Sharon M. Coleman

Ability to Delay Gratification at Age 4 Years and Risk of Overweight at Age 11 Years

OBJECTIVES To determine if limited ability to delay gratification (ATDG) at age 4 years is independently associated with an increased risk of being overweight at age 11 years and to assess confounding or moderation by child body mass index z score at 4 years, self-reported maternal expectation of child ATDG for food, and maternal weight status. DESIGN Longitudinal prospective study. SETTING Ten US sites. PARTICIPANTS Participants in the National Institute of Child Health and Human Development Study of Early Child Care and Youth Development. Main Exposure Ability to delay gratification at 4 years, measured as pass or fail on a validated task. OUTCOME MEASURES Overweight at 11 years, defined as a body mass index greater than or equal to the 85th percentile based on measured weight and height. RESULTS Of 805 children, 47% failed the ATDG task. Using multiple logistic regression, children who failed the ATDG task were more likely to be overweight at 11 years (relative risk, 1.29; 95% confidence interval, 1.06-1.58), independent of income to needs ratio. Body mass index z score at 4 years and maternal expectation of child ATDG for food did not alter the association, but maternal weight status reduced the association significantly. CONCLUSIONS Children with limited ATDG at age 4 years were more likely to be overweight at age 11 years, but the association was at least partially explained by maternal weight status. Further understanding of the association between the childs ATDG and maternal and child weight status may lead to more effective obesity intervention and prevention programs.

US Housing insecurity and the health of very young children.

OBJECTIVES We investigated the association between housing insecurity and the health of very young children. METHODS Between 1998 and 2007, we interviewed 22,069 low-income caregivers with children younger than 3 years who were seen in 7 US urban medical centers. We assessed food insecurity, child health status, developmental risk, weight, and housing insecurity for each childs household. Our indicators for housing insecurity were crowding (> 2 people/bedroom or>1 family/residence) and multiple moves (≥ 2 moves within the previous year). RESULTS After adjusting for covariates, crowding was associated with household food insecurity compared with the securely housed (adjusted odds ratio [AOR] = 1.30; 95% confidence interval [CI] = 1.18, 1.43), as were multiple moves (AOR = 1.91; 95% CI = 1.59, 2.28). Crowding was also associated with child food insecurity (AOR = 1.47; 95% CI = 1.34, 1.63), and so were multiple moves (AOR = 2.56; 95% CI = 2.13, 3.08). Multiple moves were associated with fair or poor child health (AOR = 1.48; 95% CI =1.25, 1.76), developmental risk (AOR 1.71; 95% CI = 1.33, 2.21), and lower weight-for-age z scores (-0.082 vs -0.013; P= .02). CONCLUSIONS Housing insecurity is associated with poor health, lower weight, and developmental risk among young children. Policies that decrease housing insecurity can promote the health of young children and should be a priority.

Food Insecurity and Risk of Poor Health Among US-Born Children of Immigrants

OBJECTIVES We investigated the risk of household food insecurity and reported fair or poor health among very young children who were US citizens and whose mothers were immigrants compared with those whose mothers had been born in the United States. METHODS Data were obtained from 19,275 mothers (7216 of whom were immigrants) who were interviewed in hospital-based settings between 1998 and 2005 as part of the Childrens Sentinel Nutrition Assessment Program. We examined whether food insecurity mediated the association between immigrant status and child health in relation to length of stay in the United States. RESULTS The risk of fair or poor health was higher among children of recent immigrants than among children of US-born mothers (odds ratio [OR] = 1.26; 95% confidence interval [CI] = 1.02, 1.55; P < .03). Immigrant households were at higher risk of food insecurity than were households with US-born mothers. Newly arrived immigrants were at the highest risk of food insecurity (OR = 2.45; 95% CI = 2.16, 2.77; P < .001). Overall, household food insecurity increased the risk of fair or poor child health (OR = 1.74; 95% CI = 1.57, 1.93; P < .001) and mediated the association between immigrant status and poor child health. CONCLUSIONS Children of immigrant mothers are at increased risk of fair or poor health and household food insecurity. Policy interventions addressing food insecurity in immigrant households may promote child health.

A Brief Indicator of Household Energy Security: Associations With Food Security, Child Health, and Child Development in US Infants and Toddlers

OBJECTIVE. Household energy security has not been measured empirically or related to child health and development but is an emerging concern for clinicians and researchers as energy costs increase. The objectives of this study were to develop a clinical indicator of household energy security and assess associations with food security, health, and developmental risk in children <36 months of age. METHODS. A cross-sectional study that used household survey and surveillance data was conducted. Caregivers were interviewed in emergency departments and primary care clinics form January 2001 through December 2006 on demographics, public assistance, food security, experience with heating/cooling and utilities, Parents Evaluation of Developmental Status, and child health. The household energy security indicator includes energy-secure, no energy problems; moderate energy insecurity, utility shutoff threatened in past year; and severe energy insecurity, heated with cooking stove, utility shutoff, or ≥1 day without heat/cooling in past year. The main outcome measures were household and child food security, child reported health status, Parents Evaluation of Developmental Status concerns, and hospitalizations. RESULTS. Of 9721 children, 11% (n = 1043) and 23% (n = 2293) experienced moderate and severe energy insecurity, respectively. Versus children with energy security, children with moderate energy insecurity had greater odds of household food insecurity, child food insecurity, hospitalization since birth, and caregiver report of child fair/poor health, adjusted for research site and mother, child, and household characteristics. Children with severe energy insecurity had greater adjusted odds of household food insecurity, child food insecurity, caregivers reporting significant developmental concerns on the Parents Evaluation of Developmental Status scale, and report of child fair/poor health. No significant association was found between energy security and child weight for age or weight for length. CONCLUSIONS. As household energy insecurity increases, infants and toddlers experienced increased odds of household and child food insecurity and of reported poor health, hospitalizations, and developmental risks.

Maternal Feeding Practices Become More Controlling After and Not Before Excessive Rates of Weight Gain

It is unclear whether controlling maternal feeding practices (CMFPs) lead to or are a response to increases in a childs BMI. Our goal was to determine the direction of this relationship. Data were obtained from National Institute of Child Health and Human Developments Study of Early Child Care and Youth Development. Child BMI z‐score (zBMI) was calculated from measured weight and height. CMFP was defined by, “Do you let your child eat what he/she feels like eating?”. Change in child zBMI was calculated between 4–7 years and 7–9 years, and dichotomized into “increasing” vs. “no change or decreasing”. Change in CMFP was calculated over the same time periods, and dichotomized into “more controlling” vs. “no change or less controlling.” Multiple logistic regression, stratified by gender and controlling for race, maternal education, maternal weight status, and baseline child weight status, was used for analysis. A total of 789 children were included. From 4 to 9 years, mean zBMI increased (P = 0.02) and mothers became more controlling (P < 0.001). Increasing CMFP between 4 and 7 years was associated with decreased odds of increasing zBMI between 7 and 9 years in boys (odds ratio = 0.52, 95% confidence interval = 0.27–1.00). There was no relationship in girls. Increasing zBMI between 4 and 7 years was associated with increasing CMFPs between 7 and 9 years in girls (odds ratio = 1.72, 95% confidence interval = 1.08–2.74), but not boys. Early increases in CMFP were not associated with later increases in zBMI for boys or girls. However, early increases in zBMI among girls were associated with later increases in CMFP. Clarifying the relationship between maternal feeding practices and child weight will inform future recommendations.

Short Stature in a Population-Based Cohort: Social, Emotional, and Behavioral Functioning

OBJECTIVE: The goal was to determine whether there were significant differences between children of normative versus short stature in behavioral functioning and peer relationships, according to teacher and child reports. METHODS: The study included 712 boys and girls in the sixth grade, from the National Institute of Child Health and Human Development Study of Early Child Care and Youth Development. Main outcome measures included Achenbach Teachers Report Form internalizing, externalizing, and total scores; Childrens Depression Inventory scores (child report); Life Orientation Test-Revised scores (child report); Child Behavior with Peers questionnaire asocial with peers, excluded by peers, and peer victimization subscale scores (teacher report); peer social support and victimization scores (child report); and relationships with peers score (teacher report). In bivariate comparisons, these outcomes were compared for children of relatively short (height of <10th percentile) versus nonshort (height of ≥10th percentile) stature, and effect sizes were calculated. Multivariate linear regression models adjusted for maternal education, income/needs ratio, race, and gender. RESULTS: Effect sizes ranged from 0.00 to 0.35. Short children reported marginally higher levels of self-perceived peer victimization, compared with their nonshort peers. There were no significant differences in the rest of the outcomes for children of short versus nonshort stature, in either unadjusted or adjusted models. CONCLUSION: Although short children from a population-based sample reported marginally higher levels of self-perceived peer victimization, they did not differ from their nonshort peers in a range of social, emotional, and behavioral outcomes.

Risk factors for late-stage HIV disease presentation at initial HIV diagnosis in Durban, South Africa.

Background After observing persistently low CD4 counts at initial HIV diagnosis in South Africa, we sought to determine risk factors for late-stage HIV disease presentation among adults. Methods We surveyed adults prior to HIV testing at four outpatient clinics in Durban from August 2010 to November 2011. All HIV-infected adults were offered CD4 testing, and late-stage HIV disease was defined as a CD4 count <100 cells/mm3. We used multivariate regression models to determine the effects of sex, emotional health, social support, distance from clinic, employment, perceived barriers to receiving healthcare, and foregoing healthcare to use money for food, clothing, or housing (“competing needs to healthcare”) on presentation with late-stage HIV disease. Results Among 3,669 adults screened, 830 were enrolled, newly-diagnosed with HIV and obtained a CD4 result. Among those, 279 (33.6%) presented with late-stage HIV disease. In multivariate analyses, participants who lived ≥5 kilometers from the test site [adjusted odds ratio (AOR) 2.8, 95% CI 1.7–4.7], reported competing needs to healthcare (AOR 1.7, 95% CI 1.2–2.4), were male (AOR 1.7, 95% CI 1.2–2.3), worked outside the home (AOR 1.5, 95% CI 1.1–2.1), perceived health service delivery barriers (AOR 1.5, 95% CI 1.1–2.1), and/or had poor emotional health (AOR 1.4, 95% CI 1.0–1.9) had higher odds of late-stage HIV disease presentation. Conclusions Independent risk factors for late-stage HIV disease presentation were from diverse domains, including geographic, economic, demographic, social, and psychosocial. These findings can inform various interventions, such as mobile testing or financial assistance, to reduce the risk of presentation with late-stage HIV disease.

Sex Trafficking and Initiation-Related Violence, Alcohol Use, and HIV Risk Among HIV-Infected Female Sex Workers in Mumbai, India

Female sex workers (FSWs) are the group at greatest risk for human immunodeficiency virus (HIV) infection in India. Women and girls trafficked (ie, forced or coerced) into sex work are thought to be at even greater risk because of high exposure to violence and unprotected sex, particularly during the early months of sex work, that is, at initiation. Surveys were completed with HIV-infected FSWs (n = 211) recruited from an HIV-related service organization in Mumbai, India. Approximately 2 in 5 participants (41.7%) reported being forced or coerced into sex work. During the first month in sex work, such FSWs had higher odds of sexual violence (adjusted odds ratio [AOR], 3.1; 95% confidence interval [CI], 1.6-6.1), ≥ 7 clients per day (AOR, 3.3; 1.8-6.1), no use of condoms (AOR, 3.8, 2.1-7.1), and frequent alcohol use (AOR, 1.9; 1.0-3.4) than HIV-infected FSWs not entering involuntarily. Those trafficked into sex work were also at higher odds for alcohol use at first sex work episode (AOR, 2.2; 95% CI, 1.2-4.0). These results suggest that having been trafficked into sex work is prevalent among this population and that such FSWs may face high levels of sexual violence, alcohol use, and exposure to HIV infection in the first month of sex work. Findings call into question harm reduction approaches to HIV prevention that rely primarily on FSW autonomy.

Maternal perception of neighborhood safety as a predictor of child weight status: The moderating effect of gender and assessment of potential mediators

OBJECTIVE To determine if there is a relationship between maternal perception of neighborhood safety in 3(rd) grade and weight status in 5(th) grade children, to test if gender moderates this relationship, and to identify potential mediators. METHOD Data from 868 children and their mothers involved in the National Institute of Child Health and Human Development Study of Early Child Care and Youth Development (NICHD-SECCYD) were used to examine the relationship between maternal perception of neighborhood safety in the 3(rd) grade and child body mass index (BMI) z-score in the 5(th) grade. Multiple regression models tested this relationship, the effect of gender, and potential mediating variables (time outdoors in neighborhood, television viewing, child behavior problems and puberty status). RESULTS Neighborhood safety ratings in the least safe tertile, compared with the safest tertile, were associated with an increased risk of obesity independent of gender, race and income-to-needs ratio (OR=1.59; 95% confidence interval [CI]: 1.03, 2.46), and higher child BMI z-scores among girls, but not boys, compared with the safest tertile (beta=0.33; 95% CI: 0.09, 0.57). Neither amount of time spent outdoors in the neighborhood, television viewing, child behavior problems (internalizing or externalizing), nor puberty status altered the relationship. CONCLUSIONS Maternal perception of the neighborhood as unsafe in 3(rd) grade independently predicted a higher risk of obesity, and a higher BMI z-score among girls, but not boys, in the 5(th) grade. The relationship was not explained by several potential mediators. Further investigation is needed to explore these gender differences and potential mediators.

Does Self-Report Data on HIV Primary Care Utilization Agree with Medical Record Data for Socially Marginalized Populations in the United States?

To test whether self-report data agree with medical record data in marginalized, HIV-infected populations, we collected information about HIV primary care visits over a 6-month period from both sources. Patients were drawn from a large study of engagement and retention in care conducted between 2003 and 2005. Self-report data were collected in face-to-face interviews and medical records were extracted using a rigorous, standardized protocol with multiple quality checks. We found poor overall agreement (weighted kappa = 0.36, 95% confidence interval = 0.28, 0.43). Factors associated with disagreement included younger age (adjusted odds ratio for 20 versus 40 years = 1.25, 95% confidence interval = 0.98, 1.60), non-Hispanic black race/ethnicity (adjusted odds ratio for non-Hispanic blacks versus non-Hispanic whites = 1.48, 95% confidence interval = 1.03, 2.13), lower education (adjusted odds ratio for high school education, GED, or less versus some college or college graduate = 1.43, 95% confidence interval = 0.96, 2.13), and substance use (adjusted odds ratio for any illicit drug/heavy alcohol use in the past 6 months versus no use = 1.39, 95% confidence interval = 1.02, 1.90). These findings do not support a conclusion that unconfirmed self-report data of HIV primary care visits are a sufficient substitute for rigorously collected medical record data in studies focusing on marginalized populations. Use of other data sources (e.g., administrative data), use of other self-reported outcome measures that have better concordance with medical records/administrative data (e.g., CD4 counts), or incorporation of rigorous measures to increase reliability of self-report data may be needed. Limitations of this study include the lack of a true gold standard with which to compare self-report data.