Rebecca J. Scharf

Sugar-Sweetened Beverages and Weight Gain in 2- to 5-Year-Old Children

BACKGROUND AND OBJECTIVE: Although sugar-sweetened beverage (SSB) consumption has been tightly linked to weight status among older children, the data regarding these relationships in children aged 2 to 5 years have been mixed. Our objective was to evaluate longitudinal and cross-sectional relationships between SSB consumption and weight status among children aged 2 to 5 years. METHODS: We assessed SSB consumption and BMI z scores among 9600 children followed in the Early Childhood Longitudinal Survey—Birth Cohort, using linear and logistic regression and adjusting for race/ethnicity, socioeconomic status, mother’s BMI, and television viewing. RESULTS: Higher rates of SSB consumption were associated with higher BMI z scores among children age 4 (P < .05) and 5 (P < .001) but not yet at 2 years. Children aged 5 years who drank SSB regularly (compared with infrequent/nondrinkers) had a higher odds ratio for being obese (1.43, confidence interval 1.10–1.85, P < .01). In prospective analysis, children drinking SSB at 2 years (compared with infrequent/nondrinkers) had a greater subsequent increase in BMI z score over the ensuing 2 years (P < .05). CONCLUSIONS: Similar to what is seen among older children, children aged 2 to 5 years drinking SSB demonstrate both prospective and cross-sectional correlations with higher BMI z score. Pediatricians and parents should discourage SSB consumption to help avoid potential unhealthy weight gain in young children. From a public health standpoint, strong consideration should be made toward policy changes leading to decreases in SSB consumption among children.

Biomarkers of environmental enteropathy, inflammation, stunting, and impaired growth in children in Northeast Brazil

Critical to the design and assessment of interventions for enteropathy and its developmental consequences in children living in impoverished conditions are non-invasive biomarkers that can detect intestinal damage and predict its effects on growth and development. We therefore assessed fecal, urinary and systemic biomarkers of enteropathy and growth predictors in 375 6–26 month-old children with varying degrees of malnutrition (stunting or wasting) in Northeast Brazil. 301 of these children returned for followup anthropometry after 2-6m. Biomarkers that correlated with stunting included plasma IgA anti-LPS and anti-FliC, zonulin (if >12m old), and intestinal FABP (I-FABP, suggesting prior barrier disruption); and with citrulline, tryptophan and with lower serum amyloid A (SAA) (suggesting impaired defenses). In contrast, subsequent growth was predicted in those with higher fecal MPO or A1AT and also by higher L/M, plasma LPS, I-FABP and SAA (showing intestinal barrier disruption and inflammation). Better growth was predicted in girls with higher plasma citrulline and in boys with higher plasma tryptophan. Interactions were also seen with fecal MPO and neopterin in predicting subsequent growth impairment. Biomarkers clustered into markers of 1) functional intestinal barrier disruption and translocation, 2) structural intestinal barrier disruption and inflammation and 3) systemic inflammation. Principle components pathway analyses also showed that L/M with %L, I-FABP and MPO associate with impaired growth, while also (like MPO) associating with a systemic inflammation cluster of kynurenine, LBP, sCD14, SAA and K/T. Systemic evidence of LPS translocation associated with stunting, while markers of barrier disruption or repair (A1AT and Reg1 with low zonulin) associated with fecal MPO and neopterin. We conclude that key noninvasive biomarkers of intestinal barrier disruption, LPS translocation and of intestinal and systemic inflammation can help elucidate how we recognize, understand, and assess effective interventions for enteropathy and its growth and developmental consequences in children in impoverished settings.

Longitudinal evaluation of milk type consumed and weight status in preschoolers

Objective To evaluate relationships between type of milk consumed and weight status among preschool children. Design Longitudinal cohort study. Setting The Early Childhood Longitudinal Study, Birth Cohort, a representative sample of US children. Participants 10 700 US children examined at age 2 and 4 years. Main outcome measures Body mass index (BMI) z score and overweight/obese status as a function of milk type intake. Results The majority of children drank whole or 2% milk (87% at 2 years, 79.3% at 4 years). Across racial/ethnic and socio-economic status subgroups, 1%/skim milk drinkers had higher BMI z scores than 2%/whole milk drinkers. In multivariable analyses, increasing fat content in the type of milk consumed was inversely associated with BMI z score (p<0.0001). Compared to those drinking 2%/whole milk, 2- and 4-year-old children drinking 1%/skim milk had an increased adjusted odds of being overweight (age 2 OR 1.64, p<0.0001; age 4 OR 1.63, p<0.0001) or obese (age 2 OR 1.57, p<0.01; age 4 OR 1.64, p<0.0001). In longitudinal analysis, children drinking 1%/skim milk at both 2 and 4 years were more likely to become overweight/obese between these time points (adjusted OR 1.57, p<0.05). Conclusions Consumption of 1%/skim milk is more common among overweight/obese preschoolers, potentially reflecting the choice of parents to give overweight/obese children low-fat milk to drink. Nevertheless, 1%/skim milk does not appear to restrain body weight gain between 2 and 4 years of age in this age range, emphasising a need for weight-targeted recommendations with a stronger evidence base.

Nighttime sleep duration and externalizing behaviors of preschool children

Objective: To examine how many hours preschool children in the United States sleep at night and to test the hypothesis that children with shorter nighttime sleep duration are more likely to exhibit externalizing behaviors. Methods: The Early Childhood Longitudinal Study-Birth Cohort is a nationally representative longitudinal cohort study that followed children born in 2001 through kindergarten. This cross-sectional study examines the preschool wave (n = ∼8950). We estimated nighttime sleep duration from parents reports of their 4-year-old childs typical weekday bed and wake times. Parents rated their child on 6 different externalizing behaviors (overactivity, anger, aggression, impulsivity, tantrums, and annoying behaviors) on a scale from 1 through 5 using the Preschool and Kindergarten Behavior Scale—second edition. Multivariable regression analyses were used to examine the association between sleep duration and behavior scores and to control for possible confounders. Results: Results are weighted to total United States population, ∼3,895,100 children born in 2001. Mean sleep duration was 10.47 hours. Mean bedtime was 8:39 PM and wake time was 7:13 AM. The adjusted odds ratios for children sleeping <9.44 hours (1 standard deviation below the mean) versus those sleeping ≥9.44 hours for 6 different externalizing behavior outcomes were as follows: overactivity = 1.30 (95% confidence interval [CI], 1.03–1.65); anger = 1.40 (95% CI, 1.15–1.71); aggression = 1.81 (95% CI, 1.36–2.41); impulsivity = 1.44 (95% CI, 1.12–1.86); tantrums = 1.46 (95% CI, 1.16–1.85); and annoying behaviors = 1.40 (95% CI, 0.97–1.87). Conclusion: Shorter nighttime sleep duration in preschool children is associated with higher likelihood of externalizing behavioral symptoms based on parental report.

Geography, Population, Demography, Socioeconomic, Anthropometry, and Environmental Status in the MAL-ED Cohort and Case-Control Study Sites in Fortaleza, Ceará, Brazil

The Etiology, Risk Factors and Interactions of Enteric Infections and Malnutrition and the Consequences for Child Health and Development (MAL-ED) cohort in the studys Fortaleza, Brazil, catchment area has a population of approximately 82 300 inhabitants. Most of the households (87%) have access to clean water, 98% have electricity, and 69% have access to improved toilet/sanitation. Most childbirths occur at the hospital, and the under-5 mortality rate is 20 per 1000 live births. The MAL-ED case-control study population, identified through the Institute for the Promotion of Nutrition and Human Development (IPREDE), serves 600 000 inhabitants from areas totaling about 42% of the city of Fortaleza. IPREDE receives referrals from throughout the state of Ceará for infant nutrition, and provides services including teaching activities and the training of graduate students and health professionals, while supporting research projects on child nutrition and health. In this article, we describe the geographic, demographic, socioeconomic, anthropometric, and environmental status of the MAL-ED cohort and case-control study populations in Fortaleza, Brazil.

The MAL-ED Cohort Study: Methods and Lessons Learned When Assessing Early Child Development and Caregiving Mediators in Infants and Young Children in 8 Low- and Middle-Income Countries

More epidemiological data are needed on risk and protective factors for child development. In The Etiology, Risk Factors and Interactions of Enteric Infections and Malnutrition and the Consequences for Child Health and Development (MAL-ED) cohort study, we assessed child development in a harmonious manner across 8 sites in Bangladesh, Brazil, India, Nepal, Pakistan, Peru, South Africa, and Tanzania. From birth to 24 months, development and language acquisition were assessed via the Bayley Scales of Infant and Toddler Development and a modified MacArthur Communicative Development Inventory. Other measures were infant temperament, the childs environment, maternal psychological adjustment, and maternal reasoning abilities. We developed standard operating procedures and used multiple techniques to ensure appropriate adaptation and quality assurance across the sites. Test adaptation required significant time and human resources but is essential for data quality; funders should support this step in future studies. At the end of this study, we will have a portfolio of culturally adapted instruments for child development studies with examination of psychometric properties of each tool used.

Systemic inflammation, growth factors, and linear growth in the setting of infection and malnutrition.

Objectives Deficits in weight gain and linear growth are seen frequently among children in areas where malnutrition and recurrent infections are common. Although both inflammation and malnutrition can result in growth hormone (GH) resistance, the interrelationships of infection, inflammation, and growth deficits in developing areas remain unclear. The aim of this study was to evaluate relationships between low levels of systemic inflammation, growth factors, and anthropometry in a case–control cohort of underweight and normal weight children in northern Brazil. Methods We evaluated data from 147 children ages 6 to 24 mo evaluated in the MAL-ED (Interactions of Malnutrition and Enteric Disease) case–control study following recruitment from a nutrition clinic for impoverished families in Fortaleza, Brazil. We used nonparametric tests and linear regression to evaluate relationships between current symptoms of infections (assessed by questionnaire), systemic inflammation (assessed by high-sensitivity C-reactive protein [hsCRP]), the GH insulin-like growth factor-1 (IGF-1) axis, and measures of anthropometry. All models were adjusted for age and sex. Results Children with recent symptoms of diarrhea, cough, and fever (compared with those without symptoms) had higher hsCRP levels; those with recent diarrhea and fever also had lower IGF-1 and higher GH levels. Stool myeloperoxidase was positively associated with serum hsCRP. hsCRP was in turn positively associated with GH and negatively associated with IGF-1 and IGF-binding protein-3 (IGFBP-3), suggesting a state of GH resistance. After adjustment for hsCRP, IGF-1 and IGFBP-3 were positively and GH was negatively associated with Z scores for height and weight. Conclusions Infection and inflammation were linked to evidence of GH resistance, whereas levels of GH, IGF-1, and IGFBP-3 were associated with growth indices independent of hsCRP. These data implicate complex interrelationships between infection, nutritional status, GH axis, and linear growth in children from a developing area.

Milk intake, height and body mass index in preschool children

Objectives To evaluate links between the volume of milk consumed and weight and height status in children aged 4 and 5 years. Design We analysed data from 8950 children followed up as part of the Early Childhood Longitudinal Survey, Birth cohort, a nationally representative cohort of children. We used linear and logistic regression to assess associations of daily servings of milk intake at age 4 years with z-scores of body mass index (BMI), height and weight-for-height at 4 and 5 years, adjusted for sex, race/ethnicity, socioeconomic status and type of milk consumed. Results Among children who drank milk at age 4 years, higher milk consumption was associated with higher z-scores of BMI, height and weight-for-height at 4 years (all p<0.05). This corresponded to differences between children drinking <1 and ≥4 milk servings daily of approximately 1 cm in height and 0.15 kg in weight. By age 5 years, only the association with height remained significant (p<0.001). At 4 years, children drinking ≥3 servings of milk daily were more likely to be overweight/obese (BMI≥85th percentile) than those drinking 0.5–2 servings of milk daily (adjusted OR 1.16 (95% CI 1.02 to 1.32) p=0.02). Conclusions In a cohort of children at age 4 years, the volume of milk consumed was associated with higher weight status and taller stature, while at 5 years, higher milk consumption continued to be associated with taller stature. Given higher odds of overweight/obesity with milk consumption ≥3 servings daily, this study supports current American Academy of Pediatrics recommendations that pre-school children consume two milk servings daily.

Sugar-Sweetened Beverages and Children's Health

Temporal trends in the epidemic of childhood obesity have been paralleled by increases in the consumption of sugar-sweetened beverages (SSB) during childhood. Consumption has increased dramatically over the past several decades in all age ranges, with some moderation over the past 10 years. Evidence from cross-sectional, longitudinal, and interventional studies supports links between SSB consumption in childhood and unhealthy weight gain, as well as other untoward health outcomes. These data have stimulated public health efforts to curtail consumption as a means of improving childhood weight status and related health outcomes. Reducing ready access to SSBs, changing the message environment to which children are exposed, and replacing SSBs with healthier beverages have had moderate success in decreasing SSB consumption and curbing unhealthy weight gain.

Early-life enteric infections: relation between chronic systemic inflammation and poor cognition in children

The intestinal microbiota undergoes active remodeling in the first 6 to 18 months of life, during which time the characteristics of the adult microbiota are developed. This process is strongly influenced by the early diet and enteric pathogens. Enteric infections and malnutrition early in life may favor microbiota dysbiosis and small intestinal bacterial overgrowth, resulting in intestinal barrier dysfunction and translocation of intestinal bacterial products, ultimately leading to low-grade, chronic, subclinical systemic inflammation. The leaky gut-derived low-grade systemic inflammation may have profound consequences on the gut-liver-brain axis, compromising normal growth, metabolism, and cognitive development. This review examines recent data suggesting that early-life enteric infections that lead to intestinal barrier disruption may shift the intestinal microbiota toward chronic systemic inflammation and subsequent impaired cognitive development.