Lorrene D. Ritchie

ETHNIC ISSUES IN THE EPIDEMIOLOGY OF CHILDHOOD OBESITY

Childhood obesity may be seen as a marker for high-risk dietary and physical inactivity practices. Recent increases in the prevalence of overweight and obesity among American children are not limited to one age, gender, or ethnic group, which suggests that unique behaviors of the members of various racial or ethnic subgroups of the population are unlikely to be the major contributing factors. Rather, it seems that environmental changes promoting increased energy intake and decreased energy output are occurring and have widespread impact on children from various backgrounds. Although no ethnic group is immune from the current shift in energy balance, differential rates of overweight seem to exist among ethnic groups. National probability samples of African-American, Hispanic, and white children in the United States provide clear evidence that white children are at lower risk for childhood overweight than are African-American or Hispanic children. Of concern is the lack of national data on the prevalence of overweight and obesity for Native-American and Asian-American groups. Also of concern is the aggregation of racial and ethnic subgroups, which may render prevalence rates meaningless. This possibility is clearly true with some surveys of weight status that combine diverse populations, such as Asians and Pacific Islanders, into one group. The high rates of obesity in African-American, Hispanic, and Native-American children are of concern. Although parental SES is associated inversely with childhood obesity among whites, higher SES does not seem to protect African-American and Hispanic children against obesity. In these groups, childhood obesity does not seem to be associated significantly with parental income and education. Health consequences of childhood obesity include a higher prevalence of type 2 diabetes and an increased risk for adverse levels of lipids, lipoproteins, and blood pressure. The effects of recently reported unprecedented levels of childhood overweight on subsequent risk for obesity in middle age are not known until future longitudinal data can be collected. It seems likely, however, that future health consequences of current early and severe childhood obesity will be staggering. Funding for adult follow-up of longitudinal studies of high-risk African American, Hispanic, and Native-American children is needed urgently to provide information on the long-term effects of childhood obesity. Halting the obesity epidemic is a formidable task, but the success in recent decades of drastically reducing childhood undernutrition offers hope and should spur similar action and leadership efforts. Promotion of efforts to reduce excess caloric intake with efforts to increase energy expenditure should receive paramount attention in the design of health programs. Given the relatively few published obesity-prevention and treatment studies that are designed to address specific cultural issues, it is important to promote the development of culturally appropriate intervention strategies that are shown to be effective among youth of diverse backgrounds. Although the dietary and activity goals will be similar, parental, family, and community messages and techniques grounded in cultural traditions and norms will be different for each ethnic group. This approach is crucial in the United States, a country with an increasingly diverse population.

Position of the academy of nutrition and dietetics: interventions for the prevention and treatment of pediatric overweight and obesity.

It is the position of the Academy of Nutrition and Dietetics that prevention and treatment of pediatric overweight and obesity require systems-level approaches that include the skills of registered dietitians, as well as consistent and integrated messages and environmental support across all sectors of society to achieve sustained dietary and physical-activity behavior change. This position paper provides guidance and recommendations for levels of intervention targeting overweight and obesity prevention and treatment from preschool age through adolescence. Methods included a review of the literature from 2009 to April 2012, including the Academys 2009 evidence analysis school-based reviews. Multicomponent interventions show the greatest impact for primary prevention; thus, early childhood and school-based interventions should integrate behavioral and environmental approaches that focus on dietary intake and physical activity using a systems-level approach targeting the multilevel structure of the socioecological model as well as interactions and relationships between levels. Secondary prevention and tertiary prevention/treatment should emphasize sustained family-based, developmentally appropriate approaches that include nutrition education, dietary counseling, parenting skills, behavioral strategies, and physical-activity promotion. For obese youth with concomitant serious comorbidities, structured dietary approaches and pharmacologic agents should be considered, and weight-loss surgery can be considered for severely obese adolescents. Policy and environmental interventions are recommended as feasible and sustainable ways to support healthful lifestyles for children and families. The Academy supports commitment of resources for interventions, policies, and research that promote healthful eating and physical-activity behaviors to ensure that all youth have the opportunity to achieve and maintain a weight that is optimal for health.

To what extent have sweetened beverages contributed to the obesity epidemic

OBJECTIVE A systematic literature review was conducted to determine whether sweetened beverage intake increases the risk for obesity, and the extent to which it has contributed to recent increases in energy intake and adiposity in the USA. DESIGN The search included studies published between 1970 and 2010 that examined secular trends, mechanisms, observational associations and intervention outcomes. Observational and intervention studies were abstracted and systematically evaluated for quality. SETTING Trends in obesity prevalence in the USA and studies from industrialized (developed) countries were included. SUBJECTS Studies were included for all ages, genders, ethnic and socio-economic groups for which data were available. RESULTS Obesity rates and sweetened beverage intake have increased in tandem in the USA. Studies consistently show that higher intake of sweetened beverages is associated with higher energy intake. Energy in liquid form is not well compensated for by reductions in the intake of other sources of energy. Well-designed observational studies consistently show a significant positive relationship between sweetened beverage intake and adiposity. More importantly, several well-conducted randomized controlled trials have shown statistically significant changes in adiposity as a result of corresponding changes in sweetened beverage intake. CONCLUSIONS All lines of evidence consistently support the conclusion that the consumption of sweetened beverages has contributed to the obesity epidemic. It is estimated that sweetened beverages account for at least one-fifth of the weight gained between 1977 and 2007 in the US population. Actions that are successful in reducing sweetened beverage consumption are likely to have a measurable impact on obesity.

Revised WIC food package improves diets of WIC families.

OBJECTIVE To explore the impact of the new Special Supplemental Nutrition Program for Women, Infants and Children (WIC) food package on WIC participant consumption of fruit, vegetables, whole-grain food, and lower-fat milk. DESIGN Telephone surveys of cross-sectional samples of California WIC families before and after the changes to the food package. PARTICIPANTS Random samples of pregnant or postpartum women and/or caregivers of children enrolled in WIC: 3,004 in September, 2009; 2,996 in March, 2010. MAIN OUTCOME MEASURES Consumption of fruit, vegetables, whole-grain food, and lower-fat milk. ANALYSIS Comparisons of outcome variables were made by examining the differences by time point, adjusted for sociodemographic variables, using ANOVA (for means) or logistic regression (for percentages). RESULTS Following the changes to the WIC food package, consumption of whole-grain food increased by 17.3 percentage points, a 51% increase over baseline. Caregivers and children who usually consumed whole milk decreased by 15.7 and 19.7 percentage points, respectively, a 60%-63% reduction over baseline. Accompanying increases in lower-fat milk consumption were demonstrated. Small but significant increases in consumption of fruits and vegetables were also observed. CONCLUSIONS AND IMPLICATIONS Federal policy changes to the WIC program had the intended effect of increasing consumption of the prescribed food items.

The neighborhood food environment: sources of historical data on retail food stores

With the rapidly increasing prevalence of obesity in the United States, and the minimal success of education-based interventions, there is growing interest in understanding the role of the neighborhood food environment in determining dietary behavior. This study, as part of a larger study, identifies historical data on retail food stores, evaluates strengths and limitations of the data for research, and assesses the comparability of historical retail food store data from a government and a commercial source.Five government and commercial listings of retail food stores were identified. The California State Board of Equalization (SBOE) database was selected and then compared to telephone business directory listings. The Spearmans correlation coefficient was used to assess the congruency of food store counts per census tract between the SBOE and telephone business directory databases. The setting was four cities in Northern California, 1979–1990.The SBOE and telephone business directory databases listed 127 and 351 retail food stores, respectively. The SBOE listed 36 stores not listed by the telephone business directories, while the telephone business directories listed 260 stores not listed by the SBOE. Spearmans correlation coefficients between estimates of stores per census tract made from the SBOE listings and those made from the telephone business directory listings were approximately 0.5 (p < .0001) for the types of stores studied (chain supermarkets, small grocery stores, and chain convenience markets). We conclude that, depending on the specific aims of the study, caution and considerable effort must be exercised in using and applying historical data on retail food stores.

Less frequent eating predicts greater BMI and waist circumference in female adolescents

BACKGROUND Little is known about the effect of eating frequency on adiposity. OBJECTIVE The study aim was to assess the prospective relation of an objective measure of eating frequency with adiposity in girls from ages 9-10 to 19-20 y. DESIGN By using data from 3-d diet records collected from 2372 girls in the National Heart, Lung, and Blood Institute Growth and Health Study, meal, snack, and total eating frequencies aggregated over the first 2 study years were examined in relation to 10-y change in BMI and waist circumference (WC). RESULTS Eating frequency was lower in black and older girls than in white and younger girls (P < 0.0001). In whites, lower initial snack and total eating frequencies were related to greater 10-y increases in BMI (P = 0.023 and 0.012, respectively) and WC (P = 0.030 and 0.015, respectively). In blacks, lower initial meal and snack frequencies were related to greater increases in BMI (P = 0.004 and 0.022, respectively) and WC (P = 0.052 and 0.005, respectively). Also, in blacks, lower initial total eating frequency was related to greater increases in WC (P = 0.010). After adjustment for baseline adiposity measure, race, parental education, physical activity, television and video viewing, total energy intake, and dieting for weight loss, lower initial total eating frequency remained related to greater 10-y increases in BMI (P = 0.013) and WC (P = 0.036). CONCLUSIONS A lower eating frequency predicts a greater gain in adiposity in adolescent females. Intervention trials are needed to test if changing the frequency of eating can affect obesity risk.

Favorable Impact of Nutrition Education on California WIC Families

OBJECTIVE To explore the impact of coordinated statewide nutrition education on Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) family behavior regarding fruits and vegetables, whole grains, and lower-fat milk. DESIGN Survey of different cross-sectional samples of WIC families before and after education. SETTING Intervention delivered at all WIC sites in California from April-September 2009. PARTICIPANTS Random samples of pregnant or postpartum women and/or caregivers of children enrolled in WIC: 3,015 before and 3,004 after coordinated nutrition education. INTERVENTION Education directed at families to eat more, and a greater variety of, fruits and vegetables; eat more whole grains; and drink lower-fat milk instead of whole milk. MAIN OUTCOME MEASURES Data collected by phone interview of women and caregivers on recognition of education messages, intention to consume, and change in family consumption of target food items. ANALYSIS Means and frequencies computed. Chi-square and t tests used to compare responses before and after education and for Spanish and English subgroups. RESULTS Following nutrition education, women and caregivers reported increased recognition of education messages, positive movement in stage of change for target food items, increased family consumption of fruits and whole grains, and replacement of whole milk with lower-fat milk. Impacts were similar for Spanish and English speakers. CONCLUSIONS AND IMPLICATIONS Coordinated nutrition education in WIC can significantly influence consumption toward more healthful food choices.

Alarming trends in pediatric overweight in the United States

SummaryObjectives:A comprehensive review of the pediatric overweight literature was undertaken to examine secular changes in the prevalence of pediatric overweight, the current magnitude and scope of pediatric overweight, and the identity of high-risk groups in the U.S.Methods:Articles published in the last two decades and studies of nationally representative numbers of children were highlighted.Results:An unprecedented three-fold increase in the prevalence of pediatric overweight has occurred in recent decades in the U.S. and evidence suggests that this trend is continuing unabated. While no sociodemographic or racial group has escaped this trend, particularly at risk are African American girls, Hispanic girls and boys, and children from low-income households.Conclusions:The rising prevalence of pediatric overweight in the U.S. is a harbinger of increases in diabetes, cardiovascular disease and numerous other health problems. Furthermore, disparities in pediatric overweight along ethnic and socio-economic lines are expected to further exacerbate current disparities in rates of chronic disease. Strategies and programs to prevent overweight among children are urgently needed.ZusammenfassungAlarmierende Trends in der Verbreitung von Übergewicht im Kindesalter in den USAZielsetzung:Eine umfassende Prüfung der Literatur zu Übergewicht im Kindesalter wurde vorgenommen, um langfristige Veränderungen im Vorkommen, das gegenwärtige Ausmass und die Reichweite von Übergewicht im Kindesalter zu untersuchen und um Gruppen mit besonders hohem Risiko in den USA zu identifizieren.Methoden:Spezifisch berücksichtigt wurden Artikel, die während der letzten 20 Jahre publiziert wurden und Studien mit national repräsentativen Teilnehmerzahlen.Ergebnisse:Eine noch nie da gewesene Verdoppelung der Prävalenz für Übergewicht im Kindesalter war in den letzten Jahrzehnten zu verzeichnen und die Datenlage deutet darauf hin, dass sich dieser Trend unvermindert fortsetzt. Keine sozio-ökonomische oder ethnische Untergruppe konnte sich diesem Trend entziehen. Afroamerikanische Mädchen und lateinamerikanische Mädchen und Knaben sowie Kinder aus Haushalten mit niedrigem Einkommen sind besonders gefährdet.Schlussfolgerungen:Die steigende Prävalenz für Übergewicht im Kindesalter in den USA ist ein Vorbote für eine Zunahme von Diabetes, Herzkreislauferkrankungen und zahlreichen anderen Gesundheitsproblemen. Weiterhin ist zu erwarten, dass die ethnischen und sozio-ökonomischen Ungleichheiten bei Übergewicht im Kindesalter die bereits bestehenden Ungleichheiten im Vorkommen von Krankheiten noch verstärken. Es bedarf dringend Strategien und Programme zur Vorbeugung von Übergewicht bei Kindern.RésuméTendance alarmante du surpoids pédiatrique aux Etats-UnisObjectifs:Une revue exhaustive de la littérature sur le surpoids pédiatrique a été effectuée pour examiner les changements au cours du siècle de la prévalence du surpoids, son importance actuelle et son extension, ainsi que pour identifier les groupes à haut risque aux Etats-Unis.Méthodes:Etude des articles publiés au cours des 20 dernières années et des études portant sur des échantillons d’enfants représentatifs au niveau national.Résultats:Un doublement sans précédant de la prévalence du surpoids pédiatrique s’est produit au cours des récentes décennies aux Etats-Unis et les données suggèrent que cette tendance se poursuit inexorablement. Bien que cette tendance touche tous les groupes socio-démographiques et ethniques, les filles africaines-américaines, les garçons et les filles hispaniques et les enfants de familles ayant un bas revenu sont particulièrement à risque.Conclusions:La prévalence croissante du surpoids pédiatrique aux Etats-Unis est une source d’accroissement du diabète, de maladies cardio-vasculaires et de nombreux autres problèmes de santé. De plus, les disparités de surpoids pédiatriques selon l’ethnie ou le niveau socio-économique ont probablement exacerbé les inégalités actuelles concernant les taux de maladies chroniques. Il est urgent de développer des stratégies et des programmes destinés à prévenir le surpoids chez les enfants.

Dietary calcium and pregnancy-induced hypertension: is there a relation?

The evidence that calcium plays a role in the etiology, prevention, and treatment of pregnancy-induced hypertension (PIH) is reviewed. The precise factors involved in the pathogenesis of PIH are unclear, but several alterations in calcium metabolism have been identified. Epidemiologic data suggest an inverse correlation between dietary calcium intake and incidence of PIH. Although evidence suggests a possible beneficial effect of supplemental calcium, contradictions persist in clinical trials of pregnant women. Presently, there is insufficient evidence to support routine calcium supplementation of all pregnant women. However, high-risk groups, such as pregnant teens, populations with inadequate calcium intake, and women at risk of developing PIH, may benefit from consuming additional dietary calcium.

Participation in the Child and Adult Care Food Program Is Associated with More Nutritious Foods and Beverages in Child Care

BACKGROUND Nearly two million California children regularly spend time in child care. Surprisingly little is known about the nutrition environments of these settings. The aim of this study was to compare foods and beverages served to 2- to 5-year-olds by type of child care and participation in the federally funded Child and Adult Care Food Program (CACFP). METHODS A statewide survey of child care providers (n = 429) was administered. Licensed child care was divided into six categories: Head Start centers, state preschools, centers that participate in CACFP, non-CACFP centers, homes that participate in CACFP, and non-CACFP homes. RESULTS CACFP sites in general, and Head Start centers in particular, served more fruits, vegetables, milk, and meat/meat alternatives, and fewer sweetened beverages and other sweets and snack-type items than non-CACFP sites. Reported barriers to providing nutritious foods included high food costs and lack of training. CONCLUSIONS CACFP participation may be one means by which reimbursement for food can be increased and food offerings improved. Further research should investigate whether promoting CACFP participation can be used to provide healthier nutrition environments in child care and prevent obesity in young children.