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Lauren Silver Quantitative Methods II w/Professor Atherly

4/25/2009
THE IMPACT OF BEHAVIORAL AND SOCIODEMOGRAPHIC FACTORS
ON BODY MASS INDEX
INTRODUCTION
Over the past few decades, the U.S. has seen a dramatic increase in both the incidence and
prevalence of obesity in children, adolescents, and adults. The most widely accepted measure of
overweight and obesity is a persons body mass index (!"#, defined as weight in $ilograms
divided by height in meters. "ndividuals who are overweight and obese are more li$ely to
experience diabetes type "", cardiovascular disease, and pulmonary disease than are their normal
weight counterparts. To contribute to effective policy formulation aimed at combating the rise in
obesity, the current study sought to identify behavioral and sociodemographic factors associated
with increased !" in a nationwide sample of adults %& years old and older.
REVIEW OF THE LITERATURE
Behavioral Factors associated with BMI
'iet and exercise are the two critical behavioral factors that impact an individuals !",
which in large part, is determined by the amount of energy consumed relative to the amount of
energy expended. !ore specifically, it is hypothesi(ed that those consuming more fruits and
vegetables are more li$ely to have lower !" values than those who consume little to no fruits
and vegetables. )vidence supporting this hypothesis, however, remains mixed. Tohill et al.
reviewed %* peer+reviewed ,ournal articles published between -anuary %.** and -uly /001 that
included 2epidemiologic investigations3 and reported significance tests of fruit and vegetable
consumption and body weight in adults.
%
Seven studies found a significant inverse relationship
between fruit and4or vegetable consumption and obesity5lower !" values were associated with
higher fruit and4or vegetable inta$e in these studies. Six studies found no significant difference in
!" relative to fruit4vegetable consumption, and two studies found a positive relationship
between fruit4vegetable consumption and !". These inconsistent findings warrant further
investigation.
roc$ et al. performed a weighted least s6uares regression analysis using the /007 89SS
to examine the impact of insufficient physical activity5while controlling for age, race, gender,
and median household income5on state prevalence of obesity and found a significant positive
association.
/
"nsufficient physical activity accounted for approximately /0 percent of the state+
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Lauren Silver Quantitative Methods II w/Professor Atherly
4/25/2009
level variance in obesity prevalence while ad,usting for all other factors. !affeis found a similar,
significant relationship in children as well5obese children spent more time watching television
than non+obese children and less time 2performing vigorous play.3
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Sociodemographic Factors associated with BMI
ur$e et al. assessed differences in !" between lac$ and :hite women, aged %& to 10
years old and found that lac$ women had significantly higher age+ad,usted mean !" values
than white women.
;
The authors hypothesi(ed that this observed difference in !" was due to
racial differences in energy consumption and physical activity (lower and higher for white women
compared to blac$ women, respectively#, and age at first menarche and at first childbirth (both
earlier for blac$ women than white women#. "n addition, ur$e and ild assessed five+year
weight change as part of the <=8'"= (<oronary =rtery 8is$ 'evelopment in >oung =dults#
study and found that weight gain was significantly higher in blac$ men compared to white men
and in blac$ women compared to white women.
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ur$e and ild also found5as part of the <=8'"= study5that greater weight gain was
significantly associated with participants self+reported education and age.
*
lac$ women, white
women, and white men who reported an education level of high school or less experienced greater
weight gain than their college graduate counterparts over the five+year period. The researchers also
found a 2greater absolute weight gain in younger men, suggesting that weight gain is a greater
problem among those aged %& to /; than those aged /7 to 17 years old.3
?
This unexpected finding
warrants further investigation.
@rior research has demonstrated a relationship between !" and region of residence.
Singh et al. examined state and regional disparities in obesity prevalence among approximately
;*,000 U.S. children and adolescents aged %0+%? years old.
&
The researchers found that the south
central regions of U.S. exhibited the highest prevalence of obesity (A%&B# and the mountain
regions exhibited the lowest (%%.;B#.
The relationship between !" and socioeconomic status and gender remains unclear.
:ang and Chang assessed changes in the association between obesity and family income between
%.?% and /00/, and found that trends in the association between S)S and obesity varied by age,
sex, and ethnic group.
.

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Lauren Silver Quantitative Methods II w/Professor Atherly
4/25/2009
DATA SOURCE
'ata for this study came from the <enters for 'isease <ontrol and @reventions (<'<#
/00? ehavioral 8is$ 9actor Surveillance System (89SS# survey, a cross+sectional telephone
survey conducted by state health departments with technical assistance provided by the <'<.
Only one adult5%& years or older5per household is interviewed in all 70 states, the 'istrict of
<olumbia, @uerto 8ico, the U.S. Dirgin "slands, and Euam.. "nformation is collected on health ris$
behaviors (e.g., diet and exercise#, preventive health practices, health care access, chronic
conditions, and sociodemographic characteristics. "n the /00? 89SS, there was a total of ;10,.%/
observations.
THE MODEL
Dependent Variable
The dependent variable examined in this study is body mass index, defined as weight in
$ilograms divided by height in meters. !" was chosen to operationali(e adiposity5as opposed
to some other metric5so that results from this study could easily be compared to the substantial
amount of existing research on factors associated with !". = continuous version of the !"
variable was chosen over a categorical version (i.e., in which respondents are categori(ed as
normal weight, overweight, or obese according to their !"# because the categorical version does
not necessarily represent meaningful cutoff points along the range of !" values. y way of
example, a respondent would be categori(ed as overweight with a !" of /. while a respondent
with a !" of 10 would be categori(ed as obese. The trivial difference between these two values
5even though they fall within two separate categories5does not improve the interpretability of
the impact of the predictors examined in this study on !".
"n /00?, calculated !" values for 89SS respondents ranged from &.71 to ....&. Eiven
that a !" of %7 is considered grossly underweight, a new !" variable was created in which all
respondents with a !" of less than %7 were set to missing. This resulted in a loss of /0,%.0
observations, or ;.*& percent of the full sample. 9or the remaining ;%0,?// observations, the mean
!" of 89SS respondents was /?.77 with a standard deviation of 7../. !" values ranged from
%7 to .&.&7 with a median of /*.*1.
Independent Variables
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Lauren Silver Quantitative Methods II w/Professor Atherly
4/25/2009
The independent variables included in the model (Table %# were chosen based on findings
from the literature review regarding the association between !" and certain behavioral (i.e.,
physical activity and nutrition# and sociodemographic factors (i.e., race, income, gender,
education, age, sex, and region of residence#. !ore specifically, predictors were chosen based on
whether research to date has demonstrated a consistent significant association with !" and
whether research to date has resulted in contradictory evidence regarding the association with
!". =s a result, this study sought to further clarify the relationship between !" and those
predictors for which inconsistent evidence exists on the association with !"5while controlling
for predictors that have an established significant association with !". The model is depicted
below.
BMI
i
= f(AL
i
, AE
i
, REC
i
, FV
i
, RACE
i
, INC
i
, EDU
i
, AGE
i
, SEX
i
, SOU
i
) + , where
=Fi G a dummy variable e6ual to % if the ith respondent reported that he or she was limited in any
way in activities due to physical, mental, or emotional problems, 0 otherwise
=)i G a dummy variable e6ual to % if the ith respondent reported that he or she participated in any
physical activities or exercises5not including his or her ,ob5such as running, gardening,
calisthenics, etc., 0 otherwise
8)<i G a three+category dummy variable representing whether the ith respondent met one or both
of the <'<s recommended amount of moderate and4or physical activity (2insufficient physical
activity3 and 2no physical activity3 compared to 2meets physical activity recommendations3 as the
reference group#
9Di G a four+category dummy variable representing the number of servings of fruits and
vegetables the ith respondent reported consuming daily (2once but less than 1 times per day,3 1 but
less than 7 times per day,3 and 27 or more times per day3 compared to 2less than once per day or
never3 as the reference group#
8=<)i G an eight+category dummy variable representing the ith respondents reported race
(2lac$ only,3 2=sian only,3 2Hative Iawaiian or other @acific "slander only,3 2=merican "ndian
or =las$an Hative only,3 2Iispanic,3 2!ultiracial, non+Iispanic,3 and 2other race, non+Iispanic3
compared to 2:hite only3 as the reference group#.
"H<i G a five+category dummy variable representing the ith respondents reported annual income
(2less than J%7,000,3 2J%7,000 to less than J/7,000,3 2J/7,000 to less than J1;,000,3 and J17,000
to less than J70,0003 compared to 2J70,000 or more3 as the reference group#
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Lauren Silver Quantitative Methods II w/Professor Atherly
4/25/2009
)'Ui G a six+category dummy variable representing the ith respondents reported education level
(2never attended school or only $indergarten,3 2grades % through &,3 2grades . through %%,3
2grade %/ or E)',3 and 2college % to 1 years3 compared to 2college ; years or more as the
reference group#
=E)i G a five+category dummy variable representing the ith respondents age in years (2/7 to 1;,3
217 to ;;,3 2;7 to 7;,3 277 to *;,3 and 2*7 or older3 compared to 2%& to /;3 as the reference
group#
S)Ki G a dummy variable e6ual to % if the ith respondents sex was male, 0 otherwise
SOUi G a dummy variable e6ual to % if the ith respondent resided in one of the eight states
categori(ed as southern states by the U.S. <ensus ureau, 0 otherwise
Table 1. Descriptive Statistics for Behavioral Factors, BRFSS 2007
Independent Variable (n) Fre!enc" #$%
Activity limitation due to health problems? (423,447)
Yes 101,828 24.05
No 21,!1" #5."5
Any e$ercise in the past 0 days e$cludin% &ob? (430,421)
Yes 1#,15 #.!8
No 11,2!8 2!.2
'eets ()( physical activity recommendations? (399,183)
'eets recommendations 18!,140 4!.!
*nsu++icient physical activity 151,!"1 8.00
No physical activity !1,52 15.#
,ervin%s o+ +ruit and ve%etables consumed daily (420,696)
-1 servin% per day 1",!"# 4.!!
1 to - servin%s per day 140,5!4 .41
to -5 servin%s per day 154,1#" !.!5
.5 servin%s per day 10!,5! 25.28
=ll independent variables were either original or calculated 89SS+generated variables
except for SOUi (whether a respondent resides in the south#. This variable was created from the
89SS state 9"@S code variable by coding all respondents who were living in Horth <arolina,
South <arolina, Eeorgia, =labama, !ississippi, Fouisiana, =r$ansas, and Tennessee as a % and
coding all others as a 0.
Hypothesized Signs of the Slope Coefficients
@rior to conducting the analysis, the signs of the slope coefficients for each independent
variable were hypothesi(ed. 9or the independent variables representing behavioral characteristics
that are associated with !", it was hypothesi(ed that respondents who reported limited physical
activity due to mental, physical, or emotion disability would have higher !" values while
respondents who reported eating more fruits and vegetables, those who reported meeting moderate
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Lauren Silver Quantitative Methods II w/Professor Atherly
4/25/2009
and4or vigorous physical activity recommendations, and those who reported participating in any
exercise the past 10 days other than their regular ,ob would have lower !" values. Thus, relative
to their respective reference groups, a positive slope for the =Fi coefficient was expected,
whereas, negative slopes were expected for the =)i, 8)<i, and 9Di coefficients.
9or the independent variables representing sociodemographic characteristics, non+:hites,
those with lower levels of education and income, older respondents, and females were expected to
exhibit greater !" values. 8elative to their respective reference groups, a positive slope
coefficient was expected for the different categories of 8=<)i, )'Ui, "H<i, =E)i, and S)Ki.
Table 2. Descriptive Statistics for Sociode&o'raphic Factors, BRFSS 2007
Independent Variable (n) Fre!enc" #$%
/ace (426,675)
0hite 8,!11 #".!
1lac2 ,21! #.#8
Asian !,420 1.50
3ispanic 1,10 #.4
4aci+ic *slander or Native 3a5aiian 1,0! 0.25
American *ndian or Alas2a Native !,1#1 1.45
'ultiracial, non63ispanic #,0"4 1.!!
7ther, non63ispanic 2,#"0 0.!5
*ncome (371,923)
-815,000 41,"1 11.1
815,000 to -825,000 !4,415 1#.2
825,000 to -85,000 4#,408 12.#5
85,000 to -850,000 !0,54 1!.28
.850,000 158,1#5 42.5
9ducation (429,645)
Never attended school or only 2inder%arten 8!1 0.20
:rades 168 ;elementary and middle< 15,0"2 .51
:rades "611 ;some hi%h school< 28,"11 !.#
:rade 12 or :9) ;hi%h school %raduate< 11,! 0.!4
(olle%e 16 years ;some colle%e or technical
school<
112,!#2 2!.22
(olle%e 4 years or more ;colle%e %raduate< 140,4#! 2.#0
A%e in years (430,912)
18 to 24 15,"! .#0
25 to 4 44,5"4 10.5
5 to 44 !#,#"2 15.#
45 to 54 "0,14# 20."2
55 to !4 8",858 20.85
!5 or older 122,585 28.45
,e$ (430,912)
'ale 1!0,#51 #.0
=emale 2#0,1!1 !2.#0
/esidence in the ,outh (430,912)
Yes !5,"2 15.18
No !5,520 84.82
*
Lauren Silver Quantitative Methods II w/Professor Atherly
4/25/2009
ESTIMATED SPECIFICATIONS
"n addition to the model described above, estimates were computed for two other models5
one using the natural log of !" as the dependent variable and one identical to the above model,
but excluding the variable for whether respondents reported residing in a state classified as the
South.
dditional estimated specification !"
ln(BMI
i
) = f(AL
i
, AE
i
, REC
i
, FV
i
, RACE
i
, INC
i
, EDU
i
, AGE
i
, SEX
i
, SOU
i
) +
This specification was estimated to compare the interpretability of the coefficients in terms of !"
units (the first model outlined# to the percentage change in !" that is attributable to each
independent variable while controlling for all other factors (ln(!"##.
dditional estimated specification !#
BMI
i
= f(AL
i
, AE
i
, REC
i
, FV
i
, RACE
i
, INC
i
, EDU
i
, AGE
i
, SEX
i
) +
8esidence in the South was statistically significant when regressed on !" as the only
independent variable in the model, but became insignificant in the presence of the other predictors
included in the model. ased on theory and prior findings from the literature that show a
significant association between !" and residence in a southern state, however, this variable was
included in the final model.
The model for which the results are presented in Table / was chosen because %# residence
in the South belonged in the model based on theory, and /# interpreting the coefficients in terms of
!" units is more straightforward than in terms of percentage change in !"
ANALYSIS
$he Impact of Behavioral Factors on BMI
=mong the behavioral predictors examined in this study, physical activity consistently
demonstrated a significant inverse relationship with !", while controlling for all other factors in
the model. 8espondents who reported exercising in the past 10 days, excluding ,ob+related
activity, had significantly lower !" values5on average, one unit lower than those who did not
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Lauren Silver Quantitative Methods II w/Professor Atherly
4/25/2009
exercise in the past 10 days. =dditionally, those who reported limited physical activity due to
health problems (L G %.*7# and those whose physical activity level was insufficient to meet <'<s
recommendations (L G %.%%# demonstrated significantly higher !" values than respondents who
were not limited or who met <'<s recommendations for moderate or vigorous activity.
8esults regarding the impact of diet on !" are less definitive. 9or two levels of the
variable operationali(ing the number of servings of fruits and vegetables consumed daily, the sign
of the slope coefficient was in the unexpected direction. Those who reported consuming one to
less than three servings a day and those who reported consuming thee to less than five servings a
day demonstrated significantly higher !" values, however, the magnitude of the difference is
6uite small with each groups !" value, on average, higher than those who reported consuming
no fruits and vegetables by 0.%* and 0.%/ units, respectively. Those who reported consuming five
or more servings of fruits and vegetables daily demonstrated lower !" values than those who
consumed no fruits or vegetables, but the difference is small and not statistically significant.
$he Impact of Sociodemographic Factors on BMI
=mong the sociodemographic factors examined in this study, the relationship between
race, income, education, and age with !" was as expected. lac$, Iispanic, and @acific
"slander4Hative Iawaiian respondents showed significantly greater !" values than their :hite
counterparts. "n particular, lac$ respondents exhibited !" values that, on average, were two
units higher than :hite respondents. 8espondents of =sian decent, however, demonstrated
significantly lower !" values5on average, about /.* units lower than :hite respondents.
=ll income groups demonstrated significantly higher !" values than respondents
reporting annual incomes within the highest income category of J70,000 or more. This finding
agrees with the hypothesi(ed relationship between !" and income, however, the difference
between the lower income groups compared to the highest are 6uite small5all are less than one+
half of a !" unit.
)xcept for respondents who were aged *7 years or older, the magnitude of differences in
!" values with increased with increasing age. <ompared to respondents of ages %& to /; years,
those who were /7 to 1;, 17 to ;;, and ;7 to 7;, and 77 to *; demonstrated significantly higher
!" values (%.., /.1, /.7, and /.7 units, respectively# higher than the youngest age group.
8espondents who were *7 years old or older showed significantly higher !" values by one unit.
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Lauren Silver Quantitative Methods II w/Professor Atherly
4/25/2009
9inally, results regarding the relationship between sex and residence in the South were
contrary to findings in the literature. 9emales exhibited significantly lower !" values, on
average, than males by almost a full unitM and residence in the south turned out to be statistically
non+significantly related to !" while controlling all other predictors in the model.
Table (. The I&pact of Behavioral and Sociode&o'raphic Factors on B)I, BRFSS 2007
Independent Variable
#n*((+,,,1%
-
.
Rob!st S/ 01val!e
Activity limitation due to health problems?
Yes 1.!52>> .028 0.000
Any e$ercise in the past 0 days e$cludin% &ob?
Yes 61.000>> .02" 0.000
'eets ()( physical activity recommendations?
*nsu++icient physical activity 1.10#>> .021 0.000
No physical activity 1.28>> .0" 0.000
,ervin%s o+ +ruits and ve%etables consumed daily
1 to - servin%s per day 0.158> .058 0.00#
to -5 servin%s per day 0.11#> 0.05" 0.04!
.5 servin%s per day 60.04# 0.0!0 0.440
/ace
1lac2 2.004>> 0.045 0.000
Asian 62.5#2>> 0.0!0 0.000
3ispanic 0.42">> 0.042 0.000
4aci+ic *slander or Native 3a5aiian 0."81>> 0.2# 0.000
American *ndian or Alas2an Native 1.2">> 0.0" 0.000
'ultiracial, non63ispanic 0.8!2>> 0.085 0.000
7ther, non63ispanic 60.2> 0.1! 0.014
*ncome
-815,000 0.4!!>> 0.045 0.000
815,000 to -825,000 0.1">> 0.0 0.000
825,000 to -85,000 0.2"#>> 0.0 0.000
85,000 to -850,000 0.!8>> 0.028 0.000
9ducation
Never attended school or only 2inder%arten 0.5#2> 0.1 0.084
:rades 168 ;elementary and middle< 0.#"8>> 0.0#4 0.000
:rades "611 ;some hi%h school< 0.882>> 0.052 0.000
:rade 12 or :9) ;hi%h school %raduate< 0.814>> 0.02! 0.000
(olle%e 16 years ;some colle%e or technical school< 0.88>> 0.025 0.000
A%e in years
25 to 4 1.8!1>> 0.0! 0.000
5 to 44 2.15>> 0.0!1 0.000
45 to 54 2.485>> 0.05" 0.000
55 to !4 2.54#>> .05" 0.000
!5 or older 1.005>> 0.058 0.000
,e$
=emale 60.8#1 0.020 0.000
/esidence in the ,outh
Yes 0.04 0.02" 0.242
>>,i%ni+icant at ?@0.001A >,i%ni+icant at ?@0.05
.
Lauren Silver Quantitative Methods II w/Professor Atherly
4/25/2009
%conometric Iss&es %nco&ntered
= graphic test for heteros$edasticity5in which residuals were plotted against predicted
!" values5revealed a textboo$ case of heteros$edasticity. The variance of !" increased as
predicted values of !" increased. To address this problem, the analysis was conducted using
corrected standard errors for the slope coefficients.
One original variable included in the hypothesi(ed model5a dummy variable e6ual to % if
respondents met recommended levels of moderate and vigorous physical activity and e6ual to 0
otherwise5was dropped from the analysis because it was perfectly collinear with the three+
category variable of whether respondents met <'<s recommended level of physical activity.
Three three+category variable was preferred over the two+category variable because it offered a
more detailed measurement of respondents physical activity. Dariance inflation factors for all
other independent variables signaled no additional problems with collinearity.
"n addition, according to the 8amsey 8eset test (9G7/.01, p+valueG0.000# for omitted
variables, there are indeed relevant variables that have not been included in the model. @otential
missing variables include more precise measurements of diet and physical activity, amount of
sleep, parents adiposity, and the amount of leisure time relative to ,ob+related wor$ time (e.g., on+
the+,ob hours, commute time, etc.#.
DISCUSSION & DIRECTIONS FOR FUTURE RESEARCH
"n policyma$ing, the importance of identifying factors that are consistently associated with
obesity cannot be overloo$ed. This study further establishes that certain behavioral factors5
particularly physical activity5and certain sociodemographic factors5race, education, income,
and age5are consistently associated with obesity. <onse6uently, future research should see$ to
uncover the exact nature of these associations. y way of example, to what extent are racial
differences in !" due to socioeconomic, cultural, or lifestyle factorsN :hat ma$es =mericans
more prone to gain weight as they ageN =dditionally, more rigorous studies should investigate the
relative importance of physical activity versus diet given that diet has produced inconsistent
findings to date.
%0
Lauren Silver Quantitative Methods II w/Professor Atherly
4/25/2009
REFERENCES
%%
%
Tohill <, Seymour -, Serdula !, Oettel+Ohan F, 8olls -. :hat epidemiologic studies tell us about the relationship
between fruit and vegetable consumption and body weight. Hutrition 8eviews. /00; OctM*/(%0#P1*7+?;.
/
roc$ ':, Thomas O, <owan <', =llison ', Eaesser E=, Iunter E8. =ssociation between insufficiently physically
active and the prevalence of obesity in the United States. Journal of Physical Activity and Health. /00. -anM*(%#P%+7.
1
!affeis <, Talamini E, TatQ F. "nfluence of diet, physical activity and parentsR obesity on childrenRs adiposityP a four+year
longitudinal study. International Journal of Obesity and Related Metabolic Disorders. %..& =ugM//(&#P?7&+*;.
;
ur$e EF, Savage @-, !anolio T=, Spraf$a -!, :agen$necht F), Sidney S, @er$ins FF, Fiu O, -acobs '8 -r. <orrelates
of obesity in young blac$ and white womenP the <=8'"= Study. American Journal of Public Health. %../
'ecM&/(%/#P%*/%+7.
7
ur$e EF, ild '), Iilner -), 9olsom =8, :agen$necht F), Sidney S. 'ifferences in weight gain in relation to race,
gender, age and education in young adultsP the <=8'"= Study. <oronary =rtery 8is$ 'evelopment in >oung =dults.
Ethnicity and Health. %..* 'ecM%(;#P1/?+17.
*
"bid.
?
"bid.
&
Singh EO, Oogan !', van 'yc$ @<. = multilevel analysis of state and regional disparities in childhood and adolescent
obesity in the United States. Journal of Community Health. /00& =prM11(/#P.0+%0/.
.
:ang >, Chang S. =re =merican children and adolescents of low socioeconomic status at increased ris$ of obesityN
<hanges in the association between overweight and family income between %.?% and /00/. The American Journal of
Clinical utrition. /00*M&;P?0?+%*.

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