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Ruggiero CF, Trexberg KM, Moore AM, Savage JS. Applying the Family Stress Model to responsive feeding and early obesity prevention. Appetite 2024; 200:107515. [PMID: 38797237 PMCID: PMC11227407 DOI: 10.1016/j.appet.2024.107515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Revised: 05/13/2024] [Accepted: 05/23/2024] [Indexed: 05/29/2024]
Abstract
Rapid weight gain during infancy and obesity during early childhood may lead to adverse health outcomes during later childhood and into adulthood, especially in families experiencing economic hardship. Families experiencing economic hardship may also experience food insecurity, which can impact child development and responsive feeding, an important target for obesity prevention in early life. The Family Stress Model suggests that stress, particularly economic hardship, can negatively impact parents' mental health, parenting, and quality of family relationships. This review proposes a conceptual model that expands upon the original Family Stress Model by including parent-child dyadic interactions during feeding (i.e., responsive feeding) as well as the coparenting relationship around feeding. Our conceptual model integrates responsive feeding into the Family Stress Model and includes the impact of food insecurity on feeding and child health outcomes. Such models that consider multiple influences on child development have implications for the design of effective interventions to promote healthy growth for entire families. Future directions in this research will empirically test the model and explore early intervention strategies that aim to promote responsive feeding, nutrition security, and health within families. Continuing interdisciplinary research between the fields of nutrition and family development will be key to addressing the complex interplay of family stressors, parent responsiveness, and childhood obesity.
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Affiliation(s)
- Cara F Ruggiero
- Center for Childhood Obesity Research, The Pennsylvania State University, 129 Noll Laboratory, University Park, PA, 16802, USA; Department of Nutritional Sciences, The Pennsylvania State University, 110 Chandlee Laboratory, University Park, PA, 16802, USA
| | - Kaitlin M Trexberg
- Department of Human Development and Family Studies, The Pennsylvania State University, 119 Health and Human Development Building, University Park, PA, 16802, USA.
| | - Amy M Moore
- Center for Childhood Obesity Research, The Pennsylvania State University, 129 Noll Laboratory, University Park, PA, 16802, USA.
| | - Jennifer S Savage
- Center for Childhood Obesity Research, The Pennsylvania State University, 129 Noll Laboratory, University Park, PA, 16802, USA; Department of Nutritional Sciences, The Pennsylvania State University, 110 Chandlee Laboratory, University Park, PA, 16802, USA.
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2
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Myers KP, Temple JL. Translational science approaches for food insecurity research. Appetite 2024; 200:107513. [PMID: 38795946 PMCID: PMC11227396 DOI: 10.1016/j.appet.2024.107513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Revised: 05/20/2024] [Accepted: 05/22/2024] [Indexed: 05/28/2024]
Abstract
Food insecurity is a pervasive problem that impacts health and well-being across the lifespan. The human research linking food insecurity to poor metabolic and behavioral health outcomes is inherently correlational and suffers from a high degree of variability both between households and even within the same household over time. Further, food insecurity is impacted by societal and political factors that are largely out of the control of individuals, which narrows the range of intervention strategies. Animal models of food insecurity are being developed to address some of the barriers to mechanistic research. However, animal models are limited in their ability to consider some of the more complex societal elements of the human condition. We believe that understanding the role that food insecurity plays in ingestive behavior and chronic disease requires a truly translational approach, and that understanding the health impacts of this complex social phenomenon requires understanding both its psychological and physiological dimensions. This brief review will outline some key features of food insecurity, highlighting those that are amenable to investigation with controlled animal models and identifying areas where integrating animal and human studies can improve our understanding of the psychological burden and health impacts of food insecurity. In the interest of brevity, this review will largely focus on food insecurity in the United States, as the factors that contribute to food insecurity vary considerably across the globe.
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Affiliation(s)
- Kevin P Myers
- Department of Psychology, Animal Behavior & Neuroscience Programs, Bucknell University, Lewisburg, PA, USA.
| | - Jennifer L Temple
- Departments of Exercise and Nutrition Sciences, Community Health and Health Behavior, School of Public Health and Health Professions, University at Buffalo, Buffalo, NY, USA
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3
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Ferreira F, Tavares M, Barros R, Dias CC, Morais R, Ortigão M, Padrão P, Rodrigues M, Moreira P. Food Insecurity and Nutritional Inadequacy in Children and Adolescents of Basic Education Schools of Cantagalo District in São Tomé and Príncipe, Central Africa. Nutrients 2024; 16:2802. [PMID: 39203938 PMCID: PMC11357393 DOI: 10.3390/nu16162802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2024] [Revised: 08/14/2024] [Accepted: 08/15/2024] [Indexed: 09/03/2024] Open
Abstract
Food insecurity (FI) is a critical socioeconomic and public health problem globally, particularly affecting children's nutritional status and development. This cross-sectional study aimed to assess the prevalence of nutritional inadequacy among children and adolescents in the Cantagalo district of São Tomé and Príncipe (STP), in Central Africa. It also assessed their households' FI situation and examined sociodemographic, anthropometric, and nutritional characteristics associated with severe FI. Data included 546 children/adolescents (51.8% males, aged 9-15 years) from the eight public basic education schools. A structured questionnaire provided sociodemographic data, while anthropometric measurements assessed nutritional status. Dietary intake data were gathered using a single 24 h dietary recall, and the adjusted prevalences of nutritional inadequacy were obtained using version 2.0 of the PC-Software for Intake Distribution Estimation (PC-SIDE®). The Household Food Insecurity Access Scale was used to assess FI, and households were classified as severely or non-severely food insecure. Multivariable binary logistic regression models adjusted for potential confounders identified factors related to FI. Children's/adolescents' thinness was exhibited in 34.1% of participants, and over 95% had inadequate intake of essential micronutrients, including iron. Notably, 73.7% were severely food insecure. A higher severity of FI was positively associated with a lower intake of iron and certain household head characteristics, such as being female or older, and negatively associated with having a home garden.
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Affiliation(s)
- Francisca Ferreira
- Faculty of Nutrition and Food Sciences, University of Porto, 4150-180 Porto, Portugal; (F.F.); (R.B.); (R.M.); (P.P.)
| | - Maria Tavares
- Helpo-Non-Governmental Development Organization, 2750-318 Cascais, Portugal; (M.T.); (M.O.)
| | - Renata Barros
- Faculty of Nutrition and Food Sciences, University of Porto, 4150-180 Porto, Portugal; (F.F.); (R.B.); (R.M.); (P.P.)
- Epidemiology Research Unit, Laboratory for Integrative and Translational Research in Population Health, Institute of Public Health, University of Porto, 4050-600 Porto, Portugal;
| | - Cláudia Camila Dias
- CINTESIS@RISE, Department of Community Medicine, Information and Health Decision Sciences (MEDCIDS), Faculty of Medicine, University of Porto (FMUP), 4200-450 Porto, Portugal;
- Knowledge Management Unit, Faculty of Medicine, University of Porto (FMUP), 4200-319 Porto, Portugal
| | - Rita Morais
- Faculty of Nutrition and Food Sciences, University of Porto, 4150-180 Porto, Portugal; (F.F.); (R.B.); (R.M.); (P.P.)
| | - Madalena Ortigão
- Helpo-Non-Governmental Development Organization, 2750-318 Cascais, Portugal; (M.T.); (M.O.)
| | - Patrícia Padrão
- Faculty of Nutrition and Food Sciences, University of Porto, 4150-180 Porto, Portugal; (F.F.); (R.B.); (R.M.); (P.P.)
- Epidemiology Research Unit, Laboratory for Integrative and Translational Research in Population Health, Institute of Public Health, University of Porto, 4050-600 Porto, Portugal;
| | - Mónica Rodrigues
- Epidemiology Research Unit, Laboratory for Integrative and Translational Research in Population Health, Institute of Public Health, University of Porto, 4050-600 Porto, Portugal;
| | - Pedro Moreira
- Faculty of Nutrition and Food Sciences, University of Porto, 4150-180 Porto, Portugal; (F.F.); (R.B.); (R.M.); (P.P.)
- Epidemiology Research Unit, Laboratory for Integrative and Translational Research in Population Health, Institute of Public Health, University of Porto, 4050-600 Porto, Portugal;
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Bodepudi S, Hinds M, Northam K, Reilly-Harrington NA, Stanford FC. Barriers to Care for Pediatric Patients with Obesity. Life (Basel) 2024; 14:884. [PMID: 39063637 PMCID: PMC11277597 DOI: 10.3390/life14070884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2024] [Revised: 06/21/2024] [Accepted: 07/10/2024] [Indexed: 07/28/2024] Open
Abstract
This review article emphasizes the challenges pediatric patients face during obesity treatment. Prior research has been compartmentalized, acknowledging that stigma, the ability to implement lifestyle changes, social health determinants, and healthcare accessibility are considerable impediments for obese children. These issues emerge at various levels, including the individual or family, the community and school, and even national policy. This suggests the need for a more comprehensive, team-based approach to tackle pediatric obesity. Understanding these barriers is the first step toward creating effective strategies and solutions to overcome these challenges.
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Affiliation(s)
- Sreevidya Bodepudi
- MGH Weight Center, Massachusetts General Hospital, Boston, MA 02114, USA; (K.N.); (N.A.R.-H.)
- Harvard Medical School, Boston, MA 02115, USA
| | | | - Kayla Northam
- MGH Weight Center, Massachusetts General Hospital, Boston, MA 02114, USA; (K.N.); (N.A.R.-H.)
| | - Noreen A. Reilly-Harrington
- MGH Weight Center, Massachusetts General Hospital, Boston, MA 02114, USA; (K.N.); (N.A.R.-H.)
- Harvard Medical School, Boston, MA 02115, USA
| | - Fatima Cody Stanford
- Harvard Medical School, Boston, MA 02115, USA
- MGH Weight Center, Massachusetts General Hospital, Department of Medicine-Division of Endocrinology-Neuroendocrine, Department of Pediatrics-Division of Endocrinology, Nutrition Obesity Research Center at Harvard (NORCH), Boston, MA 02114, USA
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Armstrong SC. Pediatric obesity is a complex disease. It is time we start reimbursing for care. Pediatr Res 2024; 96:7-9. [PMID: 38844542 DOI: 10.1038/s41390-024-03201-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Accepted: 03/25/2024] [Indexed: 07/20/2024]
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Teli R, Messito MJ, Kim CN, Duh-Leong C, Katzow M, Gross R. Prolonged Early Food Insecurity and Child Feeding Practices among a Low-Income Hispanic Population: Role of Parenting Stress. Acad Pediatr 2024:S1876-2859(24)00236-5. [PMID: 38945524 DOI: 10.1016/j.acap.2024.06.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Revised: 06/17/2024] [Accepted: 06/23/2024] [Indexed: 07/02/2024]
Abstract
OBJECTIVE To examine associations between prolonged early household food insecurity (FI) during pregnancy, infancy, and toddlerhood, and child feeding practices, and the mediating role of dysfunctional parent-child interactions. METHODS We conducted secondary longitudinal analyses of data from the Starting Early Program (StEP) randomized controlled trial, which studied a primary care-based child obesity prevention program for low-income Hispanic families. Our independent variable was FI, using the USDA Food Security Module, during the third trimester of pregnancy and at child ages 10- and 19-months. Frequency of reported FI was defined by the number of periods with FI (0, 1, 2, or 3). Our dependent variables were feeding practices at child age 28-months using the Comprehensive Feeding Practices Questionnaire. Our mediating variable was dysfunctional parent-child interactions using the Parenting Stress Index subscale at age 19-months. We used linear regression to determine associations between frequency of reported FI and feeding practices adjusting for covariates, and mediation analyses to determine if dysfunctional parent-child interactions mediate these associations. RESULTS Three hundred and forty four mothers completed assessments at child age 28-months. Of the 12 feeding practices examined, higher frequency of reported FI was positively associated with using food as a reward, restriction of food for weight control, and using food for emotional regulation, and was negatively associated with monitoring of less healthy foods. There was a significant indirect effect of frequency of reported FI on these practices through dysfunctional parent-child interactions. CONCLUSION Higher frequency of reported FI was associated with four feeding practices, through dysfunctional parent-child interactions. Understanding these pathways can inform preventive interventions.
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Affiliation(s)
- Radhika Teli
- Department of Pediatrics (R Teli, MJ Messito, CN Kim, C Duh-Leong and R Gross), New York University Grossman School of Medicine, New York, NY.
| | - Mary Jo Messito
- Department of Pediatrics (R Teli, MJ Messito, CN Kim, C Duh-Leong and R Gross), New York University Grossman School of Medicine, New York, NY
| | - Christina N Kim
- Department of Pediatrics (R Teli, MJ Messito, CN Kim, C Duh-Leong and R Gross), New York University Grossman School of Medicine, New York, NY
| | - Carol Duh-Leong
- Department of Pediatrics (R Teli, MJ Messito, CN Kim, C Duh-Leong and R Gross), New York University Grossman School of Medicine, New York, NY
| | - Michelle Katzow
- Department of Pediatrics (M Katzow), Zucker School of Medicine at Hofstra/Northwell, New York, NY
| | - Rachel Gross
- Department of Pediatrics (R Teli, MJ Messito, CN Kim, C Duh-Leong and R Gross), New York University Grossman School of Medicine, New York, NY
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Bastian GE. Exploring Sociodemographic and Chronic Disease Factors Associated With Chronic, Seasonal, Intramonthly, and Intermittent Presentations of Food Security Instability. J Acad Nutr Diet 2024; 124:686-699. [PMID: 38081383 DOI: 10.1016/j.jand.2023.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 12/03/2023] [Accepted: 12/06/2023] [Indexed: 01/09/2024]
Abstract
BACKGROUND Food insecurity impacts 13.5 million US households yearly. Although food security instability (FS-I) can have many temporal presentations, these are not measured in the current US Household Food Security Survey Module. OBJECTIVE Explore sociodemographic and chronic disease correlates of 4 FS-I types (chronic, seasonal, intramonthly, and intermittent) using a 3-item US Household Food Security Survey Module instability supplement. DESIGN This study was a secondary analysis of cross-sectional survey pilot data collected to validate the US Household Food Security Survey Module instability supplement. PARTICIPANTS AND SETTING Adults at risk for food insecurity (n = 420) were recruited and answered the survey on their households' behalf from April to June 2021. The participants were recruited from 7 community organizations from 5 states (California, Florida, Maryland, North Carolina, and Washington). MAIN OUTCOME MEASURES The main outcomes were the odds of having a chronic, seasonal, intramonthly, or intermittent FS-I score ≥1 based on several sociodemographic factors and having ≥1 chronic disease. STATISTICAL ANALYSES PERFORMED Differences among the 4 FS-I types were analyzed using contingency tables and χ2 tests of independence. Then, mixed-effects logistic binary and conditional regressions were run for each FS-I type using clustering by state and odds ratios and 95% CI to interpret results. RESULTS The most common FS-I type experienced by the sample was intramonthly (n = 183 [43%]). Nonchronic food insecurity was most likely to happen during the winter, at the end of the month, or randomly with no certain time frame. FS-I in any form was associated with low income, chronic FS-I was associated with younger age and male sex, seasonal FS-I was associated with having no government-subsidized health insurance and females, intramonthly FS-I was associated with participation in nutrition assistance programs, and intermittent FS-I had lower odds among Hispanic/Latino households. CONCLUSIONS Further research is needed to explore other FS-I correlates and establish causative relationships; however, these results can be used with clinical judgment for targeted food insecurity screening and treatment.
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Affiliation(s)
- Graham E Bastian
- School of Health and Consumer Sciences, South Dakota State University, Brookings, South Dakota.
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Lister NB, Baur LA, Paxton SJ, Garnett SP, Ahern AL, Wilfley DE, Maguire S, Sainsbury A, Steinbeck K, Braet C, Hill AJ, Nicholls D, Jones RA, Dammery G, Grunseit A, Cooper K, Kyle TK, Heeren FA, Hunter KE, McMaster CM, Johnson BJ, Seidler AL, Jebeile H. Eating Disorders In weight-related Therapy (EDIT) Collaboration: rationale and study design. Nutr Res Rev 2024; 37:32-42. [PMID: 36788665 PMCID: PMC7615933 DOI: 10.1017/s0954422423000045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
Abstract
The cornerstone of obesity treatment is behavioural weight management, resulting in significant improvements in cardio-metabolic and psychosocial health. However, there is ongoing concern that dietary interventions used for weight management may precipitate the development of eating disorders. Systematic reviews demonstrate that, while for most participants medically supervised obesity treatment improves risk scores related to eating disorders, a subset of people who undergo obesity treatment may have poor outcomes for eating disorders. This review summarises the background and rationale for the formation of the Eating Disorders In weight-related Therapy (EDIT) Collaboration. The EDIT Collaboration will explore the complex risk factor interactions that precede changes to eating disorder risk following weight management. In this review, we also outline the programme of work and design of studies for the EDIT Collaboration, including expected knowledge gains. The EDIT studies explore risk factors and the interactions between them using individual-level data from international weight management trials. Combining all available data on eating disorder risk from weight management trials will allow sufficient sample size to interrogate our hypothesis: that individuals undertaking weight management interventions will vary in their eating disorder risk profile, on the basis of personal characteristics and intervention strategies available to them. The collaboration includes the integration of health consumers in project development and translation. An important knowledge gain from this project is a comprehensive understanding of the impact of weight management interventions on eating disorder risk.
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Affiliation(s)
- Natalie B Lister
- Children's Hospital Westmead Clinical School, The University of Sydney, Westmead, New South Wales2145, Australia
- Charles Perkins Centre, The University of Sydney, Sydney, New South Wales2145, Australia
| | - Louise A Baur
- Children's Hospital Westmead Clinical School, The University of Sydney, Westmead, New South Wales2145, Australia
- Charles Perkins Centre, The University of Sydney, Sydney, New South Wales2145, Australia
| | - Susan J Paxton
- School of Psychology and Public Health, La Trobe University, Melbourne, Victoria, Australia
| | - Sarah P Garnett
- Children's Hospital Westmead Clinical School, The University of Sydney, Westmead, New South Wales2145, Australia
- Kids Research, Sydney Children's Hospital Network, Westmead, New South Wales2145, Australia
| | - Amy L Ahern
- MRC Epidemiology Unit, University of Cambridge, Cambridge, CB2 0QQ, UK
| | - Denise E Wilfley
- School of Medicine, Washington University in St. Louis, St. Louis, USA
| | - Sarah Maguire
- InsideOut Institute for Eating Disorders, Boden Collaboration for Obesity, Nutrition and Eating Disorders, Charles Perkins Centre, The University of Sydney, Sydney, New South Wales, Australia
| | - Amanda Sainsbury
- School of Human Sciences, The University of Western Australia, Crawley, Western Australia, Australia
| | - Katharine Steinbeck
- Children's Hospital Westmead Clinical School, The University of Sydney, Westmead, New South Wales2145, Australia
- The Academic Department of Adolescent Medicine, The Children's Hospital at Westmead, Westmead, New South Wales2145, Australia
| | - Caroline Braet
- Department of Developmental, Personality and Social Psychology, Ghent University, Henri Dunantlaan 2, 9000 Ghent, Belgium
| | - Andrew J Hill
- Leeds Institute of Health Sciences, University of Leeds, UK
| | - Dasha Nicholls
- Division of Psychiatry, Imperial College London, 2nd Floor, Commonwealth Building, Du Cane Road, London, W12 0NN, UK
| | - Rebecca A Jones
- MRC Epidemiology Unit, University of Cambridge, Cambridge, CB2 0QQ, UK
| | - Genevieve Dammery
- InsideOut Institute for Eating Disorders, Boden Collaboration for Obesity, Nutrition and Eating Disorders, Charles Perkins Centre, The University of Sydney, Sydney, New South Wales, Australia
| | - Alicia Grunseit
- The Children's Hospital at Westmead, Nutrition and Dietetics, Weight Management Services, Westmead, New South Wales, NSW 2145, Australia
| | | | | | - Faith A Heeren
- Department of Health Outcomes and Biomedical Informatics, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Kylie E Hunter
- National Health and Medical Research Council Clinical Trials Centre, The University of Sydney, Sydney, New South Wales, Australia
| | - Caitlin M McMaster
- Children's Hospital Westmead Clinical School, The University of Sydney, Westmead, New South Wales2145, Australia
| | - Brittany J Johnson
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Adelaide, South Australia5042, Australia
| | - Anna Lene Seidler
- National Health and Medical Research Council Clinical Trials Centre, The University of Sydney, Sydney, New South Wales, Australia
| | - Hiba Jebeile
- Children's Hospital Westmead Clinical School, The University of Sydney, Westmead, New South Wales2145, Australia
- Charles Perkins Centre, The University of Sydney, Sydney, New South Wales2145, Australia
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Batioja K, Elenwo C, Hendrix-Dicken A, Ali L, Wetherill MS, Hartwell M. Associations of social determinants of health and childhood obesity: a cross-sectional analysis of the 2021 National Survey of Children's Health. J Osteopath Med 2024; 124:231-239. [PMID: 38190347 DOI: 10.1515/jom-2023-0239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Accepted: 12/04/2023] [Indexed: 01/10/2024]
Abstract
CONTEXT Childhood obesity is a growing health problem in the United States, with those affected having an increased likelihood of developing chronic diseases at a younger age. Social determinants of health (SDOH) are known to influence overall health. Families who are of low socioeconomic status (SES) have also been shown to be more likely to experience food insecurity. OBJECTIVES Our primary objective was to utilize the National Survey of Children's Health (NSCH) 2021 data to determine the current associations between childhood obesity and SDOH. Secondarily, we estimated the prevalence of select SDOH among children with obesity. METHODS We conducted a cross-sectional analysis of 2021 NSCH to extract data related to the SDOH domains. We extracted sociodemographic variables to utilize as controls and constructed logistic regression models to determine associations, via odds ratios, between SDOH and childhood obesity. RESULTS Within the binary regression models, children with obesity (≥95th percentile) were more likely than children without obesity to experience SDOH in all domains. After controlling for sociodemographic variables, children with obesity were significantly more likely to experience food insecurity when compared to children without obesity (adjusted odds ratio [AOR]=1.39; 95 % confidence interval [CI]: 1.13-1.17). CONCLUSIONS In line with the current American Academy of Pediatrics (AAP) Clinical Practice Guidelines (CPG), improving policies for nutrition programs and addressing the lack of access to nutritious foods may alleviate some food insecurity. Ensuring that children have access to sufficient nutritious foods is critical in addressing childhood obesity and thus decreasing risk of chronic disease.
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Affiliation(s)
- Kelsi Batioja
- Oklahoma State University Center for Health Sciences, Tulsa, OK 74107, USA
- Office of Medical Student Research, Oklahoma State University College of Osteopathic Medicine at Cherokee Nation, Tahlequah, OK, USA
| | - Covenant Elenwo
- Office of Medical Student Research, Oklahoma State University College of Osteopathic Medicine at Cherokee Nation, Tahlequah, OK, USA
| | - Amy Hendrix-Dicken
- Department of Pediatrics, University of Oklahoma School of Community Medicine, Tulsa, OK, USA
| | - Lamiaa Ali
- Department of Pediatrics, University of Oklahoma School of Community Medicine, Tulsa, OK, USA
| | - Marianna S Wetherill
- College of Public Health - Schusterman Center, University of Oklahoma Health Sciences Center, Tulsa, OK, USA
| | - Micah Hartwell
- Oklahoma State University Center for Health Sciences, Tulsa, OK 74107, USA
- Department of Psychiatry and Behavioral Sciences, Oklahoma State University Center for Health Sciences, Tulsa, OK, USA
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10
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Lee J, Helgeson E, Horning ML, Elgesma KM, Kubik MY, Fulkerson JA. Food Insecurity and Changes in Diet Quality and Body Mass Index z-Scores Among Elementary School Students. Child Obes 2024. [PMID: 38546529 DOI: 10.1089/chi.2023.0185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/19/2024]
Abstract
Background: Previous research has identified food insecurity as a risk factor for obesity but those studies employed cross-sectional designs and were largely focused on adults and young children. In addition, there is a paucity of studies examining the association between food insecurity and changes in children's overall diet quality. This study aimed to assess whether food insecurity is associated with subsequent changes in diet quality and BMI z-scores over 2 years among 7- to 12-year-old children. Methods: We used 2011-2019 secondary data (n = 404) from three randomized controlled trials in Minnesota. Food insecurity was identified using the U.S. Household Food Security Survey Module at baseline (Time 0). Diet quality was determined using the Healthy Eating Index (HEI)-2015 from 24-hour recalls, and BMI z-scores were calculated using measured height and weight. These two outcomes were measured at Time 0, Time 1 (10-12 months from Time 0), and Time 2 (15-24 months from Time 0). Results: Compared with children from food-secure households, those from food-insecure households experienced a 0.13 greater increase in BMI z-scores from Time 0 to Time 2 [95% confidence interval (CI): 0.04 to 0.21] and a 4.5 point increase in HEI-2015 from Time 0 to Time 1 (95% CI: 0.99 to 8.01). Conclusion: Household food insecurity may widen weight disparities among elementary school-aged children. Further studies are needed to identify the role of diet quality in weight changes among children with food insecurity. Clinical Trial Registration Number: NCT01538615, NCT02029976, NCT02973815.
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Affiliation(s)
- Jiwoo Lee
- School of Nursing, University of Minnesota, Minneapolis, MN, USA
| | - Erika Helgeson
- Division of Biostatistics and Health Data Science, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | | | | | - Martha Y Kubik
- School of Nursing, College of Public Health, George Mason University, Fairfax, VA, USA
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11
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Bomberg EM, Kyle TK, Stanford FC. The need for increasing pediatric obesity advocacy. Complement Ther Med 2024; 80:103012. [PMID: 38161055 PMCID: PMC10908360 DOI: 10.1016/j.ctim.2023.103012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Accepted: 12/28/2023] [Indexed: 01/03/2024] Open
Affiliation(s)
- Eric M Bomberg
- Center for Pediatric Obesity Medicine, Division of Pediatric Endocrinology, Department of Pediatrics, University of Minnesota Medical School, 717 Delaware Street SE, Room 370, Minneapolis, MN 55414, USA.
| | - Theodore K Kyle
- ConscienHealth, 2270 Country Club Drive, Pittsburgh, PA 15421, USA.
| | - Fatima C Stanford
- Massachusetts General Hospital, Department of Medicine - Division of Endocrinology -Neuroendocrine, Department of Pediatrics - Division of Endocrinology, Nutrition Obesity Research Center at Harvard (NORCH), Harvard Medical School, 4th Floor Weight Center, 50 Staniford Street, Boston, MA 02114, USA.
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12
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Messiah SE, Xie L, Kapti EG, Chandrasekhar A, Srikanth N, Hill K, Williams S, Reid A, Mathew MS, Barlow SE. Prevalence of the metabolic syndrome by household food insecurity status in the United States adolescent population, 2001-2020: a cross-sectional study. Am J Clin Nutr 2024; 119:354-361. [PMID: 38042411 DOI: 10.1016/j.ajcnut.2023.11.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Revised: 10/27/2023] [Accepted: 11/27/2023] [Indexed: 12/04/2023] Open
Abstract
BACKGROUND Household food insecurity (FI) is a modifiable social determinant of health linked to chronic health outcomes. Little is known, however, about the prevalence of metabolic syndrome (MetS) in pediatric population-based studies by household FI status. OBJECTIVES The objective of the study was to estimate the prevalence of the MetS by household FI status over the past 2 decades. METHODS This cross-sectional study used data from the 2001-2020 National Health and Nutrition Examination Survey (NHANES). Participants were nonpregnant adolescents ages 12- 18 y in United States. The prevalence of MetS [elevated waist circumference and >2 of the following risk factors: elevated blood pressure, and fasting glucose, triglyceride, and/or low high-density lipoprotein (HDL) cholesterol concentrations] by FI status was evaluated using chi-square and logistic regression analyses. RESULTS The estimated prevalence of MetS was 2.66% [95% confidence interval (CI): 2.28%, 3.09%] in the final analytical sample (unweighted N = 12,932). A total of 3.39% (95% CI: 2.53%, 4.53%) of adolescents from FI households had MetS compared to 2.48% (95% CI: 2.11%, 2.9%) among adolescents with no household FI. Hispanic adolescents had the highest prevalence of MetS (3.73%, 95% CI: 3.05, 4.56) compared with adolescents who identified as non-Hispanic White (2.78%, 95% CI: 2.25, 3.43), non-Hispanic Black (1.58%, 95% CI: 1.19, 2.10). Adolescents with household FI (23.20%) were more likely to have MetS [odds ratio (OR): 1.38; 95% CI: 1.02, 1.88; I=0.039) compared with adolescents with no household FI, but in fully adjusted models this was not significant (OR: 1.13; 95% CI: 0.75, 1.72). CONCLUSIONS Using the most current NHANES data, the estimated prevalence of MetS in adolescents in United States was slightly higher among those from FI households. However, after adjusting for potential confounders, the relationship between household FI and MetS was nonsignificant, highlighting the complexity of factors contributing to MetS in this population. Hispanic adolescents share a disproportionate burden of MetS compared with their non-Hispanic counterparts.
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Affiliation(s)
- Sarah E Messiah
- Department of Epidemiology, Human Genetics and Environmental Sciences, University of Texas Health (UTHealth) Science Center at Houston, School of Public Health, Dallas, TX, United States; Center for Pediatric Population Health, UTHealth School of Public Health at Houston, Dallas, TX, United States; Department of Pediatrics, UTHealth Houston McGovern Medical School, Houston, TX, United States.
| | - Luyu Xie
- Department of Epidemiology, Human Genetics and Environmental Sciences, University of Texas Health (UTHealth) Science Center at Houston, School of Public Health, Dallas, TX, United States; Center for Pediatric Population Health, UTHealth School of Public Health at Houston, Dallas, TX, United States
| | - Eda Gozel Kapti
- Department of Epidemiology, Human Genetics and Environmental Sciences, University of Texas Health (UTHealth) Science Center at Houston, School of Public Health, Dallas, TX, United States; Center for Pediatric Population Health, UTHealth School of Public Health at Houston, Dallas, TX, United States
| | - Aparajita Chandrasekhar
- Department of Epidemiology, Human Genetics and Environmental Sciences, University of Texas Health (UTHealth) Science Center at Houston, School of Public Health, Dallas, TX, United States; Center for Pediatric Population Health, UTHealth School of Public Health at Houston, Dallas, TX, United States
| | | | - Kristina Hill
- Department of Epidemiology, Human Genetics and Environmental Sciences, University of Texas Health (UTHealth) Science Center at Houston, School of Public Health, Dallas, TX, United States; Center for Pediatric Population Health, UTHealth School of Public Health at Houston, Dallas, TX, United States; Children's Health System of Texas, Dallas, TX, United States
| | | | - Aleksei Reid
- Children's Health System of Texas, Dallas, TX, United States
| | - Mathew Sunil Mathew
- Department of Epidemiology, Human Genetics and Environmental Sciences, University of Texas Health (UTHealth) Science Center at Houston, School of Public Health, Dallas, TX, United States; Center for Pediatric Population Health, UTHealth School of Public Health at Houston, Dallas, TX, United States
| | - Sarah E Barlow
- Children's Health System of Texas, Dallas, TX, United States; Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, United States
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13
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Scott VP, Rhee KE. Using the lens of trauma informed care to inform pediatric obesity management. Curr Opin Pediatr 2024; 36:49-56. [PMID: 37965895 DOI: 10.1097/mop.0000000000001314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2023]
Abstract
PURPOSE OF REVIEW Summarize the evolution of the trauma-informed care (TIC) approach in pediatrics, highlight the importance of using this lens in pediatric obesity management and treating the whole patient and family, and suggest recommendations for providers to incorporate TIC into their practice. RECENT FINDINGS Implementing TIC in pediatric obesity management is recommended and offers an approach to address trauma-related symptoms associated with obesity. The TIC framework creates a safe, nurturing space to have open conversations with patients and families to promote resilience and reduce stigma related to obesity without re-traumatization. Screening tools may expose symptoms related to trauma, but are limited. Provider training is available and development of TIC related skills may be improved through using the arts and humanities. Success of TIC requires a tailored, integrated healthcare system approach with commitment from all levels. SUMMARY The TIC approach offers providers skills to uncover trauma-related symptoms and address obesity-related health disparities while reducing stigma. Collaboration across all levels of the healthcare system and community partners is essential. Further research is warranted on the effectives of this approach in pediatric obesity prevention and management.
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Affiliation(s)
- Vanessa P Scott
- UC San Diego School of Medicine, Department of Pediatrics, UC San Diego Health, Academic General Pediatrics, La Jolla, California, USA
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14
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Cruz Herrera E, Figueroa-Nieves AI, Woo Baidal JA. The potential role of social care in reducing childhood obesity. Curr Opin Pediatr 2024; 36:10-16. [PMID: 37972976 DOI: 10.1097/mop.0000000000001309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Abstract
PURPOSE OF REVIEW This review evaluates the current evidence for relationships of social factors with childhood obesity and for a role of social care in reduction of childhood obesity. RECENT FINDINGS Most literature on the relationship between social factors and childhood obesity has examined food insecurity as a risk factor for obesity. Associations between food insecurity and excess weight in children are most consistent during infancy and among those with food insecurity at more than one time point. A few pilot food security interventions that link patients with produce or groceries show feasibility and potential promise for reducing childhood obesity risk factors. However, full-scale, randomized studies to examine interventions that reduce social needs and their effects on childhood obesity are lacking. Future research is needed to examine holistic social care approaches to effectively reduce childhood obesity risk factors. SUMMARY Food insecurity acts as a barrier to childhood obesity prevention and treatment. Patient-centered, validated measures of social needs and effective interventions to address social needs are needed to equitably prevent and treat childhood obesity.
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Affiliation(s)
- Evianna Cruz Herrera
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Columbia University Irving Medical Center and NewYork-Presbyterian, New York, New York, USA
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15
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Woo Baidal J, Finkel MA, Kelman E, Duong N, Bien-Aime C, Goldsmith J, Albrecht SS, Hulse E, Rosenthal A, Reiss J, Schwartz R, Meyer D. Longitudinal Associations of Food Security with Health and Dietary Factors among Food FARMacy Participants during COVID-19 in New York City. Nutrients 2024; 16:434. [PMID: 38337718 PMCID: PMC10857290 DOI: 10.3390/nu16030434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Revised: 01/23/2024] [Accepted: 01/26/2024] [Indexed: 02/12/2024] Open
Abstract
In cross-sectional studies, food insecurity is associated with adverse health and dietary outcomes. Whether self-reported health and dietary outcomes change in response to improvements in food security has not been examined. We sought to examine how increases in food security are related to changes in health and dietary factors. In this longitudinal, observational study, we included adult participants in a clinical-community emergency food assistance program in New York City from July 2020 to November 2021. Program staff measured food security with a validated six-item measure at program enrollment and six-month re-enrollment. Participants self-reported health and dietary factors (vegetable, fruit, juice, and sugar-sweetened beverage (SSB) consumption frequency). We used multivariable regression to examine associations between change in food security with change in health and dietary factors over six months. Among 310 participants, the mean food security score improved by 1.7 ± 2.3 points over six months. In unadjusted models, each point improvement in food security was associated with increased vegetable (β = 0.10 times; 95% CI: 0.05-0.15); fruit (β = 0.08 times; 95% CI: 0.03-0.14); and juice (β = 0.10 times; 95% CI: 0.05-0.15) consumption. In adjusted models, results remained significant for vegetable and fruit consumption, but not juice. Change in food security was not associated with change in health or SSB outcomes. In this cohort during COVID-19, improved food security was associated with improved vegetable and fruit consumption. Randomized trials that examine the effectiveness of clinical-community partnerships focused on improving food security and nutrition are warranted.
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Affiliation(s)
- Jennifer Woo Baidal
- Department of Pediatrics, Columbia University Vagelos College of Physicians & Surgeons, New York, NY 10032, USA; (M.A.F.); (N.D.); (C.B.-A.); (D.M.)
- NewYork-Presbyterian Morgan Stanley Children’s Hospital, New York, NY 10032, USA
| | - Morgan A. Finkel
- Department of Pediatrics, Columbia University Vagelos College of Physicians & Surgeons, New York, NY 10032, USA; (M.A.F.); (N.D.); (C.B.-A.); (D.M.)
- NewYork-Presbyterian Morgan Stanley Children’s Hospital, New York, NY 10032, USA
| | - Elizabeth Kelman
- Department of Pediatrics, Columbia University Vagelos College of Physicians & Surgeons, New York, NY 10032, USA; (M.A.F.); (N.D.); (C.B.-A.); (D.M.)
| | - Ngoc Duong
- Department of Pediatrics, Columbia University Vagelos College of Physicians & Surgeons, New York, NY 10032, USA; (M.A.F.); (N.D.); (C.B.-A.); (D.M.)
| | - Celine Bien-Aime
- Department of Pediatrics, Columbia University Vagelos College of Physicians & Surgeons, New York, NY 10032, USA; (M.A.F.); (N.D.); (C.B.-A.); (D.M.)
| | - Jeff Goldsmith
- Department of Biostatistics, Columbia University Mailman School of Public Health, New York, NY 10032, USA;
| | - Sandra S. Albrecht
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY 10032, USA;
| | - Emma Hulse
- Division of Community and Population Health, New York Presbyterian Hospital, New York, NY 10032, USA;
| | | | - Jeremy Reiss
- Henry Street Settlement, New York, NY 10002, USA;
| | | | - Dodi Meyer
- Department of Pediatrics, Columbia University Vagelos College of Physicians & Surgeons, New York, NY 10032, USA; (M.A.F.); (N.D.); (C.B.-A.); (D.M.)
- NewYork-Presbyterian Morgan Stanley Children’s Hospital, New York, NY 10032, USA
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16
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Yudkin JS, Koym K, Hamad Y, Malthaner LQ, Burgess RM, Ortiz LN, Dhurjati N, Mitha S, Calvi G, Hill K, Brownell M, Wei E, Swartz K, Atem FD, Galeener CA, Messiah SE, Barlow SE, Allicock MA. Family-based pediatric weight management interventions in US primary care settings targeting children ages 6-12 years old: A systematic review guided by the RE-AIM framework. Transl Behav Med 2024; 14:34-44. [PMID: 37632769 DOI: 10.1093/tbm/ibad051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/28/2023] Open
Abstract
Obesity is a pandemic that disproportionately affects children from vulnerable populations in the USA. Current treatment approaches in primary care settings in the USA have been reported to be insufficient at managing pediatric obesity, primarily due to implementation challenges for healthcare systems and barriers for families. While the literature has examined the efficacy of pediatric obesity interventions focused on internal validity, it lacks sufficient reporting and analysis of external validity necessary for successful translation to primary care settings. We conducted a systematic review of the primary-care-setting literature from January 2007 to March 2020 on family-based pediatric weight management interventions in both English and/or Spanish for children ages 6-12 years in the USA using the Reach, Efficacy/Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) framework. A literature search, using PRISMA guidelines, was conducted in January 2022 using the following electronic databases: Medline Ovid, Embase, and Cochrane Library. 22 270 records were screened, and 376 articles were reviewed in full. 184 studies were included. The most commonly reported dimensions of the RE-AIM framework were Reach (65%), Efficacy/Effectiveness (64%), and Adoption (64%), while Implementation (47%) and Maintenance (42%) were less often reported. The prevalence of reporting RE-AIM construct indicators ranged greatly, from 1% to 100%. This systematic review underscores the need for more focus on external validity to guide the development, implementation, and dissemination of future pediatric obesity interventions based in primary care settings. It also suggests conducting additional research on sustainable financing for pediatric obesity interventions.
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Affiliation(s)
- Joshua S Yudkin
- The University of Texas Health Science Center at Houston (UTHealth) School of Public Health, Dallas, TX, USA
| | - Kelsey Koym
- Texas Medical Center Library, Houston, TX, USA
| | - Yasmin Hamad
- The University of Texas Health Science Center at Houston (UTHealth) School of Public Health, Dallas, TX, USA
| | - Lauren Q Malthaner
- The University of Texas Health Science Center at Houston (UTHealth) School of Public Health, Dallas, TX, USA
| | - Rebecca Meredith Burgess
- The University of Texas Health Science Center at Houston (UTHealth) School of Public Health, Dallas, TX, USA
| | | | - Nalini Dhurjati
- The University of Texas Health Science Center at Houston (UTHealth) School of Public Health, Dallas, TX, USA
| | - Sharmin Mitha
- The University of Texas Health Science Center at Houston (UTHealth) School of Public Health, Dallas, TX, USA
| | - Gabriela Calvi
- The University of Texas Health Science Center at Houston (UTHealth) School of Public Health, Dallas, TX, USA
| | - Kristina Hill
- The University of Texas Health Science Center at Houston (UTHealth) School of Public Health, Dallas, TX, USA
- Children's Health, Children's Medical Center Dallas, Dallas, TX, USA
- Center for Pediatric Population Health, The University of Texas Health Science Center at Houston (UTHealth) School of Public Health, Dallas, TX, USA
| | | | - Elena Wei
- Johns Hopkins University, School of Medicine, Baltimore, MD, USA
| | - Kyle Swartz
- The University of Texas Health Science Center at Houston (UTHealth) School of Public Health, Dallas, TX, USA
| | - Folefac D Atem
- The University of Texas Health Science Center at Houston (UTHealth) School of Public Health, Dallas, TX, USA
| | - Carol A Galeener
- The University of Texas Health Science Center at Houston (UTHealth) School of Public Health, Dallas, TX, USA
| | - Sarah E Messiah
- The University of Texas Health Science Center at Houston (UTHealth) School of Public Health, Dallas, TX, USA
- Center for Pediatric Population Health, The University of Texas Health Science Center at Houston (UTHealth) School of Public Health, Dallas, TX, USA
| | - Sarah E Barlow
- Children's Health, Children's Medical Center Dallas, Dallas, TX, USA
- Department of Pediatrics, Division of Pediatric Gastroenterology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Marlyn A Allicock
- The University of Texas Health Science Center at Houston (UTHealth) School of Public Health, Dallas, TX, USA
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17
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Frank ML, Korth CX, Shields CV, Hultstrand KV, Putt GE, Walston MW, Wulkan ML, Perusek AK, Sato AF. Food Insecurity Predicts Magnitude of Early BMI Change in a Pediatric Weight Management Intervention. J Dev Behav Pediatr 2024; 45:e79-e85. [PMID: 38117677 DOI: 10.1097/dbp.0000000000001242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2023]
Abstract
OBJECTIVE The aim of this study was to estimate the prevalence of food insecurity among children with overweight/obesity presenting for weight management treatment and examine whether food insecurity predicts early change in body mass index (BMI), expressed as a percentage of the 95th percentile (%BMIp95). METHOD Children (N = 69; ages 3-18 years) presenting to a hospital-based pediatric weight management intervention and 1 parent/guardian per child (N = 69) were included. At the first appointment, parents/guardians completed the US Household Food Security Survey Module: Six-item Short Form and a demographics questionnaire. Height and weight of the children were measured at the first and third appointments to calculate %BMIp95. RESULTS Among participating families, 29.0% reported experiencing food insecurity. Controlling for the ratio of income to poverty, 11.4% of the variance in %BMIp95 change from the first to third appointments was accounted for by food insecurity, ▵F (1, 66) = 8.46, p = 0.01. Children with greater food insecurity demonstrated a smaller magnitude of %BMIp95 decrease, representing a small-to-medium effect size within the context of the regression model (f2 = 0.13). CONCLUSION A high proportion of families with children receiving weight management treatment reported experiencing food insecurity in comparison with US households with children. There may be unique characteristics of food insecurity, as opposed to household income alone, that explain the smaller magnitude of BMI decrease observed early in treatment. Future research should explore complex associations among food insecurity, income, BMI, and race over time.
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Affiliation(s)
- Miranda L Frank
- Department of Psychological Sciences, Kent State University, Kent, OH
| | - Christina X Korth
- Department of Psychological Sciences, Kent State University, Kent, OH
| | | | - Kara V Hultstrand
- Department of Psychological Sciences, Kent State University, Kent, OH
| | - Geoffrey E Putt
- Healthy Active Living Program, Akron Children's Hospital, Akron, OH
| | - Marnie W Walston
- Healthy Active Living Program, Akron Children's Hospital, Akron, OH
| | - Mark L Wulkan
- Healthy Active Living Program, Akron Children's Hospital, Akron, OH
- Department of General Surgery, Department of Pediatrics, Northeast Ohio Medical University, Rootstown, OH
| | - Amy K Perusek
- Healthy Active Living Program, Akron Children's Hospital, Akron, OH
| | - Amy F Sato
- Department of Psychological Sciences, Kent State University, Kent, OH
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18
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Armstrong SC, Skinner AC. Severe Obesity in Toddlers: A Canary in the Coal Mine for the Health of Future Generations. Pediatrics 2024; 153:e2023063799. [PMID: 38105671 DOI: 10.1542/peds.2023-063799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/22/2023] [Indexed: 12/19/2023] Open
Affiliation(s)
- Sarah C Armstrong
- Departments of Pediatrics and Population Health Sciences, Duke Center for Childhood Obesity Research, Duke Clinical Research Institute, Duke Global Health Institute, Duke University School of Medicine, Durham, North Carolina
| | - Asheley C Skinner
- Departments of Pediatrics and Population Health Sciences, Duke Center for Childhood Obesity Research, Duke Clinical Research Institute, Duke Global Health Institute, Duke University School of Medicine, Durham, North Carolina
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19
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Schratz LM, Larkin O, Dos Santos N, Martin C. Caregiver Influences on Eating Behaviors in Children: An Opportunity for Preventing Obesity. Curr Atheroscler Rep 2023; 25:1035-1045. [PMID: 38032429 DOI: 10.1007/s11883-023-01171-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/09/2023] [Indexed: 12/01/2023]
Abstract
PURPOSE OF REVIEW This review seeks to define caregiver practices that impact childhood eating behaviors and identify ways to utilize these relationships to prevent childhood obesity. RECENT FINDINGS Childhood obesity, which correlates with adult obesity and increased cardiovascular risk, is increasing in prevalence and severity. Caregivers play a significant role in shaping a child's eating behaviors and their predisposition to obesity. Maternal influences during pregnancy and infancy impact a child's future food preferences. Caregiver feeding styles (authoritarian, authoritative, indulgent, and uninvolved) are associated with distinct effects on children's eating behaviors and self-regulation. Authoritative feeding styles promote child autonomy while setting boundaries in the feeding environment. Early caregiver education and coaching regarding nutrition and feeding practices is beneficial to establishing healthy eating behaviors for children. Various caregivers, including parents, grandparents, siblings, teachers, and others, influence a child's eating habits at different stages of development. These caregivers can both positively and negatively impact a child's diet. Comprehensive interventions involving these various caregivers to promote healthy eating practices in children is ideal. Such interventions should be sensitive to cultural and environmental factors. Childhood obesity is a complex issue with long-term health effects. Early intervention using comprehensive approaches including all caregivers, community support, and public policies to address the social determinants of health will be beneficial. Future research should focus on valid outcome measures and equitable interventions that encompass all aspects of a child's life.
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Affiliation(s)
- Lorraine M Schratz
- Division of Pediatric Cardiology, Department of Pediatrics, Massachusetts General Hospital for Children and Harvard Medical School, 175 Cambridge Street, 5Th Floor , Boston, MA, USA.
| | - Olivia Larkin
- Division of Pediatric Cardiology, Department of Pediatrics, Massachusetts General Hospital for Children and Harvard Medical School, 175 Cambridge Street, 5Th Floor , Boston, MA, USA
| | - Nilse Dos Santos
- Division of Pediatric Cardiology, Department of Pediatrics, Massachusetts General Hospital for Children and Harvard Medical School, 175 Cambridge Street, 5Th Floor , Boston, MA, USA
| | - Christine Martin
- Division of Pediatric Cardiology, Department of Pediatrics, Massachusetts General Hospital for Children and Harvard Medical School, 175 Cambridge Street, 5Th Floor , Boston, MA, USA
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20
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Persaud A, Evans EW, Perkins M, Simione M, Cheng ER, Luo M, Burgun R, Taveras EM, Fiechtner L. The association of food insecurity on body mass index change in a pediatric weight management intervention. Pediatr Obes 2023; 18:e13075. [PMID: 37679964 PMCID: PMC10662037 DOI: 10.1111/ijpo.13075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 08/15/2023] [Accepted: 08/20/2023] [Indexed: 09/09/2023]
Abstract
BACKGROUND Childhood obesity is a critical public health concern. One potential determinant to obesity that is less understood is food insecurity. OBJECTIVE To examine the association of food security status on body mass index (BMI) change in a Pediatric Weight Management Intervention (PWMI) consistent with national treatment recommendations. METHODS This analysis included 201 participants from the Healthy Weight Clinic (HWC). Using linear mixed models, we compared BMI and %BMIp95 change per year between the food insecure group and food secure group, adjusting for baseline BMI, age and sex, and SNAP enrolment. RESULTS In fully adjusted models, children in households with food insecurity had a 0.50 (0.26-0.74) kg/m2 BMI increase per year and a 2.10 (1.02-3.19) %BMIp95 increase per year compared to households that were food secure. CONCLUSIONS When comparing the BMI effect of the HWC between the food insecure group and food secure group, those experiencing food insecurity in the HWC had an increase in BMI compared to those with food security. These findings suggest that food insecurity may reduce the effectiveness of PWMIs consistent with national recommendations; however, more studies should be conducted to better understand this relationship.
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Affiliation(s)
- Alicia Persaud
- Brown School, Washington University in St. Louis, 1 Brookings Drive, St. Louis, MO, 63130
- Division of General Academic Pediatrics, Massachusetts General Hospital for Children, Boston, MA, 02114
| | - E. Whitney Evans
- Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, 222 Richmond St, Providence, RI, 02903
- The Weight Control and Diabetes Research Center, The Miriam Hospital, 196 Richmond St, Providence, RI, 02903
| | - Meghan Perkins
- Division of General Academic Pediatrics, Massachusetts General Hospital for Children, Boston, MA, 02114
| | - Meg Simione
- Division of General Academic Pediatrics, Massachusetts General Hospital for Children, Boston, MA, 02114
| | - Erika R. Cheng
- Division of Children’s Health Services Research, Indiana University School of Medicine, 410 West 10th Street, Suite 2000, Indianapolis, IN, 46202
| | - Mandy Luo
- Division of General Academic Pediatrics, Massachusetts General Hospital for Children, Boston, MA, 02114
| | - Rachel Burgun
- Greater Boston Food Bank,70 South Bay Ave, Boston, MA, 02118
| | - Elsie M. Taveras
- Division of General Academic Pediatrics, Massachusetts General Hospital for Children, Boston, MA, 02114
- Department of Nutrition, Harvard T.H. Chan School of Public Health, 677 Huntington Ave, Boston, MA, 02115
| | - Lauren Fiechtner
- Division of General Academic Pediatrics, Massachusetts General Hospital for Children, Boston, MA, 02114
- Greater Boston Food Bank,70 South Bay Ave, Boston, MA, 02118
- Division of Gastroenterology and Nutrition, Massachusetts General Hospital for Children, 55 Fruit St, Boston, MA, 02114
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21
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Bateson M, Pepper GV. Food insecurity as a cause of adiposity: evolutionary and mechanistic hypotheses. Philos Trans R Soc Lond B Biol Sci 2023; 378:20220228. [PMID: 37661744 PMCID: PMC10475876 DOI: 10.1098/rstb.2022.0228] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 07/27/2023] [Indexed: 09/05/2023] Open
Abstract
Food insecurity (FI) is associated with obesity among women in high-income countries. This seemingly paradoxical association can be explained by the insurance hypothesis, which states that humans possess evolved mechanisms that increase fat storage to buffer against energy shortfall when access to food is unpredictable. The evolutionary logic underlying the insurance hypothesis is well established and experiments on animals confirm that exposure to unpredictable food causes weight gain, but the mechanisms involved are less clear. Drawing on data from humans and other vertebrates, we review a suite of behavioural and physiological mechanisms that could increase fat storage under FI. FI causes short-term hyperphagia, but evidence that it is associated with increased total energy intake is lacking. Experiments on animals suggest that unpredictable food causes increases in retained metabolizable energy and reductions in energy expenditure sufficient to fuel weight gain in the absence of increased food intake. Reducing energy expenditure by diverting energy from somatic maintenance into fat stores should improve short-term survival under FI, but the trade-offs potentially include increased disease risk and accelerated ageing. We conclude that exposure to FI plausibly causes increased adiposity, poor health and shorter lifespan. This article is part of a discussion meeting issue 'Causes of obesity: theories, conjectures and evidence (Part II)'.
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Affiliation(s)
- Melissa Bateson
- Centre for Healther Lives and Biosciences Institute, Newcastle University, Newcastle upon Tyne, NE2 4HH, UK
| | - Gillian V. Pepper
- Department of Psychology, Northumbria University, Newcastle upon Tyne, NE1 8ST, UK
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Ohno M, Dzurova D, Smejkal P. Health inequalities in post-COVID-19 outcomes among adults aged 50+ in Europe: has COVID-19 exposed divide between postcommunist countries and Western Europe? J Epidemiol Community Health 2023; 77:601-608. [PMID: 37423747 PMCID: PMC10423549 DOI: 10.1136/jech-2023-220771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 06/10/2023] [Indexed: 07/11/2023]
Abstract
BACKGROUND COVID-19 affected people and countries disproportionately and continues to impact the health of people. The aim is to investigate protective health and socio-geographical factors for post-COVID-19 conditions in adults aged 50 years and older in Europe. METHODS Using longitudinal data from the Survey of Health, Ageing and Retirement in Europe, collected from June to August 2021, protective factors against post-COVID-19 condition among 1909 respondents who self-reported a positive COVID-19 test result were investigated using multiple logistic regression models. RESULTS Male adults living outside of Czechia, Poland, Hungary and Slovakia (Visegrad group, V4), who received the COVID-19 vaccination, tertiary or higher education, had a healthy weight (body mass index, BMI 18.5-24.9 kg/m2) and no underlying health condition/s, showed protective effects against post-COVID-19 condition. Health inequalities associated with BMI were observed in education attainment and comorbidities, with higher BMI having lower education attainment and higher comorbidities. Health inequality was particularly evident in individuals in V4 with higher obesity prevalence and lower attainment of higher education than those living in other regions in the study. CONCLUSION Our study suggests that healthy weight and higher education attainment are predictors associated with a lower incidence of post-COVID-19 condition. Health inequality associated with education attainment was particularly relevant in V4. Our results highlight health inequality in which BMI was associated with comorbidities and educational attainment. To reduce obesity prevalence among older people with lower education, raising awareness about the risks of obesity and providing assistance in maintaining a healthy weight are needed.
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Affiliation(s)
- Maika Ohno
- Research Centre on Health, Quality of Life and Lifestyle in a Geodemographic and Socioeconomic Context (GeoQol), Department of Social Geography and Regional Development, Faculty of Science, Charles University, Prague, Czech Republic
| | - Dagmar Dzurova
- Research Centre on Health, Quality of Life and Lifestyle in a Geodemographic and Socioeconomic Context (GeoQol), Department of Social Geography and Regional Development, Faculty of Science, Charles University, Prague, Czech Republic
| | - Petr Smejkal
- Infectious Disease and Infection Control, IKEM Hospital, Prague, Czech Republic
- Hospitalist and Infection Control, Mount Desert Island Hospital, Bar Harbor, Maine, USA
- 1st Medical Faculty, Institute of Hygiene and Epidemiology, Charles University, Prague, Czech Republic
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23
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Magaña S, Eliasziw M, Bowling A, Must A. Racial and ethnic disparities in obesity and contributions of social determinants of health among boys with autism spectrum disorder. Front Pediatr 2023; 11:1198073. [PMID: 37497299 PMCID: PMC10366372 DOI: 10.3389/fped.2023.1198073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 06/29/2023] [Indexed: 07/28/2023] Open
Abstract
Children with autism spectrum disorders (ASD) are at greater obesity risk compared to typically developing peers. Although many potential risk factors for this relationship have been identified, the causal chain must be better understood, particularly modifiable social determinants of obesity risk in ASD, and especially for children with ASD from minoritized racial/ethnic groups. We aimed to: (1) examine racial/ethnic disparities in obesity status in boys with ASD; (2) assess associations between social determinants of health and obesity status; and (3) understand if social determinants of health factors mediate the relationship between race/ethnicity and obesity status for these youth. We used data for 124 boys, aged 9-10 with ASD enrolled in an ongoing longitudinal study. Social determinants of health explored included socioeconomic position, Area Deprivation Index, neighborhood safety, food and housing insecurity, and racial/ethnic discrimination. The racial/ethnic distribution was: 17.1% Black, 14.6% Latino, and 68.3% White; average age was 10 years. Both Black (PR 2.57, 95% CI: 1.26-5.26) and Latino boys (PR 2.08, 95% CI: 1.08-4.03) with ASD were more likely to be obese than their White peers. While there were significant differences in some social determinants of health by race/ethnicity, only food insecurity mediated associations between race/ethnicity (Black vs. White) and obesity. The striking disparities in obesity and differences in social determinants of health between Black and Latino children with ASD compared to White children emphasize the need to identify factors that contribute to healthy weight among these children and to address these factors in practice.
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Affiliation(s)
- Sandy Magaña
- Steve Hicks School of Social Work, University of Texas at Austin, Austin, TX, United States
| | - Misha Eliasziw
- Department of Public Health & Community Medicine, Tufts University School of Medicine, Boston, MA, United States
| | - April Bowling
- Department of Nursing and Health Sciences, Merrimack College, Andover, MA, United States
- E.K. Shriver Center, UMASS Chan Medical School, Worcester, MA, United States
| | - Aviva Must
- Department of Public Health & Community Medicine, Tufts University School of Medicine, Boston, MA, United States
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24
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Kakinami L, Danieles PK, Hosseininasabnajar F, Barnett TA, Henderson M, Van Hulst A, Serbin LA, Stack DM, Paradis G. The longitudinal effects of maternal parenting practices on children's body mass index z-scores are lagged and differential. BMC Pediatr 2023; 23:270. [PMID: 37248489 DOI: 10.1186/s12887-023-03902-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 02/10/2023] [Indexed: 05/31/2023] Open
Abstract
BACKGROUND The longitudinal relation between parenting practices and styles with children's body mass index z-scores (zBMI) is poorly understood. Previous studies suggest the relationship may be complex, but small samples and short follow-ups diminish the strength of the evidence. The objectives of this study were to investigate whether the relationship is bidirectional, time-varying, and lagged using data from a large, representative birth cohort of Quebec children. METHODS Data were from the Québec Longitudinal Study of Child Development (QLSCD), a prospective birth cohort (n = 1,602). The mothers' interactions with their children (at ages 6, 8, 10, and 12 years) were utilized in factor analysis to identify three latent parenting practices (disciplinarian, lenient, and responsive). The parenting practices were analyzed with K-means clustering to identify the parenting styles. The temporal and bidirectional relationships were assessed in a cross-lagged path analysis using a structural equation modelling framework. Mixed models controlling for age, sex, income, mother's education, and whether the participant was first-born were estimated. Missing data were handled with full information maximum likelihood. RESULTS From the linear mixed models, greater lenient and responsive parenting practices were associated with higher zBMI (B = 0.03, p < 0.05) two years later. However, there was no evidence that the relationship was bidirectional nor that parenting style was predictive of children's zBMI. CONCLUSION While mothers' parenting practices were unaffected by their children's zBMI, parental practices were predictive of future zBMI among their prepubertal children. More in-depth exploration of parenting practices and their potential impact on pediatric weight is needed.
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Affiliation(s)
- Lisa Kakinami
- Department of Mathematics and Statistics, Concordia University, 1455 de Maisonneuve Blvd West, Montréal, QC, H3G 1M8, Canada.
- PERFORM Centre, Concordia University, Montréal, QC, Canada.
| | - Prince Kevin Danieles
- Department of Mathematics and Statistics, Concordia University, 1455 de Maisonneuve Blvd West, Montréal, QC, H3G 1M8, Canada
| | - Fatemeh Hosseininasabnajar
- Department of Mathematics and Statistics, Concordia University, 1455 de Maisonneuve Blvd West, Montréal, QC, H3G 1M8, Canada
| | - Tracie A Barnett
- Department of Family Medicine, McGill University, Montréal, QC, Canada
- Centre de Recherche du CHU Sainte-Justine, Montréal, QC, Canada
| | - Mélanie Henderson
- Centre de Recherche du CHU Sainte-Justine, Montréal, QC, Canada
- Department of Pediatrics, Université de Montréal, Montréal, QC, Canada
- School of Public Health, Department of Social and Preventive Medicine, Université de Montréal, Montréal, QC, Canada
| | | | - Lisa A Serbin
- Department of Psychology, Concordia University, Montréal, QC, Canada
- Centre for Research in Human Development, Montréal, Canada
| | - Dale M Stack
- Department of Psychology, Concordia University, Montréal, QC, Canada
- Centre for Research in Human Development, Montréal, Canada
| | - Gilles Paradis
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montréal, QC, Canada
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25
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Ortiz-Marrón H, Ortiz-Pinto MA, Urtasun Lanza M, Cabañas Pujadas G, Valero Del Pino V, Belmonte Cortés S, Gómez Gascón T, Ordobás Gavín M. Household food insecurity and its association with overweight and obesity in children aged 2 to 14 years. BMC Public Health 2022; 22:1930. [PMID: 36253730 PMCID: PMC9578200 DOI: 10.1186/s12889-022-14308-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 09/22/2022] [Accepted: 09/27/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The objective was to estimate the prevalence of household food insecurity (HFI) depending on sociodemographic factors and its association with lifestyle habits and childhood overweight and obesity. METHODS Data was collected from 1,938 children aged 2 to 14 years who participated in the "Study about Malnutrition" of the Community of Madrid. Weight and height were obtained through physical examination. Body mass index was calculated as weight/height2 (kg/m2) and the criteria of the WHO were used for determining conditions of overweight and obesity. The participants' parents answered a structured questionnaire about their diet, lifestyle (physical activity and screen time), and food insecurity. The diet quality was assessed with the Healthy Eating Index in Spain and food insecurity, defined as the lack of consistent access to sufficient food for a healthy life, was measured via three screening questions and the Household Food Insecurity Access Scale (HFIAS). Odds Ratios (ORs) and Relative Risk Ratios (RRRs) were estimated using logistic regression models and adjusted for confounding variables. RESULTS The overall prevalence of HFI was 7.7% (95% CI: 6.6‒9.0), with lower values in children 2 to 4 years old (5.7%, 95% CI: 4.0‒8.1) and significantly higher values in households with low family purchasing power [37.3%; OR: 8.99 (95% CI: 5.5‒14.6)]. A higher prevalence of overweight (33.1%) and obesity (28.4%) was observed in children from families with HFI, who presented a lower quality diet and longer screen time compared to those from food-secure households (21.0% and 11.5%, respectively). The RRR of children in families with HFI relative to those from food-secure households was 2.41 (95% CI: 1.5‒4.0) for overweight and 1.99 (95% CI: 1.2‒3.4) for obesity. CONCLUSION The prevalence of HFI was high in the paediatric population, especially in households with low family purchasing power. HFI was associated with lower diet quality and higher prevalence of childhood overweight and obesity. Our results suggest the need for paediatric services to detect at-risk households at an early stage to avoid this dual burden of child malnutrition.
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Affiliation(s)
- Honorato Ortiz-Marrón
- Epidemiology Service. General Directorate of Public Health, Department of Health, Community of Madrid, C/ San Martín de Porres nº 6, 28035, Madrid, Spain.
| | - Maira Alejandra Ortiz-Pinto
- Epidemiology Service. General Directorate of Public Health, Department of Health, Community of Madrid, C/ San Martín de Porres nº 6, 28035, Madrid, Spain
| | - María Urtasun Lanza
- Group of Epidemiology and Public Health, Faculty of Medicine, University of Alcalá, Alcalá de Henares, Spain.,APLICA Cooperative, Madrid, Spain
| | - Gloria Cabañas Pujadas
- Epidemiology Service. General Directorate of Public Health, Department of Health, Community of Madrid, C/ San Martín de Porres nº 6, 28035, Madrid, Spain
| | - Virginia Valero Del Pino
- Epidemiology Service. General Directorate of Public Health, Department of Health, Community of Madrid, C/ San Martín de Porres nº 6, 28035, Madrid, Spain
| | - Susana Belmonte Cortés
- Nutrition Service, Department of Health, Community of Madrid, General Directorate of Public Health, Madrid, Spain
| | - Tomás Gómez Gascón
- Foundation for Biosanitary Research and Innovation in Primary Care ES Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain Faculty of Medicine. Universidad Complutense de Madrid, Madrid, Spain
| | - María Ordobás Gavín
- Epidemiology Service. General Directorate of Public Health, Department of Health, Community of Madrid, C/ San Martín de Porres nº 6, 28035, Madrid, Spain
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26
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Reverri EJ, Arensberg MB, Murray RD, Kerr KW, Wulf KL. Young Child Nutrition: Knowledge and Surveillance Gaps across the Spectrum of Feeding. Nutrients 2022; 14:3093. [PMID: 35956275 PMCID: PMC9370290 DOI: 10.3390/nu14153093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 07/18/2022] [Accepted: 07/25/2022] [Indexed: 11/16/2022] Open
Abstract
The first 1000 days is a critical window to optimize nutrition. Young children, particularly 12-24 month-olds, are an understudied population. Young children have unique nutrient needs and reach important developmental milestones when those needs are met. Intriguingly, there are differences in the dietary patterns and recommendations for young children in the US vs. globally, notably for breastfeeding practices, nutrient and food guidelines, and young child formulas (YCFs)/toddler drinks. This perspective paper compares these differences in young child nutrition and identifies both knowledge gaps and surveillance gaps to be filled. Parental perceptions, feeding challenges, and nutrition challenges are also discussed. Ultimately, collaboration among academia and clinicians, the private sector, and the government will help close young child nutrition gaps in both the US and globally.
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Affiliation(s)
- Elizabeth J. Reverri
- Abbott Nutrition, Abbott Laboratories, Columbus, OH 43219, USA; (M.B.A.); (K.W.K.); (K.L.W.)
| | - Mary Beth Arensberg
- Abbott Nutrition, Abbott Laboratories, Columbus, OH 43219, USA; (M.B.A.); (K.W.K.); (K.L.W.)
| | - Robert D. Murray
- Department of Pediatrics, The Ohio State University, Columbus, OH 43219, USA;
| | - Kirk W. Kerr
- Abbott Nutrition, Abbott Laboratories, Columbus, OH 43219, USA; (M.B.A.); (K.W.K.); (K.L.W.)
| | - Karyn L. Wulf
- Abbott Nutrition, Abbott Laboratories, Columbus, OH 43219, USA; (M.B.A.); (K.W.K.); (K.L.W.)
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