How early should obesity prevention start?

Trained Immunity: Linking Obesity and Cardiovascular Disease across the Life-Course?

Obesity, a chronic inflammatory disease, is the most prevalent modifiable risk factor for cardiovascular disease. The mechanisms underlying inflammation in obesity are incompletely understood. Recent developments have challenged the dogma of immunological memory occurring exclusively in the adaptive immune system and show that the innate immune system has potential to be reprogrammed. This innate immune memory (trained immunity) is characterized by epigenetic and metabolic reprogramming of myeloid cells following endogenous or exogenous stimulation, resulting in enhanced inflammation to subsequent stimuli. Trained immunity phenotypes have now been reported for other immune and non-immune cells. Here, we provide a novel perspective on the putative role of trained immunity in mediating the adverse cardiovascular effects of obesity and highlight potential translational pathways.

Eating behaviors moderate the associations between risk factors in the first 1000 days and adiposity outcomes at 6 years of age

BACKGROUND

Several risk factors in the first 1000 d are linked with increased obesity risk in later childhood. The role of potentially modifiable eating behaviors in this association is unclear.

OBJECTIVES

This study examined whether the association between cumulated risk factors in the first 1000 d and adiposity at 6 y is moderated by eating behaviors.

METHODS

Participants were 302 children from the GUSTO (Growing Up in Singapore Towards healthy Outcomes) cohort. Risk factors included maternal prepregnancy and paternal overweight, excessive gestational weight gain, raised fasting plasma glucose during pregnancy, short breastfeeding duration, and early introduction of solid foods. Composite risk scores reflecting the prevalence and the importance of the risk factors present were computed. Adiposity outcomes were child BMI and sum of skinfolds (SSF), and candidate eating behavior moderators were portion size, eating rate, and energy intake during lunch and in an eating in the absence of hunger task.

RESULTS

Higher composite risk score predicted higher BMI z scores (B = 0.08; 95% CI: 0.04, 0.13) and larger SSF (0.70 mm; 0.23, 1.18 mm), and was associated with larger self-served food portions (5.03 kcal; 0.47, 9.60 kcal), faster eating rates (0.40 g/min; 0.21, 0.59 g/min), and larger lunch intakes (7.05 kcal; 3.37, 10.74 kcal). Importantly, the association between composite risk score and adiposity was moderated by eating behaviors. The composite risk score was unrelated to SSF in children who selected smaller food portions, ate slower, and consumed less energy, but was positively associated with SSF among children who selected larger food portions, ate faster, and consumed more energy (eating behavior × risk score interactions: P < 0.05).

CONCLUSIONS

The association between risk factors in the first 1000 d and adiposity at 6 y varies by eating behaviors, highlighting modifiable behavioral targets for interventions.This trial was registered at clinicaltrials.gov as NCT01174875.

Electronic Monitoring Of Mom's Schedule (eMOMS™): Protocol for a feasibility randomized controlled trial to improve postpartum weight, blood sugars, and breastfeeding among high BMI women

Background

Overweight and obesity are major risk factors for gestational diabetes among U.S. women. Evidence suggests that longer duration of breastfeeding among women with a history of gestational diabetes is associated with lower incidence of developing type 2 diabetes after pregnancy. Women may potentially benefit from a lifestyle change program that includes breastfeeding education and support.

Purpose

To describe the design and justification of a combined breastfeeding, national Diabetes Prevention Program (DPP)-based feasibility randomized controlled trial, the electronic Monitoring Of Mom's Schedule (eMOMS^TM) study. eMOMS^TM compares the feasibility and efficacy of three interventions on six-month postpartum weight loss among women with a BMI ≥25.

Methods

The intervention is delivered via Facebook and includes three groups: DPP and breastfeeding (eMOMS1); DPP only (eMOMS2); and Usual Care (eMOMS3). Recruitment is ongoing at two clinical sites (rural and urban). A total of 72 women, 24 per group, will be randomly assigned to one of the three groups. It is anticipated that women in eMOMS1 will have greater weight loss and increased length of breastfeeding at three and six months postpartum compared to women in eMOMS2 and eMOMS3. Additional data will be collected on metabolic markers, anthropometrics, physical activity, nutrition, breastfeeding, and depression. Program cost will be compared to that of traditionally scheduled group meetings. Expected study completion date: October 2021.

Conclusions

This study has the potential to define a high impact, cost effective intervention that can improve public health by reducing negative health outcomes associated with gestational diabetes among an at-risk population.

Primordial Prevention of High Blood Pressure in Childhood: An Opportunity Not to be Missed

Hypertension is a condition with increased risk for subsequent adverse events, and treatment of hypertension is prescribed for primary prevention of adverse events. Primordial prevention is a concept that precedes primary prevention and focuses on risk factor prevention. Primordial prevention of hypertension consists of strategies to maintain blood pressure in a normal range and prevent development of elevated blood pressure or hypertension. Childhood is a period in which primordial prevention could be effective and if sustained throughout childhood could contribute to a healthier young adulthood. Targets for primordial prevention in childhood include preventing and reducing childhood obesity, achieving an optimal diet that includes avoiding excessive salt consumption, and removing barriers to physical activity and healthy sleep throughout childhood. Primordial prevention also includes the prenatal period wherein some maternal conditions and exposures are associated with higher blood pressure in child offspring.

Effectiveness of a Multifactorial Intervention in the First 1000 Days of Life to Prevent Obesity and Overweight in Childhood: Study Protocol

(1) Background: Obesity is a global health problem, and its prevention must be a priority goal of public health, especially considering the seriousness of the problem among children. It is known that fetal and early postnatal environments may favor the appearance of obesity in later life. In recent years, the impact of the programs to prevent obesity in childhood has been scarce. The aim of this research is to evaluate the effectiveness of an intervention based on the concept of early programming. (2) Methods: Non-randomized controlled trial design. Inclusion criteria are: two-year-old infants whose gestational period begins in the 14 months following the start of the intervention, and whose mothers have made the complete follow-up of their pregnancy in the same clinical unit of the study. The intervention will be developed over all the known factors that affect early programming, during pregnancy up to 2 years of life. Data will be collected through a data collection sheet by the paediatricians. A unibivariate and multivariate analysis of the data will be carried out. (3) Ethics and dissemination: The trial does not involve any risk to participants and their offspring. Signed informed consent is obtained from all participants. Ethical approval has been obtained. (4) Results: It is expected that this study will provide evidence on the importance of the prevention of obesity from the critical period of the first 1000 days of life, being able to establish this as a standard intervention in primary care.

Protocol for a pilot randomized controlled feasibility study of brief interpersonal psychotherapy for addressing social-emotional needs and preventing excess gestational weight gain in adolescents

BACKGROUND

Excess gestational weight gain (GWG) in pregnant adolescents is a major public health concern. Excess GWG increases risk of pregnancy complications as well as postpartum and offspring obesity and cardiometabolic disease. Prevention interventions for pregnant adults that target lifestyle modification (i.e., healthy eating/physical activity) show insufficient effectiveness. Pregnant adolescents have distinct social-emotional needs, which may contribute to excess GWG. From an interpersonal theoretical framework, conflict and low social support increase negative emotions, which in turn promote excess GWG through mechanisms such as overeating and physical inactivity.

METHODS

The current manuscript describes the design of a pilot randomized controlled feasibility trial of adolescent interpersonal psychotherapy (IPT) to address social-emotional needs and prevent excess GWG. Up to 50 pregnant, healthy adolescents 13-19y, 12-18 weeks gestation are recruited from an interdisciplinary adolescent maternity hospital clinic and randomized to IPT + usual care or usual care alone. IPT involves 6 individual 60-minute sessions delivered by a trained behavioral health clinician during 12-30 weeks gestation. Sessions include relationship psychoeducation, emotion identification and expression, and teaching/role-playing communication skills. Between sessions, adolescents are instructed to complete a daily journal and to have conversations to work on relationship goals. Outcomes are assessed at baseline, mid-program, post-program, and 3-months postpartum. Primary outcomes are feasibility and acceptability based upon rate of recruitment, session attendance, program acceptability ratings, and follow-up retention. Secondary outcomes are perinatal social functioning, stress, depression, and eating behaviors assessed with validated surveys and interviews; perinatal physical activity and sleep measured via accelerometer; GWG from measured weights; and at 3-months postpartum only, maternal adiposity by dual energy x-ray absorptiometry, maternal insulin sensitivity derived from 2-hour oral glucose tolerance testing, and infant adiposity by air displacement plethysmography.

DISCUSSION

This pilot trial will address a key gap in extant understanding of excess GWG prevention for a high-risk population of adolescents. If feasible and acceptable, brief psychotherapy to address social-emotional needs should be tested for its effectiveness to address excess GWG and postpartum maternal/infant health. If effective, such an approach has potential to interrupt an adverse, intergenerational cycle of social-emotional distress, obesity, and cardiometabolic disease among young mothers and their offspring.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03086161, retrospectively registered.

Greater analgesic effects of sucrose in the neonate predict greater weight gain to age 18 months

Intraoral sucrose has analgesic effects in the newborn period. The hedonic and analgesic effects of sucrose overlap and hedonic response to sweet food is associated with adiposity. The potential association between the analgesic effects of intraoral sucrose in the newborn period and subsequent weight gain has not been examined. Healthy, term newborns received 25% intraoral sucrose or water prior to metabolic screen heel stick. Negative affect, quiet alert behavior, and sleepiness were coded during heel stick. Weight and length were measured and z-score (WLZ) calculated at birth, 9, and 18 months. Mixed models tested associations of behavioral response to heel stick with WLZ trajectory among infants receiving sucrose (n = 154) versus water (n = 117). Among infants receiving sucrose prior to heel stick with birth WLZ ≥ the median, less negative affect and more sleepiness during heel stick were each associated with greater increases in WLZ. These associations were not present among infants receiving water only prior to heel stick. Greater analgesic effects of sucrose in the neonate were associated with greater future increases in WLZ, especially among infants with higher birth WLZ. Greater opioid-mediated newborn behavioral response to intraoral sucrose may be a marker for future obesity risk. CLINICAL TRIALS NUMBER: NCT02728141.

Maternal postload 1-hour glucose level during pregnancy and offspring's overweight/obesity status in preschool age

BACKGROUND

Childhood obesity is associated with adverse outcomes such as metabolic syndrome, diabetes, and cardiovascular diseases in adulthood. Identifying risk factors related to excessive adiposity in early childhood is of great importance for obesity intervention. The results of studies for associations between maternal with gestational diabetes and offspring obesity are conflicting. Nonetheless, the association of maternal glucose across a spectrum of glucose values with childhood adiposity outcomes is less clear.

AIM

To assess the association of maternal glucose across a spectrum of glucose values with childhood adiposity at age 5 years.

METHODS

A population-based cohort study was conducted between 2011 and 2018. Using the healthcare records data were from the Medical Birth Registry in Xiamen, China. The primary outcome was offspring obese/obesity. Primary predictors were maternal oral glucose tolerance test values during pregnancy.

RESULTS

6090 mother-child pairs were analyzed. The mean age of the children at follow-up was 5.2 years. At multiple logistic regression, after adjustment for variables, including maternal pre-pregnancy body mass index (BMI), birth weight of offspring, and insulin therapy, ORs for offspring overweight/obesity were 1.13 (95% CI 0.90 to 1.42) for maternal fasting glucose levels, 1.12 (95% CI 1.04 to 1.22) for 1-hour glucose, and 1.04 (95% CI 0.95 to 1.14) for 2-hour glucose. The adjusted association of offspring BMI Z-score with maternal 1-hour glucose level remained significant. There were no significant associations between BMI Z-score and maternal fasting glucose and 2-hour glucose level. Exploratory sex-specific analyses indicated generally consistent associations for boys and girls.

CONCLUSION

Maternal postload 1-hour glucose across a spectrum of glucose values during pregnancy was an independent risk for offspring weight gain at age 5 years, indicating the importance of screen and management of maternal 1-hour glucose level, except for fasting glucose and 2-hour glucose level during pregnancy in order to prevent offspring weight gain in early childhood.

Adverse pregnancy outcomes on the risk of overweight offspring: a population-based retrospective study in Xiamen, China

The growth trajectory of Chinese preschoolers still remains unclear. Our objective was to determine whether there was an association between adverse pregnancy outcomes and overweight offspring. We analyzed population-based retrospective cohort data from the Medical Birth Registry of Xiamen, which comprised 33,157 children examined from 1 to 6 years of age. Longitudinal analyses were used to evaluate the growth trajectories of offspring body mass index (BMI). Multivariate logistic regression was used to assess the effects of two adverse pregnancy outcomes, gestational diabetes mellitus (GDM) and being large-for-gestational age (LGA), on childhood overweight. Offspring of mothers with GDM and LGA has a higher annual BMI z-score from 1 to 6 years of age (all P < 0.05). But, a higher annual BMI z-score was only observed in children aged 1-5 years in models 1-3. Overall BMI z-score of offspring aged 1-6 who were born to mothers with GDM and LGA were also higher in models 1-3 (all P < 0.05). Additionally, offspring of mothers with GDM and LGA had a higher risk for overweight in model 1, from 1 to 6 years of age (odds ratio (OR), 1.814; 95% confidence interval (CI), 1.657-1.985; P < 0.0001). However, this association was attenuated after adjusting for maternal pre-pregnancy BMI (OR, 1.270; 95% CI, 0.961-1.679; P = 0.0930). Offspring of mothers with GDM and LGA had a higher BMI z-score and increased risk for overweight. Indeed, intrauterine exposure to maternal GDM and LGA could bias offspring to overweight, whereas maternal pre-pregnancy BMI may play a key role in offspring overweight for children born to mothers with GDM and LGA.

Association Between Maternal Exposure to Lead, Maternal Folate Status, and Intergenerational Risk of Childhood Overweight and Obesity

IMPORTANCE

The first pediatric lead screening typically occurs at 1-year well-child care visits. However, data on the extent of maternal lead exposure and its long-term consequences for child health are lacking.

OBJECTIVE

To investigate the associations between maternal red blood cell (RBC) lead levels and intergenerational risk of overweight or obesity (OWO) and whether adequate maternal folate status is associated with a reduction in OWO risk.

DESIGN, SETTING, AND PARTICIPANTS

Prospective birth cohort study. The analysis was conducted from July 14, 2018, to August 2, 2019, at Johns Hopkins Bloomberg School of Public Health. This study included 1442 mother-child pairs recruited at birth from October 27, 2002, to October 10, 2013, and followed up prospectively at Boston Medical Center.

MAIN OUTCOMES AND MEASURES

Child body mass index (BMI) z score, calculated according to US national reference data, and OWO, defined as BMI at or exceeding the 85th percentile for age and sex. Maternal RBC lead levels and plasma folate levels were measured in samples obtained 24 to 72 hours after delivery; child whole-blood lead level was obtained from the first pediatric lead screening.

RESULTS

The mean (SD) age of mothers and children was 28.6 (6.5) years and 8.1 (3.1) years, respectively; 50.1% of children were boys. The median maternal RBC lead level and plasma folate level were 2.5 (interquartile range [IQR], 1.7-3.8) μg/dL and 32.2 (IQR, 22.1-44.4) nmol/L, respectively. The median child whole-blood lead level and child BMI z score were 1.4 (IQR, 1.4-2.0) μg/dL and 0.78 (IQR, -0.08 to 1.71), respectively. Maternal RBC lead level was associated with child OWO risk in a dose-response fashion, with an odds ratio (OR) of 1.65 (95% CI, 1.18-2.32) for high maternal RBC lead level (≥5.0 μg/dL) compared with low maternal RBC lead level (<2.0 μg/dL). Child OWO was highest among children of OWO mothers with high RBC lead levels (adjusted OR, 4.24; 95% CI, 2.64-6.82) compared with children of non-OWO mothers with low RBC lead levels. Children of OWO mothers with high RBC lead levels had 41% lower OWO risk (OR, 0.59; 95% CI, 0.36-0.95; P = .03) if their mothers had adequate plasma folate levels (≥20.4 nmol/L) compared with their counterparts.

CONCLUSIONS AND RELEVANCE

In this sample of a US urban population, findings suggest that maternal elevated lead exposure was associated with increased risk of intergenerational OWO independent of postnatal blood lead levels. Adequate maternal folate status appeared to be associated with lower OWO risk. If confirmed by additional studies, these findings have implications for prenatal lead screening and management to minimize adverse health consequences on children.

Infant and young child feeding interventions targeting overweight and obesity: A narrative review

findings from systematic reviews into infant feeding and later adiposity are largely negative. World Health Organization (WHO) is auspicing Healthy Life Trajectories Initiative (HeLTI), a suite of trials aiming to prevent overweight/obesity in childhood. To inform planning, this narrative review sought to detail potentially effective components of nutrition-related interventions involving children aged 0 to 2 years. Systematic searches of PubMed and the Cochrane Library (2006-2016) identified 108 systematic reviews. These included 31 randomized trials in the age group of interest. Of these, 11 reported greater than or equal to 1 statistically significant (P < 0.05) benefit on body weight and/or composition. Six multicomponent trials whose interventions incorporated education to promote breastfeeding (four trials), responsive feeding (two trials), and healthy diet (eg, increasing fruit and vegetables and limiting unhealthy snack foods; five trials), delivered through home visits or at baby health clinics, reported relative reductions in body mass index (BMI) at the end of intervention. Early benefits were not maintained in the two trials reporting follow-up 1 to 3 years later. Other potentially effective approaches included lower protein formulas in formula-fed infants and education around reducing sugar-sweetened beverages. There is some evidence that infant feeding interventions can have a transient positive impact on a child's BMI. It is not known whether ongoing intervention can avoid the subsequent expected wash-out.

Development and Validation of a New Questionnaire Assessing Feeding Styles in Toddlers: Toddler Feeding Style Questionnaire (TFSQ)

PURPOSE

To develop and validate a new questionnaire assessing feeding styles in toddlers, the Toddler Feeding Style Questionnaire (TFSQ).

DESIGN AND METHODS

An instrumental design was used in this study. A convenience sample of 546 Spanish mothers of a toddler (12-24 months-old) completed the TFSQ and a web-based survey to obtain data on feeding styles, sociodemographic and anthropometric characteristics, weaning and attachment style. Items were developed and classified into two content domains: responsiveness and demandingness. For the construct validity analysis, the sample was randomly divided into two halves used to the exploratory and confirmatory factor analysis, respectively. Validation hypotheses about the differences in the TFSQ scores were suggested.

RESULTS

The factorial analysis revealed a responsiveness scale and a demandingness scale. The McDonald's Omega and Cronbach's alpha values coincided in both scales, being 0.84 and 0.75, respectively. A high responsiveness and demandingness feeding styles degree of agreement showed a statistically significant association with the correspondent scale (p < .01). The 33.3% of children who are overweight or obese have mothers who classify themselves as neglectful. Both scales were related to the mothers' attachment styles, toddler's age and the time of weaning at 6 and 12 months.

CONCLUSIONS

The TFSQ provides a valid and reliable Responsiveness and Demandingness scale to evaluate feeding styles in toddlers.

PRACTICE IMPLICATIONS

Parental feeding styles influence future eating behavior and children's weight. There is a lack of validated instruments used to evaluate feeding styles in toddlerhood based on the two theoretical dimensions of responsiveness and demandingness.

A reduction in sedentary behaviour in obese women during pregnancy reduces neonatal adiposity: the DALI randomised controlled trial

AIMS/HYPOTHESIS

Offspring of obese women are at increased risk of features of the metabolic syndrome, including obesity and diabetes. Lifestyle intervention in pregnancy might reduce adverse effects of maternal obesity on neonatal adiposity.

METHODS

In the Vitamin D And Lifestyle Intervention for Gestational Diabetes Mellitus (GDM) Prevention (DALI) lifestyle trial, 436 women with a BMI ≥29 kg/m² were randomly assigned to counselling on healthy eating (HE), physical activity (PA) or HE&PA, or to usual care (UC). In secondary analyses of the lifestyle trial, intervention effects on neonatal outcomes (head, abdominal, arm and leg circumferences and skinfold thicknesses, estimated fat mass, fat percentage, fat-free mass and cord blood leptin) were assessed using multilevel regression analyses. Mediation of intervention effects by lifestyle and gestational weight gain was assessed.

RESULTS

Outcomes were available from 334 neonates. A reduction in sum of skinfolds (-1.8 mm; 95% CI -3.5, -0.2; p = 0.03), fat mass (-63 g; 95% CI -124, -2; p = 0.04), fat percentage (-1.2%; 95% CI -2.4%, -0.04%; p = 0.04) and leptin (-3.80 μg/l; 95% CI -7.15, -0.45; p = 0.03) was found in the HE&PA group, and reduced leptin in female neonates in the PA group (-5.79 μg/l; 95% CI -11.43, -0.14; p = 0.05) compared with UC. Reduced sedentary time, but not gestational weight gain, mediated intervention effects on leptin in both the HE&PA and PA groups.

CONCLUSIONS/INTERPRETATION

The HE&PA intervention resulted in reduced adiposity in neonates. Reduced sedentary time seemed to drive the intervention effect on cord blood leptin. Implications for future adiposity and diabetes risk of the offspring need to be elucidated.

TRIAL REGISTRATION

ISRCTN70595832.

Quercetin and its derivative Q2 modulate chromatin dynamics in adipogenesis and Q2 prevents obesity and metabolic disorders in rats

Recently the attention of the scientific community has focused on the ability of polyphenols to counteract adverse epigenetic regulation involved in the development of complex conditions such as obesity. The aim of this study was to investigate the epigenetic mechanisms underlying the anti-adiposity effect of Quercetin (3,3',4',5,7-pentahydroxyflavone) and of one of its derivatives, Q2 in which the OH groups have been replaced by acetyl groups. In 3 T3-L1 preadipocytes, Quercetin and Q2 treatment induce chromatin remodeling and histone modifications at the 5' regulatory region of the two main adipogenic genes, c/EBPα and PPARγ. Chromatin immunoprecipitation assays revealed a concomitant increase of histone H3 di-methylation at Lys9, a typical mark of repressed gene promoters, and a decrease of histone H3 di-methylation at Lys 4, a mark of active transcription. At the same time, both compounds inhibited histone demethylase LSD1 recruitment to the 5' region of c/EBPα and PPARγ genes, a necessary step for adipogenesis. The final effect is a significant reduction in c/EBPα and PPARγ gene expression and attenuated adipogenesis. Q2 supplementation in rats reduced the gain in body weight and in white adipose tissue, as well as the increase in adipocyte size determined by high fat diet. Moreover, Q2 improved dyslipidemia, glucose tolerance and decreased the hepatic lipid accumulation by activating the expression of beta-oxidation related genes. Our data suggest that Q2, as well as Quercetin, has the potential to revert the unfavorable epigenomic profiles associated with obesity onset. This opens the possibility to use these compounds in targeted prevention strategies against obesity.

Polygenic risk, adherence to a healthy lifestyle, and childhood obesity

BACKGROUND

Both polygenic and unhealthy lifestyle factors contribute to individual-level risk of obesity during childhood. The extent to which increased polygenic risk can be offset by healthy lifestyle is unknown.

OBJECTIVE

To examine whether increased polygenic risk of obesity is modified by a healthy lifestyle during childhood.

METHODS

A total of 997 children (418 boys and 579 girls) who had complete DNA genotyping and body mass index (BMI) were eligible for the study were analyzed from an established prospective puberty cohort. The polygenic risk score (PRS) was computed based on 11 BMI-increasing single nucleotide polymorphisms (SNPs) derived from a published genome-wide association study (GWAS) for child obesity. Seven lifestyle factors were selected to determine a composite healthy lifestyle, such as food responsiveness, slowness in eating, satiety responsiveness, physical activity, screen time, sleep duration, and sugar-sweetened beverages consumption, and which was classified as healthy (<P₂₅ ), intermediate (P₂₅ -P₇₅ ) and unhealthy (>P₇₅ ) lifestyle. Linear and logistic regression analyses were conducted.

RESULTS

Children carrying additional BMI susceptibility alleles increased the BMI by 0.11 kg/m² , after adjusting gender, age and socio-economic status (SES). A healthy lifestyle was associated with a substantially lower risk of obesity than an unhealthy lifestyle, regardless of the polygenic risk category. Among children at high polygenic risk, a healthy lifestyle was associated with an 85% lower risk of obesity than an unhealthy lifestyle (odds ratio, 0.15; 95% CI, 0.04 to 0.59; p = 0.007).

CONCLUSIONS

Our findings suggest that increased polygenic risk might be largely offset by healthy lifestyle as early as in childhood.

Translating behavioral medicine evidence to public policy

Behavioral medicine has made significant contributions to our understanding of how to prevent disease and improve health. However, social and environmental factors continue to have a major influence on health in ways that will be difficult to combat on a population level without concerted efforts to scale interventions and translate the evidence into public health policies. Now is also the right time to increase our efforts to produce policy relevant research and partnerships that will maximize the chances that our evidence is taken to scale in ways that can influence population health broadly, and perhaps contribute to the reduction of the recalcitrant health disparities that plague virtually every area of behavioral medicine focus. As a field we must take an active role in policy translation, learning from the public policy and political science disciplines, and our own pioneers in policy translation. This article discusses importance of accelerating evidence translation to policy, and suggests several factors that could enhance our translation efforts, including embracing policy translation as a key goal in behavioral medicine, increasing our understanding in variability of evidence-based policy adoption across and within states, improving our understanding of how to most effectively communicate our findings to policy makers, conducting research that is responsive to policy makers' needs, and considering the important role of local policy partnerships.

Prenatal determinants of childhood obesity: a review of risk factors 1

Childhood obesity is a predictor of adult obesity and has its roots in the pre-pregnancy or pregnancy period. This review presents an overview of the prenatal risk factors for childhood obesity, which were categorized into 2 groups: biological risk factors (maternal pre-pregnancy body mass index, gestational weight gain, diabetes in pregnancy, and caesarean section), and environmental and behavioural risk factors (maternal smoking and exposure to obesogens, maternal dietary patterns, maternal intestinal microbiome and antibiotics exposure, and maternal psychosocial stress). Identifying modifiable predisposing prenatal factors for obesity will inform further development of inventions to prevent obesity over the life course, and future directions for research and intervention are discussed.

Lifestyle intervention strategies in early life to improve pregnancy outcomes and long-term health of offspring: a narrative review

Adverse exposures during fetal life and the postnatal period influence physical, cognitive and emotional development, and predispose to an increased risk of various chronic diseases throughout the life course. Findings from large observational studies in various populations and experimental animal studies have identified different modifiable risk factors in early life. Adverse maternal lifestyle factors, including overweight, unhealthy diet, sedentary behavior, smoking, alcohol consumption and stress in the preconception period and during pregnancy, are the most common modifiable risk factors leading to a suboptimal in-utero environment for fetal development. In the postnatal period, breastfeeding, infant growth and infant dietary intake are important modifiable factors influencing long-term offspring health outcomes. Despite the large amount of findings from observational studies, translation to lifestyle interventions seems to be challenging. Currently, randomized controlled trials focused on the influence of lifestyle interventions in these critical periods on short-term and long-term maternal and offspring health outcomes are scarce, have major limitations and do not show strong effects on maternal and offspring outcomes. New and innovative approaches are needed to move from describing these causes of ill-health to start tackling them using intervention approaches. Future randomized controlled lifestyle intervention studies and innovative observational studies, using quasi-experimental designs, are needed focused on the effects of an integrated lifestyle advice from preconception onwards on pregnancy outcomes and long-term health outcomes in offspring on a population level.

Antecedents of Obesity Among Children Born Extremely Preterm

BACKGROUND

Childhood obesity is a pervasive public health problem with risk factors such as maternal prepregnancy BMI and rapid infant weight gain. Although catch-up weight gain promotes more favorable neurodevelopment among infants born preterm, it is not clear whether faster weight gain early in life, or other correlates of preterm birth, are associated with later obesity in this population.

METHODS

We used prospective data from the multicenter, observational Extremely Low Gestational Age Newborn Study. Among 1506 eligible individuals in the initial cohort, 1198 were eligible for follow-up at 10 years of age. We examined BMI in 871 children (58% of the cohort; 74% of survivors) and analyzed relationships between antecedents and overweight or obesity at 10 years of age. A time-oriented approach to multinomial multivariable regression enabled us to calculate odds of overweight and obesity associated with pre- and postnatal antecedents.

RESULTS

Prepregnancy maternal BMI ≥25 and top quartile infant weight gain in the first year were associated with increased risk of both overweight and obesity at 10 years of age. Single marital status was a risk factor for later child obesity and exposure to tobacco smoke was a risk factor for later child overweight.

CONCLUSIONS

The risk profiles for overweight and obesity at 10 years of age among children born extremely preterm appear to be similar to the risk profiles of overweight and obesity among children born at term.

Pathways into and out of overweight and obesity from infancy to mid-childhood

OBJECTIVES

To investigate whether high weight in infancy predicts obesity in childhood.

METHOD

Data from two UK cohorts (Newcastle Growth and Development N = 795, Gateshead Millennium N = 393) and one Finnish (Tampere N = 1262) were combined. Z scores of weight at 3 and 12 months and body mass index (BMI) at 5 and 8 years were categorized as raised/overweight (1 to <2 SD) or high/obese (≥2 SD).

RESULTS

The majority of infants with raised or high weight at birth tended to revert to normal by 3 months and to track in the same category from 3 to 12 months. Although infants with high weight were five times more likely to have BMI ≥ 2 SD at 8 years (p < 0.001), only 22% went on to have BMI ≥ 2 SD, while 64% of infants with raised weight had normal BMI at 8 years. Of children with BMI ≥ 2 SD aged 8 years, only 22% had raised weight in infancy and half had BMI ≥ 2 SD for the first time at that age.

CONCLUSIONS

Infants with raised weight in infancy tend to remain so, but most children who go on to have BMI ≥ 2 SD were not unusually heavy infants and the majority of infants with high weight reverted to overweight or normal weight in childhood.

Mode of infant feeding, eating behaviour and anthropometry in infants at 6-months of age born to obese women - a secondary analysis of the UPBEAT trial

BACKGROUND

Maternal obesity and rapid infant weight gain have been associated with increased risk of obesity in childhood. Breastfeeding is suggested to be protective against childhood obesity, but no previous study has addressed the potential benefit of breastfeeding as a preventive method of childhood obesity amongst obese women. The primary aim of this study was to assess the relationship between mode of feeding and body composition, growth and eating behaviours in 6-month-old infants of obese women who participated in UPBEAT; a multi-centre randomised controlled trial comparing a lifestyle intervention of diet and physical activity to standard care during pregnancy.

METHODS

Three hundred and fifty-three mother and infant pairs attended a 6-months postpartum follow-up visit, during which they completed the Baby-Eating Behaviour Questionnaire, a parent-reported psychometric measure of appetite traits. Measures of infant body composition were also undertaken. As there was no effect of the antenatal intervention on infant feeding and appetite the study was treated as a cohort. Using regression analyses, we examined relationships between: 1) mode of feeding and body composition and growth; 2) mode of feeding and eating behaviour and 3) eating behaviour and body composition.

RESULTS

Formula fed infants of obese women in comparison to those exclusively breastfed, demonstrated higher weight z-scores (mean difference 0.26; 95% confidence interval 0.01 to 0.52), higher rate of weight gain (0.04; 0.00 to 0.07) and greater catch-up growth (2.48; 1.31 to 4.71). There was also a lower enjoyment of food (p = 0.002) amongst formula fed infants, following adjustment for confounders. Independent of the mode of feeding, a measure of infant appetite was associated with sum of skinfold thicknesses (β 0.66; 95% CI 0.12 to 1.21), calculated body fat percentage (0.83; 0.15 to 1.52), weight z-scores (0.21; 0.06 to 0.36) and catch-up growth (odds ratio 1.98; 1.21 to 3.21).

CONCLUSIONS

In obese women, exclusive breastfeeding was protective against increasing weight z-scores and trajectories of weight gain in their 6-month old infants. Measures of general appetite in early infancy were associated with measures of adiposity, weight and catch up growth independent of cord blood leptin concentrations and mode of early feeding.

Improving Documentation of Pediatric Height, Weight, and Body Mass Index by Primary Care Providers

The regular documentation of anthropometric data in an electronic medical record (EMR) is one tracking method used by primary care providers to follow the growth trajectory and development of children in their health care practices. EMR reminders have been proposed as a method to increase recording of pediatric height and weight by primary care providers, leading to potentially better detection and management of children classified as overweight or obese. The aim of this pre-post study was to improve a Family Health Team's physician documentation of pediatric height and weight through the implementation of an EMR reminder alert tool. The documentation rate for children 4-7 years old in the 6 months before intervention was 36% of children seen. After implementation of EMR reminder alerts, primary care physicians' documentation rate rose to 45% (9% increase; P < 0.01), but it was below the 15% target increase. Better documentation of pediatric height and weight by family physicians is needed to improve monitoring of children's growth trajectories. Additional strategies to increase documentation rates are needed.

Maternal Metabolomic Profile and Fetal Programming of Offspring Adiposity: Identification of Potentially Protective Lipid Metabolites

SCOPE

The fetal programming paradigm posits that the origins of obesity can be traced, in part, to the intrauterine period of life. However, the mechanisms underlying fetal programming are not well understood, and few studies have measured offspring adiposity in the neonatal period. The aim of this study is to identify maternal metabolites, and their determinants, that are associated with neonatal adiposity.

METHODS AND RESULTS

A targeted metabolomics approach is applied to analyze plasma samples collected across gestation from a well-characterized cohort of 253 pregnant women participating in a prospective study at the University of California, Irvine. Whole-body dual X-ray absorptiometry (DXA) imaging of body composition is obtained in N = 121 newborns. Statistical models are adjusted for potential confounders and multiple testing. The authors identify six alkyl-linked phosphatidylcholines (PCae), containing fatty acid 20:4, that are significantly and negatively associated with neonatal body fat percentage. Factors indicating higher socioeconomic status, non-Hispanic ethnicity, and higher nonesterified fatty acid percentages are positively associated with these PCae.

CONCLUSIONS

The polyunsaturated fatty acid 20:4 contained in PCae may exert a beneficial effect with respect to future propensity for obesity development. Prepregnancy and early pregnancy factors are determinants of these PCae, highlighting the importance of addressing preconceptional conditions for fetal programming of newborn adiposity.

The effectiveness of an online intervention in preventing excessive gestational weight gain: the e-moms roc randomized controlled trial

BACKGROUND

Excessive gestational weight gain (GWG) is common and contributes to the development of obesity in women and their offspring. Electronic or e-health interventions have the potential to reach large groups of women and prevent excessive GWG, but their effectiveness has not been demonstrated. The purpose of this study was to evaluate, in a real-world setting, the effectiveness of a self-directed, integrated online and mobile phone behavioral intervention in preventing excessive GWG.

METHODS

This effectiveness trial was a double-blind, three-arm trial with a parallel group design. Two arms received the same e-health intervention during pregnancy with the third arm serving as the placebo control. The intervention was based on a previously efficacious non-digital intervention that was adapted to electronic format. It included three behavior change tools: a weight gain tracker, and separate diet and physical activity goal-setting and self-monitoring tools. Both treatment conditions received access to informational tools, event reminders, and a blogging feature. Healthy pregnant women age 18-35 years with body mass indexes (BMI) ≥18.5 and < 35, at ≤20 weeks gestation, and an e-mail address were eligible. The proportion of women with excessive total GWG, as defined by the Institute of Medicine (IOM), was the primary outcome. 1689 randomized women were analyzed in the intent-to-treat (ITT) analysis. The study was designed to have 87% power to detect a 10 percentage point reduction from a control rate of 55% with a sample of 1641 (p = 0.0167, two-sided).

RESULTS

In the ITT sample, 48.1% (SD = 2.0%) gained excessively in the intervention group as did 46.2% (SD = 2.4%) in the placebo control group. These proportions were not significantly different (RR 1.09; 95% CI 0.98, 1.20, p = 0.12). The results were not altered in several sensitivity analyses.

CONCLUSION

The addition of three behavior change tools to an informational placebo control did not result in a difference in the proportion of women with excessive total GWG compared to the placebo control in this effectiveness trial of an online, self-directed intervention. The similarity of intervention and control treatments and low usage of the behavior change tools in the intervention group are possible explanations.

TRIAL REGISTRATION

NCT01331564 , ClinicalTrials.gov.

Offspring risk of obesity in childhood, adolescence and adulthood in relation to gestational diabetes mellitus: a sex-specific association

Background

Animal data suggest sexually dimorphic programming of obesity in response to altered intrauterine environment, but the longitudinal impact of gestational diabetes mellitus (GDM) on sex-specific risk of offspring obesity in humans is unclear.

Methods

We conducted a prospective analysis of 15 009 US individuals (7946 female and 7063 male) from the Growing-Up Today Study, who were followed from 1996 (ages 9-14 years) through 2010. Height and weight from validated questionnaires were used to derive body mass index (BMI) at different ages. Obesity during childhood (< 18 years) and adulthood (≥ 18 years) were defined using the International Obesity Task Force and the World Health Organization criteria. GDM exposure was identified through self-reported questionnaires from mothers. Relative risks were estimated using multivariable log-binomial regression models with generalized estimating equations accounting for clustering within the same family.

Results

Male offspring born from pregnancies complicated by GDM had higher BMI compared with non-GDM offspring and had increased risk of obesity; the adjusted relative risk [RR, 95% confidence interval (CI)] was 1.47 (1.11-1.95) for all age groups, 1.59 (1.05-2.41) for late childhood, 1.48 (1.06-2.06) for adolescence and 1.39 (1.00-1.94) for early adulthood. No significant association between obesity and maternal GDM was observed among female participants (RR = 0.97, 95% CI: 0.71-1.33).

Conclusions

The association of GDM with offspring obesity from late childhood through early adulthood may differ by sex; a significant association was observed among male but not female offspring.

The associations of large-for-gestational-age and infant feeding practices with children's body mass index z-score trajectories: the Early Childhood Longitudinal Study, Birth Cohort

Very few studies have examined if high birth weight and infant feeding practices have implications for the trajectory of body mass index (BMI) growth across the early childhood period. The goal of this study was to assess if large-for-gestational-age (LGA) and infant feeding practices (exclusive breastfeeding for 6 months, and early introduction of complementary food prior to 4 months) are associated with BMI z-score trajectories over the early childhood period. Group-based trajectory modelling (GBTM) methods were employed to describe and classify developmental BMI z-score trajectories (the outcome of interest) in children from 9 months to 4 years of age (n = 4497) born to prenatal non-smoking mothers in the Early Childhood Longitudinal Study, Birth Cohort (2001-2005). Further analyses examined if the identified BMI z-score trajectories varied systematically with the exposures, LGA and specific infant feeding practices, after accounting for sociodemographic and other early-life factors. Two BMI z-score trajectory groups were identified: normal BMI z-score (56.2%) and high BMI z-score (43.8%). Children who were LGA infants had 2.3 times (risk ratio 95% confidence interval: 1.2, 4.5) greater risk of being in high BMI z-score group relative to normal BMI z-score group. BMI z-score trajectory groups did not differ by infant feeding practices, after controlling for LGA at birth. Membership in the high BMI z-score group was associated with LGA, but not with infant feeding practices. Healthcare professionals should provide early obesity counselling to parents of LGA infants so that parents can take appropriate obesity prevention measures for their children.

Intergenerational diabetes and obesity-A cycle to break?

Ronald Ma and Barry Popkin discuss the urgent need and challenges to reduce intergenerational transmission of obesity and diabetes.

Postnatal Prevention of Childhood Obesity in Offspring Prenatally Exposed to Gestational Diabetes mellitus: Where Are We Now?

Children exposed to gestational diabetes mellitus (GDM) in utero are at high risk of developing many health problems such as obesity. There is an urgent need to find new strategies to prevent obesity development among high-risk populations such as those children. Accordingly, the aim of this review was to summarize current knowledge on the postnatal prevention of childhood obesity in offspring born from mothers with GDM. Specifically, this review addresses the impact of breastfeeding, complementary feeding practices as well as dietary intake and physical activity during childhood on obesity risk of children exposed to GDM in utero. Furthermore, breast milk composition of diabetic mothers and its potential impact on growth is discussed. According to the available literature, breastfeeding may reduce obesity risk in children exposed to GDM in utero but a longer duration seems necessary to achieve its protective effect against obesity. Detailed analysis of breast milk composition of mothers with GDM will be necessary to fully understand the relationship between breastfeeding and obesity in this specific population. This review highlights the need for more studies addressing the impact of complementary feeding practices and lifestyle habits during childhood on obesity risk of children exposed to GDM in utero.

Modifiable risk factors in the first 1000 days for subsequent risk of childhood overweight in an Asian cohort: significance of parental overweight status

BACKGROUND/OBJECTIVE

Many studies have identified early-life risk factors for subsequent childhood overweight/obesity, but few have evaluated how they combine to influence risk of childhood overweight/obesity. We examined associations, individually and in combination, of potentially modifiable risk factors in the first 1000 days after conception with childhood adiposity and risk of overweight/obesity in an Asian cohort.

METHODS

Six risk factors were examined: maternal pre-pregnancy overweight/obesity (body mass index (BMI) ⩾25 kg m^-2), paternal overweight/obesity at 24 months post delivery, maternal excessive gestational weight gain, raised maternal fasting glucose during pregnancy (⩾5.1 mmol l^-1), breastfeeding duration <4 months and early introduction of solid foods (<4 months). Associations between number of risk factors and adiposity measures (BMI, waist-to-height ratio (WHtR), sum of skinfolds (SSFs), fat mass index (FMI) and overweight/obesity) at 48 months were assessed using multivariable regression models.

RESULTS

Of 858 children followed up at 48 months, 172 (19%) had none, 274 (32%) had 1, 244 (29%) had 2, 126 (15%) had 3 and 42 (5%) had ⩾4 risk factors. Adjusting for confounders, significant graded positive associations were observed between number of risk factors and adiposity outcomes at 48 months. Compared with children with no risk factors, those with four or more risk factors had s.d. unit increases of 0.78 (95% confidence interval 0.41-1.15) for BMI, 0.79 (0.41-1.16) for WHtR, 0.46 (0.06-0.83) for SSF and 0.67 (0.07-1.27) for FMI. The adjusted relative risk of overweight/obesity in children with four or more risk factors was 11.1(2.5-49.1) compared with children with no risk factors. Children exposed to maternal pre-pregnancy (11.8(9.8-13.8)%) or paternal overweight status (10.6(9.6-11.6)%) had the largest individual predicted probability of child overweight/obesity.

CONCLUSIONS

Early-life risk factors added cumulatively to increase childhood adiposity and risk of overweight/obesity. Early-life and preconception intervention programmes may be more effective in preventing overweight/obesity if they concurrently address these multiple modifiable risk factors.

Tobacco Exposure and Conditional Weight-for-Length Gain by 2 Years of Age

Objective

To prospectively examine dose-response and timing effects of prenatal (PTE) and postnatal tobacco exposure on obesity risk assessed by conditional weight-for-length gain (CWFLG), by 2 years of age. CWFLG over the first 2 years of life was examined for 117 PTE and 57 nonexposed children. Repeated assessments of PTE were conducted beginning in the first trimester of pregnancy, using multiple methods. PTE or postnatal exposure status was not predictive of CWFLG. However, there was a dose-response association and an association with fetal exposure ascertained by infant meconium positive for nicotine and metabolites. PTE is related to restricted growth at birth, yet associated with accelerated CWFLG by 2 years of age, a measure that controls for birthweight differences. Results highlight the importance of examining dose-response and timing of exposure associations, along with the importance of obesity risk-reduction interventions within the first 2 years of life among PTE children.

The relation between birthweight, childhood body mass index, and overweight and obesity in late adolescence: a longitudinal cohort study from Norway, The Tromsø Study, Fit Futures

OBJECTIVES

Childhood overweight/obesity is associated with later overweight/obesity. However, the association between birth weight and later overweight/obesity has not been established. The aim of this study was to investigate the relation between both birth weight and childhood body mass index (BMI), and adolescent overweight/obesity in a Norwegian population.

METHODS

The Tromsø Study - Fit Futures is a population-based cohort study conducted in 2010-2011 and 2012-2013 in Tromsø, Norway. A representative sample of 961 adolescents participated. Longitudinal anthropometric data were obtained from the Medical Birth Registry of Norway, childhood health records at 2-4 and 5-7 years of age, and repeated measurements at 15-18 and 18-20 years of age. Outcome was defined as normal weight (adult BMI <25 kg/m2) or overweight/obese (adult BMI ≥2 5 kg/m2) at 15-20 years of age according to international age- and sex-specific cut-off values for children. Associations were investigated using generalised estimating equations.

RESULTS

In adjusted analyses, a 1-SD (586 g) higher birth weight was associated with a higher OR for overweight/obesity at 15-20 years of age (OR 1.25, 95% CI 1.06 to 1.48). Childhood BMI was also associated with overweight/obesity at 15-20 years of age: a 1-SD (1.35 kg/m2) increase in BMI at age 2-4 years rendered an OR of 1.66 (95% CI 1.40 to 1.96); a 1-SD (1.83 kg/m2) increase in BMI at age 5-7 years rendered an OR of 3.23 (95% CI 2.56 to 4.07). When compared with normal-weight children, those with severe overweight/obesity in childhood (adult BMI ≥27 kg/m2) showed stronger associations with overweight/obesity at 15-20 years of age: OR 3.01 (95% CI 1.47 to 6.18) and OR 11.51 (95% CI 6.63 to 19.99) at ages 2-4 and 5-7, respectively.

CONCLUSION

Associations between birth weight and overweight/obesity at 15-20 years of age were modest, whereas the influence of BMI at 2-4 and 5-7 years on overweight/obesity at 15-20 years was moderate to strong.

Two-year follow-up of a primary care-based intervention to prevent and manage childhood obesity: the High Five for Kids study

BACKGROUND

The obesity epidemic has spared no age group, even young infants. Most childhood obesity is incident by the age of 5 years, making prevention in preschool years a priority.

OBJECTIVE

To examine 2-year changes in age- and sex-specific BMI z-scores and obesity-related behaviours among 441 of the 475 originally recruited participants in High Five for Kids, a cluster randomized controlled trial in 10 paediatric practices.

METHODS

The intervention included a more intensive 1-year intervention period (four in-person visits and two phone calls) followed by a less intensive 1-year maintenance period (two in-person visits) among children who were overweight or obese and age 2-6 years at enrolment. The five intervention practices restructured care to manage these children including motivational interviewing and educational modules targeting television viewing and intakes of fast food and sugar-sweetened beverages.

RESULTS

After 2 years, compared with usual care, intervention participants had similar changes in BMI z-scores (-0.04 units; 95% CI -0.14, 0.06), television viewing (-0.20 h/d; -0.49 to 0.09) and intakes of fast food (-0.09 servings/week; -0.34 to 0.17) and sugar-sweetened beverages (-0.26 servings/day; -0.67 to 0.14).

CONCLUSION

High Five for Kids, a primarily clinical-based intervention, did not affect BMI z-scores or obesity-related behaviours after 2 years.

Developmental origins of type 2 diabetes: a perspective from China

There has been a marked increase in the prevalence of diabetes in Asia, including China, over the last few decades. While the increased prevalence of diabetes has often been attributed to the nutritional transition associated with recent economic development, emerging data suggest that early-life exposures also play a major role in shaping developmental trajectories, and contributes to alter an individual's susceptibility to diabetes and other non-communicable diseases (NCDs). Early-life exposures such as in utero exposure to undernutrition has been consistently linked with later risk of diabetes and obesity. Furthermore, in utero exposure to maternal hyperglycemia, maternal obesity and excess gestational weight gain are all linked with increased childhood obesity and later risk of diabetes. Emerging data have also highlighted the potential link between early-feeding practices, the role of one-carbon metabolism in metabolic programming and endocrine disrupting chemicals (EDCs) with later risk of diabetes. These different developmental exposures may all be highly relevant to the current epidemic of diabetes in China. For example, the prevalence of gestational diabetes has increased markedly over the last two decades, and may contribute to the diabetes epidemic by driving macrosomia, childhood obesity and later risk of diabetes. In order to address the current burden of diabetes, a lifecourse perspective, incorporating multisectoral efforts from public health policy down to the individuals, will be needed. Several major initiatives have been launched in China as part of its national plans for NCD prevention and treatment, and the experience from these efforts would be invaluable.

Parent and Clinician Perspectives on Sustained Behavior Change after a Prenatal Obesity Program: A Qualitative Study

BACKGROUND

Infants of obese women are at a high risk for development of obesity. Prenatal interventions targeting gestational weight gain among obese women have not demonstrated consistent benefits for infant growth trajectories.

METHODS

To better understand why such programs may not influence infant growth, qualitative semi-structured interviews were conducted with 19 mothers who participated in a prenatal nutrition intervention for women with BMI 30 kg/m2 or greater, and with 19 clinicians (13 pediatric, 6 obstetrical). Interviews were transcribed and coded with themes emerging inductively from the data, using a grounded theory approach.

RESULTS

Mothers were interviewed a mean of 18 months postpartum and reported successful postnatal maintenance of behaviors that were relevant to the family food environment (Theme 1). Ambivalence around the importance of postnatal behavior maintenance (Theme 2) and enhanced postnatal healthcare (Theme 3) emerged as explanations for the failure of prenatal interventions to influence child growth. Mothers acknowledged their importance as role models for their children's behavior, but they often believed that body habitus was beyond their control. Though mothers attributed prenatal behavior change, in part, to additional support during pregnancy, clinicians had hesitations about providing children of obese parents with additional services postnatally. Both mothers and clinicians perceived a lack of interest or concern about infant growth during pediatric visits (Theme 4).

CONCLUSIONS

Prenatal interventions may better influence childhood growth if paired with improved communication regarding long-term modifiable risks for children. The healthcare community should clarify a package of enhanced preventive services for children with increased risk of developing obesity.

Video-Based Grocery Shopping Intervention Effect on Purchasing Behaviors Among Latina Shoppers

OBJECTIVES

To compare changes in food-purchasing knowledge, self-efficacy, and behavior after viewing nutrition education videos among Los Angeles, California Latinas responsible for household grocery shopping.

METHODS

From February to May 2015, a convenience sample of 113 Latinas watched 1 video (El Carrito Saludable) featuring MyPlate guidelines applied to grocery shopping (1-video intervention) and another convenience sample of 105 Latinas watched 2 videos (El Carrito Saludable and Ser Consciente), the latter featuring mindfulness to support attention and overcome distractions while grocery shopping (2-video intervention). We administered questionnaires before and after intervention. A preselected sample in each intervention condition (n = 72) completed questionnaires at 2-months after intervention and provided grocery receipts (before and 2-months after intervention).

RESULTS

Knowledge improved in both intervention groups (P < .001). The 2-video group improved more in self-efficacy and use of a shopping list (both P < .05) and purchased more healthy foods (d = 0.60; P < .05) at 2 months than did the 1-video group.

CONCLUSIONS

Culturally tailored videos that model food-purchasing behavior and mindfulness show promise for improving the quality of foods that Latinas bring into the home.

Early rapid weight gain and subsequent overweight and obesity in middle childhood in Peru

Background

Rapid postnatal weight gain is associated with risk of overweight and obesity, but it’s unclear whether this holds in populations exposed to concurrent obesogenic risk factors and for children who have been extensively breastfed. This study investigates whether an increase in weight for age from birth to 1 year (infancy) and from 1 to 5 years (early childhood) predicts overweight and obesity, and waist circumference at 8 years, using data from a longitudinal cohort study in Peru.

Methods

Generalized estimating equations (GEE) models were constructed for overweight and obesity, obesity alone and waist circumference at 8 years versus rapid weight gain in infancy, and early childhood including adjusted models to account for confounders.

Results

Rapid weight gain in both periods was associated with double the risk of overweight and obesity, obesity alone at 8 years and increased waist circumference even after controlling for maternal BMI and education level, sex of child, height-for-age at 8 years, consumption of “fast food” and number of days of active exercise. The association was significant, with some differences, for children in both rural and urban environments.

Conclusions

Rapid weight gain in infancy and in early childhood in Peru is associated with overweight and obesity at age 8 years even when considering other determinants of childhood obesity.

Electronic supplementary material

The online version of this article (doi:10.1186/s40608-016-0135-z) contains supplementary material, which is available to authorized users.

The Impact of Timing of Introduction of Solids on Infant Body Mass Index

OBJECTIVES

To evaluate the associations between breastfeeding duration, age at solids introduction, and their interaction in relation to infant (age 9-15 months) above normal body mass index (BMI).

STUDY DESIGN

Cross-sectional, population-based study with 3153 infants from Melbourne (2007-2011). Above normal BMI (z score > 2, equivalent to >97.7th percentile) defined using the World Health Organization standard.

RESULTS

Both longer duration of full and any (full or partial) breastfeeding were associated with lower odds of above normal BMI (eg, aOR, 0.37 [95% CI, 0.22-0.60] for full breastfeeding 4-5 months versus 0-1 months). Compared with introduction of solids at 5-6 months, both early and delayed introduction were associated with increased odds of above normal BMI (aOR for 4 months, 1.75 [95% CI, 1.10-2.80] and for ≥7 months, 2.64 [95% CI, 1.26-5.54] versus 6 months). Such associations differ by breastfeeding status at 4 months (interaction P = .08). Early introduction of solids was associated with increased odds of above normal BMI in both infants fully or partially breastfed for ≥4 months (aOR, 3.66; 95% CI, 1.41-9.51) and those breastfed for <4 months (aOR, 3.11; 95% CI, 1.39-6.97). Introduction of solids at ≥7 months was associated with increased odds of above normal BMI (aOR, 5.79; 95% CI, 1.91-17.49) among infants breastfed for <4 months only.

CONCLUSION

Introduction of solids at 5-6 months, compared with either early or delayed introduction, is associated with decreased odds of above normal BMI at 1 year of age, regardless of infants' breastfeeding status at 4 months. These results may have implications for public health guidelines with regard to recommendations about the optimal timing of the introduction of solid foods in infancy.

Predictors of Obesity in a Cohort of Children Enrolled in WIC as Infants and Retained to 3 Years of Age

This longitudinal study of children enrolled as infants in the New York State (NYS) Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) examined predictors of obesity (body mass index ≥ 95th percentile) at 3 years of age. NYS WIC administrative data which included information from parent interviews and measured heights and weights for children were used. All 50,589 children enrolled as infants in WIC between July to December 2008 and July to December 2009 and retained in WIC through age three were included. At 3 years of age, 15.1% of children were obese. Multiple logistic regression analysis showed that children of mothers who received the Full Breastfeeding Food Package when their infant was enrolled in WIC (adjusted OR = 0.52) and children with ≤2 h screen time daily at age 3 (adjusted OR = 0.88) were significantly less likely to be obese (p < 0.001) controlling for race/ethnicity, birth weight, and birthplace. In this cohort of NYS WIC participants, maternal receipt of the Full Breastfeeding Food Package (a surrogate measure of exclusive breastfeeding) is associated with lower levels of obesity in their children at age 3. The relationships between participation in WIC, exclusive breastfeeding, and obesity prevention merit further study.

Can Fetal Limb Soft Tissue Measurements in the Third Trimester Predict Neonatal Adiposity?

OBJECTIVES

Neonatal adiposity is associated with chronic metabolic sequelae such as diabetes and obesity. Identifying fetuses at risk for excess neonatal body fat may lead to research aimed at limiting nutritional excess in the prenatal period. We sought to determine whether fetal arm and leg soft tissue measurements at 28 weeks' gestation were predictive of neonatal percent body fat METHODS : In this prospective observational cohort study of singleton term pregnancies, we performed sonography at 28 and 36 weeks' gestation, including soft tissue measurements of the fetal arm and thigh (fractional limb volume and cross-sectional area). We estimated the neonatal body composition (percent body fat) using anthropometric measurements and air displacement plethysmography. We estimated Spearman correlations between sonographic findings and percent body fat and performed modeling to predict neonatal percent body fat using maternal characteristics and sonographic findings.

RESULTS

Our analysis of 44 women yielded a mean maternal age of 30 years, body mass index of 26 kg/m(2), and birth weight of 3382 g. Mean neonatal percent body fat was 8.1% by skin folds at birth and 12.2% by air displacement plethysmography 2 weeks after birth. Fractional thigh volume measurements at 28 weeks yielded the most accurate model for predicting neonatal percent body fat (R(2) = 0.697; P = .001), outperforming models that used abdominal circumference (R(2)= 0.516) and estimated fetal weight (R(2)= 0.489).

CONCLUSIONS

Soft tissue measurements of the fetal thigh at 28 weeks correlated better with neonatal percent body fat than currently used sonographic measurements. After validation in a larger cohort, our models may be useful for prenatal intervention strategies aimed at the prevention of excess fetal fat accretion and, potentially, optimization of long-term metabolic health.

Longitudinal study of maternal body mass index, gestational weight gain, and offspring asthma

BACKGROUND

Sparse data are available on the relationship between prenatal exposures and asthma during later childhood. In a longitudinal study of adolescents and their mothers, we examined the association of (i) maternal prepregnancy body mass index (BMI) and (ii) gestational weight gain (GWG), with incidence of allergic and nonallergic asthma in offspring.

METHODS

Analyses were conducted using data from 12 963 children aged 9-14 years at enrolment in the Growing Up Today Study, and their mothers, who are participants in the Nurses' Health Study II. Physician-diagnosed asthma and allergies were assessed by questionnaires sent regularly to participants and their mothers. Logistic regression was used to evaluate associations of maternal BMI and GWG with offspring asthma, overall and by subtype.

RESULTS

Physician-diagnosed asthma during childhood or adolescence was reported by 2694 children (21%). Maternal prepregnancy overweight (OR: 1.19, 95% CI: 1.03-1.38) and obesity (1.34, 1.08-1.68) were associated with offspring asthma. In asthma subtype analyses, the association was seen only for asthma onset before age 12 years. Moreover, the association of maternal obesity with nonallergic asthma was observed in boys (2.39, 1.40-4.09) and not in girls (0.96, 0.50-1.85; Pinteraction = 0.03); the opposite pattern was suggested for allergic asthma. With regard to GWG, an association was suggested between gains of <15 lb and higher risk of offspring asthma (1.28, 0.98-1.66), without clear allergy- or sex-related patterns.

CONCLUSION

The relation of several prenatal factors to risk of childhood asthma supports the early origins hypothesis for asthma. The observed allergy- and sex-specific patterns suggest multiple etiologic pathways.

Nutrition in the First 1000 Days: The Origin of Childhood Obesity

Childhood obesity is a major global issue. Its incidence is constantly increasing, thereby offering a threatening public health perspective. The risk of developing the numerous chronic diseases associated with this condition from very early in life is significant. Although complex and multi-factorial, the pathophysiology of obesity recognizes essential roles of nutritional and metabolic aspects. Particularly, several risk factors identified as possible determinants of later-life obesity act within the first 1000 days of life (i.e., from conception to age 2 years). The purpose of this manuscript is to review those key mechanisms for which a role in predisposing children to obesity is supported by the most recent literature. Throughout the development of the human feeding environment, three different stages have been identified: (1) the prenatal period; (2) breast vs. formula feeding; and (3) complementary diet. A deep understanding of the specific nutritional challenges presented within each phase might foster the development of future preventive strategies.

Body-mass index and all-cause mortality: individual-participant-data meta-analysis of 239 prospective studies in four continents

BACKGROUND

Overweight and obesity are increasing worldwide. To help assess their relevance to mortality in different populations we conducted individual-participant data meta-analyses of prospective studies of body-mass index (BMI), limiting confounding and reverse causality by restricting analyses to never-smokers and excluding pre-existing disease and the first 5 years of follow-up.

METHODS

Of 10 625 411 participants in Asia, Australia and New Zealand, Europe, and North America from 239 prospective studies (median follow-up 13·7 years, IQR 11·4-14·7), 3 951 455 people in 189 studies were never-smokers without chronic diseases at recruitment who survived 5 years, of whom 385 879 died. The primary analyses are of these deaths, and study, age, and sex adjusted hazard ratios (HRs), relative to BMI 22·5-<25·0 kg/m(2).

FINDINGS

All-cause mortality was minimal at 20·0-25·0 kg/m(2) (HR 1·00, 95% CI 0·98-1·02 for BMI 20·0-<22·5 kg/m(2); 1·00, 0·99-1·01 for BMI 22·5-<25·0 kg/m(2)), and increased significantly both just below this range (1·13, 1·09-1·17 for BMI 18·5-<20·0 kg/m(2); 1·51, 1·43-1·59 for BMI 15·0-<18·5) and throughout the overweight range (1·07, 1·07-1·08 for BMI 25·0-<27·5 kg/m(2); 1·20, 1·18-1·22 for BMI 27·5-<30·0 kg/m(2)). The HR for obesity grade 1 (BMI 30·0-<35·0 kg/m(2)) was 1·45, 95% CI 1·41-1·48; the HR for obesity grade 2 (35·0-<40·0 kg/m(2)) was 1·94, 1·87-2·01; and the HR for obesity grade 3 (40·0-<60·0 kg/m(2)) was 2·76, 2·60-2·92. For BMI over 25·0 kg/m(2), mortality increased approximately log-linearly with BMI; the HR per 5 kg/m(2) units higher BMI was 1·39 (1·34-1·43) in Europe, 1·29 (1·26-1·32) in North America, 1·39 (1·34-1·44) in east Asia, and 1·31 (1·27-1·35) in Australia and New Zealand. This HR per 5 kg/m(2) units higher BMI (for BMI over 25 kg/m(2)) was greater in younger than older people (1·52, 95% CI 1·47-1·56, for BMI measured at 35-49 years vs 1·21, 1·17-1·25, for BMI measured at 70-89 years; pheterogeneity<0·0001), greater in men than women (1·51, 1·46-1·56, vs 1·30, 1·26-1·33; pheterogeneity<0·0001), but similar in studies with self-reported and measured BMI.

INTERPRETATION

The associations of both overweight and obesity with higher all-cause mortality were broadly consistent in four continents. This finding supports strategies to combat the entire spectrum of excess adiposity in many populations.

FUNDING

UK Medical Research Council, British Heart Foundation, National Institute for Health Research, US National Institutes of Health.

Three-year follow-up of a randomised controlled trial to reduce excessive weight gain in the first two years of life: protocol for the POI follow-up study

BACKGROUND

The Prevention of Overweight in Infancy (POI) study was a four-arm randomised controlled trial (RCT) in 802 families which assessed whether additional education and support on sleep (Sleep group); food, physical activity and breastfeeding (FAB group); or both (Combination group), reduced excessive weight gain from birth to 2 years of age, compared to usual care (Control group). The study had high uptake at recruitment (58 %) and retention at 2 years (86 %). Although the FAB intervention produced no significant effect on BMI or weight status at 2 years, the odds of obesity were halved in those who received the sleep intervention, despite no apparent effect on sleep duration. We speculate that enhanced self-regulatory behaviours may exist in the Sleep group. Self-regulation was not measured in our initial intervention, but extensive measures have been included in this follow-up study. Thus, the overall aim of the POI follow-up is to determine the extent to which augmented parental support and education on infant sleep, feeding, diet, and physical activity in the first 2 years of life reduces BMI at 3.5 and 5 years of age, and to determine the role of self-regulation in any such relationship.

METHODS/DESIGN

We will contact all 802 families and seek renewed consent to participate in the follow-up study. The families have received no POI intervention since the RCT finished at 2 years of age. Follow-up data collection will occur when the children are aged 3.5 and 5 years (i.e. up to 3 years post-intervention). Outcomes of interest include child anthropometry, body composition (DXA scan), diet (validated food frequency questionnaire), physical activity (accelerometry), sleep (questionnaire and accelerometry), and self-regulation (questionnaires and neuropsychological assessment).

DISCUSSION

Our follow-up study has been designed primarily to enable us to determine whether the intriguing benefit of the sleep intervention suggested at 2 years of age remains as children approach school age. However, cohort analyses will also investigate how BMI, self-regulation, and sleep consolidation develop during the early years. This information will be valuable to researchers and policy makers progressing the field of early childhood obesity prevention.

TRIAL REGISTRATION

ClinicalTrials.gov number NCT00892983 .

Exposure to Tobacco Metabolites via Breast Milk and Infant Weight Gain: A Population-Based Study

BACKGROUND

Although the immutable benefits of breastfeeding are well documented, information on the potential consequences of exposure to tobacco metabolites specifically via breastfeeding is sparse.

OBJECTIVE

The aim was to conduct the first study of the association between exposure to tobacco metabolites specifically through breastfeeding and infant weight gain.

METHODS

We used historical data from the US Collaborative Perinatal Project. Mothers were classified as nonsmokers, light smokers (1-19 cigarettes/day), and heavy (20+ cigarettes/day) smokers. In-hospital feeding type was observed during a nursery stay after delivery. We conducted stratified analyses among average-for-gestational-age (AGA; N = 23 571) and small-for-gestational-age (SGA; N = 2552) infants. We isolated the effect of exposure to tobacco metabolites specifically through breastfeeding.

RESULTS

Overall, maternal smoking was associated with change in weight-for-length z-score in a dose-response manner. Change in weight z-score was most pronounced among SGA infants of heavy smokers (breastfed: 0.53; 95% confidence interval [CI], 0.12-0.94; formula fed: 0.17; 95% CI, 0.03-0.30). Exposure to tobacco metabolites specifically through breastfeeding was not associated with additional weight gain among AGA infants. Among the much smaller sample of SGA infants, exposure specifically through breastfeeding was associated with marginally significant additional weight gain (0.46; 95% CI, 0.00-0.91) among infants of heavy smokers.

CONCLUSION

Our findings are in accord with recommendations by health agencies for smokers to breastfeed. However, SGA infants exposed to tobacco metabolites via breastfeeding by heavy smokers appear to gain weight more rapidly than other infants. Practical implications of our findings are discussed.

Parental Perceptions of Weight During the First Year of Life

BACKGROUND

More than half of parents underestimate their overweight child's weight; however, previous research focuses on children older than 2 years of age. The objective of this study was to assess whether parents of 2- to 12-month-old infants are able to accurately perceive their children's weight status.

METHODS

We performed a cross-sectional analysis of data collected from the Greenlight study, a cluster randomized obesity prevention trial, at 4 pediatric clinics serving diverse and low-income populations. Infants' length and weight were measured at well-child checks, and parents completed questionnaires including demographic characteristics and perception of their children's weight. Weight-for-length (WFL) percentile at the fifth to ≤95 was considered healthy weight and WFL percentile >95th was considered overweight. We used chi-squared tests to compare accuracy according to weight category and performed logistic regression analysis to assess accuracy at each time point.

RESULTS

Approximately 85% to 90% of infants (n = 853 at 2 months, n = 563 at 12 months) were at a healthy WFL at all measurement times, and parents of these infants were more likely to have an accurate perception of their child's weight (accuracy 89%-95%) than overweight children (accuracy 7%-26%; P < .001 across time points). Approximately 10% of healthy weight infants were perceived as underweight by their parents at all time points. At 12 months, mothers who were overweight were significantly more likely to underestimate their child's weight status (P = .008).

CONCLUSIONS

In our diverse and low-income sample, parents of overweight infants infrequently know that their infants are overweight. Future studies should examine how perception is related to feeding habits and weight status over time.

Adolescent education: an opportunity to create a Developmental Origins of Health and Disease (DOHaD) circuit breaker

Health before conception, and periconceptional nutritional environments, contribute to conditioning of later-life health and disease. Health behaviors developed during adolescence continue into adulthood. Thus, even when the gap between pregnancy and adolescence is substantial, behaviors developed during adolescence influence later-life non-communicable disease (NCD) vulnerability in offspring. Consequently, adolescence is an important life phase where development of positive health behaviors can contribute to disruption of transgenerational cycles of NCD risk. Schooling is a core activity during adolescence. Modern curricula focus on development of capabilities associated with critical, engaged citizenship, empowering learning that supports action-based engagement in complex issues. Contexts relevant to adolescents and their communities, such as the NCD epidemic, are used to facilitate learning. Thus, engaging the education sector as participants in the work of the Developmental Origins of Health and Disease community offers an important strategy to capture the potential of adolescence as a life stage for transgenerational primary prevention of obesity and NCD risk.

Greater early and mid-pregnancy gestational weight gains are associated with excess adiposity in mid-childhood

OBJECTIVE

It is unclear how specific periods of gestational weight gain (GWG) during pregnancy relate to childhood adiposity. The goal of this study was to assess the differential impact of GWG timing on childhood body composition.

METHODS

In 979 mother-child pairs from the pre-birth Project Viva cohort, trimester-specific GWG was calculated using clinically recorded weights. Outcomes included body mass index (BMI) z-score, dual X-ray absorptiometry fat mass index (kg/m(2) ), and fat-free mass index (kg/m(2) ) in mid-childhood. Linear regression models were used to assess associations of each trimester's GWG (per 0.2 kg/week) with childhood outcomes, adjusted for maternal prepregnancy BMI, sociodemographic variables, lifestyle, and GWG in prior trimester(s).

RESULTS

Mean (SD) first trimester GWG was 0.22 (0.22) kg/week, second trimester 0.49 (0.18) kg/week, and third trimester 0.47 (0.20) kg/week. Faster first trimester GWG was associated with higher BMI z-score (0.06 units [95% CI: 0.01-0.12] per 0.2 kg/week) and with higher adiposity according to all indices; associations were strongest in women with prepregnancy BMI >30 kg/m(2) . Faster second trimester GWG was associated with higher BMI z-score (0.11 [0.04-0.18]), fat mass (fat mass index = 0.16 [0.02-0.31] kg/m(2) ), and lean mass (fat-free mass index = 0.11 [0.01-0.22] kg/m(2) ). Third trimester GWG was not associated with childhood adiposity.

CONCLUSIONS

These results reinforce the importance of addressing appropriate GWG in early pregnancy.