United States pediatric guidelines recommend that childhood obesity counseling be conducted in the primary care setting. Primary care-based interventions can be effective in improving health behaviors, but also costly. The purpose of this study was to evaluate the cost of a primary care-based obesity prevention intervention targeting children between the ages of two and six years who are at elevated risk for obesity, measured against usual care.
High Five for Kids was a cluster-randomized controlled clinical trial that aimed to modify children’s nutrition and TV viewing habits through a motivational interviewing intervention. We assessed visit-related costs from a societal perspective, including provider-incurred direct medical costs, provider-incurred equipment costs, parent time costs and parent out-of-pocket costs, in 2011 dollars for the intervention (n = 253) and usual care (n = 192) groups. We conducted a net cost analysis using both societal and health plan costing perspectives and conducted one-way sensitivity and uncertainty analyses on results.
The total costs for the intervention group and usual care groups in the first year of the intervention were $65,643 (95% CI [$64,522, $66,842]) and $12,192 (95% CI [$11,393, $13,174]). The mean costs for the intervention and usual care groups were $259 (95% CI [$255, $264]) and $63 (95% CI [$59, $69]) per child, respectively, for a incremental difference of $196 (95% CI [$191, $202]) per child. Children in the intervention group attended a mean of 2.4 of a possible 4 in-person visits and received 0.45 of a possible 2 counseling phone calls. Provider-incurred costs were the primary driver of cost estimates in sensitivity analyses.
High Five for Kids was a resource-intensive intervention. Further studies are needed to assess the cost-effectiveness of the intervention relative to other pediatric obesity interventions.
ClinicalTrials.gov Identifier: NCT00377767.
Child; Preschool; Obesity; Cost; Economic evaluation
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.
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.
The purpose of the present study was to assess the nutritional quality of foods and beverages listed on menus serving children in government-sponsored child-care centres throughout Mexico.
For this cross-sectional menu assessment, we compared (i) food groups and portion sizes of foods and beverages on the menus with MyPlate recommendations and (ii) macronutrients, sugar and fibre with Daily Reference Intake standards.
Menus reflected foods and beverages served to children attending one of 142 government-sponsored child-care centres throughout Mexico.
There were fifty-four distinct menus for children aged 4–6 months, 7–9 months, 10–12 months, 13–23 months, 24–47 months and 48–72 months.
Menus included a variety of foods meeting minimum MyPlate recommendations for each food category except whole grains for children aged 48–72 months. Menus listed excessive amounts of high-energy beverages, including full-fat milk, fruit juice and sugar-sweetened beverages for children of all ages. The mean daily energy content of menu items yielded an average of 2·76 MJ for infants, 4·77 MJ for children aged 13–23 months, 5·36 MJ for children aged 24–47 months and 5·87 MJ for children aged 48–72 months. Foods and beverages on menus provided sufficient grams of carbohydrate and fat, but excessive protein.
Menus provided a variety of foods but excessive energy. Whole grains were limited, and high-energy beverages were prevalent. Both may be appropriate targets for nutrition intervention. Future studies should move beyond menus and assess what children actually consume in child care.
Child care; Mexico; Nutrition; Obesity
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.
Obesity prevention; Pediatrics; Parents; Weight perception; Primary care
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.
Computers; Internet; health information seeking; overweight; obesity; preschool age children
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.
supermarkets; food establishments; children; body mass index; obesity
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.
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.
Obesity; Race/Ethnicity; Pregnancy; Infancy; Childhood; Prevention
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.
childhood obesity; maternal behavior; television; fast food; sugar-sweetened beverages
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.
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.
Obesity; Race/Ethnicity; Pregnancy; Infancy; Childhood; Prevention
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.
obesity; parental perceptions; motivational interviewing; intervention; child; preschool
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.
Sleep; urbanicity; population density; infancy; built environment
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.
Infant; Motor development; Obesity; Physical activity
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.
Adiposity; Obesity; DXA; BMI
To examine whether the obesity prevalence is increasing, level, or decreasing among young US children (aged <6 years) in the past decade; and to compare regional data to those of 2 national databases.
We analyzed data from 108 762 well-child visits (36 827 children) at a multisite pediatric practice in eastern Massachusetts during 1999–2008. By using the Centers for Disease Control and Prevention 2000 gender-specific growth charts, we defined obesity as weight-for-length ≥95th percentile for children aged <24 months and BMI ≥95th percentile for children aged 24 to <72 months. By using multivariable logistic regression, we estimated gender-specific obesity trends in 2 separate periods, 1999–2003 and 2004–2008, adjusting for age group, race/ethnicity, health insurance, and practice site.
From 1999 to 2003, the obesity prevalence was fairly stable among both boys and girls. From 2004 to 2008, the obesity prevalence substantially decreased among both boys and girls. The decline in obesity prevalence during 2004–2008 was more pronounced among children insured by non-Medicaid health plans than among those insured by Medicaid.
Among children aged <6 years at this multisite pediatric practice, obesity prevalence decreased during 2004–2008, which is in line with national data showing no increase in prevalence during this time period. The smaller decrease among Medicaid-insured children may portend widening of socioeconomic disparities in childhood obesity.
obesity; BMI; child; infant; prevalence; trends; epidemiology
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.
To assess the feasibility of a pediatric primary care based intervention to promote healthful behaviors among 0–6 month old infants and their mothers. We enrolled two intervention practices (60 mother-infant pairs) and one usual care control practice (24 pairs) in a non-randomized controlled trial. We completed visits and interviews with 80 (95%) pairs at birth and 6 months. The intervention included (1) brief focused negotiation by pediatricians, (2) motivational counseling by a health educator, and (3) group parenting workshops. We evaluated the intervention effects on infant feeding, sleep duration, TV viewing, and mothers’ responsiveness to satiety cues. Maternal behavioral targets included postpartum diet, physical activity, TV and sleep. At 6 months, fewer intervention than control infants had been introduced to solid foods (57% vs. 82%; P = 0.04), and intervention infants viewed less TV (mean 1.2 vs. 1.5 h/d; P = 0.07). Compared to control infants, intervention infants had larger increases in their nocturnal sleep duration from baseline to follow up (mean increase 1.9 vs. 1.3 h/d; P = 0.05); larger reductions in settling time (mean reduction −0.70 vs. −0.10 h/d; P = 0.02); and larger reductions in hours/day of nighttime wakefulness (mean reduction −2.9 vs. −1.5 h/d; P = 0.08). There were no differences in breastfeeding, response to satiety cues, or maternal health behaviors. A program of brief focused negotiation by pediatricians, individual coaching by health educators using motivational interviewing, and group parenting workshops tended to improve infant feeding, sleep and media exposure, but had less impact on mothers’ own health-related behaviors.
Postpartum women; Infancy; Nutrition; Physical activity; Obesity prevention
The effect of maternal attempt to lose weight during the postpartum period on later child weight has not been explored. Among 1,044 mother–infant pairs in Project Viva, we estimated longitudinal associations of maternal attempt to lose weight during the postpartum period with child weight and adiposity at age 3 years and examined differences in associations by type of weight loss strategy used. Using covariate-adjusted linear and logistic regression models, we estimated associations before and after adjusting for maternal weight-related variables including prepregnancy BMI. At 6 months postpartum, 53% mothers were trying to lose weight. At age 3 years, mean (s.d.) child BMI z-score was 0.44 (1.01) and 8.9% of children were obese. Children whose mothers were trying to lose weight at 6 months postpartum had higher BMI z-scores (0.30 (95% confidence interval (CI) 0.18, 0.42)) and were more likely to be obese (3.0 (95% CI 1.6, 5.8)) at 3 years of age. Addition of maternal prepregnancy BMI to the models attenuated but did not eliminate the associations seen for BMI z-score (0.24 (95% CI 0.12, 0.36) and obesity (2.4 (95% CI 1.2, 4.7)). Attempting to lose weight by exercising alone was the only weight loss strategy that consistently predicted higher child BMI z-score (0.36 (95% CI 0.14, 0.58)) and odds of obesity (6.0 (95% CI 2.2, 16.5)) at age 3 years. In conclusion, we observed an association between maternal attempt to lose weight at 6 months postpartum, particularly through exercise alone, measured using a single item and child adiposity at age 3 years. This association should be thoroughly examined in future studies.
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.
Sleep; Inflammation; Postpartum women
Childhood obesity is currently one of the most prevailing and challenging public health issues among industrialized countries and of international priority. The global prevalence of obesity poses such a serious concern that the World Health Organization (WHO) has described it as a “global epidemic.” Recent literature suggests that the genesis of the problem occurs in the first years of life as feeding patterns, dietary habits, and parental feeding practices are established. Obesity prevention evidence points to specific dietary factors, such as the promotion of breastfeeding and appropriate introduction of nutritious complementary foods, but also calls for attention to parental feeding practices, awareness of appropriate responses to infant hunger and satiety cues, physical activity/inactivity behaviors, infant sleep duration, and family meals. Interventions that begin at birth, targeting multiple factors related to healthy growth, have not been adequately studied. Due to the overwhelming importance and global significance of excess weight within pediatric populations, this narrative review was undertaken to summarize factors associated with overweight and obesity among infants and toddlers, with focus on potentially modifiable risk factors beginning at birth, and to address the need for early intervention prevention.
Modeling childhood body mass index (BMI) trajectories, versus estimating change in BMI between specific ages, may improve prediction of later body-size-related outcomes. Prior studies of BMI trajectories are limited by restricted age periods and insufficient use of trajectory information.
Among 3,289 children seen at 81,550 pediatric well-child visits from infancy to 18 years between 1980 and 2008, we fit individual BMI trajectories using mixed effect models with fractional polynomial functions. From each child's fitted trajectory, we estimated age and BMI at infancy peak and adiposity rebound, and velocity and area under curve between 1 week, infancy peak, adiposity rebound, and 18 years.
Among boys, mean (SD) ages at infancy BMI peak and adiposity rebound were 7.2 (0.9) and 49.2 (11.9) months, respectively. Among girls, mean (SD) ages at infancy BMI peak and adiposity rebound were 7.4 (1.1) and 46.8 (11.0) months, respectively. Ages at infancy peak and adiposity rebound were weakly inversely correlated (r = -0.09). BMI at infancy peak and adiposity rebound were positively correlated (r = 0.76). Blacks had earlier adiposity rebound and greater velocity from adiposity rebound to 18 years of age than whites. Higher birth weight z-score predicted earlier adiposity rebound and higher BMI at infancy peak and adiposity rebound. BMI trajectories did not differ by birth year or type of health insurance, after adjusting for other socio-demographics and birth weight z-score.
Childhood BMI trajectory characteristics are informative in describing childhood body mass changes and can be estimated conveniently. Future research should evaluate associations of these novel BMI trajectory characteristics with adult outcomes.
To examine the association between timing of introduction of solid foods during infancy and obesity at 3 years of age.
We studied 847 children in Project Viva, a prospective pre-birth cohort study. The primary outcome was obesity at 3 years of age (BMI for age and gender ≥95th percentile). The primary exposure was the timing of introduction of solid foods, categorized as <4, 4 to 5, and ≥6 months. We ran separate logistic regression models for infants who were breastfed for at least 4 months (“breastfed”) and infants who were never breastfed or stopped breastfeeding before the age of four months (“formula-fed”), adjusting for child and maternal characteristics, which included change in weight-for-age z score from 0 to 4 months–a marker of early infant growth.
In the first 4 months of life, 568 infants (67%) were breastfed and 279 (32%) were formula-fed. At age 3 years, 75 children (9%) were obese. Among breastfed infants, the timing of solid food introduction was not associated with odds of obesity (odds ratio: 1.1 [95% confidence interval: 0.3–4.4]). Among formula-fed infants, introduction of solid foods before 4 months was associated with a sixfold increase in odds of obesity at age 3 years; the association was not explained by rapid early growth (odds ratio after adjustment: 6.3 [95% confidence interval: 2.3–6.9]).
Among formula-fed infants or infants weaned before the age of 4 months, introduction of solid foods before the age of 4 months was associated with increased odds of obesity at age 3 years.
obesity; infant feeding; complementary foods
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.
Asthma; wheeze; adiposity; children; prospective study
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.
Sleep; Adiposity; Cardio-Metabolic Status; Postpartum women
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.
The majority of infants in the United States are in non-parental child care, yet little is known about the effect of child care on development of obesity.
To examine the relationship between child care attendance from birth to 6 months and adiposity at 1 and 3 years of age.
We studied 1138 children from a prospective cohort of pregnant women and their offspring. The main exposure was time in child care from birth to 6 months of age, overall and by type of care: (1) child care center; (2) someone else’s home; and (3) child’s own home by nonparent. The main outcomes were weight-for-length (WFL) z score at 1 year and BMI z score at 3 years of age.
A total of 649 (57%) infants attended child care; 17% were cared for in a center, 27% in someone else’s home, and 21% in their own home by a nonparent. After adjustment for confounders, overall time in child care was associated with an increased WFL z score at 1 year and BMI z score at 3 years of age but not skinfold thicknesses. Center and own home care were not associated with the outcomes, but care in someone else’s home was associated with an increase in both the 1- and 3-year outcomes.
Child care in the first 6 months of life, especially in someone else’s home, was associated with an increased WFL z score at 1 year and BMI z score at 3 years of age.
child care; childhood obesity; nutrition; physical activity; infancy