Elsie M. Taveras

Recommendations for Treatment of Child and Adolescent Overweight and Obesity

In this article, we review evidence about the treatment of obesity that may have applications in primary care, community, and tertiary care settings. We examine current information about eating behaviors, physical activity behaviors, and sedentary behaviors that may affect weight in children and adolescents. We also review studies of multidisciplinary behavior-based obesity treatment programs and information about more aggressive forms of treatment. The writing group has drawn from the available evidence to propose a comprehensive 4-step or staged-care approach for weight management that includes the following stages: (1) Prevention Plus; (2) structured weight management; (3) comprehensive multidisciplinary intervention; and (4) tertiary care intervention. We suggest that providers encourage healthy behaviors while using techniques to motivate patients and families, and interventions should be tailored to the individual child and family. Although more intense treatment stages will generally occur outside the typical office setting, offices can implement less intense intervention strategies. We not ony address specific patient behavior goals but also encourage practices to modify office systems to streamline office-based care and to prepare to coordinate with professionals and programs outside the office for more intensive interventions.

Racial/Ethnic Differences in Early-Life Risk Factors for Childhood Obesity

OBJECTIVE: By the preschool years, racial/ethnic disparities in obesity prevalence are already present. The objective of this study was to examine racial/ethnic differences in early-life risk factors for childhood obesity. METHODS: A total of 1343 white, 355 black, and 128 Hispanic mother–child pairs were studied in a prospective study. Mothers reported childs race/ethnicity. The main outcome measures were risk factors from the prenatal period through 4 years old that are known to be associated with child obesity. RESULTS: In multivariable models, compared with their white counterparts, black and Hispanic children exhibited a range of risk factors related to child obesity. In pregnancy, these included higher rates of maternal depression (odds ratio [OR]: 1.55 for black, 1.89 for Hispanic); in infancy more rapid weight gain (OR: 2.01 for black, 1.75 for Hispanic), more likely to introduce solid foods before 4 months of age (OR: 1.91 for black, 2.04 for Hispanic), and higher rates of maternal restrictive feeding practices (OR: 2.59 for black, 3.35 for Hispanic); and after 2 years old, more televisions in their bedrooms (OR: 7.65 for black, 7.99 for Hispanic), higher intake of sugar-sweetened beverages (OR: 4.11 for black, 2.48 for Hispanic), and higher intake of fast food (OR: 1.65 for black, 3.14 for Hispanic). Black and Hispanic children also had lower rates of exclusive breastfeeding and were less likely to sleep at least 12 hours/day in infancy. CONCLUSIONS: Racial/ethnic differences in risk factors for obesity exist prenatally and in early childhood. Racial/ethnic disparities in childhood obesity may be determined by factors that operate at the earliest stages of life.

Short Sleep Duration in Infancy and Risk of Childhood Overweight

OBJECTIVE To examine the extent to which infant sleep duration is associated with overweight at age 3 years. DESIGN Longitudinal survey. SETTING Multisite group practice in Massachusetts. PARTICIPANTS Nine hundred fifteen children in Project Viva, a prospective cohort. Main Exposure At childrens ages 6 months, 1 year, and 2 years, mothers reported the number of hours their children slept in a 24-hour period, from which we calculated a weighted average of daily sleep. MAIN OUTCOME MEASURES We used multivariate regression analyses to predict the independent effects of sleep duration (< 12 h/d vs > or = 12 h/d) on body mass index (BMI) (calculated as the weight in kilograms divided by the height in meters squared) z score, the sum of subscapular and triceps skinfold thicknesses, and overweight (BMI for age and sex > or = 95th percentile) at age 3 years. RESULTS The childrens mean (SD) duration of daily sleep was 12.3 (1.1) hours. At age 3 years, 83 children (9%) were overweight; the mean (SD) BMI z score and sum of subscapular and triceps skinfold thicknesses were 0.44 (1.03) and 16.66 (4.06) mm, respectively. After adjusting for maternal education, income, prepregnancy BMI, marital status, smoking history, and breastfeeding duration and childs race/ethnicity, birth weight, 6-month weight-for-length z score, daily television viewing, and daily participation in active play, we found that infant sleep of less than 12 h/d was associated with a higher BMI z score (beta, 0.16; 95% confidence interval, 0.02-0.29), higher sum of subscapular and triceps skinfold thicknesses (beta, 0.79 mm; 95% confidence interval, 0.18-1.40), and increased odds of overweight (odds ratio, 2.04; 95% confidence interval, 1.07-3.91). CONCLUSION Daily sleep duration of less than 12 hours during infancy appears to be a risk factor for overweight and adiposity in preschool-aged children.

Weight Status in the First 6 Months of Life and Obesity at 3 Years of Age

OBJECTIVE. The goal was to examine the associations of weight-for-length at birth and at 6 months with obesity at 3 years of age. METHODS. We studied 559 children in Project Viva, an ongoing, prospective, cohort study of pregnant women and their children. We measured length and weight at birth, 6 months, and 3 years. Our main exposures were weight-for-length z score at birth adjusted for gestational age and weight-for-length z score at 6 months adjusted for weight-for-length z score at birth. We used multivariate regression analyses to predict the independent effects of birth weight-for-length z score and, separately, 6-month weight-for-length z score on BMI z score, the sum of subscapular and triceps skinfold thicknesses, and obesity (BMI for age and gender of ≥95th percentile) at age 3. RESULTS. Mean weights at birth, 6 months, and 3 years were 3.55, 8.15, and 15.67 kg, respectively. Corresponding lengths were 49.9, 66.9, and 97.4 cm. At 3 years, 48 children (9%) were obese. After adjustment for confounding variables and birth weight-for-length z score, each increment in 6-month weight-for-length z score was associated with higher BMI z scores, higher sums of subscapular and triceps skinfold thicknesses, and increased odds of obesity at age 3. The predicted obesity prevalence among children in the highest quartiles of both birth and 6-month weight-for-length z scores was 40%, compared with 1% for children in the lowest quartiles of both. Whereas birth weight-for-length z scores were associated with higher BMI z scores, the magnitude of effect was smaller than that of weight-for-length z scores at 6 months. CONCLUSIONS. More-rapid increases in weight for length in the first 6 months of life were associated with sharply increased risk of obesity at 3 years of age. Changes in weight status in infancy may influence risk of later obesity more than weight status at birth.

Association of Consumption of Fried Food Away From Home With Body Mass Index and Diet Quality in Older Children and Adolescents

Objectives. Rates of overweight have increased dramatically among children in the United States. Although an increase in consumption of food prepared away from home has paralleled overweight trends, few data exist relating food prepared away from home to change in BMI in children. The goals of this study were to (1) examine the cross-sectional and longitudinal associations between consumption of fried foods away from home (FFA) and BMI and (2) examine the cross-sectional associations between intake of FFA and several measures of diet quality. Methods. We studied a cohort of 7745 girls and 6610 boys, aged 9 to 14 years, at baseline in 1996. We obtained BMI from self-reported height and weight, measures of diet quality from a food frequency questionnaire, and weekly servings of FFA during the previous year. We performed linear regression analyses to assess the longitudinal associations between change in consumption of FFA on change in BMI, using data from three 1-year periods from 1996 through 1999. We also related consumption of FFA with intake of selected foods and nutrients at baseline. Results. In cross-sectional analyses, adjusting for potential confounders, mean (SE) BMI was 19.1 (0.13) among children who ate FFA “never or <1/week,” 19.2 (0.13) among those who responded “1 to 3 times/week,” and 19.3 (0.18) among those who responded “4 to 7 times/week.” In longitudinal multivariate models, increasing (over 1 year) consumption of FFA “never or <1/week” to “4 to 7/week” was associated with increasing BMI (β = 0.21 kg/m2; 95% confidence interval: 0.03–0.39) compared with those with low consumption of FFA at baseline and 1 year later. At baseline, frequency of eating FFA was associated with greater intakes of total energy, sugar-sweetened beverages, and trans fat, as well as lower consumption of low-fat dairy foods and fruits and vegetables. Conclusions. These data suggest that older children who consume greater quantities of FFA are heavier, have greater total energy intakes, and have poorer diet quality. Furthermore, increasing consumption of FFA over time may lead to excess weight gain.

Timing of Solid Food Introduction and Risk of Obesity in Preschool-Aged Children

OBJECTIVE: To examine the association between timing of introduction of solid foods during infancy and obesity at 3 years of age. METHODS: We studied 847 children in Project Viva, a prospective pre-birth cohort study. The primary outcome was obesity at 3 years of age (BMI for age and gender ≥95th percentile). The primary exposure was the timing of introduction of solid foods, categorized as <4, 4 to 5, and ≥6 months. We ran separate logistic regression models for infants who were breastfed for at least 4 months (“breastfed”) and infants who were never breastfed or stopped breastfeeding before the age of four months (“formula-fed”), adjusting for child and maternal characteristics, which included change in weight-for-age z score from 0 to 4 months–a marker of early infant growth. RESULTS: In the first 4 months of life, 568 infants (67%) were breastfed and 279 (32%) were formula-fed. At age 3 years, 75 children (9%) were obese. Among breastfed infants, the timing of solid food introduction was not associated with odds of obesity (odds ratio: 1.1 [95% confidence interval: 0.3–4.4]). Among formula-fed infants, introduction of solid foods before 4 months was associated with a sixfold increase in odds of obesity at age 3 years; the association was not explained by rapid early growth (odds ratio after adjustment: 6.3 [95% confidence interval: 2.3–6.9]). CONCLUSIONS: Among formula-fed infants or infants weaned before the age of 4 months, introduction of solid foods before the age of 4 months was associated with increased odds of obesity at age 3 years.

Randomized controlled trial to improve primary care to prevent and manage childhood obesity the high five for kids study

OBJECTIVE To examine the effectiveness of a primary care-based obesity intervention over the first year (6 intervention contacts) of a planned 2-year study. DESIGN Cluster randomized controlled trial. SETTING Ten pediatric practices, 5 intervention and 5 usual care. PARTICIPANTS Four hundred seventy-five children aged 2 to 6 years with body mass index (BMI) in the 95th percentile or higher or 85th to less than 95th percentile if at least 1 parent was overweight; 445 (93%) had 1-year outcomes. INTERVENTION Intervention practices received primary care restructuring, and families received motivational interviewing by clinicians and educational modules targeting television viewing and fast food and sugar-sweetened beverage intake. OUTCOME MEASURES Change in BMI and obesity-related behaviors from baseline to 1 year. RESULTS Compared with usual care, intervention participants had a smaller, nonsignificant change in BMI (-0.21; 95% confidence interval [CI], -0.50 to 0.07; P = .15), greater decreases in television viewing (-0.36 h/d; 95% CI, -0.64 to -0.09; P = .01), and slightly greater decreases in fast food (-0.16 serving/wk; 95% CI, -0.33 to 0.01; P = .07) and sugar-sweetened beverage (-0.22 serving/d; 95% CI, -0.52 to 0.08; P = .15) intake. In post hoc analyses, we observed significant effects on BMI among girls (-0.38; 95% CI, -0.73 to -0.03; P = .03) but not boys (0.04; 95% CI, -0.55 to 0.63; P = .89) and among participants in households with annual incomes of

Trends and racial/ethnic disparities in severe obesity among US children and adolescents, 1976–2006

50 000 or less (-0.93; 95% CI, -1.60 to -0.25; P = .01) but not in higher-income households (0.02; 95% CI, -0.30 to 0.33; P = .92). CONCLUSION After 1 year, the High Five for Kids intervention was effective in reducing television viewing but did not significantly reduce BMI.

Developmental Origins of Childhood Overweight: Potential Public Health Impact

Abstract Introduction. This study aims to describe the trends and racial/ethnic differences in prevalence of severe obesity among US children. Methods. We examined height and weight measurements from US children and adolescents aged 2 to 19 years using three National Health and Nutrition Examination Surveys (NHANES II: 1976-1980, N = 7 201, NHANES III: 1988-1994, N = 10 600, and NHANES 1999-2006, N = 15 980). We estimated the prevalence of severe obesity, defined as having a body mass index (BMI) above 35 kg/m(2) or 120% of the age- and sex-specific 95(th) percentile on the CDC reference standards, stratified by sex and age groups (aged 2-5 years, 6-11 years, and 12-19 years). We compared prevalence estimates among non-Hispanic white, non-Hispanic black, and Hispanic children. Results. The age-standardized prevalence of severe obesity increased from 1.1%/1.3% (boys/girls) in NHANES II, to 2.9%/3.1% in NHANES III and 5.1%/4.7% in NHANES 1999-2006 (p-values for trend <0.001). We observed some differences in prevalence by race/ethnicity. Hispanic boys 6-11 years of age (9.0%, 95% CI: [6.4, 11.5]) and non-Hispanic black girls 12-19 years of age (12.6%, 95% CI: [10.6, 14.6]) had the highest prevalence of severe obesity in the most recent NHANES data. On average, obese youth were 9.7 kg (95% CI: [9.2, 10.2]) above the obesity standard, and severely obese youth were 21.3 kg (95% CI: [20.5, 22.3]) above. Conclusions. The prevalence of severe obesity among US youth is increasing, especially among Hispanic boys and non-Hispanic black girls. Our findings suggest that the degree of pediatric obesity is substantial and will likely have profound impact on adult morbid obesity and other morbidities.

Management of obesity: Improvement of health-care training and systems for prevention and care

Several modifiable pre‐ and postnatal determinants of childhood overweight are known, but no one has examined how they influence risk of overweight in combination. We estimated the risk of overweight at age 3 years according to levels of maternal smoking during pregnancy, gestational weight gain, breastfeeding duration, and infant sleep duration. We studied 1,110 mother‐child pairs in Project Viva, a prospective prebirth cohort study. The main outcome measure was child overweight (BMI for age and sex ≥95th percentile) at age 3. We ran logistic regression models with all four modifiable risk factors as well as the covariates maternal BMI and education, child race/ethnicity, and household income. From the model, we obtained the estimated probability of overweight for each of the 16 combinations of the four risk factors. During pregnancy, 9.8% of mothers smoked and 50% gained excessive weight. In infancy, 73% mother‐child pairs breastfed for <12 m, and 31% of infants slept <12 h/day. Among the 3‐year‐old children in the cohort, 9.5% were overweight. In the prediction model, the estimated probability of overweight ranged from 0.06 among children exposed to favorable levels of all four risk factors, to 0.29 with adverse levels of all four. Healthful levels of four behaviors during early development predicted much lower probability of overweight at age 3 than adverse levels. Interventions to modify several factors during pregnancy and infancy could have substantial impact on prevention of childhood overweight.