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Obesity, Abdominal Obesity, Physical Activity, and Caloric Intake in U.S. Adults:1988-2010

Uri Ladabaum, M.D., M.S. Ajitha Mannalithara, Ph.D. Parvathi A. Myer, M.D., M.H.S.Gurkirpal Singh, M.D.

PII: S0002-9343(14)00191-0

DOI: 10.1016/j.amjmed.2014.02.026

Reference: AJM 12419

To appear in: The American Journal of Medicine

Received Date: 13 February 2014

Revised Date: 20 February 2014

Accepted Date: 20 February 2014

Please cite this article as: Ladabaum U, Mannalithara A, Myer PA, Singh G, Obesity, AbdominalObesity, Physical Activity, and Caloric Intake in U.S. Adults: 1988-2010, The American Journal ofMedicine (2014), doi: 10.1016/j.amjmed.2014.02.026.

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http://dx.doi.org/10.1016/j.amjmed.2014.02.026

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OBESITY, ABDOMINAL OBESITY, PHYSICAL ACTIVITY, AND CALORIC INTAKE

IN U.S. ADULTS: 1988-2010

Uri Ladabaum, M.D., M.S.,1,2 Ajitha Mannalithara, Ph.D.,1,2 Parvathi A. Myer, M.D., M.H.S.,1,2

Gurkirpal Singh, M.D.,1,2

1Division of Gastroenterology and Hepatology, 2Department of Medicine,

Stanford University School of Medicine, Stanford, CA

Short Title: Trends in obesity, physical activity and caloric intake

Grant Support: NIH T32 Training Grant T32DK007056 Awarded to Dr. Parvathi A. Myer Correspondence: Uri Ladabaum, M.D., M.S. Division of Gastroenterology and Hepatology Stanford University School of Medicine 300 Pasteur Drive, M211

Stanford, CA 94305 e-mail: [email protected]

Disclosures: None. No conflicts of interest exist. Author Contributions: Conception and design: UL, AM, PM, GS; Acquisition of data: AM, GS; Analysis and interpretation of Data: UL, AM, GS; Drafting of manuscript: UL, PM, GS; Critical revision of manuscript for important intellectual content: UL, AM, PM, GS; Statistical analysis: UL, AM, GS; Obtained funding: UL; Study supervision: UL, GS.

Word count: 2,997

Key words: body-mass index, waist circumference, weight, diet, exercise, adiposity, calories, obesity, abdominal obesity, physical activity

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CLINICAL SIGNIFICANCE

• Average body-mass index (BMI) and waist circumference, obesity and abdominal obesity

prevalence, and the population fraction reporting no leisure-time physical activity increased

substantially in U.S. adults from 1998-2010. BMI and waist circumference trends were

associated with physical activity level, but not daily caloric intake.

• Although U.S. obesity rates may be stabilizing, our results lend support to the emphasis

placed on physical activity in the Institute of Medicine report on obesity.

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ABSTRACT

Background: Obesity and abdominal obesity are independently associated with morbidity and

mortality. Physical activity attenuates these risks. We examined trends in obesity, abdominal

obesity, physical activity, and caloric intake in U.S. adults from 1988 to 2010.

Methods: Univariate and multivariate analyses were performed using National Health and

Nutrition Examination Survey (NHANES) data.

Results: Average body-mass index (BMI) increased by 0.37% (95% 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 to 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.

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INTRODUCTION

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 cardiovascular disease and cancer, and higher

risk of all-cause mortality.1, 2 Overweight, defined as a BMI of 25.0-29.9 kg/m2, has been

associated with an increased risk of death in several studies.2-4 Over two thirds of U.S. adults are

considered obese or overweight.5, 6 The cost of obesity-related illness approximates 20% of

annual U.S. health care spending.1 Life expectancy could decline due to 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 in order

to help guide weight management.12

The causes of obesity are multifactorial, and reflect the balance between energy intake

and expenditure.1, 13 Physical activity is a key component of weight management.12 Of the

IOM’s five recommendations to address the national obesity epidemic, the first is to make

physical activity an integral and routine part of life.1

Our aims were to characterize trends in, and associations between, overweight and

obesity, abdominal obesity, physical activity, and caloric intake in U.S. adults in the last two

decades. We explored trends in the prevalence of abdominal obesity within strata defined by

BMI, given the health risks of increased waist circumference independent of BMI, and we

explored the relationships between measures of obesity and levels of physical activity and caloric

intake.

METHODS

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Data source

We used data from the National Health and Nutrition Examination Survey (NHANES),

beginning with NHANES-III (1988-1994) and including the continuous NHANES 2-year survey

cycles from 1999-2000 to 2009-2010.14 The samples in each cycle were selected using a

stratified, multistage, clustered probability sampling design, described in detail before.15, 16

Study population

All examined participants of age 18 years and older, except pregnant women, were

included. For the caloric intake analyses, only eligible participants who had reliable and

complete 24-hour dietary recall data were included.

Subgroup analyses were performed for subgroups of self-identified race/ethnicity with

sufficiently large samples: non-Hispanic white, non-Hispanic black, and Mexican-American.14

Definition of anthropometric measures

During the examination component of NHANES, height, weight and waist circumference

were measured. Based on BMI, individuals were categorized as normal weight (18.5-24.99

kg/m2), overweight (25.0-29.99 kg/m2), or obese (30 kg/m2 or higher).8 Abdominal obesity was

defined based on a waist circumference of >88 cm for women and >102 cm for men.8, 17

Definition of leisure-time physical activity levels

Participants were grouped into three levels of leisure-time physical activity: ideal,

intermediate, and none. This was accomplished by following the methods and definitions of the

specific NHANES surveys (Appendix).

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Definition of dietary measures

Total caloric intake per day was estimated based on the total energy intake (kcal, or

calories) reported in the first 24-hour recall data set. These data were obtained during the

examination component of NHANES by trained dietary interviewers using an automated dietary

interview system.15, 16

Statistical analyses

Analyses were performed for all adults, and after stratification by gender, predefined age

strata of 18-39, 40-64, and 65 years and older, and race/ethnicity. Data from each cycle were

considered to be from the mid-point of each period.

To examine trends in BMI, waist circumference and daily energy intake, we calculated

national estimates of age-adjusted averages and 95% confidence intervals (CIs) for each survey

cycle. We used linear regression to assess trends in log transformed BMI, waist circumference

and daily energy intake by including the midpoints of each survey cycle as a continuous variable.

In order to address possible changes in BMI trends over time, we used joinpoint analysis

(Appendix).18 The results are expressed as annual percentage change (APC).

To examine trends in the prevalence of obesity, abdominal obesity and the levels of

physical activity, we calculated national estimates of age-adjusted proportions and 95% CIs for

each survey cycle. We assessed changes over time using logistic regression analysis by

including the midpoints of each survey cycle as a continuous variable. We present odds ratios

and 95% CIs reflecting the odds of fulfilling criteria for a specific category in a given year versus

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the previous year. We performed separate analyses to examine trends in abdominal obesity for

overweight and obese adults, defined by BMI.

Analyses stratified by three pre-specified levels of leisure-time physical activity were

performed for trends in the measures of obesity and daily energy intake. To examine the

independent effects of physical activity and daily energy intake, we performed multivariate

regression analysis with log transformed BMI and waist circumference as response variables,

and year, physical activity level, and daily energy intake as explanatory variables, adjusted for

age, age squared and gender. As sensitivity analyses, we first used only the continuous

NHANES data, in which total minutes spent on physical activity can be estimated; and second,

only data from 1999-2000 to 2005-2006, including activity related to transportation and domestic

work, as the physical activity questionnaire was consistent in these cycles (Appendix).

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 U.S. standard population.19

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RESULTS

Body-Mass Index and Obesity

From 1988-1994 to 2009-2010, the average BMI in the U.S. 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

18-39 year-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).

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, 31.0-

38.1%) 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 to 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, Appendix Table 1).

Waist Circumference and Abdominal Obesity

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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 18-39

year-old women (Table 1). Among women, average waist circumference was largest among

non-Hispanic blacks and smallest among non-Hispanic whites; in contrast, among men, it was

largest among non-Hispanic whites and smallest among non-Hispanic blacks (Figure 2, Table 1,

Appendix Table 1).

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). Sex-specific

differences between racial/ethnic groups in abdominal obesity prevalence paralleled the waist

circumference results (Table 1, Appendix Figure 2, Appendix Table 1).

Abdominal Obesity by Body-Mass Index Category

Among adults categorized as normal weight based on 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).

Among adults categorized as overweight based on 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

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2). Compared to 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 U.S. adults categorized as obese based on BMI were also

categorized as having abdominal obesity (Appendix Table 2).

Appendix Table 2 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, 17.3-21.0%) 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. 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 to 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 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). Average daily caloric intake

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increased significantly for women who reported no leisure-time physical activity, and decreased

significantly for men who reported an ideal level of leisure-time physical activity (Table 3).

Body-Mass Index and Obesity by Physical Activity Strata

Average BMI increased in women and men in all three strata of leisure-time physical

activity (Appendix Table 4). Increases in average BMI were observed in nearly all age and

gender subgroups stratified by leisure-time physical activity (Appendix Table 4). The

prevalence of obesity increased in women and men in all three 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 three strata of

leisure-time physical activity (Appendix Table 4). Increases in average waist circumference

were observed in nearly all age and gender subgroups stratified by leisure-time physical activity

(Appendix Table 4). The prevalence of abdominal obesity increased in women and men within

all strata of 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.

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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 leisure-time 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).

Sensitivity analyses showed similar results (Appendix).

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DISCUSSION

Our analyses highlight important dimensions of the public health problem of obesity in

the U.S. Average BMI, average waist circumference, the prevalence of obesity, and the

prevalence of abdominal obesity increased substantially over the past two 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 non-Hispanic black women.

Furthermore, the prevalence of abdominal obesity has increased among normal weight women,

and among 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.

While the overall trends in obesity in the U.S. 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 1999-2010

in males aged 2-19 years, but not in females,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

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Our findings do not support the popular notion that the rise in obesity in the U.S. 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

two 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 1971-1975 through 1999-2002 reported

an increase in food energy density roughly parallel to U.S. 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). Analyses

of the major macronutrients, however, 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 U.S. adults may be

stabilizing.5, 6 Our joinpoint analyses of BMI in women are consistent with these results. While

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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.

Our study has limitations. The NHANES surveys do not follow a cohort of individuals

prospectively, so our reported associations with physical activity must be interpreted with

caution. While 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 under-reported 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

In conclusion, average BMI and waist circumference both increased among U.S. adults

from 1998-2010. Abdominal obesity, an independent predictor of mortality, has become more

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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 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.

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ACKNOWLEDGMENTS

Grant Support: NIH T32 Training Grant T32DK007056 Awarded to Dr. Parvathi A. Myer. The sponsor had no design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication

Disclosures: Uri Ladabaum has served as a consultant for Endosphere. No other

potential conflicts of interest exist. Author Contributions: Conception and design: UL, AM, PM, GS; Acquisition of data: AM, GS; Analysis and interpretation of Data: UL, AM, GS; Drafting of manuscript: UL, PM, GS; Critical revision of manuscript for important intellectual content: UL, AM, PM, GS; Statistical analysis: UL, AM, GS; Obtained funding: UL; Study supervision: UL, GS.

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FIGURE LEGENDS

Figure 1. Trends in average body-mass index (BMI) in U.S. 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.

Figure 2. Trends in average waist circumference in U.S. 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.

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REFERENCES

1. Accelerating Progress in Obesity Prevention: Solving the Weight of the Nation.

Washington, DC: IOM (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(1):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(8):763-78.

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(23):2211-9.

5. Flegal KM, Carroll MD, Ogden CL, Curtin LR. Prevalence and trends in obesity among

US adults, 1999-2008. JAMA. 2010;303(3):235-41.

6. Flegal KM, Carroll MD, Kit BK, Ogden CL. Prevalence of obesity and trends in the

distribution of body mass index among US adults, 1999-2010. JAMA. 2012;307(5):491-7.

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(11):1138-45.

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(20):2105-20.

10. Koster A, Leitzmann MF, Schatzkin A, et al. Waist circumference and mortality. Am J

Epidemiol. 2008;167(12):1465-75.

11. Jacobs EJ, Newton CC, Wang Y, et al. Waist circumference and all-cause mortality in a

large US cohort. Arch Intern Med. 2010;170(15):1293-301.

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(25):2392-404.

MANUSCRIP

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14. Centers for Disease Control and Prevention (CDC). National Center for Health Statistics

(NCHS). National Health and Nutrition Examination Survey Data. Hyattsville, MD. Accessed

April 17, 2013 http://www.cdc.gov/nchs/nhanes/nhanes_questionnaires.htm.

15. National Center for Health Statistics. Analytical and Reporting Guidelines. The Third

National Health and Nutrition Examination Survey, 1988–1994, Hyattsville, MD. 1996.

Accessed April 17, 2013 at http://www.cdc.gov/nchs/data/nhanes/nhanes3/nh3gui.pdf.

16. National Center for Health Statistics. Analytical and Reporting Guidelines. The National

Health and Nutrition Examination Survey (NHANES). Hyattsville, MD. 2005. Accessed April

17, 2013 at

http://www.cdc.gov/nchs/data/nhanes/nhanes_03_04/nhanes_analytic_guidelines_dec_2005.pdf.

17. Lean ME, Han TS, Morrison CE. Waist circumference as a measure for indicating need

for weight management. BMJ. 1995;311(6998):158-61.

18. Kim HJ, Fay MP, Feuer EJ, Midthune DN. Permutation tests for joinpoint regression

with applications to cancer rates. Stat Med. 2000;19(3):335-51.

19. Day, Jennifer Cheeseman, 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, U.S. Government Printing Office, Washington, DC, 1996. Accessed April 17, 2013 at

http://www.census.gov/prod/1/pop/p25-1130/p251130.pdf. .

20. Okosun IS, Chandra KM, Boev A, et al. Abdominal adiposity in U.S. adults: prevalence

and trends, 1960-2000. Prev Med. 2004;39(1):197-206.

21. 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(1):216-24.

22. Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of obesity and trends in body

mass index among US children and adolescents, 1999-2010. JAMA. 2012;307(5):483-90.

23. Casazza K, Fontaine KR, Astrup A, et al. Myths, presumptions, and facts about obesity.

N Engl J Med. 2013;368(5):446-54.

24. 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.

The American journal of clinical nutrition. 2011;93(4):836-43.

25. Ford ES, Dietz WH. Trends in energy intake among adults in the United States: findings

from NHANES. The American journal of clinical nutrition. 2013;97(4):848-53.

MANUSCRIP

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26. 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(15):1821-7.

27. 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(2):145-50.

28. 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(26):2694-703.

29. Hankinson AL, Daviglus ML, Bouchard C, et al. Maintaining a high physical activity

level over 20 years and weight gain. JAMA. 2010;304(23):2603-10.

30. Koster A, Harris TB, Moore SC, et al. Joint associations of adiposity and physical

activity with mortality: the National Institutes of Health-AARP Diet and Health Study. Am J

Epidemiol. 2009;169(11):1344-51.

31. Sui X, LaMonte MJ, Laditka JN, et al. Cardiorespiratory fitness and adiposity as

mortality predictors in older adults. JAMA. 2007;298(21):2507-16.

32. Kant AK, Graubard BI. Secular trends in patterns of self-reported food consumption of

adult Americans: NHANES 1971-1975 to NHANES 1999-2002. The American journal of

clinical nutrition. 2006;84(5):1215-23.

33. Qi Q, Chu AY, Kang JH, et al. Sugar-sweetened beverages and genetic risk of obesity. N

Engl J Med. 2012;367(15):1387-96.

34. Tremaroli V, Backhed F. Functional interactions between the gut microbiota and host

metabolism. Nature. 2012;489(7415):242-9.

35. Yanovski SZ, Yanovski JA. Obesity prevalence in the United States--up, down, or

sideways? N Engl J Med. 2011;364(11):987-9.

36. 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. International journal of

obesity (2005). 2012.

37. 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.

2009;(240):1-159.

38. 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(4):454-61.

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39. Barry CL, Gollust SE, Niederdeppe J. Are Americans ready to solve the weight of the

nation? N Engl J Med. 2012;367(5):389-91.

40. Vital signs: state-specific obesity prevalence among adults --- United States, 2009.

MMWR Morb Mortal Wkly Rep. 2010;59(30):951-5.

41. 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(2):186-92.

42. 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(9):1909-14.

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Table 1. Trends in average body-mass index, waist circumference, and prevalence of obesity and abdominal obesity, U.S. adults,

1988-2010 *

Body mass index and waist circumference Category based on body-mass index Category based on waist circumference

Mean body mass index 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)

Women 18 years and older

1988-1994 26.4 (26.2-26.7) 88.6 (87.9-89.3) 24.9 (23.1-26.8) 25.5 (24.1-26.9) 45.7 (43.7-47.7) 46.0 (43.9-48.0) 2009-2010 28.6 (28.3-28.9) 94.9 (93.9-95.8) 35.4 (33.6-37.3) 27.4 (24.5-30.3) 34.3 (31.9-36.8) 61.5 (58.8-64.2)

Trend APC 0.37 (0.30-0.44) APC 0.37 (0.30-0.43) OR 1.026 (1.019-1.033) OR 1.004 (0.997-1.011) OR 0.976 (0.970-0.983) OR 1.036 (1.029-1.044) 18-39 years

1988-1994 25.2 (24.8-25.6) 83.2 (82.4-84.1) 20.0 (17.6-22.3) 19.4 (17.5-21.3) 55.4 (52.8-58.0) 29.3 (26.0-32.6) 2009-2010 27.8 (27.1-28.4) 91.3 (89.6-93.1) 31.2 (27.9-34.5) 23.4 (18.9-27.8) 42.2 (37.4-47.0) 49.1 (43.6-54.6)


1988-1994 27.6 (27.2-28.1) 92.2 (91.2-93.2) 30.6 (27.7-33.4) 28.5 (26.2-30.7) 38.3 (35.2-41.4) 55.7 (52.8-58.6) 2009-2010 29.1 (28.7-29.6) 96.9 (95.9-97.9) 38.5 (34.8-42.1) 29.4 (26.0-32.8) 29.4 (25.9-32.8) 68.7 (65.3-72.0)

Trend APC 0.26 (0.15-0.36) APC 0.28 (0.20-0.36) OR 1.018 (1.008-1.029) OR 1.000 (0.990-1.009) OR 0.982 (0.972-0.992) OR 1.030 (1.020-1.040) 65 years and older

1988-1994 26.6 (26.3-26.9) 93.2 (92.4-94.1) 23.6 (21.4-25.9) 33.3 (31.2-35.4) 39.6 (36.7-42.4) 63.7 (60.3-67.1) 2009-2010 29.2 (28.5-29.9) 98.5 (97.4-99.7) 38.6 (33.5-43.7) 32.5 (27.7-37.2) 26.9 (23.6-30.3) 74.9 (72.4-77.5)

Trend APC 0.37 (0.27-0.48) APC 0.26 (0.17-0.34) OR 1.029 (1.017-1.041) OR 1.002 (0.992-1.012) OR 0.976 (0.966-0.987) OR 1.028 (1.016-1.041) 18 years and older, non-Hispanic white

1988-1994 26.0 (25.6-26.3) 87.7 (86.8-88.6) 22.5 (20.3-24.8) 24.2 (22.6-25.9) 49.3 (46.8-51.8) 43.2 (40.6-45.9) 2009-2010 28.0 (27.6-28.4) 94.2 (93.0-95.4) 32.2 (29.1-35.3) 26.8 (22.3-31.3) 37.8 (34.6-41.0) 59.0 (55.5-62.5)

Trend APC 0.37 (0.27-0.47) APC 0.38 (0.30-0.46) OR 1.026 (1.016-1.035) OR 1.007 (0.998-1.016) OR 0.975 (0.967-0.984) OR 1.037 (1.027-1.047) 18 years and older, non-Hispanic black

1988-1994 28.9 (28.5-29.3) 93.6 (92.7-94.5) 37.4 (34.7-40.0) 29.3 (27.5-31.1) 30.4 (28.0-32.8) 60.2 (57.6-62.8) 2009-2010 32.2 (31.3-33.1) 100.5 (98.3-102.7) 57.3 (51.8-62.8) 23.4 (20.2-26.6) 17.1 (13.7-20.5) 75.9 (69.9-81.9)

Trend APC 0.51 (0.37-0.64) APC 0.38 (0.28-0.48) OR 1.039 (1.028-1.050) OR 0.987 (0.979-0.996) OR 0.963 (0.952-0.974) OR 1.038 (1.025-1.052) 18 years and older, Mexican-American

1988-1994 28.2 (27.9-28.6) 92.4 (91.7-93.2) 34.1 (31.4-36.8) 33.1 (30.9-35.3) 31.3 (28.5-34.0) 60.7 (58.5-62.9) 2009-2010 29.8 (29.3-30.2) 97.4 (96.1-98.7) 43.8 (40.4-47.1) 34.0 (30.4-37.7) 21.5 (18.6-24.3) 74.1 (69.9-78.3)

Trend APC 0.32 (0.21-0.44) APC 0.38 (0.28-0.47) OR 1.027 (1.014-1.040) OR 1.000 (0.989-1.010) OR 0.973 (0.961-0.985) OR 1.043 (1.029-1.057) Men

18 years and older 1988-1994 26.6 (26.4-26.8) 95.6 (95.1-96.0) 19.9 (18.4-21.3) 39.7 (38.1-41.3) 39.1 (37.1-41.2) 29.1 (27.4-30.7) 2009-2010 28.6 (28.2-29.0) 100.4 (99.3-101.5) 34.6 (31.0-38.1) 38.1 (35.9-40.3) 26.3 (22.6-29.9) 42.0 (38.6-45.3)


1988-1994 25.7 (25.4-26.0) 90.1 (89.4-90.8) 14.5 (12.8-16.2) 34.4 (31.7-37.1) 49.4 (46.8-51.9) 14.3 (12.6-16.1) 2009-2010 27.9 (27.3-28.5) 95.4 (94.0-96.8) 31.8 (26.5-37.2) 33.4 (30.3-36.5) 33.5 (28.3-38.8) 29.2 (25.1-33.3)


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1988-1994 27.5 (27.2-27.8) 99.1 (98.5-99.8) 25.1 (23.0-27.3) 43.3 (40.5-46.1) 30.8 (27.6-34.0) 37.5 (34.4-40.6) 2009-2010 29.3 (28.7-29.8) 103.3 (101.8-104.8) 36.8 (32.8-40.8) 42.8 (38.4-47.2) 19.5 (15.1-24.0) 47.8 (43.2-52.4)

Trend APC 0.33 (0.23-0.43) APC 0.23 (0.16-0.31) OR 1.032 (1.021-1.043) OR 0.998 (0.989-1.008) OR 0.964 (0.951-0.977) OR 1.029 (1.017-1.041) 65 years and older

1988-1994 26.6 (26.3-26.9) 100.5 (99.7-101.3) 20.3 (17.2-23.4) 44.0 (40.6-47.5) 33.8 (30.4-37.3) 45.3 (41.9-48.7) 2009-2010 28.7 (28.2-29.1) 105.7 (104.5-106.9) 36.0 (31.0-41.0) 38.3 (33.1-43.4) 24.6 (19.8-29.3) 59.4 (54.4-64.4)


1988-1994 26.6 (26.4-26.9) 96.3 (95.9-96.8) 20.0 (18.2-21.8) 40.3 (38.3-42.4) 38.4 (36.0-40.8) 30.2 (28.4-31.9) 2009-2010 28.6 (28.1-29.1) 101.3 (100.0-102.6) 35.2 (30.7-39.8) 37.7 (35.1-40.3) 26.1 (21.5-30.7) 44.4 (40.3-48.5)


1988-1994 26.5 (26.2-26.7) 92.4 (91.8-93.0) 20.6 (18.6-22.6) 36.2 (34.1-38.3) 40.9 (38.7-43.2) 23.1 (21.2-25.0) 2009-2010 29.2 (28.5-29.9) 98.4 (97.0-99.8) 38.0 (33.2-42.7) 30.3 (25.9-34.6) 30.3 (27.6-33.0) 37.9 (33.7-42.1)


1988-1994 27.2 (26.9-27.4) 95.6 (94.9-96.2) 23.3 (21.4-25.2) 43.6 (41.0-46.2) 32.1 (29.8-34.3) 29.1 (26.7-31.4) 2009-2010 29.0 (28.2-29.7) 100.2 (98.4-101.9) 34.8 (29.5-40.1) 46.3 (42.2-50.3) 18.6 (14.1-23.2) 41.6 (35.9-47.4)

Trend APC 0.41 (0.28-0.55) APC 0.32 (0.22-0.43) OR 1.038 (1.021-1.056) OR 1.007 (0.997-1.018) OR 0.957 (0.943-0.972) OR 1.038 (1.019-1.056)

APC = annual percentage change; OR = odds ratio for being in given category compared to previous year * Appendix Table 1 shows results by age/ethnicity

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Table 2. Trends in reported levels of leisure-time physical activity and daily caloric intake, U.S. adults, 1988-2010 *

Reported leisure-time physical activity Mean energy intake in kcal/day(95% CI) None,

% of population (95% CI) Intermediate level,

% of population (95% CI) Ideal level,

% of population(95% CI) Women 18 years and older

1988-1994 19.1 (17.3-21.0) 45.0 (43.1-46.9) 35.9 (33.2-38.5) 1761 (1735-1788) 2009-2010 51.7 (48.9-54.5) 18.6 (17.3-19.8) 29.8 (27.7-31.9) 1781 (1749-1812)

Trend OR 1.074 (1.064-1.084) OR 0.939 (0.933-0.944) OR 0.990 (0.981-0.999) APC 0.07 (-0.06-0.20) 18-39 years

1988-1994 14.0 (11.9-16.1) 50.0 (46.6-53.4) 36.0 (32.9-39.1) 1941 (1889-1992) 2009-2010 47.5 (43.4-51.5) 20.4 (17.7-23.1) 32.1 (29.1-35.2) 1873 (1820-1926)

Trend OR 1.078 (1.066-1.090) OR 0.932 (0.923-0.941) OR 1.002 (0.993-1.012) APC -0.20 (-0.38--0.02) 40-64 years

1988-1994 19.2 (16.7-21.7) 46.0 (43.6-48.3) 34.9 (31.4-38.4) 1697 (1666-1727) 2009-2010 49.9 (47.0-52.7) 19.4 (17.4-21.4) 30.7 (28.4-33.0) 1771 (1705-1837)

Trend OR 1.072 (1.059-1.086) OR 0.938 (0.930-0.947) OR 0.990 (0.978-1.002) APC 0.23 (0.01-0.45) 65 years and older

1988-1994 31.8 (28.4-35.2) 30.3 (27.7-32.8) 38.0 (34.0-41.9) 1474 (1446-1503) 2009-2010 66.3 (60.9-71.7) 12.1 (8.7-15.5) 21.7 (16.7-26.7) 1578 (1508-1647)

Trend OR 1.071 (1.056-1.087) OR 0.956 (0.946-0.967) OR 0.956 (0.941-0.972) APC 0.37 (0.17-0.57) 18 years and older, non-Hispanic white

1988-1994 15.6 (13.7-17.4) 46.7 (44.5-49.0) 37.7 (34.6-40.8) 1771 (1740-1802) 2009-2010 46.1 (41.1-51.0) 20.0 (18.0-22.1) 33.9 (30.3-37.5) 1791 (1754-1828)

Trend OR 1.077 (1.062-1.092) OR 0.939 (0.932-0.946) OR 0.994 (0.982-1.006) APC 0.09 (-0.06-0.24) 18 years and older, non-Hispanic black

1988-1994 30.5 (27.4-33.5) 41.3 (39.1-43.5) 28.3 (25.5-31.0) 1729 (1696-1763) 2009-2010 66.2 (62.5-69.8) 17.1 (15.3-18.9) 16.8 (13.2-20.3) 1787 (1697-1877)

Trend OR 1.064 (1.052-1.076) OR 0.943 (0.935-0.952) OR 0.982 (0.971-0.993) APC 0.16 (-0.08-0.40) 18 years and older, Mexican-American

1988-1994 33.2 (30.9-35.5) 41.0 (38.5-43.4) 25.8 (22.4-29.2) 1698 (1656-1741) 2009-2010 66.5 (61.6-71.3) 12.1 (9.5-14.7) 21.4 (17.1-25.7) 1732 (1633-1832)

Trend OR 1.069 (1.054-1.085) OR 0.928 (0.915-0.942) OR 0.991 (0.975-1.006) APC 0.06 (-0.27-0.40) Men

18 years and older 1988-1994 11.4 (10.0-12.8) 43.5 (41.7-45.3) 45.0 (42.8-47.2) 2616 (2569-2663) 2009-2010 43.5 (40.7-46.3) 14.8 (12.8-16.8) 41.7 (38.1-45.3) 2511 (2443-2578)


1988-1994 8.9 (7.1-10.6) 44.0 (41.0-47.1) 47.1 (44.0-50.2) 2973 (2900-3046) 2009-2010 34.1 (28.6-39.5) 14.3 (11.6-17.0) 51.6 (45.6-57.5) 2678 (2583-2772)


1988-1994 11.2 (9.3-13.2) 46.5 (43.3-49.7) 42.2 (39.2-45.3) 2516 (2444-2587) 2009-2010 47.9 (45.3-50.4) 16.2 (13.3-19.1) 35.9 (32.6-39.3) 2561 (2466-2656)

Trend OR 1.100 (1.084-1.116) OR 0.928 (0.917-0.939) OR 0.981 (0.970-0.991) APC 0.16 (-0.06-0.37)

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65 years and older 1988-1994 18.3 (15.8-20.8) 35.1 (32.6-37.6) 46.6 (43.3-50.0) 1977 (1927-2027) 2009-2010 56.1 (52.0-60.2) 12.7 (10.1-15.2) 31.3 (27.6-35.0) 1978 (1905-2050)

Trend OR 1.087 (1.073-1.100) OR 0.942 (0.932-0.953) OR 0.964 (0.954-0.974) APC -0.01 (-0.24-0.23) 18 years and older, non-Hispanic white

1988-1994 9.6 (8.1-11.0) 45.0 (42.6-47.4) 45.4 (42.8-48.0) 2667 (2616-2718) 2009-2010 39.3 (35.6-43.1) 16.3 (13.2-19.3) 44.4 (39.0-49.9) 2569 (2485-2654)

Trend OR 1.089 (1.072-1.105) OR 0.933 (0.925-0.942) OR 0.994 (0.983-1.004) APC -0.09 (-0.26-0.07) 18 years and older, non-Hispanic black

1988-1994 15.9 (13.4-18.4) 38.3 (36.0-40.7) 45.8 (42.8-48.7) 2455 (2388-2521) 2009-2010 51.6 (47.2-55.9) 8.8 (4.8-12.7) 39.7 (35.8-43.5) 2442 (2284-2600)


1988-1994 23.6 (20.1-27.1) 40.7 (37.7-43.6) 35.8 (33.4-38.1) 2468 (2411-2526) 2009-2010 58.2 (50.8-65.7) 12.1 (7.6-16.6) 29.7 (25.5-33.9) 2411 (2323-2499)

Trend OR 1.061 (1.044-1.079) OR 0.917 (0.902-0.933) OR 1.003 (0.990-1.017) APC -0.13 (-0.41-0.15)

APC = annual percentage change; OR = odds ratio for being in given category compared to previous year * Appendix Table 3 shows results by age/ethnicity

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Table 3. Trends in prevalence of obesity, abdominal obesity and daily caloric intake stratified by reported level of leisure-time physical activity, U.S. adults, 1988-2010.

Category based on body-mass index, Odds ratio (95% CI) of being in category in any given year compared

to previous year

Category based on waist circumference,

Odds ratio (95% CI) of being in category in any given year compared to previous year

Mean energy intake, Annual percentage change (95% CI)

Obese Overweight Normal weight Abdominal obesity

Women

No reported leisure-time physical activity

1.020 (1.010-1.030) 0.997 (0.985-1.009) 0.987 (0.978-0.995) 1.026 (1.015-1.038) 0.27 (0.02-0.52)

Intermediate level of reported leisure-time

physical activity

1.029 (1.018-1.040) 1.003 (0.993-1.014) 0.974 (0.963-0.985) 1.037 (1.027-1.048) 0.09 (-0.11-0.28)

Ideal level of reported leisure-time physical

activity

1.020 (1.008-1.032) 1.013 (1.002-1.025) 0.977 (0.966-0.989) 1.037 (1.025-1.048) 0.08 (-0.13-0.30)

Men


1.053 (1.037-1.070) 1.003 (0.991-1.016) 0.947 (0.933-0.962) 1.048 (1.032-1.065) 0.19 (-0.14-0.53)

Intermediate level of reported leisure-time

physical activity

1.029 (1.016-1.041) 1.004 (0.993-1.014) 0.971 (0.959-0.983) 1.029 (1.018-1.039) -0.13 (-0.34-0.09)

Ideal level of reported leisure-time physical

activity

1.045 (1.030-1.060) 1.000 (0.992-1.008) 0.967 (0.955-0.978) 1.036 (1.024-1.048) -0.22 (-0.40--0.04)

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APPENDIX

OBESITY, ABDOMINAL OBESITY, PHYSICAL ACTIVITY, AND CALORIC INTAKE IN U.S. ADULTS:

1988-2010

Uri Ladabaum, M.D., M.S.,1,2 Ajitha Mannalithara, Ph.D.,1,2 Parvathi A. Myer, M.D., M.H.S.,1,2

Gurkirpal Singh, M.D.,1,2

1Division of Gastroenterology and Hepatology, 2Department of Medicine,

Stanford University School of Medicine, Stanford, CA

Page 2: Definition of Leisure-Time Physical Activity Levels

Page 3: Trends in Body-Mass Index: Joinpoint Analyses

Pages 3-5: Sensitivity Analyses: Effect of Physical Activity on Body-Mass Index and Waist

Circumference (Methods and Results)

Pages 6-7: Appendix Table 1: Trends in average body-mass index, waist circumference, and

prevalence of obesity and abdominal obesity, U.S. adults stratified by

race/ethnicity, 1988-2010

Pages 8-9: Appendix Table 2: Annual changes in prevalence of abdominal obesity, stratified

by obesity category based on body-mass index, U.S. adults, 1988-2010

Pages 10-11: Appendix Table 3. Trends in reported levels of leisure-time physical activity and

daily caloric intake, U.S. adults, stratified by race/ethnicity, 1988-2010

Pages 12-13: Appendix Table 4: Annual changes in mean body-mass index, mean waist

circumference and daily caloric intake, stratified by reported level of leisure-time

physical activity, U.S. adults, 1988-2010

Page 14: Appendix Table 5: Relative increase in body-mass index and waist circumference in

“Intermediate” and “No reported” groups compared to “Ideal” reported leisure

time physical activity in U.S. adults, 1988-2010.

Pages 15-16: Appendix Table 6: Annual changes in daily intake of fat, carbohydrate and protein,

stratified by reported level of leisure-time physical activity, U.S. adults, 1988-

2010.

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Page 17: Appendix Figure 1. Trends in prevalence of obesity in U.S. adult women (A) and

men (B), by racial/ethnic group.

Page 18: Appendix Figure 2. Trends in prevalence of abdominal obesity in U.S. adult

women (A) and men (B), by racial/ethnic group.

Page 19: References

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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 MET (metabolic equivalent of task). 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 onwards, 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 for the continuous NHANES waves, as 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 five or more times per week or in

vigorous activities three or more 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 based on the reported

frequency, intensity and duration of activities. An ideal level of physical activity was defined as

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≥150 minutes per week of moderate activities, or ≥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, or 1 to

74 minutes per week of vigorous activities, or 1 to149 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 if the change in the trend is significant

by performing permutation tests and fits a log-linear model to each segment. The specifications

set in advance were: maximum number of joinpoints was set to 1, 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 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

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physical activity, we calculated intensity-adjusted leisure-time physical activity minutes per

week based on the recommendations given in Physical Activity Guidelines for Americans:

Appendix 1 (http://www.health.gov/paguidelines/guidelines/appendix1), 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 top-truncated to 1,680 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 also after stratification by

gender.

To compare the trends with any physical activity or leisure-time physical activity as an

explanatory variable, we performed a sub-analysis using only NHANES data from 1999-2000 to

2005-2006 as 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, as well as leisure-time 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.

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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 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.

In the analyses restricted to NHANES data from 1999-2000 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.

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Appendix Table 1. Trends in average body-mass index, waist circumference, and prevalence of obesity and abdominal obesity, U.S. adults stratified by race/ethnicity, 1988-2010 Body mass index and waist circumference Category based on body-mass index Category based on waist

circumference

Mean body mass index 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)

Women 18-39 years, non-Hispanic white

1988-1994 24.6 (24.1-25.0) 82.0 (80.9-83.2) 17.7 (14.9-20.5) 16.4 (14.2-18.7) 60.5 (57.2-63.8) 25.9 (21.8-30.0) 2009-2010 27.1 (26.4-27.8) 90.4 (88.3-92.5) 26.6 (22.6-30.7) 23.4 (16.6-30.3) 46.4 (40.5-52.4) 46.3 (39.7-52.9)

Trend APC 0.48 (0.32-0.64) APC 0.52 (0.39-0.65) OR 1.031 (1.015-1.048) OR 1.019 (1.004-1.035) OR 0.970 (0.958-0.983) OR 1.048 (1.032-1.065) 40-64 years, non-Hispanic white

1988-1994 27.3 (26.8-27.8) 91.5 (90.3-92.6) 27.5 (24.0-31.1) 28.8 (26.1-31.5) 41.0 (37.4-44.7) 52.7 (49.6-55.8) 2009-2010 28.5 (27.9-29.1) 96.4 (95.1-97.7) 35.6 (30.7-40.5) 28.1 (23.0-33.2) 33.0 (29.0-36.9) 66.0 (61.7-70.4)


1988-1994 26.3 (26.1-26.6) 92.9 (91.8-93.9) 22.4 (20.0-24.8) 32.5 (30.3-34.7) 41.5 (38.3-44.6) 63.1 (59.1-67.1) 2009-2010 29.0 (28.2-29.8) 98.4 (97.2-99.6) 37.6 (32.4-42.8) 32.0 (26.5-37.5) 28.3 (24.6-32.0) 73.6 (70.3-76.9)

Trend APC 0.38 (0.27-0.50) APC 0.26 (0.17-0.35) OR 1.028 (1.015-1.041) OR 1.006 (0.994-1.017) OR 0.975 (0.964-0.986) OR 1.026 (1.011-1.041) 18-39 years, non-Hispanic black

1988-1994 27.4 (26.8-27.9) 87.6 (86.3-88.9) 28.7 (25.4-31.9) 25.9 (23.4-28.4) 41.8 (37.7-45.9) 42.1 (38.1-46.2) 2009-2010 31.1 (29.5-32.7) 96.5 (92.2-100.7) 54.1 (44.3-63.8) 18.8 (13.5-24.0) 23.6 (17.2-30.0) 65.7 (54.3-77.1)


1988-1994 30.3 (29.7-30.9) 98.0 (96.5-99.5) 46.8 (42.1-51.4) 30.0 (26.5-33.6) 20.9 (16.8-24.9) 72.3 (67.8-76.9) 2009-2010 33.8 (32.3-35.2) 104.6 (102.8-106.3) 61.4 (55.0-67.7) 27.3 (22.0-32.5) 10.4 (6.8-14.0) 83.9 (76.7-91.1)


1988-1994 29.1 (28.4-29.8) 97.9 (96.1-99.7) 36.3 (31.6-40.9) 36.1 (31.3-40.8) 25.1 (21.5-28.8) 75.7 (70.8-80.7) 2009-2010 31.4 (29.9-33.0) 100.7 (98.1-103.4) 55.6 (44.4-66.7) 25.8 (16.1-35.5) 17.1 (9.8-24.5) 81.9 (72.0-91.8)

Trend APC 0.35 (0.12-0.57) APC 0.18 (0.03-0.32) OR 1.042 (1.020-1.065) OR 0.968 (0.947-0.990) OR 0.983 (0.961-1.006) OR 1.024 (0.995-1.054) 18-39 years, Mexican-American

1988-1994 26.9 (26.5-27.3) 86.7 (85.8-87.7) 26.6 (23.4-29.8) 30.2 (25.8-34.6) 40.5 (37.2-43.7) 42.5 (39.9-45.2) 2009-2010 28.8 (27.9-29.6) 94.3 (91.8-96.8) 36.8 (32.1-41.6) 29.3 (24.2-34.5) 33.2 (26.8-39.6) 60.5 (51.3-69.7)


1988-1994 29.7 (29.0-30.3) 96.4 (95.2-97.6) 43.6 (39.3-48.0) 33.7 (30.2-37.3) 22.2 (17.3-27.2) 74.4 (70.6-78.2) 2009-2010 31.0 (30.1-31.9) 100.0 (97.5-102.6) 54.2 (45.7-62.7) 36.0 (27.4-44.6) 9.4 (5.5-13.2) 84.6 (78.6-90.6)


1988-1994 28.0 (27.1-28.9) 97.0 (94.5-99.6) 29.7 (23.1-36.4) 38.8 (31.1-46.5) 30.3 (23.0-37.6) 72.7 (64.5-80.9) 2009-2010 29.3 (28.6-29.9) 98.8 (97.5-100.1) 35.7 (27.0-44.4) 41.0 (31.0-51.0) 21.6 (15.8-27.3) 82.2 (73.2-91.2)

Trend APC 0.26 (0.04-0.48) APC 0.18 (-0.01-0.37) OR 1.017 (0.991-1.043) OR 1.006 (0.981-1.031) OR 0.975 (0.951-1.001) OR 1.039 (1.001-1.078) Men

18-39 years, non-Hispanic white

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1988-1994 25.7 (25.3-26.1) 91.0 (90.2-91.9) 14.4 (12.1-16.7) 34.7 (31.3-38.1) 49.1 (45.8-52.4) 15.2 (12.8-17.5) 2009-2010 27.8 (27.0-28.5) 96.2 (94.1-98.2) 33.1 (25.7-40.4) 30.4 (26.7-34.0) 35.4 (28.3-42.5) 30.6 (24.0-37.1)

Trend APC 0.35 (0.23-0.47) APC 0.26 (0.18-0.35) OR 1.051 (1.034-1.069) OR 0.994 (0.983-1.006) OR 0.972 (0.960-0.984) OR 1.045 (1.030-1.060) 40-64 years, non-Hispanic white

1988-1994 27.6 (27.2-27.9) 99.8 (99.1-100.5) 25.5 (22.8-28.2) 44.1 (40.8-47.3) 29.8 (26.3-33.3) 38.7 (35.2-42.2) 2009-2010 29.3 (28.7-29.9) 104.2 (102.7-105.7) 36.6 (31.7-41.5) 44.5 (38.3-50.8) 18.1 (12.9-23.3) 51.3 (45.9-56.7)


1988-1994 26.7 (26.4-27.1) 101.0 (100.2-101.9) 20.5 (17.3-23.8) 45.3 (41.5-49.0) 32.5 (28.9-36.1) 46.7 (43.2-50.2) 2009-2010 28.9 (28.4-29.4) 106.7 (105.6-107.8) 37.3 (31.3-43.3) 39.3 (33.9-44.8) 22.3 (18.8-25.8) 62.1 (57.6-66.6)


1988-1994 26.1 (25.7-26.4) 87.8 (87.0-88.6) 18.8 (16.7-21.0) 31.1 (28.1-34.0) 48.3 (44.8-51.8) 13.9 (12.2-15.5) 2009-2010 28.9 (27.6-30.2) 92.8 (90.2-95.4) 35.2 (26.6-43.9) 27.1 (20.3-33.8) 35.7 (30.2-41.1) 28.0 (19.8-36.1)


1988-1994 27.0 (26.7-27.4) 95.3 (94.2-96.5) 22.4 (18.8-25.9) 41.6 (37.7-45.6) 34.4 (30.9-38.0) 27.9 (24.2-31.6) 2009-2010 30.0 (29.0-30.9) 102.3 (100.1-104.4) 42.9 (36.8-49.0) 31.7 (26.1-37.2) 24.8 (19.9-29.7) 41.1 (35.5-46.6)


1988-1994 26.0 (25.4-26.6) 96.9 (95.4-98.3) 20.7 (16.5-25.0) 35.9 (31.5-40.2) 38.4 (33.1-43.8) 34.2 (29.2-39.3) 2009-2010 28.0 (26.8-29.1) 102.6 (99.6-105.6) 32.9 (23.6-42.2) 34.7 (28.5-41.0) 30.4 (23.6-37.2) 54.8 (46.8-62.9)


1988-1994 26.0 (25.6-26.5) 89.8 (88.6-90.9) 15.0 (11.8-18.2) 40.6 (37.1-44.2) 43.1 (38.9-47.3) 13.5 (9.9-17.0) 2009-2010 28.4 (27.3-29.6) 96.6 (93.8-99.4) 30.5 (23.5-37.4) 44.5 (42.0-46.9) 24.4 (17.6-31.2) 31.8 (23.0-40.6)


1988-1994 28.5 (28.1-28.9) 100.0 (98.9-101.1) 33.4 (28.9-37.8) 45.0 (40.7-49.2) 21.1 (17.9-24.4) 40.5 (35.9-45.1) 2009-2010 29.5 (29.0-30.0) 102.0 (100.4-103.5) 38.7 (32.8-44.7) 47.8 (41.0-54.6) 13.5 (10.6-16.4) 44.6 (37.2-52.1)


1988-1994 26.7 (26.1-27.3) 99.1 (97.6-100.5) 19.8 (14.0-25.6) 47.7 (40.0-55.4) 31.0 (25.5-36.5) 40.0 (31.6-48.4) 2009-2010 29.0 (27.2-30.8) 104.8 (102.1-107.4) 36.1 (20.7-51.5) 47.1 (35.9-58.2) 16.9 (6.5-27.3) 58.7 (49.7-67.7)

Trend APC 0.44 (0.11-0.77) APC 0.31 (0.16-0.46) OR 1.057 (1.010-1.106) OR 0.993 (0.966-1.021) OR 0.960 (0.930-0.992) OR 1.040 (1.013-1.069)

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Appendix Table 2: Annual changes in prevalence of abdominal obesity, stratified by obesity category based on body-mass index, U.S. adults, 1988-2010

Abdominal obesity, % of population (95% CI)

1988-1994 2009-2010

Abdominal obesity category based on waist circumference,

Odds ratio (95% CI) of being in category in any given year compared to previous year

Women

Obese

18 years and older 96.4 (94.5-98.3) 99.6 (99.1-100.0) 1.144 (1.090-1.200)

18-39 years 92.5 (87.5-97.5) 99.2 (97.9-100.0) 1.155 (1.083-1.232)

40-64 years 98.5 (97.6-99.4) 99.9 (99.7-100.0) 1.130 (1.068-1.195)

65 years and older 99.8 (99.4-100.0) 99.5 (98.4-100.0) 0.907 (0.707-1.164)

Overweight

18 years and older 66.1 (62.7-69.4) 80.8 (78.1-83.5) 1.045 (1.032-1.057)

18-39 years 47.2 (39.9-54.5) 69.8 (62.7-76.9) 1.051 (1.030-1.072)

40-64 years 71.9 (67.3-76.5) 85.6 (80.4-90.7) 1.044 (1.025-1.063)

65 years and older 85.4 (81.9-88.9) 86.4 (81.7-91.1) 1.026 (0.998-1.055)

Normal weight

18 years and older 9.6 (8.1-11.0) 13.8 (10.1-17.5) 1.026 (1.012-1.040)

18-39 years 2.6 (1.2-4.0) 5.6 (3.2-8.1) 1.042 (1.011-1.075)

40-64 years 13.4 (10.8-16.1) 17.2 (10.6-23.7) 1.018 (0.995-1.042)

65 years and older 28.3 (24.2-32.4) 31.4 (26.8-36.0) 1.009 (0.993-1.026)

Men

Obese

18 years and older 89.4 (86.7-92.1) 91.1 (89.7-92.5) 1.012 (0.991-1.033)

18-39 years 79.7 (74.3-85.1) 81.5 (77.6-85.5) 1.004 (0.977-1.032)

40-64 years 94.7 (91.5-97.8) 95.7 (94.1-97.4) 1.017 (0.978-1.057)

65 years and older 97.0 (94.4-99.7) 98.9 (97.2-100.0) 1.062 (0.978-1.152)

Overweight

18 years and older 24.5 (22.1-26.8) 27.8 (24.3-31.3) 1.017 (1.007-1.027)

18-39 years 8.6 (6.2-11.0) 10.4 (5.9-14.9) 1.012 (0.991-1.033)

40-64 years 31.4 (27.8-35.0) 29.7 (24.5-34.9) 1.007 (0.993-1.022)

65 years and older 52.1 (47.8-56.4) 61.7 (55.5-68.0) 1.028 (1.013-1.044)

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Normal weight

18 years and older 0.7 (0.4-1.0) 0.2 (0.0-0.5) 0.979 (0.951-1.008)

18-39 years -- * -- * -- *

40-64 years 1.2 (0.2-2.2) 0.5 (0.0-1.2) 0.946 (0.904-0.990)

65 years and older 3.4 (1.7-5.2) 0.3 (0.0-0.8) 0.992 (0.954-1.031)

* Small sample size precludes estimation

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Appendix Table 3. Trends in reported levels of leisure-time physical activity and daily caloric intake, U.S. adults, stratified by race/ethnicity, 1988-2010 Reported leisure-time physical activity

Mean energy intake in kcal/day(95% CI) None,

% of population (95% CI) Intermediate level,

% of population (95% CI) Ideal level,

% of population(95% CI) Women 18-39 years, non-Hispanic white

1988-1994 10.4 (8.2-12.6) 51.3 (46.9-55.7) 38.3 (34.2-42.4) 1939 (1874-2005) 2009-2010 41.3 (34.9-47.7) 21.9 (17.5-26.4) 36.8 (31.5-42.1) 1861 (1820-1903)

Trend OR 1.080 (1.061-1.100) OR 0.933 (0.920-0.945) OR 1.010 (0.996-1.024) APC -0.16 (-0.38-0.06) 40-64 years, non-Hispanic white

1988-1994 15.2 (12.7-17.8) 48.6 (45.8-51.4) 36.2 (32.1-40.2) 1715 (1685-1746) 2009-2010 43.4 (38.4-48.4) 21.3 (18.0-24.7) 35.2 (31.5-39.0) 1795 (1708-1882)

Trend OR 1.077 (1.056-1.099) OR 0.936 (0.925-0.948) OR 0.995 (0.980-1.011) APC 0.17 (-0.08-0.42) 65 years and older, non-Hispanic white

1988-1994 29.3 (25.8-32.7) 30.9 (28.0-33.9) 39.8 (35.3-44.3) 1491 (1459-1523) 2009-2010 64.2 (58.0-70.4) 12.1 (7.9-16.3) 23.7 (18.0-29.4) 1607 (1523-1690)

Trend OR 1.073 (1.055-1.090) OR 0.957 (0.945-0.970) OR 0.957 (0.940-0.974) APC 0.40 (0.18-0.62) 18-39 years, non-Hispanic black

1988-1994 19.5 (16.2-22.8) 47.4 (43.8-51.0) 33.0 (29.4-36.7) 1970 (1915-2025) 2009-2010 59.9 (54.1-65.8) 19.4 (13.7-25.1) 20.7 (15.8-25.5) 1957 (1790-2125)

Trend OR 1.070 (1.055-1.086) OR 0.936 (0.922-0.949) OR 0.989 (0.975-1.004) APC -0.14 (-0.52-0.24) 40-64 years, non-Hispanic black

1988-1994 33.0 (28.7-37.3) 39.6 (35.5-43.8) 27.4 (23.1-31.6) 1645 (1587-1703) 2009-2010 71.1 (64.0-78.2) 14.3 (10.2-18.3) 14.6 (8.4-20.8) 1728 (1613-1843)

Trend OR 1.064 (1.046-1.083) OR 0.948 (0.933-0.964) OR 0.972 (0.954-0.990) APC 0.41 (0.02-0.79) 65 years and older, non-Hispanic black

1988-1994 51.3 (44.7-57.9) 30.1 (25.2-35.0) 18.6 (13.5-23.7) 1340 (1261-1419) 2009-2010 69.7 (61.4-77.9) 18.0 (11.7-24.3) 12.4 (3.7-21.1) 1509 (1298-1720)

Trend OR 1.040 (1.015-1.066) OR 0.962 (0.938-0.985) OR 0.980 (0.949-1.011) APC 0.56 (-0.03-1.15) 18-39 years, Mexican-American

1988-1994 29.9 (26.6-33.3) 44.0 (40.8-47.2) 26.0 (22.2-29.9) 1873 (1833-1913) 2009-2010 57.2 (49.4-65.0) 16.7 (12.2-21.2) 26.1 (18.5-33.7) 1844 (1698-1990)

Trend OR 1.056 (1.034-1.079) OR 0.934 (0.917-0.952) OR 1.002 (0.981-1.024) APC -0.10 (-0.51-0.30) 40-64 years, Mexican-American

1988-1994 30.8 (27.7-33.9) 42.8 (39.2-46.4) 26.4 (22.7-30.0) 1697 (1621-1772) 2009-2010 70.3 (60.3-80.2) 9.6 (3.9-15.3) 20.1 (13.2-27.1) 1733 (1595-1872)


1988-1994 47.2 (41.5-53.0) 28.9 (23.0-34.8) 23.8 (16.9-30.7) 1271 (1198-1344) 2009-2010 80.2 (74.1-86.3) 6.8 (3.6-10.0) 13.0 (5.9-20.0) 1455 (1381-1528)

Trend OR 1.081 (1.058-1.105) OR 0.934 (0.909-0.959) OR 0.950 (0.918-0.984) APC 0.77 (0.20-1.35) Men

18-39 years, non-Hispanic white

1988-1994 7.3 (5.5-9.1) 46.0 (42.2-49.8) 46.7 (42.6-50.7) 3050 (2965-3134)

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2009-2010 28.6 (21.6-35.6) 16.7 (12.0-21.4) 54.7 (45.7-63.8) 2773 (2632-2913) Trend OR 1.064 (1.042-1.085) OR 0.936 (0.922-0.949) OR 1.016 (1.001-1.032) APC -0.38 (-0.63--0.12)

40-64 years, non-Hispanic white 1988-1994 9.1 (6.8-11.3) 48.0 (44.0-52.0) 42.9 (39.5-46.3) 2547 (2472-2621) 2009-2010 43.9 (40.7-47.1) 17.3 (13.5-21.0) 38.8 (33.7-44.0) 2590 (2497-2682)

Trend OR 1.107 (1.085-1.130) OR 0.928 (0.915-0.942) OR 0.983 (0.970-0.997) APC 0.17 (-0.05-0.40) 65 years and older, non-Hispanic white

1988-1994 16.3 (13.9-18.7) 35.3 (32.6-38.1) 48.4 (44.9-51.8) 2013 (1957-2069) 2009-2010 54.9 (50.2-59.5) 12.8 (9.7-15.9) 32.3 (28.5-36.2) 2018 (1951-2085)

Trend OR 1.094 (1.079-1.109) OR 0.942 (0.931-0.954) OR 0.962 (0.951-0.972) APC -0.03 (-0.28-0.22) 18-39 years, non-Hispanic black

1988-1994 6.7 (4.6-8.7) 35.9 (32.9-38.8) 57.4 (53.9-61.0) 2917 (2800-3034) 2009-2010 37.6 (28.9-46.3) 5.3 (1.4-9.3) 57.0 (46.3-67.7) 2510 (2388-2632)

Trend OR 1.070 (1.047-1.093) OR 0.922 (0.908-0.937) OR 1.004 (0.987-1.022) APC -0.56 (-0.85--0.26) 40-64 years, non-Hispanic black

1988-1994 19.6 (15.8-23.4) 42.3 (37.9-46.7) 38.1 (34.2-42.0) 2314 (2226-2403) 2009-2010 57.4 (48.3-66.5) 11.8 (7.2-16.4) 30.8 (23.5-38.0) 2593 (2285-2901)

Trend OR 1.070 (1.050-1.091) OR 0.928 (0.913-0.944) OR 0.987 (0.970-1.003) APC 0.58 (0.08-1.08) 65 years and older, non-Hispanic black

1988-1994 29.6 (22.5-36.7) 35.0 (28.9-41.2) 35.4 (29.0-41.7) 1651 (1559-1744) 2009-2010 71.9 (63.5-80.3) 9.9 (1.4-18.4) 18.2 (10.3-26.1) 1912 (1803-2021)

Trend OR 1.080 (1.056-1.103) OR 0.939 (0.913-0.965) OR 0.957 (0.934-0.980) APC 1.04 (0.43-1.65) 18-39 years, Mexican-American

1988-1994 19.5 (15.2-23.8) 42.0 (37.0-46.9) 38.6 (34.3-42.8) 2792 (2697-2887) 2009-2010 52.8 (42.6-63.1) 10.7 (4.6-16.9) 36.4 (29.9-43.0) 2613 (2442-2784)

Trend OR 1.052 (1.032-1.074) OR 0.914 (0.895-0.934) OR 1.018 (1.001-1.036) APC -0.35 (-0.72-0.03) 40-64 years, Mexican-American

1988-1994 24.2 (20.0-28.5) 44.3 (40.5-48.0) 31.5 (27.7-35.3) 2424 (2364-2484) 2009-2010 63.2 (53.6-72.9) 13.5 (8.5-18.5) 23.3 (16.2-30.3) 2409 (2240-2578)


1988-1994 32.1 (25.6-38.6) 28.8 (22.5-35.1) 39.1 (32.4-45.8) 1777 (1657-1897) 2009-2010 59.4 (48.2-70.6) 12.0 (5.4-18.6) 28.6 (22.0-35.3) 1919 (1693-2144)

Trend OR 1.061 (1.029-1.095) OR 0.947 (0.919-0.976) OR 0.968 (0.941-0.997) APC 0.45 (-0.21-1.11)

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Appendix Table 4: Annual changes in mean body-mass index, mean waist circumference and daily caloric intake, stratified by reported level of leisure-time physical activity, U.S. adults, 1988-2010

Mean body mass index

in kg/m2 (95% CI) Mean waist circumference

in cm (95% CI) Mean energy intake in kcal/day(95% CI)

1988-1994 2009-2010

Annual percentage

change (95% CI)

1988-1994 2009-2010

Annual percentage

change (95% CI)

1988-1994 2009-2010

Annual percentage

change (95% CI)

Women


18 years and older

27.9 (27.3-28.6)

29.7 (29.2-30.2)

0.28 (0.16 - 0.40)

92.9 (91.4-94.4)

97.3 (95.6-99.1)

0.25 (0.14 - 0.37)

1714 (1664-1764)

1791 (1753-1828)

0.27 (0.02-0.52)

18-39 years

26.7 (25.6-27.8)

28.5 (27.7-29.3)

0.26 (0.03 - 0.49)

87.4 (84.6-90.2)

92.9 (90.4-95.4)

0.31 (0.11 - 0.51)

1875 (1793-1958)

1914 (1827-2001)

-0.04 (-0.52-0.44)

40-64 years

29.5 (28.5-30.6)

30.7 (29.9-31.5)

0.16 (-0.04 - 0.35)

97.4 (95.3-99.6)

100.4 (98.5-102.3)

0.18 (0.03 - 0.33)

1681 (1600-1762)

1762 (1668-1855)

0.29 (-0.14-0.72)

65 years and older

27.2 (26.6-27.9)

30.2 (29.2-31.2)

0.50 (0.33 - 0.67)

95.6 (93.7-97.5)

100.9 (99.1-102.8)

0.30 (0.17 - 0.43)

1395 (1336-1454)

1556 (1497-1616)

0.63 (0.29-0.96)

Intermediate level of reported leisure-time physical activity

18 years and older

26.6 (26.2-27.0)

28.4 (27.9-28.8)

0.39 (0.28 - 0.51)

89.1 (88.2-90.0)

94.7 (93.7-95.7)

0.38 (0.30 - 0.46)

1776 (1738-1814)

1783 (1714-1851)

0.09 (-0.11-0.28)

18-39 years

25.4 (24.9-25.9)

27.9 (26.9-29.0)

0.50 (0.33 - 0.68)

83.8 (82.6-84.9)

92.2 (89.9-94.5)

0.53 (0.41 - 0.65)

1969 (1889-2050)

1757 (1663-1852)

-0.27 (-0.60-0.06)

40-64 years

27.7 (27.2-28.2)

28.8 (27.7-29.9)

0.32 (0.15 - 0.49)

92.4 (91.1-93.7)

96.5 (94.1-98.9)

0.28 (0.16 - 0.41)

1702 (1665-1739)

1874 (1776-1972)

0.38 (0.13-0.64)

65 years and older

26.9 (26.4-27.4)

28.3 (26.3-30.3)

0.26 (0.06 - 0.47)

94.3 (93.0-95.6)

96.5 (91.5-101.6)

0.14 (-0.02 - 0.29)

1478 (1427-1530)

1627 (1392-1861)

0.41 (0.00-0.82)

Ideal level of reported leisure-time physical activity

18 years and older

25.5 (25.2-25.7)

26.7 (26.1-27.2)

0.28 (0.16 - 0.39)

86.0 (85.2-86.7)

90.5 (89.2-91.8)

0.33 (0.25 - 0.41)

1765 (1722-1808)

1774 (1705-1843)

0.08 (-0.13-0.30)

18-39 years

24.3 (23.9-24.7)

26.6 (25.4-27.8)

0.48 (0.32 - 0.65)

80.9 (79.9-81.8)

88.5 (85.9-91.2)

0.52 (0.39 - 0.64)

1926 (1856-1996)

1892 (1795-1988)

-0.12 (-0.42-0.18)

40-64 years

26.5 (26.1-26.9)

26.8 (25.9-27.6)

0.10 (-0.08 - 0.28)

89.2 (87.8-90.5)

91.6 (89.6-93.6)

0.20 (0.06 - 0.33)

1697 (1616-1779)

1719 (1603-1835)

0.18 (-0.23-0.59)

65 years and older

25.9 (25.4-26.3)

26.6 (25.2-27.9)

0.12 (-0.06 - 0.31)

90.8 (89.7-91.9)

92.8 (90.6-95.0)

0.13 (0.01 - 0.24)

1530 (1472-1588)

1616 (1508-1723)

0.41 (0.07-0.75)

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Men


18 years and older

26.6 (26.1-27.1)

29.2 (28.6-29.8)

0.52 (0.37 - 0.66)

96.1 (94.4-97.8)

102.6 (100.9-104.2)

0.35 (0.23 - 0.47)

2438 (2343-2533)

2487 (2384-2589)

0.19 (-0.14-0.53)

18-39 years

26.0 (25.0-26.9)

28.4 (27.6-29.3)

0.44 (0.20 - 0.67)

90.7 (88.1-93.2)

97.8 (95.3-100.2)

0.32 (0.13 - 0.51)

2714 (2536-2891)

2663 (2492-2834)

-0.06 (-0.63-0.50)

40-64 years

27.6 (26.8-28.4)

29.8 (29.0-30.6)

0.52 (0.32 - 0.71)

100.1 (97.5-102.7)

105.2 (103.0-107.4)

0.34 (0.18 - 0.51)

2471 (2322-2620)

2548 (2428-2669)

0.34 (-0.15-0.83)

65 years and older

25.9 (25.1-26.7)

29.4 (28.9-29.9)

0.66 (0.51 - 0.81)

99.7 (97.7-101.8)

108.1 (107.1-109.2)

0.43 (0.32 - 0.53)

1679 (1595-1762)

1903 (1820-1986)

0.38 (-0.02-0.77)

Intermediate level of reported leisure-time physical activity

18 years and older

27.0 (26.7-27.4)

28.3 (27.6-28.9)

0.28 (0.17 - 0.38)

97.1 (96.3-97.9)

100.0 (98.3-101.7)

0.21 (0.14 - 0.29)

2636 (2576-2695)

2532 (2408-2655)

-0.13 (-0.34-0.09)

18-39 years

25.8 (25.3-26.2)

28.0 (26.6-29.5)

0.37 (0.21 - 0.52)

91.2 (90.0-92.3)

96.3 (93.0-99.7)

0.29 (0.17 - 0.41)

2972 (2864-3080)

2710 (2483-2937)

-0.36 (-0.68--0.03)

40-64 years

28.2 (27.7-28.7)

28.9 (28.0-29.8)

0.21 (0.05 - 0.37)

101.2 (100.1-102.3)

102.9 (100.8-105.1)

0.15 (0.04 - 0.26)

2548 (2466-2631)

2537 (2337-2738)

0.10 (-0.21-0.40)

65 years and older

27.3 (26.8-27.9)

27.4 (25.9-28.9)

0.14 (-0.05 - 0.33)

102.1 (100.5-103.7)

101.9 (98.1-105.8)

0.12 (-0.02 - 0.27)

2015 (1934-2096)

2077 (1818-2336)

-0.03 (-0.44-0.39)

Ideal level of reported leisure-time physical activity

18 years and older

26.2 (25.9-26.4)

28.0 (27.5-28.6)

0.35 (0.26 - 0.44)

93.9 (93.2-94.5)

98.2 (96.7-99.7)

0.25 (0.18 - 0.32)

2639 (2579-2699)

2536 (2452-2620)

-0.22 (-0.40--0.04)

18-39 years

25.5 (25.1-25.9)

27.5 (26.6-28.3)

0.37 (0.24 - 0.50)

89.0 (87.9-90.0)

93.6 (91.6-95.6)

0.28 (0.17 - 0.38)

3023 (2912-3134)

2678 (2564-2792)

-0.60 (-0.87--0.32)

40-64 years

26.7 (26.4-27.1)

28.7 (27.9-29.6)

0.35 (0.21 - 0.49)

96.6 (95.7-97.4)

100.9 (98.9-102.9)

0.24 (0.13 - 0.34)

2491 (2395-2587)

2585 (2447-2722)

0.23 (-0.09-0.55)

65 years and older

26.4 (26.0-26.7)

27.8 (27.0-28.6)

0.28 (0.15 - 0.42)

99.5 (98.4-100.5)

103.1 (100.4-105.8)

0.22 (0.11 - 0.34)

2047 (1981-2113)

2066 (1942-2191)

0.06 (-0.29-0.41)

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Appendix Table 5: Relative increase in body-mass index and waist circumference in “Intermediate” and “No reported” groups compared to “Ideal” reported leisure time physical activity in U.S. adults, 1988-2010. Relative increase in BMI compared to Ideal level of Reported leisure

time physical activity Relative increase in waist circumference compared to Ideal level of

Reported leisure time physical activity

Intermediate

Percent Change (95% CI) None

Percent Change (95% CI) Intermediate

Percent Change (95% CI) None

Percent Change (95% CI)

Women

non-Hispanic white 6.14 (4.64 - 7.65) 8.75 (7.26 - 10.25) 4.63 (3.57 - 5.70) 7.19 (6.02 - 8.37)

non-Hispanic black 1.10 (-2.11 - 4.41) 0.65 (-2.17 - 3.55) 1.28 (-1.03 - 3.66) 1.10 (-1.10 - 3.36)

Mexican-American 3.49 (0.62 - 6.44) 5.06 (2.78 - 7.40) 2.83 (0.60 - 5.10) 3.73 (2.08 - 5.41)

Men

non-Hispanic white 1.36 (0.26 - 2.46) 2.52 (1.25 - 3.82) 2.10 (1.28 - 2.93) 3.36 (2.40 - 4.33)

non-Hispanic black 0.10 (-2.76 - 3.03) -2.21 (-4.38 - 0.00) 2.01 (-0.45 - 4.53) 0.22 (-1.51 - 1.98)

Mexican-American 0.39 (-2.04 - 2.88) 1.62 (-0.81 - 4.11) 0.55 (-1.10 - 2.23) 1.16 (-0.59 - 2.95)

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Appendix Table 6: Annual changes in daily intake of fat, carbohydrate and protein, stratified by reported level of leisure-time physical activity, U.S. adults, 1988-2010.

Reported level of leisure-time physical activity

None Intermediate Ideal

Mean fat Intake in

g/day(95% CI)

Mean carbohydrate

intake in g/day (95% CI)

Mean protein intake in

g/day (95% CI)

Mean fat intake in

g/day(95% CI)

Mean carbohydrate



g/day (95% CI)

Mean fat intake in

g/day(95% CI)

Mean carbohydrate



g/day (95% CI)

Women

18 years and older

1988-1994 66 (64 - 68) 216 (209 - 224) 64 (62 - 67) 69 (67 - 71) 219 (213 - 225) 66 (64 - 68) 65 (63 - 68) 225 (220 - 230) 67 (65 - 69)

2009-2010 67 (65 - 68) 228 (223 - 233) 67 (66 - 69) 67 (63 - 72) 224 (217 - 231) 68 (64 - 72) 65 (62 - 68) 222 (212 - 232) 69 (67 - 71)

Trend APC 0.26 (-0.07 - 0.59)

APC 0.21 (-0.07 - 0.49)

APC 0.50 (0.18 - 0.81)

APC -0.02 (-0.32 - 0.28)

APC 0.18 (-0.03 - 0.39)

APC 0.22 (-0.03 - 0.48)

APC 0.45 (0.11 - 0.78)

APC -0.19 (-0.44 - 0.07)

APC 0.26 (0.02 - 0.49)

18-39 years

1988-1994 72 (67 - 76) 238 (228 - 248) 68 (64 - 73) 77 (73 - 81) 240 (229 - 251) 71 (67 - 74) 71 (68 - 75) 244 (234 - 254) 70 (67 - 72)

2009-2010 71 (67 - 75) 245 (235 - 256) 68 (65 - 72) 64 (58 - 69) 227 (214 - 240) 66 (61 - 71) 69 (64 - 73) 239 (227 - 250) 72 (70 - 75)

Trend APC -0.15

(-0.79 - 0.49) APC -0.03

(-0.57 - 0.51) APC 0.37

(-0.26 - 1.00) APC -0.55

(-1.03 - -0.07) APC -0.04

(-0.41 - 0.33) APC -0.10

(-0.51 - 0.30) APC 0.18

(-0.26 - 0.62) APC -0.36

(-0.71 - 0.00) APC 0.22

(-0.16 - 0.59)

40-64 years

1988-1994 65 (61 - 69) 208 (198 - 219) 64 (59 - 68) 67 (64 - 69) 208 (202 - 214) 65 (63 - 67) 64 (59 - 68) 214 (204 - 224) 66 (63 - 69)

2009-2010 65 (61 - 69) 223 (211 - 235) 69 (65 - 73) 71 (66 - 76) 233 (222 - 244) 72 (66 - 77) 63 (59 - 67) 212 (192 - 232) 68 (64 - 71)

Trend APC 0.11 (-0.48 - 0.70)

APC 0.31 (-0.14 - 0.75)

APC 0.52 (0.01 - 1.03)

APC 0.26 (-0.12 - 0.63)

APC 0.50 (0.20 - 0.79)

APC 0.53 (0.21 - 0.84)

APC 0.53 (-0.03 - 1.09)

APC -0.16 (-0.66 - 0.34)

APC 0.30 (-0.10 - 0.71)

65 years and older

1988-1994 52 (49 - 54) 182 (174 - 190) 55 (52 - 58) 54 (51 - 57) 193 (185 - 202) 58 (56 - 60) 54 (50 - 57) 203 (195 - 211) 62 (59 - 65)

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2009-2010 59 (56 - 63) 197 (188 - 205) 61 (58 - 64) 67 (55 - 79) 194 (165 - 224) 64 (56 - 71) 60 (55 - 64) 205 (192 - 218) 64 (58 - 70)

Trend APC 1.02 (0.43 - 1.61)

APC 0.37 (0.03 - 0.71)

APC 0.62 (0.19 - 1.05)

APC 1.01 (0.47 - 1.54)

APC -0.01 (-0.47 - 0.45)

APC 0.44 (-0.01 - 0.90)

APC 0.97 (0.48 - 1.46)

APC 0.20 (-0.14 - 0.54)

APC 0.26 (-0.16 - 0.68)

Men

18 years and older

1988-1994 95 (90 - 100) 293 (278 - 308) 92 (89 - 96) 102 (99 - 106) 309 (301 - 317) 100 (97 - 103) 100 (97 - 104) 320 (311 - 329) 99 (97 - 102)

2009-2010 93 (88 - 98) 296 (284 - 308) 97 (92 - 102) 96 (91 - 101) 305 (288 - 321) 96 (91 - 101) 93 (88 - 97) 297 (287 - 308) 102 (99 - 105)

Trend APC 0.22 (-0.23 - 0.67)

APC 0.04 (-0.35 - 0.43)

APC 0.37 (0.00 - 0.75)

APC -0.13 (-0.41 - 0.15)

APC -0.12 (-0.36 - 0.13)

APC 0.07 (-0.19 - 0.32)

APC -0.31 (-0.59 - -0.02)

APC -0.41 (-0.62 - -0.20)

APC 0.17 (-0.01 - 0.34)

18-39 years

1988-1994 105 (96 - 115) 323 (299 - 348) 101 (94 - 107) 115 (110 - 119) 346 (335 - 358) 110 (105 - 114) 116 (111 - 122) 363 (348 - 378) 111 (106 - 116)

2009-2010 95 (87 - 103) 326 (307 - 345) 102 (93 - 110) 101 (89 - 113) 327 (298 - 356) 100 (90 - 110) 94 (89 - 99) 324 (308 - 340) 106 (102 - 110)

Trend APC -0.30

(-1.09 - 0.50) APC -0.23

(-0.79 - 0.34) APC 0.30

(-0.39 - 1.00) APC -0.43

(-0.85 - 0.00) APC -0.27

(-0.60 - 0.05) APC -0.13

(-0.54 - 0.28) APC -0.93

(-1.34 - -0.53) APC -0.64

(-0.94 - -0.34) APC -0.17

(-0.45 - 0.11)

40-64 years

1988-1994 97 (89 - 105) 297 (273 - 321) 95 (89 - 101) 100 (95 - 105) 297 (285 - 310) 99 (95 - 103) 94 (88 - 99) 302 (287 - 316) 95 (91 - 98)

2009-2010 99 (94 - 104) 293 (275 - 311) 100 (94 - 106) 97 (88 - 105) 304 (278 - 329) 98 (88 - 108) 97 (89 - 105) 292 (276 - 308) 106 (101 - 112)

Trend APC 0.56 (-0.10 - 1.21)

APC 0.19 (-0.43 - 0.81)

APC 0.45 (-0.05 - 0.95)

APC 0.16 (-0.24 - 0.57)

APC 0.01 (-0.38 - 0.40)

APC 0.28 (-0.09 - 0.65)

APC 0.37 (-0.08 - 0.83)

APC -0.13 (-0.50 - 0.23)

APC 0.68 (0.35 - 1.01)

65 years and older

1988-1994 62 (57 - 67) 209 (194 - 225) 67 (62 - 71) 78 (73 - 82) 245 (234 - 256) 78 (75 - 82) 76 (72 - 79) 255 (245 - 264) 81 (77 - 84)

2009-2010 72 (68 - 76) 228 (216 - 240) 76 (73 - 80) 82 (68 - 95) 250 (216 - 285) 80 (70 - 90) 80 (73 - 86) 243 (225 - 262) 83 (77 - 89)

Trend APC 0.48 (-0.03 - 1.00)

APC 0.24 (-0.28 - 0.76)

APC 0.35 (-0.11 - 0.81)

APC -0.02 (-0.59 - 0.55)

APC 0.05 (-0.45 - 0.56)

APC 0.08 (-0.33 - 0.49)

APC 0.34 (-0.11 - 0.78)

APC -0.23 (-0.62 - 0.17)

APC 0.13 (-0.26 - 0.52)

APC = annual percentage change

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Appendix Figure 1

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Appendix Figure 2

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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. Dec 2009;4(12):1901-

1906.

2. U.S. Department of Health and Human Services. Physical Activity Guidelines Advisory

Committee fınal report. Accessed April 17, 2013 at

http://www.health.gov/PAGuidelines/Report/Default.aspx.

3. Kim HJ, Fay MP, Feuer EJ, Midthune DN. Permutation tests for joinpoint regression

with applications to cancer rates. Stat Med. Feb 15 2000;19(3):335-351.

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. Accessed April 17, 2013 at

http://surveillance.cancer.gov/joinpoint/.

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. Nutrition journal. 2012;11:40.

obesity, abdominal obesity, physical activity, and caloric ... aug14 ladabaum.pdfobesity, physical...

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