SUPPLEMENT ARTICLE Consistently Inconsistent: A Snapshot of Across- and Within-State Disparities in the Prevalence of Childhood Overweight and Obesity Christina Bethell, PhD, MBA, MPH a , Debra Read, MPH a , Elizabeth Goodman, MD b , Jessica Johnson, BA a , John Besl, MA c , Julie Cooper, MPA d , Lisa A. Simpson, MB, BCh, MPH, FAAP c a Child and Adolescent Health Measurement Initiative, Department of Pediatrics, Oregon Health and Science University, Portland, Oregon; b Floating Hospital for Children at Tufts Medical Center, Tufts University School of Medicine, Boston, Massachusetts; c Child Policy Research Center, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio; d Child Health Institute at the University of Washington, Seattle, Washington The authors have indicated they have no financial relationships relevant to this article to disclose. ABSTRACT BACKGROUND. The epidemic of childhood overweight and obesity is characterized by known disparities. Less is known about how these disparities vary across and within the state in which a child lives. OBJECTIVE. To examine the magnitude and patterns of across- and within-state differ- ences in the prevalence of childhood overweight and obesity according to children’s insurance type (public versus private), household income level, race (non-Hispanic black versus non-Hispanic white), and ethnicity (Hispanic versus non-Hispanic). METHODS. State-level overweight and obesity prevalence rates for children aged 10 –17 were calculated by using data from the 2003 National Survey of Children’s Health. Statistical significance of across-state variation was assessed. Disparity ratios assessed within-state equity according to children’s insurance type, income, race, and eth- nicity. State ranks on overall prevalence and ranks on disparity indices were corre- lated and regression models were fit to examine within-state consistency, state-level clustering effects and whether the effect of child characteristics varied across key population subgroups. RESULTS. Prevalence of childhood overweight and obesity varied significantly across states. A total of 31 states had a prevalence lower than the national rate of 30.6% (14 statistically significant), and 20 had higher rates (9 statistically significant). Within- state disparity indices ranged from a low of 1.0 (no disparity) to a high of 3.44 (nearly 3.5 times higher). Correlations between state ranks on overall prevalence and their ranks on disparity indices were not significant for the insurance type, income, or race disparity groups examined. A modest state-clustering effect was found. Compared with non-Hispanic white children, the effect of lower household income and lower household education level education were significantly less for non-Hispanic black and Hispanic children, who were more likely to be overweight or obese regardless of these other factors. CONCLUSIONS. Disparities in the prevalence of childhood overweight and obesity vary significantly both within and across states. Patterns of variation are inconsistent within states, highlighting the need for states to undertake state- and population-specific analyses and interventions to address the epidemic. Pediatrics 2009;123:S277–S286 C HILDHOOD OVERWEIGHT AND obesity are major public health problems that have the potential to cause enormous medical, psychosocial, and financial costs and are characterized by known disparities. 1–5 During the periods 1976 –1980, 1988 –1994, and 1999 –2002, rates of obesity increased for all children regardless of age, race, ethnicity, or gender. 6 The epidemic of childhood overweight and obesity is gaining significant attention from policy makers at the state and federal levels. Although a rich literature is emerging on disparities in childhood obesity, 7–15 less is known about the degree to which these disparities exist and vary across and within individual states. Examination of within- and across-state variation in childhood obesity rates is critical to shaping effective national and state-level policy and program responses to prevent and reduce overweight and obesity among children. This study builds on previous research that outlined state-level prevalence of overweight and obesity 16,17 and the existence of disparities according to demographic characteristics of children. 18 The objective of this study was to examine the magnitude, statistical significance, and patterns of across- and within-state differences in the prevalence of childhood overweight and obesity according to children’s insurance type (public versus private), household www.pediatrics.org/cgi/doi/10.1542/ peds.2008-2780F doi:10.1542/peds.2008-2780F Key Words childhood overweight and obesity, state variations, disparities, National Survey of Children’s Health Abbreviations NSCH—National Survey of Children’s Health MCHB—Maternal and Child Health Bureau FPL—federal poverty level COV— coefficient of variation ICC—interclass correlation mOR—median odds ratio aOR—adjusted odds ratio Accepted for publication Feb 18, 2009 Address correspondence to Christina Bethell, PhD, MBA, MPH, Child and Adolescent Health Measurement Initiative, Department of Pediatrics, Oregon Health and Science University, 707 SW Gaines Ave, Mail Code CDRC-P, Portland, OR 97219. E-mail: bethellc@ ohsu.edu PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). Copyright © 2009 by the American Academy of Pediatrics PEDIATRICS Volume 123, Supplement 5, June 2009 S277 by guest on November 16, 2016 Downloaded from