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December 6, 2006: 

The Honorable Bill Frist: 
Majority Leader: 
United States Senate: 

Subject: Childhood Obesity: Factors Affecting Physical Activity: 

Dear Senator Frist: 

The latest data show continued increases in rates of childhood 
obesity.[Footnote 1] For example, obesity rates for children 6 to 11 
years old are estimated to have increased from 15.1 to 18.8 percent 
between 1999 and 2004.[Footnote 2] The Department of Health and Human 
Services estimates that 20 percent of children and youth in the United 
States will be obese by 2010. There are numerous negative health 
outcomes and financial consequences related to childhood obesity. 
Researchers have found that childhood obesity is associated with a 
number of disorders including hypertension, insulin resistance, sleep 
apnea, menstrual abnormalities, and orthopedic problems. According to 
one estimate, insured children treated for obesity are approximately 
three times more expensive for the health system than the average 
insured child.[Footnote 3] 

Obesity results from an imbalance between the amount of energy consumed 
and the amount of energy expended. While there are many elements that 
affect the energy balance (for example, genetics, growth, and 
physiology), children and their parents can influence both energy 
consumed through diet and energy expended through physical activity. 
Some researchers have suggested that childhood obesity is largely the 
result of a decline in regular physical activity. In our October 2005 
report,[Footnote 4] we surveyed experts on the key strategies to 
include in the design or implementation of a program to prevent or 
reduce childhood obesity. The program strategy identified by experts as 
most important was "increasing physical activity." 

You asked us to provide information on the factors affecting physical 
activity in children. Enclosure I contains the information we provided 
to your staff at our November 15, 2006, briefing. 

To carry out our work, we conducted a literature review. We selected 53 
articles that described work focused on factors affecting rates of 
physical activity for school-aged children, published from 2003 through 
2006. Enclosure II is a bibliography of the materials we reviewed. To 
select the articles, we reviewed study abstracts identified in your 
request letter and conducted a literature search of five 
databases.[Footnote 5] We focused on studies of children and 
adolescents and excluded studies of infants and preschool-aged 
children. For purposes of this report, we use the term obese to refer 
collectively to the terms obese and overweight, which were both used by 
authors. We supplemented the studies with information obtained from 
organizations that recently published information on childhood obesity 
including the Institute of Medicine and the Trust for America's Health. 
Our literature search was not exhaustive, and for this report we did 
not discuss all of the articles we reviewed, but instead highlighted 
selected articles to provide examples of findings. We conducted our 
work from August 2006 through November 2006 in accordance with 
generally accepted government auditing standards. 

In summary, the articles we reviewed identified a number of factors 
affecting levels of physical activity in children. We categorized the 
factors presented in the articles we reviewed into three groups-- 
demographic factors, cognitive and behavioral factors, and community 
factors. Demographic factors include socioeconomic status and race. 
Cognitive and behavioral factors include attitudes, beliefs, and 
perceptions and sedentary behaviors.[Footnote 6] Community factors 
include the built environment[Footnote 7] and school-based physical 
activity. The articles and additional materials we reviewed identified 
additional research needs, such as using objective measures of physical 
activity and sedentary time. The body of research we examined suggests 
that multiple factors that affect physical activity among children may 
contribute to childhood obesity. 

As we agreed with your office, unless you publicly announce the 
contents of this report earlier, we plan no further distribution until 
30 days after the date of this letter. 

At that time, this report will be available at no charge on the GAO Web 
site at [Hyperlink, http://www.gao.gov]. Contact points for our Offices 
of Congressional Relations and Public Affairs may be found on the last 
page of this report. 

If you and your staff have any questions or need additional 
information, please contact me at (202) 512-7101, or bascettac@gao.gov. 
Major contributors to this report were Linda Kohn, Assistant Director; 
Shannon Slawter; and Julie Thomas. 

Sincerely yours, 

Signed by: 

Cynthia A. Bascetta: 
Director, Health Care: 

Enclosures: 

GAO Congressional Briefing: 

Childhood Obesity: Factors Affecting Physical Activity: 

Briefing Outline: 

Introduction: 

Objective, scope, and methodology: 

Factors affecting physical activity: 
Additional research needs: 

Concluding observations: 

Introduction: 

The latest data show continued increases in rates of childhood 
obesity.[Footnote 8] HHS estimates that 20% of children and youth in 
the U.S. will be obese by 2010. 

There are numerous negative health outcomes and financial consequences 
related to childhood obesity. 

According to one estimate, total health care spending for children who 
receive a diagnosis of obesity is approximately $750 million per 
year.[Footnote 9] 

Obesity results from an imbalance between the amount of energy consumed 
and the amount of energy expended. 

Children and their parents can influence both energy consumed through 
diet and energy expended through physical activity. 

Some researchers have suggested that childhood obesity is largely the 
result of a decline in regular physical activity. 

For our October 2005 report, Childhood Obesity. Most Experts Identified 
Physical Activity and the Use of Best Practices as Key to Successful 
Programs (GAO-06-127R), we surveyed experts on the key strategies to 
include in the design or implementation of a program to prevent or 
reduce childhood obesity. The program strategy identified by experts as 
most important was "increasing physical activity." 

Objective, Scope, and Methodology: 

Our objective in this briefing is to summarize the relevant literature 
about the factors affecting levels of physical activity among children 
that may contribute to childhood obesity.[Footnote 10] We will also 
discuss additional research needs identified in the literature. 

In our review of the literature, we did not examine research that 
addresses whether there have been decreases in the physical activity of 
children over time, a trend which some researchers dispute. 

We reviewed study abstracts identified in the request letter and 
conducted a literature search of five databases.[Footnote 11] 

We selected 53 studies that described new work focused on factors 
affecting rates of physical activity for children, published from 2003 
through 2006. 

We supplemented the studies with information obtained from 
organizations such as the Institute of Medicine (IOM), the Trust for 
America's Health, and The Robert Wood Johnson Foundation. 

We conducted our work from August 2006 through November 2006 in 
accordance with generally accepted government auditing standards. 

Limitations of our work: 

* Literature search was not exhaustive. 

* We will not discuss all of the articles that we reviewed, but instead 
highlight selected articles to provide examples of findings. 

Factors Affecting Physical Activity: 

*We grouped the factors affecting physical activity into three 
categories: 

* Demographic factors: 

* Cognitive and behavioral factors: 

* Community factors: 

Demographic Factors: 

Socioeconomic status (SES): 

* Studies tied low SES to physical inactivity. 

Race/ethnicity: 

* While several studies included race/ethnicity as a variable, they 
focused on other factors, which we will discuss later. 

Cognitive and Behavioral Factors: 

Attitudes, beliefs, and perceptions: 

* Among other factors, studies identified lack of motivation, self- 
consciousness, and concerns about not being good enough as contributing 
to reduced physical activity. 

* Studies found some differences between white and African-American 
girls in their attitudes and perceptions about physical activity. 

* Studies found that adolescents who were obese perceived more barriers 
to physical activity than adolescents who were not. 

Family and social influences: 

* Studies found that parental and social support for physical activity 
was associated with increased physical activity. 

Sedentary behaviors[Footnote 12] 

* Studies differed in their findings on the relationship between 
sedentary behaviors and obesity, but not all of them explained the 
relationship between sedentary behaviors and physical activity. 

* Some studies found that increases in sedentary behaviors are 
associated with decreases in physical activity. 

* Studies reported differences in sedentary behavior patterns by gender 
and the influence of family on children's television viewing habits. 

Community Factors: 

General/safety: 

* One study found that adolescents in older suburban communities engage 
in more physical activity. 

* One study found that adolescents in unsafe neighborhoods engage in 
less physical activity. 

Built environment[Footnote 13] 

* Studies found that environmental characteristics, such as lack of 
streetlights and the need to cross busy roads, were negatively related 
to children's physical activity, including walking and biking to 
school. 

Availability of venues for physical activity: 

* One study found that lack of venue (e.g., sports areas, swimming 
pools, parks) was related to lower rates of physical activity. 

* Studies found that areas of low SES and high minority populations had 
fewer venues for physical activity. 

School-based physical activity: 

* School-based physical education policies vary widely by state, school 
district, and school. 

Additional Research Needs: 

The literature we reviewed contained two commonly suggested themes for 
research improvement: 

* Study design: 

- longitudinal instead of cross-sectional: 

- venue affordability, quality, and usage instead of venue availability 
only: 

* Measurement: 

- objective measures of physical activity and sedentary time: 

- other measures, such as health status: 

IOM and the Transportation Research Board also identified additional 
needs, including: 

* Need for additional evaluations to provide evidence for new or 
modified programs or policies: 

* Built environment: 

- need to develop better ways to measure the built environment -need to 
connect data on the built environment to data on health and physical 
activity: 

Concluding Observations: 

Reversing trends in childhood obesity requires an understanding of the 
factors affecting children's energy imbalance, including their physical 
activity levels. 

The articles we reviewed identified a number of factors affecting 
levels of physical activity in children. 

The body of research we examined suggests that multiple factors that 
affect physical activity among children may contribute to childhood 
obesity. 

[End of Section] 

Bibliography: 

Articles included in GAO's review: 

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Braza, M., W. Shoemaker, and A. Seeley. "Neighborhood design and rates 
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Centers for Disease Control and Prevention. "Participation in high 
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Datar, A. and R. Sturm. "Physical education in elementary school and 
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Davison, K.K., L.A. Francis, and L.L. Birch. "Reexamining obesigenic 
families: parents' obesity-related behaviors predict girls' change in 
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De Bourdeaudhuij, I., J. Lefevre, B. Deforche, K. Wijndaele, L. Matton, 
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Deforche, B.I., I.M. De Bourdeaudhuij, and A.P. Tanghe. "Attitude 
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568. 

Dowda, M., R.R. Pate, G.M. Felton, R. Saunders, D.S. Ward, R.K. 
Dishman, and S.G. Trost. "Physical activities and sedentary pursuits in 
African American and Caucasian girls." Research Quarterly for Exercise 
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Elgar, F.J., C. Roberts, L. Moore, and C. Tudor-Smith. "Sedentary 
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Epstein, L.H., J.N. Roemmich, R.A. Paluch, and H.A. Raynor. "Physical 
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Behavioral Medicine, vol. 29, no. 3 (2005): 200-209. 

Fleming-Moran, M. and K. Thiagarajah. "Behavioral interventions and the 
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Going, S., J. Thompson, S. Cano, D. Stewart, E. Stone, L. Harnack, C. 
Hastings, J. Norman, and C. Corbin. "The effects of the Pathways 
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children." Preventive Medicine, vol. 37, no. 6 (2003): S62-S69. 

Gómez, J.E., B.A. Johnson, M. Selva, and J.F. Sallis. "Violent crime 
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Gordon-Larsen, P., P. Griffiths, M.E. Bentley, D.S. Ward, K. Kelsey, K. 
Shields, and A. Ammerman. "Barriers to physical activity - Qualitative 
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Gordon-Larsen, P., M.C. Nelson, P. Page, and B.M. Popkin. "Inequality 
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Graf, C., B. Koch, S. Dordel, S. Schindler-Marlow, A. Icks, A. 
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Hesketh, K., E. Waters, J. Green, L. Salmon, and J. Williams. "Healthy 
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Jago, R., T. Baranowski, I. Zakeri, and M. Harris. "Observed 
environmental features and the physical activity of adolescent males." 
American Journal of Preventive Medicine, vol. 29, no. 2 (2005): 98-104. 

Janssen, I., W.F. Boyce, K. Simpson, and W. Pickett. "Influence of 
individual-and area-level measures of socioeconomic status on obesity, 
unhealthy eating, and physical inactivity in Canadian adolescents." 
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Janssen, I., P.T. Katzmarzyk, W.F. Boyce, M.A. King, and W. Pickett. 
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Jefferson, A. "Breaking down barriers - examining health promoting 
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Kelly, L.A., J.J. Reilly, A. Fisher, C. Montgomery, A. Williamson, J.H. 
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Kimm, S.Y.S., N.W. Glynn, R.P. McMahon, C.C. Voorhees, R.H. Striegel- 
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Nichols-English, G.J., C.R. Lemmon, M.S. Litaker, S.G. Cartee, Z. Yin, 
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Norman, G.J., B.A. Schmid, J.F. Sallis, K.J. Calfas, and K. Patrick. 
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Olds, T., K. Ridley, and J. Dollman. "Screenieboppers and extreme 
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Powell, L.M., S. Slater, and F.J. Chaloupka. "The relationship between 
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Richmond, T.K., R.A. Hayward, S. Gahagan, A.E. Field, and M. Heisler. 
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Salmon, J., K.J. Campbell, and D.A. Crawford. "Television viewing 
habits associated with obesity risk factors: a survey of Melbourne 
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Salmon, J., A. Timperio, V. Cleland, and A. Venn. "Trends in children's 
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Thompson, V.J., T. Baranowski, K.W. Cullen, L. Rittenberry, J. 
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(290567): 

FOOTNOTES 

[1] Some experts use the term obesity to refer to children and 
adolescents who have a body mass index (BMI) that is at or above the 
sex-specific 95th percentile for their age on the BMI charts developed 
by the Centers for Disease Control and Prevention (CDC) in 2000. CDC 
uses the term overweight, instead of obese, to describe children and 
adolescents with this BMI range. 

[2] C.L Ogden, M.D. Carroll, L.R. Curtin, M.A. McDowell, C.J. Tabak, 
and K.M. Flegal, "Prevalence of Overweight and Obesity in the United 
States, 1999-2004," JAMA, vol. 295, no. 13 (2006). These data are for 
children at or above the 95TH percentile of BMI for age and sex. 

[3] Thomson Medstat, Childhood Obesity: Costs, Treatment Patterns, 
Disparities in Care, and Prevalent Medical Conditions, 2006, 
[Hyperlink, http://www.medtstat.com/pdfs/childhood_obesity.pdf], 
(downloaded Nov. 3, 2006). Thomson Medstat used medical claims to 
estimate total health care spending for children who receive a 
diagnosis of obesity. 

[4] GAO, Childhood Obesity: Most Experts Identified Physical Activity 
and the Use of Best Practices as Key to Successful Programs, GAO-06- 
127R (Washington, D.C.: Oct. 7, 2005). 

[5] We also contacted several experts in the field to help us identify 
relevant literature. 

[6] Sedentary behaviors include, for example, television watching, 
video game playing, and computer use. 

[7] The built environment is broadly defined to include land use 
patterns, the transportation system, and design features that together 
provide opportunities for travel and physical activity. 

[8] Some experts use the term obesity to refer to children and 
adolescents who have a body mass index (BMI) for age that is at or 
above the sex- specific 95th percentile of the BMI charts developed by 
the Centers for Disease Control and Prevention in 2000. 

[9] Thomson Medstat used medical claims to estimate total health care 
spending for children who receive a diagnosis of obesity. Children who 
received a diagnosis of obesity are a small subset of the percentage of 
children who are considered obese. Thomson Medstat estimates that 
children treated for obesity are roughly three times more expensive for 
the health system than the average insured child. 

[10] For our literature review, we focused on studies of children and 
adolescents and excluded studies of infants and preschool-aged 
children. For purposes of this briefing, we use the term obese to refer 
collectively to obese and overweight children. 

[11] We also contacted several experts in the field to help us identify 
relevant literature. 

[12] Sedentary behaviors include, for example, television watching, 
video game playing, and computer use. 

[13] The built environment is broadly defined to include land use 
patterns, the transportation system, and design features that together 
provide opportunities for travel and physical activity.  

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