RESUMO
Importance: Despite strong evidence linking place and obesity risk, the extent to which this link is causal or reflects sorting into places is unclear. Objective: To examine the association of place with adolescents' obesity and explore potential causal pathways, such as shared environments and social contagion. Design, Setting, and Participants: This natural experiment study used the periodic reassignment of US military servicemembers to installations as a source of exogenous variation in exposure to difference places to estimate the association between place and obesity risk. The study analyzed data from the Military Teenagers Environments, Exercise, and Nutrition Study, a cohort of adolescents in military families recruited from 2013 through 2014 from 12 large military installations in the US and followed up until 2018. Individual fixed-effects models were estimated that examined whether adolescents' exposure to increasingly obesogenic places over time was associated with increases in body mass index (BMI) and probability of overweight or obesity. These data were analyzed from October 15, 2021, through March 10, 2023. Exposure: Adult obesity rate in military parent's assigned installation county was used as a summary measure of all place-specific obesogenic influences. Main Outcomes and Measures: Outcomes were BMI, overweight or obesity (BMI in the 85th percentile or higher), and obesity (BMI in the 95th percentile or higher). Time at installation residence and off installation residence were moderators capturing the degree of exposure to the county. County-level measures of food access, physical activity opportunities, and socioeconomic characteristics captured shared environments. Results: A cohort of 970 adolescents had a baseline mean age of 13.7 years and 512 were male (52.8%). A 5 percentage point-increase over time in the county obesity rate was associated with a 0.19 increase in adolescents' BMI (95% CI, 0.02-0.37) and a 0.02-unit increase in their probability of obesity (95% CI, 0-0.04). Shared environments did not explain these associations. These associations were stronger for adolescents with time at installation of 2 years or longer vs less than 2 years for BMI (0.359 vs. 0.046; P value for difference in association = .02) and for probability of overweight or obesity (0.058 vs. 0.007; P value for difference association = .02), and for adolescents who lived off installation vs on installation for BMI (0.414 vs. -0.025; P value for association = .01) and for probability of obesity (0.033 vs. -0.007; P value for association = .02). Conclusion and Relevance: In this study, the link between place and adolescents' obesity risk is not explained by selection or shared environments. The study findings suggest social contagion as a potential causal pathway.
