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1.  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
2.  Timing of Solid Food Introduction and Risk of Obesity in Preschool-Aged Children 
Pediatrics  2011;127(3):e544-e551.
To examine the association between timing of introduction of solid foods during infancy and obesity at 3 years of age.
We studied 847 children in Project Viva, a prospective pre-birth cohort study. The primary outcome was obesity at 3 years of age (BMI for age and gender ≥95th percentile). The primary exposure was the timing of introduction of solid foods, categorized as <4, 4 to 5, and ≥6 months. We ran separate logistic regression models for infants who were breastfed for at least 4 months (“breastfed”) and infants who were never breastfed or stopped breastfeeding before the age of four months (“formula-fed”), adjusting for child and maternal characteristics, which included change in weight-for-age z score from 0 to 4 months–a marker of early infant growth.
In the first 4 months of life, 568 infants (67%) were breastfed and 279 (32%) were formula-fed. At age 3 years, 75 children (9%) were obese. Among breastfed infants, the timing of solid food introduction was not associated with odds of obesity (odds ratio: 1.1 [95% confidence interval: 0.3–4.4]). Among formula-fed infants, introduction of solid foods before 4 months was associated with a sixfold increase in odds of obesity at age 3 years; the association was not explained by rapid early growth (odds ratio after adjustment: 6.3 [95% confidence interval: 2.3–6.9]).
Among formula-fed infants or infants weaned before the age of 4 months, introduction of solid foods before the age of 4 months was associated with increased odds of obesity at age 3 years.
PMCID: PMC3065143  PMID: 21300681
obesity; infant feeding; complementary foods
3.  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
4.  Changes in dietary intake from the first to the second trimester of pregnancy 
Rifas-Shiman SL, Rich-Edwards JW, Willett WC, Kleinman KP, Oken E, Gillman MW. Changes in dietary intake from the first to the second trimester of pregnancy.
Maternal diet may influence outcomes of pregnancy and childhood. Diet in the first trimester may be more important to development and differentiation of various organs, whereas diet later in pregnancy may be important for overall fetal growth as well as for brain development. To our knowledge, no studies have examined individual-level changes in food and nutrient intake from the 1st to 2nd trimester of pregnancy. The objective of this study was to examine changes in dietary intake from the 1st to 2nd trimester of pregnancy. As part of the ongoing US prospective cohort study, Project Viva, we studied 1543 women who completed food-frequency questionnaires that assessed dietary intakes during the 1st and 2nd trimester of pregnancy. For both foods and energy-adjusted nutrients, we examined changes in dietary intake from 1st to 2nd trimester.
Reported mean energy intake was similar for the 1st (2046 kcal) and 2nd (2137 kcal) trimesters. Foods and energy-adjusted nutrients from foods whose overall mean intakes increased more than 5% from 1st to 2nd trimester were skim or 1% dairy foods (22%), whole-fat dairy foods (15%), red and processed meat (11%), saturated fat (6%) and vitamin D (7%). Intake of caffeinated beverages (−30%) and alcoholic beverages (−88%) decreased more than 5%. Because mean multivitamin intake increased by 35% from the 1st to 2nd trimester, total micronutrient intake increased appreciably more than micronutrient intake from foods only. Correlations across trimesters ranged from 0.32 for vitamin B12 to 0.68 for fruit and vegetables.
In conclusion, for many outcomes of pregnancy and childhood, the incremental information obtained from assessing complete diet in both early and late pregnancy may not outweigh the burden to participants and investigators. However, investigators should assess caffeine, alcohol, and vitamin and supplement use in both the 1st and 2nd trimester, and consider doing so for foods and nutrients for which trimester-specific hypotheses are well substantiated.
PMCID: PMC1488723  PMID: 16420339
pregnancy; maternal diet; nutrients; dietary supplements; changes in pregnancy
5.  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
6.  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
7.  Characteristics of Walkable Built Environments and BMI z-Scores in Children: Evidence from a Large Electronic Health Record Database 
Environmental Health Perspectives  2014;122(12):1359-1365.
Background: Childhood obesity remains a prominent public health problem. Walkable built environments may prevent excess weight gain.
Objectives: We examined the association of walkable built environment characteristics with body mass index (BMI) z-score among a large sample of children and adolescents.
Methods: We used geocoded residential address data from electronic health records of 49,770 children and adolescents 4 to < 19 years of age seen at the 14 pediatric practices of Harvard Vanguard Medical Associates from August 2011 through August 2012. We used eight geographic information system (GIS) variables to characterize walkable built environments. Outcomes were BMI z-score at the most recent visit and BMI z-score change from the earliest available (2008–2011) to the most recent (2011–2012) visit. Multivariable models were adjusted for child age, sex, race/ethnicity, and neighborhood median household income.
Results: In multivariable cross-sectional models, living in closer proximity to recreational open space was associated with lower BMI z-score. For example, children who lived in closest proximity (quartile 1) to the nearest recreational open space had a lower BMI z-score (β = –0.06; 95% CI: –0.08, –0.03) compared with those living farthest away (quartile 4; reference). Living in neighborhoods with fewer recreational open spaces and less residential density, traffic density, sidewalk completeness, and intersection density were associated with higher cross-sectional BMI z-score and with an increase in BMI z-score over time.
Conclusions: Overall, built environment characteristics that may increase walkability were associated with lower BMI z-scores in a large sample of children. Modifying existing built environments to make them more walkable may reduce childhood obesity.
Citation: Duncan DT, Sharifi M, Melly SJ, Marshall R, Sequist TD, Rifas-Shiman SL, Taveras EM. 2014. Characteristics of walkable built environments and BMI z-scores in children: evidence from a large electronic health record database. Environ Health Perspect 122:1359–1365;
PMCID: PMC4256697  PMID: 25248212
8.  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
9.  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
10.  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
11.  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
12.  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
13.  Weight gain in pregnancy and risk of maternal hyperglycemia 
The purpose of this study was to examine associations of weight gain from prepregnancy to glycemic screening with glucose tolerance status.
Main outcomes were failed glycemic screening (1-hour glucose result ≥ 140 mg/dL) with either 1 high value on 3-hour oral glucose tolerance testing (impaired glucose tolerance in pregnancy) or ≥ 2 high values on 3-hour oral glucose tolerance testing (gestational diabetes mellitus). We performed multinomial logistic regression to determine the odds of these glucose intolerance outcomes by quartile of gestational weight gain among 1960 women in Project Viva.
Mean gestational weight gain was 10.2 ± 4.3 (SD) kg. Compared with the lowest quartile of weight gain, participants in the highest quartile had an increased odds of impaired glucose tolerance in pregnancy (adjusted odds ratio, 2.54; 95% confidence interval, 1.25–5.15), but not gestational diabetes mellitus (odds ratio, 0.93; 95% confidence interval, 0.50–1.70).
Higher weight gain predicted impaired glucose tolerance in pregnancy, but not gestational diabetes mellitus.
PMCID: PMC4050656  PMID: 19371858
gestational diabetes mellitus; impaired glucose tolerance; obesity; pregnancy; weight gain
14.  Television Viewing in Infancy and Child Cognition at 3 Years of Age in a US Cohort 
Pediatrics  2009;123(3):e370-e375.
To examine the extent to which infant television viewing is associated with language and visual motor skills at 3 years of age.
We studied 872 children who were participants in Project Viva, a prospective cohort. The design used was a longitudinal survey, and the setting was a multisite group practice in Massachusetts. At 6 months, 1 year, and 2 years, mothers reported the number of hours their children watched television in a 24-hour period, from which we derived a weighted average of daily television viewing. We used multivariable regression analyses to predict the independent associations of television viewing between birth and 2 years with Peabody Picture Vocabulary Test III and Wide-Range Assessment of Visual Motor Abilities scores at 3 years of age.
Mean daily television viewing in infancy (birth to 2 years) was 1.2 (SD: 0.9) hours, less than has been found in other studies of this age group. Mean Peabody Picture Vocabulary Test III score at age 3 was 104.8 (SD: 14.2); mean standardized total Wide-Range Assessment of Visual Motor Abilities score at age 3 was 102.6 (SD: 11.2). After adjusting for maternal age, income, education, Peabody Picture Vocabulary Test III score, marital status, and parity, and child's age, gender, birth weight for gestational age, breastfeeding duration, race/ethnicity, primary language, and average daily sleep duration, we found that each additional hour of television viewing in infancy was not associated with Peabody Picture Vocabulary Test III or total standardized Wide-Range Assessment of Visual Motor Abilities scores at age 3.
Television viewing in infancy does not seem to be associated with language or visual motor skills at 3 years of age.
PMCID: PMC4042392  PMID: 19254972
television viewing; infancy; media; cognition
Breastfeeding and infant weight change are both associated with adiposity. We examined the extent to which infant weight change mediates the association between breastfeeding and adiposity at age 3 years.
We studied 884 children in a prospective cohort study. We determined breastfeeding status at 6 months. Our primary outcomes at 3 years were body mass index (BMI) z score and the sum of subscapular and triceps skinfold thicknesses (SS + TR); we also assessed obesity. We defined infant weight change as change in weight-for-age z score between birth and 6 months. We performed multivariable regression analyses.
At age 6 months, 25.0% of infants were fully breastfed. At age 3 years, mean (SD) BMI z score was 0.45 (1.03). In linear regression analyses adjusted for mother’s educational level, race/ethnicity, smoking, BMI, pregnancy weight gain and birth weight (adjusted for gestational age), the BMI z score of fully breastfed children was 0.17 (95% CI:−0.43, 0.09) units lower than never breastfed children. After additional adjustment for infant weight change, the estimate was attenuated (−0.03, 95% CI: −0.27, 0.20). Adjustment for infant weight change only modestly attenuated estimates for SS + TR (from −1.48 (95% CI: −2.52, −0.44) to −1.16 mm (95% CI: −2.18, −0.14)), and for the odds of being obese (from 0.21 (95% CI: 0.07, 0.68) to 0.29 (95% CI: 0.08, 1.05)).
Infant weight change between birth and 6 months mediates associations of breastfeeding with BMI, but only partially with indicators of child adiposity.
PMCID: PMC3977954  PMID: 20979572
body mass index; breastfeeding; infant weight change; obesity; overweight
16.  Air Pollution Exposure and Abnormal Glucose Tolerance during Pregnancy: The Project Viva Cohort 
Environmental Health Perspectives  2014;122(4):378-383.
Background: Exposure to fine particulate matter (PM with diameter ≤ 2.5 μm; PM2.5) has been linked to type 2 diabetes mellitus, but associations with hyperglycemia in pregnancy have not been well studied.
Methods: We studied Boston, Massachusetts–area pregnant women without known diabetes. We identified impaired glucose tolerance (IGT) and gestational diabetes mellitus (GDM) during pregnancy from clinical glucose tolerance tests at median 28.1 weeks gestation. We used residential addresses to estimate second-trimester PM2.5 and black carbon exposure via a central monitoring site and spatiotemporal models. We estimated residential traffic density and roadway proximity as surrogates for exposure to traffic-related air pollution. We performed multinomial logistic regression analyses adjusted for sociodemographic covariates, and used multiple imputation to account for missing data.
Results: Of 2,093 women, 65 (3%) had IGT and 118 (6%) had GDM. Second-trimester spatiotemporal exposures ranged from 8.5 to 15.9 μg/m3 for PM2.5 and from 0.1 to 1.7 μg/m3 for black carbon. Traffic density was 0–30,860 vehicles/day × length of road (kilometers) within 100 m; 281 (13%) women lived ≤ 200 m from a major road. The prevalence of IGT was elevated in the highest (vs. lowest) quartile of exposure to spatiotemporal PM2.5 [odds ratio (OR) = 2.63; 95% CI: 1.15, 6.01] and traffic density (OR = 2.66; 95% CI: 1.24, 5.71). IGT also was positively associated with other exposure measures, although associations were not statistically significant. No pollutant exposures were positively associated with GDM.
Conclusions: Greater exposure to PM2.5 and other traffic-related pollutants during pregnancy was associated with IGT but not GDM. Air pollution may contribute to abnormal glycemia in pregnancy.
Citation: Fleisch AF, Gold DR, Rifas-Shiman SL, Koutrakis P, Schwartz JD, Kloog I, Melly S, Coull BA, Zanobetti A, Gillman MW, Oken E. 2014. Air pollution exposure and abnormal glucose tolerance during pregnancy: the Project Viva Cohort. Environ Health Perspect 122:378–383;
PMCID: PMC3984217  PMID: 24508979
17.  Second Trimester Estimated Fetal Weight and Fetal Weight Gain Predict Childhood Obesity 
The Journal of pediatrics  2012;161(5):864-870.
To determine the extent to which fetal weight during mid-pregnancy and fetal weight gain from mid-pregnancy to birth predict adiposity and blood pressure (BP) at age 3 years.
Study design
Among 438 children in the Project Viva cohort, we estimated fetal weight at 16–20 (median 18) weeks gestation using ultrasound biometry measures. We analyzed fetal weight gain as change in quartile of weight from the second trimester until birth, and we measured height, weight, subscapular and triceps skinfold thicknesses and BP at age 3.
Mean (SD) estimated weight at 16–20 weeks was 234 (30) grams and birth weight was 3518 (420) grams. In adjusted models, weight estimated during the second trimester and at birth were associated with higher BMI z-scores at age 3 years (0.32 units [95% C.I. 0.04, 0.60] and 0.53 units [95% C.I. 0.24, 0.81] for the highest v. lowest quartile of weight). Infants with more rapid fetal weight gain and those who remained large from mid-pregnancy to birth had higher BMI z-scores (0.85 units [95% C.I. 0.30, 1.39] and 0.63 units [95% C.I. 0.17, 1.09], respectively) at age 3 than infants who remained small during fetal life. We did not find associations between our main predictors and sum or ratio of subscapular and triceps skinfold thicknesses or systolic BP.
More rapid fetal weight gain and persistently high fetal weight during the second half of gestation predicted higher BMI z-score at age 3 years. The rate of fetal weight gain throughout pregnancy may be important for future risk of adiposity in childhood.
PMCID: PMC3962288  PMID: 22682615
childhood blood pressure; cohort
18.  Feasibility and impact of Creciendo Sanos, a clinic-based pilot intervention to prevent obesity among preschool children in Mexico City 
BMC Pediatrics  2014;14:77.
Mexico has the highest adult overweight and obesity prevalence in the Americas; 23.8% of children <5 years old are at risk for overweight and 9.7% are already overweight or obese. Creciendo Sanos was a pilot intervention to prevent obesity among preschoolers in Instituto Mexicano del Seguro Social (IMSS) clinics.
We randomized 4 IMSS primary care clinics to either 6 weekly educational sessions promoting healthful nutrition and physical activity or usual care. We recruited 306 parent-child pairs: 168 intervention, 138 usual care. Children were 2-5 years old with WHO body mass index (BMI) z-score 0-3. We measured children’s height and weight and parents reported children’s diet and physical activity at baseline and 3 and 6-month follow-up. We analyzed behavioral and BMI outcomes with generalized mixed models incorporating multiple imputation for missing values.
93 (55%) intervention and 96 (70%) usual care families completed 3 and 6-month follow-up. At 3 months, intervention v. usual care children increased vegetables by 6.3 servings/week (95% CI, 1.8, 10.8). In stratified analyses, intervention participants with high program adherence (5-6 sessions) decreased snacks and screen time and increased vegetables v. usual care. No further effects on behavioral outcomes or BMI were observed. Transportation time and expenses were barriers to adherence. 90% of parents who completed the post-intervention survey were satisfied with the program.
Although satisfaction was high among participants, barriers to participation and retention included transportation cost and time. In intention to treat analyses, we found intervention effects on vegetable intake, but not other behaviors or BMI.
Trial registration NCT01539070.
Comisión Nacional de Investigación Científica del IMSS: 2009-785-120.
PMCID: PMC3999907  PMID: 24649831
Obesity prevention; Intervention; Trial; Pediatrics; Primary care; Mexico; Preschool
19.  Effects of promoting increased duration and exclusivity of breastfeeding on adiposity and insulin-like growth factor-I at age 11.5 years: a randomized trial 
Evidence that increased duration and exclusivity of breastfeeding reduces child obesity risk is based on observational studies that are prone to confounding.
To investigate effects of an intervention to promote increased duration and exclusivity of breastfeeding on child adiposity and circulating insulin-like growth factor (IGF)-I (which regulates growth).
Cluster-randomized controlled trial.
31 Belarusian maternity hospitals and their affiliated polyclinics, randomized to usual practices (n=15) or a breastfeeding promotion intervention (n=16).
17,046 breastfeeding mother-infant pairs enrolled in 1996/7, of whom 13,879 (81.4%) were followed-up between January 2008 and December 2010 at a median age of 11.5 years.
Breastfeeding promotion intervention modeled on the WHO/UNICEF Baby Friendly Hospital Initiative.
Main outcome measures
Body mass index (BMI), fat and fat-free mass indices (FMI and FFMI), percent body fat, waist circumference, triceps and subscapular skinfold thicknesses, overweight and obesity, and whole-blood IGF-I. Primary analysis was based on modified intention-to-treat (without imputation), accounting for clustering within hospitals/clinics.
The experimental intervention substantially increased breastfeeding duration and exclusivity (43% vs. 6% and 7.9% vs. 0.6% exclusively breastfed at 3 and 6 months, respectively) versus the control intervention. Cluster-adjusted mean differences in outcomes at 11.5 years between experimental vs. control groups were: 0.19 kg/m2 (95% 4 CI: −0.09, 0.46) for BMI; 0.12 kg/m2 (−0.03, 0.28) for FMI; 0.04 kg/m2 (−0.11, 0.18) for FFMI; 0.47% (−0.11, 1.05) for % body fat; 0.30 cm (−1.41, 2.01) for waist circumference; −0.07 mm (−1.71, 1.57) for triceps and −0.02 mm (−0.79, 0.75) for subscapular skinfold thicknesses; and −0.02 standard deviations (−0.12, 0.08) for IGF-I. The cluster-adjusted odds ratio for overweight / obesity (BMI ≥85th percentile vs <85th percentile) was 1.18 (1.01, 1.39) and for obesity (BMI ≥95th vs <85th percentile) was 1.17 (0.97, 1.41).
Conclusions and relevance
Among healthy term infants in Belarus, an intervention that succeeded in improving the duration and exclusivity of breastfeeding did not prevent overweight or obesity, nor did it affect IGF-I levels, at age 11.5 years. Breastfeeding has many advantages, but population strategies to increase the duration and exclusivity of breastfeeding are unlikely to curb the obesity epidemic.
PMCID: PMC3752893  PMID: 23483175
Breast feeding; lactation; adiposity; body mass index; randomized controlled trial; insulin-like growth factor-1; childhood
20.  A Randomized Controlled Trial to Improve Primary Care to Prevent and Manage Childhood Obesity: The High Five for Kids Study 
Archives of pediatrics & adolescent medicine  2011;165(8):10.1001/archpediatrics.2011.44.
To examine the effectiveness of a primary care-based obesity intervention over the first year (6 intervention contacts) of a planned 2 year study.
Cluster-randomized controlled trial.
10 pediatric practices; 5 Intervention and 5 Usual Care.
475 children ages 2 – 6 years with body mass index (BMI) ≥ 95th percentile or 85th- < 95th percentile if at least one parent was overweight; 445 (93%) had 1 year outcomes.
Intervention practices received primary care restructuring, and families received motivational interviewing by clinicians and educational modules targeting TV, fast food, and sugar sweetened beverages.
Outcome Measures
Change in BMI and obesity-related behaviors from baseline to 1 year.
Compared with usual care, intervention participants had a smaller, non-significant increase in BMI (−0.21 kg/m2; 95% CI: −0.50, 0.07; p=0.15), greater decreases in TV viewing (−0.36 hours/day; 95% CI: −0.64, −0.09; p=0.01) and had slightly greater decreases in fast food (−0.16 servings/week; 95% CI: −0.33, 0.01; p=0.07) and sugar sweetened beverages (−0.22 servings/day; 95% CI: −0.52, 0.08; p=0.15). In post-hoc analyses, we observed significant effects on BMI among females (−0.38 kg/m2; 95% CI: −0.73, −0.03; p=0.03) but not males (0.04 kg/m2; 95% CI: −0.55, 0.63; p=0.89) and among participants in households with annual incomes $50,000 or less (−0.93 kg/m2; 95% CI: −1.60, −0.25; p=0.01) but not in higher income households (0.02 kg/m2; 95% CI: −0.30, 0.33; p=0.92).
After 1 year, the High Five for Kids intervention was effective in reducing TV viewing but did not significantly reduce BMI.
PMCID: PMC3881272  PMID: 21464376
21.  Differential associations of leptin with adiposity across early childhood 
Obesity (Silver Spring, Md.)  2013;21(7):1430-1437.
We examined associations of perinatal and 3-year leptin with weight gain and adiposity through 7 years.
Design and Methods
In Project Viva, we assessed plasma leptin from mothers at 26–28 weeks’ gestation (n=893), umbilical cord vein at delivery (n=540), and children at 3 years (n=510) in relation to body mass index (BMI) z-score, waist circumference, skinfold thicknesses, and dual X-ray absorptiometry body fat.
50.1% of children were male and 29.5% non-white. Mean(SD) maternal, cord, and age 3 leptin concentrations were 22.9(14.2), 8.8(6.4), and 1.8(1.7) ng/mL, respectively, and 3- and 7-year BMI z-scores were 0.46(1.00) and 0.35(0.97), respectively. After adjusting for parental and child characteristics, higher maternal and cord leptin was associated with less 3- year adiposity. For example, mean 3-year BMI z-score was 0.5 lower (95%CI:−0.7,−0.2; p-trend=0.003) among children whose mothers’ leptin concentrations were in the top vs. bottom quintile. In contrast, higher age 3 leptin was associated with greater weight gain and adiposity through age 7 [e.g., change in BMI z-score from 3 to 7 years was 0.2 units (95%CI:−0.0,0.4; p-trend=0.05)].
Higher perinatal leptin was associated with lower 3-year adiposity, whereas higher age 3 leptin was associated with greater weight gain and adiposity by 7 years.
PMCID: PMC3659179  PMID: 23408391
leptin; body mass index (BMI); children
22.  Correlates of participation in a pediatric primary care-based obesity prevention intervention 
Obesity (Silver Spring, Md.)  2010;19(2):449-452.
The purpose of this study was to examine correlates of participation in a childhood obesity prevention trial. We sampled parents of children recruited to participate in a randomized controlled trial. Eligible children were 2.0 - 6.9 years with BMI ≥ 95th percentile or 85th-<95th percentile if at least one parent was overweight. We attempted contact with parents of children who were potentially eligible. We recruited 475 parents via telephone following an introductory letter. We also interviewed 329 parents who refused participation. Parents who refused participation (n=329) did not differ from those who participated (n=475) by number of children at home (OR 0.94 per child; 95% CI: 0.77, 1.15) or by child age (OR 1.07 per year; 95% CI: 0.95, 1.20) or sex (OR 1.06 for females v. males; 95% CI: 0.80, 1.41). After multivariate adjustment, parents who were college graduates v. < college graduates were less likely to participate (OR 0.62; 95% CI: 0.46, 0.83). In addition, parents were less likely (OR 0.41; 95% CI: 0.31, 0.56) to participate if their child was overweight v. obese. Among the 115 refusers with obese children, 21% cited as a reason for refusal that their children did not have a weight problem, v. 30% among the 214 refusers with overweight children. In conclusion, parents of preschool-age children with a BMI 85-95th%ile are less likely to have their children participate in an obesity prevention trial than parents of children with BMI >95th%ile. One reason appears to be they less frequently consider their children to have a weight problem.
PMCID: PMC3864039  PMID: 20847735
Obesity prevention; Pediatrics; Parents; Weight perception; Primary care
23.  Can the Internet be used to Reach Parents for Family-Based Childhood Obesity Interventions? 
Clinical pediatrics  2011;51(4):10.1177/0009922811423310.
Identify socioeconomic correlates of computer/Internet use among parents of overweight preschool-aged children.
Studied 470 baseline participants in a trial to prevent obesity in children 2–6.9 years with BMI ≥ 95th percentile or 85th–95th percentile with one overweight parent. Interviews with parents used Health Information National Trends Survey (HINTS) questions.
Ninety-four percent had home computers and 93% reported Internet usage. In adjusted models, parents with ≤ college degree (OR 4.8 [95% CI 1.2, 18.3]) or with household income ≤ $50,000 (OR 7.6 [95% CI 2.2, 26.8]) had decreased likelihood of computer ownership. Of parents who reported going on-line, 63% used Internet to look for health/medical information for themselves and 42% for their children. Parents with ≤ a college degree or with BMI <25 kg/m2 were less likely to use Internet. Results support using the Internet for early childhood obesity prevention with enhanced outreach efforts for low socioeconomic families.
PMCID: PMC3840912  PMID: 21997144
Computers; Internet; health information seeking; overweight; obesity; preschool age children
24.  Proximity to Supermarkets Associated with Higher Body Mass Index among Overweight and Obese Preschool-Age Children 
Preventive medicine  2012;56(0):10.1016/j.ypmed.2012.11.023.
The objective of this study is to examine associations of proximity to food establishments with body mass index (BMI) among preschool-age children.
We used baseline data from 438 children ages 2–6.9 years with a BMI ≥ 85th percentile participating in a RCT in Massachusetts from 2006 to 2009. We used a geographic information system to determine proximity to six types of food establishments: 1) convenience stores, 2) bakeries, coffee shops, candy stores, 3) full service restaurants, 4) large supermarkets, 5) small supermarkets, and 6) fast-food restaurants. The main outcome was child’s BMI.
Children’s mean (SD) BMI was 19.2 (2.4) kg/m2; 35% lived ≤ 1 mile from a large supermarket, 42% lived >1 to 2 miles, and 22% lived >2 miles. Compared to children living >2 miles from a large supermarket, those who lived within 1 mile had a BMI 1.06 kg/m2 higher. Adjustment for socioeconomic characteristics and distance to fast-food restaurants attenuated this estimate to 0.77 kg/m2. Living in any other distance category from a large supermarket and proximity to other food establishments were not associated with child BMI.
Living closer to a large supermarket was associated with higher BMI among preschool-age children who were overweight or obese.
PMCID: PMC3837524  PMID: 23219681
supermarkets; food establishments; children; body mass index; obesity
25.  Racial/Ethnic Differences in Early Life Risk Factors for Childhood Obesity 
Pediatrics  2010;125(4):10.1542/peds.2009-2100.
By the preschool years, racial/ethnic disparities in obesity prevalence are already present.
To examine racial/ethnic differences in early life risk factors for childhood obesity.
Design, Setting, Participants
343 white, 355 black, and 128 Hispanic mother-child pairs in a prospective study.
Main Exposure
Mother’s report of child’s race/ethnicity.
Main Outcome Measures
Risk factors from the prenatal period through age 4 years known to be associated with child obesity.
In multivariable models, compared to their white counterparts, black and Hispanic children exhibited a range of risk factors related to child obesity. In pregnancy, these included higher rates of maternal depression (OR: 1.55 for blacks; 1.89 for Hispanics); in infancy more rapid weight gain (OR: 2.01 for blacks; 1.75 for Hispanics), more likely to introduce solid foods before 4 months of age (OR: 1.91 for blacks; 2.04 for Hispanics), higher rates of maternal restrictive feeding practices (OR: 2.59 for blacks; 3.35 for Hispanics), and after age 2 years, more televisions in their bedrooms (OR: 7.65 for blacks; 7.99 for Hispanics), higher intake of sugar-sweetened beverages (OR: 4.11 for blacks; 2.48 for Hispanics), and higher intake of fast food (OR: 1.65 for blacks; 3.14 for Hispanics). Blacks and Hispanics also had lower rates of exclusive breastfeeding and were less likely to sleep at least 12 hours/day in infancy.
Racial/ethnic differences in risk factors for obesity exist prenatally and in early childhood. Racial/ethnic disparities in childhood obesity may be determined by factors operating at the earliest stages of life.
PMCID: PMC3836212  PMID: 20194284
Obesity; Race/Ethnicity; Pregnancy; Infancy; Childhood; Prevention

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