Diet, growth, and obesity development throughout childhood in the Avon Longitudinal Study of Parents and Children

Understanding the association of longitudinal body mass index patterns in children and their parents: A data-driven study from the TARGet Kids! cohort

BACKGROUND

Obesity remains a persistent global health issue across generations. Targeting family-level factors may help improve child and adolescent body mass index (BMI) outcomes. While associations between parental and offspring BMI are well-documented, the temporal patterns and risk factors driving these relationships remain unclear. This study aimed to identify longitudinal family-level BMI patterns incorporating child, maternal, and paternal BMI and apply interpretable machine learning (ML) methods to uncover key predictors.

METHODS

This longitudinal study included 6092 children and their parents from the TARGet Kids! cohort, with BMI measurements collected from birth to 150 months. Group-based multi-trajectory modeling identified joint trajectories of child BMI-for-age Z-scores (zBMI) and parental BMI. Five ML classifiers predicted group membership using 78 predictors spanning sociodemographic, dietary, parental health, and child lifestyle variables. To explore the modifying effect of parental overweight/obesity (OW/OB) on the relationship between child age and BMI, Bayesian generalized additive mixed models (GAMMs) with smoothed term interactions were applied.

RESULTS

Five distinct joint trajectory groups were identified. Children in the highest BMI trajectory group typically had both parents following similar high BMI trajectories. Parental OW/OB status emerged as the strongest predictor of child OW/OB (37 % classification probability), followed by breastfeeding duration (17 %) and child physical activity (15 %). The influence of parental OW/OB was particularly pronounced in early childhood (0-60 months). Bayesian GAMMs confirmed the robust, longitudinal association between child and parental BMI trajectories.

CONCLUSIONS

Parental BMI patterns strongly influence child BMI development, with age-dependent effects. These findings highlight the importance of early family-based interventions.

Cross-sectional associations between Mediterranean diet and body composition in preschool children. CORAL study

BACKGROUND

Overweight and obesity in children are rising globally, and the Mediterranean diet may help reduce obesity and related diseases.

OBJECTIVE

To assess the association between adherence to the Mediterranean diet and body composition in Spanish preschool children.

METHODS

This study included 1218 children aged 3-6 years from the CORALS cohort. Mediterranean diet adherence was evaluated using the validated MED4CHILD and COME-Kids F&B-FQ questionnaires. Body composition measurements included weight, height, waist circumference, BMI, Fat Mass (FM), Fat-Free Mass Index (FFMI), and Waist-to-Height ratio (WtHR). Multivariate regression and ANCOVA were used to examine associations, adjusting for factors like age, physical activity, and energy intake. We also performed a Cohen's d analysis to assess effect size.

RESULTS

Adherence to the Mediterranean diet was associated with more favourable body composition in children. Specifically, both the MED4CHILD score and the COME-Kids-derived score showed significant associations with BMI, FFMI, and Waist-to-Height ratio, showing differences by sex. Children who adhered to the Mediterranean diet exhibited lower BMI and higher fat-free mass, and a more favourable waist-to-height ratio. Additionally, although some measures showed weaker associations, all analyses highlighted a trend towards improved body composition with higher adherence. Cohen's d analysis showed small to moderate effect sizes.

CONCLUSION

Adherence to the Mediterranean diet was significantly linked to favorable body composition indices in Spanish children, highlighting the importance of promoting healthy dietary patterns to prevent overweight and obesity.

Measuring Dietary Quality Among Toddlers in the Feeding Infants and Toddlers Study, 2016, Using the New Healthy Eating Index-Toddlers-2020

BACKGROUND

Child diet can influence risk for obesity and other related noncommunicable diseases. Few studies have used the Healthy Eating Index (HEI)-Toddlers-2020 to assess diet quality among toddlers (children aged 12 to 23.9 months).

OBJECTIVE

The aim of this study was to examine diet quality among toddlers participating in the Feeding Infants and Toddlers Study, 2016, and determine differences by sociodemographic characteristics. Caregiver perception of how their toddler's diet aligns with HEI-Toddlers-2020 diet quality scores was also assessed.

DESIGN

This cross-sectional study used 24-hour dietary records collected in 2016.

PARTICIPANTS AND SETTING

Data were collected on toddlers ages 12 to 23.9 months (N = 1133) participating in the Feeding Infants and Toddlers Study, 2016.

MAIN OUTCOME MEASURES

Diet quality was assessed using the HEI-Toddlers-2020.

STATISTICAL ANALYSES PERFORMED

The population ratio method was used for all analyses using weighted data to estimate HEI-Toddlers-2020 scores overall and within subgroups. To determine significant differences of the HEI-Toddlers-2020 score between subgroups, pairwise t tests were used. Statistical significance at P < .05 was used as a cutoff for all 2-sided P values.

RESULTS

Average HEI-Toddlers-2020 score among toddlers ages 12 to 23.9 months participating in the Feeding Infants and Toddlers Study, 2016, was 71.2 out of a possible 100. Total scores (mean, standard error) varied by race and ethnicity with Hispanic toddlers having higher scores compared with non-Hispanic White toddlers (76.4 ± 2.5 vs 69.0 ± 1.2; P = .03) and by federal poverty level with those >200% of the poverty level having higher scores compared with those <100% of the poverty level (74.7 ± 1.5 vs 67.0 ± 2.6; P = .01).

CONCLUSIONS

Opportunities for improvement in dietary intake were identified using the new HEI-Toddlers-2020 to assess diet quality among children ages 12 to 23.9 months. Scores were indicative of toddlers consuming excess added sugars and lower-than-recommended amounts of seafood and plant proteins, greens and beans, whole grains, and vegetables. Interventions to improve diet quality in toddlers may benefit from focusing on foods children should eat more of along with foods to consume in moderation.

Influence of Urban and Rural Areas, Type of School, and Parents' Education Level on Nutrition Habits and Their Relationship with Dental Caries in Schoolchildren in Mallorca

Background/Objectives: Habits such as a diet high in sugars and poor dental biofilm control are linked to a higher prevalence of caries and low socioeconomic status. This study aimed to analyze the nutrition habits of schoolchildren in Mallorca and their relationship with the presence of dental caries, depending on the type of school, geographic location, and parents' education level. Methods: A cross-sectional study was conducted to examine the prevalence of dental caries based on World Health Organization (WHO) standards and nutritional practices following guidelines from the Food and Agriculture Organization of the United Nations (FAO) and the European Food Safety Authority (EFSA). This study included 718 students from three age groups: first-year elementary students (ages 5-6), sixth-year elementary students (age 12), and fourth-year secondary school students (age 15). Relevant sociodemographic factors were also considered in the analysis. Results: In schoolchildren aged 5-6 years, higher monthly consumption of processed and sugary foods, such as sweets (rural: 24.66 (CI 95%: 20.30-29.02); urban: 19.29 (CI 95%:16.27-22.304); p = 0.044), was noted in schoolchildren from rural sectors compared to those residing in urban areas. At 15 years of age, there was a higher consumption of potato chips in public schools than in subsidized/private schools (public: 26.95 (CI 95%: 24.42-29.49); subsidized/private: 18.29 (CI 95%: 13.92-22.65) p = 0.004). A high consumption of sweets is associated with an increased risk of caries (OR sweets: 1.76 CI: 1.04-2.98; p = 0.035). Fewer students with mothers with a lower education level eat dinner (elementary: 75%; secondary 91%; higher: 98%; p = 0.003). Conclusions: Higher consumption of sweets in rural areas and potato chips in public schools, along with the association between sweet consumption and caries risk, highlight how geographic location, school type, and parents' education level influence children's nutrition habits and caries.

Effectiveness of behavioural and psychological interventions for managing obesity in children and adolescents: A systematic review and meta-analysis framed using minimal important difference estimates based on GRADE guidance to inform a clinical practice guideline

OBJECTIVE

Conduct a systematic review and meta-analysis of randomized controlled trials (RCTs) of behavioural and psychological interventions for managing paediatric obesity.

METHODS

Eligible studies, published between 1985 and 2022, included 0 to 18 year olds with outcomes reported ≥3 months post-baseline, including patient-reported outcome measures (PROMs), cardiometabolic and anthropometric outcomes, and adverse events (AEs). We pooled data using a random effects model and assessed certainty of evidence (CoE) related to minimally important difference estimates for outcomes using GRADE.

RESULTS

We included 73 unique RCTs (n = 6305 participants, 53% female). Intervention types included physical activity (n = 1437), nutrition (n = 447), psychological (n = 1336), technology-based (n = 901) or multicomponent (≥2 intervention types, n = 2184). Physical activity had a small effect on health-related quality of life (HRQoL), varying effects ranging from moderate to very large on blood pressure, lipids and insulin resistance, and a small effect on BMIz. Nutrition had a small effect on lipids, insulin resistance and BMIz. Psychological interventions showed a small effect on HRQoL and triglycerides and moderate benefits on depressive symptoms, while technology interventions showed small benefits on blood pressure and BMIz. Multicomponent interventions had a large benefit on anxiety, small benefit on depressive symptoms, with large to very large benefits on lipids, and small benefits for diastolic blood pressure, insulin resistance and BMIz. AEs were reported infrequently, and when reported, were described as mild.

CONCLUSION

Physical activity and multicomponent interventions showed improvements in PROMs, cardiometabolic and anthropometric outcomes. Future trials should consistently measure PROMs, evaluate outcomes beyond the intervention period, and study children <6 years of age.

Ultraprocessed food intake and body mass index change among youths: a prospective cohort study

BACKGROUND

Suboptimal diets may promote undesired weight gain in youths, with high ultraprocessed food (UPF) intake becoming a significant concern in the United States.

OBJECTIVES

We evaluated the association between UPF intake and body mass index [BMI (in kg/m2)] change in large United States youth cohorts.

METHODS

Participants included children and adolescents (7-17 y) from the Growing Up Today Study (GUTS1 and GUTS2) who completed baseline and ≥1 follow-up diet and anthropometrics assessment (GUTS1 1996-2001: N = 15,797; GUTS2 2004-2011: N = 9720). Follow-up years were based on diet assessment availability. UPFs were categorized using the Nova system, with intakes evaluated as the cumulative mean percent energy from UPFs and subgroups. BMI was assessed using self-reported body weight/height. Changes in BMI annually and over 2, 4-5, and 7 y in association with UPF intake were examined using multivariable repeated-measure linear mixed models.

RESULTS

At baseline, the mean percentage of energy from UPFs was 49.9% in GUTS1 and 49.5% in GUTS2 participants; mean BMI was 18.7 and 19.8, respectively. After multivariable adjustments for sociodemographic and lifestyle factors, each 10% increment in UPF intake was associated with a 0.01 (95% confidence interval: 0.003, 0.03) increase annually and a 0.07 (0.01, 0.13) increase over 5 y in GUTS1 participants. In GUTS2, increases were 0.02 (0.003, 0.04) annually and 0.09 (0.01, 0.18) over 4 y. Among GUTS1, statistically significant annual BMI increases of 0.02-0.07 were associated with elevated intake of ultraprocessed breakfast cereals, savory snacks, and ready-to-eat/heat foods, especially pizza, burgers, and sandwiches. No association was found between UPF intake and overweight/obesity risk.

CONCLUSIONS

A higher UPF intake was associated with a modest yet significant increase in BMI in large prospective cohorts of United States youths, calling for public health efforts to promote healthful food intake among youths to prevent excessive weight gain.

Association between breastfeeding duration and BMI, 2009-2018: a population-based study

Background

In the 21st century, childhood overweight and obesity have become major public health issues worldwide. Previous studies have shown that breastfeeding helps prevent overweight or obesity in children. Despite the significant advantages of breastfeeding, the global exclusive breastfeeding rate for infants under 6 months old is only 40%, while in the United States, the rate is only 25%. The aim of this study is to explore the relationship between breastfeeding duration and BMI in children aged 2 to 6 in the United States, and to raise awareness of breastfeeding.

Methods

A cross-sectional study included 2,769 participants between the ages of 2 and 6 from a sample that represented the entire NHANES 2009-2018. Data was analyzed using EmpowerStats, (www.empowerstats.com) linear regression as well as Chi-square test, t-tests, multivariate regression analysis and smooth cure fitting were done.

Results

Breastfeeding duration long-term group exhibited a statistically significant negative association with BMI, with a regression coefficient of -0.21 (P < 0.05). The continuous analysis of breastfeeding duration by tertile also demonstrate a statistically significant negative association with BMI. Subgroup analysis revealed that the potential benefits of breastfeeding on BMI were more obvious in low-income environments and maternal age 18 to 35 years, with a regression coefficient of -0.57 and -0.24, respectively (all P < 0.05).

Conclusion

The findings emphasize the importance of breastfeeding in reducing childhood overweight/obesity and preventing associated diseases, both in clinical and public health settings.

Later eating rhythm measured in children at 7 years of age in the ALSPAC cohort

Later eating rhythm (LER) refers to later timing, greater energy intake (EI), and higher frequency of eating occasions (meal/snack) in the evening. The significance of LER in child health is becoming increasingly recognised. However, the lack of consensus regarding definitions of LER make it challenging to fully comprehend its role. This data note describes LER variables derived in the Avon Longitudinal Study of Parents and Children (ALSPAC), an ongoing birth cohort which enrolled 14,541 pregnant women living in Avon, UK, with an expected date of delivery between April 1991 - December 1992. When children were 7 years, parents completed a structured 3-day food diary, recording all foods/drinks consumed over 3 days (preferably 1 weekend day and 2 weekdays). Data was available for 7,285 children (50.1% response rate). A subsample of 4,869 children had exact time of eating occasions added to the existing database, which only included broad indications of eating timing based on 2-7 hour long meal slots. 13 LER variables were derived for the entire week and weekdays/weekend days separately. These comprise: 1) eating around individual bedtime (number days); 2) eating around average bedtime (number days); 3) time of evening main meal (hrs:mins); 4) time of last eating occasion (hrs:mins); 5) EI in the evening (percentage of total daily energy intake, %TDEI); 6) EI within 2hrs before bedtime (%TDEI); 7) EI for evening main meal (%TDEI); 8) EI for evening snacks (%TDEI); 9) Night eating1 (NE1): eating over 30% of total daily energy intake after 18:00 (number days); 10) NE2: eating over 25% of total daily energy intake within 2hrs before bedtime (number days); 11) eating frequency after 17:00 (number of eating occasions); 12) regularity of dinner (number of days); 13) frequency of evening snacks (number days). We describe the derivation, prevalence and inter-corelations between LER variables.

Association between diet quality during pregnancy of mothers and that of 3-year-old offspring: a prospective hospital-based birth cohort study

Children's eating habits are established early in life and parents play a major role therein. Pregnancy is a teachable moment for the promotion of healthy eating because many women are concerned about their babies' health and have frequent contact with healthcare providers. We aimed to investigate the association between diet quality during pregnancy and the offspring. A total of 691 sets of data on pregnant mothers and their 3-year-old offspring were obtained from the Seiiku Boshi cohort study. Dietary intake was assessed using a validated food frequency questionnaire for mothers in mid-to-late pregnancy and a validated diet history questionnaire for Japanese preschool children at the 36-month checkup. Diet quality was scored using the Japanese Food Guide Spinning Top. Maternal diet quality score was categorised into quartiles, and the association between offspring and maternal diet quality score, adjusted for socioeconomic factors, was assessed using multiple linear regression. The total offspring diet quality score showed a linear trend with the maternal diet quality score (the mean increments (confidential intervals) for each quartile were -0.12 (-1.32-1.08), 1.54 (0.34-2.73), and 1.22 (0.03-2.42)). In particular, offspring vegetable dishes scored higher in all quartiles of maternal vegetable dish scores than in the lowest quartile (0.69 (0.21-1.17), 0.97 (0.50-1.45), and 1.36 (0.88-1.83)). A high diet quality score during pregnancy was positively associated with that of offspring, suggesting the importance of nutritional education in pregnant women to improve their diet quality.

Early exposure to sugar sweetened beverages or fruit juice differentially influences adult adiposity

OBJECTIVE

To examine associations between different types of sweet drinks consumed in early life and adult adiposity.

DESIGN

The analysis involved the secondary analysis of the Avon Longitudinal Study of Parents and Children which followed children from birth to 24 years. Adiposity was measured using Dual-energy X-ray absorptiometry while food frequency questionnaires and diaries monitored diet. 'Early exposure' to sweet drinks was defined as giving a sugar-sweetened beverage or 100% fruit juice (FJ), before two years of age.

RESULTS

Early exposure to cola was associated with higher fat mass, android fat mass and BMI at age 24 years; whereas early exposure to apple juice was associated with lower adult adiposity in females but not males. When age three, exposure to cola was associated with a greater intake of energy, carbohydrates, protein, fat, and less fruit and more fried foods. In contrast, early exposure to apple juice was associated with higher protein and lower fat intakes and consuming more fruits/vegetables and less fried foods. Parental education, adiposity and socio-economic status influenced whether SSB or FJ was given to a child.

CONCLUSIONS

Early drinking of sugar sweetened beverages was associated with a less healthy dietary pattern, and greater adult adiposity. Early drinking of apple juice was associated with a healthier dietary pattern, and lower fat mass in adult females. The choice of drink was associated with social deprivation. As the dietary causes of adult obesity begin in early childhood, increased attention should be given to diet in the first years of life.

Interventions to prevent obesity in children aged 5 to 11 years old

BACKGROUND

Prevention of obesity in children is an international public health priority given the prevalence of the condition (and its significant impact on health, development and well-being). Interventions that aim to prevent obesity involve behavioural change strategies that promote healthy eating or 'activity' levels (physical activity, sedentary behaviour and/or sleep) or both, and work by reducing energy intake and/or increasing energy expenditure, respectively. There is uncertainty over which approaches are more effective and numerous new studies have been published over the last five years, since the previous version of this Cochrane review.

OBJECTIVES

To assess the effects of interventions that aim to prevent obesity in children by modifying dietary intake or 'activity' levels, or a combination of both, on changes in BMI, zBMI score and serious adverse events.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search date was February 2023.

SELECTION CRITERIA

Randomised controlled trials in children (mean age 5 years and above but less than 12 years), comparing diet or 'activity' interventions (or both) to prevent obesity with no intervention, usual care, or with another eligible intervention, in any setting. Studies had to measure outcomes at a minimum of 12 weeks post baseline. We excluded interventions designed primarily to improve sporting performance.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our outcomes were body mass index (BMI), zBMI score and serious adverse events, assessed at short- (12 weeks to < 9 months from baseline), medium- (9 months to < 15 months) and long-term (≥ 15 months) follow-up. We used GRADE to assess the certainty of the evidence for each outcome.

MAIN RESULTS

This review includes 172 studies (189,707 participants); 149 studies (160,267 participants) were included in meta-analyses. One hundred forty-six studies were based in high-income countries. The main setting for intervention delivery was schools (111 studies), followed by the community (15 studies), the home (eight studies) and a clinical setting (seven studies); one intervention was conducted by telehealth and 31 studies were conducted in more than one setting. Eighty-six interventions were implemented for less than nine months; the shortest was conducted over one visit and the longest over four years. Non-industry funding was declared by 132 studies; 24 studies were funded in part or wholly by industry. Dietary interventions versus control Dietary interventions, compared with control, may have little to no effect on BMI at short-term follow-up (mean difference (MD) 0, 95% confidence interval (CI) -0.10 to 0.10; 5 studies, 2107 participants; low-certainty evidence) and at medium-term follow-up (MD -0.01, 95% CI -0.15 to 0.12; 9 studies, 6815 participants; low-certainty evidence) or zBMI at long-term follow-up (MD -0.05, 95% CI -0.10 to 0.01; 7 studies, 5285 participants; low-certainty evidence). Dietary interventions, compared with control, probably have little to no effect on BMI at long-term follow-up (MD -0.17, 95% CI -0.48 to 0.13; 2 studies, 945 participants; moderate-certainty evidence) and zBMI at short- or medium-term follow-up (MD -0.06, 95% CI -0.13 to 0.01; 8 studies, 3695 participants; MD -0.04, 95% CI -0.10 to 0.02; 9 studies, 7048 participants; moderate-certainty evidence). Five studies (1913 participants; very low-certainty evidence) reported data on serious adverse events: one reported serious adverse events (e.g. allergy, behavioural problems and abdominal discomfort) that may have occurred as a result of the intervention; four reported no effect. Activity interventions versus control Activity interventions, compared with control, may have little to no effect on BMI and zBMI at short-term or long-term follow-up (BMI short-term: MD -0.02, 95% CI -0.17 to 0.13; 14 studies, 4069 participants; zBMI short-term: MD -0.02, 95% CI -0.07 to 0.02; 6 studies, 3580 participants; low-certainty evidence; BMI long-term: MD -0.07, 95% CI -0.24 to 0.10; 8 studies, 8302 participants; zBMI long-term: MD -0.02, 95% CI -0.09 to 0.04; 6 studies, 6940 participants; low-certainty evidence). Activity interventions likely result in a slight reduction of BMI and zBMI at medium-term follow-up (BMI: MD -0.11, 95% CI -0.18 to -0.05; 16 studies, 21,286 participants; zBMI: MD -0.05, 95% CI -0.09 to -0.02; 13 studies, 20,600 participants; moderate-certainty evidence). Eleven studies (21,278 participants; low-certainty evidence) reported data on serious adverse events; one study reported two minor ankle sprains and one study reported the incident rate of adverse events (e.g. musculoskeletal injuries) that may have occurred as a result of the intervention; nine studies reported no effect. Dietary and activity interventions versus control Dietary and activity interventions, compared with control, may result in a slight reduction in BMI and zBMI at short-term follow-up (BMI: MD -0.11, 95% CI -0.21 to -0.01; 27 studies, 16,066 participants; zBMI: MD -0.03, 95% CI -0.06 to 0.00; 26 studies, 12,784 participants; low-certainty evidence) and likely result in a reduction of BMI and zBMI at medium-term follow-up (BMI: MD -0.11, 95% CI -0.21 to 0.00; 21 studies, 17,547 participants; zBMI: MD -0.05, 95% CI -0.07 to -0.02; 24 studies, 20,998 participants; moderate-certainty evidence). Dietary and activity interventions compared with control may result in little to no difference in BMI and zBMI at long-term follow-up (BMI: MD 0.03, 95% CI -0.11 to 0.16; 16 studies, 22,098 participants; zBMI: MD -0.02, 95% CI -0.06 to 0.01; 22 studies, 23,594 participants; low-certainty evidence). Nineteen studies (27,882 participants; low-certainty evidence) reported data on serious adverse events: four studies reported occurrence of serious adverse events (e.g. injuries, low levels of extreme dieting behaviour); 15 studies reported no effect. Heterogeneity was apparent in the results for all outcomes at the three follow-up times, which could not be explained by the main setting of the interventions (school, home, school and home, other), country income status (high-income versus non-high-income), participants' socioeconomic status (low versus mixed) and duration of the intervention. Most studies excluded children with a mental or physical disability.

AUTHORS' CONCLUSIONS

The body of evidence in this review demonstrates that a range of school-based 'activity' interventions, alone or in combination with dietary interventions, may have a modest beneficial effect on obesity in childhood at short- and medium-term, but not at long-term follow-up. Dietary interventions alone may result in little to no difference. Limited evidence of low quality was identified on the effect of dietary and/or activity interventions on severe adverse events and health inequalities; exploratory analyses of these data suggest no meaningful impact. We identified a dearth of evidence for home and community-based settings (e.g. delivered through local youth groups), for children living with disabilities and indicators of health inequities.

Interventions to prevent obesity in children aged 12 to 18 years old

BACKGROUND

Prevention of obesity in adolescents is an international public health priority. The prevalence of overweight and obesity is over 25% in North and South America, Australia, most of Europe, and the Gulf region. Interventions that aim to prevent obesity involve strategies that promote healthy diets or 'activity' levels (physical activity, sedentary behaviour and/or sleep) or both, and work by reducing energy intake and/or increasing energy expenditure, respectively. There is uncertainty over which approaches are more effective, and numerous new studies have been published over the last five years since the previous version of this Cochrane Review.

OBJECTIVES

To assess the effects of interventions that aim to prevent obesity in adolescents by modifying dietary intake or 'activity' levels, or a combination of both, on changes in BMI, zBMI score and serious adverse events.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search date was February 2023.

SELECTION CRITERIA

Randomised controlled trials in adolescents (mean age 12 years and above but less than 19 years), comparing diet or 'activity' interventions (or both) to prevent obesity with no intervention, usual care, or with another eligible intervention, in any setting. Studies had to measure outcomes at a minimum of 12 weeks post baseline. We excluded interventions designed primarily to improve sporting performance.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our outcomes were BMI, zBMI score and serious adverse events, assessed at short- (12 weeks to < 9 months from baseline), medium- (9 months to < 15 months) and long-term (≥ 15 months) follow-up. We used GRADE to assess the certainty of the evidence for each outcome.

MAIN RESULTS

This review includes 74 studies (83,407 participants); 54 studies (46,358 participants) were included in meta-analyses. Sixty studies were based in high-income countries. The main setting for intervention delivery was schools (57 studies), followed by home (nine studies), the community (five studies) and a primary care setting (three studies). Fifty-one interventions were implemented for less than nine months; the shortest was conducted over one visit and the longest over 28 months. Sixty-two studies declared non-industry funding; five were funded in part by industry. Dietary interventions versus control The evidence is very uncertain about the effects of dietary interventions on body mass index (BMI) at short-term follow-up (mean difference (MD) -0.18, 95% confidence interval (CI) -0.41 to 0.06; 3 studies, 605 participants), medium-term follow-up (MD -0.65, 95% CI -1.18 to -0.11; 3 studies, 900 participants), and standardised BMI (zBMI) at long-term follow-up (MD -0.14, 95% CI -0.38 to 0.10; 2 studies, 1089 participants); all very low-certainty evidence. Compared with control, dietary interventions may have little to no effect on BMI at long-term follow-up (MD -0.30, 95% CI -1.67 to 1.07; 1 study, 44 participants); zBMI at short-term (MD -0.06, 95% CI -0.12 to 0.01; 5 studies, 3154 participants); and zBMI at medium-term (MD 0.02, 95% CI -0.17 to 0.21; 1 study, 112 participants) follow-up; all low-certainty evidence. Dietary interventions may have little to no effect on serious adverse events (two studies, 377 participants; low-certainty evidence). Activity interventions versus control Compared with control, activity interventions do not reduce BMI at short-term follow-up (MD -0.64, 95% CI -1.86 to 0.58; 6 studies, 1780 participants; low-certainty evidence) and probably do not reduce zBMI at medium- (MD 0, 95% CI -0.04 to 0.05; 6 studies, 5335 participants) or long-term (MD -0.05, 95% CI -0.12 to 0.02; 1 study, 985 participants) follow-up; both moderate-certainty evidence. Activity interventions do not reduce zBMI at short-term follow-up (MD 0.02, 95% CI -0.01 to 0.05; 7 studies, 4718 participants; high-certainty evidence), but may reduce BMI slightly at medium-term (MD -0.32, 95% CI -0.53 to -0.11; 3 studies, 2143 participants) and long-term (MD -0.28, 95% CI -0.51 to -0.05; 1 study, 985 participants) follow-up; both low-certainty evidence. Seven studies (5428 participants; low-certainty evidence) reported data on serious adverse events: two reported injuries relating to the exercise component of the intervention and five reported no effect of intervention on reported serious adverse events. Dietary and activity interventions versus control Dietary and activity interventions, compared with control, do not reduce BMI at short-term follow-up (MD 0.03, 95% CI -0.07 to 0.13; 11 studies, 3429 participants; high-certainty evidence), and probably do not reduce BMI at medium-term (MD 0.01, 95% CI -0.09 to 0.11; 8 studies, 5612 participants; moderate-certainty evidence) or long-term (MD 0.06, 95% CI -0.04 to 0.16; 6 studies, 8736 participants; moderate-certainty evidence) follow-up. They may have little to no effect on zBMI in the short term, but the evidence is very uncertain (MD -0.09, 95% CI -0.2 to 0.02; 3 studies, 515 participants; very low-certainty evidence), and they may not reduce zBMI at medium-term (MD -0.05, 95% CI -0.1 to 0.01; 6 studies, 3511 participants; low-certainty evidence) or long-term (MD -0.02, 95% CI -0.05 to 0.01; 7 studies, 8430 participants; low-certainty evidence) follow-up. Four studies (2394 participants) reported data on serious adverse events (very low-certainty evidence): one reported an increase in weight concern in a few adolescents and three reported no effect.

AUTHORS' CONCLUSIONS

The evidence demonstrates that dietary interventions may have little to no effect on obesity in adolescents. There is low-certainty evidence that activity interventions may have a small beneficial effect on BMI at medium- and long-term follow-up. Diet plus activity interventions may result in little to no difference. Importantly, this updated review also suggests that interventions to prevent obesity in this age group may result in little to no difference in serious adverse effects. Limitations of the evidence include inconsistent results across studies, lack of methodological rigour in some studies and small sample sizes. Further research is justified to investigate the effects of diet and activity interventions to prevent childhood obesity in community settings, and in young people with disabilities, since very few ongoing studies are likely to address these. Further randomised trials to address the remaining uncertainty about the effects of diet, activity interventions, or both, to prevent childhood obesity in schools (ideally with zBMI as the measured outcome) would need to have larger samples.

Psychosocial Adjustment as a Mediator in the Relationship between Childhood Exposure to Maternal Depression and Subsequent BMI and Overweight Risk

OBJECTIVES

This study investigated the correlation between early exposure to maternal depression (from 1 month to Grade 3) and the body mass index (BMI) and potential for overweight in adolescents at age 15. It further examined if the pathway of this correlation was influenced by psychosocial adjustment during mid-childhood (Grade 3 to Grade 6), specifically through internalizing and externalizing behaviors.

METHODS

Our study utilized data from 844 participants in the NICHD Study of Early Child Care and Youth Development (SECCYD) to assess the effects of maternal depression, observed from when the children were one month old to Grade 3, on BMI and the likelihood of overweight or obesity in adolescents aged 15. We also explored whether the average scores of internalizing and externalizing behaviors between Grades 3 and 6 mediated the impact of early maternal depressive symptoms on subsequent health outcomes. The analysis was adjusted for demographic and socioeconomic factors.

RESULTS

Findings revealed that internalizing and externalizing behavioral issues significantly mediated the relationship between prolonged maternal depression exposure and subsequent BMI, as well as the risk of overweight or obesity, in adolescents at age 15. Notably, this mediating effect was predominantly evident in girls.

CONCLUSIONS

Our research demonstrated that the correlation between prolonged exposure to maternal depressive symptoms in childhood and increased BMI and overweight risk in adolescence was significantly mediated through psychosocial adjustment behaviors. We advocate for further exploration of additional mediating factors in future studies.

Promoting hEalthy Diet and Active Lifestyle (PEDAL): a protocol for the development and feasibility study of a multicomponent intervention among primary school children in Singapore

BACKGROUND

Setting healthy lifestyle habits during the formative years of childhood is critical as habits can track to adulthood and help prevent obesity and chronic disease risks in later life. While multicomponent interventions have been shown to be effective in changing the lifestyle behaviours of children, there is a limited understanding of the feasibility of such interventions in primary schools in Singapore. A multiphase mixed method study was conducted to develop and examine the feasibility of a theory-based multicomponent school-based intervention-Promoting hEatlthy Eating and Active Lifestyle (PEDAL).

METHODS

Underpinned by Kincaid's ideation model, the PEDAL intervention was developed to increase fruit and vegetable consumption and decrease sedentary behaviours among children. This study consists of three phases. Phase 1 details the development of PEDAL, which consists of four components: (A) a series of interactive health education lessons, (B) actionable home activities to support habit formation, (C) parental/guardian engagement, and (D) optimising the school environment. In Phase 2, components A and B of PEDAL were implemented in two public, co-educational primary schools among Primary 5 students (aged 10-12 years) in Singapore. Data was collected quantitatively using questionnaires and qualitatively using focus group discussions (FGDs) with students and teachers. The feasibility dimensions of components A and B, including recruitment capability, data collection, social validity, and practicality were examined, and ideation on healthy eating and physical activity was explored. In Phase 3, the full PEDAL intervention was pilot-tested in two other public, co-education primary schools with the same target population, using a concurrent mixed method quasi-experimental study design. Feasibility dimensions and potential effectiveness of the intervention will be assessed.

DISCUSSION

This study will provide insights into the feasibility of PEDAL and inform its refinement. Findings from the pilot test will guide the planning of a larger-scale definitive trial.

TRIAL REGISTRATION

Registered with ISRCTN registry (ISRCTN16114046) on 16 October 2022.

Adherence to plant-based dietary patterns and anthropometric indices among primary school girls in Kerman: A cross-sectional study

The objective of the study was to evaluate the association between adherence to plant-based dietary patterns and anthropometric indices among primary school girls in Kerman. This cross-sectional study included 330 girls aged 6-12. A reliable and validated dish-based food frequency questionnaire was used to collect dietary data. Weight, height, and mid-arm circumference were measured, and z-score charts from the World Health Organization for girls between the ages of 5 and 19 were utilized. We used Satija et al. method to calculate plant-based diet index scores. After adjusting for age and energy, participants in the higher tertile of the overall plant-based diet index (PDI) had a lower height-for-age z score (HAZ) (0.38±0.12 vs. 0.59±0.12 kg; P = 0.033). Higher unhealthful plant-based diet index (uPDI) scores were significantly associated with decreased HAZ in models 2 (p = 0.028) and 3 (p = 0.035). A higher PDI score was associated with lower odds of being underweight and overweight, respectively (Model 1: P trend = 0.007, <0.001; Model 2: P trend = 0.010, 0.001). A significant inverse association was found between healthful plant-based diet index (hPDI) scores and underweight risk in the crude and adjusted models. (Model 1: P trend = 0.021; model 2: P trend = 0.018; Model 3: P trend = 0.031). Higher uPDI scores were associated with increased odds of being overweight and obese in all three models (Model 1: p trend<0.001; Model 2: p trend<0.001; Model 3: p trend = 0.001). We concluded that children who followed a plant-based diet had lower odds of being overweight and obese. Higher scores on the hPDI were linked to a decreased risk of being underweight, while higher scores on the uPDI were associated with an increased risk of being overweight and obese. The study suggests healthy plant-based diet may benefit children's weight and growth.

Mothers' experiences of reducing family mealtime screen use in Australian households with young children

OBJECTIVE

Screen use at mealtimes is associated with poor dietary and psychosocial outcomes in children and is disproportionately prevalent among families of low socio-economic position (SEP). This study aimed to explore experiences of reducing mealtime screen use in mothers of low SEP with young children.

DESIGN

Motivational interviews, conducted via Zoom or telephone, addressed barriers and facilitators to reducing mealtime screen use. Following motivational interviews, participants co-designed mealtime screen use reduction strategies and trialled these for 3-4 weeks. Follow-up semi-structured interviews then explored maternal experiences of implementing strategies, including successes and difficulties. Transcripts were analysed thematically.

SETTING

Australia.

PARTICIPANTS

Fourteen mothers who had no university education and a child between six months and six years old.

RESULTS

A range of strategies aimed to reduce mealtime screen use were co-designed. The most widely used strategies included changing mealtime location and parental modelling of expected behaviours. Experiences were influenced by mothers' levels of parenting self-efficacy and mealtime consistency, included changes to mealtime foods and an increased value of mealtimes. Experiences were reportedly easier, more beneficial and offered more opportunities for family communication, than anticipated. Change required considerable effort. However, effort decreased with consistency.

CONCLUSIONS

The diverse strategies co-designed by mothers highlight the importance of understanding why families engage in mealtime screen use and providing tailored advice for reduction. Although promising themes were identified, in this motivated sample, changing established mealtime screen use habits still required substantial effort. Embedding screen-free mealtime messaging into nutrition promotion from the inception of eating will be important.

Breast and Formula Milk and Early Puberty Onset

Nutrients have an enormous impact on many hormonal systems and aspects of health, and nutrition status is a crucial regulator of growth and pubertal development in children and adolescents. In this narrative review, we explore the connection between these feeding methods and the timing of puberty to provide a clearer understanding of how infant nutrition might contribute to the early development of puberty. Puberty is a key stage in the transition from childhood to adulthood and the timing of puberty represents a significant biological milestone of growth. Breast milk seems to have a pivotal role in puberty onset, mainly due to its dynamism, which shape indirectly the gut microbiota in early life, besides direct exposure of the baby to the milk microbiota through gut-breast axis. Concerning breast and formula milk and their effects on the onset of puberty, a protective role of the former occurs. As for the potential harmful effects of soy-based formulas and the isoflavones that they contain, the studies reported demonstrate conflicting opinions, underlining the need for further research on this topic. A healthy and well-nourished diet from the earliest stages of life has significant preventive potential for overall well-being, reducing the risk of many health problems later in life.

Impact of the Family Environment on the Frequency of Animal-Based Product Consumption in School-Aged Children in Central Poland

Animal-sourced foods (ASFs) have a high nutritional value, which makes them important elements of young people's diets. Several environmental factors might affect the dietary habits of children and adolescents, and their identification seems to be a principal reason to maintain their healthy eating practice. Thus, we aimed to investigate selected environmental factors (a place of residence, net income, mother's education level, number of siblings, and mother's BMI), which may be linked to the consumption frequency of ASFs among school-aged children. In total, 892 mothers of primary school children aged 7-14 years from central Poland took part in the anonymous and voluntary survey. The frequency of meat and meat product consumption was affected by the mother's education level, place of residence, and net income. Generally, meat was eaten more often by the city children (G = 0.178, p < 0.01) of better-educated mothers (G = 0.268, p < 0.001) and higher-income families (G = 0.209, p < 0.001). A higher level of education was linked to more frequent fish consumption but only in the younger group (G = 0.130, p < 0.05). The frequency of egg intake was positively associated with the maternal level of education (G = 0.185, p < 0.001), children's gender (girls > boys, G = 0.123, p < 0.05), and place of residence (city > village, G = 0.214, p < 0.001). In turn, the frequency of milk and dairy intake was related only to the place of residence (village > city, G = 0.97, p <0.05). It can be concluded that the mother's level of education is a key factor linked to the selected children's dietary habits. Thus, we believe that successful health education programs designed for young people should include the maternal capacity to interpret and adapt information into daily practice.

"That's the routine": A qualitative exploration of mealtime screen use in lower educated Australian families with young children

BACKGROUND

Family meals are an opportune context for initiating healthy eating habits in young children. However, using screens at family mealtimes may negate some of the associated nutritional and social benefits. In High Income countries, frequent mealtime screen use is common, particularly in families of low socioeconomic position (SEP). This study aimed to explore experiences and acceptability of mealtime screen use in families of low SEP with young children.

METHODS

Qualitative interviews with 25 mothers of low SEP were conducted via telephone or Zoom™ using Photo Interviewing and a semi-structured interview script. Transcripts were analysed thematically using a Constructivist paradigm.

RESULTS

Many parents reported an eagerness for reducing family mealtime screen use. Three major themes were identified in explaining the reasons behind levels of engagement in family mealtime screen use. These included parental self-efficacy, such as parental confidence in saying no to screens at mealtimes, physical resources such as having enough space in the home for a functioning dining table without view of a television, and temporal priorities such as prioritising screen use for managing children's difficult behaviour at mealtimes over long-term health considerations.

CONCLUSIONS

This study highlights that although family mealtime screen use is likely linked with a range of child behaviours and parenting practices that may negatively influence children's dietary intake and social engagement, parents often considered screens acceptable at mealtimes. Nonetheless, parents' desire to reduce family mealtime screen use provides an important opportunity to determine how best to support parents to achieve this.

Obesity in Children

Child obesity is widely prevalent, and general pediatricians play an important role in identifying and caring for patients with obesity. Appropriate evaluation and treatment require an understanding of the complex etiology of child obesity, its intergenerational transmission, and its epidemiologic trends, including racial/ethnic and socioeconomic disparities. The American Academy of Pediatrics has published screening, evaluation, and treatment guidelines based on the best available evidence. However, gaps in evidence remain, and implementation of evidence-based recommendations can be challenging. It is important to review optimal care in both the primary care and multidisciplinary weight management settings. This allows for timely evaluation and appropriate referrals, with the pediatrician playing a key role in advocating for patients at higher risk. There is also a role for larger-scale prevention and policy measures that would not only aid pediatricians in managing obesity but greatly benefit child health on a population scale.

Preventing the Early Introduction of Juice and Sugar-Sweetened Beverages in Infants' Diets: A Randomized Controlled Trial

A randomized controlled trial was conducted to determine whether a simple educational intervention targeting parents of young infants could have an impact on the consumption of juice and sugar-sweetened beverages (SSBs) in early childhood and decrease overweight and obesity rates. Parents of 2- to 4-month-old infants were randomized into intervention (n = 67) and control (n = 77) groups. Parents completed questionnaires about juice and SSB consumption and knowledge at baseline and 1-year follow-up. Intervention parents received informational handouts and watched videos about the health effects of juice and SSBs. Knowledge about juice increased significantly in the intervention group compared with control (P < .01) and was significantly higher in black/African American parents (P < .05) and those with some college education (P < .05). The intervention had a significant impact on the knowledge gained by parents about the health effects of juice and SSBs but did not decrease the consumption of sugary drinks or change children's weight status.

Interdisciplinary Educational Interventions Improve Knowledge of Eating, Nutrition, and Physical Activity of Elementary Students

This research aimed to evaluate the interdisciplinary educational intervention effects on knowledge of eating, nutrition, and physical activity in elementary-school students. Participants were 368 school children enrolled in public schools. The research was organized in three stages: pre-intervention, intervention and post-intervention. In pre-intervention, children were evaluated regarding their nutritional status. They also answered questionnaires related to eating and nutrition and physical activity. In the intervention stage, educational interventions were carried out on the same topics for a period of five months; in post-intervention, children answered the same questionnaires applied in pre-intervention. Despite most children having normal nutritional status (58.2%), a high number of students were overweight (38%). In the initial phase, it was found that most children had excellent knowledge of eating, nutrition, and good physical activity knowledge (p-value < 0.05). Educational health intervention significantly increased children’s knowledge of eating, nutrition, and physical activity, when evaluated in the post-intervention period. Both boys and girls increased their knowledge of eating, nutrition, and physical activity after the application of interdisciplinary interventions (p-value < 0.05). A similar effect was observed for children with different nutritional status. It is concluded that interdisciplinary educational interventions carried out for children in an elementary-school environment are effective for improving knowledge of eating, nutrition, and in physical activity, promoting healthier habits among children.

Nutrition, obesity, and dental development in young adolescents in Chicago

OBJECTIVES

Childhood obesity is a systemic disease with multiple downstream consequences, including shifts in timing of growth and development. It has been documented that children with high body mass index (BMI) show accelerated timing of dental development, but the mechanism for this acceleration is unknown. Prior work has suggested that inflammation and/or nutrition may play a role. We investigate the potential association between diet (caloric intake, macronutrients), obesity, and accelerated dental development.

METHODS

Children and adolescents (age 10-15; n = 112) were recruited from dental clinics at the University of Illinois Chicago. We collected subjects' height, weight, panoramic radiographic records, and each subject filled out a Block Food Frequency Questionnaire.

RESULTS

The only macronutrient level associated with BMI was a negative correlation to Total Fat consumption (p = .01), though this relationship was not significant in the path analysis (p > .05). Regression analyses indicated that BMI (p = .003) and total caloric intake (controlling for BMI; rho = 0.19; p = .04) were both significantly correlated with timing of dental development. However, when a path analysis was conducted, it was revealed that only BMI was statistically significant (p = .008).

CONCLUSIONS

Body mass index percentile, regardless of caloric intake, is positively associated with accelerated dental development. While it is possible that excess caloric intake itself plays a minor role in timing of dental development, we do not see unambiguous evidence for this in our sample. We posit that another mechanism, such as inflammation, may be the link between obesity status and dental development.

Association between gut MIcrobiota, GROWth and Diet in peripubertal children from the TARGet Kids! cohort (The MiGrowD) study: protocol for studying gut microbiota at a community-based primary healthcare setting

INTRODUCTION

The gut microbiota interacts with diet to affect body health throughout the life cycle. Critical periods of growth, such as infancy and puberty, are characterised by microbiota remodelling and changes in dietary habits. While the relationship between gut microbiota and growth in early life has been studied, our understanding of this relationship during puberty remains limited. Here, we describe the MIcrobiota, GROWth and Diet in peripubertal children (The MiGrowD) study, which aims to assess the tripartite growth-gut microbiota-diet relationship at puberty.

METHODS AND ANALYSIS

The MiGrowD study will be a cross-sectional, community-based study involving children 8-12 years participating in the TARGet Kids!

COHORT

TARGet Kids! is a primary healthcare practice-based research network in Canada. Children will be asked to provide a stool sample, complete two non-consecutive 24-hour dietary recalls and a pubertal self-assessment based on Tanner Stages. Anthropometry will also be conducted. The primary outcome is the association between gut microbiota composition and longitudinal growth from birth until entry into the study. Anthropometrics data from birth will be from the data collected prospectively through TARGet Kids!. Body mass index z-scores will be calculated according to WHO. The secondary outcome is the association between gut microbiota, diet and pubertal stage.

ETHICS AND DISSEMINATION

Ethics approval has been obtained by the Hospital for Sick Children and St. Michael's Hospital-Unity Health, and the University of Toronto. Results will be disseminated in the public and academic sector, including participants, TARGet Kids! primary healthcare physicians teams, scientists via participation in the TARGet Kids! science and physician meetings, conferences and publications in peer-reviewed journals. The MiGrowD study results will help researchers understand the relationships underlying growth, gut microbiota and pubertal maturation in children.

Lack of an association between dietary patterns and adiposity among primary school children in Kilimanjaro Tanzania

Introduction

Healthy dietary habits prevent childhood overweight and obesity and the risk of non-communicable diseases (NCDs) later in life. We examined dietary patterns and their association with adiposity among primary school children in northern Tanzania.

Methods

Dietary data was collected by 24-h recall and food frequency questionnaire (FFQ) for 1170 primary school children aged 9 – 11 years from 20 primary schools in the Kilimanjaro region. Factor analysis and FFQ data were used to identify dietary patterns. Children were categorized into terciles of their adherence to each dietary pattern. Multilevel logistic regression was used to evaluate the association of dietary pattern terciles with adiposity indicators: body mass index z–scores (BMI z scores), body fat percentage by bioelectrical impedance, triceps, subscapular skinfold thicknesses, and waist circumference.

Results

Fifteen percent of children had BMI Z > 1.0, indicating overweight or obesity. Two dietary patterns were identified by factor analysis: a healthy pattern characterized by frequent consumption of fruits and vegetables; and a mixed dietary pattern characterized by intake of fatty snacks, sweets and sugar snacks, sugary beverages, meat and alternatives, milk, and milk products. After adjusting for potential confounders, for both models: model 1 (age and sex), and model 2 (age, sex, school type, time spent walking to school, district [urban/ rural], availability of television and electronic gadgets at home and neighbourhood playground); we found no significant associations between dietary patterns and adiposity measures.

Conclusion

Dietary patterns were not associated with adiposity in Tanzanian primary school children, possibly because of limitations of the FFQ, which did not record information on portion sizes. Future research should focus on understanding the key foods / snacks consumed by school children, portion sizes and their long-term effects on adiposity in children.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40795-022-00529-4.

A multi-component tailored intervention in family childcare homes improves diet quality and sedentary behavior of preschool children compared to an attention control: results from the Healthy Start-Comienzos Sanos cluster randomized trial

BACKGROUND

Childcare settings are important environments for influencing child eating and physical activity (PA). Family childcare homes (FCCH) care for many children of low-income and diverse racial/ethnic backgrounds who are at greater risk for poor diet quality, low PA, and obesity, but few interventions have targeted this setting. The aim of this study was to assess the efficacy of a multicomponent intervention conducted in FCCH on the diet quality and PA of 2-5 year old children in their care.

TRIAL DESIGN

Cluster randomized trial.

METHODS

The cluster-randomized trial, Healthy Start/Comienzos Sanos (2015-2019) evaluated an 8-month nutrition and PA intervention that included four components: (1) monthly telephone calls from a support coach using brief motivational interviewing, (2) tailored reports, newsletters and videos, (3) group support meetings, and (4) active play toys. After completing baseline measurement, FCCH were randomized into intervention or comparison groups in matched pairs. Both groups received the same intervention components but on different topics (intervention: nutrition/PA vs. comparison: reading readiness/literacy). Evaluation staff were blinded to group assignment. Child primary outcome measures collected at baseline and 8-months included: 1) Healthy Eating Index (HEI-2015) scores calculated from diet observation, and 2) accelerometer measurement of PA. Process measures were collected from field data and provider surveys. Generalized Estimating Equation Models assessed changes in HEI-2015 scores and PA over time by experimental condition.

RESULTS

Ethnically diverse FCCH providers (n = 119) and 2-to-5-year-old children in their care (n = 377) were included in the final analysis. Process evaluation showed high participation in all intervention components except for group meetings. Compared to children in comparison group FCCH, children in intervention FCCH increased total HEI-2015 scores by 7.2 points (p < .001) including improvement in component scores for vegetables (0.84 points, p = .025) and added sugar (0.94 points, p = .025). For PA, compared to children in the comparison group, children in intervention FCCH decreased sedentary time by 5.7% (p = .021).

CONCLUSIONS

The multicomponent Healthy Start intervention was effective in improving diet quality and sedentary behavior of children in FCCH, which demonstrates the promise of obesity prevention interventions in this setting. Future research could include enhancing the Healthy Start intervention to strengthen the PA component, considering virtual peer support, and determining how to best translate and disseminate the intervention into FCCH nationally.

TRIAL REGISTRATION

National Institutes of Health, NCT02452645 . Registered 5 May 2015.

Energy Intake from Healthy Foods Is Associated with Motor Fitness in Addition to Physical Activity: A Cross-Sectional Study of First-Grade Schoolchildren in Japan

Childhood motor fitness is important for the physical and mental health of children and the prevention of future lifestyle diseases. This study aimed to investigate how energy intake from healthy foods and physical activity are associated with motor fitness among first-grade children. First-grade children (aged 6–7 years) attending three public elementary schools in Tokyo, Japan (n = 884), participated in this cross-sectional study. Self-administered questionnaires were distributed, which focused on lifestyle habits and required completion of a 1-day dietary record of meals that children ate at home. School lunch consumption was also assessed. Motor fitness was assessed by the New Physical Fitness Test (NPFT). Multiple regression analysis was used to investigate the association of the amount of energy from healthy foods and physical activity with NPFT scores. NPFT scores were positively correlated with involvement in after school exercise classes, playing outside (in boys only), and total energy intake. Energy intake from healthy foods showed a positively associated with NPFT scores (boys, β = 0.120, p = 0.011; girls, β = 0.140, p = 0.004), while energy intake from unhealthy foods did not. Energy intake from healthy foods was associated with motor fitness in children in addition to physical activity.

Prospective associations between dietary patterns, screen and outdoor play times at 2 years and age at adiposity rebound: The EDEN mother-child cohort

Although an early adiposity rebound (AR) is an established risk factor for later obesity, little is known regarding its determinants, especially modifiable ones. Using data from the French EDEN mother–child cohort (1903 children born in 2003–2006), we aimed to examine the association between diet and activity-related behaviors at 2 years of age and the timing of the AR. Two-year-old children (n = 1138) with parent-reported data on their foods/drinks intake, TV/DVD watching time, outdoor playtime, and with an estimated (via growth modelling) age at AR were included in the present study. Two dietary patterns, labelled 'Nutrient-dense foods' and 'Processed and fast foods', were identified in a previous study. Multivariable linear and logistic regression models were used to assess the association between dietary patterns and activity-related behaviors and, respectively, the age at AR (continuous) and the likelihood of having a very early AR (before 3.6 years for girls and 3.8 years for boys, i.e., below the 10th percentile of sex-specific distribution). A higher score on the ‘Processed and fast foods’ dietary pattern was associated with a higher likelihood of having a very early AR (OR = 1.23; 95% CI: 1.00 to 1.50). No significant association was observed between the ‘Nutrient-dense foods’ dietary pattern, TV/DVD watching and outdoor playing times and the timing of the AR. This finding emphasizes the importance of reducing nutrient-dense and processed foods from the early years of life, and provides further support for early interventions aimed at helping parents establish healthy eating habits for their growing child from the complementary period.

Longitudinal associations between prepubertal childhood total energy and macronutrient intakes and subsequent puberty timing in UK boys and girls

PURPOSE

Early puberty is associated with adverse health outcomes. To identify potential modifiable factors for puberty timing, we examined the associations of prepubertal childhood macronutrient intakes with puberty timing in boys and girls.

METHODS

In the Avon Longitudinal Study of Parents and Children, macronutrient intakes at age 6 years were predicted using random intercepts linear regression models of dietary data at 3, 4, 7 (assessed by food frequency questionnaires) and 7.5 years (by 3-day food diaries). Timings of puberty onset (Tanner stage 2 genital or breast (B2) development) and puberty completion (voice breaking (VB) or menarche) were calculated from annual parental and child reports at 8-17 years. Age at peak height velocity (PHV) was derived from repeated height measurements at 5-20 years. Linear regression models were fit to estimate the associations of total energy (TEI) and macronutrient intakes (carbohydrate, fat, protein) with puberty timing traits, adjusting for maternal and infant characteristics.

RESULTS

Among 3811 boys, higher TEI, but no macronutrient, was associated with earlier VB. Among 3919 girls, higher TEI was associated with earlier ages at B2, PHV, and menarche. Higher protein intake but not carbohydrate or fat intake (in energy partition models) and substitution of dietary protein for carbohydrate (in nutrient density and residual models) was associated with earlier B2, PHV, and menarche in girls. Findings were not attenuated on additional adjustment for body fat percentage during adolescence.

CONCLUSIONS

These findings suggest habitual total energy intakes in children, and protein intakes in girls, as potential modifiable determinants of puberty timing.

Exploring Overweight Risk Trajectories During Childhood and Their Associations With Elevated Blood Pressure at Late Adolescence: a Retrospective Cohort Study

BACKGROUND

Overweight during childhood is significantly associated with higher risk of high blood pressure (HBP) in later life. However, recognition of critical intervention period is limited. We aimed to analyze the changes in overweight risk during school-age and its relationship with HBP.

METHODS

Seventeen thousand eight hundred sixteen school-aged children (53.9% boys) with a mean follow-up time of 8.2 years were involved. Children's overweight was defined as body mass index Z score ≥1 and was fitted with a group-based trajectory model. The 4 trajectories were labeled as constant low, high decreasing, low rising, and constant high according to the change of overweight risk during follow-up. Population-averaged logit model and log-binomial regression models were used to analyze HBP risk. Cox proportional hazard model was used to analyze the HBP incidence among distinct groups.

RESULTS

Children with higher overweight risk generally had higher HBP risk during follow-up. However, the HBP risk in low rising group was low at baseline and increased to 3.14 (95% CI, 2.54-3.88; P<0.001) for boys and 3.23 (95% CI, 2.08-5.01; P=0.004) for girls at end point, which were comparable to the relative risk in the constant high group (4.60 [95% CI, 4.02-5.27] for boys and 5.28 [95% CI, 3.94-7.07] for girls).

CONCLUSIONS

Findings of this study provide insights on patterns of overweight risks during childhood. Children with transition from normal to overweight during teen years would be high-risk in HBP incidence.

Convenience Food Options and Adequacy of Nutrient Intake among School Children during the COVID-19 Pandemic

The COVID-19 pandemic has caused changes in the family food environment, resulting in more families relying on convenience food options. This study aimed to investigate diet quality by convenience food options (namely instant, frozen, and take-out foods) among Japanese school children during the COVID-19 pandemic. We examined the relationship between the frequency of consumption of convenience food options and nutritional status of the school children. The participants (671 children, 10–14 years old) were chosen to form a nationally representative sample of the Japanese population. Using questionnaires completed by the participants’ guardians, information was collected on the frequency of instant, frozen, and take-out food consumption. Habitual food and nutrient intake were collected using a validated food frequency questionnaire, completed by the children with help from their guardian(s). “Frequent” consumption was defined as consumption of instant, frozen, and/or take-out foods on more than 5 days per week. Using 19 nutrients and their respective dietary reference intake (DRI) values, an index was created to label each child’s nutrient intake as “Adequate”, “Inadequate”, “Excess”, or “Deficient.” Compared to children with non-frequent consumption, school children with frequent instant food consumption had significantly higher rates of inadequate nutrient intake (risk ratio (RR) = 3.0 [95% CI: 1.6–5.6]) and excess nutrient intake (RR = 2.3 [95% CI: 1.3–4.2]), while school children with frequent take-out food consumption had significantly higher rates of inadequate nutrient intake (RR = 2.1 [95% CI: 1.3–3.3]). There were no significant differences for children with frequent frozen-food intake. These associations did not change when adjusting for sociodemographic factors. Our results suggest that the frequent consumption of instant or take-out foods among school children results in non-adequate nutritional intake.

Barriers, Attitudes, and Influences Towards Dietary Intake Amongst Elite Rugby Union Players

Background: Dietary intakes can impact an athletes health and performance. Although evidence exists about what an athlete should eat, an athlete's nutritional intake is influenced by many factors. The limited research available suggests the main barriers preventing optimal nutritional intakes reported by athletes are lack of time, food accessibility, poor cooking skills, costs, taste, and time spent in “off-season.” Although these factors have been shown to influence dietary intake they remain relatively unexplored in Rugby Union. This study aimed to describe the nutritional influences on dietary intake amongst Rugby Union player's.

Methods: This was a qualitative study utilising in person individual interviews with all participants. Participants were Rugby Union players (n = 30) for either a Super Rugby franchise or one of their development squads in New Zealand. Participant's undertook recorded face to face interviews, which were later transcribed. A thematic approach was used to code the transcripts by the primary coder and the themes were subsequently evaluated by the research team.

Results: Childhood upbringing, organisational skills, time and food security also emerged as barriers. Body composition and sport nutrition knowledge emerged as both barriers and enablers to nutritional intake. Influence on performance was an enabler to optimal dietary intake. Fully professional rugby players have access to dietitians, whereas development and semi-professional rugby players only have limited if any access, and they were more likely to seek nutritional information via social media.

Conclusion: This study suggests a need for greater nutrition education at developmental levels with an emphasis on affordable food choices, meal planning and skills for interpreting online nutrition information.

Ultraprocessed food consumption and dietary nutrient profiles associated with obesity: A multicountry study of children and adolescents

This study assessed associations between ultraprocessed food consumption and dietary nutrient profile linked to obesity in children and adolescents in Argentina, Australia, Brazil, Chile, Colombia, Mexico, the United Kingdom, and the United States using nationally representative data collected between 2004 and 2014. Linear regression models were used to evaluate associations between dietary share of ultraprocessed foods (country and age group-specific quintiles and a 10% share increase) and the energy density of diets and their content of free sugars and fiber. Ultraprocessed foods, defined by the NOVA system, ranged from 18% of total energy intake among preschool children in Colombia to 68% among adolescents in the United Kingdom. In almost all countries and age groups, increases in the dietary share of ultraprocessed foods were associated with increases in energy density and free sugars and decreases in fiber, suggesting that ultraprocessed food consumption is a potential determinant of obesity in children and adolescents. Effective global policy action to address growing ultraprocessed food consumption and childhood obesity is urgently needed.

Inequalities in body mass index, diet and physical activity in the UK: Longitudinal evidence across childhood and adolescence

We use longitudinal data across a key developmental period, spanning much of childhood and adolescence (age 5 to 17, years 2006-2018) from the UK Millennium Cohort Study, a nationally representative study with an initial sample of just over 19,000. We first examine the extent to which inequalities in overweight, obesity, BMI and body fat over this period are consistent with the evolution of inequalities in health behaviours, including exercise and healthy diet markers (i.e., skipping breakfast) (n = 7,220). We next study the links between SES, health behaviours and adiposity (BMI, body fat), using rich models that account for the influence of a range of unobserved factors that are fixed over time. In this way, we improve on existing estimates measuring the relationship between SES and health behaviours on the one hand and adiposity on the other. The advantage of the individual fixed effects models is that they exploit within-individual changes over time to help mitigate biases due to unobserved fixed characteristics (n = 6,883). We observe stark income inequalities in BMI and body fat in childhood (age 5), which have further widened by age 17. Inequalities in obesity, physical activity, and skipping breakfast are observed to widen from age 7 onwards. Ordinary Least Square estimates reveal the previously documented SES gradient in adiposity, which is reduced slightly once health behaviours including breakfast consumption and physical activity are accounted for. The main substantive change in estimates comes from the fixed effects specification. Here we observe mixed findings on the SES associations, with a positive association between income and adiposity and a negative association with wealth. The role of health behaviours is attenuated but they remain important, particularly for body fat.

The Role of Pediatric Nutrition as a Modifiable Risk Factor for Precocious Puberty

Puberty is a critical phase of growth and development characterized by a complex process regulated by the neuroendocrine system. Precocious puberty (PP) is defined as the appearance of physical and hormonal signs of pubertal development at an earlier age than is considered normal. The timing of puberty has important public health, clinical, and social implications. In fact, it is crucial in psychological and physical development and can impact future health. Nutritional status is considered as one of the most important factors modulating pubertal development. This narrative review presents an overview on the role of nutritional factors as determinants of the timing of sexual maturation, focusing on early-life and childhood nutrition. As reported, breast milk seems to have an important protective role against early puberty onset, mainly due to its positive influence on infant growth rate and childhood overweight prevention. The energy imbalance, macro/micronutrient food content, and dietary patterns may modulate the premature activation of the hypothalamic-pituitary-gonadal axis, inducing precocious activation of puberty. An increase in knowledge on the mechanism whereby nutrients may influence puberty will be useful in providing adequate nutritional recommendations to prevent PP and related complications.

Using Body Composition Groups to Identify Children and Adolescents at Risk of Dyslipidemia

The impact of body composition on the early origin of chronic diseases is an increasingly appreciated phenomenon. Little is known about the characteristics of children with varying body composition. The aim of this study was to investigate serum lipid profiles and other characteristics in relation to body composition. The data of 1394 participants (aged 6 to <18 years) of the observational general population-based Austrian LEAD Study have been analyzed. Body composition groups were defined by appendicular lean mass (ALMI) and fat mass (FMI) indices assessed by DXA. Serum lipid profiles (triglycerides, LDL-c, HDL-c) and other characteristics (e.g., prematurity, smoke exposure, physical activity, nutrition) were investigated in these body composition groups. Different body composition groups, which are not distinguishable by BMI, exist. Children with high ALMI and high FMI showed higher triglycerides and LDL-c, but lower HDL-c levels. In contrast, levels did not differ between those with high FMI but low (or normal) ALMI, and other body composition groups. BMI should be interpreted cautiously, and body composition should be measured by more precise techniques. In particular, children and adolescents with high FMI who have concomitantly high ALMI should be followed closely in future studies to investigate whether they are at increased risk of cardiovascular problems.

Umbilical cord serum concentrations of perfluorooctane sulfonate, perfluorooctanoic acid, and the body mass index changes from birth to 5 1/2 years of age

Prenatal exposure to perfluoroalkyl substances (PFAS) has been reported to affect body weight from birth to childhood, but the results remain inconclusive. We investigated whether umbilical cord blood concentrations of perfluorooctane sulfonate (PFOS) and perfluorooctanoic acid (PFOA) are associated with children’s risk trajectory for obesity. 600 children were randomly selected from the Hamamatsu Birth Cohort for Mothers and Children (HBC study) and their umbilical cord serum PFAS concentrations were quantified. Participants underwent BMI measurements at ages 1, 4, 10, 18, 24, 32, 40, 50, and 66 months. Growth curve modeling with random intercept was performed with standardized BMI as outcome variable. PFOS was negatively associated with standardized BMI (β =  − 0.34; p = 0.01), with a marginally significant interaction with the child’s age (β = 0.0038; p = 0.08). PFOA was negatively associated with standardized BMI (β =  − 0.26, 95% CI − 0.51, 0; p = 0.05), with a significant interaction with the child’s age (β = 0.005; p = 0.01). Stratified analysis by sex revealed that these effects were significant only among girls. Prenatal exposure to PFAS initially was associated with lower standardized BMI during infancy, but this effect dissipated over time and reversed in direction during later childhood. The effects of prenatal PFAS on higher standardized BMI is stronger in girls.

Low-income mothers' perspectives on the involvement of family members in child feeding

Nearly all research on child feeding has focused on mothers. Very little is known about other family members' roles in feeding children nor how mothers engage with these family members regarding child feeding. The objective of this study was to examine mothers' perceptions of other family members' child feeding roles and practices within low-income families, including the challenges experienced and strategies employed by mothers when sharing responsibility for child feeding. Low-income mothers (n = 100) of pre-adolescent children participated in semi-structured interviews regarding child feeding including shared responsibility for child feeding. A content analysis was then conducted to identify main themes in mothers' responses, with three main themes arising from the interviews. First, many family members were actively involved in child feeding and food-related decision-making. The majority of mothers (85%) reported that another family member was involved in feeding their child including fathers and father figures, who were involved in feeding in 63% of families. Other family members, mainly grandparents, were involved in feeding in 35% of families. Mothers identified several concerns regarding their child's eating when with other family members, particularly when grandparents fed children. Finally, mothers employed several strategies to control their children's eating when children were cared for by other family members. Future interventions to promote healthy child feeding among low-income families may benefit from helping mothers negotiate child feeding with other family members, particularly grandparents, and supporting family members' engagement in child feeding.

Associations of maternal diet and nutritional status with offspring hepatic steatosis in the Avon longitudinal study of parents and children

BACKGROUND

Priming for cardiometabolic diseases, including non-alcoholic fatty liver disease (NAFLD), is hypothesized to begin in utero. The primary objective of this study is to determine whether there is an association between maternal nutritional status and offspring NAFLD.

METHODS

Data come from the Avon Longitudinal Study of Parents and Children (ALSPAC) in the UK. The analytic sample included 3353 participants who had maternal information on pre-pregnancy BMI, gestational weight gain, diabetes, and free sugar intake as percent of total energy and were assessed for mild-severe hepatic steatosis at 24 years by transient elastography (controlled attenuation parameter score ≥ 248 dB/m). Multiple logistic regression was used to evaluate the association between maternal factors and offspring hepatic steatosis at 24 years.

RESULTS

In confounder-adjusted models the independent associations for each maternal factor with mild to severe vs low hepatic steatosis at 24 years were: pre-pregnancy overweight (OR: 1.84, 95%CL: 1.43-2.38) or obesity (OR: 2.73, 95%CL: 1.84-4.03), more than recommended gestational weight gain (OR: 1.30, 95%CL: 1.04-1.64), diabetes (OR: 1.39, 95%CI: 0.87, 2.21), and high free sugar intake during pregnancy (OR: 1.04, 95% CI: 0.82, 1.33). These associations were largely mediated by BMI at 24 years, but not by birthweight or breastfeeding.

CONCLUSIONS

Our results suggest that maternal nutritional status is associated with the development of NAFLD in their adult offspring, although the relationship is largely mediated by offspring BMI in adulthood.

Longitudinal Diet Quality Trajectories Suggest Targets for Diet Improvement in Early Childhood

BACKGROUND

There is little information about how diet quality evolves in early childhood, whether children exhibit varying diet quality trajectories, or which components of diet quality should be targeted for intervention.

OBJECTIVE

The goal of this study was to identify and evaluate trajectories of dietary quality in young children.

DESIGN

This was a secondary analysis of an observational, longitudinal cohort study of non-Hispanic African American or White children and their parents from racially concordant households with 4 years of follow-up (up to 13 study visits). Data on mother, infant feeding, and body mass index were assessed at baseline. Diet was evaluated using 3-day diaries at each visit.

PARTICIPANTS/SETTING

Of 372 children enrolled, 349 children had at least 3 study visits with dietary data for this analysis. Participants were enrolled at age 3 years between March 2001 and August 2002 in Cincinnati, OH. Final study visits were conducted between February 2005 and June 2006.

MAIN OUTCOME MEASURE

The main outcome measure was the total Healthy Eating Index 2005 (HEI-2005) score and HEI-2005 component scores.

STATISTICAL ANALYSES

Diet quality trajectories were modeled using group-based modeling techniques.

RESULTS

The total HEI-2005 score was low at age 3 years (mean ± standard error = 55.1 ± 0.4 of maximum 100 points) and remained stable to age 7 years (mean ± standard error = 54.0 ± 0.6; P = 0.08 for trend). Five HEI-2005 trajectory groups were identified, of which 1 declined and 1 improved over time. HEI-2005 component scores, except milk intake and meat/beans scores, differed significantly (all, P ≤ 0.02) among trajectory groups at age 3 years, and most differences were maintained at age 7 years. Total vegetables, dark green and orange vegetables and legumes, and whole grains component scores were low for all trajectory groups. Whole fruit; total fruit; saturated fat; and calories from solid fats, alcoholic beverages, and added sugars (SoFAAS) were highly variable among trajectory groups. Children in the lowest diet quality trajectory group were less likely to be breastfed and more likely to have been regular consumers of soft drinks (e.g., powdered drink mixes, sport drinks, or soda pop) before age 3 years.

CONCLUSIONS

Young childhood diet quality was low at age 3 years and remained stable to age 7 years. Improving intake of vegetables and whole grains is needed for all children. Focused attention regarding increasing fruit intake and reducing SoFAAS may be needed for families at increased risk for low overall diet quality.

Toddler milk perceptions and purchases: the role of Latino ethnicity

OBJECTIVES

Toddler milk (i.e. a nutrient-fortified milk-based drink marketed for children 12-36 months old) is increasingly being marketed in the USA despite not being recommended for young children. There is evidence of targeted toddler milk marketing to Latinos in the USA. This study aimed to explore toddler milk perceptions and behaviours among Latino and non-Latino parents.

DESIGN

An online survey assessed toddler milk perceptions, behaviours and interpretations of nutrition-related claims. Multivariable logistic and linear regression explored socio-demographic correlates of parent reported past purchases and perceived healthfulness.

SETTING

Online.

PARTICIPANTS

National convenience sample of 1078 US parents of children aged 2-12 years (48 % Latino).

RESULTS

About half of parents (51 %) had previously purchased toddler milk and few (11 %) perceived toddler milk as unhealthy. Latino parents were more likely to have purchased toddler milk than non-Latino parents (P < 0·001), but there were no differences in perceived product healthfulness (P = 0·47). Compared to parents born in the USA, parents living in the USA 10 years or less were more likely to have purchased toddler milk (P < 0·001) and perceive toddler milk as healthier (P = 0·002). Open-ended interpretations of claims were primarily positive, suggesting 'health halo' effects.

CONCLUSIONS

Common misperceptions about toddler milk healthfulness suggest stronger labelling regulations are needed. Greater reported purchases by Latino parents and recent immigrants warrant further investigation.

Prepubertal Dietary and Plasma Phospholipid Fatty Acids Related to Puberty Timing: Longitudinal Cohort and Mendelian Randomization Analyses

Dietary intakes of polyunsaturated, monounsaturated and saturated fatty acids (FAs) have been inconsistently associated with puberty timing. We examined longitudinal associations of prepubertal dietary and plasma phospholipid FAs with several puberty timing traits in boys and girls. In the Avon Longitudinal Study of Parents and Children, prepubertal fat intakes at 3-7.5 years and plasma phospholipid FAs at 7.5 years were measured. Timings of Tanner stage 2 genital or breast development and voice breaking or menarche from repeated reports at 8-17 years, and age at peak height velocity (PHV) from repeated height measurements at 5-20 years were estimated. In linear regression models with adjustment for maternal and infant characteristics, dietary substitution of polyunsaturated FAs for saturated FAs, and higher concentrations of dihomo-γ-linolenic acid (20:3n6) and palmitoleic acid (16:1n7) were associated with earlier timing of puberty traits in girls (n = 3872) but not boys (n = 3654). In Mendelian Randomization models, higher genetically predicted circulating dihomo-γ-linolenic acid was associated with earlier menarche in girls. Based on repeated dietary intake data, objectively measured FAs and genetic causal inference, these findings suggest that dietary and endogenous metabolic pathways that increase plasma dihomo-γ-linolenic acid, an intermediate metabolite of n-6 polyunsaturated FAs, may promote earlier puberty timing in girls.

Improving Care for Childhood Obesity: A Quality Improvement Initiative

Obesity affected 13.7 million children in the United States in 2015. The American Academy of Pediatrics (AAP) offers an evidence-based approach to obesity management, but adherence to recommendations is suboptimal. Our objective was to improve provider adherence to the AAP recommendations for care of patients with obesity by making systematic changes in our practice for patients of ages > 2 and younger than 19 years with a BMI > 95th percentile.

PUTRA-Adol study: protocol for an observational follow-up study to assess the tracking of dietary patterns linked to cardiometabolic risk factors and its prospective relationship with non-alcoholic fatty liver disease, carotid intima-medial thickness and mental well-being during adolescence in Malaysia

INTRODUCTION

Growing evidence suggesting that dietary intakes of adolescents are generally of poor quality but not adequately assessed in relation to the early manifestation of non-communicable diseases. This study aimed; (1) to examine tracking of an empirical dietary pattern (DP) linked to cardiometabolic risk factors and, (2) to assess prospective relationships between a DP characterised by high intakes of dietary energy density (DED) and added sugar, and cardiometabolic risk factors, non-alcoholic fatty liver disease (NAFLD), carotid intima-medial thickness (CIMT) and mental well-being during adolescence.

METHODS AND ANALYSIS

The PUTRA-Adol is a prospective follow-up study that builds up from 933 Malaysian adolescents who were initially recruited from three southern states in Peninsular Malaysia in 2016 (aged 13 years then). Two sessions are planned; the first session will involve the collection of socio-economy, physical activity, dietary intakes, mental well-being, body image, risk taking behaviour, sun exposure, family functioning and menstrual (in women) information. The second session of data collection will be focused on direct assessments such as venesection for blood biochemistry, anthropometry and ultrasonography imaging of liver and bilateral carotid arteries. Z-scores for an empirical DP will be identified at 16 years using reduced rank regression. Multilevel modelling will be conducted to assess the tracking of DP and prospective analysis between the DP, cardiometabolic health, NAFLD, CIMT and mental well-being.

ETHICS AND DISSEMINATION

Ethical approval for the conduct of this follow-up study was obtained from the Universiti Putra Malaysia's Ethics Committee for Research Involving Human Subjects (JKEUPM) (Reference number: JKEUPM-2019-267). The findings from this study will be disseminated in conferences and peer-reviewed journals.

DISCUSSION

The findings gathered from this study will provide evidence on prospective relationships between DPs, cardiometabolic risk factors, NAFLD, early atherosclerosis and mental well-being and that it may be mediated particularly DED and added sugar during adolescence.