Jennifer A. Woo Baidal

Design of the Massachusetts Childhood Obesity Research Demonstration (MA-CORD) Study

BACKGROUND Childhood obesity is highly prevalent, is associated with both short- and long-term adverse outcomes, disproportionately affects racial/ethnic minority and economically deprived children, and represents a major threat to public health. Among the most promising approaches for its prevention and management are multilevel, multisector strategies. METHODS/DESIGN The Massachusetts Childhood Obesity Research Demonstration (MA-CORD) Study was a comprehensive, systematic intervention to prevent and reduce childhood obesity among low-income children ages 2-12 years in two selected cities in Massachusetts. Building on the Obesity Chronic Care Model, MA-CORD expanded a state public health department community-level obesity prevention initiative that incorporated evidence-based interventions in primary healthcare, the Women, Infants, and Children program, early care and education, schools/afterschool programs, as well as community-wide programs to improve food, beverage, physical activity (PA), and messaging environments. The study used a combination of pre- and post-time series and quasi-experimental designs to examine the extent to which the intervention resulted in changes in BMI, individual-level lifestyle behaviors, satisfaction with healthcare services, and quality of life among children, as well as changes in health policies, programs, and environments in the two intervention cities, compared to a comparison city. The intervention period was 2 years. CONCLUSIONS MA-CORD will determine the extent to which a multisetting, multilevel intervention that integrates activities in primary care with broader public health interventions in schools, early care and education, and the community at large can improve childrens dietary and PA behaviors and ultimately reduce obesity in low-income children.

Protecting Progress against Childhood Obesity — The National School Lunch Program

Two years after their implementation, new school-nutrition standards are at risk. In response to complaints about food waste and difficulties in meeting certain goals, among other issues, lawmakers have proposed granting schools waivers if they are losing revenue.

Parental Perceptions of a Motivational Interviewing–Based Pediatric Obesity Prevention Intervention

Motivational interviewing (MI) shows promise for pediatric obesity prevention, but few studies address parental perceptions of MI. The aim of this study was to identify correlates of parental perceptions of helpfulness of and satisfaction with a MI-based pediatric obesity prevention intervention. We studied 253 children 2 to 6 years of age in the intervention arm of High Five for Kids, a primary care–based randomized controlled trial. In multivariable models, parents born outside the United States (odds ratio [OR] = 8.81; 95% confidence interval [CI] = 2.44, 31.8), with lower household income (OR = 3.60; 95% CI = 1.03, 12.55), and with higher BMI (OR = 2.86; 95% CI = 1.07, 7.65) were more likely to perceive MI-based visits as helpful in improving children’s obesity-related behaviors after the first year of the intervention. Parents of female (vs male), black (vs white), and Latino (vs white) children had lower intervention satisfaction. Our findings underscore the importance of tailoring pediatric obesity prevention efforts to target populations.

Clinical effectiveness of the Massachusetts Childhood Obesity Research Demonstration initiative among low-income children

To examine the extent to which a clinical intervention resulted in reduced BMI z scores among 2‐ to 12‐year‐old children compared to routine practice (treatment as usual [TAU]).

Childhood obesity prevention in the Women, Infants, and Children Program: Outcomes of the MA-CORD study

To examine the extent to which a Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) intervention improved BMI z scores and obesity‐related behaviors among children age 2 to 4 years.

Early life exposure to per- and polyfluoroalkyl substances and mid-childhood lipid and alanine aminotransferase levels.

BACKGROUND Growing evidence suggests that exposure to per- and polyfluoroalkyl substances (PFASs) may disrupt lipid homeostasis and liver function, but data in children are limited. OBJECTIVE We examined the association of prenatal and mid-childhood PFAS exposure with lipids and alanine aminotransferase (ALT) levels in children. METHODS We studied 682 mother-child pairs from a Boston-area pre-birth cohort. We quantified PFASs in maternal plasma collected in pregnancy (median 9.7weeks gestation, 1999-2002) and in child plasma collected in mid-childhood (median age 7.7years, 2007-2010). In mid-childhood we also measured fasting total (TC), high-density lipoprotein cholesterol (HDL-C), triglycerides (TG), and ALT. We then derived low-density lipoprotein cholesterol (LDL-C) from TC, HDL-C, and TG using the Friedewald formula. RESULTS Median (interquartile range, IQR) perfluorooctane sulfonate (PFOS), perfluorooctanoate (PFOA), and perfluorodecanoate (PFDeA) concentrations in child plasma were 6.2 (5.5), 4.3 (3.0), and 0.3 (0.3) ng/mL, respectively. Among girls, higher child PFOS, PFOA, and PFDeA concentrations were associated with detrimental changes in the lipid profile, including higher TC and/or LDL-C [e.g., β per IQR increment in PFOS=4.0mg/dL (95% CI: 0.3, 7.8) for TC and 2.6mg/dL (-0.5, 5.8) for LDL-C]. However, among both boys and girls, higher plasma concentrations of these child PFASs were also associated with higher HDL-C, which predicts better cardiovascular health, and slightly lower ALT, which may indicate better liver function. Prenatal PFAS concentrations were also modestly associated with improved childhood lipid and ALT levels. CONCLUSIONS Our data suggest that prenatal and mid-childhood PFAS exposure may be associated with modest, but somewhat conflicting changes in the lipid profile and ALT levels in children.

Associations of Early to Mid-Childhood Adiposity with Elevated Mid-Childhood Alanine Aminotransferase Levels in the Project Viva Cohort

Objectives To examine the longitudinal relationship of early to mid‐childhood adiposity measures with mid‐childhood alanine aminotransferase (ALT) levels. Study design We studied 635 children in the Project Viva cohort. Research staff measured weight, height, skinfolds thicknesses, and waist and hip circumferences at early (median 3.2 years) and mid‐childhood (median 7.7 years) visits. At mid‐childhood, we collected blood for ALT analysis. We used established sex‐specific ALT cut‐offs to define elevated ALT. In multivariable linear and logistic regression models, we assessed the association of adiposity measures from early to mid‐childhood with mid‐childhood ALT level, adjusting for confounders. Results Children were 48% female, 59% white, 21% black, 6% Hispanic/Latino, and 3% Asian. At early childhood, 29% had overweight/obesity and mean waist circumference was 51.5 (SD 3.8) cm. At mid‐childhood, mean ALT was 20.3 (SD 7.3) units/L, and 23% had an elevated ALT. In multivariable‐adjusted regression models, each additional 10‐cm greater waist circumference at early childhood was associated with 1.99 (95% CI 1.19‐3.33) greater odds of elevated ALT at mid‐childhood. Greater increases from early to mid‐childhood in body mass index z score, sum of subscapular and triceps skinfold thicknesses, waist circumference, and hip circumference were associated with greater ALT at mid‐childhood. Conclusions In this prospective cohort, greater waist circumference at early childhood and greater increases in adiposity measures from early to mid‐childhood were associated with greater ALT levels at mid‐childhood.

Association of vitamin E intake at early childhood with alanine aminotransferase levels at mid‐childhood

The extent to which vitamin E (alpha‐tocopherol) intake early in childhood is associated with alanine aminotransferase (ALT) level later in childhood is unknown. The objective of this research is to test the hypothesis that higher alpha‐tocopherol intake during early childhood is associated with lower odds of elevated ALT levels during mid‐childhood and to examine how body mass index (BMI) influences these relationships. We studied 528 children in Project Viva. Mothers reported child dietary intake at early childhood visits (median 3.1 years) using a validated food frequency questionnaire. At mid‐childhood (median 7.6 years), we collected child blood and anthropometric data. The main outcome was elevated sex‐specific mid‐childhood ALT level (≥22.1 U/L for female children and ≥25.8 U/L for male children). In multivariable logistic regression models, we assessed the association of energy‐adjusted alpha‐tocopherol intake with ALT levels, adjusting for child age, sex, race/ethnicity, diet, and age‐adjusted sex‐specific BMI z‐score at mid‐childhood. Among children in this study, 48% were female, 63% were non‐Hispanic white, 19% were non‐Hispanic black, and 4% were Hispanic/Latino. Mean alpha‐tocopherol intake was 3.7 ± 1.0 mg/day (range, 1.4‐9.2) at early childhood. At mid‐childhood, mean BMI z‐score was 0.41 ± 1.0 units and 22% had an elevated ALT level. In multivariable‐adjusted logistic regression models, children with higher early childhood vitamin E intake had lower odds of elevated mid‐childhood ALT (adjusted odds ratio [AOR], 0.62; 95% confidence interval [CI], 0.39, 0.99) for quartiles 2‐4 compared with the lowest quartile of intake. Findings persisted after accounting for early childhood diet (AOR, 0.62; 95% CI, 0.36, 1.08) and were strengthened after additionally accounting for mid‐childhood BMI z‐score (AOR, 0.56; 95% CI, 0.32, 0.99). Conclusion: In this cohort, higher early childhood intake of alpha‐tocopherol was associated with lower odds of elevated mid‐childhood ALT level. (Hepatology 2018;67:1339‐1347).

Racial/Ethnic Differences in the Effectiveness of a Multisector Childhood Obesity Prevention Intervention

Objectives To investigate racial/ethnic and language differences in the effectiveness of the Massachusetts Childhood Obesity Research Demonstration (MA-CORD) study among children aged 2 to 4 years enrolled in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). Methods We performed a multisector quasiexperimental study in 2 MA-CORD intervention communities and 1 comparison community. Using WIC data from 2010 to 2015, we examined intervention effect on child weight and behavior outcomes by child race/ethnicity and parental primary language using multilevel linear regression models with an interaction term. Results Non-Hispanic Black children exposed to the intervention demonstrated a greater decrease in body mass index (BMI) than did other children (P < .05). Racial/ethnic minority children in the comparison site had greater increases in BMI than did their White counterparts (P < .05). There were no differences in intervention effectiveness by race/ethnicity or language for health behaviors. Conclusions White children demonstrated decreased BMI in both the intervention and control groups. However, intervention minority children demonstrated greater improvements in BMI than did control minority children. Public Health Implications To reduce racial/ethnic disparities, we need to disseminate effective obesity prevention interventions during early childhood in low-income settings.