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1.  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
2.  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
3.  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
5.  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
6.  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
7.  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
8.  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
9.  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
10.  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
11.  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
12.  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
13.  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
14.  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
15.  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
16.  Associations of obesogenic behaviors in mothers and obese children participating in a randomized trial 
Obesity (Silver Spring, Md.)  2012;20(7):10.1038/oby.2012.43.
Relatively little research has assessed the association between obesogenic behaviors in parents and their children. The objective of the present analysis was to examine cross-sectional associations in television (TV)/video viewing, sugar-sweetened beverage intake, and fast food intake between mothers and their pre-school aged children. We studied baseline data among 428 participants in High Five for Kids, a randomized controlled trial of behavior change among overweight and obese children ages 2-6.9 years. The main exposures were whether mothers viewed TV/videos <1 hour/day, drank <1 serving/day of sugar-sweetened beverages, and ate fast food <1 time/week. The main outcomes were whether children met these goals for the same behaviors. Using multivariate logistic regression adjusted for maternal and child characteristics, we estimated odds ratios of children meeting the behavioral goals. The majority of mothers ate fast food <1 time/week (73%) and drank <1 serving/day of sugar-sweetened beverages (73%), while few mothers viewed <1 hour/day of TV/videos (31%). Most children met the fast food goal (68%), but not the goals for sugar-sweetened beverages (31%) or TV/video viewing (13%). In adjusted models, the odds ratios for a child meeting the goal were 3.2 (95% CI 1.7, 6.2) for TV/video viewing, 5.8 (95% CI 2.8, 12.0) for sugar-sweetened beverage intake, and 17.5 (95% CI 9.8, 31.2) for fast food intake if their mothers met the goal for the same behavior. Obesogenic behaviors of mothers and pre-school aged children were strongly associated. Our findings lend support to obesity prevention strategies that target parental behavior and the family environment.
PMCID: PMC3835375  PMID: 22349735
childhood obesity; maternal behavior; television; fast food; sugar-sweetened beverages
17.  Reducing Racial/Ethnic Disparities in Childhood Obesity: The Role of Early Life Risk Factors 
JAMA pediatrics  2013;167(8):10.1001/jamapediatrics.2013.85.
Many early life risk factors for childhood obesity are more prevalent among blacks and Hispanics than among whites and may explain the higher prevalence of obesity among racial/ethnic minority children.
To examine the extent to which racial/ethnic disparities in adiposity and overweight are explained by differences in pregnancy (gestational diabetes and depression), infancy (rapid infant weight gain, non-exclusive breastfeeding, early introduction of solid foods) and early childhood (sleeping less than 12 hours/day, presence of a television in the bedroom, any intake of sugar-sweetened beverages, and any intake of fast food) risk factors.
Prospective, pre-birth cohort study.
Multi-site group practice in Massachusetts.
1116 (63% white, 17% black, and 4% Hispanic) mother-child pairs.
Main Exposure
Mother’s report of child’s race/ethnicity.
Main Outcome Measures
Age- and sex-specific body mass index (BMI) z-score, total fat mass index (FMI) from dual-energy X-ray absorptiometry, and overweight/obesity defined as a BMI ≥ 85th percentile at age 7.
Black (0.48 units [95% CI: 0.31, 0.64]) and Hispanic (0.43 [0.12, 0.74]) children had higher BMI z-scores, as well as higher total FMI and overweight/obesity prevalence, than white children. After adjusting for socioeconomic confounders and parental BMI, differences in BMI z-score were attenuated for blacks (0.22 [0.05, 0.40]) and Hispanics (0.22 [−0.08, 0.52]). Adjustment for pregnancy risk factors did not substantially change these estimates. However, after further adjustment for infancy and childhood risk factors, we observed only minimal differences in BMI z-score for whites, blacks (0.07 [−0.11, 0.26]) and Hispanics (0.04 [−0.27, 0.35]). We observed similar attenuation of racial/ethnic differences in adiposity and overweight/obesity prevalence.
Conclusions and Relevance
Racial/ethnic disparities in childhood adiposity and obesity are determined by factors operating in infancy and early childhood. Efforts to reduce obesity disparities should focus on preventing early life risk factors.
PMCID: PMC3835398  PMID: 23733179
Obesity; Race/Ethnicity; Pregnancy; Infancy; Childhood; Prevention
18.  Parental Perceptions of a Motivational Interviewing–Based Pediatric Obesity Prevention Intervention 
Clinical pediatrics  2013;52(6):540-548.
Motivational interviewing (MI) shows promise for pediatric obesity prevention, but few studies address parental perceptions of MI. The aim of this study was to identify correlates of parental perceptions of helpfulness of and satisfaction with a MI-based pediatric obesity prevention intervention. We studied 253 children 2 to 6 years of age in the intervention arm of High Five for Kids, a primary care–based randomized controlled trial. In multivariable models, parents born outside the United States (odds ratio [OR] = 8.81; 95% confidence interval [CI] = 2.44, 31.8), with lower household income (OR = 3.60; 95% CI = 1.03, 12.55), and with higher BMI (OR = 2.86; 95% CI = 1.07, 7.65) were more likely to perceive MI-based visits as helpful in improving children’s obesity-related behaviors after the first year of the intervention. Parents of female (vs male), black (vs white), and Latino (vs white) children had lower intervention satisfaction. Our findings underscore the importance of tailoring pediatric obesity prevention efforts to target populations.
PMCID: PMC3800680  PMID: 23564304
obesity; parental perceptions; motivational interviewing; intervention; child; preschool
19.  Delivery by caesarean section and risk of obesity in preschool age children: a prospective cohort study 
Archives of disease in childhood  2012;97(7):610-616.
To examine whether delivery by caesarean section is a risk factor for childhood obesity.
Prospective pre-birth cohort study (Project Viva).
Eight outpatient multi-specialty practices based in the Boston, Massachusetts area.
We recruited women during early pregnancy between 1999 and 2002, and followed their children after birth. We included 1255 children with body composition measured at 3 years of age.
Main outcome measures
Body mass index (BMI) z-score, obesity (BMI for age and sex ≥ 95th percentile), and sum of triceps + subscapular skinfold thicknesses, at 3 years of age.
284 children (22.6 percent) were delivered by caesarean section. At age 3, 15.7% of children delivered by caesarean section were obese, compared with 7.5% of children born vaginally. In multivariable logistic and linear regression models adjusting for maternal pre-pregnancy BMI, birth weight, and other covariates, birth by caesarean section was associated with a higher odds of obesity at age 3 (OR 2.10, 95%CI 1.36 to 3.23), higher mean BMI z-score (0.20 units, 95% CI 0.07 to 0.33), and higher sum of triceps + subscapular skinfold thicknesses (0.94 mm, 95% CI 0.36 to 1.51).
Infants delivered by caesarean section may be at increased risk of childhood obesity. Further studies are needed to confirm our findings and to explore mechanisms underlying this association.
PMCID: PMC3784307  PMID: 22623615
20.  The Association of Urbanicity with Infant Sleep Duration 
Health & place  2012;18(5):1000-1005.
Short sleep duration is associated with multiple adverse child outcomes. We examined associations of the built environment with infant sleep duration among 1226 participants in a pre-birth cohort. From residential addresses, we used a geographic information system to determine urbanicity, population density, and closeness to major roadways. The main outcome was mother’s report of her infant’s average daily sleep duration at 1 year of age. We ranked urbanicity and population density as quintiles, categorized distance to major roads into 8 categories, and used linear regression adjusted for socio-demographic characteristics, smoking during pregnancy, gestational age, fetal growth, and television viewing at 1 year. In this sample, mean (SD) sleep duration at age 1 year was 12.8 (1.6) hours/day. In multivariable adjusted analyses, children living in the highest quintile of urbanicity slept −19.2 minutes/day (95% CI: −37.0, −1.50) less than those living in the lowest quintile. Neither population density nor closeness to major roadways was associated with infant sleep duration after multivariable adjustment. Our findings suggest that living in more urban environments may be associated with reduced infant sleep.
PMCID: PMC3732783  PMID: 22795497
Sleep; urbanicity; population density; infancy; built environment
21.  Plasma 25-Hydroxyvitamin D During Pregnancy & Small-for-Gestational Age in Black and White Infants 
Annals of Epidemiology  2012;22(8):581-586.
In a prospective prenatal cohort study, we examined associations of second trimester and cord plasma 25-hydroxyvitamin D (25[OH]D) with small-for-gestational age (SGA), and the extent to which vitamin D might explain black/white differences in SGA.
We studied 1067 white and 236 black mother-infant pairs recruited from 8 obstetrical offices early in pregnancy in Massachusetts. We analyzed 25(OH)D levels using an immunoassay and performed multivariable logistic models to estimate the odds of SGA by category of 25(OH)D level.
Mean (standard deviation [SD]) second trimester 25(OH)D level was 60 nmol/L (21) and was lower for black (46 nmol/L [22]) than white (62 nmol/L [20]) women. 59 infants were SGA (4.5%) and more black than white infants were SGA (8.5% vs. 3.7%). The odds of SGA were higher with maternal 25(OH)D levels <25 vs. ≥25 nmol/L (adjusted odds ratio [OR] 3.17; 95% confidence interval [CI]:1.16, 8.63). The increased odds of SGA among black vs. white participants decreased from an OR of 2.04(1.04, 4.04) to 1.68(0.82, 3.46) after adjusting for 25(OH)D.
Second trimester 25(OH)D levels <25 nmol/L were associated with higher odds of SGA. Our data raise the possibility that Vitamin D status may contribute to racial disparities in SGA.
PMCID: PMC3396717  PMID: 22658824
Vitamin D; Infant; Small for Gestational Age; African Continental Ancestry Group; Health Status Disparities; Pregnancy
22.  Age of Achievement of Gross Motor Milestones in Infancy and Adiposity at Age 3 Years 
Maternal and Child Health Journal  2012;16(5):1015-1020.
Early life physical activity may help prevent obesity but is difficult to measure. The purpose of this study was to examine associations of age of achievement of gross motor milestones in infancy with adiposity at age 3 years. Seven forty one mother/infant dyads participated in a longitudinal study in Massachusetts. Exposures were age of attainment of 4 gross motor milestones—rolling over, sitting up, crawling, and walking. Outcomes were 3-year sum of subscapular and triceps skinfold thickness (SS + TR) for overall adiposity, their ratio (SS:TR) for central adiposity, and body mass index (BMI) z-score. We used linear regression models adjusted for confounders to examine motor milestone achievement and later adiposity. Rolling over (0.04, 95% CI: 0.008, 0.07) and sitting up (0.02, 95% CI: 0.001, 0.05) at ≥6 months were associated with increased SS:TR compared with attainment before 6 months. Walking at ≥15 months was associated with 0.98 mm higher SS + TR (95% CI: 0.05, 1.91) compared with walking before 12 months. Age at crawling was not associated with the outcomes. None of the milestones were associated with BMI z-score. Age of motor milestone achievement was only a modest predictor of adiposity. Later rolling over and sitting up were associated with greater central adiposity, and later age at walking was associated with greater overall adiposity at age 3 years. Although we controlled for birth weight and 6-month weight-for-length in our models, more detailed assessment of early adiposity prior to achievement of motor milestones is needed to help determine causality.
PMCID: PMC3321389  PMID: 21643834
Infant; Motor development; Obesity; Physical activity
23.  Maternal intake of methyl-donor nutrients and child cognition at 3 years of age 
Methyl-donor nutrients are substrates for methylation reactions involved in neurodevelopment processes. The role of maternal intake of these nutrients on cognitive performance of the offspring is poorly understood. We examined the associations of maternal intake of folate, vitamin B12, choline, betaine, and methionine during the first and second trimesters of pregnancy, with tests of cognitive performance in the offspring at 3 y of age using data from 1210 participants in Project Viva, a prospective pre-birth cohort study in Massachusetts. We assessed nutrient intake with the use of food frequency questionnaires. Children’s cognition at age 3 y was evaluated with the Peabody Picture Vocabulary Test III (PPVT-III) and visual-motor skills with the Wide Range Assessment of Visual Motor Abilities (WRAVMA) test. In multivariable models adjusting for potential sociobehavioral and nutritional confounders, for each 600 µg/d increment in total folate intake during the first trimester, PPVT-III score at age 3 y was 1.6 points [95% CI: 0.1, 3.1; P = 0.04] higher. There was a weak inverse association between vitamin B12 intake during the second trimester and PPVT-III scores [−0.4 points per 2.6 µg/d; 95% CI: −0.8, −0.1; P = 0.01]. We did not find associations between choline, betaine, or methionine and cognitive outcomes at this age. Results of this study suggest that higher intake of folate in early pregnancy is associated with higher scores on the PPVT-III, a test of receptive language that predicts overall intelligence, at age 3 y.
PMCID: PMC3375854  PMID: 22686384
folate; vitamin B12; choline; methionine; pregnancy; cognition; children
24.  Trends in Antibiotic Use in Massachusetts Children, 2000–2009 
Pediatrics  2012;130(1):15-22.
Antibiotic use rates have declined dramatically since the 1990s. We aimed to determine if, when, and at what level the decline in antibiotic-dispensing rates ended and which diagnoses contributed to the trends.
Antibiotic dispensings and diagnoses were obtained from 2 health insurers for 3- to <72-month-olds in 16 Massachusetts communities from 2000 to 2009. Population-based antibiotic-dispensing rates per person-year (p-y) were determined according to year (September–August) for 3 age groups. Fit statistics were used to identify the most likely year for a change in trend. Rates for the first and last years were compared according to antibiotic category and associated diagnosis.
From 2000–2001 to 2008–2009, the antibiotic-dispensing rate for 3- to <24-month-olds decreased 24% (2.3–1.8 antibiotic dispensings per p-y); for 24- to <48-month-olds, it decreased 18% (1.6–1.3 antibiotic dispensings per p-y); and for 48- to <72-month-olds, it decreased 20% (1.4–1.1 antibiotic dispensings per p-y). For 3- to <48-month-olds, rates declined until 2004–2005 and remained stable thereafter; the downward trend for 48- to <72-month-olds ended earlier in 2001–2002. Among 3- to <24-month-olds, first-line penicillin use declined 26%. For otitis media, the dispensing rate decreased 14% and the diagnosis rate declined 9%, whereas the treatment fraction was stable at 63%.
The downward trend in antibiotic dispensings to young children in these communities ended by 2004–2005. This trend was driven by a declining otitis media diagnosis rate. Continued monitoring of population-based dispensing rates will support efforts to avoid returning to previous levels of antibiotic overuse.
PMCID: PMC3382917  PMID: 22732172
antibiotic use; managed care programs; otitis media
25.  Correlations among adiposity measures in school-aged children 
BMC Pediatrics  2013;13:99.
Given that it is not feasible to use dual x-ray absorptiometry (DXA) or other reference methods to measure adiposity in all pediatric clinical and research settings, it is important to identify reasonable alternatives. Therefore, we sought to determine the extent to which other adiposity measures were correlated with DXA fat mass in school-aged children.
In 1110 children aged 6.5-10.9 years in the pre-birth cohort Project Viva, we calculated Spearman correlation coefficients between DXA (n=875) and other adiposity measures including body mass index (BMI), skinfold thickness, circumferences, and bioimpedance. We also computed correlations between lean body mass measures.
50.0% of the children were female and 36.5% were non-white. Mean (SD) BMI was 17.2 (3.1) and total fat mass by DXA was 7.5 (3.9) kg. DXA total fat mass was highly correlated with BMI (rs=0.83), bioimpedance total fat (rs=0.87), and sum of skinfolds (rs=0.90), and DXA trunk fat was highly correlated with waist circumference (rs=0.79). Correlations of BMI with other adiposity indices were high, e.g., with waist circumference (rs=0.86) and sum of subscapular plus triceps skinfolds (rs=0.79). DXA fat-free mass and bioimpedance fat-free mass were highly correlated (rs=0.94).
In school-aged children, BMI, sum of skinfolds, and other adiposity measures were strongly correlated with DXA fat mass. Although these measurement methods have limitations, BMI and skinfolds are adequate surrogate measures of relative adiposity in children when DXA is not practical.
PMCID: PMC3693882  PMID: 23799991
Adiposity; Obesity; DXA; BMI

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