Summer Sherburne Hawkins

An ecological systems approach to examining risk factors for early childhood overweight: findings from the UK Millennium Cohort Study

Objective: To use an ecological systems approach to examine individual-, family-, community- and area-level risk factors for overweight (including obesity) in 3-year-old children. Methods: A prospective nationally representative cohort study conducted in England, Wales, Scotland, Northern Ireland. Participants included 13 188 singleton children aged 3 years in the Millennium Cohort Study, born between 2000 and 2002, who had complete height/weight data. The main outcome measure was childhood overweight (including obesity) defined by the International Obesity TaskForce cut-offs for body mass index. Results: 23.0% of 3-year-old children were overweight or obese. In the fully adjusted model, primarily individual- and family-level factors were associated with early childhood overweight: birthweight z-score (adjusted odds ratio, 1.36, 95% CI 1.30 to 1.42), black ethnicity (1.41, 1.11 to 1.80) (compared with white), introduction to solid foods <4 months (1.12, 1.02 to 1.23), lone motherhood (1.32, 1.15 to 1.51), smoking during pregnancy (1–9 cigarettes daily: 1.34, 1.17 to 1.54; 10–19: 1.49, 1.26 to 1.75; 20+: 1.34, 1.05 to 1.70), parental overweight (both: 1.89, 1.63 to 2.19; father only: 1.45, 1.28 to 1.63; mother only: 1.37, 1.18 to 1.58), prepregnancy overweight (1.28, 1.14 to 1.45) and maternal employment ⩾21 hours/week (1.23, 1.10 to 1.37) (compared with never worked). Breastfeeding ⩾4 months (0.86, 0.76 to 0.97) (compared with none) and Indian ethnicity (0.63, 0.42 to 0.94) were associated with a decreased risk of early childhood overweight. Children from Wales were also more likely to be overweight than children from England. Conclusions: Most risk factors for early childhood overweight are modifiable or would allow at-risk groups to be identified. Policies and interventions should focus on parents and providing them with an environment to support healthy behaviours for themselves and their children.

A review of risk factors for overweight in preschool children: A policy perspective

An increasing number of preschool children are becoming overweight. Although many risk factors have been identified for school-age children, less is known about this young age group. Ecological models have been developed to illustrate how individual characteristics, family characteristics, community-level factors, and policies may influence weight gain. We used this model to review factors that influence overweight in children, aged six months to five years, which are amenable to policy intervention in resource-rich countries. We found strong evidence for a direct association between childhood overweight and maternal prepregnancy body size, maternal smoking during pregnancy, and childrens television/media use; strong evidence for an inverse relationship between breastfeeding and overweight, and moderate evidence for childrens physical activity. There was limited research on community-level factors, policies and interventions. Future policies and interventions should be subject to evaluation and aim to support parents and young children to develop health-related behaviours that may prevent early childhood overweight.

Maternal employment and early childhood overweight: findings from the UK Millennium Cohort Study

Background:In most developed countries, maternal employment has increased rapidly. Changing patterns of family life have been suggested to be contributing to the rising prevalence of childhood obesity.Objectives:Our primary objective was to examine the relationship between maternal and partner employment and overweight in children aged 3 years. Our secondary objective was to investigate factors related to early childhood overweight only among mothers in employment.Design:Cohort study.Subjects:A total of 13 113 singleton children aged 3 years in the Millennium Cohort Study, born between 2000 and 2002 in the United Kingdom, who had complete height/weight data and parental employment histories.Measurements:Parents were interviewed when the child was aged 9 months and 3 years, and the childs height and weight were measured at 3 years. Overweight (including obesity) was defined by the International Obesity Task Force cut-offs.Results:A total of 23% (3085) of children were overweight at 3 years. Any maternal employment after the childs birth was associated with early childhood overweight (odds ratio (OR) [95% confidence interval (CI)]; 1.14 [1.00, 1.29]), after adjustment for potential confounding and mediating factors. Children were more likely to be overweight for every 10 h a mother worked per week (OR [95% CI]; 1.10 [1.04, 1.17]), after adjustment. An interaction with household income revealed that this relationship was only significant for children from households with an annual income of £33 000 (

Influence of moving to the UK on maternal health behaviours: prospective cohort study

57 750) or higher. There was no evidence for an association between early childhood overweight and whether or for how many hours the partner worked, or with mothers’ or partners’ duration of employment. These relationships were also evident among mothers in employment. Independent risk factors for early childhood overweight were consistent with the published literature.Conclusions:Long hours of maternal employment, rather than lack of money may impede young childrens access to healthy foods and physical activity. Policies supporting work–life balance may help parents reduce potential barriers.

Lifecourse influences on women's smoking before, during and after pregnancy.

Objective To compare health behaviours during pregnancy (smoking and alcohol consumption) and after birth (initiation and duration of breast feeding) between British/Irish white mothers and mothers from ethnic minority groups; and, in mothers from ethnic minority groups, to examine whether indicators of acculturation (generational status, language spoken at home, length of residency in the United Kingdom) were associated with these health behaviours. Design Prospective nationally representative cohort study. Setting England. Participants 6478 British/Irish white mothers and 2110 mothers from ethnic minority groups. Main outcome measures Any smoking during pregnancy; any alcohol consumption during pregnancy; initiation of breast feeding; breast feeding for at least four months. Results Compared with British/Irish white mothers, mothers from ethnic minority groups were less likely to smoke (15% v 37%) or consume alcohol (14% v 37%) during pregnancy but more likely to initiate breast feeding (86% v 69%) and breast feed for at least four months (40% v 27%). Among mothers from ethnic minority groups, first and second generation mothers were more likely to smoke during pregnancy (odds ratio 3.85, 95% confidence interval 2.50 to 5.93, and 4.70, 2.49 to 8.90, respectively), less likely to initiate breast feeding (0.92, 0.88 to 0.97, and 0.86, 0.75 to 0.99), and less likely to breast feed for at least four months (0.72, 0.62 to 0.83, and 0.52, 0.30 to 0.89) than immigrants, after adjustment for sociodemographic characteristics. There were no consistent differences in alcohol consumption. Among immigrants, for every additional five years spent in the UK the likelihood of mothers smoking during pregnancy increased by 31% (4% to 66%) and they were 5% (0% to 10%) less likely to breast feed for at least four months. Conclusions After immigration, maternal health behaviours worsen with length of residency in the UK. Health professionals should not underestimate women’s likelihood of engaging in risky health behaviours because of their ethnicity.

Effects of infant feeding practice on weight gain from birth to 3 years

The concept of the socioeconomic lifecourse is increasingly informing understanding of the social patterning of cigarette smoking. We investigated lifecourse influences on (i) womens smoking status (smoker/non-smoker) before pregnancy and (ii) quitting in pregnancy in the UK Millennium Cohort study. Our analyses included conventional measures of the socioeconomic lifecourse (womans childhood circumstances, education, current socioeconomic circumstances) and measures of her domestic lifecourse (age of becoming a mother, current cohabitation status), as well as parity (first/subsequent child). In analyses of quitting, we also included pre-pregnancy cigarette consumption. Our study underlined, firstly, the importance of lifecourse disadvantage. Those experiencing greater disadvantage with respect to their childhood circumstances, education and current circumstances were at greater risk of being a smoker before pregnancy. A disadvantaged domestic lifecourse - earlier entry into motherhood and lone motherhood-further increased the risk. Poorer childhood circumstances, educational disadvantage, poorer current circumstances and early motherhood also significantly increased the odds of quitting in pregnancy. Secondly, parity was a major predictor of smoking behaviour. First-time mothers had higher odds both of smoking before pregnancy and quitting in pregnancy. The effects of parity were independent of womens lifecourse. Our study supports tobacco control policies which recognise and address inequalities across the lifecourse. However, our study suggests that the dye is not irrevocably cast by social disadvantage: first pregnancy uniformly increases the chances of quitting. Interventions which help smokers having their first baby to quit have an important part to play in promoting maternal and child health.

The impact of maternal employment on breast-feeding duration in the UK Millennium Cohort Study

Objective: The influence of infant feeding practices on weight gain during childhood remains unresolved, with few studies adjusting appropriately for confounding factors. This study examined the effect of breastfeeding initiation, breastfeeding duration and age at introduction of solid foods on weight gain from birth to 3 years. Design: Nationally representative prospective study. Setting: England, Wales, Scotland and Northern Ireland. Participants: 10 533 3-year-old children from the UK Millennium Cohort Study. Main outcome measure: Conditional weight gain z-scores from birth to 3 years (adjusted for birthweight); multiple linear regression analyses were conducted to examine the impact of infant feeding practices on this measure after adjustment for confounding factors. Results: Breastfeeding initiation and breastfeeding duration were significantly associated with weight gain from birth to 3 years. Infants receiving no breast milk grew faster than those whose mothers initiated breastfeeding (adjusted regression coefficient (difference in z-scores) 0.06, 95% CI 0.02 to 0.09), as did those breastfed for less than 4 months (0.05, 95% CI 0.01 to 0.09) versus those breastfed 4 months or longer. Early introduction of solids was not associated with faster weight gain after adjustment for height z-score at 3 years (−0.01, 95% CI −0.04 to 0.03). Conclusions: Initiating and prolonging breastfeeding may reduce excess weight gain by preschool age. Association of the early introduction of solids with rapid weight gain during early childhood is mediated through childhood stature. Although effects sizes are small, at a population level they are of public health importance as these risk factors are potentially modifiable. Strategies to support mothers to follow internationally recommended infant feeding practices are required.

Risk factors for rapid weight gain in preschool children: findings from a UK-wide prospective study

OBJECTIVE To examine the relationship of maternal employment characteristics, day care arrangements and the type of maternity leave pay to breast-feeding for at least 4 months. DESIGN Cohort study. SETTING Babies aged 9 months in the Millennium Cohort Study, born between September 2000 and January 2002. SUBJECTS A total of 6917 British/Irish white employed mothers with singleton babies. RESULTS Mothers employed part-time or self-employed were more likely to breast-feed for at least 4 months than those employed full-time (adjusted rate ratio (aRR) and 95% confidence interval (CI) 1.30 (1.17-1.44) and 1.74 (1.46-2.07), respectively). The longer a mother delayed her return to work postpartum, the more likely she was to breast-feed for at least 4 months (P for trend < 0.001). Mothers were less likely to breast-feed for at least 4 months if they returned to work for financial reasons (aRR 0.86, 95% CI 0.80-0.93) or used informal day care arrangements rather than care by themselves or their partner (aRR 0.81, 95% CI 0.71-0.91). Mothers were more likely to breastfeed for at least 4 months if their employer offered family-friendly (aRR 1.14, 95% CI 1.02-1.27) or flexible work arrangements (aRR 1.24, 95% CI 1.00-1.55), or they received Statutory Maternity Pay (SMP) plus additional pay during their maternity leave rather than SMP alone (aRR 1.13, 95% CI 1.02-1.26). These findings were independent of confounding factors, such as socio-economic status and maternal education. CONCLUSIONS Current policies may encourage mothers to enter or return to employment postpartum, but this may result in widening inequalities in breast-feeding and persistence of low rates. Policies should aim to increase financial support and incentives for employers to offer supportive work arrangements.

Examining the relationship between maternal employment and health behaviours in 5-year-old British children

Objective:To examine risk factors for rapid weight gain between 3 and 5 years of age.Design:Nationally representative prospective cohort study.Participants:A total of 11 653 preschool children participating in the UK Millennium Cohort Study, with anthropometry at 3 and 5 years.Measurements:Weight gain z-scores were calculated from 3 to 5 years. Children in the top quarter of this distribution were classified as gaining weight rapidly. A total of 26 biological and early life, social, psychological, behavioural and environmental risk factors were examined.Results:Among the participants, 13% of normal weight, 63% of overweight and 88% of obese 5-year olds had experienced rapid weight gain since 3 years of age. Six biological and early life factors and two social factors were found to be significantly associated with this growth pattern. In a mutually adjusted model, children were more likely to gain weight rapidly if they had a higher body mass index at age 3 (adjusted odds ratio: 1.27, 95% confidence interval: 1.23–1.32), if they were of Bangladeshi (adjusted odds ratio: 1.88, 95% confidence interval: 1.27–2.79) or black (adjusted odds ratio: 1.47, 95% confidence interval: 1.07–2.02) ethnicity, if their mother was overweight (adjusted odds ratio: 1.32, 95% confidence interval: 1.15–1.51) or had been overweight before pregnancy (adjusted odds ratio: 1.56, 95% confidence interval: 1.36–1.79), if their father was overweight (adjusted odds ratio: 1.56, 95% confidence interval: 1.34–1.81) or if their mother smoked during pregnancy (adjusted odds ratio:1.23, 95% confidence interval: 1.09–1.38). Children were also more likely to gain weight rapidly if others smoked in the same room (adjusted odds ratio: 1.31, 95% confidence interval: 1.16–1.49) or if they were a lone child in the household (adjusted odds ratio: 1.14, 95% confidence interval: 1.01–1.30).Conclusions:Factors operating during pregnancy and early life increase the risk of rapid weight gain in young children; thus, signalling the importance of obesity prevention programmes before and during pregnancy and for children at an early age. In particular, these programmes should address parental weight status and smoking habits, both modifiable risk factors.

Evaluating the Impact of the Baby-Friendly Hospital Initiative on Breast-feeding Rates: A Multi-state Analysis

Background: There is little known about potential mechanisms underlying the association between maternal employment and childhood obesity. The relationships between maternal hours worked per week (none, 1–20 hours, 21+ hours) and children’s dietary and physical activity/inactivity habits were examined. Where mothers were employed, the relationships between flexible work arrangements and these health behaviours were also examined. Methods: Data from 12 576 singleton children age 5 years in the UK Millennium Cohort Study were analysed. Mothers reported information about their employment patterns. Mothers also reported on indicators of their child’s dietary (crisps/sweets, fruit/vegetables, sweetened beverage, fruit consumption), physical activity (participation in organised exercise, transport to school) and inactivity (television/computer use) habits at age 5. Results: After adjustment for potential confounding and mediating factors, children whose mothers worked part-time or full-time were more likely to primarily drink sweetened beverages between meals (compared to other beverages), use the television/computer at least 2 hours daily (compared to 0–2) or be driven to school (compared to walk/cycle) than children whose mothers had never been employed. Children whose mothers worked full-time were less likely to primarily eat fruit/vegetables between meals (compared to other snacks) or eat three or more portions of fruit daily (compared to two or fewer). Although in unadjusted analyses children whose mothers used flexible work arrangements engaged in healthier behaviours, relationships were no longer significant after adjustment. Conclusions: For many families the only parent or both parents are working. This may limit parents’ capacity to provide their children with healthy foods and opportunities for physical activity. Policies and programmes are needed to help support parents and create a health-promoting environment.