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Krupsky KL, Zvara BJ, Khalsa AS, Andridge R, Keim SA, Anderson SE. Household chaos, child temperament, and structure-related feeding practices in toddlerhood: A moderation analysis. Eat Behav 2024; 52:101838. [PMID: 38048650 PMCID: PMC11037389 DOI: 10.1016/j.eatbeh.2023.101838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 10/30/2023] [Accepted: 11/28/2023] [Indexed: 12/06/2023]
Abstract
Structure-related feeding practices may promote intuitive child eating behaviors and foster responsiveness to internal cues of hunger and satiety. Caregivers' ability to engage in structure-related feeding practices likely depends on a complex ecology of factors, including household- and child-characteristics. This study examined associations between household chaos and structure-related feeding practices, and the moderating effect of child temperament. Data were from 275 caregiver-toddler dyads from central Ohio. Child temperament was reported by caregivers when children were 18 months of age, whereas household chaos and structure-related feeding practices were reported by caregivers when children were 36 months of age. Multivariable linear regression models were constructed to assess the relationship between chaos and structure-related feeding practices. Interaction terms between household chaos and three dimensions of child temperament were tested to determine whether temperament moderated the relationship between chaos and structure-related feeding practices. Household chaos was not independently associated with structure-related feeding practices, but higher levels of child effortful control were associated with greater mealtime structure. There was a statistically significant interaction between household chaos and child temperamental surgency, such that greater levels of chaos were associated with less structured mealtimes, but only when children had low-surgency. Findings suggest household chaos and child temperament inform caregiver feeding practices, but the influence of chaos may depend on more proximal factors, like child temperament. Recommendations to improve caregiver-child feeding interactions should be sensitive to characteristics of the broader family home environment.
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Affiliation(s)
- Kathryn L Krupsky
- Division of Epidemiology, College of Public Health, The Ohio State University, 336 Cunz Hall, 1841 Neil Ave, Columbus, OH 43210, USA.
| | - Bharathi J Zvara
- Department of Maternal and Child Health, Gillings School of Public Health, University of North Carolina at Chapel Hill, 135 Dauer Dr., Chapel Hill, NC 27599, USA.
| | - Amrik Singh Khalsa
- Division of Primary Care Pediatrics, Center for Child Health Equity and Outcomes Research, Nationwide Children's Hospital, 700 Children's Dr., Columbus, OH, USA; Department of Pediatrics, College of Medicine, Ohio State University, Columbus, OH, USA.
| | - Rebecca Andridge
- Division of Biostatistics, College of Public Health, The Ohio State University, 1841 Neil Ave, Columbus, OH 43210, USA.
| | - Sarah A Keim
- Division of Epidemiology, College of Public Health, The Ohio State University, 336 Cunz Hall, 1841 Neil Ave, Columbus, OH 43210, USA; Department of Pediatrics, College of Medicine, Ohio State University, Columbus, OH, USA; Center for Biobehavioral Health, Abigail Wexner Research Institute at Nationwide Children's Hospital, 700 Children's Dr. NEOB 3rd Floor, Columbus, OH 43205, USA.
| | - Sarah E Anderson
- Division of Epidemiology, College of Public Health, The Ohio State University, 336 Cunz Hall, 1841 Neil Ave, Columbus, OH 43210, USA.
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Hill EB, Chen L, Bailey MT, Singh Khalsa A, Maltz R, Kelleher K, Spees CK, Zhu J, Loman BR. Facilitating a high-quality dietary pattern induces shared microbial responses linking diet quality, blood pressure, and microbial sterol metabolism in caregiver-child dyads. Gut Microbes 2022; 14:2150502. [PMID: 36457073 PMCID: PMC9721422 DOI: 10.1080/19490976.2022.2150502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Low-resource individuals are at increased risk of obesity and cardiovascular disease (CVD), partially attributable to poor dietary patterns and dysfunctional microbiota. Dietary patterns in childhood play critical roles in physiological development and are shaped by caregivers, making caregiver-child dyads attractive targets for dietary interventions to reduce metabolic disease risk. Herein, we targeted low-resource caregiver-child dyads for a 10-week, randomized, controlled, multifaceted lifestyle intervention including: nutrition and physical activity education, produce harvesting, cooking demonstrations, nutrition counseling, and kinetic activites; to evaluate its effects on dietary patterns, CVD risk factors, and microbiome composition. Subjects in the lifestyle intervention group improved total diet quality, increased whole grain intake, decreased energy intake, and enhanced fecal elimination of the microbe-derived metabolite lithocholic acid (LCA) in contrast to control subjects. Microbiomes were highly personalized, similar within dyads, and altered by lifestyle intervention. Differential modeling of microbiome composition identified taxa associated with total diet quality, whole grain intake, and LCA elimination including recognized fiber-degrading bacteria such as Subdoligranulum, and bile acid metabolizing organisms like Bifidobacterium. Inclusion of taxa identified in diet and metabolite modeling within blood pressure models improved prediction accuracy of microbiome-blood pressure associations. Importantly, microbiota-blood pressure relationships were shared between dyads, implying shared host-microbiota responses to lifestyle intervention. Overall, these outcomes provide insight into mechanisms by which dietary interventions impact the gut-cardiovascular axis to reduce future CVD risk. Registered at clinicaltrials.gov: NCT05367674.
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Affiliation(s)
- Emily B. Hill
- Department of Pediatrics, Section of Nutrition, University of Colorado Anschutz Medical Campus, School of Medicine, Aurora, CO, USA
| | - Li Chen
- Department of Human Sciences and James Comprehensive Cancer Center, College of Education and Human Ecology, The Ohio State University, Columbus, OH, USA
| | - Michael T. Bailey
- Center for Microbial Pathogenesis, Abigail Wexner Research Institute at Nationwide Children’s Hospital, Columbus, OH, USA,Division of Primary Care Pediatrics, Center for Child Health Equity and Outcomes Research, The Abigail Wexner Research Institute, Nationwide Children’s Hospital, Columbus, OH, USA,Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Amrik Singh Khalsa
- Division of Primary Care Pediatrics, Center for Child Health Equity and Outcomes Research, The Abigail Wexner Research Institute, Nationwide Children’s Hospital, Columbus, OH, USA,Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Ross Maltz
- Department of Pediatric Gastroenterology, Hepatology, and Nutrition, The Abigail Wexner Research Institute, Nationwide Children’s Hospital, Columbus, OH, USA
| | - Kelly Kelleher
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Colleen K. Spees
- Division of Medical Dietetics, School of Health and Rehabilitation Sciences, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Jiangjiang Zhu
- Department of Human Sciences and James Comprehensive Cancer Center, College of Education and Human Ecology, The Ohio State University, Columbus, OH, USA
| | - Brett R. Loman
- Department of Animal Sciences, the University of Illinois at Urbana-Champaign, Urbana, IL, USA,Division of Nutritional Sciences, the University of Illinois at Urbana-Champaign, Urbana, IL, USA,CONTACT Brett R. Loman Department of Animal Sciences, University of Illinois at Urbana-Champaign, 1207 W Gregory Drive, Urbana, IL61801, USA
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Khalsa AS, Burton J, Bailey MT, Zhu J, Kelleher KJ, Maltz RM, Loman BR, Spees CK. Collection of biospecimens from parent-child dyads in a community garden-based nutrition intervention: protocol and feasibility. BMC Nutr 2022; 8:141. [PMID: 36471397 PMCID: PMC9720919 DOI: 10.1186/s40795-022-00640-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Accepted: 11/18/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Non-invasive human biospecimens, including stool, urine, and hair, are important in understanding the relationship between diet and changes in human physiologic processes that affect chronic disease outcomes. However, biospecimen collection can be difficult when collecting samples for research studies that occur away from a centralized location. We describe the protocol and feasibility in collecting stool, urine, and hair biospecimens from parents and their children at a remote location as a part of a summer community garden-based intervention. METHODS Stool, urine, and hair were collected as a part of the Summer Harvest Adventure (SHA) study, a randomized controlled, community garden-based intervention targeting children (ages 8-11 years) and their parents from low-resource neighborhoods. Biospecimens were collected from willing children and/or their parent/adult caregivers at baseline and post-intervention for evaluation of microbiome, metabolomics, and hair analyses among both intervention and control groups at a location distant from the academic laboratories conducting the analysis. The protocol used to assemble, deliver, collect, and process biospecimens are presented along with the frequencies with which specimens were successfully obtained. RESULTS One hundred forty six participants (73 parent-child dyads) were part of the larger SHA study and thus eligible to provide a biospecimen. A total of 126 participants, 115 participants, and 127 participants consented to provide their hair, stool and urine samples, respectively. Of the participants that consented to provide a sample, 44 children (69.8%) and 38 parents (60.3%) provided at least one hair sample, 27 children (48.2%) and 37 parents (62.7%) provided at least one stool sample, and 36 children (57.1%) and 42 parents (65.6%) provided at least one urine sample. Sample collection at the offsite location, transport, and handling at the academic center were successful and all biospecimens were deemed adequate for analyses. DNA and metabolomics yield on a subset of stool samples obtained provided excellent results in terms of an abundance of species and metabolities, as would be predicted. Urine and hair analyses are underway. CONCLUSION Our work is one of the first to describe the feasibility of collecting human biospecimens, specifically stool, urine, and hair, from both parents and their children from low-resourced neighborhoods in a non-traditional garden research setting. Future work will report findings related to mechanisms between diet, microbiome, metabolites, and clinical outcomes.
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Affiliation(s)
- Amrik Singh Khalsa
- grid.240344.50000 0004 0392 3476Primary Care Pediatrics, Nationwide Children’s Hospital, 700 Children’s Dr, Columbus, OH 43205 USA ,grid.240344.50000 0004 0392 3476Center for Child Health Equity and Outcomes Research, Abigail Wexner Research Institute, Nationwide Children’s Hospital, 700 Children’s Dr, Columbus, OH 43205 United States ,grid.261331.40000 0001 2285 7943Department of Pediatrics, College of Medicine, The Ohio State University, Columbus, OH 43210 USA
| | - Jonathan Burton
- grid.20627.310000 0001 0668 7841Heritage College of Osteopathic Medicine, Ohio University, Dublin, OH 43016 USA
| | - Michael T. Bailey
- grid.261331.40000 0001 2285 7943Department of Pediatrics, College of Medicine, The Ohio State University, Columbus, OH 43210 USA ,grid.240344.50000 0004 0392 3476Center for Microbial Pathogenesis, Nationwide Children’s Hospital, Columbus, OH 43205 USA ,grid.240344.50000 0004 0392 3476Oral and Gastrointestinal Microbiology Research Affinity Group, Abigail Wexner Research Institute at Nationwide Children’s Hospital, Columbus, OH 43205 USA
| | - Jiangjiang Zhu
- grid.261331.40000 0001 2285 7943College of Education and Human Ecology, Department of Human Sciences, The Ohio State University, Columbus, OH 43210 USA ,grid.261331.40000 0001 2285 7943James Comprehensive Cancer Center, The Ohio State University, Columbus, OH 43210 USA
| | - Kelly J. Kelleher
- grid.240344.50000 0004 0392 3476Center for Child Health Equity and Outcomes Research, Abigail Wexner Research Institute, Nationwide Children’s Hospital, 700 Children’s Dr, Columbus, OH 43205 United States ,grid.261331.40000 0001 2285 7943Department of Pediatrics, College of Medicine, The Ohio State University, Columbus, OH 43210 USA
| | - Ross M. Maltz
- grid.261331.40000 0001 2285 7943Department of Pediatrics, College of Medicine, The Ohio State University, Columbus, OH 43210 USA ,grid.240344.50000 0004 0392 3476Center for Microbial Pathogenesis, Nationwide Children’s Hospital, Columbus, OH 43205 USA ,grid.240344.50000 0004 0392 3476Oral and Gastrointestinal Microbiology Research Affinity Group, Abigail Wexner Research Institute at Nationwide Children’s Hospital, Columbus, OH 43205 USA ,grid.240344.50000 0004 0392 3476Division of Pediatric Gastroenterology, Hepatology and Nutrition, Nationwide Children’s Hospital, Columbus, OH 43205 USA
| | - Brett R. Loman
- grid.35403.310000 0004 1936 9991Department of Animal Sciences, University of Illinois at Urbana-Champaign, Urbana, IL 61801 USA ,grid.35403.310000 0004 1936 9991Division of Nutritional Sciences, University of Illinois at Urbana-Champaign, Urbana, IL 61801 USA
| | - Colleen K. Spees
- grid.261331.40000 0001 2285 7943Division of Medical Dietetics, College of Medicine, The Ohio State University, Columbus, OH 43210 USA
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Khalsa AS, Copeland KA, Kharofa RY, Geraghty SR, Dewitt TG, Woo JG. The Longitudinal Relation between Infant Feeding Styles and Growth Trajectories among Families from Low-Income Households. J Nutr 2022; 152:2015-2022. [PMID: 35641195 DOI: 10.1093/jn/nxac123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 04/11/2022] [Accepted: 05/24/2022] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Parental feeding styles, including the emotional environment parents create to modify a child's eating behaviors, have been associated with measures of adiposity in cross-sectional studies. The longitudinal relation between parental feeding styles in early infancy and adiposity in later infancy/toddlerhood are scant and have shown mixed results, particularly in families from low-income households. OBJECTIVES This study examined the relation between parental feeding styles and infant BMI z-score trajectories between 6 and 18 mo in families from low-income households. METHODS Parent-infant dyads were recruited during the infant's 6-, 9-, or 12-mo well-child visit. Feeding styles were assessed using the Infant Feeding Style Questionnaire (IFSQ). Infant anthropometrics from birth through 18 mo were extracted from the electronic medical record. BMI z-score slopes were estimated for each infant between 0-6 mo and 6-18 mo. Associations between feeding styles and BMI z-score slopes were examined using mixed models controlling for demographic, clinical, and feeding covariates. RESULTS The final analytic sample included 198 dyads (69% Black; median infant age: 9.0 mo; IQR: 6.8-10.3 mo). The predominant parent feeding styles included the following: laissez-faire (30%), restrictive (28%), responsive (23%), and pressuring (19%). In adjusted models, the predominant feeding style at enrollment was associated with the BMI z-score slope between 6 and 18 mo, with the responsive feeding style exhibiting a steeper increase in BMI z-score than other feeding styles. Infant feeding style was not associated with BMI z-score slope between birth and 6 mo of age. Infants of parents who exhibited restrictive feeding styles were more likely to have a BMI ≥85th percentile at their last measurement. CONCLUSIONS The predominant parent feeding style during infancy in a low-income population was associated with infant BMI z-score between 6 and 18 mo of age, but not earlier. Further studies are needed to better understand how predictive factors collectively contribute to BMI increase in the first 2 y.
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Affiliation(s)
- Amrik Singh Khalsa
- Division of General and Community Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH.,Division of Primary Care Pediatrics and Center for Child Health Equity and Outcomes Research, Nationwide Children's Hospital, Columbus, OH.,Department of Pediatrics, College of Medicine, The Ohio State University, Columbus, OH
| | - Kristen A Copeland
- Division of General and Community Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Roohi Y Kharofa
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH.,Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Sheela R Geraghty
- Division of General and Community Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Thomas G Dewitt
- Division of General and Community Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Jessica G Woo
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH.,Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
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Khalsa AS, Li R, Rausch J, Klebanoff MA, Ingol TT, Boone KM, Keim SA. Early childhood growth trajectories in a Medicaid population. Pediatr Obes 2022; 17:e12918. [PMID: 35307980 PMCID: PMC9357091 DOI: 10.1111/ijpo.12918] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 02/07/2022] [Accepted: 02/28/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Evidence on the role of early growth trajectories and later obesity risk is primarily based on privately insured or universally insured samples. OBJECTIVES We aimed to characterize and determine factors associated with early growth trajectories and estimate associations with overweight/obesity risk in a Medicaid-insured and uninsured cohort. METHODS Infants seen at a large pediatric academic centre in 2010-2016 were included. Weight and length/height measurements were converted to age and sex-specific BMI z-scores (BMIz) based on the World Health Organization (WHO) Growth Standards. Group-based trajectories were modelled using BMIz created groups. Logistic and log-binomial regression models estimated associations between membership in trajectories and maternal/child factors and overweight or obesity at 36, 48, and 60 months, separately. Analyses were performed between 2019 and 2021. RESULTS The best-fitting model identified five BMIz trajectories among 30 189 children and 310 113 clinical encounters; two trajectories showed rapid rise in BMIz. Lower maternal education, pre-pregnancy maternal overweight/obese status, and maternal smoking were positively associated with both rapid-rising BMIz trajectories. Children in either of the two rapid-rising trajectories were 3.00 (95% CI: 2.85, 3.25), 2.97 (95% CI: 2.77, 3.18) and 2.76 (95% CI: 2.53, 3.01) times more likely to have overweight or obesity at 36, 48, and 60 months, respectively compared to children in the stable trajectory groups. CONCLUSIONS Among Medicaid insured and uninsured children, several maternal and child characteristics were associated with early rapid-rise in BMIz. Clinical monitoring of early rapidly rising BMI may be important to address modifiable risk factors for obesity in families from low-income households.
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Affiliation(s)
- Amrik Singh Khalsa
- Division of Primary Care Pediatrics, Nationwide Children’s Hospital 700 Children’s Drive Columbus, OH 43205
- Center for Child Health Equity and Outcomes Research, The Abigail Wexner Research Institute, Nationwide Children’s Hospital 700 Children’s Drive, Columbus, OH 43205
- Department of Pediatrics, College of Medicine, The Ohio State University 370 W. 9th Ave. Columbus, OH 43210
| | - Rui Li
- Department of Hematology, James Cancer Hospital & Solove Research Institute, The Ohio State University Wexner Medical Center 460 W 10th Ave, Columbus, OH 43210
| | - Joseph Rausch
- Department of Pediatrics, College of Medicine, The Ohio State University 370 W. 9th Ave. Columbus, OH 43210
- Center for Biobehavioral Health, The Abigail Wexner Research Institute, Nationwide Children’s Hospital 700 Children’s Drive Columbus, OH 43205
| | - Mark A. Klebanoff
- Department of Pediatrics, College of Medicine, The Ohio State University 370 W. 9th Ave. Columbus, OH 43210
- Center for Perinatal Research, The Abigail Wexner Research Institute, Nationwide Children’s Hospital 700 Children’s Drive Columbus, OH 43205
- Division of Epidemiology, College of Public Health, The Ohio State University 370 W. 9 Ave. Columbus, OH 43210
| | - Taniqua T. Ingol
- Division of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 135 Dauer Drive, Chapel Hill, NC 27599
| | - Kelly M. Boone
- Center for Biobehavioral Health, The Abigail Wexner Research Institute, Nationwide Children’s Hospital 700 Children’s Drive Columbus, OH 43205
| | - Sarah A. Keim
- Department of Pediatrics, College of Medicine, The Ohio State University 370 W. 9th Ave. Columbus, OH 43210
- Center for Biobehavioral Health, The Abigail Wexner Research Institute, Nationwide Children’s Hospital 700 Children’s Drive Columbus, OH 43205
- Division of Epidemiology, College of Public Health, The Ohio State University 370 W. 9 Ave. Columbus, OH 43210
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Khalsa AS, Weber ZA, Zvara BJ, Keim SA, Andridge R, Anderson SE. Factors associated with parenting stress in parents of 18-month-old children: Parenting stress in parents of toddlers. Child Care Health Dev 2022; 48:521-530. [PMID: 34978103 PMCID: PMC9203946 DOI: 10.1111/cch.12954] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 12/01/2021] [Accepted: 12/20/2021] [Indexed: 01/26/2023]
Abstract
AIM Parenting stress is associated with less optimal outcomes for children. Risk factors contributing to parenting stress in healthy toddlers have received little empirical attention. This study sought to determine the factors that are associated with parenting stress in parents of 18-month-old children. METHODS We analysed cross-sectional survey data from a prospective cohort study focused on parent-child mealtime interactions. Families with an 18-month-old child were recruited in Columbus, Ohio, USA, between December 2017 and May 2019. Adjusted stepwise linear regression models estimated associations between child factors (e.g., temperament), parental factors (e.g., depressive symptoms), quality of romantic relationship factors (e.g., adult attachment style) and home environment factors (e.g., household income) and parenting stress (Parental Distress subscale of the Parenting Stress Index-4 Short Form). RESULTS The 299 children included 129 (43%) females. Parents were on average 30.6 (SD 6.1) years old and included a diverse racial/ethnic cohort. Mean Parental Distress score was 24.3 (SD 6.8; score range 12-60). Higher Parental Distress scores were associated with greater parental depressive symptoms (B = 5.1 [95% CI: 2.4, 7.7]) and avoidant (B = 2.8 [95% CI: 0.9, 4.6]) attachment style. Other child, parental and home environment factors did not demonstrate statistically significant relationships with parental distress in the final model. CONCLUSION Our findings align with recommendations for paediatric providers to screen for parenting stress and mental health.
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Affiliation(s)
- Amrik Singh Khalsa
- Division of Primary Care Pediatrics, Center for Child Health Equity and Outcomes Research, Nationwide Children’s Hospital 700 Children’s Drive Columbus, OH 43205,Department of Pediatrics, College of Medicine, The Ohio State University 370 W. 9th Ave. Columbus, OH 43210
| | - Zachary A. Weber
- Division of Epidemiology, College of Public Health, The Ohio State University 1841 Neil Ave. Columbus, OH 43210
| | - Bharathi J. Zvara
- Department of Maternal and Child Health, Gillings School of Global Public Health, The University of North Carolina 421C Rosenau Hall, Chapel Hill, NC 27599
| | - Sarah A. Keim
- Department of Pediatrics, College of Medicine, The Ohio State University 370 W. 9th Ave. Columbus, OH 43210,Division of Epidemiology, College of Public Health, The Ohio State University 1841 Neil Ave. Columbus, OH 43210,Center for Biobehavioral Health, The Abigail Wexner Research Institute, Nationwide Children’s Hospital 700 Children’s Drive Columbus, OH 43205
| | - Rebecca Andridge
- Division of Biostatistics, College of Public Health, The Ohio State University 1841 Neil Ave, Columbus, OH 43210
| | - Sarah E. Anderson
- Division of Epidemiology, College of Public Health, The Ohio State University 1841 Neil Ave. Columbus, OH 43210
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Kharofa RY, Khalsa AS, Copeland KA. Is Parent Readiness to Change Predictive of Follow-through with Diet and Activity Modifications in Children? J Health Care Poor Underserved 2021; 32:2181-2190. [PMID: 34803067 DOI: 10.1353/hpu.2021.0190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Assessing parental readiness to change their child's lifestyle behaviors can be used as a guide for counseling during well-child appointments. The aim of our study was to determine if parental readiness to change pre-visit was associated with plan adherence post-visit in a predominantly low-income population. Parents (n=178) self-identified readiness to change on a Likert scale and subsequently received counseling. Multivariate logistic regression was used to evaluate associations between readiness to change and plan adherence. There was no association between readiness to change and self-reported follow-through with nutrition plans (AOR at 3 months: 1.5 [0.52; 4.18]; p=.5). The ready-to-change group reported higher, albeit non-significant, follow-through with activity plans at three months (AOR 3.6 [0.82; 15.96]; p=.09). Providers should engage all parent/child dyads in behavior modification for nutrition and activity regardless of parents' pre-visit readiness to change.
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Loman B, Hill E, Bailey M, Zhu J, Khalsa AS, Kelleher K, Spees C. A High-Fiber Diet Intervention Improves Diet Quality and Is Related to Blood Pressure and Bacteriome Composition in Caregiver-Child Dyads. Curr Dev Nutr 2021. [DOI: 10.1093/cdn/nzab054_023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Objectives
High-fiber dietary patterns are associated with cardiovascular health and intestinal microbiome composition. Caregivers influence diets of children, affecting dyadic health and microbiomes. The objectives of this study were to evaluate the relationship between changes in caregiver diet quality and caregiver and child: 1) systolic blood pressure (SBP) and 2) fecal bacteriome composition.
Methods
Caregiver-child (age 8–9 years) dyads were randomized to either a 10-week high-fiber diet intervention (fruits, vegetables, and whole grains) or control. Caregiver diet quality (30-day FFQs and Healthy Eating Index (HEI)), and caregiver and child SBP and fecal samples were collected pre- and post-intervention. Fecal bacteriomes were analyzed via 16S rRNA gene amplicon sequencing. HEI and SBP were tested via 2-way ANOVA. Bacteriome differentials (i.e., ratio of amplicon sequence variants (ASVs) with related relative abundances) associated with HEI were identified via Songbird and Qurro. Caregiver HEI was used to guide differential assembly in caregiver bacteriomes and as a proxy for child diet quality to guide differential assembly in child bacteriomes. Pearson correlations assessed inter-data relationships.
Results
Complete data were collected from 19 caregivers and 16 children. Intervention caregivers increased total (T) HEI (+4.4 vs − 1.7 points, P = 0.047) and whole grain (WG) HEI component scores (+1.7 vs 0 points, P = 0.014) compared to control. WG-HEI was correlated with caregiver SBP (r = −0.37, P = 0.046). T-HEI was correlated with caregiver and child T-HEI bacteriome differentials (r = 0.36, P = 0.027 and r = 0.57, P = 0.001). WG-HEI correlated with caregiver and child WG-HEI bacteriome differentials (r = 0.45, P = 0.013 and r = 0.60, P < 0.001). Child WG-HEI differential correlated with child SBP (r = −0.46, P = 0.01). Five ASVs were shared between caregiver and child T-HEI bacteriome differentials, implying shared bacterial responses to intervention.
Conclusions
A high-fiber dietary intervention positively impacts diet quality and is related to changes in SBP and bacteriome composition in caregiver-child dyads. Metabolites derived from bacterial metabolism of dietary fiber should be investigated for their role in blood pressure.
Funding Sources
USDA NIFA, Nationwide Children's Hospital.
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Affiliation(s)
- Brett Loman
- The Research Institute at Nationwide Children's Hospital
| | | | - Michael Bailey
- The Research Institute at Nationwide Children's Hospital
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Kharofa RY, Khalsa AS, Zeller MH, Modi AC, Ollberding NJ, Copeland KA. Giving "prescriptions" for paediatric weight management follow-up in primary care. Clin Obes 2021; 11:e12448. [PMID: 33733574 DOI: 10.1111/cob.12448] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Revised: 02/04/2021] [Accepted: 02/12/2021] [Indexed: 12/01/2022]
Abstract
The American Academy of Paediatrics recommends that primary care paediatricians "prescribe" follow-up for weight management between well child checks. We sought to describe rates and predictors of prescribed and actual clinic attendance for weight management in primary care in a predominantly low-income population. A chart review was performed at a large, hospital-based, primary care clinic, where a treatment algorithm for obesity exists. Eligible children were 6 to 12 years of age with a body mass index (BMI) ≥85th percentile and seen for a well child check in 2014. Primary outcomes were the physician prescribing follow-up in primary care and the patient returning for weight management. Multivariable logistic regression was used to identify predictors of prescribing follow-up and predictors of return. Participants included 1339 patients: mean age 9 years (SD: 1.8 years); 53% female; 79% Black; 89% Medicaid-insured; 56% with an obese BMI (vs overweight). Twenty-seven percent of patients were prescribed follow-up in primary care, of which 13% returned (only 4% of the original sample). The odds of the physician prescribing follow-up were greater if the child had obesity (vs overweight), was older, female or non-Medicaid insured. Older and non-Black patients had greater odds of returning. Patients prescribed follow-up within 2 months or less (vs 3-6 months) were also more likely to return (aOR 2.66; CI: 1.34, 5.26). Rates of prescription for weight management in primary care are low and few patients return, even when follow-up is prescribed. Prescribing follow-up at shorter intervals from the index visit (≤ 2 months) may improve patient return.
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Affiliation(s)
- Roohi Y Kharofa
- Centre for Better Health and Nutrition, The Heart Institute, Cincinnati Children's Hospital Medical Centre, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Amrik Singh Khalsa
- Division of Primary Care Pediatrics, Nationwide Children's Hospital, Columbus, Ohio, USA
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Meg H Zeller
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- Centre for Child Behavior and Nutrition Research and Training, Cincinnati Children's Hospital Medical Centre, Cincinnati, Ohio, USA
| | - Avani C Modi
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- Centre for Adherence and Self-Management, Cincinnati Children's Hospital Medical Centre, Cincinnati, Ohio, USA
| | - Nicholas J Ollberding
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Centre, Cincinnati, Ohio, USA
| | - Kristen A Copeland
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- Division of General and Community Pediatrics, Cincinnati Children's Hospital Medical Centre, Cincinnati, Ohio, USA
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10
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Odar Stough C, Garr K, Singh Khalsa A, Combs A, Copeland KA. Longitudinal examination of weight-for-length and developmental screening results in infancy and toddlerhood. Children's Health Care 2020. [DOI: 10.1080/02739615.2020.1848569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
| | - Katlyn Garr
- Department of Psychology, University of Cincinnati, Cincinnati, OH, USA
| | - Amrik Singh Khalsa
- Division of Primary Care Pediatrics, Nationwide Children’s Hospital, Columbus, OH, USA
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Angela Combs
- Department of Psychology, University of Cincinnati, Cincinnati, OH, USA
| | - Kristen A. Copeland
- Division of General and Community Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
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Khalsa AS, Copeland KA, Misik L, Brown CL, Kharofa RY, Ollberding NJ. Maternal Body Dissatisfaction and Accuracy of Infant Weight Perception in Families From Low-Income Backgrounds. Acad Pediatr 2020; 20:793-800. [PMID: 32247669 DOI: 10.1016/j.acap.2020.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Accepted: 03/22/2020] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To examine the association between maternal body dissatisfaction and mother's (mis)perception of their infant's weight classification among families from low-income households. METHODS Mother-infant dyads were recruited during well-child visits from 2 urban primary care clinics. Maternal body dissatisfaction was measured using the Stunkard Figure Rating Scale. Perception of infant weight was assessed using a 5-point Likert scale. Infant weight-for-length percentiles were calculated using World Health Organization growth charts. Associations between maternal body dissatisfaction score and mother's (mis)perception of their infant's weight classification were examined using logistic regression allowing for nonlinear associations via restricted cubic splines. RESULTS Mothers (n = 180) were 26.6 ± 5.1 years old and 72% Black; infants were 8.8 ± 2.1 months old. Mean infant weight-for-length percentile was 64 ± 26. On average, mothers wanted to be one body figure smaller than their perceived current body size. Most mothers (82%) accurately perceived their infant's weight classification while few overestimated (7%) or underestimated (11%) their child's weight category. The probability of mothers misperceiving their infant's weight classification increased as maternal body dissatisfaction increased in either extreme in unadjusted (P < .05) and adjusted analysis (P = .06). CONCLUSIONS Increased maternal body dissatisfaction may be associated with mother's misperception of infant weight classification. Future studies should examine this relationship in a heterogeneous population.
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Affiliation(s)
- Amrik Singh Khalsa
- Division of Primary Care Pediatrics, Nationwide Children's Hospital (AS Khalsa), Columbus, Ohio; Department of Pediatrics, The Ohio State University College of Medicine (AS Khalsa), Columbus, Ohio.
| | - Kristen A Copeland
- Division of General and Community Pediatrics, Cincinnati Children's Hospital Medical Center (KA Copeland), Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati College of Medicine (KA Copeland, RY Kharofa, and NJ Ollberding), Cincinnati, Ohio
| | - Lauren Misik
- Northeast Ohio Medical University, College of Medicine (L Misik), Rootstown, Ohio
| | - Callie L Brown
- Department of Pediatrics, Wake Forest University School of Medicine (CL Brown), Winston-Salem, NC
| | - Roohi Y Kharofa
- Department of Pediatrics, University of Cincinnati College of Medicine (KA Copeland, RY Kharofa, and NJ Ollberding), Cincinnati, Ohio; The Heart Institute, Cincinnati Children's Hospital Medical Center (RY Kharofa), Cincinnati, Ohio
| | - Nicholas J Ollberding
- Department of Pediatrics, University of Cincinnati College of Medicine (KA Copeland, RY Kharofa, and NJ Ollberding), Cincinnati, Ohio; Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center (NJ Ollberding), Cincinnati, Ohio
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Wood AC, Blissett JM, Brunstrom JM, Carnell S, Faith MS, Fisher JO, Hayman LL, Khalsa AS, Hughes SO, Miller AL, Momin SR, Welsh JA, Woo JG, Haycraft E. Caregiver Influences on Eating Behaviors in Young Children: A Scientific Statement From the American Heart Association. J Am Heart Assoc 2020; 9:e014520. [PMID: 32389066 PMCID: PMC7660848 DOI: 10.1161/jaha.119.014520] [Citation(s) in RCA: 67] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
A substantial body of research suggests that efforts to prevent pediatric obesity may benefit from targeting not just what a child eats, but how they eat. Specifically, child obesity prevention should include a component that addresses reasons why children have differing abilities to start and stop eating in response to internal cues of hunger and satiety, a construct known as eating self‐regulation. This review summarizes current knowledge regarding how caregivers can be an important influence on children's eating self‐regulation during early childhood. First, we discuss the evidence supporting an association between caregiver feeding and child eating self‐regulation. Second, we discuss what implications the current evidence has for actions caregivers may be able to take to support children's eating self‐regulation. Finally, we consider the broader social, economic, and cultural context around the feeding environment relationship and how this intersects with the implementation of any actions. As far as we are aware, this is the first American Heart Association (AHA) scientific statement to focus on a psychobehavioral approach to reducing obesity risk in young children. It is anticipated that the timely information provided in this review can be used not only by caregivers within the immediate and extended family but also by a broad range of community‐based care providers.
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Herbst RB, Khalsa AS, Schlottmann H, Kerrey MK, Glass K, Burkhardt MC. Effective Implementation of Culturally Appropriate Tools in Addressing Overweight and Obesity in an Urban Underserved Early Childhood Population in Pediatric Primary Care. Clin Pediatr (Phila) 2019; 58:511-520. [PMID: 30841719 DOI: 10.1177/0009922819832088] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Overweight and obese children are at an increased risk of remaining obese. The American Academy of Pediatrics recommends addressing healthy habits at well-child checks, but this poses challenges, especially in low-income populations. A clinical innovation project was designed to adapt recommendations in a busy urban clinic and consisted of motivational interviewing, culturally tailored tools, and standardizing documentation. A quasi-experimental design examined innovation outcomes. Of 137 overweight and obese children aged 24 to 66 months, providers' documentation of weight during well-child check visits improved post-innovation ( P < .01), as did development of healthy habits goals ( P < .001). Families were more likely to return for visits post-innovation ( P = .01). A logistic regression analysis showed that adding body mass index to the problem list and establishing a specific follow-up timeframe most predicted follow-up visits to assess progress ( P < .001). Comprehensive innovations consisting of motivational interviewing, implementation of culturally tailored tools, and standardized documentation can enhance engagement in an urban clinic setting.
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Affiliation(s)
- Rachel Becker Herbst
- 1 Department of Pediatrics, University of Cincinnati, College of Medicine, Cincinnati, OH, USA.,2 Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Amrik Singh Khalsa
- 3 Nationwide Children's Hospital, Columbus, OH, USA.,4 The Ohio State University, Columbus, OH, USA
| | - Haley Schlottmann
- 2 Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | | | - Katherine Glass
- 2 Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
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Khalsa AS, Woo JG, Kharofa RY, Geraghty SR, DeWitt TG, Copeland KA. Parental intuitive eating behaviors and their association with infant feeding styles among low-income families. Eat Behav 2019; 32:78-84. [PMID: 30658288 DOI: 10.1016/j.eatbeh.2019.01.001] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Revised: 01/07/2019] [Accepted: 01/09/2019] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Feeding styles, the attitudes and behaviors parents use to direct their child's eating, shape a child's ability to self-regulate food intake and affects their future risk of obesity. This study examined how parental intuitive eating, where parents follow their own hunger and satiety cues, relates to infant feeding styles in a low-income, predominately Black population. METHODS Parents of healthy infants aged 5.5-12.5 months were recruited during well-child visits at two urban primary care clinics. Parent's intuitive eating behaviors and infant feeding styles were measured using the Intuitive Eating Scale-2 (IES-2) and the Infant Feeding Style Questionnaire (IFSQ), respectively. Multivariable regression analysis, controlling for maternal and child demographic variables, was conducted to determine the relationship between parent intuitive eating behaviors and five infant feeding styles: restrictive, pressuring, indulgent, laissez-faire, and responsive. RESULTS 201 parents completed the study, 90% were mothers and 69% were Black. Average infant age was 8.8 ± 2.0 months. Parents who reported relying on their own hunger and satiety cues when eating were more likely to feed their infant in a responsive style (β 0.10 ± 0.04, p < 0.05). Parents who reported eating unconditionally, not labeling foods as forbidden, were more likely to feed their infant in a laissez-faire (β 0.16 ± 0.06, p < 0.05) and indulgent (β 0.09 ± 0.03, p < 0.05) feeding style. CONCLUSIONS Parental intuitive eating behaviors are associated with both responsive and non-responsive infant feeding styles. Future studies should examine how parental intuitive eating and infant feeding styles affect infant growth trajectories.
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Affiliation(s)
- Amrik Singh Khalsa
- Division of Ambulatory Pediatrics, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA; Department of Pediatrics, The Ohio State University College of Medicine, 370 W. 9th Ave., Columbus, OH 43210, USA.
| | - Jessica G Woo
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave MLC 5041, Cincinnati, OH 45229, USA; Department of Pediatrics, University of Cincinnati College of Medicine, 3230 Eden Avenue, Cincinnati, OH 45267, USA
| | - Roohi Y Kharofa
- Division of General and Community Pediatrics, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue MLC 7035, Cincinnati, OH 45229, USA; Department of Pediatrics, University of Cincinnati College of Medicine, 3230 Eden Avenue, Cincinnati, OH 45267, USA
| | - Sheela R Geraghty
- Division of General and Community Pediatrics, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue MLC 7035, Cincinnati, OH 45229, USA; Department of Pediatrics, University of Cincinnati College of Medicine, 3230 Eden Avenue, Cincinnati, OH 45267, USA
| | - Thomas G DeWitt
- Division of General and Community Pediatrics, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue MLC 7035, Cincinnati, OH 45229, USA; Department of Pediatrics, University of Cincinnati College of Medicine, 3230 Eden Avenue, Cincinnati, OH 45267, USA
| | - Kristen A Copeland
- Division of General and Community Pediatrics, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue MLC 7035, Cincinnati, OH 45229, USA; Department of Pediatrics, University of Cincinnati College of Medicine, 3230 Eden Avenue, Cincinnati, OH 45267, USA
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15
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Khalsa AS, Kharofa R, Ollberding NJ, Bishop L, Copeland KA. Attainment of '5-2-1-0' obesity recommendations in preschool-aged children. Prev Med Rep 2017; 8:79-87. [PMID: 28856085 PMCID: PMC5573793 DOI: 10.1016/j.pmedr.2017.08.003] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2017] [Revised: 08/09/2017] [Accepted: 08/14/2017] [Indexed: 02/01/2023] Open
Abstract
Obesity prevention guidelines recommend children eat ≥ 5 servings of fruits and vegetables, view ≤ 2 h of screen time, participate in 1 h of physical activity, and consume 0 sugar-sweetened beverages daily, commonly known as '5-2-1-0'. We sought to determine: the extent to which preschool-aged children attending child care meet these guidelines, predictors of attainment, and associations of attainment with weight status. We analyzed in 2016, 24-hour dietary, physical activity, and screen time data collected in 2009-10 from 398 preschool-aged children in 30 child-care centers in Cincinnati, OH. Dietary intake, screen time and body-mass index (BMI) were obtained by research staff during child care and from parents when at home. Accelerometers measured physical activity. Mixed-effects models and generalized estimating equations were used to determine associations between '5-2-1-0' recommendations, demographic variables, and BMI z-scores. Average child age was 4.3 ± 0.7 years; 26% had a BMI ≥ 85th percentile. Seventeen percent of children with complete dietary data (n = 307) consumed ≥ 5 servings of fruits and vegetables and 50% consumed 0 sugar-sweetened beverages. < 1% with complete physical activity data (n = 386) met the activity recommendation; 81% of children (n = 379) had ≤ 2 h of screen time. Only 1 child met all of the '5-2-1-0' recommendations. There were no consistent demographic predictors of attaining individual recommendations. An additional hour of screen time was associated with a 0.11 (SD 0.06) increase in BMI z-score. Our data suggests there is ample room to increase fruit and vegetable intake and physical activity in preschool-aged children.
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Affiliation(s)
- Amrik Singh Khalsa
- Division of General and Community Pediatrics, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, MLC 7035, Cincinnati, OH 45229, United States
| | - Roohi Kharofa
- Division of General and Community Pediatrics, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, MLC 7035, Cincinnati, OH 45229, United States
| | - Nicholas J. Ollberding
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, MLC 5041, Cincinnati, OH 45229, United States
| | - Laurie Bishop
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, MLC 5041, Cincinnati, OH 45229, United States
| | - Kristen A. Copeland
- Division of General and Community Pediatrics, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, MLC 7035, Cincinnati, OH 45229, United States
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