Obesity prevalence varies by income and education level, although patterns might differ
among adults and youths (
1
–
3
). Previous analyses of national data showed that the prevalence of childhood obesity
by income and education of household head varied across race/Hispanic origin groups
(
4
). CDC analyzed 2011–2014 data from the National Health and Nutrition Examination
Survey (NHANES) to obtain estimates of childhood obesity prevalence by household income
(≤130%, >130% to ≤350%, and >350% of the federal poverty level [FPL]) and head of
household education level (high school graduate or less, some college, and college
graduate). During 2011–2014 the prevalence of obesity among U.S. youths (persons aged
2–19 years) was 17.0%, and was lower in the highest income group (10.9%) than in the
other groups (19.9% and 18.9%) and also lower in the highest education group (9.6%)
than in the other groups (18.3% and 21.6%). Continued progress is needed to reduce
disparities, a goal of Healthy People 2020. The overall Healthy People 2020 target
for childhood obesity prevalence is <14.5% (
5
).
NHANES is a cross-sectional survey designed to monitor the health and nutritional
status of the civilian noninstitutionalized U.S. population (
6
). The survey consists of in-home interviews and standardized physical examinations
conducted in mobile examination centers. The NHANES sample is selected using a complex,
multistage probability design. During 2011–2014, non-Hispanic black, non-Hispanic
Asian, and Hispanic persons, among other groups, were oversampled. Any non-Hispanic
person reporting more than one race was included in an “other” category and included
in the total estimates but not reported separately. The NHANES response rate for youths
aged <20 years was 77.6% during 2011–2012 and 76.1% during 2013–2014. During the physical
examination, standardized measurements of weight and height were obtained. Body mass
index (BMI) was calculated as weight in kilograms divided by height in meters squared,
rounded to the nearest 10th. Obesity among youths was defined as a BMI at or above
the age- and sex-specific 95th percentile of the 2000 CDC growth charts (https://www.cdc.gov/growthcharts/cdc_charts.htm).
Household income was defined using FPL information, which accounts for inflation and
family size (https://aspe.hhs.gov/prior-hhs-poverty-guidelines-and-federal-register-references)
and categorized as ≤130%, >130% to ≤350%, and >350% of FPL. The cut-off point for
participation in the Supplemental Nutrition Assistance Program is 130% of FPL, and
350% provides relatively equal sample sizes for each income group. Education was defined
using education level of head of household and was categorized as a high school graduate
or less, some college, and college graduate.
All estimates accounted for the complex survey design including examination sample
weights. Confidence intervals for estimates were constructed using the Korn and Graubard
method (
7
). Differences between groups were tested using a 2-sided univariate t statistic (p<0.05).
Linear and quadratic trends from 1999–2002 to 2011–2014 were conducted using 4-year
survey cycles. Pregnant females and persons with missing weight or height were excluded
(139) for a total sample size of 6,878 during 2011–2014. For estimates by FPL another
517 persons were missing data and were excluded from analyses of FPL; for estimates
by education level, 224 persons were missing data and were excluded from analyses
of education.
Overall, 17.0% of youths aged 2–19 years had obesity during 2011–2014 (Table). The
prevalence was 18.9% among those in the lowest income group, 19.9% among those in
the middle group, and 10.9% among those in the highest income group. Among females,
patterns in non-Hispanic white, non-Hispanic Asian, and Hispanic youths were similar,
with the prevalence of obesity lower in the highest income group than in both other
groups, but the differences by income were statistically significant only among non-Hispanic
white females. Obesity prevalence did not differ by income among non-Hispanic black
females. Among males, there was a lower obesity prevalence in the highest income group
only in non-Hispanic Asian youths (compared with the lowest income group) and Hispanic
youths (compared with both other income groups).
TABLE
Prevalence of obesity among youths (persons aged 2–19 years), by race/Hispanic origin,
sex, household income, and education of household head — National Health and Nutrition
Examination Survey, United States, 2011–2014
Characteristic
No.
% (95% CI)
All
Race/Hispanic origin
White, non-Hispanic
Black, non-Hispanic
Asian, non-Hispanic
Hispanic
Total
6,878
17.0 (15.5–18.6)
14.7 (12.3–17.3)
19.5 (17.1–22.2)
8.6 (6.4–11.2)
21.9 (20.0–23.9)
Females
3,371
17.1 (15.1–19.3)
15.1 (11.7–19.1)
20.7 (17.1–24.6)
5.3 (2.9–8.6)
21.4 (18.8–24.1)
Males
3,507
16.9 (15.1–19.0)
14.3 (11.2–17.9)
18.4 (16.1–21.0)
11.8 (8.3–16.1)
22.4 (19.9–24.9)
Household income relative to federal poverty level
Total
≤130%
3,131
18.9 (17.3–20.6)
15.5 (12.8–18.5)
19.4 (17.0–22.0)
13.2 (8.2–19.7)
22.8 (19.4–26.5)
>130% to ≤350%
1,974
19.9 (16.8–23.3)
18.0 (12.6–24.6)
19.9 (15.5–25.0)
8.9 (4.9–14.6)
23.7 (19.4–28.5)
>350%
1,256
10.9 (8.0–14.4)*,†
11.0 (7.3–15.7)
19.8 (12.2–29.4)
4.4 (1.9–8.4)*,§
11.8 (7.5–17.4)*,†
Females
≤130%
1,539
19.7 (17.4–22.1)
17.8 (13.3–23.1)
19.9 (15.7–24.6)
8.4 (2.6–19.1)¶
22.5 (18.9–26.3)
>130% to ≤350%
969
21.5 (16.9–26.8)
21.2 (13.0–31.6)
21.6 (16.3–27.6)
8.2 (2.4–19.0)¶
22.7 (17.0–29.2)
>350%
613
8.0 (5.0–12.0)*,†
7.2 (3.5–12.8)*,†
21.1 (9.6–37.2)
1.3 (0.1–4.8)¶
13.8 (6.3–25.2)
Males
≤130%
1,592
18.1 (15.5–21.0)
13.5 (9.2–18.7)
19.0 (15.7–22.6)
18.0 (10.1–28.6)
23.1 (18.0–28.9)
>130% to ≤350%
1,005
18.4 (15.6–21.4)
15.0 (10.0–21.2)
18.1 (12.1–25.5)
9.5 (3.9–18.7)§
24.6 (20.0–29.7)
>350%
643
13.7 (9.5–18.8)
14.7 (9.2–21.9)
18.7 (12.1–26.9)
7.6 (2.8–16.0)*,§
10.0 (4.8–17.9)*,†
Education level of head of household
Total
High school graduate or less
3,254
21.6 (20.0–23.3)
19.6 (16.2–23.3)
21.1 (17.5–25.0)
13.2 (8.5–19.3)
24.2 (20.9–27.7)
Some college
1,936
18.3 (15.4–21.5)**
17.6 (12.4–23.9)
19.7 (16.3–23.4)
12.0 (6.0–20.7)
19.9 (16.2–23.9)
College graduate
1,464
9.6 (7.3–12.5)**,††
8.5 (5.8–12.1)**,††
15.4 (9.8–22.5)
5.5 (3.1–8.9)**
13.5 (6.9–22.8)**
Females
High school graduate or less
1,583
22.7 (20.7–24.9)
22.5 (17.5–28.1)
21.0 (16.0–26.7)
9.2 (4.4–16.5)
23.9 (20.1–28.0)
Some college
938
18.3 (14.6–22.6)**
18.0 (11.8–25.7)
22.1 (17.4–27.4)
8.0 (1.3–23.7)¶
17.3 (12.5–23.0)**
College graduate
739
8.5 (5.5–12.4)**,††
7.5 (3.9–12.8)**,††
16.3 (10.2–24.1)
3.3 (0.7–9.2)¶
14.0 (6.8–24.3)**
Males
High school graduate or less
1,671
20.6 (18.1–23.2)
16.9 (11.6–23.3)
21.1 (17.5–25.1)
16.9 (9.0–27.7)
24.4 (20.5–28.7)
Some college
998
18.3 (14.7–22.4)
17.3 (11.0–25.3)
17.2 (13.4–21.6)
14.6 (6.7–26.4)
22.3 (15.9–29.8)
College graduate
725
10.7 (7.6–14.7)**,††
9.6 (5.5–15.2)**
14.5 (6.9–25.4)
7.9 (3.8–14.0)
12.9 (5.8–23.9) §,**
Abbreviation: CI = confidence interval.
* Significantly different from ≤130% of FPL, p<0.05.
† Significantly different from >130% to ≤350% of FPL, p<0.05.
§ Estimate might be unreliable because relative standard error is between 30% and
40%.
¶ Estimate might be unreliable because relative standard error is >40%.
** Significantly different from high school graduate or less, p<0.05.
†† Significantly different from some college, p<0.05.
Among youths, the prevalence of obesity decreased with increasing level of education
of the head of household: 21.6% (high school graduate or less), 18.3% (some college),
and 9.6% (college graduate). The same pattern was seen overall and in females and
males in all race-Hispanic origin groups, but differences were not significant for
non-Hispanic black youths (total, male, or female) or non-Hispanic Asian males or
females.
From 1999–2002 to 2011–2014 the prevalence of obesity increased among females in the
two lowest income groups (Figure 1). There was a nonsignificant decrease in obesity
prevalence among females in the highest income group, and the difference in childhood
obesity prevalence between the lowest and highest income groups increased over time.
Among males, a quadratic trend was observed in the lowest income group: obesity prevalence
was 16.9% during 1999–2002, increased to 21.0% during 2007–2010, and then declined
to 18.1% during 2011–2014. The difference in prevalence between the lowest and highest
income groups did not change over time for males.
FIGURE 1
Trends*,† in obesity prevalence among youths (persons aged 2–19 years), by household
income — National Health and Nutrition Examination Survey, United States, 1999–2002
through 2011–2014
Abbreviation: FPL = federal poverty level.
* Linear trend (p<0.05) for females ≤130% of FPL, >130% to ≤350% of FPL.
† Quadratic trend (p<0.05) for males ≤130% of FPL.
The figure above is a line graph showing trends in obesity prevalence among youths
(persons aged 2–19 years), by household income, in the United States, from 1999–2002
through 2011–2014.
Obesity prevalence among youths increased from 1999–2002 to 2011–2014 among females
and males in households headed by persons with the least education (high school graduate
or less) and among females in households headed by persons with some college education.
There were no other significant trends. In addition, the difference in childhood obesity
prevalence between the lowest and highest head of household education groups increased
over time for females but not for males (Figure 2).
FIGURE 2
Trends* in prevalence of obesity among youths (persons aged 2–19 years), by education
level of head of household — National Health and Nutrition Examination Survey, United
States, 1999–2002 through 2011–2014
* Linear trend (p<0.05) for females, high school graduate or less and some college,
and males, high school graduate or less.
The figure above is a line graph showing trends in prevalence of obesity among youths
(persons aged 2–19 years), by education level of head of household, in the United
States, from 1999–2002 through 2011–2014.
Discussion
During 2011–2014, the relationships between childhood obesity and income and childhood
obesity and education of household head were complex, differing depending upon the
subgroup of the population. The prevalence of obesity among youths living in households
headed by college graduates was lower than that among those living in households headed
by less educated persons for each race-Hispanic origin group. The same was not true
for those living in the highest income group. Moreover, differences by income and
education of household head are widening among females.
Similar to results based on data from 2005 to 2008 (
4
), during 2011–2014 childhood obesity prevalence was lower among youths living in
households in the highest income group. However, this was not the pattern seen in
all subgroups. For example, obesity prevalence was lower in the highest income group
compared with the other groups among non-Hispanic white females, but not among non-Hispanic
black females, non-Hispanic white males, or non-Hispanic black males. Obesity prevalence
decreased as head of household education increased in all subgroups examined. The
prevalence of obesity was consistently lowest among children in households headed
by college graduates, which differed from the pattern seen by income level. This difference
in the relationship between obesity and income versus education has been observed
in at least one other study (
8
). In addition, some relationships changed since 2005–2008. For example, there was
a significant decreasing trend in obesity prevalence by income among non-Hispanic
white males during 2005–2008 (
4
) but there were no differences during 2011–2014.
This report also presents differences in childhood obesity prevalence by income and
education among non-Hispanic Asian youths in the United States. It has been suggested
that the cut-off point that typically defines obesity might underestimate associated
health risks among Asian persons (
9
).
The findings in this report are subject to at least one limitation. The sample size
was small among some subgroups, such as non-Hispanic Asian females living in households
with income above 350% of the FPL, where the prevalence of obesity is very low (1.3%)
and the sample size is small (138). Additional years of data might provide more information
about obesity prevalence by income, especially among non-Hispanic Asian youths.
Trends in childhood obesity prevalence by income and education level of head of household
indicate that disparities have existed at least since NHANES III, 1988–1994 (
10
). These differences have widened since 1999–2002 among females but not among males,
where differences in obesity prevalence by income and education of the head of household
have remained relatively constant from 1999–2002 to 2011–2014.
These findings demonstrate that lower levels of income are not universally associated
with childhood obesity. The association is complex and differs by sex, race, and Hispanic
origin, and possibly over time. Differences by education are more consistent across
subgroups than differences by income. More progress is needed to reduce disparities
in childhood obesity prevalence, an important Healthy People 2020 objective.
Summary
What is already known about this topic?
Studies have suggested that childhood obesity prevalence varies by income and education,
although patterns might differ between adults and youths.
What is added by this report?
Analysis of data from the 2011–2014 National Health and Nutrition Examination Survey
(NHANES) demonstrates that childhood obesity prevalence patterns among persons aged
2–19 years by household income are less consistent by race and Hispanic origin than
are the patterns by level of education attained by the head of household. Moreover,
the differences in childhood obesity prevalence by income and education of household
head are widening among females while differences among males have remained relatively
constant over time.
What are the implications for public health practice?
NHANES will continue to be an important source of data for monitoring disparities
in childhood obesity. These data will help track the Healthy People 2020 objective
of reducing disparities and might inform obesity prevention programs at the federal,
state, and local levels.