When tribes build casinos, obesity falls in youth

After American Indians built casinos on California tribal lands, their incomes rose and their children’s obesity rates fell, according to a new study.

The study’s authors sought to highlight the merits of investing in communities to prevent disease. They found that an infusion of resources was linked to a reduction in poverty and youth health risks.

“The casino is serving as a proxy,” Dr. Neal Halfon told Reuters Health. “If we had some kind of big syringe, and we inject money into a community, it does change the odds. Here it lowered obesity.”

Halfon directs the Center for Healthier Children, Families and Communities at the University of California, Los Angeles. He was not involved in the current study but wrote an accompanying editorial in the Journal of the American Medical Association.

“An enormous loss of human potential results from unsafe, uncertain, stressful childhood environments,” Halfon writes in his editorial. “A casino in every neighborhood is not the answer, but increasing family income and removing other pressures that reduce the capacity of families to invest in their children should be part of the solution.”

American Indian children have disproportionately high rates of obesity, the study says. An estimated 48 percent of them are overweight or obese, and they are one and a half times more likely to be overweight than other American youth, lead author Jessica C. Jones-Smith told Reuters Health.

 When tribes build casinos, obesity falls in youth Jones-Smith, from the Johns Hopkins Bloomberg School of Public Health in Baltimore, and her team used data from the U.S. Census and California physical fitness programs to measure the impact an influx of funds into a community has on its youth.

They examined the heights and weights of American Indian children ages seven to 18 from California public school districts in areas with tribal lands. Then they tracked what happened when some of those communities built or expanded casinos between 2001 and 2012.

Of the 117 public school districts included in the study, 57 either opened or expanded casinos. Of the remaining districts, 24 had existing casinos that did not expand and 36 had none.

Socioeconomic Influences on Child HealthBuilding New Ladders of Social Opportunity
Health is a universal aspiration and basic human need. An increasing body of research shows that life success and long-term well-being are results of the conditions in which children live, grow, learn, and play, and that a basic scaffolding of health, education, and family support is needed to achieve optimal lifelong well-being. However, providing this ladder of support for low-income minority children in increasingly income-segregated US communities can be elusive. Growing up in a family that is struggling economically in a neighborhood that is plagued with failed schools, crime, disorder, and violence creates cumulative health risks and functional deficits that contribute to higher rates of many health conditions, including asthma, attention-deficit/hyperactivity disorder, and obesity. Without a coherent and functional system of high-quality services such as child care, early education, family support, health care, and mental health services, risks go unaddressed, preventable health problems develop, and disabling conditions compound over time, becoming more pronounced as sick and impaired teens become chronically ill and disabled adults.

Districts that opened or expanded casinos added an average of 13 slot machines per resident. Such a change was associated with a drop in the proportion of local youth who were overweight or obese by 2.5 percent, Jones-Smith said.

The researchers counted students as overweight if their weight was in the 85th percentile or above on the pediatric growth chart.

“We weren’t trying to weigh in on whether casinos should be held up as an example of economic development,” Jones-Smith said. “Instead, we were trying to isolate the impact of economic resources on kids’ health.”

Although why obesity rates fell in communities that added or expanded casinos remains unknown, Jones-Smith has some ideas.

Her study suggested an addition of 13 slot machines per capita in a community was linked to an increase in annual income of $7,000 for each resident. The increased income might allow families to purchase healthier, less fattening food, she said.

Federal law mandates that casinos return profits to their communities or make charitable donations, Jones-Smith said. As a result, she said tribes often build recreation centers, parks and playing fields - places where youth participate in sports and other weight-reducing activities.

Halfon said this study and others “demonstrating the health benefits of alleviating poverty are particularly important given the growing income inequalities, persistently high rates of childhood poverty and stagnant wage growth in families with young children.”

Almost half of American children grow up in poor or “near poor” families, he writes in his editorial.

UNICEF, the United Nations Children’s Fund, ranked the U.S. 26th out of 29 developed countries on children’s overall well-being last year, Halfon noted.

“All we have to do is look at other nations and see what they do to raise the children out of poverty,” he said.

“Many of these countries are spending the same overall on health and social programs. They spend it earlier in the lifespan so they’re launching their children into a healthy trajectory, rather than waiting until their adults are burdened with lots of chronic health problems and having to pay for rescue care.”

SOURCES: Journal of the American Medical Association, online March 4, 2014.


Association Between Casino Opening or Expansion and Risk of Childhood Overweight and Obesity
Jessica C. Jones-Smith, PhD1; William H. Dow, PhD2; Kristal Chichlowska, PhD

Importance  Economic resources have been inversely associated with risk of childhood overweight/obesity. Few studies have evaluated whether this association is a direct effect of economic resources or is attributable to unmeasured confounding or reverse causation. American Indian–owned casinos have resulted in increased economic resources for some tribes and provide an opportunity to test whether these resources are associated with overweight/obesity.

Objective  To assess whether openings or expansions of American Indian–owned casinos were associated with childhood overweight/obesity risk.

Design, Setting, and Participants  We used repeated cross-sectional anthropometric measurements from fitness testing of American Indian children (aged 7-18 years) from 117 school districts that encompassed tribal lands in California between 2001 and 2012. Children in school districts encompassing American Indian tribal lands that either gained or expanded a casino were compared with children in districts with tribal lands that did not gain or expand a casino.

Main Outcomes and Measures  Per capita annual income, median annual household income, percentage of population in poverty, total population, child overweight/obesity (body mass index [BMI] ?85th age- and sex-specific percentile) and BMI z score.

Results  Of the 117 school districts, 57 gained or expanded a casino, 24 had a preexisting casino but did not expand, and 36 never had a casino. The mean slots per capita was 7 (SD, 12) and the median was 3 (interquartile range [IQR], 0.3-8). Among districts where a casino opened or expanded, the mean change in slots per capita was 13 (SD, 19) and the median was 3 (IQR, 1-11). Forty-eight percent of the anthropometric measurements were classified as overweight/obese (11 048/22 863). Every casino slot machine per capita gained was associated with an increase in per capita annual income (? = $541; 95% CI, $245-$836) and a decrease in percentage in poverty (? = -0.6%; 95% CI, -1.1% to -0.20%) among American Indians living on tribal lands. Among American Indian children, every slot machine per capita gained was associated with a decreased probability of overweight/obesity by 0.19 percentage points (95% CI, -0.26 to -0.11 percentage points) and a decrease in BMI z score (? = -0.003; 95% CI, -0.005 to -0.0002).

Conclusions and Relevance  In this study, opening or expanding a casino was associated with increased economic resources and decreased risk of childhood overweight/obesity. Given the limitations of an ecological study, further research is needed to better understand the mechanisms behind this association.


JAMA. 2014;311(9):929-936. doi:10.1001/jama.2014.604

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