A remotely-delivered pilot and feasibility program to promote physical and food literacy in adolescents with intellectual disabilities.

BACKGROUND: Youth with intellectual disabilities experience disparities in physical activity and diet quality. Physical and food literacy are hypothesised to support adoption of healthy lifestyles; however, few such interventions have been developed for this population. METHOD: Participants with intellectual disabilities ages 12-16 years were recruited for a 12-week online sports skills and nutrition education intervention. Feasibility, acceptability, and preliminary efficacy were assessed by attendance, satisfaction, and pre-post measures of motor skills, perceived competence and motivation for physical activity, classifying foods, making healthy choices, and food consumption. RESULTS: Six teens participated in the program and attended 87.5% of the sessions. Satisfaction data suggested that the program was well-received by both teens and parents. Trends toward improvements on physical activity and nutrition outcome measures were observed. CONCLUSIONS: Preliminary data from this pilot study suggest that physical and food literacy in youth with intellectual disabilities can be improved, which in turn may contribute to the adoption of healthy lifestyles.

Nutrient adequacy, dietary patterns and diet quality among children with and without intellectual disabilities.

BACKGROUND: Children with intellectual disabilities (ID) frequently have feeding problems, but there has been limited research on nutrient intake, dietary patterns and diet quality in this population. METHOD: Nutrient intakes, dietary patterns and the Healthy Eating Index were compared between 48 children with ID and 55 typically developing (TD) children aged 3-8 years who participated in the Children's Mealtime Study. Three-day food records that included two weekdays and one weekend day were used to assess dietary intake. Food intake was entered into the Nutrition Data System for Research for analysis of nutrient intake, dietary patterns and diet quality. Height and weight were measured to determine body mass index (BMI). The relation of dietary patterns to weight status was also assessed. RESULTS: Typically developing children and children with ID met the Estimated Average Requirement/Adequate Intake (EAR/AI) for most nutrients. However, a substantial number of children in both groups did not meet the EAR for vitamins E and D and calcium and the AI for vitamin K. Only one TD child met the AI for potassium. A small percentage of children in both groups did not meet the EAR for vitamin A and vitamin C, and in the ID group, a small percentage did not meet the EAR for vitamin B12 . Children in the ID group consumed, on average, fewer servings of vegetables than TD children (0.5 vs. 1.2, P < 0.001), but there was no significant difference in servings of fruit (0.8 vs. 1.1, respectively), fruit juice (less than a half serving in both groups), sugar-sweetened beverages (less than a half serving in both groups) or snacks (1.1 vs. 1.4, respectively) after adjusting for BMI z-score, parental education and race. We found a significant correlation between snack intake and BMI z-score among children with ID but not among TD children (r = 0.48, P < 0.0001 vs. r = 0.19, P = 0.16, respectively). The Healthy Eating Index indicated, on average, poor overall diet quality in both groups (58.2 in the ID group and 59.1 in the TD group). CONCLUSIONS: This study suggests that the diets of children with ID, as in TD children, need improvement. Targeting healthy eating in children with ID would improve diet quality and overall health.

Association of the Familial Coexistence of Child Stunting and Maternal Overweight with Indigenous Women in Guatemala.

Objectives This study investigated the association of the familial coexistence of child stunting and maternal overweight with indigenous women in Guatemala. Methods We selected 2388 child-mother pairs from the data set of the Living Standards Measurement Study conducted in Guatemala in 2000. This study examined the association between maternal and household characteristics and the nutritional status of children aged 6-60 months and mothers aged 18-49 years by using multivariable logistic regression models. Results Compared with non-indigenous households, a significantly higher percentage of indigenous households exhibited stunted child and overweight mother (SCOM) pairs (15.9 vs. 22.2%). Compared with normal-weight mothers, overweight mothers were less likely to have stunted children [adjusted odds ratio (AOR) 0.66, 95% confidence interval (CI) 0.50-0.88]. However, compared with mothers who were not short and overweight, short and overweight mothers were significantly more likely to have stunted children (AOR 1.80, 95% CI 1.19-2.73) and were more likely to be indigenous women living in urban areas (AOR 3.01, 95% CI 1.19-7.60) or rural areas (AOR 3.02, 95% CI 1.28-7.14). The order of observed prevalence of SCOM pairs in different types of households was as follows: urban indigenous (25.0%), rural indigenous (21.2%), rural non-indigenous (19.8%), and urban non-indigenous households (10.7%). Conclusions for Practice Urban indigenous households were more likely to have SCOM pairs. This study provided useful information for identifying the most vulnerable groups and areas with a high prevalence of the familial coexistence of child stunting and maternal overweight.

Is body mass index a useful measure of excess body fatness in adolescents and young adults with Down syndrome?

BACKGROUND: To determine the validity of body mass index (BMI) to identify excess fatness in youth with Down syndrome (DS). METHODS: Using the Centers for Disease Control and Prevention (CDC) growth reference, we defined overweight (≥ 85th percentile) and obesity (≥ 95th percentile) based on participants' age- and sex-specific BMI z-scores, calculated from measured height and weight. Percentage body fat was measured by dual-energy X-ray absorptiometry. We determined sensitivity, specificity, positive predictive value, negative predictive value and efficiency of BMI percentiles to identify excess adiposity relative to elevated percentage body fat cut-offs developed from the Pediatric Rosetta Body Composition project in 32 youth (20 boys/12 girls), ages 13-21 years with Down syndrome. RESULTS: For adolescents with Down syndrome using the cut-off points of 95th percentile for BMI (obesity), sensitivity and specificity were 71% and 96% respectively. Positive predictive value was 83% and negative predictive value was 92%. Overall efficiency was 91%. Sensitivity and specificity for BMI cut-offs above the 85th percentile (overweight) were 100% and 60% respectively. The positive predictive value was 41% and negative predictive value was 100%. Overall efficiency was 69%. CONCLUSION: On the whole, the obesity (≥ 95th percentile) cut-off performs better than the overweight cut-off (85th-94th percentile) in identifying elevated fatness in youth with DS.

Sedentary behavior and sleep: paradoxical effects in association with childhood obesity.

Sedentary behavior and sleep may be working in concert to increase the likelihood of a child becoming overweight, but in paradoxical ways. Reduction of sedentary behavior (that is, media screen time) has been extensively researched and touted as an intervention target. Inadequate sleep as a putative risk factor for obesity is only beginning to be explored. In this paper, we review the current state of research regarding these factors, and describe the existing evidence and mechanisms proposed to explain these relationships. Whereas the association between weight and sedentary behavior has been consistently shown in observational studies, effect sizes are small, and multiple mechanisms appear to be operating. Recent cross-sectional and longitudinal evidence suggests a link between short sleep duration and weight. Possible mechanisms here include direct metabolic effects as well as indirect behavioral pathways, including the presence of electronic media in children's bedrooms. Measurement issues present a challenge to both areas of research. Prospective studies that include more accurate measures of both sedentary behavior and of sleep will be needed to clarify causal pathways.

Modifiable risk factors in relation to changes in BMI and fatness: what have we learned from prospective studies of school-aged children?

Considerable interest and resources are currently being directed to primary and secondary prevention of childhood obesity among school-aged children. Intervention studies in this age group have yielded mixed results, begging the question as to whether the correct targets for intervention have been identified. To evaluate the evidence base, we reviewed prospective observational studies published in English between 1990-2007 that reported weight or fatness changes in relation to diet, physical activity, and sedentary behavior. Sugar-sweetened beverage consumption emerged as the most consistent dietary factor in association with subsequent increases in weight status or fatness. Other foods and eating patterns showed less consistent associations and when associations were present, magnitudes were generally small. This may reflect the known limitations of standard dietary methodology to assess meal patterns and dietary intake. Findings for physical activity showed more consistent inverse associations with fatness outcomes than for weight status, and as was found for dietary factors, magnitudes of association were modest. Sedentary behavior effects on weight status differ by gender in many studies, with many, but not all, showing greater positive associations among girls. The lack of consistency observed in the studies of sedentary behaviors may reflect the range of variable definitions, measurement challenges, and the changing nature of electronic media. The intrinsic interplay among eating patterns, activity and sedentary behavior adds further complexity to the interpretation of the results of these studies. More sophisticated approaches to the analysis of these complex data in future studies may maximize what is learned. Although the classic obesity risk factors seem to play a role in the development of excess weight and fatness, some more recently identified potential factors, such as sleep, warrant further investigation in prospective studies before they are ready for evaluation using more controlled study designs.

Obesity and psychopathology in women: a three decade prospective study.

OBJECTIVE: To evaluate prospective associations between elevations in body mass index (BMI) at average age 27 and generalized anxiety disorder (GAD) and major depressive disorder (MDD) at average age 59 in a community sample of women. DESIGN: Three waves of data collected over three decades were drawn from mothers in the Children in the Community (CIC) Study. Binary logistic regression was used to estimate predictive effects of two BMI cutpoints (> or =30 and > or =25) on GAD and MDD independent of other risks for psychopathology. SUBJECTS: The 544 mothers who were interviewed in the original wave of the CIC Study in 1975 and in the first and most recent follow-up waves in 1983 and 2002-2005. MEASUREMENTS: Information about height and weight was obtained by self-report in face-to-face interviews. GAD and MDD were assessed by structured interview covering DSM-IV diagnostic criteria. Other potential risk factors examined included age, race, education, prior depressive symptoms and marital status, chronic disease, social support and financial strain concurrent with GAD and MDD. RESULTS: A baseline BMI > or =30 significantly increased the odds for subsequent GAD and MDD by 6.27 and 5.25 times, respectively, after adjusting for other significant risk factors. Odds of GAD also increased significantly given a baseline BMI > or =25 (by 2.44 times); however this association was not independent of other significant risk factors. Predictive associations between a baseline BMI > or =30 and MDD were not attenuated by attained BMI assessed at outcome. CONCLUSION: Findings extend existing evidence of the mental health consequences of obesity in a representative sample of mothers, and suggest that obesity may have long-term implications for mental distress in women at a clinical level over the adult years.

The healthy weight research network: a research agenda to promote healthy weight among youth with autism spectrum disorder and other developmental disabilities.

The Healthy Weight Research Network (HWRN) for children with autism and developmental disabilities is an interdisciplinary network with national representation. This paper discusses the modified Delphi procedure that was used to develop the HWRN's research agenda to address the problem of obesity in children with autism and developmental disabilities. The five research areas identified for priority included: (i) family practices around food/mealtimes; (ii) physical activity and sedentary behaviours in relation to weight; (iii) relationship between food patterns, behaviour and weight gain; (iv) programme-adaption and delivery; and (v) influence of school and community-based organizations on food intake and physical activity. The goals and agenda of the HWRN hold promise for making progress toward the prevention and successful treatment of obesity in this population.

Impact of overweight on the risk of developing common chronic diseases during a 10-year period.

BACKGROUND: Overweight adults are at an increased risk of developing numerous chronic diseases. METHODS: Ten-year follow-up (1986-1996) of middle-aged women in the Nurses' Health Study and men in the Health Professionals Follow-up Study to assess the health risks associated with overweight. RESULTS: The risk of developing diabetes, gallstones, hypertension, heart disease, and stroke increased with severity of overweight among both women and men. Compared with their same-sex peers with a body mass index (BMI) (calculated as weight in kilograms divided by the square of height in meters) between 18.5 and 24.9, those with BMI of 35.0 or more were approximately 20 times more likely to develop diabetes (relative risk [RR], 17.0; 95% confidence interval [CI], 14.2-20.5 for women; RR, 23.4; 95% CI, 19.4-33.2 for men). Women who were overweight but not obese (ie, BMI between 25.0 and 29.9) were also significantly more likely than their leaner peers to develop gallstones (RR, 1.9), hypertension (RR, 1.7), high cholesterol level (RR, 1.1), and heart disease (RR, 1.4). The results were similar in men. CONCLUSIONS: During 10 years of follow-up, the incidence of diabetes, gallstones, hypertension, heart disease, colon cancer, and stroke (men only) increased with degree of overweight in both men and women. Adults who were overweight but not obese (ie, 25.0 < or = BMI < or = 29.9) were at significantly increased risk of developing numerous health conditions. Moreover, the dose-response relationship between BMI and the risk of developing chronic diseases was evident even among adults in the upper half of the healthy weight range (ie, BMI of 22.0-24.9), suggesting that adults should try to maintain a BMI between 18.5 and 21.9 to minimize their risk of disease.

Food selectivity, mealtime behavior problems, spousal stress, and family food choices in children with and without autism spectrum disorder.

Mealtime behavior problems and family stress occur frequently among families of children with autism spectrum disorder (ASD). However, it is unknown whether food selectivity is an associated factor. The associations of high food selectivity with mealtime behavior problems, spousal stress, and influence on family members were assessed among 53 children with ASD and 58 typically developing (TD) children ages 3-11 years. Compared to TD children, children with ASD were more likely to have high food selectivity, and their parents reported more mealtime behavior problems, higher spousal stress, and influence on what other family members ate. High food selectivity was associated with mealtime behavior problems in both groups. Interventions to reduce food selectivity may lead to decreases in mealtime behavior problems.

The role of eating frequency on relative weight in urban school-age children.

BACKGROUND: The role of eating frequency on relative weight in childhood is not well understood. OBJECTIVE: To clarify this relationship by assessing the cross-sectional and prospective relationships of weekday eating frequency with BMI z-score (BMIz) and change in BMIz in a sample of schoolchildren. METHODS: Eating frequency, the average number of reported daily eating occasions, was assessed using two weekday 24-h diet recalls. BMIz was measured at baseline, 6 months and 1 year in 155 urban schoolchildren, ages 9-15 years. Multiple linear regression models were used. RESULTS: Cross-sectional analyses at baseline suggest that BMIz was 0.23 units lower for each additional reported eating occasion (regression coefficient = -0.23; 95% confidence interval [CI]: -0.44, -0.07). From baseline to 6 months, BMIz increased by 0.03 units for each additional reported eating occasion (regression coefficient = 0.03; 95% CI: 0.01, 0.05). This relationship was no longer statistically significant at 1 year (regression coefficient = 0.01; 95% CI: -0.01, 0.03). CONCLUSIONS: The findings suggest that the relationship of eating frequency with BMIz differs from that of change in BMIz. This difference may be due to methodological deficiencies of cross-sectional studies, challenges of dietary assessment or differences in eating patterns among normal and overweight youth. Controlled trials are needed to further clarify this relationship.

Morbidity and mortality associated with elevated body weight in children and adolescents.

The immediate and long-term risks associated with overweight in childhood and adolescence are best considered separately. Short-term mortality is rarely associated with overweight of the young. The greatest health burden of overweight in children and adolescents arises from long-term consequences. Long-term follow-up studies of children and adolescents indicate that the risk of adult overweight is about twofold greater for individuals who were overweight as children compared with individuals who were not overweight. Persistence is greatest for extreme overweight and when overweight is carried through late adolescence. The few studies of long-term health consequences in adolescent males find that even moderate overweight is associated with excess mortality in adulthood. Females have been studied infrequently; it appears that overweight confers long-term health risks, but these are less severe. However, because of concern about weight preoccupation in this age group and lack of data of sufficient precision to support specific recommendations, weight guidelines for children and adolescents are not now warranted.

Reference data for obesity: 85th and 95th percentiles of body mass index (wt/ht2) and triceps skinfold thickness.

Body mass index (BMI) and triceps skinfold thickness (TSF) are commonly used measures of adiposity in clinical and epidemiologic studies. The 85th and 95th percentiles of BMI and TSF are often used operationally to define obesity and superobesity, respectively. Race-specific and population-based 85th and 95th percentiles of BMI and TSF for people aged 6-74 y were generated from anthropometric data gathered in the National Health and Nutrition Examination Survey 1 (NHANES I). The complex sample design of the survey is reflected in the reference values presented. Racial differences in these extremes of the distribution do not emerge until adulthood. Researchers may choose population-based, race-specific, or age-specific criteria for obesity on the basis of assumptions underlying their specific research questions.

Validity of reported energy intake in preadolescent girls.

Energy intake and energy expenditure were assessed in 109 girls aged 8-12 y. Intake was estimated from a 7-d dietary record based on household measures. Expenditure was measured with the doubly labeled water technique during 2-wk period. Overall, the mean (+/-SD) energy intake was 7.0 +/- 1.67 MJ/d and the mean energy expenditure was 8.03 +/- 1.28 MJ/d. The mean difference between intake and expenditure was 1.03 +/- 1.77 MJ/d (P < 0.0001). The mean proportion of actual intake reported was 88.3 +/- 21.0%. Multivariate-regression analysis showed that age and total daily energy expenditure were significantly and independently related to the reporting error. Coefficients for age and total daily energy expenditure were both positive, indicating that as age and daily energy expenditure increased, the magnitude of the error of reporting increased. Income, ethnicity, parental obesity, and body fat were not significantly related to accuracy of reporting. The use of food records to determine energy intake appears to provide more accurate results in younger than in older girls, and the accuracy of the method apparently decreases as energy expenditure increases.

Accuracy of standardized equations for predicting metabolic rate in premenarcheal girls.

Several different equations based on height, weight, sex, and age are available to predict metabolic rate in children and adolescents. The purpose of this study was to determine which of the published standardized equations most accurately predicts metabolic rate in premenarcheal girls. Resting metabolic rate (RMR) was measured in 186 premenarcheal girls by using open-circuit indirect calorimetry with a ventilated hood. Measured RMR was compared with equations provided by the FAO/WHO/UNU, the Mayo Clinic, and Robertson and Reid for girls of the same age. The accuracy of each equation differed for each Tanner stage. The Mayo Clinic standards significantly differed from measured RMR among girls in Tanner stages 1 and 2. The Robertson and Reid standards differed from measured RMR for girls in Tanner stage 1. Only the FAO/WHO/UNU equation predictions did not differ from measured RMR for all Tanner stages studied. These results indicate that the FAO/WHO/UNU equation is the best predictor of RMR in premenarcheal girls at different stages of development. Furthermore, because RMR measured under inpatient and outpatient conditions did not differ significantly, an overnight measurement is not necessary for a reliable determination of RMR.

Predictors of overweight and overfatness in a multiethnic pediatric population. Child and Adolescent Trial for Cardiovascular Health Collaborative Research Group.

The goal of the study was to determine whether overweight or overfatness were predicted from sex, race or ethnicity, school site, and intervention or control status for children who were 9 y old at the outset of the Child and Adolescent Trial for Cardiovascular Health (CATCH). In this ethnically and geographically diverse group of 5106 students, height, weight, and triceps skinfold thickness were measured at 9 (baseline) and 11 y (follow-up) of age. The strongest predictors of status at follow-up were baseline overweight (odds ratio: 69.0; 95% CI: 54.9, 96.3) and overfatness (odds ratio: 27.4; 95% CI: 22.4, 33.4); site, African American race or ethnicity, and male sex were also significant independent associations. Children in the overweight (> 85th percentile for body mass index) group had significantly higher adjusted means for total blood cholesterol, higher apolipoprotein B concentrations, lower mean HDL-cholesterol concentrations, and lower performance on the 9-min run than those in other groups (< 15th, 15-49th, or 50-85th body mass index percentiles). Similar results were found for these factors for those subjects with greater triceps skinfold-thickness measurements. Groups of children who were overweight and overfat at baseline were more likely to be overweight and overfat at follow-up and to have more cardiovascular risk factors than their peers.

Tutorial in Biostatistics: Evaluating the impact of 'critical periods' in longitudinal studies of growth using piecewise mixed effects models.

Recent developments in modern multivariate methods provide applied researchers with the means to address many important research questions that arise in studies with repeated measures data collected on individuals over time. One such area of applied research is focused on studying change associated with some event or critical period in human development. This tutorial deals with the use of the general linear mixed model for regression analysis of correlated data with a two-piece linear function of time corresponding to the pre- and post-event trends. The model assumes a continuous outcome is linearly related to a set of explanatory variables, but allows for the trend after the event to be different from the trend before it. This task can be accomplished using a piecewise linear random effects model for longitudinal data where the response depends upon time of the event. A detailed example that examines the influence of menarche on changes in body fat accretion will be presented using data from a prospective study of 162 girls measured annually from approximately age 10 until 4 years post menarche.

Childhood energy intake and cancer mortality in adulthood.

A retrospective mortality follow-up of a British survey of family diet and health (1937-1939) identified significant associations between childhood energy intake and mortality from cancer, particularly those cancers not thought to be associated with smoking. This is the first large-scale epidemiologic study to suggest that the observed reduction in tumor incidence in energy-restricted rodents has relevance for humans.

Television viewing as a cause of increasing obesity among children in the United States, 1986-1990.

BACKGROUND AND METHODS: The prevalence of obesity among children and adolescents has increased, and television viewing has been suggested as a cause. We examined the relation between hours of television viewed and the prevalence of overweight in 1990, and the incidence and remission of overweight from 1986 to 1990 in a nationally representative cohort of 746 youths aged 10 to 15 years in 1990 whose mothers were 25 to 32 years old. Overweight was defined as a body mass index higher than the 85th percentile for age and gender. RESULTS: We observed a strong dose-response relationship between the prevalence of overweight in 1990 and hours of television viewed. The odds of being overweight were 4.6 (95% confidence interval, 2.2 to 9.6) times greater for youth watching more than 5 hours of television per day compared with those watching 0 to 2 hours. When adjustments were made for previous overweight (in 1986), baseline maternal overweight, socioeconomic status, household structure, ethnicity, and maternal and child aptitude test scores, results were similar (odds ratio, 5.3; 95% confidence interval, 2.3 to 12.1). We also found significant relations between television viewing and increased incidence and decreased remission of overweight during this 4-year period, adjusted for baseline covariates. The adjusted odds of incidence were 8.3 (95% confidence interval, 2.6 to 26.5) times greater for youth watching more than 5 hours of television per day compared with those watching for 0 to 2 hours. Estimates of attributable risk indicate that more than 60% of overweight incidence in this population can be linked to excess television viewing time. CONCLUSION: Television viewing affects overweight among youth, and reductions in viewing time could help prevent this increasingly common chronic health condition.

Prevalence of marked overweight and obesity in a multiethnic pediatric population: findings from the Child and Adolescent Trial for Cardiovascular Health (CATCH) study.

OBJECTIVE: Determine the prevalence of marked overweight and obesity among children in the Child and Adolescent Trial for Cardiovascular Health (CATCH), identify high risk groups, and compare findings to other recent studies. DESIGN: Cohort study. SUBJECTS/SETTING: Five thousand one hundred-six school children who were participants in CATCH at baseline (age approximately 9 years) during 1991 and 4,019 of those children who had follow-up data from 1994 (age approximately 1 years) available. METHODS: Body mass index (BMI), triceps and subscapular skinfolds, subscapular to triceps skinfold (S/T) ratio, and an estimate of body fat distribution from skinfolds was calculated. Findings were compared to population-based reference data from the First National Health and Nutrition Examination Survey, 1971 to 1973 (NHANES I), to data from the Bogalusa Heart Study, and to data from the Third National Health and Nutrition Examination Survey, 1988 to 1994 (NHANES III). RESULTS: Children in CATCH were markedly heavier and fatter than the NHANES I population and more comparable to the NHANES III population, especially those in the upper percentiles. The prevalence of obesity based on BMI and triceps skinfolds >95th percentile among CATCH children was higher in boys than in girls at both baseline (boys 9.1%, girls 8.6%) and follow-up (boys 11.7%, girls 7.2%). It was higher among African-Americans and Hispanics than whites for both sexes. S/T ratios did not differ appreciably from those observed in the NHANES I reference population, suggesting that body fat distribution was more stable over time than BMI and skinfolds. APPLICATIONS: Our findings support other recent reports that American children, especially African-American and Hispanic children, are becoming heavier and fatter. Preventive measures are warranted, especially for high-risk youth.