Perinatal Factors Associated with Cardiovascular Disease Risk among Preschool-Age Children in the United States: An Analysis of 1999–2008 NHANES Data

Article · May 2012with17 Reads
DOI: 10.1155/2012/157237 · Source: PubMed
Abstract
We examined the relationships between selected perinatal and early infancy factors (maternal smoking during pregnancy, infant low birthweight, breastfeeding, and early introduction of solid foods [<6 months of age] and increased BMI [≥85th, ≥95th percentiles for age, sex]), waist circumference (WC), C-reactive protein (CRP), triglycerides, total cholesterol, low-density lipoprotein (LDL) cholesterol, non-high-density lipoprotein (HDL) cholesterol, and decreased HDL cholesterol during early childhood. The population-based sample included 3,644 3-to-6-year-old Non-Hispanic White (NHW), Hispanic, and Non-Hispanic Black (NHB) children who participated in the 1999-2008 National Health and Nutrition Examination Surveys. Analysis showed that breastfeeding was significantly protective against early childhood obesity (OR 0.43, 95% CI, 0.27-0.69) and the highest quintile for WC (OR 0.58, 95% CI, 0.37-0.32) among NHW, and against the highest quintile of non-HDL cholesterol among NHB (OR 0.56, 95% CI, 0.32-0.98). Additionally, NHW children were significantly more likely to be obese (OR 2.22, 95% CI 1.30-3.78) and have higher CRP levels (OR 1.63, 95% CI, 1.05-2.51) if their mothers smoked during pregnancy. These results support the observation that breastfeeding may be protective against early childhood obesity while maternal smoking during pregnancy is a risk factor for obesity and increased CRP levels among NHW young children.
Hindawi Publishing Corporation
International Journal of Pediatrics
Volume 2012, Article ID 157237, 9pages
doi:10.1155/2012/157237
Clinical Study
Perinatal Factors Associated with Cardiovascular Disease Risk
among Preschool-Age Children in the United States: An Analysis
of 1999–2008 NHANES Data
Sarah E. Messiah,1, 2 Kristopher L. Arheart,1, 2, 3 Steven E. Lipshultz,1, 2
Emmalee S. Bandstra,4and Tracie L. Miller1, 2
1Division of Pediatric Clinical Research, Department of Pediatrics, University of Miami Leonard M. Miller School of Medicine,
Batchelor Children’s Research Institute, 580 NW 10th Avenue (D820), Miami, FL 33101, USA
2Department of Epidemiology and Public Health, University of Miami Leonard M. Miller School of Medicine, Miami,
FL 33101, USA
3Division of Biostatistics, University of Miami Leonard M. Miller School of Medicine, Miami, FL 33101, USA
4Division of Neonatology, University of Miami Leonard M. Miller School of Medicine, Miami, FL 33101, USA
Correspondence should be addressed to Sarah E. Messiah, smessiah@med.miami.edu
Received 15 October 2011; Revised 11 January 2012; Accepted 26 January 2012
Academic Editor: Tessa J. Roseboom
Copyright © 2012 Sarah E. Messiah et al. This is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly
cited.
We examined the relationships between selected perinatal and early infancy factors (maternal smoking during pregnancy,
infant low birthweight, breastfeeding, and early introduction of solid foods [<6 months of age] and increased BMI [85th,
95th percentiles for age, sex]), waist circumference (WC), C-reactive protein (CRP), triglycerides, total cholesterol, low-density
lipoprotein (LDL) cholesterol, non-high-density lipoprotein (HDL) cholesterol, and decreased HDL cholesterol during early
childhood. The population-based sample included 3,644 3-to-6-year-old Non-Hispanic White (NHW), Hispanic, and Non-
Hispanic Black (NHB) children who participated in the 1999–2008 National Health and Nutrition Examination Surveys. Analysis
showed that breastfeeding was significantly protective against early childhood obesity (OR 0.43, 95% CI, 0.27–0.69) and the highest
quintile for WC (OR 0.58, 95% CI, 0.37–0.32) among NHW, and against the highest quintile of non-HDL cholesterol among NHB
(OR 0.56, 95% CI, 0.32–0.98). Additionally, NHW children were significantly more likely to be obese (OR 2.22, 95% CI 1.30–3.78)
and have higher CRP levels (OR 1.63, 95% CI, 1.05–2.51) if their mothers smoked during pregnancy. These results support the
observation that breastfeeding may be protective against early childhood obesity while maternal smoking during pregnancy is a
risk factor for obesity and increased CRP levels among NHW young children.
1. Introduction
The theory that events in the perinatal period have latent
eects throughout the life course has become increasingly
accepted [1]. The literature on the fetal-origins hypothesis
strongly suggests that while maternal malnutrition and poor
maternal health might not cause major malformations in
childhood, such exposures can nevertheless have enduring,
or latent, eects such as restricted growth, hypertension,
cardiovascular events, and altered renal function in adult-
hood. [1,2] These potential maternal environments can
be physiological (e.g., maternal metabolic regulation), psy-
chobehavioral (e.g., stress, smoking), and/or ecological (e.g.,
poverty, unstable food supply).
The literature is emerging on how these environments
aect the long-term growth and health of children as they
develop into adulthood. [35] A recently published review
of 135 studies to evaluate factors in early childhood (5
years of age) that are the most significant predictors of the
development of obesity in adulthood reported that possible
early markers of obesity included maternal smoking and
maternal weight gain during pregnancy [6]. Probable early
2International Journal of Pediatrics
markers of obesity included maternal body mass index,
childhood growth patterns (early rapid growth and early
adiposity rebound), childhood obesity, and father’s employ-
ment (a proxy measure for socioeconomic status [SES] in
many studies). Other recent studies have examined the rela-
tionship between prenatal exposures such as smoking during
pregnancy and early feeding practices (e.g., breastfeeding,
early introduction of solid foods) and adverse cardiovascular
health outcomes in preschool age children [7,8]. Results
of these studies showed that maternal smoking during
pregnancy was associated with a higher body mass index
(BMI) at four years of age in children with a normal birth
weight and in those who were small for gestational age
at birth [7] and that shorter breastfeeding duration and
exclusivity (no formula or solid food) during the first 6
months tended to be associated with increased growth rates
for length, weight and BMI between the age of 3 and 6
months but not with the risks of overweight and obesity until
the age of 3 years [8].
Early childhood is an important stage of growth to
examine given that one in four US children under age 5 is
either overweight (85th to <95th age- and sex-adjusted
percentiles for BMI) or obese (95th age- and sex-adjusted
percentiles for BMI) [9,10]. Overweight preschool-age
children are five times more likely to be overweight during
adolescence and more than four times as likely to become
obese as adults than are their normal-weight counterparts
[11]. Recent studies have shown that obesity in this age
range is associated with cardiovascular disease risk factors
and varies by ethnic group [12]. The concern is that
childhood overweight will contribute to the earlier onset of
overall morbidity and mortality in adulthood, making early
intervention crucially important [4,5].
Preschool children are at an ideal age to examine these
relationships because there are fewer exposures to envi-
ronmental confounders and interactions compared to older
children and adults when it might be much more challenging
to distinguish the contribution of the environment versus
physiology. The relationship between overweight/obesity,
cardiovascular disease (CVD) risk factors and birthweight,
mother’s smoking status during pregnancy, breastfeeding,
and early introduction of solids and how these relation-
ships vary by ethnic group specifically is largely unknown.
Therefore, we assessed these relationships in a population-
based multiethnic sample of 3-to-6-year-olds to determine
the influence of breastfeeding, early introduction of solid
foods, smoking during pregnancy, and low birth weight on
the prevalence of CVD risk factors.
2. Methods
2.1. Study Population. The periodic National Health and
Nutrition Examination Survey (NHANES) uses a stratified,
multistage probability design to capture a representative
sample of the civilian, noninstitutionalized US population
[13]. This design allows survey results from two or more
periods to be combined to increase the sample size and
analytic options. Each 2-year period, and any combination
of 2-year periods, is a nationally representative sample. To
produce estimates with greater statistical reliability for demo-
graphic subgroups and rare events, combining two or more
2-year periods of the survey results is strongly recommended
[13]. Therefore, for this study, NHANES data files for 1999-
2000, 2001-2002, 2003-2004, 2005-2006, and 2007-2008
were combined to form a single analytic file.
2.2. Eligibility Criteria. From the above-cited NHANES
1999–2008 data file all Non-Hispanic White (NHW), His-
panic (Mexican American, other Hispanic groups com-
bined), and Non-Hispanic Black (NHB) boys and girls aged
3 to 6 years and their mothers were included. The following
measurements were available for analysis in this age group:
age, sex, ethnicity, height and weight (for BMI), WC,
C-reactive protein (CRP), total cholesterol, high-density
lipoprotein (HDL), low-density lipoprotein (LDL) choles-
terol, and triglycerides (available in the morning-only ran-
domized subsample).
Using data on response rates found on the CDC website
[14], we estimated the total number of 3-to-6-year-old
children who were screened in the surveys from 1999–
2008 to be 4,627. Of the children screened, 4,091 (88%)
participated in the interview and 3,876 (84%) participated in
the examination. We eliminated 225 children who were in the
“other” ethnic group category (not Hispanic, NHW or NHB)
and another 7 children who were diabetic or on metabolic
altering drugs; therefore, our analytic sample included 3,644
children (79% of children screened). With a sample size of
more than 1000 in each ethnic group (Tabl e 2 ), it is possible
to detect a small eect size of 0.20 at the two-tailed 0.05 level
with 80% power [15].
2.3. Measures and Data Collection. Persons selected to partic-
ipate in the NHANES survey were invited to be interviewed
in their homes. Household interview data were collected with
computer-assisted personal interviewing procedures and
included demographic, socioeconomic, dietary, and health-
related information. Because the children were so young (less
than 7 years old), the mothers answered all questions on their
behalf. Mothers were asked questions about their pregnancy
with the index child included in this analysis. Specifically
included were the responses regarding self-reported smoking
status during pregnancy, infant birthweight, whether the
infant was breastfed, and if solid foods were introduced in
the infant’s diet before six months of age. After the interview,
each child received a standardized physical examination at a
local Medical Examination Center.
Laboratory and anthropometric measurement methods
used at the Medical Examination Centers are described in
The NHANES Laboratory/Medical Technologists Procedures
Manual.[16] Briefly, anthropometric measures taken during
the standardized examination consisted of barefoot standing
height (with a stadiometer), weight with minimal clothing
(on a digital, electronic scale) [1], and waist circumference
(in the horizontal plane at a point marked just above the right
International Journal of Pediatrics 3
Tab l e 1: Values defining cardiovascular disease risk factors for 3-to-6-year-old children in the 1999–2008 NHANES data, by sex and ethnicity.
Body mass index
kg/m2
Waist
circumference, cm
C-reactive
protein, mg/dL
Total cholesterol,
mg/dL
HDL cholesterol,
mg/dL
Non-HDL
cholesterol, mg/dL
LDL cholesterol,
mg/dL
Tri g l y c e r ides ,
mg/dL
Group n85th %95th %nHighest
quintile nHighest
quintile nHighest
quintile nLowest
quintile nHighest
quintile nHighest
quintile nHighest
quintile
Overall 3555 26.5 13.8 3456 57.2 2521 0.13 1754 182 1752 42 1751 128 625 109 626 103
Girls
Non-Hispanic Black 516 23.4 13.0 506 55.6 365 0.10 268 182 268 44 268 127 100 112 100 87
Hispanic 694 33.9 14.6 670 57.9 502 0.20 346 181 344 41 344 127 113 102 113 110
Non-Hispanic White 530 24.0 10.8 513 57.0 341 0.11 238 188 238 40 238 135 90 103 90 105
Boys
Non-Hispanic Black 555 18.0 12.4 538 55.5 391 0.08 272 183 272 46 272 123 120 108 120 85
Hispanic 684 18.9 19.0 660 59.0 516 0.16 368 179 369 42 368 124 119 105 120 112
Non-Hispanic White 576 18.9 11.8 569 57.2 406 0.10 262 181 261 41 261 130 83 112 83 118
Centers for Disease Control and Prevention standardized cut-point values for age and sex
Cut-point for defining overweight
Cut-point for defining obesity
4International Journal of Pediatrics
ileum on the midaxillary line, at minimal respiration after
normal expiration) [16,17].
Triglycerides and low-density lipoprotein (LDL) choles-
terol were measured via blood on a nonfasting subsample
(those who were examined in the morning session only) of
all children ages 3 to 11 (N=626). All serum blood samples
were collected, processed, stored at 20C, and shipped to
the Lipid Laboratory, Johns Hopkins University, Baltimore,
MD (lipids) for the1999–2006 surveys and to the University
of Minnesota, Minneapolis, MN, for the 2007-2008 survey
for analysis [18].
High-density lipoprotein (HDL) cholesterol was mea-
sured in supernatants after precipitation of apo B-containing
lipoproteins with heparin-manganese chloride and removal
of excess manganese by precipitation with sodium bicarbon-
ate. Triglycerides were analyzed enzymatically with the use
of commercial reagents and was measured in EDTA plasma
after hydrolysis by lipoprotein lipase to glycerol and fatty
acids. Glycerol is enzymatically phosphorylated and then
oxidized to release hydrogen peroxide, which is peroxidized
to form a quinine-imine chromophore that can then be
read at 490 to 550 nm in a spectrophotometer [18]. Low-
density lipoprotein cholesterol (LDL) was derived using
the Friedewald calculation (LDL =total cholesterol-HDL
cholesterol-triglyceride/5) [19].
CRP was quantified by latex-enhanced nephelometry
(CRP present in the test sample forms an antigen antibody
complex with the latex particles). Serum blood specimens
were processed, stored and shipped to University of Washing-
ton, Seattle, WA [18]. Particle-enhanced assays were based on
the reaction between a soluble analyte and the corresponding
antigen or antibody bound to polystyrene particles. A dilute
solution of test sample was mixed with latex particles
coated with mouse monoclonal anti-CRP antibodies. Non-
HDLcholesterolisdenedastotalcholesterolminusHDL
cholesterol.
2.4. Statistical Methods. The highest quintile for CRP, total
cholesterol, LDL cholesterol, non-HDL cholesterol and
triglycerides and the lowest quintile for HDL cholesterol,
for the entire study population were used as cut-points for
analysis (Tab l e 1 ). These cut-points are consistent with the
percentages used for abnormal values in studies of older
children [20,21]. Logistic regression analysis was used to
explore the relationships between each of the selected perina-
tal and infant conditions and anthropometric measurements
and CVD risk factors for each ethnic group. Child’s age and
sex, the family’s poverty/income ratio, the year of the survey
(to account for possible trend over the 10 years of data),
and mother’s age at the child’s birth were included in each
model to control for potential confounding eects. Separate
analyses were run for the three race/ethnicity categories.
Analyses were performed with SAS SURVEY procedures
(SAS version 9.2, SAS Institute, Cary, NC) to accommodate
the complex sample survey design of the NHANES data.
Alpha was set at 0.05 and all tests were two tailed, without
correction for multiple comparisons.
Tab l e 2: Demographic characteristics of 3,644 3-to-6-year-olds in
the National Health and Nutrition Examination Survey, 1999–2008.
NWeighted NPercent 95% CI
Gender
Boys 1,865 7,399,751 50.9 48.6–53.2
Girls 1,779 7,135,318 49.1 46.8–51.4
Age (years)
3 922 3,493,552 24.0 22.1–26.0
4 976 3,701,859 25.5 23.5–27.4
5 887 3,581,816 24.6 22.7–26.6
6 859 3,757,841 25.9 23.9–27.8
Ethnicity
Non-Hispanic White 1,138 9,000,820 61.9 58.2–65.7
Hispanic 1,416 3,285,391 22.6 19.5–25.7
Non-Hispanic Black 1,090 2,248,857 15.5 13.0–17.9
Total 3,644 14,535,068
3. Results
We analyzed data from 3,644 (weighted sample size,
14,535,068) children and their mothers (Tables 2and 3).
Overall, 13.8% of children had a BMI 95th percentile and
26.5% had a BMI 85th percentile for age and sex (Tabl e 1 ).
Approximately 65% of mothers reported breastfeeding while
42% reported introducing solids before 6 months. Almost
10% of the infants were low birth weight (<2500 grams) and
17% of the mothers reported smoking while being pregnant
(Tab l e 3 ).
Tab l e 4 shows that breastfeeding was significantly protec-
tive against obesity (BMI 95th percentile ile for age and
sex) (OR 0.43, 95% CI, 0.27–0.69), overweight (OR 0.61,
95% CI, 0.42–0.87), and being in the highest quintile for
waist circumference (OR 0.58, 95% CI, 0.37–0.92) among
the NHW group and against highest quintile for non-HDL
cholesterol among NHB (OR 0.56, 95% CI, 0.32–0.98).
Conversely, introducing solid foods before 6 months was not
shown to be a risk factor for any CVD risk factors among all
ethnic groups.
Smoking during pregnancy was a significant risk factor
for obesity (OR 2.22, 95% CI, 1.13–2.83), overweight (OR
1.79, 95% CI 1.13–2.83), and highest quintile of CRP (OR
1.63, 95% CI, 1.05–2.51) among NHW (Tab l e 5 ).
Tab l e 6 shows that in general low birth weight was not
a risk factor for becoming overweight or obese or having
elevated CVD risk factors in this age group was associated
with a diminished risk among NHW for being overweight
(OR 0.33, 95% CI 0.14–0.76) and having the highest quintile
of waist circumference (OR 0.34, 95% CI 0.16–0.74).
4. Discussion
The results reported here show that CVD risk in young chil-
dren is associated with perinatal and infancy factors among
NHW. Specifically, our analysis shows that breastfeeding is
International Journal of Pediatrics 5
Tab l e 3: Sample, estimated national characteristics, and range of values for measurements in 3,644 3-to-6-year-olds in the National Health
and Nutrition Examination Survey, 1999–2008.
NWeighted NMean 95% CI
Total sample 3,644 14,535,068 4.52 4.48–4.57
Anthropometrics
BMI (kg/m2) 3,555 14,165,622 16.30 16.20–16.39
Waist Circumference (cm) 3,456 13,795,833 53.86 53.56–54.17
CVD risk factor
C-reactive protein (mg/dL) 2,521 9,679,388 0.16 0.13–0.19
Total cholesterol (mg/dL) 1,754 6,895,867 161.88 160.07–163.68
HDL cholesterol (mg/dL) 1,752 6,885,787 51.95 51.18–52.72
Non-HDL cholesterol (mg/dL) 1,751 6,884,098 20.8 17.9–23.6
LDL cholesterol (mg/dL) 625 5,807,247 92.75 90.58–94.92
Triglycerides (mg/dL) 626 5,811,466 84.87 78.37–91.37
Prenatal, infant, and social risk factor NWeighted NPercent 95% CI
Breastfed 3,628 14,485,571 64.8 61.7–67.9
Solid food <6 months 3,594 14,340,199 42.0 39.4–44.5
Smoking while pregnant 3,626 14,459,865 17.4 14.9–19.8
Low birth weight 3,343 13,299,081 9.7 8.1–11.3
Poverty income ratio <1 3,378 13,649,782 25.3 23.0–27.6
Poverty income ratio <2 3,378 13,649,782 51.6 48.2–55.0
CVD risk factor NWeighted NPercent 95% CI
BMI 85 %ile for age, sex 3,555 14,165,622 24.5 22.6–26.3
BMI 95 %ile for age, sex 3,555 14,165,622 12.7 11.3–14.1
Waist circumference13,456 13,795,833 20.7 18.8–22.6
C-reactive protein12,521 9,679,388 21.0 18.9–23.0
Total cholesterol11,754 6,895,867 21.0 18.6–23.5
HDL cholesterol21,752 6,885,787 18.3 15.7–20.8
LDL cholesterol1625 5,807,247 23.3 19.2–27.4
Tri g l y c e r ide1626 5,811,466 21.8 16.9–26.8
1Highest quintile
2Lowest quintile
protective against obesity and smoking during pregnancy is
a risk factor for obesity in NHW. Low birth weight was not
a risk factor for CVD risk factors, particularly among NHW
women. With the exception of breastfeeding being protective
against the highest quintile of non-HDL cholesterol in NHB,
early introduction of solid foods, smoking during pregnancy,
andlowbirthweightwerenotfoundtoberelatedtoCVD
risk factors in early childhood.
Previous NHANES analyses have shown mixed results
when analyzing whether or not breastfeeding is protective
against children becoming overweight and that there is a
dose-dependent eect based on duration. One analysis of
infant feeding and child overweight status among 3-to-5-
year olds from the NHANES III showed that after adjusting
for potential confounders, there was a reduced risk of
being overweight for ever-breastfed children compared with
those never breastfed [22]. However, there was no reduced
risk of being overweight (obese). Furthermore, there was
no demonstrable threshold eect or clear dose-dependent
eect of the duration of full breastfeeding on being at risk
of overweight or overweight (now termed overweight and
obese).
Other large population-based studies have also examined
whether increasing duration of breastfeeding is associated
with a lower risk of overweight in a low-income population
of 4-year olds in the United States. Analysis from the Pedi-
atric Nutrition Surveillance System [23] of children up to
60 months of age found that the duration of breastfeeding
showed a dose-response, protective relationship with the risk
of overweight only among NHW; no significant association
was found among NHB or Hispanics, very similar to our
results reported here.
Others have examined a broad range of factors that may
simultaneously contribute to childhood overweight in a pop-
ulation-based cohort of children followed from birth to 4.5
years, to determine which factors exert the most influence
in early life [24]. The Quebec Longitudinal Study of Child
Development 1998–2002 (QLSCD) followed a representative
sample (n=2103) of children born in 1998 in the Canadian
province of Quebec. Measured height and weight were
6International Journal of Pediatrics
Tab l e 4: Elevated cardiovascular disease risk factors among US 3-to-6-year-olds by ethnicity and infant nutrition practices, National Health
and Nutrition Examination Survey, 1999–2008.
Hispanic Non-Hispanic Black Non-Hispanic White
Perinatal factor Odds ratio
(95% CI) P-value Odds ratio
(95% CI) P-value Odds ratio
(95% CI) Pvalue
Breastfed (Y/N)
BMI 85th %ile for age, sex 1.14 (0.82–1.57) 0.43 0.84 (0.58–1.22) 0.37 0.61 (0.42–0.87) 0.01
BMI 95th %ile for age, sex 0.96 (0.65–1.41) 0.83 0.82 (0.53–1.28) 0.39 0.43 (0.27–0.69) <0.001
Waist circumference11.33 (0.91–1.93) 0.14 0.71 (0.44–1.14) 0.16 0.58 (0.37–0.92) 0.02
C-reactive protein10.78 (0.53–1.16) 0.22 1.24 (0.84–1.82) 0.28 0.76 (0.52–1.13) 0.18
Total cholesterol11.45 (0.83–2.55) 0.19 0.62 (0.33–1.15) 0.13 0.92 (0.49–1.70) 0.78
HDL cholesterol20.98 (0.63–1.52) 0.93 0.87 (0.41–1.85) 0.73 0.48 (0.23–1.04) 0.06
Non-HDL cholesterol11.23 (0.70–2.14) 0.48 0.56 (0.32–0.98) 0.04 1.10 (0.60–2.02) 0.76
LDL cholesterol11.90 (1.01–3.55) 0.05 0.74 (0.30–1.86) 0.53 1.89 (0.52–6.83) 0.33
Triglycerides12.01 (0.71–5.71) 0.19 1.24 (0.56–2.74) 0.59 1.40 (0.47–4.19) 0.54
Solids <6months(Y/N)
BMI 85th %ile for age, sex 1.06 (0.77–1.46) 0.72 1.13 (0.81–1.56) 0.47 1.17 (0.82–1.68) 0.38
BMI 95th %ile for age, sex 0.85 (0.61–1.20) 0.36 1.03 (0.68–1.56) 0.90 1.28 (0.82–1.99) 0.28
Waist circumference10.90 (0.60–1.35) 0.61 1.05 (0.75–1.45) 0.79 1.38 (0.96–1.98) 0.09
C-reactive protein10.79 (0.50–1.23) 0.29 0.80 (0.57–1.12) 0.20 1.50 (0.99–2.26) 0.06
Total cholesterol11.08 (0.59–1.98) 0.80 1.07 (0.58–1.99) 0.83 1.39 (0.76–2.54) 0.29
HDL cholesterol20.79 (0.45–1.37) 0.41 0.93 (0.52–1.69) 0.82 0.67 (0.38–1.16) 0.15
Non-HDL cholesterol10.85 (0.48–1.50) 0.57 1.60 (0.91–2.81) 0.10 1.34 (0.80–2.23) 0.27
LDL cholesterol10.33 (0.12–0.94) 0.04 1.47 (0.74–2.90) 0.27 0.87 (0.36–2.08) 0.75
Triglycerides10.71 (0.26–1.92) 0.50 0.80 (0.30–2.09) 0.64 0.90 (0.30–2.69) 0.85
1Highest quintile
2Lowest quintile
Tab l e 5: Elevated cardiovascular disease risk factors among US 3-to-6-year-olds by ethnic group and maternal smoking during pregnancy,
National Health and Nutrition Examination Survey, 1999–2008.
Hispanic Non-Hispanic Black Non-Hispanic White
Perinatal Factor Odds Ratio
(95% CI) P-value Odds ratio
(95% CI) P-value Odds ratio
(95% CI) P-value
Maternal Smoking (Y/N)
BMI 85th %ile for age, sex 1.49 (0.82–2.73) 0.19 0.99 (0.53–1.85) 0.98 1.79 (1.13–2.83) 0.01
BMI 95th %ile for age, sex 1.29 (0.62–2.68) 0.49 1.35 (0.58–3.14) 0.48 2.22 (1.30–3.78) <0.01
Waist circumference11.06 (0.56–1.98) 0.87 1.18 (0.65–2.12) 0.59 1.40 (0.83–2.36) 0.20
C-reactive protein10.85 (0.38–1.90) 0.69 1.23 (0.56–2.75) 0.61 1.63 (1.05–2.51) 0.03
Total cholesterol10.61 (0.18–2.02) 0.42 0.62 (0.19–2.06) 0.43 0.73 (0.39–1.40) 0.35
HDL cholesterol20.61 (0.19–1.93) 0.40 1.11 (0.56–2.18) 0.77 1.29 (0.58–2.86) 0.53
Non-HDL cholesterol10.58 (0.18–1.82) 0.35 0.67 (0.19–2.41) 0.54 0.79 (0.46–1.36) 0.40
LDL cholesterol10.71 (0.16–3.26) 0.66 0.65 (0.14–2.99) 0.58 0.24 (0.06–0.90) 0.03
Triglycerides10.71 (0.15–3.31) 0.66 0.58 (0.15–2.25) 0.43 1.39 (0.34–5.69) 0.64
1Highest Quintile
2Lowest Quintile
available for 1550 children aged 4.5 years. Results showed
that being in the highest quintiles of weight gain between
birth and 5 months, as well as maternal smoking during
pregnancy, almost doubles the odds of being overweight at
4.5 years.
The Viva La Familia Study was designed to identify ge-
netic and environmental factors aecting obesity and its
comorbidities in 1030 Hispanic children from 319 families
[25]. Salient independent risk factors for childhood obesity
in this cohort of Hispanic children were age, birth weight,
International Journal of Pediatrics 7
Tab l e 6: Elevated cardiovascular disease risk factors among US 3-to-6-year-olds if low birth weight, by ethnic group, National Health and
Nutrition Examination Survey, 1999–2008.
Hispanic Non-Hispanic Black Non-Hispanic White
Perinatal Factor Odds Ratio
(95% CI) P-value Odds Ratio
(95% CI) P-value Odds Ratio
(95% CI) P-value
Low birth weight (Y/N)
BMI 85th %ile for age, sex 0.82 (0.47–1.44) 0.49 0.88 (0.44–1.37) 0.38 0.33 (0.14–0.76) 0.01
BMI 95th %ile for age, sex 0.99 (0.54–1.83) 0.97 1.01 (0.46–2.23) 0.98 0.37 (0.11–1.22) 0.10
Waist circumference10.89 (0.43–1.86) 0.89 1.03 (0.56–1.88) 0.93 0.34 (0.16–0.74) <0.01
C-reactive protein11.74 (0.94–3.22) 0.08 1.37 (0.81–2.29) 0.24 0.51 (0.17–1.50) 0.22
Total cholesterol11.58 (0.66–3.83) 0.31 0.64 (0.28–1.44) 0.28 1.51 (0.54–4.21) 0.43
HDL cholesterol21.37 (0.53–3.54) 0.52 1.14 (0.53–2.47) 0.74 1.28 (0.32–5.08) 0.72
Non-HDL cholesterol11.88 (0.75–4.68) 0.18 0.55 (0.25–1.25) 0.16 0.81 (0.26–2.53) 0.72
LDL cholesterol11.58 (0.40–6.23) 0.51 0.87 (0.19–3.96) 0.85 0.39 (0.02–6.71) 0.52
Triglycerides10.98 (0.20–4.71) 0.98 0.99 (0.40–2.43) 0.99 1.37 (0.22–8.49) 0.74
1Highest quintile
2Lowest quintile
maternal obesity, paternal obesity, number of children in the
family, and the percentage of awake time spent in sedentary
activity. They also reported that breastfeeding might have a
small protective eect against childhood obesity, although
the authors concluded that residual confounding might exist.
The authors reported no significant eect of early introduc-
tion of solid foods on childhood obesity, consistent with our
findings here. Conversely, a prospective nationally represen-
tative cohort study conducted in England, Wales, Scotland,
and Northern Ireland [26] included 13,188 singleton chil-
dren aged 3 years in the Millennium Cohort Study, born
between 2000 and 2002, who had complete height/weight
data. The main outcome measure was childhood overweight
(including obesity) defined by the International Obesity Task
Force cut-os for body mass index. In the fully adjusted
model, primarily individual- and family-level factors were
associated with early childhood overweight: birthweight z-
score, black ethnicity (compared with white), introduction
to solid foods <4 months, and smoking during pregnancy.
However, in agreement with both the findings here and in the
Viva La Familia Study, breastfeeding 4 months (compared
with none) was associated with a decreased risk of early
childhood overweight.
Other population-based studies have shown an asso-
ciation between maternal smoking during pregnancy and
childhood obesity. Specifically, a total of 11,653 preschool
children participating in the UK Millennium Cohort Study
had their weight gain z-scores calculated from 3 to 5 years
[27]. In a mutually adjusted model, children were more
likely to gain weight rapidly if their mothers smoked during
pregnancy. Due to the cross-sectional nature of the current
dataset, we were unable to explore longitudinal growth
but the concept of catch-up growth has gained recent and
increased attention in the literature [2830].
Because our findings are among very young children,
they may have implications throughout childhood. Our
group has reported previously that risk factors for car-
diometabolic disease can be detected as early as the preschool
years (12) and 8 years old [31]. Other studies have noted
that several CVD risk factors persist strongly and consistently
through childhood into adulthood [32,33]. The Cardio-
vascular Risk in Young Finns Study was one of the first
groups to explore childhood predictors of the metabolic
syndrome (MS), a constellation of abnormal waist circum-
ference, insulin resistance, dyslipidemia, and hypertension
[32]. In this study, fasting insulin at baseline was related to
development of the syndrome after a 6-year follow-up of
1,865 children and adolescents 6-to-18-years-old. Reported
results showed that baseline insulin concentration was higher
in children who subsequently developed the MS, lending
support to the theory that insulin resistance precedes the
development of the condition in childhood.
5. Study Limitations
In a cross-sectional study, causality cannot be inferred. Blood
pressure, insulin and glucose measures, which are important
components of metabolic syndrome and risk factors for
adult-onset CVD and diabetes, were not collected in this
age group and thus were not available for analysis. Because
triglycerides and LDL were measured on a subsample of the
surveyed children, analyses for these variables may not have
sucient statistical power to detect significant dierences.
Dietary and physical activity level data were not included
because the children in this analysis were so young and their
eating and exercise patterns tend to be inconsistent as a result.
Smoking status during pregnancy and infant feeding behav-
iors were self-reported and therefore subject to systematic
biases. Finally, genetic influences were not examined.
6. Conclusions
This study indicates that behavioral and social factors exert
critical influences on the onset of childhood overweight in
preschool years among NHW families in particular. Regard-
less of ethnic background, all women should be advised not
8International Journal of Pediatrics
to smoke, especially while being pregnant, and should be
encouraged to breastfeed, unless contraindicated, as a means
of providing optimal nutrition. This may in turn prove to be
protective against chronic obesity and later life onset of CVD.
Acknowledgment
This paper is funded by National Institutes of Health Grant
K01 DA 026993 (SEM).
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    • A recent study from a sample of overweight adolescents revealed that breastfeeding of an infant is associated with lower incidence of obesity and complications related to metabolic syndrome in the off- spring [5] . Other studies have revealed that longer duration of breastfeeding of an infant may be protective against obesity in childhood or reduce the risk of being overweight in childhood6789 . Researchers have identified several physiological links between breastfeeding and body size of the offspring.
    [Show abstract] [Hide abstract] ABSTRACT: Background: The current study investigated the association between breastfeeding and adult weight distribution using an emerging indicator of weight distribution, the waist-to-height ratio (WHtR). Methods: The study sample consisted of two subsamples of individuals that were part of the National Longitudinal Study of Adolescent Health. One sample (n = 1 179) consisted of individuals from the sibling pair data. A second sample (n = 4 648) consisted of individuals that were not part of the paired data. Regression models were constructed to establish if there was a relationship between breastfeeding and two measures of weight distribution: WHtR and body mass index (BMI). Controls for parental socioeconomic status, maternal smoking, race, sex, age, birth weight, maternal BMI, genetic ancestry, and a genetic risk score (GRS) for obesity were included. In addition, a behavioral risk score (BRS) was constructed to control for other residual confounding factors. Results: A significant, inverse relationship between breastfeeding and adult WHtR persisted in models constructed from the sibling pair sample (P = 0.002) and unrelated sample (P <0.0001). This association remained significant with the inclusion of ancestry principal components, GRS, and a measure of maternal obesity. Conclusions: The moderate association between breastfeeding and weight distribution persists into adulthood while controlling for potential confounders. This paper also provides evidence that the WHtR may be a superior outcome measure to BMI in studies investigating breastfeeding and obesity.
    Full-text · Article · Dec 2015
    • Age of introduction of solids < 4 mo Kikafunda et al. 2009 [70] Age of introduction of solids > 6 mo Kramer et al. 2011 [71] Age of introduction of solids at 1, 2, 3 mo Lartey et al. 1999 [72] Age of introduction of solids > 6 mo López-Alarcón et al.1997 [73] Age of introduction of solids < 4 mo Marlin et al. 1980 [74] Age of introduction of solids < 4 mo Marquis et al. 1997 [75] Infants age group 12-15 mo Messiah et al. 2012 [76] Non specific information on how exclusive breastfeeding in BF and in CF groups Nielsen et al.1998 [77] No analysis on association between age of introduction of solids among EBF and growth Piwoz et al. 1996 [78] Age of introduction of solids < 4 mo Popkin et al. 1990 [79] Age of introduction of solids non specified Quigley et al. 2009 [80] No analysis on the type of milk received by CF group Rowland et al. 1988 [81] Age of introduction of solids non specified Saarinen & Siimes 1978 [82] Age of introduction of solids < 4 mo. Mixed feeding (formula + BM) Salmenpera et al. 1985 [83] Age of introduction of solids < 4 mo Simondon & Simondon 1997 [84] Age of introduction of solids < 4 mo Sloan et al. 2008 [85] Age of introduction of solids < 4 mo Victora et al. 1998 [86] Age of introduction of solids < 4 mo, low birth weight infants included in the analysis Wilson et al. 1998 [87] Age of introduction of solids < 4 mo Wilson et al. 2006 [88] Age of introduction of solids < 4 mo Zhou et al. 2012 [89] Age of introduction of solids > 6 mo N.B: CF complementary feeding, EBF exclusively breastfeeding, mo month
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  • [Show abstract] [Hide abstract] ABSTRACT: Breastfeeding has been found to have a protective effect on subsequent development of obesity in childhood, particularly in white, non-Hispanic populations. The protective effect of nursing for more than 12 months in children of Latina women is less clear, which may be due to differences in levels of acculturation in previously studied populations. We evaluated the association between breastfeeding for 12 months or more and risk for obesity in a cohort of children of recently immigrated relatively unacculturated Latina mothers. Maternal characteristics at birth, including length of stay in the United States, breastfeeding habits at 4-6 weeks of age, 6 months, and 1 year, and anthropometric measurements were obtained for a cohort of 196 children participating in a prospective study. At 1 year of age 39.0 % of infants were being breastfed. Being breastfed at 1 year of age was associated with a decreased risk of obesity in both univariate (odds ratio (OR) 0.49, 95 % confidence interval (CI) 0.21-0.83) and multivariate models (OR 0.39, 95 % CI 0.02-0.93) adjusting for maternal BMI, marital status, education level, country of origin, age, years of living in the United States, and child's birth weight at 3 years of age, regardless of mother's acculturation status using length of stay in the United States as a proxy for acculturation. The association with breastfeeding persisted at 4 years of age as a protective factor for obesity (OR 0.29, 95 % CI 0.11-0.80). Breastfeeding for longer than 12 months provides a significant protective effect on the development of obesity in early childhood in a cohort of children of high-risk recently immigrated Latina women in San Francisco who were relatively unacculturated to the United States.
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  • [Show abstract] [Hide abstract] ABSTRACT: Introduction: Excessive and inadequate gestational weight gain can complicate a woman's pregnancy and put her and her child at risk for poor delivery and birth outcomes. Further, feeding and activity habits established early in life can significantly impact the development of childhood obesity. Methods: The on-going Delta Healthy Sprouts Project is a randomized, controlled, comparative trial testing the efficacy of two Maternal, Infant, and Early Childhood Home Visiting programs on weight status and health behaviors of 150 mothers and their infants residing in the rural Mississippi Delta region of the United States. Women are enrolled in their second trimester of pregnancy and randomized to one of two treatment arms. The control arm curriculum is based on Parents as Teachers, an evidence based approach to increase parental knowledge of child development and improve parenting practices. The experimental arm, labeled Parents as Teachers Enhanced, builds upon the control curriculum by including culturally tailored nutrition and physical activity components specifically designed for the gestational and postnatal periods. We hypothesize that, as compared to the control arm, the experimental arm will be more effective in preventing inappropriate gestational weight gain, reducing postnatal weight retention, and decreasing infant obesity rates. We also will evaluate mother and child dietary and physical activity outcomes, breastfeeding initiation and continuation, and child feeding practices. Conclusion: The Delta Healthy Sprouts Project tests a novel, combined approach to maternal weight management and childhood obesity prevention in pregnant women and their children at high risk for obesity and chronic disease.
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