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Cited by 460Obesity, Physical Activity, DietObesity and Health PracticesPhysical Activity and Health

Differences in Obesity Prevalence by Demographics and Urbanization in US Children and Adolescents, 2013-2016

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Ogden, Cynthia L., Fryar, Cheryl D., Hales, Craig M., Carroll, Margaret D., Aoki, Yutaka, Freedman, David S.·2018·JAMA
DOI 10.1001/jama.2018.5158PMC PMC6393914
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Abstract

Importance: Differences in childhood obesity by demographics and urbanization have been reported. Objective: To present data on obesity and severe obesity among US youth by demographics and urbanization and to investigate trends by urbanization. Design, Setting, and Participants: Measured weight and height among youth aged 2 to 19 years in the 2001-2016 National Health and Nutrition Examination Surveys, which are serial, cross-sectional, nationally representative surveys of the civilian, noninstitutionalized population. Exposures: Sex, age, race and Hispanic origin, education of household head, and urbanization, as assessed by metropolitan statistical areas (MSAs; large: ≥ 1 million population). Main Outcomes and Measures: Prevalence of obesity (body mass index [BMI] ≥95th percentile of US Centers for Disease Control and Prevention [CDC] growth charts) and severe obesity (BMI ≥120% of 95th percentile) by subgroups in 2013-2016 and trends by urbanization between 2001-2004 and 2013-2016. Results: Complete data on weight, height, and urbanization were available for 6863 children and adolescents (mean age, 11 years; female, 49%). In 2013-2016, the prevalence among youth aged 2 to 19 years was 17.8% (95% CI, 16.1%-19.6%) for obesity and 5.8% (95% CI, 4.8%-6.9%) for severe obesity. Prevalence of obesity in large MSAs (17.1% [95% CI, 14.9%-19.5%]), medium or small MSAs (17.2% [95% CI, 14.5%-20.2%]) and non-MSAs (21.7% [95% CI, 16.1%-28.1%]) were not significantly different from each other (range of pairwise comparisons P = .09-.96). Severe obesity was significantly higher in non-MSAs (9.4% [95% CI, 5.7%-14.4%]) compared with large MSAs (5.1% [95% CI, 4.1%-6.2%]; P = .02). In adjusted analyses, obesity and severe obesity significantly increased with greater age and lower education of household head, and severe obesity increased with lower level of urbanization. Compared with non-Hispanic white youth, obesity and severe obesity prevalence were significantly higher among non-Hispanic black and Hispanic youth. Severe obesity, but not obesity, was significantly lower among non-Hispanic Asian youth than among non-Hispanic white youth. There were no significant linear or quadratic trends in obesity or severe obesity prevalence from 2001-2004 to 2013-2016 for any urbanization category (P range = .07-.83). Conclusions and Relevance: In 2013-2016, there were differences in the prevalence of obesity and severe obesity by age, race and Hispanic origin, and household education, and severe obesity was inversely associated with urbanization. Demographics were not related to the urbanization findings.

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Crossref · 10.1001/jama.2018.5158

Cites

31 of 31 references verified0 citation errors · 0 not checkable

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Claims the paper makes

0 of 34 cited sources checked · 0 supported · 0 flagged

  • Findingown data

    In 2013-2016, obesity prevalence did not differ significantly across large MSAs, medium or small MSAs, and non-MSAs.

    “Prevalence of obesity in large MSAs (171% [95% CI, 14.9%−19.5%]), medium or small MSAs (17.2% [95% CI, 14.5%−20.2%]) and non-MSAs (21.7% [95% CI, 16.1%−28.1%]) were not significantly different from each other (range of pairwise comparisons P = .09–.96).”
    Quote in the paperSubstantial claim
  • Findingown data

    In adjusted analyses, obesity prevalence was significantly higher among youth in households headed by individuals with high school diploma or less and some college compared with college graduates.

    “The prevalence of obesity among youth living in households headed by individuals with a high school diploma or less (22.3%) or in households headed by individuals with some college education (18.1%) was significantly higher compared with youth living in households headed by college graduates (11.6%) (adjusted difference for youth living in households headed by individuals with ≤high school diploma”
    Quote in the paperSubstantial claim
  • Findingown data

    The smoothed 95th percentile of BMI for non-MSAs was higher than for large MSAs and medium or small MSAs until age 18 years.

    “Although the 50th percentiles overlapped between urbanization categories until about 10 years, the 95th percentile for non-MSAs was higher than in large MSAs and medium or small MSAs until age 18 years.”
    Quote in the paperSubstantial claim
  • Findingown data

    In adjusted analyses, severe obesity prevalence increased significantly with greater age among US youth.

    “In adjusted analyses, obesity and severe obesity significantly increased with greater age and lower education of household head, and severe obesity increased with lower level of urbanization.”
    Quote in the paperSubstantial claim
  • Findingnone given

    The prevalence of severe obesity among US youth was more than 10% in some adolescent subgroups.

    “The prevalence of severe obesity among US youth was more than 10% in some adolescent subgroups.”
    Quote in the paperNot a substantial claim
  • The quote only partly states this claim. 1
  • May combine two claims. 14
  • Classified as probably not a substantial claim. 29

  • The quote only partly states this claim.

    Findingown data

    In adjusted analyses, obesity prevalence increased significantly with lower education of household head.

    “There was a significant linear trend in obesity by education of household head (P < .001).”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    The association between urbanization and obesity was in the same direction as severe obesity but was not significant.

    “The association between urbanization and obesity was in the same direction as severe obesity but was not significant.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Among adolescents aged 14 years, the smoothed 95th percentile of BMI was 38 in non-MSAs and 33.5 in large MSAs.

    “The smoothed 95th percentile of BMI among adolescents aged 14 years living in non- MSAs was 38 (ie, 5% of adolescents aged 14 years had a BMI >38), whereas the 95th percentile among adolescents aged 14 years living in large MSAs was 33.5.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    These results are in contrast with the current results in which adjustment for socioeconomic status did not change the association between urbanization and obesity.

    “These results are in contrast with the current results in which adjustment for socioeconomic status did not change the association between urbanization and obesity.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    In one study, severe obesity was associated with higher risk for hypertension compared with lesser obesity.

    “In one study,30 severe obesity was associated with higher risk for hypertension compared with lesser obesity.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [30]

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    NHANES includes oversampling in its complex probability sample design.

    “NHANES includes oversampling in its complex probability sample design.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Study design and conductnone given

    The NHANES complex sample design was incorporated in standard error estimates and all statistical testing.

    “The NHANES complex sample design was incorporated in standard error estimates and all statistical testing.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductnone given

    BMI is not a direct measure of adiposity and health risk.

    “First, BMI is not a direct measure of adiposity and health risk.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Study design and conductreasoning

    NHANES was not designed to provide estimates representative of different urbanization categories or counties, so some cells have low degrees of freedom, which can result in inflated standard errors and reduced statistical power.

    “Third, NHANES was not designed to provide estimates representative of different urbanization categories or counties, so some cells have low degrees of freedom, which can result in inflated standard errors and reduced statistical power.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Research has suggested that youth with severe obesity have a worse cardiovascular disease risk profile than youth with lesser obesity.

    “Research has suggested that youth with severe obesity have a worse cardiovascular disease risk profile than youth with lesser obesity.18”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [18]

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    In low-income and middle-income countries, urban areas have had higher levels of BMI but the differences have been attenuated after adjusting for socioeconomic status.

    “In low- income and middle-income countries, urban areas have had higher levels of BMI but the differences have been attenuated after adjusting for socioeconomic status.29”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [29]

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data

    Unweighted agreement between urbanization level categories based on county of residence and county location of examination was 99.9% for NHANES 2007-2014 participants.

    “Unweighted agreement between urbanization level categories based on county of residence and county location of examination was 99.9% for NHANES 2007–2014 participants.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationown data

    The BMI distribution among youth in non-MSAs is more skewed to the right and shifted to the right compared with other urbanization categories starting around age 10 years.

    “This Figure shows different patterns in BMI distribution by urbanization category suggesting the distribution in non-MSAs is more skewed to the right than in other areas and that, starting around age 10 years, the distribution in non-MSAs is also shifted to the right compared with other urbanization categories.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductcitation

    The NHANES examination response rate for youth was 76% in 2013-2014 and 64.6% in 2015-2016.

    “For youth aged 1 to 19 years, the response rate for the examination component was 76% in 2013–2014 and 64.6% in 2015–2016; response rates for youth from 2001–2002 to 2011–2012 ranged from 87% to 77%.15”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    No adjustments were made for multiple comparisons.

    “No adjustments were made for multiple comparisons.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data

    No data on urbanization were missing.

    “No data on urbanization were missing.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Study design and conductnone given

    Examination sample weights were used in all analyses and adjusted for differential probabilities of selection, noncoverage, and nonresponse.

    “Examination sample weights were used in all analyses and adjusted for the differential probabilities of selection, noncoverage, and nonresponse.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data

    Estimates by urbanization category could not be presented by demographic subgroup due to small sample size and low degrees of freedom.

    “Estimates by urbanization category could not be presented by demographic subgroup due to small sample size and low degrees of freedom.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Study design and conductnone given

    Standardized measurements of weight and height were obtained during the NHANES examination.

    “Standardized measurements of weight and height were obtained during the NHANES examination.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductcitation

    Statistical reliability was assessed using the NCHS data presentation standards for proportions.

    “Statistical reliability was assessed using the NCHS data presentation standards for proportions.23”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [23] source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductown data

    In 2013-2016, 152 youth were missing weight, height, or both and 9 were pregnant and excluded, leaving a total sample size of 6863.

    “In 2013–2016, 152 youth aged 2 to 19 years were missing weight, height, or both and 9 were pregnant and were excluded from the analysis (unweighted percentage, 161 of 7024 participants [2.3%]) leaving a total sample size of 6863.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data

    An additional 229 youth were missing data on education of household head and were excluded from analyses that included this variable.

    “An additional 229 youth were missing data on education of household head and were excluded from analyses that included this variable.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Measured weight and height from 1999-2006 showed that rural children aged 2 to 19 years had consistently higher odds of overweight and obesity even after adjustment for sociodemographics, health, diet, and exercise.

    “Measured weight and height from 1999–2006 showed that rural children aged 2 to 19 years had consistently higher odds of overweight and obesity even after adjustment for sociodemographics, health, diet, and exercise.12”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [12]

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Differences have also been reported by education and income.

    “Differences have also been reported by education and income.5”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [5] source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    In an analysis of 2001-2010 NHANES data, racial differences in weight among US youth were explained entirely by social determinants including neighborhood factors.

    “In an analysis of 2001–2010 NHANES data, racial differences in weight among US youth were explained entirely by social determinants including neighborhood factors.7”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [7] source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    One study found that South Asian youth had higher BMI-adjusted blood pressure than white youth in the United States.

    “One study found that South Asian youth had higher BMI-adjusted blood pressure than white youth in the United States.36”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [36]

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    These differences vary by sex, and race and Hispanic origin and may be changing over time.

    “These differences, however, vary by sex, and race and Hispanic origin and may be changing over time.5”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [5] source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Adiposity among non-Hispanic black youth is lower than among non-Hispanic white and Mexican American youth at the same BMI level.

    “Adiposity among non-Hispanic black youth is lower than among non-Hispanic white and Mexican American youth at the same BMI level.34”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [34]

      Not checked in the free run.

  • Classified as probably not a substantial claim. May combine two claims.

    Study design and conductreasoning

    Tabular and graphical presentation of obesity and severe obesity prevalence over 2001-2016 included point estimates and CIs with combined 4-year NHANES data because these estimates were more stable than estimates based on 2 years of data.

    “Tabular and graphical presentation of obesity and severe obesity prevalence over this period included point estimates and CIs with combined 4-year NHANES data for 2001–2004, 2005–2008, 2009–2012, and 2013–2016 because these estimates were more stable than the estimates based on 2 years of data.”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim. May combine two claims.

    Study design and conductnone given

    No adjustments were made for measures of socioeconomic status beyond education and the analyses focused on prevalence, not mean BMI.

    “In the current analysis, however, no adjustments were made for measures of socioeconomic status beyond education and the analyses focused on prevalence, not mean BMI.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Among Asian adults, health risk begins at a lower BMI than in white adults.

    “However, among Asian adults, health risk begins at a lower BMI than in white adults.35”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [35]

      Not checked in the free run.

  • Classified as probably not a substantial claim. May combine two claims.

    Study design and conductcitation

    The NCHS metropolitan categories were collapsed for this analysis to increase sample size for subgroups and produce stable estimates based on the NCHS data presentation standards for proportions.

    “The NCHS metropolitan categories were collapsed for this analysis to increase sample size for subgroups and produce stable estimates based on the NCHS data presentation standards for proportions.23”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [23] source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    A review of the literature, including 2 studies using NHANES data from 1999-2006 and 2003-2006, reported that obesity prevalence was higher among rural children than among children living in urban areas, and this difference was larger among older children compared with younger children.

    “A review of the literature, including 2 studies using NHANES data from 1999–2006 and 2003–2006, reported that obesity prevalence was higher among rural children than among children living in urban areas, and this difference was larger among older children compared with younger children.6”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [6] source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    A study using school-based BMI from elementary schools in Pennsylvania found differences in obesity prevalence by urbanization.

    “A study using school-based BMI from elementary schools in Pennsylvania found differences in obesity prevalence by urbanization.8”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [8] source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Analysis of overall trends in obesity among youth beginning in 1999-2000 show an increase in prevalence, suggesting changes from 1999-2000 to 2015-2016 have been driven by changes very early in this period.

    “Analysis of overall trends in obesity among youth beginning in 1999–2000 show an increase in prevalence,2 suggesting changes from 1999–2000 to 2015–2016 have been driven by changes very early in this period.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [2]

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Premisecitation

    Differences in childhood obesity prevalence by demographics have been reported in the United States.

    “Differences in childhood obesity prevalence by demographics have been reported in the United States,1,2 and Healthy People 2020 objectives include reducing disparities.3”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [1] source

      Not checked in the free run.

    • cites [2]

      Not checked in the free run.

36 of 36

  • The paper relies on this without support.

    The youth excluded from analysis due to missing weight, height, or pregnancy did not differ systematically from included youth in ways that would bias obesity prevalence estimates.

    “In 2013–2016, 152 youth aged 2 to 19 years were missing weight, height, or both and 9 were pregnant and were excluded from the analysis (unweighted percentage, 161 of 7024 participants [2.3%]) leaving a total sample size of 6863.”

  • The paper relies on this without support.

    The changes in NCHS urbanization classification schemes across 2001-2016 did not affect the comparability of urbanization categories over time.

    “Level of urbanization was categorized based on 1990 (for NHANES 2001–2004), 2006 (for NHANES 2005–2012), and 2013 (for NHANES 2013–2016) NCHS classification schemes for counties.”

  • The paper relies on this without support.

    The 99.9% agreement between county of residence and county of examination location observed for 2007-2014 applies to all survey cycles.

    “Unweighted agreement between urbanization level categories based on county of residence and county location of examination was 99.9% for NHANES 2007–2014 participants.”

  • The paper relies on this without support.

    The self-reported race and Hispanic origin and education of household head are accurate enough for the analyses.

    “Race and Hispanic origin was reported by participants or proxy respondents (such as parents) and was categorized as non-Hispanic white, non-Hispanic black, non-Hispanic Asian, Hispanic, and other (including multiple races).”

  • The paper relies on this without support.

    The NHANES sample weights adequately adjust for nonresponse and noncoverage.

    “Examination sample weights were used in all analyses and adjusted for the differential probabilities of selection, noncoverage, and nonresponse.”
5 of 5

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

Each contradiction between two passages listed here was confirmed by an independent check.

  • Noncore counties are described as metropolitan but grouped as non-MSA

    Minor

    The methods describe noncore counties as metropolitan counties, then place noncore counties in the non-MSA category.

1 of 1

Cites

Flagged first, then by citations

2 of the 33 references couldn’t be matched to a known paper.

Research works printed but not linked: 3

  1. Ingram, 2012, NCHS urban-rural classification scheme for counties., Vital Health Stat 2, 1
  2. Korn, 1998, Confidence intervals for proportions with small expected number of positive counts estimated from survey data., Surv Methodol, 24
  3. Cochran, 1977, Sampling techniques

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Related

Authors
Ogden, C. L., Fryar, C. D., Hales, C. M., Carroll, M. D., Aoki, Y., & Freedman, D. S.
Affiliations
Centers for Disease Control and Prevention (US)
Corresponding author
Ogden, Cynthia L.
ORCID
Venue
JAMA
Publisher
American Medical Association (AMA)
Published
2018-06-19
Volume
319
Issue
23
Pages
2410
ISSN
  • 0002-9955 (ISSN-L)
  • 0098-7484
DOI
10.1001/jama.2018.5158
PMC
PMC6393914
OpenAlex
W2809044706
Cited by
459
References
33
Citations by year
2026: 14 · 2025: 35 · 2024: 55 · 2023: 57 · 2022: 65 · 2021: 85 · 2020: 78 · 2019: 58 · 2018: 11
FWCI
55.19
Type
journal article
Language
en
Open access
Locations
  • JAMA (publishedVersion)
  • PubMed (publishedVersion)
  • Europe PMC (PubMed Central) (acceptedVersion)
  • PubMed Central (acceptedVersion)
Funders
National Institutes of Health (CC999999)
Topics
  • Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Obesity, Physical Activity, Diet
  • Health Sciences › Health Professions › Pharmacy › Obesity and Health Practices
  • Health Sciences › Medicine › Physiology › Physical Activity and Health
Keywords
childhood obesity, adolescent obesity, morbid obesity, urbanization, metropolitan statistical areas, obesity prevalence, demographic disparities, racial and ethnic disparities, Hispanic origin, household income, educational attainment, sex differences, obesity trends, body mass index, children and adolescents, United States, NHANES
MeSH terms
Adolescent, Child, Child, Preschool, Cross-Sectional Studies, Educational Status, Female, Hispanic or Latino, Humans, Male, Nutrition Surveys, Obesity, Morbid, Population, Risk Factors, United States, Body Mass Index, Prevalence, Age Distribution, Sex Distribution, Young Adult, Pediatric Obesity

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