Maternal gestational diabetes and childhood adiposity risk from 6 to 8 years of age.

BACKGROUND/OBJECTIVE: Previous studies found conflicting results on the association between maternal gestational diabetes mellitus (GDM) and childhood overweight/obesity. This study was to assess the association between maternal GDM and offspring's adiposity risk from 6 to 8 years of age. METHODS: The present study longitudinally followed 1156 mother-child pairs (578 GDM and 578 non-GDM) at 5.9 ± 1.2 years postpartum and retained 912 mother-child pairs (486 GDM and 426 non-GDM) at 8.3 ± 1.6 years postpartum. Childhood body mass index (BMI), waist circumference, body fat and skinfold were measured using standardized methods. RESULTS: Compared with the counterparts born to mothers with normal glucose during pregnancy, children born to mothers with GDM during pregnancy had higher mean values of adiposity indicators (waist circumference, body fat, subscapular skinfold and suprailiac skinfold) at 5.9 and 8.3 years of age. There was a positive association of maternal GDM with changes of childhood adiposity indicators from the 5.9-year to 8.3-year visit, and ß values were significantly larger than zero: +0.10 (95% CI: 0.02-0.18) for z score of BMI for age, +1.46 (95% CI: 0.70-2.22) cm for waist circumference, +1.78% (95% CI: 1.16%-2.40%) for body fat, +2.40 (95% CI: 1.78-3.01) mm for triceps skinfold, +1.59 (95% CI: 1.10-2.09) mm for subscapular skinfold, and +2.03 (95% CI: 1.35-2.71) mm for suprailiac skinfold, respectively. Maternal GDM was associated with higher risks of childhood overweight/obesity, central obesity, and high body fat (Odd ratios 1.41-1.57 at 5.9 years of age and 1.73-2.03 at 8.3 years of age) compared with the children of mothers without GDM. CONCLUSIONS: Maternal GDM was a risk factor of childhood overweight/obesity at both 5.9 and 8.3 years of age, which was independent from several important confounders including maternal pre-pregnancy BMI, gestational weight gain, children's birth weight and lifestyle factors. This significant and positive association became stronger with age.

An examination of the relationships between the neighborhood social environment, adiposity, and cardiometabolic disease risk in adolescence: a cross-sectional study.

BACKGROUND: Disadvantaged neighborhood environments are a source of chronic stress which undermines optimal adolescent health. This study investigated relationships between the neighborhood social environment, specifically, chronic stress exposures, adiposity, and cardiometabolic disease risk factors among 288 Louisiana adolescents aged 10 to 16 years. METHODS: This cross-sectional study utilized baseline data from the Translational Investigation of Growth and Everyday Routines in Kids (TIGER Kids) study. Adolescent data were obtained using self-reported questionnaires (demographics and perceived neighborhood disorder), anthropometry, body imaging, and a blood draw while objective neighborhood data for the concentrated disadvantage index were acquired from the 2016 American Community Survey five-year block group estimates, 2012-2016. Multilevel linear regression models were used to examine whether neighborhood concentrated disadvantage index and perceived neighborhood disorder were associated with body mass index, waist circumference, body fat, adipose tissue, blood pressure, and lipids. We performed multilevel logistic regression to determine the odds of elevated adiposity and cardiometabolic disease risk for adolescents living in neighborhoods with varying levels of neighborhood concentrated disadvantage and disorder. RESULTS: Adolescents living in neighborhoods with higher disadvantage or disorder had greater waist circumference and total percent body fat compared to those in less disadvantaged and disordered neighborhoods (p for trend < 0.05). Neighborhood disadvantage was also positively associated with percentage of the 95th Body Mass Index percentile and visceral abdominal adipose tissue mass while greater perceived neighborhood disorder was related to higher trunk fat mass and diastolic blood pressure (p for trend < 0.05). Living in the most disadvantaged was associated with greater odds of obesity (OR: 2.9, 95% CI:1.3, 6.5) and being in the top tertile of body fat mass (OR: 3.0, 95% CI: 1.4, 6.6). Similar results were found with neighborhood disorder for odds of obesity (OR: 2.1, 95% CI:1.1, 4.2) and top tertile of body fat mass (OR: 2.1, 95% CI:1.04, 4.1). CONCLUSIONS: Neighborhood social environment measures of chronic stress exposure were associated with excess adiposity during adolescence, and relationships were most consistently identified among adolescents living in the most disadvantaged and disordered neighborhoods. Future studies should account for the influences of the neighborhood environment to stimulate equitable improvements in adolescent health. CLINICAL TRIALS REGISTRATION: # NCT02784509.

Painted playgrounds for preschoolers' physical activity and fundamental motor skill improvement: a randomized controlled pilot trial of effectiveness.

BACKGROUND: Preschool children are not meeting recommended levels of physical activity (PA) nor are they proficient in fundamental motor skills (FMS), which are the foundation for PA. As such, interventions are needed to increase PA and FMS in young children. This trial examined the effects of an environmental ("painted playgrounds") and capacity-building (written toolkit) intervention on child FMS, PA, and sedentary behavior at early childhood education (ECE) centers and examined feasibility. METHODS: In a randomized controlled trial, four ECE centers were randomly assigned to an intervention group or wait-list control. For intervention centers, stencils were spray painted adjacent to playgrounds and teachers were provided material for using stencils for FMS practice. Follow-up assessments were conducted six to eight weeks after baseline. Time spent in PA and sedentary behavior was assessed via accelerometry and FMS were evaluated using the Test of Gross Motor Development (TGMD-3) at baseline and follow-up. A repeated measures linear model was performed to test the effects of the painted playgrounds on the primary outcomes of interest. Feasibility was measured by stencil engagement via direct observation and satisfaction surveys. RESULTS: A total of 51 preschoolers completed baseline assessments (4.3±0.6 years; 43.1% male). There were no significant changes in PA or sedentary behavior (all confidence intervals contain 0) between control and intervention groups. Intervention children significantly improved ball skill, locomotor, and overall TGMD-3 percentile scores at follow-up (all (all confidence intervals contain 0), which was not observed in control group. However, there was no significant change in FMS between the control and intervention groups (confidence intervals contain 0). For stencil use, boys and girls interacted with different stencils during their free play. Directors and teachers reported children incorporated academic concepts and initiated games, and teachers prompted more PA opportunities on the playground. CONCLUSIONS: This intervention did not show statistically significant changes in children's PA, FMS, or sedentary behavior compared to a control group; however, small FMS improvements for the intervention group were found from baseline to follow-up. Further work should examine intervention fidelity as well as inexpensive supplies, teacher training, or other strategies to increase preschool children's PA and improve FMS at ECE centers.

Comparison of abdominal visceral adipose tissue measurements in adolescents between magnetic resonance imaging and dual-energy X-ray absorptiometry.

Excess abdominal visceral adipose tissue (VAT) is associated with cardiometabolic risk factors in adolescents. VAT is mainly measured using Magnetic Resonance Imaging (MRI), yet dual-energy x-ray absorptiometry (DXA) is more affordable and available. The purpose was to compare adolescent VAT values obtained by MRI and DXA. A sample of 330 adolescents 10-16 years of age were recruited (52.3% female, 58.5% White). Abdominal VAT was measured using a General Electric (GE) Discovery MRI scanner with imaging software. A whole-body DXA (GE iDXA) scan was performed, and software calculated VAT within the android region. Wilcoxon signed-rank t-tests were used to determine differences between VAT values, within sex, race (White, African American, and Other race), and BMI categories (normal weight, overweight, and obese). VAT values from MRI and DXA were significantly correlated (r = 0.78, p < 0.001). Average VAT from MRI (0.54 ± 0.43 kg) was significantly higher than VAT from DXA (0.33 ± 0.39 kg) in the overall sample (p < 0.001) and within all subgroups (p < 0.001). All standardized values between the two measurements fell within ±1.96 standard deviations, and differences between the methods were not associated with level of VAT. In this sample, DXA values were correlated with MRI values, but DXA consistently underestimated VAT compared with MRI.

Harnessing technological solutions for childhood obesity prevention and treatment: a systematic review and meta-analysis of current applications.

BACKGROUND: Technology holds promise for delivery of accessible, individualized, and destigmatized obesity prevention and treatment to youth. OBJECTIVES: This review examined the efficacy of recent technology-based interventions on weight outcomes. METHODS: Seven databases were searched in April 2020 following PRISMA guidelines. Inclusion criteria were: participants aged 1-18 y, use of technology in a prevention/treatment intervention for overweight/obesity; weight outcome; randomized controlled trial (RCT); and published after January 2014. Random effects models with inverse variance weighting estimated pooled mean effect sizes separately for treatment and prevention interventions. Meta-regressions examined the effect of technology type (telemedicine or technology-based), technology purpose (stand-alone or adjunct), comparator (active or no-contact control), delivery (to parent, child, or both), study type (pilot or not), child age, and intervention duration. FINDINGS: In total, 3406 records were screened for inclusion; 55 studies representing 54 unique RCTs met inclusion criteria. Most (89%) included articles were of high or moderate quality. Thirty studies relied mostly or solely on technology for intervention delivery. Meta-analyses of the 20 prevention RCTs did not show a significant effect of prevention interventions on weight outcomes (d = 0.05, p = 0.52). The pooled mean effect size of n = 32 treatment RCTs showed a small, significant effect on weight outcomes (d = ‒0.13, p = 0.001), although 27 of 33 treatment studies (79%) did not find significant differences between treatment and comparators. There were significantly greater treatment effects on outcomes for pilot interventions, interventions delivered to the child compared to parent-delivered interventions, and as child age increased and intervention duration decreased. No other subgroup analyses were significant. CONCLUSIONS: Recent technology-based interventions for the treatment of pediatric obesity show small effects on weight; however, evidence is inconclusive on the efficacy of technology based prevention interventions. Research is needed to determine the comparative effectiveness of technology-based interventions to gold-standard interventions and elucidate the potential for mHealth/eHealth to increase scalability and reduce costs while maximizing impact.

Adolescents' sedentary time, affect, and contextual factors: An ecological momentary assessment study.

BACKGROUND: Few adolescents achieve sufficient levels of physical activity, and many are spending most of their time in sedentary behavior. Affective response following sedentary time may influence motivation to remain sedentary. Ecological Momentary Assessment (EMA) is a real-time data capture methodology that can be used to identify factors influencing sedentary time, such as the context of the home setting, and resulting affective state within a free-living setting. The purpose of this study was to evaluate the relationship between context at home and adolescent sedentary time, and the relationship of sedentary time and subsequent affect. METHODS: Adolescents (n = 284; 10-16 y) participated in an EMA study that used random, interval-based sampling methods. Adolescents each received 22 unannounced surveys over 7-days through a smartphone application. One survey was randomly sent within each 2-h time-period. These time-periods occurred between 4:00 pm-8:00 pm on weekdays and 8:00 am-8:00 pm on the weekend. This 15-question survey included a series of questions on context (indoors/outdoors, alone/not alone) and positive affect. Adolescents concurrently wore an accelerometer at the hip, and the 30-min bout of accelerometry data prior to each survey was used in analyses. Mixed-effect location scale models were used to examine the association between context at home and sedentary time (stage 1) and the adjusted sedentary time and positive affect (stage 2), with each model adjusted for covariates. RESULTS: Adolescents were 12.6 ± 1.9 y of age on average, about half were White (58%), and engaged in high levels of sedentary behavior during the 30 min prior to the survey (21.4 ± 6.8 min). Most surveys occurred when adolescents were with others (59%) and indoors (88%). In Stage 1, both being alone and being indoors at home were positively associated with sedentary time (p <  0.001 for both). In Stage 2, adjusted sedentary time was not related to positive affect. Age was negatively related to positive affect (p <  0.001). CONCLUSIONS: Both contextual factors, being alone and indoors at home, were related to additional time spent sedentary compared to being with someone or outdoors. After adjustment, sedentary time was not related to subsequent positive affect, indicating other factors may be related to adolescent's positive affect in home settings.

Household chaos, family routines, and young child movement behaviors in the U.S. during the COVID-19 outbreak: a cross-sectional study.

BACKGROUND: The home environment is an important facilitator of young child movement behaviors, including physical activity (PA), sleep, and screen-time. Household chaos, characterized by crowding, noise, and disorder in the home, may hinder efforts to obtain adequate amounts of movement behaviors. The COVID-19 outbreak impacted many families, and social distancing during this time may create conditions for more household chaos. Family routines can help establish order in the home and encourage an appropriate balance of movement behaviors, such as less screen-time and more sleep. The purpose of this study was to evaluate the association between household chaos and young child movement behaviors during the COVID-19 outbreak in the United States, and the role of family routines in this relationship. METHODS: A national online survey including 1836 mothers of preschoolers (3.0-5.9 years) was conducted during May 2020. Mothers reported demographic characteristics, household chaos, family routines, and the preschooler's movement behaviors during the outbreak. Mothers completed a household chaos questionnaire and were grouped into chaos categories (low, moderate/low, moderate/high, and high) for analysis. Linear regression was used to assess the association between chaos category, family routines, and movement behaviors with adjustment for covariates. RESULTS: Mothers were 35.9 ± 4.1 years of age, middle income (47.8%), and preschoolers were 3.8 ± 0.8 years of age. Most mothers reported their preschooler was less physically active (38.9%), slept the same amount of time (52.1%), and increased their screen-time (74.0%) after the COVID-19 outbreak. Preschoolers in the high chaos households performed less total PA (ß = - 0.36 days/week, 95% CI:-0.62 to - 0.09, p = 0.008), slept less (ß = - 0.42 h, 95% CI:-0.59 to - 0.25, p = 0.001) and had more screen-time (ß = 0.69 h, 95% CI:0.45 to 0.92, p = 0.001) compared to those in low chaos households. In most chaos categories, having a bed-time ritual was related to more child sleep, and mothers who viewed routines as "less/not important" reported more preschooler screen-time compared to mothers who viewed routines as "very important". CONCLUSION: Promoting bed-time rituals and prioritizing routines, even somewhat, may be related to an improved balance of child movement behaviors. Innovative measures are needed to support families during periods of disruption such as that experienced in the COVID-19 pandemic.

Global effect of COVID-19 pandemic on physical activity, sedentary behaviour and sleep among 3- to 5-year-old children: a longitudinal study of 14 countries.

BACKGROUND: The restrictions associated with the 2020 COVID-19 pandemic has resulted in changes to young children's daily routines and habits. The impact on their participation in movement behaviours (physical activity, sedentary screen time and sleep) is unknown. This international longitudinal study compared young children's movement behaviours before and during the COVID-19 pandemic. METHODS: Parents of children aged 3-5 years, from 14 countries (8 low- and middle-income countries, LMICs) completed surveys to assess changes in movement behaviours and how these changes were associated with the COVID-19 pandemic. Surveys were completed in the 12 months up to March 2020 and again between May and June 2020 (at the height of restrictions). Physical activity (PA), sedentary screen time (SST) and sleep were assessed via parent survey. At Time 2, COVID-19 factors including level of restriction, environmental conditions, and parental stress were measured. Compliance with the World Health Organizations (WHO) Global guidelines for PA (180 min/day [≥60 min moderate- vigorous PA]), SST (≤1 h/day) and sleep (10-13 h/day) for children under 5 years of age, was determined. RESULTS: Nine hundred- forty-eight parents completed the survey at both time points. Children from LMICs were more likely to meet the PA (Adjusted Odds Ratio [AdjOR] = 2.0, 95%Confidence Interval [CI] 1.0,3.8) and SST (AdjOR = 2.2, 95%CI 1.2,3.9) guidelines than their high-income country (HIC) counterparts. Children who could go outside during COVID-19 were more likely to meet all WHO Global guidelines (AdjOR = 3.3, 95%CI 1.1,9.8) than those who were not. Children of parents with higher compared to lower stress were less likely to meet all three guidelines (AdjOR = 0.5, 95%CI 0.3,0.9). CONCLUSION: PA and SST levels of children from LMICs have been less impacted by COVID-19 than in HICs. Ensuring children can access an outdoor space, and supporting parents' mental health are important prerequisites for enabling pre-schoolers to practice healthy movement behaviours and meet the Global guidelines.

Concurrent screen use and cross-sectional association with lifestyle behaviours and psychosocial health in adolescent females.

AIM: To describe concurrent screen use and any relationships with lifestyle behaviours and psychosocial health. METHODS: Participants wore an accelerometer for seven days to calculate physical activity sleep and sedentary time. Screen ownership and use and psychosocial variables were self-reported. Body mass index (BMI) was measured. Relationships were explored using mixed models accounting for school clustering and confounders. RESULTS: In 816 adolescent females (age: 12.8 SD 0.8 years; 20.4% non-white European) use of ≥2 screens concurrently was: 59% after school, 65% in evenings, 36% in bed and 68% at weekends. Compared to no screens those using: ≥1 screens at weekends had lower physical activity; ≥2 screens at the weekend or one/two screen at bed had lower weekend moderate-to-vigorous physical activity; one screen in the evening had lower moderate-to-vigorous physical activity in the after-school and evening period; ≥1 screens after school had higher BMI; and ≥3 screens at the weekend had higher weekend sedentary time. Compared to no screens those using: 1-3 after-school screens had shorter weekday sleep; ≥1 screens after-school had lower time in bed. CONCLUSION: Screen use is linked to lower physical activity, higher BMI and less sleep. These results can inform screen use guidelines.

Bullying experiences, body esteem, body dissatisfaction, and the moderating role of weight status among adolescents.

INTRODUCTION: The present study examined the relationships between bullying victimization experiences, body esteem (BE), and body dissatisfaction (BD) by obesity status. METHODS: Using a cross-sectional design, adolescents (10-16y) from the U.S. completed surveys. Weight and height were objectively assessed. Bullying was assessed using the Personal Experiences Checklist, with a total score that included three subscales (cyber, verbal-relational, and physical). BE was assessed using total score on the BE Scale, and BD was assessed using the Body Image Assessment for Pre-Adolescents, operationalized as the discrepancy between current and ideal body figure. Linear regression models, controlling for sociodemographics, were used to examine obesity status (with vs. without obesity) and sex as moderators of the relationships between bullying, BE, and BD. RESULTS: On average, adolescents (n = 328) were 12.6 ± 1.9 y, 45.4% male, 58.2% White, 35.7% Black, and 36.0% had obesity. Obesity status moderated the relationship between bullying experiences and BE, such that these relationships were only significant (B = -0.38, p<.05) among adolescents with obesity compared to adolescents without obesity. In both groups, greater verbal-relational bullying experiences were associated with lower BE, while greater physical bullying experiences were related to higher BE only among adolescents with obesity. In adolescent girls without obesity, greater cyberbullying experiences were associated with lower BD. CONCLUSIONS: The findings suggest different associations between sub-types of bullying victimization experiences and BE and BD, highlighting the importance of examining these associations separately by obesity status.

Validation of the Activity Preference Assessment: a tool for quantifying children's implicit preferences for sedentary and physical activities.

BACKGROUND: High levels of sedentary behavior and low physical activity are associated with poor health, and the cognitive determinants of these behaviors in children and adolescents are not well understood. To address this gap, we developed a novel, non-verbal, computer-based assessment to quantify the degree to which youth prefer to be sedentary relative to physically active in their leisure time. METHODS: The Activity Preference Assessment (APA) uses a forced-choice paradigm to understand implicit decision-making processes when presented with common sedentary and physical activities. The APA bias score ranges from - 100 to + 100, with positive scores indicating a relative preference for sedentary activities, and negative scores representing a preference for physical activities. In 60 children ages 8-17 years, we assessed the validity of this behavioral task against a free-choice play observation, accelerometry-measured activity, anthropometrics and body composition, and cardiorespiratory fitness. We explored neighborhood, family, and individual-level factors that may influence implicit activity preferences. Test-retest reliability was assessed over one week. RESULTS: The majority of children (67%) preferred sedentary relative to physical activities. APA bias scores were positively associated with sedentary time during free-choice play. In girls, bias scores were negatively associated with average daily MVPA. APA bias scores were positively associated with body fat and negatively associated with cardiorespiratory fitness. These findings were independent of age, sex, and race/ethnicity. Neighborhood access to physical activity spaces, the number of people in the home, perceived physical self-competence (e.g., coordination, strength), and self-reported depressive symptoms were associated with activity preferences. The intra-class correlation for test-retest reliability was r = 0.59. CONCLUSIONS: The APA shows promise as a novel tool for quantifying children's relative preference for sedentary versus physical activities. Implicit bias scores from the APA are clinically meaningful, as shown by significant associations with adiposity and cardiorespiratory fitness. Future longitudinal studies should examine the directionality of the association between preferences and health markers, and the degree to which implicit activity preferences are modifiable. Importantly, the task only takes an average of 10 min to complete, highlighting a potential role as an efficient screening tool for the propensity to be sedentary versus physically active. TRIAL REGISTRATION: ClinicalTrials.gov NCT03624582 .

A natural experiment of state-level physical activity and screen-time policy changes early childhood education (ECE) centers and child physical activity.

BACKGROUND: Early childhood education (ECE) centers are an important place for preschool-aged children to obtain physical activity (PA). A U.S. state government (Louisiana) recently updated requirements for licensed centers' PA and screen-time policies, which allowed for assessment of 1) ECE center practices, environment, staff behaviors, and policies changes on child-level PA and 2) state level changes on the ECE center. METHODS: ECE centers were assessed at the beginning of state licensing changes and 1-year later. The ECE centers were assessed via the Environmental Policy Assessment and Observation (EPAO) tool. The EPAO Sedentary Opportunities score, which primarily assesses television viewing time, was revised to reflect viewing non-television devices (e.g. tablets). Child-level PA was measured using accelerometry. For Aim 1, mixed models assessed ECE center changes and child PA with adjustment for demographic characteristics (fixed effects), baseline EPAO score (random effects), and clustering for center. For Aim 2, paired t-tests assessed ECE center environment differences between baseline and follow-up. RESULTS: Nine ECE centers participated and 49 preschoolers provided complete measures at both time points. For Aim 1, increases in the EPAO revised-Sedentary Opportunities score (as in less non-television screen-time) resulted in increased child PA (p = 0.02). For Aim 2, ECE centers improved their EPAO Active Opportunities and Staff Behaviors score (p = 0.04 and p = 0.02 respectively). CONCLUSIONS: ECE centers improved their environment after 1-year, resulting in additional child PA. Changes in ECE centers environment, possibly through policy, can positively influence children's PA.

A Pilot Study of Cardiorespiratory Fitness, Adiposity, and Cardiometabolic Health in Youth With Overweight and Obesity.

OBJECTIVE: To conduct a preliminary assessment of the relationships between cardiorespiratory fitness, adiposity, and cardiometabolic health using gold standard measures in diverse youth ranging from overweight to severe obesity. METHODS: Twenty of 30 participants (mean [SD]; age 13.2 [1.8] y, 55% female, 45% African American) met the criteria for VO2peak during a graded cycle ergometer test to volitional fatigue. The body composition was measured by dual-energy X-ray absorptiometry (percentage of body fat, fat mass index, and fat-free mass) and magnetic resonance imaging (abdominal visceral and subcutaneous [SAT] adipose tissue). The VO2peak was expressed relative to fat-free mass. Fasting lipid levels, glycemic biomarkers, and vital signs were examined individually and used in a composite cardiometabolic risk score. Accelerometer-measured physical activity and sedentary time were included as covariates. RESULTS: VO2peak was negatively associated with abdominal SAT (r = -.49, P < .05), but not visceral adipose tissue or markers of cardiometabolic health. The association between SAT and VO2peak was partly explained by habitual sedentary time. CONCLUSIONS: We demonstrated a significant negative association between cardiorespiratory fitness and SAT in a diverse group of high-risk youth. The inclusion of rigorous, laboratory-based measures and youth with severe obesity extends the previous work in pediatric populations.

Uncovering physiological mechanisms for health disparities in type 2 diabetes.

Type 2 diabetes (T2D) prevalence in the United States is significantly higher in African Americans vs Whites. Yet, the physiological mechanisms contributing to this health disparity have been poorly described. To design effective strategies to reduce this disparity, there is a need to determine whether racial differences in diabetes prevalence are attributable to modifiable or non-modifiable factors. This review synthesizes and critically evaluates the potential physiological and genetic mechanisms that may contribute to the higher susceptibility of African Americans to T2D. These mechanisms include: 1) obesity and fat distribution; 2) metabolic flexibility; 3) muscle physiology; 4) energy expenditure and fitness; and 5) genetics. We focus on the clinical significance of findings and limitations of the recent literature.

Physical activity, screen time, and sitting among U.S. adolescents.

The purpose of this study was to describe self-reported levels of sitting, moderate- to vigorous-intensity physical activity (MVPA), television viewing, and computer use in a representative sample of US adolescents and to make comparisons between sex, race/ethnicity, weight status, and age groups. Results are based on 3556 adolescents aged 12-19 years from the 2007-2012 National Health and Nutrition Examination Survey. Participants self-reported demographic, sitting, MVPA, television viewing (2011-2012 only) and computer use (2011-2012 only) variables. Height and weight were measured to calculate body mass index. On average, 7.5 hr/day were spent sitting and 34 median min/day were spent participating in MVPA, with females sitting more and participating in less MVPA than males across most demographic groups. Furthermore, obese males sat more and participated in less MVPA than nonoverweight males. Non-Hispanic white females participated in more MVPA than females in all other race/ethnicity groups. For television and computer, 38% and 22% of the sample engaged in >2 hr/day, respectively, and several race/ethnicity differences were observed. This study provides the first U.S. adolescent population estimates on self-reported sitting and updates population estimates on self-reported MVPA, television viewing and computer use. Continued efforts are needed to promote healthy active lifestyles in American adolescents.

Cardiometabolic risk factors and fat distribution in children and adolescents.

OBJECTIVES: To determine if cardiometabolic risk factors have differential associations with the proportion of fat distributed in the trunk, leg, and arm, in White and African American children and adolescents. STUDY DESIGN: The sample included 391 White and African American 5- to 18 year-olds. Total and regional (trunk, leg, and arm) fat were measured by dual energy X-ray absorptiometry. Resting blood pressure and fasting triglycerides, high density lipoprotein cholesterol (HDL-C), glucose, insulin, and C-reactive protein were measured in a clinical setting. Insulin resistance was determined with the homeostatic model of insulin resistance. Multivariable linear and logistic regression models were used to examine associations between each cardiometabolic risk factor and proportion of fat (trunk, leg, or arm fat divided by whole body fat), with whole body fat, age, sex, race, sexual maturity status, and self-reported physical activity as covariates. RESULTS: Higher odds of low HDL-C, high triglycerides, insulin resistance, and high C-reactive protein were associated with % trunk fat. Lower odds of low HDL-C, high triglycerides, and insulin resistance were associated with % leg fat. No cardiometabolic risk factor was associated with % arm fat. CONCLUSIONS: Cardiometabolic risk factors in children and adolescents were attenuated when a larger proportion of fat was distributed in the leg. The clinical assessment of children's fat distribution may be useful in determining cardiometabolic risk.

Modification of childcare's outdoor setting for toddler physical activity and nature-based play: A mixed methods study.

BACKGROUND: Toddler physical activity is critical for child health, but little is known about its applications in early childhood education (ECE) centers. The aims of this study were 1) to determine if pragmatic and nature-based modifications to an ECE center's outdoor setting were feasible and acceptable, and 2) to identify barriers and facilitators of toddler physical activity at ECE centers. METHODS: A multiphase mixed-methods study (QUANT+QUAL) was conducted. In the QUANT study, a stepped, sequential modification of the outdoor setting, using pragmatic and cost-effective nature-based elements, was conducted with a delayed control group over 10-weeks, with follow-up assessments 3-months later (week-20). Five elements (tree cookies, garden, teacher training, playground stencils, and nature table) were introduced individually. Feasibility was assessed using teacher surveys. Acceptability and engagement were assessed by direct observation of toddler use of outdoor elements. Accelerometers were used to assess toddlers' physical activity during outdoor sessions. The QUAL study included semi-structured interviews from ECE center directors (n = 27, 55.6% African American, 92.5% female) that were analyzed using content analysis for themes related to 1) toddler physical activity, 2) barriers and facilitators to toddler outdoor environment changes, 3) perspectives on nature-based elements, and 4) provider training. Member check focus groups (n = 2, 7-10/group) were conducted for additional interpretation. All three sources were reviewed for integration. RESULTS: Toddlers engaged in physical activity for most of the outdoor sessions (>85%). This limited the effect of the intervention, but aligned with directors' and members' sentiments that toddlers were already quite active. Across directors, reported barriers to toddler outdoor environment changes were teacher turnover and finances. All nature-based elements, except the stencils, were feasible and acceptable, even at week-20. Directors and members identified additional age-appropriate elements, and desired pragmatic training with technical assistance and funding to implement these changes. Directors and members also desired a curriculum that could be used outdoors. CONCLUSIONS: Nature-based elements were feasible and acceptable to toddlers. Directors were enthusiastic about nature-based elements, but barriers exist in linking directors with these elements. Opportunities to combine toddler-age curricula and pragmatic options for outdoor play may improve ECE centers' outdoor settings and ultimately toddler health.

A pragmatic trial of a family-centered approach to childhood obesity treatment: Rationale and study design.

BACKGROUND: Family-based behavioral treatment (FBT) is an effective intensive health behavior and lifestyle treatment for obesity reduction in children and adolescents, but families have limited access. The purpose of this randomized, pragmatic, comparative effectiveness trial was to examine changes in child relative weight in a 12-month, enhanced standard of care (eSOC) intervention combined with FBT (eSOC+FBT) vs. eSOC alone. METHODS: Children aged 6 to 15 years with obesity, and their primary caregiver, were recruited from primary care clinics. Families were randomized 1:1 to eSOC, a staged approach led by the primary care provider that gradually intensified dependent on a child's response to care and aligns with the American Medical Association guidelines, or the eSOC+FBT arm, which included regular meetings with a health coach for healthy eating, physical activity, positive parenting strategies, and managing social and environmental cues. Both treatments align with the 2023 American Academy of Pediatrics clinical practice guidelines. Assessments occurred at baseline, midpoint (month 6), end-of-intervention (month 12), and follow-up (month 18). Primary outcome was change from baseline to 12 months in child percent overweight (percentage above the median body mass index in the general US population normalized for age and sex). Secondary outcomes were parent weight, child psychosocial factors, heterogeneity of treatment effects, and cardiometabolic risk factors. Exploratory outcomes assessed reach, effectiveness, adoption, implementation, and maintenance. CONCLUSION: This pragmatic trial will generate evidence for the comparative effectiveness of implementing two guidelines-based approaches in primary care for obesity reduction in children and adolescents. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03843424.

Validation of remote child weight and height measurements within a weight management trial.

OBJECTIVE: The aim of this substudy within the Treatment Efforts Addressing Child Weight Management by Unifying Patients, Parents, and Providers (TEAM UP) pragmatic clinical trial was to compare the validity of anthropometric measurements collected remotely versus in person (≤7 days apart) among youth with obesity who were 6 to 15 years of age. METHODS: Child (n = 37) weight and height were measured in person by a trained data assessor. These were compared with measurements taken remotely by the child's parent with live videoconferencing observation by a study data assessor. In-person and remote measurements were compared using Bland-Altman plots, Pearson correlations, and two one-sided paired t tests. A priori bounds of acceptability were set at ±0.68 kg to allow for typical weight fluctuations within the 7-day comparison period. RESULTS: Measurements were highly correlated (height: r = 0.991, p < 0.0001; weight: r = 0.999; p = 0.03). For height, two one-sided t tests for upper, t(36) = 3.95, and lower, t(36) = -2.63, bounds (-1, 1) revealed an overall p = 0.006; absolute error was 3.5 cm. For weight, two one-sided t tests for upper, t(36) = 1.93, and lower, t(36) = -7.91, bounds (-0.68, 0.68) revealed an overall p = 0.03; absolute error was 1.7 kg. CONCLUSIONS: The present findings support the utility and interpretation of remotely assessed weight management outcomes for both research and clinical purposes. These procedures may offer greater accessibility to evidence-based measurement.