What exposures in early life are risk factors for childhood obesity?

Eating Habits and Lifestyle Factors Related to Childhood Obesity Among Children Aged 5-6 Years: Cluster Analysis of Panel Survey Data in Korea

BACKGROUND

Childhood obesity has emerged as a major health issue due to the rapid growth in the prevalence of obesity among young children worldwide. Establishing healthy eating habits and lifestyles in early childhood may help children gain appropriate weight and further improve their health outcomes later in life.

OBJECTIVE

This study aims to classify clusters of young children according to their eating habits and identify the features of each cluster as they relate to childhood obesity.

METHODS

A total of 1280 children were selected from the Panel Study on Korean Children. Data on their eating habits (eating speed, mealtime regularity, consistency of food amount, and balanced eating), sleep hours per day, outdoor activity hours per day, and BMI were obtained. We performed a cluster analysis on the children's eating habits using k-means methods. We conducted ANOVA and chi-square analyses to identify differences in the children's BMI, sleep hours, physical activity, and the characteristics of their parents and family by cluster.

RESULTS

At both ages (ages 5 and 6 years), we identified 4 clusters based on the children's eating habits. Cluster 1 was characterized by a fast eating speed (fast eaters); cluster 2 by a slow eating speed (slow eaters); cluster 3 by irregular eating habits (poor eaters); and cluster 4 by a balanced diet, regular mealtimes, and consistent food amounts (healthy eaters). Slow eaters tended to have the lowest BMI (P<.001), and a low proportion had overweight and obesity at the age of 5 years (P=.03) and 1 year later (P=.005). There was a significant difference in sleep time (P=.01) and mother's education level (P=.03) at the age of 5 years. Moreover, there was a significant difference in sleep time (P=.03) and the father's education level (P=.02) at the age of 6 years.

CONCLUSIONS

Efforts to establish healthy eating habits in early childhood may contribute to the prevention of obesity in children. Specifically, providing dietary guidance on a child's eating speed can help prevent childhood obesity. This research suggests that lifestyle modification could be a viable target to decrease the risk of childhood obesity and promote the development of healthy children. Additionally, we propose that future studies examine long-term changes in obesity resulting from lifestyle modifications in children from families with low educational levels.

Development and validation of a short dietary questionnaire for assessing obesity-related dietary behaviours in young children

There are few short, validated tools to assess young children's obesity-related dietary behaviours, limiting the rapid screening of dietary behaviours in research and practice-based early obesity prevention. This study aimed to develop and assess the reliability and validity of a caregiver-reported short dietary questionnaire to rapidly assess obesity-related dietary behaviours in children aged 6 months to 5 years. The Early Prevention of Obesity in Childhood Dietary Questionnaire (EPOCH-DQ) was developed using a rigorous process to determine content and structural validity. Three age-appropriate versions were developed for (1) infants, aged 6-12 months, (2) toddlers, aged 1-2.9 years and (3) pre-schoolers, aged 3-5 years. The questionnaire (7-15 items) measures dietary behaviours, including diet risk from non-core food and beverage intake, diet quality from vegetable frequency, bread type and infant feeding practices. Test-retest reliability was assessed from repeated administrations 1 week apart (n = 126). Internal consistency, concurrent validity (against a comparison questionnaire, the InFANT Food Frequency Questionnaire), construct validity and interpretability were assessed (n = 209). Most scores were highly correlated and significantly associated (p < 0.05) for validity (rs: 0.45-0.89, percentage agreement 68%-100%) and reliability (intraclass correlation coefficient: 0.61-0.99) for diet risk, diet quality and feeding practice items. The EPOCH-DQ shows acceptable validity and reliability for screening of obesity-related behaviours of children under 5 years of age. The short length and, thus, low participant burden of the EPOCH-DQ allows for potential applications in various settings. Future testing of the EPOCH-DQ should evaluate culturally and socio-economically diverse populations and establish the predictive validity and sensitivity to detect change.

Attachment, Feeding Practices, Family Routines and Childhood Obesity: A Systematic Review of the Literature

Childhood obesity is considered a major public health problem. To help prevention and intervention programs targeting families with obese children, this paper is aimed at synthesizing multifactorial and transactional data resulting from studies and reviews assessing relational factors between the child and his or her parents and the child's obesity risk, including the child's and CG's attachment quality, parental feeding practices, and family routines. It is also aimed at assessing the mediation of these links by specific self-regulatory capacities across different developmental periods (0-2, 2-8, and 8-18 years old). The Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines were applied in the review methodology. Ten papers were analyzed, including seven empirical studies and three reviews proposing etiological models of childhood obesity. The quality of empirical studies was assessed, and a synthetical model of the results was proposed. This literature review showed that the caregiver's (CG) and the child's attachment quality, along with controlling or permissive feeding practices, and few family routines are mostly mediated by appetite dysregulation and emotional regulation strategies with the development of child obesity. New research topics are proposed to understand other facets of childhood obesity, as well as how to better prevent and treat it.

Is the cost-effectiveness of an early-childhood sleep intervention to prevent obesity affected by socioeconomic position?

OBJECTIVE

This study aimed to determine whether the cost-effectiveness of an infant sleep intervention from the Prevention of Overweight in Infancy (POI) trial was influenced by socioeconomic position (SEP).

METHODS

An SEP-specific economic evaluation of the sleep intervention was conducted. SEP-specific intervention costs and effects at age 5 years, derived from the trial data, were applied to a representative cohort of 4,898 4- to 5-year-old Australian children. Quality-adjusted life years and health care costs were simulated until age 17 years using a purpose-built SEP-specific model. Incremental cost-effectiveness ratios and acceptability curves were derived for each SEP group.

RESULTS

The incremental cost-effectiveness ratios, in Australian dollars per quality-adjusted life year gained, were smaller in the low- ($23,010) and mid-SEP ($18,206) groups compared with the high-SEP group ($31,981). The probability that the intervention was cost-effective was very high in the low- and mid-SEP groups (92%-100%) and moderately high in the high-SEP group (79%).

CONCLUSIONS

An infant sleep intervention is more cost-effective in low- and mid-SEP groups compared with high-SEP groups. Targeting this intervention to low-SEP groups would not require trade-offs between efficiency and equity.

A Critical Analysis of Representations of Inequalities in Childhood Obesity in Australian Health Policy Documents

BACKGROUND

In Australia, childhood obesity follows a socioeconomic gradient whereby children with lower socioeconomic position are disproportionately burdened. To reduce these inequalities in childhood obesity requires a multi-component policy-driven response. Action to address health issues is underpinned by the ways in which they are represented as 'problems' in public policy. This study critically examines representations of inequalities in childhood obesity within Australian health policy documents published between 2000-2019.

METHODS

Australia's federal, state and territory government health department websites were searched for health policy documents including healthy weight, obesity, healthy eating, food and nutrition strategies; child and youth health strategies; and broader health and wellbeing, prevention and health promotion policies that proposed objectives or strategies for childhood obesity prevention. Thematic analysis of eligible documents was guided by a theoretical framework informed by problematization theory, ecological systems theory, and theoretical principles for equity in health policy.

RESULTS

Eighteen policy documents were eligible for inclusion. The dominant representation of inequalities in childhood obesity was one of individual responsibility. The social determinants of inequalities in childhood obesity were acknowledged, yet policy actions predominantly focused on individual determinants. Equity was positioned as a principle of policy documents but was seldom mentioned in policy actions.

CONCLUSION

Current representations of inequalities in childhood obesity in Australian health policy documents do not adequately address the underlying causes of health inequities. In order to reduce inequalities in childhood obesity future policies will need greater focus on health equity and the social determinants of health (SDoH).

The Role of Human Milk Lipids and Lipid Metabolites in Protecting the Infant against Non-Communicable Disease

Non-communicable diseases continue to increase globally and have their origins early in life. Early life obesity tracks from childhood to adulthood, is associated with obesity, inflammation, and metabolic dysfunction, and predicts non-communicable disease risk in later life. There is mounting evidence that these factors are more prevalent in infants who are formula-fed compared to those who are breastfed. Human milk provides the infant with a complex formulation of lipids, many of which are not present in infant formula, or are present in markedly different concentrations, and the plasma lipidome of breastfed infants differs significantly from that of formula-fed infants. With this knowledge, and the knowledge that lipids have critical implications in human health, the lipid composition of human milk is a promising approach to understanding how breastfeeding protects against obesity, inflammation, and subsequent cardiovascular disease risk. Here we review bioactive human milk lipids and lipid metabolites that may play a protective role against obesity and inflammation in later life. We identify key knowledge gaps and highlight priorities for future research.

Obesity in children and adolescents: epidemiology, causes, assessment, and management

This Review describes current knowledge on the epidemiology and causes of child and adolescent obesity, considerations for assessment, and current management approaches. Before the COVID-19 pandemic, obesity prevalence in children and adolescents had plateaued in many high-income countries despite levels of severe obesity having increased. However, in low-income and middle-income countries, obesity prevalence had risen. During the pandemic, weight gain among children and adolescents has increased in several jurisdictions. Obesity is associated with cardiometabolic and psychosocial comorbidity as well as premature adult mortality. The development and perpetuation of obesity is largely explained by a bio-socioecological framework, whereby biological predisposition, socioeconomic, and environmental factors interact together to promote deposition and proliferation of adipose tissue. First-line treatment approaches include family-based behavioural obesity interventions addressing diet, physical activity, sedentary behaviours, and sleep quality, underpinned by behaviour change strategies. Evidence for intensive dietary approaches, pharmacotherapy, and metabolic and bariatric surgery as supplemental therapies are emerging; however, access to these therapies is scarce in most jurisdictions. Research is still needed to inform the personalisation of treatment approaches of obesity in children and adolescents and their translation to clinical practice.

Risk Factors for Obesity in Five-Year-Old Children: Based on Korean National Health Insurance Service (NHIS) Data

This study aimed to identify the risk factors for obesity in five-year-old children using data from the database of the Korean National Health Insurance Service. We identified 26,047 children who underwent the sixth screening (at age 5) from the 2017 National Health Screening Program for Infant and Children and for whom data from the fourth screening (at age 3) database and the mothers’ health screening and eligibility database were available. To identify the risk factors of obesity, odds ratios and 95% confidence intervals were calculated by a hierarchical multiple logistic regression. Female sex, a birth weight of over 4 kg, the “caution/refer” remark during developmental screening at ages three and five, maternal obesity, and a middle-level income were risk factors for obesity in the subjects. Good appetite, high consumption of milk, heavy intake of sweet food at age three, speedy eating, irregular meals and snack times, large single-meal quantities, heavy intake of oily and salty food, and not performing physical exercise at age five were also considered significant risk factors. For early intervention efforts to prevent childhood obesity, modifiable behavioral factors and other obesity risk factors identified in this study could be used to target high-risk children and dietary behaviors.

Evaluation of Risk Scores to Predict Pediatric Severe Asthma Exacerbations

BACKGROUND

Asthma exacerbations commonly lead to unplanned health care utilization and are costly. Early identification of children at increased risk of asthma exacerbations would allow a proactive management approach.

OBJECTIVE

We evaluated common asthma risk factors to predict the probability of exacerbation for individual children aged 0-21 years using data from the electronic medical record (EMR).

METHODS

We analyzed longitudinal EMR data for over 3000 participants with asthma seen at Cincinnati Children's Hospital Medical Center over a 7-year period. The study population was divided into 3 age groups: 0-4, 5-11, and 12-21 years. Each age group was divided into a derivation cohort and a validation cohort, which were used to build a risk score model. We predicted risk of exacerbation in the next 12 months, validated the scores by risk stratum, and developed a clinical tool to determine the risk level based on this model.

RESULTS

Risk model results were confirmed with validation cohorts by calendar year and age groups. Race, allergic sensitization, and smoke exposure were each important risk factors in the 0-4 age group. Abnormal spirometry and obesity were more sensitive predictors of exacerbation in children >12 years. For each age group, a higher expanded score was associated with a higher predicted probability of an asthma exacerbation in the subsequent year.

CONCLUSION

This asthma exacerbation prediction model, and the associated clinical tool, may assist clinicians in identifying children at high risk for exacerbation that may benefit from more aggressive management and targeted risk mitigation.

Dietary Habits and Choices of 4-to-6-Year-Olds: Do Children Have a Preference for Sweet Taste?

Children develop food preferences by coming into direct contact with various food products through the senses of taste, touch, sight and smell. The aim of this study was to analyze the food preferences of children aged 4 to 6 years and to determine whether age and gender influence children’s food preferences and whether the preference for sweet taste changes with age. The study involved a paper questionnaire containing images of 115 different food products and dishes. The respondents expressed their preferences by choosing the appropriate emoji (happy, sad or neutral face). The study was conducted between 2018 and 2020, and it involved 684 children from 10 kindergartens. Girls chose a significantly higher number of foods and dishes they liked than boys (p = 0.002), and 4-year-olds gave a higher number of “neutral” responses than 5- and 6-year-olds (p = 0.001). Dietary diversity increased with age, and younger children were familiar with fewer foods than 6-year-olds (p = 0.002). Children had a clear preference for sweet taste, regardless of age and gender. Young children (4-year-olds) were more likely to accept healthy foods despite the fact that they were familiar with fewer products and dishes.

Lessons From the Feasibility Testing of a Parent-Focused, Life Skills-Based Intervention to Prevent Obesity in Preschoolers From Underserved Families

This article describes lessons from the feasibility testing of a parent-focused, life skills-based intervention to promote healthy weight in 58 low-income children aged 2 to 5 years. This intervention was feasible and acceptable, with a potential to impact child weight and diet (calories) and parental quality of life (QOL). The group delivery approach through a partnering organization (Head Start) was a more efficient way to reach/engage parents. Compared with one-on-one sessions, the group could provide an avenue to enhance parental psychosocial well-being, given QOL improvements among parents in group sessions. Lessons will inform future research to test the effectiveness of life skills interventions.

Addressing obesity in the first 1000 days in high risk infants: Systematic review

Early intervention is critical for addressing the challenge of childhood obesity. Yet many preventive interventions do not target infants most at risk of future overweight or obesity. This systematic review examines interventions delivered before 2 years that aim to ameliorate excess weight gain among infants at high risk of overweight or obesity, due to sociodemographic characteristics, parental weight or health status, infant feeding or health behaviours. We searched six databases for interventions: (a) delivered before age two, (b) specifically aimed at infants at high risk of childhood obesity and (c) that reported outcomes by weight status beyond 28 days. The search identified over 27,000 titles, and 49 papers from 38 studies met inclusion criteria: 10 antenatal interventions, 16 postnatal and 12 conducted both before and after birth. Nearly all targeted infant and/or maternal nutrition. Studies varied widely in design, obesity risk factors, outcomes and quality. Overall, nine interventions of varying quality reported some evidence of significantly improved child weight trajectory, although effects tended to diminish over time. Interventions that improved weight outcomes tended to engage parents for a longer period, and most offered health professional input and support. Two studies of limited quality reported significantly worse weight outcomes in the intervention group.

Current Activities Centered on Healthy Living and Recommendations for the Future: A Position Statement from the HL-PIVOT Network

We continue to increase our cognizance and recognition of the importance of healthy living (HL) behaviors and HL medicine (HLM) to prevent and treat chronic disease. The continually unfolding events precipitated by the coronavirus disease 2019 (COVID-19) pandemic have further highlighted the importance of HL behaviors, as indicated by the characteristics of those who have been hospitalized and died from this viral infection. There has already been recognition that leading a healthy lifestyle, prior to the COVID-19 pandemic, may have a substantial protective effect in those who become infected with the virus. Now more than ever, HL behaviors and HLM are essential and must be promoted with a renewed vigor across the globe. In response to the rapidly evolving world since the beginning of the COVID-19 pandemic, and the clear need to change lifestyle behaviors to promote human resilience and quality of life, the HL for Pandemic Event Protection (HL-PIVOT) network was established. The 4 major areas of focus for the network are: (1) knowledge discovery and dissemination; (2) education; (3) policy; (4) implementation. This HL-PIVOT network position statement provides a current synopsis of the major focus areas of the network, including leading research in the field of HL behaviors and HLM, examples of best practices in education, policy, and implementation, and recommendations for the future.

Diabetes prevention interventions for women after gestational diabetes mellitus: an overview of reviews

Aims

To present an overview of reviews of interventions for the prevention of diabetes in women after gestational diabetes mellitus (GDM) with the overall aim of gaining information in order to establish local interventions.

Methods

Six databases were searched for quantitative, qualitative or mixed‐methods systematic reviews. All types of interventions or screening programmes were eligible. The outcomes were effectiveness of reducing diabetes incidence, encouraging healthy behavioural changes and enhancing women's perceptions of their increased risks of developing type 2 diabetes following GDM.

Results

Eighteen reviews were included: three on screening programmes and seven on participation and risk perceptions. Interventions promoting physical activity, healthy diet, breastfeeding and antidiabetic medicine reported significantly decreased incidence of postpartum diabetes, up to 34% reduction after any breastfeeding compared to none. Effects were larger if the intervention began early after birth and lasted longer. Participation in screening rose up to 40% with face‐to‐face recruitment in a GDM healthcare setting. Interventions were mainly based in healthcare settings and involved up to nine health professions, councillors and peer educators, mostly dieticians. Women reported a lack of postpartum care and demonstrated a low knowledge of risk factors for developing type 2 diabetes. Typical barriers to participation were lack of awareness of increased risk and low levels of support from family.

Conclusions

Lifestyle interventions or pharmacological treatment postpartum was effective in decreasing diabetes incidence following GDM. Women's knowledge of the risk of diabetes and importance of physical activity was insufficient. Early face‐to‐face recruitment increased participation in screening. Programmes aimed at women following a diagnosis of GDM ought to provide professional and social support, promote screening, breastfeeding, knowledge of risk factors, be long‐lasting and offered early after birth, preferably by face‐to‐face recruitment.

Introduction to complementary feeding in the first year of life and risk of overweight at 24 months of age: changes from 2004 to 2015 Pelotas (Brazil) Birth Cohorts

Complementary feeding (CF) and overweight relationships during early childhood are inconsistent in the literature. We described the association of CF during the first year of life with risk of overweight at 24 months of age in the population-based 2004 and 2015 Pelotas (Brazil) Birth Cohorts (2004c and 2015c). CF introduction was evaluated at the 3 and 12 months' follow-ups by asking mothers using a list of foods. Risk of overweight at 24 months of age was BMI-for-age z-score above +1sd from the median of the WHO 2006 growth standards. Our analyses included 3823 (2004c) and 3689 (2015c) children. Early introduction CF (before 6 months of age) prevalence in 2004c was 93·3 (95 % CI 92·5, 94·1) % and in 2015c was 87·2 (95 % CI 86·1, 88·2) %. Tea was the item introduced earlier in both 2004c (68·8 %) and 2015c (55·7 %). At 6 months of age, vegetable mash was the most introduced food in 2004c (33·5 %) and 2015c (47·9 %). Between 2004c and 2015c, the introduction of fresh milk decreased 82·1 to 60·5 % and yogurt from 94·4 to 78·1 % during the first year. Risk of overweight prevalence at 24 months was 33·0 (95 % CI 31·6, 34·5) % in 2004c and 32·0 (95 % CI 30·5, 33·5) % in 2015c. In 2015c, the adjusted odds of risk of overweight at 24 months were increased 1·66 and 1·50 times with the early introduction of fresh/powdered milk: plus water, tea or juice, and plus semi-solid/solid food groups, respectively. It is essential to reinforce the adherence to global recommendations on timely feeding introduction and encourage exclusive breast-feeding until 6 months of age to prevent child overweight.

Grow well/Crecer bien: a protocol for research on infant feeding practices in low-income families

BACKGROUND

The prevalence of obesity among children remains high. Given obesity's significant lifelong consequences, there is great interest in preventing obesity early in life. There is a need to better understand the relation of common infant feeding styles and practices to obesity in infants using longitudinal study designs. There is also an urgent need to understand the role of caregivers other than mothers in feeding. A better understanding of variation in feeding styles and practices can inform the identification of risk groups and the tailoring of interventions to them.

METHODS

In partnership with Early Head Start programs across four counties in southern California, mothers and infants will be enrolled in a two-year longitudinal study collecting survey and anthropometric data. A subsample of mothers and their selected other caregivers will participate in qualitative research involving feeding diaries and dyadic interviews. The results will be used to develop and test an enhanced nutrition education program.

DISCUSSION

We outline a study methodology to examine feeding styles and practices and their association with early childhood obesity risk and enhance an existing intervention to promote healthy infant feeding and growth among children in low-income families.

Neighbourhood greenspace influences on childhood obesity in Sheffield, UK

BACKGROUND

One cause of childhood obesity is a reduction in the amount of unstructured time spent outdoors, resulting in less physical activity. Greenspaces have the potential to increase children's physical activity levels, so it is desirable to understand how to create spaces that promote visitation and activity.

OBJECTIVES

We investigate the relationship between rates of obesity at ages 4 to 5 and 10 to 11 in small-area census geographies, and indicators of the neighbourhood greenspace environment, in the northern English city of Sheffield.

METHODS

To capture the environment at scales relevant to children, we test the importance of overall green cover; garden size; tree density around residential addresses; and accessibility within 300 m of any greenspace, greenspaces that meet quality criteria, and greenspaces with play facilities. We use a multimodel inference approach to improve robustness.

RESULTS

The density of trees around addresses is significant at both ages, indicating the importance of the greenspace environment in the immediate vicinity of houses. For 10 to 11 year olds, accessibility of greenspaces meeting quality criteria is also significant, highlighting that the wider environment becomes important with age and independence.

CONCLUSIONS

More attention should be given to children's requirements of greenspace when considering interventions to increase physical activity or planning new residential areas.

Update on childhood/adolescent obesity and its sequela

PURPOSE OF REVIEW

We aim to describe current concepts on childhood and adolescent obesity with a strong focus on its sequela. Childhood obesity is a national epidemic with increasing prevalence over the past three decades placing children at increased risk for many serious comorbidities, previously felt to be only adult-specific diseases, making this topic both timely and relevant for general pediatricians as well as for subspecialists.

RECENT FINDINGS

Childhood obesity develops through an interplay of genetics, environment, and behavior. Treatment includes lifestyle modification, and now metabolic and bariatric surgery is more commonly considered in carefully selected adolescents. The off-label use of adjunct medications for weight loss in childhood and adolescent obesity is still in its infancy, but will likely become the next logical step in those with lifestyle modification refractory obesity. Obesity can lead to several comorbidities, which can persist into adulthood potentially shortening the child's lifespan.

SUMMARY

Efforts should be focused primarily on reducing childhood and adolescent obesity, and when indicated treating its sequela in effort to reduce future morbidity and mortality in this precious population. VIDEO ABSTRACT: http://links.lww.com/MOP/A36.

Early mother-child dyadic pathways to childhood obesity risk: A conceptual model

Understanding the emotional quality of the mother-child dyadic relationship and parent-child feeding interactions may further clarify early developmental pathways to eating behaviours and obesity risk. The quality of parent-child relationships fosters all aspects of child development but has not yet been extensively examined in relation to childhood weight gain. The aim of this paper is to propose a conceptual model, which outlines early mother-child dyadic pathways linking parent-child feeding interactions to child body mass index, where parent-child relationships have a central role. It maps out individual and dyadic mother-child factors (i.e., attachment, child temperament and maternal mental health) that influence the nature and quality of parent-child feeding interactions from infancy to toddlerhood. Our model bridges the gap between research fields by bringing together key maternal and child factors implicated in child development. Understanding early parent-child feeding interactional patterns and their influence on child self-regulation and eating behaviours may be relevant to multidisciplinary approaches toward preventing childhood obesity. High quality quantitative and observational data capturing meaningful parent, child and dyadic level interactions around food contexts, attachment security, maternal mental health, child temperament and self-regulation will help to inform new, aetiologically important, targets for preventative intervention.

The Early Introduction of Complementary (Solid) Foods: A Prospective Cohort Study of Infants in Chengdu, China

The objective of this study was to document the types of foods introduced to infants before six months of age and identify factors associated with their early introduction. A prospective cohort study of infant feeding for the first six months after birth was undertaken in the city of Chengdu, PR China. The participants were 845 mothers who delivered their infants in hospitals in Chengdu. Mothers were interviewed within 15 days of giving birth and were followed up with for six months. The outcome measures were the introduction of complementary foods to infants within four and six months postpartum. Complementary foods are defined as any food, whether manufactured or locally prepared, used as a complement to breast milk or infant formula. In this study the emphasis was on solids and not liquid foods. More than 94% of the infants were given complementary foods (semi-solid or solid foods) before the age of six months and 10% by four months. The most commonly introduced food was infant cereal, which was given to three quarters of the infants by six months. Multivariate analysis showed that maternal education level was a significant factor affecting the introduction of complementary foods before four months, adjusted odds ratio 2.983 (1.232–7.219), with the more educated mothers introducing complementary foods earlier. More antenatal and postnatal health promotion efforts are required to highlight the benefits of introducing solid foods later than is the current practice in Chengdu, at or close to six months of age. Further education is also required for training health professionals including pediatricians, midwives, and community health staff.