Patricia B. Crawford

Comparative advantage of 3-day food records over 24-hour recall and 5-day food frequency validated by observation of 9- and 10-year-old girls

OBJECTIVE The validity of the 24-hour recall, 3-day food record, and 5-day food frequency was assessed to decide on a dietary assessment method for the National Heart, Lung, and Blood Institute (NHLBI) Growth and Health Study. DESIGN All subjects were assigned to one of three dietary assessment methods. Unobtrusive observers recorded types and amounts of foods eaten during lunch, and these were compared with the foods reported by the girls in the study. SETTING School lunchrooms in California and Ohio. SUBJECTS 58 girls, aged 9 and 10 years. MAIN OUTCOME MEASURES Reporting errors for dietary assessment methods. STATISTICAL ANALYSES PERFORMED Descriptive statistics, matched pair t tests, and Spearman correlation coefficients. RESULTS Comparison of the intakes of energy and selected macronutrients showed different ranges of, and median percentage absolute errors for, each dietary assessment method. Percentage absolute errors ranged between 20 and 33 for the 5-day food frequency method; 19 and 39 for the 24-hour recall; and 12 and 22 for the 3-day food record. The proportion of missing foods (ie, observed food items not reported) and phantom foods (ie, reported food items not observed) by each method were 46% and 40%, respectively, for the 5-day food frequency; 30% and 33%, respectively, for the 24-hour recall; and 25% and 10%, respectively, for the 3-day food record. APPLICATIONS/CONCLUSIONS Errors in food reporting and quantification can vary with the type of dietary methodology. Agreement between observed and reported intakes from 3-day food records made it the best overall choice. On this basis, it was selected as the method of assessment for the NHLBI Growth and Health Study.

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.

Eating disorder symptoms in a cohort of 11 to 16‐year‐old black and white girls: The NHLBI growth and health study

OBJECTIVE This study sought to provide reference data for the Eating Disorder Inventory (EDI) with use of young adolescent black and white girls. Moreover, the study examined the relationship between race, age, socioeconomic status, and adiposity and each of the eight EDI scales. METHOD To achieve these aims, data were used that had been collected in Years 3, 5, and 7 as part of the National Heart, Lung, and Blood Institute Growth and Health Study, a longitudinal cohort study of risk factors for obesity in black and white girls. For the present report, data were available from 2,228 girls in Year 3, 2,056 girls in Year 5, and 1,902 girls in Year 7. RESULTS EDI scores were found to vary by race, age, socioeonomic status, and body weight of respondents. Black girls scored different from white girls on all EDI subscales. Scores on all but two subscales (Body Dissatisfaction, Drive for Thinness) decreased significantly with increasing age. Significant inverse associations were found between maximum parental education and all EDI subscales except Body Dissatisfaction and Perfectionism. Elevated body weight was associated significantly with Body Dissatisfaction, Drive for Thinness, Bulimia, Interoceptive Awareness, and Ineffectiveness. DISCUSSION Our results illustrate the importance of taking into consideration the potentially confounding role of demographic characteristics and body weight when comparing different race or ethnic groups on the EDI.

Nutritional and health status of Tibetan children living at high altitudes

BACKGROUND Children living at high altitudes often have delayed growth, but whether growth retardation is related to altitude or to other factors is not known. METHODS A multicultural health care team assessed 2078 Tibetan children 0 to 84 months of age for anthropometric and clinical signs of malnutrition. The children lived in 11 counties, which contained more than 50 diverse urban and nonurban (nomadic, agricultural, or periurban) communities in the Tibet Autonomous Region of China. The height and weight of the children were compared with those of U.S. children. Height and weight were expressed as z scores (the number of standard deviations from the median of the age- and sex-specific reference group). RESULTS The mean z score for height fell from -0.5 to -1.6 in the first 12 months of life and generally ranged from -2.0 to -2.4 in older children. Overall, of 2078 children, 1067 (51 percent) had moderately or severely stunted growth, as defined by a z score of -2.0 or lower. Of the 1556 children 24 months of age or older, 871 (56 percent) had stunted growth, which was severe (z score, -3.0 or lower) in 380 (24 percent). Among the children in this age group, 787 of the 1313 nonurban children (60 percent) had stunting, as compared with 84 of the 243 urban children (35 percent). Stunting was associated with clinical conditions such as rickets, abdominal distention, hair depigmentation, and skin lesions and with a maternal history of hepatitis or goiter. Stunting was not associated with altitude, after adjustment for the type of community. CONCLUSIONS In Tibetan children, severe stunting due to malnutrition occurs early in life, and morbidity is high.

The effects of race, household income, and parental education on nutrient intakes of 9- and 10-year-old girls. NHLBI Growth and Health Study.

Nutrient intakes of 2149 black and white, 9- and 10-year-old girls varied by race, household income, and parental education. Of the three variables, higher education was most consistently associated with more desirable levels of nutrient intakes, that is, lower percentage of dietary fat and higher levels of vitamin C, calcium, and potassium. Higher income was related to higher intakes of vitamin C, but lower intakes of calcium and iron. Higher income was associated with lower percentage of dietary fat. After adjustment for income and education, race was associated with intakes of calcium, vitamin C, and to a lesser extent, percentages of kilocalories from total fat and polyunsaturated fat, and potassium. Black girls had a significantly lower intake of calcium (720 versus 889 mg) and a higher intake of vitamin C (91 versus 83 mg). Proportions of the cohort with inadequate or excessive intakes of micronutrients and macronutrients were also estimated. A high proportion of girls exceeded the recommended intake level of 30% of kilocalories from total fat (90% of black girls; 84% of white girls) and 10% of kilocalories from saturated fat (92 and 93%, respectively). Low intakes of calcium (40% of black girls and and 20% og white girls) and zinc (36 and 38%, respectively) commonly were found for girls of both names.

The effect of vitamins C and E on biomarkers of oxidative stress depends on baseline level

Oxidative stress is elevated in obesity, and may be a major mechanism for obesity-related diseases. Nonsmokers (n=396) were randomized to 1000 mg/day vitamin C, 800 IU/day vitamin E, or placebo, for 2 months. Treatment effect was examined in multiple regression analyses using an intention-to-treat approach. Vitamin C (P=0.001) and vitamin E (P=0.043) reduced plasma F2-isoprostanes. In the overall sample, changes from baseline were +6.8, -10.6, and -3.9% for placebo, vitamin C, and vitamin E groups, respectively. However, a significant interaction with baseline F2-isoprostane was found. When baseline F2-isoprostane was >50 microg/mL, vitamin C reduced F2-isoprostane by 22% (P=0.01). Vitamin E reduced it by 9.8% (P=0.46). Below that cut point, neither treatment produced further reductions. F2-isoprostane>50 microg/mL was strongly associated with obesity, and was present in 42% of the sample. Change in malondialdehyde concentration was minimal. These findings suggest a role for vitamin C in reducing lipid peroxidation. Future research on effects of vitamins C or E on plasma F2-isoprostane should limit participants to those with baseline levels >50 mug/mL. Further studies are needed to establish whether treatment with vitamins C or E in persons with concentrations above that cut point could slow the development of cardiovascular disease.

The relationship between meal frequency and body mass index in black and white adolescent girls: more is less

Objective:To document meal frequency and its relationship to body mass index (BMI) in a longitudinal sample of black and white girls from ages 9–19 years.Design:Ten-year longitudinal observational study.Subjects:At baseline, 1209 Black girls (539 age nine years, 670 age 10 years) and 1,166 White girls (616 age nine years, 550 age 10 years) were enrolled in the National Heart, Lung and Blood Institute Growth and Health Study (NGHS).Measurements:Three-day food diaries, measured height and weight and self-reported physical activity and television viewing were obtained at annual in-person visits.Results:Over the course of the study, the percentage of girls eating 3+ meals on all 3 days was reduced by over half (15 vs 6%). Participants who ate 3+ meals on more days had lower BMI-for-age z-scores. Black girls, but not white girls, who ate 3+ meals on more days were less likely to meet criteria for overweight.Conclusion:Meal frequency was related to BMI and should be considered when developing guidelines to prevent childhood overweight.

Lessons Learned From Evaluations of California's Statewide School Nutrition Standards

OBJECTIVES We assessed the impact of legislation that established nutrition standards for foods and beverages that compete with reimbursable school meals in California. METHODS We used documentation of available foods and beverages, sales accounts, and surveys of and interviews with students and food service workers to conduct 3 studies measuring pre- and postlegislation food and beverage availability, sales, and student consumption at 99 schools. RESULTS Availability of nutrition standard-compliant foods and beverages increased. Availability of noncompliant items decreased, with the biggest reductions in sodas and other sweetened beverages, regular chips, and candy. At-school consumption of some noncompliant foods dropped; at-home consumption of selected noncompliant foods did not increase. Food and beverage sales decreased at most venues, and food service à la carte revenue losses were usually offset by increased meal program participation. Increased food service expenditures outpaced revenue increases. CONCLUSIONS Regulation of competitive foods improved school food environments and student nutritional intake. Improvements were modest, partly because many compliant items are fat- and sugar-modified products of low nutritional value. Additional policies and actions are needed to achieve more substantive improvements in school nutrition environments and student nutrition and health.

Disparities in Peaks, Plateaus, and Declines in Prevalence of High BMI Among Adolescents

OBJECTIVES: The objective of this study was to investigate trends in prevalence of high BMI from 2001 to 2008 and examine racial/ethnic disparities. METHODS: Records for a total of 8 283 718 fifth-, seventh-, and ninth-grade students who underwent Californias school-based BMI screening between 2001 and 2008 were included. Logistic regression identified trends in prevalence of high BMI (≥85th, ≥95th, ≥97th, and ≥99th percentiles). RESULTS: For 3 of 4 BMI cut points, prevalence continued to increase for black and American Indian girls through 2008, Hispanic girls plateaued after 2005, non-Hispanic white girls declined to 2001 prevalence levels after peaking in 2005, and Asian girls showed no increases. Non-Hispanic white boys peaked in 2005, then declined to 2001 prevalence levels for all BMI cut points; Hispanic and Asian boys declined after 2005 (for 3 lowest BMI cut points only) but remained above 2001 levels; and American Indian boys peaked later (2007) and declined only for BMI ≥95th. No girls and few boys showed a decline after peaking in prevalence of BMI ≥99th percentile. In 2008, disparities in prevalence were greatest for BMI ≥99th percentile, with prevalence of 4.9% for American Indian girls and 4.6% for black girls versus 1.3% for non-Hispanic white girls. CONCLUSIONS: On the basis of statewide California data, prevalence of high BMI is declining for some groups but has not declined for American Indian and black girls. These trends portend greater disparities over time, particularly in severe obesity. Interventions and policies that are tailored to the highest risk groups should be pursued.

The California Endowment's Healthy Eating, Active Communities Program: A Midpoint Review

OBJECTIVES We conducted a midpoint review of The California Endowments Healthy Eating, Active Communities (HEAC) program, which works in 6 low-income California communities to prevent childhood obesity by changing childrens environments. The HEAC program conducts interventions in 5 key childhood environments: schools, after-school programs, neighborhoods, health care, and marketing and advertising. METHODS We measured changes in foods and beverages sold at schools and in neighborhoods in HEAC sites; changes in school and after-school physical activity programming and equipment; individual-level changes in childrens attitudes and behaviors related to food and physical activity; and HEAC-related awareness and engagement on the part of community members, stakeholders, and policymakers. RESULTS Childrens environments changed to promote healthier lifestyles across a wide range of domains in all 5 key childhood environments for all 6 HEAC communities. Children in HEAC communities are also engaging in more healthy behaviors than they were before the programs implementation. CONCLUSIONS HEAC sites successfully changed childrens food and physical activity environments, making a healthy lifestyle a more viable option for low-income children and their families.