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1.  Modifiable early-life risk factors for childhood adiposity and overweight: an analysis of their combined impact and potential for prevention1234 
Background: Early life may be a “critical period” when appetite and regulation of energy balance are programmed, with lifelong consequences for obesity risk. Insight into the potential impact of modifying early-life risk factors on later obesity can be gained by evaluating their combined effects.
Objective: The objective was to examine the relation between the number of early-life risk factors and obesity outcomes among children in a prospective birth cohort (Southampton Women's Survey).
Design: Five risk factors were defined: maternal obesity [prepregnant body mass index (BMI; in kg/m2) >30], excess gestational weight gain (Institute of Medicine, 2009), smoking during pregnancy, low maternal vitamin D status (<64 nmol/L), and short duration of breastfeeding (none or <1 mo). Obesity outcomes examined when the children were aged 4 and 6 y were BMI, dual-energy X-ray absorptiometry–assessed fat mass, overweight, or obesity (International Obesity Task Force). Data were available for 991 mother-child pairs, with children born between 1998 and 2003.
Results: Of the children, 148 (15%) had no early-life risk factors, 330 (33%) had 1, 296 (30%) had 2, 160 (16%) had 3, and 57 (6%) had 4 or 5. At both 4 and 6 y, there were positive graded associations between number of early-life risk factors and each obesity outcome (all P < 0.001). After taking account of confounders, the relative risk of being overweight or obese for children who had 4 or 5 risk factors was 3.99 (95% CI: 1.83, 8.67) at 4 y and 4.65 (95% CI: 2.29, 9.43) at 6 y compared with children who had none (both P < 0.001).
Conclusions: Having a greater number of early-life risk factors was associated with large differences in adiposity and risk of overweight and obesity in later childhood. These findings suggest that early intervention to change these modifiable risk factors could make a significant contribution to the prevention of childhood obesity.
PMCID: PMC4307207  PMID: 25646335
adiposity; childhood obesity; early life; obesity; lifecourse; prevention
2.  Association of early childhood abdominal circumference and weight gain with blood pressure at 36 months of age: secondary analysis of data from a prospective cohort study 
BMJ Open  2014;4(7):e005412.
To assess whether changes in measures of fat distribution and body size during early life are associated with blood pressure at 36 months of age.
Analysis of data collected from a prospective cohort study.
Community-based investigation in Southampton, UK.
761 children with valid blood pressure measurements, born to women participating in the Southampton Women’s Survey.
Primary and secondary outcome measures
Anthropometric measurements were collected at 0, 6, 12, 24 and 36 months and conditional changes between the time points calculated. Blood pressure was measured at 36 months. Factors possibly influencing the blood pressure were assessed using linear regression. All independent variables of interest and confounding variables were included in stepwise multiple regression to identify the model that best predicted blood pressure at 36 months.
Greater conditional gains in abdominal circumference (AC) between 0–6 and 24–36 months were associated with higher systolic and diastolic blood pressures at 36 months (p<0.001). Subscapular skinfold and height gains were weakly associated with higher blood pressures, while greater weight gains between 0–6, 12–24 and 24–36 months were more strongly associated, but the dominant influences were AC gains, particularly from 0–6 to 24–36 months. Thus one SD score increases in AC between 0–6 and 24–36 months were associated with 1.59 mm Hg (95% CI 0.97 to 2.21) and 1.84 mm Hg (1.24 to 2.46) higher systolic blood pressures, respectively, and 1.04 mm Hg (0.57 to 1.51) and 1.02 mm Hg (0.56, 1.48) higher diastolic pressures, respectively.
Conditional gains in abdominal circumference, particularly within 6 months of birth and in the year preceding measurement, were more positively associated with blood pressure at 36 months than gains in other anthropometric measures. Above-average AC gains in early childhood may contribute to adult hypertension and increased cardiovascular disease risk.
PMCID: PMC4091398  PMID: 24993768
3.  Associations between grip strength of parents and their 4 year old children: findings from the Southampton Women’s Survey 
Relationships between birthweight and grip strength throughout the lifecourse suggest that early influences on the growth and development of muscle are important for long-term muscle function. However, little is known about parental influences on children’s grip strength. We have explored this in the Southampton Women’s Survey, a prospective general population cohort study from before conception through childhood. Grip strength was measured using a Jamar handgrip dynamometer in the mother at 19 weeks’ gestation and her partner, and in the child at age four years. Pre-pregnancy heights and weights were measured in the mothers; reported weights and measured heights were available for the fathers. Complete data on parents and children were available for 444 trios. In univariate analyses, both parents’ grip strengths were significantly associated with that of the child (r=0.17, p<0.001 for mothers, r=0.15, p=0.002 for fathers). These correlations were similar to that between the grip strength of the mothers and the father (r=0.17, P<0.001). In the multivariate model, after adjustment for child’s height and physical activity, the correlations with the child’s grip strength were attenuated, being 0.10 (P=0.02) and 0.11 (P=0.01) for mothers’ and fathers’ grip strength respectively. The findings show that grip strength of both parents is associated with that of their child, indicating that heritable influences and the shared family environment influence the development of muscle strength. This contributes to our understanding of the role of heritable and environmental factors on early muscle growth and development, which are important for muscle function across the lifecourse.
PMCID: PMC3685131  PMID: 22150705
muscle; grip strength; growth and development; genetic and environmental influences; height
4.  Does maternal long chain polyunsaturated fatty acid status in pregnancy influence the bone health of children? The Southampton Women’s Survey 
Maternal diet in pregnancy has been linked to childhood bone mass, but the mechanisms and nutrients involved are uncertain. Long-chain polyunsaturated fatty acids (LCPUFAs) have been shown to affect bone metabolism, but the relationship between maternal fatty acid status and bone mass in the offspring remains unknown.
We evaluated the association between maternal LCPUFA status in late pregnancy (34 weeks gestation) and bone density in their children at age four years, within 727 mother-child pairs taking part in the Southampton Women’s Survey.
Concentrations of the n-3 LCPUFA component of maternal plasma phosphatidylcholine were positively associated with a number of bone mineral measures at the age of 4 years; these associations persisted after adjustment for maternal body build, walking speed and infant feeding. Relationships were most evident for eicosapentaenoic acid (r=0.09, p=0.02 for whole body areal bone mineral density [aBMD] and r=0.1, p=0.008 for lumbar spine aBMD) and for docosapentaenoic acid (r=0.09, p=0.02 for whole body aBMD and r=0.12, p=0.002 for lumbar spine aBMD).
These findings suggest that variation in early exposure to n-3 and n-6 LCPUFA may have potential consequences for bone development and that the effects appear to persist into early childhood.
PMCID: PMC3679517  PMID: 22159749
Epidemiology; osteoporosis; development; nutrition; bone mass
5.  Type of milk feeding in infancy and health behaviours in adult life: findings from the Hertfordshire Cohort Study 
The British journal of nutrition  2012;109(6):1114-1122.
A number of studies suggest that breastfeeding has beneficial effects on adult cardiovascular risk factors in adulthood, although the mechanisms involved are unknown. One possible explanation is that adults who were breastfed differ in their health behaviours. In a historical cohort, adult health behaviours were examined in relation to type of milk feeding in infancy. From 1931-1939, records were kept on all infants born in Hertfordshire, UK. Their type of milk feeding was summarised as breastfed only, breast & bottle-fed, or bottle-fed only. Information about adult health behaviours was collected from 3217 of these men and women when they were aged 59-73 years. Diet was assessed by administered food frequency questionnaire; the key dietary pattern was a ‘prudent’ pattern, that described compliance with ‘healthy’ eating recommendations. 60% of the men and women were breastfed, 31% were breast & bottle-fed, 9% were bottle-fed. Type of milk feeding did not differ according to social class at birth, and was not related to social class attained in adult life. There were no differences in smoking status, alcohol intake or reported physical activity according to type of milk feeding, but there were differences in the participants’ dietary patterns. In a multivariate model that included gender and infant weight gain, there were independent associations between type of feeding and prudent diet scores in adult life (P=0.009), such that higher scores were associated with being breast fed. These data support experimental findings that suggest that early dietary exposures can have lifelong influences on food choice.
PMCID: PMC3628663  PMID: 23021469
Breastfeeding; food choice; dietary patterns; health behaviours
6.  Infant Nutrition and Later Health: A Review of Current Evidence 
Nutrients  2012;4(8):859-874.
There is a growing recognition of the need for a lifecourse approach to understanding the aetiology of adult disease, and there is now significant evidence that links patterns of infant feeding to differences in health outcomes, both in the short and longer term. Breastfeeding is associated with lower rates of infection in infancy; in high-income populations, it is associated with reductions in blood pressure and total blood cholesterol, and lower risks of obesity and diabetes in adult life. Breastfeeding rates are suboptimal in many countries, and strategies to promote breastfeeding could therefore confer important benefits for health at a population level. However, there are particular challenges in defining nutritional exposures in infancy, including marked social gradients in initiation and duration of breastfeeding. In recent studies of low and middle-income populations of children and young adults, where the influences on infant feeding practice differ, beneficial effects of breastfeeding on blood pressure, BMI and risk of diabetes have not been confirmed, and further information is needed. Little is currently known about the long-term consequences of differences in the timing and nature of the weaning diet. Future progress will depend on new studies that provide detailed prospective data on duration and exclusivity of breastfeeding together with appropriate characterisation of the weaning diet.
PMCID: PMC3448076  PMID: 23016121
infant; breastfeeding; formula feeding; weaning; programming; lifecourse
7.  Nutrition and Sarcopenia: A Review of the Evidence and Implications for Preventive Strategies 
Journal of Aging Research  2012;2012:510801.
Prevention of age-related losses in muscle mass and strength is key to protecting physical capability in older age and enabling independent living. To develop preventive strategies, a better understanding is needed of the lifestyle factors that influence sarcopenia and the mechanisms involved. Existing evidence indicates the potential importance of diets of adequate quality, to ensure sufficient intakes of protein, vitamin D, and antioxidant nutrients. Although much of this evidence is observational, the prevalence of low nutrient intakes and poor status among older adults make this a current concern. However, as muscle mass and strength in later life are a reflection of both the rate of muscle loss and the peak attained in early life, efforts to prevent sarcopenia also need to consider diet across the lifecourse and the potential effectiveness of early interventions. Optimising diet and nutrition throughout life may be key to preventing sarcopenia and promoting physical capability in older age.
PMCID: PMC3312288  PMID: 22506112
8.  Dietary patterns change little from before to during pregnancy1 
The Journal of nutrition  2009;139(10):1956-1963.
Principal component analysis is a popular method of dietary patterns analysis, but our understanding of its use to describe changes in dietary patterns over time is limited. We assessed the diets of 12,572 non-pregnant women aged 20-34 from Southampton, UK using a food frequency questionnaire, of whom 2,270 and 2,649 became pregnant and provided complete dietary data in early and late pregnancy respectively. Intakes of white bread, breakfast cereals, cakes and biscuits, processed meat, crisps, fruit and fruit juices, sweet spreads, confectionery, hot chocolate drinks, puddings, cream, milk, cheese, full-fat spread, cooking fats and salad oils, red meat and soft drinks increased in pregnancy. Intakes of rice and pasta, liver and kidney, vegetables, nuts, diet cola, tea and coffee, boiled potatoes and crackers decreased in pregnancy. Principal component analysis at each time point produced two consistent dietary patterns, labeled ‘prudent’ and ‘high-energy’. At each time point in pregnancy, and for both the prudent and high-energy patterns, we derived two dietary pattern scores for each woman: a ‘natural’ score, based on the pattern defined at that time point, and an ‘applied’ score, based on the pattern defined before pregnancy. Applied scores are preferred to natural scores to characterize changes in dietary patterns over time because the scale of measurement remains constant. Using applied scores there was a very small mean decrease in prudent diet score in pregnancy, and a very small mean increase in high-energy diet score in late pregnancy, indicating little overall change in dietary patterns in pregnancy.
PMCID: PMC3113465  PMID: 19710161
Diet; Dietary patterns; Pregnancy; Principal component analysis
9.  Weight gain in pregnancy and childhood body composition: findings from the Southampton Women’s Survey 
Intrauterine life may be a critical period for the programming of later obesity, but there is conflicting evidence about whether pregnancy weight gain is an important determinant of offspring adiposity.
The purpose of this study was to examine the relationship of pregnancy weight gain with neonatal and childhood body composition.
The participants (n=948) were children born to women in the Southampton Women’s Survey who had dual-energy x-ray absorptiometry measurements of body composition at birth, 4 or 6 years. Pregnancy weight gain was derived from the mothers’ measured weights before pregnancy and at 34 weeks gestation, analyzed using 2009 Institute of Medicine (IOM) categories (inadequate, adequate or excessive), and as a continuous measure.
Almost half (49%) the children were born to women who gained excessive weight in pregnancy. In comparison with children born to women with adequate weight gain, they had a greater fat mass in the neonatal period (0.17 SD (95% CI 0.02, 0.32), P=0.03), at 4 years (0.17 SD (0.00, 0.34), P=0.05) and at 6 years (0.30 SD (0.11, 0.49), P=0.002). Greater pregnancy weight gain, as a continuous measure, was associated with greater neonatal fat mass (0.10 SD per 5kg weight gain (0.04, 0.15), P=0.0004) and, weakly, with fat mass at 6 years (0.07 SD per 5kg (0.00, 0.14), P=0.05), but not at 4 years (0.02 SD per 5kg (−0.04, 0.08), P=0.55).
Appropriate pregnancy weight gain, as defined by 2009 IOM recommendations, is linked to lower levels of adiposity in the offspring.
PMCID: PMC3091013  PMID: 20375187
10.  Dietary patterns in pregnant women: a comparison of food frequency questionnaires and four-day prospective diaries 
The British journal of nutrition  2007;99(4):869-875.
There is growing interest in the use of dietary patterns as measures of exposure in studies of diet-disease relationships. However, relatively little is known about the impact of the type of dietary assessment method on the patterns observed. Using food frequency questionnaire (FFQ) and food diary data collected from 585 women in early pregnancy we used principal component analysis to define dietary patterns. The first pattern was very similar in both datasets and was termed the ‘prudent’ diet. The second pattern, whilst comparable for the FFQ and food diaries, showed greater variation in coefficients than the prudent pattern; it was termed the ‘Western’ diet. Differences between the FFQ and diary scores were calculated for each woman for both the prudent and Western diet patterns. 95% of the differences in the prudent diet score lay within ±1.58 standard deviations of the mean, and 95% of the differences in the Western diet scores lay within ±2.22 standard deviations of the mean. Pearson’s correlation coefficients were 0.67 (P < 0.001) for the prudent diet score and 0.35 (P < 0.001) for the Western diet score. The agreement between the FFQ and diary scores was lowest amongst respondents who were younger, had lower educational attainment and whose diaries were coded as ‘poor, probably incomplete’, although these effects were small. The first two dietary patterns identified in this cohort of pregnant women appear to be defined similarly by both FFQ and diary data, suggesting that FFQ data provide useful information on dietary patterns.
PMCID: PMC3091014  PMID: 18005481
Dietary patterns; principal component analysis; food frequency questionnaire
11.  Do women change their health behaviours in pregnancy? Findings from the Southampton Women’s Survey 
A woman’s lifestyle choices before and during pregnancy have important implications for her unborn child, but information on behaviour can be unreliable when data are collected retrospectively. In particular there are no large longitudinal datasets that include information collected prospectively before pregnancy to allow accurate description of changes in behaviour into pregnancy.
The Southampton Women’s Survey is a longitudinal study of women in Southampton, UK, characterised when they were not pregnant and again during pregnancy. The objective of the analyses presented here is to describe the degree to which women comply with diet and lifestyle recommendations before and during pregnancy, and changes between these time points.
The analyses are based on 1490 women who delivered between 1998 and 2003 and who provided information before pregnancy and at 11 and 34 weeks gestation. At each time point a trained research nurse ascertained smoking status and assessed food and drink consumption using a food frequency questionnaire. We derived the proportions of women who complied with recommendations not to smoke, to eat five portions of fruit and vegetables per day and to drink no more than four units of alcohol per week and 300mg of caffeine per day.
There was a notable reduction in smoking when women became pregnant; before pregnancy 27% of women smoked, whereas in early pregnancy 15% smoked. Similarly there were significant reductions in alcohol consumption and intake of caffeinated drinks; before pregnancy 54% of women drank more than 4 units of alcohol per week and 39% had estimated intakes of caffeine in drinks of more than 300mg per day, whereas comparable figures for early pregnancy were 10% and 16% respectively. However, there was little change in fruit and vegetable intake; the percentages of women who did not achieve the recommendation to eat at least five portions of fruit and vegetables per week were 47% before pregnancy and 46% in early pregnancy. Younger women and those with fewer educational qualifications were less likely to comply with public health recommendations. 81% of women in early pregnancy complied with at least three of the recommendations. Although there is encouraging evidence of changed health behaviours in pregnancy, young women and those with few educational qualifications may particularly benefit from targeted health initiatives.
PMCID: PMC3091015  PMID: 19689495
Pregnancy; smoking; alcohol drinking; fruit and vegetables; caffeinated drinks
12.  Development of a 20-item food frequency questionnaire to assess a ‘prudent’ dietary pattern amongst young women in Southampton 
To develop a short food frequency questionnaire (FFQ) that can be used amongst young women in Southampton to assess compliance with a prudent dietary pattern characterised by high consumption of wholemeal bread, fruit and vegetables, and low consumption of sugar, white bread, and red and processed meat.
Diet was assessed using a 100-item interviewer-administered FFQ in 6,129 non-pregnant women aged 20-34 years. 94 of these women were re-interviewed two years later using the same FFQ. Subsequently diet was assessed in 378 women attending SureStart Children’s Centres in the Nutrition and Well-being Study using a 20-item FFQ. The 20 foods included were those that characterised the prudent dietary pattern.
The 20-item prudent diet score was highly correlated with the full 100-item score (r=0.94) in the Southampton Women’s Survey. Both scores were correlated with red blood cell folate (r=0.28 for the 100-item score and r=0.25 for the 20-item score). Amongst the women re-interviewed after two years, the change in prudent diet score was correlated with change in red cell folate for both the 20-item (rS=0.31) and 100-item scores (rS=0.32). In the Nutrition and Well-being Study a strong association between the 20-item prudent diet score and educational attainment (r=0.41) was observed, similar to that seen in the Southampton Women’s Survey (r=0.47).
The prudent diet pattern describes a robust axis of variation in diet. A 20-item FFQ based on the foods that characterise the prudent diet pattern has clear advantages in terms of time and resources, and is a helpful tool to characterise the diets of young women in Southampton.
PMCID: PMC3091018  PMID: 19756032
Food frequency questionnaire; Principal component analysis
13.  Dietary patterns in the Southampton Women’s Survey 
European journal of clinical nutrition  2006;60(12):1391-1399.
Dietary pattern analysis is receiving increasing attention as a means of summarising the multi-dimensional nature of dietary data. This research aims to compare principal component analysis and cluster analysis using dietary data collected from young women in the UK.
Diet was assessed using a 100-item interviewer-administered food frequency questionnaire. Principal component analysis and cluster analysis were used to examine dietary patterns.
Southampton, UK.
6125 non-pregnant women aged 20 to 34 years
Principal component analysis identified two important patterns: a ‘prudent’ diet, and a ‘high-energy’ diet. Cluster analysis defined two clusters, a ‘more healthy’ and a ‘less healthy’ cluster. There was a strong association between the prudent diet score and the two clusters, such that the mean prudent diet score in the less healthy cluster was −0.73 standard deviations and in the more healthy cluster was +0.83 standard deviations; the difference in the high-energy diet score between the two clusters was considerably smaller.
Both approaches revealed a similar dietary pattern. The continuous nature of the outcome of principal component analysis was considered to be advantageous compared with the dichotomy identified using cluster analysis.
PMCID: PMC3091020  PMID: 16804555
Dietary patterns; Principal component analysis; Cluster analysis
14.  Dietary patterns in infancy and cognitive and neuropsychological function in childhood 
Trials in developing countries suggest that improving young children's diet may benefit cognitive development. Whether dietary composition influences young children's cognition in developed countries is unclear. Although many studies have examined the relation between type of milk received in infancy and subsequent cognition, there has been no investigation of the possible effect of variations in the weaning diet.
We studied 241 children aged 4 years, whose diet had been assessed at age 6 and 12 months. We measured IQ with the Wechsler Pre-School and Primary Scale of Intelligence, visual attention, visuomotor precision, sentence repetition and verbal fluency with the Developmental Neuropsychological Assessment (NEPSY), and visual form-constancy with the Test of Visual Perceptual Skills.
In sex-adjusted analyses, children whose diet in infancy was characterised by high consumption of fruit, vegetables and home-prepared foods (‘infant guidelines’ dietary pattern) had higher full-scale and verbal IQ and better memory performance at age 4 years. Further adjustment for maternal education, intelligence, social class, quality of the home environment and other potential confounding factors, attenuated these associations but the relations between higher ‘infant guidelines’ diet score and full-scale and verbal IQ remained significant. For a standard deviation increase in ‘infant guidelines’ diet score at 6 or 12 months full scale IQ rose by 0.18 (95% CI 0.04 to 0.31) of a standard deviation. For a standard deviation increase in ‘infant guidelines’ diet score at 6 months verbal IQ rose by 0.14 (0.01 to 0.27) of a standard deviation. There were no associations between dietary patterns in infancy and 4-year performance on the other tests.
These findings suggest that dietary patterns in early life may have some effect on cognitive development. It is also possible that they reflect the influence of unmeasured confounding factors.
PMCID: PMC2698009  PMID: 19236526
15.  Women’s compliance with nutrition and lifestyle recommendations before pregnancy: general population cohort study 
Objective To examine the extent to which women planning a pregnancy comply with recommendations for nutrition and lifestyle.
Design Prospective cohort study.
Setting Southampton, United Kingdom.
Participants 12 445 non-pregnant women aged 20-34 recruited to the Southampton Women’s Survey through general practices, 238 of whom became pregnant within three months of being interviewed.
Main outcome measures Folic acid supplement intake, alcohol consumption, smoking, diet, and physical activity before pregnancy.
Results The 238 women who became pregnant within three months of the interview were only marginally more likely to comply with recommendations for those planning a pregnancy than those who did not become pregnant in this period. Among those who became pregnant, 2.9% (95% confidence interval 1.2% to 6.0%) were taking 400 μg or more of folic acid supplements a day and drinking four or fewer units of alcohol a week, compared with 0.66% (0.52% to 0.82%) of those who did not become pregnant. 74% of those who became pregnant were non-smokers compared with 69% of those who did not become pregnant (P=0.08). Women in both groups were equally likely to consume five or more portions of fruit and vegetables a day (53% in each group, P=1.0), but only 57% of those who became pregnant had taken any strenuous exercise in the past three months compared with 64% in those who did not become pregnant (P=0.03).
Conclusion Only a small proportion of women planning a pregnancy follow the recommendations for nutrition and lifestyle. Greater publicity for the recommendations is needed, but as many pregnancies are unplanned, improved nutrition and lifestyles of women of childbearing age is also required.
PMCID: PMC2643441  PMID: 19213768

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