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Biostaticians’ Role in Study Design

Anna Rodriguez-Vasquez
MPH 520 Biostatistics
August 17,2018
Part 1

Framing the problem

Johnson County has encountered a significant increase in clinically obese children which
is putting a significant burden on the county’s Medicaid budget. Due to this issue , Dr.John D.
Davison is scheduled to fill the position of State Director for Public Health for Johnson County.
Dr.Davidson has been the director of community and family health and has been described to be
hard working, innovative and a supportive leader. Governor Greg Patterson is hoping that by
having Dr.Davison as the director, Johnson county’s national figures improve and are not
classified to be in the top 20% of the states with children who are clinically obese. “​Overweight
and obesity in childhood are known to have significant impact on both physical and
psychological health. Overweight and obese children are likely to stay obese into adulthood and
more likely to develop non-communicable diseases like diabetes and cardiovascular diseases at a
younger age. The mechanism of obesity development is not fully understood and it is believed to
be a disorder with multiple causes. Environmental factors, lifestyle preferences, and cultural
environment play pivotal roles in the rising prevalence of obesity worldwide.” (Sahoo et al 2015)

Research Question

Research Question : Can obesity be due to living in an low income household ?

Research Hypothesis : There is a correlation between obesity and low income households

Null Hypothesis: There is a correlation between obesity and low income households
Part 2
Annual Household
BMI Income
26 128.45
28 100.5
33 125.05
37 125.95
27 95.8
30 166.55
28 136.75
35 86.7
36 169.05
39 148.25
31 138.1
25 142.05
32 114.9
38 124.45
24 157.65
35 215.45
38 119.25
32 111.95
37 106.45
31 132.85
29 117.5
36 131.4
28 121.55
39 146.25
45 146.1
35 100.55
32 127.45
27 141.1
25 135.9
28 105.75

Groups Count Sum Average Variance

Obese Family Member30 16 0.5333333333 0.2574712644
Annual Household
Income 30 3919.7 130.6566667 658.5273678
BMI 30 966 32.2 26.71724138

Regression Statistics
Multiple R 0.09338297362
R Square 0.008720379762
Adjusted R Square -0.02668246382
Standard Error 5.237377512
Observations 30

df SS MS F Significance F
Regression 1 6.75655024 6.75655024 0.2463186253 0.6235531248
Residual 28 768.0434498 27.43012321
Total 29 774.8

Coefficient Standard Lower Upper Lower Upper

s Error t Stat P-value 95% 95% 95% 95%
29.74241 5.043238 5.897483 41218220 19.41181 40.07302 19.41181 40.07302
Intercept 716 96 223 2 059 373 059 373
X Variable 0.018809 0.037899 0.496304 0.623553 -0.058823 0.096442 -0.058823 0.096442
1 47145 01877 9721 1244 14823 09113 14823 09113
The methodology being used to test the hypothesis will be linear regression test. We are

using linear regression because we are testing the correlation between two independent variables

( obesity and household income) in regards to the issue of obesity rates in Johnson County. In

our hypothesis we are testing a correlation between obesity and household income. When

performing the linear regression test we are determining whether these groups are statistically

significant to each other through predictive analysis in addition to figuring out if these two

variables are dependent on eachother.By using the data for obese family members, annual

household and household BMIs, we are trying to assess if our hypothesis of a potential

correlation between obesity and household income exist. Since our P-Value was less than our

significance level, we reject our null hypothesis; meaning that there is a significant correlation

between our variables. In terms of analyzing this data, often families who have lower income do

not have the means to purchase healthy foods. Which they often turn to fast foods and

convenience foods due to cost, leading to health problems such as obesity, high blood pressure

and heart disease. “​The U.S. is one of the wealthiest countries in the world and accordingly has

high obesity rates; one-third of the population has obesity plus another third is overweight. The

situation is predicted to worsen; rising childhood obesity rates forewarn of worsening

statistics...Several reasons may explain why people living in poor countries are less active. One

reason may be that violence tracks with poverty, thereby preventing people from being active

out-of-doors. Similarly, parks and sports facilities are less available to people living in poor

countries , and people who live in poverty-dense regions may be less able to afford gym

membership, sports clothing, and/or exercise equipment.” (​ Levine, James A. 2011 ) The

association between obesity and income is often due to the lack of resources and time. Families
who lack financial stability often live in low income neighborhoods, resulting in increased crime

rate. Additionally these families are unable to invest in their health, such as having a gym

membership or any resources that allows them daily exercise. In addition to lack of exercise, fast

paced lifestyles are associated with these demographics , due to busy full time jobs, families

often do not have the time to prepare nutrient filled meals and opt for fast convenience foods due

to cost and time.

Part 3

Johnson County is currently undergoing new change; from implementing a new State

Director for Public Health to dealing with a severe obesity epidemic. The new Director ,

Dr.John Davison is requesting the assistance of the Public Health Department to evaluate and

analyze data results in order to implement a plan to eradicate the obesity problem, especially the

childhood obesity problem. As research analyst we first had to come up with a research question,

we decided to observe if there were any potential correlations between obesity and annual

household income ?

We chose to move forward with analyzing our data with and questioning our hypothesis

with an linear regression test because we observing two independent variables (in this case

obesity and household income). Through this analysis we determined that there is a correlation

between the two variables; Obesity ( High BMI ) and household income.
Graph 1 : Column graph of average family BMI and Annual Household Income
Graph 2 : Linear scatter plot

Source of Variation SS df MS F P-value F crit

Between Groups 145405.7282 1 145405.7282 424.3907248 0 4.006872653

Within Groups 19872.09367 58 342.6223046

Total 165277.8218 59
Table 1 : ANOVA Results

Groups Count Sum Average Variance

Annual Household Income 30 3919.7 130.6566667 658.5273678

BMI 30 966 32.2 26.71724138

Table 2 : Data Summary

According to the National Institute of Health “BMI is an estimate of body fat and a good

measure of your patients' risk for diseases that can occur with overweight and obesity. For adults,

a healthy weight is defined as the appropriate body weight in relation to height. This ratio of

weight to height is known as the body mass index (BMI). People who are overweight (BMI of

25–29.9) have too much body weight for their height. People who are obese (BMI of 30 or

above) almost always have a large amount of body fat in relation to their height.” (NIH National

Heart, Lung and Blood Institute 2018) According to our dataset, our average BMI is 32.3;

meaning that the average household is considered obese, additionally the average income for

households is 130.65 hundred thousand. How does these two correlate ? Referring to graph 1 :

Column graph of average family BMI and Annual Household Income we can observe that

families with an annual income of 110,000 and below have a higher likelihood of having higher

BMI. But how are lower incomes and obesity rates correlated ? Often the argument made is that

lower income households usually have a higher obesity due to fast paced lifestyles and inability

to afford nutrient dense foods. Additionally being unable to acquire gym memberships or have
extra time for leisurely activities due to the necessity of having a full time job or even more than

one job at a time. Obesity is prevalent in children who come from low income households which

Johnson County is currently seeing a large increase in obese children. “p​hysical home

environments characterized by greater availability of unhealthy foods, fewer fruits and

vegetables, more media equipment throughout the home and in the child’s bedroom, and fewer

sports/recreational equipment items have been linked to childhood obesity risk...childhood

obesity proportionately affects low-income children , which may contribute to socioeconomic

disparities in obesity-related chronic diseases throughout the lifespan . Socioecological models

attribute childhood obesity to intersecting social, economic, environmental, and psychobiologic

drivers of energy intake and expenditure” (Appelhans et al 2014)

In public health ,we often see these types of situations often. Having a problem due to

social and economic factors. In this case families who make less money, run the higher

possibility of being obese. I came from a significantly low income community, and growing up

as an obese child it was difficult to pick and choose what we were able to eat because we didn’t

have a choice. Meaning that we ate what we could afford and had time to grab. My mother was

the head of our household and she raised us as a single mother, often we relied on fast food

meals that were low or minimally nutrient dense. Many middle to low income families face this

situation due to cost of living, and being unable to afford basic necessities take a told and result

in stress which coincide as a factor leading to adult obesity. “Low-income women are

disproportionately burdened by severe obesity and are faced with multiple stressors that may be

due to financial constraints and lack of power. Low-income mothers of young children may be

particularly stressed if faced with being the sole provider for their children. How stress might
increase severe obesity through eating behaviors and diet quality while accounting for

unmeasured pathways (e.g., biological) in low-income women is poorly understood.” (

Richardson et al 2015) Many biases that people in these situations face are that obese people are

lazy or that you can eat healthy on a budget; the latter being true but it is extremely time

consuming . Time that many families do not have to spare. Obesity and laziness have nothing to

do with each other in this case, it’s sad to say that the most affordable foods are calorie dense and

nutrient deficient, but when supporting a family on a fixed budget there isn’t much room to


Part 4

The reasoning behind researching any potential correlation between obesity and

household income is due to the multiple programs and research centering around the idea that

low income families usually are heavier than higher income families due to lack of resources and

funds. There is often the misconception that obese people are heavier due to being lazy but

studies show us that due to lack of time because these families often have more than one job to

support the household and due to not being able to afford nutrient dense foods is why health

declines with lower income families. In this case it was observed that there was a correlation

between obesity and lower income families. “​Reduced variability in these behaviors may account

for the lack of observed associations, as low-income children’s physical activity and diet may be

constrained by school physical education policies, reliance on subsidized school meals, local

access to healthy food and physical activity venues, and socioeconomic influences on household

food choices. The presence of such constraints may result in sleep accounting for a larger

proportion of variance in weight status in this population”(Appelhans et al 2014) ​According to

our data set the average BMI was 32.2 for households with an income of 130,000; meaning that

BMI is within obesity range. My suggestions in tackling this obesity epidemic in Johnson

County is to focus on lower income families; initiate a kickstarter program that assist lower

income families through providing whole foods and grains at a lower cost, and hosting free to

low cost gym memberships or exercise classes at a local gym or school. In addition to providing

wholesome meals to students and minimizing access to cheap fast foods to reduce obesity rates

in children.
Appelhans, B. M., Fitzpatrick, S. L., Li, H., Cail, V., Waring, M. E., Schneider, K. L., … Pagoto,
S. L. (2014). The home environment and childhood obesity in low-income households:
indirect effects via sleep duration and screen time. ​BMC Public Health,​ ​14,​ 1160.

“Body Mass Index, BMI Calculator, Healthy BMI.” ​National Heart Lung and Blood Institute,​
U.S. Department of Health and Human Services, 2018,​.

Levine, J. A. (2011). Poverty and Obesity in the U.S. ​Diabetes​, ​60​(11), 2667–2668.

Richardson, A. S., Arsenault, J. E., Cates, S. C., & Muth, M. K. (2015). Perceived stress,
unhealthy eating behaviors, and severe obesity in low-income women. ​Nutrition Journal,​
14​, 122.

Sahoo, K., Sahoo, B., Choudhury, A. K., Sofi, N. Y., Kumar, R., & Bhadoria, A. S. (2015).
Childhood obesity: causes and consequences. ​Journal of Family Medicine and Primary
Care​, ​4​(2), 187–192.