Judith B. Borja

Cohort Profile: The Cebu Longitudinal Health and Nutrition Survey

The Cebu Longitudinal Health and Nutrition Survey (CLHNS) was originally conceptualized as an interdisciplinary study of infant-feeding patterns, particularly the overall sequencing of feeding events (milks and complementary foods), the factors affecting feeding decisions and how feeding patterns affect the infant, mother and household. The idea was to study these topics within as natural a setting as possible and to analyse how infant-feeding decisions interacted with social, economic and environmental factors to affect health, nutritional, demographic and economic outcomes. The study was subsequently expanded to cover a wide range of maternal and child health and demographic issues that could be well studied using a prospective, community-based sample. The study was initially the product of collaboration among researchers at the Carolina Population Center at the University of North Carolina at Chapel Hill (led by B.M.P. with J.S.A. and D.K.G.), The Office of Population Studies Foundation at the University of San Carlos in Cebu, Philippines (led by the late Director Wilhelm Fleiger) and the Nutrition Center of the Philippines (led by Florentino Solon). L.S.A. took the lead for follow-up surveys beginning in 1990. Later, the study team was expanded to include researchers presently at the Northwestern University (C.W.K. and T.M.D.) and Johns Hopkins University (M.J.H.). The study was initiated with cooperation and approval from the Cebu Department of Health. The CLHNS website includes a full list of investigators and their affiliations. The CLHNS was one of the first large-scale, population-based surveys designed with a conceptual framework in mind. The guiding framework was adapted from Mosley and Chen’s health determinants model, which posits that underlying community-, householdand individual-level variables affect a set of proximate health behaviours which, in turn, influence health outcomes such as growth and infectious disease morbidity and mortality. The study was designed by a highly interdisciplinary group of economists, sociologists, nutritionists, demographers and physicians. The CLHNS has been funded by a large number of government and non-government organizations (listed in the Funding section).

Development and validation of the Infant Feeding Style Questionnaire

This study describes and validates the Infant Feeding Style Questionnaire (IFSQ), a self-report instrument designed to measure feeding beliefs and behaviors among mothers of infants and young children. Categorical confirmatory factor analysis was used to estimate latent factors for five feeding styles, laissez-faire, restrictive, pressuring, responsive and indulgent, and to validate that items hypothesized a priori as measures of each style yielded well-fitting models. Models were tested and iteratively modified to determine the best fitting model for each of 13 feeding style sub-constructs, using a sample of 154 low-income African-American mothers of infants aged 3-20 months in North Carolina. With minor changes, models were confirmed in an independent sample of 150 African-American first-time mothers, yielding a final instrument with 39 questions on maternal beliefs, 24 questions on behaviors and an additional 20 behavioral items pertaining to solid feeding for infants over 6 months of age. Internal reliability measures for the sub-constructs ranged from 0.75 to 0.95. Several sub-constructs, responsive to satiety cues, pressuring with cereal, indulgent pampering and indulgent soothing, were inversely related to infant weight-for-length z-score, providing initial support for the validity of this instrument for assessing maternal feeding beliefs and behaviors that may influence infant weight outcomes.

Infants Perceived as “Fussy” Are More Likely to Receive Complementary Foods Before 4 Months

OBJECTIVE: Our purpose was to assess early infant-feeding patterns in a cohort of low-income black mothers and to examine associations between maternal perception of infant temperament and complementary feeding (CF) before 4 months. METHODS: We used cross-sectional data from the 3-month visit (n = 217) of the Infant Care, Feeding and Risk of Obesity Study to assess relationships between early feeding of solids or juice and 6 dimensions of perceived infant temperament. Descriptive statistics were used to assess infant-feeding patterns, and logistic regression models were fit for each diet-temperament relationship found significant in the bivariate analyses. RESULTS: Seventy-seven percent of the infants were fed solid foods at 3 months, 25% were fed juice, and 6% were exclusively breastfed. In multivariable analyses, 2 dimensions of perceived infant temperament were associated with early feeding of solid foods (distress-to-limitations odds ratio [OR]: 1.97 [95% confidence interval (CI): 1.12–3.44]; activity-level OR: 1.75 [95% CI: 1.07–2.85]), whereas 1 dimension, low-intensity pleasure, was associated with early feeding of juice (OR: 0.51 [95% CI: 0.34–0.78]). Maternal characteristics significantly associated with early CF included breastfeeding, obesity, and depressive symptoms. CONCLUSIONS: Low-income black mothers may represent a priority population for interventions aimed at improving adherence to optimal infant feeding recommendations. That maternal perceptions of several domains of perceived infant temperament are related to early CF suggests that this is an important factor to include in future observational research and in the design of interventions.

Genome-wide association study for adiponectin levels in Filipino women identifies CDH13 and a novel uncommon haplotype at KNG1–ADIPOQ

Adiponectin is an adipocyte-secreted protein involved in a variety of metabolic processes, including glucose regulation and fatty acid catabolism. We conducted a genome-wide association study to investigate the genetic loci associated with plasma adiponectin in 1776 unrelated Filipino women from the Cebu Longitudinal Health and Nutrition Survey (CLHNS). Our strongest signal for adiponectin mapped to the gene CDH13 (rs3865188, P ≤ 7.2 × 10(-16)), which encodes a receptor for high-molecular-weight forms of adiponectin. Strong association was also detected near the ADIPOQ gene (rs864265, P = 3.8 × 10(-9)) and at a novel signal 100 kb upstream near KNG1 (rs11924390, P = 7.6 × 10(-7)). All three signals were also observed in 1774 young adult CLHNS offspring and in combined analysis including all 3550 mothers and offspring samples (all P ≤ 1.6 × 10(-9)). An uncommon haplotype of rs11924390 and rs864265 (haplotype frequency = 0.050) was strongly associated with lower adiponectin compared with the most common C-G haplotype in both CLHNS mothers (P = 1.8 × 10(-25)) and offspring (P = 8.7 × 10(-32)). Comprehensive imputation of 2653 SNPs in a 2 Mb region using as reference combined CHB, JPT and CEU haplotypes from the 1000 Genomes Project revealed no variants that perfectly tagged this haplotype. Our findings provide the first genome-wide significant evidence of association with plasma adiponectin at the CDH13 locus and identify a novel uncommon KNG1-ADIPOQ haplotype strongly associated with adiponectin levels in Filipinos.

Infant overweight is associated with delayed motor development

OBJECTIVE To examine how infant overweight and high subcutaneous fat relate to infant motor development. STUDY DESIGN Participants were from the Infant Care, Feeding, and Risk of Obesity Project, a prospective, longitudinal study of low-income African-American mother-infant dyads assessed from 3 to 18 months of age (836 observations on 217 infants). Exposures were overweight (weight-for-length z-score>or=90th percentile of 2000 Centers for Disease Control/National Center for Health Statistics growth reference) and high subcutaneous fat (sum of 3 skinfold measurements>90th percentile of our sample). Motor development was assessed by using the Bayley Scales of Infant Development-II. Developmental delay was characterized as a standardized Psychomotor Development Index score<85. Longitudinal models estimated developmental outcomes as functions of time-varying overweight and subcutaneous fat, controlling for age and sex. Alternate models tested concurrent and lagged relationships (earlier weight or subcutaneous fat predicting current motor development). RESULTS Motor delay was 1.80 times as likely in overweight infants compared with non-overweight infants (95% CI,1.09-2.97) and 2.32 times as likely in infants with high subcutaneous fat compared with infants with lower subcutaneous fat (95% CI, 1.26-4.29). High subcutaneous fat was also associated with delay in subsequent motor development (odds ratio, 2.27; 95% CI, 1.08-4.76). CONCLUSIONS Pediatric overweight and high subcutaneous fat are associated with delayed infant motor development.

Genome-wide association study of homocysteine levels in Filipinos provides evidence for CPS1 in women and a stronger MTHFR effect in young adults

Plasma homocysteine (Hcy) level is associated with cardiovascular disease and may play an etiologic role in vascular damage, a precursor for atherosclerosis. We performed a genome-wide association study for Hcy in 1786 unrelated Filipino women from the Cebu Longitudinal Health and Nutrition Survey (CLHNS). The most strongly associated single-nucleotide polymorphism (SNP) (rs7422339, P = 4.7 x 10(-13)) encodes Thr1405Asn in the gene CPS1 and explained 3.0% of variation in the Hcy level. The widely studied MTHFR C677T SNP (rs1801133) was also highly significant (P = 8.7 x 10(-10)) and explained 1.6% of the trait variation. We also genotyped these two SNPs in 1679 CLHNS young adult offspring. The MTHFR C677T SNP was strongly associated with Hcy (P = 1.9 x 10(-26)) and explained approximately 5.1% of the variation in the offspring. In contrast, the CPS1 variant was significant only in females (P = 0.11 in all; P = 0.0087 in females). Combined analysis of all samples confirmed that the MTHFR variant was more strongly associated with Hcy in the offspring (interaction P = 1.2 x 10(-5)). Furthermore, although there was evidence for a positive synergistic effect between the CPS1 and MTHFR SNPs in the offspring (interaction P = 0.0046), there was no significant evidence for an interaction in the mothers (P = 0.55). These data confirm a recent finding that CPS1 is a locus influencing Hcy levels in women and suggest that genetic effects on Hcy may differ across developmental stages.

Assessment of infant feeding styles among low-income African-American mothers: Comparing reported and observed behaviors

This studys goal was to provide a detailed description of feeding styles adopted by a sample of African-American women in feeding their infants in North Carolina, and to examine the correspondence between reported and observed feeding styles. Cross-sectional semi-structured interview and videotaped data were gathered in the homes of 20 participating low-income mothers of infants aged 3-20 months. Feeding styles were characterized through a tailored coding scheme (the Infant Feeding Styles Video Coding Scheme, IFSVCS) applied to both interview and video-taped data. We found that the most frequent feeding styles identified for both interviews and videotaped observations was restrictive, but that mothers were roughly equally divided among predominantly controlling (pressuring or restrictive) and less controlling (laissez-faire or indulgent) styles across methods. However, for over 2/3 of the sample, there was a lack of correspondence between interview and video-taped feeding styles. This unique characterization and comparison of observed and reported infant feeding styles provides additional insights into parental feeding approaches among mothers of infants at high risk of obesity, and highlights the need for further study of feeding style assessment and potential impact on infant weight outcomes.

Do environments in infancy moderate the association between stress and inflammation in adulthood? Initial evidence from a birth cohort in the Philippines.

Chronic inflammation is a potentially important pathway through which psychosocial stressors increase risk for cardiovascular disease. However, prior research on stress and inflammation has been conducted almost exclusively in high income, industrialized populations with low levels of infectious disease. In this study we test the hypothesis that psychosocial stressors are associated with elevated concentrations of C-reactive protein (CRP) among young adults in the Philippines (n=1622), who have grown up in an ecological and epidemiological setting that differs substantially from that of the US. In addition, we apply a developmental, ecological perspective to consider whether microbial and nutritional environments in infancy alter patterns of association between stressors and CRP. Data come from the Cebu Longitudinal Health and Nutrition Survey, a prospective cohort study that began collecting data in 1983-1984 when participants were in utero. A series of regression models indicate trends toward significant interactions between perceived stress and environmental factors in infancy, including exposure to animal feces, season of birth, and birth weight. Parental absence in childhood was a significant predictor of CRP in adulthood in interaction with exposure to animal feces in infancy. Positive associations between stressors and CRP were only evident for individuals with lower levels of microbial exposure in infancy, or lower birth weight. These results suggest that early environments influence the development of inflammatory phenotypes in ways that moderate sensitivity to psychosocial stressors in adulthood, and they underscore the value of a comparative, developmental approach to research on social environments, inflammation, and disease.

Grandmothers, Fathers, and Depressive Symptoms Are Associated with Food Insecurity among Low-Income First-Time African-American Mothers in North Carolina

African Americans experience household food insecurity, ie, the limited availability of nutritionally adequate and safe food, or ability to acquire acceptable foods in socially acceptable ways, at three times the rate of non-Hispanic whites. Thirty percent of all African-American children live in food-insecure households. The purpose of this study was to identify characteristics associated with household food insecurity among a high-risk postpartum population. Two-hundred six low-income, African-American mother-infant dyads were recruited through the Special Supplemental Nutrition Program for Women, Infants, and Children clinics. The six-item US Department of Agriculture food security scale was used to classify households as food secure, marginally food secure, or food insecure. Multinomial logistic regression was used to estimate the association between selected maternal/household characteristics and household food-security status. Fifty-three percent of households were food secure, 34% were marginally food secure, and 13% were food insecure. Maternal education less than college (relative risk ratio [RRR]=0.46; 95% confidence interval [CI]: 0.22 to 0.98) was inversely associated with marginal food security. Depressive symptoms (RRR=1.09; 95% CI: 1.02 to 1.16) and having the babys father in the household (RRR=3.46; 95% CI: 1.22 to 9.82) were associated with household food insecurity, while having a grandmother in the household (RRR=0.15; 95% CI: 0.03 to 0.80) was inversely associated with experiencing household food insecurity. Findings from this study suggest that young, low-income, African-American families with only one child are particularly susceptible to experiencing household food insecurity. Intergenerational support and transfer of knowledge can be a key protective attribute among low-income African-American households.

Family Background, Service Providers, and Early Childhood Development in the Philippines: Proxies and Interactions

We examine the importance of family background for early childhood development (ECD) using data collected in 2001 from 3,556 children ages 0–36 months in three regions of the Philippines. We focus on four main research questions: (1) Are associations of family background with ECD in part proxying for health and ECD‐related programs? (2) Are associations of family background with ECD biased due to omission of unobserved community characteristics that may be related to placement of health and ECD‐related services? (3) Are there important interactions between family background and health and ECD‐related programs in their effect on ECD? (4) Are there important interactions among the components of family background? Physical assets and human assets have a number of important positive associations with ECD. These include the positive relations between physical assets and the anthropometrics and hemoglobin levels of children, as well as lower occurrence of worms. Each parent’s schooling and height also have notable positive effects on these outcomes and the motor and language skills of children. The failure to account for community characteristics is related to often substantial bias in the estimated effect of family background on ECD. We do not find strong evidence that interactions are important.