Child behavioural problems and body size among 2-6 year old children predisposed to overweight. results from the "healthy start" study

Evidence for the protein leverage hypothesis in preschool children prone to obesity

BACKGROUND & AIMS

The protein leverage hypothesis (PLH) proposed that strict regulation of protein intake drives energy overconsumption and obesity when diets are diluted by fat and/or carbohydrates. Evidence about the PLH has been found in adults, while studies in children are limited. Thus, we aimed to test the PLH by assessing the role of dietary protein on macronutrients, energy intake, and obesity risk using data from preschool children followed for 1.3 years.

METHODS

553 preschool children aged 2-6 years from the 'Healthy Start' project were included.

EXPOSURES

The proportion of energy intake from protein, fat, and carbohydrates collected from a 4-day dietary record.

OUTCOMES

Energy intake, BMI z-score, fat mass (FM) %, waist- (WHtR) and hip-height ratio (HHtR). Power function analysis was used to test the leverage of protein on energy intake. Mixture models were used to explore interactive associations of macronutrient composition on all these outcomes, with results visualized as response surfaces on the nutritional geometry.

RESULTS

Evidence for the PLH was confirmed in preschool children. The distribution of protein intake (% of MJ, IQR: 3.2) varied substantially less than for carbohydrate (IQR: 5.7) or fat (IQR: 6.3) intakes, suggesting protein intake is most tightly regulated. Absolute energy intake varied inversely with dietary percentage energy from protein (L = -0.14, 95% CI: -0.25, -0.04). Compared to children with high fat or carbohydrate intakes, children with high dietary protein intake (>20% of MJ) had a greater decrease in WHtR and HHtR over the 1.3-year follow-up, offering evidence for the PLH in prospective analysis. But no association was observed between macronutrient distribution and changes in BMI z-score or FM%.

CONCLUSIONS

In this study in preschool children, protein intake was the most tightly regulated macronutrient, and energy intake was an inverse function of dietary protein concentration, indicating the evidence for protein leverage. Increases in WHtR and HHtR were principally associated with the dietary protein dilution, supporting the PLH. These findings highlight the importance of protein in children's diets, which seems to have significant implications for childhood obesity risk and overall health.

Associations between Child Mental Well-Being or Conflicts during Mealtime and Picky Eating Behaviour

Pickiness is an eating behavior that many families with young children face. Having joint family meals may impact the child’s pickiness, for instance by influencing their willingness to try novel foods. Moreover, picky children have been shown to display greater emotionality. The aim of this study was to investigate if children’s mental well-being and parent-reported conflicts during mealtime were associated with pickiness among obesity-prone children. Data was obtained from the baseline examination of the Healthy Start intervention study, the Danish Medical Birth registry and the Danish Health Visitor’s Child Health Database, and included 635 children aged 2–6 years that were all at high risk for becoming overweight later in life. Children’s mental well-being was measured by the strengths and difficulties questionnaire. Crude and adjusted ordinal logistic regressions were used to investigate the cross-sectional associations. Children had a higher odds associated with changing from a category of less pickiness to a category of more pickiness for each one point higher SDQ score (ORadj. = 1.35, 95% CI = 1.14; 1.61) and lower odds (ORadj. = 0.57, 95% CI = 0.38; 0.86) associated with changing pickiness category towards more pickiness for each one point higher SDQ prosocial score. Moreover, children with conflicts during mealtime had higher odds of being in a worse pickiness category compared to children without conflicts (ORadj. = 3.37, 95% CI = 2.27; 5.01). This study showed that among obesity-prone children, behavioral problems, as well as conflicts during mealtime, were associated with more picky behaviors. Further longitudinal studies are needed to confirm the findings, as are studies including general child population subsets.

Longitudinal association of nighttime sleep duration with emotional and behavioral problems in early childhood: results from the Danish Healthy Start Study

STUDY OBJECTIVES

To examine the longitudinal and bidirectional association between nighttime sleep duration and emotional and behavioral problems (EBPs) over 15 months among preschool children.

METHODS

Data of children aged 2 to 6 years from the control group of the Danish Healthy Start Study, a 15-month obesity prevention intervention, were used. Nighttime sleep duration was measured using a 7-day sleep record. EBPs were assessed by the Strengths and Difficulties Questionnaire Total Difficulties (SDQ-TD) score and Prosocial Behavior (SDQ-PSB) score. Multivariable regression models were conducted to examine the bidirectional associations between changes in nighttime sleep duration and SDQ scores.

RESULTS

With adjustment for child, family factors, and parental stress level, every hour extra nighttime sleep at baseline was associated with a 1.02 decrease in SDQ-TD score and 77% lower odds of having an abnormal SDQ-TD score (≥90th percentile) at the follow-up (p = 0.01). Children who increased their nighttime sleep duration over the 15-month demonstrated a similar concurrent reduction in SDQ-TD score (β = -1.28, p = 0.02) compared with those who decreased or had no change in nighttime sleep duration. After additional adjustment for sleep problem and habit variables, the significant associations remained. No associations were found between nighttime sleep duration and SDQ-PSB scores. Examination of SDQ scores as predictors of subsequent changes in nighttime sleep duration showed no significant associations.

CONCLUSIONS

Among preschool children, longer nighttime sleep duration was associated with a decline in EBPs, but not vice versa. Our study provides new longitudinal evidence to support sleep interventions to improve EBPs in early childhood.Clinical trials: The Healthy Start Study: https://clinicaltrials.gov/ct2/show/NCT01583335Trial registration: ID NCT01583335.

Associations between Parental Stress and Subsequent Changes in Dietary Intake and Quality among Preschool Children Susceptible to Obesity

BACKGROUND

Cross-sectional studies indicate that parental stress may be a barrier for healthy dietary behaviours among children. However, there is a lack of evidence from longitudinal studies on the association between parental stress and changes in dietary intake among toddlers. The aim of this study was to examine the association between parental stress and changes in dietary intake and quality among preschool children susceptible to obesity.

METHODS

In the Healthy Start study, parents to 250 preschool children had completed a modified version of the Parental Stress Index and assessed the dietary intake of their children at baseline and after 15 months of follow up. The association between parental stress and changes in dietary intake and quality was examined using multiple linear regression analyses with adjustment for potential confounders. We tested for potential effect modification by group allocation and sex.

RESULTS

There were no significant associations between parental stress and subsequent changes in child total energy intake, intake of macronutrients or intake of fruit, vegetables, sugar sweetened beverages, fish or starch, or dietary quality.

CONCLUSION

This study provides no evidence to support an association between parental stress and subsequent change in dietary intake and quality of their children.

TRIAL REGISTRATION

ClinicalTrials.gov, Trial number: NCT01583335, Registered: 31 March 2012, retrospectively registered.

Psychological health in preschool children with underweight, overweight or obesity: a regional cohort study

OBJECTIVE

To examine if underweight (UW), overweight (OW) or obesity (OB), or body mass index (BMI) expressed as its SD score (BMI SDS), were associated with psychological difficulties in preschool children.

DESIGN

Regional cohort study.

SETTING

Oppland County, Norway.

METHODS

At the routine school entry health assessment at 5-6 years of age, parents were invited to participate by local public health nurses. The parents completed questionnaires on sociodemographic, health and lifestyle factors of the child and the family, and on the child's neurocognitive development. They assessed psychological health with the Strengths and Difficulties Questionnaire (SDQ). Public health nurses measured weight and height on all eligible children and reported age, sex, height and weight anonymously for the children who declined to participate.

PARTICIPANTS

We obtained information on 1088 of 1895 (57%) eligible children. The proportion of UW, OW and OB was slightly higher among the children who declined.

MAIN OUTCOME MEASURES

SDQ subscale and Total Difficulties Scores.

RESULTS

The mean SDQ scores and proportion of scores ≥the 90th percentile had a curvilinear pattern from UW through normal weight (NW), OW and OB with NW as nadir, but the pattern was only significant for the mean Emotional problems, Peer problems and Total SDQ Scales, and for the Total SDQ Score ≥the 90th percentile (TDS90). After adjusting for relevant social, developmental, health and behavioural characteristics, TDS90 was only significantly associated with UW in multiple logistic regression analyses, and only with the lowest quartile of BMI SDS in a linear spline regression analysis.

CONCLUSIONS

The study suggests that UW and low BMI, but not OW, OB or higher BMI, are independent risk factors for having psychological symptoms in preschool children.

Child behaviour and subsequent changes in body weight, composition and shape

Objective

Studies have found an association between child behavioural problems and overweight, but the existing evidence for this relationship is inconsistent, and results from longitudinal studies are sparse. Thus, we examined the association between behavioural problems and subsequent changes in body mass index (BMI) and anthropometry over a follow-up period of 1.3 years among children aged 2–6 years.

Design

The study was based on a total of 345 children from The Healthy Start Study; all children were healthy weight but predisposed to develop overweight. The Danish version of the Strengths and Difficulties Questionnaire (SDQ), classified as SDQ Total Difficulties (SDQ-TD) and SDQ Prosocial Behaviour (SDQ-PSB), was used to assess child behaviour. Linear regression analyses were used to examine associations between SDQ scores and subsequent change in BMI z-score, body fat percentage, waist circumference and waist-hip ratio, while taking possible confounding factors into account.

Results

We found an association between SDQ-PSB and subsequent change in BMI z-score (β: 0.040 [95% CI: 0.010; 0.071, p = 0.009]). However, there was no evidence of an association between SDQ-PSB and measures of body composition or body shape.

Conclusions

Among 2 to 6 years old children predisposed to overweight, the association between SDQ-scores and weight gain is either absent or marginal. The SDQ-PSB score may be associated with subsequent increases in BMI z-score, but this association does not seem driven by an increased relative fat accumulation.

Association between hair cortisol concentration and dietary intake among normal weight preschool children predisposed to overweight and obesity

Background

The association between chronically elevated cortisol, as measured by hair cortisol concentration (HCC), and dietary intake among children has generally not been explored. Moreover, it is unknown whether there is an association between parental HCC and dietary intake among their children.

Objective

To examine associations between HCC and dietary intake among children, and to explore the association between parental HCC and dietary intake among their children.

Methods

We conducted a cross-sectional study based on 296 children predisposed to overweight and obesity who participated in the Healthy Start study. Multiple Linear regression analyses were conducted to assess the association between HCC and total energy intake, macronutrients, fruit and vegetables, added sugar, sugar-sweetened beverages (SSB), and a diet quality index (DQI).

Results

Among the children, we found that higher HCC was associated with a lower consumption of dietary fat (β: -0.7 g/day [95% CI: -1.3, -0.0] per 100 pg/mg HCC). We found no statistically significant association between HCC and intake of total energy, protein, carbohydrate, fruit and vegetables, added sugar, SSB or DQI. We found no association between parental HCC and intake of total energy, added sugar, selected food groups or DQI among their children. However, stratified analyses showed that paternal HCC was associated with a borderline significant lower total energy intake and significantly lower protein intake, but only among daughters (adjusted β: -42 kcal/day [95% CI: -85, 0] and -2.6 g/day [95% CI: -4.4, -0.8] per 100 pg/mg HCC, respectively).

Conclusion

Among children, chronic stress as measured by HCC may be associated with a lower fat consumption, and paternal HCC may be associated with a lower intake of energy and protein among their daughters. However, the associations observed were weak, and any clinical relevance of these findings remains questionable.

Risk and Protective Factors for Child Overweight/Obesity Among Low Socio-Economic Populations in Israel: A Cross Sectional Study

Background and Aims: Scientific evidence regarding protective factors that contribute to healthy weight in childhood is limited and is particularly scarce in lower socio-economic populations in different ethnic groups. This study aimed to assess the prevalence of biological, behavioral and psychosocial factors for child overweight/obesity in Jewish and Arab population groups in Israel, and to compare their associations with child overweight/obesity in the two groups. Methods: Children aged 5-6 years were randomly selected from 20 Mother and Child Health clinics in towns and villages of lowest socio-economic ranking in Northern Israel. Children and mothers were invited for a special "One Stop Shop-Preparation for School" visit which included growth measurements. Questionnaires were distributed to mothers for self-report on biological, SES, psychological and lifestyle factors. Perinatal and early nutritional data were retrieved from clinic records. Multivariate analyses using logistic regression models predicting child overweight/obesity were conducted separately for Jewish (N = 371) and Arab (N = 575) children. Results: Overweight/obesity (BMI ≥85th centile) rates were higher in Jewish (25%) than Arab (19%) children. In both Jewish and Arab groups, respectively, maternal BMI (OR = 1.10 [95%CI = 1.04, 1.17]; OR = 1.08 [95%CI = 1.04, 1.13]), and child birthweight (OR = 1.33 [95%CI = 1.04, 1.71]; OR = 1.39 [95%CI = 1.11, 1.73]) were significant risk factors for overweight/obesity, and maternal self-efficacy regarding child's lifestyle was significantly protective (OR = 0.49 [95%CI = 0.28, 0.85]; OR = 0.54 [95%CI = 0.34, 0.85]). Additionally, four other maternal psychological and child behaviors were significantly associated with overweight/obesity in the Jewish group and two child lifestyle behavior factors in the Arab group. Moreover, significant interactions indicating moderation effects were found only in the Jewish group: maternal education and maternal age moderated the effect of maternal BMI on child overweight/obesity. No other moderation of risk factors was found. Discussion: In this study of children from low SES families, protective factors contributed to healthy child weight alongside risk factors for overweight/obesity. They differed between the population groups, and fewer variables explained overweight/obesity in Arab children. Although further expansion of these findings is required they point at the relevance of protective factors, maternal self-efficacy in particular, for understanding childhood obesity in specific ethnic contexts and for planning culturally adapted prevention programs in disadvantaged populations.

Association between Hair Cortisol Concentration and Adiposity Measures among Children and Parents from the "Healthy Start" Study

Background

Previous studies have suggested a direct association between hair cortisol concentration (HCC) and Body Mass Index (BMI), as well as other adiposity measures. However, these studies have mostly been conducted among adult populations.

Objective

To examine the association between HCC and different measures of adiposity among a selected group of children predisposed to obesity and their parents.

Methods

We conducted a cross-sectional study based on 363 children and their parents (301 mothers and 231 fathers) participating in the “Healthy Start” study. Linear regression analysis was used to investigate associations between HCC and adiposity measures while taking into account possible confounding factors. Analyses were performed examining the association between HCC and BMI, fat mass and fat free mass index Z-scores, as well as waist circumference and waist-hip ratio among the children. Likewise, the association between HCC and BMI among the parents was explored. Finally, we examined the association between parental HCC and children’s adiposity measures.

Results

HCC was directly associated with a higher BMI among the fathers (0.49 kg/m² [95% CI: 0.09, 0.90, P = 0.02] per 100 pg/mg) and the mothers (0.93 kg/m² [95% CI: 0.24, 1.61, P = 0.01] per 100 pg/mg). We found no clear evidence of an association between HCC and adiposity measures among children. However, a high maternal HCC was associated with a high fat mass index and low fat free mass index z-score in the offspring (0.14 SD [95% CI: 0.02, 0.26, P = 0.02] and -0.17 SD [95% CI: -0.30, -0.05, P = 0.01] per 100 pg/mg, respectively).

Conclusions

Our study found no evidence of an association between HCC and measures of adiposity among children predisposed to obesity. However, HCC may be directly associated with BMI among men and women, and maternal HCC may be related to a higher fat mass and a lower fat free mass among their children.

The relationship between weight status and emotional and behavioral problems in Spanish preschool children

OBJECTIVE

To examine cross-sectional and longitudinal associations between behavioral problems and weight status, considering body mass index (BMI) z-scores and overweight status, in a community sample of preschoolers.

METHODS

The Strengths and Difficulties Questionnaire and the Diagnostic Interview for Children and Adolescents were administered to 611 parents. Adjusted general linear models and binary logistic regressions were used.

RESULTS

Children who were overweight and had a higher BMI were at increased risk of peer problems and attention-deficit/hyperactivity disorder (ADHD) symptoms. Prospective analyses showed that a higher BMI at the age of 3 years was predictive of peer problems at ages 4 and 5 years and hyperactivity and ADHD symptoms at the age of 4 years.

CONCLUSION

This is the first study using a diagnostic-based instrument that shows a relationship between weight status and ADHD symptoms in preschoolers. Overweight children might benefit from screening for behavioral disorders and peer relationship problems.