Prenatal Dietary Patterns and Associations With Weight-Related Pregnancy Outcomes in Hispanic Women With Low Incomes

Background: Dietary patterns during pregnancy may contribute to gestational weight gain (GWG) and birthweight, but there is limited research studying these associations in racial and ethnic minority groups. The objective of this study was to evaluate associations between prenatal dietary patterns and measures of GWG and birthweight in a cohort of culturally diverse Hispanic women with low incomes. Methods: Data were analyzed from 500 mother-infant dyads enrolled in the Starting Early Program, a childhood obesity prevention trial. Diet over the previous year was assessed in the third trimester of pregnancy using an interviewer-administered food frequency questionnaire. Dietary patterns were constructed using the Healthy Eating Index-2015 (HEI-2015) and principal components analysis (PCA) and analyzed as tertiles. GWG and birthweight outcomes were abstracted from medical records. Associations between dietary pattern tertiles and outcomes were assessed by multivariable linear and multinomial logistic regression analyses. Results: Dietary patterns were not associated with measures of GWG or adequacy for gestational age. Greater adherence to the HEI-2015 and a PCA-derived dietary pattern characterized by nutrient-dense foods were associated with higher birthweight z-scores [β: 0.2; 95% confidence interval (CI): 0.04 to 0.4 and β: 0.3; 95% CI: 0.1 to 0.5, respectively], but in sex-specific analyses, these associations were only evident in male infants (β: 0.4; 95% CI: 0.03 to 0.7 and β: 0.3; 95% CI: 0.03 to 0.6, respectively). Conclusions: Among a cohort of culturally diverse Hispanic women, adherence to healthy dietary patterns during pregnancy was modestly positively associated with increased birthweight, with sex-specific associations evident only in male infants.

Household Food Insecurity and Maternal-Toddler Fruit and Vegetable Dietary Concordance

OBJECTIVE

To examine whether prenatal or concurrent household food insecurity influences associations between maternal and toddler fruit and vegetable (FV) intake.

DESIGN

Application of a life-course framework to an analysis of a longitudinal dataset.

SETTING

Early childhood obesity prevention program at a New York City public hospital.

PARTICIPANTS

One-hundred and fifty-six maternal-toddler dyads self-identifying as Hispanic or Latino.

VARIABLES MEASURED

Maternal and toddler FV intake was measured using Centers for Disease Control and Prevention dietary measures when toddlers were aged 19 months. Household food insecurity (measured prenatally and concurrently at 19 months) was measured using the US Department of Agriculture Food Security Module.

ANALYSIS

Regression analyses assessed associations between adequate maternal FV intake and toddler FV intake. Interaction terms tested whether prenatal or concurrent household food insecurity moderated this association.

RESULTS

Adequate maternal FV intake was associated with increased toddler FV intake (B = 6.2 times/wk, 95% confidence interval, 2.0-10.5, P = 0.004). Prenatal household food insecurity was associated with decreased toddler FV intake (B = -6.3 times/wk, 95% confidence interval, -11.67 to -0.9, P = 0.02). There was a significant interaction between the level of maternal-toddler FV association (concordance or similarity in FV intake between mothers and toddlers) and the presence of food insecurity such that maternal-toddler FV association was greater when prenatal household food insecurity was not present (B = -11.6, P = 0.04).

CONCLUSIONS AND IMPLICATIONS

Strategies to increase FV intake across the life course could examine how the timing of household food insecurity may affect intergenerational maternal-child transmission of dietary practices.

Prenatal and Pediatric Primary Care-Based Child Obesity Prevention: Effects of Adverse Social Determinants of Health on Intervention Attendance and Impact

Background: Adverse social determinants of health (SDoHs), specifically psychosocial stressors and material hardships, are associated with early childhood obesity. Less is known about whether adverse SDoHs modify the efficacy of early childhood obesity prevention programs. Methods: We conducted a secondary analysis of publicly insured birthing parent-child dyads with Latino backgrounds participating in a randomized controlled trial of the Starting Early Program (StEP), a child obesity prevention program beginning in pregnancy. We measured baseline adverse SDoHs categorized as psychosocial stressors (low social support, single marital status, and maternal depressive symptoms) and material hardships (food insecurity, housing disrepair, and financial difficulties) individually and cumulatively in the third trimester. Logistic regression models tested effects of adverse SDoHs on StEP attendance. We then tested whether adverse SDoHs moderated intervention impacts on weight at age 2 years. Results: We observed heterogeneous effects of adverse SDoHs on outcomes in 358 parent-child dyads. While housing disrepair decreased odds of higher attendance [adjusted odds ratio (aOR) 0.52, 95% confidence interval (CI): 0.29-0.94], high levels of psychosocial stressors doubled odds of higher attendance (aOR 2.36, 95% CI: 1.04-5.34). Similarly, while certain adverse SDoHs diminished StEP impact on weight (e.g., housing disrepair), others (e.g., high psychosocial stress) enhanced StEP impact on weight. Conclusions: Effects of adverse SDoHs on intervention outcomes depend on the specific adverse SDoH. Highest engagement and benefit occurred in those with high psychosocial stress at baseline, suggesting that StEP components may mitigate aspects of psychosocial stressors. Findings also support integration of adverse SDoH assessment into strategies to enhance obesity prevention impacts on families with material hardships. Trial Registration: This study is registered on clinicaltrials.gov: Starting Early Obesity Prevention Program (NCT01541761); https://clinicaltrials.gov/ct2/show/NCT01541761.

Do Appetite Traits Mediate the Link Between Birth Weight and Later Child Weight in Low-Income Hispanic Families?

Background: Birth weight and appetite traits (ATs) are important early life determinants of child weight and obesity. Objectives: The aim of this study is to examine whether (1) birth weight-for-gestational age z-scores (BWGAzs) were associated with ATs at child age 2 years and (2) ATs mediated the link between BWGAzs and weight-for-age z-scores (WFAzs) at child ages 3 and 4 years among Hispanic children. Methods: We conducted a secondary longitudinal analysis of data from the Starting Early Program of low-income, Hispanic mother-child pairs. ATs were assessed using the Child Eating Behavior Questionnaire at age 2 years. Child birth weight was obtained from medical records. Birth weight, sex, and gestational age were used to generate BWGAzs with Fenton growth curves. WFAz was calculated based on the CDC 2000 growth charts. Regression and mediation analyses were used to explore associations between BWGAzs, ATs, and WFAzs. Results: Infants with higher BWGAzs had significantly lower Satiety Responsiveness (B = -0.10) and Food Fussiness (B = -0.13) scores at age 2 years and higher WFAzs at ages 3 (B = 0.44) and 4 (B = 0.34) years. Lower Satiety Responsiveness at age 2 years was associated with higher WFAzs at ages 3 (B = -0.11) and 4 (B = -0.34; all p < 0.01) years. Lower Satiety Responsiveness partially mediated the positive relationship between birth weight and child WFAzs at ages 3 and 4 years. Conclusions: Children with higher birth weight and lower Satiety Responsiveness scores may be at higher risk of developing obesity in childhood. Further research is needed to understand the mechanisms through which birth weight influences child appetite. Clinical Trial Registration: ClinicalTrials.gov: NCT01541761.

Protective Effect of Prenatal Social Support on the Intergenerational Transmission of Obesity in Low-Income Hispanic Families

Background: Prepregnancy overweight/obesity (OW/OB) is a strong risk factor for child obesity. Few studies have identified modifiable factors that mitigate this risk. Objective: The objective of this study was to determine if prenatal social support buffers the effect of prepregnancy OW/OB on child birth weight z-score (BWz) and weight-for-age z-score (WFAz) trajectory. Methods: We performed a longitudinal secondary analysis of 524 mother-infant pairs enrolled in a randomized controlled trial of the Starting Early Program, a child obesity prevention program for Hispanic families with low income. Social support was assessed in the third trimester of pregnancy; maternal prepregnancy OW/OB and child WFAz from birth to age 3 years were obtained from medical records. Linear regression and multilevel modeling tested the effects of maternal prepregnancy OW/OB on child weight outcomes, and whether prenatal social support moderated these effects. Results: Prepregnancy OW/OB was associated with significantly higher child BWz (B = 0.23, p = 0.01) and WFAz trajectories (B = 0.19, 0.01). The interaction between social support and prepregnancy OW/OB was negatively related to child BWz (B = -0.26, p = 0.02) and WFAz trajectory (B = -0.40, p = 0.047). Conclusions: Prenatal social support may be protective against the intergenerational transmission of obesity risk. Interventions for the prevention of child obesity should consider incorporating social support into their design. Clinical Trial Registration Number: NCT01541761.

Obesity in Children

Child obesity is widely prevalent, and general pediatricians play an important role in identifying and caring for patients with obesity. Appropriate evaluation and treatment require an understanding of the complex etiology of child obesity, its intergenerational transmission, and its epidemiologic trends, including racial/ethnic and socioeconomic disparities. The American Academy of Pediatrics has published screening, evaluation, and treatment guidelines based on the best available evidence. However, gaps in evidence remain, and implementation of evidence-based recommendations can be challenging. It is important to review optimal care in both the primary care and multidisciplinary weight management settings. This allows for timely evaluation and appropriate referrals, with the pediatrician playing a key role in advocating for patients at higher risk. There is also a role for larger-scale prevention and policy measures that would not only aid pediatricians in managing obesity but greatly benefit child health on a population scale.

Infant appetite traits, feeding practices and child obesity in low-income Hispanic families

BACKGROUND

Appetite traits and feeding practices are important determinants of child weight and obesity.

OBJECTIVES

This study examined whether: (1) infant appetite traits were associated with feeding practices and (2) feeding practices mediated the link between appetite traits and weight-for-age z-scores at age 3 years.

METHODS

We conducted a secondary data analysis from the 'Starting Early Program' of low-income, Hispanic mother-child pairs. Appetite traits were assessed using the Baby Eating Behaviour Questionnaire. Infant feeding practices were collected using 24-h dietary recalls and surveys: (1) breastfeeding exclusivity, intensity and duration; (2) early introduction to complementary foods/liquids and (3) any 100% fruit juice consumption at age 10 months. Regression and mediation analyses were used to explore associations between appetite, feeding and weight.

RESULTS

Higher infant Slowness in Eating scores were associated with greater breastfeeding exclusivity, intensity and duration, compared to lower Slowness in Eating. Infants with higher Slowness in Eating and Satiety Responsiveness had lower odds of early introduction to complementary foods/liquids. Infants with higher Enjoyment of Food had greater odds of 100% juice consumption. Breastfeeding duration mediated the relationship between higher infant Slowness in Eating and lower weight-for-age z-scores.

CONCLUSIONS

Appetite traits represent potential targets for early life infant feeding interventions.

Age-dependent association of obesity with COVID-19 severity in paediatric patients

BACKGROUND

Limited research has addressed the obesity-COVID-19 severity association in paediatric patients.

OBJECTIVE

To determine whether obesity is an independent risk factor for COVID-19 severity in paediatric patients and whether age modifies this association.

METHODS

SARS-CoV-2-positive patients at NYU Langone Health from 1 March 2020 to 3 January 2021 aged 0-21 years with available anthropometric measurements: weight, length/height and/or body mass index (BMI). Modified log-Poisson models were utilized for the analysis. Main outcomes were 1) hospitalization and 2) critical illness (intensive care unit [ICU] admission).

RESULTS

One hundred and fifteen of four hundred and ninety-four (23.3%) patients had obesity. Obesity was an independent risk factor for critical illness (adjusted risk ratio [ARR] 2.02, 95% CI 1.17 to 3.48). This association was modified by age, with obesity related to a greater risk for critical illness in adolescents (13-21 years) [ARR 3.09, 95% CI 1.48 to 6.47], but not in children (0-12 years). Obesity was not an independent risk factor for hospitalization for any age.

CONCLUSION

Obesity was an independent risk factor for critical illness in paediatric patients, and this association was modified by age, with obesity related to a greater risk for critical illness in adolescents, but not in children. These findings are crucial for patient risk stratification and care.

Transforming Obesity Prevention for CHILDren (TOPCHILD) Collaboration: protocol for a systematic review with individual participant data meta-analysis of behavioural interventions for the prevention of early childhood obesity

INTRODUCTION

Behavioural interventions in early life appear to show some effect in reducing childhood overweight and obesity. However, uncertainty remains regarding their overall effectiveness, and whether effectiveness differs among key subgroups. These evidence gaps have prompted an increase in very early childhood obesity prevention trials worldwide. Combining the individual participant data (IPD) from these trials will enhance statistical power to determine overall effectiveness and enable examination of individual and trial-level subgroups. We present a protocol for a systematic review with IPD meta-analysis to evaluate the effectiveness of obesity prevention interventions commencing antenatally or in the first year after birth, and to explore whether there are differential effects among key subgroups.

METHODS AND ANALYSIS

Systematic searches of Medline, Embase, Cochrane Central Register of Controlled Trials, Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycInfo and trial registries for all ongoing and completed randomised controlled trials evaluating behavioural interventions for the prevention of early childhood obesity have been completed up to March 2021 and will be updated annually to include additional trials. Eligible trialists will be asked to share their IPD; if unavailable, aggregate data will be used where possible. An IPD meta-analysis and a nested prospective meta-analysis will be performed using methodologies recommended by the Cochrane Collaboration. The primary outcome will be body mass index z-score at age 24±6 months using WHO Growth Standards, and effect differences will be explored among prespecified individual and trial-level subgroups. Secondary outcomes include other child weight-related measures, infant feeding, dietary intake, physical activity, sedentary behaviours, sleep, parenting measures and adverse events.

ETHICS AND DISSEMINATION

Approved by The University of Sydney Human Research Ethics Committee (2020/273) and Flinders University Social and Behavioural Research Ethics Committee (HREC CIA2133-1). Results will be relevant to clinicians, child health services, researchers, policy-makers and families, and will be disseminated via publications, presentations and media releases.

PROSPERO REGISTRATION NUMBER

CRD42020177408.

Unpacking the behavioural components and delivery features of early childhood obesity prevention interventions in the TOPCHILD Collaboration: a systematic review and intervention coding protocol

INTRODUCTION

Little is known about how early (eg, commencing antenatally or in the first 12 months after birth) obesity prevention interventions seek to change behaviour and which components are or are not effective. This study aims to (1) characterise early obesity prevention interventions in terms of target behaviours, delivery features and behaviour change techniques (BCTs), (2) explore similarities and differences in BCTs used to target behaviours and (3) explore effectiveness of intervention components in preventing childhood obesity.

METHODS AND ANALYSIS

Annual comprehensive systematic searches will be performed in Epub Ahead of Print/MEDLINE, Embase, Cochrane (CENTRAL), CINAHL, PsycINFO, as well as clinical trial registries. Eligible randomised controlled trials of behavioural interventions to prevent childhood obesity commencing antenatally or in the first year after birth will be invited to join the Transforming Obesity in CHILDren Collaboration. Standard ontologies will be used to code target behaviours, delivery features and BCTs in both published and unpublished intervention materials provided by trialists. Narrative syntheses will be performed to summarise intervention components and compare applied BCTs by types of target behaviours. Exploratory analyses will be undertaken to assess effectiveness of intervention components.

ETHICS AND DISSEMINATION

The study has been approved by The University of Sydney Human Research Ethics Committee (project no. 2020/273) and Flinders University Social and Behavioural Research Ethics Committee (project no. HREC CIA2133-1). The study's findings will be disseminated through peer-reviewed publications, conference presentations and targeted communication with key stakeholders.

PROSPERO REGISTRATION NUMBER

CRD42020177408.

Grandparent Coresidence and Risk of Early Child Overweight and Obesity in Low-Income, Hispanic Families in New York City

OBJECTIVE

Children in low-income Hispanic families are at high risk of obesity and are more likely to live with grandparents than their non-Hispanic white counterparts. We aimed to determine if grandparent coresidence (prenatal through age 2 years) was associated with: 1) obesogenic feeding practices; and 2) child weight outcomes from birth to three years.

METHODS

We analyzed data from 267 low-income, Hispanic mother-infant pairs in the control group of an obesity prevention trial in New York City. Linear and logistic regression tested differences in obesogenic feeding practices and weight outcomes at 2 and 3 years, dependent upon grandparent coresidence. Multilevel modeling tested associations between grandparent coresidence and WFAz over time.

RESULTS

Persistent grandparent coresidence (vs none) was associated with putting cereal in the bottle (adjusted odds ratio [aOR] 3.46; 95% confidence interval [CI] 1.43, 8.40). Persistent grandparent coresidence (vs none) was associated with higher mean WFAz (2 years: B 0.83; 95% CI 0.41, 1.25; 3 years: B 0.79; 95% CI 0.32, 1.25) and higher odds of child overweight/obesity risk (2 years: aOR 4.38; 95% CI 1.64, 11.69; 3 years: aOR 3.15; 95% CI 1.19, 8.36). In multilevel models, more occasions of grandparent coresidence were associated with higher WFAz.

CONCLUSIONS

Grandparent coresidence may be associated with higher risk of child overweight/obesity in low-income, Hispanic families. Further research is needed to elucidate mechanisms of these associations and to inform obesity prevention strategies in the context of multigenerational families.

Maternal Stress and Infant Feeding in Hispanic Families Experiencing Poverty

OBJECTIVES

Maternal stress has been associated with early child obesity through pathways related to decreased exclusive breastfeeding and increased nonresponsive maternal-infant feeding styles. We sought to gain an in-depth understanding of how maternal stress, sadness, and isolation are perceived to affect feeding, in order to inform modifiable targets of intervention.

METHODS

We conducted semi-structured qualitative interviews with Hispanic mothers living in poverty with young infants between 3 and 7 months old (n = 32) from the intervention group of a randomized controlled trial of an early child obesity prevention intervention (Starting Early Program). Bilingual English-Spanish interviewers conducted the interviews, which were audio recorded, transcribed, and translated. Building on an existing theoretical framework developed by the National Scientific Council on the Developing Child, we used an iterative process of textual analysis to code the transcripts, until thematic saturation was reached.

RESULTS

Three key themes were described: 1) maternal stress responses were varied and included positive (brief and mild), tolerable (sustained but limited long-term impacts), or toxic stress (sustained and severe); 2) buffers included support from family, infants, health care providers, social service programs, and community organizations; 3) perceived effects on infant feeding included decreased breastfeeding due to concerns about stress passing directly through breast milk and indirectly through physical closeness, and increased nonresponsive feeding styles.

CONCLUSIONS

Maternal stress, particularly toxic stress, was perceived to negatively affect infant feeding. Mothers reported disrupting healthy feeding to avoid infant exposure to stress. Interventions to enhance buffering may help to mitigate toxic stress and promote healthy feeding interactions.

Associations Between Birthweight and Appetite Traits: Appetite Traits Partially Mediate the Link Between Birthweight and Later Child Weight in Low-Income Hispanic Families

Objectives

To examine whether: 1) birthweight was associated with child appetite traits (AT) at age 2 years; and 2) ATs mediated the link between birthweight and weight at age 3 years among Hispanic children.

Methods

This study is a secondary longitudinal analysis of data collected from the “Starting Early Program” randomized controlled obesity prevention trial of low-income, Hispanic mother-child pairs (n = 533). Birthweight-for-gestational-age z-scores (BWGAz) were determined using Fenton growth curves; weight-for-age z-scores (WFAz) were determined using World Health Organization growth charts. Four ATs, including Food Responsiveness (FR), Enjoyment of Food (EF), Satiety Responsiveness (SR), and Slowness in Eating (SE), were assessed using the Child Eating Behavior Questionnaire at age 2 years. Simple linear regression analysis was used to assess direct associations between BWGAz and each AT. Bootstrapping analyses were used to assess whether ATs were significantly associated with BWGAz, and mediated the relationship between BWGAz and later child WFAz.

Results

Of the 401 children with both BWGAz and AT measures, 49% were male with mean birthweight of 3.4 kg. After adjusting for covariates related to child weight, infants with higher BWGAz had lower SR scores at age 2 years (B = −0.11, 95%CI = −0.18 to − 0.04, P &lt; 0.01) and higher WFAz at age 3 years (B = 0.39, 95%CI = 0.26 to 0.53; P &lt; 0.001). Lower SR was also associated with higher WFAz at age 3 years (B = −0.42, 95%CI = −0.62 to −0.22, P &lt; 0.001). A significant indirect effect of BWGAz on WFAz at age 3 years through SR at age 2 years was detected (B = 0.04, 95%CI = 0.01 to 0.08; P &lt; 0.01 [indirect effect]); however, only 10% of the total effect was mediated by this indirect pathway. Therefore, SR partially mediated the positive relationship between BWGAz and child WFAz at age 3 years. BWGAz was not associated with other ATs.

Conclusions

Higher BWGAz was associated with lower SR scores at age 2 years and higher WFAz at age 3 years. SR partially mediated the link between BWGAz and child WFAz. Our findings warrant exploring additional pathways through which birthweight effects appetite traits, as well as later child weight.

Funding Sources

USDA AFRI.

Infant and Early Child Appetite Traits and Child Weight and Obesity Risk in Low-Income Hispanic Families

BACKGROUND

Child appetite traits (ATs) are associated with later child weight and obesity risk. Less research has focused on ATs in low-income Hispanic children or included longitudinal associations with infant weight.

OBJECTIVE

To determine stability of ATs during infancy and childhood and their relationship with subsequent weight and obesity risk at age 3 years among low-income Hispanic children.

DESIGN

A secondary longitudinal analysis of data from the Starting Early Program randomized controlled obesity prevention trial.

PARTICIPANTS/SETTING

Three hundred twenty-two low-income, Hispanic mother-child pairs enrolled between 2012 and 2014 in a public hospital in New York City.

MAIN OUTCOME MEASURES

ATs, including Slowness in Eating, Satiety Responsiveness, Food Responsiveness, and Enjoyment of Food were assessed using the Baby and Child Eating Behavior Questionnaires at ages 3 months, 2 years, and 3 years. Main outcome measures were child standardized weight-for-age z score (WFAz) and obesity risk (WFA≥95th percentile) at age 3 years.

STATISTICAL ANALYSES PERFORMED

AT stability was assessed using correlations and multilevel modeling. Linear and logistic regression analyses examined associations between ATs and child WFAz and obesity risk at age 3 years.

RESULTS

There was limited stability for all ATs measured over time. During infancy, Slowness in Eating was associated with lower 3-year WFAz (B = -0.18, 95% CI -0.33 to -0.04; P = 0.01). At age 2 years, Slowness in Eating and Satiety Responsiveness were associated with lower WFAz (B = -0.29, 95% CI -0.47 to -0.12; P < 0.01; B = -0.36, 95% CI -0.55 to -0.17; P < 0.01) and obesity risk (adjusted odds ratio 0.49, 95% CI 0.28 to 0.85; adjusted odds ratio 0.61, 95% CI 0.38 to 0.99) at 3 years. Increased Slowness in Eating and Satiety Responsiveness over time were associated with lower 3-year WFAz (B = -0.74, 95% CI -1.18 to -0.2 [Slowness in Eating]; B = -1.19, 95% CI -1.87 to -0.52 [Satiety Responsiveness], both P values = 0.001). Higher Enjoyment of Food over time was associated with higher 3-year WFAz (B = 0.62, 95% CI 0.24 to 1.01; P = 0.002).

CONCLUSIONS

Infants with lower Slowness in Eating and Satiety Responsiveness may have higher levels of obesity risk and need more tailored approaches to nutrition counseling and obesity prevention.

Integrating Health Care Strategies to Prevent Poverty-Related Disparities in Development and Growth: Addressing Core Outcomes of Early Childhood

Poverty-related disparities appear early in life in cognitive, language, and social-emotional development, and in growth, especially obesity, and have long-term consequences across the life course. It is essential to develop effective strategies to promote healthy behaviors in pregnancy and the early years of parenthood that can mitigate disparities. Primary preventive interventions within the pediatric primary care setting offer universal access, high engagement, and population-level impact at low cost. While many families in poverty or with low income would benefit from preventive services related to both development and growth, most successful interventions have tended to focus on only one of these domains. In this manuscript, we suggest that it may be possible to address both development and growth simultaneously and effectively. In particular, current theoretical models suggest alignment in mechanisms by which poverty can create barriers to parent-child early relational health (i.e., parenting practices, creating structure, and parent-child relationship quality), constituting a final common pathway for both domains. Based on these models and related empirical data, we propose a strength-based, whole child approach to target common antecedents through positive parenting and prevent disparities in both development and growth; we believe this approach has the potential to transform policy and practice. Achieving these goals will require new payment systems that make scaling of primary prevention in health care feasible, research funding to assess efficacy/effectiveness and inform implementation, and collaboration among early childhood stakeholders, including clinicians across specialties, scientists across academic disciplines, and policy makers.

Persistent organic pollutants exposure in newborn dried blood spots and infant weight status: A case-control study of low-income Hispanic mother-infant pairs

Persistent organic pollutants (POPs) are believed to alter metabolic homeostasis during fetal development, leading to childhood obesity. However, limited studies have explored how fetal chemical exposures relate to birth and infant weight outcomes in low-income Hispanic families at the highest risk of obesity. Therefore, we sought to determine associations between neonatal POPs exposure measured in newborn dried blood spots (DBS) and prenatal diet quality, birth weight, and overweight status at 18 months old. We conducted a case-control study nested within the Starting Early Program randomized controlled trial comparing POPs concentrations in infants with healthy weight (n = 46) and overweight status (n = 52) at age 18 months. Three categories of POPs, organochlorine pesticides (OCPs), polybrominated diphenyl ethers (PBDEs) and perfluoroalkyl substances (PFASs) were measured in archived newborn DBS. We assessed correlations between prenatal diet quality and neonatal POPs concentrations. Multivariable regression analyses examined associations between POPs (dichotomized at the mean) and birth weight z-score and weight status at 18 months, controlling for confounders. Seven of eight chemicals had detectable levels in greater than 94% of the sample. Higher protein, sodium and refined grain intake during pregnancy were correlated with lower POPs in newborn DBS. We found that high concentrations of perfluorooctanesulfonate (unstandardized coefficient [B]: -0.62, 95% confidence interval [CI]: -0.96 to -0.29) and perfluorohexanesulfate (B: -0.65, 95% CI: -0.99 to -0.31) were related to lower birth weight z-scores compared to those with low concentrations. We did not find associations between PBDEs, OCPs, and the other PFASs with birth weight z-scores, or between any POPs and weight status at 18 months. In conclusion, two PFASs were associated with lower birth weight, an important indicator of child health and growth, although direct associations with infant overweight status were not found. Whether neonatal POPs exposures contribute to economic and ethnic disparities in early obesity remains unclear.

Prenatal and Pediatric Primary Care-Based Child Obesity Prevention Program: A Randomized Trial

OBJECTIVES

To determine impact of a primary care-based child obesity prevention intervention beginning during pregnancy on early childhood weight outcomes in low-income Hispanic families.

METHODS

A randomized controlled trial comparing mother-infant pairs receiving either standard care or the Starting Early Program providing prenatal and postpartum nutrition counseling and nutrition parenting support groups targeting key obesity-related feeding practices in low-income groups. Primary outcomes were reduction in weight-for-age z-scores (WFAzs) from clinical anthropometric measures, obesity prevalence (weight for age ≥95th percentile), and excess weight gain (WFAz trajectory) from birth to age 3 years. Secondary outcomes included dose effects.

RESULTS

Pregnant women (n = 566) were enrolled in the third trimester; 533 randomized to intervention (n = 266) or control (n = 267). Also, 358 children had their weight measured at age 2 years; 285 children had weight measured at age 3 years. Intervention infants had lower mean WFAz at 18 months (0.49 vs 0.73, P = .04) and 2 years (0.56 vs 0.81, P = .03) but not at 3 years (0.63 vs 0.59, P = .76). No group differences in obesity prevalence were found. When generalized estimating equations were used, significant average treatment effects were detected between 10-26 months (B = -0.19, P = .047), although not through age 3 years. In within group dose analyses at 3 years, obesity rates (26.4%, 22.5%, 8.0%, P = .02) decreased as attendance increased with low, medium, and high attendance.

CONCLUSIONS

Mean WFAz and growth trajectories were lower for the intervention group through age 2 years, but there were no group differences at age 3. Further study is needed to enhance sustainability of effects beyond age 2.

Starting Early Program Impacts on Feeding at Infant 10 Months Age: A Randomized Controlled Trial

Background: Disparities in obesity-promoting feeding patterns begin in pregnancy and infancy, underscoring the need for early primary prevention in high-risk groups. We sought to determine the impact of a primary care-based child obesity prevention intervention beginning during pregnancy on maternal infant feeding practices, knowledge, and styles at 10 months in low-income Hispanic families. Methods: The Starting Early Program (StEP) randomized controlled trial enrolled pregnant women at a third trimester visit. Women (n = 533) were randomized to standard care or an intervention with prenatal/postpartum individual nutrition counseling and nutrition and parenting support groups coordinated with pediatric visits. Feeding practices (breastfeeding, family meals, juice, and cereal in the bottle) were assessed using questions from the Infant Feeding Practices Study II. Feeding styles were assessed using the Infant Feeding Style Questionnaire. We analyzed impacts on feeding practices, knowledge, and styles using regression analyses adjusting for covariates. Results: Four hundred twelve mothers completed 10-month assessments. Intervention mothers were more likely to give breast milk as the only milk source [adjusted odds ratio (AOR) 1.65, 95% confidence interval (CI) 1.06-2.58] and have daily family meals (AOR 1.91, 95% CI 1.19-3.05), and less likely to give juice (AOR 0.60, 95% CI 0.39-0.92) or cereal in the bottle (AOR 0.54, 95% CI 0.30-0.97) compared to controls. Intervention mothers were more likely to exhibit lower pressuring, indulgent and laissez-faire feeding styles, and to have higher knowledge. Attending a greater number of group sessions increased intervention impacts. Conclusions: StEP led to reduced obesity-promoting feeding practices and styles, and increased knowledge and provides great potential for population-scalability.

Infant Appetite Traits and Early Infant Feeding Practices in Low-Income Hispanic Families

Objectives

This study examined the association of infant appetite traits and exclusive breastfeeding (EBF), BF intensity, early introduction of complementary foods/liquids and 100% fruit juice consumption among Hispanic infants during the first year of life.

Methods

This study is a cross-sectional analysis of data collected from the “Starting Early Program" randomized controlled obesity prevention trial of low-income, Hispanic mother-child pairs (n = 533). Four infant appetite traits including Food Responsiveness (FR), Enjoyment of Food (EF), Satiety Responsiveness (SR), and Slowness in Eating (SE) were assessed using the Baby Eating Behavior Questionnaire. Each appetite trait was based on a 5-point Likert frequency scale. Infant feeding measures were collected using 24-hour recall methodology and survey based on the Infant Feeding Practices Study II. Linear and logistic regressions assessed the associations between appetite traits and infant feeding practices, specifically 1) EBF, 2) BF intensity (% of daily milk consumption that is breast milk), 3) early introduction to complementary foods/liquids defined as receiving prior to infant age 4 months, and 4) Any 100% fruit juice consumption at age 10 months.

Results

Of the 473 children with both appetite and infant feeding measures, 48% were male with mean birth weight of 3.4 kg. After adjusting for confounders, infants with higher SE scores had higher odds of EBF duration (≥3 months) (OR = 1.7, P &lt; 0.001), and higher odds of having medium (20% ≤ score ≤ 80%) and high (&gt;80%) BF intensity (OR = 1.8, P = 0.002; OR = 2.5, P &lt; 0.001), compared to infants with lower SE scores. Infants with higher SE and SR were less likely to receive early complementary foods/liquids (OR = 0.59, P = 0.026; OR = 0.51, P = 0.009). Infants with higher EF were more likely to consume any 100% fruit juice at age 10 months (OR = 1.7, P = 0.047). The other appetite traits were not significantly related to infant feeding measures.

Conclusions

Higher SE was associated with greater EBF and BF intensity. Infants with higher SE and SR were less likely to have early introduction to complementary foods/liquids. Infants with higher EF were more likely to have juice at 10 months. Appetite traits are associated with potentially obesogenic feeding practices and may represent a target for early life infant feeding interventions.

Funding Sources

USDA AFRI.

Total and trimester-specific gestational weight gain and infant anthropometric outcomes at birth and 6 months in low-income Hispanic families

OBJECTIVE

To describe total and trimester-specific gestational weight gain (GWG) among low-income Hispanic women and determine whether these GWG exposures are associated with infant anthropometric outcomes at birth and 6 months.

STUDY DESIGN

Data were from 448 mother-infant pairs enrolled in the Starting Early child obesity prevention trial. Prenatal weights were used to calculate total GWG and 2^nd and 3^rd trimester GWG rates (kg/week) and categorized as inadequate, adequate, and excessive according to the 2009 Institute of Medicine recommendations. Multivariable linear and modified Poisson regressions estimated associations of infant anthropometric outcomes (birthweight, small-for-gestational age [SGA], large-for-gestational age [LGA], rapid weight gain, and weight-for-age, length-for-age, and weight-for-length z-scores at 6 months) with GWG categories.

RESULTS

For total GWG, 39% and 27% of women had inadequate and excessive GWG, respectively. 57% and 46% had excessive GWG rates in the 2^nd and 3^rd trimesters, respectively, with 29% having excessive rates in both trimesters. Inadequate total GWG was associated with lower infant weight and length outcomes (ß range for z-scores = -0.21 to -0.46, p < 0.05) and lower risk of LGA (adjusted Relative Risk, aRR = 0.38; 95% confidence intervals, CI: 0.16, 0.95) and rapid weight gain (aRR = 0.72; 95%CI: 0.51, 1.00). GWG rates above recommendations in the 2^nd trimester or 2^nd /3^rd trimesters were associated with greater weight outcomes at birth and 6 months (ß range for z-scores = 0.24 to 0.35, p < 0.05).

CONCLUSIONS

Counseling women about health behaviors and closely monitoring GWG beginning in early pregnancy is necessary, particularly among populations at high-risk of obesity.

Glyphosate exposures and kidney injury biomarkers in infants and young children

The goal of this study was to assess biomarkers of exposure to glyphosate and assess potential associations with renal function in children. Glyphosate is used ubiquitously in agriculture worldwide. While previous studies have indicated that glyphosate may have nephrotoxic effects, few have examined potential effects on kidney function in children. We leveraged three cohorts across different phases of child development and measured urinary levels of glyphosate. We evaluated associations of glyphosate with three biomarkers of kidney injury: albuminuria (ACR), neutrophil gelatinase-associated lipocalin (NGAL), and kidney injury marker 1 (KIM-1). Multivariable regression analyses examined associations of glyphosate with kidney injury biomarkers controlling for covariates. We identified glyphosate in 11.1% of the total participants. The herbicide was detected more frequently in the neonate population (30%). Multivariable regression models failed to identify significant associations of log-transformed glyphosate with any of the kidney injury biomarkers, controlling for covariates age, sex, and maternal education. While we confirm detectability of glyphosate in children's urine at various ages and stages of life, there is no evidence in this study for renal injury in children exposed to low levels of glyphosate. Further studies of larger sample size are indicated to better understand putative deleterious effects of the herbicide after different levels of exposure.

Material Hardships and Infant and Toddler Sleep Duration in Low-Income Hispanic Families

OBJECTIVE

To assess relationships between material hardships, shortened sleep duration, and suboptimal sleep practices across infancy and toddlerhood in low-income Hispanic families.

METHODS

We analyzed longitudinal data of 451 low-income Hispanic mother-child pairs from a child obesity prevention trial. During infancy and toddlerhood, we used adjusted linear regression to assess associations between material hardship (financial difficulty, food insecurity, housing disrepair, and multiple hardships), sleep duration (24-hour, night), and the number of suboptimal sleep practices (eg, later bedtime, co-sleeping). We used adjusted linear regression to assess the longitudinal association between the number of suboptimal sleep practices in infancy and toddlerhood, and tested whether specific or multiple hardships moderated this association.

RESULTS

In infants, financial difficulty and multiple hardships were associated with decreased night sleep (B = -0.59 hours, 95% confidence interval [CI]: -1.04, -0.14; and B = -0.54 hours, 95% CI: -1.00, -0.08). Housing disrepair was associated with decreased 24-hour sleep (B = -0.64 hours, 95% CI: -1.29, -0.01). In toddlers, each additional suboptimal sleep practice was associated with a decrease in night sleep (B = -0.19 hours, 95% CI: -0.29, -0.09). Each additional suboptimal sleep practice in infancy was associated with a 0.30 increase in the number of suboptimal sleep practices in toddlerhood (P < .001), with greater increases for those with food insecurity or multiple hardships.

CONCLUSION

Specific and multiple hardships shortened sleep duration during infancy, and moderated the increase of suboptimal sleep behaviors between infancy and toddlerhood. Future studies should consider these early critically sensitive periods for interventions to mitigate material hardships and establish healthy sleep practices.

Food Insecurity During Pregnancy and Breastfeeding by Low-Income Hispanic Mothers

BACKGROUND AND OBJECTIVES

Pregnancy, infancy, and toddlerhood are sensitive times in which families are particularly vulnerable to household food insecurity and when disparities in child obesity emerge. Understanding obesity-promoting infant-feeding beliefs, styles, and practices in the context of food insecurity could better inform both food insecurity and child obesity prevention interventions and policy guidelines.

METHODS

We performed purposive sampling of low-income Hispanic mothers (n = 100) with infants in the first 2 years of life, all of whom were participants in a randomized controlled trial of an early child obesity prevention intervention called the Starting Early Program. Bilingual English-Spanish interviewers conducted semistructured qualitative interviews, which were audio recorded, transcribed, and translated. By using the constant comparative method, transcripts were coded through an iterative process of textual analysis until thematic saturation was reached.

RESULTS

Three key themes emerged: (1) contributors to financial strain included difficulty meeting basic needs, job instability, and high vulnerability specific to pregnancy, infancy, and immigration status; (2) effects on infant feeding included decreased breastfeeding due to perceived poor maternal diet, high stress, and limiting of healthy foods; and (3) coping strategies included both home- and community-level strategies.

CONCLUSIONS

Stakeholders in programs and policies to prevent poverty-related disparities in child obesity should consider and address the broader context by which food insecurity is associated with contributing beliefs, styles, and practices. Potential strategies include addressing misconceptions about maternal diet and breast milk adequacy, stress management, building social support networks, and connecting to supplemental nutrition assistance programs.

The Protective Effect of Prenatal Social Support on Infant Adiposity in the First 18 Months of Life

OBJECTIVE

To determine whether prenatal social support was associated with infant adiposity in the first 18 months of life in a low-income, Hispanic sample, known to be at high risk of early child obesity.

STUDY DESIGN

We performed a longitudinal analysis of 262 low-income, Hispanic mother-infant pairs in the control group of the Starting Early child obesity prevention trial. Prenatal social support was measured using an item from the Maternal Social Support Index. We used multilevel modeling to predict weight-for-length z-score trajectories from birth to age 18 months and logistic regression to predict macrosomia and overweight status at ages 6, 12, and 18 months.

RESULTS

High prenatal social support was independently associated with lower infant adiposity trajectories from birth to age 18 months (B = -0.40; 95% CI, -0.63 to -0.16), a lower odds of macrosomia (aOR = 0.35; 95% CI, 0.15-0.80), and a lower odds of overweight at ages 12 (aOR = 0.28; 95% CI, 0.10-0.74) and 18 months (aOR = 0.35; 95% CI, 0.14-0.89). Prenatal social support was not significantly associated with overweight status at age 6 months.

CONCLUSIONS

Prenatal social support may protect against excessive infant adiposity and overweight in low-income, Hispanic families. Further research is needed to elucidate mechanisms underlying these associations and to inform preventive strategies beginning in pregnancy.

Predicting childhood obesity using electronic health records and publicly available data

Background

Because of the strong link between childhood obesity and adulthood obesity comorbidities, and the difficulty in decreasing body mass index (BMI) later in life, effective strategies are needed to address this condition in early childhood. The ability to predict obesity before age five could be a useful tool, allowing prevention strategies to focus on high risk children. The few existing prediction models for obesity in childhood have primarily employed data from longitudinal cohort studies, relying on difficult to collect data that are not readily available to all practitioners. Instead, we utilized real-world unaugmented electronic health record (EHR) data from the first two years of life to predict obesity status at age five, an approach not yet taken in pediatric obesity research.

Methods and findings

We trained a variety of machine learning algorithms to perform both binary classification and regression. Following previous studies demonstrating different obesity determinants for boys and girls, we similarly developed separate models for both groups. In each of the separate models for boys and girls we found that weight for length z-score, BMI between 19 and 24 months, and the last BMI measure recorded before age two were the most important features for prediction. The best performing models were able to predict obesity with an Area Under the Receiver Operator Characteristic Curve (AUC) of 81.7% for girls and 76.1% for boys.

Conclusions

We were able to predict obesity at age five using EHR data with an AUC comparable to cohort-based studies, reducing the need for investment in additional data collection. Our results suggest that machine learning approaches for predicting future childhood obesity using EHR data could improve the ability of clinicians and researchers to drive future policy, intervention design, and the decision-making process in a clinical setting.

Correlates of Prenatal Diet Quality in Low-Income Hispanic Women

BACKGROUND

Low-income Hispanic women are at-risk of poor prenatal diet quality. Correlates associated with prenatal diet quality in this group of women are understudied.

OBJECTIVE

The objective of this study was to examine the associations between financial, cultural, psychosocial, and lifestyle correlates and prenatal diet quality in low-income Hispanic women.

DESIGN

This cross-sectional analysis used data from pregnant women enrolled in the Starting Early Trial, a randomized-controlled trial of a primary-care based child obesity prevention program beginning in pregnancy. The trial enrolled women from clinics affiliated with a large urban medical center in New York City from 2012 to 2014. Financial, cultural, psychosocial, and lifestyle variables were collected using a comprehensive baseline questionnaire. Usual dietary intakes over the past year were assessed using the Block Food Frequency Questionnaire 2005 bilingual version.

PARTICIPANTS

The study enrolled low-income Hispanic women between 28 and 32 gestational weeks (N=519).

MAIN OUTCOME MEASURES

Prenatal diet quality was measured by the Healthy Eating Index 2015.

STATISTICAL ANALYSES PERFORMED

Unadjusted and adjusted multivariable linear regression analyses were performed to determine independent associations between financial, cultural, psychosocial, and lifestyle correlates and Healthy Eating Index 2015 total score.

RESULTS

Overall prenatal diet quality was poor (mean Healthy Eating Index 2015 total score=69.0±9.4). Most women did not meet the maximum score for total vegetables (65.3%), whole grains (97.1%), dairy (74.8%), fatty acids (84.4%), refined grains (79.8%), sodium (97.5%), saturated fats (92.9%), and added sugars (66.5%). Women who reported screen time ≤2 hours/day, physical activity before and/or during pregnancy, and being born outside the United States had higher mean Healthy Eating Index 2015 total score than women with screen time >2 hours/day, no physical activity, and those born in the United States.

CONCLUSIONS

Prenatal diet quality of low-income pregnant Hispanic women was suboptimal. This cross-sectional study revealed associations between cultural and lifestyle factors and prenatal diet quality in low-income Hispanic women. Longitudinal studies are needed to determine long-term influences and specific behaviors to target for effective intervention studies.

Melamine and cyanuric acid exposure and kidney injury in US children

BACKGROUND

Melamine and cyanuric acid, which are currently used in a variety of common consumer products and present in foods, have been implicated in the development of urolithiasis and acute kidney injury in Chinese children. To determine whether US children have measurable concentrations of these chemicals in their bodies and whether they are at greater risk of acute kidney injury, we measured melamine and cyanuric acid exposure in a cohort of US children and determined their relationship with markers of kidney injury.

METHODS

We measured urinary melamine and cyanuric acid in a convenience sample of 109 children (4 months - 8 years) from Seattle, WA and New York City, NY using liquid chromatography with tandem mass spectrometry. We measured several urinary markers of kidney injury: fatty acid binding protein 3 (FABP3), kidney injury molecule 1 (KIM1), neutrophil gelatinase-associated lipocalin (NGAL) using Luminex xMAP methods, and urine urea was measured using standard laboratory methods. We described urinary melamine and cyanuric acid concentrations and assessed predictors of the exposures. We used multivariable linear regression to assess relationships between melamine/cyanuric acid and kidney injury markers in unadjusted and adjusted (creatinine, age, sex) analyses.

RESULTS

Melamine and cyanuric acid were above the limit of detection (LOD) in 78% and 95% of all samples, respectively. The mean concentrations (SD) for melamine and cyanuric acid were 27.4 ng/ml (141.9 ng/ml) and 35.3 ng/ml (42.4 ng/ml). In unadjusted analyses, we observed statistically significant increases in the percentages of FABP3 and KIM1 in relation to a one log unit change in melamine and cyanuric acid, respectively. In adjusted analyses, we observed a 55% (95% CI 0, 141) increase in KIM1 in relation to a one log unit increase in cyanuric acid.

CONCLUSIONS

US children have detectable concentrations of melamine and cyanuric acid in urine, and these concentrations are higher than those reported in children from other countries. This is a novel finding that improves upon previous exposure estimates using questionnaires only and suggests widespread exposure in the population. Cyanuric acid is associated with increased KIM 1 concentrations, suggesting kidney injury. Given the potential widespread exposure, future analyses should examine melamine and cyanuric acid in relation to chronic kidney disease and markers of kidney injury in a larger cohort that is representative of the general population.

Additive effects of household food insecurity during pregnancy and infancy on maternal infant feeding styles and practices

Food insecurity, or the limited access to food, has been associated with maternal child feeding styles and practices. While studies in other parenting domains suggest differential and additive impacts of poverty-associated stressors during pregnancy and infancy, few studies have assessed relations between food insecurity during these sensitive times and maternal infant feeding styles and practices. This study sought to analyze these relations in low-income Hispanic mother-infant pairs enrolled in a randomized controlled trial of an early obesity prevention program (Starting Early). Food insecurity was measured prenatally and during infancy at 10 months. Food insecurity timing was categorized as never, prenatal only, infancy only, or both. Regression analyses were used to determine relations between food insecurity timing and styles and practices at 10 months, using never experiencing food insecurity as the reference, adjusting for family characteristics and material hardships. 412 mother-infant pairs completed 10-month assessments. Prolonged food insecurity during both periods was associated with greater pressuring, indulgent and laissez-faire styles compared to never experiencing food insecurity. Prenatal food insecurity was associated with less vegetable and more juice intake. If food insecurity is identified during pregnancy, interventions to prevent food insecurity from persisting into infancy may mitigate the development of obesity-promoting feeding styles and practices.

Perception of Child Weight and Feeding Styles in Parents of Chinese-American Preschoolers

Parent perception of weight and feeding styles are associated with obesity in other racial groups but have not been explored in-depth in Chinese-American preschoolers. Cross-sectional survey of 253 Chinese-American parents with preschoolers was performed in a community clinic. Regression analysis was used to assess relationships between parental perception of weight and feeding styles. Parent under-perception of weight was common but more likely in boys than girls (χ² = 4.91, p = 0.03). Pressuring was also greater in boys [adjusted mean difference (95% CI) 0.24 (0.004, 0.49)]. In girls, pressuring was lower for children perceived as overweight [adjusted mean difference in CFQ scores -0.75 (-1.27, -0.23)]; in boys, pressuring was high regardless of perceived child weight. Weight perceptions and feeding styles related to childhood obesity in other groups were identified in Chinese-American families. Parent under-perception of child weight and pressure to eat were more common in boys. These factors should be addressed in Chinese-American preschooler obesity prevention programs.

Randomized controlled trial of an early child obesity prevention intervention: Impacts on infant tummy time

OBJECTIVE

To describe infant activity at 3 months old and to test the efficacy of a primary care-based child obesity prevention intervention on promoting infant activity in low-income Hispanic families.

METHODS

This study was a randomized controlled trial (n = 533) comparing a control group of mother-infant dyads receiving standard prenatal and pediatric primary care with an intervention group receiving "Starting Early," with individual nutrition counseling and nutrition and parenting support groups coordinated with prenatal and pediatric visits. Outcomes included infant activity (tummy time, unrestrained floor time, time in movement-restricting devices). Health literacy was assessed using the Newest Vital Sign.

RESULTS

Four hundred fifty-six mothers completed 3-month assessments. Infant activity results were: 82.6% ever practiced tummy time; 32.0% practiced tummy time on the floor; 34.4% reported unrestrained floor time; 56.4% reported ≥1 h/d in movement-restricting devices. Inadequate health literacy was associated with reduced tummy time and unrestrained floor time. The intervention group reported more floor tummy time (OR 2.16, 95% CI 1.44-3.23) and unrestrained floor time (OR 1.69, 95% CI 1.14-2.49) compared to controls. No difference in the time spent in movement-restricting devices was found.

CONCLUSIONS

Tummy time and unrestrained floor time were low. Primary care-based obesity prevention programs have potential to promote these activities.

Characteristics Associated With Adding Cereal Into the Bottle Among Immigrant Mother-Infant Dyads of Low Socioeconomic Status and Hispanic Ethnicity

OBJECTIVE

Determine maternal and infant characteristics associated with adding cereal into the bottle.

DESIGN

Secondary data analysis.

PARTICIPANTS

Study participants were immigrant, low-income, urban mother-infant dyads (n = 216; 91% Hispanic, 19% US-born) enrolled in a randomized controlled trial entitled the Bellevue Project for Early Language, Literacy and Education Success.

MAIN OUTCOME MEASURES

Maternal characteristics (age, marital status, ethnicity, primary language, country of origin, education, work status, income, depressive symptoms, and concern about infant's future weight) and infant characteristics (gender, first born, and difficult temperament).

ANALYSIS

Fisher exact test, chi-square test, and simultaneous multiple logistic regression of significant (P < .05) variables identified in unadjusted analyses.

RESULTS

Twenty-seven percent of mothers added cereal into the bottle. After adjusting for confounding variables identified in bivariate analyses, mothers who were single (P = .02), had moderate to severe depressive symptoms (P = .01) and perceived their infant had a difficult temperament (P = .03) were more likely to add cereal into the bottle. Conversely, mothers who expressed concern about their infants becoming overweight were less likely to add cereal (P = .02).

CONCLUSIONS AND IMPLICATIONS

Health care providers should screen for adding cereal in infant bottles. Further research is needed to investigate the impact of adding cereal into the bottle on weight trajectories over time. Causal associations also need to be identified to effectively prevent this practice.

Material Hardship and Internal Locus of Control Over the Prevention of Child Obesity in Low-Income Hispanic Pregnant Women

OBJECTIVE

To determine the relations between household material hardships and having a low internal locus of control over the prevention of child obesity in low-income Hispanic pregnant women.

METHODS

We performed a cross-sectional analysis of baseline data collected during a third trimester prenatal visit from women participating in the Starting Early Study, a randomized controlled trial to test the efficacy of a primary care-based family-centered early child obesity prevention intervention. Using multiple logistic regression analyses, we determined whether 4 domains of material hardship (food insecurity, difficulty paying bills, housing disrepair, neighborhood stress), considered individually and also cumulatively, were associated with having a low internal locus of control over the prevention of child obesity.

RESULTS

The sample included 559 low-income Hispanic pregnant women, with 60% having experienced at least 1 hardship. Food insecurity was independently associated with a low internal locus of control over the prevention of child obesity (adjusted odds ratio, 2.38; 95% confidence interval, 1.50-3.77), controlling for other hardships and confounders. Experiencing a greater number of material hardships was associated in a dose-dependent relationship with an increased odds of having a low internal locus of control.

CONCLUSIONS

Prenatal material hardships, in particular food insecurity, were associated with having a lower prenatal internal locus of control over the prevention of child obesity. Longitudinal follow-up of this cohort is needed to determine how relations between material hardships and having a low internal locus of control will ultimately affect infant feeding practices and child weight trajectories.

Randomized Controlled Trial of a Primary Care-Based Child Obesity Prevention Intervention on Infant Feeding Practices

OBJECTIVE

To determine the effects of a child obesity prevention intervention, beginning in pregnancy, on infant feeding practices in low-income Hispanic families.

STUDY DESIGN

The Starting Early randomized controlled trial enrolled pregnant women at a third trimester visit. Women (n = 533) were randomly allocated to a standard care control group or an intervention group participating in prenatal and postpartum individual nutrition/breastfeeding counseling and subsequent nutrition and parenting support groups coordinated with well-child visits. Outcome measures included infant feeding practices and maternal infant feeding knowledge at infant age 3 months, using questions adapted from the Infant Feeding Practices Study II and an infant 24-hour diet recall.

RESULTS

A total of 456 families completed 3-month assessments. The intervention group had higher prevalence of exclusive breastfeeding on the 24-hour diet recall (42.7% vs 33.0%, P = .04) compared with controls. The intervention group reported a higher percentage of breastfeeding vs formula feeding per day (mean [SD] 67.7 [39.3] vs 59.7 [39.7], P = .03) and was less likely to introduce complementary foods and liquids compared with controls (6.3% vs 16.7%, P = .001). The intervention group had higher maternal infant feeding knowledge scores (Cohen d, 0.29, 95% CI .10-.48). The effect of Starting Early on breastfeeding was mediated by maternal infant feeding knowledge (Sobel test 2.86, P = .004).

CONCLUSIONS

Starting Early led to increased exclusive breastfeeding and reduced complementary foods and liquids in 3-month-old infants. Findings document a feasible and effective infrastructure for promoting breastfeeding in families at high risk for obesity in the context of a comprehensive obesity prevention intervention.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT01541761.

Screening for Social Determinants of Health Among Children and Families Living in Poverty: A Guide for Clinicians

Approximately 20% of all children in the United States live in poverty, which exists in rural, urban, and suburban areas. Thus, all child health clinicians need to be familiar with the effects of poverty on health and to understand associated, preventable, and modifiable social factors that impact health. Social determinants of health are identifiable root causes of medical problems. For children living in poverty, social determinants of health for which clinicians may play a role include the following: child maltreatment, child care and education, family financial support, physical environment, family social support, intimate partner violence, maternal depression and family mental illness, household substance abuse, firearm exposure, and parental health literacy. Children, particularly those living in poverty, exposed to adverse childhood experiences are susceptible to toxic stress and a variety of child and adult health problems, including developmental delay, asthma and heart disease. Despite the detrimental effects of social determinants on health, few child health clinicians routinely address the unmet social and psychosocial factors impacting children and their families during routine primary care visits. Clinicians need tools to screen for social determinants of health and to be familiar with available local and national resources to address these issues. These guidelines provide an overview of social determinants of health impacting children living in poverty and provide clinicians with practical screening tools and resources.

Maternal infant feeding behaviors and disparities in early child obesity

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Phthalates and the diets of U.S. children and adolescents

BACKGROUND

Di-2-ethylhexylphthalate (DEHP) is an ester of phthalic acid commonly found in processed foods. DEHP may contribute to obesity and insulin resistance in children and adolescents, yet dietary exposures have been not been studied in this vulnerable subpopulation.

OBJECTIVE

To assess diet and its relation to urinary phthalates in a nationally representative sample of US children and adolescents.

DESIGN

Cross-sectional analysis of 24-h dietary recall and urinary phthalate metabolites from 2743 6-19 year olds participating in the 2003-8 National Health and Nutrition Examination Surveys. Regression analyses examined relationships of food consumption with log-transformed metabolite concentrations, examined as low-molecular weight, high molecular weight and di-2-ethylhexylphthalate categories, controlling for urinary creatinine, age group, body mass index category, race/ethnicity, caloric intake and gender.

RESULTS

We identified a -0.04% (95% CI: -0.08, -0.01) increment in di-2-ethylhexylphthalate metabolite concentration/additional gram fruit consumption, a +0.01% increment/additional calorie dietary intake (95% CI: +0.003, +0.02), and a +0.09% (95% CI: +0.02, +0.17) increment/additional gram meat/poultry/fish consumption. Soy consumption (-0.40% increment/additional gram consumed, 95% CI: -0.66, -0.14) was inversely associated with di-2-ethylhexylphthalate, while poultry (+0.23% increment/additional gram consumed, 95% CI: +0.12, +0.35) was positively associated. Findings were robust to examination of metabolite concentrations per unit body mass index and weight, and inclusion of fasting time.

CONCLUSIONS

Diet contributes to urinary phthalate concentrations in children and adolescents. Further study is needed to examine the implications of di-2-ethylhexylphthalate exposure, especially earlier in life, when more permanent metabolic changes may occur.

Food insecurity and obesogenic maternal infant feeding styles and practices in low-income families

OBJECTIVES

We explored the relationship between household food insecurity and maternal feeding styles, infant feeding practices, and perceptions and attitudes about infant weight in low-income mothers.

METHODS

Mothers participating in the Special Supplemental Food Program for Women, Infants, and Children with infants aged between 2 weeks and 6 months were interviewed. By using regression analyses, the following relationships were examined between food insecurity and: (1) controlling feeding styles (restrictive and pressuring); (2) infant feeding practices, including breastfeeding, juice consumption, and adding cereal to the bottle; and (3) perceptions and attitudes about infant weight. Path analysis was used to determine if perceptions and attitudes about infant weight mediated the relationships between food insecurity and controlling feeding styles.

RESULTS

The sample included 201 mother-infant pairs, with 35% reporting household food insecurity. Food-insecure mothers were more likely to exhibit restrictive (B [SE]: 0.18 [0.08]; 95% confidence interval [CI]: 0.02-0.34) and pressuring (B [SE]: 0.11 [0.06]; 95% CI: 0.001-0.22) feeding styles compared with food-secure mothers. No associations were found with feeding practices. Concern for their infant becoming overweight in the future was associated with food insecurity (adjusted odds ratio: 2.11 [95% CI: 1.02-4.38]). This concern mediated the relationship between food insecurity and both restrictive (P = .009) and pressuring (P = .01) feeding styles.

CONCLUSIONS

Increased concern about future overweight and controlling feeding styles represent potential mechanisms by which food insecurity could be related to obesity. Obesity prevention should aim to decrease food insecurity and to reduce controlling feeding styles in families who remain food insecure.

Maternal controlling feeding styles during early infancy

This study sought to determine the relationship between maternal controlling feeding styles and maternal perception of their infant's ability to regulate feeding and infant weight. A cross-sectional survey of 208 mothers with infants between 2 weeks and 6 months old was performed in a private pediatric office. The authors assessed the relationship between restrictive and pressuring feeding styles with (a) maternal perception of the infant's ability to regulate feeding and (b) infant weight (both actual and perceived). Restrictive feeding style was associated with the perception that infants could not recognize their own hunger or satiety and with concern that the infant would become overweight in the future. Pressuring feeding style was associated with the perception that the baby's appetite is less than other babies and with concern that the infant would become underweight in the future. Maternal perceptions of infant feeding and weight should be incorporated into early obesity prevention strategies.

Maternal perceptions of infant hunger, satiety, and pressuring feeding styles in an urban Latina WIC population

OBJECTIVE

Controlling feeding styles in which parents regulate feeding without responding to child cues have been associated with poor self-regulation of feeding and increased weight, but have not been well studied in infancy. We sought to assess maternal perception of infant feeding cues and pressuring feeding styles in an urban Latina Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) population.

METHODS

Secondary analysis of a larger study of Latina mothers participating in New York City WIC programs. We examined maternal perception of infant feeding cues and pressuring feeding style. Using logistic regression, we assessed: 1) characteristics associated with perceptions of cues and pressuring to feed, including sociodemographics, breastfeeding, and maternal body mass index; and 2) whether perceptions of cues were associated with pressuring feeding style.

RESULTS

We surveyed 368 mothers (84% response rate). Most mothers perceived that babies sense their own satiety. However, 72% believed that infant crying must indicate hunger. Fifty-three percent believed that mothers should always make babies finish the bottle ("pressure to feed"). Pressuring feeding style was associated with foreign maternal country of birth (adjusted odds ratio [AOR] 3.05; 95% confidence interval [CI], 1.66-5.60) and less than a high school education (AOR 1.81; 95% CI, 1.12-2.91). Two perceptions of feeding cues were related to pressuring feeding style: belief that infant crying must indicate hunger (AOR 2.59; 95% CI, 1.52-4.42) and infant hand sucking implies hunger (AOR 1.83; 95% CI, 1.10-3.03).

CONCLUSIONS

Maternal characteristics influence perception of infant hunger and satiety. Interpretation of feeding cues is associated with pressuring feeding style. Improving responsiveness to infant cues should be a component of early childhood obesity prevention.

Physicians' attitudes about obesity and their associations with competency and specialty: a cross-sectional study

Background

Physicians frequently report negative attitudes about obesity which is thought to affect patient care. However, little is known about how attitudes toward treating obese patients are formed. We conducted a cross-sectional survey of physicians in order to better characterize their attitudes and explore the relationships among attitudes, perceived competency in obesity care, including report of weight loss in patients, and other key physician, training, and practice characteristics.

Methods

We surveyed all 399 physicians from internal medicine, pediatrics, and psychiatry specialties at one institution regarding obesity care attitudes, competency, including physician report of percent of their patients who lose weight. We performed a factor analysis on the attitude items and used hierarchical regression analysis to explore the degree to which competency, reported weight loss, physician, training and practice characteristics explained the variance in each attitude factor.

Results

The overall response rate was 63%. More than 40% of physicians had a negative reaction towards obese patients, 56% felt qualified to treat obesity, and 46% felt successful in this realm. The factor analysis revealed 4 factors–Physician Discomfort/Bias, Physician Success/Self Efficacy, Positive Outcome Expectancy, and Negative Outcome Expectancy. Competency and reported percent of patients who lose weight were most strongly associated with the Physician Success/Self Efficacy attitude factor. Greater skill in patient assessment was associated with less Physician Discomfort/Bias. Training characteristics were associated with outcome expectancies with newer physicians reporting more positive treatment expectancies. Pediatric faculty was more positive and psychiatry faculty less negative in their treatment expectancies than internal medicine faculty.

Conclusion

Physician attitudes towards obesity are associated with competency, specialty, and years since postgraduate training. Further study is necessary to determine the direction of influence and to explore the impact of these attitudes on patient care.

Neuropathy and anti-MAG antibodies without detectable serum M-protein

Anti-MAG IgM antibodies were detected by ELISA in a patient with slowly progressive peripheral neuropathy. Serum IgM content was normal, and no M-protein was detected by serum protein electrophoresis, immunoelectrophoresis, or immunostaining. By immunoblot analysis, the anti-MAG antibodies were IgMk; they reacted with human and bovine MAG but not with mouse MAG. The data suggest that there was an anti-MAG IgM M-protein in concentration too low to be detected by conventional techniques. Tests for anti-MAG antibodies should be done in patients with slowly progressive neuropathy of unknown etiology, even in the absence of detectable serum M-protein.

Anti-MAG IgM antibodies in patients with neuropathy and IgM M proteins: detection by ELISA

In some patients with plasma cell dyscrasia and neuropathy, there are IgM M proteins that react with the myelin-associated glycoprotein (MAG). We used an enzyme-linked immunosorbent assay (ELISA) system to detect anti-MAG IgM antibodies. Reactivity with human MAG by ELISA correlated with demonstration of anti-MAG IgM antibodies by the "immunoblot" technique. Human MAG was more effective than bovine MAG as antigen, and there was no significant reactivity with mouse MAG. The ELISA system is a simple and convenient method for detecting anti-MAG IgM antibodies.

Measurement of myelin basic protein and of anti-basic protein antibodies by ELISA utilizing biotinylated antibodies

Immunoglobulins were conjugated to peroxidase by the biotin-avidin method and used in ELISA systems for measuring myelin basic protein (MBP) and anti-MBP antibodies. To measure concentration of MBP, microplate wells were coated with affinity purified rabbit anti-MBP antibodies and incubated with varying concentrations of MBP. Bound antigen was measured by incubating with biotinylated anti-MBP antibodies and avidin-peroxidase. As little as 0.2 ng/ml of MBP could be measured by this assay. To measure anti-MBP antibodies, microplate wells were coated with human MBP and incubated with varying concentrations of affinity purified rabbit anti-human MBP antibodies. Binding was measured by incubating with either peroxidase-conjugated anti-rabbit antibodies or biotinylated anti-rabbit antibodies and avidin peroxidase. The two methods were equally sensitive. The avidin-biotin method for enzyme conjugation promises to be a useful and versatile tool for ELISA systems.