups.
Stratified Random The population is divided into groups Individuals from each stratum are Sampling weights must be used to
Sampling (“strata”) based on a characteristic represented in the sample. calculate a population estimate of
(e.g., sex, age group, race or prevalence or trend.
ethnicity); a random sample is then
drawn from each stratum, which
ensures their inclusion in the sample.
Complex Multistage A large area is divided into clusters that Represents the entire population Can be complex to design.
Sampling are sampled; sampled clusters are and targeted subgroups. Often require advanced statistical
divided into smaller clusters, which analysis.
are again sampled.b
Sampling mechanisms inside clusters may
vary according to study goals.
NOTE: Other sampling approaches exist.

a The potential advantages and disadvantages are contingent on the population assessed, the methodology employed, the analytic approach, and

the end user seeking to apply such information. Population and methodologic considerations are discussed throughout this chapter. The analytic
considerations are more fully explored in Chapter 5, while considerations related to end users are discussed in Chapter 6.
b Multistage sample involves two or more rounds of sampling. The principle is the same for each subsequent round of sampling.
67
BOX 3-3
Two Examples in Which Sampling Was Not Used
Because the Vast Majority of the Population Contributed Data
Height and Weight Data Measured at Women, Infants, and Children (WIC) Clinics
WIC is an income-based nutrition assistance program that is operated in

U.S. territories, Indian Tribal Organizations, and all 50 states. Because height
and weight measurements are a requirement for enrollment and continued par
ticipation, a wealth of data exists for this specific population. Accordingly, WIC
administrative data have been used to calculate prevalence of and assess trends
in obesity (Dalenius et al., 2012; Sekhobo et al., 2010). Given the near complete
coverage of this data source, statistics for a WIC agency—for example, at the
state- or clinic-level—are typically regarded as reflecting the actual prevalence
of obesity among WIC child participants at selected location, as opposed to an
estimate of prevalence. The results, however, cannot be generalized to all low-
income children, because income-eligible non-participants are not represented in
the data.
Electronic Health Records (EHRs)
Rather than using a sampling approach, select reports on obesity prevalence

and trends have based their analyses on all available EHRs meeting inclusion
criteria (e.g., age of patient, time period being assessed). These evaluations
provide insight into the obesity status of all individuals seen at a particular prac
tice or within a specific health system within the defined inclusion criteria. The
prevalence and trends statistics, however, do not include individuals who received
care from different providers or medical systems, or those who did not seek medi
cal attention. Accordingly, the ability to generalize findings beyond the patients
included in the analysis is limited.
Sample Size
As exemplified by the need for intentional oversampling, the sample
size largely determines what statistical procedures and comparisons can be
meaningfully conducted. Estimates of prevalence and trend are more stable
when they are based on larger samples. Even in very large samples, the rep-
resentation of a subpopulation of interest may be small, which could lead
to highly variable estimates. Variability in estimates is generally expressed
in terms of standard error and confidence intervals.
Stability of the Population Over Time

When considering estimates of prevalence over a period of time, the
extent to which the underlying population studied remained stable is an

important consideration. Changes in the distribution of exposures and

sociodemographic characteristics within subgroups of the population over
time can affect the interpretation of obesity prevalence data. These changes
should be measured and accounted for during the analysis. Comparisons
of contextual variables, such as the birth rate, unemployment rate, poverty
rate, income distribution, and the racial and ethnic composition of the
study sample at the first time point and at subsequent measurement points,
can provide a basis for gauging the stability of the population under con-
sideration. The influx or efflux of population groups, especially those with
a disproportionate risk of obesity, can affect the interpretation of the results
if not accounted for during the analysis.
DATA COLLECTION METHODOLOGIES

Surveillance systems and studies use a variety of protocols to capture
data on obesity status, as well as various measures to capture the key demo-
graphic characteristics discussed in Chapter 2. This variability presents
challenges for data analysis and interpretation.
Collecting Data Related to Obesity Status

BMI is calculated from an individual’s height and weight. This infor-
mation can be captured either through direct measure or by proxy- or self-
report. The potential advantages and disadvantages of these approaches are
summarized in Table 3-4.
Directly Measured Heights and Weights

Directly measured heights and weights require a data collector, a scale,
and a means for measuring height (typically a stadiometer). As described in
Box 3-4, protocols for capturing directly measured height and weight vary
in terms of the equipment used, participant procedures, and data collector
procedures.
Special Considerations Obtaining a directly measured height or weight

may present a challenge in some populations, such as young children and
individuals with severe obesity.
Young children The accuracy of directly measured height and weights
in preschool-aged children is contingent, in part, on the child’s ability to
cooperate and follow directions. Compared to their school-aged and older
counterparts, preschool-aged children are more susceptible to obesity sta-
tus misclassification with relatively small inaccuracies in height or weight
(Ogden, 2015) (see Table 3-5).

TABLE 3-4 Potential Advantages and Disadvantages of Directly

Measured and Reported Height and Weight Data
Approach Potential Advantagesa Potential Disadvantagesa
Directly Increases accuracy. Requires the data collector and the participant
measured to be in the same location at the same time.
Necessitates data collectors be trained and
execute a standardized protocol to ensure
quality and accuracy of measurement.
Variations may exist in data collection
protocols.
Proxy- or Convenient, easily captured. Prevalence estimates are not comparable to

self-report Can provide insight into estimates generated from directly measured
trends over time. heights and weights.
a The potential advantages and disadvantages are contingent on the population assessed, the
methodology employed, the analytic approach, and the end user seeking to apply such infor
mation. Population and methodologic considerations are discussed throughout this chapter.
Individuals with severe obesity Individual who have severe obesity

may not be able to follow the standard protocol for height and weight. The
anthropometric protocol for NHANES, for example, instructs data collec-
tors to capture height when head, shoulder blades, buttocks, and heels are
in contact with the stadiometer backboard, but provides additional instruc-
tions for capturing height when obesity prevents such a positioning (CDC,
2013b). An individual who has severe obesity also can have a weight that
exceeds the capacity of the scale. NHANES provides additional procedures
for capturing weight in such instances (CDC, 2013b). Not all protocols,
however, make such specifications (see Appendix D, Tables D-1 and D-2).
Reported Heights and Weights

A variety of factors—such as study design, sample size, participant
characteristics, and participant accessibility—can make directly measuring
height and weight not feasible. Rather than forego evaluation of obesity
status in these instances, investigators ask a participant and/or a proxy
for the participant to report weight and height. The convenience and ease
of capturing self- and proxy-reported height and weight data make it an
attractive option for data collection.
The collection of self- or proxy-reported height and weight data should
be accompanied by consideration of the impact on the representative-

BOX 3-4
Differences in Direct Measure Protocols
The committee reviewed protocols and manuals that provide detailed instruc
tions for gathering directly measured heights and weights (see Appendix D, Tables
D-1, D-2, and D-3). It should be noted that these protocols only encompass
research-based initiatives and select school-based assessments, and do not
include data collected in the medical or public health services settings. Although
the protocols were conceptually similar, differences emerged in the details, as
summarized below:
Differences in Protocols for Measuring Height

• Type of stadiometer (wall-mounted, portable)
• Number of contact points with the stadiometer
• Methods for handling hairstyles or headpieces that interfere with the measurement
Differences Across Protocols for Measuring Weight

• Type of scale used (digital, electronic, balance, dial)
• Scale calibration (procedures, frequency)
• Clothing status of participants (light street clothing, clinical gown)
Differences in Data Collector Procedures

• Training and oversight of data collectors
• Staff position of the data collector (e.g., research staff, school nurse, physical
education teacher, other staff)
• Precision of the data recorded (e.g., to the nearest pound, 1/10th of a pound)
• Number of measurement replications (measure in duplicate, triplicate)
• Thresholds for additional measurements (e.g., two heights must be within 1/4
inch of each other)
• Data entry (e.g., direct entry, transfer hand-written values)
ness of the sampled population. Reported weight and height may be cap-
tured through a paper questionnaire, interview (phone or in-person), or
computer-based survey and can enhance or restrict the sampled population
in different ways. For example, a paper-based questionnaire will generally
require the participant to have reading comprehension at or above the
level in which the question is written. Phone-based interviews, in contrast,
require the participant or the household to have an operational phone at
the time of data collection. In the same vein, language of delivery also
has implications for the sample included in the report. Some protocols
have the capacity to ask the question only in English. Other protocols have
the capacity to ask the question in English, Spanish, and other languages
that are dominant within the population(s) of interest (UCLA Center for
Health Policy Research, 2016). Phrasing and clarity of the question also

72
TABLE 3-5 Illustrative Examples Demonstrating Differences in Height or Weight That Categorically Change Weight
Status from Normal to Obese at Two Different Ages
Characteristics of the Height Weight Body Mass Index Weight Status Difference That Changes Weight
Individual (centimeters) (kilograms) (kg/m2) Classification Status from Normala to Obeseb
Female, age 2.0 years 86.3 13.4 18.0 Normala —
86.3 14.3 19.2 Obeseb +0.9 kilograms
83.7 13.4 19.1 Obeseb –2.6 centimeters
Female, age 15.0 years 152.4 55.7 24.0 Normala —

152.4 65.3 28.1 Obeseb +9.6 kilograms
140.8 55.7 28.1 Obeseb –11.6 centimeters
NOTE: All data are hypothetical. Calculations were performed using the CDC BMI Calculator for Child and Teen (CDC, 2015a). Values were
selected to correspond to a BMI that would be at the upper threshold of the normal BMI-for-age category, or at the lower bound of the obese category.
The CDC calculator allows for height to be entered to the nearest tenth of a centimeter and weight to be entered to the nearest tenth of a kilogram.
a Approximates the 84th percentile on the 2000 CDC sex-specific BMI-for-age growth charts. This is the upper threshold for what is classified as
“normal.” Other terminology that has been used for this category is “healthy.”
b Approximates the 95th percentile on the 2000 CDC sex-specific BMI-for-age growth charts. This is the lower threshold for what is classified
as “obese.”

vary slightly across different data sources. Most protocols and surveys
use a similar question base (“How much do you weigh?”/“How tall are
you?”), but some will expand on these to include a time frame (“now”),
desired units (“in pounds”/“in feet and inches”), and specify “without
shoes on” (see Table 3-6). Finally, the person providing the reported weight
and height should be considered. Some collect self-reported data only
from high-school aged students. Others will collect information about
elementary-school aged children from a parent or guardian, but allow ado-
lescents to report for themselves.
TABLE 3-6 Variation in Questions Asking for Reported Weight and Height
Question for Reported Weight Question for Reported Height Reference
“How much does [sample child] “How tall is [sample child] now?” (NSCH, 2012)
weigh now?”
“How much do you weigh?” “How tall are you?” (NLS, 2008)
“How much do you weigh? “How tall are you? (Project EAT,
__ __ __ pounds” __ feet __ __ inches” 2010)
“About how much do you weigh “About how tall are you without (CDC, 2014a)
without shoes?” shoes?”
“About how much do you “About how tall are you (child) (CHIS, 2015)
(child) weigh without shoes? [IF without shoes? [IF NEEDED, SAY:
NEEDED, SAY: ‘Your best guess ‘Your best guess is fine.’]”
is fine.’]”
“How much do you weigh “How tall are you without your (YRBS, 2015)
without your shoes on? shoes on?
Directions: Write your weight in Directions: Write your height in
the shaded blank boxes. Fill in the shaded blank boxes. Fill in
the matching oval below each the matching oval below each
number.” number.”
“How much do you weigh “How tall are you without your (Healthy Youth
without your shoes on? shoes on? Survey, 2014)
Directions: Write your weight Directions: Write your height
in the blank boxes and fill in in the blank boxes and fill in
the matching circle below each the matching circle below each
number on your answer sheet.” number on your answer sheet.”

Measured Versus Reported Weights and Heights

The discussion below highlights the differences between proxy-reported
heights and weights and self-reported heights and weights, in relation to
directly measured values.
Proxy-Reported Heights and Weights Depending on the data source, the

proxy reporting the child’s height and weight can be a parent, guardian, or
adult in the household who is most knowledgeable about a child. In young
children, relatively small differences between proxy-reported and directly
measured values can cause a significant shift in the child’s weight status
classification (see Table 3-5), with estimates of obesity prevalence notably
affected by errors in proxy-reported heights (Akinbami and Ogden, 2009;
Weden et al., 2013). In general, proxy-reported weights are lower than
directly measured values, but the error may vary by factors such as the
child’s age, sex, and weight status (Lundahl et al., 2014; O’Connor and
Gugenheim, 2011).
In a study comparing different nationally representative surveys, inves-
tigators found mean height from the NHIS proxy-reported data was 3 to
6 cm less than the mean height from NHANES directly measured data
among children ages 2 to 11 years (data 1999-2004; P<0.001) (Akinbami
and Ogden, 2009). Akinbami and Ogden (2009) concluded that discrepan-
cies between proxy-reported and measured values lead to misclassification
of weight status and BMI in preschool- and elementary-aged children, and
therefore recommended that proxy-reported measures not be used to esti-
mate obesity prevalence for these ages (see Table 3-7).
Although the differences between proxy-reported and directly mea-
sured height and weight values have been assessed in cross-sectional study
designs, the committee did not identify reports comparing secular or longi-
tudinal trends in the two data collection approaches.
Self-Reported Heights and Weights In general, self-reported heights

and weights tend to underestimate BMI in both adolescents and adults,
although reporting error can vary by factors such as age, sex, race and
ethnicity, and weight status (Gillum and Sempos, 2005; Jayawardene et
al., 2014; Mozumdar and Liguori, 2016). Elementary school-aged chil-
dren generally do not accurately self-report their heights and weights and
ability to self-report reasonable values appears to be better among older
children than younger children (Beck et al., 2012). In a convenience sample
of adolescents, self-reported height were overreported and weight under-
reported, but were found to be reliably reported when tested and re-tested
over a 2-week period (Brener et al., 2003). Some reports have noted that
female adolescents have a tendency to underreport their weight more than

TABLE 3-7 Differences in Mean Heights and Weights from Nationally

Representative Directly Measured (NHANES) and Proxy-Reported
(NHIS) Data and Associated Effects on Obesity Prevalence Estimates
Absolute Difference Absolute Difference Effect on
Age Between Measured Between Measured Obesity
Group and Reported Height and Reported Prevalence
(Years) Sex (cm) Weight (kg) Estimatea
2-3 Male 3.1b –0.3b Overestimate
Female 3.2b –0.2b
4-5 Male 4.1b 0.7b
Female 5.2b 0.5b
6-7 Male 5.6b 0.3
Female 5.3b 0.3
8-9c Male 6.1b 1.2b
Female 6.9b 2.5b
10-11c Male 4.7b 0.5
Female 6.3b 4.1b
12-13d Male 2.3b –0.1 Similar estimate
Female 2.9b 3.0b
14-15e Male 2.6b 0.5 Underestimate
Female 1.3b 2.5b
16-17e Male 0.0 0.7
Female 0.4 2.6b
NOTES: Absolute difference values were obtained from mean height and weight data from
two nationally representative surveys, NHANES (directly measured) and NHIS (proxy-
reported), 1999-2004. Data presented do not express changes in bias over the life course, but
rather estimates at a specific time.
a Obesity defined as BMI ≥95th percentile according to the 2000 CDC sex-specific BMI-
for-age growth charts.

b Statistical significance based on t-test P<0.05.
c Trends suggested an overestimation of obesity prevalence for this age group.
d Trends suggested a similar estimate of obesity prevalence for this age group.
e Trends suggested an underestimation of obesity prevalence for this age group.
SOURCE: Akinbami and Ogden, 2009. Data adapted and reprinted with permission.

their male counterparts (Sherry et al., 2007). When evaluated by weight

status, data self-reported by adolescents with elevated weight statuses tend
to lead to an underestimation of BMI, while those reported by adolescents
with underweight tend to overestimate BMI (Jayawardene et al., 2014;
Morrissey et al., 2006). Because bias in self-reported height and weight
affects the resulting BMI and can thereby affect obesity prevalence (see
Table 3-8), some investigators have suggested that such data have limited
utility for estimating obesity prevalence in adolescent populations or may
be used cautiously when measured data are not available (Morrissey et al.,
TABLE 3-8 Bias in Self-Reported Heights and Weights Compared to

Directly Measured Data and Associated Effect on Obesity Prevalence
Among Children and Adolescents
Age Effect on Obesity
(years) Height Weight Prevalencea Reference
~6-11 Underestimate Underestimate Overestimateb Beck et al., 2012
10-16 Not Significantly Underestimate Underestimate Morrissey et al.,
Different 2006c
12-18 Overestimate Underestimate Underestimate Himes et al., 2005d
~12-18 NR Underestimate Underestimatee Goodman et al., 2000
~12-18 Overestimated Underestimated Underestimate Pérez et al., 2015f
~14-18 Overestimate Underestimate Underestimate Brener et al, 2003g;
Jayawardene et al.,
2014h
NOTES: Only studies evaluating U.S. child and adolescent populations are included. This table
describes the overall bias, and not the magnitude, of under- or overestimation of height, weight
and obesity prevalence. Reporting error can vary by age, sex, race and ethnicity, weight status,
and other variables, not described by this table. Data presented do not express changes in bias
over the life course, but rather estimates at a specific time. NR, not reported.
a Shows overall direction of bias; obesity defined as BMI ≥95th percentile according to the
2000 CDC sex-specific BMI-for-age growth charts.

b n = 21, 61, and 123 for grades 1, 3, and 5, respectively. After removing unreasonable
values, children in all three grade levels significantly underreported their height and weight;
the report only discussed effect on prevalence of overweight and obesity (collectively) among
students in grade 5 providing reasonable height and weight values.
c n = 426.
d n = 3,797.
e n = 11,495; data from the nationally representative National Longitudinal Study of
Adolescent to Adult Health (Add Health). Investigators noted that obesity status was correctly
classified for 96 percent of assessed adolescents.
f n = 24,221 students in grades 8 and 11.
g n = 2,032 from a convenience sample of students in grades 9-12.
h n = 7,160; study sample included students in grades 9-12.

2006; Sherry et al., 2007). Underestimation of weight and overestimation

of height by self-report have also been observed among adults, leading
to an underestimation of obesity prevalence (Gillum and Sempos, 2005;
Kuczmarski et al., 2001). In some cases, correction equations have been
developed in order to improve estimates of obesity prevalence from self-
reported data (Mozumdar and Liguori, 2016; Pérez et al., 2015).
Evidence on changes in reporting bias in children is limited. One longi-
tudinal study concluded that females tended to underreport weight in ado-
lescence, a trend that increased into early adulthood, while no change was
observed in males in adolescence or early adulthood (Clarke et al., 2014).
Although adolescent self-reported height and weight data generally do
not lead to obesity estimates comparable to those generated from directly
measured data, analyses of national YRBS data suggest adolescent self-
reported data may provide insight into the directionality of the overall
trend. The national YRBS trend analysis suggests a significant linear trend
in obesity prevalence among high school students between 1999 through
2013, but no statistically significant change between the two most recent
cycles of data collection (2011, 2013) (CDC, 2014c; YRBS, 2014). These
findings are similar in directionality to what has been reported among ado-
lescents with directly measured heights and weights in NHANES (Ogden
et al., 2014; Skinner and Skelton, 2014).
Collecting Data Related to Demographic Factors

Demographic characteristics are used to describe individuals included
in the study’s population, to determine whether the study population is
representative of the target population of interest, and to divide the study
population into subgroups for comparisons. Consistent with its task, the
committee evaluated the methodological approaches that have been used
in recent reports to characterize diverse U.S. populations, particularly those
that are socially disadvantaged (see Box 3-5).
Sex
For children, adolescents, and young adults, sex is a required demo-
graphic factor for classifying obesity status. Although most reports evalu-
ate obesity prevalence and trends across both sexes, some reports evaluate
just one.
Age
Like sex, age is required for classifying obesity status among children,
adolescents, and young adults. Most studies and surveillance systems deter-

BOX 3-5
Operationalizing Social Disadvantage
The assessment of disparities in obesity requires creating subgroups that

reflect social disadvantage status. Despite the complexities underlying social
disadvantage, analyses often operationalize groups based on demographic char
acteristics (e.g., race, ethnicity, sex, income, geography).
Challenges exist in adequately characterizing populations. Race and ethnicity,
for example, is often used as a measure of social disadvantage. Categories that
are frequently offered for race (e.g., American Indian or Alaska Native, Asian, Black
or African American, Native Hawaiian or Other Pacific Islander, White) and ethnicity
(Hispanic or Latino, Not Hispanic or Latino) do not necessarily reflect the growing
diversity and within-group heterogeneity that exists (Ennis et al., 2011; Hixson et
al., 2011; Hoeffel et al., 2012; Norris et al., 2012; Rastogi et al., 2011). Even if
measured well, neither race nor ethnicity assesses acculturation or the degree to
which immigrants both maintain their original cultural heritage and integrate into
the new culture (Thomson and Hoffman-Goetz, 2009).
Many studies have addressed the relationship of socioeconomic disadvantage
to obesity. Both lower parental education and lower household income, frequently
used to assess socioeconomic disadvantage, have been associated with in
creased prevalence of obesity. These associations are found at the individual,
community, state, and national levels (Bethell et al., 2009; Economos et al., 2007;
Goodman, 1999). Income and education are not synonymous and cannot be used
as proxies for each other, however. Although they are thought to create health
impact through different mechanisms (Adler and Ostrove, 1999; Matthews and
Gallo, 2011), both are not always captured. When measured, income is often as
sessed in relation to the federal poverty level (FPL) as an income-to-needs ratio.
These FPLs are too low because families today spend about 1/7 of their income
on food, as opposed to 1/3, which is what families spent in the 1960s, when the
federal poverty levels were developed. Moreover, the FPL does not adjust for
geographic variation in cost of living and does not account for other child-related
expenses like child care or child-related benefits (e.g., Supplemental Nutrition
Assistance Program) (NRC, 1995).
Opportunities exist to improve data collection approaches for the purposes of
identifying obesity disparities. The “supplemental poverty measure,” which began
to be assessed in 2011, provides a more accurate assessment of poverty (Short,
2012). Additionally, a 2015 American Academy of Pediatrics Policy Statement
highlights the need for consideration of both biological and social mechanisms
of action of race, ethnicity, and socioeconomic status and makes specific recom
mendations for measurement of these constructs (Cheng and Goodman, 2015).
mine exact age based on recorded date of birth and date of measurement.
Reports using de-identified or publicly available data may have access only
to an age in years rather than year and months. Skinner and Skelton (2014),
for example, explained that a cycle of NHANES data provided age in years
only for those ages 2 to 19 years and could not be used in the same way

as the available data for previous cycles.2 To address this limitation, the
investigators chose to use the midpoint of the provided age in year (“e.g.,
an 11-year-old child would be considered 11.5 years of age”; Skinner and
Skelton, 2014).
Race and Ethnicity

Race and ethnicity are frequently collected as descriptors of a popu-
lation, but the way these data are collected varies. In some studies and
assessments, race is a selection criterion (e.g., study of American Indian
children). In broader and more general assessments, race and ethnicity
are generally presented as a list of categories from which the participant
chooses. One standard for race and ethnicity classification, developed by
the Office of Management and Budget (OMB), offers five race categories
(American Indian or Alaska Native, Asian, Black or African American,
Native H awaiian or Other Pacific Islander, White) and two ethnicity catego-
ries (Hispanic or Latino, Not Hispanic or Latino) (OMB, 1994). The stan-
dard high school YRBS questionnaire, for example, uses this classification.
Some studies go beyond the OMB approach to deconstruct the diversity
classification of one or multiple race or ethnicity categories. This refinement
often reflects the broader diversity of the target population as well as efforts
to identify population groups at highest risk. Stingone et al. (2011), for
example, further differentiated the participants identifying as Latino into
Puerto Rican, Dominican, Mexican, or other Latino groups. Similarly, the
2013-2014 NHANES demographic questionnaire provided participants
identifying as of Hispanic, Latino, or Spanish origin 29 ancestry groups
from which to select, those identifying as of Asian origin 35 ancestry groups
from which to select, and those identifying as Native Hawaiian or Pacific
Islander origin 4 ancestry groups from which to select (NHANES, 2013).
During data collection, participants are often offered more race and ethnic-
ity categories to select from than appear in the results of reports. This is
typically an analytic decision made due to sample size (for further explana-
tion, see Chapter 5).
Socioeconomic Status
Measures of socioeconomic status (SES) vary across published reports
of obesity prevalence and trends. Different measures exist at the individual-
level and the population-level (see Appendix D, Table D-5).
2 The datasets have since been updated and include age in months for the variable of age
for participants ages 0 to 19 years (CDC, 2015b). Date of birth, however, is not publicly
released information.

At the individual-level, household income can be used to produce dif-

ferent variables of SES. These include the income-to-poverty ratio; the child
or family’s eligibility for and/or participation in assistance programs (e.g.,
WIC); and the child’s individual eligibility for free or reduced-price school
meals. In many cases, these measures are preferable to assessing income
directly because they offer more information regarding the family’s income
status in a broader community context, and also generally have a higher
response rate in questionnaires (Potter et al., 2005; Shavers, 2007).
Education also is used as a proxy of SES at the individual level, but the
measures are not clearly defined. For example, parental/caregiver educa-
tion has been reported as the highest level of education attained by either
parent, both parents, or just the mother (Delva et al., 2007; Halloran et
al., 2012; Huh et al., 2012; Sherwood et al., 2009). Education is more
stable and often easier information to access than income, but the cor-
relation with income is not direct, and same investment in education will
likely yield a different income and SES in individuals of a different sex and
race or ethnicity. Parent education, as well as parent employment status,
age, and family structure, also have been used in reports as demographic
variables on their own, and not as a proxy for SES (Fakhouri et al., 2013).
Parental employment status is used in some cases as a variable to assess
SES but has been regarded as a weaker assessment than income or educa-
tion (Nuru-Jeter et al., 2010). Some studies also have used measures of
geography to assess SES, based on trends that show disparities between
urban and rural populations, as well as differences based on geographic
location within the United States.
SES also has been examined at the community level. In school-based
assessments, the percentage of students receiving free or reduced-price
school meals and the racial or ethnic majority population have been used
(Sanchez-Vaznaugh et al., 2015). Estimates of neighborhood income level
and neighborhood education level also are used to gauge neighborhood
SES level. Community SES measures offer additional information about an
individual’s environment, and some studies have suggested that they may
be used in some cases to substitute where individual data are not available,
but more research is needed (Krieger et al., 2003). In studies examining
the impact of SES on obesity, the investigators have even developed unique
measures of community SES level to fit their needs and facilitate answering
the investigators’ specific research question(s). For example, Sekhobo et al.
(2014) divided New York City boroughs into low-risk and high-risk areas
depending on their proximity or inaccessibility, respectively, to a District
Public Health Office providing services for maternal and child health, and
compared obesity rates between children in those communities.

Geography
The geographic locale of the population evaluated is an inherent char-
acteristic of a data source and is directly linked to the representativeness
of the sample. Some data collection efforts are purposely sampled in a
way to represent the nation, a specific state, or defined community. Other
data sources, for example WIC administrative data or school-based BMI
assessments, are defined because their collection at the state or local level
is required by law. Some data sources, however, are not representative of
a geographic location but rather a physical location. Obesity prevalence
and trends analyses of EHRs from a single medical practice would be one
such example. The evaluated population may include all patients seen
for a well-child appointment in a given year, for example, but would not
be representative of all children in the city or town in which the medical
practice is located. Beyond a single geographic location, some data sources
are designed to capture multiple states or localities, which can be used for
comparative assessments. Specific examples are described in Chapter 4.
Rurality
The rurality of a defined geographic region has been classified and
used in different ways in reports on obesity prevalence and trends. The
level of rurality (or urbanicity) is typically defined by the total population
or population density. For example, an evaluation of obesity among white
and American Indian school children in South Dakota dichotomized the
samples as residing in urban (two cities with a population >50,000) or rural
(rest of state) locations (Hearst et al., 2013). In contrast, an evaluation in
Pennsylvania had four categories: urban (≥1,000 population per square
mile), suburban (999 to 300 population per square mile), rural (299 to 100
population per square mile), and ultrarural (<100 population per square
mile) (Bailey-Davis et al., 2012). In some reports, the level of rurality or
urbanicity defines the entire sampled and target population. Data from the
Bogalusa Heart Study, for example, are described by investigators as being
from a “semirural” population in Louisiana (Broyles et al., 2010).
SUMMARY
Data on height and weight have been collected for research studies using
cross-sectional, repeated cross-sectional, and, to a lesser extent, longitudinal
designs. These data also have been collected for other purposes including
school-based screenings, surveillance, and as part of routine health care.
The ability to generalize estimates beyond the study population is
contingent, in part, on how the individuals were selected for inclusion.

Sampling procedures have been used to not only arrive at a representative

sample, but also to generate more precise estimates for relatively small
subgroups of interest.
Approaches used to capture height and weight data direct measure
ment include self-report and proxy-report. Estimates of obesity prevalence
calculated from these data collection approaches are generally not inter-
changeable. Obesity trends based on self-reported heights and weights from
nationally representative samples of high school students suggest such data
may provide insight into the general directionality of obesity trends over
time, similar to those calculated from directly measured data.
Collecting and using data on key demographic characteristics varies
across data sources and reports. Obesity status classification for children,
adolescents, and young adults depends on both sex and age of the partici-
pant, and these two variables appear in most reports. The number of race
and ethnicity categories offered to participants varies across data sources,
with some studies capturing specific origin and ancestry groups. Similarly,
measures of SES used across reports differ and may not be directly com-
parable. The geographic boundaries of estimates are reliant on the repre-
sentativeness of the sampled population; not all data sources represent a
broader geography. Finally, approaches to classifying levels of rurality and
the number of categories included vary across reports.
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Comparison of Data Sources Used to

Assess Obesity Prevalence and Trends
Key Messages
• Data used to assess obesity prevalence and trends are derived
from a wide variety of sources, including population surveys,
school-based assessments, clinical and public health services
administrative data, and cohort studies.
• The National Health and Nutrition Examination Survey
(NHANES) is currently the only ongoing nationally represen-
tative population survey that directly measures participants’
heights and weights. All other nationally representative surveil-
lance surveys with samples that include children and adoles-
cents collect self- or proxy-reported height and weight data.
• At the time of this report, the Youth Risk Behavior Surveillance
System (YRBSS, describing high school students) and adminis-
trative data from the Special Supplemental Nutrition Program
for Women, Infants, and Children (WIC, describing program
participants) are two data sources that currently include indi-
viduals ages 18 years and younger and generate obesity preva-
lence estimates for multiple individual states and localities. The
redesigned National Survey of Children’s Health (NSCH) is
expected to begin releasing state-level estimates in 2017.
• School-based assessments are a key source of directly measured
height and weight data for children and adolescents. States
have used the school-based assessment to evaluate regional,
89

county, and, in some cases, local obesity prevalence and trends.

States differ in their approaches to collecting these data.
• Newer approaches to collecting and sharing health data, such
as through electronic health records (EHRs) and public health
registries, have created opportunities to assess obesity status
at the state and local level. However, these data represent only
those who make use of the health care system.
• Cohort studies are another source of obesity prevalence and
trends estimates. Those that assess participants longitudinally can
provide unique insight into incidence and remission of obesity.
The data collection methodologies discussed in Chapter 3 do not exist

or operate in isolation, but rather coalesce to form a data system. The study
design, sample selection, and data collection approaches interact with each
other and ultimately inform the interpretation of the associated analyses.
The purpose of this chapter is to review and compare data sources used to
assess obesity prevalence and trends. Throughout this chapter, key compo-
nents of data collection methodologies will be highlighted.
Through its review of the evidence, the committee identified four broad
categories of data sources used to assess obesity prevalence and trends
among children, adolescents, and young adults. These include population
surveillance surveys, direct measurement in the school setting, clinical and
public health setting administrative data, and cohort studies. Although they
are presented as distinct, these categories can overlap, depending on the
design of the data source. These intersections, and the inability to discretely
classify data collection efforts, emphasize the nuances, inconsistencies, and
complexities that currently exist.
Detailed information about design and methods often reside in reports,
protocols, and other documentation specific to a particular data source. It is
the intent of this chapter to bring together condensed overviews of various
data sources used to estimate obesity prevalence and trends, particularly
among individuals ages 18 years and younger, to demonstrate how they
are designed and how their differences would affect estimates presented in
published reports.1 The total sampled population2 and methodologies, for
example, will be described for the purposes of comparison. The committee
1 For additional information about a range of surveillance systems that collect weight-related
data, the reader is referred to the National Collaborative on Childhood Obesity Research’s
Catalogue of Surveillance Systems (http://tools.nccor.org/css [accessed June 7, 2016]).
2 This chapter provides a broad overview of select data sources and their total sample popu-
lations. Published reports using these specific datasets often do not use the entire sample. When
evaluating a report on obesity prevalence or trends, end users are advised to assess the sample
used in the analysis in addition to considering the total sampled population.

COMPARISON OF DATA SOURCES USED 91
acknowledges that the list of data sources in this chapter is not exhaustive
and others exist beyond those included here.
POPULATION SURVEILLANCE SURVEYS

Population surveillance surveys are a key source of data used in reports
on obesity prevalence and trends in a range of U.S. populations. Some
population surveys that capture height and weight data are designed to
describe the country as a whole (“nationally representative”). Those in
which children and adolescents are included in the surveyed population
include the National Health and Nutrition Examination Survey (NHANES),
the National Health Interview Survey (NHIS), and the Medical Expendi-
ture Panel Survey-Household Component (MEPS-HC). Other surveys and
surveillance systems are designed to be both nationally representative and
representative of multiple states and localities. This has been accomplished
in two ways. The first way is the approach taken by the Youth Risk Behav-
ior Surveillance System (YRBSS), which conducts a nationally represen-
tative survey in addition to separate surveys for participating states and
large urban school districts. The second way is the approach taken by the
National Survey of Children’s Health (NSCH), which used samples col-
lected in each state to generate statistics of prevalence for each state and
at the national level. The following sections describes each of these surveys
to highlight the similarities, differences, and gaps that exist across nation-
ally representative data sources and data sources designed to represent the
nation, multiple states, and various localities (summarized at the end of
this section in Table 4-1). The barriers to comprehensively evaluating and
comparing individual state and local population surveys also are described.
The committee’s synthesis of this information is summarized at the end of
this section.
Population Surveillance Surveys Designed to be Nationally Representative

Population surveillance surveys with the primary intent of being nation-
ally representative describe the country as a whole. These surveys are gen-
erally not designed to generate estimates of obesity prevalence or trends
for specific regions, states, or localities within a given year or cycle of data
collection.3 The sample size and sampling procedures in these surveys,
3 This statement comes with three caveats. First, some researchers have been able to use
the nationally representative data to calculate estimates for populous states and counties
that are well represented within the data source (Johnson et al., 2013b; Porter et al., 2011).
This, however, cannot be done for most locations. Second, the committee acknowledges that
model-based estimation approaches are being used to generate estimates for smaller areas than
those for which a survey or study was designed to represent. For that reason, the statement in

however, may provide enough data to allow for comparisons of select

population groups. At the present, data sources with this general sam-
pling approach that capture height and weight data and have samples that
include individuals ages 18 years and younger are NHANES, NHIS, and
MEPS-HC.
National Health and Nutrition Examination Survey

NHANES is a nationally representative, repeated cross-sectional sur-
vey that explores the relationship between nutrition and health, identifies
emerging public health issues, and provides baseline information on the
health and nutritional status of the nation (CDC, 2016a). The first iteration
of the NHANES program, called the National Health Examination Survey
I, was conducted in 1960-1962, with various cycles following in the years
thereafter. In 1999, NHANES became a continuous survey. To produce
reliable estimates and to decrease the likelihood of identifying individual
participants, data are released in 2-year cycles (Curtin et al., 2012).
Approximately 5,000 individuals of all ages are surveyed as part of
NHANES each year (Johnson et al., 2014). Participants are selected through
a complex, four-stage sampling design. Each year, individuals are sam-
pled from 15 locations from across the country, with data being collected
throughout the year (NHANES, 2013a). Both the locations4 and the indi
vidual participants change annually. NHANES oversamples various popu-
lation groups in an effort to provide more precise and stable estimates of
health parameters. In the 2011-2012 and 2013-2014 cycles of NHANES,
the oversampled groups included: Hispanic persons, non-Hispanic black
persons, non-Hispanic non-black Asian persons, low-income non-Hispanic
non-black non-Asian white and other persons (≤130 percent of the federal
poverty level), and adults ages 80 years and older (Johnson et al., 2014).
The groups that are oversampled have changed over time, which affects the
amount of data available for trend analyses for population groups that have
comprised or currently represent a small portion of the total U.S. population.
Information is gathered from participants through an interview and a
physical examination (Zipf et al., 2013). Heights and weights are directly
measured from trained data collectors. The digital scale currently used to
obtain the body weight is linked to the study database, as is the stadiometer
used to measure height (CDC, 2013b). Demographic variables collected
include, among others, sex, date of birth, income, occupation, and highest
the text pertains to direct survey estimates rather than synthetic estimates. Third, some data
sources are both nationally representative and representative of multiple states and localities.
These data sources will be discussed later in the chapter.
4 While the selected locations for NHANES data collection do change annually, a location
can be used in multiple cycles.

level of educational attainment. NHANES asks participants to choose from

a large number of race and ethnicity categories, with recent demographic
questions offering 29 Hispanic, Latino, or Spanish origin and ancestry
groups, 35 Asian origin and ancestry groups, and 4 Native Hawaiian or
Pacific Islander origin and ancestry groups (NHANES, 2013b).
NHANES is widely considered the gold standard for nationally repre-
sentative estimates of obesity among the U.S. population at large. Results
from NHANES analyses have been used as benchmarks to which state and
local estimates are compared. A key strength of NHANES for assessing
obesity prevalence is that heights and weights are measured by staff trained
“to follow standardized examination protocols, to calibrate equipment
according to a prescribed schedule and method, and to measure and record
the survey data with precision” (CDC, 2013b).
Despite its methodologic strengths, NHANES may not meet the infor-
mation needs of stakeholders at the state and local level. NHANES is not
designed to assess variations in prevalence estimates that exist across and
within regions, states, and localities. The purpose of NHANES is to provide
nationally representative estimates overall and in select subgroups of inter-
est while maintaining high-quality data (including clinical examinations and
biomarker measurements). This limits the number of participants who can
be included in the sample in a given year. Assessing obesity prevalence in
select population groups, therefore, may require the use of multiple cycles’
worth of data. Although this can improve the stability of estimates, it also
expands the time frame a prevalence estimate describes. This, in turn,
affects the interpretation and comparability of the estimate.
National Health Interview Survey

NHIS, which has been continuously operating since 1957, is a cross-
sectional household survey that assesses a variety of health topics, including
the prevalence of, outcome of, and services received related to illnesses and
disabilities. Although data are collected from participants in each of the
50 states and the District of Columbia, the annual prevalence estimates are
representative at the national- and U.S. Census region-levels only (NHIS,
2014). Select data can be combined across years to produce a stable state-
level estimate (NHIS, 2015a). The questionnaire used in NHIS is peri-
odically updated, with the most recent revision implemented in 1997, and
another redesign scheduled for 2018 (NHIS, 2015a).
The NHIS uses a multistage, stratified sampling approach (Parsons et
al., 2014). One adult and one child (if applicable) are randomly selected
from each household (CDC, 2016b). When the sampling design is fully
executed, approximately 35,000 households (approximately 87,500 indi-
viduals) provide complete interviews each year (NHIS, 2015a). The NHIS
currently oversamples black, Hispanic, and (more recently) Asian persons

(NHIS, 2015a). Additionally, adults ages 65 years and older who are of one
of these three race or ethnicity groups are at an increased odds of being
selected to be the sample adult (NHIS, 2015a). In 2014, the NHIS evalu-
ated approximately 3,000 additional Native Hawaiian and Pacific Islander
(NHPI) households throughout the country to better characterize the health
status, health needs, and well-being of this population (CDC, 2015f).
NHIS is conducted as an in-person interview. Heights and weights,
however, are not directly measured. Instead, data for children ages 12 years
and older are obtained through proxy-report (i.e., an adult in the household
knowledgeable about the child) (NHIS, 2015c). In 2008, NHIS discontinued
collecting proxy-reported height and weight data on children younger than
age 12 years due to concerns about the accuracy of these values (NCHS,
2015a). In addition to height and weight, the NHIS interview questions cover
a range of health topics, including health insurance coverage, health care use,
health conditions, health behaviors, and general health status. Demographic
characteristics also are captured. For example, participants are asked to
identify with one or more of 16 different options for race and, if applicable,
8 different options for Hispanic origin or ancestry (NHIS, 2015b).
NHIS has several strengths in relation to the assessment of obesity
prevalence and trends at the national level. For instance, it is a rich source
of data not only on adolescents’ and adults’ obesity status, but also on
health behavior, health status, and other sociodemographic indicators.
The oversampling procedures employed allow for evaluation of select sub
populations. Furthermore, NHIS data are available annually, generally
within 6 months of the end of data collection (NCHS, 2015b). In spite of
these strengths, the NHIS data also have limitations with respect to assess-
ing obesity prevalence and trends in children. First, height and weight data
are not collected on children younger than age 12 years. Height and weight
that are collected for children ages 12 to 17 years are based on proxy-
report, which is subject to bias (see Chapter 3). Another consideration
for the NHIS data is that data files with state-level and other geographic
identifiers can be accessed only through 1 of 20 Federal Statistical Research
Data Centers across the country. The limited access to state identifiers,
the national sampling frame, and relatively small state samples restricts the
regular use of these data for state or local area analysis. Researchers have
developed model-based estimates of state obesity prevalence, but these are
difficult to replicate, which limits their use for surveillance purposes.
The Medical Expenditure Panel Survey-Household Component

MEPS-HC is a nationally representative survey sponsored by the Agency
for Healthcare Research and Quality (AHRQ). The MEPS-HC has collected
data on health conditions, health status, and the use and cost of health care
services since 1996. Participants in the MEPS-HC are drawn from house-

holds that participated in the previous year’s NHIS. This sampling approach
allows for oversampling of demographic characteristics and health-related
conditions identified through the NHIS responses (Mirel and Machlin, 2013).
Data are collected from participants through five interviews over the
course of 30 months (Ezzati-Rice et al., 2008). Paper-based questionnaires,
provided in English and Spanish, are occasionally sent out to participants
to gather supplemental information (MEPS, 2011). Height and weight are
proxy-reported for children and self-reported for adults.
A primary advantage to the MEPS-HC is that participants are drawn
from NHIS. As such, data from the surveys can be linked, providing com-
plementary information. The opportunity for linking data across the NHIS
and the MEPS-HC, however, can be incomplete. New members of the
household (e.g., through marriage, birth) may not be represented in NHIS,
and the interval between NHIS participation and beginning of MEPS-HC
participation can vary (Mirel and Machlin, 2013). As with any longitudi-
nal study, attrition grows as time passes. Furthermore, estimates of obesity
prevalence in children derived from this data source are not pervasive in
the literature and not currently included in MEPS-HC summary tables or
query system (MEPS, 2009). AHRQ has, however, published prevalence of
obesity for adults ages 20 and older using data from the 2009 MEPS-HC
(Carroll and Rhoades, 2012).
Population Surveillance Surveys Designed to Represent

the Nation and Individual States and Localities
Nationally representative statistics provide invaluable insight into the
overall health status of the country. However, nationally representative
estimates encompass a considerable amount of variability that exists at the
state and local levels. To have a better sense of who is affected and where,
surveillance systems and surveys have been developed that generate esti-
mates for individual states and localities, in addition to generating national
estimates. This section describes two such data sources that include children
and adolescents: YRBSS and NSCH.
The committee also identified two additional data sources that can be
used to assess obesity prevalence across states. First, described in Box 4-1,
is the Behavioral Risk Factor Surveillance System (BRFSS). The BRFSS is
designed to produce state-specific prevalence estimates of behaviors and
practices associated with disease and injury in U.S. adults ages 18 years
and older. Although it does not currently collect information about the
weight status of children or adolescents, it represents a critical state-level
data source related to obesity surveillance, and has therefore been included
in this chapter. Second, Box 4-2 describes how administrative data from
the Special Supplemental Nutrition Program for Women, Infants, and Chil-
dren (WIC) have been used to produce estimates of obesity prevalence

BOX 4-1
Behavioral Risk Factor Surveillance System (BRFSS)
The BRFSS produces state-specific estimates of behaviors and practices as

sociated with disease and injury in U.S. adults ages 18 years and older. Data are
collected annually through a telephone-based survey in all 50 states, the District of
Columbia, and participating U.S. territories. The BRFSS is a collaborative project
in which the Centers for Disease Control and Prevention (CDC) provides technical
and methodological assistance to state health departments, who manage the field
operations. Surveys are conducted by the health departments themselves or are
contracted out by the health departments to university survey research centers or
commercial firms (CDC, 2015g). The CDC processes and analyzes the data col
lected and provides a summary back to the participating locations (CDC, 2015g).
More than 400,000 interviews are conducted each year across all locations
(CDC, 2015h). The survey includes core questions that must be asked, including
self-reported height (“About how tall are you without shoes?”) and weight (“About
how much do you weigh without shoes?”) (CDC, 2015d). BRFSS provides annual
state-level estimates of health parameters captured through the survey, including
obesity prevalence, which have been used for health monitoring and program
planning purposes, among other applications. In addition to state-level estimates,
the BRFSS also can be used to monitor select cities, counties, and regions.a
Although it provides valuable insight into the health status of adults through
out the United States, the BRFSS has limitations. Because BRFSS collects data
through self-report, estimates of obesity prevalence may not be aligned with
those derived from directly measured height and weight data. Le et al. (2014), for
example, reported different geographic patterns of adult obesity prevalence de
pending on the height and weight data collection approached used (i.e., self-report
versus direct measure). Furthermore, response rates to telephone surveys have
been declining in recent years. In 2014, the cellular telephone survey response
rate for BRFSS was 40.5 percent and the landline telephone survey response rate
was 48.7 percent (CDC, 2015b). Difference in the execution of the survey in each
state (e.g., sampling frame, deviations from protocol) and changes to the survey
data collection and analytic procedures have affected the comparability of data
across states and over time (CDC, 2015c).
a The Selected Metropolitan/Micropolitan Area Risk Trends (SMART) BRFSS is an ongo
ing project that generates estimates for select cities, regions, and counties with adequate
sample size (CDC, 2012, 2015h). This information, however, is not available for all locations
throughout a state, and subgroup analyses are largely not possible due to small sample size
(CDC, 2013c).
among participants in WIC. The discussion of WIC data is included here,

rather than in the section on clinical and public health administrative data,
because it is a prominent data source used to estimate prevalence for indi-
vidual states and multiple localities, albeit for a select population.

BOX 4-2
Administrative Data from the Special Supplemental Nutrition
Program for Women, Infants, and Children (WIC)
The Discontinued National Pediatric Nutrition Surveillance System (PedNSS)
In 1975, the CDC began a nationally orchestrated, state-based surveillance

program to assess low-income individuals who make use of publicly funded health
services. PedNSS was part of that program.a The data collected through PedNSS
were used to estimate the prevalence and trends of nutrition- and behavior-related
indicators, including measures of obesity status, for children who participated in
WICb and other federally-funded programs for low-income children in a given
calendar year. Although WIC continues to operate, PedNSS was discontinued in
2012 (CDC, 2011). The rationale for discontinuing PedNSS included the existence
of other population-based systems, such as NHANES and NHIS, that provided
estimates across all income strata, not just low-income groups (CDC, 2011).
Furthermore, the U.S. Department of Agriculture (USDA), which administers WIC,
produces a biennial report that provides similar, although not identical, analyses
(see below).
When PedNSS was operational, states, U.S. territories, and Indian Tribal
Organizations (ITOs) that participated compiled routine clinic-level data (e.g.,
measured height, weight, hemoglobin) and submitted it to the CDC for analysis.c
During the 2010 data collection cycle, 46 states, the District of Columbia, Puerto
Rico, the U.S. Virgin Islands, and 6 ITOs provided data on nearly 9 million low-
income children, birth to age 4 years (Dalenius et al., 2012). A major strength
of PedNSS was the identical analyses across contributors and annual regional,
state, and local estimates for a particularly high-risk population group. Additionally,
PedNSS included information on nearly all individuals who participated in WIC at
contributing agencies during the assessment year.
Although the national PedNSS no longer exists, individual state WIC programs
continue to collect measured height and weight using a standard protocol con
sistent with federal WIC regulations. These height and weight data can be used
to generate state-level PedNSS-like reports depending on internal capacity for
data analysis in individual states. Not all states that continue to assess obesity
prevalence do so using the same analytic approach as the national PedNSS,
which limits the ability to compare prevalence statistics over time (Colorado WIC
Program, 2013).
WIC Participant and Program Characteristics Report
USDA produces a biennial “WIC Participant and Program Characteristics (PC)”

report that provides similar, although not identical, analyses to PedNSS. USDA’s
Food and Nutrition Service (FNS) first released the biennial WIC PC report in the
1980s. The PC reports have since served as a means to monitor the WIC program
(Thorn et al., 2015). Since 1992, PC reports have collected near-census level data
on participants enrolled during the month of April of the assessment year (USDA,
continued

BOX 4-2 Continued
1994). This sampling approach differs from that used for PedNSS and as such,
obesity prevalence statistics that were determined from PedNSS data are not
interchangeable with obesity prevalence statistics determined with PC data.
With respect to obesity prevalence among children, recent final PC reports
have presented collective estimates, rather than contributor-level or local-level
estimates (i.e., 50 states, the District of Columbia, 5 U.S. territories, and 34 ITOs)
(Johnson et al., 2013a; Thorn et al., 2015). The CDC, however, has developed
an interactive map that shows the prevalence of obesity among WIC participants
(ages 2 to 4 years) in each state and three U.S. territories (CDC, 2016c). The
map can currently present data from PC2008, PC2010, and PC2012. As was dis
cussed in Chapter 3 (see Box 3-3), WIC administrative data are a particularly rich
source of directly measured height and weight data on low-income children who
participate in the program. However, estimates of obesity cannot be generalized
to all children younger than age 5 years or even to low-income children younger
than age 5 years.
a The Pregnancy Nutrition Surveillance System was a similar surveillance system for preg
nant women participating in the WIC program, which has also been discontinued.
b WIC, a federal grants program to states through USDA, provides nutrition education,
supplemental foods, and health care referrals to low-income pregnant women, postpartum
mothers, breastfeeding mothers, infants, and children younger than age 5 years.
c Not all agencies that administered WIC participated in PedNSS.
Youth Risk Behavior Surveillance System

The YRBSS monitors health risk behaviors contributing to the leading
causes of death and disability among America’s youth. The YRBSS is not a
single evaluation, but rather a collection of assessments.5 Within the system,
the school-based Youth Risk Behavior Survey (YRBS) is administered every
other year to high school students in a nationally representative sample, in
participating states, and in select large urban school districts.6
On average, approximately 14,500 students are included in the national
sample each cycle (CDC, 2013a). The sampling frame includes both public
5 In addition to the Youth Risk Behavior Survey (YRBS), the YRBSS includes one-time,
specialty population, and methods surveys.

6 The CDC provides both the YRBS questionnaire and an implementation guide through
its website, allowing schools, districts, and communities that are not part of the YRBSS to
conduct their own assessment (CDC, 2014, 2015j). The committee acknowledges that reports
using these data may exist at the state and local level. The discussion in this chapter, however,
pertains only to data collected and analyzed through the YRBSS.

and private high schools and includes strategies for oversampling black and
Hispanic students (CDC, 2013a). The large sample size allows for estimates
of prevalence to be calculated by a single demographic characteristic (i.e.,
sex, grade, race and ethnicity categories [white, black, Hispanic]), and by
interactions between demographic characteristics (i.e., grade*sex; race/
ethnicity*sex; race/ethnicity*grade) with a high degree of confidence (CDC,
2013a).
The sampling frame for the state and localities typically consists of
public schools, although some samples are derived from both public and
private schools and others include alternative schools (CDC, 2013a). Some
jurisdictions forego sampling and collect data from all schools (CDC,
2013a). Accordingly, sample sizes vary considerably across the state and
local YRBS, ranging from 1,102 to 53,785 participants in 2013 (Kann et
al., 2014). Sample sizes are often adequate to stratify the analyses by sex,
but estimates by race and ethnicity groups can be unstable. The state and
local YRBS assessments are designed to be representative of students in
grades 9 to 12 within the jurisdiction (CDC, 2013a). The representativeness
however, is contingent on the overall response rate. If the overall response
rate is at least 60 percent, the sample is weighted during analysis to be
representative of the jurisdiction; otherwise, the results are unweighted and
represent only those who participated (CDC, 2013a).
The type of parental consent obtained for any of the YRBS evaluations
is determined by the state, the school district, or the individual schools.
Some states require active consent (i.e., having to take an action to opt
in) for all participants (CDC, 2015a), though the majority of assessments
use passive consent (i.e., participating unless an action is taken to opt out)
(CDC, 2013a). As discussed in Chapter 3, the type of consent used affects
the sample size.
The YRBS is an anonymous, voluntary, self-report, paper-based sur-
vey (CDC, 2013a). Questions about height and weight are required on
all administrations at the national, state, and local levels, which eliminate
issues related to comparability of data collection instruments across sites.
For demographic characteristics, students are asked about their age, sex,
and grade. Age is not based on date of birth, but rather students select
from one of seven age categories. Students are asked whether they are
Hispanic or Latino, and are also instructed to select from five race catego-
ries ( American Indian or Alaska Native; Asian; black or African American;
Native Hawaiian or Other Pacific Islander; white) (CDC, 2015j). An indica-
tor of socioeconomic status is not collected from the student.
Because the YRBS is based on adolescent self-report, it is limited in its
ability to estimate obesity prevalence (Brener et al., 2003). A validation
study demonstrated that students tend to underestimate their weight by
approximately 3.5 pounds and overestimate their height by approximately

2.7 inches (Brener et al., 2003). Underestimation of weight was more com-
mon among females. Overestimation of height was positively associated
with grade level and is more common among white students. Collectively,
the underreporting of weight and overreporting of height leads to estimates
of obesity prevalence lower than would be obtained using direct measured
height and weight data. The errors in reporting height were the primary
drivers of the errors seen in body mass index (BMI) estimates (Brener et
al., 2003).
Another consideration for YRBS is that the target population does
not necessarily represent all U.S. adolescents. Rather, the national sample
describes students enrolled in grades 9 to 12 in private and public schools.
The sample does not typically represent students who attend alternative
or charter schools, who are home-schooled, or who have dropped out.
Furthermore, state and local YRBS evaluations can be limited in their com-
parability across jurisdictions, as sites vary in terms of sampling approach,
parental consent process, and response rate. Changes to these factors over
time also can affect the trends analysis for a particular jurisdiction, as
the data may not be comparable. Finally, results are not generated by zip
code, census tract, or individual schools due to student confidentiality and
instability of estimates due to sample size (CDC, 2015k). This can limit the
application of state YRBS data at the local level.
National Survey of Children’s Health—2003, 2007, and 2011-2012

The NSCH, which is currently being redesigned (see next section),
was a cross-sectional survey designed to produce both state-specific and
national prevalence estimates for a variety of health-related topics for chil-
dren younger than age 18 years. NSCH data are available through the Data
Resource Center for Child and Adolescent Health (Data Resource C enter
for Child and Adolescent Health, 2016c) and can be queried through
Web-based interactive tools to generate national, Health Resources and
Services Administration region, and state estimates on select parameters
(Data Resource Center for Child and Adolescent Health, 2016b). Because
data are still accessible, a discussion highlighting the strengths, limitations,
and methodologies of the previous cycles of the NSCH is included here.
The three cycles of the NSCH (2003, 2007, and 2011-2012) were
conducted through the State and Local Area Integrated Telephone Survey
(SLAITS) program (CDC, 2015i). Developed by the CDC’s National Center
for Health Statistics, SLAITS is a mechanism used to supplement data
collected through ongoing surveillance programs (CDC, 2015i). SLAITS
is not a single survey but a vehicle that government agencies, nonprofits,
and other survey sponsors can use to collect customized data from select
or defined populations. The NSCH sampling frame is based on the cross-

sectional telephone sample frame (land and cell phone lines) used for the
National Immunization Survey. Households owning a wireless phone were
included in the sample beginning in 2011 (Data Resource Center for Child
and Adolescent Health, 2016a).
The target population for the NSCH was children birth to age 17
years in all 50 states, Washington, DC, and the U.S. Virgin Islands (added
in 2011-2012). Each cycle of the NSCH had minimum enrollment goals:
2,000 participants per state in NSCH 2003, 1,700 per state in NSCH 2007,
and 1,800 per state in NSCH 2011-2012 (NSCH, 2003, 2007, 2012b). This
relatively small sample size limits the ability to perform subgroup analyses,
especially in racially and ethnically diverse states. For example, national
NSCH estimates for Asian, American Indian, Alaska Native, and Native
Hawaiian/Pacific Islander children were categorized in a single “Other”
category. Data for these groups individually are available only for states
where the group represented at least 5 percent of the total population (Data
Resource Center for Child and Adolescent Health, 2016a).
Because it was a telephone survey, the data on height and weight were
collected through proxy-report. The person in the household with the most
knowledge about the child’s health and health care needs was asked to
report the child’s weight and height (NSCH, 2012a). Although the child’s
age was not listed as a criterion for asking about height or weight (NSCH,
2012a), Web-based tools presenting prevalence estimates from NSCH data
restrict the results to children ages 10 to 17 years (Data Resource Center
for Child and Adolescent Health, 2016b). Similar to the NHIS, the rationale
for such a restriction was based on findings that proxies generally under-
reported heights and over-reported weights of young children.
The rapidly changing technological climate also limited the ability to
accurately sample NSCH’s target population. Although the 2011-2012
cycle included sampling of wireless phones, their inclusion presented some
methodologic barriers. Sampling wireless phones is an expensive endeavor
and, because of their portability, an area code no longer represents a cur-
rent residence (MCHB, 2015). This consideration, among others, led to the
redesign of the NSCH, which will be combined with the National Survey
of Children with Special Health Care Needs (NS-CSHCN).
National Survey of Children with Special Health Care Needs

Similar in design to the NSCH, the NS-CSHCN was a telephone-based
survey conducted through SLAITS. NS-CSHCN was designed to produce
nationally representative and state-level estimates of children ages birth to
17 years “who have or are at increased risk for a chronic physical, devel-
opmental, behavioral, or emotional condition and who also require health
and related services of a type or amount beyond that required by children

generally” (CDC, 2015e; McPherson et al., 1998). The NS-CSHCN did not
collect information about the child’s height or weight, so it is not a data
source that can be used to assess obesity prevalence or trends. It is, however,
a survey that is currently being integrated with the redesigned NSCH.
Redesigned National Survey of Children’s Health

Although the NSCH and the NS-CSHCN served unique purposes,
they shared many elements. Because of this, it was decided that the two
separate surveys should be combined and redesigned as a single, continuous
survey moving forward, providing both state-level and national estimates
on a range of health indicators. The redesigned survey will no longer
rely on telephone-based sampling or interviewing, but instead will use a
household address-based approach, with data collected through mail or
Web-based surveys. Content from the two previous surveys will be merged
and streamlined to address current and emerging priorities. The redesigned
NSCH/NS-CSHCN is expected to be a data source of national and state-
level estimates. The redesigned survey will continue to provide accessible
data and summaries to users of all levels through the Data Resource Center
for Children and Adolescent Health. Efforts are being made to be able to
generate local-level estimates through approaches such as model-based
estimation (see Chapter 5 for additional details). At the time of this report,
the redesigned survey’s content has been reviewed and edited, cognitive
interviews and associated survey revisions have taken place, and the mode
of delivery has been tested. The survey is currently being pretested, with
the full fielding of the survey anticipated to take place in mid- to late-2016.
The first public release of data is anticipated in 2017 (MCHB, 2015). Ques-
tions about the participant child’s height and weight have been included.
As with the prior cycles of NSCH, height and weight data are collected
through proxy-report.
Considerations for Assessing Population Surveys Used

to Estimate Obesity Prevalence and Trends
The nationally representative population surveillance surveys used to
assess obesity prevalence and trends among children, adolescents, and
young adults have different goals and objectives. As a result, the target pop-
ulation and data collection methodologies differ across these data sources.
At present, NHANES is the only nationally representative, continuous
survey that directly measures heights and weights of participants. The high
quality and quantity of data collected limits the number of individuals who
can be measured in any given year. The restricted sample size, in turn, limits
which population groups have sufficient data to estimate obesity prevalence

and trends. Although the other nationally representative population surveil-

lance surveys have total sample sizes significantly greater than NHANES,
height and weight data are currently collected through self- or proxy-report
rather than direct measure. Concerns over the accuracy of proxy-reported
height and weight for young and school-aged children (younger than ages
10 to 12 years) have led to the discontinuation of capturing or reporting
on such data for some of the nationally representative data sources (i.e.,
NHIS, previous cycles of NSCH).
Some data sources are designed to be both nationally representative and
representative of individual states and locations. For example, WIC admin-
istrative data are used to characterize low-income participants enrolled in
the program, at the national, state, and agency level. Directly measured
height and weight data are collected as part of program delivery. Estimates
of obesity prevalence, however, cannot be generalized to those who do
not participate in the program. The YRBSS, a population survey-based
surveillance system, is specifically designed to produce obesity prevalence
and trends estimates from a nationally representative sample and across
multiple states and localities. YRBS obesity prevalence estimates, however,
describe only high school students and are based on self-reported heights
and weights. The upcoming redesigned NSCH/NS-CSHCN is intended to
be a source of state-level estimates. Although this survey plans to capture
data in a large range of ages (birth to 17 years), it will be doing so through
proxy-report, which has inherent limitations especially with younger chil-
dren, as noted above and described in Chapter 3. No population surveil-
lance survey or system currently produces state-level estimates of obesity
prevalence in school-aged children, adolescents, or young adults from
directly measured height and weight data collected in a consistent manner
across multiple states.
The committee was unable to comprehensively assess or compare popu-
lation surveys being conducted in individual states and localities. No cen-
tralized resource comprehensively catalogues the wide array of population
survey efforts that have been and are being conducted in these jurisdictions.
The availability of information about data collection procedures for such
population surveys varies, which further limited the committee’s ability to
comprehensively assess methodologies. For these reasons, it was not pos-
sible to describe the current practices of, or draw comparisons between,
population surveys conducted in individual states and localities. In spite
of these evidentiary barriers, the committee recognizes that population
surveys are used to assess prevalence and trends in obesity at the state and
local levels. Box 4-3 provides an illustrative example of one such survey.
The committee acknowledges, however, that other state and local surveys
of different designs and objectives exist.

TABLE 4-1 Comparison of Data Sources Used to Estimate Obesity

Prevalence and Trends Among Children, Adolescents, and Young Adults
Nationally and Across Multiple States or Localities
Representativeness of Sample
Approximate
Data Source Sample Size Nationally States, Localities
NHANES 5,000 per year U.S. population N/A
NHIS 87,500 individuals U.S. populationb N/Ac

(35,000
households per
year)
MEPS-HC 33,000 persons per U.S. population N/A

year (13,000
households per
year)d
YRBS, 14,500 per survey U.S. high school N/A

nationale year students
YRBS, state Varies by locationf N/A U.S. high school students;

and locale locations vary by yearg
WIC PC 9.3 million WIC participants, WIC participants, as of April of

Data nationally; as of April of the assessment yearh
varies by the assessment
locationh yearh
NSCH, 96,000 per cycle U.S. children ages Children ages 0 to 17 years, in:
(2003, 2007, (1,800 per state 0 to 17 years • All 50 states
2011-2012) in each cycle) • Washington, DC
• U.S. Virgin Islandsi
Redesigned N/Ak U.S. children ages Children ages 0 to 17 years, in:

NSCH/ 0 to 17 yearsj All 50 states
NS-CSHCNj Washington, DCj

Height and
Weight Data Potential Advantagesa Potential Disadvantagesa
Directly Height and weight Confined sample size, limiting subgroup
measured directly measured. comparisons.
Continuous survey.
Interview Large sample size. Height and weight not directly measured.
(proxy-, Generates Census region- Height and weight data not captured for
self-report) level estimates. children younger than age 12 years.
Data rapidly available.
Interview Panel design allows Height and weight not directly measured.
(proxy-, evaluation over time. Longitudinal data subject to attrition.
self-report) Reports based on this data source are not
common in the literature.
Paper-based Large sample size. Height and weight not directly measured.
survey Only captures students attending public
(self-report) and private schools.
Paper-based Large sample size. Height and weight not directly measured.
survey Most states and several Differences in sampling frame, consent
(self-report) localities participate. process, and response rate can limit
comparability across sites.
Directly Height and weight Only describes participants enrolled in

measured directly measured. WIC.
Large sample size. Does not describe all participants in a
All agencies provide data. given year, only those enrolled in the
month of April.
Telephone survey Estimates were generated No longer being conducted.

(proxy-report) for each state using the Height and weight not directly measured.
same protocol. Cellular phone sampling limited ability to
User-friendly data select based on geography.
querying tool available Limited ability to perform subgroup
through the Web. analyses.
Obesity status not typically reported for
children younger than age 10 years.
Web- and Sampling will be address- Height and weight data will be collected
mail-based based rather than through proxy-report, limiting utility of
questionnaire telephone-based.j obesity prevalence estimates, especially
(proxy-report)j for children school-age and younger.j
continued

TABLE 4-1 Continued
NOTE: MEP, Medical Expenditure Panel Survey; N/A, not applicable; NHANES, N ational
Health and Nutrition Examination Survey; NHIS, National Health Interview Survey;
NS-CSHCN, National Survey of Children with Special Health Care Needs; NSCH, National
Survey of Children’s Health; PC Data, Participant and Program Characteristics; WIC, Special
Supplemental Nutrition Program for Women, Infants, and Children; YRBS, Youth Risk
Behavior Survey.
a The potential advantages and disadvantages are contingent on the population assessed,
the methodology employed, the analytic approach, and the end user seeking to apply such
information. Population and methodologic considerations are discussed in Chapter 3. The
analytic considerations are more fully explored in Chapter 5, while considerations related to
end users are discussed in Chapter 6.
b Sampling is nationally representative. However, height and weight data are not collected
on children younger than age 12 years.

c Participants are drawn from all 50 states and Washington, DC. However, sample size for
each state is generally too small to generate precise state-level estimates from a single year
(NHIS, 2015a).
d Based on average participation from 2004-2013; includes all participants surveyed in the
year (i.e., both panels being followed in a given year) (AHRQ, 2015).
e The national YRBS and the state and local YRBS are separate surveys with different sam-
pling procedures, and therefore presented separately.

f In the 2013 cycle, sample sizes ranged from 1,107 to 53,785 participants across states and
from 1,102 to 10,778 across large urban school districts (Kann et al., 2014).
g State and large urban school districts that participate vary by YRBS cycle; not all states
participate (CDC, 2015b).

h Participants in the WIC program must meet eligibility criteria, including income guidelines.
Participants include pregnant women, postpartum women, breastfeeding mothers, infants, and
children younger than age 5 years.
i Added in the 2011-2012 cycle (CDC, 2015i).
j Anticipated, based on information about the pretesting phase (MCHB, 2015).
k At the time of this report, this survey has yet to be conducted.

BOX 4-3
Example of a State-Based Population Survey: The California
Health Interview Survey
The California Health Interview Survey (CHIS) is a population-based assess

ment of children (birth through age 11 years), adolescents (ages 12 to 17 years),
and adults (ages 18 years and older) in the state of California. This multistage
random-digit-dial phone-based survey is conducted by the Center for Health
Policy Research at the University of California, Los Angeles. In the 2013-2014
assessment, CHIS sampled a total of 20,207 households across the state of
California, consisting of 19,516 adults, 1,052 adolescents, and 2,592 children
(CHIS, 2014). Collaborators include the California Department of Public Health
and the Department of Health Care Services. Initially designed to be a biennial
assessment, the CHIS was redesigned in 2011 to be a continuous survey (UCLA
Center for Health Policy Research, 2016a). Adults and adolescents (with parental
consent) are directly interviewed, while an adult with the most knowledge of the
child serves as a proxy for children younger than age 12 years. The survey in
cludes a variety of topics related to health behaviors and use of health care, and
includes questions about the participant’s height and weight (UCLA Center for
Health Policy Research, 2015).
CHIS oversamples select subgroups of interest, such as Koreans and Viet
namese, Japanese Americans (UCLA Center for Health Policy Research, 2016b),
and American Indian and Alaska Natives (UCLA Center for Health Policy R esearch,
2016a) and select counties that fund additional interviews to obtain sub-county
estimates (UCLA Center for Health Policy Research, 2016b). The surveys are
conducted in English, Spanish, Chinese (Cantonese and Mandarin), Korean, and
Vietnamese, and expanded to include Tagalog in the 2013-2014 cycle (UCLA
Center for Health Policy Research, 2016b).
The CHIS data can be used to generate estimates of obesity prevalence at
the county-, regional-, and state-levels. The CHIS also exemplifies a partnership
model that has been proven to be fruitful, and includes cooperation between
academia, public health departments, public agencies, and private organizations.
The CHIS focuses on the wide range of users of their data, and as such, the study
website has extensive documentation, easy-to-read summaries for key topics, and
Web-based portals for generating individualized reports (ask.chis.ucla.edu).
Although the data are structured to be representative at multiple levels, the
sample size can still be a limitation. Estimates can rapidly become unreliable as
analyses are stratified by factors. For example, the results are statistically un
stable when searching for children ages 8 to 12 years who are overweight-for-age
in Sacramento using pooled data from 2013-2014.a
a Data query based on results from Ask CHIS Web-based system (ask.chis.ucla.edu [ac
cessed March 25, 2016]). The Web-based system does not currently offer an option to query
for obesity only, so overweight-for-age was used as an illustrative example.

DATA COLLECTED IN THE SCHOOL SETTING

As described in Chapter 3, schools are a common setting for capturing
data used to assess obesity prevalence and trends in children and adoles-
cents. In gathering evidence related to data collection methodologies of
school-based efforts, the committee encountered barriers similar to those it
faced when gathering evidence related to state and local population surveys.
Centralized information on the range of state and local initiatives capturing
height and weight in the school setting does not currently exist. Informa-
tion regarding these efforts must be sought out from each individual state
or locality. For illustrative purposes, the following sections describe three
school-based efforts (Arkansas, California, and Texas) that directly mea-
sure students’ heights and weights. Their similarities and differences are
presented in Table 4-2 at the end of this section, followed by a summary of
the committee’s assessment of current school-based efforts.
The committee elected to differentiate the efforts included in this sec-
tion from population surveys conducted in schools that collect self-reported
height and weight data (i.e., YRBS), in order to compare different ways
that states are collecting directly measured height and weight data from
students. It is for this reason that the Texas School Physical Activity and
Nutrition (SPAN) Survey appears here rather than the preceding discussion
on population surveys. The committee acknowledges that school-based
assessments employing sampling strategies, like SPAN, have different con-
siderations than those that seek to capture data on all students.
Arkansas
In 2003, Arkansas passed legislation that required an assessment of
each public school child’s BMI and a confidential report sent to the student’s
parents on an annual basis (Act 1220 of 2003, HB 1583, 84th General
Assembly, Regular Session [AR 2003]). Initially, height and weight mea-
surements were collected on all students. In 2007, however, legislation was
passed to assess public school students only in kindergarten, and grades
2, 4, 6, 8, and 10 and to further clarify that parents had the right to opt
out of the BMI assessment of their child (Act 201 of 2007, HB 1173, 86th
General Assembly, Regular Session [AR 2007]).
The Arkansas Center for Health Improvement (ACHI), a nonpartisan
health policy center, coordinates the assessment of BMI within the schools.
Schools are provided with scales and involved staff members, including
nurses and teachers, are trained in the measurements procedures. BMI
assessments results are reported back to ACHI through a “secure, web-
based computer system that is used to generate individual, confidential
Child Health Reports for parents” (ACHI, 2014).

Participation, both at the school and individual level at participating

schools, has been high since its inception, exceeding 90 percent for each
year7 (ACHI, 2015). Reports are produced with summary data on the per-
cent of students within each BMI classification for a given school, school
district, and county. Data also are summarized for the entire state, and
shown by sex, grade, and race and ethnicity groups. Schools or districts that
provide too little data do not receive summary profiles. Data are collected
annually, which provides a substantial number of data points for trends
analyses. Although the Arkansas BMI assessments broadly cover public
school students, considerations should be made for the students not repre-
sented in the data. The results, for example, may not be readily applicable
to the more than 25,000 students enrolled in private schools in Arkansas
(Broughman, 2013).
California
All California schools are required to administer an annual physical
fitness test to students in grades 5, 7, and 9 (California Education Code
section 60800). In 1996, the State Board of Education designated the
FitnessGram®8 to be the test used to evaluate students’ physical fitness.
The FitnessGram® contains six components, including an assessment
of body composition. Body composition can be measured in one of three
ways: skinfold measurements, BMI, or bioelectric impedance analysis (see
Chapter 2). The vast majority of schools opts to measure height and weight
and performs the BMI assessment (98 percent in 2013-2014) (California
Department of Education, 2015). Results for the FitnessGram® are submit-
ted electronically (California Department of Education, 2016). In recent
years, approximately 92 to 94 percent of enrolled students across the three
grades have been assessed through the FitnessGram®. The annual dataset
has more than a million records per year of children throughout the state.
As such, estimates have been generated for select groups that are not
adequately represented in nationally representative surveys on a consistent
basis (e.g., Filipinos).
The California Department of Education maintains a comprehensive
website and provides a tool for evaluating FitnessGram® results. The tool
can query data since the 1998-1999 school year, by school, district, county,
and state levels (California Department of Education, 2013). Reports can
provide results at the state, county, district, and school level and can be pre-
7 This number represents only the participation, not the percent of students with valid
measurements used for analyses.
8 The FitnessGram® was developed and is a registered trademark of The Cooper Institute®,
Dallas, Texas.

sented by sex, economic disadvantage (yes or no), or race and ethnicity cat-
egory (black, American Indian/Alaskan Native, Asian, Filipino, Hispanic,
Native Hawaiian/Pacific Islander, white, or two or more races) (California
Department of Education, 2013). The BMI classification approach used
by the California FitnessGram® has changed over time and differs from
approaches typically taken in the literature. As such, caution should be
taken when assessing BMI-related results generated from these data (see
Chapter 5, Box 5-2 for more details).
Texas
Another approach being taken to monitor obesity prevalence in school-
aged children is the Texas SPAN Survey.9 SPAN is conducted by university
researchers supported by Texas Department of State Health and Services
funding. In addition to establishing a surveillance system for monitoring
obesity in school-aged children in the state, SPAN collects contextual data
on dietary practices, nutrition knowledge, and physical activity (SPAN,
2016). SPAN is currently in its fourth cycle (2015-2016), having collected
data in 2000-2002, 2004-2005, and 2009-2011. Students in grades 4, 8,
and 11 were evaluated in each of the cycles. The 2009-2011 cycle added
a parental survey for students in grade 4 and the current cycle has added
students in grade 2 and a parental survey to their target population (SPAN,
2016).
The sampling approach seeks to be representative of the entire state
and provide subgroup estimates by grade level, sex, race and ethnicity
categories, and state health service regions (HSRs)10 (Hoelscher et al.,
2004). The sample size has changed over time, as additional evaluations
have been added (Hoelscher et al., 2010). Across the survey cycles, SPAN
participants’ heights and weights are measured by study staff or by state or
county personnel (Hoelscher et al., 2010). As a quality assurance measure,
repeated measurements are performed on 5 percent of the students—more
than 98 percent of these measurements were within 0.2 kilograms and 1.2
centimeters of the original values (Hoelscher et al., 2010).
9 Each school district throughout Texas is required to conduct an annual fitness assessment
of students in grades 3 through 12 (Texas Education Code, § 38.101 and § 38.103). Like other
states and localities, Texas uses the FitnessGram® (Texas Education Agency, 2016), which has
many similar considerations, advantages, and disadvantages as the California administration.
The Texas School Physical Activity and Nutrition (SPAN) Survey is conducted in addition to
the FitnessGram® assessments.
10 Health service regions (HSRs) are regional divisions that allowed for administrative man-
agement and program implementation. Texas was originally divided into 11 HSRs, but was
later reorganized into 8 HSRs (Texas Department of State Health Services, 2016).

SPAN produces both state and regional estimates of obesity using mea-
sured height and weights. However, where many school-based assessments
are collected annually, SPAN data have been collected approximately every
5 years. This expanse of time between assessments can be a challenge for
those seeking current estimates.
Considerations in Assessing School-Based Efforts That

Collect Directly Measured Height and Weight Data
School-based assessments that directly measure students’ heights and
weights address some of the limitations of population surveys (e.g., large
samples of children, directly measured height and weight data). As illus-
trated by California, school-based data collection initiatives in locations
that are racially and ethnically diverse can allow for assessments of popula-
tion groups that are not sampled in sufficient quantities to produce reliable
estimates from nationally representative population surveys. In states where
direct measurement of height and weight in schools is mandated, obesity
prevalence and trends have been assessed at the regional, county, and, in
some cases, local levels, to the degree to which sufficient data are avail-
able and the presentation of the results cannot lead to the identification of
individual students.
School-based assessments, however, can be difficult to compare
across states because different grades are represented in the data, differ-
ent approaches exist for determining which students are measured, and
different protocols are used to measure height and weight. Furthermore,
the prevalence or trends that are generated from these data sources are
not necessarily representative of all children or adolescents living within a
given jurisdiction.

TABLE 4-2 Comparison of Three Examples of School-Based Efforts That Directly Measure Students’ Heights and Weights
112
Students Who Performs Potential

Assessment Assessed Sample Size Measurement Collaborators Potential Advantagesa Disadvantagesa
Arkansas All public school 181,000 per School staff Arkansas Dept. of Data collected Only represents public
BMI students, yearb member Education annually since school students.
Assessment Pre-K/K, and Arkansas Dept. of 2003.
grades 2, 4, Health Estimates available for
6, 8, 10 ACHI schools, districts,
Schools, districts counties, and state.
California All public school 1.3 million Local California Dept. of Data collected Reports related to
Annual students, per year education Education annually. BMI not readily
FitnessGram® grades 5, 7, 9 agency or Local education Large sample size. comparable over
county agencies Diverse populations time or other
education represented in the non-FitnessGram®
office data. reports.
employee
Texas SPAN Public school 17,000 per Project staff University researchers Produces both state Collected
Surveyc students, cycle and Dept. Texas Dept. of State and regional approximately every
grades 4, of State Health and Services estimate. 5 years.

8, 11 in Health and Selected schools,
sampled Services districts
schoolsd employees
NOTE: ACHI, Arkansas Center for Health Improvement; BMI, body mass index; Dept., Department; Pre-K/K, pre-kindergarten/kindergarten; SPAN,
School Physical Activity and Nutrition (Survey).
a The potential advantages and disadvantages are contingent on the population assessed, the methodology employed, the analytic approach, and
the end user seeking to apply such information. Population and methodologic considerations are discussed in Chapter 3. The analytic considerations
are more fully explored in Chapter 5, while considerations related to end users are discussed in Chapter 6.

b Based on average number of students who had valid measurements from 2010-2011 through 2013-2014 school years (ACHI, 2014).
c Texas also conducts a FitnessGram® assessment of public school students in grades 3-12, similar to California’s administration.
d The 2015-2016 SPAN is also including students in grade 2 (SPAN, 2016).
CLINICAL AND PUBLIC HEALTH ADMINISTRATIVE DATA

Height and weight measurements collected in clinical and public health
settings have also been used as a source of obesity prevalence and trend
data. Because these measurements are part of routine care or procedures,
they are considered administrative data. A range of administrative data
exists, including those collected in public health programs, such as WIC
(see Box 4-2). This section, however, discusses the potential for and cur-
rent challenges in using electronic health records (EHRs) and immunization
registries for the purposes of monitoring obesity prevalence and trends.
Electronic Health Records

The concept of integrating EHRs with public health surveillance efforts
is embedded in the meaningful use criteria outlined in the Health Infor-
mation Technology for Economic and Clinical Health Act of 2009 and
promoted by Medicare and Medicaid through bonus payments. The Federal
Health IT Strategic Plan for 2015-2020 includes a specific strategy to
improve community health, well-being, and resilience by increasing “public
health entities’ ability to use, benefit from, and manage advances in real-
time electronic health information for public health surveillance, situational
awareness, and targeted alerting” (ONC, 2016).
One basic question that has been and is being explored through EHR
data is the extent to which a measure is actually documented in a patient’s
record. The results from such a data query would not, for example, provide
insight into how many patients had obesity, but do provide information
about the consistency to which height, weight, and BMI are recorded within
a given medical practice, plan, or system. The Healthcare Effectiveness Data
and Information Set (HEDIS®)11 is a performance measure tool that cur-
rently captures such information (see Box 4-4).
Using EHRs for the purposes of assessing obesity prevalence and trends
has many appealing features. EHRs house data over the course of a patient’s
participation within a given health care system. Accordingly, data can be
used to assess cross-sectional prevalence within the patient population as
well as over time. Investigators are using EHRs within and between health
care systems to assess obesity status on a large number of patients (often
millions) and can track individual patients longitudinally (see Box 4-5).
Although EHR datasets can be a particularly rich source of measured
height and weight data on a large number of patients, the interpretation of
assessments of obesity prevalence and trends comes with several important
considerations. One caveat is that the data represent only patients mak-
11 HEDIS® is a registered trademark of the National Committee for Quality Assurance.

BOX 4-4
Documenting the Measurement of Weight and Height Through
the Healthcare Effectiveness Data and Information Set
The National Committee for Quality Assurance administers HEDIS®, a quality

monitoring system that uses a set of performance measures to assess health
plans in the following areas: effectiveness of care, access to and availability of
care, experience of care, utilization and risk-adjusted utilization, relative resource
use, and descriptive characteristics (NCQA, 2016a). With more than 90 percent of
health plans in the United States using HEDIS®, their standardized measures can
be used to compare different plans and assess areas needing quality improve
ments within a plan (NCQA, 2014).
HEDIS® is used to determine the extent to which a procedure, practice, or
service was delivered to patients either within a given year or by an age mile
stone (NCQA, 2016b). HEDIS® has two measures for BMI: (1) adult patients
(ages 18 to 74 years) with an outpatient visit who had their BMI documented
within the past 2 years, and (2) children and adolescents patients (ages 3 to 17
years) with an outpatient visit who had height, weight, and BMI-for-age percentile
documented in the given year (NCQA, 2016b). For those ages 18 to 20 years, the
HEDIS® measure is BMI-for-age percentile, rather than a BMI value (BlueCross
BlueShield, 2015; JHHC, 2016). Patient records in which height and weight are
captured, but no BMI or BMI-for-age is determined, do not meet the HEDIS®
measure criteria.
The HEDIS® measures provide insight into the consistency and frequency
with which practitioners assess patients’ BMI in the clinical setting. Based on
2013 data of plans using HEDIS®, the national average for documenting children
and adolescents’ BMI percentile was approximately 57 percent among Medicaid
and commercial health maintenance organizations plans and 33 percent among
preferred provider organization plans (NCQA, 2015).
At the present, HEDIS® captures only the extent to which a specific measure—
in this case BMI or BMI-for-age percentile—is documented in a patient’s record in
a given time period. It does not provide insight into numeric value of the BMI or the
BMI-for-age percentile. Accordingly, HEDIS® is not a data source for determining
obesity prevalence or trends. Instead, HEDIS® provides insight to the extent to
which BMI is being assessed and documented in medical settings.
ing use of the medical system. As such, use of EHR data may underrepre-
sent low-income, the uninsured, and other populations. Furthermore, the
population represented in an EHR does not necessarily equate to a defined
geographic area, but rather to patients who elect to be seen at a particu-
lar medical facility or system. Accordingly, the results of an EHR-based
assessment are not necessarily generalizable beyond the medical facilities
themselves. A final consideration is EHR interoperability. Multiple EHR
software systems are currently being used throughout the country. Not all

BOX 4-5
The Pediatric EHR Data Sharing Network
The Pediatric EHR Data Sharing Network (PEDSnet) is one example of how a
collection of institutions are working collaboratively to explore the utility of query
ing EHR data. Described as a “learning health system,” PEDSnet consists of eight
children’s hospitals, two existing patient-centered disease-specific pediatric net
works, a newly formed pediatric obesity network, and two national data partners
(Forrest et al., 2014). PEDSnet has used the collection of EHRs across institutions
to evaluate the ability to conduct surveillance-type assessments (Bailey et al.,
2013).
PEDSnet has been used to produce rapid interval assessments for large
populations because of its broad scope and ongoing collection of data. Because
PEDSnet relies on routine clinical data, some individual measurement error is ex
pected. However, the large sample size and repeated data collection over multiple
visits reduces the margin of error and results in stable population estimates over
time. BMI distributions have been found to be relatively comparable to NHANES.
This is particularly useful in measuring obesity in adolescence, where individual
variation is usually larger because of the onset of puberty (Bailey et al., 2013).
Another advantage is the ability to easily track co-morbidities with linked clinical
data (Bailey et al., 2013). Like all EHR assessments, however, PEDSnet data
include only those who make use of the medical networks involved. The number
and spacing of measurements is contingent on when an individual decides to be
seen by a health care practitioner and whether height and weight is documented.
of these systems are able to interact with each other, meaning that it may
not be possible to collect longitudinal data on patients who switch between
practices that use different EHR systems. This limitation has implications
for trends analyses.
Immunization Registries
States are increasingly interested in using their immunization registries
for BMI surveillance. One such example is highlighted in Box 4-6. The goal
is to have clinics collect weight and height data and report these data to a
state registry for surveillance purposes. This could include reports submit-
ted by clinics at the time of immunization, or even to a separate database
from reports required for physical exams for enrollment or school-based
BMI screening. The registry concept aligns with the public health objectives
of “meaningful use” criteria for clinics, in that it anticipates the ability to
send information from EHRs to state public health departments. Immu-
nization registries can be used to calculate incidence rates and prevalence

BOX 4-6
Michigan Care Improvement Registry—BMI Growth Module
The Michigan Care Improvement Registry (MCIR) was originally established

by the Michigan Department of Health and Human Services to maintain a cen
trally located accessible record of child immunizations in accordance with Public
Act 540 of the Public Acts of 1996, Amended 2006, Act 91. Health care providers
are required to report all immunizations for children ages 0 to 18 years to MCIR
within 72 hours of immunization unless the child’s parent or guardian objects
by written notice. MCIR recommends that providers report immunizations for all
ages.
In recent years, a BMI Growth Module has been added to the MCIR to col
lect BMI information on patients. Entering information into the MCIR-BMI Growth
Module is currently voluntary, but if health care providers choose to participate,
they are prompted to enter height and weight values, as well as additional obesity-
related data, for patients when the immunization is recorded in the registry. BMI
information is provided through passive consent of the patient. Data are available
to any health care provider who cares for children ages 0 to 18, both public and
private. Proper usage of data is regulated by Michigan law.
SOURCE: MCIR, 2014.
rates, if data are collected over time and tracked by individual. Additional
information can be collected and transmitted to allow for risk profiles and
for monitoring trends over time.
COHORT STUDIES
Data from cohort studies also have been used to assess obesity preva-
lence and trends. Cohort studies are observational studies of a select study
population (“cohort”) that is followed over time to determine risk factors
associated with changes in levels of disease incidence. Cohort studies can be
used to calculate incidence, remission, and prevalence of obesity, as well as
trends. Cohort studies can be a way to obtain obesity prevalence estimates
on subpopulations of interest that may not be represented in the larger
national surveys because of sample restrictions on size and representative-
ness. They also are useful to provide information on trends over time and to
identify risk factors and other characteristics that might be associated with
obesity prevalence and trends. However, one limitation of cohort studies is
that participation may vary over long periods of time due to loss of follow-
up. Three illustrative examples of cohort studies that collected height and
weight data are presented below.

The National Longitudinal Study of Adolescent to Adult Health

The National Longitudinal Study of Adolescent to Adult Health (Add
Health) is a large, comprehensive study that follows adolescents as they
progress to adulthood. It originated in 1994 and is supported by grants
from the Eunice Kennedy Shriver National Institute of Child Health and
Human Development (NICHD), as well as other federal agencies and foun-
dations (Add Health, 2016; Chantala and Tabor, 2010). The original ques-
tionnaire was administered in schools to a nationally representative sample
of students in grades 7 to 12, and the study followed up with a series of
in-home interviews in 1995, 1996, 2001-2002, and 2007-2008. Height and
weight data were obtained by interviewers in each wave. A fifth wave is
currently under way (2016-2018).
Add Health provides valuable longitudinal data on obesity trends in
a fixed, nationally representative population starting in middle and high
school through early and mid-adulthood. Data are released immediately
after cleaning, with public use data available from the Odum Institute at the
University of North Carolina at Chapel Hill, the Inter-University Consortium
for Political and Social Research, and Sociometrics (Add Health, 2016). A
larger restricted-use sample is available by contractual agreement to certified
researchers who commit themselves to maintaining limited data access.
Growing Up Today Study

The Growing Up Today Study (GUTS) began in 1996 to follow the
children of Nurses’ Health Study participants. The initial cohort included
16,882 children ages 9 to 14 years. In 2004, GUTS enrolled a new group of
10,923 children between the ages of 10 and 17 years (GUTS, 2013). These
participants are now young adults and many continue to complete annual
online health questionnaires, which collect information on self-reported
weight and height along with information on health and social behaviors.
Nearly 100 peer-reviewed research articles have been published from these
data looking at obesity-related risk factors and trends in risk factors over time.
Minneapolis Childhood Cohort Studies

The Minneapolis Childhood Cohort Study is one of seven cohort
s tudies included in the International Childhood Cardiovascular Cohort (i3C)
Consortium.12 The Consortium is focused on identifying risk factors asso-
12 The seven cohorts include the (1) Muscatine Study, (2) Bogalusa Heart Study, (3) Car-
diovascular Risk in Young Finns Study, (4) Childhood Determinants of Adult Health Study,
(5) Minneapolis Childhood Cohort Study, (6) Princeton Lipid Research Clinics Study, and
(7) National Heart, Lung, and Blood Institute Growth and Health Study.

ciated with childhood origin of cardiovascular disease by leveraging data

collected on more than 40,000 children in the collaborating cohorts (i3C,
2011). The Minneapolis study included three cohorts: the first study recruited
1,200 children ages 7 to 9 years in 1978 with measured height and weight
yearly until age 20, at age 24, and in 2007 through 2011 for follow-up; the
second cohort started in 1985 and recruited students in grades 5 through 8
who were seen a second time recently at ages 25 to 30 years for additional
weight and height measures; the third study recruited 400 children starting
in 1995 who were seen roughly at ages 13, 15, 19, and 24 years with mea-
sured height and weight data collected. The studies also collected data on a
wide range of factors that may influence the development of cardiovascular
disease (i3C, 2011).
SUMMARY
Data sources being used to assess obesity prevalence and trends include
population surveillance surveys, direct measurement in the school setting,
clinical and public health administrative data, and cohort studies. Each has
a unique approach and captures different types of data in different ways.
Data sources that include directly measured height and weight data for
children, adolescents, and young adults include NHANES, school-based
assessments, EHRs, and select cohort studies.
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Analytic Approaches and Considerations
Key Messages
• Not all reports on obesity prevalence and trends have identical
purposes. A report’s stated purpose provides context for the
selected data source and analytic procedures.
• The Centers for Disease Control and Prevention (CDC), the
International Obesity Task Force (IOTF), and the World
Health Organization (WHO) each provide reference popula-
tions to which a child or adolescent’s BMI can be compared.
Although similar in overall intent of describing the BMI distri-
bution within a given population, these references do not result
in identical estimates of obesity prevalence and therefore are
not interchangeable each other.
• Extreme values in height, weight, or BMI—so-called biologi-
cally implausible values (BIVs)—are identified and handled in
inconsistent ways across reports. Evidence suggests BIV criteria
can affect estimates of obesity prevalence.
• Published reports based on surveys use response rates as a
gauge of the potential for nonresponse bias. A high response
rate, however, does not always mean the data are unbiased.
Missing data and study design also can provide insight into the
potential for bias.
• Weighting a sample is one approach to correct for imperfec-
tions in sampling, account for non-response, and better repre-
123

sent the target population described by the estimates. Not all

datasets will need to be weighted.
• The analytic sample size determines what statistical procedures
and comparisons can be meaningfully conducted.
• Prevalence estimates that encompass diverse population groups
may not adequately describe the variability that exists within
the subgroups the population contains.
• The time frame used in trends analyses is crucial to interpreting
the findings. Analyses using the same data source but different
time frames can reach different conclusions.
• Ample sample size, similar data collection methodologies, and
adequate characterization of population groups facilitate the
ability to compare obesity prevalence and trends estimates
across subgroups and between reports.
The analytic approach taken to arrive at an estimate of obesity preva-

lence or trend is determined by a number of factors, including the intent of
the specific analysis, the quality control measures taken during data collec-
tion, the study design from which the data were derived, and the amount of
data available. A range of options exist to analyze the data and to present
the results. In its review of the evidence, the committee identified various
aspects of the analytic approaches used in published reports that have
implications for interpreting results. Some analytic approaches, such as the
reference population selected to classify body mass index (BMI), specifi-
cally pertain to the assessment of obesity among children, adolescents, and
young adults. Other interpretive considerations are fundamental principles
of epidemiology and statistics and are widely applicable to any assessment
of prevalence or trends. Both are integral to a thorough consideration and
informed interpretation of results.
This chapter highlights key considerations that extend across the broad
range of published reports on obesity prevalence and trends. Throughout,
analytic approaches will be described. These descriptions are not intended
to provide detailed guidance on how to perform the specific procedures, but
rather are included to contextualize the consideration, especially for those
who do not have advanced understanding of statistics and epidemiology.
The committee acknowledges that other analytic procedures and consider-
ations exist beyond those presented here.
This chapter contains terms and phrases that have the potential to be
used or interpreted in multiple ways. For clarity, the committee’s definitions
are as follows (a full glossary can be found in Appendix A):

ANALYTIC APPROACHES AND CONSIDERATIONS 125
• “Analytic approach” encompasses both the preparation of data for

analysis and the statistical analyses themselves.
• “Statistical analysis” or “statistical approach” will specifically refer
to the analytic procedures that result in an estimate of obesity
prevalence or trend.
• “Estimate of obesity prevalence or trend,” or the term “estimate,”
describes a statistic about the proportion or number of individuals
affected with obesity at one point in time (prevalence) or over time
(trend).
• “Change” refers to the difference between two points in time, and
“trend” refers to a difference over three or more points in time.
• “Investigators” describe those who perform the analyses.
THE PUBLISHED REPORT’S STATEMENT OF PURPOSE

A published report’s stated purpose provides a link between the data
source and the analytic procedure. It also can provide initial insight into
the type of findings to be presented (e.g., prevalence, change, trends).
The committee identified recurring themes in the stated purposes across a
wide variety of published reports (see Table 5-1). This list of themes is not
exhaustive, but it illustrates that a range of purposes can fall under the pur-
view of a “report on obesity prevalence or trends.” Although some analytic
approaches are common across all published reports (e.g., classification of
obesity status), the statistical analyses performed are tailored to the specific
research question or defined set of questions being asked of the data.
PREPARATION OF THE DATA FOR ANALYSIS

Published reports commonly describe the steps taken to prepare the
data for statistical analysis. Some data preparation procedures are specific
to an evaluation of obesity, especially when the sample includes children,
adolescents, and young adults. Other data preparation procedures are
general and rooted in the principles of epidemiologic research and statisti-
cal analyses. The extent to which these specific and general procedures are
performed can vary.
The committee identified three key aspects of data preparation that
can affect the interpretation of findings presented in a published report
on obesity prevalence and trends. These include: the approach to obesity
classification, identification and handling of biologically implausible values
(BIVs), and representativeness of the sample.

TABLE 5-1 Potential Advantages and Disadvantages of Published

Reports on Obesity Prevalence and Trends, by Thematic Characterization
of the Report’s Statement of Purposea
Purpose Potential Advantagesb Potential Disadvantagesb
Report obesity As the primary objective, the Describes only one point in time.
prevalence in a estimates are typically easy Does not provide insight into
single population to identify. incidence or variations over
time.
Compare obesity Provides insight into how Subgroupings can rapidly

prevalence and different groups are become small in size, limiting
trends of different affected. meaningful comparisons.
population groups Time frame(s) selected affects
results, interpretation of
findings.
Compare obesity Helps elucidate how prevalence May not account for all
prevalence estimates estimates relate to each differences between locations
between multiple other geographically. that can affect estimates of
locations, regions, or obesity prevalence.
states Jurisdictions of interest to the end
user may not have comparable
data or be included in the
report.
Compare an National estimates provide a Groups will inherently fall

estimate to a benchmark. above and below the national
national statistic estimate because it represents a
central tendency.
Assess change in Provides a broad picture of Causality cannot be established.

prevalence after the status before and after a There are limits to what can be
implementation of a population-wide change. controlled for in the analysis.
policy or initiativec
Assess how a group Assesses intrapersonal change Attrition is likely, which can limit
of individuals or trajectories. generalizability.
change over time Results highly contingent on time
period assessed, with shorter
trends typically being less
stable than longer ones.
a The list is not exhaustive and categories are not mutually exclusive.
b The potential advantages and disadvantages are contingent on the population assessed,
analytic considerations are more fully explored in this chapter, while considerations related to
c Considered natural experiments, which are observational rather than interventional in
design.

Obesity Classification for Children, Adolescents, and Young Adults

As described in Chapter 2, obesity status must be operationalized into
a metric that can be categorized. BMI is the predominant measure used to
classify obesity status. Although the adult cut point for obesity classifica-
tion of >30 kg/m2 applies to both sexes regardless of age, the cut point for
children is determined by comparing BMI to a reference population. The
2000 Centers for Disease Control and Prevention (CDC) sex-specific BMI-
for-age growth charts are the predominant reference used for U.S. children,
ages 2 years and older. However, other BMI-for-age references appear in
published reports, specifically the International Obesity Task Force (IOTF)
cut points and the World Health Organizations (WHO) growth standards
and charts. The following sections describe the utility and comparability of
these reference populations and Table 5-2 summarizes them. Other growth
references exist, but because they are not typically used in published reports
on U.S. populations, they are not included in this section.
Growth References for Classifying Obesity Status

2000 CDC BMI-for-Age Growth Charts The 2000 CDC sex-specific BMI-
for-age growth charts are designed for individuals ages 2 to 20 years (see
Figure 2-1 for an example) (Kuczmarski et al., 2000). Data used to develop
the BMI-for-age growth charts came from the National Health Exami-
nation Survey (NHES) II (1963-1965), NHES III (1966-1970), National
Health and Nutrition Examination Survey (NHANES) I (1971-1974), and
NHANES II (1976-1980). Data from NHANES III (1988-1994) were used
only for children younger than age 6 years because obesity prevalence
was substantially higher in this NHANES cycle than the previous cycles
and inclusion would have shifted cut off points for obesity classification
(Kuczmarski et al., 2000). Smoothed percentiles are assigned throughout
the distribution of each of the sex-specific curves. The percentiles serve
as the basis for classification of weight status. A child with a BMI at or
above the 95th percentile for age and sex is classified as having obesity (see
Box 2-3 for discussion about recent shifts in nomenclature).
Using the growth charts to classify obesity status has two interpre-
tive considerations. First, like all reference population-based classification
approaches, the 2000 CDC BMI-for-age growth charts represent the dis-
tribution of BMIs that existed within the source population, which con-
sisted of nationally representative samples of U.S. children from the 1960s
through the 1980s. The children who were included were not selected based
on health criteria, and as such, the distribution describes only the distribu-
tion as it existed and does not necessarily reflect optimal growth. Second,
by definition, 5 percent of the children whose data were used to develop the

TABLE 5-2 Summary of the 2000 CDC BMI-for-Age Growth Charts, the
IOTF Cut Points, the WHO Growth Standard, and the WHO Growth
Reference
Growth Cut Point to Classify Age Aligned with
Reference Source Populationa Obesity Adult Cut Pointb
CDC Nationally representative ≥95th percentile Males: 19.3 years
cross-sectional samples Females: 17.5 years
of U.S. children,
adolescents, and young
adultsd
IOTF Representative samples Centile corresponding 18 years

from six locations to a BMI of 30 kg/
m2 at age 18 years
applied throughout the
distribution
WHO, MGRS +2 standard deviations N/A

growth
standard
WHO, 1977 National Center for +2 standard deviations 19 years

growth Health Statistics/WHO (approximately)
reference growth reference,
merged with the
MGRS data
NOTE: CDC, Centers for Disease Control and Prevention; IOTF, International Obesity Task
Force; MGRS, Multicentre Growth Reference Study; N/A, not applicable; WHO, World
Health Organization.
a Only pertains to the BMI-for-age growth charts.
b Age in which the growth reference crosses 30 kg/m2.
c The potential advantages and disadvantages are contingent on the population assessed,
BMI-for-age growth chart would have exceeded the 95th percentile cut off
point (Ogden, 2015). Together, these considerations emphasize the statisti-
cal principles underlying the classification of obesity status using the growth
chart approach.
The 2000 CDC BMI-for-age growth charts have several practical
advantages. One advantage, as nationally representative growth references,
is that their use is pervasive in the U.S. published literature, which facilitates
comparability across reports. Another advantage is that the CDC provides
tools, including a Web-based calculator (CDC, 2015a) and a download-
able spreadsheet (CDC, 2015c), that calculate BMI percentile (and thereby
obesity status) when height, weight, date of measurement, and date of birth
are entered.

Potential Advantagesc Potential Disadvantagesc Interpretations

Pervasive in the literature. Does not describe optimal Comparison to a distribution
Source data were nationally growth. of previous nationally
representative of U.S. Not directly aligned with representative U.S. samples.
population. the adult cutoff.
Provides continuity with Does not describe optimal Comparison to distribution of

adult obesity cut point. growth. six previous representative
Can be used internationally. international samples.
Source population represents Available only for young Comparison to young children
optimal growth. children. believed to exemplify
Can be used internationally. optimal growth.
Aligned with the age 0 to Does not describe optimal Comparison to a distribution
5 year growth standard growth. of previous nationally
for continuity. representative U.S. samples.
Can be used internationally.

analytic considerations are more fully explored in this chapter, while considerations related to
d Data from the National Health Examination Survey (NHES) II (1963-1965), NHES III
(1966-1970), National Health and Nutrition Examination Survey (NHANES) I (1971-1974),

and NHANES II (1976-1980). Data from NHANES III (1988-1994) were used only for chil-
dren younger than age 6 years (Kuczmarski et al., 2000).
The use of the 2000 CDC BMI-for-age growth charts also has some
limitations. The age in which an individual transitions from the growth
charts to the adult cut point for obesity is inconsistent across reports.
Some investigators use the growth charts for individuals through age 19
years (Gee et al., 2013; Ogden et al., 2014), while others use the 30 kg/m2
cut point for all individuals ages 18 years and older (Hinkle et al., 2012).
The 95th percentiles on the growth charts do not correspond to a BMI of
30 kg/m2 at either age for either sex. On the female growth chart, the 95th
percentile crosses a BMI of 30 kg/m2 at age 17.5 years and corresponds to
BMIs higher than 30 kg/m2 thereafter. For females aged 17.5 to 20.0 years,
use of the growth chart has the potential to result in a lower obesity
prevalence than a prevalence based on the 30 kg/m2 cut point. For males,

the 95th percentile does not cross the adult BMI cutoff until 19.3 years of
age. Before this age, use of the growth chart has the potential to result in a
higher obesity prevalence compared to a prevalence based in the 30 kg/m2
cut point. After age 19.3 years, where the 95th percentile corresponds to a
BMI greater than 30 kg/m2, obesity prevalence based in the growth charts
has the potential to be lower than prevalence based on the adult cut point.
To account for these differences, some investigators classify adolescents and
young adults as having obesity if their BMI is either ≥95th percentile or
≥30 kg/m2, whichever corresponded to a lower BMI (Benson et al., 2009,
2011; Freedman et al., 2012; Robinson et al., 2013). Although the use of
the adult criterion in conjunction with the growth charts is one method
for handling the discrepancy between the different approaches, it has the
potential to classify more individuals as having obesity than the growth
charts alone. Although rarely reported in the published literature, the extent
to which the estimate of obesity prevalence changes with the inclusion and
exclusion of the 30 kg/m2 criterion for an analytic sample provides evidence
of its utility and need for a given population.
IOTF BMI Cut Points Although the IOTF BMI cut points are not as com-
mon as the 2000 CDC BMI-for-age growth charts in the published literature,
they have been used in reports on U.S. children and adolescent populations
(Rodriguez-Colon et al., 2011; von Hippel and Nahhas, 2013; Williamson
et al., 2011). The sex-specific IOTF cut points are based on cross-sectional,
nationally representative data from six different countries from various
years: Brazil (data from 1989), Great Britain (data from 1978-1993), Hong
Kong (data from 1993), the Netherlands (data from 1980), Singapore (data
from 1993), and the United States (data from 1963-1980) (Cole et al.,
2000). The U.S. data included in the IOTF analyses are the same data that
were used to develop the 2000 CDC BMI-for-age growth charts (i.e., NHES
II, NHES III, NHANES I, and NHANES II). The IOTF BMI cut points,
however, are based on pooled nationally representative data from different
parts of the world, and are therefore intended for international use.
The IOTF BMI cut points provide classification continuity from child-
hood through adulthood. By design, a BMI of 30 kg/m2 at age 18 years for
both sexes corresponds to being classified as having obesity (Cole et al.,
2000). The centile associated with this cut point was then applied to the
rest of the BMI distribution to establish obesity and other weight classifica-
tion cut points throughout childhood and adolescence (Cole et al., 2000).
These cut points also have been updated so that they can be expressed as
a centile or standard deviation score (z-score; see Box 5-3 for description)
(Cole and Lobstein, 2012).
Although the IOTF cut points have international applications and
allow for a seamless transition to the adult cut point for obesity, the inter-

pretation of obesity classification is still rooted in the source populations

of the data. Like the 2000 CDC BMI-for-age growth charts, the IOTF BMI
distributions were derived from nationally representative samples—in this
instance, six international populations—and therefore do not necessarily
describe optimal growth. Thus, obesity classification using the IOTF is a
comparison of a BMI to the distribution of children’s BMIs that existed
at the time points the data were collected from various international
locations.
WHO Growth Standards and Growth Charts The WHO developed

growth standards for children 0 to 5 years of age and growth references
for children 5 to 19 years of age. A growth reference and a growth standard
differ in attributes of the source population. A reference describes the typi-
cal physical development found in a population but does not necessarily
provide insight into what deviations from typical values mean. A standard,
in contrast, describes the development of children who are believed to
exemplify optimal growth and “may be considered as prescriptive or nor-
mative references” (de Onis, 2004). The CDC endorses the use of a modi-
fied version of the WHO growth charts for U.S. children younger than age
2 years (Grummer-Strawn et al., 2010) but recommends use of the 2000
CDC growth charts thereafter (CDC, 2010). Accordingly, use of the WHO
growth standards and charts are not particularly common in reports on
obesity prevalence and trends among U.S. population groups.
Data for the growth standards for children ages 0 to 5 years came from
the Multicentre Growth Reference Study (MGRS), a population-based,
international effort that sought to describe optimal growth of children
(de Onis, 2004). It consisted of a longitudinal assessment of children from
birth to 24 months of age and a cross-sectional assessment of children ages
18 to 72 months. Participants were recruited from six study sites (Accra,
Ghana; Davis, California, United States; Muscat, Oman; New Delhi, India;
Oslo, Norway; and Pelotas, Brazil) and met strict inclusion criteria, in an
effort to capture the growth status and growth trajectory of children with
optimal health, nutrition, and environmental exposures. The strict inclusion
criteria allowed for an assessment of comparability of growth across the
locations, in which racial and ethnic compositions of the assessed popula-
tions and cultural practices differed. For linear growth, approximately
3 percent of the variability was attributed to location, while 70 percent
was attributed to individual variation (WHO MGRS, 2006). As described
in Box 5-1, the limited variability in growth that can be attributed to racial,
ethnic, or international geographic location among young children provides
evidence to support the use of a single reference population across various
racial and ethnic groups, with considerations for environmental and socio-
economic status.

BOX 5-1
Use of a Reference Population Across
Various Racial and Ethnic Groups
In its rationale for promoting a set of growth charts for all racial and ethnic
groups (CDC, 2016a), the Centers for Disease Control and Prevention (CDC)
cite various studies including the work of the Multicentre Growth Reference Study
(MGRS) Group. The World Health Organization (WHO) MGRS Group found
similar growth among ethnically and geographically diverse breastfed infants from
“economically privileged families (relative to national norms)” (Garza and de Onis,
2004). This concept has been further bolstered by the limited amount of variation
in linear growth attributable to geographic location in the MGRS sample (WHO
MGRS, 2006). Furthermore, recent work by the INTERGROWTH-21st Project
reports that limited variation in fetal growth and newborn size could be attributed
to the international geographic location among children whose mothers who were
of “optimum health, nutrition, education, and socioeconomic status” (Villar et al.,
2014). Collectively, current evidence indicates that differences in growth patterns
among infants and young children are more attributable to factors related to
environmental exposure and socioeconomic status than to inherent differences
between racial and ethnic groups.
For the growth reference for children and adolescents ages 5 to 19

years, data from the ages 0 to 5 year growth standards were merged
with data used to develop the 1977 National Center for Health Statistics
(NCHS)/WHO growth references, which were from NHES II, NHES III,
and NHANES I (de Onis et al., 2007). The reference population for the
WHO growth charts, therefore, includes much, but not all, of the data used
to develop the 2000 CDC BMI-for-age growth charts. The WHO growth
references are aligned with the age 0 to 5 years growth standards, providing
continuity as children younger than age 5 years transition to the growth
reference for those ages 5 to 19 years.
For the WHO growth charts, a child with a BMI exceeding +2 stan-
dard deviations (approximately the 98th percentile) is classified as having
obesity. The +2 standard deviation cut point for both sexes at age 19 years
closely corresponds to the adult cut point for obesity (29.7 kg/m2 versus
30 kg/m2, respectively) (de Onis et al., 2007).
Comparability of Growth References for Obesity Classification

The CDC, IOTF, and WHO growth references each used U.S. nation-
ally representative data in their development, alone or in combination with
other data sources. The reference populations and associated BMI-for-age

distributions differ across the growth charts. The selected cut points used to
categorize obesity status also differ. As a result, obesity prevalence can vary
depending on which reference is used. For school-aged children, for example,
the IOTF cut points are more closely aligned with the CDC’s 97th percentile
than the 95th percentile (Freedman et al., 2011). Because IOTF cut points
correspond to a higher threshold, obesity prevalence calculated using the
IOTF will be lower than prevalence based on CDC growth charts (Freedman
et al., 2011; Lang et al., 2011). In contrast, the WHO and CDC obesity clas-
sification approaches have been noted to yield estimates of obesity prevalence
relatively aligned with each other, although variation exists. Both Maalouf-
Manasseh et al. (2011) and Mei et al. (2008), for example, reported higher
obesity prevalence in populations younger than age 5 years using the WHO
growth charts compared to the CDC. Thus, obesity prevalence estimates
using the different reference populations are not interchangeable.
Alternative Obesity Classification Approach

Some published reports do not use any of the aforementioned refer-
ence populations and instead use novel or different criteria for obesity
classification. Some published reports, for example, are based on publicly
available data in which the alternative classification criteria are embedded
in the data collection or reporting system from which the data were derived
(see Box 5-2 for an illustrative example). Other reports have the primary
purpose of determining the utility of an alternative obesity classification
criterion. Reports of this nature have the potential to alter how obesity is
determined and described, and thereby serve an important research niche.
However, use of such reports for the purposes of determining obesity
prevalence and trends can be challenging. The statistic must be interpreted
in context of the criteria used to classify the data and can be limited in its
comparability to existing statistics.
Summary of Considerations Related to Obesity Status Classification

• Different reference populations exist. The CDC, IOTF, and WHO
each provide different reference population to which BMIs can be
compared.
• Interpretation of obesity classification is embedded in the design
of the growth charts. The three reference populations describe the
distribution of BMIs as they existed within the source population.
The obesity cut points selected are statistically derived from those
distributions.
• Obesity prevalence is contingent on the reference population selected.
Because the CDC, IOTF, and WHO cut points were developed using

BOX 5-2
Illustrative Example:
Alternative Obesity Classification Approach
The FitnessGram®a is a school-based assessment of students’ aerobic capacity;

muscle strength, endurance, and flexibility; and body composition. The body com
position component is largely assessed through directly measured heights and
weights used to calculate BMI.
Standard FitnessGram® administration and reporting compares students’ BMI
to Healthy Fitness Zone®b (HFZ) ranges rather than directly to 2000 CDC BMI-
for-age growth charts. HFZs are stratified by sex and given per year age of the
student (e.g., males age 15 years). Students falling above or below the HFZ are
considered to not meet the criterion for the body composition component. Beyond
the HFZ is a category called “Needs Improvement–Health Risk” (NI–HR), which
currently corresponds to the CDC’s 95th percentile at the midpoint of the year of
age (see Appendix D, Table D-8). The HFZs, however, have changed over time
(California Department of Education, 2016). Accordingly, estimates of prevalence
are not directly interchangeable to those based on the 2000 CDC BMI-for-age
growth charts or to those that used different HFZ ranges.
California is one state that maintains an extensive website with the results
of its annual FitnessGram® assessments. In querying the summary data, the
results for the body composition component are reported in relation to the HFZs
and the N I-HR criteria (California Department of Education, 2013). At the present,
the online tool cannot be used to compare the height and weight data to a specific
reference population.
Not all FitnessGram® administrations or reports based on FitnessGram® data
use the HFZ for the body composition component. The New York City FitnessGram®,
for example, has used the CDC growth charts for weight status classification (NYC
Department of Education, 2016). Researchers also have been able to use mea
sured height and weight values from locations that use HFZ to classify students and
estimate prevalence based on standard reference populations (Aryana et al., 2012;
Jin and Jones-Smith, 2015; Sanchez et al., 2012).
a The FitnessGram® was developed and is a registered trademark of The Cooper Institute®,
Dallas, Texas.
b Healthy Fitness Zone® is a registered trademark of The Cooper Institute.
different source data, the distributions and associated obesity cut

points are not identical. Obesity prevalence is typically lower when
using the IOTF cut points, compared to CDC growth charts.
Biologically Implausible Values

Extreme values for height, weight, and BMI occur in datasets. The
identification and handling of these BIVs is a data processing procedure

that is common, although not universal, among reports on obesity preva-

lence and trends. A BIV may represent an error in measurement or data
entry and can exist on both ends of the spectrum—that is, values can be
implausibly high or implausibly low. Both inclusion of BIV data that are
errors and exclusion of BIV that are legitimate data points can affect an
obesity prevalence or trend estimate. Because the purpose of identifying
BIVs is to locate extreme values in the data, BIV criteria are often based on
evaluation of growth reference z-scores rather than percentiles (Flegal and
Ogden, 2011) (see Box 5-3).
To identify data that qualify as BIVs, investigators establish a range of
plausible values. Data falling outside of the plausible range are classified as
BIVs. BMI is an index of height and weight, and as such, BIVs can exist in
height, weight, and BMI data. Lawman et al. (2015), however, note that
not all large-scale epidemiologic studies report evaluating BIV in height,
weight, and BMI data—some only report evaluating extremes in BMI data.
The following provides an overview of the different types of BIV criteria
that exist and how BIVs have been handled.
Types of BIV Criteria

The criteria used to identify BIVs can be flexible or fixed (CDC, 2016b;
WHO, 1995). Flexible BIV criteria are constructed around the observed
BOX 5-3
The Use of Z-Scores Instead of Percentiles for Identifying BIVs
A z-score and a percentile correspond to each other but describe data in

different ways. A z-score describes the number of standard deviations a value
is away from the mean of a given distribution and thereby contains information
about the numerical value of BMI. A percentile, in contrast, represents a ranking
of a value against the selected distribution (i.e., the percent that are below the
observed value). When assessing obesity status of children and adolescents, an
individual’s BMI is compared to a reference population. The BMI-for-age z-score
and percentile describe how the individual’s BMI compares to the distribution that
existed within the reference population, not the distribution that exists within the
study sample. As BMI-for-age values become more extreme, their z-score will
continue to reflect the change as compared to the reference population mean.
The BMI-for-age percentile, however, will never exceed 100. It is for this reason
that z-scores are often used for identifying extreme values for children and ado
lescents rather than percentiles.
SOURCE: Wang and Chen, 2012.

mean of the collected data for a particular study. This approach is particu-
larly useful when the sample’s distribution is shifted because it allows the
acceptable range of deviation to be wider. Fixed BIV criteria, in contrast,
are absolute cutoffs that are independent of the collected data and are based
on the reference population. Fixed BIV criteria recommended by a 1995
WHO expert committee are presented in Table 5-3. Using fixed data is use-
ful when the assessed population’s mean z-score, as compared to the refer-
ence population, is relatively close to zero. Fixed criteria can be adapted
to account for skewed population distributions. If an assessed population
BMI-for-age distribution is skewed, as was the case for Pan et al. (2012),
a higher cut point for implausible values may be used (e.g., +8 standard
deviations instead of +5) (CDC, 2015d).
The fixed criteria presented in Table 5-3 were released before the
development of the BMI-for-age growth charts. When the 2000 CDC BMI-
for-age growth charts were developed, skewness in the distribution was
handled in such a way that extreme values converge to high but still
plausible z-scores (CDC, 2002, 2016b; Flegal and Cole, 2013). As such,
extrapolation beyond the 97th percentile on the growth charts should be
carried out with caution (CDC, 2002; Flegal and Cole, 2013; Flegal et al.,
2009). To overcome this limitation, the CDC has developed a statistical
program that calculates modified age- and sex-specific z-scores that can be
used for BIV identification (CDC, 2015d).
As described in a review of BIV criteria used in large epidemiologic
studies, not all reports use the same approach to identifying BIVs related
to height, weight, or BMI (Lawman et al., 2015). Instead, BIV criteria have
been based on z-scores (for height, weight, and BMI), measurement values
(e.g., BMI <10 kg/m2), and percentile (e.g., >99th percentile) (Lawman et
al., 2015). When longitudinal data are being assessed, change in height,
weight, and BMI values also may be included in the BIV assessment.
Reports use different number of and combinations of BIV criteria, which
TABLE 5-3 Fixed Exclusion Range Criteria for Growth Chart Z-Scores,
as Established by a 1995 WHO Expert Committee
Exclusion Criterion
Growth Chart Low z-scores High z-scores
Height-for-age <–5.0 >+3.0
Weight-for-age <–5.0 >+5.0
Weight-for-heighta <–4.0 >+5.0
a
Criteria can be applied to the modified BMI-for-age z-scores (CDC, 2016b).
SOURCE: WHO, 1995.

can in turn affect the number of participants identified as having BIV. For
example, when Lawman et al. (2015) applied various BIV criteria to a lon-
gitudinal sample of 13,662 students in Philadelphia, the percent of students
with BIVs ranged from 0.04 to 1.68 percent.
The procedures and tools for capturing data can affect the selection
and use of BIV criteria. For example, data collectors in the NHANES
do not manually enter values of height and weight into the data collec-
tion system, unless an equipment malfunction occurs. Instead, values are
transmitted directly from the scale and stadiometer to the database (CDC,
2013c). This data collection approach minimizes data entry error, and
presumably all captured height and weight data represent legitimate data
points. A study by Freedman et al. (2015) suggests that use of BIV criteria
among children and adolescents in NHANES may lead to misclassification,
as most identified as BIV had other measures indicating that the extreme
values were valid data points. In contrast, some initiatives may not have
an opportunity to identify BIVs until data entry or data preparation.
This is currently the case for the Youth Risk Behavior Survey (YRBS), in
which high school aged students self-report the data using paper-based
surveys (CDC, 2013b). As such, YRBS has age- and sex-specific biologi-
cally p
lausible ranges that responses must meet for inclusion in the dataset
(CDC, 2014).
Handling of BIV Data

Two common approaches can be used to handle BIV data. The first
is to eliminate all data points that fall outside of the established plausible
range. In cross-sectional studies, it is often difficult to determine if a height,
weight, or BMI value is an error or is accurate unless additional measure-
ments, such as waist circumference or skinfold thickness, are included in
the dataset. For this reason, elimination of all BIVs may be the only option.
The other approach is to use BIV criteria as a means to identify data points
that merit further investigation. This may involve reviewing hand-written
measurements on data collection sheets or looking at additional data on the
individual to determine whether the value makes sense given other evidence.
Longitudinal studies have contextualized irregular values to help determine
whether a BIV represents an error or a legitimate value, and often allow for
correction of errors because the data are collected repeatedly. An advantage
to using such additional information to make decisions about BIVs is that
the sample can retain extreme, yet legitimate, data points. Considerations
for use of this approach, however, include the quality of the additional data,
the consistency with which they were collected, and whether the additional
criterion or criteria were systematically applied across the dataset. Finally,
a sensitivity analysis in which prevalence and trends are estimated with and

without BIVs also can be helpful in characterizing whether estimates are

sensitive to the handling of BIVs.
Summary of Considerations Related to BIVs

• Not all values flagged as a BIV are errors. Extreme values in weight
and BMI can exist within a population. Excluding all data that are
flagged as BIV has the potential to underestimate the prevalence of
obesity (Freedman et al., 2015).
• Data collection approach matters. Systems that have data quality
assurance built into measuring and recording height and weight
data, such as NHANES, will inherently have different criteria for
BIV than collection systems that do not have such systems in place
for data collection.
• The distribution of the measure or index within the population
can affect BIV selection. BIV cutoffs may need to be changed if the
distribution of the population’s measurements is skewed or shifted
(e.g., high prevalence of severe obesity).
• Additional measurements can inform BIV status. In cross-sectional
evaluations, additional measurements, such as waist circumfer-
ence and skinfold thickness, may provide insight into whether a
measurement error or data entry error occurred. In longitudinal
datasets, repeated measures and patterns in growth and weight
gain can contextualize a BIV.
• Use of different criteria can lead to different estimates. This is
especially important in trend analyses. Changing criteria over time
can affect the estimates.
Representativeness of the Sample

As discussed in Chapter 3, sampling approaches used during data
collection can affect the representativeness of a resulting sample. The com-
mittee identified three key elements that investigators assess to establish
the representativeness of an analytic sample used in a published report:
response rate, missing data, and weighting. These elements are not exclusive
to reports on obesity prevalence or trends, but rather are general principles
of epidemiologic research and data analysis. Therefore, the discussion that
follows has broader application than just the assessment of obesity.
Response Rate
A response rate, as defined by the American Association for Public
Opinion Research, is “the number of complete interviews with report-

ing units divided by the number of eligible reporting units in the sample”
(AAPOR, 2008). Investigators who use survey data in their analyses are
often instructed to present response rates in their reports [for example,
JAMA (2016)] in an effort to provide evidence that the validity of findings
were not affected by nonresponse bias.
The state and local YRBS are common data sources in which the
response rate is a criterion that determines the analytic procedures and sub-
sequent interpretation of results (see Chapter 4 for more information about
the YRBS). Because the sampling procedures include selecting schools, then
sampling students within participating schools, the measure of response
rate used for YRBS data is overall response rate—the product of the school
response rate (i.e. percent of sampled schools that were asked to participate
that actually did) and the student response rate (i.e., percent of sampled
students asked to participate who actually provided usable data) (CDC,
2014). Only locations that have an overall response rate of 60 percent or
greater are used to generate population estimates (CDC, 2013b).
Although the response rate has been long associated with the concept
of survey quality, it is not absolute. Surveys with high response rates can
be biased, and conversely, surveys with low response rates can be relatively
unbiased (AAPOR, 2016; Keeter et al., 2006). Accordingly, response rates
can provide some insight into parameters of the analytic sample, but are
not the sole determinant of representativeness.
Missing Data
Missing data are a frequent occurrence in research and surveillance.
Among the reasons for lack of observations in a dataset are that partici-
pants may decline to provide information, the protocol may not be properly
executed, or the data were missing by design.
Missing data can lead to the exclusion of an otherwise eligible indi-
vidual or observation from the analysis and therefore have the potential to
introduce bias into the results. In a recent report on approaches to manag-
ing missing data in clinical trials, Little et al. (2012) identified a number
of issues about missing data in that context that may be similar between
approaches used in surveys and observational studies. Factors that can
contribute to the degree to which missing data might bias results include
the amount of data that are missing and the mechanism that generated
missing values.
Analytic procedures have been developed to handle missing data. With
each, bias remains a consideration. One simple approach commonly used
by investigators is to eliminate all participants with missing data from
analysis. Indeed, this is found in a number of published reports on obesity
prevalence and trends (Kim et al., 2011; Madsen et al., 2010; Saab, 2011;

Sekhobo et al., 2014). A consideration with this approach is the extent

to which those eliminated from the sample resembled the group included
in the analysis and the population at large. If those eliminated are fun-
damentally different with respect to key variables (e.g., obesity status) or
encompass a large portion of a sampled population group (e.g., high school
seniors), the interpretation of resulting statistics changes. Another approach
that has been used is to fill in the missing data using the average from the
sample or group. For example, Ezendam et al. (2011) reported using logical
and mean imputation for some variables, such as height and weight. This
approach, though easy to implement, often leads to biased results, almost
always leads to inaccurate estimates of variance, and can result in incor-
rect or inaccurate conclusions (Schafer and Graham, 2002). Similarly, in
longitudinal studies, in which some subjects drop out of the study, a simple
approach is to use a subject’s last measured time point to replace the miss-
ing time points (i.e., this is known as “last observation carried forward”).
Again, this simple approach often leads to biased results and incorrect con-
clusions (Gadbury et al., 2003; NRC, 2010). More statistically advanced
approaches (e.g., weighted estimating equation methods, likelihood esti-
mation, multiple imputation, and Bayesian approaches) better account for
the level of uncertainty that arises when adjusting for missing data in an
analysis. Sensitivity analyses also can be used to assess the robustness of
results obtained from applying various assumptions about missing data to
an analysis (Little et al., 2012). Ultimately, the potential for bias is greater
when larger fractions of data are missing.
Weighting1
As discussed in Chapter 3, the selected sampling procedure used in
a study can result in samples with different degrees of representative-
ness of a broader population. Weighting is one approach to correct for
imbalances in sampling (both those that occur by design or by systematic
non-response), account for non-response, and better represent the target
population the estimate is describing. Not every study will have, or will
need, sample weights. A well-designed and well-executed random sample,
for example, may be sufficiently representative of the target population.
Weighting also may not be used if the sample includes the entire popula-
tion of interest. One example of such datasets would be those derived using
the national Pediatric Nutrition Surveillance System procedures for select-
ing administrative data (see Box 4-2). In this approach, height and weight
1 This section provides a general overview of the concept and uses of weighting, but will
not provide an in-depth analysis of specific sampling approaches. For advanced reading on
the topic, the reader is referred to “Survey Sampling” (Kish, 1965).

data from all children seen in a specific Women, Infants, and Children
program in a given year are included. Published reports that are based on
such data do not use weighting procedures because the analytic sample is
the entire target population, except those excluded due to missing data or
BIVs (Sekhobo et al., 2010; Weedn et al., 2014). Many studies, however,
do not achieve a representative sampling outright and have used weighting
to prevent biasing the results (CDC, 2013a; Osborne, 2011).
The general concept of sample weighting involves assigning each par-
ticipant a value (“weight”), often proportional to the inverse of their prob-
ability of selection. Those having lower probabilities of selection would be
assigned larger weights. The weights also can be adjusted to account for
response rate, with those from groups that had lower response rate being
assigned larger weights, to make up for the data that are missing from
those who did not respond. Furthermore, the sample can be weighted to
match the distribution of demographic characteristics within the target
population for which the estimate is designed to represent. This requires
that a known distribution of the characteristic in the target population be
described and requires data about such attributes to be collected from the
sampled population.
The degree to which sampling weights differ across individuals in a
sample can affect the statistical analysis and interpretation. When sampling
weights are highly variable in a sample, for example, it is possible that the
resulting obesity prevalence would have large standard error and thereby
be imprecise. Although intentional oversampling can increase variability
of sampling weights, it also can be used to ensure an adequate number of
individuals are included in order to produce estimates for subpopulations of
interest that may not be large relative to the size of the full sample. Statisti-
cians with survey sampling expertise are typically needed to ensure a survey
is designed to make inferences that are valid both for the full population
and for special subpopulations of interest.
The sample weights and weighting procedures that are used in an
analysis reflect the purpose of the report and the parameters of the avail-
able data. For example, analyses that aim to be nationally representative
of children ages 2 to 19 years would use different weights than analyses
aiming to be representative of high school students in a racially and ethni-
cally diverse city. The span of time that the data represent also can affect the
weighting procedures. For example, when combining multiple 2-year cycles’
worth of NHANES data, perhaps to stabilize estimates of prevalence for a
population group that has a small sample size in each cycle, investigators
need to construct weights that represent the midpoint year of the combined
survey period (NCHS, 2012). In trend analyses, each prevalence estimate
informing the trend may be weighted differently. For example, a repeated
cross-sectional trend analysis of obesity among kindergarten to 7th grade

students in Anchorage, Alaska, weighted the data from each school year
based on enrollment data for the given year, from 2003-2004 to 2010-2011
(CDC, 2013e). From an interpretation standpoint, the results describe
obesity prevalence over time as they existed within the kindergarten to
7th grade student population. The multivariate logistic regression model
used to assess the existence of a trend adjusted for sex, grade, race and
ethnicity, and socioeconomic status, which would account for demographic
shifts that may have occurred over time.
Summary of Considerations Representativeness of the Sample

• The response rate is one approach investigators have used to dem-
onstrate representativeness. Response rate, however, is only one
aspect that determines data quality and representativeness.
• Missing data can bias results. Individuals who contribute full data
may not be the same as those with incomplete data.
• Weighting can be used to correct for imbalances in a sample. Not
all samples will need weighting, however.
STATISTICAL ANALYSIS
The committee encountered barriers to comprehensively assessing the
range of statistical approaches currently being used in published reports
on obesity prevalence and trends. The primary obstacle was rooted in the
fact that statistics of this nature can reside in reports that have different
purposes (see Table 5-1), and the analytic approaches used in reports were
often specific to the particular question being asked of the data. Instead
of evaluating statistical procedures individually, the committee identified
considerations that would broadly apply to a wide range of published
reports. The topics in this section cover considerations related to the sample
size, determining the prevalence, assessing the prevalence over time, and
performing comparisons. The discussions that follow pertain to direct esti-
mates of obesity prevalence and trends. The committee, however, acknowl-
edges a growing interest and use of model-based estimation (see Box 5-4).
Sample Size
The size of the analytic sample largely determines what statistical pro-
cedures and comparisons can be meaningfully conducted. In general, larger
sample sizes are associated with more reliable estimates than are smaller
sample sizes, holding other factors equal. A measure is deemed reliable
when it reproduces under similar conditions. When the outcome of interest
is highly variable in a target population, a larger sample size will be needed

BOX 5-4
Small Area Estimates of Obesity Prevalence and Trends
Data sources, like population surveys, are designed with the intent of generat
ing reliable estimates for a specific population. Several of the key data sources
used to estimate obesity prevalence and trends are designed to describe a broad
geographic region—the nation or individual states. Although estimates generated
from such data sources (“direct estimates”) have important applications, their
relevance to smaller geographic regions can be limited.
Using nationally representative data to calculate a direct survey estimate for
smaller geographic areas is challenging and can easily lead to unreliable esti
mates. To overcome this barrier, small area estimation (SAE) is sometimes used.
In SAE, both direct survey data and auxiliary data (e.g., Census data) are used to
create a statistical model. In this approach, the model will often include (auxiliary)
data from outside areas with similar characteristics to the area of interest. In this
way, the statistical model is used to obtain indirect estimates for the geographical
areas of interest that are considered to be “small.” In other words, the information
from respondents who are outside the geographical area and other geographical
characteristics are used to provide an estimate for the “small” area of interest,
through the use of a statistical model. These techniques are contingent on the
quality and quantity of data used to develop such models and are reliant on
assumptions that should be carefully checked. In particular, the auxiliary data
sources must be chosen carefully as it is a key assumption of this approach.
As an example, Zhang et al. (2013) used data from the National Survey on
Children’s Health to directly calculate census block-group, state- and county-level
estimates of obesity prevalence. The investigators developed a statistical model
to produce obesity prevalence estimates and evaluated the estimates by compar
ing them to the directly measured estimates at the state and county level. Their
procedure showed good agreement at these higher levels, which provided some
degree of confidence that the census-block level estimates also were reliable.
Model-based (or “synthetic”) estimation is one approach that may help provide
information to local public health practitioners who need information pertinent to
their jurisdiction. This is a promising approach, but model development and inter
pretation of resulting estimates require statistical sophistication.
to adequately capture the range that exists. Similarly, the desire to obtain a
more precise estimate with less error would necessitate a larger sample size.
Although these concepts are not specific to obesity prevalence or trends,
they are reflected in statistical approaches present in published reports. The
sample size is a primary determinant of what population groupings and
what time periods are presented in the results of a published report. Sample
size also has implications for the public health significance of statistically
significant findings (see Box 5-5).

BOX 5-5
Statistical versus Public Health Significance
Establishing statistical significance in comparisons of obesity prevalence by

subgroup or over time is crucial in understanding whether such differences are
real. From a practical standpoint the following question arises: “Are differences or
changes meaningful to the health of a population?”
According to national prevalence data, between 1980 and 2012, obesity among
children ages 6 to 11 years has increased from 7 percent to nearly 18 percent and
from 5 percent to nearly 21 percent among adolescents ages 12 to 19 years (CDC,
2015b). If a consistent incremental increase is assumed (overall change in percent
age divided by number of years), the average increase per year is approximately
one-third of a percentage point among children and one-half of a percentage point
among adolescents. If obesity prevention and mitigation efforts are as effective as
the factors that led to increases in obesity, 2 to 3 years would be needed to see a
1 percentage point decrease. Recent studies, however, suggest that declines may
be even more gradual. Prevalence data from children ages 5 to 18 years in the
Philadelphia, PA, school district show a decline in obesity prevalence from 21.7 per
cent to 21.3 percent between 2006 and 2012 (Robbins et al., 2015). Similarly, data
on New York City public school students ages 5 to 14 years show a decrease in
obesity prevalence from 21.9 percent to 20.7 percent between 2006 and 2010
(Day et al., 2014). If a consistent incremental decrease is assumed, the average
decrease per year is one-fifth of a percentage point. Small sample sizes and few
years of available data will hamper efforts to detect small changes over time.
Sample Size and Population Groupings

Sample size typically limits the number and quality of obesity preva-
lence or trends estimates that can be derived from a single data source.
In an effort to describe population groups other than the entire sample,
investigators often create broad population groupings. As demonstrated
in Appendix D (see Tables D-4, D-5, and D-6), the groupings of partici-
pants are highly variable and often report-specific, even for seemingly basic
characteristics such as race and ethnicity, socioeconomic status, and age.
In spite of the variability that exists, subgroup comparisons are necessary
to understand the differences that exist within a population and for the
assessment of disparities (see Box 5-6).
The sample size can affect how participants are grouped. Across pub-
lished reports on obesity prevalence and trends, it frequently manifests
in categorizing race and ethnicity (see Appendix D, Table D-4), particu-
larly when stratifying by age groups and gender as well. This concept
can be illustrated by discussing NHANES, although it should be noted
that it occurs across data sources and published reports. As described in

BOX 5-6
The Importance of Subgroups: Assessing Disparities
Disparities affect marginalized groups that, by definition, are not the majority.
This has important implications when considering population estimates of obesity.
An estimate of prevalence that describes a broad population can mask what is
occurring in these smaller groups. Unless subgroup analyses are performed, dif
ferences can be missed.
An illustrative example of this is a report by Li et al. (2015), which evaluated
trends in overweight and obesity prevalence among Massachusetts school dis
tricts from 2009 to 2014. Although the analysis revealed an absolute change of
3 percentages point statewide (34.3 percent in 2009; 31.3 percent in 2014), sub
group analyses revealed that this change was not present in districts with median
incomes less than $37,000 per year, but it was in other income groups. Without
a subgroup analysis, this difference would have been overlooked.
Chapter 4, NHANES participants can select from more than 50 different

ethnic ancestry and origin options. However, published reports on obesity
prevalence and trends among children and adolescents using NHANES data
present estimates for only a limited number of race and ethnicity groups:
non-Hispanic white, non-Hispanic black, Hispanics (previously just Mexi-
can American),2 and more recently Asians (Freedman et al., 2006; Ogden
et al., 2012, 2014; Ver Ploeg et al., 2008). Because these categories also
are examined by sex and age group, further differentiation of the race and
ethnicity groupings would not lead to a stable estimate of obesity preva-
lence due to a sample size that is too small. Thus, the population categories
presented in a report do not necessarily reflect the level of detail captured
during data collection and often reflect analytic decisions guided by the
quantity of available data.
2 In early cycles of the continuous NHANES (1999-2006), participants identifying as
exican American, a subgroup of Hispanics, were oversampled. This approach led to an

M
underrepresentation of non-Mexican American Hispanics in the total sample, and results
in unstable estimates for non-Mexican American Hispanics and Hispanics at large during
these NHANES cycles (Johnson et al., 2013). Beginning in 2007, Hispanics collectively were
oversampled. This transition allowed for more stable estimates for the broad group designated
as “Hispanics” moving forward and continues to provide stable estimates for the Mexican
American subgroup. The sampling change, however, still does not allow for meaningful evalu-
ations of other Hispanic subgroups (CDC, 2013d).

Sample Size and Time Periods

When the sample size is not large enough to produce reliable estimates
for population group of interest, one method for improving the accuracy of
estimates is to combine or pool data collected across multiple years of the
same survey. Pooling data can help to increase the analytic sample, increase
the sample size of particular geographic area or subpopulation of interest,
and allow for an estimate of the change in prevalence over time (YRBSS,
2014). Combining multiple years of data will work best for characteristics
that are relatively stable over time and less well for characteristics that may
change from year to year (The Lewin Group, 1998).
Not all data from the same survey or surveillance system can be com-
bined in a meaningful way. When combining multiple years or cycles’ worth
of data, it is important to ensure the same question is asked in the same
way across different survey years with similar response categories; that
nationally representative survey data is not combined with state, territorial,
tribal or district data; and that advance statistical guidance is sought when
considering weighting strategies, combining weighted data from different
years, and estimating standard errors (AHRQ, 2009; YRBSS, 2014).
From an interpretation standpoint, the combination of multiple years
or cycles’ worth of data has advantages and disadvantages. By collapsing
years, investigators can calculate estimates for population groups they
would not otherwise be able to adequately characterize. However, pool-
ing data expands the time frame the estimate describes and can reduce the
number of points available for a trends analysis.
Determining Prevalence
Prevalence of obesity has been presented in published reports in several
formats. The simplest prevalence estimates are point estimates calculated as
the raw percentage of those in the sample who have obesity. These statistics
are common among reports in which reporting on obesity prevalence and
trends is not the primary purpose, but obesity is included as a demographic
characteristic. The generalizability of such an estimate depends on the rep-
resentativeness of the analytic sample. Interval estimates (e.g., 95 percent
confidence intervals) are often calculated for point estimates. If the sample
is a random sample of the population, then these estimates may be repre-
sentative of the population. In some cases, sample weights are used when
complex survey designs or missing data require their use to obtain estimates
that are representative of the population. In this case, the estimates are
termed “weighted estimates.” Standardization or adjustment of rates also
is used when multiple groups being compared have different risks of obesity

due to different distributions of risk factors (for example, one group may
have a different age distribution or sex distribution from another).
Published reports often present estimates of obesity prevalence for a
broad population group (e.g., children ages 2 to 19 years, national esti-
mates). Although this type of statistic provides a glimpse into what is
generally happening within a given population, the presentation of findings
in this manner can obscure variability in the data and how estimates may
differ among subgroups.
Assessing Prevalence Over Time

Published reports evaluating prevalence of obesity over time in a popu-
lation have approached the assessment in different ways. The number of
time points, the span of time represented by each time point, and the span
of time the trend represents vary across reports. The committee identified
three key considerations related to the assessment of prevalence over time
that informs the interpretation of a report: time frame included in the
analysis, the presentation of change, and changing trends.
The Time Frame Included in the Analysis

In general, with more time points, more precise and nuanced trend
estimates can be made. In the simplest case, with only two time points, only
linear trends can be examined. Often, the difference between the two points
is expressed as an absolute or relative change rather than being described
as a trend (see next section for difference between absolute and relative
change). With more time points, nonlinear (e.g., quadratic) and other types
of trend analyses are possible. The spacing of the time points also affects
the interpretation of trends analyses. For example, if a study has data from
years 2001, 2002, and 2010, then less information is available for the time
interval between 2002 and 2010 than between 2001 and 2002, and there-
fore results are somewhat speculative inside this interval. The starting and
ending years that the data were collected dictate the period of time that the
study can potentially be generalized to describe. Extrapolation of trends
beyond the time frame included in the analyzed data is not recommended.
Interpretation of trends can differ depending on the starting and end-
ing points of the data included in the analysis. One illustrative example
can be demonstrated with recent national reports on obesity trends among
children and adolescents. Using NHANES data, Skinner and Skelton (2014)
reported a significant increase in the prevalence of obesity between 1999-
2000 and 2011-2012 among children ages 2 to 19 years. In contrast, Ogden
et al. (2014), also using NHANES data, reported no significant change in
the prevalence of obesity between 2003-2004 and 2011-2012 among chil-

dren ages 2 to 19 years. Similarly, using a school-based, self-reported survey

data, Iannotti and Wang (2013) reported an increase in obesity among U.S.
adolescents between 2001-2002 and 2005-2006, but not between 2005-
2006 and 2009-2010. In isolation, these reports describe obesity trends
among children from different perspectives and at first pass appear incon-
gruous. However, in considering the time frames included in the analyses,
the findings across the reports appears to present different aspects of the
same overall trend.
In Chapter 2, a graph based on NHANES data was used to demon-
strate the national trends in obesity among children 2 to 19 years of age. It
is presented here again (see Figure 5-1), as it exemplifies several of the key
concepts related to the considerations related to the time frame. The date
ranges presented on the x-axis represents the different cycles of data collec-
tion. NHANES data collection originally spanned several years (i.e., 1971-
1974; 1976-1980; 1988-1994), but eventually became a continuous survey
in 1999, with data released in 2-year cycles. The first three data points
on the graph, therefore, encompass longer periods of time than the data
points from 1999 and later. Between 1982 and 1984, the H ispanic Health
and Nutrition Examination Survey was conducted in lieu of NHANES,
FIGURE 5-1 Trends in obesity among children and adolescents ages 2 to 19 years,
by sex: United States, select years 1971-1974 through 2011-2012.
NOTE: Obesity was defined as a BMI greater than or equal to the sex- and age-
specific 95th percentile from the 2000 Centers for Disease Control and Prevention
Growth Chart.
SOURCE: Fryar et al., 2014. Figure 2-1
R03028
raster/ not editable
sized to fit
and as such no nationally representative data were collected for these

years. Similarly, NHANES did not resume data collection after 1994 until
1999. Accordingly, the time period between 1980 and 1988 and between
1994 and 1999 represent two spans of time in which the trend between
time points were presumed to be linear. The data points from 1999 and
later offer insight into how the estimates based on uniformly spaced cycles
vary. It is clear that the change in obesity per year will vary significantly
depending on the start and stop points on the curve (e.g. the slope is rela-
tively flat from 1971-1980, with sharper increases 1999-2004). A rate of
change calculated from 1971-2012 would be greater than that calculated
from 2004-2012, highlighting the importance of the selection of start and
stop points for characterizing trends.
The Presentation of Change

Published reports have used both absolute and relative change to
describe how prevalence differs between two points in time. Absolute
change is independent of the baseline prevalence, and is defined as the sim-
ple difference between the two estimates of prevalence (i.e., Prevalence2 –
Prevalence1). Relative change, in contrast, is dependent on the initial value
and is expressed as a percentage relative to the first point in time [i.e.,
(Prevalence2 – Prevalence1) / Prevalence1 × 100]. Not all published reports
present both absolute and relative change. An understanding of which type
of changes is being presented is fundamental for proper interpretation, as
the two are not interchangeable. A report by Gee et al. (2013) serves as an
illustrative example of how absolute and relative change describe the same
data in different ways. The investigators estimated the prevalence of obesity
among children ages 2 to 5 years who participated in an integrated health
care delivery system to be 11.3 percent in 2003 and 10.0 percent in 2010.
The investigators presented the absolute change as a 1.3 percentage point
decrease (i.e., 10.0 – 11.3 = –1.3) and the relative change as 11.5 percent
decrease [i.e., (10.0 – 11.3) / 11.3 × 100 = –11.5].
The difference between absolute and relative change also can be con-
sidered from the perspective of number of individuals affected. Figure 5-2
visualizes two hypothetical scenarios—one in which the initial prevalence
is moderately elevated (50 percent; Scenario 1) and one in which the initial
prevalence is particularly low (3 percent; Scenario 2). The absolute change
of the two scenarios is equal (i.e., 2 percentage points), but the relative
change is very different (i.e., 4 percent and 67 percent), highlighting the
importance of the initial prevalence in interpreting the relative change.
Additionally, the population size is an important consideration. When the
population is of identical size across the two scenarios (i.e., 1,000/1,000),
the same number of individuals would have changed weight status between

Percent of Population That Has Obesity
a
FIGURE 5-2 Two hypothetical scenarios illustrating the difference between abso-
lute and relative change with varying population sizes.
a The two numbers represent the population size for Scenario 1 and Scenario 2,
respectively.
Time 1 and Time 2 (i.e., 20 individuals). Increases or decreases in the

population—either across scenarios or across time points—can greatly alter
the meaning. Sample size at both time points, therefore, is key information
for interpreting estimates of change.
Changing Trends
Given the efforts dedicated to treating and preventing obesity, it is
expected that the trend line will change slope and eventually change direc-
tion in the years ahead. From a statistical standpoint, the change in trend

can be assessed in different ways. Statistical hypothesis testing and con-

struction of confidence intervals (CIs) are two closely related tools that are
often used to assess whether trends are changing.3 Statistical hypothesis
tests are used to evaluate a hypothesis (e.g., a null hypothesis of no change
in obesity prevalence over a specified 10-year period), and test results are
often summarized using a test statistic and p-value, with p-values <0.05
(indicating the almost ubiquitous 5 percent level of significance) most
often deemed statistically significant and leading to rejection of the null
hypothesis in favor of the alternative that obesity may indeed be changing
with time. CIs are often used to indicate the precision associated with an
estimate, with wider intervals indicating greater variability in estimation.
The 95 percent CI, which is closely aligned with a 5 percent significance
level in hypothesis testing, is by far the most common type of CI used.
For example, an estimated prevalence of 26 percent with a 95 percent CI
of 25 to 27 percent would be more precise than a 95 percent CI of 20 to
32 percent.
Joinpoint regression analysis is another technique that has been used to
assess whether trends are changing (Kann et al., 2014; Pan et al., 2012).4
The general concept of joinpoint regression is to test whether a meaningful
(i.e., statistically significant) change has occurred in the slope of a trend line
for obesity prevalence estimates beyond that that could occur by chance.
This test is helpful in detecting whether a previously increasing trend has
flattened or changed into a decreasing trend. Generally, joinpoint analysis
requires a relatively large number of time points and so is more relevant for
studies across many years rather than studies with data from only a small
number of years.
Comparative Evaluations
Comparative evaluations have been used to identify groups at dis-
proportionate risk of obesity. These groups may represent those in most
need of intervention or population groups that may need different types of
intervention. The committee identified three common types of comparison
that exist: comparisons of population groups within a report, comparisons
across reports, and comparisons to NHANES. Consistent with its task,
the committee also provides guidance for comparing obesity trends among
diverse populations, both within and between reports (see Box 5-7).
3 For additional information on these concepts, see “Principles of Biostatistics” (Pagano
and Gavreau, 2000).

4 For additional information on joinpoint, see Kim et al. (2000) and NCI (2016).

BOX 5-7
Guidance for Comparing Obesity Trend Estimates
As part of its charge, the committee was asked to consider approaches to

evaluating differences in trends among diverse population groups. It offers the
following guidance:
Person
• Adequately characterize the populations within each study or population sub
groups in a single study to understand what groups are being compared.
— Consider what characteristics are defining the groups, how the data for
those characteristics were collected, and how those data were categorized.
• Ensure a sufficient sample size in each subgroup to allow precise estimates
of trends.
— Wide confidence intervals (CIs), use of multiple years’ or cycles’ worth of
data for a single data point in the trend analysis, and broad subpopulation
groupings are indicators that the sample size may have been small.
Place
• Clearly define and consider characteristics of the geographic areas repre
sented by different study populations when comparing across reports.
— Consider whether the populations included in the analyses represent a spe-
cific level of geography (national, state, regional, local). If possible, consider
the similarities and differences of the geographic areas being compared.
Time
• Include at least three data points for each population over time.
— The difference between two points in time (change) does not always pro-
vide a clear picture of how prevalence is changing in a time period.
• Assess and account for demographic shifts over time.
— Changes in the underlying population over time can change the meaning
of trends estimates. Statistical adjustments can be made to account for
demographic shifts.
• Ensure that the time frame and intervals used in the analyses are as similar
as possible, if not identical.
— The meaning of trends estimates is bound by the beginning and end date
included in the analyses.
Analytic Approaches
• Ensure that the analytic approach is consistent across each of the time points
within a study and is comparable across reports.
— Consider what data processing procedures and what statistical tests were
performed. Ensure that the reference population(s) used to define obe-
sity among children is comparable across studies. Recognize that use
of different reference populations (e.g., Centers for Disease Control and
Prevention, International Obesity Task Force, World Health Organization)
can lead to different estimates of obesity prevalence, and are therefore
not interchangeable. Ensure the classification criteria are the same across
reports and population groups of interest.

Comparing Population Groups Within a Report

When comparing subgroups of subjects in the same study, it is impor-
tant to consider the subsample size and whether the same measurements
and data collection techniques were applied in all subgroups. The precision
of estimates is based on the sample size. When the sample size prevents a
precise estimate, valid comparisons cannot be made. Another important
consideration is that of misclassification of subjects in some subgroups but
not in others, although, without having access to the raw data, it is difficult
to ascertain the extent of misclassification within a given published report.
Comparing Across Reports

Several considerations impede comparisons between the results of one
study to those of another. Design, sampling, and measurement issues are at
the forefront of these considerations. Ideally, the studies should have been
performed during the same time period in order to avoid the problem of
secular changes that may apply to one but not both populations. The design
and the inclusion and exclusion criteria should be the same in both studies
in order to permit valid comparisons between studies. Similarly, the age,
sex, racial, and ethnic composition of two populations should be the same
to allow meaningful comparisons. Regional and geographic differences
can also compromise comparisons between populations to the extent that
such differences are present. Additionally, measurement issues emerge when
comparing two populations. As discussed in Chapter 3, the comparabil-
ity of directly measured and self- or proxy-reported heights and weights
is limited. If different measurement tools are used without providing the
necessary calibrations and conversion factors, then the study results cannot
be meaningfully compared.
Comparing Reports to NHANES

Published reports have used NHANES estimates as a comparator for
statistics derived from a different dataset. Shustak et al. (2012), for exam-
ple, compared the prevalence of obesity among patients with and without
congenital and acquired heart disease to obesity prevalence from NHANES
data. Both datasets based BMI on directly measured height and weight and
defined obesity as having a BMI at or above the 95th percentile on the
2000 CDC sex-specific BMI-for-age growth charts. Shustak et al. aligned
the population groupings with NHANES in sex and age categories (2 to 5,
6 to 11, and 12 to 19 years). Data were collected over a similar time period
(2005-2006 for NHANES versus 2006 heart disease sample). Another pub-
lished report compared obesity prevalence in a sample of Special Olympics

participants to NHANES obesity prevalence estimates (Foley et al., 2014).

In this report, the investigators used directly measured heights and weights,
defined obesity as having a BMI at or above the 95th percentile according
to the 2000 CDC BMI-for-age growth charts, and aligned data collec-
tion years. However, because participants cannot be enrolled in Special
Olympics until age 8 years, age categories were 8 to 11 years and 12 to 17
years, whereas the NHANES analysis categorized ages as 6 to 11 and 12 to
17 years. These examples illustrate that alignment of available demographic
characteristics, data collection methodologies, and years included serve as
the foundation for considering such comparisons.
Similarities of study results with NHANES results should not be used
as an indicator of the validity of those results, as NHANES results repre-
sent the average estimate (or central tendency measure) for the entire U.S.
population, and have been known to mask levels or trends that vary in
some regions or parts of the country or among demographic groups that
may not be represented adequately in national samples.
SUMMARY
Estimates of obesity prevalence and trends reside in published reports
with a variety of purposes. The published report’s purpose can provide
insight into why a data source was selected and why specific analytic deci-
sions were made. A range of analytic decisions affect the interpretation of
the resulting statistic of obesity prevalence, change, or trend, and occur
both in the preparation of the data and the statistical analysis of the data.
In preparing the data, investigators must classify obesity status, and can
elect to identify BIVs and evaluate the representativeness of the data source,
as appropriate. For children, adolescents, and young adults, the 2000 CDC
BMI-for-age growth charts are most typically used, but others exist, such as
the IOTF cut points and the WHO growth charts. Use of different reference
populations can lead to different estimates of obesity prevalence. A range of
different methods exists for identifying and handling BIVs across published
reports, which can affect estimates of obesity prevalence. Potential sources
of bias related to the population in a dataset can be assessed through the
study design, response rates, and amount of data that are missing. Weighting
a sample is one approach to correct for imperfections in sampling, account
for non-response, and better represent the target population described by the
estimates, although not all datasets will need to be weighted.
The statistical analysis that produces an estimate of obesity prevalence
or trend is guided by the analytic sample size and the interpretation of the
estimate informed by the population groups and the time points it encom-
passes. The analytic sample size determines what statistical procedures and
comparisons can be meaningfully conducted. Prevalence estimates that

encompass diverse population groups may not adequately describe the vari-
ability that exists within the subgroups it contains. The time frame used
in trends analyses is crucial to interpreting the findings. Analyses using the
same data source but different time frames can reach different conclusions.
Ample sample size, similar data collection methodologies, and adequate
characterization of population groups facilitate the ability to compare obe-
sity prevalence and trends estimates across subgroups and between reports.
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Framework for Assessing

to Inform Decision Making
Key Messages
• The committee offers a conceptual framework to aid end users
in assessing published reports on obesity prevalence and trends
for the purpose of informing decision making.
• The Assessing Prevalence and Trends (APT) Framework guides
end users to assess reports in the context of their intended use
and application of the evidence.
• To interpret estimates of obesity prevalence and trends, the end
user needs to assess the population included in the study, the
data collection methodologies, and the analytic procedures.
To apply those findings for decision making, end users need to
weigh the strengths and weaknesses of the report in relation
to their specific goal.
The variation that exists in the methods, data sources, and analytic
approaches used to estimate obesity prevalence and trends has made navi-
gating and understanding the literature challenging. Interpreting estimates
requires attention to the details, nuances, and caveats of published reports.
Evaluating studies for the purpose of informing a decision requires more
than just deciphering what the statistics represent. Appropriate application
of reports involves considering how the parameters of the estimate align
with a specific information need.
161

This chapter presents a conceptual guide to assist those seeking to

better understand and use published estimates of obesity prevalence and
trends. Two important concepts are integrated into this tool. The first is the
committee’s synthesis of the evidence presented in the preceding chapters. In
considering how to facilitate the interpretation of estimates, the committee
defined three interdependent, core components of a study: the individuals
assessed (“population”), the data collection methods employed (“methodol-
ogy”), and the analytic approaches used (“analysis”). The second concept
focuses on the policy makers, program planners, and others who use reports
on obesity to inform decision making (“end users”). As discussed below,
these end users have different and often specific information needs.
END USERS OF OBESITY PREVALENCE AND TRENDS REPORTS

Prevalence and trends reports provide insight into the scope and status
of obesity within a defined population. This type of information is funda-
mental to understanding and describing the issue, and often serves as a key
piece of evidence used to inform decisions related to policies, strategies,
advocacy, funding, programs, and other plans for forward progress.
Potential end users of obesity prevalence and trends reports encompass
a broad range of individuals, groups, and organizations that operate at the
national, state, regional, and community levels (see Box 6-1). They come
from a variety of sectors, including various levels of government, com-
BOX 6-1
Examples of Potential End Users of
Obesity Prevalence and Trends Reports
• State and local health departments

• Elected officials, state legislatures
• Community-based organizations
• Departments of education, school districts, and schools
• Public agencies (e.g., transportation, planning, parks and recreation)
• Nonprofit and philanthropic organizations
• Advocacy organizations
• Academic researchers and other data generators
• Health care providers
• Health care payers
• Private sector
NOTE: The list is not intended to be exhaustive, but rather illustrative of the range
that exists.

FRAMEWORK FOR ASSESSING PREVALENCE AND TRENDS IN OBESITY 163
munity organizations, schools, health care organizations, and the private

sector (IOM, 2013). Interest in obesity, however, is wide ranging because
its determinants are broad and extend well outside the traditional sphere of
health. A host of seemingly tangential decisions can have an impact on the
obesity status of a population and may be informed by the obesity litera-
ture. These could include, but are not limited to, decisions about education
and assistance programs (IOM et al., 2009).
Specific Information Needs

Prevalence or trend estimates describe obesity in a particular popula-
tion. An estimate for individuals identifying as Asian, for example, repre-
sents the collective prevalence in this group but does not necessarily reveal
differences that may exist among subgroups that fall under this broad cat-
egory (e.g., by age, by geographic area, by racial or ethnic origin groups).
Similarly, a nationally representative estimate that describes the country as
a whole encapsulates the variability within each state, region, and commu-
nity. Prevalence at different levels of geography (region, state, and locality)
will inherently fall above and below a broad national estimate.
Identifying the boundaries of an estimate is necessary for both proper
interpretation and appropriate application. When using published reports
for decision making, end users must seek estimates that are not only of
the highest quality, but also most closely aligned with their own goals or
information needs. Box 6-2 provides illustrative examples of the need for
and uses of specific and relevant estimates, from the perspective of end users
at the local level. Ideally, reliable, representative, comparable, and current
estimates would exist for a wide range of groups at the national, state, and
local level. At present, however, select groups and populations are better
represented in published reports than are others. Many reasons exist for
this, with a prominent one being that investigators who design and con-
duct obesity prevalence and trends studies face limitations with respect to
purpose, feasibility, cost, time, and sample size. Investigators must decide
which groups to include and what information will be used to establish
those groups. As such, the extent to which available analyses meet the exact
information needs of end users will vary.
ASSESSING PREVALENCE AND TRENDS (APT)

FRAMEWORK: INTERPRETING OBESITY
REPORTS TO INFORM DECISION MAKING
To help end users interpret and apply estimates, the committee offers
the Assessing Prevalence and Trends (APT) Framework (see Figure 6-1).
The proposed framework provides a conceptual process for how end users

BOX 6-2
Need for and Uses of Data at the Local Level
On July 28, 2015, the committee convened a public workshop. The quotes
below highlight key concepts conveyed by invited speakers about the need for
and uses of data relevant to the local end user.
“a problem is that the local perception of obesity or a target may not match
that of a national perception or a national standard.” (Ricketts, 2015)
“We are trying to look at obesity on a very local level, county-based level.
For us, that is a huge challenge. And the national level estimates do us little
good. . . .” (Pivec, 2015)
“local, community-based efforts need to be supported by available trend data

to reduce resource waste . . . when there [are] no trend data available, local
communities tend to reinvent the wheel, which really ends up being a waste
of many, oftentimes scarce, resources.” (Pronk, 2015)
“Here are some examples of how [local Youth Risk Behavior Survey] data
are being used by a couple of our cities. Chicago is supporting an updated
district-wide policy requiring daily physical education for all of its students.
San Diego is using its obesity data to help school nurses understand the
purpose and need for the district’s new wellness policy.” (Kann, 2015)
can approach published reports, consider the strengths and weaknesses

of obesity estimates, and synthesize the information for the purposes of
decision making. The assessment process is separated in to three phases:
(1) end user’s identification of goal or information need, (2) assessment of
published report(s), and (3) end user’s synthesis to inform decision making.
Driving the assessment are questions related to each of the framework ele-
ments. An expanded list of questions is provided in Table 6-1.
Phase 1: Identify the Goal

In the first phase of the framework, end users identify their goal for
assessing the published report(s). This includes a consideration of the deci-
sion to be made as well as the need for additional information to fill a gap
in the evidence. Being clear about their goal is intended to help end users
determine the utility of the findings presented in a report in light of their
unique information needs.
End user goals will vary in depth, complexity, and specificity. Some
goals may be relatively narrow, focusing on the estimates included in the

FIGURE 6-1 The Assessing Prevalence and Trends (APT) Framework: Interpreting Obesity Reports. Assessment of published reports
to inform decision making is contextually framed in the end user’s intended use of the findings.

a Population refers to individuals assessed in the report.
b Methodology refers to all the elements related to study design and data collection.
165
c Analysis refers to all elements related to data processing, cleaning, and statistical analysis.
TABLE 6-1 Expanded List of Questions End Users Can Use to Guide
Assessment of Published Reports to Inform Decision Making
Framework Framework
Phase Element Potential Questions
End User’s Identify Goal • What type of information about obesity prevalence or
Goal trends do you not currently have?
• What additional information do you need to make an
informed decision?
• If you are unable to find a report matching your exact
information needs, can you prioritize which component
of a report is most important to you: (1) the population
represented, (2) the method used for data collection, or
(3) the type and rigor of the analysis?a
Assessing Population • What population groups and subgroups were included in

Published the report?
Reports — How were people selected to be in the study?b
— Were any groups or subgroups explicitly excluded?c
— How many people were in each group and subgroup?c
• Do the people in the study represent a broader
population group or a specific geographic area?c
• If describing change or trends:
— Were the people evaluated at each point in time the
same or different?
— Was the broader population relatively the same over
time, or did it change?
Methodology • In what settings were data collected (e.g., school, public
health program)?d
• How were height and weight data collected?
— If directly measured:
o What procedures and equipment were used?
o Who collected the data and what was their level of
training?
— If someone reported the height and weight data
without direct measurement:
o What was the phrasing of the question(s) used to
collect the data?
o Who was asked to report the height and weight
data (self-report or proxy-report)?
o Was the information collected in person, on a
website, or by telephone?
• What additional demographic data were collected?d
— What measures were used?
— What response options were provided to the
participants?

TABLE 6-1 Continued
Framework Framework
Phase Element Potential Questions
Analysis • How was obesity status classified?
— What growth chart and/or cut point were used to
classify obesity?
• Were extreme values in height, weight, and/or body mass
index assessed?b
— What criteria were used to identify the extreme values?
— Were the extreme values included or excluded from
the final obesity estimates?
• Was the potential for bias assessed (e.g., response rate,
missing data)?
• Were estimates of obesity prevalence for subgroups
presented?d
— How were groups defined?b,d
— Were any groups combined or eliminated due to
sample size?d
• Do the prevalence estimates appear stable (e.g., width of
confidence intervals)?e
• If prevalence was assessed over time:
— What beginning and end dates were included in the
analysis?
— How many time points were data collected?
— Were multiple cycles of the data combined in the
analysis?
— Is relative or absolute change presented? If so, is the
sample size also presented?
— Were changes in trends assessed?
End User’s Weigh • Do the number and magnitude of the strengths outweigh
Synthesis Strengths and the weaknesses, relative to your overall goal?
to Inform Weaknesses • How do the strengths and weaknesses of the report relate
Decision to your prioritization of the three core report elements?
Making
End User • Does this published report enhance your understanding
Interpretation of the prevalence and/or trends in obesity in your
population of interest?
• After assessing the report, what additional information
about obesity prevalence and/or trends do you need to
inform your decision?
NOTES: The provided list is intended to facilitate the assessment process. The list of questions
is not exhaustive, and the relevance of each question will depend on the report being assessed
and the end user’s goal.
a End users may prioritize population, methodology, and analysis differently, depending on
their particular overarching goal. For example, end users may rank finding a population that
most closely resembles their population of interest higher than methodologic and analytic ap-
continued

TABLE 6-1 Continued
proaches. Others may specifically be seeking information collected through direct measure, or
find an analysis that uses a similar statistical approach.
b Pertinent to the methodology framework element, as well.
c Pertinent to the analysis framework element, as well.
d Pertinent to the population framework element, as well.
e Reports based on “census-level” data may not present confidence intervals, as the estimate
is thought to reflect the actual prevalence in the population.
published reports. For example, an end user may simply want to know
what can be said about a single estimate describing a certain population
group. Although implicit in the use of the framework, this goal represents
a fundamental and common challenge shared by a wide range of end users.
This goal may also serve as a starting point for using the framework in an
iterative, stepwise manner, progressively moving toward a more complex
goal (see Box 6-3). Other report-centric goals may be comparative in
nature. For instance, an end user may have multiple reports providing dif-
ferent estimates for the same population and may need to decide which, if
any, provides the strongest evidence. The end user goal can also be broad
in nature, with the obesity estimates serving as one piece in a wide range of
evidence being weighed. For example, those designing strategies to address
health disparities in a given population may include obesity as one of the
health outcomes being considered. In this scenario, the broad goal would be
determining what strategies should be developed, and the obesity literature
would be used to assess the existence of disparities in weight status. This
goal may be further refined by the characteristics defining the population
of interest. For instance, one end user may be focused on rural families in
a town on the U.S.–Mexico border, while another may be concerned with
young adults in a large metropolitan area in the Northeast. Despite the
overall goal being the same for these two end users, the specific informa-
tion they will need to inform their decision will be significantly different.
A balance must be struck during this initial reflection. Personal interests
and objectives can influence how information is processed and conclusions
are drawn (Tversky and Kahneman, 1974). End user goals that seek to
“justify” or “prove” a particular point of view can bias the identification
of reports and interpretation of findings. The purpose of end users identify-
ing their own goal or need for information at the outset of the process is
done so as not to cloud judgment or lose objectivity, but rather to define
the boundaries for the assessment.

BOX 6-3
Hypothetical Example: Iterative Use of the APT Framework and
Progressively More Focused End User Goals
A group of parents have contacted the school superintendent regarding con

cerns they have for their middle school-aged children. The parents note that
although they have seen positive changes in the school nutrition and physical
activity policies, they remained worried that obesity prevalence remains high. The
superintendent brings the matter to the attention of the school wellness commit
tee. In considering how to respond to the parents, the committee decides to draw
evidence from published reports. The committee identifies 13 studies published
in the past 10 years that have assessed obesity prevalence and trends among
middle school-aged children. The wellness committee decides to use the APT
Framework in an iterative, stepwise fashion to structure their thinking.
First Pass Through the APT Framework
Because the committee is comprised of members that have diverse back

grounds and levels of comfort with published literature, they recognize that the first
decision they need to make is: “What can be said of each report?” They review
each report separately and the committee determines the groups and subgroups
included in the report, the type of data collected and measurement used, and how
estimates were developed.
Second Pass Through the APT Framework
The wellness committee recognizes stark differences in the populations and

subpopulations included and in the data collection methodologies and analytic
methods used in each of the 13 reports. In the second round of using the APT
Framework, their overarching goal is to determine what is the strongest evidence
related to the students that most closely reflects their own middle school students.
For the purposes of this decision, the committee agrees that their priority is to
focus on the reports with a study population that most closely resembles their own
schools, followed by the data collection methodology, then analytic procedures.
Third Pass Through the APT Framework
After the second pass through the APT Framework, two relevant reports
remain. One report describes the trends in obesity prevalence from 2003 to 2011
using proxy-reported, repeated cross-sectional data. The estimates are presented
for the entire state, by grade level (3, 5, 7, and 9), and by three race and ethnic
ity categories (Hispanic, white, other). The second report describes the weight
status of students enrolled in grades 6, 7, and 8 during the 2012-2013 school
year, and is based on directly measured data. The estimates represent a larger
and more diverse school district in a different region of the state. Estimates are
presented by grade level, but not by race and ethnicity subgroups. The wellness
committee establishes a new overarching goal: determine whether any initiative or
changes they are considering should initially focus on one grade or if they should
be applied more broadly. They use the remaining two studies to consider how the
prevalence differs across the different grade levels.

Phase 2: Assess Published Reports

In the second phase of the assessment process, end users evaluate the
published report(s). The three core components of a report (population,
methodology, analysis) inform the interpretation of the estimate. The pre-
vious chapters’ discussions of considerations associated with study design,
data collection, specific data sources, and analysis are intended to facilitate
such an appraisal (see Chapters 3 through 5). The dynamic assessment of
these three components in context of each other provides a means for end
users to consider how the approach taken in one may have benefited or
limited one or both of the other components. By the end of the assessment
of the published report, end users should clearly understand the parameters
associated with the estimate.
Phase 3: Synthesize Findings to Inform Decision Making

In the final phase of the assessment process, end users turn back to their
goal in order to synthesize and interpret the report(s) findings in context of
their information needs for decision making. To accomplish this, end users
first weigh the strengths and weaknesses of each report. The end user is
encouraged to consider the strengths and weaknesses generally at first, then
in relation to their specific information needs and decision-making priorities.
End users will categorize the same feature of the report differently,
depending on their overall objective and the data gap they are trying to fill.
For example, some end users would consider state-representative samples a
strength of a report, while some end users at the community level may view
this parameter as a weakness for their particular decision-making process.
Once the end user has established what the strengths and weaknesses are,
they then determine how the findings inform their decision.
In most instances, the report(s) on obesity prevalence and trends will
only be one of many sources of information considered when making a
decision. The extent to which such additional information is used in the
decision-making process, however, should not detract from the importance
of the concepts presented in the APT Framework.
UNDERLYING PRINCIPLES OF THE FRAMEWORK

The APT Framework is a conceptual guide intended to serve as a start-
ing point for those who wish to better understand and apply published
reports and brings together considerations specific to the assessment of
obesity status and general to any prevalence and trends study. It is grounded
in six underlying principles discussed below and summarized in Box 6-4.

BOX 6-4
A Summary of the Underlying Principles of the APT Framework
1. The APT Framework can be used both for assessing individual reports and for
synthesizing multiple reports.
2. A variety of end users can use the APT Framework.
3. An end user’s goal informs the application of any report or reports.
4. The three core components of a published report are interdependent.
5. Questions lead the end user through the assessment process.
6. The APT Framework facilitates an assessment of the evidence to inform the
decision-making process.
The APT Framework Can Be Used Both for Assessing

Individual Reports and for Synthesizing Multiple Reports
The committee used the word “report” to describe a publication, peer-
reviewed or otherwise, with original analysis that produces estimates of
obesity prevalence or trend for a defined population group and/or sub-
group. Some reports, especially at the state and local level, are summaries
of primary analyses and may not contain the detail needed to adequately
assess the findings. In these instances, end users are advised to identify and
review the primary source of the results, if possible.
The APT Framework guides an end user through the assessment thought
process. The number of reports assessed and how they are evaluated through
the APT Framework will depend on the end user and the availability of
reports related to the end user’s goal. In some instances, the framework
would be used to assess a single report. In other instances, as described
in Box 6-3, an end user can start by using the framework to identify the
parameters that affect the interpretation of the individual estimates, then
progressively consider them together. In practice, a broader assessment of
multiple reports would bolster decision making. However, given the limita-
tions of the current state of the literature, the committee recognizes that
pertinent information may only reside within a single report for certain end
users’ goals.
A Variety of End Users Can Use the APT Framework

End users are varied and are not limited to obesity stakeholders. A wide
range of individuals, groups, and organizations may need to refer to preva-
lence and trends reports for decision making (see Box 6-1). It is anticipated
that end users will have various backgrounds and expertise. The intent of

the framework is to provide a range of end users with sufficient guidance

on the elements that affect the interpretation and application of estimates,
while remaining general enough to accommodate the diverse literature and
the broad array of decisions that may be informed by obesity prevalence
and trends reports. Box 6-5 describes the skills end users may need using
the APT Framework.
An End User’s Goal Informs the Application of Any Report or Reports

Reports on obesity prevalence and trends are generally designed to
address a specific set of questions within a defined set of parameters. The
estimates presented in reports are guided not only by the question the
report’s authors sought to answer, but also methodologies used and ana-
lytic limits of the collected data. The APT Framework directs the end users
to further this line of thinking and reflect on the type of information that
is needed to ultimately inform their decision making. An end user’s goal
need not directly align with the stated purpose of a report for that report
to offer the end user valuable information. Clearly defined goals can help
end users identify reports for assessment, and can help them prioritize and
BOX 6-5
End User Skillset and Use of the APT Framework
Given their diverse range of expertise and backgrounds, end users’ level of
comfort with reading and interpreting published reports will vary. For some, the
concepts described by the APT Framework are basic and would merely serve as
a starting point for an in-depth assessment. For others—especially those who do
not have advanced training in research methods, epidemiology, or statistics—
some of the concepts may be novel. The APT Framework is meant to serve as
a common ground for all end users, and is intended to help them recognize and
contextualize key elements that inform the interpretation of estimates in a sys
tematic way. End users can use the framework to the extent that it enhances their
understanding of a published report.
Some central skills are implicit in the use of the APT Framework. It is expected
that end users are able to:
• F ind reports that are potentially applicable to the decision they are trying to
make.
• Locate pertinent information, which may reside in different locations across
reports.
• Make judgment calls when available evidence is equivocal or seek additional
guidance for clarification.

weigh the core components within a report (see below) or across a set of
reports (see above).
The Three Core Components of a Published Report Are Interdependent

Three core components in a report inform the interpretation of an
obesity prevalence or trend estimate: the population assessed, the meth-
odologies employed, and the analysis approach used. As discussed and
demonstrated throughout the preceding chapters, these components do not
exist or operate in isolation. A decision made in one of the components can
affect either or both of the other components. The assessment of reports
on obesity prevalence and trends necessitates a fundamental understanding
of each of these components in relation to the others. As such, appraisal
of the population, methodology, and analysis is not a linear process, but
rather is dynamic and iterative.
Questions Lead the End User Through the Assessment Process

The APT Framework illustrates the conceptual process of assessing a
study’s applicability to a decision-making goal. In each of the phases of the
APT Framework, the end user is prompted to consider pertinent questions
to ask, as represented by the lower portion of the visual. The questions that
appear on the figure itself serve as a starting point. Table 6-1 provides an
expanded list of potential questions that end users can use to guide their
assessment. The list of questions presented in this chapter is by no means
prescriptive or exhaustive. End users may find some of the question more
relevant to their specific information needs than others, and as they are
thinking through the evaluative process may develop questions of their
own.
The APT Framework Facilitates an Assessment of the

Evidence to Inform the Decision-Making Process
In the first phase of the framework, identification of end user goal
grounds the assessment in the specific information need. The second phase
of the framework helps the end user understand the bounds of an estimate.
The final phase brings the first two phases together, and the end user consid-
ers how that estimate compares to the information being sought. By using
the end user’s goal to contextually frame the assessment process, the APT
Framework highlights the interface between reading a report for meaning
and using the findings for a specific application. This concept is further
explored in the example presented in Box 6-6.

BOX 6-6
Hypothetical Example: Use of the APT Framework
The following section uses a hypothetical example to illustrate how the APT
Framework could be used to assess and interpret multiple reports.a In this sce
nario, the end user seeks evidence to assist in guiding a state allocation of funding
to counties for childhood obesity prevention funding.
The Director of the Office of Community Health (JD) at a State Depart

ment of Health located in the southwestern region of the United States
is approached by a group of local legislators who want to see their leg
islative districts receive more funding for childhood obesity prevention
grants during the coming fiscal year. This group of legislators represents
largely urban counties with socioeconomically and ethnically diverse
populations. The legislators have ordered Director JD to appear in front
of the State Assembly to answer questions related to what is known
about obesity prevalence in different parts of their state. They are par
ticularly interested in this problem for preschool children because they
have heard that more children entering kindergarten are now obese
than was true a decade ago. Director JD is concerned that legislators
who represent rural counties could legitimately criticize prioritization of
childhood obesity prevention grants for predominantly urban counties
as being biased and not based on current knowledge about prevalence
of obesity in the State. Director JD has received anecdotal evidence
from directors of some rural childcare centers about a growing problem
of obesity among preschool children.
Use of the APT Framework
End User’s Identification of Goal
The overarching goal for Director JD is to determine whether the prevalence

of obesity among preschool children may be equally high in both rural and urban
counties across her state. She identifies three reports published by r esearchers in
the state. She also finds a data brief from the National Center for Health Statistics
that estimates that 8.9 percent of children age 2 to 5 years are obese, based on
2011-2014 National Health and Nutrition Examination Survey (NHANES) data
(Ogden et al., 2015). She considers NHANES estimates a gold standard for nation
ally representative data, and decides to use it as a comparative benchmark for the
reports she is assessing through the APT Framework.
• S tudy 1 assesses the magnitude of overweight and obesity and associated

sociodemographic characteristics among preschool children residing in the
largest city in the state, which is not only diverse but is also bordered by a few
rural communities with many low-income families.
• Study 2 seeks to assess the relationship between the history of antibiotic use
and obesity in a cohort of pediatric patients at a private health care network in
the state.

• S
tudy 3 uses height and weight data collected from preschool children enrolled
in the state’s Special Supplemental Nutrition Program for Women, Infants, and
Children (WIC) to assess change in childhood obesity prevalence.
Assessing the Published Reports
JD considers the three core components (population, methodology, analysis)

for each report.
Population Study 1 is a cross-sectional study based on data collected in the fall

of 2007. The convenience sample consists of 270 preschool (ages 2 to 5 years)
children recruited from communities in and around the largest metropolitan area
in the state. The socioeconomic environments of the participants are character
ized and used in the analysis. The study does not include children from nearby
rural communities, thus making it impossible to evaluate urban-rural differences
in obesity prevalence.
Study 2 is used the electronic health records (EHRs) of 3,580 children ages 2
to 10 years who received pediatric care at a large private health care network in
the state. JD recognizes that the sample represents only those who make use of
that specific health care network and encompasses a wider age range than her
specific population of interest.
Study 3 is a repeated cross-sectional study that evaluated obesity status by
sampling administrative data from the state WIC program to assess change in
obesity prevalence among child participants (ages 2 to 4 years). Two time points
were assessed: 2010, which had 3,542 child participants, and 2014, which had
2,773 child participants.
Methods Study 1 uses proxy-reported heights and weights to assess obesity

status. Community socioeconomic status, defined as percent of people living at
or below the federal poverty level, and demographic characteristics are used to
assess differences in obesity prevalence.
Study 2 uses the directly measured heights and weights obtained by clinical
staff and documented in the child’s EHR. The number of antibiotic prescriptions
prescribed to the child before the most recent height and weight measurements
is used to estimate cumulative exposure to antibiotics. The report does not dis
cuss measures of socioeconomic status or provide information about where the
children reside.
Study 3 uses the directly measured height and weight data among children
ages 2 to 4 years enrolled in WIC. Given the income criterion for WIC, all partici
pants of the study are considered to be low-income.
All studies use the 95th percentile on the 2000 Centers for Disease Control
and Prevention sex-specific body mass index-for-age growth charts to classify
obesity status.
Analyses Study 1 presents obesity prevalence as a count and a percentage
continued

BOX 6-6 Continued
of the sample. Prevalence statistics are presented by sex, two race and ethnicity
categories, and two categories of socioeconomic status. The investigators note
that they did not detect a statistically significant difference in the prevalence of
obesity between any of the groups.
Study 2 constructs a statistical model to determine the risk of obesity in rela
tion to antibiotic exposure. Obesity prevalence is presented as a demographic
characteristic.
Study 3 weights the samples to reflect demographic characteristics of the
state’s WIC population in 2010 and 2014. The prevalence estimates and 95 per
cent confidence intervals (CIs) are constructed and presented along with absolute
and relative change between the two time points. Only estimates for the entire
state are provided.
End User’s Synthesis and Interpretation
Study 1 reports that preschool-aged children living in socioeconomic disadvan

taged areas of the large metropolitan area have a similar prevalence of obesity
compared to those living in more advantaged areas (15 percent versus 16 per
cent). The study evaluates the age group of interest to JD and provides insight
into socioeconomic characteristics. However, the participants are selected as a
convenience sample, the data are nearly a decade old, and the report does not
indicate that the representativeness of the sample in relation to the entire metro
politan area was assessed. Furthermore, the height and weight data are based
on proxy-report, which has the potential to bias obesity prevalence statistics.
Study 2 finds no relationship between obesity status and antibiotic use among
the assessed children. JD considers the directly measured height and weight data
a strength of the study. Although the sample size is relatively large, the intent of
the analysis is not to characterize obesity prevalence or trend within the state.
As such, the prevalence data are presented only as demographic characteristics
REFINEMENT, ADAPTATIONS, AND

ALTERNATIVE USES OF THE APT FRAMEWORK
The concepts presented in the proposed framework represent the com-
mittee’s synthesis of key considerations related to inconsistencies that exist
in the literature and consideration for principles of epidemiology, data
collection, and statistical analysis that affect the interpretation of estimates
of obesity prevalence and trends. It is expected that as a wide variety of
end users begin using the framework, various components will be further
refined to enhance its utility. The committee also foresees opportunities for

(20.9 percent) and used in a statistical model to consider its relationship with an
tibiotic use. The sample represents only children who were seen by practitioners
within the private health care system, and therefore are not representative of all
children in the state. Furthermore, the analysis does not consider urban or rural
residence of the patients.
Study 3 indicates no statistically significant difference in obesity among the
state’s WIC children at the two time points (18.4 [CI:17.5-19.3] percent versus
18.3 [CI:17.4-19.3] percent). JD again considers the directly measured height and
weight data to be a strength of the study. The investigators sampled administrative
data and weighted to ensure the results were representative of the participants
in the WIC program at both time points assessed. The results provide insight into
the precision of the estimate. However, only two time points were assessed. No
results are available to understand changes that occurred between those two time
points. Furthermore, the results only pertain to low-income children in the state
who participated in WIC in 2010 and 2014. Only a state-level estimate is provided.
Because none of the reports was conducted in rural areas of the state, JD
recognizes that the available reports do not directly pertain to the evidence gap
she sought to fill. Based on the available evidence, JD concludes that, collectively,
obesity prevalence among children living in less affluent and more affluent areas
appears to be similar. In comparison to the NHANES estimate, the reports seem
to indicate that the state prevalence may exceed the national estimate for this age
range, although JD recognizes that none of the reports had a sample representa
tive of preschool children throughout the state.
Along with the anecdotal evidence from the directors of some rural childcare
centers, Director JD concludes she is comfortable telling the legislature that
although no scientific reports are available on childhood obesity prevalence in
rural and urban areas in the state, the available evidence suggests that preschool
age children should be a target population of prevention efforts.
a The three studies described in this scenario are hypothetical and do not represent a
specific published report. In contrast, the NHANES estimate is derived from actual data brief
and is therefore cited.
the framework to be adapted for specific end user groups (e.g., community-
based organizations, elected officials, school boards). In these adaptations,
the fundamental concepts would remain, but the specific questions helping
guide the assessment would be those that are most relevant to that particu-
lar end user group.
Opportunities also exist to use the APT Framework for purposes other
than understanding and applying an estimate. One such scenario would be
the planning of data collection. An end user could assess a published report
not to interpret a specific estimate, but rather to determine whether the

design and data collection methodologies led to reliable estimates, allow-

ing them to consider specific methods or study designs in generating new
data. Alternatively, end users could use the framework to walk through key
considerations related to each element to bring clarity to their planning.
Another possible alternative use for the APT Framework is to provide guid-
ance to those preparing results for publication. Investigators and authors
can compare their report to the elements in the framework to ensure all rel-
evant details are included and presented in an accessible manner. This could
lead to better alignment of systematic information presentation, eventually
allowing for easier comparisons across reports.
REFERENCES
IOM (Institute of Medicine). 2013. Evaluating obesity prevention efforts: A plan for measur-
ing progress. Washington, DC: The National Academies Press.
IOM, TRB (Transportation Research Board), and NRC (National Research Council). 2009.
Local government actions to prevent childhood obesity. Washington, DC: The National
Academies Press.
Kann, L. 2015. Youth Risk Behavior Surveillance System: Measurement of obesity. PowerPoint
presentation at Evaluating Approaches to Assessing Prevalence and Trends in Obesity:
Data Gathering Public Workshop, Washington, DC.
Ogden, C. L., M. D. Carroll, C. D. Fryar, and K. M. Flegal. 2015. Prevalence of obesity
among adults and youth: United States, 2011–2014 219. http://www.cdc.gov/nchs/data/
databriefs/db219.htm (accessed February 17, 2016).
Pivec, L. 2015. Panel remarks at Evaluating Approaches to Assessing Prevalence and Trends
in Obesity: Data Gathering Public Workshop, Washington, DC.
Pronk, N. 2015. From research to roadmap: Frameworks to connect knowing and doing.
PowerPoint presentation at Evaluating Approaches to Assessing Prevalence and Trends
Ricketts, T. 2015. Panel remarks at Evaluating Approaches to Assessing Prevalence and Trends
Tversky, A., and D. Kahneman. 1974. Judgment under uncertainty: Heuristics and biases.
Science 185:1124-1131.

Conclusions and Recommendations
At the heart of obesity prevalence and trends analyses are seemingly

basic questions—How many people have obesity? Are any groups dispro-
portionately affected? How has this changed over time? These questions,
however, encompass tremendous methodological and interpretive complex-
ity. Investigators have assessed obesity prevalence and trends from different
perspectives, using a range of data sources and various analytic approaches.
The inconsistencies across published reports have created b arriers to inter-
preting and using such statistics. To understand how best to extract meaning
from recent reports, to determine what data gaps need to be filled, and to
consider how the future of data collection can be improved, a thorough eval-
uation of existing differences and why they exist is crucial. In providing such
information, this report serves as an initial step toward obesity prevalence
and trends estimates that are more transparent, aligned, and comprehensive.
To address its task (see Box 1-2), the committee assessed common data
sources, extracted information from recent published reports, and reviewed
associated protocols and data collection instruments. The committee con-
sidered other information sources, but primarily relied on the methodo-
logic approaches to data collection and analysis presented in peer-reviewed
published reports when formulating its conclusions and recommendations.
CONCLUSIONS
The interpretation of obesity prevalence and trends estimates is contin-
gent on considerations specific to the assessment of obesity status, principles
that are founded in epidemiology, and concepts that are fundamental to
179

s tatistics. This interplay of these elements, which span from general to specific,
is reflected in the committee’s conclusions. Much of the available evidence
indicates that at the core of several of the current limitations are seemingly
basic challenges faced by any population-based prevalence or trends evalua-
tion. The fact that these issues exist, however, underscores the challenges of
finding viable solutions. The committee’s conclusions focus on key domains
that cut across the broad literature base. These include current sources of
data, data for specific population groups, measured versus reported data,
estimates of changes and trends over time, and interpretations of estimates.
Current Sources of Data

A wide variety of data sources capture height and weight data. Popu-
lation surveys serve as a primary source of nationally representative esti-
mates, but often differ from each other in terms of overall design, sample
size, t arget population(s), geographic representation (e.g., national, multiple
states, and localities), and method for collecting height and weight data. Few
data sources are designed to generate estimates of multiple states and those
that do tend to describe select population groups (e.g., Youth Risk Behavior
Surveillance System: high school students). School-based body mass index
(BMI) assessments have emerged as a prominent source of data used to
describe obesity prevalence and trends among school-aged children within
states and smaller geographic areas (e.g., counties, school districts, indi-
vidual schools). Such data, however, can be limited by issues related to data
quality, data privacy, and sample representativeness and can be difficult to
compare across states due to differing protocols. Clinical and public health
administrative data also have been used as a source of data. Although such
data sources often contain an enormous number of records with directly
measured heights and weights, they can be limited for the purposes of obe-
sity prevalence and trends estimation as they do not necessarily represent
populations outside of those who use the services. Finally, cohort studies
have been used in published reports to describe cross-sectional prevalence,
longitudinal trends, and intrapersonal changes in obesity status. Cohort
studies, however, are not as common in the obesity prevalence and trends
literature as cross-sectional or repeated cross-sectional assessments, because
they can be challenging and expensive to properly design and implement.
Conclusion 1: The committee concludes that existing data sources used

to estimate prevalence and trends in obesity vary by factors, including
study design, geographic representation, data collection methodolo-
gies, and overall intent. Each offers specific and distinct information
about the state of obesity. The differences between data sources, how-
ever, can limit the comparability of reports.

CONCLUSIONS AND RECOMMENDATIONS 181
Data for Specific Population Groups

Investigators divide analytic samples into subgroups to determine the
extent to which obesity prevalence and trends vary within a broader popu-
lation. Although participants are commonly grouped by geographic level
(e.g., state, region, county) and demographic characteristics (e.g., age,
race, ethnicity, socioeconomic status), the factors defining the groups (e.g.,
span of ages, race and ethnicity categories) can vary widely across reports,
even those that analyze data from the same data source. Groupings do
not always represent the level of detail captured during data collection,
but rather often reflect decisions investigators make to best answer spe-
cific research question(s) given limitations of the data. Published reports
often cite inadequate sample size as the reason for omitting one or mul-
tiples subgroups from the analyses or for combining heterogeneous groups
into a single category. Advanced statistical techniques, such as small area
estimation, are one means to generate model-based estimates for smaller
geographic areas and population groups for which reliable direct survey
estimates cannot be generated. These techniques are contingent on the
quality and quantity of data used to develop such models and require a fair
degree of statistical sophistication in order to provide meaningful results.
Conclusion 2: The committee concludes that inclusion of subgroups

in data sources provides essential insight into how obesity prevalence
and trends estimates vary within and between population groups.
However, insufficient sample size is a primary limitation to generating
reliable estimates.
Measured Versus Reported Data

Comparing BMI to a population reference, typically the 2000 Centers
for Disease Control and Prevention (CDC) sex-specific BMI-for-age growth
charts and associated cut point, is the prevailing approach for classify-
ing obesity status among children, adolescents, and young adults. Height
and weight data used to calculate BMI are collected through direct mea-
surement, proxy-report, and self-report. Within each collection approach,
variability exists in the specific data collection protocol. Proxy- and self-
reported height and weight questions have been incorporated into various
population surveys in which factors such as the overall design and mode of
delivery (e.g., phone interview) do not allow for direct measurement. These
surveys often have large sample sizes and some have been used to generate
estimates that are compared across states and select localities. Factors such
as sex, age, and weight status can affect the degree to which reported height
and weight values differ from directly measured values. Evidence indicates

that use of proxy-reported data for young and school-aged children gen-
erally does not lead to accurate estimates of prevalence. As such, some
population surveys (i.e., National Health Interview Survey, previous cycles
of the National Survey of Children’s Health) have discontinued collecting
proxy-reported height and weight data and/or generating obesity prevalence
estimates from such data for these age groups (children younger than ages
10 to 12 years). Limited evidence, based on different nationally representa-
tive surveys, suggests that trends in obesity estimated from self-reported and
directly measured heights and weights among high school-aged individuals
exhibit similar patterns, albeit at different values.
Conclusion 3: The committee concludes that although all measures

have limitations, directly measured height and weight data collected
using a standardized protocol provide the best estimates of obesity
prevalence. Self- and proxy-reported height and weight data can be
used to fill data gaps and provide insight into overall obesity trends,
although these data collection methods do not produce prevalence
estimates comparable to those based on direct measure.
Estimates of Changes and Trends Over Time

Published reports assessing obesity prevalence over time have presented
findings as change (the difference between two time points) or trends (the
difference over three or more time points). Such estimates pertain only to
the specific time points included in the analyses. Trend estimates typically
become more precise and nuanced as the number of time points increases.
However, the number of time points is dependent, in part, on the reliability of
the prevalence estimates. Investigators often combine multiple years or cycles
of data to increase the reliability of the estimates used to determine the trend,
thereby reducing the number of data points. Changes to the time interval
included in the trend analyses directly affect the estimate and its meaning.
Conclusion 4: The committee concludes that comparability of trend

reports is enhanced when analyses use similar start and end dates and
time intervals to define the trend.
Interpretation of Estimates
Factors that affect the interpretation of obesity prevalence and trends
estimates not only include characteristics of a data source, but also encom-
pass decisions made during analysis. Data sources differ with respect to
who the sample is designed to represent and who contributes data. Changes
to the sampling or data collection procedures over time affect what data

are available for trend analyses. The portion of the overall sample that is
used for analysis varies across published reports for a number of reasons,
including: what question(s) is being asked of the data, how the data were
prepared for analysis, and whether the samples size led to reliable estimates
of prevalence. Differences exist in data collection methodologies, with the
options height and weight data collection leading to estimates that are gen-
erally not equivalent. The statistical analyses are varied and are guided by
the intent of the specific report, the quality control measures taken during
data collection, the study design from which the data were derived, and the
amount of data available.
Conclusion 5: The committee concludes that appropriate interpretation

of estimates of obesity prevalence and trends requires consideration of
the population in the sample, the data collection methodologies, and
the analytic procedures together in a guided way.
RECOMMENDATIONS
Data sources that capture height and weight largely operate in isolation
or within a single surveillance system, resulting in designs and protocols
that differ from each other. Although these differences often limit compa-
rability of prevalence and trends estimates, their existence underscores the
diverse context in which decisions and compromises have to be made in the
design, collection, and analysis of the data. Given this landscape, the com-
mittee offers recommendations in three areas: assessing published reports
on obesity prevalence and trends; improving future data collection efforts;
and conducting research to address data gaps.
Assessing Obesity Prevalence and Trends Reports

Because understanding and appropriately applying estimates of obesity
prevalence and trends is a complex process, the committee provides the
Assessing Prevalence and Trends (APT) Framework as a conceptual guide for
stakeholders who seek to better understand and use reports. The framework
draws on the committee’s synthesis of key considerations related to incon-
sistencies that exist in the literature while simultaneously drawing on funda-
mental principles of epidemiology and statistics. The framework emphasizes
that the population assessed, methods used, and analyses performed are not
simply discrete characteristics of a published report, but interconnected ele-
ments that inform each other and the interpretation of obesity prevalence
and trends estimates. The committee considers determining the utility of
estimates presented in published reports a highly individualized process,
determined by the end user’s overall goal and specific data needs.

Recommendation 1: The committee recommends that stakeholders

who use or seek to use estimates of obesity prevalence and trends to
inform policy making, program planning, and decision making follow
the Assessing Prevalence and Trends (APT) Framework to guide their
interpretation of published reports.
The committee recognizes that end users who operate at the national,
state, and local levels often have different information needs. The extent to
which available analyses meet those needs varies considerably. Individual
end users are therefore likely to have different priorities when it comes to
the strengths and weaknesses of published reports. In order to be adaptable
to a range of possible applications, the APT Framework integrates consid-
eration of the end user’s context to guide the assessment.
The relevance or importance of the framework elements and guiding
questions will vary by end users. As the framework is disseminated, used,
and evaluated, opportunities to refine and adapt its various components
will emerge. The committee foresees application of the framework beyond
evaluating existing published reports. The concepts presented in the frame-
work have the potential to guide the design of new prevalence and trends
studies and to better align reporting practices of investigators publishing
their research.
Future Data Collection

By evaluating the methodological approaches presented in published
literature on obesity prevalence and trends, this report serves as an impor-
tant starting point for moving toward comparable, more unified data col-
lection, analysis, and reporting practices. Current practices, however, are
determined by more than just the analytic and scientific rationale presented
in a published report. Factors such as cost, existing infrastructure, and
available resources play a role in the selection of a study design and the suc-
cess of its implementation. As such, the committee recognizes that it would
be premature to offer explicit, prescriptive guidance on specific methodolo-
gies to be used by the research and public health surveillance communities.
Such a determination requires consideration of the experiential knowledge
of those who fund, develop, and carry out such activities.
Recommendation 2: The committee recommends that an organization

with a track record of cross-sector leadership in the field of obesity,
such as the National Collaborative on Childhood Obesity Research or
the Robert Wood Johnson Foundation, convene relevant stakeholders
to examine and identify feasible and practical approaches to stan-

dardizing methodologies for data collection and reporting, appropri-

ate for application at the national, state, and local levels to enhance
comparability of obesity prevalence and trend analyses.
The committee envisions the proposed convening of stakeholders as

a vital next step needed to inform the decision of which methodologies
should be used to generate comparable estimates of obesity prevalence and
trends nationally. Guided by the APT Framework and methodologic consid-
erations presented throughout this report, the proposed convening would
serve as an opportunity to discuss challenges to implementation that exist
and consider opportunities for innovation. The committee recommends a
range of relevant topics be considered, including
• Determining ways to leverage existing infrastructure and surveil-

lance systems, and improve and sustain capacity.
• Harmonizing time periods used to determine trends.
• Defining the level of detail of information that should be presented
in published reports and ways in which it should be presented (e.g.,
relative versus absolute change).
• Considering opportunities to overcome sample size limitations so
that reliable estimates can be determined and trends can be assessed
for a broad range of population subgroups.
To include a range of participants, the committee recommends that the

organization(s) sponsoring the proposed activity not only have a national
prominence, but also strong ties to stakeholders who operate at the state
and local levels. The organizations included in the recommendation—the
National Collaborative on Childhood Obesity Research (NCCOR) and
the Robert Wood Johnson Foundation (RWJF)—have missions and experi-
ence that are well aligned with the recommendation goals. With a goal of
improving childhood obesity surveillance at the national, state, and local
levels, NCCOR represents one potential sponsor. The funding partners of
NCCOR are the CDC, the National Institutes of Health, RWJF, and the
U.S. Department of Agriculture (USDA). Similarly, RWJF has a documented
history of cross-sector collaboration and, as the sponsor of this study, may
seek to continue building on the work of this committee. These are two
examples of potential conveners. However, the committee notes that other
conveners or collaborators may enrich the proposed activity as well.
The committee further recommends that a broad range of stakeholders
who operate at the national, state, and local levels be involved in this activ-
ity, including, but not limited to

• Local and state public health agencies;

• Federal governmental agencies (e.g., CDC, USDA, Agency for
Healthcare Research and Quality);
• Community-based organizations;
• School officials (e.g., state Departments of Education, superinten-
dents, school nurses, and physical education teachers);
• Academic researchers;
• Research organizations;
• Research funders;
• Obesity oriented and public health professional organizations; and
• Other decision makers at who operate at the national, state, and
local levels.
Research to Address Gaps

The assessment of obesity prevalence and trends estimates continues to
change with technological, methodological, and statistical advancements.
Some of the inconsistencies and limitations that currently exist in the litera-
ture represent prime opportunities for improvement and progress.
Recommendation 3: The committee recommends that the research

community design and conduct studies to strengthen the evidence base
and improve methodological approaches to assessing obesity.
Opportunities for improvement encompass a wide range disciplines.

The research community described in the recommendation includes, but
is not limited to, federally funded researchers, clinical researchers, social
scientists, and engineers.
Specific research initiatives could include
• Evaluating how the 2000 CDC BMI-for-age growth charts can

better provide continuity to obesity classification across the life
course. The committee acknowledges that the 2000 CDC BMI-for-
age growth charts are the predominant reference currently in use in
the United States for children ages 2 years and older and supports
its continued use as a platform for comparability of estimates of
obesity among children and adolescents. The committee antici-
pates findings from current and future initiatives (e.g., the Dietary
Guidance Development Project for Birth to 24 Months and Preg-
nancy [B-24/P], the INTERGROWTH-21st Fetal and Newborn
Growth Consortium, and the Environmental Influences on Child
Health Outcomes [ECHO] Program) will inform an evidence-based
consensus on how weight status should be classified for children

younger than age 2 years. Additionally, opportunities exist to clar-

ify when and how best to transition young adults to the adult
criterion for obesity classification.
• Identifying appropriate measures of core demographic variables—
including but not limited to race and ethnicity, socioeconomic
status, and rurality—that can be captured in a consistent manner
across various data collection efforts at the national, state, and
local levels. As the demographic landscape of the country continues
to change, it will become increasingly vital to characterize popula-
tions in ways that capture the diversity that exists.
• Developing innovative, practical, and accurate tools for assessing
adiposity. Although BMI is the predominant measure of relative
weight used to classify obesity status, it is not without limitations.
For the purposes of population-based assessments, a new measure
of obesity will need to be a simple alternative that provides com-
parable or improved predictive ability, that can be measured in a
variety of settings, and that is relevant to diverse population groups
across the life course.
• Preventing the misclassification of data from individuals with
severe obesity as biologically implausible values. Technology-based
systems that are used for direct data entry often have features
that automatically detect extreme values in height and weight.
Identification at the time of measurements allows for the values to
be corrected or properly documented. Data collection procedures
that first record measurements on paper or in systems without
automatic detection of extreme values often have limited ability to
check the quality of data until entry into a database or analysis.
Opportunities exist to expand the use of technology in data collec-
tion to enhance the accuracy of recorded measurements.
• Identifying innovative opportunities to capture longitudinal data
throughout childhood. A variety of data sources—including elec-
tronic health records and school-based BMI assessments—are
primed to be used in novel ways to serve as the basis for or supple-
ment longitudinal evaluations.


Future Directions for Filling Data Gaps
Key Messages
• The U.S. population is becoming more diverse, and this diver-
sity must be adequately represented in obesity research that is
used to identify prevalence and trends. This includes racial and
ethnic composition, the full spectrum of childhood from birth
to age 18 years, and childhood populations at increased risk
of obesity.
• Opportunities exist to leverage existing infrastructure and
enhance collaborative efforts that could contribute to filing
data gaps, such as accurately and consistently measuring and
reporting height and weight across different ages and popula-
tion groups.
• Emerging technologies can be used for data collection to cap-
ture obesity prevalence and trends.
At present, prevalence and trends in obesity are assessed using body

mass index (BMI) as the chief form of measurement. Data collection meth-
odologies typically focus on specific geographic regions and populations,
and the data collected are often collapsed to present summary statistics.
However, as previously discussed in this report, the level of granularity
available in data that is needed to assess specific differences among and
across population subgroups, particularly at local and state levels, is often
189

insufficient. Furthermore, the myriad of studies and surveys assessing obe-

sity prevalence and trends too often function in isolation. Because of this,
information about the magnitude, significance, and comparability of trends
is often inconsistent. Variations in and across population groups as well
as inconsistency in the analytical methods used to collect data from these
groups make comparisons between, or within, populations challenging.
This can create gaps in understanding and interpreting reports on obesity
prevalence and trends. However, the limitations inherent in data collec-
tion and analysis offer several promising opportunities to provide more
complete and reliable information, while also improving future methods
for collecting data. New and emerging technologies in data collection,
aggregation, and distribution offer alternative ways to fill these data gaps.
NEW AND EMERGING OPPORTUNITIES FOR FILLING DATA GAPS

In discussing future directions in obesity research, the committee con-
sidered three primary domains: demographics and population subgroups,
infrastructure, and technological advances. Within each of these domains,
the committee considered approaches to leveraging existing data collec-
tion while recognizing opportunities for innovation in this space. In the
following discussions, the committee describes opportunities for improving
data collection and filling data gaps within these domains as a means of
ultimately improving estimates used to assess and report prevalence and
trends in obesity.
Domain 1: Demographics and Population Subgroups
Race and Ethnicity

A number of demographic indicators are associated with incidence of
obesity that can be used to predict prevalence of obesity in some popula-
tion subgroups. Race and ethnicity are among these factors. As described
in Chapter 2, Box 2-5, the demographic landscape of the United States is
transitioning away from a single majority group and toward a more racial
and ethnically diverse population. These shifts have the potential to affect
obesity prevalence and indicators of trends, particularly in light of racial
and ethnic differences in obesity prevalence that currently exist.
Current approaches to classifying race and ethnicity use broad catego-
ries, such as American Indian or Alaska Native, Asian, black or African
American, Native Hawaiian or Other Pacific Islander, white, and Hispanic.
These categories may not adequately differentiate groups. Heterogeneity
among Hispanic and Asian populations is well described in reports from
the U.S. Census Bureau (Ennis et al., 2011; Hoeffel et al., 2012). The mul-

FUTURE DIRECTIONS FOR FILLING DATA GAPS 191
tiplicity of tribes of indigenous Americans, as well as the diverse nature of

African American and white population groups also have been described
in Census reports (Hixson et al., 2011; Norris et al., 2012; Rastogi et al.,
2011). Another element of heterogeneity within populations is immigra-
tion and acculturation (Grieco et al., 2012; Perez-Escamilla, 2011). This
type of heterogeneity is important because it may serve as an indicator that
can help answer questions about the generalizability and comparability of
reports from one population or sets of populations to other populations.
Opportunities for Filling Data Gaps The continuing changes in Ameri-

can demographics present an opportunity to re-examine data collection
approaches and identify ways to capture within-group heterogeneity among
racial and ethnic subgroups. This could include the concepts of country of
origin or ancestry, years of residency in the United States, and acculturation,
when appropriate.
Under-Represented Periods of Childhood

One under-represented population subgroup whose obesity status is
not adequately documented is infants and very young children through
2 years of age. Obesity is difficult to measure and define in early child-
hood because of rapid and sometimes unpredictable physiologic changes
that occur during this period in life. These changes, in turn, can have a
short-term impact on body composition and fat mass. Furthermore, no
commonly recognized definition of obesity in children birth to age 2 years
has been developed. Measures or estimates of weight status in infancy and
early childhood are not consistently included in national, state, and local
surveillance systems.
Infants and children up to age 2 years represent the youngest popula-
tion subgroup sampled, and trend data in this population set the stage for
understanding the evolution of obesity in the other age cohorts. Thus, pat-
terns of weight gain across life stages may affect interpretation of trend data
depending on timing of data collection. Identifying a means for determining
obesity status during early life stages could contribute to better understand-
ing of obesity trends later in life.
Opportunities for Filling Data Gaps Capturing relevant data points in

early growth patterns that can be used to predict later childhood obesity
is both a challenge and an opportunity. Development and adoption of a
standardized reporting format will facilitate documentation of correlations
between body composition changes and childhood developmental stages.
This type of information will contribute to understanding whether obesity
at a given developmental stage affects obesity trends later in life.

Children with Medical Conditions

Children with physical limitations often have higher prevalence of
obesity (Bandini et al., 2005). Moreover, they may face challenges in being
measured, especially in settings with equipment limitations (CDC, 2016).
Some medical conditions, such as childhood cancer, can present an increased
risk of later obesity; both genetic variants and medical treatments are being
examined as possible factors (Wilson et al., 2015).
Opportunities for Filling Data Gaps Development of methodological

approaches to monitoring these populations over time will contribute to
reporting accuracy as well as representation of an overlooked population
subgroup in obesity prevalence and trend reports.
Children with Severe Obesity

Severe obesity currently exists among U.S. children and adolescents,
with some subpopulation groups appearing to be at higher risk (Claire
Wang et al., 2011; Lo et al., 2014; Robbins et al., 2015; Skinner and
Skelton, 2014). Children with severe obesity experience increased obesity-
related comorbidities in childhood and are at high risk of adult obesity and
related chronic disease (Kelly et al., 2013). As discussed in Chapter 2, the
criteria used to classify severe obesity and the terminology used to describe
severe obesity have been inconsistent, although a cut point of 120 percent
of the 95th percentile on the 2000 CDC sex-specific BMI-for-age growth
charts is now common in the literature.
Opportunities for Filling Data Gaps Limitations in the published literature

about the levels of extreme obesity and how this is changing over time are
a research opportunity. Children with severe obesity represent a high-risk
population, thus developing standard reporting formats that consider severe
obesity classifications across national, state, and local datasets will allow for
better understanding of the movement of individuals from lower to higher
obesity categories.
Domain 2: Data Infrastructure
Building on Existing Infrastructure

National immunization registries are an example of an informational
database with the potential to be expanded to include height and weight
data, as well as calculated BMI. Such information can be included in the

database along with recording immunization statistics. This opportunity

has already been considered in some states (Longjohn et al., 2010; Sheon
et al., 2011) and may afford an opportunity to enhance and standardize
data collection and storage of large population samples across life stages.
Opportunities for Filling Data Gaps The ability to collect and access
height and weight data on a population over time provides an opportunity
to include longitudinal assessment to estimates of obesity trends from local
and state to national levels.
School-Based Assessment
School-based health assessments offer an opportunity to obtain con-
sistent measures of height and weight and have the potential to facilitate
longitudinal trend assessment in the school-age population. Standardized
methodologies to sample a representative group of students in all schools
across the United States offers an approach to build on existing infrastruc-
ture and take advantage of the experience of others. However, some poten-
tial barriers exist to the expansion of school-based assessments, including
the Family Educational Rights and Privacy Act (FERPA; see Box 3-2), a fed-
eral law that protects the privacy of student records; the Health Insurance
Portability and Accountability Act of 1996 (HIPAA) (Public Law 104-191,
110 Stat. 1936), a federal law that protects the privacy of a person’s medi-
cal and health information; and Institutional Review Boards (IRBs), which
must approve proposed non-exempt research involving human participants.
Guidance from reports, such as the Joint Guidance on the Application of
the Family Educational Rights and Privacy Act (FERPA) and the Health
Insurance Portability and Accountability Act of 1996 (HIPAA) to Stu-
dent Health Records (HHS and DOE, 2008), may help school and health
officials better understand legal and policy implications associated with
accessing school health data. Legal technical assistance provided to schools
and school districts by the National Policy and Legal Analysis Network to
Prevent Childhood Obesity (NPLAN, 2016) can help school and health
officials understand issues related to joint use agreements and may be a
pathway to overcome barriers to using school health assessments as a data
source for research.
Opportunities for Filling Data Gaps These programs and others like them
may offer an alternative mechanism to use existing infrastructure as a
mechanism for obtaining estimates to assess obesity prevalence and trends
in school-age populations.

Informing Emerging New Infrastructures

Big data techniques offer an opportunity to harmonize approaches
used to measure and collect data by using large electronic databases and
resources. The Precision Medicine Initiative (NIH, 2016), unveiled by the
Obama administration in 2015, will build a national research participant
group of a million individuals of all ages. This cohort will include par-
ticipants from diverse populations living in diverse social and economic
circumstances, and represent an array of health statuses.
Opportunities for Filling Data Gaps Big data initiatives could present an
opportunity to include more demographic characteristics in the population
as well as apply a standardized protocol for collecting measured height and
weight, calculated BMI, and birth weight. To ensure the accuracy of data
collection, quality control measures, such as standardized protocols, will
have to be in place.
Electronic Health Records

Electronic health records (EHRs) provide an extensive resource for
obtaining aggregate data on individuals’ height and weight within and
across populations. Some federal agencies (e.g., Health Resources and
Services Administration) have adopted quality-of-care measures related
to measuring BMI in clinical settings (e.g., Healthcare Effectiveness Data
and Information Set). Validation studies show that clinical prevalence
assessments obtained through EHRs compare favorably with common
population-based assessments (Arterburn et al., 2010). However, it is
important to recognize that some groups are not represented in this type
of data source.
Opportunities for Filling Data Gaps A future step to build on the EHR
infrastructure is to move the performance metric from collecting BMI to
reporting BMI or percent of obesity within the population.
Collaboration
Collaboration is an informal and intangible component of infrastruc-
ture, particularly within universities, state and local government agencies
(e.g., health departments), and stakeholder groups, that provides a format
for developing strong and mutually beneficial relationships. This type of
infrastructure also offers the opportunity to combine and share responsibili-
ties for surveillance analysis, fiscal support, and consumer engagement. An
example of a mutually beneficial collaboration is the Worcester Academic

Health Department, a partnership between The City of Worcester and

Clark University to combine scholarship and practice to improve public
health.
The Patient Protection and Affordable Care Act, enacted in 2010,
added new requirements for charitable 501(c)(3) hospital organizations
that include conducting a community health needs assessment (CHNA)
and adopting an implementation strategy at least once every 3 years (IRS,
2015).
Opportunities for Filling Data Gaps Standardizing the metrics used in

CHNAs is an example of an opportunity to achieve comparability of data
across communities. Consensus about standardized methodologies to col-
lect and assess data needed for obesity prevalence estimates and trends
mapping could leverage existing infrastructure and enhance collaborations
to effectively achieve this strategy.
Domain 3: Advances in Technology
E-Health and Mobile Health Systems

The Global Observatory for eHealth defines mobile health (mHealth)
as a “medical and public health practice supported by mobile devices,
such as mobile phones, patient monitoring devices, personal digital assis-
tants, and other wireless devices” (WHO, 2011). mHealth also is a term
that incorporates applications (i.e., apps) as a software tool that can be
made available on hand-held devices. The ubiquity of smartphones makes
mHealth a potential tool to easily collect height and weight from indi
viduals. An example of a mobile health application is the Health E-Heart
Study that pre-enrolls participants using a Web-based enrollment (Olgin
et al., 2016). The application captures biometrics, behavior patterns, and
family and medical history. Individual participants are re-“surveyed” every
6 months. mHealth and other mobile technologies used for data collection
still face challenges in development, implementation, and utility. Bietz et
al. (2015) describes some of the major barriers, including data ownership,
access, and privacy, as well as difficulties in ensuring data quality. In an
ever-changing technological landscape, unpredictability in the field also
presents a challenge. Although promising for the future of data collection,
these barriers currently limit the effectiveness of mHealth for the purposes
of collecting prevalence or trend data.
Opportunities for Filling Data Gaps By itself, mobile device use and
response for health surveillance can produce variable response rates (WHO,
2011). However, the usefulness could be improved if the app is used as a

complement to existing resources and approaches for surveillance. Although

the use of mHealth is rapidly expanding, evaluation of this tool will need
to be implemented at the same time.
Applications and Tools to Facilitate Self-Report

A number of Web-based tools and apps are commercially available
to facilitate self-reporting of anthropometric data. Bluetooth and Wi-Fi-
connected scales for weight measurement are one example. This technol-
ogy combines a measurement device and a computer that can be linked
to a personal home network. Each user in the network is individually
defined, and data are uploaded automatically and can be reviewed by the
user at any time. Such opportunities also may exist for other measures of
adiposity, although the accuracy and reliability of these tools, at present, is
a consideration. Devices used to assess body composition (e.g., bioelectrical
impedance analysis scales, handheld devices), for example, are available
for individual use, although they have not been validated for data col-
lection purposes (Bioelectrical impedance analysis in body composition
measurement: National Institutes of Health technology assessment confer-
ence statement, 1996; Kyle et al., 2014).
Opportunities for Filling Data Gaps The use of mobile, Web-based, and
other technologies is a rapidly emerging field with far-reaching implica-
tions for data collection and research. This technology could be useful as a
complement to surveillance data to produce estimates to predict trends in
obesity across and among population groups.
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Appendix A
Acronyms and Glossary
ACRONYMS
AAP American Academy of Pediatrics
ACHI Arkansas Center for Health Improvement
Add Health National Longitudinal Survey of Adolescent to Adult
Health
ADP air-displacement plethysmography
AHRQ Agency for Healthcare Research and Quality
APT Assessing Prevalence and Trends (Framework)
B-24/P Dietary Guidance Development Project for Birth to

24 Months and Pregnancy
BIA bioelectrical impedance analysis
BIV biologically implausible value
BMI body mass index
BRFSS Behavioral Risk Factor Surveillance System
CARDIAC Coronary Artery Risk Detection in Appalachian

Communities (Study)
CAYPOS Child and Youth Prevalence of Overweight Survey
CDC Centers for Disease Control and Prevention
CENTURY Collecting Electronic Nutrition Trajectory Data Using
Records of Youth (Study)
CHAMACOS Center for the Health Assessment of Mothers and
Children of Salinas
199

CHIS California Health Interview Survey

CHNA community health needs assessment
CI confidence interval
DXA dual-energy X-ray absorptiometry
EAT Eating Among Teens (Study)

ECHO Environmental Influences on Child Health Outcomes
ECLS-B Early Childhood Longitudinal Survey-Birth Cohort
EHR electronic health record
FERPA Family Educational Rights and Privacy Act

FNS Food and Nutrition Service (USDA)
FPL federal poverty level
GOe Global Observatory for eHealth

GUTS Growing Up Today Study
HEALTH-KIDS Healthy Eating and Active Lifestyles from

school To Home for KIDS
HEDIS Healthcare Effectiveness Data and Information Set
HFZ Healthy Fitness Zone®1
HIPAA Health Insurance Portability and Accountability Act of
1996
HSR health service region
i3C International Childhood Cardiovascular Cohort

(Consortium)
ICD International Classification of Diseases
IOM Institute of Medicine
IOTF International Obesity Task Force
IRB Institutional Review Board
ITO Indian Tribal Organization
KPSC Kaiser Permanente Southern California
MCIR Michigan Care Improvement Registry

MEPS-HC Medical Expenditure Panel Survey-Household
Component
MGRS Multicentre Growth Reference Study
mHealth mobile health
1 Healthy Fitness Zone® is a registered trademark of The Cooper Institute.

APPENDIX A 201
NCCOR National Collaborative on Childhood Obesity Research

NCHS National Center for Health Statistics
NCQA National Committee for Quality Assurance
NHANES National Health and Nutrition Examination Survey
NHES National Health Examination Survey
NHIS National Health Interview Survey
NHPI Native Hawaiian and Pacific Islander
NICHD National Institute of Child Health and Human
Development
NI–HR Needs Improvement–Health Risk
NLSY National Longitudinal Survey of Youth
NSCH National Survey of Children’s Health
NS-CSHCN National Survey of Children with Special Health Care
Needs
OMB Office of Management and Budget
PC WIC Participant and Program Characteristics

PedNSS Pediatric Nutrition Surveillance System
PEDSnet Pediatric EHR Data Sharing Network
PII personally identifiable information
REGARDS REasons for Geographic Differences in Stroke (Study)

RWJF Robert Wood Johnson Foundation
SAE small area estimation

SES socioeconomic status
SLAITS State and Local Area Integrated Telephone Survey
SPAN School Physical Activity and Nutrition (Survey)
USDA U.S. Department of Agriculture
WHO World Health Organization

WHR waist-to-hip ratio
WHtR waist-to-height ratio
WIC Special Supplemental Nutrition Program for Women,
Infants, and Children
YRBS Youth Risk Behavior Survey

YRBSS Youth Risk Behavior Surveillance System

GLOSSARY
Abdominal adiposity
Fat accumulated around a person’s midsection; often assessed by mea-
suring waist circumference or waist-to-hip ratio.
Absolute change
The simple difference between the estimated prevalence during time 2
and the estimated prevalence during time 1.
Adipose tissue
Body fat.
Adiposity
See Adipose tissue.
Adiposity rebound
The point at which body mass index begins an increasing trajectory,
after decreasing in early childhood due to a more rapid increase in
height than weight. Adiposity rebound typically occurs between the
ages of 4 and 7.
Air-displacement plethysmography
A technique used to assess body composition by determining body
volume and density.
Analytic approach
Approaches used for data preparation and statistical analysis.
Bias
Systematic deviation of results or inferences from the truth. This could
result in the over- or under-estimation of the true value.
Bioelectrical impedance analysis (BIA)
A body composition assessment approach based on the principle that
electrical currents travel at different speeds through lean body mass and
water than through adipose tissue. In BIA, electrical currents are sent
through the body and the resulting resistance (impedance) to the cur-
rent is measured. The measure of impedance is used to calculate total
body water, fat-free body mass, and fat mass.
Biologically implausible value (BIV)
An extreme value (high or low) falling outside of an expected range
that may represent error in measuring an anthropometric factor or an
error in data entry.
BMI-for-age percentile
Describes how a child’s body mass index ranks compared to a reference
population of the same sex and age. A BMI-for-age at the 95th percen-
tile, for example, means that 95 percent of the reference population of
the same sex and age had a BMI below that value, while 5 percent had
a BMI above that value.

APPENDIX A 203
BMI-for-age z-score
The number of standard deviations an individual’s BMI falls above
or below the sex- and age-specific reference population’s mean. For
example, a BMI z-score of +3 indicates a BMI that is 3 standard devia-
tions higher than the mean BMI value in the reference population of
the same sex and age.
Body composition
The distribution of body fat, lean muscle tissue, water, and bone in an
individual.
Body mass index (BMI)
An index commonly used to classify an individual’s weight status. BMI
is calculated using the following equation:
BMI (kg/m2) = weight (kilograms) ÷ height (meters)2
Adults with a BMI of 30 kg/m2 or more are classified as having obesity.

Children’s BMIs, in contrast, vary by sex and age. To be classified, a
child’s BMI must be compared to a sex-specific, age-based distribution
that has been determined in a reference population.
Central adiposity
See Abdominal adiposity.
Change
In this report, “change” describes the difference in obesity prevalence
in a given population between two points in time. Change can be
expressed as absolute or relative change (see Absolute change and
Relative change).
Cohort study
An analytic epidemiologic study in which a defined population has been
followed over time and the exposure of interest precedes the outcome
variable. The main feature of a cohort study is the comparison of inci-
dence rates in groups that differ in exposure levels.
Confidence interval (CI)
When a dataset does not include every individual in the population, the
values that are produced are estimates of the true population param-
eter (e.g., prevalence of obesity). A CI can be constructed around the
estimate, providing a range of values likely to include the true popula-
tion parameter (e.g., actual prevalence of obesity in the population)
and over unlimited repetitions of the study the CI will contain the true
parameter with a frequency no less than its confidence level (often 95
percent is the stated level). Wider CIs indicate less precision around the
estimate than narrower CIs.

Cross-sectional study
An observational study that examines participants at one point in time.
The temporal sequence of exposure and outcome (i.e., cause and effect)
cannot be assured.
Demographic shift
Significant changes to the demographic landscape of a population over
time. Demographic shifts occurring in the U.S. population include
increasing median age of the population, and changes in the racial and
ethnic majority and minority groups.
Dual-energy X-ray absorptiometry (DXA)
A body composition assessment approach. Bone mineral density, fat
mass, and lean body mass are determined based on the attenuation
of two x-rays of differing energy levels as they pass through the body.
Body composition estimates are derived from system-specific algo-
rithms, which can differ between DXA machine manufacturers.
End user
In this report, “end user” refers to an individual, group, or organiza-
tion that uses one or multiple reports on obesity prevalence and trends
to inform a decision.
Estimate
In this report, “estimate (of obesity prevalence or trend)” describes a
statistic about the proportion or number of individuals affected with
obesity at one point in time (prevalence) or over time (trend). Estimates
are known, believed, or suspected to incorporate some degree of error.
Estimate of obesity prevalence or trend
See Estimate.
Growth reference
Distribution of growth among a reference population; the 2000 Centers
for Disease Control and Prevention sex-specific BMI-for-age growth
charts are an example of a growth reference. See Reference population.
Growth standard
Distribution of growth parameters among a reference population that
exemplifies optimal growth. The World Health Organization has devel-
oped growth standards for children birth to age 5 years. See Reference
population.
Health disparities
Systemic and preventable differences in the burden of disease and dis-
ability or opportunities to achieve optimal health between particular
population groups due to economic, racial, cultural, geographic, social
factors, or other determinants.

APPENDIX A 205
Immunization registry
An online population-based database to record and monitor all immu-
nizations administered by health care providers; immunization regis-
tries are not required for all health care providers.
Intervention study
An experimental study designed to test a specific hypothesis in which
one or multiple factors are modified to determine the factor’s effect(s)
on outcomes of interest.
Investigators
In this report, “investigators” describes anyone who designs studies or
performs data collection, analyses, or reporting.
Lean body mass
Body mass not including adipose tissue.
Longitudinal study
An observational study that examines a selected population at multiple
points over time. A cohort study is a longitudinal study. See Cohort
study.
Methodology
In this report, “methodology” describes elements related to study design
and data collection.
Mobile health (mHealth)
The use of mobile devices and the development of applications for
medical and public health purposes.
Morbidity
Disease or illness in a population. Morbidity is frequently measured as
prevalence of a disease.
Mortality
Deaths in a population.
Obesity
A state of excess adiposity. For more information on how obesity is
commonly assessed in population-based assessments, see Body mass
index.
Oversampling
Sampling procedure used to increase the number of individuals from a
specific subgroup included in a dataset. Population groups that repre-
sent a small portion of the overall target population can be intention-
ally oversampled in order to generate a reliable estimate of obesity
Population
In this report, “population” refers to the total set of individuals about
whom inferences are being made in a study. A sample is the subset of
people included in the analysis.

Prevalence
In this report, “prevalence” describes the number of individuals in a
sample or subgroup classified as having obesity in relation to the total
sample or subgroup at a given point in time.
Proxy-report
In this report, “proxy-report” refers to data provided by someone other
than the child of interest. This may be a parent, guardian, or other
adult who is knowledgeable about the child.
Published report
In this report, “published report” refers to a publication, peer-reviewed
or otherwise, with original analysis that produces an estimate of obesity
Reference population
A group of individuals that serve as a comparison for growth and
development. See Growth reference and Growth standard.
Relative change
The change in the estimated prevalence in percentage terms (i.e., the
absolute change as a percentage of the estimated prevalence during
time 1).
Reliability
The extent to which results obtained through a specific measurement
protocol or assessment technique can be replicated or reproduced.
Repeated cross-sectional study
A cross-sectional study conducted at multiple points in time. The sam-
ple of individuals is different at each assessment (as opposed to a
longitudinal study, where the participants remain the same over time).
Report on prevalence or trends
In this report, describes a publication, peer-reviewed or otherwise, with
original analysis that produces a value of magnitude and/or a direction-
ality of the magnitude over time of the issue of obesity within a defined
population group.
Sampling
The process used for selection of individuals to be included in a dataset.
School-based assessment
In this report, “school-based assessment” refers to any data collec-
tion effort conducted in the school setting (a single school or multiple
schools), specifically those that collect height and weight data.
Screening
Any tool used to identify potential signs of illness or disease before
symptoms are apparent. In the context of this report, BMI serves as a
screening tool for excess adiposity.
Secular trends
Long-term trends, usually over 10 years or more.

APPENDIX A 207
Self-report
In this report, “self-report” refers to information reported by individu-
als about themselves.
Severe obesity
A further classification of obesity status. Adults with a BMI of 40 kg/
m2 or greater are classified as having severe obesity. Children’s BMIs, in
contrast, vary by sex and age, so a single BMI cut point cannot be used.
Instead, a child’s BMI must be compared to an age-based distribution
that has been assessed in a reference population.
Skinfold thickness
Skinfold thickness is an assessment of body fat based on a measure of
a double fold of the skin and subcutaneous fat at various selected sites
on the body. Skinfold thickness measurement can be used in predictive
equations to determine an individual’s percent body fat.
Standard deviation
A measure used to quantify the amount of variation or dispersion in
a dataset. The standard deviation is the square root of the variance.
Standard error
An estimate of the standard deviation of the sampling distribution of a
statistic, most commonly of the mean. See Standard deviation.
Statistical analysis
In this report, “statistical analysis” specifically refers to the analytic
procedures that result in an estimate of obesity prevalence or trend.
Statistical approach
See Statistical analysis.
Subcutaneous fat
Adipose tissue directly under the skin.
Surveillance
In this report, surveillance refers to the process of ongoing and sys-
tematic data collection, analysis, and interpretation, and subsequent
disclosure of results.
Target population
The population group an estimate from the study population is intended
to reflect.
Total adiposity
Total body fat; does not describe the location and distribution of adi-
pose tissue.
Trend
In this report, a trend is the change in prevalence of obesity in a given
population over three or more points in time.
Underwater weighing
A body composition assessment calculated by measuring body weight
(as taken on land), body weight underwater, and the amount of dis-

placed water when an individual is submerged in a water tank. The

protocol for underwater weighing requires an individual to be fully
submerged, to have blown out as much air from their lungs as possible,
and to remain still while the measurement is being taken.
Validity
The extent to which an assessment measures what it is intended to
measure. Or, the relative absence of bias or systematic error.
Visceral fat
Fat surrounding body organs.
Waist circumference
A measure of abdominal adiposity; standard protocol for measuring
waist circumference varies.
Waist-to-height ratio
Calculated by dividing waist circumference by height; often used in
relation to obesity-related comorbidities.
Waist-to-hip ratio
Calculated by dividing waist circumference by hip circumference; often
used in relation to obesity-related comorbidities.
Weighting
With respect to obesity prevalence and trends estimates representative
of a target population, assigning each participant a value (“weight”)
corresponding to their probability of selection. Those having higher
probabilities of selection (e.g., being from a group that was overs-
ampled) would be assigned smaller weights.

Appendix B
Public Workshop Agenda
The committee held a data-gathering session in Washington, DC, on July 28,

2015. The agenda for the public workshop is presented below.
COMMITTEE ON EVALUATING APPROACHES TO

ASSESSING PREVALENCE AND TRENDS IN OBESITY
DATA-GATHERING WORKSHOP AGENDA

National Academy of Sciences Building
NAS Auditorium
2101 Constitution Avenue, NW
Washington, DC 20418
July 28, 2015
8:00 a.m. Registration
OPENING REMARKS
8:30 Welcome and Introductions

Shari Barkin, Committee Chair
8:40 Opening Remarks

Tina Kauh, Robert Wood Johnson Foundation
209

SESSION I: DATA ANALYSIS AND INTERPRETATION

Moderator: Amy Herring, University of North Carolina at Chapel Hill
8:50 Childhood Obesity Trends in the United States:

Beyond the Data
Cynthia Ogden, Centers for Disease Control and Prevention
9:50 The Youth Risk Behavior Surveillance System and

Measurement of Obesity
Laura Kann, Centers for Disease Control and Prevention
10:50 Break
SESSION II: FRAMEWORKS

Moderator: Jackson Sekhobo, New York State Department of Health
11:00 Establishing Research Standards: Case Study of the

What Works Clearinghouse (WWC)
Jill Constantine, Mathematica Policy Research
11:30 From Research to Roadmap: Frameworks to Connect

Knowing and Doing
Nico Pronk, HealthPartners and Harvard University, T.H.
Chan School of Public Health
12:00 p.m. Lunch
SESSION III: PANEL DISCUSSION

Moderator: Michael Perri, University of Florida
1:00 Panel Discussion with Potential Framework End Users

Lisa Pivec, Cherokee Nation Health Services
Thomas Ricketts, University of North Carolina at Chapel
Hill
Paul Simon, Los Angeles County Department of Public
Health and University of California, Los Angeles,
Fielding School of Public Health
Joseph Thompson, Arkansas Center for Health Improvement,
University of Arkansas for Medical Sciences
2:30 Break

APPENDIX B 211
SESSION IV: FORWARD THINKING AND TECHNOLOGICAL

ADVANCEMENTS
Moderator: Lynn Blewett, University of Minnesota, Minneapolis
2:45 U.S. Children’s Demographics: Race-Ethnicity-Immigrant-

Origins, Income Inequality, and Parental Education
Donald Hernandez, City University of New York
3:15 Investigating Child Obesity in a Pediatric Learning Health

System
Charles Bailey, PEDSnet and Children’s Hospital of
Philadelphia
3:45 Data Capturing Related to Obesity via Emerging Mobile

Technologies
Stephen Intille, Northeastern University
4:15 Break
SESSION V: PUBLIC COMMENT SESSION
4:30 Public Comment Opening Remarks

Shari Barkin, Committee Chair
4:40 Public Comments*
5:15 Adjournment
*If there are insufficient public comments to fill the allotted agenda period,
the open session may end earlier than shown.


Appendix C
Literature Search Approach
The committee conducted a literature search to review the methodo-

logic approaches to data collection and analysis presented in recent reports
on obesity prevalence and trends. The purpose of the literature search was
not to be exhaustive, provide quantitative assessments, or answer the ques-
tion “What is the current prevalence of, and trends in, obesity?” Rather,
this review of literature was intended to provide the committee with insight
into the range of approaches that are used. The literature selected does not
encompass every methodology, but does point to commonalities and differ-
ences across reports and datasets. The evaluated literature also highlights
specific issues related to assessing the weight status of children, adolescents,
and young adults (defined by the Statement of Task as age 18 years, with
consideration up to age 21 years).
Because trends encompass prevalence estimates, the initial approach to
identifying reports consisted of a PubMed search for the words (“trend”
OR “trends”) and “obesity” in the title or abstract. The results were
reduced by using the following preset PubMed filters: published in the past
10 years, human, English, Child: birth-18 years, and Young Adult: 19-24
years. The search resulted in 1,748 publications.
To further explore approaches and methodologies used in publications
presenting prevalence estimates, an additional, modified PubMed search
was used. In initial assessment of the trends reports, the committee recog-
nized that the terminology shift that occurred in 2007 in classifying body
mass index (BMI)-for-age percentiles (i.e., “at risk of overweight” and
“overweight” becoming “overweight” and “obese,” respectively) limited
the ability to search for 2005-2007 reports assessing what is now defined as
213

“obesity” in children. For that reason, the prevalence searches were filtered
to include only those published in the past 5 years. Because the volume of
literature on the topic is expansive, the search approach was restricted to
reports with “obesity” and “children” and “prevalence” and (“cross sec-
tion” or “cross sectional”) in the title or abstract of the publication. The
search was also rerun, replacing “children” with (“adolescent” or “adoles-
cence”). The prevalence searches generated 590 results.
Titles and abstracts from these 2,338 publications were reviewed and
hand-sorted to identify those reporting on or comparing obesity prevalence
or trends in U.S. children and young adults that used BMI to define obesity.
Reports assessing obesity prevalence before and after a policy change or
other local- or state-based initiative were considered natural experiments
and were retained, while publications reporting on the effectiveness or
efficacy of a small-scale trial or other interventions were excluded. A total
of 137 articles were included from this literature search, and served as
the committee’s basis for determining what data collection and analytic
approaches appear in reports on obesity prevalence and trends.

Appendix D
Presentation of Findings
This appendix contains tables summarizing the committee’s review

of the evidence. From the collection of 137 recent published reports (the
selection of reports is described in Appendix C), associated manuals, proto-
cols, training materials, and other intructions for directly measuring height
and weight were identified. Tables D-1, D-2, and D-3 outline the height,
weight, and data collector procedures, respectively, across 32 different
protocols. Next, Tables D-4, D-5, and D-6 outline the different ways race
and ethnicity, socioeconomic status, and age have been categorized and
presented in the collection of recent published reports. Table D-7 summa-
rizes the statistical approaches taken in the published reports to arrive at
an estimate of prevalence, change, or trend, or assess differences between
groups or other reports. Table D-8 presents a simulation demonstrating
that the current FitnessGram’s®1 “Needs Improvement-Health Risk” cut
points correspond to the 95th percentile on the 2000 Centers for Disease
Control and Prevention (CDC) sex-specific body mass index (BMI)-for-age
growth charts. Finally, references for all eight tables can be found at the
end of this appendix.
1 The FitnessGram® was developed and is a registered trademark of The Cooper Institute®,
Dallas, Texas.
215

LIST OF TABLES
• Table D-1 Examples of Protocols for Directly Measuring Height,
217
• Table D-2 Examples of Protocols for Directly Measuring Weight,
222
• Table D-3 Examples of Protocols for Data Collectors, 226
• Table D-4 Race and Ethnicity Categories, as Presented in a Collec-
tion of Recent Published Reports, 229
• Table D-5 Individual and Community-Level Socioeconomic Status
(SES) Categories, as Presented in a Collection of Recent Published
Reports, 233
• Table D-6 Variables and Categories Related to Age, as Presented in
a Collection of Recent Published Reports, 237
• Table D-7 Summary of Statistical Approaches Taken in a Collection
of Recent Published Reports, 242
• Table D-8 2000 CDC Body Mass Index-for-Age Percentiles Corre-
sponding to the 2015 FitnessGram’s® Needs Improvement-Health
Risk (NI-HR) Cut Points, by Age and Sex, 266

TABLE D-1 Examples of Protocols for Directly Measuring Height
Precision of Number Measured
Study or Data Stadiometer Recorded Number of of Contact Without
Sourcea Reference Type Height Repetitions Pointsb Shoes Special Instructions
Add Health Entzel et al., Portablec 0.50 cm 4 X No hat, hair
2009 ornament, or
other accessories
that would affect
measurement
Measurement taken
at the end of a
normal exhalation
Bogalusa Heart BioLINCC, Wall-mountedd 0.10 cm 3 X In socks
Study 2008 Flat hairstyles
California FitnessGram, Wall-mounted 1.00 in
FitnessGram® 2016
CARDIAC Lilly et al., Wall-mounted X
2014
CAYPOS Kolbo et al., Wall-mounted 1.00 in X No belts

2012 No jackets
No heavy jewelry
Child Health Brown et al., Wall-mounted 0.25 in X No excess clothing
Measures Study 2010
Cincinnati Crowley et al., Wall-mounted X
Children’s Hospital 2011
Medical Center

Echocardiography
Database
217
continued
TABLE D-1 Continued
218

Community Alliance Kallem et al., Wall-mounted
for Research and 2013e
Engagement
Creating Tovar et al., Portable 0.30 cm 3
Healthy, Active 2012e (1/8 in)
and Nurturing
Growing-up
Environments
Early Childhood Najarian et al., Portable 2 X Light clothing
Longitudinal Survey- 2010
Birth Cohort
EAT-I, EAT-2010 Larson et al., Portable 0.10 cm
2013f
Fels Longitudinal Sun et al., Portable 0.10 cm 2
Study 2012g
HEALTH-KIDS Wang et al., Portable 0.10 cm 2 X Light clothing
2009
Louisiana Health Williamson et Portable X Normal clothing
Control Participants al., 2011 No socks
Mississippi Delta Gamble et al., 1.00 cm
Study 2012

New York City New York City 0.30 cm X No hats or hairpieces
FitnessGram® Departmemt (1/8 in)
of Education,
2016

NHANES CDC, 2013a Wall-mounted 4 X No hair ornaments,

or Portable jewelry, buns, or
braids on top of
head
Measurement taken
on exhale
Head aligned in
horizontal planeh
Ohio Schools Ohio Wall-mounted 0.30 cm X No hats
Department of or Portable (1/8 in) No bulky clothing
Health, 2010 Looking straight
ahead
Penn State Child Bixler et Portable 0.10 cm X Light clothing
Cohort al., 2008;
Rodríguez-
Colón et al.,
2011
Philadelphia Schools Pennsylvania Wall-mounted 0.25 in or 4 if X No hats or hairpieces
Department of 0.10 cm possible, No bulky clothing

Health, 2011 minimum 2 Feet flat on the floor
Head aligned in
horizontal planeh
Philadelphia Schools Lawman et al., Portable 0.10 cm 2i X No bulky clothing
2015 No items in pockets
Pine Ridge Hearst et al., Portable 0.10 cm
Reservation School- 2011

Based Assessment,
1998-2002
219
continued
TABLE D-1 Continued
220

South Dakota Hearst et al., Wall-mounted 0.10 cm
School-Based BMI 2013
Assessment
Special Olympics Special Wall-mounted 0.01 cm 4 X Feet flat on the floor
International Olympics Looking straight
Healthy Athletes International, aheadh,j
Database 2007
Texas SPAN Texas School Portable 1.00 cm 2 X
Study Physical
Activity and
Nutrition
(SPAN) Study,
2016
Not Specified Acharya et al., Wall-mounted 0.10 cm
2011k
Not Specified Huh et al., Portable 0.10 cm 2 2 X Head aligned in
2012 horizontal planeh
Not Specified Nafiu et al., Wall-mounted 0.10 cm X Head aligned in
2014 horizontal planeh
Not Specified Rogozinski et Wall-mountedl
al., 2007

Not Specified Taylor et al., Wall-mounted 0.25 in
2014

NOTE: This table presents only information available given in the source study’s methods. If a general anthropometric measurement manual was
referenced, it is noted in the footnotes; cm, centimeter; in, inch; all study and dataset acronyms are listed in Appendix A.
a The manuals and measurement protocolsin this table are from the data sources included in the committee’s review of recent reports. If the
publication did not specifically name the data source that was used, but provided details about data collection protocol, it is labeled as “Not Speci-
fied” in the table.
b Common contact points with stadiometer include back of head, shoulder blades, buttocks, and heels.
c Carpenter’s square and steel tape measure used for measurement.
d Used both manual and electronic measuring board.
e Measurement protocol based on Economos et al., 2007. A community intervention reduces BMI z-score in children: Shape up Somerville first
year results. Obesity (Silver Spring) 15(5):1325-1336 and Lohman, 1993. Advances in body composition assessment. Current Issues in Exercise
Science (Monograph No. 3) 5(2):200-201.
f Measurement protocol based on Gibson, 1990. Principles of nutritional assessment. New York: Oxford University Press.
g Measurement protocol is based on Lohman, et al., 1988. Anthropometric standardization reference manual. Champaign, IL: Human Kinetics Books.
h Standardized measurement technique where a horizontal line drawn from the ear canal to the lower border of the orbit of the eye is parallel to
the floor and perpendicular to the vertical backboard; also called the Frankfort horizontal plane.
i Duplicate measures required to be within 0.10 cm of each other.
j For individuals who were not able to stand, arm span was used as a proxy for height.
k Measurement protocol is based on Lohman et al., 1991. Anthropometric standardization reference manual: Abridged edition. Champaign, IL:
Human Kinetics Books.

l For children who had difficulty standing fully erect because of weakness or knee flexion contractures, recumbent height was measured with use
of a flexible tape measure.

221
TABLE D-2 Examples of Protocols for Directly Measuring Weight
222
Precision of
Recorded Number of Clothing Status of Special
Study or Data Sourcea Reference Scale Type Weight Repetitions Participant Instructions
Add Health Entzel et al., 2009 Digitalb 0.10 kg No shoes
No change, wallets,
keys in pockets
Bogalusa Heart Study BioLINCC, 2008 Digital 2 Short sleeve hospital

gown
Underpants
Socks
No shoes
CARDIAC Project Lilly et al., 2014 Digital No shoes
CAYPOS Kolbo et al., 2012 Digitalc 1.00 lb No belts

No heavy jewelry
No jackets
No shoes
Child Health Measures Brown et al., 2010 Digitald 0.10 lb No shoes

Study No excess clothing
Cincinnati Children’s Crowley et al, 2011 Not specifiedd Light street clothing
Hospital Medical Center No shoes
Echocardiography
Database

Community Alliance for Kallem et al., 2013 Digital 0.10 kge
Research and Engagement

Creating Healthy, Tovar et al., 2012f Digital 0.50 lb 3 Light clothing
Active and Nurturing No shoes
Growing-up Environments
EAT-I, EAT-2010 Larson et al., 2013g Beam or 0.10 kg
Electronicd
ECLS-B Najarian et al. 2010 Digital 2 Light clothing

No shoes
Fels Longitudinal Study Sun et al., 2012h Beam 0.10 kg 2
HEALTH-KIDS Wang et al., 2009 Electronic 0.10 kg 2 Light clothing

No shoes
Louisiana Health Control Williamson et al., Digital Normal school

Participants 2011 clothing
No shoes
No socks
Mississippi Delta Study Gamble et al., 2012 Portable
New York City New York City Digital Beam No shoes

FitnessGram® Department of No heavy jackets

Education, 2016
NHANES CDC, 2013a Digital, Standard Small children

Portablei examination Casts or
gown, including prosthesis
slippers Wearing street
No shoes clothes
Exceeding scale’s

capacity
Ohio Schools Ohio Department of Digital 0.20 lb 2 No shoes
223
Health, 2010 No bulky clothing

continued
TABLE D-2 Continued
224
Precision of
Recorded Number of Clothing Status of Special
Study or Data Sourcea Reference Scale Type Weight Repetitions Participant Instructions
Penn State Child Cohort Bixler et al., 2008; Digitalj 0.01 lb Light clothing
Rodríguez-Colón et No shoes
al., 2011
Philadelphia Schools Robbins et al., 2012 Digital, Beam, 0.25 lb Light clothing Note special
Diald No shoes devices
No jackets worn (e.g.,
Empty pockets prosthesis)
Philadelphia Schools Lawman et al., 2015 Digital 0.20 kg 2k No shoes

No excess clothing
Empty pockets
Pine Ridge Reservation Hearst et al., 2011 Balance 0.10 lb

School-Based Assessment
South Dakota School- Hearst et al., 2013 Beam 0.10 lb

Based BMI Assessment
Special Olympics Special Olympics Digital, 0.10 kg No shoes Weighing

International Healthy International, 2007 Beamd No sports packs individuals in
Athletes Database No jackets or other wheelchairs
bulky items
Texas SPAN Study SPAN Study, 2016 Digitald 0.25 lb 2 No shoes

No jacket
No heavy clothing
Empty pockets

Not Specified Acharya et al., 2011l Electronic 0.10 kg
Not Specified Huh et al., 2012 Digital 0.10 kg 2 Light clothing

No shoes
No coat
Not Specified Nafiu et al, 2014 Electronicd 0.10 kg Hospital gowns
Not Specified Rogozinski et al., Beam, force

2007 platform
Not Specified Taylor et al., 2014 Beam 0.25 lb
NOTE: This table presents only information available given in the source study’s methods. If a general anthropometric measurement manual was
referenced, it is noted in the footnotes; kg, kilogram; lb, pound; all study and dataset acronyms are listed in Appendix A.
a The manuals and measurement protocols in this table are from the data sources included in the committee’s review of recent reports. If the
publication did not specifically name the data source that was used, but provided details about data collection protocol, it is labeled as “Not Speci-
fied” in the table.
b Calibrated weekly.
c Calibrated after every 10th measurement.
d “Calibrated.”
e Measurement protocol based on World Health Organization, 2008. STEPS surveillance manual. Geneva: World Health Organization.
f Measurement protocol based on Economos et al., 2007. A community intervention reduces BMI z-score in children: Shape up Somerville first
year results. Obesity (Silver Spring) 15(5):1325-1336 and Lohman, 1993. Advances in body composition assessment. Current Issues in Exercise
g Measurement protocol based on Gibson, 1990. Principles of nutritional assessment. New York: Oxford University Press.
h Measurement protocol is based on Lohman, et al., 1988. Anthropometric standardization reference manual. Champaign, IL: Human Kinetics Books.
i Portable scales were used in cases of power outage, malfunction of primary scale, or individuals over 440 pounds maximum weight. In the case
of individuals over 440 pounds, two scales were used to determine weight.
j Calibrated daily.

k Duplicate measurements must be within 0.2 kg of each other.
l Measurement protocol is based on Lohman, et al., 1991. Anthropometric standardization reference manual: Abridged edition. Champaign, IL:
Human Kinetics Books.

225
TABLE D-3 Examples of Protocols for Data Collectors

Data
Collector
Study or Data Source Position of the Received Data Entry
Namea Reference Data Collector Training Method
Add Health, Wave IV Entzel et al., Interviewer Hand-written
2009 values on Post-it
note; later
entered into a
computer
Anchorage and CDC, 2013b School nurse
Matanuska-Susitna
Borough School
Districts, Alaska
California Madsen et al., Physical Xb
FitnessGram® 2010 Fitness Test
coordinators,
teachers, and
other local
educational
agency staff
CAYPOS Kolbo et al., School nurse Direct entry to a
2012 secure website
Chicago school-based, Wang et al., Research staff X
environmental obesity 2009
prevention program
in low-income African
American adolescents
Child Health Brown et al., Staff X
Measures Study 2010
Community Alliance Kallem et al., Research X
for Research and 2013 assistants
Engagement
Control Group from Carlson et al., Staff X
the MOVE Projectc 2012
Creating Healthy, Tovar et al., Staff X

Active and Nurturing 2012
Growing-up
Environments
ECLS-B Najarian et Interviewer X Hand-written in
al. 2010 Child Assessment
Booklet and
entered into
computer-based
system

APPENDIX D 227
TABLE D-3 Continued
Data
Collector
Fels Longitudinal Sun et al., Researchers
Study 2012
Head Start Simmons et Teachers and X
al., 2012 assistants
Health e-Tools for Lohrmann, School nurse
Schools, Pennsylvania 2014;
YoussefAgha
et al., 2013
New York City Rundle et al., Physical Xd Hand-written;
FitnessGram® 2012 education later entry into
teachers a Web-based
systeme
NHANES CDC, 2013a Examiner and Direct entry into
recorder ISISf
Ohio Schools Ohio Volunteer X
Department health care
of Health, professionals
2010
Penn State Child Rodríguez- Research staff
Cohort Colón et al.,
2011
Philadelphia Schools Lawman et Research X
al., 2015 assistants
Philadelphia Schools Pennsylvania School nurse Direct entry to
Department a secure school
of Health, district database
2011
Pine Ridge Hearst et al., Research staff Xg
Reservation School- 2011
Based Assessment
South Dakota School- Hearst et al., Staff including X
Based BMI Assessment 2013 school nurses
and physical
education or
health teachers
continued

TABLE D-3 Continued
Data
Collector
Special Olympics Special Trained Special X Hand-written
International Healthy Olympics Olympics on athlete’s
Athletes Database International, volunteer individual sheet
2007 clinicians (e.g.,
nurses, doctors,
dieticians)
Texas SPAN Ezendam, Study staff or Hand-written
Study 2011 state or county directly on
personnel student’s
questionnaire
form
The Tucson Children’s Goodwin et Research staff
Assessment of Sleep al., 2001 (two-person
Apnea Study team)
Not Specified Acharya et Interviewer
al., 2011
Not Specified Huh et al., Research
2012 assistants
Not Specified Nafiu et al., Research X
2014 assistants
Not Specified Taylor et al., Nursing X
2014 students
enrolled in
community
health course
NOTE: All study and dataset acronyms are listed in Appendix A.

a The manuals and measurement protocols in this table are from the data sources included
in the committee’s review of recent reports. If the publication did not specifically name the
data source that was used, but provided details about data collection protocol, it is labeled as
“Not Specified” in the table.
b Schools have the option of participating in training and purchasing equipment for the
FitnessGram®; however, documentation of school participation in training is not available.

c The MOVE Project is a 12-month childhood obesity prevention program with a 24-month
follow-up.
d Training received through an NYC DOE-sponsored workshop, with additional reference
material posted online.

e System has built-in validation features that alert the teacher to possible data entry errors.
f Integrated Survey Information System.
g Staff were trained by a public health nurse and Indian Health Service physician.

APPENDIX D 229
TABLE D-4 Race and Ethnicity Categories, as Presented in a Collection

of Recent Published Reports
Race and Ethnicity Categories Reference
One Category
African American Chen and Wang, 2012; Reed et al.,
2013
American Indian Arcan et al., 2012
American Indian (% Indian Heritage) Hearst et al., 2011
Caucasian Johnson et al., 2012, 2013; Sun et
al., 2012; von Hippel and Nahhas,
2013
Mexican American Warner et al., 2013
Two Categories
African American/Black; White Broyles et al., 2010; Freedman et al.,
2012; Halloran et al., 2012; Kolbo
et al., 2012; Molaison et al., 2010;
Staiano et al., 2013; Williamson et
al., 2011; Zhang et al., 2014
Native American; Other (not specified) Brown et al., 2010
American Indian; Non-Hispanic White Hearst et al., 2013
White/Caucasian; Non-White Adams et al., 2008; Kolbo et al.,
2008; Rodríguez-Colón et al., 2011
Non-Hispanic White; Non-White Nader et al., 2014
White/Non-Whitea Bailey-Davis et al., 2012
Three Categories
American Indian/Alaskan Native; Non-Hispanic CDC, 2013b
White; All Other
Mexicans; Mexican immigrants; Mexican Hernandez-Valero et al., 2012
Americans
Mexican American (U.S. born); Non-Hispanic Robinson et al., 2013b
Black; Non-Hispanic White
Mexican American; Non-Hispanic Black; Non- Din-Dzietham et al., 2007b;
Hispanic White Freedman et al., 2006b; Ogden et
al., 2006b; Okosun et al., 2010b; ver
Ploeg et al., 2008b
Black; Hispanic; White Acharya et al., 2011
Black; White; Other Hsu et al., 2007
Four Categories
(Non-Hispanic) Blackc; (Non-Hispanic) Whitec; Lee et al., 2010b
Mexican-Americand; Otherd
continued

TABLE D-4 Continued
African American; Latino; White; Other Huang et al., 2013
African American; Latino; Non-Hispanic White; Kim, 2012
Other
African American/Black; Hispanic; White; Other Benson et al., 2009, 2011; Skinner et
al., 2015b; Tovar et al., 2012
Asian-American (Chinese, Filipino, Other Gordon-Larsen et al., 2010
Asian); Hispanic (Cuban, Puerto Rican, Central/
South American, Mexican, Other Hispanic);
Non-Hispanic Black; Non-Hispanic White
Mexican American; Non-Hispanic Black; Non- Skelton et al., 2009b; Wang and
Hispanic White; Other Zhang, 2006b; Wang et al., 2012b
Mexican American; Non-Hispanic Black; Non- Rossen and Schoendorf, 2012b
Hispanic White; Otherd
Mexican Americand; Non-Hispanic Black; Non- Murasko, 2011b
Hispanic White; Other Hispanicd
Hispanic (includes Mexican American); Ogden et al., 2012b
Mexican American; Non-Hispanic Black; Non-
Hispanic White
Hispanicd; Non-Hispanic Black; Non-Hispanic Lee et al., 2011
White; Otherd
Hispanic/Mexican Americane; Non-Hispanic Skinner and Skelton, 2014b
Black; Non-Hispanic White; Other
Hispanic; Non-Hispanic Black; Non-Hispanic Oza-Frank et al., 2013; Taber et al.,
White; Non-Hispanic Other 2012
Hispanic; Non-Hispanic Black; Non-Hispanic Sekhobo et al., 2010f
White; Other
Five Categories
African American; Asian; Caucasian; Hispanic; Shustak et al., 2012
Unknownd
African American; Black Caribbean; Black Saab et al., 2011
Hispanic; Hispanic White; White
African American; Asian; Hispanic; Non- Lawman et al., 2015; Robbins et al.,
Hispanic White; Other 2012
American Indian/Alaska Native; Asian/Pacific CDC, 2009f; Hinkle et al., 2012; Pan
Islander; Hispanic; Non-Hispanic Black; Non- et al., 2012f
Hispanic White
Asian; Black; Hispanic; White; Other Rundle et al., 2012; Wen et al., 2012
Asian/Pacific Islander; Black; Hispanic; White; Lo et al., 2014
Other/Unknownd

APPENDIX D 231
TABLE D-4 Continued
Asian/Pacific Islander; Hispanic; Non-Hispanic Day et al., 2014
Black; Non-Hispanic White; Other (including
multiple races)
Hispanic; Black; White; Other (includes Eaton et al., 2008,g 2010,g 2012g;
American Indian, Alaska Native, Asian, Native Kann et al., 2014g
Hawaiian or other Pacific Islander, or Mixed);
Missing
Hispanic-Mexican American; Hispanic-Other; Khoury et al., 2013b; Trasande et al.,
Non-Hispanic Black; Non-Hispanic White; 2012b
Other
Hispanic; Native American; Non-Hispanic Harris et al., 2006
Asian; Non-Hispanic Black; Non-Hispanic
White
Hispanic; Non-Hispanic Asian; Non-Hispanic Ogden et al., 2014b
Black; Non-Hispanic White; Non-Hispanic
Other/Multipled
Six or More Categories
African American; American Indian; Asian; Babey et al., 2010
Latino; White; Mixed Races or Other
African American; Asian/Pacific Islander; Huh et al., 2012
European American; Latinah; Native American;
Other/Mixedd
African American; American Indian/Alaska Jin and Jones-Smith, 2015
Native; Asian; Filipino; Hispanic/Latino; Pacific
Islander/Native Hawaiian; White; Two or More
Races
African American; American Indian/Alaskan Madsen et al., 2010
Native; Asiani; Filipinoi; Hispanic/Latino; Pacific
Islanderi; Non-Hispanic White
African American; American Indian/Alaskan Weedn et al., 2014
Native; Asiand; Hispanic; Multiraciald; Native
Hawaiian/Pacific Islanderd; White
African/African American; American Native/ Aryana et al., 2012
Alaska Native; Asian/Asian American; Filipino/
Filipino American; Hispanic; Pacific Islander;
White
African-American; Asian; Latino; Dominican; Stingone et al., 2011
Mexican; Puerto Rican; Other Latino; White;
Other
American Indian/Native Alaskan; Asian/Pacific Hruby et al., 2015
Islander; Hispanic; Non-Hispanic Black; Non-
Hispanic White; Other/Unknown
continued

TABLE D-4 Continued
Asian; Black; Hispanic/Latino; White; Other; Gee et al., 2013
Unknown
Asian; Black; Hispanic; Native American; Neumark-Sztainer et al., 2012b
White; Other/Mixed (includes those who
identified as Hawaiian or Pacific Islander)
Asian/Pacific Islander; Black; Non-Hispanic Christensen et al., 2013
White; White Hispanic; Other or Multiple;
Unknownd
Asian/Part Asian; Filipino; Hawaiian/Part Stark et al., 2011
Hawaiian; Pacific Islander; White; Other
(Hispanic, Black, other)
NOTE: Table does not include reports where race/ethnicity was only presented as demograph-
ics table or adjusted for in statistical models. Reports listed in the table are individual reports.
There is repetition of datasets.
a Estimates were generated for school districts with a population above and below the
median for percent non-white.

b Primary dataset was NHANES.
c Dichotomized as “White” and “Black” in NHANES 1971-1975, 1976-1980.
d Presented in aggregate estimates, but did not have estimate separate from other racial/
ethnic groups.
e Claims to have categorized “Mexican American” and “other Hispanics” in separate
groups in the methods section, but results are presented as “Hispanic.”

f Primary dataset was PedNSS.
g Primary dataset was YRBS; the number of participating states and cities varies with each
YRBS cycle.
h Study only included females.
i To protect the confidentiality of students, those responding “Pacific Islander” or “Filipino”
were collapsed into the “Asian” category.

APPENDIX D 233
TABLE D-5 Individual and Community Level Socioeconomic Status

(SES) Categories, as Presented in a Collection of Recent Published
Reports
Measure of SES Categories Presented in the Report Reference
Measure of Individual SES Status
Household <$15,000, $15,000-$34,999, $35,000+ Arcan et al., 2012
Income, Gross
<$25,000, $25,000-$74,999, $75,000+ Okosun et al., 2010
Cutoffs
<$15,999, $16,000-$23,999, $24,000- Adams et al., 2008
$31,999, $32,000+
<$9,999, $10,000-$29,999, $30,000- Reed et al., 2013a
$49,999, $50,000+, Missing
<$20,000, $20,000-$39,999, $40,000- Stingone et al., 2011
$74,999, $75,000+
Household 0-99%,100-199%, 200-399%, 400%+ Kim et al., 2011;
Income, Percent Rossen and
of Federal Schoendorf, 2012a,b
Poverty Level
0-199%, 200%+ Holtby et al., 2015;
(FPL)
Kim, 2012
0-100%, 100-300%, 300%+ Babey et al., 2010;
Wang et al., 2012
0-130%, 130-350%, 350%+ Fakhouri et al., 2013
0-130%, 130-300%, 300%+ Ver Ploeg et al., 2008c
0-185%, 185-300%, 300%+ Ver Ploeg et al., 2008c
Household Study sample divided into tertiles based on Wang and Zhang,
Income, Poverty- PIR distribution 2006a
to-Income Ratio
Study sample divided into quartiles based on Trasande et al., 2012a
(PIR)
PIR distribution
PIR <1, PIR >1 Lalwani et al., 2013
PIR <1, PIR >4 Murasko, 2011
PIR <1, 1 to 3, >3 Skelton et al., 2009a
PIR <1 to <2, 2 to <4, >4 Li et al., 2012
PIR calculated, no further grouping Sekhobo et al., 2014
continued

TABLE D-5 Continued
Highest Less than high school, High school, Greater Kim, 2012a
Education Level than high school
Attained by
Less than high school, High school graduate, Suglia et al., 2014
Either Parent/
Greater than high school, College or greater
Caregiver
Less than high school, Some high school, Trasande et al., 2012d
High school graduate or GED, Some college,
College graduate or greater
Grade school graduate, Some high school, Huh et al., 2012
High school graduate, Some college,
Advanced degree
Maternal Less than high school graduate, High school Kim et al., 2011
Education Level graduate or greater
Less than high school, Some high school, Lemay et al., 2008
High school graduate
Less than high school, High school graduate, Tovar et al., 2012a
Some college, College/graduate school
Categorized as high, average, or low based Halloran et al., 2012
on expected years of education at reported
age
Parent or No college degree, College degree or more Carlson et al., 2012
Caregiver’s
Less than high school, High school diploma/ Stingone et al., 2011
Education Level
GED, Some college, College degree
(not specified
further)
Eligibility for Eligible for free or reduced lunch (yes/no) Day et al., 2014; Jin
Free or Reduced- and Jones-Smith,
Price Lunch 2015a; Kallem et al.,
2013; Robbins et al.,
2012; Rundle et al.,
2012
Insurance Type Medicaid/public, non-Medicaid/private Black et al., 2012e;
Christensen et al.,
2013e; Demment et
al., 2014a,f; Halloran
et al., 2012; Lemay et
al., 2008; Stark et al.,
2011a; Wen et al., 2012

APPENDIX D 235
TABLE D-5 Continued
Participitation Head Start enrollment Acharya et al., 2011g
in an Assistance
Head Start enrollment and SNAP Simmons et al., 2012g
Program
participation
WIC participation CDC, 2009g;
Davis et al., 2014g;
Hinkle et al., 2012g;
Sekhobo et al., 2010,g
2014g; Weedn et al.,
2014g
WIC or SNAP enrollment Ver Ploeg et al., 2008
Participation in any assistance program CDC, 2013cg;
Murasko, 2011g
Eligibility for any assistance program Reed et al., 2013;
Tovar et al., 2012
Perception of Neighborhood perceived as safe (yes/no) Kim et al., 2011
Neighborhood
as Safe
Measure of Community-Level SES Status
Eligibility for Percentage of students eligible for free or Sanchez-Vaznaugh et
Free or Reduced- reduced-price school meals al., 2015
Price School
Percentage of students receiving free or CDC, 2013ba,h, Oza-
Meals
reduced-price lunch Frank et al., 2013a;
Rundle et al., 2012
Racial/Ethnic Greater or less than 70% black, greater or Rundle et al., 2012
Population less than 70% Hispanic students in schools
Percentage black and percentage white in Gamble et al., 2012
county
Percentage of non-white population in Bailey-Davis et al.,
school district 2012a
Mean <$15,000, $15,000-$34,999, $35,000- Black et al., 2012
Neighborhood $49,999, $50,000-$74,999, $75,000-
Income, Gross $99,999, $100,000-$149,999, $150,000+
Cutoffs
Mean Percent of households living below federal Day et al., 2014i,
Neighborhood poverty line Gamble et al., 2012;
Income, Percent Taylor et al., 2014;
of FPL Warner et al., 2013
Median Study sample grouped into income tertiles Sanchez-Vaznaugh et
Neighborhood based on annual median income in the al., 2015a
Income census tract
continued

TABLE D-5 Continued
Neighborhood Percentage of adults 25 years and older with Sanchez-Vaznaugh et
Education Level 16 or more years of education al., 2015a
Percentage of adults 25 years and older with Taylor et al., 2014
less than high school education
Less than high school, High school graduate, Black et al., 2012;
Some college or associated degree, Bachelor’s Langer-Gould et al.,
degree or higher 2013
Less than high school, High school graduate, Christensen et al., 2013
Some college or associated degree, Bachelor’s
degree, Graduate or professional degree
Other SES Participant residence in low-risk areas (those Sekhobo et al., 2014
Assessmentsj with Dept. of Public Health Office) versus
high-risk areas (those without Dept. Public
Health Office)
Participant residence in a socioeconomically Spilsbury et al., 2015
distressed neighborhood
Participant residence classified by a Hearst et al., 2011a
neighborhood deprivation index
School district distress index Bailey-Davis et al.,
2012a
Percentage of economically disadvantaged Ezendam et al., 2011
students in school (based on eligibility for
free/reduced lunch, income below FPL, or
other assistance program)
NOTE: Individual studies identified in literature search are represented in the table. Datasets
are repeated across presented published reports. Reports often use multiple variables, SES or
otherwise, in combination with each other.
a Obesity prevalence or trend estimate was reported for these subgroup, rather than only
being a demographic characteristic.

b Actual cutoffs for this study were 0-100% FPL, 101-200% FPL, 201-400% FPL, >400%
FPL.
c Percent of FPL was used only in cases where study participants were income eligible but
non-participants in assistance programs.

d In the analysis, this variable was dichotomized to “some college and more” versus “no
college.”
e Used Medi-Cal in addition to Medicaid.
f Used Child Health Plus in addition to Medicaid.
g Study population only included those participating in the specificed assistance program.
h Schools subdivided further into 2 groups: less than 50% of students receiving free/reduced
lunch and more than 50% of students receiving free/reduced lunch.

i Study population groupings were <10%, 10% to <20%, 20% to <30%, ≥30%.
j Refers to a standardized assessment, usually based on a combination of factors, used to
better capture unique populations and fit study goals.

APPENDIX D 237
TABLE D-6 Variables and Categories Related to Age, as Presented in a

Collection of Recent Published Reports
Measure
of Age Categories Presented in the Report Reference
Age 0.75 (9 months), 2, 4, 5-6 Castetbon and Andreyeva, 2012a
(years)
2, 3, 4 CDC, 2013c; Pan et al., 2012b
3, 4, 5 Lo et al., 2014b
7 Warner et al., 2013
10, 11, 12 Sanchez-Vaznaugh et al., 2015
12, 13, 14, 15, 16, 17, 18, 19, 20, Lee et al., 2011b
21, 22, 23, 24, 25, 26
<14, 15, 16, 17+ Nickelson et al, 2012
14, 15, 16, 17, 18, 19 Adams et al., 2008b
18 Hsu et al., 2007b
Age 0-5 Holtby et al., 2015

Groups
(years)
0-<0.5, 0.5-<1, 1-<2, 2-<3, 3-<6 Wen et al., 2012
1-16 Saland et al., 2010

1-18, 19+ Song et al., 2012b
2-4 CDC, 2009; Davis et al., 2014; Weedn

et al., 2014
2-4, 5-9, 10-14, 15-19 Robinson et al., 2013b,c
2-4, 5-19 Ver Ploeg et al., 2008
2 to <5 Sekhobo et al., 2010
2-5 Simmons et al., 2012
2-5, 6-11, 12-17, 18+ Eilerman et al., 2014b
2-5, 6-11, 12-17 Freedman et al., 2006
2-5, 6-11, 12-18 Skelton et al., 2009b; Skinner and
Skelton, 2014
2-5, 6-11, 12-19 Gee et al., 2013; Ogden et al., 2006,
2012,b 2014; Shustak et al., 2012;
Wang et al., 2012b
2-9, 10-18 Wang and Zhang, 2006b
2-9, 10-19, 20-29, 30-39, 40-49, Lee et al., 2010b
50-59, 60-69, 70-79
2-10 (2-3, 4-5, 6-10) Stark et al., 2011b
2-11, 12-19 Murasko, 2011
2-15 Demment et al., 2014
2-17, 18+ Arterburn et al., 2010
2-18 Benson et al., 2009, 2011; Johnson
et al., 2012; Nader et al., 2014;
Rossen and Schoendorf, 2012
continued

TABLE D-6 Continued
Measure
2-19 Crowley et al., 2011
3-4 Sekhobo et al., 2014

3-5 Acharya et al., 2011
3-5, 6-8, 9-11, 12-14, 15-19 Hearst et al., 2011b
3-18 von Hippel and Nahhas, 2013
3-19 (3-5, 6-11, 12-19) Skinner et al., 2015b
5-6, 7-8, 9-10, 11-12, 13-14, 15-16, Staiano et al., 2013

17-18
5-6, 7-10, 11-14 Day et al., 2014b
5-8, 9-11, 12-14, 15+ Brown et al., 2010b
5-8.9, 9-11.9, 12-14.9, 15-19.9 Hearst et al., 2013
5-9, 10-14, 15-19 Hernandez-Valero, 2012b
5-9, 10-14 Broyles et al., 2010b
5-12 Bailey-Davis et al., 2012; Calhoun et
al., 2011
5-17 Broyles et al., 2010b; Freedman et al.,
2012
5-18 Khoury et al., 2013
6-8, 9-11 Fakhouri et al., 2013

6-9 Carlson et al., 2012
6-10, 11-14, 15-19 Black et al., 2012
6-11 Archbold et al., 2012; Gamble et al.,
2012; Tovar et al., 2012
6-11, 12-18 Li et al., 2012b
6-11, 12-19 Trasande et al., 2012b
6-12 Lasserre et al., 2007
6-17 Kim et al., 2011
6-18 Huang et al., 2013b; Nafiu et al., 2014
6-25 Koebnick et al., 2009
<8, 8-10, 10+ Rogozinski et al., 2007

8-<19 Foley et al., 2014b
8-11, 12-14, 15-17 Din-Dzietham et al., 2007d
8-11, 12-17 Madsen et al., 2010b
8-11, 16-19 Spilsbury et al., 2015
8-17 Rosner et al., 2013; Zachariah et al.,
2014
8-18 Sun et al., 2012
8-20 Joyce et al., 2015

APPENDIX D 239
TABLE D-6 Continued
Measure
9-15 Kallem et al., 2013
10-12 Reed et al., 2013b

10-14 Chen and Wang, 2012
11-17 Halloran et al., 2012; Kim, 2012b
12-13, 14-15, 16-17, 18-19 May et al., 2012

12-14, 15-17 Babey et al., 2010b
12-15, 16-17, 18-21 Gordon-Larsen et al., 2010b,e
12-15, 16-19 Lalwani et al., 2013
12-17 Okosun et al., 2010
12-19 Harris et al., 2006b,f
13-14, 15-16, 17-18 Blank et al., 2015

13-19 Huh et al., 2012
14-19 Lemay et al., 2008b
<15, 16-17, 18-19, 20-24 Salihu et al., 2010b

15-19 Christensen et al., 2013
15-34, 35-44 George et al., 2011
<18, 18-24, 25-34, 35-44, 45-54, Crawford et al., 2010g

55-59, 60-64, 65-67, 70+
18-20, 21-23, 24-28, 29-54 Hinkle et al., 2012
<20, 20-<30, 30-<40, 40+ Hruby et al., 2015

<20, 20-39, 40-59, 60+ Crawford et al., 2010h
<20 and >20 Ng et al., 2014
Mean Age 5.8 Arcan et al., 2012

of Study
Sample
(years)
8.8 Taylor et al., 2014
10.0 Choumenkovitch et al., 2013
12.2 Wilson et al., 2011
13 Jin and Jones-Smith, 2015
15.6 Saab et al., 2011
16 (adolescents), 20 (young adults) Suglia et al., 2014
continued

TABLE D-6 Continued
Measure
Birth 1928-1953; 1954-1972; 1973-1999 Johnson et al., 2012
Cohort
Year
1958-1970; 1971-1983; 1984-1995i Johnson et al., 2013
1971-1975; 1976-1980; 1981-1985; Robinson et al., 2013b
1986-1990; 1991-1995; 1996-
2000; 2001-2005; 2006-2010
1988-1994; 1999-2000; 2001- Rosner et al., 2013
2002; 2003-2004; 2005-2006;
2007-2008
1995 (June)-1997 (July) Demment et al., 2014
Grade in K, 1 and 3, 5 and 7 CDC, 2013b

School
1, 2, 3, 4, 5, 6 Lawman et al., 2015
3 Oza-Frank et al., 2013
4 Ezendam et al., 2011
4, 5, 6 Williamson et al., 2011
5 Lilly et al., 2014
5, 7, 8 Kallem et al., 2013
5, 7, 9 Jin and Jones-Smith, 2015
5, 8, 12 Lohrmann et al., 2014
6, 7, 9 Aryana et al., 2012
8, 10, 12 Kern et al., 2014; Slater et al., 2013
9, 10, 11, 12 Eaton et al., 2008, 2010, 2012; Kann
et al., 2014
10 Saab et al., 2011
Grade K-5 Rodríguez-Colón et al., 2011; Stingone

Range et al., 2011
K-5, 6-8, 9-12 Kolbo et al., 2008, 2012; Molaison
et al., 2010; Robbins et al., 2012;
Rundle et al., 2012; YoussefAgha et
al., 2013; Zhang et al., 2014
K-6 Taylor et al., 2014
3-6 Choumenkovitch et al., 2013
6-10 Iannotti and Wang, 2013
9-12 Taber et al., 2012
School Middle school, high school Ritzman and Elmore, 2006

Level
NOTES: Each reference corresponds to a published report. There is repetition of datasets (e.g.,
National Health and Nutrition Examination Survey); K, Kindergarten.
a Assessed the same child at each age given.
b Estimate of obesity prevalence or trend reported by age groupings given.

APPENDIX D 241
TABLE D-6 Continued
c Ages based on cohort birth year.
d This age categorization is clinical and not data based; it was used because the Tanner index
of sexual maturation was not measured at all periods.
e Age at last birthday.
f Ages at onset of study, assessed again at additional time interval.
g Groupings used in bivariate analysis.
h Groupings used in multivariate analysis.
i Aged 8-<18 years at assessment.

TABLE D-7 Summary of Statistical Approaches Taken in a Collection of

Recent Published Reports
Statistical Approach
Data
Study or Data Source Collection
Namea Reference Years Prevalence
Add Health Gordon-Larsen et 1996, Percent (95 percent CI)
al., 2010 2001-2002,
2007-2009
Add Health Harris et al., 2006 1994-1995, Proportion (95 percent

1996, CI)
2001-2002
Add Health Suglia et al., 2014 1994-2001 Percent (standard error)
Anchorage and CDC, 2013b 2003-2004 Weighted percentages;

Matanuska-Susitna through unadjusted obesity
Borough School 2010-2011 prevalence; 95 percent
Districts, Alaska confidence interval
Bogalusa Heart Study Broyles et al., 2010 1973-2008b Percent
Bright Start Study Acran et al., 2012 2005-2006 Number of participants

California FitnessGram® Madsen et al., 2001-2008 Percent (standard
2010 error; most considered
negligible)
California FitnessGram® Sanchez-Vaznaugh 2001-2010 Percent

et al., 2015
California FitnessGram® Aryana et al., 2012 2003-2008 Percentc
California FitnessGram® Jin and Jones- 2010-2012 Percent

Smith, 2015

APPENDIX D 243
Comparisons Between Changes Trends

Groups, Datasets (2 points in time) (≥3 points in time)
Stratified by sex and race, NR Stratified prevalence estimates
ethnicity categories plotted on chart
F-statistic and t-test used to
compare groups
Stratified by sex, race and Marginal (or “population- NR
ethnicity categories average”) longitudinal
regression model
Presented absolute change
and 95 percent confidence
interval (CI)
Regression models NR NR
(difference between sexes)
Pearson Chi-square test Relative percent change Multivariate logistic regression
Stratified by socioeconomic model; linear term for time,
status, gender, race and Unadjusted weighted
ethnicity, grade grouping prevalence (95 percent CIs)
plotted
Stratified analyses (by age Estimated secular trends Generalized estimating
groups) were presented per 10 years equations; accounted for
Plotted results on same demographic shift
graph as NHANES
prevalence Linear (additive) model;
group-by-time interaction
effect included in the models
NR NR NR
Stratified analyses Adjusted odds ratios Logistic regression
Logistic regression between first year and peak
year compared
Stratified percentages Trend line slope Multilevel logistic regression

Cross-product terms added Multilevel logistic with spline terms
to trend models regression
General linear model for NR Cochran-Armitage trend test
analysis of variance for Multivariable logistic
subgroup comparisons over regression
time
Percent, stratified by NR NR
income status
Log-binomial regression;
relative risk of obesity
continued

TABLE D-7 Continued
Data
CARDIAC Project Lilly et al., 2014 2002-2012 Average BMI percentile
with standard error
The Caring Initiative Adams et al., 2008 1996-2005 n (%)
CAYPOS Kolbo et al., 2008 2005-2007 Weighted estimates and

standard errors
CAYPOS Molaison et al., 2005-2009 Weighted estimates and

2010 standard errors
CAYPOS Kolbo et al., 2012 2005-2011 Weighted estimates and

standard errors
CAYPOS Zhang et al., 2014 2005-2013 Weighted estimates and

standard errors
CENTURY Study Wen et al., 2012 1999-2008 Percent
Percent (standard error)
CHAMACOS Study Warner et al., 2013 1999-2008 Number of participants

(%)
Child Health Measures Brown et al., 2010 2007-2008 n (%)

Study
Children of NLSY79 Huang et al., 2013 1986-2008 NR
Participants
Chronic Kidney Disease Wilson et al., 2011 2005-2009 n (%)
in Children Study

APPENDIX D 245

NR NR Generalized estimating
equation model
NR NR Graphed the prevalence for

each year; approach not
described
Proc Crosstab NR NR
Considered non-
overlapping 95 percent CI
significant
Proc Crosstab NR Compared values across the
Considered non- 3 years
overlapping 95 percent CI
significant
Proc Crosstab NR Logistic regression used to
Considered non- assess linearity of longitudinal
overlapping 95 percent CI trends; linear coefficients and
significant quadratic coefficients
Proc Crosstab NR Logistic regression used to
Considered non- assess linearity of longitudinal
overlapping 95 percent CI trends; linear coefficients and
significant quadratic coefficients were
assigned
Stratified analyses Relative change Multivariable logistic
regression models during two
Compared to NHANES, Absolute change 5-year periods separately
PedNSS
Adjusted obesity risk per
year
Logistic regression NR Generalized estimating
equation model
NR NR NR
Chi-square analyses NR Trajectory modeling

Multivariate analyses
NR NR NR
continued

TABLE D-7 Continued
Data
Chronic Kidney Disease Saland et al., 2010 As of May n (%)
in Children Study 2009
Cleveland Children’s Spilsbury et al., n (%)

Sleep and Health Study 2015
Community Alliance Kallem et al., 2013 NR n (%)

for Research and
Engagement – Baseline
Creating Healthy, Tovar et al., 2012 NR Number of participants

Active and Nurturing
Growing-up
Environments
Creating Healthy, Choumenkovitch 2008 Percent

Active and Nurturing et al., 2013
Growing-up
Environments
ECLS-B Castetbon and 2005-2006, Percent
Andreyeva, 2012 2006-2007
Fels Longitudinal Study Johnson et al., 1930-2008d Mean (standard

2012 deviation) BMI, BMI
z-score;
Percent (number of
participants)e
Fels Longitudinal Study Sun et al., 2012 1960-1999d NR
Fels Longitudinal Study Johnson et al., 1958-1995d NR

(born 1958-1995) 2013
GE Centricity EMR Crawford et al., NR n (%)

2010

APPENDIX D 247

NR NR NR
Presented by age groups NR NR
Multiple linear regression NR NR

analyses
Present characteristics by NR NR
weight category (e.g., n
[%])
Logistic regression
(unadjusted and adjusted)
Generalize linear model NR NR
Multiple logistic regression
Stratified by sex, presented NR NR

by age groups (4, 5-6 years)
Presented by birth cohort NR Mixed effects growth modesl
Presented by birth cohort NR Sex-specific mixed-effect

repeated measure analysis
of variance model (BMI not
percentile)
Stratified by sex*birth Generalized estimating
cohort equations (GEEs) specifying
Two-degrees-of-freedom an autoregressive correlation
chi-square test comparing structure
each subsequent birth
cohort to the first
Stratified by comorbidity NR NR
(*race, ethnicity groups;
*sex), age group
continued

TABLE D-7 Continued
Data
Hawaiian HMO Stark et al., 2011 2003 n (%)
Health Behavior in Iannotti and Wang, 2001-2002, Percent (SE)

School-aged Children 2013 2005-2006,
Quadrennial Surveys 2009-2010
Health eTools for YoussefAgha et al., 2005-2009 n (%)
Schools, Pennsylvania 2013
Health eTools for Lohrmann et al., 2007-2011 Percentage

Schools, Pennsylvania 2014
HMO Network Arterburn et al., 2005-2006 Percent

2010
Kaiser Permanente Gee et al., 2013 2003-2005, Mean (95 percent CI)
Northern California 2009-2010
Kaiser Permanente Lo et al., 2014 2007-2010 Percentage

Northern California
KPSC Children’s Health Christensen et al., 2007-2009 n (%)

Study 2013
KPSC Children’s Health Black et al., 2012 2007-2009 Percentage

Study n (%)
KPSC pediatric Langer-Gould et 2004-2010, n (%)
acquired demyelinating al., 2013 2007-2009
diseases Cohort, KPSC
Children’s Health Study
MetroHealth System, Benson et al., 2009 1999-2007 Number of participants

EpicCare – Northeast
Ohio

APPENDIX D 249

Wald Chi-square analysis NR NR
Logistic regression
Multinomial logistic Multinomial logistic Multinomial logistic

regression analysis regression analysis regression analysis
Presented by school level Least-squares method, a

for each year simple linear regression
Compared prevalence by formula
HS grades to YRBS (just
percent, no CI)
Pearson chi-square NR Least-squares method, a
simple linear regression
formula
Stratified by site NR NR
Stratified logistic regression Absolute and relative NR

models, combination of age change presented
and race categories Logistic regression
Compared to NHANES,
California FitnessGram®
Chi-square test NR NR
Cochrane-Armitage test
Chi-square test NR NR
Multiple logistic regression
models
Presented by asthma status NR NR
chi-square
Chi-square NR NR
Logistic regression Performed; presumably Generalized estimating

through the generalized equations for logistic
estimating equation regression with autoregressive
correlation structure
continued

TABLE D-7 Continued
Data
MetroHealth System, Benson et al., 2011 1999-2008 Number of participants
EpicCare – Northeast
Ohio
Miami-Dade County Saab et al., 2011 1999-2005 Percent
Schools Health
Screenings
Military Health System Eilerman et al., 2009-2012 Crude and age-adjusted
2014 prevalence
Entire population; no
standard error or CIs
presented
Monitoring the Future Slater et al., 2013 2010 Percent
MOVE Projectf Carlson et al., 2007-2010 n (%)

2012
Multiple datasetsg Lee et al., 2011 1959-2002 Plotted on a graph
Multiple datasetsh Ng et al., 2014 1984-2012 Age-standardized

prevalence rates
Multiple datasetsj Hernández-Valero 2001-2007 Percent

et al., 2012
Multiple datasetsk Lasserre et al., Varied by Percent

2007 dataset
National Comorbidity Blank et al., 2015 2001-2002 Number of participants

Survey – Adolescent
Supplement
National Hospital Koebnick et al., 1986-2006 Calculated per 100,000
Discharge Survey 2009 population for 3-year
periods

APPENDIX D 251

NR NR NR
Presented by school year NR Logistic regression analyses

Analyses stratified, by sex
Stratified by sex, active NR Presented prevalence for each

duty status year
Compared calculated
prevalence to NHANES 95
percent confidence interval
Multivariable logistic NR NR
regression
NR Absolute change in NR
BMI z-score (standard
deviation); paired t-test
Presented by dataset used Linear regression Plotted on a graph
Stratified by sex, race, and coefficients for time periods Linear regression analysis
sex*age Growth curve models
(longitudinal)
Stratified by sex and age NR Spatiotemporal regression
(<20 and >20 years) model and Gaussian process
regression with smoothing
function smoothing functioni
Stratified by origin and NR NR
resident status
Chi-square
Univariate and multivariate
multinomial logistic
regression models
Compared three different NR Plotted on graph and
countries discussed
Percent ± standard error NR NR

Logistic regression adjusted
for age, sex, and race
Chi-square NR Plotted on a graph
continued

TABLE D-7 Continued
Data
Nationwide George et al., 2011 1995-2008 Percent (standard error)
Inpatient Sample
New York City Day et al., 2014 2006-2007 Percent

FitnessGram® through
2010-2011
New York City Rundle et al., 2012 2007-2008 Percent
FitnessGram®
New York City PedNSS Sekhobo et al., 2004-2006 n (%)

2014 versus
2008-2010
New York State PedNSS Sekhobo et al., 2002-2007 Percent
2010
NHANES Din-Dzietham et 1963-2002 Prevalence with Taylor
al., 2007 series linearization for
variance estimation
Unadjusted weighted
prevalence (standard
error)
NHANES Freedman et al., 1971-1974, Percent (standard error)
2006 1976-1980,
1988-1994,
1999-2002
NHANES Murasko, 2011 1971-1980 NR
versus
1999-2008
NHANES Song et al., 2012 1971-1994 Prevalence with Taylor
series linearization for
variance estimation
NHANES Wang and Zhang, 1971-2002 Percent ± standard
2006 error

APPENDIX D 253

Stratified by sex, age NR Linear regression; orthogonal
groups polynomial contrasts across
time periods
Wald statistic Relative change presented Multivariable logistic models
Presented by gender* race* NR NR

school-level groups
Multivariable generalized
estimating equations with a
logit link
Stratified by high-risk and Chi-square tests Ecologic, time-trend analysis
low-risk neighborhoods,
and by borough Absolute change presented
Present percent by sex and NR Prevalence presented for each
sex*race/ethnicity year; plotted on a graph
Present unadjusted NR Present unadjusted weighted
prevalence (standard error) prevalence and mean (SE)
by race and NHANES of participants’ selected
cycles characteristics by race/
ethnicity over time
Presented by race/ethnicity Present absolute change Logistic regression models

groups (*sex; *age groups)
Stratified by age groups, Absolute difference (BMI Bayesian penalized-spline

income level z-score) technique for structured
additive models
NR NR NR
Chi-square NR Pooled data; logistic and

linear regression analysis;
Logistic regression; odds of included survey periods in
obesity by socioeconomic models
status and race/ethnicity
continued

TABLE D-7 Continued
Data
NHANES Lee et al., 2010 1971-2006 Prevalence with Taylor
variance estimation
NHANES Robinson et al., 1971-2008 Contingency table of

2013 prevalence, percent
NHANES Wang et al., 2012 1971-2008 NR
NHANES Skelton et al., 1976-1980, n (%), 95 percent CI

2009 1988-1994, Standard errors were
1999-2000, estimated using Taylor
2001-2002, series linearization
2003-2004 Extrapolated estimates
to entire U.S.
population
NHANES Ver Ploeg et al., 1976-2002 NR
2008
NHANES Zachariah et al., 1976-2008 Percent
2014
NHANES Rosner et al., 2013 1988-2008 Mean ± standard error
BMI
NHANES Ogden et al., 2006 1999-2000, Weighted prevalence
2001-2002, estimates (95 percent
2003-2004 CI); Taylor series
linearization for
variance estimation
NHANES May et al., 2012 1999-2008 Weighted prevalence,
n (%)
% (standard error)
NHANES Khoury et al., 1999-2008 Present mean ±
2013 standard deviation of
BMI

APPENDIX D 255

No statistical comparisons; Absolute increases in Age-period-birth cohort
discussed absolute obesity prevalence were analysis
differences calculated for the age trend
by birth cohort analyses
Age-period-cohort analysis NR Age-period-cohort analysis

(median polish technique) (median polish technique)
Models presented by age Average annual changes Average annual changes
groups and race/ethnicity estimated by regression estimated by regression
models models
Logistic regression models Logistic regression models
also fitted Differences in the slope of
trends tested (per/post 1999)
Chi-square tests NR Cochran-Armitage trend test
Bonferroni correction for

multiple comparisons
Multiple regression analysis Multiple regression analysis Multiple regression analysis

Logit models Logit models Logit models
NR NR Present percent by NHANES
cycle
Stratified by NHANES NR NR
cycle, sex
Sex-specific multiple logistic NR Sex-specific logistic regression;
regression models survey years was used as a
T-tests ordinal variable
Chi-square tests NR Presented prevalence

Bonferroni correction for (standard error) by NHANES
multiple comparisons cycle
NR NR NR
continued

TABLE D-7 Continued
Data
NHANES Ogden et al., 2012 1999-2010 Weighted prevalence
estimates (95 percent
CI); Taylor series
linearization for
variance estimation
NHANES Skinner et al., 1999-2012 n, weighted percentl
2015
NHANES Skinner and 1999-2012 Prevalence estimates for
Skelton, 2014 each obesity definition
by 2-year NHANES
cycles
NHANES Rossen and 2001-2002, Multivariable logistic

Schoendorf, 2012 2009-2010 regression generated
adjusted
probabilities
(prevalence); Taylor
variance estimation
NHANES Okosun et al., 2003-2004 Number of participants
2010
NHANES Ogden et al., 2014 2003-2004, Weighted prevalence

2005-2006, estimates (95 percent
2007-2008, CI); Taylor series
2009-2010, linearization for
2011-2012 variance estimation
NHANES Trasande et al., 2003-2008 Number of participants

2012 Percent ± standard
error
NHANES Lalwani et al., 2005-2006 Number of participants
2013
NHANES Li et al., 2012 2005-2008 Percent ± standard

error
NHANES Fakhouri et al., 2009-2010 Number of participants
2013

APPENDIX D 257

Sex-specific multiple logistic “Regression models using Sex-specific multiple logistic
regression models survey period as a discrete regression models; linear
T-tests (difference by sex variable with appropriate trends tested with survey cycle
overall, between race/ contrast matrices” as discrete and continuous
ethnicity groups) variable
Stratified by age category NR NR
Adjusted Wald tests Adjusted Wald test Logistic regression; regressed

of differences by NHANES years as an ordinal
demographics variable on the binary
outcome; coefficient and
standard errors represent a
test for a linear trend
Presented by race, ethnicity Presented estimates by cycle NR
groups, and socioeconomic year
status by cycle year
One-way ANOVA NR NR
Pearson chi-square tests
T-tests (sex difference) Absolute change Unadjusted prevalence trends

ANOVA (difference tested with t statistics and
between race/ethnicity orthogonal contrast matrices
categories); T-tests
Adjustments not made for Sex- and age-specific logistic
multiple comparisons regression models
Multivariable logistic NR NR
regression
Cochrane-Armitage trend NR NR
test (across various levels of
hearing loss groups)
Independent t-test
Stratified by age groups NR NR
NR NR NR
continued

TABLE D-7 Continued
Data
NSCH Kim, 2012 2002-2003, Percent
2006-2007
NSCH Kim et al., 2011 2003 Percent
Ohio Schools – Third Oza-Frank et al., 2004-2005 Percent (95 percent CI)
Grade Dataset 2013 through Adjusted prevalence
2009-2010 estimates; predictive
margins
Oklahoma WIC Datam Weedn et al., 2014 2005-2010 n (%)
PedNSS CDC, 2009 1998, 2003, n (%)

2008
PedNSS Pan et al., 2012 1998-2010 Percent (95 percent CI)
PedNSS CDC, 2013c 2008-2011 n (%)
Penn State Child Cohort Rodríguez-Colón 2002-2006 n (%)

et al., 2011
Penn State Child Cohort Calhoun et al., NR Average BMI percentile
2011 presented
Pennsylvania Public Bailey-Davis et al., 2006-2007, Proportion

School BMI Surveillance 2012 2007-2008, Presented by school
2008-2009 years and as 3-year
mean

APPENDIX D 259

Logistic regression; odds of NR NR
obesity by school physical
education requirements
Stratified by sex NR NR
Regression analyses used to
assess adjusted odd ratios
by ADHD and medication
status
Presented prevalence by NR Logistic regression; survey
age, sex, race/ethnicity, year included as ordinal
National School Lunch variable
Program participation,
county type
Sex-stratified multivariable NR Sex-specific regression models;
logistic regression with year included as continuous
interaction terms variable
Presented by state for three Chi-square tests for Graphed the prevalence for
different years difference in proportions the entire sample over the
Figure present prevalence 3-year period
over time by race/ethnicity Average absolute change
categories
T-tests with Bonferroni NR Joinpoint regression
adjustments Piecewise logistic regression
Logistic regression Absolute change presented Logistic regression models
Crude and adjusted odds
ratios are presented
NR NR NR
Average BMI percentile NR NR

presented by groups
Bivariate comparisons; NR Box-plots presented by school

ANOVA year
Multivariate models
with adjusted pairwise Linear models used and F test
comparisons and model coefficients
continued

TABLE D-7 Continued
Data
Philadelphia Schools Robbins et al., 2006-2007 Percent
2012 through
2009-2010
Philadelphia Schools Lawman et al., 2011-2012 Percent

2015
Pine Ridge Reservation Hearst et al., 2011 1998-2002 Percent (number of

School-Based participants)
Assessment
PNSS Hinkle et al., 2012 1999, 2004, n (%)
2008
South Dakota School- Hearst et al., 2013 1998-2010 n (%)

Based BMI Assessment
Special Olympics Foley et al., 2014 2005-2010 Percent (95 percent CI)
International Healthy
Athletes Database
Texas SPAN Study Ezendam et al., 2000- Percent

2011 2002 to
2004-2005
Total Army Injury Hruby et al., 2015 1989-2012 Percent
and Health Outcomes
Database
Truven Health Analytics Joyce et al., 2015 2004-2010 n (%)
MarketScan Database
The Tucson Children’s Archbold et al., 1999-2004 n (%)
Assessment of Sleep 2012
Apnea Study

APPENDIX D 261

Prevalence presented Relative percent change Testing a linear variable for
by grade groups, sex, presented school year in multivariable
sex*race/ethnicity group, models
by eligibility for free/ P-value for trend was
reduced-priced lunch calculated using Wald Chi-
square test
Stratified by sex, race, and Present absolute change Ordinal regression mixed
grade model
Multinomial logistic
regressions
Chi-square
Presented by age groups, NR NR
sex, percent Indian heritage
Wald Chi-square test
Presented by participating Average annual percentage Cochran-Armitage test for
locations, by demographic point changes trend
characteristics by year
1 degree of freedom Wald 1 degree of freedom Wald

chi-square test chi-square test
Chi-squared tests NR Chi-squared tests
comparing results to Presented percent (95 percent
NHANES CI)
Logistic regression used Plotted prevalence for each
to assess effect of age year on a graph
and gender on overall
prevalence (2005-2010)
Chi-square test Present percent at both NR
Cross-sectional mediation time points
analysis
Multivariate logistic Present prevalence by each Multivariate logistic
regression year regression with time interval
as a predictor
Multivariate regression NR NR
NR Student paired t-test NR

and the 2-sample test of
proportions
continued

TABLE D-7 Continued
Data
Washington State Kern et al., 2014 2004-2012 Percent ± 95 percent CI
Healthy Youth Survey
YRBS (national, state, Eaton et al., 2012 1999-2011 Percent (95 percent CI)
large urban school
districts)
YRBS (national, state, Kann et al., 2014 1999-2013 Percent (95 percent CI)
large urban school
districts)
local)
local)
YRBS, Florida Nickelson et al., 2006 n (%)

2012
YRBS, North Carolina Ritzman and 2001, 2005 Percent
Elmore, 2006
YRBSS Taber et al., 2012 2001-2007 Percent
Not Specified Acharya et al., 2004-2005 Percent

2011
Not Specified Chen and Weng, 2004 Percent
2012
Not Specified Crowley et al., 1986-1989, n (%)
2011 2008
Not Specified Gamble et al., 2009-2010 Percent
2012
Not Specified Halloran et al., 1993-2006 n (%)
2012
Not Specified Huh et al., 2012 NR Percent

APPENDIX D 263

Stratified analyses Logistic regression analysis; Logistic regression analysis
Interaction terms in logistic change in odds (2010 (2004-2012); adjusted for
regression (group*year) versus 2012) potential confounders
T-test T-test Logistic regression analyses;
simultaneously assessed linear
and quadratic time effects
Joinpoint analysis
NR NR NR
Present by school level Simply report apercentage NR

for each year
Linear mixed models NR Sex-stratified linear model and
(between state included a quadratic term for
comparisons) time
Chi-square, by race, NR NR
ethnicity
Logistic regression NR NR
adjusting for covariates
Stratified by “era” (1986- Likelihood ratio NR
1989, 2008) chi-square test
One-way ANOVA; Tukey’s NR NR
post-hoc tests
Chi-square test NR Cochran-Armitage test of
Plotted graphs by race trend
Plotted prevalence for each
year on a graph, by race
Models regressed on age; NR Longitudinal regression
age and ethnicity; and analyses using generalized
age*ethnicity interaction estimating equation
continued

TABLE D-7 Continued
Data
Not Specified Lemay et al., 2008 2001-2005 Percent
Not Specified Nader et al., 2014 2003, 2006, n (%)

2009
Not Specified Nafiu et al., 2014 NR Number of participants
Not Specified Reed et al., 2013 2010 n (%)
Not Specified Rogozinski et al., 1994-2004 Percent

2007 Percent (N)
Not Specified Salihu et al., 2010 2004-2007 Percent

Not Specified Simmons et al., 2008-2010 Percent
2012
Not Specified Staiano et al., NR Mean ± standard
2013 deviation; BMI and
BMI z-score
Not Specified Stingone et al., NR n (%)
2011
Not Specified Taylor et al., 2014 NR Percent (mean, median,
standard deviation,
min, max)
Not Specified Williamson et al., 2006-2008 n (%)
2011
NOTES: CI, confidence interval; NR, not reported in published report; * indicates interactions
in analysis; all study and dataset acronyms are listed in Appendix A.
a Study or data source name provided in text of the publication. If the publication did not
specifically name the data source that was used, but provided details about data collection
protocol, it is labeled as “Not Specified” in the table.
b The 2008-2009 data came from routine measurements of students from the middle school
(grades 6-8) and high school (grades 9-12), which enrolls ~81% of students in the community.
c Percent in the body composition “Healthy Fitness Zone.”
d Birth cohort years; end year of data collection not specified in the published report.
e Presented as overweight and obese at age 10 years.
f The MOVE project is a 12-month childhood obesity prevention program with a 24-month
follow-up.
g Includes NHANES (1959-1962, 1966-1970, 1971-1975, 1976-1980, 1988-1994, 1999-
2000, 2001-2002); Add Health (Wave 1: 1994-1995; Wave 2: 1996; Wave 3: 2001-2002);
NHIS (1980, 1990, 2000-2003); NLSY79 (1981-1982, 1985); NLSY97 (1997, 2001).
h Includes National Longitudinal Survey of Youth (1997-2011); National Survey of Fam-
ily Growth (2006, 2007, 2008, 2009); National Longitudinal Survey of Adolescent Health
(1994); International Social Survey Programme (ISSP) (2012); National Health Measurement

APPENDIX D 265

Chi-square tests Reported the percent at NR
each time point
Univariate and multivariate Chi-square test Cochran–Armitage test for
logistic regression models trend
NR NR NR
ANOVA NR NR
Chi-square
Compared estimates to NR Chi-square test for trend
NHANES (graph) Multiple logistic regression
analysis
Chi-square for trend NR NR
Chi-square test Wilcoxon signed-rank test NR
NR NR NR
NRn NR NR
Pearson product-moment NR NR
correlation coefficients
(partial correlations)
NR n (%) at both time points NR
presented
Survey (2006); National Survey on Drug Abuse (1995); NHANES (1988, 1999, 2001, 2003,
2005, 2007, 2009, 2011); BRFSS (1984-2012); National Longitudinal Survey - Child/Young
Adult (1986, 1988, 1990, 1992, 1992, 1996, 1998, 200, 2002, 2004, 2006, 2008, 2010);
Health Behavior in School-Aged Children (2001, 2005, 2009); National Health Interview
Survey (NHIS) (1980-2012); PedNSS (1980-2012).
i U.S. data included in the “developed” country age-birth cohort trend.
j Includes Cohort of Mexican School Age Children and Adolescents (2004-2006); Mano a
Mano Cohort (2001-2003); and From Mother to Child Project (2004-2007).

k Includes previously published NHANES data; published aggregate data from Switzer-
land (Zurich [1960/1965; 1980/1990]; national data [2002]); and raw data from Seychelles
(1998-2004).
l Only assessed children at or above the 85th percentile on the 2000 Centers for Disease
Control and Prevention BMI-for-age growth charts; prevalence presented by gradation of

obesity categories.
m Oklahoma did not report to national PedNSS during this time.
n Obesity prevalence is presented in the text, but the figures and tables describe overweight
rather than obesity.

TABLE D-8 2000 CDC Body Mass Index-for-Age Percentiles Corresponding to the 2015 FitnessGram’s® Needs
266
Improvement-Health Risk (NI-HR) Cut Points, by Age and Sex

Hypothetical Information Used to Calculate a BMI Corresponding to the NI-HR BMI Cut Point
Date of Height, Weight, NI-HR BMI Corresponding BMI-for-
Age, years Sex Date of Birth Measurement inchesa poundsb Cut Pointc Age Percentiled
5.0 F 01/01/1999 01/01/2004 48 60.6 18.5 95.8
5.5 F 01/01/1999 07/01/2004 48 60.6 18.5 95.0
6.0 F 01/01/1999 01/01/2005 48 62.9 19.2 96.0
6.5 F 01/01/1999 07/01/2005 48 62.9 19.2 95.0
7.0 F 01/01/1999 01/01/2006 48 66.2 20.2 96.1
7.5 F 01/01/1999 07/01/2006 48 66.2 20.2 95.1
8.0 F 01/01/1999 01/01/2007 48 69.5 21.2 96.0
8.5 F 01/01/1999 07/01/2007 48 69.5 21.2 95.0
9.0 F 01/01/1999 01/01/2008 48 73.4 22.4 96.0
9.5 F 01/01/1999 07/01/2008 48 73.4 22.4 95.0
10.0 F 01/01/1999 01/01/2009 48 77.3 23.6 95.9
10.5 F 01/01/1999 07/01/2009 48 77.3 23.6 95.1
11.0 F 01/01/1999 01/01/2010 48 81.0 24.7 95.8
11.5 F 01/01/1999 07/01/2010 48 81.0 24.7 95.0

12.0 F 01/01/1999 01/01/2011 48 84.6 25.8 95.7
12.5 F 01/01/1999 07/01/2011 48 84.6 25.8 95.0
13.0 F 01/01/1999 01/01/2012 48 87.8 26.8 95.6
13.5 F 01/01/1999 07/01/2012 48 87.8 26.8 95.0
14.0 F 01/01/1999 01/01/2013 48 90.8 27.7 95.5
14.5 F 01/01/1999 07/01/2013 48 90.8 27.7 95.0
15.0 F 01/01/1999 01/01/2014 48 93.4 28.5 95.4
15.5 F 01/01/1999 07/01/2014 48 93.4 28.5 95.0
16.0 F 01/01/1999 01/01/2015 48 96.0 29.3 95.4

16.5 F 01/01/1999 07/01/2015 48 96.0 29.3 95.0
17.0 F 01/01/1999 01/01/2016 48 98.3 30.0 95.4
17.5 F 01/01/1999 07/01/2016 48 98.3 30.0 95.0

5.0 M 01/01/1999 01/01/2004 48 59.3 18.1 95.8

5.5 M 01/01/1999 07/01/2004 48 59.3 18.1 94.9
6.0 M 01/01/1999 01/01/2005 48 61.6 18.8 96.3
6.5 M 01/01/1999 07/01/2005 48 61.6 18.8 95.2
7.0 M 01/01/1999 01/01/2006 48 64.2 19.6 96.2
7.5 M 01/01/1999 07/01/2006 48 64.2 19.6 95.1
8.0 M 01/01/1999 01/01/2007 48 67.5 20.6 96.1
8.5 M 01/01/1999 07/01/2007 48 67.5 20.6 95.1
9.0 M 01/01/1999 01/01/2008 48 70.8 21.6 95.9
9.5 M 01/01/1999 07/01/2008 48 70.8 21.6 95.0
10.0 M 01/01/1999 01/01/2009 48 74.4 22.7 95.9
10.5 M 01/01/1999 07/01/2009 48 74.4 22.7 95.1
11.0 M 01/01/1999 01/01/2010 48 77.7 23.7 95.7
11.5 M 01/01/1999 07/01/2010 48 77.7 23.7 95.0
12.0 M 01/01/1999 01/01/2011 48 81.0 24.7 95.7
12.5 M 01/01/1999 07/01/2011 48 81.0 24.7 95.0
13.0 M 01/01/1999 01/01/2012 48 83.9 25.6 95.6
13.5 M 01/01/1999 07/01/2012 48 83.9 25.6 95.0
14.0 M 01/01/1999 01/01/2013 48 86.9 26.5 95.6
14.5 M 01/01/1999 07/01/2013 48 86.9 26.5 95.1
15.0 M 01/01/1999 01/01/2014 48 89.1 27.2 95.5

15.5 M 01/01/1999 07/01/2014 48 89.1 27.2 95.0
16.0 M 01/01/1999 01/01/2015 48 91.4 27.9 95.5
16.5 M 01/01/1999 07/01/2015 48 91.4 27.9 95.0
17.0 M 01/01/1999 01/01/2016 48 93.7 28.6 95.5
17.5 M 01/01/1999 07/01/2016 48 93.7 28.6 95.0
NOTE: NI-HR, Needs Improvement-Health Risk.

a For ease of calculation of the BMI corresponding to the 2015 FitnessGram’s® NI-HR cut points, all heights were set to 48 inches.
b Values are weights in pounds that correspond to the NI-HR BMI cut point, based on a height of 48 inches.

c BMI cut points correspond to the values used in the 2015-2016 California Physical Fitness Test (California Department of Education, 2015).
d Percentiles correspond to the 2000 CDC sex-specific BMI-for-age growth charts. BMI-for-age percentile calculated using the CDC Children’s
267
BMI Tool for Schools spreadsheet (CDC, 2015).

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Appendix E
Committee Member Biographical Sketches
Shari Barkin, M.D., M.S.H.S. (Chair), is a Professor of Pediatrics and the

William K. Warren Foundation Endowed Chair, Director of Pediatric Obesity
Research in the Diabetes Center, and Chief of General Pediatrics at V
anderbilt
University Medical Center. Dr. Barkin studies family-based community-
centered behavioral interventions to measurably reduce pediatric obesity
during sensitive windows of childhood development. Research focuses on
changing early growth trajectories in childhood, applying the ecologic model
that considers the child in the context of their family, and the family in the
context of their community. Studies use a micro- to macro-level systems con-
ceptual model that examines the interaction between behavior, environment,
and genetics during periods of early childhood. She is a National Institutes
of Health–funded researcher in the area of injury prevention and obesity
prevention and early intervention. She conducted the first intervention trial
in the Pediatric Research in Office Settings Network testing the effectiveness
of office-based youth violence prevention, including more than 200 pro
viders and close to 5,000 families. More recently, Dr. Barkin has conducted
interventional trials to prevent and treat childhood obesity, with attention
to health disparities, working with minority populations. Currently, she is
conducting a 7-year randomized controlled trial to prevent childhood obesity,
the Growing Right Onto Wellness Trial funded by National Heart, Lung,
and Blood Institute (NHLBI) and National Institute of Child Health and
Human Development (NICHD). She received her M.D. from the University
of Cincinnati, completed her pediatric residency at Children’s Hospital of Los
Angeles, and a Robert Wood Johnson Clinical Scholars fellowship in Health
Services Research at University of California, Los Angeles.
279

Cheryl A. M. Anderson, Ph.D., M.P.H., is Associate Professor in the

Department of Family Medicine and Public Health at the University
of California, San Diego. Dr. Anderson’s research centers on nutrition-
related issues in chronic disease prevention in minority and under-served
populations. She is a co-investigator on the National Institute of Diabetes
and Digestive and Kidney Disease (NIDDK)–funded national, multicenter
Chronic Renal Insufficiency Cohort Study, which aims to identify risk
factors and mechanisms of progressive renal disease and cardiovascular
events in individuals with chronic kidney disease. She is a co-investigator
on the National Heart, Lung, and Blood Institute–funded OMNI-Carb
study a randomized feeding study that compares the effects of type
(glycemic index) and amount of carbohydrate on cardiovascular risk

factors. Dr. Anderson is principal investigator of a study testing a unique
biomarker (using carbon isotopic data) of intake of sweets (funded by an
Innovation Grant Award from the Johns Hopkins Bloomberg School of
Public Health).
Lynn A. Blewett, Ph.D., is Professor of Health Policy and Director of

the State Health Access Data Assistance Center (SHADAC) in the School
of Public Health at the University of Minnesota. SHADAC is a research
and policy center focused on issues related to health insurance coverage,
barriers to access to needed care, the implementation of the Affordable
Care Act, and use of the federal and state population-level data to inform
health policy. Dr. Blewett brings expertise in state and federal health data
resources including the Current Population Survey (CPS), the American
Community Survey (ACS), the National Health Interview Survey (NHIS),
and the Behavior Risk Factor Surveillance System (BRFSS), which are all
accessible through SHADAC’s interactive online Data Center. Dr. Blewett
was instrumental in establishing the University of Minnesota’s Minnesota
Research Data Center (RDC) which is a part of the Federal Statistical Data
Center Network. She is also principal investigator of the Integrated Health
Interview Series (IHIS), a project funded by the National Institute Child
Health and Human Development (NICHD) to harmonize and integrate
more than 50 years of the NHIS and more recently survey data from the
Agency for Healthcare Research and Quality’s Medical Expenditure Panel
Survey (MEPS). Dr. Blewett is a board member of AcademyHealth, a multi
disciplinary professional association committed to advancing the field of
health services research; serves on the board of the Local Access to Care
Program, Portico Healthnet; and is a member of the National Academy of
Social Insurance. Dr. Blewett earned a master’s degree in public affairs and
a doctorate degree in health services research, policy, and administration
from the University of Minnesota.

APPENDIX E 281
Elizabeth Goodman, M.D., is Associate Chief for Community-Based

Research at the MassGeneral Hospital for Children, and a Professor of
Pediatrics at Harvard Medical School. She was a Robert Wood Johnson
Clinical Scholar at the University of California, San Francisco, a William
T. Grant Scholar, and fellow at the Joint Program in Society and Health at
New England Medical Center and the Harvard School of Public Health.
Dr. Goodman is a national expert on social stratification and its effect on
adolescent health and is well known for her research on social stratifica-
tion, obesity, insulin resistance, and other cardiometabolic risks. Through
her research, she has been attempting to understand how the structure of
our society, created through social and economic policies and practices,
influences health and well-being, or what she has termed “the biology of
social justice.” As part of this program of research, Dr. Goodman has pio-
neered the study of subjective social status in adolescence. A major focus
for the past 5 years has been the physiological and psychological processes
through which differences in social status influence children’s health and the
trajectory toward adult cardiovascular health, particularly obesity and
metabolic risk. A second line of research explores whether the concept
of metabolic syndrome relates to child health and, if so, how.
Ross Hammond, Ph.D., is Senior Fellow in Economics at Brookings and

Director of the Center on Social Dynamics and Policy, which applies com-
plex systems science modeling methodologies, such as agent-based model-
ing, to problems in social science and public health. He has 20 years of
experience with these core methodologies and has taught computational
modeling at Harvard, the University of Michigan, Washington University,
and the National Institutes of Health. Much of his research has focused on
the interaction of individual behavior, biology, and social/environmental
dynamics. He holds appointments at Harvard School of Public Health,
the Santa Fe Institute, and the Brown School at Washington University in
St Louis. He is on the editorial board of the journals Behavioral Science
& Policy and Childhood Obesity and has been a member of four NIH-
funded research networks: MIDAS (Models of Infectious Disease Agent
Study), ENVISION (part of the National Collaborative on Childhood Obe-
sity Research), NICH (Network on Inequality, Complexity, and Health),
and SCTC (State and Community Tobacco Control). Dr. Hammond is an
appointed member of the National Institute on Minority Health and Health
Disparities advisory council, and serves as a public health advisor for the
National Cancer Institute, an Advisory Special Government Employee for
the Food and Drug Administration Center for Tobacco Products, and a
commissioner for the Lancet Commission on Obesity. He has contributed to
multiple Institute of Medicine reports, including one approaching the U.S.
food system from a complex systems perspective and one focused on the use

of agent-based models to inform tobacco policy. Dr. Hammond received his

B.A. from Williams College and his Ph.D. from the University of Michigan.
Sandra Hassink, M.D., M.Sc., is the Immediate Past President of the Ameri-
can Academy of Pediatrics (AAP) and the Director of the American Acad-
emy of Pediatrics Institute of Healthy Childhood Weight and Chair of the
AAP Institute for Healthy Childhood Weight Advisory Board and Steering
Committee. She has testified on Childhood Obesity for the House Energy
and Commerce Committee and the Senate Committee on Health, Educa-
tion, Labor and Pensions. Dr. Hassink has chaired the ethics committee
at the A.I. DuPont Hospital for Children and co-chaired the Delaware
state ethics committee. Dr. Hassink is an author on the obesity preven-
tion segment of the Expert Committee recommendations, senior editor of
“A Parent’s Guide to Childhood Obesity,” author of “Pediatric Obesity:
Prevention, Intervention, and Treatment Strategies for Primary Care,” and
author of “Clinical Guide to Pediatric Weight Management.” She worked
on the GLIDES project funded by the Agency for Healthcare Research and
Quality to embed the Expert Committee recommendation on obesity into
the emergency health record at Nemours and was the principal investigator
on an Obesity Cluster Grant developing population health management
systems for children with obesity. She has collaborated in basic research
efforts to identify pathophysiologic mechanisms of obesity, centering on
the role of leptin, and has lectured widely in the field of pediatric obesity.
She is a Fellow of the American Academy of Pediatrics. Dr. Hassink holds
a master’s degree in Pastoral Care and Counseling from Neumann College
and an M.D. from Vanderbilt University School of Medicine.
Amy H. Herring, Sc.D., is the Carol Remmer Angle Distinguished Professor

of Children’s Environmental Health, and Professor and Associate Chair
of Biostatistics in the Gillings School of Global Public Health at the Uni-
versity of North Carolina (UNC) at Chapel Hill. In addition, Dr. Herring
is an elected Faculty Fellow at UNC’s Carolina Population Center, where
she conducts research using new statistical methods and innovative appli-
cations of statistics in public health and medicine. Dr. Herring has more
than 210 peer-reviewed publications and is currently the principal inves-
tigator of a 5-year National Institutes of Health–funded project exploring
Bayesian methods for high-dimensional epidemiologic data. Her longstand-
ing research interests include environmental health science, reproductive
epidemiology, maternal and child health, neonatology, nutrition, and obe-
sity. Dr. Herring earned a Sc.D. in biostatistics at Harvard University.
Giridhar Mallya, M.D., M.S.H.P., has been the Director of Policy and Plan-
ning for the Philadelphia Department of Public Health since October 2008.

APPENDIX E 283
In this position, Dr. Mallya helps to define public health priorities for the
city, coordinates the Department’s research and data analysis activities, and
works with key leadership—including the Board of Health—to set policies
and develop regulations. He also leads the Department’s Get Healthy Philly
tobacco control and obesity prevention initiatives. His research interests
include chronic disease prevention, public health regulation, tobacco con-
trol, obesity prevention. Dr. Mallya earned his A.B. in Biology from Brown
University, graduated from the Warren Alpert Medical School of Brown Uni-
versity, and completed a residency in Family and Community Medicine at
Thomas Jefferson University Hospital in Philadelphia. Following residency,
he was a Robert Wood Johnson Foundation Clinical Scholar at the Univer-
sity of Pennsylvania where he received an M.S. in Health Policy Research.
Michael G. Perri, Ph.D., is Dean of the College of Public Health and Health
Professions and the Robert G. Frank Endowed Professor of Clinical and
Health Psychology at the University of Florida. His research focuses on
health promotion and disease prevention through changes in diet and
physical activity. He has contributed to more than 175 publications, and
the 25 randomized clinical trials conducted by Dr. Perri and his team have
contributed significantly to theory, research, and clinical care in the area
of lifestyle management of obesity. Dr. Perri is an elected Fellow of the
American Psychological Association, the Society of Behavioral Medicine,
and The Obesity Society. He is a recipient of the American Psychological
Association’s Samuel M. Turner Award for Distinguished Contributions to
Applied Research and the Society of Behavioral Medicine’s Distinguished
Research Mentor Award. He served as the Behavioral Consultant for the
2015 Dietary Guidelines for Americans and as a member of the 2014
NIH Working Group on Innovative Research to Improve the Maintenance
of Weight Loss. Dr. Perri is certified by the American Board of Profes-
sional Psychologists (ABPP) and received a Ph.D. from the University of
Missouri-Columbia.
Eduardo Sanchez, M.D., M.P.H., FAAFP, is Chief Medical Officer for Pre-
vention and Chief of the Center for Health Metrics and Evaluation for the
American Heart Association. Formerly, Dr. Sanchez served as Vice President
and Chief Medical Officer for Blue Cross and Blue Shield of Texas from
2008 to 2013. Dr. Sanchez led the Institute for Health Policy at The Uni-
versity of Texas School of Public Health (UTSPH) as Director from 2006
to 2008. From 2001 to 2006, he served as Texas Commissioner of Health,
leading the Texas Department of State Health Services (DSHS) from 2004
to 2006 and the Texas Department of Health (TDH) from 2001 to 2004.
Dr. Sanchez currently serves as Chair of the Texas Public Health Coalition
(TPHC) and the National Commission on Prevention Priorities (NCPP).

He co-chairs the Dallas Health and Wellness Alliance for Children. He

serves on the National Academies of Sciences, Engineering, and Medicine’s
Roundtable on Obesity Solutions and the National Quality Forum (NQF)
Disparities Standing Committee. In addition, he is a member of the Trust
for America’s Health Board of Directors and AcademyHealth’s Board of
Directors. He serves on the Robert Wood Johnson Foundation Health
Policy Fellow Advisory Board. He also serves on The University of Texas
System Health Care Advisory Committee. From 2008 to 2012, he served as
chair of the Advisory Committee to the Director of the Centers for Disease
Control and Prevention (CDC). He is the recipient of the 2011 Association
of State and Territorial Health Officials (ASTHO) Alumni Award and the
2011Texas Public Health Association (TPHA) James E. Peavy Memorial
Award. In 2005, he was awarded the Texas School Health Association
(TSHA) John P. McGovern Award and the 2005 American Academy of
Family Physicians (AAFP) Public Health Award. In 2004, he received the
American Heart Association Louis B. Russell Memorial Award, for out-
standing service in addressing health care disparities, by the American
Heart Association. Dr. Sanchez received an M.D. from The University of
Texas (UT) Southwestern Medical School in Dallas, an M.P.H. from the UT
Health Science Center at Houston School of Public Health. Before attend-
ing medical school, he attained an M.S. in biomedical engineering from
Duke University. He holds a B.S. in biomedical engineering and a B.A. in
chemistry from Boston University. Dr. Sanchez is board certified in family
medicine.
Jackson P. Sekhobo, Ph.D., M.P.A., is the Director of Evaluation, Research,

and Surveillance in the Division of Nutrition of the New York State Depart-
ment of Health. Previously, he was an Assistant Medical Professor at the
Sophie Davis School of Biomedical Education, City College of New York,
City University of New York. Dr. Sekhobo has authored or co-authored
articles on the nutrition-related epidemics of obesity and diabetes. He
served as an evaluation consultant for the New York City Department
of Health and Mental Hygiene for the New York City Diabetes Registry
project. Before this role, he served on the Diabetes Evaluation and Diabetes
Indicators Workgroups for the Centers for Disease Control and Prevention.
He was the principal investigator of two Special Supplemental Nutrition
Program for Women, Infants, and Children (WIC) Special Projects Grants,
namely, the NY Fit WIC Grant: Revitalizing WIC Nutrition Service and
the NY WIC Retention Promotion Study: Keep, Reconnect and Thrive. He
co-leads the study, “First Steps Evaluation of Childhood Obesity Prevention
Policies in the New York State WIC Program,” which is funded by the Rob-
ert Wood Johnson Foundation and the New York State Health Foundation.
He currently serves on the Evaluation Committee for the National WIC

APPENDIX E 285
Association and is a member of an Advisory Expert Panel for the Third

National Survey of WIC Participants. He recently served on the Institute
of Medicine Planning Committee for a WIC Research Agenda. Dr. Sekhobo
received a Ph.D. in epidemiology from the University of Albany, State Uni-
versity of New York and an M.P.A. in health policy and management from
New York University.
Shumei S. Sun, Ph.D., is the W. Hans Carter Professor and Chair of the
Department of Biostatistics and Professor in the Department of Epidemiol-
ogy and Community Health at Virginia Commonwealth University. Before
holding these positions, Dr. Sun served as the Brage Golding Distinguished
Research Professor at Wright State University in Dayton, Ohio. Dr. Sun’s
research seeks to understand the natural history of human growth and
body composition, and to identify risk factors in childhood that predict the
onset of cardiovascular and metabolic diseases later in life. Her research
on health promotion and disease prevention contributes to improving lon-
gevity and quality of life. Dr. Sun’s statistical research includes modeling
complex cross-sectional and longitudinal data for body composition and
cardiovascular risk factors to elucidate the multifactorial matrix of vari-
ables associated with cardiovascular and metabolic disease. Dr. Sun cur-
rently collaborates with investigators at the University of Pittsburgh and the
University of Colorado on methods to study changes of body composition
in children. Dr. Sun received a B.P.H. in public health from the College of
Medicine, National Taiwan University; an M.S. in applied mathematics and
statistics, State University of New York; and a Ph.D. in biostatistics from
the University of Pittsburgh.


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Assessing Prevalence and Trends in Obesity:

FIND RELATED TITLES SUGGESTED CITATION

Committee on Evaluating Approaches to Assessing

Food and Nutrition Board

Health and Medicine Division

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THE NATIONAL ACADEMIES PRESS 500 Fifth Street, NW Washington, DC 20001

International Standard Book Number-13: 978-0-309-44271-8

Copyright 2016 by the National Academy of Sciences. All rights reserved.

Printed in the United States of America

Suggested citation: National Academies of Sciences, Engineering, and Medicine. 2016.

Copyright National Academy of Sciences. All rights reserved.

The National Academy of Sciences was established in 1863 by an Act of Congress,

The National Academy of Medicine (formerly the Institute of Medicine) was

Copyright National Academy of Sciences. All rights reserved.

Copyright National Academy of Sciences. All rights reserved.

COMMITTEE ON EVALUATING APPROACHES TO

SHARI BARKIN (Chair), Professor of Pediatrics and William K. Warren

Copyright National Academy of Sciences. All rights reserved.

Copyright National Academy of Sciences. All rights reserved.

This report has been reviewed in draft form by individuals chosen

Lawrence D. Brown, University of Pennsylvania

Although the reviewers listed above have provided many constructive

Copyright National Academy of Sciences. All rights reserved.

Copyright National Academy of Sciences. All rights reserved.

Obesity prevalence and trend estimates are at the crux of informing

Copyright National Academy of Sciences. All rights reserved.

am struck by the number of factors the committee identified as having an

Copyright National Academy of Sciences. All rights reserved.

to work with inspirational, intelligent colleagues who push you to think

Shari Barkin, Chair

Copyright National Academy of Sciences. All rights reserved.

Copyright National Academy of Sciences. All rights reserved.

3 Methodological Approaches to Data Collection 57

4 Comparison of Data Sources Used to Assess Obesity Prevalence

5 Analytic Approaches and Considerations 123

6 Framework for Assessing Prevalence and Trends in Obesity

7 Conclusions and Recommendations 179

8 Future Directions for Filling Data Gaps 189

Copyright National Academy of Sciences. All rights reserved.

A Acronyms and Glossary 199

B Public Workshop Agenda 209

C Literature Search Approach 213

D Presentation of Findings 215

E Committee Member Biographical Sketches 279

Copyright National Academy of Sciences. All rights reserved.

The ability to answer research questions about measures of obesity prev-

Copyright National Academy of Sciences. All rights reserved.

2 ASSESSING PREVALENCE AND TRENDS IN OBESITY

STUDY TASK AND APPROACH

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An ad hoc committee under the auspices of the National Academies of Sci­

THE LANDSCAPE OF DATA COLLECTION,

Copyright National Academy of Sciences. All rights reserved.

4 ASSESSING PREVALENCE AND TRENDS IN OBESITY

FRAMEWORK FOR ASSESSING

Copyright National Academy of Sciences. All rights reserved.

4 Comparison of Data Sources Used to Assess Obesity Prevalence

6 Framework for Assessing Prevalence and Trends in Obesity

An ad hoc committee under the auspices of the National Academies of Sci

An ad hoc committee under the auspices of the National Academies of Sci