Obesity, Abdominal Obesity, Physical Activity, and Caloric Intake in US ...

CLINICAL RESEARCH STUDY

Obesity, Abdominal Obesity, Physical Activity, and Caloric Intake in US Adults: 1988 to 2010 Uri Ladabaum, MD, MS,a,b Ajitha Mannalithara, PhD,a,b Parvathi A. Myer, MD, MHS,a,b Gurkirpal Singh, MDa,b a

Division of Gastroenterology and Hepatology, bDepartment of Medicine, Stanford University School of Medicine, Stanford, Calif.

ABSTRACT BACKGROUND: Obesity and abdominal obesity are associated independently with morbidity and mortality. Physical activity attenuates these risks. We examined trends in obesity, abdominal obesity, physical activity, and caloric intake in US adults from 1988 to 2010. METHODS: Univariate and multivariate analyses were performed using National Health and Nutrition Examination Survey data. RESULTS: Average body mass index (BMI) increased by 0.37% (95% confidence interval [CI], 0.30-0.44) per year in both women and men. Average waist circumference increased by 0.37% (95% CI, 0.30-0.43) and 0.27% (95% CI, 0.22-0.32) per year in women and men, respectively. The prevalence of obesity and abdominal obesity increased substantially, as did the prevalence of abdominal obesity among overweight adults. Younger women experienced the greatest increases. The proportion of adults who reported no leisure-time physical activity increased from 19.1% (95% CI, 17.3-21.0) to 51.7% (95% CI, 48.9-54.5) in women, and from 11.4% (95% CI, 10.0-12.8) to 43.5% (95% CI, 40.7-46.3) in men. Average daily caloric intake did not change significantly. BMI and waist circumference trends were associated with physical activity level but not caloric intake. The associated changes in adjusted BMIs were 8.3% (95% CI, 6.9-9.6) higher among women and 1.7% (95% CI, 0.68-2.8) higher among men with no leisure-time physical activity compared with those with an ideal level of leisure-time physical activity. CONCLUSIONS: Our analyses highlight important dimensions of the public health problem of obesity, including trends in younger women and in abdominal obesity, and lend support to the emphasis placed on physical activity by the Institute of Medicine. Ó 2014 Elsevier Inc. All rights reserved. The American Journal of Medicine (2014) 127, 717-727 KEYWORDS: Abdominal obesity; Adiposity; Body mass index; Calories; Diet; Exercise; Obesity; Physical activity; Waist circumference; Weight SEE RELATED EDITORIAL p. 681

The Institute of Medicine (IOM) identifies obesity as a health issue of monumental importance to the nation.1 Obesity, defined as a body mass index (BMI) of 30 kg/m2, is associated with multiple comorbidities, including Funding: National Institutes of Health T32 Training Grant T32DK007056 Awarded to PAM. The sponsor had no design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. Conflict of Interest: UL has served as a consultant for Endosphere. Authorship: All authors had access to the data and played a role in writing this manuscript. Requests for reprints should be addressed to Uri Ladabaum, MD, MS, Division of Gastroenterology and Hepatology, Stanford University School of Medicine, 300 Pasteur Drive, M211, Stanford, CA 94305. E-mail address: [email protected] 0002-9343/$ -see front matter Ó 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.amjmed.2014.02.026

cardiovascular disease and cancer, and a higher risk of allcause mortality.1,2 Overweight, defined as a BMI of 25.0 to 29.9 kg/m2, has been associated with an increased risk of death in several studies.2-4 More than two thirds of US adults are considered obese or overweight.5,6 The cost of obesity-related illness approximates 20% of annual US health care spending.1 Life expectancy could decline because of the effects of obesity.7 Increased waist circumference is an independent predictor of morbidity and mortality, even in persons with a normal BMI.8-11 The National Institutes of Health recommends measuring waist circumference in addition to weight and height in primary care practice to help guide weight management.12 The causes of obesity are multifactorial and reflect the balance between energy intake and expenditure.1,13 Physical

718

The American Journal of Medicine, Vol 127, No 8, August 2014

activity is a key component of weight management.12 Of the Definition of Dietary Measures IOM’s 5 recommendations to address the national obesity Total caloric intake per day was estimated on the basis epidemic, the first is to make physical activity an integral of the total energy intake (kcal, or calories) reported in the first and routine part of life.1 24-hour recall data set. These data were obtained during Our aims were to characterize trends in and associations the examination component of NHANES by trained dietary among overweight and obesity, abdominal obesity, physical interviewers using an automated dietary interview system.15,16 activity, and caloric intake in US adults in the last 2 decades. We CLINICAL SIGNIFICANCE Statistical Analyses explored trends in the prevalence Analyses were performed for all of abdominal obesity within strata Average body mass index and waist adults and after stratification by defined by BMI, given the health circumference, obesity and abdominal gender; predefined age strata of 18 risks of increased waist circumobesity prevalence, and the population to 39 years, 40 to 64 years, and 65 ference independent of BMI, and fraction reporting no leisure-time physyears; and race/ethnicity. Data from we explored the relationships beical activity increased substantially in US each cycle were considered to be tween measures of obesity and adults from 1988 to 2010. from the midpoint of each period. levels of physical activity and To examine trends in BMI, waist caloric intake. Body mass index and waist circumfercircumference, and daily energy ence trends were associated with physintake, we calculated national estiMETHODS ical activity level but not daily caloric mates of age-adjusted averages and intake. 95% confidence intervals (CIs) for Data Source Although US obesity rates may be staeach survey cycle. We used linear We used data from the National regression to assess trends in logbilizing, our results lend support to the Health and Nutrition Examination transformed BMI, waist circumferSurvey (NHANES), beginning with emphasis placed on physical activity in ence, and daily energy intake by NHANES-III (1988-1994) and inthe Institute of Medicine report on including the midpoints of each cluding the continuous NHANES obesity. survey cycle as a continuous vari2-year survey cycles from 1999able. To address possible changes 2000 to 2009-2010.14 The samples in BMI trends over time, we used joinpoint analysis in each cycle were selected using a stratified, multistage, (Appendix, online).18 The results are expressed as annual clustered probability sampling design, described in detail 15,16 percentage change. before. To examine trends in the prevalence of obesity and abdominal obesity, and the levels of physical activity, we Study Population calculated national estimates of age-adjusted proportions All examined participants aged 18 years, except pregnant and 95% CIs for each survey cycle. We assessed changes women, were included. For the caloric intake analyses, only over time using logistic regression analysis by including the eligible participants who had reliable and complete 24-hour midpoints of each survey cycle as a continuous variable. We dietary recall data were included. Subgroup analyses were present odds ratios and 95% CIs reflecting the odds of fulperformed for subgroups of self-identified race/ethnicity filling criteria for a specific category in a given year versus with sufficiently large samples: non-Hispanic white, non14 the previous year. We performed separate analyses to Hispanic black, and Mexican-American. examine trends in abdominal obesity for overweight and obese adults, defined by BMI. Definition of Anthropometric Measures Analyses stratified by 3 prespecified levels of leisureDuring the examination component of NHANES, height, time physical activity were performed for trends in the weight, and waist circumference were measured. On the measures of obesity and daily energy intake. To examine the basis of BMI, individuals were categorized as normal independent effects of physical activity and daily energy weight (18.5-24.99 kg/m2), overweight (25.0-29.99 kg/m2), intake, we performed multivariate regression analysis with or obese (30 kg/m2).8 Abdominal obesity was defined on log-transformed BMI and waist circumference as response the basis of a waist circumference of >88 cm for women variables, and year, physical activity level, and daily energy and >102 cm for men.8,17 intake as explanatory variables, adjusted for age, age squared, and gender. For sensitivity analyses, we first used Definition of Leisure-time Physical Activity only the continuous NHANES data, in which total minutes Levels spent on physical activity can be estimated; and second, we used only data from 1999-2000 to 2005-2006, including Participants were grouped into 3 levels of leisure-time activity related to transportation and domestic work, because physical activity: ideal, intermediate, and none. This was the physical activity questionnaire was consistent in these accomplished by following the methods and definitions of cycles (Appendix). the specific NHANES surveys (Appendix, online).

Ladabaum et al

Trends in Obesity, Physical Activity, and Caloric Intake

All analyses were performed with appropriate survey procedures in SAS v9.3 (SAS Institute Inc, Cary, NC). Survey design variables and weight variables were used to account for the complexity of the NHANES survey design with stratification and clustering. Averages and prevalence rates were age-adjusted to the year 2000 US standard population.19

RESULTS Body Mass Index and Obesity From 1988-1994 to 2009-2010, the average BMI in the United States increased by 0.37% (95% CI, 0.30-0.44) per year in both women and men. Average BMI increased in all age and racial/ethnic groups (Figure 1, Table 1). The age subgroup with the greatest annual increase was 18- to 39year-old women (Table 1). Joinpoint analyses identified a change in the trend for average BMI only in women, with annual increases of 0.60% (95% CI, 0.50-0.69) from 1991 to 2002, and smaller annual increases of 0.22% (95% CI, 0.11-0.32) from 2002 to 2010. Among women, average BMI was highest among non-Hispanic blacks and lowest among non-Hispanic whites; among men, it was similar across racial/ethnic groups (Figure 1, Table 1, Appendix Table 1 [online]).

719

The prevalence of obesity increased from 24.9% (95% CI, 23.1-26.8) to 35.4% (95% CI, 33.6-37.3) in women, and from 19.9% (95% CI, 18.4-21.3) to 34.6% (95% CI, 31.038.1) in men. These increases were associated with decreases in the proportions of normal-weight women and men, and no change in the proportions of overweight women and men (Table 1). Compared with the previous year, the odds ratio for being categorized as obese in any given year was 1.026 (95% CI, 1.019-1.033) for women and 1.042 (95% CI, 1.033-1.050) for men. Similar trends were observed in all age groups (Table 1). Sex-specific differences between racial/ethnic groups in obesity prevalence paralleled the BMI results (Table 1, Appendix Figure 1 [online], Appendix Table 1 [online]).

Waist Circumference and Abdominal Obesity The average waist circumference increased by 0.37% (95% CI, 0.30-0.44) per year in women and 0.27% (95% CI, 0.22-0.32) per year in men. Increases in average waist circumference were observed in all age and racial/ethnic groups (Figure 2, Table 1). As with BMI, the subgroup with the greatest annual increase in average waist circumference was 18- to 39-year-old women (Table 1). Among women, average waist circumference was largest

Figure 1 Trends in average BMI in US adults, 1988-2010. (A) Trends in women by age group. (B) Trends in men by age group. (C) Trends in women by racial/ethnic group. (D) Trends in men by racial/ethnic group. BMI ¼ body mass index.

720

Table 1

Trends in Average Body Mass Index, Waist Circumference, and Prevalence of Obesity and Abdominal Obesity, US Adults, 1988-2010* Category Based on Waist Circumference

Category Based on BMI

Mean BMI in kg/m2 (95% CI)

Mean Waist Circumference in cm (95% CI)

Obese, % of Population (95% CI)

Overweight, % of Population (95% CI)

Normal Weight, % of Population (95% CI)

Abdominal Obesity, % of Population (95% CI)

(26.2-26.7) (28.3-28.9) (0.30-0.44)

88.6 (87.9-89.3) 94.9 (93.9-95.8) APC, 0.37 (0.30-0.43)

24.9 (23.1-26.8) 35.4 (33.6-37.3) OR, 1.026 (1.019-1.033)

25.5 (24.1-26.9) 27.4 (24.5-30.3) OR, 1.004 (0.997-1.011)

45.7 (43.7-47.7) 34.3 (31.9-36.8) OR, 0.976 (0.970-0.983)

46.0 (43.9-48.0) 61.5 (58.8-64.2) OR, 1.036 (1.029-1.044)

(24.8-25.6) (27.1-28.4) (0.35-0.59)

83.2 (82.4-84.1) 91.3 (89.6-93.1) APC, 0.49 (0.40-0.59)

20.0 (17.6-22.3) 31.2 (27.9-34.5) OR, 1.033 (1.022-1.044)

19.4 (17.5-21.3) 23.4 (18.9-27.8) OR, 1.011 (1.000-1.022)

55.4 (52.8-58.0) 42.2 (37.4-47.0) OR, 0.972 (0.963-0.981)

29.3 (26.0-32.6) 49.1 (43.6-54.6) OR, 1.046 (1.033-1.058)

(27.2-28.1) (28.7-29.6) (0.15-0.36)

92.2 (91.2-93.2) 96.9 (95.9-97.9) APC, 0.28 (0.20-0.36)

30.6 (27.7-33.4) 38.5 (34.8-42.1) OR, 1.018 (1.008-1.029)

28.5 (26.2-30.7) 29.4 (26.0-32.8) OR, 1.000 (0.990-1.009)

38.3 (35.2-41.4) 29.4 (25.9-32.8) OR, 0.982 (0.972-0.992)

55.7 (52.8-58.6) 68.7 (65.3-72.0) OR, 1.030 (1.020-1.040)

(26.3-26.9) (28.5-29.9) (0.27-0.48)

93.2 (92.4-94.1) 98.5 (97.4-99.7) APC, 0.26 (0.17-0.34)

23.6 (21.4-25.9) 38.6 (33.5-43.7) OR, 1.029 (1.017-1.041)

33.3 (31.2-35.4) 32.5 (27.7-37.2) OR, 1.002 (0.992-1.012)

39.6 (36.7-42.4) 26.9 (23.6-30.3) OR, 0.976 (0.966-0.987)

63.7 (60.3-67.1) 74.9 (72.4-77.5) OR, 1.028 (1.016-1.041)

(25.6-26.3) (27.6-28.4) (0.27-0.47)

87.7 (86.8-88.6) 94.2 (93.0-95.4) APC, 0.38 (0.30-0.46)

22.5 (20.3-24.8) 32.2 (29.1-35.3) OR, 1.026 (1.016-1.035)

24.2 (22.6-25.9) 26.8 (22.3-31.3) OR, 1.007 (0.998-1.016)

49.3 (46.8-51.8) 37.8 (34.6-41.0) OR, 0.975 (0.967-0.984)

43.2 (40.6-45.9) 59.0 (55.5-62.5) OR, 1.037 (1.027-1.047)

(28.5-29.3) (31.3-33.1) (0.37-0.64)

93.6 (92.7-94.5) 100.5 (98.3-102.7) APC, 0.38 (0.28-0.48)

37.4 (34.7-40.0) 57.3 (51.8-62.8) OR, 1.039 (1.028-1.050)

29.3 (27.5-31.1) 23.4 (20.2-26.6) OR, 0.987 (0.979-0.996)

30.4 (28.0-32.8) 17.1 (13.7-20.5) OR, 0.963 (0.952-0.974)

60.2 (57.6-62.8) 75.9 (69.9-81.9) OR, 1.038 (1.025-1.052)

(27.9-28.6) (29.3-30.2) (0.21-0.44)

92.4 (91.7-93.2) 97.4 (96.1-98.7) APC, 0.38 (0.28-0.47)

34.1 (31.4-36.8) 43.8 (40.4-47.1) OR, 1.027 (1.014-1.040)

33.1 (30.9-35.3) 34.0 (30.4-37.7) OR, 1.000 (0.989-1.010)

31.3 (28.5-34.0) 21.5 (18.6-24.3) OR, 0.973 (0.961-0.985)

60.7 (58.5-62.9) 74.1 (69.9-78.3) OR, 1.043 (1.029-1.057)

Women 18 y 1988-1994 26.4 2009-2010 28.6 Trend APC, 0.37 18-39 y 1988-1994 25.2 2009-2010 27.8 Trend APC, 0.47 40-64 y 1988-1994 27.6 2009-2010 29.1 Trend APC, 0.26 65 y 1988-1994 26.6 2009-2010 29.2 Trend APC, 0.37 18 y, non-Hispanic white 1988-1994 26.0 2009-2010 28.0 Trend APC, 0.37 18 y, non-Hispanic black 1988-1994 28.9 2009-2010 32.2 Trend APC, 0.51 18 y, Mexican American 1988-1994 28.2 2009-2010 29.8 Trend APC, 0.32


BMI and Waist Circumference

Continued Category Based on BMI


Mean Waist Circumference in cm (95% CI)





(26.4-26.8) (28.2-29.0) (0.30-0.44)

95.6 (95.1-96.0) 100.4 (99.3-101.5) APC, 0.27 (0.22-0.32)

19.9 (18.4-21.3) 34.6 (31.0-38.1) OR, 1.042 (1.033-1.050)

39.7 (38.1-41.3) 38.1 (35.9-40.3) OR, 0.997 (0.992-1.003)

39.1 (37.1-41.2) 26.3 (22.6-29.9) OR, 0.967 (0.959-0.975)

29.1 (27.4-30.7) 42.0 (38.6-45.3) OR, 1.036 (1.028-1.044)

(25.4-26.0) (27.3-28.5) (0.31-0.49)

90.1 (89.4-90.8) 95.4 (94.0-96.8) APC, 0.29 (0.22-0.36)

14.5 (12.8-16.2) 31.8 (26.5-37.2) OR, 1.052 (1.039-1.065)

34.4 (31.7-37.1) 33.4 (30.3-36.5) OR, 0.999 (0.990-1.008)

49.4 (46.8-51.9) 33.5 (28.3-38.8) OR, 0.967 (0.958-0.976)

14.3 (12.6-16.1) 29.2 (25.1-33.3) OR, 1.045 (1.034-1.057)

(27.2-27.8) (28.7-29.8) (0.23-0.43)

99.1 (98.5-99.8) 103.3 (101.8-104.8) APC, 0.23 (0.16-0.31)

25.1 (23.0-27.3) 36.8 (32.8-40.8) OR, 1.032 (1.021-1.043)

43.3 (40.5-46.1) 42.8 (38.4-47.2) OR, 0.998 (0.989-1.008)

30.8 (27.6-34.0) 19.5 (15.1-24.0) OR, 0.964 (0.951-0.977)

37.5 (34.4-40.6) 47.8 (43.2-52.4) OR, 1.029 (1.017-1.041)

(26.3-26.9) (28.2-29.1) (0.29-0.47)

100.5 (99.7-101.3) 105.7 (104.5-106.9) APC, 0.28 (0.21-0.35)

20.3 (17.2-23.4) 36.0 (31.0-41.0) OR, 1.042 (1.028-1.057)

44.0 (40.6-47.5) 38.3 (33.1-43.4) OR, 0.990 (0.978-1.002)

33.8 (30.4-37.3) 24.6 (19.8-29.3) OR, 0.974 (0.962-0.987)

45.3 (41.9-48.7) 59.4 (54.4-64.4) OR, 1.036 (1.024-1.047)

(26.4-26.9) (28.1-29.1) (0.27-0.43)

96.3 (95.9-96.8) 101.3 (100.0-102.6) APC, 0.26 (0.21-0.32)

20.0 (18.2-21.8) 35.2 (30.7-39.8) OR, 1.040 (1.030-1.050)

40.3 (38.3-42.4) 37.7 (35.1-40.3) OR, 0.996 (0.989-1.003)

38.4 (36.0-40.8) 26.1 (21.5-30.7) OR, 0.968 (0.959-0.978)

30.2 (28.4-31.9) 44.4 (40.3-48.5) OR, 1.039 (1.030-1.047)

(26.2-26.7) (28.5-29.9) (0.41-0.61)

92.4 (91.8-93.0) 98.4 (97.0-99.8) APC, 0.35 (0.28-0.42)

20.6 (18.6-22.6) 38.0 (33.2-42.7) OR, 1.052 (1.040-1.064)

36.2 (34.1-38.3) 30.3 (25.9-34.6) OR, 0.989 (0.980-0.999)

40.9 (38.7-43.2) 30.3 (27.6-33.0) OR, 0.968 (0.961-0.976)

23.1 (21.2-25.0) 37.9 (33.7-42.1) OR, 1.045 (1.034-1.056)

(26.9-27.4) (28.2-29.7) (0.28-0.55)

95.6 (94.9-96.2) 100.2 (98.4-101.9) APC, 0.32 (0.22-0.43)

23.3 (21.4-25.2) 34.8 (29.5-40.1) OR, 1.038 (1.021-1.056)

43.6 (41.0-46.2) 46.3 (42.2-50.3) OR, 1.007 (0.997-1.018)

32.1 (29.8-34.3) 18.6 (14.1-23.2) OR, 0.957 (0.943-0.972)

29.1 (26.7-31.4) 41.6 (35.9-47.4) OR, 1.038 (1.019-1.056)

Men 18 y 1988-1994 26.6 2009-2010 28.6 Trend APC, 0.37 18-39 y 1988-1994 25.7 2009-2010 27.9 Trend APC, 0.40 40-64 y 1988-1994 27.5 2009-2010 29.3 Trend APC, 0.33 65 y 1988-1994 26.6 2009-2010 28.7 Trend APC, 0.38 18 y, non-Hispanic white 1988-1994 26.6 2009-2010 28.6 Trend APC, 0.35 18 y, non-Hispanic black 1988-1994 26.5 2009-2010 29.2 Trend APC, 0.51 18 y, Mexican American 1988-1994 27.2 2009-2010 29.0 Trend APC, 0.41


Category Based on Waist Circumference


Ladabaum et al

Table 1

APC ¼ annual percentage change; CI ¼ confidence interval; OR ¼ odds ratio (for being in given category compared with previous year). *Appendix Table 1 shows results by age/ethnicity.

721

722


Figure 2 Trends in average waist circumference in US adults, 1988-2010. (A) Trends in women by age group. (B) Trends in men by age group. (C) Trends in women by racial/ethnic group. (D) Trends in men by racial/ethnic group.

among non-Hispanic blacks and smallest among non-Hispanic whites; in contrast, among men, it was largest among nonHispanic whites and smallest among non-Hispanic blacks (Figure 2, Table 1, Appendix Table 1 [online]). The changes in average waist circumference were associated with increases in the prevalence of abdominal obesity (Appendix Figure 2, Table 1), from 46.0% (95% CI, 43.9-48.0) to 61.5% (95% CI, 58.8-64.2) in women, and from 29.1% (95% CI, 27.4-30.7) to 42.0% (95% CI, 38.6-45.3) in men. The annual increases were most pronounced in younger persons, but the prevalence of abdominal obesity increased with age (Table 1). Sexspecific differences between racial/ethnic groups in abdominal obesity prevalence paralleled the waist circumference results (Table 1, Appendix Figure 2 [online], Appendix Table 1 [online]).

Abdominal Obesity by Body Mass Index Category Among adults categorized as normal weight on the basis of BMI, the prevalence of abdominal obesity increased significantly only in women, from 9.6% (95% CI, 8.1-11.0) to 13.8% (95% CI, 10.1-17.5) (Appendix Table 2 [online]).

Among adults categorized as overweight on the basis of BMI, the prevalence of abdominal obesity increased from 66.1% (95% CI, 62.7-69.4) to 80.8% (95% CI, 78.1-83.5) in women, and from 24.5% (95% CI, 22.1-26.8) to 27.8% (95% CI, 24.3-31.3) in men (Appendix Table 2, online). Compared with the previous year, the odds ratio for fulfilling criteria for abdominal obesity in a given year was 1.045 (95% CI, 1.032-1.057) for overweight women and 1.017 (95% CI, 1.007-1.027) for overweight men. The majority (>90%) of US adults categorized as obese on the basis of BMI also were categorized as having abdominal obesity (Appendix Table 2, online). Appendix Table 2 (online) displays the results by age group.

Physical Activity The proportion of adults who reported no leisure-time physical activity increased from 19.1% (95% CI, 17.321.0) to 51.7% (95% CI, 48.9-54.5) in women, and from 11.4% (95% CI, 10.0-12.8) to 43.5% (95% CI, 40.7-46.3) in men. These changes were accompanied by decreases in the proportions of adults who reported intermediate or ideal levels of leisure-time physical activity (Table 2). Compared

Ladabaum et al Table 2


723

Trends in Reported Levels of Leisure-time Physical Activity and Daily Caloric Intake, US Adults, 1988-2010* Reported Leisure-time Physical Activity None, % of Population (95% CI)

Women 18 y 1988-1994 19.1 2009-2010 51.7 Trend OR, 1.074 18-39 y 1988-1994 14.0 2009-2010 47.5 Trend OR, 1.078 40-64 y 1988-1994 19.2 2009-2010 49.9 Trend OR, 1.072 65 y 1988-1994 31.8 2009-2010 66.3 Trend OR, 1.071 18 y, non-Hispanic white 1988-1994 15.6 2009-2010 46.1 Trend OR, 1.077 18 y, non-Hispanic black 1988-1994 30.5 2009-2010 66.2 Trend OR, 1.064 18 y, Mexican American 1988-1994 33.2 2009-2010 66.5 Trend OR, 1.069

Intermediate Level, % of Population (95% CI)

Ideal Level, % of Population (95% CI)

(17.3-21.0) (48.9-54.5) (1.064-1.084)

45.0 (43.1-46.9) 18.6 (17.3-19.8) OR, 0.939 (0.933-0.944)

35.9 (33.2-38.5) 29.8 (27.7-31.9) OR, 0.990 (0.981-0.999)

(11.9-16.1) (43.4-51.5) (1.066-1.090)

50.0 (46.6-53.4) 20.4 (17.7-23.1) OR, 0.932 (0.923-0.941)

36.0 (32.9-39.1) 32.1 (29.1-35.2) OR, 1.002 (0.993-1.012)

(16.7-21.7) (47.0-52.7) (1.059-1.086)

46.0 (43.6-48.3) 19.4 (17.4-21.4) OR, 0.938 (0.930-0.947)

34.9 (31.4-38.4) 30.7 (28.4-33.0) OR, 0.990 (0.978-1.002)

1697 (1666-1727) 1771 (1705-1837) APC, 0.23 (0.01-0.45)

(28.4-35.2) (60.9-71.7) (1.056-1.087)

30.3 (27.7-32.8) 12.1 (8.7-15.5) OR, 0.956 (0.946-0.967)

38.0 (34.0-41.9) 21.7 (16.7-26.7) OR, 0.956 (0.941-0.972)

1474 (1446-1503) 1578 (1508-1647) APC, 0.37 (0.17-0.57)

(13.7-17.4) (41.1-51.0) (1.062-1.092)

46.7 (44.5-49.0) 20.0 (18.0-22.1) OR, 0.939 (0.932-0.946)

37.7 (34.6-40.8) 33.9 (30.3-37.5) OR, 0.994 (0.982-1.006)

1771 (1740-1802) 1791 (1754-1828) APC, 0.09 (0.06-0.24)

(27.4-33.5) (62.5-69.8) (1.052-1.076)

41.3 (39.1-43.5) 17.1 (15.3-18.9) OR, 0.943 (0.935-0.952)

28.3 (25.5-31.0) 16.8 (13.2-20.3) OR, 0.982 (0.971-0.993)

1729 (1696-1763) 1787 (1697-1877) APC, 0.16 (0.08-0.40)

(30.9-35.5) (61.6-71.3) (1.054-1.085)

41.0 (38.5-43.4) 12.1 (9.5-14.7) OR, 0.928 (0.915-0.942)

25.8 (22.4-29.2) 21.4 (17.1-25.7) OR, 0.991 (0.975-1.006)

1698 (1656-1741) 1732 (1633-1832) APC, 0.06 (0.27-0.40)

with the previous year, the odds ratio for reporting no leisure-time physical activity in a given year was 1.074 (95% CI, 1.064-1.084) for women and 1.083 (95% CI, 1.071-1.094) for men (Table 2). Among both women and men, the proportions reporting no leisure-time physical activity were higher among non-Hispanic blacks and Mexican Americans than among non-Hispanic whites (Table 2). Table 2 and Appendix Table 3 (online) display the results by age and race/ethnicity.

Caloric Intake Average daily caloric intake did not change significantly over time for women or men as a whole or when stratified by race/ethnicity (Table 2). The results differed by age, gender, and leisure-time physical activity level (Table 3, Appendix Table 4 [online]). Average daily caloric intake increased significantly for women who reported no leisuretime physical activity and decreased significantly for men who reported an ideal level of leisure-time physical activity (Table 3).

Mean Energy Intake in kcal/d (95% CI)

1761 (1735-1788) 1781 (1749-1812) APC, 0.07 (0.06-0.20) 1941 (1889-1992) 1873 (1820-1926) APC, 0.20 (0.38 to 0.02)

Body Mass Index and Obesity by Physical Activity Strata Average BMI increased in women and men in all 3 strata of leisure-time physical activity (Appendix Table 4 [online]). Increases in average BMI were observed in nearly all age and gender subgroups stratified by leisure-time physical activity (Appendix Table 4 [online]). The prevalence of obesity increased in women and men in all 3 strata of leisure-time physical activity (Table 3). Similar patterns were seen across racial/ethnic groups (data not shown).

Waist Circumference and Abdominal Obesity by Physical Activity Strata Average waist circumference increased over time in women and men in all 3 strata of leisure-time physical activity (Appendix Table 4 [online]). Increases in average waist circumference were observed in nearly all age and gender subgroups stratified by leisure-time physical activity (Appendix Table 4 [online]). The prevalence of abdominal obesity increased in women and men within all strata of

724


Table 2

Continued Reported Leisure-time Physical Activity None, % of Population (95% CI)

Men 18 y 1988-1994 11.4 2009-2010 43.5 Trend OR, 1.083 18-39 y 1988-1994 8.9 2009-2010 34.1 Trend OR, 1.065 40-64 y 1988-1994 11.2 2009-2010 47.9 Trend OR, 1.100 65 y 1988-1994 18.3 2009-2010 56.1 Trend OR, 1.087 18 y, non-Hispanic white 1988-1994 9.6 2009-2010 39.3 Trend OR, 1.089 18 y, non-Hispanic black 1988-1994 15.9 2009-2010 51.6 Trend OR, 1.071 18 y, Mexican American 1988-1994 23.6 2009-2010 58.2 Trend OR, 1.061


Ideal Level, % of Population (95% CI)


(10.0-12.8) (40.7-46.3) (1.071-1.094)

43.5 (41.7-45.3) 14.8 (12.8-16.8) OR, 0.931 (0.924-0.937)

45.0 (42.8-47.2) 41.7 (38.1-45.3) OR, 0.993 (0.985-1.001)

2616 (2569-2663) 2511 (2443-2578) APC, 0.17 (0.32 to 0.01)

(7.1-10.6) (28.6-39.5) (1.051-1.079)

44.0 (41.0-47.1) 14.3 (11.6-17.0) OR, 0.930 (0.920-0.940)

47.1 (44.0-50.2) 51.6 (45.6-57.5) OR, 1.012 (1.001-1.023)

2973 (2900-3046) 2678 (2583-2772) APC, 0.48 (0.69 to 0.28)

(9.3-13.2) (45.3-50.4) (1.084-1.116)

46.5 (43.3-49.7) 16.2 (13.3-19.1) OR, 0.928 (0.917-0.939)

42.2 (39.2-45.3) 35.9 (32.6-39.3) OR, 0.981 (0.970-0.991)

2516 (2444-2587) 2561 (2466-2656) APC, 0.16 (0.06-0.37)

(15.8-20.8) (52.0-60.2) (1.073-1.100)

35.1 (32.6-37.6) 12.7 (10.1-15.2) OR, 0.942 (0.932-0.953)

46.6 (43.3-50.0) 31.3 (27.6-35.0) OR, 0.964 (0.954-0.974)

1977 (1927-2027) 1978 (1905-2050) APC, 0.01 (0.24-0.23)

(8.1-11.0) (35.6-43.1) (1.072-1.105)

45.0 (42.6-47.4) 16.3 (13.2-19.3) OR, 0.933 (0.925-0.942)

45.4 (42.8-48.0) 44.4 (39.0-49.9) OR, 0.994 (0.983-1.004)

2667 (2616-2718) 2569 (2485-2654) APC, 0.09 (0.26-0.07)

(13.4-18.4) (47.2-55.9) (1.058-1.084)

38.3 (36.0-40.7) 8.8 (4.8-12.7) OR, 0.926 (0.916-0.937)

45.8 (42.8-48.7) 39.7 (35.8-43.5) OR, 0.994 (0.983-1.005)

2455 (2388-2521) 2442 (2284-2600) APC, 0.03 (0.25-0.30)

(20.1-27.1) (50.8-65.7) (1.044-1.079)

40.7 (37.7-43.6) 12.1 (7.6-16.6) OR, 0.917 (0.902-0.933)

35.8 (33.4-38.1) 29.7 (25.5-33.9) OR, 1.003 (0.990-1.017)

2468 (2411-2526) 2411 (2323-2499) APC, 0.13 (0.41-0.15)

APC ¼ annual percentage change; CI ¼ confidence interval; OR ¼ odds ratio (for being in given category compared with previous year). *Appendix Table 3 shows results by age/ethnicity.

leisure-time physical activity (Table 3). Similar patterns were seen across racial/ethnic groups (data not shown).

Body Mass Index and Waist Circumference: Associations with Leisure-time Physical Activity and Caloric Intake BMI and waist circumference both increased significantly in women and men after adjusting for leisure-time physical activity, caloric intake, and age. The magnitude of the increases was associated with level of leisure-time physical activity, but not with caloric intake. The associated changes in BMI were 5.5% (95% CI, 4.3-6.7) higher among women with an intermediate level of leisure-time physical activity and 8.3% (95% CI, 6.9-9.6) higher among women with no leisure-time physical activity than among women with an ideal level of leisure-time physical activity. For men, the respective measures were 1.2% (95% CI, 0.15-2.2) higher and 1.7% (95% CI, 0.68-2.8) higher.

The associated changes in waist circumferences were 4.2% (95% CI, 3.3-5.0) higher among women with an intermediate level of leisure-time physical activity and 6.4% (95% CI, 5.4-7.4) higher among women with no leisuretime physical activity than among women with an ideal level of leisure-time physical activity. For men, the respective measures were 2.1% (95% CI, 1.4-2.9) higher and 2.5% (95% CI, 1.7-3.3) higher. In analyses stratified by race/ethnicity, the associations between increases in BMI and waist circumference and level of leisure-time physical activity were statistically significant for non-Hispanic white women and men, and Mexican American women (Appendix Table 5 [online]). Sensitivity analyses showed similar results (Appendix [online]).

DISCUSSION Our analyses highlight important dimensions of the public health problem of obesity in the United States. The average BMI, average waist circumference, prevalence of obesity,

0.22 (0.40 to 0.04) 1.036 (1.024-1.048) APC ¼ annual percentage change; BMI ¼ body mass index; CI ¼ confidence interval; OR ¼ odds ratio.

1.000 (0.992-1.008) 1.045 (1.030-1.060)

0.967 (0.955-0.978)

0.19 (0.14-0.53) 0.13 (0.34-0.09) 1.048 (1.032-1.065) 1.029 (1.018-1.039) 1.003 (0.991-1.016) 1.004 (0.993-1.014) 1.053 (1.037-1.070) 1.029 (1.016-1.041)

0.947 (0.933-0.962) 0.971 (0.959-0.983)

0.08 (0.13-0.30) 1.037 (1.025-1.048) 1.013 (1.002-1.025)

0.977 (0.966-0.989)

0.27 (0.02-0.52) 0.09 (0.11-0.28) 1.026 (1.015-1.038) 1.037 (1.027-1.048) 0.987 (0.978-0.995) 0.974 (0.963-0.985)

1.020 (1.008-1.032)

Overweight

0.997 (0.985-1.009) 1.003 (0.993-1.014)

Obese

1.020 (1.010-1.030) 1.029 (1.018-1.040)

Abdominal Obesity

Category Based on BMI, OR (95% CI) of Being in Category in Any Given Year Compared with Previous Year

Normal Weight

Category Based on Waist Circumference, OR (95% CI) of Being in Category in Any Given Year Compared with Previous Year

Mean Energy Intake, APC (95% CI)


Women No reported leisure-time physical activity Intermediate level of reported leisure-time physical activity Ideal level of reported leisure-time physical activity Men No reported leisure-time physical activity Intermediate level of reported leisure-time physical activity Ideal level of reported leisure-time physical activity

Table 3

Trends in Prevalence of Obesity, Abdominal Obesity, and Daily Caloric Intake Stratified by Reported Level of Leisure-time Physical Activity, US Adults, 1988-2010

Ladabaum et al

725

and prevalence of abdominal obesity increased substantially over the past 2 decades in both women and men. The annual increases in BMI have been most pronounced in younger women, the greatest increases in the prevalence of abdominal obesity have been in younger women and men, and both obesity and abdominal obesity preferentially affected nonHispanic black women. Furthermore, the prevalence of abdominal obesity has increased among normal-weight women and overweight women and men. These changes have occurred in the context of substantial increases in the proportion of adults reporting no leisure-time physical activity, but in the absence of any significant population-level changes in average daily caloric intake. At the population level, we found a significant association between the level of leisure-time physical activity, but not daily caloric intake, and the increases in both BMI and waist circumference. Although the overall trends in obesity in the United States are well appreciated and obesity prevalence may be stabilizing,5,6,20,21 our analyses highlight troublesome trends in younger adults, in women, and in abdominal obesity prevalence, as well as persistent racial/ethnic disparities. Overall, normal-weight women and overweight women and men have become more “abdominally obese.” Given that obesity prevalence increased significantly between 1999 and 2010 in male subjects aged 2 to 19 years, but not in female subjects,22 it is possible that young adult women may be particularly vulnerable to weight gain. It remains controversial whether overweight alone increases mortality risk,2 but the trends in abdominal obesity among the overweight are concerning in light of the risks associated with increased waist circumference independent of BMI.8-11 Our findings do not support the popular notion that the increase in obesity in the United States can be attributed primarily to sustained increases over time in the average daily caloric intake of Americans.23 We found no evidence that average daily caloric intake has increased over the last 2 decades. Previous analyses have noted increases over longer time periods,24 but decreases more recently.25 In contrast, our analyses identified significant associations between the reported level of leisure-time physical activity in the population and all measures of obesity. Other investigators have examined this relationship.26,27 Physical inactivity is an independent predictor of mortality.28 Physical activity can protect against weight gain29 and attenuates the increased mortality risk associated with obesity.30,31 However, an ideal level of physical activity does not by itself ensure a normal weight (Table 3). Our results are based on a series of cross-sectional surveys, and not a prospective cohort study. They do not suggest that caloric intake is not an important determinant of obesity at the level of an individual. A previous analysis of NHANES from 1971-1975 to 1999-2002 reported an increase in food energy density approximately parallel to US obesity prevalence rates.32 Diet composition may be relevant at the population level, but we found no substantial changes in the daily fat, carbohydrate, and protein intake during our study period (Appendix Table 6 [online]).

726 However, analyses of the major macronutrients do not address specific sources of calories, such as simple sugars, and interactions with genetic risk.33 The impact of the microbiome on host metabolism is beginning to be explored.34 Our results should be viewed in the context of existing studies. Studies restricted to more recent time periods suggest that the trends in obesity prevalence in US adults may be stabilizing.5,6 Our joinpoint analyses of BMI in women are consistent with these results. Although this is encouraging, the prevalence of obesity remains unacceptably high.35 Trends in abdominal obesity could reflect in part a birth cohort effect.36 Some but not all previous studies on physical activity trends have reached conclusions similar to ours.37 The heterogeneity in results may be due in part to diversity in surveys and study methods.

Study Limitations The NHANES surveys do not follow a cohort of individuals prospectively, so our reported associations with physical activity must be interpreted with caution. Although height, weight, and waist circumference are measured, caloric intake and physical activity are self-reported, and we analyzed caloric intake on 24-hour recall. Caloric intake may be underreported and physical activity overestimated,38 but this cannot explain the high rates of no leisure-time physical activity in our study. Changes in survey methodology over time could have affected physical activity estimates. We used cycle midpoints as a continuous variable.

Societal considerations merit discussion. Obesity is a public health problem across racial, ethnic, and socioeconomic groups,39 but African Americans, Hispanics, those with lesser education, older persons, and some states are affected disproportionally.40 Despite the trends in overweight and obesity, the rates of self-diagnosis, clinical diagnosis, and weight counseling in primary care have declined.41,42 Societal realities, including divergent views about the roles of individuals and government, compound the challenges encountered in the medical setting.39 The first goal related to physical activity environments proposed by the IOM is to make physical activity an integral and routine part of life.1 The IOM also recommends transforming messages about physical activity and nutrition, stressing the roles of health care providers, insurers, employers, and schools in promoting health, with physical activity as a major focus.1

CONCLUSIONS Average BMI and waist circumference both increased among US adults from 1988 to 2010. Abdominal obesity, an independent predictor of mortality, has become more prevalent among normal-weight women and overweight women and men. At the population level, we found associations between the reported level of leisure-time physical activity

The American Journal of Medicine, Vol 127, No 8, August 2014 and obesity, but even among adults reporting an ideal level of leisure-time physical activity, obesity prevalence has increased. Although it is encouraging that obesity rates may be stabilizing, our results lend support to the emphasis placed on physical activity in the IOM report on obesity.

References 1. Accelerating Progress in Obesity Prevention: Solving the Weight of the Nation. Washington, DC: Institute of Medicine; 2012. 2. Flegal KM, Kit BK, Orpana H, Graubard BI. Association of all-cause mortality with overweight and obesity using standard body mass index categories: a systematic review and meta-analysis. JAMA. 2013;309: 71-82. 3. Adams KF, Schatzkin A, Harris TB, et al. Overweight, obesity, and mortality in a large prospective cohort of persons 50 to 71 years old. N Engl J Med. 2006;355:763-778. 4. Berrington de Gonzalez A, Hartge P, Cerhan JR, et al. Body-mass index and mortality among 1.46 million white adults. N Engl J Med. 2010;363:2211-2219. 5. Flegal KM, Carroll MD, Ogden CL, Curtin LR. Prevalence and trends in obesity among US adults, 1999-2008. JAMA. 2010;303:235-241. 6. Flegal KM, Carroll MD, Kit BK, Ogden CL. Prevalence of obesity and trends in the distribution of body mass index among US adults, 19992010. JAMA. 2012;307:491-497. 7. Olshansky SJ, Passaro DJ, Hershow RC, et al. A potential decline in life expectancy in the United States in the 21st century. N Engl J Med. 2005;352:1138-1145. 8. Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults: The Evidence Report. Washington, DC: National Heart, Lung and Blood Institutes, National Institutes of Health; 1998. 9. Pischon T, Boeing H, Hoffmann K, et al. General and abdominal adiposity and risk of death in Europe. N Engl J Med. 2008;359: 2105-2120. 10. Koster A, Leitzmann MF, Schatzkin A, et al. Waist circumference and mortality. Am J Epidemiol. 2008;167:1465-1475. 11. Jacobs EJ, Newton CC, Wang Y, et al. Waist circumference and allcause mortality in a large US cohort. Arch Intern Med. 2010;170: 1293-1301. 12. The Practical Guide Identification, Evaluation, and Treatment of Overweight and Obesity in Adults. Washington, DC: National Heart, Lung and Blood Institutes, National Institutes of Health; 2000. 13. Mozaffarian D, Hao T, Rimm EB, et al. Changes in diet and lifestyle and long-term weight gain in women and men. N Engl J Med. 2011;364:2392-2404. 14. Centers for Disease Control and Prevention (CDC). National Center for Health Statistics (NCHS). National Health and Nutrition Examination Survey Data. Hyattsville, MD. Available at: http://www.cdc.gov/nchs/ nhanes/nhanes_questionnaires.htm. Accessed April 17, 2013. 15. National Center for Health Statistics. Analytical and Reporting Guidelines. The Third National Health and Nutrition Examination Survey, 1988e1994, Hyattsville, MD. 1996. Available at: http://www.cdc.gov/ nchs/data/nhanes/nhanes3/nh3gui.pdf. Accessed April 17, 2013. 16. National Center for Health Statistics. Analytical and Reporting Guidelines. The National Health and Nutrition Examination Survey (NHANES). Hyattsville, MD. 2005. Available at: http://www.cdc. gov/nchs/data/nhanes/nhanes_03_04/nhanes_analytic_guidelines_dec_ 2005.pdf. Accessed April 17, 2013. 17. Lean ME, Han TS, Morrison CE. Waist circumference as a measure for indicating need for weight management. BMJ. 1995;311:158-161. 18. Kim HJ, Fay MP, Feuer EJ, Midthune DN. Permutation tests for joinpoint regression with applications to cancer rates. Stat Med. 2000;19:335-351. 19. Day JC. Population Projections of the United States by Age, Sex, Race, and Hispanic Origin: 1995 to 2050, U.S. Bureau of the Census, Current Population Reports, P25-1130. Washington DC: U.S.

Ladabaum et al

20. 21.

22.

23. 24.

25.

26.

27.

28.

29.

30.


Government Printing Office; 1996. Available at: http://www.census. gov/prod/1/pop/p25-1130/p251130.pdf. Accessed April 17, 2013. Okosun IS, Chandra KM, Boev A, et al. Abdominal adiposity in U.S. adults: prevalence and trends, 1960-2000. Prev Med. 2004;39:197-206. Li C, Ford ES, McGuire LC, Mokdad AH. Increasing trends in waist circumference and abdominal obesity among US adults. Obesity (Silver Spring, Md). 2007;15:216-224. Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of obesity and trends in body mass index among US children and adolescents, 19992010. JAMA. 2012;307:483-490. Casazza K, Fontaine KR, Astrup A, et al. Myths, presumptions, and facts about obesity. N Engl J Med. 2013;368:446-454. Austin GL, Ogden LG, Hill JO. Trends in carbohydrate, fat, and protein intakes and association with energy intake in normal-weight, overweight, and obese individuals: 1971-2006. Am J Clin Nutr. 2011;93:836-843. Ford ES, Dietz WH. Trends in energy intake among adults in the United States: findings from NHANES. Am J Clin Nutr. 2013;97: 848-853. Qi Q, Li Y, Chomistek AK, et al. Television watching, leisure time physical activity, and the genetic predisposition in relation to body mass index in women and men. Circulation. 2012;126: 1821-1827. Weinsier RL, Hunter GR, Heini AF, et al. The etiology of obesity: relative contribution of metabolic factors, diet, and physical activity. Am J Med. 1998;105:145-150. Hu FB, Willett WC, Li T, et al. Adiposity as compared with physical activity in predicting mortality among women. N Engl J Med. 2004;351:2694-2703. Hankinson AL, Daviglus ML, Bouchard C, et al. Maintaining a high physical activity level over 20 years and weight gain. JAMA. 2010;304: 2603-2610. Koster A, Harris TB, Moore SC, et al. Joint associations of adiposity and physical activity with mortality: the National Institutes of

31.

32.

33. 34. 35. 36.

37.

38.

39. 40. 41.

42.

727

Health-AARP Diet and Health Study. Am J Epidemiol. 2009;169: 1344-1351. Sui X, LaMonte MJ, Laditka JN, et al. Cardiorespiratory fitness and adiposity as mortality predictors in older adults. JAMA. 2007;298: 2507-2516. Kant AK, Graubard BI. Secular trends in patterns of self-reported food consumption of adult Americans: NHANES 1971-1975 to NHANES 1999-2002. Am J Clin Nutr. 2006;84:1215-1223. Qi Q, Chu AY, Kang JH, et al. Sugar-sweetened beverages and genetic risk of obesity. N Engl J Med. 2012;367:1387-1396. Tremaroli V, Backhed F. Functional interactions between the gut microbiota and host metabolism. Nature. 2012;489:242-249. Yanovski SZ, Yanovski JA. Obesity prevalence in the United Stateseup, down, or sideways? N Engl J Med. 2011;364:987-989. Robinson WR, Utz RL, Keyes KM, et al. Birth cohort effects on abdominal obesity in the United States: the Silent Generation, Baby Boomers and Generation X. Int J Obes (Lond). 2013;37:1129-1134. Pleis JR, Lucas JW. Summary Health Statistics for U.S. Adults: National Health Interview Survey, 2007. Vital and Health Statistics Series 10, Data from the National Health Survey. Hyattsville MD: U.S. Department of Health and Human Services; 2009:1-159. Tucker JM, Welk GJ, Beyler NK. Physical activity in U.S.: adults compliance with the Physical Activity Guidelines for Americans. Am J Prev Med. 2011;40:454-461. Barry CL, Gollust SE, Niederdeppe J. Are Americans ready to solve the weight of the nation? N Engl J Med. 2012;367:389-391. Vital signs: state-specific obesity prevalence among adultseUnited States, 2009. MMWR Morb Mortal Wkly Rep. 2010;59:951-955. Kraschnewski JL, Sciamanna CN, Stuckey HL, et al. A silent response to the obesity epidemic: decline in US physician weight counseling. Med Care. 2013;51:186-192. Yates EA, Macpherson AK, Kuk JL. Secular trends in the diagnosis and treatment of obesity among US adults in the primary care setting. Obesity (Silver Spring, Md). 2012;20:1909-1914.

727.e1

APPENDIX DEFINITION OF LEISURE-TIME PHYSICAL ACTIVITY LEVELS During the home interview component of NHANES, a physical activity questionnaire was administered. In NHANES-III, participants were asked to record the frequency of leisure-time activities in the past month in terms of times per month. Each activity was given an intensity rating, reflecting the ratio of energy expenditure relative to that of the resting metabolic rate in metabolic equivalent of task (MET). In NHANES 1999-2000 to 2005-2006, participants were asked to report the frequency, duration, and level of exertion for each of the reported leisure-time activities in the past month. MET scores were assigned for each activity. From NHANES 2007-2008 onward, participants were asked to report the number of days per week that they engaged in moderate or vigorous leisure-time activities and the duration of these activities per day. The MET score thresholds used to define moderate and vigorous activity were 4 and 8, respectively. To define the physical activity levels of participants, different approaches were followed for NHANES-III and the continuous NHANES waves, because NHANES-III did not consider duration of the activities. For NHANES-III, based on the MET scores, the intensity of activities was defined as moderate (3-6 METS) or vigorous (>6 METS). An ideal level of physical activity was defined as engaging in moderate activities 5 times per week or in vigorous activities 3 times per week.1 An intermediate level of physical activity was defined as engaging in at least some leisure-time physical activities without meeting the criteria for the ideal group. For continuous NHANES surveys, the number of minutes of moderate activity per week and the number of minutes of vigorous activity per week were calculated on the basis of the reported frequency, intensity, and duration of activities. An ideal level of physical activity was defined as 150 minutes per week of moderate activities, 75 minutes per week of vigorous activities, or 150 minutes per week of a combination of moderate and vigorous activities.2 An intermediate level of physical activity was defined as 1 to 149 minutes per week of moderate activities, 1 to 74 minutes per week of vigorous activities, or 1 to 149 minutes per week of a combination of moderate and vigorous activities.

TRENDS IN BODY MASS INDEX: JOINPOINT ANALYSES Trends in age-adjusted mean BMI over time were analyzed using Joinpoint Regression Program version 4.0.1 from the National Cancer Institute,3,4 as previously used in similar analyses.5 Joinpoint regression methodology is widely used to identify statistically significant changes in trends. The joinpoint program determines the number of joinpoints (a time point at which the direction or magnitude of trend changes), tests whether the change in the trend is significant by performing permutation tests, and fits a log-linear model

The American Journal of Medicine, Vol 127, No 8, August 2014 to each segment. The specifications set in advance were as follows: The maximum number of joinpoints was set to 1, and the minimum number of observations for a joinpoint from the beginning or end of data series was set to 3. The slope of a line segment is described as the Annual Percentage Change (APC).

SENSITIVITY ANALYSES: EFFECT OF PHYSICAL ACTIVITY ON BODY MASS INDEX AND WAIST CIRCUMFERENCE Methods To further tease out the effect of physical activity on BMI and waist circumference, we performed a sensitivity analysis using only the continuous NHANES data, in which the number of minutes of participation in physical activity are available. To estimate total minutes spent on physical activity, we calculated intensity-adjusted leisure-time physical activity minutes per week on the basis of the recommendations given in “Physical Activity Guidelines for Americans: Appendix 1” (http://www.health.gov/paguidelines/guidelines/appendix1. aspx), which states that “1 minute of vigorous-intensity activity counts the same as 2 minutes of moderate-intensity activity.” The intensity-adjusted total minutes were toptruncated to 1680 minutes/week. We performed the multivariate regression analysis with log-transformed BMI and waist circumference as the response variables, and year, intensity-adjusted leisure-time physical activity minutes per week, and calorie intake as the explanatory variables, and adjusted for age, age squared, and gender. Analyses were performed for all adults and after stratification by gender. To compare the trends with any physical activity or leisure-time physical activity as an explanatory variable, we performed a subanalysis using only NHANES data from 1999-2000 to 2005-2006 because the physical activity questionnaires were consistent in these survey cycles. Any physical activity includes walking or bicycling for transport, activities around the home or yard information, and leisuretime physical activity.

Results The results of these sensitivity analyses were similar to the results of the primary analyses. BMI increased significantly over the years in both women (APC, 0.21; 95% CI, 0.03-0.38) and men (APC, 0.35; 95% CI, 0.17-0.53) after adjusting for physical activity, caloric intake, and age. The level of physical activity was associated with the degree of increase in BMI. In contrast, the effect of caloric intake was not significant. In women, BMI decreased by 0.94% (95% CI, 0.76-1.1) for every 100 minutes/week increase in physical activity. In men, BMI decreased by 0.24% (95% CI, 0.11-0.36) for every 100 minutes/week increase in physical activity. Waist circumference increased significantly over the years in both women (APC, 0.31; 95% CI, 0.15-0.46) and men (APC, 0.19; 95% CI, 0.06-0.32) after adjusting for physical activity, caloric intake, and age. The level of physical activity was associated with the degree of increase

Ladabaum et al


in waist circumference. In contrast, the effect of caloric intake was not significant. In women, waist circumference decreased by 0.79% (95% CI, 0.66-0.91) for every 100 minutes/week increase in physical activity. In men, waist circumference decreased by 0.32% (95% CI, 0.23-0.42) for every 100 minutes/week increase in physical activity.

727.e2

In the analyses restricted to NHANES data from 19992000 to 2005-2006, average BMI, average waist circumference, prevalence of obesity, and prevalence of abdominal obesity all increased significantly only in the subgroup with no physical activity. The trends were comparable with any physical activity or leisure-time physical activity as an explanatory variable.

Trends in Average Body Mass Index, Waist Circumference, and Prevalence of Obesity and Abdominal Obesity, US Adults Stratified by Race/Ethnicity, 1988-2010 Category Based on Waist Circumference



Mean waist Circumference in cm (95% CI)





82.0 (80.9-83.2) 90.4 (88.3-92.5) APC, 0.52 (0.39-0.65)

17.7 (14.9-20.5) 26.6 (22.6-30.7) OR, 1.031 (1.015-1.048)

16.4 (14.2-18.7) 23.4 (16.6-30.3) OR, 1.019 (1.004-1.035)

60.5 (57.2-63.8) 46.4 (40.5-52.4) OR, 0.970 (0.958-0.983)

25.9 (21.8-30.0) 46.3 (39.7-52.9) OR, 1.048 (1.032-1.065)

91.5 (90.3-92.6) 96.4 (95.1-97.7) APC, 0.30 (0.20-0.40)

27.5 (24.0-31.1) 35.6 (30.7-40.5) OR, 1.021 (1.007-1.035)

28.8 (26.1-31.5) 28.1 (23.0-33.2) OR, 0.998 (0.985-1.012)

41.0 (37.4-44.7) 33.0 (29.0-36.9) OR, 0.981 (0.970-0.993)

52.7 (49.6-55.8) 66.0 (61.7-70.4) OR, 1.032 (1.021-1.044)

92.9 (91.8-93.9) 98.4 (97.2-99.6) APC, 0.26 (0.17-0.35)

22.4 (20.0-24.8) 37.6 (32.4-42.8) OR, 1.028 (1.015-1.041)

32.5 (30.3-34.7) 32.0 (26.5-37.5) OR, 1.006 (0.994-1.017)

41.5 (38.3-44.6) 28.3 (24.6-32.0) OR, 0.975 (0.964-0.986)

63.1 (59.1-67.1) 73.6 (70.3-76.9) OR, 1.026 (1.011-1.041)

87.6 (86.3-88.9) 96.5 (92.2-100.7) APC, 0.51 (0.35-0.66)

28.7 (25.4-31.9) 54.1 (44.3-63.8) OR, 1.051 (1.034-1.068)

25.9 (23.4-28.4) 18.8 (13.5-24.0) OR, 0.990 (0.977-1.004)

41.8 (37.7-45.9) 23.6 (17.2-30.0) OR, 0.952 (0.937-0.968)

42.1 (38.1-46.2) 65.7 (54.3-77.1) OR, 1.049 (1.030-1.068)

98.0 (96.5-99.5) 104.6 (102.8-106.3) APC, 0.29 (0.17-0.41)

46.8 (42.1-51.4) 61.4 (55.0-67.7) OR, 1.024 (1.009-1.038)

30.0 (26.5-33.6) 27.3 (22.0-32.5) OR, 0.991 (0.977-1.005)

20.9 (16.8-24.9) 10.4 (6.8-14.0) OR, 0.974 (0.956-0.993)

72.3 (67.8-76.9) 83.9 (76.7-91.1) OR, 1.024 (1.002-1.047)

97.9 (96.1-99.7) 100.7 (98.1-103.4) APC, 0.18 (0.03-0.32)

36.3 (31.6-40.9) 55.6 (44.4-66.7) OR, 1.042 (1.020-1.065)

36.1 (31.3-40.8) 25.8 (16.1-35.5) OR, 0.968 (0.947-0.990)

25.1 (21.5-28.8) 17.1 (9.8-24.5) OR, 0.983 (0.961-1.006)

75.7 (70.8-80.7) 81.9 (72.0-91.8) OR, 1.024 (0.995-1.054)

86.7 (85.8-87.7) 94.3 (91.8-96.8) APC, 0.51 (0.38-0.65)

26.6 (23.4-29.8) 36.8 (32.1-41.6) OR, 1.031 (1.014-1.049)

30.2 (25.8-34.6) 29.3 (24.2-34.5) OR, 0.998 (0.983-1.014)

40.5 (37.2-43.7) 33.2 (26.8-39.6) OR, 0.976 (0.961-0.990)

42.5 (39.9-45.2) 60.5 (51.3-69.7) OR, 1.051 (1.031-1.071)

96.4 (95.2-97.6) 100.0 (97.5-102.6) APC, 0.19 (0.04-0.35)

43.6 (39.3-48.0) 54.2 (45.7-62.7) OR, 1.022 (1.001-1.044)

33.7 (30.2-37.3) 36.0 (27.4-44.6) OR, 1.000 (0.980-1.021)

22.2 (17.3-27.2) 9.4 (5.5-13.2) OR, 0.964 (0.943-0.986)

74.4 (70.6-78.2) 84.6 (78.6-90.6) OR, 1.029 (1.004-1.054)

97.0 (94.5-99.6) 98.8 (97.5-100.1) APC, 0.18 (0.01-0.37)

29.7 (23.1-36.4) 35.7 (27.0-44.4) OR, 1.017 (0.991-1.043)

38.8 (31.1-46.5) 41.0 (31.0-51.0) OR, 1.006 (0.981-1.031)

30.3 (23.0-37.6) 21.6 (15.8-27.3) OR, 0.975 (0.951-1.001)

72.7 (64.5-80.9) 82.2 (73.2-91.2) OR, 1.039 (1.001-1.078)

Women 18-39 y, non-Hispanic white 1988-1994 24.6 (24.1-25.0) 2009-2010 27.1 (26.4-27.8) Trend APC, 0.48 (0.32-0.64) 40-64 y, non-Hispanic white 1988-1994 27.3 (26.8-27.8) 2009-2010 28.5 (27.9-29.1) Trend APC, 0.25 (0.12-0.38) 65 y, non-Hispanic white 1988-1994 26.3 (26.1-26.6) 2009-2010 29.0 (28.2-29.8) Trend APC, 0.38 (0.27-0.50) 18-39 y, non-Hispanic black 1988-1994 27.4 (26.8-27.9) 2009-2010 31.1 (29.5-32.7) Trend APC, 0.64 (0.44-0.84) 40-64 y, non-Hispanic black 1988-1994 30.3 (29.7-30.9) 2009-2010 33.8 (32.3-35.2) Trend APC, 0.39 (0.21-0.57) 65 y, non-Hispanic black 1988-1994 29.1 (28.4-29.8) 2009-2010 31.4 (29.9-33.0) Trend APC, 0.35 (0.12-0.57) 18-39 y, Mexican American 1988-1994 26.9 (26.5-27.3) 2009-2010 28.8 (27.9-29.6) Trend APC, 0.40 (0.24-0.57) 40-64 y, Mexican American 1988-1994 29.7 (29.0-30.3) 2009-2010 31.0 (30.1-31.9) Trend APC, 0.21 (0.02-0.40) 65 y, Mexican American 1988-1994 28.0 (27.1-28.9) 2009-2010 29.3 (28.6-29.9) Trend APC, 0.26 (0.04-0.48)



727.e3

Appendix Table 1

Continued Category Based on Waist Circumference


Mean waist Circumference in cm (95% CI)





91.0 (90.2-91.9) 96.2 (94.1-98.2) APC, 0.26 (0.18-0.35)

14.4 (12.1-16.7) 33.1 (25.7-40.4) OR, 1.051 (1.034-1.069)

34.7 (31.3-38.1) 30.4 (26.7-34.0) OR, 0.994 (0.983-1.006)

49.1 (45.8-52.4) 35.4 (28.3-42.5) OR, 0.972 (0.960-0.984)

15.2 (12.8-17.5) 30.6 (24.0-37.1) OR, 1.045 (1.030-1.060)

99.8 (99.1-100.5) 104.2 (102.7-105.7) APC, 0.25 (0.18-0.33)

25.5 (22.8-28.2) 36.6 (31.7-41.5) OR, 1.030 (1.018-1.043)

44.1 (40.8-47.3) 44.5 (38.3-50.8) OR, 1.000 (0.987-1.012)

29.8 (26.3-33.3) 18.1 (12.9-23.3) OR, 0.963 (0.948-0.978)

38.7 (35.2-42.2) 51.3 (45.9-56.7) OR, 1.033 (1.020-1.047)

101.0 (100.2-101.9) 106.7 (105.6-107.8) APC, 0.30 (0.24-0.37)

20.5 (17.3-23.8) 37.3 (31.3-43.3) OR, 1.043 (1.027-1.059)

45.3 (41.5-49.0) 39.3 (33.9-44.8) OR, 0.992 (0.979-1.004)

32.5 (28.9-36.1) 22.3 (18.8-25.8) OR, 0.970 (0.958-0.982)

46.7 (43.2-50.2) 62.1 (57.6-66.6) OR, 1.040 (1.030-1.051)

87.8 (87.0-88.6) 92.8 (90.2-95.4) APC, 0.36 (0.24-0.48)

18.8 (16.7-21.0) 35.2 (26.6-43.9) OR, 1.052 (1.035-1.071)

31.1 (28.1-34.0) 27.1 (20.3-33.8) OR, 0.995 (0.981-1.008)

48.3 (44.8-51.8) 35.7 (30.2-41.1) OR, 0.967 (0.955-0.979)

13.9 (12.2-15.5) 28.0 (19.8-36.1) OR, 1.052 (1.033-1.072)

95.3 (94.2-96.5) 102.3 (100.1-104.4) APC, 0.33 (0.21-0.44)

22.4 (18.8-25.9) 42.9 (36.8-49.0) OR, 1.053 (1.034-1.072)

41.6 (37.7-45.6) 31.7 (26.1-37.2) OR, 0.981 (0.967-0.994)

34.4 (30.9-38.0) 24.8 (19.9-29.7) OR, 0.970 (0.956-0.985)

27.9 (24.2-31.6) 41.1 (35.5-46.6) OR, 1.035 (1.020-1.051)

96.9 (95.4-98.3) 102.6 (99.6-105.6) APC, 0.37 (0.21-0.52)

20.7 (16.5-25.0) 32.9 (23.6-42.2) OR, 1.045 (1.020-1.071)

35.9 (31.5-40.2) 34.7 (28.5-41.0) OR, 0.995 (0.979-1.012)

38.4 (33.1-43.8) 30.4 (23.6-37.2) OR, 0.971 (0.950-0.992)

34.2 (29.2-39.3) 54.8 (46.8-62.9) OR, 1.052 (1.030-1.074)

89.8 (88.6-90.9) 96.6 (93.8-99.4) APC, 0.40 (0.27-0.54)

15.0 (11.8-18.2) 30.5 (23.5-37.4) OR, 1.048 (1.024-1.072)

40.6 (37.1-44.2) 44.5 (42.0-46.9) OR, 1.010 (0.997-1.024)

43.1 (38.9-47.3) 24.4 (17.6-31.2) OR, 0.954 (0.937-0.971)

13.5 (9.9-17.0) 31.8 (23.0-40.6) OR, 1.051 (1.026-1.077)

100.0 (98.9-101.1) 102.0 (100.4-103.5) APC, 0.16 (0.05-0.27)

33.4 (28.9-37.8) 38.7 (32.8-44.7) OR, 1.019 (1.000-1.040)

45.0 (40.7-49.2) 47.8 (41.0-54.6) OR, 1.004 (0.988-1.020)

21.1 (17.9-24.4) 13.5 (10.6-16.4) OR, 0.968 (0.949-0.987)

40.5 (35.9-45.1) 44.6 (37.2-52.1) OR, 1.017 (0.996-1.038)

99.1 (97.6-100.5) 104.8 (102.1-107.4) APC, 0.31 (0.16-0.46)

19.8 (14.0-25.6) 36.1 (20.7-51.5) OR, 1.057 (1.010-1.106)

47.7 (40.0-55.4) 47.1 (35.9-58.2) OR, 0.993 (0.966-1.021)

31.0 (25.5-36.5) 16.9 (6.5-27.3) OR, 0.960 (0.930-0.992)

40.0 (31.6-48.4) 58.7 (49.7-67.7) OR, 1.040 (1.013-1.069)

Men 18-39 y, non-Hispanic white 1988-1994 25.7 (25.3-26.1) 2009-2010 27.8 (27.0-28.5) Trend APC, 0.35 (0.23-0.47) 40-64 y, non-Hispanic white 1988-1994 27.6 (27.2-27.9) 2009-2010 29.3 (28.7-29.9) Trend APC, 0.33 (0.22-0.43) 65 y, non-Hispanic white 1988-1994 26.7 (26.4-27.1) 2009-2010 28.9 (28.4-29.4) Trend APC, 0.40 (0.30-0.49) 18-39 y, non-Hispanic black 1988-1994 26.1 (25.7-26.4) 2009-2010 28.9 (27.6-30.2) Trend APC, 0.52 (0.36-0.68) 40-64 y, non-Hispanic black 1988-1994 27.0 (26.7-27.4) 2009-2010 30.0 (29.0-30.9) Trend APC, 0.49 (0.33-0.65) 65 y, non-Hispanic black 1988-1994 26.0 (25.4-26.6) 2009-2010 28.0 (26.8-29.1) Trend APC, 0.48 (0.27-0.70) 18-39 y, Mexican American 1988-1994 26.0 (25.6-26.5) 2009-2010 28.4 (27.3-29.6) Trend APC, 0.50 (0.33-0.68) 40-64 y, Mexican American 1988-1994 28.5 (28.1-28.9) 2009-2010 29.5 (29.0-30.0) Trend APC, 0.22 (0.08-0.36) 65 y, Mexican American 1988-1994 26.7 (26.1-27.3) 2009-2010 29.0 (27.2-30.8) Trend APC, 0.44 (0.11-0.77)

APC ¼ annual percentage change; BMI ¼ body mass index; CI ¼ confidence interval; OR ¼ odds ratio.

727.e4




Ladabaum et al

Appendix Table 1

727.e5 Appendix Table 2 Adults, 1988-2010

The American Journal of Medicine, Vol 127, No 8, August 2014 Annual Changes in Prevalence of Abdominal Obesity, Stratified by Obesity Category Based on Body Mass Index, US Abdominal Obesity, % of Population (95% CI)

Women Obese 18 y 18-39 y 40-64 y 65 y Overweight 18 y 18-39 y 40-64 y 65 y Normal weight 18 y 18-39 y 40-64 y 65 y Men Obese 18 y 18-39 y 40-64 y 65 y Overweight 18 y 18-39 y 40-64 y 65 y Normal weight 18 y 18-39 y 40-64 y 65 y

1988-1994

2009-2010

Abdominal Obesity Category Based on Waist Circumference, Odds Ratio (95% CI) of Being in Category in Any Given Year Compared with Previous Year

96.4 92.5 98.5 99.8

(94.5-98.3) (87.5-97.5) (97.6-99.4) (99.4-100.0)

99.6 99.2 99.9 99.5

(99.1-100.0) (97.9-100.0) (99.7-100.0) (98.4-100.0)

1.144 1.155 1.130 0.907

(1.090-1.200) (1.083-1.232) (1.068-1.195) (0.707-1.164)

66.1 47.2 71.9 85.4

(62.7-69.4) (39.9-54.5) (67.3-76.5) (81.9-88.9)

80.8 69.8 85.6 86.4

(78.1-83.5) (62.7-76.9) (80.4-90.7) (81.7-91.1)

1.045 1.051 1.044 1.026

(1.032-1.057) (1.030-1.072) (1.025-1.063) (0.998-1.055)

9.6 2.6 13.4 28.3

(8.1-11.0) (1.2-4.0) (10.8-16.1) (24.2-32.4)

13.8 5.6 17.2 31.4

(10.1-17.5) (3.2-8.1) (10.6-23.7) (26.8-36.0)

1.026 1.042 1.018 1.009

(1.012-1.040) (1.011-1.075) (0.995-1.042) (0.993-1.026)

89.4 79.7 94.7 97.0

(86.7-92.1) (74.3-85.1) (91.5-97.8) (94.4-99.7)

91.1 81.5 95.7 98.9

(89.7-92.5) (77.6-85.5) (94.1-97.4) (97.2-100.0)

1.012 1.004 1.017 1.062

(0.991-1.033) (0.977-1.032) (0.978-1.057) (0.978-1.152)

24.5 8.6 31.4 52.1

(22.1-26.8) (6.2-11.0) (27.8-35.0) (47.8-56.4)

27.8 10.4 29.7 61.7

(24.3-31.3) (5.9-14.9) (24.5-34.9) (55.5-68.0)

1.017 1.012 1.007 1.028

(1.007-1.027) (0.991-1.033) (0.993-1.022) (1.013-1.044)

0.7 (0.4-1.0) –* 1.2 (0.2-2.2) 3.4 (1.7-5.2)

CI ¼ confidence interval. *Small sample size precludes estimation.

0.2 (0.0-0.5) –* 0.5 (0.0-1.2) 0.3 (0.0-0.8)

0.979 (0.951-1.008) –* 0.946 (0.904-0.990) 0.992 (0.954-1.031)

Ladabaum et al


727.e6

Appendix Table 3 Trends in Reported Levels of Leisure-time Physical Activity and Daily Caloric Intake, US Adults, Stratified by Race/ Ethnicity, 1988-2010 Reported Leisure-time Physical Activity None, % of Population (95% CI) Women 18-39 y, non-Hispanic white 1988-1994 10.4 (8.2-12.6) 2009-2010 41.3 (34.9-47.7) Trend OR, 1.080 (1.061-1.100) 40-64 y, non-Hispanic white 1988-1994 15.2 (12.7-17.8) 2009-2010 43.4 (38.4-48.4) Trend OR, 1.077 (1.056-1.099) 65 y, non-Hispanic white 1988-1994 29.3 (25.8-32.7) 2009-2010 64.2 (58.0-70.4) Trend OR, 1.073 (1.055-1.090) 18-39 y, non-Hispanic black 1988-1994 19.5 (16.2-22.8) 2009-2010 59.9 (54.1-65.8) Trend OR, 1.070 (1.055-1.086) 40-64 y, non-Hispanic black 1988-1994 33.0 (28.7-37.3) 2009-2010 71.1 (64.0-78.2) Trend OR, 1.064 (1.046-1.083) 65 y, non-Hispanic black 1988-1994 51.3 (44.7-57.9) 2009-2010 69.7 (61.4-77.9) Trend OR, 1.040 (1.015-1.066) 18-39 y, Mexican American 1988-1994 29.9 (26.6-33.3) 2009-2010 57.2 (49.4-65.0) Trend OR, 1.056 (1.034-1.079) 40-64 y, Mexican American 1988-1994 30.8 (27.7-33.9) 2009-2010 70.3 (60.3-80.2) Trend OR, 1.088 (1.063-1.114) 65 y, Mexican American 1988-1994 47.2 (41.5-53.0) 2009-2010 80.2 (74.1-86.3) Trend OR, 1.081 (1.058-1.105)


Ideal level, % of Population (95% CI)


51.3 (46.9-55.7) 21.9 (17.5-26.4) OR, 0.933 (0.920-0.945)

38.3 (34.2-42.4) 36.8 (31.5-42.1) OR, 1.010 (0.996-1.024)

1939 (1874-2005) 1861 (1820-1903) APC, 0.16 (0.38-0.06)

48.6 (45.8-51.4) 21.3 (18.0-24.7) OR, 0.936 (0.925-0.948)

36.2 (32.1-40.2) 35.2 (31.5-39.0) OR, 0.995 (0.980-1.011)

1715 (1685-1746) 1795 (1708-1882) APC, 0.17 (0.08-0.42)

30.9 (28.0-33.9) 12.1 (7.9-16.3) OR, 0.957 (0.945-0.970)

39.8 (35.3-44.3) 23.7 (18.0-29.4) OR, 0.957 (0.940-0.974)

1491 (1459-1523) 1607 (1523-1690) APC, 0.40 (0.18-0.62)

47.4 (43.8-51.0) 19.4 (13.7-25.1) OR, 0.936 (0.922-0.949)

33.0 (29.4-36.7) 20.7 (15.8-25.5) OR, 0.989 (0.975-1.004)

1970 (1915-2025) 1957 (1790-2125) APC, 0.14 (0.52-0.24)

39.6 (35.5-43.8) 14.3 (10.2-18.3) OR, 0.948 (0.933-0.964)

27.4 (23.1-31.6) 14.6 (8.4-20.8) OR, 0.972 (0.954-0.990)

1645 (1587-1703) 1728 (1613-1843) APC, 0.41 (0.02-0.79)

30.1 (25.2-35.0) 18.0 (11.7-24.3) OR, 0.962 (0.938-0.985)

18.6 (13.5-23.7) 12.4 (3.7-21.1) OR, 0.980 (0.949-1.011)

1340 (1261-1419) 1509 (1298-1720) APC, 0.56 (0.03-1.15)

44.0 (40.8-47.2) 16.7 (12.2-21.2) OR, 0.934 (0.917-0.952)

26.0 (22.2-29.9) 26.1 (18.5-33.7) OR, 1.002 (0.981-1.024)

1873 (1833-1913) 1844 (1698-1990) APC, 0.10 (0.51-0.30)

42.8 (39.2-46.4) 9.6 (3.9-15.3) OR, 0.917 (0.897-0.937)

26.4 (22.7-30.0) 20.1 (13.2-27.1) OR, 0.975 (0.954-0.997)

1697 (1621-1772) 1733 (1595-1872) APC, 0.18 (0.37-0.72)

28.9 (23.0-34.8) 6.8 (3.6-10.0) OR, 0.934 (0.909-0.959)

23.8 (16.9-30.7) 13.0 (5.9-20.0) OR, 0.950 (0.918-0.984)

1271 (1198-1344) 1455 (1381-1528) APC, 0.77 (0.20-1.35)

727.e7 Appendix Table 3

The American Journal of Medicine, Vol 127, No 8, August 2014 Continued Reported Leisure-time Physical Activity None, % of Population (95% CI)

Men 18-39 y, non-Hispanic white 1988-1994 7.3 (5.5-9.1) 2009-2010 28.6 (21.6-35.6) Trend OR, 1.064 (1.042-1.085) 40-64 y, non-Hispanic white 1988-1994 9.1 (6.8-11.3) 2009-2010 43.9 (40.7-47.1) Trend OR, 1.107 (1.085-1.130) 65 y, non-Hispanic white 1988-1994 16.3 (13.9-18.7) 2009-2010 54.9 (50.2-59.5) Trend OR, 1.094 (1.079-1.109) 18-39 y, non-Hispanic black 1988-1994 6.7 (4.6-8.7) 2009-2010 37.6 (28.9-46.3) Trend OR, 1.070 (1.047-1.093) 40-64 y, non-Hispanic black 1988-1994 19.6 (15.8-23.4) 2009-2010 57.4 (48.3-66.5) Trend OR, 1.070 (1.050-1.091) 65 y, non-Hispanic black 1988-1994 29.6 (22.5-36.7) 2009-2010 71.9 (63.5-80.3) Trend OR, 1.080 (1.056-1.103) 18-39 y, Mexican American 1988-1994 19.5 (15.2-23.8) 2009-2010 52.8 (42.6-63.1) Trend OR, 1.052 (1.032-1.074) 40-64 y, Mexican American 1988-1994 24.2 (20.0-28.5) 2009-2010 63.2 (53.6-72.9) Trend OR, 1.080 (1.055-1.106) 65 y, Mexican American 1988-1994 32.1 (25.6-38.6) 2009-2010 59.4 (48.2-70.6) Trend OR, 1.061 (1.029-1.095)


Ideal level, % of Population (95% CI)


46.0 (42.2-49.8) 16.7 (12.0-21.4) OR, 0.936 (0.922-0.949)

46.7 (42.6-50.7) 54.7 (45.7-63.8) OR, 1.016 (1.001-1.032)

3050 (2965-3134) 2773 (2632-2913) APC, 0.38 (0.63 to 0.12)

48.0 (44.0-52.0) 17.3 (13.5-21.0) OR, 0.928 (0.915-0.942)

42.9 (39.5-46.3) 38.8 (33.7-44.0) OR, 0.983 (0.970-0.997)

2547 (2472-2621) 2590 (2497-2682) APC, 0.17 (0.05-0.40)

35.3 (32.6-38.1) 12.8 (9.7-15.9) OR, 0.942 (0.931-0.954)

48.4 (44.9-51.8) 32.3 (28.5-36.2) OR, 0.962 (0.951-0.972)

2013 (1957-2069) 2018 (1951-2085) APC, 0.03 (0.28-0.22)

35.9 (32.9-38.8) 5.3 (1.4-9.3) OR, 0.922 (0.908-0.937)

57.4 (53.9-61.0) 57.0 (46.3-67.7) OR, 1.004 (0.987-1.022)

2917 (2800-3034) 2510 (2388-2632) APC, 0.56 (0.85 to 0.26)

42.3 (37.9-46.7) 11.8 (7.2-16.4) OR, 0.928 (0.913-0.944)

38.1 (34.2-42.0) 30.8 (23.5-38.0) OR, 0.987 (0.970-1.003)

2314 (2226-2403) 2593 (2285-2901) APC, 0.58 (0.08-1.08)

35.0 (28.9-41.2) 9.9 (1.4-18.4) OR, 0.939 (0.913-0.965)

35.4 (29.0-41.7) 18.2 (10.3-26.1) OR, 0.957 (0.934-0.980)

1651 (1559-1744) 1912 (1803-2021) APC, 1.04 (0.43-1.65)

42.0 (37.0-46.9) 10.7 (4.6-16.9) OR, 0.914 (0.895-0.934)

38.6 (34.3-42.8) 36.4 (29.9-43.0) OR, 1.018 (1.001-1.036)

2792 (2697-2887) 2613 (2442-2784) APC, 0.35 (0.72-0.03)

44.3 (40.5-48.0) 13.5 (8.5-18.5) OR, 0.919 (0.900-0.938)

31.5 (27.7-35.3) 23.3 (16.2-30.3) OR, 0.976 (0.955-0.997)

2424 (2364-2484) 2409 (2240-2578) APC, 0.21 (0.30-0.71)

28.8 (22.5-35.1) 12.0 (5.4-18.6) OR, 0.947 (0.919-0.976)

39.1 (32.4-45.8) 28.6 (22.0-35.3) OR, 0.968 (0.941-0.997)

1777 (1657-1897) 1919 (1693-2144) APC, 0.45 (0.21-1.11)

APC ¼ annual percentage change; CI ¼ confidence interval; OR ¼ odds ratio.

Annual Changes in Mean Body Mass Index, Mean Waist Circumference, and Daily Caloric Intake, Stratified by Reported Level of Leisure-time Physical Activity, US

1988-1994

2009-2010

Mean Waist Circumference in cm (95% CI) APC (95% CI)

1988-1994

Women No reported leisure-time physical activity 18 y 27.9 (27.3-28.6) 29.7 (29.2-30.2) 0.28 (0.16-0.40) 92.9 (91.4-94.4) 18-39 y 26.7 (25.6-27.8) 28.5 (27.7-29.3) 0.26 (0.03-0.49) 87.4 (84.6-90.2) 40-64 y 29.5 (28.5-30.6) 30.7 (29.9-31.5) 0.16 (0.04-0.35) 97.4 (95.3-99.6) 65 y 27.2 (26.6-27.9) 30.2 (29.2-31.2) 0.50 (0.33-0.67) 95.6 (93.7-97.5) Intermediate level of reported leisure-time physical activity 18 y 26.6 (26.2-27.0) 28.4 (27.9-28.8) 0.39 (0.28-0.51) 89.1 (88.2-90.0) 18-39 y 25.4 (24.9-25.9) 27.9 (26.9-29.0) 0.50 (0.33-0.68) 83.8 (82.6-84.9) 40-64 y 27.7 (27.2-28.2) 28.8 (27.7-29.9) 0.32 (0.15-0.49) 92.4 (91.1-93.7) 65 y 26.9 (26.4-27.4) 28.3 (26.3-30.3) 0.26 (0.06-0.47) 94.3 (93.0-95.6) Ideal level of reported leisure-time physical activity 18 y 25.5 (25.2-25.7) 26.7 (26.1-27.2) 0.28 (0.16-0.39) 86.0 (85.2-86.7) 18-39 y 24.3 (23.9-24.7) 26.6 (25.4-27.8) 0.48 (0.32-0.65) 80.9 (79.9-81.8) 40-64 y 26.5 (26.1-26.9) 26.8 (25.9-27.6) 0.10 (0.08-0.28) 89.2 (87.8-90.5) 65 y 25.9 (25.4-26.3) 26.6 (25.2-27.9) 0.12 (0.06-0.31) 90.8 (89.7-91.9) Men No reported leisure-time physical activity 18 y 26.6 (26.1-27.1) 29.2 (28.6-29.8) 0.52 (0.37-0.66) 96.1 (94.4-97.8) 18-39 y 26.0 (25.0-26.9) 28.4 (27.6-29.3) 0.44 (0.20-0.67) 90.7 (88.1-93.2) 40-64 y 27.6 (26.8-28.4) 29.8 (29.0-30.6) 0.52 (0.32-0.71) 100.1 (97.5-102.7) 65 y 25.9 (25.1-26.7) 29.4 (28.9-29.9) 0.66 (0.51-0.81) 99.7 (97.7-101.8) Intermediate level of reported leisure-time physical activity 18 y 27.0 (26.7-27.4) 28.3 (27.6-28.9) 0.28 (0.17-0.38) 97.1 (96.3-97.9) 18-39 y 25.8 (25.3-26.2) 28.0 (26.6-29.5) 0.37 (0.21-0.52) 91.2 (90.0-92.3) 40-64 y 28.2 (27.7-28.7) 28.9 (28.0-29.8) 0.21 (0.05-0.37) 101.2 (100.1-102.3) 65 y 27.3 (26.8-27.9) 27.4 (25.9-28.9) 0.14 (0.05-0.33) 102.1 (100.5-103.7) Ideal level of reported leisure-time physical activity 18 y 26.2 (25.9-26.4) 28.0 (27.5-28.6) 0.35 (0.26-0.44) 93.9 (93.2-94.5) 18-39 y 25.5 (25.1-25.9) 27.5 (26.6-28.3) 0.37 (0.24-0.50) 89.0 (87.9-90.0) 40-64 y 26.7 (26.4-27.1) 28.7 (27.9-29.6) 0.35 (0.21-0.49) 96.6 (95.7-97.4) 65 y 26.4 (26.0-26.7) 27.8 (27.0-28.6) 0.28 (0.15-0.42) 99.5 (98.4-100.5)


2009-2010

APC (95% CI)

1988-1994

2009-2010

APC (95% CI)

97.3 92.9 100.4 100.9

(95.6-99.1) (90.4-95.4) (98.5-102.3) (99.1-102.8)

0.25 0.31 0.18 0.30

(0.14-0.37) (0.11-0.51) (0.03-0.33) (0.17-0.43)

1714 1875 1681 1395

(1664-1764) (1793-1958) (1600-1762) (1336-1454)

1791 1914 1762 1556

(1753-1828) 0.27 (0.02-0.52) (1827-2001) 0.04 (0.52-0.44) (1668-1855) 0.29 (0.14-0.72) (1497-1616) 0.63 (0.29-0.96)

94.7 92.2 96.5 96.5

(93.7-95.7) (89.9-94.5) (94.1-98.9) (91.5-101.6)

0.38 0.53 0.28 0.14

(0.30-0.46) (0.41-0.65) (0.16-0.41) (0.02-0.29)

1776 1969 1702 1478

(1738-1814) (1889-2050) (1665-1739) (1427-1530)

1783 1757 1874 1627

(1714-1851) 0.09 (0.11-0.28) (1663-1852) 0.27 (0.60-0.06) (1776-1972) 0.38 (0.13-0.64) (1392-1861) 0.41 (0.00-0.82)

90.5 88.5 91.6 92.8

(89.2-91.8) (85.9-91.2) (89.6-93.6) (90.6-95.0)

0.33 0.52 0.20 0.13

(0.25-0.41) (0.39-0.64) (0.06-0.33) (0.01-0.24)

1765 1926 1697 1530

(1722-1808) (1856-1996) (1616-1779) (1472-1588)

1774 1892 1719 1616

(1705-1843) 0.08 (0.13-0.30) (1795-1988) 0.12 (0.42-0.18) (1603-1835) 0.18 (0.23-0.59) (1508-1723) 0.41 (0.07-0.75)

102.6 97.8 105.2 108.1

(100.9-104.2) (95.3-100.2) (103.0-107.4) (107.1-109.2)

0.35 0.32 0.34 0.43

(0.23-0.47) (0.13-0.51) (0.18-0.51) (0.32-0.53)

2438 2714 2471 1679

(2343-2533) (2536-2891) (2322-2620) (1595-1762)

2487 2663 2548 1903

(2384-2589) 0.19 (0.14-0.53) (2492-2834) 0.06 (0.63-0.50) (2428-2669) 0.34 (0.15-0.83) (1820-1986) 0.38 (0.02-0.77)

100.0 96.3 102.9 101.9

(98.3-101.7) (93.0-99.7) (100.8-105.1) (98.1-105.8)

0.21 0.29 0.15 0.12

(0.14-0.29) (0.17-0.41) (0.04-0.26) (0.02-0.27)

2636 2972 2548 2015

(2576-2695) (2864-3080) (2466-2631) (1934-2096)

2532 2710 2537 2077

(2408-2655) 0.13 (0.34-0.09) (2483-2937) 0.36 (0.68 to 0.03) (2337-2738) 0.10 (0.21-0.40) (1818-2336) 0.03 (0.44-0.39)

98.2 93.6 100.9 103.1

(96.7-99.7) (91.6-95.6) (98.9-102.9) (100.4-105.8)

0.25 0.28 0.24 0.22

(0.18-0.32) (0.17-0.38) (0.13-0.34) (0.11-0.34)

2639 3023 2491 2047

(2579-2699) (2912-3134) (2395-2587) (1981-2113)

2536 2678 2585 2066

(2452-2620) 0.22 (0.40 to 0.04) (2564-2792) 0.60 (0.87 to 0.32) (2447-2722) 0.23 (0.09-0.55) (1942-2191) 0.06 (0.29-0.41)



Ladabaum et al

Appendix Table 4 Adults, 1988-2010

APC ¼ annual percentage change; CI ¼ confidence interval.

727.e8

727.e9


Appendix Table 5 Relative Increase in Body Mass Index and Waist Circumference in “Intermediate” and “No Reported” Groups Compared with “Ideal” Reported Leisure-time Physical Activity in US Adults, 1988-2010

Women Non-Hispanic white Non-Hispanic black Mexican American Men Non-Hispanic white Non-Hispanic black Mexican American

Relative Increase in BMI Compared with Ideal Level of Reported Leisure-time Physical Activity

Relative Increase in Waist Circumference Compared with Ideal Level of Reported Leisure-time Physical Activity

Intermediate Percent Change (95% CI)

Intermediate Percent Change (95% CI)

None Percent Change (95% CI)

None Percent Change (95% CI)

6.14 (4.64-7.65) 1.10 (2.11-4.41) 3.49 (0.62-6.44)

8.75 (7.26-10.25) 0.65 (2.17-3.55) 5.06 (2.78-7.40)

4.63 (3.57-5.70) 1.28 (1.03-3.66) 2.83 (0.60-5.10)

7.19 (6.02-8.37) 1.10 (1.10-3.36) 3.73 (2.08-5.41)

1.36 (0.26-2.46) 0.10 (2.76-3.03) 0.39 (2.04-2.88)

2.52 (1.25-3.82) 2.21 (4.38-0.00) 1.62 (0.81-4.11)

2.10 (1.28-2.93) 2.01 (0.45-4.53) 0.55 (1.10-2.23)

3.36 (2.40-4.33) 0.22 (1.51-1.98) 1.16 (0.59-2.95)

BMI ¼ body mass index; CI ¼ confidence interval.

Ladabaum et al

Annual Changes in Daily Intake of Fat, Carbohydrate, and Protein, Stratified by Reported Level of Leisure-time Physical Activity, US Adults, 1988-2010

Reported Level of Leisure-time Physical Activity None

Women Aged 18 y 1988-1994 2009-2010 Trend 18-39 y 1988-1994 2009-2010 Trend 40-64 y 1988-1994 2009-2010 Trend 65 y 1988-1994 2009-2010 Trend

Intermediate

Ideal

Mean Fat Intake in g/d (95% CI)

Mean Carbohydrate Intake in g/d (95% CI)

Mean Protein Intake in g/d (95% CI)







66 (64-68) 67 (65-68) APC, 0.26 (0.07-0.59)

216 (209-224) 228 (223-233) APC, 0.21 (0.07-0.49)

64 (62-67) 67 (66-69) APC, 0.50 (0.18-0.81)

69 (67-71) 67 (63-72) APC, 0.02 (0.32-0.28)

219 (213-225) 224 (217-231) APC, 0.18 (0.03-0.39)

66 (64-68) 68 (64-72) APC, 0.22 (0.03-0.48)

65 (63-68) 65 (62-68) APC, 0.45 (0.11-0.78)

225 (220-230) 222 (212-232) APC, 0.19 (0.44-0.07)

67 (65-69) 69 (67-71) APC, 0.26 (0.02-0.49)

72 (67-76) 71 (67-75) APC, 0.15 (0.79-0.49)

238 (228-248) 245 (235-256) APC, 0.03 (0.57-0.51)

68 (64-73) 68 (65-72) APC, 0.37 (0.26-1.00)

77 (73-81) 64 (58-69) APC, 0.55 (1.03 to 0.07)

240 (229-251) 227 (214-240) APC, 0.04 (0.41-0.33)

71 (67-74) 66 (61-71) APC, 0.10 (0.51-0.30)

71 (68-75) 69 (64-73) APC, 0.18 (0.26-0.62)

244 (234-254) 239 (227-250) APC, 0.36 (0.71-0.00)

70 (67-72) 72 (70-75) APC, 0.22 (0.16-0.59)

65 (61-69) 65 (61-69) APC, 0.11 (0.48-0.70)

208 (198-219) 223 (211-235) APC, 0.31 (0.14-0.75)

64 (59-68) 69 (65-73) APC, 0.52 (0.01-1.03)

67 (64-69) 71 (66-76) APC, 0.26 (0.12-0.63)

208 (202-214) 233 (222-244) APC, 0.50 (0.20-0.79)

65 (63-67) 72 (66-77) APC, 0.53 (0.21-0.84)

64 (59-68) 63 (59-67) APC, 0.53 (0.03-1.09)

214 (204-224) 212 (192-232) APC, 0.16 (0.66-0.34)

66 (63-69) 68 (64-71) APC, 0.30 (0.10-0.71)

52 (49-54) 59 (56-63) APC, 1.02 (0.43-1.61)

182 (174-190) 197 (188-205) APC, 0.37 (0.03-0.71)

55 (52-58) 61 (58-64) APC, 0.62 (0.19-1.05)

54 (51-57) 67 (55-79) APC, 1.01 (0.47-1.54)

193 (185-202) 194 (165-224) APC, 0.01 (0.47-0.45)

58 (56-60) 64 (56-71) APC, 0.44 (0.01-0.90)

54 (50-57) 60 (55-64) APC, 0.97 (0.48-1.46)

203 (195-211) 205 (192-218) APC, 0.20 (0.14-0.54)

62 (59-65) 64 (58-70) APC, 0.26 (0.16-0.68)


Appendix Table 6

727.e10

727.e11

Appendix Table 6

Continued Reported Level of Leisure-time Physical Activity None

Men 18 y 1988-1994 2009-2010 Trend

40-64 y 1988-1994 2009-2010 Trend 65 y 1988-1994 2009-2010 Trend

Ideal










95 (90-100) 93 (88-98) APC, 0.22 (0.23-0.67)

293 (278-308) 296 (284-308) APC, 0.04 (0.35-0.43)

92 (89-96) 97 (92-102) APC, 0.37 (0.00-0.75)

102 (99-106) 96 (91-101) APC, 0.13 (0.41-0.15)

309 (301-317) 305 (288-321) APC, 0.12 (0.36-0.13)

100 (97-103) 96 (91-101) APC, 0.07 (0.19-0.32)

100 (97-104) 93 (88-97) APC, 0.31 (0.59 to 0.02)

320 (311-329) 297 (287-308) APC, 0.41 (0.62 to 0.20)

99 (97-102) 102 (99-105) APC, 0.17 (0.01-0.34)

105 (96-115) 95 (87-103) APC, 0.30 (1.09-0.50)

323 (299-348) 326 (307-345) APC, 0.23 (0.79-0.34)

101 (94-107) 102 (93-110) APC, 0.30 (0.39-1.00)

115 (110-119) 101 (89-113) APC, 0.43 (0.85-0.00)

346 (335-358) 327 (298-356) APC, 0.27 (0.60-0.05)

110 (105-114) 100 (90-110) APC, 0.13 (0.54-0.28)

116 (111-122) 94 (89-99) APC, 0.93 (1.34 to 0.53)

363 (348-378) 324 (308-340) APC, 0.64 (0.94-0.34)

111 (106-116) 106 (102-110) APC, 0.17 (0.45-0.11)

97 (89-105) 99 (94-104) APC, 0.56 (0.10-1.21)

297 (273-321) 293 (275-311) APC, 0.19 (0.43-0.81)

95 (89-101) 100 (94-106) APC, 0.45 (0.05-0.95)

100 (95-105) 97 (88-105) APC, 0.16 (0.24-0.57)

297 (285-310) 304 (278-329) APC, 0.01 (0.38-0.40)

99 (95-103) 98 (88-108) APC, 0.28 (0.09-0.65)

94 (88-99) 97 (89-105) APC, 0.37 (0.08-0.83)

302 (287-316) 292 (276-308) APC, 0.13 (0.50-0.23)

95 (91-98) 106 (101-112) APC, 0.68 (0.35-1.01)

62 (57-67) 72 (68-76) APC, 0.48 (0.03-1.00)

209 (194-225) 228 (216-240) APC, 0.24 (0.28-0.76)

67 (62-71) 76 (73-80) APC, 0.35 (0.11-0.81)

78 (73-82) 82 (68-95) APC, 0.02 (0.59-0.55)

245 (234-256) 250 (216-285) APC, 0.05 (0.45-0.56)

78 (75-82) 80 (70-90) APC, 0.08 (0.33-0.49)

76 (72-79) 80 (73-86) APC, 0.34 (0.11-0.78)

255 (245-264) 243 (225-262) APC, 0.23 (0.62-0.17)

81 (77-84) 83 (77-89) APC, 0.13 (0.26-0.52)

APC ¼ annual percentage change; CI ¼ confidence interval.


18-39 y 1988-1994 2009-2010 Trend

Intermediate

Ladabaum et al


Appendix Figure 1 (A) Age-adjusted prevalence of obesity in women by race. (B) Age-adjusted prevalence of obesity in men by race.

References 1. Beddhu S, Baird BC, Zitterkoph J, Neilson J, Greene T. Physical activity and mortality in chronic kidney disease (NHANES III). Clin J Am Soc Nephrol. 2009;4:1901-1906. 2. U.S. Department of Health and Human Services. Physical Activity Guidelines Advisory Committee fõnal report. Available at: http://www. health.gov/PAGuidelines/Report/Default.aspx. Accessed April 17, 2013. 3. Kim HJ, Fay MP, Feuer EJ, Midthune DN. Permutation tests for joinpoint regression with applications to cancer rates. Stat Med. 2000;19:335-351.

727.e12

Appendix Figure 2 (A) Age-adjusted prevalence of abdominal obesity in women by race. (B) Age-adjusted prevalence of abdominal obesity in men by race.

4. JoinPoint Regression Program, Version 4.0.1-January 2013; Statistical Methodology and Applications Branch and Data Modeling Branch, Surveillance Research Program National Cancer Institute. Available at: http://surveillance.cancer.gov/joinpoint/. Accessed April 17, 2013. 5. Johansson I, Nilsson LM, Stegmayr B, Boman K, Hallmans G, Winkvist A. Associations among 25-year trends in diet, cholesterol and BMI from 140,000 observations in men and women in Northern Sweden. Nutr J. 2012;11:40.