title: Association between casino opening or expansion and risk of childhood overweight and obesity.
abstract: OBJECTIVE
  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.
  
  
  METHODS
  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.
  
  
  METHODS
  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 (β = $541; 95% CI, $245-$836) and a decrease in percentage in poverty (β = -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 (β = -0.003; 95% CI, -0.005 to -0.0002).
  
  
  CONCLUSIONS
  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.
authors.affiliation: Department of International Health (Human Nutrition), Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.
authors.forename: Jessica C
authors.initials: JC
authors.lastname: Jones-Smith
authors.affiliation: School of Public Health, University of California, Berkeley.
authors.forename: William H
authors.initials: WH
authors.lastname: Dow
authors.affiliation: independent consultant, Sacramento, California.
authors.forename: Kristal
authors.initials: K
authors.lastname: Chichlowska
mesh_terms: D000293:Adolescent; D015992:Body Mass Index; D002140:California / Q000453:epidemiology; D002648:Child; D005260:Female; D005715:Gambling; D006801:Humans; D007182:Income; D007198:Indians, North American; D008297:Male; D009765:Obesity / Q000208:ethnology* / Q000517:prevention & control; D050177:Overweight / Q000208:ethnology* / Q000517:prevention & control; D010067:Ownership; D012306:Risk; D012923:Social Class