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Article

Obesity Prevalence and Trend Among Mississippi High-School Students: Youth Risk Behavior Surveillance System (YRBSS) 2001–2021

by
Zhen Zhang
1,
Xiaoshan Z. Gordy
2 and
Lei Zhang
2,*
1
Department of Epidemiology and Biostatistics, Jackson State University, 1400 John R. Lynch St., Jackson, MS 39217, USA
2
School of Nursing, University of Mississippi Medical Center, 2500 N. State Street, Jackson, MS 39216, USA
*
Author to whom correspondence should be addressed.
Obesities 2025, 5(1), 6; https://doi.org/10.3390/obesities5010006 (registering DOI)
Submission received: 20 December 2024 / Revised: 7 January 2025 / Accepted: 23 January 2025 / Published: 26 January 2025
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Abstract

:
Obesity has become the most consequential threat to the health of Mississippians, as it is known to be associated with major chronic diseases such as type II diabetes, heart disease, and strokes. Obesity prevalence among Mississippi adolescents has been among the highest in the nation. In this study, data from Mississippi Youth Risk Behavior Surveillance System (YRBSS) 2001–2021 were obtained from the Centers for Disease Control and Prevention (CDC). YRBSS is a survey using a self-administered questionnaire to track the risk behaviors of students in grades 9 to 12. The survey packages in R were utilized for summary statistics to account for the YRBSS complex sampling design that includes stratification, clustering, and unequal probabilities of selection. Logistic regression models and Joinpoint software 5.3.0 were used for trend analysis. Obesity prevalence in Mississippi high-school students demonstrated a significant increasing trend from 2001 to 2021, as a whole or stratified by gender or race. Furthermore, Mississippi obesity prevalence among high-school students has been increasing at a greater pace compared to that of the United States. The increasing trend in obesity prevalence among Mississippi high-school students warrants urgent attention at the government, community, school, family, and personal levels. Concerted efforts must be made to fight and eventually reverse this epidemic.

1. Introduction

Childhood and adolescent obesity has emerged as a global public health concern over the past few decades [1]. According to the World Health Organization [2], 160 million children and adolescents aged 5–19 years are living with obesity. Among the population, adolescent obesity increased fourfold from 2% in 1990 to 8% in 2022. In the United States (U.S.), the prevalence of childhood and adolescent obesity has surged to epidemic levels [3]. Approximately one in five, around 14.7 million, U.S. children and adolescents between two and 19 years old have obesity, with adolescents aged 12–19 exhibiting the highest prevalence of obesity (22.2%) compared to children aged 2–5 (12.7%) and 6–11 (20.7%) [4].
Research studies have identified several potential risk factors for childhood and adolescent obesity. These include genetic factors, such as endocrine disorders; environmental factors, such as living conditions; lifestyle factors, such as physical activity, sleep duration, and dietary choices; and socioenvironmental factors, such as family social class, community, and school environment [5,6,7,8]. Other potential early-life risk factors were also identified in the literature, which include intrauterine and perinatal characteristics such as birth weight, sex, and maternal gestational age; infant feeding practice—breastfeeding versus formula feeding; the age of introduction to solid foods; the number of siblings, etc. [5].
Childhood and adolescent obesity is associated with comorbidities and adverse physical health consequences, such as an increased risk of heart diseases, hypertension, type 2 diabetes, liver disease, reproductive disorders, cancer risk, dyslipidemia, asthma, orthopedic complications, sleep apnea [3,9,10]. It is also known to be associated with psychosocial comorbidities such as depression, anxiety, emotional and behavioral disorders, and negative social experiences such as teasing and bullying [11,12,13,14]. The combined physical and psychosocial impacts of obesity can, in turn, affect cognitive functioning and academic performance [15,16,17,18]. In addition, childhood and adolescent obesity has been shown to continue into adulthood. Simmonds et al.’s [19] study indicated that children and adolescents with obesity are approximately five times more likely to be obese in adulthood compared to their non-obese peers. About 55% of obese children become obese adolescents, and around 80% of obese adolescents remain obese in adulthood. Additionally, approximately 70% of these individuals will continue to be obese after age 30.
According to a recent systematic review and meta-analysis of the economic burden of childhood obesity [20], childhood obesity resulted in higher total medical, outpatient visits, and hospitalization costs than children with healthy weights. The increased annual total medical costs due to childhood obesity was USD 307.72 per capita, and the increased total medical costs were approximately USD 5 billion/year. Per the same study, by 2025, adolescent overweight medical costs are expected to reach USD 13.62 billion in annual direct costs and USD 49.02 billion in annual indirect costs.
Mississippi has been leading the nation in the prevalence of childhood and adolescent obesity. The overweight or obesity rate for children ages 10–17 is 41.4%, ranking 50th in the nation, in comparison to 24.3% in Wyoming—the lowest in the nation, and the national average of 33.5% [21]. Many Mississippi-specific factors may have contributed to the high prevalence, such as poverty, limited neighborhood amenities, and limited access to care to name a few [22,23,24]. Almost one-third (27.7%) of Mississippi children under 18 live in households below the poverty line, which also ranks 50th in the nation compared to the 16.9% national average and the lowest 8.1% in Utah [25]. To add to ranking 50th in the list, only 12.9% of children ages 0–17 have access to neighborhood amenities such as a playground or park, a recreation center, a library, sidewalks, or walking paths [26]. The national average for children with access to neighborhood amenities is 35.5%, and the top states are Colorado and Illinois at 53.4%. Unsurprisingly, the percentage of children ages 0–17 whose health is very good or excellent, 85.4%, is ranked the lowest in the nation, at 50th, compared to 90.2% of the national average and the highest of 93.9% in Nebraska [27].
In this study, we utilized 2001–2021 data from the Youth Risk Behavior Surveillance System (YRBSS), conducted by the Mississippi State Department of Health and the Mississippi Department of Education every two years, to analyze the obesity trends among Mississippi high-school students.

2. Materials and Methods

2.1. Data Source

YRBSS is a cross-sectional complex sampling survey with a multistage probability design to ensure that a representative sample is selected, used to monitor six categories of health risk behaviors that contribute to the leading causes of death, disability, and social problems, as well as obesity, asthma, and other priority health-related behaviors from public high-school students. The primary sampling unit (PSU) for YRBSS is at the county level. The PSUs are then categorized into strata according to their demographic composition and urbanity. The secondary sampling unit (SSU) is defined at the school level. Both PSUs and SSUs are sampled with a probability proportional to overall school enrollment size. The third stage is to randomly sample one or two classrooms in each grade, 9–12, of the selected schools [28,29]. A national YRBSS is conducted every two years by the CDC, whereas the Mississippi YRBSS is conducted by the Mississippi Departments of Health and Education. National and Mississippi YRBSS data 2001–2021 were obtained from the CDC public domain [30].

2.2. Measurements

The data point of interest for this study, QNOBESE, is a calculated variable by the CDC. BMI percentile (calculated using students’ height, weight, sex, and DOB) is used to determine the student’s status of obesity. The student is considered obese, and QNOBESE is set to “1”, when the BMI percentile is at or above the 95th percentile for the body mass index, based on sex- and age-specific reference data from the 2000 CDC growth charts. If BMI is missing, then QNOBESE is set to missing. The data points used for this study also include gender (male, female) and race/ethnicity (Non-Hispanic American Indian or Alaska Native, Non-Hispanic Asian, Non-Hispanic Black, Hispanic, Non-Hispanic Native Hawaiian or Other Pacific Islander, Non-Hispanic White, and Non-Hispanic Multiple races). Due to the distribution of demographics of Mississippi high-school students, race is recorded as three categories for analysis: White (Non-Hispanic White), Black (Non-Hispanic Black), and Other. The “Other” race category includes Hispanic, Asian, American Indian/Alaskan Native, Native Hawaiian/other PI, and multiple races [31,32].

2.3. Statistical Analysis

The survey year 2021 data were used to calculate the obesity prevalence ratio (PR) and 95% confidence intervals (CIs) and to compare gender and race. Chi-squared tests of independence were applied to determine the statistical significance of PR. In the instances where the 95% CI contains 1 but the p-value is less than 0.05, we reported the difference as statistically significant [33,34].
Data from the survey years 2001–2021 were used for obesity trend analysis. First, we applied logistic regression models to detect linear or higher-dimension trends. Time variables were treated as continuous covariates in the models. Log odds ratios of each variable were estimated as a function of time (year), time in quadratic terms, and time in cubic terms, respectively. The highest-order time variable in the model is considered valid. If only a linear year-contrast term is found to be significant, then the associated beta and p-value for that term are used to determine the direction and significance of the trend. If quadratic and/or cubic changes are detected, we generate the sex, race, and grade-adjusted obesity prevalence and standard error for each survey year for the second step of the trend analysis using Joinpoint regression. Joinpoint regression analysis determines the critical values of trend segments. The parametric method was applied to calculate the confidence intervals for the annual percentage change (APC) of the resulting segments and the average annual percentage change (AAPC) of the whole trend from 2001 to 2021 [35,36,37].
R software version 4.4.0 was used for the sample characteristic statistics, summary statistics, and logistic regression models. The survey packages in R are identified by the CDC as appropriate tools capable of accounting for the complex sampling design of YRBSS data. Joinpoint software version 5.1.0 was downloaded with permission from the National Cancer Institute and used for Joinpoint regression analysis [38].

3. Results

Demographic Characteristics of 2021 Data

The Mississippi 2021 YRBSS sample size was 1747. Female and male students were approximately equally represented: 49.9% female and 50.1% male (valid percentage). The sample consisted of 35.4% White, 49.2% Black, and 15.4% Other races.
Table 1 shows that in 2021, the overall obesity prevalence in Mississippi high-school students was 23.2%. Obesity prevalence for males is significantly higher than that of females (PD = 9.5%; PR = 1.13); Black students had significantly higher obesity prevalence compared to their White counterparts (PD = 6.6%; PR = 1.09); Other race students also had significantly higher obesity prevalence compared to their White counterparts (PD = 6.1%; PR = 1.08).
From 2001 to 2021, as shown in Figure 1 and Table 2, obesity prevalence in Mississippi high-school students showed a significant increasing trend with an AAPC of 2.4%. Figure 2 and Table 2 show that trends of increase were more pronounced in females (AAPC = 3.2%) than males (AAPC = 1.8%). The increase in females was linear from 2001 to 2021, whereas in males, there was no significant change from 2001 to 2013, but from 2013 to 2021, an increasing trend was observed (AAPC = 3.4%). Figure 3 and Table 2 show that all race categories had increasing trends, with AAPC being 2.3%, 2.5%, and 3.7% for White, Black, and Other race students, respectively.
Figure 4 and Table 3 show that while both the U.S. and Mississippi had trends of increase in obesity prevalence from 2001 to 2021, Mississippi had a greater pace of increase at 2.4% average annual percentage change, compared to 1.5% for the U.S.

4. Discussion

Our analysis of Mississippi high-school students’ obesity prevalence based on YRBSS data indicated that the overall obesity rate among Mississippi high-school students was 23.2%. In the same year, the U.S. high-school students’ obesity prevalence rate was 16.3% and the lowest was Utah at 10.2% [39]. Research conducted in Mississippi over the past few decades has consistently shown that the obesity prevalence among Mississippi children remained higher than the national average [40,41,42,43,44]. The trend analysis from 2001 to 2021 showed a significant increase, with AAPC being 2.4%, at an alarming pace that is significantly faster than the U.S. high-school students as a whole (AAPC = 1.5%). A similar trend analysis using the National Health and Nutrition Examination Survey (NHANES) showed a corresponding upward trend [45,46,47], highlighting the urgency to address this critical public health issue, not only in Mississippi but across the nation.
Our study revealed that in 2021, the obesity prevalence rate for Mississippi high-school male students was significantly higher than that of female students. In contrast, the YRBSS 2019 data indicated that the obesity prevalence for Mississippi high-school female students was 21.1%, with 25.8% for male students, and there was no significant difference [48]. Our biennial Child and Youth Prevalence of Obesity Survey (CAYPOS) 2019 data, which collected the anthropometric height and weight data of Mississippi school-aged children since 2003, also showed an insignificant difference in obesity prevalence between high-school male (27.8%) and female (28.1%) students [49]. In fact, historical CAYPOS data indicated that this lack of significant difference between male and female students has been consistent [40,42,50,51,52]. In addition, though our study also found that the AAPC for females (3.2%) was higher than that of males (1.8%), the APC for males, 3.4% from 2013 to 2021 in comparison to 0.01% from 2001 to 2013, has been increasing at a much higher pace since 2013. It is reasonable to assume that the presence of significant gender differences in 2021 is driven by the increase in male obesity prevalence. Ongoing monitoring is needed to determine if male high-school students in Mississippi are facing a more severe issue with obesity than their female counterparts and if immediate interventions should prioritize the male population.
Our study also indicated that in 2021, the obesity prevalence rate for Mississippi high-school Black students was significantly higher than that of White students. This is consistent with the CAYPOS findings [40,42,43,44,52] and 1999–2015 YRBSS findings by Aranmolate [53]. In addition, AAPC for all races demonstrated an increasing trend with 2.3% for White students, 2.5% for Black students, and 3.7% for Other race students. Moreover, the differences among races have shown a growing widening trend, indicating that racial disparities remain a concerning issue in the state. Krueger and Either [54] asserted that racial or ethnical disparities arose from social, behavioral, and biological mechanisms influenced by factors such as neighborhood context, social networks, access to medical care, diet and physical activity, sleep duration, screen time, sedentary behaviors, genetics, and epigenetics. Therefore, they encouraged researchers and policymakers to implement multifaceted interventions that could address these multiple mechanisms simultaneously, targeting low-income neighborhoods, promoting health literacy and social connections, and prioritizing early-life interventions.
In Mississippi, several agencies have been collaborating and making concerted efforts to improve the health of school students in the last few decades. In 2007, Mississippi Legislature passed the Mississippi Healthy School Act, which mandates health education and physical activity requirements and requires that schools provide programs to reduce obesity in the state [55]. In 2015, The Mississippi Department of Education (MDE) established the Smart Snacks Standards for all foods and beverages sold in schools in Rule 17.10 Smart Snacks Standards for All Foods and Beverages Sold in Mississippi Schools [56], which mandates schools to provide students healthier choices such as whole grain-rich products, fruits, vegetables, leaner protein, and lower-fat milk. Regarding health literary, in 2020, MDE introduced a high-school course titled Contemporary Health [57], which was designed to teach students knowledge, attitudes, and skills needed to make healthy choices and adopt behaviors to promote health literacy. It also offered the Health Science Core course for students in the health sciences pathways to provide students with foundational knowledge in safety, medical terminology, body organization, basic anatomy and physiology, etc. [58]. The Mississippi State Department of Health (MSDH) actively collaborates with the MDE, as well as the CDC, to enhance student health. Coordinated School Health is a reflection of such collaboration. This program aims to improve the health of students by integrating health education, physical activity, nutrition services, and counseling services within schools [59]. The Center for Mississippi Health Policy (CMHP) is another agency that has been actively involved in improving student health and health literacy. This center provided evaluations of the Mississippi Healthy Students Act and published various research reports focusing on the prevalence of childhood obesity in Mississippi and the role of school health initiatives in addressing this issue [60]. Continuous collaborations among schools, health systems, researchers, and policymakers are needed in Mississippi to address the widening gap among races.
The strength of the study primarily lies in the inclusion of twenty-year data for trend analysis. This extensive timeframe provided a clear picture of how obesity prevalence changed over time and allowed for the identification of long-term patterns in the population. Another strength is that both Mississippi- and U.S. YRBSS samples were representative of their study population. The study has limitations. Mississippi YRBSS only surveyed students from public high schools; thus, the data do not represent all adolescents in the age group, in that it excluded students from private schools, homeschools, and those not in school. In addition, data bias may exist because of the self-reporting nature of the survey. Future research should continue focusing on monitoring the obesity prevalence trends in Mississippi. Moreover, more detailed analyses stratified by gender and race, age, and other risk factors could be conducted to provide a holistic view of this major public health concern.

5. Conclusions

This study revealed that the obesity prevalence of Mississippi high-school students is higher than the national average and exhibited significant increasing trends from 2001 to 2021, as a whole or stratified by gender or race. Furthermore, Mississippi adolescents’ obesity is increasing at a greater pace compared to that of the United States. The upward trend in obesity prevalence among Mississippi high-school students warrants urgent attention at the government, community, school, family, and personal levels. Concerted efforts must be made to fight and reverse this epidemic.

Author Contributions

Conceptualization, Z.Z. and L.Z.; methodology, Z.Z. and L.Z.; software, Z.Z. and L.Z.; validation, Z.Z. and L.Z.; formal analysis, Z.Z. and L.Z.; investigation, Z.Z. and L.Z.; resources, Z.Z. and L.Z.; data curation, Z.Z. and L.Z.; writing—original draft preparation, Z.Z., X.Z.G. and L.Z.; writing—review and editing Z.Z., X.Z.G. and L.Z.; supervision, L.Z.; project administration, Z.Z. and L.Z. All authors have read and agreed to the published version of the manuscript.

Funding

This research received no external funding.

Institutional Review Board Statement

Institutional Review Board approval was not required for this study.

Informed Consent Statement

Not applicable.

Data Availability Statement

The data used and analyzed during the current study are available from the corresponding author upon reasonable request.

Conflicts of Interest

The authors declare no conflicts of interest.

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Figure 1. Obesity Trends among Mississippi High-school Students, 2001–2021. * denotes APC being significant.
Figure 1. Obesity Trends among Mississippi High-school Students, 2001–2021. * denotes APC being significant.
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Figure 2. Obesity Trends among Mississippi High-school Students by Gender, 2001–2021. * denotes APC being significant.
Figure 2. Obesity Trends among Mississippi High-school Students by Gender, 2001–2021. * denotes APC being significant.
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Figure 3. Obesity Trends among Mississippi High-school Students by Race, 2001–2021. * denotes APC being significant.
Figure 3. Obesity Trends among Mississippi High-school Students by Race, 2001–2021. * denotes APC being significant.
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Figure 4. Obesity Trends among High-school Students: Mississippi vs United States, 2001–2021. * denotes APC being significant.
Figure 4. Obesity Trends among High-school Students: Mississippi vs United States, 2001–2021. * denotes APC being significant.
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Table 1. Obesity prevalence of Mississippi high-school students by demographic characteristics YRBSS 2021.
Table 1. Obesity prevalence of Mississippi high-school students by demographic characteristics YRBSS 2021.
CharacteristicPrevalence (95% CI) (%)PD * (%)PR (95% CI)p-Value
Total23.2 (20.5, 25.9)NANANA
  Gender
   Female18.5 (16.8, 20.7)RefRef
   Male28.0 (25.2, 30.7)9.51.13 (1.07, 1.19)p < 0.001
  Race
   White19.7 (15.5, 23.9)RefRef
   Black26.3 (22.9, 29.7)6.61.09 (1.02, 1.16)p = 0.007
   Other25.8 (20.2, 31.5)6.11.08 (1.00, 1.17)p = 0.046
* PD—prevalence difference; PR—prevalence ratio; Ref—reference group.
Table 2. Obesity prevalence trends in Mississippi high-school students, YRBSS 2001–2021.
Table 2. Obesity prevalence trends in Mississippi high-school students, YRBSS 2001–2021.
CharacteristicAAPC * (95% CI), %p-ValueSegment 1APC
(95% CI), %		p-ValueSegment 2APC
(95% CI), % 		p-Value
(2001–2021)
Total2.4 (1.4, 3.4)<0.001NANANANANANA
Gender
   Female3.2 (1.3, 5.1)<0.01NANANANANANA
   Male1.8 (0.5, 3.2)<0.01(2001–2013)0.01 (−2.2, 2.3)0.98(2013–2021)3.4 (1.8, 5.0)<0.01
Race
   White2.3 (1.0, 3.6)<0.01NANANANANANA
   Black2.5 (1.4, 3.6)<0.01NANANANANANA
   Other3.7 (1.2, 6.3)<0.01NANANANANANA
* AAPC—average annual percentage change in obesity prevalence during 2001–2021; APC—annual percentage change in obesity prevalence for the segment.
Table 3. Obesity trend among Mississippi and U.S. high-school students, YRBSS 2001–2021.
Table 3. Obesity trend among Mississippi and U.S. high-school students, YRBSS 2001–2021.
Adj. Prevalence * (%)AAPC (95% CI), %p-Value
20012021Linear **Quadratic **Joinpoint
Mississippi14.023.02.4 (1.4, 3.4)<0.001NA<0.001
U.S. 10.816.01.5 (1.0, 2.1)<0.001NA<0.001
* Adjusted prevalence: adjusted for sex, race, and grade; ** results of logistic regression models.
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MDPI and ACS Style

Zhang, Z.; Gordy, X.Z.; Zhang, L. Obesity Prevalence and Trend Among Mississippi High-School Students: Youth Risk Behavior Surveillance System (YRBSS) 2001–2021. Obesities 2025, 5, 6. https://doi.org/10.3390/obesities5010006

AMA Style

Zhang Z, Gordy XZ, Zhang L. Obesity Prevalence and Trend Among Mississippi High-School Students: Youth Risk Behavior Surveillance System (YRBSS) 2001–2021. Obesities. 2025; 5(1):6. https://doi.org/10.3390/obesities5010006

Chicago/Turabian Style

Zhang, Zhen, Xiaoshan Z. Gordy, and Lei Zhang. 2025. "Obesity Prevalence and Trend Among Mississippi High-School Students: Youth Risk Behavior Surveillance System (YRBSS) 2001–2021" Obesities 5, no. 1: 6. https://doi.org/10.3390/obesities5010006

APA Style

Zhang, Z., Gordy, X. Z., & Zhang, L. (2025). Obesity Prevalence and Trend Among Mississippi High-School Students: Youth Risk Behavior Surveillance System (YRBSS) 2001–2021. Obesities, 5(1), 6. https://doi.org/10.3390/obesities5010006

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