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1.  Gestational Weight Gain: Now and the Future 
Circulation  2012;125(11):1339-1340.
PMCID: PMC4187208  PMID: 22344036
editorials; cardiovascular risk factors; epidemiology; obesity; pregnancy; gestational weight gain
2.  Assessing care providers’ perceptions and beliefs about physical activity in infants and toddlers: baseline findings from the Baby NAP SACC study 
BMC Public Health  2015;15:100.
As children now spend increasing amounts of time in out-of-home care, care providers play an important role in promoting positive health behaviors. Little is currently known about providers’ perceptions and beliefs about physical activity, particularly for very young children. This study describes providers’ perceptions and beliefs about infants’ and toddlers’ physical activity, and assesses their knowledge of physical activity guidelines, to establish if and where providers may need support to promote physical activity in child care settings.
We analyzed baseline data from a pilot randomized-controlled trial conducted in 32 child care centers in Massachusetts, USA. Providers completed physical activity-related questionnaires from which we compared twenty perception and belief questions for infant and toddler care providers.
203 care providers (96% female, mean ± SD age: 32.7 ± 11.2 years) from 29 centers completed questionnaires. A large proportion of providers (n = 114 (61.9%)) believed that infants should be active for 45 minutes or less each day, and only 56 providers (29.7%) perceived toddlers to require more than 90 minutes of activity per day. 97% of providers perceived it was their job to ensure children engaged in a healthy amount of physical activity and most (94.1%) perceived physical activity to be important to own their health, despite 13.3% finding it hard to find the energy to be physically active.
This study is the first to assess the physical activity perceptions and attitudes of providers caring for infants and toddlers. Though all providers believed toddlers should engage in more physical activity than infants, most providers believed that young children require only a short amount of physical activity each day, below recommended guidelines. How provider perceptions influence children’s physical activity behavior requires investigation.
PMCID: PMC4334406
Infants; Toddlers; Physical activity; Child care; Baby NAPSACC
3.  Effects of Promoting Longer Term and Exclusive Breastfeeding on Cardiometabolic Risk Factors at Age 11.5 Years: A Cluster-Randomized, Controlled Trial 
Circulation  2013;129(3):321-329.
The duration and exclusivity of breastfeeding in infancy have been inversely associated with future cardiometabolic risk. We investigated the effects of an experimental intervention to promote increased duration of exclusive breastfeeding on cardiometabolic risk factors in childhood.
Methods and results
We followed-up children in the Promotion of Breastfeeding Intervention Trial, a cluster-randomized trial of a breastfeeding promotion intervention based on the World Health Organization/United Nations Children’s Fund Baby-Friendly Hospital Initiative. 17,046 breastfeeding mother-infant pairs were enrolled in 1996/7 from 31 Belarussian maternity hospitals and affiliated polyclinics (16 intervention vs 15 control sites); 13,879 (81.4%) children were followed-up at 11.5 years, with 13,616 (79.9%) fasted and without diabetes. The outcomes were blood pressure; fasting insulin, adiponectin, glucose and apolipoprotein A1; and presence of metabolic syndrome. Analysis was by intention to treat, accounting for clustering within hospitals/clinics. The intervention substantially increased breastfeeding duration and exclusivity compared with the control arm (43% vs. 6% and 7.9% vs. 0.6% exclusively breastfed at 3 and 6 months, respectively). Cluster-adjusted mean differences at 11.5 years between experimental vs control groups were: 1.0mmHg (95% CI: −1.1, 3.1) for systolic and 0.8mmHg (−0.6, 2.3) for diastolic blood pressure; −0.1mmol/l (−0.2, 0.1) for glucose; 8% (−3%, 34%) for insulin; −0.33μ/ml (−1.5, 0.9) for adiponectin; and 0.0g/l (−0.1, 0.1) for ApoA1. The cluster-adjusted odds ratio for metabolic syndrome, comparing experimental vs control groups, was 1.21 (0.85, 1.72).
An intervention to improve breastfeeding duration and exclusivity among healthy term infants did not influence cardiometabolic risk factors in childhood.
Clinical Trial Registration Information
Current Controlled Trials: ISRCTN37687716 (; Identifier: NCT01561612.
PMCID: PMC3946966  PMID: 24300437
Breastfeeding; lactation; blood pressure; fasting insulin; glucose; adiponectin; lipids; randomized controlled trial; childhood
4.  Gestational Glucose Tolerance and Cord Blood Leptin Levels Predict Slower Weight Gain in Early Infancy 
The Journal of pediatrics  2010;158(2):227-233.
To determine the extent to which known pre- and perinatal predictors of childhood obesity also predict weight gain in early infancy.
Study design
We studied 690 infants participating in the prospective cohort Project Viva. We measured length and weight at birth and at 6 months. Using multivariable linear regression, we examined relationships of selected maternal and infant factors with change in weight-for-length z-score (WFL-z) from 0 to 6 months.
Mean (SD) change in WFL-z from 0 to 6 months was 0.23 (1.11), which translates to 4500 grams gained from birth to 6 months of life in an infant with average birth weight and length. After adjustment for confounding variables and birth weight-for-gestational age z-score (-0.28 [95% C.I. -0.37, -0.19] per unit), cord blood leptin (-0.40 [95% C.I. -0.61, -0.19] per 10 ng/ml) and gestational diabetes (-0.50 [95% C.I. -0.88, -0.11] versus normal glucose tolerance) were each associated with slower gain in WFL-z from 0 to 6 months.
Higher neonatal leptin and gestational diabetes predicted slower weight gain in the first 6 months of life. The hormonal milieu of the intrauterine environment may determine growth patterns in early infancy and thus later obesity.
PMCID: PMC4270123  PMID: 20855080
5.  Opportunities to Strengthen Childhood Obesity Prevention in Two Mexican Health Care Settings 
The purpose of this study was to examine Mexican caregivers’ perceptions of the role of primary care in childhood obesity management, understand the barriers and facilitators of behavior change, and identify opportunities to strengthen obesity prevention and treatment in clinical settings.
We conducted 52 in-depth interviews with parents and caregivers of overweight and obese children age 2–5 years in 4 Ministry of Health (public, low SES) and 4 Social Security Institute (insured, higher SES) primary care clinics in Mexico City and did systematic thematic analysis.
In both health systems, caregivers acknowledged childhood overweight but not its adverse health consequences. Although the majority of parents had not received nutrition or physical activity recommendations from health providers, many were open to clinician guidance. Despite knowledge of healthful nutrition and physical activity, parents identified several barriers to change including child feeding occurring in the context of competing priorities (work schedules, spouses’ food preferences), and cultural norms (heavy as healthy, food as nurturance) that take precedence over adherence to dietary guidelines. Physical activity, while viewed favorably, is not a structured part of most preschooler’s routines as reported by parents.
The likelihood of success for clinic-based obesity prevention among Mexican preschoolers will be higher by addressing contextual barriers such as cultural norms regarding children’s weight and support of family members for behavior change. Similarities in caregivers’ perceptions across 2 health systems highlight the possibility of developing comprehensive interventions for the population as a whole.
PMCID: PMC4269346  PMID: 25530836
Mexico; childhood obesity; clinical settings; qualitative research; pediatric; behavior
6.  Preterm infant linear growth and adiposity gain: tradeoffs for later weight status, and IQ 
The Journal of pediatrics  2013;163(6):10.1016/j.jpeds.2013.06.032.
Among preterm infants, to examine tradeoffs between cognitive outcome and overweight/obesity at school age and in young adulthood in relation to infancy weight gain and linear growth.
Study design
We studied 945 participants in the Infant Health and Development Program, an 8-center study of preterm (≤37 weeks), low birth weight (≤2500 grams) infants from birth to 18 years. Adjusting for maternal and child factors in logistic regression, we estimated the odds of overweight/obesity (BMI ≥85th percentile at age 8 or ≥25 kg/m2 at age 18) and in separate models, low IQ (<85) per z-score change in infant length and BMI from term to 4 months, 4-12 months, and 12-18 months.
More rapid linear growth from term to 4 months was associated with lower odds of IQ<85 at age 8 (OR 0.82, 95% CI 0.70, 0.96), but a higher odds of overweight/obesity (OR 1.27, 95% CI 1.05, 1.53). More rapid BMI gain in all 3 infant time intervals was also associated with a higher odds of overweight/obesity, and from 4-12 months with a lower odds of IQ <85 at age 8. Results at age 18 were similar.
In preterm, low birth weight infants born in the 1980’s, faster linear growth soon after term was associated with better cognition but also with a higher risk of overweight/obesity at 8 and 18 years of age. BMI gain over the entire 18 months after term was associated with later risk of overweight/obesity, with less evidence for a benefit to IQ.
PMCID: PMC3834090  PMID: 23910982
7.  Associations of breastfeeding with bulimic behaviors and eating disorders among adolescents 
To use the lifecourse framework to examine the association between duration of breastfeeding and risk of developing bulimic behaviors or a diagnosed eating disorder.
Questionnaires were sent every 12–24 months between 1996 and 2005 to 6436 females and 5756 males in the Growing Up Today Study, who were 9–14 years at baseline. Duration of breastfeeding was reported by the participants’ mothers in 1997. We used generalized estimating equations to estimate the association of breastfeeding with purging, binge eating, engaging in bulimic behaviors, and having a diagnosed eating disorder.
Compared to girls who were breastfed for more than nine months, those who were breastfed for less than four months did not have a significantly different prevalence of purging, binge eating, bulimic behaviors and self-reported history of diagnosed eating disorders. Adjusting for gestational age/birthweight, age, age at menarche, maternal history of an eating disorder, and maternal BMI, short duration of breastfeeding was not associated with any outcome among the girls (adjusted odds ratios (AOR) ranged from 0.8 to 1.1). Among the boys, the results showed no significant associations between duration of breastfeeding and purging, binge eating and self-reported history of diagnosed eating disorder. However, there was a suggestion that boys who had been breastfed for less than 4 months were at a higher risk of engaging in bulimic behaviors [AOR: 1.5, 95% CI, 1.0–2.3].
No association was found between duration of breastfeeding and risk of developing bulimic behaviors or a diagnosed eating disorder among girls or boys with the one exception of longer duration of breastfeeding associated with fewer bulimic behaviors in boys. Although there are many benefits to breastfeeding, our data suggest that breastfeeding does not offer any protection against binge eating or purging, nor does it present harmful effects.
PMCID: PMC3931514  PMID: 23922082
lifecourse approach; breastfeeding; disordered weight control behaviors (DWCB); purging; binge eating; bulimic behaviors; eating disorders
8.  Association between television viewing and poor diet quality in young children 
To examine the association between television/video (TV) viewing and markers of diet quality among 3-year-old children.
We studied 613 boys and 590 girls, age 3 years old, who were participants in Project Viva. Each mother reported the number of hours her child watched TV on an average weekday and weekend day in the past month, from which we calculated a weighted mean. The main outcomes were intakes of selected foods and nutrients from a validated food frequency questionnaire. In linear regression models we adjusted for mother’s sociodemographic information, parental body mass index (BMI), and child’s age, sex, race/ethnicity, BMI z-score, sleep duration, and breast feeding duration.
Mean (standard deviation, SD) age of subjects was 3.2 (0.2) years; 372 children (31%) were non-white and 151 (13%) had a household income <$40 000, and 330 mothers (28%) had completed less than a college degree. Mean (SD) TV viewing was 1.7 (1.0) hours per day. For each 1-hour increment of TV viewing per day, we found higher intakes of sugar-sweetened beverages (0.06 servings/day [95% CI 0.03, 0.10]), fast food (0.32 servings/month [95% CI 0.16, 0.49]), red and processed meat (0.06 servings/day [95% CI 0.02, 0.09]), total energy intake (48.7 kcal/day [95% CI 18.7, 78.6]), and percent energy intake from trans fat (0.05 [95% CI 0.03, 0.07]). We found lower intakes of fruit and vegetables (−0.18 servings/day [95% CI −0.32, −0.05]), calcium (−24.6 mg/day [95% CI −41.0, −8.1]), and dietary fiber (−0.44 g/day [95% CI −0.65, −0.22]).
Among 3-year-olds, more TV viewing is associated with adverse dietary practices. Interventions to reduce TV viewing in this age group may lead to improved diet quality.
PMCID: PMC4249761  PMID: 19086298
Cross-sectional; diet quality; fast food; preschool children; television
9.  Effect of Treatment of Gestational Diabetes Mellitus on Obesity in the Next Generation 
Diabetes Care  2010;33(5):964-968.
Gestational diabetes mellitus (GDM) may cause obesity in the offspring. The objective was to assess the effect of treatment for mild GDM on the BMI of 4- to 5-year-old children.
Participants were 199 mothers who participated in a randomized controlled trial of the treatment of mild GDM during pregnancy and their children. Trained nurses measured the height and weight of the children at preschool visits in a state-wide surveillance program in the state of South Australia. The main outcome measure was age- and sex-specific BMI Z score based on standards of the International Obesity Task Force.
At birth, prevalence of macrosomia (birth weight ≥4,000 g) was 5.3% among the 94 children whose mothers were in the intervention group, and 21.9% among the 105 children in the routine care control group. At 4- to 5-years-old, mean (SD) BMI Z score was 0.49 (1.20) in intervention children and 0.41 (1.40) among controls. The difference between treatment groups was 0.08 (95% CI −0.29 to 0.44), an estimate minimally changed by adjustment for maternal race, parity, age, and socio-economic index (0.08 [−0.29 to 0.45]). Evaluating BMI ≥85th percentile rather than continuous BMI Z score gave similarly null results.
Although treatment of GDM substantially reduced macrosomia at birth, it did not result in a change in BMI at age 4- to 5-years-old.
PMCID: PMC2858199  PMID: 20150300
10.  Early Infancy as a Critical Period for Development of Obesity and Related Conditions 
The current obesity epidemic has affected even the youngest children in our societies, including those in the first months of life. Animal experiments suggest that the early postnatal period may be critical to development of healthful energy homeostasis and thus prevention of obesity. In humans, observational studies and follow-up of randomized feeding trials show that rapid weight gain in the first half of infancy predicts later obesity and higher blood pressure. Despite the mounting consistency of results, several questions remain to be answered before clinical or public health implications are clear. These include the need for body composition data in infancy and data from the developing world to identify modifiable determinants of gain in adiposity in the early weeks of life, to mount interventions to modify these determinants, to examine tradeoffs of more vs. less rapid weight gain for different outcomes, and to incorporate any interventions that prove to be efficacious into clinical and public health practice in a cost-effective manner.
PMCID: PMC4187212  PMID: 20139671
11.  Sex-Specific Associations of Gestational Glucose Tolerance With Childhood Body Composition 
Diabetes Care  2013;36(10):3045-3053.
To examine the associations of maternal gestational glucose tolerance with offspring body composition in late childhood.
Among 958 women in the prebirth cohort Project Viva, glucose tolerance was assessed in the second trimester by nonfasting 50-g 1-h glucose challenge test (GCT), followed if abnormal by fasting 100-g 3-h oral glucose tolerance test (OGTT). We categorized women as normoglycemic (83.3%) if GCT was ≤140 mg/dL, isolated hyperglycemia (9.1%) if GCT was abnormal but OGTT normal, intermediate glucose intolerance (IGI) (3.3%) if there was one abnormal value on OGTT, or gestational diabetes mellitus (GDM) (4.5%) if there were two or more abnormal OGTT values. Using multivariable linear regression, we examined adjusted associations of glucose tolerance with offspring overall (N = 958) and central (N = 760) adiposity and body composition using dual X-ray absorptiometry (DXA) measured at the school-age visit (95 ± 10 months).
Compared with that in the male offspring of normoglycemic mothers, DXA fat mass was higher in male offspring of GDM mothers (1.89 kg [95% CI 0.33–3.45]) but not in male offspring of mothers with IGI (0.06 kg [−1.45 to 1.57]). DXA trunk-to-peripheral fat mass, a measure of central adiposity, was also somewhat higher in male offspring of GDM mothers (0.04 [−0.01 to 0.09]). In girls, DXA fat mass was higher in offspring of mothers with IGI (2.23 kg [0.12–4.34]) but not GDM (−1.25 kg [−3.13 to 0.63]). We showed no association of gestational glucose tolerance with DXA lean mass.
In this study, only male offspring of GDM mothers manifested increased adiposity, whereas only female offspring of mothers with IGI did so. Sex differences in glycemic sensitivity may explain these findings.
PMCID: PMC3781569  PMID: 23877978
12.  Diagnostic accuracy of the bronchodilator response in children 
The bronchodilator response (BDR) reflects the reversibility of airflow obstruction and is recommended as an adjunctive test to diagnose asthma. The validity of the commonly used definition of BDR, a 12% or greater change in FEV1 from baseline, has been questioned in childhood.
We sought to examine the diagnostic accuracy of the BDR test by using 3 large pediatric cohorts.
Cases include 1041 children with mild-to-moderate asthma from the Childhood Asthma Management Program.
Control subjects (nonasthmatic and nonwheezing) were chosen from Project Viva and Home Allergens, 2 population-based pediatric cohorts. Receiver operating characteristic curves were constructed, and areas under the curve were calculated for different BDR cutoffs.
A total of 1041 cases (59.7% male; mean age, 8.9 ± 2.1 years) and 250 control subjects (46.8% male; mean age, 8.7 ± 1.7 years) were analyzed, with mean BDRs of 10.7% ± 10.2% and 2.7% ± 8.4%, respectively. The BDR test differentiated asthmatic patients from nonasthmatic patients with a moderate accuracy (area under the curve, 73.3%).
Despite good specificity, a cutoff of 12% was associated with poor sensitivity (35.6%). A cutoff of less than 8% performed significantly better than a cutoff of 12% (P = .03, 8% vs 12%).
Our findings highlight the poor sensitivity associated with the commonly used 12% cutoff for BDR. Although our data show that a threshold of less than 8% performs better than 12%, given the variability of this test in children, we conclude that it might be not be appropriate to choose a specific BDR cutoff as a criterion for the diagnosis of asthma.
PMCID: PMC3759549  PMID: 23683464
Asthma; bronchodilator response; diagnosis
13.  Infant feeding and childhood cognition at ages 3 and 7 years: effects of breastfeeding duration and exclusivity 
JAMA pediatrics  2013;167(9):836-844.
Breastfeeding may benefit child cognitive development, but few studies have quantified breastfeeding exclusivity or duration, nor has any study examined the role of maternal diet during lactation on child cognition.
(1) To examine associations of breastfeeding duration and exclusivity with child cognition at 3 and 7 years; and (2) to examine the extent to which maternal fish intake during lactation modifies associations of infant feeding with later cognition
Prospective cohort study
Project Viva, a U.S. pre-birth cohort that enrolled mothers from 1999-2002 and followed children to age 7 years
1312 Project Viva mothers and children
Main exposure
Duration of any breastfeeding to 12 months
Main outcome measures
Child receptive language assessed with the Peabody Picture Vocabulary Test (PPVT-III) age 3 years; Wide Range Assessment of Visual Motor Abilities (WRAVMA) at 3 and 7 years; and Kaufman Brief Intelligence Test (KBIT) and Wide Range Assessment of Memory and Learning (WRAML) at 7 years.
Adjusting for sociodemographics, maternal intelligence, and home environment in linear regression, longer breastfeeding duration was associated with higher age 3 PPVT-III scores (0.21 points/month, 95% CI: 0.03, 0.38) and greater age 7 intelligence (0.35 verbal KBIT points/month, 95% CI: 0.16, 0.53; 0.29 non-verbal KBIT points/month, 95% CI: 0.05, 0.54). Breastfeeding duration was not associated with WRAML scores. Beneficial effects of breastfeeding on the WRAVMA at age 3 appeared greater for women who consumed ≥2 fish servings/week (0.24 points, 95% CI: 0.00, 0.47) vs. <2 servings/week (-0.01 points, 95% CI: -0.22, 0.20); interaction p-value 0.16.
Conclusions and relevance
Our results support a causal relationship of breastfeeding duration with receptive language and verbal and non-verbal intelligence later in life.
PMCID: PMC3998659  PMID: 23896931
14.  Infant Weight Gain and School-age Blood Pressure and Cognition in Former Preterm Infants 
Pediatrics  2010;125(6):e1419-e1426.
More rapid infant weight gain may be associated with better neurodevelopment but also with higher blood pressure (BP). The objective of this study was to determine the extent to which infant weight gain is associated with systolic BP (SBP) and IQ at school age in former preterm, low birth weight infants.
We studied 911 participants in the Infant Health and Development Program, an 8-center longitudinal study of children born at ≤37 weeks' gestation and ≤2500 g. Study staff weighed participants at term and at 4 and 12 months' corrected ages; measured BP 3 times at 6.5 years; and administered the Wechsler Intelligence Scale for Children, Third Edition (WISC-III), an IQ test, at 8 years. In linear regression, we modeled our exposure “infant weight gain” as the 12-month weight z score adjusted for the term weight z score.
Median (interquartile range) weight z score was −0.7 (−1.5 to −0.0) at 12 months. Mean ± SD SBP at 6.5 years was 104.2 ± 8.4 mm Hg, and mean ± SD WISC-III total score at 8 years was 91 ± 18. Adjusting for child gender, age, and race and maternal education, income, age, IQ, and smoking, for each z score additional weight gain from term to 12 months, SBP was 0.7 mm Hg higher and WISC-III total score was 1.9 points higher.
In preterm infants, there seem to be modest neurodevelopmental advantages of more rapid weight gain in the first year of life and only small BP-related effects.
PMCID: PMC4138041  PMID: 20478940
preterm infant; infant; blood pressure; cognition; fetal programming; growth and development; postnatal growth; small for gestational age
15.  Developmental Origins of Childhood Overweight: Potential Public Health Impact 
Obesity (Silver Spring, Md.)  2008;16(7):1651-1656.
Several modifiable pre- and postnatal determinants of childhood overweight are known, but no one has examined how they influence risk of overweight in combination. We estimated the risk of overweight at age 3 years according to levels of maternal smoking during pregnancy, gestational weight gain, breastfeeding duration, and infant sleep duration. We studied 1,110 mother–child pairs in Project Viva, a prospective prebirth cohort study. The main outcome measure was child overweight (BMI for age and sex ≥95th percentile) at age 3. We ran logistic regression models with all four modifiable risk factors as well as the covariates maternal BMI and education, child race/ethnicity, and household income. From the model, we obtained the estimated probability of overweight for each of the 16 combinations of the four risk factors. During pregnancy, 9.8% of mothers smoked and 50% gained excessive weight. In infancy, 73% mother–child pairs breastfed for <12 m, and 31% of infants slept <12 h/day. Among the 3-year-old children in the cohort, 9.5% were overweight. In the prediction model, the estimated probability of overweight ranged from 0.06 among children exposed to favorable levels of all four risk factors, to 0.29 with adverse levels of all four. Healthful levels of four behaviors during early development predicted much lower probability of overweight at age 3 than adverse levels. Interventions to modify several factors during pregnancy and infancy could have substantial impact on prevention of childhood overweight.
PMCID: PMC2650814  PMID: 18451768
16.  Associations of Parental Control of Feeding with Eating in the Absence of Hunger and Food Sneaking, Hiding, and Hoarding 
Childhood Obesity  2013;9(4):346-349.
Overweight children as young as 5 years old exhibit disturbances in eating behaviors.
Using follow-up data from 419 participants in High Five for Kids, a randomized controlled trial of overweight children, the prevalence of (1) eating in the absence of hunger and (2) food sneaking, hiding, and hoarding was estimated and cross-sectional associations of parental control of feeding and these behaviors were examined using covariate-adjusted logistic regression models.
At follow-up, mean [standard deviation (SD)] age of the children was 7.1 (1.2) years; 49% were female; 16% were healthy weight, 35% were overweight, and 49% were obese. On the basis of parental report, 16.5% of children were eating in the absence of hunger and 27.2% were sneaking, hiding, or hoarding food; 57.5% of parents endorsed parental control of feeding. In adjusted models, children exposed to parental control of feeding were more likely to eat in the absence of hunger [odds ratio (OR) 3.37, 95% confidence interval (CI) 1.66, 6.86], but not to sneak, hide, or hoard food (OR 1.43, 95% CI 0.87, 2.36).
Disturbances in eating behaviors are common among overweight children. Future research should be dedicated to identifying strategies that normalize eating behaviors and prevent excess weight gain among overweight children.
PMCID: PMC3728724  PMID: 23806073
17.  Antenatal and postpartum depressive symptoms are differentially associated with early childhood weight and adiposity 
Antenatal depression is associated with small for gestational age, but few studies have examined associations with weight during childhood. Similarly few studies address whether antenatal and postpartum depression differentially affect child weight. Among 838 mother-child dyads in Project Viva, a prospective cohort study, we examined relationships of antenatal and postpartum depression with child weight and adiposity. We assessed maternal depression at mid-pregnancy and 6 months postpartum with the Edinburgh Postnatal Depression Scale (score >13 indicating probable depression). We assessed child outcomes at age 3 years: body mass index (BMI) z-score, weight-for-height z-score (WHZ), sum of subscapular (SS) and triceps (TR) skinfold thickness (SS+TR) for overall adiposity, and SS:TR ratio for central adiposity. Sixty-nine (8.2%) women experienced antenatal depression and 59 (7.0%) postpartum depression. Mean (SD) outcomes at age 3 were: BMI z-score, 0.45 (1.01); SS+TR, 16.72 (4.03) mm; SS:TR, 0.64 (0.15). In multivariable models, antenatal depression was associated with lower child BMI z-score (-0.24 [95% confidence interval: -0.49, 0.00]), but higher SS:TR (0.05 [0.01, 0.09]). There was no evidence of a dose-response relation between antenatal depression and these outcomes. Postpartum depression was associated with higher SS+TR (1.14 [0.11, 2.18]). In conclusion, whereas antenatal depression was associated with smaller size and central adiposity at age 3 years, postpartum depression was associated with higher overall adiposity.
PMCID: PMC4106300  PMID: 20415775
18.  Dietary Quality during Pregnancy Varies by Maternal Characteristics in Project Viva: A US Cohort 
Maternal diet may influence outcomes of pregnancy and childhood, but data on correlates of food and nutrient intake during pregnancy are scarce.
To examine relationships between maternal characteristics and diet quality during the first trimester of pregnancy. Secondarily we examined associations of diet quality with pregnancy outcomes.
As part of the ongoing US prospective cohort study Project Viva, we studied 1,777 women who completed a food frequency questionnaire during the first trimester of pregnancy. We used linear regression models to examine the relationships of maternal age, prepregnancy body mass index, parity, education, and race/ethnicity with dietary intake during pregnancy. We used the Alternate Healthy Eating Index, slightly modified for pregnancy (AHEI-P), to measure diet quality on a 90-point scale with each of the following nine components contributing 10 possible points: vegetables, fruit, ratio of white to red meat, fiber, trans fat, ratio of polyunsaturated to saturated fatty acids, and folate, calcium, and iron from foods.
Mean AHEI-P score was 61±10 (minimum 33, maximum 89). After adjusting for all characteristics simultaneously, participants who were older (1.3 points per 5 years, 95% confidence interval [CI] [0.7 to 1.8]) had better AHEI-P scores. Participants who had higher body mass index (−0.9 points per 5 kg/m2, 95% CI [−1.3 to −0.4]), were less educated (−5.2 points for high school or less vs college graduate, 95% CI [−7.0 to −3.5]), and had more children (−1.5 points per child, 95% CI [−2.2 to −0.8]) had worse AHEI-P scores, but African-American and white participants had similar AHEI-P scores (1.3 points for African American vs white, 95% CI [−0.2 to 2.8]). Using multivariate adjusted models, each five points of first trimester AHEI-P was associated lower screening blood glucose level (β −.64 [95% CI −0.02 to −1.25]). In addition, each five points of second trimester AHEI-P was associated with a slightly lower risk of developing preeclampsia (odds ratio 0.87 [95% CI 0.76 to 1.00]), but we did not observe this association with first trimester AHEI-P (odds ratio 0.96 [95% CI 0.84 to 1.10]).
Pregnant women who were younger, less educated, had more children, and who had higher prepregnancy body mass index had poorer-quality diets. These results could be used to tailor nutrition education messages to pregnant women to avoid long-term sequelae from suboptimal maternal nutrition.
PMCID: PMC4098830  PMID: 19465182
19.  Misdiagnosis of Overweight and Underweight Children Younger Than 2 Years of Age Due to Length Measurement Bias 
Accurate determination of the length of very young children is important because weight-for-length standards are used to assess both under- and overweight. Clinical measurements of length, which usually involve a paper-and-pencil method, may often be inaccurate in children younger than 2 years.
To compare length measured by the conventional clinical paper-and-pencil method with length measured by the research standard recumbent length-board method in a sample of children under 2 years of age.
Research assistants measured 160 children 0 through 23 months of age using the recumbent length-board method, and clinical staff measured the same children using the paper-and-pencil method. To assess the relationship between the research and clinical length measurements, we used ordinary least squares regression.
We found a strong linear relationship between the 2 measures of length (R2 = 0.98). The paper-and-pencil method systematically overestimated length in children under 2 years of age. A fitted regression equation estimated that the research standard length was 95.3% of the clinical measurement plus 1.88 cm. Over the entire age span, the mean (SD) difference between clinical and research measurements was 1.3 (1.5) cm.
Using the paper-and-pencil method can lead to underestimates of overweight and exaggerated estimates of thinness. To improve the accuracy of length measurement, medical providers should use standardized procedures with a recumbent length board to measure children under 2 years of age, at least for children whose initial paper-and-pencil measurement of length puts them at one extreme or the other.
PMCID: PMC1488725  PMID: 16614678
20.  Perinatal Predictors of Atopic Dermatitis Occurring in the First Six Months of Life 
Pediatrics  2004;113(3 Pt 1):468-474.
Previous studies of predictors of atopic dermatitis have had limited sample size, small numbers of variables, or retrospective data collection. The purpose of this prospective study was to investigate several perinatal predictors of atopic dermatitis occurring in the first 6 months of life.
We report findings from 1005 mothers and their infants participating in Project Viva, a US cohort study of pregnant women and their offspring. The main outcome measure was maternal report of a provider’s diagnosis of eczema or atopic dermatitis in the first 6 months of life. We used multiple logistic regression models to assess the associations between several simultaneous predictors and incidence of atopic dermatitis.
Cumulative incidence of atopic dermatitis in the first 6 months of life was 17.1%. Compared with infants born to white mothers, the adjusted odds ratio (OR) for risk of atopic dermatitis among infants born to black mothers was 2.41 (95% confidence interval [CI]: 1.47, 3.94) and was 2.58 among infants born to Asian mothers (95% CI: 1.27, 5.24). Male infants had an OR of 1.76 (95% CI: 1.24, 2.51). Increased gestational age at birth was a predictor (OR: 1.14; 95% CI: 1.02, 1.27, for each 1-week increment), but birth weight for gestational age was not. Infants born to mothers with a history of eczema had an OR of 2.67 (95% CI: 1.74, 4.10); paternal history of eczema also was predictive, although maternal atopic history was more predictive than paternal history. Several other perinatal, social, feeding, and environmental variables were not related to risk of atopic dermatitis.
Black and Asian race/ethnicity, male gender, higher gestational age at birth, and family history of atopy, particularly maternal history of eczema, were associated with increased risk of atopic dermatitis in the first 6 months of life. These findings suggest that genetic and pre- and perinatal influences are important in the early presentation of this condition. Pediatrics
PMCID: PMC1488729  PMID: 14993536
atopic dermatitis; eczema; perinatal; infancy; gestational age; race/ethnicity; gender; BMI, body mass index; OR, odds ratio; CI, confidence interval; IgE, immunoglobulin E
21.  Electronic Reminders for Cancer Prevention: Factors Associated with Preference for Automated Voice Reminders or Text Messages 
Preventive medicine  2012;55(2):151-154.
Prompting may promote engagement with behavior change interventions. Prompts can be delivered inexpensively via automated voice response (AVR) reminders or short message service (SMS) text messages. We examined the association between participants’ characteristics and preferred reminder modality.
Healthy Directions 2 is a cluster randomized controlled trial implemented in Boston, Massachusetts to promote change in multiple behavioral cancer risk factors. At baseline (2009), participants completed a survey assessing socio-demographics, health status, height/weight, and factors associated with technology. One-third of participants randomized to receive the intervention (n=598) were randomized to receive automated reminders, with participants selecting modality.
27.9% (167/598) of participants selected SMS reminders. Controlling for clustering by primary care provider, younger participants (OR=0.97, 95% CI=(0.95, 0.99) p<.01), those most comfortable with computers (very uncomfortable OR= 0.54, 95% CI=(0.29, 1.01), p≤0.05: referent group=very comfortable), and those who frequently sent/received text messages (never OR=0.09 CI=(0.04, 0.16) p<.01; 1-3 times/month OR=0.38, CI=(0.15, 0.93) p= 0.04: referent group= 1-5 times/wk) were more likely to choose SMS.
Interventions should make both modalities available to ensure that more participants can benefit from prompting. Studies examining the effect of automated reminders may have reduced effectiveness or generalizability if they employ only one modality.
PMCID: PMC4077718  PMID: 22659227
SMS text messages; automated voice recordings; prompting; electronic reminders
22.  Breast-feeding and Overweight in Adolescence: Within-family analysis  
Epidemiology (Cambridge, Mass.)  2006;17(1):112-114.
Previous reports have found associations between having been breast-fed and a reduced risk of being overweight. These associations may be confounded by sociocultural determinants of both breast-feeding and obesity. We addressed this possibility by assessing the association of breast-feeding duration with adolescent obesity within sibling sets.
We surveyed 5614 siblings age 9 to 14 years and their mothers. These children were a subset of participants in the Growing Up Today Study, in which we had previously reported an inverse association of breast-feeding duration with overweight. We compared the prevalence of overweight (body mass index exceeding the age-sex-specific 85th percentile) in siblings who were breast-fed longer than the mean duration of their sibship with those who were breast-fed for a shorter period. Then we compared odds ratios from this within-family analysis with odds ratios from an overall (ie, not within-family) analysis.
Mean ± standard deviation breast-feeding duration was 6.4 ± 4.0 months, and crude prevalence of overweight was 19%. On average, siblings who were breast-fed longer than their family mean had breast-feeding duration 3.7 months longer than their shorter-duration siblings. The adjusted odds ratio (OR) for overweight among siblings with longer breast-feeding duration, compared with shorter duration, was 0.92 (95% confidence interval = 0.76–1.11). In overall analyses, the adjusted OR was 0.94 (0.88–1.00) for each 3.7-month increment in breast-feeding duration.
The estimated OR for the within-family analysis was close to the overall estimate, suggesting that the apparent protective effect of breast-feeding on later obesity was not highly confounded by unmeasured sociocultural factors. A larger study of siblings, however, would be needed to confirm this conclusion.
PMCID: PMC1994917  PMID: 16357604
23.  Invited Commentary: Antecedents of Obesity—Analysis, Interpretation, and Use of Longitudinal Data 
American journal of epidemiology  2007;166(1):14-18.
The obesity epidemic causes misery and death. Most epidemiologists accept the hypothesis that characteristics of the early stages of human development have lifelong influences on obesity-related health outcomes. Unfortunately, there is a dearth of data of sufficient scope and individual history to help unravel the associations of prenatal, postnatal, and childhood factors with adult obesity and health outcomes. Here the authors discuss analytic methods, the interpretation of models, and the use to which such rare and valuable data may be put in developing interventions to combat the epidemic. For example, analytic methods such as quantile and multinomial logistic regression can describe the effects on body mass index range rather than just its mean; structural equation models may allow comparison of the contributions of different factors at different periods in the life course. Interpretation of the data and model construction is complex, and it requires careful consideration of the biologic plausibility and statistical interpretation of putative causal factors. The goals of discovering modifiable determinants of obesity during the prenatal, postnatal, and childhood periods must be kept in sight, and analyses should be built to facilitate them. Ultimately, interventions in these factors may help prevent obesity-related adverse health outcomes for future generations.
PMCID: PMC1989664  PMID: 17490988
birth weight; body mass index; body size; growth; obesity; overweight
24.  Maternal Corticotropin-Releasing Hormone Levels during Pregnancy and Offspring Adiposity 
Obesity (Silver Spring, Md.)  2006;14(9):1647-1653.
Animal models suggest that fetal exposure to glucocorticoids can program adiposity, especially central adiposity, later in life. We examined associations of maternal corticotropin-releasing hormone (CRH) levels in the late 2nd trimester of pregnancy, a marker of fetal glucocorticoid exposure, with child adiposity at age 3 years.
Research Methods and Procedures
We analyzed data from 199 participants in Project Viva, a prospective cohort study of pregnant women and their children, At age 3 years, the main outcomes were age-sex-specific BMI z score and the sum of subscapular (SS) and triceps (TR) skinfold thicknesses to represent overall adiposity, and ratio of SS to TR (SS:TR) to represent central adiposity.
Mean (standard deviation) maternal 2nd trimester log CRH was 4.94 (0.56) pg/mL. At age 3, mean (standard deviation) for BMI z score was 0.52 (1.02); for SS + TR, 16.51 (3.94) mm; and for SS:TR, 0.67 (0.17). Log CRH was mildly inversely correlated with birth weight (r = −0.08), chiefly because of its association with length of gestation (r = −0.21) rather than fetal growth (r = −0.004). After adjustment for sociodemographic factors, maternal smoking, BMI, and gestational weight gain, fetal growth, length of gestation, breastfeeding duration, and (for SS:TR only) child’s 3-year BMI, each increment of 1 unit of log CRH was associated with a reduction in BMI z score [−0.43; 95% confidence interval (CI), −0.73, −0.14; p = 0.004] and possible reduction in SS + TR (−1.10; 95% CI, −2.33, 0.14; p = 0.08). In contrast, log CRH was associated with higher SS:TR (0.07; 95% CI, 0.02, 0.13; p = 0.007).
Fetal exposure to glucocorticoids, although associated with an overall decrease in body size, may cause an increase in central adiposity.
PMCID: PMC1899091  PMID: 17030976
pregnancy; pediatrics; placenta; glucocorticoids; child overweight
25.  Choline Intake During Pregnancy and Child Cognition at Age 7 Years 
American Journal of Epidemiology  2012;177(12):1338-1347.
Animal models indicate that exposure to choline in utero improves visual memory through cholinergic transmission and/or epigenetic mechanisms. Among 895 mothers in Project Viva (eastern Massachusetts, 1999–2002 to 2008–2011), we estimated the associations between intakes of choline, vitamin B12, betaine, and folate during the first and second trimesters of pregnancy and offspring visual memory (measured by the Wide Range Assessment of Memory and Learning, Second Edition (WRAML2), Design and Picture Memory subtests) and intelligence (measured using the Kaufman Brief Intelligence Test, Second Edition (KBIT-2)) at age 7 years. Mean second-trimester intakes were 328 (standard deviation (SD), 63) mg/day for choline, 10.5 (SD, 5.1) µg/day for vitamin B12, 240 (SD, 104) mg/day for betaine, and 1,268 (SD, 381) µg/day for folate. Mean age 7 test scores were 17.2 (SD, 4.4) points on the WRAML 2 Design and Picture Memory subtests, 114.3 (SD, 13.9) points on the verbal KBIT-2, and 107.8 (SD, 16.5) points on the nonverbal KBIT-2. In a model adjusting for maternal characteristics, the other nutrients, and child's age and sex, the top quartile of second-trimester choline intake was associated with a child WRAML2 score 1.4 points higher (95% confidence interval: 0.5, 2.4) than the bottom quartile (P-trend = 0.003). Results for first-trimester intake were in the same direction but weaker. Intake of the other nutrients was not associated with the cognitive tests administered. Higher gestational choline intake was associated with modestly better child visual memory at age 7 years.
PMCID: PMC3676149  PMID: 23425631
choline; cognition; folate; memory; pregnancy

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