Preventive Medicine 81 (2015) 138141

Contents lists available at ScienceDirect

Preventive Medicine
journal homepage: www.elsevier.com/locate/ypmed

Brief Original Report

Gender-specic relationships between socioeconomic disadvantage and

obesity in elementary school students
Whitney E. Zahnd a,, Valerie Rogers b, Tracey Smith c, Susan J. Ryherd a, Albert Botchway a, David E. Steward d
a

Center for Clinical Research, Southern Illinois University School of Medicine, 201 E. Madison, Springeld, IL 62794-9664, United States
Springeld Public Schools-District 186, 900 W. Edwards, Springeld, IL 62704, United States
Department of Family and Community Medicine, Southern Illinois University School of Medicine, 913 N. Rutledge, Springeld, IL 62794-9671, United States
d
Ofce of Community Health and Service, Southern Illinois University School of Medicine, 201 E. Madison, Springeld, IL 62794-9604, United States
b
c

a r t i c l e

i n f o

Available online 5 September 2015

Keywords:
Pediatric obesity
Poverty
Schools

a b s t r a c t
Objective. To assess the gender-specic effect of socioeconomic disadvantage on obesity in elementary school
students.
Methods. We evaluated body mass index (BMI) data from 2,648 rst- and fourth-grade students (1,377 male
and 1,271 female students) in eight elementary schools in Springeld, Illinois, between 2012 and 2014. Other
factors considered in analysis were grade level, year of data collection, school, race/ethnicity, gender, and
socioeconomic disadvantage (SD). Students were considered SD if they were eligible for free/reduced price
lunch, a school-based poverty measure. We performed Fisher's exact test or chi-square analysis to assess
differences in gender and obesity prevalence by the other factors and gender-stratied logistic regression
analysis to determine if SD contributed to increased odds of obesity.
Results. A higher proportion of SD female students (20.8%) were obese compared to their non-SD peers
(15.2%) (p = 0.01). Unadjusted and adjusted logistic regression analysis indicated no difference in obesity in
SD and non-SD male students. However, in both unadjusted and adjusted analyses, SD female students had
higher odds of obesity than their peers. Even after controlling for grade level, school, year of data collection,
and race/ethnicity, SD female students had 49% higher odds of obesity than their non-SD classmates (odds
ratio:1.49; 95% condence interval: 1.092.04).
Conclusions. Obesity was elevated in SD female students, even after controlling for factors such as race/
ethnicity, but such an association was not seen in male students. Further study is warranted to determine the
cause of this disparity, and interventions should be developed to target SD female students.
2015 Elsevier Inc. All rights reserved.

Introduction
Obesity prevalence among American children is now at 17%, more
than triple the rate of a generation ago (Ogden et al., 2014). Rates of
obesity in Illinois children are particularly high, ranking in the top
quartile of states for obesity in low-income preschoolers and adolescents (Trust for America's Health & Robert Wood Johnson Foundation).
Obesity in children and adolescents is dened as 95th percentile of
Center for Disease Control and Prevention (CDC) 2000 growth rate
charts. The BMI-for-age percentile growth categories and related
percentiles are the most commonly used metric for childhood size and
growth patterns (Barlow & the Expert Committee, 2007). Obese children are more likely to remain obese into adolescence and adulthood
and have a heightened risk of chronic conditions, such as cardiovascular

Corresponding author at: 201 E. Madison Room 235, PO Box 19664, Springeld, IL
62794-9664, United States.
E-mail address: wzahnd@siumed.edu (W.E. Zahnd).

http://dx.doi.org/10.1016/j.ypmed.2015.08.021
0091-7435/ 2015 Elsevier Inc. All rights reserved.

disease, diabetes, and cancer (The Surgeon General's Vision for a Healthy
& Fit Nation).
Many studies have indicated that racial, ethnic, socioeconomic status
(SES), and gender factors can individually contribute to an increased
likelihood of obesity in children (Ogden et al., 2014; Singh et al.,
2010a). Although some U.S. subgroups show improved childhood obesity trends, minority and low SES populations continue to struggle
with obesity disparities. Overweight and obesity rates tend to be higher
for minority children across SES parameters (Shih et al., 2013). Studies
have shown that Hispanic and African American children were more
likely to be obese than their white or Asian peers (Rossen, 2014; Singh
et al., 2010a). Other recent studies have found obesity disparities
among African American girls specically. Wang et al. reported that
severe obesity occurrence increased among U.S. youth, with higher
prevalence among non-Hispanic black girls and Hispanic boys (Wang
et al., 2011). Wang also found that non-Hispanic black girls aged 12
19 years showed the highest prevalence of severe obesity. Furthermore,
children from low-income and/or low education households or who live
in neighborhoods with high economic deprivation had an increased risk

W.E. Zahnd et al. / Preventive Medicine 81 (2015) 138141

of obesity compared to children from higher income households or

neighborhoods (Shih et al., 2013; Singh et al., 2010b). The children of
parents with only a high school diploma compared to those with a
college degree, as well as children living in poverty compared to
children in families with incomes N 400% of the poverty level, showed
higher odds of being obese or overweight. (Singh et al., 2010b)
However, the combined relationship of obesity with gender and SES
is complex and less well-understood. While the literature describing the
association between lower socioeconomic status, race/ethnicity, and
obesity is extensive, there is a relative dearth in the literature exploring
these associations stratied by gender. Evidence of association between
gender, race/ethnicity, and SES could point to potential school-based
and public health interventions to signicantly reduce existing U.S.
childhood obesity disparities. Studies examining gender-stratied
effects of poverty on obesity have been performed primarily in young
children (aged 25 years) and adolescents or have studied the
effect of childhood poverty on adult obesity (Clarke et al., 2009;
Gordon-Lausen et al., 2003; Hernandez & Pressler, 2014; Suglia et al.,
2013). A study by Suglia and colleagues found that cumulative social
risks, such as poverty-related factors (e.g. housing and food insecurity),
in girls under the age of ve increased their obesity risk (Suglia et al.,
2013). Gordon-Larsen and colleagues reported disparities in obesity,
race, and SES combined, but the only clear association was found
between low SES and obesity in adolescent girls (Gordon-Lausen et al.,
2003). A study by Clarke and colleagues found increased obesity in
adult women associated with childhood poverty (Clarke et al., 2009).
Our study is unique in that it evaluates the gender-specic
association between socioeconomic disadvantage and obesity in
elementary school studentsan understudied population, but a key
population for preventive interventions. The objective of this study
was to examine the association of socioeconomic disadvantage and
obesity in elementary school male and female students in Springeld,
Illinois.
Methods
We performed a cross-sectional, gender-stratied analysis of aggregated
data collected on 2,648 rst- and fourth-grade students from eight schools
in Springeld, Illinois Public School District 186 (SPS) in 2012, 2013 and
2014. These data were collected as part of the efforts of the Springeld
Collaborative for Active Child Health, an academic-community partnership
comprised of SPS, the Springeld Urban League, the Illinois Department of
Public Health, the Southern Illinois University School of Medicine and
other informal community partners. The collaborative is active in eight of
SPS's elementary schools. Its aim is to prevent and reduce childhood obesity
and promote physical activity and proper nutrition through collaboration,
education, and evaluation.
School nurses performed height and weight measurements during the fall of
each respective year. Body mass index (BMI) was calculated using child height,
weight, gender, and age at date of measurement. CDC criterion was used to dene obese as a gender-specic, BMI-for-age percentile greater than or equal to
the 95th percentile based upon the 2000 CDC growth charts (Barlow & the
Expert Committee, 2007). Socioeconomic disadvantage (SD) was determined
by eligibility for free or reduced rate lunch, a measure of poverty previously
used in research exploring the association between socioeconomic status and
obesity (Li & Hooker, 2010). Eligibility for free or reduced rate lunch is based
upon a student's family's income. Students whose family income is 130% of
the poverty level are eligible for free lunch, and students whose family income
is between 130% and 185% of the poverty level are eligible for the reduced
lunch rate (United States Department of Agriculture). Other factors included
in our study analysis were school, gender, grade level, year of data collection,
and race/ethnicity. SPS students' race/ethnicity was categorized as white,
African American, Hispanic, Asian, American Indian, Native Hawaiian, or
multi-racial. There were few students in the Asian, American Indian, and Native
Hawaiian groups. We collapsed those race/ethnicity groups into one group:
other race/ethnicity. Therefore, in our analysis, there were ve race/ethnicity
categories: white, African American, Hispanic, Multi-Racial, and other.
Our study was approved by our institutional review board (IRB), the
Springeld Committee on Research Involving Human Subjects.

139

Statistical analyses
We performed Fisher's exact test or chi-square test of independence to
assess differences in gender and obesity proportions by school, year of data
collection, grade, SD, and race/ethnicity.
We tested a multilevel model to account for clustering effects due to having
students clustered in schools. The resulting likelihood ratio test indicated that
the random effect was non-signicant, and the intraclass correlation value was
very low (b 0.01), indicating that multilevel models were not necessary to test
our data (Hayes, 2006). We ultimately performed gender-stratied unadjusted
and adjusted logistic regression to assess the effect of SD on obesity. Analyses
were performed in SPSS 22 (IBM Corporation). Adjusted models controlled for
school, year of data collection, grade level, and race/ethnicity.

Results
There were no differences in the year of data collection, socioeconomic status, or race/ethnicity by gender (Table 1). However, the
proportion of male and female students differed by grade (p = 0.02).
The prevalence of obesity signicantly varied by school, grade level,
and socioeconomic status, but not by year of data collection or race.
Obesity prevalence differed by grade, as 16.3% of rst-grade students
and 20.3% of fourth-grade students were obese (p = 0.01) (Table 1).
A higher proportion of SD students (19.6%) were obese compared to
non-SD students (16.0%) (p = 0.02). There was no difference in obesity
prevalence between SD and non-SD male students (18.4% and 16.7%,
respectively; p = 0.46). However, obesity was more prevalent in SD
female students compared to their non-SD peers (20.8% and 15.2%,
respectively; p = 0.01).
Unadjusted logistic regression indicated no difference in non-SD
male students compared to SD male students (Table 2). This remained
after controlling for school, year of data collection, grade level, and
race/ethnicity. In female students, unadjusted logistic regression
yielded increased odds of obesity in SD female students (odds ratio
[OR] = 1.47; 95% condence interval [CI] = 1.092.00). This association
remained after controlling for year of data collection, school, grade level,
and race/ethnicity (OR = 1.49; 95% CI = 1.092.04).
Discussion
We analyzed BMI data from 2,648 1st- and 4th-grade students over a
3-year time period. These analyses indicated gender difference by
grade, but not by any other factors. Obesity prevalence differed by
school and by socioeconomic status, as a higher percentage of SD
students were obese compared to non-SD students overall and among
female students specically. Logistic regression analysis indicated that
there were no differences in likelihood of obesity in SD and non-SD
male students, even after controlling for relevant factors. However,
analysis of female students indicated that SD female students had a
higher chance of being obese compared to their non-SD peers. The
increased likelihood of obesity was maintained in adjusted analysis.
After controlling for race/ethnicity, grade level, year of data collection,
and school, female students who were socioeconomically disadvantaged had 49% higher odds of being obese compared to their non-SD
peers.
Our ndings corroborate other studies suggesting a gender-specic
link between lower socioeconomic status and obesity. Using data from
the nationally representative 2007 National Survey of Children's Health,
a study by Singh and colleagues, found that adolescent girls who lived in
neighborhoods with poorer socioeconomic conditions were two to four
times more likely to be overweight or obese than girls from wealthier
neighborhoods (Singh et al., 2010a). Another study by Suglia and colleagues used data from the Fragile Families and Child Wellbeing
Study, a study that surveyed families of preschool children in twenty
U.S. cities, and found that there was a greater risk of obesity in ve
year old girls with greater cumulative social risks (Suglia et al., 2013).
Suglia suggests that unmeasured factors associated with social stress

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W.E. Zahnd et al. / Preventive Medicine 81 (2015) 138141

Table 1
Student demographics by gender and obesity status of elementary school students in Springeld, Illinois, 20122014.
All students
(n = 2,648)
Schoola
A
B
C
D
E
F
G
H
Year of data collectiona
2012
2013
2014
Gradeb,c
1st grade
4th grade
Socioeconomic status
SD
Non-SD
Race/Ethnicitya
White
African American
Hispanic
Multi-Racial
Other

Male students
(n = 1,378)

Female students
(n = 1,271)

313 (11.8%)
288 (10.9%)
256 (9.7%)
325 (12.3%)
442 (16.7%)
241 (9.1%)
456 (17.2%)
327 (12.3%)

173 (55.3%)
151 (52.4%)
127 (49.6%)
157 (48.3%)
249 (56.3%)
111 (46.1%)
244 (53.5%)
165 (50.5%)

140 (44.7%)
137 (47.6%)
129 (50.4%)
168 (51.7%)
193 (43.7%)
130 (53.9%)
212 (46.5%)
162 (49.5%)

902 (34.1%)
780 (29.5%)
966 (36.5%)

459 (50.9%)
417 (53.5%)
501 (51.9%)

443 (49.1%)
363 (46.5%)
465 (48.1%)

1328 (50.2%)
1318 (49.8%)

662 (49.8%)
714 (54.2%)

666 (50.2%)
604 (45.8%)

1703 (64.3%)
945 (35.7%)

887 (64.4%)
490 (35.6%)

816 (64.2%)
455 (35.8%)

1291 (48.8%)
917 (34.6%)
193 (7.3%)
177 (6.7%)
70 (2.6%)

672 (52.1%)
489 (53.3%)
91 (47.2%)
86 (48.6%)
39 (55.7%)

619 (47.9%)
428 (46.7%)
102 (52.8%)
91 (51.4%)
31 (44.3%)

P-value

Obese students
(n = 484)

Non-obese students
(n = 2,162)

0.13

P-value
0.008

69 (22.0%)
33 (11.5%)
47 (18.4%)
60 (18.5%)
86 (19.5%)
54 (22.4%)
69 (15.1%)
66 (20.2%)

244 (78.0%)
33 (88.5%)
209 (81.6%)
265 (81.5%)
356 (80.5%)
187 (77.6%)
387 (84.9%)
261 (79.8%)

145 (16.1%)
145 (18.6%)
194 (20.1%)

757 (83.9%)
635 (81.4%)
772 (79.9%)

217 (16.3%)
267 (20.3%)

1111 (83.7%)
1051 (79.7%)

333 (19.6%)
151 (16.0%)

1370 (81.7%)
794 (84.0%)

215 (16.7%)
180 (19.6%)
37 (19.2%)
40 (22.6%)
12 (17.1%)

1076 (83.3%)
737 (80.4%)
156 (80.8%)
137 (77.4%)
58 (82.9%)

0.57

0.08

0.03

0.01

0.94

0.02

0.45

0.22

SD = socioeconomic disadvantage
a
Chi-square test for independence.
b
Fisher's exact test.
c
3 students were missing on grade level.

may contribute to the increased risk of obesity in girls. The risk of

obesity in socioeconomically disadvantaged females extends beyond
childhood into adulthood. An analysis of the National Longitudinal
Study of Youth found that cumulative poverty in childhood increased
the risk of overweight and obesity in young adult women of all races
and ethnicities (Hernandez & Pressler, 2014). These authors suggest
that the increased risk was due to gender-specic behavioral and
physiological factors that occur with long-term social stresses. With
the growing evidence of association between poverty and obesity in
females, further research is needed to elucidate the sociological, behavioral, and physiological causes of increased risk of obesity in girls and
women of low socioeconomic status.
Our results were unique in that obesity was elevated in SD girls, even
after controlling for race/ethnicity. Previous studies have found elevated
levels of obesity in Hispanic and African American girls (Rossen, 2014;
Singh et al., 2010a). Our ndings, however, suggest that socioeconomic
factors play a larger role than race/ethnicity in girls and thus may be an

Table 2
Obesity odds in socioeconomically disadvantaged vs. non-socioeconomically disadvantaged elementary school students in Springeld, Illinois, 20122014.

Male
Socioeconomic disadvantage
School
Grade
Year of data collection
Race/ethnicity
Female
Socioeconomic disadvantage
School
Grade
Year of data collection
Race/ethnicity
Unadjusted analysis.

Unadjusted odds ratio

(95% condence interval)

Adjusted odds ratio

(95% condence interval)

1.12 (0.881.42)

1.10 (0.821.48)
1.01 (0.951.07)
1.10 (1.001.21)
1.05 (0.891.24)
1.19 (1.051.36)

1.47 (1.092.00)

1.49 (1.092.04)
1.02 (0.961.08)
1.10 (1.001.20)
1.21 (1.021.44)
0.96 (0.831.10)

appropriate factor for consideration in targeted interventions (Singh

et al., 2010a). A review of school-based obesity interventions indicated
gender-specic interventions may be most effective (Kropski et al.,
2008). Other research suggests targeting interventions specically at
low-income students (Kumanyika & Grier, 2006). However, our ndings
indicate the potential utility of considering both gender and socioeconomic status when developing and testing obesity prevention interventions in school-aged children.

Limitations and strengths

There were some limitations to our study. Specically, we were not
able to account for additional social risk factors for childhood obesity,
such as parent education levels and single parent households, and we
were not able to consider neighborhood contextual factors that may
play a role in obesity prevalence, such as access to parks and other
recreation facilities. Additionally, we utilized a convenience sample of
students who were assessed as part of our collaborative's evaluation.
Thus, our results may not be representative of students in the same
grades at other schools in our district, state or nation.
However, there were strengths to our study. First, we used a
student-specic socioeconomic indicatoreligibility for free/reduced
rate school lunchwhich categorizes students individually in the
context of poverty level. Other studies that evaluated the relationship
between socioeconomic factors and childhood obesity often used
neighborhood level socioeconomic measures as a proxy measure for
individual-level socioeconomic status. An additional strength of our
study was our use of height and weight measures conducted by trained
school nurses using standardized techniques to determine BMI, which is
a more reliable method than self-report or parental report. Also, we
assessed data from elementary school-aged students whereas most
other studies examined students in preschool or adolescence. The agegroup we examined may be the most appropriate for interventions, as
elementary schools provide cost-effective infrastructure for childhood
obesity interventions and students spend 68 hours a day at school
(Budd & Volpe, 2006; Wang et al., 2003).

W.E. Zahnd et al. / Preventive Medicine 81 (2015) 138141

Conclusions
Our study found that, even after controlling for factors such as race/
ethnicity, obesity prevalence was elevated in SD female elementary
school students compared to their non-SD classmates. This association
was not seen in male students. This suggests that interventions targeted
at SD female students could be helpful to prevent and reduce childhood
obesity. Future research should be initiated to help determine the
causes of increased obesity in SD girls.
Conict of interest
The authors declare that there are no conicts of interest.
Acknowledgments
This study was funded, in part, by Healthy Kids, Healthy Families
funding from Blue Cross Blue Shield of Illinois. The authors wish to
thank Melissa Cleer and Donna Treadwell for their contributions as
project coordinators for the Springeld Collaborative for Active Child
Health and to all partner organizations involved in the work of the
Collaborative. The authors also wish to acknowledge Steve Scaife for
his assistance in data management and Dr. Steve Verhulst and Georgia
Mueller-Luckey for their statistical guidance.
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