proximal and distal environmental correlates

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Official Journal of ISPAHwww.JPAH-Journal.com

ORIGINAL RESEARCH

Journal of Physical Activity and Health, 2014, 11, 1179 -1186http://dx.doi.org/10.1123/jpah.2012-0245 2014 Human Kinetics, Inc.

Nesbit ([email protected]) is with the Dept of Physical Therapy, University of the Pacific, Stockton, CA. Kolobe and Arnold are with the Dept of Rehabilitation Sciences, University of Oklahoma, Oklahoma City, OK. Sisson is with the Dept of Nutritional Sciences, University of Oklahoma Health Sciences Center, Oklahoma City, OK. Anderson is with the Dept of Biostatistics and Epidemiology, University of Oklahoma, Oklahoma City, OK.

Proximal and Distal Environmental Correlates of Adolescent Obesity

Kathryn C. Nesbit, Thubi A. Kolobe, Sandra H. Arnold, Susan B. Sisson, and Michael P. Anderson

Background: The purpose of this study was to determine how proximal (home) and distal (neighborhood) environmental characteristics interact to influence obesity in early and middle adolescents. Methods: This was a descriptive, cross-sectional study using the 2007 National Survey of Childrens Health (NCSH). Participants were 39,542 children ages 11 to 17 years. Logistic regressions were used to examine the relationship between adolescent obesity and environmental factors, the relative strength of these factors, and the influence of age and gender. Results: Proximal environmental factors were stronger correlates of adolescent obesity than distal environmental factors. Sedentary behavior related to TV watching time at home was the stron-gest correlate of adolescent obesity overall (OR 1.13, 95% CI 1.111.15). Parks and playgrounds (OR 0.86, 95% CI 0.080.92), as well as recreation centers (OR 0.91, 95% CI 0.850.97) were significant distal environmental factor correlates. Girls and middle adolescents were at less risk for obesity than boys and early adolescents (OR 0.51, 95% CI 0.680.82; OR 0.75, 95% CI 0.680.96). Conclusion: The results of this study reveal the importance of proximal environmental characteristics on adolescent obesity relative to distal environmental characteristics. Obesity intervention strategies for adolescents should target sedentary behavior and opportunities for physical activity with a focus on early adolescents and boys.

Keywords: pediatrics, sedentary behavior, neighborhood characteristics

A higher risk of obesity has been shown at critical time periods of development: early infancy, 5 to 6 years of age, and adoles-cence.1,2 Between 19662006, the prevalence of adolescent obesity has more than tripled from 5% to 17.6%.3,4 According to the 2007 National Survey of Childrens Health (NSCH), 16.4% of children ages 10 to 17 years in the United States (US) are obese5 (defined as body mass index (BMI) 95th percentile for age and sex).6

Adolescence is a developmental transition period characterized by physical, social, emotional, behavioral, and cognitive changes triggered by the neuroendocrine network activated at puberty.7 It is defined as persons 11 to 21 years of age with subcategories of early adolescence at 11 to 14 years of age, middle adolescence at 15 to 17 years of age and late adolescence at 18 to 21 years of age.8 Given that adolescents develop relationships outside of the home, it would appear that as they get older they are likely to be influenced increasingly by factors in the neighborhood. The terms proximal (home) and distal (neighborhood) environment have been used to distinguish these settings.9 The physical and social aspects of the proximal and distal environment are explained by Kolobe et al.9 In the proximal environment, the physical aspect includes the home space and materials in the home. The social aspect of the proximal environment includes parent perceptions that influence childrear-ing practices and adolescent behaviors in the home. In the distal environment, the physical aspect includes the built community such as the presence of sidewalks, parks, playgrounds and recreation

centers. The social aspect of the distal environment includes rela-tionships with peers and adults in the community, and behaviors in the neighborhood. The shifts in relationships and interactions with the environment that occur with adolescence raise questions about the relative importance of factors in the distal environment to the increasing prevalence of adolescent obesity.7,10,11 Also, stage of ado-lescence (early, middle, late) and gender are potentially associated with differential engagement with the distal and proximal environ-ments as they relate to obesogenic behaviors.3,12,13 Understanding the specificity of the influence of various environmental factors is necessary for effective obesity prevention and intervention.

National population-based studies of the collective influences of proximal and distal environmental factors on adolescent obesity are lacking. In the few studies that have reported significant influ-ence of both proximal and distal factors on BMI, participants were either limited to specific geographic areas, homogeneous in terms of ethnic representation, or younger than adolescent age.14,15

Individual influences of either proximal environmental fac-tors13,18,20 or distal environmental characteristics on adolescent BMI,12,21 but not both. Sedentary activities have been shown to be associated with higher weight status in 9- to 12-year-olds.20 In analyses of the 2003 NSCH and the 20012006 National Health and Nutrition Examination Survey (NHANES), higher television view-ing was associated with higher adolescent obesity prevalence.13,22 Sisson et al23 reported that 6 to 17 year olds with low physical activ-ity and high leisure time screen-based activity were at a higher risk of overweight status (defined as a BMI in the 85th to 94th percentile for age and sex).6 The combined influence of high TV watching time and low vigorous physical activity on the odds of adolescents being overweight was also reported based on the logistic regression analysis of the Youth Risk Behavior Survey by Eisenmann et al.24

Other studies focus on the social aspect of the proximal envi-ronment including parent perception of safety. Timperio et al,17 in a cross-sectional survey of 10 to 12 year olds, also observed that

1180 Nesbit et al

children whose parents were concerned about road safety were more likely to be obese than children whose parents were not concerned. Parent concern about neighborhood safety was associated with an increased risk of being overweight in children at the age of 7 years25 and among 10- to 12-year-olds.17 Singh et al12 estimated that the odds of being obese or overweight were higher among children in neighborhoods with unfavorable conditions (such as, lack of safety, lack of amenities, presence of dilapidated hous-ing). The findings by Slater et al19 showed a positive relationship between more physical disorder (loitering, dilapidated buildings, vandalism) and higher weight, and a significant increase in the odds of a lower BMI in more compact communities (dense residential areas, connecting streets). Norman et al16 found an association of community design with physical activity, but not with BMI. Although pervious research provides background on the influences of individual attributes of the proximal or distal environment on adolescent obesity, the collective influence of these proximal and distal factors has not been examined.

Population-based studies are necessary to add to the body of evidence about the interplay and impact of proximal and distal envi-ronmental factors on the adolescent obesity epidemic particularly across socioeconomic level, race, ethnic and geographic groups26 and provide the basis for appropriately targeted intervention initia-tives.27 The current study is based on the 2007 NSCHa nationwide survey with weighted results to reflect population characteristics of noninstitutionalized children ages 10 to 17 years representative of each state and the District of Columbia.28 The purpose of this study was to examine how the factors in the proximal (home) and distal (neighborhood) environment interact to impact obesity in 11- to 17-year-olds. This US population-based study addressed the following questions:

1. Which attributes of the proximal environment and distal envi-ronment are correlates of adolescent obesity?

2. What is the relative strength of their direct and indirect associa-tion with adolescent obesity?

3. Is there a difference in the relationship between proximal and distal environmental factors and their influence on obesity for early (1114 years of age) and middle (1517 years of age) adolescents?

4. Is there a difference in the relationship between proximal and distal environmental factors and their influence on obesity for adolescents based on gender?

We hypothesized that a) proximal factors related to sedentary behavior and parent perception of safety, and distal factors related to the built environment, will be related to adolescent obesity; b) the distal factors will be more related to obesity in adolescents than proximal factors; c) the influence of factors in the distal environ-ment will be greater on middle (1517 years) than early (1114 years) adolescents; and d) the influence of factors in the proximal environment will be greater on girls than boys.

Methods

The study design is descriptive and cross-sectional. Data were extracted from the 2007 NSCH database obtained from the public-use data set from the data resource center for Child and Adolescent Health Measurement Initiative (CAHMI).5,28 Data were filtered for the age range for this study (1117 years), the independent variables, and the dependent variable. We conducted all analyses using PASW

Statistics GradPack18.029 and missing data were handled by removal of specific missing values (pairwise deletion).

Study Data

The participants in the 2007 NSCH were households with children less than 18 years of age. These households were identified from 2.8 million randomly generated landline telephone numbers from the Centers for Disease Control and Preventions (CDC) National Immunization Survey (NIS) sampling frame. Blumberg et al28 report details of the 2007 NSCH sample design, questionnaire content development, sampling weights, and methods. A total of 91,642 interviews were conducted with at least 1700 interviews from each of the 50 states and Washington DC. Geographic infor-mation other than the state identifiers was not in the publicly avail-able 2007 NSCH dataset. The sample included 39,542 children aged 11 to 17 years. The interview completion rate was 66%. The procedure for the survey began with identification of a person or people in the household under the age of 18, the randomly selected child, and a respondent 18 years of age or older. Informed verbal consent was obtained after the respondent (knowledgeable adult) was identified.

Sample Size Estimate

The sample size estimate needed for a 99% confidence level (1% margin of error) is 9068.30 The sample size estimate for 15 predictor variables with a small effect size (0.02), and 0.8 power at alpha = .01 is 1284.31 The sample size of 39,542 for this study far exceeds these estimates.

Study Variables

The independent variables examined in the study included age, gender, proximal environmental characteristics available in the NSCH (parent perception that the child is safe, parent perception that others watch for the child, parent trusts that people will help the child, reading time on an average weekday, computer time on an average weekday, TV watching time on an average weekday, and presence of a TV in the bedroom), and distal environmental characteristics (presence of sidewalks and walking paths, presence of parks and playgrounds, pres-ence of community or recreation center, presence of litter or garbage, presence of dilapidated housing, presence of vandalism).

The dependent variable, obesity classification, was determined by having a body mass index 95th percentile based on gender and age specific growth charts, as defined by cut offs established by the Centers for Disease Control and Prevention (CDC).6 The respondent (ie, generally parent) reported height and weight for the selected child.

Data Analysis

To determine which attributes of the proximal and distal environ-ments were predictive of adolescent obesity, univariate logistic regression models were fit to explore the relationship between ado-lescent obesity and each factor individually. To examine the relative strength of the direct and indirect associations, we used multiple logistic regression to consider all of the proximal and distal factors collectively in the model, but retained only those that were sig-nificant. To explore the influence of early and middle adolescence, we considered proximal and distal environmental factors, and age group interaction terms in the model, but retained only those that were significant. To determine the influence of proximal and distal

Correlates of Adolescent Obesity 1181

environmental factors on boys and girls, we considered proximal and distal environmental factors, and gender interaction terms in the model, but retained only those that were significant. The age and gender interaction terms were included in the variable selection procedures and those interaction terms that were not significant were not retained in the final models. The forward and backward variable selection procedures for multiple logistic regression were used to identify variables important to the model. Because the best model fit for the forward and backward procedures did not yield the same model, the best-fit models for each procedure were compared using Akaikes Information Criteria (AIC). The model with the best overall fit (the lowest AIC) was reported.32

ResultsCharacteristics of the Sample

Baseline demographic characteristics of the sample are available in Table 1.

Environmental Attributes

The results of the univariate logistic regression models are presented in Table 2. Several proximal factors were associated with obesity, including television in the bedroom, time watching television, as well as parent perception of safety, that others watch their children and trust in others. All distal factors were also associated with obe-sity including adolescents living in neighborhoods with sidewalks, playgrounds and parks, a recreation center, vandalism, dilapidated housing, and litter.

Strength of Associations

The results of the multiple logistic regression analysis showing the relative strength of the direct and indirect associations of the proximal and distal environmental determinants are presented in Table 3. Proximal environmental factors with the greatest influence on adolescent obesity were TV watching time (2 = 210.695), TV in the bedroom (2 = 247.199), and parent report of safety (2 = 53.776). Distal environmental factors with the greatest influence on adolescent obesity were parks and playground (2 =16.652), and availability of a recreation center (2 = 8.059). This model also included computer time and parent perception of trust that others will help the child variables.

Influence of Age Group on Environmental Determinants

The results of the multiple logistic regression analysis including proximal and distal environmental factors, and early and middle adolescent age group interaction terms are presented in Table 4. Only 1 age interaction term, that of age and TV watching time, was marginally significant (2 = 3.586, P = .058) and was retained in the model. The effect of TV watching time on obesity for middle adolescents was stronger than early adolescents. Odds of a middle adolescent being obese were less than the odds of an early adoles-cent (2 = 40.493). Proximal environmental factors in the model with age group interaction terms that showed the greatest influence on adolescent obesity were TV watching time (2 =149.613), TV in the bedroom (2 = 268.022), and parent report of safety (2 = 53.335). Distal environmental factors were parks and playgrounds (2 = 16.380), and recreation center (2 = 10.123).

Table 1 Demographic Characteristics of Adolescents in the 2007 National Survey of Childrens Health

Characteristic Percentage

Age

11 11.4

12 12.9

13 13.1

14 14.3

15 14.9

16 16.4

17 17.0

Gender

Girl 47.8

Boy 52.1

BMI for age classification

Underweight < 5th percentile 4.6

Normal weight 5th to 84th percentile 67.6

Overweight 85th to 94th percentile 14.9

Obese 95th percentile or above 12.9

Race/ethnicity

Hispanic 10.7

White, non-Hispanic 70.9

Black, non-Hispanic 10.3

Multiracial, non-Hispanic 4.2

Other, non-Hispanic 3.9

Poverty level

099% federal poverty level 20.4



400% federal poverty level or greater 39.8

Birth order

1 47.1

2 32.5

3 17.9

4 2.2

5 0.3

Mothers sducation

Less than high school 7.8

12 years/high school graduate 22.0

More than high school 69.8

Dont know/refused 0.3

Influence of Gender on Environmental Determinants

The results of the multiple logistic regression analysis with proximal and distal environmental factors, and gender interaction terms are presented in Table 5. Only 1 gender interaction term, that of gender

1182 Nesbit et al

Table 2 Univariate Logistic Regression of Proximal and Distal Environmental Attributes for Prediction of Obesity

VariableOdds ratioa 95% CIb

Proximal attributes

TV bedroom

Presence Referent

Absence 0.54 0.510.58

TV watching time (hours/day) 1.16c 1.141.78

Computer time (hours/day) 1.04c 1.021.06

Reading time (hours/day) 1.01 0.981.03

Parent perception of safety

Never safe 2.15c 1.712.70

Sometimes safe 1.65c 1.491.83

Usually or always safe Referent

Parent perception that others watch child

Definitely agree 0.59c 0.510.69

Somewhat agree 0.63c 0.540.74

Somewhat disagree 0.77c 0.630.94

Definitely disagree Referent

Parent perception of trust in others



Somewhat disagree 0.81 0.651.01


Distal attributes

Sidewalk

Presence 0.80c 0.820.94

Absence Referent

Parks and playgrounds

Presence 0.80c 0.750.86

Absence Referent

Recreation center

Presence 0.85c 0.800.91

Absence Referent

Vandalism

Presence 1.19c 1.081.32

Absence Referent

Housing

Presence 1.26c 1.161.37

Absence Referent

Litter

Presence 1.28c 1.181.39

Absence Referent

a Exp (B).b CI, Confidence Interval.c Wald Chi-Square is significant at the 0.05 level.

Table 3 Multiple Logistic Regression of Proximal and Distal Environmental Attributes for Prediction of Obesity

Outcome Predictor variablesOdds ratioa 95% CIb

Obesity Proximal attributes

TV bedroom

Presence Referent

Absence 0.60 0.560.63


Computer time (hours/day)

Safe 0.98c 0.960.99




Trust


Somewhat agree 0.85 0.711.01



Distal attributes


Presence 0.86c 0.800.92

Absence Referent

Recreation center

Presence 0.91c 0.850.97

Absence Referent


and TV watching time was significant (OR 1.07, 95% CI 1.031.10). The odds of a girl being obese were less than the odds of a boy (2 = 194.012). Proximal environmental factors in the model with gender interaction terms indicate that the greatest influence on adolescent obesity were TV in the bedroom (2 = 230.552), and parent report of safety (2 = 61.967). Distal environmental factors in the model with gender interaction terms were parks and playground (2 = 15.858), and recreation center (2 = 8.681).

DiscussionWhen examined individually, the results of this population-based study showing influences of proximal and distal environmental fac-tors on adolescent obesity support the findings from sample-based studies. Sedentary activities have been shown to be associated with higher prevalence of adolescent obesity.13,20,2224 Parent concern about safety has also been shown to be associated with an higher risk of obesity.17,25 Unfavorable conditions of the neighborhood built environment have been shown to have a positive relationship with a higher BMI and decreased physical activity.12,16,19,33 Our analysis showed that specific proximal and distal factors such as TV in the


Table 4 Multiple Logistic Regression of Proximal and Distal Environmental Attributes With Age Group Interaction Terms



TV bedroom

Presence Referent

Absence 0.59c 0.550.63






Parent perception trust in others


Somewhat agree 0.87 0.731.03



Distal attributes


Presence 0.86c 0.800.93

Absence Referent

Recreation center

Presence 0.90c 0.840.96

Absence Referent

Age group

Early (1114 years) Referent

Middle (1517 years) 0.75c 0.680.82

Interaction terms

Age group by TV watching time

0.97 (ratio early/

middle)

0.941.00


bedroom, perception about safety, and neighborhood amenities have the strongest impact.

We hypothesized, based on relational and interactional shifts that occur with adolescence, that distal factors would be more related to obesity than proximal factors. However, proximal environmental factors (TV watching time, presence of TV in the bedroom, com-puter time, parent report of safety, and parent report or trust that people will help the child) were stronger correlates of adolescent obesity than distal environmental factors (presence of parks and recreation centers). Sedentary behavior related to TV watching time was the strongest correlate of adolescent obesity overall.

Our findings offer a unique perspective because no studies with a sample that is representative of US adolescents have examined the collective and relative strength of the influence of proximal

Table 5 Multiple Logistic Regression of Proximal and Distal Environmental Attributes With Gender Interaction Terms



TV bedroom

Presence Referent

Absence 0.60c 0.560.64

TV watching time (hours/day) 1.03 0.991.01

Computer time (hours/day) 0.96c 0.960.99





Parent perception of trust in others





Distal attributes


Presence 0.86c 0.800.93

Absence Referent

Recreation center

Presence 0.90c 0.850.97

Absence Referent

Gender

Boys Referent

Girls 0.51c 0.460.56

Interaction terms

Gender by TV watching time

1.07c (ratio boys/girls)

1.031.10


and distal factors on adolescent obesity based on the actual BMI. A study by Mota et al14 showed the combined influence of percep-tions of the neighborhood environment and attributes of the built environment on physical activity, although the relationship between obesity was not analyzed and the study sample was from a limited geographic area. Elder et al15 also examined proximal and distal environmental correlates together in a study of Latino elementary school children. Their study showed a relative importance to obe-sity of proximal factors (parents weight) as compared with distal factors (community characteristics). A longitudinal study by Kahn et al34 that considered both proximal and distal determinants of adolescent physical activity included a large adolescent population that lacked ethnic diversity and did not include the BMI. Several

1184 Nesbit et al

review articles also included proximal and distal factors, but lacked a supported a comprehensive analysis of their relative strength of association with obesity.11,35

The interaction between the physical and social aspects of environmental contexts, and the interplay between the home and neighborhood settings are important to the interpretation of the study results.9 On one hand, the proximal environmental factors in this study represent both physical characteristics of the home as well as behaviors in the home and parents perceptions that may contribute to childrearing practices. On the other hand, the distal environmental factors in this study represent only physical characteristics. It is possible that the distal social factors related to adolescent behavior in the neighborhood, such as actual use of the neighborhood ameni-ties, and perception of their neighborhood condition, may also offer valuable insight. For example, did TV watching time (the strongest correlate to obesity) vary with the relative usage of neighborhood amenities? The shift in the influence of the distal environment might occur with the actual usage of amenities in the environment.

Age and Gender Group DifferencesWe hypothesized that the influence of factors in the distal envi-ronment on obesity would be greater in middle than in early ado-lescence based on the trends for increasing independence in the community with increasing age, and literature about the role of distal environmental characteristics.12 Our findings suggested that the risk of obesity was higher in early than in middle adolescents. This finding is consistent with findings from the 2003 NSCH,12 but different from findings from the 2006 NHANES showing slightly more obese 12- to 19-year-olds than 6- to 11-year-olds.3 In our analyses age group did not have a significant impact on the influ-ence of proximal or distal factors on obesity. These findings may be related to differences in the range of age studied and the cut-off for the various age groups.

We also hypothesized that the influence on obesity of factors in the proximal environment would be greater for girls than for boys based on girls tendency to remain in proximity to the home and indications in the literature.13,24,36 Our finding that gender was a strong predictor of adolescent obesity with boys being at a higher risk than girls is supported in the literature.3,13 In contrast to the expected results, a characteristic of the proximal environment (TV watching time) had a greater influence on the odds of obesity in boys than the odds of obesity in girls. The results of the studies in the literature that use both physical activity and TV watching time as predictive risk factors for obesity are mixed with some showing an equal effect on boys and girls18 and others showing girls more effected than boys.13,24

Implications for PracticeInsight into the influence of individual and collective proximal and distal environmental attributes can inform theory for ado-lescent obesity intervention planning. Our findings based on a nationwide, representative sample of US adolescents suggest that specific environmental attributes of the home and neighbor-hood may influence adolescent obesity and should therefore be the target for prevention programs. These results support current approaches to obesity intervention which incorporate community level interventions,37,38 school-based interventions,39 home seden-tary behaviors,40 and the use of parents as agents of intervention delivery.41 The results of the relative strength of proximal and distal environmental correlates combined suggest that efforts to decrease TV watching time must be coupled with intervention

strategies that increase the utility of neighborhood amenities. In addition to targeting sedentary behaviors, obesity intervention strategies for adolescents should also focus on the groups at a higher risk for obesity: early adolescents and boys. Specific strategies to reduce TV watching time should particularly target adolescent boys.

Limitations

The responses to the 2007 NSCH were based on the report of a knowledgeable person in the household that would proxy report on the sample childs health and behaviors. The behaviors were not directly observed, and the obesity status was not directly measured. The questions about amenities in the community provide informa-tion about the presence of the amenities but do not necessarily reflect their use for physical activity or the possible differences between respondents perception of their environment and the actual characteristics.42 Questions about television, computer, and reading time ask about the adolescents behavior on an average weekday, and may not necessarily reflect typical behavior on the weekend. The lack of specific geographic information (not publicly available in the 2007 NSCH) did not allow analysis of groups-levels for distal environmental characteristics. However, the aim of this study was to estimate the influence of the distal factors, rather than the vari-ability of geographic clusters.

Future Research

The study of adolescent obesity is a complex topic involving mul-tiple variables that need to be well understood if obesity prevention efforts are to be focused and efficient. This study provided a much-needed background for the development of a conceptual and inter-vention model that could guide intervention efforts. The intricacies of the interactions of the environmental factors and the differences in the interactions based on gender and age group may be further understood in the future through development of conceptual models that include constructs based on measurable variables.

ConclusionsThe results of this US population-based study begin to fill the gap in adolescent obesity research with an improved understanding of the relatedness and relative importance of proximal and distal environmental determinants of adolescent obesity. Home, family, and community influences on adolescent obesity highlight the mul-tidimensional nature of interactions with the environment during this stage of development.4345 Recognizing the serious public health concern of adolescent obesity, The American Academy of Pediatrics46 and the Society for Adolescent Medicine47 advocate for increased understanding of environmental risk factors. The results of this study increase the understanding of not only the collective influences of proximal and distal environmental characteristics, but also their relative importance related to adolescent obesity. This study highlights the importance of proximal environmental characteristics on adolescent obesity relative to distal environmental characteristics, and the overall consistency of the influences of proximal and distal environmental factors on obesity across age groups and gender. The specific environmental influences identi-fied indicate that obesity intervention strategies for adolescents should target sedentary behavior and opportunities for physical activity with a focus on the groups at a higher risk for obesity: early adolescents and boys.


Acknowledgments

This work was a partial requirement for the Doctor of Science degree program in Rehabilitation Sciences at the University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma for K. C. Nesbit and was partially supported by grant #H325K080335 from OSEP.

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