Body weight status, dietary habits, and physical activity levels of middle school-aged children in rural Mississippi.

Objectives: Obesity and cardiovascular diseases are more prevalent in the Southeast as compared with other geographic regions of the United States. However, few investigations have addressed health disparities among children in rural Southeastern areas. The purpose of this investigation was to determine the risk of overweight and obesity in middle school-aged children residing in a racially diverse rural community, and to characterize their dietary and physical activity habits.

Methods: Two hundred and five middle school children from Scott County, Mississippi were enrolled in this investigation. Measurements included height, weight, body mass index, dietary intake using a 24-hour recall, and physical activity level using pedometers.

Results: Of the 205 children studied, 54% were "overweight" or "at risk for overweight" according to a body mass index-for-age sexspecific percentile. Intake of saturated fat and sodium exceeded recommended levels, whereas intake of calcium, fruits, and vegetables was inadequate. One third of the sample consumed 12 fluid ounces or more of soda on the day of the recall. Physical activity level was below that previously reported for children in this age range, and knowledge of the importance of diet and physical activity in the prevention of cardiovascular disease was poor, particularly among African-American children.

Conclusions: The children in our sample are at increased risk for overweight and obesity. Factors that may be targeted for intervention include a reduction in dietary intake of fat, saturated fat, sodium, and soft drinks, and an increased intake of fruits and vegetables. Physical activity should be encouraged. Many of these factors could be improved through changes within the school environment.

Key Words: children, dietary intake, health disparities, overweight, physical activity

**********

As with adults, the prevalence of overweight among children in the United States continues to increase. (1,2) Current estimates (2) indicate that the majority of Americans are overweight (eg, 65%), and one third are obese. Mississippi leads the nation in statewide prevalence of obesity. (3) Among children in the United States aged 6 to 19 years, 30% are overweight or at risk for overweight, and the prevalence rises to 36 to 40% among African-American children within this age range. (1)

Obesity in children increases the risk of orthopedic and sleep disorders, gallbladder disease, and cardiovascular diseases (CVD). (4) Furthermore, childhood obesity and CVD risk factors track into adulthood. (5-7) Established lifestyle risk factors for CVD include obesity, physical inactivity, and an atherogenic diet. (8) A high consumption of saturated fat and sodium, and a low consumption of fruits, vegetables, and fiber-rich grains are associated with increased risk of CVD. (9) In addition, dietary fiber intake predicts weight gain and CVD risk factors in young adults. (10) With regard to dietary micronutrients, calcium intake is inversely associated with risk of obesity. (11) Dietary guidelines to reduce CVD risk recommend the consumption of five or more servings of fruits and vegetables per day, an adequate intake of fiber-rich foods, a limited consumption of foods high in saturated fat, cholesterol, and sodium, and a moderate intake of foods with a high added sugar content. These guidelines are recommended for all healthy individuals older than 2 years of age. (9)

Healthy People 2010 (12) includes an objective to promote health and reduce chronic disease associated with diet and weight, such as diabetes and CVD. Coronary heart disease and hypertension, as well as most forms of CVD, are more prevalent in the Southeast compared with other regions of the United States. (13) One potential contributing factor may be related to population distribution. Specifically, more than one half (53%) of the population in Mississippi live in areas classified as rural. (14) A rural population distribution is identified in the Healthy People 2010 report as a contributing factor to health disparities among segments of the population. Other potential factors causing these regional geographic differences include a lower average socioeconomic status, poor dietary habits, physical inactivity, and a higher prevalence of obesity in the South.

Few investigations have addressed health disparities among children in rural Southern areas. The Bogalusa Heart Study (15) examined CVD risk factors among children and adolescents in a biracial rural community in Louisiana. In the Bogalusa community, the prevalence of overweight and obesity among children steadily increased during a 20-year period. (16) The Child and Adolescent Trial for Cardiovascular Health (CATCH) study (17) included elementary schools in Louisiana, and reported comparable rates of overweight and obesity (eg, approximately 30%) as compared with children in the Bogalusa Heart Study. However, these investigations only reported data collected through 1994. In light of the increasing nationwide prevalence of overweight and obesity, it is likely that these statistics have worsened, particularly in rural Southeastern areas.

The present investigation is part of an ongoing community-wide effort to improve health and reduce diet- and weight-related chronic disease in a racially diverse rural area of Mississippi. One major objective of this endeavor is to design, implement, and evaluate intervention strategies to reduce the risk of obesity and CVD among school-aged children. Therefore, the purposes of this investigation were to 1) determine the prevalence of overweight and obesity and 2) to characterize current diet and physical activity habits in middle school-aged children in this community so that appropriate intervention strategies to reduce the risk of obesity and CVD can be designed and implemented.

Materials and Methods

Participants

All children in the fifth grade at two middle schools in Scott County, Mississippi, were recruited for participation in this investigation. Written parental consent was obtained for all participants before enrollment. Two hundred and five children were enrolled in the investigation. The Institutional Review Board of the University of Mississippi Medical Center approved the protocol and the informed consent document for this investigation.

Measurements

Height without shoes was determined in each child using a scale-mounted stadiometer, and weight was measured in light clothing without shoes using a physician's balance scale (Detecto, Webb City, MO). Body mass index (BMI) was calculated for each child, and BMI percentile was determined using the Centers for Disease Control BMI-for-age gender-specific growth charts. (18) The children were classified as "at risk for overweight" if their BMI percentile was greater than 85th but less than 95th, and "overweight" if the BMI percentile was greater than or equal to 95th. (4)

A trained interviewer or research dietitian (BD) conducted a 24-hour dietary recall on each child using plastic food models (Nasco, Fort Atkinson, WI) and measuring cups and spoons. School lunch menus were obtained from school foodservice managers to assist the children in correctly remembering breakfast and lunch meals. Recalls were performed with all children on the same two days of the week (Thursday or Friday) so that the day recalled was always a weekday. The recalls were analyzed for macronutrients, micronutrients and caffeine content by the research dietitian using computerized nutritional analysis software designed for research (FIAS Food Intake Analysis System 3.99, University of Texas School of Public Health, Houston, TX). The FIAS database consists of the Primary Data Set and the Survey Nutrient Database of the National Nutrient Data Bank, developed and maintained by the US Department of Agriculture. The recalls were then reviewed individually to determine consumption of fruits and vegetables, fluid ounces of soft drinks, and breakfast. These items were chosen based upon their respective association with CVD, obesity, and overall nutritional well-being of children. (9,19,20)

The Child Dietary Fat Questionnaire (CDFQ) (21) was sent home with each child for a parent or caregiver to complete. This 17-item questionnaire provides an estimate of the child's intake of fat (% total energy), saturated fat (% total energy), and cholesterol (mg) based on the responses of the parent/caregiver. (21) Caregivers are asked to circle a response to each question (eg, "always," "usually," "often," "sometimes," "rarely," or "never"), for example: "In the past month, how often did you give your child 2% milk instead of whole milk?"

Physical activity level was determined by step counts using pedometers (Omron HJ-105, Omron Healthcare Corp., Schaumberg, IL). Children wore a pedometer clipped to their waistband for a consecutive 3-day period and kept a daily step count log during this period. An average of the 3-day step count was used as an indicator of physical activity level. Previous investigations have indicated that assessment of physical activity level using pedometers correlates well with accelerometers, observed time in physical activity, and aerobic fitness. (22,23)

Finally, each child's knowledge of diet, physical activity, body weight, and cardiovascular health was determined using 34 questions adapted from the "Know Your Body" health knowledge questionnaire (24) developed for students aged 10 to 14 years. Sample questions include the following: "Cholesterol is a fatty substance in everyone's blood," "High blood cholesterol levels are found only in adults," and "Regular physical exercise may help delay or prevent a heart attack." Students complete this questionnaire by responding "true," "false," or "don't know" to each question. The score on this questionnaire was expressed as the percentage correct (eg, the number of questions answered correctly out of 34 questions).

Statistical analysis

Statistical analyses were performed using computerized statistical analysis software (SPSS 10.1 for Windows, SPSS Inc., Chicago, IL). Pearson correlational analyses were performed to identify relations among variables. Independent sample t tests were used to determine differences between groups. Data are expressed as mean [+ or -] SEM. The level of significance was set a priori at P < 0.05.

Results

Participant characteristics

The overall participation rate in the study among the fifth graders in the two schools was 81% (205 of a total of 252 children). The mean age of the children in this investigation was 11.9 [+ or -] 0.06 years. Of this sample, 43% were female and 57% were male. The racial characteristics of our sample were as follows: 59% African-American, 34% white, 6% Hispanic, and 1% "other." According to school administrators, 76% of the children were eligible for free or reduced-cost breakfast and lunches (eg, household income below 185% of the federal poverty level, which is approximately $14,000 for a family of three).

Height, weight, BMI, and BMI percentiles are provided in Table 1. Of the children in this sample, 54% were classified as either "overweight" or "at risk for overweight" according to Centers for Disease Control BMI classifications (22% at risk for overweight; 32% overweight). No significant differences were noted between females and males with respect to BMI or BMI percentile. However, there was a trend for a higher mean BMI percentile in the males as compared with the females (P = 0.053). The mean BMI in the African-American children was significantly higher than in the white children (24.0 [+ or -] 0.7 versus 21.3 [+ or -] 0.5, P = 0.005), as was the BMI percentile (78.5 [+ or -] 2.2 versus 68.5 [+ or -] 3.3, P = 0.009).

Dietary intake

Dietary intake data were successfully collected on 194 of the 205 children in this sample. The remaining 11 children were either absent on the days the recalls were conducted, ill on the day before the recall so that their intake was atypical, or they elected not to participate in this aspect of the investigation. Dietary macronutrient and cholesterol, sodium, iron, calcium, vitamin C, and caffeine intake is shown in Table 2. The mean intake of saturated fat was 12% of total energy, exceeding recommended levels of less than 10% of energy. (9) Sodium intake exceeded the recommended 2,400 mg/d. (9) However, the mean cholesterol intake was below the recommended 300 mg/d. The recommended dietary fiber intake for children in this age range is approximately 16 g/d, (25) and the children in our sample reported a mean intake of 13 g/d. Iron intake met the recommended level of 8 mg/d, but calcium intake was only 62% of the recommended 1,300 mg/d. (26) Vitamin C intake exceeded the recommended 45 mg/d for children aged 9 to 13 years. (26) Significant differences in males versus females were detected for absolute (eg, gram amount) dietary protein intake, but not as a percentage of total energy. Sodium and calcium intake was significantly higher in males as compared with females (all P < 0.05).

African-American children consumed significantly less fiber per 1,000 kcal than white children (6.7 [+ or -] 0.2 versus 7.7 [+ or -] 0.4 g/d, P = 0.021), but no other racial differences in macronutrient intake were noted. With regard to micronutrient intake, African-American children consumed significantly more vitamin C than did white children (93 [+ or -] 8 versus 45 [+ or -] 4 mg/d, P = 0.0001), but no differences in the intake of iron or calcium were detected.

Mean servings of fruits and vegetables, fluid ounces of soft drinks, and breakfast consumption are shown in Table 3. Fruit and vegetable intake was well below the recommended five servings per day, with a mean intake of less than one fruit serving and 1/2 vegetable serving per day in our sample. Females reported consuming more vegetables than did males (P = 0.04). On the day of the recall, the percentage of children who reported consuming no servings of fruits was 45%, and the percentage who reported consuming no servings of vegetables was 59%. Only 2 of the 194 children (1% of sample) consumed the recommended three servings of vegetables per day, whereas 34 (18% of sample) consumed the recommended two fruit servings per day. The African-American children consumed significantly more fruit servings than the white children (1.0 [+ or -] 0.1 versus 0.5 [+ or -] 0.1, P = 0.004), but no differences in vegetable intake were found.

Approximately 50% of the children consumed two or more fluid ounces of soft drink on the day of the recall. One third of the children consumed 12 fluid ounces or more of soda on the day of the recall. The children who ingested soft drinks consumed significantly more total energy and reported a lower percentage of energy from fat and protein and a higher percentage of energy from carbohydrate than did the non-soda drinkers (all P < 0.05). The soda drinkers also consumed significantly more caffeine than those who did not drink soda (47 [+ or -] 4 versus 16 [+ or -] 3 mg, P < 0.001). The white children consumed significantly more soft drinks than did the African-American children (9.1 [+ or -] 1.3 versus 6.1 [+ or -] 0.8 fl oz, P = 0.045). The intake of caffeine was also higher in the white as compared with the African-American children (48 [+ or -] 5.8 versus 23 [+ or -] 3.3 mg, P = 0.0001).

Although 76% of our sample was eligible for free or reduced-cost school breakfast, only 64% of our sample consumed breakfast on the day of the recall. The children who ate breakfast consumed significantly more energy than non-breakfast eaters (2,038 [+ or -] 64 versus 1,630 [+ or -] 82 kcal, P < 0.001) but also significantly more iron, calcium, and vitamin C (data not shown, all P < 0.001). The breakfast eaters also consumed more servings of fruits (1.0 [+ or -] 0.1 versus 0.6 [+ or -] 0.1, P = 0.007) and vegetables (0.6 [+ or -] 0.1 versus 0.3 [+ or -] 0.1, P = 0.017) than the non-breakfast eaters.

Of the 205 children studied, 52% had a parent or caregiver fully complete the CDFQ. The mean fat (% total energy), the saturated fat (% total energy), and the cholesterol intake (mg) estimated using the CDFQ were 35.1 [+ or -] 0.3%, 15 [+ or -] 0.2%, and 270 [+ or -] 14 mg, respectively. A significant difference in CDFQ-estimated percent energy from fat among males and females was detected (females: 34.5 [+ or -] 0.4; males: 35.6 [+ or -] 0.3%, P = 0.03). No significant differences in males as compared with females were noted in percent energy from saturated fat or cholesterol (mg). The estimated cholesterol intake from the CDFQ correlated significantly with the cholesterol intake from the 24-hour recall (r = 0.21, P = 0.04), but the saturated fat and the cholesterol intake from the CDFQ versus 24-hour recall were not significantly correlated.

Physical activity

Eighty-five percent of our sample successfully completed the 3-day step count log using their pedometers. As shown in Figure 1, the daily average of the 3-day step counts was not significantly different by sex (P = 0.07) or by race in our sample. However, step counts in our sample were below that previously reported for children in this age range (Fig. 1). (23)

[FIGURE 1 OMITTED]

Health knowledge

Of the 205 children studied, 82% completed the self-administered health knowledge questionnaire. The average percentage of questions answered correctly on the health knowledge questionnaire was 46 [+ or -] 1%. No significant sex difference was detected, but scores were significantly higher in the white as compared with the African-American children (49 [+ or -] 2 versus 44 [+ or -] 1%, P = 0.027).

Discussion

The first major finding of this investigation was that 54% of the children in our sample were either "overweight" or "at risk for overweight." This is in contrast to national data, which indicates that approximately 30% of children in this age range are "overweight" or "at risk for overweight." (1) Furthermore, these results are substantially higher than the prevalence of overweight and obesity reported from the Bogalusa Heart Study and the CATCH trial, (16,17) which used similar criteria. Children at or above the 85th BMI percentile are at significant risk of becoming obese adults. (27) This risk of adult obesity is significant for more than half of our sample. In addition, children at or above the 85th percentile should be evaluated for secondary complications of obesity, such as hypertension, abnormal glucose/insulin metabolism, and dyslipidemia. (4) This recommendation for further clinical assessment would apply to half of the children in this investigation.

Our second major finding was that there are several prevalent modifiable lifestyle habits in this population that increase the risk for obesity and CVD. These include the following: 1) a high intake of saturated fat, sodium, and soft drinks; 2) a low intake of fruits, vegetables, and calcium; and 3) a lower level of physical activity than previously reported for children in this age range. (23, 28) These are factors that potentially impact long-term health and thus should be specifically targeted for intervention within this rural Southeastern population. In addition, the students as a whole, and African Americans in particular, demonstrated a poor knowledge of the importance of diet and physical activity for optimal health and CVD prevention.

Among young adults in Mississippi, 9.5% report an average fruit and vegetable consumption of 0 or less than 1 serving per day, as compared with 6.8% nationwide. Furthermore, 17.6% of young adults in Mississippi report meeting the "five a day" goal as compared with 21.6% nationwide. (29) In our sample, only one child met the "five a day" recommendation.

Consumption of sugar-sweetened drinks, particularly soft drinks, is associated with obesity in children. (19) Ludwig et al (19) found that for each daily serving of sugar-sweetened drink consumed, the odds ratio of becoming obese among children increased by a factor of 1.6. These authors report that consumption of soft drinks was associated with a higher overall total energy intake, which is in agreement with our findings. Of additional concern is the amount of caffeine consumed by the children in our sample (eg, 31 mg/d), which was significantly correlated with soft drink consumption. Consumption of caffeine in teenagers is associated with disturbed/interrupted sleep patterns. (30) Thus, in addition to its association with obesity, consumption of soft drinks could potentially adversely affect classroom performance in school-aged children and thus should be strongly discouraged.

Physical inactivity is an independent and modifiable risk factor for CVD. (31) Regular physical activity improves blood lipid concentrations, insulin sensitivity, and arterial blood pressure, and helps to control body weight. (32) Mississippi is among the five least-active states in the United States, with 80% of adults reporting irregular or no leisure time physical activity. (33) A review of the literature using pedometers for assessment of physical activity level suggests that a daily step count ranging from 12,000 to 16,000 steps per day may be typical for children, with males having higher step counts than females. (28) Our mean step counts (approximately 10,000 per day) were below the low end of this range, which would roughly translate to an energy expenditure of 300 to 400 kcal/d in physical activity. (28)

Many of these factors targeted for intervention could begin in the school environment. For example, in this investigation, students had access to soft drink and snack machines at both middle schools. Removal of these machines or replacement of items in the machine with low fat, nutrientdense options would significantly improve nutrient intake in these children. Snacks and meals at school represent a significant portion of the child's total dietary intake, thus improvement of the nutritional quality of school breakfast and lunch offerings would significantly impact overall dietary intake. An analysis of 4 days of menus from the schools in this investigation indicated that the lunch meal provided an average of 911 kcal with 15% of the energy from protein, 52% from carbohydrate, 33% from fat, 12% from saturated fat, and 1,722 mg of sodium. They also provide 8 g of fiber, 608 mg of calcium, 23 mg of vitamin C, and 5 mg of iron. In Mississippi, school food services are not required, recommended, or encouraged to offer two or more servings of fruits/fruit juices or two or more servings of vegetables at lunch. They are also not prohibited from selling "junk foods" a la carte or in vending machines. (34)

A reduction in the overall fat, saturated fat, and sodium content of the school meals could be achieved by offering more fresh fruits and vegetables and fewer fried items, particularly fried potatoes. Regarding physical activity, daily physical education classes expose children to a variety of types/modes of exercise and increase activity level and offer a means to educate them on the importance of physical activity for weight management and optimal health. Physical education classes are currently not a requirement for or available to all middle school children in Mississippi.

In addition to changes in the school environment, health professionals working with children in this age group (eg, school nurses, pediatricians, and family practice physicians) should routinely inquire about physical activity level and consumption of soft drinks, fruits, and vegetables. In addition, health professionals should reinforce the importance of healthy lifestyle habits for optimal growth, development, and long-term health with children and their parents.

This investigation has several limitations. Specifically, a single 24-hour recall was used to assess dietary intake. Under- and over-reporting are potential concerns when using self-reported dietary intake assessment methods, and it is possible that a single 24-hour recall may not reflect habitual dietary intake. However, this method does not require a high level of literacy nor does it require that subjects be highly motivated, and it is considered to provide reasonable population means for intake. (35) Estimating habitual physical activity is also a challenge, particularly in children. However, pedometers have been shown to be a valid yet simple and inexpensive option for assessing physical activity level. (22) The children in our sample enjoyed using the devices and were, in most cases (eg, 174 of 205 children), able to successfully complete a 3-day log of steps with the assistance of their teachers. It is unclear whether a 3-day period of assessment reflects the habitual level of physical activity in children. Previous studies have used time periods ranging from 2 days to 1 week, and there is not yet a consensus as to the optimal duration of monitoring. (28) However, our data reflect the range of that typically reported for pedometer step counts, thus we feel that our method provided a reasonable estimate of physical activity level.

Conclusion

This investigation identified the prevalence of overweight and obesity among rural middle school-aged children in a state that leads the nation in prevalence of obesity. Also identified are several key factors that health professionals working with middle school-aged children in the rural Southeastern United States can target for intervention, namely a high consumption of saturated fat, sodium, and soft drinks, a low consumption of fruits and vegetables, a low level of physical activity, and knowledge about the role of diet and physical activity for CVD prevention. This information can be used to develop relevant strategies to improve the body weight and health status of children in rural areas of the Southeastern United States.

Table 1. Physical characteristics of middle school-aged children in
rural Mississippi (a)

                                  Females             Males
                                  (n = 89)            (n = 116)

Height (cm)                       148.2 [+ or -] 0.9  146.6 [+ or -] 1.0
Weight (kg)                        50.2 [+ or -] 1.5   51.8 [+ or -] 2.0
BMI (kg/[m.sup.2])                 22.6 [+ or -] 0.5   23.5 [+ or -] 0.7
BMI percentile                     72.9 [+ or -] 2.9   77.0 [+ or -] 2.2
% of sample
  [greater than or equal to]95th
    percentile                     31%                 32%
  [greater than or equal to]85
    but <95th percentile           19%                 25%

                                  All
                                  (n = 205)

Height (cm)                       147.3 [+ or -] 0.7
Weight (kg)                        51.1 [+ or -] 1.3 (b)
BMI (kg/[m.sup.2])                 23.1 [+ or -] 0.5
BMI percentile                     75.2 [+ or -] 1.8 (c)
% of sample
  [greater than or equal to]95th
    percentile                     32%
  [greater than or equal to]85
    but <95th percentile           22%

(a) BMI, body mass index.
(b) Significant difference in males versus females. P < 0.05.
(c) Trend for significant difference in males versus females, P = 0.053.

Table 2. Reported dietary intake of macronutrients, micronutrients, and
caffeine (a)

                         Females               Males
                         (n = 82)            (n = 112)

Energy (kcal)            1,785 [+ or -] 80   1,971 [+ or -] 68
Fat (g)                     69 [+ or -] 4       77 [+ or -] 3
  %                         34 [+ or -] 1       34 [+ or -] 1
Protein (g)                 64 [+ or -] 3       72 [+ or -] 3
  %                         15 [+ or -] 1       15 [+ or -] 0
Carbohydrate (g)           232 [+ or -] 10     252 [+ or -] 9
  %                         52 [+ or -] 1       51 [+ or -] 1
Saturated fat (g)           24 [+ or -] 1       27 [+ or -] 1
  %                         12 [+ or -] 0       12 [+ or -] 0
Polyunsaturated fat (g)     13 [+ or -] 1       14 [+ or -] 1
  %                          6 [+ or -] 0        6 [+ or -] 0
Monounsaturated fat (g)     28 [+ or -] 2       31 [+ or -] 1
  %                         13 [+ or -] 0       14 [+ or -] 0
Cholesterol (mg)           196 [+ or -] 17     215 [+ or -] 15
Sodium (mg)              2,947 [+ or -] 153  3,369 [+ or -] 115
Dietary fiber (g)           12 [+ or -] 1       14 [+ or -] 1
  (g/1000 kcal)              7 [+ or -] 0        7 [+ or -] 0
Iron (mg)                   12 [+ or -] 1       12 [+ or -] 1
Calcium (mg)               747 [+ or -] 41     854 [+ or -] 32
Vitamin C (mg)              74 [+ or -] 6       75 [+ or -] 7
Caffeine (mg)               28 [+ or -] 4       33 [+ or -] 4

                            All
                         (n = 194)

Energy (kcal)            1,893 [+ or -] 52
Fat (g)                     74 [+ or -] 3
  %                         34 [+ or -] 1
Protein (g)                 69 [+ or -] 2 (b)
  %                         15 [+ or -] 0
Carbohydrate (g)           243 [+ or -] 7
  %                         51 [+ or -] 1
Saturated fat (g)           26 [+ or -] 1
  %                         12 [+ or -] 0
Polyunsaturated fat (g)     13 [+ or -] 1
  %                          6 [+ or -] 0
Monounsaturated fat (g)     29 [+ or -] 1
  %                         14 [+ or -] 0
Cholesterol (mg)           207 [+ or -] 11
Sodium (mg)              3,190 [+ or -] 94 (b)
Dietary fiber (g)           13 [+ or -] 0*
  (g/1000 kcal)              7 [+ or -] 0
Iron (mg)                   12 [+ or -] 0
Calcium (mg)               809 [+ or -] 26 (b)
Vitamin C (mg)              74 [+ or -] 5
Caffeine (mg)               31 [+ or -] 3

(a) Data are mean [+ or -] SEM.
(b) Significant difference in males versus females, P < 0.05.

Table 3. Reported intake of fruits and vegetables, soft drinks, and
breakfast (a)

                    Females             Males             All
                    (n = 82)          (n = 112)        (n = 194)

Fruit servings      0.7 [+ or -] 0.1  0.9 [+ or -] 0.1  0.8 [+ or -] 0.1
Vegetable servings  0.6 [+ or -] 0.1  0.4 [+ or -] 0.1  0.5 [+ or -] 0.1
  (b)
Soft drinks (fl.
  oz.)              6.4 [+ or -] 1.0  7.5 [+ or -] 1.0  7.0 [+ or -] 0.7
Breakfast (%
  consuming)       62%               66%               64%

(a) Data are mean [+ or -] SEM.
(b) Significant difference in males vs. females, P < 0.05.

Acknowledgments

The authors thank Lindsay Batte, Laura Hope Sims, Chad Patel, Hal Dillon, Bobby Owens, PharmD, Melissa Smith, PharmD, and Andy Sistrunk, PharmD, for their assistance with data collection and data entry, and Marion Wofford, MD, Cindy Noble, PharmD, Sonda Johnson, and Crystal Whitfield for their support of this project.

Accepted September 30, 2003.

Copyright [c] 2004 by The Southern Medical Association

0038-4348/04/9706-0571

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RELATED ARTICLE: Key Points

* Children in rural areas of the Southeast are at increased risk for overweight and obesity.

* Dietary intake of saturated fat and sodium is well above recommended levels, and consumption of soft drinks is significant. Fruit and vegetable intake are well below recommended levels.

* Physical activity level is likely below recommended levels.

* Many of these factors could be targeted for intervention within the school environment.

Brenda M. Davy, PHD, RD, Kris Harrell, PHARMD, Jimmy Stewart, MD, and Deborah S. King, PHARMD

From the Division of Hypertension, Department of Medicine, and the Department of Pharmacy, University of Mississippi Medical Center, Jackson, MS.

Financial support was provided by Pfizer Pharmaceuticals.

The authors have no commercial, proprietary, or financial interest in any device or equipment mentioned in this article.

Reprint requests to Brenda M. Davy, PhD, RD, Department of Human Nutrition, Foods and Exercise (0430), Virginia Polytechnic Institute and State University, 221 Wallace Hall, Blacksburg, VA 24061. Email: [e-mail]