Elsevier

Preventive Medicine

Volume 130, January 2020, 105892
Preventive Medicine

Clustering of unhealthy behaviors in a nationally representative sample of U.S. children and adolescents

https://doi.org/10.1016/j.ypmed.2019.105892Get rights and content

Highlights

  • We examined patterns of unhealthy behavior clustering in a national sample of youth.

  • Prevalence of having ≥2 unhealthy behaviors increased significantly with age.

  • Excessive screen time and poor dietary quality was the most common combination.

  • Patterns by sociodemographic characteristics varied across age groups.

Abstract

Poor diet, low physical activity, sedentary behavior and smoking are modifiable risk factors for chronic diseases that often develop early in life. An improved understanding of how unhealthy behaviors co-occur within individual children across childhood and adolescence could inform the development of more effective prevention approaches. Using data from the 2011–2016 National Health and Nutrition Examination Survey, we calculated weighted prevalence of five unhealthy behaviors – excessive screen time, poor diet quality, low physical activity, fast food consumption, and smoking (adolescents only) – alone and in combination among U.S. children and adolescents, stratified by age group (2–5, 6–11, 12–15, and 16–19 years). Multivariable logistic regression was used to estimate associations between health behavior clustering (≥2 unhealthy behaviors) and sociodemographic characteristics by age group. Among 7714 children and adolescents, the most prevalent behaviors were excessive screen time and poor diet quality. Unhealthy behavior clustering increased significantly with age (from 29.0% for ages 2–5 to 73.9% for ages 16–19 years, p-trend: <0.0001). The most common health behavior combination was excessive screen time and poor diet (from 14.4% prevalence for ages 2–5 to 45.3% for ages 16–19 years). Smoking prevalence was low, but 97% of smokers had ≥1 other unhealthy behavior. Unhealthy behavior clustering was significantly more prevalent among black than white children (ages 2–5 and 6–11) and less prevalent among Hispanic older adolescents (age 16–19). Associations with household characteristics varied by age group. These results provide a population-level understanding of the extent to which unhealthy behaviors co-occur in U.S. children and adolescents.

Introduction

Unhealthy behaviors such as poor diet quality, inadequate physical activity, and smoking increase the risk of chronic diseases including cardiovascular disease, diabetes, and cancer (Gotay, 2005; Lloyd-Jones et al., 2010). It has been estimated that unhealthy behaviors account for nearly two-thirds of cardiovascular disease deaths worldwide (Lopez et al., 2006). Unhealthy behaviors frequently co-occur (Fine et al., 2004; Meader et al., 2016; Noble et al., 2015), and clustering of unhealthy behaviors is associated with greater risk of all-cause, cardiovascular disease, and cancer mortality (Kvaavik et al., 2010; van Dam et al., 2008). Conversely, engaging in a greater number of healthy behaviors is associated with healthier levels of cardiometabolic biomarkers and lower risk of chronic disease and all-cause mortality (Ford et al., 2012a; Ford et al., 2009; Loprinzi et al., 2016).

While chronic diseases may not emerge until adulthood, health risk behaviors often develop in childhood and adolescence (Forrest and Riley, 2004). Patterns of diet, physical activity, and sedentary behavior have been found to track from childhood into adulthood (Biddle et al., 2010; Craigie et al., 2011; Telama, 2009), underscoring the importance of targeting prevention at youth. Prior studies provide evidence of health behavior clustering in children and adolescents, most frequently combinations of diet, physical activity, and sedentary behavior (Gubbels et al., 2013; Leech et al., 2014). Although others have used nationally representative data to examine health behavior clustering in U.S. youth (Bai et al., 2016; Boone-Heinonen et al., 2008; Hartz et al., 2018; Xu et al., 2018), prior studies have not examined the prevalence and correlates of unhealthy behavior clustering across the full age spectrum from early childhood to late adolescence. In addition, while a small number of studies have examined unhealthy behavior clustering among young children (ages 2–5 years) in other countries (Gubbels et al., 2009; Miguel-Berges et al., 2017; Watanabe et al., 2016), this has not yet been examined in the United States. These gaps limit understanding of age-related patterns in health behavior clustering.

Lifestyle behaviors have complex cumulative effects on obesity and chronic disease development (Ford et al., 2012a; Ford et al., 2009; Gubbels et al., 2013; Loprinzi et al., 2016), and prevention approaches that address multiple behaviors may maximize reach and cost-effectiveness (Prochaska et al., 2008). An improved understanding of health behavior clustering, and the segments of the population for whom clustering is most common, may help in developing targeted interventions to improve health behaviors and downstream health outcomes. The primary objective of this study was to provide a population-level understanding of the extent to which five unhealthy lifestyle behaviors (excessive screen time, poor diet quality, low physical activity, excessive fast food consumption, and smoking) cluster from early childhood to late adolescence (2–5, 6–11, 12–15, and 16–19 years) using a recent nationally representative sample of U.S. children and adolescents. The secondary objective was to identify sociodemographic characteristics associated with unhealthy behavior clustering by age group.

Section snippets

Study population

Data from the 2011/2012, 2013/2014, and 2015/2016 waves of the continuous National Health and Nutrition Examination Survey (NHANES) were used. NHANES is a nationally representative, cross-sectional survey and health exam that assesses health and nutritional status among non-institutionalized members of the United States population across all ages enrolled using a complex, multistage probability sampling process. Details about NHANES have been published previously (Curtin et al., 2012). NHANES

Results

The study population included a total of 7714 children and adolescents, representing 74,171,795 youth in the U.S. population. Table 2 shows the distribution of sociodemographic characteristics across age groups. Adolescents were more likely to be born outside the U.S. compared to children. Older adolescents were less likely to have health insurance, a usual source of health care, and a married household reference person compared to younger age groups.

Discussion

Existing studies have examined clustering of cardiometabolic risk factor behaviors in youth, but have not examined how patterns differ across age groups from early childhood to late adolescence. In this nationally representative sample of US children and adolescents, unhealthy behaviors were highly prevalent, particularly excessive screen time and poor dietary quality. Unhealthy behaviors also commonly co-occurred, a pattern that increased with age from nearly one-third of young children to

Conclusion

Unhealthy behaviors, particularly excessive screen time and poor diet quality, commonly co-occurred in a nationally representative sample of U.S children and adolescents. While unhealthy behavior clustering increased with age, nearly one-third of 2- to 5-year-old children already exhibited at least two risk factor behaviors. Results suggest interventions should target diet and screen time in combination, and that smoking interventions among adolescents may benefit from targeting other unhealthy

Acknowledgments

Funding for this research was provided by the Possibilities Project at the Children's Hospital of Philadelphia.

Funding

Funding for this project was provided by the Children's Hospital of Philadelphia.

Declaration of competing interest

None.

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