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Health Status and Health Care Expenditures in a Nationally Representative Sample: How Do Overweight and Healthy-Weight Children Compare?

^a Department of Health Policy and Administration
^b Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, North Carolina
^c Charles Drew Community Health Center, Piedmont Health Services, Burlington, North Carolina
^d Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, North Carolina

	ABSTRACT

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OBJECTIVE. Childhood overweight is epidemic in the United States. Although limited, previous studies suggest that overweight children have chronic health problems. A more complete understanding of the effect of overweight on children's health requires a nationally representative, population-based sample. Our objective was to examine whether overweight children have (1) more chronic conditions, (2) poorer health, and (3) greater health care expenditures than healthy-weight children.

PATIENTS AND METHODS. This was a cross-sectional study of children aged 6 to 17 years participating in 1 of 2 nationally representative surveys of civilian, noninstitutionalized Americans, the 2001–2002 National Health and Nutrition Examination Survey and 2002 Medical Expenditure Panel Survey. The main outcome measures were prevalence of dyslipidemia, hyperglycemia, and hypertension; self-reported health status; and health care expenditures.

RESULTS. Overweight children, compared with healthy-weight children, have significantly increased risk for high total cholesterol levels (15.7% vs 7.2%), high low-density lipoprotein (11.4% vs 7.7%) or borderline low-density lipoprotein cholesterol levels (20.2% vs 12.5%), low high-density lipoprotein cholesterol levels (15.5% vs 3.0%), high triglyceride levels (6.7% vs 2.1%), high fasting glucose levels (2.9% vs 0.0%), high glycohemoglobin levels (3.7% vs 0.5%), and high systolic blood pressure (9.0% vs 1.6%). Overweight children, compared with healthy-weight children, demonstrate significantly lower prevalence of excellent health (National Health and Nutrition Examination Survey: 36.5% vs 53.3%; Medical Expenditure Panel Survey: 42.8% vs 55.6%). These differences persist in multiple regression models that control for potential confounders. In adjusted analyses, expenditures were comparable between overweight and healthy-weight children.

CONCLUSIONS. Our data demonstrate that overweight children have more chronic conditions and poorer health but have health care expenditures that are no greater than those for healthy-weight children. Addressing the health care needs of overweight children may prevent the development of chronic conditions and improve health status. These findings demonstrate the need to more thoroughly consider whether (1) overweight children have appropriate access to care, (2) physicians fully recognize the impact of overweight, and (3) physicians have resources to address overweight.

Key Words: childhood obesity • chronic conditions • health care costs • health status • access to care

Abbreviations: NHANES—National Health and Nutrition Examination Survey • MEPS—Medical Expenditure Panel Survey • OR—odds ratio • aOR—adjusted odds ratio • LDL—low-density lipoprotein • HDL—high-density lipoprotein • CSHCN—children with special health care needs

The prevalence of childhood overweight is increasing in the United States.¹ Although previous studies on childhood overweight are limited by the use of small samples and nonrepresentative clinical populations, they suggest that overweight children are at increased risk for chronic disease,^2–5 poorer health status^6–8 as a child, and overweight or obesity in adulthood.^9,10 Hypertension, dysglycemia (including type 2 diabetes), and hyperlipidemia are especially important chronic health conditions that have been associated with overweight in children.^{3–5,11–18} When present in childhood, these conditions may persist into adulthood and contribute to cardiovascular disease.^19,20 Previous studies have also suggested that additional chronic conditions may disproportionately affect overweight children, including hepatic steatosis,^21–24 cholelithiasis,^25–27 sleep apnea,^28,29 orthopedic conditions,^30–32 and polycystic ovarian syndrome.³³ Consequently, overweight children might be expected to report poorer health and experience higher health care expenditures when compared with their healthy-weight counterparts.

To our knowledge, the prevalence of these conditions has not previously been established in a nationally representative sample, and few studies to date have investigated the effects of overweight on overall health status and health care expenditures. A more complete understanding of the effect of overweight on children's health requires a nationally representative, population-based sample. Using 2 such national surveys, we examine whether, compared with healthy-weight children, overweight children have (1) a higher prevalence of selected chronic conditions (eg, hypertension, dysglycemia, and hyperlipidemia), (2) poorer health, and (3) greater health care expenditures.

	METHODS

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Data
Our sample consisted of children aged 6 to 17 years, the ages at which overweight is most prevalent for the child population,¹ from 2 nationally representative surveys of civilian, noninstitutionalized Americans that provide complementary data to address our question. The 2001–2002 National Health and Nutrition Examination Survey (NHANES)³⁴ is a stratified, multistage probability sample in which household interviews are conducted with proxies (ie, parents or guardians) for children <16 of age or directly with minors 16 years of age with parent or guardian consent.³⁴ The NHANES includes clinical data, including a physical examination and urine and blood specimens. The 2002 Medical Expenditure Panel Survey (MEPS)³⁵ uses an overlapping panel design, where one third of the panel is replaced each year, and each panel is followed for a total of 2.5 years. Although the MEPS does not contain clinical data, the household component provides information on actual use and expenditures, in addition to health status and demographics. Thus, these 2 data sources allow us to examine both clinical and economic outcomes of childhood obesity. A more complete comparison of these 2 surveys regarding their design and measurement of key variables can be found in Appendix 1.

Measures
Overweight
Using height and weight, BMI was calculated and converted to percentiles for age in months and gender using the Centers for Disease Control and Prevention's SAS programming code.³⁶ Height and weight are from physical examination data in the NHANES and parent reports in the MEPS. Current growth charts are based on historical distribution of weight in the child population, and, thus, the percentiles do not represent the distribution of the current population. Unlike adults, for whom obesity is measured using a set BMI, BMI varies throughout childhood and adolescence, and, therefore, there is no set BMI to determine overweight for all ages. As such, >5% of the population <18 years of age can be above the 95th percentile for BMI and considered overweight. Using the current growth charts for their age and gender, we classified children on the basis of their BMI as overweight (>95th percentile), at risk for overweight (85th to <95th percentiles), and healthy weight (5th to <85th percentile).^37,38 Children with BMI <5th percentile may have underlying malnutrition and/or medical conditions³⁹ and were excluded from all of the analyses.

Chronic Conditions
We used laboratory data from the NHANES to determine the presence of 3 chronic conditions related to obesity in adults. We used American Association of Pediatrics⁴⁰ and American Heart Association⁴¹ criteria for hyperlipidemia; American Diabetes Association criteria for hyperglycemia^42,43; and percentiles from the population of systolic and diastolic values, based on height, age, and gender,⁴⁴ to define hypertension (Appendix 2).

Health
We used 3 indicators of health: parent- or self-reported health status, school days missed because of illness or injury, and functional limitations. Health status is increasingly recognized as an important outcome in pediatric research, and parent report has been found to be a valid proxy for child self-report.^45,46 In addition, although it is possible that parent-reported health status is not independent of the presence of overweight, it remains a representation of the general health of this population. A functional limitation is measured in the NHANES as having any walk, run, or play limitation, whereas in the MEPS it is measured as having any limitation in physical functioning, including any limitation in housework or school and vision and hearing limitations (Appendix 1).

Health Care Expenditures
Because dollars represent a common metric for use, we estimated use using MEPS expenditure data.³⁵ Expenditures in the MEPS represent the actual amount paid for health care services, rather than the amounts charged or billed, and include out-of-pocket payments, insurance payments, and any other payment source. Outpatient expenditures include office-based visits to physicians, nurse practitioners, physician assistants, occupational or physical therapists, and an outpatient department. Inpatient expenditures are for hospital admissions, including associated emergency department charges, for those admissions that originated in the emergency department. Emergency department expenditures are payments for emergency department visits that did not result in an inpatient admission. Total health care expenditures represent all of the expenditures and, thus, included, but were not limited to, the previously described outpatient, inpatient, and emergency department use.

Socioeconomic Control Variables
We controlled for child's age in years, gender, race, poverty, and insurance type. Age is categorized as 6 to 11 years and 12 to 17 years. Race is categorized as white non-Hispanic, black non-Hispanic, Hispanic, or other. Poverty is a binary variable indicating whether household income is at or below the federal poverty level. Insurance is defined as private insurance only, public insurance at any point, or uninsured for the full year. We conducted additional analyses using continuous measures of age and age-gender interactions. Because these continuous measures performed similarly to control variables categorized above, we report only the models using categorized control variables.

Analytic Methods
All of the analyses were adjusted for the complex survey designs of the NHANES and MEPS, with clustering on the sampling units and the use of individual probability weights. All of the analyses were performed by using the survey commands in Stata 8.0 (Stata Corp, College Station, TX).

All of the variables were examined for bivariate differences using a Pearson ² statistic, adjusted for survey design. Binary outcomes were examined using logistic regression, reported as an odds ratio (OR) for unadjusted results and an adjusted OR (aOR) controlling for all of the socioeconomic covariates. Expenditures were analyzed using 2-part models. First, a logistic regression was used to examine the likelihood of any expenditure. Second, ordinary least-squares regression was used to examine total expenditures among those with any expenditure. The natural log of expenditures was used given the large number of outliers. Both unadjusted and adjusted models were calculated. All of the adjusted models included the following covariates: age, gender, race, poverty, and health insurance status, as described above, and were added in a single step to the models. Because 15% of the sample was missing weight in the MEPS, we included a separate dummy variable in all of the MEPS analyses.

	RESULTS

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Demographics
Both surveys yielded similar demographic findings (Table 1). On the basis of BMI calculated from parent-reported child height and weight, more children in the MEPS were overweight (22.4%) than in the NHANES, in which BMI calculated from actual measured height and weight yielded a lower percentage of overweight (17.1%).

Expenditures
Compared with healthy-weight children, overweight children reported fewer health care expenditures (OR: 0.7; P < .01; Table 5); this difference did not remain after adjusting for socioeconomic status (aOR: 0.9; P value not significant). Among those with any expenditure, overweight children had 15% fewer (P < .05) health care expenditures than healthy-weight children; these differences were not significant after adjusting for socioeconomic status. Overweight children did not demonstrate any increased expenditures for any of the specific service types. The same pattern of effect was found with the unlogged version (results not shown here).

	DISCUSSION

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Our results suggest that clinicians should be encouraged to screen overweight children for abnormal lipid values, elevated blood pressure, and diabetes. Although some studies suggest that blood pressure screening is routine, far fewer providers frequently screen overweight children for dyslipidemia⁴⁸ and type 2 diabetes.⁴⁹ Current guidelines specify that children with a family history of the condition should be screened for dyslipidemia,⁴⁰ and children with multiple risk factors should be screen for dysglycemia,⁴² but the guidelines do not specifically identify overweight alone as a reason for screening. In addition, the guidelines for screening and treatment of these conditions in children are not as well established as they are for adults, which may limit translation of our findings into clinical practice. However, once a diagnosis is made based on clinical findings, overweight youth may be more motivated to pursue lifestyle changes, and physicians and parents may be more likely to encourage healthier behaviors. Moreover, the most severely overweight children may require referrals to intensive nutritional or specialty care intervention.⁵⁰

Consistent with previous studies,^6–8 overweight children in our nationally representative samples reported poorer health compared with healthy-weight children. This finding is not surprising, given the associations reported previously between overweight and multiple medical problems, including type 2 diabetes,^17,18 hepatic steatosis,^21–24 cholelithiasis,^25–27 pseudotumor cerebri,^51,52 sleep apnea,^28,29 orthopedic conditions,^30–32 and polycystic ovarian syndrome.³³ Curiously, despite reports of poorer health, overweight children did not report missing more days of school than healthy-weight children. If children continue to attend school despite poor health, they may not be able to learn and perform optimally. Given that previous studies have described the associations between poorer school performance and overweight,^53,54 the specific reasons for reported poor health in overweight children deserve elucidation in future studies.

Despite having more chronic conditions and poorer health, overweight children have lower health care expenditures than normal-weight children in unadjusted analyses. This is likely because of greater prevalence of poverty and minority status among overweight children,^55,56 because we no longer observed significant differences in expenditures by overweight, at risk for overweight, and healthy weight after adjusting for race, insurance, and poverty status. In addition, although we did not find statistically significant differences in specific types of care expenditures, our data suggested that overweight children may be more likely to accumulate expenditures because of inpatient care and less likely to accumulate them in outpatient office settings.

What can be done to bridge the gap documented here between the need for care among overweight children based on their high prevalence of medical conditions and the amount and type of care that they actually receive? Overweight children may benefit from access to health care to both screen for weight-related conditions and address the underlying overweight problems. Children who are overweight are disproportionately poor and are likely to face multiple barriers to health care access. One policy option to facilitate access is to designate overweight children as children with special health care needs (CSHCN). The Maternal and Child Health Bureau defines CSHCN as those who have, or are at increased risk for, chronic physical, developmental, behavioral, or emotional conditions and require health-related services of a type or amount beyond that required by children generally.⁵⁷ The CSHCN designation is intended to improve access to care, help secure a medical home, and make available public programs that address the health needs of designees. The CSHCN designation for overweight children could bring to the forefront the importance of addressing overweight in children and provide resources to direct health care resources toward overweight children, including referral to services that foster healthy diet, exercise, and weight loss. Because there is evidence that CSHCN with medical homes have lower health care costs⁵⁸ and fewer unmet health needs,⁵⁹ designating overweight children as CSHCN could be a useful strategy for accessing appropriate care.

There are several potential challenges to a CSHCN need designation for overweight. First, it "medicalizes" overweight, suggesting that the solution lies within the medical system. Defining overweight as a medical problem has been resisted by many because it de-emphasizes behavioral and lifestyle changes that are necessary for weight loss, as well as the larger social and environmental challenges to reducing childhood obesity. Second, would children who successfully lose weight also lose the benefits of the CSHCN designation? Whereas one would not argue that a child with well-controlled diabetes still has diabetes (and, therefore, requires access to a medical home), would the same hold for overweight? Third, physicians are trained to diagnose and manage diseases but not necessarily overweight. Given the prevalence of overweight, physicians may be overwhelmed by the increased volume of children who seek care for overweight, a condition that requires skills for which they feel inadequately trained. It is not clear whether the infrastructure is adequately developed to permit referral of overweight children to outside sources of care, such as nutritionists. Adding to the potential for physicians to be overwhelmed is that, as shown in these analyses, overweight children are at increased risk for having chronic conditions that require medical attention. None of these issues can be fully addressed with currently available knowledge and will require continued research and discussion.

Our study has several limitations. First, data are cross-sectional, thus limiting our ability to make causal links between overweight and health and care expenditures. However, we selected chronic conditions for which it is unlikely that they are the cause of overweight. Second, the MEPS uses self-reported weight, which may be less accurate. Previous studies have demonstrated that, whereas self-report of weight is often biased downward, this results in very few errors in classification into overweight, at risk for overweight, and healthy weight.⁶⁰ However, underreporting of BMI would result in more overweight children being classified as healthy weight. This bias would dilute the effects of weight on our outcomes. Of interest, however, is that our findings show a much greater prevalence of overweight when using parent-reported data. One possible explanation is the significant proportion of the sample with missing values for weight, who may, as a group, have been more likely to underestimate weight. A final limitation is that parent-reported health status may not be independent of overweight. Parents may consider an overweight child to be less healthy solely because he or she is overweight, regardless of the manifestation of any health problems. Although this limits the ability to use parent-reported health status as a proxy for other health conditions, it remains an important indicator of the general health of this population.

	CONCLUSIONS

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Our data from 2 nationally representative surveys suggests that overweight children have more chronic conditions, poorer health, and lower health care expenditures than healthy-weight children. To ensure that overweight children are receiving appropriate health care, we must recognize that childhood overweight is an indicator of both current and future health concerns. We must determine ways to support clinicians in detecting the chronic conditions associated with overweight and enhance the access to health care resources available to overweight children. Such strategies are critical to prevent chronic conditions, improve health status, and reduce health care expenditures, both during childhood and into adulthood.

	APPENDIX 1 Comparison of the NHANES and MEPS

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	APPENDIX 2 Categorical Definitions for Clinical Measures

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	ACKNOWLEDGMENTS

 
Dr Skinner's time was funded by National Research Service Award H-T32-HS00032-14 from the Agency for Healthcare Research and Quality, and Dr Mayer's time was funded through Agency for Healthcare Research and Quality grant 1-K02-HS013309-01A1.

We thank Suzanne Havala-Hobbs, DrPH, and Gary Rozier, DDS, for assistance in the design of the project.

	FOOTNOTES

 
Accepted Jul 16, 2007.

Address correspondence to Asheley Cockrell Skinner, PhD, University of North Carolina, CB 7411, Chapel Hill, NC 27599-7411. E-mail: asheley{at}unc.edu

The authors have indicated they have no financial relationships relevant to this article to disclose.

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