Preventive Medicine 52 (2011) 218–222

Contents lists available at ScienceDirect

Preventive Medicine
j o u r n a l h o m e p a g e : w w w. e l s e v i e r. c o m / l o c a t e / y p m e d

Health behaviors and obesity among US children with attention deficit hyperactivity
disorder by gender and medication use
Juhee Kim a,⁎, Bala Mutyala a, Stamatis Agiovlasitis b, Bo Fernhall a
a
Dept. of Kinesiology and Community Health, University of Illinois at Urbana Champaign, 1206 S. 4th St, 213 Huff Hall, Champaign, IL 61820, USA
b
Department of Kinesiology, Mississippi State University, 233 McCarthy Gym., Mississippi State, MS 39762, USA

a r t i c l e i n f o a b s t r a c t

Available online 15 January 2011 Objective. We examined the levels of physical activity, sedentary behaviors, and obesity among children
with attention deficit hyperactivity disorder (ADHD) by gender and medication use and estimated the
Keywords: associations between health behaviors and obesity.
Physical activity Methods. Cross-sectional analysis of children 6–17 years-old enrolled in the National Survey of Children's
Sedentary behaviors
Health 2003 (n = 66,707). Odds ratios were adjusted for multistage-sampling and survey-design effects.
Depression
Obesity
Results. ADHD prevalence was 8.6%. In general, children with ADHD engaged in less physical activity,
National Survey of Children's Health (NSCH) organized sports, and reading than their counterparts. Children with ADHD had increased risk of obesity for
ADHD boys [24.9% vs. 21.6%, OR(95% CI): 1.42(1.13–1.77)] and girls [21.9% vs. 16%, 1.85(1.26–2.73)], if not
Medication medicated. Only girls with ADHD and not on medication were more likely to have higher media time (52.7%
vs. 42%) and this was associated with higher odds for obesity [27.7% vs. 19.5%, 2.51 (1.24–5.08)]. Children with
ADHD on medication had higher prevalence of depression than those not taking medication [boys: 29.5% vs.
26.3%; girls: 30.9% vs. 23.6%] and the odds of being depressed remained significant after controlling for obesity
[boys: 1.45 (1.09–1.94); girls: 2.27 (1.48–3.49)].
Conclusions. Health promotion and obesity prevention programs targeting children with ADHD should
take gender and medication use into consideration.
© 2011 Elsevier Inc. All rights reserved.

Introduction
Attention-deficit disorder/attention-deficit hyperactivity disorder
(ADHD) is a neurobehavioral pathology affecting 7.8% of US children
aged 4–17 years (Visser et al., 2007). ADHD often coexists with
learning disabilities, conduct disorder, anxiety, depression, bipolar
disorder (National Institute of Mental Health, 2003; Waxmonsky,
2003) and developmental coordination disorder (Harvey and Reid,
2003; Watemberg et al., 2007). Youth with ADHD have problems with
interpersonal relationships and employment, while their families may
have higher risk for conflict, familial stress, and reduced social
participation (Stefanatos and Baron, 2007). These factors engender
further risk for unfavorable health behaviors and health outcomes
among ADHD-afflicted youth.
Although hyperactivity would seem to increase daily energy
expenditure, youth with ADHD show higher obesity prevalence than
youth without ADHD (Holtkamp et al., 2004; Lam and Yang, 2007;
Waring and Lapane, 2008). Obesity may result from ADHD-related
physiologic alterations (Biederman and Faraone, 2005; Faraone et al.,
⁎ Corresponding author at: 1206 South Fourth St., 213 Huff Hall, Dept. of Kinesiology and
Community Health, University of Illinois at Urbana-Champaign, Champaign, IL 61820, USA.
Fax: +1 217 333 2766.
E-mail address: juheekim@illinois.edu (J. Kim).
2003; Gadde et al., 2006; Waring and Lapane, 2008) such as changes in
dopamine receptors that could potentially cause binge eating (Cortese
and Angriman, 2008) or from increased food intake associated with
impulsive behavior in boys with ADHD (Hubel et al., 2006) and
excessive daytime sleepiness (Cortese and Angriman, 2008). However,
there are no epidemiological studies available to identify the high risk
subgroups and the determinants of obesity among ADHD youth.
A recent study reported lower prevalence of obesity among ADHD
youth on medication than those not medicated (Waring and Lapane,
2008). This is not surprising since stimulant medications used for ADHD
symptoms cause appetite suppression and weight loss (Biederman and
Faraone, 2005; National Institute of Mental Health, 2003; Pliszka, 2007).
Nevertheless, only 56% of US children with ADHD receive pharmacologic
treatment (Biederman and Faraone, 2005). Thus, ADHD medication use
may not completely account for the observed differences in obesity
prevalence between individuals with and without ADHD. Factors
contributing to obesity may differ between boys and girls with ADHD.
Girls with ADHD are prescribed medication at half the rate of boys
(Faraone et al., 2003; Zuvekas et al., 2006), probably because of lower
hyperactivity levels and other externalizing behaviors (Biederman and
Faraone, 2005). Furthermore, girls in the general population are less
active than boys, especially during adolescence (Andersen et al., 1998;
Anderssen and Wold, 1992; Cardon and De Bourdeaudhuij, 2008). These
differences between boys and girls may impact health behaviors and

0091-7435/$ – see front matter © 2011 Elsevier Inc. All rights reserved.
doi:10.1016/j.ypmed.2011.01.003
 J. Kim et al. / Preventive Medicine 52 (2011) 218–222
may result in higher odds of obesity among youth with ADHD. In
addition to medication effects, other factors such as low physical
activity, lack of familial supports, or neighborhood conditions that have
been implied as contributors to obesity prevalence among US youth may
also play an important role in ADHD youth (Acevedo-Polakovich et al.,
2006; Burdette and Whitaker, 2005).
This study examined whether parent reports of their child's physical
activity, sedentary behaviors, depression, and home and neighborhood
conditions vary as a function of gender and medication use in ADHD
children, and if children with ADHD were different from children
without ADHD, using a nationally-representative sample of US youth.
We also evaluated whether these health behaviors and contextual
factors are associated with obesity within the ADHD subgroups.
Methods
Study sample
The study population included children aged 6–17 years enrolled in the
National Survey of Children's Health (NSCH) 2003. These data were collected
by the US Department of Health and Human Services from all 50 states and
the District of Columbia by employing the State and Local Area Integrated
Telephone Survey sampling program (Blumberg et al., 2005). Trained
interviewers collected data from parents or guardians (weighted response
was 55.3%). After excluding children whose height and weight were not
biologically plausible (n = 2023) and children with missing information on
ADHD (n = 301), a total of 66,707 children were included. The protocol was
approved by the Institutional Review Board of the University of Illinois at
Urbana-Champaign.
Measures
The definition of ADHD was derived from two questions. “Has a doctor or
health professional ever told you that your child has ADHD” and “Is your child
currently taking medication for ADHD?” The exposure variable has three
levels: 1) “ADHD ever; child currently takes medication” 2) “ADHD ever; child
not taking medication now” and 3) “Never told child has ADHD”. Obesity was
dichotomized as obese or not obese based on the CDC guidelines of weight-
for-height ≥ 95th percentile (Centers for Disease Control and Prevention). An
ecological model of obesity was used as a framework for the selection of
obesity-related variables for this study (Davison and Birch, 2001). Child
health behaviors and contextual factors that place children at increased odds
of obesity such as family and community environment were selected for
bivariate analysis to assess whether they were related to ADHD or obesity.
The level of physical activity was dichotomized as meeting or not meeting
the Healthy People 2010 goal — for instance, participating in vigorous activity
20 min for 3+ days per week or engaging in sedentary behavior such as
watching TV, videos, or playing video games more than two hours per school
day. Additional variables were included such as: depression or anxiety
problems (yes/no), number of family mealtimes together (b 5 days a week),
family rules about the TV program (yes/no), pleasure reading (yes/no),
computer use (yes/no), rode a bike, scooter, skateboard, roller skates, or
rollerblades during the past 12 months (yes/no), participation in organized
sports during the past 12 months (yes/no), participation in clubs or
organizations during the past 12 months (yes/no), not enough sleep
(b 7 days a week or not), do not live in a supportive neighborhood (yes/no),
do not feel safe about neighborhood (some/never and usually/always), and
do not feel safe at school (some/never and usually/always). The ‘supportive
neighborhood’ was a composite variable indicating parent's perceived
neighborhood social capital based on the four questions; “help each other
out”, “watch out each other's children”, “countable people in neighborhood”,
and “neighbors help my child”. Socio-demographic variables such as age,
family income, race/ethnicity, family structure, maternal education, and
household smoking were included in the analysis.
Analyses
All analyses were stratified by gender and weighted to generate
representative estimates of the US children by applying sampling weights.
Bivariate analyses were performed to compare socio-demographic character-
istics and obesity-related variables by ADHD. Among the obesity-related
219
variables of interest, only variables associated with ADHD remained in the
final model and are presented in the tables. Regression analyses were applied
for each health behavior and obesity-related conditions to determine the
differences by ADHD condition (Table 2) and between medicated and not-
medicated ADHD children (Table 3), simultaneously controlling for the socio-
demographic variables such as age, race/ethnicity, maternal education, family
structure, household income, and household smoking. We also evaluated the
potential mediation effect of obesity on obesity-related behaviors by ADHD
condition (data not shown) and by the medication status of ADHD children
(Table 3) by fitting the model with and without obesity. Furthermore,
bivariate and multivariate logistic regression models were built to evaluate
whether each variable is associated with obesity status within each group of
ADHD condition and the results were presented after controlling for socio-
demographic variables and depression or anxiety problems (Table 4).
Regression analyses were adjusted for the multistage sampling and survey
design effects. Analyses were conducted with SAS 9.2 (SAS Institute, Cary,
NC).
Results
The prevalence of ADHD (Table 1) was 8.6% in 2003 and differed by
gender (boys, 12.3%; girls, 5%). The use of medication was similar for
boys (59.7%) and girls (57.2%) with ADHD. The prevalence of obesity
was highest for both boys and girls with ADHD who were not on
medication when compared to those without the ADHD condition
(Table 2). Boys who were not on medication for ADHD had 42% higher
odds of being obese compared to boys without ADHD, after
controlling for socio-demographic variables. Girls, who were not on
medication for ADHD, had 85% higher odds of being obese compared
to those without ADHD (Table 2).
ADHD children on medication had 14 times higher odds of being
diagnosed with depression/anxiety compared to those without ADHD.
Both boys and girls with ADHD, regardless of medication status,
engaged in less physical activity, organized sports, and pleasure
reading when compared to those without ADHD. Girls with ADHD and
on medication were less likely to participate in club activities. Girls
with ADHD and not taking medication were more likely to spend time
on media [OR(95% CI) = 1.60(1.20–2.13)]. There was no difference in
computer use among girls, whereas boys with ADHD who did not take
medication showed less computer use compared to those without
ADHD. Both boys and girls with ADHD were less likely to live in
supportive neighborhoods compared to those without ADHD. Only
boys with ADHD who were not taking medication did not feel safe at
school. There was no mediating effect of obesity on the obesity-
related health behaviors and conditions except the ‘do not feel safe
neighborhood’ among girls. After adding obesity in the model, the OR
(95% CI) was changed to 1.51(0.99–2.31) for girls with ADHD not on
medication and to 1.38(0.90–2.17) for girls with ADHD on medication.
The differences between medicated and not-medicated ADHD
children were estimated (Table 3). Both boys and girls on ADHD
medication were more likely to have depression. The odds ratios
became stronger after adding obesity in the model, reflecting a
potential additive effect of obesity on depression. Only boys with
ADHD medication did not feel safe in the neighborhood, but this effect
disappeared when adding obesity in the model. Girls with medicated
ADHD had lower media time compared to their non-medicated peers;
obesity status did not change the odds of this behavior.
We evaluated whether health behaviors and other indicators were
associated with obesity by ADHD condition (Table 4). Among boys
with ADHD who were not taking medication, ‘Not riding a bike’ was
associated with being obese [OR(95% CI) = 2.11(1.22–3.67)]. Partic-
ipating in organized sports [OR(95% CI) = 1.57(1.06–2.34)] and not
having enough sleep [OR(95% CI) = 0.62(0.41–0.94)] were associated
with obesity for boys with ADHD and on medication. Watching media
more than 2 h a day was also associated with increased odds of being
obese among girls with ADHD and not medicated, compared with
those without ADHD.
220 J. Kim et al. / Preventive Medicine 52 (2011) 218–222

Table 1
Socio-demographic characteristics by attention deficit hyperactivity disorder (ADHD) condition among children aged 6 to 17 years from the National Survey of Children's Health
2003.

Boys Girls

No ADHD ADHD, not medicated ADHD, medicated No ADHD ADHD, not medicated ADHD, medicated

n (%) 29,801 (87.7) 1757 (5.3) 2599 (7.0) 30,772 (95.0) 733 (2.2) 981 (2.8)
Race/ethnicity
Hispanic 3591 (16.8) 149 (8.9) 164 (5.8) 3505 (16.2) 61 (10.8) 59 (7.5)
African American 2775 (13.8) 188 (17.8) 211 (13.3) 3018 (15.1) 68 (15.5) 72 (10.0)
Other 2085 (7.2) 135 (7.0) 160 (4.8) 2229 (7.0) 64 (5.8) 63 (6.5)
White 20,963 (62.0) 1270 (66.2) 2033 (76.2) 21,565 (61.6) 529 (67.9) 775 (76.1)
Family structure
Two parent biological/adopted 18,431 (60.6) 782 (42.6) 1242 (45.7) 18,701 (59.5) 320 (40.6) 494 (50.4)
Two parent stepfamily 3053 (10.9) 281 (18.2) 417 (17.0) 3171 (11.2) 119 (21.5) 137 (17.1)
Single mother 5956 (22.7) 483 (32.3) 674 (31.8) 6526 (24.9) 217 (31.4) 251 (28.1)
other 1689 (5.8) 138 (6.9) 162 (5.5) 1520 (4.5) 42 (6.5) 57 (4.4)
More than high school graduates 22,468 (32.7) 1216 (40.4) 1907 (33.4) 23,017 (34.3) 545 (30.0) 748 (32.8)
Household income
0–99% FPL 2759 (15.8) 259 (24.9) 307 (18.4) 2906 (15.9) 95 (17.3) 104 (14.5)
100–199% FPL 5125 (21.6) 345 (21.5) 494 (22.7) 5475 (22.9) 140 (22.7) 192 (25.4)
200–399% FPL 10,225 (34.6) 571 (30.5) 861 (32.9) 10,279 (33.7) 263 (37.7) 307 (29.7)
400 + % FPL 8992 (28.0) 427 (23.2) 771 (26.0) 9303 (27.6) 168 (22.3) 306 (30.4)
Household smoking, yes 8803 (28.7) 786 (42.8) 1,025 (43.5) 9282 (30.0) 321 (41.4) 377 (38.1)

All percentages were weighted to represent children aged 6 to 17 years nationally.

Weighted percentages represent the column percentage except the prevalence of ADHD condition.

Discussion
We evaluated whether the prevalence of health behaviors and
obesity differed by gender and ADHD medication status from a
representative sample of US youth and identified the potential
determinants for obesity in this study population. This study provides
epidemiological evidence that children with ADHD, regardless of
medication status and gender, are less likely to participate in vigorous
physical activity and organized sports compared to those without
ADHD. Previous studies on movement skills and motor performance
in ADHD children provide some insight into the underlying factors for
the observed low physical activity in this population. For example,
children with ADHD exhibit low gross motor performance, physical
fitness, and delayed motor development (Harvey and Reid, 1997,
2003). A recent qualitative study found that children with ADHD had
only superficial knowledge about movement skills, paid little
attention to specific details and entertained negative feelings about
physical activity (Harvey et al., 2009).
We confirmed that obesity prevalence was higher among children
with ADHD (Holtkamp et al., 2004; Lam and Yang, 2007) and

Table 2
The prevalence and adjusted odds ratios for obesity, depression, and health behaviors by attention deficit hyperactivity disorder (ADHD) condition among children aged 6 to 17 years
from the National Survey of Children's Health 2003.

% OR(95% CI) Boys Girls

No ADHD ADHD, not medicated ADHD, medicated No ADHD ADHD, not medicated ADHD, medicated

Obesity 21.6 24.9 20.5 16.0 21.9 18.6

Ref. 1.42 (1.13–1.77) 0.89 (0.72–1.09) Ref. 1.85 (1.26–2.73) 1.21 (0.84–1.73)
Depression/anxiety problems 2.8 26.3 29.5 3.4 23.6 30.9
Ref. 10.3 (7.9–13.5) 14.1 (11.4–17.6) Ref. 6.4 (4.6–9.1) 14.1 (10.9–18.2)
Low physical activity (b 3 days/week) 79.3 26.6 25.8 68.9 42.7 35.6
Ref. 1.45 (1.23–1.70) 1.36 (1.10–1.68) Ref. 1.71 (1.28–2.27) 1.29 (1.01–1.64)
Media time (≥2 h a day) 46.4 52.3 52.1 42.0 52.7 39.4
Ref. 1.09 (0.90–1.31) 1.14 (0.98–1.32) Ref. 1.60 (1.20–2.13) 0.90 (0.70–1.15)
Family rules about TV programs 15.1 18.1 10.0 85.4 82.9 86.1
Ref. 0.92 (0.73–1.17) 0.65 (0.51–0.81) Ref. 1.01 (0.70–1.45) 1.03 (0.72–1.46)
No pleasure reading 19.4 34.0 28.1 11.5 22.3 17.3
Ref. 1.65 (1.35–2.01) 1.54 (1.30–1.81) Ref. 1.93 (1.37–2.70) 1.75 (1.32–2.32)
No computer use 28.7 32.2 30.2 27.6 27.6 31.4
Ref. 1.32 (1.06–1.65) 1.15 (0.97–1.37) Ref. 1.20 (0.86–1.68) 1.23 (0.94–1.63)
Not rode a bike, scooter, skateboard, etc. 15.2 16.7 11.7 22.6 24.4 17.5
Ref. 0.88 (0.67–1.04) 0.83 (0.99–1.28) Ref. 0.83 (0.61–1.14) 0.87 (0.65–1.17)
Not participated in organized sports 36.6 49.0 48.8 45.4 55.7 54.6
Ref. 1.50 (1.23–1.82) 1.67 (1.44–1.94) Ref. 1.39 (1.02–1.90) 1.63 (1.27–2.09)
Not participated in any clubs or organizations 51.0 54.3 51.3 42.3 47.7 48.9
Ref. 1.09 (0.90–1.33) 1.02 (0.88–1.19) Ref. 1.25 (0.93–1.69) 1.43 (1.10–1.83)
Not enough sleep (b 7 days a week) 30.1 38.1 33.6 31.2 36.7 35.4
Ref. 1.22 (1.00–1.47) 1.15 (0.99–1.34) Ref. 1.17 (0.87–1.59) 1.19 (0.90–1.58)
Do not live in a supportive neighborhood 16.2 23.8 20.1 16.1 23.9 21.6
Ref. 1.51 (1.18–1.91) 1.29 (1.04–1.60) Ref. 1.66 (1.13–2.43) 1.53 (1.13–2.08)
Do not feel safe neighborhood 12.2 14.7 11.2 13.5 16.2 14.1
Ref. 1.54 (1.18–2.01) 1.14 (0.89–1.46) Ref. 1.62 (1.08–2.44) 1.45 (0.94–2.22)
Do not feel safe at school 9.9 15.1 10.1 10.1 13.5 9.3
Ref. 1.44 (1.10–1.88) 1.22 (0.87–1.72) Ref. 1.44 (0.98–2.11) 1.40 (0.86–2.27)

All percentages were weighted to represent children aged 6 to 17 years nationally. The covariates in the multivariate analyses were socio-demographic variables of age, race/
ethnicity, maternal education, family structure, household income, and household smoking. Bold type represents statistical significance at the 5 percent level.
 J. Kim et al. / Preventive Medicine 52 (2011) 218–222 221

Table 3
The adjusted odds ratios for depression and health behaviors between the medicated and not medicated attention deficit hyperactivity disorder (ADHD) among children aged 6 to
17 years from the National Survey of Children's Health 2003.

Boys Girls

Unit: OR(95% CI) ADHD, medicated (n=2599) vs. not ADHD, medicated (n = 2505) vs. ADHD, medicated (n = 981) vs. not ADHD, medicated (n = 944) vs.
medicated (n=1757), without not medicated (n = 1696), with medicated (n = 733), without not medicated (n = 712), with
obesity obesity obesity obesity

Depression/anxiety 1.36 (1.02–1.80) 1.45 (1.09–1.94) 2.04 (1.33–3.15) 2.27 (1.48–3.49)

problems
Low physical activity 1.05 (0.81–1.35) 1.04 (0.81–1.35) 0.89 (0.62–1.29) 0.95 (0.65–1.39)
(b 3 days/week)
Media time (≥2 h a day) 1.03 (0.82–1.30) 1.01 (0.80–1.28) 0.64 (0.45–0.92) 0.66 (0.46–0.95)
Family rules about TV 0.65 (0.48–0.90) 0.66 (0.48–0.91) 0.97 (0.60–1.59) 0.94 (0.58–1.54)
programs
No pleasure reading 0.90 (0.71–1.15) 0.90 (0.70–1.16) 0.87 (0.57–1.32) 0.85 (0.55–1.30)
No computer use 0.87 (0.67–1.13) 0.89 (0.68–1.16) 1.09 (0.72–1.65) 1.03 (0.68–1.57)
Not rode a bike, scooter, 0.85 (0.62–1.18) 0.90 (0.65–1.26) 1.02 (0.67–1.57) 1.08 (0.71–1.66)
skateboard, etc.
Not participated in 1.15 (0.91–1.47) 1.20 (0.94–1.53) 1.24 (0.84–1.84) 1.23 (0.82–1.83)
organized sports
Not participated in any clubs 0.96 (0.76–1.21) 0.96 (0.76–1.21) 1.20 (9.82–1.76) 1.20 (0.81–1.77)
or organizations
Not enough sleep 0.91 (0.72–1.15) 0.91 (0.72–1.16) 0.87 (0.60–1.28) 0.84 (0.57–1.22)
(b 7 days a week)
Do not live in a supportive 0.82 (0.60–1.12) 0.83 (0.60–1.14) 0.99 (0.62–1.57) 1.03 (0.64–1.66)
neighborhood
Do not feel safe 0.69 (0.48–0.98) 0.71 (0.50–1.02) 0.90 (0.53–1.53) 0.95 (90.55–1.63)
neighborhood
Do not feel safe at school 0.80 (0.55–1.18) 0.80 (0.52–1.23) 0.99 (0.58–1.71) 0.97 (0.54–1.74)

The covariates in the multivariate analyses were socio-demographic variables of age, race/ethnicity, maternal education, family structure, household income, and household smoking. Bold
type represents statistical significance at the 5 percent level.

medication use was a protective factor for obesity among children with
ADHD (Waring and Lapane, 2008). We also found the odds of being
obese were higher among girls than boys with non-medicated ADHD
compared to those without ADHD. In addition, only health behaviors
such as not participating in organized sports and lack of sleep were
associated with obesity in boys with ADHD on medication, even
though all children with ADHD were less likely to be physically
active. Interestingly, our study found that lack of sleep protects
against obesity in boys with ADHD on medication, which is
contradictory to the previous finding that lack of sleep is a risk factor
for obesity in the general population (Cappuccio et al., 2008; Chaput
and Tremblay, 2009). Whether insomnia, a side effect of stimulant
medication for ADHD (Lerner and Wigal, 2008), changes the odds of
obesity among medicated ADHD youth warrants further research.
While medication does not appear to alter movement skills in children
with ADHD (Harvey et al., 2007), it is unknown if medication
mitigates other unhealthy behaviors leading to obesity in our study
population.

Table 4
The adjusted odds ratios of depression and health behaviors for obesity by attention deficit hyperactivity disorder (ADHD) condition among children aged 6 to 17 years from the
National Survey of Children's Health 2003.

Boys Girls

Unit: OR(95% CI) No ADHD ADHD, not medicated ADHD, medicated No ADHD ADHD, not medicated ADHD, medicated

Depression/anxiety 1.49 (1.06–2.10) 1.44 (0.88–2.38) 1.14 (0.73–1.78) 1.59 (1.13–2.26) 2.02 (0.89–4.62) 1.69 (0.88–3.23)
(yes vs. no)
Low physical activity 1.30 (1.13–1.50) 1.33 (0.83–2.12) 0.99 (0.67–1.46) 1.46 (1.27–1.69) 1.18 (0.60–2.32) 1.24 (0.66–2.31)
(b 3 days/week) vs. not
Media time (≥2 h a day) vs. not 1.13 (1.01–1.28) 1.24 (0.82–1.87) 1.08 (0.73–1.58) 1.31 (1.14–1.50) 2.51 (1.24–5.08) 1.75 (0.92–3.30)
Family rules about TV 1.14 (0.94–1.37) 1.37 (0.80–2.34) 0.94 (0.52–1.68) 1.16 (0.93–1.45) 0.77 (0.24–2.53) 0.76 (0.29–1.99)
programs (yes vs. no)
Pleasure reading (no vs. yes) 1.21 (1.04–1.41) 1.10 (0.68–1.78) 0.83 (0.53–1.31) 0.84 (0.66–1.07) 0.91 (0.42–1.97) 1.35 (0.67–2.74)
Computer use (no vs. yes) 0.99 (0.87–1.13) 1.53 (0.95–2.48) 0.75 (0.48–1.17) 0.95 (0.82–1.11) 1.06 (0.44–2.59) 1.22 (0.63–2.36)
Rode a bike, scooter, skateboard, 1.27 (1.06–1.52) 2.11 (1.22–3.67) 1.54 (0.86–2.73) 1.43 (1.18–1.73) 1.10 (0.47–2.56) 1.56 (0.71–3.42)
etc.(no vs. yes)
Participated in organized sports 1.29 (1.14–1.47) 1.23 (0.81–1.85) 1.57 (1.06–2.34) 1.35 (1.18–1.54) 2.01 (0.99–4.06) 1.90 (0.88–4.10)
(no vs. yes)
Participated in any clubs or 1.03 (0.92–1.15) 1.35 (0.88–2.07) 1.17 (0.80–1.70) 1.05 (0.91–1.21) 1.57 (0.75–3.29) 0.83 (0.43–1.59)
organizations (no vs. yes)
Not enough sleep 1.02 (0.90–1.15) 0.77 (0.51–1.17) 0.62 (0.41–0.94) 0.90 (0.78–1.04) 1.42 (0.75–2.68) 1.69 (0.81–3.52)
(b 7 vs. 7 days a week)
Live in a supportive neighborhood 0.90 (0.77–1.06) 1.34 (0.78–2.29) 0.89 (0.52–1.54) 1.19 (0.98–1.45) 1.35 (0.62–2.92) 1.63 (0.78–3.38)
(no vs. yes)
Feel safe neighborhood 1.04 (0.86–1.26) 1.21 (0.69–2.10) 0.64 (0.35–1.15) 1.23 (1.02–1.49) 1.33 (0.57–3.14) 1.97 (0.71–5.49)
(no vs. yes)
Feel safe at school 0.91 (0.74–1.12) 0.87 (0.50–1.51) 0.74 (0.38–1.44) 1.16 (0.92–1.46) 2.00 (0.72–5.57) 2.51 (0.90–7.05)
(no vs. yes)

All percentages were weighted to represent children aged 6 to 17 years nationally. The covariates in the multivariate analyses were the socio-demographic variables of age, race,
maternal education, family structure, household poverty, household smoking and depression or anxiety problems. Bold type represents statistical significance at the 5 percent level.
222 J. Kim et al. / Preventive Medicine 52 (2011) 218–222
A novel finding in our study was that media time was associated
with being obese among non-medicated girls with ADHD when
compared to those without ADHD; such association was not observed
for boys with ADHD. More than half of non-medicated girls with
ADHD spent more than 2 h/day on media and they were estimated to
have 60% more media time compared to girls without ADHD. In
addition, girls with medicated ADHD spent less media time than girls
with non-medicated ADHD. Although media time may not impact
attention and cognitive engagement abilities of elementary school
children with ADHD (Acevedo-Polakovich et al., 2006), our study
found that medicated ADHD girls had lower media time than non-
medicated girls. Media use, especially television watching, indeed
influences physical activity, body fat and weight among healthy
children (Andersen et al., 1998). Additionally, parental perception of
neighborhood safety influences media time in preschool children
(Burdette and Whitaker, 2005). We found that non-medicated girls
with ADHD were more likely to live in less safe neighborhoods than
girls without ADHD, whereas this was not observed among girls
medicated for ADHD. It is possible that parents of non-medicated
ADHD girls may prefer their children to use media rather than engage
in physical activity, a preference potentially contributing to obesity.
Depression was higher among youth with ADHD and their odds
were even higher with medication use, which is consistent with
earlier studies (National Institute of Mental Health, 2003; Waring and
Lapane, 2008; Waxmonsky, 2003). In our study, the associations
between health behaviors and obesity among children with ADHD
condition remained strong even after controlling for depression.
Given the cross-sectional nature of the data, we cannot establish
the direction of the relationship. We cannot differentiate whether
children with ADHD, who are not obese, are more likely to be treated
with medication or whether those on medication are more likely to
receive weight management program such as physical activity.
Importantly, the NSCH study did not collect information on specific
medications used for ADHD; thus the effects of specific medications
on health behaviors and obesity could not be estimated. Furthermore,
the main study outcomes, ADHD and obesity, were not based on DSM-
IV criteria. In addition, our binary classification for continuous
variables provides an easy interpretation for program implementation
and evaluation, but may not fully explain the nature of behaviors or
perceptions on the study questions. For this reason, there is a potential
for misclassification which could lead to either overestimation or
underestimation of the observed relationships.
Conclusions
ADHD children are less likely to engage in physical activity regardless
of gender and medication use compared to children without ADHD,
whereas their odds of being obese are dependent on gender and
medication status. Behavioral modification and obesity intervention
programs should take these factors into consideration.
Conflict of interest statement
There are no financial or material support interests to disclose.
References
Acevedo-Polakovich, I.D., Lorch, E.P., Milich, R., Ashby, R.D., 2006. Disentangling the
relation between television viewing and cognitive processes in children with
attention-deficit/hyperactivity disorder and comparison children. Arch. Pediatr.
Adolesc. Med. 160, 354–360.
Andersen, R.E., Crespo, C.J., Bartlett, S.J., Cheskin, L.J., Pratt, M., 1998. Relationship of
physical activity and television watching with body weight and level of fatness
among children: results from the Third National Health and Nutrition Examination
Survey. JAMA 279, 938–942.
Anderssen, N., Wold, B., 1992. Parental and peer influences on leisure-time physical
activity in young adolescents. Res. Q. Exerc. Sport 63, 341–348.
Biederman, J., Faraone, S.V., 2005. Attention-deficit hyperactivity disorder. Lancet 366,
237–248.
Blumberg, S.J., Olson, L., Frankel, M.R., Osborn, L., Srinath, K.P., Giambo, P., 2005. Design
and Operation of the National Survey of Children's Health, 2003: Vital Health Stat.,
43.
Burdette, H.L., Whitaker, R.C., 2005. A national study of neighborhood safety, outdoor
play, television viewing, and obesity in preschool children. Pediatrics 116,
657–662.
Cappuccio, F.P., Taggart, F.M., Kandala, N.B., et al., 2008. Meta-analysis of short sleep
duration and obesity in children and adults. Sleep 31, 619–626.
Cardon, G.M., De Bourdeaudhuij, I.M., 2008. Are preschool children active enough?
Objectively measured physical activity levels. Res. Q. Exerc. Sport 79, 326–332.
Centers for Disease Control and Prevention, n. A SAS Program for the CDCGrowth
ChartsRetrieved Jan. 10, 2007, from http://www.cdc.gov/nccdphp/dnpa/growth
charts/sas.htm.
Chaput, J.P., Tremblay, A., 2009. Obesity and physical inactivity: the relevance of
reconsidering the notion of sedentariness. Obes. Facts 2, 249–254.
Cortese, S., Angriman, M., 2008. Attention-deficit/hyperactivity disorder and obesity:
moving to the next research generation. Pediatrics 122, 1155 (author reply
1155-6).
Davison, K.K., Birch, L.L., 2001. Childhood overweight: a contextual model and
recommendations for future research. Obes. Rev. 2, 159–171.
Faraone, S.V., Sergeant, J., Gillberg, C., Biederman, J., 2003. The worldwide prevalence of
ADHD: is it an American condition? World Psychiatry 2, 104–113.
Gadde, K.M., Yonish, G.M., Wagner II, H.R., Foust, M.S., Allison, D.B., 2006. Atomoxetine
for weight reduction in obese women: a preliminary randomised controlled trial.
Int. J. Obes. Lond 30, 1138–1142.
Harvey, W.J., Reid, G., 1997. Motor performance of children with attention-deficit
hyperactivity disorder: a preliminary investigation. Adapt. Phys. Act. Q. 14,
189–202.
Harvey, W.J., Reid, G., 2003. Attention-deficit/hyperactivity disorder: a review of
research on movement skill performance and physical fitness. Adapt. Phys. Act. Q.
20, 1–25.
Harvey, W.J., Reid, G., Grizenko, N., Mbekou, V., Ter-Stepanian, M., Joober, R., 2007.
Fundamental movement skills and children with attention-deficit hyperactivity
disorder: peer comparisons and stimulant effects. J. Abnorm. Child Psychol. 35,
871–882.
Harvey, W.J., Reid, G., Bloom, G.A., et al., 2009. Physical activity experiences of boys with
and without ADHD. Adapt. Phys. Activ. Q. 26, 131–150.
Holtkamp, K., Konrad, K., Muller, B., et al., 2004. Overweight and obesity in children
with attention-deficit/hyperactivity disorder. Int. J. Obes. Relat. Metab. Disord. 28,
685–689.
Hubel, R., Jass, J., Marcus, A., Laessle, R.G., 2006. Overweight and basal metabolic rate in
boys with attention-deficit/hyperactivity disorder. Eat. Weight Disord. 11,
139–146.
Lam, L.T., Yang, L., 2007. Overweight/obesity and attention deficit and hyperac-
tivity disorder tendency among adolescents in China. Int. J. Obes. Lond 31,
584–590.
Lerner, M., Wigal, T., 2008. Long-term safety of stimulant medications used to treat
children with ADHD. Pediatr. Ann. 37, 37–45.
National Institute of Mental Health, 2003. Attention Deficit Hyperactivity Disorder. US
Department of Health and Human Services, Bethesda, MD. Retrieved March 25,
2008.
Pliszka, S.R., 2007. Pharmacologic treatment of attention-deficit/hyperactivity disorder:
efficacy, safety and mechanisms of action. Neuropsychol. Rev. 17, 61–72.
Stefanatos, G.A., Baron, I.S., 2007. Attention-deficit/hyperactivity disorder: a neuropsy-
chological perspective towards DSM-V. Neuropsychol. Rev. 17, 5–38.
Visser, S.N., Lesesne, C.A., Perou, R., 2007. National estimates and factors associated with
medication treatment for childhood attention-deficit/hyperactivity disorder.
Pediatrics 119 (Suppl. 1), S99–S106.
Waring, M.E., Lapane, K.L., 2008. Overweight in children and adolescents in relation to
attention-deficit/hyperactivity disorder: results from a national sample. Pediatrics
122, e1–e6.
Watemberg, N., Waiserberg, N., Zuk, L., Lerman-Sagie, T., 2007. Developmental
coordination disorder in children with attention-deficit-hyperactivity disorder
and physical therapy intervention. Dev. Med. Child Neurol. 49, 920–925.
Waxmonsky, J., 2003. Assessment and treatment of attention deficit hyperactivity
disorder in children with comorbid psychiatric illness. Curr. Opin. Pediatr. 15,
476–482.
Zuvekas, S.H., Vitiello, B., Norquist, G.S., 2006. Recent trends in stimulant medication
use among US children. Am. J. Psychiatry 163, 579–585.