Time spent in sedentary behavior and changes in childhood BMI: a longitudinal study from ages 9 to 15 years.

OBJECTIVE: To determine if time spent in objectively measured sedentary behavior is associated with a change in body mass index (BMI) between ages 9 and 15 years, adjusting for moderate-to-vigorous physical activity (MVPA). DESIGN: Prospective observational study of children at ages 9 (2000), 11 (2002), 12 (2003) and 15 years (2006). Longitudinal quantile regression was used to model the influence of predictors on changes at the 10th, 25th, 50th, 75th and 90th BMI percentiles over time. SUBJECTS: Participants were enrolled in the National Institute of Child Health and Human Development (NICHD) Study of Early Child Care and Youth Development and include both boys and girls (n=789). MEASUREMENTS: Objectively measured BMI (kg m(-2)) was the outcome variable and objectively measured sedentary behavior was the main predictor. Adjustment was also made for MVPA, gender, race, maternal education, hours of sleep and healthy eating index. RESULTS: Increases in BMI were observed at all percentiles, with the greatest increase observed at the 90th BMI percentile. Spending more time in sedentary behavior (h per day) was associated with additional increases in BMI at the 90th, 75th and 50th BMI percentiles, independent of MVPA and the other covariates (90th percentile=0.59, 95% confidence interval (95% CI): 0.19-0.98 kg m(-2); 75th percentile=0.48, 95% CI: 0.25-0.72 kg m(-2); and 50th percentile=0.19, 95% CI: 0.05-0.33 kg m(-2)). No associations were observed between sedentary behavior and changes at the 25th and 10th BMI percentiles. CONCLUSION: Sedentary behavior was associated with greater increases in BMI at the 90th, 75th and 50th BMI percentiles between ages 9 and 15 years, independent of MVPA. Preventing an increase in sedentary behavior from childhood to adolescence may contribute to reducing the number of children classified as obese.

Infant-feeding practices and adiposity in 4-y-old Anglo- and Mexican-Americans.

A longer duration of breast-feeding and later introduction to solids may protect against excessive adiposity in infancy. This study investigated infant feeding practices and their relationship to two measures of adiposity--body mass index (BMI) and sum of skinfold thicknesses (SUMSF)--in 331 4-y-old Anglo- (43%) and Mexican-American (57%) children. No associations were detected between any of the infant feeding variables of duration of breast-feeding and introduction to solids and formula and measures of the child's adiposity. Mother's physical measures of BMI and SUMSF explained the largest portion of variance for both measures of childhood adiposity, BMI (9.5%), and SUMSF (8.3%). Genetic and environmental factors other than infant feeding practices appear to have a greater influence on a 4-y-olds' adiposity.

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.

Perspectives on the School Nutrition Dietary Assessment Study from the Child and Adolescent Trial for Cardiovascular Health.

The School Nutrition Dietary Assessment Study provides current data on the nutritional quality and adequacy of the National School Lunch Program (NSLP) and the School Breakfast Program (SBP) as well as on the dietary intakes of students participating in these programs. The study demonstrates that the NSLP and SBP meals and children's total diets do not conform to the recommendations of the US Department of Agriculture and the National Research Council and confirms the need to improve the nutritional quality of the nation's school meal program and student's overall dietary intakes. In this regard, the Child and Adolescent Trial for Cardiovascular Health (CATCH) is the first collaborative, school-based field trial that tests the effectiveness of a multi-level intervention designed to reduce the fat, saturated fat, and sodium content of school meals and student's diets. This commentary highlights the findings and questions raised by the School Nutrition Dietary Assessment Study and presents an overview of CATCH, including the implications and significant questions that can be addressed by this intervention study.

The new morbidity: use of school and community health care resources for behavioral, educational, and social-family problems.

The extent of the use of services for the new morbidity, that is, children's behavioral, educational, and family-social problems, has not previously been the subject of a community-based prospective study. The demographic characteristics and utilization of school and community health care resources over a two-year period are compared for two groups selected from a random sample (n = 671) of elementary school children. Twenty-four percent (n = 164) were observed to have behavioral, educational, or social-family problems requiring attention or intervention by health or educational personnel. This group was compared to their schoolmates (n = 507) not so identified. Although no overall differences in sex, ethnic background, or family structure were identified, the children with new morbidity problems were more frequently in the lowest socioeconomic group, and had lower reading achievement scores and higher rates of absenteeism. The new morbidity group also has higher rates of utilization of services both at school and at community sites of health care, not only for new morbidity complaints, but for other problems as well. The data suggest that this portion of the school-aged population places a significant demand for health care resources on both community and school sites. The findings support the need for training of physicians in the care and prevention of such problems.

Factors influencing access to primary health care via school health services.

The school health and community primary health care contacts were studied for a group of elementary school children who have sociodemographic characteristics often associated with poor access to primary health services. The school system is engaged in a demonstration project that attempts to link the home with community and school services. Visits to the school health room accounted for 85% of all contacts. A visit rate of 1.13 visits/child/year occurred at primary care sites. Ethnicity is the single most important predictor of use of school health services, followed by family status and number of visits for primary health care in the community. In contrast, use of community primary care facilities is best predicted by socioeconomic status (SES), family status, and sex. The patterns of care received by the population were characterized. Children whose care was initiated, referred, or facilitated by the school were designated as receiving "interactive" care, which occurred mostly among minority and lower SES children. The data suggest that the school provides access to preventive health care for all children and facilitates care for segments of the population that usually have difficulty achieving access to the health care system.

A comparison of absentee rates of elementary schoolchildren with asthma and nonasthmatic schoolmates.

Daily school attendance has been suggested as a health status measure for children. The present study compares school absence in children known to have asthma (N = 95) with a random sample of nonasthmatic elementary schoolchildren (N = 711). The differences in average percentage of days absent over one year were analyzed by comparing both groups' conditioning on ethnicity, sex, socioeconomic status, and grade. Children with asthma have a significantly higher absentee rate (absent 8.4% of days) than do nonasthmatic children (absent 5.9% of days) (P less than 9001). This significant difference holds true regardless of ethnicity of sex and for most socioeconomic groups. A comparison by grade level shows a similar trend for children with asthma and nonasthmatic children: absentee rates decrease as children get older; however, except for one grade level, children with asthma have a greater percentage of school days absent. Mean absentee rates for children with asthma were different when compared according to their mother's perception of severity of asthma--mild (6.9%), moderate (7.9%), and severe (13.9%).

Adult heart disease prevention in childhood: a national survey of pediatricians' practices and attitudes.

There is controversy about the role of pediatric care givers in reducing presumed risk factors for cardiovascular diseases in children. A national mail survey of 2,000 pediatricians was designed to determine the attitudes, current practices, and knowledge among primary care pediatricians regarding these risks. The response rate was 60% (779 primary care pediatricians). Responses indicated that a majority of pediatricians take a family history of cardiovascular diseases, assess BP, recommend exercise to school-aged children, and advise patients and parents against smoking. Few pediatricians felt confident in their ability to affect change in patient life-styles. There was a relatively low level of provision of dietary advice, and most pediatricians do not measure serum cholesterol levels, except in high-risk older children. A substantial minority do not discuss smoking, even with adolescents. Practices and attitudes varied with the age of the patient. Obesity was the topic most frequently chosen for continuing medical education. Older pediatricians were most likely to advocate and practice risk reduction in children. Attitudes and reported practices also varied by gender and geographic location of the pediatrician as well as the ethnic composition of the practice. Implications for continuing medical education are discussed.

Incidence of breast-feeding in a low socioeconomic group of mothers in the United States: ethnic patterns.

Breast-feeding has been shown to have increased in incidence during recent years in the United States. However, this increase is not particularly evident in lower socioeconomic groups. Factors associated with the decision to breast-feed or not were investigated in a population of 379 mothers. Self-completed questionnaires were obtained from 94.5% of these mothers. Data with respect to demographics, reproductive history, prenatal care, and education were collected. Only 27.2% of the study population indicated that they intended to breast-feed. Using the chi2 test for equality of proportions, marital status, head of household, maternal and paternal ethnicity, maternal education, income, and number of pregnancy were found to be the most important variables associated with breast-feeding. The effect of ethnicity predominated over that of the other demographic variables when they were examined jointly within ethnic groups. The effect of ethnicity was apparent when the number of each ethnic group in the study population was compared with the percent of that group that intended to breast-feed: 145 Anglo-Americans, 43.5% breast-feeding; 131 black Americans, 9.2%; 62 Mexican Americans, 22.6%; 19 others, 42.1%. The importance of ethnicity in the decision to breast-feed has probably been underestimated. Efforts to increase breast-feeding in the United States ought to be designed with full consideration of this factor.

The role of the pediatrician in abolishing corporal punishment in schools. Committee on School Health, American Academy of Pediatrics.

Corporal punishment in school is allowed in 30 states in the United States. The American Academy of Pediatrics, together with numerous other child-advocacy groups, has reaffirmed its position that corporal punishment in schools should be prohibited by state statute in all states. This article provides background information and recommendations regarding the potential role for pediatricians in attaining this goal.

Project SPARK. Effects of physical education on adiposity in children.

Project SPARK evaluates multiple effects of a health-related physical education (PE) program for elementary school students. Seven schools were randomly assigned to one of three conditions: usual PE or control, trained classroom teachers, or PE specialists. The intervention was implemented throughout the fourth and fifth grades. Data are available from one cohort of 550 children who were measured in the fall and spring of both grades. Adiposity was assessed by triceps and calf skinfolds, and body mass index (BMI) was also measured. Data at each measurement point were analyzed by ANOVAs, covarying for baseline values. At no measurement point were there significant group differences in total skinfold. At both fifth grade measurement points for boys and girls, however, there was a trend for the control group to have higher skinfold values than the two intervention groups. At the final measure, the difference between the highest and lowest groups was about 3 mm for girls and 2 mm for boys. BMIs were significantly lower at some measurement points for boys and girls, but this could be due to increased lean body mass in intervention students. After two years, there was a trend for the children exposed to the PE intervention to have lower levels of body fat, but the differences were not significant.

Factors parents use in selecting play spaces for young children.

BACKGROUND: The amount of time children spend in play spaces (ie, physical locations that are appropriate for children's physical activity) near their homes is correlated with their level of physical activity. OBJECTIVE: To examine factors used in parents' decisions about the selection of play spaces for their children. SUBJECTS: Parents (primarily mothers) of 178 Mexican American and 122 white children who were a mean age of 4.9 years old at the first measurement. MEASURES: In individual interviews, parents rated 24 factors on their importance in selecting for their children a play space that is away from their home or yard. Decision factors were rated from 1 (ie, not important at all) to 5 (ie, very important). RESULTS: The most important factors, with ratings ranging from 4.8 to 4.2, were safety and availability of toilets, drinking water, lighting, and shade. Mexican American parents rated 8 of 24 items significantly higher than did white parents, including lighted at night, organized activities, play supplies, and drinking water. White parents rated 5 of 24 items significantly higher than did Mexican American parents, including distance from home, cost of admission, and child's friends go there. The rated importance of 7 of 24 items increased during 1 year, including play supplies, drinking water, distance from home, and parents' friends or relatives go there. CONCLUSIONS: These results indicate that parents can identify factors they use in selecting places for their young children to play, and selection factors differ somewhat by ethnicity or socioeconomic status. Further studies are needed to determine whether improvements on the most important selection factors might be effective in increasing the use of play spaces by children and their parents. Clinicians may be able to use the most highly rated decision factors to help parents assess the acceptability of play spaces in their areas.

Three-year maintenance of improved diet and physical activity: the CATCH cohort. Child and Adolescent Trial for Cardiovascular Health.

OBJECTIVE: To assess differences through grade 8 in diet, physical activity, and related health indicators of students who participated in the Child and Adolescent Trial for Cardiovascular Health (CATCH) school and family intervention from grades 3 through 5. DESIGN: Follow-up of the 4-center, randomized, controlled field trial with 56 intervention and 40 control elementary schools. PARTICIPANTS: We studied 3714 (73%) of the initial CATCH cohort of 5106 students from ethnically diverse backgrounds in California, Louisiana, Minnesota, and Texas at grades 6, 7, and 8. RESULTS: Self-reported daily energy intake from fat at baseline was virtually identical in the control (32.7%) and intervention (32.6%) groups. At grade 5, the intake for controls remained at 32.2%, while the intake for the intervention group declined to 30.3% (P<.001). At grade 8, the between-group differential was maintained (31.6% vs 30.6%, P = .01). Intervention students maintained significantly higher self-reported daily vigorous activity than control students (P = .001), although the difference declined from 13.6 minutes in grade 5 to 11.2, 10.8, and 8.8 minutes in grades 6, 7, and 8, respectively. Significant differences in favor of the intervention students also persisted at grade 8 for dietary knowledge and dietary intentions, but not for social support for physical activity. No impact on smoking behavior or stages of contemplating smoking was detected at grade 8. No significant differences were noted among physiologic indicators of body mass index, blood pressure, or serum lipid and cholesterol levels. CONCLUSION: The original CATCH results demonstrated that school-level interventions could modify school lunch and school physical education programs as well as influence student behaviors. This 3-year follow-up without further intervention suggests that the behavioral changes initiated during the elementary school years persisted to early adolescence for self-reported dietary and physical activity behaviors.

Aggregation of dietary calories, fats, and sodium in Mexican-American and Anglo families.

There seems to be a consensus that family influences on dietary habits are important, but few studies have addressed this issue directly. To clarify inconsistent findings, we studied the aggregation of dietary fats, sodium, and calories in 95 Anglo and 111 Mexican-American families. Their diet was determined by 24-hour recall, a three-day food record, and a food frequency questionnaire, along with a measure of the urinary sodium-potassium ratio. There was evidence of moderate aggregation of all dietary variables in both ethnic groups. In Anglo families, spouse-spouse, but not sibling-sibling, correlations tended to be significant. The diets of the younger children, but not the older children, were related to their parents' diets. In Mexican-American families, both spouse-spouse and sibling-sibling correlations tended to be significant. The mothers' diets were more highly correlated with the children's diets than were the fathers'.

Predictors of dietary change in Mexican American families participating in a health behavior change program.

Previous research indicates that Mexican Americans have dietary patterns related to cardiovascular disease risk factors. Research on health beliefs in this ethnic group suggests that Mexican Americans may be less amenable to interventions based on cognitive-behavioral change models. Our study derives from the experience in a community trial, the San Diego Family Health Project, in which Mexican American families were recruited for a structured heart health intervention program. We examined correlations between one-year dietary change scores (three-day sodium, three-day fat, 24-hour sodium, 24-hour fat) and a set of predictor variables derived from social learning theory. Both adults and children had lower intake scores after the intervention, except for children's 24-hour sodium scores. Our correlational analysis found only weak and somewhat inconsistent relationships between theoretically based predictor and outcome variables for adults. The children's results showed statistically significant correlations between two theoretical variables (self-efficacy and supporting others' dietary change) and three-day fat and 24-hour sodium intake. We discuss the implications for cardiovascular disease risk reduction interventions with Mexican Americans.

A program for health behavior change in a preventive cardiology center.

The Preventive Cardiology Center at the University of California, San Diego, was designed to conduct training, service activities, and research related to behavioral modification of cardiovascular disease (CVD) risk. A primary aim is to train medical students and other health care professionals in the application of scientifically established methods of behavior change. This training takes place in the context of a behavior-change program for patients with CVD risk factors. Participants at increased risk for CVD and their families are recruited to the Preventive Cardiology Center. A comprehensive assessment of physiological and behavioral risk factors leads to the development of dietary and/or exercise behavior-change targets. A five-session group intervention instructs participants how to change health behaviors. Behavioral techniques included in the program include self-monitoring, goal-setting, social support, self-reward, self-talk, and problem solving. Students and others are trained through readings, videotapes, and coleading of intervention groups.

Cardiovascular risk factor assessment of medical students as an educational tool.

For three consecutive years, beginning in 1986, we evaluated cardiovascular disease (CVD) risk factors of medical students as part of the teaching program in a Preventive Cardiology Academic Award. Entering students in three consecutive classes were screened on the first day of orientation to medical school. The first year, we evaluated 108 students (71 men and 37 women), the second year, 99 students (75 men, 24 women), and the third year 108 students (67 men and 41 women). During the single four-hour period, we obtained data on personal and family history of CVD risk factors, type A behavior, knowledge of CVD, attitudes toward CVD prevention, measures of depression and anger, blood pressure, blood pressure reactivity, physical activity, and diet. Blood was drawn for lipid analysis. Height and weight were measured, and a physical fitness step test was administered. Pulmonary function was measured during the third year. We used a four-tiered approach to preventive cardiology education. During the assessment session, abnormalities, such as elevated blood pressure or abnormal pulse, were discussed with the student. In the second tier, the data were analyzed and returned to all students during teaching sessions, enabling them to compare their levels with the class and the national averages. For the third tier, students with high-risk values, defined as low-density lipoprotein cholesterol level > or = 150 mg/dL, a total cholesterol or triglyceride level > or = 200 mg/dL, or blood pressure > or = 140/90 mmHg, were seen by faculty physicians who suggested remedial interventions in separate sessions.(ABSTRACT TRUNCATED AT 250 WORDS)

Correlates of physical activity at home in Mexican-American and Anglo-American preschool children.

Twenty-two potential correlates of children's physical activity were examined. Two hundred and one Mexican-American and 146 Anglo-American families with 4-year-old children were studied. Children's physical activity was directly observed in the evening at home on 4 visits for 1 hr each time. Anglo-American children and male children were found to be more active. Demographic variables explained 11% of the variance in children's physical activity. After adjusting for demographics, 3 children's variables and 6 social-family variables did not account for significantly more variance. Five environmental variables accounted for 11% additional variance. Variables observed concurrently with physical activity, such as time spent outdoors and prompts to be active, were highly associated with children's physical activity.

Early childhood diet: recommendations of pediatric health care providers.

With the abundance of literature on cardiovascular disease (CVD) prevention during childhood, recommendations for restricted dietary sodium and fat intakes during infancy and childhood are both advocated for preventive health care and criticized because the safety is undetermined. Dietitians, nurse practitioners, and pediatricians were surveyed to determine what dietary recommendations they give to parents and what source of information most influenced their decisions. A fourth group, pediatricians with particular expertise in nutrition, were surveyed as well. The overall response rate was 76%, with a total usable sample of 252. In all professional groups, 54% had no preference for any one commercially prepared formula. More importance was given to sodium content than to fat composition of formulas. On the choice of whole, low-fat, or non-fat milk for both 1- and 6-year-old children, professional groups differed significantly. Dietitians and the subgroup of pediatricians with nutrition expertise were more likely to recommend milk with higher fat content than other professional groups. Recommendations for both sodium- and fat-modified diets for children depended on CVD risk, and opinions varied between groups. Pediatricians and nurse practitioners were more likely to recommend dietary modifications for children with higher CVD risk. The variation in dietary recommendations within and between professional groups strongly indicates the need for research on the safety and efficacy of dietary restrictions in childhood.

Fat and cholesterol avoidance among Mexican-American and Anglo preschool children and parents.

Is a fat-avoidance scale a useful tool for monitoring and tracking dietary fat selections of adults and children? Using a seven-point scale, we addressed this question with 341 preschool children and 421 of their parents participating in a longitudinal study of childhood behaviors in San Diego County, California. Milk type and cooking fat reported in the fat-avoidance scale was compared with data reported in a 24-hour food intake record. An overall 86% agreement for milk type and a 78% agreement for cooking fat were noted. Anglo preschoolers (n = 143) had significantly greater mean scores for fat and cholesterol avoidance than did Mexican-American preschoolers (n = 198). Anglo, but not Mexican-American, women avoided fat and cholesterol more often than did their male counterparts. A significantly higher sum score was noted for Anglo men and women and Mexican-American men as education increased. These findings indicate that the fat-avoidance scale has a relative validity compared with a 1-day food record, that fat avoidance can be measured, that differences can be noted in a biethnic sample of children and adults, and that the scale has potential for monitoring success in achieving a lower fat and cholesterol intake.