Lifecourse approach to racial/ethnic disparities in childhood obesity

Maternal infant feeding behaviors and disparities in early child obesity

BACKGROUND

Although disparities in child obesity exist during infancy, the underlying mechanisms are unclear. Assessing dissimilarities in feeding practices, styles, and beliefs may provide a better understanding of these mechanisms. This study sought to identify modifiable maternal-infant feeding behaviors that may contribute to disparities in early child obesity.

METHODS

This study is a cross-sectional analysis comparing mothers with infants (2 weeks to 6 months old) in a low-risk group of high-income white mothers to a high-risk group of low-income Hispanic mothers. Regression analysis was used to explore relationships between each group and (1) infant feeding practices, including breastfeeding, giving juice, and adding cereal to bottles, (2) controlling feeding styles, (3) beliefs about infant hunger and satiety, and (4) infant weight status.

RESULTS

The sample included 412 mothers (low-risk group, n = 208; high-risk group, n = 204). The high-risk group was less likely to exclusively breastfeed (adjusted odds ratio [AOR], 0.43; 95% confidence interval [CI], 0.22-0.83), more likely to introduce juice (AOR, 12.25; 95% CI, 3.44-43.62), and add cereal to the bottle (AOR, 10.61; 95% CI, 2.74-41.0). The high-risk group exhibited greater restrictive and pressuring feeding styles and was more likely to believe that mothers can recognize infant hunger and satiety and less likely to believe that infants know their own hunger and satiety. High-risk infants were more likely to have a weight-for-length percentile >85th percentile (AOR, 2.66; 95% CI, 1.10-6.45).

CONCLUSIONS

Differences in infant feeding behaviors may contribute to disparities in early child obesity. Longitudinal studies are needed to determine the effect of these differences on child obesity.

Racial and ethnic differences associated with feeding- and activity-related behaviors in infants

OBJECTIVE

To examine parental reports of feeding and activity behaviors in a cohort of parents of 2-month-olds and how they differ by race/ethnicity.

METHODS

Parents participating in Greenlight, a cluster, randomized trial of obesity prevention at 4 health centers, were queried at enrollment about feeding and activity behaviors thought to increase obesity risk. Unadjusted associations between race/ethnicity and the outcomes of interest were performed by using Pearson χ(2) and Kruskal-Wallis tests. Adjusted analyses were performed by using proportional odds logistic regressions.

RESULTS

Eight hundred sixty-three parents (50% Hispanic, 27% black, 18% white; 86% Medicaid) were enrolled. Exclusive formula feeding was more than twice as common (45%) as exclusive breastfeeding (19%); 12% had already introduced solid food; 43% put infants to bed with bottles; 23% propped bottles; 20% always fed when the infant cried; 38% always tried to get children to finish milk; 90% were exposed to television (mean, 346 minutes/day); 50% reported active television watching (mean, 25 minutes/day); and 66% did not meet "tummy time" recommendations. Compared with white parents, black parents were more likely to put children to bed with a bottle (adjusted odds ratio [aOR] = 1.97, P < .004; bottle propping, aOR = 3.1, P < .001), and report more television watching (aOR = 1.6, P = .034). Hispanic parents were more likely than white parents to encourage children to finish feeding (aOR = 1.9, P = .007), bottle propping (aOR = 2.5, P = .009), and report less tummy time (aOR = 0.6, P = .037).

CONCLUSIONS

Behaviors thought to relate to later obesity were highly prevalent in this large, diverse sample and varied by race/ethnicity, suggesting the importance of early and culturally-adapted interventions.

Pregnancy and post-delivery maternal weight changes and overweight in preschool children

OBJECTIVES

High maternal weight before and during pregnancy contributes to child obesity. To assess the additional role of weight change after delivery, we examined associations between pre- and post-pregnancy weight changes and preschooler overweight.

METHODS

SAMPLE

4359 children from the Children and Young Adults of the 1979 National Longitudinal Survey of Youth (NLSY) born to 2816 NLSY mothers between 1979 and 2006 and followed to age 4-5years old.

EXPOSURES

gestational weight gain (GWG) and post-delivery maternal weight change (PDWC).

OUTCOME

child overweight (body mass index (BMI) ≥85th percentile).

RESULTS

Adjusted models suggested that both increased GWG (OR: 1.08 per 5kg GWG, 95% CI: 1.01, 1.16) and excessive GWG (OR: 1.29 versus adequate GWG, 95% CI: 1.06, 1.56) were associated with preschooler overweight. Maternal weight change after delivery was also independently associated with child overweight (OR: 1.12 per 5kg PDWC, 95% CI: 1.04, 1.21). Associations were stronger among children with overweight or obese mothers.

CONCLUSIONS

Increased maternal weight gain both during and after pregnancy predicted overweight in preschool children. Our results suggest that healthy post-pregnancy weight may join normal pre-pregnancy BMI and adequate GWG as a potentially modifiable risk factor for child overweight.

Body size in early life and breast cancer risk in African American and European American women

PURPOSE

There is growing evidence that body size in early life influences lifetime breast cancer risk, but little is known for African American (AA) women.

METHODS

We evaluated body size during childhood and young adulthood and breast cancer risk among 1,751 cases [979 AA and 772 European American (EA)] and 1,673 controls (958 AA and 715 EA) in the Women's Circle of Health Study. Odds ratio (OR) and 95 % confidence intervals (CI) were computed using logistic regression models while adjusting for potential covariates.

RESULTS

Among AA women, being shorter at 7-8 years compared to peers was associated with increased postmenopausal breast cancer risk (OR 1.68, 95 % CI 1.02-2.74), and being heavier at menarche with decreased postmenopausal breast cancer risk, although of borderline significance (OR 0.45, 95 % CI 0.20-1.02). For EA women, being shorter from childhood through adolescence, particularly at menarche, was associated with reduced premenopausal breast cancer risk (OR 0.55, 95 % CI 0.31-0.98). After excluding hormone replacement therapy users, an inverse association with postmenopausal breast cancer was found among EA women reporting to be heavier than their peers at menarche (OR 0.18, 95 % CI 0.04-0.79). The inverse relationship between BMI at age 20 and breast cancer risk was stronger and only statistically significant in EA women. No clear association with weight gain since age 20 was found.

CONCLUSIONS

Findings suggest that the impact of childhood height on breast cancer risk may differ for EA and AA women and confirm the inverse association previously reported in EA populations with adolescent body fatness, in AA women.

Reducing racial/ethnic disparities in childhood obesity: the role of early life risk factors

IMPORTANCE 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. OBJECTIVE To examine the extent to which racial/ethnic disparities in adiposity and overweight are explained by differences in risk factors during pregnancy (gestational diabetes and depression), infancy (rapid infant weight gain, feeding other than exclusive breastfeeding, and early introduction of solid foods), and early childhood (sleeping <12 h/d, presence of a television set in the room where the child sleeps, and any intake of sugar-sweetened beverages or fast food). DESIGN Prospective prebirth cohort study. SETTING Multisite group practice in Massachusetts. PARTICIPANTS Participants included 1116 mother-child pairs (63% white, 17% black, and 4% Hispanic) EXPOSURE Mother's report of child's race/ethnicity. MAIN OUTCOMES AND MEASURES Age- and sex-specific body mass index (BMI) z score, total fat mass index from dual-energy x-ray absorptiometry, and overweight or obesity, defined as a BMI in the 85th percentile or higher at age 7 years. RESULTS Black (0.48 U [95% CI, 0.31 to 0.64]) and Hispanic (0.43 [0.12 to 0.74]) children had higher BMI z scores, as well as higher total fat mass index and overweight/obesity prevalence, than white children. After adjustment for socioeconomic confounders and parental BMI, differences in BMI z score were attenuated for black and Hispanic children (0.22 U [0.05 to 0.40] and 0.22 U [-0.08 to 0.52], respectively). 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 scores between whites, blacks (0.07 U [-0.11 to 0.26]), and Hispanics (0.04 U [-0.27 to 0.35]). We observed similar attenuation of racial/ethnic differences in adiposity and prevalence of overweight or obesity. 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.

Bariatric surgery for obese children and adolescents: a review of the moral challenges

BACKGROUND

Bariatric surgery for children and adolescents is becoming widespread. However, the evidence is still scarce and of poor quality, and many of the patients are too young to consent. This poses a series of moral challenges, which have to be addressed both when considering bariatric surgery introduced as a health care service and when deciding for treatment for young individuals. A question based (Socratic) approach is applied to reveal underlying moral issues that can be relevant to an open and transparent decision making process.

DISCUSSION

A wide range of moral issues with bariatric surgery for children and adolescents is identified in the literature. There is a moral imperative to help obese minors avoiding serious health problems, but there is little high quality evidence on safety, outcomes, and cost-effectiveness for bariatric surgery in this group. Lack of maturity and family relations poses a series of challenges with autonomy, informed consent, assent, and assessing the best interest of children and adolescents. Social aspects of obesity, such as medicalization, prejudice, and discrimination, raise problems with justice and trust in health professionals. Conceptual issues, such as definition of obesity and treatment end-points, present moral problems. Hidden interests of patients, parents, professionals, industry, and society need to be revealed.

SUMMARY

Performing bariatric surgery for obese children and adolescents in order to discipline their behavior warrants reflection and caution. More evidence on outcomes is needed to be able to balance benefits and risks, to provide information for a valid consent or assent, and to advise minors and parents.

Healthy Habits, Happy Homes: methods and baseline data of a randomized controlled trial to improve household routines for obesity prevention

OBJECTIVE

To develop a home-based intervention for parents of 2-5 year old children to promote household routines to prevent overweight/obesity.

METHODS

We recruited 121 children from health centers in Boston between 2011 and 2012 and randomized 62 to intervention and 59 to the control condition. The 6-month intervention included 1) motivational coaching at home and by phone with a health educator, 2) mailed educational materials, and 3) weekly text messages. The intervention promoted three household routines: eating meals as a family, obtaining adequate sleep, and limiting screen time.

RESULTS

Of the 121 children, mean (SD) age was 4.0 (1.1) years; 52% were Hispanic, 34% Black, and 14% White/Other. Nearly 60% of the sample had annual household incomes ≤ $20,000. Approximately 64% of families reported eating together ≥ 7 times per week, however, many meals were eaten in front of a TV. Over half of the children slept less than the recommended 11h/night and 78% viewed ≥ 2 h/day of screen time.

CONCLUSIONS

Household routines that increase obesity risk were prevalent among low-income families in this study. If proven to be effective, promotion of household routines related to family meals, sleep, and screen time may prevent young children from becoming overweight/obese.