Journal of Physical Activity and Health, 2014, 11, 1179-1186

http://dx.doi.org/10.1123/jpah.2012-0245
2014 Human Kinetics, Inc.

Official Journal of ISPAH

www.JPAH-Journal.com
ORIGINAL RESEARCH

Proximal and Distal Environmental Correlates

of Adolescent Obesity
Kathryn C. Nesbit, Thubi A. Kolobe, Sandra H. Arnold, Susan B. Sisson, and Michael P. Anderson
Background: The purpose of this study was to determine how proximal (home) and distal (neighborhood) environmental
characteristics interact to influence obesity in early and middle adolescents. Methods: This was a descriptive, cross-sectional
study using the 2007 National Survey of Childrens Health (NCSH). Participants were 39,542 children ages 11 to 17 years.
Logistic regressions were used to examine the relationship between adolescent obesity and environmental factors, the relative
strength of these factors, and the influence of age and gender. Results: Proximal environmental factors were stronger correlates
of adolescent obesity than distal environmental factors. Sedentary behavior related to TV watching time at home was the strongest correlate of adolescent obesity overall (OR 1.13, 95% CI 1.111.15). Parks and playgrounds (OR 0.86, 95% CI 0.080.92),
as well as recreation centers (OR 0.91, 95% CI 0.850.97) were significant distal environmental factor correlates. Girls and
middle adolescents were at less risk for obesity than boys and early adolescents (OR 0.51, 95% CI 0.680.82; OR 0.75, 95% CI
0.680.96). Conclusion: The results of this study reveal the importance of proximal environmental characteristics on adolescent
obesity relative to distal environmental characteristics. Obesity intervention strategies for adolescents should target sedentary
behavior and opportunities for physical activity with a focus on early adolescents and boys.
Keywords: pediatrics, sedentary behavior, neighborhood characteristics
A higher risk of obesity has been shown at critical time periods
of development: early infancy, 5 to 6 years of age, and adolescence.1,2 Between 19662006, the prevalence of adolescent obesity
has more than tripled from 5% to 17.6%.3,4 According to the 2007
National Survey of Childrens Health (NSCH), 16.4% of children
ages 10 to 17 years in the United States (US) are obese5 (defined as
body mass index (BMI) 95th percentile for age and sex).6
Adolescence is a developmental transition period characterized
by physical, social, emotional, behavioral, and cognitive changes
triggered by the neuroendocrine network activated at puberty.7 It
is defined as persons 11 to 21 years of age with subcategories of
early adolescence at 11 to 14 years of age, middle adolescence at
15 to 17 years of age and late adolescence at 18 to 21 years of age.8
Given that adolescents develop relationships outside of the home, it
would appear that as they get older they are likely to be influenced
increasingly by factors in the neighborhood. The terms proximal
(home) and distal (neighborhood) environment have been used to
distinguish these settings.9 The physical and social aspects of the
proximal and distal environment are explained by Kolobe et al.9 In
the proximal environment, the physical aspect includes the home
space and materials in the home. The social aspect of the proximal
environment includes parent perceptions that influence childrearing practices and adolescent behaviors in the home. In the distal
environment, the physical aspect includes the built community such
as the presence of sidewalks, parks, playgrounds and recreation
Nesbit (Casey.nesbit@gmail.com) is with the Dept of Physical Therapy,
University of the Pacific, Stockton, CA. Kolobe and Arnold are with the
Dept of Rehabilitation Sciences, University of Oklahoma, Oklahoma
City, OK. Sisson is with the Dept of Nutritional Sciences, University of
Oklahoma Health Sciences Center, Oklahoma City, OK. Anderson is with
the Dept of Biostatistics and Epidemiology, University of Oklahoma,
Oklahoma City, OK.

centers. The social aspect of the distal environment includes relationships with peers and adults in the community, and behaviors in
the neighborhood. The shifts in relationships and interactions with
the environment that occur with adolescence raise questions about
the relative importance of factors in the distal environment to the
increasing prevalence of adolescent obesity.7,10,11 Also, stage of adolescence (early, middle, late) and gender are potentially associated
with differential engagement with the distal and proximal environments as they relate to obesogenic behaviors.3,12,13 Understanding
the specificity of the influence of various environmental factors is
necessary for effective obesity prevention and intervention.
National population-based studies of the collective influences
of proximal and distal environmental factors on adolescent obesity
are lacking. In the few studies that have reported significant influence of both proximal and distal factors on BMI, participants were
either limited to specific geographic areas, homogeneous in terms
of ethnic representation, or younger than adolescent age.14,15
Individual influences of either proximal environmental factors13,18,20 or distal environmental characteristics on adolescent
BMI,12,21 but not both. Sedentary activities have been shown to
be associated with higher weight status in 9- to 12-year-olds.20 In
analyses of the 2003 NSCH and the 20012006 National Health and
Nutrition Examination Survey (NHANES), higher television viewing was associated with higher adolescent obesity prevalence.13,22
Sisson et al23 reported that 6 to 17 year olds with low physical activity and high leisure time screen-based activity were at a higher risk
of overweight status (defined as a BMI in the 85th to 94th percentile
for age and sex).6 The combined influence of high TV watching
time and low vigorous physical activity on the odds of adolescents
being overweight was also reported based on the logistic regression
analysis of the Youth Risk Behavior Survey by Eisenmann et al.24
Other studies focus on the social aspect of the proximal environment including parent perception of safety. Timperio et al,17 in
a cross-sectional survey of 10 to 12 year olds, also observed that
1179

1180Nesbit et al

children whose parents were concerned about road safety were more
likely to be obese than children whose parents were not concerned.
Parent concern about neighborhood safety was associated with
an increased risk of being overweight in children at the age of 7
years25 and among 10- to 12-year-olds.17 Singh et al12 estimated
that the odds of being obese or overweight were higher among
children in neighborhoods with unfavorable conditions (such as,
lack of safety, lack of amenities, presence of dilapidated housing). The findings by Slater et al19 showed a positive relationship
between more physical disorder (loitering, dilapidated buildings,
vandalism) and higher weight, and a significant increase in the odds
of a lower BMI in more compact communities (dense residential
areas, connecting streets). Norman et al16 found an association
of community design with physical activity, but not with BMI.
Although pervious research provides background on the influences
of individual attributes of the proximal or distal environment on
adolescent obesity, the collective influence of these proximal and
distal factors has not been examined.
Population-based studies are necessary to add to the body of
evidence about the interplay and impact of proximal and distal environmental factors on the adolescent obesity epidemic particularly
across socioeconomic level, race, ethnic and geographic groups26
and provide the basis for appropriately targeted intervention initiatives.27 The current study is based on the 2007 NSCHa nationwide
survey with weighted results to reflect population characteristics
of noninstitutionalized children ages 10 to 17 years representative
of each state and the District of Columbia.28 The purpose of this
study was to examine how the factors in the proximal (home) and
distal (neighborhood) environment interact to impact obesity in
11- to 17-year-olds. This US population-based study addressed the
following questions:
1. Which attributes of the proximal environment and distal environment are correlates of adolescent obesity?
2. What is the relative strength of their direct and indirect association with adolescent obesity?
3. Is there a difference in the relationship between proximal and
distal environmental factors and their influence on obesity for
early (1114 years of age) and middle (1517 years of age)
adolescents?
4. Is there a difference in the relationship between proximal and
distal environmental factors and their influence on obesity for
adolescents based on gender?
We hypothesized that a) proximal factors related to sedentary
behavior and parent perception of safety, and distal factors related
to the built environment, will be related to adolescent obesity; b)
the distal factors will be more related to obesity in adolescents than
proximal factors; c) the influence of factors in the distal environment will be greater on middle (1517 years) than early (1114
years) adolescents; and d) the influence of factors in the proximal
environment will be greater on girls than boys.

Methods
The study design is descriptive and cross-sectional. Data were
extracted from the 2007 NSCH database obtained from the publicuse data set from the data resource center for Child and Adolescent
Health Measurement Initiative (CAHMI).5,28 Data were filtered for
the age range for this study (1117 years), the independent variables,
and the dependent variable. We conducted all analyses using PASW

Statistics GradPack18.029 and missing data were handled by removal

of specific missing values (pairwise deletion).

Study Data
The participants in the 2007 NSCH were households with children
less than 18 years of age. These households were identified from
2.8 million randomly generated landline telephone numbers from
the Centers for Disease Control and Preventions (CDC) National
Immunization Survey (NIS) sampling frame. Blumberg et al28
report details of the 2007 NSCH sample design, questionnaire
content development, sampling weights, and methods. A total of
91,642 interviews were conducted with at least 1700 interviews
from each of the 50 states and Washington DC. Geographic information other than the state identifiers was not in the publicly available 2007 NSCH dataset. The sample included 39,542 children
aged 11 to 17 years. The interview completion rate was 66%. The
procedure for the survey began with identification of a person or
people in the household under the age of 18, the randomly selected
child, and a respondent 18 years of age or older. Informed verbal
consent was obtained after the respondent (knowledgeable adult)
was identified.

Sample Size Estimate

The sample size estimate needed for a 99% confidence level (1% margin
of error) is 9068.30 The sample size estimate for 15 predictor variables
with a small effect size (0.02), and 0.8 power at alpha = .01 is 1284.31
The sample size of 39,542 for this study far exceeds these estimates.

Study Variables
The independent variables examined in the study included age, gender,
proximal environmental characteristics available in the NSCH (parent
perception that the child is safe, parent perception that others watch
for the child, parent trusts that people will help the child, reading
time on an average weekday, computer time on an average weekday,
TV watching time on an average weekday, and presence of a TV in
the bedroom), and distal environmental characteristics (presence of
sidewalks and walking paths, presence of parks and playgrounds, presence of community or recreation center, presence of litter or garbage,
presence of dilapidated housing, presence of vandalism).
The dependent variable, obesity classification, was determined
by having a body mass index 95th percentile based on gender
and age specific growth charts, as defined by cut offs established
by the Centers for Disease Control and Prevention (CDC).6 The
respondent (ie, generally parent) reported height and weight for
the selected child.

Data Analysis
To determine which attributes of the proximal and distal environments were predictive of adolescent obesity, univariate logistic
regression models were fit to explore the relationship between adolescent obesity and each factor individually. To examine the relative
strength of the direct and indirect associations, we used multiple
logistic regression to consider all of the proximal and distal factors
collectively in the model, but retained only those that were significant. To explore the influence of early and middle adolescence,
we considered proximal and distal environmental factors, and age
group interaction terms in the model, but retained only those that
were significant. To determine the influence of proximal and distal

Correlates of Adolescent Obesity 1181

environmental factors on boys and girls, we considered proximal

and distal environmental factors, and gender interaction terms in
the model, but retained only those that were significant. The age
and gender interaction terms were included in the variable selection
procedures and those interaction terms that were not significant
were not retained in the final models. The forward and backward
variable selection procedures for multiple logistic regression were
used to identify variables important to the model. Because the best
model fit for the forward and backward procedures did not yield the
same model, the best-fit models for each procedure were compared
using Akaikes Information Criteria (AIC). The model with the best
overall fit (the lowest AIC) was reported.32

Results
Characteristics of the Sample
Baseline demographic characteristics of the sample are available
in Table 1.

Environmental Attributes
The results of the univariate logistic regression models are presented
in Table 2. Several proximal factors were associated with obesity,
including television in the bedroom, time watching television, as
well as parent perception of safety, that others watch their children
and trust in others. All distal factors were also associated with obesity including adolescents living in neighborhoods with sidewalks,
playgrounds and parks, a recreation center, vandalism, dilapidated
housing, and litter.

Table 1 Demographic Characteristics of Adolescents

in the 2007 National Survey of Childrens Health
Characteristic

Percentage

Age
11

11.4

12

12.9

13

13.1

14

14.3

15

14.9

16

16.4

17

17.0

Gender
Girl

47.8

Boy

52.1

BMI for age classification

Underweight < 5th percentile

4.6

Normal weight 5th to 84th percentile

67.6

Overweight 85th to 94th percentile

14.9

Obese 95th percentile or above

12.9

Race/ethnicity
Hispanic

10.7

White, non-Hispanic

70.9

Black, non-Hispanic

10.3

Multiracial, non-Hispanic

4.2

Strength of Associations

Other, non-Hispanic

3.9

The results of the multiple logistic regression analysis showing

the relative strength of the direct and indirect associations of the
proximal and distal environmental determinants are presented in
Table 3. Proximal environmental factors with the greatest influence
on adolescent obesity were TV watching time (2 = 210.695), TV
in the bedroom (2 = 247.199), and parent report of safety (2 =
53.776). Distal environmental factors with the greatest influence
on adolescent obesity were parks and playground (2 =16.652),
and availability of a recreation center (2 = 8.059). This model also
included computer time and parent perception of trust that others
will help the child variables.

Poverty level

Influence of Age Group on Environmental

Determinants
The results of the multiple logistic regression analysis including
proximal and distal environmental factors, and early and middle
adolescent age group interaction terms are presented in Table 4.
Only 1 age interaction term, that of age and TV watching time, was
marginally significant (2 = 3.586, P = .058) and was retained in
the model. The effect of TV watching time on obesity for middle
adolescents was stronger than early adolescents. Odds of a middle
adolescent being obese were less than the odds of an early adolescent (2 = 40.493). Proximal environmental factors in the model
with age group interaction terms that showed the greatest influence
on adolescent obesity were TV watching time (2 =149.613), TV
in the bedroom (2 = 268.022), and parent report of safety (2 =
53.335). Distal environmental factors were parks and playgrounds
(2 = 16.380), and recreation center (2 = 10.123).

099% federal poverty level

20.4

100199% federal poverty level

26.0

200399% federal poverty level

33.8

400% federal poverty level or greater

39.8

Birth order
1

47.1

32.5

17.9

2.2

0.3

Mothers sducation
Less than high school

7.8

12 years/high school graduate

22.0

More than high school

69.8

Dont know/refused

0.3

Influence of Gender on Environmental

Determinants
The results of the multiple logistic regression analysis with proximal
and distal environmental factors, and gender interaction terms are
presented in Table 5. Only 1 gender interaction term, that of gender

1182Nesbit et al

Table 2 Univariate Logistic Regression of Proximal

and Distal Environmental Attributes for Prediction
of Obesity
Variable

Odds
ratioa

95% CIb

Proximal attributes

Table 3 Multiple Logistic Regression of Proximal

and Distal Environmental Attributes for Prediction
of Obesity
Outcome Predictor variables
Obesity

TV bedroom
Presence

Odds
ratioa

95% CIb

Proximal attributes
TV bedroom

Referent

Presence

Referent

Absence

0.54

0.510.58

Absence

0.60

0.560.63

TV watching time (hours/day)

1.16c

1.141.78

TV watching time (hours/day)

1.13c

1.111.15

Computer time (hours/day)

1.04c

1.021.06

Computer time (hours/day)

Reading time (hours/day)

1.01

0.981.03

Safe

0.98c

0.960.99

Never safe

1.65c

1.302.10

1.41c

1.271.57

Parent perception of safety

Never safe

2.15c

1.712.70

Sometimes safe

Sometimes safe

1.65c

1.491.83

Usually or always safe

Usually or always safe

Referent

Referent

Trust

Parent perception that others watch child

0.76c

0.650.90

Somewhat agree

0.85

0.711.01

Somewhat disagree

0.95

0.761.18

Definitely agree

Definitely agree

0.59c

0.510.69

Somewhat agree

0.63c

0.540.74

Somewhat disagree

0.77c

0.630.94

Definitely disagree

Referent

Definitely disagree

Referent

Distal attributes

Parent perception of trust in others

Parks and playgrounds

Definitely agree

0.57c

0.480.66

Presence

0.86c

Somewhat agree

0.68c

0.580.81

Absence

Referent

Somewhat disagree

0.81

0.651.01

Recreation center

Definitely disagree

Referent

Distal attributes
Sidewalk

Presence

0.91c

Absence

Referent

0.800.92

0.850.97

a Exp

Presence

0.80c

Absence

Referent

0.820.94

(B).
b CI, Confidence Interval.
c Wald Chi-Square is significant at the 0.05 level.

Parks and playgrounds

Presence

0.80c

Absence

Referent

0.750.86

Recreation center
Presence

0.85c

Absence

Referent

0.800.91

Vandalism
Presence

1.19c

Absence

Referent

1.081.32

Discussion

Housing
Presence

1.26c

Absence

Referent

1.161.37

Litter
Presence

1.28c

Absence

Referent

Exp (B).
CI, Confidence Interval.
c Wald Chi-Square is significant at the 0.05 level.
a

and TV watching time was significant (OR 1.07, 95% CI 1.031.10).

The odds of a girl being obese were less than the odds of a boy (2 =
194.012). Proximal environmental factors in the model with gender
interaction terms indicate that the greatest influence on adolescent
obesity were TV in the bedroom (2 = 230.552), and parent report
of safety (2 = 61.967). Distal environmental factors in the model
with gender interaction terms were parks and playground (2 =
15.858), and recreation center (2 = 8.681).

1.181.39

When examined individually, the results of this population-based

study showing influences of proximal and distal environmental factors on adolescent obesity support the findings from sample-based
studies. Sedentary activities have been shown to be associated with
higher prevalence of adolescent obesity.13,20,2224 Parent concern
about safety has also been shown to be associated with an higher
risk of obesity.17,25 Unfavorable conditions of the neighborhood built
environment have been shown to have a positive relationship with
a higher BMI and decreased physical activity.12,16,19,33 Our analysis
showed that specific proximal and distal factors such as TV in the

Correlates of Adolescent Obesity 1183

Table 4 Multiple Logistic Regression of Proximal

and Distal Environmental Attributes With Age Group
Interaction Terms
Outcome Predictor variables
Obesity

Odds
ratioa

95% CIb

Proximal attributes

Table 5 Multiple Logistic Regression of Proximal

and Distal Environmental Attributes With Gender
Interaction Terms
Outcome Predictor variables
Obesity

TV bedroom

Odds
ratioa

95% CIb

Proximal attributes
TV bedroom

Presence

Referent

Absence

0.59c

TV watching time (hours/day)

1.14c

Presence

Referent

0.550.63

Absence

0.60c

0.560.64

1.121.17

TV watching time (hours/day)

1.03

0.991.01

Computer time (hours/day)

0.96c

0.960.99

Parent perception of safety

Never safe

1.58c

1.261.98

Parent perception of safety

Sometimes safe

1.40c

1.261.55

Never safe

1.77c

1.392.24

Sometimes safe

1.45c

1.301.61

Usually or always safe

Referent

Parent perception trust in others

Usually or always safe

Definitely agree

0.78c

0.660.92

Somewhat agree

0.87

0.731.03

Somewhat disagree

1.01

0.821.25

Definitely disagree

Referent

Parent perception of trust in

others

Distal attributes
Parks and playgrounds
Presence

0.86c

Absence

Referent

Referent

Definitely agree

0.75c

0.640.89

Somewhat agree

0.83c

0.700.99

Somewhat disagree

0.94

0.751.80

Definitely disagree

Referent

Distal attributes

0.800.93

Parks and playgrounds

Recreation center
0.840.96

Presence

0.86c

Absence

Referent

Presence

0.90c

Absence

Referent

Recreation center
Presence

0.90c

Referent

Absence

Referent

Age group
Early (1114 years)
Middle (1517 years)

0.850.97

0.75c

0.680.82

Gender
Boys

Referent

0.97 (ratio
early/
middle)

0.941.00

Girls

0.51c

0.460.56

1.07c (ratio
boys/girls)

1.031.10

Interaction terms
Age group by TV watching
time

0.800.93

(B).
b CI, Confidence Interval.
c Wald Chi-Square is significant at the 0.05 level.

Interaction terms
Gender by TV watching
time

a Exp

bedroom, perception about safety, and neighborhood amenities have

the strongest impact.
We hypothesized, based on relational and interactional shifts
that occur with adolescence, that distal factors would be more related
to obesity than proximal factors. However, proximal environmental
factors (TV watching time, presence of TV in the bedroom, computer time, parent report of safety, and parent report or trust that
people will help the child) were stronger correlates of adolescent
obesity than distal environmental factors (presence of parks and
recreation centers). Sedentary behavior related to TV watching time
was the strongest correlate of adolescent obesity overall.
Our findings offer a unique perspective because no studies with
a sample that is representative of US adolescents have examined
the collective and relative strength of the influence of proximal

a Exp

(B).
Confidence Interval.
c Wald Chi-Square is significant at the 0.05 level.
b CI,

and distal factors on adolescent obesity based on the actual BMI.

A study by Mota et al14 showed the combined influence of perceptions of the neighborhood environment and attributes of the built
environment on physical activity, although the relationship between
obesity was not analyzed and the study sample was from a limited
geographic area. Elder et al15 also examined proximal and distal
environmental correlates together in a study of Latino elementary
school children. Their study showed a relative importance to obesity of proximal factors (parents weight) as compared with distal
factors (community characteristics). A longitudinal study by Kahn
et al34 that considered both proximal and distal determinants of
adolescent physical activity included a large adolescent population
that lacked ethnic diversity and did not include the BMI. Several

1184Nesbit et al

review articles also included proximal and distal factors, but lacked
a supported a comprehensive analysis of their relative strength of
association with obesity.11,35
The interaction between the physical and social aspects of
environmental contexts, and the interplay between the home and
neighborhood settings are important to the interpretation of the study
results.9 On one hand, the proximal environmental factors in this
study represent both physical characteristics of the home as well as
behaviors in the home and parents perceptions that may contribute
to childrearing practices. On the other hand, the distal environmental
factors in this study represent only physical characteristics. It is
possible that the distal social factors related to adolescent behavior
in the neighborhood, such as actual use of the neighborhood amenities, and perception of their neighborhood condition, may also offer
valuable insight. For example, did TV watching time (the strongest
correlate to obesity) vary with the relative usage of neighborhood
amenities? The shift in the influence of the distal environment might
occur with the actual usage of amenities in the environment.

Age and Gender Group Differences

We hypothesized that the influence of factors in the distal environment on obesity would be greater in middle than in early adolescence based on the trends for increasing independence in the
community with increasing age, and literature about the role of
distal environmental characteristics.12 Our findings suggested that
the risk of obesity was higher in early than in middle adolescents.
This finding is consistent with findings from the 2003 NSCH,12 but
different from findings from the 2006 NHANES showing slightly
more obese 12- to 19-year-olds than 6- to 11-year-olds.3 In our
analyses age group did not have a significant impact on the influence of proximal or distal factors on obesity. These findings may
be related to differences in the range of age studied and the cut-off
for the various age groups.
We also hypothesized that the influence on obesity of factors
in the proximal environment would be greater for girls than for
boys based on girls tendency to remain in proximity to the home
and indications in the literature.13,24,36 Our finding that gender was
a strong predictor of adolescent obesity with boys being at a higher
risk than girls is supported in the literature.3,13 In contrast to the
expected results, a characteristic of the proximal environment (TV
watching time) had a greater influence on the odds of obesity in
boys than the odds of obesity in girls. The results of the studies in
the literature that use both physical activity and TV watching time
as predictive risk factors for obesity are mixed with some showing
an equal effect on boys and girls18 and others showing girls more
effected than boys.13,24

Implications for Practice

Insight into the influence of individual and collective proximal
and distal environmental attributes can inform theory for adolescent obesity intervention planning. Our findings based on a
nationwide, representative sample of US adolescents suggest
that specific environmental attributes of the home and neighborhood may influence adolescent obesity and should therefore be
the target for prevention programs. These results support current
approaches to obesity intervention which incorporate community
level interventions,37,38 school-based interventions,39 home sedentary behaviors,40 and the use of parents as agents of intervention
delivery.41 The results of the relative strength of proximal and
distal environmental correlates combined suggest that efforts to
decrease TV watching time must be coupled with intervention

strategies that increase the utility of neighborhood amenities. In

addition to targeting sedentary behaviors, obesity intervention
strategies for adolescents should also focus on the groups at
a higher risk for obesity: early adolescents and boys. Specific
strategies to reduce TV watching time should particularly target
adolescent boys.

Limitations
The responses to the 2007 NSCH were based on the report of a
knowledgeable person in the household that would proxy report on
the sample childs health and behaviors. The behaviors were not
directly observed, and the obesity status was not directly measured.
The questions about amenities in the community provide information about the presence of the amenities but do not necessarily
reflect their use for physical activity or the possible differences
between respondents perception of their environment and the actual
characteristics.42 Questions about television, computer, and reading
time ask about the adolescents behavior on an average weekday,
and may not necessarily reflect typical behavior on the weekend.
The lack of specific geographic information (not publicly available
in the 2007 NSCH) did not allow analysis of groups-levels for distal
environmental characteristics. However, the aim of this study was
to estimate the influence of the distal factors, rather than the variability of geographic clusters.

Future Research
The study of adolescent obesity is a complex topic involving multiple variables that need to be well understood if obesity prevention
efforts are to be focused and efficient. This study provided a muchneeded background for the development of a conceptual and intervention model that could guide intervention efforts. The intricacies
of the interactions of the environmental factors and the differences
in the interactions based on gender and age group may be further
understood in the future through development of conceptual models
that include constructs based on measurable variables.

Conclusions
The results of this US population-based study begin to fill the gap
in adolescent obesity research with an improved understanding
of the relatedness and relative importance of proximal and distal
environmental determinants of adolescent obesity. Home, family,
and community influences on adolescent obesity highlight the multidimensional nature of interactions with the environment during
this stage of development.4345 Recognizing the serious public
health concern of adolescent obesity, The American Academy of
Pediatrics46 and the Society for Adolescent Medicine47 advocate for
increased understanding of environmental risk factors. The results
of this study increase the understanding of not only the collective
influences of proximal and distal environmental characteristics,
but also their relative importance related to adolescent obesity.
This study highlights the importance of proximal environmental
characteristics on adolescent obesity relative to distal environmental
characteristics, and the overall consistency of the influences of
proximal and distal environmental factors on obesity across age
groups and gender. The specific environmental influences identified indicate that obesity intervention strategies for adolescents
should target sedentary behavior and opportunities for physical
activity with a focus on the groups at a higher risk for obesity:
early adolescents and boys.

Correlates of Adolescent Obesity 1185

Acknowledgments
This work was a partial requirement for the Doctor of Science degree
program in Rehabilitation Sciences at the University of Oklahoma Health
Sciences Center, Oklahoma City, Oklahoma for K. C. Nesbit and was
partially supported by grant #H325K080335 from OSEP.

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