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1.  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
2.  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
3.  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
4.  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
5.  Leveraging Text Messaging and Mobile Technology to Support Pediatric Obesity-Related Behavior Change: A Qualitative Study Using Parent Focus Groups and Interviews 
Text messaging (short message service, SMS) is a widely accessible and potentially cost-effective medium for encouraging behavior change. Few studies have examined text messaging interventions to influence child health behaviors or explored parental perceptions of mobile technologies to support behavior change among children.
Our aim was to examine parental acceptability and preferences for text messaging to support pediatric obesity-related behavior change.
We conducted focus groups and follow-up interviews with parents of overweight and obese children, aged 6-12 years, seen for “well-child” care in eastern Massachusetts. A professional moderator used a semistructured discussion guide and sample text messages to catalyze group discussions. Seven participants then received 3 weeks of text messages before a follow-up one-on-one telephone interview. All focus groups and interviews were recorded and transcribed verbatim. Using a framework analysis approach, we systematically coded and analyzed group and interview data to identify salient and convergent themes.
We reached thematic saturation after five focus groups and seven follow-up interviews with a total of 31 parents of diverse race/ethnicity and education levels. Parents were generally enthusiastic about receiving text messages to support healthy behaviors for their children and preferred them to paper or email communication because they are brief and difficult to ignore. Participants anticipated high responsiveness to messaging endorsed by their child’s doctor and indicated they would appreciate messages 2-3 times/week or more as long as content remains relevant. Suggestions for maintaining message relevance included providing specific strategies for implementation and personalizing information. Most felt the negative features of text messaging (eg, limited message size) could be overcome by providing links within messages to other media including email or websites.
Text messaging is a promising medium for supporting pediatric obesity-related behavior change. Parent perspectives could assist in the design of text-based interventions.
Trial Registration NCT01565161; (Archived by WebCite at
PMCID: PMC3869083  PMID: 24317406
child; obesity; overweight; health behavior; text messaging; telemedicine
6.  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
7.  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
8.  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
9.  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
10.  Are You Talking to ME? The Importance of Ethnicity and Culture in Childhood Obesity Prevention and Management 
Childhood Obesity  2012;8(1):23-27.
Childhood obesity is prevalent, is of consequence, and disproportionately affects racial/ethnic minority populations. By the preschool years, racial/ethnic disparities in obesity prevalence and substantial differences in many risk factors for obesity are already present, suggesting that disparities in obesity prevalence have their origins in the earliest stages of life. The reasons for racial/ethnic variation in obesity are complex and may include differences in cultural beliefs and practices, level of acculturation, ethnicity-based differences in body image, and perceptions of media, sleep, and physical activity. In addition, racial/ethnic differences in obesity may evolve as a consequence of the socio- and environmental context in which families live. The primary care setting offers unique opportunities to intervene and alter the subsequent course of health and disease for children at risk for obesity. Regular visits during childhood allow both detection of elevated weight status and offer opportunities for prevention and treatment. Greater awareness of the behavioral, social–cultural, and environmental determinants of obesity among ethnic minority populations could assist clinicians in the treatment of obesity among diverse pediatric populations. Specific strategies include beginning prevention efforts early in life before obesity is present and recognizing and querying about ethnic- and culturally specific beliefs and practices, the role of the extended family in the household, and parents' beliefs of the causative factors related to their child's obesity. Efforts to provide culturally and linguistically appropriate care, family-based treatment programs, and support services that aim to uncouple socioeconomic factors from adverse health outcomes could improve obesity care for racial/ethnic minority children.
PMCID: PMC3647541  PMID: 22799474
11.  Maternal Short Sleep Duration is associated with Increased Levels of Inflammatory Markers at 3 Years Postpartum 
The purpose of this study was to examine the association of short sleep duration among women in the first year postpartum with inflammation at 3-years postpartum.
We studied 479 women in Project Viva, a prospective cohort. At 6 months and 1 year postpartum, women reported the number of hours they slept in a 24-hour period, from which we calculated a weighted average of daily sleep. We used multivariable median regression analyses to predict the independent effects of short sleep duration (≤ 5 h/d v.> 5 h/d) on markers of inflammation, e.g. interleukin-6 [IL6] and C-reactive protein [CRP] at 3-years postpartum.
Women's mean (SD) hours of daily sleep in the first year postpartum was 6.7 (0.96) hours. After adjusting for age, race/ethnicity, education, parity, pre-pregnancy body mass index, excessive gestational weight gain and gestational age at delivery, we found that postpartum sleep ≤ 5 h/d was associated with elevated IL6 (β 0.25 pg/mL; 95% CI: 0.14, 0.43) compared with > 5 h/d. Although postpartum sleep ≤ 5 h/d appeared to also be associated with elevated CRP (β 0.15 mg/dL; 95% CI: −0.08, 0.52), these results did not reach statistical significance.
Short sleep duration in the first year postpartum is associated with elevated levels of the pro-inflammatory marker, IL6, at 3-years postpartum.
PMCID: PMC3117066  PMID: 21040938
Sleep; Inflammation; Postpartum women
12.  Higher adiposity in infancy associated with recurrent wheeze in a prospective cohort of children 
Few prospective data link early childhood adiposity with asthma-related symptoms.
We sought to examine the associations of weight-for-length (WFL) at age 6 months with incidence of wheezing by age 3 years.
We studied 932 children in a prospective cohort of children. The main outcome was recurrent wheezing, which was defined as parents’ report of wheezing between 2 and 3 years of age plus wheezing in either year 1 or 2 of life. Secondary outcomes included any wheezing from 6 months to 3 years and current asthma. We used multiple logistic regression to examine associations of 6-month WFL z scores with these outcomes.
At 6 months, the infants’ mean WFL z score was 0.68 (SD, 0.94; range −2.96 to 3.24). By age 3 years, 14% of children had recurrent wheezing. After adjustment for a variety of potential confounders, we found that each 1-unit increment in 6-month WFL z score was associated with greater odds of recurrent wheezing (odds ratio [OR], 1.46; 95% CI, 1.11–1.91) and any wheezing (OR, 1.23; 95% CI, 1.03–1.48). We observed a weaker association between 6-month WFL z score and current asthma (OR, 1.22; 95% CI, 0.94–1.59).
Infants with higher WFL z scores at 6 months of age had a greater risk of recurrent wheezing by age 3 years. It is unclear whether the relationship of infant adiposity and early-life wheeze extends to allergic asthma or wheeze that can persist into later childhood. Our findings suggest that early interventions to prevent excess infant adiposity might help reduce children’s risk of asthma-related symptoms.
PMCID: PMC3253368  PMID: 18466784
Asthma; wheeze; adiposity; children; prospective study
13.  Association of Maternal Short Sleep Duration with Adiposity and Cardio-Metabolic Status at 3 Years Postpartum 
Obesity (Silver Spring, Md.)  2010;19(1):171-178.
The purpose of this study was to examine the association of short sleep duration among women in the first year postpartum with adiposity and cardio-metabolic status at 3-years postpartum. We studied 586 women in Project Viva, a prospective cohort. At 6 months and 1 year postpartum, women reported the number of hours they slept in a 24-hour period, from which we calculated a weighted average of daily sleep. We used multivariable regression analyses to predict the independent effects of short sleep duration (≤ 5 h/d v.> 5 h/d) on adiposity, glucose metabolism, lipid metabolism, and adipokines at 3-years postpartum. Women’s mean (SD) hours of daily sleep in the first year postpartum was 6.7 (0.97) hours. After adjusting for age, race/ethnicity, education, parity, pre-pregnancy body mass index, and excessive gestational weight gain, we found that postpartum sleep ≤ 5 h/d was associated with higher postpartum weight retention (β 1.50 kg; 95% CI: 0.02, 2.86), higher subscapular + triceps skinfold thickness (β 3.94 mm; 95% CI: 1.27, 6.60) and higher waist circumference (β 3.10 cm; 95% CI: 1.25, 4.94) at 3-years postpartum. We did not observe associations of short sleep duration with measures of cardio-metabolic status at 3-years postpartum. In conclusion, short sleep duration in the first year postpartum is associated with higher adiposity at 3-years postpartum.
PMCID: PMC3099421  PMID: 20489690
Sleep; Adiposity; Cardio-Metabolic Status; Postpartum women
14.  Associations of Early Life Risk Factors with Infant Sleep Duration 
Academic pediatrics  2010;10(3):187-193.
Insufficient sleep in children is associated with adverse health effects. We examined the associations of early life risk factors with infant sleep duration.
We studied 1676 mother-infant pairs in a pre-birth cohort study. Main outcomes were mothers’ report of their infants’ average 24-hour sleep duration at 6 months, 1 year, and 2 years of age.
Infants slept mean (SD) durations of 12.2 (2.0) hours/day at 6 months, 12.8 (1.6) hours/day at 1 year, and 11.9 (1.3) hours/day at 2 years. In multivariable regression models, maternal antenatal depression, introduction of solids < 4 months, and infant TV/video viewing were associated with shorter sleep durations at both 1 and 2 years of age. Estimates were 0.36 fewer hours/day of sleep for maternal antenatal depression, 0.39 fewer hours/day of sleep if infant was introduced to solids < 4 months, and 0.11 fewer hours/day of sleep for each 1-hour of TV viewed per week. Attendance at child care outside the home was associated with 0.18 fewer hours/day of sleep at age 2 years. At 2 years of age, black, Hispanic, and Asian infants slept 0.40, 0.82, and 0.95 fewer hours per day, respectively, than white infants.
Maternal depression during pregnancy, early introduction of solid foods, infant TV viewing, and attendance of child care were associated with shorter infant sleep duration. Racial/ethnic minority children slept fewer hours in the first two years of life than white children. Our results suggest that various risk factors, some potentially modifiable, are worthy of clinical consideration when addressing infant sleep duration.
PMCID: PMC2866807  PMID: 20347414
15.  Weight Status in the First 6 Months of Life and Obesity at 3 Years of Age 
Pediatrics  2009;123(4):1177-1183.
The goal was to examine the associations of weight-for-length at birth and at 6 months with obesity at 3 years of age.
We studied 559 children in Project Viva, an ongoing, prospective, cohort study of pregnant women and their children. We measured length and weight at birth, 6 months, and 3 years. Our main exposures were weight-for-length z score at birth adjusted for gestational age and weight-for-length z score at 6 months adjusted for weight-for-length z score at birth. We used multivariate regression analyses to predict the independent effects of birth weight-for-length z score and, separately, 6-month weight-for-length z score on BMI z score, the sum of subscapular and triceps skinfold thicknesses, and obesity (BMI for age and gender of ≥95th percentile) at age 3.
Mean weights at birth, 6 months, and 3 years were 3.55, 8.15, and 15.67 kg, respectively. Corresponding lengths were 49.9, 66.9, and 97.4 cm. At 3 years, 48 children (9%) were obese. After adjustment for confounding variables and birth weight-for-length z score, each increment in 6-month weight-for-length z score was associated with higher BMI z scores, higher sums of subscapular and triceps skinfold thicknesses, and increased odds of obesity at age 3. The predicted obesity prevalence among children in the highest quartiles of both birth and 6-month weight-for-length z scores was 40%, compared with 1% for children in the lowest quartiles of both. Whereas birth weight-for-length z scores were associated with higher BMI z scores, the magnitude of effect was smaller than that of weight-for-length z scores at 6 months.
More-rapid increases in weight for length in the first 6 months of life were associated with sharply increased risk of obesity at 3 years of age. Changes in weight status in infancy may influence risk of later obesity more than weight status at birth.
PMCID: PMC2761645  PMID: 19336378
obesity; early infancy; weight for length; birth size
16.  Short Sleep Duration in Infancy and Risk of Childhood Overweight 
To examine the extent to which infant sleep duration is associated with overweight at age 3 years.
Longitudinal survey.
Multisite group practice in Massachusetts.
Nine hundred fifteen children in Project Viva, a prospective cohort.
Main Exposure
At children's ages 6 months, 1 year, and 2 years, mothers reported the number of hours their children slept in a 24-hour period, from which we calculated a weighted average of daily sleep.
Main Outcome Measures
We used multivariate regression analyses to predict the independent effects of sleep duration (≤12 h/d vs≥12 h/d) on body mass index (BMI) (calculated as the weight in kilograms divided by the height in meters squared) z score, the sum of subscapular and triceps skinfold thicknesses, and over-weight (BMI for age and sex≥95th percentile) at age 3 years.
The children's mean (SD) duration of daily sleep was 12.3 (1.1) hours. At age 3 years, 83 children (9%) were overweight; the mean (SD) BMI z score and sum of subscapular and triceps skinfold thicknesses were 0.44 (1.03) and 16.66 (4.06) mm, respectively. After adjusting for maternal education, income, prepregnancy BMI, marital status, smoking history, and breastfeeding duration and child's race/ethnicity, birth weight, 6-month weight-for-length z score, daily television viewing, and daily participation in active play, we found that infant sleep of less than 12 h/d was associated with a higher BMI z score (β, 0.16; 95% confidence interval, 0.02−0.29), higher sum of subscapular and triceps skinfold thicknesses (β, 0.79 mm; 95% confidence interval, 0.18−1.40), and increased odds of overweight (odds ratio, 2.04; 95% confidence interval, 1.07−3.91).
Daily sleep duration of less than 12 hours during infancy appears to be a risk factor for overweight and adiposity in preschool-aged children.
PMCID: PMC2650815  PMID: 18391138
17.  Association of Birth Weight With Asthma-Related Outcomes at Age 2 Years 
Pediatric pulmonology  2006;41(7):643-648.
Summary. Background: Although lower birth weight associated with prematurity raises the risk of asthma in childhood, few prospective studies have examined higher birth weight, and few have separated the two components of birth weight, fetal growth and length of gestation.
Objective. To examine the associations of fetal growth and length of gestation with asthma-related outcomes by age 2 years.
Methods. We studied 1,372 infants and toddlers born after 34 weeks’ gestation in Project Viva, a prospective cohort study of pregnant mothers and their children. The main outcome measures were parent report of (1) any wheezing (or whistling in the chest) from birth to age 2 years, (2) recurrent wheezing during the first 2 years of life, and (3) doctor’s diagnosis of asthma, wheeze or reactive airwaydisease (“asthma”) by age 2. We calculated gestational age from the last menstrual period or ultrasound examination, and determined birth weight for gestational age z-value (“fetal growth”) using US national reference data.
Results. Infants’ mean birth weight was 3,527 (SD, 517; range, 1,559–5,528) grams. By age 2 years, 34% of children had any wheezing, 14% had recurrent wheezing, and 16% had doctor-diagnosed asthma. After adjusting for several parent, child, and household characteristics in logistic regression models, we found that infants with birth weight ≥4,000 g were not more likely to have any wheezing (odds ratio (OR), 0.91; 95% confidence interval (CI): 0.62, 1.34) or doctor-diagnosed asthma (OR, 0.80; 95% CI: 0.49, 1.31) than infants with birth weight 3,500–3,999 g. In models examining length of gestation and fetal growth separately, neither the highest nor the lowest groups of either predictor were associated with the three outcomes. Boys had a higher incidence of asthma-related outcomes than girls, and exposure to passive smoking, parental history of asthma, and exposure to older siblings were all associated with greater risk of recurrent wheeze or asthma-related outcomes at age 2 years.
Conclusion. Although male sex, exposure to smoking, parental history of asthma, and exposure to older siblingswere associated with increased riskof wheezing and asthma-related outcomes in this prospective study of children born after 34 weeks gestation, fetal growth and length of gestation were not.
PMCID: PMC1488724  PMID: 16703577
asthma; birth weight; fetal growth; length of gestation; wheezing
18.  Longitudinal Relationship Between Television Viewing and Leisure-Time Physical Activity During Adolescence 
Pediatrics  2007;119(2):e314-e319.
The goal was to examine the longitudinal associations of changes in television viewing and other sources of sedentary behavior with changes in leisure-time moderate/vigorous physical activity in adolescence.
We studied a cohort of 6369 girls and 4487 boys who were 10 to 15 years of age in 1997. During each of 4 years of follow-up assessments, participants self-reported their weekly hours of television viewing. By using a seasonal questionnaire, we also obtained detailed information on physical activities over the previous year, from which we calculated total leisure-time moderate/vigorous physical activity. We performed linear regression analyses to assess the longitudinal associations between 1-year changes in television viewing and 1-year changes in leisure-time moderate/vigorous physical activity during the same year, using data from 1997 through 2001.
One-year changes (mean ± SD) were −0.13 ± 7.2 hours/week for leisure-time moderate/vigorous physical activity, −0.55 ± 7.0 hours/week for television viewing, and −1.02 ± 11.0 hours/week for total sedentary behaviors. In longitudinal models adjusted for age, age2, gender, race/ethnicity, Tanner stage, menarche (in girls), baseline physical activity, and baseline television viewing, we found no substantive relationship between year-to-year changes in television viewing and changes in leisure-time moderate/vigorous physical activity (0.03 hours/week, for each 1-hour/week change in television viewing). There were no material associations in age or gender subgroups.
In this longitudinal study, changes in television viewing were not associated with changes in leisure-time moderate/vigorous physical activity. Our findings suggest that television viewing and leisure-time physical activity are separate constructs, not functional opposites.
PMCID: PMC1994915  PMID: 17272594
physical activity; television viewing; sedentary behavior; prospective study
19.  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
20.  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
21.  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
22.  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
23.  A qualitative study of gestational weight gain counseling and tracking 
Maternal and child health journal  2013;17(8):1508-1517.
Excessive gestational weight gain (GWG) predicts adverse pregnancy outcomes and later obesity risk for both mother and child. Women who receive GWG advice from their obstetric clinicians are more likely to gain the recommended amount, but many clinicians do not counsel their patients on GWG, pointing to the need for new strategies. Electronic medical records (EMRs) are a useful tool for tracking weight and supporting guideline-concordant care, but their use for care related to GWG has not been evaluated.
We performed in-depth interviews with 16 obstetric clinicians from a multi-site group practice in Massachusetts that uses an EMR. We recorded, transcribed, coded, and analyzed the interviews using immersion-crystallization.
Many respondents believed that GWG had “a lot” of influence on pregnancy and child health outcomes but that their patients did not consider it important. Most indicated that excessive GWG was a big or moderate problem in their practice, and that inadequate GWG was rarely a problem. All used an EMR feature that calculates total GWG at each visit. Many were enthusiastic about additional EMR-based supports, such as a reference for recommended GWG for each patient based on pre-pregnancy body mass index, a “growth chart” to plot actual and recommended GWG, and an alert to identify out-of-range gains, features which many felt would remind them to counsel patients about excessive weight gain.
Additional decision support tools within EMRs would be well received by many clinicians and may help improve the frequency and accuracy of GWG tracking and counseling.
PMCID: PMC3574181  PMID: 23065312
Gestational weight gain; obstetrics; electronic medical record; counseling
24.  Obesity-Related Behaviors of US and Non-US Born Parents and Children in Low-income Households 
To examine differences in obesity-related behaviors by parental US born status among low-income, minority families participating in Healthy Habits, Happy Homes, an intervention trial to improve household routines for childhood obesity prevention. Evidence suggests lower obesity risk among adult immigrants, but research is inconclusive regarding the influence of having a non-US born parent on childhood obesity.
We sampled 57 US born and 64 non-US born families of children ages 2–5.9 years living in the Boston area. At baseline, parents reported their own screen time, physical activity, diet, and sleep as well as their children’s behaviors. We used linear and logistic regression to examine the association of parental US born status with obesity-related behaviors.
Mean (SD) BMI z-score was 0.94 (1.16) and did not differ between groups. After adjusting for parental education and child race/ethnicity, children of non-US (v. US) born parents had later bedtimes (0.81 hours later; 95% CI: 0.37, 1.25) and wake-up times (0.56 hours later; 95% CI: 0.16, 0.95) and engaged in less active play (0.15 fewer hours/day; 95% CI: −0.28, −0.01). Non-US (v. US) born parents had less screen exposure.
In this cross-section of low-income, urban families, having a parent born outside the US was associated with a profile of risk and protective behavior; adjustment for education and race/ethnicity removed protective associations of parental nativity with child behavior. Obesity-related differences in behaviors and home environments should be considered when designing interventions targeting low-income communities with a high proportion of non-US born participants.
PMCID: PMC4159704  PMID: 24131876
25.  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

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